Tumor Growth Kinetics Based on Initial Tumor Volume Doubling Time in Active Surveillance of Low-Risk Papillary Thyroid Carcinoma.

BACKGROUND: During active surveillance (AS) of low-risk papillary thyroid carcinomas (PTCs), the majority remain stable, while some exhibit either increase or decrease in tumor diameter or tumor volume (TV). We aimed to evaluate the clinical outcomes and relevant parameters influencing tumor growth kinetics of low-risk PTCs. METHODS: This retrospective cohort study evaluated clinical parameters of 402 patients with low-risk PTC sized <2 cm, with a follow-up duration over 3 years. Changes in maximum tumor diameter, TV, and initial TV doubling time (i-TVDT) calculated within 3-year were assessed. A significant change in TV was defined as a change of 75% or more. RESULTS: Of the 402 patients with low-risk PTC, 93.3% (375/402) were diagnosed with papillary thyroid microcarcinoma. During a median follow-up of 5 years, 3.4% (14/402) of patients developed new cervical lymph node (LN) metastasis, and 8.2% (33/402) experienced maximal diameter increase of ≥3 mm. The i-TVDT of <5 years emerged as an independent risk factor for both maximal diameter growth and new LN metastasis (p<0.001 and p=0.04, respectively). Based on TV changes and i-TVDT during AS, we identified four statistically significant tumor kinetic patterns (p<0.001): Stable (±75% change in TV), Rapid growth (TV increase >75% and i- TVDT <5 years), Slow growth (TV increase >75% and i-TVDT ≥5 years), and Shrinkage (TV decrease >75%). Most of the PTCs remained stable (67.7%), but 17.2% were rapidly growing, with a median onset of growth of 2.0 years. Slowly growing PTCs, comprising 10.9%, grew at a median of 4.3 years. A minority, 4.2%, exhibited shrinkage. In total, 115 (28.6%) patients underwent delayed surgery >12 months after initiating AS. The reasons for delayed surgery included patient preference (51/115, 44.3%), disease progression (31/115, 27.0%), and suspected disease progression, which was referred to as tumor growth not meeting the criteria of an increase of ≥3 mm in maximal tumor diameter (17/115, 14.8%). CONCLUSION: An i-TVDT of <5 years serve as an important prognostic indicator for disease progression, including tumor growth and new LN metastasis. The four tumor kinetic patterns based on TV changes and i-TVDT assist in guiding personalized decisions early in AS.

Exploring the Benefits of a Reduced-Port Approach in Robotic Posterior Retroperitoneoscopic Adrenalectomy: A Comparative Study of the Two-Port and Three-Port Techniques.

Background: Robotic adrenalectomy has become a surgical treatment option for benign and selected malignant adrenal diseases. We aimed to evaluate the eligibility of two-port robotic posterior retroperitoneoscopic adrenalectomy (PRA) as an alternative to the conventional three-port technique by comparing their surgical outcomes. Materials and Methods: This retrospective cohort study compared the clinicopathological factors and surgical outcomes among 197 patients who underwent two-port or three-port robotic adrenalectomy between 2016 and 2020 in a single tertiary center. For further evaluation, propensity score matching was performed to reduce the selection bias in population characteristics. Results: Patients were categorized by the number of ports (two-port group, 87; and three-port group, 110). The two-port group compared with the three-port group was significantly older (P = .006) and had a smaller mean tumor size (P = .003) and shorter mean operation time (P = .001). Upon comparing clinicopathologic characteristics according to adrenal disorders, for pheochromocytoma, the three-port group had a larger tumor size and a longer operation time. For Cushing's syndrome, the operation time was short and numeric rating scale pain score was significantly low in the two-port group. After propensity score matching, the two-port group had a short operation time and a significantly low postoperative pain score (P < .05). Predictive factors associated with prolonged operation time included male gender, an increased number of ports, and large tumor size. Conclusions: The two-port technique resulted in a shorter operation time and lower pain score compared with the three-port technique. The two-port technique may be a safe alternative to the conventional three-port technique for robotic PRA.

Silent pheochromocytoma in adrenal incidentaloma: unveiling clinical and radiological characteristics.

