The Role of Demographic and Clinical Factors in Germline Mutation Testing for Patients with Primary Hyperparathyroidism.

INTRODUCTION: Guidelines recommending genetic counseling in primary hyperparathyroidism (PHPT) vary. To further delineate current recommendations, this study examined genetic counseling referral patterns and rates of mutations in surgical patients with PHPT. PATIENTS AND METHODS: A single-institution review was performed of adult patients who underwent parathyroidectomy for presumed sporadic PHPT. Genetic testing indications of hypercalcemia onset ≤ 40 years, multigland disease (MGD), family history (FHx) of PHPT, or other clinical indications suspicious for a PHPT-related endocrinopathy were examined by demographics and mutation detection rates. RESULTS: Genetic counseling was performed in 237 (37.9%) of 625 patients. Counseling was discussed but not performed in 121 (19.4%) patients. No evidence was noted of genetic referral discussion in the remaining 267 (42.7%). Of these groups, patients who received genetic counseling were youngest, p < 0.001 [median age 55.3 (IQR 43.2, 66.7) years]. The majority of patients with indications of age ≤ 40 years (65.7%), FHx (78.0%), and other clinical indications (70.7%) underwent genetic counseling, while most with MGD (57.0%) did not. Eight mutations were detected in 227 patients (3.5%). Mutations included: MEN1 (n = 2), CDC-73 (n = 4), and CASR (n = 2). Detection was most common in patients with FHx (4/71, 5.6%), then age ≤ 40 years (3/66, 4.5%), and other clinical indications (3/80, 3.8%). No mutations were identified in 48 patients tested solely for MGD. CONCLUSIONS: Most patients with onset of hypercalcemia age ≤ 40 years, positive FHx, or other clinical concerns underwent genetic counseling, while most with MGD did not. As no germline mutations were identified in patients with MGD alone, further investigation of MGD as a sole indication for genetic counseling may be warranted.

Severity of Prior Coronavirus Disease 2019 is Associated With Postoperative Outcomes After Major Inpatient Surgery.

OBJECTIVE: To determine how the severity of prior history (Hx) of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection influences postoperative outcomes after major elective inpatient surgery. BACKGROUND: Surgical guidelines instituted early in the coronavirus disease 2019 (COVID-19) pandemic recommended a delay in surgery of up to 8 weeks after an acute SARS-CoV-2 infection. This was based on the observation of elevated surgical risk after recovery from COVID-19 early in the pandemic. As the pandemic shifts to an endemic phase, it is unclear whether this association remains, especially for those recovering from asymptomatic or mildly symptomatic COVID-19. METHODS: Utilizing the National COVID Cohort Collaborative, we assessed postoperative outcomes for adults with and without a Hx of COVID-19 who underwent major elective inpatient surgery between January 2020 and February 2023. COVID-19 severity and time from infection to surgery were each used as independent variables in multivariable logistic regression models. RESULTS: This study included 387,030 patients, of whom 37,354 (9.7%) were diagnosed with preoperative COVID-19. Hx of COVID-19 was found to be an independent risk factor for adverse postoperative outcomes even after a 12-week delay for patients with moderate and severe SARS-CoV-2 infection. Patients with mild COVID-19 did not have an increased risk of adverse postoperative outcomes at any time point. Vaccination decreased the odds of respiratory failure. CONCLUSIONS: Impact of COVID-19 on postoperative outcomes is dependent on the severity of illness, with only moderate and severe disease leading to a higher risk of adverse outcomes. Existing perioperative policies should be updated to include consideration of COVID-19 disease severity and vaccination status.

Variation in parathyroid adenoma size in patients with sporadic, primary hyperparathyroidism: small gland size does not preclude single gland disease.

