Comparison of incidental parathyroid tissue detection rates on pathology after total thyroidectomy performed with or without near-infrared autofluorescence imaging.

BACKGROUND: Near-infrared autofluorescence imaging is an adjunct to parathyroid identification. As it does not show perfusion, it is important to study its impact during thyroidectomy by measuring quantifiable data on parathyroid detection rather than function. The aim of this study was to compare incidental parathyroidectomy rates in patients undergoing total thyroidectomy with or without near-infrared autofluorescence. METHODS: Retrospective study of patients who underwent total thyroidectomy between 2014 and 2022 at one center. Clinical parameters, including rates of incidental parathyroid tissue on pathology reports, were compared between near-infrared autofluorescence and non-near-infrared autofluorescence groups. Near-infrared autofluorescence was used to guide dissection (identification) and/or to confirm tissue as parathyroid (confirmation). Statistical analysis was done with Wilcoxon rank sum test and χ2 analysis. RESULTS: There were 300 patients in the near-infrared autofluorescence and 750 patients in the non-near-infrared autofluorescence group. The rate of incidental parathyroid tissue detection on final pathology was 13.3% (n = 40) in the near-infrared autofluorescence and 23.2% (n = 174) in the non-near-infrared autofluorescence group (P < .001). The rate of incidental parathyroid tissue detected on pathology with near-infrared autofluorescence decreased when used for identification and confirmation of parathyroid tissue (30.0% to 13.4%, P < .001), but not when used for confirmation only (19.6% to 18.5%, P = .89). Impact of near-infra red autofluorescence in decreasing the rate of incidental parathyroid tissue was more profound for early (38.5% to 17.1%) versus mid-late career surgeons (20% to 13%). CONCLUSION: Our results suggest that the use of near-infrared autofluorescence may help decrease the rate of incidental parathyroid tissue detected on final pathology if used for both identification and confirmation of parathyroid glands during thyroidectomy.

Characterization of indocyanine green fluorescence imaging patterns of pheochromocytomas.

BACKGROUND: Indocyanine green (ICG) fluorescence is a new intraoperative imaging modality for adrenal tumors. Previous work suggested that pheochromocytomas did not show fluorescence, but experience is limited. The objective of this study is to analyze fluorescence imaging patterns of pheochromocytomas. METHODS: This was an IRB-approved retrospective study. Patients who underwent adrenalectomy with ICG imaging were identified from a departmental database. Intraoperative fluorescence patterns were analyzed by reviewing surgical videos. Descriptive and comparative statistical analyses were performed to determine factors associated with different fluorescence patterns of pheochromocytomas. RESULTS: Of the 46 pheochromocytomas included, 50% (n = 23) exhibited fluorescence. Parameters predicting fluorescence on univariate analysis were age, tumor size and hereditary. On multivariate analysis, tumor size was the only predictive parameter of ICG fluorescence, with loss of fluorescence at a threshold of > 3.2 cm (p = 0.004). CONCLUSIONS: This is the largest cohort to date assessing fluorescence properties of pheochromocytomas. In contrast to previous studies, we demonstrated that smaller pheochromocytomas do exhibit fluorescence. This may support the application of intraoperative ICG imaging for smaller or bilateral pheochromocytomas, which may assist in identification and/or cortical-sparing during adrenalectomy.

A multicenter evaluation of near-infrared autofluorescence imaging of parathyroid glands in thyroid and parathyroid surgery.

BACKGROUND: The usefulness of incorporating near-infrared autofluorescence into the surgical workflow of endocrine surgeons is unclear. Our aim was to develop a prospective registry and gather expert opinion on appropriate use of this technology. METHODS: This was a prospective multicenter collaborative study of patients undergoing thyroidectomy and parathyroidectomy at 7 academic centers. A questionnaire was disseminated among 24 participating surgeons. RESULTS: Overall, 827 thyroidectomy and parathyroidectomy procedures were entered into registry: 42% of surgeons found near-infrared autofluorescence useful in identifying parathyroid glands before they became apparent; 67% correlated near-infrared autofluorescence pattern to normal and abnormal glands; 38% of surgeons used near-infrared autofluorescence, rather than frozen section, to confirm parathyroid tissue; and 87% and 78% of surgeons reported near-infrared autofluorescence did not improve the success rate after parathyroidectomy or the ability to find ectopic glands, respectively. During thyroidectomy, 66% of surgeons routinely used near-infrared autofluorescence to rule out inadvertent parathyroidectomy. However, only 36% and 45% felt near-infrared autofluorescence decreased inadvertent parathyroidectomy rates and improved ability to preserve parathyroid glands during central neck dissections, respectively. CONCLUSION: This survey study identified areas of greatest potential use for near-infrared autofluorescence, which can form the basis of future objective trials to document the usefulness of this technology.

