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Pasieka JL. Aphorisms that I have come to live by. Am J Surg 2024; 229:209-210. [PMID: 38042722 DOI: 10.1016/j.amjsurg.2023.11.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 11/07/2023] [Accepted: 11/09/2023] [Indexed: 12/04/2023]
Affiliation(s)
- Janice L Pasieka
- Surgery and Oncology, Cuming School of Medicine, Department of Surgery, Section General Surgery, Division Endocrine Surgery, 1403 29th Street NW, Foothills Medical Center, North Tower, Floor 10, T2N 2T9, Calgary, Alberta, Canada.
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2
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Samnani S, Cenzer I, Kline GA, Lee SJ, Hundemer GL, McClurg C, Pasieka JL, Boscardin WJ, Ronksley PE, Leung AA. Time to Benefit of Surgery vs Targeted Medical Therapy for Patients With Primary Aldosteronism: A Meta-analysis. J Clin Endocrinol Metab 2024; 109:e1280-e1289. [PMID: 37946600 PMCID: PMC10876395 DOI: 10.1210/clinem/dgad654] [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: 09/18/2023] [Revised: 10/20/2023] [Accepted: 11/06/2023] [Indexed: 11/12/2023]
Abstract
CONTEXT Primary aldosteronism (PA) is one of the most common causes of secondary hypertension, but the comparative outcomes of targeted treatment remain unclear. OBJECTIVE To compare the clinical outcomes in patients treated for primary aldosteronism over time. METHODS Medline and EMBASE were searched. Original studies reporting the incidence of mortality, major adverse cardiovascular outcomes (MACE), progression to chronic kidney disease, or diabetes following adrenalectomy vs medical therapy were selected. Two reviewers independently abstracted data and assessed study quality. Standard meta-analyses were conducted using random-effects models to estimate relative differences. Time to benefit meta-analyses were conducted by fitting Weibull survival curves to estimate absolute risk differences and pooled using random-effects models. RESULTS 15 541 patients (16 studies) with PA were included. Surgery was consistently associated with an overall lower risk of death (hazard ratio [HR] 0.34, 95% CI 0.22-0.54) and MACE (HR 0.55, 95% CI 0.36-0.84) compared with medical therapy. Surgery was associated with a significantly lower risk of hospitalization for heart failure (HR 0.48 95% CI 0.34-0.70) and progression to chronic kidney disease (HR 0.62 95% CI 0.39-0.98), and nonsignificant reductions in myocardial infarction and stroke. In absolute terms, 200 patients would need to be treated with surgery instead of medical therapy to prevent 1 death after 12.3 (95% CI 3.1-48.7) months. CONCLUSION Surgery is associated with lower all-cause mortality and MACE than medical therapy for PA. For most patients, the long-term surgical benefits outweigh the short-term perioperative risks.
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Affiliation(s)
- Sunil Samnani
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB T2T 5C7, Canada
| | - Irena Cenzer
- Division of Geriatrics, Department of Medicine, University of California (SanFrancisco), San Francisco, CA 94121, USA
- Geriatrics, Palliative and Extended Care Service Line, SanFrancisco VA (Veterans Affairs) Health Care System, San Francisco, CA 94121, USA
| | - Gregory A Kline
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB T2T 5C7, Canada
| | - Sei J Lee
- Division of Geriatrics, Department of Medicine, University of California (SanFrancisco), San Francisco, CA 94121, USA
- Geriatrics, Palliative and Extended Care Service Line, SanFrancisco VA (Veterans Affairs) Health Care System, San Francisco, CA 94121, USA
| | - Gregory L Hundemer
- Department of Medicine (Division of Nephrology) and the Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON K1H 7W9, Canada
| | - Caitlin McClurg
- Library and Cultural Resources, University of Calgary, Calgary, AB T2N 4N1, Canada
| | - Janice L Pasieka
- Departments of Surgery and Oncology, University of Calgary, Calgary, AB T2N 2T9, Canada
| | - W John Boscardin
- Division of Geriatrics, Department of Medicine, University of California (SanFrancisco), San Francisco, CA 94121, USA
- Department of Epidemiology and Biostatistics, University of California (SanFrancisco), San Francisco, CA 94158, USA
| | - Paul E Ronksley
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 4Z6, Canada
| | - Alexander A Leung
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB T2T 5C7, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 4Z6, Canada
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Collins RA, DiGennaro C, Beninato T, Gartland RM, Chaves N, Broekhuis JM, Reddy L, Lee J, Deimiller A, Alterio MM, Campbell MJ, Lee YJ, Khilnani TK, Stewart LA, O’Brien MA, Alvarado MVY, Zheng F, McAneny D, Liou R, McManus C, Dream SY, Wang TS, Yen TW, Alhefdhi A, Finnerty BM, Fahey TJ, Graves CE, Laird AM, Nehs MA, Drake FT, Lee JA, McHenry CR, James BC, Pasieka JL, Kuo JH, Lubitz CC. Limited disease progression in endocrine surgery patients with treatment delays due to COVID-19. Surgery 2023; 173:93-100. [PMID: 36210185 PMCID: PMC9420726 DOI: 10.1016/j.surg.2022.06.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 05/31/2022] [Accepted: 06/13/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND The COVID-19 pandemic profoundly impacted the delivery of care and timing of elective surgical procedures. Most endocrine-related operations were considered elective and safe to postpone, providing a unique opportunity to assess clinical outcomes under protracted treatment plans. METHODS American Association of Endocrine Surgeon members were surveyed for participation. A Research Electronic Data Capture survey was developed and distributed to 27 institutions to assess the impact of COVID-19-related delays. The information collected included patient demographics, primary diagnosis, resumption of care, and assessment of disease progression by the surgeon. RESULTS Twelve out of 27 institutions completed the survey (44.4%). Of 850 patients, 74.8% (636) were female; median age was 56 (interquartile range, 44-66) years. Forty percent (34) of patients had not been seen since their original surgical appointment was delayed; 86.2% (733) of patients had a delay in care with women more likely to have a delay (87.6% vs 82.2% of men, χ2 = 3.84, P = .05). Median duration of delay was 70 (interquartile range, 42-118) days. Among patients with a delay in care, primary disease site included thyroid (54.2%), parathyroid (37.2%), adrenal (6.5%), and pancreatic/gastrointestinal neuroendocrine tumors (1.3%). In addition, 4.0% (26) of patients experienced disease progression and 4.1% (24) had a change from the initial operative plan. The duration of delay was not associated with disease progression (P = .96) or a change in operative plan (P = .66). CONCLUSION Although some patients experienced disease progression during COVID-19 delays to endocrine disease-related care, most patients with follow-up did not. Our analysis indicated that temporary delay may be an acceptable course of action in extreme circumstances for most endocrine-related surgical disease.
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Affiliation(s)
- Reagan A. Collins
- Department of Surgery, Massachusetts General Hospital, Boston, MA,Texas Tech University Health Sciences Center School of Medicine, Lubbock, TX,Institute of Technology Assessment, Massachusetts General Hospital, Boston, MA
| | - Catherine DiGennaro
- Institute of Technology Assessment, Massachusetts General Hospital, Boston, MA
| | - Toni Beninato
- Department of Surgery, Rutgers Cancer Institute of New Jersey, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
| | | | - Natalia Chaves
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA
| | - Jordan M. Broekhuis
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA,Harvard Medical School, Boston, MA
| | - Lekha Reddy
- Department of Surgery, Rutgers Cancer Institute of New Jersey, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
| | - Jenna Lee
- Department of Surgery, Rutgers Cancer Institute of New Jersey, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
| | | | - Maeve M. Alterio
- Elson S. Floyd College of Medicine, Washington State University, Spokane, WA
| | | | - Yeon Joo Lee
- Department of Surgery, Weill Cornell Medicine/New York-Presbyterian Hospital, New York, NY
| | | | - Latoya A. Stewart
- Columbia University Vagelos College of Physicians and Surgeons, New York, NY
| | - Mollie A. O’Brien
- Department of Surgery, Boston Medical Center and Boston University School of Medicine, MA
| | | | - Feibi Zheng
- Department of Surgery, Baylor College of Medicine, Houston, TX
| | - David McAneny
- Department of Surgery, Boston Medical Center and Boston University School of Medicine, MA
| | - Rachel Liou
- Section of Endocrine Surgery, Columbia University, New York, NY
| | | | - Sophie Y. Dream
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Tracy S. Wang
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Tina W. Yen
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Amal Alhefdhi
- Department of General Surgery, Breast and Endocrine Section, King Faisal Specialist Hospital and Research Centre, Al Mathar Ash Shamali, Riyadh, Saudi Arabia
| | - Brendan M. Finnerty
- Department of Surgery, Weill Cornell Medicine/New York-Presbyterian Hospital, New York, NY
| | - Thomas J. Fahey
- Department of Surgery, Weill Cornell Medicine/New York-Presbyterian Hospital, New York, NY
| | | | - Amanda M. Laird
- Department of Surgery, Rutgers Cancer Institute of New Jersey, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
| | - Matthew A. Nehs
- Department of Surgery, Brigham and Women’s Hospital, Boston, MA
| | | | - James A. Lee
- Section of Endocrine Surgery, Columbia University, New York, NY
| | - Christopher R. McHenry
- Department of Surgery, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH
| | - Benjamin C. James
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA,Harvard Medical School, Boston, MA
| | - Janice L. Pasieka
- Department of Surgery, Cumming School of Medicine, University of Calgary, Alberta, Canada
| | - Jennifer H. Kuo
- Section of Endocrine Surgery, Columbia University, New York, NY
| | - Carrie Cunningham Lubitz
- Department of Surgery, Massachusetts General Hospital, Boston, MA,Institute of Technology Assessment, Massachusetts General Hospital, Boston, MA,Harvard Medical School, Boston, MA,Reprint requests: Carrie Cunningham Lubitz, MD, MPH, 55 Fruit Street, Boston, MA 02114
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4
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Wu J, Hu XY, Ghaznavi S, Kinnear S, Symonds CJ, Grundy P, Parkins VM, Sharma P, Lamb D, Khalil M, Hyrcza M, Chandarana SP, Pasieka JL, Harvey A, Warshawski J, Hart R, Deutschman M, Randall DR, Paschke R. The Prospective Implementation of the 2015 ATA Guidelines and Modified ATA Recurrence Risk Stratification System for Treatment of Differentiated Thyroid Cancer in a Canadian Tertiary Care Referral Setting. Thyroid 2022; 32:1509-1518. [PMID: 36226405 DOI: 10.1089/thy.2022.0055] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Objective: To present clinical outcomes of the prospective implementation of the 2015 American Thyroid Association (ATA) guidelines for the management of thyroid nodules and differentiated thyroid cancer (DTC) using the modified ATA recurrence risk (RR) stratification system. Methods: We prospectively analyzed 612 patients with DTC treated between April 2017 and December 2021 in Calgary, Alberta. Each patient was prospectively assigned a modified ATA RR and American Joint Committee Cancer 8th edition stage. Initial risk stratification and consideration of the 2015 ATA guidelines guided surgical management as well as the indication for and dose of radioiodine (RAI) and other adjuvant therapies. Patients were assessed for their response to treatment (RTT) at 2-years postoperatively. Results: There were 479 patients who had 2-year follow-up data and were included in the study. Of these patients, there were 253 (53%) low-, 129 (27%) intermediate-, and 97 (20%) high-RR patients. Of these, 227 patients (47%) underwent total thyroidectomy (TTX) plus RAI, 178 (37%) underwent TTX only, and 74 (16%) underwent lobectomy. The RTT at 2 years was excellent for 89% (66) of patients with lobectomy, 84% (149) for TTX only, and 53% (121) for TTX plus RAI. Among 253 patients who were deemed low RR, 85% (216) had excellent RTT, 13% (32) indeterminate RTT, 2% (4) biochemical incomplete RTT, and 1 patient had structural incomplete RTT. The intermediate RR group had the following RTT outcomes: 64% (83) excellent, 23% (30) indeterminate, 6% (7) biochemical incomplete, and 7% (9) structural incomplete. The high RR group had the worst RTT outcomes, with 38% (37) excellent, 19% (18) indeterminate, 10% (10) biochemical incomplete, and 33% (32) structural incomplete RTT. Conclusions: The 2015 ATA RR stratification system is useful for predicting disease status at 2-year post-treatment in patients with DTC. The 2015 ATA guidelines and modified ATA RR stratification treatment recommendations may reduce thyroid cancer overtreatment by including lobectomy as a definitive treatment option for low-risk thyroid cancers and selective use of RAI for intermediate and high-risk patients.
