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BACKGROUND: We investigated if anatomic patterns of abnormal parathyroid glands have ch anged for primary hyperparathyroidism (pHPT) as atypical biochemical presentation (normohormonal and normocalcemic) has increased. METHODS: Retrospective review of patients with pHPT who underwent routine bilateral neck exploration. RESULTS: 2762 patients were included. The "late" cohort (2014-2020) exhibited lower preoperative calcium (10.8 vs 11.1 âmg/dL; P â= â0.001) and PTH levels (101 vs. 146 âpg/mL; P â= â0.001) compared to the "early" cohort (2000-2006). Patients with atypical biochemical profiles increased from 25.5% to 31.3% (P â< â0.001). The prevalence of single adenoma (SA) decreased (66.1% vs 58.9%, P â= â0.02) while the proportion of double adenoma (DA) increased (17.3% vs. 22.6%, P â< â0.01). Upper parathyroid adenoma(s) remained the most common finding for SA and DA in both time points. CONCLUSIONS: Despite changes in patient characteristics, single upper adenoma and bilateral double upper adenomas remain the most common findings for patients with pHPT.
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Adenoma , Hiperparatiroidismo Primario , Neoplasias de las Paratiroides , Humanos , Hiperparatiroidismo Primario/sangre , Hiperparatiroidismo Primario/cirugía , Hiperparatiroidismo Primario/diagnóstico , Neoplasias de las Paratiroides/cirugía , Neoplasias de las Paratiroides/patología , Neoplasias de las Paratiroides/complicaciones , Neoplasias de las Paratiroides/sangre , Estudios Retrospectivos , Femenino , Masculino , Persona de Mediana Edad , Adenoma/sangre , Adenoma/patología , Adenoma/cirugía , Adenoma/complicaciones , Adenoma/epidemiología , Anciano , Hormona Paratiroidea/sangre , Calcio/sangre , Paratiroidectomía , AdultoRESUMEN
INTRODUCTION: 99mTC-sestamibi scintigraphy (SPECT-CT) is a common imaging modality for parathyroid localization in primary hyperparathyroidism (PHPT). Prior studies have suggested that the cellular composition of parathyroid adenomas influences SPECT-CT imaging results. Other biochemical and anatomical factors may also play a role in false negative results. Therefore, after controlling for confounding variables, we sought to determine whether the histologic composition of parathyroid adenomas is associated to SPECT-CT results in patients with single gland disease causing PHPT. METHODS: A retrospective review of patients with PHPT due to confirmed single gland disease was performed over a 2-y period. A 1:1 propensity score matching was done between patients with positive and negative SPECT-CT results with regard to demographical, biochemical, and anatomical characteristics followed by blinded pathologic examination of cell composition in the matched pairs. RESULTS: Five hundred forty two patients underwent routine four gland exploration and 287 (53%) patients were found to have a single adenoma. Of those, 26% had a negative SPECT-CT result. There were significant differences between groups with regards to biochemical profile, gland location, and gland size. All of which became nonsignificant after propensity score matching. Adenomas were primarily composed of chief cells, with no difference between groups (95% versus 97%, P = 0.30). In the positive SPECT-CT group, chief cells were the dominant cell type in 68% of the cases, followed by mixed type (13%), oxyphil cells (12%), and clear cells (7%). This was similar to the negative SPECT-CT group (P = 0.22). CONCLUSIONS: While certain patient's clinical characteristics are associated with SPECT-CT imaging results, histologic cell type is not significantly associated.
