Clinical Significance of Pheochromocytoma Size on the Timing and Extent of Surgery.

INTRODUCTION: Elevated metanephrine and catecholamine levels 3-fold upper limit of normal (ULN) are diagnostic for pheochromocytoma. We sought to determine whether size correlates with biochemical activity or symptoms which could guide timing of surgery. METHODS: Data from consecutive patients undergoing adrenalectomy for pheochromocytoma at our institution over a 10-year period were retrospectively collected. These included maximal lesion diameter on preoperative imaging, plasma/urine metanephrine and/or catecholamine levels, demographic variables and presence of typical paroxysmal symptoms. Receiver operating characteristic curves were used to assess predictive accuracy. RESULTS: Sixty-three patients were included in the analysis (41 females and 22 males). Median age was 56 (43, 69) years. Due to various referring practices, 31 patients had documented 24-h urine metanephrine, 26 had 24-h urine catecholamine, and 52 had fractionated plasma metanephrine levels available for review. Values were converted to fold change compared to ULN and the maximum of all measured values was used for logistic regression. Median tumor size was 3.40 (2.25, 4.55) cm in greatest dimension. Tumor size at which pheochromocytoma produced > 3-fold ULN was ≥2.3 cm (AUC of 0.84). Biochemical activity increased with doubling tumor size (odds ratio = 8, P = 0.0004) or ≥ 1 cm increase in tumor size (odds ratio = 3.03, P = 0.001). 40 patients had paroxysmal symptoms, but there was no significant correlation between tumor size/biochemical activity and symptoms. CONCLUSIONS: In our study, tumor size directly correlated with the degree of biochemical activity and pheochromocytomas ≥2.3 cm produced levels 3 times ULN. These findings may allow clinicians to adjust timing of operative intervention.

Quality of life in thyroid cancer-assessment of physician perceptions.

BACKGROUND: Thyroid cancer is the fastest growing malignancy in the United States. Previous studies have shown a decrease in quality of life (QoL) after the treatment of thyroid cancer. To date, there have been no studies assessing physician perceptions regarding how a diagnosis of thyroid cancer affects QoL. Based on this and other findings from our study, we aim to assess physician perceptions on the effect of thyroid cancer on QoL. MATERIALS AND METHODS: Physicians were recruited from two national organizations comprised physicians focusing on thyroid cancer. A 37-question survey was administered evaluating physician's perceptions of thyroid cancer patient satisfaction in various aspects of treatment, complications, and overall effects on QoL. QoL responses were categorized into overall QoL, physical, psychological, social, and spiritual well-being. RESULTS: One hundred five physicians completed the survey. Physician's estimates of patient's overall QoL after thyroid cancer treatment was similar to overall QoL reported by patients. However, medical physicians overestimated the decrease in thyroid cancer survivor's QoL in several subcategories including physical, psychological, and social (P < 0.05). Both surgeons and medical physicians underestimated the percentage of patients with reported symptoms of temporary and permanent voice changes, temporary dry mouth, cold/heat sensitivity, and temporary and permanent hypocalcemia (P = 0.01-0.04). CONCLUSIONS: Physicians have a varied estimation of the detrimental impact of thyroid cancer treatment on QoL. In addition, physicians underestimated the amount of physical symptoms associated with thyroid cancer treatments. Increased physician awareness of the detrimental effects of a thyroid cancer diagnosis on QoL should allow for a more accurate conversation about expected outcomes after thyroid cancer treatment.

Ultrasonic, bipolar, and integrated energy devices: comparing heat spread in collateral tissues.

