Correction to: Completion Thyroidectomy: Revisited a Quarter of a Century Later.

In the original article's XML file, Benzon M. Dy's middle initial was tagged incorrectly. The error has been addressed with this correction.

Comprehensive Lateral Neck Dissection in Papillary Thyroid Carcinoma may Reduce Lateral Neck Recurrence Rates.

OBJECTIVE: To Identify predictors of recurrent disease following lateral neck dissection (LND) for papillary thyroid carcinoma (PTC). METHODS: A retrospective review of patients who underwent first-time LND for PTC at our institution (2000-2015) was performed. Medical records were examined for biopsy or pathologically proven lateral neck recurrence. Differences between the groups with and without recurrence were compared. All LNDs were then classified in to two groups: "comprehensive" (CND), involving levels IIa-Vb at minimum, or "selective", labelling less extensive dissection (SND). RESULTS: Four hundred nine patients underwent 467 LNDs. Surveillance data were available for 317 patients who underwent 362 LNDs (mean age 45 ± 16; range 18-88). The median follow-up was 64 ± 48 months (range 3-197). Recurrence was detected in 71 lateral necks (20%). The total number of lymph nodes was greater in the group without recurrence compared to those with recurrence (23 vs. 19, p = 0.02). Among patient demographics, radioactive iodine treatment, primary tumor characteristics and characteristics of nodal metastases, only an older patient age (mean 50 vs. 43 years) was associated with lateral neck recurrence (p < .01). CND was performed in 102 lateral necks and SND in 143 necks. There were 12 recurrences recorded in the CND group (12%) vs. 31 in the SND group (22%, p = .04). The majority of recurrences (70%) involved levels included in the original dissection. CONCLUSIONS: Younger patients, more extensive dissection and a higher total number of lymph nodes removed are associated with a lower incidence of lateral neck recurrence after LND for papillary thyroid carcinoma.

Thyroglobulin Measurement in Fine-Needle Aspiration Improves the Diagnosis of Cervical Lymph Node Metastases in Papillary Thyroid Carcinoma.

BACKGROUND: Papillary thyroid carcinoma (PTC) is frequently associated with cervical lymph node metastases. Guidelines recommend performing ultrasound-guided fine-needle aspiration cytology (FNAC) for suspicious nodes to guide management. No specific recommendations are available for the use of FNA thyroglobulin assay (FNA-Tg). This study investigated the diagnostic value of performing FNAC and FNA-Tg. METHODS: Patient demographics, preoperative investigations, surgery, and lymph node pathology were collected for patients with PTC who underwent lateral neck lymphadenectomy and central compartment reexploration from January 2000 to July 2015. Sensitivities and accuracies were obtained. Patients with both diagnostic studies performed were compared using McNemar's test of paired proportion. Patient, imaging, and lymph node characteristics were correlated with test accuracy. RESULTS: The 480 patients in this study underwent 706 lateral neck dissections or central compartment reexploration. All the patients underwent preoperative neck ultrasound. Among these patients, FNAC alone was performed before 426 operations (60 %), FNAC with FNA-Tg before 105 operations (15 %), and surgery without biopsy for 175 patients (25 %). The sensitivity, positive predictive value, and accuracy were respectively 96, 95, 100 % for FNAC, 99, 97, and 97 % for FNA-Tg, and 95, 92, and 97 % for FNAC in combination with FNA-Tg. In the subgroup of patients who had both tests performed, the sensitivity of FNA-Tg was superior to that of FNAC (95 vs 87 %; p = 0.04). The addition of FNA-Tg to FNAC increased the detection of metastatic PTC by 13 %. CONCLUSIONS: For diagnosing cervical lymph node metastases in PTC, FNA-Tg is a valuable adjunct to FNAC. Its use should be considered to avoid missing metastatic disease in patients who may benefit from lymphadenectomy.

Surgical Treatment of Malignant Pheochromocytoma and Paraganglioma: Retrospective Case Series.