Laparoscopic versus robotic adrenalectomy in severely obese patients.

BACKGROUND: Over the last 20 years, the prevalence of severe obesity (body mass index ≥ 35 kg/m2) has almost doubled. This condition increases the challenge of laparoscopic adrenalectomy (LA) by creating problems with instrument reach, adequate exposure, and visualization. The aim was to compare perioperative outcomes of laparoscopic versus robotic adrenalectomy (RA) in severely obese patients. METHODS: This was an institutional review board-approved retrospective study. Prospectively collected clinical parameters of patients who underwent LA versus RA between 2000 and 2021 at a single center were compared using Mann-Whitney U, ANOVA, Chi-square, and multivariate regression analysis. Continuous data are expressed as median (interquartile range). RESULTS: For lateral transabdominal (LT) adrenalectomies, skin-to-skin operative time (OT) [164.5 (71.0) vs 198.8 (117.0) minutes, p = 0.006] and estimated blood loss [26.2 (15.0) vs 72.6 (50.0) ml, p = 0.010] were less in RA versus LA group, respectively. Positive margin rate, hospital stay and 90-day morbidity were similar between the groups (p = NS). For posterior retroperitoneal (PR) approach, operative time and perioperative outcomes were similar between LA and RA groups. Multivariate analysis demonstrated robotic versus laparoscopic technique (p = 0.006) to be an independent predictor of a shorter OT. CONCLUSION: There was a benefit of robotic over the laparoscopic LT adrenalectomy regarding OT and estimated blood loss. Although limited by the small sample size, there was no difference regarding perioperative outcomes between RA and LA performed through a PR approach.

Quantifying disease-specific symptom improvement after parathyroid and thyroid surgery using patient-reported outcome measures.

BACKGROUND: Patient-reported outcome measures for parathyroid and thyroid disease (PROMPT) is a 30-question, previously validated, survey assessing symptoms on a scale from 0 to 100. Using PROMPT, we aimed to assess symptom improvement for patients undergoing thyroidectomy and parathyroidectomy. METHODS: Single-center prospective study in which PROMPT was used to assess symptom improvement in patients undergoing parathyroidectomy or thyroidectomy. A postoperative assessment was performed approximately 6 months after surgery and compared to its baseline preoperative assessment. RESULTS: A total of 144 patients completed both assessments (71 parathyroidectomy, 73 thyroidectomy). Parathyroidectomy patients demonstrated significant improvements in all hyperparathyroidism domains (38.2-28.3, p < 0.001) regardless of preoperative calcium and parathyroid hormone levels. Thyroidectomy patients experienced improvement in their compressive symptoms (25.6-16.5, p < 0.001). CONCLUSIONS: PROMPT objectively demonstrates the clinical effectiveness of parathyroidectomy and thyroidectomy in alleviating subjective patient symptoms. PROMPT offers promising use as a standardized metric to assess quality of life improvement within endocrine surgery.

Laparoscopic versus robotic adrenalectomy in pheochromocytoma patients.

BACKGROUND AND OBJECTIVES: Pheochromocytoma is a challenging tumor type requiring resection with a clear margin and an intact capsule to prevent recurrences. Our aim was to compare perioperative outcomes of laparoscopic adrenalectomy (LA) versus robotic adrenalectomy (RA) for pheochromocytoma. METHODS: In an institutional review board-approved retrospective study, clinical parameters of patients who underwent LA versus RA at a single center were compared using Mann-Whitney U, χ2 , and survival analyses. Continuous data are expressed as median (interquartile range). RESULTS: There was a total of 157 patients (RA: n = 87, LA: n = 70) analyzed. Estimated blood loss (36.3 [35.0] vs. 99.9 [65.0] cc, p = 0.020) and hospital stay (1.3 [0.0] vs. 2.2 [1.0] days, p = 0.010) were lower in robotic versus laparoscopic group, respectively. Disease-free and overall survival was similar between groups. The rate of conversion to open for tumors ≥5 cm was less in the robotic group (0% vs. 14%, respectively, p = 0.048). CONCLUSION: In this study, long-term outcomes of LA and RA were similar, although adrenalectomies performed robotically were associated with less blood loss, shorter hospital stay, and a lower chance of conversion to open in the case of large tumors.