BACKGROUND: Integrated devices incorporating ultrasonic and bipolar technology have been used in laparoscopic surgery, however, are not yet incorporated into open operations. Here, we compare thermal spread and recurrent laryngeal nerve (RLN) functional data of the integrated THUNDERBEAT Open Fine Jaw device, the bipolar Ligasure Small Jaw, and the ultrasonic Harmonic Focus for open thyroidectomy. MATERIALS AND METHODS: The three energy devices were compared in a live porcine model using three tissue types including liver, muscle, and thyroid. The devices were fired three times on each energy setting, and the thermal spread was measured by thermocouples that were inserted in surrounding tissues at 1-mm intervals. To determine RLN injury, devices were fired at successive 1-mm increments from the RLN until the monitor signal was lost. RESULTS: When comparing heat generated across these devices at 1 mm, the peak temperature (Celsius) reached in liver tissue was observed with the ultrasonic device (115.4 ± 86.7), in muscle tissue with the integrated device (104.2 ± 82.1), and in thyroid with the bipolar device (81.4 ± 41.3). Temperatures generated at individual settings on each device were similar (P = 0.11-0.81). RLN injury occurred after firing on manually approximated tissue 1-mm away from the RLN for all devices; however, there was no signal loss at ≥2 mm. CONCLUSIONS: Heat transfer was similar among all devices with the exception of the ultrasonic device when used in the liver, which showed higher temperatures. Liver tissue showed the most consistent results. RLN injury did not occur if the devices were fired on manually approximated tissue ≥2 mm from the nerve.

The Incidence and Survival of Rare Cancers of the Thyroid, Parathyroid, Adrenal, and Pancreas.

PURPOSE: With the exception of papillary and follicular thyroid cancer, malignant cancers of the thyroid, parathyroid, adrenal, and endocrine pancreas are uncommon. These rare malignancies present a challenge to both the clinician and patient, because few data exist on their incidence or survival. We analyzed the incidence and survival of these rare endocrine cancers (RECs), as well as the trends in incidence over time. METHODS: We used the NCI's SEER 18 database (2000-2012) to investigate incidence and survival of rare cancers of the thyroid, parathyroid, adrenal, and endocrine pancreas. Cancers were categorized using the WHO classification systems. We collected data on incidence, gender, stage, size, and survival. Time trends were evaluated from 2000-2002 to 2010-2012. RESULTS: We identified 36 types of rare cancers in the endocrine organs captured in the SEER database. RECs of the thyroid had the highest combined incidence rate (IR8.26), followed by pancreas (IR 3.24), adrenal (IR 2.71), and parathyroid (IR 0.41). The incidence rate for all rare endocrine organs combined increased 32.4 % during the study period. The majority of the increase was attributable to rare cancers of thyroid, which increased in not only microcarcinomas, but in all sizes. The mean 5-year survival for RECs is 59.56 % (range 2.49­100 %). CONCLUSIONS: This study is a comprehensive analysis ofthe incidence and survival for rare malignant endocrine cancers. There has been an increase in incidence rate of almost all RECs and their survival is low. We hope that our data will serve as a source of information for clinicians as well as bring awareness regarding these uncommon cancers.

Epigenetic Alterations and Canonical Pathway Disruption in Papillary Thyroid Cancer: A Genome-wide Methylation Analysis.

BACKGROUND: Alterations in DNA methylation have been demonstrated in a variety of malignancies, including papillary thyroid cancer (PTC). The full extent of dysregulation in PTC and the downstream affected pathways remains unclear. Here we report a genome-wide analysis of PTC methylation, the dysregulation of various canonical pathways, and assess its potential as a diagnostic test. METHODS: A discovery set utilized 49 PTCs and matched normal controls from The Cancer Genome Atlas. Another set of 16 PTCs and 13 normal controls were used as a replication set. Genome-wide methylation analysis was done using Illumina 450 K methylation chips. Differentially methylated loci (DML) were identified by comparing PTC and matched normal tissues. DML were defined as false-discovery rate p < 0.05 and absolute Δß ≥ 0.2. DML were then analyzed for pathway and disease commonalities using Qiagen Ingenuity Pathway Analysis. RESULTS: Of 485,577 CpG sites analyzed, 1226 DML were identified in our discovery and replication sets, and 1061 (86.5 %) DML showed hypomethylation when comparing tumor with normal tissue. Support vector machine classification was able to differentiate benign from malignant tissue in 107 (94.7 %) of 113 tested samples, including 15 (83.3 %) of 18 samples lacking a clearly deleterious mutation. Statistically significant associations with multiple canonical pathways, diseases, and biofunctions were observed including PI3K, PTEN, wnt/ß-catenin, and p53. CONCLUSIONS: Epigenetic dysregulation of multiple canonical pathways are associated with the development of PTC. This methylation signature shows promise as a future adjunctive screening test for thyroid nodules.

