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Bojoga A, Balasubramanian SP, Mihai R. Surgery for phaeochromocytomas and paragangliomas: Current practice in the United Kingdom. Ann R Coll Surg Engl 2024. [PMID: 38362758 DOI: 10.1308/rcsann.2023.0054] [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] [Indexed: 02/17/2024] Open
Abstract
INTRODUCTION There is wide variability in the perioperative management of phaeochromocytoma and paraganglioma (PPGL) in different centres. This study aimed to summarise the management of PPGLs as reported in the United Kingdom Registry for Endocrine and Thyroid Surgery (UKRETS) database and to determine current perioperative management of PPGLs by surveying UK clinicians. METHODS Data recorded on UKRETS from 2005 to 2021 were subjected to descriptive analyses. British Association of Endocrine and Thyroid Surgeons members were invited to participate in an open survey relating to the perioperative management of patients with PPGLs. RESULTS A total of 2,007 operations for PPGL from 49 participating centres were included. The median annual workload in each centre was four cases. Operations were performed predominantly laparoscopically (69%). The median length of stay (4 days) was the same in groups of surgeons stratified by volume. The survey had 29 respondents from 22 centres across the UK, and a formal protocol for perioperative management exists in 48% of the centres. Phenoxybenzamine (72%) was preferred for alpha-blockade. The practice of admitting patients for optimisation from 1 to 7 days before the day of surgery was common (62%). Central venous pressure and blood glucose monitoring were mentioned as routine intraoperative adjuncts by 72% of the responders. CONCLUSIONS There is significant variation in the workload and perioperative management of PPGLs in the UK. This is potentially detrimental to patient outcomes and a consensus document might be beneficial to harmonise practice across the UK.
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Affiliation(s)
- A Bojoga
- University of Medicine and Pharmacy Carol Davila, Bucharest, Romania
| | - S P Balasubramanian
- Sheffield Teaching Hospitals NHS Foundation Trust, UK
- University of Sheffield, UK
| | - R Mihai
- Oxford University Hospitals NHS Foundation Trust, UK
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Rajan S, Patel N, Stechman M, Balasubramanian SP, Mihai R, Aspinall S. Impact of adrenal surgeon volume on outcome: analysis of 4464 operations from the United Kingdom Registry of Endocrine and Thyroid Surgery (UKRETS). Br J Surg 2024; 111:znae002. [PMID: 38306505 DOI: 10.1093/bjs/znae002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 11/01/2023] [Accepted: 12/27/2023] [Indexed: 02/04/2024]
Abstract
BACKGROUND There is a surgeon volume-outcome effect in adrenal surgery but the threshold for high-volume surgeon remains controversial. This study aimed to determine predictors of high-risk adrenal operations and to explore whether these should be restricted to high-volume surgeons. METHODS Patients undergoing adrenal surgery and registered in the United Kingdom Registry of Endocrine and Thyroid Surgery between 2004 and 2021 were analysed. Outcomes included postoperative complications, duration of hospital stay, and mortality. Factors included in multivariable analysis were age, sex, diagnosis, surgical approach, laterality, and surgeon volume. Patients with missing data were excluded. RESULTS A total of 4464 of 6174 patients (72.3%) were analysed. Postoperative complications occurred in 418 patients (9.4%) and 14 (0.3%) died. Median duration of hospital stay was 3 (i.q.r. 2-5) days. Co-variables significantly associated with an increase or decrease in postoperative complications (P < 0.050) were age (OR 1.02, 95% c.i. 1.01 to 1.03), adrenal cancer (OR 1.64, 1.14 to 2.36), minimally invasive approach (OR 0.317, 0.248 to 0.405), bilateral surgery (OR 1.66, 1.03 to 2.69), and surgeon volume (OR 0.98, 0.96 to 0.99). An increase or decrease in mortality was associated with patient age (OR 1.08, 1.03 to 1.13), minimally invasive approach (OR 0.08, 0.02 to 0.27), and bilateral surgery (OR 6.93, 1.40 to 34.34). The incidence of postoperative complications was significantly lower above a threshold of 12 operations per year (P = 0.034) and 20 per year (P < 0.001), but not six per year (P = 0.540). Median duration of hospital stay was 2 days for surgeons doing over 20 operations per year, compared with 3 days for those undertaking fewer than 20, fewer than 12 or fewer than 6 operations per year. CONCLUSION Increasing surgical volume is associated with shorter hospital stay and fewer complications. This analysis supports the case for centralization of surgery for adrenal cancer and bilateral tumours to higher-volume surgeons performing a minimum of 12 operations per year.
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Affiliation(s)
- Sendhil Rajan
- Breast and Endocrine Surgery, Norfolk and Norwich University Hospital, Norwich, UK
| | - Neil Patel
- Endocrine Surgery, University Hospital of Wales, Cardiff, UK
| | | | | | - Radu Mihai
- Endocrine Surgery, Churchill Cancer Centre, Oxford, UK
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Mihai R. Stage, Grade, Resection status, Age, Symptoms (S-GRAS) score in predicting survival after resection of adrenocortical carcinomas. BJS Open 2024; 8:zrae001. [PMID: 38323882 PMCID: PMC10848302 DOI: 10.1093/bjsopen/zrae001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 05/19/2023] [Accepted: 06/28/2023] [Indexed: 02/08/2024] Open
Affiliation(s)
- Radu Mihai
- Department of Endocrine Surgery, Churchill Cancer Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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Mihai R, De Crea C, Guerin C, Torresan F, Agcaoglu O, Simescu R, Walz MK. Surgery for advanced adrenal malignant disease: recommendations based on European Society of Endocrine Surgeons consensus meeting. Br J Surg 2024; 111:znad266. [PMID: 38265812 PMCID: PMC10805373 DOI: 10.1093/bjs/znad266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 08/02/2023] [Indexed: 01/25/2024]
Affiliation(s)
- Radu Mihai
- Churchill Cancer Centre, Oxford University Hospital NHS Foundation Trust, Oxford, UK
| | - Carmela De Crea
- Centro di Ricerca in Chirurgia delle Ghiandole Endocrine e dell’Obesità, Università Cattolica del Sacro Cuore, Rome, Italy
- Endocrine Surgery Unit, Hospital Fatebenefratelli Isola Tiberina—Gemelli Isola, Rome, Italy
| | - Carole Guerin
- Department of Endocrine and Metabolic Surgery, Aix-Marseille University, Hôpital de La Conception, Marseille, France
| | - Francesca Torresan
- Endocrine Surgery Unit, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Orhan Agcaoglu
- Department of General Surgery, Koc University School of Medicine, Istanbul, Turkey
| | - Razvan Simescu
- Department of General and Endocrine Surgery, Medlife-Humanitas Hospital, Cluj-Napoca, Romania
| | - Martin K Walz
- Department of Surgery and Minimally Invasive Surgery, Kliniken Essen-Mitte, Essen, Germany
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Tirotta F, Hodson J, Alcorn D, Al-Mukhtar A, Ayre G, Barlow A, Chong P, Cosker T, Dileo P, Figueiredo R, French J, Gulamhusein A, Jones R, Hayes A, Key C, Malik H, Mahrous A, Mihai R, Nixon I, Partington K, Quinn M, Roberts J, Sayyed R, Shankar A, Strauss D, Turner P, Desai A. Assessment of inter-centre agreement across multidisciplinary team meetings for patients with retroperitoneal sarcoma. Br J Surg 2023; 110:1189-1196. [PMID: 37317571 DOI: 10.1093/bjs/znad157] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 05/03/2023] [Accepted: 05/05/2023] [Indexed: 06/16/2023]
Abstract
BACKGROUND Decision-making in the management of patients with retroperitoneal sarcoma is complex and requires input from a number of different specialists. The aim of this study was to evaluate the levels of agreement in terms of resectability, treatment allocation, and organs proposed to be resected across different retroperitoneal sarcoma multidisciplinary team meetings. METHODS The CT scans and clinical information of 21 anonymized retroperitoneal sarcoma patients were sent to all of the retroperitoneal sarcoma multidisciplinary team meetings in Great Britain, which were asked to give an opinion about resectability, treatment allocation, and organs proposed to be resected. The main outcome was inter-centre reliability, which was quantified using overall agreement, as well as the chance-corrected Krippendorff's alpha statistic. Based on the latter, the level of agreement was classified as: 'slight' (0.00-0.20), 'fair' (0.21-0.40), 'moderate' (0.41-0.60), 'substantial' (0.61-0.80), or 'near-perfect' (>0.80). RESULTS Twenty-one patients were reviewed at 12 retroperitoneal sarcoma multidisciplinary team meetings, giving a total of 252 assessments for analysis. Consistency between centres was only 'slight' to 'fair', with rates of overall agreement and Krippendorff's alpha statistics of 85.4 per cent (211 of 247) and 0.37 (95 per cent c.i. 0.11 to 0.57) for resectability; 80.4 per cent (201 of 250) and 0.39 (95 per cent c.i. 0.33 to 0.45) for treatment allocation; and 53.0 per cent (131 of 247) and 0.20 (95 per cent c.i. 0.17 to 0.23) for the organs proposed to be resected. Depending on the centre that they had attended, 12 of 21 patients could either have been deemed resectable or unresectable, and 10 of 21 could have received either potentially curative or palliative treatment. CONCLUSIONS Inter-centre agreement between retroperitoneal sarcoma multidisciplinary team meetings was low. Multidisciplinary team meetings may not provide the same standard of care for patients with retroperitoneal sarcoma across Great Britain.
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Affiliation(s)
- Fabio Tirotta
- Department of Sarcoma and General Surgery, Midlands Abdominal and Retroperitoneal Sarcoma Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - James Hodson
- Research Development and Innovation, Institute of Translational Medicine, University Hospital Birmingham NHS Foundation Trust, Birmingham, UK
| | - Des Alcorn
- Department of Radiology, The Beatson West of Scotland Cancer Centre, Glasgow, UK
| | - Ahmed Al-Mukhtar
- Department of Surgery, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Gareth Ayre
- Department of Oncology, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Adam Barlow
- Department of Surgery, The Leeds Teaching Hospital NHS Trust, Leeds, UK
| | - Peter Chong
- Department of Surgery, The Beatson West of Scotland Cancer Center, Glasgow, UK
| | - Thomas Cosker
- Nuffield Department of Surgery, Oxford University Hospital NHS Foundation Trust, Oxford, UK
| | - Palma Dileo
- Department of Oncology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Rodrigo Figueiredo
- Department of Surgery, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle, UK
| | - Jeremy French
- Department of Surgery, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle, UK
| | - Aziz Gulamhusein
- Department of Urology, The CHRISTIE NHS Foundation Trust, Manchester, UK
| | - Robert Jones
- Department of Surgery, Royal Liverpool University Hospital NHS Foundation Trust, Liverpool, UK
| | - Andrew Hayes
- Department of Academic Surgery, Sarcoma Unit, The Royal Marsden Hospital NHS Foundation Trust, London, UK
| | - Catherine Key
- Department of Radiology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Hassan Malik
- Department of Surgery, Royal Liverpool University Hospital NHS Foundation Trust, Liverpool, UK
| | - Ahmed Mahrous
- Department of Urology, North Bristol NHS Trust, Bristol, UK
| | - Radu Mihai
- Nuffield Department of Surgery, Oxford University Hospital NHS Foundation Trust, Oxford, UK
| | - Ioanna Nixon
- Department of Oncology, The Beatson West of Scotland Cancer Center, Glasgow, UK
| | - Karen Partington
- Department of Radiology, Oxford University Hospital NHS Foundation Trust, Oxford, UK
| | - Martha Quinn
- Department of Surgery, The Beatson West of Scotland Cancer Center, Glasgow, UK
| | - James Roberts
- Department of Radiology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Raza Sayyed
- Department of Academic Surgery, Sarcoma Unit, The Royal Marsden Hospital NHS Foundation Trust, London, UK
| | - Arjun Shankar
- Department of Surgery, University College London Hospitals NHS Foundation Trust, London, UK
| | - Dirk Strauss
- Department of Academic Surgery, Sarcoma Unit, The Royal Marsden Hospital NHS Foundation Trust, London, UK
| | - Paul Turner
- Department of Radiology, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle, UK
| | - Anant Desai
- Department of Sarcoma and General Surgery, Midlands Abdominal and Retroperitoneal Sarcoma Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
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Mihai R. Voice and swallowing symptoms after thyroid surgery assessed using the ThyVoice online platform. Eur Thyroid J 2023:ETJ-23-0008. [PMID: 37115021 DOI: 10.1530/etj-23-0008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Accepted: 04/28/2023] [Indexed: 04/29/2023] Open
Abstract
OBJECTIVE The aim of this multicentre study was to investigate the progression of patient-reported outcomes after thyroid surgery, with emphasis on voice and swallowing difficulties. METHODS An online platform was used to collect replies to standardised questionnaires (voice handicap index, VHI; voice related quality of life, VrQoL; EAT-10) preoperatively and at 2-6 weeks and 3-6-12 months after surgery. RESULTS A total of 236 patients were recruited from five centres that contributed with median 11 cases (range 2-186 cases). Average symptoms scores showed voice changes lasting up to 3 months: VHI increased from 4115 (preop) to 4821 (6w) and returned to 4115 at 6 months. Similarly, VrQoL increased from 124 to 156 and returned to 124 (6m). Severe voice changes (VHI>60) were reported in 12% of patients preop, 22% at 2w, 18% at 6w, 13% at 3m and 7% at 12m. Only five patients with normal preoperative voice had persistent severe voice changes after 6-12 months. Those with severe voice changes at 2 w (median VHI 70.5, IQR 65-81) had significant improvement by 6 months (median VHI 54, IQR 39-65) (p<0.001). Swallowing assessment showed a median preop score 0 (IQR 0-3) increasing to median 2 (IQR 0-8) at 2 weeks and normal values afterwards. CONCLUSION The ThyVoice online platform allows assessment of patient-reported outcome measures in thyroid surgery. Voice morbidity appears to be more frequent than commonly reported and this risk should the quoted during informed consent. Swallowing difficulties are mild but significant in the first 2 weeks.
