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The aim of this study was to determine the predictive value of the preoperative three-dimensional reconstructed volume (3D volumetry) for outcomes of laparoscopic splenectomy. The impact of splenomegaly on the feasibility of laparoscopic splenectomy is still debated. We hypothesized that splenic volumetry may accurately estimate splenic volume preoperatively and be used by surgeons to select patients for laparoscopic splenectomy.We performed a retrospective review of 88 patients seen at a tertiary referral center undergoing laparoscopic or open splenectomy between 2001 and 2010. Patients included in the study underwent elective splenectomy without associated procedures and had preoperative imaging available at our institution. We evaluated clinical, demographic characteristics and perioperative imaging as predictors of outcome. Study endpoints included conversion to open splenectomy, operating time, estimated blood loss (EBL), length of stay (LOS), postoperative complications, and mortality.In all, 53 procedures were started laparoscopically. Among them, 7 (13.2 %) were converted to open splenectomy and 7 (13.2 %) to hand-assisted laparoscopic splenectomy. The conversion group was matched with 35 patients who underwent open splenectomy to determine differences in outcomes between these groups. There were no conversions in spleens measuring1100 cc, whereas spleens of 1100 to 2700 cc had a conversion rate of 41 %. Spleen volume2700 cc was associated with an 87.5 % conversion rate. Spleen 3D volumetry2700 cc was the only independent predictor of surgical conversion on multivariate analysis (odds ratio 38.0, confidence interval 4.02-358.75, p = 0.001). Patients who underwent open splenectomy had shorter operating times (160.3 vs. 253.0 min, p = 0.001) than those converted from laparoscopic to open splenectomy.A 3D reconstructed splenic volume of2700 cc is a predictor of conversion from laparoscopic to open splenectomy. For spleens measuring2700 cc, laparoscopic splenectomy may be performed by experienced surgeons with low to moderate rates of conversion. For spleens with a 3D reconstructed volume2700 cc, laparoscopic splenectomy is associated with high rates of conversion to open surgery.

This study aims to determine the efficacy of calcimimetics in improving bone mineral density (BMD) in patients with primary hyperparathyroidism (pHPT) and compare those results to patients undergoing parathyroidectomy.Parathyroidectomy has been shown to improve BMD in pHPT, but calcimimetics have recently been advocated as a medical alternative to parathyroidectomy for pHPT.We identified 17 patients that were treated with calcimimetics for pHPT. Seventeen patients with pHPT who underwent parathyroidectomy served as surgical controls. Serum calcium level, parathyroid hormone (PTH) level, and femur and spine BMD T scores were compared before and 1 year after therapy.Both groups were demographically matched. Calcium levels normalized in 70.6% of medically versus 100% of surgically treated patients (P = 0.026). PTH levels normalized in 35% of patients treated with calcimimetics versus 76% of surgical patients (P = 0.036). Femur BMD improved in 18.8% of medically treated patients versus 58.8% of surgical patients (P = 0.032). Spine BMD improved in 70.6% of medically treated patients versus 82.4% of surgical patients (P = 0.69). Further analysis demonstrated that regardless of treatment, normalization of PTH was associated with significant improvement in femur (P = 0.03) and spine BMD (P0.001). Normalization of calcium without normalization of PTH did not impact BMD.Parathyroidectomy results in greater normalization of serum calcium and PTH levels and significantly improves cortical BMD compared to calcimimetics. Regardless of treatment, normalization of PTH is associated with significant improvement in spine and femur BMD, suggesting that the superior effects of surgery may be mediated by better control of PTH.

Differentiation is central to development, while dedifferentiation is central to cancer progression. Hence, a quantitative assessment of differentiation would be most useful. We propose an unbiased method to derive organ-specific differentiation indices from gene expression data and demonstrate its usefulness in thyroid cancer diagnosis. We derived a list of thyroid-specific genes by selecting automatically those genes that are expressed at higher level in the thyroid than in any other organ in a normal tissue's genome-wide gene expression compendium. The thyroid index of a tissue was defined as the median expression of these thyroid-specific genes in that tissue. As expected, the thyroid index was inversely correlated with meta-PCNA, a proliferation metagene, across a wide range of thyroid tumors. By contrast, the two indices were positively correlated in a time course of thyroid-stimulating hormone (TSH) activation of primary thyrocytes. Thus, the thyroid index captures biological information not integrated by proliferation rates. The differential diagnostic of follicular thyroid adenomas and follicular thyroid carcinoma is a notorious challenge for pathologists. The thyroid index discriminated them as accurately as did machine-learning classifiers trained on the genome-wide cancer data. Hence, although it was established exclusively from normal tissue data, the thyroid index integrates the relevant diagnostic information contained in tumoral transcriptomes. Similar results were obtained for the classification of the follicular vs classical variants of papillary thyroid cancers, that is, tumors dedifferentiating along a different route. The automated procedures demonstrated in the thyroid are applicable to other organs.

Background Over the past 3 decades, there has been a significant increase in the incidence of gastrointestinal carcinoid tumors in the United States. Incidentally discovered carcinoids in the lower gastrointestinal tract have probably contributed to this increase. In this study we aimed to compare the clinicopathologic characteristics of incidentally discovered carcinoids of the small and large bowel with those identified as a result of symptoms. Study Design We performed a retrospective review of 58 consecutive patients with nonappendiceal gastrointestinal carcinoids: 30 small bowel and 28 large bowel. We compared asymptomatic patients with lower gastrointestinal tract carcinoids identified by routine colonoscopy with those identified as a result of symptoms. Results Twenty-eight (48.3%) incidentally identified carcinoids (15 small bowel and 13 large bowel) were compared with 30 (51.7%) symptomatic carcinoids. Incidental ileal carcinoids were similar in size (mean ± SD, 1.3 ± 0.61 vs 1.7 ± 1.13, p=0.45) and incidence of lymph node metastases (12 in 15 vs 9 in 15, p=0.43) to symptomatic ileal carcinoids. However, incidental ileal carcinoids had a lower incidence of distant metastases (1 in 15 vs 7 in 15, p=0.035) compared with symptomatic ileal carcinoids. There was no difference in tumor size, extent of lymph node metastases, or distant metastases between incidental and symptomatic large bowel carcinoids. Conclusions Ileal carcinoids identified at screening colonoscopy are associated with a significantly decreased incidence of distant metastases compared with those identified after development of symptoms, despite similar size and extent of lymph node metastases. However, incidental large bowel carcinoids appear to have similar staging to those identified as a result of symptoms.

