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Cisco RM. Lessons from Dr. Norton. Ann Surg Oncol 2024; 31:3622-3625. [PMID: 38416347 DOI: 10.1245/s10434-024-15081-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Accepted: 02/08/2024] [Indexed: 02/29/2024]
Affiliation(s)
- Robin M Cisco
- Department of Surgery, Stanford University, Stanford, CA, USA.
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Seib CD, Meng T, Cisco RM, Lin DT, McAninch EA, Chen J, Tamura MK, Trickey AW, Kebebew E. Risk of Permanent Hypoparathyroidism Requiring Calcitriol Therapy in a Population-Based Cohort of Adults Older Than 65 Undergoing Total Thyroidectomy for Graves' Disease. Thyroid 2023; 33:223-229. [PMID: 36416252 PMCID: PMC9963476 DOI: 10.1089/thy.2022.0140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Objective: Total thyroidectomy for Graves' disease (GD) is associated with rapid treatment of hyperthyroidism and low recurrence rates. However, it carries the risk of surgical complications including permanent hypoparathyroidism, which contributes to long-term impaired quality of life. The objective of this study was to determine the incidence of permanent hypoparathyroidism requiring calcitriol therapy among a population-based cohort of older adults undergoing total thyroidectomy for GD in the United States. Methods: We performed a population-based cohort study using 100% Medicare claims from beneficiaries older than 65 years with GD who underwent total thyroidectomy from 2007 to 2017. We required continuous enrollment in Medicare Parts A, B, and D for 12 months before and after surgery to ensure access to comprehensive claims data. Patients were excluded if they had a preoperative diagnosis of thyroid cancer or were on long-term preoperative calcitriol. Our primary outcome was permanent hypoparathyroidism, which was identified based on persistent use of calcitriol between 6 and 12 months following thyroidectomy. We used multivariable logistic regression to identify characteristics associated with permanent hypoparathyroidism, including patient age, sex, race/ethnicity, neighborhood disadvantage, Charlson-Deyo Comorbidity Index, urban or rural residence, and frailty. Results: We identified 4650 patients who underwent total thyroidectomy for GD during the study period and met the inclusion criteria (mean age = 72.8 years [standard deviation = 5.5], 86% female, and 79% white). Among this surgical cohort, 104 (2.2% [95% confidence interval, CI = 1.8-2.7%]) patients developed permanent hypoparathyroidism requiring calcitriol therapy. Patients who developed permanent hypoparathyroidism were on average older (mean age 74.1 vs. 72.8 years) than those who did not develop permanent hypoparathyroidism (p = 0.04). On multivariable regression, older age was the only patient characteristic associated with permanent hypoparathyroidism (odds ratio age ≥76 years = 1.68 [CI = 1.13-2.51] compared with age 66-75 years). Conclusions: The risk of permanent hypoparathyroidism requiring calcitriol therapy among this national, U.S. population-based cohort of older adults with GD treated with total thyroidectomy was low, even when considering operations performed by a heterogeneous group of surgeons. These findings suggest that the risk of hypoparathyroidism should not be a deterrent to operative management for GD in older adults who are appropriate surgical candidates.
