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Brown T.C.,Section of Endocrine Surgery | Healy J.M.,Section of Endocrine Surgery | Hansson J.H.,Yale University | Quinn C.E.,Section of Endocrine Surgery
Yale Journal of Biology and Medicine | Year: 2014

We describe a patient who presented with multi-system organ failure due to extreme hy-percalcemia (serum calcium 19.8 mg/dL), resulting from primary hyperparathyroidism. He was found to have a 4.8 cm solitary atypical parathyroid adenoma. His course was complicated by complete heart block, acute kidney injury, and significant neurocognitive disturbances. Relevant literature was reviewed and discussed. Hyperparathyroidism-induced hypercalcemic crisis (HIHC†) is a rare presentation of primary hyperparathyroidism and only a small minority of these patients develop significant cardiac and renal complications. In cases of HIHC, a multidisciplinary effort can facilitate rapid treatment of life-threatening hy-percalcemia and definitive treatment by surgical resection. As such, temporary transvenous cardiac pacing and renal replacement therapy can provide a life-saving bridge to definitive parathyroidectomy in cases of HIHC. © 2014, Yale Journal of Biology and Medicine Inc. All rights reserved.


PubMed | Section of Endocrine Surgery and Duke University
Type: | Journal: OncoTargets and therapy | Year: 2016

Hrthle cell carcinoma (HCC) can present either as a minimally invasive or as a widely invasive tumor. HCC generally has a more aggressive clinical behavior compared with the other differentiated thyroid cancers, and it is associated with a higher rate of distant metastases. Minimally invasive HCC demonstrates much less aggressive behavior; lesions <4 cm can be treated with thyroid lobectomy alone, and without radioactive iodine (RAI). HCC has been observed to be less iodine-avid compared with other differentiated thyroid cancers; however, recent data have demonstrated improved survival with RAI use in patients with HCC >2 cm and those with nodal and distant metastases. Patients with localized iodine-resistant disease who are not candidates for a wait-and-watch approach can be treated with localized therapies. Systemic therapy is reserved for patients with progressive, widely metastatic HCC.


Clerici T.,Kantonsspital St Gallen | Kolb W.,Kantonsspital St Gallen | Beutner U.,Kantonsspital St Gallen | Bareck E.,Krankenhaus Wiener Neustadt | And 3 more authors.
British Journal of Surgery | Year: 2010

Background: Follicular thyroid microcarcinomas (mFTCs) of 10 mm or less in size rarely manifest clinically and their clinical significance is controversial. This study assessed their characteristics and incidence, and analysed treatment modalities used for mFTC. Methods: Members of the German Association of Endocrine Surgeons were asked to review patients with mFTC operated on between 1.990 and 2005. Results: Data for 90 patients from 26 institutions were reported. Histopathological slides were available for re-evaluation in 35 patients. Most initial diagnoses had to be revised because of incorrect size assessment or incorrect diagnosis (benign adenoma, papillary thyroid carcinoma (PTC), follicular variant of PTC). The diagnosis of mFTC was confirmed in only four patients. As a result of the incorrect histopathological diagnosis, unnecessary completion thyroidectomy and radioiodine ablation were performed in 17 and 20 patients respectively. The incidence of mFTC was calculated to be 0.12 per million population per year. Conclusion: mFTC is exceptionally rare. Such tumours are overdiagnosed, resulting in unnecessary treatment associated with avoidable morbidity. Histopathological re-evaluation by an experienced pathologist is recommended before embarking on further treatments when a diagnosis of mFTC is made. Copyright © 2010 British Journal of Surgery Society Ltd.


