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Ullmann TM, Sosa JA. Delay in Surgery for Papillary Thyroid Cancer: A Proxy for Lower-Quality Care? J Clin Endocrinol Metab 2023; 108:e1753-e1754. [PMID: 37084398 DOI: 10.1210/clinem/dgad232] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 04/18/2023] [Indexed: 04/23/2023]
Affiliation(s)
- Timothy M Ullmann
- Section of Endocrine Surgery, Department of Surgery, Albany Medical College, Albany, NY 12208, USA
| | - Julie Ann Sosa
- Department of Surgery, University of California San Francisco (UCSF), San Francisco, CA 94143, USA
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Ullmann TM, Mulder M, Davis S, Rajwani T, Khanafshar E, Duh QY. Somatic and Germline Mutations in Atypical Parathyroid Tumors. JAMA Otolaryngol Head Neck Surg 2023; 149:942-943. [PMID: 37651136 PMCID: PMC10472260 DOI: 10.1001/jamaoto.2023.2342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 06/25/2023] [Indexed: 09/01/2023]
Abstract
This case series examines somatic and germline mutations in atypical parathyroid adenomas using broad next-generation sequencing of tumor samples obtained from patients who underwent surgical resection from 2020 to 2022.
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Affiliation(s)
- Timothy M. Ullmann
- Section of Endocrine Surgery, Department of Surgery, University of California San Francisco, San Francisco
| | - Michelle Mulder
- Section of Endocrine Surgery, Department of Surgery, University of California San Francisco, San Francisco
| | - Stephanie Davis
- Section of Endocrine Surgery, Department of Surgery, University of California San Francisco, San Francisco
| | - Taufiq Rajwani
- Section of Endocrine Surgery, Department of Surgery, University of California San Francisco, San Francisco
| | - Elham Khanafshar
- Department of Pathology, University of California San Francisco, San Francisco
| | - Quan-Yang Duh
- Section of Endocrine Surgery, Department of Surgery, University of California San Francisco, San Francisco
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3
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Limberg J, Egan CE, Gray KD, Singh M, Loewenstein Z, Yang Y, Riascos MC, Al Asadi H, Safe P, El Eshaky S, Liang H, Ullmann TM, Wang W, Li W, Zhang T, Xiang J, Stefanova D, Jin MM, Zarnegar R, Fahey TJ, Min IM. Activation of the JAK/STAT Pathway Leads to BRAF Inhibitor Resistance in BRAFV600E Positive Thyroid Carcinoma. Mol Cancer Res 2023; 21:397-410. [PMID: 36790391 PMCID: PMC10159921 DOI: 10.1158/1541-7786.mcr-21-0832] [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] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 03/25/2022] [Accepted: 01/11/2023] [Indexed: 02/16/2023]
Abstract
A subset of thyroid cancers, recurrent differentiated thyroid cancers and anaplastic thyroid cancer (ATC), are difficult to treat by thyroidectomy and systemic therapy. A common mutation in thyroid cancer, BRAFV600E, has targetable treatment options; however, the results have been disappointing in thyroid cancers compared with BRAFV600E melanoma, as thyroid cancers quickly become resistant to BRAFV600E inhibitor (BRAFi). Here, we studied the molecular pathway that is induced in BRAFV600E thyroid cancer cells and patient-derived tumor samples in response to BRAFi, vemurafenib, using RNA-sequencing and molecular analysis. Both inducible response to BRAFi and acquired BRAFi resistance in BRAFV600E thyroid cancer cells showed significant activation of the JAK/STAT pathway. Functional analyses revealed that the combination of BRAFi and inhibitors of JAK/STAT pathway controlled BRAFV600E thyroid cancer cell growth. The Cancer Genome Atlas data analysis demonstrated that potent activation of the JAK/STAT signaling was associated with shorter recurrence rate in patients with differentiated thyroid cancer. Analysis of tumor RNA expression in patients with poorly differentiated thyroid cancer and ATC also support that enhanced activity of JAK/STAT signaling pathway is correlated with worse prognosis. Our study demonstrates that JAK/STAT pathway is activated as BRAFV600E thyroid cancer cells develop resistance to BRAFi and that this pathway is a potential target for anticancer activity and to overcome drug resistance that commonly develops to treatment with BRAFi in thyroid cancer. IMPLICATIONS Dual inhibition of BRAF and JAK/STAT signaling pathway is a potential therapeutic treatment for anticancer activity and to overcome drug resistance to BRAFi in thyroid cancer.
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Affiliation(s)
- Jessica Limberg
- Department of Surgery, Weill Cornell Medicine, New York, NY 10065
| | - Caitlin E. Egan
- Department of Surgery, Weill Cornell Medicine, New York, NY 10065
| | | | - Mandeep Singh
- Department of Surgery, Weill Cornell Medicine, New York, NY 10065
| | | | - Yanping Yang
- Department of Surgery, Weill Cornell Medicine, New York, NY 10065
| | | | - Hala Al Asadi
- Department of Surgery, Weill Cornell Medicine, New York, NY 10065
| | - Parima Safe
- Department of Surgery, Weill Cornell Medicine, New York, NY 10065
| | - Steve El Eshaky
- Department of Surgery, Weill Cornell Medicine, New York, NY 10065
| | - Heng Liang
- Department of Surgery, Weill Cornell Medicine, New York, NY 10065
| | | | - Weibin Wang
- Department of Surgery, Weill Cornell Medicine, New York, NY 10065
| | - Wei Li
- Department of Surgery, Weill Cornell Medicine, New York, NY 10065
| | - Tuo Zhang
- Genomics Resource Core Facility, Weill Cornell Medicine, New York, NY 10065
| | - Jenny Xiang
- Genomics Resource Core Facility, Weill Cornell Medicine, New York, NY 10065
- Department of Microbiology and Immunology, Weill Cornell Medicine, New York, NY 10065
| | | | - Moonsoo M. Jin
- Department of Radiology, Weill Cornell Medicine, New York, NY 10065
| | - Rasa Zarnegar
- Department of Surgery, Weill Cornell Medicine, New York, NY 10065
| | - Thomas J. Fahey
- Department of Surgery, Weill Cornell Medicine, New York, NY 10065
| | - Irene M. Min
- Department of Surgery, Weill Cornell Medicine, New York, NY 10065
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Davis S, Ullmann TM, Roman S. Disparities in Treatment for Differentiated Thyroid Cancer. Thyroid 2023; 33:287-293. [PMID: 36329677 DOI: 10.1089/thy.2022.0432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Purpose: Disparities in the diagnosis and treatment of patients with differentiated thyroid cancer (DTC) have been described. This review includes the most recent literature on existing diagnostic and treatment disparities in the United States and proposes practical clinical and policy ideas for improving the gap in the treatment of DTC. Methodology: We performed a comprehensive literature review to include key articles related to DTC and disparities of treatment, diagnosis, and outcomes for disadvantaged patient populations. Results: Vulnerable patient populations with DTC have been extensively studied, and the literature shows that clear disparities of diagnosis and treatment exist. Socioeconomically disadvantaged patients, uninsured, rural, elderly, and patients belonging to minoritized racial and ethnic groups are more likely to present with advanced disease at presentation. These same vulnerable patient populations are less likely to have access to high-volume surgeons, less likely to be treated according to guidelines, and receive less aggressive treatment (such as radioactive iodine) compared with white patients. Further, these patients experience financial toxicity more so than their counterparts. Conclusions: Disparities of care exist for certain vulnerable patient populations with DTC. Approaches to rectify these should be multipronged and involve improving access to high-volume specialists with ongoing use of telehealth consults, language concordant care, an emphasis on guideline-directed therapies, ensuring continuity of care and long-term follow-up with better community partnerships, engage diverse patients in national guideline-writing committees of prominent societies and reducing the financial burden of cancer treatments at the state and national policy level.
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Affiliation(s)
- Stephanie Davis
- Department of Surgery, University of California San Francisco, San Francisco, California, USA
| | - Timothy M Ullmann
- Department of Surgery, University of California San Francisco, San Francisco, California, USA
| | - Sanziana Roman
- Department of Surgery, University of California San Francisco, San Francisco, California, USA
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5
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Ullmann TM, Papaleontiou M, Sosa JA. Current Controversies in Low-Risk Differentiated Thyroid Cancer: Reducing Overtreatment in an Era of Overdiagnosis. J Clin Endocrinol Metab 2023; 108:271-280. [PMID: 36327392 PMCID: PMC10091361 DOI: 10.1210/clinem/dgac646] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 10/25/2022] [Accepted: 10/31/2022] [Indexed: 11/06/2022]
Abstract
CONTEXT Low-risk differentiated thyroid cancer (DTC) is overdiagnosed, but true incidence has increased as well. Owing to its excellent prognosis with low morbidity and mortality, balancing treatment risks with risks of disease progression can be challenging, leading to several areas of controversy. EVIDENCE ACQUISITION This mini-review is an overview of controversies and difficult decisions around the management of all stages of low-risk DTC, from diagnosis through treatment and follow-up. In particular, overdiagnosis, active surveillance vs surgery, extent of surgery, radioactive iodine (RAI) treatment, thyrotropin suppression, and postoperative surveillance are discussed. EVIDENCE SYNTHESIS Recommendations regarding the diagnosis of DTC, the extent of treatment for low-risk DTC patients, and the intensity of posttreatment follow-up have all changed substantially in the past decade. While overdiagnosis remains a problem, there has been a true increase in incidence as well. Treatment options range from active surveillance of small tumors to total thyroidectomy followed by RAI in select cases. Recommendations for long-term surveillance frequency and duration are similarly broad. CONCLUSION Clinicians and patients must approach each case in a personalized and nuanced fashion to select the appropriate extent of treatment on an individual basis. In areas of evidential equipoise, data regarding patient-centered outcomes may help guide decision-making.
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Affiliation(s)
- Timothy M Ullmann
- Division of General Surgery, Department of Surgery, Albany Medical College, 50 New Scotland Ave., MC-193, Albany, NY 12208, USA
| | - Maria Papaleontiou
- Division of Metabolism, Endocrinology, and Diabetes, Department of Internal Medicine, University of Michigan, 2800 Plymouth Road, Bldg. 16, Rm 453S, Ann Arbor, MI 48109, USA
| | - Julie Ann Sosa
- Section of Endocrine Surgery, Department of Surgery, University of California, San Francisco, 513 Parnassus Ave. Ste. S320, Box 0104, San Francisco, CA 94143, USA
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Greenberg J, Limberg J, Verma A, Kim D, Chen X, Lee YJ, Moore MD, Ullmann TM, Thiesmeyer JW, Loewenstein Z, Chen KJ, Egan CE, Stefanova D, Bareja R, Zarnegar R, Finnerty BM, Scognamiglio T, Du YCN, Elemento O, Fahey TJ, Min IM. Metastatic pancreatic neuroendocrine tumors feature elevated T cell infiltration. JCI Insight 2022; 7:160130. [PMID: 36301668 PMCID: PMC9746918 DOI: 10.1172/jci.insight.160130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 10/26/2022] [Indexed: 01/12/2023] Open
Abstract
Pancreatic neuroendocrine tumors (PNETs) are malignancies arising from the islets of Langerhans. Therapeutic options are limited for the over 50% of patients who present with metastatic disease. We aimed to identify mechanisms to remodel the PNET tumor microenvironment (TME) to ultimately enhance susceptibility to immunotherapy. The TMEs of localized and metastatic PNETs were investigated using an approach that combines RNA-Seq, cancer and T cell profiling, and pharmacologic perturbations. RNA-Seq analysis indicated that the primary tumors of metastatic PNETs showed significant activation of inflammatory and immune-related pathways. We determined that metastatic PNETs featured increased numbers of tumor-infiltrating T cells compared with localized tumors. T cells isolated from both localized and metastatic PNETs showed evidence of recruitment and antigen-dependent activation, suggestive of an immune-permissive microenvironment. A computational analysis suggested that vorinostat, a histone deacetylase inhibitor, may perturb the transcriptomic signature of metastatic PNETs. Treatment of PNET cell lines with vorinostat increased chemokine CCR5 expression by NF-κB activation. Vorinostat treatment of patient-derived metastatic PNET tissues augmented recruitment of autologous T cells, and this augmentation was substantiated in a mouse model of PNET. Pharmacologic induction of chemokine expression may represent a promising approach for enhancing the immunogenicity of metastatic PNET TMEs.