Incidence, Risk Factors, and Clinical Outcomes of Incidental Parathyroidectomy During Thyroid Surgery.

BACKGROUND: The reported rate of incidental parathyroidectomy (IP) during thyroid surgery is between 5.2 and 21.6 %. Current literature reports wide discrepancy in incidence, risk factors, and outcomes. Thus study was designed to address definitively the topic of IP and identify associated risk factors and clinical outcomes with this multi-institutional study. METHODS: This retrospective cohort study included 1767 total thyroidectomies that occurred between 1995 and 2014 at two academic centers. Pathologic reports were reviewed for the presence of unintentionally removed parathyroid glands. Demographics, potential risk factors, and postoperative calcium levels were compared with matched control group. Logistic regression, t tests, and Chi squared tests were used when appropriate. RESULTS: IP occurred in 286 (16.2 %) of thyroidectomies. Risk factors for IP were: malignancy, neck dissection, and lymph node metastases (p = 0.005, <0.001, and <0.001). Fifty-three (19.2 %) of IPs were intrathyroidal. Those with IP were more likely to have postoperative biochemical (65.6 vs. 42.0 %; p < 0.001) and symptomatic (13.4 vs. 8.1 %; p = 0.044) hypocalcemia than controls. The number of parathyroids identified intraoperatively was inversely correlated with the number of parathyroid glands in the specimen (p < 0.001). CONCLUSIONS: Our findings indicate that malignancy, lymph node dissection, and metastatic nodal disease are risk factors for IP. Patients with IP were more likely to have postoperative biochemical and symptomatic hypocalcemia than controls, showing that there is a physiologic consequence to IP. Additionally, intraoperative surgeon identification of parathyroid glands results in a lower incidence of IP, highlighting the importance of awareness of parathyroid anatomy during thyroid surgery.

One-hour PTH after thyroidectomy predicts symptomatic hypocalcemia.

BACKGROUND: A major morbidity after total thyroidectomy is hypocalcemia. Although many clinical factors and laboratory studies have been correlated with both biochemical and symptomatic hypocalcemia, the ideal use and timing of these tests remain unclear. We hypothesize 1-h (PACU) parathyroid hormone (PTH) will identify patients at risk for symptomatic hypocalcemia. METHODS: This prospective study evaluated 196 patients undergoing total thyroidectomy. Serum calcium and PTH levels were measured 1 h after surgery and on postoperative day 1 (POD1). Performance of a central compartment lymph node dissection, parathyroid autotransplantation, indication for procedure, pathology, and presence of parathyroid tissue in the pathology specimen were recorded. RESULTS: Of 196 patients, nine (4.6%) developed symptomatic hypocalcemia. Thirty four (17.3%) had a 1-h PACU PTH ≤10 pg/dL, whereas 31 (15.8%) had a POD1 PTH of ≤10. Five (56%) of the nine symptomatic patients underwent central compartment lymph node dissection, four (44%) had parathyroid autotransplantation, and four (44%) had a PACU PTH ≤10. PACU and POD1 PTH levels were correlated (R(2) = 0.682). Multivariate regression identified central compartment dissection, autotransplantation, and PACU or POD1 PTH correlated with symptomatic hypocalcemia. PACU PTH, POD1 PTH, PACU Ca, malignant final pathology, and age ≤45 y correlated with biochemical hypocalcemia. CONCLUSIONS: A 1-h postoperative PACU PTH is equivalent to POD1 PTH in predicting the development of symptomatic hypocalcemia. Biochemical hypocalcemia was not predictive of symptoms in the immediate postoperative period. Lymph node dissection and parathyroid autotransplantation correlated with symptomatic hypocalcemia and improve the sensitivity of biochemical screening alone.

