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van der Plas W, Kruijff S, Sidhu SB, Delbridge LW, Sywak MS, Engelsman AF. Parathyroidectomy for patients with secondary hyperparathyroidism in a changing landscape for the management of end-stage renal disease. Surgery 2020; 169:275-281. [PMID: 33059930 DOI: 10.1016/j.surg.2020.08.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 07/15/2020] [Accepted: 08/04/2020] [Indexed: 01/29/2023]
Abstract
BACKGROUND The landscape of patients with end-stage renal disease is changing with the increasing availability of kidney transplantation. In the near future, a less aggressive approach to treat secondary hyperparathyroidism might be beneficial. We report outcomes of parathyroidectomy for end-stage renal disease-related hyperparathyroidism comparing the outcomes of limited, subtotal, and total parathyroidectomy. METHODS We performed a retrospective analysis of prospectively collected data. Patients were divided into 3 parathyroidectomy subgroups: limited (<3 glands removed), subtotal (3-3.5 glands), and total (4 glands) parathyroidectomy. Primary outcome was serum levels of parathyroid hormone. Secondary endpoints were serum levels of calcium, phosphate, and alkaline phosphatase, postoperative complications, and persistent or recurrent disease rates. RESULTS In total, 195 patients were included for analysis of whom 13.8% underwent limited parathyroidectomy, 46.7% subtotal parathyroidectomy, and 39.5% total parathyroidectomy. Preoperative parathyroid hormone levels (pg/mL) were 471 (210-868), 1,087 (627-1,795), and 1,070 (475-1,632) for the limited, subtotal, and total parathyroidectomy groups, respectively (P < .001). A decrease in serum parathyroid hormone was seen in all groups; however, postoperative levels remained greater in the limited parathyroidectomy group compared to the subtotal and total parathyroidectomy groups (P < .001). Serum calcium, phosphate, and alkaline phosphatase levels decreased in all groups to within the reference range. In the limited parathyroidectomy group, persistent disease and recurrence occurred more frequently (P = .02 and P = .07, respectively). CONCLUSION Subtotal parathyroidectomy is the optimal strategy in an era with an increasing availability of kidney transplantation and improved regimens of dialysis. In this changing practice, the approach to parathyroid surgery, however, might shift to a less aggressive and patient-tailored approach.
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Affiliation(s)
- Willemijn van der Plas
- Department of Endocrine Surgery, Endocrine Surgery Unit, University of Sydney, Australia; Department of Surgery, University of Groningen, University Medical Centre Groningen, The Netherlands
| | - Schelto Kruijff
- Department of Surgery, University of Groningen, University Medical Centre Groningen, The Netherlands
| | - Stan B Sidhu
- Department of Endocrine Surgery, Endocrine Surgery Unit, University of Sydney, Australia
| | - Leigh W Delbridge
- Department of Endocrine Surgery, Endocrine Surgery Unit, University of Sydney, Australia
| | - Mark S Sywak
- Department of Endocrine Surgery, Endocrine Surgery Unit, University of Sydney, Australia
| | - Anton F Engelsman
- Department of Endocrine Surgery, Endocrine Surgery Unit, University of Sydney, Australia; Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Netherlands.
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DiMarco AN, Wong MS, Jayasekara J, Cole-Clark D, Aniss A, Glover AR, Delbridge LW, Sywak MS, Sidhu SB. Risk of needing completion thyroidectomy for low-risk papillary thyroid cancers treated by lobectomy. BJS Open 2019; 3:299-304. [PMID: 31183445 PMCID: PMC6551396 DOI: 10.1002/bjs5.50137] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [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: 09/27/2018] [Accepted: 11/27/2018] [Indexed: 12/30/2022] Open
Abstract
Background Low-risk differentiated thyroid cancers may, according to the American Thyroid Association (ATA) 2015 guidelines, be managed initially with lobectomy. However, definitive risk categorization requires pathological assessment of the specimen, resulting in completion thyroidectomy being recommended when discordance between preoperative and postoperative staging occurs. This study sought to establish the expected rate of completion thyroidectomy in patients with papillary thyroid cancer (PTC) treated by lobectomy. Methods Patients with PTC treated over 5 years (2013-2017 inclusive) and meeting the ATA criteria for lobectomy were identified from the prospectively developed database of a high-volume, university department of endocrine surgery. Concordance between the ATA initial and final recommendation, and the putative rate of completion thyroidectomy were calculated. Multivariable analysis was used to assess preoperative factors as predictors of the need for total thyroidectomy. Results Of 275 patients with PTC who met ATA preoperative criteria for lobectomy there was concordance between this and the final recommendation in 158 (57·5 per cent) and discordance in 117 (43·5 per cent). Most common reasons for discordance were: angioinvasion (30·8 per cent), local invasion (23·9 per cent) or both (20·5 per cent). Four patients (1·5 per cent) had permanent hypoparathyroidism. On multivariable analysis, age, sex, tumour size and family history did not independently predict the final treatment required. Conclusion Although many patients may be treated adequately with lobectomy, just under half would require completion thyroidectomy. Further work is needed on preoperative risk stratification but, before this, total thyroidectomy remains the treatment of choice for low-risk 1-4-cm PTC in the hands of high-volume thyroid surgeons who can demonstrate low complication rates.
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Affiliation(s)
- A N DiMarco
- Endocrine Surgery Unit, Faculty of Health Sciences University of Sydney Sydney New South Wales Australia.,Department of Surgery and Cancer Imperial College London London UK
| | - M S Wong
- Endocrine Surgery Unit, Faculty of Health Sciences University of Sydney Sydney New South Wales Australia
| | - J Jayasekara
- Endocrine Surgery Unit, Faculty of Health Sciences University of Sydney Sydney New South Wales Australia
| | - D Cole-Clark
- Endocrine Surgery Unit, Faculty of Health Sciences University of Sydney Sydney New South Wales Australia
| | - A Aniss
- Endocrine Surgery Unit, Faculty of Health Sciences University of Sydney Sydney New South Wales Australia
| | - A R Glover
- Endocrine Surgery Unit, Faculty of Health Sciences University of Sydney Sydney New South Wales Australia
| | - L W Delbridge
- Endocrine Surgery Unit, Faculty of Health Sciences University of Sydney Sydney New South Wales Australia
| | - M S Sywak
- Endocrine Surgery Unit, Faculty of Health Sciences University of Sydney Sydney New South Wales Australia
| | - S B Sidhu
- Endocrine Surgery Unit, Faculty of Health Sciences University of Sydney Sydney New South Wales Australia
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van der Plas WY, Engelsman AF, Umakanthan M, Mather A, Sidhu SB, Delbridge LW, Pollock C, Waugh D, Sywak MS, Kruijff S. Treatment strategy of end stage renal disease-related hyperparathyroidism before, during, and after the era of calcimimetics. Surgery 2018; 165:135-141. [PMID: 30413324 DOI: 10.1016/j.surg.2018.04.092] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Revised: 04/03/2018] [Accepted: 04/07/2018] [Indexed: 12/15/2022]
Abstract
BACKGROUND Since 2004, end-stage renal disease related hyperparathyroidism patients are treated mainly with cinacalcet, which ceased to be subsidized through the Australian Pharmaceutical Benefits Scheme in 2015. We aimed to investigate the impact of these changes on the treatment strategy in the Australian end-stage renal disease population. METHODS The following groups were formed according to the date of parathyroidectomy: A, before calcimimetics; B, during the era of calcimimetics; and C, after cinacalcet removal by the Australian Pharmaceutical Benefits Scheme. The primary outcome was time from start of dialysis to parathyroidectomy. Regression analysis was used to examine trends in parathyroidectomy rates. RESULTS Between 1998 and 2016, 195 parathyroidectomies were performed. Median time to referral was 69 (33-123), 67 (31-110) and 44 (23-102) months for groups A, B, and C, respectively (P = .55). Parathyroidectomy rates increased throughout the years (CI 0.09-1.13, R2=0.27, P = .02). A trend toward a dip in parathyroidectomy rates was seen during the era of cinacalcet (P = .08). Median preoperative parathyroid hormone levels increased significantly (842 [418-1,553] versus 1,040 [564-1,810] versus 1,350 [1,037-1,923] pg/mL, for groups A, B, and C, respectively [P < .01]). CONCLUSION Parathyroidectomy rates seem to vary according to the availability of cinacalcet. This change in treatment strategy is accompanied with increased preoperative parathyroid hormone levels, reflecting delayed surgery and increased disease severity.
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Affiliation(s)
- Willemijn Y van der Plas
- Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands; Department of Endocrine Surgery, University of Sydney, Endocrine Surgery Unit, Sydney, Australia
| | - Anton F Engelsman
- Department of Endocrine Surgery, University of Sydney, Endocrine Surgery Unit, Sydney, Australia; Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Marille Umakanthan
- Department of Renal Medicine, Royal North Shore Hospital, St Leonards, Australia
| | - Amanda Mather
- Department of Renal Medicine, Royal North Shore Hospital, St Leonards, Australia
| | - Stan B Sidhu
- Department of Endocrine Surgery, University of Sydney, Endocrine Surgery Unit, Sydney, Australia
| | - Leigh W Delbridge
- Department of Endocrine Surgery, University of Sydney, Endocrine Surgery Unit, Sydney, Australia
| | - Carol Pollock
- Department of Renal Medicine, Royal North Shore Hospital, St Leonards, Australia
| | - David Waugh
- Department of Renal Medicine, Royal North Shore Hospital, St Leonards, Australia
| | - Mark S Sywak
- Department of Endocrine Surgery, University of Sydney, Endocrine Surgery Unit, Sydney, Australia
| | - Schelto Kruijff
- Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands.
