Hypoparathyroidism (hypoPT) is the most common complication following bilateral thyroid operations. Thyroid surgeons must employ strategies for minimizing and preventing post-thyroidectomy hypoPT. ...The objective of this American Thyroid Association Surgical Affairs Committee Statement is to provide an overview of its diagnosis, prevention, and treatment.
HypoPT occurs when a low intact parathyroid hormone (PTH) level is accompanied by hypocalcemia. Risk factors for post-thyroidectomy hypoPT include bilateral thyroid operations, autoimmune thyroid disease, central neck dissection, substernal goiter, surgeon inexperience, and malabsorptive conditions. Medical and surgical strategies to minimize perioperative hypoPT include optimizing vitamin D levels, preserving parathyroid blood supply, and autotransplanting ischemic parathyroid glands. Measurement of intraoperative or early postoperative intact PTH levels following thyroidectomy can help guide patient management. In general, a postoperative PTH level <15 pg/mL indicates increased risk for acute hypoPT. Effective management of mild to moderate potential or actual postoperative hypoPT can be achieved by administering either empiric/prophylactic oral calcium and vitamin D, selective oral calcium, and vitamin D based on rapid postoperative PTH level(s), or serial serum calcium levels as a guide. Monitoring for rebound hypercalcemia is necessary to avoid metabolic and renal complications. For more severe hypocalcemia, inpatient management may be necessary. Permanent hypoPT has long-term consequences for both objective and subjective well-being, and should be prevented whenever possible.
OBJECTIVE:To develop evidence-based recommendations for safe, effective, and appropriate thyroidectomy.
BACKGROUND:Surgical management of thyroid disease has evolved considerably over several decades ...leading to variability in rendered care. Over 100,000 thyroid operations are performed annually in the US.
METHODS:The medical literature from 1/1/1985 to 11/9/2018 was reviewed by a panel of 19 experts in thyroid disorders representing multiple disciplines. The authors used the best available evidence to construct surgical management recommendations. Levels of evidence were determined using the American College of Physicians grading system, and management recommendations were discussed to consensus. Members of the American Association of Endocrine Surgeons reviewed and commented on preliminary drafts of the content.
RESULTS:These clinical guidelines analyze the indications for thyroidectomy as well as its definitions, technique, morbidity, and outcomes. Specific topics include Pathogenesis and Epidemiology, Initial Evaluation, Imaging, Fine Needle Aspiration Biopsy Diagnosis, Molecular Testing, Indications, Extent and Outcomes of Surgery, Preoperative Care, Initial Thyroidectomy, Perioperative Tissue Diagnosis, Nodal Dissection, Concurrent Parathyroidectomy, Hyperthyroid Conditions, Goiter, Adjuncts and Approaches to Thyroidectomy, Laryngology, Familial Thyroid Cancer, Postoperative Care and Complications, Cancer Management, and Reoperation.
CONCLUSIONS:Evidence-based guidelines were created to assist clinicians in the optimal surgical management of thyroid disease.
Primary aldosteronism is a common cause of secondary hypertension. Treatment with adrenalectomy or mineralocorticoid receptor-blockers can prevent long-term adverse outcomes. This study aimed to ...determine primary aldosteronism screening rats in patients with hypertension in an underserved urban healthcare system.
We reviewed records of outpatient adults in an urban healthcare system from 2013 to 2017. Chart review along with International Statistical Classification of Diseases, 9th and 10th editions, diagnosis codes were used to identify patients meeting inclusion criteria for screening according to the 2016 Endocrine Society guidelines. The corresponding aldosterone, plasma renin activity, and 24-hour urine aldosterone values were identified. Multivariate logistic regression was performed to determine positive predictors of screening.
Of 15,511 hypertensive patients seen, 6,809 (43.8%) met criteria for screening. Blacks were the most common racial group, and Medicare and Medicaid were the most frequent insurers. The aldosterone-to-renin ratio level was checked in 86 (1.3%) patients; 22 (25.6%) had an aldosterone-to-renin ratio >20. Of the 77 patients with hypertension and incidentaloma, 14 (18.2%) had an aldosterone-to-renin ratio checked. Additional positive predictors for being screened were hypertension and hypokalemia and sustained hypertension.
Screening rates for primary aldosteronism in an underserved population are low. Proper identification of primary aldosteronism in those at risk could help ameliorate long-term effects of disease.