Background The clinical significance of synchronous bilateral papillary thyroid carcinoma (SBiPTC) has not been fully defined, and the prevalence of BRAFV600E mutation in SBiPTC remains unknown. The purpose of this study is to compare the clinical outcomes and BRAFV600E mutation incidence of SBiPTC patients with those of unilateral papillary thyroid carcinoma (UiPTC) patients.

The management of papillary thyroid carcinoma continues to evolve. Although the debate over the extent of thyroidectomy has largely faded, the role of elective neck dissection in the surgical management of papillary thyroid cancer has become a topic of contention. The current standard of care for patients with papillary thyroid cancer includes total thyroidectomy and a therapeutic lymph node dissection for patients presenting with clinically evident nodal disease. However, many surgeons advocate prophylactic central neck lymph node dissections in patients who present with no clinical or radiographic evidence of lymph node involvement. Proponents of prophylactic central compartment neck dissection argue that the incidence of central neck metastases is high and the sensitivity of preoperative ultrasound is low. Furthermore, central neck dissection advocates argue that clearing the central neck at the initial operation improves staging accuracy, assists in deciding on postoperative radioactive iodine treatment, and potentially avoids a higher-risk reoperative central neck dissection. Selective lateral neck dissections, as well as modified radical neck dissections, are accepted as necessary therapy in patients with clinically or radiographically positive lateral compartment disease. An essential component of any discussion on the extent of lymphadenectomy is whether patients derive any additional benefit from having a lymphadenectomy with total thyroidectomy and whether this can be done without significantly increasing the morbidity of the operation. Here we discuss the surgical options for approaching lymphadenectomy in patients presenting with papillary thyroid carcinoma.

Poorly-differentiated thyroid cancer (PDTC) and anaplastic thyroid cancer (ATC) are associated with a rapidly progressive course and poor median survival. Recently we published promising results in a murine model showing efficient clearance of metastatic tumor burden of human ATC cell line 8505c and an anaplastic patient-derived cell line using healthy donor T cells transduced with a third-generation chimeric antigen receptor (CAR) construct targeting intercellular adhesion molecule-1 (ICAM1). However, patient-derived T cells using an identical ICAM1-targeted CAR construct demonstrated slower tumor-killing in vitro. To investigate the role of immune checkpoint proteins PD-L1 and PD-1 in thyroid cancer and as potential inhibitors of ICAM1-CAR T, we stained formalin-fixed paraffin-embedded archived tissue samples for PD-L1 (papillary thyroid cancer, PTC, n = 17; ATC, n = 13) using immunohistochemistry (IHC) and extracted peripheral blood mononuclear cells (PBMCs) from patient blood samples and healthy donors to evaluate PD-1 expression on CD3+/CD8+ T cells using flow cytometry (healthy donor, n = 2; PTC, n = 7; PDTC/ATC, n = 6). Twelve percent of PTC samples were PD-L1+ (threshold >1% positivity) versus 69% of PDTC/ATC samples (Chi-square, p = 0.012); PD-L1 positivity was associated with circumferential ICAM1 staining on IHC (Chi-square, p = 0.003). Similarly, median percentage of PD-1 expression on PBMC's was higher in PDTC/ATC than PTC (58.1% versus 5.2%, Wilcoxon rank sum test; p = 0.03). Interestingly, expression of elevated PD-1 was seen in PBMC samples from patients in the absence of PD-L1 positivity of the primary tumor (IHC) in 4 of 5 matched tumor samples. This suggests that PD-1 in circulating CD8+ cells may be an important predictor of response to checkpoint inhibitor therapy. Finally, effector:target assays with patient-derived ICAM1-CAR T effector cells (baseline PD-1 expression 96%) against 8505c (PD-L1 100%/ICAM1 68%) and matched patient-derived cell line (PD-L1 >50%/ICAM1 88%) showed enhanced tumor killing in the presence of anti-PD-1, which approached the level of tumor cell death seen with healthy donor ICAM1-CAR T. Our results show that PD-1 is increased in the peripheral blood of patients with poorly differentiated and anaplastic thyroid cancer and is a potential therapeutic target. Furthermore, anti-PD-1 may be used to counter PD-L1+ tumor-induced T cell suppression (or exhaustion) to increase the efficacy of CAR T cells in ATC. Citation Format: Katherine D. Gray, Yogindra Vedvyas, Olivia Kalloo, Enda Shevlin, Theresa Scognamiglio, Marjan Zaman, Andrew Tassler, Moonsoo M. Jin, Rasa Zarnegar, Thomas J. Fahey, Irene M. Min. PD-L1/PD-1 checkpoint inhibition in anaplastic thyroid cancer and enhancement of ICAM1-targeted chimeric antigen receptor (CAR)-T cell tumor lysis [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 2738.

The effectiveness of prophylactic central neck dissection (pCND) in the treatment of patients with papillary thyroid carcinoma (PTC) to prevent local recurrence is controversial. We performed a meta-analysis to assess the effect of pCND on local recurrence in PTC. Exhaustive search of online search engines identified five retrospective studies that compared the local recurrence rates of PTC in patients without clinically detectable nodal disease in patients undergoing thyroidectomy + pCND (group A) to those undergoing thyroidectomy alone (group B). A meta-analysis was performed by the fixed effects method. Recurrence was documented by imaging, thyroglobulin detection, or reoperation. Location of recurrence was identified in either the central or lateral neck compartment. A total of 1264 patients were included, 396 in group A and 868 in group B. Follow-up ranged from 6 months to 27 years. The overall recurrence rate was 2.02% in group A versus 3.92% in group B (odds ratio [OR] = 1.05, 95% confidence interval [95% CI] 0.48–2.31). The recurrence rate in the central neck compartment in group A was 1.86% compared to 1.68% in group B (OR = 1.31, 95% CI 0.44–3.91). The recurrence rate in the lateral neck compartment in group A was 3.73% compared to 3.79% in group B (OR = 1.21, 95% CI 0.52–2.75). There was no statistically significant difference in the OR in the local recurrence between the two groups. This meta-analysis indicates that pCND does not greatly reduce local recurrence in thyroid cancer. However, the available studies have substantial limitations and a prospective multicenter study to determine the indications for pCND is warranted.