Purpose: Silent pheochromocytoma refers to tumors without signs and symptoms of catecholamine excess. This study aimed to clarify the clinical, radiological characteristics, and perioperative features of silent pheochromocytomas diagnosed after adrenalectomy for adrenal incidentaloma. Methods: Medical records of patients who underwent adrenalectomy for adrenal incidentaloma and were subsequently diagnosed with silent pheochromocytoma between January 2000 and December 2020 were retrospectively reviewed for demographic, diagnostic, surgical, and pathological findings. Results: Of the 130 patients who underwent adrenalectomy for incidentaloma, 8 (6.1%) were diagnosed with silent pheochromocytoma. Almost all patients had no hypertensive symptoms and their baseline hormonal levels remained within normal ranges. All patients exhibited tumor size >4 cm, precontrast Hounsfield unit >10, and absolute washout <60%. Intraoperative hypertensive events were noted in 2 patients (25.0%) in whom antiadrenergic medications were not administered. All patients in the intraoperative hypertensive event group exhibited atypical features on CT, whereas 83.3% of patients in the non-intraoperative hypertensive event group showed atypical features on CT imaging. Conclusion: Silent pheochromocytomas share radiological traits with malignant adrenal tumors. Suspicious features on CT scans warrant surgical consideration for appropriate treatment. Administering alpha-blockers can enhance hemodynamic stability during adrenalectomy in suspected silent pheochromocytoma cases.

Diagnostic consistency between computed tomography and adrenal vein sampling of primary aldosteronism: leading to successful curative outcome after adrenalectomy; a retrospective study.

BACKGROUND: Adrenal computed tomography (CT) is a useful tool for locating adrenal lesion in primary aldosteronism (PA) patients. However, adrenal vein sampling (AVS) is considered as a gold standard for subtype diagnosis of PA. The aim of this study was to investigate the consistency of CT and AVS for the diagnosis of PA subtypes and evaluate the concordance of surgical outcomes. MATERIALS AND METHODS: This retrospective study included 264 PA patients having both CT and AVS. Diagnostic consistency between CT and AVS was accessed, and clinical and biochemical outcomes were evaluated at 6 months after adrenalectomy. RESULTS: Of all, 207 (78%) had a CT unilateral lesion, 31 (12%) CT bilateral lesion, and 26 (10%) CT bilateral normal findings. Among the CT unilateral lesion group, 138 (67%) had ipsilateral AVS lateralization. For CT bilateral lesion and bilateral normal, AVS unilateral lateralization was found in 17 (55%) and 2 (8%), respectively. The consistency between CT lesion and AVS lateralization including CT unilateral with AVS ipsilateral, and CT bilateral lesion with AVS bilateral patients was 63.8% (152/238). Of 77 patients with available data out of 138 patients who underwent adrenalectomy with consistency between CT and AVS, the clinical success rate was 96%, for 17 inconsistency patients out of 22 patients who underwent adrenalectomy, the clinical success rate was 94% after adrenalectomy following the lateralization result of AVS. CONCLUSION: CT is a useful tool to diagnose the adrenal lesion in PA patients. However, AVS is more sufficient to detect the unilateral PA subtype, which could provide curable treatment to surgical candidates of PA such that AVS can identify patients with contralateral PA in CT unilateral lesion and unilateral PA in CT bilateral lesion. The surgical outcome was successful when an adrenalectomy was performed according to the AVS lateralization result.

Predictive factors for persistent hypercalcemia following parathyroidectomy in patients with persistent hyperparathyroidism after kidney transplantation: a retrospective cohort study.

