Postoperative surveillance of small appendiceal carcinoid tumors.

BACKGROUND: The necessity and frequency of postoperative surveillance for appendiceal carcinoid tumors ≤1 cm are undetermined. METHODS: A retrospective review was conducted of all patients with appendiceal carcinoid tumors ≤1 cm managed at an academic, tertiary referral center. Clinicopathologic characteristics, treatment, surveillance, recurrence, and survival were assessed and analyzed. RESULTS: Over a 16-year period, 31 patients met the inclusion criteria. Appendicitis (n = 17) and pelvic mass (n = 5) were the most common presentations. Median tumor diameter was 5 mm (range, 1-10 mm). Two patients had mesoappendiceal involvement. No patients had regional lymph node involvement or distant metastasis. Postoperatively, 14 patients (45%) received follow-up recommendations, including ≥1 of the following: imaging (n = 9), medical oncology referral (n = 7), colonoscopy (n = 5), and laboratory studies (n = 5). There were no recurrences or disease-specific deaths during a median follow-up period of 5 years (range, 0-15 years). CONCLUSIONS: Appendiceal carcinoids ≤1 cm are unlikely to recur. Therefore, postoperative surveillance may be unnecessary.

Improvement of sleep disturbance and insomnia following parathyroidectomy for primary hyperparathyroidism.

BACKGROUND: The aim of the present study was to investigate the incidence of sleep disturbance and insomnia in patients with primary hyperparathyroidism (PHPT), and to evaluate the effect of parathyroidectomy. METHODS: A questionnaire was prospectively administered to adult patients with PHPT who underwent curative parathyroidectomy over an 11-month period. The questionnaire, administered preoperatively and 6 months postoperatively, included the Insomnia Severity Index (ISI) and eight additional questions regarding sleep pattern. Total ISI scores range from 0 to 28, with >7 signifying sleep difficulties and scores >14 indicating clinical insomnia. RESULTS: Of 197 eligible patients undergoing parathyroidectomy for PHPT, 115 (58.3 %) completed the preoperative and postoperative questionnaires. The mean age was 60.0 ± 1.2 years and 80.0 % were women. Preoperatively, 72 patients (62.6 %) had sleep difficulties, and 29 patients (25.2 %) met the criteria for clinical insomnia. Clinicopathologic variables were not predictive of clinical insomnia. There was a significant reduction in mean ISI score after parathyroidectomy (10.3 ± 0.6 vs 6.2 ± 0.5, p < 0.0001). Postoperatively, 79 patients (68.7 %) had an improved ISI score. Of the 29 patients with preoperative clinical insomnia, 21 (72.4 %) had resolution after parathyroidectomy. Preoperative insomnia patients had an increase in total hours slept after parathyroidectomy (5.4 ± 0.3 vs 6.1 ± 0.3 h, p = 0.02), whereas both insomnia patients and non-insomnia patients had a decrease in the number of awakenings (3.7 ± 0.4 vs 1.9 ± 0.2 times, p = 0.0001). CONCLUSIONS: Sleep disturbances and insomnia are common in patients with PHPT, and the majority of patients will improve after curative parathyroidectomy.

Timing of symptom improvement after parathyroidectomy for primary hyperparathyroidism.

BACKGROUND: The timing of symptom improvement after parathyroidectomy for primary hyperparathyroidism (PHPT) has not been well characterized. METHODS: This prospective study involved administering a questionnaire to patients with PHPT who underwent curative parathyroidectomy over an 11-month period. The questionnaire evaluated the frequency of 18 symptoms of PHPT on a 5-point Likert scale and was administered preoperatively and 1 week, 6 weeks, and 6 months postoperatively. RESULTS: Of 197 eligible patients, 132 (67%) participated in the study. The questionnaires were completed at a rate of 91%, 92%, and 86% at 1 week, 6 weeks, and 6 months postoperatively, respectively. The most commonly reported preoperative symptoms were fatigue (98%), muscle aches (89%), and bone/joint pain (87%). Improvement in symptom severity occurred across all symptoms and was separated into three categories based on the timing of improvement. Fatigue and bone/joint pain demonstrated "Immediate Improvement" (>50% of patients reporting improvement by post-operative week 1), whereas the majority of symptoms showed peak improvement at 6 weeks ("Delayed Improvement"). Symptoms categorized as "Continuous Improvement" were those showing progressive improvement up to 6 months postoperatively (polydipsia, headaches, and nausea/vomiting). CONCLUSION: Symptom improvement was most prominent 6 weeks postparathyroidectomy, although some symptoms showed continued improvement at 6 months.

