Surgeon Training and Use of Radioactive Iodine in Stage I Thyroid Cancer Patients

Background

The majority of thyroid cancer diagnoses in the United States are stage I well-differentiated cancer. The use of radioactive iodine (RAI) in these low-risk patients has increased over time. The role of surgeon training in decision making regarding treatment with RAI is unknown.

Methods

Thyroid surgeons affiliated with 368 hospitals associated with the US National Cancer Database (NCDB) were surveyed. Survey data were linked to the NCDB data. A multivariable weighted analysis controlling for surgeon and hospital characteristics was conducted to examine the relationship between surgeon training, continuing education and hospital-level RAI use for stage I well-differentiated thyroid cancer.

Results

The response rate was 70 % (560 of 804). In both univariate and multivariable analysis controlling for hospital case volume, practice setting and surgeon specialty, training with a thyroid surgeon was associated with less RAI use for stage I thyroid cancer (P = 0.022 and 0.028, respectively). Attending one or more professional society meetings a year was associated with a lower rate of hospital-level RAI use in univariate analysis (P = 0.044) but not multivariable analysis.

Conclusions

Training with a surgeon or group of surgeons who focus on thyroid surgery was associated with a lower proportion of stage I thyroid cancer patients receiving RAI after total thyroidectomy. This study emphasizes the importance of surgeon training in hospital practice patterns.     

Total Thyroidectomy is Associated with Increased Risk of Complications for Low- and High-Volume Surgeons

Background

There has been an increased use of total thyroidectomy (TT), including in the management of benign thyroid diseases. We sought to compare the risk of complications between TT and unilateral thyroidectomy (UT) and to evaluate the effect of surgeon’s experience on outcomes.

Methods

Nationwide Inpatient Sample from 2003 to 2009 was used to perform cross-sectional analysis of all adult patients who underwent TT and UT for benign or malignant conditions. Logistic regression was used to evaluate outcomes and to provide correlation between outcome and surgeon volume. Surgeon volume was categorized as low or high (performing <10 or >99 thyroid operations/year, respectively).

Results

A total of 62,722 procedures were included. Most cases were TT (57.9 %) performed for benign disease. There was a significantly increased risk of complication after TT compared to UT (20.4 vs. 10.8 %: p < 0.0001). High-volume surgeons performed only 5.0 % of the procedures overall, with 62.6 % of the high-volume surgeon procedures being TTs. Low-volume surgeons were more likely to have postoperative complications after TT compared to high-volume surgeons (odds ratio 1.53, 95 % confidence interval 1.12, 2.11, p = 0.0083). Mean charges were significantly higher for TT compared to lobectomy ($19,365 vs. $15,602, p < 0.0001), and length of stay was longer for TT compared to lobectomy (1.63 vs. 1.29 days, p < 0.0001).

Conclusions

TT is associated with a significantly higher risk of complications compared to UT even among high-volume surgeons. Higher surgeon volume is associated with improved patient outcomes.     

Can Plasma Bile Salt, Triglycerides, and apoA-V Levels Predict Liver Regeneration?

Background

Preoperative portal vein embolization (PVE) is used to increase the future remnant liver (FRL) in patients requiring extensive liver resection. Computed tomography (CT) volumetry, performed not earlier than 3–6 weeks after PVE, is commonly employed to assess hypertrophy of the FRL following PVE. Early parameters to predict effective hypertrophy are therefore desirable. The aim of the present study was to assess plasma bile salt levels, triglycerides (TG), and apoA-V in the prediction of the hypertrophy response during liver regeneration.

Methods

Serum bile salt, TG, and apoA-V levels were determined in 20 patients with colorectal metastases before PVE, and 5 h, 1, and 21 days after PVE, as well as prior to and after (day 1–7, and day 21) subsequent liver resection. These parameters were correlated with liver volume as measured by CT volumetry (%FRL-V), and liver function was determined by technetium-labeled mebrofenin hepatobiliary scintigraphy using single photon emission computed tomography.

