Examining National Guideline Changes Association With Hemithyroidectomy Rates by Surgeon Volume.

INTRODUCTION: The 2015 American Thyroid Association (ATA) guidelines established that hemithyroidectomy (HT) is an appropriate treatment for patients with low-risk thyroid cancer. HT rates increased since the ATA guidelines were released; however, the relationship between surgeon volume and the initial extent of surgery has not been established. METHODS: A statewide database was used to identify patients with thyroid cancer who underwent initial thyroidectomy from 2013 to 2020. High-volume thyroid surgeons were defined as those who performed >25 thyroid procedures per year. A mixed-effect logistic model was used to compare low- and high-volume surgeons' initial extent of surgery pre-2015 and post-2015 ATA guidelines. Descriptive statistics were used to describe other surgical outcomes. RESULTS: The analysis included 3199 patients with thyroid cancer who underwent initial thyroidectomy. Twenty-four surgeons (6%) were considered high-volume; they performed 48% (n = 1349) of the operations. After the 2015 ATA guidelines were released, the rate of HT increased significantly for low- (23% to 28%, P = 0.042) but not high-volume (19% to 23%, P = 0.149) surgeons. Low-volume surgeons had significantly higher rates of readmission (P = 0.008), re-operation (P = 0.030), complications (P < 0.001), and emergency room visits (P = 0.002) throughout the entire study period. CONCLUSIONS: The publication of the 2015 ATA guidelines was associated with a significant increase in HT rates, primarily in low-volume thyroid surgeons. While low-volume surgeons began performing more HTs, they continued to have higher rates of readmission, reoperations, complications, and emergency room visits than high-volume surgeons.

Identifying Strategies for Struggling Surgery Residents.

BACKGROUND: Struggling residents are not uncommon in general surgery. Early identification of these residents and effective remediation remain imperfect. MATERIALS AND METHODS: We performed a survey of program directors (PD) across all general surgery residencies. Survey questions included the following: demographic information about the program and PD, 10 vignettes about hypothetical residents struggling in various ACGME milestones to assess how PDs would address these deficiencies, and self-reported PD preparedness and availability of resources to support struggling residents. RESULTS: In total, we received 82 responses to our survey. All PDs who participated in our study reported having struggling residents in their program. The three most common ways struggling residents are identified were faculty word-of-mouth, formal evaluations such as milestones and ABSITE performance, and resident word-of-mouth. Over 18% of PDs reported having little to no relevant training in addressing the needs of a struggling resident, and 65.9% of PDs did not feel that their program had 'completely adequate' resources to address these needs. In the majority of cases, PDs offer mentorship with themselves or other faculty as a remediation strategy with infrequent use of other resources. CONCLUSIONS: Strategies to identify struggling residents and remediation strategies varied widely across programs. Diversifying remediation approaches should be considered for more effective remediation.

REFERRAL OF OLDER THYROID CANCER PATIENTS TO A HIGH-VOLUME SURGEON: RESULTS OF A MULTIDISCIPLINARY PHYSICIAN SURVEY.

OBJECTIVE: Surgical outcomes of thyroid cancer patients are improved with high-volume surgeons. However, age disparities in referral to specialist surgical centers still exist. The factors that influence decision making regarding referral of older thyroid cancer patients to high-volume surgeons remain unknown. METHODS: We surveyed members of the Endocrine Society, American College of Physicians, and American Academy of Family Practice. RESULTS: Overall, 270 physicians completed the survey. Patient preference (69%), transportation barriers (62%), and confidence in local surgeon (54%) were the most cited factors decreasing likelihood of referral to a high-volume surgeon. In clinical scenarios, referral rates to a high-volume surgeon were similar for patients aged 40 and 65 years with a 1-cm thyroid nodule diagnostic of thyroid cancer (n = 137 [54%]; n = 132 [52%], respectively) as for an 85-year-old with a 4-cm nodule (n = 148 [59%]). When comorbidities were introduced, more physicians (n = 186 [74%]) would refer a 65-year-old with a 4-cm thyroid nodule and comorbidities, compared to an 85-year-old with the same nodule size without comorbidi-ties. In multivariable analysis, treating >10 thyroid cancer patients/year (P<.001; P<.005) and endocrinology specialty (P = .003; P = .003) were associated with referral to a high-volume surgeon for a 65-year-old with comorbidities and an 85-year-old without comorbidities, respectively. CONCLUSION: Understanding surgical referral patterns of older thyroid cancer patients is vital in identifying obstacles in the referral process. We found that patient factors including comorbidities and physician factors including specialty and patient volume influence these patterns. This is the first step towards developing targeted interventions for these patients.

