Peter J. Mazzaglia

Limited Value of Adrenal Biopsy in the Evaluation of Adrenal Neoplasm: A Decade of Experience

OBJECTIVE To determine the value of percutaneous adrenal biopsy in the evaluation of adrenal neoplasm. DESIGN Retrospective review. SETTING Tertiary referral center. PATIENTS All adult patients undergoing image-guided adrenal biopsy from 1997 to 2007. Main Outcome Measure Biopsy sensitivity for malignancy. RESULTS There were 163 biopsies performed on 154 patients. Mean (SD) age was 66 (12.5) years. Eighty-eight biopsies (53.4%) were performed in patients with a prior diagnosis of cancer. Forty-five (26.4%) were performed when imaging study results suggested previously undiagnosed cancer with a simultaneous adrenal metastasis. Thirty (20.2%) were performed for isolated adrenal incidentalomas. Rates of positive biopsy results in these 3 groups were 70.6%, 69.0%, and 16.7%, respectively. Prebiopsy evaluation for pheochromocytoma was performed in less than 5% of patients with established or suspected nonadrenal malignancies and 32% of patients with incidentalomas. In patients with isolated adrenal incidentaloma, a radiology report recommended biopsy 33% of the time for characteristics inconsistent with benign adenoma. Benign incidentalomas measured mean (SD) 4.2 (2.1) cm (range, 1.4-10.7 cm), and malignancies measured mean (SD) 9.3 (3.3) cm (range, 5.3-14 cm) (P < .05). All incidentalomas 5 cm or less (n = 18) were benign. There were 4 false-negative biopsy results: 3 adrenocortical carcinomas and 1 pheochromocytoma. CONCLUSIONS Biopsy is unhelpful in patients with isolated adrenal incidentaloma. Despite atypical radiographic findings, all nonfunctioning nodules 5 cm or less were benign. The negative predictive value is unacceptably low and cannot be relied on to rule out malignancy. The value of biopsy remains the diagnosis of metastatic carcinoma in patients with a nonadrenal primary malignancy, proven by the more than 70% positive rate in this group.

Does failure to perform prophylactic level VI node dissection leave persistent disease detectable by ultrasonography in patients with low-risk papillary carcinoma of the thyroid?

BACKGROUND There is controversy regarding the need for prophylactic level VI central node dissection in patients with low-risk papillary thyroid carcinoma (PTC). This study focuses on the incidence of persistent level VI nodal disease in low-risk PTC without prophylactic central node dissection. METHODS PTC was known at the time of thyroidectomy in 304 of the 761 patients who had initial thyroid surgery from 2001 to 2007. Therapeutic level VI node dissection was performed for suspicious or positive nodes. A prophylactic central node dissection was not done if suspicious nodes were not identified. All patients had a high-resolution ultrasonography, and almost all patients had a suppressed serum thyroglobulin level 4-6 months after thyroidectomy. RESULTS A total of 112 of 304 patients (37%) had a therapeutic level VI node dissection. A prophylactic central node dissection was not performed in the remaining 192 patients. One hundred and sixty-one of the 192 patients (84%) were low risk. Biopsy-proven persistent disease was identified at the 4-6-month postoperative ultrasonography in only 3 of the 161 low-risk patients (1.8%). The suppressed serum thyroglobulin level was increased in these 3 patients and 2 additional patients. CONCLUSION Failure to perform a prophylactic central node dissection in low-risk PTC resulted in both a very low incidence of persistent level VI nodal disease and elevated suppressed thyroglobulin 4-6 months after thyroidectomy.

The phenotype of primary hyperparathyroidism with normal parathyroid hormone levels: How low can parathyroid hormone go?

BACKGROUND While normocalcemic hyperparathyroidism is well recognized in primary hyperparathyroidism (PHP), less is known about patients with high calcium but normal intact parathyroid hormone (iPTH). We aimed to describe this entity and designated it normohormonal primary hyperparathyroidism (NHPHP). METHODS From a prospectively maintained database of patients undergoing bilateral parathyroid exploration for PHP, we identified and compared those with preoperative iPTH levels below (NHPHP) and above (typical PHP) normal reference peak (60 pg/mL). RESULTS NHPHP occurred in 46 of 843 patients (5.5%) undergoing initial parathyroidectomy for PHP. All had hypercalcemia (11.1 mg/dL). Regarding preoperative iPTH, 7 patients (15%) had values <40 pg/mL, 19 (41%) had values <60 pg/mL; and 20 (44%) had intermittent values >60 pg/mL. Unlike patients with elevated iPTH, nearly all NHPHP patients had additional testing delaying the operation. Imaging correctly localized NHPHP parathyroid disease in 80%. At the time of operation, 74% of NHPHP patients had single adenomas. Intraoperatively postmobilization, using the same assay that was used preoperatively, 82% had PTH levels >60 pg/mL (mean, 279 pg/mL). During the follow-up period, iPTH levels remained lower among NHPHP patients (21 pg/mL) compared to 41 pg/mL for patients with preoperative iPTH 60 to 100 pg/mL and 56 pg/mL for patients with preoperative iPTH 100 to 200 pg/mL (P < .0001). CONCLUSION Lower PTH set points may exist in some patients with otherwise typical PHP features. Although high normal iPTH is inappropriate for hypercalcemia and should suggest PHP, this disorder may occur with iPTH levels as low as 5 pg/mL. Awareness of the unusual phenotype of NHPHP may facilitate earlier diagnosis and surgery.

Laparoscopic adrenalectomy: Balancing the operative indications with the technical advances†

Laparoscopic adrenalectomy contributed significantly to reduction of morbidity and improvement of postoperative patient recovery time. The adoption of this technique had substantial impact on the management of adrenal incidentalomas. Although laparoscopic adrenalectomy should be in general avoided for known primary adrenal cancers, it is appropriate for metastasectomy of isolated adrenal metastatic disease. J. Surg. Oncol. 2010; 101:739‐744.

Hereditary pheochromocytoma and paraganglioma

Hereditary pheochromocytomas (pheo) and paragangliomas (pgl) are caused by identifiable germline mutations. The previously well‐known associated syndromes include neurofibromatosis type 1, multiple endocrine neoplasia 2 A and B, and von Hippel‐Lindau syndrome. Newly discovered mutations in the succinate dehydrogenase gene complex have been identified as a cause of inherited pgls and pheos. It is now clear that up to 30% of patients presenting with sporadic pheos/pgls harbor a recognizable germline mutation, and therefore directed genetic testing is recommended for many of these patients. J. Surg. Oncol. 2012; 106:580–585.

The Natural History of the Benign Thyroid Nodule: What Is the Appropriate Follow-Up Strategy?

BACKGROUND Long-term monitoring of benign thyroid nodules is not addressed in the present American Thyroid Association guidelines. The objective of this study was to determine the appropriate nature and length of follow-up for patients with a benign thyroid nodule. STUDY DESIGN A retrospective review was performed of all patients referred to single endocrine surgeon for evaluation of thyroid nodules between 2006 and 2012. The review included 263 patients who had benign fine needle aspiration (FNA) cytology and either underwent thyroidectomy or had at least a 1-year follow-up ultrasound. Main outcomes measures were repeat FNA and pathology results. RESULTS There were 231 women and 32 men. Forty-eight patients underwent immediate thyroidectomy, with pathology showing 2 papillary thyroid cancers (PTC), and 215 patients were followed with annual ultrasounds. During follow-up, 89 (41.3%) nodules underwent repeat FNA after initial biopsy. The repeat FNA cytology showed 91% benign, 7% follicular neoplasm, and 2% PTC. During follow-up, 81 (37.6%) patients underwent thyroidectomy after 3.3±2.8 years. Reasons for surgery included development of symptoms in 58 (71.6%), a non-benign repeat FNA in 8 (9.8%), or patient preference in 15 (18.5%). Surgical pathology identified 70 (86.4%) benign, 7 (8.6%) PTC, 3 (4%) follicular thyroid cancers, and 1 (1.2%) lymphoma. Median time from initial FNA to thyroidectomy in patients who had malignancy was 4.3 years. The maximum initial nodule size and average increase in nodule size did not differ between benign and malignant nodules (p=0.54 and p=0.75, respectively). CONCLUSIONS Significant numbers of benign thyroid nodules enlarge more than 5 mm over 3 years, triggering repeat FNA or thyroidectomy. Larger diameter nodules and more rapidly growing nodules were not predictive of malignancy. The practice of annually obtaining ultrasound for benign thyroid nodules should be discouraged.