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Affiliation(s)
- Jiahui Wu
- Arnie Charbonneau Cancer Institute, Departments of Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Xun Yang Hu
- Arnie Charbonneau Cancer Institute, Departments of Cumming School of Medicine, University of Calgary, Calgary, Canada
- Department of Medicine, Section of Endocrinology, University of Calgary, Calgary, Canada
| | - Sana Ghaznavi
- Arnie Charbonneau Cancer Institute, Departments of Cumming School of Medicine, University of Calgary, Calgary, Canada
- Department of Medicine, Section of Endocrinology, University of Calgary, Calgary, Canada
| | - Susan Kinnear
- Arnie Charbonneau Cancer Institute, Departments of Cumming School of Medicine, University of Calgary, Calgary, Canada
- Department of Medicine, Section of Endocrinology, University of Calgary, Calgary, Canada
| | - Christopher John Symonds
- Arnie Charbonneau Cancer Institute, Departments of Cumming School of Medicine, University of Calgary, Calgary, Canada
- Department of Medicine, Section of Endocrinology, University of Calgary, Calgary, Canada
| | - Peter Grundy
- Arnie Charbonneau Cancer Institute, Departments of Cumming School of Medicine, University of Calgary, Calgary, Canada
- Department of Medicine, Section of Endocrinology, University of Calgary, Calgary, Canada
| | - Vicky M Parkins
- Arnie Charbonneau Cancer Institute, Departments of Cumming School of Medicine, University of Calgary, Calgary, Canada
- Department of Medicine, Section of Endocrinology, University of Calgary, Calgary, Canada
| | - Priyanka Sharma
- Arnie Charbonneau Cancer Institute, Departments of Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Debbie Lamb
- Arnie Charbonneau Cancer Institute, Departments of Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Moosa Khalil
- Pathology and Laboratory Medicine and Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Martin Hyrcza
- Pathology and Laboratory Medicine and Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Shamir P Chandarana
- Arnie Charbonneau Cancer Institute, Departments of Cumming School of Medicine, University of Calgary, Calgary, Canada
- Surgery, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Janice L Pasieka
- Surgery, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Adrian Harvey
- Surgery, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Joseph Warshawski
- Surgery, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Robert Hart
- Surgery, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Michael Deutschman
- Surgery, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Derrick R Randall
- Surgery, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Ralf Paschke
- Department of Medicine, Section of Endocrinology, Oncology, Pathology and Laboratory Medicine, Biochemistry and Molecular Biology, and Arnie Charbonneau Cancer Institute, Cumming School of Medicine, University of Calgary, Calgary, Canada
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5
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Pasieka JL, Wentworth K, Yeo CT, Cremers S, Dempster D, Fukumoto S, Goswami R, Houillier P, Levine MA, Pasternak JD, Perrier ND, Sitges-Serra A, Shoback DM. Etiology and Pathophysiology of Hypoparathyroidism: A Narrative Review. J Bone Miner Res 2022; 37:2586-2601. [PMID: 36153665 PMCID: PMC10364481 DOI: 10.1002/jbmr.4714] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [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: 02/11/2022] [Revised: 08/29/2022] [Accepted: 09/22/2022] [Indexed: 01/19/2023]
Abstract
The approach utilized a systematic review of the medical literature executed with specifically designed criteria that focused on the etiologies and pathogenesis of hypoparathyroidism. Enhanced attention by endocrine surgeons to new knowledge about parathyroid gland viability are reviewed along with the role of intraoperative parathyroid hormone (ioPTH) monitoring during and after neck surgery. Nonsurgical etiologies account for a significant proportion of cases of hypoparathyroidism (~25%), and among them, genetic etiologies are key. Given the pervasive nature of PTH deficiency across multiple organ systems, a detailed review of the skeletal, renal, neuromuscular, and ocular complications is provided. The burden of illness on affected patients and their caregivers contributes to reduced quality of life and social costs for this chronic endocrinopathy. © 2022 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).
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Affiliation(s)
- Janice L Pasieka
- Clinical Professor of Surgery and Oncology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Kelly Wentworth
- Assistant Adjunct Professor of Medicine, University of California, San Francisco, Zuckerberg San Francisco General Hospital, San Francisco, CA, USA
| | - Caitlin T Yeo
- Clinical Lecturer of Surgery and Oncology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Serge Cremers
- Associate Professor of Pathology and Cell Biology and Medicine, Vagelos College of Physicians and Surgeons of Columbia University, New York, NY, USA
| | - David Dempster
- Professor of Clinical Pathology and Cell Biology, Vagelos College of Physicians and Surgeons of Columbia University, New York, NY, USA
| | - Seiji Fukumoto
- Specially Appointed Professor, Fujii Memorial Institute of Medical Sciences, Institute of Advanced Medical Sciences, Tokushima University, Tokushima, Japan
| | - Ravinder Goswami
- Professor, Department of Endocrinology and Metabolism, All India Institute of Medical Sciences, New Delhi, India
| | - Pascal Houillier
- Département de Physiologie, Professor of Physiology, Centre de Recherche des Cordeliers, INSERM, Sorbonne Université, Université de Paris, Assistance Publique-Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Paris, France
| | - Michael A Levine
- Professor Emeritus of Pediatrics and Medicine, University of Pennsylvania, Director, Center for Bone Health, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Jesse D Pasternak
- Endocrine Surgery Section Head, Division of General Surgery, Department of Surgery, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Nancy D Perrier
- Professor of Surgery, University of Texas MD Anderson Cancer Center, Department of Surgical Oncology, Section of Surgical Endocrinology, Houston, TX, USA
| | - Antonio Sitges-Serra
- Emeritus Professor, Universitat Autònoma de Barcelona, Endocrine Surgery, Hospital del Mar, Barcelona, Spain
| | - Dolores M Shoback
- Professor of Medicine, University of California, San Francisco, Endocrine Research Unit, San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
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Khan AA, Bilezikian JP, Brandi ML, Clarke BL, Gittoes NJ, Pasieka JL, Rejnmark L, Shoback DM, Potts JT, Guyatt GH, Mannstadt M. Evaluation and Management of Hypoparathyroidism Summary Statement and Guidelines from the Second International Workshop. J Bone Miner Res 2022; 37:2568-2585. [PMID: 36054621 DOI: 10.1002/jbmr.4691] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [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] [Received: 02/11/2022] [Revised: 08/18/2022] [Accepted: 08/24/2022] [Indexed: 11/10/2022]
Abstract
This clinical practice guideline addresses the prevention, diagnosis, and management of hypoparathyroidism (HypoPT) and provides evidence-based recommendations. The HypoPT task forces included four teams with a total of 50 international experts including representatives from the sponsoring societies. A methodologist (GG) and his team supported the taskforces and conducted the systematic reviews. A formal process following the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology and the systematic reviews provided the structure for seven of the guideline recommendations. The task force used a less structured approach based on narrative reviews for 20 non-GRADEd recommendations. Clinicians may consider postsurgical HypoPT permanent if it persists for >12 months after surgery. To predict which patients will not develop permanent postsurgical HypoPT, we recommend evaluating serum PTH within 12 to 24 hours post total thyroidectomy (strong recommendation, moderate quality evidence). PTH > 10 pg/mL (1.05 pmol/L) virtually excludes long-term HypoPT. In individuals with nonsurgical HypoPT, genetic testing may be helpful in the presence of a positive family history of nonsurgical HypoPT, in the presence of syndromic features, or in individuals younger than 40 years. HypoPT can be associated with complications, including nephrocalcinosis, nephrolithiasis, renal insufficiency, cataracts, seizures, cardiac arrhythmias, ischemic heart disease, depression, and an increased risk of infection. Minimizing complications of HypoPT requires careful evaluation and close monitoring of laboratory indices. In patients with chronic HypoPT, the panel suggests conventional therapy with calcium and active vitamin D metabolites as first-line therapy (weak recommendation, low-quality evidence). When conventional therapy is deemed unsatisfactory, the panel considers the use of PTH. © 2022 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).
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Affiliation(s)
- Aliya A Khan
- Department of Medicine, Division of Endocrinology and Metabolism, McMaster University, Hamilton, ON, Canada
| | - John P Bilezikian
- Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | | | - Bart L Clarke
- Mayo Clinic Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Rochester, MN, USA
| | - Neil J Gittoes
- Centre for Endocrinology Diabetes & Metabolism, Queen Elizabeth Hospital, Birmingham, UK
| | - Janice L Pasieka
- Department of Surgery and Oncology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Lars Rejnmark
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Dolores M Shoback
- Endocrine Research Unit, San Francisco Veterans Affairs Medical Center, University of California, San Francisco, CA, USA
| | - John T Potts
- Endocrine Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Gordon H Guyatt
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Michael Mannstadt
- Endocrine Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
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7
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Leung AA, Symonds CJ, Hundemer GL, Ronksley PE, Lorenzetti DL, Pasieka JL, Harvey A, Kline GA. Performance of Confirmatory Tests for Diagnosing Primary Aldosteronism: a Systematic Review and Meta-Analysis. Hypertension 2022; 79:1835-1844. [PMID: 35652330 PMCID: PMC9278709 DOI: 10.1161/hypertensionaha.122.19377] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [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] [Indexed: 12/30/2022]
Abstract
Background: Confirmatory tests are recommended for diagnosing primary aldosteronism, but the supporting evidence is unclear. Methods: We searched Medline, EMBASE, and the Cochrane Central Register of Controlled Trials. Studies evaluating any guideline-recommended confirmatory test (ie, saline infusion test, salt loading test, fludrocortisone suppression test, and captopril challenge test), compared with a reference standard were included. The Quality Assessment of Diagnostic Accuracy Studies-2 tool was used to assess the risk of bias. Meta-analyses were conducted using hierarchical summary receiver operating characteristic models. Results: Fifty-five studies were included, comprising 26 studies (3654 participants) for the recumbent saline infusion test, 4 studies (633 participants) for the seated saline infusion test, 2 studies (99 participants) for the salt loading test, 7 studies (386 participants) for the fludrocortisone suppression test, and 25 studies (2585 participants) for the captopril challenge test. Risk of bias was high, affecting more than half of studies, and across all domains. Studies with case-control sampling overestimated accuracy by 7-fold (relative diagnostic odds ratio, 7.26 [95% CI, 2.46–21.43]) and partial verification or use of inconsistent reference standards overestimated accuracy by 5-fold (5.12 [95% CI, 1.48–17.77]). There were large variations in how confirmatory tests were conducted, interpreted, and verified. Under most scenarios, confirmatory testing resulted in an excess of missed cases. The certainty of evidence underlying each test (Grading of Recommendations, Assessment, Development, and Evaluations) was very low. Conclusions: Recommendations for confirmatory testing in patients with abnormal screening tests and high probability features of primary aldosteronism are based on very low-quality evidence and their routine use should be reconsidered.
