Christian Passler

Advantages of Recurrent Laryngeal Nerve Identification in Thyroidectomy and Parathyroidectomy and the Importance of Preoperative and Postoperative Laryngoscopic Examination in More Than 1000 Nerves at Risk

Objectives/Hypothesis Recurrent laryngeal nerve palsy (RLNP) is a major obstacle in thyroid and parathyroid surgery. Therefore, methods that reduce the number of temporary and, especially, permanent recurrent laryngeal nerve palsies are of great interest. One promising way to ensure the integrity of the recurrent laryngeal nerve (RLN) is to identify the nerve always. The first question raised in the present study was whether RLN preparation reduces the number of recurrent laryngeal nerve palsies or whether it introduces additional risks. Second, from former cases we know that the absence of postoperative hoarseness does not exclude RLNP, nor does postoperative hoarseness exclusively imply RLNP. Besides, misdiagnosis is not uncommon. Therefore, preoperative and postoperative laryngoscopic examination was given attention.

Hypoparathyroidism After Total Thyroidectomy: A Prospective Study

HYPOTHESIS Combined measurement of intact parathyroid hormone (iPTH) and serum calcium (sCa) levels is useful for predicting postoperative hypocalcemia with minimal laboratory effort and low costs. DESIGN Prospective analysis of 170 consecutive patients. SETTING University hospital referral center. PATIENTS One hundred seventy patients underwent total thyroidectomy. Defining hypoparathyroidism as albumin-adjusted sCa levels of less than 1.9 mmol/L with or without clinical symptoms or subnormal sCa levels (1.9-2.1 mmol/L) with neuromuscular symptoms, the influences of central lymph node dissection, experience of the surgeon, and parathyroid autotransplantation were observed. We measured the sCa and iPTH levels separately and in combination and the postoperative sCa slope to predict patients who were at risk of hypoparathyroidism. MAIN OUTCOME MEASURES Predictive values for iPTH and sCa levels were compared to identify postoperative hypoparathyroidism. RESULTS Of the 170 study patients, 41 developed transient hypoparathyroidism and 2 developed permanent hypoparathyroidism. The morphologic features and function of the thyroid gland, central neck dissection, experience of the surgeon, and parathyroid autotransplantation did not influence development of postoperative hypoparathyroidism. The best sensitivity for predicting postoperative hypoparathyroidism was 97.7% for measurement of iPTH levels, and the best specificity was 96.1% for measurement of sCa levels. Negative and positive predictive values reached their best (99.0% and 86.0%, respectively) when we combined sCa and iPTH values. CONCLUSIONS Patients with iPTH levels of 15 pg/mL or less and sCa levels of 1.9 mmol/L or less are at increased risk of developing postoperative hypoparathyroidism. Measuring iPTH levels 24 hours after total thyroidectomy in combination with sCa levels on the second postoperative day allows the prediction of hypoparathyroidism with a high sensitivity, specificity, and positive predictive value.

Long‐term follow‐up of patients with bone metastases from differentiated thyroid carcinoma – surgery or conventional therapy?

objective Surgery of bone metastases from differentiated thyroid carcinoma seems indicated in individual patients. This study was performed (1) to analyse retrospectively patients with bone metastases from differentiated thyroid carcinoma and (2) to evaluate the impact of surgery of bone metastases on survival.

Anaplastic (undifferentiated) thyroid carcinoma (ATC)

Background: Old age, reduced general condition and far advanced tumor stage associated with poor prognosis induced the belief that, apart from verifying the diagnosis of anaplastic thyroid carcinoma (ATC) by biopsy, no additional surgery would be justified. However, in some cases, an ultraradical approach was recommended in order to improve the quality of life and survival. Methods: These are the results of a retrospective analysis involving 120 patients subjected to restricted radical surgery (excising as much as possible of the tumor and local metastases, foregoing ultraradical removal of vital organs such as esophagus, larynx and trachea). Results: Irrespective of the surgical approach used, 6±2% of the patients were alive after 5 years (median survival time: 3.1 months). Patients without tumor residues (R0-resections; extending to soft tissue only; Kaplan-Meier estimate – cumulative survival 15±5%) had a significantly better prognosis than patients with tumor residues (R1/R2-resections; no patient survived 5 years; P<0.001). Tumor morphology (spindle cells, giant cells, mixed cells) or differentiated parts of the tumor as well as lymph-node involvement had no statistically significant impact on the prognosis. Conclusions: In ATC, the objective should be to remove as much of the carcinoma as possible (in the ideal case, a thyroidectomy); if lymph nodes are affected, neck dissection should be the goal, if possible (restricted radical approach, improving quality of life). Ultradical surgery to include segmental resection of larynx, trachea or esophagus do not seem to be indicated, as prolonged survival is questionable and quality of life is certainly diminished.

