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Significant genotype-phenotype variability among multiple endocrine neoplasia type 2A patients with a RET V804M mutation has been reported.Patients with a RET V804M mutation treated at a single center were identified (January 1996-December 2020). The baseline characteristics, operative details, pathology, biochemical, and long-term data were analyzed.There were 79 patients; none developed pheochromocytoma or hyperparathyroidism or died in the study period. The mean age was 41.5 years (range = 1.0-81.0 years); 46.8% were men. Of 68 surgical patients, 53 (77.9%) underwent total thyroidectomy and 15 (22.1%) underwent total thyroidectomy with central neck dissection with or without lateral neck dissection. Twenty-four patients had elevated preoperative calcitonin, of whom 12 underwent total thyroidectomy (median = 7.5; range = 5.0-237.0 pg/mL), 10 underwent total thyroidectomy + central neck dissection (median = 27.6; range = 5.1-147.0 pg/mL), and 2 underwent total thyroidectomy + central neck dissection + lateral neck dissection (median = 3182.0; range = 361.0-6003.0 pg/mL). Pathology was benign (27.9%), papillary thyroid cancer alone (1.5%), C-cell hyperplasia (23.5%), and medullary thyroid cancer (47.1%; median tumor size = 3.0 mm). Three patients had elevated calcitonin postoperatively (median follow-up time = 60.0 months). In adjusted modeling, a preoperative calcitonin5 pg/mL was associated with having medullary thyroid cancer on final pathology (odds ratio = 13.3; 95% confidence interval, 3.2-56.3; P.001).In this large United States cohort of surgical patients with a RET V804M mutation, most had indolent disease and were without classic multiple endocrine neoplasia type 2A features. Calcitonin5 pg/mL may serve as a meaningful value to guide surveillance and timing of surgery.

Studies comparing endocrine-specific outcomes following parathyroidectomy (PTx) versus concurrent parathyroidectomy and thyroidectomy (PTx + Tx) are few.10,019 patients were selected from the Collaborative Endocrine Surgery Quality Improvement Program (2014-2019). Baseline characteristics and short-term (≤30 days) outcomes for PTx + Tx vs PTx patients were compared using bivariate and multivariable methods.PTx + Tx patients were more likely to experience clinical hypoparathyroidism (6.7% vs 0.5%, p 0.001), recurrent laryngeal nerve transection, (0.4% vs 0.1%, p = 0.002) and hematoma requiring evacuation (1.0% vs 0.2%, p 0.001). Readmissions and ED visits for hypocalcemia were more frequent after PTx + Tx vs PTx. Concurrent surgery was associated with an 8-fold increase in risk of short-term complications (Odds Ratio (OR): 8.0, 95% Confidence Interval (CI): 5.7-11.1, p 0.001).Patients undergoing PTx + Tx have increased rates of postoperative complications, ED visits, and readmissions compared to patients undergoing parathyroidectomy alone. These findings could help guide surgeon-patient discussions on the risks of concurrent surgery.

Differentiated thyroid carcinomas is associated with an excellent prognosis. The treatment of choice for differentiated thyroid carcinoma is surgery, followed by radioactive iodine ablation (iodine-131) in select patients and thyroxine therapy in most patients. Surgery is also the main treatment for medullary thyroid carcinoma, and kinase inhibitors may be appropriate for select patients with recurrent or persistent disease that is not resectable. Anaplastic thyroid carcinoma is almost uniformly lethal, and iodine-131 imaging and radioactive iodine cannot be used. When systemic therapy is indicated, targeted therapy options are preferred. This article describes NCCN recommendations regarding management of medullary thyroid carcinoma and anaplastic thyroid carcinoma, and surgical management of differentiated thyroid carcinoma (papillary, follicular, Hürthle cell carcinoma).

To design and establish a prospective biospecimen repository that integrates multi-omics assays with clinical data to study mechanisms of controlled injury and healing.Elective surgery is an opportunity to understand both the systemic and focal responses accompanying controlled and well-characterized injury to the human body. The overarching goal of this ongoing project is to define stereotypical responses to surgical injury, with the translational purpose of identifying targetable pathways involved in healing and resilience, and variations indicative of aberrant peri-operative outcomes.Clinical data from the electronic medical record combined with large-scale biological data sets derived from blood, urine, fecal matter, and tissue samples are collected prospectively through the peri-operative period on patients undergoing 14 surgeries chosen to represent a range of injury locations and intensities. Specimens are subjected to genomic, transcriptomic, proteomic, and metabolomic assays to describe their genetic, metabolic, immunologic, and microbiome profiles, providing a multidimensional landscape of the human response to injury.The highly multiplexed data generated includes changes in over 28,000 mRNA transcripts, 100 plasma metabolites, 200 urine metabolites, and 400 proteins over the longitudinal course of surgery and recovery. In our initial pilot dataset, we demonstrate the feasibility of collecting high quality multi-omic data at pre- and postoperative time points and are already seeing evidence of physiologic perturbation between timepoints.This repository allows for longitudinal, state-of-the-art geno-mic, transcriptomic, proteomic, metabolomic, immunologic, and clinical data collection and provides a rich and stable infrastructure on which to fuel further biomedical discovery.

Background Cognitive dysfunction after surgery is a major issue in older adults. Here, we determined the effect of APOE4 on perioperative neurocognitive function in older patients. Methods We enrolled 140 English-speaking patients ≥60 yr old scheduled for noncardiac surgery under general anaesthesia in an observational cohort study, of whom 52 underwent neuroimaging. We measured cognition; Aβ, tau, p-tau levels in CSF; and resting-state intrinsic functional connectivity in six Alzheimer's disease-risk regions before and 6 weeks after surgery. Results There were no significant APOE4-related differences in cognition or CSF biomarkers, except APOE4 carriers had lower CSF Aβ levels than non-carriers (preoperative median CSF Aβ [median absolute deviation], APOE4 305 pg ml−1 [65] vs 378 pg ml−1 [38], respectively; P=0.001). Controlling for age, APOE4 carriers had significantly greater preoperative functional connectivity than non-carriers between several brain regions implicated in Alzheimer's disease, including between the left posterior cingulate cortex and left angular gyrus (β [95% confidence interval, CI], 0.218 [0.137–0.230]; PFWE=0.016). APOE4 carriers, but not non-carriers, experienced significant connectivity decreases from before to 6 weeks after surgery between several brain regions including between the left posterior cingulate cortex and left angular gyrus (β [95% CI], –0.196 [–0.256 to –0.136]; PFWE=0.001). Most preoperative and postoperative functional connectivity differences did not change after controlling for preoperative CSF Aβ levels. Conclusions Postoperative change trajectories for cognition and CSF Aβ, tau or p-tau levels did not differ between community dwelling older APOE4 carriers and non-carriers. APOE4 carriers showed greater preoperative functional connectivity and greater postoperative decreases in functional connectivity in key Alzheimer's disease-risk regions, which occur via Aβ-independent mechanisms.

