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Stillman MD, Kuo EJ, Liou R, Almuqate A, Virk R, Lee JA, Kuo JH, McManus CM. Molecular Testing for Bethesda III Thyroid Nodules: Trends in Implementation, Cytopathology Call Rates, Surgery Rates, and Malignancy Yield at a Single Institution. Thyroid 2024; 34:460-466. [PMID: 38468547 DOI: 10.1089/thy.2023.0664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/13/2024]
Abstract
Background: Molecular testing (MT) has become standard practice to more accurately rule out malignancy in indeterminate Bethesda III (BIII) thyroid lesions. We sought to assess the adoption of this technology and its impact on cytology reporting, malignancy yield, and rates of surgery across community and academic sites affiliated with a tertiary medical center. Methods: We performed a retrospective cross-sectional study including all fine-needle aspirations (FNAs) analyzed at our institution from 2017 to 2021. We analyzed trends in MT utilization by platform and by community or academic site. We compared BIII call rates, MT utilization rates, rates of subsequent surgery, and malignancy yield on final pathology before and after MT became readily available using chi-square analysis and linear regression. Results: A total of 8960 FNAs were analyzed at our institution from 2017 to 2021. There was broad adoption of MT across both community and academic sites. There was a significant increase in both the BIII rate and the utilization of MT between the pre- and post-MT periods (p < 0.001 and p < 0.001). There was no significant change in the the malignancy yield on final pathology (57.1% vs. 50.0%, p = 0.347), while the positive predictive value of MT decreased from 85% to 50% (p = 0.008 [confidence interval 9.5-52.5% decrease]). Conclusions: The use of MT increased across the institution over the study period, with the largest increase seen after a dedicated pass for MT was routinely collected. This increased availability of MT may have led to an unintended increase in the rates of BIII lesions, MT utilization, and surgery for benign nodules. Physicians who use MT should be aware of potential consequences of its adoption to appropriately counsel patients.
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Affiliation(s)
- Mason D Stillman
- Division of GI/Endocrine Surgery, Columbia University Irving Medical Center, New York, New York, USA
| | - Eric J Kuo
- Division of GI/Endocrine Surgery, Columbia University Irving Medical Center, New York, New York, USA
| | - Rachel Liou
- Division of GI/Endocrine Surgery, Columbia University Irving Medical Center, New York, New York, USA
| | - Abdullah Almuqate
- Department of Pathology and Cell Biology, Columbia University Irving Medical Center, New York, New York, USA
| | - Renu Virk
- Department of Pathology and Cell Biology, Columbia University Irving Medical Center, New York, New York, USA
| | - James A Lee
- Division of GI/Endocrine Surgery, Columbia University Irving Medical Center, New York, New York, USA
| | - Jennifer H Kuo
- Division of GI/Endocrine Surgery, Columbia University Irving Medical Center, New York, New York, USA
| | - Catherine M McManus
- Division of GI/Endocrine Surgery, Columbia University Irving Medical Center, New York, New York, USA
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Hu QL, Chen L, Kuo EJ, Lee JA, Kuo JH, Wright JD, McManus CM. A national study of postoperative thyroid hormone supplementation rates after thyroid lobectomy. Surgery 2024; 175:1029-1033. [PMID: 38097483 DOI: 10.1016/j.surg.2023.11.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 10/17/2023] [Accepted: 11/07/2023] [Indexed: 03/17/2024]
Abstract
BACKGROUND 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. METHODS 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). RESULTS 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). CONCLUSION 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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Affiliation(s)
- Q Lina Hu
- Division of GI/Endocrine Surgery, Columbia University, New York, NY.
| | - Ling Chen
- Division of Gynecology, Columbia University, New York, NY
| | - Eric J Kuo
- Division of GI/Endocrine Surgery, Columbia University, New York, NY
| | - James A Lee
- Division of GI/Endocrine Surgery, Columbia University, New York, NY
| | - Jennifer H Kuo
- Division of GI/Endocrine Surgery, Columbia University, New York, NY
| | - Jason D Wright
- Division of Gynecology, Columbia University, New York, NY
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Huang Y, Chan SJ, Wright JD, Kuo JH, McManus CM, Lee JA, Kuo EJ. Does the Adoption of Molecular Testing Cause Decreased Thyroidectomy Rates in a National Cohort? A Quasiexperimental Study of High- Versus Low-Adoption States. Thyroid 2024; 34:388-398. [PMID: 38251649 DOI: 10.1089/thy.2023.0651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2024]
Abstract
Background: Over the last decade, the utilization of molecular testing (MT) for the evaluation of thyroid nodules has increased. Rates and patterns of adoption of MT and its effect on thyroidectomy rates nationally are unknown. Varying rates of MT adoption at the state level provide an opportunity to study the effects of MT on thyroidectomy rates using a quasiexperimental study design. Methods: We performed a retrospective analysis of American adult patients in the Merative™ MarketScan® Research Databases who underwent thyroid fine-needle aspiration (FNA) from 2011 to 2021. MT included commercially available DNA and RNA platforms and traditional targeted mutational analysis. Interrupted time series analysis was used to evaluate the inflection of MT adoption and thyroidectomy rates after 2015. Difference-in-differences (DID) analysis was used to causally analyze the effect of MT adoption on thyroidectomy rates in high-adoption (at least a 10% increase in MT utilization) versus low-adoption states (no more than 5% increase in MT utilization) from 2015 to 2021. Results: We identified 471,364 patients who underwent thyroid FNA. The utilization of MT increased over the study period from 0.01% [confidence interval, CI: 0.00% to 0.02%] to 10.1% [CI: 9.7% to 10.5%], in 2021, with an immediate (β2 = 1.61, p = 0.002) and deeper (β3 = 0.6, p < 0.001) increase in MT adoption after 2015. Utilization of MT was lower in black patients, the elderly, rural areas, and patients with Medicaid (p < 0.05). Thyroidectomy rates were inversely correlated with MT utilization (r = -0.98, p < 0.0001). From 2015 to 2021, the average MT utilization rate increased from 2.4% to 15.3% in high-adoption states and 1.6% to 5.6% in low-adoption states. In low-adoption states, thyroidectomy rates decreased more but to similar levels (18.5-13.2%) compared with high-adoption states (15.9-13.4%) with an adjusted DID rate of -3.3% [CI -5.6% to -0.8%]. Conclusions: The acceleration in adoption of MT after 2015 likely coincides with the publication of American Thyroid Association guidelines. Black, elderly, and rural patients are less likely to receive MT. Although thyroidectomy rates were inversely correlated with MT utilization, our study suggests that this correlation is not causal. The effect of MT on thyroidectomy rates may be overshadowed by decreasing aggressiveness of thyroid nodule evaluation.
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Affiliation(s)
- Yongmei Huang
- Department of Obstetrics and Gynecology, Columbia University, New York, New York, USA
| | - Stephanie J Chan
- Department of Surgery, Division of GI/Endocrine Surgery, Columbia University, New York, New York, USA
| | - Jason D Wright
- Department of Obstetrics and Gynecology, Columbia University, New York, New York, USA
- Herbert Irving Comprehensive Cancer Center, Columbia University, New York, New York, USA
| | - Jennifer H Kuo
- Department of Surgery, Division of GI/Endocrine Surgery, Columbia University, New York, New York, USA
| | - Catherine M McManus
- Department of Surgery, Division of GI/Endocrine Surgery, Columbia University, New York, New York, USA
| | - James A Lee
- Department of Surgery, Division of GI/Endocrine Surgery, Columbia University, New York, New York, USA
| | - Eric J Kuo
- Department of Surgery, Division of GI/Endocrine Surgery, Columbia University, New York, New York, USA
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Collins RA, McManus C, Kuo EJ, Liou R, Lee JA, Kuo JH. The impact of social determinants of health on thyroid cancer mortality and time to treatment. Surgery 2024; 175:57-64. [PMID: 37872045 DOI: 10.1016/j.surg.2023.04.062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 03/20/2023] [Accepted: 04/27/2023] [Indexed: 10/25/2023]
Abstract
BACKGROUND 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. METHODS 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. RESULTS 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). CONCLUSION 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.
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Affiliation(s)
- Reagan A Collins
- Division of Surgical Oncology, Department of Surgery, Massachusetts General Hospital, Boston, MA; Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA
| | - Catherine McManus
- Section of Endocrine Surgery, Department of Surgery, Columbia University, New York, NY
| | - Eric J Kuo
- Section of Endocrine Surgery, Department of Surgery, Columbia University, New York, NY
| | - Rachel Liou
- Section of Endocrine Surgery, Department of Surgery, Columbia University, New York, NY
| | - James A Lee
- Section of Endocrine Surgery, Department of Surgery, Columbia University, New York, NY
| | - Jennifer H Kuo
- Section of Endocrine Surgery, Department of Surgery, Columbia University, New York, NY.
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Carlisle KM, Brown JP, Kim J, Turner DJ, Slejko JF, Kuo JH, Mullins CD, Hu Y. Age-stratified comparison of active surveillance versus radiofrequency ablation for papillary thyroid microcarcinoma using decision analysis. Surgery 2024; 175:153-160. [PMID: 37872047 PMCID: PMC10845124 DOI: 10.1016/j.surg.2023.06.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 05/09/2023] [Accepted: 06/20/2023] [Indexed: 10/25/2023]
Abstract
BACKGROUND Papillary thyroid microcarcinomas may be treated with radiofrequency ablation, active surveillance, or surgery. The objective of this study was to use mathematical modeling to compare treatment alternatives for papillary thyroid microcarcinomas among those who decline surgery. We hypothesized that radiofrequency ablation would outperform active surveillance in avoiding progression and surgery but that the effect size would be small for older patients. METHODS We engaged stakeholders to identify meaningful long-term endpoints for papillary thyroid microcarcinoma treatment-(1) cancer progression/surgery, (2) need for thyroid replacement therapy, and (3) permanent treatment complication. A Markov decision analysis model was created to compare the probability of these endpoints after radiofrequency ablation or active surveillance for papillary thyroid microcarcinomas and overall cost. Transition probabilities were extracted from published literature. Model outcomes were estimated to have a 10-year time horizon. RESULTS The primary outcome yielded a number needed to treat of 18.1 for the avoidance of progression and 27.4 for the avoidance of lifelong thyroid replacement therapy for radiofrequency ablation compared to active surveillance. However, as patient age increased, the number needed to treat to avoid progression increased from 5.2 (age 20-29) to 39.1 (age 60+). The number needed to treat to avoid lifelong thyroid replacement therapy increased with age from 7.8 (age 20-29) to 59.3 (age 60+). The average 10-year cost/treatment for active surveillance and radiofrequency ablation were $6,400 and $11,700, respectively, translating to a cost per progression-avoided of $106,500. CONCLUSION As an alternative to active surveillance, radiofrequency ablation may have a greater therapeutic impact in younger patients. However, routine implementation may be cost-prohibitive for most patients with papillary thyroid microcarcinomas.
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Affiliation(s)
- Kendyl M Carlisle
- Department of Surgery, University of Maryland, Baltimore, Baltimore, MD
| | - Jessica P Brown
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD
| | - Justin Kim
- Department of Surgery, University of Maryland, Baltimore, Baltimore, MD
| | - Douglas J Turner
- Department of Surgery, University of Maryland, Baltimore, Baltimore, MD
| | - Julia F Slejko
- Department of Practice, Sciences, and Health Outcomes Research, University of Maryland School of Pharmacy, Baltimore, MD
| | - Jennifer H Kuo
- Department of Surgery, Columbia University Medical Center, New York, NY
| | - C Daniel Mullins
- Department of Practice, Sciences, and Health Outcomes Research, University of Maryland School of Pharmacy, Baltimore, MD
| | - Yinin Hu
- Department of Surgery, University of Maryland, Baltimore, Baltimore, MD.
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6
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Sinclair CF, Baek JH, Hands KE, Hodak SP, Huber TC, Hussain I, Lang BHH, Noel JE, Papaleontiou M, Patel KN, Russ G, Russell J, Spiezia S, Kuo JH. General Principles for the Safe Performance, Training, and Adoption of Ablation Techniques for Benign Thyroid Nodules: An American Thyroid Association Statement. Thyroid 2023; 33:1150-1170. [PMID: 37642289 PMCID: PMC10611977 DOI: 10.1089/thy.2023.0281] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/31/2023]
Abstract
Background: The primary goal of this interdisciplinary consensus statement is to provide a framework for the safe adoption and implementation of ablation technologies for benign thyroid nodules. Summary: This consensus statement is organized around three key themes: (1) safety of ablation techniques and their implementation, (2) optimal skillset criteria for proceduralists performing ablative procedures, and (3) defining expectations of success for this treatment option given its unique risks and benefits. Ablation safety considerations in pre-procedural, peri-procedural, and post-procedural settings are discussed, including clinical factors related to patient selection and counseling, anesthetic and technical considerations to optimize patient safety, peri-procedural risk mitigation strategies, post-procedural complication management, and safe follow-up practices. Prior training, knowledge, and steps that should be considered by any physician who desires to incorporate thyroid nodule ablation into their practice are defined and discussed. Examples of successful clinical practice implementation models of this emerging technology are provided. Conclusions: Thyroid ablative procedures provide valid alternative treatment strategies to conventional surgical management for a subset of patients with symptomatic benign thyroid nodules. Careful patient and nodule selection are critical to the success of these procedures as is extensive pre-procedural patient counseling. Although these emerging technologies hold great promise, they are not without risk and require the development of a unique skillset and environment for optimal, safe performance and consistent outcomes.
