Cord Sturgeon

Extent of Surgery Affects Survival for Papillary Thyroid Cancer

Background:The extent of surgery for papillary thyroid cancers (PTC) remains controversial. Consensus guidelines have recommended total thyroidectomy for PTC ≥1 cm; however, no study has supported this recommendation based on a survival advantage. The objective of this study was to examine whether the extent of surgery affects outcomes for PTC and to determine whether a size threshold could be identified above which total thyroidectomy is associated with improved outcomes. Methods:From the National Cancer Data Base (1985–1998), 52,173 patients underwent surgery for PTC. Survival was estimated by the Kaplan-Meier method and compared using log-rank tests. Cox Proportional Hazards modeling stratified by tumor size was used to assess the impact of surgical extent on outcomes and to identify a tumor size threshold above which total thyroidectomy is associated with an improvement in recurrence and long-term survival rates. Results:Of the 52,173 patients, 43,227 (82.9%) underwent total thyroidectomy, and 8946 (17.1%) underwent lobectomy. For PTC <1 cm extent of surgery did not impact recurrence or survival (P = 0.24, P = 0.83). For tumors ≥1 cm, lobectomy resulted in higher risk of recurrence and death (P = 0.04, P = 0.009). To minimize the influence of larger tumors, 1 to 2 cm lesions were examined separately: lobectomy again resulted in a higher risk of recurrence and death (P = 0.04, P = 0.04). Conclusions:The results of this study demonstrate that total thyroidectomy results in lower recurrence rates and improved survival for PTC ≥1.0 cm compared with lobectomy. This is the first study to demonstrate that total thyroidectomy for PTC ≥1.0 cm improves outcomes.

The American Association of Endocrine Surgeons Guidelines for Definitive Management of Primary Hyperparathyroidism

Importance Primary hyperparathyroidism (pHPT) is a common clinical problem for which the only definitive management is surgery. Surgical management has evolved considerably during the last several decades. Objective To develop evidence-based guidelines to enhance the appropriate, safe, and effective practice of parathyroidectomy. Evidence Review A multidisciplinary panel used PubMed to review the medical literature from January 1, 1985, to July 1, 2015. Levels of evidence were determined using the American College of Physicians grading system, and recommendations were discussed until consensus. Findings Initial evaluation should include 25-hydroxyvitamin D measurement, 24-hour urine calcium measurement, dual-energy x-ray absorptiometry, and supplementation for vitamin D deficiency. Parathyroidectomy is indicated for all symptomatic patients, should be considered for most asymptomatic patients, and is more cost-effective than observation or pharmacologic therapy. Cervical ultrasonography or other high-resolution imaging is recommended for operative planning. Patients with nonlocalizing imaging remain surgical candidates. Preoperative parathyroid biopsy should be avoided. Surgeons who perform a high volume of operations have better outcomes. The possibility of multigland disease should be routinely considered. Both focused, image-guided surgery (minimally invasive parathyroidectomy) and bilateral exploration are appropriate operations that achieve high cure rates. For minimally invasive parathyroidectomy, intraoperative parathyroid hormone monitoring via a reliable protocol is recommended. Minimally invasive parathyroidectomy is not routinely recommended for known or suspected multigland disease. Ex vivo aspiration of resected parathyroid tissue may be used to confirm parathyroid tissue intraoperatively. Clinically relevant thyroid disease should be assessed preoperatively and managed during parathyroidectomy. Devascularized normal parathyroid tissue should be autotransplanted. Patients should be observed postoperatively for hematoma, evaluated for hypocalcemia and symptoms of hypocalcemia, and followed up to assess for cure defined as eucalcemia at more than 6 months. Calcium supplementation may be indicated postoperatively. Familial pHPT, reoperative parathyroidectomy, and parathyroid carcinoma are challenging entities that require special consideration and expertise. Conclusions and Relevance Evidence-based recommendations were created to assist clinicians in the optimal treatment of patients with pHPT.