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Affiliation(s)
- Alexander A Leung
- Division of Endocrinology and Metabolism, Department of Medicine (A.A.L., C.J.S., G.A.K.), University of Calgary, AB.,Department of Community Health Sciences (A.A.L., P.E.R., D.L.L.), University of Calgary, AB
| | - Christopher J Symonds
- Division of Endocrinology and Metabolism, Department of Medicine (A.A.L., C.J.S., G.A.K.), University of Calgary, AB
| | - Gregory L Hundemer
- Division of Nephrology, Department of Medicine and the Ottawa Hospital Research Institute, University of Ottawa, ON (G.L.H.)
| | - Paul E Ronksley
- Department of Community Health Sciences (A.A.L., P.E.R., D.L.L.), University of Calgary, AB
| | - Diane L Lorenzetti
- Department of Community Health Sciences (A.A.L., P.E.R., D.L.L.), University of Calgary, AB
| | - Janice L Pasieka
- Department of Surgery (J.L.P., A.H.), University of Calgary, AB.,Department of Oncology (J.L.P., A.H.), University of Calgary, AB
| | - Adrian Harvey
- Department of Surgery (J.L.P., A.H.), University of Calgary, AB.,Department of Oncology (J.L.P., A.H.), University of Calgary, AB
| | - Gregory A Kline
- Division of Endocrinology and Metabolism, Department of Medicine (A.A.L., C.J.S., G.A.K.), University of Calgary, AB
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8
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Sam D, Kline GA, So B, Hundemer GL, Pasieka JL, Harvey A, Chin A, Przybojewski SJ, Caughlin CE, Leung AA. External Validation of Clinical Prediction Models in Unilateral Primary Aldosteronism. Am J Hypertens 2022; 35:365-373. [PMID: 34958097 PMCID: PMC8976177 DOI: 10.1093/ajh/hpab195] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 12/03/2021] [Accepted: 12/22/2021] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Targeted treatment of primary aldosteronism (PA) is informed by adrenal vein sampling (AVS), which remains limited to specialized centers. Clinical prediction models have been developed to help select patients who would most likely benefit from AVS. Our aim was to assess the performance of these models for PA subtyping. METHODS This external validation study evaluated consecutive patients referred for PA who underwent AVS at a tertiary care referral center in Alberta, Canada during 2006–2018. In alignment with the original study designs and intended uses of the clinical prediction models, the primary outcome was the presence of lateralization on AVS. Model discrimination was evaluated using the C-statistic. Model calibration was assessed by comparing the observed vs. predicted probability of lateralization in the external validation cohort. RESULTS The validation cohort included 342 PA patients who underwent AVS (mean age, 52.1 years [SD, 11.5]; 201 [58.8%] male; 186 [54.4%] with lateralization). Six published models were assessed. All models demonstrated low-to-moderate discrimination in the validation set (C-statistics; range, 0.60–0.72), representing a marked decrease compared with the derivation sets (range, 0.80–0.87). Comparison of observed and predicted probabilities of unilateral PA revealed significant miscalibration. Calibration-in-the-large for every model was >0 (range, 0.35–1.67), signifying systematic underprediction of lateralizing disease. Calibration slopes were consistently <1 (range, 0.35–0.87), indicating poor performance at the extremes of risk. CONCLUSIONS Overall, clinical prediction models did not accurately predict AVS lateralization in this large cohort. These models cannot be reliably used to inform the decision to pursue AVS for most patients.
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Affiliation(s)
- Davis Sam
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Gregory A Kline
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Benny So
- Department of Radiology, University of Calgary, Calgary, Alberta, Canada
| | | | - Janice L Pasieka
- Department of Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Adrian Harvey
- Department of Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Alex Chin
- Alberta Precision Laboratories, Alberta Health Services, Calgary, Alberta, Canada
- Department of Pathology and Laboratory Medicine, University of Calgary, Calgary, Alberta, Canada
| | | | - Cori E Caughlin
- Department of Radiology, University of Calgary, Calgary, Alberta, Canada
| | - Alexander A Leung
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- Correspondence: Alexander A. Leung ()
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9
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Yeo CT, Pasieka JL, Assadzadeh GE, Harvey A. The adoption of the endoscopic retroperitoneal approach to the adrenal gland - Conversion factors and learning points. Am J Surg 2022; 224:703-709. [DOI: 10.1016/j.amjsurg.2022.03.057] [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] [Received: 11/25/2021] [Revised: 03/19/2022] [Accepted: 03/31/2022] [Indexed: 11/01/2022]
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10
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Kishlyansky D, Kline G, Mahajan A, Koro K, Pasieka JL, Champagne P. Ectopic Cushing's syndrome from an ACTH-producing pheochromocytoma with a non-functioning pituitary adenoma. Endocrinol Diabetes Metab Case Rep 2022; 2022:21-0189. [PMID: 35319487 PMCID: PMC9002181 DOI: 10.1530/edm-21-0189] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Accepted: 02/17/2022] [Indexed: 12/21/2022] Open
Abstract
Summary An adrenocorticotropic hormone (ACTH)-producing pheochromocytoma (PCC)/paraganglioma is the cause of ectopic Cushing's syndrome (CS) in 5.2% of cases reported in the literature. We present a previously healthy 43-year-old woman admitted to our hospital with cushingoid features and hypertensive urgency (blood pressure = 200/120 mmHg). Her 24-h urinary free cortisol was >4270 nmol/day (reference range (RR) = 100-380 nmol/day) with a plasma ACTH of 91.5 pmol/L (RR: 2.0-11.5 pmol/L). Twenty-four-hour urinary metanephrines were increased by 30-fold. Whole-body CT demonstrated a 3.7-cm left adrenal mass with a normal-appearing right adrenal gland. Sellar MRI showed a 5-mm sellar lesion. MIBG scan revealed intense uptake only in the left adrenal mass. She was managed pre-operatively with ketoconazole and phenoxybenzamine and underwent an uneventful left laparoscopic adrenalectomy, which resulted in biochemical resolution of her hypercortisolemia and catecholamine excess. Histology demonstrated a PCC (Grading System for Adrenal Pheochromocytoma and Paraganglioma score 5) with positive ACTH staining by immunohistochemistry. A PCC gene panel showed no mutations and there has been no evidence of recurrence at 24 months. This case highlights the difficult nature of localizing the source of CS in the setting of a co-existing PCC and sellar mass. Learning points An adrenocorticotropic hormone (ACTH)-producing pheochromocytoma (PCC) is an important item to be considered in all patients presenting with ectopic Cushing's syndrome (CS). In exceptionally rare cases, patients with ectopic CS may present with multiple lesions, and a systematic approach considering all potential sources is crucial to avoid misdiagnosis. CS with a large adrenal mass but lacking contralateral adrenal atrophy should raise suspicion of an ACTH-dependent process. In patients with clinical suspicion of PCC, clinicians should be mindful of the use of steroids and beta-blockers without appropriate alpha blockade as they may precipitate an adrenergic crisis.
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Affiliation(s)
- David Kishlyansky
- Division of Internal Medicine, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Gregory Kline
- Divison of Endocrinology and Metabolism, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Amita Mahajan
- Divison of Endocrinology and Metabolism, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Konstantin Koro
- Department of Pathology and Laboratory Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Janice L Pasieka
- Divison of Endocrine surgery, Surgical Oncology and Endocrinology, Department of Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Patrick Champagne
- Department of Cardiac Sciences, University of Calgary, Calgary, Alberta, Canada
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11
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Leung AA, Pasieka JL, Sadrzadeh H, Kline GA. Pheochromocytoma and paraganglioma: time and space are only part of the essence. Eur J Endocrinol 2021; 186:L3-L4. [PMID: 34709199 DOI: 10.1530/eje-21-1080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Accepted: 10/27/2021] [Indexed: 11/08/2022]
Affiliation(s)
- Alexander A Leung
- Division of Endocrinology and Metabolism, Department of Medicine
- Department of Community Health Sciences, Department of Medicine
| | - Janice L Pasieka
- Department of Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Hossein Sadrzadeh
- Department of Pathology and Laboratory Medicine, University of Calgary, Calgary, Alberta, Canada
- Alberta Precision Laboratories, Alberta Health Services, Calgary, Alberta, Canada
| | - Gregory A Kline
- Division of Endocrinology and Metabolism, Department of Medicine
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12
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Pasieka JL. Inspirational Women in Surgery: Dr. Nadine R. Caron, Canada. World J Surg 2021; 46:299-300. [PMID: 34605950 DOI: 10.1007/s00268-021-06336-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/11/2021] [Indexed: 10/20/2022]
Affiliation(s)
- Janice L Pasieka
- Department of Surgery, Section of General Surgery, University of Calgary, Cumming School of Medicine, Calgary, Canada.
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13
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Pasieka JL. Shinrin-yoku, yoga and other strategies in the fight against COVID-19. Surgery 2021; 171:94-95. [PMID: 34548159 PMCID: PMC8405594 DOI: 10.1016/j.surg.2021.07.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 07/15/2021] [Indexed: 11/01/2022]
Affiliation(s)
- Janice L Pasieka
- Clinical Professor of Surgery and Oncology, Section General Surgery, Division Endocrine Surgery, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.
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14
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Beninato T, Laird AM, Graves CE, Drake FT, Alhefdhi A, Lee JA, Kuo JH, Grubbs EG, Wang TS, Pasieka JL, Lubitz CC. Impact of the COVID-19 pandemic on the practice of endocrine surgery. Am J Surg 2021; 223:670-675. [PMID: 34315576 PMCID: PMC8294714 DOI: 10.1016/j.amjsurg.2021.07.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [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: 06/01/2021] [Revised: 07/09/2021] [Accepted: 07/10/2021] [Indexed: 12/27/2022]
Abstract
Background This study investigates the impact of the COVID-19 pandemic on endocrine surgeons. Methods A survey on the professional, educational, and clinical impact was sent to active and corresponding members of the American Association of Endocrine Surgeons (AAES) in September 2020. Chi-square and paired t-test were used for analysis. Results 77 surgeons responded (14.8 %). All reported suspension of elective surgeries; 37.7 % were reassigned to other duties during this time. The median number of cases backlogged was 30 (IQR 15–50). Most surgeons reported decreased clinical volume (74.6 %). The use of virtual platforms for clinical and educational purposes increased from pre-COVID-19 levels (all p < 0.001). Use of in-office procedures (p < 0.001) and length of observation prior to discharge for thyroid surgery (p < 0.05) decreased. Conclusion The COVID-19 pandemic led to suspension of operations and decreased practice volume for endocrine surgeons. Surgeons increased use of virtual platforms, decreased in-office procedures, and decreased duration of observation for thyroid surgery in response.
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Affiliation(s)
- Toni Beninato
- Rutgers Cancer Institute of New Jersey, Rutgers Robert Wood Johnson Medical School, 195 Little Albany Street, New Brunswick, NJ, 08903, USA.
| | - Amanda M Laird
- Rutgers Cancer Institute of New Jersey, Rutgers Robert Wood Johnson Medical School, 195 Little Albany Street, New Brunswick, NJ, 08903, USA.
| | - Claire E Graves
- University of California Davis, 4501 X Street, Suite 3010, Sacramento, CA, 95817, USA.
| | - F Thurston Drake
- Boston Medical Center, Boston University School of Medicine, 830 Harrison Avenue, Boston, MA, 02118, USA.
| | - Amal Alhefdhi
- King Faisal Specialist Hospital and Research Centre, Al Mathar Ash Shamali, Riyadh, 11564, Saudi Arabia.
| | - James A Lee
- NewYork Presbyterian Hospital-Columbia University Medical Center, 161 Fort Washington Avenue, New York, NY, 10032, USA.
| | - Jennifer H Kuo
- NewYork Presbyterian Hospital-Columbia University Medical Center, 161 Fort Washington Avenue, New York, NY, 10032, USA.
| | - Elizabeth G Grubbs
- University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030, USA.
| | - Tracy S Wang
- Medical College of Wisconsin, 8800 West Doyne Avenue, Milwaukee, WI, 53226, USA.
| | - Janice L Pasieka
- Cumming School of Medicine, University of Calgary, 1403 29(th)Street NW, Calgary, Alberta, T2N 2T9, Canada.
| | - Carrie C Lubitz
- Harvard Medical School, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA.
