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Uludag M, Cetinoglu I, Unlu MT, Kostek M, Caliskan O, Aygun N. The Role of Frozen Section Examination in Thyroid Surgery. SISLI ETFAL HASTANESI TIP BULTENI 2023; 57:441-450. [PMID: 38268652 PMCID: PMC10805043 DOI: 10.14744/semb.2023.91129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Accepted: 12/26/2023] [Indexed: 01/26/2024]
Abstract
In endocrine pathology, frozen section (FS) examination is most commonly used for the intraoperative evaluation of thyroid and parathyroid tumors, as well as cervical lymph nodes. In the past, frozen section was considered a fundamental tool in thyroid surgery. However, with advancements in preoperative ultrasound and fine-needle aspiration biopsy (FNAB), there have been increasing queries about its routine use due to the improved preoperative diagnosis. Nowadays, while the use of FS during thyroidectomy has decreased, it is still used as an additional method for different purposes intraoperatively. FS may not always provide definitive results. If FS will alter the surgical plan or extent, it should be applied. Routine FS is not recommended for evaluating thyroid nodules. But in addition to FNAB, if FS results may change the operation plan or extent, they can be utilized. FS should not be applied for thyroid lesions smaller than 1 cm, and the entire lesion should not be frozen for FS. For the assessment of thyroid nodules, the use of FS is recommended based on the Bethesda categories of FNAB. In Bethesda I category nodules, FS may contribute to distinguishing between malignant and benign lesions and guide surgical treatment. In Bethesda II nodules, where the malignancy rate is low, the performance of FNAB and FS can be compared, but it's not recommended due to the lack of a significant contribution to the surgical strategy. The sensitivity of FS in Bethesda III and IV nodules is low; its contribution to the diagnosis is limited, and it does not provide an apparent benefit to treatment; therefore, it is not recommended. In Bethesda V nodules, FS can effectively confirm the malignancy diagnosis, contribute to the surgical strategy, and reduce the possibility of completion thyroidectomy, and accordingly, it is recommended for use. Nonetheless, in Bethesda V nodules with a benign FS report, the malignancy rate remains high, so it should not be used to rule out malignancy. In Bethesda VI nodules, the performance of FS is lower or comparable to FNAB and does not significantly contribute to the treatment strategy; hence, it is not recommended. Particularly in patients with papillary thyroid cancer, intraoperative FS can be effective in detecting extrathyroidal extension and can assist the surgeon in determining the extent of thyroid surgery and central neck dissection. FS has high sensitivity and specificity in evaluating the lymphatic status of the central region intraoperatively and can be used to determine the extent of central compartment node dissection. During thyroidectomy, FS examination can be used in recognizing parathyroid tissue and distinguishing it from fatty tissue, thymus, thyroid, lymph nodes, especially in differentiating metastatic lymph nodes.
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Affiliation(s)
- Mehmet Uludag
- Department of General Surgery, University of Health Sciences Türkiye, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Türkiye
| | - Isik Cetinoglu
- Department of General Surgery, University of Health Sciences Türkiye, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Türkiye
| | - Mehmet Taner Unlu
- Department of General Surgery, University of Health Sciences Türkiye, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Türkiye
| | - Mehmet Kostek
- Department of General Surgery, University of Health Sciences Türkiye, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Türkiye
| | - Ozan Caliskan
- Department of General Surgery, University of Health Sciences Türkiye, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Türkiye
| | - Nurcihan Aygun
- Department of General Surgery, University of Health Sciences Türkiye, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Türkiye
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Siller M, Stangassinger LM, Kreutzer C, Boor P, Bulow RD, Kraus TJ, von Stillfried S, Wolfl S, Couillard-Despres S, Oostingh GJ, Hittmair A, Gadermayr M. On the Acceptance of "Fake" Histopathology: A Study on Frozen Sections Optimized with Deep Learning. J Pathol Inform 2022; 13:6. [PMID: 35136673 PMCID: PMC8794030 DOI: 10.4103/jpi.jpi_53_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 08/01/2021] [Accepted: 09/20/2021] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND The fast acquisition process of frozen sections allows surgeons to wait for histological findings during the interventions to base intrasurgical decisions on the outcome of the histology. Compared with paraffin sections, however, the quality of frozen sections is often strongly reduced, leading to a lower diagnostic accuracy. Deep neural networks are capable of modifying specific characteristics of digital histological images. Particularly, generative adversarial networks proved to be effective tools to learn about translation between two modalities, based on two unconnected data sets only. The positive effects of such deep learning-based image optimization on computer-aided diagnosis have already been shown. However, since fully automated diagnosis is controversial, the application of enhanced images for visual clinical assessment is currently probably of even higher relevance. METHODS Three different deep learning-based generative adversarial networks were investigated. The methods were used to translate frozen sections into virtual paraffin sections. Overall, 40 frozen sections were processed. For training, 40 further paraffin sections were available. We investigated how pathologists assess the quality of the different image translation approaches and whether experts are able to distinguish between virtual and real digital pathology. RESULTS Pathologists' detection accuracy of virtual paraffin sections (from pairs consisting of a frozen and a paraffin section) was between 0.62 and 0.97. Overall, in 59% of images, the virtual section was assessed as more appropriate for a diagnosis. In 53% of images, the deep learning approach was preferred to conventional stain normalization (SN). CONCLUSION Overall, expert assessment indicated slightly improved visual properties of converted images and a high similarity to real paraffin sections. The observed high variability showed clear differences in personal preferences.