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Adenoma , Hiperparatiroidismo Primario , Neoplasias de las Paratiroides , Humanos , Hiperparatiroidismo Primario/etiología , Hiperparatiroidismo Primario/complicaciones , Neoplasias de las Paratiroides/complicaciones , Neoplasias de las Paratiroides/diagnóstico por imagen , Tomografía Computarizada de Emisión de Fotón Único/métodos , Glándulas Paratiroides/diagnóstico por imagen , Tecnecio Tc 99m Sestamibi , Adenoma/complicaciones , Adenoma/diagnóstico por imagen , RadiofármacosRESUMEN
BACKGROUND: Near-infrared autofluorescence imaging is an adjunct to parathyroid identification. As it does not show perfusion, it is important to study its impact during thyroidectomy by measuring quantifiable data on parathyroid detection rather than function. The aim of this study was to compare incidental parathyroidectomy rates in patients undergoing total thyroidectomy with or without near-infrared autofluorescence. METHODS: Retrospective study of patients who underwent total thyroidectomy between 2014 and 2022 at one center. Clinical parameters, including rates of incidental parathyroid tissue on pathology reports, were compared between near-infrared autofluorescence and non-near-infrared autofluorescence groups. Near-infrared autofluorescence was used to guide dissection (identification) and/or to confirm tissue as parathyroid (confirmation). Statistical analysis was done with Wilcoxon rank sum test and χ2 analysis. RESULTS: There were 300 patients in the near-infrared autofluorescence and 750 patients in the non-near-infrared autofluorescence group. The rate of incidental parathyroid tissue detection on final pathology was 13.3% (n = 40) in the near-infrared autofluorescence and 23.2% (n = 174) in the non-near-infrared autofluorescence group (P < .001). The rate of incidental parathyroid tissue detected on pathology with near-infrared autofluorescence decreased when used for identification and confirmation of parathyroid tissue (30.0% to 13.4%, P < .001), but not when used for confirmation only (19.6% to 18.5%, P = .89). Impact of near-infra red autofluorescence in decreasing the rate of incidental parathyroid tissue was more profound for early (38.5% to 17.1%) versus mid-late career surgeons (20% to 13%). CONCLUSION: Our results suggest that the use of near-infrared autofluorescence may help decrease the rate of incidental parathyroid tissue detected on final pathology if used for both identification and confirmation of parathyroid glands during thyroidectomy.
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Glándulas Paratiroides , Tiroidectomía , Humanos , Glándulas Paratiroides/patología , Tiroidectomía/métodos , Estudios Retrospectivos , Imagen Óptica/métodos , Paratiroidectomía/métodosRESUMEN
Objective: Using population-based simulations and machine-learning algorithms to develop an adaptive restraint system that accounts for occupant anthropometry variations to further enhance safety balance throughout the whole population. Methods: Two thousand MADYMO full frontal impact crash simulations at 35 mph using two validated vehicle/restraint models representing a sedan and an SUV along with a parametric occupant model were conducted based on the maximal projection design of experiments, which considers varying occupant covariates (sex, stature, and body mass index) and vehicle restraint design variables (three for airbag, three for safety belt, and one for knee bolster). A Gaussian-process-based surrogate model was trained to rapidly predict occupant injury risks and the associated uncertainties. An optimization framework was formulated to seek the optimal adaptive restraint design policy that minimizes the population injury risk across a wide range of occupant sizes and shapes while maintaining a low difference in injury risks among different occupant subgroups. The effectiveness of the proposed method was tested by comparing the population-wise injury risks under the adaptive design policy and the traditional state-of-the-art design. Results: Compared to the traditional state-of-the-art design for midsize males, the optimal design policy shows the potential to further reduce the joint injury risk (combining head, chest, and lower extremity injury risks) among the whole population in the sedan and SUV models. Specifically, the two subgroups of vulnerable occupants including tall obese males and short obese females had higher reductions in injury risks. Conclusions: This study lays out a method to adaptively adjust vehicle restraint systems to improve safety balance. This is the first study where population-based crash simulations and machine-learning methods are used to optimize adaptive restraint designs for a diverse population. Nevertheless, this study shows the high injury risks associated with obese and female occupants, which can be mitigated via restraint adaptability.
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Equipos de Seguridad , Proyectos de Investigación , Masculino , Femenino , Humanos , Algoritmos , Antropometría , Índice de Masa CorporalRESUMEN