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Affiliation(s)
- Catherine F. Sinclair
- Icahn School of Medicine, New York, New York, USA
- Department of Otolaryngology, Monash University, Melbourne, Australia
| | - Jung Hwan Baek
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | | | - Steven P. Hodak
- Department of Medicine, NYU Grossman School of Medicine, New York, New York, USA
| | - Timothy C. Huber
- Department of Interventional Radiology, Oregon Health and Science University, Portland, Oregon, USA
| | - Iram Hussain
- Division of Endocrinology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Brian Hung-Hin Lang
- Department of Surgery, University of Hong Kong, Queen Mary Hospital, Pokfulam, Hong Kong
| | - Julia E. Noel
- Department of Otolaryngology Head & Neck Surgery, Stanford University School of Medicine, Stanford, California, USA
| | - Maria Papaleontiou
- Division of Metabolism, Endocrinology and Diabetes, University of Michigan, Ann Arbor, Michigan, USA
| | - Kepal N. Patel
- Division of Endocrine Surgery, Department of Surgery, New York University Langone Health, Bethesda, Maryland, USA
| | - Gilles Russ
- Thyroid Diseases and Endocrine Tumors Department, Pitié-Salpêtrière Hospital, Paris, France
- Institute of Cancer IUC, Clinical Research Group Thyroid Tumors No. 16, Sorbonne University, Paris, France
| | - Jonathon Russell
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Stefano Spiezia
- Endocrine and Ultrasound Guided Surgery Operative Unit, Ospedale del Mare, ASLNA1Centro, Naples, Italy
| | - Jennifer H. Kuo
- Section of Endocrine Surgery, Department of Surgery, Columbia University, New York, New York, USA
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Hu QL, Kuo JH. Choice in Ablative Therapies for Thyroid Nodules. J Endocr Soc 2023; 7:bvad078. [PMID: 37377617 PMCID: PMC10291258 DOI: 10.1210/jendso/bvad078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Indexed: 06/29/2023] Open
Abstract
Ultrasound-guided ablation procedures have been growing in popularity and offer many advantages compared with traditional surgery for thyroid nodules. Many technologies are available, with thermal ablative techniques being the most popular currently though other nonthermal techniques, such as cryoablation and electroporation, are gaining interest. The objective of the present review is to provide an overview of each of the currently available ablative therapies and their applications in various clinical indications.
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Affiliation(s)
- Q Lina Hu
- Correspondence: Q. Lina Hu, MD, MS, Division of GI/Endocrine Surgery, Columbia University, 161 Fort Washington Avenue, 8th floor, New York, NY 10032, USA.
| | - Jennifer H Kuo
- Division of GI/Endocrine Surgery, Columbia University, New York, NY 10032, USA
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8
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Cohen MS, Kuo JH, Landry C, Lindeman B, Miller BS, Sorensen M, Zheng F. American Association of Endocrine Surgeons position statement on selected endocrine surgery billing codes and procedures: Addressing gaps in the current coding paradigm. Surgery 2023:S0039-6060(23)00196-4. [PMID: 37246125 DOI: 10.1016/j.surg.2023.03.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 03/30/2023] [Indexed: 05/30/2023]
Affiliation(s)
- Mark S Cohen
- Endocrine and Oncologic Surgery, Department of Surgery, Carle Foundation Hospital; Carle Illinois College of Medicine, Urbana, IL
| | - Jennifer H Kuo
- Division of GI/Endocrine Surgery, Department of Surgery, Columbia University, New York, NY
| | - Christine Landry
- Division of Surgical Oncology, Department of Surgery, Baylor Health System, Dallas, TX
| | - Brenessa Lindeman
- Division of Breast and Endocrine Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Barbra S Miller
- Division of Surgical Oncology, Department of Surgery, The Ohio State University, Columbus, OH.
| | - Meredith Sorensen
- Division of Endocrine Surgery, Section of General Surgery, Department of Surgery, Dartmouth-Hitchcock Health System, Lebanon, NH; Geisel School of Medicine at Dartmouth, Hanover, NH
| | - Feibi Zheng
- Division of Surgical Oncology, Department of Surgery, Baylor College of Medicine, Houston, TX
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Stillman MD, Waring NA, Kuo JH. Ethanol Ablation of a Thyroglossal Duct Cyst and Review of the Literature. JCEM Case Rep 2023; 1:luad070. [PMID: 37908570 PMCID: PMC10580405 DOI: 10.1210/jcemcr/luad070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Indexed: 11/02/2023]
Abstract
Ultrasound-guided ethanol ablation (EA) is a less invasive alternative to surgical resection for the management of thyroglossal duct cysts (TGDCs). However, to date, EA is rarely used in the United States to treat TGDCs. We present a case of TGDC successfully treated with EA in the United States. A 66-year-old man presented with a mobile anterior neck mass. Neck ultrasonography revealed a complex cystic mass in the midline directly anterior to the trachea, measuring 52 × 41 × 50 mm. Fine needle aspiration revealed no malignant cells, and pathology was consistent with TGDC. The patient had no contraindications to surgical resection. The patient's pretreatment symptom score was 7 and cosmetic score was 3. One month after EA, volume reduction ratio was 40%, symptom score was 1, and cosmetic score was 3. Four months after EA, the TGDC was resolved without need for an additional procedure. The volume reduction ratio was 96.8%, and symptom score and cosmetic score were both 1. In summary, EA is a viable alternative to surgical resection, even in patients who are surgical candidates. EA is attractive due to its simplicity, cost effectiveness, and tolerable side effect profile. Further studies are needed to evaluate long-term safety and efficacy, particularly in United States patients.
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Affiliation(s)
- Mason D Stillman
- Section of Endocrine Surgery, Columbia University, New York, NY 10032, USA
| | - Nicholas A Waring
- Section of Endocrine Surgery, Columbia University, New York, NY 10032, USA
| | - Jennifer H Kuo
- Section of Endocrine Surgery, Columbia University, New York, NY 10032, USA
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10
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Kuo EJ, Chen L, Wright JD, McManus CM, Lee JA, Kuo JH. Phenoxybenzamine is no longer the standard agent used for alpha blockade before adrenalectomy for pheochromocytoma: A national study of 552 patients. Surgery 2023; 173:19-25. [PMID: 36167697 DOI: 10.1016/j.surg.2022.05.039] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2022] [Revised: 04/14/2022] [Accepted: 05/30/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Phenoxybenzamine has been the standard agent for blockade before adrenalectomy for pheochromocytoma. However, high cost and limited availability have hampered its use. This study investigated whether other agents have supplanted the use of phenoxybenzamine as the first-line agent for alpha blockade in pheochromocytoma. METHODS We performed a retrospective analysis of patients in the IBM MarketScan Database who underwent adrenalectomy for pheochromocytoma (2008-2019). Patients were categorized as having been blocked with phenoxybenzamine, selective alpha blockers, calcium channel blockers and/or beta blockers, or none of the above. The outcomes included prescription costs, perioperative costs, and length of stay. RESULTS A total of 552 patients were identified; 58.7% were female, and the median age was 49 (interquartile range 40-57) years. In total, 291 (52.7%) patients were blocked with phenoxybenzamine, 114 (20.7%) with selective alpha blockers, 42 (7.6%) with only calcium channel blockers and/or beta blockers, and 76 (13.8%) with none. The proportion of patients blocked with phenoxybenzamine decreased from 71.0% in 2008 to 21.2% in 2019. The proportion of patients blocked with selective alpha blockers increased from 6.5% in 2008 to 42.4% and in 2019. The median cost of phenoxybenzamine increased from $722 (interquartile range $441-$1,514) in 2008 to $9,616 (interquartile range $5,049-$16,373) in 2019 (P < .001). Length of stay (2 [interquartile range 1-4] days vs 2 [interquartile range 0-3] days) and total perioperative costs ($24,250 [interquartile range $17,462-$33,849] vs $22,098 [interquartile range $16,341-$29,178] between phenoxybenzamine and selective alpha blocker groups were similar. CONCLUSION There has been a significant shift away from phenoxybenzamine for preoperative blockade before resection of pheochromocytoma. Selective alpha blockers and calcium channel blockers are increasingly used, likely due to reduced costs, without compromised length of stay or intensive care unit admission.
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Affiliation(s)
- Eric J Kuo
- Division of GI/Endocrine Surgery, Columbia University, New York, NY.
| | - Ling Chen
- Joseph L. Mailman School of Public Health, Columbia University, New York, NY
| | - Jason D Wright
- Herbert Irving Comprehensive Cancer Center, Columbia University, New York, NY
| | | | - James A Lee
- Division of GI/Endocrine Surgery, Columbia University, New York, NY
| | - Jennifer H Kuo
- Division of GI/Endocrine Surgery, Columbia University, New York, NY
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11
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Collins RA, DiGennaro C, Beninato T, Gartland RM, Chaves N, Broekhuis JM, Reddy L, Lee J, Deimiller A, Alterio MM, Campbell MJ, Lee YJ, Khilnani TK, Stewart LA, O’Brien MA, Alvarado MVY, Zheng F, McAneny D, Liou R, McManus C, Dream SY, Wang TS, Yen TW, Alhefdhi A, Finnerty BM, Fahey TJ, Graves CE, Laird AM, Nehs MA, Drake FT, Lee JA, McHenry CR, James BC, Pasieka JL, Kuo JH, Lubitz CC. Limited disease progression in endocrine surgery patients with treatment delays due to COVID-19. Surgery 2023; 173:93-100. [PMID: 36210185 PMCID: PMC9420726 DOI: 10.1016/j.surg.2022.06.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 05/31/2022] [Accepted: 06/13/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND The COVID-19 pandemic profoundly impacted the delivery of care and timing of elective surgical procedures. Most endocrine-related operations were considered elective and safe to postpone, providing a unique opportunity to assess clinical outcomes under protracted treatment plans. METHODS American Association of Endocrine Surgeon members were surveyed for participation. A Research Electronic Data Capture survey was developed and distributed to 27 institutions to assess the impact of COVID-19-related delays. The information collected included patient demographics, primary diagnosis, resumption of care, and assessment of disease progression by the surgeon. RESULTS Twelve out of 27 institutions completed the survey (44.4%). Of 850 patients, 74.8% (636) were female; median age was 56 (interquartile range, 44-66) years. Forty percent (34) of patients had not been seen since their original surgical appointment was delayed; 86.2% (733) of patients had a delay in care with women more likely to have a delay (87.6% vs 82.2% of men, χ2 = 3.84, P = .05). Median duration of delay was 70 (interquartile range, 42-118) days. Among patients with a delay in care, primary disease site included thyroid (54.2%), parathyroid (37.2%), adrenal (6.5%), and pancreatic/gastrointestinal neuroendocrine tumors (1.3%). In addition, 4.0% (26) of patients experienced disease progression and 4.1% (24) had a change from the initial operative plan. The duration of delay was not associated with disease progression (P = .96) or a change in operative plan (P = .66). CONCLUSION Although some patients experienced disease progression during COVID-19 delays to endocrine disease-related care, most patients with follow-up did not. Our analysis indicated that temporary delay may be an acceptable course of action in extreme circumstances for most endocrine-related surgical disease.
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Affiliation(s)
- Reagan A. Collins
- Department of Surgery, Massachusetts General Hospital, Boston, MA,Texas Tech University Health Sciences Center School of Medicine, Lubbock, TX,Institute of Technology Assessment, Massachusetts General Hospital, Boston, MA
| | - Catherine DiGennaro
- Institute of Technology Assessment, Massachusetts General Hospital, Boston, MA
| | - Toni Beninato
- Department of Surgery, Rutgers Cancer Institute of New Jersey, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
| | | | - Natalia Chaves
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA
| | - Jordan M. Broekhuis
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA,Harvard Medical School, Boston, MA
| | - Lekha Reddy
- Department of Surgery, Rutgers Cancer Institute of New Jersey, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
| | - Jenna Lee
- Department of Surgery, Rutgers Cancer Institute of New Jersey, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
| | | | - Maeve M. Alterio
- Elson S. Floyd College of Medicine, Washington State University, Spokane, WA
| | | | - Yeon Joo Lee
- Department of Surgery, Weill Cornell Medicine/New York-Presbyterian Hospital, New York, NY
| | | | - Latoya A. Stewart
- Columbia University Vagelos College of Physicians and Surgeons, New York, NY
| | - Mollie A. O’Brien
- Department of Surgery, Boston Medical Center and Boston University School of Medicine, MA
| | | | - Feibi Zheng
- Department of Surgery, Baylor College of Medicine, Houston, TX
| | - David McAneny
- Department of Surgery, Boston Medical Center and Boston University School of Medicine, MA
| | - Rachel Liou
- Section of Endocrine Surgery, Columbia University, New York, NY
| | | | - Sophie Y. Dream
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Tracy S. Wang
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Tina W. Yen
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Amal Alhefdhi
- Department of General Surgery, Breast and Endocrine Section, King Faisal Specialist Hospital and Research Centre, Al Mathar Ash Shamali, Riyadh, Saudi Arabia
| | - Brendan M. Finnerty
- Department of Surgery, Weill Cornell Medicine/New York-Presbyterian Hospital, New York, NY
| | - Thomas J. Fahey
- Department of Surgery, Weill Cornell Medicine/New York-Presbyterian Hospital, New York, NY
| | | | - Amanda M. Laird
- Department of Surgery, Rutgers Cancer Institute of New Jersey, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
| | - Matthew A. Nehs
- Department of Surgery, Brigham and Women’s Hospital, Boston, MA
| | | | - James A. Lee
- Section of Endocrine Surgery, Columbia University, New York, NY
| | - Christopher R. McHenry
- Department of Surgery, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH
| | - Benjamin C. James
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA,Harvard Medical School, Boston, MA
| | - Janice L. Pasieka
- Department of Surgery, Cumming School of Medicine, University of Calgary, Alberta, Canada
| | - Jennifer H. Kuo
- Section of Endocrine Surgery, Columbia University, New York, NY
| | - Carrie Cunningham Lubitz
- Department of Surgery, Massachusetts General Hospital, Boston, MA,Institute of Technology Assessment, Massachusetts General Hospital, Boston, MA,Harvard Medical School, Boston, MA,Reprint requests: Carrie Cunningham Lubitz, MD, MPH, 55 Fruit Street, Boston, MA 02114
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Kuo EJ, Oh A, Hu Y, McManus CM, Lee JA, Kuo JH. If the price is right: Cost-effectiveness of radiofrequency ablation versus thyroidectomy in the treatment of benign thyroid nodules. Surgery 2023; 173:201-206. [PMID: 36334980 DOI: 10.1016/j.surg.2022.08.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 06/21/2022] [Accepted: 08/24/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND 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. METHODS 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. RESULTS 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. CONCLUSION Radiofrequency ablation is a cost-effective strategy in the treatment of benign thyroid nodules but is most sensitive to the cost of radiofrequency ablation.