INTRODUCTION: Pheochromocytoma and paraganglioma (PPGL) are rare neoplasms; about 10% are malignant. Literature regarding possible benefit from resection is extremely limited. METHODS: A 20 year review of all patients undergoing surgery for malignant PPGL at the Mayo Clinic Rochester Campus between 1994 and June 2014 was performed. RESULTS: We identified 34 patients undergoing surgery for malignant PPGL. Median follow up was 6 and 5 years survival was 90% (median 11 years). Complete resection (R0) was achieved in 14 patients (41%). Median disease-free survival was 4.6 years for patients with R0 resection (up to 12 years). Only eight patients (23%) were disease-free on last follow up. Elevated preoperative fractionated metanephrines or catecholamines were documented in 23 patients (68%); these normalized in 13 of 23 patients (56%) postoperatively-with symptom relief in 15 of 18 preoperatively symptomatic patients (79%). Among 23 patients with hormone-producing tumors, significant reduction in number of antihypertensive medications was also noted postoperatively; 11 patients have remained off all antihypertensives, 6 required 1 medication, 1 required 2, while 5 required full blockade with phenoxybenzamine and a beta-adrenergic blocker. CONCLUSION: Surgery plays a significant role in the management of selected malignant PPGL. Resection can be effective in normalizing or significantly reducing levels of catecholamines and metanephrines, and can improve hormone-related symptoms and hypertension. Surgical resection, either complete or incomplete, is associated with durable survival despite a high rate of tumor recurrence.

Surgical resection of synchronously metastatic adrenocortical cancer.

INTRODUCTION: Metastatic adrenocortical carcinoma (ACC) is rapidly fatal, with few options for treatment. Patients with metachronous recurrence may benefit from surgical resection. The survival benefit in patients with hematogenous metastasis at initial presentation is unknown. METHODS: A review of all patients undergoing surgery (European Network for the Study of Adrenal Tumors) stage IV ACC between January 2000 and December 2012 from two referral centers was performed. Kaplan-Meier estimates were analyzed for disease-free and overall survival (OS). RESULTS: We identified 27 patients undergoing surgery for stage IV ACC. Metastases were present in the lung (19), liver (11), and brain (1). A complete resection (R0) was achieved in 11 patients. The median OS was improved in patients undergoing R0 versus R2 resection (860 vs. 390 days; p = 0.02). The 1- and 2-year OS was also improved in patients undergoing R0 versus R2 resection (69.9 %, 46.9 % vs. 53.0 %, 22.1 %; p = 0.02). Patients undergoing neoadjuvant therapy (eight patients) had a trend towards improved survival at 1, 2, and 5 years versus no neoadjuvant therapy (18 patients) [83.3 %, 62.5 %, 41.7 % vs. 56.8 %, 26.6 %, 8.9 %; p = 0.1]. Adjuvant therapy was associated with improved recurrence-free survival at 6 months and 1 year (67 %, 33 % vs. 40 %, 20 %; p = 0.04) but not improved OS (p = 0.63). Sex (p = 0.13), age (p = 0.95), and location of metastasis (lung, p = 0.51; liver, p = 0.67) did not correlate with OS after operative intervention. Symptoms of hormonal excess improved in 86 % of patients. CONCLUSION: Operative intervention, especially when an R0 resection can be achieved, following systemic therapy may improve outcomes, including OS, in select patients with stage IV ACC. Response to neoadjuvant chemotherapy may be of use in defining which patients may benefit from surgical intervention. Adjuvant therapy was associated with decreased recurrence but did not improve OS.

Endovascular aortic aneurysm repair in patients with narrow aortas using bifurcated stent grafts is safe and effective.

