J Klupp

Prognostic factors in patients with differentiated thyroid carcinoma

OBJECTIVEnTo study the prognostic factors in patients with differentiated thyroid carcinoma.nnnDESIGNnRetrospective analysis.nnnSETTINGnUniversity hospital, Germany.nnnPATIENTSn139 consecutive patients who underwent surgery for follicular (n = 42) and papillary thyroid carcinoma (n = 97).nnnMAIN OUTCOME MEASURESnSurvival rate, type of operation (systematic lymphadenectomy or no lymphadenectomy).nnnRESULTSnMedian observation time was 72 months (range 1-203). The 5 and 10 year survival rates in patients with papillary carcinoma were 92% and 89% respectively, and in those with follicular carcinoma 88% and 80%, respectively. Prognostic factors for papillary carcinoma were distant metastases, age, and extrathyroidal growth, and for follicular carcinoma they were distant metastases, extrathyroidal extension, and multifocal growth. The Union International contre le Cancer and European Organisation for Research and Treatment of Cancer scores and the age, grade, extent and size score were all highly significant. The extent of lymphadenectomy, primary or secondary thyroidectomy, and partial or total thyroidectomy did not influence survival.nnnCONCLUSIONnStaging and score systems may be helpful in calculating prognosis in differentiated thyroid carcinoma, but the benefit of systematic lymphadenectomy remains controversial.

Long-term follow-up after recurrence of primary biliary cirrhosis after liver transplantation in 100 patients

Abstract: Orthotopic liver transplantation (OLT) is the only effective curative therapy for end‐stage primary biliary cirrhosis (PBC). Survival after OLT is excellent, although recent data have shown a recurrence rate of PBC of up to 32% after transplantation. The aim of this study is to investigate the course after disease recurrence, particularly with regard to liver function and survival in a long‐term follow‐up. Between April 1989 and April 2003, 1553 liver transplantations were performed in 1415 patients at the Charité, Virchow Clinic. Protocol liver biopsies were taken after one, three, five, seven, 10 and 13u2003yr. One hundred (7%) patients suffered from histologically proven PBC. Primary immunosuppression consisted of cyclosporine (n=54) or tacrolimus (Tac) (n=46). Immediately after OLT, all patients received ursodeoxycholic acid. Corticosteroids were withdrawn three to six months after OLT. The median age of the 85 women and 15 men was 55u2003yr (range 25–66u2003yr). The median follow‐up after liver transplantation was 118 months (range 16–187 months) and after recurrence 30 months (range 4–79 months). Actuarial patient survival after five, 10 and 15u2003yr was 87, 84 and 82% respectively. Ten patients (10%) died after a median survival time of 32 months. Two of these patients developed organ dysfunction owing to recurrence of PBC. Histological recurrence was found in 14 patients (14%) after a median time of 61 months (range 36–122 months). Patients with Tac immunosuppression developed PBC recurrence more often (p<0.05) and also earlier (p<0.05). Fifty‐seven patients developed an acute rejection and two patients a chronic rejection episode. Liver function did not alter within the first fiveu2003yr after histologically proven PBC recurrence. Multivariate analysis of the investigated patients showed that the recipients age and Tac immunosuppression were significant risk factors for PBC recurrence. Long‐term follow‐up of up to 15u2003yr after liver transplantation, owing to PBC, in addition to maintenance of liver function, shows excellent organ and patient survival rates. Although protocol liver biopsies revealed histological recurrence in 14 (14%) patients, only two patients developed graft dysfunction. Tac‐treated patients showed more frequently and also earlier histologically proven PBC recurrence; however, in our population we could not observe an impact on graft dysfunction and patients survival.

MMF and Calcineurin Taper in Recurrent Hepatitis C After Liver Transplantation: Impact on Histological Course

Hepatitis C virus (HCV) recurrence after orthotopic liver transplantation (OLT) is almost universal. The optimal immunosuppression for these patients is still under discussion. We designed a retrospective case‐control study to evaluate the effect of mycophenolate mofetil (MMF) treatment in patients with recurrent hepatitis C.