Importance: Identifying hereditary cancer predisposition facilitates high-risk organ-specific cancer surveillance and prevention. In PTEN hamartoma tumor syndrome (PHTS), longitudinal studies remain lacking, and there are insufficient data on cancers in children and young adults, as well as individuals with neurodevelopmental disorders (NDD). Objective: To evaluate lifetime cancer risks, including second malignant neoplasms (SMN), among patients with PHTS. Design, Setting, and Participants: Prospective longitudinal cohort study (September 1, 2005, through January 6, 2022). General population risks from the Surveillance, Epidemiology, and End Results database. Patients with PHTS, molecularly defined as carrying germline PTEN variants, were accrued from community and academic medical centers throughout North America, South America, Europe, Australia, and Asia. Data were analyzed from July 2022 to February 2023. Exposures: Review of physical and electronic medical records, and follow-up through clinical visits or telephone interviews. Main Outcomes and Measures: Lifetime cancer risks in PHTS relative to the general population. Results: A total of 7302 patients were prospectively accrued, 701 of whom had germline PTEN variants (median [IQR] age at consent, 38 [12-52] years; 413 female patients [59%]). Longitudinal follow-up data could be obtained for 260 patients (37%), with a median (IQR) follow-up of 4 (2-8) years. Of the 701 patients, 341 (49%) received at least 1 cancer diagnosis, with 144 (42%) of those having SMN. The study found significantly elevated lifetime risks for breast (91%), endometrial (48%), thyroid (33%), kidney (30%), and colorectal cancers (17%), as well as melanoma (5%). Cancer diagnoses were also observed in children and young adults with PHTS (15%) and in patients with PHTS with neurodevelopmental disorders (11%). Elevated risks (P < .001) of thyroid (age-adjusted standardized incidence ratios [SIR], 32.1; 95% CI, 26.0-39.0), kidney (SIR, 26.5; 95% CI, 18.8-36.3), endometrial (SIR, 26.0; 95% CI, 19.5-34.1), breast (SIR, 20.3; 95% CI, 17.3-23.7), and colorectal (SIR, 7.9; 95% CI, 5.2-11.7) cancers, and melanoma (SIR, 6.3; 95% CI, 3.5-10.5) were observed. Of the 341 patients with PHTS with cancer, 51 (15%) had 1 or more cancers diagnosed at age 29 years or younger, and 16 (31.4%) of those developed SMN at final follow-up. Twenty-three patients with PHTS with NDD and cancer were identified, with 5 (22%) having developed SMN at final follow-up. Individuals with PHTS and NDD showed higher lifetime cancer risks compared with individuals with PHTS but without NDD (hazard ratio, 2.7; 95% CI, 1.7-4.2; P < .001). Conclusions and Relevance: This cohort study found consistently elevated lifetime cancer risks in PHTS. Organ-specific surveillance should continue in patients with PHTS. Additional study is required to ascertain elevated cancer risks in patients with PHTS with NDD.
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Síndrome de Hamartoma Múltiple , Melanoma , Neoplasias Primarias Secundarias , Adulto Joven , Humanos , Niño , Femenino , Adulto , Adolescente , Persona de Mediana Edad , Estudios de Cohortes , Estudios Prospectivos , Estudios Longitudinales , Síndrome de Hamartoma Múltiple/epidemiología , Síndrome de Hamartoma Múltiple/patología , Predisposición Genética a la Enfermedad , Fosfohidrolasa PTEN/genéticaRESUMEN
BACKGROUND: The parathyroidectomy approach has shifted over the last few decades from routine bilateral to more commonly focused exploration. The purpose of this study is to assess the operative experience in parathyroidectomy for surgical trainees as well as overall parathyroidectomy trends. METHODS: Data from the Collaborative Endocrine Surgery Quality Improvement Program (CESQIP) were analyzed between 2014 and 2019. RESULTS: The overall distribution of focused versus bilateral parathyroidectomy remained stable (2014: 54 % focused and 46 % bilateral approach; 2019: 55 % focused and 45 % bilateral). Ninety three percent of procedures involved a trainee (fellow or resident) in 2014, this dropped to 74 % in 2019 (P < 0.005). Fellow involvement decreased significantly from 31 % to 17 % (P < 0.05) over the six-year period. CONCLUSIONS: Resident exposure to parathyroidectomies mirrored that of practicing endocrine surgeons. This works highlights the opportunities to capture more information regarding the surgical trainee experience in endocrine surgeries.
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Hiperparatiroidismo Primario , Cirujanos , Humanos , Paratiroidectomía/métodos , Mejoramiento de la Calidad , Hiperparatiroidismo Primario/cirugíaRESUMEN
Importance: Tall cell morphology (TCM) is a rare and aggressive variant of papillary thyroid carcinoma (PTC) that has been associated with poor outcomes; however, the risk factors for worse survival are not well characterized. Objective: To identify prognostic factors associated with cancer recurrence and death in patients with PTC-TCM. Design, Setting, and Participants: All patients treated for PTC-TCM at a single tertiary-level academic health care institution from January 1, 1997, through July 31, 2018, were included. Tall cell variant (TCV) was defined as PTC with TCM of 30% or more; and tall cell features (TCF) was defined as PTC with TCM of less than 30%. Patients with other coexisting histologic findings and/or nonsurgical management were excluded. Clinicopathologic features associated with worse outcomes were identified using Kaplan-Meier and Cox proportional-hazards model. Data were analyzed from March 1, 2018, to August 15, 2018. Main Outcomes and