Sarah Schaefer

Accuracy of Fine-Needle Aspiration Biopsy for Predicting Neoplasm or Carcinoma in Thyroid Nodules 4 cm or Larger

HYPOTHESIS All thyroid nodules 4 cm or larger should be surgically removed regardless of fine-needle aspiration biopsy (FNAB) results because of an unacceptably high rate of false-negative preoperative biopsy results in these large nodules. DESIGN Retrospective cohort study. SETTING Single-institution, tertiary academic referral center. PATIENTS A retrospective analysis was performed on all patients who underwent surgery for a thyroid nodule 4 cm or larger from May 1, 1994, through January 31, 2007. MAIN OUTCOME MEASURES Preoperative FNAB results were correlated with final surgical pathologic results. The FNAB results were reported as nondiagnostic, benign, inconclusive (follicular neoplasm), or malignant, whereas the final surgical pathologic data were reported as benign or malignant. RESULTS Of 155 patients who underwent a thyroidectomy for a nodule 4 cm or larger, 21 patients (13.5%) had a clinically significant thyroid carcinoma within the nodule on final pathologic analysis. Preoperative cytologic testing of the mass was performed on 97 patients, and the results read as benign for 52, inconclusive for 23, nondiagnostic for 11, and malignant for 11. In lesions 4 cm or larger, 26 of 52 FNAB results reported as benign (50.0%) turned out to be either neoplastic (22) or malignant (4) on final pathologic analysis. Among patients with nondiagnostic FNAB results, the risk of malignant neoplasms was 27.3%. CONCLUSIONS In patients with thyroid nodules 4 cm or larger, the FNAB results are highly inaccurate, misclassifying half of all patients with reportedly benign lesions. Furthermore, those patients with a nondiagnostic FNAB result display a high risk of differentiated thyroid carcinoma. Therefore, we recommend that diagnostic lobectomy be strongly considered in patients with thyroid nodules 4 cm or larger regardless of FNAB cytologic test results.

Thyroid hormone replacement after thyroid lobectomy

BACKGROUND The purpose of this study was to determine the incidence of and identify risk factors for postoperative hypothyroidism in patients undergoing thyroid lobectomy. METHODS We retrospectively reviewed patients who underwent a thyroid lobectomy for benign disease from May 2004 to December 2007. Patients with known hypothyroidism or on preoperative thyroid hormone replacement were excluded. RESULTS In this study, 14.3% of patients developed hypothyroidism and required thyroid hormone supplementation. These hypothyroid patients had a higher mean pre-operative thyroid-stimulating hormone (TSH) and lower mean free thyroxine (T4) serum levels compared with euthyroid patients (TSH, 2.12 vs 1.35 microIU/mL [P = .006]; free T4, 1.03 vs 1.34 ng/dL [P = .01]). When stratified into 3 groups based on their preoperative TSH measurement (< or =1.5, 1.51-2.5, and > or =2.51 microIU/mL), the rate of hypothyroidism increased significantly at each level (13.5%, 20.5%, and 41.3%, respectively [P < .001]). In addition, patients with Hashimotos thyroiditis were significantly more likely to become hypothyroid (odds ratio, 3.78; 95% confidence interval, 2.17-6.60). CONCLUSION After thyroid lobectomy, approximately 1 in 7 patients experience hypothyroidism requiring thyroid hormone treatment. Patients with preoperative TSH levels >1.5 microIU/mL, lower free T4 levels, and Hashimotos thyroiditis are at increased risk and should be counseled and followed appropriately.

Operative failures after parathyroidectomy for hyperparathyroidism: the influence of surgical volume.

Objective:To determine whether surgical volume influences the cause of operative failures after parathyroidectomy for hyperparathyroidism. Summary and Background Data:The surgical success rate for hyperparathyroidism from high-volume centers exceeds 95%, but some patients have unsuccessful parathyroidectomies. Although operative failure can be due to hyperfunctioning parathyroid glands in ectopic locations, less experienced surgeons may be more likely to miss an abnormal parathyroid in normal anatomic locations, which we describe as “preventable operative failure.” Methods:We used 2 prospective databases containing over 2000 consecutive patients who underwent parathyroidectomy. We identified 159 patients with persistent/recurrent hyperparathyroidism subsequently cured with additional surgery. The initially failed operations were classified as being performed at high- (>50 cases/yr) or low-volume (<50 cases/yr) hospitals. Hospital volume was obtained from a Wisconsin state database of 89 hospitals, which reported 6336 parathyroid operations during the same decade. Results:Patients who initially failed their operation performed at the high- or low-volume centers were similar with regard to age, laboratory values, gender, and parathyroid weights. Despite a higher incidence of multigland disease (which increases the likelihood of operative failure) in the high-volume group, patients in the low-volume group were more likely to have a missed parathyroid gland in a normal anatomic location (89% vs. 13%, P < 0.0001), and thus a higher proportion of preventable operative failures. Conclusions:Surgical volume influences the failure pattern after parathyroidectomy for hyperparathyroidism. Preventable operative failures are more common in low-volume centers.

