A 15-year experience: intraoperative parathyroid hormone assay for the management of primary hyperparathyroidism in a UK endocrine surgical unit.

PURPOSE: This study aims to evaluate the outcomes of first-time parathyroidectomy for primary hyperparathyroidism using intraoperative PTH (IOPTH) assay in the light of the UK National Institute for Health and Care Excellence (NICE) guidelines for the management of primary hyperparathyroidism. METHOD: This is a retrospective cohort analysis of a prospectively maintained database of endocrine surgery in a tertiary centre. Preoperative radiological localisation (concordance and accuracy), intraoperative PTH parameters and adjusted serum calcium at minimum 6-month follow-up were analysed. The accuracy of IOPTH to predict post-operative normocalcaemia and the number needed to treat (NNT) within the cohort when IOPTH was utilised were determined. Differences between groups were evaluated with Chi-squared and Fisher's exact test. RESULTS: Between January 2004 and September 2018, 849 patients (75.4% women), median age 64 years (IQR 54-72), were analysed. The median preoperative adjusted serum calcium was 2.80mmol/l (IQR 2.78-2.90), and the median preoperative PTH was 14.20pmol/l (IQR 10.70-20.25). The overall first-time cure (normocalcaemia) rate was 96.4%. The sensitivity, specificity, positive predictive value and negative predictive values of IOPTH were 96.8%, 83.2%, 97.6% and 78.8%, respectively, with an accuracy of 95.1%. For patients with concordant scans (48.3%), a targeted approach without IOPTH would have achieved a cure rate of 94.1% compared with 98.0% using IOPTH (p<0.01) CONCLUSION: The use of IOPTH assay significantly improved the rate of normocalcaemia at 6 months. The low NNT to benefit from IOPTH, particularly those patients with a single positive scan, and the inevitable reduction in the potential costs incurred from failure and reoperation justify its utilisation.

Prediction of long-term dependence on vitamin D analogues following total thyroidectomy for Graves' disease.

INTRODUCTION: This study aimed to identify patients at risk of long-term hypocalcaemia following total thyroidectomy for Graves' disease, and to determine the thresholds of postoperative day 1 serum calcium and parathyroid hormone (PTH) at which long-term activated vitamin D treatment can be safely excluded. METHODS: This study was a retrospective analysis of 115 consecutive patients undergoing total thyroidectomy for Graves' disease at a university referral centre between 2010 and 2018. Outcome measures were the day 1 postoperative adjusted calcium and PTH results, and vitamin D analogue need at 6 months postoperatively. Logistic receiver operating curves were used to identify optimal cut-off values for adjusted serum calcium and serum PTH, and sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were calculated. RESULTS: Temporary hypocalcaemia was observed in 20.9% of patients (mean day 1 serum adjusted calcium 2.2±0.14mmol/l and PTH 4.15±2.42pmol/l). Long-term (>6 months) activated vitamin D analogue therapy was required in five patients (4.3%), four of whom had normal serum PTH and one with undetectable PTH at 6 weeks post surgery. No patient with a day 1 postoperative calcium >2.05mmol/l and detectable PTH required vitamin D supplementation at 6 months post surgery (100% sensitivity, PPV 50%, NPV 100%). CONCLUSIONS: The biochemical postoperative day 1 thresholds identified in this paper have a 100% NPV in the identification of patients who are likely to require either no or only temporary activated vitamin D supplementation. We were able to identify all patients requiring activated vitamin D supplementation 6 months postoperatively from the day 1 postoperative serum calcium and PTH values, while excluding those that may only need temporary calcium supplementation. These threshold levels could be used for targeted follow-up and management of this subset of patients most at risk of long-term hypocalcaemia.

Impact of the change from the seventh to eighth edition of the AJCC TNM classification of malignant tumours and comparison with the MACIS prognostic scoring system in non-medullary thyroid cancer.

