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BACKGROUND: Lenvatinib is an oral, multitargeted tyrosine kinase inhibitor of the vascular endothelial growth factor receptors 1 through 3 (VEGFR1-VEGFR3), fibroblast growth factor receptors 1 through 4 (FGFR1-FGFR4), platelet-derived growth factor receptor α (PDGFRα), ret proto-oncogene (RET), and v-kit Hardy-Zuckerman 4 feline sarcoma viral oncogene homolog (KIT) signaling networks implicated in tumor angiogenesis. Positive phase 1 results in solid tumors prompted a phase 2 trial in patients with advanced, radioiodine-refractory, differentiated thyroid cancer (RR-DTC). METHODS: Fifty-eight patients with RR-DTC who had disease progression during the previous 12 months received lenvatinib 24 mg once daily in 28-day cycles until disease progression, unmanageable toxicity, withdrawal, or death. Previous VEGFR-targeted therapy was permitted. The primary endpoint was the objective response rate (ORR) based on independent imaging review. Secondary endpoints included progression-free survival (PFS) and safety. Serum levels of 51 circulating cytokines and angiogenic factors also were assessed. RESULTS: After ≥14 months of follow-up, patients had an ORR of 50% (95% confidence interval [CI], 37%-63%) with only partial responses reported. The median time to response was 3.6 months, the median response duration was 12.7 months, and the median PFS was 12.6 months (95% CI, 9.9-16.1 months). The ORR for patients who had received previous VEGF therapy (n = 17) was 59% (95% CI, 33%-82%). Lower baseline levels of angiopoietin-2 were suggestive of tumor response and longer PFS. Grade 3 and 4 treatment-emergent adverse events, regardless of their relation to treatment, occurred in 72% of patients and most frequently included weight loss (12%), hypertension (10%), proteinuria (10%), and diarrhea (10%). CONCLUSIONS: In patients with and without prior exposure to VEGF therapy, the encouraging response rates, median time to response, and PFS for lenvatinib have prompted further investigation in a phase 3 trial. Cancer 2015;121:2749-2756. © 2015 American Cancer Society.
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Antineoplásicos/uso terapêutico , Radioisótopos do Iodo/uso terapêutico , Compostos de Fenilureia/uso terapêutico , Inibidores de Proteínas Quinases/uso terapêutico , Quinolinas/uso terapêutico , Neoplasias da Glândula Tireoide/tratamento farmacológico , Adulto , Idoso , Biomarcadores Tumorais/análise , Progressão da Doença , Feminino , Humanos , Radioisótopos do Iodo/efeitos adversos , Masculino , Pessoa de Meia-Idade , Compostos de Fenilureia/efeitos adversos , Inibidores de Proteínas Quinases/efeitos adversos , Proto-Oncogene Mas , Quinolinas/efeitos adversos , Neoplasias da Glândula Tireoide/mortalidade , Resultado do TratamentoRESUMO
OBJECTIVE: Vitamin D deficiency affects parathyroid hormone levels and is endemic in the American population due to diet and lifestyle. The aim of this study was to evaluate a treatment algorithm using weekly doses of 50,000 IU of Vitamin D2 for thyroid and parathyroid surgery patients. STUDY DESIGN: Prospective, non-randomized. SETTING: University health sciences center. SUBJECTS AND METHODS: Patients at a thyroid center being treated for benign and malignant thyroid diseases or parathyroid disease. Subjects with total vitamin D levels less than 30 ng/dl were prospectively treated with weekly doses of 50,000 IU of vitamin D2 (D2) for durations dependent upon initial vitamin D (25-hydroxyvitamin D) levels. Vitamin D levels were measured after the treatment intervals and change in levels from baseline was determined. RESULTS: Subjects receiving 8 weeks of therapy demonstrated an average increase in vitamin D level of 13.4 ng/ml, 10 weeks of therapy showed an increase of 16.35 ng/ml, and 12 weeks showed an average increase of 21.6 ng/ml. The treatment groups had success rates of 82%, 75%, and 71% after 8, 10, and 12 weeks of therapy respectively. When only compliant patients were evaluated (defined as greater than 3-ng/ml increase after therapy), the success rates after 8, 10, and 12 weeks increased to 95%, 79%, and 71% respectively. CONCLUSIONS: A simple algorithm using 50,000 IU of vitamin D2 corrects its deficiency in the majority of subjects treated. This is a simple method of treatment for thyroid and parathyroid patients who are vitamin D deficient. Thyroid and parathyroid conditions are frequently treated by otolaryngologists and vitamin D deficiency can complicate their diagnosis and/or management.