OBJECTIVE: Narrowing of the distal aortic bifurcation can result in stent graft compression or arterial disruption during endovascular aortic aneurysm repair (EVAR). The aim of our study was to evaluate results of EVAR in patients with narrow distal aortic bifurcations. METHODS: We reviewed the clinical data of 1070 patients who underwent EVAR between 2000 and 2011. Digital computed tomography angiograms were analyzed using centerline of flow measurements to determine aortic diameters. Patients with a distal aortic bifurcation diameter <18 mm were included in the study. End points were technical success, aortic disruption with retroperitoneal hemorrhage, stent graft complications (endoleaks, migration, sac enlargement, stenosis), reintervention, and iliac limb patency. RESULTS: EVAR was used to treat 112 patients (84 men and 28 women; mean age, 75 years) with aortic bifurcation <18 mm, including 34 (30%) who had diameter of <14 mm. Mean outer and inner aortic bifurcation diameter was 16 ± 3 and 14 ± 2 mm, respectively. Bifurcated stent grafts were used in 106 patients (95%). Six patients (5%) had planned aortouniiliac converters with femoral crossover graft. The aortic bifurcation was dilated after placement of bifurcated stent grafts using kissing balloon angioplasty in 80 patients (75%). All bifurcated stent grafts were successfully implanted, with no conversions to open repair or aortouniiliac converters. There were two early deaths (1.8%), and 12 patients (11%) developed early complications. No aortic disruptions or retroperitoneal hematomas occurred in the group treated with bifurcated grafts. After a median follow-up of 35 months, 11 patients (11%) treated by bifurcated stent grafts required reintervention to treat endoleak (n = 6) or iliac limb stenosis/occlusion (n = 5). One patient (17%) treated by aortouniiliac converter developed critical stenosis of an aortouniiliac graft limb, which was successfully treated with balloon angioplasty 29 months after the initial surgery. At 1 and 5 years, freedom from reintervention was 91% ± 3% and 84% ± 4%, respectively, for bifurcated stent grafts and 100% and 83% ± 10%, respectively, for aortouniiliac converters. Primary and secondary iliac limb patency was 98% ± 3% and 100%, respectively, for bifurcated stent grafts and 83% ± 10% and 100%, respectively, for aortouniiliac converters. CONCLUSIONS: EVAR with bifurcated stent grafts is safe and effective in patients with a narrow distal aortic diameter, even when the aortic bifurcation measures <14 mm. Adjunctive balloon dilatation did not result in any bleeding complications from aortic disruption, and limb patency was excellent. Aortouniiliac converters are rarely needed for this indication.

Forensic issues in suicidal single gunshot injuries to the chest: an autopsy study.

This study presents a case series of suicides carried out by self-inflicted gunshot wounds to the chest-a relatively uncommon means of suicide. The retrospective autopsy study performed included all cases of single suicidal gunshot injuries to the chest during a 20-year period and which were committed by the use of a handgun. The sample included 67 deceased persons that were an average of 44.4 ± 19.1 years old (range, 12-89 years; 58 men and 9 women). The most common region of the entrance wound was the left side of the chest (54/67), followed by the sternum (10/67), and the right side of the chest (3/67). For 9 subjects, the range of fire could not be determined, as well as whether the shot went through their clothing. In the remaining 58 subjects, only contact or near-contact wounds were found. Of the 58, only 3 subjects had their clothing removed between the chest wall and the muzzle. Three directions of the internal bullet paths were those most frequently found: downward right-to-left (27/67), downward left-to-right (20/67), and downward parallel (10/67) (χ = 101.045, P = 0.000). Also, most bullet paths were directed downward (57/67, χ = 32.970, P = 0.000). The most frequently injured organ was the heart (47/67), and the immediate causes of death were exsanguination (49/67), heart disruption (14/67), and tamponade (4/67).

Pontomedullary lacerations in unhelmeted motorcyclists and bicyclists: a retrospective autopsy study.

Pontomedullary lacerations (PMLs) have often been reported in car occupants and pedestrians, are less frequently described in motorcyclists, and are very rarely described in bicyclists. The aim of this study was to determine the frequency of brainstem PMLs among fatally injured motorcyclists and bicyclists as well as the frequency of concomitant cranial, facial, and cervical spine injuries in such cases. A possible underlying mechanism of PML in fatally injured motorcyclists and bicyclists might thus be established. Of 443 cases of fatally injured motorcyclists and bicyclists, a sample of 381 cases of fatally injured motorcyclists and bicyclists with head injury of Abbreviated Injury Scale score of 3 or greater was formed and further analyzed. This group was composed of 345 men and 36 women. The average age was 48.8 ± 20.8 years (range, 15-99 years). In the analyzed sample group, there were 158 motorcyclists and 223 bicyclists. Partial PMLs were present in 44 cases (12%) within the sample of 381 head injuries, which breaks down to 40 men and 4 women. In our study, the impact area on the head and the specific skull base fracture type were good predictors of either PML occurrence or absence (B = -2.036, Wald = 161.312, P < 0.01, for the whole model). Impact to the chin, with or without a skull base fracture, most often led to this fatal injury due to impact force transmission, either through jawbone or vertebral column. Also, lateral head impact, the most frequent in bicyclists, with subsequent hinge fracture, PML, and frontoposterior hyperextension of the head that is associated with upper spine fracture, could be possible mechanisms of brainstem injury in fatally injured motorcyclists or bicyclists. Our study showed that the jawbone, as well as other facial bones, could act as shock absorbers, and their fracture could diminish energy transfer toward the skull and protect the brain and brainstem from injury.