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15
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Kline GA, Boyd J, Polzin B, Harvey A, Pasieka JL, Sadrzadeh HSM, Leung AA. Properly Collected Plasma Metanephrines Excludes PPGL After False-Positive Screening Tests. J Clin Endocrinol Metab 2021; 106:e2900-e2906. [PMID: 33846745 DOI: 10.1210/clinem/dgab241] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [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: 04/08/2021] [Indexed: 11/19/2022]
Abstract
CONTEXT False-positive results are common for pheochromocytoma/paraganglioma (PPGL) real-world screening. OBJECTIVE Determine the correlation between screening urine and seated plasma metanephrines in outpatients where PPGL was absent, compared to meticulously prepared and supine-collected plasma metanephrines with age-adjusted references. DESIGN Retrospective cohort study. SETTING Databases from a single-provider provincial laboratory (2012-2018), a validated PPGL registry, and a manual chart review from a specialized endocrine testing unit. PATIENTS PPGL registry data excluded known PPGL cases from the laboratory database. Outpatients having both urine and plasma metanephrines <90 days apart. METHODS The correlation between urine and seated plasma measures along with the total positivity rate. All cases of plasma metanephrines drawn in the endocrine unit were reviewed for test indication and test positivity rate. RESULTS There were 810 non-PPGL pairs of urine and plasma metanephrines in the laboratory database; 46.1% of urine metanephrines were reported high. Of seated outpatient plasma metanephrines drawn a median of 5.9 days later, 19.2% were also high (r = 0.33 and 0.50 for normetanephrine and metanephrine, respectively). In contrast, the meticulously prepared and supine collected patients (n = 139, 51% prior high urine metanephrines) had <3% rate of abnormal high results in patients without known PPGL/adrenal mass. CONCLUSIONS There was a poor-to-moderate correlation between urine and seated plasma metanephrines. Up to 20% of those with high urine measures also had high seated plasma metanephrines in the absence of PPGL. Properly prepared and collected supine plasma metanephrines had a false-positive rate of <3% in the absence of known PPGL/adrenal mass.
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Affiliation(s)
- Gregory A Kline
- Cumming School of Medicine, Department of Medicine, University of Calgary, Calgary, Canada
| | - Jessica Boyd
- Department of Clinical Pathology and Laboratory Medicine, University of Calgary, Calgary, Canada
- Alberta Precision Laboratories, Calgary, Canada
| | | | - Adrian Harvey
- Cumming School of Medicine, Department of Surgery, University of Calgary, Calgary, Canada
| | - Janice L Pasieka
- Cumming School of Medicine, Department of Surgery, University of Calgary, Calgary, Canada
| | - Hossein S M Sadrzadeh
- Department of Clinical Pathology and Laboratory Medicine, University of Calgary, Calgary, Canada
- Alberta Precision Laboratories, Calgary, Canada
| | - Alexander A Leung
- Cumming School of Medicine, Department of Medicine, University of Calgary, Calgary, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Canada
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16
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Sam D, Kline GA, So B, Pasieka JL, Harvey A, Hundemer GL, Chin A, Przybojewski SJ, Leung AA. External Validation of Prediction Models for Unilateral Primary Aldosteronism. J Endocr Soc 2021. [DOI: 10.1210/jendso/bvab048.583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
Primary aldosteronism (PA) is the most common cause of remediable hypertension. Treatment is informed by establishing whether disease is unilateral (localized to one adrenal gland) or bilateral. Adrenalectomy is the guideline-recommended treatment of choice for unilateral PA. However, the currently recommended subtyping test, adrenal vein sampling (AVS), is often limited in accessibility. Thus, prediction models have been developed to diagnose unilateral PA and therefore bypass AVS. However, their generalizability remains unknown. In this retrospective study, we aimed to externally validate the performance of prediction models for unilateral PA in a large population of PA patients at a Canadian referral center who underwent AVS during 2006–2018. The presence of unilateral disease was indicated by a lateralization index of >3 on AVS. We identified 6 clinical prediction models from the literature. The discrimination and calibration of each model were systematically evaluated. For the original models, the derivation cohorts were based out of Japan, France, Italy, and England, with mean age between 46–54 years and 43–56% being male. The derivation cohorts were generally small, with 4 of the 6 studies reporting less than 50 people with unilateral PA. Common variables reported to be predictive of unilateral PA included male sex, hypokalemia, elevated aldosterone-renin ratio, and the presence of a unilateral adrenal nodule on imaging. The validation cohort included 342 PA patients who underwent successful AVS (average age, 52.1 years; 58.8% male). Among them, 186 (54.4%) demonstrated unilateral disease, and the remaining 156 (45.6%) were considered to have bilateral disease. The baseline characteristics of the validation cohort were broadly similar to those of the derivation cohorts, except for potential differences in ethnicity. When applying the models to the validation cohort, subjects were excluded if any candidate variables were missing. All 6 models demonstrated poor discrimination in the validation set (C-statistics; range, 0.59–0.72), representing a marked decrease compared to the derivation sets where they were reported (range, 0.80–0.87). Assessment of calibration by comparing observed and predicted probabilities of the unilateral subtype revealed significant miscalibration. Calibration-in-the-large for every model was >0 (range, 0.36–2.23), signifying systematic underprediction of unilateral PA. Calibration slopes were all <1 (range, 0.35–0.85), indicating poor performance at the extremes of risk. These results suggest that the original models were optimistic due to overfitting in the derivation cohorts and therefore lack generalizability. This is primarily because these models were developed in small data sets. In conclusion, clinical assessment with prediction models for unilateral PA cannot be readily used to bypass AVS in the general PA population.
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Affiliation(s)
- Davis Sam
- University of British Columbia, Vancouver, BC, Canada
| | | | - Benny So
- University of Calgary, Calgary, AB, Canada
| | | | | | | | - Alex Chin
- University of Calgary, Calgary, AB, Canada
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17
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Leung AA, Hyrcza MD, Pasieka JL, Kline GA. Incidence of pheochromocytoma and paraganglioma varies according to altitude: meta-regression analysis. Eur J Endocrinol 2021; 184:L21-L23. [PMID: 33769960 DOI: 10.1530/eje-21-0258] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 03/15/2021] [Indexed: 11/08/2022]
Affiliation(s)
- Alexander A Leung
- Division of Endocrinology and Metabolism, Department of Medicine
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Martin D Hyrcza
- Department of Pathology and Laboratory Medicine, University of Calgary, Calgary, Alberta, Canada
- Alberta Precision Laboratories, Alberta Health Services, Calgary, Alberta, Canada
| | - Janice L Pasieka
- Department of Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Gregory A Kline
- Division of Endocrinology and Metabolism, Department of Medicine
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18
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Liu YY, King J, Kline GA, Padwal RS, Pasieka JL, Chen G, So B, Harvey A, Chin A, Leung AA. Outcomes of a Specialized Clinic on Rates of Investigation and Treatment of Primary Aldosteronism. JAMA Surg 2021; 156:541-549. [PMID: 33787826 DOI: 10.1001/jamasurg.2021.0254] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Importance Primary aldosteronism (PA) is one of the most common causes of secondary hypertension but remains largely unrecognized and untreated. Objective To understand the outcomes of a specialized clinic on rates of evaluation and treatment of PA in the context of secondary factors. Design, Setting, and Participants This population-based cohort study was conducted in Alberta, Canada, using linked administrative data between April 1, 2012, and July 31, 2019, on adults identified as having hypertension. Main Outcomes and Measures We evaluated each step of the diagnostic and care pathway for PA to determine the proportion of people with hypertension who received screening, subtyping, and targeted treatment for PA. Variations in diagnosis and treatment were examined according to individual-level, clinician-level, and system-level characteristics. Results Of the 1.1 million adults with hypertension, 7941 people (0.7%) were screened for PA. Among those who were screened, 1703 (21.4%) had positive test results consistent with possible PA, and 1005 (59.0%) of these were further investigated to distinguish between unilateral and bilateral forms of PA. Only 731 individuals (42.9%) with a positive screen result received disease-targeted treatment. Geographic zones and clinician specialty were the strongest determinants of screening, subtyping, and treatment of PA, with the highest rates corresponding to the location of the provincial endocrine hypertension program. Conclusions and Relevance In this cohort, less than 1% of patients expected to have PA were ever formally diagnosed and treated. These findings suggest that a system-level approach to assist with investigation and treatment of PA may be highly effective in closing care gaps and improving clinical outcomes.
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Affiliation(s)
- Yuan-Yuan Liu
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - James King
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada.,Alberta SPOR SUPPORT Unit Data Platform, Alberta Health Services, Calgary, Alberta, Canada
| | - Gregory A Kline
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Raj S Padwal
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Janice L Pasieka
- Department of Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Guanmin Chen
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Benny So
- Department of Radiology, University of Calgary, Calgary, Alberta, Canada
| | - Adrian Harvey
- Department of Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Alex Chin
- Department of Pathology and Laboratory Medicine, University of Calgary, Calgary, Alberta, Canada.,Alberta Precision Laboratories, Alberta Health Services, Calgary, Alberta, Canada
| | - Alexander A Leung
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada.,Division of Endocrinology & Metabolism, University of Calgary, Calgary, Alberta, Canada
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19
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Sam D, Kline GA, So B, Pasieka JL, Harvey A, Chin A, Przybojewski SJ, Leung AA. Surgical Outcomes Among Primary Aldosteronism Patients Without Visible Adrenal Lesions. J Clin Endocrinol Metab 2021; 106:e824-e835. [PMID: 33180934 PMCID: PMC7823310 DOI: 10.1210/clinem/dgaa821] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [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: 08/15/2020] [Indexed: 12/13/2022]
Abstract
CONTEXT Many patients with unilateral primary aldosteronism (PA) have normal adrenal imaging, but little is known about their outcome following adrenalectomy. OBJECTIVE To evaluate biochemical and clinical outcomes after adrenalectomy in patients with unilateral PA and normal-appearing adrenal imaging. DESIGN Retrospective cohort study of patients seen between January 2006 and May 2018. SETTING A Canadian tertiary care PA referral center. PATIENTS Consecutive individuals with PA, normal cross-sectional adrenal imaging, and lateralizing adrenal vein sampling (AVS) who underwent adrenalectomy during the study period. PRIMARY OUTCOME Biochemical response to adrenalectomy graded according to the Primary Aldosteronism Surgical Outcome criteria. RESULTS A total of 40 patients were included. Biochemical outcomes were available for 33 people (mean age, 54.7 years; 91% male; median follow-up, 2.7 months), with 28 (85%) showing a complete or partial response and 5 (15%) with no response. Clinical outcomes were available for 36 people (mean age, 54.6 years; 86% male; median follow-up, 9.8 months), with 31 (86%) demonstrating a complete or partial response and 5 (14%) with no response. CONCLUSIONS The prognosis after adrenalectomy is highly favorable for patients with unilateral PA and normal-appearing adrenal imaging. Patients with lateralizing disease should be considered for surgery despite apparently normal adrenal imaging.
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Affiliation(s)
- Davis Sam
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Gregory A Kline
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Benny So
- Department of Radiology, University of Calgary, Calgary, Alberta, Canada
| | - Janice L Pasieka
- Department of Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Adrian Harvey
- Department of Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Alex Chin
- Alberta Precision Laboratories, Alberta Health Services, Calgary, Alberta, Canada
- Department of Pathology and Laboratory Medicine, University of Calgary, Calgary, Alberta, Canada
| | | | - Alexander A Leung
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- Correspondence and Reprint Requests: Alexander A. Leung, MD, MPH, 1820 Richmond Road SW, Calgary, Alberta, T2T 5C7, Canada. E-mail:
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20
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Leung AA, Pasieka JL, Hyrcza MD, Pacaud D, Dong Y, Boyd JM, Sadrzadeh H, Kline GA. Epidemiology of pheochromocytoma and paraganglioma: population-based cohort study. Eur J Endocrinol 2021; 184:19-28. [PMID: 33112261 DOI: 10.1530/eje-20-0628] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [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: 06/05/2020] [Accepted: 10/05/2020] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Despite the significant morbidity and mortality associated with pheochromocytoma and paraganglioma, little is known about their epidemiology. The primary objective was to determine the incidence of pheochromocytoma and paraganglioma in an ethnically diverse population. A secondary objective was to develop and validate algorithms for case detection using laboratory and administrative data. DESIGN Population-based cohort study in Alberta, Canada from 2012 to 2019. METHODS Patients with pheochromocytoma or paraganglioma were identified using linked administrative databases and clinical records. Annual incidence rates per 100 000 people were calculated and stratified according to age and sex. Algorithms to identify pheochromocytoma and paraganglioma, based on laboratory and administrative data, were evaluated. RESULTS A total of 239 patients with pheochromocytoma or paraganglioma (collectively with 251 tumors) were identified from a population of 5 196 368 people over a period of 7 years. The overall incidence of pheochromocytoma or paraganglioma was 0.66 cases per 100 000 people per year. The frequency of pheochromocytoma and paraganglioma increased with age and was highest in individuals aged 60-79 years (8.85 and 14.68 cases per 100 000 people per year for males and females, respectively). An algorithm based on laboratory data (metanephrine >two-fold or normetanephrine >three-fold higher than the upper limit of normal) closely approximated the true frequency of pheochromocytoma and paraganglioma with an estimated incidence of 0.54 cases per 100 000 people per year. CONSLUSION The incidence of pheochromocytoma and paraganglioma in an unselected population of western Canada was unexpectedly higher than rates reported from other areas of the world.