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Affiliation(s)
| | | | - Akanksha Verma
- Caryl and Israel Englander Institute for Precision Medicine, Institute for Computational Biomedicine, and
| | - David Kim
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, New York, USA
| | - Xiang Chen
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, New York, USA
| | | | | | | | | | | | | | | | | | - Rohan Bareja
- Caryl and Israel Englander Institute for Precision Medicine, Institute for Computational Biomedicine, and
| | | | | | - Theresa Scognamiglio
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, New York, USA
| | - Yi-Chieh Nancy Du
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, New York, USA
| | - Olivier Elemento
- Caryl and Israel Englander Institute for Precision Medicine, Institute for Computational Biomedicine, and
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Limberg J, Egan CE, Mora HA, Putzel G, Stamatiou AT, Ullmann TM, Moore MD, Stefanova D, Thiesmeyer JW, Finnerty BM, Beninato T, McKenzie K, Robitsek RJ, Chan J, Zarnegar R, Fahey TJ. Metagenomic Sequencing of the Gallbladder Microbiome: Bacterial Diversity Does Not Vary by Surgical Pathology. J Gastrointest Surg 2022; 26:2282-2291. [PMID: 35915372 DOI: 10.1007/s11605-022-05418-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Accepted: 07/08/2022] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Alterations in the microbiome contribute to the pathogenesis of many gastrointestinal diseases. However, the composition of the microbiome in gallbladder disease is not well described. METHODS We aimed to characterize the biliary microbiome in cholecystectomy patients. Bile and biliary stones were collected at cholecystectomy for a variety of surgical indications between 2017 and 2019. DNA was extracted and metagenomic sequencing was performed with subsequent taxonomic classification using Kraken2. The fraction of bacterial to total DNA reads, relative abundance of bacterial species, and overall species diversity were compared between pathologies and demographics. RESULTS A total of 74 samples were obtained from 49 patients: 46 bile and 28 stones, with matched pairs from 25 patients. The mean age was 48 years, 76% were female, 29% were Hispanic, and 29% of patients had acute cholecystitis. The most abundant species were Klebsiella pneumoniae, Staphylococcus aureus, and Streptococcus pasteurianus. The bacterial fraction in bile and stone samples was higher in acute cholecystitis compared to other non-infectious pathologies (p < 0.05). Neither the diversity nor differential prevalence of specific bacterial species varied significantly between infectious and other non-infectious gallbladder pathologies. Multivariate analysis of the non-infectious group revealed that patients over 40 years of age had increased bacterial fractions (p < 0.05). CONCLUSIONS Metagenomic sequencing permits characterization of the gallbladder microbiome in cholecystectomy patients. Although a higher prevalence of bacteria was seen in acute cholecystitis, species and diversity were similar regardless of surgical indication. Additional study is required to determine how the microbiome can contribute to the development of symptomatic gallbladder disease.
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Affiliation(s)
- Jessica Limberg
- Department of Surgery, Weill Cornell Medicine, New York-Presbyterian Hospital, 1300 York Ave, A1027, New York, NY, 10065, USA
| | - Caitlin E Egan
- Department of Surgery, Weill Cornell Medicine, New York-Presbyterian Hospital, 1300 York Ave, A1027, New York, NY, 10065, USA.
| | - Hector A Mora
- Department of Surgery, Weill Cornell Medicine, New York-Presbyterian Hospital, 1300 York Ave, A1027, New York, NY, 10065, USA
| | - Gregory Putzel
- Department of Microbiology and Immunology, Weill Cornell Medicine, New York, NY, USA
| | - Alexia T Stamatiou
- Department of Surgery, Weill Cornell Medicine, New York-Presbyterian Hospital, 1300 York Ave, A1027, New York, NY, 10065, USA
| | - Timothy M Ullmann
- Department of Surgery, Weill Cornell Medicine, New York-Presbyterian Hospital, 1300 York Ave, A1027, New York, NY, 10065, USA
| | - Maureen D Moore
- Department of Surgery, Weill Cornell Medicine, New York-Presbyterian Hospital, 1300 York Ave, A1027, New York, NY, 10065, USA
| | - Dessislava Stefanova
- Department of Surgery, Weill Cornell Medicine, New York-Presbyterian Hospital, 1300 York Ave, A1027, New York, NY, 10065, USA
| | - Jessica W Thiesmeyer
- Department of Surgery, Weill Cornell Medicine, New York-Presbyterian Hospital, 1300 York Ave, A1027, New York, NY, 10065, USA
| | - Brendan M Finnerty
- Department of Surgery, Weill Cornell Medicine, New York-Presbyterian Hospital, 1300 York Ave, A1027, New York, NY, 10065, USA
| | - Toni Beninato
- Department of Surgery, Weill Cornell Medicine, New York-Presbyterian Hospital, 1300 York Ave, A1027, New York, NY, 10065, USA
| | - Katherine McKenzie
- Department of Surgery, Jamaica Hospital Medical Center, Jamaica, New York, NY, USA
| | - R Jonathan Robitsek
- Department of Surgery, Jamaica Hospital Medical Center, Jamaica, New York, NY, USA
| | - Jeffrey Chan
- Department of Surgery, Jamaica Hospital Medical Center, Jamaica, New York, NY, USA
| | - Rasa Zarnegar
- Department of Surgery, Weill Cornell Medicine, New York-Presbyterian Hospital, 1300 York Ave, A1027, New York, NY, 10065, USA
| | - Thomas J Fahey
- Department of Surgery, Weill Cornell Medicine, New York-Presbyterian Hospital, 1300 York Ave, A1027, New York, NY, 10065, USA
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Moore MD, Agrusa C, Ullmann TM, Beninato T, Zarnegar R, Fahey TJ, Finnerty BM. Risk factors for venous thromboembolism (VTE) after adrenalectomy for adrenal cortical neoplasms. J Surg Oncol 2022; 126:1176-1182. [PMID: 35997946 DOI: 10.1002/jso.27059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 07/23/2022] [Accepted: 07/26/2022] [Indexed: 11/08/2022]
Abstract
BACKGROUND Incidence of venous thromboembolism (VTE) after adrenalectomy for adrenal cortical carcinoma (ACC) is unknown. Herein, we aim to identify the relative incidence and risk factors of VTE after adrenalectomy for ACC. METHODS The American College of Surgeons National Surgical Quality Improvement Program database was queried to identify patients who underwent adrenalectomy for ACC, Cushing syndrome (CS), and benign adrenal cortical syndromes (BACS). Univariable and multivariable analyses were used to determine clinical characteristics, 30-day postoperative VTE occurrences, and associated risk factors. Khorana oncologic risk score (KRS) for VTE was calculated and compared between groups. RESULTS A total of 5896 patients were analyzed: 576 ACC, 371 CS, and 4949 BACS. Postoperative VTE occurred 0.9%, with the highest rate occurring in ACC (2.6% ACC vs. 1.6% CS vs. 0.7% BACS, p < 0.001). Forty percent of VTEs in the ACC cohort were diagnosed postdischarge. ACC patients with KRS ≥ 2 had a 9.6% incidence of VTE (p = 0.007). Multivariable analysis identified increased age (p = 0.03), presence of adrenal cancer (p = 0.01), and KRS ≥ 2 (p = 0.005) as risk factors for VTE after adrenalectomy. CONCLUSIONS Postoperative VTE after adrenalectomy occurs most frequently for ACC. ACC patients with increased age and/or Khorana score ≥2 should be considered for extended VTE prophylaxis.
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Affiliation(s)
- Maureen D Moore
- Department of Surgery, New York-Presbyterian Hospital, Weill Medical College of Cornell University, New York, New York, USA
| | - Christopher Agrusa
- Department of Surgery, New York-Presbyterian Hospital, Weill Medical College of Cornell University, New York, New York, USA
| | - Timothy M Ullmann
- Department of Surgery, New York-Presbyterian Hospital, Weill Medical College of Cornell University, New York, New York, USA
| | - Toni Beninato
- Department of Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - Rasa Zarnegar
- Department of Surgery, New York-Presbyterian Hospital, Weill Medical College of Cornell University, New York, New York, USA
| | - Thomas J Fahey
- Department of Surgery, New York-Presbyterian Hospital, Weill Medical College of Cornell University, New York, New York, USA
| | - Brendan M Finnerty
- Department of Surgery, New York-Presbyterian Hospital, Weill Medical College of Cornell University, New York, New York, USA
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Conroy PC, Wilhelm A, Calthorpe L, Ullmann TM, Davis S, Huang CY, Shen WT, Gosnell J, Duh QY, Roman S, Sosa JA. Endocrine surgeons are performing more thyroid lobectomies for low-risk differentiated thyroid cancer since the 2015 ATA guidelines. Surgery 2022; 172:1392-1400. [PMID: 36002375 DOI: 10.1016/j.surg.2022.06.031] [Citation(s) in RCA: 6] [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: 03/23/2022] [Revised: 05/20/2022] [Accepted: 06/26/2022] [Indexed: 10/31/2022]
Abstract
BACKGROUND The 2015 American Thyroid Association guidelines recommended either total thyroidectomy or lobectomy for surgical treatment of low-risk differentiated thyroid cancer and de-escalated recommendations for central neck dissections. The study aim was to investigate how practice patterns among endocrine surgeons have changed over time. METHODS All adult patients with low-risk differentiated thyroid cancers (T1-T2, N0/Nx, M0/Mx) in the Collaborative Endocrine Surgery Quality Improvement Program (2014-2021) were identified. The outcomes between patients undergoing lobectomy versus total thyroidectomy were compared using multivariable logistic regression. The annual percent change in the proportion of lobectomies and central neck dissections performed was estimated using joinpoint regression. RESULTS In total, 5,567 patients with low-risk differentiated thyroid cancers were identified. Of these, 2,261 (40.6%) were very low-risk tumors ≤1 cm, and 2,983 (53.6%) were low-risk tumors >1 and <4 cm. Most patients (67.9%) underwent total thyroidectomy. Compared to total thyroidectomy, lobectomy was associated with outpatient surgery (adjusted odds ratio 5.19, P < .001), a decreased risk of postoperative emergency department visits (adjusted odds ratio 0.63, P = .03), and decreased risk of hypoparathyroidism events (adjusted odds ratio 0.03, P < .001). Compared to before (2014-2015), patients undergoing surgery after publication of the revised guidelines (2016-2021) had higher odds of lobectomy and lower odds of central neck dissection for tumors ≤1 cm (lobectomy adjusted odds ratio 2.70, P < .001; central neck dissections adjusted odds ratio 0.64, P = .03) and tumors between 1 and 4 cm (lobectomy adjusted odds ratio 2.27, P < .001; central neck dissection adjusted odds ratio 0.62, P < .001). CONCLUSION After publication of the 2015 American Thyroid Association guidelines, there has been an increase in thyroid lobectomies as a proportion of all thyroid operations performed by endocrine surgeons for low-risk differentiated thyroid cancer. This has implications for reduced health care use and costs, with potential population-level benefits.
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Affiliation(s)
- Patricia C Conroy
- Department of Surgery, University of California, San Francisco, CA. https://twitter.com/PatriciaCConroy
| | | | - Lucia Calthorpe
- Department of Surgery, University of California, San Francisco, CA. https://twitter.com/CalthorpeLucia
| | - Timothy M Ullmann
- Department of Surgery, University of California, San Francisco, CA. https://twitter.com/TUllmannMD
| | - Stephanie Davis
- Department of Surgery, University of California, San Francisco, CA. https://twitter.com/stedavis21_MD
| | - Chiung-Yu Huang
- Department of Epidemiology and Biostatistics, University of California, San Francisco, CA
| | - Wen T Shen
- Department of Surgery, University of California, San Francisco, CA. https://twitter.com/wshen16
| | - Jessica Gosnell
- Department of Surgery, University of California, San Francisco, CA
| | - Quan-Yang Duh
- Department of Surgery, University of California, San Francisco, CA. https://twitter.com/EndoSurgSF
| | - Sanziana Roman
- Department of Surgery, University of California, San Francisco, CA. https://twitter.com/PheoSurgeon
| | - Julie Ann Sosa
- Department of Surgery, University of California, San Francisco, CA.
