The Role of Demographic and Clinical Factors in Germline Mutation Testing for Patients with Primary Hyperparathyroidism.

INTRODUCTION: Guidelines recommending genetic counseling in primary hyperparathyroidism (PHPT) vary. To further delineate current recommendations, this study examined genetic counseling referral patterns and rates of mutations in surgical patients with PHPT. PATIENTS AND METHODS: A single-institution review was performed of adult patients who underwent parathyroidectomy for presumed sporadic PHPT. Genetic testing indications of hypercalcemia onset ≤ 40 years, multigland disease (MGD), family history (FHx) of PHPT, or other clinical indications suspicious for a PHPT-related endocrinopathy were examined by demographics and mutation detection rates. RESULTS: Genetic counseling was performed in 237 (37.9%) of 625 patients. Counseling was discussed but not performed in 121 (19.4%) patients. No evidence was noted of genetic referral discussion in the remaining 267 (42.7%). Of these groups, patients who received genetic counseling were youngest, p < 0.001 [median age 55.3 (IQR 43.2, 66.7) years]. The majority of patients with indications of age ≤ 40 years (65.7%), FHx (78.0%), and other clinical indications (70.7%) underwent genetic counseling, while most with MGD (57.0%) did not. Eight mutations were detected in 227 patients (3.5%). Mutations included: MEN1 (n = 2), CDC-73 (n = 4), and CASR (n = 2). Detection was most common in patients with FHx (4/71, 5.6%), then age ≤ 40 years (3/66, 4.5%), and other clinical indications (3/80, 3.8%). No mutations were identified in 48 patients tested solely for MGD. CONCLUSIONS: Most patients with onset of hypercalcemia age ≤ 40 years, positive FHx, or other clinical concerns underwent genetic counseling, while most with MGD did not. As no germline mutations were identified in patients with MGD alone, further investigation of MGD as a sole indication for genetic counseling may be warranted.

Hypercalcemia and Postoperative Joint Symptoms Following Joint Replacement for Osteoarthritis.

INTRODUCTION: Calcium metabolism dysregulation in the setting of primary hyperparathyroidism (PHPT) mediated chondrocalcinosis is implicated in joint pain, a key element in the decision regarding arthroplasty for osteoarthritis. The relationship between hypercalcemia and joint pain, before and after arthroplasty, is unknown. This study investigates the association between preoperative hypercalcemia and postoperative outcomes following total knee (TKA) and total hip arthroplasty (THA). METHODS: A retrospective chart review was conducted on patients who underwent initial elective THA or TKA. Patients with a preoperative serum calcium >10.2 mg/dL were matched (1:2-1:4) with nearest neighbor to patients with normal serum calcium. THA and TKA functional outcomes were measured at baseline and 1-y postoperatively using patient-reported Hip Disability and Osteoarthritis Outcome Scores and Knee Injury and Osteoarthritis Outcome Scores surveys. Postoperative complications, readmissions, length of stay, and functional outcome scores were compared. RESULTS: Four hundred ninety-five patients (106 hypercalcemic cases, 389 matched controls) were included. Of these, 223 patients underwent THA (46 cases; 177 controls) and 272 patients underwent TKA (61 cases; 211 controls). There were no differences in Hip Disability and Osteoarthritis Outcome Scores and Knee Injury and Osteoarthritis Outcome Scores scores, postoperative complications, readmissions, or length of stay between cases and controls. Only 19/106 (18%) hypercalcemic patients had a parathyroid hormone (PTH); of these, 9 (47%) had possible PHPT (PTH > 40). CONCLUSIONS: Patients with hypercalcemia undergoing arthroplasty have similar functional and postoperative outcomes as normocalcemic patients. As PTH was obtained in <20% of hypercalcemic cases and 50% had possible PHPT, we recommend that hypercalcemic patients undergo PHPT workup. Additional investigation is needed to determine the effect of PHPT on arthroplasty outcomes.

Adoption of Robotic Adrenalectomy: A Two-Institution Study of Surgeon Learning Curve.

