Is Intraoperative Calcitonin Monitoring Useful to Modulate the Extension of Neck Dissection in Patients With Medullary Thyroid Carcinoma?

Background

The extension of the compartment-oriented neck dissection at primary surgery in medullary thyroid carcinoma (MTC) is controversial. Because a <50 % decrease in intraoperative calcitonin levels (IO-CT) after total thyroidectomy plus central neck dissection (TT-CND) has been associated with residual disease, IO-CT monitoring has been proposed to predict the completeness of surgery. The goal of the present prospective study was to verify the accuracy of IO-CT monitoring.

Methods

All patients scheduled for primary surgery for suspected or proven MTC between November 2010 and January 2013 were included. Calcitonin was measured pre-incision (basal level), after tumor manipulation, at the time TT-CND was accomplished (ablation level), 10 and 30 min after ablation. A decrease >50 % with respect to the highest IO-CT level 30 min after ablation was considered predictive of cure.

Results

Twenty-six patients were included, and IO-CT monitoring identified 18 of 23 cured patients (true negative results) and 2 of 3 patients with persistent disease (true positive result). In 5 patients with normal basal and stimulated postoperative calcitonin levels, a decrease <50 % was observed (false positive results). In one of three patients with persistent disease a >50 % decrease in IO-CT was observed (false negative results). Specificity, sensitivity, and accuracy of IO-CT were 78.2, 66.6, and 76.9 %, respectively.

Conclusions

Intraoperative calcitonin monitoring is not highly accurate in predicting the completeness of surgical resection. In the present series, relying on IO-CT would result in limited resection in about one third of the patients with residual neck disease and in unnecessary lateral neck dissection in about 20 % of the cured patients.     

Elevated Basal Calcitonin Levels in a Patient with a Hürthle-Cell Carcinoma of the Thyroid and Neuroendocrine Differentiation: Report of a Case

A thyroid nodule with elevated plasma levels of calcitonin is usually suggestive of a medullary thyroid carcinoma (MTC); however, thyroid and extrathyroid conditions have been reported with elevated plasma calcitonin levels in the absence of MTC. We report the case of a patient with a thyroid nodule and an elevated basal plasma calcitonin level of 315pg/ml (normal value <100pg/ml) who underwent a left hemithyroidectomy. Interestingly, histopathological examination revealed a Hürthle-cell carcinoma with positive neuroendocrine (NE) markers such as calcitonin and synapthophysin, but not with chromogranin staining. Thus, we discuss the phenomenon of non-NE tumors showing positivity for NE markers.     

Does Completion Thyroidectomy Improve the Outcome of Patients with Minimally Invasive Follicular Carcinoma of the Thyroid?

Background

The diagnosis of minimally invasive follicular thyroid carcinoma (MIFTC) is often made histologically after thyroid lobectomy. We attempted to determine whether completion thyroidectomy should be considered necessary for all patients diagnosed with MIFTC after thyroid lobectomy.

Methods

The subjects of this study were a total of 324 patients who underwent thyroid lobectomy as initial surgery at our institution between 1989 and 2010 and diagnosed histologically as MIFTC. Completion thyroidectomy was performed on 101 patients, and the other 223 patients were followed up without further treatments. Cumulative cause-specific survival (CSS) rates and distant-metastasis-free survival (DMFS) rates were calculated by the Kaplan–Meier method. Differences between groups were analyzed for statistical significance by the log-rank test. Multivariate analysis was performed by using the Cox proportional hazards model.

Results

During the follow-up period, 39 patients were diagnosed with distant metastasis, and 7 patients died of their disease. Age at the initial surgery was found to be a significant factor related to DMFS in both the univariate and multivariate analysis and to also be related to CSS in the univariate analysis. Completion thyroidectomy did not have a significant effect on DMFS or CSS according to the results of the univariate analysis, but it had significant effect on DMFS according to the results of the multivariate analysis.

Conclusions

Although we were unable to demonstrate sufficient statistical evidence that completion thyroidectomy improved the outcome of MIFTC patients, it is noteworthy none of the patient who underwent completion thyroidectomy died of the disease.     

Can Subepididymal Orchiectomy Re-emerge as the Treatment of Choice in Patients with Advanced Prostatic Carcinoma?

