Oliver S. Eng

Routine second-opinion cytopathology review of thyroid fine needle aspiration biopsies reduces diagnostic thyroidectomy

BACKGROUND Follicular thyroid carcinoma cannot be distinguished reliably from benign follicular neoplasia by fine needle aspiration (FNA) biopsy. Given an estimated 20% risk of malignancy, many patients with indeterminate FNA biopsies require thyroidectomy for diagnosis. Some centers have shown significant discordance when a second pathologist evaluates the same FNA biopsy. We sought to determine whether routine second-opinion cytopathology reduces the need for diagnostic thyroidectomy, especially in patients with indeterminate FNA biopsies. METHODS In all, 331 thyroid FNA biopsy specimens obtained from outside centers from 2004 to 2009 were reviewed at our institution. The FNA biopsy results were categorized into nondiagnostic (Bethesda I), benign (Bethesda II), indeterminate (follicular/Hurthle cell neoplasm, follicular/Hurthle cell lesion; Bethesda III & IV), and malignant (papillary or suspicious for papillary or other malignancy; Bethesda V and VI). Second-opinion cytology was compared with the initial opinion in 331 cases and with final operative pathology in the 250 patients who progressed to thyroidectomy. RESULTS The average patient age was 51 with a predominant number of female (79%) participants. The overall cytology concordance for all 331 FNA biopsies was 66% (218/331). Concordance was highest at 86% (74/86) with malignant FNA biopsies. Concordance in the 129 patients with indeterminate FNA biopsies was only 37% (48/129). Indeterminate FNA biopsies were reread as nondiagnostic in 21% (27/129) of patients and as benign in 42% (54/129) of patients. Twenty-two patients with an indeterminate FNA biopsy reread as benign progressed to operative therapy for reasons other than cytology (eg, symptomatic nodule and radiation exposure/high risk) and were found to be benign in 95% (21/22) of patients on operative pathology for a 95% negative predictive value. An additional 11 patients with an indeterminate FNA reread as benign had follow-up FNA biopsies, each of which was benign. Indeterminate FNA biopsies on initial cytology had a malignancy rate of 13% (17/129) on operative pathology compared with 29% (14/48) for indeterminate FNA biopsies from second opinion. A second opinion improved FNA biopsy accuracy from 60% to 74%. Overall, second-opinion cytology of indeterminate FNA biopsies avoided diagnostic operation in 25% (32/129). CONCLUSION Routine second opinion review of indeterminate thyroid FNA biopsies can potentially obviate the need for diagnostic thyroidectomy in 25% of patients without increases in false negatives.

Intraoperative Fluid Administration Is Associated With Perioperative Outcomes in Pancreaticoduodenectomy: A Single Center Retrospective Analysis

Recent studies on perioperative fluid administration in patients undergoing major abdominal surgery have suggested that increased fluid loads are associated with worse perioperative outcomes. However, results of retrospective analyses of the relationship between intraoperative fluid (IOF) administration and perioperative outcomes in patients undergoing pancreaticoduodenectomy (PD) are conflicted. We sought to investigate this relationship in patients undergoing PD at our academic center.

Outcomes of microwave ablation for colorectal cancer liver metastases: A single center experience

Surgical management of colorectal cancer liver metastases continues to evolve to optimize oncologic outcomes while maximizing parenchymal preservation. Long‐term data after intraoperative microwave ablation are limited. This study investigates outcomes and patterns of recurrence in patients who underwent intraoperative microwave ablation.

The relationship of perioperative fluid administration to outcomes in colorectal and pancreatic surgery: a review of the literature.

Optimal perioperative fluid administration in major gastrointestinal surgery remains a challenging clinical problem. Traditional dogma of a liberal approach to fluid administration in order to counteract potential hypovolemia and decreased end‐organ perfusion can often result in fluid overload, perhaps negatively impacting perioperative outcomes. This hypothesis has been investigated in several types of gastrointestinal surgery. We discuss the current literature on perioperative fluid administration in colorectal and pancreatic surgery and highlight the controversies that still exist. J. Surg. Oncol. 2015 111:472–477.