Preoperative Calcium and Parathyroid Hormone Values Are Poor Predictors of Gland Volume and Multigland Disease in Primary Hyperparathyroidism: A Review of 2000 Consecutive Patients.

OBJECTIVE: Calcium and parathyroid hormone (PTH) values are believed to have a linear relationship in patients with primary hyperparathyroidism and correlate with parathyroid gland size, with higher values predicting single-gland disease. In this modern series, these preoperative values were correlated with operative findings to determine their utility in predicting the gland involvement at parathyroid exploration. METHODS: Two thousand consecutive patients who underwent initial surgery for sporadic primary hyperparathyroidism from 2000 to 2014 were reviewed. All patients underwent a 4-gland exploration. Relationships between preoperative calcium and PTH values with the total gland volume of each patient were examined and stratified using the number of involved glands: single adenoma (SA), double adenoma (DA), and hyperplasia (H). RESULTS: There were 1274 (64%) SA, 359 (18%) DA, and 367 (18%) H cases. There was a poor correlation between preoperative calcium and PTH values (R = 0.37) and both poorly correlated with the total gland volume (R < 0.40). Similarly, subgroup analysis using the number of involved glands showed poor correlation. The mean total gland volume was similar among all subgroups (SA = 1.28 cm3, DA = 1.43 cm3, and H = 1.27 cm3; P = .52), implying that individual glands were smaller in multigland disease. SA was found in 271 (53%) of patients with calcium levels of ≤10.5 mg/dL and 122 (78%) with levels of ≥12 mg/dL (P < .001). CONCLUSION: This is the largest series correlating preoperative calcium and PTH values with operative findings of gland size and number of diseased glands. Although a lower calcium value predicts somewhat more multigland disease, the overall poor correlation should make the parathyroid surgeon aware that gland size and multigland disease cannot be predicted by preoperative laboratory testing.

A critical analysis of laparoscopic and open approaches to sporadic pancreatic insulinoma resection in the modern era.

BACKGROUND: A single center experience with sporadic pancreatic insulinoma was analyzed to develop an algorithm for modern surgical management. METHODS: Thirty-four patients undergoing surgery from 2001 to 2019 were reviewed. RESULTS: The majority underwent enucleation (10 laparoscopic, 15 open). Laparoscopy was performed in 22 patients with conversion to open in 11, mostly related to the proximity of the tumor to the pancreatic duct (n = 4). Tumors on the anterior and posterior surface of the pancreas in all anatomic locations were completed with laparoscopic enucleation. Overall, the clinically-relevant postoperative pancreatic fistula (CR-POPF) rate was 21%, with no difference between laparoscopic versus open enucleation (10% vs 20%, p = 0.50) or enucleation versus resection (16% vs 33%, p = 0.27). Laparoscopic enucleation had shorter median hospital length of stay (LOS) compared with open (4 vs 7 days, p = 0.02). CONCLUSIONS: Laparoscopic enucleation does not increase the CR-POPF risk and provides an advantage with a shorter hospital LOS in select patients. Tumor location and relationship to the pancreatic duct guide surgical decision-making. These findings highlight tumor-specific criteria that would benefit from a minimally invasive approach.

Thyroid nodule molecular profiling: The clinical utility of Afirma Xpression Atlas for nodules with Afirma Genomic Sequencing Classifier-suspicious results.

