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Lee WG, Gosnell JE, Shen WT, Duh QY, Suh I, Chen Y. Recovery After Thyroid and Parathyroid Surgery: How Do Our Patients Really Feel? J Surg Res 2023; 283:764-770. [PMID: 36470201 DOI: 10.1016/j.jss.2022.11.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 11/10/2022] [Accepted: 11/16/2022] [Indexed: 12/05/2022]
Abstract
INTRODUCTION Counseling on the immediate postoperative experience for outpatient procedures is largely based on anecdotal experience. We devised a short messaging service (SMS) survey using mobile phone text messages to evaluate real-time patient recovery following outpatient thyroid or parathyroid surgery. MATERIALS AND METHODS Daily automated SMS surveys were sent the evening of the operation until postoperative day 10. Pain, opioid use, voice quality, and energy levels were assessed. Impaired voice and energy was defined as a score < 2/3 of normal. RESULTS One hundred fifty five patients were enrolled with an overall response rate of 81.6%. One hundred thirty three patients had an individual response rate > 50% and were included in the final analysis. Median patient age was 60 y with 102 females (76.7%). Seventy patients (52.6%) underwent parathyroidectomy and 66 (49.6%) thyroidectomy and 10 (7.5%) neck dissection. Forty eight patients (36.1%) did not use any opioids postoperatively. Independent risk factors for higher total pain scores included thyroidectomy and patients with preoperative opioid or tobacco use, while increased opioid use was associated with age < 60 y, body mass index > 30 kg/m2, preoperative opioid or tobacco use, and history of anxiety or depression. Patients with loss of intraoperative recurrent laryngeal nerve signaling had a significantly worse overall voice score (54.65 versus 92.67, P < 0.001). Up to 10% of patients were still using opioids and/or reported impaired voice and energy levels beyond 1 wk postoperatively. CONCLUSIONS Real-time SMS survey is an effective and potentially valuable way to monitor patient recovery following surgery. A subset of patients reported impaired voice and energy and was still using opioids beyond 1 wk after thyroid and parathyroid surgery and these patients may benefit from closer follow-up and earlier intervention.
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Affiliation(s)
- William G Lee
- Cedars-Sinai Medical Center, Department of Surgery, Los Angeles, California
| | - Jessica E Gosnell
- University of San Francisco, Section of Endocrine Surgery, San Francisco, California
| | - Wen T Shen
- University of San Francisco, Section of Endocrine Surgery, San Francisco, California
| | - Quan-Yang Duh
- University of San Francisco, Section of Endocrine Surgery, San Francisco, California
| | - Insoo Suh
- NYU Langone Health, Division of Endocrine Surgery, New York, New York
| | - Yufei Chen
- Cedars-Sinai Medical Center, Department of Surgery, Los Angeles, California.
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Graves CE, Goyal N, Levin A, Nuño MA, Kim J, Campbell MJ, Shen WT, Gosnell JE, Roman SA, Sosa JA, Duh QY, Suh I. ANXIETY DURING THE COVID-19 PANDEMIC: A WEB-BASED SURVEY OF THYROID CANCER SURVIVORS. Endocr Pract 2022; 28:405-413. [PMID: 35032648 PMCID: PMC8754453 DOI: 10.1016/j.eprac.2022.01.002] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2021] [Revised: 01/02/2022] [Accepted: 01/07/2022] [Indexed: 12/25/2022]
Abstract
Objective Cancer patients and survivors may be disproportionately affected by COVID-19. We sought to determine the effects of the pandemic on thyroid cancer survivors’ health care interactions and quality of life. Methods An anonymous survey including questions about COVID-19 and the Patient-Reported Outcomes Measurement Information System profile (PROMIS-29, version 2.0) was hosted on the Thyroid Cancer Survivors’ Association, Inc website. PROMIS scores were compared to previously published data. Factors associated with greater anxiety were evaluated with univariable and multivariable logistic regression. Results From May 6, 2020, to October 8, 2020, 413 participants consented to take the survey; 378 (92%) met the inclusion criteria: diagnosed with thyroid cancer or noninvasive follicular neoplasm with papillary-like nuclear features, located within the United States, and completed all sections of the survey. The mean age was 53 years, 89% were women, and 74% had papillary thyroid cancer. Most respondents agreed/strongly agreed (83%) that their lives were very different during the COVID-19 pandemic, as were their interactions with doctors (79%). A minority (43%) were satisfied with the information from their doctor regarding COVID-19 changes. Compared to pre-COVID-19, PROMIS scores were higher for anxiety (57.8 vs 56.5; P < .05) and lower for the ability to participate in social activities (46.2 vs 48.1; P < .01), fatigue (55.8 vs 57.9; P < .01), and sleep disturbance (54.7 vs 56.1; P < .01). After adjusting for confounders, higher anxiety was associated with younger age (P < .01) and change in treatment plan (P = .04). Conclusion During the COVID-19 pandemic, thyroid cancer survivors reported increased anxiety compared to a pre-COVID cohort. To deliver comprehensive care, providers must better understand patient concerns and improve communication about potential changes to treatment plans.
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Affiliation(s)
- Claire E Graves
- Department of Surgery, University of California Davis, Sacramento, California.
| | - Neha Goyal
- Psycho-Oncology Program, University of California San Francisco Cancer Center, San Francisco, California
| | - Anna Levin
- Psycho-Oncology Program, University of California San Francisco Cancer Center, San Francisco, California
| | - Miriam A Nuño
- Department of Surgery, University of California Davis, Sacramento, California
| | - Jina Kim
- Department of Surgery, Inova Schar Cancer Institute, Fairfax, Virginia
| | - Michael J Campbell
- Department of Surgery, University of California Davis, Sacramento, California
| | - Wen T Shen
- Department of Surgery, University of California San Francisco, San Francisco, California
| | - Jessica E Gosnell
- Department of Surgery, University of California San Francisco, San Francisco, California
| | - Sanziana A Roman
- Department of Surgery, University of California San Francisco, San Francisco, California
| | - Julie A Sosa
- Department of Surgery, University of California San Francisco, San Francisco, California
| | - Quan-Yang Duh
- Department of Surgery, University of California San Francisco, San Francisco, California
| | - Insoo Suh
- Department of Surgery, NYU Langone Health, New York, New York
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Yap A, Hope TA, Graves CE, Kluijfhout W, Shen WT, Gosnell JE, Sosa JA, Roman SA, Duh QY, Suh I. A cost-utility analysis of 18F-fluorocholine-positron emission tomography imaging for localizing primary hyperparathyroidism in the United States. Surgery 2021; 171:55-62. [PMID: 34340823 DOI: 10.1016/j.surg.2021.03.075] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 03/16/2021] [Accepted: 03/25/2021] [Indexed: 12/28/2022]
Abstract
BACKGROUND Primary hyperparathyroidism historically necessitated bilateral neck exploration to remove abnormal parathyroid tissue. Improved localization allows for focused parathyroidectomy with lower complication risks. Recently, positron emission tomography using radiolabeled 18F-fluorocholine demonstrated high accuracy in detecting these lesions, but its cost-effectiveness has not been studied in the United States. METHODS A decision tree modeled patients who underwent parathyroidectomy for primary hyperparathyroidism using single preoperative localization modalities: (1) positron emission tomography using radiolabeled 18F-fluorocholine, (2) 4-dimensional computed tomography, (3) ultrasound, and (4) sestamibi single photon emission computed tomography (SPECT). All patients underwent either focused parathyroidectomy versus bilateral neck exploration, with associated cost ($) and clinical outcomes measured in quality-adjusted life-years gained. Model parameters were informed by literature review and Medicare costs. Incremental cost-utility ratios were calculated in US dollars/quality-adjusted life-years gained, with a willingness-to-pay threshold set at $100,000/quality-adjusted life-year. One-way, 2-way, and threshold sensitivity analyses were performed. RESULTS Positron emission tomography using radiolabeled 18F-fluorocholine gained the most quality-adjusted life-years (23.9) and was the costliest ($2,096), with a total treatment cost of $11,245 or $470/quality-adjusted life-year gained. Sestamibi single photon emission computed tomography and ultrasound were dominated strategies. Compared with 4-dimentional computed tomography, the incremental cost-utility ratio for positron emission tomography using radiolabeled 18F-fluorocholine was $91,066/quality-adjusted life-year gained in our base case analysis, which was below the willingness-to-pay threshold. In 1-way sensitivity analysis, the incremental cost-utility ratio was sensitive to test accuracy, positron emission tomography using radiolabeled 18F-fluorocholine price, postoperative complication probabilities, proportion of bilateral neck exploration patients needing overnight hospitalization, and life expectancy. CONCLUSION Our model elucidates scenarios in which positron emission tomography using radiolabeled 18F-fluorocholine can potentially be a cost-effective imaging option for primary hyperparathyroidism in the United States. Further investigation is needed to determine the maximal cost-effectiveness for positron emission tomography using radiolabeled 18F-fluorocholine in selected populations.
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Affiliation(s)
- Ava Yap
- Department of Surgery, University of California San Francisco, CA.
| | - Thomas A Hope
- Department of Radiology and Biomedical Imaging, University of California San Francisco, CA
| | | | | | - Wen T Shen
- Department of Surgery, University of California San Francisco, CA
| | | | - Julie A Sosa
- Department of Surgery, University of California San Francisco, CA
| | - Sanziana A Roman
- Department of Surgery, University of California San Francisco, CA
| | - Quan-Yang Duh
- Department of Surgery, University of California San Francisco, CA
| | - Insoo Suh
- Department of Surgery, New York University Langone Health, NY
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Graves CE, Hope TA, Kim J, Pampaloni MH, Kluijfhout W, Seib CD, Gosnell JE, Shen WT, Roman SA, Sosa JA, Duh QY, Suh I. Superior sensitivity of 18F-fluorocholine: PET localization in primary hyperparathyroidism. Surgery 2021; 171:47-54. [PMID: 34301418 DOI: 10.1016/j.surg.2021.05.056] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 04/23/2021] [Accepted: 05/04/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Preoperative parathyroid imaging guides surgeons during parathyroidectomy. This study evaluates the clinical impact of 18F-fluorocholine positron emission tomography for preoperative parathyroid localization on patients with primary hyperparathyroidism. METHODS Patients with primary hyperparathyroidism and indications for parathyroidectomy had simultaneous 18F-fluorocholine positron emission tomography imaging/magnetic resonance imaging. In patients who underwent subsequent parathyroidectomy, cure was based on lab values at least 6 months after surgery. Location-based sensitivity and specificity of 18F-fluorocholine positron emission tomography imaging was assessed using 3 anatomic locations (left neck, right neck, and mediastinum), with surgery as the gold standard. RESULTS In 101 patients, 18F-fluorocholine positron emission tomography localized at least 1 candidate lesion in 93% of patients overall and in 91% of patients with previously negative imaging, leading to a change in preoperative strategy in 60% of patients. Of 76 patients who underwent parathyroidectomy, 58 (77%) had laboratory data at least 6 months postoperatively, with 55/58 patients (95%) demonstrating cure. 18F-fluorocholine positron emission tomography successfully guided curative surgery in 48/58 (83%) patients, compared with 20/57 (35%) based on ultrasound and 13/55 (24%) based on sestamibi. In a location-based analysis, sensitivity of 18F-fluorocholine positron emission tomography (88.9%) outperformed both ultrasound (37.1%) and sestamibi (27.5%), as well as ultrasound and sestamibi combined (47.8%). CONCLUSION Long-term results in the first cohort in the United States to use 18F-fluorocholine positron emission tomography for parathyroid localization confirm its utility in a challenging cohort, with better sensitivity than ultrasound or sestamibi.
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Affiliation(s)
- Claire E Graves
- Department of Surgery, University of California San Francisco, San Francisco, CA, USA; Department of Surgery, University of California Davis, Sacramento, CA, USA. https://twitter.com/clairegravesmd
| | - Thomas A Hope
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA, USA. https://twitter.com/thomashopemd
| | - Jina Kim
- Department of Surgery, University of California San Francisco, San Francisco, CA, USA; Department of Surgery, Inova Schar Cancer Institute, Fairfax, VA, USA
| | - Miguel H Pampaloni
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA, USA
| | - Wouter Kluijfhout
- Department of Surgery, University of Utrecht, Utrecht, The Netherlands
| | - Carolyn D Seib
- Department of Surgery, Stanford University, Stanford, CA, USA. https://twitter.com/daceyseib
| | - Jessica E Gosnell
- Department of Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Wen T Shen
- Department of Surgery, University of California San Francisco, San Francisco, CA, USA. https://twitter.com/wshen16
| | - Sanziana A Roman
- Department of Surgery, University of California San Francisco, San Francisco, CA, USA. https://twitter.com/pheosurgeon
| | - Julie A Sosa
- Department of Surgery, University of California San Francisco, San Francisco, CA, USA. https://twitter.com/jasosamd
| | - Quan-Yang Duh
- Department of Surgery, University of California San Francisco, San Francisco, CA, USA. https://twitter.com/endosurgsf
| | - Insoo Suh
- Department of Surgery, University of California San Francisco, San Francisco, CA, USA; Department of Surgery, NYU Langone Health, New York, NY, USA.