Farahnak P.,Section of Surgery | Farahnak P.,Karolinska Institutet | Larfars G.,Section of Internal Medicine | Larfars G.,Karolinska Institutet | And 4 more authors.
Journal of Clinical Endocrinology and Metabolism | Year: 2011

Context: The extent and clinical significance of cardiovascular (CV) abnormalities associated with mild primary hyperparathyroidism (PHPT) are still matters for discussion. Objective: The main objective of the present study was to evaluate biochemical CV risk markers in PHPT patients before and after parathyroidectomy (PTX) in comparison with controls. Design and Subjects: In a prospective case-control design, 49 patients with PHPT and 49 healthy matched controls were included. Methods: Blood pressure (BP), 25-OH-D, plasminogen activator inhibitor-1 activity, von Willebrand factor antigen, homocysteine, high-sensitivity C-reactive protein, IGF-I, and lipid profile were evaluated at baseline and 15 ± 4 months after PTX. Results: At baseline, the level of 25-OH-D was significantly lower in patients compared with controls (40.1 ± 16.5 vs. 64.6 ± 20.8 nmol/liter, P < 0.001) and increased after PTX (58.9 ± 19.5, P < 0.001). Postoperatively, 25-OH-D was inversely correlated to the PTH level (r = -0.34; P < 0.05). Systolic BP (127.2 ± 17.4 vs. 119.3 ± 12.5mmHg, P < 0.05) and triglyceride (TG; 1.04 ± 0.60 vs. 0.86 ± 0.43 mmol/liter, P < 0.05) were higher in patients compared with controls and decreased slightly in patients after PTX (BP, 124.4 ± 16.8mmHg, and TG, 0.94 ± 0.50 mmol/liter, P < 0.05). Otherwise, there were no intergroup differences in coagulation, inflammatory, metabolic, and lipid status. Conclusions: Except for a lower 25-OH-D level and slightly higher systolic BP and TG levels, patients with mild PHPT without other CV risk factors did not differ from healthy controls as regards biomarkers predicting CV diseases. PTX had an overall positive effect on TG level, BP, and vitamin D status. Copyright © 2011 by The Endocrine Society.


Ruel E.,Metabolism and Nutrition | Thomas S.,Duke University | Dinan M.,Duke Clinical Research Institute | Perkins J.M.,Metabolism and Nutrition | And 4 more authors.
Journal of Clinical Endocrinology and Metabolism | Year: 2015

Context: Papillary thyroid cancer (PTC) is the most common endocrine malignancy. The long-term prognosis is generally excellent. Due to a paucity of data, debate exists regarding the benefit of adjuvant radioactive iodine therapy (RAI) for intermediate-risk patients. Objective: The objective of the study was to examine the impact of RAI on overall survival in intermediate-risk PTC patients. Design/Setting: Adult patients with intermediate-risk PTC who underwent total thyroidectomy with/without RAI in the National Cancer Database, 1998-2006, participated in the study. Patients: Intermediate-risk patients, as defined by American Thyroid Association risk and American Joint Commission on Cancer disease stage T3, N0, M0or Mx, and T1-3, N1, M0, orMxwere included in the study. Patients with aggressive variants and multiple primaries were excluded. Main Outcome Measures: Overall survival (OS) for patients treated with and without RAI using univariate and multivariate regression analyses was measured. Results: A total of 21 870 patients were included; 15 418 (70.5%) received RAI and 6452 (29.5%) did not. Mean follow-up was 6 years, with the longest follow-up of 14 years. In an unadjusted analysis, RAI was associated with improved OS in all patients (P <.001) as well as in a subgroup analysis among patients younger than 45 years (n = 12 612, P =.002) and 65 years old and older (median OS 140 vs128 mo, n = 2122, P =.008). After a multivariate adjustment for demographic and clinical factors, RAI was associated with a 29% reduction in the risk of death, with a hazard risk 0.71 (95% confidence interval 0.62-0.82, P <.001). For age younger than 45 years, RAI was associated with a 36% reduction in risk of death, with a hazard risk 0.64 (95% confidence interval 0.45-0.92, P =.016). Conclusion: This is the first nationally representative study of intermediate-risk PTC patients and RAI therapy demonstrating an association of RAI with improved overall survival. We recommend that this patient group should be considered for RAI therapy. Copyright © 2015 by the Endocrine Society.


