Long-term voice changes after thyroidectomy: Results from a validated survey.

BACKGROUND: Long-term dysphonia may persist after thyroid surgery even in the absence of overt nerve injury. Therefore, we evaluated long-term dysphonia after thyroidectomy using a validated survey. METHODS: Patients undergoing thyroidectomy at a single institution from 1990 to 2018 were surveyed via telephone to complete the Voice Handicap Index-10 Survey. Individuals with documented nerve injury were excluded. RESULTS: In total, 308 patients completed the survey (mean age 51 ± 14 years, 78% female). Median time since surgery was 10.7 (interquartile range 2.3-17.5) years. The mean Voice Handicap Index-10 Survey score was 2.6 ± 5.2. Of the 113 (37%) patients who reported subjective dysphonia, the mean Voice Handicap Index-10 Survey score was 7.1 ± 6.5. Twenty-two (7.1%) patients had a Voice Handicap Index-10 Survey score above the empiric normative cutoff of 11, with a mean score of 17.6 ± 6.8. The most frequent complaints included "The clarity of my voice is unpredictable" (N = 71, 23%), "People have difficulty understanding me in a noisy room" (N = 70, 23%), and "I feel as though I have to strain to produce voice" (N = 65, 21%). CONCLUSION: Long-term follow-up of patients after thyroidectomy suggests that more than 30% without nerve injury report dysphonia. Research to further assess the etiology and impact of these changes on quality of life is needed.

Can Cytologic and Sonographic Features Help Prevent Overtreatment of Bethesda V Thyroid Nodules?

BACKGROUND: Although nearly half of thyroid nodules with Bethesda V cytology (suspicious for malignancy) may be benign or harbor low-grade neoplasms that can be sufficiently treated with lobectomy, many patients with Bethesda V cytology continue to be treated with total thyroidectomy. The objectives of this study were to establish whether cytomorphologic and ultrasonographic features can determine appropriate surgery for thyroid nodules with Bethesda V cytology and how often patients are overtreated with total instead of partial thyroidectomy. METHODS: Utilizing a 10-y prospective database starting January 1, 2004, cytomorphologic and ultrasonographic features of thyroid nodules with Bethesda V cytology were reviewed. Overtreatment was defined as total thyroidectomy when histopathology revealed benign nodule, noninvasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTP) or a unilateral < 4 cm low risk cancer. RESULTS: Sixty-three patients were included in the study. Seventeen (27%) had benign, 14 (22%) NIFTP, and 32 (51%) malignant nodules. On cytology, nuclear pseudoinclusions, and on ultrasound, taller-than-wide configuration, were more common in malignant than benign or NIFTP nodules. Among 56 patients who underwent total thyroidectomy, 14 and 11 had a benign or NIFTP nodule, respectively, and 13 had a unilateral < 4 cm low risk cancer, suggesting that 68% (38/56) were overtreated. CONCLUSIONS: Total thyroidectomy for Bethesda V thyroid nodules may result in overtreatment in more than half of the patients. Although certain cytomorphologic and ultarsonographic features may be helpful in determining appropriate surgery for Bethesda V thyroid nodules, additional characteristics are needed to reduce overtreatment of these nodules.

Patient-Reported Financial Burden in Thyroid Cancer.

BACKGROUND: The incidence of thyroid cancer is increasing at a rapid rate. Prior studies have demonstrated financial burden and decreased quality of life in patients with thyroid cancer. Here, we characterize patient-reported financial burden in patients with thyroid cancer over a 28y period. MATERIALS AND METHODS: Patients who underwent thyroidectomy for thyroid cancer from 1990-2018 completed a phone survey assessing financial burden and its related psychological financial hardship. Descriptive statistics were performed to characterize these outcomes and correlation with sociodemographic data was assessed. RESULTS: Respondents (N = 147) were 73% female, 75% white, and had a median follow up of 7 y. The majority had a full-time job (59%) and private insurance (81%) at the time of diagnosis. Overall, 16% of respondents reported financial burden and 50% reported psychological financial hardship. Those reporting financial burden were disproportionately impacted by psychological financial hardship (87% versus 43%, P < 0.001). One in four (25%) respondents reported not being adequately informed about costs. CONCLUSIONS: Financial burdens are important outcomes of thyroid cancer which occur even among patients with protective financial factors, suggesting an even greater impact on the general population of patients with thyroid cancer. Further research is needed to explore the intersection of financial burden, cost, and quality of life.

Rectal eversion: safe and effective way to achieve low transaction in minimally invasive Ileal pouch-anal anastomosis surgery, short- and long-term outcomes.

