The diagnosis of encapsulated or minimally invasive follicular carcinoma of the thyroid requires the proof of vascular or capsular invasion. The aim of the present study was to evaluate the ...relationship between intraoperative diagnosis (benign, suggestive of carcinoma, or malignant) and the final histopathologic criteria for encapsulated or minimally invasive follicular carcinoma (tumor size, capsular invasion, vascular invasion, and differentiation). This was a retrospective study of 63 cases of encapsulated or minimally invasive carcinomas, with the final histopathologic diagnosis taken as the "gold standard." The sensitivity of frozen sections for the diagnosis of malignant neoplasm was 17%. The median number of vascular invasions was 1, identified with a mean number of 9 paraffin-blocks of the tumor. In most cases, intraoperative frozen sections are unable to establish the proof of malignant neoplasm. Intraoperative study of tumor differentiation is useful to select follicular tumors that require a rapid definitive diagnosis and a completion thyroidectomy within 48 to 72 hours (73% of the cases in our study).
The recurrent laryngeal nerve (RLN) can be injured during thyroid surgery, which can negatively affect a patient's quality of life. The impact of intraoperative anatomic variations of the RLN on ...nerve injury remains unclear. Objectives of this study were to (1) better understand the detailed surgical anatomic variability of the RLN with a worldwide perspective; (2) establish potential correlates between intraoperative RLN anatomy and electrophysiologic responses; and (3) use the information to minimize complications and assure accurate and safe intraoperative neuromonitoring (IONM).
A large international registry database study with prospectively collected data was conducted through the International Neural Monitoring Study Group (INMSG) evaluating 1000 RLNs at risk during thyroid surgery using a specially designed online data repository. Monitored thyroid surgeries following standardized IONM guidelines were included. Cases with bulky lymphadenopathy, IONM failure, and failed RLN visualization were excluded. Systematic evaluation of the surgical anatomy of the RLN was performed using the International RLN Anatomic Classification System. In cases of loss of signal (LOS), the mechanism of neural injury was identified, and functional evaluation of the vocal cord was performed.
A total of 1000 nerves at risk (NARs) were evaluated from 574 patients undergoing thyroid surgery at 17 centers from 12 countries and 5 continents. A higher than expected percentage of nerves followed an abnormal intraoperative trajectory (23%). LOS was identified in 3.5% of NARs, with 34% of LOS nerves following an abnormal intraoperative trajectory. LOS was more likely in cases of abnormal nerve trajectory, fixed splayed or entrapped nerves (including at the ligament of Berry), extensive neural dissection, cases of cancer invasion, or when lateral lymph node dissection was needed. Traction injury was found to be the most common form of RLN injury and to be less recoverable than previous reports.
Multicenter international studies enrolling diverse patient populations can help reshape our understanding of surgical anatomy during thyroid surgery. There can be significant variability in the anatomic and intraoperative characteristics of the RLN, which can impact the risk of neural injury.
Morphologic examination is the gold standard for diagnosing papillary thyroid carcinoma (PTC). This diagnosis, especially for the follicular variant, may be variable even among experts. Our objective ...was to analyze the frequency of PTC microscopic criteria in a series of thyroid tumors including follicular adenoma (FA) and PTC to build a score which could constitute a novel way for microscopic analysis of such thyroid tumors. Sixty-six PTC and 66 FA were matched for age, sex, and thyroiditis. Two independent observers delineated the classical PTC microscopic criteria. PTC microscopic criteria were variably expressed in individual tumors. Under univariate analysis, all criteria were significantly more frequent in PTC than in FA (
p
< 0.05). Under multivariate analysis, the most important criteria were: dark staining colloid >25%, nuclear grooves, enlarged nuclei, ovoid nuclei >5% of tumor cells, and lack of polarization. Using linear discriminant analysis, these five criteria allowed us to build a scaled score. The score proposed did not allow the making of a definite distinction between FA and PTC in routine practice. It represents the variety of microscopic presentations of FA and PTC on the basis of a statistical analysis and could help in further evaluation of immunohistochemical or molecular markers.