Frozen section analysis in the post-Bethesda era.

BACKGROUND: The utility of frozen section (FS) for indeterminate thyroid nodules is controversial. In 2009, the Bethesda System for Reporting Thyroid Cytopathology was established to further subcategorize indeterminate fine-needle aspiration results (follicular lesions, FL) into Bethesda category 3 (BC3) and Bethesda category 4 (BC4). We hypothesize that FS will have less utility in the evaluation of BC3 lesions when compared to BC4. MATERIALS AND METHODS: A total of 479 patients who underwent thyroid lobectomy from January 2008 to July 2014 were retrospectively reviewed. Patients without appropriate Bethesda categorization were excluded. A total of 135 patients (65 FL, 45 BC3, 25 BC4) comprised the study groups. The sensitivity and specificity of FS within these three categories were determined. RESULTS: In the FL group, 6 of 65 patients were found to have thyroid cancer. Three were identified on frozen section (FS) resulting in a sensitivity and specificity of 50% and 100%, respectively. Thus, FS changed the operation in 3 of 65 cases (4.6%). In the BC3 group, 5 of 45 patients were found to have cancer. One was identified on FS resulting in a sensitivity and specificity of 20% and 100%, respectively. Thus, FS changed the operation in 1 of 45 patients (2.2%). In the BC4 group, 4 of 25 patients were found to have cancer. Two were identified on FS resulting in a sensitivity and specificity of 50% and 100% respectively. Thus, FS changed the operation in 2 of 25 patients (8%). CONCLUSIONS: There is improved utility of FS in BC 4 patients as 8% avoided reoperation. However, this benefit hinges on surgeon practice regarding the management of differentiated thyroid cancer >1 cm and <4 cm.

Outcomes of total thyroidectomy with therapeutic central and lateral neck dissection with a single dose of radioiodine in the treatment of regionally advanced papillary thyroid cancer and effects on serum thyroglobulin.

BACKGROUND: Achieving an undetectable serum thyroglobulin (Tg) level (<1.0 ng/mL) after surgical and radioiodine treatment for papillary thyroid cancer (PTC) is associated with low recurrence rates and has been termed biochemical remission. This study aimed to determine the effectiveness of total thyroidectomy with therapeutic central and lateral neck dissection for regionally advanced (T1-4bN1bM0) PTC with regard to posttreatment Tg levels. METHODS: This is a single-institution retrospective cohort study of patients with regionally advanced PTC initially treated with total thyroidectomy and therapeutic levels 2-7 neck dissection from 2002 to 2012. Pathologic findings, complications, serum Tg levels, and outcomes were analyzed. RESULTS: Sixty-one patients were initially treated with total thyroidectomy and therapeutic central and lateral neck dissection for PTC involving the lateral cervical nodes (N1b). The median number of lymph nodes excised and positive was 27 (range 5-112) and 9 (range 1-67), respectively. Extranodal extension occurred in 48 %. Radioiodine was administered after surgery with a median total dose of 150 mCi (range 30-244 mCi). Recurrent or persistent cervical disease occurred in 8 (13 %) and 3 (5 %) patients, respectively, and required additional radioiodine treatment in 2 and reoperative neck dissection in 10. Three patients developed new distant metastasis, and 1 died during the median follow-up of 20 months (range 1-109 months). Undetectable unstimulated Tg (<1.0 ng/mL) without clinically detectable recurrence was experienced in 68 % of patients with initial treatment. CONCLUSIONS: Biochemical remission can be experienced in most patients presenting with regionally advanced PTC with total thyroidectomy and compartment based therapeutic neck dissection followed by a single dose of radioiodine.