Background Alpha-blockade is the standard management preoperatively to prevent intraoperative hemodynamic instability (IHD) during resection of a pheochromocytoma. Calcium channel blockers also have ...been shown to lessen the risk of IHD. We aim to determine differences between these classes of antihypertensive agents in minimizing IHD. Methods This was a retrospective analysis from a tri-institutional database. Inclusion criteria were unilateral transabdominal adrenalectomy for pheochromocytomas between 2002 and 2012. IHD was defined as at least one systolic blood pressure (SBP) measurement >160 mm Hg and at least one episode of mean arterial pressure 60 mm Hg. Results A total of 155 patients were included: 110 receiving calcium channel blockers, 41 alpha-blockade, and 4 no medication. Intraoperatively, mean maximal SBP was less after alpha-blockade ( P < .0001) as well as the incidence and duration of episodes of SBP >200 mm Hg ( P < .01); however, severe hypotensive episodes (MAP <60 mm Hg) were more frequent ( P < .001) and longer ( P < .0001) with alpha-blockade. Consequently, intraoperative vasoactive drugs were used more frequently ( P = .03), and mean fluid volume infused was larger ( P < .001). Fifty-four patients had IHD, but these were independent of type of preoperative medication used. Familial disease was the only independent predictor of IHD. Conclusion IHD was independent of type of preoperative medical management but was dependent on familial disease. These findings broaden options for clinicians in the preoperative management of pheochromocytoma.
CONTEXT Surgical site infection (SSI) in the general surgical population is
a significant public health issue. The use of a high fractional inspired concentration
of oxygen (FIO2) during the ...perioperative period has been reported
to be of benefit in selected patients, but its role as a routine intervention
has not been investigated. OBJECTIVE To determine whether the routine use of high FIO2 during
the perioperative period alters the incidence of SSI in a general surgical
population. DESIGN, SETTING, AND PATIENTS Double-blind, randomized controlled trial conducted between September
2001 and May 2003 at a large university hospital in metropolitan New York
City of 165 patients undergoing major intra-abdominal surgical procedures
under general anesthesia. INTERVENTIONS Patients were randomly assigned to receive either 80% oxygen (FIO2 of 0.80) or 35% oxygen (FIO2 of 0.35) during surgery and
for the first 2 hours after surgery. MAIN OUTCOME MEASURES Presence of clinically significant SSI in the first 14 days after surgery,
as determined by clinical assessment, a management change, and at least 3
prospectively defined objective criteria. RESULTS The study groups were closely matched in a large number of clinical
variables. The overall incidence of SSI was 18.1%. In an intention-to-treat
analysis, the incidence of infection was significantly higher in the group
receiving FIO2 of 0.80 than in the group with FIO2 of
0.35 (25.0% vs 11.3%; P = .02). FIO2 remained
a significant predictor of SSI (P = .03) in multivariate
regression analysis. Patients who developed SSI had a significantly longer
length of hospitalization after surgery (mean SD, 13.3 9.9 vs 6.0 4.2
days; P<.001). CONCLUSIONS The routine use of high perioperative FIO2 in a general surgical
population does not reduce the overall incidence of SSI and may have predominantly
deleterious effects. General surgical patients should continue to receive
oxygen with cardiorespiratory physiology as the principal determinant.
Context:
The RAF inhibitor vemurafenib has provided a major advance for the treatment of patients with BRAF-mutant metastatic melanoma. However, BRAF-mutant thyroid cancer is relatively resistant to ...vemurafenib, and the reason for this disparity remains unclear. Anti-cancer therapy induced autophagy can trigger adaptive drug resistance in a variety of cancer types and treatments. To date, role of autophagy during BRAF inhibition in thyroid cancer remains unknown.
Objective:
In this study, we investigate if autophagy is activated in vemurafenib treated BRAF-mutant thyroid cancer cells, and whether autophagy inhibition improves or impairs the treatment efficacy of vemurafenib.
Design:
Autophagy level was determined by western blot assay and transmission electron microscopy. The combined effects of autophagy inhibitor and vemurafenib were assessed in terms of cell viability in vitro and tumor growth rate in vivo. Whether the endoplasmic reticulum (ER) stress was in response to vemurafenib-induced autophagy was also analyzed.
Results:
Vemurafenib induced a high level of autophagy in BRAF-mutant thyroid cancer cells. Inhibition of autophagy by either a pharmacological inhibitor or interfering RNA knockdown of essential autophagy genes augmented vemurafenib-induced cell death. Vemurafenib-induced autophagy was independent of MAPK signaling pathway and was mediated through the ER stress response. Finally, administration of vemurafenib with the autophagy inhibitor hydroxychloroquine promoted more pronounced tumor suppression in vivo.
Conclusions:
Our data demonstrate that vemurafenib induces ER stress response-mediated autophagy in thyroid cancer and autophagy inhibition may be a beneficial strategy to sensitize BRAF-mutant thyroid cancer to vemurafenib.