COMPLICATIONS ASSOCIATED WITH DIFFERENT SURGICAL APPROACHES TO DIFFERENTIATED THYROID CARCINOMA

Introduction: With the good prognosis associated with differentiated carcinoma, the morbidity and mortality of different surgical approaches are of crucial importance. Methods: At the Department of Surgery (Virchow Klinikum Berlin), 139 patients who underwent surgery for differentiated thyroid carcinoma between 1979 and 1994 were reviewed, focussing on postoperative complications. In 113 and 18 patients, respectively, primary and completion thyroidectomy was performed. In five patients, less than total thyroidectomy and in three patients only palliative surgery was carried out. We performed thyroidectomy without systematic lymphadenectomy (LAD) in 70 patients (51.1%). In 15 patients (10.8%), lymphadenectomy of the lateral compartment and, in 53 patients (38.1%), central LAD was performed. LAD did not significantly influence survival time in either follicular (n = 42) or papillary carcinoma (n = 97). Results: No patient died because of postoperative complications. Permanent laryngeal nerve palsy occurred in no patients after thyroidectomy without LAD, in one patient after central LAD (1.9%) and in one patient after lateral LAD (6.7%). Transient laryngeal nerve palsy was seen in ten patients [six (8.6%) after thyroidectomy only, two (3.7%) after central LAD and two (13.3%) after lateral LAD] (P = 0.19). Hypocalcemia was distributed equally within the LAD groups: total transient hypocalcemia could be recorded in 54 patients (38.8%), but permanent hypocalcemia occurred only in one patient (0.7%). Postoperative recovery was delayed in patients when a more radical approach was used (P = 0.03). Conclusion: The magnitude of the benefit of LAD in therapy for differentiated thyroid carcinoma is still controversial. This more radical approach is not necessarily accompanied, however, by higher morbidity and mortality.

Mycophenolate mofetil in combination with tacrolimus versus neoral after liver transplantation

MYCOPHENOLATE mofetil (MMF) is an accepted immunosuppressive agent after kidney transplantation. Possible indications for MMF after liver transplantation include: (1) rejection therapy; (2) reduction of cyclosporine or tacrolimus dosage in patients with nephro-, neuro-, or hepatotoxicity; and (3) early steroid withdrawal. The potential role of additive MMF therapy in patients with HCV cirrhosis has been explored; however, data concerning MMF induction or maintenance therapy are limited.

Right hepatic lobectomy for recurrent cholangitis after combined bile duct and right hepatic artery injury during laparoscopic cholecystectomy: a report of two cases

Background. Bile duct injuries in combination with major vascular injuries may cause serious morbidity and may even require liver resection in some cases. We present two case studies of patients requiring right hepatic lobectomy after bile duct and right hepatic artery injury during laparoscopic cholecystectomy.nPatients. Two patients sustained combined major bile duct and hepatic artery injury during laparoscopic cholecystectomy. Surgical management consisted of immediate hepaticojejunostomy with reconstruction of the artery in one patient and hepaticojejunostomy alone in the other patient. In both cases the initial postoperative course was uncomplicated.n Results. After 4 and 6xa0months both patients suffered recurrent cholangitis due to anastomotic stricture. Both developed secondary biliary cirrhosis and required right hepatic lobectomy with left hepaticojejunostomy. The patients remain well 31xa0months and 4.5xa0years after surgery.nConclusions. The outcome of bile duct reconstruction may be worse in the presence of combined biliary and vascular injuries than in patients with an intact blood supply of the bile ducts. We recommend arterial reconstruction when possible in early recognized injuries to prevent late strictures. Short-term follow-up is most important for early recognition of postoperative strictures and to avoid further complications such as secondary biliary cirrhosis.

