David T. Hughes

Influence of prophylactic central lymph node dissection on postoperative thyroglobulin levels and radioiodine treatment in papillary thyroid cancer

BACKGROUND Prophylactic central lymph node dissection with total thyroidectomy (TT) for the treatment of papillary thyroid cancer (PTC) is controversial because of the possibility of increased morbidity with uncertain benefit. The purpose of this study is to determine whether prophylactic central neck dissection provides any advantages over TT alone. METHODS Retrospective cohort study of patients with PTC without preoperative evidence of lymph node involvement undergoing either TT or TT with bilateral central lymph node dissection (TT + BCLND). RESULTS From 2002 to 2009, 143 patients with clinically node-negative PTC underwent either TT (n = 65) or TT + BCLND (n = 78). The groups were similar in age, gender, tumor size, multifocality, angioinvasion, and metastasis/age/completeness-of-resection/invasion/size score. The presence of involved central neck lymph nodes upstaged 28.6% of patients in the TT + BCLND group to stage III disease, which resulted in higher radioactive iodine ablation doses. Stimulated serum thyroglobulin levels and the number of patients with undetectable stimulated thyroglobulin levels before and 1 year after radioactive iodine ablation were equivalent. CONCLUSION The addition of routine central lymph node dissection to TT for the treatment of PTC upstages nearly one third of patients over the age of 45 thereby changing the dose of radioactive iodine ablative therapy, but does not change postoperative thyroglobulin levels after completion of radioiodine treatment.

The most commonly occurring papillary thyroid cancer in the United States is now a microcarcinoma in a patient older than 45 years.

BACKGROUND The incidence of papillary thyroid cancer (PTC) is growing at a faster rate than any other malignancy. However, it is unknown what effect age is having on the changing PTC incidence rates. With the goal of understanding the role of age in thyroid cancer incidence, this study analyzes the changing demographics of patients with PTC over the past three decades. METHODS This was a retrospective evaluation of the incidence rates of PTC from 1973 to 2006 reported by the National Cancer Institutes Surveillance, Epidemiology, and End Results database. RESULTS From 1973-2006 the age group most commonly found to have PTC has shifted from patients in their 30s to patients in the 40-50-year-old age group. In 1973 60% of PTC cases were found in patients younger than 45, and the majority of cases continued to occur in younger patients until 1999. After 1999 PTC became more common in patients older than 45 years, and in 2006, 61% of PTC cases were in patients older than 45 years. From 1988 to 2003 there has been an increasing incidence of all sizes of PTC in all age groups with the largest increase in tumors <1 cm in patients older than 45. Forty-three percent of tumors in patients older than 45 are now <1 cm, whereas only 34% are <1 cm in patients younger than 45. Of the nearly 20,000 thyroid cancer cases in 2003, 24% were microcarcinomas in patients over the age of 45. CONCLUSIONS The incidence of PTC is increasing disproportionally in patients older than 45 years. The number of PTC tumors smaller than 1 cm is increasing in all age groups, and now the most commonly found PTC tumor in the United States is a microcarcinoma in a patient older than 45 years. These changing patterns relating age and incidence have important prognostic and treatment implications for patients with PTC.

Feasibility of surgeon-performed transcutaneous vocal cord ultrasonography in identifying vocal cord mobility: A multi-institutional experience