Pontomedullary lacerations in pedestrians: an autopsy study.

It is common that injuries to the head are among the most frequent injuries found in pedestrian accidents, and can constitute a serious, if not fatal, threat. Brainstem lesions have only occasionally been reported in pedestrian injuries. The aim of this study has been to determine the frequency of brainstem pontomedullary lacerations (PMLs) among fatally injured pedestrians, the frequency of concomitant cranial, facial and cervical spine injuries in such cases, as well as to establish their possible underlying mechanism. In this work, PML was present in a significant number of fatally injured pedestrians from a sample of 50 out of 360 cases with head injuries (14%). When observed alone, the most frequent head impact areas were the chin, lateral and frontal (χ(2) = 14.200, df = 4, P = 0.007) in the subgroup with PML. Hinge fractures were most often seen in this subgroup (25 cases), followed by the absence of skull base fractures (χ(2) = 26.320, df = 3, P < 0.01). There are several possible mechanisms of PML in these cases. Impact to the chin, with or without a skull base fracture, could lead to this fatal injury due to impact force transmission. Additionally, lateral head impacts, the most frequent in pedestrians, with subsequent hinge fractures, PML and fronto-posterior hyperextension of the head that is associated with upper-spine fractures, may be possible mechanisms of brainstem injury in fatally injured pedestrians.

Lung fat embolism in a body changed by putrefaction: a hip fracture antemortem in origin.

Fat embolism in the lungs can unreservedly be accepted as a vital reaction even in cases of advanced putrefaction. A case is presented herein of an 80-year-old woman, found dead in her locked flat, lying on her right side on the floor. In addition to hip fracture, an external examination of the body and a forensic autopsy revealed putrefactive changes. The histological examination of frozen Sudan III-stained sections of the lungs was performed, where orange, drop, sausage- and branching-shaped fat emboli were found. Despite advanced postmortem putrefaction changes, findings of fat emboli in the lung vessels demonstrated that the hip fracture was antemortem in origin. In this case study, the utility of a lung fat embolism is highlighted as being a vital sign even in cases where the body of the deceased has been changed by advanced putrefaction.

Pontomedullary lacerations and concomitant head and neck injuries: their underlying mechanism. A prospective autopsy study.

It is a well-documented fact that pontomedullary lacerations (PML) occur as a result of severe craniocervical injury, but their underlying mechanism has yet to be fully clarified. The aim of this prospective study has been to give greater insight into the underlying mechanism of PML through determining the site of blunt head-impact, as well as the presence of concomitant head and neck injuries in cases of brainstem PML. A total of 56 cases with partial PML have been analysed for this study. The case group was composed of 40 men and 16 women, averaging in age 44.2 ± 19.2 years and consisting of 7 motorcyclists, 4 bicyclists, 18 car occupants, 16 pedestrians, and 10 victims of falls from a height, as well as 1 victim of a fall from standing height. The presented study has shown that there are several possible mechanisms of PML. Impact to the chin, with or without a skull base fracture, most often leads to this fatal injury, due to the impact force transmission either through the jawbone or vertebral column; most likely in combination with a fronto-posterior hyperextension of the head. Additionally, lateral head-impacts with subsequent hinge fractures and PML may also be a possible mechanism. The jawbone and other facial bones are able to act as shock absorbers, and their fracture may diminish the energy transfer towards the skull and protect the brain and brainstem from injury. The upper cervical spine can act as damper and energy absorber as well, and may prevent any occurrence of fracture to the base of the skull.