BACKGROUND: Surgery for irreversible hyperparathyroidism is the preferred management for kidney transplant patients. The authors analyzed the factors associated with persistent hypercalcemia after parathyroidectomy in kidney transplant patients and evaluated the appropriate extent of surgery. MATERIALS AND METHODS: The authors retrospectively analyzed 100 patients who underwent parathyroidectomy because of persistent hyperparathyroidism after kidney transplantation at a tertiary medical center between June 2011 and February 2022. Patients were divided into two groups: 22 with persistent hypercalcemia after parathyroidectomy and 78 who achieved normocalcemia after parathyroidectomy. Persistent hypercalcemia was defined as having sustained hypercalcemia (≥10.3 mg/dl) 6 months after kidney transplantation. The authors compared the biochemical and clinicopathological features between the two groups. Multivariate logistic regression analysis was used to identify potential risk factors associated with persistent hypercalcemia following parathyroidectomy. RESULTS: The proportion of patients with serum intact parathyroid hormone (PTH) level is greater than 65 pg/ml was significantly high in the hypercalcemia group (40.9 vs. 7.7%). The proportion of patients who underwent less than subtotal parathyroidectomy was significantly high in the persistent hypercalcemia group (17.9 vs. 54.5%). Patients with a large remaining size of the preserved parathyroid gland (≥0.8 cm) had a high incidence of persistent hypercalcemia (29.7 vs. 52.6%). In the multivariate logistic regression analysis, the drop rate of intact PTH is less than 88% on postoperative day 1 (odds ratio 10.3, 95% CI: 2.7-39.1, P =0.001) and the removal of less than or equal to 2 parathyroid glands (odds ratio 6.8, 95% CI: 1.8-26.7, P =0.001) were identified as risk factors for persistent hypercalcemia. CONCLUSION: The drop rate of intact PTH is less than 88% on postoperative day 1 and appropriate extent of surgery for controlling the autonomic function were independently associated with persistent hypercalcemia. Confirmation of parathyroid lesions through frozen section biopsy or intraoperative PTH monitoring can be helpful in preventing the inadvertent removal of a parathyroid gland and achieving normocalcemia after parathyroidectomy.

Safety and feasibility of single-port surgery for posterior retroperitoneal adrenalectomy using the da Vinci SP robotic system: a retrospective cohort study.

BACKGROUND: This study demonstrates our experience of single-port robotic posterior retroperitoneal adrenalectomy (RPRA) using the da Vinci SP robot system and evaluates its technical feasibility and surgical outcomes. METHODS: We conducted a retrospective analysis of 250 RPRAs, including 117 conventional 3-port RPRAs, 103 reduced 2-port RPRAs, and 30 single-port RPRAs. Each RPRA type was compared by analyzing 30 patients in the early phase of surgery. RESULTS: All patients who underwent single-port RPRA showed excellent surgical outcomes. Age, sex, BMI, and tumor location site did not significantly differ between the three groups. In the early phase, the size of the adrenal tumor was similar between three groups, and it tended to increase as the number of ports increased (p < 0.001). The mean operation time was shorter for patients who underwent single-port RPRA than those who underwent RPRA types (p < 0.001). The numeric rating scale score did not significantly differ between the groups on most days. No major complications were observed, and no patients were converted to open surgery or required additional port insertion. CONCLUSION: Single-port RPA using the da Vinci SP robotic system showed the effectiveness of the surgical procedure and improved cosmetic outcomes for patients, while also enabling surgeons to perform operations with greater ease and convenience. Therefore, single-port RPRA could be a good alternative option for the treatment of adrenal tumors in selected situations.

Contralateral Low-to-Intermediate Suspicion Nodule Is Not a Contraindication for Lobectomy in Patients with Papillary Thyroid Carcinoma.

Background: The optimal extent of surgery for unilateral papillary thyroid carcinoma (PTC) with contralateral nodules remains unclear. This study evaluated the long-term outcomes in a large cohort of patients with unilateral PTC and contralateral low-to-intermediate suspicious nodules who underwent lobectomy. Methods: This retrospective cohort study included patients with unilateral PTC who underwent lobectomy between January 2016 and December 2017 at Asan Medical Center in Korea. Patients were divided into two groups, those with and without contralateral nodules at the time of lobectomy: the Present group and the Absent group. All contralateral nodules observed at the time of surgery and during follow-up were evaluated. Results: The study cohort consisted of 1761 patients (1879 nodules), including 700 (39.8%) with and 1061 (60.2%) without contralateral nodules. The median size of the contralateral nodules was 0.5 cm. After a median follow-up of 59 months, the median growth of the contralateral nodules in the Present group was 0.1 cm (range, -3.4 to 4.7 cm). Of the contralateral nodules present at the time of lobectomy, 54.7% remained unchanged, decreased in size, or disappeared; whereas 14.8% increased ≥0.3 cm. Of the 700 patients with contralateral nodules, 20 (2.9%) were diagnosed with contralateral PTC. The 5-year contralateral PTC disease-free survival rates in patients with and without contralateral nodules were 98.2% and 99.3% (p = 0.003), respectively, whereas the 5-year recurrence-free survival rates did not differ significantly in these two groups. Of the 39 patients who underwent completion thyroidectomy, 2 (5.1%) experienced permanent hypocalcemia. Conclusions: Lobectomy may be a safe and feasible initial treatment option for patients with unilateral low-risk PTC and contralateral low-to-intermediate suspicious nodules.

