Oncologic Outcomes of Multi-Institutional Minimally Invasive Inguinal Lymph Node Dissection for Melanoma Compared with Open Inguinal Dissection in the Second Multicenter Selective Lymphadenectomy Trial (MSLT-II).

BACKGROUND: Minimally invasive inguinal lymphadenectomy (MILND) is safe and feasible, but limited data exist regarding oncologic outcomes. METHODS: This study performed a multi-institutional retrospective cohort analysis of consecutive MILND performed for melanoma between January 2009 and June 2016. The open ILND (OILND) comparative cohort comprised patients enrolled in the second Multicenter Selective Lymphadenectomy Trial (MSLT-II) between December 2004 and March 2014.The pre-defined primary end point was the same-basin regional nodal recurrence, calculated using properties of binomial distribution. Time to events was calculated using the Kaplan-Meier method. The secondary end points were overall survival, progression-free survival, melanoma-specific survival (MSS), and distant metastasis-free survival (DMFS). RESULTS: For all the patients undergoing MILND, the same-basin regional recurrence rate was 4.4 % (10/228; 95 % confidence interval [CI], 2.1-7.9 %): 8.2 % (4/49) for clinical nodal disease and 3.4 % (6/179) for patients with a positive sentinel lymph node (SLN) as the indication. For the 288 patients enrolled in MSLT-II who underwent OILND for a positive SLN, 17 (5.9 %) had regional node recurrence as their first event. After controlling for ulceration, positive LN count and positive non-SLNs at the time of lymphadenectomy, no difference in OS, PFS, MSS or DMFS was observed for patients with a positive SLN who underwent MILND versus OILND. CONCLUSION: This large multi-institutional experience supports the oncologic safety of MILND for melanoma. The outcomes in this large multi-institutional experience of MILND compared favorably with those for an OILND population during similar periods, supporting the oncologic safety of MILND for melanoma.

Formal robotic training diminishes the learning curve for robotic pancreatoduodenectomy: Implications for new programs in complex robotic surgery.

INTRODUCTION: The learning curve associated with robotic pancreatoduodenectomy (RPD) is a hurdle for new programs to achieve optimal results. Since early analysis, robotic training has recently expanded, and the RPD approach has been refined. The purpose of this study is to examine RPD outcomes for surgeons who implemented a new program after receiving formal RPD training to determine if such training reduces the learning curve. METHODS: Outcomes for consecutive patients undergoing RPD at a single tertiary institution were compared to optimal RPD benchmarks from a previously reported learning curve analysis. Two surgical oncologists with formal RPD training performed all operations with one surgeon as bedside assistant and the other at the console. RESULTS: Forty consecutive RPD operations were evaluated. Mean operative time was 354 ± 54 min, and blood loss was 300 ml. Length of stay was 7 days. Three patients (7.5%) underwent conversion to open. Pancreatic fistula affected five patients (12.5%). Operative time was stable over the study and lower than the reported benchmark. These RPD operative outcomes were similar to reported surgeon outcomes after the learning curve. CONCLUSION: This study suggests formal robotic training facilitates safe and efficient adoption of RPD for new programs, reducing or eliminating the learning curve.

The Right Hand Must Know What the Left Hand is Doing: A False-Positive Hotspot on the Sestamibi Scan.

Objective: Imaging studies in the setting of primary hyperparathyroidism are performed to rule out an ectopic parathyroid adenoma. Although rare, false-positive scans can cause confusion and possibly more extensive procedures. Method: A 68-year-old woman with parathyroid hormone-dependent hypercalcemia was found to have uptake in the left midclavicular area on the parathyroid scan with sestamibi. Retention of the isotope was considered a possibility, and the sestamibi scan was repeated after injecting the isotope in the right hand and this did not show uptake in the left midclavicular area. Results: Sestamibi is taken up by the mitochondrial-rich adenoma cells and can help identify an ectopic location of the adenoma. Sestamibi scans are commonly performed before neck exploration to rule out an ectopic adenoma and to localize the parathyroid adenoma. Thyroid adenoma and thyroid cancer can also cause retention of isotopes. Retention of the isotope in the vein can also give an illusion of an ectopic parathyroid adenoma. Injecting the isotope in the contralateral hand can overcome this retention issue. Conclusion: Uptake on parathyroid scan outside of normal embryologic decent of the parathyroid gland should raise the possibility of a false-positive uptake.

