Azadeh A. Carr

A Single Parathyroid Hormone Level Obtained 4 Hours after Total Thyroidectomy Predicts the Need for Postoperative Calcium Supplementation

BACKGROUND Parathyroid hormone (PTH) levels after total thyroidectomy have been shown to predict the development of symptomatic hypocalcemia and the need for calcium supplementation. This study aimed to determine whether a PTH level drawn 4 hours postoperatively is as effective as a level drawn on postoperative day 1 (POD1) in predicting this need. STUDY DESIGN This is a single-institution retrospective review of 4-hour and POD1 PTH levels in patients who underwent total thyroidectomy from January 2012 to September 2012. If POD1 PTH was ≥10 pg/mL, patients did not routinely receive supplementation; if PTH was <10 pg/mL, patients received oral calcium with or without calcitriol. RESULTS Of 77 patients, 20 (26%) had a 4-hour PTH <10 pg/mL; 18 (90%) of these patients had a POD1 PTH <10 pg/mL. No patient with a 4-hour PTH ≥10 pg/mL had a POD1 PTH <10 pg/mL. All 18 patients with POD1 PTH <10 pg/mL received calcium supplementation. Three additional patients received supplementation due to reported symptoms or surgeon preference. A 4-hour PTH ≥10 pg/mL compared with a POD1 PTH had a similar ability to predict which patients would not need calcium supplementation; sensitivity was 98% vs 98%, specificity was 90% vs 86%, and and negative predictive value was 95% vs 95%. Of 21 patients who received supplementation, 13 (62%) also received calcitriol, including 9 patients (69%) with a 4-hour PTH <6 pg/mL. CONCLUSIONS A single PTH level obtained 4 hours after total thyroidectomy that is ≥10 pg/mL accurately identifies patients who do not need calcium supplementation or additional monitoring of serum calcium levels. Same-day discharge, if deemed safe, can be accomplished with or without calcium supplementation based on the 4-hour PTH level. Greater consideration should be given to calcitriol supplementation in patients with a 4-hour PTH <6 pg/mL.

Minimally Invasive Adrenalectomy

Minimally invasive adrenalectomy has become the gold standard for removal of benign adrenal tumors. The imaging characteristics, biochemical evaluation, and patient selection for laparoscopic transabdominal and posterior retroperitoneoscopic approaches are discussed with details of surgical technique for both procedures.

Institutional experience with lateral neck dissections for thyroid cancer

INTRODUCTION Compartment-oriented neck dissection is recommended for patients with evidence of thyroid cancer metastases to lateral compartment lymph nodes. This study reviews the outcomes of patients who underwent lateral neck dissections (LND) at a high-volume institution. METHODS This is a retrospective review of patients who underwent LND for metastatic thyroid cancer from January 2009 to June 2014. Preoperative evaluation, operative findings, and postoperative outcomes were analyzed. RESULTS Ninety-six patients underwent 127 LNDs. Fine-needle aspiration (FNA) confirmed metastases in 82 lateral necks (65%). The remaining 45 LNDs (35%) were performed based on clinical suspicion of metastases; 29 (64%) had metastases on final pathology. Twenty patients had 26 complications, which included chyle leak (7 [6%]), spinal accessory nerve dysfunction (7 [6%]), neck seroma requiring drainage (2 [2%]), and surgical site infection (10 [8%]). CONCLUSION LND is associated with a risk of early postoperative morbidity, but long-term complications are uncommon in the hands of experienced surgeons. In patients with thyroid cancer, a comprehensive preoperative evaluation of the lateral neck with physical examination, ultrasonography, and possible FNA should be performed. For those with suspicion of metastases, LND can be an important therapeutic option, but discussion with the patient regarding potential risks and benefits is essential.

Cosyntropin stimulation testing on postoperative day 1 allows for selective glucocorticoid replacement therapy after adrenalectomy for hypercortisolism: Results of a novel, multidisciplinary institutional protocol

BACKGROUND Secondary adrenal insufficiency (AI) can occur after unilateral adrenalectomy for adrenal-dependent hypercortisolism. Postoperative glucocorticoid replacement (GR), although given routinely, may not be necessary. We sought to identify factors that, in combination with postoperative day 1 cosyntropin stimulation testing (POD1-CST), would predict the need for GR. METHODS We reviewed 31 consecutive patients who underwent unilateral adrenalectomy for hypercortisolism (study patients) or hyperaldosteronism (control patients). A standard POD1-CST protocol was used. Hydrocortisone was started for clinical evidence of AI, basal plasma cortisol ≤ 5 (μg/dL), or a stimulated plasma cortisol <18. RESULTS A normal POD1-CST was found in all nine control patients and 11 of 22 patients (50%) with Cushings syndrome; the other 11 study patients (50%) received GR based on the POD1-CST. These patients were younger (51 vs 62 years; P = .017), had a higher body mass index (BMI; 31 vs 29 kg/m(2)), and smaller adrenal neoplasms (16.9 vs 33.0 g; P = .009) than non-GR study patients. CONCLUSION After unilateral adrenalectomy for hypercortisolism, only 50% of patients received GR. No preoperative biochemical characteristics were associated with postoperative AI, although patients who received GR were younger, and tended to have a higher BMI and smaller adrenal nodules. Use of this novel protocol for postoperative dynamic adrenal function testing prevented unnecessary GR in 50% of patients and allowed for individualized patient care.