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Affiliation(s)
- Mario Siller
- Department of Information Technology and System Management, Salzburg University of Applied Sciences, Salzburg, Austria
| | - Lea Maria Stangassinger
- Department of Biomedical Sciences, Salzburg University of Applied Sciences, Salzburg, Austria
| | - Christina Kreutzer
- Institute of Experimental Neuroregeneration, Spinal Cord Injury and Tissue Regeneration Center Salzburg, Paracelsus Medical University, Salzburg, Austria
| | - Peter Boor
- Institute of Pathology, RWTH Aachen University Hospital, Aachen, Germany
- Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD), Aachen, Germany
| | - Roman D. Bulow
- Institute of Pathology, RWTH Aachen University Hospital, Aachen, Germany
- Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD), Aachen, Germany
| | - Theo J.F. Kraus
- Institute of Pathology, University Hospital Salzburg, Paracelsus Medical University, Salzburg, Austria
| | - Saskia von Stillfried
- Institute of Pathology, RWTH Aachen University Hospital, Aachen, Germany
- Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD), Aachen, Germany
| | | | - Sebastien Couillard-Despres
- Institute of Experimental Neuroregeneration, Spinal Cord Injury and Tissue Regeneration Center Salzburg, Paracelsus Medical University, Salzburg, Austria
| | - Gertie Janneke Oostingh
- Department of Biomedical Sciences, Salzburg University of Applied Sciences, Salzburg, Austria
| | - Anton Hittmair
- Department of Pathology and Microbiology, Kardinal Schwarzenberg Klinikum, Schwarzach, Austria
| | - Michael Gadermayr
- Department of Information Technology and System Management, Salzburg University of Applied Sciences, Salzburg, Austria
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Zammit M, Pierce K, Bailey L, Rowland M, Waghorn A, Shore S. Challenging NICE guidelines on parathyroid surgery. Surgeon 2021; 20:e105-e111. [PMID: 34090811 DOI: 10.1016/j.surge.2021.04.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 04/14/2021] [Accepted: 04/23/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND National Institute of Clinical Excellence (NICE) recommend against routinely using Intra-Operative Parathyroid Hormone (IOPTH) for first-time parathyroid surgery due to its cost and minimal surgical benefit. The European Society of Endocrine Surgeons differ from this and recommends IOPTH with conflicting pre-operative or single imaging. NICE guidance acknowledged that this may change practice in larger centres. We devised a retrospective single-centre cohort study to analyse the impact of IOPTH on decision-making and cost-effectiveness. METHODOLOGY First-time parathyroidectomy procedures for primary hyperparathyroidism were assessed between 2017 and 2019. Ultrasound (US) and Sestamibi with parathyroid single-photon emission with computed tomography (SPECT-CT) were compared with IOPTH. The contribution of IOPTH to cure and cost effectiveness ratio was calculated. RESULTS 114 cases were included, with IOPTH performed in all cases, SPECT-CT in 112 and US in 108 cases. A cure rate of 99.1% (113/114) was achieved. 11.4% (13/114) of the cure rate was influenced by IOPTH (P 0.01), instigating further exploration when its levels didn't decrease. This included 7.1% (4/56) in the concordant-imaging cohort. IOPTH accuracy (96.5%) was significantly superior (P = 0.03) to both US (80%) and SPECT-CT (81%). Comparing the total costs for IOPTH testing over 2 years (£39,721) with 13 potential re-operative procedures in its absence (£63,536), a positive cost-effectiveness ratio of £1832 per re-operative procedure averted was achieved. CONCLUSION Abandoning IOPTH in first-time parathyroid surgery is too ambitious when weighing the cost of re-operative surgery against cost savings obtained by using routine IOPTH to achieve an improved cure rate, even in concordant imaging.
