Limited disease progression in endocrine surgery patients with treatment delays due to COVID-19

BACKGROUND

The COVID-19 pandemic profoundly impacted the delivery of care and timing of elective surgical procedures. Most endocrine-related operations were considered elective and safe to postpone, providing a unique opportunity to assess clinical outcomes under protracted treatment plans.

METHODS

American Association of Endocrine Surgeon members were surveyed for participation. A Research Electronic Data Capture survey was developed and distributed to 27 institutions to assess the impact of COVID-19-related delays. The information collected included patient demographics, primary diagnosis, resumption of care, and assessment of disease progression by the surgeon.

RESULTS

Twelve out of 27 institutions completed the survey (44.4%). Of 850 patients, 74.8% (636) were female; median age was 56 (interquartile range, 44-66) years. Forty percent (34) of patients had not been seen since their original surgical appointment was delayed; 86.2% (733) of patients had a delay in care with women more likely to have a delay (87.6% vs 82.2% of men, χ² = 3.84, P = .05). Median duration of delay was 70 (interquartile range, 42-118) days. Among patients with a delay in care, primary disease site included thyroid (54.2%), parathyroid (37.2%), adrenal (6.5%), and pancreatic/gastrointestinal neuroendocrine tumors (1.3%). In addition, 4.0% (26) of patients experienced disease progression and 4.1% (24) had a change from the initial operative plan. The duration of delay was not associated with disease progression (P = .96) or a change in operative plan (P = .66).

CONCLUSION

Although some patients experienced disease progression during COVID-19 delays to endocrine disease-related care, most patients with follow-up did not. Our analysis indicated that temporary delay may be an acceptable course of action in extreme circumstances for most endocrine-related surgical disease.

Selective Glucocorticoid Replacement Following Unilateral Adrenalectomy for Hypercortisolism and Primary Aldosteronism

CONTEXT

An institutional study previously demonstrated that cosyntropin stimulation testing on postoperative day 1 (POD1-CST) identified patients at risk for adrenal insufficiency (AI) following unilateral adrenalectomy (UA) for adrenal-dependent hypercortisolism (HC) and primary aldosteronism (PA), allowing for selective glucocorticoid replacement (GR).

OBJECTIVE

This study re-evaluates the need for GR following UA for patients with HC and PA in a larger cohort.

METHODS

A prospective database identified 108 patients who underwent UA for mild autonomous cortisol excess (MACE) (n = 47), overt hypercortisolism (OH) (n = 27), PA (n = 22), and concurrent PA/HC (n = 12) from September 2014 to October 2020; all underwent preoperative evaluation for HC. MACE was defined by the 1 mg dexamethasone suppression test (cortisol >1.8 μg/dL), with ≥5 defined as OH. GR was initiated for basal cortisol ≤5 or stimulated cortisol ≤14 (≤18 prior to April 2017) on POD1-CST.

RESULTS

Fifty-one (47%) patients had an abnormal POD1-CST; 54 (50%) were discharged on GR (27 MACE, 20 OH, 1 PA, 6 PA/HC). Median duration of GR was OH: 6.0 months, MACE: 2.1 months, PA: 1 month, PA/HC: 0.8 months. Overall, 26% (n = 7) of patients with OH and 43% (n = 20) of patients with MACE did not require GR. Two (2%) patients with OH had normal POD1-CST but developed AI several weeks postoperatively requiring GR. None experienced life-threatening AI.

CONCLUSION

POD1-CST identifies patients with HC at risk for AI after UA, allowing for selective GR. One-quarter of patients with OH and nearly half of patients with MACE can forgo GR after UA. Patients with PA do not require evaluation for AI if concurrent HC has been excluded preoperatively.

Confirmation of Feasibility of Selective Glucocorticoid Replacement Following Unilateral Adrenalectomy for Hypercortisolism and Primary Aldosteronism

Background: Secondary adrenal insufficiency (AI) can develop following unilateral adrenalectomy (UA) foradrenal-dependent hypercortisolism (HC) and has been reported after UA for primaryaldosteronism (PA). An institutional study previously demonstrated that cosyntropin stimulationtesting on postoperative day 1 (POD1-CST) successfully identified patients who requiredglucocorticoid replacement (GR) following UA; 50% of HC patients required GR and no PApatients required GR. The aim of this study was to reevaluate the need for GR following UA forpatients with HC and PA in a larger cohort of patients. Methods We reviewed 108 patients from a prospectively maintained adrenal database who underwent UAfor HC (n=74), PA (n=22), and concurrent HC/PA (n=12) from 9/2014-10/2020. PA patientswithout preoperative evaluation for HC were excluded. Patients with 1mg dexamethasonesuppression test (DST) cortisol >1.8 (µg/dL) were defined as having mild HC, with ³5 defined asovert Cushing’s Syndrome (CS). All patients underwent our institutional POD1-CST protocoland GR was initiated for patients with basal cortisol £5 or stimulated cortisol £14 (<18 prior to4/2017). Results: Overall, 51 (47%) patients had an abnormal POD1-CST and were discharged on GR (44 HC, 1PA, and 6 HC/PA). Two (2%) patients with CS had a normal POD1-CST but developed AIrequiring GR at 8 and 12 weeks post UA. Of the 74 patients with HC, 44 (59%) had an abnormalPOD1-CST and were discharged on GR, including 19/28 (68%) with CS and 25/46 (54%) withmild HC. Preoperative DST cortisol was higher in HC patients who required GR compared topatients with a normal POD1-CST (4.1 vs 3.6; p=0.007). Median cortisol levels for HC patientswith an abnormal POD1-CST vs those with a normal test were: basal: 3.8 vs 15.6 (p=0.027); 30-minute: 10.1 vs 20.1 (p=0.403); and 60-minute 11.4 vs 22.2 (p=0.260). Of the 22 PA patients, 19(86%) had a normal POD1-CST. Median cortisol levels for PA patients with an abnormal POD1-CST vs those with a normal test were: basal: 0.4 vs 12.1; 30-minute: 8.8 vs 24.6; and 60-minute:12.2 vs 28.9. Of the 3 (14%) PA patients with an abnormal POD1-CST, 1 was dischargedwith GR and began tapering after 2 weeks; the other 2 did not require GR and did not developAI. Of the 12 patients with combined PA/HC, 6 (50%) were discharged on GR based on POD1-CST. GR was required by 30 (59%) patients for <3 months and 82% for <12 months; 7/9 whorequired GR >12 months had CS. Conclusions: Using a standard protocol for POD1-CST in patients who underwent unilateral adrenalectomyfor HC, PA, or combined PA/HC, this study demonstrated that routine GR is not required in 32%of patients with CS and 46% of patients with mild HC. POD1-CST safely identifies patients whowill require GR with no immediate concern for adrenal insufficiency. These data also suggestthat routine evaluation for AI in postoperative PA patients is not needed if cortisol excess hasbeen excluded preoperatively.

Pearls and Pitfalls of the Virtual Interview: Perspectives From Both Sides of the Camera

As the SARS-COV-2 pandemic created the need for social distancing and the implementation of nonessential travel bans, residency and fellowship programs have moved toward a web-based virtual process for applicant interviews. As part of the Society of Asian Academic Surgeons 5th Annual Meeting, an expert panel was convened to provide guidance for prospective applicants who are new to the process. This article provides perspectives from applicants who have successfully navigated the surgical subspecialty fellowship process, as well as program leadership who have held virtual interviews.