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Lund S, Schmitz JJ, Foster T, Dy B, McKenzie T, Castro MR, Lyden ML. Ethanol ablation of papillary thyroid carcinoma nodal metastases: Long-term outcomes. Surgery 2024; 175:1034-1039. [PMID: 38195302 DOI: 10.1016/j.surg.2023.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 12/06/2023] [Accepted: 12/07/2023] [Indexed: 01/11/2024]
Abstract
BACKGROUND Percutaneous ethanol ablation has emerged as a treatment for recurrent papillary thyroid carcinoma in the lateral neck after compartment-oriented therapeutic lymphadenectomy. However, the safety and utility of percutaneous ethanol ablation as a primary treatment modality for lateral neck metastases remains undefined. We aimed to investigate long-term outcomes of percutaneous ethanol ablation of lateral neck papillary thyroid carcinoma recurrence both with and without prior lymphadenectomy. METHODS We conducted a retrospective study of patients with lateral neck papillary thyroid carcinoma treated with percutaneous ethanol ablation from 2013 to 2018. Patient characteristics, disease volume, morbidity, and recurrence (development of new lymphadenopathy within a percutaneous ethanol ablation-treated nodal compartment) were assessed. RESULTS We identified 117 patients who underwent percutaneous ethanol ablation for papillary thyroid carcinoma lateral neck metastases-67 (57%) had a prior lateral neck dissection. Median follow-up after percutaneous ethanol ablation was 5.5 years (interquartile range 3.1-7.5). On average, 1.4 lymph nodes (range: 1-6) were treated. Three patients (3%) developed transient nerve-related complications after percutaneous ethanol ablation. Of 15 patients who underwent lateral neck dissection after percutaneous ethanol ablation (including patients undergoing repeat lateral neck dissection), dissection was "difficult" in 8 (53%) (7 of whom had previously undergone lateral neck dissection), and 4 (27%) developed complications (transient nerve dysfunction = 3, lymphatic leak = 1). Thirty-three patients (28%) developed recurrent papillary thyroid carcinoma. No difference in recurrence was seen between patients who did or did not undergo pre-percutaneous ethanol ablation lateral neck dissection (no pre-percutaneous ethanol ablation lateral neck dissection: 24%, pre-percutaneous ethanol ablation lateral neck dissection, 31%; hazard ratio = 1.27, 95% confidence interval 0.62-2.58; P = .514). CONCLUSION Percutaneous ethanol ablation may be a safe primary treatment modality for papillary thyroid carcinoma lateral neck nodal recurrence in selected patients with low-volume nodal disease.
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Affiliation(s)
- Sarah Lund
- Mayo Clinic Department of Surgery, Rochester, MN.
| | - John J Schmitz
- Mayo Clinic Division of Endocrinology, Diabetes, Metabolism, & Nutrition, Rochester, MN
| | - Trenton Foster
- Mayo Clinic Division of Endocrine and Metabolic Surgery, Rochester, MN
| | - Benzon Dy
- Mayo Clinic Division of Endocrine and Metabolic Surgery, Rochester, MN
| | - Travis McKenzie
- Mayo Clinic Division of Endocrine and Metabolic Surgery, Rochester, MN
| | - M Regina Castro
- Mayo Clinic Division of Endocrinology, Diabetes, Metabolism, & Nutrition, Rochester, MN
| | - Melanie L Lyden
- Mayo Clinic Division of Endocrine and Metabolic Surgery, Rochester, MN
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Sada A, Habermann EB, Dy BM, Lyden ML, McKenzie TJ, Gruber LM, Foster TR. Incidence of venous thromboembolism following adrenalectomy: A CESQIP analysis. Am J Surg 2024; 228:226-229. [PMID: 37852845 DOI: 10.1016/j.amjsurg.2023.10.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 09/16/2023] [Accepted: 10/04/2023] [Indexed: 10/20/2023]
Abstract
BACKGROUND We aim to evaluate the incidence of venous thromboembolism (VTE) following adrenalectomy. METHODS A retrospective analysis of the Collaborative Endocrine Surgery Quality Improvement Program was performed to assess incidence for VTE, including pulmonary embolism or deep vein thrombosis, in adults undergoing adrenalectomy (2014-2022). RESULTS 2567 patients undergoing adrenalectomy were included. Surgical approach was 10% open and 90% minimally invasive. Pathology was 13% malignant and 87% benign; 19% had hypercortisolism. VTE developed in 0.27% at a median of 8 days from surgery. The incidence was higher in primary adrenal malignancy compared to benign or metastases to the adrenals, p < 0.01. VTE was associated with longer hospital stay, longer operative time, readmission, and mortality. VTE rates were similar for hypercortisolism vs no hypercortisolism and between patients with clinical vs subclinical hypercortisolism. CONCLUSION Although VTE following adrenalectomy is rare, it is more common in cases of primary adrenal malignancy, those with longer operations, or those requiring prolonged hospitalization.
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Affiliation(s)
- Alaa Sada
- Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | | | - Benzon M Dy
- Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | | | | | - Lucinda M Gruber
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, MN, USA
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Shariq OA, Abrantes VB, Lu LY, Tebben PJ, Foster TM, Dy BM, Lyden ML, Young WF, McKenzie TJ. Primary hyperparathyroidism in patients with multiple endocrine neoplasia type 1: Impact of genotype and surgical approach on long-term postoperative outcomes. Surgery 2024; 175:8-16. [PMID: 37891063 DOI: 10.1016/j.surg.2023.05.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Revised: 04/25/2023] [Accepted: 05/24/2023] [Indexed: 10/29/2023]
Abstract
BACKGROUND Protein-truncating germline pathogenic variants in the N- and C-terminal exons (2, 9, and 10) of the MEN1 gene may be associated with aggressive pancreatic neuroendocrine tumors. However, the impact of these variants on parathyroid disease is poorly understood. We sought to investigate the effects of genotype and surgical approach on clinical phenotype and postoperative outcomes in patients with multiple endocrine neoplasia type 1 (MEN1)-related primary hyperparathyroidism. METHODS We identified patients with MEN1 evaluated at our institution from 1985 to 2020 and stratified them by genotype, (truncating variants in exons 2, 9, or 10, or other variants), and index surgical approach, (less-than-subtotal parathyroidectomy [ RESULTS Of the 209 patients we identified, primary hyperparathyroidism was diagnosed in 194 (93%) and at a younger median age in those with truncating exon 2, 9, or 10 variants compared with other variants (27 years vs 31 years; P = .006). Median disease-free survival was significantly worse in patients who underwent CONCLUSION The MEN1 genotype may affect the age of onset of primary hyperparathyroidism and the time to recurrence after surgery.
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Affiliation(s)
| | | | - Lauren Y Lu
- Department of Surgery, Mayo Clinic, Rochester, MN
| | - Peter J Tebben
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN
| | | | - Benzon M Dy
- Department of Surgery, Mayo Clinic, Rochester, MN
| | | | - William F Young
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN
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Sada A, Foster TR, Al-Ward R, Sawani S, Charchar HE, Pishdad R, Ben-Shlomo A, Dy BM, Lyden ML, Bergsland E, Jasim S, Raj N, Shank JB, Hamidi O, Hamrahian AH, Chambô JL, Srougi V, Fragoso MC, Graham PH, Habra MA, Bancos I, McKenzie TJ. The effect of hormonal secretion on survival in adrenocortical carcinoma: A multi-center study. Surgery 2024; 175:80-89. [PMID: 37945477 DOI: 10.1016/j.surg.2023.04.070] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Revised: 04/25/2023] [Accepted: 04/27/2023] [Indexed: 11/12/2023]
Abstract
BACKGROUND Current evidence suggests that cortisol secreting adrenocortical carcinoma has worse prognosis compared to non-secreting adrenocortical carcinoma. However, the effect of other secretory subtypes is unknown. METHODS This multicenter study within the American-Australian-Asian Adrenal Alliance included adults with adrenocortical carcinoma (1997-2020). We compared overall survival and disease-free survival among cortisol secreting, mixed cortisol/androgen secreting, androgen secreting, and non-secreting adrenocortical carcinoma. RESULTS Of the 807 patients (mean age 50), 719 included in the secretory subtype analysis: 24.5% were cortisol secreting, 13% androgen secreting, 28% mixed cortisol/androgen, 32.5% non-secreting, and 2% were mineralocorticoid secreting. Median overall survival and disease-free survival for the entire cohort were 60 and 9 months, respectively. Median overall survival was 36 months for cortisol, 30 for mixed, 60 for androgen secreting, and 115 for non-secreting adrenocortical carcinoma, P < .01. Median disease-free survival was 7 months for cortisol, 8 for mixed, 10 for androgen, and 12 for non-secreting adrenocortical carcinoma, P = .06. On multivariable analysis of age, sex, Ki67%, secretory subtype, stage, resection, and adjuvant therapy, predictors of worse overall survival were older age, higher Ki67%, stage IV, mixed secreting, R1, and no adjuvant therapy, P < .05. On subgroup analysis of R0 resection, predictors of worse overall survival included older age and higher Ki67%. Ki67% ≥40, stage III and cortisol secretion were associated with worse disease-free survival. CONCLUSION Mixed cortisol/androgen secreting adrenocortical carcinoma was associated with worse overall survival, while cortisol or androgen secreting alone were not. Notably, among patients after R0 resection, secretory subtype did not affect overall survival. Cortisol secreting adrenocortical carcinoma demonstrated worse disease-free survival. Ki67% remained a strong predictor of worse overall survival and disease-free survival independent of stage.
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Affiliation(s)
- Alaa Sada
- Department of Surgery, Mayo Clinic, Rochester, MN. https://twitter.com/Aabdusada
| | | | - Ruaa Al-Ward
- Department of Endocrine Neoplasia and Hormonal Disorders, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Sahar Sawani
- Department of Medicine, Baylor College of Medicine, Houston, TX
| | - HElaine Charchar
- Unidade de Suprarrenal, Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Reza Pishdad
- Division of Endocrinology, Diabetes and Metabolism, Johns Hopkins University, Baltimore, MD. https://twitter.com/rpishdad
| | - Anat Ben-Shlomo
- Adrenal Program, Division of Endocrinology, Diabetes, and Metabolism, Cedars Sinai Medical Center, Los Angeles, CA
| | - Benzon M Dy
- Department of Surgery, Mayo Clinic, Rochester, MN. https://twitter.com/Benzon_dy
| | | | - Emily Bergsland
- Department of Medicine, University of California San Francisco, San Francisco, CA
| | - Sina Jasim
- Division of Endocrinology, Metabolism and Lipid Research, Washington University in St. Louis, Saint Louis, MO. https://twitter.com/Sina_jasim
| | - Nitya Raj
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Jessica B Shank
- Division of Surgical Oncology, University of Nebraska Medical Center, Omaha, NE
| | - Oksana Hamidi
- Division of Endocrinology and Metabolism, University of Texas Southwestern Medical Center, Dallas, TX
| | - Amir H Hamrahian
- Division of Endocrinology, Diabetes and Metabolism, Johns Hopkins University, Baltimore, MD
| | - José L Chambô
- Division of Urology, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Victor Srougi
- Division of Urology, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil; Division of Urology, Hospital Moriah, São Paulo, Brazil
| | - Maria Cbv Fragoso
- Unidade de Suprarrenal, Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil; Instituto do Câncer do Estado de São Paulo da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil. https://twitter.com/Fragoso_mc
| | - Paul H Graham
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Mouhammed Amir Habra
- Department of Endocrine Neoplasia and Hormonal Disorders, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Irina Bancos
- Division of Endocrinology, Mayo Clinic, Rochester, MN.