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Affiliation(s)
- Carolyn Dacey Seib
- Stanford–Surgery Policy Improvement Research and Education Center (S-SPIRE), Department of Surgery, Stanford University School of Medicine, Palo Alto, California, USA
- Department of Surgery, Stanford University School of Medicine, Palo Alto, California, USA
- Division of General Surgery, Palo Alto Veterans Affairs Health Care System, Palo Alto, California, USA
| | - Tong Meng
- Stanford–Surgery Policy Improvement Research and Education Center (S-SPIRE), Department of Surgery, Stanford University School of Medicine, Palo Alto, California, USA
- Department of Emergency Medicine, Stanford University School of Medicine, Palo Alto, California, USA
| | - Robin M. Cisco
- Department of Surgery, Stanford University School of Medicine, Palo Alto, California, USA
| | - Dana T. Lin
- Department of Surgery, Stanford University School of Medicine, Palo Alto, California, USA
| | - Elizabeth A. McAninch
- Division of Endocrinology, Gerontology and Metabolism, Stanford University School of Medicine, Palo Alto, California, USA
| | - Julie Chen
- Division of Endocrinology, Gerontology and Metabolism, Stanford University School of Medicine, Palo Alto, California, USA
| | - Manjula Kurella Tamura
- Geriatric Research, Education and Clinical Center, Veterans Affairs Palo Alto, Palo Alto, California, USA
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, California, USA
| | - Amber W. Trickey
- Stanford–Surgery Policy Improvement Research and Education Center (S-SPIRE), Department of Surgery, Stanford University School of Medicine, Palo Alto, California, USA
| | - Electron Kebebew
- Department of Surgery, Stanford University School of Medicine, Palo Alto, California, USA
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Alobuia WM, Meng T, Cisco RM, Lin DT, Suh I, Tamura MK, Trickey AW, Kebebew E, Seib CD. Racial disparities in the utilization of parathyroidectomy among patients with primary hyperparathyroidism: Evidence from a nationwide analysis of Medicare claims. Surgery 2022; 171:8-16. [PMID: 34229901 PMCID: PMC8688157 DOI: 10.1016/j.surg.2021.05.037] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 04/16/2021] [Accepted: 05/04/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND Among patients with primary hyperparathyroidism, parathyroidectomy offers a chance of cure and mitigation of disease-related complications. The impact of race/ethnicity on referral and utilization of parathyroidectomy has not been fully explored. METHODS Population-based, retrospective cohort study using 100% Medicare claims from beneficiaries with primary hyperparathyroidism from 2006 to 2016. Associations of race/ethnicity with disease severity, surgeon evaluation, and subsequent parathyroidectomy were analyzed using adjusted multivariable logistic regression models. RESULTS Among 210,206 beneficiaries with primary hyperparathyroidism, 63,136 (30.0%) underwent parathyroidectomy within 1 year of diagnosis. Black patients were more likely than other races/ethnicities to have stage 3 chronic kidney disease (10.8%) but had lower prevalence of osteoporosis and nephrolithiasis compared to White patients, Black and Hispanic patients were more likely to have been hospitalized for primary hyperparathyroidism-associated conditions (White 4.8%, Black 8.1%, Hispanic 5.8%; P < .001). Patients who were White and met operative criteria were more likely to undergo parathyroidectomy than Black, Hispanic, or Asian patients (White 30.5%, Black 23.0%, Hispanic 21.4%, Asian 18.7%; P < .001). Black and Hispanic patients had lower adjusted odds of being evaluated by a surgeon (odds ratios 0.71 [95% confidence interval 0.69-0.74], 0.68 [95% confidence interval 0.61-0.74], respectively) and undergoing parathyroidectomy if evaluated by a surgeon (odds ratios 0.72 [95% confidence interval 0.68-0.77], 0.82 [95% confidence interval 0.67-0.99]). Asian race was associated with lower adjusted odds of being evaluated by a surgeon (odds ratio 0.64 [95% confidence interval 0.57-0.71]), but no difference in odds of parathyroidectomy. CONCLUSION Racial/ethnic disparities exist in the management of primary hyperparathyroidism among older adults. Determining the factors that account for this disparity require urgent attention to achieve parity in the management of primary hyperparathyroidism.
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Affiliation(s)
- Wilson M. Alobuia
- Department of Surgery, Stanford University School of Medicine, Palo Alto, CA
| | - Tong Meng
- Stanford-Surgery Policy Improvement Research and Education Center (S-SPIRE), Department of Surgery, Stanford University School of Medicine, Palo Alto, CA.,Department of Emergency Medicine, Stanford University School of Medicine, Palo Alto, CA
| | - Robin M. Cisco
- Department of Surgery, Stanford University School of Medicine, Palo Alto, CA
| | - Dana T. Lin
- Department of Surgery, Stanford University School of Medicine, Palo Alto, CA
| | - Insoo Suh
- Division of Endocrine Surgery, NYU Langone Health, New York, NY
| | - Manjula Kurella Tamura
- Geriatric Research, Education and Clinical Center, Veterans Affairs Palo Alto, Palo Alto, CA.,Division of Nephrology, Stanford University School of Medicine, Palo Alto, CA