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Engelsman AF, Parkyn RF, Carter A, Christie J, Delbridge LW. An Elusive Parathyroid: Interesting Case Presentation. VideoEndocrinology 2018. [DOI: 10.1089/ve.2017.0110] [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] [Indexed: 11/12/2022] Open
Affiliation(s)
| | - Robert F. Parkyn
- Endocrine Surgery Unit, University of Adelaide, Adelaide, Australia
| | - Andrew Carter
- Department of Radiology, University of Adelaide, Adelaide, Australia
| | - James Christie
- Department of Radiology, University of Adelaide, Adelaide, Australia
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Howson P, Kruijff S, Aniss A, Pennington T, Gill AJ, Dodds T, Delbridge LW, Sidhu SB, Sywak MS. Oxyphil Cell Parathyroid Adenomas Causing Primary Hyperparathyroidism: a Clinico-Pathological Correlation. Endocr Pathol 2015; 26:250-4. [PMID: 26091632 DOI: 10.1007/s12022-015-9378-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Oxyphil cell parathyroid adenomas (OPA) are considered to be an uncommon cause of primary hyperparathyroidism (PHPT), and were historically thought to be clinically silent. It has been our clinical impression that these adenomas present more often than previously thought and may manifest a more severe form of primary hyperparathyroidism than classical adenoma. The aim of this study was to describe the incidence and clinical presentation of OPA. An observational case-control study was undertaken. The study group comprised patients undergoing parathyroidectomy for PHPT where the final pathology confirmed OPA. The controls were made up of an age- and sex-matched group of patients having parathyroidectomy in the same time period where the final pathology confirmed a classical or non-oxyphil adenoma. OPA were defined as parathyroid tumours containing >75% oxyphilic cells. The OPA cases were obtained by reviewing all histopathology slides over an 11-year period (2002-12) where the reports contained the words 'oxyphil' or 'oxyphilic' parathyroid adenomas. These were then reviewed by two independent pathologists to confirm a diagnosis of OPA. The primary outcome measures were preoperative serum calcium and parathyroid hormone (PTH) levels. Secondary outcome measures were symptoms at presentation, accuracy of preoperative localization studies, parathyroid gland weight following surgery, and type of surgery undertaken. In the period 2002-2012, 2739 patients underwent surgery for PHPT. Following pathological review, 91 cases were confirmed as being OPA and formed the study group. A control group (n = 91) from the same period was selected following matching on the basis of age at presentation and sex. OPA were associated with higher preoperative serum calcium (10.84 versus 10.48 mg/dL, p < 0.001) and parathyroid hormone (139 versus 64 ng/L, p < 0.001). At presentation, a lower proportion of OPA cases had asymptomatic disease (15 versus 29%, p = 0.03). There was a trend toward a higher rate of renal calculi at presentation in the OPA group (9 versus 3%, p = 0.07). Preoperative ultrasound was less accurate in localization of OPA when compared with classical adenoma. The rate of minimally invasive surgery was 67% for OPA and 78% for the control group (p = 0.06). All patients were cured of hypercalcaemia at 6-month follow up. There was no significant difference in the weight of removed parathyroid tissue between the groups (868 mg for OPA versus 789 mg for the control group, p = 0.6). OPA are frequently symptomatic and are associated with higher preoperative serum calcium and parathyroid hormone levels than classical types of parathyroid adenomas. OPA are less likely to be localised on preoperative ultrasound examination.
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Affiliation(s)
- Pamela Howson
- Royal North Shore Hospital, University of Sydney Endocrine Surgical Unit, 202/69 Christie St, St Leonards, NSW, 2065, Australia
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Sarkis LM, Zaidi N, Norlén O, Delbridge LW, Sywak MS, Sidhu SB. Bilateral recurrent laryngeal nerve injury in a specialized thyroid surgery unit: would routine intraoperative neuromonitoring alter outcomes? ANZ J Surg 2015; 87:364-367. [DOI: 10.1111/ans.12980] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/01/2014] [Indexed: 11/28/2022]
Affiliation(s)
- Leba M. Sarkis
- Endocrine Surgical Unit; Royal North Shore Hospital; The University of Sydney; Sydney New South Wales Australia
| | - Nisar Zaidi
- Endocrine Surgical Unit; Royal North Shore Hospital; The University of Sydney; Sydney New South Wales Australia
| | - Olov Norlén
- Endocrine Surgical Unit; Royal North Shore Hospital; The University of Sydney; Sydney New South Wales Australia
| | - Leigh W. Delbridge
- Endocrine Surgical Unit; Royal North Shore Hospital; The University of Sydney; Sydney New South Wales Australia
| | - Mark S. Sywak
- Endocrine Surgical Unit; Royal North Shore Hospital; The University of Sydney; Sydney New South Wales Australia
| | - Stan B. Sidhu
- Endocrine Surgical Unit; Royal North Shore Hospital; The University of Sydney; Sydney New South Wales Australia
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Campion KL, McCormick WD, Warwicker J, Khayat MEB, Atkinson-Dell R, Steward MC, Delbridge LW, Mun HC, Conigrave AD, Ward DT. Pathophysiologic Changes in Extracellular pH Modulate Parathyroid Calcium-Sensing Receptor Activity and Secretion via a Histidine-Independent Mechanism. J Am Soc Nephrol 2015; 26:2163-71. [PMID: 25556167 DOI: 10.1681/asn.2014070653] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [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: 07/07/2014] [Accepted: 11/10/2014] [Indexed: 01/06/2023] Open
Abstract
The calcium-sensing receptor (CaR) modulates renal calcium reabsorption and parathyroid hormone (PTH) secretion and is involved in the etiology of secondary hyperparathyroidism in CKD. Supraphysiologic changes in extracellular pH (pHo) modulate CaR responsiveness in HEK-293 (CaR-HEK) cells. Therefore, because acidosis and alkalosis are associated with altered PTH secretion in vivo, we examined whether pathophysiologic changes in pHo can significantly alter CaR responsiveness in both heterologous and endogenous expression systems and whether this affects PTH secretion. In both CaR-HEK and isolated bovine parathyroid cells, decreasing pHo from 7.4 to 7.2 rapidly inhibited CaR-induced intracellular calcium (Ca(2+)i) mobilization, whereas raising pHo to 7.6 potentiated responsiveness to extracellular calcium (Ca(2+)o). Similar pHo effects were observed for Ca(2+)o-induced extracellular signal-regulated kinase phosphorylation and actin polymerization and for L-Phe-induced Ca(2+)i mobilization. Intracellular pH was unaffected by acute 0.4-unit pHo changes, and the presence of physiologic albumin concentrations failed to attenuate the pHo-mediated effects. None of the individual point mutations created at histidine or cysteine residues in the extracellular domain of CaR attenuated pHo sensitivity. Finally, pathophysiologic pHo elevation reversibly suppressed PTH secretion from perifused human parathyroid cells, and acidosis transiently increased PTH secretion. Therefore, pathophysiologic pHo changes can modulate CaR responsiveness in HEK-293 and parathyroid cells independently of extracellular histidine residues. Specifically, pathophysiologic acidification inhibits CaR activity, thus permitting PTH secretion, whereas alkalinization potentiates CaR activity to suppress PTH secretion. These findings suggest that acid-base disturbances may affect the CaR-mediated control of parathyroid function and calcium metabolism in vivo.
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Affiliation(s)
- Katherine L Campion
- Faculty of Life Sciences, The University of Manchester, Manchester, United Kingdom
| | - Wanda D McCormick
- Faculty of Life Sciences, The University of Manchester, Manchester, United Kingdom; Animal Welfare, Moulton College, Northamptonshire, United Kingdom
| | - Jim Warwicker
- Faculty of Life Sciences, The University of Manchester, Manchester, United Kingdom
| | - Mohd Ezuan Bin Khayat
- Faculty of Life Sciences, The University of Manchester, Manchester, United Kingdom; Department of Biochemistry, Faculty of Biotechnology and Biomolecular Sciences, Universiti Putra Malaysia, Selangor, Malaysia; and
| | | | - Martin C Steward
- Faculty of Life Sciences, The University of Manchester, Manchester, United Kingdom
| | - Leigh W Delbridge
- School of Molecular Bioscience, University of Sydney, New South Wales, Australia
| | - Hee-Chang Mun
- School of Molecular Bioscience, University of Sydney, New South Wales, Australia
| | - Arthur D Conigrave
- School of Molecular Bioscience, University of Sydney, New South Wales, Australia
| | - Donald T Ward
- Faculty of Life Sciences, The University of Manchester, Manchester, United Kingdom;
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Kruijff S, Petersen JF, Chen P, Aniss AM, Clifton-Bligh RJ, Sidhu SB, Delbridge LW, Gill AJ, Learoyd D, Sywak MS. Patterns of structural recurrence in papillary thyroid cancer. World J Surg 2014; 38:653-9. [PMID: 24149717 DOI: 10.1007/s00268-013-2286-0] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND Papillary thyroid carcinoma (PTC) is uncommonly associated with tumor-related mortality, although local recurrence can be a frequent and difficult problem. This study was conducted to clarify the pattern of structural locoregional recurrence in PTC. MATERIAL AND METHOD A retrospective cohort study of patients undergoing surgical intervention for PTC was undertaken. Data were collected from a comprehensive thyroid cancer database maintained within a single tertiary referral center. The primary outcome measure was cancer recurrence requiring surgical intervention. Secondary outcome measures were site of recurrence, time to recurrence, and risk factors for recurrence. RESULTS In the period 1980-2013, 1,183 patients with PTC were included in the study. The overall rate of structural recurrence requiring reoperative surgery was 7.9 %. The median time to reoperation was 31 months. Younger age, male gender, large primary tumor diameter, and number of positive lymph nodes at initial presentation were all significantly associated with disease recurrence. The lateral compartments (levels I, II, III, IV, V) were involved almost twice as frequently as the central compartment (level VI) (67 vs 32 %, P < 0.01). The distribution of recurrences was level I (1 %), level II (12 %), level III (18 %), level IV (18 %), level V (17 %), level VI (32 %), level VII (2 %). CONCLUSIONS In a center with a liberal approach to central compartment lymph node dissection for PTC, the lateral neck compartment is the most common site of structural recurrence requiring reoperative surgery.