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Affiliation(s)
- Radu Mihai
- R Mihai, Department of Endocrine Surgery, Oxford University Hospitals NHS Foundation Trust, Oxford, OX3 9DU, United Kingdom of Great Britain and Northern Ireland
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Thwin M, Mihai R. Parathyroid Cancer: Updates and Postoperative Surveillance Imaging. Surg Oncol Clin N Am 2023; 32:271-278. [PMID: 36925184 DOI: 10.1016/j.soc.2022.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/16/2023]
Affiliation(s)
- May Thwin
- Endocrine Surgery Unit, Churchill Cancer Centre, Oxford University Hospitals NHS Foundation Trust, Oxford OX3 7LE, United Kingdom
| | - Radu Mihai
- Endocrine Surgery Unit, Churchill Cancer Centre, Oxford University Hospitals NHS Foundation Trust, Oxford OX3 7LE, United Kingdom.
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Abstract
BACKGROUND Fine-needle aspiration cytology (FNAC) is an integral part of thyroid nodule assessment. Nodules with an indeterminate cytology (THY3a-f) require formal histological assessment to confirm benign or malignant pathology. This study aimed to provide data for an evidence-based approach for management of patients with THY3f nodules. METHODS Retrospective review of patients who had a thyroid FNAC reported as suspicious of follicular neoplasm (THY3f) or showing atypia (THY3a) were identified, and clinical, operative and outcomes data were analysed. RESULTS Between 2018 and 2020, 200 patients (167F:33M, median age 51 years (range:18-86 years)) had a THY3f cytology. Most presented with a palpable nodule (n=104; 68.4%). Overall, 152 (76.0%;130F:23M) underwent surgery and 31 (20.4%) were found to have a thyroid carcinoma (22 follicular carcinomas, 7 papillary carcinomas, 1 medullary thyroid carcinoma and 1 metastatic renal carcinoma). An additional incidental carcinoma (size: 0.7-13mm) was found in seven (4.6%). Among those with cancer, a completion thyroidectomy and radioactive iodine treatment was indicated in nine (<6% of the entire cohort). Previously suggested risk factors for malignancy, eg male gender, large tumour size (>4cm) or age, were not found to be associated with increased risk. During the same period, THY3a cytology was reported in 53 patients, of whom 29 underwent diagnostic surgery and 4 patients were found to have a thyroid cancer (follicular, n=3 and medullary, n=1). CONCLUSION One in five patients with features suspicious of a follicular neoplasm (THY3f) has a thyroid carcinoma. This risk is much lower for THY3a. This study reinforces the current recommendation for thyroid surgery in all patients with a reliable THY3f cytology, as no further stratifying risk factors could be identified.
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Affiliation(s)
- M C de Jong
- Oxford University Hospitals NHS Foundation Trust, UK
| | - J McNamara
- Oxford University Hospitals NHS Foundation Trust, UK
| | - L Winter
- Oxford University Hospitals NHS Foundation Trust, UK
| | - D Roskell
- Oxford University Hospitals NHS Foundation Trust, UK
| | - S Khan
- Oxford University Hospitals NHS Foundation Trust, UK
| | - R Mihai
- Oxford University Hospitals NHS Foundation Trust, UK
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9
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Patel N, Mihai R. Long-term Cure of Primary Hyperparathyroidism After Scan-Directed Parathyroidectomy: Outcomes From A UK Endocrine Surgery Unit. World J Surg 2022; 46:2189-2194. [PMID: 35412058 DOI: 10.1007/s00268-022-06556-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/19/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Two-decades ago, the advent of sestamibi scintigraphy led to an enthusiastic acceptance of minimally invasive parathyroidectomy (MIP) in most surgical centres. More recently, concerns have been raised about the efficacy of limited neck exploration and some surgeons proposed bilateral neck exploration to be (once again) the gold standard operation for primary hyperparathyroidism in 2020s. METHODS A departmental database was used to identify patients who had MIP after concordant dual localisation with sestamibi scintigraphy and ultrasound scans. Long-term follow-up data were obtained from electronic patient records to ascertain any further treatment for recurrent disease and confirm most recent biochemical status. Patients with negative localisation scans and those with familial disease were excluded from analysis. RESULTS Between June 2001 and August 2014 a total of 404 patients (108 M:296F, median age 63 years, range 17-90 years) underwent MIP and had normalisation of calcium in first 6 weeks after the operation. Information on electronic patient records were missing in 14 patients; therefore, data on 390 patients were analysed. During median follow-up of 78 months (IQR: 21.25-111.75 months), 375 patients had normocalcaemia (2.36 mmol/L, IQR: 2.29-2.44 mmol/L) at a median 75 months, (IQR: 20-118 months) after their operation. Overall, 15 (3.85%) patients had biochemical evidence of recurrent disease (2.70 mmol/L IQR: 2.63-2.75 mmol/L) at 92 months (Range: 6-196) after initial operation. Of these, 5 (1.28%) patients underwent a second parathyroid procedure. CONCLUSION Recurrence after scan-directed unilateral neck exploration occurred in 4% of patients after a long disease-free interval. Only one patient had recurrent disease within 1-year of primary surgery. The data suggest that bilateral neck exploration at the time of initial operation, in this selected cohort, is unlikely to have uncovered multi-gland disease and prevent disease recurrence. Focused parathyroidectomy in patients with convincing localisation studies should continue.
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Affiliation(s)
- Neil Patel
- Department of Endocrine Surgery, Churchill Cancer Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, OX3 7LE, UK
| | - Radu Mihai
- Department of Endocrine Surgery, Churchill Cancer Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, OX3 7LE, UK.
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Shariq OA, Lines KE, English KA, Jafar-Mohammadi B, Prentice P, Casey R, Challis BG, Selberherr A, Boon H, Cranston T, Ryan FJ, Mihai R, Healy U, Kurzawinski T, Dattani MT, Bancos I, Dy BM, Lyden ML, Young WF, McKenzie TJ, Richards D, Thakker RV. Corrigendum to ‘Multiple endocrine neoplasia type 1 in children and adolescents: Clinical features and treatment outcomes’ [Surgery 171 (2021) 77–87]. Surgery 2022; 171:1708-1711. [DOI: 10.1016/j.surg.2022.03.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Sia Y, Patel N, De Jong M, Khan S, Mihai R. Unmeasurable stimulated thyroglobulin before radioactive iodine ablation predicts excellent long term outcome in patients with differentiated thyroid cancer. Br J Surg 2022. [DOI: 10.1093/bjs/znac056.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Abstract
Aim
To determine the likelihood of reaching unmeasurable stimulated thyroglobulin (sTG) levels after surgery for differentiated thyroid cancer (DTC).
Methods
Data on consecutive patients treated for DTC in a tertiary referral centre between May 2000 and June 2019 were retrospectively collected. Radioactive iodine ablation (RIA) was done after hormone withdrawal (before 2015) or after Thyrogen stimulation (more recent patients). During the study period, the biochemical assay for TG changed from a lower limit of detectability of 5 ng/dl to 0.2 ng/dl.
Results
A total of 403 patients (F=282; M=121) were included. sTG was <0.2 in 41 patients and during a median follow-up of 32 months, none had disease recurrence. sTG was 0.2–4.99 ng/dl in 104 patients and during a median follow-up of 27 months, 5 patients had evidence of either residual disease or local recurrence. sTG was reported as >5 in 258 patients and during a median follow-up of 63 months, 160 patients were disease free at the time of data collection. Patients who presented with locally advanced disease requiring modified radical neck dissection (n=78) had sTG higher than in those with earlier disease (n=325) (median 11.1 vs. 5.0ng/ml). There was a large difference in cervical uptake after RIA in patients with sTG 0.2–4.99 ng/dl (n=24) compared with those with sTG >20 ng/dl (n=32) (0.7% vs 1.54%).
Conclusion
Almost half of all patients with DTC achieved unmeasurable sTG after surgery. This could be due to earlier disease but can also serve as a quality control after thyroidectomy for thyroid cancer.
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de Jong MC, McNamara J, McGlashan N, Winter L, Mihai R. Risk of malignancy in thyroid nodules selected for fine needle aspiration biopsy based on ultrasound risk stratification. Br J Surg 2022. [DOI: 10.1093/bjs/znac056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Abstract
Aim
Risk stratification of thyroid nodules based on ultrasound scan (USS) features using the TIRADS- or U-scale has been widely adopted. However, management decisions for patients whose work-up provide conflicting information, remains challenging. The aim of this study was to assess the rate of malignancy among those with suspicious cytology after USS-evaluation.
Methods
Retrospective review of clinical, radiological and pathological data regarding patients presenting with a thyroid nodule.
Results
Between January 2018 and December 2020, a total of 214 patients underwent surgery after presenting with thyroid nodule(s) and a fine-needle aspiration (FNA) cytology report either suspicious (Thy3–4) or diagnostic (Thy5) for thyroid malignancy. The appearance on USS was stratified using the TIRADS-scale, either to select nodules needing FNA-assessment or to characterise palpable nodules.
For Thy3a-cytology, the risk of malignancy remained low, irrespective of USS-appearance (2/15 in TIRADS2-3 versus 2/9 in TIRADS 4-5). For a Thy3f-cytology, the risk of malignancy was higher if the USS-appearance was also suspicious (11/75 in TIRADS2-3 versus 17/69 in TIRADS 4-5, p=0.03).
High-risk USS-appearance (TIRADS 4-5) in the presence of suspicious/diagnostic cytology (Thy4-5) had a 95% positive predictive value (40/42) of malignancy. Future data collection should assess the risk of malignancy when USS-appearance is malignant (TIRADS 5) yet cytology is benign (Thy2).
Conclusion
The performance of USS and FNA in this cohort corroborates published data. Until genetic panels will complement the assessment of nodules with a Thy3-cytology, diagnostic thyroid lobectomy remains necessary, as the USS has limited ability to increase the yield of malignant nodules.
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Affiliation(s)
| | - John McNamara
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | | | - Lucinda Winter
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Radu Mihai
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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Pryer O, Mihai R. Scoring system to quantify clinical resolution of Cushing syndrome after adrenal surgery. Br J Surg 2022. [DOI: 10.1093/bjs/znac057.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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
Abstract
Background
Adrenalectomy for Cushing syndrome is a rare operation. There is no disease-specific tool to quantify the severity of symptoms in such patients.
Methods
Retrospective analysis of consecutive unselected patients who underwent adrenal surgery for Cushing syndrome. A standard questionnaire was used to assess symptoms on a visual analogue scale (VAS, <10=very poor, >90=excellent) or as categorical categories for severity of symptoms.
Results
Between Jan2016-Aug2021, 21 patients (10M:11F, median age 56 years) underwent unilateral (n=18) or bilateral (n=3) adrenalectomy for Cushing syndrome caused by adrenal adenoma (n=15), adrenocortical cancer (n=3) or ectopic ACTH secretion (n=3). Patients had a median admission of 3 days (range 1–20 days). Most common perioperative complications were related to thrombotic events. Patients with ectopic-ACTH syndrome due to metastatic neuroendocrine tumours are alive at 11–66 months after their operation. Patients with adrenocortical cancer were not contacted.
Eighteen patients were contacted by post at median 37 months (range 3–66 months) postop. Assessment of general health on VAS improved from median 25 to 72.5 (out of 100), symptoms score decreased from 17.5 to 6 (p<0.05) through improvement in scores for muscle power and physical signs. Length of time need for recovery ranged from a minimum of 3–6 months (n=3) to over 1–2 years (n=4). Three patients had emergency admissions with Addisonian crisis.
Conclusion
These data will inform patients about the expected timeline for symptoms resolution after adrenalectomy for Cushing syndrome. A multicentre prospective cohort study should use this new score system to quantify severity of symptoms associated with hypercortisolism.
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Patel N, Johnson P, Mihai R. Morbidity after thyroid surgery in children: patient perspective. Br J Surg 2022. [DOI: 10.1093/bjs/znac057.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Abstract
Aim
To explore the children’s/parents’ perception of morbidity after thyroid surgery.
Methods
Retrospective analysis of consecutive unselected patients who had undergone a thyroid operation under joint care of Paediatric and Endocrine surgeons. Electronic patients records were used to obtain relevant information and a standardised questionnaire was mailed to all children.
Results
Between Jan2009- Dec2020 62 children age 2–18 (median 15.2) had thyroid lobectomy (n=27) or total thyroidectomy (n=35). In-hospital stay ranged 1–3 days (mode1).
Replies were received from 20 children at a median 37 months (range 5–60 months) after lobectomy (n= 8) or total thyroidectomy (n=12). Subjective voice assessment using a visual analogue scale remained normal in all children. Voice handicap index scores were normal in 13 (65%) children and increased in 7 (35%) to a median of 4 (range 1–10). Voice-related quality of life was excellent in 18 (90%) children and very good in two children. Swallowing was normal in 14 children, moderately affected in four children and severely affected in 2 children. Appearance of the scar assessed using the Manchester score ranged from 5–16, median 9, with only one child with an ideal score of 5. Three children have had or are waiting for scar revision. There was no persistent hypoparathyroidism.
Conclusion
In this cohort of children undergoing thyroid surgery, there were no significant voice changes and swallowing morbidity was infrequent. Concerns related to scar appearance were far more common than in the adult population and this should be highlighted in the consent process.
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15
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Patel N, Mihai R. Long-term cure of primary hyperparathyroidism after scan directed parathyroidectomy. Br J Surg 2022. [DOI: 10.1093/bjs/znac057.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Abstract
Background
The advent of sestamibi scintigraphy led to an enthusiastic acceptance of minimally invasive parathyroidectomy (MIP). Recently, doubts have been raised about the efficacy of limited neck exploration and some surgeons proposed bilateral neck exploration to be (once again) the gold standard operation for primary hyperparathyroidism.
Methods
A departmental database was used to identify patients who had MIP after concordant dual localisation. Long-term follow-up data was obtained to ascertain any further treatment for recurrent disease and confirm most recent biochemical status. Patients with negative localisation scans and those with familial disease were excluded.
Results
Between June 2001 – August 2014 a total of 404 patients (108M:296F, median age 63 years, range 17–90 years) underwent MIP and had normalisation of calcium in first 6 weeks after the operation. Data were missing in 14 patients therefore data on 390 patients was analysed. During follow-up, 375 patients remained normocalcaemic (2.36mmol/L IQR: 2.29–2.44 mmol/L) at a median 75 months (IQR: 20–118months). Only 15 (3.85%) patients had biochemical evidence of recurrent hypercalcaemia (2.70mmol/L, IQR: 2.63–2.75 mmol/L) at 92 months (IQR: 6–196 months) after initial operation. Of these, 5 (1.28%) patients underwent a second parathyroid procedure.
