Noah Sands

Cost savings associated with post-thyroidectomy parathyroid hormone levels

OBJECTIVES: A 1-hour post-thyroidectomy parathyroid hormone (PTH) level of ≤8 ng/L is predictive of patients who will develop hypocalcemia and guides early supplementation with calcium and vitamin D. However, most hypocalcemic patients fail to meet this criterion. The goal of this study was to determine whether PTH ≤ 15 ng/L could be used as a better predictor of hypocalcemia. STUDY DESIGN, SUBJECTS, AND METHODS: This retrospective study involved 270 thyroidectomy patients (2004-2006). PTH and calcium levels, length of admission, supplementation, and rates of hypocalcemia were recorded. RESULTS: Forty-three percent (26/60) of patients developing hypocalcemia met the PTH ≤ 8 ng/L cut-off. In contrast, 80% (48/60) of patients developing hypocalcemia had a PTH ≤ 15 ng/L. Two point two percent of patients had a 1-hour PTH ≤ 15 ng/L and failed to develop hypocalcemia, for a specificity of 97%. CONCLUSIONS: A 1-hour PTH cut-off of ≤15 ng/L for prophylactic supplementation should allow the prevention of the majority of cases of hypocalcemia, leading to significant cost savings by shortening hospital stays.

Female Gender as a Risk Factor for Transient Post-Thyroidectomy Hypocalcemia

Objectives. Transient post-thyroidectomy hypocalcemia is a common complication following thyroid surgery. Studies have identified risk factors and possible ways to help predict post-thyroidectomy hypocalcemia with the intent of ultimately limiting its incidence. This study evaluates the role of patient gender as a potential risk factor. Study Design. A retrospective case series with chart review of 270 consecutive total thyroidectomy patients was conducted. Setting. Jewish General Hospital, a McGill University–affiliated hospital in Montreal, Canada. Subjects and Methods. 219 women and 51 men were included. Postoperative hypocalcemia was defined as any 1 of the following: total serum calcium 1.90 mmol/L or less, or signs and symptoms of hypocalcemia. The following were evaluated as potential confounding factors in the study: age, menopause, preoperative calcium, parathyroid hormone, magnesium and phosphate levels, presence of carcinoma in the surgical specimen, number of parathyroid glands preserved in situ, thyroid gland volume, and nodule size. Results. Female patients experienced transient postoperative hypocalcemia in 24.7% (54/219) of cases, which was significantly greater than the 11.8% (6/51) incidence detected in men (P < .05). This represents a female/male relative risk ratio of 2.1 (confidence interval, 1.0-4.6). There was no significant difference in rates of hypocalcemia between premenopausal and postmenopausal women (22.7% vs 26.6%). Conclusion. These findings suggest that being female is likely a risk factor for transient post-thyroidectomy hypocalcemia. Although this association is statistically significant, its magnitude and clinical relevance are uncertain and may be trivial. Additional research is needed to ascertain the physiologic mechanisms underlying this gender difference.

Preoperative parathyroid hormone levels as a predictor of postthyroidectomy hypocalcemia.

Objectives. The goal of the present study is to determine whether a decline in the 1-hour postoperative parathyroid hormone (PTH) level relative to the preoperative level is predictive of hypocalcemia. Methods. This is a retrospective study involving 142 consecutive patients who underwent total thyroidectomy. Changes in preoperative PTH levels were then compared with the 1-hour levels. Results. Thirty-four of 142 patients (23.9%) who underwent total thyroidectomy developed hypocalcemia. Thirty-one of the 34 patients who became hypocalcemic had a 1-hour postoperative PTH drop of 70% or more when compared with the preoperative value (sensitivity = 91%, specificity = 98%, positive predictive value = 94%, and negative predictive value = 97%). Conclusion. A decline in the preoperative PTH level of 70% or greater at 1 hour following total thyroidectomy appears to be a reliable predictor of patients at risk of developing hypocalcemia. By allowing thyroid surgeons to identify these patients in the early postoperative period, calcium supplementation can be initiated sooner.

Coblation technique as an alternative treatment modality for oral lymphangioma

Lymphangiomas of the tongue are relatively uncommon, and traditional treatment modalities carry a high failure rate. We present here a case report of effective treatment of lymphangioma circumscriptum of the oral tongue using radiofrequency coblation, while including a review of the current literature.

Hepatoid Adenocarcinoma of the Anterior Skull Base: A Case Report

We report the first case of hepatoid adenocarcinoma of the skull base, as well as the first reported case in the head and neck region. Hepatoid adenocarcinoma is a rare, aggressive, extrahepatic malignancy with a distinct morphological similarity to hepatocellular carcinoma, in the absence of primary hepatic disease. A 45-year-old man presented with sinus headaches and retro-orbital pain and was found to have a nasopharyngeal mass on endoscopy and a large, destructive sinonasal mass extending intracranially on imaging. Histo- and cytopathological features were similar to hepatocellular carcinoma, and the cells were immunoreactive for α-fetoprotein, epithelial membrane antigen, periodic acid-Schiff, cytokeratin (CK)8/18, CK19, and S100.

