Geoffrey B. Thompson

Papillary thyroid carcinoma managed at the Mayo Clinic during six decades (1940-1999): Temporal trends in initial therapy and long-term outcome in 2444 consecutively treated patients

It is uncertain whether more extensive primary surgery and increasing use of radioiodine remnant ablation (RRA) for papillary thyroid carcinoma (PTC) have resulted in improved rates of cause-specific mortality (CSM) and tumor recurrence (TR). Details of the initial presentation, therapy, and outcome of 2444 PTC patients consecutively treated during 1940–1999 were recorded in a computerized database. Patients were followed for more than 43,000 patient-years. The 25-year rates for CSM and TR were 5% and 14%, respectively. Temporal trends were analyzed for six decades. During the six decades, the proportion with initial MACIS (distant Metastasis, patient Age, Completeness of resection, local Invasion, and tumor Size) scores <6 were 77%, 82%, 84%, 86%, 85%, and 82%, respectively (p = 0.06). Lobectomy accounted for 70% of initial procedures during 1940–1949 and 22% during 1950–1959; during 1960–1999 bilateral lobar resection (BLR) accounted for 91% of surgeries (p <0.001). RRA after BLR was performed during 1950–1969 in 3% but increased to 18%, 57%, and 46% in successive decades (p <0.001). The 40-year rates for CSM and TR during 1940–1949 were significantly higher (p = 0.002) than during 1950–1999. During the last 50 years the 10-year CSM and TR rates for the 2286 cases did not significantly change with successive decades. Moreover, the 10-year rates for CSM and TR were not significantly improved during the last five decades of the study, either for the 1917 MACIS <6 patients or the 369 MACIS ? 6 patients. Increasing use of RRA has not apparently improved the already excellent outcome, achieved before 1970, in low risk (MACIS <6) PTC patients managed by near-total thyroidectomy and conservative nodal excision.

Laparoscopic versus open posterior adrenalectomy: a case-control study of 100 patients.

BACKGROUND Few controlled studies have compared laparoscopic transabdominal adrenalectomy (LA) to conventional open posterior adrenalectomy (PA). METHODS Five patients have undergone successful LA at our institution between 1992 and 1996. A matched case-control study of 50 PA patients was performed during a similar time period. RESULTS Follow-up was complete in 82% of patients with a mean follow-up time of 25 months. There were no statistically significant differences between the LA and PA groups with regard to the following demographic features: age, gender, endocrine disorder, side and size of tumor, and body habitus. Statistically significant differences (p < 0.05), however, were present (LA vs PA) when we compared the following results: mean hospital stay (3.1 versus 5.7 days), narcotic equivalents (28 versus 48), return to normal activity (3.8 versus 7 weeks), patient satisfaction (9 versus 7 [scale 1 to 10, 10 being most satisfied]), late morbidity (0 versus 54%), and operating room time (167 versus 127 minutes). Median hospital charges (

Unilateral total lobectomy: Is it sufficient surgical treatment for patients with AMES low-risk papillary thyroid carcinoma?

7,000 versus

Management Guidelines for Children with Thyroid Nodules and Differentiated Thyroid Cancer.

6,000) were slightly higher in the LA group (p = 0.05). CONCLUSIONS Although LA is technically more demanding and slightly more expensive to perform, advances appear to exist for LA with regard to patient comfort, patient satisfaction, hospital stay, and return to normal daily activities. Late incisional complications are dramatically less in the LA group.

Gushing syndrome doe to ectopic adrenocorticotropic hormone secretion

BACKGROUND Controversy continues regarding the optimal extent of primary thyroid resection in most patients with papillary thyroid carcinoma (PTC), who are at minimal risk of cause-specific mortality (CSM). This study was designed to compare CSM and recurrence rates after either unilateral lobectomy (UL) or bilateral lobar resection (BLR) in patients with PTC considered low risk by AMES criteria. METHODS Outcome was studied in 1685 patients initially treated during 1940 through 1991 and followed for up to 54 postoperative years (mean, 18 years). One thousand six hundred fifty-six patients (98%) had complete primary tumor resection; 634 (38%) had involvement of regional nodes. One hundred ninety-five patients (12%) had UL; BLR accounted for 1468 (near-total 60%; total thyroidectomy 18%). RESULTS Thirty-year rates for CSM and distant metastasis were 2% and 3%, respectively. Twenty-year rates for local recurrence and nodal metastasis were 4% and 8%, respectively. There were no significant differences in CSM or distant metastasis rates between UL and BLR (P > .2). After UL, 20-year rates for local recurrence and nodal metastasis were 14% and 19%, significantly higher (P = .0001) than the 2% and 6% rates seen after BLR. CONCLUSIONS UL was not associated with higher CSM rates, but it was associated with a significantly higher risk of locoregional recurrence. Thus BLR probably represents a preferable initial surgical approach to patients with low-risk PTC.