Clinicopathologic characteristics of colonic carcinoid tumors.

BACKGROUND: Extra-appendiceal colonic carcinoids are uncommon neuroendocrine tumors with a poor prognosis compared with carcinoids of other gastrointestinal origins. Few studies have examined the clinicopathologic profile and behavior of this rare tumor. MATERIALS AND METHODS: A retrospective analysis was performed on patients with colonic carcinoid tumors evaluated at a single tertiary care center between 1996 and 2012. Collected data included patient and tumor characteristics, presentation, treatment, recurrence, and survival. Results were integrated into a comprehensive review of the colonic carcinoid literature. RESULTS: In total, 114 patients with colorectal carcinoid tumors were identified, and 15 patients with extra-appendiceal tumors were analyzed. The mean age was 58.6 ± 3.0 y, and subjects were predominantly male (73.3%). The most common presenting problem was abdominal pain (33.3%), although 26.7% of patients were asymptomatic. Cecal tumors were the most prevalent (73.3%), and most patients underwent right hemicolectomy. Three patients with lesions < 1 cm were treated endoscopically. The mean tumor diameter was 2.9 ± 0.5 cm, with lymph node or distant metastasis present in 53.3% and 26.7%, respectively. All but two patients underwent a presumed curative resection. During a mean follow-up of 4.2 ± 1.0 y, there was only one death (non-carcinoid specific). Eleven patients were alive without evidence of disease at last follow-up and three patients were alive with disease, one of whom initially had a presumed curative resection that recurred. CONCLUSIONS: This case series further elucidates the clinicopathologic characteristics of colonic carcinoid tumors, which aids physicians in guiding the diagnosis and management of these rare tumors.

Synchronous and antecedent nonthyroidal malignancies in patients with papillary thyroid carcinoma.

BACKGROUND: There is a known association between the development of papillary thyroid cancer (PTC) after a primary nonthyroidal cancer (NTC). However, the prevalence of synchronous or antecedent NTCs in patients with PTC is undetermined, as are the clinicopathologic characteristics of PTC in these patients. STUDY DESIGN: A review was performed of our prospectively maintained PTC database between January 1995 and December 2010. Information collected included patient and tumor characteristics, medical history, PTC presentation, and treatment modality. RESULTS: Four hundred and thirty-three adult patients underwent thyroid resection and had PTC on final pathology. Sixty-seven cases of synchronous or antecedent NTCs were observed in 60 patients (13.9%). The most commonly associated antecedent NTCs were breast (n = 11), prostate (n = 8), and melanoma (n = 5), whereas renal cell carcinoma (n = 3) and melanoma (n = 3) were the synchronous NTCs most observed. Compared with patients without an NTC, those with an NTC were older (56.4 ± 15.5 years vs 44.9 ± 14.2 years; p < 0.0001), had experienced radiation exposure (35.0% vs 3.5%; p < 0.001), and more commonly presented with a thyroid mass incidentally on imaging (41.7% vs 9.1%; p ≤ 0.001). Papillary thyroid cancer tumor characteristics were similar between groups, except that NTC patients presented at a more advanced stage. However, when analyzed independently, primary tumor size, and nodal and distant metastases were comparable. CONCLUSIONS: The prevalence of synchronous or antecedent NTCs in patients surgically treated for PTC is 13.9%. These patients present with PTC tumor characteristics similar to those without additional NTCs, and should therefore be managed equivalently. In addition, surgeons should be aware of the frequency of synchronous PTC with these types of tumors and consider evaluation of the neck at the time of NTC diagnosis.

Surveillance of small rectal carcinoid tumors in the absence of metastatic disease.