BACKGROUND: Robotic adrenalectomy is feasible and safe, yet concerns over increased operative times and the learning curve (LC) for proficiency have limited its adoption. This study aimed to assess the LC for robotic adrenalectomy. METHODS: This is a two-institution retrospective review of consecutive unilateral minimally invasive adrenalectomies performed by four high-volume adrenal surgeons between 2007 and 2022. Two surgeons transitioned from laparoscopic to robotic adrenalectomy, and two surgeons adopted the approach, with proctoring, after completion of fellowship training without robotic experience. Operative time and complications were analyzed. Multivariable regression was used to identify factors associated with operative time. The number of cases required to overcome the LC was determined using the LC-cumulative-sum (LC-CUSUM) analysis. RESULTS: Of 457 adrenalectomies, 182 (40%) were laparoscopic and 275 (60%) robotic. The robotic approach was associated with shorter median operative time (106 vs 119 min; p = 0.002), fewer complications (6% vs 13%; p = 0.018), and fewer conversions to open adrenalectomy (1% vs 4%; p = 0.030), with no difference between the senior and junior surgeons. On adjusted analysis, factors associated with increased operative time were male sex (p < 0.001), BMI > 30 kg/m2 (p < 0.001), and higher gland weight (p < 0.001). The LC-CUSUM analysis showed proficiency after 8-29 procedures. Compared with the first 10 cases, there was a mean reduction in operative time of 14 min after 10-20 cases, 28 min after 20-30 cases, and 29 min after > 30 cases, regardless of surgeon experience. DISCUSSION: With dedicated teams and proctoring, robotic adrenalectomy can be safely adopted at high-volume centers with a minimal LC.

Surgical treatment of adrenal tumors during pregnancy.

While most adrenal tumors are identified incidentally and are non-functional, hormone-secreting tumors can cause morbidity and mortality. Hemodynamic lability and hypertension in pregnancy are associated with worse maternal and fetal outcomes. Achieving a diagnosis of hormone excess due to adrenal tumors can be clinically more difficult in the gravid patient due to normal physiologic alterations in hormones and symptoms related to pregnancy. This review focuses on some nuances of the diagnostic work-up, perioperative care, and surgical management of adrenally-mediated cortisol excess, primary aldosteronism, and pheochromocytoma and paraganglioma in the pregnant patient.

Patterns of Unnecessary Insurer Prior Authorization Denials in a Complex Surgical Oncology Practice.

INTRODUCTION: Insurance prior authorization (PA) is a determination of need, required by a health insurer for an ordered test/procedure. If the test/procedure is denied, a peer-to-peer (P2P) discussion between ordering provider and payer is used to appeal the decision. The objective of this study was to measure the number and patterns of unnecessary PA denials. METHODS: This was a retrospective review at a quaternary cancer center from October 2021 to March 2022. Included were all patients with outpatient imaging orders for surgical planning or surveillance of gastrointestinal, endocrine, or skin cancer. Primary outcome was unnecessary initial denial (UID) defined as an order that required preauthorization, was initially denied by the insurer, and subsequently overturned by P2P. RESULTS: Nine hundred fifty seven orders were placed and 419 required PA (44%). Of tests requiring authorization, 55/419 (13.1%) were denied. Variability in the likelihood of initial denial was seen across insurers, ranging from 0% to 57%. Following P2P, 32/55 were overturned (58.2% UID). The insurers most likely to have a UID were Aetna (100%), Anthem (77.8%), and Cigna (50.0%). UID was most common for gastrointestinal (58.9%) and endocrine (58.3%) cancers. Average P2P was 33.5 min (interquartile range 28-40). CONCLUSIONS: The majority of imaging studies initially denied were overturned after P2P. If all UIDs were eliminated, this would represent 108 less P2P discussions with an estimated time-savings of 60.3 h annually within a high-volume surgical oncology practice. Combined personnel costs to the health systems and stress on patients with cancer due to image-associated PAs and P2P appear hard to justify.

Survival After Adrenalectomy for Metastatic Lung Cancer.