Application of Staging Systems for Differentiated Thyroid Carcinoma in an Endemic Goiter Region With Iodine Substitution

ObjectiveTo evaluate and compare staging systems for differentiated thyroid carcinoma and predicted outcome in an endemic goiter region with iodine substitution and to examine the risk profile of differentiated thyroid carcinoma and compare it against nongoiter regions. Summary Background DataDifferentiated (papillary or follicular) thyroid carcinoma has a favorable prognostic outcome. In numerous studies prognostic factors have been identified and staging systems created, particularly in Anglo-American centers (nonendemic goiter regions), to evaluate individual prognostic outcome. MethodsIn a retrospective study, the authors assessed 440 patients with differentiated thyroid carcinoma (papillary, n = 293; follicular, n = 147) and a long-term follow-up of median 10.6 years to determine the predictive accuracy of nine staging systems applicable to the study population; the systems were compared by calculating the proportion of variation explained. ResultsWith regard to cause-specific mortality, the difference between the respective stages and/or risk groups was highly significant for every staging system. By means of calculating the proportion of variation explained, MACIS scoring supplied the most reliable prognostic information for differentiated thyroid carcinoma (relative importance 16.93%). EORTC and UICC/AJCC systems had a relative importance of 16.34% and 13.96%, respectively, also a high level of accuracy; this implies that they are superior to the other six staging systems. If we separate papillary and follicular carcinoma, for the former the MACIS score with a relative importance of 15.05% is clearly superior to the other staging systems, whereas for the latter the EORTC score and the UICC/AJCC staging system, with relative importance of 17.04% and 16.58%, respectively, yield the best prognostic information. ConclusionsBy applying staging systems in an endemic goiter region with iodine substitution, the best prognostic information for papillary thyroid carcinoma has been achieved with the MACIS score, while for follicular thyroid carcinoma the EORTC score and the UICC/AJCC system have the best prognostic accuracy. Because of the individual factors, which are easy to obtain and generally available (age, T, N, M classification), the uncomplicated handling, and the widespread use and the good predictive accuracy, the UICC/AJCC classification is the staging system of choice for comparing published results.

Nesidioblastosis in adults: a challenging cause of organic hyperinsulinism.

Background Nesidioblastosis in adults has been reintroduced into the differential diagnosis of organic hyperinsulinism by the description of ‘noninsulinoma pancreatogenous hypoglycaemia syndrome (NIPHS)’.

Impact of localization studies on feasibility of minimally invasive parathyroidectomy in an endemic goiter region

BACKGROUND A localized single-gland disease is the basis for minimally invasive parathyroidectomy (MIP) in primary hyperparathyroidism (PHPT). (99m)Tc sestamibi scanning (MIBI) and high-resolution Doppler ultrasonography (US) are well-established techniques used to localize enlarged parathyroid glands. Additionally, US enables physicians to diagnose subclinical thyroid abnormalities. The aim of this study was to optimize localization results, applying a combined interpretation of MIBI and US, and to analyze the influence of these results on the feasibility of MIP (endoscopic/video-assisted and open) in an endemic goiter region. STUDY DESIGN One hundred fifty consecutive patients with sporadic PHPT were prospectively subjected to MIBI and US to localize parathyroid lesions and to review the morphology of the thyroid gland. Bilateral cervical exploration was performed in all patients. The feasibility of MIP was calculated retrospectively on the basis of surgical findings and biochemical outcomes at least 12 months postoperatively (normocalcemia in 148 of 150 patients [99%]). RESULTS Forty-five percent of patients (67 of 148) would have been suitable for minimally invasive endoscopic or video-assisted parathyroid exploration. These procedures would have succeeded in 38% of patients (56 of 148). Sixty-four percent (94 of 148) would have been suitable for minimally invasive open parathyroidectomy, which would have succeeded in 55% (82 of 148 patients). CONCLUSIONS Not all patients are suitable for MIP. A combined interpretation of MIBI and US results is helpful in planning targeted exploration. In an endemic goiter region minimally invasive open parathyroidectomy is applicable in significantly more patients than is endoscopic and video-assisted MIP.