BACKGROUND: Ileal pouch-anal anastomosis remains a gold standard in restoring continence in patient with ulcerative colitis. Achieving low transection can be challenging and may require mucosectomy with a hand-sewn anastomosis. Rectal eversion (RE) technique provides a safe and effective alternative for both open and minimally invasive approaches. The purpose of this study is to evaluate short- and long-term outcomes of patients who underwent RE when compared to those who underwent conventional trans-abdominal transection. MATERIALS AND METHODS: This is a retrospective review performed at tertiary care center. Patients undergoing proctectomy and pouch surgery by either standard approach or with RE from November 2004 to January 2017 were evaluated. Demographics, post-operative complications, as well as 1- and 3-year functional outcomes were analyzed. RESULTS: Total of 176 underwent proctocolectomy with creation of a J pouch and 88 (50%) had the RE technique utilized. The RE group had a higher rate of corticosteroid use at the time of surgery 59.1 versus 39.8% (p = 0.0156), but otherwise groups were statistically similar. 20 cases (26.1%) of RE group and 54 (61%) of conventional group cases were accomplished in minimally invasive fashion. There was no difference in the rates of 30- and 90-day complications. Functional outcomes data were available for up to 78.4% of patient with trans-abdominal approach and 64.7% in RE group. At 1 and 3 years after surgery, there was no difference in the number of bowel movements, fecal incontinence, or nocturnal bowel movements. The rates of returning to ileostomy or pouch revision were the same. CONCLUSION: RE technique is safe and effective way to achieve a low transaction in J pouch surgery. The technique provides similar functional outcomes at 1 and 3 years after surgery and can be particularly useful in minimally invasive approaches.

Rectal Eversion Technique: A Method to Achieve Very Low Rectal Transection and Anastomosis With Particular Value in Laparoscopic Cases.

INTRODUCTION: Transection of the rectum at the anorectal junction is required for proper resection in ulcerative colitis and restorative proctocolectomy. Achieving stapled transection at the pelvic floor is often challenging, particularly during laparoscopic proctectomy. Transanal mucosectomy and handsewn anastomosis are frequently used to achieve adequate resection. Rectal eversion provides an alternative for low anorectal transection and maintains the ability to perform stapled anastomosis. TECHNIQUE: The purpose of this article is to describe a technique for low anorectal transection. The work was conducted at tertiary care center by 2 colon and rectal surgeons on patients undergoing total proctocolectomy with creation of ileal pouch rectal anastomosis for ulcerative colitis. We measured the ability to achieve low stapled anastomosis. RESULTS: Very low transection was achieved, allowing for creation of IPAA without leaving significant rectal cuff. This study was limited because it is an early experience that was not performed in the setting of a scientific investigation. No sphincter or bowel functional data were obtained or evaluated. CONCLUSIONS: Rectal eversion technique provides an alternative to mucosectomy when low pelvic transection is difficult to achieve. See Video at http://links.lww.com/DCR/A441.

The relationship between the follicular variant of papillary thyroid cancer and follicular adenomas.

BACKGROUND: Reports suggest that the incidence of tumors diagnosed as follicular variant of papillary thyroid cancer (FVPTC) is increasing and that this increase may reflect changes in diagnostic criteria with tumors presently being diagnosed as FVPTC previously being defined as follicular lesions, in particular follicular adenomas. Changes during recent years in the relationship between the incidence of FVPTC and follicular adenomas have not been reported. Herein, we have compared changes in the incidence of FVPTC with changes in the incidence of follicular adenomas. METHODS: The study is a retrospective analysis of a prospective database of patients undergoing thyroid surgery between January 1, 2004, and December 31, 2013. RESULTS: A total of 953 thyroid procedures performed in 851 patients were reviewed. The incidence of FVPTC increased approximately 4-fold during the study period when expressed as percentage of all thyroidectomies with the increase mainly reflecting an increase in the incidence of noninvasive FVPTC. The incidence of follicular adenomas decreased in a reverse fashion resulting in a >10-fold increase in the ratio between FVPTC and follicular adenomas during the study period. CONCLUSION: Although the present results suggest that some tumors previously diagnosed as follicular adenomas are increasingly classified as FVPTC, in particular noninvasive FVPTC, the possibility that the results at least in part also reflect a true increase in the incidence of FVPTC cannot be ruled out. If the increased incidence of FVPTC reflects a lowered threshold for the diagnosis of FVPTC it is possible that some tumors presently being classified as FVPTC are overdiagnosed as cancer and may currently be treated more aggressively than needed.