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Affiliation(s)
- Matthew Zammit
- Breast and Endocrine Surgical Department, Royal Liverpool University Hospital, Prescot Street, Liverpool, United Kingdom.
| | - Katriona Pierce
- Breast and Endocrine Surgical Department, Royal Liverpool University Hospital, Prescot Street, Liverpool, United Kingdom
| | - Lisa Bailey
- Department of Clinical Chemistry, Royal Liverpool University Hospital, Prescot Street, Liverpool, (L78XP), United Kingdom
| | - Matthew Rowland
- Breast and Endocrine Surgical Department, Royal Liverpool University Hospital, Prescot Street, Liverpool, United Kingdom
| | - Alison Waghorn
- Breast and Endocrine Surgical Department, Royal Liverpool University Hospital, Prescot Street, Liverpool, United Kingdom
| | - Susannah Shore
- Breast and Endocrine Surgical Department, Royal Liverpool University Hospital, Prescot Street, Liverpool, United Kingdom
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Sanabria A, Zafereo M, Thompson LDR, Hernandez-Prera JC, Kowalski LP, Nixon IJ, Shaha A, Rodrigo JP, Mäkitie A, Poorten VV, Suarez C, Zbären P, Rinaldo A, Ferlito A. Frozen section in thyroid gland follicular neoplasms: It's high time to abandon it! Surg Oncol 2020; 36:76-81. [PMID: 33316682 DOI: 10.1016/j.suronc.2020.12.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 11/23/2020] [Accepted: 12/06/2020] [Indexed: 11/30/2022]
Abstract
Thyroid nodules are a very common clinical condition. The 2015 American Thyroid Association (ATA) guidelines recommend surgical excision for Bethesda IV nodules. The use of intraoperative frozen section (FS) has been recommended as a strategy to tailor the extent of the initial surgery. We critically evaluated the literature that discusses the utility and cost-effectiveness of FS to make an intraoperative decision in patients with thyroid nodules classified as follicular neoplasm. FS should not be recommended as a routine intraoperative test to assess for malignancy in thyroid follicular patterned lesions due to its low performance; the high number of deferred results; the inability to adequately assess histologically defining features; the improvements in risk stratification guiding total thyroidectomy; and the low cost-effectiveness of FS.
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Affiliation(s)
- Alvaro Sanabria
- Department of Surgery, School of Medicine, Universidad de Antioquia, CEXCA. Centro de Excelencia en Enfermedades de Cabeza y Cuello. Medellín, Colombia.
| | - Mark Zafereo
- Head and Neck Surgery, MD Anderson Cancer Center, Houston, TX, USA
| | - Lester D R Thompson
- Department of Pathology. Southern California Permanente Medical Group, Woodland Hills Medical Center, Woodland Hills, CA, USA
| | | | - Luiz P Kowalski
- Department of Head and Neck Surgery and Otorhinolaryngology, A.C. Camargo Cancer Center, Department of Head and Neck Surgery University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Iain J Nixon
- Ear, Nose and Throat Department, NHS Lothian, University of Edinburgh, Edinburgh, UK
| | - Ashok Shaha
- Head and Neck Service, Memorial Sloan-Kettering Cancer Center, NY, USA
| | - Juan P Rodrigo
- Department of Otolaryngology, Hospital Universitario Central de Asturias-University of Oviedo, Oviedo, Spain; Instituto de Investigación Sanitaria del Principado de Asturias, IUOPA, CIBERONC, Oviedo, Spain
| | - Antti Mäkitie
- Department of Otorhinolaryngology, Head and Neck Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Vincent Vander Poorten
- Department of Oncology, Section Head and Neck Oncology, KU Leuven, and Otorhinolaryngology, Head and Neck Surgery, University Hospitals Leuven. Leuven, Belgium
| | - Carlos Suarez
- Instituto de Investigación Sanitaria del Principado de Asturias, IUOPA, CIBERONC, Oviedo, Spain
| | - Peter Zbären
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital, Bern, Switzerland
| | | | - Alfio Ferlito
- Coordinator of the International Head and Neck Scientific Group, Padua, Italy
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Vuong CD, Watson WB, Kwon DI, Mohan SS, Perez MN, Lee SC, Simental AA. Cost effectiveness of intraoperative pathology in the management of indeterminate thyroid nodules. ARCHIVES OF ENDOCRINOLOGY AND METABOLISM 2020; 64:356-361. [PMID: 32609146 PMCID: PMC10522076 DOI: 10.20945/2359-3997000000263] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Accepted: 02/07/2020] [Indexed: 11/23/2022]
Abstract
Objective This study aims to determine the cost effectiveness of rapid frozen section (RFS) for indeterminate thyroid nodules. Materials and methods A retrospective chart review was conducted between January 2009 and June 2013 at a tertiary care institution. Main outcomes were number needed to treat, RFS efficacy, and cost-savings of avoiding second completion thyroidectomy. Cost-effectiveness was estimated using 2015 Medicare reimbursement rate. Results Out of 1,114 patients undergoing thyroid surgery, 314 had preoperative AUS/FLUS cytopathology and subsequent thyroid lobectomy with RFS. RFS identified 13 of the 32 patients with malignancy resulting in a total thyroidectomy. 19 of the 29 malignancies not detected by RFS were papillary microcarcinomas. Conclusions Completion thyroidectomy was avoided in 1 out of every 24 patients resulting in cost-savings of $ 80.04 per patient. In the era of outpatient thyroid surgery, intraoperative RFS for indeterminate thyroid nodules is cost-effective.
