Peter Angelos

Management Guidelines for Children with Thyroid Nodules and Differentiated Thyroid Cancer.

BACKGROUND Previous guidelines for the management of thyroid nodules and cancers were geared toward adults. Compared with thyroid neoplasms in adults, however, those in the pediatric population exhibit differences in pathophysiology, clinical presentation, and long-term outcomes. Furthermore, therapy that may be recommended for an adult may not be appropriate for a child who is at low risk for death but at higher risk for long-term harm from overly aggressive treatment. For these reasons, unique guidelines for children and adolescents with thyroid tumors are needed. METHODS A task force commissioned by the American Thyroid Association (ATA) developed a series of clinically relevant questions pertaining to the management of children with thyroid nodules and differentiated thyroid cancer (DTC). Using an extensive literature search, primarily focused on studies that included subjects ≤18 years of age, the task force identified and reviewed relevant articles through April 2014. Recommendations were made based upon scientific evidence and expert opinion and were graded using a modified schema from the United States Preventive Services Task Force. RESULTS These inaugural guidelines provide recommendations for the evaluation and management of thyroid nodules in children and adolescents, including the role and interpretation of ultrasound, fine-needle aspiration cytology, and the management of benign nodules. Recommendations for the evaluation, treatment, and follow-up of children and adolescents with DTC are outlined and include preoperative staging, surgical management, postoperative staging, the role of radioactive iodine therapy, and goals for thyrotropin suppression. Management algorithms are proposed and separate recommendations for papillary and follicular thyroid cancers are provided. CONCLUSIONS In response to our charge as an independent task force appointed by the ATA, we developed recommendations based on scientific evidence and expert opinion for the management of thyroid nodules and DTC in children and adolescents. In our opinion, these represent the current optimal care for children and adolescents with these conditions.

Clinical Practice Guideline: Improving Voice Outcomes after Thyroid Surgery

Objective Thyroidectomy may be performed for clinical indications that include malignancy, benign nodules or cysts, suspicious findings on fine needle aspiration biopsy, dysphagia from cervical esophageal compression, or dyspnea from airway compression. About 1 in 10 patients experience temporary laryngeal nerve injury after surgery, with longer lasting voice problems in up to 1 in 25. Reduced quality of life after thyroid surgery is multifactorial and may include the need for lifelong medication, thyroid suppression, radioactive scanning/treatment, temporary and permanent hypoparathyroidism, temporary or permanent dysphonia postoperatively, and dysphagia. This clinical practice guideline provides evidence-based recommendations for management of the patient’s voice when undergoing thyroid surgery during the preoperative, intraoperative, and postoperative period. Purpose The purpose of this guideline is to optimize voice outcomes for adult patients aged 18 years or older after thyroid surgery. The target audience is any clinician involved in managing such patients, which includes but may not be limited to otolaryngologists, general surgeons, endocrinologists, internists, speech-language pathologists, family physicians and other primary care providers, anesthesiologists, nurses, and others who manage patients with thyroid/voice issues. The guideline applies to any setting in which clinicians may interact with patients before, during, or after thyroid surgery. Children under age 18 years are specifically excluded from the target population; however, the panel understands that many of the findings may be applicable to this population. Also excluded are patients undergoing concurrent laryngectomy. Although this guideline is limited to thyroidectomy, some of the recommendations may extrapolate to parathyroidectomy as well. Results The guideline development group made a strong recommendation that the surgeon should identify the recurrent laryngeal nerve(s) during thyroid surgery. The group made recommendations that the clinician or surgeon should (1) document assessment of the patient’s voice once a decision has been made to proceed with thyroid surgery; (2) examine vocal fold mobility, or refer the patient to a clinician who can examine vocal fold mobility, if the patient’s voice is impaired and a decision has been made to proceed with thyroid surgery; (3) examine vocal fold mobility, or refer the patient to a clinician who can examine vocal fold mobility, once a decision has been made to proceed with thyroid surgery if the patient’s voice is normal and the patient has (a) thyroid cancer with suspected extrathyroidal extension, or (b) prior neck surgery that increases the risk of laryngeal nerve injury (carotid endarterectomy, anterior approach to the cervical spine, cervical esophagectomy, and prior thyroid or parathyroid surgery), or (c) both; (4) educate the patient about the potential impact of thyroid surgery on voice once a decision has been made to proceed with thyroid surgery; (5) inform the anesthesiologist of the results of abnormal preoperative laryngeal assessment in patients who have had laryngoscopy prior to thyroid surgery; (6) take steps to preserve the external branch of the surperior laryngeal nerve(s) when performing thyroid surgery; (7) document whether there has been a change in voice between 2 weeks and 2 months following thyroid surgery; (8) examine vocal fold mobility or refer the patient for examination of vocal fold mobility in patients with a change in voice following thyroid surgery; (9) refer a patient to an otolaryngologist when abnormal vocal fold mobility is identified after thyroid surgery; (10) counsel patients with voice change or abnormal vocal fold mobility after thyroid surgery on options for voice rehabilitation. The group made an option that the surgeon or his or her designee may monitor laryngeal electromyography during thyroid surgery. The group made no recommendation regarding the impact of a single intraoperative dose of intravenous corticosteroid on voice outcomes in patients undergoing thyroid surgery.

