Jon A. van Heerden

Papillary Thyroid Cancer Treated at the Mayo Clinic, 1946 Through 1970: Initial Manifestations, Pathologic Findings, Therapy, and Outcome

We performed a retrospective study of 859 patients with papillary thyroid cancer, who had received their primary treatment at the Mayo Clinic during the period 1946 through 1970. The maximal follow-up was 39 years. All but 2 patients underwent a thyroid operation; 319 (37%) had metastatic cervical nodes. Of the 800 patients without distant metastatic lesions on initial examination who underwent a potentially curative surgical procedure, postoperatively 7% had nodal metastatic lesions, 6% had a local tumor recurrence, and 5% had a distant metastatic lesion. In patients who had intrathyroidal tumors initially, postoperative local recurrences or distant metastatic lesions resulted in a 10-year cancer mortality of 17 and 41%, respectively; in those with extrathyroidal tumors, postoperative recurrences were associated with significantly higher death rates. Death from thyroid cancer was highly associated with the following factors: age more than 50 years, male sex, tumor size, tumor grade, initial extent of disease, and absence of Hashimotos disease. Earlier studies of Mayo patients treated between 1926 and 1960 described no deaths due to thyroid cancer in patients with occult tumors (1.5 cm or less). Four such patients were identified among our 859 patients; all had been examined and treated after 1961. To date, 56 (6.5%) of the 859 patients have died as a result of papillary thyroid cancer. In this study, in which 16% of patients underwent total thyroidectomy and 3% had radioiodine ablation, the overall mortality observed at 30 years was only 3% above that expected.

Papillary thyroid carcinoma managed at the Mayo Clinic during six decades (1940-1999): Temporal trends in initial therapy and long-term outcome in 2444 consecutively treated patients

It is uncertain whether more extensive primary surgery and increasing use of radioiodine remnant ablation (RRA) for papillary thyroid carcinoma (PTC) have resulted in improved rates of cause-specific mortality (CSM) and tumor recurrence (TR). Details of the initial presentation, therapy, and outcome of 2444 PTC patients consecutively treated during 1940–1999 were recorded in a computerized database. Patients were followed for more than 43,000 patient-years. The 25-year rates for CSM and TR were 5% and 14%, respectively. Temporal trends were analyzed for six decades. During the six decades, the proportion with initial MACIS (distant Metastasis, patient Age, Completeness of resection, local Invasion, and tumor Size) scores <6 were 77%, 82%, 84%, 86%, 85%, and 82%, respectively (p = 0.06). Lobectomy accounted for 70% of initial procedures during 1940–1949 and 22% during 1950–1959; during 1960–1999 bilateral lobar resection (BLR) accounted for 91% of surgeries (p <0.001). RRA after BLR was performed during 1950–1969 in 3% but increased to 18%, 57%, and 46% in successive decades (p <0.001). The 40-year rates for CSM and TR during 1940–1949 were significantly higher (p = 0.002) than during 1950–1999. During the last 50 years the 10-year CSM and TR rates for the 2286 cases did not significantly change with successive decades. Moreover, the 10-year rates for CSM and TR were not significantly improved during the last five decades of the study, either for the 1917 MACIS <6 patients or the 369 MACIS ? 6 patients. Increasing use of RRA has not apparently improved the already excellent outcome, achieved before 1970, in low risk (MACIS <6) PTC patients managed by near-total thyroidectomy and conservative nodal excision.

Laparoscopic versus open posterior adrenalectomy: a case-control study of 100 patients.

BACKGROUND Few controlled studies have compared laparoscopic transabdominal adrenalectomy (LA) to conventional open posterior adrenalectomy (PA). METHODS Five patients have undergone successful LA at our institution between 1992 and 1996. A matched case-control study of 50 PA patients was performed during a similar time period. RESULTS Follow-up was complete in 82% of patients with a mean follow-up time of 25 months. There were no statistically significant differences between the LA and PA groups with regard to the following demographic features: age, gender, endocrine disorder, side and size of tumor, and body habitus. Statistically significant differences (p < 0.05), however, were present (LA vs PA) when we compared the following results: mean hospital stay (3.1 versus 5.7 days), narcotic equivalents (28 versus 48), return to normal activity (3.8 versus 7 weeks), patient satisfaction (9 versus 7 [scale 1 to 10, 10 being most satisfied]), late morbidity (0 versus 54%), and operating room time (167 versus 127 minutes). Median hospital charges (

Unilateral total lobectomy: Is it sufficient surgical treatment for patients with AMES low-risk papillary thyroid carcinoma?

