Management of primary and renal hyperparathyroidism: guidelines from the German Association of Endocrine Surgeons (CAEK).

BACKGROUND AND AIMS: The purpose of this review is to provide updated recommendations for the surgical management of primary (pHPT) and renal (rHPT) hyperparathyroidism, formulating a new guideline of the German Association of Endocrine Surgeons (CAEK). METHODS: Evidence-based recommendations for the diagnosis and therapy of pHPT and rHPT were assessed by a multidisciplinary panel using PubMed for a comprehensive literature search together with a structured consensus dialogue (S2k guideline of the Association of the German Scientific Medical Societies, AWMF). RESULTS: During the last 20 years, a variety of new preoperative localization procedures, such as sestamibi-SPECT, 4D-CT, and various PET/CT procedures, were established for pHPT. High-resolution imaging, together with intraoperative parathyroid hormone (IOPTH) measurement, enabled focused or minimally invasive surgery to become the most favored surgical technique. Patients with pHPT and nonlocalizing imaging have a higher risk of multiglandular disease. Surgical therapy provides very high cure rates, with a clear relation to the surgeon's experience in parathyroid procedures. Reoperative parathyroidectomy, children with pHPT or familial forms, and parathyroid carcinoma are addressed and require special surgical expertise. A multidisciplinary team of experienced nephrologists, transplant, and endocrine surgeons should assess the diagnosis and treatment of renal HPT. CONCLUSION: Surgery is the only curative treatment for pHPT and should be considered for all patients with pHPT. For rHPT, a more selective approach is required, and parathyroidectomy is indicated only when conservative treatment options fail. In parathyroid carcinoma, the adequacy of local resection influences local disease control.

Anaplastic thyroid carcinoma: changing trends of treatment strategies and associated overall survival.

PURPOSE: The prognosis of anaplastic thyroid cancer (ATC) is poor. Despite various attempts to modify common treatment modalities, including surgery, external beam radiation (EBRT) and chemotherapy (CTX), no standardized treatment is yet established. This study aimed to analyze the changing trends of treatment concepts and associated overall survival (OS) over the last two decades. METHODS: A retrospective analysis was conducted on 42 patients with histologically confirmed ATC. The outcome measures included the evaluation of clinical characteristics and treatments performed with regard to OS. RESULTS: Median OS for all tumor stages was 6 (range 1 week-79) months, 6.5 months for stage IVA/B and 4 months for stage IVC carcinoma patients. Twenty-one patients with stage IVA/B carcinomas underwent curative treatment, including thyroidectomy with lymphadenectomy (TTX plus LAD, n = 11) or multimodal treatment with TTX plus LAD and EBRT plus/minus CTX (n = 10). The median OS of patients with stage IVA/B carcinomas was significantly prolonged after multimodal treatment than after surgery alone (25 vs. 3 months, p = 0.04). Fifteen of 18 patients with stage IVC carcinomas received palliative, 3 patients multimodal treatment. The median OS of stage IVC patients after trimodal therapy was not significantly longer than after debulking procedures (6 vs. 7 months, p = 0.25). In the time period 1999-2009, only 4 (21%) patients received multimodal treatment compared to 9 (39%) in the period from 2009 to 2019, but this did not result in a significantly prolonged survival in the latter period (8.5 vs. 15 months, p = 0.61). CONCLUSION: Concurrent radio- and/or chemotherapy in combination with surgery seems to result in improved survival in stage IVA/B ATC, whereas this is not the case in patients with stage IVC tumors. Novel treatment regimens are urgently needed to improve the dismal prognosis of ATC.

Surgical therapy of adrenal tumors: guidelines from the German Association of Endocrine Surgeons (CAEK).