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10
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Ullmann TM, Duh QY. Isolated Lateral Neck Nodal Metastases in Patients With Papillary Thyroid Cancer: Does Cervical Compartment Matter? J Clin Endocrinol Metab 2022; 107:e3534-e3535. [PMID: 35413110 PMCID: PMC9282348 DOI: 10.1210/clinem/dgac219] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Timothy M Ullmann
- Section of Endocrine Surgery, Department of Surgery, University of California, San Francisco, San Francisco, California 94115, USA
| | - Quan-Yang Duh
- Correspondence: Quan-Yang Duh, MD, Section of Endocrine Surgery, Department of Surgery, University of California, San Francisco, UCSF Mount Zion, 1600 Divisadero St, San Francisco, California 94115, USA. ; Twitter: @EndoSurgSF
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11
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Ullmann TM, Liang H, Mora H, Greenberg J, Gray KD, Limberg J, Stefanova D, Zhu X, Finnerty B, Beninato T, Zarnegar R, Min I, Fahey TJ. Exposure to Polybrominated Diphenyl Ether Flame Retardants Causes Deoxyribonucleic Acid Damage in Human Thyroid Cells In Vitro. J Surg Res 2022; 279:77-83. [PMID: 35724546 DOI: 10.1016/j.jss.2022.04.069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 03/29/2022] [Accepted: 04/23/2022] [Indexed: 10/31/2022]
Abstract
INTRODUCTION The incidence of papillary thyroid cancer (PTC) in the United States has tripled in the past 30 y. Polybrominated diphenyl ethers (PBDEs) are flame retardants that were ubiquitously used over that time period, and exposure to PBDEs has been associated with PTC prevalence. They are potential carcinogens via their induction of reactive oxygen species (ROS) formation and resultant deoxyribonucleic acid (DNA) damage. We sought to determine the effects of PBDE and tris(2-chloroethyl) phosphate (TCEP), another flame retardant implicated in PTC incidence, on thyrocytes in vitro and measure PBDE levels in human thyroid tissue to determine their carcinogenic potential. METHODS Nthy-Ori, an immortalized benign human thyroid follicular cell line was used as a model of normal human thyroid. MTT assays were used to measure cell viability after exposure to PBDEs and TCEP. ROS levels and double-stranded and single-stranded DNA breaks were measured to determine genotoxicity. DNA damage response protein levels were measured with immunoblotting. RESULTS Exposure to 20μM PBDE or TCEP for 48 h had minimal effects on thyrocyte viability. There was no significant increase in intracellular ROS up to 6 h following PBDE or TCEP exposure in thyrocytes; however, cells exposed to PBDE 47 showed evidence of DNA single-stranded and double-stranded breaks. There was a dose-dependent increase in γH2AX levels following exposure to PBDEs 47 and 209 in Nthy-Ori cells but not with TCEP treatment. CONCLUSIONS PBDE 47 and 209 demonstrated genotoxicity but not cytotoxicity in follicular thyrocytes in vitro. Therefore, PBDE 47 and 209 may be carcinogenic in human thyroid cells.
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Affiliation(s)
- Timothy M Ullmann
- Department of Surgery, New York Presbyterian Hospital-Weill Cornell Medical Center, New York, New York
| | - Heng Liang
- Department of Surgery, New York Presbyterian Hospital-Weill Cornell Medical Center, New York, New York
| | - Hector Mora
- Weill Cornell Medical College, New York, New York
| | - Jacques Greenberg
- Department of Surgery, New York Presbyterian Hospital-Weill Cornell Medical Center, New York, New York
| | - Katherine D Gray
- Department of Surgery, New York Presbyterian Hospital-Weill Cornell Medical Center, New York, New York
| | - Jessica Limberg
- Department of Surgery, New York Presbyterian Hospital-Weill Cornell Medical Center, New York, New York
| | - Dessislava Stefanova
- Department of Surgery, New York Presbyterian Hospital-Weill Cornell Medical Center, New York, New York
| | - Xin Zhu
- Department of Surgery, New York Presbyterian Hospital-Weill Cornell Medical Center, New York, New York
| | - Brendan Finnerty
- Department of Surgery, New York Presbyterian Hospital-Weill Cornell Medical Center, New York, New York
| | - Toni Beninato
- Department of Surgery, New York Presbyterian Hospital-Weill Cornell Medical Center, New York, New York
| | - Rasa Zarnegar
- Department of Surgery, New York Presbyterian Hospital-Weill Cornell Medical Center, New York, New York
| | - Irene Min
- Department of Surgery, New York Presbyterian Hospital-Weill Cornell Medical Center, New York, New York
| | - Thomas J Fahey
- Department of Surgery, New York Presbyterian Hospital-Weill Cornell Medical Center, New York, New York.
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12
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Raman R, Villefranc JA, Ullmann TM, Thiesmeyer J, Anelli V, Yao J, Hurley JR, Pauli C, Bareja R, Wha Eng K, Dorsaint P, Wilkes DC, Beg S, Kudman S, Shaw R, Churchill M, Ahmed A, Keefer L, Misner I, Nichol D, Gumpeni N, Scognamiglio T, Rubin MA, Grandori C, Solomon JP, Song W, Mosquera JM, Dephoure N, Sboner A, Elemento O, Houvras Y. Inhibition of FGF receptor blocks adaptive resistance to RET inhibition in CCDC6-RET-rearranged thyroid cancer. J Exp Med 2022; 219:e20210390. [PMID: 35510953 PMCID: PMC9082625 DOI: 10.1084/jem.20210390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 11/23/2021] [Accepted: 03/18/2022] [Indexed: 11/18/2022] Open
Abstract
Genetic alterations in RET lead to activation of ERK and AKT signaling and are associated with hereditary and sporadic thyroid cancer and lung cancer. Highly selective RET inhibitors have recently entered clinical use after demonstrating efficacy in treating patients with diverse tumor types harboring RET gene rearrangements or activating mutations. In order to understand resistance mechanisms arising after treatment with RET inhibitors, we performed a comprehensive molecular and genomic analysis of a patient with RET-rearranged thyroid cancer. Using a combination of drug screening and proteomic and biochemical profiling, we identified an adaptive resistance to RET inhibitors that reactivates ERK signaling within hours of drug exposure. We found that activation of FGFR signaling is a mechanism of adaptive resistance to RET inhibitors that activates ERK signaling. Combined inhibition of FGFR and RET prevented the development of adaptive resistance to RET inhibitors, reduced cell viability, and decreased tumor growth in cellular and animal models of CCDC6-RET-rearranged thyroid cancer.
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Affiliation(s)
- Renuka Raman
- Department of Surgery, Weill Cornell Medical College, New York, NY
| | | | | | | | - Viviana Anelli
- Department of Surgery, Weill Cornell Medical College, New York, NY
| | - Jun Yao
- Department of Surgery, Weill Cornell Medical College, New York, NY
| | - James R. Hurley
- Department of Medicine, Weill Cornell Medical College, New York, NY
| | - Chantal Pauli
- Department of Pathology and Molecular Pathology, University Hospital Zurich, Zurich, Switzerland
| | - Rohan Bareja
- The Caryl and Israel Englander Institute for Precision Medicine and the Institute for Computational Biomedicine, Weill Cornell Medical College, New York, NY
| | - Kenneth Wha Eng
- The Caryl and Israel Englander Institute for Precision Medicine and the Institute for Computational Biomedicine, Weill Cornell Medical College, New York, NY
| | - Princesca Dorsaint
- The Caryl and Israel Englander Institute for Precision Medicine and the Institute for Computational Biomedicine, Weill Cornell Medical College, New York, NY
| | - David C. Wilkes
- The Caryl and Israel Englander Institute for Precision Medicine and the Institute for Computational Biomedicine, Weill Cornell Medical College, New York, NY
| | - Shaham Beg
- Department of Pathology and Laboratory Medicine, Weill Cornell Medical College, New York, NY
| | - Sarah Kudman
- Department of Pathology and Laboratory Medicine, Weill Cornell Medical College, New York, NY
| | - Reid Shaw
- SEngine Precision Medicine, Seattle, WA
| | | | - Adnan Ahmed
- Department of Biochemistry, Weill Cornell Medical College, New York, NY
| | | | - Ian Misner
- Personal Genome Diagnostics, Inc., Baltimore, MD
| | - Donna Nichol
- Personal Genome Diagnostics, Inc., Baltimore, MD
| | - Naveen Gumpeni
- Department of Radiology, Weill Cornell Medical College, New York, NY
| | - Theresa Scognamiglio
- Department of Pathology and Laboratory Medicine, Weill Cornell Medical College, New York, NY
| | - Mark A. Rubin
- Bern Center for Precision Medicine, University of Bern, Bern, Switzerland
| | | | - James Patrick Solomon
- Department of Pathology and Laboratory Medicine, Weill Cornell Medical College, New York, NY
| | - Wei Song
- Department of Pathology and Laboratory Medicine, Weill Cornell Medical College, New York, NY
| | - Juan Miguel Mosquera
- Department of Pathology and Laboratory Medicine, Weill Cornell Medical College, New York, NY
| | - Noah Dephoure
- Department of Biochemistry, Weill Cornell Medical College, New York, NY
- Sandra and Edward Meyer Cancer Center, Weill Cornell Medical College, New York, NY
| | - Andrea Sboner
- The Caryl and Israel Englander Institute for Precision Medicine and the Institute for Computational Biomedicine, Weill Cornell Medical College, New York, NY
- Department of Pathology and Laboratory Medicine, Weill Cornell Medical College, New York, NY
- Sandra and Edward Meyer Cancer Center, Weill Cornell Medical College, New York, NY
| | - Olivier Elemento
- The Caryl and Israel Englander Institute for Precision Medicine and the Institute for Computational Biomedicine, Weill Cornell Medical College, New York, NY
- Sandra and Edward Meyer Cancer Center, Weill Cornell Medical College, New York, NY
| | - Yariv Houvras
- Department of Surgery, Weill Cornell Medical College, New York, NY
- Department of Medicine, Weill Cornell Medical College, New York, NY
- Sandra and Edward Meyer Cancer Center, Weill Cornell Medical College, New York, NY
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13
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Ullmann TM, Adam MA, Sosa JA. Surgeon Volume and Outcomes in Primary Hyperparathyroidism-What Is Old Is New Again. JAMA Surg 2022; 157:589. [PMID: 35507376 DOI: 10.1001/jamasurg.2022.1359] [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: 11/14/2022]
Affiliation(s)
| | | | - Julie Ann Sosa
- Department of Surgery, University of California, San Francisco, San Francisco
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14
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Ullmann TM, Thiesmeyer JW, Lee YJ, Beg S, Mosquera JM, Elemento O, Fahey TJ, Scognamiglio T, Houvras Y. ASO Visual Abstract: RET Fusion-Positive Papillary Thyroid Cancers are Associated with a More Aggressive Phenotype. Ann Surg Oncol 2022. [PMID: 35499785 DOI: 10.1245/s10434-022-11450-2] [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: 11/18/2022]
Affiliation(s)
- Timothy M Ullmann
- Department of Surgery, Weill Cornell Medical College, New York, NY, USA
| | | | - Yeon Joo Lee
- Department of Surgery, Weill Cornell Medical College, New York, NY, USA
| | - Shaham Beg
- Department of Pathology, Weill Cornell Medical College, New York, NY, USA
| | | | - Olivier Elemento
- Department of Pathology, Weill Cornell Medical College, New York, NY, USA.,Englander Institute for Precision Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Thomas J Fahey
- Department of Surgery, Weill Cornell Medical College, New York, NY, USA
| | | | - Yariv Houvras
- Department of Surgery, Weill Cornell Medical College, New York, NY, USA. .,Department of Medicine, Weill Cornell Medical College, New York, NY, USA.
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15
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Ullmann TM, Thiesmeyer JW, Lee YJ, Beg S, Mosquera JM, Elemento O, Fahey TJ, Scognamiglio T, Houvras Y. RET Fusion-Positive Papillary Thyroid Cancers are Associated with a More Aggressive Phenotype. Ann Surg Oncol 2022; 29:10.1245/s10434-022-11418-2. [PMID: 35230579 DOI: 10.1245/s10434-022-11418-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Accepted: 01/16/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND It is unclear if different genetic drivers in papillary thyroid cancer (PTC) confer different phenotypic tumor behavior leading to more aggressive disease. We hypothesized that RET-driven cancers are more aggressive. PATIENTS AND METHODS We reviewed records of consecutive patients treated for newly diagnosed PTC at this single institution from 2015 to 2016. Tumor samples from these patients were genotyped to identify RET-translocated, BRAFV600E mutant, and HRAS, KRAS, and NRAS mutant tumors. Patient demographic, clinicopathologic, and outcomes data were compared to identify genotype-specific patterns of disease. RESULTS Of the 327 patients who underwent initial surgery for PTC during the study period, 192 (58.7%) had BRAFV600E mutant tumors (BRAF), 14 (4.3%) had RET-rearranged tumors (RET), 46 (14.1%) had RAS mutant tumors (RAS), and 75 (22.9%) had BRAF, RET, and RAS wildtype tumors. RET-driven tumors were more likely to have extrathyroidal extension (50.0% versus 27.0% for BRAF and 2.2% for RAS, P < 0.001), multifocal disease (85.7% versus 60.3%, and 44.4%, respectively, P = 0.017), and distant metastases (14.3% versus 1.1%, and 0%, respectively, P = 0.019). RET and BRAF patients also had worse disease-free survival than RAS patients (Kaplan-Meier log rank, P = 0.027). CONCLUSIONS Patients with RET-driven PTCs had higher rates of extrathyroidal extension, multifocal disease, and distant metastases than patients whose tumors had BRAFV600E or RAS mutations. Patients with RET-rearranged tumors had similar disease-free survival to patients with BRAFV600E mutant tumors. RET rearrangement may confer an aggressive phenotype in PTC.
