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Cardiac CT-scan is recommended for sorting patients presenting with stable or acute chest pain with low to intermediate risk of coronary artery disease (CAD). Recent studies have shown its reliability for diagnosing CAD in high-risk patients, notably those with acute coronary syndrome (ACS) without ST-elevation. Coronary CT-scan also represents a great opportunity for the screening of atherosclerosis in patients at risk and allows a better prevention of coronary artery disease by introduction of preventive treatments in patients with abnormal coronary CT-scan, especially statins. It is useful for the follow-up of patients who underwent a coronary arteries revascularization with either stents or bypasses. Coronary arteries calcium scoring appears to be an independent predictive factor of cardiovascular and total mortality and its use is recommended for stratifying the cardiovascular risk. However, its interpretation remains unobvious and the patient management is poorly improved by the results. Anyway, if the score is above zero, atherosclerosis is present and therefore a lipid lowering treatment should be discussed. Cardiac CT-scan has become the Gold Standard exam before an aortic valve replacement, for the measurement of the aortic root notably, allowing the best prothesis selection. Before atrial fibrillation ablation procedure by pulmonary vein isolation, the cardiac CT-scan allows a 3-D visualization of the two atria, especially the left atrium, and rules out any suspicion of cardiac thrombus. It allows the research of an anomalous pulmonary venous connection. The 3-D support will also enable the operator to navigate in the heart during the ablation procedure.

Resume La pandemie de COVID-19 impose une reorganisation majeure de l’ensemble de notre systeme de soins. En France, des regles generales ont ete diffusees au niveau national et sont declinees par chaque etablissement, public comme prive, sur l’ensemble du territoire. Ces recommandations, redigees par un groupe d’experts sous l’egide de l’Association francophone de chirurgie endocrinienne (AFCE), ont pour objectif de proposer des principes specifiques de prise en charge chirurgicale au cours et au decours de l’epidemie de COVID- 19, pour les pathologies chirurgicales de la thyroide, des parathyroides, du pancreas endocrine, et des surrenales.

Background Percutaneous left atrial appendage closure (LAAC) has emerged as a valid option for prevention of thromboembolic events in patients with non-valvular atrial fibrillation and contraindications for oral anticoagulation. The most recent devices have been created to improve the intervention efficiency and to allow the procedure in a wider range of anatomies. The new-generation Watchman FLX (WMFLX) features a new design but its in vivo performances have not been compared to the previous WATCHMAN 2.5 (WM2.5) prosthesis. Hence, the data regarding conformability, compression and device-related LAA remodeling are scarce. Purpose To compare the anatomical results of WM2.5 and WMFLX implantation and impact on LAA dimensions. Methods This study included LAAC patients from the WATCH-DUAL registry who benefited from a pre- and post-intervention CT scan. The WATCH-DUAL study was a dual center observational study including all the LAAC procedures prospectively collected in local registries from two high-volume centres between November 2017 and December 2020. The LAA and device dimensions were measured in a centralized core lab by 3D CT scan reconstruction methods, focusing on the device landing zone (LZ/defined as the cross section of the appendage that was perpendicular to its axis and connected the circumflex artery to a point 1 to 2 cm inside the LAA). Results This analysis included n=107 patients (n=58 WMFLX, n=49 WM2.5). The patients clinical profiles didn't differ, except for a higher proportion of coronary artery disease in WM2.5 group. The LAA dimensions were comparable between groups. There was a significantly higher proportion of chickenwing shapes in the WMFLX patients. The mean device baseline diameter was in the WMFLX compared to the WM2.5 patients (28.8±0.5 vs. 25.7±0.4 mm, p The median delay for CT control was 48 (43–62) days. The LZ area (451 (363–521) vs. 366 (260–459) mm2, p A multivariable regression analysis demonstrated that baseline LAA length, baseline LZ eccentricity and WM FLX use were independent predictors of LAA remodeling/dimensions increase. Conclusion LAA dimensions increased over time at the site of WM prosthesis implantation suggesting a local positive appendage remodeling after procedure. This phenomenon appears to be more pronounced with the WMFLX device. Funding Acknowledgement Type of funding sources: None.

Cardiac CT-scan is recommended for sorting patients presenting with stable or acute chest pain with low to intermediate risk of coronary artery disease (CAD). Recent studies have shown its reliability for diagnosing CAD in high-risk patients, notably those with acute coronary syndrome (ACS) without ST-elevation. Coronary CT-scan also represents a great opportunity for the screening of atherosclerosis in patients at risk and allows a better prevention of coronary artery disease by introduction of preventive treatments in patients with abnormal coronary CT-scan, especially statins. It is useful for the follow-up of patients who underwent a coronary arteries revascularization with either stents or bypasses. Coronary arteries calcium scoring appears to be an independent predictive factor of cardiovascular and total mortality and its use is recommended for stratifying the cardiovascular risk. However, its interpretation remains unobvious and the patient management is poorly improved by the results. Anyway, if the score is above zero, atherosclerosis is present and therefore a lipid lowering treatment should be discussed. Cardiac CT-scan has become the Gold Standard exam before an aortic valve replacement, for the measurement of the aortic root notably, allowing the best prothesis selection. Before atrial fibrillation ablation procedure by pulmonary vein isolation, the cardiac CT-scan allows a 3-D visualization of the two atria, especially the left atrium, and rules out any suspicion of cardiac thrombus. It allows the research of an anomalous pulmonary venous connection. The 3-D support will also enable the operator to navigate in the heart during the ablation procedure.