Woll M.L.,Section of Endocrine Surgery | Mazeh H.,Section of Endocrine Surgery | Anderson B.M.,University of Wisconsin - Madison | Chen H.,Section of Endocrine Surgery | Sippel R.S.,Section of Endocrine Surgery
World Journal of Surgery | Year: 2012

Background: Prior head and neck irradiation is a known risk factor for hyperparathyroidism. It is not clear whether irradiation for breast cancer, which may expose the neck to radiation, is also a risk factor for hyperparathyroidism. The present study analyzes the association between the side of radiation to the chest following breast surgery and the side of subsequent parathyroid adenoma development. Methods: We analyzed a prospective database of 1,428 consecutive patients who underwent parathyroidectomy at our institution between November 2000 and August 2010. Patients who had previously undergone breast surgery were identified. Patients with multigland disease were excluded. Patients with bilateral breast surgery were counted as having had two separate procedures; one on each side. Patients who had radiation therapy following breast surgery (RadRx) were compared to those who had breast surgery without radiation treatment (No RadRx). Results: A total of 146 breast procedures were performed in 121 patients. Forty procedures were in the RadRx group versus 106 cases in the No RadRx group. Patients with radiation therapy were older (68 ± 1.8 years versus 63 ± 1.2 years; P = 0.02) and had higher preoperative calcium levels (11.3 ± 0.1 mg/dl versus 10.9 ± 0.1 mg/dl; P = 0.001). However, there was no significant difference in either parathyroid hormone (PTH) level or gland weight. The latency period between breast irradiation and parathyroid surgery was 8 ± 0.9 years. Interestingly, the side of radiation therapy was associated with the side of the parathyroid adenoma in 76% of cases, compared to only 44% in those who had breast surgery without radiation exposure (P = 0.0004). Conclusions: The present study demonstrates that, similar to prior head and neck radiation, prior breast irradiation correlates with the development of parathyroid disease. Specifically, there is a strong correlation between the side of the radiation therapy and the side of a subsequent parathyroid adenoma. Breast irradiation should therefore be considered a risk factor for the development of parathyroid adenomas. © 2011 Société Internationale de Chirurgie.


McManus C.,Section of Endocrine Surgery | Wingo M.,Section of Endocrine Surgery | Chabot J.A.,Section of Endocrine Surgery | Lee J.A.,Section of Endocrine Surgery | Kuo J.H.,Section of Endocrine Surgery
World Journal of Surgery | Year: 2016

Introduction: Small institutional studies have shown that adrenalectomy to remove solitary metastases to the adrenal gland is safe and can improve overall survival for selective primary tumors. However, outcomes of adrenal metastasectomy have not been evaluated using large, national databases. Materials and methods: All cases of adrenal metastasectomies from 1992 to 2011 were identified in the HCUP-NIS database. The primary endpoint analyzed was death during the same hospitalization. Secondary outcomes included length of stay (LOS), blood loss requiring transfusion, surgical infection, cardiac complications, and respiratory complications. A sub-analysis of 428 patients stratified by primary tumor (where data were available) was also performed. Statistical analysis was performed using chi-square, ANOVA, and logistic regression using Stata software, significance was set at p value of 0.05. Results: A total of 2,057 cases of adrenal metastasectomies were identified. Median age of the patients was 62 ± 13.2 years (49.9 % men, 69.7 % Caucasian). Over the study period, there was a general increase in the number of cases performed and the number performed by minimally invasive approaches. There was also a decrease in LOS and number of deaths. However, age ≥71 years predicted a significantly higher rate of mortality (OR = 6.0, CI 1.3–26.5) when controlled for race, procedure type, year of surgery, and primary tumor in multivariable analysis. This age group had a higher number of cardiac complications (5.4 %, p = 0.005) that potentially contributed to the higher mortality rate. In addition, there was no difference in surgical outcomes when stratified by primary tumor type for the entire cohort of patients. Conclusion: Adrenal metastasectomy is a safe procedure with decreasing same-hospitalization mortality from 1992 to 2011. However, age ≥71 years is a significant risk factor for same-hospitalization mortality. This increased risk should be considered when discussing adrenal metastasectomy in this age population. © 2016 Société Internationale de Chirurgie


