Sudhi Agarwal

Posterior Retroperitoneoscopic Adrenalectomy for Clinical and Subclinical Cushing’s Syndrome: Letter

We read with interest the article by Alesina et al. [1] and we congratulate the authors for their contribution to the of management of Cushing’s syndrome, which is frequently encountered by endocrine surgeons. Because of severe obesity and associated co-morbid conditions, surgical excision of tumor by the conventional transperitoneal procedure, via either the open or laparoscopic approach, has always been challenging. A direct approach leading to the tumor has always been desirable. To gain a full understanding of the study of Alesina et al., we would like to know how many of their patients were morbidly obese and what their experience was in the management of such patients [2]. Second, because the chance of malignancy is much higher in patients with adrenal tumors C6 cm [3], and because of limited intraoperative exposure and inability to inspect the liver and peritoneal surfaces, the transperitoneal approach is preferred over the retroperitoneal approach in suspected adrenal malignancy [4, 5], we would like to know how many of their patients had tumors C6 cm on preoperative imaging, and what their strategy was in removing these tumors.

The Necessity and Reliability of Intraoperative Parathyroid Hormone (PTH) Testing in Patients with Mild Hyperparathyroidism and PTH Levels in the Normal Range

To the Editor, We read with interest the article by Alhefdhi et al. [1] and discussed it in our journal club. We congratulate the authors for raising the issue of using intraoperative parathyroid hormone (PTH) monitoring in mild primary hyperparathyroidism (PHPT). Because of the mild biochemical and clinical indicators and the indolent natural course of the disease, surgical intervention and its benefits remain controversial [2]. It is particularly difficult to apply intraoperative adjuncts to decide the surgical cure of the patient when the serum PTH level is within the normal range. Very few studies have focused on this issue [3], and we believe the utility of intraoperative PTH (IOPTH) monitoring in mild PHPT needs to be studied, as the incidence of mild PHPT, common in Western countries, is also becoming prevalent in developing countries. To improve our understanding of the authors’ approach, we would like clarification on several points: First, did the authors perform preoperative localization? If so, how many of their patients were diagnosed preoperatively with multigland disease? The authors mention that they investigated the patients undergoing ‘‘standard targeted parathyroidectomy’’; we are not clear what that means. Also, how did they approach patients with multiglandular disease? It would be particularly informative to know the clinicopathological and surgical details of the five patients who did not have IOPTH decline [50% until the end of the procedure. Routine cases can be managed by any means, but the characteristics of this problem group need to be addressed for improved outcome. When it became apparent that the IOPTH level had not decreased, what was done? The reported cure rate in the present study was 100%; however, the mean preoperative serum calcium level was 10.8 ± 0.1 mg/dl, and there might have been some patients with normal serum calcium with normal serum PTH (as per the inclusion criteria) Given this possibility, how did the authors decide that operative cure had been effected, especially in those five patients with no decline in the PTH level until the end of the operation?

Pattern and Risk Factors of Central Compartment Lymph Node Metastasis in Papillary Thyroid Cancer: A Prospective Study from an Endocrine Surgery Centre

Lymphatic metastasis in papillary thyroid cancer (PTC) is eminent; however, the extent of central compartment lymph nodes dissection (CCD) is controversial and requires the knowledge of pattern and risk factors for central compartment lymph nodes metastasis (CCM). We did a prospective study of 47 cases with PTC who underwent total thyroidectomy (TT) with CCD with/without lateral lymph nodes dissection (LND). Clinicopathological profile including CCM as ipsilateral and contralateral was documented. On histopathology, the mean tumour size was 3.57 ± 2.42 cm 59.6% had CCM, which was bilateral in the majority (60.72%). The tumour-size was the most important predictor for lymph nodes metastasis-(P=0.018) whereas multicentricity-(P=0.002) and ipsilateral CCM-(P=0.001) were the predictors for contralateral CCM. The long-term morbidity of CCD done in primary setting is comparable with TT-alone. Bilateral CCD should be done with thyroidectomy in PTC, otherwise the risk of residual diseases and subsequent recurrence is high. The long-term morbidity is comparable in experienced hands.