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Algoritmos , Deficiência de Vitamina D/tratamento farmacológico , Vitamina D/análogos & derivados , Administração Oral , Relação Dose-Resposta a Droga , Esquema de Medicação , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Hormônio Paratireóideo/sangue , Cooperação do Paciente , Estudos Prospectivos , Resultado do Tratamento , Vitamina D/administração & dosagem , Vitamina D/farmacocinética , Deficiência de Vitamina D/sangue , Deficiência de Vitamina D/etiologia , Vitaminas/administração & dosagem , Vitaminas/farmacocinéticaRESUMO
Positron emission tomography (PET) positive lesions are common in the thyroid. The uptake can be focal or diffuse. Diffuse thyroid uptake is thought to be indicative of autoimmune thyroiditis and not for lesions of malignant potential. Hashimoto's thyroiditis as a cause for diffusely positive thyroid glands has been demonstrated. We determine the incidence of diffuse thyroid PET positivity in hypothyroid patients, presumed to have Hashimoto's thyroiditis. The study design was retrospective database and electronic medical record review. The study setting includes tertiary care and academic health sciences center. The subjects were patients at our medical center who underwent positron emission tomography. Hypothyroid patients were identified who had total body PET imaging performed for any reason. Patients were excluded if they were not taking levothyroxine, had a history of neck surgery, neck irradiation, Graves' disease, taking lithium, thalidomide, amiodarone or interleukin. Patients remaining after the application of these exclusion criteria were presumed to be hypothyroid from Hashimoto's thyroiditis. Only 9.5% of PET scans of hypothyroid patients display diffuse thyroid activity. Only a small minority of presumed Hashimoto's thyroiditis patients will display diffuse thyroid activity after PET imaging. The etiology of this effect is unknown. Diffuse thyroid activity rarely requires surgical intervention.
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Fluordesoxiglucose F18/farmacocinética , Hipotireoidismo/metabolismo , Tomografia por Emissão de Pósitrons/métodos , Compostos Radiofarmacêuticos/farmacocinética , Glândula Tireoide/metabolismo , Idoso , Feminino , Humanos , Hipotireoidismo/diagnóstico por imagem , Incidência , Masculino , Prognóstico , Estudos Retrospectivos , Índice de Gravidade de Doença , Glândula Tireoide/diagnóstico por imagemRESUMO
BACKGROUND: Breast cancer is a significant cause of morbidity and mortality in older women. The current study presents new, comprehensive guidelines for providing chemoprevention to older women. OBJECTIVE: The objective of this study was to develop and pilot test a chemopreventive choice algorithm to assess its feasibility for older women at high risk of breast cancer. DESIGN: The study observed outcomes of 23 older adult females being treated with one of the four different chemopreventive agents. A novel algorithm protocol was utilized for individualized chemopreventive selection. SETTING: The study was conducted in a high-risk outpatient clinic for older women. PARTICIPANTS: Older outpatient females at high risk (N=23) were offered chemopreventive options based on individual criteria. INTERVENTION: Literature review for breast cancer chemopreventive agents informed our development of a logic-based algorithm to guide treatment protocol and chemopreventive choice optimization. Selective estrogen receptive modulators (SERMs) were avoided in women with endometrial cancer risk (ie, pre-hysterectomy individuals), but used in women with low thromboembolic event (TE) risk. Raloxifene was used with osteoporotic women. Aromatase inhibitors (AIs) were used in women with high TE risk. Women without TE risks are advised to take SERMs. When bone density decreased due to AI use, women were switched to raloxifene. MEASUREMENTS/RESULTS: Of 23 participants of age ranging from 59 to 80 years (mean=72.6), two women developed estrogen receptor-positive breast cancer. Two participants, one who declined chemoprevention and one treated with an AI, developed breast cancer. All initial chemopreventive agents were selected according to the algorithm. Although minor adverse events occurred, each was managed by discontinuation or replacement of the chemopreventive agent. Discontinuation was most commonly due to side effect concerns or cost rather than experienced side effects. CONCLUSION: Outcomes of the initial utilization of the chemopreventive agent choice algorithm support the viability of the protocol, but further evaluation with a larger and more diverse sample is required.