Measures: Locoregional recurrence-free survival (LRRFS), distant recurrence-free survival (DRFS), and overall survival (OS) after surgery. Results: A total of 365 patients (median [range] age, 51.8 [15.9-91.6] years; 242 [66.3%] female) with PTC-TCM (TCV, 32%; TCF, 68%) were evaluable. Total thyroidectomy was performed in 336 (92%) patients; 19 (5.2%) received radiotherapy; and 15 (4.1%) received radioactive iodine. Clinical features were pT3 or T4, 65%; node-positive, 53%; and positive surgical margins, 24%. LRRFS at 1-, 3-, 5-, and 10-year was 95%, 87%, 82%, and 73%, respectively. On multivariable analysis, male sex and age were not independent predictors of inferior 5-year LRRFS, whereas positive surgical margins (HR, 3.5; 95% CI, 2.0-6.3), positive lymph nodes (HR, 2.8; 95% CI, 1.4-5.8), and primary tumor size of 3 cm or more (HR, 3.3; 95% CI, 1.4-7.8) were strongly associated with worse LRRFS. Age 55 years or older (HR, 3.2; 95% CI, 1.5-7.0), male sex (HR 4.5; 95% CI, 2.1-10.0), positive surgical margins (HR, 2.7; 95% CI, 1.2-6.0), nodal positivity (HR, 3.1; 95% CI, 1.3-7.7), tumor diameter of 1.5 cm or more (HR, 20.6; 95% CI, 2.8-152.1), and TCV vs TCF (HR, 3.1; 95% CI, 1.5-6.7) were associated with worse DRFS. Male sex (HR, 3.1; 95% 1.4-6.8) and tumor diameter of 1.5 cm or more (HR, 2.8; 95% CI, 1.0-7.4) were associated with worse OS. A findings-based nomogram was constructed to predict 10-year LRRFS (C index, 0.8). Conclusions and Relevance: This retrospective cohort study found that in patients with PTC-TCM, positive surgical margins, node positive disease, and tumor size of 3 cm or more were risk factors for worse LRRFS. Intensified locoregional therapy, including adjuvant radiation, may be considered for treating these patients.
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Carcinoma Papilar , Neoplasias de la Tiroides , Femenino , Humanos , Masculino , Persona de Mediana Edad , Carcinoma Papilar/cirugía , Estudios de Cohortes , Radioisótopos de Yodo/uso terapéutico , Márgenes de Escisión , Recurrencia Local de Neoplasia/patología , Nomogramas , Pronóstico , Estudios Retrospectivos , Factores de Riesgo , Cáncer Papilar Tiroideo/cirugía , Neoplasias de la Tiroides/cirugía , Neoplasias de la Tiroides/patología , Tiroidectomía , Adolescente , Adulto Joven , Adulto , Anciano , Anciano de 80 o más AñosRESUMEN
BACKGROUND: The usefulness of incorporating near-infrared autofluorescence into the surgical workflow of endocrine surgeons is unclear. Our aim was to develop a prospective registry and gather expert opinion on appropriate use of this technology. METHODS: This was a prospective multicenter collaborative study of patients undergoing thyroidectomy and parathyroidectomy at 7 academic centers. A questionnaire was disseminated among 24 participating surgeons. RESULTS: Overall, 827 thyroidectomy and parathyroidectomy procedures were entered into registry: 42% of surgeons found near-infrared autofluorescence useful in identifying parathyroid glands before they became apparent; 67% correlated near-infrared autofluorescence pattern to normal and abnormal glands; 38% of surgeons used near-infrared autofluorescence, rather than frozen section, to confirm parathyroid tissue; and 87% and 78% of surgeons reported near-infrared autofluorescence did not improve the success rate after parathyroidectomy or the ability to find ectopic glands, respectively. During thyroidectomy, 66% of surgeons routinely used near-infrared autofluorescence to rule out inadvertent parathyroidectomy. However, only 36% and 45% felt near-infrared autofluorescence decreased inadvertent parathyroidectomy rates and improved ability to preserve parathyroid glands during central neck dissections, respectively. CONCLUSION: This survey study identified areas of greatest potential use for near-infrared autofluorescence, which can form the basis of future objective trials to document the usefulness of this technology.
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Glándulas Paratiroides , Glándula Tiroides , Humanos , Glándulas Paratiroides/diagnóstico por imagen , Glándulas Paratiroides/cirugía , Glándula Tiroides/diagnóstico por imagen , Glándula Tiroides/cirugía , Imagen Óptica/métodos , Paratiroidectomía/métodos , Tiroidectomía/métodosRESUMEN
BACKGROUND: Radioactive iodine (RAI) treatment is considered a rare cause of primary hyperparathyroidism (pHPT). METHOD: A multi-institutional retrospective review of patients with pHPT who underwent parathyroidectomy from 1990 to 2020 was completed to evaluate the prevalence and latency time for development of RAI-associated pHPT and determine clinical differences in pHPT patients with or without prior RAI treatment. RESULTS: 1929 patients with sporadic pHPT underwent parathyroidectomy; 48 (2.5%) had prior RAI treatment and 1881 (97.5%) did not. RAI treatment was for thyrotoxicosis in 43 (90%) patients. Average latency was 24 years (3-59 years) and inversely correlated with age. Patients with prior RAI treatment had lower preoperative calcium and PTH levels (p < 0.0001). No significant differences were observed in age, symptoms, pathology, ectopic glands and cure rate. CONCLUSION: RAI is a potential causative factor for pHPT, accounting for 2.5% of sporadic pHPT. RAI-associated pHPT may be a less severe form of sporadic pHPT and latency inversely correlates with age.