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Kim J, Graves CE, Jin C, Duh QY, Gosnell JE, Shen WT, Suh I, Sosa JA, Roman SA. Intraoperative nerve monitoring is associated with a lower risk of recurrent laryngeal nerve injury: A national analysis of 17,610 patients. Am J Surg 2021; 221:472-477. [DOI: 10.1016/j.amjsurg.2020.10.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 09/21/2020] [Accepted: 10/08/2020] [Indexed: 01/21/2023]
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Sukpanich R, Sanglestsawai S, Seib CD, Gosnell JE, Shen WT, Roman SA, Sosa JA, Duh QY, Suh I. The Influence of Cosmetic Concerns on Patient Preferences for Approaches to Thyroid Lobectomy: A Discrete Choice Experiment. Thyroid 2020; 30:1306-1313. [PMID: 32204688 DOI: 10.1089/thy.2019.0821] [Citation(s) in RCA: 10] [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: 01/05/2023]
Abstract
Background: Newer transoral thyroidectomy techniques that aim to avoid scars in the neck and maximize cosmetic outcomes have become more prevalent. We conducted a discrete choice experiment (DCE) to evaluate the influence of cosmetic concerns and other factors on patients' decision-making processes when choosing among different thyroidectomy approaches. Methods: A questionnaire was developed to identify key attributes driving patient preferences around thyroidectomy approaches using mixed analyses of patient focus groups, expert opinion, and literature review. These attributes included (i) risk of recurrent laryngeal nerve (RLN) injury, (ii) risk of mental nerve injury, (iii) travel distance for surgery, (iv) out-of-pocket cost, and (v) incision site. Using fractional factorial design, discrete choice sets consisting of randomly generated hypothetical scenarios across all attributes were created. A face-to-face DCE survey was administered to patients being evaluated in clinic for thyroid lobectomy for noncancerous thyroid disease. Participants chose among scenarios constructed from the choice sets of attributes. Analyses were conducted using a mixed logit model, and the trade-offs between different attributes that patients were willing to accept were quantified. Results: The DCE was completed by 109 participants (86 [79%] women; mean age 51.3 ± 3.0 years). Overall, the risk of having RLN and/or mental nerve injury, travel distance, and cost were the most influential attributes. Participants aged ≤60 years significantly preferred an approach without a neck incision and were willing to accept an additional $2332 USD in out-of-pocket cost, 693 miles of travel distance, 0.6% increased risk of RLN injury, and 2.2% risk of mental nerve injury. Patients aged >60 years significantly preferred a conventional neck incision and were willing to pay an additional $3401 out-of-pocket and travel 1011 miles to avoid a scarless approach. Conclusions: The risk of nerve injury, travel distance, and cost were the most important drivers for patients choosing among surgical approaches for thyroidectomy. Cosmetic considerations also influenced patient choices, but in opposing ways depending on patient age.
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Affiliation(s)
- Rupporn Sukpanich
- Endocrine Surgery Section, Department of Surgery, University of California, San Francisco, San Francisco, California, USA
- Department of General Surgery, Rajavithi Hospital, Rangsit University, Bangkok, Thailand
| | - Santi Sanglestsawai
- Department of Agricultural and Resource Economics, Kasetsart University, Bangkok, Thailand
| | - Carolyn D Seib
- Department of Surgery, Stanford University, Stanford, California, USA
| | - Jessica E Gosnell
- Endocrine Surgery Section, Department of Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Wen T Shen
- Endocrine Surgery Section, Department of Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Sanziana A Roman
- Endocrine Surgery Section, Department of Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Julie A Sosa
- Endocrine Surgery Section, Department of Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Quan-Yang Duh
- Endocrine Surgery Section, Department of Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Insoo Suh
- Endocrine Surgery Section, Department of Surgery, University of California, San Francisco, San Francisco, California, USA
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Abstract
The vast majority of medullary thyroid carcinomas (MTC) in children are inherited as part of the multiple endocrine neoplasia (MEN) syndromes MEN2A and MEN2B, and the related variant, familial MTC. Prophylactic surgery in infants and children identified through genetic screening leads to the highest survival in these patients. This article summarizes the current recommendations for screening, treatment, and surveillance of children with MTC to provide a concise clinically relevant review for pediatric practitioners.
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Affiliation(s)
- Claire E Graves
- Department of Surgery, Endocrine Surgery Section, University of California, San Francisco
| | - Jessica E Gosnell
- Department of Surgery, Endocrine Surgery Section, University of California, San Francisco.
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Abstract
The incidence of thyroid cancer is on the rise, and this disease is projected to become the fourth leading type of cancer across the globe. From 1990 to 2013, the global age-standardized incidence rate of thyroid cancer increased by 20%. This global rise in incidence has been attributed to several factors, including increased detection of early tumours, the elevated prevalence of modifiable individual risk factors (for example, obesity) and increased exposure to environmental risk factors (for example, iodine levels). In this Review, we explore proven and novel hypotheses for how modifiable risk factors and environmental exposures might be driving the worldwide increase in the incidence of thyroid cancer. Although overscreening and the increased diagnosis of possibly clinically insignificant disease might have a role in certain parts of the world, other areas could be experiencing a true increase in incidence due to elevated exposure risks. In the current era of personalized medicine, national and international registry data should be applied to identify populations who are at increased risk for the development of thyroid cancer.
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Affiliation(s)
- Jina Kim
- University of California San Francisco, San Francisco, CA, USA
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Suh I, Viscardi C, Chen Y, Nwaogu I, Sukpanich R, Gosnell JE, Shen WT, Seib CD, Duh QY. Technical Innovation in Transoral Endoscopic Endocrine Surgery: A Modified “Scarless” Technique. J Surg Res 2019; 243:123-129. [DOI: 10.1016/j.jss.2019.05.019] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Revised: 03/27/2019] [Accepted: 05/08/2019] [Indexed: 10/26/2022]
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Chen Y, Scholten A, Chomsky-Higgins K, Nwaogu I, Gosnell JE, Seib C, Shen WT, Suh I, Duh QY. Risk Factors Associated With Perioperative Complications and Prolonged Length of Stay After Laparoscopic Adrenalectomy. JAMA Surg 2019; 153:1036-1041. [PMID: 30090934 DOI: 10.1001/jamasurg.2018.2648] [Citation(s) in RCA: 59] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Importance Laparoscopic adrenalectomy is the gold standard for most adrenal disorders and its frequency in the United States is increasing. While national and administrative databases can adjust for patient factors, comorbidities, and institutional variations, granular disease-specific data that may significantly influence the incidence of perioperative complications and length of stay (LOS) are lacking. Objective To investigate factors associated with perioperative complications and LOS after laparoscopic adrenalectomy. Design, Setting, and Participants This cohort study was carried out at a single academic medical center, with all patients who underwent laparoscopic adrenalectomy between 1993 and 2017 by the endocrine surgery department. Multivariable linear and logistic regression were used to obtain adjusted odds ratios (ORs). Main Outcomes and Measures The primary outcome was perioperative complications with a Dindo-Clavien grade of 2 or more. The secondary outcome was prolonged length of stay, defined as a stay longer than the 75th percentile of the overall cohort. Results We identified 640 patients who underwent 653 laparoscopic adrenalectomies, of whom 370 (56.7%) were female. The median age was 51 (range, 5-88) years. A total of 76 complications with a Dindo-Clavien grade of 2 or more occurred in 55 patients (8.4%), with postoperative mortality in 2 patients (0.3%). The median hospital length of stay was 1 day (range, 0-32 days). Factors independently associated with increased complications were American Society of Anesthesiologists class 3 or 4 (OR, 2.78 [95% CI, 1.39-5.55]; P < .01), diabetes (OR, 2.39 [95% CI, 1.14-5.01]; P = .02), conversion to hand-assisted or open surgery (OR, 5.32 [95% CI, 1.84-15.41]; P < .01), a diagnosis of pheochromocytoma (OR, 4.31 [95% CI, 1.43-13.05]; P = .01), and a tumor size of 6 cm or greater (OR, 2.47 [95% CI, 1.05-5.78]; P = .04). Prolonged length of stay was associated with age 65 years or older (OR, 2.44 [95% CI, 1.31-4.57]; P = .01), an American Society of Anesthesiologists class 3 or 4 (OR, 3.48 [95% CI, 1.88-6.41]; P < .01), any procedural conversion (OR, 63.28 [95% CI, 12.53-319.59]; P < .01), and a tumor size of 4 cm or larger (4-6 cm: OR, 2.38 [95% CI, 1.21-4.67]; P = .01; ≥6 cm: OR, 2.46 [95% CI, 1.12-5.40]; P = .03). Conclusions and Relevance Laparoscopic adrenalectomy remains safe for most adrenal disorders. Patient comorbidities, adrenal pathology, and tumor size are associated with the risk of complications and length of stay and should all be considered in selecting and preparing patients for surgery.
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Affiliation(s)
- Yufei Chen
- Department of Endocrine Surgery, University of California, San Francisco
| | - Anouk Scholten
- Department of Endocrine Surgery, University of California, San Francisco
| | | | - Iheoma Nwaogu
- Department of Endocrine Surgery, University of California, San Francisco
| | - Jessica E Gosnell
- Department of Endocrine Surgery, University of California, San Francisco
| | - Carolyn Seib
- Department of Endocrine Surgery, University of California, San Francisco
| | - Wen T Shen
- Department of Endocrine Surgery, University of California, San Francisco
| | - Insoo Suh
- Department of Endocrine Surgery, University of California, San Francisco
| | - Quan-Yang Duh
- Department of Endocrine Surgery, University of California, San Francisco
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11
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Seib CD, Rochefort H, Chomsky-Higgins K, Gosnell JE, Suh I, Shen WT, Duh QY, Finlayson E. Association of Patient Frailty With Increased Morbidity After Common Ambulatory General Surgery Operations. JAMA Surg 2019; 153:160-168. [PMID: 29049457 DOI: 10.1001/jamasurg.2017.4007] [Citation(s) in RCA: 124] [Impact Index Per Article: 24.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Importance Frailty is a measure of decreased physiological reserve that is associated with morbidity and mortality in major elective and emergency general surgery operations, independent of chronological age. To date, the association of frailty with outcomes in ambulatory general surgery has not been established. Objective To determine the association between frailty and perioperative morbidity in patients undergoing ambulatory general surgery operations. Design, Setting, and Participants A retrospective cohort study was conducted of 140 828 patients older than 40 years of age from the 2007-2010 American College of Surgeons National Surgical Quality Improvement Program Participant Use File who underwent ambulatory and 23-hour-stay hernia, breast, thyroid, or parathyroid surgery. Data analysis was performed from August 18, 2016, to June 21, 2017. Main Outcomes and Measures The association between the National Surgical Quality Improvement Program modified frailty index and perioperative morbidity was determined via multivariable logistic regression with random-effects modeling to control for clustering within Current Procedural Terminology codes. Results A total of 140 828 patients (80 147 women and 60 681 men; mean [SD] age, 59.3 [12.0] years) underwent ambulatory hernia (n = 71 455), breast (n = 51 267), thyroid, or parathyroid surgery (n = 18 106). Of these patients, 2457 (1.7%) experienced any type of perioperative complication and 971 (0.7%) experienced serious perioperative complications. An increasing modified frailty index was associated with a stepwise increase in the incidence of complications. In multivariable analysis adjusting for age, sex, race/ethnicity, anesthesia type, tobacco use, renal failure, corticosteroid use, and clustering by Current Procedural Terminology codes, an intermediate modified frailty index score (0.18-0.35, corresponding to 2-3 frailty traits) was associated with statistically significant odds ratios of 1.70 (95% CI, 1.54-1.88; P < .001) for any complication and 2.00 (95% CI, 1.72-2.34; P < .001) for serious complications. A high modified frailty index score (≥0.36, corresponding to ≥4 frailty traits) was associated with statistically significant odds ratios of 3.35 (95% CI, 2.52-4.46; P < .001) for any complication and 3.95 (95% CI, 2.65-5.87; P < .001) for serious complications. Anesthesia with local and monitored anesthesia care was the only modifiable covariate associated with decreased odds of serious 30-day complications, with an adjusted odds ratio of 0.66 (95% CI, 0.53-0.81; P < .001). Conclusions and Relevance Frailty is associated with increased perioperative morbidity in common ambulatory general surgery operations, independent of age, type of anesthesia, and other comorbidities. Surgeons should consider frailty rather than chronological age when counseling and selecting patients for elective ambulatory surgery.