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Affiliation(s)
- Timothy M Ullmann
- Department of Surgery, Weill Cornell Medical College, New York, NY, USA
| | | | - Yeon Joo Lee
- Department of Surgery, Weill Cornell Medical College, New York, NY, USA
| | - Shaham Beg
- Department of Pathology, Weill Cornell Medical College, New York, NY, USA
| | | | - Olivier Elemento
- Department of Pathology, Weill Cornell Medical College, New York, NY, USA
- Englander Institute for Precision Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Thomas J Fahey
- Department of Surgery, Weill Cornell Medical College, New York, NY, USA
| | | | - Yariv Houvras
- Department of Surgery, Weill Cornell Medical College, New York, NY, USA.
- Department of Medicine, Weill Cornell Medical College, New York, NY, USA.
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16
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Greenberg JA, Thiesmeyer JW, Ullmann TM, Egan CE, Valle Reyes F, Moore MD, Ivanov NA, Laird AM, Finnerty BM, Zarnegar R, Fahey TJ, Beninato T. Association of the Affordable Care Act with access to highest-volume centers for patients with thyroid cancer. Surgery 2021; 171:132-139. [PMID: 34489109 DOI: 10.1016/j.surg.2021.04.059] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 04/02/2021] [Accepted: 04/20/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Disparities exist in access to high-volume surgeons, who have better outcomes after thyroidectomy. The association of the Affordable Care Act's Medicaid expansion with access to high-volume thyroid cancer surgery centers remains unclear. METHODS The National Cancer Database was queried for all adult thyroid cancer patients diagnosed from 2010 to 2016. Hospital quartiles (Q1-4) defined by operative volume were generated. Clinicodemographics and adjusted odds ratios for treatment per quartile were analyzed by insurance status. An adjusted difference-in-differences analysis examined the association between implementation of the Affordable Care Act and changes in payer mix by hospital quartile. RESULTS In total, 241,448 patients were included. Medicaid patients were most commonly treated at Q3-Q4 hospitals (Q3 odds ratios 1.05, P = .020, Q4 1.11, P < .001), whereas uninsured patients were most often treated at Q2-Q4 hospitals (Q2 odds ratios 2.82, Q3 2.34, Q4 2.07, P < .001). After expansion, Medicaid patients had lower odds of surgery at Q3-Q4 compared with Q1 hospitals (odds ratios Q3 0.82, P < .001 Q4 0.85, P = .002) in expansion states, but higher odds of treatment at Q3-Q4 hospitals in nonexpansion states (odds ratios Q3 2.23, Q4 1.86, P < .001). Affordable Care Act implementation was associated with increased proportions of Medicaid patients within each quartile in expansion compared with nonexpansion states (Q1 adjusted difference-in-differences 5.36%, Q2 5.29%, Q3 3.68%, Q4 3.26%, P < .001), and a decrease in uninsured patients treated at Q4 hospitals (adjusted difference-in-differences -1.06%, P = .001). CONCLUSIONS Medicaid expansion was associated with an increased proportion of Medicaid patients undergoing thyroidectomy for thyroid cancer in all quartiles, with increased Medicaid access to high-volume centers in expansion compared with nonexpansion states.
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Affiliation(s)
- Jacques A Greenberg
- Department of Surgery, Weill Cornell Medicine, New York, NY. https://twitter.com/JacquesGreenbe2
| | - Jessica W Thiesmeyer
- Department of Surgery, Weill Cornell Medicine, New York, NY. https://twitter.com/JessicaThiesme1
| | - Timothy M Ullmann
- Department of Surgery, Weill Cornell Medicine, New York, NY. https://twitter.com/TUllmannMD
| | - Caitlin E Egan
- Department of Surgery, Weill Cornell Medicine, New York, NY. https://twitter.com/CaitlinEgan18
| | | | - Maureen D Moore
- Department of Surgery, Weill Cornell Medicine, New York, NY. https://twitter.com/maureenmooremd
| | - Nikolay A Ivanov
- Department of Surgery, Weill Cornell Medicine, New York, NY. https://twitter.com/n_a_ivanov
| | - Amanda M Laird
- Department of Surgery Rutgers-Cancer Institute of New Jersey, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ. https://twitter.com/amlaird
| | - Brendan M Finnerty
- Department of Surgery, Weill Cornell Medicine, New York, NY. https://twitter.com/FinnertyMD
| | - Rasa Zarnegar
- Department of Surgery, Weill Cornell Medicine, New York, NY. https://twitter.com/RasaZarnegarMD
| | - Thomas J Fahey
- Department of Surgery, Weill Cornell Medicine, New York, NY. https://twitter.com/tjf3endosurg
| | - Toni Beninato
- Department of Surgery Rutgers-Cancer Institute of New Jersey, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ.
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17
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Thiesmeyer JW, Ullmann TM, Stamatiou AT, Limberg J, Stefanova D, Beninato T, Finnerty BM, Vignaud T, Leclerc J, Fahey TJ, Brunaud L, Mirallie E, Zarnegar R. Association of Adrenal Venous Sampling With Outcomes in Primary Aldosteronism for Unilateral Adenomas. JAMA Surg 2021; 156:165-171. [PMID: 33146695 DOI: 10.1001/jamasurg.2020.5011] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Importance Adrenal venous sampling is recommended prior to adrenalectomy for all patients with hyperaldosteronism; however, cross-sectional imaging resolution continues to improve, while the procedure remains invasive and technically difficult. Therefore, certain patients may benefit from advancing straight to surgery. Objective To determine whether clinical and biochemical resolution varied for patients with primary aldosteronism with unilateral adenomas who underwent adrenal venous sampling vs those who proceeded to surgery based on imaging alone. Design, Setting, and Participants Retrospective, international cohort study of patients treated at 3 tertiary medical centers from 2004 to 2019, with a median follow-up of approximately 6 months. A total of 217 patients were consecutively enrolled. Exclusion criteria consisted of unknown postoperative serum aldosterone level and imaging inconsistent with unilateral adenoma with a normal contralateral gland. A total of 125 patients were included in the analysis. Data were analyzed between October 2019 and July 2020. Exposures Adrenal venous sampling performed preoperatively. Main Outcomes and Measures The primary outcome measurements were the clinical and biochemical success rates of surgery for the cure of hyperaldosteronism secondary to aldosterone-producing adenoma. Results A total of 125 patients were included (45 cross-sectional imaging with adrenal venous sampling and 80 imaging only). The mean (SD) age of the study participants was 50.2 (10.6) years and the cohort was 42.4% female (n = 53). Of those patients for whom race or ethnicity were reported (n = 80), most were White (72.5%). Adrenal venous sampling failure rate was 16.7%, and the imaging concordance rate was 100%. Relevant preoperative variables were similar between groups, except ambulatory systolic blood pressure, which was higher in the imaging-only group (150 mm Hg; interquartile range [IQR], 140-172 mm Hg vs 143 mm Hg, IQR, 130-158 mm Hg; P = .03). Resolution of autonomous aldosterone secretion was attained in 98.8% of imaging-only patients and 95.6% of adrenal venous sampling patients (P = .26). There was no difference in complete clinical success (43.6% [n = 34] vs 42.2% [n = 19]) or partial clinical success (47.4% [n = 37] vs 51.1% [n = 23]; P = .87) between groups. Complete biochemical resolution was similar as well (75.9% [n = 41] vs 84.4% [n = 27]; P = .35). There was no difference in clinical or biochemical cure rates when stratified by age, although complete clinical success rates downtrended in the older cohorts, and sample sizes were small. Conclusions and Relevance Given the improved sensitivity of cross-sectional imaging in detection of adrenal tumors, adrenal venous sampling may be selectively performed in appropriate patients with clearly visualized unilateral adenomas without affecting outcomes. This may facilitate increased access to surgical cure for aldosterone-producing adenomas and will decrease the incidence of morbidities associated with the procedure.
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Affiliation(s)
- Jessica W Thiesmeyer
- Department of Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, New York
| | - Timothy M Ullmann
- Department of Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, New York
| | - Alexia T Stamatiou
- Department of Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, New York
| | - Jessica Limberg
- Department of Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, New York
| | - Dessislava Stefanova
- Department of Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, New York
| | - Toni Beninato
- Department of Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, New York
| | - Brendan M Finnerty
- Department of Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, New York
| | - Timothée Vignaud
- Department of Oncologic, Digestive, and Endocrine Surgery, Nantes University Hospital, Nantes, France
| | - Julie Leclerc
- Department of Surgery, Nancy University Hospital, Nancy, France
| | - Thomas J Fahey
- Department of Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, New York
| | - Laurent Brunaud
- Department of Surgery, Nancy University Hospital, Nancy, France
| | - Eric Mirallie
- Department of Oncologic, Digestive, and Endocrine Surgery, Nantes University Hospital, Nantes, France
| | - Rasa Zarnegar
- Department of Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, New York
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18
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Finnerty BM, Gray KD, Ullmann TM, Zarnegar R, Fahey TJ, Beninato T. Frailty is More Predictive than Age for Complications After Thyroidectomy for Multinodular Goiter. World J Surg 2021; 44:1876-1884. [PMID: 32052107 DOI: 10.1007/s00268-020-05422-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
BACKGROUND Risks of thyroidectomy for multinodular goiter (MNG) in older and frail patients are unclear, particularly regarding hematoma and recurrent laryngeal nerve (RLN) palsy. METHODS MNG patients undergoing total thyroidectomy were reviewed in the ACS-NSQIP procedure-targeted database (2016-2017). Outcomes were analyzed between adult (age <65), older-adult (age ≥65 and <80), and oldest-old (age ≥80) patients. Five-factor modified frailty index (mFI-5) was calculated based on functional status, diabetes, COPD, CHF, and hypertension, and used in comparative analyses. RESULTS A total of 2189 adult, 635 older-adult, and 59 oldest-old patients were included. Compared to adult patients, older-adult and oldest-old patients had higher mFI-5 ≥0.4 rates (14% vs. 22% vs. 31%, respectively, p < 0.001). The overall complication rate was 17.0% and similar between groups; however, oldest-old patients had higher rates of surgical site infection (3.4% vs. 0.3% vs. 0.4%), pneumonia (5.1% vs. 0.3% vs. 0.2%), and readmission (10.2% vs. 2.4% vs. 2.6%) compared to older-adult and adult patients, respectively (p < 0.05). On multivariable analyses of thyroidectomy-specific complications, mFI-5 ≥0.4 (OR 2.5, 95%-CI 1.4-4.4) and bleeding disorder (OR 4.6, 95%-CI 1.3-16.3) were predictive of hematoma, whereas vessel-sealant device usage (OR 0.4, 95%-CI 0.3-0.7) was protective. mFI-5 ≥ 0.4 (OR 1.5, 95%-CI 1.1-2.2), bleeding disorder (OR 2.8, 95%-CI 1.04-7.8), parathyroid autotransplantation (OR 1.7, 95%-CI 1.2-2.6), and prolonged operative time (OR 1.4, 95%-CI 1.02-1.8) were predictive of RLN palsy. Age was not a significant predictor of hematoma or RLN palsy. CONCLUSIONS Patients ≥80 years old are at increased risk for systemic complications and readmission after thyroidectomy for MNG. Frailty index better risk-stratifies patients than age for thyroidectomy-specific complications.