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Affiliation(s)
- Christopher D Vuong
- Department of Otolaryngology- Head and Neck Surgery, Loma Linda University Medical Center, Loma Linda, California, United States
| | - WayAnne B Watson
- Loma Linda School of Medicine, Loma Linda University Medical Center, Loma Linda, California, United States
| | - Daniel I Kwon
- Department of Otolaryngology-Head and Neck Surgery, University of Southern California, Los Angeles, California, United States
| | - Sonia S Mohan
- Department of Pathology, Laboratory Medicine, Loma Linda University Medical Center, Loma Linda, California, United States
| | - Mia N Perez
- Department of Pathology, Laboratory Medicine, Loma Linda University Medical Center, Loma Linda, California, United States
| | - Steve C Lee
- Department of Otolaryngology- Head and Neck Surgery, Loma Linda University Medical Center, Loma Linda, California, United States
| | - Alfred A Simental
- Department of Otolaryngology- Head and Neck Surgery, Loma Linda University Medical Center, Loma Linda, California, United States
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Intraoperative Adjunct Methods for Localization in Primary Hyperparathyroidism. MEDICAL BULLETIN OF SISLI ETFAL HOSPITAL 2020; 53:84-95. [PMID: 32377064 PMCID: PMC7199831 DOI: 10.14744/semb.2019.37542] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Accepted: 04/09/2019] [Indexed: 12/16/2022]
Abstract
Primary hyperparathyroidism (pHPT) is a frequently seen endocrine disease, and its main treatment is surgery. In the majority of pHPT, the disease involves only a single gland, and the majority of the pathological glands can be determined by preoperative localization methods.In addition to preoperative localization studies in parathyroidectomy, the use of adjunct methods to improve intraoperative localization in order to increase success of surgery is becoming widespread. These methods include different approaches, mainly intraoperative parathyroid hormone (PTH) measurement, followed by intraoperative gamma probe application, intraoperative ultrasonography, parathyroid imaging with methylene blue, and frozen section examination. Recently, especially promising new imaging methods have been described in the literature with various optical technologies to increase the localization of the parathyroid glands and to evaluate their viability. These methods include parathyroid imaging with autofluorescence, indocyanine green imaging with autofluorescence, autofluorescence imaging with methylene blue, autofluorescence imaging with 5-aminolevulinic acid, optical coherence tomography, laser speckle contrast imaging, dynamic optical contrast imaging, and Raman spectroscopy. Currently, minimally invasive parathyroidectomy has become the standard treatment for selected pHPT patients with the aid of preoperative imaging and intraoperative auxiliary methods . The aim of the present study was to evaluate the routinely used new promising intraoperative adjunct methods in pHPT.
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Surgical options in treating patients with primary hyperparathyroidism. Radiol Oncol 2020; 54:22-32. [PMID: 32114525 PMCID: PMC7087427 DOI: 10.2478/raon-2020-0010] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Accepted: 11/15/2019] [Indexed: 11/20/2022] Open
Abstract
Background Primary hyperparathyroidism is the third most common endocrine disorder for which surgical procedure called parathyroidectomy is the most effective treatment. Since the early 20th century, parathyroid surgery has improved extensively. With the advances in preoperative imaging and with understanding the causes of disease, new and minimally invasive surgical approaches overrode the standard bilateral exploratory operations. Directed parathyroidectomy is currently the standard technique for treatment of primary hyperparathyroidism worldwide. Conclusions Surgery is the only definitive treatment of primary hyperparathyroidism. The most appropriate type of surgical procedure depends on the number and localization of the hyperactive parathyroid glands, availability of modern imaging techniques, limitation of each type of procedure and expertise.