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Affiliation(s)
- Carolyn D Seib
- Department of Surgery, University of California, San Francisco
| | - Holly Rochefort
- Department of Surgery, University of California, San Francisco
| | | | | | - Insoo Suh
- Department of Surgery, University of California, San Francisco
| | - Wen T Shen
- Department of Surgery, University of California, San Francisco
| | - Quan-Yang Duh
- Department of Surgery, University of California, San Francisco
| | - Emily Finlayson
- Department of Surgery, University of California, San Francisco
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12
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Chen Y, Nwaogu I, Chomsky-Higgins K, Gosnell JE, Seib C, Shen WT, Duh QY, Suh I. Postoperative Pain and Opioid Use After Thyroid and Parathyroid Surgery-A Pilot, Prospective SMS-Based Survey. J Surg Res 2019; 240:236-240. [PMID: 31004971 DOI: 10.1016/j.jss.2019.03.016] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2018] [Revised: 01/31/2019] [Accepted: 03/18/2019] [Indexed: 11/27/2022]
Abstract
BACKGROUND New persistent opioid use has been identified following minor surgical procedures and may contribute to the national opioid epidemic. Prescription patterns vary and we have limited data on patient pain experiences in the outpatient setting. We devised a novel short messaging service survey to record pain scores and opioid use following outpatient thyroid or parathyroid surgery. MATERIALS AND METHODS Automated short messaging service was sent daily starting the evening of the operation until postoperative day (POD) 10. Pain was assessed on a 0-10 numeric pain rating scale and opioid use over the prior 24 h was queried. RESULTS A total of 1264 survey questions were sent with overall response rate of 84.3%. Fifty-three of 58 patients had a response rate >50% and were included in the final analysis. Average pain score was highest on POD1 at 3.2. Overall, 42.5% of patients utilized opioids on POD0, 55.6% on POD1, and steadily decreased to 7% by POD10. Overall, 34% of patients did not utilize any opioids postoperatively. Scaled total pain scores were higher in patients with thyroid surgery (23.5 versus 12.1, P = 0.02) and lower in those who reported alcohol use (14.9 versus 31.6, P < 0.02). Scaled total opioid days were lower in those aged >60 (1.5 versus 3.6, P < 0.01) and higher in those with active tobacco use (4.5 versus 2.3, P = 0.04). Pain scores correlated weakly with total opioid days (r = 0.32). CONCLUSIONS We demonstrate a novel approach of obtaining patient reported daily, prospective pain scores. This may help us understand patient pain and opioid use in the acute postoperative period especially following outpatient surgery.
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Affiliation(s)
- Yufei Chen
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California.
| | - Iheoma Nwaogu
- University of California San Francisco, Section of Endocrine Surgery, San Francisco, California
| | - Kathryn Chomsky-Higgins
- University of California San Francisco, Section of Endocrine Surgery, San Francisco, California
| | - Jessica E Gosnell
- University of California San Francisco, Section of Endocrine Surgery, San Francisco, California
| | - Carolyn Seib
- University of California San Francisco, Section of Endocrine Surgery, San Francisco, California
| | - Wen T Shen
- University of California San Francisco, Section of Endocrine Surgery, San Francisco, California
| | - Quan-Yang Duh
- University of California San Francisco, Section of Endocrine Surgery, San Francisco, California
| | - Insoo Suh
- University of California San Francisco, Section of Endocrine Surgery, San Francisco, California
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Seib CD, Chomsky-Higgins K, Gosnell JE, Shen WT, Suh I, Duh QY, Finlayson E. Patient Frailty Should Be Used to Individualize Treatment Decisions in Primary Hyperparathyroidism. World J Surg 2018; 42:3215-3222. [PMID: 29696330 DOI: 10.1007/s00268-018-4629-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Primary hyperparathyroidism (PHPT) is a common endocrine disorder that predominantly affects patients >60 and is increasing in prevalence. Identifying risk factors for poor outcomes after parathyroidectomy in older adults will help tailor operative decision making. The impact of frailty on surgical outcomes in parathyroidectomy has not been established. METHODS We performed a retrospective review of patients ≥40 years who underwent parathyroidectomy in the 2005-2010 ACS NSQIP. Frailty was assessed using the modified frailty index (mFI). Multivariable regression was used to determine the association of frailty with 30-day complications, length of stay (LOS), and reoperation. RESULTS We identified 13,123 patients ≥40 who underwent parathyroidectomy for PHPT. The majority of patients were not frail, with 80% with a low NSQIP mFI score (0-1 frailty traits), 19% with an intermediate mFI score (2-3), and 0.9% with a high mFI score (≥4). Overall 30-day complications were rare, occurring in 141 (1.1%) patients. Increasing frailty was associated with an increased risk of complications with adjusted odds ratios (ORs) of 1.76 (95% CI 1.20-2.59; p = 0.004) for intermediate and 8.43 (95% CI 4.33-16.41; p < 0.001) for high mFI score. Patient age was independently associated with an increased risk of complications only when ≥75, as was African-American race. Anesthesia with local, monitored anesthesia care, or regional block was the only factor associated with decreased odds of complications. A high NSQIP mFI was also associated with a significant 4.77-day adjusted increase in LOS (95% CI 4.28-5.25; p < 0.001) and increased odds of reoperation (OR 4.20, 95% CI 1.64-10.74; p = 0.003). CONCLUSION Patient frailty is associated with increased complications, reoperation and prolonged LOS in patients undergoing parathyroidectomy for PHPT. The risks of surgical management should be weighed against potential benefits in frail patients with PHPT to individualize treatment decisions in this vulnerable population.
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Affiliation(s)
- Carolyn D Seib
- Department of Surgery, University of California, San Francisco, 1600 Divisadero Street, 4th Floor, Box 1674, San Francisco, CA, 94143, USA.
| | - Kathryn Chomsky-Higgins
- Department of Surgery, University of California, San Francisco, 1600 Divisadero Street, 4th Floor, Box 1674, San Francisco, CA, 94143, USA
| | - Jessica E Gosnell
- Department of Surgery, University of California, San Francisco, 1600 Divisadero Street, 4th Floor, Box 1674, San Francisco, CA, 94143, USA
| | - Wen T Shen
- Department of Surgery, University of California, San Francisco, 1600 Divisadero Street, 4th Floor, Box 1674, San Francisco, CA, 94143, USA
| | - Insoo Suh
- Department of Surgery, University of California, San Francisco, 1600 Divisadero Street, 4th Floor, Box 1674, San Francisco, CA, 94143, USA
| | - Quan-Yang Duh
- Department of Surgery, University of California, San Francisco, 1600 Divisadero Street, 4th Floor, Box 1674, San Francisco, CA, 94143, USA
| | - Emily Finlayson
- Department of Surgery, University of California, San Francisco, 1600 Divisadero Street, 4th Floor, Box 1674, San Francisco, CA, 94143, USA
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Drake FT, Beninato T, Xiong MX, Shah NV, Kluijfhout WP, Feeney T, Suh I, Gosnell JE, Shen WT, Duh QY. Laparoscopic adrenalectomy for metastatic disease: Retrospective cohort with long-term, comprehensive follow-up. Surgery 2018; 165:958-964. [PMID: 30591377 DOI: 10.1016/j.surg.2018.11.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Revised: 11/08/2018] [Accepted: 11/16/2018] [Indexed: 12/21/2022]
Abstract
BACKGROUND Several malignancies metastasize to the adrenal gland, especially non-small cell lung cancer, renal cell carcinoma, and melanoma. Adrenalectomy is associated with prolonged survival, but laparoscopic adrenalectomy for this indication is controversial. Our objective was to characterize and quantify outcomes after laparoscopic adrenalectomy for metastases to the adrenal gland. METHODS A prospectively maintained surgical database and institutional cancer registry were queried for patients who underwent adrenalectomy for metastases. From 1995 to 2016, a total of 62 patients underwent adrenalectomy for metastases, with 59 (95.%) having been performed laparoscopically. Primary end points were cumulative probability of 5-year survival and median survival. Patients in the institutional series were compared with Surveillance, Epidemiology, and End Results patients with metastatic non-small cell lung cancer, renal cell carcinoma, and melanoma. RESULTS There were no deaths within a 30-day period, 6 complications, and 2 conversions to open adrenalectomy. Non-small cell lung cancer (N = 20), renal cell carcinoma (N = 14), and melanoma (N = 8) were the 3 most common adrenal metastases. Overall, cumulative probability of 5-year survival was 37% and median survival was 34 months (95% CI 26-53 months). Median survival for non-small cell lung cancer was 26 months, for renal cell carcinoma was 67 months, and for melanoma was 30 months (P = NS). There was no demonstrable survival benefit for metachronous versus synchronous presentations, no association with size or disease-free interval, nor the presence/history of other metastases. CONCLUSION Laparoscopic adrenalectomy for metastases is safe when performed by experienced surgeons. Outcomes are similar or improved compared with series with predominantly open adrenalectomies. Patients selected for laparoscopic adrenalectomy to treat metastatic disease also have prolonged survival compared with Surveillance, Epidemiology, and End Results patients with metastatic non-small cell lung cancer, renal cell carcinoma, or melanoma who do not undergo resection of metastatic disease.
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Affiliation(s)
- Frederick Thurston Drake
- Division of Endocrine Surgery, Department of Surgery, University of California, San Francisco, CA; Section of Surgical Oncology, Department of Surgery, Boston University School of Medicine, MA.
| | - Toni Beninato
- Division of Endocrine Surgery, Department of Surgery, University of California, San Francisco, CA; Division of Endocrine Surgery, Department of Surgery, Weill Cornell Medicine, New York, NY
| | - Maggie X Xiong
- Division of Endocrine Surgery, Department of Surgery, University of California, San Francisco, CA
| | - Nirav V Shah
- Division of Endocrine Surgery, Department of Surgery, University of California, San Francisco, CA
| | - Wouter P Kluijfhout
- Division of Endocrine Surgery, Department of Surgery, University of California, San Francisco, CA
| | - Timothy Feeney
- Section of Surgical Oncology, Department of Surgery, Boston University School of Medicine, MA
| | - Insoo Suh
- Division of Endocrine Surgery, Department of Surgery, University of California, San Francisco, CA
| | - Jessica E Gosnell
- Division of Endocrine Surgery, Department of Surgery, University of California, San Francisco, CA
| | - Wen T Shen
- Division of Endocrine Surgery, Department of Surgery, University of California, San Francisco, CA
| | - Quan-Yang Duh
- Division of Endocrine Surgery, Department of Surgery, University of California, San Francisco, CA
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Chen Y, Chomsky-Higgins K, Nwaogu I, Gosnell JE, Seib C, Shen WT, Suh I, Duh QY. Trends in Adrenal Surgery-The Changing Nature of Tumors and Patients. J Surg Res 2018; 236:129-133. [PMID: 30694747 DOI: 10.1016/j.jss.2018.11.031] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Revised: 10/09/2018] [Accepted: 11/19/2018] [Indexed: 11/17/2022]
Abstract
BACKGROUND The volume of adrenal surgery is increasing. There has been a concern that the widespread use of axial imaging and minimally invasive approaches has led to changing indications for adrenalectomy. We reviewed trends in adrenal surgery at a single academic institution. MATERIALS AND METHODS This was a retrospective analysis of all patients who underwent adrenal surgery between 1993 and 2018 by the endocrine surgery service. Patient demographics, diagnosis, operative details, and perioperative complications were evaluated. Trend analysis was performed across ordered year groups (<2000, 2000-2004, 2005-2009, 2010-2014, and 2015-2018). RESULTS We identified 732 patients who underwent 751 adrenal operations. Fifty-seven percent of the patients were women, and the median age was 51 y (range: 5-88). There was an increase in the number of procedures performed (P < 0.01, trend analysis). Over time, there was a higher proportion of patients with hypertension (54.7% [<2000] versus 73.6% [>2015], P < 0.01), diabetes (4.7% versus 22.1%, P = 0.01), and classified as American Society of Anesthesiology class 3/4 (15.7% versus 45.7%, P < 0.01). More patients had their adrenal lesion found incidentally (19.4% versus 39.3%, P < 0.01), and there was a larger proportion of pheochromocytomas (25% versus 36.4%, P < 0.01) and fewer nonfunctioning adenomas (7.4% versus 4.3%, P = 0.03). Median tumor size decreased from 3.5 cm to 2.9 cm (P = 0.03). Complication rates increased over time (8.3% versus 15%, P < 0.01), but the overall 30-d mortality remained low (0.3%). CONCLUSIONS Adrenal surgery is being performed more commonly with an increasing number of incidentalomas and pheochromocytomas. Our patients have higher comorbidities with increase in complication rates over time, although perioperative mortality remains low. This highlights the importance of a thorough preoperative evaluation to identify suitable patients who may benefit from adrenalectomy.
