Thyroseq V3 Molecular Profiling for Tailoring the Surgical Management of Hürthle Cell Neoplasms.

Hürthle cell predominant thyroid nodules often confound the diagnostic utility of fine needle aspiration biopsy (FNAB) with cytology often interpreted as a Hürthle cell lesion with an indeterminate risk of malignancy, Bethesda category (BC) III or IV. Molecular diagnostics for Hürthle cell predominant nodules has also been disappointing in further defining the risk of malignancy. We present a case of a slowly enlarging nodule within a goiter initially reported as benign on FNAB, BC II but on subsequent FNAB suspicious for a Hürthle cell neoplasm, BC IV. The patient had initially requested a diagnostic lobectomy for a definitive diagnosis despite a higher risk of malignancy based on the size of the nodule > 4 cm alone. To better tailor this patient's treatment plan, a newer expanded gene mutation panel, ThyroSeq® v3 that includes copy number alterations (CNAs) and was recently found to have greater positive predictive value (PPV) for identifying Hürthle cell carcinoma (HCC), was performed on the FNAB material. Molecular profiling with ThyroSeq® v3 was able to predict a greater risk of carcinoma, making a more convincing argument in favor of total thyroidectomy. Surgical pathology confirmed a Hürthle cell carcinoma with 5 foci of angioinvasion and foci of capsular invasion.

A simplified approach to minimally invasive parathyroidectomy.

OBJECTIVES/HYPOTHESIS: To assess the feasibility of a simplified approach for the use of a rapid intraoperative parathyroid hormone (IOPTH) assay based on a single 10-minute post-excision level using the workup parathyroid hormone level (wPTH) as the baseline in minimally invasive parathyroidectomy (MIP) and to compare the predictive value of this criterion with other recommended criteria. STUDY DESIGN: Case series with chart review. METHODS: A single surgeon's prospectively maintained parathyroidectomy database at an academic center was reviewed over a 2-year period from June 2009 through June 2011. RESULTS: A total of 102 patients undergoing MIP met the inclusion criteria. An IOPTH threshold of a ≥ 50% drop at 10 minutes post-excision from the wPTH baseline resulted in acceptable false positive (1.9%) and false negative (0.9%) rates. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of this modified criterion was 98.9%, 71.4%, 98%, 83.3%, and 97%, respectively. CONCLUSIONS: In our patient cohort, the pre-incision and pre-excision IOPTH levels did not seem to change the overall accuracy of predicting surgical success in MIP if a single 10-minute post-excision IOPTH level is used along with the wPTH, and is commensurate with the commonly used Miami and Vienna criteria. A single intraoperative blood sample demonstrating a ≥50% drop from the wPTH at 10 minutes post-excision should be explored further as a feasible simplified criterion that avoids multiple IOPTH samples.

Parathyroid gland preservation and selective autotransplantation utilizing topical lidocaine in total thyroidectomy.

OBJECTIVES/HYPOTHESIS: To review a new technique during total thyroidectomy that facilitates parathyroid gland preservation and selective autotransplantation utilizing topical 2% plain lidocaine as a spasmolytic/vasodilator agent. STUDY DESIGN: Retrospective case series review at a university hospital. METHODS: The study population comprised 100 consecutive patients (84 women and 16 men; mean age, 52 years) undergoing total thyroidectomy from January 2007 to December 2008. Interventions were: parathyroid glands (PGs) with signs of devascularization treated with a topical solution of 2% plain lidocaine in an attempt to restore blood flow before committing to autotransplantation. RESULTS: The main outcome measure was the incidence of hypoparathyroidism. A total of 40 parathyroid glands were autotransplanted. None of the 100 patients developed permanent hypoparathyroidism. There were no adverse effects utilizing this technique. CONCLUSIONS: In our experience, the use of lidocaine spasmolysis is a useful technique in thyroid surgery for salvaging devascularized PGs. Its utility as a selection method for PG autotransplantation incurs minimal risk or cost and might further reduce the incidence of permanent hypoparathyroidism. Further study is warranted.

Rapid intraoperative localization of parathyroid glands utilizing methylene blue infusion.

OBJECTIVE: To review a single surgeon's experience utilizing an intraoperative methylene blue infusion (IMBI) to identify parathyroid glands during neck exploration for primary hyperparathyroidism. STUDY DESIGN AND SETTING: Retrospective review of 35 patients who underwent bilateral neck exploration utilizing an IMBI at a dose of 7.5 mg/kg following the induction of general anesthesia. RESULTS: All patients reverted to normocalcemia with a mean follow-up of 17 months. IMBI facilitated the identification of abnormal parathyroid tissue in 34/35 patients (97%). A dark blue-purple staining was observed in 33/37 stained adenomas (89%). Four adenomas and four hyperplastic glands stained a lighter shade of blue-green. Among 89 normal glands, 41(46%) stained a pale green-grey color. CONCLUSIONS: IMBI is a safe, readily available, cost-effective, and underutilized technique that facilitates rapid identification of parathyroid adenomas, helps distinguish normal glands from hyperplastic glands, and helps to locate ectopic glands. An overall reduction in operative time, especially for bilateral neck exploration, can be anticipated.