Melanie Goldfarb

SAGES guidelines for minimally invasive treatment of adrenal pathology

The guidelines for Minimally Invasive Surgical Treatment of Adrenal Pathology are a series of systematically developed statements to educate and guide the surgeon (and patient) in the appropriate use of minimally invasive techniques for the treatment of adrenal disease. The guidelines address the indications, risks, benefits, outcomes, alternatives, and controversies of the procedures used in specific clinical circumstances. The statements included in these guidelines were derived from a systematic review of published work on the topic, and the recommendations are explicitly linked to the supporting evidence. The strengths and weaknesses of the available evidence are highlighted, and expert opinion is sought where published evidence lacks depth.

Clinic-Based Ultrasound Can Predict Malignancy in Pediatric Thyroid Nodules

BACKGROUND Thyroid nodules in pediatric patients may carry a greater risk for malignancy than in adults. Most nodules >1 cm in patients ≤ 21 years of age may require thyroidectomy for definitive diagnosis and treatment. Although clinic-based ultrasound (CBUS) has been shown useful in the evaluation of thyroid nodules in adults, its utility in evaluating nodules in the pediatric population remains unclear. METHODS Prospectively collected data regarding 50 patients ≤ 21 years who underwent preoperative CBUS and initial thyroidectomy at a single institution were retrospectively reviewed. All CBUS were performed by endocrine surgeons certified in basic and cervical ultrasonography. Preoperative CBUS characteristics of pediatric thyroid nodules were analyzed with respect to final pathology. RESULTS Of the 50 patients ≤ 21 years of age who underwent surgical resection for a dominant thyroid nodule, there were 45 females and 5 males with an average age of 17.4 years (range: 10-21 years). On univariate analysis, microcalcifications (p<0.001), abnormal lymph nodes (p<0.001), and dimensions taller more than wide (p=0.033) were individual CBUS characteristics predictive of thyroid malignancy. All nine patients with abnormal lymph nodes on CBUS had malignant disease on final pathology. Multiple thyroid nodules, a cystic component, and echogenicity did not predict malignancy; regular borders trended toward predicting a benign nodule (p=0.066). When malignant ultrasound features were considered (i.e., hypoechoic, irregular borders, microcalcifications, abnormal lymph nodes, and shape taller more than wide), having one malignant feature predicted malignancy with an odds ratio of 2.0 while having ≥ 2 features held even greater significance (p=0.004, OR 4.0). All patients with ≥ 3 malignant ultrasound features had thyroid cancer on final pathology. CONCLUSION CBUS is a useful diagnostic modality in determining malignancy status of thyroid nodules in patients ≤ 21 years of age. CBUS should be employed as part of an initial assessment of any pediatric patient presenting with thyroid nodules to help further guide management and treatment.

Role of SPECT and SPECT/CT in the Surgical Treatment of Primary Hyperparathyroidism

Primary hyperparathyroidism is the most common cause of hypercalcemia in the outpatient population. This condition is usually the result of a single hyperfunctioning parathyroid gland. Targeted parathyroidectomy guided by intraoperative parathyroid hormone monitoring (IPM) through a small cervical incision has replaced traditional bilateral neck exploration (BNE) as the initial approach in the surgical treatment of primary hyperparathyroidism at many medical centers worldwide. Preoperative sestamibi-technetium 99m scintigraphy serves as an important prerequisite for successful targeted parathyroidectomy. Single-photon emission computed tomography (SPECT) and CT fusion, however, is a recent imaging technique that provides a three-dimensional functional image with advanced contrast resolution to greatly improve preoperative localization of parathyroid tumors.

Parathyroid carcinoma in more than 1,000 patients: A population-level analysis.