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Affiliation(s)
- Eric J Kuo
- Section of Endocrine Surgery, Columbia University, New York, NY.
| | - Aaron Oh
- Albert Einstein College of Medicine, New York, NY
| | - Yinin Hu
- Division of General and Oncologic Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
| | | | - James A Lee
- Section of Endocrine Surgery, Columbia University, New York, NY
| | - Jennifer H Kuo
- Section of Endocrine Surgery, Columbia University, New York, NY
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Kluger MD, Huang YY, Kuo JH, Kwon W, Thomas AS, Hershman DL, Schrope BA, Sugahara KN, Chabot JA, Wright JD. Perioperative and persistent opioid utilization following pancreatectomy in the United States. HPB (Oxford) 2022; 24:912-924. [PMID: 34815188 DOI: 10.1016/j.hpb.2021.10.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 07/08/2021] [Accepted: 10/29/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Opioids are central to analgesia for pancreatic diseases. Individuals undergoing pancreatectomy have largely been excluded from studies of opioid use, because of malignancy or chronic use. Surgeons need to understand usage patterns, and practices that may incline patients toward persistent post-operative use. METHODS A retrospective study using IBM Watson Health MarketScan database examined patterns of peri-pancreatectomy opioid use between 2009 and 2017. Patients were grouped by opioid use 12 months to 31 days prior to pancreatectomy and followed for persistent use (refills 90-180 days postoperatively). Morphine milligram equivalents (MME) were calculated. Multivariable models explored associations between clinical characteristics, perioperative use and persistent use. RESULTS Opioids were used within the year prior to surgery by 35.6% of 8325 patients. The median MME for opioid naïve patients (400 mg) was a fraction of the 1800 mg prescribed to chronic opioid users for peri-operative analgesia. The rate of persistent opioid use was 15.1% among naïve, 27.2% among intermittent and 77.3% among chronic opioid users. Multivariable models demonstrated naïve and intermittent users who filled a prescription within 30 days prior to pancreatectomy, those who were prescribed total MME ≥1500 mg, and a ≥14 day supply were most at risk of persistent opioid use. Almost 23% of chronic users stopped using opioids post-operatively, suggesting surgery can provide relief. CONCLUSION Preoperative and persistent opioid use after pancreatectomy is substantially greater than expected based on other operations. Providers may mitigate this by recognizing the issue, managing expectations, and altering the timing and quantities of opioids prescribed.
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Affiliation(s)
- Michael D Kluger
- Division of GI/Endocrine Surgery, Department of Surgery, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA.
| | - Yongmei Y Huang
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
| | - Jennifer H Kuo
- Division of GI/Endocrine Surgery, Department of Surgery, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
| | - Wooil Kwon
- Division of GI/Endocrine Surgery, Department of Surgery, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
| | - Alexander S Thomas
- Division of GI/Endocrine Surgery, Department of Surgery, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
| | - Dawn L Hershman
- Division of Hematology/Oncology, Department of Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA; Herbert Irving Comprehensive Cancer Center, New York, NY, USA
| | - Beth A Schrope
- Division of GI/Endocrine Surgery, Department of Surgery, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
| | - Kazuki N Sugahara
- Division of GI/Endocrine Surgery, Department of Surgery, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
| | - John A Chabot
- Division of GI/Endocrine Surgery, Department of Surgery, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA; Herbert Irving Comprehensive Cancer Center, New York, NY, USA
| | - Jason D Wright
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA; Herbert Irving Comprehensive Cancer Center, New York, NY, USA
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Stewart LA, Steinl GK, Huang BL, McManus C, Lee JA, Kuo JH, Walker MD. Primary Hyperparathyroidism Is Associated With Shorter QTc Intervals, but Not Arrhythmia. J Clin Endocrinol Metab 2022; 107:e1689-e1698. [PMID: 34752632 PMCID: PMC8947224 DOI: 10.1210/clinem/dgab820] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Indexed: 11/19/2022]
Abstract
CONTEXT Primary hyperparathyroidism (PHPT) is associated with subclinical cardiovascular disease, but data regarding cardiac conduction abnormalities are limited. OBJECTIVE AND DESIGN Retrospective cross-sectional comparison of cardiac conduction in patients with PHPT or thyroid disease (TD). PARTICIPANTS AND SETTING Patients ≥40 years old who underwent parathyroidectomy or thyroidectomy at a single tertiary institution from 2013 to 2018. METHODS AND OUTCOMES Demographics and preoperative electrocardiogram (EKG) parameters were compared using the Mann-Whitney U, chi-square test, and linear regression. RESULTS A total of 1242 patients were included: 49.8% PHPT (n = 619) and 50.2% TD (n = 623). Median age was 60.5 years [interquartile range (IQR) 53.6-67.9]. Compared to controls, PHPT patients had higher median serum calcium [10.7 mg/dL (IQR 10.4-11.1) vs 9.5 mg/dL (IQR 9.3-9.8), P < 0.001] as expected, as well as, a higher prevalence of hyperlipidemia (49% vs 36%, P < 0.001) and hypertension (50.1% vs 42.2%, P < 0.01). Based on EKG, there was no difference in PR interval or the prevalence of arrhythmia, atrioventricular block, ST segment/T wave changes, premature ventricular complexes, right bundle branch block, or left bundle branch block after adjusting for covariates. The PHPT group had a lower mean corrected QT interval (414 ± 24) ms vs 422 ± 24 ms, P < 0.01), adjusted for covariates. Serum calcium predicted QTc independently of age, sex, and other covariates. CONCLUSIONS In the largest study to date, PHPT patients had shorter QTc intervals compared to TD controls but no increased prevalence of arrhythmia based on preoperative EKG.
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Affiliation(s)
- Latoya A Stewart
- Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
| | - Gabrielle K Steinl
- Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
| | - Bernice L Huang
- Section of Endocrine Surgery, Columbia University Irving Medical Center, New York, NY, USA
| | - Catherine McManus
- Section of Endocrine Surgery, Columbia University Irving Medical Center, New York, NY, USA
| | - James A Lee
- Section of Endocrine Surgery, Columbia University Irving Medical Center, New York, NY, USA
| | - Jennifer H Kuo
- Section of Endocrine Surgery, Columbia University Irving Medical Center, New York, NY, USA
| | - Marcella D Walker
- Department of Medicine, Division of Endocrinology, Columbia University Irving Medical Center, New York, NY, USA
- Correspondence: Marcella Walker, MD, Division of Endocrinology, 180 Fort Washington Ave, 9th Floor #904, Columbia University Irving Medical Center, New York, NY 10032, USA.
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16
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Kuo JH, Sinclair CF, Lang B, Spiezia S, Yu M, Ha EJ, Na DG, Offi C, Patel KN, Baek JH. A comprehensive review of interventional ablation techniques for the management of thyroid nodules and metastatic lymph nodes. Surgery 2021; 171:920-931. [PMID: 34776258 DOI: 10.1016/j.surg.2021.07.043] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 07/03/2021] [Accepted: 07/06/2021] [Indexed: 01/15/2023]
Abstract
Thyroidectomy remains the gold standard treatment for benign, symptomatic, or enlarging thyroid nodules, malignant nodules, and metastatic lymph node disease. However, in the past 2 decades, image-guided interventional techniques have emerged as promising alternative treatments for these conditions. Percutaneous ethanol ablation is now an accepted first-line treatment for recurring cystic thyroid nodules. Thermal ablation techniques such as high-intensity focused ultrasound, laser ablation, radiofrequency ablation, and microwave ablation have shown efficacy in producing a nodular volume reduction of greater than 50% that is maintained for several years with resolution of local compressive symptoms. There is also increasing evidence that these techniques can effectively treat papillary thyroid microcarcinomas and recurrent metastatic lymph node disease. Because these interventional ablation techniques are performed safely in an outpatient setting, are well tolerated, and the risk for needing thyroid hormone supplementation is negligible, they are becoming a popular alternative treatment to surgical resection. In this comprehensive review, we discuss each of these percutaneous interventions: the devices and techniques, the advantages and disadvantages of each energy, and summarize the outcomes published in the literature.
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Affiliation(s)
- Jennifer H Kuo
- Section of Endocrine Surgery, Columbia University, New York, NY.
| | - Catherine F Sinclair
- Head and Neck Surgery, Mt. Sinai Hospital, New York, NY. https://twitter.com/drcathsinclair
| | - Brian Lang
- Division of Endocrine Surgery, Queen Mary Hospital, Hong Kong. https://twitter.com/BrianHLang1
| | - Stefano Spiezia
- Division of Endocrine Surgery and Interventional Ultrasound, Hospital "Ospedale del Mare" ASLNA1centro, Naples, Italy
| | - Mingan Yu
- Department of Interventional Ultrasound, China-Japan Friendship Hospital, Beijing China
| | - Eun Ju Ha
- Department of Radiology, Ajou University, Suwon, South Korea. https://twitter.com/EunjuHa3
| | - Dong Gyu Na
- Department of Radiology, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, South Korea
| | - Chiara Offi
- Division of Endocrine Surgery and Interventional Ultrasound, Hospital "Ospedale del Mare" ASLNA1centro, Naples, Italy
| | - Kepal N Patel
- Division of Endocrine Surgery, NYU Langone Health, New York, NY
| | - Jung Hwan Baek
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Affiliation(s)
- J H Kuo
- Section of Endocrine Surgery, Columbia University, New York, New York
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Dream S, Kuo JH, Wang TS. Virtual interactive presence, a novel approach to remote proctoring for the adoption of innovative technologies and interventions. Am J Surg 2021; 223:600-602. [PMID: 34535290 DOI: 10.1016/j.amjsurg.2021.09.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 07/30/2021] [Accepted: 09/07/2021] [Indexed: 11/01/2022]
Affiliation(s)
- Sophie Dream
- Department of Surgery, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI, 53266, USA.
| | | | - Tracy S Wang
- Department of Surgery, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI, 53266, USA.
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Beninato T, Laird AM, Graves CE, Drake FT, Alhefdhi A, Lee JA, Kuo JH, Grubbs EG, Wang TS, Pasieka JL, Lubitz CC. Impact of the COVID-19 pandemic on the practice of endocrine surgery. Am J Surg 2021; 223:670-675. [PMID: 34315576 PMCID: PMC8294714 DOI: 10.1016/j.amjsurg.2021.07.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 07/09/2021] [Accepted: 07/10/2021] [Indexed: 12/27/2022]
Abstract
Background This study investigates the impact of the COVID-19 pandemic on endocrine surgeons. Methods A survey on the professional, educational, and clinical impact was sent to active and corresponding members of the American Association of Endocrine Surgeons (AAES) in September 2020. Chi-square and paired t-test were used for analysis. Results 77 surgeons responded (14.8 %). All reported suspension of elective surgeries; 37.7 % were reassigned to other duties during this time. The median number of cases backlogged was 30 (IQR 15–50). Most surgeons reported decreased clinical volume (74.6 %). The use of virtual platforms for clinical and educational purposes increased from pre-COVID-19 levels (all p < 0.001). Use of in-office procedures (p < 0.001) and length of observation prior to discharge for thyroid surgery (p < 0.05) decreased. Conclusion The COVID-19 pandemic led to suspension of operations and decreased practice volume for endocrine surgeons. Surgeons increased use of virtual platforms, decreased in-office procedures, and decreased duration of observation for thyroid surgery in response.