Predictive value of intact parathyroid hormone measurement during surgery for renal hyperparathyroidism

Background and aimsIn contrast to that in patients with primary hyperparathyroidism, the value of intraoperative intact parathyroid hormone (iPTH) measurement is still unclear in patients with renal hyperparathyroidism and was, therefore, evaluated in a large cohort of patients.PatientsIntraoperative iPTH measurement was performed in 153 patients with renal hyperparathyroidism (129 with terminal renal failure and 24 with functioning kidney graft). Subtotal and total parathyroidectomy were performed in 123 and 13 patients, respectively, during initial surgery. In patients with recurrent disease (17), the respective hyperfunctioning tissue was removed. Intraoperative blood samples were obtained by puncture of the internal jugular vein before preparation of the parathyroids (PTH0) and 15xa0min after parathyroidectomy (PTH15). iPTH was measured with the Elecsys 2010 system. Postoperative iPTH levels (PTHpost) were determined at postoperative daysxa01 to 3 and at weekxa02. Patients were arbitrarily divided in four groups according to the postoperative iPTH values: 0–25xa0pg/ml (groupxa01), 26–65xa0pg/ml (groupxa02), 66–150xa0pg/ml (groupxa03) and more than 150xa0pg/ml (groupxa04).ResultsThe mean PTH0 value was 869±57xa0pg/ml, which decreased to 167±15xa0pg/ml at PTH15. The mean relative PTH15 value was 21.6±1.7%. Postoperatively, iPTH decreased to 42±9xa0pg/ml. The postoperative iPTH value of the 129 patients with terminal renal failure was 25xa0pg/ml or less in 99 patients, 26–65xa0pg/ml in 11 patients, 66–150xa0pg/ml in eight patients and higher than 150xa0pg/ml in 11 patients. Two successive criteria of iPTH decrease were used: first, a PTH15 of ≤150xa0pg/ml or, second, a relative PTH15 of ≤30% less was used. Fifteen patients did not fulfil both criteria. In 13 of them (86.7%) iPTHpost was higher than 65xa0pg (true failure to decline). Of 114 patients who fulfilled the criteria, 108 (94.7%) had normal postoperative iPTH values (true decline). Absolute PTH15 values of less than 150xa0pg/ml predicted normal postoperative iPTH levels in 77 of 78 patients.ConclusionA PTH15 value of 150xa0pg/ml or less predicts operative success in patients with renal failure in 98.7% of cases, independently of the relative decay. In contrast, if the relative PTH15 is higher than 30%, high postoperative PTH values are predicted with a probability of 86.7%. Although there remain some borderline cases, intraoperative iPTH measurement is accurate and also can be useful in patients with renal hyperparathyroidism.

Prevalence of Thyroid Nodules and Carcinomas in Patients Operated on for Renal Hyperparathyroidism: Experience with 339 Consecutive Patients and Review of the Literature

The association between renal hyperparathyroidism (HPT) and differentiated thyroid carcinoma is discussed. To determine the prevalence and potential risk factors, we performed a retrospective analysis of our patients (1998–2004) and compared the data with the data from other surgical and autopsy studies. At our hospital, a total of 347 parathyroidectomies in 339 patients with renal HPT were performed. Most patients underwent preoperative ultrasound investigation of the thyroid gland and, if indicate, thyroid scintigraphy. Intraoperatively, both thyroid lobes were mobilized and palpated. Detected thyroid nodules were adequately resected and investigated histologically. A systematic analysis of the international literature was performed using the PubMed/MEDLINE system to identify publications on the prevalence of papillary thyroid carcinoma (PTC) in patients with renal HPT and in the overall population. Altogether, 133 patients (39.2%) underwent simultaneous thyroid surgery. The initial operation was hemithyroidectomy in 55 (16.2%), Dunhill operation in 36 (10.6%), unilateral subtotal resection in 17 (5.0%), bilateral subtotal resection in 5 (1.5%), and enucleation of a thyroid nodule in 18 (5.3%). A PTC was found in 8 of 339 patients (2.4%) and a follicular thyroid carcinoma in 1. Among 311 patients with primary cervical operation, 6 (1.9%) had a papillary thyroid carcinoma. All papillary tumors were classified as pT1 with a diameter of 1 to 12 mm; three were bifocal, and only one patient had positive lymph nodes. None of the analyzed factors showed a significant correlation with the occurrence of thyroid carcinoma. Depending on the screening method, the prevalence of occult PTC in European autopsy studies ranged from 5% to 9% and was markedly higher in almost all studies than in the present one. The prevalence of PTC in the present study makes an etiologic association between renal HPT and PTC unlikely. The clinical significance of these tumors remains unclear becauses all incidental tumors were small. However, if easily and safely feasible, relevant thyroid nodules should be removed during parathyroid surgery.