Radiofrequency ablation of benign thyroid nodules: the value of anterolateral hydrodissection.

PURPOSE: This study aimed to evaluate the technical feasibility, efficacy, and safety of anterolateral hydrodissection (ALHD) in radiofrequency ablation (RFA) for benign thyroid nodules. METHODS: Between November 2019 and April 2020, 39 patients underwent 41 sessions of RFA with the ALHD technique to treat benign thyroid nodules. ALHD was performed with cold (0°C-4°C) 5% dextrose solution during RFA to minimize pain and secure sufficient safety margins from critical neck structures. The initial ablation ratio (IAR) was measured to assess the technique's efficiency. Ultrasound examinations, symptoms, and cosmetic scores were evaluated pre-procedure and at 6 and 12 months post-procedure. Procedure-related pain during RFA and complications were recorded. RESULTS: The mean index nodule volume was 20.5±21.6 mL. ALHD was technically feasible in all patients. The mean IAR was 90.7%±8.3%, and significant reductions in mean nodule volume were noted at 6- and 12-month follow-ups (P<0.001, 63.9%±19.0%, and 76.3%±18.9%, respectively). Symptom and cosmetic scores showed significant improvements at 6- and 12-month follow-ups (P<0.001). Pain during the procedure was well-controlled with ALHD in all patients. After the initial use of 5-10 mL of lidocaine at the start of the procedure, no further lidocaine injection was given to any patient. Transient voice change was observed in one patient, but the patient recovered spontaneously within 30 minutes. CONCLUSION: The ALHD technique was technically feasible and effective in all patients, achieving a mean IAR of 90.7%. The ALHD technique also had a pain-relieving effect, resulting in only low amounts of lidocaine administration being required during the procedure.

Short-term outcome of adrenal radiofrequency ablation of adrenal cysts: a single-center experience.

Percutaneous thermal ablation is a minimally invasive treatment for liver, kidney, lung, bone, and thyroid tumors. This treatment also has been used to treat adrenal tumors in patients, but there is no evidence for the efficacy of thermal ablation of adrenal cysts. The present study was performed to analyze the experience of a single center with percutaneous radiofrequency ablation (RFA) of adrenal cysts and to evaluate its efficacy. The present study enrolled all patients who underwent percutaneous RFA for unilateral adrenal cysts from 2019 to 2021. All patients underwent USG-guided percutaneous aspiration of cystic fluid, followed by RFA. A total nine patients with adrenal cysts were included in this study. All of them underwent technically successful percutaneous RFA, with no immediate complication. Follow-up CT 3 months after RFA showed that six of the nine adrenal cysts showed good responses, with reductions in cyst volume ranging from 86.4 to 97.9%. One patient had poor response in the cyst size (volume reduction rate 11.2%). She underwent secondary RFA with resulting that the cyst volume reduced by 91.1%. After a median follow-up period of 17.2 months, eight patients showed no evidence of regrowth. The patient, who showed evidence of regrowth, declined any other treatment and has been under regular surveillance. None of the nine patients developed adrenal insufficiency during the follow-up period. In conclusion, percutaneous RFA is a safe and effective minimally invasive treatment for adrenal cysts, suggesting that percutaneous RFA may be a good alternative option in selected patients.

Change of treatment modality and outcomes of adrenocortical carcinoma: a retrospective review of single tertiary center experience over 24 years.