Gender as a Risk Factor of Malignancy in a Thyroid Nodule

tively (p 0.004). The mean treatment delay for the false negative SLNB group was 525 days compared to 23 days in the positive SLNB group (p 0.001). CONCLUSION: False negative SLNB is more likely to occur in cases with a single sentinel lymph node harvested. False negative SLNB results in a significant treatment delay. False negative SLNB is associated with a poor outcome in patients with head and neck melanoma and warrants further investigation.

Female Gender: A Post-Thyroidectomy Hypocalcemia Risk Factor

Objective 1) To evaluate the role of patient gender as a potential risk factor for post-thyroidectomy hypocalcemia. 2)To elucidate, from previous studies, potential physiologic mechanisms underlying any identified gender disparity. 3)To help better predict post-thyroidectomy hypocalcemia and ultimately limit its incidence with prophylactic/early calcium supplementation. Methods A retrospective review of 270 consecutive total thyroidectomy patients (October 2004-December 2006) was conducted, consisting of 219 females and 51 males. Postoperative hypocalcemia was defined as any one of the following: total serum calcium of less than or equal to 1.90 mmol/L up to 1 month following surgery or symptoms of hypocalcemia. The following were evaluated as potential confounding factors in the study: age, menopause, pre-operative calcium and parathyroid hormone levels, magnesium and phosphate levels, pathology and number of parathyroid glands preserved in situ. Chisquared testing was used to evaluate for statistical significance. Results Female patients experienced transient postoperative hypocalcemia in 24.7% (54/219) of cases, which was significantly greater than the 11.8% (6/51) incidence detected in males (p less than 0.05). This represents a female:male relative risk ratio of 2.1 (C.I. 1.0–4.6). There was no significant difference in rates of hypocalcemia between pre-menopausal (age less than 50) and post-menopausal women (22.7% vs. 26.6%). Conclusions These findings suggest that being female is a significant risk factor for transient post-thyroidectomy hypocalcemia. Furthermore, females appear to experience this postoperative complication more than twice as frequently as males. Additional research is needed in order to ascertain the physiologic mechanisms underlying this identified gender difference.

10:40: Can Preoperative PTH Predict Post-Thyroidectomy Hypocalcemia

prior to definitive treatment. METHODS: Nonrandomized retrospective cohort analysis. Twenty-seven consecutive patients with previously untreated HNSCC who underwent PET-CT imaging in addition to chest radiographs (CXR) as part of their metastatic work-up were eligible for inclusion. RESULTS: The majority of patients (89%) had TNM stage III or IV disease. PET-CT was suspicious for pulmonary malignancy in 4 patients (15%) and indeterminate in 1 patient (4%). CXR was suspicious for pulmonary malignancy in 2 patients (7%). Pulmonary metastases or a new lung primary was present in 2 patients (7%): 2 of 4 patients with positive PET-CT scans (50%) and 0 of 23 patients with negative or indeterminate PET-CT scans (0%), compared with 1 of 2 patients with positive CXR (50%) and 1 of 25 patients with negative CXR (4%). The sensitivity and specificity of PET-CT in predicting pulmonary malignancy was 100% and 92%, respectively, with a positive predictive value of 50% and a negative predictive value of 100%. The sensitivity and specificity of CXR in predicting pulmonary malignancy was 50% and 96%, respectively, with a positive predictive value of 50% and a negative predictive value of 96%. The overall incidence of distant metastatic disease was 15% (4/27) with 11% (3/27) unsuspected prior to PET-CT. CONCLUSIONS: PET-CT improves detection of metastatic disease and should be performed as part of the routine evaluation of high-risk HNSCC patients prior to surgical intervention.

11:06: Cost Savings Associated With Post-Thyroidectomy PTH Levels

OBJECTIVES: Evaluate the diagnostic value of rhinolaryngoscopy using the narrow band imaging (NBI) system, a novel optical technique that enhances endoscopic diagnostic capability, in detecting squamous cell carcinoma of the head and neck (SCCHN) in patients with esophageal cancer (EC), who are at a high risk for developing SCCHNs. METHODS: Between January 2006 and December 2006, 667 consecutive EC patients prospectively underwent rhinolaryngoscopy screening by using both conventional white light and NBI system. The Lugol staining and histological examinations were performed on superficial demarcated brownish lesions detected by NBI system and demarcated red lesions, elevated lesions, or depressive lesions detected by white light. Sensitivity, specificity, accuracy, and positive/negative predictive value for detecting SCCHNs by each method were calculated by the histological results and compared with the chi-square test. Difference was considered significant at p 0.05. RESULTS: Forty-five (6.7%) of 667 patients had SCCHNs, including those at the oral cavity (n 1), larynx (n 1), oropharynx (n 7), and hypopharynx (n 36). Sensitivity, specificity, accuracy, positive predictive value, and negative predictive value for detecting SCCHNs by white light system were 51.1%, 99.7, 96.4%, 92%, 96.6%. In contrast, those by the NBI system were 97.7%**, 98.9%, 98.8%*, 86.3%, 99.8%** (*p 0.01, **p 0.001 vs. white light). Notably, sensitivity for detecting small lesions of 10mm or less in diameter was 100% for NBI whereas 18% for the white light system (p 0.001). CONCLUSIONS: The NBI endoscope significantly improves diagnostic accuracy, sensitivity, and negative predictive value in detecting SCCHN in EC patients. The NBI endoscope would be highly beneficial in detecting superficial SCCHNs in high-risk patients.