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Roychoudhury S, Souza F, Gimenez C, Glass R, Cocker R, Chau K, Kohn N, Das K. Utility of intraoperative frozen sections for thyroid nodules with prior fine needle aspiration cytology diagnosis. Diagn Cytopathol 2017; 45:789-794. [PMID: 28603866 DOI: 10.1002/dc.23765] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2017] [Revised: 05/03/2017] [Accepted: 05/17/2017] [Indexed: 11/09/2022]
Abstract
INTRODUCTION The objective of this study was to evaluate the role of intraoperative frozen section (IFS) in determining the course of surgery in thyroid nodules with a prior fine needle aspiration (FNA) biopsy diagnosis. In addition, reliability of FNA interpretation to guide surgical management without IFS was investigated. MATERIAL AND METHODS This is a retrospective study of all patients who had a FNA biopsy, IFS, and final pathology performed on a thyroid nodule over a 9 month period. The extent of surgery at the time of the IFS was recorded. Subsequent change in surgical procedure following the IFS diagnosis was noted in each of the Bethesda diagnostic categories. RESULTS 55% of the cases were deferred at IFS overall, with 68 and 86% in Bethesda III and IV categories, respectively. Overall, there was a change in management in 6% of cases. CONCLUSIONS Our study does not support the use of IFS for nodules with prior FNA interpretation of Bethesda II, III, IV and VI as management was not significantly changed. IFS is of value for nodules with prior FNA diagnosis of Bethesda I for interpretation of nodule, and Bethesda V for planning surgery. A confirmatory diagnosis could not be rendered at IFS for lesions with follicular architecture, which comprised most of the cases in Bethesda III and IV.
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Affiliation(s)
- Sudarshana Roychoudhury
- Department of Pathology, Hofstra Northwell Health School of Medicine, Lake Success, New York
| | - Fabiola Souza
- Department of Pathology, Hofstra Northwell Health School of Medicine, Lake Success, New York
| | - Cecilia Gimenez
- Department of Pathology, Hofstra Northwell Health School of Medicine, Lake Success, New York
| | - Ryan Glass
- Department of Pathology, Hofstra Northwell Health School of Medicine, Lake Success, New York
| | - Rubina Cocker
- Department of Pathology, Hofstra Northwell Health School of Medicine, Lake Success, New York
| | - Karen Chau
- Department of Pathology, Hofstra Northwell Health School of Medicine, Lake Success, New York
| | - Nina Kohn
- Department of Biostatistics Manhasset, The Feinstein Institute for Medical Research, New York
| | - Kasturi Das
- Department of Pathology, Hofstra Northwell Health School of Medicine, Lake Success, New York
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Pathological aspects of the assessment of head and neck cancers: United Kingdom National Multidisciplinary Guidelines. The Journal of Laryngology & Otology 2017; 130:S59-S65. [PMID: 27841114 PMCID: PMC4873923 DOI: 10.1017/s0022215116000451] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
This is the official guideline endorsed by the specialty associations involved in the care of head and neck cancer patients in the UK. It introduces the current best practice in histopathology and cytopathology as it pertains to head and neck and thyroid cancers. Recommendations • Accurate diagnosis of the type of malignancy is a key component of effective management. (R) • Surgeons and oncologists should understand the scope and limitations of cellular pathology in order to inform multidisciplinary discussions. (R) • A clinically suspected diagnosis of malignancy should be confirmed by biopsy or cytology before operation. (R) • Cytopathological diagnoses should be discussed with surgeons and radiologists to maximise the information gained from each modality of investigation. (R) • Pathological investigations are the basis for accurate cancer staging and stratification of clinical outcomes. (R).
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Jain M, Krasne DL, Singer FR, Giuliano AE. Recurrent primary hyperparathyroidism due to Type 1 parathyromatosis. Endocrine 2017; 55:643-650. [PMID: 27743301 DOI: 10.1007/s12020-016-1139-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Accepted: 09/24/2016] [Indexed: 10/20/2022]
Abstract
Parathyromatosis is a rare condition consisting of multiple nodules of benign hyperfunctioning parathyroid tissue scattered throughout the neck and superior mediastinum. As a potential cause of recurrent or persistent hyperparathyroidism, parathyromatosis is a challenging condition to diagnose and treat. The optimal evaluation and management of patients with parathyromatosis is not well established. The reported case involves a patient who was initially diagnosed with primary hyperparathyroidism. The diagnosis of Type 1 parathyromatosis was made after the patient developed recurrent hyperparathyroidism with hypercalcemia and osteoporosis 17 years after the initial operation and underwent two additional operations. The majority of parathyromatosis cases are diagnosed in the setting of secondary hyperparathyroidism. Consensus regarding the preoperative diagnosis and evaluation is lacking due to the paucity of cases of this rare clinical entity. Management involves complete surgical extirpation of all identifiable rests of parathyroid tissue. Intra-operative parathyroid hormone level monitoring and frozen section examination are excellent tools that could increase the rates of initial operative success. Despite this, long-term disease remission is rare, and medical therapy, including calcimimetics and bisphosphonates, may be required for postoperative or non-operative management.