BACKGROUND: The incidence of rectal carcinoids is rapidly increasing, typically presenting as small (<1.0 cm), localized tumors. Although the evaluation of rectal carcinoids on presentation is well standardized, surveillance after resection has not been well established. METHODS: A prospective database documented patients with rectal carcinoids at our institution between January 1995 and September 2011. Information collected included patient and tumor characteristics, treatment method, surveillance schedule, recurrence, and survival. RESULTS: Twenty-eight patients with rectal carcinoid were identified. Ten patients were excluded for tumors >1 cm, known metastases at presentation, <6 months follow-up, or previous resections. The mean age of the remaining patients was 56 ± 3 years, and 61% of the patients were female. All patients were diagnosed at endoscopy, with 50% diagnosed incidentally on screening endoscopy. Treatment methods included endoscopic therapy (n = 13, 72%), transanal excision (n = 3, 17%), and transanal endoscopic microsurgery (n = 1, 5.5%). One patient (5.5%) received no additional invasive therapy after diagnostic endoscopy. The mean tumor diameter was 4.6 ± 0.5 mm. The average length of follow-up was 5.4 ± 0.9 years, with a median number of 2 follow-up endoscopies (range 0-6). Two patients (11%) died within the follow-up period from noncarcinoid causes. Importantly, no surviving patients developed local or distant recurrence with up to 12.3 years of follow-up. CONCLUSIONS: On the basis of this experience, patients presenting with small (≤1.0 cm), nonmetastatic rectal carcinoids are unlikely to develop local or distant recurrence after resection. Aggressive surveillance with repeat endoscopies or other imaging studies after resection may be unnecessary in this patient population.

Incidence of concomitant hyperparathyroidism in patients with thyroid disease requiring surgery.

BACKGROUND: Thyroid disease and hyperparathyroidism (HPT) are among the most common endocrine disorders, however, their association has not been well established. The aim of the present study was to determine the incidence of concomitant HPT in patients with thyroid disease requiring surgery, because a single definitive surgery should ideally be performed. METHODS: We retrospectively reviewed a prospectively maintained database of patients who underwent thyroidectomy at a single institution. Data collected included the patients' initial indication for surgery, preoperative workup, and operative findings. RESULTS: Of the 1,049 patients who underwent thyroidectomy, 56 (5%) had concomitant HPT and underwent simultaneous parathyroidectomy. Of these 56 patients, 36 initially presented with thyroid disease and 20 with HPT. The mean age was 59 ± 2 years, and 79% were women. The mean preoperative calcium and parathyroid hormone levels were elevated at 10.4 ± 0.1 mg/dL and 87 ± 7 pg/mL, respectively. Most of these patients had primary HPT (n = 54, 96%). Of the 36 patients presenting initially with thyroid disease, 26 had an elevated calcium or parathyroid hormone value and were preoperatively diagnosed with HPT. The remaining 10 patients had normal laboratory findings; however, a pathologically enlarged parathyroid gland was found at thyroidectomy. The overall cure rate for HPT within our series was 96%. CONCLUSION: The incidence of concomitant HPT in patients with thyroid disease requiring surgery is significant at 5%. Recognition of concurrent disease is important, because it allows for a single definitive surgery to treat both pathologies.

Severe electrolyte disturbances after hyperthermic intraperitoneal chemotherapy: oxaliplatin versus mitomycin C.

BACKGROUND: Oxaliplatin (OX) is increasingly used for hyperthermic intraperitoneal chemotherapy (HIPC) for patients with peritoneal metastases. Our aim was to review electrolyte disturbances and complications after HIPC with oxaliplatin (OX) versus mitomycin C (MMC). MATERIALS AND METHODS: We included patients enrolled in single-institution prospective clinical trials who underwent cytoreductive surgery and HIPC with MMC or OX. We reviewed patient demographics, pathology, perioperative course, HIPC administration, and postoperative electrolyte disturbances. Measured postoperative sodium values were corrected for systemic hyperglycemia using the formula: (measured Na(+)) × [(glucose - 100/100) × 1.6]. RESULTS: From January 2002 to April 2009 we performed 80 HIPC procedures. A total of 60 patients (75%) received MMC (dose range 12.5-50 mg/m(2)) carried in lactated ringers solution. There were 20 patients (25%) who received OX (dose range 300 × 400 mg/m(2)) carried in 5% dextrose solution. For patients receiving HIPC with OX, electrolyte disturbances were the most common complication. Compared with MMC, patients receiving OX had significant 24-h postoperative uncorrected hyponatremia (P < 0.001), corrected hyponatremia (P < 0.001), hyperglycemia (P < 0.001), and metabolic acidosis (P < 0.001). In the OX group, corrected (mean 130.5) and uncorrected (mean 127.4) sodium levels were significantly lower than preoperatively (mean 139.9, P < 0.001). The overall nonelectrolyte complication rate was 56.2%. (MMC n = 33, 55.0%; OX n = 12, 60%); the 30-day mortality rate was 0% in both groups. CONCLUSIONS: Compared with MMC, HIPC with OX was associated with significant but predictable electrolyte disturbances; however, these electrolyte disturbances were not associated with higher overall complication rates. Close monitoring with early correction is imperative to maximize perioperative care. Further studies are needed to provide mechanistic insight.