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Affiliation(s)
- Alexander A Leung
- Division of Endocrinology and Metabolism, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, University of Calgary
| | | | - Martin D Hyrcza
- Department of Pathology and Laboratory Medicine, University of Calgary, Calgary, Alberta, Canada
- Alberta Precision Laboratories, Alberta Health Services, Calgary, Alberta, Canada
| | - Danièle Pacaud
- Department of Paediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Yuan Dong
- Department of Community Health Sciences, University of Calgary
| | - Jessica M Boyd
- Department of Pathology and Laboratory Medicine, University of Calgary, Calgary, Alberta, Canada
- Alberta Precision Laboratories, Alberta Health Services, Calgary, Alberta, Canada
| | - Hossein Sadrzadeh
- Department of Pathology and Laboratory Medicine, University of Calgary, Calgary, Alberta, Canada
- Alberta Precision Laboratories, Alberta Health Services, Calgary, Alberta, Canada
| | - Gregory A Kline
- Division of Endocrinology and Metabolism, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
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Pasieka JL. Re-evaluating 'Surgical Dogma' in the Postoperative Management of Pheochromocytoma/Paragangliomas: Reflecting on the Data Cannot Help but to Bring About Change. World J Surg 2020; 45:797-798. [PMID: 33215252 DOI: 10.1007/s00268-020-05871-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/15/2020] [Indexed: 11/24/2022]
Affiliation(s)
- Janice L Pasieka
- Cumming School of Medicine, University of Calgary, Calgary, Canada.
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22
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Yeo CT, Tharmalingam S, Pasieka JL. The value of dynamic surgeon-directed imaging in the preoperative planning of patients with primary hyperparathyroidism. Surgery 2020; 169:519-523. [PMID: 32828545 DOI: 10.1016/j.surg.2020.07.008] [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: 05/05/2020] [Revised: 06/18/2020] [Accepted: 07/03/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Preoperative localization plays an important role in primary hyperparathyroidism. Sestamibi scans read by the radiologist as nonlocalizing were localizing when independently interpreted by the surgeon. The ability to perform dynamic surgeon-directed imaging, a of combination scans interpreted by the surgeon and surgeon-performed ultrasound done in tandem, appeared to improve preoperative localization. The objective was to evaluate scans read by the radiologist compared with dynamic surgeon-directed imaging. METHODS A retrospective chart review was performed. Demographics, biochemistry, radiologist read scans, dynamic surgeon-directed imaging, operation, pathology, and follow-up results were collected. Localization rate, sensitivity, positive predictive value, and accuracy were calculated. RESULTS In the study, 474 charts met inclusion criteria. Only 63% of scans read by the radiologist were localizing, compared with 96% of dynamic surgeon-directed imaging. Overall dynamic surgeon-directed imaging was superior to scans read by the radiologist with 95% versus 60% sensitivity, 85% versus 85% positive predictive value, and 82% versus 54% accuracy. Dynamic surgeon-directed imaging remained superior when analyzing only those with single gland disease (n = 391). In addition, 85% of the 174 nonlocalized radiologist scans were correctly localized by dynamic surgeon-directed imaging. CONCLUSION The ability to perform an interpretation of both surgeon-performed ultrasound and scan interpreted by the surgeon in tandem improves the preoperative localization rate when compared with static reading of radiologist scans. This underscores the importance of having all primary hyperparathyroidism patients assessed by an experienced parathyroid surgical team, especially when the scans read by the radiologist is nonlocalizing.
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Affiliation(s)
- Caitlin T Yeo
- Departments of Surgery and Oncology, Sections of General Surgery and Surgical Oncology, University of Calgary, Cumming School of Medicine, Calgary, Alberta, Canada
| | - Senthuran Tharmalingam
- Departments of Surgery and Oncology, Sections of General Surgery and Surgical Oncology, University of Calgary, Cumming School of Medicine, Calgary, Alberta, Canada
| | - Janice L Pasieka
- Departments of Surgery and Oncology, Sections of General Surgery and Surgical Oncology, University of Calgary, Cumming School of Medicine, Calgary, Alberta, Canada.
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23
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Craig SJ, Bysice AM, Nakoneshny SC, Pasieka JL, Chandarana SP. The Identification of Intraoperative Risk Factors Can Reduce, but Not Exclude, the Need for Completion Thyroidectomy in Low-Risk Papillary Thyroid Cancer Patients. Thyroid 2020; 30:222-228. [PMID: 31813323 PMCID: PMC7047120 DOI: 10.1089/thy.2019.0274] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Background: The extent of initial surgical resection for low-risk papillary thyroid cancer (PTC) remains debatable. Since the 2015 American Thyroid Association (ATA) guidelines, several retrospective studies have reported that 40-60% of patients initially treated with lobectomy would require a completion thyroidectomy (CTx) due to high-risk pathological features (HRFs). These studies are limited by variable preoperative stratification and inability to quantify the value of intraoperative assessment. The study objectives were to determine whether diligent preoperative and intraoperative assessment improves the appropriateness of initial surgery for low-risk PTCs and whether varying the criteria for lobectomy reduces the need for CTx. Methods: A prospectively collected province-wide database was analyzed over a 10-year period (2008-2017) for patients who underwent a total thyroidectomy (TT) for PTC without preoperative HRFs. All patients had preoperative ultrasound and fine-needle aspirates. Unique to this database are mandatory synoptic operative fields that identify intraoperative risk factors such as positive lymph nodes and local invasion. Results: In total, 74% of patients (709/959) were deemed eligible for lobectomy. Of those eligible, 149 (21%) had intraoperative risk factors that would necessitate conversion to TT at the initial operation. A further 209 (30%) would require CTx due to HRFs on final pathology. Varying the preoperative criteria for lobectomy did not significantly affect intraoperative conversion or CTx rates. Conclusions: Although intraoperative assessment reduced the need for CTx in 21%, up to 30% of patients would still require a second operation. Altering the preoperative criteria does not influence this outcome. Patients deemed eligible for lobectomy should be informed that despite careful pre- and intraoperative assessment, there is up to a 30% risk of requiring CTx.
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Affiliation(s)
- Steven J. Craig
- Section of General Surgery, Department of Surgery, University of Calgary, Calgary, Canada
| | - Andrew M. Bysice
- Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Steven C. Nakoneshny
- Ohlson Research Initiative, Arnie Charbonneau Cancer Institute, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Janice L. Pasieka
- Section of General Surgery, Department of Surgery, University of Calgary, Calgary, Canada
- Section of Surgical Oncology, Department of Surgery, University of Calgary, Calgary, Canada
- Section of Endocrinology, Department of Medicine, University of Calgary, Calgary, Canada
| | - Shamir P. Chandarana
- Ohlson Research Initiative, Arnie Charbonneau Cancer Institute, Cumming School of Medicine, University of Calgary, Calgary, Canada
- Section of Surgical Oncology, Department of Surgery, University of Calgary, Calgary, Canada
- Section of Otolaryngology—Head and Neck Surgery, Department of Surgery, University of Calgary, Calgary, Canada
- Address correspondence to: Shamir P. Chandarana, MD, Foothills Medical Centre, North Tower Rm 1012, 1403 29 St NW, Calgary T2N 2T9, Alberta, Canada
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24
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Pasieka JL. Endocrine Surgery Without the Bells and Whistles: Editorial of the International Association of Endocrine Surgeons Symposium. World J Surg 2019; 44:617. [PMID: 31748886 DOI: 10.1007/s00268-019-05297-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Janice L Pasieka
- Department of Surgery and Oncology, Foothills Medical Center, Section General Surgery, Cumming's School of Medicine, University of Calgary, Calgary, AB, Canada.
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25
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Ball CG, Grondin SC, Pasieka JL, Kirkpatrick AW, MacLean AR, Cantle P, Dixon E, Schneider P, Hamilton M. Examples of dramatic failures and their effectiveness in modern surgical disciplines: can we learn from our mistakes? J Comp Eff Res 2018; 7:709-720. [PMID: 29888953 DOI: 10.2217/cer-2017-0090] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [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: 12/15/2022] Open
Abstract
Innovation can be variably defined, but when applied to healthcare is often considered to be the introduction of something new, whether an idea, method or device, into an unfilled void or needy environment. Despite the introduction of many positive surgical subspecialty altering concepts/devices however, epic failures are not uncommon. These failures can be dramatic in regards to both their human and economic costs. They can also be very public or more quiet in nature. As surgical leaders in our communities and advocates for patient safety and outcomes, it remains crucial that we meet new introductions in technology and patient care with a measured level of curiosity, skepticism and science-based conclusions. The aim of an expert committee was to identify the most dominant failures in technological innovation and/or dogmatic clinical beliefs within each major surgical subspecialty. In summary, this effort was pursued to highlight the past failures and remind surgeons to remain vigilant and appropriately skeptical with regard to the introduction of new innovations and clinical beliefs within our craft.
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Affiliation(s)
- Chad G Ball
- Department of Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Sean C Grondin
- Department of Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Janice L Pasieka
- Department of Surgery, University of Calgary, Calgary, Alberta, Canada
| | | | - Anthony R MacLean
- Department of Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Paul Cantle
- Department of Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Elijah Dixon
- Department of Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Prism Schneider
- Department of Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Mark Hamilton
- Department of Surgery, University of Calgary, Calgary, Alberta, Canada.,Department of Neurosciences, University of Calgary, Calgary, Alberta, Canada
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26
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Deutschmann MW, Chin-Lenn L, Nakoneshny SC, Dort JC, Pasieka JL, Chandarana SP. Practice patterns among thyroid cancer surgeons: implications of performing a prophylactic central neck dissection. J Otolaryngol Head Neck Surg 2016; 45:55. [PMID: 27793192 PMCID: PMC5084429 DOI: 10.1186/s40463-016-0169-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [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: 08/27/2016] [Accepted: 10/24/2016] [Indexed: 11/23/2022] Open
Abstract
Background Indications for performing a prophylactic central neck dissection (pCND) in papillary thyroid cancer (PTC) remain controversial. It is unclear how identification of lymph node (LN) metastases should impact the decision to treat with radioactive iodine (RAI). The goals of this study were to identify indications for performing pCND and identify factors that predict the use of adjuvant RAI. Methods This was a population based cross-sectional analysis. A prospectively collected database identified 594 patients who underwent total thyroidectomy +/− CND. A multivariate model was constructed to identify indications for pCND and predictors of the use of RAI. Results 425 CNDs were performed of which 224 were prophylactic. Conventional risk factors (age, tumor size, extra-thyroidal extension) were not associated with performing a pCND. The presence of clinically suspicious lymphadenopathy was the only factor associated with performing CND, thus rendering the CND therapeutic. Positive LNs were retrieved in 39 % of pCND’s, upstaging 87 patients. Among all peri-operative predictors of receiving RAI, presence of LN metastases was the strongest predictor [OR = 5.9 (3.7–9.5)], while tumor size was a modest predictor [OR = 1.8 (1.5–2.1)]. Other conventional risk factors did not predict use of adjuvant RAI. Conclusions Conventional risk factors were not indications for performing a pCND, implying that the decision was based on individual surgeon preference. Performing pCND upstaged 39 % of patients from cN0 to pN1a, increasing the likelihood of receiving RAI 6-fold. Conventional risk factors were not predictors of receiving adjuvant RAI. This highlights the need for a unified approach to performing a pCND and administering RAI.