Risk Factors for Gastrointestinal Leak after Perforated Peptic Ulcer Disease Operative Repair.

BACKGROUND: There are limited studies regarding the impact of post-operative leak on perforated peptic ulcer disease (PPUD) and conflicting results regarding routine drain placement in operative repair of PPUD. This study aims to identify risk factors for gastrointestinal leak after operative repair of PPUD to better guide intra-operative decisions about drain placement. METHODS: We performed a retrospective cohort study at a tertiary care center from 2008 to 2019, identifying 175 patients who underwent operative repair of PPUD. RESULTS: Patients who developed a leak (17%) were compared to patients who did not. Both hypoalbuminemia (albumin < 3.5 g/dL) (P = .03) and duodenal ulcers (P < .01) were identified as significant risk factors for leak. No significant difference was found between leak and no leak groups for AAST disease severity grade, repair technique, or pre-operative use of tobacco, alcohol, or steroids. Post-operative leaks were associated with prolonged hospital stay (29 days compared to 10, P < .01), increased complication rates (77% compared to 48%, P < .01), and increased re-operation rates (73% compared to 26%, <0.01). No difference was identified in patient characteristics or operative leak rates between patients who had drains placed at the index operation and those that did not. DISCUSSION: Leak after operative PPUD repair is associated with significant post-operative morbidity. Hypoalbuminemia and duodenal perforations are significant risk factors for post-operative leaks.

Predicting Postthyroidectomy Hypocalcemia: Improving Predictive Ability of Parathyroid Hormone Level.

We performed a retrospective study of our large patient cohort aiming to examine the ability to predict postthyroidectomy hypocalcemia. A retrospective review of patients who underwent total or near-total thyroidectomy at our institution between 2008 and 2018 was performed. Postoperative hypocalcemia was defined as Ca level <8.0 mg/dL (reference range: 8.9-10.1 mg/dL) within 30 days of operation. Logistic regression was used to develop models for prediction of the occurrence of postoperative hypocalcemia. Inclusion criteria were met by 1463 patients. Hypocalcemia was documented in 223 patients (15%). Models based on parathyroid hormone (PTH) levels alone had an associated receiver operator characteristic with an areas under the curve (AUC) of 0.79. There was an inverse relationship between time of measurement and PTH levels within the first two hours after thyroidectomy (P < 0.01). When measured two to six hours after closure, the predictive ability of PTH compared favorably (AUC = 0.82) with either earlier (within the first two hours after closure, AUC = 0.79) or later measurement (6-24 hours after closure, AUC = 0.77). When measured between two and six hours postoperatively, PTH < 19 pg/mL had a sensitivity of 90 per cent and negative predictive value of 96 per cent for postoperative hypocalcemia. The model that included the PTH level, concurrently measured total blood calcium level, and time of measurement had an improved predictive ability with an AUC of 0.87. PTH level of 19 pg/mL measured two to six hours after thyroidectomy had a sensitivity of 90 per cent and a negative predictive value of 96 per cent in our cohort. The model including postoperative PTH level, calcium level, and time of measurement may further improve the ability to predict postthyroidectomy hypocalcemia.

Parathyroidectomy improves hypercalciuria in patients with primary hyperparathyroidism.

BACKGROUND: Hypercalciuria is an important manifestation of primary hyperparathyroidism and may contribute to the risk of nephrolithiasis. This study examined the impact of parathyroidectomy on 24-hour urinary calcium (24-hour UCa) levels and rates of resolution of hypercalciuria after surgery. METHODS: A retrospective cohort study was performed of patients who underwent curative parathyroidectomy for primary hyperparathyroidism from 2007 to 2017. Baseline and postoperative urine and serum biochemistry levels were analyzed. The relationship between preoperative 24-hour UCa levels and the absolute decrease in postoperative UCa excretion was assessed using Spearman's rank correlation coefficient. RESULTS: Of 110 patients, 84 (76.4%) experienced a ≥20% decrease in 24-hour UCa level postoperatively. These patients had a higher baseline median 24-hour UCa level (293.5 vs 220.5 mg/24-hour; P = .001), higher baseline mean serum parathyroid hormone (106.5 vs 83; P = .05) and were more likely to have single gland disease (85.7% vs 65.4%, P = .04) compared with patients in whom 24-hour UCa excretion did not improve. Of the 28 patients (25%) who were hypercalciuric (24-hour UCa >400 mg/day) at baseline, 22 (79%) became normocalciuric postoperatively. A linear correlation was observed between preoperative 24-hour UCa levels and the decline in 24-hour UCa excretion after surgery (R2 = 0.59, P < .0001) such that the degree of improvement could be predicted using the following equation: absolute decrease in postoperative 24-hour UCa = 0.68 × preoperative 24-hour UCa-68. CONCLUSION: Parathyroidectomy reduces 24-hour UCa excretion in the majority of patients with PHPT and restores normocalciuria in 79% of patients with hypercalciuria at baseline.