Conclusion
Recurrence after scan-directed unilateral neck exploration occurred in 4% of patients after a long disease-free interval. Only one patient had recurrent disease within 1 year of primary surgery. Bilateral neck exploration at the time of initial operation, in this selected cohort, is unlikely to had uncovered multi-gland disease and prevent disease recurrence. Focused parathyroidectomy in patients with convincing localisation studies should continue.
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16
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Abstract
AIM Adrenocortical cancer (ACC) is an aggressive malignancy and robust prognostic factors remain unclear. The presence of sarcopenia has been shown to negatively impact survival for other malignancies, but has not been extensively analyzed in ACC. METHODS Patients who underwent resection of their ACC between 2010 and 2020 were identified; therapeutic, operative, and outcome data were analyzed. Sarcopenia was assessed by calculation of the skeletal muscle index (SMI) and was defined as an SMI <52.4cm2/m2 for males and <38.5cm2/m2 for females. RESULTS Data on 35 patients (18 F: 17 M; median age 54 [range: 18-86]) who had primary surgical treatment were analyzed. Median tumor size was 10 cm [range:3-15]. In eleven patients (31%), the tumor was hormonally active (cortisol = 8;23%). Seventeen patients (49%) were classified as having sarcopenia on their pre-operative CT scan. The Intraclass Correlation Coefficient (ICC) for intra- and inter-observer variability showed very good agreement (0.99 and 0.98). There was no difference in incidence of sarcopenia stratifying for sex, BMI, or tumor-size, but incidence was higher with increasing age (p < .05). Overall median survival was 36 months, with 1- and 3-year survival rates of 77% and 52%. The presence of sarcopenia was strongly associated with a shorter overall survival (HR = 3.21; [95%CI: 1.06-9.69];p = .03) on unadjusted analyses. Moreover, age, higher T-stage, and presence of capsular invasion were also associated with poorer survival on univariable analyses. CONCLUSION The presence of sarcopenia in patients undergoing surgery for ACC could be a predictor of reduced overall survival, although replications of these analyses should be performed in similar, larger cohorts. Specifically, the influence of a patient's hormonal status on the manifestation of sarcopenia should be further defined.
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Affiliation(s)
- Mechteld C de Jong
- Department of Endocrine Surgery - Churchill Cancer Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Neel Patel
- Department of Radiology - Churchill Cancer Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Zaki Hassan-Smith
- Centre for Endocrinology, Diabetes & Metabolism, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Radu Mihai
- Department of Endocrine Surgery - Churchill Cancer Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Shahab Khan
- Department of Endocrine Surgery - Churchill Cancer Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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17
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Puttergill B, Khan S, Christakis I, Dumbill R, Mclaren A, Sadler G, Mihai R. Thyroid lobectomy for low-risk thyroid cancers. Ann R Coll Surg Engl 2021; 104:113-116. [PMID: 34813398 DOI: 10.1308/rcsann.2021.0058] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND The 2016 American Thyroid Association (ATA) guidelines proposed thyroid lobectomy for low-risk differentiated thyroid cancer (DTC); however, this approach is yet to be widely adopted. The aim of the study was to review our practice over three years following the publication of these guidelines identifying patients who underwent lobectomy-only for low-risk DTC in two regional units in the same multidisciplinary team (MDT). METHOD A retrospective review of patients who were operated between January 2016 and December 2018 was carried out. RESULTS In total, 288 patients undergoing thyroid surgery were included. The preoperative distribution of cytology was: Thy 1 or 2 in 46, THY3a in 57, THY3f in 154, THY4 in 18 and THY5 in 13 patients. Median size of nodules was 26mm (range 1-70mm). DTC was diagnosed in 95 patients (33%). Overall, 39% (n = 37) of patients underwent completion thyroidectomy according to ATA recommendations on size or adverse histological features. The only variable associated with likelihood of completion was tumour size (p < 0.05, OR 1.14). Ten patients were discharged following surgery with no further follow-up as they had T1a/b well-differentiated DTC with no high-risk histological features. CONCLUSION Lobectomy-only appears to be the current surgical practice in two-thirds of patients presenting to our regional units with differentiated thyroid carcinoma. In the context of the current drive to reduce the extent of treatment for low-risk thyroid cancer, there is a need for a more homogeneous approach to these patients and for protocols for long-term follow-up after lobectomy-only.
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Affiliation(s)
| | - S Khan
- Oxford University Hospital NHS Trust, UK
| | | | | | | | - G Sadler
- Oxford University Hospital NHS Trust, UK
| | - R Mihai
- Oxford University Hospital NHS Trust, UK
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18
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Shariq OA, Lines KE, English KA, Jafar-Mohammadi B, Prentice P, Casey R, Challis BG, Selberherr A, Boon H, Cranston T, Ryan FJ, Mihai R, Healy U, Kurzawinski T, Dattani MT, Bancos I, Dy BM, Lyden ML, Young WF, McKenzie TJ, Richards D, Thakker RV. Multiple endocrine neoplasia type 1 in children and adolescents: Clinical features and treatment outcomes. Surgery 2021; 171:77-87. [PMID: 34183184 DOI: 10.1016/j.surg.2021.04.041] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 04/03/2021] [Accepted: 04/20/2021] [Indexed: 12/26/2022]
Abstract
BACKGROUND Clinical manifestations and treatment outcomes in children and adolescents with multiple endocrine neoplasia type 1 are not well characterized. METHODS We conducted a retrospective cohort study of 80 patients with multiple endocrine neoplasia type 1 who commenced tumor surveillance at ≤18 years of age. RESULTS Fifty-six patients (70%) developed an endocrine tumor by age ≤18 years (median age = 14 years, range = 6-18 years). Primary hyperparathyroidism occurred in >80% of patients, with >70% undergoing parathyroidectomy, in which less-than-subtotal (<3-gland) resection resulted in decreased disease-free outcomes versus subtotal (3-3.5-gland) or total (4-gland) parathyroidectomy (median 27 months versus not reached; P = .005). Pancreaticoduodenal neuroendocrine tumors developed in ∼35% of patients, of whom >70% had nonfunctioning tumors, >35% had insulinomas, and <5% had gastrinomas, with ∼15% having metastases and >55% undergoing surgery. Pituitary tumors developed in >30% of patients, and ∼35% were macroprolactinomas. Tumor occurrence in male patients and female patients was not significantly different. Genetic analyses revealed 38 germline MEN1 mutations, of which 3 were novel. CONCLUSION Seventy percent of children aged ≤18 years with multiple endocrine neoplasia type 1 develop endocrine tumors, which include parathyroid tumors for which less-than-subtotal parathyroidectomy should be avoided; pancreaticoduodenal neuroendocrine tumors that may metastasize; and pituitary macroprolactinomas.
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Affiliation(s)
- Omair A Shariq
- Academic Endocrine Unit, Radcliffe Department of Medicine, University of Oxford, Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, United Kingdom; Department of Surgery, Mayo Clinic, Rochester, MN. https://twitter.com/@omairshariq
| | - Kate E Lines
- Academic Endocrine Unit, Radcliffe Department of Medicine, University of Oxford, Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, United Kingdom. https://twitter.com/@klines500
| | - Katherine A English
- Academic Endocrine Unit, Radcliffe Department of Medicine, University of Oxford, Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, United Kingdom. https://twitter.com/@Katie__English
| | - Bahram Jafar-Mohammadi
- Department of Endocrinology Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, United Kingdom
| | - Philippa Prentice
- Department of Paediatric Endocrinology, Great Ormond Street Hospital for Children and UCL Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Ruth Casey
- Department of Endocrinology, Cambridge University Hospital NHS Foundation Trust, United Kingdom
| | - Benjamin G Challis
- Department of Endocrinology, Cambridge University Hospital NHS Foundation Trust, United Kingdom
| | | | - Hannah Boon
- Oxford Medical Genetics Laboratories, Oxford University Hospitals NHS Foundation Trust, Churchill Hospital, United Kingdom
| | - Treena Cranston
- Oxford Medical Genetics Laboratories, Oxford University Hospitals NHS Foundation Trust, Churchill Hospital, United Kingdom
| | - Fiona J Ryan
- Department of Paediatric Endocrinology, Oxford Children's Hospital, University of Oxford, United Kingdom
| | - Radu Mihai
- Department of Endocrine Surgery, University of Oxford, United Kingdom. https://twitter.com/RaduMiSurgeon
| | - Ultan Healy
- Department of Endocrinology Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, United Kingdom
| | - Tom Kurzawinski
- Centre for Endocrine Surgery, Great Ormond Street Hospital for Children, London, United Kingdom
| | - Mehul T Dattani
- Department of Paediatric Endocrinology, Great Ormond Street Hospital for Children and UCL Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Irina Bancos
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN. https://twitter.com/@IrinaBancos
| | - Benzon M Dy
- Department of Surgery, Mayo Clinic, Rochester, MN
| | | | - William F Young
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN
| | | | - Duncan Richards
- Oxford Clinical Trials Research Unit, Botnar Research Centre, United Kingdom
| | - Rajesh V Thakker
- Academic Endocrine Unit, Radcliffe Department of Medicine, University of Oxford, Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, United Kingdom.
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19
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Patel N, Mihai R. Relative hypoxia at high altitudes increases the incidence of phaeochromocytomas. Eur J Endocrinol 2021; 184:L17-L19. [PMID: 33769963 DOI: 10.1530/eje-21-0063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 03/01/2021] [Indexed: 11/08/2022]
Affiliation(s)
- Neil Patel
- Department of Endocrine Surgery, Churchill Cancer Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, Oxfordshire, UK
| | - Radu Mihai
- Department of Endocrine Surgery, Churchill Cancer Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, Oxfordshire, UK
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20
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Mihai R, Thakker RV. MANAGEMENT OF ENDOCRINE DISEASE: Postsurgical hypoparathyroidism: current treatments and future prospects for parathyroid allotransplantation. Eur J Endocrinol 2021; 184:R165-R175. [PMID: 33599211 PMCID: PMC8052514 DOI: 10.1530/eje-20-1367] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Accepted: 02/17/2021] [Indexed: 12/27/2022]
Abstract
BACKGROUND Permanent postsurgical hypoparathyroidism (POSH) is a major complication of anterior neck surgery in general and of thyroid surgery in particular. Depending on diagnostic criteria, up to 10% of patients undergoing bilateral thyroid surgery develop POSH. This leads to a multitude of symptoms that decrease the quality of life and burden the healthcare provision through complex needs for medication and treatment of specific complications, such as seizures and laryngospasm. METHODS Narrative review of current medical treatments for POSH and of the experience accumulated with parathyroid allotransplantation. RESULTS In most patients, POSH is controlled with regular use of calcium supplements and active vitamin D analogues but a significant proportion of patients continue to experience severe symptoms requiring repeated emergency admissions. Replacement therapy with synthetic PTH compounds (PTH1-34, Natpara® and PTH1-84, teriparatide, Forsteo®) has been assessed in multicentre trials, but the use of this medication is restricted by costs and concerns related to the risk of development of osteosarcoma. Based on recent case reports of successful allotransplantation of parathyroid tissue between siblings, there is renewed interest in this technique. Data on selection of donors, parathyroid cell preparation before allotransplantation, site and timing of transplantation, need for immunosuppression and long-term outcomes are reviewed. CONCLUSION A prospective trial to assess the efficacy of parathyroid allotransplantation in patients with severely symptomatic protracted post-surgical hypoparathyroidism is warranted.
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Affiliation(s)
- Radu Mihai
- Department of Endocrine Surgery, Churchill Cancer Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, Oxfordshire, UK
- Correspondence should be addressed to R Mihai;
| | - Rajesh V Thakker
- Academic Endocrine Unit, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
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21
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Agcaoglu O, Sezer A, Makay O, Erdogan MF, Bayram F, Guldiken S, Raffaelli M, Sonmez YA, Lee YS, Vamvakidis K, Mihai R, Duh QY, Akinci B, Alagol F, Almquist M, Barczynski M, Bayraktaroglu T, Berber E, Bukey Y, Cakmak GK, Canturk NZ, Canturk Z, Celik M, Celik O, Ceyhan BO, Cherenko S, Clerici T, Coombes DS, Demircan O, Deyneli O, Dionigi G, Emre AU, Erbil Y, Filiz AI, Gozu HI, Gurdal SO, Gurleyik G, Haciyanli M, Kebudi A, Kim S, Koutelidakis G, Kuru B, Mert M, Oruk GG, Ozbas S, Palazzo F, Pandev R, Riss P, Sabuncu T, Sahin I, Sakman G, Saygili F, Senyurek YG, Sleptsov I, Van Slycke S, Teksoz S, Terzioglu T, Tezelman S, Tunca F, Ugurlu MU, Uludag M, Villar-Del-Moral J, Vriens M, Yazici D. Management of endocrine surgical disorders during COVID-19 pandemic: expert opinion for non-surgical options. Updates Surg 2021; 74:325-335. [PMID: 33840069 PMCID: PMC8036242 DOI: 10.1007/s13304-021-00979-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Accepted: 01/12/2021] [Indexed: 12/03/2022]
Abstract
Purpose The COVID-19 pandemic brought unprecedented conditions for overall health care systems by restricting resources for non-COVID-19 patients. As the burden of the disease escalates, routine elective surgeries are being cancelled. The aim of this paper was to provide a guideline for management of endocrine surgical disorders during a pandemic. Methods We used Delphi method with a nine-scale Likert scale on two rounds of voting involving 64 experienced eminent surgeons and endocrinologists who had the necessary experience to provide insight on endocrine disorder management. All voting was done by email using a standard questionnaire. Results Overall, 37 recommendations were voted on. In two rounds, all recommendations reached an agreement and were either endorsed or rejected. Endorsed statements include dietary change in primary hyperparathyroidism, Cinacalcet treatment in secondary hyperparathyroidism, alpha-blocker administration for pheochromocytoma, methimazole ± β-blocker combination for Graves’ disease, and follow-up for fine-needle aspiration results of thyroid nodules indicated as Bethesda 3–4 cytological results and papillary microcarcinoma. Conclusion This survey summarizes expert opinion for the management of endocrine surgical conditions during unprecedented times when access to surgical treatment is severely disrupted. The statements are not applicable in circumstances in which surgical treatment is possible.