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Affiliation(s)
- Brendan M Finnerty
- Department of Surgery, New York Presbyterian Hospital, Weill Cornell Medicine, 525 E 68th Street, F-838, New York, NY, 10065, USA.
| | - Katherine D Gray
- Department of Surgery, New York Presbyterian Hospital, Weill Cornell Medicine, 525 E 68th Street, F-838, New York, NY, 10065, USA
| | - Timothy M Ullmann
- Department of Surgery, New York Presbyterian Hospital, Weill Cornell Medicine, 525 E 68th Street, F-838, New York, NY, 10065, USA
| | - Rasa Zarnegar
- Department of Surgery, New York Presbyterian Hospital, Weill Cornell Medicine, 525 E 68th Street, F-838, New York, NY, 10065, USA
| | - Thomas J Fahey
- Department of Surgery, New York Presbyterian Hospital, Weill Cornell Medicine, 525 E 68th Street, F-838, New York, NY, 10065, USA
| | - Toni Beninato
- Department of Surgery, New York Presbyterian Hospital, Weill Cornell Medicine, 525 E 68th Street, F-838, New York, NY, 10065, USA
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19
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Gray KD, McCloskey JE, Vedvyas Y, Kalloo OR, Eshaky SE, Yang Y, Shevlin E, Zaman M, Ullmann TM, Liang H, Stefanova D, Christos PJ, Scognamiglio T, Tassler AB, Zarnegar R, Fahey TJ, Jin MM, Min IM. PD1 Blockade Enhances ICAM1-Directed CAR T Therapeutic Efficacy in Advanced Thyroid Cancer. Clin Cancer Res 2020; 26:6003-6016. [PMID: 32887724 DOI: 10.1158/1078-0432.ccr-20-1523] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 07/17/2020] [Accepted: 09/01/2020] [Indexed: 02/07/2023]
Abstract
PURPOSE Advanced thyroid cancers, including poorly differentiated and anaplastic thyroid cancer (ATC), are lethal malignancies with limited treatment options. The majority of patients with ATC have responded poorly to programmed death 1 (PD1) blockade in early clinical trials. There is a need to explore new treatment options. EXPERIMENTAL DESIGN We examined the expression of PD-L1 (a ligand of PD1) and intercellular adhesion molecule 1 (ICAM1) in thyroid tumors and ATC cell lines, and investigated the PD1 expression level in peripheral T cells of patients with thyroid cancer. Next, we studied the tumor-targeting efficacy and T-cell dynamics of monotherapy and combination treatments of ICAM1-targeting chimeric antigen receptor (CAR) T cells and anti-PD1 antibody in a xenograft model of ATC. RESULTS Advanced thyroid cancers were associated with increased expression of both ICAM1 and PD-L1 in tumors, and elevated PD1 expression in CD8+ T cells of circulating blood. The expression of ICAM1 and PD-L1 in ATC lines was regulated by the IFNγ-JAK2 signaling pathway. ICAM1-targeted CAR T cells, produced from either healthy donor or patient T cells, in combination with PD1 blockade demonstrated an improved ability to eradicate ICAM1-expressing target tumor cells compared with CAR T treatment alone. PD1 blockade facilitated clearance of PD-L1 high tumor colonies and curtailed excessive CAR T expansion, resulting in rapid tumor clearance and prolonged survival in a mouse model. CONCLUSIONS Targeting two IFNγ-inducible, tumor-associated antigens-ICAM1 and PD-L1-in a complementary manner might be an effective treatment strategy to control advanced thyroid cancers in vivo.
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Affiliation(s)
- Katherine D Gray
- Department of Surgery, Weill Cornell Medicine, New York, New York
| | | | - Yogindra Vedvyas
- Department of Radiology, Weill Cornell Medicine, New York, New York
| | - Olivia R Kalloo
- Department of Surgery, Weill Cornell Medicine, New York, New York
| | - Steve El Eshaky
- Department of Surgery, Weill Cornell Medicine, New York, New York
| | - Yanping Yang
- Department of Radiology, Weill Cornell Medicine, New York, New York
| | - Enda Shevlin
- Department of Radiology, Weill Cornell Medicine, New York, New York
| | - Marjan Zaman
- Department of Radiology, Weill Cornell Medicine, New York, New York
| | | | - Heng Liang
- Department of Surgery, Weill Cornell Medicine, New York, New York
| | | | - Paul J Christos
- Department of Population Health Sciences, Weill Cornell Medicine, New York, New York
| | | | - Andrew B Tassler
- Department of Head and Neck Surgery, Weill Cornell Medicine, New York, New York
| | - Rasa Zarnegar
- Department of Surgery, Weill Cornell Medicine, New York, New York
| | - Thomas J Fahey
- Department of Surgery, Weill Cornell Medicine, New York, New York.
| | - Moonsoo M Jin
- Department of Radiology, Weill Cornell Medicine, New York, New York.
| | - Irene M Min
- Department of Surgery, Weill Cornell Medicine, New York, New York.
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20
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Limberg J, Gray KD, Singh M, Ullmann TM, Wyrwas B, Wang W, Lowenstein Z, Eshaky SE, Liang H, Li W, Zhang T, Xiang J, Stefanova D, Zarnegar R, Fahey TJ, Min IM. Abstract 1895: The role of the IFNγ pathway in the development of vemurafenib resistance in BRAFV600E mutant thyroid carcinoma. Cancer Res 2020. [DOI: 10.1158/1538-7445.am2020-1895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
BRAFV600E is the most common driver mutation in anaplastic thyroid cancer, and BRAF inhibitors are increasingly being used in the treatment of this disease. However, the therapeutic benefit of BRAFV600E inhibitors, such as vemurafenib, has been limited in thyroid cancer due to rapid development of drug resistance in clinical practice. Here, we characterize a targetable mechanism of vemurafenib resistance by studying vemurafenib-resistant clones derived from BRAFV600E mutant anaplastic thyroid cancer cell lines (8505C and FRO), and propose a drug combination to overcome resistance. Vemurafenib resistance in these established clones was verified by persistent activation of ERK1/2 after vemurafenib treatment by western blot analysis. RNA-sequencing and subsequent ingenuity pathway analysis (IPA) was used to identify differences in pathway activation after vemurafenib treatment in parental and vemurafenib-resistant cell lines. Treatment of parental cells with vemurafenib resulted in differential gene expression correlating with upstream activation of the IFNγ-STAT1-IRF1 pathway (All FDR < 0.05). Furthermore, parental cells treated with vemurafenib demonstrated higher HLA-II and HLA-A2 expression than untreated cells when analyzed by flow cytometry, implying the activation of IFNγ signaling pathway. In the IPA of a vemurafenib-resistant clone (8505C Res1), IFNγ, STAT1 and IRF1 expression was upregulated compared to their respective untreated parental cell line (All FDR < 0.05). Increased IRF1 expression in 8505C Res1 compared to parental cells was also demonstrated by qPCR, supporting innate IFNγ activation in the resistant clone. Inhibition of the IFNγ pathway with increasing concentrations of neutralizing anti-IFNγ antibody sensitized resistant thyroid cancer cells to vemurafenib. Pharmacologically blocking the IFNγ downstream pathway in resistant clones with AZD1480 (JAK2 inhibitor) or fludarabine (STAT1 inhibitor), resulted in decreased cell viability in combination treatment groups compared to vemurafenib treatment only (cell viability: 92% vemurafenib vs 19% fludarabine combination, p < 0.05) (cell viability: 73% vemurafenib vs 37% AZD1480 combination, p < 0.05). These results demonstrate that activation of the IFNγ pathway is a potential mechanism for the development of resistance of anaplastic thyroid cancer to BRAFV600E inhibitors. Our study suggests that blockade of the IFNγ pathway may potentiate the therapeutic benefit of vemurafenib treatment in this disease.
Citation Format: Jessica Limberg, Katherine D. Gray, Mandeep Singh, Timothy M. Ullmann, Brian Wyrwas, Weibin Wang, Zachary Lowenstein, Steve El Eshaky, Heng Liang, Wei Li, Tuo Zhang, Jenny Xiang, Dessislava Stefanova, Rasa Zarnegar, Thomas J. Fahey, Irene M. Min. The role of the IFNγ pathway in the development of vemurafenib resistance in BRAFV600E mutant thyroid carcinoma [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr 1895.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Heng Liang
- Weill Cornell Medical College, New York, NY
| | - Wei Li
- Weill Cornell Medical College, New York, NY
| | - Tuo Zhang
- Weill Cornell Medical College, New York, NY
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Gray KD, Ullmann TM, Elmously A, Beninato T, Fahey TJ, Pomp A, Zarnegar R, Afaneh C. Treatment Utilization and Socioeconomic Disparities in the Surgical Management of Gastroparesis. J Gastrointest Surg 2020; 24:1795-1801. [PMID: 31292891 DOI: 10.1007/s11605-019-04294-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Accepted: 06/03/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND Gastroparesis is an end-organ sequela of diabetes. We evaluated the roles of race and socioeconomic status in hospitalization rates and utilization of surgical treatments in these patients. METHODS Data was extracted from the National Inpatient Sample (NIS) between the years 2012 and 2014, and any discharge diagnosis of gastroparesis (536.3) was included. Gastrostomy, jejunostomy, and total parenteral nutrition were considered nutritional support procedures, and procedures aimed at improving motility were considered definitive disease-specific procedures: pyloroplasty, endoscopic pyloric dilation, gastric pacemaker placement, and gastrectomy. RESULTS There were 747,500 hospitalizations reporting a discharge diagnosis of gastroparesis. On multivariable analysis, black race (OR 1.93, 95% CI 1.89-1.98; p < 0.001) and Medicaid insurance (OR 1.46, 95% CI 1.42-1.50; p < 0.001) were the strongest socioeconomic risk factors for hospitalization due to gastroparesis. Patients in urban teaching institutions were most likely to undergo a surgical intervention for gastroparesis (5.53% of patients versus 3.94% of patients treated in urban non-teaching hospitals and 2.38% of patients in rural hospitals; p < 0.001). Uninsured patients were less than half as likely to receive treatment compared to those with private insurance (OR 0.41, 95% CI 0.34-0.48; p < 0.001), and black patients had an OR 0.75 (95% CI 0.69-0.81; p < 0.001) for receiving treatment. Urban teaching hospitals had a twofold higher likelihood of intervention (OR 2.12, 95% CI 1.84-2.44; p < 0.001). CONCLUSIONS Marked racial and economic disparities exist in surgical distribution of care for gastroparesis, potentially driven by differences in utilization of care.
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Affiliation(s)
- Katherine D Gray
- Department of Surgery, New York Presbyterian Hospital - Weill Cornell Medicine, 525 East 68th St, Box 294, New York, NY, 10065, USA
| | - Timothy M Ullmann
- Department of Surgery, New York Presbyterian Hospital - Weill Cornell Medicine, 525 East 68th St, Box 294, New York, NY, 10065, USA
| | - Adham Elmously
- Department of Surgery, New York Presbyterian Hospital - Weill Cornell Medicine, 525 East 68th St, Box 294, New York, NY, 10065, USA
| | - Toni Beninato
- Department of Surgery, New York Presbyterian Hospital - Weill Cornell Medicine, 525 East 68th St, Box 294, New York, NY, 10065, USA
| | - Thomas J Fahey
- Department of Surgery, New York Presbyterian Hospital - Weill Cornell Medicine, 525 East 68th St, Box 294, New York, NY, 10065, USA
| | - Alfons Pomp
- Department of Surgery, New York Presbyterian Hospital - Weill Cornell Medicine, 525 East 68th St, Box 294, New York, NY, 10065, USA
| | - Rasa Zarnegar
- Department of Surgery, New York Presbyterian Hospital - Weill Cornell Medicine, 525 East 68th St, Box 294, New York, NY, 10065, USA
| | - Cheguevara Afaneh
- Department of Surgery, New York Presbyterian Hospital - Weill Cornell Medicine, 525 East 68th St, Box 294, New York, NY, 10065, USA.
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Stefanova D, Ullmann TM, Limberg J, Moore M, Beninato T, Zarnegar R, Fahey TJ, Finnerty BM. Risk Factors for Prolonged Length of Stay and Readmission After Parathyroidectomy for Renal Secondary Hyperparathyroidism. World J Surg 2020; 44:3751-3760. [PMID: 32737558 DOI: 10.1007/s00268-020-05711-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/18/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Population-based analyses of 30-day outcomes after parathyroidectomy for renal secondary hyperparathyroidism are limited. We sought to identify risk factors associated with prolonged length of stay (LOS) and readmission in this patient population. METHODS Patients with secondary hyperparathyroidism who underwent parathyroidectomy were reviewed in the ACS-NSQIP database (2011-2016). Patients were identified by ICD codes specific to secondary hyperparathyroidism of renal origin and the ACS-NSQIP variable for current preoperative dialysis. Multivariable logistic regression was used to identify independent factors associated with prolonged LOS and 30-day readmission after parathyroidectomy. RESULTS The cohort included 1846 patients with secondary hyperparathyroidism on dialysis who underwent parathyroidectomy. There were 416 (22.5%) patients classified under the prolonged LOS group. On multivariable analysis, factors associated with prolonged LOS included elevated preoperative alkaline phosphatase [OR 3.13 (95%-CI 2.09-4.70), p < 0.001], decreased preoperative hematocrit [OR 1.83 (95%-CI 1.25-2.68), p = 0.002], unplanned reoperation (OR 5.02 [95%-CI 2.22-11.3], p < 0.001) and any postoperative complication [OR 6.12 (95%-CI 3.31-11.3), p < 0.001]. The overall 30-day readmission rate was 15.0%. Hypocalcemia and hungry bone syndrome accounted for 47.0% (n = 93/198) of readmissions. On multivariable analysis, patients with a history of hypertension and those undergoing unplanned reoperation were at risk of readmission [2.16 (95%-CI 1.21-3.87), p = 0.009, and 2.40 (95%-CI 1.15-5.02), p = 0.020, respectively], whereas reoperative parathyroidectomy was inversely associated with readmission (OR 0.24, 95%-CI 0.07-0.80, p = 0.021). CONCLUSION In patients undergoing parathyroidectomy for renal secondary hyperparathyroidism, several readily available preoperative biochemical markers, including those of increased bone turnover and anemia, are associated with prolonged postoperative LOS. Unplanned reoperation was predictive of both increased LOS and readmission.