Although the role of prophylactic central neck lymph node dissection (CNLD) in the treatment of papillary thyroid carcinoma (PTC) is controversial, many surgeons perform routine prophylactic CNLD. The present study compares local recurrence rates in PTC patients undergoing total thyroidectomy with and without prophylactic CNLD. A retrospective review of 206 patients undergoing thyroidectomy for PTC was conducted at two tertiary referral centers. Of these, 81 patients had total thyroidectomy for PTC and a follow-up between 2 and 9 years with a mean of 3.1 years. Of these 81 patients, 45 underwent routine prophylactic CNLD and 36 did not. For those two groups, demographics, clinical and pathologic findings, radioactive iodine (RAI) treatment, and the incidence of recurrence were compared. Univariate statistical analysis was performed. There was no significant difference in age, gender, multifocality, or extrathyroidal extension for the two groups. Patients with CNLD had an average tumor size of 1.4 cm versus 2 cm in the group without CNLD (p

Objective: Many patients undergoing thyroidectomy for papillary thyroid carcinoma (PTC) have subclinical nodal disease at the time of surgery. Prophylactic bilateral central neck dissection (CND) is gaining acceptance in the treatment of PTC as studies have shown nodal disease increases the rate of local recurrence and may alter postsurgical radioactive iodine dosing. Given the potential complications of bilateral CND, we undertook a prospective study to determine the adequacy of prophylactic ipsilateral CND for PTC. Methods: A total of 116 patients with PTC underwent total thyroidectomy and routine prophylactic CND at a tertiary referral center. Of these, 45 had right and left central neck lymph node basins submitted separately for pathologic examination. We examined the laterality of positive lymph nodes based on tumor location and size. Results: Overall, positive lymph nodes were found in 45% of patients. Of the patients having a lateralized CND, 33% had ipsilateral positive nodes only, while 20% had bilateral positive nodes. None of the patients with tumor size ≤1 cm had bilateral positive lymph nodes compared with 31% of patients with tumors > 1 cm (P = 0.02). Multifocality did not affect lymph node metastasis in tumors ≤1 cm. Parathyroids were found in the pathology specimen of 34% of patients, 40% had parathyroids autotransplanted, 47% had temporary hypocalcemia, and 0% had permanent hypocalcemia. Rates of temporary and permanent recurrent laryngeal nerve injury were 5% and 0% respectively. Conclusions: Ipsilateral CND appears to be sufficient in patients with tumors ≤1 cm. In tumors >1 cm, bilateral CND should be considered as these patients are more likely to have bilateral positive nodes. If tumor size is used as criteria for prophylactic CND, approximately one-third of patients can be spared a bilateral CND.

T HE HISTORY OF surgery at The New York Hospital, the second oldest hospital in the United States, reflects the evolution of surgery in America and is marked by some of the most extraordinary achievements in medicine. The New York Hospital was the cradle of early surgical developments and instruction in America, earning a worldwide reputation for excellence and innovation. With the affiliation agreement between New York Hospital and Cornell University almost 100 years ago, the Department of Surgery developed into an academic unit that contributed clinical care and education to countless patients, students, and residents and generated innovations for the benefit of the surgical patient. With the more recent merger of New York Hospital and Presbyterian Hospital into a new entity, NewYork–Presbyterian Hospital, our Department is poised to continue making additional important contributions to the advancement of the art and science of surgery by building on our rich legacy of surgical care, teaching, and innovations.

The clinical significance of papillary thyroid microcarcinoma (PTMC) tumorsor =1 cm is widely debated. The objective of this study was to compare conventional papillary thyroid carcinoma (PTC) (tumors1 cm) to PTMC and assess for differences in tumor characteristics and patient outcome.A retrospective chart review of patients with PTC or PTMC who were followed for a minimum of 3 years postoperatively and managed at a single academic institute was performed.Of 202 patients in the study, 66 (32.7%) had PTMC and 136 (67.3%) had conventional PTC. Patient and tumor characteristics including tumor multifocality, extrathyroidal extension, angiolymphatic invasion, and lymph node metastasis were similar between both groups. Twenty-one percent of the PTMC tumors were discovered incidentally. Patients with conventional PTC were significantly more likely to undergo treatment with radioactive iodine therapy compared to PTMC patients (86.4% vs. 66.7%, respectively, p0.003). Disease recurrence was observed in 40 patients and was not statistically different between the two groups; 11 (16.7%) in PTMC and 29 (21.3%) in conventional PTC, p = 0.57. Within the PTMC group, tumors of patients that recurred were significantly larger than those who remained disease free (8.1 mm vs. 6.4 mm, p0.05). None of the patients with incidental PTMC had disease recurrence. Angiolymphatic invasion was the only significant prognostic indicator of recurrence on multivariate analysis (p0.02).Nonincidental PTMC can have aggressive tumor features and disease recurrence similar to conventional PTC. These tumors should be managed like any other papillary thyroid malignancy.

Background The aim of this study was to analyze the utility of preoperative thin cut (2.5 mm) computed tomography (CT) in patients with primary hyperparathyroidism (PHPT) and negative sestamibi scans. Methods A retrospective review of patients with PHPT was conducted from the prospective parathyroid registries of 2 tertiary referral centers. Of 482 patients, 63 with negative sestamibi scanning underwent thin cut CT of the neck and were included in the final analysis. Results CT was 85% sensitive and 94% specific for correctly lateralizing the side(s) of diseased glands and 66% sensitive and 89% specific for predicting exactly the location of diseased glands. Sixty-six percent of patients underwent focused explorations, and 87% of patients underwent parathyroidectomy under local anesthesia. Pathology revealed a single adenoma in 83%, multigland disease in 14%, carcinoma in 1%, and no pathology in 2%. Average operative time was 73 minutes overall, but only 55 minutes in patients with precise CT localization ( P = .02). Conclusion Thin cut CT is a helpful adjunct to preoperative workup in PHPT patients who have negative sestamibi localization and permits a focused neck exploration in a high percentage of those patients.