Background: In 2018, AJCC TNM staging changed for differentiated (DTC) and anaplastic (ATC) thyroid carcinoma. The impact of this change on mortality rates was investigated and compared with the MACIS prognostic score. Methods: Analysis of a prospective database of DTC/ATC was undertaken. Patients were staged according to TNM7 and TNM8 criteria, and MACIS scores calculated. Five-year disease-specific mortality rates were determined. Proportions were compared with Fisher's exact and χ2 goodness-of-fit tests. Results: Between August 2002 and December 2016, 310 patients had primary surgery for thyroid cancer. After exclusions, 159 patients (154 DTC, 5 ATC) remained to be studied. The MACIS score was less than 6 in 105 patients (66·0 per cent), 6-6·99 in 19 (11·9 per cent), 7-7·99 in 14 (8·8 per cent) and 8 or more in 21 (13·2 per cent), with corresponding disease-specific 5-year mortality rates of 0, 5, 14 and 86 per cent. For TNM7 the distribution was stage I in 53·5 per cent (85 patients), stage II in 10·1 per cent (16), stage III in 14·5 per cent (23) and stage IV in 22·0 per cent (35), and differed from that for TNM8: 76·7 per cent (122), 10·7 per cent (17), 4·4 per cent (7) and 8·2 per cent (13) respectively (P < 0·001). Overall disease-specific 5-year mortality rates by stage for TNM7 versus TNM8 were: stage I, 0 of 85 versus 3 of 100 (P = 0·251); stage II, 0 of 16 versus 6 of 16 (P = 0·018); stage III, 3 of 23 versus 2 of 7 (P = 0·565); stage IV, 20 of 32 versus 11 of 11 (P = 0·020). Conclusion: Compared with TNM7, TNM8 downstaged more patients to stage I and accurately reflected worse prognosis for stage IV disease. TNM8 is an inferior predictor of mortality compared with MACIS.

Outcomes of surgery for benign and malignant adrenal disease from the British Association of Endocrine and Thyroid Surgeons' national registry.

BACKGROUND: This study investigated the indications, procedures and outcomes for adrenal surgery from the UK Registry of Endocrine and Thyroid Surgery database from 2005 to 2017, and compared outcomes between benign and malignant disease. METHODS: Data on adrenalectomies were extracted from a national surgeon-reported registry. Preoperative diagnosis, surgical technique, length of hospital stay, morbidity and in-hospital mortality were examined. RESULTS: Some 3994 adrenalectomies were registered among patients with a median age of 54 (i.q.r. 43-65) years (55·9 per cent female). Surgery was performed for benign disease in 81·5 per cent. Tumour size was significantly greater in malignant disease: 60 (i.q.r. 34-100) versus 40 (24-55) mm (P < 0·001). A minimally invasive approach was employed in 90·2 per cent of operations for benign disease and 48·2 per cent for cancer (P < 0·001). The conversion rate was 3·5-fold higher in malignant disease (17·3 versus 4·7 per cent; P < 0·001). The length of hospital stay was 3 (i.q.r. 2-5) days for benign disease and 5 (3-8) days for malignant disease (P < 0·050). In multivariable analysis, risk factors for morbidity were malignant disease (odds ratio (OR) 1·69, 1·22 to 2·36; P = 0·002), tumour size larger than 60 mm (OR 1·43, 1·04 to 1·98; P = 0·028) and conversion to open surgery (OR 3·48, 2·16 to 5·61; P < 0·001). The in-hospital mortality rate was below 0·5 per cent overall, but significantly higher in the setting of malignant disease (1·2 versus 0·2 per cent; P < 0·001). Malignant disease (OR 4·88, 1·17 to 20·34; P = 0·029) and tumour size (OR 7·47, 1·52 to 39·61; P = 0·014) were independently associated with mortality in multivariable analysis. CONCLUSION: Adrenalectomy is a safe procedure but the higher incidence of open surgery for malignant disease appears to influence postoperative outcomes.

