Randomized clinical trial comparing open with video-assisted minimally invasive parathyroid surgery for primary hyperparathyroidism.

BACKGROUND: : Previous studies of video-assisted techniques for parathyroidectomy in patients with primary hyperparathyroidism have found similar or better results compared with bilateral neck exploration. The aim of the present study was to compare open minimally invasive parathyroidectomy with the video-assisted technique for primary hyperparathyroidism in a multicentre randomized trial. METHODS: : Some 143 patients were randomized to open (n = 75) or video-assisted (n = 68) parathyroidectomy after positive sestamibi scintigraphy. There were no differences in preoperative data. The open operation was performed through a 15-mm incision. The video-assisted techniques used were minimally invasive video-assisted parathyroidectomy (MIVAP) or video-assisted parathyroidectomy using the lateral approach (VAPLA). Data were collected prospectively including postoperative pain scoring. RESULTS: : The procedure was significantly quicker for the open compared to the video assisted operations: mean(s.d.) 60(35) versus 84(47) min (P = 0.001). Both groups of patients had similar conversion rates and the same outcome, with comparable incision lengths, low scores for postoperative neck discomfort, high cosmetic satisfaction and low complication rates. CONCLUSION: : Open minimally invasive parathyroidectomy for primary hyperparathyroidism was quicker than either video-assisted technique. REGISTRATION NUMBER: NCT00877981 (http://www.clinicaltrials.gov)

Ultrasound-guided drainage of breast abscesses: results in 151 patients.

The aim of this paper is to describe the efficacy of ultrasound-guided drainage of breast abscesses with special attention to the risk of recurrence and the need for surgical treatment in a consecutive patient population. 151 patients, 89 with puerperal and 62 with non-puerperal breast abscesses, were treated with ultrasound-guided drainage, by needle or catheter under local anaesthesia. Follow-up punctures were performed at 2 or 3 day intervals until the clinical condition and ultrasound findings had improved. All patients were treated with oral antibiotics. Mammography was performed to search for underlying cancer. 86 (97%) out of 89 patients with puerperal abscesses and 50 (81%) out of 62 with non-puerperal abscesses recovered after the first round of ultrasound-guided drainage. One patient in each group had recurrence in loco but recovered after further ultrasound-guided drainage. 13 patients, 11 with non-puerperal and two with puerperal abscesses, underwent surgical excision of the abscess cavity or fistulas. Breastfeeding continued and 117 patients were treated as outpatients. The median number of follow up examinations in the ultrasound-department was four (range 1-10) for the group of patients with puerperal abscess and three (range 1-7) in the group of patients with non-puerperal abscess. The corresponding figure for the median number of punctures was for both groups one (range 1-6 and 1-4). There were no reports of newly diagnosed breast cancer in the 2 year follow-up period. This study supports the use of ultrasound-guided drainage in puerperal and non-puerperal breast abscesses. The method is less invasive than traditional surgery and has a high rate of success.

Immunohistochemical assessment of oestrogen and progesterone receptors: correlations with the DCC method and clinical outcome in primary breast cancer patients.

Two different methods to determine steroid receptors were analysed with respect to their ability to estimate prognosis in primary breast cancer patients. The immunohistochemical assay (IHA) was compared with the dextran-coated charcoal (DCC) method of receptor determination. A random sample of 281 patients with invasive ductal carcinoma was drawn from 841 consecutive patients with primary breast carcinoma treated at Odense University Hospital between 1 January 1980 and 31 December 1990. Receptor determination by the DCC method had been carried out previously in 164 patients for the oestrogen receptor and in 132 patients for the progesterone receptor. The former group was reassessed by IHA with the antibody ER1D5, and the latter with the antibody PgR-ICA. The median follow-up time was 8.3 years (range 2.9-12.9 years). A cutoff of zero was used for the DCC method. Immunohistochemical results were quantified by counting in systematically random sampled fields of vision and values above zero were considered to be positive. Overall agreement of positive and negative cases was 86% for the oestrogen receptor and 83% for the progesterone receptor. Although the study included a limited number of patients, receptor positive cases fared better than negative cases in all situations. Investigation of the prognostic power revealed that classification based on IHA allowed better discrimination of patients than classification based on the DCC method. The reason for this difference might be because distinction between benign and malignant tissue is possible using the IHAmethod. Thus, IHAresults appear to be more clinically relevant.

A tumour in the breast: vaccination granuloma as a differential diagnosis.