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OBJECTIVE: To quantify how frequently intraoperative parathyroid hormone levels increase during thyroid surgery and to explore a possible relationship between secondary hyperparathyroidism due to vitamin D deficiency and elevation in intraoperative parathyroid hormone. STUDY DESIGN: Case series with chart review. SETTING: Tertiary academic center. SUBJECTS AND METHODS: A total of 428 consecutive patients undergoing completion and total thyroidectomy by the senior author over a 7-year period were included for analysis. All patients had baseline and postexcision intraoperative parathyroid hormone levels as well as vitamin D levels from the same laboratory. Institute of Medicine criteria were employed for vitamin D stratification (>30, normal; 20-29.9, insufficient; <20, deficient) . Other data analyzed include sex, age, neck dissection status, and parathyroid autotransplantation. RESULTS: A total of 118 patients (27.6%) had an intraoperative parathyroid hormone elevation above baseline. Patients with vitamin D deficiency were significantly more likely to experience hormone elevation ( P = .04). When parathyroid hormone rose, it did so by a mean 32.1 pg/mL. Patients with vitamin D deficiency demonstrated significantly larger hormone increases ( P = .03). CONCLUSION: Elevation in intraoperative parathyroid hormone levels above baseline after completion and total thyroidectomy occurs in over one-fourth of cases and is significantly associated with vitamin D deficiency. This study is the first to report this observation. We hypothesize that vitamin D deficiency in these patients may create a subclinical secondary hyperparathyroidism that leads to intraoperative parathyroid hormone elevation when the glands are manipulated. Additional studies will be needed to explore this physiologic mechanism and its clinical significance.
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Hiperparatireoidismo Secundário/etiologia , Complicações Intraoperatórias/etiologia , Hormônio Paratireóideo/sangue , Doenças da Glândula Tireoide/cirurgia , Tireoidectomia/efeitos adversos , Deficiência de Vitamina D/complicações , Feminino , Humanos , Hiperparatireoidismo Secundário/diagnóstico , Complicações Intraoperatórias/diagnóstico , Masculino , Monitorização Intraoperatória , Estudos Retrospectivos , Doenças da Glândula Tireoide/sangue , Doenças da Glândula Tireoide/complicações , Deficiência de Vitamina D/sangueRESUMO
OBJECTIVE: Fluorodeoxyglucose (FDG) whole body positron emission tomography (PET) scan may show clinically occult second lesions. Such lesions in the thyroid are increasingly common. There are several recent reports of a high probability of malignancy in these lesions ranging from 14% to 63%. STUDY DESIGN AND SETTING: This is a retrospective review of 15,711 PET scans at a multi-disciplinary thyroid clinic at a tertiary care university medical center. Twenty-two patients were referred with thyroid PET "incidentalomas." The review included 18 FDG-PET scans, ultrasound guided fine needle aspiration biopsies, and thyroid surgery pathology. Aspiration cytology or pathology were the main outcome measures. RESULTS: Three patients had malignancy of the PET-positive thyroid lesions. Papillary thyroid micro carcinomas were detected in four of the specimens that showed a benign pathology of the dominant nodule. CONCLUSION: Our experience shows a 14% malignancy rate for the dominant (imaged) nodule and a total malignancy rate of 32% when the incidental micro carcinomas are included. Both of these rates are significantly lower than results published previously.
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Carcinoma/diagnóstico por imagem , Carcinoma/epidemiologia , Achados Incidentais , Neoplasias da Glândula Tireoide/diagnóstico por imagem , Neoplasias da Glândula Tireoide/epidemiologia , Adenoma Oxífilo/diagnóstico por imagem , Adenoma Oxífilo/epidemiologia , Adenoma Oxífilo/patologia , Carcinoma/patologia , Fluordesoxiglucose F18 , Humanos , Incidência , Tomografia por Emissão de Pósitrons , Compostos Radiofarmacêuticos , Estudos Retrospectivos , Neoplasias da Glândula Tireoide/patologia , Imagem Corporal TotalAssuntos
Achados Incidentais , Nódulo da Glândula Tireoide , Diagnóstico Diferencial , Humanos , Imagem Multimodal/métodos , Tomografia por Emissão de Pósitrons , Prevalência , Nódulo da Glândula Tireoide/diagnóstico , Nódulo da Glândula Tireoide/epidemiologia , Tomografia Computadorizada por Raios XRESUMO
BACKGROUND: The purpose of this study was to define and characterize the thyroid tumor-draining lymph nodes in genetically engineered mice harboring thyroid-specific expression of oncogenic BrafV600E with and without Pten insufficiency. METHODS: After intratumoral injection of methylene blue, the lymphatic drainage of the thyroid gland was visualized in real time. The thyroid gland/tumor was resected en bloc with the respiratory system for histological analysis. RESULTS: Although mice harboring BrafV600E mutations were smaller in body size compared with their wild-type (WT) littermates, the size of their thyroid glands and deep cervical lymph nodes were significantly larger. Additionally, the tumor-draining lymph nodes showed increased and enlarged lymphatic sinuses that were distributed throughout the cortex and medulla. Tumor-reactive lymphadenopathy and histiocytosis, but no frank metastases, were observed in all mice harboring BrafV600E mutations. CONCLUSIONS: The tumor-draining lymph nodes undergo significant structural alterations in immunocompetent mice, and this may represent a primer for papillary thyroid carcinoma (PTC) metastasis.