American Association of Clinical Endocrinologists and American Association of Endocrine Surgeons Medical Guidelines for the Management of Adrenal Incidentalomas: Executive summary of recommendations

The American Association of Clinical Endocrinologists and American Association of Endocrine Surgeons Medical Guidelines for the Management of Adrenal Incidentalomas are systematically developed statements to assist health care providers in medical decision making for specific clinical conditions. Most of the content herein is based on literature reviews. In areas of uncertainty, professional judgment was applied. These guidelines are a working document that reflects the state of the field at the time of publication. Because rapid changes in this area are expected, periodic revisions are inevitable. We encourage medical professionals to use this information in conjunction with their best clinical judgment. The presented recommendations may not be appropriate in all situations. Any decision by practitioners to apply these guidelines must be made in light of local resources and individual circumstances.

Gangrenous cholecystitis: Analysis of risk factors and experience with laparoscopic cholecystectomy

BACKGROUND Gangrenous cholecystitis occurs in up to 30% of patients admitted with acute cholecystitis. Factors predicting gangrenous disease in patients with acute cholecystitis remain poorly defined, making preoperative diagnosis difficult. Identification of these factors and early diagnosis of gangrenous cholecystitis will indicate more aggressive treatment, earlier operation, and a lower threshold for conversion of laparoscopic to open cholecystectomy. METHODS We reviewed our experience with acute cholecystitis during the 2-year period of 1995 to 1996. Admitting history, physical examination, operative report, laboratory and radiology data, and pathology report were analyzed for each patient. Acute cholecystitis and its gangrenous complication were diagnosed by both gross and microscopic examination. RESULTS One hundred fifty-four patients were admitted to the hospital with acute cholecystitis and underwent cholecystectomy; gallbladder gangrene was found in 27 (18%) of these patients. Four patients with gallbladder gangrene underwent open cholecystectomy and 23 patients underwent laparoscopic cholecystectomy, of which 15 (65%) were completed laparoscopically and 8 (35%) had open conversion as a result of severe inflammation. Risk factors for gallbladder gangrene included male gender, age older than 50 years, history of cardiovascular disease, and leukocytosis greater than 17,000 white blood cells/mL. CONCLUSIONS Older male patients (age older than 50 years) with history of cardiovascular disease, leukocytosis greater than 17,000 white blood cells/mL, and acute cholecystitis have increased risk of gallbladder gangrene and conversion of laparoscopic cholecystectomy to open cholecystectomy. Urgent laparoscopic cholecystectomy with low threshold for conversion to open cholecystectomy should be considered in these patients at high risk for gallbladder gangrene.

The Clinical and Economic Burden of a Sustained Increase in Thyroid Cancer Incidence

Background: Thyroid cancer incidence is increasing worldwide at an alarming rate, yet little is known of the impact this increase will have on society. We sought to determine the clinical and economic burden of a sustained increase in thyroid cancer incidence in the United States and to understand how these burdens correlate with the National Cancer Institutes (NCI) prioritization of thyroid cancer research funding. Methods: We used the NCIs SEER 13 database (1992–2009) and Joinpoint regression software to identify the current clinical burden of thyroid cancer and to project future incidence through 2019. We combined Medicare reimbursement rates with American Thyroid Association guidelines, and our clinical practice to create an economic model of thyroid cancer. We obtained research-funding data from the NCIs Office of Budget and Finance. Results; By 2019, papillary thyroid cancer will double in incidence and become the third most common cancer in women of all ages at a cost of