Management of Incidental Adrenal Masses: A White Paper of the ACR Incidental Findings Committee

The ACR Incidental Findings Committee presents recommendations for managing adrenal masses that are incidentally detected on CT or MRI. These recommendations represent an update to the adrenal component of the JACR 2010 white paper on managing incidental findings in the adrenal glands, kidneys, liver, and pancreas. The Adrenal Subcommittee, constituted by abdominal radiologists and an endocrine surgeon, developed this algorithm. The algorithm draws from published evidence coupled with expert subspecialist opinion and was finalized by a process of iterative consensus. Algorithm branches categorize incidental adrenal masses on the basis of patient characteristics and imaging features. For each specified combination, the algorithm concludes with characterization of benignity or indolence (sufficient to discontinue follow-up) and/or a subsequent management recommendation. The algorithm addresses many, but not all, possible pathologies and clinical scenarios. Our goal is to improve the quality of patient care by providing guidance on how to manage incidentally detected adrenal masses.

Severe Group A Streptococcus Surgical Site Infection after Thyroid Lobectomy

BACKGROUND Thyroidectomy is rarely complicated by a surgical site infection (SSI). Despite its low incidence, post-thyroidectomy SSI is especially concerning because of its proximity to vital head and neck structures and the very real potential for airway compromise and death. Severe SSIs frequently are caused by Group A Streptococcus (GAS) because of its potential for developing into necrotizing fascitis. No description of the surgical approach to a necrotizing soft-tissue infection after thyroid resection is available in the current literature. METHODS Case report and review of the pertinent English-language literature. RESULTS A 47-year-old male underwent a right thyroid lobectomy and isthmusectomy for a follicular neoplasm. On post-operative day 2, the patient presented to the emergency department with persistent pain, rapid onset of swelling, and airway compromise shown on computed tomography scan. Emergency incision and drainage revealed a severe soft tissue infection. Because of subsequent worsening erythema and soft-tissue swelling, the patient had to be re-explored. The infection, later identified as caused by GAS, might have been transmitted from the patients daughter. CONCLUSION To our knowledge, this is the first case reported of exposure to a family member with GAS pharyngitis. Successful treatment requires an appropriately high level of suspicion followed by emergent operative debridement and systemic antibiotics.

Radiographic evaluation of nonfunctioning adrenal neoplasms.

Incidental adrenal neoplasms are usually nonfunctioning benign adenomas. Once hormonal production has been assessed, the nonsecreting lesions must be evaluated for the possibility of malignancy. This evaluation relies primarily on the radiographic characteristics. This article focuses on the current state of radiologic technology available to accurately assess nonfunctioning adrenal incidentalomas. As this technology advances, a lesions malignant potential can more accurately be determined, thereby allowing physicians to make more informed treatment recommendations.

Controversy Over Radioiodine Ablation In Thyroid Cancer: Who Benefits?

Recent studies have proposed that overdiagnosis is probably the principal cause of the increased incidence of thyroid cancer. The controversy around radioiodine ablation is complicated by the ever increasing numbers of small, low-risk thyroid cancers being diagnosed. This article examines the history and evolving epidemiology of the disease and treatment.