Lymph node imaging for thyroid cancer.

Cervical lymph nodes (LNs) in the central (level VI) and lateral (levels II-V) compartments of the neck are the most common sites of locoregional metastases associated with thyroid cancer. Prophylactic nodal dissections are uncommon in modern thyroid surgery and are not routinely performed due to concern for increased morbidity and do not offer improved survival. Therefore, a selective approach for LN dissections is increasingly important. Preoperatively, this is most frequently assessed with cervical ultrasound (US). Contrast-enhanced computed tomography (CT) of the neck can also be used for preoperative assessment. Both US and CT imaging can be used to characterise LNs in levels II-VI and their risk of malignancy based on size, morphology, and growth. US-guided fine-needle aspiration of equivocal LN with thyroglobulin (Tg) washout can also determine if a LN harbours malignancy. For postoperative surveillance after total thyroidectomy, both US and CT continue to play an important role at 6-12 months intervals. These patients may also benefit from additional biochemical data such as Tg levels in addition to LN and thyroid bed imaging. Thyroid uptake scans may also play a role in LN surveillance postoperatively for well-differentiated thyroid carcinoma in certain clinical contexts. Less commonly, positron emitted tomography may play a role, but is typically reserved for patients with aggressive or radioactive iodine refractory disease.

Evaluating Discrimination of ACS-NSQIP Surgical Risk Calculator in Thyroidectomy Patients.

BACKGROUND: The ACS-NSQIP surgical risk calculator (SRC) often guides preoperative counseling, but the rarity of complications in certain populations causes class imbalance, complicating risk prediction. We aimed to compare the performance of the ACS-NSQIP SRC to other classical machine learning algorithms trained on NSQIP data, and to demonstrate challenges and strategies in predicting such rare events. METHODS: Data from the NSQIP thyroidectomy module ys 2016 - 2018 were used to train logistic regression, Ridge regression and Random Forest classifiers for predicting 2 different composite outcomes of surgical risk (systemic and thyroidectomy-specific). We implemented techniques to address imbalanced class sizes and reported the area under the receiver operating characteristic (AUC) for each classifier including the ACS-NSQIP SRC, along with sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) at a 5% - 15% predicted risk threshold. RESULTS: Of 18,078 included patients, 405 (2.24%) patients suffered systemic complications and 1670 (9.24%) thyroidectomy-specific complications. Logistic regression performed best for predicting systemic complication risk (AUC 0.723 [0.658 - 0.778]); Random Forest with RUSBoost performed best for predicting thyroidectomy-specific complication risk (0.702; 0.674 - 0.726). The addition of optimizations for class imbalance improved performance for all classifiers. CONCLUSIONS: Complications are rare after thyroidectomy even when considered as composite outcomes, and class imbalance poses a challenge in surgical risk prediction. Using the SRC as a classifier where intervention occurs above a certain validated threshold, rather than citing the numeric estimates of complication risk, should be considered in low-risk patients.

Time Heals Most Wounds - Perceptions of Thyroidectomy Scars in Patients With Thyroid Cancer.

BACKGROUND: Patients understandably have concerns about thyroidectomy scars. This study aimed to characterize patients' perceptions of their thyroidectomy scar before and up to 1-y after surgery. METHODS: Patients with papillary thyroid cancer (n = 83) completed semi-structured interviews before and at 2-wks, 6-Wk, 6-mo, and 1-y post-thyroidectomy. Interviews probed about scar concerns and appearance. Content analysis was used to identify themes. RESULTS: The majority of participants did not express concerns about scar appearance. When expressed, preoperative concerns often stemmed from previous surgery experiences or unease with neck incisions. Postoperatively, concerns about scar appearance decreased over time throughout the healing period with most patients being satisfied with their scar appearance by 6-mo after surgery. CONCLUSIONS: Patients with papillary thyroid cancer express few concerns about scar thyroidectomy appearance. Surgeons can reassure patients who have preoperative concerns that most patients are satisfied with their scar appearance by 6-mo after surgery.