ANTECEDENTES: Este estudio investigó las indicaciones, procedimientos y resultados de la cirugía de la glándula suprarrenal a partir de la base de datos de la UKRETS desde 2005-2017 y comparó los resultados entre enfermedad benigna y maligna. MÉTODOS: Se examinó un registro nacional con datos notificados por cirujanos que incluye 3.994 suprarrenalectomías; 57% mujeres, mediana de edad 53 (8-88 años). Se evaluaron el diagnóstico preoperatorio, la técnica quirúrgica, la duración de la estancia hospitalaria, la morbilidad y la mortalidad hospitalaria. RESULTADOS: En el 82% de los casos la cirugía se realizó por enfermedad benigna. El tamaño del tumor fue significativamente mayor en la enfermedad maligna: 60 mm (34-100 mm) versus 40 mm (24-55 mm), P < 0,001. Se utilizó un abordaje mínimamente invasivo en el 90% de los casos de enfermedad benigna y en el 48% de las operaciones por cáncer (P < 0,001). La tasa de conversión fue 3,5 veces más alta en la enfermedad maligna (17% versus 4,9%, P < 0,001). La duración de la estancia fue 3 días (rango intercuartílico, interquartile range, IQR 2-5) para la enfermedad benigna y 5 (IQR 3-8) días para la enfermedad maligna (P < 0,05). En el análisis multivariable, los factores de riesgo para la morbilidad fueron: enfermedad maligna (razón de oportunidades, odds ratio, OR 1,64, 1,217-2,359; P = 0,002), tamaño del tumor (OR 1,433, 1.040-1,967; P = 0,028) y conversión a cirugía abierta (OR 3,483, 2,160-5,612; P < 0,0001). La mortalidad hospitalaria global fue baja (< 0,5%) pero significativamente mayor en el escenario de la enfermedad maligna (1,2% versus 0,2%, P < 0,001). La enfermedad maligna (OR 4,881, 1,171-20,343; P = 0,029) y el tamaño del tumor (OR 7,474, 1,515-39,610; P = 0,014) se asociaron de forma independiente con la mortalidad en el análisis multivariable. CONCLUSIÓN: La suprarrenalectomía es un procedimiento seguro, pero la mayor incidencia de cirugía abierta para la enfermedad maligna parece tener un impacto sobre los resultados postoperatorios.

Intraoperative Parathyroid Hormone Assay Remains Predictive of Cure in Renal Impairment in Patients with Single Parathyroid Adenomas.

BACKGROUND: Parathyroid hormone (PTH) has a short half-life and is cleared by the liver and kidneys. This study examined whether declining estimated glomerular filtration rate (eGFR) affects application of the Miami criterion for intraoperative PTH (ioPTH) decline during parathyroidectomy for primary hyperparathyroidism (pHPT). METHODS: A retrospective review of consecutive patients undergoes parathyroidectomy for pHPT. Patients with multi-gland disease, without ioPTH, failure-to-cure and those <18 years were excluded. Baseline demographics, pre-operative PTH, ioPTH and 6-month follow-up data were available. Patients were categorised into normal or chronic kidney disease (CKD stage 2-5) based on pre-operative eGFR. Nonparametric data were compared using Mann-Whitney U test/Kruskal-Wallis test. The primary outcome measure was to assess whether CKD-affected ioPTH decline in parathyroidectomy for pHPT. RESULTS: A total of 476 patients were included [75.4% women; median age 63.8 years (18-92)]. CKD was present in 362 (76%) (CKD2:289; CKD3:66; CKD4/5:7). Increasing CKD stage was associated with advancing age [normal 53 years (41-61); CKD2 65 (57-73); CKD3 73.5 (66-78); CKD4/5 74(63-81); p < 0.001] and higher pre-operative PTH [16.6 pmol/L (11.1-22.9); 13.1 (10.4-17.7); 22.6 (13.8-33.7); 33.8(12.4-41.7); p < 0.001]. Baseline and post-excision ioPTH were significantly higher in those with CKD4/5 (p < 0.05). The Miami criterion was met in all patients, but median fall in ioPTH at 10-min varied between groups [normal:0.78 (0.71-0.82); CKD2:0.76 (0.69-0.83); CKD3:0.75 (0.69-0.82); CKD4/5:0.69 (0.61-0.70); p = 0.048)]. It was significantly lower in those with CKD4/5 compared with the remainder of patients [0.69 (0.61-0.70) vs. 0.76 (0.70-0.82); p = 0.008]. CONCLUSIONS: Although the reduction in ioPTH after successful parathyroidectomy is lower in severe CKD, the Miami criterion remains predictive of cure. Differences in absolute levels of PTH and tumour weight suggest that renal HPT may be a confounding factor.

Is Unilateral Neck Surgery Feasible in Patients with Sporadic Primary Hyperparathyroidism and Double Negative Localisation?