Same-day thyroidectomy program: Eligibility and safety evaluation

BACKGROUND Same-day thyroidectomy has not gained widespread acceptance owing to concerns of life-threatening complications. The aim of this study is to describe a single institution same-day thyroidectomy results. METHODS We included patients who underwent thyroid surgery between 2005 and 2011 by a single surgeon. The outcomes of patients who underwent inpatient (IP) and same-day thyroidectomy were compared. Routine postoperative parathyroid hormone testing for same-day thyroidectomy commenced in 2010, and results were also compared after that date. RESULTS Thyroid surgery was performed in 608 patients; 298 (49%) were performed as same-day thyroidectomy. Patients undergoing same-day thyroid lobectomy had similar, low documented complication rate as IP lobectomy. Patients with same-day total thyroidectomy (SDTT) had similar rates of documented transient hypocalcemia and neck hematoma compared with IPs. After 2010, all patients without restrictive underlying comorbidities were scheduled for same-day thyroidectomy unless otherwise specifically requested by the patient. Only 4 (3%) patients scheduled for SDTT were converted to IPs, all without neck complications. CONCLUSION Same-day thyroidectomy is safe and can be routinely performed by experienced surgeons who have low complication rates and a patient support system.

What is the clinical significance of an elevated parathyroid hormone level after curative surgery for primary hyperparathyroidism

Objectives:Recent reports have demonstrated that between 8%–40% of patients after curative surgery for primary hyperparathyroidism (HPT) have an elevated parathyroid hormone level (ePTH). To determine the clinical significance of ePTH and if it is a potential risk factor for recurrent HPT, we reviewed our experience. Methods:611 consecutive patients underwent curative parathyroidectomy for primary HPT by one surgeon. Patients with ePTH [defined as postoperative parathyroid hormone (PTH) levels ≥65 pg/mL at least 1 week after surgery with normal calcium levels] were compared with those with normal PTH. Results:ePTH occurred in 111/611 (18.2%) patients. When compared with those with normal PTH, ePTH patients were older and had higher preoperative PTH and alkaline phosphatase levels (P < 0.05). Importantly, recurrent HPT was significantly higher in patients with ePTH (5.4% versus 1.2%, P < 0.05). Further analysis of the ePTH patients revealed that serum calcium 1-week after surgery was predictive of recurrent HPT. In ePTH patients with postoperative calcium ≥9.7 mg/dL, the recurrence rate was 16% compared with 0% in those whose calcium was <9.7 mg/dL. Conclusions:Most of patients (95%) with ePTH after curative parathyroidectomy for primary HPT will not develop recurrent HPT. However, recurrent disease is significantly more common among patients with ePTH and was always associated with postoperative calcium ≥9.7 mg/dL. Thus, these data suggest that streamlining postoperative surveillance to this subset of patients may optimize resource utilization.

A rising ioPTH level immediately after parathyroid resection: are additional hyperfunctioning glands always present? An application of the Wisconsin Criteria.

Objective:This study was designed to determine if a rising intraoperative parathyroid hormone (ioPTH) level following parathyroid resection indicates multiple hyperfunctioning glands and to determine the appropriate intraoperative management. Summary Background Data:IoPTH monitoring is commonly used to guide parathyroid surgery. A significant rise in the ioPTH immediately after resection of a single parathyroid is often perceived to be indicative of the presence of additional hyperfunctioning glands. Methods:A total of 797 consecutive patients underwent parathyroidectomy for primary hyperparathyroidism with ioPTH monitoring. Patients with an elevated 5 minute ioPTH were extensively studied. Operative success was defined as normocalcemia 6 months after surgery. Results:Of the 797 patients, 108 (14%) had a rising ioPTH 5 minutes after resection of a single parathyroid. Of these 108 patients, 36 (33%) continued to have elevated ioPTH levels and further exploration revealed additional hyperfunctioning glands. Importantly, in the majority of patients (n = 72 or 67%), the ioPTH started to fall after an additional 5 minutes (10 minutes after resection). The ioPTH declined by more than 50% from the 5 minute elevated value in 30%, 89%, and 99% of patients at 10, 15, and 20 minutes after resection, respectively. Importantly, this fall correctly predicted operative success in 100% of patients after removal of a single abnormal gland. Conclusions:A rising ioPTH level immediately after parathyroidectomy is observed in 14% of patients. The majority of these patients do not have additional hyperfunctioning glands. Most of patients fell below 50% of the 5 minute elevated value within 20 minutes of gland resection and in all cases this fall correctly predicted operative success.