BACKGROUND AND AIMS: Previous guidelines addressing surgery of adrenal tumors required actualization in adaption of developments in the area. The present guideline aims to provide practical and qualified recommendations on an evidence-based level reviewing the prevalent literature for the surgical therapy of adrenal tumors referring to patients of all age groups in operative medicine who require adrenal surgery. It primarily addresses general and visceral surgeons but offers information for all medical doctors related to conservative, ambulatory or inpatient care, rehabilitation, and general practice as well as pediatrics. It extends to interested patients to improve the knowledge and participation in the decision-making process regarding indications and methods of management of adrenal tumors. Furthermore, it provides effective medical options for the surgical treatment of adrenal lesions and balances positive and negative effects. Specific clinical questions addressed refer to indication, diagnostic procedures, effective therapeutic alternatives to surgery, type and extent of surgery, and postoperative management and follow-up regime. METHODS: A PubMed research using specific key words identified literature to be considered and was evaluated for evidence previous to a formal Delphi decision process that finalized consented recommendations in a multidisciplinary setting. RESULTS: Overall, 12 general and 52 specific recommendations regarding surgery for adrenal tumors were generated and complementary comments provided. CONCLUSION: Effective and balanced medical options for the surgical treatment of adrenal tumors are provided on evidence-base. Specific clinical questions regarding indication, diagnostic procedures, alternatives to and type as well as extent of surgery for adrenal tumors including postoperative management are addressed.

[Update of the S2k guidelines : Surgical treatment of benign thyroid diseases]. / Aktualisierung der S2k-Leitlinie : Operative Therapie benigner Schilddrüsenerkrankungen.

Thyroid resections represent one of the most common operations with 76,140 interventions in the year 2016 in Germany (source Destatis). These are predominantly benign thyroid gland diseases. Recommendations for the operative treatment of benign thyroid diseases were last published by the CAEK in 2010 as S2k guidelines (Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften e.V. [AWMF] 003/002) against the background of increasingly more radical resection procedures. Hemithyroidectomy and thyroidectomy are routinely performed for benign thyroid disease in practice. The operation-specific risks show a clear increase with the extent of the resection. Therefore, weighing-up of the risk-indications ratio between unilateral lobectomy or thyroidectomy necessitates an independent evaluation of the indications for both sides. This principle in particular has been used to update the guidelines. In addition, the previously published recommendations of the CAEK for correct execution and consequences of intraoperative neuromonitoring were included into the guidelines, which in particular serve the aim to avoid bilateral recurrent laryngeal nerve paralysis. Moreover, the recommendations for the treatment of postoperative complications, such as hypoparathyroidism and postoperative infections were revised. The updated guidelines therefore represent the current state of the science as well as the resulting surgical practice.

[Paratracheal lymph node with suspicion of carcinoma]. / Paratrachealer Knoten mit Karzinomverdacht.

Three paratracheal lymph nodes of a 20-year-old patient were submitted for examination, of which one showed numerous thyrocytes with large void nuclei and was suspected of being metastatic papillary thyroid carcinoma. The simultaneously resected thyroid gland, which was subsequently submitted showed findings consistent with Hashimoto's autoimmune thyroiditis (AIT). In the context of the resected goiter tissue, the suspected lymph node metastasis was identified as a hyperplastic ectopic (so-called parasitic) goiter nodule with thyrocytic changes typically seen in Hashimoto's AIT, such as oxyphilic cell alterations and a high plasma cell content. The re-examination of the suspicious lymph node revealed complete lack of a marginal sinus, thus excluding the diagnosis of a lymph node as well as the diagnosis of thyroid carcinoma metastasis.

[Lymph node dissection in papillary and follicular thyroid cancer]. / Lymphknotendissektion beim papillären und follikulären Schilddrüsenkarzinom.

BACKGROUND: There is still unresolved debate about the optimal surgical management of papillary (PTC) and follicular (FTC) thyroid cancer regarding lymph node dissection. So far the German guidelines recommend the same extent of surgery for both tumors. PATIENTS AND METHODS: This study is based on 626 patients with PTC and 191 with FTC from a group of 1062 own patients with thyroid malignancies. The extent of surgery, tumor size, and pN status were analysed. The results were compared with those in the current literature. RESULTS: Tumors < or = 20 mm in size were found significantly more often in PTC than FTC (69.6% vs 28.3%, P<0.05). Positive lymph nodes were found significantly more often in PTC than FTC as well (33.2% vs 5.2%, P<0.05). In PTC up to 10 mm and from 11 mm to 20 mm in size, 16% and 34.4% of patients, respectively, showed positive lymph nodes. In FTC positive lymph nodes occurred only in tumors >25 mm. CONCLUSION: Due to prevalence and importance of lymph node metastasis differing between PTC and FTC, we recommend treating both tumor entities differently. For PTC a more extended lymph dissection is necessary, even in tumors < or = 20 mm. In small FTC it seems adequate to limit the operation to thyroidectomy without prophylactic lymph dissection.