MicroRNA (miRNA) microarray analysis has consistently found altered expression of miRNAs in thyroid tumors, suggesting their roles in thyroid carcinogenesis. To explore whether this differential expression can be used as a diagnostic tool in surgical pathology and fine-needle aspirate (FNA) specimens, the expression of selected miRNA was evaluated by quantitative RT-PCR, using total RNA from 84 formalin-fixed paraffin-embedded tissues and 40 ex vivo aspirate specimens. miRNA from all paraffin-embedded tissues and all but one FNA sample were found to be analyzable, with paraffin sections yielding better miRNA quality. Preliminary analysis of 6 miRNAs in 10 papillary thyroid carcinoma and 10 follicular adenoma identified significant overexpression of miR-146b, -221, and -222 in papillary thyroid carcinoma (P0.02), but not miR-146a, -155, or -187 (P0.08). The expression of these first three miRNAs was examined in a series of 5 normal thyroid, 11 hyperplastic nodules, 24 follicular adenoma, 27 classical papillary thyroid carcinoma, 5 follicular variant papillary thyroid carcinoma, 2 follicular carcinoma, and 10 encapsulated follicular lesions with partial nuclear features of papillary carcinoma. Results showed miR-146b to be most consistently overexpressed in both classical papillary carcinoma and follicular variants, whereas all other groups showed lower expression at a similar level (P0.001 for pair-wise comparisons between papillary carcinoma and all other groups). Follicular lesions with partial features of papillary carcinoma all showed low miR-146b levels similar to other non-papillary carcinoma groups, suggesting that they are biologically distinctive from papillary carcinoma. miR-221 and miR-222 also showed higher expression in papillary carcinoma, but with substantial overlaps with the other groups. When applied to 40 FNA samples of various lesions, only miR-146b and miR-222 persisted as distinguishing markers for papillary carcinoma. We concluded that miRNAs, particularly miR-146b, might potentially be adjunct markers for diagnosing papillary thyroid carcinoma in both FNA and surgical pathology specimens.

Benign thyroid tumors account for most nodular thyroid disease. Determination of whether a thyroid nodule is benign or malignant is a major clinical dilemma and underlies the decision to proceed to surgery in many patients. Although the accuracy of thyroid nodule fine-needle aspiration (FNA) has reduced the need for surgery over the years, questions regarding how to follow FNA-designated benign nodules remain unresolved. This is true at least in part because of uncertainty over whether some benign nodules harbor malignant potential.An evidence-based review of recent clinical, pathologic, and molecular data is presented. A summary of data and observations from our own experience is also provided.Review of our recent 10-year experience indicates that 2% of thyroid malignancies arise within a preexisting benign thyroid nodule. In addition, both cytologic and molecular tumor markers, including Gal-3, CITED1, HBME-1, Ras, RET/PTC, and PAX8/PPAR gamma, have been identified in some histopathologically classified benign nodules. Gene expression profiling suggests that follicular adenomas and Hürthle cell adenomas have similarities to both benign and malignant tumors, suggesting that some of these tumors are premalignant. In addition, 10% of surgically excised follicular tumors are encapsulated follicular lesions with nuclear atypia, which have been termed "well-differentiated tumors of uncertain malignant potential." The data available suggest that these tumors could be precursors to carcinoma.Some benign thyroid nodules have malignant potential. Further molecular testing of these tumors can shed light on the pathogenesis of early malignant transformation.

Since the 1950s, preoperative medical preparation has been widely applied in patients with pheochromocytoma to improve intraoperative hemodynamic instability and postoperative complications. However, advancements in preoperative imaging, laparoscopic surgical techniques, and anesthesia have considerably improved management in patients with pheochromocytoma. In consequence, there is no validated consensus on current predictive factors for postoperative morbidity. The aim of this study was to determine perioperative factors which are predictive for postoperative morbidity in patients undergoing laparoscopic adrenalectomy for pheochromocytoma. It is a retrospective analysis of prospectively maintained databases in five medical centers from 2002 to 2013. Inclusion criteria were consecutive patients who underwent non-converted laparoscopic unilateral total adrenalectomy for pheochromocytoma. Two-hundred and twenty-five patients were included. All-cause and cardiovascular postoperative morbidity rates were 16 % (n = 36) and 4.8 % (n = 11), respectively. Preinduction blood pressure normalization after preoperative medical preparation had no impact on postoperative morbidity. However, past medical history of coronary artery disease (OR [CI95 %] = 3.39; [1.317–8.727]) and incidence of intraoperative hemodynamic instability episodes (both SBP ≥ 160 mmHg and MAP

International audience; BackgroundThe cost disparity between the United States and other advanced health care systems, including France, is expanding. In this report we identified the management of papillary thyroid cancer (PTC) that contribute to reimbursement disparity.MethodsA tri-institutional, retrospective review included 200 patients with PTC (100 from the United States, 100 from France) treated by total thyroidectomy with/without central neck dissection. A cost model was generated incorporating perioperative management variables (within 1 year) and their reimbursement rates according to the 2014 US Medicare and French government fee-schedules.ResultsIn the United States, total thyroidectomy with central neck dissection was more frequent (92% vs 35%, P < .001), median duration of stay was less (1 vs 3 days, P < .001), and use of radioactive iodine was less (66% vs 93%, P < .001), although Thyrogen stimulation was more prevalent (100% vs 43%, P < .001). Overall, the median cost per patient was greater in the United States ($14,069 vs $4,590, P < .001). Reimbursements to the hospital facility accounted for 70% of the disparity, despite lesser durations of stay. Nuclear medicine accounted for 19%, mostly from Thyrogen reimbursement despite less use of radioactive iodine. Surgeon fees accounted for 6%, followed by office visits, laboratory/imaging, anesthesia/pathology fees, and medications.ConclusionThe costs of management of PTC are substantially greater in the US compared with France. Efforts to decrease this disparity should focus on reimbursements for hospital facility and use of nuclear medicine imaging.

Although recent single-institution series have reported low morbidity and zero mortality after substernal thyroidectomy, a direct comparison of outcomes between substernal thyroidectomy and conventional cervical thyroidectomy has not been performed. We hypothesized that substernal thyroidectomy would be associated with higher morbidity and mortality as compared with cervical thyroidectomy.Data were extracted from the New York State Statewide Planning and Research Cooperative System database for the years 1998 to 2004. The primary predictor variable was substernal as compared with cervical thyroidectomy. Outcomes variables included postoperative complications, length of stay, and mortality. Multiple logistic regression was used to access the independent effects of substernal thyroidectomy on postoperative outcome.A total of 33,930 patients underwent thyroidectomy, 1,153 (3.4%) of whom underwent substernal thyroidectomy. Compared with patients who underwent cervical thyroidectomy (n=32,777), patients who underwent substernal thyroidectomy were older (p0.0001), more likely to have a comorbid condition (p0.0001), more likely to be men (p0.0001), more likely to lack private insurance (p0.0001), more likely to undergo total thyroidectomy (p0.0001), less likely to undergo thyroidectomy for malignancy (p0.0001), and less likely to undergo thyroidectomy at a high-volume center (p=0.001). After controlling for these covariates, patients who underwent substernal thyroidectomy were considerably more likely to experience recurrent laryngeal nerve injury (p=0.0002), postoperative bleeding (p=0.004), deep venous thrombosis (p=0.0002), and respiratory failure (p0.0001), and were more likely to receive a red blood cell transfusion (p0.0001). Patients who underwent substernal thyroidectomy also had a considerably increased length of stay (p0.0001), and more than an eightfold increase in likelihood of mortality (p0.0001).Substernal thyroidectomy, as compared with cervical thyroidectomy, is associated with a markedly increased likelihood of both postoperative complications and mortality.