Online Information for Treatment for Low-Risk Thyroid Cancer: Assessment of Timeliness, Content, Quality, and Readability.

The Internet is a key source of health information, yet little is known about resources for low-risk thyroid cancer treatment. We examined the timeliness, content, quality, readability, and reference to the 2015 American Thyroid Association (ATA) guidelines in websites about thyroid cancer treatment. We identified the top 60 websites using Google, Bing, and Yahoo for "thyroid cancer." Timeliness and content analysis identified updates in the ATA guidelines (n = 6) and engaged a group of stakeholders to develop essential items (n = 29) for making treatment decisions. Website quality and readability analysis used 4 validated measures: DISCERN; Journal of the American Medical Association (JAMA) benchmark criteria; Health on the Net Foundation certification (HONcode); and the Suitability Assessment of Materials (SAM) method. Of the 60 websites, 22 were unique and investigated. Content analysis revealed zero websites contained all updates from the ATA guidelines and rarely (18.2%) referenced them. Only 31.8% discussed all 3 treatment options: total thyroidectomy, lobectomy, and active surveillance. Websites discussed 28.2% of the 29 essential items for making treatment decisions. Quality analysis with DISCERN showed "fair" scores overall. Only 29.9% of the JAMA benchmarks were satisfied, and 40.9% were HONcode certified. Readability analysis with the SAM method found adequate readability, yet 90.9% scored unsuitable in literacy demand. The overall timeliness, content, quality, and readability of websites about low-risk thyroid cancer treatment is fair and needs improvement. Most websites lack updates from the 2015 ATA guidelines and information about treatment options that are necessary to make informed decisions.

A Randomized Controlled Clinical Trial: No Clear Benefit to Prophylactic Central Neck Dissection in Patients With Clinically Node Negative Papillary Thyroid Cancer.

OBJECTIVE: The aim of this prospective randomized-controlled trial was to evaluate the risks/benefits of prophylactic central neck dissection (pCND) in patients with clinically node negative (cN0) papillary thyroid cancer (PTC). BACKGROUND: Microscopic lymph node involvement in patients with PTC is common, but the optimal management is unclear. METHODS: Sixty patients with cN0 PTC were randomized to a total thyroidectomy (TT) or a TT+ pCND. All patients received postoperative laryngoscopies and standardized radioiodine treatment. Thyroglobulin (Tg) levels and/or neck ultrasounds were performed at 6 weeks, 6 months, and 1 year. RESULTS: Tumors averaged 2.2 ±â€Š0.2 cm and 11.9% had extra-thyroidal extension. Thirty patients underwent a pCND and 27.6% had positive nodes (all ≤6 mm). Rates of postoperative PTH < 10 (33.3% vs 24.1%, P = 0.57) and transient nerve dysfunction (13.3% vs 10.3%, P = 1.00) were not significantly different between groups. Six weeks after surgery, both TT and TT + pCND were equally likely to achieve a Tg < 0.2 (54.5% vs 66.7%, P = 0.54) and/or a stimulated Tg (sTg) <1 (59.3% vs 64.0%, P = 0.78). At 1 year, rates of Tg < 0.2 (88.9% vs 90.0%, P = 1.00) and sTg < 1 (93.8% vs 92.3%, P = 1.00) remained similar between groups. Neck ultrasounds at 1 year were equally likely to be read as normal (85.7% in TT vs 85.1% in pCND, P = 1.00). CONCLUSIONS: cN0 PTC patients treated either with TT or TT + pCND had similar complication rates after surgery. Although microscopic nodes were discovered in 27.6% of pCND patients, oncologic outcomes were comparable at 1 year.

Assessing American Thyroid Association Guidelines for Total Thyroidectomy in Graves' Disease.