Potential effects of molecular testing of indeterminate thyroid nodule fine needle aspiration biopsy on thyroidectomy volume.

BACKGROUND: Increasing utilization of genetic expression profiling (GEP) for thyroid nodules with indeterminate fine needle aspiration (FNA) results will potentially decrease the number of patients requiring diagnostic thyroidectomy. This study sought to determine the potential effects of GEP for indeterminate thyroid FNA results on thyroidectomy volume. METHODS: A retrospective review of thyroidectomy procedures performed over 1 year at the University of Michigan in the endocrine surgery division evaluated the indications for thyroidectomy, FNA Bethesda classification, and final surgical pathology to determine how application of GEP on indeterminate FNA results would affect decision for surgery and subsequent thyroidectomy volume. RESULTS: During the study period, 358 thyroidectomies were performed. The indication for procedure included: FNA findings, n = 122; symptomatic multinodular goiter, n = 85; nodule >4 cm, n = 30; Graves', n = 26; other, n = 95. FNA was performed in 231 patients. Bethesda classification included: benign, n = 69; malignant, n = 55; follicular lesion of undetermined significance, n = 59; follicular neoplasm, n = 20; suspicious for malignancy, n = 16; nondiagnostic, n = 12. If standard GEP was performed for all indeterminate FNA results, it would have influenced the decision for surgery in 68 (19 %) patients. Assuming 38 % of indeterminate FNA specimens will have benign results on genetic profiling, 27 patients would not have undergone thyroidectomy, translating into a 7.2 % decrease in overall thyroidectomy volume over a year. CONCLUSIONS: In an academic endocrine surgery program, the most common indication for thyroidectomy is an FNA result; however, standard application of GEP for all indeterminate thyroid FNAs would result in a minimal reduction in overall thyroidectomy volume.

Reoperative lymph node dissection for recurrent papillary thyroid cancer and effect on serum thyroglobulin.

BACKGROUND: Papillary thyroid cancer (PTC) has an excellent prognosis with current treatment methods. However, the rates of locoregional recurrence after initial surgical management remain significant. This study evaluates the effect of reoperative neck dissection for locoregional recurrence of PTC after initial total thyroidectomy and radioiodine therapy on the incidence of cervical recurrence and postoperative serum thyroglobulin (Tg) levels. METHODS: This is a retrospective cohort study conducted in a single academic medical center of patients with recurrent or persistent PTC isolated to the neck after previous total thyroidectomy with or without lymph node dissection and adjuvant I(131) therapy who were treated with reoperative lymph node dissection. Outcomes including operative complications, pathologic findings, and effect of surgery on Tg levels and rates of recurrent disease were analyzed. RESULTS: From 2001 to 2010, a total of 61 patients had reoperative neck dissections for recurrent cervical PTC with a complication rate of 5 %. Seventy-two percent of patients were clinically free of detectable disease, and 28 % of patients had recurrent, persistent, or newly metastatic disease detected during the follow-up period. All patients had significant decreases in Tg levels, with a median 98 % reduction in preoperative levels. However, only 21 % of patients had an undetectable stimulated Tg (<0.5 ng/mL) during the follow-up period of 15.5 months. CONCLUSIONS: Reoperative treatment of recurrent or persistent PTC can be performed with low complication rates, and Tg levels greatly decrease in most patients; however, few achieve undetectable stimulated Tg.

Evaluation of postoperative radioactive iodine scans in patients who underwent prophylactic central lymph node dissection.