To study the effectiveness of bilateral subepididymal orchiectomy compared to bilateral simple and subcapsular orchiectomy in terms of androgen ablation, control of disease progression and esthetic superiority. 114 patients of advanced prostatic carcinoma (T3, T4, M1) were randomized to 3 groups- Group A: bilateral simple orchiectomy (38 patients), Group B: bilateral subcapsular orchiectomy (38 patients), & Group C: bilateral subepididymal orchiectomy (38 patients). Serum PSA and serum testosterone values were checked pre-operatively and at 3 months follow-up. Patients'' esthetic satisfaction was scored on a quality of life scale of 1–5. In Groups A, B and C, at 3 months the post-operative mean serum testosterone values were 34.7, 38.1 and 36.7 ng/dl (p = 0.0524); and mean serum PSA values were 4.2, 3.9 and 3.4 ng/ml (p = 0.09) respectively, the differences not being statistically significant. On esthetic satisfaction scale the average scores were 1.8, 2.7 and 4.0 respectively, the difference being highly significant (p < 0.0001). Subepididymal orchiectomy maintains esthetic appearance of scrotum and provides superior patient satisfaction as compared to standard total and subcapsular orchiectomy, while achieving equal efficacy. Bilateral sub-epididymal orchiectomy may thus be considered procedure of choice to achieve androgen ablation in advanced prostatic carcinoma.     

Can Axillary Node Dissection Be Omitted in a Subset of Patients with Low Local and Regional Failure Rates?

Axillary node dissection (ALND) is the standard of care for patients who have a positive sentinel lymph node (SLN) on sentinel lymph node biopsy (SLNB). We sought to identify a low-risk patient population with positive SLN that may not need cALND. We analyzed SLNB for breast cancer at our institutions between 1999 and 2007. We identified 130 patients who had a positive SLN but did not undergo completion ALND. We evaluated clinical data, adjuvant treatment patterns and intermediate locoregional and distant events. The median patient age was 50; 19% had N0(i+) disease, 53% had micrometastatic (N1mi) disease, and 28% had macrometastasis. Eighty-eight percent of patients underwent radiation therapy; 66 patients (51%) had documented nodal radiation (of these 50 were treated with three fields and 14 with high tangents. Local recurrence in the breast occurred in two patients (2%) and nine patients (7%) developed distant metastases; there were no axillary/nodal recurrences. In this highly selected group of patients who had a positive SLNB but did not undergo cALND, we observed no axillary recurrences.     

ASO Visual Abstract: Surgical Treatment of Patients with Poorly Differentiated Pancreatic Neuroendocrine Carcinoma—An NCDB Analysis

Annals of Surgical Oncology -     

TAPP or TEP? Population-Based Analysis of Prospective Data on 4,552 Patients Undergoing Endoscopic Inguinal Hernia Repair

Background

Whether total extraperitoneal inguinal hernia repair (TEP) is associated with worse outcomes than transabdominal preperitoneal inguinal hernia repair (TAPP) continues to be a matter of debate. The objective of this large cohort study is to compare outcomes between patients undergoing TEP or TAPP.

Methods

Based on prospective data of the Swiss association of laparoscopic and thoracoscopic surgery, all patients undergoing unilateral TEP or TAPP between 1995 and 2006 were included. The following outcomes were compared: conversion rates, intraoperative and postoperative complications, duration of operation.

Results

Data on 4,552 patients undergoing TEP (n?=?3,457) and TAPP (n?=?1,095) were collected prospectively. Average age and American Society of Anesthesiologists score were similar in the two groups. Patients undergoing TEP had a significantly higher rate of intraoperative complications (TEP 1.9?% vs. TAPP 0.9?%, p?=?0.029) and surgical postoperative complications (TEP: 2.3?% vs. TAPP: 0.8?%, p?=?0.003). The postoperative length of stay was longer for patients undergoing TAPP (2.9 vs. 2.3?days, p?=?0.002), whereas the duration of the operation was longer for TEP (66.6 vs. 59.0?min, p?<?0.001) and the conversion rate was higher (TEP 1.0?% vs. TAPP 0.2?%, p?=?0.011).

Conclusions

This study is one of the first population-based analyses comparing TEP and TAPP in a prospective cohort of more than 4,500 patients. Intraoperative and surgical postoperative complications were significantly higher in patients undergoing TEP. TEP is also associated with longer operating times and higher conversion rates. Therefore, on a population-based level, the TAPP technique appears to be superior to the TEP repair in patients undergoing unilateral inguinal hernia repair.     