Not all adrenal incidentalomas require biochemical testing to exclude pheochromocytoma: Mayo clinic experience and a meta-analysis.

BACKGROUND: Excluding a pheochromocytoma is important when a patient presents with an incidentally discovered adrenal mass. However, biochemical testing for pheochromocytoma can be cumbersome, time consuming, or falsely positive. Our objective was to determine if unenhanced computed tomography (CT) imaging alone can be used to rule out pheochromocytoma. METHODS: We performed a retrospective study of all patients with a pathologically confirmed pheochromocytoma and unenhanced CT imaging who were treated at the Mayo Clinic between 1998 and 2016. Additionally, we performed a systematic review and meta-analysis of original studies published after 2005 with patients who had adrenal masses, more than 10 patients with pheochromocytomas, and reported attenuation on unenhanced CT imaging in Hounsfield units (HU). RESULTS: In the Mayo cohort, we identified 186 patients and 199 pheochromocytomas with unenhanced CT imaging. The mean unenhanced CT attenuation was 35±9 HU (range, 15-62), and only 15 tumors had attenuation ≤20 HU. The systematic review identified 26 studies (1,217 tumors), and 23 studies provided a mean unenhanced CT attenuation. The overall mean unenhanced CT attenuation across the studies was 35.6 HU (95% CI, 22.0-49.1 HU). A cutoff of >10 HU had a 100% sensitivity (95% CI, 1.00-1.00) for pheochromocytoma with low heterogeneity between the 21 qualified studies (I2=0%). Sensitivity for pheochromocytoma was 100% and 99% for an unenhanced CT attenuation cutoff of >15 and >20 HU. CONCLUSIONS: Biochemical testing may not be required to exclude pheochromocytoma if an incidental adrenal mass has low attenuation (<10 HU) on unenhanced CT images.

Small bowel obstruction in a virgin abdomen.

INTRODUCTION: Surgical exploration is still considered mandatory in the setting of small bowel obstruction (SBO) and a virgin abdomen by some large centers. The aim of this study is to determine the etiology of SBO in patients without prior abdominal operation. METHODS: Retrospective review of the patients treated for SBO and virgin abdomen at the Mayo Clinic between 2006 and 2016 was performed. Follow up data, operative and pathologic findings were examined to determine the etiology of SBO. RESULTS: Sixty patients met inclusion criteria; abdominal exploration was performed in 50 patients (83%) and 10 patients (17%) were managed non-operatively. Exploration was therapeutic in 29 (58%), negative in 20 (40%) and non-therapeutic in one patient (2%). Overall, 8 patients (13%) were diagnosed with a malignancy: right-sided colon cancer (n = 3), small bowel (SB) neuroendocrine tumor (n = 2), SB lymphoma (n = 2) and carcinomatosis peritonei (n = 1); Upon retrospective review, both SB neuroendocrine tumors and one SB lymphoma were visible on the initial imaging. Leukocytosis (p = .03) and no recent weight loss (p = .04) were associated with negative exploration. CONCLUSION: Patients with SBO and virgin abdomen frequently have a benign etiology. Careful imaging review directed at subtle signs of an underlying malignancy is warranted. If non-operative management is chosen, close follow up is essential and it should include a careful personal and family history as well as updated colonoscopy.

Treatment of lateral neck papillary thyroid carcinoma recurrence after selective lateral neck dissection.