BACKGROUND: Prophylactic central lymph node dissection (CLND) accompanying total thyroidectomy for papillary thyroid cancer (PTC) remains controversial. Our hypothesis is that CLND may help select patients who benefit from postoperative radioactive iodine (RAI). METHODS: A total of 119 patients who were clinically node-negative underwent total thyroidectomy/bilateral CLND for papillary thyroid cancer (PTC) > 1 cm during 2002-2010. Pathology results, RAI results, and outcomes were compared between node-positive (NP) and node-negative (NN) patients. RESULTS: NP and NN patients were similar in age, gender, tumor size, and MACIS score. Median number of nodes excised was six. The rate of permanent hypocalcemia was 1.7% without permanent recurrent laryngeal nerve injuries. Thirteen of 52 (25%) NN patients and 24 of 67 (36%) NP patients had suspicious nodes by intraoperative inspection. The node assessment negative predictive value was 75%; positive predictive value was 36%. Fifty-six percent (67/118) were NP; 100 patients were treated with RAI. Fourteen of 62 NP patients had abnormal postoperative RAI scans aside from the thyroid remnant versus 4 of 38 NN patients (23 vs. 11%, p = 0.18). Median 1-year stimulated thyroglobulin (Tg) level was 0.0 for both (range 0.0-1.2, NN; 0.0-22.7, NP; p = 0.1). NP patients received higher doses of RAI (150 vs. 30 mCi, p < 0.001). Rate of recurrent or persistent disease was 3.4%. CONCLUSIONS: Few node-negative patients have abnormal RAI scans outside of the thyroid bed. Node-positive patients had greater variability in stimulated 1-year Tg levels after higher doses of RAI. CLND may identify the patients most likely to have persistently elevated stimulated Tg after initial therapy for PTC.

Worsening central sarcopenia and increasing intra-abdominal fat correlate with decreased survival in patients with adrenocortical carcinoma.

BACKGROUND: Accurate prediction of survival from adrenocortical carcinoma (ACC) is difficult and current staging models are unreliable. Central sarcopenia as part of the cachexia syndrome is a marker of frailty and predicts mortality. This study seeks to confirm that psoas muscle density (PMD), lean psoas muscle area (LPMA), lumbar skeletal muscle index (LSMI), and intra-abdominal (IA) or subcutaneous fat (SC) can be used in combination to more accurately predict survival in ACC patients. METHODS: PMD, LPMA, IA, and SC fat were measured on serial CT scans of patients with ACC. Clinical outcome was correlated with quantitative data from patients with ACC and analyzed. A linear regression model was used to describe the relationship between PMD, LPMA, LSMI, IA, and SC fat, time to recurrence, and length of survival according to tumor stage. RESULTS: One hundred twenty-five ACC patients (94 females) were treated from 2005 to 2011. Significant morphometric predictors of survival include PMD, LPMA, and IA fat (p ≤ 0.0001, ≤ 0.0024, <0.0001, respectively) and improve prediction of survival compared to using stage alone. A 100-mm(2) increase in LPMA confers an 8 % lower hazard of death. LSMI does not change significantly between stages (p = 0.3196). CONCLUSION: Decreased PMD, LPMA, and increased IA fat suggest decreased survival in ACC patients and correlate with traditional staging systems. A more precise prediction of survival may be achieved when staging systems and morphometric measures are used in combination. Serial measurements of morphometric data are possible. The rate of change of these variables over time may be more important than the absolute value.

Paraganglioma: not just an extra-adrenal pheochromocytoma.

PURPOSE: Pheochromocytoma (PCC) and paraganglioma (PG) are evaluated and treated similarly. This study evaluates the hypothesis that tumor characteristics and outcome of patients with PCC and PG are equivalent. METHODS: Records of patients from a single institution undergoing resection of PCC or PG from 1999 to 2010 were reviewed. Data were collected for demographics, operative records, laboratory and pathologic results, adjuvant and palliative therapy given, recurrence, and length of survival. Descriptive statistics were used to describe differences between patients with benign and malignant PCC and PG. Analysis was performed using the Wilcoxon-Mann-Whitney test with p = 0.05 considered as significant. RESULTS: One hundred fifteen patients were identified (106 PCC and nine PG). Of the tumors, 5.2% were bilateral and 10.4% were malignant. Forty-three of the 115 patients underwent genetic testing; 21 out of 37 (56.8%) PCC and five out of six (83.3%) PG had a genetic mutation. Twelve patients (seven PCC and five PG) had malignant tumors. Malignant PG (mPG) exhibited more invasive pathologic characteristics. The median sizes of benign and malignant PCC (mPCC) were 4.0 (0.7-14 cm) and 5.5 cm (3.7-11.2 cm), respectively, p = 0.03. The median sizes of benign and mPG were 4.1 (2.7-5.4 cm) and 5.8 cm (4-6.2 cm), respectively, p = 0.11. Sites of recurrence were similar between the groups. Patients with mPG received chemotherapy more often than those with mPCC. With a median follow-up of 54.7 months (2.0-185.3), two out of five mPG and zero out of seven mPCC had died of the disease. CONCLUSION: Tumor size does not appear to correlate with malignancy in a clinically significant manner. Malignant paraganglioma may be more aggressive than malignant pheochromocytoma and is frequently offered more adjuvant therapy. PCC and PG should be evaluated separately in future analyses of these diseases.