BACKGROUND: The Afirma Genomic Sequencing Classifier uses whole transcriptome RNA sequencing to identify thyroid nodules as benign or suspicious. The Afirma Xpression Atlas became available in 2018 and reports findings across 593 genes, including 905 variants and 235 fusions. When an alteration is identified, its risk of malignancy and associated neoplasm type is listed. We report the results of Afirma Xpression Atlas testing at our institution during its first 2 years of clinical use. METHODS: All patient charts with indeterminate thyroid nodules and Afirma Xpression Atlas results at our institution were reviewed. Thyroid nodule characteristics, cytology, Afirma Genomic Sequencing Classifier results, Afirma Xpression Atlas results, and final histopathology were reported. RESULTS: Afirma Xpression Atlas was performed on 136 indeterminate nodules since May 2018, and 103 met inclusion criteria. Forty-three nodules had positive Afirma Xpression Atlas results, and of these, 83.7% were follicular cell-derived thyroid cancer on surgical histopathology. This is similar to the overall 82.5% positive predictive value among Afirma Genomic Sequencing Classifier-suspicious indeterminate nodules during the same time period. Of the 60 nodules with negative Afirma Xpression Atlas, 73.3% were follicular cell-derived thyroid cancer on surgical histopathology. CONCLUSION: Afirma Xpression Atlas positivity is predictive of follicular cell-derived thyroid cancer, but its positive predictive value is similar to that of Genomic Sequencing Classifier-suspicious results alone at our institution, which is higher than previously published. Specific mutations likely predict follicular cell-derived thyroid cancer with higher accuracy, but our current sample size of any given mutation is too small to evaluate this further. Larger studies are needed to determine whether Afirma Xpression Atlas results predictably inform the risk of malignancy and tumor characteristics in thyroid nodules.

Standardization of thyroid fine needle aspiration procedure and outcomes within an endocrine surgery department.

BACKGROUND: Fine needle aspiration (FNA) biopsy is an essential procedure for thyroid nodules. Although, the efficacy of surgeon-performed thyroid FNA biopsies has been demonstrated in the literature, there are insufficient data regarding how to establish an efficient program with a low insufficiency rate within a group practice. METHODS: An endocrine surgery thyroid FNA biopsy program was established in 2000 by one surgeon, with training of additional partners during fellowship and upon recruitment. The results within 18 years were analyzed. The FNA biopsies were performed by endocrine surgeons under ultrasound guidance without on-site pathologist review. RESULTS: A total of 5,469 FNA biopsies were performed by 7 surgeons. The total number of FNA biopsies performed by each surgeon varied between 291-1,378. FNA biopsies were performed in 2 passes using 22-gauge needles under constant suction. The overall insufficiency rate was 4.3%, with individual surgeon rates ranging between 2.7% and 7.2%. The insufficiency rate for the whole team ranged between 3.3% and 5% when examined in 5-year blocks. CONCLUSIONS: This study shows that an establishment of a highly efficient thyroid FNA biopsy program within a group practice is possible with a structured endocrine surgical training and adoption of a standard technique.

QIC: A Pilot Quality Improvement Curriculum Utilizing Interactive, Team-based Workshops.

BACKGROUND: Incorporation of quality improvement (QI) training is essential to meet the milestones set forth by the Accreditation Council for Graduate Medical Education. However, there is no standardized curriculum. OBJECTIVE: We aimed to create a QI curriculum through the integration of didactics and team-based learning via the completion of resident-led QI projects. METHODS: An institutional review board-approved QI curriculum consisting of four interactive workshops was developed. The workshops introduced the various components of QI, with a focus on Plan-Do-Study-Act. Anonymous and voluntary precurriculum and postcurriculum surveys were administered during the study period in 2018. RESULTS: Fifty surgical residents participated in the curriculum, and four QI projects were completed, with 23 residents completing both precurriculum and postcurriculum surveys. Following the curriculum, residents were more confident in their ability to design a QI project (5.7 ± 2.6 versus 7.1 ± 1.9, P = 0.02), write a problem statement (6.7 ± 2.5 versus 7.8 ± 1.1, P = 0.04), and write an aim statement (6.7 ± 2.6 versus 7.8 ± 1.2, P = 0.04). Residents also improved in perceived ability to lead a QI project (5.6 ± 2.9 versus 6.9 ± 1.9, P = 0.05), knowing the steps to complete a QI project (6.0 ± 2.8 versus 7.4 ± 1.7, P = 0.04), and familiarity with QI terminology (5.6 ± 2.6 versus 7.0 ± 1.9, P = 0.03). CONCLUSIONS: We found that the curriculum was a success and was well received. In addition, there was an improvement in perceived competency and confidence surrounding some of the steps necessary to complete a QI endeavor.

Intraoperative near-infrared imaging of parathyroid glands: A comparison of first- and second-generation technologies.