Microscopic Tumor Cell Dissemination in Gastric Cancer

PurposeThere is still much controversy surrounding the prognostic significance of microscopic tumor cell dissemination in gastric cancer and its correlation with histopathologic parameters. We herein investigate such dissemination, predominantly restricted to the subserosa, in patients with gastric cancer.MethodsIntraoperative bone marrow aspiration was done in 26 patients undergoing resection of gastric carcinoma. Peritoneal lavage could not be done in 8 of these 26 patients. The R0-resection rate was 84% (n = 22). A cytokeratin-directed antibody and an antibody directed against carcinoembryonic antigen served for the immunocytochemical detection of tumor cells, and the alkaline phosphatase antialkaline phosphatase method was used for visualization.ResultsThe bone marrow aspirate and peritoneal lavage fluid were immunocytochemically positive in 31% and 56% of the patients, respectively. There was a trend (P = 0.10) towards higher overall survival rates in patients with negative bone marrow samples than in those with tumor cells detected in bone marrow samples. Analyzing the results of peritoneal lavage did not reveal any significant differences. In the group of T1/2 cancers, survival was significantly worse if the bone marrow was positive for tumor cells, with 3-year survival rates of 25% vs 77%, respectively (P < 0.05).ConclusionThe rates of tumor cell dissemination into the bone marrow or into the peritoneal cavity were within the scope of previous reports. Dissemination into the bone marrow resulted in significantly impaired survival in patients with T1 and T2 gastric carcinoma, and it did not correlate with known prognostic parameters.

Prognostisch relevante Faktoren beim follikulären Schilddrüsenkarzinom

SummaryThe discussion of the prognosis of follicular thyroid carcinoma is controversial. To evaluate the factors which influence the prognosis we retrospectively analyzed our patients from 1. 1. 1964 to 31. 12. 1987. 76 patients with a follicular thyroid carcinoma were treated during this time. Factors influencing the prognosis were: (1) multiple tumor growth; (2) pT-classification; (3) vascular invasion; (4) tumor stage; (5) degree of cellular differentation and (6) metastases. Because of the prognostic influence of multiple tumor growth and the slight prognostic influence of lymph node metastases we recommend a total thyroidectomy with neck dissection for follicular thyroid carcinoma.ZusammenfassungDie Therapie beim follikulären Schilddrüsenkarzinom wird teilweise kontrovers diskutiert. Zur Überprüfung der für die Prognose relevanten Faktoren wurde das Krankengut der Klinik und Poliklinik für Allgemein- und Abdominalchirurgie der Johannes Gutenberg-Universität Mainz vom 1. 1. 1964 bis zum 31. 12. 1987 retrospektiv analysiert. In diesem Zeitraum wurden 76 Patienten mit einem follikulären Schilddrüsenkarzinom behandelt. Von prognostischer Relevanz waren: 1. ein multifokales Tumorwachstum, 2. die pT-Einteilung, 3. eine Gefäßinvasion, 4. das Tumorstadium, 5. der Differenzierungsgrad, 6. Fernmetastasen. Aufgrund der prognostischen Relevanz eines multifokalen Tumorwachstums sowie eines tendenziellen prognostischen Einflußes von Lymphknotenmetastasen befürworten wir beim follikulären Schilddrüsenkarzinom eine totale Thyreoidektomie mit modifiziert radikaler Neck-dissection.