How We Do It: An Innovative General Surgery Mentoring Program.

OBJECTIVE: The taxing nature of surgery residency is well-documented in the literature, with residents demonstrating high rates of burnout, depression, suicidal thoughts, sexual harassment, and racial discrimination. Mentoring has been shown to improve camaraderie, address challenges of underrepresentation in medicine, and be associated with lower burnout. However, existing formal mentoring programs tend to be career-focused and hierarchal without opportunity to discuss important sociocultural issues. An innovative approach is needed to address these cultural and anthropological issues in surgery residencies while creating camaraderie and learning alternative perspectives across different levels of training. We sought to describe the framework we used to fill these needs by creating and implementing a novel mentoring program. DESIGN: A vertical, near-peer mentoring system of 7 groups was created consisting of the following members: 1 to 2 medical students, a PGY-1 general surgery resident, a PGY-4 research resident, and a faculty member. Meetings occur every 3 to 4 months in a casual setting with the first half of the meeting dedicated to intentional reflection and the second half focused on an evidence-based discussion regarding a specific topic in the context of surgery (i.e., burnout, discrimination, allyship, and finding purpose). SETTING: Program implementation took place at the University of Michigan in Ann Arbor, MI. PARTICIPANTS: Medical students, general surgery residents, and general surgery faculty were recruited. CONCLUSIONS: We have successfully launched the pilot year of a cross-spectrum formal mentoring program in general surgery. This program emphasizes camaraderie throughout training while providing opportunities for evidence-based discussion regarding sociocultural topics. We have included increased opportunities for community inclusivity and mentoring while allowing trainees and faculty members to discuss sensitive topics in a supportive environment. We plan to continue developing the program with robust evaluation and to expand the program to other surgical specialties and to other institutions.

Intraoperative parathyroid hormone monitoring in patients with recognized multiglandular primary hyperparathyroidism.

BACKGROUND: Intraoperative parathyroid hormone (IOPTH) monitoring reliably predicts cure of primary hyperparathyroidism (PHPT) due to single-gland disease. However, its utility in PHPT caused by multiple-gland disease (MGD) is still debated, for both detection and prediction of adequate resection. Our hypothesis is that once MGD is encountered during an operation, more stringent criteria for determining adequate resection can improve cure rates. METHODS: This was a retrospective cohort study of patients with PHPT who were found to have MGD during the course of focused parathyroidectomy. IOPTH levels after completed multiple parathyroid gland excision were compared between cured patients and those with persistent hyperparathyroidism. RESULTS: Of 1855 patients undergoing focused parathyroidectomy, 243 were found to have MGD. Of the 207 study patients with MGD, 193 were cured and 14 had persistent hyperparathyroidism. After final gland excision, the mean±SEM percentage decrease in IOPTH from the baseline was of significantly greater magnitude for the cured group (90.0±0.5%) than for the persistent group (74.0±3.8%) (p<0.01). The mean±SEM IOPTH after completed multigland excision was higher in the persistent group (44.0±8.4 pg/ml) than in the cured group (34.0±3.5 pg/ml) (p=0.19), although both were within the normal range (12-65 pg/ml). When the groups were analyzed for an incremental fall of IOPTH from the baseline, the criteria of ≥75% drop and into the normal range improved the positive predictive value from 93.2 to 96.6% when compared to the standard criterion of a 50% decrease from the baseline. CONCLUSIONS: When PHPT due to MGD is recognized and focused parathyroidectomy is extended, a final postexcision PTH level that is ≥75% decreased from the baseline PTH level and in the normal range should be used to predict adequate gland resection.