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Affiliation(s)
- Orhan Agcaoglu
- Department of General Surgery, School of Medicine, Koc University, Istanbul, Turkey
| | - Atakan Sezer
- Department of General Surgery, School of Medicine, Trakya University, Balkan Yerleskesi, 22030, Edirne, Turkey.
| | - Ozer Makay
- Department of General Surgery, School of Medicine, Ege University, Bornova, Turkey
| | - Murat Faik Erdogan
- Department of Endocrinology and Metabolism, School of Medicine, Ankara University, Ankara, Turkey
| | - Fahri Bayram
- Department of Endocrinology and Metabolism, School of Medicine, Erciyes University, Kayseri, Turkey
| | - Sibel Guldiken
- Department of Endocrinology and Metabolism, School of Medicine, Trakya University, Edirne, Turkey
| | - Marco Raffaelli
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore, Milan, Italy
| | - Yusuf Alper Sonmez
- Department of Endocrinology and Metabolism, Gulhane School of Medicine, University of Health Sciences, Istanbul, Turkey
| | - Yong-Sang Lee
- Department of General Surgery, Gangnam Severance Thyroid Center, Yonsei University, Seoul, South Korea
| | | | - Radu Mihai
- Department of General Surgery, Churchill Cancer Center, Oxford University, Oxford, UK
| | - Quan-Yang Duh
- Department of General Surgery, University of California, San Francisco, USA
| | - Baris Akinci
- Department of Endocrinology and Metabolism, School of Medicine, Dokuz Eylul University, İzmir, Turkey
| | - Faruk Alagol
- Department of Endocrinology and Metabolism, School of Medicine, Koc University, Istanbul, Turkey
| | - Martin Almquist
- Department of General Surgery, Skåne University Hospital, Malmö, Sweden
| | - Marcin Barczynski
- Department of General Surgery, Jagiellonian University Medical College, Kraków, Poland
| | - Taner Bayraktaroglu
- Department of Endocrinology and Metabolism, School of Medicine, Zonguldak Bulent Ecevit University, Zonguldak, Turkey
| | - Eren Berber
- Division of Endocrine Surgery, Department of General Surgery, Cleveland Clinic Foundation, Cleveland, USA
| | - Yusuf Bukey
- Department of General Surgery, School of Medicine, Cerrahpasa University, Istanbul, Turkey
| | - Guldeniz Karadeniz Cakmak
- Department of General Surgery, School of Medicine, Zonguldak Bulent Ecevit University, Zonguldak, Turkey
| | - Nuh Zafer Canturk
- Department of General Surgery, School of Medicine, Kocaeli University, İzmit, Turkey
| | - Zeynep Canturk
- Department of Endocrinology and Metabolism, School of Medicine, Kocaeli University, İzmit, Turkey
| | - Mehmet Celik
- Department of Endocrinology and Metabolism, School of Medicine, Trakya University, Edirne, Turkey
| | - Ozlem Celik
- Department of Endocrinology and Metabolism, School of Medicine, Acibadem University, Istanbul, Turkey
| | | | - Sergii Cherenko
- Department of General Surgery, International Medical Center, Kyiv, Ukraine
| | - Thomas Clerici
- Department of Endocrinology and Metabolism, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | | | - Orhan Demircan
- Department of General Surgery, School of Medicine, Acibadem University, Istanbul, Turkey
| | - Oguzhan Deyneli
- Department of Endocrinology and Metabolism, School of Medicine, Koc University, Istanbul, Turkey
| | - Gianlorenzo Dionigi
- Department of General Surgery, School of Medicine, Messina University, Messina, Italy
| | - Ali Ugur Emre
- Department of General Surgery, School of Medicine, Zonguldak Bulent Ecevit University, Zonguldak, Turkey
| | | | - Ali Ilker Filiz
- Department of General Surgery, School of Medicine, Okan University, Istanbul, Turkey
| | - Hulya Ilıksu Gozu
- Department of Endocrinology and Metabolism, School of Medicine, Marmara University, Istanbul, Turkey
| | - Sibel Ozkan Gurdal
- Department of General Surgery, Namik Kemal University, Zonguldak, Turkey
| | - Gunay Gurleyik
- Department of General Surgery, Haydarpasa Numune Training and Research Hospital, Istanbul, Turkey
| | - Mehmet Haciyanli
- Department of General Surgery, İzmir Ataturk Training and Research Hospital, İzmir, Turkey
| | - Abut Kebudi
- Department of General Surgery, School of Medicine, Okan University, Istanbul, Turkey
| | - Seokmo Kim
- Department of General Surgery, Gangnam Severance Thyroid Center, Yonsei University, Seoul, South Korea
| | - Giannis Koutelidakis
- Department of General Surgery, Aristoteleio University of Thessaloniki, Thessaloniki, Greece
| | - Bekir Kuru
- Department of General Surgery, School of Medicine, Ondokuz Mayis University, Samsun, Turkey
| | - Meral Mert
- Department of Endocrinology and Metabolism, Bakirkoy Sadi Konuk Training and Research Hospital, İstanbul, Turkey
| | - Guzide Gonca Oruk
- Department of Endocrinology and Metabolism, Ataturk Training and Research Hospital, Katip Celebi University, İzmir, Turkey
| | | | - Fausto Palazzo
- Department of Endocrinology and Metabolism, Imperial College, Hammersmith Hospital, London, UK
| | - Rumen Pandev
- Department of General Surgery, School of Medicine, Medical University Sofia, Sofia, Bulgaria
| | - Phillip Riss
- Department of General Surgery, School of Medicine, Medical University of Vienna, Vienna, Austria
| | - Tevfik Sabuncu
- Department of Endocrinology and Metabolism, School of Medicine, Harran University, Şanlıurfa, Turkey
| | - Ibrahim Sahin
- Department of Endocrinology and Metabolism, School of Medicine, Malatya University, Malatya, Turkey
| | - Gurhan Sakman
- Department of General Surgery, School of Medicine, Cukurova University, Adana, Turkey
| | - Fusun Saygili
- Department of Endocrinology and Metabolism, School of Medicine, Ege University, Bornova, Turkey
| | - Yasemin Giles Senyurek
- Department of General Surgery, Istanbul School of Medicine, Istanbul University, Istanbul, Turkey
| | - Ilya Sleptsov
- North-West Center of Endocrinology and Metabolism, St. Petersburg State University, St. Petersburg, Russia
| | - Sam Van Slycke
- Department of General Surgery, Vattikutti Foundation, OLV Hospital, Aalst, Belgium
| | - Serkan Teksoz
- Department of General Surgery, School of Medicine, Cerrahpasa University, Istanbul, Turkey
| | - Tarik Terzioglu
- Department of General Surgery, VKV American Hospital, Istanbul, Turkey
| | - Serdar Tezelman
- Department of General Surgery, School of Medicine, Koc University, Istanbul, Turkey
| | - Fatih Tunca
- Department of General Surgery, Istanbul School of Medicine, Istanbul University, Istanbul, Turkey
| | - Mustafa Umit Ugurlu
- Department of General Surgery, School of Medicine, Marmara University, Istanbul, Turkey
| | - Mehmet Uludag
- Department of General Surgery, Sisli Etfal Training and Research Hospital, Istanbul, Turkey
| | | | - Menno Vriens
- Department of General Surgery, University Medical Center Utrecht, Utrecht, Netherlands
| | - Dilek Yazici
- Department of Endocrinology and Metabolism, School of Medicine, Koc University, Istanbul, Turkey
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22
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Schache A, Kerawala C, Ahmed O, Brennan PA, Cook F, Garrett M, Homer J, Hughes C, Mayland C, Mihai R, Newbold K, O'Hara J, Roe J, Sibtain A, Smith M, Thavaraj S, Weller A, Winter L, Young V, Winter SC. British Association of Head and Neck Oncologists (BAHNO) standards 2020. J Oral Pathol Med 2021; 50:262-273. [PMID: 33655561 DOI: 10.1111/jop.13161] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Andrew Schache
- Liverpool Head & Neck Centre, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | | | - Omar Ahmed
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | | | - Florence Cook
- University College London Hospitals NHS Foundation Trust, London, UK
| | - Matthew Garrett
- University College London Hospitals NHS Foundation Trust, London, UK
| | - Jarrod Homer
- Manchester Academic Health Sciences Centre (MAHSC), University of Manchester, Manchester, UK
| | - Ceri Hughes
- University Hospitals Bristol & Weston NHS Foundation Trust, Bristol, UK
| | - Catriona Mayland
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
| | - Radu Mihai
- Oxford University NHS Foundation Trust, Oxford, UK
| | - Kate Newbold
- The Royal Marsden NHS Foundation Trust, London, UK
| | | | - Justin Roe
- Department of Speech, Voice and Swallowing, The Royal Marsden NHS Foundation Trust, London, UK
| | | | - Maria Smith
- Greater Glasgow & Clyde Health Board, Royal Alexandra Hospital and Queen Elizabeth University Hospital, Glasgow, UK
| | - Selvam Thavaraj
- Guy's & St Thomas' NHS Foundation Trust/King's College London, London, UK
| | - Alex Weller
- London North West University Healthcare NHS Trust, London, UK
| | | | | | - Stuart C Winter
- Oxford University NHS Foundation Trust, Oxford, UK.,Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
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Crona J, Baudin E, Terzolo M, Chrisoulidou A, Angelousi A, Ronchi CL, Oliveira CL, Nieveen van Dijkum EJM, Ceccato F, Borson-Chazot F, Reimondo G, Tiberi GAM, Ettaieb H, Kiriakopoulos A, Canu L, Kastelan D, Osher E, Yiannakopoulou E, Arnaldi G, Assié G, Paiva I, Bourdeau I, Newell-Price J, Nowak KM, Romero MT, De Martino MC, Bugalho MJ, Sherlock M, Vantyghem MC, Dennedy MC, Loli P, Rodien P, Feelders R, de Krijger R, Van Slycke S, Aylwin S, Morelli V, Vroonen L, Shafigullina Z, Bancos I, Trofimiuk-Müldner M, Quinkler M, Luconi M, Kroiss M, Naruse M, Igaz P, Mihai R, Della Casa S, Berruti A, Fassnacht M, Beuschlein F. ENSAT registry-based randomized clinical trials for adrenocortical carcinoma. Eur J Endocrinol 2021; 184:R51-R59. [PMID: 33166271 DOI: 10.1530/eje-20-0800] [Citation(s) in RCA: 6] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 11/05/2020] [Indexed: 11/08/2022]
Abstract
Adrenocortical carcinoma (ACC) is an orphan disease lacking effective systemic treatment options. The low incidence of the disease and high cost of clinical trials are major obstacles in the search for improved treatment strategies. As a novel approach, registry-based clinical trials have been introduced in clinical research, so allowing for significant cost reduction, but without compromising scientific benefit. Herein, we describe how the European Network for the Study of Adrenal Tumours (ENSAT) could transform its current registry into one fit for a clinical trial infrastructure. The rationale to perform randomized registry-based trials in ACC is outlined including an analysis of relevant limitations and challenges. We summarize a survey on this concept among ENSAT members who expressed a strong interest in the concept and rated its scientific potential as high. Legal aspects, including ethical approval of registry-based randomization were identified as potential obstacles. Finally, we describe three potential randomized registry-based clinical trials in an adjuvant setting and for advanced disease with a high potential to be executed within the framework of an advanced ENSAT registry. Thus we, therefore, provide the basis for future registry-based trials for ACC patients. This could ultimately provide proof-of-principle of how to perform more effective randomized trials for an orphan disease.