Surgeon-Performed Ultrasound Can Predict Differentiated Thyroid Cancer in Patients with Solitary Thyroid Nodules

We had read this article with interest and want to congratulate Dr. Jabiev and his team for their approach in predicting differentiated thyroid cancer in patients with solitary thyroid nodules. However, we would like to have more clarification on few points. Had the authors performed preoperative FNAC in these patients and compared the results with surgeonperformed ultrasound findings? If so, what were their findings? Cappelli et al. described the predictive value of ultrasonographic findings and compared them with cytology results in thyroid nodules and found that microcalcifications were the strongest predictor for malignancy. They also found that Type 2 vascularity (intranodular flow with multiple vascular images) and size are also statistically significant predictors for malignancy. Also we would like to know whether intraoperative frozen section biopsies were done in these patients. If so, what was the indication? Moon et al. combined ultrasound and intraoperative frozen section in patients of papillary thyroid carcinomas, concluding that frozen section should be used when the features on ultrasound do not predict malignancy. Had the authors compared their ultrasonographic findings with the radiologist-performed ultrasound findings and could they find that surgeon-performed ultrasound is better than radiologist-performed ultrasound? If yes, in what way and what is their recommendation? A patient with thyroid nodule should undergo radiologist-performed ultrasound or not, if facility for both; surgeon-performed as well as radiologist-performed ultrasound is available?

Incidental Papillary Microcarcinoma of the Thyroid—Further Evidence of a Very Low Malignant Potential: A Retrospective Clinicopathologic Study with up to 30 Years of Follow-up

As the article by Neuhold et al. indicates, the management of micropapillary carcinoma, particularly that which is incidentally detected, has always been controversial. The study of the natural course of the disease would be helpful in deciding the aggressiveness of the initial treatment. This information can be obtained from studies with lengthy follow-up periods, such as that of Neuhold et al. To date, few studies have provided such lengthy follow-up. However, once any anticancer treatment is provided to a particular patient in the form of either surgery or radioactive iodine therapy, the natural course of the disease alters and may confound the results. These factors should be examined in detail. Thus, we would like clarification from the authors regarding a few points. In the study of Neuhold et al., the lymph nodes were clinically palpable in 5 cases; were those lymph nodes central or lateral? Because all other papillary microcarcinomas were diagnosed incidentally, what was the rationale of performing lymph node dissection in 20% of cases, and which group of lymph nodes was dissected, central or lateral? In the present series, radioactive iodine was administered in 22% cases; how were these patients selected for radioactive iodine therapy? Among four cases of recurrence, in their patient 2, a 38year-old woman who had nonincidentally detected papillary microcarcinoma due to palpable cervical lymph nodes, why was the lymph node dissection not performed in a primary setting? Similarly, in their patient 3, a 39-year-old woman, the tumor size was 5.5/10.7. What does this imply? The authors mentioned that the World Health Organization definition for papillary microcarcinoma is tumor B1 cm in size, a definition that the authors probably followed; why, then, is a tumor [1 cm in size included among papillary microcarcinomas? Finally, what do the authors mean by the term ‘‘extended thyroidectomy,’’ and is it recognized by any other authority?

A Novel Method for Managing Postthyroidectomy or Parathyroidectomy Hematoma: Single-Institution Experience With More Than 4000 Central Neck Operations

We read the article by Dixon et al. [1] with interest and congratulate the authors for their novel method of treating hematomas following thyroid and parathyroid surgery under local anesthesia and also for sharing their challenges in managing these hematomas. Hematomas following thyroid and parathyroid surgeries are at times ephemeral instead of obvious, with no definitive bleeding identified. The surgeon then needs all of his or her experience to tackle this dreaded complication, which has resulted in many surgeons not opting for day surgeries. However, there are certain observations in the article by Dixon et al. that need further clarification and comments that can be of use for future researchers. For instance, did the inexperience of the surgeon result in an increased incidence of hematomas [2]? Did patient characteristics such as muscularity of the individual or hypertension play a role [3]? Did the authors analyze factors such as the size of the goiter and/or retrosternal extension to determine if they increased the incidence of hematoma. As the duration of this study was over a period of 16 years, did the introduction of newer techniques (e.g., sutureless thyroidectomy) and the learning curves result in increased hematomas [4]? Were surgical factors analyzed, such as the type of suture material used for ligation and whether routine use of hemostatic agents (e.g., oxidized cellulose polymer) played a role? We agree with the authors about not using drains routinely [5], but did the authors use a drain after reexploration? Finally, were the patients educated preoperatively about these possible complications? Did a member of the operating team assess the patients before they were discharged?