Background Pulmonary vein isolation (PVI) is the cornerstone of atrial fibrillation (AF) ablation. Tools and techniques used for confirmation of PVI vary greatly, and it is unclear whether the use of any particular combination of tools and techniques provides greater sensitivity for identifying gaps periprocedurally. A high-density mapping catheter enabling simultaneous recording of adjacent bipolar EGMs in two directions is now available in multiple geographies, and it has been suggested that this technology may provide improved sensitivity for gap identification. Purpose To identify trends in the incidence of gaps identified in de novo PVI lines using three diagnostic catheter technologies, which may be suggestive of improved sensitivity for gap identification. Methods Self-reported procedural data was prospectively collected in de novo atrial fibrillation ablation cases utilizing one of three technologies to confirm PVI: 10-pole circular mapping catheter (CMC10), 20-pole circular mapping catheter (CMC20), and Advisor HD Grid catheter (HD Grid). Techniques for PVI confirmation were analyzed for each group, and the incidence and location of gaps identified by each technology was quantified. Results Data was collected in 99 cases across 11 centers in Europe and the United States. PVI was confirmed via entrance and/or exit block in all cases. CMC10 was utilized in 30 cases, CMC20 in 36, and HD Grid in 33. Use of adenosine varied across groups (CMC10: 6.7%; CMC20: 86.1%; HD Grid: 41.7%), as did application of a waiting period (CMC10: 96.7%; CMC20: 2.8%; HD Grid: 11.1%). Gaps were identified in in 36.7%, 38.9%, and 81.8% of cases using CMC10, CMC20, and HD Grid, respectively. HD Grid identified significantly more gaps than the other two technologies (p = 0.015), identifying an average of 49.0% and 139.1% more gaps per patient than CMC20 and CMC10, respectively (HD Grid: 2.15/patient; CMC20: 1.44/patient; CMC10: 0.9/patient). The location and incidence of gaps identified by each technology is shown in Figure 1. Conclusions Significantly more gaps were identified by the Advisor HD Grid catheter, as compared to a 10-pole or 20-pole circular mapping catheter. While this does not represent a direct comparison of the sensitivity for identification of gaps across these three technologies, and results could be impacted by other factors (e.g., operator, ablation technique, PVI confirmation technique, etc.), the strong trend toward an increased number of gaps identified with the HD Grid is striking. This may warrant further study including direct comparison of gap identification across technologies, and the resulting impact on long-term clinical outcomes when these additional gaps are ablated during the index procedure. Abstract Figure.

Résumé La pandémie de COVID-19 impose une réorganisation majeure de l’ensemble de notre système de soins. En France, des règles générales ont été diffusées au niveau national et sont déclinées par chaque établissement, public comme privé, sur l’ensemble du territoire. Ces recommandations, rédigées par un groupe d’experts sous l’égide de l’Association francophone de chirurgie endocrinienne (AFCE), ont pour objectif de proposer des principes spécifiques de prise en charge chirurgicale au cours et au décours de l’épidémie de COVID- 19, pour les pathologies chirurgicales de la thyroïde, des parathyroïdes, du pancréas endocrine, et des surrénales.

Left atrial appendage occlusion (LAAO) is an alternative option to oral anticoagulation therapy in patients with non-valvular atrial fibrillation. According to French regulations, this procedure is currently reserved for patients with formal contraindications to VKA and direct thrombin inhibitors. LAAO procedures reduce ischemic and stroke risks compared to no treatment and also reduce bleeding events compared to VKA therapy in eligible patients. The peri-procedural complications risk has been reported to be limited in the different series published so far. Although elderly patients (>75 years) have either higher ischemic and bleeding risk than younger subjects, they hardly benefit from optimal anticoagulation. Thus, these subjects might greatly benefit from LAAO. Published studies reported excellent feasibility and efficiency of LAAO procedure in elderly patients. Yet there is a trend towards a higher incidence of peri-procedural complications (including tamponade), long-term safety is excellent and comparable to what is observed in patients

Objectif L’hypoparathyroidie definitive est une complication sous-estimee de la chirurgie thyroidienne dont les consequences sont peu connues. L’objectif de cette etude etait de comparer les qualites de vie et de la voix de patients ayant eu une thyroidectomie totale presentant ou non une hypoparathyroidie definitive. Patients et methodes L’etude QoL-hypopara (ClinicalTrial.gov NCT04053647 ) etait une etude observationnelle nationale, incluant entre janvier et juin 2020 des patients ayant eu une thyroidectomie totale. Une PTH serique Resultats Sur 141 patients inclus, 45 presentaient une hypoparathyroidie. Le delai median apres la chirurgie etait de 6 [4–11] ans chez les hypoparathyroidiens et 4 [4–5] ans chez les controles. Le score mental (SF-36) etait significativement altere chez les hypoparathyroidiens (0,88 [0,63–1,01] versus 1,04 [0,82–1,13], p = 0,003). En analyse multivariee, l’hypoparathyroidie etait associee a un score mental altere independamment de l’âge, du sexe, de la presence d’un cancer thyroidien ou d’une TSH anormale (−0,17 [−0,28––0,07], p = 0,002). Les patients hypoparathyroidiens presentaient une qualite de la voix alteree (rapports des taux d’incidences du VHI : 1,83 [1,61–2,08], p Discussion L’hypoparathyroidie definitive s’accompagne d’une alteration significative de la qualite de vie et de la voix et de symptomes frequents. Ces resultats encouragent a renforcer la prevention de cette complication.

Background Percutaneous left atrial appendage occlusion (LAAO) has emerged as a valid alternative to oral anticoagulation therapy for the prevention of systemic embolism in patients with non-valvular atrial fibrillation (AF). Microvesicles (MVs) are shed-membrane particles generated during various cellular types activation/ apoptosis that carry out diverse biological effects, including procoagulant effects. Left atrial appendage has been suspected to be a potential source of MVs during AF, but the effects of LAAO on MVs production and circulating levels are unknown.The aim of this work study was to assess the variations of circulating MVs levels following LAAO. Methods The study includedn=25 LAAO patients and n=25 control patients who underwent coronary angiography. LAAO and control patients were treated by clopidogrel+ aspirin loading doses before procedures. Blood samples were drawn before antiplatelets therapy & 2 days after for all. A third sample was collected 6 weeks after procedure in LAAO patients. In N=10 extra patients, blood samples were collected from right atrium, left appendage and pulmonary vein during LAAO procedure. Circulating procoagulant (AnnV+), endothelial (CD62e+), platelets (CD41+), red blood cells/RBC (CD235+), leukocytes (CD11+) derived-MVs were measured using flow cytometry methods. Results Control and LAAO groups baseline characteristics were comparable, except for the higher age & incidence of previous stroke and lower incidence of coronary artery disease in LAAO patients. Baseline levels of the different microvesicles were comparable in both groups. In the LAAO group, we observed a significant increase of AnnV+ MVs (4355 [1712–8478] vs. 1798 [1006–2759] ev/μL, p=0.001), platelets (1615 [833–4772] vs. 802 [358–1376] ev/, p=0.005), RBC (207 [85–708] vs. 35 [5–84] ev/μL, p Conclusions LAAO impact circulating MVs and could create mild pro-coagulant status, inflammation and potential erythrocytes activation due to device presence during the first 6 weeks following intervention. These results suggest that careful attention should be paid in the anti-platelet/anti-coagulant therapy in the post procedural course. Acknowledgement/Funding This work was funded by a research grant from the French Society of Cardiology and a research grant from St Jude/Abbott