Results

Triglyceride levels at baseline correlate with volume increase of the future remnant liver (FRL-V) post-PVE. Also, bile salts and TG 5 h after PVE positively correlated with the increase in FRL volume (r = 0.672, p = 0.024; r = 0.620, p = 0.042, resp.) and liver function after 3 weeks (for bile salts r = 0.640, p = 0.046). Following liver surgery, TG levels at 5 h and 1 day after resection were associated with liver remnant volume after 3 months (r = 0.921, p = 0.026 and r = 0.981, p = 0.019, resp). Plasma apoA-V was increased during liver regeneration.

Conclusions

Bile salt and TG levels at 5 h after PVE/resection are significant early predictors of liver volume and functional increase. It is suggested that these parameters can be used for early timing of volume assessment and resection after PVE.     

Evaluating the Prognostic Factors Associated with Cancer-specific Survival of Differentiated Thyroid Carcinoma Presenting with Distant Metastasis

Background

Because patients with differentiated thyroid carcinoma (DTC) presenting with distant metastasis (DM) have a particularly poor prognosis, examining the prognostic factors in this group is essential. We aimed to evaluate the prognostic factors affecting cancer-specific survival (CSS) in DTC patients presenting with DM.

Methods

Of the 1227 DTC patients, 51 (4.2 %) presented with DM at diagnosis. All patients underwent a total thyroidectomy, followed by radioiodine (RAI) ablation and postablation whole body scan (WBS). Patients were considered to have an osseous metastasis if one of the metastatic sites involved a bone, while RAI avidity was determined by any visual uptake in a known metastatic site on the first WBS. Factors predictive of CSS were determined by univariate and multivariate analyses by the Cox proportional hazard model.

Results

In univariate analysis, older age (relative risk [RR] 1.050, 95 % confidence interval [CI] 1.010–1.091, P = 0.014), DM discovered before WBS (RR 3.401, 95 % CI 1.127–10.309, P = 0.030), follicular thyroid carcinoma (RR 3.095, 95 % CI 1.168–8.205, P = 0.025), osseous metastasis (RR 4.695, 95 % CI 1.379–15.873, P = 0.013), non-RAI avidity (RR 3.355, 95 % CI 1.280–8.772, P = 0.014), and external beam radiotherapy to DM (RR 3.241, 95 % CI 1.093–9.614, P = 0.034) were significant poor prognostic factors for CSS. In the multivariate analysis, after adjusting for other factors, osseous metastasis (RR 6.849, 95 % CI 1.495–31.250, P = 0.013) and non-RAI avidity (RR 7.752, 95 % CI 2.198–27.027, P = 0.001) were the two independent poor prognostic factors for CSS. Older age almost reached statistically significance (RR 1.055, 95 % CI 0.996–1.117, P = 0.068).

Conclusions

DTC patients presenting with DM accounted for 4.2 % of all patients. Because osseous metastasis and RAI avidity were independent prognostic factors, future therapy should be directed at improving the treatment efficacy of osseous and/or non-RAI-avid metastases.     

Prognostic Implications of Radioiodine Avidity and Serum Thyroglobulin in Differentiated Thyroid Carcinoma with Distant Metastasis

Background

Although differentiated thyroid carcinoma (DTC) rarely develops distant metastases, the present study was performed to evaluate factors that affect the survival of patients with DTC who present with distant metastasis.

Methods

Among 4,989 patients who underwent thyroid surgery for DTC, 82 presenting with distant metastasis were analyzed. Based on radioiodine (¹³¹I) avidity and the thyroid-stimulating hormone-stimulated serum thyroglobulin (sTg) level at the time of metastasis, patients were divided into three groups: group 1 (¹³¹I uptake + sTg ≤ 215 ng/mL, n = 46), group 2 (¹³¹I uptake + sTg > 215 ng/mL, n = 24), group 3 (no ¹³¹I uptake, n = 12). Disease-specific survival (DSS) was estimated using the Kaplan–Meier method. Factors predicting the outcome were evaluated using Cox proportional hazard regression analysis.