The risk of metastatic disease among carcinoid tumors of the appendix increases with tumor size. However, it is unclear if any features other than size are also associated with an increased risk of metastatic disease.The aim of this study was to review the characteristics of appendiceal carcinoid tumors and determine if other histologic features besides size should guide surgical decision making.This study involved a retrospective case series.This study was conducted at a single tertiary acute care hospital.Patients diagnosed with an appendiceal carcinoid tumor between 2000 and 2014 were identified. Goblet cell carcinoids, adenocarcinomas with neuroendocrine features, and tumors from other primary locations were excluded.Simple appendectomy or segmental/total colectomy with lymphadenectomy was performed.The primary outcomes measured were metastases, recurrence, and overall survival.Seventy-nine patients were included. The overall incidence of metastatic disease was 10%. Patients with metastatic disease were more likely to be male (75% vs 28%, p = 0.008), have small-vessel invasion (43% vs 5%, p = 0.001), and have larger tumors (median 2.0 cm vs 0.5 cm, p0.001). Among tumors2 cm, the incidence of metastases among tumors with small-vessel invasion was 60% compared with 0% among those without small-vessel invasion (p0.001). Among tumors ≥2 cm, the incidence of metastases was 50% irrespective of small-vessel invasion. If small-vessel invasion was used as a second indication for performing a right hemicolectomy along with size ≥2 cm, both the sensitivity and negative predictive value would have been 100% compared with 63% and 96% if size was used alone. Patients with metastatic disease had a higher incidence of recurrence (13% vs 0%, p = 0.003), but overall survival was 100% in both groups.Small sample size, retrospective design, and limited long-term follow-up were the limitations of this study.Carcinoid tumors of the appendix2 cm with small-vessel invasion have similar metastatic potential as tumors ≥2 cm. Therefore, a recommendation for a right hemicolectomy should be considered for tumors2 cm with small-vessel invasion. Additional prospective multicenter studies are warranted.

Early referral for catheter-based esophageal pH monitoring is more cost-effective than empiric proton-pump inhibitor (PPI) therapy to diagnose gastroesophageal reflux disease (GERD). We hypothesize that BRAVO wireless pH monitoring will also demonstrate substantial cost-savings compared to empiric PPI therapy, given its superior sensitivity and comfort. We reviewed 100 consecutive patients who underwent wireless pH monitoring for suspected GERD at our institution. A cost model and a cost equivalence calculation were generated. Cost-saving analyses were performed for both esophageal and extraesophageal symptoms. Eighty-seven patients were available for analysis. Median PPI use prior to referral was 215 weeks (range 0–520). Forty-three patients (49 %) had BRAVO results diagnosing GERD; 98 % of these had esophageal symptoms. Patients with negative BRAVO studies had a median of 113 (0–520) weeks of unnecessary PPI therapy. Cost-savings ranged from $1048 to $15,853 per patient, depending on sensitivity (75–95 %), PPI dosage, and brand. Maximum cost-savings occurred in patients with extraesophageal symptoms ($2948–$31,389 per patient). The PPI cost equivalence of BRAVO placement was 36 and 6 weeks for low- and high-dose therapy, respectively. BRAVO wireless pH testing is more cost-effective than prolonged empiric medical management for GERD and should be incorporated early in the treatment algorithm.

Recent advances in research on thyroid carcinogenesis have yielded applications of diagnostic molecular biomarkers and profiling panels in the management of thyroid nodules. The specific utility of these novel, clinically available molecular tests is becoming widely appreciated, especially in perioperative decision making by the surgeon regarding the need for surgery and the extent of initial resection.A task force was convened by the Surgical Affairs Committee of the American Thyroid Association and was charged with writing this article.This review covers the clinical scenarios by cytologic category for which the thyroid surgeon may find molecular profiling results useful, particularly for cases with indeterminate fine-needle aspiration cytology. Distinct strengths of each ancillary test are highlighted to convey the current status of this evolving field, which has already demonstrated the potential to streamline decision making and reduce unnecessary surgery, with the accompanying benefits. However, the performance of any diagnostic test, that is, its positive predictive value and negative predictive value, are exquisitely influenced by the prevalence of cancer in that cytologic category, which is known to vary widely at different medical centers. Thus, it is crucial for the clinician to know the prevalence of malignancy within each indeterminate cytologic category, at one's own institution. Without this information, the performance of the diagnostic tests discussed below may vary substantially.

Bilaterality is common in papillary thyroid cancer (PTC), but its clinical and prognostic implications are still controversial, and it remains unclear whether its behavior is more aggressive than multifocality.The clinicopathologic features of 2211 consecutive patients with PTC who underwent surgical treatment at the authors' institute between 1997 and 2011 were reviewed. Among these surgical patients, 425 (19.2%) had bilateral PTCs, and 1786 had unilateral PTCs. The patients who had unilateral PTCs were subdivided into a group with unilateral-multifocal PTCs (210 patients) and a group with solitary PTCs (1576 patients). The 10-year disease-free survival (DFS) rates were calculated to compare the prognosis between groups. B-Raf proto-oncogene, serine/threonine kinase (BRAF) mutation status was examined by direct DNA sequencing.Patients who had bilateral PTCs were likely to have larger tumors, higher rates of extrathyroid extension and lymph node metastasis, and more advanced tumor stage than those who had unilateral-multifocal PTCs. Multivariate analysis identified only lymph node metastasis as an independent risk factor for PTC recurrence (P .001). The 10-year DFS rate for patients with bilateral PTCs was much lower than that for those with unilateral-multifocal and solitary PTCs (78.8% vs 85.7% and 89.3%, respectively; P = .005). It is noteworthy that patients who had bilateral PTCs with lymph node metastasis had the worst prognosis in terms of DFS. Incidence of the BRAF V600E mutation (valine to glutamic acid mutation at position 600) was higher in the bilateral PTC group than that in the unilateral and unilateral-multifocal PTC groups.The current results provide initial evidence that bilateral PTCs are more aggressive than unilateral-multifocal PTCs, and patients who have bilateral disease have more advanced stage and shorter DFS. The poorer outcome of patients with bilateral PTCs may be caused in part by their high incidence of lymph node metastasis. Cancer 2016;122:198-206. © 2015 American Cancer Society.