Natural Language Processing to Estimate Clinical Competency Committee Ratings.

OBJECTIVE: Residency program faculty participate in clinical competency committee (CCC) meetings, which are designed to evaluate residents' performance and aid in the development of individualized learning plans. In preparation for the CCC meetings, faculty members synthesize performance information from a variety of sources. Natural language processing (NLP), a form of artificial intelligence, might facilitate these complex holistic reviews. However, there is little research involving the application of this technology to resident performance assessments. With this study, we examine whether NLP can be used to estimate CCC ratings. DESIGN: We analyzed end-of-rotation assessments and CCC assessments for all surgical residents who trained at one institution between 2014 and 2018. We created models of end-of-rotation assessment ratings and text to predict dichotomized CCC assessment ratings for 16 Accreditation Council for Graduate Medical Education (ACGME) Milestones. We compared the performance of models with and without predictors derived from NLP of end-of-rotation assessment text. RESULTS: We analyzed 594 end-of-rotation assessments and 97 CCC assessments for 24 general surgery residents. The mean (standard deviation) for area under the receiver operating characteristic curve (AUC) was 0.84 (0.05) for models with only non-NLP predictors, 0.83 (0.06) for models with only NLP predictors, and 0.87 (0.05) for models with both NLP and non-NLP predictors. CONCLUSIONS: NLP can identify language correlated with specific ACGME Milestone ratings. In preparation for CCC meetings, faculty could use information automatically extracted from text to focus attention on residents who might benefit from additional support and guide the development of educational interventions.

Early biochemical response to parathyroidectomy for primary hyperparathyroidism and its predictive value for recurrent hypercalcemia and recurrent primary hyperparathyroidism.

BACKGROUND: The traditional definition of cure after parathyroidectomy (PTX) for primary hyperparathyroidism is normocalcemia. Our hypothesis was that early postoperative levels of serum calcium and parathyroid hormone after PTX would have predictive value for later recurrence. METHODS: We performed a retrospective study of 1,146 patients with primary hyperparathyroidism who underwent PTX and had long-term biochemical follow-up. The first postoperative serum level of calcium and parathyroid hormone values were used to categorize patients into the following four early biochemical response groups: (1) complete response (normal calcium and normal parathyroid hormone), (2) partial response with hyperparathormonemia (normal calcium and increased parathyroid hormone), (3) partial response with hypercalcemia (increased calcium and normal parathyroid hormone), and (4) non-response (increases in both calcium and parathyroid hormone). Incidences of recurrent hypercalcemia and recurrent primary hyperparathyroidism >6 months after operation were then analyzed. RESULTS: The overall rate of any elevated serum levels of calcium and any increase in serum levels of parathyroid hormone during >6-month follow-up was 9.8% (112 of 1146), with 6.6% (57 of 861) for group 1, 27% (35 of 129) for group 2, and 16% (20 of 127) for group 3 (P < .02). Partial biochemical responses with either increased serum calcium or increased parathyroid hormone levels were the strongest predictors of any episode of increased serum levels of calcium after 6 months and was associated with 2.7× to 4.3× the risk of recurrent primary hyperparathyroidism, respectively. CONCLUSION: This study demonstrates the importance of measuring parathyroid hormone in the early postoperative period to better predict later recurrent primary hyperparathyroidism.

Comparing intraoperative parathyroid identification based on surgeon experience versus near infrared autofluorescence detection - A surgeon-blinded multi-centric study.

BACKGROUND: Near infrared autofluorescence (NIRAF) detection has previously demonstrated significant potential for real-time parathyroid gland identification. However, the performance of a NIRAF detection device - PTeye® - remains to be evaluated relative to a surgeon's own ability to identify parathyroid glands. METHODS: Patients eligible for thyroidectomy and/or parathyroidectomy were enrolled under 6 endocrine surgeons at 3 high-volume institutions. Participating surgeons were categorized based on years of experience. All surgeons were blinded to output of PTeye® when identifying tissues. The surgeon's performance for parathyroid discrimination was then compared with PTeye®. Histology served as gold standard for excised specimens, while expert surgeon's opinion was used to validate in-situ tissues. RESULTS: PTeye® achieved 92.7% accuracy across 167 patients recruited. Junior surgeons (<5 years of experience) were found to have lower confidence in parathyroid identification and higher tissue misclassification rate per specimen when compared to PTeye® and senior surgeons (>10 years of experience). CONCLUSIONS: NIRAF detection with PTeye® can be a valuable intraoperative adjunct technology to aid in parathyroid identification for surgeons.