Left atrial appendage occlusion (LAAO) is an alternative option to oral anticoagulation therapy in patients with non-valvular atrial fibrillation. According to French regulations, this procedure is currently reserved for patients with formal contraindications to VKA and direct thrombin inhibitors. LAAO procedures reduce ischemic and stroke risks compared to no treatment and also reduce bleeding events compared to VKA therapy in eligible patients. The peri-procedural complications risk has been reported to be limited in the different series published so far. Although elderly patients (75 years) have either higher ischemic and bleeding risk than younger subjects, they hardly benefit from optimal anticoagulation. Thus, these subjects might greatly benefit from LAAO. Published studies reported excellent feasibility and efficiency of LAAO procedure in elderly patients. Yet there is a trend towards a higher incidence of peri-procedural complications (including tamponade), long-term safety is excellent and comparable to what is observed in patients75 years. Therefore, interventional percutaneous LAAO is an attractive strategy in elderly patients with atrial fibrillation that should be incorporated in a multidisciplinary management.

Resume Les performances de l’imagerie medicale entrainent la decouverte fortuite de nombreuses lesions tumorales silencieuses et ignorees. Le terme « incidentalome » surrenalien designe une masse surrenalienne, egale ou superieure a 1 cm de grand axe, decouverte fortuitement lors d’un examen d’imagerie abdominale non motive par l’exploration d’une pathologie surrenalienne. Ces incidentalomes peuvent etre secretants ou non, benins ou malins. Ces caracteristiques doivent etre determinees par le clinicien afin de l’aider dans le choix de la prise en charge. Il s’aide de la biologie et de l’imagerie, essentiellement du scanner sans et avec injection d’un produit de contraste iode. Les examens doivent etre choisis avec soin afin de ne pas proposer d’examens inutiles et couteux a un trop grand nombre de patients et, a l’inverse, de ne pas meconnaitre le diagnostic d’une tumeur maligne ou secretante. De ces examens va dependre la prise en charge des patients : chirurgicale ou surveillance. En cas de simple surveillance, des criteres precis doivent etre respectes dans les modalites de cette surveillance (clinique, imagerie, biologie) et dans sa duree.

Inferior laryngeal nerve (ILN) palsy and hypocalcemia remain the two most frequent major complications after thyroid surgery. Their occurrences may be explained by the influence of factors related to the patient, the surgical procedure, thyroid pathology, or the surgeon's technique. This study aims To assess whether systematically following a rigorous surgical technique during thyroidectomy affects postoperative complications and long-term patient recovery.We conducted a multicenter, cross-sectional study of prospectively collected data in five high-volume referral centers enrolling all patients who underwent thyroid surgery between April 2008 and December 2009. Inferior laryngeal nerve (ILN) palsy and hypocalcemia were systematically assessed during hospitalization based on objective criteria. A six-month follow-up was conducted in cases of early complications. Multivariate regression models were computed to quantify their relationship with potential risk factors.A total of 3574 thyroid procedures were completed. Non-visualization of the ILN during dissection and a large thyroid mass were major risk factors for permanent ILN palsy (OR, 4.17 and 2.61, p0.01) and persistent complications after initial injury (OR, 4.17 and 2.42, p0.05). The presence of thyroiditis on the surgical specimen was an independent risk factor for permanent hypoparathyroidism and poor recovery after initial dysfunction (OR, 1.76 and 1.88, p0.05).Thorough meticulous technique in thyroid surgery is a determinant of ILN function but fails to prevent persistent hypoparathyroidism.

Objectives To evaluate hability of a threshold value in ShearWave™ elastography to rule out malignant thyroid nodules while studying its pertinence in association with morphological signs. Equipment and methods 148 patients (110 women and 38 men; 52.5 y.o. 15.8) referred for surgery of thyroid nodules underwent standard ultrasound as well as elastography. Characteristics of the morphological signs and maximum elastographic index were calculated in relation to histology. Association of morphological signs alone and then of elastography was also evaluated. One hundred and fifty one nodules were studied on a double-blind basis. Results 297 nodules were studied. Thirty-five cancers were detected (11.6%). Elastographic index was higher in malignant nodules (115kPa 60.4) than in benign nodules (41kPa 25.8) ( p t -test). Cut off value of 66kPa was the best to discriminate malignant nodules with a sensitivity of 80% (CI 95%, 62.5; 90.9) and a specificity of 90.5% (CI 95%, 86.1; 93.6) ( p =0.0001). Association of elastography and morphological ultrasound signs presented a sensitivity of 97% (CI 95%, 83.3; 99.8) and a negative predictive value of 99.5% (CI 95%, 95.6; 99.9). Interobserver reproducibility proved to be excellent with an interclass correlation of 0.97 (CI 95%, 0.96; 0.98) ( p Conclusion The 66kPa threshold in Shear Wave elastography is the best ultrasound sign to rule out malignant thyroid nodules. The method is simple, quantitative, reproducible and usable in the study of nodules larger than 3cm. Progress must still be made in the study of calcified nodules and follicular tumors.

Introduction Les paralysies recurrentielles (PR) sont retrouvees chez 3 % des patients apres thyroidectomie. L’utilisation du neuromonitoring (NIM) des nerfs recurrents se generalise. Le but de notre travail etait d’evaluer l’impact du NIM sur le taux de PR apres thyroidectomie. Methodes Cette etude prospective, multicentrique compare les taux de PR apres thyroidectomie totale avec ou sans NIM. Les patients ont eu une laryngoscopie postoperatoire systematique. Resultats Parmi les 1328 patients inclus, 807 (60,8 %) ont ete operes avec le NIM et 521 sans NIM. En postoperatoire, 131 (9,93 %) ont presente une PR. Dans le groupe NIM, 69 (8,6 %) avaient une PR ; 38 avaient une PR partielle (4,7 %) et 31 (3,8 %) une complete. Dans le groupe sans NIM, 62 (12,1 %) avaient une PR ; 38 (7,4 %) une PR partielle et 24 (4,7 %) une complete. Cette difference etait significative en analyse univariee (OR : 0,68, IC 95 % : 0,47–0,98, p = 0,003). La difference n’etait plus significative en analyse multivariee (OR : 0,74, IC 95 % : 0,47–1,17, p = 0,19). Les sensibilite, specificite, valeur predictives positive et negative etaient respectivement de 29 %, 98 %, 61 % et 94 %. Conclusion Dans notre etude, le NIM ne permettait pas de diminuer significativement le taux de PR. Sa bonne specificite permet de prevoir de facon fiable une bonne mobilite des cordes vocales.