BACKGROUND: Intraoperative near-infrared imaging (NIFI) of parathyroid glands (PG) by first-generation technology had limited image quality and depth penetration. Second-generation NIFI has recently been introduced. Our aim was to compare (1) capability to detect PG and (2) image quality between older and newer technologies. METHODS: Accurately detecting PG, as well as, quality of autofluorescence (AF) was compared between an older charge-coupled device (CCD) camera and a newer complementary metal-oxide semiconductor (CMOS). χ2 , t test, and analysis of variance were used for analysis. RESULTS: There were 300 patients who underwent parathyroidectomy (PTX) and/or thyroidectomy (THY) with NIFI, 200 with CCD, and 100 with CMOS. Although both NIFI technologies detected >94% of PG, CMOS was superior to CCD. Comparing AF quality, mean pixel intensity of PG compared with the background was higher with CMOS compared with CCD. When comparing PG detected by NIFI before visual identification by a surgeon, both CCD and CMOS had similar results (25% vs. 22%; p = .3). CONCLUSION: Both NIFI cameras were excellent at detecting PG. Second-generation NIFI (CMOS) displayed higher detection rates and AF intensity. Although surgeons identified majority of PG before NIFI detection, 25% of PG were identified with NIFI first, suggesting future advancements of this technology may expand its applications during parathyroid/thyroid operations.

Selective parathyroid venous sampling in reoperative parathyroid surgery: A key localization tool when noninvasive tests are unrevealing.

BACKGROUND: Preoperative localization studies are essential for parathyroid re-exploration. When noninvasive studies do not regionalize the abnormal parathyroid gland, selective parathyroid venous sampling may be employed. We studied the utility of parathyroid venous sampling in reoperative parathyroid surgery and the factors that may affect parathyroid venous sampling results. METHODS: Patients with hyperparathyroidism and previous cervical surgery undergoing evaluation for reoperative parathyroidectomy over a 20-year period were identified. Patients with indeterminate or negative noninvasive studies underwent parathyroid venous sampling. Parathyroid hormone values were mapped with a ≥2-fold increase above peripheral signifying positive parathyroid venous sampling. These results were correlated with reoperative findings. RESULTS: Parathyroid venous sampling was positive in 113 of 140 (81%). Re-exploration occurred in 75 (66%). Parathyroid venous sampling correctly detected the region of abnormal glands in 58 (77%). With 1 gradient, 1 abnormal gland was found in 81%. With multiple gradients, 1 abnormal gland was found in 78%, most often at the site with the largest gradient. Eighty percent of patients who underwent reoperative parathyroidectomy were biochemically cured. CONCLUSION: Parathyroid venous sampling can guide parathyroid re-exploration when noninvasive localizing studies are indeterminate. Expectation of 1 versus multiple remaining glands was key in interpreting the results.

Friendship paradox biases perceptions in directed networks.

Social networks shape perceptions by exposing people to the actions and opinions of their peers. However, the perceived popularity of a trait or an opinion may be very different from its actual popularity. We attribute this perception bias to friendship paradox and identify conditions under which it appears. We validate the findings empirically using Twitter data. Within posts made by users in our sample, we identify topics that appear more often within users' social feeds than they do globally among all posts. We also present a polling algorithm that leverages the friendship paradox to obtain a statistically efficient estimate of a topic's global prevalence from biased individual perceptions. We characterize the polling estimate and validate it through synthetic polling experiments on Twitter data. Our paper elucidates the non-intuitive ways in which the structure of directed networks can distort perceptions and presents approaches to mitigate this bias.

Need for Completion Thyroidectomy in Patients Undergoing Lobectomy for Indeterminate and High-Risk Nodules: Impact of Intra-Operative Findings and Final Pathology.