To demonstrate safety, feasibility, and effectiveness of cryoablation of recurrent papillary thyroid cancer ineligible for reoperation because of scarring, eligible for focal ablation as defined within 2015 American Thyroid Association guideline sections C16 and C17.With multidisciplinary consensus, cryoablation was performed with curative intent for 15 tumors in 10 patients between January 2019 and July 2021. Demographics, procedural details, and serial postprocedural imaging findings were analyzed.The mean age was 72.5 years (range, 57-88 years), and 80% of the patients were women. The tumors (mean size, 16 mm ± 6; range, 9-29 mm) received 1 session of cryoablation with 100% technical success. The mean and median postcryoablation tumor volumetric involution rates were 88% and 99%, respectively, with 9 (60%) of 15 tumors involuting completely or down to the scar and 6 (40%) involuting partially at the end of the study period. Tumor size did not increase after cryoablation (0% local progression rate). All tumors abutted the trachea, skin, and/or vascular structures, and hydrodissection failed in all cases because of scarring. The major adverse event rate was 20% (3/15), with 2 cases of voice change and 1 case of Horner syndrome; all resolved at 6 months with no permanent sequelae. No vascular, tracheal, dermal, or infectious adverse events occurred during a mean follow-up of 242 days (range, 114-627 days). One patient died at 386 days after cryoablation because of unrelated cholangiocarcinoma.Cryoablation of local recurrences of papillary thyroid cancer abutting the trachea and/or neurovascular structures in the setting of hydrodissection failure because of scarring yielded a mean volumetric involution of 88%, primary efficacy of 60%, and objective response rate of 100% with no local recurrences or permanent complications during a mean follow-up of 242 days. The secondary efficacy and longer-term outcomes remain forthcoming.

Background: Patient preferences pertaining to surgical options for thyroid cancer management are not well studied. Our aim was to conduct a discrete choice experiment (DCE) to characterize participants' views on the relative importance of various risks and benefits associated with lobectomy versus total thyroidectomy for low-risk thyroid cancer. Methods: Adult participants with low-risk thyroid cancer or a thyroid nodule requiring surgery were asked to choose between experimentally designed surgical options with varying levels of risk of nerve damage (1%, 9%, 14%), hypocalcemia (0%, 3%, 8%), risk of needing a second surgery (0%, 40%), cancer recurrence (1%, 3%, 5%), and need for daily thyroid hormone supplementation (yes, no). Their choices were analyzed using random-parameters logit regression. Results: One hundred fifty participants completed an online DCE survey. Median age was 58 years; 82% were female. Twenty-four participants (16%) had a diagnosis of thyroid cancer at the time of completing the survey, and 126 (84%) had a thyroid nodule necessitating surgery. On average, 35% of participants' choices were explained by differences in the risk of cancer recurrence; 28% by the chance of needing a second surgery; 19% by the risk of nerve damage; and 9% by differences in risks of hypocalcemia and the need for thyroid hormone supplementation. When accounting for differences in postoperative risks, the average patient favored lobectomy over total thyroidectomy as long as the chance of needing a second (i.e., completion) surgery after initial lobectomy remained below 30%. Participants would accept a 4.1% risk of cancer recurrence if the risk of a second surgery could be reduced from 40% to 10%. Conclusions: While patients with thyroid cancer may have clear preferences for extent of surgery, common themes moderating preferences for surgical interventions were identified in the DCE. Adequate preoperative evaluation to decrease the chance of a second surgery and providing patients with a good understanding of risks and benefits associated with extent of surgery can lead to better treatment decision-making.

OBJECTIVE: Lumbar punctures (LPs) are important for obtaining CSF in neurology studies but are associated with adverse events and feared by many patients. We determined adverse event rates and pain scores in patients prospectively enrolled in two cohort studies who underwent LPs using a standardized protocol and 25g needle. METHODS: 809 LPs performed in 262 patients age ≥60 years in the MADCO-PC and INTUIT studies were analyzed. Medical records were monitored for LP-related adverse events, and patients were queried about subjective complaints. We analyzed adverse event rates, including headaches and pain scores. RESULTS: There were 22 adverse events among 809 LPs performed, a rate of 2.72% (95% CI 1.71% – 4.09%). Patient hospital stay did not increase due to adverse events. Four patients (0.49%) developed a post-lumbar puncture headache (PLPH). Twelve patients (1.48%) developed nausea, vasovagal responses, or headaches that did not meet PLPH criteria. Six patients (0.74%) reported lower back pain at the LP site not associated with muscular weakness or paresthesia. The median pain score was 1 [0, 3]; the mode was 0 out of 10. CONCLUSIONS: The LP protocol described herein may reduce adverse event rates and improve patient comfort in future studies.

Laparoscopic adrenalectomy can be performed using a transabdominal or posterior retroperitoneal approach. Choosing the optimal approach can be challenging.Using data from the Collaborative Endocrine Surgery Quality Improvement Program (2014-2018), baseline patient characteristics and outcomes were compared with bivariate methods; univariate and multivariate analyses were used to estimate the association between operative approach and complication risk.Among 833 patients, 35.3% underwent posterior retroperitoneal. Median age was 54 years. Patients undergoing posterior retroperitoneal had lesser rates of body mass index40 (9.2% vs 17.4%, P = .001), smaller nodules (median 2.4 vs 3.2 cm, P.001), and more commonly right-sided nodules (46.6% vs 36.9%, P = .02). Posterior retroperitoneal was associated with a lesser rate of conversion to an open procedure (0.7% vs 4.1%, P = .004), less complications (3.1% vs 8.7%, P = .002), and shorter hospital stay (≤48 h: 92.2% vs 76.6%, P.001), but a greater rate of capsular disruption (12.6% vs 7.6%, P = .02). For posterior retroperitoneal cases with capsular disruption, median nodule size was 2.2 cm, and 16.2% were metastatic tumors. After multivariate adjustment, posterior retroperitoneal was 2.2 times as likely to result in capsular disruption as transabdominal (95% confidence interval, 1.04-4.79, P = .04).This study revealed a greater rate for capsular disruption during posterior retroperitoneal even for small tumors. Our findings from the Collaborative Endocrine Surgery Quality Improvement Program (2014-2018) suggests that posterior retroperitoneal should be used selectively, especially when a malignancy is suspected.