INTRODUCTION: Ultrasound and Tc99mMIBI scans are used to localise parathyroid tumours in sporadic primary hyperparathyroidism (pHPT). Intra-operative PTH (ioPTH) assay facilitates unilateral neck exploration (UNE). When both ultrasound and MIBI are negative, it is our policy to explore the left side of the neck and only proceed to bilateral neck exploration (BNE) when either a tumour is not found or when ioPTH does not fall to >50% of the highest pre-excision value. The aim of this study was to investigate the outcome of our approach to 'double negative' patients. METHODS: A retrospective analysis of patients undergoing primary parathyroidectomy for pHPT. Data were obtained from a prospective surgical database and the hospital electronic patient record. RESULTS: Between January 2004 and November 2014, 746 patients underwent a parathyroidectomy for pHPT. Those who did not have both pre-operative scans, ioPTH or a minimum of 6-month follow-up were excluded. Of 552 patients, 111 (20%) had double negative scans (group A), and in 441, either one or both scans were positive (group B). Median age was 61.5 years (range 10-88). Pre-operative PTH level was significantly lower in group A: 11.8 pmol/l (range 3.1-38.8) versus 14.9 pmol/l (range 2.8-101.6; P < 0.01). Median tumour weight was significantly lower in group A: 280 mg (range 50-3710) versus 573 mg (range 10-12,000; P < 0.01). Overall rate of multiple gland disease (MGD) was 11%; 24% in group A and 7% in group B (P < 0.01). Overall rate of UNE in Group A was 28% and converse to the rate in Group B (76%; P < 0.01). Sensitivity and specificity of ioPTH to detect MGD were 98 and 98% in Group A versus 98 and 100% in Group B. First-time cure rate was 92.7% in group A and 96.8% in group B (P < 0.05). CONCLUSION: A double negative scan is associated with small tumours and higher rates of MGD. Despite these challenges, surgery is successful in this group of patients reinforcing the message that negative localisation is not a contraindication for parathyroidectomy. We demonstrated that it is feasible to offer unilateral neck surgery to 28% of patients with double negative scans. A randomised trial is needed to compare BNE with ioPTH/UNE in this select population.

Management of thyroid cancer: United Kingdom National Multidisciplinary Guidelines.

This is the official guideline endorsed by the specialty associations involved in the care of head and neck cancer patients in the UK. This paper provides recommendations on the management of thyroid cancer in adults and is based on the 2014 British Thyroid Association guidelines. Recommendations • Ultrasound scanning (USS) of the nodule or goitre is a crucial investigation in guiding the need for fine needle aspiration cytology (FNAC). (R) • FNAC should be considered for all nodules with suspicious ultrasound features (U3-U5). If a nodule is smaller than 10 mm in diameter, USS guided FNAC is not recommended unless clinically suspicious lymph nodes on USS are also present. (R) • Cytological analysis and categorisation should be reported according to the current British Thyroid Association Guidance. (R) • Ultrasound scanning assessment of cervical nodes should be done in FNAC-proven cancer. (R) • Magnetic resonance imaging (MRI) or computed tomography (CT) should be done in suspected cases of retrosternal extension, fixed tumours (local invasion with or without vocal cord paralysis) or when haemoptysis is reported. When CT with contrast is used pre-operatively, there should be a two-month delay between the use of iodinated contrast media and subsequent radioactive iodine (I131) therapy. (R) • Fluoro-deoxy-glucose positron emission tomography imaging is not recommended for routine evaluation. (G) • In patients with thyroid cancer, assessment of extrathyroidal extension and lymph node disease in the central and lateral neck compartments should be undertaken pre-operatively by USS and cross-sectional imaging (CT or MRI) if indicated. (R) • For patients with Thy 3f or Thy 4 FNAC a diagnostic hemithyroidectomy is recommended. (R) • Total thyroidectomy is recommended for patients with tumours greater than 4 cm in diameter or tumours of any size in association with any of the following characteristics: multifocal disease, bilateral disease, extrathyroidal spread (pT3 and pT4a), familial disease and those with clinically or radiologically involved nodes and/or distant metastases. (R) • Subtotal thyroidectomy should not be used in the management of thyroid cancer. (G) • Central compartment neck dissection is not routinely recommended for patients with papillary thyroid cancer without clinical or radiological evidence of lymph node involvement, provided they meet all of the following criteria: classical type papillary thyroid cancer, patient less than 45 years old, unifocal tumour, less than 4 cm, no extrathyroidal extension on ultrasound. (R) • Patients with metastases in the lateral compartment should undergo therapeutic lateral and central compartment neck dissection. (R) • Patients with follicular cancer with greater than 4 cm tumours should be treated with total thyroidectomy. (R) • I131 ablation should be carried out only in centres with appropriate facilities. (R) • Serum thyroglobulin (Tg) should be checked in all post-operative patients with differentiated thyroid cancer (DTC), but not sooner than six weeks after surgery. (R) • Patients who have undergone total or near total thyroidectomy should be started on levothyroxine 2 µg per kg or liothyronine 20 mcg tds after surgery. (R) • The majority of patients with a tumour more than 1 cm in diameter, who have undergone total or near-total thyroidectomy, should have I131 ablation. (R) • A post-ablation scan should be performed 3-10 days after I131 ablation. (R) • Post-therapy dynamic risk stratification at 9-12 months is used to guide further management. (G) • Potentially resectable recurrent or persistent disease should be managed with surgery whenever possible. (R) • Distant metastases and sites not amenable to surgery which are iodine avid should be treated with I131 therapy. (R) • Long-term follow-up for patients with differentiated thyroid cancer (DTC) is recommended. (G) • Follow-up should be based on clinical examination, serum Tg and thyroid-stimulating hormone assessments. (R) • Patients with suspected medullary thyroid cancer (MTC) should be investigated with calcitonin and carcino-embryonic antigen levels (CEA), 24 hour catecholamine and nor metanephrine urine estimation (or plasma free nor metanephrine estimation), serum calcium and parathyroid hormone. (R) • Relevant imaging studies are advisable to guide the extent of surgery. (R) • RET (Proto-oncogene tyrosine-protein kinase receptor) proto-oncogene analysis should be performed after surgery. (R) • All patients with known or suspected MTC should have serum calcitonin and biochemical screening for phaeochromocytoma pre-operatively. (R) • All patients with proven MTC greater than 5 mm should undergo total thyroidectomy and central compartment neck dissection. (R) • Patients with MTC with lateral nodal involvement should undergo selective neck dissection (IIa-Vb). (R) • Patients with MTC with central node metastases should undergo ipsilateral prophylactic lateral node dissection. (R) • Prophylactic thyroidectomy should be offered to RET-positive family members. (R) • All patients with proven MTC should have genetic screening. (R) • Radiotherapy may be useful in controlling local symptoms in patients with inoperable disease. (R) • Chemotherapy with tyrosine kinase inhibitors may help in controlling local symptoms. (R) • For individuals with anaplastic thyroid carcinoma, initial assessment should focus on identifying the small proportion of patients with localised disease and good performance status, which may benefit from surgical resection and other adjuvant therapies. (G) • The surgical intent should be gross tumour resection and not merely an attempt at debulking. (G).