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Affiliation(s)
- Joakim Crona
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Eric Baudin
- Gustave Roussy, Université Paris-Saclay, Département d'imagerie, Service d'oncologie endocrinienne, Villejuif, France
| | - Massimo Terzolo
- Department of Clinical and Biological Sciences, University of Turin at San Luigi Hospital, Orbassano, Italy
| | | | - Anna Angelousi
- 1st Department of Internal Medicine, Unit of Endocrinology, National and Kapodistrian University of Athens, Laiko Hospital, Athens, Greece
| | - Cristina L Ronchi
- Institute of Metabolism and System Research, University of Birmingham, Birmingham, UK
- Division of Endocrinology and Diabetes, University Hospital of Würzburg, Würzburg, Germany
| | | | - Els J M Nieveen van Dijkum
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Filippo Ceccato
- Endocrinology Unit, Department of Medicine DIMED, University-Hospital of Padova, Padova, Italy
| | - Françoise Borson-Chazot
- Hospices Civils de Lyon, Fédération d'Endocrinologie, Université Claude Bernard Lyon 1, Lyon, France
| | - Giuseppe Reimondo
- Internal Medicine, Department of Clinical and Biological Sciences, San Luigi Gonzaga Hospital, University of Turin, Orbassano, Turin, Italy
| | - Guido A M Tiberi
- Surgical Clinic, Department of Clinical and Experimental Sciences, University of Brescia at ASST Spedali Civili, Brescia, Italy
| | - Hester Ettaieb
- Division of Endocrinology, Department of Internal Medicine, Maxima Medical Center, Eindhoven/Veldhoven, The Netherlands
| | - Andreas Kiriakopoulos
- 5th Surgical Clinic, 'Evgenidion Hospital' National and Kapodistrian University of Athens School of Medicine, Athens, Greece
| | - Letizia Canu
- Department of Experimental and Clinical Biomedical Sciences, University of Florence, Florence, Italy
| | - Darko Kastelan
- Department of Endocrinology, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Esthr Osher
- Institute of Endocrinology, Metabolism and Hypertension, Tel Aviv-Sourasky Medical Center Israel, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Eugenia Yiannakopoulou
- Department of Biomedical Sciences, Faculty of Health Sciences, University of West Attica, Athens, Greece
| | - Giorgio Arnaldi
- Division of Endocrinology, Department of Clinical and Molecular Sciences, Polytechnic University of Marche, Ancona, Italy
| | - Guillaume Assié
- Université de Paris, Institut Cochin, INSERM, CNRS, Paris, France
- Endocrinology, Assistance Publique Hôpitaux de Paris, Hôpital Cochin, Paris, France
| | - Isabel Paiva
- Department os Endocrinology, Diabetes and Metabolism, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Isabelle Bourdeau
- Division of Endocrinology, Department of Medicine, Research Center, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Québec, Canada
| | - John Newell-Price
- Department of Oncology and Metabolism, The Medical School University of Sheffield, Sheffield, UK
| | - Karolina M Nowak
- Department of Endocrinology, Centre of Postgraduate Medical Education, Bielanski Hospital, Warsaw, Poland
| | - M Tous Romero
- UGC Endocrinología y Nutrición, Hospital Universitario Virgen Macarena, Seville, Spain
| | - Maria Cristina De Martino
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy
| | - Maria João Bugalho
- Serviço de Endocrinologia, Diabetes e Metabolismo, CHULN and Faculdade de Medicina da Universidade de Lisboa, Lisboa, Portugal
| | - Mark Sherlock
- Department of Endocrinology, Beaumont Hospital and the Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Marie-Christine Vantyghem
- Endocrinology, Diabetology, Metabolism and Nutrition Department, Lille University Hospital, Lille, France
| | - Michael Conall Dennedy
- Department of Endocrinology & Diabetes Mellitus, c/o Department of Medicine, Clinical Sciences Institute, National University of Ireland, Galway, Galway, Ireland
| | - Paula Loli
- Ospedale Niguarda Ca' Granda, Endocrinology, Napoli, Italy
| | - Patrice Rodien
- Service d'Endocrinologie Diabétologie et Nutrition, CHU d'Angers, Angers Cedex 9, France
| | - Richard Feelders
- Erasmus Medical Center, Division of Endocrinology, Department of Internal Medicine, Rotterdam, The Netherlands
| | - Ronald de Krijger
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
- Department of Pathology, University Medical Center, Utrecht, The Netherlands
| | - Sam Van Slycke
- General and Endocrine Surgery, OLV Hospital Aalst, Aalst, Belgium
| | | | - Valentina Morelli
- Endocrinology Unit, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Laurent Vroonen
- Department of Endocrinology, Centre Hospitalier Universitaire de Liège, Liege, Belgium
| | - Zulfiya Shafigullina
- Endocrinology Department, North-Western Medical University named after I.I.Mechnikov, Saint-Petersburg, Russia
| | - Irina Bancos
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
| | | | | | - Michaela Luconi
- Department of Experimental and Clinical Biomedical Sciences, University of Florence, Florence, Italy
| | - Matthias Kroiss
- Division of Endocrinology and Diabetes, University Hospital of Würzburg, Würzburg, Germany
- Comprehensive Cancer Center Mainfranken, University of Würzburg, Würzburg, Germany
| | - Mitsuhide Naruse
- Endocrine Center, Ijinkai Takeda General Hospital and Clinical Research Institute of Endocrinology and Metabolism, NHO Kyoto Medical Center, Kyoto, Japan
| | - Peter Igaz
- 2nd Department of Internal Medicine, Semmelweis University, Budapest, Hungary
- MTA-SE Molecular Medicine Research Group, Hungarian Academy of Sciences and Semmelweis University, Budapest, Hungary
| | - Radu Mihai
- Churchill Cancer Centre, Department of Endocrine Surgery, Oxford University, Oxford, UK
| | - Silvia Della Casa
- Endocrinology Department, Gemelli Polyclinic Foundation, Catholic University, Rome, Italy
| | - Alfredo Berruti
- Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, Medical Oncology, University of Brescia at ASST Spedali Civili, Brescia, Italy
| | - Martin Fassnacht
- Division of Endocrinology and Diabetes, University Hospital of Würzburg, Würzburg, Germany
- Comprehensive Cancer Center Mainfranken, University of Würzburg, Würzburg, Germany
| | - Felix Beuschlein
- Klinik für Endokrinologie, Diabetologie und Klinische Ernährung, Universitätsspital Zürich, Zürich, Switzerland
- Department of Endocrinology, Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Munich, Germany
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24
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de Jong MC, Khan S, Christakis I, Weaver A, Mihai R. Comparative performances of nomograms and conditional survival after resection of adrenocortical cancer. BJS Open 2021; 5:6102899. [PMID: 33609384 PMCID: PMC7893456 DOI: 10.1093/bjsopen/zraa036] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2020] [Accepted: 10/08/2020] [Indexed: 11/17/2022] Open
Abstract
Background Adrenocortical carcinomas (ACCs) carry a poor prognosis. This study assessed the comparative performance of existing nomograms in estimating the likelihood of survival, along with the value of conditional survival estimation for patients who had already survived for a given length of time after surgery. Methods This was an observational study based on a prospectively developed departmental database that recorded details of patients operated for ACC in a UK tertiary referral centre. Results Of 74 patients with ACC managed between 2001 and 2020, data were analysed for 62 patients (32 women and 30 men, mean(s.d.) age 51(17) years) who had primary surgical treatment in this unit. Laparoscopic (9) or open adrenalectomies (53) were performed alone or in association with a multivisceral resection (27). Most of the tumours were left-sided (40) and 18 were cortisol-secreting. Overall median survival was 33 months, with 1-, 3- and 5-year survival rates of 79, 49, and 41 per cent respectively. Age over 55 years, higher European Network for Study of Adrenal Tumours stage, and cortisol secretion were associated with poorer survival in univariable analyses. Four published nomograms suggested widely variable outcomes that did not correlate with observed overall survival at 1, 3 or 5 years after operation. The 3-year conditional survival at 2 years (probability of surviving to postoperative year 5) was 65 per cent, compared with a 5-year actuarial survival rate of 41 per cent calculated from the time of surgery. Conclusion Survival of patients with ACC correlates with clinical parameters but not with published nomograms. Conditional survival might provide a more accurate estimate of survival for patients who have already survived for a certain amount of time after resection.
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Affiliation(s)
- M C de Jong
- Churchill Cancer Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - S Khan
- Churchill Cancer Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - I Christakis
- Churchill Cancer Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - A Weaver
- Churchill Cancer Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - R Mihai
- Churchill Cancer Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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25
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Lines KE, Stevenson M, Mihai R, Grigorieva IV, Shariq OA, Gaynor KU, Jeyabalan J, Javid M, Thakker RV. Hypoxia stimulates angiogenesis and a metabolic switch in human parathyroid adenoma cells. Endocr Oncol 2021; 1:23-32. [PMID: 37435188 PMCID: PMC10265544 DOI: 10.1530/eo-21-0014] [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] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Accepted: 07/28/2021] [Indexed: 07/13/2023]
Abstract
Hypoxia, a primary stimulus for angiogenesis, is important for tumour proliferation and survival. The effects of hypoxia on parathyroid tumour cells, which may also be important for parathyroid autotransplantation in patients, are, however, unknown. We, therefore, assessed the effects of hypoxia on gene expression in parathyroid adenoma (PA) cells from patients with primary hyperparathyroidism. Cell suspensions from human PAs were cultured under normoxic or hypoxic conditions and then subjected to cDNA expression analysis. In total, 549 genes were significantly upregulated and 873 significantly downregulated. The most highly upregulated genes (carbonic anhydrase 9 (CA9), Solute carrier family 2A1 (SLC2A1) and hypoxia-inducible lipid droplet-associated protein (HIG2)) had known involvement in hypoxia responses. Dysregulation of oxidative phosphorylation and glycolysis pathway genes were also observed, consistent with data indicating that cells shift metabolic strategy of ATP production in hypoxic conditions and that tumour cells predominantly utilise anaerobic glycolysis for energy production. Proliferation- and angiogenesis-associated genes linked with growth factor signalling, such as mitogen-activated protein kinase kinase 1 (MAP2K1), Jun proto-oncogene (JUN) and ETS proto-oncogene 1 (ETS1), were increased, however, Ras association domain family member 1 (RASSF1), an inhibitor of proliferation was also upregulated, indicating these pathways are unlikely to be biased towards proliferation. Overall, there appeared to be a shift in growth factor signalling pathways from Jak-Stat and Ras signaling to extracellular signal-regulated kinases (ERKs) and hypoxia-inducible factor (HIF)-1α signalling. Thus, our data demonstrate that PAs, under hypoxic conditions, promote the expression of genes known to stimulate angiogenesis, as well as undergoing a metabolic switch.
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Affiliation(s)
- K E Lines
- OCDEM, Radcliffe Department of Medicine, University of Oxford, Churchill Hospital, Headington, Oxford, UK
| | - M Stevenson
- OCDEM, Radcliffe Department of Medicine, University of Oxford, Churchill Hospital, Headington, Oxford, UK
| | - R Mihai
- Department of Endocrine Surgery, Oxford University Hospitals NHS Foundation Trust, Headington, Oxford, UK
| | - I V Grigorieva
- OCDEM, Radcliffe Department of Medicine, University of Oxford, Churchill Hospital, Headington, Oxford, UK
| | - O A Shariq
- OCDEM, Radcliffe Department of Medicine, University of Oxford, Churchill Hospital, Headington, Oxford, UK
| | - K U Gaynor
- OCDEM, Radcliffe Department of Medicine, University of Oxford, Churchill Hospital, Headington, Oxford, UK
| | - J Jeyabalan
- OCDEM, Radcliffe Department of Medicine, University of Oxford, Churchill Hospital, Headington, Oxford, UK
| | - M Javid
- OCDEM, Radcliffe Department of Medicine, University of Oxford, Churchill Hospital, Headington, Oxford, UK
| | - R V Thakker
- OCDEM, Radcliffe Department of Medicine, University of Oxford, Churchill Hospital, Headington, Oxford, UK
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26
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Prete A, Taylor AE, Bancos I, Smith DJ, Foster MA, Kohler S, Fazal-Sanderson V, Komninos J, O’Neil DM, Vassiliadi DA, Mowatt CJ, Mihai R, Fallowfield JL, Annane D, Lord JM, Keevil BG, Wass JAH, Karavitaki N, Arlt W. Response to Letter to the Editor from Chee et al: "Prevention of Adrenal Crisis: Cortisol Response to Major Stress Compared to Stress Dose Hydrocortisone Delivery". J Clin Endocrinol Metab 2021; 106:e407-e408. [PMID: 33029637 PMCID: PMC7765640 DOI: 10.1210/clinem/dgaa719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Alessandro Prete
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
| | - Angela E Taylor
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
| | - Irina Bancos
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
- Division of Endocrinology, Metabolism and Nutrition, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - David J Smith
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
- School of Mathematics, University of Birmingham, Birmingham, UK
| | - Mark A Foster
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
- NIHR Surgical Reconstruction and Microbiology Research Centre, Queen Elizabeth Hospital, Birmingham, UK
- Royal Centre for Defence Medicine, Queen Elizabeth Hospital, Birmingham, UK
| | - Sibylle Kohler
- Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, Oxford, UK
| | - Violet Fazal-Sanderson
- Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, Oxford, UK
| | - John Komninos
- Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, Oxford, UK
| | - Donna M O’Neil
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | - Dimitra A Vassiliadi
- Department of Endocrinology, Diabetes and Metabolism, Evangelismos Hospital, Athens, Greece
| | - Christopher J Mowatt
- Department of Anaesthesiology, Royal Shrewsbury Hospital, The Shrewsbury and Telford Hospital NHS Trust, Shrewsbury, UK
| | - Radu Mihai
- Department of Endocrine Surgery, Churchill Hospital, Oxford, UK
| | | | - Djillali Annane
- Critical Care Department, Hôpital Raymond-Poincaré, Laboratory of Infection & Inflammation U1173 INSERM/University Paris Saclay-UVSQ, Garches, France
| | - Janet M Lord
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
- NIHR Surgical Reconstruction and Microbiology Research Centre, Queen Elizabeth Hospital, Birmingham, UK
- NIHR Birmingham Biomedical Research Centre, University of Birmingham and University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Brian G Keevil
- Department of Clinical Biochemistry, University Hospital of South Manchester, Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK
| | - John A H Wass
- Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, Oxford, UK
| | - Niki Karavitaki
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
| | - Wiebke Arlt
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
- Department of Clinical Biochemistry, University Hospital of South Manchester, Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK
- Correspondence and Reprint Requests: Wiebke Arlt, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, B15 2TT, UK. E-mail:
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27
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Prete A, Taylor AE, Bancos I, Smith DJ, Foster MA, Kohler S, Fazal-Sanderson V, Komninos J, O’Neil DM, Vassiliadi DA, Mowatt CJ, Mihai R, Fallowfield JL, Annane D, Lord JM, Keevil BG, Wass JAH, Karavitaki N, Arlt W. Response to Letter to the Editor: "Prevention of Adrenal Crisis: Cortisol Response to Major Stress Compared to Stress Dose Hydrocortisone Delivery". J Clin Endocrinol Metab 2021; 106:e404-e406. [PMID: 33027808 PMCID: PMC7765653 DOI: 10.1210/clinem/dgaa712] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Indexed: 11/27/2022]
Affiliation(s)
- Alessandro Prete
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
| | - Angela E Taylor
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
| | - Irina Bancos
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
- Division of Endocrinology, Metabolism and Nutrition, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - David J Smith
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
- School of Mathematics, University of Birmingham, Birmingham, UK
| | - Mark A Foster
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
- NIHR Surgical Reconstruction and Microbiology Research Centre, Queen Elizabeth Hospital, Birmingham, UK
- Royal Centre for Defence Medicine, Queen Elizabeth Hospital, Birmingham, UK
| | - Sibylle Kohler
- Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, Oxford, UK
| | - Violet Fazal-Sanderson
- Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, Oxford, UK
| | - John Komninos
- Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, Oxford, UK
| | - Donna M O’Neil
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | - Dimitra A Vassiliadi
- Department of Endocrinology, Diabetes and Metabolism, Evangelismos Hospital, Athens, Greece
| | - Christopher J Mowatt
- Department of Anaesthesiology, Royal Shrewsbury Hospital, The Shrewsbury and Telford Hospital NHS Trust, Shrewsbury, UK
| | - Radu Mihai
- Department of Endocrine Surgery, Churchill Hospital, Oxford, UK
| | | | - Djillali Annane
- Critical Care Department, Hôpital Raymond-Poincaré, Laboratory of Infection & Inflammation U1173 INSERM/University Paris Saclay-UVSQ, Garches, France
| | - Janet M Lord
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
- NIHR Surgical Reconstruction and Microbiology Research Centre, Queen Elizabeth Hospital, Birmingham, UK
- NIHR Birmingham Biomedical Research Centre, University of Birmingham and University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Brian G Keevil
- Department of Clinical Biochemistry, University Hospital of South Manchester, Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK
| | - John A H Wass
- Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, Oxford, UK
| | - Niki Karavitaki
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
| | - Wiebke Arlt
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
- NIHR Birmingham Biomedical Research Centre, University of Birmingham and University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Correspondence: Wiebke Arlt, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, B15 2TT, UK. E-mail:
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28
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Eyre KS, Lewis F, Cui H, Grout E, Mihai R, Turney BW, Howles SA. Utility of blood tests in screening for metabolic disorders in kidney stone disease. BJU Int 2020; 127:538-543. [PMID: 32967050 DOI: 10.1111/bju.15250] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVES To determine the clinical utility of blood tests as a screening tool for metabolic abnormalities in patients with kidney stone disease. SUBJECTS AND METHODS Clinical and biochemical data from 709 patients attending the Oxford University Hospitals NHS Foundation Trust for assessment and treatment of kidney stones were prospectively collected between April 2011 and February 2017. Data were analysed to determine the utility of serum calcium, parathyroid hormone (PTH), urate, chloride, bicarbonate, potassium and phosphate assays in screening for primary hyperparathyroidism, normocalcaemic hyperparathyroidism, hyperuricosuria, distal renal tubular acidosis (dRTA) and hypercalciuria. RESULTS An elevated serum calcium level was detected in 2.3% of patients. Further investigations prompted by this finding resulted in a diagnosis of primary hyperparathyroidism in 0.2% of men and 4.6% of women for whom serum calcium was recorded. An elevated serum PTH level in the absence of hypercalcaemia was detected in 15.1% of patients. Of these patients, 74.6% were vitamin D-insufficient; no patients were diagnosed with normocalcaemic hyperparathyroidism. Hyperuricosuria was present in 21.6% of patients and hypercalciuria in 47.1%. Hyperuricaemia was not associated with hyperuricosuria, nor was hypophosphataemia associated with hypercalciuria. No patient was highlighted as being at risk of dRTA using serum chloride and bicarbonate as screening tests. CONCLUSION This study indicates that individuals presenting with renal calculi should undergo metabolic screening with a serum calcium measurement alone. Use of additional blood tests to screen for metabolic disorders is not cost-effective and may provide false reassurance that metabolic abnormalities are not present. A full metabolic assessment with 24-h urine collection should be undertaken in recurrent stone formers and in those at high risk of future stone disease to identify potentially treatable metabolic abnormalities.