18-F-fluoro-2-deoxyglucose positron emission tomography (
18FDG-PET) is useful in the detection of iodine-negative differentiated thyroid carcinoma (DTC). The aim of this prospective study was to ...assess therapeutic impact of
18FDG-PET imaging using a PET/computed tomography (CT) system in patients with iodine-negative recurrence of DTC.
From 2002 to 2006, patients with recurrence of DTC diagnosed by elevated thyroglobulin level and negative 131-I whole-body scan were included.
Forty-five patients (31 women, 14 men), with a mean age of 55 years, with 36 papillary, 5 follicular, and 4 Hürthle carcinomas, were studied. All patients had previously undergone total thyroidectomy and postoperative thyroid remnant ablation with 131-I. The findings of
18FDG-PET/CT were positive in 31 patients (68.8%) and negative in 14 (32.2%). Results were true positive in 24 of 31 patients. The sensitivity, positive predictive value, and accuracy of
18FDG-PET/CT were 63%, 77%, and 53%, respectively. Twenty patients were operated on, 19 had neck surgery with mediastinal lymph node dissection (1 case) and lung resection (1 case), and 1 underwent lung resection. Seven patients had a stimulated thyroglobulin level <1 ng/mL.
18FDG-PET/CT is able to select patients who can benefit from surgery. Normalization of thyroglobulin is observed in one third of operated patients.
Intraoperative hormonal measurements have been used successfully to guide the surgical treatment of various endocrine diseases. In this study, we report the results of intraoperative insulin ...measurement (IIM) in patients with organic hypoglycemia. IIMs were performed during 52 operations in 51 patients. Hyperinsulinism was secondary to a sporadic insulinoma (M= 40), a type I multiple endocrine neoplasia (MEN‐I) (M= 8), an insulin‐secreting carcinoma (M= 1), or pancreatic nesidioblastosis (M= 2). The insulin was measured with a radioimmunologic assay in blood samples simultaneously drawn from a peripheral vein and the portal vein at the beginning of the operation (T1) and 20 minutes after tumor removal (T2). Normoglycemia was achieved after surgery in 50 cases (96%). Systemic and portal insulin levels were normal at T1 in eight patients, precluding any further interpretation of the test. Completeness of surgery was confirmed by normalization of both systemic and portal insulin levels at T2 in 36 patients. In seven cases the systemic or portal insulin levels (or both) remained elevated at T2 despite a favorable outcome after surgery. Failure of the surgical procedure was predicted in two patients by the persistence of high levels of insulin at T2. In patients with initially elevated serum insulin levels, the positive predictive value and the specificity of intraoperative insulin measurement for completeness of surgery were both 100%. The sensitivity was 84%, the negative predictive value 22%, and the accuracy of the test 84%. We concluded that IIM is a simple, highly reliable tool for predicting the completeness of surgery in patients with organic hypoglycemia. IIM appears to be a valuable addendum to the surgical armamentarium against insulinoma especially for patients with atypical causes, such as MEN, insulin‐secreting carcinoma, or pancreatic nesidioblastosis.
The definitive diagnostic criteria for malignant adrenocortical tumors are distant metastasis and/or local invasion. The Weiss histopathologic system is the most commonly used method for assessing ...malignancy because of its simplicity and reliability. Unfortunately, its application remains subjective. This current retrospective study evaluated the Weiss system and assessed the value of MIB-1 labeling in the diagnosis of adrenocortical malignancy. Twenty-four malignant tumors with distant metastasis, gross local invasion, or recurrence were selected and matched on their functioning status to 25 benign tumors. Two independent observers delineated the Weiss criteria. An MIB-1 labeling index was determined. Presence of three or more Weiss microscopic criteria was related to malignancy (specificity 96%, sensitivity 100%), thus confirming the value of the Weiss system. Interobserver agreement for the Weiss system (total score) was excellent (r = 0.94). The lack of reliability for some Weiss criteria led us to propose a statistically modified system, based on the most reliable criteria (2.mitotic rate x 2.cytoplasm x abnormal mitoses x necrosis x capsular invasion) with a significant correlation with the Weiss system (r = 0.98). The MIB-1 labeling index was significantly higher in malignant tumors (p <0.0001). MIB1 could also help to differentiate malignant from benign adrenocortical tumors.