A decade of change in the uptake of parathyroidectomy in England and Wales.

INTRODUCTION: Since the late 1990s, a number of factors have reduced the threshold for parathyroidectomy in patients with primary hyperparathyroidism. This study examined whether this has translated into increased numbers of parathyroid operations over the last decade. METHODS: A retrospective analysis was performed of the Patient Episode Database for Wales and English Hospital Episode Statistics annual data from 2000 to 2010 for parathyroidectomy admissions per 100,000 population. Statistical analysis was by linear regression. RESULTS: Between 2000 and 2010 there were 24,247 parathyroid operations in England and Wales (0.005% of the population), with 3 times as many women treated as men. Overall, incidence of parathyroidectomy rose from 3.3/100,000 population in 2000 to 5.8/100,000 in 2010 (p<0.0001). In England, it increased from 3.3/100,000 population to 5.8/100,000 and in Wales, it increased from 2.4/100,000 population to 4.6/100,000. Despite similar population demographics, the difference in the rate of change between England and Wales was significant (p<0.05). Uptake also varied according to age; in those aged 0-14 years, incidence of parathyroidectomy remained static whereas in all other age groups, uptake of parathyroidectomy increased significantly from 2000 to 2010. Most notably, surgical intervention in those aged 60-74 and >75 years nearly doubled over the decade (p<0.0001). CONCLUSIONS: The incidence of parathyroidectomy in adults has increased significantly in the last decade in England and Wales. This likely reflects changes in population demography, available guidelines, lower threshold for referral, changing surgical approach and the realisation that surgical morbidity is now infrequent.

Recurrent urolithiasis following parathyroidectomy for primary hyperparathyroidism.