Threshold numbers for defining adequacy of lymph node (LN) yield have been determined for evaluation of occult nodal disease during papillary thyroid cancer (PTC) surgery. This study assesses the prevalence of adequate LN yield and estimates its association with patient clinicopathologic characteristics.Adult patients with cN1 pT1b or pT2 and cN0 or cN1 pT3 M0 PTC ≥1 cm who received surgery with ≥1 LN resected were identified from the National Cancer Database, 2004-2015. Adequate yield was defined as removing ≥6, 9, and 18 LNs for pT1b, pT2, and pT3 stages, respectively, based on recently published literature. Univariable and multivariable logistic regression were used to determine factors associated with adequate yield.A total of 23,131 patients were included; 7544 (32.6%) had adequate LN yield. Rate of adequate yield increased from 19.9% to 36.6% over time. After adjustment, patients at academic facilities were more likely to have adequate yield than those at community centers [OR 1.94 (95% CI 1.55-2.41), P 0.001]. Patients with more advanced tumors were less likely to have adequate yield (pT1b: 75.9% versus pT2: 64.5% versus pT3: 24.6% adequate LN yield, P 0.001). Patients with adequate LN yield were 0.89 times likely to receive radioactive iodine compared with those with inadequate yield [OR 0.98 (95% CI 0.81-0.98), P = 0.02].The rate of adequate LN yield has increased over time, but only a minority of lymphadenectomies performed for PTC can be defined as adequate. Disparities still exist based on patient and facility characteristics; patients with more advanced tumors appear less likely to have adequate LN yield.

Animal models suggest POCD may be caused by brain monocyte influx. To study this in humans, we developed a flow cytometry panel to profile CSF samples collected before and after major non-cardiac surgery in in 5 patients age ≥ 60 years who developed POCD and 5 matched controls who did not. We detected 12,654±4895 cells/10 ml CSF sample (mean±SD). Patients who developed POCD showed an increased CSF monocyte/lymphocyte ratio and MCP-1 receptor downregulation on CSF monocytes 24 hours after surgery. These pilot data demonstrate that CSF flow cytometry can be used to study mechanisms of postoperative neurocognitive dysfunction. CLINICAL TRIAL NUMBER AND REGISTRY URL: , https://clinicaltrials.gov/ct2/show/NCT01993836 (This manuscript describes a nested case-control study, performed within the larger cohort study, .)

Little is known about nationwide practice patterns for the management medullary thyroid cancer (MTC) in relation to the 2015 American Thyroid Association guidelines and their impact on survival.Using the Surveillance, Epidemiology, and End Results Program database (2000-2018), MTC treatment patterns were evaluated in terms of adherence to the 2015 American Thyroid Association guidelines across three time periods (2000-2009, 2010-2015, and 2016-2018). Outcomes of interest were guideline concordance, treatment utilization trends, disease-specific survival (DSS), and overall survival (OS).A total of 3332 patients with MTC were identified. Of which, 53.8%, 33.2%, and 11.4% of patients had localized, regional, and distant disease, respectively. In patients with locoregional disease, the rate of guideline-concordant surgery improved over time from 63.0% in 2000-2009 to 76.0% in 2016-2018 (P 0.001). Guideline-concordant care was associated with increased OS (HR = 1.85, 95% CI: 1.42-2.43, P 0.001) in patients with localized disease and increased DSS (HR = 1.65, 95% CI: 1.01-2.54, P 0.001) and OS (HR = 1.89, 95% CI: 1.35-2.58, P 0.001) in patients with regional disease. The median OS and DSS in patients with distant disease were 31 and 55 mo, respectively, and the rate of chemotherapy use rose from 21.6% to 39.2% (P = 0.003).The rate of guideline-concordant surgery for locoregional MTC increased after guideline publication in 2015, with an observed prolongment in OS and DSS. Chemotherapy use among patients with distant disease has increased over time, but their prognosis remains variable.

Background: Graves' disease accounts for ∼80% of all cases of hyperthyroidism and is associated with significant morbidity and decreased quality of life. Understanding the association of total thyroidectomy with patient-reported quality-of-life and thyroid-specific symptoms is critical to shared decision-making and high-quality care. We estimate the change in patient-reported outcomes (PROs) before and after surgery for patients with Graves' disease to inform the expectations of patients and their physicians. Methods: PROs using the MD Anderson Symptom Inventory (MDASI) validated questionnaire were collected prospectively from adult patients with Graves' disease from January 1, 2015, to November 20, 2020, on a longitudinal basis. Survey responses were categorized as before surgery (≤120 days), short term after surgery (

Background: Molecular testing (MT) is commonly used to refine cancer probability in thyroid nodules with indeterminate cytology. Whether or not ultrasound (US) patterns and clinical parameters can further inform the risk of thyroid cancer in nodules predicted to be positive or negative by MT remains unknown. The aim of this study was to test if clinical parameters, including patient age, sex, nodule size (by US), Bethesda category (III, IV, V), US pattern (American Thyroid Association [ATA] vs. American College of Radiology Thyroid Image Reporting and Data System [TI-RADS] systems), radiation exposure, or family history of thyroid cancer can modify the probability of thyroid cancer or noninvasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTP) predicted by MT. Methods: We studied 257 thyroid nodules in 232 patients from 10 study centers with indeterminate fine needle aspiration cytology and informative MT results using the ThyroSeq v3 genomic classifier (TSv3). Univariate and multivariate logistic regression was used for data analysis. Results: The presence of cancer/NIFTP was associated with positive TSv3 results (odds ratio 61.39, p

Objective: This study compares the American Thyroid Association (ATA) classification system with the 2017 American College of Radiology (ACR) Thyroid Imaging Reporting and Data System (TI-RADS) for predicting cancer risk in thyroid nodules. Methods: This is a retrospective review of ultrasound imaging of all adult patients with thyroid nodules >5 mm who underwent thyroidectomy at a tertiary care hospital in 2016. We assessed the ability of either system to predict malignancy based on surgical histopathology. Sensitivity, specificity, negative predictive values (NPV) and positive predictive values (PPV), and area-under-the-curve (AUC) were calculated and compared using McNemar's, Fisher exact, or DeLong's tests. Results: Three hundred and twenty-three nodules from 213 adults were included. Median patient age was 55 years; 75.6% were female. 27.2% nodules were malignant. Both ATA and ACR TI-RADS provide effective diagnostic performance, a sensitivity of 77.3% versus 78.4%, respectively, a specificity of 76.6% versus 73.2%, respectively, a PPV of 55.3% versus 52.3%, respectively, and a NPV of 90% for both. The level of agreement between the two classification systems was almost perfect (weighted Kappa statistic = 0.93, AUC 0.77 ATA versus 0.76 TI-RADS [P = .18]). However, of the 40 (TI-RADS level 3) TR3 nodules (

The NCCN Guidelines for Thyroid Carcinoma provide recommendations for the management of different types of thyroid carcinoma, including papillary, follicular, Hurthle cell, medullary, and anaplastic carcinomas. These NCCN Guidelines Insights summarize the panel discussion behind recent updates to the guidelines, including the expanding role of molecular testing for differentiated thyroid carcinoma, implications of the new pathologic diagnosis of noninvasive follicular thyroid neoplasm with papillary-like nuclear features, and the addition of a new targeted therapy option for BRAF V600E-mutated anaplastic thyroid carcinoma.

