J. F. Henry

Morbidity of prophylactic lymph node dissection in the central neck area in patients with papillary thyroid carcinoma

Abstract The benefits of prophylactic central neck dissection (PCND) in patients with papillary thyroid carcinoma (PTC) have not been clearly demonstrated so far and should be weighed against the potential risks of the procedure. The aim of the study was to assess the recurrent laryngeal nerve and parathyroid risks of PCND after total thyroidectomy in patients with PTC and to compare the results with those obtained in patients who underwent total thyroidectomy only. Methods: We selected 100 patients who underwent a total thyroidectomy: 50 for nontoxic benign multinodular goiter (Group 1) and 50 for PTC (Group 2). Patients with PTC had no evidence of macroscopic lymph node invasion during surgery and underwent, in addition to the total thyroidectomy, a PCND. All of the 100 patients were operated on by two experienced endocrine surgeons. All patients had pre- and postoperative investigations of vocal cord movements. Calcemia and phosphoremia were systematically evaluated preoperatively and on day 1 and day 2 after surgery. All patients presenting a postoperative calcemia below 1.90 mmol/l were considered to present an early postoperative hypoparathyroidism and received calcium-vitamin D therapy. The hypoparathyroidism was considered permanent when calcium-vitamin D therapy was still necessary 1 year after surgery. Results: None of the patients presented permanent nerve palsy. There were three cases of transient nerve palsy (6%) in Group 1 and two (4%) in Group 2. In Group 1 there was no permanent hypoparathyroidism and four cases of transient hypoparathyroidism (8%). In Group 2, seven patients presented transient hypoparathyroidism (14%) and two patients (4%) remained with definitive hypoparathyroidism. Conclusion: After total thyroidectomy for PTC, PCND does not increase recurrent laryngeal nerve morbidity but it is responsible for a high rate of hypoparathyroidism, especially in the early postoperative course. Even taking into account the possible benefits, the results make it difficult to advocate PCND as a routine procedure in all patients presenting a PTC.

Quality of life changes and clinical outcomes in thyroid cancer patients undergoing radioiodine remnant ablation (RRA) with recombinant human TSH (rhTSH): a randomized controlled study

Background  Recombinant human TSH (rhTSH) has become the modality of choice for radioiodine remnant ablation (RRA) in low‐risk thyroid cancer patients.

The role of 18F‐FDOPA and 18F‐FDG–PET in the management of malignant and multifocal phaeochromocytomas

Background  18F‐DOPA has emerged as a promising tool in the localization of chromaffin‐tissue‐derived tumours. Interestingly, phaeochromocytomas (PHEO) are also FDG avid.

Limited Value of 18F-F-DOPA PET to Localize Pancreatic Insulin-Secreting Tumors in Adults with Hyperinsulinemic Hypoglycemia

CONTEXT Fluorine-18-L-dihydroxyphenylalanine positron emission tomography (18F-FDOPA PET) imaging is increasingly used in the workup of neuroendocrine tumors. It has been shown to be an accurate tool in the diagnosis of congenital hyperinsulinism, but limited information is available on its value in adult disease. OBJECTIVE, PATIENTS, AND DESIGN: The objective of this study was to review our experience with 18F-FDOPA PET imaging in six consecutive patients with hyperinsulinemic hypoglycemia (HH) (four solitary insulinomas, one diffuse beta-cell hyperplasia, one malignant insulinoma). 18F-FDOPA uptake was also evaluated in 37 patients (43 procedures) without HH or other pancreatic neuroendocrine tumors, which acted as a control group. RESULTS Using visual analysis, 18F-FDOPA-PET proved positive in only one case (a multiple endocrine neoplasia type 1 related insulinoma). In diffuse beta-cell hyperplasia, the pancreatic uptake was similar to controls. In the patient with liver metastases, the extent of disease was underestimated. The pancreatic uptake was not statistically different between controls and hyperinsulinemic patients. The main limitation for identifying insulinomas or beta-cell hyperplasia in adults appears to be to the 18F-FDOPA uptake and retention in the whole pancreas. This drawback is potentially circumvented in focal hyperplasia in newborns due to a lower aromatic amino acid decarboxylase expression in the extralesional pancreatic parenchyma. CONCLUSIONS 18F-FDOPA PET is of limited value in localizing pancreatic insulin secreting tumors in adult HH. Our results contrast with the referential study and require further analysis.

Intraoperative diagnosis and treatment of parathyroid cancer and atypical parathyroid adenoma

Distinction of parathyroid cancer from atypical parathyroid adenoma (APA) at operation is difficult. The aim of this study was to determine whether parathyroid cancer and APA have different operative findings and long‐term outcomes.

Iodine Biokinetics and Radioiodine Exposure after Recombinant Human Thyrotropin-Assisted Remnant Ablation in Comparison with Thyroid Hormone Withdrawal