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Sada A, Ramachandran D, Oberoi M, Habermann EB, Lyden ML, Dy BM, Foster TR, Halfdanarson TR, Levy MJ, Vella A, McKenzie TJ. Ethanol Ablation for Benign Insulinoma: Intraoperative and Endoscopic Approaches. J Surg Res 2024; 293:663-669. [PMID: 37839097 DOI: 10.1016/j.jss.2023.08.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 07/09/2023] [Accepted: 08/23/2023] [Indexed: 10/17/2023]
Abstract
INTRODUCTION Ethanol ablation can be utilized to manage insulinoma. We aimed to analyze our outcomes of endoscopic ultrasound (EUS) and intraoperative ultrasound (IOUS) guided Ethanol ablation of insulinoma. METHODS A single institution retrospective review of adults undergoing Ethanol ablation of benign pancreatic insulinoma (2007-2022) was performed. Outcomes were categorized as resolution of hypoglycemia, improvement, or no change at last follow-up. RESULTS A total of 16 patients underwent Ethanol ablation of benign insulinoma (N = 8 EUS, N = 8 IOUS): median age was 68 y, 8 (50%) were females, and 2 (12.5%) were associated with multiple endocrine neoplasia type-1. Median insulinoma size was 12 (range 7, 25) mm. Ethanol ablation was preferred over resection to avoid pancreaticoduodenectomy when it was not possible to enucleate the tumor in 10 (62.5%) patients while the rest underwent ablation due to being poor surgical candidates or because of a history of previous pancreatic resection. The median follow-up (interquartile range) was 43 (19.5, 81.5) mo. Resolution of hypoglycemia occurred in 11 patients (5 EUS, 6 IOUS), while the rest (3 EUS, 2 IOUS) experienced improvement in the severity and frequency of hypoglycemia. A single patient underwent resection following a previous ablation for symptomatic hypoglycemia 5 y after EUS guided ablation. CONCLUSIONS Ethanol ablation provides an alternative therapeutic option for patients with insulinoma. Both EUS and IOUS guided approaches are associated with a favorable resolution rate although EUS guided ablation may require multiple procedures to optimize outcomes.
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Affiliation(s)
- Alaa Sada
- Department of Surgery, Mayo Clinic, Rochester, Minnesota
| | | | - Meher Oberoi
- Department of Surgery, Mayo Clinic, Rochester, Minnesota
| | | | | | - Benzon M Dy
- Department of Surgery, Mayo Clinic, Rochester, Minnesota
| | | | | | - Michael J Levy
- Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota
| | - Adrian Vella
- Division of Endocrinology, Mayo Clinic, Rochester, Minnesota
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Richards BA, Vierkant RA, Dy BM, Foster TR, McKenzie TJ, Lyden ML. Intraoperative Parathyroid Hormone Monitoring Is of Limited Usefulness in Guiding Autotransplantation in Reoperative or Subtotal Parathyroidectomy for Primary Hyperparathyroidism. Am Surg 2023; 89:5421-5427. [PMID: 36786277 DOI: 10.1177/00031348231156758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/15/2023]
Abstract
INTRODUCTION Patients with primary hyperparathyroidism (1HPT) undergoing reoperative or subtotal parathyroidectomy (PTX) may undergo autotransplantation (ATX) when the viability of remaining tissue is unknown. This study aims to identify whether intraoperative parathyroid hormone levels (IOPTH) can determine ATX candidacy. METHODS Patients with 1HPT who underwent PTX with ATX at our institution were identified. IOPTH and PTH values within 24 h, 2-4 weeks, and >1 month postoperative were analyzed. Patients were classified as either a candidate for ATX (low PTH after 2-4 weeks) or not a candidate based on postoperative PTH (normal PTH after 2-4 weeks). Associations of ATX candidate status with demographic and clinical attributes were studied. RESULTS 268 had a reoperative (49%) or subtotal PTX with ATX. 151 had data for PTH analysis, and 21 (14%) were identified as candidates for ATX. The mean % decline in IOPTH from baseline to 20 min post-excision was 51% in noncandidates vs 73% in candidates (P = .002). The mean change in IOPTH from baseline to final was 52% in noncandidates and 83% in candidates (P = .009). A decrease in IOPTH from baseline to 20 min post-excision of 23.4% or greater or a final PTH of 52 pg/mL or less would be an indication for ATX. Of the 21 who needed an ATX, it failed in 10. CONCLUSION Parathyroid ATX is frequently unnecessary, and the viability is less than expected. While candidates for ATX have a greater IOPTH % decline at all points during surgery and a lower final IOPTH, the clinical practicality of using IOPTH to determine ATX candidacy is limited.
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Affiliation(s)
| | - Robert A Vierkant
- Department of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, MN, USA
| | - Benzon M Dy
- Department of Surgery, Mayo Clinic, Rochester, MN, USA
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7
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Sada A, Hanson KT, Habermann EB, McKenzie TJ, Lyden ML, Foster TR, Clarke BL, Dy BM. Disparities in Parathyroidectomy: Who Receives Appropriate Treatment for Primary Hyperparathyroidism? J Surg Res 2023; 291:151-157. [PMID: 37399633 DOI: 10.1016/j.jss.2023.05.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 05/05/2023] [Accepted: 05/15/2023] [Indexed: 07/05/2023]
Abstract
INTRODUCTION Parathyroidectomy is underperformed despite clear benefits in primary hyperparathyroidism (PHPT). We evaluated disparities in receipt of parathyroidectomy following PHPT diagnosis to explore barriers to care. METHODS Adults diagnosed with PHPT 2013-2018 at a health system were identified. Recommended indications for parathyroidectomy include age ≤50 y, calcium >11 mg/dL, or the presence of nephrolithiasis, hypercalciuria, nephrocalcinosis, decreased glomerular filtration rate, osteopenia, osteoporosis, or pathological fracture 1 y prior to diagnosis. Kaplan-Meier analysis assessed rates of parathyroidectomy within 12 mo following diagnosis as well as median time to parathyroidectomy, and multivariable Cox proportional hazards analyses assessed factors associated with undergoing parathyroidectomy. RESULTS Of 2409 patients, 75% were females, 12% aged ≤50 y, and 92% non-Hispanic White, while 52% had Medicaid/Medicare, 36% were commercial/self-pay or uninsured, and 12% unknown. Parathyroidectomy was performed within 1 y in 50% of patients. Within the 68% that met recommendations, parathyroidectomy was performed within 1 y in 54%; median time from diagnosis to surgery was shorter for males, patients aged ≤50 y, commercial/self-pay/no insurance patients (versus Medicaid/Medicare), and those with fewer comorbidities, P < 0.05. Multivariable analysis demonstrated non-Hispanic White patients and those with commercial/self-pay/uninsured were more likely to undergo parathyroidectomy after adjusting for comorbidity, age, and facility site. Among those strongly indicated, patients not on Medicare/Medicaid and aged ≤50 y were more likely to undergo parathyroidectomy after adjusting for race, comorbidity, and facility site. CONCLUSIONS Disparities in parathyroidectomy for PHPT were observed. Insurance type was associated with undergoing parathyroidectomy; patients on governmental insurance were less likely to undergo surgery and waited longer for surgery despite strong indications. Barriers to referral and access to surgery should be investigated and addressed to optimize all patients' access to care.
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Affiliation(s)
- Alaa Sada
- Department of Surgery, Mayo Clinic, Rochester, Minnesota
| | - Kristine T Hanson
- Division of Health Care Delivery Research, Mayo Clinic, Rochester, Minnesota
| | | | | | | | | | - Bart L Clarke
- Division of Endocrinology, Mayo Clinic, Rochester, Minnesota
| | - Benzon M Dy
- Department of Surgery, Mayo Clinic, Rochester, Minnesota.
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Szabo Yamashita T, Gudmundsdottir H, Foster TR, Lyden ML, Dy BM, Tebben PJ, McKenzie T. Pediatric primary hyperparathyroidism: Surgical pathology and long-term outcomes in sporadic and familial cases. Am J Surg 2023; 225:699-702. [PMID: 36270819 DOI: 10.1016/j.amjsurg.2022.10.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Revised: 09/24/2022] [Accepted: 10/11/2022] [Indexed: 11/21/2022]
Abstract
BACKGROUND Primary Hyperparathyroidism (PHPT) is rare in pediatric patients. Data regarding surgical outcomes are scarce. METHODS Single-center retrospective review (1994-2020) of patients ≤21 years undergoing surgery for PHPT. RESULTS 66 patients were identified (61% female, 17 ± 3 years). 71% of patients were symptomatic at diagnosis. 32% of patients had known familial syndromes, most commonly MEN-1. 23% of patients without a known mutation had genetic testing, 22% positive. 56% of the total and 19% of the familial cohort underwent focused exploration. Single gland disease was found in 19% of familial vs 85% of sporadic cases, p < 0.00001. Persistence was 9%, all in the sporadic group, p = 0.11. Recurrence was 15%: 38% in the familial vs 2% in the sporadic groups, p=0.0004. Time to recurrence was 59 months (Q1-38, Q3-95), familial 61 vs 124 months sporadic, p=0.001. CONCLUSION Pediatric PHPT is frequently sporadic, although 5% of apparent sporadic cases are secondary to syndromes. Familial cases have higher rates of recurrence, requiring closer follow-up.
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Affiliation(s)
| | | | - Trenton R Foster
- Mayo Clinic, Department of Surgery, 200 1st Street SW, 55905, Rochester, MN, USA.
| | - Melanie L Lyden
- Mayo Clinic, Department of Surgery, 200 1st Street SW, 55905, Rochester, MN, USA.
| | - Benzon M Dy
- Mayo Clinic, Department of Surgery, 200 1st Street SW, 55905, Rochester, MN, USA.
| | - Peter J Tebben
- Mayo Clinic, Division of Endocrinology, Diabetes, Metabolism, and Nutrition and Department of Pediatric and Adolescent Medicine, 200 1st Street SW, 55905, Rochester, MN, USA.
| | - Travis McKenzie
- Mayo Clinic, Department of Surgery, 200 1st Street SW, 55905, Rochester, MN, USA.
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Dip F, Alesina PF, Anuwong A, Arora E, Berber E, Bonnin-Pascual J, Bouvy ND, Demarchi MS, Falco J, Hallfeldt K, Lee KD, Lyden ML, Maser C, Moore E, Papavramidis T, Phay J, Rodriguez JM, Seeliger B, Solórzano CC, Triponez F, Vahrmeijer A, Rosenthal RJ, White KP, Bouvet M. Use of fluorescence imaging and indocyanine green during thyroid and parathyroid surgery: Results of an intercontinental, multidisciplinary Delphi survey. Surgery 2022; 172:S6-S13. [PMID: 36427932 DOI: 10.1016/j.surg.2022.09.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 08/19/2022] [Accepted: 09/02/2022] [Indexed: 11/23/2022]
Abstract
BACKGROUND In recent years, fluorescence imaging-relying both on parathyroid gland autofluorescence under near-infrared light and angiography using the fluorescent dye indocyanine green-has been used to reduce risk of iatrogenic parathyroid injury during thyroid and parathyroid resections, but no published guidelines exist regarding its use. In this study, orchestrated by the International Society for Fluorescence Guided Surgery, areas of consensus and nonconsensus were examined among international experts to facilitate future drafting of such guidelines. METHODS A 2-round, online Delphi survey was conducted of 10 international experts in fluorescence imaging use during endocrine surgery, asking them to vote on 75 statements divided into 5 modules: 1 = patient preparation and contraindications to fluorescence imaging (n = 11 statements); 2 = technical logistics (n = 16); 3 = indications (n = 21); 4 = potential advantages and disadvantages of fluorescence imaging (n = 20); and 5 = training and research (n = 7). Several methodological steps were taken to minimize voter bias. RESULTS Overall, parathyroid autofluorescence was considered better than indocyanine green angiography for localizing parathyroid glands, whereas indocyanine green angiography was deemed superior assessing parathyroid perfusion. Additional surgical scenarios where indocyanine green angiography was thought to facilitate surgery are (1) when >1 parathyroid gland requires resection; (2) during redo surgeries, (3) facilitating parathyroid autoimplantation; and (4) for the predissection visualization of abnormal glands. Both parathyroid autofluorescence and indocyanine green angiography can be used during the same procedure and employing the same imaging equipment. However, further research is needed to optimize the dose and timing of indocyanine green administration. CONCLUSION Though further research remains necessary, using fluorescence imaging appears to have uses during thyroid and parathyroid surgery.