Quality of Life in Thyroid Cancer is Similar to That of Other Cancers with Worse Survival.

BACKGROUND: The incidence of thyroid cancer is increasing. As such, the number of survivors is rising, and it has been shown that their quality of life (QOL) is worse than expected. Using results from the North American Thyroid Cancer Survivorship Study (NATCSS), a large-scale survivorship study, we aim to compare the QOL of thyroid cancer survivors to the QOL of survivors of other types of cancer. METHODS: The NATCSS assessed QOL overall and in four subcategories: physical, psychological, social, and spiritual well-being using the QOL-Cancer Survivor (QOL-CS) instrument. Studies that used the QOL-CS to evaluate survivors of other types of cancers were compared to the NATCSS findings using two-tailed t tests. RESULTS: We compared results from NATCSS to QOL survivorship studies in colon, glioma, breast, and gynecologic cancer. The mean overall QOL in NATCSS was 5.56 (on a scale of 0-10, where 10 is the best). Overall QOL of patients with thyroid cancer was similar to that of patients with colon cancer (mean 5.20, p = 0.13), glioma (mean 5.96, p = 0.23), and gynecologic cancer (mean 5.59, p = 0.43). It was worse than patients surveyed with breast cancer (mean 6.51, p < 0.01). CONCLUSIONS: We found the self-reported QOL of thyroid cancer survivors in our study population is overall similar to or worse than that of survivors of other types of cancer surveyed with the same instrument. This should heighten awareness of the significance of a thyroid cancer diagnosis and highlights the need for further research in how to improve care for this enlarging group of patients.

Adenoma localization for recurrent or persistent primary hyperparathyroidism using dynamic four-dimensional CT and venous sampling.

PURPOSE: To determine if parathyroid venous sampling (PVS) combined with four-dimensional (4D) computed tomography (CT) improves sensitivity and accuracy of identification of parathyroid adenoma in patients with recurrent or persistent primary hyperparathyroidism (pHPT) and negative technetium-99m methoxyisobutyl isonitrile ((99m)Tc-MIBI) and ultrasound (US) scans. MATERIALS AND METHODS: Both PVS and 4D CT were performed in 28 patients with recurrent or persistent pHPT and negative (99m)Tc-MIBI and US examinations. Localization by 4D CT alone and in combination with PVS and lateralization by PVS alone were retrospectively assessed for correlation with surgical results. Suspected adenomas on 4D CT were said to correlate with PVS if venous drainage identified on CT corresponded to sites of elevated parathyroid hormone concentration on PVS. Lesions difficult to identify on 4D CT were lesions < 1 cm in longest dimension. Results of 4D CT were classified as positive, negative, or equivocal. RESULTS: Surgery was performed in 22 of 28 patients. Surgery identified 23 parathyroid adenomas, 1 carcinoma, and 2 hyperplastic glands in 20 patients. 4D-CT alone localized 11 lesions in 10 patients. PVS helped localize 13 additional lesions in nine more patients and clarified two lesions that were equivocal on 4D CT. Comparing 4D CT alone with 4D CT plus PVS, the sensitivity increased from 50% to 95% (P = .004), and accuracy increased from 55% to 91% (P = .022). PVS lateralization had a sensitivity of 93.3%, positive predictive value of 66.7%, and accuracy of 63.6%. CONCLUSIONS: PVS significantly improves 4D CT localization of parathyroid adenomas in patients undergoing repeat surgery for pHPT with negative (99m)Tc-MIBI and US.

What's in a name?: Providing clarity in the definition of minimally invasive parathyroidectomy.