CONTEXT A few prospective studies have evaluated the use of recombinant human TSH (rhTSH) for radioiodine remnant ablation. OBJECTIVE Our objective was to compare the effects of the both TSH regimens on iodine biokinetics in the thyroid remnant, dosimetry, and radiation protection. DESIGN We conducted a prospective randomized study. MATERIALS AND METHODS Eighty-eight patients were enrolled for radioiodine ablation to either the hypothyroid or rhTSH arms. A whole-body scan was performed at 48 and 144 h after therapy. Dose rates were assessed at 24, 48, and 144 h. Urinary samples were obtained during the first 48 h. Thyroglobulin was assessed before and after therapy. Iodine biokinetics in the remnants were calculated from gamma-count rates. Radiation-absorbed dose was calculated using OLINDA software. Exposure estimation was based on a validated model. RESULTS The effective half-life in the remnant thyroid tissue was significantly longer after rhTSH than during hypothyroidism (P = 0.01), whereas 48-h (131)I uptakes and residence times were similar. After therapy, thyroglobulin release (a marker of cell damage) was lower in the rhTSH arm. The mean total-body effective half-life and residence time were shorter in patients treated after rhTSH. Residence time was also lower for the colon and stomach. Absorbed dose estimates were lower in the rhTSH arm for the lower large intestine, breasts, ovaries, and the bone marrow. Dose rates at the time of discharge were lower in the rhTSH group with a reduction in cumulative radiation exposure to contact persons. CONCLUSIONS In comparison with thyroid hormone withdrawal, rhTSH is associated with longer remnant half-life of radioactive iodine while also reducing radiation exposure to the rest of the body and also to the general public who come in contact with such patients.

Leçons retenues après 274 surrénalectomies laparoscopiques

Aims: To define the role of minimally invasive videoassisted surgery in the surgical management of adrenal disease and discuss the respective indications of the trans and retroperitoneal video assisted approaches. Materials and Methods: During the last 8 years (1994–2001), 330 adrenalectomies were performed in 305 patients: 274 (83%) laparoscopic approaches and 56 (17%) open approach. Open surgery was reserved for patients presenting with large or malignant tumours (29 cases), multiple and/or extraadrenal phaeochromocytomas (13 cases), previous intraabdominal intestinal surgery (10 cases), and in those requiring concomitant intraabdominal surgery (4 cases). Laparoscopic adrenalectomy was performed using the lateral transperitoneal approach for 89 Conn’s syndrome, 67 Cushing’s syndrome, 2 virilising tumours, 51 phaeochromocytomas and 65 non secretory tumours greater than 4 cm in diameter. Nineteen patients underwent bilateral adrenalectomy. Results: There were no deaths. Twenty patients (7.3%) had a complication. Eleven cases required open conversion (4%) because of difficulties with dissection (8 cases), peroperative suspicion of malignancy (2 cases), and one pneumothorax. The average size of tumours was 34 mm (7–110 mm). There were 18 malignant tumours (6.5%): 8 adrenocortical carcinomas, 1 leiomyosarcoma, and 9 metastases. All patients with hormonally secreting tumours were cured of their endocrinopathy. There was 1 death secondary to hepatic metastases in a patient with an adrenocortical carcinoma. Conclusion: Most adrenal tumours are suitable for video assisted excision. The only absolute contraindication is an invasive carcinoma requiring an extended excision. The lateral, transperitoneal approach is the most suitable for tumours greater than 5–6 cm in diameter. Both the transperitoneal or retroperitoneal approaches are suitable for smaller tumours depending on operator choice and experience. However in the presence of a large right lobe of liver or previous intraabdominal surgery the retroperitoneal approach may be preferable.

Comparison of [111In]pentetreotide‐SPECT and [18F]FDOPA‐PET in the localization of extra‐adrenal paragangliomas: the case for a patient‐tailored use of nuclear imaging modalities

Aims and methods  The aim of this prospective study was to compare the diagnostic value of [18F]FDOPA‐PET and [111In]pentetreotide‐SPECT somatostatin receptor scintigraphy (SRS) in patients with nonmetastatic extra‐adrenal paragangliomas (PGLs). Twenty‐five consecutive unrelated patients who were known or suspected of having nonmetastatic extra‐adrenal PGLs were prospectively evaluated with SRS and [18F]FDOPA‐PET. 131I‐MIBG and [18F]FDG‐PET were added to the work‐up in patients with a personal or familial history of PGL, predisposing mutations, abdominal PGLs, metanephrine hypersecretion and abdominal foci on SRS and/or [18F]FDOPA‐PET.

Utility of malignancy markers in fine-needle aspiration cytology of thyroid nodules: comparison of Hector Battifora mesothelial antigen-1, thyroid peroxidase and dipeptidyl aminopeptidase IV

The purpose of this study was to compare the diagnostic interest of Hector Battifora mesothelial antigen-1 (HBME-1), thyroid peroxidase (TPO), and dipeptidyl aminopeptidase IV (DPP4) in thyroid fine-needle aspirates obtained from 200 resected thyroid lesions (55 colloid nodules, 54 follicular adenomas, 59 papillary cancers, and 32 follicular carcinomas). Hector Battifora mesothelial antigen-1 or TPO expression (% positive cells) and DPP4 staining score (12-point scale) were evaluated. Receiver operating characteristic (ROC) curves were plotted and optimal cutoff values for diagnosing malignancy were determined. The TPO ROC curve was consistently higher than the HBME-1 ROC curve. The TPO curve was also higher than the DPP4 curve with regard to sensitivity, but dipped below the DPP4 curve with regard to specificity. Using a cutoff value of <80% positive cells for TPO, >10% positive cells for HBME-1, and staining score ⩾1 for DPP4, sensitivity to specificity ratios were 98–83% for TPO, 90–60% for HBME-1, and 88–80% for DPP4. Two particularly interesting findings of this study were the low negative likelihood ratio of TPO (0.02) allowing highly reliable exclusion of malignancy and the 100% specificity of DPP4 staining scores=12. Due to poor performance on follicular lesions, HBME-1 showed no advantage over TPO or DPP4.

Lymph node involvement in macroscopic medullary thyroid carcinoma

Medullary thyroid carcinoma (MTC) is a rare disease, with variable tendency to lymphatic spread. The aim of this retrospective study was to identify distinctive features of large MTC with and without nodal metastases.