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Affiliation(s)
- Yufei Chen
- University of California San Francisco, Section of Endocrine Surgery, San Francisco, California.
| | - Kathryn Chomsky-Higgins
- University of California San Francisco, Section of Endocrine Surgery, San Francisco, California
| | - Iheoma Nwaogu
- University of California San Francisco, Section of Endocrine Surgery, San Francisco, California
| | - Jessica E Gosnell
- University of California San Francisco, Section of Endocrine Surgery, San Francisco, California
| | - Carolyn Seib
- University of California San Francisco, Section of Endocrine Surgery, San Francisco, California
| | - Wen T Shen
- University of California San Francisco, Section of Endocrine Surgery, San Francisco, California
| | - Insoo Suh
- University of California San Francisco, Section of Endocrine Surgery, San Francisco, California
| | - Quan-Yang Duh
- University of California San Francisco, Section of Endocrine Surgery, San Francisco, California
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Chen Y, Chomsky-Higgins K, Nwaogu I, Seib CD, Gosnell JE, Shen WT, Duh QY, Suh I. Hidden in Plain Sight: Transoral and Submental Thyroidectomy as a Compelling Alternative to “Scarless” Thyroidectomy. J Laparoendosc Adv Surg Tech A 2018; 28:1374-1377. [DOI: 10.1089/lap.2018.0146] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Yufei Chen
- Section of Endocrine Surgery, Department of Surgery, University of California, San Francisco, San Francisco, California
| | - Kathryn Chomsky-Higgins
- Section of Endocrine Surgery, Department of Surgery, University of California, San Francisco, San Francisco, California
| | | | - Carolyn D. Seib
- Section of Endocrine Surgery, Department of Surgery, University of California, San Francisco, San Francisco, California
| | - Jessica E. Gosnell
- Section of Endocrine Surgery, Department of Surgery, University of California, San Francisco, San Francisco, California
| | - Wen T. Shen
- Section of Endocrine Surgery, Department of Surgery, University of California, San Francisco, San Francisco, California
| | - Quan-Yang Duh
- Section of Endocrine Surgery, Department of Surgery, University of California, San Francisco, San Francisco, California
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Nwaogu I, Sedaghati M, Sukpanich R, Chomsky-Higgins KH, Chen Y, Seib CD, Suh I, Shen WT, Gosnell JE, Duh QY. Parathyroid Cryopreservation: Clinical Applications in the Era of Synthetic Parathyroid Hormone. J Am Coll Surg 2018. [DOI: 10.1016/j.jamcollsurg.2018.08.325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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18
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Chen Y, Nwaogu I, Chomsky-Higgins KH, Seib CD, Gosnell JE, Shen WT, Duh QY, Suh I. Postoperative Pain and Opioid Use after Thyroid and Parathyroid Surgery: A Novel, Prospective Short Messaging Service-Based Survey. J Am Coll Surg 2018. [DOI: 10.1016/j.jamcollsurg.2018.08.327] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Chen Y, Chomsky-Higgins KH, Nwaogu I, Seib CD, Gosnell JE, Shen WT, Duh QY, Suh I. Transoral and Submental Thyroidectomy. VideoEndocrinology 2018. [DOI: 10.1089/ve.2018.0127] [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: 11/13/2022] Open
Affiliation(s)
- Yufei Chen
- Section of Endocrine Surgery, Department of Surgery, University of California, San Francisco, California
| | - Kathryn H. Chomsky-Higgins
- Section of Endocrine Surgery, Department of Surgery, University of California, San Francisco, California
| | - Iheoma Nwaogu
- Section of Endocrine Surgery, Department of Surgery, University of California, San Francisco, California
| | - Carolyn D. Seib
- Section of Endocrine Surgery, Department of Surgery, University of California, San Francisco, California
| | - Jessica E. Gosnell
- Section of Endocrine Surgery, Department of Surgery, University of California, San Francisco, California
| | - Wen T. Shen
- Section of Endocrine Surgery, Department of Surgery, University of California, San Francisco, California
| | - Quan-Yang Duh
- Section of Endocrine Surgery, Department of Surgery, University of California, San Francisco, California
| | - Insoo Suh
- Section of Endocrine Surgery, Department of Surgery, University of California, San Francisco, California
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Beninato T, Kluijfhout WP, Drake FT, Khanafshar E, Gosnell JE, Shen WT, Duh QY, Suh I. Squamous differentiation in papillary thyroid carcinoma: a rare feature of aggressive disease. J Surg Res 2018; 223:39-45. [DOI: 10.1016/j.jss.2017.10.023] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Revised: 09/15/2017] [Accepted: 10/12/2017] [Indexed: 10/18/2022]
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Chomsky-Higgins KH, Chen Y, Nwaogu I, Gosnell JE, Seib CD, Shen WT, Suh I, Duh QY. Blue Dye Injection Technique for Resection of Nodal Recurrence in Thyroid Cancer. VideoEndocrinology 2018. [DOI: 10.1089/ve.2018.0120] [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: 11/12/2022] Open
Affiliation(s)
- Kathryn H. Chomsky-Higgins
- Section of Endocrine Surgery, Department of Surgery, University of California, San Francisco, California
- Department of Surgery, University of California, East Bay, Oakland, California
| | - Yufei Chen
- Section of Endocrine Surgery, Department of Surgery, University of California, San Francisco, California
| | - Iheoma Nwaogu
- Section of Endocrine Surgery, Department of Surgery, University of California, San Francisco, California
| | - Jessica E. Gosnell
- Section of Endocrine Surgery, Department of Surgery, University of California, San Francisco, California
| | - Carolyn D. Seib
- Section of Endocrine Surgery, Department of Surgery, University of California, San Francisco, California
| | - Wen T. Shen
- Section of Endocrine Surgery, Department of Surgery, University of California, San Francisco, California
| | - Insoo Suh
- Section of Endocrine Surgery, Department of Surgery, University of California, San Francisco, California
| | - Quan-Yang Duh
- Section of Endocrine Surgery, Department of Surgery, University of California, San Francisco, California
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22
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Asban A, Kluijfhout WP, Drake FT, Beninato T, Wang E, Chomsky-Higgins K, Shen WT, Gosnell JE, Suh I, Duh QY. Trends of genetic screening in patients with pheochromocytoma and paraganglioma: 15-year experience in a high-volume tertiary referral center. J Surg Oncol 2018; 117:1217-1222. [PMID: 29315604 DOI: 10.1002/jso.24961] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2017] [Accepted: 11/25/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND OBJECTIVES Genetic testing for pheochromocytoma and paraganglioma allows for early detection of hereditary syndromes and enables close follow-up of high-risk patient. We investigated the trends in genetic testing among patients at a high-volume referral center and evaluated the prevalence of pheochromocytomas and paragangliomas. METHODS We reviewed the charts of 129 patients who underwent adrenalectomy for pheochromocytoma and paraganglioma between January 2000 and July 2015. To evaluate for trends in genetic testing, patients were divided by year of diagnosis: 2000-2005 (group 1, n = 35), 2006-2010 (group 2, n = 44), and 2011-2015 (group 3, n = 50). RESULTS Among 129 patients the mean age was 47 years and 56% were women. Groups 2 and 3 were more frequently referred for genetic consultation than group 1, 73%, and 94% versus 26% (P < 0.001). A total of 67% followed up on the referral. The prevalence of genetic mutation was 50% (21/42 tested). The percentage with a genetic syndrome was 23%, 28%, and 22% respectively for groups 1, 2, and 3. CONCLUSIONS Referral for genetic counseling significantly increased in the past 15 years. However, only two-thirds of patients followed up with genetic counselors and, therefore, clinicians can do more to improve the adherence rate for genetic counseling.
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Affiliation(s)
- Ammar Asban
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | | | | | - Toni Beninato
- Department of Surgery, New York Presbyterian Hospital - Weill Cornell Medicine, New York, New York
| | - Elizabeth Wang
- Department of Surgery, Endocrine Surgery Section, University California, San Francisco, California
| | - Kate Chomsky-Higgins
- Department of Surgery, Endocrine Surgery Section, University California, San Francisco, California
| | - Wen T Shen
- Department of Surgery, Endocrine Surgery Section, University California, San Francisco, California
| | - Jessica E Gosnell
- Department of Surgery, Endocrine Surgery Section, University California, San Francisco, California
| | - Insoo Suh
- Department of Surgery, Endocrine Surgery Section, University California, San Francisco, California
| | - Quan-Yang Duh
- Department of Surgery, Endocrine Surgery Section, University California, San Francisco, California
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Affiliation(s)
- Jessica E Gosnell
- Section of Endocrine Surgery, Department of Surgery, University of California, San Francisco
| | - Quan-Yang Duh
- Section of Endocrine Surgery, Department of Surgery, University of California, San Francisco
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Affiliation(s)
- Quan-Yang Duh
- Section of Endocrine Surgery, Department of Surgery, University of California, San Francisco, UCSF-Mount Zion, San Francisco
| | - Jessica E Gosnell
- Section of Endocrine Surgery, Department of Surgery, University of California, San Francisco, UCSF-Mount Zion, San Francisco
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25
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Kluijfhout WP, Drake FT, Pasternak JD, Beninato T, Vriens MR, Shen WT, Gosnell JE, Liu C, Suh I, Duh QY. Incidental positive lymph nodes in patients with papillary thyroid cancer is independently associated with recurrent disease. J Surg Oncol 2017; 116:275-280. [PMID: 28570769 DOI: 10.1002/jso.24680] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Accepted: 04/07/2017] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND OBJECTIVES Pathological examination occasionally reveals incidental central lymph nodes metastasis (iLNM) after thyroidectomy for patients with papillary thyroid cancer (PTC) who did not undergo compartment-orientated lymphadenectomy. We aimed to investigate the risk of recurrence for patients with iLNM. METHODS We conducted a retrospective review of all patients undergoing total thyroidectomy for PTC (January 2000 to January 2010). Patients with distant metastases, central- or lateral neck dissection and pre-operative suspicious lymph nodes (by ultrasound or clinical examination) were excluded. The association between iLNM and recurrent disease was investigated using Kaplan-Meier survival estimates and Cox proportional hazards analysis. RESULTS 225/1000 patients had incidental nodes after total thyroidectomy for PTC. 183 were node-negative and 42 had iLNM. Mean age was 46 years and 201 (89%) were women. Mean number of resected nodes was 2.3. Disease recurred in 8/183 (4.4%) of patients with N0 versus 7/42 (17%) with iLNM. After adjusting for other factors, iLNM was independently associated with recurrent disease (hazard ratio = 4.01 [95% CI 1.21-13.3]). CONCLUSIONS Positive incidental lymph nodes are independently associated with recurrent disease in patients with PTC. These patients should therefore be monitored more carefully.