Do Perioperative Blood Transfusions Influence Prognosis of Gastric Cancer Patients? Analysis of 927 Patients and Interactions with Splenectomy

Background

This study was to assess the influence of perioperative blood transfusions on the prognosis of patients undergoing a potentially curative resection for gastric cancer and to investigate the interaction between transfusions and splenectomy.

Materials and Methods

Between January 1990 and December 2005, 927 patients from 6 Italian tertiary referral centers underwent curative resections for gastric cancer. Clinical and pathologic variables were prospectively collected. The influence of perioperative blood transfusions on survival were evaluated by univariate and multivariate analysis. Moreover, the influence of splenectomy both in transfused and nontransfused patients undergoing total gastrectomy was also evaluated.

Results

The overall 5-year survival was 54.6%. The 5-year survival rate in transfused patients (n = 327) was 50.6% compared with 56.6% in nontransfused patients (n = 600) (P = .094). In the subgroup of patients who underwent total gastrectomy with spleen preservation (n = 209), 5-year survival rate was 46% and 51.4% in transfused and nontransfused patients, respectively (P = .418); those who underwent total gastrectomy with splenectomy (n = 199) presented a 5-year survival rate of 45% in transfused group compared with 39.1% in nontransfused patients (P = .571).

Conclusions

Our study indicates a slightly, but not significantly, negative effect of allogeneic blood transfusion on prognosis of gastric cancer patients. In the subgroup of patients who underwent total gastrectomy, splenectomy seems to invert this mild effect, with a positive influence on overall survival.     

Can Tyrosine Kinase Inhibitors be Discontinued in Patients with Metastatic Renal Cell Carcinoma and a Complete Response to Treatment? A Multicentre,Retrospective Analysis

Background

Discontinuation of treatment with tyrosine kinase inhibitors (TKIs) and readministration in case of recurrence could improve quality of life (QoL) and reduce treatment costs for patients with metastatic renal cell carcinoma (mRCC) in which a complete remission (CR) is achieved by medical treatment alone or with additional resection of residual metastases.

Objective

To evaluate whether TKIs can be discontinued in these selected patients with mRCC.

Design, setting, and participants

A retrospective analysis of medical records and imaging studies was performed on all patients with mRCC treated with TKIs (n = 266) in five institutions. Patients with a CR under TKI treatment alone or with additional metastasectomy of residual disease following a partial response (PR), in which TKIs were discontinued, were included in the analysis. Outcome criteria analysed were time to recurrence of previous metastases, occurrence of new metastases, symptomatic progression, improvement of adverse events, and response to reexposure to TKIs.

Interventions

Sunitinib 50 mg/day for 4 wk on and 2 wk off, sorafenib 800 mg/day.

Measurements

Response according to Response Evaluation Criteria in Solid Tumours (RECIST).

Results and limitations

We identified 12 cases: 5 CRs with sunitinib, 1 CR with sorafenib, and 6 surgical CRs with sunitinib followed by residual metastasectomy. Side-effects subsided in all patients off treatment. At a median follow-up of 8.5 mo (range: 4–25) from TKI discontinuation, 7 of 12 patients remained without recurrence and 5 had recurrent disease, with new metastases in 3 cases. Median time to progression was 6 mo (range: 3–8). Readministration of TKI was effective in all cases. The study is limited by small numbers and retrospective design.

Conclusions

Discontinuation of TKI in patients with mRCC and CR carries the risk of progression with new metastases and potential complications. Further investigation in a larger cohort of patients is warranted before such an approach can be regarded as safe.     

Can the Dropout Risk of Candidates with Hepatocellular Carcinoma Predict Survival after Liver Transplantation?