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Hiperparatiroidismo Primario , Neoplasias de la Tiroides , Humanos , Hiperparatiroidismo Primario/radioterapia , Hiperparatiroidismo Primario/cirugía , Radioisótopos de Yodo/efectos adversos , Neoplasias de la Tiroides/cirugía , Paratiroidectomía , Estudios Retrospectivos , Calcio , Hormona ParatiroideaRESUMEN
In the precision medicine era, there is a growing need for precision radiotherapy where the planned radiation dose needs to be optimally determined by considering a myriad of patient-specific information in order to ensure treatment efficacy. Existing artificial-intelligence (AI) methods can recommend radiation dose prescriptions within the scope of this available information. However, treating physicians may not fully entrust the AI's recommended prescriptions due to known limitations or at instances when the AI recommendation may go beyond physicians' current knowledge. This paper lays out a systematic method to integrate expert human knowledge with AI recommendations for optimizing clinical decision making. Towards this goal, Gaussian process (GP) models are integrated with deep neural networks (DNNs) to quantify the uncertainty of the treatment outcomes given by physicians and AI recommendations, respectively, which are further used as a guideline to educate clinical physicians and improve AI models performance. The proposed method is demonstrated in a comprehensive dataset where patient-specific information and treatment outcomes are prospectively collected during radiotherapy of 67 non-small cell lung cancer (NSCLC) patients and are retrospectively analyzed.
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Carcinoma de Pulmón de Células no Pequeñas , Neoplasias Pulmonares , Inteligencia Artificial , Carcinoma de Pulmón de Células no Pequeñas/radioterapia , Toma de Decisiones Clínicas , Humanos , Neoplasias Pulmonares/radioterapia , Estudios RetrospectivosRESUMEN
Background: PTEN hamartoma tumor syndrome (PHTS) is associated with a high prevalence and early onset of differentiated thyroid cancer and benign thyroid disease. However, a consensus on the time of initiation and frequency of thyroid cancer surveillance has not yet been reached. Most commonly, guidelines recommend annual thyroid ultrasounds, but vary widely in the time of initiation, ranging from shortly after birth to 18 years of age. Minimal data are available on the development and progression of thyroid disease over time in this population. This study aimed to target this knowledge gap by investigating the time to develop thyroid nodules and thyroid cancer from an initial ultrasound in 76 PHTS patients. Methods: The electronic records of 281 prospectively accrued PHTS patients were retrospectively reviewed between 2005 and 2021, and 76 patients were identified as having at least two thyroid ultrasounds. Time-to-event analyses were performed, determining the probability of developing thyroid nodules and thyroid cancer over time. Results: We demonstrated that PHTS patients with an initial thyroid ultrasound without nodules (n = 41) had >90% likelihood of remaining free of a clinically actionable nodule at 3 years and an 85% likelihood at 6 years. None of these patients developed thyroid cancer over the entire follow-up period (mean 4.6 years). In patients with a clinically nonactionable nodule, defined as not meeting criteria for fine needle aspiration or thyroidectomy (n = 14), we demonstrated that 80% will not have an actionable nodule at 3 years, and none developed thyroid cancer over the entire follow-up period. Conclusions: Our observations suggest stratifying surveillance intervals based on thyroid ultrasound result, and support extending surveillance intervals in PHTS patients without nodules on ultrasound to 3-5 years, and patients with clinically nonactionable nodules to 2-3 years, in contrast to the current recommendation of annual ultrasounds. This change in practice would decrease the burden of frequent ultrasounds, especially in young children and adolescents who are more likely to have a normal or nonactionable ultrasound result.