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Affiliation(s)
- Wouter P Kluijfhout
- Department of Surgery, University California San Francisco Medical Center, San Francisco, California.,Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Frederick T Drake
- Department of Surgery, University California San Francisco Medical Center, San Francisco, California
| | - Jesse D Pasternak
- Department of Surgery, University Health Network Toronto, Toronto, Canada
| | - Toni Beninato
- Department of Surgery, University California San Francisco Medical Center, San Francisco, California
| | - Menno R Vriens
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Wen T Shen
- Department of Surgery, University California San Francisco Medical Center, San Francisco, California
| | - Jessica E Gosnell
- Department of Surgery, University California San Francisco Medical Center, San Francisco, California
| | - Chienying Liu
- Division of Endocrinology, University California San Francisco Medical Center, San Francisco, California
| | - Insoo Suh
- Department of Surgery, University California San Francisco Medical Center, San Francisco, California
| | - Quan-Yang Duh
- Department of Surgery, University California San Francisco Medical Center, San Francisco, California
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26
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Kluijfhout WP, Pasternak JD, Gosnell JE, Shen WT, Duh QY, Vriens MR, de Keizer B, Hope TA, Glastonbury CM, Pampaloni MH, Suh I. 18F Fluorocholine PET/MR Imaging in Patients with Primary Hyperparathyroidism and Inconclusive Conventional Imaging: A Prospective Pilot Study. Radiology 2017; 284:460-467. [PMID: 28121522 DOI: 10.1148/radiol.2016160768] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Purpose To investigate the performance of flourine 18 (18F) fluorocholine (FCH) positron emission tomography (PET)/magnetic resonance (MR) imaging in patients with hyperparathyroidism and nonlocalized disease who have negative or inconclusive results at ultrasonography (US) and technetium 99m (99mTc) sestamibi scintigraphy. Materials and Methods This study was approved by the institutional review board. Between May and December 2015, 10 patients (mean age, 70.4 years; range, 58-82 years) with biochemical primary hyperparathyroidism and inconclusive results at US and 99mTc sestamibi scintigraphy were prospectively enrolled. All patients gave informed consent. Directly after administration of 3 MBq/kg of FCH, PET imaging was performed, followed by T1- and T2-weighted MR imaging before and after gadolinium enhancement. Intraoperative localization and histologic results were the reference standard for calculating sensitivity and positive predictive value. The Wilcoxon rank test was used to calculate the mean difference in maximum standardized uptake value (SUVmax) between abnormal parathyroid uptake and physiologic thyroid uptake. The Wilcoxon rank-sum test was performed. Results MR imaging alone showed true-positive lesions in five patients and a false-positive lesion in one patient. FCH PET/MR imaging allowed correct localization of nine of 10 adenomas (90% sensitivity), without any false-positive results (100% positive predictive value). One patient had four-gland hyperplasia, of which three hyperplastic glands were not localized. The median SUVmax of the nine preoperatively identified adenomas was 4.9 (interquartile range, 2.45-7.35), which was significantly higher than the SUV, 2.7 (interquartile range, 1.6-3.8), of the thyroid (P = .008). Conclusion FCH PET/MR imaging allowed localization of adenomas with high accuracy when conventional imaging results were inconclusive and provided detailed anatomic information. More patients must be examined to confirm our initial results, and the accuracy of FCH PET/MR imaging for localization of glands in patients with four-gland hyperplasia remains to be investigated. © RSNA, 2017.
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Affiliation(s)
- Wouter P Kluijfhout
- From the Departments of Surgery (W.P.K., J.E.G., W.T.S., Q.Y.D., I.S.) and Radiology and Nuclear Medicine (T.A.H., C.M.G., M.H.P.), University of California San Francisco, UCSF Mount Zion, 1600 Divisadero St, Hellman Building Room C347, San Francisco, CA 94115; Departments of Surgery (W.P.K., M.R.V.) and Radiology and Nuclear Medicine (B.d.K.), University Medical Center Utrecht, Utrecht, the Netherlands; and Department of Surgery, University Health Network, Toronto, Ont, Canada (J.D.P.)
| | - Jesse D Pasternak
- From the Departments of Surgery (W.P.K., J.E.G., W.T.S., Q.Y.D., I.S.) and Radiology and Nuclear Medicine (T.A.H., C.M.G., M.H.P.), University of California San Francisco, UCSF Mount Zion, 1600 Divisadero St, Hellman Building Room C347, San Francisco, CA 94115; Departments of Surgery (W.P.K., M.R.V.) and Radiology and Nuclear Medicine (B.d.K.), University Medical Center Utrecht, Utrecht, the Netherlands; and Department of Surgery, University Health Network, Toronto, Ont, Canada (J.D.P.)
| | - Jessica E Gosnell
- From the Departments of Surgery (W.P.K., J.E.G., W.T.S., Q.Y.D., I.S.) and Radiology and Nuclear Medicine (T.A.H., C.M.G., M.H.P.), University of California San Francisco, UCSF Mount Zion, 1600 Divisadero St, Hellman Building Room C347, San Francisco, CA 94115; Departments of Surgery (W.P.K., M.R.V.) and Radiology and Nuclear Medicine (B.d.K.), University Medical Center Utrecht, Utrecht, the Netherlands; and Department of Surgery, University Health Network, Toronto, Ont, Canada (J.D.P.)
| | - Wen T Shen
- From the Departments of Surgery (W.P.K., J.E.G., W.T.S., Q.Y.D., I.S.) and Radiology and Nuclear Medicine (T.A.H., C.M.G., M.H.P.), University of California San Francisco, UCSF Mount Zion, 1600 Divisadero St, Hellman Building Room C347, San Francisco, CA 94115; Departments of Surgery (W.P.K., M.R.V.) and Radiology and Nuclear Medicine (B.d.K.), University Medical Center Utrecht, Utrecht, the Netherlands; and Department of Surgery, University Health Network, Toronto, Ont, Canada (J.D.P.)
| | - Quan-Yang Duh
- From the Departments of Surgery (W.P.K., J.E.G., W.T.S., Q.Y.D., I.S.) and Radiology and Nuclear Medicine (T.A.H., C.M.G., M.H.P.), University of California San Francisco, UCSF Mount Zion, 1600 Divisadero St, Hellman Building Room C347, San Francisco, CA 94115; Departments of Surgery (W.P.K., M.R.V.) and Radiology and Nuclear Medicine (B.d.K.), University Medical Center Utrecht, Utrecht, the Netherlands; and Department of Surgery, University Health Network, Toronto, Ont, Canada (J.D.P.)
| | - Menno R Vriens
- From the Departments of Surgery (W.P.K., J.E.G., W.T.S., Q.Y.D., I.S.) and Radiology and Nuclear Medicine (T.A.H., C.M.G., M.H.P.), University of California San Francisco, UCSF Mount Zion, 1600 Divisadero St, Hellman Building Room C347, San Francisco, CA 94115; Departments of Surgery (W.P.K., M.R.V.) and Radiology and Nuclear Medicine (B.d.K.), University Medical Center Utrecht, Utrecht, the Netherlands; and Department of Surgery, University Health Network, Toronto, Ont, Canada (J.D.P.)
| | - Bart de Keizer
- From the Departments of Surgery (W.P.K., J.E.G., W.T.S., Q.Y.D., I.S.) and Radiology and Nuclear Medicine (T.A.H., C.M.G., M.H.P.), University of California San Francisco, UCSF Mount Zion, 1600 Divisadero St, Hellman Building Room C347, San Francisco, CA 94115; Departments of Surgery (W.P.K., M.R.V.) and Radiology and Nuclear Medicine (B.d.K.), University Medical Center Utrecht, Utrecht, the Netherlands; and Department of Surgery, University Health Network, Toronto, Ont, Canada (J.D.P.)
| | - Thomas A Hope
- From the Departments of Surgery (W.P.K., J.E.G., W.T.S., Q.Y.D., I.S.) and Radiology and Nuclear Medicine (T.A.H., C.M.G., M.H.P.), University of California San Francisco, UCSF Mount Zion, 1600 Divisadero St, Hellman Building Room C347, San Francisco, CA 94115; Departments of Surgery (W.P.K., M.R.V.) and Radiology and Nuclear Medicine (B.d.K.), University Medical Center Utrecht, Utrecht, the Netherlands; and Department of Surgery, University Health Network, Toronto, Ont, Canada (J.D.P.)
| | - Christine M Glastonbury
- From the Departments of Surgery (W.P.K., J.E.G., W.T.S., Q.Y.D., I.S.) and Radiology and Nuclear Medicine (T.A.H., C.M.G., M.H.P.), University of California San Francisco, UCSF Mount Zion, 1600 Divisadero St, Hellman Building Room C347, San Francisco, CA 94115; Departments of Surgery (W.P.K., M.R.V.) and Radiology and Nuclear Medicine (B.d.K.), University Medical Center Utrecht, Utrecht, the Netherlands; and Department of Surgery, University Health Network, Toronto, Ont, Canada (J.D.P.)
| | - Miguel H Pampaloni
- From the Departments of Surgery (W.P.K., J.E.G., W.T.S., Q.Y.D., I.S.) and Radiology and Nuclear Medicine (T.A.H., C.M.G., M.H.P.), University of California San Francisco, UCSF Mount Zion, 1600 Divisadero St, Hellman Building Room C347, San Francisco, CA 94115; Departments of Surgery (W.P.K., M.R.V.) and Radiology and Nuclear Medicine (B.d.K.), University Medical Center Utrecht, Utrecht, the Netherlands; and Department of Surgery, University Health Network, Toronto, Ont, Canada (J.D.P.)
| | - Insoo Suh
- From the Departments of Surgery (W.P.K., J.E.G., W.T.S., Q.Y.D., I.S.) and Radiology and Nuclear Medicine (T.A.H., C.M.G., M.H.P.), University of California San Francisco, UCSF Mount Zion, 1600 Divisadero St, Hellman Building Room C347, San Francisco, CA 94115; Departments of Surgery (W.P.K., M.R.V.) and Radiology and Nuclear Medicine (B.d.K.), University Medical Center Utrecht, Utrecht, the Netherlands; and Department of Surgery, University Health Network, Toronto, Ont, Canada (J.D.P.)
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Kluijfhout WP, Pasternak JD, Beninato T, Drake FT, Gosnell JE, Shen WT, Duh QY, Allen IE, Vriens MR, de Keizer B, Hope TA, Suh I. Diagnostic performance of computed tomography for parathyroid adenoma localization; a systematic review and meta-analysis. Eur J Radiol 2017; 88:117-128. [PMID: 28189196 DOI: 10.1016/j.ejrad.2017.01.004] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Revised: 11/02/2016] [Accepted: 01/03/2017] [Indexed: 01/02/2023]
Abstract
PURPOSE To perform a systematic review and meta-analysis of the sensitivity and positive predictive value (PPV) of CT for preoperative parathyroid localization in patients with primary hyperparathyroidism (pHPT), and subsequently compare the different protocols and their performance in different patient groups. MATERIALS AND METHODS We performed a search of the Embase, Pubmed and Cochrane Library databases to identify studies published between January 1, 2000 and March 31, 2016 investigating the diagnostic value of CT for parathyroid localization in patients with biochemical diagnosis of pHPT. Performance of CT was expressed in sensitivity and PPV with pooled proportion using a random-effects model. Factors that could have affected the diagnostic performance were investigated by subgroup analysis. RESULTS Thirty-four studies evaluating a total of 2563 patients with non-familial pHPT who underwent CT localization and surgical resection were included. Overall pooled sensitivity of CT for localization of the pathological parathyroid(s) to the correct quadrant was 73% (95% CI: 69-78%), which increased to 81% (95% CI: 75-87%) for lateralization to the correct side. Subgroup analysis based on the number of contrast phases showed that adding a second contrast phase raises sensitivity from 71% (95% CI: 61-80%) to 76% (95% CI: 71-87%), and that adding a third phase resulted in a more modest additional increase in performance with a sensitivity of 80% (95% CI: 74-86%). CONCLUSION CT performs well in localizing pathological glands in patients with pHPT. A protocol with two contrast phases seems to offer a good balance of acceptable performance with limitation of radiation exposure.