The frequency and cost of postoperative surveillance for older adults (65 y) with T1N0M0 low-risk papillary thyroid cancer (PTC) have not been well studied.Using the SEER-Medicare (2006-2013) database, frequency and cost of surveillance concordant with American Thyroid Association (ATA) guidelines (defined as an office visit, ≥1 thyroglobulin measurement, and ultrasound 6- to 24-month postoperatively) were analyzed for the overall cohort of single-surgery T1N0M0 low-risk PTC, stratified by lobectomy versus total thyroidectomy.Majority of 2097 patients in the study were white (86.7%) and female (77.5%). Median age and tumor size were 72 y (interquartile range 68-76) and 0.6 cm (interquartile range 0.3-1.1 cm), respectively; 72.9% of patients underwent total thyroidectomy. Approximately 77.5% of patients had a postoperative surveillance visit; however, only 15.9% of patients received ATA-concordant surveillance. Patients who underwent total thyroidectomy as compared with lobectomy were more likely to undergo surveillance testing, thyroglobulin (61.7% versus 24.8%) and ultrasound (37.5% versus 29.2%) (all P 0.01), and receive ATA-concordant surveillance (18.5% versus 9.0%, P 0.001). Total surveillance cost during the study period was $621,099. Diagnostic radioactive iodine, ablation, and advanced imaging (such as positron emission tomography scans) accounted for 55.5% of costs ($344,692), whereas ATA-concordant care accounted for 44.5% of costs. After multivariate adjustment, patients who underwent total thyroidectomy as compared with lobectomy were twice as likely to receive ATA-concordant surveillance (adjusted odds ratio 2.0, 95% confidence interval: 1.5-2.8, P 0.001).Majority of older adults with T1N0M0 low-risk PTC do not receive ATA-concordant surveillance; discordant care was costly. Total thyroidectomy was the strongest predictor of receiving ATA-concordant care.

Background Underinsured and uninsured surgical-oncology patients are at higher risk of perioperative morbidity and mortality. Curricular innovation is needed to train medical students to work with this vulnerable population. We describe the implementation of and early educational outcomes from a student-initiated pilot program aimed at improving medical student insight into health disparities in surgery. Materials/Methods First-year medical students participated in a dual didactic and perioperative-liaison experience over a 10-month period. Didactic sessions included surgical-skills training and faculty-led lectures on financial toxicity and management of surgical-oncology patients. Students were partnered with uninsured and Medicaid patients receiving surgical-oncology care and worked with these patients by providing appointment reminders, clarifying perioperative instructions, and accompanying patients to surgery and clinic appointments. Students’ interest in surgery and self-reported comfort in 15 Association of American Medical Colleges core competencies were assessed with preparticipation and postparticipation surveys using a 5-point Likert scale. Results Twenty-four first-year students were paired with 14 surgical-oncology patients during the 2017-2018 academic year. Sixteen students (66.7%) completed both preprogram and postprogram surveys. Five students (31.3%) became “More Interested” in surgery, whereas 11 (68.8%) reported “Similar Interest or No Change.” Half of the students (n = 8) felt more prepared for their surgery clerkship after participating. Median self-reported comfort improved in 7/15 competencies including Oral Communication and Ethical Responsibility. All students reported being “Somewhat” or “Extremely Satisfied” with the program. Conclusions We demonstrate that an innovative program to expose preclinical medical students to challenges faced by financially and socially vulnerable surgical-oncology patients is feasible and may increase students’ clinical preparedness and interest in surgery.

Background: Molecular testing (MT) is commonly used to refine cancer probability in thyroid nodules with indeterminate cytology. Whether or not ultrasound (US) patterns and clinical parameters can further modify the risk of cancer in nodules predicted to be positive or negative by molecular testing remains unknown. Aim: To test if clinical parameters, including age, gender, nodule size (by US), Bethesda category (III, IV, V), US pattern (American Thyroid Association [ATA] system vs American College of Radiology TIRADS), radiation exposure, and family history of thyroid cancer (TC) can modify the probability of TC or NIFTP predicted by MT in thyroid nodules with indeterminate cytology. Methods: We studied 257 thyroid nodules from 10 study centers with fine-needle aspiration (FNA) yielding indeterminate cytology and informative MT results using the ThyroSeq v3 genomic classifier (TSv3). Univariate and multivariate logistic regression were used for data analysis. Results: In this group of thyroid nodules, out of all parameters studied using univariate regression, patient gender, age, and Bethesda category were significantly associated with TC/NIFTP probability (P

Recurrent laryngeal nerve (RLN) injury is a well-known, potentially serious complication of thyroid surgery. We investigated factors associated with RLN injury during thyroid surgery using a multi-institutional data set.Patients who underwent either lobectomy or total thyroidectomy were abstracted from the American College of Surgeons National Surgical Quality Improvement Program thyroidectomy-specific database (2016-2017). Baseline and operative factors associated with RLN injury ≤30 d of surgery were analyzed using bivariate and multivariate methods. Secondary complications of interest included unplanned reintubation and hypocalcemia.RLN injury occurred in 6.0% (n = 677) of the 11,370 patients included in the study. The RLN injury rate varied significantly based on the primary indication for surgery, from 4.3% in patients undergoing surgery for a single nodule to 9.0% in patients undergoing surgery for differentiated cancer (P 0.01). RLN injury occurred more often in thyroidectomies than lobectomies (6.9% versus 4.3%, P 0.01) and in surgeries without intraoperative nerve monitoring (6.5% versus 5.6%, P = 0.01). After multivariate adjustment, RLN injury was independently associated with age ≥65 y [odds ratio (OR) 1.6, 95% confidence interval (CI) 1.3-2.0], total thyroidectomy (OR = 1.4, 95% CI 1.1-1.6), and diagnosis of thyroid malignancy (OR = 2.1, 95% CI = 1.6-2.7) (all P 0.001) but not intraoperative RLN monitoring (OR = 0.9, 95% CI = 0.7-1.0, P = 0.06).In this large multi-institutional study, RLN injury ≤30 d of surgery occurred in nearly 6% of thyroid surgeries. This comprehensive analysis of RLN injury can be used to guide informed consent discussions and aid surgeons in identifying candidates who may be at higher risk for injury.