PURPOSE: Small, abnormal parathyroid glands are usually associated with multigland hyperplasia in patients with primary hyperparathyroidism (pHPT). The purpose of this study was to determine the association between parathyroid adenoma size and biochemical cure rates in patients undergoing single gland parathyroidectomy. METHODS: The study included patients with sporadic pHPT who underwent initial parathyroidectomy and met intraoperative PTH criteria for cure after resection of a single adenoma (SGD). Patients were divided into quartiles (Q1 = smallest) based on gland weight and maximum dimension; cure rates were compared across groups. RESULTS: A single parathyroid adenoma was removed in 517 patients, with a median gland weight of 500 mg (range 50-11890). Median maximum gland dimension was 15 mm (range 5-55). With median follow-up of 28 months (range 6-81), the biochemical cure rate was 97.1%. There was no difference in cure rate by gland weight (Q1 94.6%, Q2 96.9%, Q3 98.4%, Q4 98.5%, p = 0.217) or maximum gland dimension (Q1 95.6%, Q2 97.6%, Q3 97.1%, Q4 98.2%, p = 0.641). When Q1 patients (by gland weight) were divided by quartile, there was no difference in cure rates (93.1% [50-140 mg]; 95.2% [150-190 mg]; 97.1% [200-230 mg]; 93.3% [240-280 mg]; p = 0.665). CONCLUSION: For patients with pHPT who underwent single gland parathyroidectomy, there was no difference in cure rates by gland weight or maximum dimension. These data suggest that the removal of parathyroid adenomas as small as 50 mg with an appropriate decline in ioPTH likely represent single gland disease and additional exploration may not be necessary.

Choice of local therapy for young women with early-stage breast cancer who have young-aged children.

BACKGROUND: Decision making regarding the initial treatment of women with breast cancer is complicated. In the current study, the authors examined the relationship between treatment choices and their children's ages among young women with early-stage breast cancer. METHODS: Using the MarketScan Commercial Claims and Encounters database, the authors identified women aged 20 to 50 years who underwent lumpectomy or mastectomy for early-stage breast cancer between 2008 and 2014. Predictors of compliance with radiotherapy after undergoing lumpectomy and of undergoing mastectomy were determined using multinomial logistic regression. The authors conducted sensitivity analyses to explore the impact of the number of young-aged children and a reduction in the sample size in 2014 due to the attrition of health plans contributing to MarketScan. RESULTS: A total of 21,052 women were included in the current analysis. Among women with at least 1 child aged <7 years, the adjusted rate of lumpectomy was 59.9%; approximately 22% of these women did not receive radiotherapy. Compared with women undergoing lumpectomy plus radiotherapy, women with at least 1 child aged <7 years or aged 7 to 12 years were 25% and 16%, respectively, more likely to undergo lumpectomy alone compared with women with no children aged <18 years (P = .002 and P = .012, respectively) and 64% and 37%, respectively, more likely to undergo mastectomy (P < .001). CONCLUSIONS: Among privately insured women with breast cancer, having young children was found to be strongly associated with the omission of postlumpectomy radiotherapy or undergoing mastectomy. Having >1 young-aged child further amplified these associations. The findings of the current study suggested that caring for young children may present unique challenges to young women with breast cancer.

Prevalence and scope of advanced practice provider oncology care among Medicare beneficiaries with breast cancer.

PURPOSE: Advanced practice providers (APPs) have increasingly become members of the oncology care team. Little is known about the scope of care that APPs are performing nationally. We determined the prevalence and extent of APP practice and examined associations between APP care and scope of practice regulations, phase of cancer care, and patient characteristics. METHODS: We performed an observational study among women identified from Medicare claims as having had incident breast cancer in 2008 with claims through 2012. Outpatient APP care included at least one APP independently billing for cancer visits/services. APP scope of practice was classified as independent, reduced, or restricted. A logistic regression model with patient-level random effects was estimated to determine the probability of receiving APP care at any point during active treatment or surveillance. RESULTS: Among 42,550 women, 6583 (15%) received APP care, of whom 83% had APP care during the surveillance phase and 41% during the treatment phase. Among women who received APP care during a given year of surveillance, the overall proportion of APP-billed clinic visits increased with each additional year of surveillance (36% in Year 1 to 61% in Year 4). Logistic regression model results indicate that women were more likely to receive APP care if they were younger, black, healthier, had higher income status, or lived in a rural county or state with independent APP scope of practice. CONCLUSIONS: This study provides important clinical and policy-relevant findings regarding national practice patterns of APP oncology care. Among Medicare beneficiaries with incident breast cancer, 15% received outpatient oncology care that included APPs who were billing; most of this care was during the surveillance phase. Future studies are needed to define the degree of APP oncology practice and training that maximizes patient access and satisfaction while optimizing the efficiency and quality of cancer care.

Update on Pheochromocytoma and Paraganglioma from the SSO Endocrine/Head and Neck Disease-Site Work Group. Part 1 of 2: Advances in Pathogenesis and Diagnosis of Pheochromocytoma and Paraganglioma.

