Autoinfarction of Giant Parathyroid Adenoma after Preoperative Withdrawal of Anticoagulants.

A 71-year-old man with known history of atrial fibrillation (treated with routine rivaroxaban therapy) was found to have incidental biochemical elevated calcium and parathyroid hormone (PTH) levels. His physical examination demonstrated the presence of a palpable right neck mass. Subsequent imaging studies revealed a large parathyroid mass as well as multiple bone lesions, raising the suspicion of parathyroid carcinoma. The anticoagulant therapy was stopped 5 days prior to his elective surgery. The night before his elective surgery, he presented to the emergency room with profound hypocalcemia. The surgery was postponed and rescheduled after calcium correction. Intraoperative findings and detailed histopathological examination revealed an infarcted 4.0 cm parathyroid adenoma with cystic change. His bony changes were related to brown tumors associated with long-standing hyperparathyroidism. Autoinfarction of a large parathyroid adenoma causing severe hypocalcemia is a rare phenomenon and may be considered in patients with large parathyroid adenomas after withdrawal of anticoagulants.

Characteristics of Adrenal Masses in Familial Adenomatous Polyposis.

BACKGROUND: Adrenal masses are a known extraintestinal manifestation of familial adenomatous polyposis. However, the literature on this association is largely confined to case reports. OBJECTIVE: This study aimed to determine the characteristics of adrenal masses in familial adenomatous polyposis and their clinical significance, as well as to estimate their prevalence. Mutational analysis was conducted to determine if any potential genotype-phenotype correlations exist. DESIGN: This is a retrospective cohort study. SETTING: Analysis included all patients meeting the criteria of classic familial adenomatous polyposis who were registered with the Familial Gastrointestinal Cancer Registry, a national Canadian database. PATIENTS: Appropriate imaging or autopsy reports were available in 311 registry patients. Patients with adrenal metastases were excluded. OUTCOME MEASURES: Data collection included demographic data, mutation genotype, adrenal mass characteristics, surgical interventions and mortality. RESULTS: The prevalence of adrenal masses was 16% (n = 48/311). The median age at diagnosis of adrenal mass was 45 years. The median diameter of adrenal mass at diagnosis was 1.7 cm (interquartile range, 1.4-3.0) with a median maximal diameter of 2.5 cm (interquartile range, 1.7-4.1) with median imaging follow-up of 48 months. The majority of adrenal masses were benign (97%, n = 61/63). Surgery was performed on 7 patients because of concerns for size, malignancy, or hormonal secretion. One adrenal-related death was due to an adrenocortical carcinoma. Mutation analysis did not identify any specific genotype-phenotype correlations. LIMITATIONS: There were incomplete or insufficient endocrinology data available in the registry to allow for the analysis of hormone secretion patterns. CONCLUSIONS: Adrenal masses are approximately twice as prevalent in the familial adenomatous polyposis population as in previous studies of the general population. Nearly all mutations led to truncation of the APC gene; however, there was no genetic signature to help predict those at increased risk. The majority of adrenal lesions identified were of benign etiology; thus, an intensive management or surveillance strategy with imaging screening is likely unwarranted. See Video Abstract at http://links.lww.com/DCR/A507.

Clinical Safety of Renaming Encapsulated Follicular Variant of Papillary Thyroid Carcinoma: Is NIFTP Truly Benign?

BACKGROUND: Renaming encapsulated follicular variant of papillary thyroid carcinoma (EFVPTC) to noninvasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTP) was recently suggested to prevent the overtreatment, cost and stigma associated with this low-risk entity. The purpose of this study is to document the incidence and further assess the clinical outcomes of reclassifying EFVPTC to NIFTP. METHODS: We searched synoptic pathologic reports from a high-volume academic endocrine surgery hospital from 2004 to 2013. The standard of surgical pathology practice was based on complete submission of malignant thyroid nodules along with the nontumorous thyroid parenchyma. Rigid morphological criteria were used for the diagnosis of noninvasive EFVPTC, currently known as NIFTP. A retrospective chart review was conducted looking for evidence of malignant behavior. RESULTS: One hundred and two patients met the strict inclusion criteria of NIFTP. The incidence of NIFTP in our cohort was 2.1% of papillary thyroid cancer cases during the studied time period. Mean follow-up was 5.7 years (range 0-11). Five patients were identified with nodal metastasis and one patient with distant metastasis. Overall, six patients showed evidence of malignant behavior representing 6% of patients with NIFTP. CONCLUSION: Our study demonstrates that the incidence of NIFTP is significantly lower than previously thought. Furthermore, evidence of malignant behavior was seen in a significant number of NIFTP patients. Although the authors fully support the de-escalation of aggressive treatment for low-risk thyroid cancers, NIFTP behaves as a low-risk thyroid cancer rather than a benign entity and ongoing surveillance is warranted.

How Social Are We? A Cross-Sectional Study of the Website Presence and Social Media Activity of Canadian Plastic Surgeons.

The internet and social media are increasingly being used by patients not only for health-related research, but also for obtaining information on their surgeon. Having an online presence via a website and social media profile is one-way plastic surgeons can meet this patient driven demand. The authors sought to document current website and social media usage of Canadian plastic surgeons and to determine if this usage correlated with years in practice. A Google search was performed using publicly available lists of all plastic surgeons registered with the Royal College of Physicians and Surgeons of Canada (RCPSC) and the Canadian Society for Aesthetic Plastic Surgery (CSAPS). This search found 42% (268/631) of RCPSC plastic surgeons had a website and 85% (536/631) had a profile on social media. Younger RCPSC surgeons (registered for less years) were significantly more likely to have a website (12.8 vs. 21.9 years, P < 0.0001) and an active social media profile (16.2 vs. 23.9 years, P < 0.002). The social media platform most used was RateMDs (81%) followed in decreasing order by: LinkedIn (28%), RealSelf (22%), Facebook (20%), Google+ (17%) and Twitter (16%). Dual RCPSC-CSAPS members were more likely than RCPSC-only members to have a website (56 vs. 36%, P < 0.0001) and an active social media profile (P < 0.05). Overall, current website usage and social media presence by Canadian plastic surgeons is comparable to counterparts in the US and UK. It may be possible to better optimize online presence through education of current search engine technology and becoming active on multiple social media platforms.