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Affiliation(s)
- Schelto Kruijff
- University of Sydney Endocrine Surgery Unit, Royal North Shore Hospital, Suite 202, 69 Christie St., St. Leonards, Sydney, NSW, 2065, Australia,
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9
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Brown SJ, Lee JC, Christie J, Maher R, Sidhu SB, Sywak MS, Delbridge LW. Four-dimensional computed tomography for parathyroid localization: a new imaging modality. ANZ J Surg 2014; 85:483-7. [DOI: 10.1111/ans.12571] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/21/2014] [Indexed: 12/31/2022]
Affiliation(s)
- Sebastian J. Brown
- Endocrine Surgical Unit; The University of Sydney; Sydney New South Wales Australia
| | - James C. Lee
- Endocrine Surgery Unit; Monash University; Melbourne Victoria Australia
| | - James Christie
- North Shore Radiology; North Shore Private Hospital; Sydney New South Wales Australia
| | - Richard Maher
- North Shore Radiology; North Shore Private Hospital; Sydney New South Wales Australia
| | - Stanley B. Sidhu
- Endocrine Surgical Unit; The University of Sydney; Sydney New South Wales Australia
| | - Mark S. Sywak
- Endocrine Surgical Unit; The University of Sydney; Sydney New South Wales Australia
| | - Leigh W. Delbridge
- Endocrine Surgical Unit; The University of Sydney; Sydney New South Wales Australia
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Kruijff S, Sywak MS, Sidhu SB, Shun A, Novakovic D, Lee JC, Delbridge LW. Thyroidal abscesses in third and fourth branchial anomalies: not only a paediatric diagnosis. ANZ J Surg 2014; 85:578-81. [DOI: 10.1111/ans.12576] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/11/2014] [Indexed: 11/28/2022]
Affiliation(s)
- Schelto Kruijff
- Endocrine Surgical Unit; The University of Sydney; Sydney New South Wales Australia
| | - Mark S. Sywak
- Endocrine Surgical Unit; The University of Sydney; Sydney New South Wales Australia
| | - Stan B. Sidhu
- Endocrine Surgical Unit; The University of Sydney; Sydney New South Wales Australia
| | - Albert Shun
- Department of Surgery; The Children's Hospital at Westmead; Sydney New South Wales Australia
| | - Daniel Novakovic
- Otolaryngology; Head and Neck Surgery; The University of Sydney; Sydney New South Wales Australia
| | - James C. Lee
- Endocrine Surgical Unit; The University of Sydney; Sydney New South Wales Australia
| | - Leigh W. Delbridge
- Endocrine Surgical Unit; The University of Sydney; Sydney New South Wales Australia
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Kruijff S, Aniss AM, Chen P, Sidhu SB, Delbridge LW, Robinson B, Clifton-Bligh RJ, Roach P, Gill AJ, Learoyd D, Sywak MS. Decreasing the dose of radioiodine for remnant ablation does not increase structural recurrence rates in papillary thyroid carcinoma. Surgery 2013; 154:1337-44; discussion 1344-5. [DOI: 10.1016/j.surg.2013.06.034] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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12
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Lee JC, Zhao JT, Clifton-Bligh RJ, Gill A, Gundara JS, Ip JC, Glover A, Sywak MS, Delbridge LW, Robinson BG, Sidhu SB. MicroRNA-222 and microRNA-146b are tissue and circulating biomarkers of recurrent papillary thyroid cancer. Cancer 2013; 119:4358-65. [PMID: 24301304 DOI: 10.1002/cncr.28254] [Citation(s) in RCA: 118] [Impact Index Per Article: 10.7] [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: 03/20/2013] [Revised: 05/13/2013] [Accepted: 05/17/2013] [Indexed: 12/19/2022]
Abstract
BACKGROUND Papillary thyroid cancer (PTC) persistence or recurrence and the need for long-term surveillance can cause significant inconvenience and morbidity in patients. Currently, recurrence risk stratification is accomplished by using clinicopathologic factors, and serum thyroglobulin is the only commercially available marker for persistent or recurrent disease. The objective of this study was to determine microRNA (miRNA) expression in PTC and determine whether 1 or more miRNAs could be measured in plasma as a biomarker for recurrence. METHODS Patients with recurrent PTC (Rc-PTC) and those without recurrence (NR-PTC) were retrospectively recruited for a comparison of their tumor miRNA profiles. Patients with either newly diagnosed PTC or multinodular goiter who were undergoing total thyroidectomy were prospectively recruited for an analysis of preoperative and postoperative circulating miRNA levels. Healthy volunteers were recruited as the control group. RESULTS MicroRNA-222 and miR-146b were over-expressed 10.8-fold and 8.9-fold, respectively, in Rc-PTC tumors compared with NR-PTC tumors (P = .014 and P = .038, respectively). In plasma from preoperative PTC patients, levels of miR-222 and miR-146b were higher compared with the levels in plasma from healthy volunteers (P < .01 for both). Reductions of 2.7-fold and 5.1-fold were observed in the plasma levels of miR-222 and miR-146b, respectively, after total thyroidectomy (P = .03 for both). CONCLUSIONS This study demonstrated that tumor levels of miR-222 and miR-146b are associated with PTC recurrence and that miR-222 and miR-146b levels in the circulation correspond to the presence of PTC. The potential of these miRNAs as tumor biomarkers to improve patient stratification according to the risk of recurrence and as circulating biomarkers for PTC surveillance warrants further study.
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Affiliation(s)
- James C Lee
- Kolling Institute of Medical Research, Cancer Genetics Laboratory, Royal North Shore Hospital and University of Sydney, St. Leonards, New South Wales, Australia; Endocrine Surgical Unit, Royal North Shore Hospital and University of Sydney, St. Leonards, New South Wales, Australia
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Glover AR, Gundara JS, Lee JC, Sywak MS, Delbridge LW, Sidhu SB. Thermal sealing systems with and without tissue divider for total thyroidectomy. ANZ J Surg 2013; 84:383-5. [DOI: 10.1111/ans.12406] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/30/2013] [Indexed: 11/30/2022]
Affiliation(s)
- Anthony R. Glover
- Kolling Institute of Medical Research; Cancer Genetics Laboratory; Royal North Shore Hospital and The University of Sydney; Sydney New South Wales Australia
| | - Justin S. Gundara
- Kolling Institute of Medical Research; Cancer Genetics Laboratory; Royal North Shore Hospital and The University of Sydney; Sydney New South Wales Australia
| | - James C. Lee
- Kolling Institute of Medical Research; Cancer Genetics Laboratory; Royal North Shore Hospital and The University of Sydney; Sydney New South Wales Australia
| | - Mark S. Sywak
- Endocrine Surgical Unit; Royal North Shore Hospital and The University of Sydney; Sydney New South Wales Australia
| | - Leigh W. Delbridge
- Endocrine Surgical Unit; Royal North Shore Hospital and The University of Sydney; Sydney New South Wales Australia
| | - Stan B. Sidhu
- Kolling Institute of Medical Research; Cancer Genetics Laboratory; Royal North Shore Hospital and The University of Sydney; Sydney New South Wales Australia
- Endocrine Surgical Unit; Royal North Shore Hospital and The University of Sydney; Sydney New South Wales Australia
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Kruijff S, Sidhu SB, Sywak MS, Gill AJ, Delbridge LW. Negative parafibromin staining predicts malignant behavior in atypical parathyroid adenomas. Ann Surg Oncol 2013; 21:426-33. [PMID: 24081804 DOI: 10.1245/s10434-013-3288-8] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2013] [Indexed: 01/06/2023]
Abstract
BACKGROUND The histopathological criteria for carcinoma proposed by the World Health Organization (WHO) are imperfect predictors of the malignant potential of parathyroid tumors. Negative parafibromin (PF) and positive protein gene product 9.5 (PGP9.5) staining are markers of CDC73 mutation and occur commonly in carcinoma but rarely in adenomas. We investigated whether PF and PGP9.5 staining could be used to predict the behavior of atypical parathyroid adenomas--tumors with atypical features that do not fulfill WHO criteria for malignancy. METHODS Long-term outcomes were compared across four groups: group A, WHO-positive criteria/PF-negative staining; group B, WHO(+)/PF(+), group C; WHO(-)/PF(-); and group D, WHO(-)/PF(+). RESULTS Eighty-one patients were included in the period 1999-2012: group A (n = 13), group B (n = 14), group C (n = 21), and group D (n = 33). Mortality and recurrence rates, respectively, for group A were 15 and 38%, for group B 7 and 36%, for group C 0 and 10%, and for group D 0 and 0%. The PGP9.5(+) ratios for groups A to D were 85, 78, 71, and 12%, further informing prognosis. Five-year disease-free survival for groups A to D were 55, 80, 78, and 100%, respectively. Tumor recurrence was significantly associated with PF (p = 0.048) and PGP9.5 (p = 0.003) staining. CONCLUSIONS Although WHO criteria are essential to differentiate parathyroid carcinoma from benign tumors, the presence of negative PF staining in an atypical adenoma predicts outcome better, whereas PF-positive atypical adenomas do not recur and can be considered benign. PF-negative atypical adenomas have a low but real recurrence risk and should be considered tumors of low malignant potential.
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Affiliation(s)
- Schelto Kruijff
- Endocrine Surgical Unit, University of Sydney, Sydney, NSW, Australia,
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15
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Wang LY, Versnick MA, Gill AJ, Lee JC, Sidhu SB, Sywak MS, Delbridge LW. Level VII is an Important Component of Central Neck Dissection for Papillary Thyroid Cancer. Ann Surg Oncol 2013; 20:2261-5. [DOI: 10.1245/s10434-012-2833-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2012] [Indexed: 11/18/2022]
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16
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O'Neill CJ, Coorough N, Lee JC, Clements J, Delbridge LW, Sippel R, Sywak MS, Chen H, Sidhu SB. Disease outcomes and nodal recurrence in patients with papillary thyroid cancer and lateral neck nodal metastases. ANZ J Surg 2013; 84:240-4. [PMID: 23316684 DOI: 10.1111/ans.12045] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/17/2012] [Indexed: 11/30/2022]
Abstract
BACKGROUND The prognostic influence of lateral neck nodal metastases present at the time of diagnosis of papillary thyroid cancer (PTC) remains controversial. This study aims to document disease outcomes and nodal recurrence rates in such patients. METHODS Patients with PTC and lateral neck nodal metastases who underwent concurrent total thyroidectomy, central and lateral compartment neck dissection between 2000 and 2010 were identified from the prospectively maintained surgical databases of The University of Sydney and University of Wisconsin Endocrine Surgical Units. Disease outcomes and nodal recurrence rates were compared at 12 months post-operatively and in longer-term follow-up. RESULTS During this 11-year period, 121 patients were identified. Mean age was 45 years; 58% were female and 98% underwent post-operative radioactive iodine ablation. At a median follow-up of 31 months (range 12-140), there were no disease-specific deaths and disease-free survival (defined by stimulated serum thyroglobulin (Tg) < 2.0 μg/L, negative clinical and radiological examination) was 66%. Of the 50 patients with persistently elevated Tg measured 12 months post-operatively, 15 developed clinical lateral neck nodal recurrence. All have undergone re-operative surgery. Elevated stimulated Tg at 12 months post-operatively and a nodal ratio of >30% were significantly associated with an increased risk of lateral neck nodal recurrence. CONCLUSION With total thyroidectomy, formal compartmental neck dissection and radioactive iodine treatment, disease-free survival can be achieved in the majority of patients with PTC and synchronous lateral neck nodal metastases. A persistently elevated Tg post-operatively and a high ratio of metastatic nodes identify patients at increased risk of locoregional recurrence.
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Affiliation(s)
- Christine J O'Neill
- Endocrine Surgical Unit, The University of Sydney, Sydney, New South Wales, Australia
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17
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Kruijff S, Mastboom WJ, Vriens MR, Sidhu SB, Delbridge LW. [Recurrent neck abscess due to a branchial cleft remnant]. Ned Tijdschr Geneeskd 2013; 157:A5806. [PMID: 23714293] [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] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
BACKGROUND Abscesses arising from a third or fourth branchial cleft remnant are uncommon clinical entities and are often not recognised in a timely manner. CASE DESCRIPTION In a 33-year-old female patient with a recurrent abscess in the left side of her neck, the cause turned out to be a fistula in the third branchial cleft remnant. She was treated initially with antibiotics and prednisone without adequate results. When the abscess was finally surgically drained, she became very ill and was admitted to the ICU with sepsis and multiple organ failure. She was discharged from hospital after six weeks. Four months later, a third-branchial cleft remnant was found during pharyngoscopy, immediately after which the cleft remnant fistula was excised and an ipsilateral hemi-thyroidectomy was performed. CONCLUSION In young patients with recurring peri-thyroidal abscesses, a branchial cleft remnant should be considered a causative factor; this could avoid high morbidity and a delay in the appropriate treatment.