Toll-like receptor 4 signaling regulates the acute local inflammatory response to injury and the fibrosis/neovascularization of sterile wounds.

The role of Toll-like receptor 4 (TLR4) in the regulation of inflammation and fibrosis in sterile wounds was investigated in TLR4 signal-deficient (C3H/HeJ or TLR4(-/-) ) and control mice using the subcutaneously implanted polyvinyl alcohol sponge wound model. Total and differential wound cell counts 1, 3, and 7 days after injury did not differ between C3H/HeJ and C3H/HeOuJ animals. Blood monocytes from both strains expressed CCR2 equally. Day one wounds in C3H/HeJ mice contained fewer Gr-1(high) wound macrophages, CCL3, and CCL5, and more CCL17 than those in controls. The accumulation of CCL2, CX3CL1, tumor necrosis factor-α, interleukin (IL)-6, IL-10, IL-12, and interferon-γ in wound fluids was not TLR4 dependent. Wound macrophages from C3H/HeJ and C3H/HeOuJ mice expressed CCR4 and CCR5, but not CCR1 or CCR3. Wound macrophage recruitment was not altered in CCR5(-/-) mice or in C3H/HeOuJ animals injected with neutralizing anti-CCL3 and anti-CCL5 antibodies. Neutralization of the CCR4 ligand CCL17 in C3H/HeJ mice did not alter wound macrophage populations. There was a twofold increase in collagen content and number of neovessels in 21-day-old wounds in C3H/HeJ vs. C3H/HeOuJ mice. There were no differences between strains in the number of myofibroblasts in the wounds 7 or 21 days postwounding. The increased fibrosis and angiogenesis in wounds from /HeJ mice correlated with higher concentrations of transforming growth factor-ß and fibroblast growth factor 2 in wound fluids from these animals. Wound fluids did not contain detectable lipopolysaccharide and did not induce IκBα degradation in J774.A1 macrophages. Results support a role for endogenous ligands of TLR4 in the regulation of inflammation and repair in sterile wounds.

Outcomes in patients with mucosal melanomas.

BACKGROUND AND OBJECTIVE: Our goal was to evaluate the different subtypes of mucosal melanoma and describe specific variables that predict outcomes. METHODS: Prospective review of two tertiary care center databases identified 76 mucosal melanoma patients; 73 with complete records were included. Demographic and clinical data were analyzed. Cox regression determined variables impacting recurrence and survival. RESULTS: In the 73 patients, the mean age was 64 years, and 74% were female. Sixty-seven percent presented with lymph node involvement, and 73% had ulcerated tumors. Major sites affected were nasal/palate/oral (36%), vulvar/vaginal/cervical (48%), and anorectal (15%). Mean overall and disease-free survival were 56.9 and 27.2 months. Variables associated with decreased survival included: lymphovascular invasion (HR17.70, P = 0.0093), Caucasian race (HR3.02, P = 0.0362), nasal/palate/oral sub-group (HR1.85, P = 0.026), Breslow thickness (HR1.23, P = 0.00004), T stage (HR1.34, P = 0.0075), M stage (HR3.03, P = 0.0039), and chemotherapy (HR3.13, P = 0.0002). The worst prognosis was seen in the nasal/palate/oral sub-group, with a median overall survival of 9.7 months and recurrence-free time of 4.5 months. This subtype also demonstrated high lymph node positivity, ulceration, and larger tumor size. CONCLUSION: The nasal, palate, oral subtype has the worst prognosis compared to other mucosal melanoma locations. Studies are ongoing to evaluate pathologic and genomic variables that may predict outcomes.

Radioactive Seed Localization for Non-Breast Tissue Excision.

Lymph nodes are common basins for cancer recurrence; however, during surgery, lymphatic tissue is often indistinguishable from surrounding tissue making local excision difficult. Novel breast surgery techniques have utilized radioactive seed localization (RSL) to preoperatively tag tissue so it can be identified intraoperatively with a gamma probe. Our goal was to assess the use of RSL in non-breast tissues. This was a retrospective case series of non-breast cancer patients undergoing RSL. Overall, 42 patients met inclusion criteria. Pathology results indicated benign findings in 20 patients (47.62%), toxoplasma in 1 patient (2.38%), non-necrotizing granulomatous disease in 2 patients (4.76%), and malignant progression in 19 patients (45.24%). Two patients had non-lymphatic tissue removed: one in the abdominal wall and one in the lower lumbar region. Radioactive seed localization is an effective technique to localize and excise non-palpable lymph nodes and masses identified on imaging, highlighting its wide variety of uses in non-breast cancer cases.