The Value of Intraoperative Parathyroid Hormone Monitoring in Localized Primary Hyperparathyroidism: A Cost Analysis

BackgroundMinimally invasive parathyroidectomy (MIP) is the preferred approach to primary hyperparathyroidism (PHPT) when a single adenoma can be localized preoperatively. The added value of intraoperative parathyroid hormone (IOPTH) monitoring remains debated because its ability to prevent failed parathyroidectomy due to unrecognized multiple gland disease (MGD) must be balanced against assay-related costs. We used a decision tree and cost analysis model to examine IOPTH monitoring in localized PHPT.MethodsLiterature review identified 17 studies involving 4,280 unique patients, permitting estimation of base case costs and probabilities. Sensitivity analyses were performed to evaluate the uncertainty of the assumptions associated with IOPTH monitoring and surgical outcomes. IOPTH cost, MGD rate, and reoperation cost were varied to evaluate potential cost savings from IOPTH.ResultsThe base case assumption was that in well-localized PHPT, IOPTH monitoring would increase the success rate of MIP from 96.3 to 98.8%. The cost of IOPTH varied with operating room time used. IOPTH reduced overall treatment costs only when total assay-related costs fell below

Minimally Invasive Video-Assisted Thyroidectomy for Follicular Neoplasm: Is There an Advantage Over Conventional Thyroidectomy?

110 per case. Inaccurate localization and high reoperation cost both independently increased the value of IOPTH monitoring. The IOPTH strategy was cost saving when the rate of unrecognized MGD exceeded 6% or if the cost of reoperation exceeded

Parathyroid cyst : Often mistaken for a thyroid cyst

12,000 (compared with initial MIP cost of

How Does the Operative Strategy for Primary Hyperparathyroidism Impact the Findings and Cure Rate? A Comparison of 800 Parathyroidectomies

3733). Setting the positive predictive value of IOPTH at 100% and reducing the false-negative rate to 0% did not substantially alter these findings.ConclusionsInstitution-specific factors influence the value of IOPTH. In this model, IOPTH increased the cure rate marginally while incurring approximately 4% additional cost.

How should age at diagnosis impact treatment strategy in asymptomatic primary hyperparathyroidism? A cost-effectiveness analysis.

BackgroundMinimally invasive video-assisted thyroidectomy (MIVAT) is safe and effective for selected patients, but its advantages are not clearly defined. Results of MIVAT for follicular neoplasms at a single institution were retrospectively evaluated to define its advantages or disadvantages.MethodsBetween October 2002 and May 2004, 22 patients underwent MIVAT. Twenty-six patients who underwent conventional thyroidectomy during the same time period served as matched controls. Operative times, pathologic findings, complications, analgesic requirements, and incision lengths were retrospectively evaluated.ResultsFour MIVAT and three conventional surgery patients underwent total thyroidectomy. Eighteen MIVAT and 23 conventional patients underwent hemithyroidectomy. The operative time (mean ± SEM) for hemithyroidectomy was 102 ± 4 minutes for MIVAT and 86 ± 3 minutes for conventional surgery (P < .05). In subgroup analysis that excluded patients with thyroiditis, operative times were not significantly different: MIVAT, 99 ± 4 minutes; conventional, 88 ± 4 minutes. The mean incision length was 2.3 ± .5 cm in the MIVAT group. Conventional thyroidectomy was performed through a 4- to 5-cm incision. The average amount of narcotic used was not significantly different (intravenous, 9.9 ± 3.1 mg [MIVAT] vs. 12.4 ± 3.8 mg; oral, 10.3 ± 4.2 mg [MIVAT] vs. 3.5 ± 2.0 mg). The conventional group received more cyclooxygenase 2 inhibitor (527 ± 9 mg vs. 187 ± 84 mg; P < .05). One patient in each group experienced transient hoarseness. There were no cases of permanent hypoparathyroidism or recurrent laryngeal nerve injury in either group.ConclusionsMIVAT is as safe and effective as conventional thyroidectomy and is associated with similar narcotic analgesic requirements, but it can be performed through smaller incisions. Operative times were significantly longer for MIVAT, but when patients with thyroiditis were excluded, operative times were not significantly different.