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Affiliation(s)
- Schelto Kruijff
- Royal North Shore Hospital, Endocrine surgery unit, Sydney, Australia.
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18
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Lee JC, Mazeh H, Serpell J, Delbridge LW, Chen H, Sidhu S. Adenomas of cervical maldescended parathyroid glands: pearls and pitfalls. ANZ J Surg 2012; 85:957-61. [PMID: 23216673 DOI: 10.1111/ans.12017] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/02/2012] [Indexed: 11/28/2022]
Abstract
BACKGROUND Missed parathyroid adenoma (PTA) is the commonest cause of persistent hyperparathyroidism. Although many are subsequently found in well-described locations, some are found in unusual regions of the neck. This paper presents the combined experience of three large tertiary endocrine surgery centres with maldescended PTA (MD-PTA). METHODS Patients were recruited from the endocrine surgical databases of three tertiary endocrine surgery units. Patients with PTA found >1 cm above the superior thyroid pole or other cervical locations as a result of abnormal or incomplete descent were included for analysis. RESULTS MD-PTA was identified in 16 patients out of a total of 5241 patients who had undergone parathyroidectomies in the 7-year study period (incidence 0.3%). Seven (44%) patients had minimally invasive parathyroidectomy, while nine (56%) had bilateral neck exploration. The mean excised gland weight was 750 + 170 mg. Cure was achieved in all patients with a minimum follow-up of 6 months. The locations of MD-PTA in this study included submandibular triangle, retropharyngeal space, carotid sheath (at carotid bifurcation and intravagal), parapharyngeal space (superior to thyroid cartilage or superior thyroid pole) and cricothyroid space. CONCLUSIONS Despite their rare occurrence, incompletely or abnormally descended PTAs can be encountered by any surgeon who performs parathyroidectomies. It is important to develop a strategy to systematically locate these glands. High cure rates can still be achieved with minimally invasive parathyroidectomy if confident preoperative localization is available. A sound knowledge of embryology and a thorough exploration also facilitate an overall high success rate with open exploration.
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Affiliation(s)
- James C Lee
- Endocrine Surgical Unit, Royal North Shore Hospital, Sydney, New South Wales, Australia.,Department of Surgery, The University of Sydney, Sydney, New South Wales, Australia
| | - Haggi Mazeh
- Section of Endocrine Surgery, Department of Surgery, University of Wisconsin, Madison, Wisconsin, USA
| | - Jonathan Serpell
- Endocrine Surgical Unit, Department of Surgery, Monash University, Melbourne, Victoria, Australia
| | - Leigh W Delbridge
- Endocrine Surgical Unit, Royal North Shore Hospital, Sydney, New South Wales, Australia.,Department of Surgery, The University of Sydney, Sydney, New South Wales, Australia
| | - Herbert Chen
- Section of Endocrine Surgery, Department of Surgery, University of Wisconsin, Madison, Wisconsin, USA
| | - Stanley Sidhu
- Endocrine Surgical Unit, Royal North Shore Hospital, Sydney, New South Wales, Australia.,Department of Surgery, The University of Sydney, Sydney, New South Wales, Australia
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19
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Bullock M, O'Neill C, Chou A, Clarkson A, Dodds T, Toon C, Sywak M, Sidhu SB, Delbridge LW, Robinson BG, Learoyd DL, Capper D, von Deimling A, Clifton-Bligh RJ, Gill AJ. Utilization of a MAB for BRAF(V600E) detection in papillary thyroid carcinoma. Endocr Relat Cancer 2012; 19:779-84. [PMID: 22997209 DOI: 10.1530/erc-12-0239] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Identification of BRAF(V600E) in thyroid neoplasia may be useful because it is specific for malignancy, connotes a worse prognosis, and is the target of novel therapies currently under investigation. Sanger sequencing is the 'gold standard' for mutation detection but is subject to sampling error and requires resources beyond many diagnostic pathology laboratories. In this study, we compared immunohistochemistry (IHC) using a BRAF(V600E) mutation-specific MAB to Sanger sequencing on DNA from formalin-fixed paraffin-embedded tissue, in a well-characterized cohort of 101 papillary thyroid carcinoma (PTC) patients. For all cases, an IHC result was available; however, five cases failed Sanger sequencing. Of the 96 cases with molecular data, 68 (71%) were BRAF(V600E) positive by IHC and 59 (61%) were BRAF(V600E) positive by sequencing. Eleven cases were discordant. One case was negative by IHC and initially positive by sequencing. Repeat sequencing of that sample and sequencing of a macrodissected sample were negative for BRAF(V600E). Of ten cases positive by IHC but negative by sequencing on whole sections, repeat sequencing on macrodissected tissue confirmed the IHC result in seven cases (suggesting that these were false negatives of sequencing on whole sections). In three cases, repeat sequencing on recut tissue remained negative (including using massive parallel sequencing), but these cases demonstrated relatively low neoplastic cellularity. We conclude that IHC for BRAF(V600E) is more sensitive and specific than Sanger sequencing in the routine diagnostic setting and may represent the new gold standard for detection of BRAF(V600E) mutation in PTC.
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Affiliation(s)
- M Bullock
- Hormones and Cancer Group, Cancer Genetics Laboratory, Kolling Institute of Medical Research, Royal North Shore Hospital, Sydney, New South Wales, Australia
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20
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Lee JC, Zhao JT, Clifton-Bligh RJ, Gill AJ, Gundara JS, Ip J, Sywak MS, Delbridge LW, Robinson BG, Sidhu SB. Papillary Thyroid Carcinoma in Pregnancy: A Variant of the Disease? Ann Surg Oncol 2012; 19:4210-6. [DOI: 10.1245/s10434-012-2556-3] [Citation(s) in RCA: 12] [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: 04/09/2012] [Indexed: 12/18/2022]
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21
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Prichard RS, O'Neill CJ, Oucharek JJ, Holmes CYV, Delbridge LW, Sywak MS. A prospective study of heart rate variability in endocrine surgery: surgical training increases consultant's mental strain. J Surg Educ 2012; 69:453-458. [PMID: 22677581 DOI: 10.1016/j.jsurg.2012.04.002] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/05/2011] [Revised: 02/29/2012] [Accepted: 04/04/2012] [Indexed: 06/01/2023]
Abstract
BACKGROUND The aim of this study was to determine whether instructing surgical trainees in technically demanding procedures causes alterations in heart rate variability (HRV) and mental strain in supervising surgeons. METHODS A prospective study of HRV in two consultant surgeons and three endocrine surgical fellows undertaking 50 total thyroidectomy procedures was performed. Fellows and consultant surgeons performed 50 lobectomies as primary operator and 50 as assistants in a cross-over design. HRV was measured during dissection around the recurrent laryngeal nerve. The overall heart rate, time, and frequency domain parameters of HRV, specifically the low frequency/high frequency (LF/HF) ratio, which was used as a measure of cardiac and mental stress, were correlated with the surgical role, particularly teaching surgical fellows at critical points. RESULTS HRV data were collected between October 2009 and March 2010. There was no statistically significant difference in the mean heart rate for either group of participants regardless of role. Energy expenditure was greater for fellows when operating (p = 0.03). Fellows demonstrated a higher LF/HF ratio when acting as the primary operator (p = 0.02). All time domain parameters of HRV increased when attending surgeons were operating, denoting more cardiac relaxation. Similarly, the LF/HF ratio was significantly greater for attending surgeons when teaching (p = 0.05), suggesting an increase in mental strain. CONCLUSIONS The teaching of complex but common endocrine surgical procedures is associated with a measurable increase in mental strain of consultant surgeons, as determined by HRV. Fellows demonstrated increased levels of stress when acting as primary operators.
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Affiliation(s)
- Ruth S Prichard
- University of Sydney, Endocrine Surgical Unit, Sydney, NSW, Australia
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22
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Prichard RS, Lee JC, Gill AJ, Sywak MS, Fingleton L, Robinson BG, Sidhu SB, Delbridge LW. Mucoepidermoid carcinoma of the thyroid: a report of three cases and postulated histogenesis. Thyroid 2012; 22:205-9. [PMID: 22224821 DOI: 10.1089/thy.2011.0276] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Primary mucoepidermoid carcinoma (MEC) of the thyroid is a rare clinical and pathological entity that accounts for <0.5% of all thyroid malignancies. Although the histogenesis has been controversial, most investigators now favor it as arising from either metaplasia of thyroid follicular epithelium or heterologous de-differentiation from papillary thyroid carcinoma (PTC). We report three cases of thyroid MEC found in continuity with, and clearly arising from de-differentiation of, well-differentiated thyroid carcinomas (WDTCs). PATIENT FINDINGS AND SUMMARY The cases presented here included two women (aged 22 and 52) and one man (aged 58). One of these cases arose in conjunction with PTC, one with follicular thyroid carcinoma (FTC), and one with Hurthle cell carcinoma (HCC). In all three cases, there was a gradual transition in morphology between the areas of typical WDTC and the areas showing MEC differentiation. In addition, immunohistochemistry demonstrated a gradual loss of thyroid specific markers (thyroid transcription factor-1, thyroglobulin) mirroring the change in morphology. CONCLUSION We conclude that thyroid MEC can arise from metaplastic de-differentiation of WDTC, including FTC or HCC in addition to PTC. Currently, we recommend that after excision, each of the WDTC and MEC components of these tumors be treated with targeted adjuvant therapies, which may involve radioactive-iodine ablation, thyrotropin suppression, and external beam radiotherapy.
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Affiliation(s)
- Ruth S Prichard
- Department of Endocrine and Oncology Surgery, Royal North Shore Hospital, Sydney, Australia
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23
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Vasica G, O'Neill CJ, Sidhu SB, Sywak MS, Reeve TS, Delbridge LW. Reoperative surgery for bilateral multinodular goitre in the era of total thyroidectomy. Br J Surg 2012; 99:688-92. [DOI: 10.1002/bjs.8684] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/14/2011] [Indexed: 11/08/2022]
Abstract
Abstract
Background
Total thyroidectomy, rather than bilateral subtotal thyroidectomy, is now accepted as the preferred management for bilateral benign multinodular goitre (BMNG) in order to reduce the need for reoperative surgery. The aim of this study was to examine whether this approach has had an impact on presentation for bilateral reoperative thyroid surgery.
Methods
This was a retrospective cohort study. The study group comprised patients presenting with recurrent BMNG who underwent bilateral reoperative thyroid surgery following previous bilateral subtotal or partial thyroidectomy. They were compared with patients undergoing unilateral reoperative thyroid surgery following previous lobectomy, and those undergoing primary total thyroidectomy for BMNG.