Molecular classification and prognostication of adrenocortical tumors by transcriptome profiling.

PURPOSE: Our understanding of adrenocortical carcinoma (ACC) has improved considerably, yet many unanswered questions remain. For instance, can molecular subtypes of ACC be identified? If so, what is their underlying pathogenetic basis and do they possess clinical significance? EXPERIMENTAL DESIGN: We did a whole genome gene expression study of a large cohort of adrenocortical tissues annotated with clinicopathologic data. Using Affymetrix Human Genome U133 Plus 2.0 oligonucleotide arrays, transcriptional profiles were generated for 10 normal adrenal cortices (NC), 22 adrenocortical adenomas (ACA), and 33 ACCs. RESULTS: The overall classification of adrenocortical tumors was recapitulated using principal component analysis of the entire data set. The NC and ACA cohorts showed little intragroup variation, whereas the ACC cohort revealed much greater variation in gene expression. A robust list of 2,875 differentially expressed genes in ACC compared with both NC and ACA was generated and used in functional enrichment analysis to find pathways and attributes of biological significance. Cluster analysis of the ACCs revealed two subtypes that reflected tumor proliferation, as measured by mitotic counts and cell cycle genes. Kaplan-Meier analysis of these ACC clusters showed a significant difference in survival (P < 0.020). Multivariate Cox modeling using stage, mitotic rate, and gene expression data as measured by the first principal component for ACC samples showed that gene expression data contains significant independent prognostic information (P < 0.017). CONCLUSIONS: This study lays the foundation for the molecular classification and prognostication of adrenocortical tumors and also provides a rich source of potential diagnostic and prognostic markers.

An international perspective on ultrasound training and use for thyroid and parathyroid disease.

BACKGROUND: Use of ultrasound (USN) by endocrine surgeons has dramatically increased. Presently, optimal training and certification requirements have not been standardized at any level (resident/fellow/attending). We sought to define the types of USN training endocrine surgeons receive and how USN is employed in practice. We hypothesized that in more recent years fellowship-trained endocrine surgeons were more likely to receive formal training in the use of USN during their endocrine surgery fellowship. METHODS: A survey link was sent via email to a large group of endocrine surgeons around the world asking about the settings in which they received USN training, the type of instruction received, current use of USN, and other various questions. chi(2) analysis was performed and P < 0.05 was considered significant. RESULTS: One hundred twenty-one surveys were collected from respondents in 27 countries. Median time from completion of residency to the present was 17 years (range = 2-49). Fifty-nine percent of both fellowship- and nonfellowship-trained endocrine surgeons currently use USN in their practice. Of those currently performing USN, 38% reported no USN training of any kind (47% international vs. 23% United States). USN experience among international and U.S. residents was not different (P = 0.27). Fifty-nine percent of respondents reported completing an endocrine surgery fellowship; of those, 85% reported no formal USN training. Forty-one percent reported not being comfortable performing USN at the completion of their endocrine surgery fellowships, requiring the presence of someone else to assist with the exam. CONCLUSIONS: USN training among endocrine surgeons varies widely around the world. Despite an increase in the number of formal endocrine surgery fellowships offered, it does not appear that the number with formal USN training and certification has increased. Formal USN certification is achieved in only a minority of cases among practicing endocrine surgeons. It is currently unknown whether there is a difference in competency between endocrine surgeons with formal versus informal USN training.

Proposal for modification of the ENSAT staging system for adrenocortical carcinoma using tumor grade.