BACKGROUND Transcutaneous vocal cord ultrasonography (TVCUS) is a noninvasive study used to identify true vocal cord (TVC) mobility. Its sensitivity in predicting TVC paralysis when compared with indirect flexible laryngoscopy (IFL) ranges from 62 to 93%. This study aimed to evaluate the feasibility of surgeon-performed TVCUS in assessing TVC mobility in the outpatient setting. METHODS At 5 institutions, 510 consecutive patients underwent 887 TVCUS performed by 8 surgeons during initial surgical evaluation. IFL was obtained in selected patients. TVCUS was repeated during the first postoperative visit, and IFL was obtained only when judged necessary. Clinical parameters were collected and later correlated with TVC visualization. RESULTS TVC visualization was possible in 688 of 887 TVCUS (77%); visibility ranged from 41 to 86% among performing surgeons. IFL was done in 81 patients (16%) and TVCUS predicted TVC paralysis in all cases when TVC were seen. TVC visualization was possible more often in females than males (83% vs 17%; P < .0005) and in patients without thyroid cartilage calcification than those with calcification (83% vs 42%; P < .0005). CONCLUSION Experienced surgeon-ultrasonographers can use TVCUS to visualize TVC in most female patients and less so in males. TVCUS is highly sensitive, but operator dependent. This study demonstrates the feasibility of TVCUS and directs further attention to defining its optimal role in assessment of TVC mobility.

Central Neck Dissection for Papillary Thyroid Cancer

BACKGROUND Central compartment lymph node dissection is a common adjunct to thyroidectomy in the treatment of papillary thyroid cancer. The indications, surgical technique, potential benefits, and operative risks of this procedure should be clearly defined in order to provide optimal care to these patients. METHODS A systematic review of the literature and an analysis of evidence-based recommendations were performed regarding central neck node dissection for patients with papillary thyroid carcinoma. RESULTS Cervical nodal metastasis in papillary thyroid cancer is a common occurrence. The presence of metastasis is associated with increased recurrence rates and may decrease survival. Detection of central and lateral neck nodal metastasis preoperatively with clinical examination and cervical ultrasound is important in determining the appropriate initial surgical management. Level VI neck dissection and central neck dissection are terms often used interchangeably to describe surgical excision of all lymph nodes from the hyoid bone to the sternal notch between the carotid arteries, but the addition of the superior mediastinal lymph nodes in compartment VII should be included in the central neck dissection. Due to improved recurrence rates and survival, therapeutic central neck dissection is recommended for all patients with nodal involvement detected pre- or intraoperatively. Prophylactic central neck dissection in patients without detectable nodal disease remains a controversial topic due to a lack of definitive evidence of improved recurrence rates or survival and the possibility of higher complication rates compared to total thyroidectomy alone. Reoperative central nodal dissection can be a challenging procedure with increased complication rates but with good outcomes in experienced centers. CONCLUSIONS Central neck lymph node dissection plays an important role in the appropriate treatment of papillary thyroid cancer at initial presentation and in cases of recurrent disease. Surgeons caring for this group of patients should have familiarity and skill with this procedure.

The Effect of Extent of Surgery and Number of Lymph Node Metastases on Overall Survival in Patients with Medullary Thyroid Cancer

CONTEXT Total thyroidectomy with central lymph node dissection is recommended in patients with medullary thyroid cancer (MTC). However, the relationship between disease severity and extent of resection on overall survival remains unknown. OBJECTIVE The aim of the study was to identify the effect of surgery on overall survival in MTC patients. METHODS Using data from 2968 patients with MTC diagnosed between 1998 and 2005 from the National Cancer Database, we determined the relationship between the number of cervical lymph node metastases, tumor size, distant metastases, and extent of surgery on overall survival in patients with MTC. RESULTS Older patient age (5.69 [95% CI, 3.34-9.72]), larger tumor size (2.89 [95% CI, 2.14-3.90]), presence of distant metastases (5.68 [95% CI, 4.61-6.99]), and number of positive regional lymph nodes (for ≥16 lymph nodes, 3.40 [95% CI, 2.41-4.79]) were independently associated with decreased survival. Overall survival rate for patients with cervical lymph nodes resected and negative, cervical lymph nodes not resected, and 1-5, 6-10, 11-16, and ≥16 cervical lymph node metastases was 90, 76, 74, 61, 69, and 55%, respectively. There was no difference in survival based on surgical intervention in patients with tumor size ≤ 2 cm without distant metastases. In patients with tumor size > 2.0 cm and no distant metastases, all surgical treatments resulted in a significant improvement in survival compared to no surgery (P < .001). In patients with distant metastases, only total thyroidectomy with regional lymph node resection resulted in a significant improvement in survival (P < .001). CONCLUSIONS The number of lymph node metastases should be incorporated into MTC staging. The extent of surgery in patients with MTC should be tailored to tumor size and distant metastases.