Results

The age of patients (p = 0.04), frequency of follicular thyroid carcinoma (p = 0.002), tumor size (p < 0.001), and number of multiple metastatic sites (p = 0.004) differed significantly among the groups. With a median follow-up after surgery of 72 months, the 5- and 10-year DSSs for all patients were 84 and 69 %, respectively. The predictors of survival were age (p = 0.004), symptoms at the time of presentation (p = 0.045), histology (p = 0.01), sites of metastasis (p = 0.03), and ¹³¹I avidity and sTg level at the time of metastasis (p = 0.002). In the multivariate analysis, age, histology, and ¹³¹I avidity and sTg level at the time of metastasis remained significant factors for survival.

Conclusions

Certain DTC patients with distant metastasis demonstrate favorable outcomes dependent on age, histology, and ¹³¹I avidity and sTg level at the time of metastasis.     

Differentiated Thyroid Cancer Presenting with Distant Metastases: A Population Analysis Over Two Decades

Background

Differentiated thyroid cancer (DTC) with distant metastases at presentation is uncommon; the prognosis of patients with this condition is more favorable than for other cancers. Demographic, clinical, and pathologic characteristics are described at a population level; factors associated with long-term disease-specific survival are identified.

Methods

Patients were identified in the Surveillance, Epidemiology, and End Results (SEER) database between 1988 and 2009. They were divided into two groups: patients with distant metastases (met-DTC) and patients without distant metastases (DTC) at presentation. Data analyses were performed with chi square tests, ANOVA, Kaplan–Meier analysis, and binary logistic and Cox proportional hazards regression.

Results

A total of 1,291 patients with met-DTC at diagnosis and 58,518 with DTC were included. The met-DTC rate was 2.2 %; compared to DTC, met-DTC patients were more often male (22.7 vs 41.3 %, respectively; p < 0.001) and older (mean 48.8 vs 62.7 years; p < 0.001). Patients with met-DTC were more likely not to have had surgery (23.3 vs 2.0 %; p < 0.001) or to have received radiation therapy (RAI) (66.8 vs 46.5 %; p < 0.001). Met-DTC tumors were larger (mean 41.0 vs 20.5 mm; p < 0.001). Independent factors associated with distant metastases were male gender, older age, single status, black and “other” races, follicular and Hurthle cell histology, larger tumors, and positive regional lymph nodes. Disease-specific survival was lower for met-DTC; this has not improved over the past two decades (p = 0.494). Independent factors associated with mortality included patient age ≥45 years, single status, follicular and Hurthle cell histologies, tumor size >4 cm, and not receiving surgery and/or RAI.

Conclusions

Overall, met-DTC is uncommon. Given the lack of survival improvement observed over the last two decades, novel treatments should be pursued aggressively for this subset of patients.     

Use of Spiral Computed Tomography Volumetry for Determining the Operative Approach in Patients with Graves’ Disease

Background

The purposes of the present study were to assess (1) the correlation between the weight of the postoperative thyroid specimen and the spiral computed tomography (CT) volumetry results of the thyroid gland in patients with Graves’ disease, and (2) the utility of CT volumetry for determining the operative approach.

Methods

From 2009 to 2010, a total of 56 patients with Graves’ disease underwent total or subtotal thyroidectomy. An enhanced spiral CT was taken in all patients prior to the operation. From 2.5 mm-thick slices of the thyroid gland, the surface area was calculated to measure the volume of the thyroid gland. The glandular volume was compared to the weight of the postoperative thyroid specimen.

Results

A total of 42 and 14 patients underwent total and subtotal thyroidectomy, respectively. The mean weight of the postoperative thyroid specimen was 43.9 ± 33.4 g, and the mean volume obtained by CT volumetry was 44.2 ± 32.8 mL. A good correlation was observed between the weight of the postoperative thyroid specimen and the volume calculated by CT (r = 0.98, p < 0.001). When 100 mL was set as the higher cut-off value of the thyroid volume for minimally invasive thyroid surgery, the estimated blood loss showed a significant difference between the >100 mL and the ≤100 mL groups (608.3 ± 540.8 vs. 119.7 ± 110.4 mL; p = 0.036).

Conclusions

: Spiral CT volumetry may be used to measure the thyroid volume reliably in patients with Graves’ disease. For cases in which surgery is indicated in patients with Graves’ disease, CT volumetry provides useful information from which to determine the operative approach. One hundred milliliter or less of thyroid volume in CT volumetry is recommended to perform minimally invasive thyroid surgery.     