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Affiliation(s)
- Wouter P Kluijfhout
- Department of Surgery, University of California San Francisco, United States; Department of Surgery, University Medical Center Utrecht, The Netherlands.
| | | | - Toni Beninato
- Department of Surgery, University of California San Francisco, United States
| | | | - Jessica E Gosnell
- Department of Surgery, University of California San Francisco, United States
| | - Wen T Shen
- Department of Surgery, University of California San Francisco, United States
| | - Quan-Yang Duh
- Department of Surgery, University of California San Francisco, United States
| | - Isabel E Allen
- Department of Epidemiology and Biostatistics, University of California San Francisco, USA
| | - Menno R Vriens
- Department of Surgery, University Medical Center Utrecht, The Netherlands
| | - Bart de Keizer
- Department of Radiology, University Medical Center Utrecht, The Netherlands
| | - Thomas A Hope
- Department of Radiology, University of California San Francisco, USA
| | - Insoo Suh
- Department of Surgery, University of California San Francisco, United States
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Kluijfhout WP, Drake FT, Pasternak JD, Beninato T, Mitmaker EJ, Gosnell JE, Shen WT, Suh I, Freise CE, Duh QY. De novo thyroid cancer following solid organ transplantation-A 25-year experience at a high-volume institution with a review of the literature. J Surg Oncol 2017; 115:105-108. [DOI: 10.1002/jso.24495] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Accepted: 07/19/2016] [Indexed: 12/25/2022]
Affiliation(s)
- Wouter P. Kluijfhout
- Section of Endocrine Surgery; University California San Francisco; San Francisco California
- Department of Surgery; University Medical Center Utrecht; Utrecht The Netherlands
| | - Frederick T. Drake
- Section of Endocrine Surgery; University California San Francisco; San Francisco California
| | - Jesse D. Pasternak
- Division of General Surgery; University Health Network Toronto; Toronto Canada
| | - Toni Beninato
- Section of Endocrine Surgery; University California San Francisco; San Francisco California
| | | | - Jessica E. Gosnell
- Section of Endocrine Surgery; University California San Francisco; San Francisco California
| | - Wen T. Shen
- Section of Endocrine Surgery; University California San Francisco; San Francisco California
| | - Insoo Suh
- Section of Endocrine Surgery; University California San Francisco; San Francisco California
| | - Chris E. Freise
- Division of Transplant Surgery; University California San Francisco; San Francisco California
| | - Quan-Yang Duh
- Section of Endocrine Surgery; University California San Francisco; San Francisco California
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Venkatesh S, Pasternak JD, Beninato T, Drake FT, Kluijfhout WP, Liu C, Gosnell JE, Shen WT, Clark OH, Duh QY, Suh I. Cost-effectiveness of active surveillance versus hemithyroidectomy for micropapillary thyroid cancer. Surgery 2017; 161:116-126. [DOI: 10.1016/j.surg.2016.06.076] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2016] [Revised: 05/01/2016] [Accepted: 06/16/2016] [Indexed: 11/25/2022]
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Beninato T, Kluijfhout WP, Drake FT, Lim J, Kwon JS, Xiong M, Shen WT, Gosnell JE, Liu C, Suh I, Duh QY. Resection of Pheochromocytoma Improves Diabetes Mellitus in the Majority of Patients. Ann Surg Oncol 2016; 24:1208-1213. [PMID: 27896511 DOI: 10.1245/s10434-016-5701-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2016] [Indexed: 11/18/2022]
Abstract
BACKGROUND Catecholamine excess in patients with pheochromocytoma often results in impaired glucose tolerance, leading to diabetes mellitus. Little data are available on the long-term effect of surgery on diabetes. OBJECTIVE The primary aim of this study was to determine the likelihood of diabetes cure after surgery, while secondary objectives were to determine risk factors for development of diabetes preoperatively and persistence of diabetes postoperatively. METHODS All patients undergoing surgery for pheochromocytoma from 1996 to 2015 were retrospectively reviewed to identify those with a preoperative diagnosis of diabetes. Demographic and diabetes-specific data were collected. Median follow-up was 52.1 months. RESULTS Overall, 153 patients underwent surgery. Diabetes was seen in 36 (23.4%) patients. Eight patients met the exclusion criteria and were removed from the final analysis, while 22 (78.6%) patients had complete resolution of diabetes. Four patients remained on medication with improved control. Overall, 93.0% of patients had improvement of their diabetes; two patients did not improve. Patients with large, symptomatic tumors were more likely to develop preoperative diabetes, and diabetes was more likely to persist in patients who had an elevated body mass index (BMI). CONCLUSIONS Diabetes was found concurrently with pheochromocytoma in 23% of patients, more often in those with large, symptomatic tumors. The majority of patients had long-term resolution of diabetes after successful resection; however, some patients may continue to require treatment of diabetes after operation, especially those with a higher BMI.
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Affiliation(s)
- Toni Beninato
- Department of Surgery, University of California, San Francisco, CA, USA.,Department of Surgery, New York Presbyterian Hospital-Weill Cornell Medicine, New York, NY, USA
| | - Wouter P Kluijfhout
- Department of Surgery, University of California, San Francisco, CA, USA.,Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Frederick Thurston Drake
- Department of Surgery, University of California, San Francisco, CA, USA.,Department of Surgery, Boston University School of Medicine, Boston, MA, USA
| | - James Lim
- Department of Surgery, University of California, San Francisco, CA, USA
| | - Julie S Kwon
- Department of Surgery, University of California, San Francisco, CA, USA
| | - Maggie Xiong
- Department of Surgery, University of California, San Francisco, CA, USA
| | - Wen T Shen
- Department of Surgery, University of California, San Francisco, CA, USA
| | - Jessica E Gosnell
- Department of Surgery, University of California, San Francisco, CA, USA
| | - Chienying Liu
- Department of Medicine, Division of EndocrinologyUniversity of California, San Francisco, CA, USA
| | - Insoo Suh
- Department of Surgery, University of California, San Francisco, CA, USA
| | - Quan-Yang Duh
- Department of Surgery, University of California, San Francisco, CA, USA.
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Drake FT, Beninato TM, Xiong MX, Shah N, Kluijfhout WP, Suh I, Gosnell JE, Shen WT, Duh QY. Laparoscopic Adrenalectomy for Metastatic Disease: Prospective Case Series from a High- Volume Center. J Am Coll Surg 2016. [DOI: 10.1016/j.jamcollsurg.2016.08.244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Beninato TM, Kluijfhout WP, Drake FT, Khanafshar E, Gosnell JE, Shen WT, Duh QY, Suh I. Squamous Differentiation in Papillary Thyroid Carcinoma: a Rare Feature of Aggressive Disease. J Am Coll Surg 2016. [DOI: 10.1016/j.jamcollsurg.2016.08.250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Abstract
Bacterial endotoxin (LPS) elicits dramatic responses in the host including elevated plasma lipid levels due to the increased synthesis and secretion of triglyceride (TG)-rich lipoproteins by the liver, and the inhibition of lipoprotein lipase. This cytokine-induced hyperlipoproteinemia, clinically termed the `lipemia of sepsis', was customarily thought to represent the mobilization of lipid stores to fuel the host response to infection. However, since lipoproteins can also bind and neutralize LPS, we hypothesize that TG-rich lipoproteins (VLDL and chylomicrons) are also components of an innate, non-adaptive host immune response to infection. Herein we review data demonstrating the capacity of lipoproteins to bind LPS, protect against LPS-induced toxicity, and modulate the overall host response to this bacterial toxin. Lastly, we propose a pathway whereby lipoprotein-bound LPS may represent a novel, endogenous mechanism for regulating the hepatic acute phase response.
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Affiliation(s)
- Hobart W. Harris
- UCSF Surgical Research Laboratory at San Francisco General Hospital, San Francisco, California, USA,
| | - Jessica E. Gosnell
- UCSF Surgical Research Laboratory at San Francisco General Hospital, San Francisco, California, USA, Department of Surgery, University of California, Davis-East Bay, Oakland, California, USA
| | - Zindaba L. Kumwenda
- UCSF Surgical Research Laboratory at San Francisco General Hospital, San Francisco, California, USA
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Applewhite MK, White MG, Xiong M, Pasternak JD, Abdulrasool L, Ogawa L, Suh I, Gosnell JE, Kaplan EL, Duh QY, Angelos P, Shen WT, Grogan RH. Incidence, Risk Factors, and Clinical Outcomes of Incidental Parathyroidectomy During Thyroid Surgery. Ann Surg Oncol 2016; 23:4310-4315. [DOI: 10.1245/s10434-016-5439-1] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Indexed: 11/18/2022]
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Livhits MJ, Pasternak JD, Xiong M, Li N, Gosnell JE, Yeh MW, Chiu HK. PRE-ABLATION THYROGLOBULIN AND THYROGLOBULIN TO THYROID-STIMULATING HORMONE RATIO MAY BE ASSOCIATED WITH PULMONARY METASTASES IN CHILDREN WITH DIFFERENTIATED THYROID CANCER. Endocr Pract 2016; 22:1259-1266. [PMID: 27482611 DOI: 10.4158/ep161360.or] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
OBJECTIVE Pediatric differentiated thyroid cancer (DTC) frequently presents with extensive disease. We studied the value of pre-ablation thyroglobulin (Tg) and Tg normalized to thyroid-stimulating hormone (TSH) levels in predicting distant metastases in pediatric patients with DTC. METHODS This is a retrospective cohort study of patients <21 years old who underwent thyroidectomy followed by 131I ablation for DTC at 3 university hospitals over 20 years. Tg levels and the Tg/TSH ratio following surgery but prior to 131I ablation were assessed. The presence of distant metastatic disease was determined from the postablation whole-body scan. RESULTS We studied 44 patients with a mean age of 15.2 years (range 7 to 21 years) and mean tumor size of 2.8 cm. Eight patients had distant metastases and had a higher mean pre-ablation Tg value compared to patients without distant metastases (1,037 μg/L versus 93.5 μg/L, P<.01). The pre-ablation Tg/TSH ratio was also associated with the presence of distant metastases: 12.5 ± 18.8 μg/mU in patients with distant metastases versus 0.7 ± 1.8 μg/mU in patients without (P<.01). A nomogram to predict distant metastases yielded areas under the receiver operating characteristic curve of 0.85 for Tg and 0.83 for Tg/TSH ratio. CONCLUSION After initial thyroidectomy, elevated preablation Tg and Tg/TSH ratio are associated with distant metastatic disease in pediatric DTC. This may inform the decision to ablate with 131I, as well as the dosage. ABBREVIATIONS ATA = American Thyroid Association CI = confidence interval DTC = differentiated thyroid cancer OR = odds ratio ROC = receiver operating characteristic Tg = thyroglobulin.
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Cox C, Chen Y, Cress R, Semrad AM, Semrad T, Gosnell JE, Campbell MJ. Are there disparities in the presentation, treatment and outcomes of patients diagnosed with medullary thyroid cancer?-An analysis of 634 patients from the California Cancer Registry. Gland Surg 2016; 5:398-404. [PMID: 27563561 PMCID: PMC4971346 DOI: 10.21037/gs.2016.04.02] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2016] [Accepted: 03/22/2016] [Indexed: 02/04/2023]
Abstract
BACKGROUND Race, gender and socioeconomic disparities have been suggested to adversely influence stage at presentation, treatment options and outcomes in patients with cancer. Underserved minorities and those with a low socioeconomic status (SES) present with more advanced disease and have worse outcomes for differentiated thyroid cancer, but this relationship has never been evaluated for medullary thyroid cancer (MTC). METHODS We used the California Cancer Registry (CCR) to evaluate disparities in the presentation, treatment and outcomes of patients diagnosed with MTC. RESULTS We identified 634 patients with MTC diagnosed between 1988 and 2011. Almost everyone (85%) underwent thyroidectomy with 50% having a central lymph node dissection (CLND). There were no statistically significant differences by age, race or SES in mean tumor size or the proportion of patients diagnosed with localized disease, but men were diagnosed with larger tumors than women and were less likely to be diagnosed at a localized stage. Younger patients and women were more likely to be treated with a thyroidectomy. There were no statistically significant differences in surgical treatment by race or SES. Patients in the highest SES category had a better overall survival, but not disease specific survival, than those in the lowest SES (HR =0.3, CI =0.1-0.7). Patients treated with thyroidectomy had a better overall and cause specific survival, but the effect of CLND was not statistically significant after adjustment for other factors. CONCLUSIONS In MTC, we did not find that race, gender or SES influenced the presentation, treatment or outcomes of patients with MTC. Men with MTC present with larger tumors and are less likely to have localized disease. Half of the MTC patients in California do not undergo a CLND at the time of thyroidectomy, which may suggest a lack appropriate care across a range of healthcare systems.
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Affiliation(s)
- Christine Cox
- Department of Internal Medicine, Division of Endocrinology, University of California, Davis, USA
| | - Yingjia Chen
- Department of Public Health Sciences, Division of Epidemiology, University of California, Davis, USA
| | - Rosemary Cress
- Department of Public Health Sciences, Division of Epidemiology, University of California, Davis, USA
| | - Alison M. Semrad
- Department of Internal Medicine, Division of Endocrinology, University of California, Davis, USA
| | - Thomas Semrad
- Department of Internal Medicine, Division of Hematology and Oncology, University of California, Davis, USA
| | - Jessica E. Gosnell
- Department of Surgery, Section of Endocrine Surgery, University of California, San Francisco, USA
| | - Michael J. Campbell
- Department of Surgery, Section of Endocrine Surgery, University of California, Davis, USA
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Kluijfhout WP, Pasternak JD, Lim J, Kwon JS, Vriens MR, Clark OH, Shen WT, Gosnell JE, Suh I, Duh QY. Frequency of High-Risk Characteristics Requiring Total Thyroidectomy for 1-4 cm Well-Differentiated Thyroid Cancer. Thyroid 2016; 26:820-4. [PMID: 27083216 DOI: 10.1089/thy.2015.0495] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [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 The extent of thyroidectomy for low-risk well-differentiated thyroid cancer (WDTC) remains controversial. Historically, total thyroidectomy (TT) has been recommended for WDTC ≥1 cm in size. However, recent National Comprehensive Cancer Network and American Thyroid Association guidelines recognize unilateral thyroid lobectomy as a viable alternative for 1-4 cm cancers due to their otherwise favorable prognosis, with TT remaining the preferred option for tumors with unfavorable pathological characteristics. This study sought to determine how often a completion TT would be recommended based on these guidelines if lobectomy was initially performed in patients with 1-4 cm WDTC without preoperatively known risk factors. METHODS Patients who underwent thyroidectomy for 1-4 cm WDTC (January 2000 to January 2010) were retrospectively reviewed. Patients with preoperatively known high-risk characteristics, including gross extrathyroidal extension (ETE) on preoperative imaging, clinically apparent lymph node metastases, distant metastases, history of radiation, and positive family history, were excluded. The pathology specimens from the cancer-containing lobe were evaluated for features that would lead to a recommendation for TT based on current guidelines, including aggressive histology, vascular invasion, microscopic ETE, positive margins, and any positive lymph nodes within the specimen. RESULTS Of 1000 consecutive patients operated for WDTC, 287 would have been eligible for lobectomy as the initial operation. The mean age in this cohort was 45 years, and 80% were women. Aggressive tall-cell variant histology was found in one patient (0.5%), angio-invasion in 34 (12%), ETE in 48 (17%), positive margins in 51 (18%), and positive lymph nodes in 49 (18%) patients. Completion TT would have been recommended in 122/287 (43%) patients. Even in those with 1-2 cm cancers, completion TT would have been recommended in 52/143 (36%) patients. CONCLUSIONS Nearly half of the patients with 1-4 cm WDTC who are eligible for lobectomy under current guidelines would require completion TT based on pathological characteristics of the initial lobe. Surgeons, endocrinologists, and patients need to balance the relative benefits, risks, and costs of initial TT versus the possible need for reoperative completion TT.