Results
Between 1 January 1987 and 31 December 2009, 12 354 consecutive thyroid procedures were undertaken. Among those with BMNG, primary total thyroidectomy was undertaken in 3298 patients, unilateral reoperative thyroidectomy in 337 and bilateral reoperative thyroidectomy in 191. Presentations of patients with recurrent BMNG declined gradually over the study period following the change in policy from subtotal to total thyroidectomy; only five patients (representing less than 0·5 per cent of all thyroid surgery) underwent bilateral reoperative surgery for BMNG in the last year of the study. Four of these patients had their initial operation before 1987 and in another unit, whereas the remaining patient initially had surgery overseas.
Conclusion
The introduction of a policy of initial total thyroidectomy for bilateral BMNG has essentially eliminated the need for bilateral reoperative surgery for recurrent goitre.
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Affiliation(s)
- G Vasica
- University of Sydney Endocrine Surgical Unit, Sydney, New South Wales, Australia
| | - C J O'Neill
- University of Sydney Endocrine Surgical Unit, Sydney, New South Wales, Australia
| | - S B Sidhu
- University of Sydney Endocrine Surgical Unit, Sydney, New South Wales, Australia
| | - M S Sywak
- University of Sydney Endocrine Surgical Unit, Sydney, New South Wales, Australia
| | - T S Reeve
- University of Sydney Endocrine Surgical Unit, Sydney, New South Wales, Australia
| | - L W Delbridge
- University of Sydney Endocrine Surgical Unit, Sydney, New South Wales, Australia
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Zhang J, Gill AJM, Issacs JD, Atmore B, Johns A, Delbridge LW, Lai R, McMullen TPW. The Wnt/β-catenin pathway drives increased cyclin D1 levels in lymph node metastasis in papillary thyroid cancer. Hum Pathol 2011; 43:1044-50. [PMID: 22204713 DOI: 10.1016/j.humpath.2011.08.013] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.8] [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: 05/16/2011] [Revised: 08/22/2011] [Accepted: 08/24/2011] [Indexed: 01/09/2023]
Abstract
We examined the expression of cyclin D1 in conjunction with β-catenin and the phosphorylated inactive form of glycogen synthase kinase 3β (GSK-3β) in benign, nonneoplastic thyroid tissue as well as papillary thyroid carcinoma primary tumors and nodal metastases. We aim to unravel the regulation of cyclin D1 and determine if this cell cycle protein is a useful biomarker for metastatic disease. It is clear that expression of cyclin D1 (P < .0001), β-catenin (P < .0001), and inactive form of GSK-3β (P < .0001) are significantly higher in papillary thyroid carcinoma primary tumors than in corresponding benign, nonneoplastic tissue thyroid specimens. Interestingly, β-catenin and cyclin D1 expressions in papillary thyroid carcinoma are correlated (P = .025), implying that β-catenin is a factor driving higher levels of cyclin D1 consistent with previous cell models linking Wnt/β-catenin signaling and cyclin D1 expression. Conversely, inactive form of GSK-3β expression does not correlate with cyclin D1 (P = .52) or β-catenin expression (P = .54). We also did not observe any relationship between tumor size and marker expression. Comparing papillary thyroid carcinoma primary tumors with or without nodal metastases, we did not see any differences in expression of inactive form of GSK-3β (P = .95), β-catenin (P = .14), or cyclin D1 (P = .46). However, in papillary thyroid carcinoma lymph node specimens, the up-regulation of cyclin D1 (P = .0083) was highly significant compared with primary tumors. pGSK-3β and β-catenin expression did not vary between primary tumors and nodal specimens. In conclusion, we have demonstrated that expression of cyclin D1 is linked to nodal metastases and that cyclin D1 levels are regulated by Wnt/β-catenin signaling. GSK pathway-mediated regulation of β-catenin or cyclin D1 expression does not appear operative in papillary thyroid carcinoma.
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Affiliation(s)
- Jingdong Zhang
- Department of Surgical Oncology, Cross Cancer Institute, Edmonton, Canada
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25
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Prichard RS, O’Neill CJ, Oucharek JJ, Sippel RS, Delbridge LW, Sidhu SB, Chen H. Is Focused Minimally Invasive Parathyroidectomy Appropriate for Patients With Familial Primary Hyperparathyroidism? Ann Surg Oncol 2011; 19:1264-8. [DOI: 10.1245/s10434-011-2092-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2010] [Indexed: 11/18/2022]
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26
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Isaacs JD, McMullen TPW, Sidhu SB, Sywak MS, Robinson BG, Delbridge LW. Predictive value of the Delphian and level VI nodes in papillary thyroid cancer. ANZ J Surg 2011; 80:834-8. [PMID: 20969694 DOI: 10.1111/j.1445-2197.2010.05334.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Recent published data has shown that metastatic involvement of the prelaryngeal or Delphian lymph node (DLN), the highest of the central (level VI) cervical lymph nodes, is highly predictive of advanced nodal disease in papillary thyroid cancer (PTC). The aims of this study were to determine the diagnostic accuracy of all the level VI cervical nodes in PTC and to determine which node group, if any, is the most accurate in predicting lateral node (N1b) disease. METHODS This was a retrospective cohort study. Data were obtained from the University of Sydney Endocrine Surgical Unit Database and through a review of the histopathology records. The study cohort was composed of 177 consecutive patients with a final diagnosis of PTC who underwent total thyroidectomy and lymph node dissection, spanning the period from May 2001 to December 2006. RESULTS Of the 177 patients with PTC, 86 had the DLN removed, 51 had a pretracheal node removed and 76 had the paratracheal group removed. DLN, paratracheal and pretracheal node disease was present in 21%, 39% and 46%, respectively. Lateral node (N1b) disease was present in 35%. Paratracheal node involvement was mildly predictive of further disease with patients 1.7 times more likely to have lateral node involvement (sensitivity=55%, specificity=68%). Pretracheal node involvement was moderately predictive of further disease with patients three times more likely to have lateral node involvement (sensitivity=72%, specificity=74%). DLN involvement was highly predictive of further node involvement with patients nine times more likely to have lateral node disease (sensitivity=53%, specificity=94%) and 40 times more likely to have any nodal disease (sensitivity=41%, specificity=100%). CONCLUSION This is the first study to examine the diagnostic accuracy of all level VI lymph nodes in PTC. While, metastatic involvement of all central nodal groups is indicative of further disease, the DLN is the most accurate predictor.
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Affiliation(s)
- Joseph D Isaacs
- University of Sydney Endocrine Surgery Unit, Sydney, Australia
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27
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O'Neill CJ, Bullock M, Chou A, Sidhu SB, Delbridge LW, Robinson BG, Gill AJ, Learoyd DL, Clifton-Bligh R, Sywak MS. BRAF(V600E) mutation is associated with an increased risk of nodal recurrence requiring reoperative surgery in patients with papillary thyroid cancer. Surgery 2011; 148:1139-45; discussion 1145-6. [PMID: 21134544 DOI: 10.1016/j.surg.2010.09.005] [Citation(s) in RCA: 79] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2010] [Accepted: 09/14/2010] [Indexed: 11/28/2022]
Abstract
BACKGROUND The role of the B-isoform of the Raf kinase (BRAF) mutation BRAF(V600E) as an independent prognostic factor in papillary thyroid cancer (PTC) remains controversial. Some studies suggest that tumors containing BRAF(V600E) have decreased radioiodine avidity and present a greater risk of nodal recurrence and distant metastases. METHODS Paraffin-embedded specimens from consecutive patients who underwent surgery for PTC before 2003 were independently reviewed by an endocrine pathologist. DNA was extracted, amplified by polymerase chain reaction, and the presence of the BRAF(V600E) mutation was determined by restriction digest. Tumor characteristics and long-term disease outcomes were analyzed according to BRAF(V600E) status. RESULTS BRAF(V600E) was identified in 60 (59%) of 101 patients. At a median follow-up of 106 months, the overall disease-free survival was 78%. Clinically evident nodal recurrence occurred in 11% of BRAF(V600E)-positive patients, and all patients required lateral neck dissection (P = .02). In contrast, subclinical nodal recurrence occurred in 7% of BRAF(V600E)-negative patients, and all recurrences were successfully ablated with radioactive iodine. There was a trend toward poorer disease-free survival among patients with stage III/IV PTC and BRAF(V600E) mutation (P = .08). All 5 disease-related deaths occurred in patients with BRAF(V600E)-positive primary tumors (P = .06). CONCLUSION The BRAF(V600E) mutation in PTC is associated with an increased risk of palpable nodal recurrence and the need for reoperative surgery.
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Affiliation(s)
- Christine J O'Neill
- Endocrine Surgical Unit, University of Sydney, St Leonards, New South Wales, Australia
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28
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Oucharek JJ, O’Neill CJ, Suliburk JW, Sywak MS, Delbridge LW, Sidhu SB. Durability of Focused Minimally Invasive Parathyroidectomy in Young Patients with Sporadic Primary Hyperparathyroidism. Ann Surg Oncol 2010; 18:1290-2. [DOI: 10.1245/s10434-010-1417-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2010] [Indexed: 11/18/2022]
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29
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McMullen TPW, Learoyd DL, Williams DC, Sywak MS, Sidhu SB, Delbridge LW. Hyperparathyroidism in pregnancy: options for localization and surgical therapy. World J Surg 2010; 34:1811-6. [PMID: 20386905 DOI: 10.1007/s00268-010-0569-2] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Hyperparathyroidism in pregnancy is a threat to the health of both mother and fetus. The mothers suffer commonly from nephrolithiasis, hyperemesis, or even hypercalcemic crisis. Untreated disease will commonly complicate fetal development and fetal death is a significant risk. Treatment options, including medical and surgical therapy, are debated in the literature. METHODS This is a case series comprising seven patients with primary hyperparathyroidism in pregnancy. Data collected included symptoms at diagnosis, biochemical abnormalities, pathologic findings, treatment regimes, and subsequent maternal and fetal outcomes. RESULTS Seven women, aged 20 to 39 years, presented with hyperparathyroidism during pregnancy. The earliest presented at 8 weeks and the latest at 38 weeks. Four of seven patients experienced renal calculi. Calcium levels were 2.7-3.5 mmol/l. All were found to have solitary parathyroid adenomas, of which two were in ectopic locations. Fetal complications included three preterm deliveries and one fetal death with no cases of neonatal tetany. Maternal and fetal complications could not be predicted based on duration or severity of hypercalcemia. Three patients were treated during pregnancy with surgery, and two of these had ectopic glands that required reoperations with a novel approach using Tc-99m sestamibi scanning during pregnancy to assist in localizing the abnormal gland. Four cases were treated postpartum with a combination of open and minimally invasive approaches after localization. No operative complications or fetal loss related to surgery were observed in this cohort. CONCLUSIONS Primary hyperparathyroidism in pregnancy represents a significant risk for maternal and fetal complications that cannot be predicted by duration of symptoms or serum calcium levels. Surgical treatment should be considered early, and a minimally invasive approach with ultrasound is best suited to mitigating risk to mother and fetus. Equally important, Tc-99m sestamibi imaging may be used safely for localization of the parathyroids after negative cervical explorations.