Less is More: The Impact of Multidisciplinary Thyroid Conference on the Treatment of Well-Differentiated Thyroid Carcinoma

Background

In 2006, a multidisciplinary thyroid conference (MDTC) was implemented to better plan management of thyroid cancer patients at our institution. This study assessed the clinical impact of a MDTC on radioactive iodine (RAI) treatment patterns.

Methods

A prospective database (2003–2014) collected patient and tumor characteristics, RAI doses, and tumor recurrences. Patients treated with total thyroidectomy for differentiated thyroid carcinoma ≥1 cm were stratified based on American Thyroid Association (ATA) risk classification. RAI regimens were compared before initiation of MDTC (2003–2005, n = 88), after establishment of MDTC (2007–2009, n = 95), and after the release of 2009 ATA guidelines (2011–2014, n = 181). RAI doses were defined as low (≤75 mCi), intermediate (76–150 mCi), and high (>150 mCi).

Results

There was a significant decrease in the number of patients who received high-dose RAI after implementation of MDTC compared to before initiation of MDTC in the intermediate and high-risk patient groups (p = 0.04 and p < 0.01) without an associated increase in tumor recurrence (11 vs. 7%, p = 0.74). On multivariable analysis, presentation of a patient at MDTC was a negative predictor for receiving high-dose RAI (p = 0.002). As might be expected, there was also a significant decrease in use of RAI after the 2009 ATA guidelines were issued compared to after implementation of MDTC (p < 0.01).

Conclusion

In conjunction with implementation of a thyroid malignancy multidisciplinary conference, we observed significantly decreased postoperative dosing of RAI without increased tumor recurrence. The 2009 ATA guidelines were associated with a further decrease in RAI administration. Treatment for patients with thyroid carcinoma is optimized by a multidisciplinary approach.

     

Accuracy of preoperative automatic measurement of the liver volume by CT-scan combined to a 3D virtual surgical planning software (3DVSP)

Background

Liver volumetry is a critical component of safe hepatic surgery, in order to minimize the risk of postoperative liver failure. Liver volumes can be calculated routinely using the time-consuming gold standard method of manual volumetry. The current work sought to evaluate an alternative automatic technique based on a novel 3D virtual planning software, and to compare it to the manual technique.

Methods

A prospective study of patients undergoing liver resection was conducted. Every patient had a pre and 2-day postoperative CT-scan. For each patient, total, remnant and resected volumes were calculated manually and automatically. Planes of resection were verified by a hepatobiliary surgeon and compared with postoperative volumes. Paired t-tests and correlation coefficients were calculated.

Results

A major hepatectomy was carried out in 36/43 patients. The automatic TLV (1,759 mL) and the manual TLV (1,832 mL) were significantly different (p < 0.001), but extremely highly correlated (r = 0.989). The percentages of preoperative RLV (manual 58.5 %, automatic 58.9 %) were similar, with an excellent correlation of 0.917. The preoperative RLV were matched with the 2-day postoperative RLV showing a significant difference (p = 0.0301). The resected volumes using both techniques (871 and 832 mL) were compared with the resected specimen volume (670 mL), showing a significant difference (p < 0.001) but a high degree of correlation (r = 0.874).

Conclusion

The 3D virtual surgical planning software is accurate and reliable in determining the total liver and future remnant liver volumes. This technique demonstrates a good correlation with the manual technique. Future work will be required to confirm these findings and to evaluate the clinical value of the three-dimensional planning platform.     

Influence of Prophylactic Neck Dissection on Rate of Retreatment for Papillary Thyroid Carcinoma

Background

Prophylactic neck dissection (PND) for papillary thyroid cancer is controversial. The objective of this study was to analyze the influence of PND on the rate of retreatment.

Methods

In this retrospective case-control study, papillary thyroid carcinomas >10 mm without ultrasonographic evidence of nodal disease (cN0) were treated with total thyroidectomy (TT) or TT with bilateral central compartment PND. All received postoperative radioactive iodine (¹³¹I) and were followed for at least 1 year. We compared the rate of retreatment (surgery or ¹³¹I).