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Síndrome de Hamartoma Múltiple , Neoplasias de la Tiroides , Nódulo Tiroideo , Adolescente , Niño , Preescolar , Síndrome de Hamartoma Múltiple/complicaciones , Síndrome de Hamartoma Múltiple/diagnóstico por imagen , Síndrome de Hamartoma Múltiple/patología , Humanos , Fosfohidrolasa PTEN/genética , Estudios Retrospectivos , Neoplasias de la Tiroides/patología , Nódulo Tiroideo/patología , TiroidectomíaRESUMEN
BACKGROUND: Patient-reported outcome measures for parathyroid and thyroid disease (PROMPT) is a 30-question, previously validated, survey assessing symptoms on a scale from 0 to 100. Using PROMPT, we aimed to assess symptom improvement for patients undergoing thyroidectomy and parathyroidectomy. METHODS: Single-center prospective study in which PROMPT was used to assess symptom improvement in patients undergoing parathyroidectomy or thyroidectomy. A postoperative assessment was performed approximately 6 months after surgery and compared to its baseline preoperative assessment. RESULTS: A total of 144 patients completed both assessments (71 parathyroidectomy, 73 thyroidectomy). Parathyroidectomy patients demonstrated significant improvements in all hyperparathyroidism domains (38.2-28.3, p < 0.001) regardless of preoperative calcium and parathyroid hormone levels. Thyroidectomy patients experienced improvement in their compressive symptoms (25.6-16.5, p < 0.001). CONCLUSIONS: PROMPT objectively demonstrates the clinical effectiveness of parathyroidectomy and thyroidectomy in alleviating subjective patient symptoms. PROMPT offers promising use as a standardized metric to assess quality of life improvement within endocrine surgery.
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Calidad de Vida , Glándula Tiroides , Humanos , Glándulas Paratiroides , Paratiroidectomía , Medición de Resultados Informados por el Paciente , Estudios Prospectivos , TiroidectomíaRESUMEN
BACKGROUND AND OBJECTIVES: Pheochromocytoma is a challenging tumor type requiring resection with a clear margin and an intact capsule to prevent recurrences. Our aim was to compare perioperative outcomes of laparoscopic adrenalectomy (LA) versus robotic adrenalectomy (RA) for pheochromocytoma. METHODS: In an institutional review board-approved retrospective study, clinical parameters of patients who underwent LA versus RA at a single center were compared using Mann-Whitney U, χ2 , and survival analyses. Continuous data are expressed as median (interquartile range). RESULTS: There was a total of 157 patients (RA: n = 87, LA: n = 70) analyzed. Estimated blood loss (36.3 [35.0] vs. 99.9 [65.0] cc, p = 0.020) and hospital stay (1.3 [0.0] vs. 2.2 [1.0] days, p = 0.010) were lower in robotic versus laparoscopic group, respectively. Disease-free and overall survival was similar between groups. The rate of conversion to open for tumors ≥5 cm was less in the robotic group (0% vs. 14%, respectively, p = 0.048). CONCLUSION: In this study, long-term outcomes of LA and RA were similar, although adrenalectomies performed robotically were associated with less blood loss, shorter hospital stay, and a lower chance of conversion to open in the case of large tumors.
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Neoplasias de las Glándulas Suprarrenales , Laparoscopía , Feocromocitoma , Procedimientos Quirúrgicos Robotizados , Neoplasias de las Glándulas Suprarrenales/patología , Neoplasias de las Glándulas Suprarrenales/cirugía , Adrenalectomía , Humanos , Tiempo de Internación , Feocromocitoma/patología , Feocromocitoma/cirugía , Estudios RetrospectivosRESUMEN
BACKGROUND: The Afirma Genomic Sequencing Classifier uses whole transcriptome RNA sequencing to identify thyroid nodules as benign or suspicious. The Afirma Xpression Atlas became available in 2018 and reports findings across 593 genes, including 905 variants and 235 fusions. When an alteration is identified, its risk of malignancy and associated neoplasm type is listed. We report the results of Afirma Xpression Atlas testing at our institution during its first 2 years of clinical use. METHODS: All patient charts with indeterminate thyroid nodules and Afirma Xpression Atlas results at our institution were reviewed. Thyroid nodule characteristics, cytology, Afirma Genomic Sequencing Classifier results, Afirma Xpression Atlas results, and final histopathology were reported. RESULTS: Afirma Xpression Atlas was performed on 136 indeterminate nodules since May 2018, and 103 met inclusion criteria. Forty-three nodules had positive Afirma Xpression Atlas results, and of these, 83.7% were follicular cell-derived thyroid cancer on surgical histopathology. This is similar to the overall 82.5% positive predictive value among Afirma Genomic Sequencing Classifier-suspicious indeterminate nodules during the same time period. Of the 60 nodules with negative Afirma Xpression Atlas, 73.3% were follicular cell-derived thyroid cancer on surgical histopathology. CONCLUSION: Afirma Xpression Atlas positivity is predictive of follicular cell-derived thyroid cancer, but its positive predictive value is similar to that of Genomic Sequencing Classifier-suspicious results alone at our institution, which is higher than previously published. Specific mutations likely predict follicular cell-derived thyroid cancer with higher accuracy, but our current sample size of any given mutation is too small to evaluate this further. Larger studies are needed to determine whether Afirma Xpression Atlas results predictably inform the risk of malignancy and tumor characteristics in thyroid nodules.