The clinical presentation of primary hyperparathyroidism (PHPT) varies widely, although the underlying mechanistic reasons for this disparity remain unknown. We recently reported that parathyroid tumors can be functionally segregated into two distinct groups on the basis of their relative responsiveness to ambient calcium, and that patients in these groups differ significantly in their likelihood of manifesting bone disability. To examine the molecular basis for this phenotypic variation in PHPT, we compared the global gene expression profiles of calcium-sensitive and calcium-resistant parathyroid tumors. RNAseq and proteomic analysis identified a candidate set of differentially expressed genes highly correlated with calcium-sensing capacity. Subsequent quantitative assessment of the expression levels of these genes in an independent cohort of parathyroid tumors confirmed that calcium-sensitive tumors cluster in a discrete transcriptional profile group. These data indicate that PHPT is not an etiologically monolithic disorder and suggest that divergent molecular mechanisms could drive the observed phenotypic differences in PHPT disease course, provenance, and outcome.

Adrenocortical carcinoma (ACC) is a rare, aggressive cancer; complete surgical resection offers the best chance for long-term survival. The impact of surgical margin status on survival is poorly understood. Our objective was to determine the association of margin status with survival.Patients with ACC were identified from the National Cancer Data Base, 1998-2012, and stratified based on surgical margin status (negative vs. microscopically positive [+] vs. macroscopically [+]). Univariate/multivariate regression/survival analyses were utilized to determine factors associated with margin status and overall survival (OS).A total of 1553 patients underwent surgery at 589 institutions: 86% had negative, 12% microscopically (+), and 2% macroscopically (+) margins. Those with microscopically (+) and macroscopically (+) margins more often received adjuvant chemotherapy (39.4% macroscopically (+) vs. 38.5% microscopically (+) vs. 25.2% negative margins, p 0.001). For unadjusted analysis, there was a significant difference in OS between the groups (log-rank p 0.001), with median survival times of 58 months (95% confidence interval [CI] 49-66) for those with negative margins, 22 months (95% CI 18-34) microscopically (+), and 14 months (95% CI 6-27) macroscopically (+) margins. After adjustment, both microscopically (+) (HR 1.76, p 0.001) and macroscopically (+) (HR 2.10, p = 0.0019) margin status were associated with compromised survival.Having micro- or macroscopically (+) margin status after ACC resection is associated with dose-dependent compromised survival. These results underscore the importance of achieving negative surgical margins for optimizing long-term patient outcomes.

Thyroid cancer is the most common endocrine malignancy in children, albeit still rare. This study sought to measure the association between outcomes and case volume of the treatment facility for pediatric patients with thyroid cancer.The National Cancer Data Base (1998-2011) was queried for all pediatric patients (age ≤ 18 years) with thyroid cancer. Demographic, clinical, and pathologic features were evaluated for all patients. Case volume of the treating facility was defined as the number of pediatric thyroid cancer patients at that facility during the study period. Restricted cubic spline modeling was used to determine a volume threshold associated with decreased risk of 30-day readmission. Patients were assigned to volume groups based on this threshold. Logistic regression was utilized to estimate the effect of volume on 30-day readmission.In total, 4,466 patients met inclusion criteria. The majority were girls (79.1%), white (86.1%), and underwent total thyroidectomy (86.9%). Compared with patients treated at the low-volume facilities, those treated at the high-volume facilities were more likely to have medullary thyroid cancer (10.7% versus 3.7%) and undergo total thyroidectomy (90.8% versus 86.3%) (all P .01). After adjustment, treatment at low-volume facilities was associated with an increased likelihood of readmission after operative treatment (odds ratio = 3.52, P = .01).Pediatric patients with thyroid cancer treated at low-volume facilities are more likely to be readmitted after thyroid surgery than patients treated at high-volume facilities. Providers should consider the case volume status at the treating facility when referring these children for thyroid surgery.

An association has been suggested between increasing surgeon volume and improved patient outcomes, but a threshold has not been defined for what constitutes a "high-volume" adrenal surgeon.Adult patients who underwent adrenalectomy by an identifiable surgeon between 1998-2009 were selected from the Healthcare Cost and Utilization Project National Inpatient Sample. Logistic regression modeling with restricted cubic splines was utilized to estimate the association between annual surgeon volume and complication rates in order to identify a volume threshold.A total of 3,496 surgeons performed adrenalectomies on 6,712 patients; median annual surgeon volume was 1 case. After adjustment, the likelihood of experiencing a complication decreased with increasing annual surgeon volume up to 5.6 cases (95% confidence interval, 3.27-5.96). After adjustment, patients undergoing resection by low-volume surgeons (6 cases/year) were more likely to experience complications (odds ratio 1.71, 95% confidence interval, 1.27-2.31, P = .005), have a greater hospital stay (relative risk 1.46, 95% confidence interval, 1.25-1.70, P = .003), and at increased cost (+26.2%, 95% confidence interval, 12.6-39.9, P = .02).This study suggests that an annual threshold of surgeon volume (≥6 cases/year) that is associated with improved patient outcomes and decreased hospital cost. This volume threshold has implications for quality improvement, surgical referral and reimbursement, and surgical training.

Background: This study aims to compare the seventh and eighth editions of the American Joint Commission on Cancer/Union for International Cancer Control (AJCC/UICC) tumor, node, metastasis staging system for patients with papillary thyroid cancer (PTC) in two national patient cohorts. Methods: Adult PTC patients undergoing surgery were selected from the Surveillance, Epidemiology and End Results (SEER) program (2004–2012) and the National Cancer Database (2004–2012). Staging criteria for the seventh and eighth AJCC/UICC editions were applied separately to each cohort. Survival probabilities were estimated using the Kaplan–Meier method. Multivariable Cox proportional hazards models were used to estimate the association of stage with survival in both settings. The Akaike information criterion was used to assess model performance. Results: About 23% of patients were downstaged from the seventh to the eighth edition in SEER, while 24% were downstaged in the National Cancer Database. Disease-specific survival (DSS) and overall survival (OS) were significantly related to stage at diagnosis when using both the seventh and eighth editions of the AJCC/UICC staging system (p

The optimal surgery for patients with renal hyperparathyroidism has been controversial, as either subtotal parathyroidectomy (subtotal PTX) or total parathyroidectomy with auto-transplantation (total PTX-AT) may be employed.Adult patients having subtotal PTX or total PTX-AT for secondary hyperparathyroidism were identified from the American College of Surgeons National Surgical Quality Improvement Program, 2005-2013.Of 1130 patients, the majority (n = 765, 68%) underwent subtotal PTX. Total PTX-AT was associated with longer operative time (median 150 vs. 120 min, p 0.001). Rates of complications, reoperation, readmission, and 30-day mortality were not significantly different. After adjustment, the odds of having a complication [OR 0.97, p = 0.88] and being readmitted within 30 days [OR 0.86 p = 0.62] were similar between the two procedures. Total PTX-AT was associated with prolonged hospital stay [Adjusted mean 5.0 vs. 4.1 days; (RR) 1.22, p 0.001] compared to subtotal PTX.Subtotal PTX and total PTX-AT have similar rates of complications, readmission, and 30-day mortality, but subtotal PTX is less likely to have extended hospital stay. These findings have important cost implications for patients, payers, and hospitals.