Results

Altogether, 246 patients (mean age 46 years, 78 % women) underwent TT (n = 91) or TT + PND (n = 155). The groups were similar in age, sex, tumor size, and follow-up (median 6.3 years) (p > 0.05). Overall, 11 (12 %) of the patients in the TT group underwent reoperation in the central compartment for recurrence versus 3 (2 %) in the TT + PND group (p < 0.001). There were 1.18 administrations of ¹³¹I for the TT group versus 1.08 for the TT + PND group (p = 0.08). The average cumulative dose of ¹³¹I was 3.9 ± 1.8 GBq for the TT group and 3.8 ± 1.3 GBq for the TT + PND group (p = 0.52). Actuarial (Kaplan-Meier) 5-year retreatment rates were 14.7 % in the TT group and 6.5 % in the TT + PND group (p = 0.01, log-rank). The rate of permanent recurrent nerve paralysis was 2 % for the TT group and 1 % for the TT + PND group (p = 0.98). The rates of permanent hypoparathyroidism were 7 versus 3 %, respectively (p = 0.12).

Conclusions

Five-year retreatment rates were lower in patients treated with PND, with no added permanent morbidity.     

Marker-based or model-based RSA for evaluation of hip resurfacing arthroplasty? A clinical validation and 5-year follow-up

Background

The stability of implants is vital to ensure a long-term survival. RSA determines micro-motions of implants as a predictor of early implant failure. RSA can be performed as a marker- or model-based analysis. So far, CAD and RE model-based RSA have not been validated for use in hip resurfacing arthroplasty (HRA).

Materials/methods

A phantom study determined the precision of marker-based and CAD and RE model-based RSA on a HRA implant. In a clinical study, 19 patients were followed with stereoradiographs until 5 years after surgery. Analysis of double-examination migration results determined the clinical precision of marker-based and CAD model-based RSA, and at the 5-year follow-up, results of the total translation (TT) and the total rotation (TR) for marker- and CAD model-based RSA were compared.

Results

The phantom study showed that comparison of the precision (SD_diff) in marker-based RSA analysis was more precise than model-based RSA analysis in TT (p _CAD < 0.001; p _RE = 0.04) and TR (p _CAD = 0.01; p _RE < 0.001). The clinical precision (double examination in 8 patients) comparing the precision SD_diff was better evaluating the TT using the marker-based RSA analysis (p = 0.002), but showed no difference between the marker- and CAD model-based RSA analysis regarding the TR (p = 0.91). Comparing the mean signed values regarding the TT and the TR at the 5-year follow-up in 13 patients, the TT was lower (p = 0.03) and the TR higher (p = 0.04) in the marker-based RSA compared to CAD model-based RSA.

Interpretation

The precision of marker-based RSA was significantly better than model-based RSA. However, problems with occluded markers lead to exclusion of many patients which was not a problem with model-based RSA. HRA were stable at the 5-year follow-up. The detection limit was 0.2 mm TT and 1° TR for marker-based and 0.5 mm TT and 1° TR for CAD model-based RSA for HRA.     

A comparative North American experience of robotic thyroidectomy in a thyroid cancer population

Purpose

This study seeks to explore the efficacy of robotic thyroidectomy in treating a North American population with differentiated thyroid cancer (DTC) as compared with the conventional cervical approach.

Methods

A retrospective analysis of our prospectively collected thyroid surgery database was performed. We included all consecutive patients that underwent thyroidectomy for the treatment of well-differentiated thyroid cancer, performed by a single surgeon.

Results

Twenty-four robotic transaxillary and 35 conventional thyroidectomy procedures were performed. Average size of the tumor was 1.1?±?0.2 cm in the robotic group and 1.7?±?0.3 cm in the cervical group (p?=?0.16). Average total operative time for the robotic group was 133?±?65.4 and 119.7?±?22.5 min in the cervical group (p?=?0.34). No robotic cases required conversion. One patient required reoperation for recurrent disease at 24 months follow-up. Both groups had similar blood loss (p?=?0.37) and all margins were negative for malignancy on permanent pathology. All patients were discharged home within 24 h. Postoperative stimulated thyroglobulin levels were similar for the two groups (p?=?0.82).