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Affiliation(s)
- Fernando Dip
- Instituto Argentino de Diagnóstico y Tratamiento, Buenos Aires, Argentina; Cleveland Clinic Florida, Weston, FL.
| | | | | | - Eham Arora
- Grant Medical College and Sir JJ Group of Hospitals, Mumbai, India
| | | | | | | | | | - Jorge Falco
- University Hospital Das Clinicas, Buenos Aires, Argentina
| | - Klaus Hallfeldt
- Klinikum der Ludwig-Maximilians-Universität München, Germany
| | | | | | | | - Edwina Moore
- Peninsula Private Hospital, Frankston Melbourne, Australia
| | | | | | | | | | | | | | | | | | - Kevin P White
- ScienceRight Research Consultations, Inc, London, Ontario, Canada
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Dogra P, Rivera M, McKenzie TJ, Foster TR, Dy BM, Lyden ML, Young WF, Bancos I. Clinical course and imaging characteristics of benign adrenal cysts: a single-center study of 92 patients. Eur J Endocrinol 2022; 187:429-437. [PMID: 35894855 PMCID: PMC9380426 DOI: 10.1530/eje-22-0285] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 07/04/2022] [Indexed: 01/07/2023]
Abstract
OBJECTIVE Benign adrenal cysts are rare lesions of the adrenal glands. Limited data are available to guide management. We aimed to describe the presentation and outcomes of patients with benign adrenal cysts. DESIGN Retrospective longitudinal cohort study. METHODS Consecutive patients with histologically or radiologically confirmed adrenal cysts between 1995 and 2021 were identified. Pheochromocytomas and malignancy were excluded. RESULTS Benign adrenal cysts were diagnosed in 92 patients (53, 57% women) at a median age of 45 years. Mode of discovery was incidental on imaging in 81 (88%), symptoms of mass effect in 9 (9.8%), and others in 2 (2.2%). Majority (89, 97%) of patients had unilateral cysts (45 right, 44 left) with a median size of 48 mm (range 4-200) at diagnosis. On imaging, most cysts were round/oval (85.4%), homogenous (83.2%) lesions with calcifications (64.0%) and no vascular enhancement (97.7%). During a median follow-up of 65 months (range 7-288), adrenal cysts demonstrated minimal enlargement (median size change 6 mm, median growth rate 2 mm/year). On hormonal evaluation, 10% (5/50 tested) had an abnormal overnight dexamethasone suppression test, and 9.5% (4/42 tested) had an abnormal case detection testing for primary aldosteronism. Patients treated with adrenalectomy (46, 50%) were younger (36.9 years vs 50.8 years, P = 0.0009) and had more rapidly enlarging cysts (median growth rate 5.5 mm/year vs 0.4 mm/year, P = 0.0002). CONCLUSION Benign adrenal cysts are usually incidentally discovered, non-functional, homogenous lesions without vascular enhancement that demonstrate minimal growth. Adrenalectomy should be reserved for patients with heterogeneous lesions, abnormal hormonal evaluation, or those with mass effect symptoms.
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Affiliation(s)
- Prerna Dogra
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, MN, USA
| | - Michael Rivera
- Department of Laboratory and Pathology, Mayo Clinic, Rochester, MN, USA
| | | | | | - Benzon M Dy
- Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | | | - William F Young
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, MN, USA
| | - Irina Bancos
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, MN, USA
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Nanba K, Baker JE, Blinder AR, Bick NR, Liu CJ, Lim JS, Wachtel H, Cohen DL, Williams TA, Reincke M, Lyden ML, Bancos I, Young WF, Else T, Giordano TJ, Udager AM, Rainey WE. Histopathology and Genetic Causes of Primary Aldosteronism in Young Adults. J Clin Endocrinol Metab 2022; 107:2473-2482. [PMID: 35779252 PMCID: PMC9761569 DOI: 10.1210/clinem/dgac408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2021] [Indexed: 11/19/2022]
Abstract
CONTEXT Due to its rare incidence, molecular features of primary aldosteronism (PA) in young adults are largely unknown. Recently developed targeted mutational analysis identified aldosterone-driver somatic mutations in aldosterone-producing lesions, including aldosterone-producing adenomas (APAs), aldosterone-producing nodules (APNs), and aldosterone-producing micronodules, formerly known as aldosterone-producing cell clusters. OBJECTIVE To investigate histologic and genetic characteristics of lateralized PA in young adults. METHODS Formalin-fixed, paraffin-embedded adrenal tissue sections from 74 young patients with lateralized PA (<35 years old) were used for this study. Immunohistochemistry (IHC) for aldosterone synthase (CYP11B2) was performed to define the histopathologic diagnosis. Somatic mutations in aldosterone-producing lesions were further determined by CYP11B2 IHC-guided DNA sequencing. RESULTS Based on the CYP11B2 IHC results, histopathologic classification was made as follows: 48 APAs, 20 APNs, 2 multiple aldosterone-producing nodules (MAPN), 1 double APN, 1 APA with MAPN, and 2 nonfunctioning adenomas (NFAs). Of 45 APAs with successful sequencing, 43 (96%) had somatic mutations, with KCNJ5 mutations being the most common genetic cause of young-onset APA (35/45, 78%). Of 18 APNs with successful sequencing, all of them harbored somatic mutations, with CACNA1D mutations being the most frequent genetic alteration in young-onset APN (8/18, 44%). Multiple CYP11B2-expressing lesions in patients with MAPN showed several aldosterone-driver mutations. No somatic mutations were identified in NFAs. CONCLUSION APA is the most common histologic feature of lateralized PA in young adults. Somatic KCNJ5 mutations are common in APAs, whereas CACNA1D mutations are often seen in APNs in this young PA population.
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Affiliation(s)
- Kazutaka Nanba
- Correspondence: Kazutaka Nanba, MD, Department of Endocrinology and Metabolism, National Hospital Organization Kyoto Medical Center, 1-1, Mukaihata-cho, Fukakusa, Fushimi-ku, Kyoto, 612-8555, Japan.
| | - Jessica E Baker
- Department of Molecular and Integrative Physiology, University of Michigan, Ann Arbor, MI, 48109, USA
| | - Amy R Blinder
- Department of Molecular and Integrative Physiology, University of Michigan, Ann Arbor, MI, 48109, USA
| | - Nolan R Bick
- Department of Pathology, University of Michigan, Ann Arbor, MI, 48109, USA
| | - Chia-Jen Liu
- Department of Pathology, University of Michigan, Ann Arbor, MI, 48109, USA
| | - Jung Soo Lim
- Department of Molecular and Integrative Physiology, University of Michigan, Ann Arbor, MI, 48109, USA
| | - Heather Wachtel
- Division of Endocrine and Oncologic Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Debbie L Cohen
- Division of Renal, Electrolyte and Hypertension, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Tracy Ann Williams
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Ludwig-Maximilians-Universität München, München, 80336, Germany
- Division of Internal Medicine and Hypertension, Department of Medical Sciences, University of Turin, Turin, 10126, Italy
| | - Martin Reincke
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Ludwig-Maximilians-Universität München, München, 80336, Germany
| | - Melanie L Lyden
- Department of Surgery, Mayo Clinic, Rochester, MN, 55905, USA
| | - Irina Bancos
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN, 55905, USA
| | - William F Young
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN, 55905, USA
| | - Tobias Else
- Division of Metabolism, Endocrine, and Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, 48109, USA
| | - Thomas J Giordano
- Department of Pathology, University of Michigan, Ann Arbor, MI, 48109, USA
- Division of Metabolism, Endocrine, and Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, 48109, USA
- Rogel Cancer Center, University of Michigan, Ann Arbor, MI, 48109, USA
| | - Aaron M Udager
- Department of Pathology, University of Michigan, Ann Arbor, MI, 48109, USA
- Rogel Cancer Center, University of Michigan, Ann Arbor, MI, 48109, USA
- Michigan Center for Translational Pathology, University of Michigan, Ann Arbor, MI, 48109, USA
| | - William E Rainey
- Correspondence: William E. Rainey, PhD, Department of Molecular and Integrative Physiology, University of Michigan, 2558 MSRB II, 1150 W. Medical Center Dr., Ann Arbor, MI 48109, USA.
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Shariq OA, Lines KE, English KA, Jafar-Mohammadi B, Prentice P, Casey R, Challis BG, Selberherr A, Boon H, Cranston T, Ryan FJ, Mihai R, Healy U, Kurzawinski T, Dattani MT, Bancos I, Dy BM, Lyden ML, Young WF, McKenzie TJ, Richards D, Thakker RV. Corrigendum to ‘Multiple endocrine neoplasia type 1 in children and adolescents: Clinical features and treatment outcomes’ [Surgery 171 (2021) 77–87]. Surgery 2022; 171:1708-1711. [DOI: 10.1016/j.surg.2022.03.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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13
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Sada A, Ahmed E, Bancos I, Lyden ML, Dy B, Foster T, Habermann EB, McKenzie T. Understanding Characteristics and Survival of the Various Secretory Types of Adrenocortical Carcinoma. J Am Coll Surg 2021. [DOI: 10.1016/j.jamcollsurg.2021.08.103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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14
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Sada A, Glasgow AE, Lyden ML, Dy BM, Foster TR, Habermann EB, Bancos I, McKenzie TJ. Informing therapeutic lymphadenectomy: Location of regional metastatic lymph nodes in adrenocortical carcinoma. Am J Surg 2021; 223:1042-1045. [PMID: 34696848 DOI: 10.1016/j.amjsurg.2021.10.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 09/28/2021] [Accepted: 10/11/2021] [Indexed: 11/01/2022]
Abstract
BACKGROUND The anatomic boundaries of lymphadenectomy for adrenocortical carcinoma (ACC) are not defined. METHODS Adults undergoing resection of ACC were included. Locations were categorized based on positive LN locations on final pathology. RESULTS Of 231 resected ACC, 6% had positive LN during initial resection. Positive LN in left ACC (n = 7) were: 2 para-aortic, 2 left renal-hilar, 1 para-aortic and left renal-hilar and 1 unknown, while for right ACC (n = 7): 2 para-caval, 1 para-caval and right renal-hilar, 1 inter-aortocaval, 1 celiac, 1 para-aortic, and 1 unknown. Of 55 resections for recurrent ACC, positive LN in left ACC (n = 2) were: 1 para-aortic, and 1 para-aortic with left renal-hilar, while LN for right ACC (n = 7): 2 inter-aortocaval, 2 right renal-hilar, 2 para-caval and one retrocrural. CONCLUSION The most common LN metastases are para-caval for right, and para-aortic and left renal-hilar for left ACC. Further studies are necessary to determine the boundaries of lymphadenectomy in ACC resection.
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Affiliation(s)
- Alaa Sada
- Department of Surgery, Mayo Clinic, 200th 1st Street, Rochester, MN, 55905, USA
| | - Amy E Glasgow
- Department of Quantitative Health Sciences, USA; Division of Health Care Delivery Research, Mayo Clinic, Rochester, MN, USA
| | - Melanie L Lyden
- Department of Surgery, Mayo Clinic, 200th 1st Street, Rochester, MN, 55905, USA
| | - Benzon M Dy
- Department of Surgery, Mayo Clinic, 200th 1st Street, Rochester, MN, 55905, USA
| | - Trenton R Foster
- Department of Surgery, Mayo Clinic, 200th 1st Street, Rochester, MN, 55905, USA
| | - Elizabeth B Habermann
- Department of Quantitative Health Sciences, USA; Division of Health Care Delivery Research, Mayo Clinic, Rochester, MN, USA
| | - Irina Bancos
- Division of Endocrinology, Mayo Clinic, 200th 1st Street, Rochester, MN, 55905, USA
| | - Travis J McKenzie
- Department of Surgery, Mayo Clinic, 200th 1st Street, Rochester, MN, 55905, USA.
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Yamashita TS, Rogers RT, Foster TR, Lyden ML, Morris JC, McKenzie T, Thompson GB, Dy BM. Ultrasound-Guided Percutaneous Ethanol Ablation for Local Regional Recurrence of Medullary Thyroid Cancer. Am Surg 2021; 87:1396-1399. [PMID: 34461779 DOI: 10.1177/00031348211041563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | | | | | | | - John C Morris
- Department of Endocrinology, 6915Mayo Clinic, Rochester, MN, USA
| | | | | | - Benzon M Dy
- Department of Surgery, 6915Mayo Clinic, Rochester, MN, USA
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16
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Szabo Yamashita T, Rogers RT, Foster TR, Lyden ML, Morris JC, Thompson GB, McKenzie T, Dy BM. Medullary thyroid cancer: What is the optimal management of the lateral neck in a node negative patient at index operation? Surgery 2021; 171:177-181. [PMID: 34284893 DOI: 10.1016/j.surg.2021.04.052] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 04/14/2021] [Accepted: 04/15/2021] [Indexed: 12/23/2022]
Abstract
BACKGROUND Medullary thyroid cancer is a neuroendocrine malignancy that can occur sporadically or as the result of genomic rearranged during transfection mutations. Medullary thyroid cancer has a higher rate of metastasis than well-differentiated thyroid cancer. Lateral neck dissection is often performed, and its prophylactic use is controversial. METHODS Single-center, retrospective review (2000-2017) of patients undergoing primary surgical treatment for medullary thyroid cancer who had negative lateral neck imaging preoperatively. Demographics, genetic associations, clinical, and imaging findings were analyzed. Locoregional recurrence, overall recurrence, and overall survival were examined. RESULTS A total of 110 patients were identified, of which 18 underwent prophylactic lateral neck dissection and 92 did not. Age, sex distribution, preoperative calcitonin levels, and follow-up were similar among groups. Overall recurrence was 20% for no prophylactic lateral neck dissection and 39% for prophylactic lateral neck dissection (P = .46). Most recurrences were locoregional recurrence, 7.6% for no prophylactic lateral neck dissection versus 22% for prophylactic lateral neck dissection (P = .08), half of it being to the lateral neck in both groups. A total of 7 patients from the no prophylactic lateral neck dissection group required treatment for recurrences versus 4 patients in prophylactic lateral neck dissection group (P = .57). Overall survival at 5 years was similar, 43% the no prophylactic lateral neck dissection group and 31% for prophylactic lateral neck dissection group (P = .52). CONCLUSION Lateral neck dissection has no effect in decreasing locoregional or overall recurrences in medullary thyroid cancer and has no effect in overall survival when performed prophylactically at index surgical intervention.