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Carcinoma Papilar/secundário , Linfonodos/anatomia & histologia , Neoplasias da Glândula Tireoide/patologia , Animais , Animais Geneticamente Modificados , Carcinoma Papilar/patologia , Carcinoma Papilar/cirurgia , Corantes , Feminino , Linfonodos/fisiopatologia , Metástase Linfática , Sistema Linfático/fisiopatologia , Masculino , Azul de Metileno , Camundongos , Camundongos Endogâmicos , Mutação , Proteínas Proto-Oncogênicas B-raf/genética , Glândula Tireoide/anatomia & histologia , Glândula Tireoide/patologia , Neoplasias da Glândula Tireoide/cirurgiaRESUMO
OBJECTIVE: The purpose of this study was to determine the cost considerations and strategies for incorporating ultrasound (US) in a head and neck practice. STUDY DESIGN AND SETTING: A retrospective chart review of office-based US procedures from 2001 to 2005 was completed at our academic medical center. Billing and coding for US and US guided fine needle aspiration (USFNA) were examined. RESULTS: The appropriate CPT codes are 76536 for US and 76942 and 10022 for USFNA-related procedures. The USFNA codes should be used repeatedly for correct coding of biopsies from multiple sites. Cost (equipment) sharing between specialties is a potential strategy for office-based US incorporation. CONCLUSION: Based on practice volume, specific CPT coding, and Medicare reimbursements, office-based US equipment and certification costs could be offset in 1 year. SIGNIFICANCE: Office-based US can be readily incorporated with significant benefits to patients. Billing and usage strategies were identified that would improve the economics of providing office-based US.
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Cabeça/diagnóstico por imagem , Pescoço/diagnóstico por imagem , Otolaringologia/economia , Administração da Prática Médica/economia , Biópsia por Agulha Fina/economia , Current Procedural Terminology , Humanos , Reembolso de Seguro de Saúde , Visita a Consultório Médico/economia , Estudos Retrospectivos , Ultrassonografia/economiaRESUMO
OBJECTIVE: To describe a safe and effective postoperative prophylactic calcium regimen for same-day discharge thyroid and parathyroid surgery. STUDY DESIGN: Case series with chart review. SETTING: Tertiary referral academic institution. SUBJECTS AND METHODS: In total, 162 adult patients who underwent total thyroidectomy, completion thyroidectomy, unilateral parathyroidectomy, parathyroidectomy with bilateral neck exploration, or revision parathyroidectomy were identified preoperatively to be candidates for same-day discharge. All patients in this study were successfully discharged the same day on our standard prophylactic calcium regimen. RESULTS: Less than 1% (1/162) of patients re-presented to the hospital within 30 days of surgery, and that patient was successfully discharged from the emergency department after negative workup for hypocalcemia. There was no significant difference between preoperative and postoperative calcium levels in the total/completion thyroidectomy groups (9.3 vs 9.2 mg/dL, respectively; P = .14). The average postoperative calcium level in the parathyroid group was well within normal limits (9.5 mg/dL), and the difference in postoperative calcium levels between revision and primary parathyroidectomy cases was not significantly different (P = .34). CONCLUSION: The reported calcium regimen demonstrates a safe, effective, and objective means of postoperative calcium management in outpatient thyroid and parathyroid surgery in appropriately selected patients.
