Jie-Jen Lee

Phyllodes Tumor of the Breast: The Challenge Persists

IntroductionPhyllodes tumors of the breast are uncommon, and it is difficult to predict biologic behavior based on clinicopathologic features. Despite the wealth of data on the factors to predict recurrence, little is known about the impact of treatment refinements. This study seeks to define changes in patient characteristics, histopathologic parameters, and outcome between the two periods before and after the care of patients with breast diseases was centralized to a breast specialty.MethodsThe records of 182 patients with phyllodes tumors managed surgically were reviewed. Patients treated from 1985 to 1996 (n = 81) were compared with those seen from 1997 to 2004 (n = 101).ResultsThe analysis of the two treatment periods revealed that there was a decrease in tumor size at diagnosis, from 7.7 cm during the earlier period to 4.6 cm during the recent period (P = 0.003). The patients undergoing breast-conserving surgery were significantly increased during the recent period. In contrast, pathologic features and local recurrence rates remained unchanged during the study period. Multivariate analysis revealed that positive surgical margin was the only independent predictor of recurrence, with an increased hazard of 8.0. Overall, upgrading to the next grade was observed in 16% of recurrences.ConclusionsBreast-conserving surgery with clear margins is the current treatment of choice for phyllodes tumors, but this strategy does not further reduce local recurrence effectively. Optimal management continues to be a challenge.

Blood neutrophil‐to‐lymphocyte ratio correlates with tumor size in patients with differentiated thyroid cancer

Inflammation has been implicated in the initiation and progression of thyroid cancer. Neutrophil‐to‐lymphocyte ratio (NLR) is a simple index of systemic inflammatory response, and has been shown to be a prognostic indicator in some types of cancer. The aim of this study was to examine the relationship between NLR and clinicopathological features in patients with differentiated thyroid cancer.

Preoperative Ultrasonography Assessment of Vocal Cord Movement During Thyroid and Parathyroid Surgery

BackgroundPreoperative detection of vocal cord palsy is important in thyroid and parathyroid surgery. However, routine fiberoptic laryngoscopy may bring patients unnecessary discomfort. The aim of this study was to determine the feasibility of using surgeon-performed ultrasonography (US) as a screening tool for preoperative assessment of vocal cord movement.MethodsIn the first phase, patients had both laryngoscopic and US examination before surgery. In the second phase, patients had US evaluation first. Those with abnormal vocal cord movement on US, with invisible cord movement, or presenting with significant vocal symptoms underwent laryngeal examination.ResultsIn all, 93 (82xa0%) of 114 patients had successful US evaluation of vocal cord movement during the first phase. Two of them had vocal cord paralysis. In the second phase, vocal cord movement could be evaluated by US in 349 (84xa0%) of 415 patients. Four patients with abnormal movement were confirmed to have vocal cord palsy by laryngoscopy. None of 46 symptomatic patients with normal movement on US had vocal cord palsy. One other patient whose cord movement could not be seen by US had vocal cord palsy on laryngoscopic examination.ConclusionsSurgeon-performed US appears to be a relatively accurate method for assessing vocal cord movement in the preoperative setting. It can be used to select patients to undergo laryngoscopic examination before thyroidectomy and parathyroidectomy.

Clinicopathologic significance of leptin and leptin receptor expressions in papillary thyroid carcinoma

BACKGROUNDnEpidemiologic studies have shown that obesity is associated with an increased risk of thyroid cancer. Leptin, an adipocyte-derived cytokine, can act as a growth factor on certain normal and transformed cells. Aberrant expression of leptin or leptin receptor has been detected in some types of cancer. The aim of this study is to determine immunohistochemical expression of leptin and leptin receptor in papillary thyroid cancer to investigate the relationship between their expression and clinicopathologic features.nnnMETHODSnThe expression of leptin and leptin receptor was assessed in 49 primary neoplasms and 15 lymph node metastases using a semiquantitative immunohistochemical staining method.nnnRESULTSnLeptin and leptin receptor were expressed in 37% and 51% of papillary thyroid cancer, respectively. They were not expressed in normal follicles. In the primary neoplasms and the metastatic nodes, expression of leptin correlated closely with leptin receptor (P < .001 for the primary neoplasms and P = .017 for nodal metastases). Expression of either protein was associated with greater neoplasm size (leptin expression, 32.0 +/- 10.7 vs 20.5 +/- 8.4 mm; P = .001; leptin receptor expression, 27.9 +/- 11.5 vs 21.4 +/- 9.0 mm; P = .032). Coexpression of leptin and leptin receptor in primary neoplasms had greater incidence of lymph node metastasis (P = .038).nnnCONCLUSIONnExpression of leptin and/or leptin receptor in papillary thyroid cancer is associated with neoplasm aggressiveness, including tumor size and lymph node metastasis.

Characterization of thyroid nodules using the proposed thyroid imaging reporting and data system (TI-RADS)†

The Thyroid Imaging Reporting and Data System (TI‐RADS) was proposed based on a scheme similar to Breast Imaging Reporting and Data System (BI‐RADS) lexicon used in breast lesions. The purpose of this study was to evaluate its interobserver variability and accuracy.