Resume Dans ce chapitre est rapporte le compte rendu du symposium Nycomed intitule « 60 minutes pour comprendre : de l’hemostase aux regles du management »

The determination of elasticity index by elastography has been recently proposed in the evaluation of thyroid nodules, since malignancy is correlated with stiffness of the nodules. The aim of this report is to give an overview on different techniques and results reported by eleven groups active on the field. Advantages and limitations of elastography are also discussed. In our opinion, further studies, preferentially multicentric, are necessary before being able to conclude about the place of elastography in thyroid nodules evaluation, versus fine-needle aspiration cytology (FNAC), the gold standard. Indeed, elastography could reduce FNAC or at least allow to select nodule's (or nodular zone's) for aspirations.

Summary Aims and methods The aim of this prospective study was to compare the diagnostic value of [18F]FDOPA-PET and [111In]pentetreotide-SPECT somatostatin receptor scintigraphy (SRS) in patients with nonmetastatic extra-adrenal paragangliomas (PGLs). Twenty-five consecutive unrelated patients who were known or suspected of having nonmetastatic extra-adrenal PGLs were prospectively evaluated with SRS and [18F]FDOPA-PET. 131I-MIBG and [18F]FDG-PET were added to the work-up in patients with a personal or familial history of PGL, predisposing mutations, abdominal PGLs, metanephrine hypersecretion and abdominal foci on SRS and/or [18F]FDOPA-PET. Results SRS correctly detected 23/45 lesions of which 20 were head or neck lesions (H&N) and 3 were abdominal lesions. [18F]FDOPA-PET detected significantly more lesions than SRS (39/45, P

Introduction L’hypercortisolisme est a l’origine de consequences cliniques severes qui persistent apres la remission. Ces sequelles physiques impactent fortement la qualite de vie des patients. Comme certains facteurs psychologiques peuvent etre correles avec cette qualite de vie, notre objectif etait de determiner le poids specifique de ces determinants psychologiques dans la qualite de vie de ces patients en remission. Patients et methodes Dans cette etude observationnelle, 63 patients avec un hypercortisolisme en remission ont rempli des auto-questionnaires portant sur la qualite de vie (WHOQoL-BREF et CushingQoL), la depression, l’anxiete, l’estime de soi, l’image corporelle, et les strategies de « coping ». Des analyses multivariees ont ete effectuees, pour determiner les determinants de la qualite de vie : anxiete, depression, estime de soi, image corporelle, insuffisance surrenale ont ete analyses dans ce sens. Resultats Le delai median de remission etait de 3 ans. Les patients avaient une qualite de vie significativement plus faible que celle des patients porteurs de maladies chroniques, et que celle de la population general francaise. La depression impactait significativement tous les compartiments de la WHOQol et de la CushingQol. L’image corporelle impactait les relations socioprofessionnelles : 42,9 % des patients avaient un poste de travail amenage, 19 % avaient arrete de travailler ou etaient reconnus travailleurs handicapes. Conclusion La remission fonctionnelle, concept principalement utilise en psychiatrie et oppose a la remission biologique, est rarement observee apres remission de l’hypercortisolisme du fait principalement d’une depression persistante : une collaboration endocrinologue/psychiatre est donc indispensable tout au long de la maladie et apres.

A few prospective studies have evaluated the use of recombinant human TSH (rhTSH) for radioiodine remnant ablation.Our objective was to compare the effects of the both TSH regimens on iodine biokinetics in the thyroid remnant, dosimetry, and radiation protection.We conducted a prospective randomized study.Eighty-eight patients were enrolled for radioiodine ablation to either the hypothyroid or rhTSH arms. A whole-body scan was performed at 48 and 144 h after therapy. Dose rates were assessed at 24, 48, and 144 h. Urinary samples were obtained during the first 48 h. Thyroglobulin was assessed before and after therapy. Iodine biokinetics in the remnants were calculated from gamma-count rates. Radiation-absorbed dose was calculated using OLINDA software. Exposure estimation was based on a validated model.The effective half-life in the remnant thyroid tissue was significantly longer after rhTSH than during hypothyroidism (P = 0.01), whereas 48-h (131)I uptakes and residence times were similar. After therapy, thyroglobulin release (a marker of cell damage) was lower in the rhTSH arm. The mean total-body effective half-life and residence time were shorter in patients treated after rhTSH. Residence time was also lower for the colon and stomach. Absorbed dose estimates were lower in the rhTSH arm for the lower large intestine, breasts, ovaries, and the bone marrow. Dose rates at the time of discharge were lower in the rhTSH group with a reduction in cumulative radiation exposure to contact persons.In comparison with thyroid hormone withdrawal, rhTSH is associated with longer remnant half-life of radioactive iodine while also reducing radiation exposure to the rest of the body and also to the general public who come in contact with such patients.

Aims: To determine if primary hyperparathyroidism (pHPT) per se may be responsible of hypercalcitoninemia. pHPT induces chronic hypercalcemia that should be expected to be a potential stimulatory pathway of calcitonin (CT) secretion and to cause hypercalcitoninemia. Method: We studied relationships between CT and pHPT-related chronic hypercalcemia in 122 patients aged 25–83 years who underwent parathyroid surgery. CT, calcium and PTH plasma levels were measured in all patients preoperatively. CT was measured by a current immunometric assay specific of mature CT monomer. Results: Of our 122 patients with pHPT-related hypercalcemia, 120 (98.4%) had normal CT values of less than 10 pg/ml and two (1.6%) exhibited a mildly increased CT above 10 pg/ml (11 and 12 pg/ml, respectively). We evidenced no relationship between CT and calcium level or PTH level. Conclusions: Chronic pHPT-related hypercalcemia per se does not cause hypercalcitoninemia. The finding of pHPT concomitant with high CT levels should raise suspicion of multiple endocrine neoplasia type 2A.