Medical Students' Communication Preferences for the Ideal Surgical Educator.

OBJECTIVE: Medical students have expectations and preferences for how they are taught by clinical surgical educators. The goal of this study was to (a) determine medical students' prioritizations of ideal teaching behaviors and characteristics for surgical educators, and (b) delineate which teaching behaviors and characteristics were considered to be less important for surgical education. DESIGN: Using a necessity (low) and luxury (high) budget allocation methodology to build their ideal surgical educator, MSIII and MSIV students (N = 82) completed a survey to prioritize and invest in 10 effective teaching behaviors and characteristics identified in the instructional communication literature (assertiveness, responsiveness, clarity, relevance, competence, character, caring, immediacy, humor, and disclosure). RESULTS: Repeated-measures ANOVAs indicated MSIII and MSIV students invested significantly more of their teaching budget allocations for their ideal surgical educator into instructor clarity, competence, relevance, responsiveness, and caring, both within a (low) necessity budget (F[5.83, 472.17] = 24.09, p < 0.001, η2p = 0.23) and (high) luxury budget (F(7.65, 619.76) = 67.56, p < 0.001, η2p = 0.46). Using paired t-tests, comparisons of repeated investments in low and high budget allocations revealed that students invested slightly more of a percentage of funds in instructor immediacy (+2.62%; t(81) = 2.90, p = 0.005; d = 0.32) and disclosure (+1.44%; t(81) = 3.26, p = 0.002; d = 0.36), indicating they viewed these teaching behaviors more as luxury components of surgical education rather than necessities, but these behaviors were significantly less important than their ideal prioritizations of instructor clarity, competence, relevance, responsiveness, and caring. CONCLUSIONS: Results indicated that medical students want a surgical educator who is largely a rhetorical educator; that is, a surgical specialist who clearly communicates expertise and relevant content that students can apply to their careers as future surgeons. However, a relational component was viewed as ideal by students as students also preferred surgical educators to be sensitive and sympathetic to their academic needs.

The PASS Course: Practical Anatomy and Surgical Skills Course as a Pragmatic Primer for Senior Medical Students Pursuing Surgical Residency.

The senior year of undergraduate medical education has been scrutinized for lacking emphasis from educators and value for students. Surgical residency program directors and medical students have reported different sets of perceived weaknesses as surgical trainees enter residency. With this in mind, we developed a novel rotation for senior medical students pursuing surgical residency. The rotation incorporates practical didactics, robust skill and simulation training, and an enriching anatomy experience that entails dissections and operations on embalmed and fresh tissue cadavers. To our knowledge, this is the first reported formal training experience for medical students that involves working with fresh tissue cadavers, which have been described as effective models for live human tissue in the operating room. We describe our multifaceted curriculum in detail, discuss its organization, and elaborate on its potential value. We also provide detailed explanations of the curriculum components so that other surgical educators may consider adopting them.

Outside the Thorax: Doege-Potter Syndrome Presenting as a Retroperitoneal Abdominal Mass.

OBJECTIVE: We present a case of refractory hypoglycemia, weight loss, and retroperitoneal solitary fibrous tumor. Case report. A 68-year-old female presented with symptomatic hypoglycemia, weight loss, and abdominal mass identified on CT scan of the abdomen. Blood work during symptomatic hypoglycemia was consistent with an IGF-2-producing tumor. The abdominal mass pathology was consistent with solitary fibrous tumor surrounding the adrenal gland, and resection resulted in complete resolution of hypoglycemia. Discussion. Understanding the biochemical mechanisms behind glucose regulation is necessary to diagnose and adequately treat Doege-Potter syndrome, a paraneoplastic syndrome observed in patients with solitary fibrous tumors. Solitary fibrous tumors can be characterized by specific histologic and immunohistochemical studies. CONCLUSION: This report describes the clinical workup of a patient presenting with hypoglycemia and a retroperitoneal tumor. This case is unique because of its presentation with severe, refractory hypoglycemia and the tumor's location in the retroperitoneum, given the majority of solitary fibrous tumors are found in the lungs originating from the pleura.