BACKGROUND: In recent years minimally invasive parathyroidectomy has become the procedure of choice for many surgeons, but the meaning of the term is unclear. This is confusing for both the medical community and patients. We hypothesize that because the definition of minimally invasive parathyriodectomy in the literature is so variable this term has little meaning. METHODS: We performed a Pubmed search using the terms: parathyroidectomy, minimally invasive, localized, focused, unilateral, radio-guided, video-assisted, and endoscopic. Data were collected for: author, journal title, year published, and all described aspects of parathyroidectomy. RESULTS: We analyzed 443 (44%) articles after applying the exclusion criteria. Eighteen words were used in 75 different combinations to describe minimally invasive parathyroidectomy. We established four categories that encompassed all 75 definitions: 1. operative approach (incision size, describing as open; endoscopic; robotic; or video-assisted), 2. number of glands explored, 3. operative adjuncts, and 4. anesthesia type. Operative approach was the most commonly described attribute and was mentioned in 47% (n = 207) of the articles (mean incision size was found to be 2.2 cm), followed by number of glands explored, operative adjuncts, and anesthesia type. CONCLUSIONS: The finding that there are 75 different definitions for minimally invasive parathyroidectomy confirms that this term is too generic to be useful. We propose a new taxonomic format to describe minimally invasive parathyroidectomy based on the four descriptive categories identified: (operative approach), (# of glands explored), parathyroidectomy using (operative adjuncts) under (anesthesia type). For example, "2 cm, single gland parathyroidectomy using intraoperative parathyroid hormone measurement, under general anesthesia".

Age of diagnosing physician impacts the incidence of thyroid cancer in a population.

BACKGROUND: Thyroid ultrasound and fine-needle aspiration (FNA) have been implicated in the overdiagnosis of thyroid cancer. To study how the use of diagnostic tools impacts thyroid cancer incidence, we propose using physician age as a surrogate. We aimed to determine whether thyroid cancer incidence is higher in areas with a high density of young physicians compared with areas with a high density of older physicians. METHODS: SEER 13 database was used to determine thyroid cancer incidence. These data were linked to the Area Resource File data (2000), containing information on physician age at a county-specific level. Cohorts were divided by age based on the concentration of physicians within a population of 1,000,000 persons. The study period was divided into two time periods (1992-1995, 2006-2009). RESULTS: The incidence of thyroid cancer was stable in areas with high concentrations of young and older physicians during the 1992-1995 time period [<35: 5.97; 55-64: 6.82; ≥65: 6.70 (per 100,000py)]. Areas with high concentrations of young physicians had an increased incidence of thyroid cancer compared with areas of high concentrations of older physicians during the 2006-2009 period [<35: 13.3; 55-64: 9.86; ≥65: 7.47 (per 100,000py)]. CONCLUSIONS: Thyroid cancer incidence was lower in areas with high concentrations of older physicians. This may be the result of increased adoption of thyroid ultrasound and FNA among younger physicians who have trained after diagnostic tools became common. Age of the diagnosing physician is a surrogate for diagnostic utility contributing to thyroid cancer trends.

The acceleration in papillary thyroid cancer incidence rates is similar among racial and ethnic groups in the United States.

BACKGROUND: Reports of similar age-specific incidence rates and a female-to-male gender disparity by racial/ethnic groups suggests that further consideration of race-specific patterns may confer insight into the possible causes of thyroid cancer or explanations for the increase in incidence. METHODS: We used the National Cancer Institute's (NCIs) surveillance, epidemiology, and end results (SEER) program and Joinpoint Regression for cases diagnosed during 1992-2009 to investigate trends and rates of acceleration for papillary thyroid cancer by gender and race/ethnicity. RESULTS: We determined the annual percent change (APC) and found a yearly increase of 7.0 % for papillary thyroid cancer for the most recent APC trend, with an APC of 6.3 and 7.1 % for white males and females, respectively; an APC of 4.3 and 8.4 % for black males and females, respectively; an APC of 4.2 and 6.7 % for Hispanic males and females, respectively; and an APC of 3.4 and 6.4 % in Asian/PI males and females, respectively. The APC projections show the rates of papillary thyroid cancer rising in males, but the patterns are more dramatic in females, with rates of papillary thyroid cancer in females surpassing rates of common cancers and becoming the third most common cancer in women of all ages by 2019. CONCLUSIONS: Although the lowest rates of thyroid cancer are observed in blacks, the greatest rate of acceleration is occurring in black females. Our data also show that the rate of papillary thyroid cancer will continue to surpass rates of ovarian cancer, and in white women: it is projected to be more incident than colorectal cancer as well; and in Hispanic and Asian/Pacific Islander women, rates of papillary thyroid cancer are projected to be higher than lung, colorectal, and ovarian cancers in the near future.

