Background Nonfunctioning pancreatic neuroendocrine tumors (NF-PNETs) are often discovered at a small size. No clear consensus exists on the management of NF-PNETs ≤ 2 cm. The aim of our study was to ...determine the prognostic value of indicators of malignancy in sporadic NF-PNETs ≤ 2 cm. Methods Eighty patients were evaluated retrospectively in 7 French University Hospital Centers. Patients were managed by operative resection (operative group OG) or observational follow-up (non-OG NOG). Pathologic characteristics and outcomes were analyzed. Results Sixty-six patients (58% women) were in the OG (mean age, 59 years; 95% CI, 56.0–62.3; mean tumor size, 1.6 cm; 95% CI, 1.5–1.7); 14 (72% women, n = 10) were in the NOG (mean age, 63 years; 95% CI, 56–70; mean tumor size, 1.4 cm; 95% CI, 1.0–1.7). All PNETs were ranked using the European Neuroendocrine Tumor Society grading system. Fifteen patients (19%) had malignant tumors defined by node or liver metastasis (synchronous or metachronous). The median disease-free survival was different between malignant and nonmalignant PNETs, respectively: 16 (range, 4–72) versus 30 months (range, 1–156; P = .03). On a receiver operating characteristic (ROC) curve, tumor size had a significant impact on malignancy (area under the curve AUC, 0.75; P = .03), but not Ki-67 (AUC, 0.59; P = .31). A tumor size cutoff was found on the ROC curve at 1.7 cm (odd ratio, 10.8; 95% CI; 2.2–53.2; P = .003) with a sensitivity of 92% and a specificity of 75% to predict malignancy. Conclusion Based on our retrospective study, the cutoff of 2 cm of malignancy used for small NF-PNETs could be decreased to 1.7 cm to select patients more accurately.
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.
Background Adrenocortical carcinoma is a rare neoplasm with a high rate of recurrence. We studied the impact of surgery on the survival in recurrent adrenocortical carcinoma patients. Methods We ...performed a retrospective review of patients with recurrent adrenocortical carcinoma, managed in 5 French University Hospitals between 1980 and 2014. We compared surgery and medical management for ACC recurrence. Results Fifty-nine patients were included, 46 of whom had an initial R0 resection. Twenty-nine patients underwent reoperation for recurrence, while 30 had nonoperative treatments. Operated patients had a greater median overall survival after recurrence than nonoperated patients (91 vs 15 months; P < .001). Patients operated on for local or distant recurrence had similar overall survival (110 vs 91 months; P = .81). In nonoperated patients, types of medical managements did not impact survival. Surgery for recurrence ( P = .037) and a disease-free interval between initial resection and recurrence >12 months ( P = .059) were both prognostic factors for improved survival, whereas age, stage, and tumor size ( P ≥ .2 each) were not. A Ki67 <25% tended to be associated with better overall survival ( P = .051). Conclusion Both surgery for recurrence and disease-free interval between the initial resection of an adrenocortical carcinoma and recurrence >12 months are associated with better overall survival.
Background Only a minority of patients with primary hyperparathyroidism (pHPT) present with the “classic” symptoms. Most patients have numerous nonspecific symptoms. The aim of this study was to ...evaluate patients’ quality of life and nonspecific symptoms before and after cure for pHPT. Methods This prospective, multicentric study, which took place from May 2003 to September 2004, included 100 patients. Six academic departments of Endocrine Surgery in France participated in the study: the University of Angers, Limoges, Nancy, Nantes, Marseille, and Poitiers. Only cured patients were included. All patients were given preoperative and postoperative questionnaires (the SF-36v2 Health Survey) at 3, 6, and 12 months to evaluate quality of life and nonspecific symptoms. Results Preoperatively, the main nonspecific symptoms included the following: anxiety (89%); muscular, bone, or join pain (87%); abdominal distention (82%); forgetfulness (81%); headaches (81%); and mood swings (79%). Quality of life was significantly improved at 3 and 6 months ( P < .05). At 1 year postoperatively, statistically significant improvement ( P < .05) persisted in all 8 domains of the SF-36v2. At 1 year after parathyroidectomy, 5 symptoms remained significantly improved: appetite loss, weight loss, thirst, headache, and nausea. Conclusions Operative cure of primary hyperparathyroidism significantly improves quality of life and nonspecific symptoms for at least 1 year.