| | - Amber W. Trickey
- Stanford-Surgery Policy Improvement Research and Education Center (S-SPIRE), Department of Surgery, Stanford University School of Medicine, Palo Alto, CA
| | - Electron Kebebew
- Department of Surgery, Stanford University School of Medicine, Palo Alto, CA
| | - Carolyn D. Seib
- Department of Surgery, Stanford University School of Medicine, Palo Alto, CA.,Stanford-Surgery Policy Improvement Research and Education Center (S-SPIRE), Department of Surgery, Stanford University School of Medicine, Palo Alto, CA.,Division of General Surgery, Palo Alto Veterans Affairs Health Care System, Palo Alto, CA
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Seib CD, Meng T, Suh I, Cisco RM, Lin DT, Morris AM, Trickey AW, Kebebew E. Undertreatment of primary hyperparathyroidism in a privately insured US population: Decreasing utilization of parathyroidectomy despite expanding surgical guidelines. Surgery 2021; 169:87-93. [PMID: 32654861 PMCID: PMC7736152 DOI: 10.1016/j.surg.2020.04.066] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Revised: 03/29/2020] [Accepted: 04/29/2020] [Indexed: 01/21/2023]
Abstract
BACKGROUND Primary hyperparathyroidism is associated with substantial morbidity, including osteoporosis, nephrolithiasis, and chronic kidney disease. Parathyroidectomy can prevent these sequelae but is poorly utilized in many practice settings. METHODS We performed a retrospective cohort study using the national Optum de-identified Clinformatics Data Mart Database. We identified patients aged ≥35 with a first observed primary hyperparathyroidism diagnosis from 2004 to 2016. Multivariable logistic regression was used to determine patient/provider characteristics associated with parathyroidectomy. RESULTS Of 26,522 patients with primary hyperparathyroidism, 10,101 (38.1%) underwent parathyroidectomy. Of the 14,896 patients with any operative indication, 5,791 (38.9%) underwent parathyroidectomy. Over time, there was a decreasing trend in the rate of parathyroidectomy overall (2004: 54.4% to 2016: 32.4%, P < .001) and among groups with and without an operative indication. On multivariable analysis, increasing age and comorbidities were strongly, inversely associated with parathyroidectomy (age 75-84, odds ratio 0.50 [95% confidence interval 0.45-0.55]; age ≥85, odds ratio 0.21 [95% confidence interval 0.17-0.26] vs age 35-49; Charlson Comorbidity Index ≥2 vs 0 odds ratio 0.62 [95% confidence interval 0.58-0.66]). CONCLUSION The majority of US privately insured patients with primary hyperparathyroidism are not treated with parathyroidectomy. Having an operative indication only modestly increases the likelihood of parathyroidectomy. Further research is needed to address barriers to treatment and the gap between guidelines and clinical care in primary hyperparathyroidism.
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Affiliation(s)
- Carolyn D Seib
- Stanford-Surgery Policy Improvement Research and Education Center (S-SPIRE), Department of Surgery, Stanford University School of Medicine, CA; Department of Surgery, Stanford University School of Medicine, CA; Division of General Surgery, Palo Alto Veterans Affairs Health Care System, CA.
| | - Tong Meng
- Stanford-Surgery Policy Improvement Research and Education Center (S-SPIRE), Department of Surgery, Stanford University School of Medicine, CA; Department of Emergency Medicine, Stanford University School of Medicine, CA
| | - Insoo Suh
- Department of Surgery, University of California, San Francisco, CA
| | - Robin M Cisco
- Department of Surgery, Stanford University School of Medicine, CA
| | - Dana T Lin
- Department of Surgery, Stanford University School of Medicine, CA
| | - Arden M Morris
- Stanford-Surgery Policy Improvement Research and Education Center (S-SPIRE), Department of Surgery, Stanford University School of Medicine, CA; Department of Surgery, Stanford University School of Medicine, CA
| | - Amber W Trickey
- Stanford-Surgery Policy Improvement Research and Education Center (S-SPIRE), Department of Surgery, Stanford University School of Medicine, CA
| | - Electron Kebebew
- Department of Surgery, Stanford University School of Medicine, CA
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Sedaghati M, Lin DT, Cisco RM, Kebebew E. Pediatric vs Adult Adrenocortical Carcinoma: Different Rate of Surgical Treatment and Patient Outcome. J Am Coll Surg 2019. [DOI: 10.1016/j.jamcollsurg.2019.08.191] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Pasternak JD, Seib CD, Seiser N, Tyrell JB, Liu C, Cisco RM, Gosnell JE, Shen WT, Suh I, Duh QY. Differences Between Bilateral Adrenal Incidentalomas and Unilateral Lesions. JAMA Surg 2016. [PMID: 26200882 DOI: 10.1001/jamasurg.2015.1683] [Citation(s) in RCA: 28] [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: 11/14/2022]
Abstract
