Samuel P. Bugis

Review of the pathologic diagnoses of 2,216 appendectomy specimens

A retrospective review of 2,216 patients surgically treated for a clinical diagnosis of acute appendicitis was performed. In 80% of cases, histologic acute appendicitis was found; 57% of these patients were male. The rate of normal appendectomy was 16%, and females comprised 68% of that group. The remaining 102 cases (4%) were designated as the alternate diagnosis group. Apart from histologic diagnoses that could be considered variants of normal (57) or acute inflammation (20), the alternate diagnosis group included such entities as neoplasm, parasitic infection, mucocele, and diverticulitis.

Role of frozen section and clinical parameters in distinguishing benign from malignant follicular neoplasms of the thyroid

The determination of malignancy preoperatively or intraoperatively is difficult in patients with follicular neoplasms of the thyroid. This study reviews a series of 395 patients treated for follicular neoplasms at the Vancouver General Hospital and the British Columbia Cancer Agency between the years of 1955 and 1988, 198 of whom had frozen section at the time of surgery. Frozen section was 79% accurate in differentiating follicular adenomas from carcinomas, with a sensitivity of 52% and a specificity of 100%. The positive predictive value of a frozen section showing carcinoma was 100%, and the negative predictive value was 73%. An incorrect diagnosis of a benign lesion was made in 21% of patients in whom the final diagnosis by fixed section was carcinoma. These same statistics were calculated for patients aged greater than 50 years, tumor size greater than 3 cm, and patients with a history of previous neck irradiation, three clinical factors shown in a previous study to be strong prognostic indicators of malignancy. The results were compared with those found by frozen section. The implications of these results in terms of patient management are discussed.

Management of blunt and penetrating colon injuries

The records of 28 patients with traumatic colon injuries (TCI) were retrospectively reviewed. Sixteen patients (57%) with 17 TCI had blunt trauma, whereas 8 patients (29%) experienced penetrating trauma. Four TCI were from intraluminal injury. Blunt trauma commonly involved the left colon, whereas penetrating trauma usually involved the right or transverse colon. Fifty-nine percent of the blunt TCI were treated with primary repair, including resection and primary anastomosis, as were 88% of the penetrating TCI. Shock, transfusion requirement of more than 4 units, contamination, and associated injuries did not necessarily preclude primary repair. One of 16 patients (6%) who underwent primary repair developed morbidity related to the colon injury. The morbidity rate for the colostomy group was 13% (1 of 8). The mortality rate was 13% in the patients who experienced external trauma (3 of 24). Two of these deaths were related to severe head injury and chest injury, respectively. These data represent a much higher proportion of blunt injuries to the colon than is reported in the literature. The low rate of morbidity for all patients treated by primary repair tends to support the more liberal trend toward this technique for both blunt and penetrating TCI.

An evaluation of prognostic scoring systems in patients with follicular thyroid cancer

BACKGROUND Prognostic scoring systems for thyroid cancer have not been investigated in patients with pure follicular cancer; thus, the purpose of this study was to compare the following prognostic indices: the European Organization for Research and Treatment of Cancer (EORTC) method; the Age, Grade, Extent, Size (AGES) score; and the Age, Metastasis, Extent, Size (ALIES) score. PATIENTS AND METHODS A retrospective study reviewing 122 patients actively treated between 1955 and 1990 was conducted. Scoring systems were calculated and survival analysis completed. AGES low-risk patients were analyzed with respect to known risk factors. RESULTS The AGES scoring system significantly defined low- and high-risk groups (P = 0.0041); the ratio of deaths between high-versus low-risk groups was 1.9:1. EORTC scores distinguished four risk groups (P = 0.002). The AMES scoring system did not significantly assign risk. In multivariate analysis of low-risk AGES patients, age, perithyroidal tissue involvement, and positive frozen section reached statistical significance. CONCLUSIONS The AGES and EORTC scoring systems best defined low- and high-risk groups of patients with pure follicular cancer, although the separation between groups was low.

Determinants of Tc-99m sestamibi SPECT scan sensitivity in primary hyperparathyroidism

BACKGROUND The aim of this study was to evaluate the influence of patient and adenoma characteristics on (99m)Tc-methoxy isobutyl isonitrile (MIBI) scan performance in individuals diagnosed with primary hyperparathyroidism (PHP). METHODS Records of patients undergoing parathyroidectomy for PHP over 6 years at a single center were reviewed. RESULTS The overall true-positive (TP) rate for (99m)Tc-MIBI scans was 56%. Adenomas sized 1.9 to 3.5 cm were more likely to have TP scans than 0.3-cm to 1.8-cm adenomas (74% vs 40%, P < .001). Preoperative ionized calcium levels between 1.49 and 1.72 mmol/L were more likely to have TPs than levels between 1.27 and 1.48 mmol/L (65% vs 47%, P < .05). No single class of medication was shown to significantly effect TP rates. A decrease in TP rate was observed for larger adenomas in patients on >or=1 medication (74% vs 65%, P = .05). CONCLUSIONS In PHP, (99m)Tc-MIBI scan positivity is most related to adenoma size and preoperative ionized calcium level.