Conclusions

Our experience with robotic transaxillary thyroidectomy confirms this technique is feasible. It is possible to achieve a safe and effective oncologic result in a select group of North American patients with DTC.     

Influence of Preoperative Chemotherapy on CT Volumetric Liver Regeneration Following Right Hemihepatectomy

Background

An increasing number of patients undergo major liver resection following preoperative chemotherapy. Liver regeneration may be impaired in these patients, predisposing them to postoperative liver dysfunction. The aim of the present study was to evaluate the effects of preoperative chemotherapy on liver regeneration after partial liver resection.

Methods

Patients planned to receive right hepatectomy either with (group B) or without (group A) prior chemotherapy were identified retrospectively from a prospective multi-institutional database created in the conduct of a national randomized controlled trial (RCT). Prior chemotherapy was neither an inclusion nor an exclusion criterion of the trial. Future remnant liver volume (FRLV) was calculated by measuring total functional liver volume and resection specimen on preoperative computed tomography (CT) scans. Remnant liver volume after 7 days (V _RLV7days) was measured on scheduled postoperative CT scans. The early regeneration index 7 days after surgery (RI _early) was calculated as [(V _RLV7days ? FRLV) / FRLV] × 100 %. Data are expressed as median (interquartile range).

Results

A total of 72 patients were enrolled: 45 in group A and 27 in group B. For the whole group, the liver remnant showed a 58 % (39 %) increase in volume at day 7 (1) day. The RI _early was not significantly different between groups A and B, 60 % (36 %) and 50 % (43 %), respectively (p = 0.47). The RI _early was significantly lower in patients who had undergone more than six cycles of chemotherapy.

Conclusions

Preoperative chemotherapy does not seem to have a negative impact on early liver regeneration after partial liver resection.     

Surgeon Elective Abdominal Aortic Aneurysm Repair Volume and Outcomes of Ruptured Abdominal Aortic Aneurysm Repair: A 12-year Nationwide Study

Background

The purpose of the present study was to examine the effects of surgeon elective abdominal aortic aneurysm repair volume on outcomes after ruptured abdominal aortic aneurysm (rAAA) repair.

Methods

A nationwide claims database was used to identify patients who underwent rAAA repair from 1998 to 2009. Surgeon elective open abdominal aortic aneurysm repair (EAR) volume was classified as low, medium, or high. Associations between surgeon EAR volume and in-hospital mortality, overall survival, and complications after open rAAA repair (RAR) were compared with multivariate analysis. Associations between surgeon elective endovascular abdominal aortic aneurysm repair (EER) volume and outcomes after endovascular rAAA repair (RER) were also analyzed.

Results

A total of 537 patients who underwent rAAA repair were identified, including 498 who underwent RAR and 39 who underwent RER. In-hospital mortality rates after RAR were 49, 38, and 24 % in the low, medium, and high EAR volume groups, respectively (p < 0.001). Patients in the low surgeon EAR volume group had higher in-hospital mortality than those in the high surgeon EAR volume group [odds ratio 3.39, 95 % confidence interval (CI) 1.52, 7.59; p = 0.003]. Patients in the low surgeon EAR volume group also had higher long-term mortality (hazard ratio 1.86, 95 % CI 1.21, 2.85; p = 0.005). There were no significant differences in complication rates among the surgeon EAR volume groups or in-hospital mortality after RER among the surgeon EER volume groups.

Conclusions

Surgeon EAR volume is associated with in-hospital mortality and long-term survival after RAR.     

Failure of Radioactive Iodine in the Treatment of Hyperthyroidism

Background

Persistent or recurrent hyperthyroidism after treatment with radioactive iodine (RAI) is common and many patiedlxnts require either additional doses or surgery before they are cured. The purpose of this study was to identify patterns and predictors of failure of RAI in patients with hyperthyroidism.

Methods

We conducted a retrospective review of patients treated with RAI from 2007 to 2010. Failure of RAI was defined as receipt of additional dose(s) and/or total thyroidectomy. Using a Cox proportional hazards model, we conducted univariate analysis to identify factors associated with failure of RAI. A final multivariate model was then constructed with significant (p < 0.05) variables from the univariate analysis.