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Affiliation(s)
- Todd P W McMullen
- Department of Surgery 2D, Walter C. Mackenzie Health Science Centre, 8440-112 Street, Edmonton, AB, T6G 2B7, Canada.
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Suliburk JW, Sywak MS, Sidhu SB, Delbridge LW. 1000 minimally invasive parathyroidectomies without intra-operative parathyroid hormone measurement: lessons learned. ANZ J Surg 2010; 81:362-5. [PMID: 21518187 DOI: 10.1111/j.1445-2197.2010.05488.x] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Minimally invasive parathyroidectomy (MIP) has become the procedure of choice in the treatment of primary hyperparathyroidism where a single adenoma can be localized preoperatively. The role for intra-operative parathyroid hormone measurement (IOPTH) is controversial. Some experts recommend that IOPTH is a mandatory requirement for successful MIP while others state that the technique is not needed. We reviewed 10 years of MIP in a single unit without the use of IOPTH in order to examine causes of failure. METHODS This study is a retrospective review of the University of Sydney Endocrine Surgery Database from May of 1998 to August of 2008. The database was queried for MIPs performed as well as for failed operations. Patient record analysis was completed to determine the reason for failure of the operation. RESULTS In the period January 1998 to August 2008, a total of 2343 parathyroidectomy procedures were performed. Of these, 1020 were MIPs with 23 (2.2%) failures. One patient was found to have benign familial hypercalcemia, whereas five were lost to follow-up. Reasons for failure in the remaining 17 patients were: 10 patients (59%) were found to have double adenomas, 3 (17%) patients with hyperplasia and 4 (24%) patients with single gland disease were missed at initial operation. All 17 were cured on repeat exploration. CONCLUSION MIP can be performed safely and with 98% success without the need for IOPTH. The most common cause of failure after MIP is an occult double adenoma. Given that repeat sestamibi scan correctly identifies persistent disease in most cases, consideration can be given to MIP as a choice of procedure for repeat operation.
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Affiliation(s)
- James W Suliburk
- Baylor College of Medicine, Department of Surgery, Houston, Texas, USA
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Bargren AE, Meyer-Rochow GY, Sywak MS, Delbridge LW, Chen H, Sidhu SB. Diagnostic utility of fine-needle aspiration cytology in pediatric differentiated thyroid cancer. World J Surg 2010; 34:1254-60. [PMID: 20091309 DOI: 10.1007/s00268-010-0391-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Pediatric patients present with thyroid nodules less often than adults, but the rate of malignancy is much higher. This study was designed to determine the ability of fine-needle aspiration cytology (FNA) to diagnose accurately and facilitate management of thyroid neoplasms in pediatric patients. METHODS A retrospective study revealed 110 patients <19 years old who had undergone thyroid surgery and FNA biopsy at two academic institutions over the last 28 years. FNA sensitivity for diagnosing papillary thyroid cancer (PC) and follicular neoplasm (FN) was investigated. RESULTS Of 110 patients who presented for surgery, 27 had PC and 33 had a FN: 4 follicular carcinomas (FCs) and 29 follicular adenomas (FAs). Among the PCs patients, the FNA results were as follows: 1 (4%) nondiagnostic, 6 (22%) atypical, 2 (7%) benign, and 18 (67%) malignant lesions. The sensitivity of a malignant FNA was 90% for diagnosing a PC. Sensitivity of an atypical FNA was 75% for FCs and 69% for FAs, giving an overall FN sensitivity of 70%. Of the atypical FNA readings, 60% had confirmed histological atypical features, and 19% were malignant. In 95% of the malignant FNA reports, final histology confirmed PC, resulting in a positive predictive value of 95%. CONCLUSIONS FNA biopsy can reliably diagnose malignancy in pediatric thyroid patients and should be used as a standard technique to indicate surgical treatment. Atypical or suspicious FNA results do not predict cancer effectively, confirming the current accepted practice for adults that diagnostic excision is required to exclude malignancy in pediatric patients.
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Affiliation(s)
- Anna E Bargren
- Section of Endocrine Surgery, Department of Surgery, H4/722 Clinical Science Center, University of Wisconsin, 600 Highland Avenue, Madison, WI 53792, USA.
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Affiliation(s)
- Leigh W Delbridge
- Department of Surgery, Royal North Shore Hospital, St Leonards, NSW 2065, Australia.
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Meyer-Rochow GY, Schembri GP, Benn DE, Sywak MS, Delbridge LW, Robinson BG, Roach PJ, Sidhu SB. The utility of metaiodobenzylguanidine single photon emission computed tomography/computed tomography (MIBG SPECT/CT) for the diagnosis of pheochromocytoma. Ann Surg Oncol 2009; 17:392-400. [PMID: 19949879 DOI: 10.1245/s10434-009-0850-5] [Citation(s) in RCA: 45] [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: 07/04/2009] [Indexed: 01/02/2023]
Abstract
BACKGROUND The enhancement of metaiodobenzylguanidine single photon emission computed tomography (MIBG SPECT) imaging through the addition of CT images fused with SPECT data (coregistered MIBG SPECT/CT imaging) is new technology that allows direct correlation of anatomical and functional information. We hypothesized that MIBG SPECT/CT imaging would provide additional information and improve diagnostic confidence for the radiological localization of a pheochromocytoma, in particular for patients at high risk of multifocal or recurrent disease. METHODS A retrospective study of all patients investigated by MIBG SPECT/CT at our institution from 2006 to 2008 for a suspected pheochromocytoma was performed. Each case was compared with conventional radiological investigations to determine whether MIBG SPECT/CT was able to improve diagnostic confidence and provide additional diagnostic information compared with conventional imaging alone. RESULTS Twenty-two patients had MIBG SPECT/CT imaging for a suspected pheochromocytoma. Fourteen patients had positive MIBG SPECT/CT imaging results correlating with imaging by CT or magnetic resonance imaging in all cases. In six cases, MIBG SPECT/CT provided additional information that altered the original radiological diagnosis. Five patients with a pheochromocytoma-associated germline mutation had multifocal disease excluded by MIBG SPECT/CT. Patients without a germline mutation that had positive biochemistry and a solitary lesion with conventional imaging had no diagnostic improvement with MIBG SPECT/CT imaging. CONCLUSIONS MIBG SPECT/CT fusion imaging is a sensitive and specific radiological imaging tool for patients suspected to have pheochromocytoma. The particular strengths of MIBG SPECT/CT are detection of local recurrence, small extra-adrenal pheochromocytomas, multifocal tumors, or the presence of metastatic disease.
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Affiliation(s)
- Goswin Y Meyer-Rochow
- Cancer Genetics, Kolling Institute of Medical Research, Royal North Shore Hospital, University of Sydney, Sydney, Australia.
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Meyer-Rochow GY, Soon PSH, Delbridge LW, Sywak MS, Bambach CP, Clifton-Bligh RJ, Robinson BG, Sidhu SB. Outcomes of minimally invasive surgery for phaeochromocytoma. ANZ J Surg 2009; 79:367-70. [PMID: 19566519 DOI: 10.1111/j.1445-2197.2009.04891.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Laparoscopic adrenalectomy is now accepted as the procedure of choice for the resection of benign adrenocortical tumours, but few studies have assessed whether the outcomes of laparoscopic adrenalectomy for adrenal phaeochromocytoma are similar to that of other adrenal tumour types. This is a retrospective cohort study. Clinical and operative data were obtained from an adrenal tumour database and hospital records. A total of 191 patients had laparoscopic adrenalectomy, of which 36 were for phaeochromocytoma, over a 12-year period. Length of hospital stay (4.8 vs 3.6 days, P= 0.03) and total operating times (183 vs 157 min, P= 0.01) were greater in the laparoscopic phaeochromocytoma resection group. Despite the greater size of the phaeochromocytomas compared to the remaining adrenal tumour types (44 mm vs 30 mm, P < 0.01), however, rate of conversion and morbidity were no different. Laparoscopic adrenalectomy for phaeochromocytoma is a safe procedure with similar outcomes to laparoscopic adrenalectomy for other adrenal tumour types.
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Affiliation(s)
- Goswin Y Meyer-Rochow
- Cancer Genetics, Hormones and Cancer Group, Kolling Institute of Medical Research, Royal North Shore Hospital, University of Sydney, St Leonards, NSW 2065, Australia.
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Bargren AE, Meyer-Rochow GY, Delbridge LW, Sidhu SB, Chen H. Outcomes of Surgically Managed Pediatric Thyroid Cancer. J Surg Res 2009; 156:70-3. [DOI: 10.1016/j.jss.2009.03.088] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2009] [Revised: 03/29/2009] [Accepted: 03/31/2009] [Indexed: 10/20/2022]
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Abstract
With the widespread use of abdominal imaging, the detection and therefore incidence of adrenal tumours is increasing. The laparoscopic approach to primary surgical resection of adrenal tumours has now become the standard of care. There is scarce published literature regarding the management and outcomes of recurrent adrenal tumours. The aim of the present study was therefore to review the authors' experience with reoperative adrenal surgery. A retrospective review of reoperative adrenalectomy cases identified from the prospectively maintained University of Sydney Endocrine Surgical Unit Database from January 1988 to July 2007 was carried out. There were nine (3.5%) reoperative adrenalectomies in six patients. Two were cases of adrenocortical carcinoma, two involved cases of familial phaeochromocytomas and two cases were due to sporadic phaeochromocytomas. Reoperative adrenal surgery is an uncommon event. During the index surgery for adrenal tumours, all adrenal tissue should be removed and knowledge of the vagaries of adrenal anatomy is essential. Reoperative adrenal surgery is a safe procedure and may confer survival benefit or symptom relief. Lifelong follow up is essential for all patients who have had surgery for functional and malignant adrenal tumours.