This first part of a two-part review of pheochromocytoma and paragangliomas (PPGLs) addresses clinical presentation, diagnosis, management, treatment, and outcomes. In this first part, the epidemiology, prevalence, genetic etiology, clinical presentation, and biochemical and radiologic workup are discussed. In particular, recent advances in the genetics underlying PPGLs and the recommendation for genetic testing of all patients with PPGL are emphasized. Finally, the newer imaging methods for evaluating of PPGLs are discussed and highlighted.

Update on Pheochromocytoma and Paraganglioma from the SSO Endocrine and Head and Neck Disease Site Working Group, Part 2 of 2: Perioperative Management and Outcomes of Pheochromocytoma and Paraganglioma.

This is the second part of a two-part review on pheochromocytoma and paragangliomas (PPGLs). In this part, perioperative management, including preoperative preparation, intraoperative, and postoperative interventions are reviewed. Current data on outcomes following resection are presented, including outcomes after cortical-sparing adrenalectomy for bilateral adrenal disease. In addition, pathological features of malignancy, surveillance considerations, and the management of advanced disease are also discussed.

Confirmation of Parathyroid Tissue: Are Surgeons Aware of New and Novel Techniques?

BACKGROUND: Ex vivo aspiration of parathyroid glands for the measurement of intraoperative parathyroid hormone (IOPTH) levels is a rapid point-of-care method to confirm parathyroid tissue during parathyroidectomy and an alternative to frozen section (FS). This study sought to determine the awareness and utilization of this technique among endocrine surgeons. MATERIALS AND METHODS: A de-identified 12-question survey regarding techniques for intraoperative identification/confirmation of parathyroid tissue and the use of IOPTH monitoring was distributed to all 608 members of the American Association of Endocrine Surgeons. RESULTS: Among the 182 (30%) respondents, FS was the most common primary technique utilized by 115 (63%) respondents to confirm parathyroid tissue; only 12 (7%) utilized ex vivo aspiration, although 78 (42%) were familiar with the technique. Availability and familiarity were the principal reasons for use of the primary technique; the most common barrier was time. Serum IOPTH monitoring was routinely used by 124 (74%). Of respondents who utilized FS, serum IOPTH monitoring was routinely used by 75% (86/115), including 71% (45/63) who reported time as a barrier to FS. Of these 45, only 15 (33%) were familiar with ex vivo parathyroid aspiration. Only 48% of surgeons knew how PTH samples were charged. CONCLUSIONS: FS was the most common method of identification/confirmation of parathyroid tissue. Although most respondents routinely performed IOPTH monitoring, relatively few utilized ex vivo aspiration as a technique for parathyroid identification and less than 50% were familiar with this technique. Broader dissemination about novel techniques such as ex vivo aspiration and cost awareness are recommended.

Persistent/Recurrent Primary Hyperparathyroidism: Does the Number of Abnormal Glands Play a Role?

BACKGROUND: Persistent/recurrent hyperparathyroidism occurs in 2%-5% of patients with sporadic primary hyperparathyroidism (PHPT). In this study, the incidence and time to recurrence in patients with single-gland disease (SGD), double adenomas (DAs), or four-gland hyperplasia (FGH) at initial parathyroidectomy were compared. METHODS: This retrospective review included adult patients with sporadic PHPT who underwent initial parathyroidectomy with intraoperative parathyroid hormone monitoring (IOPTH) from 1/2000 to 12/2016 with ≥6 mo follow-up. An abnormal parathyroid was defined by a gland weight of ≥50 mg. A concurrent serum calcium >10.2 mg/dL and parathyroid hormone >40 pg/mL was defined as persistent PHPT if present <6 mo and recurrent PHPT if present ≥6 mo postoperatively after initial normocalcemia. RESULTS: Of 1486 patients, 1203 (81%) had SGD, 159 (11%) DA, and 124 (8%) FGH. Among the 3 groups, there was no difference in the percent decrease from the baseline or time of excision to final postexcision IOPTH levels between groups (79% versus 80% versus 80%, respectively; P = 0.954) or in the proportion of patients with a final IOPTH ≥40 (22% versus 18% versus 14%; P = 0.059). Overall, 22 (1.5%) had persistent PHPT and 26 (1.7%) had recurrent PHPT. Persistent PHPT was more frequent with DAs (6; 3.8%) than other groups (SGD: 16, 1.3%; FGH: 0; P = 0.02). At median follow-up of 33 mo (IQR, 18-60), there was no difference in recurrence rate (1.6% versus 2.5% versus 2.4%; P = 0.57) or median time (mo) to recurrence (SGD: 59 [IQR, 21-86], DAs: 36 [IQR, 29-58], FGH: 23 [IQR, 17-40]; P = 0.46). CONCLUSIONS: Recurrent PHPT occurred in 1.7% of patients who underwent curative initial parathyroidectomy, with no difference in incidence or time to recurrence between groups based on the number of glands removed. Patients with DA more commonly had persistent PHPT, raising the possibility of unrecognized FGH.