Objective To assess the attitudes of residents and program directors (PDs) involved in flexible training to gauge satisfaction with this training paradigm and elicit limitations. Design Anonymous surveys were sent to residents and PDs in participant programs. Respondents were asked to rate responses on a 5-point Likert scale (1 = strongly disagree and 5 = strongly agree). Setting A total of 9 residency programs that are collaborating to prospectively study the effect of flexible tracks on resident performance and outcome. Participants A total of 138 residents who were in clinical years 4 and 5 and 10 PDs. Results Of the 138 possible residents, 100 responded to the resident survey (72.5% response rate). Among resident respondents, 33% were participating in a flexible track option. The most frequently listed specialties of focus were cardiothoracic surgery (19%), vascular surgery (13%), acute care surgery (11%), colorectal surgery (8%), surgical oncology (7%), and pediatric surgery (7%). Participants in flexible tracks tended to strongly agree that their career would be enhanced by flexible rotations; interestingly, of those not in flexible tracks, most tended to also agree that flexible rotations would enhance their future careers. Flexible track participants report receiving greater autonomy on flexible rotations and believe they would be better prepared for fellowship and career. They express overall very high satisfaction with the flexible experience. Limitations expressed by residents (in flexible tracks or not) include uncertainty for how this paradigm serves those interested in comprehensive general surgery, concern about scheduling difficulties, and some displeasure in missing high-volume general surgery rotations in lieu of specialty-focused rotations. The PD survey was completed by 8 of 9 PDs for a response rate of 89%. All the respondents agreed or strongly agreed that careers of residents are enhanced by flexible rotations and that important operative and clinical experiences are gained. Overall, 87.5% of PD respondents agreed or strongly agreed that those in flexible tracks have greater opportunities for mentorship in their chosen field. PDs also expressed high levels of satisfaction with flexible rotations. Limitations include concerns that the flexibility option presents scheduling difficulties and does not go far enough in reforming postgraduate education. Conclusions This survey of 9 residency programs participating in flexible tracks indicates satisfaction with this training option. The role of comprehensive general surgery as a training end point and scheduling difficulties remain as major challenges. Outcomes of graduates in these tracks and control peers are being prospectively evaluated.

Background Thyroid surgery is performed by a large number of surgeons with varying experience in thyroidectomy. The standard technique involves the use of general anesthesia, which provides patient comfort and virtually unlimited time to conduct the operation. Historically, thyroid surgery was conducted under local anesthesia by surgeons with significant expertise in the treatment of thyroid diseases. Over the past decade, there has been a renewed interest in the art of performing thyroidectomy under local/regional anesthesia in some specialized high volume endocrine surgery centers. Methods Here we review the indications and contraindications and technical considerations for performing thyroidectomy under local or regional anesthesia. Results and conclusion Local and regional anesthesia is safe and well tolerated for the majority of thyroid surgery.

Current preoperative diagnostic procedures for thyroid nodules rely mainly on the cytological interpretation of fine-needle aspirates (FNAs). DNA microarray analysis has been shown to reliably distinguish benign and malignant thyroid nodules in surgically resected specimens, but its diagnostic potential in thyroid FNA has not been examined. In the present study, the expression profiles of 50 benign thyroid lesions and papillary thyroid carcinoma tissue samples were compared, generating a list of 25 differentially expressed genes from this training set. A test set of 22 FNA specimens was evaluated by unsupervised hierarchical cluster analysis using this gene list, and the results were compared to FNA cytology. FNA specimens were found to fall into three clusters: malignant (n = 10), benign (n = 7), and indeterminate (n = 5). The benign and malignant groups showed complete concordance with the final histological diagnosis except for one histologically benign lesion, which was rediagnosed as follicular variant of papillary thyroid carcinoma on histological review. Paired analysis between FNA and matched tissues samples illustrated adequate sampling with FNA. These results illustrate that microarray analysis of FNA is feasible and has the potential to improve the accuracy of FNA in categorizing benign from malignant lesions beyond routine cytological evaluation.

Thyroid carcinomas comprise 1.5% of malignancies worldwide and are the most common endocrine cancer. It was projected that 23,600 patients would be given a diagnosis of thyroid cancer in theUnited States in 2004, which is an estimated 3% annual increase in incidence. A much greater portion of the US population, almost 7%, develops a clinically significant thyroid nodule, the vast majority of which are benign. Given the different treatment strategies for benign andmalignant nodules, as well as the inherent morbidity associatedwith surgery, better preoperative determination of benign versus malignant nodules has been a lofty but elusive goal. The development and implementation of fine-needle aspiration (FNA) 30 years ago substantially decreased the need for operative intervention by improving preoperative diagnostics. However, only one quarter of operative specimens are currently determined to be malignant, mainly as a result of our continued inability to definitively classify “indeterminate” aspirates seen in up to one fifth of FNA specimens. The differentiation of follicular adenomas, follicular carcinomas, and the follicular variant of papillary carcinomas remains the subject of intense research. In addition, FNA is not ca

Background Though Hurthle cell tumors are considered a variant of follicular lesions, recent data have suggested that Hurthle cell carcinomas may be more closely related to papillary thyroid carcinomas (PTCs). These studies were conducted to determine if molecular profiling can enhance our understanding of Hurthle cell neoplasms. Methods Thirteen Hurthle cell tumors (9 adenomas, 4 carcinomas) were analyzed with the Affymetrix HU-95 gene chips. Molecular profiles obtained were compared to 14 follicular adenomas (FAs), 7 follicular carcinomas (FCs), 10 PTCs, 11 follicular variant PTCs, and 9 hyperplastic nodules. Hierarchical cluster analysis defined potential groupings and differences among samples. Results Hurthle cell carcinomas grouped with FCs 100% of the time. Surprisingly, Hurthle cell adenomas clustered with FCs when compared to FAs and FCs in 8/9 (88%) cases. All 13 Hurthle cell lesions migrated as a distinct group separate from PTCs and FVPTCs. Finally, all Hurthle cell lesions clustered with FCs, rather than PTCs, when compared to both groups. Conclusions Molecular profiles of Hurthle cell adenomas and carcinomas are more similar to FCs than benign lesions or PTCs. Although Hurthle cell adenomas generally behave in a benign fashion, the molecular signature of these lesions suggests a more malignant phenotype.