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Affiliation(s)
- Monica Jain
- Department of Surgery, Cedars-Sinai Medical Center, 8700 Beverly Blvd, Los Angeles, CA, 90048, USA.
| | - David L Krasne
- Department of Pathology, Providence Saint John's Health Center, 2121 Santa Monica Blvd, Santa Monica, CA, 90404, USA
| | - Frederick R Singer
- Endocrine/Bone Disease Program, John Wayne Cancer Institute at Providence Saint John's Health Center, 2121 Santa Monica Blvd, Santa Monica, CA, 90404, USA
| | - Armando E Giuliano
- Department of Surgery, Cedars-Sinai Medical Center, 8700 Beverly Blvd, Los Angeles, CA, 90048, USA
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Intraoperative ex vivo parathyroid aspiration: A point-of-care test to confirm parathyroid tissue. Surgery 2016; 160:850-857. [PMID: 27545996 DOI: 10.1016/j.surg.2016.06.036] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2016] [Revised: 06/15/2016] [Accepted: 06/23/2016] [Indexed: 11/22/2022]
Abstract
BACKGROUND Ex vivo aspiration of a parathyroid gland with intraoperative parathyroid hormone determination is a method for intraoperative confirmation of parathyroid tissue. The aim of this study was to describe the use and applicability of this technique at a single, high-volume institution. METHODS This is a retrospective review of patients who underwent parathyroidectomy and ex vivo aspiration of suspected, abnormal parathyroid tissue for intraoperative parathyroid hormone level (pg/mL). Sensitivity and specificity were calculated for aspirate intraoperative parathyroid hormone levels which were compared with the baseline serum aspirate intraoperative parathyroid hormone obtained prior to parathyroid excision in each patient. RESULTS Of 921 tissue aspirates, 847 (92%) were confirmed as parathyroid on histopathology, with a mean ± standard deviation aspirate intraoperative parathyroid hormone of 3,838 ± 1,615 pg/mL. The 847 aspirates included 833 (98%) with aspirate intraoperative parathyroid hormone levels greater than the serum aspirate intraoperative parathyroid hormone and 14 (2%) with aspirate intraoperative parathyroid hormone levels less than the serum aspirate intraoperative parathyroid hormone; 74 (8%) aspirates were not parathyroid tissue, with a mean aspirate intraoperative parathyroid hormone level of 25 ± 12.7 pg/mL. An aspirate intraoperative parathyroid hormone ≥1.5 times the serum aspirate intraoperative parathyroid hormone represented the optimal threshold for confirmation of parathyroid tissue. CONCLUSION Intraoperative ex vivo aspiration of presumed parathyroid gland is a sensitive and specific point-of-care method to confirm the presence of parathyroid tissue. An aspirate intraoperative parathyroid hormone ≥1.5 times greater than the baseline serum aspirate intraoperative parathyroid hormone minimizes the likelihood of misidentifying parathyroid tissue.