BACKGROUND: There is a paucity of data regarding optimal treatment options and outcomes for recurrent disease after lateral neck dissection in patients with papillary thyroid carcinoma. METHODS: Retrospective review of patients who underwent either percutaneous ethanol injection or surgery for first-time ipsilateral recurrences after ipsilateral lateral neck dissection for papillary thyroid carcinoma was performed. RESULTS: Follow-up data were available for 54 patients with recurrences in 57 lateral necks treated by either percutaneous ethanol injection (n = 32) or surgery (n = 25). Tumor burden at the time of lateral neck recurrence differed between the groups including the largest lymph node diameter (mean: 13 mm vs 18 mm, P < .01) and the mean number of metastatic lymph nodes identified on ultrasound (1.3 vs 1.9, P = .04). Each modality alone achieved similar estimated rates of disease control at 36 months (75% for percutaneous ethanol injection and 74% for surgery, P = .8) with similar number of reinterventions (1.8 for percutaneous ethanol injection, 1.6 for surgery, P = .6). CONCLUSIONS: Both ethanol ablation and surgery can achieve disease control in the majority of patients with recurrences after ipsilateral lateral neck dissection for papillary thyroid carcinoma. Ethanol ablation, when used for treatment of a single small lymph node, can result in outcomes that are similar to reoperative surgery for larger and multiple lymph nodes.

Primary aldosteronism: making sense of partial data sets from failed adrenal venous sampling-suppression of adrenal aldosterone production can be used in clinical decision making.

BACKGROUND: It has been suggested that accurate clinical decisions may be made in patients with primary aldosteronism (PA) in the setting of failed cannulation of an adrenal vein, thereby utilizing only data from either right or left adrenal venous sampling (AVS) alone. METHODS: Retrospective analysis was performed for all patients with PA who underwent successful bilateral AVS. Adrenal vein/inferior vena cava index (AV/IVC index) was calculated by dividing aldosterone/cortisol ratio of the adrenal vein by aldosterone/cortisol ratio in the inferior vena cava, as described in a previously published study. We examined the rates of inappropriate adrenalectomy and failure to recognize unilateral disease when previously published cutoffs are used. RESULTS: Inclusion criteria were met in 150 patients; 61 with bilateral and 89 with unilateral disease. AV/IVC index cutoff of ≤0.5 to predict contralateral disease would have not led to any inappropriate adrenalectomies and would have missed 19% of patients with unilateral disease; AV/IVC index cutoff of ≥5.5 to predict ipsilateral unilateral disease would have resulted in inappropriate adrenalectomy in 18% of patients (95% CI 8-34%, P < .01) and would have not recognized 55% of patients with unilateral disease (P < .01). CONCLUSION: The cortisol-corrected adrenal vein/inferior vena cava aldosterone index with a cutoff value of ≤0.5 performed well in identifying patients with contralateral unilateral disease. AV/IVC index of ≥5.5 cannot be used to reliably diagnose ipsilateral unilateral disease because 18% of patients undergoing adrenalectomy based on this cutoff would have bilateral disease.

The role of lateral neck ultrasound in detecting single or multiple lymph nodes in papillary thyroid cancer.

BACKGROUND: Lateral neck dissection (LND) for papillary thyroid cancer (PTC) transitioned from isolated lymphadenectomy or "berry picking" based on clinical examination to multicompartment lymphadenectomy. We aimed to assess ultrasound (US) as a predictor of solitary (SLN) or multiple lymph node (MLN) metastases. METHODS: Demographics, US findings, extent of LND, and pathology were collected in patients with PTC who underwent LND. US sensitivity and specificity were calculated, and accuracy was correlated with US findings and patient characteristics. RESULTS: A total of 462 patients underwent 590 LNDs. US showed an SLN in 179 patients (30%) and MLNs in 411 patients (70%). Sensitivity, positive predictive value, and accuracy were 61%, 43%, and 75% for US detected SLN and 78%, 89%, and 75% for US detected MLNs. US accuracy for MLNs increased as node size increased (<10 mm, 63%; 10 to 20 mm, 71%; >20 mm, 89%; P < .0001). CONCLUSIONS: US has limited accuracy in the detection SLN metastasis in the lateral neck. Care should be taken when considering a focused compartment dissection.