Secular Trends in the Presentation and Management of Functioning Insulinoma at the Mayo Clinic, 1987–2007

BACKGROUND Previous guidelines for the management of thyroid nodules and cancers were geared toward adults. Compared with thyroid neoplasms in adults, however, those in the pediatric population exhibit differences in pathophysiology, clinical presentation, and long-term outcomes. Furthermore, therapy that may be recommended for an adult may not be appropriate for a child who is at low risk for death but at higher risk for long-term harm from overly aggressive treatment. For these reasons, unique guidelines for children and adolescents with thyroid tumors are needed. METHODS A task force commissioned by the American Thyroid Association (ATA) developed a series of clinically relevant questions pertaining to the management of children with thyroid nodules and differentiated thyroid cancer (DTC). Using an extensive literature search, primarily focused on studies that included subjects ≤18 years of age, the task force identified and reviewed relevant articles through April 2014. Recommendations were made based upon scientific evidence and expert opinion and were graded using a modified schema from the United States Preventive Services Task Force. RESULTS These inaugural guidelines provide recommendations for the evaluation and management of thyroid nodules in children and adolescents, including the role and interpretation of ultrasound, fine-needle aspiration cytology, and the management of benign nodules. Recommendations for the evaluation, treatment, and follow-up of children and adolescents with DTC are outlined and include preoperative staging, surgical management, postoperative staging, the role of radioactive iodine therapy, and goals for thyrotropin suppression. Management algorithms are proposed and separate recommendations for papillary and follicular thyroid cancers are provided. CONCLUSIONS In response to our charge as an independent task force appointed by the ATA, we developed recommendations based on scientific evidence and expert opinion for the management of thyroid nodules and DTC in children and adolescents. In our opinion, these represent the current optimal care for children and adolescents with these conditions.

Complications of Central Neck Dissection in Patients with Papillary Thyroid Carcinoma: Results of a Study on 1087 Patients and Review of the Literature