Development of a Senior Medical Student Robotic Surgery Training Elective.

As robotic surgery has become more widespread, early exposure to the robotic platform is becoming increasingly important, not only to graduate medical education, but also for medical students pursuing surgical residency. In an effort to orient students to robotic technology and decrease the learning curve for what is likely to become an integral part of residency training, we created a formal, elective robotic surgery curriculum for senior medical students. Throughout this 2-week fourth year rotation, students completed online training modules and assessment; mastered exercises on the simulator system related to the console, camera, energy, dexterity, and suturing skills; attended didactics; utilized the dual console during one-on-one simulation lab sessions with attending robotic surgery experts; and translated new skills to biotissue anastomoses as well as bedside-assisting in the operating room. During cases, students were able to have more meaningful observation experiences, recognizing the significance of various robotic approaches employed and utilization of specific instruments. Future aims of this rotation will assess student experience as it impacts readiness for surgical residency.

Disruption of interleukin-1 signaling improves the quality of wound healing.

In this study, we investigated the role of interleukin (IL)-1 signaling in wound healing. IL-1 receptor type I (IL-1R) knockout (KO) mice showed reduced fibrosis in both cutaneous and deep tissue wounds, which was accompanied by a reduction in inflammatory cellular infiltration in cutaneous but not in deep tissue wounds. There were no differences in either total collagenolytic activity or in the expression of selected matrix metalloproteinases or tissue inhibitors of metalloproteinases between the wound fluids from wild-type or IL-1R KO mice. However, wound fluids from IL-1R KO mice contained lower levels of IL-6 compared with wild-type controls. In addition, the infusion of IL-6 into wounds in IL-1R KO mice did not increase fibrosis. Skin wounds in IL-1R KO animals had lower levels of collagen and improved restoration of normal skin architecture compared with skin wounds in wild-type mice. However, neither the tensile strength of incisional skin wounds nor the rate of closure of excisional wounds differed between IL-1R KO and wild-type animals. The reduced fibrotic response in wounds from IL-1R KO mice could be reproduced by the administration of an IL-1R antagonist. These findings suggest that pharmacological interference with IL-1 signaling could have therapeutic value in the prevention of hypertrophic scarring and in the treatment of fibrotic diseases.

Optimizing resection for "responding" hepatic metastases after neoadjuvant chemotherapy.

Fifty percent of patients with colorectal cancer will develop metastases at some time during their disease, with the liver being the most common site. Recent advances in the treatment of metastatic colorectal cancer have led to a change in treatment paradigm. What follows is a review of the surgical management of hepatic colorectal metastases responding to neoadjuvant chemotherapy. In addition, the complexity of treating patients with "disappearing" colorectal liver metastases is discussed.

Resection of a colonic mass following trauma: a diagnostic dilemma.

A 53-year-old Caucasian male presented with a 2-week history of abdominal distension, pain, nausea and lethargy. His symptoms began 1 day after an all-terrain vehicle accident during which he suffered blunt-force trauma to his mid-right abdomen. CT scan demonstrated abnormal thickening of the ascending colon and terminal ilium with surrounding inflammation within the retroperitoneum and colonic mesentery. Given his likely mechanism and symptomatic improvement, he was initially managed conservatively. However, he was readmitted with recurrence of symptoms, and a repeat CT scan demonstrated no interval improvement. An exploratory laparotomy was performed and a firm, fixed mass of the right-colon and colonic mesentery was found. Final histopathology of the mass revealed a diffuse lymphoid infiltrate with numerous mitotic figures and apoptotic cells. Immunohistochemical staining was positive for CD45, CD20, CD10, and BCL-6 and negative for CD3, TdT, and BCL-2, indicating a diagnosis of Burkitt lymphoma.

Surgical palliation: getting back to our roots.

This article provides an overview of the approach to patients who may benefit from palliative care. While the article's details lend themselves to the treatment of complications secondary to advanced malignancies, the data herein can also be extrapolated to other chronic, terminal diseases. Guidelines for patient selection are discussed, using currently available outcomes data as a platform for the critical decision making process. Suggestions for a multidisciplinary team approach are offered, using the palliative triangle as the ideal model of communication and cooperation. Finally, methods for measuring success are detailed, along with proposals for how to better equip the surgeons of tomorrow with the knowledge and experience needed to tackle these difficult and intimate problems.