Primary hyperparathyroidism in adolescents: the same but different.

PURPOSE: Primary hyperparathyroidism has been studied more extensively in adults than in adolescents. The objective of this study is to define the similarities and differences that exist between these groups. METHODS: A retrospective review of 1,000 primary hyperparathyroidism patients undergoing parathyroidectomy at a single tertiary-care university teaching hospital between 1990 and 2004. All patients 20 years of age or younger comprised our study cohort, and were compared to two historical adult groups. RESULTS: Of 1,000 parathyroidectomies, 21 (2.1 %) were 20 years of age or younger (adolescent). The adolescents presented with higher serum calcium levels (p < 0.01) more severe symptoms (p = 0.02), more renal stones (p = 0.048), and a higher incidence of hypercalcemic crisis (p = 0.02), when compared with adults. We found that 67 % suffered from a triad of tiredness, weakness, and depression versus 39 % of adults (p = 0.02). Sestamibi scans were less helpful in the adolescents than in adults. Similar to the adults, 86 % of adolescent patients had single gland disease, and 95 % were cured at the first operation. CONCLUSION: Adolescents with primary hyperparathyroidism typically have more severe disease than adults. Contrary to popular belief, most adolescents have single gland disease and not hyperplasia associated with a genetic disorder.

Preoperative calcitriol reduces postoperative intravenous calcium requirements and length of stay in parathyroidectomy for renal-origin hyperparathyroidism.

BACKGROUND: Patients undergoing subtotal parathyroidectomy for renal-origin hyperparathyroidism often develop postoperative hypocalcemia, requiring calcitriol and intravenous calcium (Postop-IVCa). We hypothesized that in subtotal parathyroidectomy for renal-origin hyperparathyroidism, preoperative calcitriol treatment reduces the use of postoperative administration of intravenous calcium. METHODS: A retrospective chart review compared subtotal parathyroidectomy for renal-origin hyperparathyroidism patients who received preoperative calcitriol treatment with those patietns who did not receive preoperative calcitriol treatment at one institution. Preoperative calcitriol treatment loading doses were 0.5 mcg twice daily for 5 days. All patients received postoperative calcitriol and oral calcium carbonate. Postoperative administration of intravenous calcium was given for symptoms, calcium <7.0 mg/dL, or surgeon preference. The Fisher exact test was used to compare proportions. The Wilcoxon test was used to compare continuous data. Multivariable logistic regression adjusted for confounders. RESULTS: Included were 81 patients who received subtotal parathyroidectomy for renal-origin hyperparathyroidism (41 patients who received preoperative calcitriol treatment, 40 patients who did not receive preoperative calcitriol treatment). Preoperative calcitriol treatment use increased over time (0% 2004-2010, 69% 2011-2016). Groups who received preoperative calcitriol treatment and groups who did not receive preoperative calcitriol treatment were similar in preoperative serum calcium, vitamin D, parathyroid hormone, and median age (P > .05 for all). Patients who received preoperative calcitriol treatment less often required postoperative administration of intravenous calcium (34% vs 90% of patients who did not receive preoperative calcitriol treatment, P < .001). Median length of stay was 2.0 days shorter for patients who received preoperative calcitriol treatment versus patients who did not receive preoperative calcitriol treatment patients (P < .001). Factors associated with postoperative administration of intravenous calcium included not receiving preoperative calcitriol treatment, low preoperative calcium, and high preoperative parathyroid hormone. After multivariable adjustment, preoperative calcitriol treatment remained independently associated with reduced postoperative administration of intravenous calcium (OR 0.02, P < .001). CONCLUSION: Preoperative calcitriol therapy lowered use of postoperative administration of intravenous calcium by 56% and length of stay by 50% in subtotal parathyroidectomy for renal-origin hyperparathyroidism patients. We believe preoperative calcitriol treatment should become standard of care for subtotal parathyroidectomy for renal-origin hyperparathyroidism.