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Affiliation(s)
- Toni Beninato
- Rutgers Cancer Institute of New Jersey, Rutgers Robert Wood Johnson Medical School, 195 Little Albany Street, New Brunswick, NJ, 08903, USA.
| | - Amanda M Laird
- Rutgers Cancer Institute of New Jersey, Rutgers Robert Wood Johnson Medical School, 195 Little Albany Street, New Brunswick, NJ, 08903, USA.
| | - Claire E Graves
- University of California Davis, 4501 X Street, Suite 3010, Sacramento, CA, 95817, USA.
| | - F Thurston Drake
- Boston Medical Center, Boston University School of Medicine, 830 Harrison Avenue, Boston, MA, 02118, USA.
| | - Amal Alhefdhi
- King Faisal Specialist Hospital and Research Centre, Al Mathar Ash Shamali, Riyadh, 11564, Saudi Arabia.
| | - James A Lee
- NewYork Presbyterian Hospital-Columbia University Medical Center, 161 Fort Washington Avenue, New York, NY, 10032, USA.
| | - Jennifer H Kuo
- NewYork Presbyterian Hospital-Columbia University Medical Center, 161 Fort Washington Avenue, New York, NY, 10032, USA.
| | - Elizabeth G Grubbs
- University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030, USA.
| | - Tracy S Wang
- Medical College of Wisconsin, 8800 West Doyne Avenue, Milwaukee, WI, 53226, USA.
| | - Janice L Pasieka
- Cumming School of Medicine, University of Calgary, 1403 29(th)Street NW, Calgary, Alberta, T2N 2T9, Canada.
| | - Carrie C Lubitz
- Harvard Medical School, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA.
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Sharma RK, Lee J, Liou R, McManus C, Lee JA, Kuo JH. Optimal surgeon-volume threshold for neck dissections in the setting of primary thyroid malignancies. Surgery 2021; 171:172-176. [PMID: 34266647 DOI: 10.1016/j.surg.2021.04.046] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 04/11/2021] [Indexed: 01/08/2023]
Abstract
BACKGROUND Although the surgeon-volume relationship is well documented for thyroidectomy, less is known about central neck and lateral neck dissections. The aim of this study was to evaluate and determine the surgeon-volume threshold for central neck and lateral neck dissections for thyroid cancer. METHODS A retrospective analysis of patients with thyroid malignancies who received a central or lateral neck dissection in the New York Statewide Planning and Research Cooperative System was performed (2007-2017). Demographic variables included age, sex, race, and a Charlson Comorbidity Score. Thirty-day complications were identified using International Classification of Diseases (ICD) codes for central neck, lateral neck, and other surgical complications. Optimal surgeon-volume threshold was estimated using a change-point logistic regression. Using the identified threshold, surgeons were then classified to low versus high volume surgeons. Logistic regression analysis was conducted to examine the effect of high-volume status on outcomes. RESULTS In total, 3,808 patients who underwent neck dissections (3,485 central neck dissections and 977 lateral neck dissections) were analyzed. Surgeon-volume threshold to distinguish high volume surgeons for central neck dissections and lateral neck dissections was 7.0 (95% bootstrap confidence interval 1.3-7.5) and 3.3 (1.2-4.8) neck dissections/year, respectively. For central neck dissection, high volume surgeons were associated with a lower rate of vocal cord paralysis (odds ratio 0.45 [0.24-0.82]), hypocalcemia (0.31 [0.14-0.65]), and all-cause complications (0.42 [0.29-0.59]). For lateral neck dissection, high volume surgeons were associated with a lower odds all-cause complications (0.42 [0.23-0.74]) but not lateral neck specific complications (0.18 [0.01-1.07]). CONCLUSION A threshold of 7.0 central neck dissections and 3.3 lateral neck dissections for thyroid cancer per year improves outcomes. Guidelines for training and centralization of care can be guided by these results to reduce complications.
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Affiliation(s)
- Rahul K Sharma
- Division of Endocrine Surgery, Columbia University Irving Medical Center, New York, NY. https://twitter.com/RKSharma0407
| | - Jihui Lee
- Division of Biostatistics, Department of Population Health Sciences, Weill Cornell Medicine, New York, NY
| | - Rachel Liou
- Division of Endocrine Surgery, Columbia University Irving Medical Center, New York, NY
| | - Catherine McManus
- Division of Endocrine Surgery, Columbia University Irving Medical Center, New York, NY
| | - James A Lee
- Division of Endocrine Surgery, Columbia University Irving Medical Center, New York, NY
| | - Jennifer H Kuo
- Division of Endocrine Surgery, Columbia University Irving Medical Center, New York, NY.
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Geary AD, Wang TS, Lindeman B, Kuo JH, Lyden ML, Shen WT, Morris-Wiseman LF, Carty SE, Drake FT. Perspectives on virtual interviews-A follow-up study of the Comprehensive Endocrine Surgery Fellowship interview process. Surgery 2021; 171:259-264. [PMID: 34266646 DOI: 10.1016/j.surg.2021.03.069] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 03/23/2021] [Accepted: 03/28/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND The American Association of Endocrine Surgeons Comprehensive Endocrine Surgery Fellowship interview stakeholders previously favored in-person interviews, despite time and expense. This study assessed perception changes given mandated virtual interviews because of coronavirus disease 2019. METHODS Immediately after the 2020 Match, anonymous surveys were distributed to applicants (n = 37) and program directors (n = 22). Mixed-methods analyses were used to evaluate responses. Results were compared to data from a prior study of the 2013 to 2018 in-person interview process. RESULTS Response rates were 82% (program directors) and 60% (applicants). Compared with prior applicants, 2020 applicants attended similar numbers of interviews (1-10, 32% vs 37%; P = .61), used fewer vacation days (23% vs 56%; P = .01), and most reported 0 expenses. Burdens included lack of protected time for interviews. The virtual format did not compromise applicant ability to meet faculty (mean rank = 6.8/10) or make favorable impressions (mean rank = 6.8/10). Program directors reported equivalent or improved assessments of applicants. Program directors (72%) and applicants (77%) indicated that future interviews should be partially or completely virtual. CONCLUSION In contrast to prior survey data, applicants and program directors now express interest in virtual or hybrid interview processes. Virtual interviews were less costly, less time-consuming, and met goals effectively. Integrating virtual interview components will require innovative strategies to reduce redundancies and promote equitable access.
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Affiliation(s)
- Alaina D Geary
- Boston University School of Medicine and Boston Medical Center, MA. https://twitter.com/GearyMD
| | - Tracy S Wang
- Medical College of Wisconsin, Milwaukee, WI. https://twitter.com/tracyswangNYMKE
| | - Brenessa Lindeman
- University of Alabama at Birmingham, AL. https://twitter.com/BrenessaL
| | - Jennifer H Kuo
- Columbia University Medical Center, New York, NY. https://twitter.com/JenniferKuo5
| | | | - Wen T Shen
- University of California, San Francisco, CA. https://twitter.com/wshen16
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Kuo JH, McManus C, Lee JA. Analyzing the adoption of radiofrequency ablation of thyroid nodules using the diffusion of innovations theory: understanding where we are in the United States? Ultrasonography 2021; 41:25-33. [PMID: 34551469 PMCID: PMC8696140 DOI: 10.14366/usg.21117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 07/01/2021] [Indexed: 11/09/2022] Open
Abstract
Thyroid nodules are very common and found in up to 68% of the general U.S. population on ultrasound. Although thyroidectomy has long been the mainstay of treatment for malignant and symptomatic benign thyroid nodules, various interventional ablative techniques have emerged in the last couple of decades as alternative non-surgical treatment options. Globally, the most widely adopted technique has been ultrasound-guided radiofrequency ablation (RFA). RFA of thyroid nodules was first performed in 2002, and there has been an expanding body of evidence since 2006 showing that RFA and other interventional ablative techniques are effective treatments for benign solid thyroid nodules, toxic adenomas, and thyroid cysts. More recently, evidence has emerged that these techniques may be effective treatment for low-risk thyroid cancer and recurrent disease. Despite these findings, the United States has been slow to adopt these techniques, with only a single publication on RFA more than a decade after the first series was published. EM Rogers’ Diffusion of Innovation Theory provides us the appropriate lens to carefully analyze the process of adoption of RFA for thyroid nodules-to understand where we are currently, as well as, the important next steps that must be accomplished in order for RFA and other ablative techniques to be successfully adopted into the management algorithm of thyroid nodules in the United States.
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Affiliation(s)
- Jennifer H Kuo
- Section of Endocrine Surgery, Columbia University, New York, NY, USA
| | - Catherine McManus
- Section of Endocrine Surgery, Columbia University, New York, NY, USA
| | - James A Lee
- Section of Endocrine Surgery, Columbia University, New York, NY, USA
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Stewart LA, Steinl GK, Huang BL, McManus C, Lee JA, Walker MD, Kuo JH. Patients With Primary Hyperparathyroidism Have Shorter QT/QTc Intervals. J Endocr Soc 2021. [PMCID: PMC8090402 DOI: 10.1210/jendso/bvab048.539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Background: Previous studies suggest that patients with primary hyperparathyroidism (PHPT) have subclinical cardiovascular disease, but data regarding cardiac conduction abnormalities are limited. The aim of this study was to assess cardiac conduction abnormalities in patients with PHPT compared to controls with thyroid disease (TD). Method: We conducted a retrospective analysis of patients over 40 years of age who underwent parathyroidectomy or thyroidectomy at a single tertiary institution between 2013 and 2018. Demographics and EKG parameters from pre-operative EKG reports were compared using the Mann-Whitney U and Chi Square tests. Regression was used to compare EKG differences between the PHPT and control groups adjusted for sex, age, and other variables found to be significant on univariate analysis. Results: A total of 1181 patients were analyzed, 51% in the PHPT group (n=602) and 49% in the TD group (n=579). The median age was 60.5 years (IQR 53.5–67.9) and there was no difference in sex between the cohorts. PHPT patients had a higher prevalence of hyperlipidemia (HLD, 49% vs 36%, p<0.001) and hypertension (HTN, 50.7% vs 42.1%, p<0.01), but had no differences in EKG rhythm patterns or prevalence of arrhythmia compared to TD patients. As expected, mean serum calcium levels were higher for the PHPT group, 10.74 (0.66) vs 9.53 (0.44). However, the PHPT group included both normocalcemic and hypercalcemic patients. The PHPT group had a lower median QT interval compared to the TD group, 386ms (IQR 368–406) vs 398ms (IQR 376–418), p<0.001 and a higher median PR value, 158ms (IQR 144–174.5) vs 156ms (IQR 143.5–171), p<0.05. More PHPT patients (n=21, 3.5%) had a short QTc interval (<360ms males/<370ms females), compared to TD controls (n=1, 0.2%). Among PHPT patients with a short QT interval, the proportion of patients with hypercalcemia (95%) was higher than that of the PHPT group overall (75%). On multivariable analysis, PHPT patients had a shorter QT interval than TD controls after controlling for sex, age, HLD, HTN. There was no difference between PHPT and TD when serum calcium was included in the model, suggesting that calcium mediates the relationship between QT interval and disease status. Conclusion: PHPT patients have shorter QT/QTc intervals compared to TD controls, but no increased prevalence of arrythmia at baseline. While the QT interval was associated with degree of serum calcium elevation, these findings in a large cohort suggest that PHPT is not associated with arrythmia at baseline among those undergoing parathyroidectomy.
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Steinl GK, Yeh R, McManus CM, Lee JA, Kuo JH. Variations in the Course of the Carotid Arteries in Patients with Retropharyngeal Parathyroid Adenomas. AJNR Am J Neuroradiol 2021; 42:749-752. [PMID: 33602744 DOI: 10.3174/ajnr.a6995] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Accepted: 11/24/2020] [Indexed: 12/17/2022]
Abstract
The carotid arteries, classically described as taking a relatively straight course through the neck, deviate medially in a minority of patients. At the extreme, the internal carotid arteries may "kiss" in the midline, coming extremely close to the pharyngeal wall. In this clinical report, we describe 5 patients with primary hyperparathyroidism, all with ectopic retropharyngeal parathyroid adenomas but all with varying carotid artery anatomy. We describe these variations using a previously developed clinical grading system that highlights 1) the relationship between carotid artery location and risk of injury during pharyngeal procedures and 2) the importance of universal, objective criteria to classify carotid anatomy. Radiologists should be familiar with variations in carotid anatomy and communicate them to the operative team.
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Affiliation(s)
- G K Steinl
- From the Department of Surgery, Division of GI/Endocrine Surgery (G.K.S., C.M.M., J.A.L., J.H.K.), Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, New York
| | - R Yeh
- Department of Radiology (R.Y.), Memorial Sloan Kettering Cancer Center, New York, New York
| | - C M McManus
- From the Department of Surgery, Division of GI/Endocrine Surgery (G.K.S., C.M.M., J.A.L., J.H.K.), Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, New York
| | - J A Lee
- From the Department of Surgery, Division of GI/Endocrine Surgery (G.K.S., C.M.M., J.A.L., J.H.K.), Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, New York
| | - J H Kuo
- From the Department of Surgery, Division of GI/Endocrine Surgery (G.K.S., C.M.M., J.A.L., J.H.K.), Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, New York
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25
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Steinl GK, Yeh R, Walker MD, McManus C, Lee JA, Kuo JH. Preoperative imaging predicts change in bone mineral density after parathyroidectomy for primary hyperparathyroidism. Bone 2021; 145:115871. [PMID: 33540118 PMCID: PMC9450481 DOI: 10.1016/j.bone.2021.115871] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Revised: 01/27/2021] [Accepted: 01/27/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Bone Mineral Density (BMD) improves after parathyroidectomy (PTX), but data on factors that predict bone recovery are limited. No studies have evaluated if preoperative imaging findings are associated with postoperative change in BMD. We hypothesized that larger, metabolically active glands would be associated with greater increase in BMD after PTX. METHODS Patients with primary hyperparathyroidism (PHPT) who underwent combined Tc-99m sestamibi and 4D-CT imaging prior to PTX and had pre- and post-operative dual-energy X-ray absorptiometry (DXA) at our institution were considered for inclusion. Retrospectively, data were collected from imaging studies on each parathyroid gland, including estimated weight (using the ellipsoid formula) and contrast enhancement on 4D-CT as well as sestamibi avidity. Total estimated parathyroid weight was calculated. The main outcome measure was the percent change in BMD at the lumbar spine (LS) from pre- to post-operative DXA. Predictors of change in BMD at the LS were assessed. RESULTS Complete DXA data was available in 25 patients. Median total parathyroid weight on 4D-CT was 270 mg, and mean change in BMD at the LS was 2.4 ± 4.3%. The increase in BMD was best predicted by higher preoperative serum calcium (p = 0.01), greater estimated parathyroid weight (p = 0.001), sestamibi avidity (p = 0.03), and increased time between DXA scans (p = 0.03) in the multivariable model (R2 = 0.79, p < 0.0001). CONCLUSION In PHPT, higher preoperative serum calcium, parathyroid gland weight on imaging, and sestamibi avidity are associated with greater increases in BMD after curative PTX. These findings suggest that larger, metabolically active adenomas may mobilize more calcium from bone.