Pasireotide (SOM230) is effective for the treatment of pancreatic neuroendocrine tumors (PNETs) in a multiple endocrine neoplasia type 1 (MEN1) conditional knockout mouse model

BACKGROUND Pasireotide (SOM230), a long-acting somatostatin analogue (LAR), has improved agonist activity at somatostatin receptors. We tested the effect of SOM230 on insulin secretion, serum glucose concentrations, tumor growth, and survival using an MEN1 transgenic mouse model. METHODS Eight 12-month-old conditional Men1 knockout mice with insulinoma were assessed. The treatment (n = 4) and control groups (n = 4) received monthly subcutaneous injections of SOM230 or PBS. Serum insulin and glucose levels were determined by enzyme-linked immunosorbent assay and enzymatic colorimetric assay, respectively. Tumor activity, growth, and apoptosis were determined by microPET/CT scan and histologic analysis. RESULTS On day 7, there was a decrease in serum insulin levels from 1.06 ± 0.28 μg/L to 0.37 ± 0.17 μg/L (P = .0128) and a significant increase in serum glucose from 4.2 ± 0.45 mmol/L to 7.12 ± 1.06 mmol/L (P = .0075) in the treatment group but no change in the control group. Tumor size was less in the treatment group (2,098 ± 388 μm(2)) compared with the control group (7,067 ± 955 μm(2); P = .0024). Furthermore, apoptosis was increased in the treatment group (6.9 ± 1.23%) compared with the control group (0.29 ± 0.103%; P = .002). CONCLUSION SOM230 demonstrates antisecretory, antiproliferative, and proapoptotic activity in our MEN1 model of insulinoma. Further studies of the effects of SOM230 in PNET patients with MEN1 mutations are warranted.

Factors in conversion from minimally invasive parathyroidectomy to bilateral parathyroid exploration for primary hyperparathyroidism

BACKGROUND Ongoing experience has documented equivalence of minimally invasive parathyroidectomy (MIP) and standard bilateral parathyroid exploration (BPE) for primary hyperparathyroidism in most patients; however, intraoperative conversion of MIP to BPE is required for multiple indications. This study analyzes the factors, predictors, and cure rates in converted MIP. METHODS We retrospectively analyzed a database of 1,002 patients undergoing initial parathyroidectomy for primary hyperparathyroidism from 2008 to 2011 for rate of successful MIP, converted MIP, planned BPE, and factors leading to conversion from MIP to BPE. RESULTS Of 989 included parathyroidectomies, 647 (65%) were successful MIP, 186 (19%) were converted MIP, and 156 (16%) were planned BPE. The most common indication for conversion included intraoperative parathyroid hormone (IOPTH) criteria not met (46%), localization incorrect (36%), and evidence of multigland disease (17%). Converted MIP had lower preoperative calcium and PTH and lower baseline IOPTH compared with successful MIP. Complication rates were similar; however, rates of persistent hyperparathyroidism were highest in converted MIPs (6%) versus planned BPEs (3%) and successful MIPs (2%; P < .01). CONCLUSION Patients requiring conversion of MIP to BPE have lower preoperative serum calcium and PTH levels, a less dramatic decrease in IOPTH, and a greater rate of persistent disease than successful MIP.