IMPORTANCE Adrenal incidentalomas are found in 1% to 5% of abdominal cross-sectional imaging studies. Although the workup and management of unilateral lesions are well established, limited information exists for bilateral incidentalomas. OBJECTIVE To compare the natural history of patients having bilateral incidentalomas with those having unilateral incidentalomas. DESIGN, SETTING, AND PARTICIPANTS Retrospective analysis of a prospective database of consecutive patients referred to an academic multidisciplinary adrenal conference. The setting was a tertiary care university hospital among a cohort of 500 patients with adrenal lesions between July 1, 2009, and July 1, 2014. MAIN OUTCOMES AND MEASURES Prevalence, age, imaging characteristics, biochemical workup, any intervention, and final diagnosis. RESULTS Twenty-three patients with bilateral incidentalomas and 112 patients with unilateral incidentalomas were identified. The mean age at diagnosis of bilateral lesions was 58.7 years. The mean lesion size was 2.4 cm on the right side and 2.8 cm on the left side. Bilateral incidentalomas were associated with a significantly higher prevalence of subclinical Cushing syndrome (21.7% [5 of 23] vs 6.2% [7 of 112]) (P = .009) and a significantly lower prevalence of pheochromocytoma (4.3% [1 of 23] vs 19.6% [22 of 112]) (P = .003) compared with unilateral lesions, while rates of hyperaldosteronism were similar in both groups (4.3% [1 of 23] vs 5.4% [6 of 112]) (P > .99). Only one patient with bilateral incidentalomas underwent unilateral resection. The mean follow-up was 4 years (range, 1.2-13.0 years). There were no occult adrenocortical carcinomas. CONCLUSIONS AND RELEVANCE Bilateral incidentalomas are more likely to be associated with subclinical Cushing syndrome and less likely to be pheochromocytomas. Although patients with bilateral incidentalomas undergo a workup similar to that in patients with unilateral lesions, differences in their natural history warrant a greater index of suspicion for subclinical Cushing syndrome.
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Affiliation(s)
- Jesse D Pasternak
- Section of Endocrine Surgery, Department of Surgery, University of California, San Francisco
| | - Carolyn D Seib
- Section of Endocrine Surgery, Department of Surgery, University of California, San Francisco
| | - Natalie Seiser
- Section of Endocrine Surgery, Department of Surgery, University of California, San Francisco
| | - J Blake Tyrell
- Division of Endocrinology, Department of Medicine, University of California, San Francisco
| | - Chienying Liu
- Division of Endocrinology, Department of Medicine, University of California, San Francisco
| | - Robin M Cisco
- Department of Surgery, Good Samaritan Hospital, San Jose, California
| | - Jessica E Gosnell
- Section of Endocrine Surgery, Department of Surgery, University of California, San Francisco
| | - Wen T Shen
- Section of Endocrine Surgery, Department of Surgery, University of California, San Francisco
| | - Insoo Suh
- Section of Endocrine Surgery, Department of Surgery, University of California, San Francisco
| | - Quan-Yang Duh
- Section of Endocrine Surgery, Department of Surgery, University of California, San Francisco
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Cohen JK, Cisco RM, Scholten A, Mitmaker E, Duh QY. Pheochromocytoma crisis resulting in acute heart failure and cardioembolic stroke in a 37-year-old man. Surgery 2014; 155:726-7. [DOI: 10.1016/j.surg.2012.11.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2012] [Accepted: 11/12/2012] [Indexed: 10/27/2022]
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Cisco RM, Kuo JH, Ogawa L, Scholten A, Tsinberg M, Duh QY, Clark OH, Gosnell JE, Shen WT. Impact of race on intraoperative parathyroid hormone kinetics: an analysis of 910 patients undergoing parathyroidectomy for primary hyperparathyroidism. ACTA ACUST UNITED AC 2013; 147:1036-40. [PMID: 22801754 DOI: 10.1001/archsurg.2012.1476] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
HYPOTHESIS African American patients exhibit different intraoperative parathyroid hormone (IOPTH) profiles than non-African American patients. DESIGN Retrospective review. SETTING University medical center. PATIENTS Nine hundred ten patients who underwent parathyroidectomy for primary hyperparathyroidism between July 2005 and August 2010. INTERVENTIONS All patients underwent preoperative imaging with ultrasonography and sestamibi; operative exploration; and IOPTH measurement at 2 points preexcision and 5 and 10 minutes postexcision. MAIN OUTCOME MEASURES Preexcision and postexcision IOPTH measurements. RESULTS Of the 910 patients, 734 self-reported their race as white (81%); 91, Latino/other (10%); 56, Asian (6%); and 28, African American (3%). African American patients had significantly higher initial preexcision IOPTH levels compared with white patients (348 vs 202 pg/mL; P = .048) and significantly higher 5-minute postexcision IOPTH levels (151 vs 80 pg/mL; P = .01). The 10-minute postexcision IOPTH levels were similar between the 2 groups (52 vs 50 pg/mL). A similar percentage of white and African American patients had a 50% drop in IOPTH level at 10 minutes postexcision. No differences in IOPTH kinetics were observed in the other racial groups examined. CONCLUSIONS African American patients with primary hyperparathyroidism exhibit significantly higher preincision and 5-minute postexcision IOPTH values when compared with white patients. The 10-minute postexcision IOPTH values did not differ between races. The altered IOPTH kinetics identified in African American patients may reflect the severity of biochemical disease but may also be related to genetically predetermined differences in parathyroid hormone metabolism.
