Gilbert G. Fareau

A Single Parathyroid Hormone Level Obtained 4 Hours after Total Thyroidectomy Predicts the Need for Postoperative Calcium Supplementation

BACKGROUND Parathyroid hormone (PTH) levels after total thyroidectomy have been shown to predict the development of symptomatic hypocalcemia and the need for calcium supplementation. This study aimed to determine whether a PTH level drawn 4 hours postoperatively is as effective as a level drawn on postoperative day 1 (POD1) in predicting this need. STUDY DESIGN This is a single-institution retrospective review of 4-hour and POD1 PTH levels in patients who underwent total thyroidectomy from January 2012 to September 2012. If POD1 PTH was ≥10 pg/mL, patients did not routinely receive supplementation; if PTH was <10 pg/mL, patients received oral calcium with or without calcitriol. RESULTS Of 77 patients, 20 (26%) had a 4-hour PTH <10 pg/mL; 18 (90%) of these patients had a POD1 PTH <10 pg/mL. No patient with a 4-hour PTH ≥10 pg/mL had a POD1 PTH <10 pg/mL. All 18 patients with POD1 PTH <10 pg/mL received calcium supplementation. Three additional patients received supplementation due to reported symptoms or surgeon preference. A 4-hour PTH ≥10 pg/mL compared with a POD1 PTH had a similar ability to predict which patients would not need calcium supplementation; sensitivity was 98% vs 98%, specificity was 90% vs 86%, and and negative predictive value was 95% vs 95%. Of 21 patients who received supplementation, 13 (62%) also received calcitriol, including 9 patients (69%) with a 4-hour PTH <6 pg/mL. CONCLUSIONS A single PTH level obtained 4 hours after total thyroidectomy that is ≥10 pg/mL accurately identifies patients who do not need calcium supplementation or additional monitoring of serum calcium levels. Same-day discharge, if deemed safe, can be accomplished with or without calcium supplementation based on the 4-hour PTH level. Greater consideration should be given to calcitriol supplementation in patients with a 4-hour PTH <6 pg/mL.

Systemic chemotherapy for adrenocortical carcinoma: comparative responses to conventional first-line therapies.

The objective of this study was to evaluate and compare the efficacies of conventional first-line chemotherapies for adrenocortical carcinoma. We reviewed the records of adult patients (≥17 years) who had received first-line systemic chemotherapy with serial pretreatment and posttreatment radiologic staging studies in our institution between 1980 and 2000. Overall survival (OS) and time to progression (TTP) for different treatment groups were determined using the Kaplan–Meier method and were compared using the log-rank test. Univariate and multivariate models were fitted to different subsets of patients for OS and TTP and used to calculate hazard ratios (HRs) with 95% confidence intervals. We identified 224 patients with a diagnosis of adrenocortical carcinoma, 57 of whom met the inclusion criteria for further study. Chemotherapy groups included: mitotane (n=12), platinum and etoposide (n=16), mitotane with platinum and etoposide (n=11), mitotane and other cytotoxics (n=5), platinum and etoposide with other cytotoxics (n=3), and other miscellaneous cytotoxics (n=10). No statistically significant differences in OS (P=0.31) were noted among the treatment groups, but there was a statistically significant difference in TTP (P=0.02) favoring mitotane alone (TTP=6.24 months; 95% confidence interval, 3.58–32.13). Multivariate analysis was most notable for a significantly greater OS (HR=0.49, P=0.04) and TTP (HR=0.3, P=0.01) associated with peritoneal metastases. Our analysis revealed no clear advantage for any single agent or combination over any of the other conventional frontline chemotherapeutic choices for adrenocortical carcinoma. Novel agents are thus sorely needed in the treatment of this aggressive cancer.

Institutional experience with lateral neck dissections for thyroid cancer

INTRODUCTION Compartment-oriented neck dissection is recommended for patients with evidence of thyroid cancer metastases to lateral compartment lymph nodes. This study reviews the outcomes of patients who underwent lateral neck dissections (LND) at a high-volume institution. METHODS This is a retrospective review of patients who underwent LND for metastatic thyroid cancer from January 2009 to June 2014. Preoperative evaluation, operative findings, and postoperative outcomes were analyzed. RESULTS Ninety-six patients underwent 127 LNDs. Fine-needle aspiration (FNA) confirmed metastases in 82 lateral necks (65%). The remaining 45 LNDs (35%) were performed based on clinical suspicion of metastases; 29 (64%) had metastases on final pathology. Twenty patients had 26 complications, which included chyle leak (7 [6%]), spinal accessory nerve dysfunction (7 [6%]), neck seroma requiring drainage (2 [2%]), and surgical site infection (10 [8%]). CONCLUSION LND is associated with a risk of early postoperative morbidity, but long-term complications are uncommon in the hands of experienced surgeons. In patients with thyroid cancer, a comprehensive preoperative evaluation of the lateral neck with physical examination, ultrasonography, and possible FNA should be performed. For those with suspicion of metastases, LND can be an important therapeutic option, but discussion with the patient regarding potential risks and benefits is essential.

Diagnostic challenges in adrenocortical carcinoma: recommendations for surveillance after surgical resection of selected adrenal nodules.