INTRODUCTION: The effect of parathyroidectomy on the incidence of recurrent stone formation is uncertain. We aimed to compare the biochemistry and recurrence rate of urolithiasis in patients with primary hyperparathyroidism (pHPT) and stone formation (SF) and non-stone formation (NSF) with idiopathic stone formers (ISF). METHODS: Patients with pHPT and SF (Group 1) were identified from a prospective database. pHPT patients and NSF (Group 2) and ISFs (Group 3) were randomly selected from respective databases to form three equal groups. Preoperative and postoperative biochemical data were analysed and recurrent urolithiasis diagnosed if present on follow-up radiology. Out-of-area patients were asked about recurrence via telephone. RESULTS: From July 2002 to October 2011, 640 patients had parathyroidectomy for pHPT. Of these, 66 (10.3%) had a history of renal colic; one was lost to follow-up. Patient demographics were similar across all three groups. Three months post-parathyroidectomy, Groups 1 and 2 had significantly reduced serum calcium concentrations (p<0.01). Group 1 had lower urinary calcium excretion after parathyroidectomy (p<0.01), but estimated glomerular filtration rate did not change following surgery. During median follow-up of 4.33 years (0.25-9 years) in Groups 1 and 2 and 5.08 years (0.810-8 years) in Group 3, one patient (1.5%) in Group 1 and 16 patients (25%) in Group 3 had recurrent urolithiasis (p<0.01). No Group 2 patients developed stones. CONCLUSION: Curative parathyroidectomy confers a low recurrence rate for urolithiasis, but does not prevent recurrence in all patients. Further research should aim to identify the risk factors for continued SF in these patients.

Hypocalcaemia following thyroidectomy for treatment of Graves' disease: implications for patient management and cost-effectiveness.

BACKGROUND: No consensus exists on optimal treatment for Graves' disease once anti-thyroid medication fails to induce remission. Total thyroidectomy is a more cost-effective treatment than radioactive iodine or life-long anti-thyroid medication, but hypocalcaemia is an important complication, leading to longer hospital admissions and increased prescription costs. This study aimed to compare the relative risk of hypocalcaemia requiring medical treatment for patients with Graves' disease. METHODS: Prospective cohort study of patients undergoing total thyroidectomy for Graves' disease and for multinodular goitre, calculating serum calcium levels 24-hours post-operatively and prescription rates. RESULTS: Mean corrected calcium concentrations 24 hours post-operatively were 2.05 mmol/l for Graves' disease patients and 2.14 mmol/l for multinodular goitre patients (p = 0.003). Biochemical hypocalcaemia developed in 92 per cent (n = 34) of Graves' disease patients and 71 per cent (n = 43) of multinodular goitre patients (p = 0.012). Graves' disease patients were more likely to be prescribed calcium supplementation pre-discharge (p = 0.037). CONCLUSION: Total thyroidectomy for Graves' disease carries an increased risk of hypocalcaemia at 24 hours, and of calcium supplementation pre-discharge. Graves' disease patients should be informed of the increased risk of hypocalcaemia associated with total thyroidectomy, and this risk must be factored into future cost-effectiveness analysis.

Orthognathic surgery and related papers published in the British Journal of Oral and Maxillofacial Surgery 2008-2009.

This paper provides a review of articles relating to deformity, orthognathic surgery, and distraction osteogenesis published in the British Journal of Oral and Maxillofacial Surgery during 2008 and 2009. A total of 42 papers (26 full length articles, 5 technical notes, and 11 short communications or letters to the editor) were published. It was pleasing that 62% were full length articles; this is encouraging as such papers have a high educational value and are likely to be cited in future publications.

A rare and life-threatening cause of pseudo-obstruction in two surgical patients.

We describe two patients who presented with non-mechanical bowel obstruction as a consequence of an underlying, undiagnosed phaeochromocytoma. The first patient was referred by his general practitioner with signs and symptoms of small bowel obstruction on a background of frequent constipation. An abdominal scan revealed an adrenal tumour (subsequently found to be a phaeochromocytoma) but no structural cause for obstruction. Treatment of the phaeochromocytoma was associated with prompt restoration of bowel function. The second patient was transferred to the intensive care unit on the 8th postoperative day following an elective hip joint replacement. Signs and symptoms of bowel obstruction together with labile blood pressure and progressive lactic acidosis prompted admission to the intensive treatment unit. An abdominal scan identified an infiltrative adrenal tumour but no mechanical cause for bowel obstruction. Histology confirmed a malignant phaeochromocytoma. Bowel obstruction as the presenting symptom of phaeochromocytoma is well described but rarely identified.

How is adrenocortical cancer being managed in the UK?