AIMS: Breast cancer is the most frequent type of cancer in women; special attention is therefore paid to tumours in the breast region. Vaccination granuloma is a differential diagnosis of tumours in the upper part of the breast. METHODS: All granulomatous lesions in the breast region since 1970 were retrieved from the files of the Departments of Pathology at Odense University Hospital and Svendborg Hospital. RESULTS: Fourteen cases with a histology compatible with vaccination granuloma were found. Eight patients had a known history of tetanus vaccination. The tumours were ovoid, or even rod-shaped, and measured between 8x3 mm and 12x10 mm. Histologically, there were necrotic foci surrounded by histiocytes, lymphocytes, and plasma cells. Aluminium was detected by staining with solochrome azurine. CONCLUSIONS: The possibility of a vaccination granuloma should be kept in mind in patients with a palpable tumour in the upper part of the breast, as well as in mammography screening conditions and in follow-up patients after previous treatment for breast cancer.

The importance of surgery and accurate axillary staging for survival in breast cancer.

AIMS: The purpose of this study was to investigate, within the context of the Danish Breast Cancer Cooperative Group (DBCG) programmes, whether a dedicated surgical approach had a significant bearing on the outcome of breast cancer treatment. METHODS: From 1 January 1980 to 31 December 1990, patients below 70 years of age with operable breast cancer from Odense University Hospital (n=743) were compared with those from the rest of Denmark (denoted rest-DK) (n=15,419). All patients were treated according to nationwide DBCG guidelines and reported to the DBCG Data Centre. The potential median observation time was 11.2 years (range 6.0-16.9). Patients underwent mastectomy or breast conserving therapy, and high risk lymph-node positive patients had adjuvant systemic therapy with or without radiotherapy. RESULTS: Comparing total patients series, overall survival (OS) was significantly superior in patients from Odense compared with rest-DK (P=0.02), with 10-year OSs of 62% (95% CI: 58-65%) and 56% (55-57%), respectively. In subgroups, the OS of low-risk node negative patients (protocol A) in Odense compared with rest-DK was significantly better (P=0.02); 10-year OS was 78% (73-84%) versus 72% (70-73%). Among the high-risk pre-menopausal patients (protocol B), the OS was significantly better in Odense (P=0.009); 10-year OS was 67% (60-75%) versus 53% (51-55%) in rest-DK. Post-menopausal high-risk patients (protocol C) did not differ significantly in OS between Odense and rest-DK (P=0.61). Locoregional control in the Odense series was superior compared with rest-DK. More lymph nodes were recovered and examined from the axilla in the Odense series than in rest-DK, a median of 10 vs. 6 nodes. In the Odense series, a significantly higher proportion of pre-menopausal patients had positive lymph nodes, predominantly one to three positive nodes, and subsequently a lower proportion of pre-menopausal patients had negative lymph nodes compared with rest-DK (P=0.02), indicating a more accurate staging in Odense vs. rest-DK. The survival benefit among the patients from Odense cannot be explained by stage migration alone, but seems to represent a true survival advantage. Overall mortality was significantly lower in the Odense series compared with rest-DK. Whether or not this difference could be explained by lower background mortality in the Odense series or was caused by superior treatment is discussed. CONCLUSIONS: The extent of surgery seems important for locoregional tumour control and accurate axillary lymph-node staging. In combination, these might lead to superior recurrence-free and overall survival, although differences in background mortality cannot be ignored. Surgery, therefore, might represent a risk factor by itself.

[Intrathoracic goiter. Diagnostic aspects, surgical complications and permanent sequelae]. / Intratorakal struma. Diagnostiske aspekter, kirurgiske komplikationer og varige følgetilstande.

During the course of 1151 thyroidectomies performed during an 11-year period, 195 patients were found to have intrathoracic goitre. Centre experience of operating this disease and the usefulness of applied diagnostic methods are analysed. The sensitivity of physical examination (palpation), technetium scintigraphy and chest roentgenogram is respectively 52%, 33% and 65%, while specificity is respectively 99%, 98% and 95%. These three methods together ensure the diagnosis in 82% of the patients. Positive predictive values are respectively 95%, 78%, and 72%, while negative predictive values are found to be 91%, 89%, and 93%. Frequency of permanent unilateral vocal cord paresis is 2.5%, no cases of bilateral recurrent nerve damage occurred. The frequency of unilateral vocal cord paresis is found to be 1.4%, if nerves of risk are considered. The incidence of hypocalcemia requiring permanent treatment reaches 2%. Intrathoracic goitre can be treated surgically with an only slightly elevated risk for surgical complications and permanent sequelae, especially when performed in the elective phase and within the frame of centre facilities. Intrathoracic components can nearly always (97%) be reached through cervical incision.

[Primary adenocarcinoma in appendiceal diverticulitis]. / Primaert adenokarcinom i appendixdivertikel.