Gushing syndrome (CS) caused by ectopic adrenocorticotropic hormone (ACTH) production (EA) poses major challenges diagnostically by mimicking the pituitary-dependent form of CS and therapeutically by producing severe, life-threatening hypercortisolemia. This retrospective follow-up study describes the clinical characteristics and course of EA in a large referral center. Computer-based cross-index codes for EA, CS, and bilateral adrenalectomy were used to identify patients treated at the Mayo Clinic between 1956 and 1998. EA was confirmed in 106 patients. Gender distribution showed a slight female predominance (61:45). Bronchial carcinoid was the most frequent cause of EA (25%), followed by islet cell cancer (16%), small-cell lung carcinoma (11%), medullary thyroid cancer (8%), disseminated neuroendocrine tumor of unknown primary source (7%), thymic carcinoid (5%), pheochromocytoma (3%), disseminated gastrointestinal carcinoid (1%), and other tumors (8%). No tumor was found in 16% of patients. Altogether, 28 patients were managed medically, and the others underwent curative tumor resection (13 patients) or bilateral adrenalectomy (65 patients). Surgically treated patients had longer survival, but this was most likely affected by treatment bias. The diagnoses of CS and ACTH-secreting neoplasm were usually concurrent, although, there were remarkable cases in which the two conditions were diagnosed several years apart. Curative resection of the tumor producing EA was possible in a small proportion of patients (12%). When curative resection is not possible, patients who are reasonable surgical candidates are likely to benefit from adrenalectomy. Additional experience with bilateral laparoscopic adrenalectomy should increase the number of patients who benefit from adrenal-directed surgery.RésuméLe syndrome de Cushing (SC) par production exotopique d’ACTH (ACTHe) pose un problème majeur soit au plan diagnostique car l’ACTHe peut simuler une forme hypophyse-dépendante du SC ou au plan thérapeutique en produisant une hypercortisolémie sévère menaçant le pronostique vital. Cette étude rétrospective de suivi décrit les caractéristiques clinque et l’évolution de l’ACTHe dans un grand centre de référence. Par un système de codes indexés, croisés, pour «ACTHe», «SC» et «surrénalectomie bilatérale», on a pu recenser sur l’ordinateur tous les patients traités à la clinique Mayo entre 1956 et 1998. Une sécrétion d’ACTHe a été identifiée chez 106 patients. Le sexe ratio a été de 61 femmes pour 45 hommes. La tumeur bronchique carcinoïde a été la source la plus fréquente de sécrétion ACTHe (25%), suivie de cancer des lots du pancréas (16%), le carcinome à petites cellules du poumon (11%), le cancer médullaire de la thyroïde (8%), la tumeur neuroendocrine disséminée de source primitive inconnue (7%), le carcinoïde thymique (5%), le phéochromocytome (3%), le carcinoïde gastrointestinale disséminé (1%), et d’autres (8%). Aucune tumeur n’a été retrouvé chez 16% des patients. Vingt-huit patients ont été pris en charge médicalement, et les autres ont eu soit une résection de tumeur à visée curative (13 patients) soit une surrénalectomie bilatérale (65 patients). La survie des patients traités chirurgicalement était plus longue mais il s’agissait certainement d’un effet de biais de traitement. Habituellement on fait le diagnostic de SC et de néoplasme avec ACTHe de façon simultanée, cependant, il y avait deux cas inhabituels car le deuxième diagnostic a été fait plusieurs années après le premier. La résection à visée curative de la tumeur produisant de l’ACTHe a été possible chez seulement 12% des patients. Même lorsqu’une résection à visée curative n’est pas possible, les patients qui sont des candidats raisonnables à la chirurgie tireront un certain bénéfice de la surrénalectomie quand même. Une expérience croissante de la surrénalectomie bilatérale par laparoscopic devrait augmenter le nombre de patients qui peuvent bénéficier de la chirurgie de la surrénale.ResumenEl Sindrome de Cushing (SC) causado por producciön ectöpica de ACTH (AE) significa un desafio mayor tanto desde el punto de vista diagnöstico, por cuanto simula el SC dependiente de la hipöfisis, como desde el punto de vista terapéutico, por cuanto produce una hipercortisolemia potencialmente fatal. El présente estudio retrospectivo describe las caracterîsticas y la evolution clînica de la AE en un centro médico de referenda, la Clînica Mayo. Se utilizaron cödigos computadorizados para el SC, la AE y la adrenalectomîa bilateral para identificar los pacientes tratados entre 1956 y 1998. Se confirmé AE en 106 casos. La distribution por sexos moströ ligero predominio femenino (61: 45). El carcinoide bronquial apareciö como la causa mas frecuente de AE (25%), seguido por cancer de céulas insulares (16%), Carcinoma pulmonar de células pequenas (11%). cancer medular de tiroides (8%), tumor neuroendocrine diseminado de origen desconocido (7%), carcinoide timico (5%), feocromocitoma (3%), carcinoide gastrointestinal diseminado (1%) y otros tumores (8%). No se hallo tumor en 16% de los pacientes. Veintiocho casos fueron manejados médicamente, y el resto fue sometido a resection curativa del tumor (13 casos) o a adrenalectomîa bilateral (65 casos). Los pacientes tratados quirûrgicamente exhibieron supervivencia mas prolongada, pero esto probablemente se debe a sesgo terapéutico. Los diagnösticos de SC y de neoplasmas secretores de ACTH usualmente fueron concurrentes; sin embargo, se presentaron casos en que las dos condiciones fueron diagnosticadas con intervalo de anos. La resection curativa del tumor productor de AE fue posible apenas en una proportion menor de pacientes (12%). Cuando no es posible la resection curativa, aquellos pacientes de riesgo quirûrgico razonable se pueden beneficiar con una adrenalectomîa. La mayor experiencia con adrenalectormîa bilateral laparoscöpica debe incrementar el numéro de pacientes que pueden recibir bénéficie) de la cirugïa enfocada a las suprarrenales.