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Affiliation(s)
- Dessislava Stefanova
- Department of Surgery, Weill Cornell Medical College, NewYork-Presbyterian Hospital, 525 E 68th Street, Suite F-838, New York, NY, 10065, USA
| | - Timothy M Ullmann
- Department of Surgery, Weill Cornell Medical College, NewYork-Presbyterian Hospital, 525 E 68th Street, Suite F-838, New York, NY, 10065, USA
| | - Jessica Limberg
- Department of Surgery, Weill Cornell Medical College, NewYork-Presbyterian Hospital, 525 E 68th Street, Suite F-838, New York, NY, 10065, USA
| | - Maureen Moore
- Department of Surgery, Weill Cornell Medical College, NewYork-Presbyterian Hospital, 525 E 68th Street, Suite F-838, New York, NY, 10065, USA
| | - Toni Beninato
- Department of Surgery, Weill Cornell Medical College, NewYork-Presbyterian Hospital, 525 E 68th Street, Suite F-838, New York, NY, 10065, USA
| | - Rasa Zarnegar
- Department of Surgery, Weill Cornell Medical College, NewYork-Presbyterian Hospital, 525 E 68th Street, Suite F-838, New York, NY, 10065, USA
| | - Thomas J Fahey
- Department of Surgery, Weill Cornell Medical College, NewYork-Presbyterian Hospital, 525 E 68th Street, Suite F-838, New York, NY, 10065, USA
| | - Brendan M Finnerty
- Department of Surgery, Weill Cornell Medical College, NewYork-Presbyterian Hospital, 525 E 68th Street, Suite F-838, New York, NY, 10065, USA.
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Limberg J, Stefanova D, Ullmann TM, Thiesmeyer JW, Bains S, Beninato T, Zarnegar R, Fahey TJ, Finnerty BM. The Use and Benefit of Adjuvant Radiotherapy in Parathyroid Carcinoma: A National Cancer Database Analysis. Ann Surg Oncol 2020; 28:502-511. [PMID: 32661850 PMCID: PMC7357448 DOI: 10.1245/s10434-020-08825-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [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: 04/16/2020] [Accepted: 06/21/2020] [Indexed: 12/21/2022]
Abstract
Background The routine use of external beam radiotherapy (EBRT) is not recommended for parathyroid carcinoma (PC). However, case series have demonstrated a potential benefit in preventing local recurrence with EBRT. We aimed to characterize the patient population treated with EBRT and identify any impact of EBRT on overall survival (OS) in parathyroid carcinoma. Methods Patients who underwent surgery for PC from 2004 to 2016 were identified from the National Cancer Database. Clinicopathologic variables and OS were compared between patients based on treatment with EBRT. Multivariable logistic and Cox regression models were performed with propensity scores and inverse-probability-weighting (IPW) adjustment to reduce treatment-selection bias in the OS analysis. Results A total of 885 patients met the inclusion criteria, with 126 (14.2%) undergoing EBRT. Demographics were similar between the two cohorts (EBRT vs. no EBRT). However, patients treated with EBRT had a higher frequency of regionally extensive disease, nodal metastases, and residual microscopic disease (all p < 0.05). On multivariable analysis, Black race, regional tumor extension, nodal metastasis, and treatment at an urban facility were independently associated with EBRT. The 5-year OS was 85.3% with a median follow-up of 60.8 months. EBRT was not associated with a difference in OS in crude, multivariable, or IPW models. More importantly, 10.5% of patients with completely resected localized disease (M0, N0 or Nx) underwent EBRT without a benefit in OS (p = 0.183). Conclusions EBRT is not associated with any survival benefit in the treatment of PC. Therefore, it may be overutilized, particularly in patients with localized disease and complete surgical resection.
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Affiliation(s)
- Jessica Limberg
- Department of Surgery, NewYork-Presbyterian Hospital, Weill Cornell Medical College, New York, NY, USA.
| | - Dessislava Stefanova
- Department of Surgery, NewYork-Presbyterian Hospital, Weill Cornell Medical College, New York, NY, USA
| | - Timothy M Ullmann
- Department of Surgery, NewYork-Presbyterian Hospital, Weill Cornell Medical College, New York, NY, USA
| | - Jessica W Thiesmeyer
- Department of Surgery, NewYork-Presbyterian Hospital, Weill Cornell Medical College, New York, NY, USA
| | - Sarina Bains
- Department of Surgery, NewYork-Presbyterian Hospital, Weill Cornell Medical College, New York, NY, USA
| | - Toni Beninato
- Department of Surgery, NewYork-Presbyterian Hospital, Weill Cornell Medical College, New York, NY, USA
| | - Rasa Zarnegar
- Department of Surgery, NewYork-Presbyterian Hospital, Weill Cornell Medical College, New York, NY, USA
| | - Thomas J Fahey
- Department of Surgery, NewYork-Presbyterian Hospital, Weill Cornell Medical College, New York, NY, USA
| | - Brendan M Finnerty
- Department of Surgery, NewYork-Presbyterian Hospital, Weill Cornell Medical College, New York, NY, USA
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Stefanova DI, Limberg JN, Ullmann TM, Liu M, Thiesmeyer JW, Beninato T, Finnerty BM, Schnoll-Sussman FH, Katz PO, Fahey TJ, Zarnegar R. Quantifying Factors Essential to the Integrity of the Esophagogastric Junction During Antireflux Procedures. Ann Surg 2020; 272:488-494. [DOI: 10.1097/sla.0000000000004202] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Limberg J, Stefanova D, Ullmann TM, Thiesmeyer JW, Buicko JL, Finnerty BM, Zarnegar R, Fahey TJ, Beninato T. Not all laparoscopic adrenalectomies are equal: analysis of postoperative outcomes based on tumor functionality. Surg Endosc 2020; 35:2601-2606. [PMID: 32495185 DOI: 10.1007/s00464-020-07678-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 05/27/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Laparoscopic adrenalectomy is known to have a low complication rate; however, the influence of functional tumor subtype on postoperative outcomes is not well defined. METHODS Patients undergoing laparoscopic adrenalectomy for benign adrenal tumors between 2009 and 2017 were selected from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. Patient demographics, postoperative outcomes, and length of stay were compared between tumor subtypes. RESULTS A total of 3946 patients underwent a laparoscopic adrenalectomy during the study period; 3214 (81.5%) were performed for non-functional adenomas, and 732 (18.6%) for functional tumors-467 (64%) aldosteronomas, 184 (25%) cortisol-producing adenomas, and 81 (11%) pheochromocytomas. The risk of any complication was highest for patients with Cushing's (6.5%) and lowest with Conn's syndrome (1.1%) compared to other lesions (3.7% pheochromocytoma, 5.3% adenoma, p < 0.001). Among the patients with functional tumors, those with cortisol-producing adenomas had the highest rates of both deep surgical site infection (1.6%, p = 0.026) and urinary tract infection (2.2%, p = 0.029), whereas myocardial infarction was most prevalent in patients with pheochromocytoma (2.5%, p = 0.012). When adjusted for demographic differences, BMI, and comorbidity scores, no tumor type was associated with increased complication rate; instead aldosteronoma (vs. benign adenoma) was independently predictive of fewer adverse events [0.3 (95% CI 0.1-0.7), p = 0.004] and a shorter length of hospital stay [0.6 (95% CI 0.4-0.8), p = 0.001]. The overall mortality rate was low at 0.4%, although significantly higher in Cushing's patients (2.2%, p = 0.015). CONCLUSIONS Laparoscopic adrenalectomy is a safe operation with low mortality and complication rates. However, postoperative risks differ between tumor subtype, so patients should be counseled accordingly.
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Affiliation(s)
- Jessica Limberg
- Department of Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, 1300 York Ave, New York, NY, USA.
| | - Dessislava Stefanova
- Department of Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, 1300 York Ave, New York, NY, USA
| | - Timothy M Ullmann
- Department of Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, 1300 York Ave, New York, NY, USA
| | - Jessica W Thiesmeyer
- Department of Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, 1300 York Ave, New York, NY, USA
| | - Jessica L Buicko
- Department of Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, 1300 York Ave, New York, NY, USA
| | - Brendan M Finnerty
- Department of Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, 1300 York Ave, New York, NY, USA
| | - Rasa Zarnegar
- Department of Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, 1300 York Ave, New York, NY, USA
| | - Thomas J Fahey
- Department of Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, 1300 York Ave, New York, NY, USA
| | - Toni Beninato
- Department of Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, 1300 York Ave, New York, NY, USA
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Thiesmeyer JW, Ullmann TM, Greenberg J, Williams NT, Limberg J, Stefanova D, Beninato T, Finnerty BM, Vignaud T, Leclerc J, Fahey TJ, Mirallie E, Brunaud L, Zarnegar R. Hypertension resolution after adrenalectomy for primary hyperaldosteronism: Which is the best predictive model? Surgery 2020; 169:133-137. [PMID: 32507297 DOI: 10.1016/j.surg.2020.04.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 04/08/2020] [Accepted: 04/09/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND We aimed to compare the predictive performance of three distinct clinical models purported to predict the resolution of aldosteronoma-associated hypertension after adrenalectomy. METHODS A tri-institutional database of aldosteronoma patients who underwent adrenalectomy between 2004 and 2019 was retrospectively reviewed. The three models of interest incorporate various preoperative clinical factors, such as age and sex. The predictive accuracy, as measured by area under the curve of receiver operator characteristic, was estimated. Receiver operator characteristic was evaluated across the whole cohort, then stratified by treatment location. RESULTS A total of 200 patients were included (91 American, 109 French). The clinicodemographic variables between groups were similar; the French cohort had a lower mean body mass index (P = .02). The overall complete clinical resolution of hypertension after adrenalectomy for the entire data set was 45.5% (n = 91). The regression coefficients in the Utsumi et al (2014) Japanese model produced a superior overall area under the curve (0.78, 95% confidence interval [CI] [0.71-0.84]). This model also performed best when the cohort was stratified by treatment location (French area under the curve = 0.74, 95% CI [0.64-0.83], US area under the curve = 0.82, 95% CI [0.72-0.91]). CONCLUSION When comparing three predictive models of aldosteronoma-associated hypertension resolution after adrenalectomy, the Utsumi et al model demonstrated the highest predictive validity across all cohorts. Counseling based on this model regarding probability of cure is recommended.
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Affiliation(s)
- Jessica W Thiesmeyer
- Department of Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, NY, USA
| | - Timothy M Ullmann
- Department of Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, NY, USA
| | - Jacques Greenberg
- Department of Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, NY, USA
| | - Nicholas T Williams
- Division of Biostatistics and Epidemiology, Department of Healthcare Policy & Research, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, NY, USA
| | - Jessica Limberg
- Department of Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, NY, USA
| | - Dessislava Stefanova
- Department of Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, NY, USA
| | - Toni Beninato
- Department of Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, NY, USA
| | - Brendan M Finnerty
- Department of Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, NY, USA
| | - Timothée Vignaud
- Department of Surgery, Nantes University Hospital, Nantes, France
| | - Julie Leclerc
- Department of Surgery, Nancy University Hospital, Nancy, France
| | - Thomas J Fahey
- Department of Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, NY, USA
| | - Eric Mirallie
- Department of Surgery, Nantes University Hospital, Nantes, France
| | - Laurent Brunaud
- Department of Surgery, Nancy University Hospital, Nancy, France
| | - Rasa Zarnegar
- Department of Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, NY, USA.
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Thiesmeyer JW, Limberg J, Ullmann TM, Stefanova D, Bains S, Beninato T, Zarnegar R, Fahey TJ, Finnerty BM. Impact of multikinase inhibitor approval on survival and physician practice patterns in advanced or metastatic medullary thyroid carcinoma. Surgery 2020; 169:50-57. [PMID: 32487357 DOI: 10.1016/j.surg.2020.03.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 03/26/2020] [Accepted: 03/30/2020] [Indexed: 11/16/2022]
Abstract
BACKGROUND This study aimed to identify whether multikinase inhibitor approval for medullary thyroid carcinoma was associated with changes in systemic therapy administration or overall survival. METHODS The National Cancer Database was queried for advanced medullary thyroid carcinoma patients. Clinicopathologic comparisons were performed between premultikinase inhibitor (2005-2010) and postmultikinase inhibitor (2011-2016) approval groups. Multivariable logistic and Cox regressions were applied to assess predictors of systemic therapy and overall survival. RESULTS A total of 2,891 patients met the criteria. Postmultikinase inhibitor patients were less likely to undergo radiation (P = .02) and more likely to receive systemic therapy (P = .01). The rate of systemic therapy nearly doubled from 2010 to 2011 (8.1% to 13.8%, P = .04); it subsequently declined back toward preapproval rates. Before multikinase inhibitor approval, only metastases and radiation were associated with systemic therapy (P < .05). After multikinase inhibitor approval, patients with small tumors, extrathyroidal extension, positive lymph nodes, or metastases were more likely to receive systemic therapy (P < .05). The 5-year overall survival between pre and postmultikinase inhibitor groups, for those who received systemic therapy (n = 288), was similar (P = .58), even when restricted to patients with distant metastases (P = .55). CONCLUSION After approval of multikinase inhibitors, physicians broadened the criteria for systemic therapy. Prescription rates have since declined. Given the toxicities of these drugs and no improvement in overall survival since introduction, selective utilization may be warranted.