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Affiliation(s)
- Gabrielle K Steinl
- Columbia University Vagelos College of Physicians & Surgeons, United States of America
| | - Randy Yeh
- Memorial Sloan Kettering Cancer Center, Department of Radiology, United States of America
| | - Marcella D Walker
- Columbia University Irving Medical Center Department of Medicine, Endocrinology, United States of America
| | - Catherine McManus
- Columbia University Irving Medical Center Department of Surgery, Division of GI/Endocrine Surgery, United States of America
| | - James A Lee
- Columbia University Irving Medical Center Department of Surgery, Division of GI/Endocrine Surgery, United States of America
| | - Jennifer H Kuo
- Columbia University Irving Medical Center Department of Surgery, Division of GI/Endocrine Surgery, United States of America.
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Sharma RK, Huang B, Lee JA, Kuo JH. Trends and Outcomes of Surgical Management of Primary Papillary Carcinoma in the Pediatric Population. J Surg Res 2021; 263:207-214. [PMID: 33690052 DOI: 10.1016/j.jss.2021.01.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 12/03/2020] [Accepted: 01/29/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Childhood papillary thyroid cancer is more aggressive than carcinomas in adults. Current American Thyroid Association pediatric guidelines recommend a total or near-total thyroidectomy for all pediatric patients without gross evidence of lymph node metastases. Our objective is to analyze trends in the surgical management of pediatric papillary thyroid cancer and assess how well the guidelines are implemented. METHODS A retrospective cohort study of pediatric patients (ages 19 y and under) who underwent a thyroidectomy was conducted using the Surveillance, Epidemiology, and End Results database 2006-2017. Procedure type was classified as lobectomy or less and subtotal or total thyroidectomy. Descriptive statistics to illustrate patient and tumor characteristics as well as chi-square analysis to evaluate frequency of treatment with total thyroidectomies versus lobectomy or less were performed. Logistic regression analysis controlling for age, sex, size of tumor, rural versus urban institutions, and surgery year was conducted to identify factors predictive of procedure type. RESULTS A total of 2271 children underwent surgical management of papillary thyroid cancer between 2006 and 2017. Most patients received a subtotal or total thyroidectomy as surgical management (n = 2,085, 91.8%). One hundred eighty-six patients (8.2%) received a lobectomy or less. The number of lobectomies or less increased with time, with 41 (6.6%) patients between 2006 and 2009, 98 (8.0%) between 2009 and 2015, and 47 (11.1%) between 2016 and 2017 (P = 0.03). Mortality rates were low (n = 15, 0.7%). On logistic regression analysis, later stages, larger sizes, and earlier operative years were predictive of a near-total or total thyroidectomy. CONCLUSIONS Despite the American Thyroid Association Guidelines recommending a total thyroidectomy for pediatric well-differentiated thyroid cancer, the results of this study demonstrate that thyroid lobectomies are being performed in increasing frequency for smaller tumors in earlier stages of disease. Further investigation of whether this trend actually affects the outcomes in this patient cohort is needed.
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Affiliation(s)
- Rahul K Sharma
- Section of Endocrine Surgery, Columbia University Irving Medical Center, New York, New York; Columbia University Vagelos College of Physicians and Surgeons, New York, New York
| | - Bernice Huang
- Section of Endocrine Surgery, Columbia University Irving Medical Center, New York, New York
| | - James A Lee
- Section of Endocrine Surgery, Columbia University Irving Medical Center, New York, New York
| | - Jennifer H Kuo
- Section of Endocrine Surgery, Columbia University Irving Medical Center, New York, New York.
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Sharma RK, McManus C, Kuo JH. Idiopathic thyroid abscess in a healthy 22-year old female – A case of anchoring bias. Journal of Clinical and Translational Endocrinology: Case Reports 2021. [DOI: 10.1016/j.jecr.2020.100073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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Muhammad H, Santhanam P, Russell JO, Kuo JH. RFA and benign thyroid nodules: Review of the current literature. Laryngoscope Investig Otolaryngol 2021; 6:155-165. [PMID: 33614945 PMCID: PMC7883624 DOI: 10.1002/lio2.517] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Revised: 12/11/2020] [Accepted: 12/26/2020] [Indexed: 12/11/2022] Open
Abstract
Benign thyroid nodules (BTNs) are commonly found in the general population. They are usually asymptomatic and their incidence has increased as a result of wide-spread use of ultrasound. Benign nodules are typically monitored clinically until they increase in size, resulting in compressive symptoms warranting surgery. However, although surgery is generally well-tolerated and of low-risk, it is associated with a small risk for several complications including hypothyroidism, nerve injury, hematoma, injury to other structures and wound infection. Recently, newer image-guided ablation techniques including radiofrequency ablation (RFA) have been introduced. RFA has a similar safety profile when compared to surgery and has shown promising results in challenging surgical candidates. Though several studies have been published in Asian and European countries on the efficacy of RFA, limited data is available on the North American population. The aim of the study is to review the current literature establishing the clinical outcomes and safety of RFA for benign nodules. LEVEL OF EVIDENCE V.
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Affiliation(s)
- Haris Muhammad
- Department of Internal MedicineGreater Baltimore Medical CenterTowsonMarylandUSA
| | - Prasanna Santhanam
- Division of Endocrinology, Diabetes, & Metabolism, Department of MedicineJohns Hopkins University School of MedicineBaltimoreMarylandUSA
| | - Jonathon O. Russell
- Department of Otolaryngology—Head and Neck SurgeryJohns Hopkins University School of MedicineBaltimoreMarylandUSA
| | - Jennifer H. Kuo
- Department of Surgery, Section of Endocrine SurgeryColumbia University Medical CenterNew YorkNew YorkUSA
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Abstract
Secondary hyperparathyroidism (SHPT) affects a majority of patients with chronic kidney disease (CKD) of stage 3 or worse. Despite the development of calcimimetics and their effectiveness in treating SHPT, many patients continue to fail medical management and should be referred to a parathyroid surgeon. In this narrative review, we summarize the indications for surgical referral, preoperative planning, intraoperative strategies to guide resection, and postoperative management. In the absence of universal guidelines, it can be difficult to determine when it is appropriate to make this referral. The majority of studies evaluating parathyroidectomy (PTX) for SHPT use the criteria of parathyroid hormone level (PTH) >800 pg/ml with hypercalcemia and/or hyperphosphatemia, which may be accompanied by symptoms such as bone pain and pruritis that can improve after surgery. Although the reported utility of the various imaging modalities (i.e., 99m-technetium-sestamibi scintigraphy with computed tomography [SPECT/CT], CT, or ultrasound) is highly variable in SHPT, SPECT/CT appears to be the most sensitive. Intraoperatively, PTH monitoring is effective in predicting long-term cure of SHPT but not in predicting hypoparathyroidism. Ectopic and supernumerary parathyroid glands are common in these patients and are often implicated in persistent or recurrent disease. Postoperatively, patients are at risk of severe hypocalcemia and hungry bone syndrome requiring close monitoring and replenishment.
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Affiliation(s)
- Gabrielle K. Steinl
- Columbia University Vagelos College of Physicians & Surgeons, New York, New York, USA
| | - Jennifer H. Kuo
- Department of Surgery, Division of Gastrointestinal/Endocrine Surgery, Columbia University Irving Medical Center, New York, New York, USA
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Abstract
Derived from follicular epithelial cells, differentiated thyroid cancer (DTC) accounts for the majority of thyroid malignancies. The threefold increase in DTC incidence over the last three decades has been largely attributed to advancements in detection of papillary thyroid microcarcinomas. Efforts to address the issue of overtreatment have notably included the reclassification of encapsulated follicular variant papillary thyroid cancers (EFVPTC) to non-invasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTP). In the last 5 years, the overall management approach for this relatively indolent cancer has become less aggressive. Although surgery and radioiodine ablation remain the mainstay of DTC therapy, the role of active surveillance is being explored. Furthermore, the most recent American Thyroid Association (ATA) guidelines offer flexibility between lobectomy and total thyroidectomy for thyroid nodules between 1 cm and 4 cm in the absence of extrathyroidal extension or nodal disease. As our understanding of the natural history and molecular underpinnings of DTC evolves, so might our approach to managing low-risk patients, obviating the need for invasive intervention. Simultaneously, advances in interventional and systemic therapies have greatly expanded treatment options for high-risk surgical candidates and patients with widespread disease, and continue to be areas of active investigation. Continued research efforts are essential to improve our ability to offer effective individualized therapy to patients at all disease stages and to reduce the incidence of recurrent and progressive disease.
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Affiliation(s)
- Latoya A. Stewart
- Columbia University Vagelos College of
Physicians and Surgeons, New York, NY, USA
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Jurkiewicz M, Cimic A, Murty VV, Kuo JH, Hsiao S, Fazlollahi L, Fernandes H. Detection of STRN-ALK fusion in thyroid nodules with indeterminate cytopathology facilitates papillary thyroid cancer diagnosis. Diagn Cytopathol 2020; 49:E146-E151. [PMID: 33085842 DOI: 10.1002/dc.24647] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Revised: 09/18/2020] [Accepted: 10/12/2020] [Indexed: 11/06/2022]
Abstract
Thyroid cancer is the most common endocrine malignancy. Approximately 70% of cases of papillary thyroid carcinoma and 50% of poorly differentiated and anaplastic thyroid carcinoma harbor well-characterized driver mutations and chromosomal rearrangements that drive tumorigenesis. Molecular profiling has been helpful in identifying and informing follow-up strategies in tumors with more aggressive trajectories. Here, we report a case of papillary thyroid cancer (PTC) discovered in a patient with thyroid nodules with relatively benign ultrasound and fine needle aspiration (FNA) findings. Molecular testing in this patient identified a rare STRN-ALK fusion in two thyroid nodules with indeterminate and/or benign cytology. This led to the patient undergoing a thyroid lobectomy and a subsequent confirmation of papillary thyroid carcinoma upon resection. The report highlights the role of comprehensive molecular testing in thyroid lesions of indeterminate cytology.
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Affiliation(s)
- Magdalena Jurkiewicz
- Department of Pathology and Cell Biology, Columbia University Irving Medical Center, New York, New York, USA
| | - Adela Cimic
- Department of Pathology and Cell Biology, Columbia University Irving Medical Center, New York, New York, USA
| | - Vundavalli V Murty
- Department of Pathology and Cell Biology, Columbia University Irving Medical Center, New York, New York, USA
| | - Jennifer H Kuo
- Department of Surgery, Columbia University Irving Medical Center, New York, New York, USA
| | - Susan Hsiao
- Department of Pathology and Cell Biology, Columbia University Irving Medical Center, New York, New York, USA
| | - Ladan Fazlollahi
- Department of Pathology and Cell Biology, Columbia University Irving Medical Center, New York, New York, USA
| | - Helen Fernandes
- Department of Pathology and Cell Biology, Columbia University Irving Medical Center, New York, New York, USA
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Drake FT, Lyden ML, Kuo JH, Shen WT, Morris-Wiseman LF, Carty SE, Wang TS. Optimizing the fellowship interview process: Perspectives from applicants and program directors of the comprehensive endocrine surgery fellowship program. Surgery 2020; 169:488-495. [PMID: 32854969 DOI: 10.1016/j.surg.2020.06.037] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Accepted: 06/21/2020] [Indexed: 11/20/2022]
Abstract
BACKGROUND Approximately 80% of general surgery residents undertake some form of fellowship training. Our objective was to characterize goals and burdens of the interview process among applicants to Comprehensive Endocrine Surgery Fellowship programs. METHODS Participants included trainees from 2013 to 2019. Results for ranking questions are presented as a mean rank reported out of the total number of selections. RESULTS Response rate was 54% (n = 75). The most important goal for interviews was meeting the faculty (mean rank 2.4/9), followed by "behind the scenes information" and "make a good impression" (mean rank 3.6 and 3.7, respectively). The most substantial burden for the applicant was expense (mean rank 2.1/7), followed by time away from residency (mean rank 3.1/7). The economic burden of 51% of the applicants was $2,500 to $7,500. Geographic location and expense were the top 2 reasons applicants declined offers of interviews. Despite the process, 76% of respondents indicated that no improvements to the interview process are necessary. Alternative strategies such as videoconferencing or centralized interviews received little support (<10%). CONCLUSION Despite identifying several burdens, survey respondents believed that in-person interviews are an integral component of the fellowship application process. Indeed, 70% of applicants do not have a first-choice program before interviews, and meeting the faculty is ranked as the greatest priority goal. Our data illustrate the importance of individual specialties evaluating and optimizing their own processes for fellowship interviews.