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Assistência Ambulatorial , Cálcio/uso terapêutico , Hipocalcemia/tratamento farmacológico , Doenças das Paratireoides/cirurgia , Paratireoidectomia , Doenças da Glândula Tireoide/cirurgia , Tireoidectomia , Adulto , Idoso , Biomarcadores/sangue , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Hormônio Paratireóideo/sangue , Alta do Paciente , Complicações Pós-OperatóriasRESUMO
BACKGROUND: Megestrol acetate (MA) is a synthetic progestin commonly used to promote weight gain in malnourished older individuals. In small studies, MA administration has been associated with reduced serum cortisol concentrations in patients with cancer or AIDS. The impact of MA on the pituitary secretion of adrenocorticotropic hormone (ACTH) and other hormones is unclear, and the prevalence and extent of hypocortisolemia in older individuals after MA treatment is unknown. A randomized, placebo-controlled study of the effects of testosterone (T) and resistance training (RT) on body composition after MA administration in older men has been reported previously. OBJECTIVE: The purpose of this post hoc analysis was to examine the effect of 12 weeks of MA on pituitary function and end-organ hormone secretion in healthy older individuals using frozen serum samples from that study. METHODS: The previous study was conducted at the Department of Geriatrics, Donald W. Reynolds Center on Aging and the General Clinical Research Center at The University of Arkansas for Medical Sciences, Little Rock, Arkansas. Healthy male volunteers aged 60 to 85 years were recruited from the center and were randomly assigned to 1 of 4 study groups: RT + T, T, RT + placebo (P), or P. Subjects enrolled in the RT groups underwent supervised upper- and lower-body strength-training exercises 3 d/wk at 80% of 1 repetition maximum. Subjects in the groups to receive T received injections of testosterone enanthate 100 mg i.m. QW for 12 weeks. Subjects receiving P were given 1-mL saline injections i.m. QW for 12 weeks. All subjects received MA 800 mg p.o. QD concurrently for 12 weeks. For the present analysis, serum concentrations of the pituitary hormones follicle-stimulating hormone (FSH), thyroid-stimulating hormone (TSH), ACTH, prolactin (PRL), and luteinizing hormone (LH), as well as the end-organ hormones estradiol (E2), cortisol, free T4, and T, were measured in samples obtained at baseline (week 0) and after 12 weeks of MA treatment. RESULTS: Serum samples from 21 men (mean [SD]age, 67.0 [7.3]years; mean [SD] body mass index, 23.1 [10.4] kg/m2; mean [SD] percentage of body fat, 22.5% [8.8%]; RT + T, T, RT + P, and P groups, n = 4, 5, 6, and 6 subjects, respectively) were available from the original study. The mean percentage changes from baseline in serum pituitary hormone concentrations after 12 weeks of MA administration were as follows: TSH, -14.7%; ACTH, -89.5%; PRL, 162.2%; and LH, -49.0%; (P = 0.03, <0.001, <0.001, and <0.001, respectively). The mean (SD) percentage changes from baseline in serum end-organ hormone concentrations with MA at 12 weeks were as follows: E2, 181.6%; and cortisol, -90.8% (both, P < 0.001). In the P and RT + P groups, the mean percentage changes from baseline in T were -84% and -85%, respectively (both, P < 0.001). FSH and free T4 concentrations were not significantly changed. CONCLUSIONS: This analysis of serum samples from healthy older men suggests that MA administration significantly affected the secretion of several pituitary hormones and end-organ hormone synthesis. Most notably, ACTH secretion and serum cortisol levels were statistically significantly suppressed in 20 of 21 subjects, without the development of clinically significant adrenal suppression.
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Envelhecimento/sangue , Hormônios/sangue , Acetato de Megestrol/farmacologia , Hipófise/efeitos dos fármacos , Hipófise/metabolismo , Hormônios Adeno-Hipofisários/sangue , Idoso , Idoso de 80 Anos ou mais , Distribuição da Gordura Corporal , Índice de Massa Corporal , Exercício Físico , Congelamento , Hormônios/metabolismo , Humanos , Masculino , Acetato de Megestrol/administração & dosagem , Hormônios Adeno-Hipofisários/antagonistas & inibidores , Hormônios Adeno-Hipofisários/metabolismo , Congêneres da Progesterona/farmacologia , Ensaios Clínicos Controlados Aleatórios como Assunto , Soro/química , Fatores de TempoRESUMO
BACKGROUND: The objective of this study was to describe national trends in robotic thyroid surgery from 2009 through 2013. METHODS: The University HealthSystem Consortium (UHC) database was searched for patients undergoing robotic thyroidectomy (RT) from 2009 through 2013. Another U.S. institution's RT data, not included in the UHC database, were also evaluated. Patient demographics, institutional volume, comorbid conditions, complications, and cost information were analyzed. RESULTS: Sixty-one institutions performed 484 RT during the study period. From 2009 through 2011, U.S. annual RT volume increased from 39 cases to 140. Annual volume dropped to 69 cases in 2012 and 93 cases in 2013. Higher-volume centers reported lower complication rates (p<0.02). Hematoma formation (3.7%) was the most common complication, and there was one death. More than 10% of patients were obese. Brachial plexus injury and axillary skin flap perforations were reported in <1% of cases. Mean cost for a total RT was $13,287 ($5,125-42,444). CONCLUSIONS: From 2009 through early 2011, there was a steady increase in RT volume, especially among high-volume institutions. In mid-to-late 2011, there was a noticeable drop in RT volume, which significantly altered the projected trajectory of the procedure in this country. Despite higher complication rates, lower-volume centers perform the majority of RT and are also responsible for recent increases in RT utilization patterns in the United States.