Quantification of human and rodent brown adipose tissue function using 99mTc-methoxyisobutylisonitrile SPECT/CT and 18F-FDG PET/CT.

UNLABELLED: For brown adipose tissue (BAT) to be effective at consuming calories, its blood flow must increase enough to provide sufficient fuel to sustain energy expenditure and also transfer the heat created to avoid thermal injury. Here we used a combination of human and rodent models to assess changes in BAT blood flow and glucose utilization. METHODS: (99m)Tc-methoxyisobutylisonitrile (MIBI) SPECT (n = 7) and SPECT/CT (n = 74) scans done in adult humans for parathyroid imaging were reviewed for uptake in regions consistent with human BAT. Site-directed biopsies of subcutaneous and deep neck fat were obtained for electron microscopy and gene expression profiling. In mice, tissue perfusion was measured with (99m)Tc-MIBI (n = 16) and glucose uptake with (18)F-FDG (n = 16). Animals were kept fasting overnight, anesthetized with pentobarbital, and given intraperitoneally either the ß3-adrenergic receptor agonist CL-316,243, 1 mg/kg (n = 8), or saline (n = 8) followed by radiotracer injection 5 min later. After 120 min, the mice were imaged using SPECT/CT or PET/CT. Vital signs were recorded over 30 min during the imaging. BAT, white adipose tissue (WAT), muscle, liver, and heart were resected, and tissue uptake of both (99m)Tc-MIBI and (18)F-FDG was quantified by percentage injected dose per gram of tissue and normalized to total body weight. RESULTS: In 5.4% of patients (4/74), (99m)Tc-MIBI SPECT/CT showed increased retention in cervical and supraclavicular fat that displayed multilocular lipid droplets, dense capillary investment, and a high concentration of ovoid mitochondria. Expression levels of the tissue-specific uncoupling protein-1 were 180 times higher in BAT than in subcutaneous WAT (P < 0.001). In mice, BAT tissue perfusion increased by 61% (P < 0.01), with no significant changes in blood flow to WAT, muscle, heart, or liver. CL-316,243 increased glucose uptake in BAT even more, by 440% (P < 0.01). CONCLUSION: Pharmacologic activation of BAT requires increased blood flow to deliver glucose and oxygen for thermogenesis. However, the glucose consumption far exceeds the vascular response. These findings demonstrate that activated BAT increases glucose uptake beyond what might occur by increased blood flow alone and suggest that activated BAT likely uses glucose for nonthermogenic purposes.

Large parathyroid tumors have an increased risk of atypia and carcinoma.

BACKGROUND: Risk for atypia and carcinoma in large parathyroid tumors is not known. Atypia and carcinoma were determined in small (<2 g) and large (≥2 g) tumors in patients undergoing parathyroidectomy for primary hyperparathyroidism. METHODS: The study was a retrospective analysis of a 5-year prospective database. Tumor weight, histopathology, age, gender, calcium, and parathyroid hormone levels were registered. Patients with 4-gland disease were not included. RESULTS: Among 353 parathyroid tumors, 313 weighed <2 g and 40 weighed ≥2 g. There was no difference in age between groups. Patients with large tumors were more frequently men and had higher calcium and parathyroid hormone levels. Atypia was found in 4 of 313 (1.3%) and 7 of 40 (17.5%) small and large tumors, respectively (P < .05). Corresponding figures for carcinoma were 1 of 313 (.3%) and 2 of 40 (5.0%) (P < .05). CONCLUSIONS: Large parathyroid tumors have increased risk for atypia and carcinoma. Even so, most large parathyroid tumors are benign.

Efficacy of radiofrequency ablation in the treatment of small functional adrenal neoplasms.