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Affiliation(s)
- Frederick Thurston Drake
- Department of Surgery, Boston University School of Medicine and Boston Medical Center, Boston, MA.
| | | | - Jennifer H Kuo
- Department of Surgery, Columbia University Medical Center, New York City, NY
| | - Wen T Shen
- Department of Surgery, University of California, San Francisco Medical Center, San Francisco, CA
| | | | - Sally E Carty
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Tracy S Wang
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
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McManus C, Oh A, Lee JA, Hur C, Kuo JH. Timing of parathyroidectomy for tertiary hyperparathyroidism with end-stage renal disease: A cost-effectiveness analysis. Surgery 2020; 169:94-101. [PMID: 32732069 DOI: 10.1016/j.surg.2020.06.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 05/08/2020] [Accepted: 06/01/2020] [Indexed: 11/16/2022]
Abstract
BACKGROUND Tertiary hyperparathyroidism associated with end-stage renal disease is characterized by progression from secondary hyperparathyroidism to an autonomous overproduction of parathyroid hormone that leads to adverse health outcomes. Rates of parathyroidectomy (PTX) have decreased with the use of calcimimetics. Optimal timing of PTX in relation to kidney transplant remains controversial. We aimed to identify the most cost-effective strategy for patients with tertiary hyperparathyroidism undergoing kidney transplant. METHODS We constructed a patient level state transition microsimulation to compare 3 management schemes: cinacalcet with kidney transplant, cinacalcet with PTX before kidney transplant, or cinacalcet with PTX after kidney transplant. Our base case was a 55-year-old on dialysis with tertiary hyperparathyroidism awaiting kidney transplant. Outcomes, including quality-adjusted life years, surgical complications, and mortality, were extracted from the literature, and costs were estimated using Medicare reimbursement data. RESULTS Our base case analysis demonstrated that cinacalcet with PTX before kidney transplant was dominant, with a lesser cost of $399,287 and greater quality-adjusted life years of 10.3 vs $497,813 for cinacalcet with PTX after kidney transplant (quality-adjusted life years 9.4) and $643,929 for cinacalcet with kidney transplant (quality-adjusted life years 7.4). CONCLUSION Cinacalcet alone with kidney transplant is the least cost-effective strategy. Patients with end-stage renal disease-related tertiary hyperparathyroidism should be referred for PTX, and it is most cost-effective if performed prior to kidney transplant.
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Affiliation(s)
- Catherine McManus
- Department of Surgery, Section of Endocrine Surgery, Columbia University Medical Center, New York, NY.
| | - Aaron Oh
- Department of Surgery, Section of Endocrine Surgery, Columbia University Medical Center, New York, NY
| | - James A Lee
- Department of Surgery, Section of Endocrine Surgery, Columbia University Medical Center, New York, NY
| | - Chin Hur
- Department of Surgery, Section of Endocrine Surgery, Columbia University Medical Center, New York, NY
| | - Jennifer H Kuo
- Department of Surgery, Section of Endocrine Surgery, Columbia University Medical Center, New York, NY
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Abstract
Background: Thyroid abscess is a rare pathology, exhibiting an incidence of less than 1% of all thyroid diseases. The thyroid is highly resilient against infections. Those who do experience thyroid abscesses are commonly immunocompromised. We illustrate a case of a thyroid abscess in a young, healthy patient. Clinical Case: A previously healthy 22-year-old woman presented to the emergency department complaining of a sore throat, fever, nausea, and body aches. On exam, the patient was febrile, but had no obvious cervical lymphadenopathy, masses, or oropharyngeal lesions/growths. Initial labs showed leukocytosis to 13.5 k/ul with left-shift. The patient was diagnosed with acute pharyngitis, and was discharged on oral steroids and antibiotics for an incidental urinary tract infection. After some improvement, the patient returned to the ED 14 days later with a worsening odynophagia, dysphagia, and hematemesis. The patient was afebrile, but had neck swelling and possible thyromegaly. Lab results showed leukocytosis to 17.3 k/ul, and CT of the neck identified a 3.1cm x 3.3cm x 4.4c heterogeneous cystic/solid mass that nearly completely replaced the normal right thyroid lobe parenchyma and extended to the isthmus. Right-sided lymphadenopathy was also present. Initial evaluation suggested thyroid carcinoma. The patient was re-initiated on steroids due previous improvement, and was referred to a tertiary academic medical center for biopsy and further evaluation. 2 days later, the patient returned to the ED for worsening symptoms. However, she was discharged to home with no further management. At her endocrine surgery consultation visit, the patient reported worsening pain, inability to move her neck, inability to eat or drink, inability to lie flat, and new-onset sialorrhea and voice changes. A bedside ultrasound was performed with findings suggestive of an abscess. An in-office fine-needle aspiration produced purulent fluid, which relieved some of the patient’s compressive symptoms. Cytology showed inflammatory cells (mostly neutrophils) and numerous bacteria. The patient was emergently taken to the operating room for neck exploration, hemithyroidectomy, and incision/drainage of a suspected thyroid abscess. A drain was placed and removed POD 2 after minimal output. The patient was discharged on oral antibiotics. 1-week post-operatively, the patient returned to the ED due to reaccumulation of the abscess. This was successfully treated with IR placement of a drain. The drain was removed 2-weeks post-operatively, and the patient is doing well. Conclusion: Thyroid abscesses are rare but possible in young and immune-competent patients. While the imaging findings can point towards a more common diagnosis, such as thyroid carcinoma, avoiding anchoring bias is important. Imaging data should be considered in the context of the clinical picture to avoid the possibility of misdiagnosis.
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Affiliation(s)
- Rahul K Sharma
- Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
| | - Catherine McManus
- Division of Endocrine Surgery, Columbia University Irving Medical Center, New York, NY, USA
| | - Jennifer H Kuo
- Division of Endocrine Surgery, Columbia University Irving Medical Center, New York, NY, USA
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Sharma RK, Huang B, Lee JA, Kuo JH. SAT-156 Shorter Hospital Stays Are Not Associated with Increased Readmission or Complication Rates in Patients Undergoing Laparoscopic Adrenalectomies. J Endocr Soc 2020. [PMCID: PMC7208025 DOI: 10.1210/jendso/bvaa046.1760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
Background : Traditionally, elective adrenalectomies have been performed as an inpatient procedure. However, the adoption of laparoscopic adrenalectomy as the gold standard has allowed for shorter postoperative stays. Our objective was to assess the safety of same-day discharge for patients undergoing laparoscopic adrenalectomy.
Methods : A retrospective cohort study of patients who underwent laparoscopic adrenalectomy from 2011-2017 was conducted using The American College of Surgeons National Surgical Quality Improvement Project (ACS NSQIP) database. Demographic data was obtained. Multivariable logistic regression models to assess the association between length of stay and both postoperative complication rates and 30-day readmission rates were regressed on age, sex, race, comorbidities, functional status, postoperative diagnosis, and operative time. Statistical significance was defined as p<.05.
Results : 5,611 unique patients who underwent a laparoscopic adrenalectomy were identified. 1,564 patients had a postoperative diagnosis of a pheochromocytoma (27.9%), 162 with Cushing’s syndrome (2.9%) and 210 (3.7%) had metastatic disease to the adrenal glands. The average postoperative length of stay was 2.4 days (SD=3.9). 93 patients (1.7%) were discharged on the same day as their surgery (POD0). 2,509 (44.7%) were discharged on postoperative day 1 (POD1), 1,558 (27.8%) on postoperative day 2 (POD2), and 1,451 (25.9%) after POD2. Longer hospital stays were predicted by male sex, non-white race, longer operating time, and postoperative complications in regression models.
351 patients (6.26%) experienced a complication postoperatively. Complication rates were 3.23% for patients discharged on POD0, 1.67% for those discharged on POD1, 3.27% for those discharged on POD2, and 17.57% for those discharged after POD2 (p<.01). An increased risk of postoperative complications was also associated with male sex, impaired functional status and the presence of multiple comorbidities in regression models.
290 patients (5.17%) experienced a readmission. Readmission rates were 4.30% for patients discharged on POD0, 3.67% for those discharged on POD1, 4.49% for those discharged on POD2, and 8.55% for those discharged after POD2 (p<.01). Multiple comorbidities, African American race, and post-operative complications were associated with higher readmission rates. Length of hospital stay was not associated with readmission rates in regression models.
Conclusions : Readmission rates were not significantly different for patients discharged on POD0 than POD1 after a laparoscopic adrenalectomy. Readmission rates were higher for patients who had complications or multiple comorbidities. Therefore, low-risk patients with uncomplicated laparoscopic adrenalectomies can be considered for same day discharge to potentially reduce hospital spending and resource utilization.
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Affiliation(s)
- Rahul K Sharma
- Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
| | - Bernice Huang
- Division of Endocrine Surgery, Columbia University Irving Medical Center, New York, NY, USA
| | - James A Lee
- Division of Endocrine Surgery, Columbia University Irving Medical Center, New York, NY, USA
| | - Jennifer H Kuo
- Division of Endocrine Surgery, Columbia University Irving Medical Center, New York, NY, USA
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Abstract
Primary hyperaldosteronism (PA) is one of the most common causes of hypertension that is amenable to surgical cure. Once a patient has a biochemical diagnosis of PA, workup should proceed with tumor lateralization to determine whether the patient has unilateral or bilateral disease. Tumor lateralization can be done with noninvasive imaging such as a CT or MRI. However, in older patients or in patients with non-lateralizing imaging, arteriovenous sampling (AVS) should be considered. If the patient has confirmed unilateral disease, options for surgical intervention include laparoscopic or, less commonly, open. Laparoscopic adrenalectomy for PA has been shown to be a safe and effective procedure that is associated with less morbidity compared to open adrenalectomy. Patients can either undergo a laparoscopic transabdominal adrenalectomy via a lateral (most common) or anterior approach or a retroperitoneoscopic adrenalectomy via a posterior approach. The majority of patients have complete biochemical success, defined as normalization of plasma aldosterone, renin and potassium levels and appropriate suppression with stimulation tests. Less than half of patients have complete clinical success, defined as normotensive with no antihypertensive medications. However, the majority of patients who do not have complete clinical success will have some improvement in their blood pressure and/or are able to decrease the number of antihypertensive medications that they require.
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Affiliation(s)
- Catherine McManus
- Department of Surgery, Section of Endocrine Surgery, Columbia University Medical Center, New York, NY, USA
| | - Jennifer H Kuo
- Department of Surgery, Section of Endocrine Surgery, Columbia University Medical Center, New York, NY, USA
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Madani A, Grover K, Kuo JH, Mitmaker EJ, Shen W, Beninato T, Livhits M, Smith PW, Miller BS, Sippel RS, Duh QY, Lee JA. Defining the competencies for laparoscopic transabdominal adrenalectomy: An investigation of intraoperative behaviors and decisions of experts. Surgery 2020; 167:241-249. [DOI: 10.1016/j.surg.2019.03.035] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2019] [Revised: 03/12/2019] [Accepted: 03/16/2019] [Indexed: 10/25/2022]
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Pearlstein SS, Kuo JH, Chabot JA, Lee JA. Periadrenal Volume is a Better Predictor of Prolonged Operative Time in Laparoscopic Retroperitoneal Adrenalectomy than BMI. World J Surg 2019; 44:578-584. [DOI: 10.1007/s00268-019-05324-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Huang BL, Ebner SA, Makkar JS, Bentley-Hibbert S, McConnell RJ, Lee JA, Hecht EM, Kuo JH. A Multidisciplinary Head-to-Head Comparison of American College of Radiology Thyroid Imaging and Reporting Data System and American Thyroid Association Ultrasound Risk Stratification Systems. Oncologist 2019; 25:398-403. [PMID: 31740569 DOI: 10.1634/theoncologist.2019-0362] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2019] [Accepted: 10/17/2019] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Ultrasound plays a critical role in evaluating thyroid nodules. We compared the performance of the two most popular ultrasound malignancy risk stratification systems, the 2015 American Thyroid Association (ATA) guidelines and the American College of Radiology Thyroid Imaging and Reporting Data System (ACR TI-RADS). MATERIALS AND METHODS We retrospectively identified 250 thyroid nodules that were surgically removed from 137 patients. Their ultrasound images were independently rated using both ATA and ACR TI-RADS by six raters with expertise in ultrasound interpretation. For each system, we generated a receiver operating characteristic curve and calculated the area under the curve (AUC). RESULTS Sixty-five (26%) nodules were malignant. There was "fair agreement" among raters for both ATA and ACR TI-RADS. Our observed malignancy risks for ATA and ACR TI-RADS categories were similar to expected risk thresholds with a few notable exceptions including the intermediate ATA risk category and the three highest risk categories for ACR TI-RADS. Biopsy of 226 of the 250 nodules would be indicated by ATA guidelines based on nodule size and mean ATA rating. One hundred forty-six nodules would be biopsied based on ACR TI-RADS. The sensitivity, specificity, and negative and positive predictive values were 92%, 10%, 79%, and 27%, respectively, for ATA and 74%, 47%, 84%, and 33%, respectively, for ACR TI-RADS. The AUC for ATA was 0.734 and for ACR TI-RADS was 0.718. CONCLUSION Although both systems demonstrated good diagnostic performance, ATA guidelines resulted in a greater number of thyroid biopsies and exhibited more consistent malignancy risk prediction for higher risk categories. IMPLICATIONS FOR PRACTICE With the rising incidence of thyroid nodules, the need for accurate detection of malignancy is important to avoid the overtreatment of benign nodules. Ultrasonography is one of the key tools for the evaluation of thyroid nodules, although the use of many different ultrasound risk stratification systems is a hindrance to clinical collaboration in everyday practice and the comparison of data in research. The first step toward the development of a universal thyroid nodule ultrasound malignancy risk stratification system is to better understand the strengths and weaknesses of the current systems in use.