Results

Of the 325 patients analyzed, 74 patients (22.8 %) failed initial RAI treatment, 53 (71.6 %) received additional RAI, 13 (17.6 %) received additional RAI followed by surgery, and the remaining 8 (10.8 %) were cured after thyroidectomy. The percentage of patients who failed decreased in a stepwise fashion as RAI dose increased. Similarly, the incidence of failure increased as the presenting T3 level increased. Sensitivity analysis revealed that RAI doses <12.5 mCi were associated with failure while initial T3 and free T4 levels of at least 4.5 pg/mL and 2.3 ng/dL, respectively, were associated with failure. In the final multivariate analysis, higher T4 (hazard ratio [HR] 1.13; 95 % confidence interval [CI] 1.02–1.26; p = 0.02) and methimazole treatment (HR 2.55; 95 % CI 1.22–5.33; p = 0.01) were associated with failure.

Conclusions

Laboratory values at presentation can predict which patients with hyperthyroidism are at risk for failing RAI treatment. Higher doses of RAI or surgical referral may prevent the need for repeat RAI in selected patients.     

The Impact of Surgical Volume on Racial Disparity in Thyroid and Parathyroid Surgery

Purpose

The aim of this study was to evaluate the association between surgeon volume and patient outcomes among different race ethnicities undergoing thyroid or parathyroid surgery.

Methods

The nationwide inpatient sample was used to identify all thyroidectomy and parathyroidectomy admissions from 2003 to 2009, using International Classification of Diseases, 9th Clinical Modification (ICD-9-CM) procedure codes. Race, demographic, and clinical characteristics of patients were collected, along with surgeon volume, to predict the length of stay (LOS), complication rates, mortality, and total charges by racial group, using univariate and multivariate analyses.

Results

A total of 106,314 thyroid and parathyroid surgeries were included in the current analysis. Of these patients, 54 % were Caucasian, 11 % African American, 7 % Hispanic, and 3 % Asian. Mean LOS was longer for African American patients (4 ± 8.7 days) than for Caucasians (2.3 ± 5.5 days) [p < 0.001]. African Americans had higher overall complications (16.8 %) compared with Caucasians (11 %), Hispanics (13.5 %), and Asians (12 %) [p < 0.001]. In-hospital mortality was higher for African Americans (0.8 %) compared with that from other race groups (0.3 %) [p < 0.001]. Mean total charges were significantly higher for African Americans ($33,292 ± $67,387) compared with those for Caucasians ($22,855 ± $40,167) (p < 0.001). African Americans had less access to intermediate- (10–99 cases) and high- (>100 cases) volume surgeons compared with Caucasians—45 versus 49 %, and 16 versus 19 %, respectively (p < 0.001). Higher surgeon volume was associated with improved outcomes (p < 0.001). Racial disparity in all investigated outcomes was still significantly evident even after stratification by surgeon volume.

Conclusion

Higher surgeon volume is associated with improved patient outcomes. However, our data suggests that the observed racial disparities in thyroid and parathyroid surgery go beyond access to quality healthcare providers.     

Spinal penetration index assessment in adolescent idiopathic scoliosis using EOS low-dose biplanar stereoradiography

Purpose

The spinal penetration index (SPI) quantifies the portion of the rib cage occupied by vertebrae. When measured by computed tomography (CT) or magnetic resonance imaging, SPI can only be determined in the reclining position, which modifies spinal and thoracic morphology. CT results in high radiation exposure. The authors studied rib cage and spinal morphology using low-dose biplanar stereoradiography and their impact on respiratory function in adolescent idiopathic scoliosis (AIS).

Methods

In eighty thoracic AIS patients, a slot-scanning radiologic device allowing simultaneous acquisition of orthogonal images and 3D reconstructions with low exposure to radiation (EOS) was used to determine thoracic volume, mean spinal penetration index (SPIm), apical spinal penetration index (SPIa), main thoracic (MT) curve Cobb angle, T4–T12 kyphosis, and apical vertebral rotation (AVR).