Use of Ly6G-specific monoclonal antibody to deplete neutrophils in mice.

The anti-granulocyte receptor-1 (Gr-1) mAb, RB6-8C5, has been used extensively to deplete neutrophils in mice and to investigate the role of these cells in host defense. RB6-8C5 binds to Ly6G, which is present on neutrophils, and to Ly6C, which is expressed on neutrophils, dendritic cells, and subpopulations of lymphocytes and monocytes. It is thus likely that in vivo administration of RB6-8C5 may deplete not only neutrophils but also other Gr-l+ (Ly6C+) cells. This study describes the use of an Ly6G-specific mAb, 1A8, as an alternative means to deplete neutrophils. In vivo administration of RB6-8C5 reduced blood neutrophils and Gr-1+ monocytes, whereas administration of 1A8 reduced blood neutrophils but not Gr-1+ monocytes. Plasma TNF-alpha in endotoxemia was increased 20-fold by RB6-8C5 pretreatment and fourfold by 1A8 pretreatment. In a wound model, pretreatment with either antibody decreased wound neutrophils and macrophages. TNF-alpha staining in brefeldin-treated wound leukocytes was increased by pretreatment with RB6-8C5, but not 1A8. Neutrophil depletion with 1A8 offers advantages over the use of RB6-8C5, as it preserves non-neutrophil Gr-1+ cells depleted by the anti-Gr-1 antibody. The loss of non-neutrophil Gr-1+ populations in RB6-8C5-treated animals is associated with increased TNF-alpha responses, suggesting these cells may function to suppress TNF-alpha production.

Appendiceal intussusception in the setting of ulcerative colitis.

Appendiceal intussusception is a very rare condition with an estimated incidence of 0.01%. Most cases present in adults with chronic waxing and waning of symptoms over a period of weeks to months. We report a case of a 39-year-old Caucasian female with a 5-week history of worsening right-sided abdominal pain. Computed tomography revealed cecal thickening without visualization of the appendix. A colonoscopy revealed mild diffuse erythema and edema in the ascending colon as well as a mass within the lumen of the cecum. Biopsies of the colon were suggestive of mild ulcerative colitis (UC). The patient's symptoms continued and laparoscopic assisted ileocecectomy was performed revealing an inverted appendix protruding into the cecal lumen. The patient was discharged without any complications and began mesalamine therapy for her UC.

Modern chemotherapy mitigates adverse prognostic effect of regional nodal metastases in stage IV colorectal cancer.

BACKGROUND: In colorectal cancer, the involvement of regional lymph nodes with metastasis is an established prognostic factor. The impact of the number of positive nodes on patient outcome with stage IV disease is not well defined. METHODS: A retrospective review was performed of 1,421 patients at two tertiary referral centers with stage IV colorectal cancer who underwent primary tumor resection. Associations between regional nodes, lymph node ratio (LNR), and overall survival (OS) from date of diagnosis were analyzed. RESULTS: The number of positive regional nodes and LNR correlated with multiple sites of metastases (p < 0.001). Survival was significantly associated with the number of positive nodes and LNR, with a median OS of 43 months with negative nodes, compared to 20 months with ≥7 positive nodes (p < 0.001). The number of regional nodal metastases correlated with OS among 400 patients undergoing resection of liver metastases (p = 0.005) but lost prognostic significance in the subset of 223 patients who underwent hepatectomy with perioperative oxaliplatin- or irinotecan-based chemotherapy (p = 0.48). CONCLUSIONS: In stage IV colorectal cancer, an increasing number of positive regional nodes and LNR correlate with multiple sites of metastases and poorer survival. The number of metastatic regional lymph nodes loses prognostic significance with modern chemotherapy in patients undergoing resection of liver metastases.

Initial results of minimally invasive Ivor Lewis esophagectomy after induction chemoradiation (50.4 gy) for esophageal cancer.