In the last US national conference on liver transplantation for hepatocellular carcinoma (HCC), a continuous priority score, that incorporates model for end‐stage liver disease (MELD), alpha‐fetoprotein and tumor size, was recommended to ensure a more equitable liver allocation. However, prioritizing highest alpha‐fetoprotein levels or largest tumors may select lesions at a higher risk for recurrence; similarly, patients with higher degree of liver failure could have lower postoperative survival. Data from 300 adult HCC recipients were reviewed and the proposed HCC‐MELD equation was applied to verify if it can predict post‐transplantation survival. The 5‐year survival and recurrence rates after transplantation were 72.8 and 13.5%, respectively. Cox regression analysis confirmed HCC‐MELD as predictive of both postoperative survival and recurrence (p < 0.001). The 5‐year predicted survival and recurrence rates were plotted against the HCC‐MELD‐based dropout probability: the higher the dropout probability while on waiting list, the lower the predicted survival after transplantation, that is worsened by hepatitis C positivity; similarly, the higher the predicted HCC recurrence rate after transplantation. The HCC priority score could predict the postoperative survival of HCC recipients and could be useful in selecting patients with greater possibilities of survival, resulting in higher post‐transplantation survival rates of HCC populations.     

Analysing the Serum Levels of Tumour Markers and Primary Tumour Data in Stage III Melanoma Patients in Correlation to the Extent of Lymph Node Metastases—a Prospective Study in 231 Patients

Background : Serum tumour markers correlate with biological tumour behaviour and prognosis of patients. We collected prospective data of melanoma patients in tumour stage III before radical lymph node dissection. Materials and methods : Between 2003 until 2007 we collected 231 tumour stage III patients and analysed the preoperative serum tumour markers S100 (S100 calcium binding protein), NSE (Neuron specific enolase, Enolase 2), Albumin, LDH (Lactate dehydrogenase) and CRP (C-reactive protein) and evaluated the correlation to clinical and pathological data. We divided patients into a group with only a positive sentinel lymph node (group 1; n = 109) and a second with further lymph node metastases (group 2; n = 122).

Results : Patients of group 2 had a significant higher T level (p < 0.0001) and Breslow index (p < 0.0001). Patients with a higher Breslow index had a higher S100 serum level (p = 0.021). Patients of group 2 displayed a significant higher level of serum S100. The serum level of CRP correlated with increasing number of lymph node metastases. Conclusions : A higher Breslow index in tumour stage III patients seems to have an influence on lymph node metastases and on S100 serum level. Patients with more than a positive sentinel lymph node do have a higher S100 level.     

Does Regular Lipid Apheresis in Patients With Isolated Elevated Lipoprotein(a) Levels Reduce the Incidence of Cardiovascular Events?

Elevated lipoprotein(a) (Lp(a)) is known as an independent risk factor for atherosclerosis and cardiovascular events. Regular lipid apheresis decreases elevated Lp(a) concentrations. However, there is a lack of reliable data regarding the effect of lipid apheresis on cardiovascular endpoints. To assess the effects of apheresis, we compared the occurrence of cardiovascular events in 37 patients treated regularly with lipid apheresis at the time periods of preinitiation of apheresis and during apheresis treatment. A retrospective analysis of 37 patients (35 men and two women; aged 58 years ± 11 [mean ± standard deviation]; body mass index 26 kg/m² ± 3; low‐density lipoprotein (LDL)‐cholesterol before apheresis 84 mg/dL ± 21; Lp(a) before apheresis 112 mg/dL ± 34) treated regularly with lipid apheresis was performed. Patients' medical records were screened for cardiovascular events at the preapheresis and during apheresis periods. Apheresis led to a significant reduction of lipid levels (LDL cholesterol ?60%; Lp(a) –68%) measured after apheresis. The event‐free survival rate after 1 year in the preapheresis period was 38% (22–54%, 95% confidence interval [CI]) vs. 75% (61–89%, 95% CI) in the during‐apheresis period with a statistically significant difference (P < 0.0001). Apheresis seems to lower the progression of atherosclerosis leading to a reduced number of cardiovascular events in hyperlipoproteinemia(a). Because prospective and controlled trials are lacking, the therapeutic effectiveness of lipid apheresis can only be estimated.     

Skill Assessment of Urological Laparoscopic Surgeons: Can Criterion Levels of Surgical Performance Be Determined Using the Pelvic Box Trainer?