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Procedimentos Cirúrgicos Robóticos/tendências , Glândula Tireoide/cirurgia , Neoplasias da Glândula Tireoide/cirurgia , Tireoidectomia/tendências , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Axila/cirurgia , Plexo Braquial/cirurgia , Estudos de Coortes , Feminino , Hematoma/etiologia , Humanos , Masculino , Pessoa de Meia-Idade , Período Pós-Operatório , Prognóstico , Procedimentos Cirúrgicos Robóticos/efeitos adversos , Neoplasias da Glândula Tireoide/epidemiologia , Tireoidectomia/efeitos adversos , Estados Unidos , Adulto JovemRESUMO
OBJECTIVE: To determine differences in the mean parathyroid hormone (PTH) levels for normocalcemic and hypocalcemic total thyroidectomy patients who were tested for PTH during the intraoperative or early postoperative period. DATA SOURCES: MEDLINE, the Cochrane Database, and other databases from 1960 to 2014 in the English language and specific to humans for relevant articles. REVIEW METHODS: Studies were included if PTH was obtained within 24 hours of thyroidectomy. Studies were excluded (1) if only a hemithyroidectomy was performed, (2) if means of studied PTH values were not reported in the article, or (3) if the time of the PTH draw fell outside of defined "intraoperative" or "early postoperative" windows. PTH values were divided into 3 groups: preoperative (control group), intraoperative (ie, discharge decisions were based on PTH values drawn in the operating room), and early postoperative (ie, PTH values at 1 to 4 hours after surgery were used as a guide). RESULTS: The reported means of perioperative PTH levels and percentage of patients who developed hypocalcemia were collected from 14 studies. PTH evaluated at both the intraoperative and early postoperative periods was significantly lower in patients who became hypocalcemic versus patients who remained normocalcemic. There was no significant difference when PTH was measured intraoperatively or early postoperatively. CONCLUSION: Intraoperative PTH has no significant disadvantage versus early postoperative PTH when used as a clinical guide for discharge after thyroidectomy.
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Hipocalcemia/sangue , Hormônio Paratireóideo/sangue , Tireoidectomia/métodos , Humanos , Hipocalcemia/etiologia , Período Intraoperatório , Alta do Paciente , Período Pós-Operatório , Valor Preditivo dos Testes , Tireoidectomia/efeitos adversos , Fatores de TempoRESUMO
OBJECTIVES: To measure the effect of proton pump inhibitors (PPIs), with and without concurrent bisphosphonates, on parathyroid hormone (PTH), vitamin D, and calcium. DESIGN: Retrospective chart review of individuals 60 years and older. Subjects with reduced renal function (creatinine >1.3 mg/dL) and low vitamin D (<30 ng/mL) were excluded. SETTING: Academic geriatric outpatient center in southern midwest. PARTICIPANTS: Individuals aged 60 and older with concurrent calcium, PTH, vitamin D, and creatinine laboratory measurements (N = 80) meeting labeled criteria. MEASUREMENTS: Serum calcium, PTH, vitamin D, and creatinine. RESULTS: Chronic PPI exposure was associated with statistically significantly higher PTH (65.5 vs 30.3 pg/mL, P < .001; normal range 10-55 pg/mL) and lower calcium (9.1 vs 9.4 mg/dL, P = .02; normal range 8.5-10.5 mg/dL) than no PPI exposure. Chronic PPI exposure with concurrent BP therapy was associated with statistically significantly higher PTH (65.2 vs 43.4 pg/mL, P = .05) and lower calcium (9.2 vs 9.6 mg/dL, P = .04) than BP therapy only. CONCLUSION: Based on the present study, chronic PPI exposure in elderly adults is associated with mild hyperparathyroidism regardless of concurrent oral BP administration.