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Affiliation(s)
- Jessica W Thiesmeyer
- Department of Surgery, Weill Cornell Medical College, New York Presbyterian Hospital, NY.
| | - Jessica Limberg
- Department of Surgery, Weill Cornell Medical College, New York Presbyterian Hospital, NY
| | - Timothy M Ullmann
- Department of Surgery, Weill Cornell Medical College, New York Presbyterian Hospital, NY
| | - Dessislava Stefanova
- Department of Surgery, Weill Cornell Medical College, New York Presbyterian Hospital, NY
| | - Sarina Bains
- Department of Surgery, Weill Cornell Medical College, New York Presbyterian Hospital, NY
| | - Toni Beninato
- Department of Surgery, Weill Cornell Medical College, New York Presbyterian Hospital, NY
| | - Rasa Zarnegar
- Department of Surgery, Weill Cornell Medical College, New York Presbyterian Hospital, NY
| | - Thomas J Fahey
- Department of Surgery, Weill Cornell Medical College, New York Presbyterian Hospital, NY
| | - Brendan M Finnerty
- Department of Surgery, Weill Cornell Medical College, New York Presbyterian Hospital, NY
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Ullmann TM, Gray KD, Limberg J, Stefanova D, Moore MD, Buicko J, Finnerty B, Zarnegar R, Fahey TJ, Beninato T. Insurance Status Is Associated with Extent of Treatment for Patients with Papillary Thyroid Carcinoma. Thyroid 2019; 29:1784-1791. [PMID: 31502525 DOI: 10.1089/thy.2019.0245] [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] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Background: Health insurance has been shown to be a key determinant in cancer care, but it is unknown as to what extent insurance status affects treatments provided to papillary thyroid cancer (PTC) patients. We hypothesized that insured patients with PTC would have lower-risk tumors at diagnosis and be more likely to receive adjuvant therapies at follow-up. Methods: The American College of Surgeons' National Cancer Database was queried to identify all patients diagnosed with PTCs >2 mm in size from 2004 to 2015. Patients were grouped according to insurance status, and frequency of high-risk features and microcarcinoma at diagnosis were assessed. Multivariable analyses were used to identify independent predictors of more extensive treatment: total thyroidectomy (vs. lobectomy), lymphadenectomy, and radioactive iodine (RAI). Results: There were 190,298 patients who met inclusion criteria; the majority of patients had private insurance (139,675 [73.4%]) and were female (144,824 [76.1%]). Uninsured patients, as compared with privately insured patients, had higher rates of extrathyroidal extension of their cancers (25.2% vs. 18.9%, p < 0.001), lymphovascular invasion (16.2% vs. 12.0%, p < 0.001), and positive margins on final pathology (16.0% vs. 12.2%, p < 0.001). Conversely, patients with private insurance were 51% more likely to have microcarcinomas at diagnosis (odds ratio [OR] = 1.51 [confidence interval {CI} 1.35-1.68], p < 0.001) than uninsured patients, controlling for demographic, socioeconomic, and hospital factors. Private insurance was an independent predictor for treatment with total thyroidectomy (OR = 1.18 [CI 1.01-1.37], p < 0.05), formal lymphadenectomy (OR = 1.22 [CI 1.09-1.36], p < 0.001), and adjuvant RAI therapy (OR = 1.35 [CI 1.18-1.54], p < 0.001) as compared with no insurance, adjusted for socioeconomic, demographic, hospital, and oncologic differences. Patients with Medicare or Medicaid were no more likely to receive these treatments than uninsured patients. Conclusions: Privately insured patients have less aggressive PTCs at diagnosis, and they are more likely to be treated with total thyroidectomy, lymphadenectomy, and RAI compared with uninsured patients. Clinicians should take caution to ensure proper referral and follow-up for under- and uninsured patients to reduce disparities in treatment.
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Affiliation(s)
- Timothy M Ullmann
- Department of Surgery, New York Presbyterian Hospital-Weill Cornell Medical Center, New York, New York
| | - Katherine D Gray
- Department of Surgery, New York Presbyterian Hospital-Weill Cornell Medical Center, New York, New York
| | - Jessica Limberg
- Department of Surgery, New York Presbyterian Hospital-Weill Cornell Medical Center, New York, New York
| | - Dessislava Stefanova
- Department of Surgery, New York Presbyterian Hospital-Weill Cornell Medical Center, New York, New York
| | - Maureen D Moore
- Department of Surgery, New York Presbyterian Hospital-Weill Cornell Medical Center, New York, New York
| | - Jessica Buicko
- Department of Surgery, New York Presbyterian Hospital-Weill Cornell Medical Center, New York, New York
| | - Brendan Finnerty
- Department of Surgery, New York Presbyterian Hospital-Weill Cornell Medical Center, New York, New York
| | - Rasa Zarnegar
- Department of Surgery, New York Presbyterian Hospital-Weill Cornell Medical Center, New York, New York
| | - Thomas J Fahey
- Department of Surgery, New York Presbyterian Hospital-Weill Cornell Medical Center, New York, New York
| | - Toni Beninato
- Department of Surgery, New York Presbyterian Hospital-Weill Cornell Medical Center, New York, New York
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Ullmann TM, Liang H, Moore MD, Al-Jamed I, Gray KD, Limberg J, Stefanova D, Buicko JL, Finnerty B, Beninato T, Zarnegar R, Min IM, Fahey TJ. Dual inhibition of BRAF and MEK increases expression of sodium iodide symporter in patient-derived papillary thyroid cancer cells in vitro. Surgery 2019; 167:56-63. [PMID: 31585718 DOI: 10.1016/j.surg.2019.04.076] [Citation(s) in RCA: 9] [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: 01/31/2019] [Revised: 03/28/2019] [Accepted: 04/16/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND The majority of papillary thyroid cancers are driven by acquired mutations typically in the BRAF or RAS genes that aberrantly activate the mitogen-activated protein kinase pathway. This process leads to malignant transformation, dedifferentiation, and a decrease in the expression of the sodium-iodide symporter (NIS; SLC5A5), which results in resistance to radioactive iodine therapy. We sought to determine whether inhibition of aberrant mitogen-activated protein kinase-signaling can restore NIS expression. METHODS We prospectively developed cultures of papillary thyroid cancers derived from operative specimens and applied drug treatments for 24 hours. Samples were genotyped to identify BRAF and RAS mutations. We performed quantitative PCR to measure NIS expression after treatment. RESULTS We evaluated 24 patient papillary thyroid cancer specimens; BRAFV600E mutations were identified in 18 out of 24 (75.0%); 1 patient tumor had an HRAS mutation, and the remaining 5 were BRAF and RAS wildtype. Dual treatment with dabrafenib and trametinib increased NIS expression (mean fold change 4.01 ± 2.04, P < .001), and single treatment with dabrafenib had no effect (mean fold change 0.98 ± 0.42, P = .84). Tumor samples that had above-median NIS expression increases came from younger patients (39 vs 63 years, P < .05). CONCLUSION Dual treatment with BRAF and MEK inhibitors upregulated NIS expression, suggesting that this treatment regimen may increase tumor iodine uptake. The effect was greatest in tumor cells from younger patients.
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Affiliation(s)
- Timothy M Ullmann
- Department of Surgery, New York Presbyterian Hospital-Weill Cornell Medical Center, New York
| | - Heng Liang
- Department of Surgery, New York Presbyterian Hospital-Weill Cornell Medical Center, New York
| | - Maureen D Moore
- Department of Surgery, New York Presbyterian Hospital-Weill Cornell Medical Center, New York
| | - Isra Al-Jamed
- Department of Surgery, New York Presbyterian Hospital-Weill Cornell Medical Center, New York
| | - Katherine D Gray
- Department of Surgery, New York Presbyterian Hospital-Weill Cornell Medical Center, New York
| | - Jessica Limberg
- Department of Surgery, New York Presbyterian Hospital-Weill Cornell Medical Center, New York
| | - Dessislava Stefanova
- Department of Surgery, New York Presbyterian Hospital-Weill Cornell Medical Center, New York
| | - Jessica L Buicko
- Department of Surgery, New York Presbyterian Hospital-Weill Cornell Medical Center, New York
| | - Brendan Finnerty
- Department of Surgery, New York Presbyterian Hospital-Weill Cornell Medical Center, New York
| | - Toni Beninato
- Department of Surgery, New York Presbyterian Hospital-Weill Cornell Medical Center, New York
| | - Rasa Zarnegar
- Department of Surgery, New York Presbyterian Hospital-Weill Cornell Medical Center, New York
| | - Irene M Min
- Department of Surgery, New York Presbyterian Hospital-Weill Cornell Medical Center, New York
| | - Thomas J Fahey
- Department of Surgery, New York Presbyterian Hospital-Weill Cornell Medical Center, New York.
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Moore MD, Agrusa C, Ullmann TM, Buicko JL, Beninato T, Zarnegar R, Fahey TJ, Finnerty BM. Identifying Risk Factors for Venous Thromboembolism after Adrenalectomy for Primary Adrenal Malignancy. J Am Coll Surg 2019. [DOI: 10.1016/j.jamcollsurg.2019.08.183] [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: 10/25/2022]
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Limberg J, Ullmann TM, Gray KD, Stefanova D, Zarnegar R, Li J, Fahey TJ, Beninato T. Laparoscopic Adrenalectomy Has the Same Operative Risk as Routine Laparoscopic Cholecystectomy. J Surg Res 2019; 241:228-234. [DOI: 10.1016/j.jss.2019.03.042] [Citation(s) in RCA: 5] [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: 12/07/2018] [Revised: 03/04/2019] [Accepted: 03/22/2019] [Indexed: 10/26/2022]
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Ullmann TM, Gray KD, Stefanova D, Limberg J, Buicko JL, Finnerty B, Zarnegar R, Fahey TJ, Beninato T. The 2015 American Thyroid Association guidelines are associated with an increasing rate of hemithyroidectomy for thyroid cancer. Surgery 2019; 166:349-355. [PMID: 31056200 DOI: 10.1016/j.surg.2019.03.002] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [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: 12/18/2018] [Revised: 02/27/2019] [Accepted: 03/03/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND In an attempt to prevent overly aggressive treatment of low-risk thyroid cancers, the American Thyroid Association changed guideline recommendations in late 2015 to state that either hemithyroidectomy or total thyroidectomy are acceptable operations for these patients. We hypothesized that surgeons would increasingly perform hemithyroidectomy after the release of these guidelines. METHODS The database of the National Surgery Quality Improvement Program was queried to identify all patients with thyroid cancer who were undergoing thyroidectomy between 2009 and 2017. Patients treated before the release of the 2015 American Thyroid Association guidelines were compared with those treated afterward. Temporal trends in operative rates were assessed quarterly using interrupted time series analyses. RESULTS A total of 35,291 patients were included in the study. Of those, 26,882 (76.2%) were female and 25,193 (71.3%) were white. After the release of the American Thyroid Association guidelines, there was an increase in hemithyroidectomy rate for patients with cancer from 17.3% to 22.0% (P < .001). Interrupted time series analysis controlling for patient factors demonstrated that quarterly growth in the hemithyroidectomy rate accelerated almost 10-fold (P < .001) after publication of the revised guidelines. Of note, there was no corresponding increase in the completion thyroidectomy rate (8.3% versus 7.9%, respectively, P = .213). Patients treated with hemithyroidectomy were more likely to be managed as outpatients (70.8% versus 57.1%, P < .001), had fewer surgical site infections (0.3% versus 0.5%, P = .050), and had fewer unplanned reintubations (0.2% versus 0.4%, P = .005). CONCLUSION In hospitals participating in the National Surgery Quality Improvement Program, the hemithyroidectomy rate increased significantly after the release of the 2015 American Thyroid Association guidelines. Surgeons at hospitals that participate in the National Surgery Quality Improvement Program may be changing practice patterns in response to these guidelines.