Perioperative Management and Outcomes of Hyperthyroid Patients Unable to Tolerate Antithyroid Drugs.

BACKGROUND: Prior to thyroidectomy for hyperthyroidism, it is recommended that patients are managed with antithyroid drugs (ATDs) and rendered euthyroid to decrease the risk of thyroid storm. However, not all patients tolerate ATD and the risk of thyroid storm during thyroidectomy in these patients is unclear. Therefore, the aim of this study was to compare the management and outcomes of hyperthyroid patients that were on ATDs prior to surgery to those who were not. STUDY DESIGN: A prospectively maintained, single-institution database was queried for all hyperthyroid patients who were initially treated with ATDs and underwent thyroidectomy from January 1, 2012, to June 18, 2018. Patients were divided into two groups: (1) those on ATDs at surgery (ATD group) and (2) those who could not tolerate and stopped ATDs prior to surgery (no-ATD group). Demographic and clinical data were collected. Primary outcomes were readmissions/emergency department visits and postoperative complications within 30 days of thyroidectomy. RESULTS: Of the 248 patients, 231 were in the ATD group and 17 (7%) were in the no-ATD group. There were no mortalities or thyroid storm events in either group. There was no difference in Clavien-Dindo Grade 2 or 3 complications between the two groups. There were no ED visits or 30-day readmissions in the no-ATD group compared to 17 (7%) events in the ATD group (p = 1.0). CONCLUSION: While it is preferable to render patients euthyroid prior to thyroidectomy for hyperthyroidism, results of this study suggest that when patients cannot tolerate ATDs, it is possible to perform thyroidectomy without increased risk of thyroid storm or intra- and postoperative complications.

Evaluation, Staging, and Surgical Management for Adrenocortical Carcinoma: An Update from the SSO Endocrine and Head and Neck Disease Site Working Group.

This is the first of a two-part review on adrenocortical carcinoma (ACC), a rare and aggressive malignancy that often presents at an advanced stage. Most patients present with symptoms related to cortisol and/or androgen excess. Appropriate biochemical evaluation and imaging is important in assessing the extent of disease, operative planning, and oncologic surveillance for patients with ACC. For patients with locoregional disease, potential cure requires margin-negative resection, and accumulating evidence suggests that regional lymphadenectomy should be performed. Although laparoscopic adrenalectomy is reported by some to be adequate for localized ACC, open resection in the hands of an experienced adrenal surgeon is the gold standard for operative management of this disease. Cure is rare following disease relapse, however select patients with severe symptoms related to hormone excess or pain may benefit from resection of local or distant recurrence. For best oncologic outcomes, it is recommended that all patients with ACC be treated at centers with multidisciplinary expertise in management of this rare and aggressive malignancy.

Adjuvant and Neoadjuvant Therapy, Treatment for Advanced Disease, and Genetic Considerations for Adrenocortical Carcinoma: An Update from the SSO Endocrine and Head and Neck Disease Site Working Group.

This is the second of a two-part review on adrenocortical carcinoma (ACC) management. While margin-negative resection provides the only potential cure for ACC, recurrence rates remain high. Furthermore, many patients present with locally advanced, unresectable tumors and/or diffuse metastases. As a result, selecting patients for adjuvant therapy and understanding systemic therapy options for advanced ACC is important. Herein, we detail the current literature supporting the use of adjuvant mitotane therapy, consideration of adjuvant radiation therapy, and utility of cytotoxic chemotherapy in patients with advanced disease. Ongoing investigation into molecular targeted agents, immunotherapy, and inhibitors of steroidogenesis for the treatment of ACC are also highlighted. Lastly, the importance of genetic counseling in patients with ACC is addressed as up to 10% of patients will have an identifiable hereditary syndrome.

Prevalence and Consequences of Axillary Lymph Node Dissection in the Era of Sentinel Lymph Node Biopsy for Breast Cancer.