7,000 versus

Fine-Needle Aspiration Biopsy of the Thyroid: The Problem of Suspicious Cytologic Findings

6,000) were slightly higher in the LA group (p = 0.05). CONCLUSIONS Although LA is technically more demanding and slightly more expensive to perform, advances appear to exist for LA with regard to patient comfort, patient satisfaction, hospital stay, and return to normal daily activities. Late incisional complications are dramatically less in the LA group.

PARATHYROID CARCINOMA : CLINICAL AND PATHOLOGIC FEATURES IN 43 PATIENTS

BACKGROUND Controversy continues regarding the optimal extent of primary thyroid resection in most patients with papillary thyroid carcinoma (PTC), who are at minimal risk of cause-specific mortality (CSM). This study was designed to compare CSM and recurrence rates after either unilateral lobectomy (UL) or bilateral lobar resection (BLR) in patients with PTC considered low risk by AMES criteria. METHODS Outcome was studied in 1685 patients initially treated during 1940 through 1991 and followed for up to 54 postoperative years (mean, 18 years). One thousand six hundred fifty-six patients (98%) had complete primary tumor resection; 634 (38%) had involvement of regional nodes. One hundred ninety-five patients (12%) had UL; BLR accounted for 1468 (near-total 60%; total thyroidectomy 18%). RESULTS Thirty-year rates for CSM and distant metastasis were 2% and 3%, respectively. Twenty-year rates for local recurrence and nodal metastasis were 4% and 8%, respectively. There were no significant differences in CSM or distant metastasis rates between UL and BLR (P > .2). After UL, 20-year rates for local recurrence and nodal metastasis were 14% and 19%, significantly higher (P = .0001) than the 2% and 6% rates seen after BLR. CONCLUSIONS UL was not associated with higher CSM rates, but it was associated with a significantly higher risk of locoregional recurrence. Thus BLR probably represents a preferable initial surgical approach to patients with low-risk PTC.

Clinical spectrum and outcome of functional extraadrenal paraganglioma

Cases in which thyroid nodules yielded suspicious cytologic findings on fine-needle aspiration biopsy were prospectively studied during a 3-year period. Of 1970 patients, 333 (17%) had suspicious cytologic findings; from this group, the cases of 253 patients were studied. The cytologic diagnoses were 96 (38%) H urthle cell neoplasms, 84 (33%) follicular cell neoplasms, and 73 (29%) nonspecific diagnoses. A thyroid scan was obtained in 123 of 203 (61%) patients with a solitary nodule, and the nodules were hypofunctional in 102 (83%). Malignant lesions were found in 60 (24%) of the 253 patients. Our findings are consistent with reports that 20% of patients who have a fine-needle aspiration biopsy will have suspicious cytologic findings and that of these, 20% may have a malignant lesion. Thyroid scanning will not distinguish between benign and malignant thyroid lesions that are suspicious on cytologic examination. Surgical excision of all suspicious lesions seems reasonable.