OBJECTIVES: To correlate between surgeons' experience in urological laparoscopy and their performance of a set of laparoscopic tasks performed on a box trainer in the laparoscopic laboratory. METHODS: 44 urologists participated in this study. A self-administrated questionnaire enquired about their experience in laparoscopy and they were divided to 4 categories: no experience, minimal experience, basic and advanced laparoscopists. Tests consisted of 4 tasks: passage of a ligature, intracorporeal knotting, intracorporeal suturing, and cutting a carton circle out of a square. All tests were supervised and time was recorded for each of the tasks. Histograms were plotted showing the mean time for performance of each task in each experience group. The Kruskal-Wallis analysis of variance was used to assess statistical significance. RESULTS: Seven participants had no previous experience in laparoscopy and 14 had minimal experience. 15 had basic experience and 8 were advanced laparoscopists. No difference in performance was found between the no experience and minimal experience group and they were united and defined as beginners. A significant difference in performance was noted between the beginners, basic and advanced groups, especially when comparing beginners to advanced. Criterion level values of surgical performance drawn from this data were highly discriminative with sensitivity of 71-85% and specificity of 74.2%-88%. CONCLUSIONS: We were able to differentiate between various levels of laparoscopic skills among the participating urologists. Values drawn from such studies could be the basis of criterion level values for technical laparoscopic performance during training programs and before granting laparoscopic privileges to urologists.     

Can SAPS II Predict Operative Mortality More Accurately Than POSSUM and P-POSSUM in Patients with Colorectal Carcinoma Undergoing Resection?

Background This study assessed the APACHE II (Acute Physiology and Chronic Health Evaluation II), SAPS II (Simplified Acute Physiology Score-II), POSSUM (Physiologic and Operative Severity Score for Enumeration of Morbidity and Mortality), and P-POSSUM (Portsmouth-POSSUM) in patients with colorectal cancer undergoing curative or palliative resection. Methods Predicted mortality rates and the observed/expected mortality ratio were computed by means of each scoring system. The results were compared between survivors and nonsurvivors and between elective and emergency operations. Each model was assessed for its accuracy to predict the risk of death using receiver operator characteristic (ROC) curve analysis, and risk stratification was generated as well. Results Some 224 patients were enrolled in the study. The overall 30-day mortality rate was 3.6% (n = 8). Predicted mortality rates generated by APACHE II, SAPS II, POSSUM, and P-POSSUM were 9.1%, 3.7%, 13.4%, and 5.2%, respectively. All the scoring systems assigned higher scores to those patients who died than to those who survived. Areas under the curve calculated by ROC curve analysis for APACHE II, SAPS II, POSSUM, and P-POSSUM were 0.786, 0.854, 0.793, and 0.831, respectively. Best stratification was achieved by the SAPS II score. Conclusions SAPS II and P-POSSUM were determined to be better predictors for patients with colorectal cancer undergoing resection. SAPS II also was found to have a higher degree of discriminatory power in colorectal resection for carcinoma. The predictive value of this useful severity score in several surgical subgroups must be examined to evaluate its routine use in risk-adjusted audit.     

Is There a Role for Unstimulated Thyroglobulin Velocity in Predicting Recurrence in Papillary Thyroid Carcinoma Patients with Detectable Thyroglobulin after Radioiodine Ablation?

Background

In the follow-up of papillary thyroid cancer (PTC) patients treated with curative thyroidectomy and radioiodine ablation, raised thyroglobulin (Tg) predicts recurrence with reasonable sensitivity and specificity. However, a proportion of patients present with raised Tg level but no other clinical evidence of disease. Only limited data on Tg kinetics have been reported to date. Here we aim to evaluate the prognostic and predictive significance of nonstimulated serum Tg velocity (TgV).

Methods

Consecutive PTC patients treated with curative thyroidectomy and radioiodine ablation between 2003 and 2010 were analyzed. Patients with at least one detectable Tg measurement (>0.2?ng/mL) were included. TgV was defined as the annualized rate of Tg change. Logistic regression analyses were performed to evaluate the role of TgV in the prediction of disease recurrence. The optimal TgV cutoff was assigned by receiver?Coperating characteristic curve analysis. Overall survival of patients above versus below the TgV cutoff were determined by the Kaplan?CMeier method and compared.

Results

Of a total of 501 patients, 87 had at least one Tg value >0.2?ng/mL; in these latter patients, 29 (33.3?%) developed recurrence. TgV was an independent predictor of the recurrence. TgV ??0.3?ng/mL per year predicted recurrence with a sensitivity of 83.3?% and specificity of 94.4?%. Patients with TgV below the cutoff had a significantly better overall survival (p?=?0.038).

Conclusions

TgV predicts recurrence with high sensitivity and specificity, and is a prognosticator of survival in postthyroidectomy and postablation PTC patients with raised Tg.