Background: Adrenocortical carcinoma, a rare malignancy, has a poor prognosis, and the treatment modalities have not been well established. This study aimed to analyze the trend of treatment modalities and outcomes of patients with adrenocortical carcinoma. Methods: We retrospectively analyzed 94 patients with adrenocortical carcinoma between January 1995 and June 2020 for distributions according to the American Joint Committee on Cancer (AJCC) 8th edition tumor-node-metastasis (TNM) staging, the yearly trend of demographic features, differences in multidisciplinary treatment, and prognostic outcomes. Multidisciplinary treatment included any combination of treatment including surgery, mitotane, chemotherapy or radiation. Results: The mean age and tumor size were 48.9 years and 11.7 cm, respectively. Fifteen patients (16.0%) underwent surgery only, and 56 (59.6%) underwent surgery with additional multidisciplinary treatments. Initial curative treatment was performed in all patients with stage 1 (n=5), 33 patients with stage 2 (n=34, 97.1%), 12 patients with stage 3 (n=19, 63.2%), and 11 patients with stage 4 (n=36, 30.6%) (P<0.0001). Two patients (40.0%) with stage 1 presented recurrence. In stages 2, 3, and 4, 57.6%, 58.3%, and 90.9% of patients who received curative treatment had recurrences, respectively. The annual trend presented statistical differences in mitotane use that have been increasing recently (P<0.0001). Conclusions: Overall distribution of adrenocortical carcinoma stage was similar throughout the years. Although the rate of mitotane use in the treatment of patients with Adrenocortical carcinoma has increased over time, recurrences were common even after multidisciplinary curative treatment in all stages. The treatment effect and prognostic outcomes presented no promising progression even with adjuvant chemotherapy and mitotane use in addition to surgical treatment. Adrenocortical carcinoma still presented an extremely poor prognosis, and further prospective studies are needed.

Diagnostic Performance of Core Needle Biopsy for Characterizing Thyroidectomy Bed Lesions.

OBJECTIVE: Thyroidectomy bed lesions frequently show suspicious ultrasound (US) features after thyroid surgery. Fine-needle aspiration (FNA) may not provide definitive pathological information about the lesions. Although core-needle biopsy (CNB) has excellent diagnostic performance in characterizing suspicious thyroid nodules, no published studies have evaluated the performance of CNB specifically for thyroidectomy bed lesions. Therefore, we aimed to evaluate the diagnostic performance and safety of CNB for characterizing thyroidectomy bed lesions. MATERIALS AND METHODS: A total of 124 thyroidectomy bed lesions in 113 patients (79 female and 34 male; age, 23-85 years) who underwent US-guided CNB between December 2008 and December 2020 were included. We reviewed the US imaging features of the target lesions and the histories of previous biopsies. The pathologic results, diagnostic performance for malignancy, and complications of CNB were analyzed. RESULTS: All samples (100%) obtained by CNB were adequate for pathological analysis. Pathological analysis revealed inconclusive results in two lesions (1.6%). According to the reference standard, 50 lesions were ultimately malignant (40.3%), and 72 were benign (58.1%), excluding the two inconclusive lesions. The performance of CNB for diagnosing malignant thyroidectomy bed lesions in the 122 lesions had a sensitivity of 98.0% (49/50), a specificity of 100% (72/72), positive predictive value of 100% (49/49), and negative predictive value of 98.6% (72/73). Eleven lesions were referred for CNB after prior inconclusive FNA results in thyroidectomy bed lesions, for all of which CNB yielded correct conclusive pathologic diagnoses. According to the pathological analysis of CNB, there were various benign lesions (58.9%, 73/124) besides recurrence, including benign postoperative lesions other than suture granuloma (32.3%, 40/124), suture granuloma (15.3%, 19/124), remnant thyroid tissue (5.6%, 7/124), parathyroid lesions (4%, 5/124), and abscesses (1.6%, 2/124). No major or minor complications were associated with the CNB procedure. CONCLUSION: US-guided CNB is accurate and safe for characterizing thyroidectomy bed lesions.

Prognosis of Patients with 1-4 cm Papillary Thyroid Cancer Who Underwent Lobectomy: Focus on Gross Extrathyroidal Extension Invading Only the Strap Muscles.

BACKGROUND: This study was designed to evaluate the prognostic implication of gross extrathyroidal extension (ETE) invading the strap muscles after thyroid lobectomy in patients with 1-4 cm papillary thyroid cancer (PTC). METHODS: This retrospective cohort study included patients with 1-4 cm PTC who underwent thyroid lobectomy from 2005 to 2012. Overall, 595 patients were enrolled after excluding patients with aggressive variants of PTC, gross ETE into a major neck structure, and lateral cervical lymph node (LN) metastasis. We evaluated the risk factors for structural recurrence after lobectomy in 1-4 cm PTC. RESULTS: Seventy-eight patients (13.1%) had gross ETE invading only the strap muscles. During the median follow-up period of 7.7 years, structural recurrence was confirmed in 35 patients (5.9%). The presence of gross ETE was an independent risk factor for structural recurrence (hazard ratio 2.54, 95% confidence interval 1.19-5.44; p = 0.016). Subgroup analysis of patients with gross ETE showed that 11 and 47 patients had low- and intermediate-risk LN metastasis, respectively. A significant difference in recurrence-free survival was observed according to the degree of cervical LN metastasis (p = 0.03). Those without LN metastasis or low-risk LNs had a 75% lower risk of recurrence when compared with those with both gross ETE and intermediate-risk LNs. CONCLUSION: Gross ETE and intermediate-risk cervical LN metastasis were associated with a significantly high risk of recurrence after lobectomy in patients with 1-4 cm PTC. Completion thyroidectomy would be considered in this subgroup of patients but not in all patients with gross ETE invading only the strap muscles.