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Affiliation(s)
- Katie S Eyre
- Department of Urology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Francesca Lewis
- Department of Urology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Helen Cui
- Department of Urology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Emily Grout
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Radu Mihai
- Department of Endocrine Surgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Benjamin W Turney
- Department of Urology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Sarah A Howles
- Department of Urology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
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29
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Prete A, Taylor AE, Bancos I, Smith DJ, Foster MA, Kohler S, Fazal-Sanderson V, Komninos J, O’Neil DM, Vassiliadi DA, Mowatt CJ, Mihai R, Fallowfield JL, Annane D, Lord JM, Keevil BG, Wass JAH, Karavitaki N, Arlt W. Prevention of Adrenal Crisis: Cortisol Responses to Major Stress Compared to Stress Dose Hydrocortisone Delivery. J Clin Endocrinol Metab 2020; 105:5805157. [PMID: 32170323 PMCID: PMC7241266 DOI: 10.1210/clinem/dgaa133] [Citation(s) in RCA: 59] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Accepted: 03/09/2020] [Indexed: 01/16/2023]
Abstract
CONTEXT Patients with adrenal insufficiency require increased hydrocortisone cover during major stress to avoid a life-threatening adrenal crisis. However, current treatment recommendations are not evidence-based. OBJECTIVE To identify the most appropriate mode of hydrocortisone delivery in patients with adrenal insufficiency who are exposed to major stress. DESIGN AND PARTICIPANTS Cross-sectional study: 122 unstressed healthy subjects and 288 subjects exposed to different stressors (major trauma [N = 83], sepsis [N = 100], and combat stress [N = 105]). Longitudinal study: 22 patients with preserved adrenal function undergoing elective surgery. Pharmacokinetic study: 10 patients with primary adrenal insufficiency undergoing administration of 200 mg hydrocortisone over 24 hours in 4 different delivery modes (continuous intravenous infusion; 6-hourly oral, intramuscular or intravenous bolus administration). MAIN OUTCOME MEASURE We measured total serum cortisol and cortisone, free serum cortisol, and urinary glucocorticoid metabolite excretion by mass spectrometry. Linear pharmacokinetic modeling was used to determine the most appropriate mode and dose of hydrocortisone administration in patients with adrenal insufficiency exposed to major stress. RESULTS Serum cortisol was increased in all stress conditions, with the highest values observed in surgery and sepsis. Continuous intravenous hydrocortisone was the only administration mode persistently achieving median cortisol concentrations in the range observed during major stress. Linear pharmacokinetic modeling identified continuous intravenous infusion of 200 mg hydrocortisone over 24 hours, preceded by an initial bolus of 50-100 mg hydrocortisone, as best suited for maintaining cortisol concentrations in the required range. CONCLUSIONS Continuous intravenous hydrocortisone infusion should be favored over intermittent bolus administration in the prevention and treatment of adrenal crisis during major stress.
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Affiliation(s)
- Alessandro Prete
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
| | - Angela E Taylor
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
| | - Irina Bancos
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
- Division of Endocrinology, Metabolism and Nutrition, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - David J Smith
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
- School of Mathematics, University of Birmingham, Birmingham, UK
| | - Mark A Foster
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
- NIHR Surgical Reconstruction and Microbiology Research Centre, Queen Elizabeth Hospital, Birmingham, UK
- Royal Centre for Defence Medicine, Queen Elizabeth Hospital, Birmingham, UK
| | - Sibylle Kohler
- Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, Oxford, UK
| | - Violet Fazal-Sanderson
- Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, Oxford, UK
| | - John Komninos
- Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, Oxford, UK
| | - Donna M O’Neil
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | - Dimitra A Vassiliadi
- Department of Endocrinology, Diabetes and Metabolism, Evangelismos Hospital, Athens, Greece
| | - Christopher J Mowatt
- Department of Anaesthesiology, Royal Shrewsbury Hospital, The Shrewsbury and Telford Hospital NHS Trust, Shrewsbury, UK
| | - Radu Mihai
- Department of Endocrine Surgery, Churchill Hospital, Oxford, UK
| | | | - Djillali Annane
- Critical Care Department, Hôpital Raymond-Poincaré, Laboratory of Infection & Inflammation U1173 INSERM/University Paris Saclay-UVSQ, Garches, France
| | - Janet M Lord
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
- NIHR Surgical Reconstruction and Microbiology Research Centre, Queen Elizabeth Hospital, Birmingham, UK
- NIHR Birmingham Biomedical Research Centre, University of Birmingham and University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Brian G Keevil
- Department of Clinical Biochemistry, University Hospital of South Manchester, Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK
| | - John A H Wass
- Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, Oxford, UK
| | - Niki Karavitaki
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
| | - Wiebke Arlt
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
- NIHR Birmingham Biomedical Research Centre, University of Birmingham and University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Correspondence and Reprint Requests: Wiebke Arlt, MD, DSc, FRCP, FMedSci, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, B15 2TT, UK. E-mail:
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Abstract
BACKGROUND/PURPOSE In Europe, the Division of Endocrine Surgery (DES) determines the number of operations (thyroid, neck dissection, parathyroids, adrenals, neuroendocrine tumors of the gastro-entero-pancreatic tract (GEP-NETs)) to be required for the European Board of Surgery Qualification in (neck) endocrine surgery. However, it is the national surgical boards that determine how surgical training is delivered in their respective countries. There is a lack of knowledge on the current situation concerning the training of surgical residents and fellows with regard to (neck) endocrine surgery in Europe. METHODS A survey was sent out to all 28 current national delegates of the DES. One questionnaire was addressing the training of surgical residents while the other was addressing the training of fellows in endocrine surgery. Particular focus was put on the numbers of operations considered appropriate. RESULTS For most of the operations, the overall number as defined by national surgical boards matched quite well the views of the national delegates even though differences exist between countries. In addition, the current numbers required for the EBSQ exam are well within this range for thyroid and parathyroid procedures but below for neck dissections as well as operations on the adrenals and GEP-NETs. CONCLUSIONS Training in endocrine surgery should be performed in units that perform a minimum of 100 thyroid, 50 parathyroid, 15 adrenal, and/or 10 GEP-NET operations yearly. Fellows should be expected to have been the performing surgeon of a minimum of 50 thyroid operations, 10 (central or lateral) lymph node dissections, 15 parathyroid, 5 adrenal, and 5 GEP-NET operations.
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Affiliation(s)
- Oliver Gimm
- Department of Surgery and Department of Clinical and Experimental Medicine (IKE), Linköping University, 58183 Linköping, Sweden
| | - Marcin Barczyński
- Department of Endocrine Surgery, Third Chair of Surgery, Jagiellonian University Medical College, 37 Prądnicka Street, 31-202 Kraków, Poland
| | - Radu Mihai
- Department of Endocrine Surgery, Churchill Cancer Centre, Oxford University Hospital NHS Foundation Trust, Oxford, OX3 7DU United Kingdom
| | - Marco Raffaelli
- U.O. Chirurgia Endocrina e Metabolica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Istituto di Semeiotica Chirurgica, Università Cattolica del Sacro Cuore, Rome, Italy
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31
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Mihai R, Donatini G, Vidal O, Brunaud L. Volume-outcome correlation in adrenal surgery-an ESES consensus statement. Langenbecks Arch Surg 2019; 404:795-806. [PMID: 31701230 PMCID: PMC6908553 DOI: 10.1007/s00423-019-01827-5] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Accepted: 09/20/2019] [Indexed: 12/21/2022]
Abstract
BACKGROUND Published data in the last decade showed that a majority of adrenal operations are done by surgeons performing only one such case per year and based on the distribution of personal workloads 'high-volume' surgeons are defined as those doing 4 or more cases/year. PURPOSE This paper summarises literature data identified by a working group established by the European Society of Endocrine Surgeons (ESES). The findings were discussed during ESES-2019 conference and members agreed on a consensus statement. RESULTS The annual of adrenal operations performed yearly in individual countries was reported to be 800/year in UK and over 1600/year in France. The learning curve of an individual surgeon undertaking laparoscopic, retroperitoneoscopic or robotic adrenalectomy is estimated to be 20-40 cases. Preoperative morbidity and length of stay are more favourable in high-volume centres. CONCLUSION The main recommendations are that adrenal surgery should continue only in centres performing at least 6 cases per year, surgery for adrenocortical cancer should be restricted to centres performing at least 12 adrenal operations per year, and an integrated multidisciplinary team should be established in all such centres. Clinical information regarding adrenalectomies should be recorded prospectively and contribution to the established EUROCRINE and ENSAT databases is strongly encouraged. Surgeons wishing to develop expertise in this field should seek mentorship and further training from established adrenal surgeons.
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Affiliation(s)
- Radu Mihai
- Churchill Cancer Centre, Oxford University NHS Hospitals Foundation Trust, Oxford, UK
| | - Gianluca Donatini
- Department of Surgery and INSERM U1082, CHU Poitiers, University of Poitiers, Poitiers, France
| | - Oscar Vidal
- ICMDiM, Hospital Clinic, IDIBAPS, Universitat de Barcelona, Barcelona, Spain
| | - Laurent Brunaud
- Department of Surgery and INSERM U954, CHU Nancy (Brabois), Université de Lorraine, Vandoeuvre les Nancy, France
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32
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Abstract
In an era when minimally invasive adrenalectomy is the gold standard treatment for majority of patients presenting with adrenal tumours, open adrenalectomy has become an operation that should be centralised in regional referral centers. Its main indication is represented by patients with large (>8 cm) phaeochromocytomas and patients with cortical adrenal tumours suspected of malignancy either because of their size (>4-6 cm) or because of radiological appearance of local invasion. Based on local expertise some of these patients might benefit from multidisciplinary input from liver or transplant surgeons. This chapter will discuss the anatomical landmarks and will comment on different steps in the procedure for right- or left-sided procedure. It is outside the scope of this chapter to settle the ongoing debate about patient selection for laparoscopic or open adrenalectomy when the diagnosis of adrenocortical cancer is suspected preoperatively.
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Affiliation(s)
- Radu Mihai
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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33
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Abstract
This paper discusses the surgical approach for the treatment of adrenal tumours extending into the right atrium (RA), using a cardio-pulmonary bypass (CPB) associated with deep hypothermic circulatory arrest (DHCA). Pre-operative planning and surgical steps are described in details. The association of CPB with hypothermic circulatory arrest (HCA) provides a bloodless operating field, direct intra-vascular vision, reduces the risk of embolization and allows extensive inferior vena cava (IVC) or RA repair in cases of infiltration of the vascular wall. Establishing a dedicated multidisciplinary team with experience in managing these challenging cases is fundamental to offer treatment to patients with advanced disease, who would otherwise risk being turned down for surgery. A close collaboration between general and cardiac surgeons and a deep understanding of the surgical procedure steps are fundamental to safely performing these procedures. We advocate centralising adrenal surgery in a small number of units with adequate multidisciplinary support.
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Affiliation(s)
- Renata Greco
- Department of Cardiac Surgery, Heart Centre, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Irene Tsappa
- Department of Cardiac Surgery, Heart Centre, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Radu Mihai
- Department of Endocrine Surgery, Churchill Cancer Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Mario Petrou
- Department of Cardiac Surgery, Heart Centre, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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Christakis I, Khan S, Sadler GP, Gleeson FV, Bradley KM, Mihai R. 18Fluorocholine PET/CT scanning with arterial phase-enhanced CT is useful for persistent/recurrent primary hyperparathyroidism: first UK case series results. Ann R Coll Surg Engl 2019; 101:501-507. [PMID: 31305126 DOI: 10.1308/rcsann.2019.0059] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
INTRODUCTION Redo parathyroidectomy for persistent/recurrent primary hyperparathyroidism is associated with a higher risk of complications and should be planned only with convincing localisation. We assessed whether 18fluorocholine positron emission tomography/computed tomography could identify parathyroid adenoma(s) in patients with persistent/recurrent primary hyperparathyroidism and negative conventional scans. MATERIALS AND METHODS A departmental database was used to identify patients with failed localisation attempts (sestamibi single photon emission computed tomography/computed tomography and/or computed tomography/magnetic resonance imaging and/or selective parathyroid hormone sampling) after previous unsuccessful surgery for primary hyperparathyroidism. 18Fluorocholine positron emission tomography was performed in all patients and redo surgery offered to those with positive findings. RESULTS 18Fluorocholine positron emission tomography incorporating arterial and portal phase enhanced computed tomography was performed in 12 patients with persistent/recurrent primary hyperparathyroidism (four men and eight women). Seven patients (58%) were cured after excision of adenomas located in ectopic positions (n = 3) or in anatomical position (n = 4). Five patients (42%) had persistent hypercalcaemia and repeat 18fluorocholine scan confirmed that the area highlighted on preoperative scans was excised. The arterial phase enhancement of the computed tomography was significantly different between cured and not-cured patients (P = 0.007). All seven cured patients had either a strong or weak enhancing pattern on computed tomography. Standardised uptake value at 60 minutes in patients with successful surgery (range 2.7-15.7, median 4.05) was higher than in patients with failed surgery (range 1.8-5.8, median 3.2) but was not statistically significant (P = 0.300). DISCUSSION 18fluorocholine scanning can identify elusive parathyroid adenomas, including those that are ectopic, and is useful in the management of patients with persistent/recurrent primary hyperparathyroidism when first-line scans are negative. The grading of the arterial phase of computed tomography can help to differentiate between true adenomas and false positive targets (lymph nodes).