PURPOSE: Various staging systems for adrenocortical carcinoma (ACC) have been proposed. We hypothesized that incorporating tumor grade into the current European Network for the Study of Adrenal Tumors (ENSAT) staging system would improve the ability to more accurately predict time to recurrence and death. METHODS: A retrospective review of patients included in the University of Michigan ACC database from 2005 to 2009 was done; and stage, tumor grade, time to recurrence, and death were recorded and analyzed using the Cox regression and Kaplan-Meier survival curves. RESULTS: Ninety one patients had complete information for inclusion. The median follow-up was 24 months while the median time to recurrence was 4.1 months. There were 28 deaths; overall, tumor grade showed a significant difference in time to tumor recurrence (p = 0.011) and time to death (p = 0.004). Time to death among stage 2 patients separated into those with high- and low-grade tumors reached statistical significance (p = 0.05), and notable but not statistically significant differences were identified in all stages. Based on tumor grade and survival curves, modifications to the current ENSAT staging system were made. CONCLUSION: Tumor grade plays a significant role in the outcome of patients with ACC. High-grade tumors are associated with shorter disease-free intervals and shorter overall survival. The proposed modification of the ENSAT staging system allows for incorporation of tumor grade when predicting overall survival.

Leadership-Specific Feedback Practices in Surgical Residency: A Qualitative Study.

OBJECTIVE: The importance of feedback is well recognized in surgical training. Although there is increased focus on leadership as an essential competency in surgical training, it is unclear whether surgical residents receive effective feedback on leadership performance. We performed an exploratory qualitative study with surgical residents to understand current leadership-specific feedback practices in one surgical training program. DESIGN: We conducted semistructured interviews with surgical residents. Using line-by-line coding in an iterative process, we focused on feedback on leadership performance to capture both semantic and conceptual data. SETTING: The general surgery residency program at the University of Michigan, a tertiary care, academic institution. PARTICIPANTS: Residents were purposively selected to include key informants and comprise a balanced sample with respect to postgraduate year, gender, and race. RESULTS: Four major themes were identified during the thematic analysis: (1) the importance of feedback for leadership development in residency; (2) inadequacy of current feedback mechanisms; (3) barriers to giving and receiving leadership-specific feedback; and (4) resident-driven recommendations for better leadership feedback. CONCLUSIONS: Many surgical residents do not receive effective leadership feedback, although they express strong desire for formal evaluation of leadership skills. Establishing avenues for feedback on leadership performance will help bridge this gap. Additionally, training to give and receive leadership-specific feedback may improve the quality and incorporation of delivered feedback for developing surgeon-leaders.

Does Intentional Support of Degree Programs in General Surgery Residency Affect Research Productivity or Pursuit of Academic Surgery? A Multi-Institutional Study.

OBJECTIVE: To determine whether pursuit of an advanced degree during dedicated research time (DRT) in a general surgery residency training program impacts a resident's research productivity. DESIGN: A retrospective, multi-institutional cohort study. SETTING: General surgery residency programs that were approved to graduate more than 5 categorical residents per year and that offered at least 1 year of DRT were contacted for participation in the study. A total of 10 general surgery residency programs agreed to participate in the study. PARTICIPANTS: Residents who started their residency between 2000 and 2012 and spent at least one full year in DRT (n = 511) were included. Those who completed an advanced degree were compared on the following parameters to those who did not complete one: total number of papers, first-author papers, the Journal Citation Reports impact factors of publication (2018, or most recent), and first position after residency or fellowship training. RESULTS: During DRT, 87 (17%) residents obtained an advanced degree. The most common degree obtained was a Master of Public Health (MPH, n = 42 (48.8%)). Residents who did not obtain an advanced degree during DRT published fewer papers (median 8, [interquartile range 4-12]) than those who obtained a degree (9, [6-17]) (p = 0.002). They also published fewer first author papers (3, [2-6]) vs (5, [2-9]) (p = 0.002) than those who obtained a degree. Resident impact factor (RIF) was calculated using Journal Citation Reports impact factor and author position. Those who did not earn an advanced degree had a lower RIF (adjusted RIF, 84 ± 4 vs 134 ± 5, p < 0.001) compared to those who did. There was no association between obtaining a degree and pursuit of academic surgery (p = 0.13) CONCLUSIONS: Pursuit of an advanced degree during DRT is associated with increased research productivity but is not associated with pursuit of an academic career.