Turkish endocrine surgery publications in international scientific journals.

OBJECTIVE: In recent years, major progress has been made in the field of endocrine surgery in Turkey, similar to that in the rest of the world. Parallel to these developments, there has been a significant increase in the number of publications in the related field. Our study aimed to evaluate Turkey's publications related to endocrine surgery in the international arena. MATERIAL AND METHODS: Members of the general surgery departments from academic centers in Turkey were determined. Using these member names, a PubMed search was performed for English papers related to "endocrine surgery." For searching papers from non-academic centers, the same engine was used. To reach manuscripts possibly missed by the PubMed search, 3 national calls were made through the website of the Turkish Society of Endocrine Surgery. The obtained papers were divided into "thyroid," "parathyroid," "adrenal," and "neuroendocrine tumors" and were listed according to the publication year. In addition, all manuscripts were listed according to the publishing journal and the 2012 impact factor of that journal. This study did not require ethical approval, because it did not involve evaluation of experimental or patient data. RESULTS: A search of Turkish general surgery clinics revealed 497 international publications, between 1976 and 2012. When listed according to the year of publication, most publications were found to be in the year 2009. Papers appeared mostly in "Surgery Today." The mean impact factor of the journals where the papers have been published was 1.9 (0.1-13.8). The rates of thyroid, parathyroid, adrenal tissue and neuroendocrine tumors related publications were 69%, 10%, 15% and 6%, respectively. Since this study is not an experimental study or a study related to patient data, we did not apply for ethical approval. CONCLUSION: The contribution of Turkish general surgeons' to world science is apparent when evaluated in terms of publications related to endocrine surgery until recently. Particularly, since 2002, with the increase in the number of publications in the field of endocrine surgery, there has been an increase in Turkey's importance on the international platform.

Comparison of the histopathology and prognosis of bilateral versus unilateral multifocal multicentric breast cancers.

BACKGROUND: Multiple breast cancers may present with different clinical and biological characteristics. The data indicate that multifocal (MF), multicentric (MC), and bilateral synchronous (BS) breast cancers (BC) are more aggressive and have an equivalent or moderately poorer survival rate compared with unilateral cases. However, a comparison of these multiple breast cancers has not been covered in the literature. The aim of this study was to describe the histopathological characteristics of patients suffering from MF, MC, and BS breast carcinoma and to compare their prognoses. METHODS: Retrospective data for MF, MC, and BS breast carcinoma patients treated in five different breast cancer units in Turkey between 2003 and 2012 were collected. MF and MC cancers were defined as more than one lesion in the same quadrant or in separate quadrants, respectively. RESULTS: There were 507 patients (271 MF, 147 MC, and 89 BS) treated in this time period. BS breast carcinoma patients were younger than the other groups (44.83 ± 9.6, 47.27 ± 11.6, and 51.11 ± 11.8 years for BS, MF, and MC breast carcinoma patients, respectively). MFBC and MCBC patients in this study were younger than the ages reported in Western literature, but this result was similar to the ages reported in Eastern literature. The five-year survival rates and recurrence rates were not statistically different among groups (P = 0.996 and P = 0.263, respectively). According to univariate analyses, tumor size, histological grade, and lymph node status were statistically significant factors that affected survival. However, only lymph node involvement was significant for survival according to multivariate analyses. CONCLUSIONS: The clinical significance of MF, MC, and BS breast cancers is still unclear and their influence on prognosis is controversial. Disease-free and overall survival rates of BS breast cancers might be similar to MF and MC breast cancers.

Radioguided occult lesion localization for minimally-invasive parathyroidectomy without quick PTH monitoring and frozen section: impact of the learning curve.

OBJECTIVES: Minimally-invasive parathyroidectomy (MIP) is a surgical procedure that reduces the duration of operation, hospital costs, and hypocalcemia, and shortens the length of hospital stay. This study addressed the important procedural details of the radioguided occult lesion localization (ROLL)-MIP technique and evaluated the consequences of the learning curve from a series of patients. PATIENTS AND METHODS: A total of 80 patients who underwent ROLL-MIP for a single parathyroid adenoma were included into this retrospective study. In order to analyze the effect of the learning curve, these subjects were then divided into 2 groups per time period and the operative times were compared. Group A consisted of 22 previously reported patients who served as the control group. Group B consisted of 58 consecutive patients. RESULTS: Serum calcium and parathyroid hormone (PTH) levels were normalized in all of the patients within 2 days and remained normal during the follow-up period (31 ± 18.5 months). None of the patients who underwent ROLL-guided parathyroidectomy suffered temporary or permanent recurrent laryngeal nerve injuries. Mean operation time (time from incision to excision of the adenoma) was 23 ± 6 min in Group A and 18 ± 7 min in Group B. Mean operative times were significantly shorter in group B. CONCLUSION: The success of MIP administered with the ROLL technique in a single adenomatous patient was quite high. This method seems especially valuable in patients with atypically located or small adenomas.