Racial disparities in the management of differentiated thyroid cancer (DTC) exist in the United States. There is a paucity of data examining their temporal trends. It was hypothesized that racial disparities in care provided to patients with DTC have improved over the past 15 years.Adult patients undergoing surgery for DTC were included from the National Cancer Data Base (1998-2012). Temporal trends in appropriate extent of thyroidectomy and radioactive iodine therapy (RAI) were described for different racial groups. Multivariable logistic regression models were employed to estimate the adjusted association of receipt of appropriate extent of surgery and RAI, specifically under- and over-treatment, among different racial groups.Among 282,043 DTC patients, 80.3% were non-Hispanic white (white), 8.1% Hispanic, 7.2% non-Hispanic black (black), and 4.4% Asian. Black versus white race/ethnicity was associated with lower odds of receiving appropriate surgery (odds ratio [OR] = 0.78 [confidence interval (CI) 0.71-0.87]; p 0.001). Appropriate RAI treatment was higher in blacks (OR = 1.07 [CI 1.02-1.12]; p = 0.01) and lower for Hispanics (OR = 0.90 [CI 0.86-0.95]; p 0.001) compared with whites. There was a higher likelihood of RAI under-treatment in minority groups (Hispanic OR = 1.27, black OR = 1.26, Asian OR = 1.25; p 0.001), and a lower likelihood of RAI over-treatment (Hispanic OR = 0.89, black OR = 0.83, Asian OR = 0.79; p 0.001) compared with whites. Over time, an increasing proportion of black and white patients underwent appropriate extent of thyroidectomy (1998 vs. 2012: 78% vs. 88% and 81% vs. 91%, respectively). Compared with 1998, fewer patients in 2012 were under-treated with RAI: whites (48% vs. 29%, respectively), blacks (51% vs. 33%), Hispanics (51% vs. 37%), and Asians (55% vs. 39%). The extent of RAI over-treatment increased (1998 vs. 2012): whites (1% vs. 4%), blacks (2% vs. 4%), Hispanics (2% vs. 4%), and Asians (2% vs. 3%), respectively.Appropriate utilization of surgery and RAI for DTC has improved over time. However, the proportion of patients receiving appropriate thyroid surgery is consistently lower for blacks compared with whites. RAI over-treatment increased for all races over the study period. Efforts are needed to standardize DTC care among minority patients.

Background: Patient perspectives on risks vs benefit tradeoffs for thyroid cancer treatment options are important but not well studied. Our aim was to conduct a stated-preference study to characterize patients’ views on the relative importance of various risks/benefits associated with lobectomy and total thyroidectomy for management of low-risk thyroid cancer. Methods: Adult patients with low-risk thyroid cancer or a thyroid nodule requiring surgery enrolled in a prospective survey-based discrete-choice experiment (DCE) to quantify benefit-risk tradeoffs pertaining to surgical management. Patients were asked to assume they had thyroid cancer for the purpose of the study; they were asked to choose between experimentally-designed surgical options with varying levels of risk of nerve damage (1%, 9%, 14%), hypocalcemia (0%, 3%, 8%), risk of requiring a second surgery (0%, 40%), cancer recurrence (1%, 3%, 5%), and need for daily thyroid hormone supplementation (yes, no). Their choices were analyzed using a random-parameters logit model to estimate the relative influence of each feature on patients’ stated preferences for surgery. The resulting estimates were used to evaluate preferences for surgical profiles representing lobectomy and total thyroidectomy. Results: From 2017-18, we enrolled 132 patients. Median age was 58 years; 79.9% were female. 83% had a thyroid nodule as the primary diagnosis; 16% hypo-/hyperthyroidism; 21% were on thyroid medications. On average, 35% of patients’ choices were explained by the difference in the risk of thyroid cancer recurrence across surgeries, and 28% of choices by the risk of requiring a second surgery. Changes in the risk of nerve damage explained 18% of their choices, while differences in the risk of hypocalcemia and the need for thyroid hormone supplementation explained 10% and 8% of choices, respectively. When inferring patients’ preferences for clinical profiles representing lobectomy and total thyroidectomy, we found that patients would generally favor total thyroidectomy largely due to their negative views on an assumed 40% risk of requiring a second surgery with lobectomy. However, if the risk of needing a second surgery after lobectomy can be reduced below 30%, the average patient would start favoring lobectomy over total thyroidectomy, based on assumptions pertaining to the difference in the risks of nerve damage and hypocalcemia between lobectomy and total thyroidectomy. Conclusions: Patients’ preferences for lobectomy or total thyroidectomy will vary depending upon combinations of risks and benefits of both procedures that apply to the individual patient. Appropriate preoperative evaluation to decrease the chance of a second surgery, excellent physician-patient communication, and surgeon experience are important for providing patients with a good understanding of risks and benefits associated with extent of surgery.

BackgroundTotal thyroidectomy is more common than lobectomy for low-risk papillary thyroid cancer, despite equipoise in survival. Because postoperative morbidity increases with age, we aimed to investigate how the extent of thyroidectomy affects short-term outcomes among older patients.MethodsUsing the Surveillance, Epidemiology, and End Results-Medicare database, we identified patients aged ≥66 years who were treated between 1996 and 2011 for papillary thyroid cancer with tumors ≤2 cm in diameter. We used multivariable logistic regression to evaluate the effect of extent of surgery on complications, emergency-department visits, and unplanned readmissions.ResultsAmong 3,341 selected patients, 77.3% were female, mean age was 72.9 years, and tumors averaged 0.8 cm in diameter. A total of 67.6% of patients underwent total thyroidectomy, and 32.4% underwent lobectomy. Total thyroidectomy was associated with complications (odds ratio= 1.99) and readmissions (odds ratio= 1.59; both P < 0.01). Complications were higher in female patients (odds ratio= 1.34), black patients (versus white patients, odds ratio= 1.65), and those with ≥2 comorbidities (vs 0, odds ratio= 1.43; all P < 0.01). Black patients and those with ≥2 comorbidities had more emergency-department visits (odds ratio= 1.50 and 1.92, respectively) and readmissions (odds ratio= 2.19 and 2.29, respectively; all P < 0.01).ConclusionTotal thyroidectomy for older adults with low-risk papillary thyroid cancer may lead to potentially avoidable complications and readmissions, particularly for black and female patients. In many cases, lobectomy may be a safer and less costly alternative.