INTRODUCTION: Current guidelines increasingly suggest the use of thyroid lobectomy for indeterminate (Bethesda 3 and 4) and high-risk (Bethesda 5 and 6) thyroid nodules; however, the clinical reality is often very different. MATERIALS AND METHODS: The aim of this study was to determine the rate of completion thyroidectomy (CTx) for indeterminate and high-risk thyroid nodules which are pre-operatively classified as suitable for unilateral resection (lobe eligible) based on current guidelines. Seven hundred consecutive patients with thyroid nodules and FNA cytology over four years (2015-2018) were reviewed. RESULTS: Distribution of the dominant nodules by Bethesda was: non-diagnostic 3.9%, benign 28.1%, atypia of unknown significance 19.0%, follicular neoplasm 23.6%, suspicious for malignancy 6.1% and malignancy 19.3%. Of 298 indeterminate nodules, 68.8% (205/298) had relative but independent indications for a total thyroidectomy (TTx) and the remainder were candidates for lobectomy. For these lobe eligible patients, the overall risk of ultimately needing a TTx was 19.4% (18/93), comprising 4.3% (4/93) from intra-operative findings and 15.7% (14/89) from final pathology. Similarly, of 170 high-risk nodules, 63.5% (108/170) had upfront indications for a TTx and the remaining 62 nodules were lobe eligible. Of the patients taken to the operating room for a lobectomy, 21.0% (13/62) were upgraded to a TTx intra-operatively and 26.5% (13/49) post-operatively. The lobe success rate for indeterminate nodules was 25.2% and for high-risk nodules was 21.2%. The rate of CTx, or the proportion of patients needing a second operation was 15.7% (14/89) and 26.5% (13/49), respectively. CONCLUSIONS: In counselling a patient for surgery, the risk of needing a more radical initial procedure or second surgery needs to be accurately explained. There are three points of care that can influence operative strategy, pre-operatively by way of high-risk clinical factors, intra-operatively via anatomical findings and post-operatively in response to unrecognized pathological features. Additionally, the patient's personal value judgment and level of risk aversion should be taken into consideration.

Autofluorescence imaging of parathyroid glands: An assessment of potential indications.

BACKGROUND: The aim of this study was to determine both the accuracy of near infrared fluorescence imaging to detect parathyroid glands and the potential indications of near infrared fluorescence imaging in thyroid and parathyroid surgery by correlating the autofluorescence signature with the pathologic specimen. METHODS: This was an institutional review board-approved, prospective study of patients undergoing thyroidectomy and parathyroidectomy with near infrared fluorescence imaging. Each specimen sent to pathology was inspected with near infrared fluorescence imaging and predicted to be either parathyroid or non-parathyroid tissue by its autofluorescence signature and then correlated with the pathologic findings. RESULTS: Autofluorescence was demonstrated to be present in 98% of the parathyroid glands, with 23% identified correctly with infrared based on the autofluorescence signature before visual identification by the surgeon. There were 550 specimens that were imaged with autofluorescence and then sent to pathology. For these samples, sensitivity, specificity, and positive and negative predictive values to predict parathyroid tissue were 98.5%, 97.2%, 95.1%, and 99.1%. In 5% of the total thyroidectomy specimens, incidentally resected parathyroid glands were identified with autofluorescence, leading to their subsequent reimplantation. In patients with parathyroid disease and negative preoperative localization, 21% of abnormal glands were recognized with autofluorescence before visual identification by the surgeon. CONCLUSION: Although the ability of infrared autofluorescence to confirm the presence of parathyroid tissue within surgical specimens was high, its power to find parathyroid glands in situ before visual recognition by surgeons was low. These advantages and limitations should be kept in mind when incorporating this technology into an endocrine surgical practice. Once a parathyroid seems to have been identified by the surgeon or tissue that looks like a parathyroid gland is identified, the autofluorescence signature is a very accurate assurance of parathyroid tissue.

Thyroglobulin washout from cervical lymph node fine needle aspiration biopsies in patients with differentiated thyroid cancer: an analysis of different expressions to use in post-total thyroidectomy follow-up.