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Affiliation(s)
- I Christakis
- Department of Endocrine Surgery, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - S Khan
- Department of Endocrine Surgery, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - G P Sadler
- Department of Endocrine Surgery, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - F V Gleeson
- Department of Radiology, Churchill Hospital, Oxford University Hospitals Foundation NHS Trust, Oxford, UK
| | - K M Bradley
- Department of Radiology, Churchill Hospital, Oxford University Hospitals Foundation NHS Trust, Oxford, UK
| | - R Mihai
- Department of Endocrine Surgery, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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35
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Affiliation(s)
- Radu Mihai
- Department of Endocrine Surgery, Churchill Cancer Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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36
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Fassnacht M, Dekkers O, Else T, Baudin E, Berruti A, de Krijger R, Haak H, Mihai R, Assie G, Terzolo M. European Society of Endocrinology Clinical Practice Guidelines on the management of adrenocortical carcinoma in adults, in collaboration with the European Network for the Study of Adrenal Tumors. Eur J Endocrinol 2018; 179:G1-G46. [PMID: 30299884 DOI: 10.1530/eje-18-0608] [Citation(s) in RCA: 463] [Impact Index Per Article: 77.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Adrenocortical carcinoma (ACC) is a rare and in most cases steroid hormone-producing tumor with variable prognosis. The purpose of these guidelines is to provide clinicians with best possible evidence-based recommendations for clinical management of patients with ACC based on the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system. We predefined four main clinical questions, which we judged as particularly important for the management of ACC patients and performed systematic literature searches: (A) What is needed to diagnose an ACC by histopathology? (B) Which are the best prognostic markers in ACC? (C) Is adjuvant therapy able to prevent recurrent disease or reduce mortality after radical resection? (D) What is the best treatment option for macroscopically incompletely resected, recurrent or metastatic disease? Other relevant questions were discussed within the group. Selected Recommendations: (i) We recommend that all patients with suspected and proven ACC are discussed in a multidisciplinary expert team meeting. (ii) We recommend that every patient with (suspected) ACC should undergo careful clinical assessment, detailed endocrine work-up to identify autonomous hormone excess and adrenal-focused imaging. (iii) We recommend that adrenal surgery for (suspected) ACC should be performed only by surgeons experienced in adrenal and oncological surgery aiming at a complete en bloc resection (including resection of oligo-metastatic disease). (iv) We suggest that all suspected ACC should be reviewed by an expert adrenal pathologist using the Weiss score and providing Ki67 index. (v) We suggest adjuvant mitotane treatment in patients after radical surgery that have a perceived high risk of recurrence (ENSAT stage III, or R1 resection, or Ki67 >10%). (vi) For advanced ACC not amenable to complete surgical resection, local therapeutic measures (e.g. radiation therapy, radiofrequency ablation, chemoembolization) are of particular value. However, we suggest against the routine use of adrenal surgery in case of widespread metastatic disease. In these patients, we recommend either mitotane monotherapy or mitotane, etoposide, doxorubicin and cisplatin depending on prognostic parameters. In selected patients with a good response, surgery may be subsequently considered. (vii) In patients with recurrent disease and a disease-free interval of at least 12 months, in whom a complete resection/ablation seems feasible, we recommend surgery or alternatively other local therapies. Furthermore, we offer detailed recommendations about the management of mitotane treatment and other supportive therapies. Finally, we suggest directions for future research.
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Affiliation(s)
- Martin Fassnacht
- Division of Endocrinology and Diabetes, Department of Internal Medicine I, University Hospital
- Comprehensive Cancer Center Mainfranken, University of Würzburg, Würzburg, Germany
| | - Olaf Dekkers
- Department of Clinical Epidemiology
- Department of Clinical Endocrinology and Metabolism, Leiden University Medical Centre, Leiden, the Netherlands
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Tobias Else
- Division of Metabolism, Endocrinology and Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Eric Baudin
- Endocrine Oncology and Nuclear Medicine, Institut Gustave Roussy, Villejuif, France
- INSERM UMR 1185, Faculté de Médecine, Le Kremlin-Bicêtre, Université Paris Sud, Paris, France
| | - Alfredo Berruti
- Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, Medical Oncology, University of Brescia at ASST Spedali Civili, Brescia, Italy
| | - Ronald de Krijger
- Department of Pathology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
- Department of Pathology, University Medical Center Utrecht, Utrecht, the Netherlands
- Department of Pathology, Reinier de Graaf Hospital, Delft, the Netherlands
- Princess Maxima Center for Pediatric Oncology, Utrecht, the Netherlands
| | - Harm Haak
- Department of Internal Medicine, Máxima Medical Centre, Eindhoven/Veldhoven, the Netherlands
- Maastricht University, CAPHRI School for Public Health and Primary Care, Ageing and Long-Term Care, Maastricht, the Netherlands
- Division of General Internal Medicine, Department of Internal Medicine, Maastricht University Medical Centre+, Maastricht, the Netherlands
| | - Radu Mihai
- Department of Endocrine Surgery, Churchill Cancer Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Guillaume Assie
- Department of Endocrinology, Reference Center for Rare Adrenal Diseases, Reference Center dor Rare Adrenal Cancers, Hôpital Cochin, Assistance Publique Hôpitaux de Paris, Paris, France
- Institut Cochin, Institut National de la Santé et de la Recherche Médicale U1016, Centre National de la Recherche Scientifique UMR8104, Université Paris Descartes, Sorbonne Paris Cité, Paris, France
| | - Massimo Terzolo
- Department of Clinical and Biological Sciences, Internal Medicine, San Luigi Hospital, University of Turin, Orbassano, Italy
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Gumaa D, Christakis I, Mihai R. Metastasis to the thyroid gland from a tonsil squamous cell carcinoma. AME Case Rep 2018; 2:7. [PMID: 30264003 DOI: 10.21037/acr.2018.01.04] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [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: 01/04/2018] [Accepted: 01/15/2018] [Indexed: 11/06/2022]
Abstract
We present a case of rare metastasis of tonsil squamous cell carcinoma to the thyroid gland, after 2 years of treatment without recurrence at the primary site. The patient had incidental finding of a nodule in the left lobe of the thyroid gland during a screening scan for his previous tonsil squamous cell carcinoma that was treated surgically 2 years ago. The patient was completely asymptomatic with normal thyroid function tests. After further investigations and discussion in the MDT meeting, the patient underwent left thyroid lobectomy as a definitive treatment for his thyroid metastasis.
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Affiliation(s)
- Duaa Gumaa
- Department of General Surgery, Endocrine Surgery Unit, Churchill Cancer Centre, Churchill Hospital, Headington, Oxford OX3 7LE, UK
| | - Ioannis Christakis
- Department of Endocrine Surgery, Endocrine Surgery Unit, Churchill Cancer Centre, Churchill Hospital, Headington, Oxford OX3 7LE, UK
| | - Radu Mihai
- Department of Endocrine Surgery, Endocrine Surgery Unit, Churchill Cancer Centre, Churchill Hospital, Headington, Oxford OX3 7LE, UK
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38
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Khan S, Sekhon H, Mihai R, Jenkins S. A rare case of symptomatic hyperparathyroidism in an elderly patient with dual pathology. AME Case Rep 2018; 2:22. [PMID: 30264018 DOI: 10.21037/acr.2018.04.04] [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: 03/15/2018] [Accepted: 04/02/2018] [Indexed: 11/06/2022]
Abstract
Primary hyperparathyroidism secondary to true sporadic synchronous parathyroid cancer (PTCa) and adenoma (PTa) is rare. This is a case of an 80-year-old female admitted with symptomatic hypercalcaemia, raised serum calcium (Ca) of 3.39 mmol/L and raised parathyroid hormone (PTH) of 44.3 pmol/L. Ultrasonic evaluation of the neck revealed a mass posterior to the right thyroid lobe. Imaging of the left neck was unremarkable. Subsequent sesta-MIBI and single-photon emission computed tomography-computed tomography (SPECT-CT) scanning highlighted conspicuous activity over the right lower neck consistent with the neck ultrasound scan findings. Pre-operatively, PTa was suspected. Intra-operatively, malignancy was suspected due to infiltration of the parathyroid tumour into the thyroid. The right inferior parathyroid and right thyroid gland were resected. Histology confirmed PTCa. Despite surgical treatment, she was found to have persistently high Ca and PTH levels. Further investigation with a repeat sesta-MIBI and SPECT-CT suggested a left inferior parathyroid tumour. Excision of this mass revealed a PTa. Recovery was unremarkable and serum biochemistry returned to normal ranges.
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Affiliation(s)
- Shahab Khan
- Department of Endocrine Surgery, Churchill Cancer Centre, Churchill Hospital, Headington, Oxford OX3 7LE, UK
| | - Harpreet Sekhon
- Department of General Surgery, Princess Alexandra Hospital, Harlow, Essex, CM20 1QX, UK
| | - Radu Mihai
- Department of Endocrine Surgery, Churchill Cancer Centre, Churchill Hospital, Headington, Oxford OX3 7LE, UK
| | - Stephanie Jenkins
- Department of General Surgery, Derriford Hospital, Plymouth, PL6 8DH, UK
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Abstract
BACKGROUND Permanent hypoparathyroidism (hypoPT) represents the most common postoperative complication associated with total thyroidectomy. Current treatment relies on high-dose calcium and/or vitamin D supplementation, but often this is insufficient and some patients remain symptomatic. Parathyroid allotransplantation is a new therapeutic option described recently in the literature. This study aims to investigate the patients' acceptability of parathyroid transplantation as a potential new treatment for hypoPT. METHOD Online survey of members of HypoParaUK, a support group for individuals affected by hypoPT. RESULTS Responses were received from 252 hypoPT patients. Majority declared to experience severe symptoms despite regular medical treatment. On a severity scale of 0-5, symptoms that were most troublesome were fatigue (3.8), low sense of well-being (3.5), and numbness/tingling (2.9). On a scale of 0-10, on average, their current quality of life (QoL) was 5 ± 3 and they expected this would improve to 7 ± 2 with correction of their hypoPT. Forty-four percent of patients were extremely interested in a potential technique involving intramuscular injection of parathyroid cell suspension compared to just 14% who were interested in the more invasive procedure of implantation of a parathyroid allograft into the forearm. The main concerns expressed were related to the possible need for immunosuppressive therapy. CONCLUSION Patients with severe symptomatic hypoPT seem interested to consider participation in a clinical trial exploring the feasibility and success rate of parathyroid transplantation.
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Affiliation(s)
| | - Radu Mihai
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK.
- Blenheim Head & Neck Unit, Churchill Cancer Centre, Old Road, Headington, Oxford, OX3 7LE, UK.
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40
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Ishii H, Mihai R, Watkinson JC, Kim DS. Systematic review of cure and recurrence rates following minimally invasive parathyroidectomy. BJS Open 2018; 2:364-370. [PMID: 30511037 PMCID: PMC6254009 DOI: 10.1002/bjs5.77] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Accepted: 04/03/2018] [Indexed: 11/28/2022] Open
Abstract
Background The majority of patients with primary hyperparathyroidism (PHPT) have a single overactive adenoma. Advances in preoperative imaging and surgical adjuncts have given rise to minimally invasive parathyroidectomy (MIP), with lower complication rates in comparison with bilateral neck exploration. Misdiagnosis and undertreatment of multiglandular disease, leading to potentially higher recurrence rates, remains a concern. This study evaluated risks of long‐term (1 year or more) recurrence following ‘targeted’ MIP in PHPT. Methods Multiple databases were searched for studies published between January 2004 and March 2017, looking at long‐term outcomes (1 year or more) following targeted MIP for PHPT. English‐language studies, with at least 50 patients and a mean follow‐up of 1 year, were included. Results A total of 5282 patients from 14 studies were included. Overall mean recurrence and cure rates were 1·6 (range 0–3·5) and 96·9 (95·5–100) per cent respectively. Mean follow‐up was 33·5 (1–145) months. When intraoperative parathyroid hormone (PTH) measurements were not done, cure rates were higher (99·3 per cent versus 98·1 per cent with use of intraoperative PTH measurement; P < 0·001) and recurrence rates lower (0·2 versus 1·5 per cent respectively; P < 0·001). Conclusion Targeted MIP for a presumed single overactive adenoma was associated with very low recurrence rates, without the need for intraoperative PTH measurement when preoperative imaging studies were concordant. Targeted MIP should be encouraged.
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Affiliation(s)
- H Ishii
- Department of Ear, Nose and Throat, Head and Neck Surgery St George's Hospital London UK
| | - R Mihai
- Department of Endocrine Surgery John Radcliffe Hospital Oxford UK
| | - J C Watkinson
- Department of Surgery Great Ormond Street Hospital London UK.,BUPA Cromwell Hospital London UK
| | - D S Kim
- Department of Ear, Nose and Throat, Head and Neck Surgery St George's Hospital London UK
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41
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Parameswaran R, Tan WB, Nga ME, Soon GST, Ngiam KY, Brooks SA, Sadler GP, Mihai R. Binding of aberrant glycoproteins recognizable by Helix pomatia agglutinin in adrenal cancers. BJS Open 2018; 2:353-359. [PMID: 30263987 PMCID: PMC6156166 DOI: 10.1002/bjs5.70] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Accepted: 03/16/2018] [Indexed: 01/28/2023] Open
Abstract
Background Aberrant glycosylation is a hallmark of cancer cells and plays an important role in oncogenesis and cancer progression including metastasis. This study aimed to assess alteration in cellular glycosylation, detected by lectin Helix pomatia agglutinin (HPA) binding, in adrenal cancers and to determine whether such altered glycosylation has prognostic significance. Methods HPA binding lectin histochemistry was performed on archival paraffin wax‐embedded specimens of adrenocortical cancers excised from patients attending two tertiary referral centres. Benign tumours were used as controls. Demographic, histological and survival data were collected and compared between patients with HPA‐positive and HPA‐negative tumours. Results Thirty‐two patients were treated for adrenal cancer between 2000 and 2016; their median age was 49 (range 23–79) years. Fifteen patients had functioning tumours (14 adrenal Cushing's tumours and 1 Conn's tumour). Mean(s.d.) tumour size was 127·71(49·70) mm. None of 10 control tumours expressed HPA‐binding glycoproteins. Invasion was associated with HPA‐binding glycoproteins (P = 0·018). Local recurrence or metastatic disease did not significantly differ between HPA‐positive and HPA‐negative adrenocortical cancers. Overall survival was significantly longer in patients with HPA‐negative tumours (median survival not reached versus 22 months in patients with HPA‐positive tumours; P = 0·002). Conclusion Altered cellular glycosylation detected by lectin HPA is associated with poor survival in patients with adrenocortical cancer.