Letter to the Editor: 25-Hydroxyvitamin D Status does not Affect Intraoperative Parathyroid Hormone Dynamics in Patients with Primary Hyperparathyroidism

We read with interest the article by Joel T. Adler et al. and we congratulate them for their productive work. The impact of vitamin D deficiency on the kinetics of parathormone (PTH) secretion and utility of intraoperative PTH (ioPTH) in predicting complete tumor-excision is always been a concern, especially in vitamin-D-deficient areas. We agree with authors, that concurrent vitamin D deficiency and primary hyperparathyroidism leads to increased gland weight; however, being from a vitamin-D-deficient endemic area, we observed relatively more severe bone complaints, with significant proportion presenting with brown tumors or fragility fractures, the serum alkalinephosphatase (ALP) and PTH levels significantly higher, and predominantly female involvement in deficient than sufficient group. Therefore, we would like to know from the authors:

Is Routine Dissection of Level II-B and V-A Necessary in Patients with Papillary Thyroid Cancer Undergoing Lateral Neck Dissection for FNA-Confirmed Metastases in Other Levels

We read with interest the article by Farrag et al. [1] published in the August 2009 issue and want to congratulate them for their highly informative effort. Spinal accessory nerve (SAN) injury been addressed by various thyroid and cancer surgeons [2], as it may lead to shoulder syndrome, which has a profound effect on the patient’s quality of life. It is also important in cases of cancers with relatively good prognosis, where other adjuvant treatment options following neck dissection for head and neck malignancies are available in the form of radioactive iodine ablation. Therefore, the risk of level IIb and Va lymph node metastasis must be weighed against the risk of SAN injury following dissection at these levels. Lee et al. [3] did the first prospective study in this regard and found that the anterolateral group were at greatest risk of lymphatic metastasis. In addition, level IIb lymph nodes metastasis was found only in association with level IIa metastasis. Similar evaluations performed retrospectively by others found similar results [4, 5]. However, we would like to gain some clarity from the authors about the exact levels of lymph nodes found positive on fine-needle aspiration cytology or peroperatively and their correlation with the level IIb lymph nodes, as the incidence of skip metastasis and multiple level disease is significantly high for papillary thyroid cancer [4, 5]. We also want to know the exact numbers, the levels of lymph nodes dissected, and the histopathologic features of the primary tumor and the metastatic lymph nodes as these data may also throw more light on the risk of involvement of level IIb lymph nodes.

Primary hyperparathyroidism from parathyroid microadenoma.

he authors thank Dr Wagner and Dr Schifftner-Smith for heir commentary on our examination of missing data ithin the American College of Surgeons National Surgical uality Improvement Program (ACS NSQIP). We acnowledge Dr Wagner’s and Dr Schifftner-Smith’s experise and appreciate their contributions to the understandng of this topic as well as to the broader evaluation of uality within health care. We also agree that further disussion of these topics is warranted and will be valuable, nd regret that there are many additional issues around the opic of missing data, including additional investigations uch as those noted by Dr Wagner and Dr Schifftnermith, which were beyond the scope of our brief article. As Dr Wagner and Dr Schifftner-Smith pointed out, the erminology of missingness is exacting, and despite this here has been some variability in usage across authors and isciplines. We apologize if our attempts to clarify and mphasize fell short of the mark in any way. We agree that e presented an emphasis distinguishing between the relaionships of missingness to independent and dependent ariables that, although typical of some earlier applications, oes not generalize across all situations. Because we demnstrated a relationship (though imperfect) between albuin missingness and outcomes, the data are not likely missng completely at random. Regarding an inquiry by Dr agner and Dr Schifftner-Smith, we do know that missngness cannot be predicted perfectly based on the oberved variables in the NSQIP data, including outcomes data not previously shown for the sake of brevity). It thereore remains possible that data are missing in a partially t-random fashion (an imperfectly covariate-dependent ashion), and that there is a not-at-random aspect. Given these issues, we would like to respectfully remphasize for the reader the primary conclusions from our ork, which remain true: