1,161 patients with adrenal incidentalomas: indications for surgery.

BACKGROUND AND AIMS: The aim of this study is to analyze the clinical data and criteria for surgery in a group of over 1,100 patients with adrenal incidentalomas (AI) observed at the Department of Endocrinology. PATIENTS AND METHODS: The material consisted of 1,161 patients (842 women and 319 men, 10-87 years old) with AI ranging in size from 1.0 to 23.0 cm. The methods included clinical examination, imaging studies, hormonal determinations in the blood and in the urine as well as histological and immunocytochemical investigations in 390 patients treated by surgery. RESULTS: Basing on these studies, we diagnosed 112 patients with primary malignant adrenal tumors (100 with carcinoma), 45 with metastatic infiltrations, and 1,004 with probable benign AI. Imaging phenotypes (especially high density on computed tomography, CT) were characteristic of malignant and chromaffin tumors. Subclinical adrenal hyperactivity was found in 8% of the patients with pre-Cushing's syndrome as the most frequent form (6.5%). Chromaffin tumors were detected in 3%. CONCLUSIONS: (1) Indications for surgery include malignant tumors (both primary and metastatic), tumors with subclinical hyperfunction, and chromaffin tumors. High density on CT, >20 HU, appeared to be an important indication for surgery. (2) A slight prevalence of oncological indications over endocrinological indications (14 vs. 11%) was found.

Coexistence of parathyroid carcinoma and non-medullary carcinoma of the thyroid.

A case of 35-year-old woman with parathyroid cancer is presented. Five years ago she underwent surgery for follicular thyroid cancer. Parathyroid cancer was evidenced by palpable, solid, irregularly shaped cervical tumor 5 cm in diameter. The patient had severe hyperparathyroidism confirmed by biochemical findings of hypercalcemia reaching 16 mg%, hypophosphatemia and hyperphosphatasemia. Serum parathormone level was 23-fold higher than the norm. These findings were accompanied by polyuria, polidypsia, symptoms of bone damage and renal calcification. After the surgery the patient's condition improved significantly despite persistent hyperparathyroidism. The level of parathormone decreased, but was still 11 times higher than the norm. Two months after the surgery she noticed a single node on her neck. The patient was re-operated for recurrence of parathyroid cancer. Serum parathormone level was then 6-8 times above the norm. Medical treatment with furosemide, calcitonin and biphosphonate resulted in normalization of calcemia and phosphatemia. Further management will aim at localization of foci of hyperactive parathyroid tissue in order to enable radical reoperation. The case is reported because of rare occurrence of parathyroid carcinoma as well as because the carcinoma occurred in a patient who previously had follicular thyroid cancer. There are no reports of coexistence of these two neoplasms in available literature.

Encapsulation of parathyroid cells in hollow fibers: a preliminary report.

The purpose of experiments was to evaluate the survival and functioning of human parathyroid cells after encapsulation in hollow fibers (HFs). The polypropylene HFs K600(PP Accurel (Akzo-Nobel, Germany) of inner diameter 0.6 mm, wall thickness 0.2 mm, original or surface modified were used for encapsulation. Production of parathormone (PTH) by encapsulated cells was measured in vitro. HF were filled with parathyroid cell suspension and tightly closed. Encapsulated cells were cultured for 9 or 33 days in RPMI 1640 containing 10% FCS or in Chang's medium. The level of PTH, produced by encapsulated cells was evaluated in the culture medium with radioimmunoassay test (RIA). The assays were performed every 2-4 days. The result of PTH assay was similar in both types of tested media as well as with unmodified and modified HFs, being 2-4 pg/ml of culture medium per 10(3) encapsulated cells. In conclusion, encapsulation in original or modified HFs ensures diffusion of nutrients from culture medium to encapsulated cells and allows for functioning of cells for at least 33 days in vitro.

Laparoscopic operative technique for adrenal tumors.

BACKGROUND AND OBJECTIVES: Laparoscopy has acquired an unquestionable position in surgical practice as a diagnostic and operative tool. Recently, the laparoscopic approach has become a valuable option for adrenalectomy. This paper reports, in detail, our experience of laparoscopic adrenalectomy performed for adrenal tumors. METHODS: We performed 12 laparoscopic adrenalectomies from October 29, 1997 to October 31, 1998. The technique of laparoscopic adrenalectomy is described thoroughly in all relevant details for either left or right-sided adrenal lesions. RESULTS: The presented technique of laparoscopic adrenalectomy in all 12 cases provided good and relatively simple exposure of the immediate operative area. All relevant vascular elements were safely controlled, adrenal tumors could be successfully removed, and adequate hemostasis was achieved. No intraoperative or postoperative complications were observed. CONCLUSIONS: Laparoscopic adrenalectomy is a safe alternative to open surgery and is preferred for most patients because of shorter postoperative hospital stay and less postoperative discomfort.

Ethical implications in the allocation of scarce medical resources in Poland.

The health care system in Poland is undergoing major change and it is possible that these changes could affect clinical research. Therefore, the situation of funding of health care is important for the future of medical research in this country. Some questions relevant in this field will be addressed. Since funds for health care and scientific research remain inadequate, their allocation raises moral, economic, legal and organisational dilemmas. The clinical aspects of resource allocation also include physicians' responsibilities towards their patients. Scientific research, clinical medicine, and clinical research have a common denominator: they rely on trust. The physician should be a fiduciary of the patient as well as being a researcher for the benefit of the patient and for society. Some physicians and researchers, despite unethical conduct, escape disclosure and punishment, but decision-makers who wrongly allocate funds for health care and research are never held accountable for their actions.

Surgery for primary hyperparathyroidism.

OBJECTIVE: To define the role of surgery for organic primary hyperparathyroidism and to evaluate the diagnostic and operative methods applied. DESIGN: Retrospective, non-randomized, non-blinded evaluation. Case series. SETTING: Tertiary referral center. Department of Surgery. SUBJECTS AND METHODS: The report documents experience in surgical management at a single institution of 312 patients with primary (and 498 patients with secondary) hyperparathyroidism in a period from 1974 to 2000. Patient symptoms, clinical features, diagnostic and localization methods, operative management, and postoperative results were evaluated by retrospective medical record review with special attention to surgical management strategy. RESULTS: Of 321 patients with primary hyperparathyroidism 312 underwent 348 operations. There were 312 primary procedures and 36 multiple reoperations on 25 patients. The permanent success rate for primary (312) operations was achieved in 287 patients (92%). The permanent success rate for 36 secondary reoperations was achieved in 19 out of 25 reoperated patients (76%). The overall full recovery was obtained in 306 operated patients (98%). There were no postoperative emergency reoperations. There were 2 postoperative hospital deaths (0.6%) of patients with sustained hypercalcemic crisis after excision one cervical adenoma, but functioning second one in mediastinum.

Effect of surgical technique in subtotal and bilateral thyroidectomy on risk of postoperative parathyroid insufficiency development--our experience.

One of the postoperative complications after strumectomy is hypoparathyroidism. Therefore, the purpose of our study was to evaluate the effect of the surgical technique on the development of parathyroid gland insufficiency in our group of patients. Subtotal, bilateral strumectomies were performed according to Rothmund's suggestions. Randomized controlled trial was performed in two groups. In the first group of 19 patients, main trunk of the inferior thyroid artery was ligated and in the second one consisting of 18 patients, only the branches of this artery were ligated. Total calcium and PTH levels were evaluated pre- and postoperatively. Based on the biochemical and clinical data, no statistically significant differences in the development of postoperative hypoparathyroidism in relation to performed surgical techniques were observed.

[Endoscopic ultrasonography in the preoperative localization of a pancreatic tumor producing insulin (insulinoma)]. / Ultrasonografia endoskopowa w przedoperacyjnej lokalizacji guza trzustki produkujacego insuline (insulinoma).