BACKGROUND: Adrenal metastasectomy is associated with increased survival in non-small cell lung cancer (NSCLC) with isolated adrenal metastases. Although clinical use of adrenal metastasectomy has expanded, indications remain poorly defined. The aim of this study was to evaluate the clinical benefit of adrenal metastasectomy for all lung cancer subtypes. PATIENTS AND METHODS: We performed a retrospective cohort study of patients who underwent adrenal metastasectomy for metastatic lung cancer at six institutions between 2001 and 2015. The primary outcomes were disease-free survival (DFS) and overall survival (OS). Cox proportional hazards regressions and Kaplan-Meier survival analysis were performed. RESULTS: For 122 patients, the mean age was 60.5 years and 49.2% were female. Median time to detection of the metastasis was 11 months, and 41.8% were ipsilateral to the primary lung cancer. Median DFS was 40 months (1 year: 64.8%; 5 year: 42.9%). Factors associated with longer DFS included primary tumor resection [hazard ratio (HR): 0.001; p = 0.005], longer time to adrenal metastasis (HR: 0.94; p = 0.005), and ipsilateral metastases (HR: 0.13; p = 0.004). Shorter DFS corresponded with older age (HR: 1.11; p = 0.01), R1 resection (HR: 8.94; p = 0.01), adjuvant radiation (HR: 9.45; p = 0.02), and open adrenal metastasectomy (HR: 10.0; p = 0.03). Median OS was 47 months (1 year: 80.2%; 5 year: 35.2%). Longer OS was associated with ipsilateral metastasis (HR: 0.55; p = 0.02) and adjuvant chemotherapy (HR: 0.35; p = 0.02). Shorter OS was associated with extra-adrenal metastases at adrenalectomy (HR: 3.52; p = 0.007), small cell histology (HR: 15.0; p = 0.04), and lung radiation (HR: 3.37; p = 0.002). DISCUSSION: Durable survival was observed in patients undergoing adrenal metastasectomy and should be considered for isolated adrenal metastases of NSCLC. Small cell histology and extra-adrenal metastases are relative contraindications to adrenal metastasectomy.

The Clinical Utility of Preoperative Thyroglobulin for Surgical Decision Making in Thyroid Disease.

BACKGROUND: Serum thyroglobulin (Tg) levels are used to monitor for differentiated thyroid cancer (DTC) recurrence and have been correlated with posttreatment disease burden. The clinical significance of Tg in the preoperative setting to predict the risk of DTC is unclear. Our aim is to examine the clinical utility of preoperative Tg levels in those undergoing thyroidectomies for DTC or benign disease. MATERIALS AND METHODS: From a prospectively collected database, we identified 385 patients who underwent thyroidectomy from 01/14 to 12/19 and had preoperative Tg levels available. Preoperative Tg levels were compared by preoperative indication for surgery, Bethesda category of biopsied nodules, presence of DTC on surgical pathology, and number of metastatic lymph nodes. RESULTS: There was no difference in mean preoperative Tg level when comparing indication for surgery (P = 0.2) or Bethesda classification (P = 0.4). Mean preoperative Tg levels were lower in patients with DTC (238 ± 77) compared to without DTC (532 ± 97) on final pathology (P = 0.02). Among 188 DTC patients who had lymph nodes removed, there was no significant correlation between the preoperative Tg level and number of positive lymph nodes on final pathology (P = 0.4). CONCLUSIONS: Preoperative serum Tg levels were lower in patients with DTC compared to those with benign disease on final pathology and did not correlate with extent of lymph node metastasis in patients with DTC. We found that serum Tg levels obtained in the preoperative setting do not predict DTC or lymph node metastasis and, therefore, do not inform the extent of surgery for differentiated thyroid cancer.

COVID-19 Positivity Following an In-Person Surgical Society Meeting: A Cross-Sectional Survey Study.

INTRODUCTION: Many surgical societies have recently resumed in-person meetings after canceling or adopting virtual formats during the COVID-19 pandemic. These meetings implemented safety measures to limit viral exposure and ensure participant safety. While there have been anecdotal reports of COVID-19 cases after attendance, no large-scale assessments have been undertaken. The objective of this study was to evaluate COVID-19 positivity following an in-person surgical society meeting. METHODS: An online survey was administered to participants of the Society for Asian Academic Surgeons annual meeting, which was held in Chicago, Illinois in September 2021. This survey assessed vaccination status, in-person versus virtual conference attendance, and COVID-19 testing and symptoms in the 7 d immediately following the meeting. RESULTS: Among the 220 meeting participants, 173 attended in person (79%). There were 91 survey respondents (41% response rate): 67% attending physicians, 27% trainees, and 6% medical students. Nearly, all (99%) reported being fully vaccinated against COVID-19. COVID-19 testing was sought within 7 d of the meeting by 15% of in-person respondents, and all reported negative results. Among individuals who were not tested, no one reported development of symptoms (cough, shortness of breath, fever, new loss of taste/smell, etc.). CONCLUSIONS: Among in-person attendees of a recent surgical society meeting, no one reported positive COVID-19 testing after the meeting, and individuals who were not tested denied developing symptoms. While these results are encouraging, societies hosting meetings should continue to proactively assess the safety of in-person meetings to promptly identify outbreaks and opportunities for improvement.