Papillary microcarcinomas of the thyroid gland and immunohistochemical analysis of expression of p53 protein in papillary microcarcinomas.

BACKGROUND: Thyroid papillary microcarcinoma (TPM) is defined according to WHO criteria as a thyroid tumor smaller than 1-1.5 cm. TPMs are encountered in 0.5-35.6% of autopsies or surgical specimens where carcinoma had been unsuspected. The purpose of the present study was to evaluate patients who had TPMs in terms of clinical findings, histopathological features and immunohistochemical evidence of expression of the tumor suppressor gene p53. METHODS: A total of 44 patients with TPMs less than 1.0 cm in diameter were included in the study. The patients were evaluated clinically and the tumors were evaluated in terms of their histopathological and immunohistochemical features, including expression of p53. RESULTS: The female/male ratio was 2.8/1, and the median age at time of diagnosis was 49 years (range 20-71 years). The maximum diameter of the smallest focus was 0.1 mm, and that of the largest was 10 mm microscopically. The mean diameter of all tumors was 5.7 mm. There was no correlation between tumor size and age or gender. Of the TPMs, 72% were found in the right lobe, 24% in the left lobe and 4% in the isthmus. Fine-needle aspiration biopsy provided the diagnosis of TPM in only 43.2% of the patients. All patients were treated with surgery, with 20 undergoing conservative surgery, i.e. lobectomy or isthmusectomy, and 24 undergoing total thyroidectomy. Frozen section provided the diagnosis of TPM in only 56.8% of the patients. We found lymphocytic thyroiditis in 13.6% of patients, follicular variants in 11.9%, capsular invasion in 26.8%, lymph node involvement in 11.9%, soft tissue metastases in the neck in 12.1% and multifocality in 31.7%, and none of these were related to age or gender (p > 0.05). No distant metastases were observed during approximately 10 years of follow up. We found p53 positivity in 34.5% of TPM tumors. However, p53 expression was not statistically related to age or gender. CONCLUSION: Our findings imply that TPMs may not be entirely innocent since they are associated with signs of poor prognosis such as capsular invasion, multifocal presentation, lymph node involvement and p53 positivity. Therefore, TPMs should be evaluated and followed like classical papillary cancers.

Invasive Ductal Carcinoma Developing From Fibroadenoma.

Fibroadenomas are the most common benign breast lesions in adolescent and young women. It is most frequently observed in the 3rd decade. Although it is considered benign, evidence of malignant transformation is available. Cancer development may be from ground of fibroadenoma or near breast tissue. A case of a fibroadenoma coexisting with an invasive ductal carcinoma of the breast in a 31-year-old female is presented. The patient presented with the chief complaint of having a palpable mass in her right breast for the last 10 years. Mammography revealed a mass with microcalcifications. Core biopsy was performed, and the results indicated an invasive carcinoma. Breast-conserving surgery with sentinel lymph node biopsy was performed. The pathological features revealed a fibroadenoma coexisting with an invasive ductal carcinoma. This case suggests that clinicians and radiologists should always pay attention to the associated malignant imaging characteristics whenever a mass was followed up as fibroadenoma.

Alpha blockade in preoperative preparation of patients with pheochromocytomas.

Preoperative preparation in pheochromocytoma is usually performed by alpha-adrenergic blockers. We retrospectively reviewed the efficiency of phenoxybenzamine, prazosin, and doxazosin in preoperative preparation. Phenoxybenzamine was used for preoperative preparation of 21 pheochromocytoma patients, prazosin was used in 11 patients, and doxazosin was used in 17 patients. Intraoperative and early postoperative blood pressure records and postoperative volume replacement records were reviewed. Intraoperative hypertension occurred in 17 patients in the phenoxybenzamine group (81%), eight patients in the prazosin group (73%), and 14 patients in the doxazosin group (82%). There was no statistical difference among the groups (P > 0.05). There was also no significant difference between postoperative blood pressure measurements and the operative and postoperative volume replacements. We have found that there were no significant difference in the operative and postoperative blood pressure and plasma volume control among the three groups. We conclude that pheochromocytoma surgery is safe with any of these preoperative medications.

Radioguided occult lesion localization for minimally invasive parathyroidectomy: technical consideration and feasibility.