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Affiliation(s)
| | | | | | | | | | | | | | - Benzon M Dy
- Department of Surgery, Mayo Clinic, Rochester, MN.
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Geary AD, Wang TS, Lindeman B, Kuo JH, Lyden ML, Shen WT, Morris-Wiseman LF, Carty SE, Drake FT. Perspectives on virtual interviews-A follow-up study of the Comprehensive Endocrine Surgery Fellowship interview process. Surgery 2021; 171:259-264. [PMID: 34266646 DOI: 10.1016/j.surg.2021.03.069] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 03/23/2021] [Accepted: 03/28/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND The American Association of Endocrine Surgeons Comprehensive Endocrine Surgery Fellowship interview stakeholders previously favored in-person interviews, despite time and expense. This study assessed perception changes given mandated virtual interviews because of coronavirus disease 2019. METHODS Immediately after the 2020 Match, anonymous surveys were distributed to applicants (n = 37) and program directors (n = 22). Mixed-methods analyses were used to evaluate responses. Results were compared to data from a prior study of the 2013 to 2018 in-person interview process. RESULTS Response rates were 82% (program directors) and 60% (applicants). Compared with prior applicants, 2020 applicants attended similar numbers of interviews (1-10, 32% vs 37%; P = .61), used fewer vacation days (23% vs 56%; P = .01), and most reported 0 expenses. Burdens included lack of protected time for interviews. The virtual format did not compromise applicant ability to meet faculty (mean rank = 6.8/10) or make favorable impressions (mean rank = 6.8/10). Program directors reported equivalent or improved assessments of applicants. Program directors (72%) and applicants (77%) indicated that future interviews should be partially or completely virtual. CONCLUSION In contrast to prior survey data, applicants and program directors now express interest in virtual or hybrid interview processes. Virtual interviews were less costly, less time-consuming, and met goals effectively. Integrating virtual interview components will require innovative strategies to reduce redundancies and promote equitable access.
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Affiliation(s)
- Alaina D Geary
- Boston University School of Medicine and Boston Medical Center, MA. https://twitter.com/GearyMD
| | - Tracy S Wang
- Medical College of Wisconsin, Milwaukee, WI. https://twitter.com/tracyswangNYMKE
| | - Brenessa Lindeman
- University of Alabama at Birmingham, AL. https://twitter.com/BrenessaL
| | - Jennifer H Kuo
- Columbia University Medical Center, New York, NY. https://twitter.com/JenniferKuo5
| | | | - Wen T Shen
- University of California, San Francisco, CA. https://twitter.com/wshen16
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Shariq OA, Lines KE, English KA, Jafar-Mohammadi B, Prentice P, Casey R, Challis BG, Selberherr A, Boon H, Cranston T, Ryan FJ, Mihai R, Healy U, Kurzawinski T, Dattani MT, Bancos I, Dy BM, Lyden ML, Young WF, McKenzie TJ, Richards D, Thakker RV. Multiple endocrine neoplasia type 1 in children and adolescents: Clinical features and treatment outcomes. Surgery 2021; 171:77-87. [PMID: 34183184 DOI: 10.1016/j.surg.2021.04.041] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 04/03/2021] [Accepted: 04/20/2021] [Indexed: 12/26/2022]
Abstract
BACKGROUND Clinical manifestations and treatment outcomes in children and adolescents with multiple endocrine neoplasia type 1 are not well characterized. METHODS We conducted a retrospective cohort study of 80 patients with multiple endocrine neoplasia type 1 who commenced tumor surveillance at ≤18 years of age. RESULTS Fifty-six patients (70%) developed an endocrine tumor by age ≤18 years (median age = 14 years, range = 6-18 years). Primary hyperparathyroidism occurred in >80% of patients, with >70% undergoing parathyroidectomy, in which less-than-subtotal (<3-gland) resection resulted in decreased disease-free outcomes versus subtotal (3-3.5-gland) or total (4-gland) parathyroidectomy (median 27 months versus not reached; P = .005). Pancreaticoduodenal neuroendocrine tumors developed in ∼35% of patients, of whom >70% had nonfunctioning tumors, >35% had insulinomas, and <5% had gastrinomas, with ∼15% having metastases and >55% undergoing surgery. Pituitary tumors developed in >30% of patients, and ∼35% were macroprolactinomas. Tumor occurrence in male patients and female patients was not significantly different. Genetic analyses revealed 38 germline MEN1 mutations, of which 3 were novel. CONCLUSION Seventy percent of children aged ≤18 years with multiple endocrine neoplasia type 1 develop endocrine tumors, which include parathyroid tumors for which less-than-subtotal parathyroidectomy should be avoided; pancreaticoduodenal neuroendocrine tumors that may metastasize; and pituitary macroprolactinomas.
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Affiliation(s)
- Omair A Shariq
- Academic Endocrine Unit, Radcliffe Department of Medicine, University of Oxford, Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, United Kingdom; Department of Surgery, Mayo Clinic, Rochester, MN. https://twitter.com/@omairshariq
| | - Kate E Lines
- Academic Endocrine Unit, Radcliffe Department of Medicine, University of Oxford, Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, United Kingdom. https://twitter.com/@klines500
| | - Katherine A English
- Academic Endocrine Unit, Radcliffe Department of Medicine, University of Oxford, Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, United Kingdom. https://twitter.com/@Katie__English
| | - Bahram Jafar-Mohammadi
- Department of Endocrinology Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, United Kingdom
| | - Philippa Prentice
- Department of Paediatric Endocrinology, Great Ormond Street Hospital for Children and UCL Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Ruth Casey
- Department of Endocrinology, Cambridge University Hospital NHS Foundation Trust, United Kingdom
| | - Benjamin G Challis
- Department of Endocrinology, Cambridge University Hospital NHS Foundation Trust, United Kingdom
| | | | - Hannah Boon
- Oxford Medical Genetics Laboratories, Oxford University Hospitals NHS Foundation Trust, Churchill Hospital, United Kingdom
| | - Treena Cranston
- Oxford Medical Genetics Laboratories, Oxford University Hospitals NHS Foundation Trust, Churchill Hospital, United Kingdom
| | - Fiona J Ryan
- Department of Paediatric Endocrinology, Oxford Children's Hospital, University of Oxford, United Kingdom
| | - Radu Mihai
- Department of Endocrine Surgery, University of Oxford, United Kingdom. https://twitter.com/RaduMiSurgeon
| | - Ultan Healy
- Department of Endocrinology Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, United Kingdom
| | - Tom Kurzawinski
- Centre for Endocrine Surgery, Great Ormond Street Hospital for Children, London, United Kingdom
| | - Mehul T Dattani
- Department of Paediatric Endocrinology, Great Ormond Street Hospital for Children and UCL Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Irina Bancos
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN. https://twitter.com/@IrinaBancos
| | - Benzon M Dy
- Department of Surgery, Mayo Clinic, Rochester, MN
| | | | - William F Young
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN
| | | | - Duncan Richards
- Oxford Clinical Trials Research Unit, Botnar Research Centre, United Kingdom
| | - Rajesh V Thakker
- Academic Endocrine Unit, Radcliffe Department of Medicine, University of Oxford, Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, United Kingdom.
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Sada A, Glasgow AE, Lyden ML, Thompson GB, Dy BM, McKenzie TJ, Habermann EB. Positive Lymph Nodes in Adrenocortical Carcinoma: What Does It Mean? World J Surg 2020; 45:188-194. [PMID: 33034710 DOI: 10.1007/s00268-020-05801-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/15/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND The role of lymphadenectomy in adrenocortical carcinoma resection is controversial. Therefore, we conducted a population-based study to assess the association between positive lymph nodes (LN) and survival. METHODS The Surveillance, Epidemiology, and End Results set of cancer registries were utilized. The associations between positive lymph nodes and tumor size, grade and laterality were assessed. Cancer specific survival (CSS) trends and factors affecting survival were analyzed. RESULTS A total of 2170 adult patients were identified; 60% underwent resection. Among those resected, LN were examined in 23% and were positive in 25% of patients with LN examined. Patients with positive LN tended to have smaller tumors compared to those with negative LN (12 ± 5 vs 15 ± 11 cm, p = 0.02). The rate of positive LN was higher in right ACC, p = 0.03. Median overall CSS was 21 months, with significant differences between resection (42 months) and no resection (4 months), p < 0.01. Median CSS did not change over time when comparing ACC patients who underwent surgery before 2000, 2000-2009, and 2010-2016. On multivariable analysis including resection group, advanced age, grades III and IV, regional and distant stage, in addition to positive LN were associated with worse survival, p < 0.05. CONCLUSION Lymphadenectomy is infrequently performed during ACC resection, and when performed, regional LN involvement tends to be associated with worse survival. Neoplasm size and grade were not associated with LN involvement and therefore, do not inform lymphadenectomy need. Further studies are needed to assess the indications for, and value of lymphadenectomy in ACC.
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Affiliation(s)
- Alaa Sada
- Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | - Amy E Glasgow
- Surgical Outcomes Program, Robert D and Patricia E Kern Center for The Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | | | | | - Benzon M Dy
- Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | | | - Elizabeth B Habermann
- Department of Surgery, Mayo Clinic, Rochester, MN, USA. .,Surgical Outcomes Program, Robert D and Patricia E Kern Center for The Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA.
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Shariq OA, Strajina V, Lyden ML, McKenzie TJ, Wermers RA, Thompson GB, Dy BM. Parathyroidectomy improves hypercalciuria in patients with primary hyperparathyroidism. Surgery 2020; 168:594-600. [DOI: 10.1016/j.surg.2020.07.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Revised: 06/30/2020] [Accepted: 07/16/2020] [Indexed: 01/21/2023]
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Shariq OA, Bews KA, McKenna NP, Dy BM, Lyden ML, Farley DR, Thompson GB, McKenzie TJ, Habermann EB. Is same-day discharge associated with increased 30-day postoperative complications and readmissions in patients undergoing laparoscopic adrenalectomy? Surgery 2020; 169:289-297. [PMID: 33008614 DOI: 10.1016/j.surg.2020.08.018] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 08/06/2020] [Accepted: 08/11/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND Advances in minimally invasive surgery and perioperative care have decreased substantially the duration of time that patients spend recovering in hospital, with many laparoscopic procedures now being performed on an ambulatory basis. There are limited studies, however, on same-day discharge after laparoscopic adrenalectomy. The objectives of this study were to investigate the outcomes and trends of ambulatory laparoscopic adrenalectomy in a multicenter cohort of patients. METHODS Adult patients who underwent elective laparoscopic adrenalectomy between 2005 and 2016 were identified in the database of the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP). Baseline demographics and 30-day outcomes were compared between patients who underwent ambulatory laparoscopic adrenalectomy and those who were discharged after an inpatient stay. Multivariable logistic regression and Cox proportional hazards modelling were used to investigate the association between same-day discharge and 30-day complications and unplanned readmissions. RESULTS Of the 4,807 patients included in the study, 88 (1.8%) underwent ambulatory laparoscopic adrenalectomy and 4,719 (98.2%) were admitted after the adrenalectomy. The same-day discharge group contained fewer obese patients (37.2% vs 50%; P = .04), a lesser proportion of American Society of Anesthesiologists class III patients (45.5% vs 61%; P = .003), and more patients with primary aldosteronism (14.8% vs 6%; P = .002) compared with the inpatient group. After adjustment for confounders, same-day discharge was not associated with 30-day overall complications (OR 1.17, 95% CI 0.35-3.85; P = .80) or unplanned readmissions (HR 2.77, 95% CI 0.86-8.96; P = .09). The percentage of laparoscopic adrenalectomies performed on an ambulatory basis at hospitals participating in the ACS NSQIP remained low throughout the study period (0-3.1% per year) with no evidence of an increasing trend over time (P = .21). CONCLUSION Ambulatory laparoscopic adrenalectomy is a safe and feasible alternative to inpatient hospitalization in selected patients. Further study is needed to determine the cost savings, barriers to uptake, and optimal selection criteria for this approach.