Wide Variability in Catecholamine Levels From Adrenal Venous Sampling in Primary Aldosteronism.

INTRODUCTION: While adrenal venous sampling (AVS) differentiates between the unilateral and bilateral disease in patients with primary aldosteronism (PA), it is unknown if AVS can determine laterality of pheochromocytoma in patients with bilateral adrenal masses. This study analyzes adrenal vein (AV) epinephrine and norepinephrine levels in nonpheochromocytoma patients to determine the "normal" range. MATERIALS AND METHODS: We reviewed patients who underwent AVS for PA between 2009 and 2019 at a single institution; pheochromocytoma was excluded. Aldosterone, cortisol, epinephrine, and norepinephrine levels were obtained from the inferior vena cava (IVC), left adrenal vein (LAV), and right adrenal vein (RAV). Successful AV cannulation was defined by an AV/IVC cortisol ratio of ≥3:1 or an AV epinephrine level ≥364 pg/mL. Plasma measurements (pg/mL) are median values with interquartile ranges; normal ranges for epinephrine and norepinephrine are 10-200 pg/mL and 80-520 pg/mL, respectively. RESULTS: AVS was performed in 172 patients in 405 AVs (173 LAV and 232 RAV). Median epinephrine levels were IVC = 19 (14 and 34), LAV = 3811 (1870 and 6915), and RAV = 2897 (1500 and 5288). Median norepinephrine levels were IVC = 325 (186 and 479), LAV = 1450 (896 and 2050), and RAV = 786 (436 and 1582). There was a difference between LAV and RAV epinephrine levels (P = 0.024) and between LAV and RAV norepinephrine (P = 0.002) levels. CONCLUSIONS: This extensive experience with AVS demonstrated a wide range of "normal" AV catecholamine levels in patients without pheochromocytoma, which suggests that the utility of AVS to determine disease laterality in patients with pheochromocytoma and bilateral adrenal nodules is likely to be limited.

Proceedings From the Advances in Surgery Channel Diversity, Equity, and Inclusion Series: Lessons Learned From Asian Academic Surgeons.

In this series of talks and the accompanying panel session, leaders from the Society of Asian Academic Surgeons discuss issues faced by Asian Americans and the importance of the role of mentors and allyship in professional development in the advancement of Asian Americans in leadership roles. Barriers, including the model minority myth, are addressed. The heterogeneity of the Asian American population and disparities in healthcare and in research, specifically as relates to Asian Americans, also are examined.

Utility of Epinephrine Levels in Determining Adrenal Vein Cannulation During Adrenal Venous Sampling for Primary Aldosteronism.

OBJECTIVE: In patients with primary aldosteronism, adrenal venous sampling (AVS) is performed to determine the presence of unilateral or bilateral adrenal disease. During AVS, verification of catheter positioning within the left adrenal vein (AV) and the right AV by comparison of AV and inferior vena cava (IVC) cortisol levels can be variable. The objective of this study was to determine the utility of AV epinephrine levels in assessing successful AV cannulation. METHODS: This was a single institution, retrospective review of patients who underwent AVS with cosyntropin stimulation for primary aldosteronism between 2009 and 2018. Successful cannulation of the AV was defined by an AV/IVC cortisol ratio selectivity index (SI) ≥3:1. Epinephrine thresholds to predict catheter placement in the AV were determined using logistic regression. The calculated epinephrine thresholds were compared with previously published thresholds. RESULTS: AVS was performed on 101 consecutive patients and, based on the SI, successful cannulation of the left AV and right AV occurred in 98 (97%) and 91(90%) patients, respectively. The calculated optimal epinephrine threshold to predict AV cannulation was 364 pg/mL (sensitivity, 92.1%; specificity, 94.6%) and the calculated optimal AV/IVC epinephrine ratio threshold was 27.4, (sensitivity, 92.1%; specificity, 91.3%). Among the 14 patients with failed AV cannulation, 3 patients would have been considered to have successful AVS using AV epinephrine levels >364 pg/mL and AV/IVC epinephrine ratio >27.4 thresholds. CONCLUSION: Obtaining 2 right AV samples routinely as well as AV and IVC epinephrine levels during AVS could prevent unnecessary repeat AVS in patients with failed AV cannulation based on cortisol-based SI <3:1.