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Affiliation(s)
- Timothy M Ullmann
- Department of Surgery, Weill Cornell Medical College, NewYork-Presbyterian Hospital, New York, NY
| | - Katherine D Gray
- Department of Surgery, Weill Cornell Medical College, NewYork-Presbyterian Hospital, New York, NY
| | - Dessislava Stefanova
- Department of Surgery, Weill Cornell Medical College, NewYork-Presbyterian Hospital, New York, NY
| | - Jessica Limberg
- Department of Surgery, Weill Cornell Medical College, NewYork-Presbyterian Hospital, New York, NY
| | - Jessica L Buicko
- Department of Surgery, Weill Cornell Medical College, NewYork-Presbyterian Hospital, New York, NY
| | - Brendan Finnerty
- Department of Surgery, Weill Cornell Medical College, NewYork-Presbyterian Hospital, New York, NY
| | - Rasa Zarnegar
- Department of Surgery, Weill Cornell Medical College, NewYork-Presbyterian Hospital, New York, NY
| | - Thomas J Fahey
- Department of Surgery, Weill Cornell Medical College, NewYork-Presbyterian Hospital, New York, NY
| | - Toni Beninato
- Department of Surgery, Weill Cornell Medical College, NewYork-Presbyterian Hospital, New York, NY.
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Gray KD, Bannani S, Caillard C, Amanat S, Ullmann TM, Romanov P, Brunaud L, Beninato T, Fahey TJ, Mirallie E, Zarnegar R. High-dose radioactive iodine therapy is associated with decreased risk of recurrence in high-risk papillary thyroid cancer. Surgery 2019; 165:37-43. [PMID: 30274732 DOI: 10.1016/j.surg.2018.04.059] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Revised: 04/23/2018] [Accepted: 04/26/2018] [Indexed: 12/18/2022]
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Li W, Xia S, Aronova A, Min IM, Verma A, Scognamiglio T, Gray KD, Ullmann TM, Liang H, Moore MD, Elemento O, Zarnegar R, Fahey TJ. CHL1 expression differentiates Hürthle cell carcinoma from benign Hürthle cell nodules. J Surg Oncol 2018; 118:1042-1049. [PMID: 30311656 DOI: 10.1002/jso.25214] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Revised: 07/12/2018] [Accepted: 07/30/2018] [Indexed: 12/17/2022]
Abstract
BACKGROUND AND OBJECTIVES Hürthle cell carcinoma (HCC) is an unusual and relatively rare type of differentiated thyroid cancer. Currently, cytologic analysis of fine-needle aspiration biopsy is limited in distinguishing benign Hürthle cell neoplasms from malignant ones. The aim of this study was to determine whether differences in the expression of specific genes could differentiate HCC from benign Hürthle cell nodules by evaluating differential gene expression in Hürthle cell disease. METHODS Eighteen benign Hürthle cell nodules and seven HCC samples were analyzed by whole-transcriptome sequencing. Bioinformatics analysis was carried out to identify candidate differentially expressed genes. Expression of these candidate genes was re-examined by quantitative real-time polymerase chain reaction (qRT-PCR). Protein expression was quantified by immunohistochemistry. RESULTS Close homolog of L1 (CHL1) was identified as overexpressed in HCC. CHL1 was found to have greater than 15-fold higher expression in fragments per kilobase million in HCC compared with benign Hurthle cell tumors. This was confirmed by qRT-PCR. Moreover, the immunoreactivity score of the CHL1 protein was significantly higher in HCC compared with benign Hürthle cell nodules. CONCLUSIONS CHL1 expression may represent a novel and useful prognostic biomarker to distinguish HCC from benign Hürthle cell disease.
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Affiliation(s)
- Wei Li
- Department of Nuclear Medicine, Tianjin Medical University General Hospital, Tianjin, China
| | - Shujun Xia
- Ultrasound Department, Rui Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Anna Aronova
- Department of Surgery, New York Presbyterian Hospital-Weill Cornell Medical College, New York, New York
| | - Irene M Min
- Department of Surgery, New York Presbyterian Hospital-Weill Cornell Medical College, New York, New York
| | - Akanksha Verma
- Department of Physiology and Biophysics, Institute for Precision Medicine, Institute for Computational Biomedicine, Weill Cornell Medical College, New York, New York
| | - Theresa Scognamiglio
- Department of Pathology, New York Presbyterian Hospital-Weill Cornell Medical College, New York, New York
| | - Katherine D Gray
- Department of Surgery, New York Presbyterian Hospital-Weill Cornell Medical College, New York, New York
| | - Timothy M Ullmann
- Department of Surgery, New York Presbyterian Hospital-Weill Cornell Medical College, New York, New York
| | - Heng Liang
- Department of Surgery, New York Presbyterian Hospital-Weill Cornell Medical College, New York, New York
| | - Maureen D Moore
- Department of Surgery, New York Presbyterian Hospital-Weill Cornell Medical College, New York, New York
| | - Olivier Elemento
- Department of Physiology and Biophysics, Institute for Precision Medicine, Institute for Computational Biomedicine, Weill Cornell Medical College, New York, New York
| | - Rasa Zarnegar
- Department of Surgery, New York Presbyterian Hospital-Weill Cornell Medical College, New York, New York
| | - Thomas J Fahey
- Department of Surgery, New York Presbyterian Hospital-Weill Cornell Medical College, New York, New York
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Gray KD, Ullmann TM, Finnerty BM, Fahey TJ, Zarnegar R, Beninato T. Laparoscopic Adrenalectomy Is Safe in Elderly Patients. J Am Coll Surg 2018. [DOI: 10.1016/j.jamcollsurg.2018.08.320] [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: 10/28/2022]
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Ullmann TM, Gray KD, Moore MD, Zarnegar R, Fahey TJ. Current controversies and future directions in the diagnosis and management of differentiated thyroid cancers. Gland Surg 2018; 7:473-486. [PMID: 30505769 DOI: 10.21037/gs.2017.09.08] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Despite the development of novel diagnostic, surgical, and chemotherapeutic approaches to differentiated thyroid cancers (DTCs), the diagnosis and management of these tumors remains controversial. The most recent American Thyroid Association (ATA) guidelines, released in 2015, reflect a recent shift towards less aggressive management for patients with DTCs. However, many clinicians have expressed concern that more conservative management will put patients at risk for disease recurrence and metastasis. In particular, the management of indeterminate nodules on fine needle aspiration (with special attention to genetic and epigenetic markers of malignancy), the extent of surgery for known differentiated cancers, the role of adjuvant radioactive iodine (RAI) therapy, and novel targeted treatments with tyrosine kinase inhibitors (TKIs) represent current areas of uncertainty and opportunities for future research. In this review, we examine the current state of the art in these areas, and address some of the questions that remain.
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Affiliation(s)
- Timothy M Ullmann
- Department of Surgery, New York Presbyterian Hospital, Weill Cornell Medicine, New York, NY, USA
| | - Katherine D Gray
- Department of Surgery, New York Presbyterian Hospital, Weill Cornell Medicine, New York, NY, USA
| | - Maureen D Moore
- Department of Surgery, New York Presbyterian Hospital, Weill Cornell Medicine, New York, NY, USA
| | - Rasa Zarnegar
- Department of Surgery, New York Presbyterian Hospital, Weill Cornell Medicine, New York, NY, USA
| | - Thomas J Fahey
- Department of Surgery, New York Presbyterian Hospital, Weill Cornell Medicine, New York, NY, USA
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Ullmann TM, Gray KD, Finnerty BM, Zarnegar R, Fahey TJ, Beninato T. Rates of Hemithyroidectomy for Thyroid Cancer After the Release of the 2015 American Thyroid Association Guidelines: Has Our Practice Changed? J Am Coll Surg 2018. [DOI: 10.1016/j.jamcollsurg.2018.07.174] [Citation(s) in RCA: 2] [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] [Indexed: 11/30/2022]
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Finnerty BM, Gray KD, Ullmann TM, Zarnegar R, Fahey TJ, Beninato T. Thyroidectomy for Multinodular Goiter in the Elderly: Age is Just a Number. J Am Coll Surg 2018. [DOI: 10.1016/j.jamcollsurg.2018.08.334] [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: 11/15/2022]
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Elmously A, Gray KD, Ullmann TM, Fahey TJ, Afaneh C, Zarnegar R. Robotic Reoperative Anti-reflux Surgery: Low Perioperative Morbidity and High Symptom Resolution. World J Surg 2018; 42:4014-4021. [DOI: 10.1007/s00268-018-4708-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Tunc-Ozcan E, Ullmann TM, Shukla PK, Redei EE. Low-dose thyroxine attenuates autism-associated adverse effects of fetal alcohol in male offspring's social behavior and hippocampal gene expression. Alcohol Clin Exp Res 2013; 37:1986-95. [PMID: 23763370 PMCID: PMC3805686 DOI: 10.1111/acer.12183] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2012] [Accepted: 04/09/2013] [Indexed: 11/30/2022]
Abstract
BACKGROUND Fetal alcohol spectrum disorder (FASD) is characterized by neurodevelopmental anomalies manifesting in cognitive and behavioral deficits in the offspring with diverse severities. Social behavior is affected in FASD, and these deficits overlap with those of autism spectrum disorder (ASD). Identifying some of the molecular characteristics related to ASD in an animal model of FASD could ultimately provide details on the underlying molecular mechanisms of both disorders that could lead to novel treatments. METHODS Pregnant Sprague-Dawley rats received the following diets: control (C; ad libitum standard laboratory chow), nutritional control pair-fed (PF), ethanol (EtOH), or an EtOH diet supplemented with 0.3, 1.5, or 7.5 mg thyroxine (T4)/l in the diet. Social behavior and memory were tested in the adult offspring. Plasma total T4, free T3 (fT3), and thyroid-stimulating hormone (TSH) levels were measured. Hippocampal expression of Gabrb3, Ube3a, Nr2b, Rasgrf1, and Dio3 were measured by RT-qPCR and protein levels of Mecp2 and Slc25a12 by Western blotting. RESULTS Adult male offspring of EtOH dams showed elevated fT3 and low TSH levels. Adult male, but not female, offspring of EtOH dams exhibited social behavior and memory deficits. Expression of autism candidates, Gabrb3, Ube3a, Mecp2, and Slc25a12, was significantly increased in the hippocampus of male offspring of EtOH dams. Hippocampal Nr2b and Dio3 were also increased, while Rasgrf1 was decreased in the same population. Peripheral thyroid function, social behavioral deficits, and altered expression of the above genes were normalized by simultaneous administration of 0.3 mg/l T4 in the EtOH diet. CONCLUSIONS Our data suggest that social interaction deficits of FASD share molecular mechanism with ASD by showing altered hippocampal expression of several ASD candidate genes. Social interaction deficits as well as the gene expression changes in the offspring of EtOH-consuming dams can be reversed by low dose of thyroid hormone supplementation to the mothers.
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Affiliation(s)
| | | | - Pradeep K. Shukla
- Department of Psychiatry and Behavioral Sciences, The Asher Center, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611
| | - Eva E. Redei
- Department of Psychiatry and Behavioral Sciences, The Asher Center, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611
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Abstract
BACKGROUND Fetal alcohol spectrum disorder (FASD) is a leading cause of nongenetic mental retardation and other neurodevelopmental deficits. Earlier diagnosis of FASD would greatly improve prognosis for individuals and families affected by this disorder. Here, we identify candidate placental biomarkers in an animal model of FASD that recapitulates many aspects of human FASD. METHODS Pregnant Sprague-Dawley (SD) females were assigned to 1 of 3 diet groups on gestation day 8 (G8): Ethanol (E), Pair-fed (PF) or Control (C). E dams received ethanol-containing liquid diet and PF dams received isocaloric liquid diet in an amount that matched the paired E dam's diet consumption the previous day. Control dams received laboratory chow and water ad libitum. Whole placentae from individual fetuses were collected on gestational day 21 (G21) for analyses. Western blotting and quantitative real-time RT-PCR were used to measure protein and mRNA levels of placental iodothyronine deiodinase III (Dio3), thyroid hormone receptor α1 (TRα1), and glucocorticoid receptor (GR). Placental mRNA levels of insulin-like growth factor 2 (Igf-2), pleckstrin homology-like domain family A member 2 (Phlda2), and cyclin-dependent kinase inhibitor 1C (Cdkn1c) were also measured. RESULTS Placental protein and mRNA levels from ethanol (E)-consuming dams showed the following changes: increased Dio3, decreased TRα1, and decreased GR compared to both C and PF dams. Placental mRNA levels of intrauterine growth restriction (IUGR) markers Igf-2, Phlda2, and Cdkn1c were altered similarly in PF and E dams. CONCLUSIONS We propose the specific pattern of increased Dio3 and decreased TRα1 and GR protein levels in the placenta as selective biomarker for intrauterine alcohol exposure.
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Affiliation(s)
- Pradeep K Shukla
- Department of Psychiatry and Behavioral Sciences, The Asher Center, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
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