Robert Udelsman

Optimal surgery for papillary thyroid carcinoma

Abstract. There has been a long, unresolved debate regarding the operation of choice for well differentiated carcinoma of the thyroid. We therefore analyzed the feasibility, scope, sample size, and length of follow-up required to determine the optimal operation for papillary thyroid carcinoma. A statistical approach was used to design a randomized prospective trial comparing the endpoints of complications, recurrence, and cause-specific mortality. A complication comparison trial is prohibitive owing to the large population required—approximately 12,000 randomized patients. A recurrence trial appears feasible based on sample size: approximately 360 to 800 patients with a 6 to 10-year follow-up. However, recurrence detection would be severely compromised in the lobectomy arm, and a unilateral lag-time bias would occur. A cause-specific mortality trial proves to be the least objectionable, although a large sample size (n = 3100) would be required. Such a trial is critically dependent on the ability to select an appropriate endpoint. A cause-specific mortality trial proves to be the most objective and statistically valid endpoint.

Radiology of the adrenal

Adrenal incidentalomas are commonly noted on abdominal cross-sectional imaging studies. Most of these lesions are benign, non-functional adrenal adenomas. Certain adrenal lesions have such characteristic radiologic findings that their diagnosis can be made with virtual certainty. This article reviews the radiologic evaluation of adrenal tumors, with particular emphasis on incidentalomas.

CHAPTER 28 – Guidelines for the Medical and Surgical Management of Primary Hyperparathyroidism

Parathyroidectomy (PTX) is for patients with primary hyperparathyroidism (PHPT) who require treatment, and the recommendations first proposed by the National Institutes of Health (NIH). If dated NIH consensus development conference continues to provide a useful algorithm for identifying patients for whom surgery is indicated. Despite advances in the understanding of the natural history of untreated PHPT, it is certain that some patients can have a mild disease that requires no specific intervention. Advances in minimally invasive surgery assure that there are fewer patients in whom surgery is contraindicated, but effort must intensify to develop rigorous, evidence-based guidelines that will identify all patients in whom surgery is likely to be beneficial. A role for estrogen therapy in postmenopausal women with PHPT is becoming more clearly defined. In women with sufficiently mild disease; the curative PTX is not immediately indicated and there is no contraindication to estrogen, this would seem to be a preferred approach over simple non-interventional observation.

Corticotropin Releasing Factor (Hormone): Physiological and Clinical Implications

In 1948, Harris suggested the possibility of humoral control of the pituitary gland by the hypothalamus (1–3). Saffran and Schally (4), and Guillemin and Rosenberg (5) demonstrated the presence of a hypothalamic corticotropin releasing (CRF) factor in 1955. Vale and coworkers isolated ovine CRF (oCRF) in 1981 (6). Shortly thereafter, Schally et al. described the composition of porcine CRF (pCRF) (7), and Rivier et al. that of rat CRF (rCRF) (8). Finally, the genes of both ovine and human CRF (hCRF) were sequenced and the amino acid composition of the corresponding peptides deduced (9,10). Rat and human CRF appear to be chemically identical. The structures of oCRF and hCRF (or rCRF) are shown in Figure 1. Human CRF differs from the oCRF molecule by 7 amino acids, giving the two peptides 83% homology.