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Affiliation(s)
- Wouter P Kluijfhout
- 1 Department of Surgery, Endocrine Surgery Section, University of California , San Francisco, California
- 2 Department of Oncological and Endocrine Surgery, University Medical Center Utrecht , The Netherlands
| | | | - James Lim
- 1 Department of Surgery, Endocrine Surgery Section, University of California , San Francisco, California
| | - Julie S Kwon
- 1 Department of Surgery, Endocrine Surgery Section, University of California , San Francisco, California
| | - Menno R Vriens
- 2 Department of Oncological and Endocrine Surgery, University Medical Center Utrecht , The Netherlands
| | - Orlo H Clark
- 1 Department of Surgery, Endocrine Surgery Section, University of California , San Francisco, California
| | - Wen T Shen
- 1 Department of Surgery, Endocrine Surgery Section, University of California , San Francisco, California
| | - Jessica E Gosnell
- 1 Department of Surgery, Endocrine Surgery Section, University of California , San Francisco, California
| | - Insoo Suh
- 1 Department of Surgery, Endocrine Surgery Section, University of California , San Francisco, California
| | - Quan-Yang Duh
- 1 Department of Surgery, Endocrine Surgery Section, University of California , San Francisco, California
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Pasternak JD, Seib CD, Seiser N, Tyrell JB, Liu C, Cisco RM, Gosnell JE, Shen WT, Suh I, Duh QY. Differences Between Bilateral Adrenal Incidentalomas and Unilateral Lesions. JAMA Surg 2016. [PMID: 26200882 DOI: 10.1001/jamasurg.2015.1683] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Adrenal incidentalomas are found in 1% to 5% of abdominal cross-sectional imaging studies. Although the workup and management of unilateral lesions are well established, limited information exists for bilateral incidentalomas. OBJECTIVE To compare the natural history of patients having bilateral incidentalomas with those having unilateral incidentalomas. DESIGN, SETTING, AND PARTICIPANTS Retrospective analysis of a prospective database of consecutive patients referred to an academic multidisciplinary adrenal conference. The setting was a tertiary care university hospital among a cohort of 500 patients with adrenal lesions between July 1, 2009, and July 1, 2014. MAIN OUTCOMES AND MEASURES Prevalence, age, imaging characteristics, biochemical workup, any intervention, and final diagnosis. RESULTS Twenty-three patients with bilateral incidentalomas and 112 patients with unilateral incidentalomas were identified. The mean age at diagnosis of bilateral lesions was 58.7 years. The mean lesion size was 2.4 cm on the right side and 2.8 cm on the left side. Bilateral incidentalomas were associated with a significantly higher prevalence of subclinical Cushing syndrome (21.7% [5 of 23] vs 6.2% [7 of 112]) (P = .009) and a significantly lower prevalence of pheochromocytoma (4.3% [1 of 23] vs 19.6% [22 of 112]) (P = .003) compared with unilateral lesions, while rates of hyperaldosteronism were similar in both groups (4.3% [1 of 23] vs 5.4% [6 of 112]) (P > .99). Only one patient with bilateral incidentalomas underwent unilateral resection. The mean follow-up was 4 years (range, 1.2-13.0 years). There were no occult adrenocortical carcinomas. CONCLUSIONS AND RELEVANCE Bilateral incidentalomas are more likely to be associated with subclinical Cushing syndrome and less likely to be pheochromocytomas. Although patients with bilateral incidentalomas undergo a workup similar to that in patients with unilateral lesions, differences in their natural history warrant a greater index of suspicion for subclinical Cushing syndrome.
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Affiliation(s)
- Jesse D Pasternak
- Section of Endocrine Surgery, Department of Surgery, University of California, San Francisco
| | - Carolyn D Seib
- Section of Endocrine Surgery, Department of Surgery, University of California, San Francisco
| | - Natalie Seiser
- Section of Endocrine Surgery, Department of Surgery, University of California, San Francisco
| | - J Blake Tyrell
- Division of Endocrinology, Department of Medicine, University of California, San Francisco
| | - Chienying Liu
- Division of Endocrinology, Department of Medicine, University of California, San Francisco
| | - Robin M Cisco
- Department of Surgery, Good Samaritan Hospital, San Jose, California
| | - Jessica E Gosnell
- Section of Endocrine Surgery, Department of Surgery, University of California, San Francisco
| | - Wen T Shen
- Section of Endocrine Surgery, Department of Surgery, University of California, San Francisco
| | - Insoo Suh
- Section of Endocrine Surgery, Department of Surgery, University of California, San Francisco
| | - Quan-Yang Duh
- Section of Endocrine Surgery, Department of Surgery, University of California, San Francisco
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Pasternak JD, Epelboym I, Seiser N, Wingo M, Herman M, Cowan V, Gosnell JE, Shen WT, Kerlan RK, Lee JA, Duh QY, Suh I. Diagnostic utility of data from adrenal venous sampling for primary aldosteronism despite failed cannulation of the right adrenal vein. Surgery 2016; 159:267-73. [DOI: 10.1016/j.surg.2015.06.048] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2015] [Revised: 06/03/2015] [Accepted: 06/24/2015] [Indexed: 10/23/2022]
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Kluijfhout WP, Pasternak JD, Kwon JS, Lim J, Shen WT, Gosnell JE, Khanafshar E, Duh QY, Suh I. Microscopic Positive Tumor Margin Does Not Increase the Risk of Recurrence in Patients with T1–T2 Well-Differentiated Thyroid Cancer. Ann Surg Oncol 2015; 23:1446-51. [DOI: 10.1245/s10434-015-4998-x] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2015] [Indexed: 11/18/2022]
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Campbell MJ, Seib CD, Candell L, Gosnell JE, Duh QY, Clark OH, Shen WT. The underestimated risk of cancer in patients with multinodular goiters after a benign fine needle aspiration. World J Surg 2015; 39:695-700. [PMID: 25446471 DOI: 10.1007/s00268-014-2854-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
IMPORTANCE Ultrasound-guided fine needle aspiration (FNA) is an excellent tool for evaluating patients with solitary thyroid nodules, with a false-negative malignancy rate of <3%. The utility of FNA in patients with a cervical multinodular goiter (MNG) is unknown, because biopsy and surveillance of thyroids with numerous nodules may be impractical. OBJECTIVE To evaluate the incidence and risk factors for unsuspected thyroid cancer on final pathology in patients with a non-functional, cervical MNG who had a benign preoperative FNA and underwent thyroidectomy. DESIGN, SETTING AND PARTICIPANTS Retrospective review of patients with non-functional, cervical MNG at a high-volume tertiary referral center between 2005 and 2012. MAIN OUTCOME MEASURE(S) Incidence of thyroid cancer on surgical pathology. RESULTS Of the 134 patients included in the study, 31 (23.1%) were found to have thyroid cancer on final pathology. Twenty-one (15.7%) patients had a microscopic papillary cancer (<1 cm) and 10 (7.5%) patients had other forms of thyroid cancer [five follicular, four papillary (>1 cm), and one patient with a papillary and follicular cancer]. On univariate analysis, male gender had a near-significant association with non-micropapillary thyroid cancer (p = 0.06). On multivariate analysis, male gender (OR = 10.2, 95% CI 1.35-76.8) and FNA cytology not reviewed at our institution (OR = 6.0, 95% CI 1.2-30) were independently associated with non-micropapillary thyroid cancer. CONCLUSIONS AND RELEVANCE The incidence of thyroid cancer in patients with MNG and benign FNA is significant. Men and patients in whom the FNA cytology is not reviewed by an experienced cytopathologist may be at an increased risk for an undetected thyroid cancer.
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Affiliation(s)
- Michael J Campbell
- University of California, Davis, 2221 Stockton Bvd, 3rd Floor Cypress Bldg, Sacramento, CA, 95817, USA,
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Campbell MJ, Candell L, Seib CD, Gosnell JE, Duh QY, Clark OH, Shen WT. Unanticipated thyroid cancer in patients with substernal goiters: are we underestimating the risk? Ann Surg Oncol 2014; 22:1214-8. [PMID: 25316492 DOI: 10.1245/s10434-014-4143-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2014] [Indexed: 11/18/2022]
Abstract
BACKGROUND The rate of unexpected thyroid cancers found at the time of thyroidectomy is thought to be similar in patients with cervical and substernal multinodular goiters (MNGs). METHODS The objective of this study was to compare the prevalence of undiagnosed cancer found in patients undergoing a thyroidectomy for a cervical or substernal MNG. We conducted a review of patients with a preoperative diagnosis of an MNG (both cervical and substernal) at a tertiary referral center between 2005 and 2012. RESULTS We identified 538 patients who underwent thyroidectomy for an MNG (144 with substernal MNGs and 394 with cervical MNGs). Patients with substernal MNGs were older (59.6 vs. 52.3; p < 0.001), more likely to be men (34 vs. 11.1 %; p < 0.001), and less likely to have a history of radiation exposure to the neck (2.1 vs. 12.4 %; p < 0.001). Thyroid cancer (>1 cm) was found in 13.7 % of substernal MNG specimens and in 6.3 % of cervical MNG specimens (p = 0.003). On multivariate analysis, substernal location [odds ratio (OR) = 2.360; confidence interval (CI), 1.201-4.638] was the only variable independently associated with an unexpected thyroid cancer on surgical pathology. CONCLUSION The rate of postoperatively discovered thyroid cancer is significant in patients with substernal MNGs and is increased when compared to patients with cervical MNGs. Surgeons should counsel their patients regarding the possibility of this unexpected result.
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Candell L, Campbell MJ, Shen WT, Gosnell JE, Clark OH, Duh QY. Ultrasound-guided methylene blue dye injection for parathyroid localization in the reoperative neck. World J Surg 2014; 38:88-91. [PMID: 24132819 DOI: 10.1007/s00268-013-2234-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The goal of this study was to review a single institution's experience using intraoperative ultrasound-guided (ioUSG) methylene blue dye injection for the localization and removal of enlarged parathyroid glands in patients with primary hyperparathyroidism and a history of previous neck surgery. METHODS We performed a retrospective review of nine consecutive patients who underwent reoperative parathyroidectomy using ioUSG methylene blue dye injection. RESULTS All patients had successful resolution of their hyperparathyroidism, with at least a 50 % decrease in intraoperative parathyroid hormone level after resection. One patient had transient recurrent laryngeal nerve paresis. There were no permanent recurrent laryngeal nerve injuries or cases of permanent hypoparathyroidism. CONCLUSIONS Blue dye injection is a safe and effective method of localizing diseased parathyroid glands in the reoperative neck.