Pancreatic endocrine tumors include insulinomas, gastrinomas and some other less frequent neoplasms produce different GI hormones. Preoperative localization of the tumor in patients with evident clinical and biochemical features is usually difficult to obtain in conventional imaging methods. This is due to typically small size of these tumors. Non-invasive methods (conventional ultrasound, computerized tomography, nuclear magnetic resonance, positron emission tomography) and invasive methods (visceral angiography, portal veins catheterization) are often of no use in such condition, as their sensitivity is low. Preoperative localization is of importance for the surgeon, as he can plan his operation for reducing the length of the procedure with obvious consequences. This paper describes for the first time on Polish literature the usefulness of endoscopic ultrasonography in preoperative assessment of insulinoma in one patient. This finding was confirmed during surgery. The operation led to enucleation of two small insulinomas in the head of the pancreas and resulting in complete healing of the patient as found in one year follow up.

Cultured parathyroid cells allotransplantation without immunosuppression for treatment of intractable hypoparathyroidism.

Cultured, viable and functioning ABO compatible parathyroid cells were allografted in 18 nonimmunosuppressed patients with a postoperative hypoparathyroidism. Variable, but promising biochemical and clinical results were obtained. Clinical and biochemical observations have documented graft function up to 14 months. The mechanism of cessation of function of implanted cultured cell suspension remains unknown. Some parameters, suggest a rejection mechanism but other mechanisms can not be excluded. This suggests that some form of immune modulation may be necessary to improve further PT allograft survival in recipients off immunosuppressive therapy.

[Usefulness of scintigraphy using 99mTc-MIBI for localization of parathyroid adenoma]. / Przydatnosc scyntygrafii z uzyciem 99mTc-MIBI w lokalizacji gruczolaków przytarczyc.

Aim of this study was to evaluate the significance of 99mTc-MIBI scintigraphy in detection of parathyroid adenomas in patients with primary and primary recurrent or persistent hyperparathyroidism after surgical treatment. The images of the neck and mediastinum were taken 20 minutes and 2 hours after i.v. injection of the radiopharmaceutic. Result of the scintigraphy was defined as positive when the initial high 99mTc-MIBI uptake persistent in the region of the neck or mediastinum. At this time the radioactivity from thyroid gland declined significantly. Parathyroid adenoma was confirmed by surgery in 10 out of 12 cases diagnosed by scintigraphy. Parathyroid imaging using 99mTc-MIBI is a promising procedure in the preoperative localisation of parathyroid adenomas in patient with hyperparathyroidism.

[Results of conservative treatment in patients with atheromatous obstruction of arteries in the leg]. / Ocena leczenia zachowawczego chorych z miazdzycowa niedroznoscia tetnic podudzi.

Late results of the treatment of 107 patients with crural arteries occlusion (21 (20%) with isolated lesions and 86 (80%) with multisegmental lesions) were evaluated. Favourable result of the conservative treatment was achieved in 38% of patients with isolated lesions, no improvement in 38%, and worsening in one patient were noted during a 5-year follow up. Percentage in the group of patients with multisegmental lesions (including crural arteries) was 23%, 50%, and 27%, respectively. No patients with isolated lesions died during follow up period, whereas 11 (13%) patients with multisegmental lesions died.

Incidentally found adrenal tumours: results of investigation of the pituitary-adrenal axis.

In the last 7 years 64 patients (48 women, 16 men, aged 25-75 yrs) with incidentally found asymptomatic adrenal tumours have been observed in the Department of Endocrinology. In 11 patients a routine clinical investigations revealed metastatic tumours at the adrenal glands. In the remaining 53 patients the diameter of the adrenal tumours was < or = 3 cm. Only two of them were treated surgically; the rest has been observed regularly and ultrasonographic examinations have been repeated every 3 to 6 months. Twenty three patients with adrenal tumours < 3 cm of diameter were treated by surgery. The macroscopical examination revealed adrenal cortical adenoma in 11 cases, adrenocortical carcinoma in seven, and pheochromocytoma in 5 patients. The investigation of the pituitary-adrenal system (urinary excretion of 17-OHCS before and during dexamethasone administration, 17-KS, "free" corticosteroids, plasma ACTH, cortisol and S-DHA levels) did not reveal any abnormality except that in 10 patients the plasma ACTH concentration was low, especially in the morning. These values were significantly lower as compared with the remaining patients and with control group. One of the possible interpretations is a pituitary suppression by only periodically increased concentrations of the corticosteroids.