Thyroid-dedicated internally-cooled wet electrode for benign thyroid nodules: experimental and clinical study.

BACKGROUND: To assess the effects of radiofrequency ablation (RFA) using an internally-cooled wet (ICW) electrode in ex vivo bovine liver and evaluate the feasibility of the ICW electrode for benign thyroid nodules. METHODS: We developed an 18-gauge ICW electrode with a microhole at the distal tip for tissue infusion of chilled (0 - 4 °C) isotonic saline (rate = 1.5 ml/min). RFA using ICW and IC electrodes were performed in bovine livers (40 pairs, 1-cm active tip, 50 W, 1-min). We compared the morphological characteristics of ablation zones and presence of carbonization. Twenty patients with benign thyroid nodules larger than 5 ml were prospectively enrolled in a clinical study and underwent ultrasound-guided RFA with ICW electrodes. Ultrasound examinations, laboratory data, and symptom and cosmetic scores were evaluated preprocedure and 1 and 6 months after the procedure. RESULTS: In the ex vivo study, the ICW achieved significantly larger ablation zones than the IC (p<.001). In the clinical study, ICW electrodes were tolerable in all patients. At last follow-up, nodule volume had decreased from 15.6 ± 12.1 ml to 4.1 ± 4.3 ml (p<.001), and the mean volume reduction ratio (VRR) was 73.3 ± 13.7% at 6.0 months follow-up. Cosmetic and symptom scores were reduced from 3.52 ± 1.03 to 2.65 ± 0.88 and 3.10 ± 2.17 to 0.85 ± 0.99 (both p<.001), respectively. After RFA, thyroid function was well preserved in all patients, and mean thyroglobulin level decreased from 36.6 ± 52.1 ng/ml to 26.9 ± 62.2 ng/ml. One patient experienced a temporary voice change that recovered within a week. CONCLUSIONS: We developed a thyroid-dedicated ICW electrode that we showed to be feasible and effective in patients with benign thyroid nodules.

Is Maintaining Thyroid-Stimulating Hormone Effective in Patients Undergoing Thyroid Lobectomy for Low-Risk Differentiated Thyroid Cancer? A Systematic Review and Meta-Analysis.

There is no clear evidence that post-operative maintenance of thyroid-stimulating hormone (TSH) in the mid to lower reference range (0.5-2 mU/L) improves prognosis in patients undergoing thyroid lobectomy for low-risk differentiated thyroid cancer (DTC). The purpose of this systematic review and meta-analysis was to compare and analyze the recurrence rate according to whether the serum TSH level was maintained below 2 mU/L in patients who underwent thyroid lobectomy for low-risk DTC. Clinical data and outcomes were collected from MEDLINE, Embase, and the Cochrane Database of Systematic Reviews. The inclusion criteria were related studies on TSH maintenance or serum TSH concentration after surgery for DTC. Seven observational studies with a total of 3974 patients were included in this study. In the patients who received TSH maintenance less than 2 mU/L, the recurrence rate during the follow-up period was 2.3%. A subgroup analysis of five studies showed that the odds ratio for recurrence in patients who received TSH maintenance was 1.45 (p-value = 0.45) compared to patients who did not receive TSH maintenance. In conclusion, the evidence for the effectiveness of post-operative TSH maintenance less than 2 mU/L in patients undergoing thyroid lobectomy for low-risk DTC is insufficient.

Parathyroidectomy versus cinacalcet in the treatment of tertiary hyperparathyroidism after kidney transplantation: a retrospective study.