BackgroundPapillary thyroid cancer (PTC) is the fastest increasing cancer in the United States; incidence increases with age. It generally has a favorable prognosis but may behave more aggressively in older patients. This study aims to describe national treatment patterns for low-risk PTC in older adults.Materials and methodsThe Surveillance, Epidemiology, and End Results-Medicare database was used to identify patients ≥66y treated for clinical T1N0M0 PTC between 1996 and 2011. Multivariable logistic regression was used to identify factors associated with extent of surgery (total thyroidectomy versus lobectomy) and radioactive iodine (RAI) administration. Cox proportional hazards modeling was used to estimate the effect of treatment type on disease-specific survival (DSS).ResultsThree thousand two hundred and fourteen patients met inclusion criteria; 77.6% were women, median age was 72y, and mean tumor size was 0.7cm. 42.7% had preoperatively diagnosed PTC (versus incidental). 65.4% underwent total thyroidectomy, 29.0% lobectomy, and 5.6% lobectomy followed by completion thyroidectomy; 33.4% received postoperative RAI. Five- and 10-year DSS were 98.9% and 98.3%, respectively. After adjustment, larger tumor size (1.1-2cm), multifocality, and a preoperative PTC diagnosis were associated with greater odds of undergoing more extensive surgery and receiving RAI (P0.05).ConclusionsMost older adults with PTC underwent total thyroidectomy and a third received RAI; neither treatment improved DSS. In the growing elderly population, less extensive interventions for PTC may reduce morbidity and improve quality of life while preserving an excellent prognosis.

Data are limited regarding the association between tumor lymphovascular invasion and survival for patients with papillary thyroid cancer (PTC). This study sought to examine lymphovascular invasion as an independent prognostic factor for patients with PTC undergoing thyroid resection. The National Cancer Data Base (2010–2011) was queried for patients with PTC who underwent total thyroidectomy or lobectomy. Patients were classified into two groups based on the presence/absence of lymphovascular invasion. Demographic, clinical and pathological features were evaluated for all patients. A Cox proportional hazards model was utilized to identify factors associated with survival. Results show that 45,415 patients met inclusion criteria; 11.6% had lymphovascular invasion. Patients with lymphovascular invasion were more likely to have larger tumors (2.8cm vs 1.5cm,PPPPPPPPPPP

Multi-institutional data describing remedial parathyroidectomy compared with index parathyroidectomy are scarce.Using data in the Collaborative Endocrine Surgery Quality Improvement Program (2014-2017), baseline characteristics and outcomes of patients undergoing remedial parathyroidectomy versus index parathyroidectomy were examined using bivariate and multivariate methods. Rates of hypercalcemia and hypocalcemia at ≥ 180 days were assessed.Among 6,795 patients, 367 (5.4%) underwent remedial parathyroidectomy. A single localization study was done in 24.8% versus 26.9% of remedial parathyroidectomy versus index parathyroidectomy (P = .37). Patients undergoing remedial parathyroidectomy had higher rates of preoperative laryngoscopy (45.5% versus 6.2%, P.001), intraoperative nerve monitoring (57.5% versus 34.5%, P.001), and50% drop in hyperparathyroidism than those undergoing index parathyroidectomy (9.6% versus 3.3%, P.001). Among patients with ≥ 180 days follow-up, none of the remedial parathyroidectomy versus three index parathyroidectomy patients (0.3%) had vocal cord dysfunction. Hypercalcemia rates for remedial parathyroidectomy and index parathyroidectomy were 10.5% versus 5.0 (P = .07), and hypocalcemia rates were 10.5% versus 2.4% (P.001). After multivariate adjustment, failure to cure was 4.0 times more likely in remedial parathyroidectomy than index parathyroidectomy (P.001).This is the first multi-institutional examination of remedial parathyroidectomy outcomes in the Collaborative Endocrine Surgery Quality Improvement Program. Nerve injury rates are low; high rates of hypercalcemia and hypocalcemia suggest potential opportunities to refine the preoperative and intraoperative management of patients undergoing remedial parathyroidectomy.

Data on the importance of margin status after total thyroidectomy for papillary thyroid cancer (PTC) remain limited. This study sought to identify factors associated with positive margins and to determine the impact of positive margins on survival for patients with PTC.The National Cancer Data Base (1998-2006) was queried for patients with PTC who had undergone total thyroidectomy. The patients were divided into three groups based on margin status (negative, microscopically positive, and macroscopically positive). Patient demographic, clinical, and pathologic features were evaluated. A binary logistic regression model was developed to identify factors associated with positive margins. A Cox proportional hazards model was developed to identify factors associated with survival.Of the 31,129 patients enrolled in the study, 91.3 % had negative margins, 8.1 % had microscopically positive margins, and 0.6 % had macroscopically positive margins. The patients with negative margins were younger and more likely to be female, white, covered by private insurance, and treated at an academic or high-volume center (p0.05). They had smaller tumors and were less likely to have advanced-stage disease. After multivariable adjustment, increasing patient age [odds ratio (OR) = 1.02; p0.01], government insurance (OR = 1.20; p0.01), and no insurance (OR = 1.34; p = 0.01) were associated with positive margins. Reception of surgery at a high-volume facility (OR = 0.72; p0.01) was protective. After multivariable adjustment, both microscopically [hazard ratio (HR), 1.49; p0.01] and macroscopically positive margins (HR = 2.38; p0.01) were associated with compromised survival.Several vulnerable patient populations have a higher risk of incomplete resection after thyroidectomy for PTC. High-risk thyroid cancer patients should be referred to high-volume centers to optimize outcomes.