Background
Perineural invasion (PNI) is associated with aggressive tumor behavior, increased locoregional recurrence, and decreased survival in many carcinomas. However, the significance of PNI in ...papillary thyroid cancer (PTC) is incompletely characterized.
Methods
Patients diagnosed with PTC and PNI from 2010-2020 at a single, academic center were identified and matched using a 1:2 scheme to patients without PNI based on gross extrathyroidal extension (ETE), nodal metastasis, positive margins, and tumor size (±4 cm). Mixed and fixed effects models were used to analyze the association of PNI with extranodal extension (ENE)—a surrogate marker of poor prognosis.
Results
In total, 78 patients were included (26 with PNI, 52 without PNI). Both groups had similar demographics and ultrasound characteristics preoperatively. Central compartment lymph node dissection was performed in most patients (71%, n = 55), and 31% (n = 24) underwent a lateral neck dissection. Patients with PNI had higher rates of lymphovascular invasion (50.0% vs. 25.0%,
p
= 0.027), microscopic ETE (80.8% vs. 44.0%,
p
= 0.002), and a larger burden median 5 (interquartile range IQR 2-13) vs. 2 (1-5),
p
= 0.010 and size median 1.2 cm (IQR 0.6-2.6) vs. 0.4 (0.2-1.4),
p
= 0.008 of nodal metastasis. Among patients with nodal metastasis, those with PNI had an almost fivefold increase in ENE odds ratio OR 4.9 (95% confidence interval CI 1.5-16.5),
p
= 0.008 compared with those without PNI. More than a quarter (26%) of all patients had either persistent or recurrent disease over follow-up (IQR 16-54 months).
Conclusions
PNI is a rare, pathologic finding that is associated with ENE in a matched cohort. Additional investigation into PNI as a prognostic feature in PTC is warranted.
Remote-access techniques have been described over the recent years as a method of removing the thyroid gland without an incision in the neck. However, there is confusion related to the number of ...techniques available and the ideal patient selection criteria for a given technique. The aims of this review were to develop a simple classification of these approaches, describe the optimal patient selection criteria, evaluate the outcomes objectively, and define the barriers to adoption.
A review of the literature was performed to identify the described techniques. A simple classification was developed. Technical details, outcomes, and the learning curve were described. Expert opinion consensus was formulated regarding recommendations for patient selection and performance of remote-access thyroid surgery.
Remote-access thyroid procedures can be categorized into endoscopic or robotic breast, bilateral axillo-breast, axillary, and facelift approaches. The experience in the United States involves the latter two techniques. The limited data in the literature suggest long operative times, a steep learning curve, and higher costs with remote-access thyroid surgery compared with conventional thyroidectomy. Nevertheless, a consensus was reached that, in appropriate hands, it can be a viable option for patients with unilateral small nodules who wish to avoid a neck incision.
Remote-access thyroidectomy has a role in a small group of patients who fit strict selection criteria. These approaches require an additional level of expertise, and therefore should be done by surgeons performing a high volume of thyroid and robotic surgery.
In an attempt to prevent overly aggressive treatment of low-risk thyroid cancers, the American Thyroid Association changed guideline recommendations in late 2015 to state that either ...hemithyroidectomy or total thyroidectomy are acceptable operations for these patients. We hypothesized that surgeons would increasingly perform hemithyroidectomy after the release of these guidelines.
The database of the National Surgery Quality Improvement Program was queried to identify all patients with thyroid cancer who were undergoing thyroidectomy between 2009 and 2017. Patients treated before the release of the 2015 American Thyroid Association guidelines were compared with those treated afterward. Temporal trends in operative rates were assessed quarterly using interrupted time series analyses.
A total of 35,291 patients were included in the study. Of those, 26,882 (76.2%) were female and 25,193 (71.3%) were white. After the release of the American Thyroid Association guidelines, there was an increase in hemithyroidectomy rate for patients with cancer from 17.3% to 22.0% (P < .001). Interrupted time series analysis controlling for patient factors demonstrated that quarterly growth in the hemithyroidectomy rate accelerated almost 10-fold (P < .001) after publication of the revised guidelines. Of note, there was no corresponding increase in the completion thyroidectomy rate (8.3% versus 7.9%, respectively, P = .213). Patients treated with hemithyroidectomy were more likely to be managed as outpatients (70.8% versus 57.1%, P < .001), had fewer surgical site infections (0.3% versus 0.5%, P = .050), and had fewer unplanned reintubations (0.2% versus 0.4%, P = .005).
In hospitals participating in the National Surgery Quality Improvement Program, the hemithyroidectomy rate increased significantly after the release of the 2015 American Thyroid Association guidelines. Surgeons at hospitals that participate in the National Surgery Quality Improvement Program may be changing practice patterns in response to these guidelines.
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