Cost-effectiveness analysis of repeat fine-needle aspiration for thyroid biopsies read as atypia of undetermined significance

IntroductionParathyroid cysts are rare but clinically significant lesions. They can be functional, mistaken for a thyroid cyst, and/or managed nonoperatively on occasion.MethodsWe identified seven patients (1 male, 6 females) with the diagnosis of parathyroid cyst from 1998 to 2003.ResultsAltogether, 33% of the patients had functional cysts. Sestamibi scans were performed in three of the seven patients, including two with functional cysts; none showed focal uptake. In toto, six of the seven cysts (86%) were found in an inferior parathyroid gland. All of the cysts had crystal-clear aspirate. C-terminal parathormone (PTH) levels were obtained from the aspirate from five of the seven (71%) patients. The mean level was 269,736 pg/ml (1970–1,268,074 pg/ml). Surgery was performed in three of the seven (43%) patients. All patients who underwent surgery improved postoperatively based on symptoms and serum levels of calcium and PTH. The four patients (57%) who were treated nonoperatively were subjected to aspiration alone; three (75%) of those patients required multiple aspirations.ConclusionsMost parathyroid cysts are nonfunctional and are rarely symptomatic. They are usually located in an inferior gland. If aspirated, most of the cysts reaccumulate fluid. Operative management is usually straightforward and alleviates symptoms and any biochemical abnormalities caused by the cyst.

METASTATIC STRUMA OVARII TREATED WITH TOTAL THYROIDECTOMY AND RADIOIODINE ABLATION

BACKGROUND We hypothesized that a higher frequency of multigland disease and higher cure rate would result if routine four-gland exploration (4GL) was used as compared with focused parathyroidectomy (FP) for treatment of primary hyperparathyroidism. STUDY DESIGN During a 5-year period, data from two academic endocrine surgical practices were retrospectively reviewed for patients having an operation for primary hyperparathyroidism. Three hundred ninety-five consecutive patients underwent 4GL at one institution (A), and 405 consecutive patients underwent FP with selective use of 4GL at the other institution (B). The main outcomes measures were gender, preoperative imaging, surgical findings, gland weight, and operative success. RESULTS Three hundred ten (78%) patients at institution A were women, and 292 (72%) at institution B were women (p < 0.05). Routine 4GL strategy at institution A yielded a 16.5% frequency of multigland disease; and an FP strategy at institution B yielded 11.1% multigland disease (p = 0.028). At both institutions, single adenomas weighed more than multigland disease. Gland weights were not significantly different between the two institutions. Nine of 395 (2.3%) patients at institution A remained hypercalcemic postoperatively compared with 15 of 405 (3.7%) at B (p = 0.24; not significant). CONCLUSIONS A greater frequency of multigland disease was found with routine 4GL. There was no statistically significant difference in operative success between the two approaches. Sound surgical technique and intraoperative judgment, including interpretation of intraoperative parathyroid hormone values, will result in a high success rate, regardless of the operative strategy chosen for primary hyperparathyroidism.

No Need to Abandon Unilateral Parathyroid Surgery

BACKGROUND The National Institutes of Health consensus conference on asymptomatic primary hyperparathyroidism (PHPT) recommended several criteria for parathyroidectomy (PTX), including age <50 years. We hypothesized that a cost-effectiveness analysis would show PTX to be the optimal strategy for asymptomatic patients >50 years of age. METHODS A Markov model was constructed comparing operative, observational, and pharmacologic treatments. Costs were estimated from a third-party payer perspective. Outcomes were weighted with utility adjustment factors, yielding quality-adjusted life-years (QALYs). Future costs and QALYs were discounted at 3%. Threshold analysis identified the optimal strategy at life expectancies ranging from 6 months to 75 years. Multivariate sensitivity analysis was completed with Monte Carlo simulation. RESULTS PTX was optimal when life expectancy reached 5 years for outpatient PTX and 6.5 years for inpatient PTX. Observation was the optimal strategy at all shorter life expectancies considered. The pharmacologic treatment strategy was not optimal at any life expectancy. CONCLUSION PTX is the optimal strategy for many patients with asymptomatic PHPT who are >50 years of age. PTX is cost effective for patients with a predicted life expectancy of 5 years (outpatient) or 6.5 years (inpatient). For patients with a shorter life expectancy, observation is the most cost-effective strategy.