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Adenocarcinoma Folicular/diagnóstico , Biomarcadores de Tumor/genética , Perfilación de la Expresión Génica/métodos , Neoplasias de la Tiroides/diagnóstico , Nódulo Tiroideo/diagnóstico , Adenocarcinoma Folicular/genética , Adenocarcinoma Folicular/patología , Biopsia con Aguja Fina , Exactitud de los Datos , Diagnóstico Diferencial , Estudios de Factibilidad , Femenino , Perfilación de la Expresión Génica/estadística & datos numéricos , Humanos , Masculino , Persona de Mediana Edad , Mutación , Valor Predictivo de las Pruebas , Estudios Retrospectivos , Glándula Tiroides/patología , Neoplasias de la Tiroides/genética , Neoplasias de la Tiroides/patología , Nódulo Tiroideo/genética , Nódulo Tiroideo/patologíaRESUMEN
OBJECTIVE: Calcium and parathyroid hormone (PTH) values are believed to have a linear relationship in patients with primary hyperparathyroidism and correlate with parathyroid gland size, with higher values predicting single-gland disease. In this modern series, these preoperative values were correlated with operative findings to determine their utility in predicting the gland involvement at parathyroid exploration. METHODS: Two thousand consecutive patients who underwent initial surgery for sporadic primary hyperparathyroidism from 2000 to 2014 were reviewed. All patients underwent a 4-gland exploration. Relationships between preoperative calcium and PTH values with the total gland volume of each patient were examined and stratified using the number of involved glands: single adenoma (SA), double adenoma (DA), and hyperplasia (H). RESULTS: There were 1274 (64%) SA, 359 (18%) DA, and 367 (18%) H cases. There was a poor correlation between preoperative calcium and PTH values (R = 0.37) and both poorly correlated with the total gland volume (R < 0.40). Similarly, subgroup analysis using the number of involved glands showed poor correlation. The mean total gland volume was similar among all subgroups (SA = 1.28 cm3, DA = 1.43 cm3, and H = 1.27 cm3; P = .52), implying that individual glands were smaller in multigland disease. SA was found in 271 (53%) of patients with calcium levels of ≤10.5 mg/dL and 122 (78%) with levels of ≥12 mg/dL (P < .001). CONCLUSION: This is the largest series correlating preoperative calcium and PTH values with operative findings of gland size and number of diseased glands. Although a lower calcium value predicts somewhat more multigland disease, the overall poor correlation should make the parathyroid surgeon aware that gland size and multigland disease cannot be predicted by preoperative laboratory testing.
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Calcio , Hiperparatiroidismo Primario , Hormona Paratiroidea/sangre , Calcio/sangre , Humanos , Hiperparatiroidismo Primario/cirugía , Glándulas Paratiroides/diagnóstico por imagen , Glándulas Paratiroides/cirugía , Paratiroidectomía , Estudios RetrospectivosRESUMEN
BACKGROUND: A single center experience with sporadic pancreatic insulinoma was analyzed to develop an algorithm for modern surgical management. METHODS: Thirty-four patients undergoing surgery from 2001 to 2019 were reviewed. RESULTS: The majority underwent enucleation (10 laparoscopic, 15 open). Laparoscopy was performed in 22 patients with conversion to open in 11, mostly related to the proximity of the tumor to the pancreatic duct (n = 4). Tumors on the anterior and posterior surface of the pancreas in all anatomic locations were completed with laparoscopic enucleation. Overall, the clinically-relevant postoperative pancreatic fistula (CR-POPF) rate was 21%, with no difference between laparoscopic versus open enucleation (10% vs 20%, p = 0.50) or enucleation versus resection (16% vs 33%, p = 0.27). Laparoscopic enucleation had shorter median hospital length of stay (LOS) compared with open (4 vs 7 days, p = 0.02). CONCLUSIONS: Laparoscopic enucleation does not increase the CR-POPF risk and provides an advantage with a shorter hospital LOS in select patients. Tumor location and relationship to the pancreatic duct guide surgical decision-making. These findings highlight tumor-specific criteria that would benefit from a minimally invasive approach.