Variation in parathyroid adenoma size in patients with sporadic, primary hyperparathyroidism: small gland size does not preclude single gland disease.

PURPOSE: Small, abnormal parathyroid glands are usually associated with multigland hyperplasia in patients with primary hyperparathyroidism (pHPT). The purpose of this study was to determine the association between parathyroid adenoma size and biochemical cure rates in patients undergoing single gland parathyroidectomy. METHODS: The study included patients with sporadic pHPT who underwent initial parathyroidectomy and met intraoperative PTH criteria for cure after resection of a single adenoma (SGD). Patients were divided into quartiles (Q1 = smallest) based on gland weight and maximum dimension; cure rates were compared across groups. RESULTS: A single parathyroid adenoma was removed in 517 patients, with a median gland weight of 500 mg (range 50-11890). Median maximum gland dimension was 15 mm (range 5-55). With median follow-up of 28 months (range 6-81), the biochemical cure rate was 97.1%. There was no difference in cure rate by gland weight (Q1 94.6%, Q2 96.9%, Q3 98.4%, Q4 98.5%, p = 0.217) or maximum gland dimension (Q1 95.6%, Q2 97.6%, Q3 97.1%, Q4 98.2%, p = 0.641). When Q1 patients (by gland weight) were divided by quartile, there was no difference in cure rates (93.1% [50-140 mg]; 95.2% [150-190 mg]; 97.1% [200-230 mg]; 93.3% [240-280 mg]; p = 0.665). CONCLUSION: For patients with pHPT who underwent single gland parathyroidectomy, there was no difference in cure rates by gland weight or maximum dimension. These data suggest that the removal of parathyroid adenomas as small as 50 mg with an appropriate decline in ioPTH likely represent single gland disease and additional exploration may not be necessary.

Adrenalectomy for Secondary Malignancy: Patients, Outcomes, and Indications.

OBJECTIVE: The goal of this study was to examine a multi-institutional experience with adrenal metastases to describe survival outcomes and identify subpopulations who benefit from adrenal metastasectomy. BACKGROUND: Adrenalectomy for metastatic disease is well-described, although indications and outcomes are incompletely defined. METHODS: A retrospective cohort study was performed of patients undergoing adrenalectomy for secondary malignancy (2002-2015) at 6 institutions. The primary outcomes were disease free survival (DFS) and overall survival (OS). Analysis methods included Kaplan-Meier and Cox proportional hazards. RESULTS: Of 269 patients, mean age was 60.1 years; 50% were male. The most common primary malignancies were lung (n = 125, 47%), renal cell (n = 38, 14%), melanoma (n = 33, 12%), sarcoma (n = 18, 7%), and colorectal (n = 12, 5%). The median time to detection of adrenal metastasis after initial diagnosis of the primary tumor was 17 months (interquartile range: 6-41). Post-adrenalectomy, the median DFS was 18 months (1-year DFS: 54%, 5-year DFS: 31%). On multivariable analysis, lung primary was associated with longer DFS [hazard ratio (HR): 0.49, P = 0.008). Extra-adrenal oligometastatic disease at initial presentation (HR: 1.84, P = 0.016), larger tumor size (HR: 1.07, P = 0.013), chemotherapy as treatment of the primary tumor (HR: 2.07 P = 0.027) and adjuvant chemotherapy (HR: 1.95, P = 0.009) were associated with shorter DFS. Median OS was 53 months (1-year OS: 83%, 5-year OS: 43%). On multivariable analysis, extra-adrenal oligometastatic disease at adrenalectomy (HR: 1.74, P = 0.031), and incomplete resection of adrenal metastasis (R1 margins; HR: 1.62, P = 0.034; R2 margins; HR: 5.45, P = 0.002) were associated with shorter OS. CONCLUSIONS: Durable survival is observed in patients undergoing adrenal metastasectomy and should be considered for subjects with isolated adrenal metastases.

Cumulative GRAS Score as a Predictor of Survival After Resection for Adrenocortical Carcinoma: Analysis From the U.S. Adrenocortical Carcinoma Database.