Activation of telomerase represents an early step in carcinogenesis. Increased telomerase expression in malignant thyroid tumors suggests that inactivation of telomerase may represent a potential chemotherapeutic target. The purpose of this study was to inhibit the protein component of telomerase, hTERT, in a human thyroid cancer cell line in vitro and in vivo using an antisense strategy. A 235-bp fragment of hTERT cDNA was subcloned, and sense and antisense hTERT expression vectors were constructed. These vectors were transfected into a human thyroid carcinoma cell line (FRO). Tumorigenic potential was determined by cellular growth assay, rate of apoptosis, anchorage-independent growth, and tumor growth in a nude mouse model. Significant down-regulation of hTERT expression was seen in the antisense transfected cells, compared with control and those transfected with the sense vector. A decrease in telomerase activity by TRAP assay was observed in the antisense hTERT cells but not in cells transfected with the sense hTERT construct. Inhibition of cell growth was observed after approximately 20 population doublings in the antisense-hTERT clones and was associated with an increase in the rate of apoptosis and a change in cellular morphology. Moreover, anchorage-independent growth was reduced in vitro, and tumor growth rate was diminished in vivo in the antisense hTERT clones. Inhibition of telomerase activity with antisense hTERT in human thyroid cancer cells is achievable and may represent a novel target to inhibit tumor growth.

While robotic-assisted operations have become more prevalent, many general surgery residencies do not have a formal robotic training curriculum. We sought to ascertain how well current general surgery training permits acquisition of robotic skills by comparing robotic simulation performance across various training levels. Thirty-six participants were categorized by level of surgical training: eight medical students (MS), ten junior residents (JR), ten mid-level residents (MLR), and eight senior residents (SR). Participants performed three simulation tasks on the da Vinci ® Skills Simulator (MatchBoard, EnergyDissection, SutureSponge). Each task’s scores (0–100) and cumulative scores (0–300) were compared between groups. There were no differences in sex, hand dominance, video gaming history, or prior robotic experience between groups; however, SR was the oldest (p

Background: Autoaugmentation gastrocystoplasty has been previously performed successfully. This set of experiments was conducted to determine the feasibility of performing autoaugmentation gastrocystoplasty laparoscopically. Methods: Hand-assisted laparoscopic autoaugmentation gastrocystoplasty was performed on 15 mongrel dogs. The surgery was carried out with two 10-mm trocars and a 6-cm Pfannenstiel incision. The gastric wedge, supplied by the right gastroepiploic artery, was resected with two applications of an endoscopic gastrointestinal anastomosis (GIA) stapler. The pedicle was demucosalized, and the anastomosis to the bladder was completed through the Pfannenstiel incision. Results: All of the dogs were successfully treated laparoscopically and were eating at 48 h. There was no evidence of anastomotic leak dehiscence at the gastric resection staple line. Conclusion: Hand-assisted laparoscopic autoaugmentation gastrocystoplasty can be performed successfully in dogs. This operation may offer a superior alternative to standard bladder autoaugmentation procedures in children suffering from congenital bladder disorders.

BACKGROUND: Legal mandates to reduce resident work hours have prompted changes in the structure of surgical training programs. Such changes have included modification of on-call schedules and the adoption of "night float" resident coverage. Little is known about the effects of these changes on surgical resident education and perceptions of quality of patient care. STUDY DESIGN: The surgical housestaff and faculty at a single institution completed a 21-point Likert survey. Subjects were asked to compare parameters of resident education, patient care, and resident quality of life before and after institution of a strict 80-hour work week resident training schedule. The number of hours worked per week before and after these changes were reported. American Board of Surgery In-Training Examination (ABSITE) scores were compared for the 2 years before and after implementation of this schedule. Total number of surgical cases performed by graduating chief residents were recorded and compared for the 3 years before and after the schedule changes. RESULTS: Resident work hours reduced significantly after schedule changes were implemented. A majority of surgical residents reported an improvement in quality of life, but residents and faculty perceived changes to have a negative impact on continuity of patient care. Mean ABSITE composite percentile scores significantly improved after the reduction of working hours. ABSITE scores for junior residents improved significantly; no significant differences were noted in scores for senior residents. CONCLUSIONS: Reduction in resident work hours has salutary effects on perception of quality of life and basic education for surgical residents. These benefits may come at the expense of patient care, particularly continuity of care. This study did not directly assess patient outcomes but the perceptions of caregivers suggest that patient care may be compromised. Further research is needed to assess the longterm effects of changes on both residents and patients.

Since the first description by Frantz in 1959 of a papillary cystic tumor of the pancreas, solid pseudopapillary tumors have been increasing in incidence. However, management of these lesions remains controversial. Patients under the age of 20 years more often undergo local excision than do their older counterparts, resulting in increased recurrence rates. The cause of this discrepancy is not clear but may be related to an inability to make a definitive preoperative diagnosis. The authors report a case of a solid pseudopapillary tumor of the pancreas in a 13-year-old girl in which the diagnosis was established preoperatively by endoscopic ultrasound scan with fine-needle aspiration (EUS-FNA). EUS-FNA represents a diagnostic technique commonly used in adults that may be useful in identifying the rare pediatric patient with pancreatic malignancy.