OBJECTIVE To discuss challenges in the diagnosis of adrenocortical carcinoma and to suggest surveillance measures after removal of selected adrenal nodules. METHODS We present the case of a 65-year-old man with worsening hypertension and new-onset hypokalemia attributed to primary hyperaldosteronism due to a 3-cm right adrenal nodule. RESULTS A laparoscopic right adrenalectomy was performed, and the histologic diagnosis was a benign adenoma. The patients hypertension and hypokalemia improved postoperatively but recurred 8 months later, and florid Cushings syndrome developed. Magnetic resonance imaging showed an 8-cm mass in the right adrenal bed and multiple hepatic metastatic lesions. Fine-needle biopsy confirmed the presence of adrenocortical carcinoma. CONCLUSION Despite a comprehensive biochemical, radiologic, and histologic assessment, the diagnosis of adrenocortical carcinoma can be missed. Particularly, we caution against undue reliance on the initial tumor size. We recommend that abdominal imaging be performed every 3 months for the first year and every 6 months for the second year after surgical removal of selected adrenal nodules.

Oncocytic papillary thyroid cancer has similar prognosis to matched classical papillary thyroid cancer controls

BACKGROUND Previous studies have suggested that oncocytic variant papillary thyroid carcinoma (PTC) may be more aggressive, with higher rates of recurrent disease. The aim of this study was to evaluate characteristics and outcomes of patients with oncocytic variant PTC compared to classical PTC. METHODS Patients with oncocytic variant PTC were retrospectively identified from 519 patients who underwent thyroidectomy for PTC between January 2009 and August 2015. Data collected included patient demographics, laboratory and pathology findings, imaging studies, treatment, and follow-up. Patients were matched 1:1 by age, sex, and TNM stage with patients who underwent total thyroidectomy for classical PTC during the same time period. RESULTS The cohort included 21 patients, of whom 18 (86%) were female, with a median age of 53 years (range 23-68 years). All patients underwent total thyroidectomy, and 17 (81%) had a central compartment neck dissection (8 [38%] prophylactic). The median tumor size was 2.0 cm (range 0.9-6.5 cm), and four (19%) patients had extrathyroidal extension. There was no significant difference in histopathologic characteristics, including extrathyroidal extension and lymphovascular invasion, between the two groups except for an increased incidence of thyroiditis in oncocytic variant PTC (90.5% vs. 57%; p = 0.01). In oncocytic variant PTC patients who underwent central compartment neck dissection, malignant lymph nodes were found in 12 (57%) patients compared to 13 (62%) classical (p = 0.75). Lateral neck dissection was performed in 5 (24%) oncocytic variant and classical PTC patients, with metastatic lymphadenopathy found in four (a median of four malignant lymph nodes; range 1-6) and five (a median of 2.5 malignant lymph nodes; range 1-9), respectively. Radioactive iodine was administered to 18 (86%) oncocytic variant PTC and 18 (86%) classical PTC patients. At a median follow-up of 51 months (interquartile range 38-61), one oncocytic variant PTC patient had recurrent disease and underwent reoperation at 24 months. In classical PTC patients with a median follow-up time of 77 months (range 56-87 months), two (9.5%) patients had detectable thyroglobulin levels indicating early recurrence, but neither has undergone reoperation. CONCLUSIONS Oncocytic variant PTC was present in 5% of PTC patients. Most (95%) patients remain disease-free at four years, similar to classical PTC outcomes, suggesting that oncocytic variant may not represent a more aggressive variant.

Management of Patients with Metastatic Medullary Thyroid Carcinoma: The Role for Systemic Therapy

Medullary thyroid carcinoma (MTC) is an uncommon neuroendocrine malignancy that arises from the parafollicular C-cells of the thyroid gland and which frequency metastasizes to local and distant sites. Although often slowly growing, progressive metastatic disease is the cause of death in most patients with advanced MTC and the prognosis typically falls between that of differentiated follicular epithelial and anaplastic forms of thyroid cancer. In the past, effective treatment options were lacking for patients with advanced MTC, since only minimal response rates were seen with the use of traditional cytotoxic agents. However, recent elucidation of key intracellular signaling cascades that contribute to tumorigenesis has fostered development of small molecule kinase inhibitors that offer effective therapeutic options for patients with progressive disease. While these novel agents have had a profound effect on the management of advanced MTC, standardization of practice is challenged by the relative rarity of this tumor and the infrequent need for systemic therapy . This chapter outlines a suggested approach to the use of systemic therapy in progressive metastatic MTC.

Menopausal Health After Breast Cancer

The gradual decline in estrogen production that follows menopause often contributes to significant climacteric symptoms, accelerated bone loss, and cardiovascular morbidity. Estrogen replacement can prevent or reverse many postmenopausal morbidities and has been widely used for several decades. The concern that researchers in early studies may have been hasty in their conclusions about the safety of estrogen replacement has prompted the reassessment of old data and further analyses of large groups of women. These new analyses take into consideration age, estrogen formulation, and duration of estrogen administration as risk factors for breast cancer. An emerging consensus is that very prolonged estrogen use may contribute to breast cancer risk. The suggestion that women who have previously undergone treatment for breast cancer should not receive exogenous estrogen has constituted one area of general agreement for many years. Accordingly, alternative strategies have been developed to address postmenopausal health needs for breast cancer survivors. However, this proscription has been challenged in recent years because both the population characteristics and health needs of women with a prior diagnosis of breast cancer have been changing. Recent information about the outcome of women who elect to take estrogen after breast cancer as well as those who develop breast cancer while taking estrogen is contributing to the emerging opinion that decisions regarding estrogen may be individualized in some cases.