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Affiliation(s)
- Leah Candell
- General Surgery, University of California, San Francisco-East Bay, Oakland, CA, USA
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Seib CD, Harari A, Conte FA, Duh QY, Clark OH, Gosnell JE. Utility of serum thyroglobulin measurements after prophylactic thyroidectomy in patients with hereditary medullary thyroid cancer. Surgery 2014; 156:394-8. [PMID: 24882762 DOI: 10.1016/j.surg.2014.03.037] [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] [Received: 01/04/2014] [Accepted: 03/19/2014] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Prophylactic thyroidectomy can be curative for patients with hereditary medullary thyroid cancer (MTC) caused by RET proto-oncogene mutations. Calcitonin is a sensitive tumor marker used to follow patients. We suggest that thyroglobulin (Tg) levels should also be monitored postoperatively in these patients. METHODS We reviewed patients with RET mutations who underwent prophylactic thyroidectomy between 1981 and 2011 at an academic endocrine surgery center. Patients were excluded if they had no postoperative Tg levels recorded. RESULTS Of the 22 patients who underwent prophylactic thyroidectomy, 14 were included in the final analysis. The average age at thyroidectomy was 9.8 years (range, 4-29). Tg levels were detectable 1.5 months to 31 years postoperatively in 11 patients (79%), all of whom were <15 years old at thyroidectomy. Median thyroid-stimulating hormone (TSH) was 2.5 mIU/L and 13.4 mIU/L in patients with undetectable and detectable Tg, respectively. Of those with detectable Tg, 5 had cervical ultrasonographic examination: Two showed no residual tissue in the thyroid bed, and 3 showed remnant thyroid tissue. CONCLUSION Tg levels can identify patients with remnant thyroid tissue after prophylactic thyroidectomy. Ultrasonography can determine whether thyroid tissue remains posterolaterally that is at risk of MTC recurrence. Maintaining normal TSH may prevent growth of remaining thyroid follicular cells.
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Affiliation(s)
- Carolyn D Seib
- Department of Surgery, University of California, San Francisco, San Francisco, CA.
| | - Avital Harari
- Department of Surgery, University of California, Los Angeles, Los Angeles, CA
| | - Felix A Conte
- Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Quan-Yang Duh
- Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Orlo H Clark
- Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Jessica E Gosnell
- Department of Surgery, University of California, San Francisco, San Francisco, CA
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Seib CD, Greenblatt DY, Campbell MJ, Shen WT, Gosnell JE, Clark OH, Duh QY. Adrenalectomy outcomes are superior with the participation of residents and fellows. J Am Coll Surg 2014; 219:53-60. [PMID: 24702888 DOI: 10.1016/j.jamcollsurg.2014.02.020] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2013] [Revised: 02/10/2014] [Accepted: 02/19/2014] [Indexed: 12/21/2022]
Abstract
BACKGROUND Adrenalectomy is a complex procedure performed in many settings, with and without residents and fellows. Patients often ask, "Will trainees be participating in my operation?" and seek reassurance that their care will not be adversely affected. The purpose of this study was to determine the association between trainee participation and adrenalectomy perioperative outcomes. STUDY DESIGN We performed a cohort study of patients who underwent adrenalectomy from the 2005 to 2011 American College of Surgeons NSQIP database. Trainee participation was classified as none, resident, or fellow, based on postgraduate year of the assisting surgeon. Associations between trainee participation and outcomes were determined via multivariate linear and logistic regression. RESULTS Of 3,694 adrenalectomies, 732 (19.8%) were performed by an attending surgeon with no trainee, 2,315 (62.7%) involved a resident, and 647 (17.5%) involved a fellow. The participation of fellows was associated with fewer serious complications (7.9% with no trainee, 6.0% with residents, and 2.8% with fellows; p < 0.001). In a multivariate model, the odds of serious 30-day morbidity were lower when attending surgeons operated with residents (odds ratio = 0.63; 95% CI, 0.45-0.89). Fellow participation was associated with significantly lower odds of overall (odds ratio = 0.51; 95% CI, 0.32-0.82) and serious (odds ratio = 0.31; 95% CI, 0.17-0.57) morbidity. There was no significant association between trainee participation and 30-day mortality. CONCLUSIONS In this analysis of multi-institutional data, the participation of residents and fellows was associated with decreased odds of perioperative adrenalectomy complications. Attending surgeons performing adrenalectomies with trainee assistance should reassure patients of the equivalent or superior care they are receiving.
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Affiliation(s)
- Carolyn D Seib
- Department of Surgery, University of California, San Francisco, San Francisco, CA.
| | | | | | - Wen T Shen
- Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Jessica E Gosnell
- Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Orlo H Clark
- Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Quan-Yang Duh
- Department of Surgery, University of California, San Francisco, San Francisco, CA
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Cisco RM, Kuo JH, Ogawa L, Scholten A, Tsinberg M, Duh QY, Clark OH, Gosnell JE, Shen WT. Impact of race on intraoperative parathyroid hormone kinetics: an analysis of 910 patients undergoing parathyroidectomy for primary hyperparathyroidism. ACTA ACUST UNITED AC 2013; 147:1036-40. [PMID: 22801754 DOI: 10.1001/archsurg.2012.1476] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
HYPOTHESIS African American patients exhibit different intraoperative parathyroid hormone (IOPTH) profiles than non-African American patients. DESIGN Retrospective review. SETTING University medical center. PATIENTS Nine hundred ten patients who underwent parathyroidectomy for primary hyperparathyroidism between July 2005 and August 2010. INTERVENTIONS All patients underwent preoperative imaging with ultrasonography and sestamibi; operative exploration; and IOPTH measurement at 2 points preexcision and 5 and 10 minutes postexcision. MAIN OUTCOME MEASURES Preexcision and postexcision IOPTH measurements. RESULTS Of the 910 patients, 734 self-reported their race as white (81%); 91, Latino/other (10%); 56, Asian (6%); and 28, African American (3%). African American patients had significantly higher initial preexcision IOPTH levels compared with white patients (348 vs 202 pg/mL; P = .048) and significantly higher 5-minute postexcision IOPTH levels (151 vs 80 pg/mL; P = .01). The 10-minute postexcision IOPTH levels were similar between the 2 groups (52 vs 50 pg/mL). A similar percentage of white and African American patients had a 50% drop in IOPTH level at 10 minutes postexcision. No differences in IOPTH kinetics were observed in the other racial groups examined. CONCLUSIONS African American patients with primary hyperparathyroidism exhibit significantly higher preincision and 5-minute postexcision IOPTH values when compared with white patients. The 10-minute postexcision IOPTH values did not differ between races. The altered IOPTH kinetics identified in African American patients may reflect the severity of biochemical disease but may also be related to genetically predetermined differences in parathyroid hormone metabolism.
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Tsinberg M, Duh QY, Cisco RM, Gosnell JE, Scholten A, Clark OH, Shen WT. Practice patterns and job satisfaction in fellowship-trained endocrine surgeons. Surgery 2012; 152:953-6. [DOI: 10.1016/j.surg.2012.08.032] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2012] [Accepted: 08/20/2012] [Indexed: 10/27/2022]
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Grogan RH, Mitmaker EJ, Hwang J, Gosnell JE, Duh QY, Clark OH, Shen WT. A population-based prospective cohort study of complications after thyroidectomy in the elderly. J Clin Endocrinol Metab 2012; 97:1645-53. [PMID: 22419716 DOI: 10.1210/jc.2011-1162] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [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: 02/11/2023]
Abstract
CONTEXT Data on the risk of postthyroidectomy complications in elderly patients are sparse, unclear, and conflicting. OBJECTIVE We sought to use a population-based cohort to determine whether thyroid operations in the elderly are as safe as those done in younger patients. DESIGN This was a prospective cohort study using the American College of Surgeons National Surgical Quality Improvement Program database from 2005 to 2008, with 30-d postoperative follow-up. SETTING The American College of Surgeons National Surgical Quality Improvement Program data set contains operative cases from a nationwide sampling of academic and community-based as well as high-volume and low-volume hospitals. PATIENTS All thyroidectomy and parathyroidectomy patients reported to the database during the study period were included in the analysis resulting in an experimental cohort of 7915 thyroidectomy cases and a control cohort of 3575 parathyroidectomy cases. MAIN OUTCOME MEASURES We aggregated 83 complications into the following outcome measures: urinary tract infection, wound infection, systemic infection, cardiac complications, pulmonary complications, 30-d mortality, and total hospital length of stay. RESULTS Increased age is a risk factor for significant pulmonary, cardiac, and infectious complications after thyroidectomy. Elderly patients are twice as likely (odds ratio 2.1, 95% confidence interval 1.4-3.3), and the superelderly are 5 times as likely (odds ratio 4.9, 95% confidence interval 2.5-9.6) to have a complication compared with their young counterparts. Preexisting comorbidities are effect modifiers and increase the risk of complications even further. CONCLUSIONS Elderly thyroidectomy patients are at increased risk for major systemic complications. A systematic approach to the care of elderly thyroidectomy patients is necessary to minimize their risk of serious postoperative complications.
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Affiliation(s)
- Raymon H Grogan
- Endocrine Surgery Research Program, Department of Surgery, Section of Endocrine Surgery, University of Chicago Medical Center, Chicago, Illinois 60637, USA.
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Grogan RH, Mitmaker E, Vriens MR, Harari A, Gosnell JE, Shen WT, Clark OH, Duh QY. Adrenal incidentaloma: does an adequate workup rule out surprises? Surgery 2010; 148:392-7. [PMID: 20576282 DOI: 10.1016/j.surg.2010.05.001] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2010] [Accepted: 05/14/2010] [Indexed: 11/29/2022]
Abstract
BACKGROUND Adrenal incidentaloma remains a diagnostic challenge. Despite well-established management guidelines, the long-term results of following these guidelines are unknown. We sought to determine how accurately these guidelines identify functioning incidentalomas and how often these guidelines result in adrenalectomy for benign tumors. METHODS We catalogued adrenal incidentalomas from a retrospective review of 500 consecutive adrenalectomies at a single institution. The outcome measures studied were patient demographics, preoperative biochemical analysis, imaging characteristics, tumor size, type of operation performed, and postoperative histologic diagnosis. RESULTS Eighty-one of the 500 adrenalectomies performed were for incidentalomas. Size was the only significant characteristic that distinguished cortical cancers from benign adenomas. Only 1 out of 26 functioning tumors was incorrectly identified on preoperative workup. We also found that 25% of cortisol-secreting incidentalomas were cystic, and that benign adenomas accounted for 42% of all tumors resected. CONCLUSION Current guidelines accurately predict the functional status of adrenal incidentalomas. Some cystic lesions may be functioning and should therefore be screened for hormonal hypersecretion. However, even with the most up-to-date diagnostic tools available, most adrenal incidentalomas resected are benign tumors.
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Affiliation(s)
- Raymon H Grogan
- Department of Endocrine Surgery, University of California San Francisco, San Francisco, CA 94143, USA
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Wells SA, Gosnell JE, Gagel RF, Moley J, Pfister D, Sosa JA, Skinner M, Krebs A, Vasselli J, Schlumberger M. Vandetanib for the treatment of patients with locally advanced or metastatic hereditary medullary thyroid cancer. J Clin Oncol 2010; 28:767-72. [PMID: 20065189 DOI: 10.1200/jco.2009.23.6604] [Citation(s) in RCA: 352] [Impact Index Per Article: 25.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
PURPOSE There is no effective therapy for patients with distant metastasis of medullary thyroid carcinoma (MTC). Activating mutations in the RET proto-oncogene cause hereditary MTC, which provides a strong therapeutic rationale for targeting RET kinase activity. This open-label, phase II study assessed the efficacy of vandetanib, a selective oral inhibitor of RET, vascular endothelial growth factor receptor, and epidermal growth factor receptor signaling, in patients with advanced hereditary MTC. METHODS Patients with unresectable locally advanced or metastatic hereditary MTC received initial treatment with once-daily oral vandetanib 300 mg. The dose was adjusted additionally in some patients on the basis of observed toxicity until disease progression or any other withdrawal criterion was met. The primary assessment was objective tumor response (by RECIST [Response Evaluation Criteria in Solid Tumors]). Results Thirty patients received initial treatment with vandetanib 300 mg/d. On the basis of investigator assessments, 20% of patients (ie, six of 30 patients) experienced a confirmed partial response (median duration of response at data cutoff, 10.2 months). An additional 53% of patients (ie, 16 of 30 patients) experienced stable disease at >/= 24 weeks, which yielded a disease control rate of 73% (ie, 22 of 30 patients). In 24 patients, serum calcitonin levels showed a 50% or greater decrease from baseline that was maintained for at least 4 weeks; 16 patients showed a similar reduction in serum carcinoembryonic antigen levels. The most common adverse events were diarrhea (70%), rash (67%), fatigue (63%), and nausea (63%). CONCLUSION In this study, vandetanib demonstrated durable objective partial responses and disease control with a manageable adverse event profile. These results demonstrate that vandetanib may provide an effective therapeutic option in patients with advanced hereditary MTC, a rare disease for which there has been no effective therapy.
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Affiliation(s)
- Samuel A Wells
- Dept of Surgery, Washington University School of Medicine, Box 8109, 660 S Euclid Ave, St Louis, MO 63110, USA.
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