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Fusion Imaging: Optimal Localization for Ectopic Parathyroid Adenoma
ENDOCRINE SURGERY
academic institution. Patients were allocated into 2 groups according to LSJ or HF use. All patients underwent vocal cord assessment using laryngoscopy preoperatively and postoperatively.
A Contemporary Analysis of The Incidence of Adrenocortical Cancer in Adrenal Incidentalomas Nisar Zaidi, MD, Khalil Tamrgha, Zaid Yaqoob, Sonya K Patel, MD, Emre Bucak, MD, Zanati M Ahmed, MD, Alexis K Okoh, MD, Cem Dural, Eren Berber, MD, FACS Cleveland Clinic Foundation, Cleveland, OH INTRODUCTION: Guidelines for the management of adrenal incidentalomas (AI) put forth by the NIH and AAES/AACE were largely based on studies utilizing old generation CTs. These guidelines recommend adrenalectomy vs observation predominantly based on tumor size. It is unknown whether the classic rates about the incidence of adrenocortical cancer (ACC) based on tumor size apply to the modern series. The objective of this study is to analyze the incidence of ACC in a contemporary series of AI.
RESULTS: Five hundred thirty patients were randomized into 2 groups (HF group, N ¼ 206 (38.86 %) LSJ instrument group, N ¼ 324(61.13 %)). Seven (2.16%) LSJ patients developed transient postoperative hypocalcaemia compared to 17 (8.25%) patients in HF group (p 0.002). Operative times were not significantly different (HF 122.4 46.94 min vs. LSJ 117.8 55.41 min; p ¼ 0.09). The LSJ use was associated with slightly more intraoperative Bood loss when compared to HF (LSJ 17.95 52.38 ml vs HF 15.7517.04 ml; p¼ 0.24). no significant difference in rate of transient laryngeal nerve injury between both groups (LSJ: 3.70% vs HF: 5.34%; p¼ 0.39. Overall postoperative complications rate was similar (LSJ: 15.17% vs HF 20.90%; p¼ 0.11).
METHODS: All patients who presented to Cleveland Clinic between 1992 and 2015 with a diagnosis of adrenal disorders (15,000 patients) were reviewed from a hospital electronic medical record database. The patients with AI were identified. This study reports an interim analysis of the first 10,000 patients reviewed.
CONCLUSIONS: Both LigasureÔ and HarmonicÒ procedures provide surgeons ergonomics and no significant differences were shown in operative time and rate of complications. However there is a trend for transient postoperative hypocalcemia in patients operated using HF compared to those with LSJ.
RESULTS: Out of 10,000 patients, 3269 patients met the criteria for AI. Hormonal workup demonstrated pheochromocytoma in 6%, primary hyperaldosteronism in 4.2% and Cushing’s syndrome in 3.5%. Four hundred fifteen patients underwent adrenalectomy. The incidence of ACC for tumors less than 4 cm was 3.7%, for tumors 4-6 cm, 4.1%, and for tumors > 6 cm, 21.1%.
Fusion Imaging: Optimal Localization for Ectopic Parathyroid Adenoma Phillip K Pellitteri, DO, James Biery Guthrie Clinic, Sayre, PA, Geisinger Medical Center, Danville, PA INTRODUCTION: Parathyroidectomy enjoys a success rate in excess of 95% for definitive cure of primary hyperparathyroidism. Approximately 10% of patients will exhibit the presence of parathyroid gland(s) in a verified ectopic location. Targeted surgery requires accurate localization. This discussion presents a dual institutional experience utilizing computed tomographyeTc99m fusion imaging with or without SPECT/CT for identification and accurate localization of ectopic parathyroid glands in patients undergoing neck exploration for primary hyperparathyroidism.
CONCLUSIONS: This interim analysis represents one of the largest contemporary analyses on the incidence of ACC in AIs. The results show that if non-operative patients with stable tumors are also accounted for, the incidence of ACC across tumor sizes is less than currently reported in the guidelines. We believe that a complete analysis of our data will generate a more accurate incidence of ACC and provide for modern recommendations in the management of AI. Comparing the Efficacy and Surgical Outcomes of HarmonicÒ Scalpel vs LigaSureÔ Small Jaw in Thyroid and Parathyroid Surgery. Taha A Hassoon, MD, Fadi Murad, Daniah Bu Ali, MD, Muhammad Anwar, MBBS, Roostam Kholmatov, MD, Zaid Al-Qurayshi, MD, Rizwan Aslam, Emad Kandil, MBBCh, FACS Tulane Medical School-Tulane University, New Orleans, LA
METHODS: A retrospective review of patients undergoing exploration for primary hyperparathyroidism at 2 academic tertiary care institutions over a 7-year period (2008-2015) was conducted. The primary objective of the study was to evaluate the localization of ectopic parathyroid glands utilizing fusion imaging and correlate the accuracy of these results with surgical findings at exploration.
INTRODUCTION: Location and rich vascularity of thyroid gland poses a challenge for a surgeon to achieve good hemostasis and minimize postoperative complications. This study aims to compare LSJ vs HF in terms of operative time, intraoperative blood loss, RLN injury, and postoperative complications.
RESULTS: Fifty-nine ectopic parathyroid glands were identified: 9 within the mediastinum, 21 within the thymus, 5 in an undescended location above the superior pole of the thyroid gland, 13 in a true retro-esophageal location and 11 within the thyroid parenchyma. Fusion imaging accurately identified the location of 54 of 59 ectopic glands, including all glands located in mediastinal, undescended, and thymic locations. Imaging failed to identify 3 intra-thyroidal glands and 2 glands in retro-esophageal locations.
