Safety of laparoscopic adrenalectomy in patients with large pheochromocytomas: a single institution review

BACKGROUND

Laparoscopic adrenalectomy is the procedure of choice for small adrenal tumors, but some concerns have been voiced when this approach is adopted for larger tumors and pheochromocytomas. The aim of this study was to examine the results of the laparoscopic resection of large pheochromocytomas.

METHODS

A retrospective review of adrenalectomies performed for adrenal pheochromocytomas>6 cm in diameter. We compiled and analyzed the early operative complications, histologic findings, and cure rates with a minimum of 1 year of follow-up after surgery.

RESULTS

From 1996 to 2005, a total of 445 laparoscopic adrenalectomies were performed in our institution using the anterolateral transperitoneal approach. From this series we identified 18 procedures for pheochromocytomas with an average diameter on imaging of 78.2 mm (range 60-130 mm). All patients were rendered safe with a standard departmental protocol involving calcium-channel blockade initiated at least 2 weeks prior to surgery. The average peak intraoperative blood pressure was 187 mmHg. Capsular disruption occurred in two cases. One patient required an intraoperative blood transfusion due to intraoperative blood loss. No immediate conversions to an open procedure were required, but one patient underwent a delayed laparotomy for hematoma formation. Histologically, four of the adrenal tumors displayed evidence of vascular invasion. Biochemical cure was achieved in all patients after a median follow-up of 58 months (16-122 months).

CONCLUSIONS

Laparoscopic adrenalectomy appears to be a safe and effective approach for large pheochromocytomas when no preoperative or intraoperative evidence of local invasion is present.

The role of 18F-FDOPA and 18F-FDG-PET in the management of malignant and multifocal phaeochromocytomas

BACKGROUND

(18)F-DOPA has emerged as a promising tool in the localization of chromaffin-tissue-derived tumours. Interestingly, phaeochromocytomas (PHEO) are also FDG avid.

AIM AND METHODS

The aim of this study was to retrospectively evaluate the results of (18)F-FDOPA and/or (18)F-FDG-PET in patients with PHEO and paragangliomas (PGLs) and to compare the outcome of this approach with the traditional therapeutic work-up. Nine patients with non-MEN2 related PHEO or PGL were evaluated. At the time of the PET studies, the patients were classified into three groups based on their clinical history, conventional and SPECT imaging. The groups were malignant disease (n = 5, 1 VHL), apparently unique tumour site in patients with previous surgery (n = 1, SDHB) and multifocal tumours (n = 3, 1 VHL, 1 SDHD). (18)F-FDOPA and (18)F-FDG-PET PET/CT were then performed in all patients.

RESULTS

PET successfully identified additional tumour sites in five out of five patients with metastatic disease that had not been identified with SPECT + CI. Whilst tumour tracer uptake varied between patients it exhibited a consistently favourable residence time for delayed acquisitions. (18)F-FDOPA uptake (SUVmax) was superior to (18)F-FDG uptake in cases of neck PGL (three patients, four tumours). If only metastatic forms and abdominal PGLs were considered, (18)F-FDG provided additional information in three cases (two metastatic forms, one multifocal disease with SDHD mutation) compared to (18)F-FDOPA.

CONCLUSIONS

Our results suggest that tumour staging can be improved by combining (18)F-FDOPA and (18)F-FDG in the preoperative work-up of patients with abdominal and malignant PHEOs. (18)F-FDOPA is also an effective localization tool for neck PGLs. MIBG however, still has a role in these patients as MIBG and FDOPA images did not completely overlap.

Does 18F-FDG PET/CT add diagnostic accuracy in incidentally identified non-secreting adrenal tumours?

PURPOSE

The widespread use of high-resolution cross-sectional imaging such as computed tomography (CT) and magnetic resonance imaging (MRI) for the investigation of the abdomen is associated with an increasing detection of incidental adrenal masses. We evaluated the ability of (18)F-fluorodeoxyglucose positron emission tomography to distinguish benign from malignant adrenal masses when CT or MRI results had been inconclusive.