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Affiliation(s)
- Omair A Shariq
- Department of Surgery, Mayo Clinic, Rochester, MN; Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK.
| | - Katherine A Bews
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | | | - Benzon M Dy
- Department of Surgery, Mayo Clinic, Rochester, MN
| | | | | | | | | | - Elizabeth B Habermann
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
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22
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Szabo Yamashita T, Sada A, Bancos I, Young WF, Dy BM, Farley DR, Lyden ML, Thompson GB, McKenzie TJ. Differences in outcomes of bilateral adrenalectomy in patients with ectopic ACTH producing tumor of known and unknown origin. Am J Surg 2020; 221:460-464. [PMID: 32921404 DOI: 10.1016/j.amjsurg.2020.08.047] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 08/12/2020] [Accepted: 08/30/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Endogenous Cushing syndrome (CS) can be caused by ectopic corticotropin-producing tumors of known (EK) and unknown origin (EU). Bilateral adrenalectomy (BA) can be used as definite treatment of hypercortisolism in such cases. This study compared patients undergoing BA for CS secondary to EK vs EU. METHODS Retrospective review (1995-2017) of patients undergoing BA due to EK or EU. We analyzed demographic characteristics, laboratory values, intraoperative variables, surgical outcomes, and survival. RESULTS 48 patients (26 EU, 22 EK) were identified. Serum cortisol and ACTH concentrations were similar. 92% of BA for EU were performed minimally invasively vs 77% for EK, P = 0.22. Complications occurred in 19% of EU and 4.5% EK, P = 0.2. Mean survival was 4.3 years for EU and 4.0 years for EK without difference in all-cause mortality P = 0.63. CONCLUSION BA cure rate was 100% for CS in EU and EK. Morbidity, long term and all-cause mortality differences were not statistically significant between EK and EU.
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Affiliation(s)
| | - Alaa Sada
- Mayo Clinic, Department of Surgery, 200 1st Street, 55905, Rochester, MN, USA
| | - Irina Bancos
- Mayo Clinic, Division of Endocrinology, Diabetes, Metabolism, and Nutrition, 200 1st Street, 55905, Rochester, MN, USA
| | - William F Young
- Mayo Clinic, Division of Endocrinology, Diabetes, Metabolism, and Nutrition, 200 1st Street, 55905, Rochester, MN, USA
| | - Benzon M Dy
- Mayo Clinic, Department of Surgery, 200 1st Street, 55905, Rochester, MN, USA
| | - David R Farley
- Mayo Clinic, Department of Surgery, 200 1st Street, 55905, Rochester, MN, USA
| | - Melanie L Lyden
- Mayo Clinic, Department of Surgery, 200 1st Street, 55905, Rochester, MN, USA
| | - Geoffrey B Thompson
- Mayo Clinic, Department of Surgery, 200 1st Street, 55905, Rochester, MN, USA
| | - Travis J McKenzie
- Mayo Clinic, Department of Surgery, 200 1st Street, 55905, Rochester, MN, USA.
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Szabo Yamashita T, Baky FJ, McKenzie TJ, Thompson GB, Farley DR, Lyden ML, Dy BM. Occurrence and Natural History of Thyroid Cancer in Patients with Cowden Syndrome. Eur Thyroid J 2020; 9:243-246. [PMID: 33088792 PMCID: PMC7548836 DOI: 10.1159/000506422] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 02/09/2020] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Cowden syndrome patients are at an increased risk of developing differentiated thyroid carcinoma (DTC). There are limited studies of thyroid cancer biology within this population. We aimed to describe the frequency and progression of DTC in this population. METHOD We reviewed all patients with clinically or genetically confirmed Cowden syndrome treated at our institution between 1979 and 2017. Presentation, operative details, pathology, and adjuvant treatment for all thyroid diseases were analyzed. RESULTS Forty-seven patients were identified. Thirty-seven received a clinical diagnosis while 10 tested positive on genetic testing for the PTEN gene. Average follow-up time was 10 years. Twenty-three patients underwent a total thyroidectomy. Nine patients were diagnosed with thyroid cancer, with a mean age of 28.5 years, 4 cases of the follicular variant of papillary thyroid cancer (PTC), 4 of PTC, and 1 of cystic PTC. One patient required an interval lateral neck dissection but no patients developed distant metastasis. Fourteen patients underwent thyroidectomy, 12 due to follicular adenoma, Hürthle cell adenoma, or multinodular goiter, 1 due to Graves' disease, and 1 who elected to undergo a prophylactic thyroidectomy. No mortality was associated with thyroid cancer in these patients. CONCLUSION Patients with Cowden syndrome are at a significantly increased risk of developing DTC and have a younger age of onset. In this study, 20% of the patients with Cowden syndrome were diagnosed with DTC, but distant metastasis and overall mortality were absent. Clinical features were similar to those of sporadic DTC, proving that, apart from screening, Cowden syndrome-related DTC can be treated in similar fashion.
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Affiliation(s)
| | | | | | | | | | | | - Benzon M. Dy
- *Benzon M. Dy, MD, Department of Surgery, Mayo Clinic, 200th First Street, Rochester, MN 55905 (USA),
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Drake FT, Lyden ML, Kuo JH, Shen WT, Morris-Wiseman LF, Carty SE, Wang TS. Optimizing the fellowship interview process: Perspectives from applicants and program directors of the comprehensive endocrine surgery fellowship program. Surgery 2020; 169:488-495. [PMID: 32854969 DOI: 10.1016/j.surg.2020.06.037] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Accepted: 06/21/2020] [Indexed: 11/20/2022]
Abstract
BACKGROUND Approximately 80% of general surgery residents undertake some form of fellowship training. Our objective was to characterize goals and burdens of the interview process among applicants to Comprehensive Endocrine Surgery Fellowship programs. METHODS Participants included trainees from 2013 to 2019. Results for ranking questions are presented as a mean rank reported out of the total number of selections. RESULTS Response rate was 54% (n = 75). The most important goal for interviews was meeting the faculty (mean rank 2.4/9), followed by "behind the scenes information" and "make a good impression" (mean rank 3.6 and 3.7, respectively). The most substantial burden for the applicant was expense (mean rank 2.1/7), followed by time away from residency (mean rank 3.1/7). The economic burden of 51% of the applicants was $2,500 to $7,500. Geographic location and expense were the top 2 reasons applicants declined offers of interviews. Despite the process, 76% of respondents indicated that no improvements to the interview process are necessary. Alternative strategies such as videoconferencing or centralized interviews received little support (<10%). CONCLUSION Despite identifying several burdens, survey respondents believed that in-person interviews are an integral component of the fellowship application process. Indeed, 70% of applicants do not have a first-choice program before interviews, and meeting the faculty is ranked as the greatest priority goal. Our data illustrate the importance of individual specialties evaluating and optimizing their own processes for fellowship interviews.
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Affiliation(s)
- Frederick Thurston Drake
- Department of Surgery, Boston University School of Medicine and Boston Medical Center, Boston, MA.
| | | | - Jennifer H Kuo
- Department of Surgery, Columbia University Medical Center, New York City, NY
| | - Wen T Shen
- Department of Surgery, University of California, San Francisco Medical Center, San Francisco, CA
| | | | - Sally E Carty
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Tracy S Wang
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
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Sada A, Glasgow AE, Dy BM, Lyden ML, Thompson GB, McKenzie TJ, Habermann EB. Impact of opioid prescribing guidelines on prescribing at discharge from endocrine surgery. Am J Surg 2020; 221:455-459. [PMID: 32847688 DOI: 10.1016/j.amjsurg.2020.08.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 06/19/2020] [Accepted: 08/06/2020] [Indexed: 11/26/2022]
Abstract
INTRODUCTION In 2018, our institution implemented opioid prescribing guidelines for endocrine surgery. METHODS We evaluated prescribing trends before and after the guidelines (60 MME following adrenal procedures and 37.5 MME for thyroid/parathyroid procedures) using chi-squared and Wilcoxon Rank-Sum tests. RESULTS We identified 357 patients in the pre-guideline and 397 in the post-guideline period. The proportion discharged with any opioid prescription decreased from 96.1% to 77.3%, p < 0.01, and the median (IQR) prescribed amount decreased from 150.0 (100.0, 200.0) to 50.0 (25.0, 75.0), p < 0.01 overall and within each category. The proportion receiving prescription above the upper guidelines limit also decreased, while opioid refills within 30-day of discharge remained stable (2.8% before and 4.5% after the guidelines, p = 0.21). CONCLUSION Opioid prescribing guidelines for endocrine surgical procedures decreased both the proportion of patients receiving opioids and the amount when prescribed, therefore further supporting the utility of opioid prescribing guidelines in decreasing over-prescription.
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Affiliation(s)
- Alaa Sada
- Department of Surgery, Mayo Clinic, 200th 1st Street, Rochester MN, 55905, USA; Department of Health Services Research, Mayo Clinic, 200th 1st Street, Rochester MN, 55905, USA
| | - Amy E Glasgow
- Department of Health Services Research, Mayo Clinic, 200th 1st Street, Rochester MN, 55905, USA; Mayo Clinic Robert D and Patricia E Kern Center for the Science of Health Care Delivery, 200th 1st Street, Rochester MN, 55905, USA
| | - Benzon M Dy
- Department of Surgery, Mayo Clinic, 200th 1st Street, Rochester MN, 55905, USA
| | - Melanie L Lyden
- Department of Surgery, Mayo Clinic, 200th 1st Street, Rochester MN, 55905, USA
| | - Geoffrey B Thompson
- Department of Surgery, Mayo Clinic, 200th 1st Street, Rochester MN, 55905, USA
| | - Travis J McKenzie
- Department of Surgery, Mayo Clinic, 200th 1st Street, Rochester MN, 55905, USA
| | - Elizabeth B Habermann
- Department of Health Services Research, Mayo Clinic, 200th 1st Street, Rochester MN, 55905, USA; Mayo Clinic Robert D and Patricia E Kern Center for the Science of Health Care Delivery, 200th 1st Street, Rochester MN, 55905, USA.
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Sada A, Yamashita TS, Glasgow AE, Habermann EB, Thompson GB, Lyden ML, Dy BM, Halfdanarson TR, Vella A, McKenzie TJ. Comparison of benign and malignant insulinoma. Am J Surg 2020; 221:437-447. [PMID: 32873371 DOI: 10.1016/j.amjsurg.2020.08.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 07/21/2020] [Accepted: 08/05/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND How malignant insulinomas present relative to benign insulinomas is unknown. METHODS A single-institution retrospective study identified patients with insulinoma. Malignancy was defined by distant metastases, positive lymph node(s), T stage of 4, direct invasion into surrounding peripancreatic tissue, or presence of lymphovascular invasion. Wilcoxon Rank Sum tests and Kaplan-Meier analysis were used. RESULTS A total of 311 patients were identified: 51 malignant and 260 benign. Patients with malignant insulinoma presented with higher levels of insulin, proinsulin, and c-peptide. Malignant lesions were larger: 4.2 ± 3.2 vs 1.8 ± 0.8 cm in benign lesions, p < 0.01. Overall survival at 5 years was 66.8% vs 95.4% for malignant and benign insulinoma respectively, p < 0.01. CONCLUSIONS Larger size of insulinoma and increased serum β-cell polypeptide concentrations were associated with malignancy. Malignant insulinoma has poorer survival. Further work-up to rule out malignancy may be indicated for larger pancreatic lesions and for patients with higher pre-operative insulin and pro-insulin.