Normocalcemic parathyroid carcinoma: an unusual clinical presentation

BackgroundParathyroid carcinoma is a rare cause of primary hyperparathyroidism and may be associated with significant disease related morbidity and mortality. Preoperative diagnosis remains a challenge, which may jeopardize appropriate and successful patient treatment.Case presentationWe report a case of parathyroid carcinoma diagnosed in a 60-year-old woman that presented with a tender nodule located at the left lower thyroid pole and had been present for several years. Ultrasound examination revealed a 2.7 × 1.6 × 2.7 cm mass within the lower left lobe of the thyroid with cystic and solid areas. Lab measurement of the intact PTH level revealed it to be three times the upper limit of normal and the serum calcium level was within normal limits. A left thyroid lobectomy and isthmusectomy was carried out. Histopathological evaluation was diagnostic for a parathyroid carcinoma. At greater than two years of follow-up, the patient has had no evidence of disease recurrence and her serum PTH and calcium levels have remained within normal.ConclusionParathyroid carcinoma is a rare endocrine tumor which must be considered in the differential diagnosis of a nodular thyroid mass. En bloc resection remains the treatment of choice for this malignancy. Disease prognosis is influenced by the extent of the initial resection, the presence of metastases, and adequate long-term follow-up.

Hemithyroidectomy is the preferred initial operative approach for an indeterminate fine needle aspiration biopsy diagnosis

BACKGROUND Fine needle aspiration biopsy represents the critical initial diagnostic test used for evaluation of thyroid nodules. Our objectives were to determine the cytological distribution, the utility of clinicopathologic characteristics for predicting malignancy and the true proportion of cancer among individuals who presented with indeterminate cytology and had undergone thyroid surgery for suspicion of cancer. METHODS We retrospectively reviewed 1040 consecutive primary thyroid operations carried out over an 8-year period at a tertiary care endocrine referral centre. Follicular neoplasm (FN), Hürthle cell neoplasm (HN), neoplasms suspicious for but not diagnostic of papillary carcinoma (IP) and neoplasms with cellular atypia (IA) were reviewed. RESULTS In all, 380 individuals presented with cytologically indeterminate thyroid nodules. Of these, 252 (66%) patients had FN, 47 (12%) HN, 44 (12%) IP, 26 (7%) IA and 11 (4%) had mixed diagnoses. Biopsied lesions were found to be malignant on pathological evaluation in 102 (27%) patients: 49 (19%) with FN, 11 (23%) HN, 28 (64%) IP and 9 (35%) with IA. Hemithyroidectomy was adequate definitive treatment in 196 of 225 (87%) patients with FN and 39 of 42 (93%) with HN. Significant associations with a cancer diagnosis were identified for smaller tumour size in patients with FN (p = 0.004) and right thyroid lobe location in patients with IP (p = 0.012), although these factors were nonsignificant in the corrected analyses for multiple comparisons. CONCLUSION In a review of the experience at a Canadian centre, 4 operations were carried out to identify each cancer, and hemithyroidectomy was the optimal initial and definitive surgical approach for most patients.

Intact parathyroid hormone measurement 1 hour after thyroid surgery identifies individuals at high risk for the development of symptomatic hypocalcemia

BACKGROUND There is currently no consensus regarding the utilization of intact parathyroid hormone (iPTH) for predicting postthyroid surgery hypocalcemia. The objective of this study was to determine a threshold value for the 1-hour postoperative iPTH level that can identify those patients at significantly increased risk for the development of symptomatic hypocalcemia. METHODS A prospective study of 21 individuals undergoing either total or completion thyroid operations was performed. One-hour postoperative iPTH levels were drawn along with ionized calcium at 6 hours postoperatively and at 7 am the following morning. Symptoms of hypocalcemia were recorded. RESULTS Of the 21 patients recruited into the study cohort, there were 18 individuals that developed hypocalcemia (4 symptomatic and 14 asymptomatic) and 3 that remained normocalcemic. The mean iPTH level 1 hour postoperatively was significantly different when comparing the normocalcemic, asymptomatic hypocalcemic, and symptomatic hypocalcemic patient groups (6.50 pmol/L versus 3.76 pmol/L versus 0.7 pmol/L, respectively; P = .007). An iPTH level <or=2.5 pmol/L was 100% sensitive for predicting which individuals would go on to develop symptomatic hypocalcemia. CONCLUSIONS This study suggests that a 1-hour postoperative iPTH level <or=2.5 pmol/L can identify those individuals at risk for developing symptomatic hypocalcemia. Therefore, we recommend early calcium supplementation for these patients to decrease their postoperative morbidity from symptomatic hypocalcemia.