BACKGROUND: Adrenocortical carcinoma (ACC) is a rare but aggressive malignancy, and many prognostic factors that influence survival remain undefined. Individually, the GRAS (Grade, Resection status, Age, and Symptoms of hormone hypersecretion) parameters have demonstrated their prognostic value in ACC. This study aimed to assess the value of a cumulative GRAS score as a prognostic indicator after ACC resection. METHODS: A retrospective cohort study of adult patients who underwent surgical resection for ACC between 1993 and 2014 was performed using the United States Adrenocortical Carcinoma Group (US-ACCG) database. A sum GRAS score was calculated for each patient by adding one point each when the criteria were met for tumor grade (Weiss criteria ≥ 3 or Ki67 ≥ 20%), resection status (micro- or macroscopically positive margin), age (≥ 50 years), and preoperative symptoms of hormone hypersecretion (present). Overall survival (OS) and disease-free survival (DFS) by cumulative GRAS score were analyzed by the Kaplan-Meier method and log-rank test. RESULTS: Of the 265 patients in the US-ACCG database, 243 (92%) had sufficient data available to calculate a cumulative GRAS score and were included in this analysis. The 265 patients comprised 23 patients (10%) with a GRAS of 0, 52 patients (21%) with a GRAS of 1, 92 patients (38%) with a GRAS of 2, 63 patients (26%) with a GRAS of 3, and 13 patients (5%) with a GRAS of 4. An increasing GRAS score was associated with shortened OS (p < 0.01) and DFS (p < 0.01) after index resection. CONCLUSION: In this retrospective analysis, the cumulative GRAS score effectively stratified OS and DFS after index resection for ACC. Further prospective analysis is required to validate the cumulative GRAS score as a prognostic indicator for clinical use.

Update on Pheochromocytoma and Paraganglioma from the SSO Endocrine/Head and Neck Disease-Site Work Group. Part 1 of 2: Advances in Pathogenesis and Diagnosis of Pheochromocytoma and Paraganglioma.

This first part of a two-part review of pheochromocytoma and paragangliomas (PPGLs) addresses clinical presentation, diagnosis, management, treatment, and outcomes. In this first part, the epidemiology, prevalence, genetic etiology, clinical presentation, and biochemical and radiologic workup are discussed. In particular, recent advances in the genetics underlying PPGLs and the recommendation for genetic testing of all patients with PPGL are emphasized. Finally, the newer imaging methods for evaluating of PPGLs are discussed and highlighted.

Update on Pheochromocytoma and Paraganglioma from the SSO Endocrine and Head and Neck Disease Site Working Group, Part 2 of 2: Perioperative Management and Outcomes of Pheochromocytoma and Paraganglioma.

This is the second part of a two-part review on pheochromocytoma and paragangliomas (PPGLs). In this part, perioperative management, including preoperative preparation, intraoperative, and postoperative interventions are reviewed. Current data on outcomes following resection are presented, including outcomes after cortical-sparing adrenalectomy for bilateral adrenal disease. In addition, pathological features of malignancy, surveillance considerations, and the management of advanced disease are also discussed.

Confirmation of Parathyroid Tissue: Are Surgeons Aware of New and Novel Techniques?

BACKGROUND: Ex vivo aspiration of parathyroid glands for the measurement of intraoperative parathyroid hormone (IOPTH) levels is a rapid point-of-care method to confirm parathyroid tissue during parathyroidectomy and an alternative to frozen section (FS). This study sought to determine the awareness and utilization of this technique among endocrine surgeons. MATERIALS AND METHODS: A de-identified 12-question survey regarding techniques for intraoperative identification/confirmation of parathyroid tissue and the use of IOPTH monitoring was distributed to all 608 members of the American Association of Endocrine Surgeons. RESULTS: Among the 182 (30%) respondents, FS was the most common primary technique utilized by 115 (63%) respondents to confirm parathyroid tissue; only 12 (7%) utilized ex vivo aspiration, although 78 (42%) were familiar with the technique. Availability and familiarity were the principal reasons for use of the primary technique; the most common barrier was time. Serum IOPTH monitoring was routinely used by 124 (74%). Of respondents who utilized FS, serum IOPTH monitoring was routinely used by 75% (86/115), including 71% (45/63) who reported time as a barrier to FS. Of these 45, only 15 (33%) were familiar with ex vivo parathyroid aspiration. Only 48% of surgeons knew how PTH samples were charged. CONCLUSIONS: FS was the most common method of identification/confirmation of parathyroid tissue. Although most respondents routinely performed IOPTH monitoring, relatively few utilized ex vivo aspiration as a technique for parathyroid identification and less than 50% were familiar with this technique. Broader dissemination about novel techniques such as ex vivo aspiration and cost awareness are recommended.

