Tumour size predicts risk of recurrence in tall cell subtype papillary thyroid carcinoma

BACKGROUND

The tall cell subtype of papillary thyroid cancer (TCPTC) is the most common aggressive subtype and often treated aggressively. This approach may not be necessary in smaller tumours without adverse histological characteristics.

METHODS

97 patients with TCPTC defined as a height-to-width ratio of ≥3:1 and at least 30% tall cells were compared against 390 classical papillary thyroid carcinoma (CPTC) based on tumour size with recurrence free survival (RFS) as the primary outcome.

RESULTS

TCPTC are more likely to present with adverse histological characteristics. In smaller tumours (<2 ​cm), only central lymph node metastasis (HR7.16 p ​= ​0.03) and multifocality (HR10.11 p ​= ​0.026) increased recurrence risk. In larger tumours, TCPTC histology (HR3.78 p ​= ​0.002), lymphovascular invasion (HR3.02 p ​= ​0.014) and central lymph node metastasis (HR3.24 p ​< ​0.001) significantly increased recurrence risk.

CONCLUSION

TCPTC tumours <2 ​cm without central lymph node metastasis and multifocality are similar in risk of recurrence to classical PTC and could be managed with lobectomy.

Lessons learnt from the global iodinated contrast media shortage in head and neck imaging

A recent shortage in the global supply of iodinated contrast media (ICM) has required health service providers to review their contrast administration policies and implement strategies to conserve inventory. This article will review the current best practices in head and neck imaging for a variety of common presentations and provide examples where alternative imaging can be considered due to the recent ICM shortage. Ultrasound and MRI techniques can feature heavily in many diagnostic processes in head and neck pathology, and a variety of common presentations can be appropriately investigated through clinical evaluation or naso-endoscopy. In many instances, for the routine assessment of non-acute adult and paediatric head and neck presentations, the use of contrast-enhanced CT can be safely minimised to conserve ICM if required.

Three-phase four-dimensional computed tomography as a first-line investigation in primary hyperparathyroidism

INTRODUCTION

Parathyroid computed tomography using multiple phases (four-dimensional computed tomography (4DCT) for parathyroid localization was first described in 2006. Since its inception, there has been variable uptake of this technique due to inconsistency of results between institutions and perceived higher radiation dose than technetium-99 sestamibi scans (MIBI). 4DCT has been the primary imaging modality for parathyroid localization at our institution since 2013.

METHODS

A retrospective study of surgically managed patients with primary hyperparathyroidism who had preoperative localization with 4DCT from 2013-2018 was performed.

RESULTS

A total of 353 patients were included for analysis. The positive predictive value (PPV) of our three-phase 4DCT protocol was 93.3%, sensitivity (localized) 85.2% with a 5.8% false-positive rate and 13.9% false-negative (non-localizing) rate when reported by a head and neck radiologist (HNR). Calculated effective dose varied from 4.5 to 8.9mSV. On multivariable logistic regression, reporting by an experienced HNR (P < 0.001) and gland weight > 200 mg (P = 0.002) were significant for higher accuracy, lower false positives and false negatives.

CONCLUSION

A first-line three-phase 4DCT protocol for primary hyperparathyroidism is an accurate technique providing precise anatomical localization of abnormal parathyroid glands, particularly when performed by a specialist HNR. In our practise, it provides the best rate of detection and superior anatomical localization needed for minimally invasive parathyroid surgery, compared to other commonly used localization techniques. It also avoids the need for four gland exploration in the majority of patients with primary hyperparathyroidism.

Bi-national Review of Phaeochromocytoma Care: Is ICU Admission Always Necessary?

BACKGROUND

Post-operative management after phaeochromocytoma resection includes monitoring of blood pressure and blood sugar, and vigilance for haemorrhage. Guidelines recommend 24 h of continuous blood pressure monitoring, usually necessitating HDU/ICU admission. We hypothesised that most patients undergoing phaeochromocytoma resection do not require post-operative HDU/ICU admission. We aim to describe current Australian and New Zealand perioperative management of phaeochromocytoma and determine whether it is safe to omit HDU/ICU care for most patients.