Anaplastic Carcinoma of the Thyroid: A Clinicopathologic Study of 82 Cases

Parathyroid carcinoma accounts for 0.5 to 5% of all cases of hyperparathyroidism. We reviewed the clinical, surgical, and pathologic features observed in all patients with parathyroid carcinoma evaluated at the Mayo Clinic from 1920 through 1991. Forty-three patients (22 women, 21 men; mean age, 54 yrs, range 29-72) were identified, including 2 with familial hyperparathyroidism. Information on initial presentation was available in 40 patients: 15 (38%) presented with polydipsia or polyuria, 11 (27%) with myalgias or arthralgias, 7 (17%) with weight loss, and 4 (10%) with nephrolithiasis; 3 patients (7%) were asymptomatic at presentation. Of 31 patients in whom the initial neck examination was recorded, 14 (45%) had a palpable neck mass. The mean serum calcium and serum phosphorus levels were 14.6 mg/dl and 2.3 mg/dl, respectively. Parathyroid hormone levels were elevated in 21 of 21 patients (mean elevation, 10.2 times upper limit of normal). Complications included nephrolithiasis in 14 of 25 patients (56%), bone disease in 20 of 22 patients (91%) and both in 8 of 15 patients (53%). All patients underwent primary surgical resection of parathyroid carcinoma. Twenty-six of 43 patients (60%) required a second operation with 18 patients requiring multiple re-explorations. At the second operation, residual tumor was found in the neck (68%), mediastinum (16%), or both (12%). Six patients received radiation therapy to the neck (5 patients) or bones (1 patient) for recurrent or metastatic disease. Of these, 1 patient appeared cured of parathyroid carcinoma by radiation therapy 11 years after documented tumor invasion of his trachea. Repeated excision of tumor recurrences was an effective means of controlling hypercalcemia in these patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Gushing syndrome doe to ectopic adrenocorticotropic hormone secretion

Abstract. Functioning extraadrenal paragangliomas represent more than 10% of all pheochromocytomas, occur at diverse anatomic locations, and are said to have a higher malignancy rate than intraadrenal pheochromocytomas. Sixty-six patients had surgery for catecholamine-producing paragangliomas between 1952 and 1992. Median follow-up was 8.8 years. Median age was 40 years (11–67 years); the male/female ratio was 29:37. Familial disease occurred in 9 patients (13.6%), and 10 patients (15.2%) also developed adrenal pheochromocytoma. Solitary paragangliomas occurred in 52 patients: 46 abdominal, 4 thoracic, and 2 head and neck. Fifty-three tumors developed in 14 patients with multiple paragangliomas: 38 abdominal and 15 thoracic. Of 28 patients with solitary tumors undergoing localization studies over the past 10 years accurate localization was achieved in 27. There was one operative death; 15 patients had persistent disease; and 50 were cured postoperatively. Of those cured, nine developed recurrence, disease-free survival being 86%, 80%, and 80% at 5, 10, and 20 years. Metastatic disease was found in 14 patients (21%), 7 of whom have died. An additional 10 patients (15%) had locally invasive disease, of whom 4 have died. Cause-specific survivals at 5, 10, and 20 years were 90%, 83%, and 72%. Risk factors for death from pheochromocytoma were tumor size > 5 cm (p = 0.0002), metastatic disease (p = 0.001), and tumor invasion (p = 0.0023). Cause-specific survival for patients with tumors > 5 cm was 59% at 15 years compared to 100% among patients with tumors ≤ 5 cm (p = 0.0003). Functional paragangliomas are frequently malignant and are associated with a high incidence of persistent or recurrent disease. Tumor size > 5 cm and the occurrence of invasive or metastatic disease are strong predictors of outcome. Most tumors are abdominal, and imaging is highly successful for localization.

Nondiagnostic Thyroid Fine-Needle Aspiration Cytology: Management Dilemmas

Anaplastic carcinoma of the thyroid accounts for about 10% to 15% of all thyroid carcinomas in the United States. Its lethality is evidenced by a 5-year survival rate of 3.6% and a median survival of 4 months. Rapid growth of a thyroid mass, frequently in a preexisting goiter, is the most common manifestation; the diagnosis should be considered and expeditiously pursued in all patients who present with this finding. Relatively favorable prognostic features seem to be unilateral tumors, a tumor diameter of less than 5 cm, no invasion of adjacent tissue, and absence of nodal involvement. For resectable lesions, thyroid lobectomy with wide margins of adjacent soft tissue on the side of the tumor seems to constitute a safe, appropriately aggressive surgical approach. Total thyroidectomy and radical neck dissection results in an increased complication rate and has no advantage over a more conservative approach. Radiotherapy, chemotherapy, immunotherapy, and combination radiotherapy and chemotherapy need further evaluation.