Using the ACMGE Milestones as a Handover Tool From Medical School to Surgery Residency

OBJECTIVE To map current medical school assessments for graduating students to the Accreditation Council for Graduate Medical Education (ACGME) milestones in general surgery, and to pass forward individual performance metrics on level 1 milestones to receiving residency programs. DESIGN The study included 20 senior medical students who were accepted into surgery internship positions. Data from medical school performance assessments from the third-year surgery clerkship, fourth-year surgery rotations, fourth-year surgery boot camp, Clinical Competency Assessment Examination, and United States Medical Licensing Examination (USMLE) Step 1 and 2 examinations were used to map each students competency assessments to the General Surgery Milestones based on a scoring system created and validated by independent assessors. This Milestones Assessment was then provided to each students receiving program director. SETTING The study was conducted at the University of Michigan Medical School, in Ann Arbor, Michigan. PARTICIPANTS Fourth-year medical students entering into surgical internship. RESULTS Of 16 Accreditation Council for Graduate Medical Education (ACGME) General Surgery Milestones subcompetencies, 12 were able to be evaluated with current medical school assessments. Of the 20 students, 11 met criteria for all the level 1 milestones and 9 needed improvement in at least 1 domain. CONCLUSIONS It was feasible to use medical school assessments to feed forward information about senior medical students on 12 of the 16 General Surgery Milestones subcompetency domains.

Population-Based Assessment of Complications following Surgery for Thyroid Cancer.

Context As thyroid cancer incidence rises, more patients undergo thyroid surgery. Although postoperative complication rates have been reported in single institution studies, population-based data are limited. Objective To determine thyroid cancer surgery complication rates and identify at-risk populations. Design/Setting/Patients Using the Surveillance, Epidemiology, and End Results-Medicare database, we evaluated general complications within 30 days and thyroid surgery-specific complications within 1 year in 27,912 patients who underwent surgery for differentiated or medullary thyroid cancer between 1998 and 2011. Multivariable analyses of patient characteristics associated with postoperative complications were performed. Main Outcome Measures General and thyroid surgery-specific complications. Results Overall, 1820 (6.5%) patients developed general postoperative complications and 3427 (12.3%) developed thyroid surgery-specific complications. In multivariable analyses, general and thyroid surgery-specific complications were significantly higher in patients >65 years [odds ratio (OR), 2.61; 95% confidence interval (CI), 2.31 to 2.95; OR, 3.12; 95% CI, 2.85 to 3.42], those with a Charlson/Deyo comorbidity score of 1 (OR, 2.40; 95% CI, 1.66 to 3.49; OR, 1.88; 95% CI, 1.53 to 2.31) and ≥2 (OR, 7.05; 95% CI, 5.33 to 9.56; OR, 3.62; 95% CI, 3.11 to 4.25), and those with regional (OR, 1.18; 95% CI, 1.03 to 1.35; OR, 1.31; 95% CI, 1.19 to 1.45) or distant disease (OR, 2.83; 95% CI, 2.30 to 3.47; OR, 1.85; 95% CI, 1.54 to 2.21), respectively. Conclusions The rates of thyroid cancer surgery complications are higher than predicted, and patients with older age, more comorbidities, and advanced disease are at greatest risk. Efforts to reduce complications are needed.

Applied clinical anatomy: the successful integration of anatomy into specialty-specific senior electives

PurposeA strong foundation in anatomical knowledge is essential for physicians in all fields. Despite this established importance, anatomy continues to be primarily taught only during the pre-clinical years of medical school. Senior medical students have more mature clinical reasoning and analytical skills; therefore, advanced anatomy courses have great potential to integrate basic and clinical sciences to better prepare senior medical students for residency.MethodsAt our institution, five electives have been implemented that integrate anatomical education in clinical contexts in the fields of emergency medicine, musculoskeletal medicine, radiology, surgery, and obstetrics and gynecology. These 4-week courses are all offered in the spring of the final year of medical school. The course curricula, content, and evaluation data are described for each of the courses.ResultsThe five electives have been extremely popular at our institution, and all have been consistently filled each year by students entering diverse disciplines. Course evaluations have been positive and students specifically note how these courses allow them the opportunity to integrate basic anatomical knowledge into clinical contexts. Students have marked improvement in anatomical knowledge after completion of these electives.ConclusionsAdvanced anatomy courses that integrate anatomical education with clinical reasoning are important curricular innovations that are popular with students and lead to important improvements in anatomical knowledge. Anatomists can lead the charge for better integration of basic sciences into senior medical school curricula.