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Affiliation(s)
- Michael W Deutschmann
- Division of Otolaryngology-Head & Neck Surgery, Department of Surgery, Red Deer Regional Hospital Center, Red Deer, Alberta, Canada
| | - Laura Chin-Lenn
- Division of General Surgery and Surgical Oncology, Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Steven C Nakoneshny
- Ohlson Research Initiative, Arnie Charbonneau Cancer Institute, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Joseph C Dort
- Ohlson Research Initiative, Arnie Charbonneau Cancer Institute, Cumming School of Medicine, University of Calgary, Calgary, Canada.,Division of Otolaryngology-Head and Neck Surgery and Surgical Oncology, Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Janice L Pasieka
- Division of General Surgery and Surgical Oncology, Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, Canada.,Division of Endocrinology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Shamir P Chandarana
- Ohlson Research Initiative, Arnie Charbonneau Cancer Institute, Cumming School of Medicine, University of Calgary, Calgary, Canada. .,Division of Otolaryngology-Head and Neck Surgery and Surgical Oncology, Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, Canada.
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27
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Wilhelm SM, Wang TS, Ruan DT, Lee JA, Asa SL, Duh QY, Doherty GM, Herrera MF, Pasieka JL, Perrier ND, Silverberg SJ, Solórzano CC, Sturgeon C, Tublin ME, Udelsman R, Carty SE. The American Association of Endocrine Surgeons Guidelines for Definitive Management of Primary Hyperparathyroidism. JAMA Surg 2016; 151:959-968. [DOI: 10.1001/jamasurg.2016.2310] [Citation(s) in RCA: 612] [Impact Index Per Article: 76.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Affiliation(s)
- Scott M. Wilhelm
- Department of Surgery, University Hospitals/Case Medical Center, Cleveland, Ohio
| | - Tracy S. Wang
- Department of Surgery, Medical College of Wisconsin, Milwaukee
| | - Daniel T. Ruan
- Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
| | - James A. Lee
- Department of Surgery, Columbia University College of Physicians and Surgeons, New York, New York
| | - Sylvia L. Asa
- Department of Pathology, University of Toronto, Toronto, Ontario, Canada
| | - Quan-Yang Duh
- Department of Surgery, University of California San Francisco Medical Center, San Francisco
| | | | - Miguel F. Herrera
- Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Janice L. Pasieka
- Department of Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Nancy D. Perrier
- Department of Surgery, MD Anderson Cancer Center, Houston, Texas
| | - Shonni J. Silverberg
- Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York
| | - Carmen C. Solórzano
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Cord Sturgeon
- Department of Surgery, Northwestern University, Chicago, Illinois
| | - Mitchell E. Tublin
- Department of Radiology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Robert Udelsman
- Department of Surgery, Yale University, New Haven, Connecticut
| | - Sally E. Carty
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
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Abstract
Follicular cell-derived thyroid cancers are derived from the follicular cells in the thyroid gland, which secrete the iodine-containing thyroid hormones. Follicular cell-derived thyroid cancers can be classified into papillary thyroid cancer (80-85%), follicular thyroid cancer (10-15%), poorly differentiated thyroid cancer (<2%) and undifferentiated (anaplastic) thyroid cancer (<2%), and these have an excellent prognosis with the exception of undifferentiated thyroid cancer. The advent and expansion of advanced diagnostic techniques has driven and continues to drive the epidemic of occult papillary thyroid cancer, owing to overdiagnosis of clinically irrelevant nodules. This transformation of the thyroid cancer landscape at molecular and clinical levels calls for the modification of management strategies towards personalized medicine based on individual risk assessment to deliver the most effective but least aggressive treatment. In thyroid cancer surgery, for instance, injuries to structures outside the thyroid gland, such as the recurrent laryngeal nerve in 2-5% of surgeries or the parathyroid glands in 5-10% of surgeries, negatively affect quality of life more than loss of the expendable thyroid gland. Furthermore, the risks associated with radioiodine ablation may outweigh the risks of persistent or recurrent disease and disease-specific mortality. Improvement in the health-related quality of life of survivors of follicular cell-derived thyroid cancer, which is decreased despite the generally favourable outcome, hinges on early tumour detection and minimization of treatment-related sequelae. Future opportunities include more widespread adoption of molecular and clinical risk stratification and identification of actionable targets for individualized therapies.
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Affiliation(s)
- Henning Dralle
- Department of General, Visceral and Vascular Surgery, University Hospital, University of Halle-Wittenberg, Ernst-Grube-Strasse 40, D-06097 Halle, Germany
| | - Andreas Machens
- Department of General, Visceral and Vascular Surgery, University Hospital, University of Halle-Wittenberg, Ernst-Grube-Strasse 40, D-06097 Halle, Germany
| | - Johanna Basa
- Division of Surgical Oncology, Department of Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Vahab Fatourechi
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
| | - Silvia Franceschi
- Infections and Cancer Epidemiology Group, International Agency for Research on Cancer, Lyon, France
| | - Ian D Hay
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
| | - Yuri E Nikiforov
- Department of Pathology and Laboratory Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Furio Pacini
- Department of Medical, Surgical and Neurological Sciences, University of Siena, Siena, Italy
| | - Janice L Pasieka
- Division of Surgical Oncology, Department of Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Steven I Sherman
- Department of Endocrine Neoplasia and Hormonal Disorders, University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA
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29
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Wolin EM, Jarzab B, Eriksson B, Walter T, Toumpanakis C, Morse MA, Tomassetti P, Weber MM, Fogelman DR, Ramage J, Poon D, Gadbaw B, Li J, Pasieka JL, Mahamat A, Swahn F, Newell-Price J, Mansoor W, Öberg K. Phase III study of pasireotide long-acting release in patients with metastatic neuroendocrine tumors and carcinoid symptoms refractory to available somatostatin analogues. Drug Des Devel Ther 2015; 9:5075-86. [PMID: 26366058 PMCID: PMC4562767 DOI: 10.2147/dddt.s84177] [Citation(s) in RCA: 141] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
In a randomized, double-blind, Phase III study, we compared pasireotide long-acting release (pasireotide LAR) with octreotide long-acting repeatable (octreotide LAR) in managing carcinoid symptoms refractory to first-generation somatostatin analogues. Adults with carcinoid tumors of the digestive tract were randomly assigned (1:1) to receive pasireotide LAR (60 mg) or octreotide LAR (40 mg) every 28 days. Primary outcome was symptom control based on frequency of bowel movements and flushing episodes. Objective tumor response was a secondary outcome. Progression-free survival (PFS) was calculated in a post hoc analysis. Adverse events were recorded. At the time of a planned interim analysis, the data monitoring committee recommended halting the study because of a low predictive probability of showing superiority of pasireotide over octreotide for symptom control (n=43 pasireotide LAR, 20.9%; n=45 octreotide LAR, 26.7%; odds ratio, 0.73; 95% confidence interval [CI], 0.27–1.97; P=0.53). Tumor control rate at month 6 was 62.7% with pasireotide and 46.2% with octreotide (odds ratio, 1.96; 95% CI, 0.89–4.32; P=0.09). Median (95% CI) PFS was 11.8 months (11.0 – not reached) with pasireotide versus 6.8 months (5.6 – not reached) with octreotide (hazard ratio, 0.46; 95% CI, 0.20–0.98; P=0.045). The most frequent drug-related adverse events (pasireotide vs octreotide) included hyperglycemia (28.3% vs 5.3%), fatigue (11.3% vs 3.5%), and nausea (9.4% vs 0%). We conclude that, among patients with carcinoid symptoms refractory to available somatostatin analogues, similar proportions of patients receiving pasireotide LAR or octreotide LAR achieved symptom control at month 6. Pasireotide LAR showed a trend toward higher tumor control rate at month 6, although it was statistically not significant, and was associated with a longer PFS than octreotide LAR.
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Affiliation(s)
- Edward M Wolin
- Markey Cancer Center, University of Kentucky, Lexington, KY, USA
| | - Barbara Jarzab
- Department of Nuclear Medicine and Endocrine Oncology, Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Gliwice Branch, Gliwice, Poland
| | - Barbro Eriksson
- Department of Medical Sciences, Endocrine Oncology Unit, University Hospital, Uppsala, Sweden
| | - Thomas Walter
- Department of Medical Oncology, Edouard Herriot Hospital, Lyon, France
| | | | - Michael A Morse
- Department of Medical Oncology, Duke University Medical Center, Durham, NC, USA
| | - Paola Tomassetti
- Department of Medical and Surgical Sciences, University Hospital St Orsola, Bologna, Italy
| | - Matthias M Weber
- Medizinische Klinik und Poliklinik, Johannes Gutenberg-Universität Mainz, Mainz, Germany
| | - David R Fogelman
- Department of Gastrointestinal Medical Oncology, MD Anderson Cancer Center, Houston, TX, USA
| | - John Ramage
- Gastroenterology Unit, North Hampshire Hospital, Basingstoke, UK
| | - Donald Poon
- Department of Medical Oncology, Raffles Hospital and Duke-NUS Graduate Medical School, Singapore
| | - Brian Gadbaw
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA
| | - Jiang Li
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA
| | - Janice L Pasieka
- Surgery and Oncology Faculty of Medicine, Foothills Hospital, Calgary, AB, Canada
| | - Abakar Mahamat
- Department of Gastrointestinal Oncology, CHU de Nice Hôpital de l'Archet 1, Nice, France
| | - Fredrik Swahn
- Department of Clinical Science, Intervention and Technology, Karolinska Universitatssjukhuset, Huddinge, Stockholm, Sweden
| | - John Newell-Price
- Department of Human Metabolism, School of Medicine and Biomedical Science, The University of Sheffield, and Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Wasat Mansoor
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, UK
| | - Kjell Öberg
- Department of Medical Sciences, Endocrine Oncology Unit, University Hospital, Uppsala, Sweden
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30
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Kline GA, Chin A, So B, Harvey A, Pasieka JL. Defining contralateral adrenal suppression in primary aldosteronism: implications for diagnosis and outcome. Clin Endocrinol (Oxf) 2015; 83:20-7. [PMID: 25400021 DOI: 10.1111/cen.12669] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [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: 08/08/2014] [Revised: 09/08/2014] [Accepted: 11/10/2014] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Unilateral primary aldosteronism (PA) should have a contralaterally normal and therefore suppressed adrenal zona glomerulosa. However, there is no validated definition of adrenal suppression. We created two biochemical hypotheses of adrenal suppression based upon measurements taken during adrenal vein sampling (AVS) to determine whether either proved useful for interpretation of AVS or prediction of hypertension outcome in operated cases. DESIGN Retrospective database analysis. PATIENTS Ninety-nine cases of PA from a tertiary hypertension unit. MEASUREMENTS Hypothesis 1 was the proportional suppression of the uninvolved/lowest adrenal(aldo/cortisol) to IVC(aldo/cortisol) ratio pre- and post cosyntropin. Hypothesis 2 was the absolute decrease in the uninvolved adrenal(aldo/cortisol) ratio after cortrosyn injection. ROC analysis performed using lateralization and hypertension resolution as the outcomes of interest. RESULTS Hypothesis 1 proved highly predictive of lateralization with a ROC AUC of 0.958, P < 0.0001, giving adrenal(aldo/cortisol):IVC(aldo/cortisol) <1.4 as the optimized criterion (sensitivity 90%, specificity 94%). For blood pressure outcomes in the surgical subgroup (n = 52), hypertension resolution was most commonly seen among subjects with adrenal suppression by both definitions although there was significant overlap with subjects requiring ongoing medication. CONCLUSIONS Post cosyntropin suppression of the uninvolved adrenal-to-IVC ratio is a highly useful definition of adrenal suppression that accurately predicts unilateral PA. This may be particularly useful in a case where AVS fails to catheterize one of the adrenal veins but suppression is seen on the other side. Adrenal suppression may also predict blood pressure outcome, however, a much larger PA database is likely necessary to determine the relative contribution of this predictor.