Persistent/Recurrent Primary Hyperparathyroidism: Does the Number of Abnormal Glands Play a Role?

BACKGROUND: Persistent/recurrent hyperparathyroidism occurs in 2%-5% of patients with sporadic primary hyperparathyroidism (PHPT). In this study, the incidence and time to recurrence in patients with single-gland disease (SGD), double adenomas (DAs), or four-gland hyperplasia (FGH) at initial parathyroidectomy were compared. METHODS: This retrospective review included adult patients with sporadic PHPT who underwent initial parathyroidectomy with intraoperative parathyroid hormone monitoring (IOPTH) from 1/2000 to 12/2016 with ≥6 mo follow-up. An abnormal parathyroid was defined by a gland weight of ≥50 mg. A concurrent serum calcium >10.2 mg/dL and parathyroid hormone >40 pg/mL was defined as persistent PHPT if present <6 mo and recurrent PHPT if present ≥6 mo postoperatively after initial normocalcemia. RESULTS: Of 1486 patients, 1203 (81%) had SGD, 159 (11%) DA, and 124 (8%) FGH. Among the 3 groups, there was no difference in the percent decrease from the baseline or time of excision to final postexcision IOPTH levels between groups (79% versus 80% versus 80%, respectively; P = 0.954) or in the proportion of patients with a final IOPTH ≥40 (22% versus 18% versus 14%; P = 0.059). Overall, 22 (1.5%) had persistent PHPT and 26 (1.7%) had recurrent PHPT. Persistent PHPT was more frequent with DAs (6; 3.8%) than other groups (SGD: 16, 1.3%; FGH: 0; P = 0.02). At median follow-up of 33 mo (IQR, 18-60), there was no difference in recurrence rate (1.6% versus 2.5% versus 2.4%; P = 0.57) or median time (mo) to recurrence (SGD: 59 [IQR, 21-86], DAs: 36 [IQR, 29-58], FGH: 23 [IQR, 17-40]; P = 0.46). CONCLUSIONS: Recurrent PHPT occurred in 1.7% of patients who underwent curative initial parathyroidectomy, with no difference in incidence or time to recurrence between groups based on the number of glands removed. Patients with DA more commonly had persistent PHPT, raising the possibility of unrecognized FGH.

Screening guidelines and recommendations for patients at high risk of developing endocrine cancers.

Screening guidelines in patients with inherited endocrine syndromes and others at high risk for developing endocrine cancers have significant implications as early tumor detection is associated with improved outcomes. Given the unique challenges in diagnosis and treatment, patients at high risk for developing endocrine cancers require multidisciplinary care. The complexity of decision making and rarity of these syndromes support referral to high-volume centers with the experience and knowledge to treat these at-risk patients.

Perioperative Management and Outcomes of Hyperthyroid Patients Unable to Tolerate Antithyroid Drugs.

BACKGROUND: Prior to thyroidectomy for hyperthyroidism, it is recommended that patients are managed with antithyroid drugs (ATDs) and rendered euthyroid to decrease the risk of thyroid storm. However, not all patients tolerate ATD and the risk of thyroid storm during thyroidectomy in these patients is unclear. Therefore, the aim of this study was to compare the management and outcomes of hyperthyroid patients that were on ATDs prior to surgery to those who were not. STUDY DESIGN: A prospectively maintained, single-institution database was queried for all hyperthyroid patients who were initially treated with ATDs and underwent thyroidectomy from January 1, 2012, to June 18, 2018. Patients were divided into two groups: (1) those on ATDs at surgery (ATD group) and (2) those who could not tolerate and stopped ATDs prior to surgery (no-ATD group). Demographic and clinical data were collected. Primary outcomes were readmissions/emergency department visits and postoperative complications within 30 days of thyroidectomy. RESULTS: Of the 248 patients, 231 were in the ATD group and 17 (7%) were in the no-ATD group. There were no mortalities or thyroid storm events in either group. There was no difference in Clavien-Dindo Grade 2 or 3 complications between the two groups. There were no ED visits or 30-day readmissions in the no-ATD group compared to 17 (7%) events in the ATD group (p = 1.0). CONCLUSION: While it is preferable to render patients euthyroid prior to thyroidectomy for hyperthyroidism, results of this study suggest that when patients cannot tolerate ATDs, it is possible to perform thyroidectomy without increased risk of thyroid storm or intra- and postoperative complications.