Background The cost disparity between the United States and other advanced health care systems, including France, is expanding. In this report we identified the management of papillary thyroid cancer ...(PTC) that contribute to reimbursement disparity. Methods A tri-institutional, retrospective review included 200 patients with PTC (100 from the United States, 100 from France) treated by total thyroidectomy with/without central neck dissection. A cost model was generated incorporating perioperative management variables (within 1 year) and their reimbursement rates according to the 2014 US Medicare and French government fee-schedules. Results In the United States, total thyroidectomy with central neck dissection was more frequent (92% vs 35%, P < .001), median duration of stay was less (1 vs 3 days, P < .001), and use of radioactive iodine was less (66% vs 93%, P < .001), although Thyrogen stimulation was more prevalent (100% vs 43%, P < .001). Overall, the median cost per patient was greater in the United States ($14,069 vs $4,590, P < .001). Reimbursements to the hospital facility accounted for 70% of the disparity, despite lesser durations of stay. Nuclear medicine accounted for 19%, mostly from Thyrogen reimbursement despite less use of radioactive iodine. Surgeon fees accounted for 6%, followed by office visits, laboratory/imaging, anesthesia/pathology fees, and medications. Conclusion The costs of management of PTC are substantially greater in the US compared with France. Efforts to decrease this disparity should focus on reimbursements for hospital facility and use of nuclear medicine imaging.
Background Primary hyperparathyroidism is associated with an increased cardiovascular morbidity and mortality. However, mechanisms underlying this association are currently unclear. As there is clear ...evidence of the independent role of aldosterone on the cardiovascular system, the aim of this study was to evaluate aldosterone levels in patients with primary hyperparathyroidism. Methods A prospective study of 134 consecutive patients with primary hyperparathyroidism before and 3 months after parathyroidectomy. Results Pre-operative serum aldosterone and parathyroid hormone (PTH) levels were correlated positively in all patients (.238; P = .005). In the 62 patients (46%) that were not on antihypertensive medications, this correlation was stronger (.441; P = .0003). In the 72 patients (54%) treated with at least 1 antihypertensive medication, no correlation between preoperative aldosterone and PTH serum levels was observed. By multivariate analysis, pre-operative PTH level (.409; P = .005) was an independent predictor of aldosterone. Pre-operative PTH level >100 ng/L was an independent predictor of abnormally elevated plasma aldosterone level (odds ratio 3.5; P = .01). At 3 months after parathyroidectomy, no correlation was observed between postoperative PTH and aldosterone levels. Conclusion Aldosterone is correlated positively to preoperative PTH levels in patients with primary hyperparathyroidism. Aldosterone might be a key mediator of cardiovascular symptoms in patients with primary hyperparathyroidism.
Background 18-F-fluoro-2-deoxyglucose positron emission tomography (18 FDG-PET) is useful in the detection of iodine-negative differentiated thyroid carcinoma (DTC). The aim of this prospective study ...was to assess therapeutic impact of18 FDG-PET imaging using a PET/computed tomography (CT) system in patients with iodine-negative recurrence of DTC. Methods From 2002 to 2006, patients with recurrence of DTC diagnosed by elevated thyroglobulin level and negative 131-I whole-body scan were included. Results 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 of18 FDG-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 of18 FDG-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. Conclusion18 FDG-PET/CT is able to select patients who can benefit from surgery. Normalization of thyroglobulin is observed in one third of operated patients.