Malignant potential of solid pseudopapillary neoplasm of the pancreas

OBJECTIVE The objective of the study was to assess changes in the presentation and diagnostic and radiological evaluation of patients with surgically confirmed insulinoma at the Mayo Clinic 1987-2007. METHODS A retrospective analysis of patients with insulinoma was conducted. Patients with prior gastric bypass were excluded. RESULTS A total of 237 patients [135 women (57%)] were identified. Hypoglycemia was reported solely in the fasting state in 73%, the fasting and postprandial state in 21%, and exclusively postprandially in 6%. There was a predominance of men in the postprandial symptom group. Considering the period of study by quartile, outpatient evaluation increased from 35 to 83% and successful preoperative localization improved from 74 to 100% comparing the first to the fourth quartiles. Although the rates of localization by noninvasive techniques remained static at approximately 75%, the addition of invasive modalities has resulted in successful preoperative localization in all patients in the past 10 yr. The sensitivity and specificity of the established diagnostic criteria using insulin, C-peptide, proinsulin, beta-hydroxybutyrate, and glucose response to iv glucagon were greater than 90% and greater than 70%, respectively. CONCLUSIONS Although fasting hypoglycemia is characteristic of patients with insulinoma, postprandial symptoms have been reported with increasing, albeit low, frequency. Trends in the evaluation and preoperative management include a shift to outpatient diagnostic testing, an emphasis on successful preoperative localization to avoid blind pancreatic exploration, and a validation of the diagnostic criteria for hyperinsulinemic hypoglycemia.

Are patients with multiple endocrine neoplasia type I prone to premature death

BACKGROUND Prophylactic central neck dissection (CND) has been proposed in the treatment of patients affected by papillary thyroid carcinoma (PTC) with clinically negative neck lymph nodes. The procedure allows pathologic staging of lymph nodes of the central compartment and treatment of the micrometastases. Nevertheless, the morbidity that its routine use adds to the total thyroidectomy must be taken into account. The aim of this study was to characterize the morbidity that CND adds to the total thyroidectomy. METHODS This was a retrospective study of 1087 patients with PTC and clinically negative neck lymph nodes. Patients were divided into three study groups: Group A, total thyroidectomy; Group B, total thyroidectomy and ipsilateral CND; Group C, total thyroidectomy and bilateral CND. Primary endpoints of the study were evaluated by comparing the rates of transient and permanent recurrent laryngeal nerve (RLN) injury and hypoparathyroidism in the three study groups. RESULTS Analysis of data showed no significant differences in the rate of transient (Group A: 3.6%, Group B: 3.9%, and Group C: 5.5%; p=0.404) and permanent (Group A: 1%, Group B: 0.5%, and Group C: 2.3%; p=0.099) RLN injury between the three study groups. Both ipsilateral CND and bilateral CND were associated with a higher rate of transient hypoparathyroidism (Group: A 27.7%, Group B: 36.1%, and Group C: 51.9%; p=0.014; odds ratio [OR]: 1.477; 95% confidence interval [CI]: 1.091-2.001; p<0.001; OR: 2.827; 95% CI: 2.065-3.870, respectively). Bilateral CND had a higher rate of permanent hypoparathyroidism (Group A: 6.3%, Group B: 7%, and Group C: 16.2%; p<0.001; OR: 2.860; 95% CI: 1.725-4.743). CONCLUSIONS The increased rates of transient and permanent hypoparathyroidism in our series suggest a critical review of indications for the routine use of prophylactic CND for PTC. Prophylactic CND ipsilateral to the tumor associated with total thyroidectomy may represent an effective strategy for reducing the rate of permanent hypoparathyroidism. Concomitant completion contralateral paratracheal lymph node neck dissection should be performed in presence of lymph node metastasis on intraoperative frozen-section pathology. This approach limits the use of bilateral CND to patients with intraoperative pathological findings of lymph node metastases.

The effects of the alveolar recruitment maneuver and positive end-expiratory pressure on arterial oxygenation during laparoscopic bariatric surgery.

Solid pseudopapillary neoplasms of the pancreas are rare malignant lesions of the pancreas that typically occur in young women. Large series from any one centre are notably absent in the literature. The aim of this study was to determine long‐term outcomes of operative therapy.