Summary Background Recombinant human TSH (rhTSH) has become the modality of choice for radioiodine remnant ablation (RRA) in low-risk thyroid cancer patients. Aims and methods The aims of the present prospective randomized study were to evaluate the impact of TSH stimulation procedure (hypothyroidism vs. rhTSH) on quality of life (QoL) of thyroid cancer patients undergoing RRA and to evaluate efficacy of both procedures. L-T4 was initiated in both groups after thyroidectomy. After randomization, L-T4 was discontinued in hypothyroid (hypo) group and continued in rhTSH group. A measure of 3·7 GBq of radioiodine was given to both groups. The functional assessment of chronic illness therapy-fatigue (FACIT-F) was administered from the early postoperative period to 9 months. Socio-demographic parameters, anxiety and depression scales were also evaluated (CES-D, BDI and Spielberger state-trait questionnaires). At 9 months, patients underwent an rhTSH stimulation test, diagnostic 131I whole body scan (dxWBS) and neck ultrasonography. Results A total of 74 patients were enrolled for the study. There was a significant decrease in QoL from baseline (t0) to t1 (RRA period) in the hypothyroid group with significant differences in FACIT-F TOI (P

The endoscopic lateral approach in thyroid and parathyroid surgery is achieved by developing the plane between the carotid sheath laterally and the strap muscles medially. This approach allows direct access to the posterior aspect of the thyroid lobe, without the need for the dissection of the strap muscles and without the need for medial retraction of the thyroid during the procedure. The lateral approach aided by endoscopic magnification provides the surgeon with the ideal view with which to safely dissect the vital structures found in the retro-thyroid space such as the inferior thyroid artery, the recurrent laryngeal nerve and the parathyroid glands. This approach was initially adopted in primary hyperparathyroidism caused by a single adenoma that had been localized preoperatively. It is now also offered to patients with an isolated thyroid nodule smaller than 25 mm in diameter requiring surgical excision. Experience with 408 parathyroidectomies and the preliminary results of 38 thyroid lobectomies allows the authors to recommend this technique to appropriately selected patients.

Background Medullary thyroid carcinoma (MTC) is a rare disease, with variable tendency to lymphatic spread. The aim of this retrospective study was to identify distinctive features of large MTC with and without nodal metastases. Methods Between 1993 and 2003, 28 consecutive patients underwent total thyroidectomy and neck node dissection for sporadic MTC larger than 10 mm in diameter. Results All tumours were confirmed to be malignant with a locally invasive pattern of growth. Lymph node metastases were present in 16 patients (N1) and absent in 12 (N0). There were no statistically significant differences between patients with N0 and N1 tumours concerning age (mean 52·1 versus 53·4 years), male:female ratio (0·7 versus 1·0), basal preoperative calcitonin concentration (mean 3238 versus 3076 pg/ml) and tumour size (23·3 versus 23·9 mm). There were differences in the incidence of tumour invasion (P < 0·001), vascular embolism (P = 0·011) and peritumoral thyroiditis (P = 0·039). Measurement of basal and stimulated calcitonin levels after surgery confirmed biochemical cure in all patients with N0 tumours and half of those with N1 disease (P = 0·006). Conclusion There were no preoperative factors that predicted node status for MTC larger than 1 cm in this series. Total thyroidectomy and nodal dissection remains the optimal treatment.

Resume Introduction . – Au cours de ces dernieres annees, plusieurs techniques de parathyroidectomie mini-invasive ont ete rapportees. Cette etude retrospective a pour but de preciser la place actuelle de la parathyroidectomie video-assistee (PVA) dans notre pratique de la chirurgie de l’hyperparathyroidisme primaire (HPT I). Patients et methodes. – En 5 ans (1998-2002), 528 patients porteurs d’un HPT I ont ete operes dans le service. Une PVA a ete proposee a tous les patients presentant un HPT I sporadique, sans goitre associe et sans antecedent de chirurgie thyroparathyroidienne, et chez qui une echographie et une scintigraphie Mibi systematiquement pratiquees en preoperatoire, etaient en faveur d’une lesion unique. La PVA a ete pratiquee par voie laterocervicale avec insufflation lorsque l’imagerie etait en faveur d’une lesion retrothyroidienne ou par voie mediane sans insufflation lorsque la lesion etait en situation cervicale anterieure. Chez tous les patients, la radicalite de l’exerese parathyroidienne a ete verifiee par des dosages rapides de PTH (rPTH). En postoperatoire, la calcemie, la phosphoremie et les taux de PTH ont ete evalues a j1, j8 puis 1 mois plus tard et 1 an plus tard. Tous les patients ont eu un controle de la mobilite de leurs cordes vocales en pre et postoperatoire. Resultats. – La parathyroidectomie a ete pratiquee par cervicotomie transverse conventionnelle chez 228 patients (43 %) et par un abord video-assiste chez 300 patients (57 %). Les 228 patientes operes par cervicotomie transverse presentaient une contre-indication a une PVA : goitre nodulaire associe necessitant eventuellement une thyroidectomie concomitante (99 cas), antecedents de chirurgie cervicale (42 cas), suspicion de lesions multiglandulaires (25 cas), absence de localisation preoperatoire (48 cas), causes diverses (14 cas). L’indication d’une PVA a ete retenue chez 300 patients presentant un HPT I sporadique : 282 patients ont ete operes par voie laterale, 17 par voie centrale et un par thoracoscopie. La duree operatoire mediane a ete de 50 min (20-130 min). Chez 42 patients (14 %), une conversion en cervicotomie transverse a ete necessaire : 11 adenomes non trouves, difficultes de dissection en rapport avec des adenomes volumineux ou adherents aux structures voisines chez 7 patients, faux positifs de l’imagerie dans 11 cas, non observation d’une decroissance de plus de 50 % des taux de rPTH chez 13 patients. Chez 10 de ces 13 patients, la conversion a confirme l’existence de lesions multiglandulaires, mais chez les 3 autres, il s’agissait d’un faux negatif de la rPTH. La mortalite a ete nulle. Un patient a presente une paralysie recurrentielle definitive. Un patient presente un HPT I persistant et un autre un probable HPT I recidivant. Conclusion. – Une PVA peut etre proposee a plus de la moitie des patients presentant une HTP I. Dans notre experience, parathyroidectomie conventionnelle et PVA sont devenues complementaires. A condition de selectionner rigoureusement les patients, les resultats precoces de la PVA sont comparables a ceux de la chirurgie conventionnelle. Le risque reel d’HPT I recidivant ne pourra etre evalue qu’apres plusieurs annees de suivi.