METHODS

We collected retrospective data on patients undergoing excision of phaeochromocytoma in 12 centres around Australia and New Zealand between 2007 and 2019. Data collected included preoperative medical management, anaesthetic management, vasopressor support, HDU/ICU admission and complications.

RESULTS

A total of 223 patients were included in the study, 173 (77%) of whom were admitted to HDU/ICU post-operatively. The group of patients treated in ICU was similar to the group of patients treated on the ward in terms of demographic and tumour characteristics, and there were significant differences in the proportion of patients admitted to HDU/ICU between centres. Of patients admitted to ICU, 71 (41%) received vasopressor support. This was weaned within 24 h in 55 (77%) patients. Patients with larger tumours (> 6 cm) and a transfusion requirement are more likely to require prolonged inotropic support. Among patients admitted to the ward, there were no complications that required escalation of care.

CONCLUSIONS

Although not widespread practice in Australia and New Zealand, it appears safe for the majority of patients undergoing minimally invasive resection of phaeochromocytoma to be admitted to the ward post-operatively.

Management of adrenocortical carcinoma in Western Australia: a perspective over 14 years

BACKGROUND

Adrenocortical carcinoma is a rare but aggressive form of endocrine neoplasm that confers a poor prognosis. To date, the only Australian data published is from New South Wales. This paper describes our experience in Western Australia with a focus on surgical approach and outcomes.

METHODS

A retrospective study of patients treated for adrenocortical carcinoma in Western Australia over 14 years was performed.

RESULTS

Over the 14-year period, a total of 33 patients underwent surgery for adrenocortical carcinoma. Resection outcomes were superior in an open en bloc approach with an 85% R0 margin (P = 0.007). Local recurrence rates were lowest in an open en bloc approach (11%) compared to laparoscopic (75%). Multivariate analysis showed that an en bloc resection is highly correlated with an R0 resection (P < 0.05) and significantly associated with lower (odds ratio = 0.06) local recurrence (P = 0.009). Higher volume surgeons (>5 cases) had lower operative times and blood loss. Compliance with mitotane was significantly improved with close monitoring of levels. The European Network for the Study of Adrenal Tumours (ENSAT) stage at presentation was most predictive of long-term survival with 100% of stage I patients alive compared to 53% of stage II, 25% of stage III and 17% of stage IV patients at the end of the follow-up period.

CONCLUSION

An open en bloc approach with a low threshold for multi-visceral resection performed by high volume surgeons have improved outcomes in local recurrence, operative times and blood loss.

Intraoperative nerve monitoring in endocrine surgery: prevalence and reasons for its use in Australia and New Zealand

BACKGROUND

Intraoperative nerve monitoring (IONM) has increasingly been used in thyroid surgery by general, endocrine and head and neck surgeons. The purpose of this paper was to explore the prevalence and reasons for the usage of IONM in endocrine surgery in Australia and New Zealand.

METHODS

A survey was sent to general surgeons registered with the Royal Australasian College of Surgeons involved in endocrine surgery and members of the Australian and New Zealand Endocrine Surgeons. Users were divided into surgeon type, area of work, hospital type and volume of surgery. These data were analysed with univariate and multivariate logistic regression models.

RESULTS

Significant differences in IONM usage levels were observed between endocrine and general surgeons, area of work and volume of surgery performed. Endocrine surgeons are significantly more likely to use IONM than general surgeons. Surgeons who work in tertiary hospitals are more likely to use IONM as compared to those working in district hospitals. Surgeons who perform less than 100 thyroidectomies were more likely to be users of IONM.

CONCLUSION

IONM is not routinely used in thyroid surgery in Australia and New Zealand. The main reasons for the use of IONM given in our study by routine users were to establish familiarity of equipment and medicolegal reasons. Selective users chose as the most common reasons, a documented pre-existing unilateral nerve paresis or a hostile surgical field. Non-users stated that there was conflicting evidence that it improves outcomes and increased costs.