BACKGROUND: The American Thyroid Association (ATA) issued specific preoperative preparatory guidelines for patients undergoing thyroidectomy for treatment of Graves' disease. Our goal is to determine if compliance with these guidelines is associated with better outcomes. METHODS: A retrospective review of a prospectively maintained database identified 228 patients with Graves' disease who underwent total thyroidectomy between August 2007 and May 2015. Patients treated in compliance with ATA guidelines were compared with those not in full compliance with the current preparatory guidelines. RESULTS: At the time of surgery, 52% of all patients followed ATA guidelines. Patients who were prepped per ATA guidelines had fewer episodes of intraoperative tachycardia (0.3 versus 4.5, P = 0.04) but had no difference in peak systolic blood pressure or in number of episodes of systolic blood pressure > 180 mmHg. ATA prepped and nonprepped patients had similar mean operating room time and length of stay. ATA prepped and nonprepped patients had similar complication rates, including transient hypocalcemia (30.4% versus 25.5%, P = 0.45), prolonged hypoparathyroidism (0.98% versus 4.3%, P = 0.15), hoarse voice (10.8% versus 7.5%, P = 0.42), permanent recurrent laryngeal nerve paralysis (2.9% versus 2.1%, P = 0.71), and hematoma (2.9% versus 0%, P = 0.09). CONCLUSIONS: Our data suggest that compliance with ATA guidelines for thyroidectomy preparation is not essential for a successful surgical outcome. Although preparation per the guidelines decreased the frequency of intraoperative tachycardia, it did not impact intraoperative hypertension, operating room time, or postoperative complications.

Outcomes after completion thyroidectomy versus total thyroidectomy for differentiated thyroid cancer: A single-center experience.

BACKGROUND: Thyroid cancer diagnoses are often discovered after diagnostic thyroid lobectomy. Completion thyroidectomy (CT) may be indicated for intermediate or high-risk tumors to facilitate surveillance and/or adjuvant treatment. The completeness of thyroid resection and the safety of CT compared to total thyroidectomy (TT) is unclear. We assessed outcomes after TT or CT to determine completeness of resection and risk of complications. METHODS: Patients undergoing TT or CT between 2000 and 2018 were retrospectively reviewed. Pathology, unstimulated thyroglobulin (uTg), parathyroid hormone (PTH), rates of hematoma, and recurrent laryngeal nerve (RLN) injury were compared. RESULTS: Differentiated thyroid cancer (DTC) was identified in 954 patients undergoing TT and 142 patients undergoing CT. Postoperative uTg at 6 months was not different between TT and CT, 0.2 vs 0.2 ng/mL, P = .37. Transient hypoparathyroidism with immediate postoperative PTH less than 10 was more common after TT, 14.3 vs 6.0% (P = .009). No differences were noted regarding postoperative hematoma, transient RLN injury, permanent hypoparathyroidism, and permanent RLN injury. CONCLUSIONS: If CT is required for DTC, a complete resection, as assessed by postoperative uTg, can be achieved. Furthermore, CT is significantly less likely to result in transient hypoparathyroidism and poses no additional risk of RLN injury, hematoma, or permanent hypoparathyroidism.

Hormonal Evaluation of Incidental Adrenal Masses: The Exception, Not the Rule.

BACKGROUND: Incidental adrenal masses (IAMs) occur in approximately 4% of patients undergoing abdominal CT scans for any indication. Hormonal evaluation is recommended for all IAMs. The purpose of this study was to identify the rate of IAMs in a screening population and to determine the adequacy of endocrine evaluation of newly identified IAMs based on established guidelines. METHODS: This was a retrospective analysis of 6913 patients undergoing a non-contrast screening CT colonography at a single academic medical center between June 2004 and July 2012. RESULTS: The prevalence of IAMs in this asymptomatic screening population was 2.1% (n = 148). Of those patients, 8.8% (n = 11) underwent some form of hormonal evaluation and only 6.4% (n = 8) patients had a "complete" workup. Cortisol, metanephrines, and an aldosterone-renin ratio were evaluated in 8.0%, 7.2%, and 4.0% of patients, respectively. Of the patients (n = 11) who underwent hormonal evaluation, 27.3% had functional masses and 36.4% underwent surgery. Of those who did not have hormonal evaluation, 42.1% (n = 48) had comorbidities that should have prompted hormonal evaluation based on established guidelines. Hormonal evaluation was not performed in 89.4% of patients with hypertension and 21.1% of patients with diabetes. 88.9% of patients on three or more antihypertensive medications did not undergo any hormonal evaluation. CONCLUSIONS: Compliance with IAM workup guidelines is poor, which may result in missed diagnosis of functional adrenal masses. Establishment of a robust protocol and education on appropriate workup for IAMs is necessary for adequate hormonal evaluation.