Resume Les kystes bronchogeniques sont habituellement des malformations congenitales benignes. Une localisation retroperitoneale est extremement rare. Nous rapportons le cas d’un kyste bronchogenique en position retroperitoneale chez un patient de 60 ans. La lesion a ete decouverte fortuitement sur la TDM abdominale du bilan d’extension d’un adenocarcinome de la prostate. Les examens biologiques, radiologiques et histologiques ont confirme le diagnostic de kyste bronchogenique. L’excision chirurgicale est le traitement de choix pour la majorite des auteurs, mais en raison du faible risque de transformation maligne, nous avons choisi d’effectuer un suivi avec tomodensitometrie abdominale tous les six mois. Pendant trois ans, les examens biologiques et radiologiques ont montre que la lesion restait stable. Il semble par consequent raisonnable de proposer une simple surveillance radiologique des kystes bronchogeniques chez des patients selectionnes.

Resume But de l’etude : Preciser la place de la chirurgie video-endoscopique dans le traitement chirurgical des differentes endocrinopathies surrenaliennes et discuter des indications respectives de l’abord trans- ou retroperitoneal video-endoscopique. Materiel et methodes : Au cours des huit dernieres annees (1994–2001), 330 surrenalectomies ont ete pratiquees chez 305 patients : 274 (83 %) par voie video-endoscopique et 56 (17 %) par voie ouverte. La voie ouverte a ete reservee aux patients presentant des tumeurs volumineuses ou malignes (29 cas), des pheochromocytomes multiples et/ou extrasurrenaliens (13 cas), des antecedents de chirurgie abdominale sus-mesocolique (dix cas) ou necessitant un geste chirurgical abdominal associe (quatre cas). Les surrenalectomies video-endoscopiques pratiquees par voie transperitoneale laterale etaient indiquees pour 89 syndromes de Conn, 67 syndromes de Cushing, deux tumeurs virilisantes, 51 pheochromocytomes et 65 tumeurs solides non secretantes d’un diametre superieur a 4 cm. Dix-neuf patients ont subi une surrenalectomie bilaterale. Resultats : La mortalite a ete nulle. Vingt patients (7,3 %) ont presente une complication. Les 11 conversions en chirurgie ouverte (4,01 %) ont ete motivees par des difficultes de dissection (8 cas), une suspicion preoperatoire de malignite (2 cas) et un pneumothorax. La taille moyenne des tumeurs etait de 34 mm (7–110). Dix-huit tumeurs (6,5 %) etaient malignes : huit corticosurrenalomes, un leiomyosarcome et neuf metastases. Tous les patients presentant une lesion secretante ont ete gueris de leur endocrinopathie. Une patiente est decedee de metastases hepatiques un an apres avoir ete operee d’un cortico-surrenalome malin. Conclusion : La plupart des tumeurs surrenaliennes peuvent etre operees par chirurgie video-endoscopique. Seules les tumeurs invasives reclamant des exereses elargies sont une contre-indication formelle. L’abord transperitoneal par voie laterale est plus adapte aux exereses des tumeurs de plus de 5–6 cm de diametre. Pour les petites tumeurs, les abords trans ou retro-peritoneaux peuvent etre indifferemment proposes selon les habitudes de l’operateur. Neanmoins un volumineux lobe hepatique droit ou des antecedents de chirurgie sus-mesocolique peuvent faire preferer l’abord retroperitoneal.

But Predire le risque d’hypocalcemie postoperatoire necessitante d’un traitement vitamino-calcique des j1, etant donne qu’en ce contexte il n’y a pas de consensus. Materiel et methodes Janvier–decembre 2014 : 477 patients operes d’une thyroidectomie totale sans hyperparathyroidie associee. Analyse systematique des calcemies corrigees (Ca.c) et PTH a j1. Les patients symptomatiques ou si Ca.c Resultats Soixante-dix patients (14,67 %) avec hypocalcemie etaient traites. Aucun patient avec Ca.c > 2,16 mmol/L et PTH > 1,9 pmol/L (68,13 %) n’a necessite de traitement (sortie a j1 ; VPP : 100 %). Tous les patients avec Ca.c 4,7 pmol/L ne necessitaient aucun traitement (n = 9 patients ; 1,88 %). Pour 44/50 patients avec calcemie entre 2,16–1,9 mmol/L et PTH > 1,9 pmol/L pas d’hypocalcemie et de traitement (sensibilite 83 % ; specificite 88,5 % ; p > 0,0001). Au total, 70 % des patients auraient pu regagner leur domicile a j1 sans risque. Conclusion Ca.c et PTH a j1 permettent de predire le risque d’hypocalcemie postoperatoire. Ils sont fiables pour la gestion clinique, permettent de reduire la duree d’hospitalisation sans risques.

Contexte Peu d’etudes ont evalue le role de la TEP/TDM au 18F-Fluorodeoxyglucose dans le diagnostic de tumeurs surrenaliennes chez les patients non oncologiques. Objectif Evaluer la contribution de la TEP/TDM au 18F-FDG dans cette indication dans le cadre d’une etude prospective. Materiel et methodes La population d’etude a consiste en 87 masses surrenales (87 patients) : 56 avec diametre > 40 mm et 31 avec diametre ≤ 40 mm mais de nature indeterminee sur le scanner surrenalien (avec calcul des lavages). Quatorze patients avaient un hypercortisolisme. Les masses surrenaliennes ont ete caracterisees par TEP/TDM au 18F-FDG. L’histologie a ete consideree comme l’etalon pour le diagnostic de lesion benigne ou maligne. Dans d’autres cas, la nature benigne de la lesion a ete basee sur le suivi par TDM a 12 mois (modification de la taille Resultats Quinze ont ete classees comme malignes (incluant 11 CSM) et 72 benignes (49 histologiquement prouvees et 23 stables). Comparees aux lesions benignes, les lesions malignes avaient une plus grande taille ( p = 0,003), une densite spontanee plus elevee ( p = 0,002), un lavage relatif plus bas ( p = 0,007) et une captation de 18F-FDG plus elevee sur l’analyse qualitative et quantitative ( p 1,5 avec des sensibilite, specificite, VPP, VPN et exactitude de 86,7 % (l’intervalle de confiance de 95 % : 62,1 %–96,3 %), 86,1 (76,3–92,3), 56,5 (36,8–74,4), 96,9 (89,3–99,1) et 86,2 (77,4–91,9), respectivement. Bien que statistiquement non significative, comparee aux parametres quantitatifs, l’analyse visuelle avait une sensibilite de 100 % (contre 90,9 % pour le ratio) dans la distinction entre l’adenome vs CSM. Un modele predictif pour le diagnostic de CSM tenant compte de la taille et du ratio a ete construit. Conclusions Nos resultats montrent que la TEP/TDM au 18F-FDG permet d’ameliorer la caracterisation des masses surrenaliennes volumineuses et/ou atypiques a la TDM et devrait etre recommandee dans cette indication.