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Affiliation(s)
- Bernice L Huang
- Department of Surgery, Columbia University Medical Center, New York, New York, USA
| | - Susana A Ebner
- Division of Endocrinology, Department of Medicine, Columbia University Medical Center, New York, New York, USA
| | - Jasnit S Makkar
- Department of Radiology, Columbia University Medical Center, New York, New York, USA
| | | | - Robert J McConnell
- Division of Endocrinology, Department of Medicine, Columbia University Medical Center, New York, New York, USA
- The Columbia Thyroid Center, Columbia University Medical Center, New York, New York, USA
| | - James A Lee
- The Columbia Thyroid Center, Columbia University Medical Center, New York, New York, USA
- Division of GI/Endocrine Surgery, Department of Surgery, Columbia University Irving Medical Center, New York, New York, USA
| | - Elizabeth M Hecht
- Department of Radiology, Columbia University Medical Center, New York, New York, USA
| | - Jennifer H Kuo
- The Columbia Thyroid Center, Columbia University Medical Center, New York, New York, USA
- Division of GI/Endocrine Surgery, Department of Surgery, Columbia University Irving Medical Center, New York, New York, USA
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Kuo JH, Duh QY, Chen H, Chabot JA, Lee JA. Membership in a Surgical Specialty Organization Is a Better Predictor of High-Volume Surgeons and Hospitals Than Specialty Training Pathway for Endocrine Operations. J Am Coll Surg 2019. [DOI: 10.1016/j.jamcollsurg.2019.08.1105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Huang BL, Chabot JA, Lee JA, Kuo JH. A stepwise analysis of the diagnostic algorithm for the prediction of malignancy in thyroid nodules. Surgery 2019; 167:28-33. [PMID: 31515126 DOI: 10.1016/j.surg.2019.05.079] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2019] [Revised: 05/16/2019] [Accepted: 05/21/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND The evaluation of the malignancy risk of thyroid nodules involves clinical factors, sonographic characteristics, cytopathology, and molecular profiling. Altogether, this algorithm can be costly and time consuming. We evaluated the stepwise contribution of each diagnostic step toward an accurate prediction of malignancy. METHODS A retrospective study of dominant nodules of 137 patients who underwent surgical excision was performed. A baseline logistic regression model for predicting malignancy was regressed on clinical factors. In a stepwise fashion, the 2015 American Thyroid Association ultrasound risk stratification, Bethesda classification of fine-needle aspiration biopsies, and molecular profiling were added to the baseline model and the significance of each step analyzed using likelihood ratio test. Receiver operating characteristic curves were calculated for each model. RESULTS The addition of American Thyroid Association risk stratification and Bethesda classification to preceding models were statistically significant (P < .001). The addition of molecular profiling (as a strategy independent of a particular test) was not significant (P = .812). The areas under the curve of the baseline model and models sequentially including American Thyroid Association stratification, cytopathology, and molecular profiling were 0.76, 0.85, 0.91, and 0.91, respectively. CONCLUSION Clinical factors, sonographic characteristics, and cytopathology are sufficiently accurate in predicting malignancy risk of most thyroid nodules.
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Affiliation(s)
- Bernice L Huang
- Division of GI and Endocrine Surgery, Columbia University, New York, NY
| | - John A Chabot
- Division of GI and Endocrine Surgery, Columbia University, New York, NY
| | - James A Lee
- Division of GI and Endocrine Surgery, Columbia University, New York, NY
| | - Jennifer H Kuo
- Division of GI and Endocrine Surgery, Columbia University, New York, NY.
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Graves CE, McManus CM, Chabot JA, Lee JA, Kuo JH. Vitamin D Does Not Affect Intraoperative Parathyroid Hormone Kinetics: A Mixed Linear Model Analysis. J Surg Res 2019; 241:199-204. [DOI: 10.1016/j.jss.2019.03.026] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Revised: 02/22/2019] [Accepted: 03/21/2019] [Indexed: 11/29/2022]
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Pendrick DM, Oberg JA, Hsiao SJ, Chung WK, Koval C, Sireci A, Kuo JH, Satwani P, Glasser CL, Sulis ML, Mansukhani MM, Glade Bender JL. Identification of a secondary RET mutation in a pediatric patient with relapsed acute myeloid leukemia leads to the diagnosis and treatment of asymptomatic metastatic medullary thyroid cancer in a parent: a case for sequencing the germline. Cold Spring Harb Mol Case Stud 2019; 5:mcs.a003889. [PMID: 30936199 PMCID: PMC6549565 DOI: 10.1101/mcs.a003889] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Accepted: 02/08/2019] [Indexed: 11/24/2022] Open
Abstract
The incorporation of tumor-normal genomic testing into oncology can identify somatic mutations that inform therapeutic measures but also germline variants associated with unsuspected cancer predisposition. We describe a case in which a RET variant was identified in a 3-yr-old male with relapsed leukemia. Sanger sequencing revealed the patient's father and three siblings carried the same variant, associated with multiple endocrine neoplasia 2A (MEN2A). Evaluation of the father led to the diagnosis and treatment of metastatic medullary thyroid carcinoma. Detection of RET mutations in families with hereditary MTC allows for genetic risk stratification and disease surveillance to reduce morbidity and mortality.
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Affiliation(s)
| | | | - Susan J Hsiao
- Department of Pathology and Cell Biology, New York, New York 10032, USA
| | - Wendy K Chung
- Department of Pediatrics, New York, New York 10032, USA.,Department of Medicine, New York, New York 10032, USA.,Herbert Irving Comprehensive Cancer Center, New York, New York 10032, USA
| | - Carrie Koval
- New York Presbyterian Hospital, New York, New York 10032, USA
| | - Anthony Sireci
- Department of Pathology and Cell Biology, New York, New York 10032, USA
| | - Jennifer H Kuo
- Department of Surgery, Columbia University Medical Center, New York, New York 10032, USA
| | | | - Chana L Glasser
- Division of Pediatric Hematology/Oncology, NYU-Winthrop Hospital, Mineola, New York 11501, USA
| | - Maria Luisa Sulis
- Department of Pathology and Cell Biology, New York, New York 10032, USA.,Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, New York 10065, USA
| | | | - Julia L Glade Bender
- Department of Pediatrics, New York, New York 10032, USA.,Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, New York 10065, USA
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Yeh R, Tay YKD, Tabacco G, Dercle L, Kuo JH, Bandeira L, McManus C, Leung DK, Lee JA, Bilezikian JP. Diagnostic Performance of 4D CT and Sestamibi SPECT/CT in Localizing Parathyroid Adenomas in Primary Hyperparathyroidism. Radiology 2019; 291:469-476. [PMID: 30835187 DOI: 10.1148/radiol.2019182122] [Citation(s) in RCA: 78] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Background There currently is no consensus on the optimal localization procedure and imaging protocol for parathyroid adenoma. Parathyroid four-dimensional (4D) CT has emerged as a promising method for preoperative localization. Purpose To evaluate the diagnostic performance of parathyroid 4D CT and technetium 99m-sestamibi (hereafter, referred to as sestamibi) SPECT/CT in preoperative localization in patients with primary hyperparathyroidism. Materials and Methods This was a single-institution retrospective study of patients with primary hyperparathyroidism who underwent a combined imaging protocol of sestamibi SPECT/CT and 4D CT (noncontrast, contrast agent-enhanced, arterial, and delayed venous phases) acquired in a single setting from February 2013 to May 2016, with subsequent parathyroidectomy within 6 months. Reference standard for correct localization was on the basis of location denoted on operative reports, with pathologic confirmation of parathyroid adenoma or hyperplasia. By using a four-quadrant analysis, sensitivity, specificity, and area under the curve (AUC) for localization of the hyperfunctioning parathyroid gland or glands at sestamibi SPECT/CT and 4D CT were compared, per modality and in combination. Results Four hundred patients (319 women, 81 men; mean age, 61 years ± 14 [standard deviation]) were evaluated. Similar diagnostic performance was found in both combined 4D CT with sestamibi SPECT/CT and 4D CT alone (area under the curve [AUC], 0.88 [95% CI: 0.86, 0.90] and 0.87 [95% CI: 0.85, 0.90], respectively; P = .82). Both modalities outperformed sestamibi SPECT/CT (AUC, 0.78; 95% CI: 0.76, 0.81; P < .001). Four-dimensional CT showed higher sensitivity than did sestamibi SPECT/CT (sensitivity, 79.3% [414 of 522] vs 58.0% [303 of 522], respectively; P < .001). In a subset analysis, 4D CT had higher sensitivity than sestamibi SPECT/CT in patients with single-gland disease (sensitivity, 92.5% [297 of 321] vs 75.1% [241 of 321], respectively; P < .001) and with multigland disease (sensitivity, 58.2% [117 of 201] vs 30.8% [62 of 201], respectively; P < .001). Conclusion Four-dimensional CT provided superior preoperative localization compared with sestamibi SPECT/CT in patients with single and multigland disease. The combination of the two modalities did not improve diagnostic performance compared with four-dimensional CT alone. © RSNA, 2019 Online supplemental material is available for this article. See also the editorial by Sinha and Oates in this issue.
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Affiliation(s)
- Randy Yeh
- From the Department of Radiology, New York-Presbyterian Hospital/Columbia University Medical Center, 622 W 168th St, New York, NY 10032 (R.Y., L.D., D.K.L.); Department of Radiology, Molecular Imaging and Therapy Service, Memorial Sloan-Kettering Cancer Center, New York, NY (R.Y.); Department of Medicine, Division of Endocrinology (Y.K.D.T., G.T., L.B., J.P.B.), and Department of Surgery, Division of GI/Endocrine Surgery (J.H.K., C.M., J.A.L.), College of Physicians & Surgeons, Columbia University, New York, NY; Osteoporosis and Bone Metabolism Unit, Department of Endocrinology, Singapore General Hospital, Singapore (Y.K.D.T.); Bristol-Myers Squibb, Princeton, NJ (D.K.L.); and Unit of Endocrinology and Diabetes, Department of Medicine Campus Bio-Medico University of Rome, Italy (G.T.)
| | - Yu-Kwang Donovan Tay
- From the Department of Radiology, New York-Presbyterian Hospital/Columbia University Medical Center, 622 W 168th St, New York, NY 10032 (R.Y., L.D., D.K.L.); Department of Radiology, Molecular Imaging and Therapy Service, Memorial Sloan-Kettering Cancer Center, New York, NY (R.Y.); Department of Medicine, Division of Endocrinology (Y.K.D.T., G.T., L.B., J.P.B.), and Department of Surgery, Division of GI/Endocrine Surgery (J.H.K., C.M., J.A.L.), College of Physicians & Surgeons, Columbia University, New York, NY; Osteoporosis and Bone Metabolism Unit, Department of Endocrinology, Singapore General Hospital, Singapore (Y.K.D.T.); Bristol-Myers Squibb, Princeton, NJ (D.K.L.); and Unit of Endocrinology and Diabetes, Department of Medicine Campus Bio-Medico University of Rome, Italy (G.T.)
| | - Gaia Tabacco
- From the Department of Radiology, New York-Presbyterian Hospital/Columbia University Medical Center, 622 W 168th St, New York, NY 10032 (R.Y., L.D., D.K.L.); Department of Radiology, Molecular Imaging and Therapy Service, Memorial Sloan-Kettering Cancer Center, New York, NY (R.Y.); Department of Medicine, Division of Endocrinology (Y.K.D.T., G.T., L.B., J.P.B.), and Department of Surgery, Division of GI/Endocrine Surgery (J.H.K., C.M., J.A.L.), College of Physicians & Surgeons, Columbia University, New York, NY; Osteoporosis and Bone Metabolism Unit, Department of Endocrinology, Singapore General Hospital, Singapore (Y.K.D.T.); Bristol-Myers Squibb, Princeton, NJ (D.K.L.); and Unit of Endocrinology and Diabetes, Department of Medicine Campus Bio-Medico University of Rome, Italy (G.T.)
| | - Laurent Dercle
- From the Department of Radiology, New York-Presbyterian Hospital/Columbia University Medical Center, 622 W 168th St, New York, NY 10032 (R.Y., L.D., D.K.L.); Department of Radiology, Molecular Imaging and Therapy Service, Memorial Sloan-Kettering Cancer Center, New York, NY (R.Y.); Department of Medicine, Division of Endocrinology (Y.K.D.T., G.T., L.B., J.P.B.), and Department of Surgery, Division of GI/Endocrine Surgery (J.H.K., C.M., J.A.L.), College of Physicians & Surgeons, Columbia University, New York, NY; Osteoporosis and Bone Metabolism Unit, Department of Endocrinology, Singapore General Hospital, Singapore (Y.K.D.T.); Bristol-Myers Squibb, Princeton, NJ (D.K.L.); and Unit of Endocrinology and Diabetes, Department of Medicine Campus Bio-Medico University of Rome, Italy (G.T.)