Utility of Early Postoperative Unstimulated Thyroglobulin in Influencing Decision Making in Patients with Papillary Thyroid Carcinoma.

BACKGROUND: Serum thyroglobulin is used to screen for disease persistence or recurrence of papillary thyroid carcinoma (PTC). We sought to assess the utility of early postoperative unstimulated thyroglobulin levels (uTg) as a decision-making tool to guide the use of radioactive iodine (RAI) in PTC patients. METHODS: We performed a retrospective analysis of a prospectively maintained database of patients surgically treated for PTC from 2015 to 2017. We analyzed uTg approximately 6 weeks postoperatively. Patients undergoing total thyroidectomy or completion thyroidectomy were included in the study, and patients were analyzed according to postoperative uTg and receipt of RAI. RESULTS: A total of 255 patients were analyzed, with 134 patients meeting the inclusion criteria. The median postoperative uTg was 0.3 ng/mL. Overall, 49.3% (66/134) of patients achieved the target uTg of ≤ 0.2 ng/mL at a mean time of 7.9 ± 0.3 weeks postoperatively; 60% (40/66) of patients who achieved uTg ≤ 0.2 ng/mL postoperatively did not receive RAI. A uTg ≤ 0.2 ng/mL was maintained at 6 months in 98.1% of patients, including 100% of patients who received RAI and 96.7% of patients who did not receive RAI (p = 0.8). Of those who did not receive RAI, none demonstrated structural disease recurrence on 6-month ultrasound. Patients with early postoperative uTg > 0.2-2.0 ng/mL showed benefit from RAI, while patients with uTg > 2.0 ng/mL did not achieve the targeted uTg level regardless of receipt of RAI. CONCLUSIONS: Postoperative uTg may be used to guide the use of RAI. Achieving near-undetectable uTg within 6 weeks postoperatively could aid providers in assessing disease burden and minimize RAI use for patients with a low-risk of disease recurrence. Continued follow-up is necessary to accurately determine long-term outcomes.

Identifying Predictors of Prolonged Levothyroxine Dose Adjustment After Thyroidectomy.

BACKGROUND: Levothyroxine (LT4) is one of the most prescribed drugs in the United States; however, many patients started on LT4 after thyroidectomy suffer from symptoms of hyper- or hypo-thyroidism before achieving euthyroidism. This study aims to describe the time required for dose adjustment before achieving euthyroidism and identify predictors of prolonged dose adjustment (PDA+) after thyroidectomy. METHODS: This is a single institution retrospective cohort study of patients who achieved euthyroidism with LT4 therapy between 2008 and 2017 after total or completion thyroidectomy for benign disease. Patients who needed at least three dose adjustments (top quartile) were considered PDA+. Binomial logistic regression was used to identify predictors of PDA+. RESULTS: The 605 patients in this study achieved euthyroidism in a median of 116 d (standard deviation 124.9) and one dose adjustment (standard deviation 1.3). The 508 PDA- patients achieved euthyroidism in a median of 101 d and one dose adjustment. The 97 PDA+ patients achieved euthyroidism in a median of 271 d and three dose adjustments. Iron supplementation (odds ratio = 4.4, 95% confidence interval = 1.4-13.5, P = 0.010) and multivitamin with mineral supplementation (odds ratio = 2.4, 95% confidence interval = 1.3-4.3, P = 0.004) were independently associated with PDA+. Age, gender, preoperative thyroid disease, and comorbidities did not independently predict PDA+. CONCLUSIONS: After thyroidectomy, achieving euthyroidism can take nearly 4 mo. Iron and mineral supplementation are associated with PDA+. This information can inform the preoperative counseling of patients and suggests that this may expedite achieving euthyroidism.