Importance of tumour size in papillary and follicular thyroid cancer

The most controversial change in the new pathological tumour node metastasis (pTNM) classification of thyroid tumours is the extension of the pT1 classification to include tumours up to 20 mm.

Treatment of small intestinal neuroendocrine tumors: is an extended multimodal approach justified?

Neuroendocrine tumors (NETs) of the small bowel are known for their low malignant behavior. Although most cases are diagnosed in an advanced stage, natural life expectancy is significantly higher than with intestinal carcinomas. The question arises if there are any benefits to combining extended (radical or debulking) surgery, interventional treatment, and medical treatment with respect to life expectancy, and quality of life. A series of 58 patients (34 men, 24 women; mean age 61 ± 12 years, range 37–87 years) with NETs of the small bowel were retrospectively reviewed and prospectively followed over 63 ± 53 months. Clinical presentation, tumor characteristics, and postoperative medical treatment were documented. Quality of life was additionally analyzed using a questionnaire. Survival probability and quality of life were compared for tumor stages and type of treatment performed. In 47 of 58 (81%) patients the NET was diagnosed based on the presence of intestinal stenosis or endocrine symptoms. Of 16 patients without liver metastases, 15 (94%) were cured by radical surgery. Multiple liver metastases were evident in 40 of 58 (69%) patients and decreased the 5- and 10-year cumulative survival to 64% ± 10% and 22% ± 10% (M0 vs. M1: p <0.05). The 5- and 10-year survival rates after multimodal treatment (surgery, bio/immunotherapy, transarterial embolization of liver metastases) were 64% ± 11% and 28% ± 12% compared to 61% ± 15% and 0% in patients without (p = NS). In patients with small intestinal NETs, a consistent multimodal treatment helps to improve the overall survival and, in most patients, the quality of life.

Can dynamic gadolinium-enhanced magnetic resonance imaging with chemical shift studies predict the status of adrenal masses?

Endoscopic adrenalectomy represents the new gold standard in the surgical treatment of benign adrenal lesions up to 6 cm. In some cases lesions larger than 10 cm have been removed laparoscopically to offer the patient the advantages of the minimally invasive technique. The larger the diameter of an adrenal lesion, the greater the probability of malignancy. In a prospective study 130 consecutive patients (88 women, 42 men; mean age 47.8 years) with 137 adrenal lesions earmarked for surgery underwent preoperative gadolinium-enhanced magnetic resonance imaging (MRI) with chemical shift studies (CSS). The aim of this study was to predict the status (benign, borderline, malignant) of adrenal lesions by MRI irrespective of tumor size. There were 14 patients with malignant tumors, 3 had borderline tumors (epithelial tumors with high malignant potential), and the remaining 120 had benign adrenal lesions. Five malignant lesions (36%) had a diameter < 6 cm. MRI correctly predicted 11 of 14 malignant tumors (1 malignant pheochromocytoma and 2 adrenocortical carcinomas had false-negative results), 117 of 120 benign lesions, and 2 of 3 borderline lesions. All but two malignant tumors were operated on using open surgery; 82 (68%) of 120 benign adrenal lesions were treated using the transperitoneal laparoscopic approach. Tumor size alone is not suitable for predicting the status of adrenal lesions. Dynamic gadolinium-enhanced MRI with CSS can predict the status of at least 95% of adrenal lesions. Tumors > 6 cm classified as benign by preoperative MRI may be removed laparoscopically by endocrine surgeons experienced in endoscopic adrenalectomy.