BACKGROUND Parathyroid carcinoma (PC) is a rare malignancy with a moderate prognosis. The staging system, prognostic indicators, and optimal surgical management are still under debate. This large cohort explores prognostic factors for PC. METHODS 1,022 cases of PC in the 1998-2011 National Cancer Data Base that underwent surgery were examined for predictors of lower overall survival (OS) and relative risk (RR) of death at 5 years. RESULTS The 5-year OS was 81.1% in 528 patients with ≥ 60 months of follow-up. The overall cohort was mainly non-Hispanic (96.5%), white (77.4%), and insured (94.3%), with a median age of 57 years. Mean OS was lower and RR of death greater in older (P < .001), black (P = .007) patients with a secondary malignancy (P = .015) and ≥ 2 comorbidities (P = .005), whose surgical specimen had positive surgical margins (P = .026) or positive lymph nodes (P < .001). Multivariate cox regression demonstrated that positive lymph nodes (hazard ratio [HR], 6.47; 95% CI, 1.81-23.11) and older age (HR, 2.35; 95% CI, 1.25-4.43) were associated with lower OS. CONCLUSION PC is a rare malignancy with a 5-year OS of 81.1%. Positive lymph nodes and older age predict lower OS and an increased risk of death.

Elective versus emergency surgery for ulcerative colitis: a National Surgical Quality Improvement Program analysis

BACKGROUND It is unclear whether advances in the medical management of ulcerative colitis (UC) have altered outcomes for medically intractable disease. Therefore, it is essential to understand the current impact of elective versus emergency surgery for UC. METHODS The American College of Surgeons National Surgical Quality Improvement Program database was used to compare outcomes for elective versus emergency UC surgery between 2005 and 2010. RESULTS Four thousand nine hundred sixty-two patients were eligible for study (94% elective and 6% emergent). Emergency surgery patients were significantly older and frequently underwent open surgery. Emergency cases were associated with a higher frequency of cardiac, pulmonary, and renal comorbidities; postoperative complications; longer hospital stays; and higher rates of return to the operating room. CONCLUSIONS In the era of advanced UC medical therapy, the need for emergency surgery still exists and is associated with substantial morbidity and mortality. Data are needed to determine if earlier selection of surgery would be beneficial.

Well-differentiated thyroid carcinoma: The role of post-operative radioactive iodine administration

Post‐operative management of differentiated thyroid cancer (DTC) often involves administration of radioactive iodine (RAI) for remnant ablation or adjuvant therapy. However, given the favorable prognosis associated with DTC, the risk versus benefit ratio of RAI remains unclear. RAI is associated with substantial, albeit rare side effects, including a possible increased risk of secondary malignancy and altered fertility, which must be balanced against the magnitude of benefit for decreasing recurrence and improving survival. J. Surg. Oncol. 2013;107:665–672.

Impact of Regional Lymph Node Dissection on Disease Specific Survival in Adrenal Cortical Carcinoma.

Adrenocortical carcinoma (ACC) is a rare malignancy with a poor prognosis. The purpose of this study is to evaluate the impact of a more extensive regional lymph node dissection (LND) has on survival in ACC patients in the United States. Patients ≥ 15 years of age without distant metastases who underwent surgical intervention for primary ACC were identified from the SEER18 registry from 1988-2009. Patients were divided into 2 groups: having a regional LND (≥ 5 LNs removed) vs. no-LND (0-4 LNs removed). Overall survival (OS) and disease specific survival (DSS) were compared between groups. Of 259 patients with complete data on nodal resection, 243 (93.8%) underwent no-LND and 16 (6.2%) LND. There was no difference in age, sex, metastases, or ENSAT stage between groups. However, LND patients had larger tumors (p=0.004), and more frequently underwent en-bloc surgery (p=0.002). One- and 3-year OS and DSS did not differ between groups. In a cox regression model, performance of a regional LND did not significantly influence DSS. However, female gender (HR: 1.67, CI: 1.04-2.69, p=0.033) and later stage (stage III-HR: 4.78, CI: 1.14-20.00, p=0.032) or positive LNs (HR: 5.92, CI: 2.05-17.08, p=0.001) were risk factors for worse DSS. Regional LND may not improve DSS or OS in nonmetastatic ACC patients undergoing adrenalectomy. It remains controversial as an essential part of the surgical management for ACC and deserves further investigation in a larger, prospective study. However, regional LND should still be considered for staging and prognostic purposes and to standardize surgical care.