Expression and Biologic Significance of Adiponectin Receptors in Papillary Thyroid Carcinoma

Obesity is associated with a higher incidence of thyroid cancer. Adiponectin is one of the most abundant adipokines with a pleiotropic role in metabolism and in the development and progression of cancer. It has been shown that circulating adiponectin level is inversely associated with the risk of thyroid cancer. This study aimed to investigate the possible association between the expression of adiponectin receptors (AdipoR1 and AdipoR2) and clinicopathological variables in papillary thyroid cancer. We found that protein levels of AdipoR1 and AdipoR2 were increased in some thyroid cancer specimens compared with adjacent normal thyroid tissues. Thyroid cancer cells expressed AdipoR1 and AdipoR2, which were attenuated by histone deacetylase inhibitors valproic acid and trichostatin A. Adiponectin stimulated AMP-activated protein kinase phosphorylation in thyroid cancer cells. We further determined the expression of AdipoR1 and AdipoR2 by immunohistochemical staining in primary tumor samples and metastatic lymph nodes. AdipoR1 was expressed in 27xa0% of primary tumors and AdipoR2 in 47xa0%. Negative expression of both adiponectin receptors was significantly associated with extrathyroidal invasion, multicentricity, and higher TNM stage. There was a trend toward decreased disease-free survival in patients with negative tumor expression of AdipoR1 and AdipoR2 (log-rank Pxa0=xa00.051). Collectively, overexpression of adiponectin receptors was observed in some tumor tissues of papillary thyroid cancer and was associated with a better prognosis.

Factors associated with prolonged stay after laparoscopic cholecystectomy in elderly patients

BackgroundLaparoscopic cholecystectomy in elderly patients has been linked to higher complication rates and longer lengths of stay. The purpose of this study was to identify risk factors associated with prolonged postoperative hospitalization in elderly patients undergoing laparoscopic cholecystectomy.MethodsThe records of 287 patients aged 65 years or older, who underwent successful laparoscopic cholecystectomy between January 2001 and July 2006, were retrospectively reviewed. Clinical data was abstracted from the chart and compared between patients with a shorter or longer postoperative stay.ResultsThe median postoperative hospital stay was three days (interquartile range 3–5). Forty-eight patients had complications, with an overall morbidity of 16% and mortality of 0.7%. The only independent predictor of prolonged postoperative stay was the occurrence of any major complication [odds ratio, 3.144; 95% confidence interval (CI), 1.882–5.251]. The physiological and operative severity score for the enumeration of mortality and morbidity (POSSUM) and underlying chronic obstructive pulmonary disease were independently associated with major complications.ConclusionsA major complication is the most important cause of prolonged hospital stay after laparoscopic cholecystectomy in the elderly. No specific comorbidity has direct impact on the duration of hospitalization, but pulmonary disease is associated with increased risk of major complications.

Gender Differences Among Patients with Secondary Hyperparathyroidism Undergoing Parathyroidectomy

OBJECTIVEnFemale gender is associated with an increased risk of parathyroid nodular hyperplasia and parathyroidectomy rate in dialysis patients. The purpose of this study was to assess differences between women and men undergoing parathyroidectomy for secondary hyperparathyroidism.nnnMETHODSnWe reviewed 121 consecutive patients with end-stage renal disease and advanced secondary hyperparathyroidism who underwent parathyroidectomy between 2004 and 2007. Preoperative characteristics and short-term outcome of these patients were evaluated.nnnRESULTSnCompared with men (n = 43), women (n = 78) had lower preoperative bone mineral density (both T-scores and Z-scores) as well as lower preoperative hemoglobin levels. The cause of renal failure was also different between the two groups. No differences in preoperative calcium-phosphorus product, alkaline phosphatase, or parathyroid hormone levels were observed. Follow-up analysis showed that biochemical improvement and 1-y recurrence rate was similar between genders.nnnCONCLUSIONnWomen with secondary hyperparathyroidism had worse bone mineral metabolism before parathyroidectomy. Additional research regarding target organ susceptibility to hyperparathyroidism in different genders is warranted.

Perioperative Care of the Elderly

SUMMARY The geriatric population is growing in number and complexity in modern surgical practice. This challenging group presents differences in physiology and outcomes that make a more comprehensive and multidisciplinary approach necessary. This review emphasizes the meticulous assessment and preparation in all facets before surgery, including a thorough examination, nutrition evaluation and intervention, and preoperative optimization of pulmonary function and cardiovascular hemodynamics. This article highlights the importance of age-related pharmacokinetic and pharmacodynamic considerations, effective pain control, as well as prevention and treatment of hypothermia, fluid and electrolyte imbalance, and postoperative delirium. The vulnerable elderly patient with multiple medical problems and functional impairment is best served by a surgeon with a particular interest and working knowledge of the changes associated with aging and the physiology of surgery and anesthesia. [International Journal of Gerontology 2007; 1(2): 89–97]

Prolonged Hospital Stay After Parathyroidectomy for Secondary Hyperparathyroidism

BackgroundProtracted hypocalcemia is the most common complication after parathyroidectomy for secondary hyperparathyroidism. Several parameters have been identified to predict the degree of postoperative hypocalcemia. The purpose of this study was to determine whether there were any factors associated with prolonged hospitalization in these patients.MethodsA total of 81 consecutive patients with end-stage renal disease and advanced secondary hyperparathyroidism who underwent parathyroidectomy between January 2004 and December 2006 were studied. The postoperative calcium infusion protocol and discharge criteria were standardized. Clinical variables were compared between patients with a shorter or longer postoperative stay.ResultsThe mean postoperative hospital stay was 5.6xa0days. Preoperative alkaline phosphatase levels were significantly higher in patients with a longer stay (pxa0=xa00.035). In a linear regression model, the postoperative length of stay was moderately but significantly correlated with preoperative alkaline phosphatase levels (R2xa0=xa00.254; pxa0<xa00.001). Receiver operating characteristic analysis showed a significant area under the curve (0.678; 95% confidence interval 0.550–0.805; pxa0=xa00.014). With a cutoff of preoperative alkaline phosphatase levels at 200xa0IU/L, the sensitivity was 0.57 and the specificity was 0.59 for predicting a prolonged stay.ConclusionsA high preoperative alkaline phosphatase level is significantly associated with prolonged hospital stay in patients undergoing parathyroidectomy for secondary hyperparathyroidism.