Jason A. Glenn

Curative surgical resection of adrenocortical carcinoma: Determining long-term outcome based on conditional disease-free probability

Objective: To evaluate conditional disease-free survival (CDFS) for patients who underwent curative intent surgery for adrenocortical carcinoma (ACC). Background: ACC is a rare but aggressive tumor. Survival estimates are usually reported as survival from the time of surgery. CDFS estimates may be more clinically relevant by accounting for the changing likelihood of disease-free survival (DFS) according to time elapsed after surgery. Methods: CDFS was assessed using a multi-institutional cohort of patients. Cox proportional hazards models were used to evaluate factors associated with DFS. Three-year CDFS (CDFS3) estimates at “x” year after surgery were calculated as follows: CDFS3 = DFS(x+3)/DFS(x). Results: One hundred ninety-two patients were included in the study cohort; median patient age was 52 years. On presentation, 36% of patients had a functional tumor and median size was 11.5 cm. Most patients underwent R0 resection (75%) and 9% had N1 disease. Overall 1-, 3-, and 5-year DFS was 59%, 34%, and 22%, respectively. Using CDFS estimates, the probability of remaining disease free for an additional 3 years given that the patient had survived without disease at 1, 3, and 5 years, was 43%, 53%, and 70%, respectively. Patients with less favorable prognosis at baseline demonstrated the greatest increase in CDFS3 over time (eg, capsular invasion: 28%–88%, &Dgr;60% vs no capsular invasion: 51%–87%, &Dgr;36%). Conclusions: DFS estimates for patients with ACC improved dramatically over time, in particular among patients with initial worse prognoses. CDFS estimates may provide more clinically relevant information about the changing likelihood of DFS over time.

Actual 10-year survivors following resection of adrenocortical carcinoma

Adrenocortical carcinoma (ACC) is a rare and aggressive malignancy with limited therapeutic options beyond surgical resection. The characteristics of actual long‐term survivors following surgical resection for ACC have not been previously reported.

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.

Association between body mass index and multigland primary hyperparathyroidism.

INTRODUCTION Multigland disease (MGD) accounts for 15% of sporadic primary hyperparathyroidism (pHPT). Several studies have reported a link between obesity and calcium metabolism (e.g., increased incidence of pHPT, higher levels of parathyroid hormone, lower vitamin D levels, and larger parathyroid glands). Obese patients have also been shown to require reoperation for persistent/recurrent pHPT more often than nonobese controls. We hypothesize that obese patients may have a higher prevalence of MGD. METHODS This was a retrospective review of a prospectively collected parathyroid database that included adult patients with sporadic pHPT, who underwent initial parathyroidectomy between 1999 and 2013. Demographic, clinicopathologic, operative, and laboratory data were assessed for associations with MGD. RESULTS Of 1305 consecutive patients, 200 (15%) had MGD. Median age was 59 y. Univariate analyses demonstrated that MGD was associated with age > 60 y, higher body mass index (BMI), history of lithium therapy, lower 24-h urine calcium excretion, higher serum alkaline phosphatase levels, and smaller size of the first excised parathyroid gland. On multivariate analyses, predictors of MGD were BMI 30-39.9 kg/m(2) (odds ratio [OR] 1.5; 95% confidence interval [CI] 1.2-2.5), BMI ≥ 40 kg/m(2) (OR 1.8; 95% CI 1.3-3.1), and smaller size of the first excised parathyroid (OR 0.7; 95% CI 0.6-0.8). CONCLUSIONS This study demonstrates a higher incidence of MGD in obese and morbidly obese patients. Due to a higher risk of MGD, surgeons should have a lower threshold to perform bilateral exploration in obese patients, especially if the first excised parathyroid gland is relatively small.

Longitudinal patterns of recurrence in patients with adrenocortical carcinoma

Background: Patterns and prognostic implications of recurrent adrenocortical carcinoma are poorly understood. In this study, we aim to describe temporal and spatial patterns of adrenocortical carcinoma recurrence. Methods: This is a retrospective review of 576 patients with adrenocortical carcinoma evaluated at a single institution. Clinicopathologic and follow‐up data were collected longitudinally. Results: A total of 354 patients underwent resection of stage I‐III adrenocortical carcinoma. We found that 249 (70%) patients developed disease recurrence. The median recurrence‐free interval after primary resection was 11 months. The most common sites of initial recurrence were lung and tumor bed. The shortest time to recurrence was associated with lung or multiple site metastases. We found that 142 of 249 patients developed one or more additional sites of recurrence (median 5 months), most commonly involving the lungs. A total of 20 patients developed a third site of recurrence. We found that 100 patients underwent one or more reoperations or metastasectomies and 79 recurred again after reoperation. Same organ or site recurrence was common after reoperation (67%). Although lung metastases occurred early, recurrences to the peritoneal cavity or to multiple sites were associated with worse survival. Metastasectomy beyond three total operations did not improve overall survival. Conclusion: Survival varies according to site of recurrence and other clinicopathologic factors. Knowledge of patterns of recurrence may assist in anticipating disease course and lead to better informed selection of treatment.

Initial Total Thyroidectomy Versus Lobectomy with Intraoperative Frozen Section for Thyroid Nodules That Are “Suspicious for PTC”

The optimal surgical management for a thyroid nodule that is ‘suspicious for papillary thyroid carcinoma (PTC)’ remains unclear. Surgical options include (1) lobectomy with intraoperative frozen section or (2) initial total thyroidectomy. To help address this clinical question we employ the GRADE approach. The current literature was reviewed, and outcomes were assessed for their impact on clinical decision-making as related to thyroid surgery. Based on our review of the literature, it is clear that there is currently a paucity of high-to-moderate quality evidence regarding the treatment of patients with thyroid nodules that are ‘suspicious for PTC’. Important aspects to consider in the decision-making process are (1) accuracy of diagnosis and (2) relative risk of surgery. When considering the available evidence, assuming relatively low complication rates by experienced surgeons, initial total thyroidectomy may be recommended.

Surgical Management of Recurrent Medullary Thyroid Cancer

Medullary thyroid cancer (MTC) is a relatively rare neuroendocrine cancer of the thyroid, accounting for up to 5 % of all thyroid cancers in the USA. Unlike differentiated thyroid cancers, which arise from the follicular cells, MTC arises from the parafollicular, or C-cells, of the thyroid. As a result, MTC is not sensitive to radioactive iodine, and therefore, the initial surgical resection is critical for obtaining biochemical and anatomic control.

Update of the Treatment Guidelines for Well-Differentiated Thyroid Cancer

The goals of clinical practice guidelines are to improve patient care by providing consensus on stage-specific therapies, reduce the use of unnecessary or harmful interventions, and to maximize the chance of treatment benefit at accepted societal costs. The American Thyroid Association (ATA) has published three prior versions of differentiated thyroid cancer (DTC) recommendation guidelines, and is set to release a fourth iteration in the upcoming year. The volume of research that has been performed in the field of thyroid cancer over the past decade has been immense. Therefore, in order to continue to maintain clinical excellence and state-of-the-art practice patterns, guidelines must be frequently updated and controversies perpetually reexamined. In this chapter, we discuss some relevant controversies and we examine some of the more significant updates in the treatment of well-differentiated thyroid cancer, as described by the ATA.