Background The tall cell (TC) variant of papillary thyroid carcinoma (PTC) is more aggressive than classic PTC, but the percentage of TC necessary to diagnose this variant has been debated. We aimed ...to better determine what percentage of TC correlates with a more aggressive phenotype. Methods Cases from 2005 to 2010 that were the TC variant of PTC or PTC with TC features were identified and compared with classic PTCs. All cases were reviewed to determine what percent, if any, of the tumors consisted of TC. Results One hundred forty-one cases of PTC were reviewed. Eighty-three cases had some TC component, and 58 cases had none. There were no differences in patient demographics. Tumors with ≥10% TC had more extrathyroidal extension, angiolymphatic invasion, positive surgical margin, and lymph node involvement than classic PTC. There were more recurrences in patients with ≥10% TC, but this was not significant. Similar findings were also observed with increasing percentages of TC. Conclusion The aggressive features conferred by the presence of TC in PTCs occur with as little as 10% TC and are maintained with increasing percentages. Therefore, TC in a PTC should be reported if they comprise at least 10% of the tumor.
Background The calcimimetic drug cinacalcet has changed the prescription patterns in patients with secondary hyperparathyroidism, despite the lack of randomized studies that compare cinacalcet with ...conventional treatment, including parathyroidectomy. The aim of this study was to evaluate current management of patients on chronic dialysis with incidental and parathyroid hormone (PTH) levels ≥500 ng/L. Methods Prospective pharmacoepidemiologic study of chronic dialysis patients with PTH level ≥500 ng/L. Results We studied 269 patients. Among the 186 patients who had 2-year follow-up, 125 (67%) were managed using cinacalcet. At 2 years, when comparing the cinacalet with the noncinacalet groups, we found that mean PTH values were 400 ± 318 versus 388 ± 251 ng/L ( P = ns) and the percentage of patients following 2009 PTH Kidney Disease Improving Global Outcomes (KDIGO) guidelines were 79 versus 85% ( P = ns). Eight patients (4%) underwent parathyroidectomy. On multivariate analysis, the use of cinacalcet was not a predictor for PTH within KDIGO guidelines at 2-year follow-up. Conclusion Cinacalcet was used in the majority (67%) of patients on chronic dialysis with secondary hyperparathyroidism, but the use of cinacalcet did not affect mean PTH values nor the proportion of patients following KDIGO guidelines compared with patients not using calcimimetics.
Background Extrathyroidal extension (ETE) is a risk factor for recurrence of papillary thyroid carcinoma (PTC). Although initial data supporting this was based on gross ETE noted at surgery, current ...treatment regimens group patients with microscopic ETE—identified only on histopathology—similarly to those with macroscopic (gross) ETE. This study was designed to assess the influence of microscopic ETE on disease recurrence. Methods Retrospective analysis of 212 patients undergoing thyroidectomy for PTC between 1995 and 2004 with minimum 3-year follow-up was conducted. Results Of 212 patients, 71 had ETE; 32% were macroscopic and 68% microscopic. Patient demographics, tumor variables, and adjuvant therapy were similar between both ETE groups. Recurrence rates were 52% for macroscopic ETE, 21% for microscopic ETE, and 13% without ETE. On multivariate analysis, patients with macroscopic ETE had a 6.4-fold increased relative risk of recurrence compared with patients with microscopic ETE ( P < .02; 95% confidence interval, 1.6–25.9) and a significantly decreased disease-free survival (DFS). Furthermore, patients with microscopic ETE had neither a significantly increased risk of recurrence nor different DFS compared with patients without ETE. Conclusion Macroscopic ETE has a higher incidence of disease recurrence than microscopic ETE, implying they should be considered separately when devising adjuvant treatment regimens. The significance of microscopic ETE is undetermined.
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.
Abstract
Background and study aims
Concomitant hiatal hernia (HH) repair with transoral incisionless fundoplication (TIF) is a therapeutic option for patients with HH > 2 cm and gastroesophageal ...reflux disease (GERD). Data comparing this approach with laparoscopic Nissen fundoplication (LNF) are lacking. We performed an exploratory analysis to compare these two approaches' adverse events (AEs) and clinical outcomes.
Patients and methods
This was a multicenter retrospective cohort study of HH repair followed by LNF versus HH repair followed by TIF in patients with GERD and moderate HH (2–5 cm). AEs were assessed using the Clavien-Dindo classification. Symptoms (heartburn/regurgitation, bloating, and dysphagia) were compared at 6 and 12 months.
Results
A total of 125 patients with HH repair with TIF and 70 with HH repair with LNF were compared. There was no difference in rates of discontinuing or decreasing proton pump inhibitor use, dysphagia, esophagitis, disrupted wrap, and HH recurrence between the two groups (
P
> 0.05). The length of hospital stay (1 day vs. 2 days), 30-day readmission rate (0 vs. 4.3 %), early AE rate (0 vs. 18.6 %), and early serious AE rate (0 vs. 4.3 %) favored TIF (all
P
< 0.05). The rate of new or worse than baseline bloating was lower in the TIF group at 6 months (13.8 % vs. 30.0 %,
P
= 0.009).
Conclusions
Concomitant HH repair with TIF is feasible and associated with lower early and serious AEs compared to LNF. Further comparative efficacy studies are warranted.
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.
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