Association between body mass index and multigland primary hyperparathyroidism.

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

Parathyroidectomy for primary hyperparathyroidism improves sleep quality: A prospective study

Background. This prospective survey study assessed changes in sleep quality in patients with primary hyperparathyroidism after parathyroidectomy. Methods. Patients undergoing parathyroidectomy for primary hyperparathyroidism (n = 110) or thyroidectomy for benign euthyroid disease (control group; n = 45) were recruited between June 2013 and June 2015 and completed the Pittsburgh Sleep Quality Index preoperatively and at 1‐ and 6 months postoperatively. “Poor” sleep quality was defined as a score >5; a clinically important and relevant improvement was a ≥3‐point decrease. Results. Preoperatively, parathyroid patients had worse sleep quality than thyroid patients (mean 8.1 vs 5.3; P < .001); 76 (69%) parathyroid and 23 (51%) thyroid patients reported poor sleep quality (P = .03). Postoperatively, only parathyroid patients demonstrated improvement in sleep quality; mean scores did not differ between the parathyroid and thyroid groups at 1 month (6.3 vs 5.3; P = .12) or 6 months (5.8 vs 4.6; P = .11). The proportion of patients with a clinically important improvement in sleep quality was greater in the parathyroid group at 1 month (37% vs 10%; P < .001) and 6 months (40% vs 17%; P = .01). Importantly, there was no difference in the proportion of patients with poor sleep quality between the 2 groups at 1 month (50% vs 40%; P = .32) and 6 months (40% vs 29%; P = .22). Conclusion. More than two‐thirds of patients with primary hyperparathyroidism report poor sleep quality. After parathyroidectomy, over one‐third experienced improvement, typically within the first month postoperatively.

Oncocytic papillary thyroid cancer has similar prognosis to matched classical papillary thyroid cancer controls

BACKGROUND Previous studies have suggested that oncocytic variant papillary thyroid carcinoma (PTC) may be more aggressive, with higher rates of recurrent disease. The aim of this study was to evaluate characteristics and outcomes of patients with oncocytic variant PTC compared to classical PTC. METHODS Patients with oncocytic variant PTC were retrospectively identified from 519 patients who underwent thyroidectomy for PTC between January 2009 and August 2015. Data collected included patient demographics, laboratory and pathology findings, imaging studies, treatment, and follow-up. Patients were matched 1:1 by age, sex, and TNM stage with patients who underwent total thyroidectomy for classical PTC during the same time period. RESULTS The cohort included 21 patients, of whom 18 (86%) were female, with a median age of 53 years (range 23-68 years). All patients underwent total thyroidectomy, and 17 (81%) had a central compartment neck dissection (8 [38%] prophylactic). The median tumor size was 2.0 cm (range 0.9-6.5 cm), and four (19%) patients had extrathyroidal extension. There was no significant difference in histopathologic characteristics, including extrathyroidal extension and lymphovascular invasion, between the two groups except for an increased incidence of thyroiditis in oncocytic variant PTC (90.5% vs. 57%; p = 0.01). In oncocytic variant PTC patients who underwent central compartment neck dissection, malignant lymph nodes were found in 12 (57%) patients compared to 13 (62%) classical (p = 0.75). Lateral neck dissection was performed in 5 (24%) oncocytic variant and classical PTC patients, with metastatic lymphadenopathy found in four (a median of four malignant lymph nodes; range 1-6) and five (a median of 2.5 malignant lymph nodes; range 1-9), respectively. Radioactive iodine was administered to 18 (86%) oncocytic variant PTC and 18 (86%) classical PTC patients. At a median follow-up of 51 months (interquartile range 38-61), one oncocytic variant PTC patient had recurrent disease and underwent reoperation at 24 months. In classical PTC patients with a median follow-up time of 77 months (range 56-87 months), two (9.5%) patients had detectable thyroglobulin levels indicating early recurrence, but neither has undergone reoperation. CONCLUSIONS Oncocytic variant PTC was present in 5% of PTC patients. Most (95%) patients remain disease-free at four years, similar to classical PTC outcomes, suggesting that oncocytic variant may not represent a more aggressive variant.