BACKGROUND: Hyperparathyroidism is common in patients with chronic kidney disease with reduced renal function and has been observed after kidney transplantation. The optimal treatment for cases in which hyperparathyroidism persists after kidney transplantation has not been determined. METHODS: This retrospective study included 83 patients with tertiary hyperparathyroidism who underwent kidney transplantation between 2000 and 2018 at a single tertiary center in Korea. Sixty-four patients underwent parathyroidectomy and 19 patients were treated with cinacalcet following renal transplantation. Biochemical parameters and clinical outcomes were compared between the two groups. RESULTS: Serum calcium and parathyroid hormone (PTH) levels improved in both the parathyroidectomy and cinacalcet groups. One year after treatment, parathyroidectomy resulted in a lower mean serum calcium level than cinacalcet (9.7 ± 0.7 mg/dL vs. 10.5 ± 0.7 mg/dL, p = 0.001). Regarding serum PTH, the parathyroidectomy group showed a significantly lower PTH level than the cinacalcet group at 6 months (129.1 ± 80.3 pg/mL vs. 219.2 ± 92.5 pg/mL, p = 0.002) and 1 year (118.8 ± 75.5 pg/mL vs. 250.6 ± 94.5 pg/ mL, p < 0.001). There was no statistically significant difference in the incidence of kidney transplant rejection, graft failure, cardiovascular events, fracture risk, or bone mineral density changes between the two groups. CONCLUSION: Parathyroidectomy appears to reduce PTH and calcium levels effectively in tertiary hyperparathyroidism. However, creatinine level and allograft rejection should be monitored closely.

The association between the type of anesthesia and hemodynamic instability during pheochromocytoma surgery: a retrospective cohort study.

BACKGROUND: Pheochromocytoma often carries a risk for perioperative hemodynamic instability (HDI). The aim of this study is to evaluate the risk factors of intraoperative HDI during minimally invasive posterior retroperitoneal adrenalectomy (PRA) for pheochromocytoma. MATERIALS AND METHODS: This retrospective study analyzed the prospectively collected data of 172 patients who underwent laparoscopic PRA or robotic PRA for pheochromocytoma between January 2014 and December 2020 at a single tertiary center. The patients were divided into two groups according to the intraoperative hypertensive event of systolic blood pressure (> 160 mmHg). The clinical manifestations and perioperative hemodynamic conditions were analysed. RESULTS: In the multivariate logistic regression analysis, the tumor size (> 3.4 cm) [OR 3.14, 95% confidence intervals (CI) (1.48-6.64), p = 0.003], type of preoperative alpha-blocker (selective type) [OR 3.9, 95% CI (1.52-10.02), p = 0.005], preoperative use of beta-blockers [OR 3.94, 95% CI (1.07-14.49), p = 0.039] and type of anesthesia [total intravenous anesthesia (TIVA) vs. balanced anesthesia (BA)] [OR 2.57, 95% CI (1.23-5.38), p = 0.012] were determined as independent risk factors of intraoperative hypertensive events during minimally invasive adrenalectomy. CONCLUSIONS: The type of anesthesia was independently associated with intraoperative HDI along with larger tumor size, type of preoperative alpha-blocker and the use of preoperative beta-blockers. TIVA increased the risk of intraoperative hypertensive events compared with BA. Thus, the consideration of the type of anesthesia prior to adrenal surgery for pheochromocytoma along with the use of preoperative non-selective alpha-blockers may be beneficial in minimizing the risk of intraoperative HDI.

New predictive factors for prolonged operation time of laparoscopic posterior retroperitoneal adrenalectomy; retrospective cohort study.