Minimally Invasive Video-Assisted Thyroidectomy A Multi-institutional North American Experience

18 to

Is preoperative investigation of the thyroid justified in patients undergoing parathyroidectomy for hyperparathyroidism

21 billion dollars in the United States. Despite these substantial clinical and economic burdens, thyroid cancer research remains significantly underfunded by comparison, and in 2009 received only

Pheochromocytoma in Pregnancy. A Case Series and Review

14.7 million (ranked 30th) from the NCI. Conclusion: The impact of thyroid cancer on society has been significantly underappreciated, as is evidenced by its low priority in national research funding levels. Impact: Increased awareness in the medical community and the general public of the societal burden of thyroid cancer, and substantial increases in research on thyroid cancer etiology, prevention, and treatment are needed to offset these growing concerns. Cancer Epidemiol Biomarkers Prev; 22(7); 1252–9. ©2013 AACR.

Recurrent Laryngeal Nerve Monitoring: State of the Art, Ethical and Legal Issues

OBJECTIVE To report the results of a multi-institutional experience with the minimally invasive video-assisted thyroidectomy, which was conceived in Europe and Asia and has only recently been embraced in the United States. DESIGN Prospective, nonrandomized analysis. SETTING Four academic thyroid surgical practices. PATIENTS Consecutive series of 228 patients who required thyroid surgery and were deemed at surgeon discretion to be eligible for a minimal access surgery. INTERVENTIONS Minimally invasive video-assisted thyroidectomy was performed in 216 patients. MAIN OUTCOME MEASURES The data, which were recorded prospectively, included age, sex, indication for surgery, incision length, and complications of surgery. RESULTS Because conversion to an open approach was required in 12 of the 228 patients, the study group comprised 216 patients (25 men and 191 women; mean [SD] age, 44.5 [14.1] years). There were no hematomas and no cases of permanent hypoparathyroidism or permanent vocal cord paralysis. Nine patients had a transient vocal cord paresis (3.2% of nerves at risk); 5 patients experienced temporary hypocalcemia (8.1% of total thyroidectomies); 1 patient reported a change in voice pitch; and 1 patient required a scar revision. CONCLUSIONS Use of the minimally invasive video-assisted thyroidectomy technique has been adopted cautiously in the United States. The safety of the procedure represented by the data from this multi-institutional experience would support its expanded adoption by high-volume thyroid surgeons.

Minimally Invasive Video-Assisted Thyroidectomy for Follicular Neoplasm: Is There an Advantage Over Conventional Thyroidectomy?

BACKGROUND The finding of coexisting nodular thyroid disease during neck exploration for hyperparathyroidism (HPT) is reported to range from 20%-60%. Thus, the surgeon may encounter a second, unrelated lesion during open parathyroidectomy. Furthermore, with the recent introduction of minimally invasive surgery for HPT, the entire neck may not be explored, and it is important to know the potential risk of missing significant, concurrent thyroid disease. The diagnosis and timely treatment of associated thyroid abnormalities is desirable because a delay in operating would result in increased morbidity associated with a second neck exploration. DESIGN We examined our 25-year experience at a large tertiary academic medical center, to determine the incidence and type of concurrent thyroid disease seen in patients with HPT. The computerized records of the Department of Pathology, from 1974-1999, were reviewed for patients with primary HPT who underwent surgery. RESULTS A review of records from 580 patients who underwent surgery for primary HPT showed 103 (18%) patients with concomitant thyroid disease at surgery. All 103 underwent thyroid resection at the time of parathyroidectomy. Thyroid histology showed: 12 (12%): well-differentiated papillary carcinomas, 31 (30%): follicular adenomas, 49 (48%): nodular hyperplasias, 8 (8%): chronic lymphocytic thyroiditis, 1 benign cyst, 1 metastasis, and 1 normal. CONCLUSIONS Synchronous thyroid disease was found in 18% of primary HPT patients undergoing surgery, and 12% of thyroid lesions were malignant. The overall malignancy rate was 2%. All primary malignancies found were papillary carcinomas, of which 7 of 12 (58%) were microcarcinomas. The significant association of simultaneous pathology in the two glands justifies preoperative thyroid imaging and fine-needle aspiration (FNA) biopsy to determine the best surgical approach for patients with HPT.