Background
There is a paucity of evidence regarding incidence and predictors of survival in pancreatic neuroendocrine tumors (PNETs) ≤2 cm in size.
Methods
Patients having undergone resection for ...nonfunctioning PNETs were selected from the SEER database (1988–2009) and an institutional pathology database (1996–2012). PNETs ≤2 cm were compared with PNETs >2 cm. Data were analyzed with
χ
2
tests, ANOVA, the Kaplan–Meier method, log rank tests, and Cox proportional hazard, and binary logistic regression.
Results
The incidence of PNETs ≤2 cm in the United States has increased by 710.4 % over the last 22 years. Rates of extrapancreatic extension, nodal metastasis, and distant metastasis in PNETs ≤2 cm in the SEER database were 17.9, 27.3, and 9.1 %, respectively. The rate of nodal metastasis in our institutional series was 5.7 %. Disease-specific survival at 5, 10, and 15 years for PNETs ≤2 cm was 91.5, 84.0, and 76.8 %. Decreased disease-specific survival was not associated with nodal metastasis, but rather with high grade moderately differentiated, hazard ratio (HR) 37.2, 95 % confidence interval (CI) 2.7–518.8; poorly differentiated, HR 94.2, 95 % CI 4.9–1,794.4; reference, well differentiated, and minority race (Asian, HR 30.2, 95 % CI 3.1–291.7; Black, HR 60.1, 95 % CI 2.1–1,027.9; reference, White).
Conclusions
Pancreatic neuroendocrine tumors ≤2 cm are increasingly common, and the most significant predictors of disease-specific survival are grade and race. The SEER database excludes PNETs considered to be benign, and rates of extrapancreatic extension, nodal metastasis, and distant metastasis are overestimated. Small size, however, does not preclude malignant behavior.
Whereas racial disparities in thyroid cancer care are well established, the role of social determinants of health is less clear. We aimed to assess the individual and cumulative impact of social ...determinants of health on mortality and time to treatment among patients with thyroid cancer.
We collected social determinants of health data from thyroid cancer patients registered in the National Cancer Database from 2004 to 2017. We created a count variable for patients in the lowest quartile of each social determinant of health (ie, low income, low education, and no insurance). We assessed the association of social determinants of health with mortality and time to treatment and the association between cumulative social determinants of health count and time to treatment using Cox regression.
Of the 142,024 patients we identified, patients with longer time to treatment had greater mortality compared to patients treated within 90 days (90-180 days, adjusted hazard ratio 1.21 (95% confidence interval 1.13-1.29, P < .001); >180 days, adjusted hazard ratio 1.57 (95% confidence interval 1.41-1.76, (P < .001). Compared to patients with no adverse social determinants of health, patients with 1, 2, or 3 adverse social determinants of health had a 10%, 12%, and 34%, respectively, higher likelihood of longer time to treatment (1 social determinant of health, hazard ratio 0.90, 95% confidence interval 0.89-0.92, P < .001; 2 social determinants of health, hazard ratio 0.88, 95% confidence interval 0.87-0.90, P < .001; 3 social determinants of health, hazard ratio 0.66, 95% confidence interval 0.62-0.71, P < .001 for all). On subgroup analysis by race, each adverse social determinant of health was associated with an increased likelihood of a longer time to treatment for Black and Hispanic patients (P < .05).
A greater number of adverse social determinants of health leads to a higher likelihood of a longer time to treatment for patients with thyroid cancer, which, in turn, is associated with an increased risk for mortality.
Radiofrequency ablation is an emerging technology in the United States to treat benign thyroid nodules. The cost-effectiveness of radiofrequency ablation in comparison with traditional thyroidectomy ...is unknown.
A patient-level state transition microsimulation decision model was constructed comparing radiofrequency ablation with lobectomy in the management of benign thyroid nodules. Our base case was a 45-year-old woman with a solitary 30-cm3 nodule. Estimates of health utilities, complications, and mortality were obtained from the literature, and costs were estimated using Medicare reimbursement data. The primary outcomes of interest included total cost, quality-adjusted life years, and incremental cost-effectiveness ratios. All model estimates were subjected to 1-way sensitivity analyses to identify factors that strongly influence cost-effectiveness. A probabilistic sensitivity analysis was run across 1 million simulations to gauge outcome confidence with a willingness-to-pay threshold set at $100,000/quality-adjusted life year.
Radiofrequency ablation was assumed to cost $5,000, with an initial success rate of 78%. Patients with volume reduction ratio <50% underwent a second treatment of radiofrequency ablation. Radiofrequency ablation represented the dominant strategy, yielding 21.31 quality-adjusted life years for a total cost of $16,563 in comparison to lobectomy, which yielded 21.13 quality-adjusted life years for a total cost of $19,262. In a 1-way sensitivity analysis varying the cost of radiofrequency ablation across of range of values, the radiofrequency ablation strategy remained cost-effective until the cost of radiofrequency ablation exceeded $12,330 at willingness-to-pay $50,000 or $17,950 at willingness-to-pay $100,000.
Radiofrequency ablation is a cost-effective strategy in the treatment of benign thyroid nodules but is most sensitive to the cost of radiofrequency ablation.
...numerous educational considerations may influence the decision to use IONM. ...prevention of RLN injury remains one of the highest priorities of thyroid surgery. Furthermore, visual identification ...alone may have additional benefits in training the next generation of endocrine surgeons. ...when it comes to the question of whether ‘to stim, or not to stim,’ the decision should be left to the purview of the operating surgeon, acknowledging that direct visualization with or without IONM are both acceptable strategies.Conflicts of interest The authors have no conflicts of interest to disclose.
Recent critiques of physics education research (PER) studies have revoiced the critical issues when drawing causal inferences from observational data where no intervention is present. In response to ...a call for a “causal reasoning primer” in PER, this paper discusses some of the fundamental issues in statistical causal inference. In reviewing these issues, we discuss well-established causal inference methods commonly applied in other fields and discuss their application to PER. Using simulated data sets, we illustrate (i) why analysis for causal inference should control for confounders but not control for mediators and colliders and (ii) that multiple proposed causal models can fit a highly correlated dataset. Finally, we discuss how these causal inference methods can be used to represent and explain existing issues in quantitative PER. Throughout, we discuss a central issue in observational studies: A good quantitative model fit for a proposed causal model is not sufficient to support that proposed model over alternative models. To address this issue, we propose an explicit role for observational studies in PER that draw statistical causal inferences: Proposing future intervention studies and predicting their outcomes. Mirroring the way that theory can motivate experiments in physics, observational studies in PER can predict the causal effects of interventions, and future intervention studies can test those predictions directly.
Patients with primary hyperparathyroidism are at risk for skeletal and renal end-organ damage.
We studied patients with biochemically confirmed primary hyperparathyroidism from 1995–2014 and ...quantified the frequency of osteoporosis, nephrolithiasis, hypercalciuria, and decrease in renal function.
The cohort comprised 9,485 patients. In total, 3,303 (35%) had preexisting end-organ effects (osteoporosis, 24%; nephrolithiasis, 10%; hypercalciuria, 5%). Of 6,182 remaining patients, 1,769 (29%) exhibited progression to 1 or more end-organ effects over a median 3.7 years. Among patients with classic primary hyperparathyroidism (calcium and parathyroid hormone increased), progression was unrelated to the degree of hypercalcemia (calcium >11.5 mg/dL, hazard ratio 1.03, 95% confidence interval 0.85–1.25; 11.1–11.5 mg/dL, HR 1.07, 95% confidence interval 0.93–1.23; 10.5–11.0 mg/dL = reference). Patients with nonclassic primary hyperparathyroidism (calcium increased, parathyroid hormone 40–65 pg/mL) had a lesser risk of progression (calcium >11.5 mg/dL, hazard ratio 0.68, 95% confidence interval 0.50–0.94; 11.1–11.5 mg/dL, hazard ratio 0.68, 95% confidence interval 0.56–0.82; 10.5–11.0 mg/dL, hazard ratio 0.66, 95% confidence interval 0.59–0.74). End-organ damage developed before or within 5 years of diagnosis for 62% of patients.
End-organ manifestations of primary hyperparathyroidism develop before biochemical diagnosis or within 5 years in most patients. End-organ damage occurred more frequently in patients with classic primary hyperparathyroidism versus nonclassic primary hyperparathyroidism, regardless of severity of hypercalcemia.
Radiofrequency ablation (RFA) effectively reduces volume and improves symptoms of benign, non-functioning thyroid nodules (NFTNs). Given RFA's unclear impact on thyroid function, we examined post-RFA ...trends in thyroid hormones and antibodies.
A retrospective cross-sectional analysis was conducted of patients treated at Columbia University with RFA for benign NFTNs between August 2019 and July 2023. Thyroid function tests were recorded pre-RFA and repeated 3, 6, and 12 months post-RFA.
We analyzed 185 patients with 243 benign NFTNs who underwent RFA. Volume reduction ratio increased post-RFA. Mean TSH increased to 2.4 mlU/L (p = 0.005) at 3 months post-RFA and decreased to 1.8 mlU/L (p = 0.551) by 12 months post-RFA. Tg and TPO antibody levels peaked at 6 months post-RFA (103.1 IU/mL, p = 0.868 and 66.6 IU/mL, p = 0.523, respectively).
With expected volume reduction post-RFA, we observed transient relative hypothyroidism as well as transient increases in thyroid antibodies, with normalization of these changes within 12 months.
•Transient relative hypothyroidism observed at 3 months after RFA of NFTNs.•Transient increases in thyroid antibodies peaked at 6 months after RFA of NFTNs.•Long-term normalization of thyroid hormone and antibody changes.
The American Thyroid Association updated guidelines in 2015 to allow lobectomy for low-risk thyroid cancers. The objectives of this study were (1) to determine thyroid hormone supplementation rates ...after lobectomy and (2) to evaluate the effect of the American Thyroid Association guideline change on lobectomy and hormone supplementation rates among thyroid cancer patients.
The Merative MarketScan Databases was used to identify adult (≥age 18) patients who underwent thyroidectomy for benign nodules or thyroid cancer. The association between indication for surgery and postoperative thyroid hormone supplementation was examined using χ2 analyses and multivariable logistic regression models. Among patients with thyroid cancer, lobectomy and hormone supplementation rates were compared in the periods before (2008–2015) and after the guideline change (2016–2019).
Of the 81,926 patients identified, 33,756 (41.2%) underwent thyroid lobectomy, 45,104 (55.1%) underwent total thyroidectomy, and 3,066 (3.7%) underwent completion thyroidectomy. Patients who underwent lobectomy for malignancy were significantly more likely to require hormone supplementation (59.3% vs 39.4% P < .001, adjusted odds ratio 2.34 95% confidence interval 2.20–2.48) compared to those with benign disease. Compared to the 2008 to 2015 period, the proportion of patients who underwent lobectomy for thyroid cancer was higher in the 2016 to 2019 period (34.3% vs 30.3%, P < .001), with fewer patients requiring completion thyroidectomy (25.6% vs 29.8%, P < .001) and thyroid hormone supplementation (56.9% vs 60.1%, P = .04).
The postoperative thyroid hormone supplementation rate was significantly higher in patients who had thyroid cancers compared to benign diseases. After the American Thyroid Association guidelines changed, lobectomy rates increased significantly without a concomitant increase in the completion of thyroidectomy.
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