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Insulinoma , Laparoscopía , Neoplasias Pancreáticas , Humanos , Insulinoma/cirugía , Pancreatectomía , Fístula Pancreática/epidemiología , Fístula Pancreática/etiología , Fístula Pancreática/prevención & control , Neoplasias Pancreáticas/patología , Neoplasias Pancreáticas/cirugía , Complicaciones Posoperatorias/cirugía , Estudios RetrospectivosRESUMEN
BACKGROUND: Fine needle aspiration (FNA) biopsy is an essential procedure for thyroid nodules. Although, the efficacy of surgeon-performed thyroid FNA biopsies has been demonstrated in the literature, there are insufficient data regarding how to establish an efficient program with a low insufficiency rate within a group practice. METHODS: An endocrine surgery thyroid FNA biopsy program was established in 2000 by one surgeon, with training of additional partners during fellowship and upon recruitment. The results within 18 years were analyzed. The FNA biopsies were performed by endocrine surgeons under ultrasound guidance without on-site pathologist review. RESULTS: A total of 5,469 FNA biopsies were performed by 7 surgeons. The total number of FNA biopsies performed by each surgeon varied between 291-1,378. FNA biopsies were performed in 2 passes using 22-gauge needles under constant suction. The overall insufficiency rate was 4.3%, with individual surgeon rates ranging between 2.7% and 7.2%. The insufficiency rate for the whole team ranged between 3.3% and 5% when examined in 5-year blocks. CONCLUSIONS: This study shows that an establishment of a highly efficient thyroid FNA biopsy program within a group practice is possible with a structured endocrine surgical training and adoption of a standard technique.
RESUMEN
BACKGROUND: Preoperative localization studies are essential for parathyroid re-exploration. When noninvasive studies do not regionalize the abnormal parathyroid gland, selective parathyroid venous sampling may be employed. We studied the utility of parathyroid venous sampling in reoperative parathyroid surgery and the factors that may affect parathyroid venous sampling results. METHODS: Patients with hyperparathyroidism and previous cervical surgery undergoing evaluation for reoperative parathyroidectomy over a 20-year period were identified. Patients with indeterminate or negative noninvasive studies underwent parathyroid venous sampling. Parathyroid hormone values were mapped with a ≥2-fold increase above peripheral signifying positive parathyroid venous sampling. These results were correlated with reoperative findings. RESULTS: Parathyroid venous sampling was positive in 113 of 140 (81%). Re-exploration occurred in 75 (66%). Parathyroid venous sampling correctly detected the region of abnormal glands in 58 (77%). With 1 gradient, 1 abnormal gland was found in 81%. With multiple gradients, 1 abnormal gland was found in 78%, most often at the site with the largest gradient. Eighty percent of patients who underwent reoperative parathyroidectomy were biochemically cured. CONCLUSION: Parathyroid venous sampling can guide parathyroid re-exploration when noninvasive localizing studies are indeterminate. Expectation of 1 versus multiple remaining glands was key in interpreting the results.
Asunto(s)
Hiperparatiroidismo/cirugía , Glándulas Paratiroides/diagnóstico por imagen , Paratiroidectomía/métodos , Radiografía Intervencional/métodos , Reoperación/métodos , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Hiperparatiroidismo/sangre , Hiperparatiroidismo/diagnóstico , Imagen por Resonancia Magnética , Masculino , Persona de Mediana Edad , Glándulas Paratiroides/irrigación sanguínea , Glándulas Paratiroides/cirugía , Hormona Paratiroidea/sangre , Cintigrafía , Recurrencia , Estudios Retrospectivos , Tomografía Computarizada por Rayos X , Venas , Adulto JovenRESUMEN
BACKGROUND: Intraoperative near-infrared imaging (NIFI) of parathyroid glands (PG) by first-generation technology had limited image quality and depth penetration. Second-generation NIFI has recently been introduced. Our aim was to compare (1) capability to detect PG and (2) image quality between older and newer technologies. METHODS: Accurately detecting PG, as well as, quality of autofluorescence (AF) was compared between an older charge-coupled device (CCD) camera and a newer complementary metal-oxide semiconductor (CMOS). χ2 , t test, and analysis of variance were used for analysis. RESULTS: There were 300 patients who underwent parathyroidectomy (PTX) and/or thyroidectomy (THY) with NIFI, 200 with CCD, and 100 with CMOS. Although both NIFI technologies detected >94% of PG, CMOS was superior to CCD. Comparing AF quality, mean pixel intensity of PG compared with the background was higher with CMOS compared with CCD. When comparing PG detected by NIFI before visual identification by a surgeon, both CCD and CMOS had similar results (25% vs. 22%; p = .3). CONCLUSION: Both NIFI cameras were excellent at detecting PG. Second-generation NIFI (CMOS) displayed higher detection rates and AF intensity. Although surgeons identified majority of PG before NIFI detection, 25% of PG were identified with NIFI first, suggesting future advancements of this technology may expand its applications during parathyroid/thyroid operations.