BACKGROUND: Despite clear guidelines for its use and wide adoption, no population-based study has examined the extent to which patients with early stage breast cancer are benefiting from sentinel lymph node biopsy (SLNB) by being spared a potentially avoidable axillary lymph node dissection (ALND) and its associated morbidity. OBJECTIVE: Examine variation in type of axillary surgery performed by surgeon volume; investigate the extent and consequences of potentially avoidable ALND. RESEARCH DESIGN/SUBJECTS: Observational study of older women with pathologically node-negative stage I-II invasive breast cancer who underwent surgery in a SEER state in 2008-2009. MEASURES: Surgeon annual volume of breast cancer cases and type of axillary surgery were determined by Medicare claims. An estimated probability of excess lymphedema due to ALND was calculated. RESULTS: Among 7686 pathologically node-negative women, 49% underwent ALND (either initially or after SLNB) and 25% were operated on by low-volume surgeons. Even after adjusting for demographic and tumor characteristics, women treated by higher volume surgeons were less likely to undergo ALND [medium volume: odds ratio, 0.69 (95% confidence interval, 0.51-0.82); high volume: odds ratio, 0.59 (95% confidence interval, 0.45-0.76)]. Potentially avoidable ALND cases were estimated to represent 21% of all expected lymphedema cases. CONCLUSIONS: In this pathologically node-negative population-based breast cancer cohort, only half underwent solely SLNB. Patients treated by low-volume surgeons were more likely to undergo ALND. Resources and guidelines on the appropriate training and competency of surgeons to assure the optimal performance of SLNB should be considered to decrease rates of potentially avoidable ALND and lymphedema.

Effect of hospital volume on processes of breast cancer care: A National Cancer Data Base study.

BACKGROUND: The purpose of this study was to examine variations in delivery of several breast cancer processes of care that are correlated with lower mortality and disease recurrence, and to determine the extent to which hospital volume explains this variation. METHODS: Women who were diagnosed with stage I-III unilateral breast cancer between 2007 and 2011 were identified within the National Cancer Data Base. Multiple logistic regression models were developed to determine whether hospital volume was independently associated with each of 10 individual process of care measures addressing diagnosis and treatment, and 2 composite measures assessing appropriateness of systemic treatment (chemotherapy and hormonal therapy) and locoregional treatment (margin status and radiation therapy). RESULTS: Among 573,571 women treated at 1755 different hospitals, 38%, 51%, and 10% were treated at high-, medium-, and low-volume hospitals, respectively. On multivariate analysis controlling for patient sociodemographic characteristics, treatment year and geographic location, hospital volume was a significant predictor for cancer diagnosis by initial biopsy (medium volume: odds ratio [OR] = 1.15, 95% confidence interval [CI] = 1.05-1.25; high volume: OR = 1.30, 95% CI = 1.14-1.49), negative surgical margins (medium volume: OR = 1.15, 95% CI = 1.06-1.24; high volume: OR = 1.28, 95% CI = 1.13-1.44), and appropriate locoregional treatment (medium volume: OR = 1.12, 95% CI = 1.07-1.17; high volume: OR = 1.16, 95% CI = 1.09-1.24). CONCLUSIONS: Diagnosis of breast cancer before initial surgery, negative surgical margins and appropriate use of radiation therapy may partially explain the volume-survival relationship. Dissemination of these processes of care to a broader group of hospitals could potentially improve the overall quality of care and outcomes of breast cancer survivors. Cancer 2017;123:957-66. © 2016 American Cancer Society.

Disparities in access to care and outcomes in patients with adrenocortical carcinoma.

BACKGROUND: Surgical resection remains the mainstay of treatment for patients with adrenocortical carcinoma (ACC). The aim of the present study is to examine disparities in access to surgical resection and identify factors associated with overall survival following surgical resection. METHODS: The National Cancer Database was queried for patients with ACC (2004-2013). Patient characteristics and disease details were abstracted. Logistic regression analysis was performed to examine the factors associated with surgical resection, and a multivariate Cox proportional hazards model was used to identify predictors of survival in the surgical cohort. RESULTS: Surgical resection was performed in 2007/2946 (68%) ACC patients. On multivariate logistic regression analysis controlling for clinicodemographic factors, surgery was less likely to be performed in patients ≥56 y, males, African-Americans, patients with government insurance, or those treated at community cancer centers (P < 0.05). On a multivariate Cox proportional hazards model adjusting for clinicodemographic and treatment variables, older age (≥56 y) and presence of comorbidities were associated with worse overall survival. CONCLUSIONS: These findings suggest that there are demographic and socioeconomic disparities in access to surgical resection for ACC. However, after adjusting for patient and clinical characteristics, only patient age and presence of comorbidities were predictors of worse survival in patients undergoing surgery for ACC. More data are needed to determine the factors driving these disparities.