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Difosfonatos/uso terapêutico , Hiperparatireoidismo/induzido quimicamente , Inibidores da Bomba de Prótons/efeitos adversos , Idoso , Cálcio/sangue , Creatinina/sangue , Humanos , Hiperparatireoidismo/diagnóstico , Pessoa de Meia-Idade , Hormônio Paratireóideo/sangue , Estudos Retrospectivos , Vitamina D/sangueRESUMO
OBJECTIVE: To evaluate 4-dimensional (4D) computed tomography (CT) for the localization of parathyroid adenomas previously considered nonlocalizing on ultrasound and single-photon emission CT with CT scanning (SPECT-CT). To measure radiation exposure associated with 4D-CT and compared it with SPECT-CT. STUDY DESIGN: Case series with chart review. SETTING: University tertiary hospital. SUBJECTS AND METHODS: Nineteen adults with primary hyperparathyroidism who underwent preoperative 4D CT from November 2013 through July 2014 after nonlocalizing preoperative ultrasound and technetium-99m SPECT-CT scans. Sensitivity, specificity, predictive values, and accuracy of 4D CT were evaluated. RESULTS: Nineteen patients (16 women and 3 men) were included with a mean age of 66 years (range, 39-80 years). Mean preoperative parathyroid hormone level was 108.5 pg/mL (range, 59.3-220.9 pg/mL), and mean weight of the excised gland was 350 mg (range, 83-797 mg). 4D CT sensitivity and specificity for localization to the patient's correct side of the neck were 84.2% and 81.8%, respectively; accuracy was 82.9%. The sensitivity for localizing adenomas to the correct quadrant was 76.5% and 91.5%, respectively; accuracy was 88.2%. 4D CT radiation exposure was significantly less than the radiation associated with SPECT-CT (13.8 vs 18.4 mSv, P = 0.04). CONCLUSION: 4D CT localizes parathyroid adenomas with relatively high sensitivity and specificity and allows for the localization of some adenomas not observed on other sestamibi-based scans. 4D CT was also associated with less radiation exposure when compared with SPECT-CT based on our study protocol. 4D CT may be considered as first- or second-line imaging for localizing parathyroid adenomas in the setting of primary hyperparathyroidism.
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Adenoma/diagnóstico , Tomografia Computadorizada Quadridimensional/métodos , Glândulas Paratireoides/diagnóstico por imagem , Neoplasias das Paratireoides/diagnóstico , Paratireoidectomia , Cuidados Pré-Operatórios/métodos , Tomografia Computadorizada de Emissão de Fóton Único/métodos , Adenoma/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Neoplasias das Paratireoides/cirurgia , Curva ROC , Compostos Radiofarmacêuticos , Tecnécio Tc 99m Sestamibi , UltrassonografiaRESUMO
Introduction. This is an extremely rare case of a patient with metastatic follicular thyroid cancer who continued to produce thyroid hormone and was iodine scan positive without stimulation after thyroidectomy and radioiodine (I-131) therapy. Patient Findings. A 76-year-old Caucasian male was diagnosed with metastatic follicular thyroid carcinoma on lung nodule biopsy. Total thyroidectomy was performed and he was ablated with 160 mCi of I-131 after recombinant human thyrotropin (rhTSH) stimulation. Whole body scan (WBS) after treatment showed uptake in bilateral lungs, right sacrum, and pelvis. The thyroglobulin decreased from 2,063 to 965 four months after treatment but rapidly increased to 2,506 eleven months after I-131. Thyroid stimulating hormone (TSH) remained suppressed and free T4 remained elevated after I-131 therapy without thyroid hormone supplementation. He was treated with an additional 209 mCi with WBS findings positive in lung and pelvis. Despite I-131, new metastatic lesions were noted in the left thyroid bed and large destructive lesion to the first cervical vertebrae four months after the second I-131 dose. Conclusions. This case is exceptional because of its rarity and also due to the dissociation between tumor differentiation and aggressiveness. The metastatic lesions continued to secrete thyroid hormone and remained radioiodine avid with rapid progression after I-131 therapy.