Keeping primary aldosteronism in mind: Deficiencies in screening at-risk hypertensives.

BACKGROUND: Primary aldosteronism is a common but underdiagnosed cause of hypertension. Patients with this disorder have worse morbidity compared with those with essential hypertension, but with timely diagnosis and appropriate intervention these patients are potentially cured and may have reversal of target organ damage. The goal of this study was to determine if hypertensive patients considered high risk were checked for primary aldosteronism. METHODS: We reviewed electronic health records to identify patients age 18 years or older with coexisting hypertension and hypokalemia or hypertension and sleep apnea, then determined if they had been investigated with measurement of aldosterone or renin. We built regression models to identify explanatory variables for screening in these 2 high-risk groups. RESULTS: Of nearly 37,000 patients with hypertension and hypokalemia, only 2.7% were ever screened for primary aldosteronism. Most opportunities for case detection were during inpatient hospitalizations, yet in this setting, patients were less likely than clinic patients be screened. Similarly, 3.0% of hypertensive patients with sleep apnea were screened since the inclusion of this group in case detection recommendations. CONCLUSION: Uptake of practice guidelines by hospital physicians, fueled by support from their specialty societies, may help to identify many more patients with unrecognized primary aldosteronism.

Analytical Differences in Intraoperative Parathyroid Hormone Assays.

BACKGROUND: We compared the rates of intraoperative parathyroid hormone (PTH) decline using the Siemens Immulite® Turbo PTH and Roche Elecsys® short turnaround time PTH assays in 95 consecutive surgical patients to investigate analytical and turnaround time (TAT) differences between the tests performed in the operating room (OR) vs the central clinical chemistry laboratory (CCL). METHODS: Serial blood samples from 95 patients undergoing parathyroidectomy were collected and measured using the 2 immunoassays. Specimens from the first 15 patients were measured simultaneously in the OR and CCL and used for the TAT study. In addition to 2 baseline samples, specimens were collected at 5, 10, and 15 min (for some patients, >15 min) after parathyroidectomy. RESULTS: In the TAT study, a significant difference was observed (OR median 20 min vs CCL median 27 min; P < 0.05). Of the 95 patient series, slower rates of parathyroid hormone decrease were observed in approximately 20% of the patients when comparing the Roche with the Immulite immunoassay. CONCLUSIONS: There was a slightly longer TAT in the CCL compared with running the assay directly within the OR (median difference of approximately 7 min). For a majority of the patients, both methods showed equivalent rates of PTH decline; however, for approximately 20% of the patients, there was a slower rate of PTH decline using the Roche assay.

Development of the ThyCAT: A clinically useful computerized adaptive test to assess quality of life in thyroid cancer survivors.

BACKGROUND: Current quality of life assessment tools for thyroid cancer survivors are not clinically useful due to the length of available questionnaires. Computerized adaptive tests are easily administered electronically and can achieve highly accurate and efficient results in minimal time. We aimed to develop a quality of life computerized adaptive tests (ThyCAT) for thyroid cancer survivors. METHODS: A bifactor item response theory model was fit to questionnaire responses from 1,078 North American Thyroid Cancer Survivorship Study participants-a longitudinal cohort study of quality of life in thyroid cancer survivors. Tuning parameters were selected to maintain a correlation of r > 0.9 with the total item bank quality of life score obtained from the original North American Thyroid Cancer Survivorship Study questions, using a minimal number of adaptively administered ThyCAT items. RESULTS: The ThyCAT assesses quality of life with strong correlation (r = 0.96) with the original 75 North American Thyroid Cancer Survivorship Study questions using an average of 9.94 questions (SD ± 3.03) administered in <2 minutes. There was no statistically significant difference in the number of ThyCAT questions required based on demographic or tumor characteristics. CONCLUSION: The ThyCAT can be administered on a smartphone app in <10 questions, and <2 minutes, allowing efficient and accurate in or out of clinic identification of patients struggling with quality of life issues after thyroid cancer treatment.