| | - Jennifer H Kuo
- From the Department of Radiology, New York-Presbyterian Hospital/Columbia University Medical Center, 622 W 168th St, New York, NY 10032 (R.Y., L.D., D.K.L.); Department of Radiology, Molecular Imaging and Therapy Service, Memorial Sloan-Kettering Cancer Center, New York, NY (R.Y.); Department of Medicine, Division of Endocrinology (Y.K.D.T., G.T., L.B., J.P.B.), and Department of Surgery, Division of GI/Endocrine Surgery (J.H.K., C.M., J.A.L.), College of Physicians & Surgeons, Columbia University, New York, NY; Osteoporosis and Bone Metabolism Unit, Department of Endocrinology, Singapore General Hospital, Singapore (Y.K.D.T.); Bristol-Myers Squibb, Princeton, NJ (D.K.L.); and Unit of Endocrinology and Diabetes, Department of Medicine Campus Bio-Medico University of Rome, Italy (G.T.)
| | - Leonardo Bandeira
- From the Department of Radiology, New York-Presbyterian Hospital/Columbia University Medical Center, 622 W 168th St, New York, NY 10032 (R.Y., L.D., D.K.L.); Department of Radiology, Molecular Imaging and Therapy Service, Memorial Sloan-Kettering Cancer Center, New York, NY (R.Y.); Department of Medicine, Division of Endocrinology (Y.K.D.T., G.T., L.B., J.P.B.), and Department of Surgery, Division of GI/Endocrine Surgery (J.H.K., C.M., J.A.L.), College of Physicians & Surgeons, Columbia University, New York, NY; Osteoporosis and Bone Metabolism Unit, Department of Endocrinology, Singapore General Hospital, Singapore (Y.K.D.T.); Bristol-Myers Squibb, Princeton, NJ (D.K.L.); and Unit of Endocrinology and Diabetes, Department of Medicine Campus Bio-Medico University of Rome, Italy (G.T.)
| | - Catherine McManus
- From the Department of Radiology, New York-Presbyterian Hospital/Columbia University Medical Center, 622 W 168th St, New York, NY 10032 (R.Y., L.D., D.K.L.); Department of Radiology, Molecular Imaging and Therapy Service, Memorial Sloan-Kettering Cancer Center, New York, NY (R.Y.); Department of Medicine, Division of Endocrinology (Y.K.D.T., G.T., L.B., J.P.B.), and Department of Surgery, Division of GI/Endocrine Surgery (J.H.K., C.M., J.A.L.), College of Physicians & Surgeons, Columbia University, New York, NY; Osteoporosis and Bone Metabolism Unit, Department of Endocrinology, Singapore General Hospital, Singapore (Y.K.D.T.); Bristol-Myers Squibb, Princeton, NJ (D.K.L.); and Unit of Endocrinology and Diabetes, Department of Medicine Campus Bio-Medico University of Rome, Italy (G.T.)
| | - David K Leung
- From the Department of Radiology, New York-Presbyterian Hospital/Columbia University Medical Center, 622 W 168th St, New York, NY 10032 (R.Y., L.D., D.K.L.); Department of Radiology, Molecular Imaging and Therapy Service, Memorial Sloan-Kettering Cancer Center, New York, NY (R.Y.); Department of Medicine, Division of Endocrinology (Y.K.D.T., G.T., L.B., J.P.B.), and Department of Surgery, Division of GI/Endocrine Surgery (J.H.K., C.M., J.A.L.), College of Physicians & Surgeons, Columbia University, New York, NY; Osteoporosis and Bone Metabolism Unit, Department of Endocrinology, Singapore General Hospital, Singapore (Y.K.D.T.); Bristol-Myers Squibb, Princeton, NJ (D.K.L.); and Unit of Endocrinology and Diabetes, Department of Medicine Campus Bio-Medico University of Rome, Italy (G.T.)
| | - James A Lee
- From the Department of Radiology, New York-Presbyterian Hospital/Columbia University Medical Center, 622 W 168th St, New York, NY 10032 (R.Y., L.D., D.K.L.); Department of Radiology, Molecular Imaging and Therapy Service, Memorial Sloan-Kettering Cancer Center, New York, NY (R.Y.); Department of Medicine, Division of Endocrinology (Y.K.D.T., G.T., L.B., J.P.B.), and Department of Surgery, Division of GI/Endocrine Surgery (J.H.K., C.M., J.A.L.), College of Physicians & Surgeons, Columbia University, New York, NY; Osteoporosis and Bone Metabolism Unit, Department of Endocrinology, Singapore General Hospital, Singapore (Y.K.D.T.); Bristol-Myers Squibb, Princeton, NJ (D.K.L.); and Unit of Endocrinology and Diabetes, Department of Medicine Campus Bio-Medico University of Rome, Italy (G.T.)
| | - John P Bilezikian
- From the Department of Radiology, New York-Presbyterian Hospital/Columbia University Medical Center, 622 W 168th St, New York, NY 10032 (R.Y., L.D., D.K.L.); Department of Radiology, Molecular Imaging and Therapy Service, Memorial Sloan-Kettering Cancer Center, New York, NY (R.Y.); Department of Medicine, Division of Endocrinology (Y.K.D.T., G.T., L.B., J.P.B.), and Department of Surgery, Division of GI/Endocrine Surgery (J.H.K., C.M., J.A.L.), College of Physicians & Surgeons, Columbia University, New York, NY; Osteoporosis and Bone Metabolism Unit, Department of Endocrinology, Singapore General Hospital, Singapore (Y.K.D.T.); Bristol-Myers Squibb, Princeton, NJ (D.K.L.); and Unit of Endocrinology and Diabetes, Department of Medicine Campus Bio-Medico University of Rome, Italy (G.T.)
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Kuo JH, McManus C, Graves CE, Madani A, Khokhar MT, Huang B, Lee JA. In brief. Curr Probl Surg 2019. [DOI: 10.1067/j.cpsurg.2018.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Lee D, Walker MD, Chen HY, Chabot JA, Lee JA, Kuo JH. Bone mineral density changes after parathyroidectomy are dependent on biochemical profile. Surgery 2019; 165:107-113. [DOI: 10.1016/j.surg.2018.04.065] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Revised: 04/12/2018] [Accepted: 04/15/2018] [Indexed: 10/28/2022]
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Kuo JH, McManus C, Graves CE, Madani A, Khokhar MT, Huang B, Lee JA. Updates in the management of thyroid nodules. Curr Probl Surg 2018; 56:103-127. [PMID: 30798796 DOI: 10.1067/j.cpsurg.2018.12.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Accepted: 12/18/2018] [Indexed: 12/17/2022]
Affiliation(s)
- Jennifer H Kuo
- Division of Endocrine Surgery, Columbia University, New York, NY.
| | | | - Claire E Graves
- Division of Endocrine Surgery, Columbia University, New York, NY
| | - Amin Madani
- Division of Endocrine Surgery, Columbia University, New York, NY
| | - Mamoona T Khokhar
- Division of Endocrine Surgery, Banner University Medical Center, Phoenix, AZ
| | - Bernice Huang
- Division of Endocrine Surgery, Columbia University, New York, NY
| | - James A Lee
- Division of Endocrine Surgery, Columbia University, New York, NY
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Tay YKD, Yeh R, Kuo JH, McManus C, Lee JA, Bilezikian JP. Pre-operative localization of abnormal parathyroid tissue by 99mTc-sestamibi in primary hyperparathyroidism using four-quadrant site analysis: an evaluation of the predictive value of vitamin D deficiency. Endocrine 2018; 60:36-45. [PMID: 29404903 DOI: 10.1007/s12020-018-1528-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2017] [Accepted: 01/09/2018] [Indexed: 10/18/2022]
Abstract
CONTEXT Accurate preoperative localization of abnormal parathyroid tissue aids importantly in minimally invasive parathyroidectomy in patients with primary hyperparathyroidism. Vitamin D deficiency may possibly influence the success and characteristics of pre-operative localization because it is associated with more active disease and possibly larger adenomas. This could increase the sensitivity of the sestamibi to identify abnormal parathyroid tissue, but earlier reports are conflicting. Vitamin D deficiency could also influence the nature of preoperative localization because it could lead to multi-gland stimulation of parathyroid tissue giving an appearance of multi-gland disease, which may lower accuracy of preoperative localization with sestamibi. OBJECTIVE To examine the relationship between vitamin D deficiency and correct parathyroid tissue localization by four-pole thyroid quadrant analysis. DESIGN Retrospective study. SETTING Referral center. PARTICIPANTS A total of 138 patients were divided into three groups according to the level of 25OHD; <20 ng/mL (vitamin D deficient), ≥20 to <30 ng/mL (vitamin D insufficient) and ≥30 ng/mL (vitamin D replete). MAIN OUTCOMES Quadrant localization using 99mTc-sestamibi/SPECT. RESULTS Among those with single-gland disease, the proportion of patients with correct quadrant localization were 60.0, 68.3 and 63.5% (p = 0.778), and the accuracy of sestamibi was 89.3, 90.6 and 89.9% for the deficient, insufficiency and replete groups, respectively. Among those with multi-gland disease, the proportion of patients with correct quadrant localization were 50.0, 25.0 and 18.2% (p = 0.619) while the accuracy was 50.0, 50.0 and 45.5%, respectively. Multi-gland disease did not occur more frequently in any of the three groups (p = 0.296). CONCLUSIONS Vitamin D levels do not affect the accuracy of preoperative localization with sestamibi.
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Affiliation(s)
- Yu-Kwang Donovan Tay
- Department of Medicine, Division of Endocrinology, College of Physicians & Surgeons, Columbia University, New York, NY, USA.
- Department of Medicine, Sengkang Health, Singapore, Singapore.
- Osteoporosis and Bone Metabolism Unit, Department of Endocrinology, Singapore General Hospital, Singapore, Singapore.
| | - Randy Yeh
- Department of Radiology, Columbia University Medical Center, New York, NY, USA
| | - Jennifer H Kuo
- Department of GI/Endocrine Surgery, Columbia University, New York, NY, USA
| | - Catherine McManus
- Department of GI/Endocrine Surgery, Columbia University, New York, NY, USA
| | - James A Lee
- Department of GI/Endocrine Surgery, Columbia University, New York, NY, USA
| | - John P Bilezikian
- Department of Medicine, Division of Endocrinology, College of Physicians & Surgeons, Columbia University, New York, NY, USA.
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Lim JY, Herman MC, Bubis L, Epelboym I, Allendorf JD, Chabot JA, Lee JA, Kuo JH. Differences in single gland and multigland disease are seen in low biochemical profile primary hyperparathyroidism. Surgery 2016; 161:70-77. [PMID: 27847113 DOI: 10.1016/j.surg.2016.08.054] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Revised: 07/12/2016] [Accepted: 08/16/2016] [Indexed: 11/26/2022]
Abstract
BACKGROUND Primary hyperparathyroidism is characterized by increased levels of serum calcium and parathyroid hormone. Recently, 2 additional mild biochemical profiles have emerged, normocalcemic and normohormonal primary hyperparathyroidism. We reviewed our surgical experience of mild biochemical profile patients and compared them with classic primary hyperparathyroidism patients. METHODS This is a single institution, retrospective cohort review of all patients who underwent parathyroidectomy for primary hyperparathyroidism from 2006-2012. Preoperative and intraoperative variables were analyzed. Univariable analysis was performed with analysis of variance and the χ2 test. A logistic regression was performed to identify significantly independent predictor variables for multigland disease. RESULTS A total of 573 patients underwent parathyroidectomy for primary hyperparathyroidism (classic, n = 405; normohormonal, n = 96; normocalcemic, n = 72). Normocalcemic primary hyperparathyroidism was associated with multigland disease in 43 (45%, P < .001) patients as compared with the normohormonal (7, 10%) and classic (36, 9%) groups. On logistic regression, significant predictors for multigland disease were the normocalcemic subtype and positive family history. Twelve month biochemical normalization rates after operative treatment were >98% in all 3 groups. CONCLUSION Our series shows that normocalcemic primary hyperparathyroidism is associated with a high incidence of multigland disease. Normohormonal disease is similar to classic disease patients with >90% presenting with single adenomas. Excellent rates of biochemical normalization can be obtained by operative treatment in all 3 groups.
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Affiliation(s)
- James Y Lim
- Division of GI/Endocrine Surgery, Columbia University, New York, NY
| | - Max C Herman
- Division of GI/Endocrine Surgery, Columbia University, New York, NY
| | - Lev Bubis
- Division of GI/Endocrine Surgery, Columbia University, New York, NY
| | - Irene Epelboym
- Division of GI/Endocrine Surgery, Columbia University, New York, NY
| | | | - John A Chabot
- Division of GI/Endocrine Surgery, Columbia University, New York, NY
| | - James A Lee
- Division of GI/Endocrine Surgery, Columbia University, New York, NY
| | - Jennifer H Kuo
- Division of GI/Endocrine Surgery, Columbia University, New York, NY.
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