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Affiliation(s)
- R Parameswaran
- Department of Endocrine Surgery National University Hospital Singapore
| | - W B Tan
- Department of Endocrine Surgery National University Hospital Singapore
| | - M E Nga
- Department of Pathology National University Hospital Singapore
| | - G S T Soon
- Department of Pathology National University Hospital Singapore
| | - K Y Ngiam
- Department of Endocrine Surgery National University Hospital Singapore
| | - S A Brooks
- School of Biological and Medical Sciences, Oxford Brookes University Oxford UK
| | - G P Sadler
- Department of Endocrine Surgery Oxford University Hospitals NHS Foundation Trust Oxford UK
| | - R Mihai
- Department of Endocrine Surgery Oxford University Hospitals NHS Foundation Trust Oxford UK
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42
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Cvasciuc T, Mihai R, Black E. Video-Assisted Thoracoscopic Parathyroidectomy for an Ectopic Parathyroid Adenoma. VideoEndocrinology 2018. [DOI: 10.1089/ve.2017.0109] [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)
- Titus Cvasciuc
- Department of Endocrine Surgery, Leeds Teaching Hospitals, Leeds, United Kingdom
| | - Radu Mihai
- Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Edward Black
- Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
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Smith S, Eatough V, Smith J, Mihai R, Weaver A, Sadler GP. 'I know I'm not invincible': An interpretative phenomenological analysis of thyroid cancer in young people. Br J Health Psychol 2018; 23:352-370. [PMID: 29356226 PMCID: PMC5901396 DOI: 10.1111/bjhp.12292] [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] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Revised: 12/17/2017] [Indexed: 11/30/2022]
Abstract
Objective Thyroid cancer is one of the most common cancers affecting young people and carries an excellent prognosis. Little is known about the psychosocial issues that face young people diagnosed with a treatable cancer. This study explored how young people experienced diagnosis, treatment, and how they made sense of an experience which challenged their views on what it means to have cancer. Method Semi‐structured interviews were conducted with eight young people diagnosed with either papillary or follicular thyroid cancer, and analysed with interpretative phenomenological analysis (IPA). Results Two inter‐related aspects of their experience are discussed: (1) the range of feelings and emotions experienced including feeling disregarded, vulnerability, shock and isolation; (2) how they made sense of and ascribed meaning to their experience in the light of the unique nature of their cancer. A thread running throughout the findings highlights that this was a disruptive biographical experience. Conclusions Young people experienced a loss of youthful immunity which contrasted with a sense of growth and shift in life perspective. Having a highly treatable cancer was helpful in aiding them to reframe their situation positively but at the same time left them feeling dismissed over a lack of recognition that they had cancer. The young peoples’ experiences point to a need for increased understanding of this rare cancer, more effective communication from health care professionals and a greater understanding of the experiential impact of this disease on young people. Suggestions to improve the service provision to this patient group are provided. Statement of contribution What is already known on this subject? Differentiated thyroid cancer has an excellent prognosis. Quality of life of thyroid cancer has marginally been explored in the literature. Little is known on the support needs of young people diagnosed with thyroid cancer.
What does this study add? Increased understanding of how young people make sense and cope with thyroid cancer despite the lack of support resources. Addressing illness perceptions through improved information support may aid coping and adjustment. Insight into the needs of young people diagnosed with thyroid cancer and recommendations on service improvements.
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Affiliation(s)
- Stephanie Smith
- Nuffield Department of Orthopaedics, Rheumatology & Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, UK
| | - Virginia Eatough
- Department of Psychological Sciences, Birkbeck University of London, UK
| | - James Smith
- Nuffield Department of Orthopaedics, Rheumatology & Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, UK
| | - Radu Mihai
- Department of Endocrine Surgery, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, UK
| | - Andrew Weaver
- Department of Oncology, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, UK
| | - Gregory P Sadler
- Department of Endocrine Surgery, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, UK
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Sbardella E, Cranston T, Isidori AM, Shine B, Pal A, Jafar-Mohammadi B, Sadler G, Mihai R, Grossman AB. Routine genetic screening with a multi-gene panel in patients with pheochromocytomas. Endocrine 2018; 59:175-182. [PMID: 28477304 DOI: 10.1007/s12020-017-1310-9] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [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] [Received: 02/11/2017] [Accepted: 04/19/2017] [Indexed: 12/14/2022]
Abstract
PURPOSE Several new gene mutations have been reported in recent years to be associated with a risk of familial pheochromocytoma. However, it is unclear as to whether extensive genetic testing is required in all patients. METHODS The clinical data of consecutive patients operated for pheochromocytoma over a decade in a tertiary referral center were reviewed. Genetic screening was performed using a 10-gene panel: RET, VHL, SDHB, SDHD, SDHA, SDHC, SDHAF2, MAX, TMEM127 and FH. RESULTS A total of 166 patients were analyzed: 87 of them had genetic screening performed (39 M: 44.8%, 48 F: 55.2%, age range 6-81 years, mean 45±16.8 years). In total, 22/87 (25.3%) patients had germline mutations, while 65/87 (74.7%) patients presented with apparently sporadic tumors. Germline VHL mutations were identified in 11.7% of patients, RET in 6.8% (five MEN2A/MEN2 and one MEN2B/MEN3), SDHD in 2.3%, MAX in 2.3%, SDHB in 1.1%, and TMEM127 in 1.1% of patients. At diagnosis, 15.1% of patients with unilateral non-syndromic pheochromocytoma showed germline mutations. We identified 19.7% of mutations in patients with unilateral-non-recurrent pheochromocytomas within 5 years vs. 50% in the recurrent-bilateral-metastatic group (p = 0.01). Germline mutations were more frequently seen with bilateral pheochromocytomas (p = 0.001): 80% of patients with bilateral disease had germline mutations (4 VHL, 3 RET, 1 MAX). CONCLUSIONS The advent of rapid genetic screening using a gene-panel makes it feasible to screen large cohorts of patients and provides a valuable tool to contribute to the prediction of bilateral and malignant disease and to screen family members.
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Affiliation(s)
- Emilia Sbardella
- Department of Endocrinology, Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, University of Oxford, Oxford, UK, OX3 7LE, UK.
- Department of Experimental Medicine, Sapienza University of Rome, Viale Regina Elena, 324, Rome, 00161, Italy.
| | - Treena Cranston
- Oxford Medical Genetics Laboratories, Churchill Hospital, University of Oxford, Oxford, UK, OX3 7LE, UK
| | - Andrea M Isidori
- Department of Experimental Medicine, Sapienza University of Rome, Viale Regina Elena, 324, Rome, 00161, Italy
| | - Brian Shine
- Department of Clinical Biochemistry,John Radcliffe Hospital, University of Oxford, Oxford, UK, OX3 9DU, UK
| | - Aparna Pal
- Department of Endocrinology, Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, University of Oxford, Oxford, UK, OX3 7LE, UK
| | - Bahram Jafar-Mohammadi
- Department of Endocrinology, Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, University of Oxford, Oxford, UK, OX3 7LE, UK
| | - Greg Sadler
- Department of Endocrine Surgery, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK, OX3 7LE, UK
| | - Radu Mihai
- Department of Endocrine Surgery, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK, OX3 7LE, UK
| | - Ashley B Grossman
- Department of Endocrinology, Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, University of Oxford, Oxford, UK, OX3 7LE, UK
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Christakis I, Khan S, Sadler G, Gleeson F, Bradley K, Mihai R. 18Fluorocholine PET/CT scanning for persistent primary hyperparathyroidism; a useful new tool. Eur J Surg Oncol 2017. [DOI: 10.1016/j.ejso.2017.10.015] [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: 11/26/2022] Open
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Christakis I, Mihai R. Survival after surgery for adrenocortical cancer cannot always be predicted using published nomograms. Eur J Surg Oncol 2017. [DOI: 10.1016/j.ejso.2017.10.056] [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: 10/18/2022] Open
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Oprea A, Glodariu T, Filipescu D, Gheorghe I, Mitu A, Boromiza M, Bucurescu D, Costache C, Cata-Danil I, Florea N, Ghita DG, Ionescu A, Marginean N, Marginean R, Mihai C, Mihai R, Negret A, Nita C, Olacel A, Pascu S, Sotty C, Suvaila R, Stan L, Stroe L, Serban A, Stiru I, Toma S, Turturica A, Ujeniuc S. Absolute cross sections of the 86Sr(α,n) 89Zr reaction at energies of astrophysical interest. EPJ Web Conf 2017. [DOI: 10.1051/epjconf/201714601016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Christakis I, Livesey JA, Sadler GP, Mihai R. Laparoscopic Adrenalectomy for Conn's Syndrome is Beneficial to Patients and is Cost Effective in England. J INVEST SURG 2017; 31:300-306. [DOI: 10.1080/08941939.2017.1323055] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Ioannis Christakis
- Department of Endocrine Surgery, Churchill Hospital, Oxford University Hospitals NHS Trust, Oxford, United Kingdom
| | - John A. Livesey
- Department of Endocrine Surgery, Churchill Hospital, Oxford University Hospitals NHS Trust, Oxford, United Kingdom
| | - Gregory P. Sadler
- Department of Endocrine Surgery, Churchill Hospital, Oxford University Hospitals NHS Trust, Oxford, United Kingdom
| | - Radu Mihai
- Department of Endocrine Surgery, Churchill Hospital, Oxford University Hospitals NHS Trust, Oxford, United Kingdom
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Gaujoux S, Mihai R. European Society of Endocrine Surgeons (ESES) and European Network for the Study of Adrenal Tumours (ENSAT) recommendations for the surgical management of adrenocortical carcinoma. Br J Surg 2017; 104:358-376. [PMID: 28199015 DOI: 10.1002/bjs.10414] [Citation(s) in RCA: 112] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2016] [Revised: 06/10/2016] [Accepted: 09/28/2016] [Indexed: 12/13/2022]
Abstract
BACKGROUND Radical surgery provides the best chance of cure for adrenocortical carcinoma (ACC), but perioperative surgical care for these patients is yet to be standardized. METHODS A working group appointed jointly by ENSAT and ESES used Delphi methodology to produce evidence-based recommendations for the perioperative surgical care of patients with ACC. Papers were retrieved from electronic databases. Evidence and recommendations were classified according to the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system, and were discussed until consensus was reached within the group. RESULTS Twenty-five recommendations for the perioperative surgical care of patients with ACC were formulated. The quality of evidence is low owing to the rarity of the disease and the lack of prospective surgical trials. Multi-institutional prospective cohort studies and prospective RCTs are urgently needed and should be strongly encouraged. CONCLUSION The present evidence-based recommendations provide comprehensive advice on the optimal perioperative care for patients undergoing surgery for ACC.
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Affiliation(s)
- S Gaujoux
- Department of Digestive and Endocrine Surgery, Cochin Hospital, Assistance Publique - Hôpitaux de Paris (APHP), Paris, France
- Faculté de Médecine Paris Descartes, Université Paris Descartes, Paris, France
- Institut National de la Santé et de la Recherche Médicale (INSERM) Unit 1016, Centre National de la Recherche Scientifique Unité Mixte de Recherche 8104, Institut Cochin, Paris, France
| | - R Mihai
- Churchill Cancer Centre, Oxford University Hospitals Foundation Trust, Oxford, UK
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Abstract
INTRODUCTION The 2012 British Association of Endocrine and Thyroid Surgeons audit report showed that only 86 of 1359 patients who underwent adrenalectomy had a bilateral operation; thus the experience with this procedure remains limited. METHODS Retrospective review of patients undergoing bilateral adrenalectomy in a tertiary referral centre. RESULTS Between November 2005 and January 2016, bilateral adrenalectomy was performed in 23 patients (6 male, 17 female, age 43 ± 4 years) diagnosed with Cushing's disease (n = 13), hereditary phaeochromocytomas (n = 6), adrenocortical cancer (n = 2), colorectal metastatic disease (n = 1) and adrenocortical adenomas (n = 1). A laparoscopic transperitoneal approach was used in 17 patients, with one conversion to open. Three patients had open adrenalectomies for adrenocortical cancer and for simultaneous phaeochromocytomas and pancreatic neuroendocrine tumours in a patient with Von Hippel-Lindau syndrome. Three patients with Cushing's had a bilateral retroperitoneoscopic operation. The mean operating time was 195 ± 16 minutes for laparoscopic operations (n = 16), 243 ± 44 minutes for open adrenalectomies (n = 4) and 151 ± 12 minutes for retroperitoneal operations. It was significantly shorter for Cushing's disease than for phaeochromocytomas (162 ± 8 vs. 257 ± 39 minutes, P < 0.01). Median length of hospital stay was 5 days. Postoperative complications (Clavien-Dindo classification) included one chest infection (level 2), one postoperative haemorrhage and two chest drains for pneumothorax (level 3), two postoperative cardiac arrests (level 4) and one late cancer death from complications related to uncontrolled hypercortisolism (level 5). DISCUSSION Synchronous bilateral adrenalectomy remains an infrequent operation. The laparoscopic approach is feasible in the majority of patients. It is likely that the retroperitoneoscopic adrenalectomy will become the standard approach for bilateral operations.
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Affiliation(s)
- D Maccora
- Department of Endocrine Surgery, Oxford University Hospitals NHS Foundation Trust , Oxford , UK
| | - G V Walls
- Department of Endocrine Surgery, Oxford University Hospitals NHS Foundation Trust , Oxford , UK
| | - G P Sadler
- Department of Endocrine Surgery, Oxford University Hospitals NHS Foundation Trust , Oxford , UK
| | - R Mihai
- Department of Endocrine Surgery, Oxford University Hospitals NHS Foundation Trust , Oxford , UK
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