INTRODUCTION: Although frequently used as an adjunct to cytology in patients with differentiated thyroid cancers, interpretation of thyroglobulin washout remains unclear. We aim to compare the utility of different analytic tools to develop recommendations for use in post-total thyroidectomy follow-up. METHODS: This is an institutional review board-approved retrospective study of patients who underwent lymph node fine needle aspiration biopsy with thyroglobulin washout between 2012 and 2018, during the post-total thyroidectomy follow-up of differentiated thyroid cancer. The utilities of thyroglobulin washout concentration, thyroglobulin washout/serum thyroglobulin ratio, and absolute thyroglobulin content were compared. RESULTS: Sixty-four patients underwent 79 fine needle aspirations with thyroglobulin washout of cervical lymph nodes. Fifty-two lymph nodes were found to be metastatic and 27 benign. One patient had a pathologically confirmed lymph node metastasis despite a thyroglobulin washout of 0. The optimal cutoffs of thyroglobulin washout, thyroglobulin washout/serum thyroglobulin ratio, and absolute thyroglobulin content to predict metastatic involvement were 2.5 ng/ml (94% sensitive, 100% specific), 0.1 (100% sensitive and specific), and 12.5 (94% sensitive, 100% specific), respectively. The second measure lacked utility in patients with undetectable serum thyroglobulin. CONCLUSION: The use of thyroglobulin washout concentration or thyroglobulin washout/serum thyroglobulin ratio has drawbacks based on variations in technique and clinical scenario. Absolute thyroglobulin content is an alternative that may be a more objective expression of thyroglobulin washout.

Recognition of primary hyperparathyroidism: Delayed time course from hypercalcemia to surgery.

BACKGROUND: Under recognition of primary hyperparathyroidism can lead to delays in diagnosis and surgical management. We aimed to establish a time course for primary hyperparathyroidism from initial hypercalcemia to surgery and evaluate the impact of guidelines for surgical referral on this time course. METHODS: A retrospective review was conducted on all patients undergoing parathyroidectomy for primary hyperparathyroidism in 2013 at the Cleveland Clinic. Patients were stratified by adherence to 2008 indications for surgery guidelines, age, calcium values, osteoporosis, history of nephrolithiasis, 24-hour urinary calcium values, and estimated glomerular filtration rate. RESULTS: 219 patients with sporadic primary hyperparathyroidism underwent initial surgery. Twenty-three (10.5%) normocalcemic patients were excluded. Time course from initial hypercalcemia to surgery was 3.9 years for 137 (70%) patients who met objective guideline criteria versus 3.8 years for 59 (30%) patients who did not meet objective guideline criteria (P = .87). Stratification by age <50 years and calcium value >11.5 mg/dL revealed earlier times to surgery. However, osteoporosis, nephrolithiasis, 24-hour urinary calcium values, and estimated glomerular filtration rate had no impact. CONCLUSION: There is a delayed time course for patients with sporadic primary hyperparathyroidism from initial hypercalcemia to surgery. Despite published objective criteria, one third of the patients who underwent surgery did not meet criteria, signifying the importance of clinician and patient decision making. Furthermore, patients with osteoporosis and nephrolithiasis who can significantly benefit from surgical cure have no apparent impact on the time to surgery. Overall, the objective guideline criteria have no effect in referral patterns suggesting a call for revision.

Validation of a novel patient-reported outcome measure for parathyroid and thyroid disease (PROMPT).

BACKGROUND: Patient-reported outcome measures are being used increasingly to assess disease severity and response to surgery. The purpose of this study was to create and validate a patient-reported outcome measure for symptoms of thyroid enlargement and hyperparathyroidism, 2 conditions where the presence of preoperative symptoms and response to surgery is often questioned. METHODS: A questionnaire reviewing common symptoms was developed from a literature review and expert opinion. Internal validity, reliability, and initial responsiveness to surgery were evaluated. RESULTS: Patient-Reported Outcome Measure for Parathyroid and Thyroid Disease (PROMPT) consists of 30 items: 10 compressive items and 20 hyperparathyroidism items; we evaluated 302 surveys collected over 10 months. PROMPT showed high internal consistency for compressive and hyperparathyroid constructs (Cronbach's α 0.84 and 0.95). Constructs were scored from 0-100, with greater scores corresponding to increased severity of symptoms. Preoperatively, patients with a goiter demonstrated greater compressive scores compared with other thyroid patients and hyperparathyroid patients (goiter, 47.5; nodule/other, 38.4; hyperparathyroid, 29.8; P < .0001). PROMPT demonstrated high test-retest reliability with acceptable intraclass correlation coefficients for both compressive score and hyperparathyroid score (0.840 and 0.646). Hyperparathyroid scores improved 2 weeks after (48.6 postop, 44.0 preop, P = .0470). CONCLUSION: We validated a novel measure for symptoms of hyperparathyroidism and goiter. PROMPT demonstrates high internal consistency, test-retest reliability, and preliminary analysis, which suggests that it is sensitive to change after surgery.