Benjamin C. James

Risk Factors for Decreased Quality of Life in Thyroid Cancer Survivors: Initial Findings from the North American Thyroid Cancer Survivorship Study

BACKGROUND The prevalence of thyroid cancer survivors is rising rapidly due to the combination of an increasing incidence, high survival rates, and a young age at diagnosis. The physical and psychosocial morbidity of thyroid cancer has not been adequately described, and this study therefore sought to improve the understanding of the impact of thyroid cancer on quality of life (QoL) by conducting a large-scale survivorship study. METHODS Thyroid cancer survivors were recruited from a multicenter collaborative network of clinics, national survivorship groups, and social media. Study participants completed a validated QoL assessment tool that measures four morbidity domains: physical, psychological, social, and spiritual effects. Data were also collected on participant demographics, medical comorbidities, tumor characteristics, and treatment modalities. RESULTS A total of 1174 participants with thyroid cancer were recruited. Of these, 89.9% were female, with an average age of 48 years, and a mean time from diagnosis of five years. The mean overall QoL was 5.56/10, with 0 being the worst. Scores for each of the sub-domains were 5.83 for physical, 5.03 for psychological, 6.48 for social, and 5.16 for spiritual well-being. QoL scores begin to improve five years after diagnosis. Female sex, young age at diagnosis, and lower educational attainment were highly predictive of decreased QoL. CONCLUSION Thyroid cancer diagnosis and treatment can result in a decreased QoL. The present findings indicate that better tools to measure and improve thyroid cancer survivor QoL are needed. The authors plan to follow-up on these findings in the near future, as enrollment and data collection are ongoing.

A novel, ultrarapid parathyroid hormone assay to distinguish parathyroid from nonparathyroid tissue

BACKGROUND Frozen section is the gold standard for distinguishing parathyroid tissue from lymph nodes, thyroid nodules, or fat during parathyroidectomy and thyroidectomy. Although a very accurate procedure, it can be time-consuming and costly. We hypothesize that the extremely high concentrations of parathyroid hormone (PTH) in parathyroid tissue allow for modification of a standard PTH assay that would distinguish parathyroid from nonparathyroid tissue in substantially less time than frozen section or any currently available PTH assay. METHODS A prospective, single-institution study using a modified PTH assay protocol and a manual luminometer was undertaken by testing 20 parathyroid adenomas and 9 control tissues. Analyses were performed simultaneously by the modified PTH protocol and the conventional intraoperative PTH assay. RESULTS PTH luminescence values from parathyroid tissue and control tissue aspirates were significantly different at 60 seconds (P = .015). ROC curve analysis showed the assay to be 100% sensitive and 100% specific in differentiating parathyroid from nonparathyroid tissue. CONCLUSION Our novel PTH assay accurately and reliably differentiates parathyroid from nonparathyroid tissue within 60 seconds of measurement onset. This assay provides a great advantage in time savings compared with frozen section as well as any currently existing PTH assays.

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.

The profile of successful applicants for endocrine surgery fellowships: results of a national survey.

BACKGROUND The American Association of Endocrine Surgeons initiated a fellowship match in 2007. The profile of applicants who successfully match into an endocrine surgery (ES) fellowship has not previously been characterized. METHODS An institutional review board-approved, web-based survey was distributed to recent and current ES fellows. RESULTS The survey response rate was 62% (56/90). The overall mean age was 33 years (standard deviation ±3), 54% were female, and 37% self-identified as non-white. Only 5% entered their surgical training with the aim of specializing in ES. During residency, respondents were exposed to high volumes of index ES cases. Sixty-two percent had dedicated research time. At the time of fellowship application, the median number of publications was 5 (range, 0 to 25), and 30% of respondents had additional advanced degrees. CONCLUSION Entering ES fellows has diverse backgrounds, with strong academic credentials. These data help inform the career mentoring of aspiring ES applicants.

Quality of life in thyroid cancer: Physician perceptions.

228 Background: In a multicenter cohort of over 1,200 patients, we have shown that thyroid cancer survivors report a decrease in quality of life (QoL) that is significant and equal to other common cancers. While these findings are striking, there have been no studies assessing physician perceptions regarding how a diagnosis of thyroid cancer affects QoL. We hypothesize that there is a large discrepancy between what physicians perceive the diagnosis and treatment of thyroid cancer has on QoL and what patients report. METHODS Physicians were recruited from two national organizations. A 37-question survey was administered evaluating demographic and treatment-related information as well as questions specific to perceptions of patient satisfaction with various aspects of treatment, complications and overall effects on QoL. Responses were categorized into physical, psychological, social and outcomes. Regression analysis was performed to determine trends in physician perceptions. RESULTS 105 physicians completed the survey. The majority of participants were endocrine surgeons (n=59, 56.2%), followed by endocrinologists (n= 31, 29.5%), general surgeons (n=8, 7.6%), otolaryngologists (n=2, 1.9%), and medical oncologists (n=1, 1%). The mean number of years in practice was 18.78 years (n=80). There was no difference in response by physician specialty. There was no difference in physician perception on psychological and social effects of thyroid cancer compared to those reported by patients (p=0.643). However, regarding physical concerns, physicians report significantly lower rates of physical concerns than reported by patients with regards to fatigue (p<0.01), weight gain (p<0.01), voice changes (p=0.0427), and heat/cold intolerance (p<0.01). CONCLUSIONS There is a discrepancy between physician perceptions on the effect of thyroid cancer on QoL in thyroid cancer survivors and what these survivors report. As such, there needs to be greater awareness about the effects of thyroid cancer on QoL. In order to better assess and monitor QoL in thyroid cancer survivors, a validated thyroid cancer-specific survivorship care plan incorporating these findings should be created to better assess and monitor patients with a diagnosis of thyroid cancer.