PURPOSE OF THE REPORT: Minimally invasive parathyroidectomy (MIP) constitutes one of the main surgical approaches for the patient with primary hyperparathyroidism (PHPT) caused by a single parathyroid adenoma. The purpose of the study was to investigate the feasibility of radioguided occult lesion localization (ROLL) for MIP and the potential effects of the method in histopathologic evaluation. MATERIALS AND METHODS: Twenty-two patients, diagnosed with PHPT biochemically and candidates for surgery, underwent ROLL-guided MIP (ROLL-MIP). Parathyroid adenomas were searched for and identified with the guidance of an intraoperative gamma probe. The final diagnosis was confirmed by histopathologic analysis. All specimens were analyzed for the presence of parenchymal hemorrhage, congestion, neutrophil leukocyte infiltration, necrosis, cystic degeneration, subcapsular hematoma, subcapsular fibrin/neutrophil leukocyte infiltration, and disarray of the fibrous capsule of adenoma. RESULTS: All injected lesions were effectively located over the skin with very high count rates depending on the injected activity and location of the lesion. Serum calcium and parathyroid hormone (PTH) levels normalized in all patients and stayed within the normal range during the follow-up period. None of the patients who underwent ROLL-MIP suffered temporary or permanent recurrent laryngeal nerve injuries. The mean operative time was 23 ± 7 min. Parenchymal hemorrhage, congestion, subcapsular hematoma, and fibrin/neutrophil leukocyte infiltration were common histopathologic features. CONCLUSION: The use of ROLL-MIP in patients with PHPT due to a single parathyroid adenoma in the neck is technically safe and effective. It is more valuable in scintigraphy-negative patients when parathyroid adenoma is either demonstrated on ultrasonography by typical findings or confirmed by PTH washout. The ROLL-MIP technique does not impair the postoperative histopathologic examination of the parathyroid glands.

Locoregional Recurrence and Survival Rates after Breast-Conserving Surgery and Hormonal Therapy in 70-Year-Old or Older Patients with Stage I or IIA Breast Carcinoma.

BACKGROUND: Data for treatment of elderly women (≥ 70 years) with estrogen receptor-positive early stage breast cancer are available. We have compared different treatment options to determine whether lumpectomy (LU) plus adjuvant hormonal therapy (HT) is as effective as combined LU, HT, and radiotherapy (RT). METHOD: Medical records of elderly patients over 69 years of age who had been treated for T1N0M0 (stage I) and T2N0M0 (stage IIA) at 2 different medical centers between March 2004 and January 2011 were assessed, and 35 patients were included in this study. 21 of these patients underwent only breast-conserving surgery (BCS) and HT (Group 1: T1N0M0-Group 1a, n = 16; T2N0M0-Group 1b, n = 5) and the others either BCS, HT and RT (Group 2, n = 4) or BCS, chemotherapy (CT), HT and RT (Group 3, n = 10). Adjuvant HT for all the patients comprised aromatase inhibitors. RESULTS: The mean follow-up period for Groups 1, 2 and 3 were 32.2, 31.3 and 20.4 months, respectively. No locoregional recurrence or cancer-specific mortality occurred in any of these patients; 1 patient from Group 1 died of a different cause. DISCUSSION: The BCS+HT regimen seems to be an efficient treatment option for early stage breast cancer in selected 70-year-old and older patient groups.

What do we leave behind after neartotal and subtotal thyroidectomy: just the tissue or the disease?

Selection of multinodular goiter (MNG) surgery procedure is stilll under discussion. Subtotal thyroidectomy (STT) and neartotal thyroidectomy (NTT) are preferred surgical procedures. However, it is uncertain whether the remnant tissue contains pathological findings or not after these procedures. We aimed to evaluate and comparison the pathologic findings in remnant tissue after NTT and STT. Thyroid tissue samples of 50 patients who underwent TT for MNG disease between January 2010 and August 2011 in our clinic were evaluated. Before the dissection of the thyroid tissue subtotal and neartotal margins were marked in both right and left lobes. After the resection of the specimen, the tissue was excised from the subtotal and neartotal margin marked during the surgery. The pathologic findings of the main tissue, the residual subtotal and neartotal tissues were evaluated and compared. All patients were followed-up 1 year. 43 (86%) females and 7 (14%) males with an average age of 50.5 (23-77) were included in the study. Incidental papillary thyroid cancer was detected in 5 patients (10%). Pathologic findings were present in 31 patients (62%) of subtotal residual tissue and 28 of the patients (56%) of neartotal residual tissue. Papillary microcarcinoma was detected in 3 (9.7%) of subtotal residual tissues and 2 (7.1%) of neartotal residual tissues. There is no significant difference between subtotal and neartotal tissues in terms of existence of pathological findings (p>0.05). There is no significant difference between the neartotal and subtotal residual tissues contralateral of dominant nodule (p>0.05). 2 of the patients (4%) had temporary hypocalcemia, 1 patient (2%) had seroma and 1 patient (2%) had recurrent laryngeal nerve injury. There are high rates of microscopic pathological findings on residual tissues both after STT and NTT. The neartotal and subtotal residual tissues contralateral to the large nodule also had high levels of pathologic findings.

Predicting the likelihood of nonsentinel lymph node metastases in triple negative breast cancer patients with a positive sentinel lymph node: Turkish Federation of Breast Disease Associations protocol MF09-01.