Concurrent endocrine and other surgical procedures: an institutional experience.

INRODUCTION: The number of endocrine procedures, specifically parathyroidectomy, thyroidectomy, and adrenalectomy, being performed is increasing. There is a paucity of literature on the feasibility of combining these procedures with other surgical procedures. Therefore, the aim of this study was to determine the effect of performing concurrent surgical procedures on postoperative outcomes. METHODS: This is a single institution retrospective review of multiple prospectively maintained databases of patients who underwent elective thyroidectomy, parathyroidectomy, and/or adrenalectomy in combination with another procedure. The other procedures included soft tissue, breast or hernia, abdominal major, abdominal minor, cervical, and "other". Demographics, operative details, length-of-stay, and 30-d outcomes were reviewed. "Endocrine-specific" complications included recurrent laryngeal nerve injury, hypoparathyroidism, cervical wound infection, hematoma, and other. RESULTS: The cohort comprised 104 patients. Overall, 19 (18%) patients had 21 complications, including endocrine-specific complications in eleven (11%) patients. These eleven complications included recurrent laryngeal nerve injury (n = 3; 3%), hematoma (n = 2; 2%), wound infection (n = 1; 1%), transient hypoparathyroidism (n = 2; 2%), and other (n = 3; 3%). The remaining complications included three (3%) general complications, six (6%) patients with complications related to the concurrent procedure, and one patient who underwent an open adrenalectomy and hysterectomy and developed a midline wound dehiscence, which could not be specifically attributed to either procedure. CONCLUSIONS: Less than 5% of patients undergoing a surgical endocrine procedure underwent a concurrent procedure, ranging from soft tissue to major abdominal. Short-term endocrine-specific complications were managed safely, suggesting that concurrent procedures can be considered, with minimal effect on patient outcomes.

Delayed Calcium Normalization After Presumed Curative Parathyroidectomy is Not Associated with the Development of Persistent or Recurrent Primary Hyperparathyroidism.

BACKGROUND: Following parathyroidectomy for primary hyperparathyroidism (pHPT), serum calcium levels typically normalize relatively quickly. The purpose of this study was to identify potential factors associated with delayed normalization of calcium levels despite meeting intraoperative parathyroid hormone (IOPTH) criteria and to determine whether this phenomenon is associated with higher rates of persistent pHPT. METHODS: This was a retrospective review of 554 patients who underwent parathyroidectomy for sporadic pHPT from January 2009 to July 2013. Patients who underwent presumed curative parathyroidectomy and had elevated POD0 calcium levels (>10.2 mg/dL) were matched 1:2 for age and gender to control patients with normal POD0 calcium levels. RESULTS: Of the 554 patients, 52 (9 %) had an elevated POD0 Ca (median 10.7, range 10.3-12.2). Compared with the control group, these patients had higher preoperative calcium (12 vs. 11.1, p < 0.001) and PTH (144 vs. 110 pg/mL, p = 0.004) levels and lower 25OH vitamin D levels (26 vs. 31 pg/mL; p = 0.024). Calcium normalization occurred in 64, 90, and 96 % of patients by postoperative days (POD) 1, 14, and 30, respectively. There was no difference in rates of single-gland disease or cure rates between the groups. CONCLUSIONS: After presumed curative parathyroidectomy, nearly 10 % of patients had transiently persistent hypercalcemia. Most of these patients had normal serum calcium levels within the first 2 weeks and did not have increased rates of persistent pHPT. Immediate postoperative calcium levels do not predict the presence of persistent pHPT, and these patients may not require more stringent follow-up.

Association between body mass index and multigland primary hyperparathyroidism.