OBJECTIVE: Esophageal cancer patients receiving induction chemoradiation to 41 Gy randomized to minimally invasive (MIS) esophagectomy have fewer postoperative pulmonary complications compared with those who underwent open procedures. We evaluated the feasibility of MIS Ivor Lewis esophagectomy in patients treated with induction chemoradiation to 50.4 Gy. METHODS: We retrospectively analyzed clinical data from 30 consecutive patients undergoing MIS Ivor Lewis esophagectomy after induction chemoradiation to a mean dose of 50.4 Gy by a single surgeon at a tertiary institution since 2010. Data collected included patient demographics, preoperative risk factors, neoadjuvant treatment modalities, histology, staging, operative factors, and perioperative complications. RESULTS: The mean age of the patients was 61 ± 9.5 years, and 87% were men. The dominant histology was adenocarcinoma (90%), with most tumors (70%) located at the gastroesophageal junction. A total of 22 patients (73%) presented with dysphagia, but only 15 (50%) had associated weight loss (mean 12.2% total body mass). All patients had R0 resections; mean number of resected lymph nodes was 27.1 ± 11.4. Mean operating room time was 535 ± 120 minutes, with the last 10 operations 2 hours shorter than the preceding 20. Four patients (13.3%) had major complications. including 2 (6.7%) anastomotic leaks. There was no operative mortality. CONCLUSIONS: Minimally invasive Ivor Lewis esophagectomy after chemoradiation to 50.4 Gy can be performed with decreased morbidity and mortality compared with historical series of open Ivor Lewis esophagectomy. Oncologic outcomes were acceptable as demonstrated by lymph node retrieval and complete resection rates. Operative time decreased significantly after 20 cases.

The phenotype of murine wound macrophages.

The phenotype of wound macrophages has not been studied by direct examination of these cells, yet macrophages recruited to sites of injury are described as alternatively activated macrophages, requiring IL-4 or IL-13 for phenotypic expression. This study characterized wound macrophage phenotype in the PVA sponge wound model in mice. Eighty-five percent of wound macrophages isolated 1 day after injury expressed Gr-1, but only 20% of those isolated at 7 days expressed this antigen. Macrophages from 1-, 3-, and 7-day wounds expressed markers of alternative activation,including mannose receptor, dectin-1, arginase 1,and Ym1, but did not contain iNOS. Day 1 wound macrophages produced more TNF-alpha, more IL-6, and less TGF-beta than Day 7 wound macrophages. Wound macrophages did not produce IL-10. The cytokines considered necessary for alternative activation of macrophages,IL-4 and IL-13, were not detected in the wound environment and were not produced by wound cells.Wound macrophages did not contain PStat6. Wound fluids inhibited IL-13-dependent phosphorylation of Stat6 and contained IL-13Ralpha2, a soluble decoy receptor for IL-13. The phenotype of wound macrophages was not altered in mice lacking IL-4Ralpha, which is required for Stat6-dependent signaling of IL-4 and IL-13.Wound macrophages exhibit a complex phenotype,which includes traits associated with alternative and classical activation and changes as the wound matures.The wound macrophage phenotype does not require IL-4 or IL-13.

Does failure to perform prophylactic level VI node dissection leave persistent disease detectable by ultrasonography in patients with low-risk papillary carcinoma of the thyroid?

BACKGROUND: There is controversy regarding the need for prophylactic level VI central node dissection in patients with low-risk papillary thyroid carcinoma (PTC). This study focuses on the incidence of persistent level VI nodal disease in low-risk PTC without prophylactic central node dissection. METHODS: PTC was known at the time of thyroidectomy in 304 of the 761 patients who had initial thyroid surgery from 2001 to 2007. Therapeutic level VI node dissection was performed for suspicious or positive nodes. A prophylactic central node dissection was not done if suspicious nodes were not identified. All patients had a high-resolution ultrasonography, and almost all patients had a suppressed serum thyroglobulin level 4-6 months after thyroidectomy. RESULTS: A total of 112 of 304 patients (37%) had a therapeutic level VI node dissection. A prophylactic central node dissection was not performed in the remaining 192 patients. One hundred and sixty-one of the 192 patients (84%) were low risk. Biopsy-proven persistent disease was identified at the 4-6-month postoperative ultrasonography in only 3 of the 161 low-risk patients (1.8%). The suppressed serum thyroglobulin level was increased in these 3 patients and 2 additional patients. CONCLUSION: Failure to perform a prophylactic central node dissection in low-risk PTC resulted in both a very low incidence of persistent level VI nodal disease and elevated suppressed thyroglobulin 4-6 months after thyroidectomy.