METHODS

We included only patients with no evidence of hormonal hypersecretion and no personal history of cancer or in whom previously diagnosed cancer was in prolonged remission. PET/CT scans were acquired after 90 min (mean, range 60-140 min) after FDG injection. The visual interpretation, maximum standardised uptake values (SUVmax) and adrenal compared to liver uptake ratio were correlated with the final histological diagnosis or clinico-radiological follow-up when surgery had not been performed.

RESULTS

Thirty-seven patients with 41 adrenal masses were prospectively evaluated. The final diagnosis was 12 malignant, 17 benign tumours, and 12 tumours classified as benign on follow-up. The visual interpretation was more accurate than SUVmax alone, tumour diameter or unenhanced density, with a sensitivity of 100% (12/12), a specificity of 86% (25/29) and a negative predictive value of 100% (25/25). The use of 1.8 as the threshold for tumour/liver SUVmax ratio, retrospectively established, demonstrated 100% sensitivity and specificity.

CONCLUSION

FDG PET/CT accurately characterises adrenal tumours, with an excellent sensitivity and negative predictive values. Thus, a negative PET may predict a benign tumour that would potentially prevent the need for surgery of adrenal tumours with inconclusive conventional imaging.

Tomoscintigraphy Improves the Determination of the Embryologic Origin of Parathyroid Adenomas, Especially in Apparently Inferior Glands: Imaging Features and Surgical Implications

Identification of the embryologic origin of hyperfunctioning parathyroid adenomas in primary hyperparathyroidism (PHPT) could determine the most suitable approach for minimally invasive surgery. The aim of this study was to prospectively evaluate the reliability of a new, combined protocol for the preoperative localization and determination of the embryologic origin of parathyroid adenomas.

METHODS

Anterior dual-isotope ((123)I/(99m)Tc-sestamibi) static planar imaging followed by tomoscintigraphy (SPECT acquisition) centered over the 140-keV photopeak (combined protocol) was performed on 35 consecutive patients with sporadic PHPT. On the basis of anatomic considerations, adenomas were classified as superior (P4 derived) if they were located above the isthmus or posterior to the thyroid on SPECT images, despite their apparently middle to inferior position, and as inferior (P3 derived) if the foci were located in inferior and anterior positions or along the thyrothymic tract. Parathyroid ultrasonography was performed on all patients.

RESULTS

A total of 36 adenomas were removed: 34 solitary adenomas and 1 double adenoma (for totals of 19 P3-derived and 17 P4-derived adenomas). Pinhole subtraction imaging, SPECT, and ultrasonography sensitivities for detecting adenomas were 86%, 78%, and 77%, respectively. False-positive contralateral images were observed only with ultrasonography (3 cases). Positive SPECT results were associated with higher gland weights. Thirteen glands were identified by SPECT as posterior glands, despite their apparently inferior position, and were removed through an appropriate lateral endoscopic approach. Eleven (85%) of these glands had a P4 origin. Only 2 corresponded to large P3-derived adenomas (>2 g).

CONCLUSION

By reclassifying apparently inferior adenomas as P4-derived adenomas prolapsed behind the thyroid gland, SPECT provides information about the most suitable surgical approach for avoiding recurrent laryngeal nerve injury. Additional pinhole images should increase the detection of small adenomas. The combined protocol offers both advantages.

Intraoperative diagnosis and treatment of parathyroid cancer and atypical parathyroid adenoma

Background

Distinction of parathyroid cancer from atypical parathyroid adenoma (APA) at operation is difficult. The aim of this study was to determine whether parathyroid cancer and APA have different operative findings and long-term outcomes.

Methods

A retrospective review was undertaken of patients with suspicious or malignant parathyroid tumours treated between 1974 and 2005. Parathyroid cancer was defined as a lesion with vascular or tissue invasion, and APA as a neoplasm with broad fibrous bands, trabecular growth, mitosis and nuclear atypia.

Results

Twenty-seven patients with suspicious or malignant parathyroid tumours were identified. After histological review, parathyroid cancer was confirmed in 11 patients (group 1) and 16 tumours were classified as APA (group 2). The clinical presentation and operative findings of the two types of tumour were indistinguishable. At initial surgery, seven patients in group 1 underwent en bloc resection, and four had parathyroidectomy. Four of the seven patients who had en bloc resection had recurrences. No recurrences were observed in the other seven patients in group 1 at a median follow-up of 65 months. In group 2, eight patients had en bloc resection and eight had parathyroidectomy; no patient had recurrence at a median follow-up of 91 months.

Conclusion

Operative findings cannot distinguish APA from parathyroid cancer reliably. Without evidence of macroscopic local invasion, the value of en bloc resection at initial surgery remains debatable.

Prospective evaluation of quality of life (SF-36v2) and nonspecific symptoms before and after cure of primary hyperparathyroidism (1-year follow-up)

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.

Isolated adrenal metastasis: the role of laparoscopic surgery

BACKGROUND

Solitary adrenal metastases (AM) are rare and their management unclear. Surgery, especially laparoscopic adrenalectomy (LA), is debatable in the management of AM. This retrospective study analysed the feasibility and the results of LA for AM.

METHODS

From 1997 to 2003, 16 patients underwent LA for isolated AM. Completeness of resection, postoperative morbidity and follow-up (FU) were recorded.

RESULTS

There were 10 synchronous AM and 6 metachronous AM. Primary tumours included lung cancer (n = 9), melanoma (n = 3), mesothelioma (n = 1), rhabdomyosarcoma (n = 1), colonic adenocarcinoma (n = 1) and renal cell carcinoma (n = 1). Five patients required conversion to an open procedure. Minor complications occurred in three patients. Pathology confirmed the diagnosis of AM. Mean tumour size was 60 (range: 15-110) mm. Nine patients (56%) had complete resections, 3 had positive margins and 4 had incomplete macroscopic resections. Mean observed FU was 25 (range: 1-68) months. Median overall calculated survival was 23 months. Overall 5-year survival was 33% (Kaplan-Meyer). At the end of study, 8 patients were alive with a mean FU of 35 months (3 without evidence of disease). No patient presented with local relapse or port-site metastasis. We did not identify any predictive factors. All patients with incomplete macroscopic resection died within 24 months.

CONCLUSIONS

LA can achieve an acceptable 5-year survival, comparable to open surgery but with better postoperative comfort. It should be considered for AM with the intention of complete resection. It offers the patient the possibility of tumour resection with the benefit of a laparoscopic approach.

Endoscopic lateral approach thyroid lobectomy: safe evolution from endoscopic parathyroidectomy

INTRODUCTION

Endoscopic thyroid surgery has been shown to be feasible. Most minimal access procedures have been performed via a midline approach. Based on our experience of more than 500 endoscopic parathyroidectomies via a lateral approach we have used the same method for thyroid lobectomy.

METHODS

We present our experience of endoscopic thyroid lobectomy via a lateral approach (ETLA) and review of the results over a 1-year period (2004). Inclusion criteria for ETLA were (1) solitary nodule with atypical/suspicious fine-needle biopsy (FNB) or solitary toxic nodule; (2) lesions with a diameter of < 3 cm. Patients with a history of previous neck surgery or radiation exposure were excluded. All patients underwent postoperative vocal cord checks and plasma calcium evaluation.

RESULTS

A total of 742 thyroid procedures were performed during 2004. Among them, 38 patients (5.1%) underwent ETLA. Indications for surgery were suspicious FNB results (36 patients) and a toxic nodule (2 patients). Mean nodule size was 19.2 mm. Mean +/- SD operating time was 102 +/- 27 minutes. All recurrent laryngeal nerves were identified (including one that was nonrecurrent). Of the 38 patients, the superior parathyroid gland was identified in 36 and the inferior parathyroid gland in 33. There were two conversions due to difficulty with the dissection. Two operations were converted because malignancy was diagnosed on frozen section examination. Two patients underwent a delayed completion thyroidectomy when definitive histology necessitated it. There were no permanent operative complications, and all patients were discharged on the first postoperative day.

CONCLUSIONS

ETLA offers excellent intraoperative visualization of the vital structures and is a safe alternative to conventional thyroid lobectomy in selected cases.

Long-term outcome following laparoscopic adrenalectomy for large solid adrenal cortex tumors

INTRODUCTION

Laparoscopic adrenalectomy (LA) is the procedure of choice for small benign adrenal tumors. In the absence of local invasion or metastases, the preoperative diagnosis of an adrenocortical carcinoma (ACC) is difficult, often leaving size as the principal predictor of malignancy. Large tumors are resectable laparoscopically, but the long-term outcome and therefore appropriateness of LA for cortical tumors > 6 cm is not known.

METHODS

We reviewed the LA experience in our institution since its introduction in June 1994. Patients who underwent LA for solid cortical tumors > or = 60 mm in diameter without preoperative or intraoperative evidence of malignancy were reviewed. Follow-up data, including clinical examination, biochemical analysis, and repeat scans, were reviewed for evidence of local or systemic recurrent disease.

RESULTS

Between 1994 and 2004 a total of 462 adrenalectomies were performed, 391 of which were done laparoscopically. Among them, 19 were solid cortical tumors > or = 60 mm in diameter with no overt malignant preoperative or intraoperative characteristics: 9 nonsecreting tumors, 8 Cushing's syndrome tumors (including 2 virilizing variants), 1 virilizing tumor, and 1 aldosteronoma. The mean age of the patients was 49.9 years (range 22-77 years), and the mean tumor size was 69.0 mm (range 60-80 mm). Histology confirmed a cortical adenoma in eight patients, malignant tumors in three, and indeterminate tumors in eight. The mean follow-up was 34 months (range 4-108 months). Two patients died of systemic recurrent disease (liver metastases) at 10 and 19 months, respectively, following surgery; two other patients died 12 and 21 months, respectively following surgery owing to unrelated cardiovascular and cerebrovascular pathology. One patient underwent surgery for local recurrence 54 months after primary surgery; the remaining 14 patients are well with no clinical or radiologic evidence of recurrent disease.

CONCLUSIONS

Laparoscopic adrenalectomy for large solid cortical tumors without pre- or intraoperative evidence of malignancy is not contraindicated, and it is unlikely to have a deleterious effect on long-term outcome. Each case should be considered individually. We provide an algorithm for the approach to adrenocortical tumors > or = 6 cm.

Lifestyle behaviours and components of energy balance as independent predictors of ghrelin and adiponectin in young non-obese women

AIM

Dysregulation of the normal levels of ghrelin, leptin and adiponectin in young non-obese subjects could promote food intake, diabetes and cardiovascular disease in later stages of life. Little information is available on how plasmatic concentrations of these hormones may be influenced by eating habits and/or components of energy balance in a young population, which if known, could facilitate their voluntary regulation.

METHODS

In this cross-sectional study we examined the predictors of fasting plasma ghrelin, adiponectin and leptin in a population of well-characterized young non-obese women (N = 63). Energy intake was assessed by 24-hour dietary recall, resting metabolic rate (RMR) by indirect calorimetry, physical activity energy expenditure (PAEE) by tri-axial accelerometer, physical fitness by VO(2 peak), and eating behaviors by self administrated questionnaire.

RESULTS

Lower RMR and higher HDL-cholesterol were independent predictors of higher plasma ghrelin explaining 17.6% of its variation even after correcting for BMI. Higher total or central fat mass was the only predictor of higher plasma leptin, and no other variable added any power to the prediction equation. Finally, higher energy intake and waist circumference and lower PAEE predicted lower plasma adiponectin in young non-obese women, explaining 43% of the variation in its concentrations even after correcting for total or central fat mass.

CONCLUSION

Components of the energy balance (ie: energy intake and/or expenditure) influence adiponectin and ghrelin circulating levels. That is, higher energy intake and lower physical activity independently predict lower adiponectin concentrations, whereas lower resting metabolic rate independently predicts higher ghrelin levels in young non-obese women. Prospective studies are needed to examine whether circulating concentrations of ghrelin and adiponectin can be voluntarily regulated by lifestyle interventions.

Thyroid surgery: postoperative hematoma--prevention and treatment

BACKGROUND AND AIMS

Postoperative haematoma formation is a fortunately rare but potentially life-threatening complication of thyroid surgery. This paper aims to identify potential aetiological factors, describe surgical techniques and newer haemostatic agents that may be used to minimise the risk of haematoma formation and propose surgical strategies to deal with haematoma formation.

MATERIALS AND METHODS

An extensive literature search as well as own considerable experience in a tertiary referral centre endocrine surgical unit was drawn upon to review this topic.

CONCLUSIONS

Postoperative haematoma may have a multifactorial aetiology. Numerous manoeuvres and surgical haemostatic agents may be employed to minimise the risk of haematoma formation but are no substitute for meticulous haemostasis. In the event of haematoma formation, early surgical re-intervention is strongly advocated with due care given to at risk structures.

[Applied embryology of parathyroid glands]

The article describes the normal structure of the parathyroid glands (PTG) and their development, anomalies of migration in the process of embryogenesis and congenital ectopias of PTG as well as possible supplementary PTG and their congenital ectopias.

Endocrine surgical technique: endoscopic thyroidectomy via the lateral approach

BACKGROUND

Minimal access approaches are increasingly used in endocrine surgery. Several minimal access approaches to the thyroid gland have been described, including a small-incision lateral approach and a video-assisted central approach, but to date no technique has been universally accepted.

METHODS

Benefiting from the experience of more than 500 endoscopic parathyroidectomies via a lateral neck approach, the authors developed an endoscopic thyroidectomy based on the same approach and principles. Patients with solitary nodules smaller than 3 cm in diameter and no history of neck surgery or irradiation were offered this operation. A detailed description of the surgical technique is provided.

RESULTS

Of the 742 thyroidectomies performed in 2004, 38 (5.1%) were endoscopic thyroidectomies. The mean nodule size was 22-mm (range, 7-47-mm), and the mean operating time was 99 min (range, 64-150-min). In all cases, the recurrent laryngeal nerve was preserved intact, and the superior and inferior parathyroids were identified, respectively, in 36 and 33 of the 38 patients. Two patients required conversion to an open cervicotomy. All patients were discharged the day after surgery.

CONCLUSIONS

The described endoscopic lateral approach combines the coherence of the minimal access lateral approach and the benefits of fiberoptic magnification. It is a safe and effective technique in the hands of an appropriately trained surgeon.

[Abrikossoff tumor of the proximal esophagus misdiagnosed as a thyroid nodule]

The diagnosis of thyroid nodules is straightforward and rarely mistaken. We present a case of a paraesophageal granular cell tumor, discovered incidentally during surgery for what it was diagnosed as a suspicious thyroid nodule by ultrasound and FNA. Complete resection was achieved without disruption of the esophageal mucosa. A terminal branch of the recurrent laryngeal nerve had to be resected en bloc with the tumor. Morphological and immunohistochemical diagnosis was established postoperatively. A review of the literature is presented.

A single-institution 25-year review of true parathyroid cysts

BACKGROUND

Parathyroid cysts (PCs) are rare, and their origin is a subject of debate. They have been described as either functional, causing hyperparathyroidism, or non-functional in eucalcaemic patients.

PATIENTS AND METHODS

We have performed a 25-year departmental review of PCs. Features studied included the clinical presentation and intra-operative findings, and a histological review was performed. Cases of cystic degeneration of parathyroid adenomas and pseudocystic change were excluded.

RESULTS

Over 25 years, 22,009 thyroidectomies and 2,505 parathyroidectomies were performed in our department. Amongst these, 38 non-functional PCs were documented in 37 patients. The mode of presentation included incidental findings on routine chest x-ray, compressive symptoms or an asymptomatic palpable neck mass. Aspiration was the initial treatment in 14 patients and was curative in 10 of these. Four out of 14 patients underwent surgical procedures for recurrence of the cyst that occurred 6 to 48 months after aspiration. In 27 patients, surgery was performed and all identified PCs were localized in the inferior parathyroid glands. Histologically, the cyst wall consisted in associations of lymphoid, muscular, thymic, salivary, adipose and mesenchymal tissues.

CONCLUSIONS

PCs are rare but should be included within the differential diagnosis of a neck lump. True PCs are non-functional. Pathological and immunohistochemical findings are suggestive of a branchial origin. Fine-needle aspiration may be curative and is diagnostic due to the characteristic appearance of the fluid and high PTH levels on assay.

ret/PTC1 and ret/PTC3 in thyroid tumors from Chernobyl liquidators: comparison with sporadic tumors from Ukrainian and French patients

Like children exposed to Chernobyl fallout, the workers who cleaned up after the accident, also known as liquidators, have exhibited an increased incidence of thyroid cancer. A high prevalence of ret/PTC3 rearrangement has been found in pediatric post-Chernobyl thyroid tumors, but this feature has not been investigated in liquidator thyroid tumors. In this study we analyzed the prevalence of ret/PTC1 and ret/PTC3 in thyroid tumors from 21 liquidators, 31 nonirradiated adult Ukrainian patients, and 34 nonirradiated adult French patients. ret rearrangements in carcinomas were found in 83.3% of liquidators, 64.7% of Ukrainian patients, and 42.9% of French patients. The prevalence of ret/PTC1 was statistically similar in the three groups. The prevalence of ret/PTC3 was significantly higher in liquidators than in French patients (P = 0.03) but it was also high in nonirradiated Ukrainian patients who exhibited values intermediate between liquidators and French patients. In adenomas the prevalence of rearrangement was significantly higher in all Ukrainians than in French patients (P = 0.004). Like children exposed to Chernobyl fallout, liquidators showed a high prevalence of ret/PTC3. This finding suggests that irradiation had the same effect regardless of age. However, given the high rate of ret/PTC3 in nonirradiated adult Ukrainians, the possibility of genetic susceptibility or low-level exposure to radiation in that group cannot be excluded.

Lymph node involvement in macroscopic medullary thyroid carcinoma

Background

Medullary thyroid carcinoma (MTC) is a rare disease, with variable tendency to lymphatic spread. The aim of this retrospective study was to identify distinctive features of large MTC with and without nodal metastases.

Methods

Between 1993 and 2003, 28 consecutive patients underwent total thyroidectomy and neck node dissection for sporadic MTC larger than 10 mm in diameter.

Results

All tumours were confirmed to be malignant with a locally invasive pattern of growth. Lymph node metastases were present in 16 patients (N1) and absent in 12 (N0). There were no statistically significant differences between patients with N0 and N1 tumours concerning age (mean 52·1 versus 53·4 years), male:female ratio (0·7 versus 1·0), basal preoperative calcitonin concentration (mean 3238 versus 3076 pg/ml) and tumour size (23·3 versus 23·9 mm). There were differences in the incidence of tumour invasion (P &lt; 0·001), vascular embolism (P = 0·011) and peritumoral thyroiditis (P = 0·039). Measurement of basal and stimulated calcitonin levels after surgery confirmed biochemical cure in all patients with N0 tumours and half of those with N1 disease (P = 0·006).

Conclusion

There were no preoperative factors that predicted node status for MTC larger than 1 cm in this series. Total thyroidectomy and nodal dissection remains the optimal treatment.

Endoscopic parathyroid surgery: results of 365 consecutive procedures

In recent years, several series have documented the feasibility of endoscopic approaches for parathyroid diseases. We performed a retrospective study to evaluate the results of endoscopic parathyroidectomy (EP) in the management of our patients with primary hyperparathyroidism (PHPT). During a 5.5 year period (1998-2003), we operated on 644 patients with PHPT. EP was proposed for patients with sporadic PHPT, without associated goiter, and without previous neck surgery in whom a single adenoma was localized by means of sonography and sestamibi scanning. EP was performed by the lateral approach with insufflation for patients with an adenoma located deep in the neck and by a gasless midline approach for patients whose adenoma was located anteriorly. A quick parathyroid (QPTH) assay was used during the surgical procedures. Among 644 patients with PHPT, 279 (43.3%) were not eligible for EP for the following reasons: associated nodular goiter (116 cases), previous neck surgery (52 cases), suspicion of multiglandular disease (31 cases), lack of preoperative localization (61 cases), and miscellaneous causes (19 cases). EP was performed in 365 patients with sporadic PHPT: 339 lateral access, 25 midline access, and one thoracoscopy. The median operating time was 49 minutes (16-130 minutes). Conversion to conventional parathyroidectomy was required in 49 patients (13.4%) for these reasons: missed adenomas (14 cases), difficulty with the dissection (8 cases), multiglandular disease correctly predicted by QPTH (11 cases), false-negative QPTH assay results (4 cases), false-positive sestamibi scan results (11 cases), and 1 false-positive sonography result. One patient presented with definitive recurrent nerve palsy. Three patients remained hypercalcemic, and one other patient had recurrent hypercalcemia. In conclusion, EP can be proposed for more than half of the patients with PHPT. Immediate results of EP are similar to those obtained with conventional parathyroidectomy, but no conclusions can be drawn in terms of the influence of EP on the outcome of the patients operated on for PHPT.

[Gastrinomas in multiple endocrine neoplasia type-1. A 127-case cohort study from the endocrine tumor group (ETG)]

On July 2000, 127 gastrinomas (31.1%) were studied by the Endocrine Tumour Group (GTE) using a 408-patient cohort of Multiple Endocrine Neoplasia Type 1 patients. The aim of this study was to assess clinical, biological, surgical data as well as their trends over three periods (<1980-1980/1989->1990). A Zollinger-Ellison syndrome (SZE) was present in 96% of the cases. Mean age at the onset of the disease was 39.4 years. There were 55.9% of men. Synchronous liver metastasis was present in 7.1%. Taken independently, the positivity of the four main diagnosis tests decreased over the time. The diagnosis of oesophagitis increased (4.5-29.7%), as well as the size of the resected tumours (9.9-16.8 mm). There was an increase in the familial background diagnosis (73.1-80%), an increasing use of Octreoscan scintigraphy and transduodenal ultrasound with positive detection of metastasis and tumours in 81.3% and 92.3%, respectively after 1991. Patients were operated on less frequently (96-52.5%), less frequently from the pancreas (87.5-37.5%), and from the gastro-intestinal tract (70.8-30%). The relative percentage of major pancreatic resections increased (with at least removal of the duodenum and the pancreatic head) (10-26.7%). The operative mortality disappeared. Six out of the seven patients (85.7%) who benefited from major pancreatic resections normalized their gastrine level postoperatively versus 15% in less radical techniques. Overall 5 years survival was 90 +/- 4.4%. Survival increased after 1985 (85 +/- 4.8% versus 95 +/- 3.6, P = 0.1).

CONCLUSION

SZE in NEM1 were diagnosed at an earlier stage and were less frequently operated on. Nevertheless, the incidence of synchronous metastasis did not change significantly. Patients were mainly operated on for gastric emergencies and pancreatic tumours in order to prevent metastasis without mortality after 1991.

Results of surgical treatment of sporadic medullary thyroid carcinoma following routine measurement of serum calcitonin

AIM

The aim of this study was to evaluate the results of the surgical management of medullary thyroid carcinoma (MTC), following the introduction of systematic calcitonin measurement in patients referred for thyroid diseases.

METHOD

We included all the patients with elevated calcitonin and MTC from January 1993 to March 2001.

RESULTS

Among 8497 patients, MTC was diagnosed in 52 with a mean age of 56.1 years. Thirty-two fine needle biopsies led to diagnose MTC in 19 cases. The median basal pre-operative calcitonin level was 245 pg/ml. Elevated calcitonin serum was the only indicator of MTC in 31 patients. Fifty-one patients underwent total thyroidectomies, with lymphadenectomy in 45. Thirteen patients had lymph node involvement. Post-operatively, 40 (77%) had normal basal and pentagastrin (Pg) stimulated calcitonin serum levels, and remained normal at a mean follow-up of 5.16 years (1.8-8).

CONCLUSION

Routine pre-operative measurement of calcitonin should be performed because it is often the only indicator of MTC at an early stage. This could lead to an improved MTC cure rate.

Does iodine-131 meta-iodobenzylguanidine (MIBG) scintigraphy have an impact on the management of sporadic and familial phaeochromocytoma?

OBJECTIVES

To assess the impact of [(131)I]meta-iodobenzylguanidine ((131)MIBG) scintigraphy on the management of phaeochromocytoma.

DESIGN AND PATIENTS

Between 1982 and 2002, 83 patients with histologically proven phaeochromocytoma or paraganglioma were investigated using (131)MIBG scintigraphy. Seventeen of these patients, with a hereditary form of the disease, presented with 23 phaeochromocytomas [three neurofibromatosis type 1 (NF1), five von Hippel-Lindau disease (VHL), eight multiple endocrine neoplasia type 2A (MEN2A) and one type 2B (MEN2B)].

RESULTS

MIBG uptake was observed in 44/54 sporadic phaeochromocytomas (sensitivity 81.5%), 14/23 familial phaeochromocytomas (60.9%), 3/6 paragangliomas and 4/6 malignant phaeochromocytomas. No significant correlations were found between the degree of tracer uptake, tumour size and urinary metanephrine levels. No patients undergoing surgery for sporadic phaeochromocytoma had a second tumour located. Nine of 54 sporadic phaeochromocytomas had normal or mildly elevated urinary metanephrine levels (< 1.5 greater than normal). In eight of these patients, (131)MIBG was positive and confirmed the diagnosis of phaeochromocytoma. In malignant phaeochromocytomas (n = 6), MIBG demonstrated additional lesions not detected with computed tomography (CT) and/or magnetic resonance imaging (MRI) in three cases. The MIBG findings in the group with apparently sporadic paragangliomas (n = 6) were negative in four cases and failed to detect a cervical lesion in one multifocal paraganglioma.

CONCLUSION

(131)MIBG was useful in confirming the diagnosis in phaeochromocytomas with low levels of catecholamine secretion. It contributed little to the management of patients when used as a means of screening for multifocality in sporadic phaeochromocytoma, or the management of patients with familial phaeochromocytoma. However, MIBG can be an informative method of investigation when dealing with malignant/ectopic forms, although the sensitivity of MIBG is lower in this group of patients.

[New surgical approaches to primary hyperparathyroidism]

We have seen recently the appearance of several new techniques for parathyroidectomy: the minimally invasive techniques all have a limited incision when compared to classic transverse cervical incision and are targeted on one specific parathyroid gland. These interventions are today possible for three main reasons: the available imaging techniques permit to locate the diseased gland, the use of rapid intraoperative PTH assay can confirm the successful extirpation, new instrumentation and miniaturised cameras have been adapted for this kind of surgery. Amongst minimally invasive techniques applied to parathyroidectomy, the video-assisted technique has the main advantage to offer a magnified view that permits a precise and careful dissection with minimal risks. Not all patients presenting a primary hyperparathyroidism are candidates for this surgery. Contraindications are mainly due to a large goiter, previous surgery in the parathyroid vicinity, suspicious multiglandular disease and equivocal preoperative localising studies. Currently 60% of patients with primary hyperparathyroidism can benefit of these techniques. Studies comparing conventional parathyroid surgery to endoscopic techniques have shown a diminution of postoperative pain and better cosmetic results with endoscopic techniques. If early results are similar to those obtained with conventional traditional open parathyroidectomies it is still too soon to evaluate what will be the recurrence rate of these new techniques.

Hématome cervical spontané secondaire à une hémorragie extracapsulaire d’un adénome parathyroïdien : à propos de 2 cas

The usual clinical manifestations of a parathyroid adenoma are due, in most of the cases, to hypercalcemia. The development of a spontaneous cervical or cervicomediastinal haematoma is a rare form of presentation. In case of a spontaneous cervical haematoma associated with dysphagia: measurement of serum calcium, phosphate and parathyroid hormone allows the diagnosis of haematoma due to extracapsular haemorrhage from a parathyroid adenoma. We report herein 2 cases.