INTRODUCTION: Multigland disease (MGD) accounts for 15% of sporadic primary hyperparathyroidism (pHPT). Several studies have reported a link between obesity and calcium metabolism (e.g., increased incidence of pHPT, higher levels of parathyroid hormone, lower vitamin D levels, and larger parathyroid glands). Obese patients have also been shown to require reoperation for persistent/recurrent pHPT more often than nonobese controls. We hypothesize that obese patients may have a higher prevalence of MGD. METHODS: This was a retrospective review of a prospectively collected parathyroid database that included adult patients with sporadic pHPT, who underwent initial parathyroidectomy between 1999 and 2013. Demographic, clinicopathologic, operative, and laboratory data were assessed for associations with MGD. RESULTS: Of 1305 consecutive patients, 200 (15%) had MGD. Median age was 59 y. Univariate analyses demonstrated that MGD was associated with age > 60 y, higher body mass index (BMI), history of lithium therapy, lower 24-h urine calcium excretion, higher serum alkaline phosphatase levels, and smaller size of the first excised parathyroid gland. On multivariate analyses, predictors of MGD were BMI 30-39.9 kg/m(2) (odds ratio [OR] 1.5; 95% confidence interval [CI] 1.2-2.5), BMI ≥ 40 kg/m(2) (OR 1.8; 95% CI 1.3-3.1), and smaller size of the first excised parathyroid (OR 0.7; 95% CI 0.6-0.8). CONCLUSIONS: This study demonstrates a higher incidence of MGD in obese and morbidly obese patients. Due to a higher risk of MGD, surgeons should have a lower threshold to perform bilateral exploration in obese patients, especially if the first excised parathyroid gland is relatively small.

The Effect of Thyroiditis on the Yield of Central Compartment Lymph Nodes in Patients with Papillary Thyroid Cancer.

BACKGROUND: In patients who have undergone thyroidectomy and central compartment neck dissection (CCND) for papillary thyroid cancer (PTC), visualization of enlarged lymph nodes may lead to more extensive CCND. This study sought to determine the effect of patient age and the presence of thyroiditis on the number of malignant and total lymph nodes resected in patients who underwent CCND for PTC. METHODS: This retrospective review examined a prospective database of patients who underwent total thyroidectomy and CCND for PTC between April 2009 and June 2013 and had thyroiditis on the final pathology. The patients were categorized into age groups by decade (18-29, 30-39, 40-49, 50-59, and ≥60 years) and compared with a control group of patients matched by age, gender, and tumor size. RESULTS: Of 74 patients with thyroiditis, 64 (87 %) were women. The median age of the patients was 47.5 years (range 18.2-72.0 years). The patients with thyroiditis had more lymph nodes resected than those without thyroiditis (median 11 vs 7; p < 0.01). However, these patients had fewer malignant lymph nodes (median 0 vs 1.5; p = 0.06), resulting in a lower lymph node ratio (0 vs 0.18; p = 0.02) for the entire cohort, but particularly for the youngest (18-29 years) and oldest (≥60 years) age groups. CONCLUSIONS: Patients with thyroiditis and PTC who underwent CCND had more lymph nodes resected but a had lower proportion of metastatic lymph nodes than those without thyroiditis. Given the relatively low yield of malignant cervical lymphadenopathy, a more judicious approach to CCND might be considered, particularly for the youngest and oldest patients with PTC and thyroiditis.

Reexamining the Relationship of Breast Cancer Hospital and Surgical Volume to Mortality: An Instrumental Variable Analysis.

OBJECTIVE: To reexamine the relationship of hospital and surgical volume to all-cause and breast cancer-specific mortality, taking into account the potential selection bias in patients treated at high-volume centers or by high-volume surgeons. DATA SOURCES: Elderly (65+) women with early-stage, incident breast cancer surgery in 2003. STUDY DESIGN: A population-based, prospective survey study. METHODS: Two-stage, instrumental variable regression models. PRINCIPAL FINDINGS: Women treated in high-volume hospitals were significantly less likely to die of any cause by 5 years after surgery, even after adjustments for self-selection and a number of other factors. The relationship was larger and more significant for breast cancer-specific mortality. Although the general pattern of better mortality outcomes held for moderately sized hospitals, the relationships were not statistically significant. In contrast, there was no relationship of surgeon volume with all-cause or breast cancer-specific mortality. CONCLUSIONS: Hospital volume, but not surgeon volume, is associated with better survival among women with breast cancer. The magnitude of the potential improvement was substantial and comparable with the benefit conferred by many systemic therapies. These findings highlight the importance of accounting for patient self-selection in volume-outcome analyses, and provide support for policy initiatives aimed at regionalizing breast cancer care in the United States.