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Affiliation(s)
- Charles T Tan
- Endocrine Surgical Unit, Royal North Shore Hospital, University of Sydney, St Leonards, NSW 2065, Australia
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Howell VM, Gill A, Clarkson A, Nelson AE, Dunne R, Delbridge LW, Robinson BG, Teh BT, Gimm O, Marsh DJ. Accuracy of combined protein gene product 9.5 and parafibromin markers for immunohistochemical diagnosis of parathyroid carcinoma. J Clin Endocrinol Metab 2009; 94:434-41. [PMID: 19017757 DOI: 10.1210/jc.2008-1740] [Citation(s) in RCA: 107] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
CONTEXT Parafibromin, encoded by HRPT2, is the first marker with significant benefit in the diagnosis of parathyroid carcinoma. However, because parafibromin is only involved in up to 70% of parathyroid carcinomas and loss of parafibromin immunoreactivity may not be observed in all cases of HRPT2 mutation, a complementary marker is needed. OBJECTIVE We sought to determine the efficacy of increased expression of protein gene product 9.5 (PGP9.5), encoded by ubiquitin carboxyl-terminal esterase L1 (UCHL1) as an additional marker to loss of parafibromin immunoreactivity for the diagnosis of parathyroid carcinoma. DESIGN In total, 146 parathyroid tumors and nine normal tissues were analyzed for the expression of parafibromin and PGP9.5 by immunohistochemistry and for UCHL1 by quantitative RT-PCR. These samples included six hyperparathyroidism-jaw tumor syndrome-related tumors and 24 sporadic carcinomas. RESULTS In tumors with evidence of malignancy, strong staining for PGP9.5 had a sensitivity of 78% for the detection of parathyroid carcinoma and/or HRPT2 mutation and a specificity of 100%. Complete lack of nuclear parafibromin staining had a sensitivity of 67% and a specificity of 100%. PGP9.5 was positive in a tumor with the HRPT2 mutation L64P that expressed parafibromin. Furthermore, UCHL1 was highly expressed in the carcinoma/hyperparathyroidism-jaw tumor syndrome group compared to normal (P < 0.05) and benign specimens (P < 0.001). CONCLUSION These results suggest that positive staining for PGP9.5 has utility as a marker for parathyroid malignancy, with a slightly superior sensitivity (P = 0.03) and similar high specificity to that of parafibromin.
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Affiliation(s)
- Viive M Howell
- Kolling Institute of Medical Research, University of Sydney, Royal North Shore Hospital, St. Leonards, New South Wales 2065, Australia
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Sywak MS, Yeh MW, McMullen T, Stalberg P, Low H, Alvarado R, Sidhu SB, Delbridge LW. A randomized controlled trial of minimally invasive thyroidectomy using the lateral direct approach versus conventional hemithyroidectomy. Surgery 2008; 144:1016-21; discussion 1021-2. [DOI: 10.1016/j.surg.2008.07.024] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2008] [Accepted: 07/30/2008] [Indexed: 11/28/2022]
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Alvarado R, McMullen T, Sidhu SB, Delbridge LW, Sywak MS. Minimally invasive thyroid surgery for single nodules: an evidence-based review of the lateral mini-incision technique. World J Surg 2008; 32:1341-8. [PMID: 18373119 DOI: 10.1007/s00268-008-9554-4] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Minimally invasive thyroidectomy techniques are being developed in an effort to minimize pain, shorten the length of hospital stay, and improve cosmesis. Various minimally invasive thyroid surgery (MITS) techniques have been shown to be safe and feasible with some benefits in terms of cosmesis and pain outcomes; however, no single technique has been broadly accepted. This study was designed to review the evidence in relation to MITS and our experience with the direct lateral mini-incision technique. METHODS A review of literature published until December 2007 on minimally invasive thyroidectomy techniques was undertaken. Three issues were addressed: 1) Does MITS provide any benefit compared with conventional open thyroidectomy? 2) Is there any advantage to the use of endoscopic or video-assisted techniques compared with the direct mini-incision technique? 3) Is the lateral mini-incision technique safe and efficacious? Additional data in relation to the above issues was derived from a retrospective cohort study of patients undergoing mini-incision thyroid surgery within our unit. RESULTS Issue 1: Five prospective randomized studies and eight studies at a lower level of evidence have demonstrated consistent advantages of MITS compared with open thyroid surgery in terms of reduced pain and improved cosmesis with equivalent operative safety. Issue 2: In compiling four level III and IV studies that compared open and video-assisted minimally invasive surgery, there do not seem to be significant differences in patient satisfaction with the incision. The video-assisted approaches require significantly longer operative times but also seem to be less painful. Issue 3: Three cohort studies (level IV) have demonstrated that the lateral mini-incision technique is both safe and efficacious compared with open surgery for hemi-thyroidectomy. Data from our cohort study of 1281 patients (open hemi-thyroidectomy 1054 vs. MITS 227) confirmed MITS to be a safe and effective procedure. The rate of postoperative hematoma formation and wound infection was equivalent between groups. The rate of permanent recurrent laryngeal nerve injury was 0.4% for MITS and 0.3% for CHT and not significantly different (p = 0.7). CONCLUSIONS MITS has demonstrated advantages over conventional open approaches for both hemi- and total thyroidectomy and the benefits do not depend on the open or video-assisted approach. For thyroid lobectomies, the lateral mini-incision approach can be performed with an operative time and postoperative complication profile equivalent to conventional hemi-thyroidectomy while providing excellent cosmesis with a 2-3 cm scar.
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Affiliation(s)
- Raul Alvarado
- Department of Endocrine and Oncology Surgery, University of Sydney Endocrine Surgical Unit, Royal North Shore Hospital, Wallace Freeborn Building, St. Leonards, NSW 2065, Australia
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Lu M, Forsberg L, Höög A, Juhlin CC, Vukojević V, Larsson C, Conigrave AD, Delbridge LW, Gill A, Bark C, Farnebo LO, Bränström R. Heterogeneous expression of SNARE proteins SNAP-23, SNAP-25, Syntaxin1 and VAMP in human parathyroid tissue. Mol Cell Endocrinol 2008; 287:72-80. [PMID: 18457912 DOI: 10.1016/j.mce.2008.01.028] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2007] [Revised: 12/26/2007] [Accepted: 01/26/2008] [Indexed: 11/16/2022]
Abstract
In regulated exocytosis synaptosomal-associated protein of 25kDa (SNAP-25) is one of the key-players in the formation of SNARE (soluble N-ethylmaleimide-sensitive fusion attachment protein receptor) complex and membrane fusion. SNARE proteins are essentially expressed in neurons, neuroendocrine and endocrine cells. Whether parathyroid cells express these proteins is not known. In this study, we have examined the expression of the SNARE protein SNAP-25 and its cellular homologue SNAP-23, as well as syntaxin1 and VAMP (vesicle-associated membrane protein) in samples of normal parathyroid tissue, chief cell adenoma, and parathyroid carcinoma, using immunohistochemistry and Western blot analysis. SNAP-23 and VAMP were evenly expressed in all studied parathyroid tissues using immunohistochemistry and/or Western blot analysis. SNAP-25 (and Syntaxin1) was not expressed in normal parathyroid tissue, but in approximately 20% of chief cell adenomas, and in approximately 45% of parathyroid carcinoma samples. It is likely that the SNARE proteins SNAP-23 and VAMP play a role in the stimulus-secretion coupling and exocytosis of parathyroid hormone as these proteins were expressed in all of the parathyroid samples we studied. In particular, preferential expression of SNAP-23 rather than SNAP-25 provides an explanation of the high level of PTH secretion that occurs under conditions of low cytoplasmic free Ca(2+) concentration (around 0.1micromol/l). SNAP-25 (and Syntaxin1) appears to be a tumour-specific protein(s) in parathyroid tissues since its expression was restricted to pathological tissues.
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Affiliation(s)
- Ming Lu
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
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Abstract
Felix Mandl from Vienna has long been acclaimed as having carried out the first parathyroidectomy for primary hyperparathyroidism in 1925. He was not, however, the first surgeon to have seen the parathyroid glands, either at surgery or in the pathology laboratory. There is evidence that the first intentional removal of a parathyroid tumour was probably carried out at the Middlesex Hospital, London, UK, by Sir John Bland-Sutton at least a decade earlier. Indeed, Sir John Bland-Sutton appeared to have been very much aware of the parathyroid gland and the pathology associated with it for many years, even before this first parathyroid operation. He described a post-mortem specimen of a parathyroid tumour in 1886; he surgically removed a parathyroid cyst in 1909; and then carried out an intentional parathyroidectomy for a parathyroid tumour some time before 1917.
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Affiliation(s)
- Leigh W Delbridge
- Department of Endocrine and Oncology Surgery, Royal North Shore Hospital, Sydney, New South Wales, Australia.
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Soon PSH, Yeh MW, Delbridge LW, Bambach CP, Sywak MS, Robinson BG, Sidhu SB. Laparoscopic surgery is safe for large adrenal lesions. Eur J Surg Oncol 2008; 34:67-70. [PMID: 17532597 DOI: 10.1016/j.ejso.2007.03.007] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.1] [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: 11/01/2006] [Accepted: 03/07/2007] [Indexed: 10/23/2022] Open
Abstract
INTRODUCTION Laparoscopic adrenalectomy has surpassed open adrenalectomy as the gold standard for excision of benign adrenal lesions. The size threshold for offering laparoscopic adrenalectomy is controversial as the prevalence of adrenocortical carcinoma increases with increasing tumour size. The aim of this paper was to assess the safety of laparoscopic adrenalectomy for large adrenal tumours (tumours > or = 60 mm). METHODS A retrospective cohort study of patients who underwent adrenalectomy in a single unit during the period 1995-2005 was undertaken. RESULTS One hundred and seventy patients with 173 tumours were included in this study. Of these, 29 were > or = 60 mm in size, and 16 of these patients underwent laparoscopic adrenalectomy. There were 8 adrenocortical carcinomas in the group with tumours > or = 60 mm in size. Five of these patients underwent an open adrenalectomy, while 2 and 1 patients had laparoscopic and laparoscopic converted to open adrenalectomy respectively. Four of the patients undergoing open adrenalectomy died of their disease while 1 is alive with recurrence 3 years later. The 3 patients who underwent either laparoscopic or laparoscopic converted to open adrenalectomy are alive without evidence of disease after 18 months follow up. CONCLUSION Our data show that patients with tumours > or = 60 mm with no preoperative or intraoperative evidence of malignancy can undergo laparoscopic adrenalectomy without evidence of recurrence on short term follow up. These findings are concordant with the growing body of literature supporting laparoscopic adrenalectomy for potentially malignant tumours > or = 60 mm in size without preoperative or intraoperative features of malignancy.