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Abu-Ghanem S, Cohen O, Raz Yarkoni T, Fliss DM, Yehuda M. Intraoperative Frozen Section in “Suspicious for Papillary Thyroid Carcinoma” after Adoption of the Bethesda System. Otolaryngol Head Neck Surg 2016; 155:779-786. [DOI: 10.1177/0194599816653114] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Accepted: 05/13/2016] [Indexed: 01/21/2023]
Abstract
Objective To evaluate the accuracy and utility of intraoperative frozen section examination (iFSE) in patients with a preoperative fine-needle aspiration (FNA) cytology of “suspicious for malignancy” (SFM)–Bethesda V, after the adoption of the Bethesda System for Reporting Thyroid Cytopathology. Study Design Case series with chart review. Setting Tertiary medical center. Subjects and Methods All patients with SFM–Bethesda V who underwent thyroid surgery with iFSE between 2010 and 2015 were included. In cases where the iFSE was reported to be malignant, a total thyroidectomy was performed; otherwise, thyroid lobectomy (hemithyroidectomy) was performed. Results The current series included 47 patients diagnosed preoperatively with FNA cytology of SFM–Bethesda V. The malignancy rate was 74.5% (35 of 47). Twenty-four patients with nonmalignant iFSE results underwent lobectomy during their initial surgery: 12 were subsequently found with benign final histology and did not undergo completion thyroidectomy; the other 12 patients had malignant results on final histology, but only 4 of them underwent completion thyroidectomy. iFSE resulted in a sensitivity and specificity of 65.7% and 100%, respectively, with a positive predictive value of 100% (23 of 23) and a negative predictive value of 50% (12 of 24). Accuracy of the iFSE methodology was 74.5% (35 of 47). Conclusions With no significant preoperative clinical or sonographic predictors for thyroid malignancy and given the high specificity of iFSE, our results support the use of iFSE for patients with preoperative FNA cytology of SFM–Bethesda V who are undergoing thyroid surgery, to determine the extent of required surgery.
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Affiliation(s)
- Sara Abu-Ghanem
- Department of Otolaryngology Head and Neck Surgery and Maxillofacial Surgery, Tel-Aviv Sourasky Medical Center, Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Oded Cohen
- Department of Otolaryngology Head and Neck Surgery, Kaplan Medical Center, Hadassah School of Medicine, Hebrew University, Rehovot, Israel
| | - Tom Raz Yarkoni
- Department of Otolaryngology Head and Neck Surgery, Kaplan Medical Center, Hadassah School of Medicine, Hebrew University, Rehovot, Israel
| | - Dan M. Fliss
- Department of Otolaryngology Head and Neck Surgery and Maxillofacial Surgery, Tel-Aviv Sourasky Medical Center, Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Moshe Yehuda
- Department of Otolaryngology Head and Neck Surgery and Maxillofacial Surgery, Tel-Aviv Sourasky Medical Center, Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
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Pathology of the Parathyroid Glands. Updates Surg 2016. [DOI: 10.1007/978-88-470-5758-6_10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Duan K, Gomez Hernandez K, Mete O. Clinicopathological correlates of hyperparathyroidism. J Clin Pathol 2015; 68:771-87. [PMID: 26163537 DOI: 10.1136/jclinpath-2015-203186] [Citation(s) in RCA: 72] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2015] [Accepted: 06/20/2015] [Indexed: 12/21/2022]
Abstract
Hyperparathyroidism is a common endocrine disorder with potential complications on the skeletal, renal, neurocognitive and cardiovascular systems. While most cases (95%) occur sporadically, about 5% are associated with a hereditary syndrome: multiple endocrine neoplasia syndromes (MEN-1, MEN-2A, MEN-4), hyperparathyroidism-jaw tumour syndrome (HPT-JT), familial hypocalciuric hypercalcaemia (FHH-1, FHH-2, FHH-3), familial hypercalciuric hypercalcaemia, neonatal severe hyperparathyroidism and isolated familial hyperparathyroidism. Recently, molecular mechanisms underlying possible tumour suppressor genes (MEN1, CDC73/HRPT2, CDKIs, APC, SFRPs, GSK3β, RASSF1A, HIC1, RIZ1, WT1, CaSR, GNA11, AP2S1) and proto-oncogenes (CCND1/PRAD1, RET, ZFX, CTNNB1, EZH2) have been uncovered in the pathogenesis of hyperparathyroidism. While bi-allelic inactivation of CDC73/HRPT2 seems unique to parathyroid malignancy, aberrant activation of cyclin D1 and Wnt/β-catenin signalling has been reported in benign and malignant parathyroid tumours. Clinicopathological correlates of primary hyperparathyroidism include parathyroid adenoma (80-85%), hyperplasia (10-15%) and carcinoma (<1-5%). Secondary hyperparathyroidism generally presents with diffuse parathyroid hyperplasia, whereas tertiary hyperparathyroidism reflects the emergence of autonomous parathyroid hormone (PTH)-producing neoplasm(s) from secondary parathyroid hyperplasia. Surgical resection of abnormal parathyroid tissue remains the only curative treatment in primary hyperparathyroidism, and parathyroidectomy specimens are frequently encountered in this setting. Clinical and biochemical features, including intraoperative PTH levels, number, weight and size of the affected parathyroid gland(s), are crucial parameters to consider when rendering an accurate diagnosis of parathyroid proliferations. This review provides an update on the expanding knowledge of hyperparathyroidism and highlights the clinicopathological correlations of this prevalent disease.