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Affiliation(s)
- Alaa Sada
- Department of Surgery, Mayo Clinic, 200th 1st Street, Rochester MN, 55905, USA; Department of Health Services Research, Mayo Clinic, 200th 1st Street, Rochester MN, 55905, USA
| | | | - Amy E Glasgow
- Department of Health Services Research, Mayo Clinic, 200th 1st Street, Rochester MN, 55905, USA; Mayo Clinic Robert D and Patricia E Kern Center for the Science of Health Care Delivery, 200th 1st Street, Rochester MN, 55905, USA
| | - Elizabeth B Habermann
- Department of Health Services Research, Mayo Clinic, 200th 1st Street, Rochester MN, 55905, USA; Mayo Clinic Robert D and Patricia E Kern Center for the Science of Health Care Delivery, 200th 1st Street, Rochester MN, 55905, USA
| | - Geoffrey B Thompson
- Department of Surgery, Mayo Clinic, 200th 1st Street, Rochester MN, 55905, USA
| | - Melanie L Lyden
- Department of Surgery, Mayo Clinic, 200th 1st Street, Rochester MN, 55905, USA
| | - Benzon M Dy
- Department of Surgery, Mayo Clinic, 200th 1st Street, Rochester MN, 55905, USA
| | | | - Adrian Vella
- Division of Endocrinology, Mayo Clinic, 200th 1st Street, Rochester MN, 55905, USA
| | - Travis J McKenzie
- Department of Surgery, Mayo Clinic, 200th 1st Street, Rochester MN, 55905, USA.
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Hamidi O, Raman R, Lazik N, Iniguez-Ariza N, McKenzie TJ, Lyden ML, Thompson GB, Dy BM, Young WF, Bancos I. Clinical course of adrenal myelolipoma: A long-term longitudinal follow-up study. Clin Endocrinol (Oxf) 2020; 93:11-18. [PMID: 32275787 PMCID: PMC7292791 DOI: 10.1111/cen.14188] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2020] [Revised: 03/23/2020] [Accepted: 03/30/2020] [Indexed: 12/31/2022]
Abstract
OBJECTIVE We aimed to describe clinical course of myelolipoma and to identify predictors of tumour growth and need for surgery. DESIGN A retrospective study. PATIENTS Consecutive patients with myelolipoma. RESULTS A total of 321 myelolipomas (median size, 2.3 cm) were diagnosed in 305 patients at median age of 63 years (range, 25-87). Median follow-up was 54 months. Most myelolipomas were incidentally detected (86%), whereas 9% were discovered during cancer staging and 5% during workup of mass effect symptoms. Thirty-seven (12%) patients underwent adrenalectomy. Compared to myelolipomas <6 cm, tumours ≥6 cm were more likely to be bilateral (21% vs 3%, P < .0001), cause mass effect symptoms (32% vs 0%, P < .0001), have haemorrhagic changes (14% vs 1%, P < .0001) and undergo adrenalectomy (52% vs 5%, P < .0001). Among patients with ≥6 months of imaging follow-up, median size change was 0 mm (-10, 115) and median growth rate was 0 mm/y (-6, 14). Compared to <1 cm growth, ≥1 cm growth correlated with larger initial size (3.6 vs 2.3 cm, P = .02), haemorrhagic changes (12% vs 2%, P = .007) and adrenalectomy (35% vs 8%, P < .0001). CONCLUSIONS Most myelolipomas are incidentally discovered on cross-sectional imaging. Myelolipomas ≥6 are more likely to cause mass effect symptoms, have haemorrhagic changes and undergo resection. Tumour growth ≥1 cm is associated with larger myelolipoma and haemorrhagic changes. Adrenalectomy should be considered in symptomatic patients with large tumours and when there is evidence of haemorrhage or tumour growth.
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Affiliation(s)
- Oksana Hamidi
- Division of Endocrinology and Metabolism, UT Southwestern Medical Center, Dallas, TX, USA
- Division of Endocrinology, Diabetes, and Nutrition, Mayo Clinic, Rochester, MN, US
| | - Ram Raman
- Department of Medicine, Charles University, Prague, Czech Republic
| | - Natalia Lazik
- Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Nicole Iniguez-Ariza
- Department of Endocrinology and Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | | | | | | | - Benzon M. Dy
- Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | - William F. Young
- Division of Endocrinology, Diabetes, and Nutrition, Mayo Clinic, Rochester, MN, US
| | - Irina Bancos
- Division of Endocrinology, Diabetes, and Nutrition, Mayo Clinic, Rochester, MN, US
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Strajina V, Dy BM, Mckenzie TJ, Thompson GB, Lyden ML. Predicting Postthyroidectomy Hypocalcemia: Improving Predictive Ability of Parathyroid Hormone Level. Am Surg 2020. [DOI: 10.1177/000313482008600231] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
We performed a retrospective study of our large patient cohort aiming to examine the ability to predict postthyroidectomy hypocalcemia. A retrospective review of patients who underwent total or near-total thyroidectomy at our institution between 2008 and 2018 was performed. Postoperative hypocalcemia was defined as Ca level <8.0 mg/dL (reference range: 8.9–10.1 mg/dL) within 30 days of operation. Logistic regression was used to develop models for prediction of the occurrence of postoperative hypocalcemia. Inclusion criteria were met by 1463 patients. Hypocalcemia was documented in 223 patients (15%). Models based on parathyroid hormone (PTH) levels alone had an associated receiver operator characteristic with an areas under the curve (AUC) of 0.79. There was an inverse relationship between time of measurement and PTH levels within the first two hours after thyroidectomy ( P < 0.01). When measured two to six hours after closure, the predictive ability of PTH compared favorably (AUC = 0.82) with either earlier (within the first two hours after closure, AUC = 0.79) or later measurement (6–24 hours after closure, AUC = 0.77). When measured between two and six hours postoperatively, PTH < 19 pg/mL had a sensitivity of 90 per cent and negative predictive value of 96 per cent for postoperative hypocalcemia. The model that included the PTH level, concurrently measured total blood calcium level, and time of measurement had an improved predictive ability with an AUC of 0.87. PTH level of 19 pg/mL measured two to six hours after thyroidectomy had a sensitivity of 90 per cent and a negative predictive value of 96 per cent in our cohort. The model including postoperative PTH level, calcium level, and time of measurement may further improve the ability to predict postthyroidectomy hypocalcemia.
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Affiliation(s)
- Veljko Strajina
- From the Department of Surgery, Mayo Clinic, Rochester, Minnesota
| | - Benzon M. Dy
- From the Department of Surgery, Mayo Clinic, Rochester, Minnesota
| | | | | | - Melanie L. Lyden
- From the Department of Surgery, Mayo Clinic, Rochester, Minnesota
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Szabo Yamashita T, Sada A, Bancos I, Young WF, Dy BM, Farley DR, Lyden ML, Thompson GB, McKenzie TJ. Bilateral Adrenalectomy: Differences between Cushing Disease and Ectopic ACTH-Producing Tumors. Ann Surg Oncol 2020; 27:3851-3857. [DOI: 10.1245/s10434-020-08451-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Indexed: 12/28/2022]
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30
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Gruber LM, Strajina V, Bancos I, Murad MH, Dy BM, Young WF, Farley DR, Lyden ML, Thompson GB, McKenzie TJ. Not all adrenal incidentalomas require biochemical testing to exclude pheochromocytoma: Mayo clinic experience and a meta-analysis. Gland Surg 2020; 9:362-371. [PMID: 32420260 DOI: 10.21037/gs.2020.03.04] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Background Excluding a pheochromocytoma is important when a patient presents with an incidentally discovered adrenal mass. However, biochemical testing for pheochromocytoma can be cumbersome, time consuming, or falsely positive. Our objective was to determine if unenhanced computed tomography (CT) imaging alone can be used to rule out pheochromocytoma. Methods We performed a retrospective study of all patients with a pathologically confirmed pheochromocytoma and unenhanced CT imaging who were treated at the Mayo Clinic between 1998 and 2016. Additionally, we performed a systematic review and meta-analysis of original studies published after 2005 with patients who had adrenal masses, more than 10 patients with pheochromocytomas, and reported attenuation on unenhanced CT imaging in Hounsfield units (HU). Results In the Mayo cohort, we identified 186 patients and 199 pheochromocytomas with unenhanced CT imaging. The mean unenhanced CT attenuation was 35±9 HU (range, 15-62), and only 15 tumors had attenuation ≤20 HU. The systematic review identified 26 studies (1,217 tumors), and 23 studies provided a mean unenhanced CT attenuation. The overall mean unenhanced CT attenuation across the studies was 35.6 HU (95% CI, 22.0-49.1 HU). A cutoff of >10 HU had a 100% sensitivity (95% CI, 1.00-1.00) for pheochromocytoma with low heterogeneity between the 21 qualified studies (I2=0%). Sensitivity for pheochromocytoma was 100% and 99% for an unenhanced CT attenuation cutoff of >15 and >20 HU. Conclusions Biochemical testing may not be required to exclude pheochromocytoma if an incidental adrenal mass has low attenuation (<10 HU) on unenhanced CT images.
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Affiliation(s)
- Lucinda M Gruber
- Division of Endocrinology, Metabolism, Nutrition & Diabetes, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Veljko Strajina
- Department of Surgery, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Irina Bancos
- Division of Endocrinology, Metabolism, Nutrition & Diabetes, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - M Hassan Murad
- Evidence Based Practice Center, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Benzon M Dy
- Department of Surgery, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - William F Young
- Division of Endocrinology, Metabolism, Nutrition & Diabetes, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - David R Farley
- Department of Surgery, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Melanie L Lyden
- Department of Surgery, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Geoffrey B Thompson
- Department of Surgery, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Travis J McKenzie
- Department of Surgery, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
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Rocco R, Murphy BL, Patel VP, Hamidi O, Chang AY, Lyden ML. A rare case of a 65 year old female with a mesenteric paraganglioma. Human Pathology: Case Reports 2020. [DOI: 10.1016/j.ehpc.2019.200349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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Traynor MD, Sada A, Thompson GB, Moir CR, Bancos I, Farley DR, Dy BM, Lyden ML, Habermann EB, McKenzie TJ. Adrenalectomy for non-neuroblastic pathology in children. Pediatr Surg Int 2020; 36:129-135. [PMID: 31691026 DOI: 10.1007/s00383-019-04589-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/13/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND Adrenalectomy for non-neuroblastic pathologies in children is rare with limited data on outcomes. We reviewed our experience of adrenalectomy in this unique population. METHODS Retrospective study of children (age ≤ 18) who underwent adrenalectomy with non-neuroblastic pathology from 1988 to 2018. Clinical and operative details of patients were abstracted. Outcomes included length of stay and 30-day postoperative morbidity. RESULTS Forty children underwent 50 adrenalectomies (12 right-sided, 18 left-sided, 10 bilateral). Six patients (15%) presented with an incidental adrenal mass while 4 (10%) had masses found on screening for genetic mutations or prior malignancy. The remaining 30 (75%) presented with symptoms of hormonal excess. Nineteen patients (48%) underwent genetic evaluation and 15 (38%) had genetic predispositions. Diagnoses included 9 patients (23%) with pheochromocytoma, 8 (20%) with adrenocortical adenoma, 8 (20%) with adrenocortical carcinoma, 7 (18%) with adrenal hyperplasia, 2 (5%) with metastasis, and 6 (14%) with additional benign pathologies. Of 50 adrenalectomies, twenty-five (50%) were laparoscopic. Median hospital length of stay was 3 days (range 0-11). Post-operative morbidity rate was 17% with the most severe complication being Clavien-Dindo grade II. CONCLUSION Adrenalectomy for non-neuroblastic pathology can be done with low morbidity. Its frequent association with genetic mutations and syndromes requires surgeons to have knowledge of appropriate pre-operative testing and post-operative surveillance.
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Affiliation(s)
- Michael D Traynor
- Department of Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Alaa Sada
- Department of Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Geoffrey B Thompson
- Department of Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | | | - Irina Bancos
- Division of Endocrinology, Mayo Clinic, Rochester, MN, USA
| | - David R Farley
- Department of Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Benzon M Dy
- Department of Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Melanie L Lyden
- Department of Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Elizabeth B Habermann
- Division of Health Care Policy and Research, Mayo Clinic, Rochester, MN, USA.,Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Travis J McKenzie
- Department of Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
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Strajina V, Dy BM, McKenzie TJ, Thompson GB, Lyden ML. Predicting Postthyroidectomy Hypocalcemia: Improving Predictive Ability of Parathyroid Hormone Level. Am Surg 2020; 86:121-126. [PMID: 32167046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
We performed a retrospective study of our large patient cohort aiming to examine the ability to predict postthyroidectomy hypocalcemia. A retrospective review of patients who underwent total or near-total thyroidectomy at our institution between 2008 and 2018 was performed. Postoperative hypocalcemia was defined as Ca level <8.0 mg/dL (reference range: 8.9-10.1 mg/dL) within 30 days of operation. Logistic regression was used to develop models for prediction of the occurrence of postoperative hypocalcemia. Inclusion criteria were met by 1463 patients. Hypocalcemia was documented in 223 patients (15%). Models based on parathyroid hormone (PTH) levels alone had an associated receiver operator characteristic with an areas under the curve (AUC) of 0.79. There was an inverse relationship between time of measurement and PTH levels within the first two hours after thyroidectomy (P < 0.01). When measured two to six hours after closure, the predictive ability of PTH compared favorably (AUC = 0.82) with either earlier (within the first two hours after closure, AUC = 0.79) or later measurement (6-24 hours after closure, AUC = 0.77). When measured between two and six hours postoperatively, PTH < 19 pg/mL had a sensitivity of 90 per cent and negative predictive value of 96 per cent for postoperative hypocalcemia. The model that included the PTH level, concurrently measured total blood calcium level, and time of measurement had an improved predictive ability with an AUC of 0.87. PTH level of 19 pg/mL measured two to six hours after thyroidectomy had a sensitivity of 90 per cent and a negative predictive value of 96 per cent in our cohort. The model including postoperative PTH level, calcium level, and time of measurement may further improve the ability to predict postthyroidectomy hypocalcemia.