A Qualitative Analysis of the Preoperative Needs of Patients With Papillary Thyroid Cancer.

BACKGROUND: Thyroid cancer patients report unmet needs after diagnosis. However, little is known about their specific needs. Therefore, we sought to characterize the needs of patients with thyroid cancer before undergoing surgery. MATERIAL AND METHODS: We conducted semistructured interviews with 32 patients with papillary thyroid cancer after their preoperative surgical consultation. Data were analyzed using thematic content analysis. RESULTS: The central need of patients with thyroid cancer was a strong patient-surgeon relationship characterized by informational and emotional support, and respect for the patient as a person. Patients preferred disease- and treatment-related information to be individualized and to take into account aspects of their daily life. They wanted adequate time for asking questions with thoughtful answers tailored to their case. Patients additionally desired emotional support from the surgeon characterized by empathy and validation of their cancer experience. They particularly wanted surgeons to address their fears and anxiety. Patients also highly valued the surgeons' ability to see beyond their disease and acknowledge them as a unique person with respect to their occupation, psychosocial state, and other individual characteristics. When surgeons met patients' needs, they felt reassured, comfortable with their cancer diagnosis, and prepared for treatment. Suboptimal support increased patients' anxiety particularly when they felt the surgeon minimized their concerns. CONCLUSIONS: Preoperatively, patients with thyroid cancer desire a strong patient-surgeon relationship. They rely on the surgeon to provide adequate informational and emotional support and respect them as individuals. In turn, patients feel reassured and prepared for treatment.

Optimizing Levothyroxine Dose Adjustment After Thyroidectomy With a Decision Tree.

BACKGROUND: After thyroidectomy, patients require Levothyroxine (LT4). It may take years of dose adjustments to achieve euthyroidism. During this time, patients encounter undesirable symptoms associated with hypo- or hyper-thyroidism. Currently, providers adjust LT4 dose by clinical estimation, and no algorithm exists. The objective of this study was to build a decision tree that could estimate LT4 dose adjustments and reduce the time to euthyroidism. METHODS: We performed a retrospective cohort analysis on 320 patients who underwent total or completion thyroidectomy at our institution. All patients required one or more LT4 dose adjustments from their initial postoperative dose before attaining euthyroidism. Using the Classification and Regression Tree algorithm, we built various decision trees from patient characteristics, estimating the dose adjustment to reach euthyroidism. RESULTS: The most accurate decision tree used thyroid-stimulating hormone values at first dose adjustment (mean absolute error = 13.0 µg). In comparison, the expert provider and naïve system had a mean absolute error of 11.7 µg and 17.2 µg, respectively. In the evaluation dataset, the decision tree correctly predicted the dose adjustment within the smallest LT4 dose increment (12.5 µg) 79 of 106 times (75%, confidence interval = 65%-82%). In comparison, expert provider estimation correctly predicted the dose adjustment 76 of 106 times (72%, confidence interval = 62%-80%). CONCLUSIONS: A decision tree predicts the correct LT4 dose adjustment with an accuracy exceeding that of a completely naïve system and comparable to that of an expert provider. It can assist providers inexperienced with LT4 dose adjustment.

Timely Evaluation and Management of Primary Hyperparathyroidism in Patients With Kidney Stones.

BACKGROUND: Nephrolithiasis is a classic, treatable manifestation of primary hyperparathyroidism (PHPT). We examined predictors of kidney stone formation in PHPT patients and determined how efficiently the diagnosis of PHPT is made in patients whose initial presentation is with stones. MATERIALS AND METHODS: We performed a retrospective analysis of surgically treated PHPT patients, comparing 247 patients who were kidney stone formers and 1047 patients with no kidney stones. We also analyzed 51 stone-forming patients whose stone evaluation and treatment were completed within our health system before PHPT diagnosis. RESULTS: Stone-forming patients had higher 24-h urinary calcium (342 versus 304 mg/d, P = 0.005), higher alkaline phosphatase (92 versus 85 IU/L, P = 0.012), and were more likely to be normocalcemic (26.6% versus 16.9%, P = 0.001). Surprisingly, 47.3% of stone formers had normal urinary calcium levels (<300 mg/d). Of the 51 stone-forming patients treated at our institution, serum calcium was measured within 6 mo of stone diagnosis in 37 (72.5%) patients. Only 16 (31.4%) of these patients had elevated calcium levels, and only 10 (62.5%) of these 16 had a serum parathyroid hormone ordered within the following 3 mo. These patients had a significantly shorter time from their first stone to surgical treatment compared to other patients (median 8.5 versus 49.1 mo, P = 0.001). CONCLUSIONS: Elevated serum and urinary calcium levels are not evaluated in the majority of PHPT patients presenting with kidney stones. In nephrolithiasis patients, provider consideration of PHPT with prompt serum calcium and parathyroid hormone evaluation significantly reduces time to treatment.

Survival in patients with medullary thyroid cancer after less than the recommended initial operation.

BACKGROUND AND OBJECTIVES: We aimed to evaluate the disease specific-survival (DSS) of patients with Medullary Thyroid Cancer (MTC) confined to the central neck based on the extent of the initial operation. METHODS: This retrospective review of patients with MTC from the SEER registry from 2004 to 2012 excluded patients with lateral neck involvement or distant metastases. RESULTS: The cohort (n = 766) included 85(11%) less than total thyroidectomies (TT), 212(28%) TT alone, and 469(61%) TT with lymph node excision. Mean tumor size was similar (2.2cm for

Selective Versus Non-selective α-Blockade Prior to Laparoscopic Adrenalectomy for Pheochromocytoma.

BACKGROUND: The optimal preoperative α-blockade strategy is debated for patients undergoing laparoscopic adrenalectomy for pheochromocytomas. We evaluated the impact of selective versus non-selective α-blockade on intraoperative hemodynamics and postoperative outcomes. METHODS: We identified patients having laparoscopic adrenalectomy for pheochromocytomas from 2001 to 2015. As a marker of overall intraoperative hemodynamics, we combined systolic blood pressure (SBP) > 200, SBP < 80, SBP < 80 and >200, pulse > 120, vasopressor infusion, and vasodilator infusion into a single variable. Similarly, the combination of vasopressor infusion in the post-anesthesia care unit (PACU) and the need for intensive care unit (ICU) admission provided an overview of postoperative support. RESULTS: We identified 52 patients undergoing unilateral laparoscopic adrenalectomy for pheochromocytoma. Selective α-blockade (i.e. doxazosin) was performed in 35 % (n = 18) of patients, and non-selective blockade with phenoxybenzamine was performed in 65 % (n = 34) of patients. Demographics and tumor characteristics were similar between groups. Patients blocked selectively were more likely to have an SBP < 80 (67 %) than those blocked with phenoxybenzamine (35 %) (p = 0.03), but we found no significant difference in overall intraoperative hemodynamics between patients blocked selectively and non-selectively (p = 0.09). However, postoperatively, patients blocked selectively were more likely to require additional support with vasopressor infusions in the PACU or ICU admission (p = 0.02). Hospital stay and complication rates were similar. CONCLUSION: Laparoscopic adrenalectomy for pheochromocytoma is safe regardless of the preoperative α-blockade strategy employed, but patients blocked selectively may have a higher incidence of transient hypotension during surgery and a greater need for postoperative support. These differences did not result in longer hospital stay or increased complications.

Optimizing Outpatient Pain Management After Thyroid and Parathyroid Surgery: A Two-Institution Experience.

BACKGROUND: Thyroidectomy and parathyroidectomy are the most commonly performed endocrine operations, and are increasingly being completed on a same-day basis; however, few data exist regarding the outpatient postoperative pain requirement of these patients. We aimed to describe the outpatient narcotic medication needs for patients undergoing thyroid and parathyroid surgery, and to identify predictors of higher requirement. METHOD: We examined patients undergoing thyroid and parathyroid surgery at two large academic institutions from 1 January-30 May 2014. Prospective data were collected on pain scores and the oral morphine equivalents (OMEQs) taken by these patients by their postoperative visit. RESULTS: Overall, 313 adult patients underwent thyroidectomy or parathyroidectomy during the study period; 83% of patients took ten or fewer OMEQs, and 93% took 20 or fewer OMEQs. Patients who took more than ten OMEQs were younger (p < 0.001) and reported significantly higher overall mean pain scores at their postoperative visit (p < 0.001) than patients who took fewer than ten OMEQs. A multivariate model was constructed on pre- and intraoperative factors that may predict use of more than ten OMEQs postoperatively. Age <45 years (p = 0.002), previous narcotic use (p = 0.037), and whether parathyroid or thyroid surgery was performed (p = 0.003) independently predicted the use of more than ten OMEQs after surgery. A subgroup analysis was then performed on thyroidectomy-only patients. CONCLUSION: Overall, 93% of patients undergoing thyroidectomy and parathyroidectomy require 20 or fewer OMEQs by their postoperative visit. We therefore recommend these patients be discharged with 20 OMEQs, both to minimize waste and increase patient safety.

Papillary thyroid microcarcinoma: decision-making, extent of surgery, and outcomes.

BACKGROUND: The optimal extent of surgery for patients with papillary thyroid microcarcinoma (PTMC), tumors ≤1 cm, is controversial because survival is excellent regardless of approach. The objective of this study was to investigate patient and surgeon decision-making about the extent of surgery for PTMC. MATERIALS AND METHODS: We conducted a retrospective review of thyroid cancer patients operated on at a single institution from 2008-2016. To examine decision-making about the extent of surgery, we performed a discourse analysis on all available documentation looking for patient or surgeon reasons. RESULTS: Of the 853 thyroid cancer patients, 125 (14.7%) had a PTMC as their largest tumor. Overall, 27.2% of the PTMC patients underwent a thyroid lobectomy, whereas 72.8% had a total thyroidectomy (TT). Of those patients diagnosed with PTMC preoperatively (19/125), a significantly higher proportion underwent a TT (94.7% versus 68.9%, P = 0.02). In all cases, documentation indicated that these preoperatively diagnosed patients followed the surgeon's recommendation regarding the extent of surgery. Reasons surgeons cited for recommending a TT included patient and disease factors (34.6%), belief that TT was the standard treatment (21.7%), ease of follow-up (8.7%), and referring provider preference (4.3%). Of the 19 patients diagnosed preoperatively, four (21.1%) patients had a complication, one (5.3%) of which was permanent and potentially avoidable with less extensive surgery. CONCLUSIONS: These data suggest that surgeons drive decision-making about the extent of thyroidectomy in patients with preoperatively diagnosed PTMC. With recent guidelines recommending thyroid lobectomy, closer examination of decision-making is needed to ensure that patients make well-informed, preference-based decisions.

Machine learning to identify multigland disease in primary hyperparathyroidism.

BACKGROUND: 20%-25% of patients with primary hyperparathyroidism will have multigland disease (MGD). Preoperatative imaging can be inaccurate or unnecessary in MGD. Identification of MGD could direct the need for imaging and inform operative approach. The purpose of this study is to use machine learning (ML) methods to predict MGD. METHODS: Retrospective review of a prospective database. The ML platform, Waikato Environment for Knowledge Analysis, was used, and we selected models for (1) overall accuracy and (2) preferential identification of MGD. A review of imaging studies was performed on a cohort predicted to have MGD. RESULTS: 2010 patients met inclusion criteria: 1532 patients had single adenoma (SA) (76%) and 478 had MGD (24%). After testing many algorithms, we selected two different models for potential integration as clinical decision-support tools. The best overall accuracy was achieved using a boosted tree classifier, RandomTree: 94.1% accuracy; 94.1% sensitivity, 83.8% specificity, 94.1% positive predictive value, and 0.984 area under the receiver operating characteristics curve. To maximize positive predictive value of MGD prediction, a rule-based classifier, JRip, with cost-sensitive learning was used and achieved 100% positive predictive value for MGD. Imaging reviewed from the cohort of 34 patients predicted to have MGD by the cost-sensitive model revealed 39 total studies performed: 28 sestamibi scans and 11 ultrasounds. Only 8 (29%) sestamibi scans and 4 (36%) ultrasounds were correct. CONCLUSIONS: ML methods can help distinguish MGD early in the clinical evaluation of primary hyperparathyroidism, guiding further workup and surgical planning.

Encapsulated follicular variant of papillary thyroid cancer: are these tumors really benign?

BACKGROUND: Recent studies suggest that the encapsulated form of follicular variant of papillary thyroid cancer (eFVPTC) behaves more similarly to benign lesions and can be treated with thyroid lobectomy alone instead of total thyroidectomy. To distinguish aggressive cancers from more benign lesions more clearly, the objective of this study was to determine if the eFVPTC behaves less aggressively than the nonencapsulated variant (neFVPTC). METHODS: A prospectively collected endocrine surgery database in our institution was reviewed for all patients with FVPTC on surgical pathology from 1999 to 2012. Samples were rereviewed to determine if the tumor was eFVPTC or neFVPTC, which were correlated with patient outcomes. RESULTS: Of the 68 patients, 59 (87%) had eFVPTC and 9 (13%) had neFVPTC. The mean age was 48 y and 63% were female. Fifty-four of 64 patients (84%) who had a total thyroidectomy received radioactive iodine. The eFVPTC group had lower rates of cervical LN involvement (5% versus 22%, P = 0.2504). The median follow-up time was 3 y (0-13 y) and only two patients had recurrence, one with eFVPTC and one with neFVPTC. None of the patients had distant metastasis or died of their disease. CONCLUSIONS: eFVPTCs appear to have a lower rate of cervical lymph node metastases compared with neFVPTCs, but recurrent disease may be seen in both subtypes. These findings suggest eFVPTC can be managed more conservatively.

Assessing the risk of hypercalcemic crisis in patients with primary hyperparathyroidism.

BACKGROUND: Hypercalcemic crisis (HC) is a potentially life-threatening manifestation of primary hyperparathyroidism (PHPT). This study aimed to identify patients with PHPT at greatest risk for developing HC. METHODS: This retrospective cohort study included patients with a preoperative calcium of at least 12 mg/dL undergoing initial parathyroidectomy for PHPT from 11/2000 to 03/2016. We compared those with HC, defined as needing hospitalization for hypercalcemia, to those without HC. RESULTS: The study cohort included 29 patients (15.8%) with HC and 154 patients (84.2%) without HC. Demographics and comorbidities were similar between the groups. Patients with HC were more likely to have a history of kidney stones (31.0% versus 14.3%, P = 0.039), higher preoperative calcium (median 13.8 versus 12.4 mg/dL, P < 0.001), higher parathyroid hormone (PTH) (median 318 versus 160 pg/mL, P = 0.001), and lower vitamin D (median 16 versus 26 ng/mL, P < 0.001) than patients without HC. Cure rates with parathyroidectomy were similar, but nearly double the proportion of patients with HC had multigland disease (24.1 versus 12.3%, P = 0.12). In multivariable analysis, higher preoperative calcium (odds ratio [OR] 1.7, 95% confidence interval [CI] 1.1-2.5), higher PTH (OR 1.0, 95% CI 1.0-1.0), and kidney stones (OR 3.0, 95% CI 1.1-8.2) were independently associated with HC. A Classification and Regression Tree revealed that HC developed in 91% of patients with a calcium ≥13.25 mg/dL and a Charlson Comorbidity Index ≥4. CONCLUSIONS: These data indicate that calcium, PTH, and kidney stones are important in predicting who are at greatest risk of HC. The Classification and Regression Tree can further help stratify risk for developing HC and allow surgeons to expedite parathyroidectomy accordingly.