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Affiliation(s)
- Kai Duan
- Department of Pathology, University Health Network, Toronto, Ontario, Canada Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - Karen Gomez Hernandez
- Endocrine Oncology Site Group, Princess Margaret Cancer Centre, Toronto, Ontario, Canada Department of Medicine, University Health Network, Toronto, Ontario, Canada
| | - Ozgur Mete
- Department of Pathology, University Health Network, Toronto, Ontario, Canada Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada Endocrine Oncology Site Group, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
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Perros P, Boelaert K, Colley S, Evans C, Evans RM, Gerrard Ba G, Gilbert J, Harrison B, Johnson SJ, Giles TE, Moss L, Lewington V, Newbold K, Taylor J, Thakker RV, Watkinson J, Williams GR. Guidelines for the management of thyroid cancer. Clin Endocrinol (Oxf) 2014; 81 Suppl 1:1-122. [PMID: 24989897 DOI: 10.1111/cen.12515] [Citation(s) in RCA: 732] [Impact Index Per Article: 73.2] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- Petros Perros
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle-upon-Tyne
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Chatterjee S, Ray U, Gupta S, Basu A. Concurrent parathyroid carcinoma and adenoma: A rare presentation of a rarer disease entity. Indian J Endocrinol Metab 2013; 17:939-941. [PMID: 24083188 PMCID: PMC3784890 DOI: 10.4103/2230-8210.117231] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Parathyroid carcinoma is a rare disease. But multiglandular parathyroid neoplasm is even rarer. A high level of suspicion, on the basis of clinical, hematological tests and intraoperative findings is necessary to treat this disease entity, particularly in the absence of palpable neck masses. Preoperative localization is important. Bilateral neck exploration should be done routinely and all 4 glands seen to avoid missing out other pathological glands.
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Affiliation(s)
| | - Udipta Ray
- Department of Surgery, Medical College, Kolkata, India
| | - Shahana Gupta
- Department of Surgery, Medical College, Kolkata, India
| | - Arghya Basu
- Department of Surgery, Medical College, Kolkata, India
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Tallini G, Gallo C. Fine-Needle Aspiration and Intraoperative Consultation in Thyroid Pathology: When and How? Int J Surg Pathol 2011; 19:141-4. [DOI: 10.1177/1066896910394842] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Fine-needle aspiration (FNA) and frozen section evaluation are traditional components of the management of thyroid lesions. Their role and usefulness are dictated by some basic facts about thyroid pathology: ( a) nodules are very common; ( b ) they are benign in the majority of cases; and ( c) the diagnosis of malignancy is primarily based on cytologic features in the case of papillary carcinoma, and on the presence of invasion of the tumor capsule or of blood vessels in the case of follicular carcinoma. The common occurrence of benign thyroid nodules mandates a cost-effective effective method for preoperative screening. Since, as already stated, the diagnosis of papillary thyroid carcinoma (by far the most common thyroid malignancy) is based on the identification of characteristic cytologic features, FNA has easily emerged in the past 30 years as the most accurate and cost-effective tool—indeed a true cornerstone—for the preoperative management of thyroid nodules. Standardized terminology to report cytologic diagnoses is highly recommended and is being implemented worldwide. Conversely, the importance of intraoperative frozen section diagnosis has been constantly decreasing over the past years, as a direct consequence of the widespread application of FNA. It may, however, be very useful in cases that are suspicious for papillary carcinoma on FNA and in selected cases with an indeterminate cytologic diagnosis.
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Affiliation(s)
| | - Carmine Gallo
- Anatomic Pathology, Ospedale Bellaria, Bologna, Italy
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Abstract
In recent years, parathyroid surgery has evolved from traditional bilateral neck exploration to minimal invasive parathyroidectomy. This trend became possible due to preoperative localization imaging that guides the surgeon in the search for a parathyroid adenoma. Intraoperative adjuncts are complementary to preoperative localization and assist in localizing parathyroid glands, confirming parathyroid tissue and establishing a cure. Institutions and surgeons utilize different intraoperative adjuncts in different protocols with varying results. The purpose of this article is to review the available intraoperative adjuncts to parathyroid surgery and critically evaluate their utility, accuracy and their added value to the surgeon.
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Affiliation(s)
- Haggi Mazeh
- a Section of Endocrine Surgery, Department of Surgery, University of Wisconsin, H4/722 Clinical Science Center, 600 Highland Avenue, Madison, WI 53792, USA
| | - Herbert Chen
- a Section of Endocrine Surgery, Department of Surgery, University of Wisconsin, H4/722 Clinical Science Center, 600 Highland Avenue, Madison, WI 53792, USA
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