Results

Thoracic volume was correlated with thoracic kyphosis (r = 0.31, p = 0.006), but not with SPI, MT Cobb angle, or AVR. SPIm and SPIa were negatively correlated with thoracic kyphosis. Forced vital capacity and forced expiratory volume in 1 s were significantly lower in the hypokyphotic patients (p = 0.04, p = 0.03, respectively) and correlated with thoracic volume and T4–T12 kyphosis. No correlation was found between spinal penetration indices and pulmonary function tests, but SPIm was significantly greater in patients with obstructive syndrome (p = 0.01).

Conclusions

With little radiation exposure, EOS biplanar stereoradiography permits routine imaging is a functional standing position. Hypokyphotic patients had significantly decreased FEV1 and FVC. SPIm was significantly higher in patients with obstructive syndrome.     

Volumetric Changes after 90Y Radioembolization for Hepatocellular Carcinoma in Cirrhosis: An Option to Portal Vein Embolization in a Preoperative Setting?

Background

Contralateral hypertrophy after ⁹⁰Y radioembolization has been described in case reports, but the incidence and quantitative extent of liver volume modifications after this therapy are unknown.

Methods

This retrospective study examined patients with hepatocellular carcinoma and underlying cirrhosis treated by ⁹⁰Y radioembolization. The main inclusion criteria were unilateral treatment, no prior liver surgery, and computed tomographic scans allowing for volumetric assessments. Treated, tumor, and contralateral liver volumes were measured. Whole liver volume and the ratio of contralateral to total functional liver volume after a virtual hepatectomy were calculated.

Results

Data of 34 patients were analyzed. Response rates were 26 % according to Response Evaluation Criteria in Solid Tumors (RECIST) and 63 % according to modified RECIST. Median overall survival was 13.5 months. Median treated volume decreased from 938 mL (interquartile range [IQR] = 719) to 702 mL (IQR = 656) (p < 0.001), while median contralateral volume increased from 724 mL (IQR = 541) to 920 mL (IQR = 530) (p < 0.001). The whole liver volume remained stable, with a median volume of 1,702 mL (IQR = 568) versus 1,577 mL (IQR 670), respectively (p = 0.55). The mean maximal increase in contralateral volume was 42 % (95 % confidence interval 16–67). Overall, 13 patients (38.2 %) exhibited increases greater than 30 %, while 13 patients (38.2 %) showed no increase or showed increases less than 10 %. The median ratio of contralateral to total functional liver volume increased from 48.5 to 64.9 % (p < 0.001), with the proportion of patients with a ratio of ≥50 % increasing from 47.1 to 67.6 % (p = 0.013).

Conclusions

⁹⁰Y radioembolization induced frequent and similar increases in functional liver remnant volume compared with portal vein embolization. This technique should be tested in a prospective study phase 2 study before liver resection.     

Spirometric and radiological evaluation of the remnant lung long after major pulmonary resection: can compensatory phenomena be recognized in clinical cases?

Purposes

The purpose of this study was to investigate the compensatory phenomena after lung resection in clinical cases by evaluating the spirometric and radiological parameters.

Methods

Forty patients undergoing lobectomy for stage IA lung cancer were divided into the following groups: (A) patients with <10 (n = 20) and (B) patients with ≥10 resected subsegments (n = 20). Comparisons were made of the predicted and observed postoperative values of spirometry and radiological parameters, such as lung volumetry and the “estimated lung weight”. Predicted values were based on the number of resected subsegments. The postoperative time to re-evaluation was at least 1 year for both groups.

Results

The predicted postoperative values of spirometry underestimated the actual values, and the differences were more significant in group B (forced vital capacity, p = 0.006, forced expiratory volume in 1 s, p = 0.011). Focusing on the remnant lungs on the surgical side, group B had significantly larger % postoperative lung volumes (161 ± 6.0 %) and % estimated lung weight (124 ± 5.4 %) than did group A (114 ± 3.8 %, p < 0.0001; 89.5 ± 4.4 %, p < 0.0001, respectively).

Conclusions

Major lung resection in clinical cases causes a compensatory restoration of the pulmonary function and tissue.