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34
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Sada A, Ubl DS, Thiels CA, Cronin PA, Dy BM, Lyden ML, Thompson GB, McKenzie TJ, Habermann EB. Optimizing Opioid-Prescribing Practices After Parathyroidectomy. J Surg Res 2020; 245:107-114. [DOI: 10.1016/j.jss.2019.07.039] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Revised: 06/03/2019] [Accepted: 07/16/2019] [Indexed: 10/26/2022]
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Rudin AV, McKenzie TJ, Thompson GB, Farley DR, Lyden ML. Evaluation of Parathyroid Glands with Indocyanine Green Fluorescence Angiography After Thyroidectomy. World J Surg 2019; 43:1538-1543. [PMID: 30659346 DOI: 10.1007/s00268-019-04909-z] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND Indocyanine green fluorescence angiography (ICGA) is a new adjunct that has been used in surgical procedures to assess blood flow. This study evaluated the utility of ICGA compared to visual inspection to predict parathyroid function, guide autotransplantation and potentially decrease permanent hypoparathyroidism. METHODS This was a retrospective study of patients who underwent total or near-total thyroidectomy (T-NT) between January 2015 and March 2018. Patients with preoperative hyperparathyroidism and those undergoing reoperation were excluded. Patients who had ICGA were compared to T-NT patients without ICGA. Data were analyzed to assess the frequency of autotransplantation and incidence of hypoparathyroidism between groups. RESULTS In total, 210 patients underwent T-NT: 86 with ICGA and 124 without. Autotransplantation was more common in the ICGA group at 36% compared to 12% in the control (p = 0.0001). There was no correlation with at least one normal parathyroid gland on ICGA and postoperative PTH levels (p = 0.75). There was a difference in having normal postoperative PTH when there were at least two normal parathyroid glands (n = 50) compared to patients with less than two normal ICGA glands (n = 36, p = 0.044). Visual assessment and ICGA assessment of vascularity were in agreement, 245/281 (87%). There were 19 glands (6.8%) that would have undergone autotransplant based on visual inspection that had adequate blood supply on ICGA. Transient hypoparathyroidism was present in 45 out of 124 controls (36%) and 32 out of 86 (37%) in the ICG group. CONCLUSIONS ICGA is a novel technique that may improve the assessment of parathyroid gland blood supply compared to visual inspection. ICGA can guide more appropriate autotransplantation without compromising postoperative parathyroid function. At least two vascularized glands on ICGA may predict postoperative parathyroid gland function.
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Affiliation(s)
- Anatoliy V Rudin
- Division of Breast, Endocrine, Metabolic and Gastrointestinal Surgery, Mayo Clinic, 200 1st St SW, Rochester, MN, 55902, USA
| | - Travis J McKenzie
- Division of Breast, Endocrine, Metabolic and Gastrointestinal Surgery, Mayo Clinic, 200 1st St SW, Rochester, MN, 55902, USA
| | - Geoffrey B Thompson
- Division of Breast, Endocrine, Metabolic and Gastrointestinal Surgery, Mayo Clinic, 200 1st St SW, Rochester, MN, 55902, USA
| | - David R Farley
- Division of Breast, Endocrine, Metabolic and Gastrointestinal Surgery, Mayo Clinic, 200 1st St SW, Rochester, MN, 55902, USA
| | - Melanie L Lyden
- Division of Breast, Endocrine, Metabolic and Gastrointestinal Surgery, Mayo Clinic, 200 1st St SW, Rochester, MN, 55902, USA.
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Abel SA, Al-Lami HS, Zeineddin S, Chandra A, Bingener-Casey J, Lyden ML. Robotic-Assisted Single Site Cholecystectomy and the Obese Patient: Single Center Outcomes Data. J Am Coll Surg 2019. [DOI: 10.1016/j.jamcollsurg.2019.08.205] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Shariq OA, Mehta K, Thompson GB, Lyden ML, Farley DR, Bancos I, Dy BM, Young WF, McKenzie TJ. Primary Aldosteronism: Does Underlying Pathology Impact Clinical Presentation and Outcomes Following Unilateral Adrenalectomy? World J Surg 2019; 43:2469-2476. [PMID: 31214831 DOI: 10.1007/s00268-019-05059-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
INTRODUCTION Patients undergoing unilateral adrenalectomy for primary aldosteronism (PA) may have a solitary adenoma, unilateral hyperplasia, or multiple adenomas on final pathology. This study investigated whether the underlying pathological diagnosis was associated with differences in clinical presentation and postoperative outcomes. METHODS A retrospective cohort study of patients undergoing unilateral adrenalectomy for PA from 2004 to 2015 at our institution was performed. Baseline clinical and laboratory parameters, as well as postoperative biochemical and hypertension cure rates, were compared across the three aforementioned pathological groups. RESULTS Of 206 patients who met criteria for inclusion, 152 (73.8%) had a single adenoma, 33 (16%) had unilateral hyperplasia, and 21 (10.2%) had multiple unilateral adenomas. Patients with unilateral hyperplasia were more likely to be male (81.2% vs 57.9%, P = .03), undergo left-sided adrenalectomy (78.8% vs 47.4%, P < .01), and had a lower median adrenal venous sampling lateralization index (9.8 vs 19.8, P = .04) compared to those with solitary, but not multiple unilateral adenomas. No differences were seen in age, duration of hypertension, preoperative plasma aldosterone levels, plasma renin activities, 24-h urinary aldosterone excretion, serum potassium concentrations, and the number of preoperative antihypertensive medications across all three pathological groups. All patients achieved biochemical cure following adrenalectomy, and no significant differences in the rates of hypertension cure or improvement were observed in comparisons across pathological subtype. CONCLUSIONS Clinical presentation and postoperative outcomes are similar regardless of underlying pathology in patients with PA. Because one in four patients may harbor unilateral hyperplasia or multiple adenomas, total unilateral adrenalectomy should be performed as the operation of choice over adrenal-sparing approaches.
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Affiliation(s)
- Omair A Shariq
- Department of Surgery, Mayo Clinic, 200 First Street S.W., Rochester, MN, 55905, USA.
| | - Kabir Mehta
- Department of Surgery, Mayo Clinic, 200 First Street S.W., Rochester, MN, 55905, USA
| | - Geoffrey B Thompson
- Department of Surgery, Mayo Clinic, 200 First Street S.W., Rochester, MN, 55905, USA
| | - Melanie L Lyden
- Department of Surgery, Mayo Clinic, 200 First Street S.W., Rochester, MN, 55905, USA
| | - David R Farley
- Department of Surgery, Mayo Clinic, 200 First Street S.W., Rochester, MN, 55905, USA
| | - Irina Bancos
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN, USA
| | - Benzon M Dy
- Department of Surgery, Mayo Clinic, 200 First Street S.W., Rochester, MN, 55905, USA
| | - William F Young
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN, USA
| | - Travis J McKenzie
- Department of Surgery, Mayo Clinic, 200 First Street S.W., Rochester, MN, 55905, USA
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Sada A, Asaad M, Bews KA, Thompson GB, Young WF, Bancos I, Farley DR, Dy BM, Lyden ML, Habermann EB, McKenzie TJ. Comparison between functional and non-functional adrenocortical carcinoma. Surgery 2019; 167:216-223. [PMID: 31543320 DOI: 10.1016/j.surg.2019.04.066] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Revised: 03/28/2019] [Accepted: 04/27/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND While roughly half of adrenocortical carcinomas are functional, whether functional status impacts outcomes remains controversial. We compared presentation and survival for functional and nonfunctional neoplasms. METHODS Adult patients presented with adrenocortical carcinomas at the Mayo Clinic were included. Tumor characteristics and outcomes were analyzed. RESULTS The 266 identified patients presented with stage I (6%), II (33%), III (26%), and IV disease (32%); stage was unknown in 3%. Fifty-three percent of tumors were functional; patients with functional adrenocortical carcinomas were younger, more likely to be female, and more likely to present with metastatic disease. Surgical resection was undertaken in 84% of patients with 69% having R0 resection. While 30-day morbidity was similar between functional and nonfunctional adrenocortical carcinomas, median overall survival was better for nonfunctional adrenocortical carcinomas (median 66 vs 22 months, P = .01). Functional adrenocortical carcinomas was independently associated with shorter survival after adjusting for age, sex, grade, stage, and resection attempt: hazard ratio = 1.5 (95% confidence interval, 1.04-2.14, P = .03). CONCLUSION In our cohort, long term survival was worse for all patients with functional tumors. However, when analyzing patients with R0 resection, there was no survival difference between functional and nonfunctional adrenocortical carcinomas, signaling need for better understanding of adrenocortical carcinomas behavior to individualize and optimize treatment strategies.
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Affiliation(s)
- Alaa Sada
- Department of Surgery, Mayo Clinic, Rochester, MN; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Malke Asaad
- Department of Surgery, Mayo Clinic, Rochester, MN
| | - Katherine A Bews
- Department of Health Services Research, Mayo Clinic, Rochester, MN; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | | | | | - Irina Bancos
- Division of Endocrinology, Mayo Clinic, Rochester, MN
| | | | - Benzon M Dy
- Department of Surgery, Mayo Clinic, Rochester, MN
| | | | - Elizabeth B Habermann
- Department of Health Services Research, Mayo Clinic, Rochester, MN; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
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Gruber LM, Hartman RP, Thompson GB, McKenzie TJ, Lyden ML, Dy BM, Young WF, Bancos I. Pheochromocytoma Characteristics and Behavior Differ Depending on Method of Discovery. J Clin Endocrinol Metab 2019; 104:1386-1393. [PMID: 30462226 DOI: 10.1210/jc.2018-01707] [Citation(s) in RCA: 76] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Accepted: 11/14/2018] [Indexed: 12/14/2022]
Abstract
CONTEXT Modern pheochromocytomas (PHEOs) are often discovered by incidental finding on cross-sectional imaging or mutation-based genetic case detection testing. Little is known about how these PHEOs behave. OBJECTIVE To describe the characteristics and behavior of PHEOs discovered incidentally on imaging or through mutation-based genetic case detection testing. DESIGN Retrospective study. SETTING Referral center. PATIENTS Consecutive patients with pathology-confirmed PHEOs, treated from 2005 to 2016. MAIN OUTCOME MEASURE(S) Tumor size, plasma/urine fractionated metanephrines and catecholamines, and preoperative management. RESULTS Two hundred seventy-one patients (52% women, median age 52.0 years) presented with 296 PHEOs. Discovery method was most often incidental finding on cross-section imaging (61%) rather than PHEO-related symptoms (27%) or mutation-based case detection testing (12%). Patients with incidentally discovered PHEOs were older than symptomatic and mutation-based case detection testing patients (median age 56.6 vs 43 vs 35 years, P < 0.0001). Mutation-based case detection PHEOs were smaller than those discovered due to symptoms (median size 29.0 vs 50.5 mm, P = 0.0027). Patients with PHEOs discovered due to symptoms had the highest median concentration of 24-hour urinary metanephrines and total plasma metanephrines (P < 0.0001). These patients required a higher cumulative phenoxybenzamine dose than patients with incidental or case detection PHEO (median 450 vs 375 vs 270 mg, P = 0.029). CONCLUSIONS PHEOs are primarily discovered due to incidental finding on cross-sectional imaging rather than PHEO-related symptoms. PHEOs discovered through mutation-based genetic case detection testing were smaller and required less α-adrenergic blockade preoperatively compared with PHEOs found due to symptoms, which supports routine case detection testing for patients genetically predisposed for PHEOs.