Introduction: Poorly differentiated thyroid cancer and anaplastic thyroid cancer (ATC) are rare yet inherently lethal malignancies with limited treatment options. Many malignant tumors, including papillary thyroid cancer (PTC) and ATC, are associated with increased expression of intercellular adhesion molecule-1 (ICAM-1), providing a rationale for utilizing ICAM-1-targeting agents for the treatment of aggressive types of thyroid cancer. Therefore, we developed a third-generation chimeric antigen receptor (CAR) targeting ICAM-1 to leverage adoptive T cell therapy as a new treatment modality against advanced thyroid cancer. Methods: We created a firefly luciferase-expressing human ATC model in mice that develops systemic metastases very rapidly. ATC engrafted mice were treated with human peripheral blood T cells modified with a lentivirus encoding an ICAM-1 specific CAR (ICAM-1-CAR) to investigate their therapeutic efficacy. Tumor burden was longitudinally measured by whole body bioluminescence imaging of luciferase-positive tumor cells. Effector:target assays consisting of ICAM-1-CAR T cells co-cultured with multiple malignant and non-malignant target cells were used to investigate specific target cell death and ‘off-tumor’ toxicity in vitro using luminescence and flow cytometry. Results: ICAM-1-CAR T cells demonstrated robust and specific killing of PTC and ATC cell lines in vitro. Strikingly, despite heterogeneous expression of ICAM-1 in ATC cell lines, addition of cytotoxic CAR T cells induced increased ICAM-1 expression by T cell-derived interferon gamma such that all cell lines became targetable by ICAM-1-CAR T cells. Patient-derived, poorly differentiated PTC cells overexpressed ICAM-1 and were also mostly eliminated by autologous ICAM-1 CAR T cells in vitro. In mice with systemic ATC, a single administration of ICAM-1-CAR-T cells at a clinical dose mediated significant tumor killing with a 100-fold reduction in primary tumor burden compared to pre-treatment. Reductions in tumor burden persisted for over 80 days and treated mice demonstrated significantly improved survival without toxicity. Conclusion: Our findings are the first demonstration of the potential for CAR-T cell therapy for metastatic, advanced thyroid cancers. ICAM-1-CAR T cells demonstrated significant therapeutic efficacy in vitro and in vivo and extended survival benefits in animal models. Citation Format: Irene M. Min, Yogindra Vedvyas, Enda Shevlin, Marjan Zaman, Brian Wyrwas, Weibin Wang, Susan Park, Maureen Moore, Theresa Scognamiglio, Rasa Zarnegar, Thomas J. Fahey, Moonsoo M. Jin. CAR T cells targeting ICAM-1 trigger strong antitumor effects against advanced human thyroid tumors [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2017; 2017 Apr 1-5; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2017;77(13 Suppl):Abstract nr 3624. doi:10.1158/1538-7445.AM2017-3624

e15046 Background: RMB, a cytostatic, biological system form of anti cancer therapy have been used in Ph I & II clinical trials in mCRC w/ evidence of improved survival benefit & QOL. Evaluation of metastatic tumor response by standard CT RECIST criteria however has been unsatisfactory. We hypothesized that using 18F FDG PET/CT scan to evaluate tumor anatomy & metabolism could provide a more accurate picture of tumor response to RMB Methods: 48 mCRC pts (14, Ph 1; 34, Ph 2a) who failed available treatments were implanted intraperitoneally w/ RMB (8mb/kg). Physicals, biomarkers & lab evaluation were obtained at baseline & days 14-90, with PET CT imaging at baseline & day 90. PET scan was acquired 1 hour after FDG injection of 9.4 mCi. CT was used for attenuation correction. Correlation between 18F FDG PET SUVmax findings & CEA & or CA19-9 responses was assessed. Positive response was defined as ≥20% decrease post implant in CEA, CA19-9 & SUV. Only tumors w/ SUVmax ≥ 2.5 were evaluated. SUV measurements were made by 1 radiologist experienced in PET-CT scanning & SUV determination Results: 123 FDG positive mCRC lesions (39, Ph 1; 84 Ph 2a) were detected in 37 evaluable pts (14 m, 23 f; mean age 58.2; SUVmax 2.5-17.5). Of the 37 pts, 28 (76%) showed stabilization & or decreased FDG uptake (4 w/ frank necrosis) as well as stable/decreased CT tumor measurements. Pts w/ pulmonary lesions showed greater responses than those w/ hepatic lesions. 9 (24%) of 37 pts showed increased SUVs. 23 pts (62%) showed decrease in CEA & or CA 19-9 ≥ 20%. 17 pts (74%; 13 decrease, 4 central & peripheral necrosis) had correlation between decreased SUVs/necrosis & biomarkers decrease Conclusions: We conclude SUVs are useful in monitoring mCRC lesions response to RMB therapy. Changes in SUVs correlate w/ CEA & CA 19-9 changes. Taken together the combined data indicate anti tumor effect in these Ph 1/2a trials & offer preliminary support for our hypothesis that 18FDG can be useful in evaluating cell system therapies. Issues of SUVmax standardization & effects of intra tumor heterogeneity however must be considered. Further studies are merited & ongoing, including a planned Ph 3 trial Clinical trial information: NCT01053013; NCT00283075.

Acute biliary pathology is a risk factor for conversion to open surgery and increased surgical morbidity during laparoscopic cholecystectomy (LC). The purpose of our study was to examine the impact of an advanced laparoscopic fellowship-trained surgeon on risks of conversion, surgical morbidity, and postoperative complications in this patient population.Of 1382 patients who underwent an LC from January 2008 to August 2011, 592 patients were diagnosed with an acute biliary process and were included in the study. Patients were divided into two groups; those operated on by an advanced laparoscopic fellowship-trained surgeon (N=237), and those operated on by a non-laparoscopic fellowship-trained surgeon (N=355). The primary end-points were conversion rates and surgical morbidity. The secondary end-point was operative time.Fellowship-trained surgeons were more likely to perform IOC (57%) versus non-fellowship trained surgeons (20%) (p0.0001). The conversion rate for the fellowship-trained group was significantly lower than for the non-fellowship trained group (1.7% vs 8.5%, p=0.0004). The intraoperative and postoperative complication rates for the fellowship-trained group were not significantly different. The operative time was slightly longer in the non-fellowship trained group compared to the fellowship-trained group (104 min vs 111 min, p=0.04).Our data demonstrate that advanced laparoscopic fellowship training decreases conversion rates of laparoscopic cholecystectomy for acute biliary pathology. Moreover, given the lower conversion rates, patients may have experienced shorter hospitalizations.Formal advanced laparoscopic fellowship training may decrease length of stay among patients presenting with acute biliary pathology who undergo laparoscopic cholecystectomy.

There are three subtypes of follicular variant papillary thyroid carcinoma (fvPTC): completely encapsulated, well circumscribed, and infiltrative. While infiltrative tumors are more aggressive than completely encapsulated, controversy exists regarding management of fvPTC subtypes. We compared the clinicopathologic features of fvPTC subtypes to those of classic PTC (cPTC) to help guide fvPTC management, using cPTC as a reference. A retrospective review was performed on 316 patients with PTC treated at a single institution from 2004 to 2011. There were 197 cPTC and 119 fvPTC tumors, including completely encapsulated (n = 46), well circumscribed (n = 46), and infiltrative (n = 27). Clinicopathologic data were compared between groups. fvPTC patients had larger tumors than cPTC patients (1.6 cm vs. 1.2 cm, p = 0.001), but age, sex, and family history did not differ. Thirty-one percent of cPTC tumors had extrathyroidal extension compared to 0 % of completely encapsulated, 0 % of well-circumscribed, and 52 % of infiltrative fvPTC tumors (p