Objectives:To describe national practice patterns regarding utilization of minimally invasive pancreaticoduodenectomy (MIPD) and compare short-term outcomes with those following open pancreaticoduodenectomy for cancer.Background:There is increasing interest in use of MIPD; however, published data ar

Some studies have reported that minimally invasive follicular carcinoma (MIFC) with vascular invasion is associated with compromised prognosis, leading to an ongoing debate regarding extent of surgery for MIFC. Our goal was to identify predictors of vascular invasion and determine its impact on patterns of care. Adult patients with MIFC were culled from the National Cancer Database, 2010–2011, and segregated according to the presence/absence of capsular or vascular invasion. Variables of interest were examined using Chi-square and student’s t tests. Multivariate analysis was performed with logistic regression. A total of 617 patients with MIFC were identified: 54 % with capsular invasion only and 46 % with vascular invasion. Demographic characteristics were similarly distributed between the two groups. Tumor size was larger in patients with vascular invasion (mean = 35.7 vs. 29.2 mm capsular invasion only, p < 0.001); a 2 % increase in risk of vascular invasion was observed with each 1 mm increase in size. The rate of total thyroidectomy was similar for MIFCs with vascular invasion compared to capsular invasion only (72.9 vs. 75.1 %, p = 0.537). The RAI administration rate was higher in patients with vascular invasion (62.1 vs. 52.6 % capsular invasion only, p = 0.017). In multivariate analysis, the presence of vascular invasion was independently associated with increased likelihood of receiving RAI (OR 1.641, p = 0.007). MIFC remains aggressively treated despite current guidelines favoring a more conservative approach. Building consensus around MIFC management is important for standardization of practice patterns and improvement in quality of care.

Background Despite universal adoption of sentinel lymph node biopsy (SLNB) for breast cancer, there remains no standardized protocol for preoperative lymphoscintographic assessment of sentinel nodes. Both immediate and delayed lymphoscintigraphy are currently utilized, although it is unclear how delayed imaging impacts SLN identification. Methods Among patients diagnosed with breast cancer who underwent SLNB at Duke from 2011 to 2012, two protocols for preoperative lymphoscintigraphy were used: protocol A included both immediate and delayed lymphoscintigraphy (n = 152), while protocol B involved immediate lymphoscintigraphy only (n = 103). Results The overall intraoperative SLN identification rate was 98.4% and did not differ between groups. A lower number of SLN were visualized on the immediate scan using protocol A compared to protocol B (P

Malignant pheochromocytoma is rare, and there is a scarcity of data on the use of minimally invasive surgery (MIS) for treatment. The aims of this study were to analyze patterns of use of MIS for malignant pheochromocytoma in the U.S. and compare short-term outcomes to those of open adrenalectomy. Patients with malignant pheochromocytoma undergoing MIS, including laparoscopy, robotic assisted, laparoscopy converted to open, or open adrenalectomy, were culled from the National Cancer Database, from 1998 to 2011. Data were examined using simple summary statistics, Χ 2 and student’s t tests, Mann–Whitney test, and logistic regression. A total of 36 MIS and 67 open adrenalectomies were identified in 2010–2011. No significant differences were observed between the two treatment groups in demographic characteristics or comorbidities. Preoperative diagnosis of malignancy was made in 52.8 % of MIS and 48.5 % of open patients (p = NS). MIS and open adrenalectomies did not differ with respect to lymph node metastases, vascular invasion, extra-adrenal-extension, and distant metastases (all p = NS). MIS tended to more often be used to perform partial adrenalectomy (38.9 vs. 20.4 % open, p = 0.061); surgical margins, 30-day readmission and mortality rates were similar to open adrenalectomy (all p = NS). Tumors removed via MIS were smaller (48.7 vs. 73.3 mm open, p = 0.003) and associated with a shorter length of stay. A significant proportion of patients with malignant pheochromocytomas underwent MIS, with short-term outcomes which are comparable to those of open surgery. Further studies focused on long-term survival and recurrence are needed to assess the role of MIS in the management of these rare tumors.

ContextA subset of PHPT patients exhibit a more severe disease phenotype characterized by bone loss, fractures, recurrent nephrolithiasis, and other dysfunctions, but the underlying reasons for this disparity in clinical presentation remain unknown.ObjectiveWe sought to identify new mechanistic indices that could inform more personalized management of PHPT.DesignPre-, peri-, and postoperative data and demographic, clinical, and pathological information from patients undergoing parathyroidectomy for PHPT were collected. Univariate and partial Spearman correlation was used to estimate the association of parathyroid tumor calcium sensing capacity with select variables.Patients or other participantsAn unselected series of 237 patients aged >18years and undergoing parathyroidectomy for PHPT were enrolled.Main outcome measuresCalcium sensing capacity, expressed as the concentration required for half-maximal biochemical response (EC50), was evaluated in parathyroid tumors from an unselected series of 74 patients and assessed for association with clinical parameters. The hypothesis was that greater disease severity would be associated with attenuated calcium sensitivity and biochemically autonomous parathyroid tumor behavior.ResultsParathyroid tumors segregated into two distinct groups of calcium responsiveness (EC50

Thyroidectomy remains the mainstay of treatment for indeterminate thyroid nodules, thyroid cancer, and thyroid nodules associated with symptoms of compression; it is an appealing option for some patients with functional thyroid nodules associated with hyperthyroidism. For thyroid cancer, the extent of thyroid resection and lymph node management needs to be individualized, taking into consideration risk stratification schema, treatment guidelines, and patient values. Treatment guidelines have been created by the American Thyroid Association to inform clinical decision-making for the surgical management of patients with thyroid nodules in different clinical settings and are referenced throughout the following chapter.

Sentinel-lymph-node biopsy is associated with increased melanoma-specific survival (i.e., survival until death from melanoma) among patients with node-positive intermediate-thickness melanomas (1.2 to 3.5 mm). The value of completion lymph-node dissection for patients with sentinel-node metastases is not clear. In an international trial, we randomly assigned patients with sentinel-node metastases detected by means of standard pathological assessment or a multimarker molecular assay to immediate completion lymph-node dissection (dissection group) or nodal observation with ultrasonography (observation group). The primary end point was melanoma-specific survival. Secondary end points included disease-free survival and the cumulative rate of nonsentinel-node metastasis. Immediate completion lymph-node dissection was not associated with increased melanoma-specific survival among 1934 patients with data that could be evaluated in an intention-to-treat analysis or among 1755 patients in the per-protocol analysis. In the per-protocol analysis, the mean (±SE) 3-year rate of melanoma-specific survival was similar in the dissection group and the observation group (86±1.3% and 86±1.2%, respectively; P=0.42 by the log-rank test) at a median follow-up of 43 months. The rate of disease-free survival was slightly higher in the dissection group than in the observation group (68±1.7% and 63±1.7%, respectively; P=0.05 by the log-rank test) at 3 years, based on an increased rate of disease control in the regional nodes at 3 years (92±1.0% vs. 77±1.5%; P