The diagnosis of thyroid nodules is straightforward and rarely mistaken. We present a case of a paraesophageal granular cell tumor, discovered incidentally during surgery for what it was diagnosed as a suspicious thyroid nodule by ultrasound and FNA. Complete resection was achieved without disruption of the esophageal mucosa. A terminal branch of the recurrent laryngeal nerve had to be resected en bloc with the tumor. Morphological and immunohistochemical diagnosis was established postoperatively. A review of the literature is presented.

Introduction Le pronostic de la NEM2 est theoriquement lie a l’âge de diagnostic du cancer medullaire thyroidien. Des recommandations ont ete faites pour uniformiser l’âge de la thyroidectomie prophylactique. Notre objectif etait d’analyser le devenir des patients NEM2 suivis dans notre centre et operes apres l’âge recommande de thyroidectomie (recommandations de l’American Thyroid Association : Wells et al., Thyroid, 2015). Methodes Etude monocentrique, retrospective. Resultats Parmi 51 patients (RET Codon 533, n = 2 ; 618, n = 2 ; 634, n = 43 ; 883, n = 2 ; 918, n = 2) analyses, 6 (918, n = 1 ; 634, n = 5) operes selon les recommandations sont en remission. Sur les 45 patients operes hors recommandations, 23 sont en remission, dont 20 porteurs d’une mutation 634 et operes en moyenne 12,7 ans apres l’âge recommande (min, 1 ; max, 43 ans apres ; dont 10 operes au moins 10 ans apres). A l’inverse, 22 patients ne sont pas gueris dont 18 porteurs d’une mutation 634 et operes en moyenne 17 ans apres l’âge recommande (min 1 ; max, 30 ans apres ; âge moyen, p = 0,19 vs patients 634 en remission ; calcitonine moyenne au dernier bilan a 900 pg/mL) : 4 patients porteurs d’une mutation 634, operes 6, 8, 10 et 13 ans apres l’âge recommande sont metastatiques. Conclusion Une fois passe l’âge recommande pour la thyroidectomie prophylactique, l’âge a la chirurgie ne prejuge pas du devenir du patient en termes de remission ou agressivite de la pathologie residuelle : chez ces patients, les chirurgies les plus tardives n’ont pas toujours le plus mauvais pronostic.

The aim of this prospective study was to compare the diagnostic value of [¹⁸F]FDOPA-PET and [¹¹¹In]pentetreotide-SPECT somatostatin receptor scintigraphy (SRS) in patients with nonmetastatic extra-adrenal paragangliomas (PGLs). Twenty-five consecutive unrelated patients who were known or suspected of having nonmetastatic extra-adrenal PGLs were prospectively evaluated with SRS and [¹⁸F]FDOPA-PET. ¹³¹I-MIBG and [¹⁸F]FDG-PET were added to the work-up in patients with a personal or familial history of PGL, predisposing mutations, abdominal PGLs, metanephrine hypersecretion and abdominal foci on SRS and/or [¹⁸F]FDOPA-PET.SRS correctly detected 23/45 lesions of which 20 were head or neck lesions (HN) and 3 were abdominal lesions. [¹⁸F]FDOPA-PET detected significantly more lesions than SRS (39/45, P0·001). Both SRS and ¹⁸F-DOPA-PET detected significantly more HN than abdominal lesions (66·7% vs 20%, P = 0·003 and 96·7% vs 67%, P = 0·012, respectively). In two patients with the succinate dehydrogenase D (SDHD) mutation, [¹⁸F]FDOPA-PET missed five abdominal PGLs which were detected by the combination of SRS, [¹³¹I]MIBG and [¹⁸F]FDG-PET. A lesion-based analysis using a forward stepwise logistic regression model demonstrates that size ≤ 10 mm (P = 0·002) and abdominal lesions (P = 0·031) were independently associated with "[¹⁸F]FDOPA-PET diagnosis only". In turn, a previous history of surgery and/or the presence of germline mutation was associated with lower lesion size (P = 0·001).The sensitivity of SRS for localizing parasympathetic PGLs is lower than originally reported, and [¹⁸F]FDOPA-PET is better than SRS for localizing small lesions. SRS should be replaced by [¹⁸F]FDOPA-PET as the first-line imaging procedure in HN PGL, especially in patients at risk of multifocal disease (predisposing mutations and or previous history of surgery).

Background Not operating on patients with mild hypercalcitoninaemia (MHCT) and sporadic thyroid disease carries the risk of omitting curative surgery for medullary thyroid cancer, but systematic surgery would result in unnecessary treatment of benign pathology. This study reviewed the management of MCHT and non-hereditary thyroid disease in one centre. Methods MCHT was defined as an increase in basal and stimulated calcitonin levels not exceeding 30 and 200 pg/ml respectively. Over 15 years, 125 patients who presented with MCHT and sporadic thyroid disease were followed. Surgery was indicated only if there were local pressure symptoms or suspicious histomorphological changes in solitary nodules. Results Fifty-five patients underwent total thyroidectomy and 18 unilateral total lobectomy. Histological examination revealed medullary microcarcinoma in six patients (two women and four men). C-cell hyperplasia was found in 54 patients (74 per cent) and 13 (18 per cent) harboured no C-cell pathology. Calcitonin levels stabilized after lobectomy and became undetectable following thyroidectomy. They normalized during follow-up in a third of patients who did not have surgery. Conclusion Not all patients with MHCT and sporadic thyroid disease require surgery.

Medullary thyroid cancer (MTC) is characterized by early regional lymph node metastasis, the presence of which represents a critical obstacle to cure. At present no molecular markers have been successfully integrated into the clinical care of sporadic MTC. The present study was designed to evaluate TP53INP1 expression in MTC and to assess its ability to guide the surgeon to the optimal extent of surgery performed with curative intent. Thirty-eight patients with sporadic MTC were evaluated. TP53INP1 immunoexpression was studied on embedded paraffin material and on cytological smears. TP53INP1 was expressed in normal C cells, in C-cell hyperplasia, and in 57.9% of MTC. It was possible to identify two groups of MTC according to the proportion of TP53INP1 expressing tumor cells: group 1 from 0% to