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CONTEXT: Lysine supplementation may have a positive influence on the regulation of glucose metabolism but it has not been tested in the geriatric population. OBJECTIVE: We evaluated the impact of acute lysine supplementation using three randomized experimental scenarios: 1) oral glucose alone (control), 2) oral glucose and low-dose lysine (2 grams), and oral glucose and high dose lysine (5 grams) lysine in 7 older (66 ± 1 years/age), overweight/obese (BMI = 28 ± 2 kg/m(2)) individuals. METHODS: We utilized a dual tracer technique (i.e., [6,6-(2)H2] glucose primed constant infusion and 1-[(13)C] glucose oral ingestion) during an oral glucose tolerance test (OGTT) to examine differences in hepatic and peripheral insulin sensitivity under all three scenarios. RESULTS: Post-absorptive plasma glucose and insulin concentrations were not different between the three trials. Similarly, the response of glucose and insulin concentrations during the oral glucose tolerance tests (OGTT) was similar in the three trials. The results of the Matsuda index (ISI/M) were also not different between the three trials. As an index of hepatic insulin sensitivity, there were no significant differences in the endogenous glucose rate of appearance (glucose Ra) for control, 2 g lysine and 5 g lysine (1.2 ± 0.1, 1.1 ± 0.1, 1.3 ± 0.1 mgâ¢kg(-1)â¢min(-1)), respectively. With respect to peripheral insulin sensitivity, there were no significant differences in the glucose rate of disappearance (glucose Rd) for control, 2 g lysine and 5 g lysine (4.2 ± 0.1, 4.3 ± 0.2, and 4.5 ± 0.4 mgâ¢kg(-1)â¢min(-1)), respectively. CONCLUSIONS: Previous studies in younger participants have suggested that lysine may have a beneficial effect on glucose metabolism. However, acute lysine supplementation in the older population does not facilitate beneficial changes in glucose Ra or glucose Rd.
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BACKGROUND: The purpose of this study was to demonstrate a role for observation of patients with differentiated thyroid cancer (DTC) with persistent, nonlocalizable disease. METHODS: Our study was conducted on outpatients seen at our institution from 1999 to 2009 having total thyroidectomy, radioactive iodine (RAI) ablation, measurable serum thyroglobulin (Tg), and no evidence of disease on whole body or positron emission tomography (PET) scans. RESULTS: Nineteen patients in our study group aged 20 to 73 with an average follow-up of 5.5 years (range, 2-12 years); all were treated with postoperative RAI (99-210 mCi, average 119). Mean Tg ranged from 0.41 to 4.34. Tg levels remained stable or gradually decreased in all patients. CONCLUSION: After total thyroidectomy and RAI therapy, patients may present with mildly elevated Tg values without localizable disease. These patients may have additional RAI treatments based on the Tg elevation. However, our clinical experience has shown that many of these patients will have Tg levels that either achieve stability or decrease over time without further treatment.
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Biomarcadores Tumorais/sangue , Carcinoma Papilar/diagnóstico , Carcinoma Papilar/terapia , Radioisótopos do Iodo/uso terapêutico , Tireoglobulina/sangue , Neoplasias da Glândula Tireoide/diagnóstico , Neoplasias da Glândula Tireoide/terapia , Adulto , Idoso , Carcinoma Papilar/sangue , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Pacientes Ambulatoriais , Valor Preditivo dos Testes , Estudos Retrospectivos , Sensibilidade e Especificidade , Neoplasias da Glândula Tireoide/sangue , Tireoidectomia , Resultado do TratamentoRESUMO
OBJECTIVES: To systematically review the preoperative diagnostic modalities, surgical treatments, and glandular pathologies associated with primary hyperparathyroidism in children and adolescents under 20 years of age. METHODS: We searched PUBMED, Cochrane databases, OVID, Web of Science (SCIE and SSCI), CINAHL, and Health Source: Nursing academic for articles involving surgical management of primary hyperparathyroidism in the pediatric population on 5/2012. SELECTION CRITERIA: Literature review, database review, and retrospective review studies date were used from 1986 until 2012. Ages ranged for 0-19 years old. RESULTS: Of the 230 cases of pediatric primary hyperparathyroidism reported since 1987, solitary adenomas (SA), multiple gland hyperplasia disease (MGHD), double adenomas (DA), and normal parathyroid gland pathology occurred in 80%, 16.5%, 0.9%, and 2.6% respectively. Of the MGHD patients (38 pts), 1/2 (19 pts) of the cases were attributed to MEN I, MEN II, or familial non MEN hyperparathyroidism. Tc(99m)-sestamibi and ultrasound were 86% (37/43) and 74.5% (70/94) sensitive, respectively for localizing parathyroid disease. CONCLUSIONS: Limited data exists on pediatric and adolescent patients with primary hyperparathyroidism. Sufficient data exists demonstrating single adenomas are most common and young patients are usually more symptomatic than adults. One may conclude that spontaneous primary hyperparathyroidism may be approached and managed similarly to adults. The incidence of primary hyperparathyroidism in this population may be under appreciated and a lower threshold for ordering a screening serum calcium should be considered.