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Affiliation(s)
- G A Kline
- Division of Endocrinology, Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - A Chin
- Section of Clinical Biochemistry, Calgary Laboratory Services, Department of Pathology and Laboratory Medicine, University of Calgary, Calgary, AB, Canada
| | - B So
- Department of Radiology, University of Calgary, Calgary, AB, Canada
| | - A Harvey
- Department of Surgery, University of Calgary, Calgary, AB, Canada
| | - J L Pasieka
- Department of Surgery, University of Calgary, Calgary, AB, Canada
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31
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Deutschmann MW, Chin-Lenn L, Au J, Brilz A, Nakoneshny S, Dort JC, Pasieka JL, Chandarana SP. Extent of central neck dissection among thyroid cancer surgeons: Cross-sectional analysis. Head Neck 2015; 38 Suppl 1:E328-32. [PMID: 25546489 DOI: 10.1002/hed.23996] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/19/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND It is unclear if surgeons are performing comprehensive central neck dissections for well-differentiated thyroid cancer. The purpose of this study was to determine mean lymph node retrieval in central neck dissection as well as variability across surgeons and institutions. METHODS A prospectively collected database identified 18 surgeons performing 425 central neck dissections, 313 unilateral and 112 bilateral. Demographics, perioperative, and pathologic factors were analyzed. RESULTS Mean lymph node yield was 7.4 and 11.9 for unilateral and bilateral central neck dissection, respectively. Although 224 central neck dissections were prophylactic, both total and pathologic lymph node yields were significantly higher in therapeutic central neck dissection. There was a significant variation in lymph node yield across individual surgeons, institutions, and regions. High-volume central neck dissection surgeons have significantly lower lymph node yield compared to low-volume surgeons. CONCLUSION Central neck dissection seems to be performed adequately; however, there is a significant variation in lymph node yield. Future initiatives should try to standardize the central neck dissections performed, with emphasis on obtaining a sufficient yield. © 2015 Wiley Periodicals, Inc. Head Neck 38: E328-E332, 2016.
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Affiliation(s)
- Michael W Deutschmann
- Department of Otolaryngology-Head & Neck Surgery, University of Kansas Medical Center, Kansas City, Kansas
| | - Laura Chin-Lenn
- Division of Surgical Oncology, Department of Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Jennifer Au
- Department of Family Medicine, Faculty of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Alan Brilz
- Department of Family Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Steve Nakoneshny
- Ohlson Research Initiative, Southern Alberta Cancer Research Institute, University of Calgary, Calgary, Alberta, Canada
| | - Joseph C Dort
- Ohlson Research Initiative, Southern Alberta Cancer Research Institute, University of Calgary, Calgary, Alberta, Canada.,Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Janice L Pasieka
- Division of Surgical Oncology, Department of Surgery, University of Calgary, Calgary, Alberta, Canada.,Division of Endocrinology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Shamir P Chandarana
- Ohlson Research Initiative, Southern Alberta Cancer Research Institute, University of Calgary, Calgary, Alberta, Canada.,Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, University of Calgary, Calgary, Alberta, Canada
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32
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Pasieka JL. What Should We Tell Our Patients? Lifetime Guarantee or is it 5- to 10-year Warranty on a Parathyroidectomy for Primary Hyperparathyroidism? World J Surg 2015; 39:1928-9. [DOI: 10.1007/s00268-015-3043-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [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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Venos ES, So B, Dias VC, Harvey A, Pasieka JL, Kline GA. A clinical prediction score for diagnosing unilateral primary aldosteronism may not be generalizable. BMC Endocr Disord 2014; 14:94. [PMID: 25495254 PMCID: PMC4320464 DOI: 10.1186/1472-6823-14-94] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2014] [Accepted: 12/08/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND A published clinical prediction score indicated that a unilateral adrenal adenoma and either hypokalemia or an estimated glomerular filtration rate of 100 ml/min/1.73 m2 was 100% specific for unilateral primary aldosteronism. This study aimed to validate this score in a separate cohort of patients with primary aldosteronism. METHODS A review of patients with primary aldosteronism from June 2005 to July 2013 at a single center's hypertension clinic. One hundred twelve patients with primary aldosteronism underwent successful adrenal vein sampling and the 110 patients with full data available were included in the final analysis. Adrenal vein sampling was performed all patients desiring surgery by the simultaneous collection of sample prior to and 15 minutes after a cosyntropin infusion with a 3:1 aldosterone/cortisol ratio diagnosing unilateral primary aldosteronism. The derived score was applied to the cohort. Sensitivity and specificity were calculated for clinical prediction score of ≥5 points. RESULTS There were 64 patients found to have unilateral primary aldosteronism and 48 had bilateral disease. A score ≥5 points had 64% sensitivity (95% confidence interval, 51-76) and 85% specificity (95% confidence interval, 71-94) for unilateral disease. Four patients had lateralization of primary aldosteronism to the side contralateral to the adenoma. CONCLUSIONS The 100% specificity of the score for the unilateral origin of primary aldosteronism was not validated in this cohort with a score of ≥5 points. At best, a high score in this prediction rule may be an additional tool for helping to confirm a decision to offer patients adrenal vein sampling.
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Affiliation(s)
- Erik S Venos
- />Division of Endocrinology, Faculty of Medicine, University of Calgary, 1820 Richmond Road SW, Calgary, AB T2T 5C7 Canada
| | - Benny So
- />Department of Radiology, University of Calgary, Calgary, AB Canada
| | - Valerian C Dias
- />Division of Clinical Pathology, University of Calgary, Calgary, AB Canada
| | - Adrian Harvey
- />Department of Surgery, University of Calgary, Calgary, AB Canada
| | - Janice L Pasieka
- />Department of Surgery, University of Calgary, Calgary, AB Canada
| | - Gregory A Kline
- />Division of Endocrinology, Faculty of Medicine, University of Calgary, 1820 Richmond Road SW, Calgary, AB T2T 5C7 Canada
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Pasieka JL, Dixon E. Small bowel neuroendocrine tumors: the benefits of surgical intervention. International Journal of Endocrine Oncology 2014. [DOI: 10.2217/ije.14.5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Well-differentiated SI NETs are on the rise. Due in part to the indolent nature of these tumors, patients typically have a delay in diagnosis and present with metastatic disease. Surgeries for symptoms of either chronic intermittent small bowel obstruction and/or ischemia or from carcinoid syndrome have proven to provide excellent palliation. Most recently, several series have demonstrated an improved survival in those patients in whom the primary, locoregional disease has been resected. Several newer adjuncts have been developed to aid in the hepatic directed therapies such as ablation therapies, embolization and Y spheres. The ability to cytoreduce 70% or more of the hepatic tumor burden has been shown to not only to provide a biochemical and as such a clinical response, but also appears to prolong survival. All patients with SI NETs should be assessed in a multidisciplinary clinic and the first line of therapy should always be to assess surgical resectabilty.
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Affiliation(s)
- Janice L Pasieka
- University of Calgary, Department of Surgery, Calgary Alberta, Canada
| | - Elijah Dixon
- University of Calgary, Department of Surgery, Calgary Alberta, Canada
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Kline GA, Pasieka JL, Harvey A, So B, Dias VC. High-probability features of primary aldosteronism may obviate the need for confirmatory testing without increasing false-positive diagnoses. J Clin Hypertens (Greenwich) 2014; 16:488-96. [PMID: 24863855 DOI: 10.1111/jch.12342] [Citation(s) in RCA: 28] [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: 01/03/2014] [Revised: 02/19/2014] [Accepted: 02/23/2014] [Indexed: 11/28/2022]
Abstract
This retrospective review examined all primary aldosteronism (PA) adrenal vein sampling (AVS), diagnoses, and outcomes from an endocrine hypertension unit where confirmatory testing was abandoned in 2005 to determine the potential rate of false-positive diagnoses. Patients with outcome-verified PA (surgical patients) were compared with patients with high-probability PA (nonsurgical but high aldosterone-renin ratio, imaging abnormalities, and/or hypokalemia) or possible PA (nonsurgical, no features besides mild elevation of aldosterone-renin ratio, a potential false diagnosis of PA). Of 83 patients, 58% had unilateral PA and 42% had bilateral aldosteronism. Less than 3% of the cohort showed bilateral aldosteronism without hypokalemia or computed tomographic findings, potentially representing the false-positive PA diagnosis rate with omission of confirmatory tests in this population. In a hypertension referral unit enriched in high-probability PA cases and where high AVS success is achieved, omission of a PA confirmatory test yields a high rate of surgical diagnosis with few potential false-positive diagnoses.
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Affiliation(s)
- Gregory A Kline
- Division of Endocrinology, Department of Medicine, University of Calgary, Calgary, AB, Canada
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Wang TS, Pasieka JL, Carty SE. Techniques of parathyroid exploration at North American endocrine surgery fellowship programs: what the next generation is being taught. Am J Surg 2014; 207:527-32. [DOI: 10.1016/j.amjsurg.2013.05.012] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2013] [Revised: 05/07/2013] [Accepted: 05/16/2013] [Indexed: 01/14/2023]
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Kline GA, Pasieka JL, Harvey A, So B, Dias VC. A marked proportional rise in IVC aldosterone following cosyntropin administration during AVS is a signal to the presence of adrenal hyperplasia in primary aldosteronism. J Hum Hypertens 2013; 28:298-302. [PMID: 24284382 DOI: 10.1038/jhh.2013.116] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2012] [Revised: 09/26/2013] [Accepted: 10/10/2013] [Indexed: 11/09/2022]
Abstract
We hypothesized aldosteronoma responsiveness to cosyntropin may be a characterizing feature that could be determined in addition to standard adrenal vein sampling (AVS) data. We reviewed an AVS database from June 2005 to October 2011 including 65 patients with confirmed primary aldosteronism (PA) who underwent AVS and, if applicable, unilateral adrenalectomy. Patients were divided into confirmed lateralized and non-lateralized groups and subgrouped by histology. Plasma aldosterone in inferior vena cava (IVC) pre- and post-cosyntropin infusion during AVS was measured. Peak aldosterone and proportional change was compared between groups. Baseline and peak IVC aldosterone was higher in lateralized patients but incremental aldosterone rise was much greater in subjects with bilateral hyperplasia. From receiver operator characteristics (ROC) analysis, the optimized diagnostic cut point of peak IVC aldosterone of >649 pmol l(-1) would have a sensitivity of 94% for surgical disease although specificity of just 59%. A 250% increase in IVC aldosterone following cosyntropin would be specific enough to exclude 87% of surgical/lateralized disease. These diagnostic capabilities are similar to other results with non-AVS tests performed for diagnosis of lateralization. Although not specific enough to replace standard AVS interpretation, a marked IVC aldosterone increase after cosyntropin during AVS is a useful additional test to diagnose non-lateralizing forms of PA. Such a calculation requires no additional expense or tests.
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Affiliation(s)
- G A Kline
- Department of Medicine, Division of Endocrinology, Faculty of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - J L Pasieka
- Department of Surgery, Faculty of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - A Harvey
- Department of Surgery, Faculty of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - B So
- Department of Radiology, Faculty of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - V C Dias
- Department of Clinical Biochemistry, Faculty of Medicine, University of Calgary, Calgary, Alberta, Canada
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Edwards JP, Stuart HC, Urbanski SJ, Pasieka JL. A rare cavernous hemangioma of the adrenal gland. Int J Surg Case Rep 2013; 5:52-5. [PMID: 24441435 PMCID: PMC3921650 DOI: 10.1016/j.ijscr.2013.11.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [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: 08/09/2013] [Revised: 10/30/2013] [Accepted: 11/02/2013] [Indexed: 11/28/2022] Open
Abstract
INTRODUCTION Cavernous hemangiomas of the adrenal gland are rare. We report a case of a cavernous hemangioma of the adrenal gland presenting as an adrenal incidentaloma suspicious for adrenal cortical carcinoma (ACC). PRESENTATION OF CASE A 78 year old woman was admitted after a fall. Abdominal computed tomography revealed a large right adrenal lesion with features suspicious for adrenal cortical carcinoma (5.4 cm × 3.3 cm, unilateral, tumor calcifications, average Hounsfield units 55). The tumor was removed intact by a laparoscopic approach and pathology revealed a cavernous hemangioma of the adrenal gland. DISCUSSION Adrenal incidentalomas are found in up to 10% of patients undergoing abdominal imaging. Differential diagnosis includes both benign and malignant lesions. Guidelines for removal of adrenal incidentalomas recommend surgery based on functional status, size, and presence of concerning features on diagnostic imaging. Cavernous hemangiomas are rare, benign vascular malformations which can be challenging to distinguish pre-operatively from malignant lesions such as ACC. CONCLUSION Cavernous hemangiomas of the adrenal gland are exceedingly rare. These benign tumors have imaging features which may be suggestive of adrenal cortical carcinoma. The treatment of choice is surgical excision due the difficulty of excluding malignancy.