PubMed | Section of Endocrine Surgery
Type: Journal Article | Journal: World journal of surgery | Year: 2012

Prior head and neck irradiation is a known risk factor for hyperparathyroidism. It is not clear whether irradiation for breast cancer, which may expose the neck to radiation, is also a risk factor for hyperparathyroidism. The present study analyzes the association between the side of radiation to the chest following breast surgery and the side of subsequent parathyroid adenoma development.We analyzed a prospective database of 1,428 consecutive patients who underwent parathyroidectomy at our institution between November 2000 and August 2010. Patients who had previously undergone breast surgery were identified. Patients with multigland disease were excluded. Patients with bilateral breast surgery were counted as having had two separate procedures; one on each side. Patients who had radiation therapy following breast surgery (RadRx) were compared to those who had breast surgery without radiation treatment (No RadRx).A total of 146 breast procedures were performed in 121 patients. Forty procedures were in the RadRx group versus 106 cases in the No RadRx group. Patients with radiation therapy were older (68 1.8 years versus 63 1.2 years; P = 0.02) and had higher preoperative calcium levels (11.3 0.1 mg/dl versus 10.9 0.1 mg/dl; P = 0.001). However, there was no significant difference in either parathyroid hormone (PTH) level or gland weight. The latency period between breast irradiation and parathyroid surgery was 8 0.9 years. Interestingly, the side of radiation therapy was associated with the side of the parathyroid adenoma in 76% of cases, compared to only 44% in those who had breast surgery without radiation exposure (P = 0.0004).The present study demonstrates that, similar to prior head and neck radiation, prior breast irradiation correlates with the development of parathyroid disease. Specifically, there is a strong correlation between the side of the radiation therapy and the side of a subsequent parathyroid adenoma. Breast irradiation should therefore be considered a risk factor for the development of parathyroid adenomas.


PubMed | Section of Endocrine Surgery
Type: Journal Article | Journal: World journal of surgery | Year: 2016

Small institutional studies have shown that adrenalectomy to remove solitary metastases to the adrenal gland is safe and can improve overall survival for selective primary tumors. However, outcomes of adrenal metastasectomy have not been evaluated using large, national databases.All cases of adrenal metastasectomies from 1992 to 2011 were identified in the HCUP-NIS database. The primary endpoint analyzed was death during the same hospitalization. Secondary outcomes included length of stay (LOS), blood loss requiring transfusion, surgical infection, cardiac complications, and respiratory complications. A sub-analysis of 428 patients stratified by primary tumor (where data were available) was also performed. Statistical analysis was performed using chi-square, ANOVA, and logistic regression using Stata software, significance was set atpvalue of 0.05.A total of 2,057 cases of adrenal metastasectomies were identified. Median age of the patients was 6213.2years (49.9% men, 69.7% Caucasian). Over the study period, there was a general increase in the number of cases performed and the number performed by minimally invasive approaches. There was also a decrease in LOS and number of deaths. However, age71years predicted a significantly higher rate of mortality (OR=6.0, CI 1.3-26.5) when controlled for race, procedure type, year of surgery, and primary tumor in multivariable analysis. This age group had a higher number of cardiac complications (5.4%, p=0.005) that potentially contributed to the higher mortality rate. In addition, there was no difference in surgical outcomes when stratified by primary tumor type for the entire cohort of patients.Adrenal metastasectomy is a safe procedure with decreasing same-hospitalization mortality from 1992 to 2011. However, age71years is a significant risk factor for same-hospitalization mortality. This increased risk should be considered when discussing adrenal metastasectomy in this age population.

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