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Affiliation(s)
- Lucinda M Gruber
- Division of Endocrinology, Diabetes, and Nutrition, Mayo Clinic, Rochester, Minnesota
| | | | - Geoffrey B Thompson
- Department of Surgery, Endocrine Subspecialty, Mayo Clinic, Rochester, Minnesota
| | - Travis J McKenzie
- Department of Surgery, Endocrine Subspecialty, Mayo Clinic, Rochester, Minnesota
| | - Melanie L Lyden
- Department of Surgery, Endocrine Subspecialty, Mayo Clinic, Rochester, Minnesota
| | - Benzon M Dy
- Department of Surgery, Endocrine Subspecialty, Mayo Clinic, Rochester, Minnesota
| | - William F Young
- Division of Endocrinology, Diabetes, and Nutrition, Mayo Clinic, Rochester, Minnesota
| | - Irina Bancos
- Division of Endocrinology, Diabetes, and Nutrition, Mayo Clinic, Rochester, Minnesota
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Zhang CD, Pichurin PN, Bobr A, Lyden ML, Young WF, Bancos I. Cushing syndrome: uncovering Carney complex due to novel PRKAR1A mutation. Endocrinol Diabetes Metab Case Rep 2019; 2019:EDM180150. [PMID: 30897549 PMCID: PMC6432981 DOI: 10.1530/edm-18-0150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2019] [Accepted: 03/04/2019] [Indexed: 11/24/2022] Open
Abstract
Carney complex (CNC) is a rare multiple neoplasia syndrome characterized by spotty pigmentation of the skin and mucosa in association with various non-endocrine and endocrine tumors, including primary pigmented nodular adrenocortical disease (PPNAD). A 20-year-old woman was referred for suspected Cushing syndrome. She had signs of cortisol excess as well as skin lentigines on physical examination. Biochemical investigation was suggestive of corticotropin (ACTH)-independent Cushing syndrome. Unenhanced computed tomography scan of the abdomen did not reveal an obvious adrenal mass. She subsequently underwent bilateral laparoscopic adrenalectomy, and histopathology was consistent with PPNAD. Genetic testing revealed a novel frameshift pathogenic variant c.488delC/p.Thr163MetfsX2 (ClinVar Variation ID: 424516) in the PRKAR1A gene, consistent with clinical suspicion for CNC. Evaluation for other clinical features of the complex was unrevealing. We present a case of PPNAD-associated Cushing syndrome leading to the diagnosis of CNC due to a novel PRKAR1A pathogenic variant. Learning points: PPNAD should be considered in the differential for ACTH-independent Cushing syndrome, especially when adrenal imaging appears normal. The diagnosis of PPNAD should prompt screening for CNC. CNC is a rare multiple neoplasia syndrome caused by inactivating pathogenic variants in the PRKAR1A gene. Timely diagnosis of CNC and careful surveillance can help prevent potentially fatal complications of the disease.
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Affiliation(s)
- Catherine D Zhang
- Departments of Internal Medicine, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
| | - Pavel N Pichurin
- Departments of Clinical Genomics, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
| | - Aleh Bobr
- Departments of Laboratory Medicine and Pathology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
| | - Melanie L Lyden
- Departments of Surgery, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
| | - William F Young
- Departments of Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
| | - Irina Bancos
- Departments of Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
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Abstract
Primary hyperparathyroidism is the most common cause of hypercalcemia. Follow-up can be resource-intensive and costly. The aim of this study was to determine if there is a subset of patients who can be defined cured earlier than six months. This was a retrospective study of patients who underwent parathyroidectomy between January 2012 and March 2014. Patients with a history of multiple endocrine neoplasia syndrome, and secondary or tertiary hyperparathyroidism were excluded. Patients with normal preoperative calcium and parathyroid hormone (PTH) and those without six months follow-up were excluded. Patients were divided into two groups: cured and not cured. Data analysis was performed between the two groups. A total of 509 patients were screened, and 214 met our inclusion criteria: 202 in the cured category and 12 in the not cured category (94% cure rate). There was no significant difference between age, gland weight, or pre-operative PTH. There was a statistically significant difference between final intraoperative PTH (IOPTH) (37 vs 55, P = 0.008) and per cent PTH decrease (69 vs 43%, P < 0.0001). There was a significant difference between intraoperative cure rate (P < 0.0006), imaging concordance (P = 0.0115), and solitary versus multiglandular disease (P = 0.0151). Subgroup analysis in patients with concordant imaging, solitary parathyroid adenoma, and IOPTH decrease by 50 per cent to normal or near-normal correlated with a six-month cure rate of 97 per cent. Patients with primary hyperparathyroidism with concordant imaging, single-adenoma pathology, and IOPTH decrease by 50 per cent to normal or near-normal levels (15–65 pg/mL) can be considered cured and may need less frequent follow-up.
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Affiliation(s)
- Anatoliy V. Rudin
- Division of Breast, Endocrine, Metabolic and Gastrointestinal Surgery, Mayo Clinic-Rochester, Rochester, Minnesota
| | - Travis J. McKenzie
- Division of Breast, Endocrine, Metabolic and Gastrointestinal Surgery, Mayo Clinic-Rochester, Rochester, Minnesota
| | - Roberta Wermer
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Department of Medicine, Mayo Clinic-Rochester, Rochester, Minnesota
| | - Geoffrey B. Thompson
- Division of Breast, Endocrine, Metabolic and Gastrointestinal Surgery, Mayo Clinic-Rochester, Rochester, Minnesota
| | - Melanie L. Lyden
- Division of Breast, Endocrine, Metabolic and Gastrointestinal Surgery, Mayo Clinic-Rochester, Rochester, Minnesota
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Rudin AV, McKenzie TJ, Wermer RA, Thompson GB, Lyden ML. Primary Hyperparathyroidism: Redefining Cure. Am Surg 2019; 85:214-218. [PMID: 30819301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Primary hyperparathyroidism is the most common cause of hypercalcemia. Follow-up can be resource-intensive and costly. The aim of this study was to determine if there is a subset of patients who can be defined cured earlier than six months. This was a retrospective study of patients who underwent parathyroidectomy between January 2012 and March 2014. Patients with a history of multiple endocrine neoplasia syndrome, and secondary or tertiary hyperparathyroidism were excluded. Patients with normal preoperative calcium and parathyroid hormone (PTH) and those without six months follow-up were excluded. Patients were divided into two groups: cured and not cured. Data analysis was performed between the two groups. A total of 509 patients were screened, and 214 met our inclusion criteria: 202 in the cured category and 12 in the not cured category (94% cure rate). There was no significant difference between age, gland weight, or preoperative PTH. There was a statistically significant difference between final intraoperative PTH (IOPTH) (37 vs 55, P = 0.008) and per cent PTH decrease (69 vs 43%, P < 0.0001). There was a significant difference between intraoperative cure rate (P < 0.0006), imaging concordance (P = 0.0115), and solitary versus multiglandular disease (P = 0.0151). Subgroup analysis in patients with concordant imaging, solitary parathyroid adenoma, and IOPTH decrease by 50 per cent to normal or near-normal correlated with a six-month cure rate of 97 per cent. Patients with primary hyperparathyroidism with concordant imaging, single-adenoma pathology, and IOPTH decrease by 50 per cent to normal or near-normal levels (15-65 pg/mL) can be considered cured and may need less frequent follow-up.
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Strajina V, Dy BM, McKenzie TJ, Al-Hilli Z, Ryder M, Farley DR, Thompson GB, Lyden ML. Comprehensive Lateral Neck Dissection in Papillary Thyroid Carcinoma may Reduce Lateral Neck Recurrence Rates. Ann Surg Oncol 2018; 26:86-92. [PMID: 30411267 DOI: 10.1245/s10434-018-6871-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Indexed: 12/26/2022]
Abstract
OBJECTIVE To Identify predictors of recurrent disease following lateral neck dissection (LND) for papillary thyroid carcinoma (PTC). METHODS A retrospective review of patients who underwent first-time LND for PTC at our institution (2000-2015) was performed. Medical records were examined for biopsy or pathologically proven lateral neck recurrence. Differences between the groups with and without recurrence were compared. All LNDs were then classified in to two groups: "comprehensive" (CND), involving levels IIa-Vb at minimum, or "selective", labelling less extensive dissection (SND). RESULTS Four hundred nine patients underwent 467 LNDs. Surveillance data were available for 317 patients who underwent 362 LNDs (mean age 45 ± 16; range 18-88). The median follow-up was 64 ± 48 months (range 3-197). Recurrence was detected in 71 lateral necks (20%). The total number of lymph nodes was greater in the group without recurrence compared to those with recurrence (23 vs. 19, p = 0.02). Among patient demographics, radioactive iodine treatment, primary tumor characteristics and characteristics of nodal metastases, only an older patient age (mean 50 vs. 43 years) was associated with lateral neck recurrence (p < .01). CND was performed in 102 lateral necks and SND in 143 necks. There were 12 recurrences recorded in the CND group (12%) vs. 31 in the SND group (22%, p = .04). The majority of recurrences (70%) involved levels included in the original dissection. CONCLUSIONS Younger patients, more extensive dissection and a higher total number of lymph nodes removed are associated with a lower incidence of lateral neck recurrence after LND for papillary thyroid carcinoma.
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Affiliation(s)
- Veljko Strajina
- Department of Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
| | - Benzon M Dy
- Department of Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Travis J McKenzie
- Department of Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Zahraa Al-Hilli
- Department of Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Mabel Ryder
- Division of Endocrinology, Metabolism, Nutrition and Diabetes, Mayo Clinic, Rochester, MN, USA
| | - David R Farley
- Department of Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Geoffrey B Thompson
- Department of Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Melanie L Lyden
- Department of Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
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Strajina V, Dy BM, McKenzie TJ, Al-Hilli Z, Lee RA, Ryder M, Farley DR, Thompson GB, Lyden ML. Treatment of lateral neck papillary thyroid carcinoma recurrence after selective lateral neck dissection. Surgery 2018; 165:31-36. [PMID: 30314726 DOI: 10.1016/j.surg.2018.04.063] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Revised: 04/02/2018] [Accepted: 04/07/2018] [Indexed: 02/05/2023]
Abstract
BACKGROUND There is a paucity of data regarding optimal treatment options and outcomes for recurrent disease after lateral neck dissection in patients with papillary thyroid carcinoma. METHODS Retrospective review of patients who underwent either percutaneous ethanol injection or surgery for first-time ipsilateral recurrences after ipsilateral lateral neck dissection for papillary thyroid carcinoma was performed. RESULTS Follow-up data were available for 54 patients with recurrences in 57 lateral necks treated by either percutaneous ethanol injection (n = 32) or surgery (n = 25). Tumor burden at the time of lateral neck recurrence differed between the groups including the largest lymph node diameter (mean: 13 mm vs 18 mm, P < .01) and the mean number of metastatic lymph nodes identified on ultrasound (1.3 vs 1.9, P = .04). Each modality alone achieved similar estimated rates of disease control at 36 months (75% for percutaneous ethanol injection and 74% for surgery, P = .8) with similar number of reinterventions (1.8 for percutaneous ethanol injection, 1.6 for surgery, P = .6). CONCLUSIONS Both ethanol ablation and surgery can achieve disease control in the majority of patients with recurrences after ipsilateral lateral neck dissection for papillary thyroid carcinoma. Ethanol ablation, when used for treatment of a single small lymph node, can result in outcomes that are similar to reoperative surgery for larger and multiple lymph nodes.
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Affiliation(s)
| | - Benzon M Dy
- Department of Surgery, Mayo Clinic, Rochester, Minnesota
| | | | | | - Robert A Lee
- Department of Radiology, Mayo Clinic, Rochester, Minnesota
| | - Mabel Ryder
- Division of Endocrinology, Metabolism, Nutrition & Diabetes, Mayo Clinic, Rochester, Minnesota
| | - David R Farley
- Department of Surgery, Mayo Clinic, Rochester, Minnesota
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Strajina V, Al-Hilli Z, Andrews JC, Bancos I, Thompson GB, Farley DR, Lyden ML, Dy BM, Young WF, McKenzie TJ. Primary aldosteronism: making sense of partial data sets from failed adrenal venous sampling-suppression of adrenal aldosterone production can be used in clinical decision making. Surgery 2018; 163:801-806. [DOI: 10.1016/j.surg.2017.10.012] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Revised: 09/25/2017] [Accepted: 10/12/2017] [Indexed: 10/18/2022]
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