A case of primary adenocarcinoma in appendiceal diverticulosis is reported. Such a case has never been mentioned before in the literature. It was not possible to diagnose the case preoperatively. This emphasizes the importance of histological examination of all appendiceal samples.

[Surgical treatment of benign recurrent goiter. Technique, complications and permanent sequelae]. / Kirurgisk behandling af benign recidivstruma. Teknik, komplikationer og varige følgetilstande.

Centre experience of reoperation for recurrent goitre in 82 patients during an 11-year period is analysed. The lateralposterior approach is used as a standard surgical technique. Postoperative complications are prevalent only among patients previously operated on the thyroid gland twice or more, among patients with recurrent intrathoracic goitre, and among patients with large goitre relapse. Frequency of permanent unilateral vocal cord paresis amounts to 3.6%. There were no cases of bilateral recurrent nerve damage. The incidence of hypocalcemia requiring permanent treatment reaches 1.2%. Centre experience tends to reduce surgical complications rates with increasing specialized training. The surgical treatment for recurrent goitre ought to be radical to avoid further relapses. We recommend lobectomy in cases of unilateral recurrence and lobectomy of the dominant lobe with contralateral resection in case of bilateral relapse.

Factors of importance for scintigraphic non-visualisation of sentinel nodes in breast cancer.

PURPOSE: The aim of this study was to analyse different factors of possible significance for non-visualisation of sentinel nodes (SNs) by preoperative lymphoscintigraphy, in order to enable improvement of the success rate of SN visualisation through modification or alteration of some of the factors. METHODS: Between March 1998 and January 2003 we analysed a series of 442 women with unilateral stage T1 and clinical N0 breast cancer. Lymphoscintigraphy was performed after periareolar or peritumoural injection of 99mTc-albumin nanocolloid, with image acquisition after 2-6 h or 18-24 h. Until January 2001, all patients received around 20 MBq tracer, irrespective of time to operation. From January 2001, patients injected on the day before surgery received at least 100 MBq while patients injected on the day of surgery received around 50 MBq. RESULTS: An SN was visualised in 87% of the patients, and at surgery the SN was detected with the hand-held gamma probe in 42% of the remaining patients. By multiple logistic regression analysis, statistically significant independent variables that increased the risk for non-visualisation were increasing age (p=0.0007), increasing body weight (p=0.0189) and peritumoural injection (p<0.0001). Significant interaction was found for imaging time and injected activity (p=0.0017). CONCLUSION: This study conclusively shows that the risk of unsuccessful SN imaging increases with age and body weight. Our findings suggest that the scintigraphic success rate may be improved by periareolar (rather than peritumoural) injection. Early and late imaging procedures are equally efficient, but if a late imaging procedure is used, activity (adjusted for physical decay) in the patient on day 2 should be more than 10 MBq.

Experience in a specialist thyroid surgery unit: a demographic study, surgical complications, and outcome.

OBJECTIVE: To present a demographic study of thyroid diseases and thyroid surgical activity, to analyse the results of one department that has specialised in thyroid surgery during an 11-year period, and to try to define those groups of patients at increased risk of complications and untoward sequelae. DESIGN: Retrospective study. SETTING: Danish regional university hospital. SUBJECTS: The total series comprised 1099 consecutive patients who were operated on for benign goitre during an 11-year period. The demographic series comprised a subgroup of 933 patients with goitres from the defined catchment area composed of five municipalities. MAIN OUTCOME MEASURES: Annual number of operations for goitre, waiting time to operation, incidence of complications, and sequelae. RESULTS: In the demographic study the number of patients operated on for benign thyroid diseases declined from about 50 cases to about 25 cases/100000 inhabitants during the study period. At the same time the average waiting time between consultation and operation increased from 5-33 weeks. In the total series (n = 1099) 18 patients developed temporary unilateral vocal cord paralysis (2%), and 8 developed permanent paralysis (0.7%). There were no bilateral vocal cord paralyses, 7 patients developed temporary postoperative hypocalcaemia (0.6%), and an additional 8 patients (0.7%) developed permanent hypocalcaemia. 5 patients developed wound haematomas (0.5%), and 3 had wound infections (0.3%). A total of 16 patients (1.5%) had a permanent complication in the form of nerve injury or damage to the parathyroid glands. The rates of postoperative complications were significantly higher among patients who had two or more operations on the neck (p = 0.0004), intrathoracic goitres (p = 0.0002), large goitres (p = 0.0002), and those having emergency operations (p = 0.0091). CONCLUSION: The decline in the number of operations for benign goitre at Odense University Hospital parallels the increase it waiting time before operation. This can be explained by loss of operating room capacity rather than introduction of some alternative cure for goitre or change of criteria for operation. Certain groups of patients are at higher risk of complications than others.