Evaluation and Treatment of Inherited Pheochromocytoma in Pregnancy

Pheochromocytomas represent a rare, but potentially devastating, cause of hypertension among pregnant patients. Inherited predisposition to these tumors requires vigilant screening, especially in women of child-bearing age. We present an illustrative case of a multiple endocrine neoplasia type 2A patient who was successfully surgically treated for a pheochromocytoma during pregnancy. A review of the existing, English-language literature and screening guidelines was undertaken. Pheochromocytomas presenting during pregnancy, can be safely and effectively treated with laparoscopic surgery, allowing the maintenance of a normal pregnancy. Screening of patients with inherited endocrinopathies that predispose to adrenal medullary tumors must be adapted to maximize the opportunity to detect a pheochromocytoma in the pregravid state. More frequent testing and a lower threshold for biochemical or radiologic investigation are suggested for women in their reproductive years.

Prophylactic Versus Selective Central Neck Dissection in Pediatric Papillary Thyroid Cancer

The first case of thyroid carcinoma in a child was described in 1902. Following this, Crile published the first case series of pediatric thyroid cancer in 1959, whereby he characterized pediatric thyroid cancer in 18 children. He noted that pediatric thyroid cancer was more commonly metastatic to cervical lymph nodes and to the lungs than was described in the adult population. Despite finding these cancers to be more aggressive than in adults, only one of the patients died of thyroid cancer and four of them were alive with lung metastases. This publication spawned many subsequent studies confirming these findings. As a result, there has been much debate on the appropriate surgical treatment of thyroid cancer in the pediatric population both with respect to the extent of surgery and the use of radioactive iodine.

Using Individual Clinical Evaluations to Assess Residents’ Clinical Judgment; Feasibility and Residents’ Perception

OBJECTIVE In surgical training, most assessment tools focus on advanced clinical decision-making or operative skill. Available tools often require significant investment of resources and time. A high stakes oral examination is also required to become board-certified in surgery. We developed Individual Clinical Evaluation (ICE) to evaluate intern-level clinical decision-making in a time- and cost-efficient manner, and to introduce the face-to-face evaluation setting. DESIGN Intern-level ICE consists of 3 clinical scenarios commonly encountered by surgical trainees. Each scenario was developed to be presented in a step-by-step manner to an intern by an attending physician or chief resident. The interns had 17 minutes to complete the face-to-face evaluation and 3 minutes to receive feedback on their performance. The feedback was transcribed and sent to the interns along with incorrect answers. Eighty percent correct was set as a minimum to pass each scenario and continue with the next one. Interns who failed were retested until they passed. Frequency of incorrect response was tracked by question/content area. After passing the 3 scenarios, interns completed a survey about their experience with ICE. SETTING Beth Israel Deaconess Medical Center, an academic tertiary care facility located in Boston, Massachusetts. PARTICIPANTS All first-year surgery residents in our institution (n = 17) were invited to complete a survey. RESULTS All 2016-2017 surgical interns (17) completed the ICEs. A total of

An update in international trends in incidence rates of thyroid cancer, 1973–2007

171 (US) was spent conducting the ICEs, and an average of 17 minutes was used to complete each evaluation. In total, 5 different residents failed 1 scenario, with the most common mistake being: failing to stabilize respiration before starting management. After completing the 3 clinical scenarios, more than 90% of respondents agreed or strongly agreed that the evaluations were appropriately challenging for training level, and that the evaluations helped to identify personal strengths and weaknesses in skill and knowledge. The majority believed their knowledge improved as a result of the ICE and felt better prepared to manage these scenarios (88% and 76%, respectively). CONCLUSIONS The ICE is an inexpensive and time efficient way to introduce interns to board type examinations and assess their preparedness for perioperative patient care issues. Common errors were identified which were able to inform educational efforts. ICEs were well accepted by residents. Next steps include extension of the ICE to PGY2 and PGY3 residents.

Pediatric toxic polycystic thyroid

PurposeOver the past several decades, there has been a reported increase in the incidence of thyroid cancer in many countries. We previously reported an increase in thyroid cancer incidence across continents between 1973 and 2002. Here, we provide an update on the international trends in thyroid cancer between 2003 and 2007.MethodsWe examined thyroid cancer incidence data from the Cancer Incidence in Five Continents (CI5) database for the period between 1973 and 2007 from 24 populations in the Americas, Asia, Europe, Africa and Oceania, and report on the time trends as well as the distribution by histologic type and gender worldwide.ResultsThe incidence of thyroid cancer increased during the period from 1998–2002 to 2003–2007 in the majority of populations examined, with the highest rates observed among women, most notably in Israel and the United States SEER registry, at over 14 per 100,000 people. This update suggests that incidence is rising in a similar fashion across all regions of the world. The histologic and gender distributions in the updated CI5 are consistent with the previous report.ConclusionsOur analysis of the published CI5 data illustrates that the incidence of thyroid cancer increased between 1998–2002 and 2003–2007 in most populations worldwide, and rising rates continue in all regions of the world.