Fluorine-18-L-dihydroxyphenylalanine positron emission tomography (18F-FDOPA PET) imaging is increasingly used in the workup of neuroendocrine tumors. It has been shown to be an accurate tool in the diagnosis of congenital hyperinsulinism, but limited information is available on its value in adult disease. OBJECTIVE, PATIENTS, AND DESIGN: The objective of this study was to review our experience with 18F-FDOPA PET imaging in six consecutive patients with hyperinsulinemic hypoglycemia (HH) (four solitary insulinomas, one diffuse beta-cell hyperplasia, one malignant insulinoma). 18F-FDOPA uptake was also evaluated in 37 patients (43 procedures) without HH or other pancreatic neuroendocrine tumors, which acted as a control group.Using visual analysis, 18F-FDOPA-PET proved positive in only one case (a multiple endocrine neoplasia type 1 related insulinoma). In diffuse beta-cell hyperplasia, the pancreatic uptake was similar to controls. In the patient with liver metastases, the extent of disease was underestimated. The pancreatic uptake was not statistically different between controls and hyperinsulinemic patients. The main limitation for identifying insulinomas or beta-cell hyperplasia in adults appears to be to the 18F-FDOPA uptake and retention in the whole pancreas. This drawback is potentially circumvented in focal hyperplasia in newborns due to a lower aromatic amino acid decarboxylase expression in the extralesional pancreatic parenchyma.18F-FDOPA PET is of limited value in localizing pancreatic insulin secreting tumors in adult HH. Our results contrast with the referential study and require further analysis.

Primary hyperparathyroidism is an unusual cause of acute pancreatitis. The aim of this study was to analyse data from multiple centers concerning patients with primary hyperparathyroidism and associated acute pancreatitis and to analyze potential predictive factors.In this retrospective multicentric study, 19 patients were identified (Group A) with the associated diagnoses of acute pancreatitis and primary hyperparathyroidism. Their clinical data was compared to that of a control group of 65 patients (group B) with primary hyperparathyroidism without acute pancreatitis.Age, parathormone levels and pathology (uni/multiglandular disease) were similar between the two groups. The mean plasma calcium level was significantly higher in group A (12.64 mg/100ml) than in group B patients without pancreatitis (11.28 mg/100ml) (p0.0001).This study confirms the causal relationship between primary hyperparathyroidism and acute pancreatitis. The degree of hypercalcemia may play an important role in this association. Calcium levels should be measured in all patients with acute pancreatitis.

The widespread use of high-resolution cross-sectional imaging such as computed tomography (CT) and magnetic resonance imaging (MRI) for the investigation of the abdomen is associated with an increasing detection of incidental adrenal masses. We evaluated the ability of (18)F-fluorodeoxyglucose positron emission tomography to distinguish benign from malignant adrenal masses when CT or MRI results had been inconclusive.We included only patients with no evidence of hormonal hypersecretion and no personal history of cancer or in whom previously diagnosed cancer was in prolonged remission. PET/CT scans were acquired after 90 min (mean, range 60-140 min) after FDG injection. The visual interpretation, maximum standardised uptake values (SUVmax) and adrenal compared to liver uptake ratio were correlated with the final histological diagnosis or clinico-radiological follow-up when surgery had not been performed.Thirty-seven patients with 41 adrenal masses were prospectively evaluated. The final diagnosis was 12 malignant, 17 benign tumours, and 12 tumours classified as benign on follow-up. The visual interpretation was more accurate than SUVmax alone, tumour diameter or unenhanced density, with a sensitivity of 100% (12/12), a specificity of 86% (25/29) and a negative predictive value of 100% (25/25). The use of 1.8 as the threshold for tumour/liver SUVmax ratio, retrospectively established, demonstrated 100% sensitivity and specificity.FDG PET/CT accurately characterises adrenal tumours, with an excellent sensitivity and negative predictive values. Thus, a negative PET may predict a benign tumour that would potentially prevent the need for surgery of adrenal tumours with inconclusive conventional imaging.

The purpose of this study was to compare the diagnostic interest of Hector Battifora mesothelial antigen-1 (HBME-1), thyroid peroxidase (TPO), and dipeptidyl aminopeptidase IV (DPP4) in thyroid fine-needle aspirates obtained from 200 resected thyroid lesions (55 colloid nodules, 54 follicular adenomas, 59 papillary cancers, and 32 follicular carcinomas). Hector Battifora mesothelial antigen-1 or TPO expression (% positive cells) and DPP4 staining score (12-point scale) were evaluated. Receiver operating characteristic (ROC) curves were plotted and optimal cutoff values for diagnosing malignancy were determined. The TPO ROC curve was consistently higher than the HBME-1 ROC curve. The TPO curve was also higher than the DPP4 curve with regard to sensitivity, but dipped below the DPP4 curve with regard to specificity. Using a cutoff value of 10% positive cells for HBME-1, and staining score ⩾1 for DPP4, sensitivity to specificity ratios were 98–83% for TPO, 90–60% for HBME-1, and 88–80% for DPP4. Two particularly interesting findings of this study were the low negative likelihood ratio of TPO (0.02) allowing highly reliable exclusion of malignancy and the 100% specificity of DPP4 staining scores=12. Due to poor performance on follicular lesions, HBME-1 showed no advantage over TPO or DPP4.

Background Distinction of parathyroid cancer from atypical parathyroid adenoma (APA) at operation is difficult. The aim of this study was to determine whether parathyroid cancer and APA have different operative findings and long-term outcomes. Methods A retrospective review was undertaken of patients with suspicious or malignant parathyroid tumours treated between 1974 and 2005. Parathyroid cancer was defined as a lesion with vascular or tissue invasion, and APA as a neoplasm with broad fibrous bands, trabecular growth, mitosis and nuclear atypia. Results Twenty-seven patients with suspicious or malignant parathyroid tumours were identified. After histological review, parathyroid cancer was confirmed in 11 patients (group 1) and 16 tumours were classified as APA (group 2). The clinical presentation and operative findings of the two types of tumour were indistinguishable. At initial surgery, seven patients in group 1 underwent en bloc resection, and four had parathyroidectomy. Four of the seven patients who had en bloc resection had recurrences. No recurrences were observed in the other seven patients in group 1 at a median follow-up of 65 months. In group 2, eight patients had en bloc resection and eight had parathyroidectomy; no patient had recurrence at a median follow-up of 91 months. Conclusion Operative findings cannot distinguish APA from parathyroid cancer reliably. Without evidence of macroscopic local invasion, the value of en bloc resection at initial surgery remains debatable.

The article describes the normal structure of the parathyroid glands (PTG) and their development, anomalies of migration in the process of embryogenesis and congenital ectopias of PTG as well as possible supplementary PTG and their congenital ectopias.