Does nodule size predict compressive symptoms in patients with thyroid nodules

BACKGROUND Thyromegaly and thyroid nodules are known to cause compressive symptoms, but the exact relationship between nodule size and development of compressive symptoms is unclear. We sought to determine whether compressive symptoms are directly related to nodule size. METHODS A retrospective analysis of 99 patients who underwent thyroidectomy by a single surgeon was performed. Patients were placed into one of two cohorts: those who experienced preoperative compressive symptoms (N=51) and those who did not (N=48). Compressive symptoms were defined as experiencing neck fullness, dysphagia, choking, or dyspnea. Nodule size, thyroid lobe size, and the presence of visible thyromegaly were compared between the two groups. RESULTS Average nodule size in patients with compressive symptoms was 3.8 versus 2.2 cm in asymptomatic patients (P<0.0001). Average lobe diameter was 6.2 cm in patients with compressive symptoms versus 4.9 cm in asymptomatic patients (P<0.001). Visible thyromegaly was present in 65.2% of patients with compressive symptoms and 15.4% of asymptomatic patients (P<0.0001). The most common symptom was dysphagia, occurring in 80% of patients, followed by neck fullness (69%), choking (49%), and dyspnea (32%). Of patients who underwent surgery for compressive symptoms, 92.7% had improvement in their symptoms postoperatively. Of patients with a thyroid nodule greater than 1.5 cm, 97% showed improvement in symptoms postoperatively. CONCLUSIONS Thyroid nodule size and lobe size appear to directly correlate with compressive symptoms. Of patients with compressive symptoms and a thyroid nodule >1.5 cm, 97% experienced improvement in symptoms postoperatively.

Safety and efficacy of LigaSure usage in pancreaticoduodenectomy

BACKGROUND Over recent years, use of the LigaSure™ vessel sealing device has increased in major abdominal surgery to include pancreaticoduodenectomy (PD). LigaSure™ use during PD has expanded to include all steps of the procedure, including the division of the uncinate margin. This introduces the potential for thermal major vascular injury or margin positivity. The aim of the present study was to evaluate the safety and efficacy of LigaSure™ usage in PD in comparison to established dissection techniques. METHODS One hundred and forty-eight patients who underwent PD from 2007 to 2012 at Robert Wood Johnson University Hospital were identified from a retrospective database. Two groups were recognized: those in which the LigaSure™ device was used (N = 114), and in those it was not (N = 34). Peri-operative outcomes were compared. RESULTS Vascular intra-operative complications directly caused by thermal injury from LigaSure™ use occurred in 1.8% of patients. Overall vascular intra-operative complications, uncinate margin positivity, blood loss, length of stay, and complication severity were not significantly different between groups. The mean operative time was 77 min less (P < 0.010) in the LigaSure™ group. Savings per case where the LigaSure™ was used amounted to

A sensitive liquid chromatography–mass spectrometry bioanalytical assay for a novel anticancer candidate – ZMC1

1776.73. CONCLUSION LigaSure™ usage during PD is safe and effective. It is associated with decreased operative times, which may decrease operative costs in PD.

Repair of a Post-Hepatectomy Posterior Sectoral Duct Injury Secondary to Anomalous Bile Duct Anatomy Using a Novel Combined Surgical-Interventional Radiologic Approach

ZMC1 {azetidinecarbothioic acid, [1-(2-pyridinyl) ethylidene] hydrazide} is a lead compound being developed as one of the first mutant p53 targeted anti-cancer drugs. Establishing a precise quantitative method is an integral component of this development. The aim of this study was to develop a sensitive LC/MS/MS assay suitable for assessing purity, stability and preclinical pharmacokinetic studies of ZMC1. Acetonitrile protein precipitation extraction was chosen for plasma sample preparation with satisfactory recovery (84.2-92.8%) for ZMC1. Chromatographic separation was achieved on an Xterra C18 column (50 × 4.6 mm, 3.5 µm) using a gradient elution with mobile phase of 0.1% formic acid in water and acetonitrile. ZMC1 and internal standard 2-amino-6-bromobenzothiazole were identified using selected-ion monitoring mode at m/z 235.2/178.2 and m/z 231.0/150.0 at retention times of 5.2 and 6.3 min, respectively. The method was validated with a linearity range of 3.9-500.0 ng/mL in human plasma and showed acceptable reproducibility with intra- and interday precisions <5.9 and 10.5%, and accuracy within ±5.4% of nominal values. This analytical method together with basic stability data in plasma and plasma binding experiments provides a reliable protocol for the study of ZMC1 pharmacokinetics. This will greatly facilitate the pre-clinical development of this novel anti-cancer drug.

Academic productivity in surgical oncology: Where is the bar set for those training the next generation?: LAROCCA et al.

A 64-year-old woman with a completely transected posterior sectoral duct following extended hepatectomy underwent a combined operative procedure with interventional radiology and surgery to restore biliary-enteric drainage. The anterior and posterior sectoral ducts were identified, and catheters were inserted into both systems. The posterior sectoral catheter was placed intraoperatively through a preoperatively placed sheath, and a new tunnel was created through the regenerated liver surface. Biliary-enteric anastomoses were created over the stents.

Preoperative Trans-Arterial Embolization and Surgical Resection for Giant Liver Hemangioma: A Multidisciplinary Approach

Promotion and tenure are important milestones for academic surgical oncologists. The aim of this study was to quantify academic metrics associated with rank in surgical oncologists training the next generation.