PURPOSE: To evaluate the use of radiofrequency (RF) ablation as a primary treatment for symptomatic primary functional adrenal neoplasms and determine the efficacy of treatment with use of clinical and biochemical follow-up. MATERIALS AND METHODS: After obtaining institutional review board approval, the authors retrospectively evaluated images and medical records from 13 consecutive patients with symptomatic functional adrenal neoplasms (<3.2 cm in diameter) who underwent RF ablation during a 7-year period. There were six men and seven women with a mean age of 54.1 years (range, 42-71 years). Cross-sectional images, findings from clinical examination, and adrenal biochemical markers were available for all patients. Ten of the 13 patients (77%) had an aldosteronoma and one patient each had a cortisol-secreting tumor, testosterone-secreting tumor, and pheochromocytoma. RF ablation was performed by two radiologists using an internally cooled electrode and a pulsed technique according to manufacturer's specifications. Clinical and laboratory follow-up was performed for all patients. Three patients underwent imaging follow-up for other reasons. RESULTS: All patients demonstrated resolution of abnormal biochemical markers after ablation (mean biochemical follow-up, 21.2 months). In addition, all patients experienced resolution of clinical symptoms or syndromes, including hypertension and hypokalemia (in patients with aldosteronoma), Cushing syndrome (in the patient with cortisol-secreting tumor), virilizing symptoms (in the patient with testosterone-secreting tumor), and hypertension (in the patient with pheochromocytoma). For the patients with aldosteronoma, improvements in hypertension management were noted. The mean blood pressure before ablation was 149/90 mm Hg with a mean (±standard deviation) of 3.1 ± 0.6 blood pressure medications, and this decreased to 122/77 mm Hg at a mean of 2.8 months after ablation with 1.3 ± 0.9 medications (P < .001) and 124/75 mm Hg at a mean of 41.4 months. There were two minor complications: one small pneumothorax and one limited hemothorax, neither of which required overnight admission. There were two episodes of transient self-remitting procedural hypertension-one in a patient with aldosteronoma and one in the patient with a cortisol-secreting tumor; however, none of these patients required further therapy during overnight observation. CONCLUSION: RF ablation may be an effective, minimally invasive method for treating small functional primary adrenal tumors.

When initial postexcision PTH level does not fall appropriately during parathyroidectomy: what to do next?

BACKGROUND: Inadequate fall in the intraoperative parathyroid hormone (PTH) level after removing enlarged parathyroid gland(s) typically signifies additional hyperfunctioning gland(s), prompting further neck dissection, but it may also be a false negative result. We analyzed intraoperative management of patients with an inadequate fall on PTH after excision of enlarged parathyroid gland(s). METHODS: Analysis involved a prospective database of 189 patients undergoing 193 procedures for primary hyperparathyroidism. The PTH level was determined before neck incision and 10-15 min after excision of enlarged parathyroid gland(s). A PTH decrease > 50% and into normal range was used as the criterion of successful parathyroidectomy. RESULTS: In 48 of 193 operations, initial postexcision PTH level did not fall appropriately. That inadequate fall in PTH level was a false negative result in 16 patients (33%) and cure was achieved without additional neck exploration in all but one patient, who had additional (negative) neck exploration after excision of a parathyroid adenoma. In all patients with false negative postexcision PTH assay, operative findings concurred with preoperative imaging tests. CONCLUSIONS: Inadequate fall in intraoperative PTH may be false negative, particularly after removal of an adenoma found in the location determined by preoperative imaging. Repeat PTH may confirm the initial assay as false negative, obviating the need for additional neck dissection. Importantly, if repeat PTH does not fall appropriately, additional neck exploration needs to be performed.

Hyalinizing trabecular adenoma--an uncommon thyroid tumor frequently misdiagnosed as papillary or medullary thyroid carcinoma.

BACKGROUND: Hyalinizing trabecular adenoma (HTA) is an uncommon benign thyroid tumor that can present as a solitary thyroid nodule, a prominent nodule in a multinodular goiter, or as an incidental finding in a thyroidectomy specimen. The clinical significance of the lesion is that it is frequently misdiagnosed as papillary carcinoma on fine-needle aspiration cytology or as papillary or medullary carcinoma on histopathological section. We reviewed our recent experience with 7 patients diagnosed with HTA. METHODS: Fine-needle aspiration biopsy was performed in 7 patients presenting with a solitary thyroid nodule (n = 4) or a multinodular goiter (n = 3). The patients underwent total thyroidectomy (n = 6) or hemithyroidectomy (n = 1). RESULTS: In 4 patients, the preoperative cytology was suggestive of papillary carcinoma, in 2 patients suspicious, and in 1 patient positive for papillary carcinoma. On histopathological section, 2 patients had a microscopic HTA, 2 patients had HTA in 1 or 2 nodules of a multinodular goiter, and 3 patients had HTA in a solitary nodule. Except in 1 patient, who had a microscopic focus (3.2 mm) of papillary carcinoma, there was no evidence of malignancy in the surgical specimens on permanent histopathological section. CONCLUSIONS: Although HTA is a rare condition of the thyroid, the surgeon needs to be aware of this entity to be able to better discuss the pathological findings with the patient, particularly since some pathologists and endocrinologists believe that HTA may represent a malignant neoplasm of low metastatic potential.