Importance
In MEN1 patients with gastric and duodenopancreatic neuroendocrine tumors (GPD-NET), surgery aims to control secretions or to prevent metastatic spread, but after GPD-NET resection, ...postoperative mortality may be related to the surgery itself or to other associated MEN1 lesions with their own uncontrolled secretions or metastatic behavior.
Objective
To analyze the causes of death within 1 year following a GPD-NET resection in MEN1 patients.
Design
An observational study collecting data from the Groupe d’étude des Tumeurs Endocrines (GTE) database. The analysis considered the time between surgery and death (early deaths <1 month after surgery versus delayed deaths beyond 1 month after surgery) and the period (before 1990 vs after 1990). Causes of death were classified as related to GDP surgery, related to surgery for other MEN1 lesions or not related to MEN1 causes.
Setting
GTE database which includes 1220 MEN1 patients and 441 GPD-NET resections.
Participants
Four hundred and forty-one GPD-NET resections.
Main outcome measures
The primary end point was postoperative mortality within 1 year after surgery.
Results
Twenty-four patients met the inclusion criteria (2%). Median age at death was 50.5 years. Sixteen deaths occurred in the 30-day postoperative period (76%). Among the 8 delayed deaths, 3 occurred as a result of medical complications between 30 and 90 postoperative days. After 1990, mean age at death increased from 48 to 58 years (
p
= 0.09), deaths related to uncontrolled acid secretion disappeared (
p
< 0.001) and deaths related to associated MEN1 lesions increased from 8 to 54% (
p
= 0.16).
Conclusion
Surgery and uncontrolled secretions remain the two main causes of death in MEN1 patients operated for a GPD-NET tumor. Improving the prognosis of these patients requires a strict evaluation of the secretory syndrome and MEN1 aggressiveness before GDP surgery.
ObjectiveManagement of insulinomas in the context of MEN1 remains poorly studied. The aim of this study was to evaluate long-term results of various surgical approaches in a large cohort of ...insulinoma–MEN1 patients.Design and methodsConsecutive insulinoma–MEN1 patients operated on for a nonmetastatic insulinoma between 1957 and 2010 were retrospectively selected from the MEN1 database of the French Endocrine Tumor Group. The type of surgery was categorized as distal pancreatectomy (DP), total pancreatectomy/cephalic duodenopancreatectomy (TP/CDP), or enucleation (E). Primary endpoint was time until recurrence of hypoglycemia after initial surgery. Secondary endpoints were post-operative complications.ResultsThe study included 73 patients (median age=28 years). Surgical procedures were DP (n=46), TP/CDP (n=9), or E (n=18). After a median post-operative follow-up of 9.0 years (inter-quartile range (IQR): 2.5–16.5 years), 60/73 patients (82.2%) remained hypoglycemia free. E and TP/CDP were associated with a higher risk of recurrent hypoglycemia episodes (unadjusted hazard ratio: 6.18 ((95% CI: 1.54–24.8); P=0.010) for E vs DP and 9.51 ((95% CI: 1.85–48.8); P=0.007) for TP/CDP vs DP. After adjustment for International Union against Cancer pTNM classification, enucleation remained significantly associated with a higher probability of recurrence. Long-term complications had occurred in 20 (43.5%) patients with DP, five (55.6%) with TP/CDP, but in none of the patients who have undergone E (P=0.002).ConclusionIn the French Endocrine database, DP is associated with a lower risk for recurrent hypoglycemia episodes. Due to lower morbidity, E alone might be considered as an alternative.
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