INTRODUCTION: Adrenocortical carcinomas are rare. This case series is reported to give an overview of how adrenocortical carcinoma is currently managed in the UK. PATIENTS AND METHODS: A retrospective review was made of case notes from patients with adrenocortical carcinomas presenting to the authors (TWJL, RDB, BJH, and DS-C) over the past 10 years in Newcastle, Sheffield and Cardiff. RESULTS: Newcastle treated twelve, Sheffield eleven and Cardiff seven cases. The median follow-up was 25.5 months (range, 1-102 months). All tumours were greater than 5 cm in diameter. The majority presented with symptoms of hormone excess. Adrenalectomy was performed in 83% - this was radical in 30% and followed by excision of recurrence in 13%. Adjuvant mitotane was given in 64% of patients, in combination with cytotoxic chemotherapy in 20%. One-third of patients did not receive any adjuvant therapy. There was no significant difference in survival between the three centres. The majority of patients (57%) died during the period of follow-up of this study. The median survival was 37 months (range, 2-102 months). CONCLUSIONS: The size of tumour, stage and mode of presentation, age and overall survival of patients in this study are comparable to published series of adrenocortical carcinomas from major endocrine surgical centres world-wide. Despite controversies about benefits, adjuvant mitotane was used in the majority of cases, whereas cytotoxic chemotherapy was only used in the minority. The exact role of adjuvant therapy in the management of adrenocortical carcinoma is not as well established as for other more common malignancies. Establishing a database for adrenocortical carcinomas in the UK would contribute to our understanding of the management of this disease.

Pheochromocytoma in Pregnancy: When is Operative Intervention Indicated?

Pheochromocytoma is rare in pregnancy, with an estimated incidence of 0.007%. Diagnosis is difficult owing to the variety of presentations and nonspecific symptoms. Nevertheless, unsuspected disease accounts for a significant proportion of morbidity and mortality. Currently, there appears to be no consensus on management with regard to the need for and timing of medical vs. surgical management. In this case report, we describe two patients who underwent different modes of treatment based on careful consideration of disease-related and nondisease-related factors. We emphasise that good outcomes can be achieved through individualized management within the context of a multidisciplinary team, involving close collaboration among physicians, surgeons, obstetricians, and anesthetists. We also illustrate the importance of genetic testing in all patients with pheochromocytoma in pregnancy, especially with the emergence of new predisposing genes (succinate dehydrogenase B and D) and the recognition that germline mutations in these and more established genes (VHL and RET) account for over a quarter of all apparently sporadic cases.

Hypocalcaemia and parathyroid hormone assay following total thyroidectomy: predicting the future.

BACKGROUND: Ambulatory surgery (23:59-hour hospital stay) is gaining popularity in endocrine surgery. Hypocalcaemia is common following total thyroidectomy. Identifying patients with low risk of hypocalcaemia may facilitate early discharge (24-hour stay). METHODS: We conducted a prospective study including all patients undergoing total thyroidectomy. Blood samples were taken immediately following skin closure and the following morning for parathyroid hormone (PTH) and calcium measurement. Calcium supplements were routinely given when serum calcium was below 2.0 mmol/l. RESULTS: Thirty patients (27 females, 3 males) underwent total thyroidectomy (including 4 nodal dissection) for multinodular goitre (14), Graves' disease (11), papillary (4) and follicular (1) thyroid carcinoma. Twelve patients developed symptomatic transient hypocalcaemia. Based on morning calcium of < 2.0 mmol/l as trigger for calcium supplementation, 8 patients received calcium supplement with 4 false negatives, resulting in a specificity of 94.4%, sensitivity of 66.7%, positive predictive value (PPV) of 88.9% and negative predictive value (NPV) of 81%. Based on PTH levels (< 1.5 pmol/l) immediately following skin closure, 11 patients would receive calcium supplement, with 1 false negative resulting in a specificity of 83.3%, sensitivity of 91.7%, PPV of 78.6% and NPV of 93.8%. If supplementation is based on PTH levels (< 1.5 pmol/l) immediately following skin closure and morning calcium level (< 2.0 mmol/l), all 12 symptomatic patients will be correctly treated, with 4 false positives resulting in a combined specificity of 77.8%, sensitivity of 100%, PPV of 75% and NPV of 100%. CONCLUSIONS: Combining the immediate postoperation PTH levels (< 1.5 pmol/l) and morning serum calcium (< 2.0 mmol/l) can accurately identify patients at risk of hypocalcaemia following total thyroidectomy, allowing safe, early discharge.