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Affiliation(s)
- Janet P Edwards
- Department of Surgery, University of Calgary, North Tower, 1403 29th Street Northwest, Calgary, Alberta, Canada T2N 2T9
| | - Heather C Stuart
- Department of Surgery, University of Calgary, North Tower, 1403 29th Street Northwest, Calgary, Alberta, Canada T2N 2T9
| | - Stefan J Urbanski
- Department of Pathology, University of Calgary, North Tower, 1403 29th Street Northwest, Calgary, Alberta, Canada T2N 2T9
| | - Janice L Pasieka
- Department of Surgery, University of Calgary, North Tower, 1403 29th Street Northwest, Calgary, Alberta, Canada T2N 2T9.
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Wolin EM, Jarzab B, Eriksson B, Walter T, Toumpanakis C, Morse M, Tomassetti P, Weber M, Fogelman DR, Ramage J, Poon D, Huang JM, Hudson M, Zhi X, Pasieka JL, Mahamat A, Swahn F, Newell-Price J, Mansoor W, Oberg KE. A multicenter, randomized, blinded, phase III study of pasireotide LAR versus octreotide LAR in patients with metastatic neuroendocrine tumors (NET) with disease-related symptoms inadequately controlled by somatostatin analogs. J Clin Oncol 2013. [DOI: 10.1200/jco.2013.31.15_suppl.4031] [Citation(s) in RCA: 6] [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] [Indexed: 11/20/2022] Open
Abstract
4031 Background: The novel somatostatin analog (SSA) pasireotide has a broader binding profile than currently available SSA (octreotide and lanreotide). Results from a phase III study (NCT00690430) of pasireotide LAR (P) vs octreotide LAR (O) in patients (pts) with NET and disease-related symptoms uncontrolled by the maximum approved dose of available SSA are shown. Methods: Pts (N=110) were randomized and stratified by predominant symptom at baseline (diarrhea [D], flushing [F], or D+F) 1:1 to P (60 mg IM) or O (40 mg IM) q28d. Primary objective was symptom response at month (M) 6. Secondary objectives included tumor response and safety. Progression-free survival (PFS) was an exploratory analysis. Results: 53 and 57 pts were enrolled in the P and O arms when the study was halted due to an interim analysis suggesting futility for symptom response. Baseline characteristics were similar between arms. Majority of primary tumor locations were small intestine (72% and 81% in the P and O arms). Symptom response at M6 was 9/43 (21%) and 12/45 (27%) in the P and O arms, odds ratio 0.73 (95% CI, 0.27-1.97; p=0.53). Median numbers of D/day and F/2 weeks and change in symptom from baseline to M6 are in Table. Hyperglycemia (11% vs 0%), diarrhea (9% vs 7%), and abdominal pain (2% vs 9%) were the most common grade 3/4 AEs in the P vs O arms in the core phase, and 7 (13%) and 4 (7%) pts discontinued due to AEs. Median investigator-assessed PFS was 11.8 months and 6.8 months in the P and O arms (HR=0.46; p=0.045). Conclusions: P and O showed a similar safety profile except for the higher frequency of hyperglycemia in P. Pts on P had PFS 5 months longer than pts on O (investigator assessment), despite no differences in symptom response rates. These results warrant a large phase III trial to clarify the role of P as a therapy for NET. Clinical trial information: NCT00690430. [Table: see text]
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Affiliation(s)
| | - Barbara Jarzab
- Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Gliwice, Poland
| | | | - Thomas Walter
- Hospices Civils de Lyon & Université Claude Bernard Lyon-Est, Lyon, France
| | | | | | | | | | | | - John Ramage
- Hampshire Hospitals NHS, Basingstoke, United Kingdom
| | - Donald Poon
- Raffles Hospital, Singapore & Duke-NUS Graduate Medical School, Singapore, Singapore
| | | | | | - Xin Zhi
- Novartis Pharmaceuticals Corp, Florham Park, NJ
| | | | | | | | | | - Wasat Mansoor
- Christie Hospital NHS Foundation Trust, Manchester, United Kingdom
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Kline GA, So B, Dias VC, Harvey A, Pasieka JL. Catheterization During Adrenal Vein Sampling for Primary Aldosteronism: Failure to Use (1-24) ACTH May Increase Apparent Failure Rate. J Clin Hypertens (Greenwich) 2013; 15:480-4. [DOI: 10.1111/jch.12096] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2012] [Revised: 02/15/2013] [Accepted: 02/21/2013] [Indexed: 11/28/2022]
Affiliation(s)
- Gregory A. Kline
- Division of Endocrinology; Department of Medicine; University of Calgary; Calgary AB Canada
| | - Benny So
- Department of Radiology; University of Calgary; Calgary AB Canada
| | - Valerian C. Dias
- Division of Clinical Pathology; University of Calgary; Calgary AB Canada
| | - Adrian Harvey
- Department of Surgery; University of Calgary; Calgary AB Canada
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Harvey A, Pasieka JL, Kline G, So B. Modification of the protocol for selective adrenal venous sampling results in both a significant increase in the accuracy and necessity of the procedure in the management of patients with primary hyperaldosteronism. Surgery 2012; 152:643-9; discussion 649-51. [DOI: 10.1016/j.surg.2012.07.007] [Citation(s) in RCA: 27] [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: 02/10/2012] [Accepted: 07/05/2012] [Indexed: 11/16/2022]
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Carty SE, Doherty GM, Inabnet WB, Pasieka JL, Randolph GW, Shaha AR, Terris DJ, Tufano RP, Tuttle RM. American Thyroid Association statement on the essential elements of interdisciplinary communication of perioperative information for patients undergoing thyroid cancer surgery. Thyroid 2012; 22:395-9. [PMID: 22352873 DOI: 10.1089/thy.2011.0423] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [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] [Indexed: 11/13/2022]
Abstract
BACKGROUND Thyroid cancer specialists require specific perioperative information to develop a management plan for patients with thyroid cancer, but there is not yet a model for effective interdisciplinary data communication. The American Thyroid Association Surgical Affairs Committee was asked to define a suggested essential perioperative dataset representing the critical information that should be readily available to participating members of the treatment team. METHODS To identify and agree upon a multidisciplinary set of critical perioperative findings requiring communication, we examined diverse best-practice documents relating to thyroidectomy and extracted common features felt to enhance precise, direct communication with nonsurgical caregivers. RESULTS Suggested essential datasets for the preoperative, intraoperative, and immediate postoperative findings and management of patients undergoing surgery for thyroid cancer were identified and are presented. For operative reporting, the essential features of both a dictated narrative format and a synoptic computer format are modeled in detail. The importance of interdisciplinary communication is discussed with regard to the extent of required resection, the final pathology findings, surgical complications, and other factors that may influence risk stratification, adjuvant treatment, and surveillance. CONCLUSIONS Accurate communication of the important findings and sequelae of thyroidectomy for cancer is critical to individualized risk stratification as well as to the clinical issues of thyroid cancer care that are often jointly managed in the postoperative setting. True interdisciplinary care is essential to providing optimal care and surveillance.
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Affiliation(s)
- Sally E Carty
- Division of Endocrine Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania 15213, USA.
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Harvey A, Pasieka JL, Al-Bisher H, Dixon E. Primary hepatic gastrinoma causing zollinger-ellison syndrome: a rare and challenging diagnosis. Cancers (Basel) 2012; 4:130-40. [PMID: 24213231 PMCID: PMC3722648 DOI: 10.3390/cancers4010130] [Citation(s) in RCA: 6] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2011] [Revised: 01/23/2012] [Accepted: 01/30/2012] [Indexed: 01/05/2023] Open
Abstract
The majority of gastrinomas causing Zollinger-Ellison syndrome (ZES) are located in the duodenum or the pancreas. Primary hepatic gastrinomas (PHG) are extremely rare and difficult to diagnose because the liver is the commonest site of metastatic disease and gastrinomas can be very small. Furthermore, gastrinomas are typically slow-growing thus a missed, occult primary tumour may not become evident for many years. The diagnosis of PHG is therefore dependent on a careful search for a primary and long-term biochemical follow-up following curative hepatic resection. We report a case of a 7 cm PHG in a 48 year old man with ZES. Preoperatively, both a basal and stimulated gastrin levels were elevated. Surgical exploration including intraoperative ultrasound and duodenotomy, failed to reveal a primary. Patient underwent a right hepatectomy. Yearly, gastrin and secretin stimulation tests remain normal 6 years following surgery. He remains symptom free off all medication. An additional 26 cases of PHG were found. Including this case, 21 had at least 1 year follow-up, however only eight had greater than 5 years (median 24 months). Post-op gastrin levels were reported in 25, however provocative testing was done in only 10. Persistence and recurrence occurred in one and four, respectively. PHG causing ZES is extremely rare. Although the current literature claims to include 26 additional cases of PHG, without a thorough search for the primary and long-term follow-up data including provocative testing, this diagnosis remains a challenge.
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Affiliation(s)
- Adrian Harvey
- Division of General Surgery and Surgical Oncology, Department of Surgery and Oncology, University of Calgary, Calgary, Alberta T2N 2T9, Canada.
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Datta I, Ball CG, Cox H, Pasieka JL. Computed Tomography Target Sign: A Case of Mistaken Intussusception. Indian J Surg 2011; 73:76-7. [DOI: 10.1007/s12262-010-0135-z] [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] [Received: 11/28/2008] [Accepted: 07/29/2009] [Indexed: 11/24/2022] Open
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Pasieka JL. Dare to be Oslerian: embracing the value of clinical medicine in today's surgical practice. Surgery 2010; 148:1047-56. [PMID: 21134532 DOI: 10.1016/j.surg.2010.09.031] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2010] [Accepted: 09/16/2010] [Indexed: 11/30/2022]
Affiliation(s)
- Janice L Pasieka
- Department of Surgery, Divisions General Surgery and Surgical Oncology, University of Calgary, Alberta, Canada.
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Schieman C, Pasieka JL, McFadden SD, Cole M, Graham AJ. Resolution of chronic diarrhea after resection of a localized pulmonary carcinoid tumor. Ann Thorac Surg 2010; 89:1275-6. [PMID: 20338354 DOI: 10.1016/j.athoracsur.2009.08.049] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2009] [Revised: 08/12/2009] [Accepted: 08/17/2009] [Indexed: 11/25/2022]
Abstract
Pulmonary carcinoid tumors are rarely associated with symptoms of the carcinoid syndrome, such as flushing and diarrhea. When present, these symptoms virtually always represent extensive hepatic metastases. In this article we describe the presentation, perioperative management, and presumed mechanisms of a patient with a localized pulmonary carcinoid with associated chronic diarrhea that resolved after operation.
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Affiliation(s)
- Colin Schieman
- Department of Surgery, Faculty of Medicine, University of Calgary, Calgary, Alberta, Canada.
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Pasieka JL. Training of the endocrine surgical scientist. Am J Transl Res 2010; 2:126-128. [PMID: 20407601 PMCID: PMC2855630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2010] [Accepted: 02/08/2010] [Indexed: 05/29/2023]
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