BACKGROUND: Triple negative (TN) tumor has a relatively high rate of recurrence and distant metastasis, but results of studies revealed that triple positive tumor is an independent predictor of axillary lymph node involvement. Our aim was to evaluate the frequency of nonsentinel lymph node metastasis (NSLNM) involvement in operable TN breast cancer with positive sentinel lymph node (SLN) and predicting the likelihood of NSLNM in this cohort of patients by using 4 different nomograms. METHODS: A total of 128 patients with TN and SLN(+) underwent complete axillary lymph node dissection in 14 different centers in Turkey. For comparison, we used our previous multicenter MF08-01 Protocol, which identified 441 patients with estrogen receptor (ER(+)) who had a positive SLN biopsy and underwent subsequent complete axillary lymph node dissection. Turkish, Cambridge, and Stanford nomograms and the Tenon Score system were used to calculate the probability of NSLNM. RESULTS: Patients with TN tumor had a larger tumor size. The actual percentage of NSLN positivity was 41% in the TN group and 47.1% in patient with ER(+). The Tenon Score was ≤3.5 in 12% of patients with TN and ER(+); the area under the curve in the receiver operating characteristics curve were 0.53 and 0.59, respectively. Based on the Turkish, Cambridge, and Stanford nomograms, areas under the curve were 0.54, 0.53, and 0.61, respectively in patients with TN, and were 0.79, 0.72, and 0.70, respectively, in patients with ER(+). CONCLUSION: Using the Tenon Score system underestimates NSLN positivity, and tested nomograms are not good discriminators of NSLNM in patients with TN and positive SLN.

The evaluation of the causes of subjective voice disturbances after thyroid surgery.

BACKGROUND: Voice changes following thyroidectomy is a rare form of morbidity not infrequently encountered. Injury to the recurrent laryngeal nerve or external branch of the superior laryngeal nerve is the most well-known cause of post-thyroidectomy voice disturbances. However, voice dysfunction is a more complex entity. The aim of the current study was to assess the possible factors that influence voice changes after thyroidectomy. METHODS: Forty-eight consecutive patients who had undergone thyroidectomy were studied. The acoustic voice analysis (mean vocal fundamental frequency [Fo], mean percentage vocal jitter and shimmer, and noise-to-harmonic ratio) and videolaryngostroboscopic examination of these patients were performed preoperatively, on the second postoperative day, and 3 months after the operation. The presence of subjective voice changes was recorded prospectively based on a symptom scale. RESULTS: No major complications occurred perioperatively or in the postoperative period. Videolaryngostroboscopic examinations were normal in all patients before and after thyroidectomy. Eighteen (37.5%) patients complained of subjective voice changes in the early postoperative period and 7 (14.6%) of these were still uncomfortable after 3 months. Although the difference was significant by means of all acoustic voice parameters measured in the early postoperative period, Fo is the only parameter that continues to be significant after 3 months. CONCLUSIONS: Irrespective from recurrent laryngeal nerve and/or injuries to the external branch of the superior laryngeal nerve, voice may temporarily be affected by thyroidectomy. Most of the subjective complaints and acoustic voice parameters return to normal in a few months after surgery.

Comparison of the complications of subtotal, near total and total thyroidectomy in the surgical management of multinodular goitre.

Purpose of the study is to compare complication rates of bilateral subtotal (BST), near total (NTT) and total thyroidectomy (TT) in a cohort of patients undergoing surgery for benign multinodular goitre (MNG). Seven hundred and fifty patients undergoing surgery for MNG were studied with a median follow-up of 53 months (range 18-102). There was no operative mortality in this group and no patients required urgent re-exploration for haematoma. After BST 14 patients (14/170 - 8.2%) developed transient hypocalcaemia and 4 patients (4/170 - 2.4%) had transient and one permanent (1/170 - 0.6%) recurrent laryngeal nerve (RLN) palsy. In NTT group 39 patients (39/320 - 12.2%) developed transient hypocalcaemia and 2 patients (0.6%) transient voice disturbances. None of the patients in this group experienced permanent complications. However, in TT group 78 patients had (78/260 - 30%) transient hypocalcaemia whereas only one patient (1/260 - 0.4%) suffered permanent hypoparathyroidism and 5 patients (5/260 - 1.9%) had temporary RLN injury but none of them remained permanent. There are only 2 (2/170 - 1.2%) recurrences and those patients are in BST group. All of the patients in BST group required at least 100 microg of thyroxine supplementation following the operation. These results demonstrate low permanent complication rates following thyroid surgery. Although the incidence of transient hypoparathyroidism increases with the extent of the resection, permanent complication rates are similar for all three surgical procedures. Even with short follow-up, there is a risk of recurrence with BST and therefore NTT or TT may be the operation of choice for MNG.