Development of a binational thyroid cancer clinical quality registry: a protocol paper

INTRODUCTION

The occurrence of thyroid cancer is increasing throughout the developed world and since the 1990s has become the fastest increasing malignancy. In 2014, a total of 2693 Australians and 302 New Zealanders were diagnosed with thyroid cancer, with this number projected to rise to 3650 in 2018. The purpose of this protocol is to establish a binational population-based clinical quality registry with the aim of monitoring and improving the quality of care provided to patients diagnosed with thyroid cancer in Australia and New Zealand.

METHODS AND ANALYSIS

The Australian and New Zealand Thyroid Cancer Registry (ANZTCR) aims to capture clinical data for all patients over the age of 16 years with thyroid cancer, confirmed by histopathology report, who have been diagnosed, assessed or treated at a contributing hospital. A multidisciplinary steering committee was formed which, with operational support from Monash University, established the ANZTCR in early 2017. The pilot phase of the registry is currently operating in Victoria, New South Wales, Queensland, Western Australia and South Australia, with over 20 sites expected to come on board across Australia in 2018. A modified Delphi process was undertaken to determine the clinical quality indicators to be reported by the registry, and a minimum data set was developed comprising information regarding thyroid cancer diagnosis, pathology, surgery and 90-day follow-up.

FUTURE PLANS

The establishment of the ANZTCR provides the opportunity for Australia and New Zealand to further understand current practice in the treatment of thyroid cancer and identify variation in outcomes. The engagement of endocrine surgeons in supporting this initiative is crucial. While the pilot registry has a focus on early clinical outcomes, it is anticipated that future collection of longer term outcome data particularly for patients with poor prognostic disease will add significant further value to the registry.

Differences between endocrinologists and endocrine surgeons in management of the solitary thyroid nodule

BACKGROUND

It is not known whether management of the solitary thyroid nodule differs between endocrinologists and endocrine surgeons.

METHODS

A questionnaire containing a hypothetical case (a 42-year-old euthyroid woman with a 2-x-3-cm solitary thyroid nodule) and 13 clinical variations was sent to endocrinologists and endocrine surgeons in Australia.

RESULTS

The response rate was 51%, including 122 endocrinologists and 48 endocrine surgeons. For the index case, serum thyroid-stimulating hormone (TSH), fine needle aspiration biopsy (FNAB) and ultrasonography were widely used by both groups, but thyroid antibody tests and scintigraphy were ordered more commonly by endocrinologists. In the setting of benign cytology, treatment differed significantly between specialties for the index case (endocrinologists: no treatment 78%, surgery 11%, thyroxine 11%; surgeons: no treatment 73%, surgery 25%, thyroxine 2%; P = 0.032). Treatment recommendations also differed significantly for 12 of the 13 clinical variations. In particular, for a patient with a suppressed serum TSH concentration, a majority of endocrinologists recommended radioiodine treatment, whereas surgeons favoured surgery (endocrinologists: radioiodine 53%, surgery 22%, no treatment 25%; surgeons: surgery 60%, radioiodine 11%, no treatment 27%; P < 0.001). For most of the variations, a higher proportion of surgeons than endocrinologists recommended surgical treatment. Comparison with previous surveys of European Thyroid Association and American Thyroid Association members (predominantly endocrinologists) demonstrated considerable international differences in management.

CONCLUSION

There are clinically significant differences between Australian endocrinologists and endocrine surgeons in management of the solitary thyroid nodule, and international differences in management of this disorder.

Concomitant compostite adrenal phoechromocytoma, multipte gastric stromal tumours and pseudohermaphrodism in a patient with von Recklinghausen's disease

Although pheochromocytoma occurs in 1% of patients with von Recklinghausen's disease, composite tumors in this syndrome are much rarer, with isolated case reports in the literature. Most gastrointestinal stromal tumors (GISTs) are solitary and sporadic. Multiple GISTs however, are associated with clinical syndromes particularly von Recklinghausen's disease. We believe this is the first report of composite adrenal pheochromocytoma and multiple GISTs occurring in an 82 year old woman with neurofibromatosis type 1 (NF1), manifested by clitoral and subcutaneous neurofibromas, epilepsy and Lisch nodules. The extreme clitoromegaly raised concerns of pseudohermaphrodism at presentation.