A Tale of Two Cancers: Traveling to Treat Pancreatic and Thyroid Cancer.

BACKGROUND: Patients diagnosed with a malignancy must decide whether to travel for care at an academic center or receive treatment at a nearby hospital. Here we examine differences in demographics, treatment, and outcomes of those traveling to academic centers for their care vs those not traveling, as well as compare travel for an aggressive vs indolent malignancy. STUDY DESIGN: All patients with papillary thyroid carcinoma (PTC) or pancreatic ductal adenocarcinoma (PDAC) undergoing surgical resection and in the National Cancer Database were examined. Travel for care was abstracted from "crowfly" distance between patients' ZIP codes and treatment facility, region, county size, urban/metro/rural status, and facility type. RESULTS: In total, 105,677 patients with PTC and 22,983 patients with PDAC were analyzed. There were no survival differences by travel in the PTC group. Survival was improved for patients with PDAC traveling from urban/rural settings (hazard ratio = 0.89; 95% CI 0.82 to 0.96; p = 0.002). Patients traveling with PDAC were more likely to have a complete resection and lymph node dissection. Those traveling were less likely to receive chemotherapy or radiotherapy (all p < 0.001). Those traveling with PTC were older, more likely to be male, have Medicare insurance, and had a higher stage of disease (all p < 0.001). Rates of radioactive iodine were lower, American Thyroid Association guidelines were more likely followed, and lymph node dissection was more common for those traveling for care of their PTC (all p < 0.001). CONCLUSIONS: There are improvements in both quality and survival for those traveling to academic centers for their cancer care. In the case of PTC, this difference in quality did not affect overall survival. In PDAC, however, differences in quality translated to a survival advantage.

Rates of secondary hyperparathyroidism after bypass operation for super-morbid obesity: An overlooked phenomenon.

BACKGROUND: With over 110,000 bariatric operations performed in the United States annually, it is important to understand the biochemical abnormalities causing endocrine dysfunction associated with these procedures. Here we compare 2 malabsorptive procedures, duodenal switch and Roux-en-Y gastric bypass, to determine the role malabsorption plays in secondary hyperparathyroidism in this population. METHODS: Data from all super-obese patients undergoing duodenal switch or Roux-en-Y gastric bypass between August 2002 and October 2005 were prospectively collected. Postoperatively, all patients received 1,200 mg of calcium citrate and 1,000 IU vitamin D3 per American Society for Metabolic and Bariatric Surgery guidelines. Beginning in 2007, duodenal switch patients were instructed to add daily vitamin D3 10,000 IU. Statistical analyses included Student t test, multivariate, and univariate logistic regression. RESULTS: Of 283 patients with a body mass index ≥50, 170 (60.1%) underwent duodenal switch, while 113 (39.9%) underwent Roux-en-Y gastric bypass. Of 132 (46.6%) patients with secondary hyperparathyroidism, 101 (59.4%) had undergone duodenal switch and 31 (27.4%) had undergone Roux-en-Y gastric bypass. Symptoms were more common in the duodenal switch group (33 patients [19.4%]) than Roux-en-Y gastric bypass (11 patients [9.7%]). Multivariate logistic regression demonstrated that the extent of bypass and duration of follow-up were the only 2 independent predictive risk factors for developing secondary hyperparathyroidism. Although vitamin D levels improved with increased vitamin D3 supplementation in 2007, rates of secondary hyperparathyroidism increased. CONCLUSION: Despite routine postoperative calcium and vitamin D3 supplementation, secondary hyperparathyroidism is common after Roux-en-Y gastric bypass and duodenal switch. The degree of iatrogenic malabsorption correlates with the incidence of secondary hyperparathyroidism. These rates suggest current supplementation guidelines are not sufficient in preventing secondary hyperparathyroidism. Further work is needed to better define the sequelae of long-term hyperparathyroidism.