Primary hyperparathyroidism--early diagnosis in patients referred for thyroid surgery.

BACKGROUND AND AIMS: From 1986 to 1998, 190 patients presented for first-time operations for sporadic, non-malignant, non-multiple endocrine neplasia primary hyperparathyroidism. Of these patients, 54% had been classified as "asymptomatic", 41% as symptomatic and 5% as acute. One hundred and thirty-five patients (71%) were referred to us for parathyroid surgery. Fifty-five patients (29%) were referred for thyroid surgery with hitherto unknown hyperparathyroidism. This corresponds to a prevalence of primary hyperparathyroidism of 1% in patients referred for thyroid surgery (5450 patients during the same period of time). PATIENTS/METHODS: Patients referred for parathyroid surgery (group I, n=135) were compared with patients originally referred for thyroid surgery (group II, n=55). Group II was divided into group IIa: hyperparathyroidism preoperatively biochemically evident (n=26), and group IIb: borderline biochemistry, parathyroid enlargement evident at the operation (n=29). The groups were compared regarding clinical manifestations, serum calcium and parathyroid hormone, pathologic-anatomical substrates, operative complications and outcome. RESULTS: Renal, osseous and gastrointestinal manifestations were more frequent in group I than in groups IIa and IIb (P<0.05). However, cardiovascular and neuromuscular symptoms were present in groups IIa and IIb in more than one-third of patients. Patients from group IIb were younger (49+/-12 years) than patients from groups IIa (60+/-13 years) and I (60+/-14 years). Adenomas were found in 85% of group I patients, in 45% of group IIa patients and in 21% of group IIb patients (P<0.01). In all other cases, hyperplasia was confirmed histologically. Serum calcium was higher in group I (3.0+/-0.42 mmol/l) than in groups IIa (2.63+/-0.16 mmol/l) and IIb (2.46+/-0.14 mmol/l) (P<0.01). Serum PTH was higher in group I (median 11.0 pmol/l) than in groups IIa and IIb (median 7.1 and 6.4 pmol/l, respectively) (P<0.05). Postoperatively, hypercalcemia persisted in two patients (1.1%) belonging to group I, with mediastinal adenomas. Serum calcium at discharge showed no differences between groups (group I: 2.22+/-0.16; group IIa: 2.22+/-0.15; group IIb: 2.20+/-0.11 mmol/l). Recurrent laryngeal nerve paralysis occurred early (4.2% of "nerves at risk") and remained permanent (0.8% of "nerves at risk") without significant differences between groups. CONCLUSION: Diagnostic efforts regarding parathyroid function should be mandatory before thyroid operations. "Asymptomatic" patients frequently (more than 30%) present with cardiovascular and neuromuscular, "unspecific" symptoms. Simultaneous parathyroid exploration is obvious in cases with biochemically evident primary hyperparathyroidism, but should also be performed in patients with borderline biochemistry.

[American football in Germany--aspects of trauma surgery]. / American Football in Deutschland--unfallchirurgische Aspekte.

While football injuries in the USA are well documented and thoroughly studied, informations on injuries caused by this spreading sport in Germany are not available. For this reason the Berufsgenossenschaftliche Unfallklinik in Frankfurt conducted a prospective study to register all injuries in major league football in southern Germany in 1991. In 49 games that were evaluated we found 281 minor injuries, mainly skin lesions and concussions of extremities. In addition 33 significant injuries were registered, amongst them 30% injuries of knee ligaments. The only severe injury was an abdominal hit causing a intrahepatic hematoma. The results of our study are comparable to the injury risks found in US college football as well as to those found in German statistics on soccer and hockey. Although no fatal injuries in our study were registered, this should not lead to neglecting the potential risks in football.