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Abstract
CONTEXT Pheochromocytoma crisis is a feared and potentially lethal complication of pheochromocytoma. OBJECTIVE We sought to determine the best treatment strategy for pheochromocytoma crisis patients and hypothesized that emergency resection is not indicated. DESIGN Retrospective cohort study (1993-2011); literature review (1944-2011). SETTING Tertiary referral center. PATIENTS There were 137 pheochromocytoma patients from our center and 97 pheochromocytoma crisis patients who underwent adrenalectomy from the literature. INTERVENTION Medical management of pheochromocytoma crisis; adrenalectomy. MAIN OUTCOME MEASURE(S) Perioperative complications, conversion, and mortality. RESULTS In our database, 25 patients (18%) presented with crisis. After medical stabilization and α-blockade, 15 patients were discharged and readmitted for elective surgery and 10 patients were operated on urgently during the same hospitalization. None underwent emergency surgery. Postoperatively, patients who underwent elective surgery had shorter hospital stays (1.7 vs 5.7 d, P = 0.001) and fewer postoperative complications (1 of 15 [7%] vs 5 of 10 [50%], P = 0.045) and were less often admitted to the intensive care unit (1 of 15 [7%] vs 5 of 10 [50%], P = 0.045) in comparison with urgently operated patients. There was no mortality. Review of the literature (n = 97) showed that crisis patients who underwent elective or urgent surgery vs emergency surgery had less intraoperative (13 of 31 [42%] vs 20 of 25 [80%], P < 0.001) and postoperative complications (15 of 45 [33%] vs 15 of 21 [71%], P = 0.047) and a lower mortality (0 of 64 vs 6 of 33 [18%], P = 0.002). CONCLUSIONS Management of patients presenting with pheochromocytoma crisis should include initial stabilization of the acute crisis followed by sufficient α-blockade before surgery. Emergency resection of pheochromocytoma is associated with high surgical morbidity and mortality.
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Affiliation(s)
- Anouk Scholten
- Section of Endocrine Surgery, University of California, San Francisco, California 94143, USA
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Tsinberg M, Duh QY, Cisco RM, Gosnell JE, Scholten A, Clark OH, Shen WT. Practice patterns and job satisfaction in fellowship-trained endocrine surgeons. Surgery 2012; 152:953-6. [DOI: 10.1016/j.surg.2012.08.032] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2012] [Accepted: 08/20/2012] [Indexed: 10/27/2022]
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Jatoi I, Benson JR, Liau SS, Chen Y, Cisco RM, Norton JA, Moley JF, Khalifeh KW, Choti MA. In Brief. Curr Probl Surg 2010. [DOI: 10.1067/j.cpsurg.2010.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Affiliation(s)
- Ismail Jatoi
- Division of Surgical Oncology, University of Texas Health Sciences Center, San Antonio, Texas, USA
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Tedesco MM, Norton JA, Cisco RM, Song TK, Harris EJ. Pancreatic Mass Resection and Revascularization. J Vasc Surg 2010. [DOI: 10.1016/j.jvs.2010.05.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Abstract
Approximately 10% of patients with gastric cancer show familial clustering, and 3% show autosomal dominance and high penetrance. Hereditary diffuse gastric cancer (HDGC) is an autosomal-dominant, inherited cancer syndrome in which affected individuals develop diffuse-type gastric cancer at a young age. Inactivating mutations in the E-cadherin gene CDH1 have been identified in 30% to 50% of patients. CDH1 mutation carriers have an approximately 70% lifetime risk of developing DGC, and affected women carry an additional 20% to 40% risk of developing lobular breast cancer. Because endoscopic surveillance is ineffective in identifying early HDGC, gene-directed prophylactic total gastrectomy currently is offered for CDH1 mutation carriers. In series of asymptomatic individuals undergoing total gastrectomy for CDH1 mutations, the removed stomachs usually contain small foci of early DGC, making surgery not prophylactic but curative. The authors of this review recommend consideration of total gastrectomy in CDH1 mutation carriers at an age 5 years younger than the youngest family member who developed gastric cancer. Individuals who choose not to undergo prophylactic gastrectomy should be followed with biannual chromoendoscopy, and women with CDH1 mutations also should undergo regular surveillance with magnetic resonance imaging studies of the breast. Because of the emergence of gene-directed gastrectomy for HDGC, today, a previously lethal disease is detected by molecular techniques, allowing curative surgery at an early stage.