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Affiliation(s)
- P S H Soon
- University of Sydney Endocrine Surgical Unit, Royal North Shore Hospital, Sydney, New South Wales, Australia
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Abstract
BACKGROUND Primary hyperaldosteronism is a frequent cause of resistant hypertension and is amenable to surgical intervention when caused by a unilateral aldosterone-producing adenoma. The aim of this study was to investigate the long-term results of laparoscopic adrenalectomy in the control of hypertension caused by primary hyperaldosteronism. METHODS A prospective case series of patients undergoing laparoscopic adrenalectomy for hyperaldosteronism was studied. Blood pressure (BP), serum aldosterone levels, plasma renin activity, serum potassium and antihypertensive requirement were measured before and after adrenalectomy. RESULTS Sixty-two patients with hyperaldosteronism underwent laparoscopic adrenalectomy in the period from December 1995 to August 2005. The median follow up was 59 months. There was a significant decrease in both systolic blood pressure and diastolic blood pressure at final follow up compared with that before operation. Systolic blood pressure decreased from 149 mmHg to 129 mmHg at final follow up (P < 0.0001). Diastolic blood pressure decreased from 89 mmHg to 80 mmHg (P < 0.0001). Antihypertensive requirement was decreased from an average of 2.6 separate medications preoperatively to 1.4 medications at final follow up (P < 0.0001). Serum aldosterone levels were significantly lower (698 (confidence interval 534-862) pg/mL vs 181 (confidence interval 139-225) pg/mL, P < 0.0001). Overall, 34% of patients had cure of hypertension and did not require any antihypertensive agent. A further 51% had improvement in BP control, whereas 5% had no change or had worsening hypertension. Multivariate regression analysis showed that age and gland size were independent factors predicting sustained hypertension after surgery. CONCLUSION In appropriately selected patients with primary hyperaldosteronism, laparoscopic adrenalectomy is effective in improving long-term BP control. Larger adrenal gland size and older age at time of surgery are predictors of persisting hypertension.
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Affiliation(s)
- Tony C Pang
- Department of Surgery, University of Sydney Endocrine Surgical Unit, Sydney, Australia
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Meyer-Rochow GY, Alvarado R, Sywak MS, Sidhu SB, Delbridge LW, Gill AJ. Letter 2: Intraoperative diagnosis and treatment of parathyroid cancer and atypical parathyroid adenoma (Br J Surg 2007; 94: 566-570). Br J Surg 2007; 94:1043; author reply 1043-4. [PMID: 17636522 DOI: 10.1002/bjs.5974] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Abstract
BACKGROUND Postoperative parathyroid gland function after total thyroidectomy (TT) has traditionally been monitored by the measurement of serum calcium concentrations. The purpose of this study is to determine whether measurement of parathyroid hormone (PTH) concentrations in the early postoperative period accurately predicts patients at risk of developing hypocalcaemia. METHODS A prospective cohort study of patients undergoing TT was carried out. PTH concentrations were measured preoperatively and at 4 and 23 h postoperatively. Serum calcium concentration was measured preoperatively and twice daily for 48 h after surgery. RESULTS One hundred patients undergoing TT were recruited into the study in the period June 2004 to July 2005. Benign multinodular goitre was the most common indication for surgery (77%). The incidence of temporary hypocalcaemia (Ca < 2.0 mmol/L) was 18%. The mean PTH concentration at 4 h after surgery was 22.3 ng/L and was not significantly different from the 23-h concentration of 23.2 ng/L (P = 0.18). A PTH concentration of < or = 3 ng/L measured at 4 h after surgery had a sensitivity, specificity and likelihood ratio of 0.71, 0.94 and 11.3, respectively, for predicting postoperative hypocalcaemia. The accuracy of a single PTH concentration at 4 h was good for predicting hypocalcaemia (area under receiver-operator characteristic curve 0.90; confidence interval 0.81-0.96). There was no significant difference in accuracy between the 4- and 24-h PTH concentrations (P = 0.14). CONCLUSIONS A single measurement of PTH concentration in the early postoperative period after TT reliably predicts patients who are likely to develop hypocalcaemia. This approach facilitates early discharge and may decrease the need for multiple postoperative blood tests.
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Affiliation(s)
- Mark S Sywak
- Department of Surgery, University of Sydney Endocrine Surgical Unit, Royal North Shore Hospital, St Leonards, New South Wales, Australia.
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Abstract
BACKGROUND Monitoring of the recurrent laryngeal nerve (RLN) has been claimed in some studies to reduce rates of nerve injury during thyroid surgery compared with anatomical dissection and visual identification of the RLN alone, whereas other studies have found no benefit. Continuous monitoring with endotracheal electrodes is expensive whereas discontinuous monitoring by laryngeal palpation with nerve stimulation is a simple and inexpensive technique. This study aimed to assess the value of nerve stimulation with laryngeal palpation as a means of identifying and assessing the function of the RLN and external branch of the superior laryngeal nerve (EBSLN) during thyroid surgery. METHODS This was a prospective case series comprising 50 consecutive patients undergoing total thyroidectomy providing 100 RLN and 100 EBSLN for examination. All patients underwent preoperative and postoperative vocal cord and voice assessment by an independent ear, nose and throat surgeon, laryngeal examination at extubation and all were asked to complete a postoperative dysphagia score sheet. Dysphagia scores in the study group were compared with a control group (n = 20) undergoing total thyroidectomy without nerve stimulation. RESULTS One hundred of 100 (100%) RLN were located without the use of the nerve stimulator. A negative twitch response occurred in seven (7%) RLN stimulated (two bilateral, three unilateral). Postoperative testing, however, only showed one true unilateral RLN palsy postoperatively (1%), which recovered in 7 weeks giving six false-positive and one true-positive results. Eighty-six of 100 (86%) EBSLN were located without the nerve stimulator. Thirteen of 100 (13%) EBSLN could not be identified and 1 of 100 (1%) was located with the use of the nerve stimulator. Fourteen per cent of EBSLN showed no cricothyroid twitch on EBSLN stimulation. Postoperative vocal function in these patients was normal. There were no instances of equipment malfunction. Dysphagia scores did not differ significantly between the study and control groups. CONCLUSION Use of a nerve stimulator did not aid in anatomical dissection of the RLN and was useful in identifying only one EBSLN. Discontinuous nerve monitoring by stimulation during total thyroidectomy confers no obvious benefit for the experienced surgeon in nerve identification, functional testing or injury prevention.
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Meyer-Rochow GY, Sywak MS, Reeve TS, Delbridge LW, Sidhu SB. Surgical trends in the management of thyroid lymphoma. Eur J Surg Oncol 2007; 34:576-80. [PMID: 17604588 DOI: 10.1016/j.ejso.2007.04.016] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [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: 12/17/2006] [Accepted: 04/28/2007] [Indexed: 02/08/2023] Open
Abstract
AIMS To determine the changing trends and current role of surgery for the management of thyroid lymphoma. METHODS A retrospective review of 50 surgical patients with a final diagnosis of thyroid lymphoma over a 35-year period. RESULTS All patients presented with an enlarging mass, with half having compressive symptoms on presentation. Two-thirds of patients had co-existent histological features of Hashimoto's thyroiditis. Surgery for patients with thyroid lymphoma peaked in the late 1970s (0.79% of all thyroid operations performed) followed by a significant decline in the 1980s with a current frequency of only 0.16% (p=0.009). A larger number of thyroid resections intended as a curative procedure was performed during the first half of this series compared to the latter half (p=0.05). There was no difference in disease-free survival between patients treated by thyroid resection when compared with an open biopsy (p=0.4875). CONCLUSION The surgical management of thyroid lymphoma has changed with time. Currently a larger proportion of patients are undergoing surgery in order to achieve a histological diagnosis rather than with therapeutic intent, however, an important role for surgery still exists in the management of a patient with severe airways obstruction.
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Affiliation(s)
- G Y Meyer-Rochow
- University of Sydney Endocrine Surgical Unit, Royal North Shore Hospital, Sydney, Australia
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Soon PSH, Yeh MW, Sywak MS, Roach P, Delbridge LW, Sidhu SB. Minimally invasive parathyroidectomy using the lateral focused miniincision approach: Is there a learning curve for surgeons experienced in the open procedure? J Am Coll Surg 2007; 204:91-5. [PMID: 17189117 DOI: 10.1016/j.jamcollsurg.2006.10.017] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [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: 06/01/2006] [Revised: 09/04/2006] [Accepted: 10/17/2006] [Indexed: 11/20/2022]
Abstract
BACKGROUND Minimally invasive parathyroidectomy (MIP) has gained acceptance as the standard of care for management of primary hyperparathyroidism in which a single adenoma can be localized. The aim of this study was to determine if there is a learning curve for MIP using the lateral focused miniincision approach performed by surgeons experienced in open parathyroidectomy. STUDY DESIGN This is a retrospective case series comprising all parathyroid operations undertaken by three surgeons in the University of Sydney Endocrine Surgical Unit from 2003 to 2005. Outcomes of the experienced surgeon were compared with those of the two surgeons commencing practice. RESULTS There were 699 parathyroidectomies performed in the Unit during the 36-month period (experienced surgeons: 438 versus commencing physicians: 261). Of the parathyroidectomies performed, 57% done by experienced surgeons were minimally invasive compared with 38% of those performed by surgeons commencing practice (p < 0.001). There were no differences in the number of complications (p = 0.21), conversions to open exploration (p = 0.6), and cure rates (p = 0.9) in the MIP patients in both groups. The initial (first 131 patients) and subsequent (next 130 patients) parathyroidectomy experiences of surgeons commencing practice were examined. In the initial experiences, 28% of the cases were minimally invasive compared with 48% in the subsequent experiences (p < 0.001). There were no differences in the number of complications (p = 0.3), conversions to open exploration (p = 0.9), and cure rates (p = 0.9). CONCLUSIONS For surgeons experienced in open parathyroidectomy, there is no technical learning curve using the lateral focused miniincision technique for MIP. There is, however, a learning curve for patient selection.
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Affiliation(s)
- Patsy S H Soon
- University of Sydney Endocrine Surgical Unit, Royal North Shore Hospital, Sydney, NSW, Australia
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Abstract
BACKGROUND Thyroidectomy is an option for the definitive management of Graves' disease. The aim of this study was to examine the role of patient preference for selecting surgery as definitive treatment. PATIENTS AND METHODS This is a retrospective cohort study comprising all patients (n = 63) presenting to a single surgeon for surgical management of Graves' disease over 3 years. Documented reasons for surgery were compared with accepted indications, as well as patients' perceptions as assessed by questionnaire. RESULTS The most frequent absolute indication was the presence of a large goiter (n = 8; 13%) or associated thyroid nodule (n = 6; 10%). Ophthalmopathy, a relative indication, comprised the largest single group overall (n = 18; 29%); however, a significant number of patients (n = 17; 27%) elected surgery in the absence of a recognized indication. There was strong concordance (73%) between the recorded indication and the patients' survey response. Overall, there was a high level of satisfaction with surgery with 88% of respondents giving a satisfaction score of 7 or greater on a visual analog scale (VAS) (0-10). CONCLUSIONS One-third of all patients electing surgery as definitive management do so in the absence of a specific indication. Overall, there is a high level of satisfaction with the decision for surgery as definitive management of Graves' disease.
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Affiliation(s)
- Simon Grodski
- University of Sydney Endocrine Surgical Unit and Kolling Institute of Medical Research, University of Sydney, Sydney, Australia
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