BACKGROUND: Laparoscopic adrenalectomy is a standard surgical procedure for benign adrenal diseases. Laparoscopic posterior retroperitoneal adrenalectomy (LPRA) has many benefits. However, it is associated with factors such as prolong operation time. The aim of the study was to determine the predictive factors associated with prolonged operation time in LPRA. MATERIALS AND METHODS: This study retrospectively analyzed data from 284 patients who underwent LPRA between 2014 and 2019 at Asan Medical Center. Then, we analyzed the predictive factors prolonging operation time using multivariate logistic regression analysis and classified the differences according to the learning curve using cumulative sum analysis. RESULTS: In multivariate logistic regression analysis, the following were determined as factors associated with prolonged operation time: male sex (OR, 2.540; 95% CI, 1.225-5.266), pheochromocytoma (OR, 3.669; 95% CI, 1.548-8.694), right site (OR, 2.499; 95% CI, 1.086-5.748), surgeon A (OR, 3.293; 95% CI, 1.522-7.122), depth of descended adrenal tumor location to kidney (OR, 3.793; 95% CI, 1.660-8.667), large periadrenal fat volume (OR, 2.366; 95% CI, 1.120-4.996), and posterior adiposity index (PAI) (OR, 2.171; 95% CI, 1.090-4.324) (all p < 0.05). However, in the period after the learning curve, periadrenal fat volume was not a significant predictor of surgery time prolongation. CONCLUSION: This study demonstrates that depth of descended adrenal tumor location to kidney is a new and important independent predictive factor for prolonged operation time in LPRA. In addition, periadrenal fat volume is a predictor of surgery time prolongation for beginner surgeons before the learning curve.

Clinical implications of age and excellent response to therapy in patients with high-risk differentiated thyroid carcinoma.

BACKGROUND: Patients with American Thyroid Association (ATA) high-risk differentiated thyroid carcinoma (DTC) have poor clinical outcomes. This study aimed to evaluate the clinical implications of age and response to therapy classification in patients with ATA high-risk DTC. DESIGN AND PATIENTS: This study included 222 patients with high-risk DTC who initially underwent therapy between 2000 and 2010 in a single tertiary center in Korea. We evaluated the prognostic parameters associated with progression-free survival (PFS) and disease-specific survival (DSS) with a focus on age and achieving an excellent response (ER). RESULTS: During the median follow-up period of 11.3 years, disease progression was detected in 77 patients (34.7%), and disease-specific mortality was reported in 31 patients (14.0%). Older age (≥55 years) and not achieving ER (not-ER) were independent risk factors associated with PFS (age, p < .001; not-ER, p < .001) and DSS (age, p < .001; not-ER, p = .015). Of the 74 patients in the ER group, 7 (9.5%) displayed disease progression and 1 (1.4%) died from DTC. There were no significant differences in PFS and DSS according to age in the ER group. However, older patients had significantly worse PFS and DSS than younger patients in the not-ER group (p = .002 and p < .001, respectively). CONCLUSIONS: Response to therapy classification is important for predicting PFS and DSS in patients with high-risk DTC. Patients in the ER group had a relatively good prognosis, but disease progression occurred in 9.5% of patients. Age was a key predictor of both PFS and DSS in high-risk patients who did not achieve ER.

A Multicenter, Randomized, Controlled Trial for Assessing the Usefulness of Suppressing Thyroid Stimulating Hormone Target Levels after Thyroid Lobectomy in Low to Intermediate Risk Thyroid Cancer Patients (MASTER): A Study Protocol.

BACKGROUND: Postoperative thyroid stimulating hormone (TSH) suppression therapy is recommended for patients with intermediate- and high-risk differentiated thyroid cancer to prevent the recurrence of thyroid cancer. With the recent increase in small thyroid cancer cases, the extent of resection during surgery has generally decreased. Therefore, questions have been raised about the efficacy and long-term side effects of TSH suppression therapy in patients who have undergone a lobectomy. METHODS: This is a multicenter, prospective, randomized, controlled clinical trial in which 2,986 patients with papillary thyroid cancer are randomized into a high-TSH group (intervention) and a low-TSH group (control) after having undergone a lobectomy. The principle of treatment includes a TSH-lowering regimen aimed at TSH levels between 0.3 and 1.99 µIU/mL in the low-TSH group. The high-TSH group targets TSH levels between 2.0 and 7.99 µIU/mL. The dose of levothyroxine will be adjusted at each visit to maintain the target TSH level. The primary outcome is recurrence-free survival, as assessed by neck ultrasound every 6 to 12 months. Secondary endpoints include disease-free survival, overall survival, success rate in reaching the TSH target range, the proportion of patients with major cardiovascular diseases or bone metabolic disease, the quality of life, and medical costs. The follow-up period is 5 years. CONCLUSION: The results of this trial will contribute to establishing the optimal indication for TSH suppression therapy in low-risk papillary thyroid cancer patients by evaluating the benefit and harm of lowering TSH levels in terms of recurrence, metabolic complications, costs, and quality of life.