A postoperative parathyroid hormone-based algorithm to reduce symptomatic hypocalcemia following completion/total thyroidectomy: A retrospective analysis of 591 patients

Background: An institutional protocol for selective calcium/calcitriol supplementation after completion/total thyroidectomy was established based on the 4‐hour postoperative parathyroid hormone level. The aim of this study was to evaluate the outcomes of this protocol 5 years after implementation. Methods: All patients who underwent completion/total thyroidectomy from January 2012 to December 2016 were reviewed. Predictors of a 4‐hour parathyroid hormone level <10 pg/mL and symptomatic hypocalcemia were assessed. Results: Of 591 patients, 448 (76%) had a 4‐hour parathyroid hormone ≥10, 72 (12%) had a 4‐hour parathyroid hormone of 5–10, and 71 (12%) had a 4‐hour parathyroid hormone <5. Hypocalcemic symptoms were infrequent (30/448, 7%) if the 4‐hour parathyroid hormone was ≥10; 56% (40/71) of those with a 4‐hour parathyroid hormone <5 reported symptoms. With 4‐hour parathyroid hormone of 5–10, symptoms were reported in 32 of 72 (44%) patients; supplementation at discharge included calcium (n=55, 76%), calcium and calcitriol (n=12, 17%), or none (n=5, 7%). Ten patients subsequently received calcitriol for persistent symptoms. On multivariate analysis, predictors of 4‐hour parathyroid hormone <10 included incidental parathyroidectomy, malignancy, and thyroiditis; predictors of hypocalcemic symptoms included age <55 and 4‐hour parathyroid hormone <10. Conclusion: After completion/total thyroidectomy, patients with a 4‐hour parathyroid hormone ≥10 can be safely discharged without routine supplementation. The addition of calcitriol to calcium supplementation should be strongly considered for patients with a 4‐hour parathyroid hormone of 5–10.

Response to comments on: Cosyntropin stimulation testing on postoperative day 1 allows for selective glucocorticoid replacement therapy following adrenalectomy for hypercortisolism: Results of a novel, multidisciplinary institutional protocol.

Response to the Editors: Thank you for your interest and comments regarding “Cosyntropin stimulation testing on postoperative day 1 allows for selective glucocorticoid replacement therapy following adrenalectomy for hypercortisolism: Results of a novel, multidisciplinary institutional protocol.” In this study, 31 consecutive patients who underwent unilateral adrenalectomy for hypercortisolism or hyperaldosteronism were subject to a standard postoperative day 1 cosyntropin stimulation-testing protocol for evaluation of adrenal insufficiency. Hydrocortisone was initiated for clinical evidence of adrenal insufficiency, basal plasma cortisol #5 mg/dL, or a stimulated plasma cortisol <18 ug/dL. No patients received perioperative glucocorticoids, and only 11 of 22 (50%) patients with hypercortisolism required glucocorticoid replacement postoperatively, thereby preventing unnecessary glucocorticoid replacement in 50% of patients undergoing adrenalectomy for hypercortisolism. None of the remaining 11 patients required glucocorticoids at any time postoperatively. Importantly, none of the patients in the cohort demonstrated evidence of adrenal insufficiency in the immediate postoperative period, even those with secondary adrenal insufficiency in whom postoperative day 1 glucocorticoid replacement was initiated. Previous studies have used a stimulated cortisol level <18 mg/dL and a basal cortisol level <3.6 mg/dL as suggestive of adrenal insufficiency. The current study protocol used a greater threshold for the basal cortisol (<5.0 mg/dL) to prevent missed adrenal insufficiency, as Kumar et al suggest. Postoperative glucocorticoids, however, would have been initiated for a patient with any symptom of adrenal insufficiency prior to postoperative day 1 cosyntropin stimulation testing, which did not occur. This suggests that the hypothalamic-pituitary-adrenal axis was able to sustain basal function sufficiently and to respond to physiologic stress adequately. We acknowledge that the cohort is relatively small; however, this is the first study to demonstrate that routine perioperative (prior to operation and in the immediate postoperative period) glucocorticoid replacement in patients undergoing adrenalectomy for hypercortisolism is not necessary. These findings do not supersede the clinical judgment of providers who may think that a particular patient with significant hypercortisolism and comorbidities could benefit from perioperative glucocorticoids. However, we have shown that with a strict protocol and careful postoperative surveillance for possible symptoms of adrenal insufficiency by an informed multidisciplinary team, selective glucocorticoid replacement is safe for this subset of patients.

Surgical Management of Parathyroid and Adrenal Glands in Inherited Medullary Thyroid Carcinoma

Hereditary medullary thyroid cancer is a component of the type 2 multiple endocrine neoplasia syndromes (MEN). This chapter focuses on the management of the adrenal glands and parathyroid glands in classical MEN2A and MEN2B. Classical MEN2A is associated with pheochromocytoma and primary hyperparathyroidism, which both have varied frequency/penetrance depending on the specific RET mutation. In MEN2B pheochromocytoma will develop in approximately 50% of patients and tends to be diagnosed at a younger age. Pheochromocytomas in MEN2 are usually benign, multicentric, bilateral, and confined to the adrenal gland. Surgical approach to pheochromocytoma in MEN2 should be aimed at removing the secreting lesion while trying to preserve adrenal function to avoid corticosteroid dependence with associated risks of acute adrenal insufficiency, which may be fatal. Cortical-sparing adrenalectomy is a safe surgical option discussed in depth in this chapter. Primary hyperparathyroidism is reported to develop in 20–30 % of patients with MEN2 and is generally mild. It may be diagnosed synchronously with medullary thyroid cancer or more likely, after thyroidectomy, but it is rarely the presenting diagnosis for a patient with MEN2A. Careful management of the parathyroid glands and the central neck contents as described in detail in this chapter help avoid hypoparathyroidism.