Comparison of secondary and primary thyroid cancer in adolescents and young adults.

Thyroid cancer is one of the 5 most common malignancies in adolescent and young adult (AYA) patients (ages 15‐39 years) and may develop de novo or in patients previously treated for cancer. This study compared the tumor characteristics, treatment, and overall survival (OS) of secondary malignant neoplasm (SMN) versus primary thyroid cancer in AYA patients.

Colorectal carcinoma in pediatric patients: A comparison with adult tumors, treatment and outcomes from the National Cancer Database

BACKGROUND Pediatric colorectal cancer (CRC) is rare. Comparison with adult CRC tumors, management, and outcomes may identify opportunities for improvement in pediatric CRC care. STUDY DESIGN CRC patients in the National Cancer Data Base from 1998 to 2011, were grouped into Pediatric (≤21years), early onset adult (22-50) and older adult (>50) patients. Groups were compared with χ(2) and survival analysis. RESULTS A total of 918 pediatric (Ped), 157,779 early onset adult (EA), and 1,304,085 older adults (OA) were identified (p<0.01 for all comparisons). Patients ≤50 presented more frequently with stage 3 and 4 disease (Ped: 62.0%, EA: 49.7%, OA: 37.3%) and rectal cancer (Ped: 23.6%, EA: 27.5%, OA: 19.2%). Pediatric histology was more likely signet ring, mucinous, and poorly differentiated. Initial treatment was usually surgery, but patients ≤50 were more likely to have radiation (Ped: 15.1%, EA: 18.6%, and OA: 9.2%) and chemotherapy (Ped: 42.0%, EA: 38.2%, and OA: 22.7%). Children and older adults showed poorer overall survival at 5years when compared to early onset adults. Adjusting for covariates, age ≤21 was a significant predictor of mortality for colon and rectal cancers (colon HR: 1.22, rectal HR: 1.69). CONCLUSIONS This is the largest cohort of pediatric CRC patients, revealing more aggressive tumor histology and behavior in children, particularly in rectal cancer. Despite standard oncologic treatment, age ≤21 was a significant predictor of mortality. This is likely owing to worse tumor biology rather than treatment disparities and may signal the need for different therapeutic strategies.

Primary malignant pulmonary tumors in children: a review of the national cancer data base

BACKGROUND The purpose is to delineate the clinical and pathological characteristics of rare primary malignant pulmonary tumors in children. METHODS Utilizing the National Cancer Data Base (NCDB), we analyzed all children (≤ 18 years) with a primary malignant pulmonary tumor from 1998 to 2011 to identify factors associated with better survival. RESULTS Of 211 children identified, the most common histology was carcinoid tumor (n=133, 63%) followed by mucoepidermoid carcinoma (MEC) (n=37, 18%), squamous cell carcinoma (SCC) (n=19, 9%), adenocarcinoma (n=16, 8%), bronchoalveolar carcinoma (BAC) (n=4, 2%), and small cell carcinoma (SCLC) (n=2, <1%). Factors that significantly affected survival include histology, race, tumor size, lymph node status, and extent of surgery. Patients with MEC and carcinoid tumors had a better overall survival compared to patients with other histologies (p<0.0001). The 5-year overall survival for MEC and carcinoid tumors was 100% and 95% (95% CI 87-98), respectively, versus 50% (95%CI 1-91) for BAC, 28% (95%CI 9-52) for SCC, and 26% (95%CI 5-55) for adenocarcinoma. CONCLUSION The majority of pediatric patients with a primary malignant pulmonary tumor present with carcinoid tumor or MEC and have an excellent prognosis. Lung cancers which are common in adults, but rare in children, have a worse prognosis.