Preserving function and quality of life after thyroid and parathyroid surgery

Endocrine disease has been recognised for thousands of years, but surgical treatment of endocrine disorders has only been widely used in the past century. Surgery is an effective treatment for hyperfunctioning glands and benign and malignant tumours. Advances in surgical technique have led to the development of short and safe operations with a high cure rate, and recent studies have not only assessed the success of the operations but also have focused on how these diseases affect patient-reported quality of life before and after surgery. In this Review, we summarise current approaches to surgical treatment of thyroid and parathyroid disease, focusing on how these approaches both preserve function and improve quality of life after surgery.

Does Routine Use of Ultrasound Result in Additional Thyroid Procedures in Patients with Primary Hyperparathyroidism

BACKGROUND Minimally invasive parathyroidectomy for primary hyperparathyroidism depends on accurate preoperative imaging. Cervical ultrasound is commonly used to localize parathyroid adenomas, but can lead to discovery of concomitant thyroid gland pathology requiring modification of the operative approach. How the identification of incidental thyroid lesions affects patient management is unclear. STUDY DESIGN A prospective database of patients undergoing parathyroidectomy was analyzed for thyroid pathology discovered by ultrasound. Lesions were biopsied if indicated, and operative management was adjusted accordingly. Clinical data were correlated with operative decision-making. RESULTS Between July 2002 and November 2009, 310 patients with primary hyperparathyroidism underwent ultrasound. Concomitant thyroid pathology was noted in 89 (29%) patients. Thirty-seven patients (42% of pathology) underwent fine-needle aspiration of a thyroid nodule. Thirteen patients (4% of all patients) underwent a thyroid operation not related to parathyroid disease: 9 thyroid lobectomies for presumably benign nodules and 4 total thyroidectomies for malignancy. Two were for confirmed papillary thyroid cancer, and the other 2 were for an indeterminate biopsy that later proved to be papillary thyroid cancer. One lobectomy discovered microscopic papillary thyroid cancer independent of the biopsied nodule. In total, 5 (2% of all patients) malignancies were discovered. CONCLUSIONS Twenty-nine percent of patients with primary hyperparathyroidism had concomitant thyroid pathology on ultrasound. Forty-two percent of these patients underwent biopsy, and 2% had malignant pathology. Routine use of ultrasound in patients with primary hyperparathyroidism leads to discovery of unrecognized thyroid pathology and cancer.

The use of the Ligasure for hemostasis during thyroid lobectomy

BACKGROUND The Ligasure electrothermal vessel sealer (Valleylab, Boulder, CO) has been introduced as a new method for hemostasis during thyroidectomy. We hypothesized that the use of Ligasure would potentially reduce operative time during thyroid surgery. METHODS From 2001 to 2005, 150 patients had a thyroid lobectomy by a single surgeon. Data from these patients were prospectively collected in a database and retrospectively analyzed. RESULTS Of the 150 patients, 51 underwent thyroid lobectomy with the use of the Ligasure and 99 patients underwent conventional ligation of vessels. There were no differences between groups with regard to demographic factors, thyroid gland pathology, or complications. Operative time was significantly shortened by 40 minutes in patients who had surgery with the Ligasure. CONCLUSION In patients undergoing thyroid lobectomy, the use of the Ligasure decreases operating room time and is associated with no increase in complications. Thus, we advocate the routine use of this technology during thyroid surgery.

Using Body Mass Index to Predict Optimal Thyroid Dosing after Thyroidectomy

BACKGROUND Current postoperative thyroid replacement dosing is weight based, with adjustments made after thyroid-stimulating hormone values. This method can lead to considerable delays in achieving euthyroidism and often fails to accurately dose over- and underweight patients. Our aim was to develop an accurate dosing method that uses patient body mass index (BMI) data. STUDY DESIGN A retrospective review of a prospectively collected thyroid database was performed. We selected adult patients undergoing thyroidectomy, with benign pathology, who achieved euthyroidism on thyroid hormone supplementation. Body mass index and euthyroid dose were plotted and regression was used to fit curves to the data. Statistical analysis was performed using STATA 10.1 software (Stata Corp). RESULTS One hundred twenty-two patients met inclusion criteria. At initial follow-up, only 39 patients were euthyroid (32%). Fifty-three percent of patients with BMI >30 kg/m(2) were overdosed, and 46% of patients with BMI <25 kg/m(2) were underdosed. The line of best fit demonstrated an overall quadratic relationship between BMI and euthyroid dose. A linear relationship best described the data up to a BMI of 50. Beyond that, the line approached 1.1 μg/kg. A regression equation was derived for calculating initial levothyroxine dose (μg/kg/d = -0.018 × BMI + 2.13 [F statistic = 52.7, root mean square error of 0.24]). CONCLUSIONS The current standard of weight-based thyroid replacement fails to appropriately dose underweight and overweight patients. Body mass index can be used to more accurately dose thyroid hormone using a simple formula.