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Affiliation(s)
- Robin M Cisco
- Department of Surgery, Stanford University School of Medicine, Stanford, California, USA
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Abstract
Hereditary diffuse gastric cancer (HDGC) is an inherited cancer-susceptibility syndrome characterized by autosomal dominance and high penetrance. In 30–50% of cases, a causative germline mutation in CDH1, the E-cadherin gene, may be identified. Female carriers of CDH1 mutations also have an increased (20–40%) risk of lobular breast cancer. Endoscopic surveillance of patients with CDH1 mutations is ineffective because early foci of HDGC are typically small and underlie normal mucosa. CDH1 mutation carriers are therefore offered the option of prophylactic gastrectomy, which commonly reveals early foci of invasive signet-ring cell cancer. We review recommendations for genetic testing, surveillance and prophylactic surgery in HDGC. Areas for future research are discussed, including development of new screening modalities, optimal timing of prophylactic gastrectomy, identification of additional causative mutations in HDGC, management of patients with CDH1 missense mutations and prevention/early detection of lobular breast cancer in CDH1 mutation carriers.
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Affiliation(s)
- Robin M Cisco
- Stanford University School of Medicine, Department of Surgery, Stanford, CA 94305, USA
| | - Jeffrey A Norton
- Stanford University School of Medicine, Department of Surgery, Stanford, CA 94305, USA
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Cisco RM, Abdel-Wahab Z, Dannull J, Nair S, Tyler DS, Gilboa E, Vieweg J, Daaka Y, Pruitt SK. Induction of Human Dendritic Cell Maturation Using Transfection with RNA Encoding a Dominant Positive Toll-Like Receptor 4. J Immunol 2004; 172:7162-8. [PMID: 15153540 DOI: 10.4049/jimmunol.172.11.7162] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Maturation of dendritic cells (DC) is critical for the induction of Ag-specific immunity. Ag-loaded DC matured with LPS, which mediates its effects by binding to Toll-like receptor 4 (TLR4), induce Ag-specific CTL in vitro and in vivo in animal models. However, clinical use of LPS is limited due to potential toxicity. Therefore, we sought to mimic the maturation-inducing effects of LPS on DC by stimulating TLR4-mediated signaling in the absence of exogenous LPS. We developed a constitutively active TLR4 (caTLR4) and demonstrated that transfection of human DC with RNA encoding caTLR4 led to IL-12 and TNF-alpha secretion. Transfection with caTLR4 RNA also induced a mature DC phenotype. Functionally, transfection of DC with caTLR4 RNA enhanced allostimulation of CD4(+) T cells. DC transfected with RNA encoding the MART (Melan-A/MART-1) melanoma Ag were then used to stimulate T cells in vitro. Cotransfection of these DC with caTLR4 RNA enhanced the generation of MART-specific CTL. This CTL activity was superior to that seen when DC maturation was induced using either LPS or a standard mixture of cytokines (TNF-alpha, IL-6, IL-1beta, and PGE(2)). We conclude that transfection of DC with RNA encoding a functional signaling protein, such as caTLR4, may provide a new tool for studying TLR signaling in DC and may be a promising approach for the induction of DC maturation for tumor immunotherapy.
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Affiliation(s)
- Robin M Cisco
- Department of Surgery, Duke University and Durham Veterans Affairs Medical Centers, Durham, NC 27710, USA
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