Ethics and genomic medicine, how to navigate decisions in surgical oncology.

Using genetic information to make medical decisions and tailor treatments to individuals will likely provide major benefits and become an important part of health care. Surgical oncologists must ethically apply scientific genetic information in a complex and evolving environment to the benefit of their patients. In this review we address ethical issues associated with: indications for genetic testing, informed consent for testing and therapy, confidentiality, targeted therapy, prophylactic surgery, and genetic testing in children.

Postoperative disposition and health services use in elderly patients undergoing colorectal cancer surgery: a population-based study.

BACKGROUND: Little is known about the postoperative status and support needs of patients undergoing colorectal cancer operations. The objective of this study was to describe the disposition and resource use of Ontario's elderly population undergoing colorectal cancer operations as well as to identify predictors of outcomes using population-based data. METHODS: A total of 33,238 patients aged 50 years and older with a diagnosis of colorectal cancer were identified using International Classification of Diseases 9 and 10 codes in the Ontario Cancer Registry linked to procedure codes in the Canadian Institute for Health Information Discharge Abstract Database representing colorectal operations within 6 months of diagnosis from 1997 to 2004. Data on an individual's home-care use were collected from the Ontario Home Care Administrative System. The cohort was divided into the following age groups: 50-64 years, 65-74 years, 75-79 years, and 80 years and older. The primary outcomes assessed were postoperative mortality, length of stay, discharge disposition, need for home care, and readmission within 30 days. RESULTS: Based on univariate and multivariate analyses, patients aged 75-79 years and 80 years and older were more likely to die in hospital (odds ratio 2.84; 95% confidence interval 2.32-3.47 and odds ratio 5.72; 95% confidence interval 4.76-6.88), stay longer in hospital (2.78 [standard error 0.22] and 5.16 [standard error 0.19] days, respectively), not return home (odds ratio 5.62; confidence interval 3.99-7.98 and odds ratio 11.59; confidence interval 8.32-16.13), receive home care (odds ratio 1.44; 95% confidence interval 1.34-1.55 and odds ratio 1.71; 95% confidence interval 1.59-1.83), and be readmitted (odds ratio 1.31; 95% confidence interval 1.19-1.45 and odds ratio 1.59; 95% confidence interval 1.44-1.75) compared with younger individuals. The rate of discharge home for patients aged 80 years and older was more than 78%. Factors predisposing patients older than 75 years to poorer outcomes were higher Charlson comorbidity score, urgent admission, construction of a stoma, and reoperation. CONCLUSION: Although discharge-related outcomes worsen with age, most elderly patients do well and can return home after a colorectal cancer operation. Elderly patients require more support; therefore, discharge planning should be part of preoperative assessment and discussions.

Pre and peri-operative erythropoietin for reducing allogeneic blood transfusions in colorectal cancer surgery.

BACKGROUND: Patients with colorectal cancer are frequently anaemic and many receive allogeneic red blood cell transfusions peri and post-operatively. Transfusions are accompanied by complications and may increase the rate of recurrence in patients who have a colorectal resection. Recombinant erythropoietin was first used in dialysis patients and more recently in orthopedic surgery to facilitate autologous transfusions. Erythropoietin levels are thought to be lower in cancer patients and erythropoietin is widely used in chemotherapy to treat anaemia and improve quality of life. There may be adverse events associated with its use. Several studies have investigated erythropoietin in colorectal cancer surgery. OBJECTIVES: The primary objective of this systematic review was to evaluate the efficacy of erythropoietin pre and peri-operatively, in reducing allogeneic blood transfusions in patients undergoing colorectal cancer surgery. Secondary objectives were to determine whether pre and peri-operative erythropoietin improves hematologic parameters (hemoglobin, hematocrit and reticulocyte count), quality of life, recurrence rate, and survival, without increasing the occurrence of thrombotic events and the peri-operative mortality. SEARCH STRATEGY: A literature search was performed using MEDLINE, EMBASE, abstracts from the annual meetings of the American Society of Clinical Oncology and the American Society of Colon and Rectal Surgeons until May 2008. SELECTION CRITERIA: Randomized controlled trials of erythropoietin versus placebo or no treatment/standard of care were eligible for inclusion. The study must have reported one of the primary or secondary outcomes and included anaemic patients undergoing surgery for colorectal cancer. DATA COLLECTION AND ANALYSIS: The methodological quality of the trials was assessed using the information provided. Data were extracted and effect sizes were estimated and reported as relative risks(RR) and mean differences (MD) as appropriate. MAIN RESULTS: Four eligible studies were identified of ten retrieved in full. There were no statistically significant differences in the proportion of patients transfused between the erythropoietin group and control group. One of the studies showed a small difference in the median number of units transfused per patient favouring treatment. Reporting of hematologic parameters was varied however, there is no evidence for clinically significant changes. There were no significant differences in post-operative mortality or thrombotic events between groups. No included study evaluated recurrences, survival, or quality of life. Studies were of fair methodologic quality and the overall sample size was small therefore results should be interpreted with caution. AUTHORS' CONCLUSIONS: There is no sufficient evidence to date to recommend pre and peri-operative erythropoietin use in colorectal cancer surgery.