METHODS: This study was conducted under IRB approved protocol to compare efficacy of LSJ vs the HF. We evaluated (530) patients who underwent surgery by a surgeon at a North American
e95
http://dx.doi.org/10.1016/j.jamcollsurg.2016.08.240 ISSN 1072-7515/16
e96
Scientific Poster Presentations: 2016 Clinical Congress
Imaging results altered the approach to exploration for glands localized to mediastinal and undescended locales. CONCLUSIONS: CTeMIBI fusion imaging represents an effective localization modality for identification of ectopic parathyroid glands, determining candidacy for, and capability of a targeted surgical approach in patients with primary hyperparathyroidism. Impact of Micro- and Macroscopically Positive Surgical Margins on Survival after Resection of Adrenocortical Carcinoma Kevin L Anderson, Linda M Youngwirth, MD, Sanziana A Roman, MD, Julie A Sosa, MD, FACS Duke University School of Medicine, Durham, NC INTRODUCTION: Adrenocortical carcinoma (ACC) is a rare, aggressive cancer; complete surgical resection offers the best chance for long-term survival. The impact of surgical margin status on survival is poorly understood. Our objective was to determine the association of margin status with overall survival (OS). METHODS: Patients with ACC were identified from the National Cancer Data Base, 1998-2012, and stratified based on surgical margin status (negative vs microscopically positive vs macroscopically positive [+]). Univariate/multivariate regression/survival analysis was utilized to determine factors associated with margin status and OS. RESULTS: A total of 1,763 patients underwent surgery at 625 institutions: 88% had negative, 10% microscopic, and 2% macroscopic(+) margins. Those with micro(+) and macro(+) margins received more adjuvant chemotherapy (33% micro(+) vs 33% macro(+) vs 22% negative margins, p¼0.005). Distant metastases were seen more often in patients with positive margins (15% micro(+) vs 24% macro(+) vs 7% negative margins, p0.02). In unadjusted analysis, there was a significant difference in OS between the groups (p<0.0001), with median survival times of 62 months (IQR 19-176) for those with negative margins, 21 months (IQR 8-68) micro(+), and 7 months (IQR 2-26) macro(+) margins. After adjustment, both micro(+) [HR 1.96, p<0.0001] and macro(+) [HR 1.81, p<0.0001] margin status were associated with compromised survival. Use of chemotherapy was an independent predictor of compromised overall survival (HR 1.52, p<0.0001). CONCLUSIONS: Having either micro- or macroscopically positive margin status after ACC resection is associated with compromised survival. These results underscore the importance of achieving negative surgical margins for optimizing long-term patient outcomes. Laparoscopic Adrenalectomy for Metastatic Disease: Prospective Case Series from a High- Volume Center Frederick T Drake, MD, MPH, Toni M Beninato, MD, Maggie X Xiong, Nirav Shah, Wouter P Kluijfhout,
J Am Coll Surg
Insoo Suh, MD, FACS, Jessica E Gosnell, MD, FACS, Wen T Shen, MD, FACS, Quan-Yang Duh, MD, FACS University of California-San Francisco, San Francisco, CA INTRODUCTION: Several malignancies are known to metastasize to the adrenal gland, especially non-small cell lung cancer, renal cell carcinoma (RCC), and melanoma. Several small series have investigated both open and laparoscopic adrenalectomy (LA) in the management of adrenal metastases, and, among appropriately selected patients this has been shown to improve survival compared to nonoperative management alone. A minimally invasive approach remains somewhat controversial. METHODS: Our institution has prospectively maintained a patient registry for all adrenalectomies since 1993. Through February 2016, 41 patients underwent adrenalectomy for metastatic disease. Primary endpoints of interest were complications and median survival. Descriptive results including demographics, primary cancer, tumor size, and operative approach were also generated. RESULTS: Forty-one adrenalectomies were performed for metastatic disease. In all but one case (synchronous RFA of hepatocellular carcinoma and LA), the indication was resection after definitive treatment of a primary lesion. There were no deaths within a 30-day period. Four patients suffered complications, including 1 patient who required take back for a retroperitoneal hematoma. There was 1 conversion to open. Two patients had bilateral adrenalectomies. NSCLC (N ¼ 11), melanoma (N ¼ 9), and RCC (N¼8) were the 3 most common adrenal metastases treated by surgery. In this series, median survival after adrenalectomy for RCC was 34 months, for NSCLC was 23 months, and for melanoma was 16 months. CONCLUSIONS: LA for metastases is safe when performed by experienced surgeons. Among the 3 most common primary cancer types, there was an association with survival: RCC was improved over NSCLC, which was improved over melanoma. Laparoscopic and Open Adrenalectomy Performed for Malignant Adrenal Tumors: An Analysis of the American College of Surgeons NSQIP Database Monica Jain, MD, Edward H Phillips, MD, FACS, Miguel A Burch, MD, FACS, Daniel Shouhed, MD, Rodrigo F Alban, MD, FACS Cedars-Sinai Medical Center, Los Angeles, CA INTRODUCTION: There is controversy regarding the optimal surgical approach to malignant adrenal tumors because of differing outcomes in retrospective series and the lack of randomized trials. Consequently, an analysis of non-oncologic outcomes was undertaken to study laparoscopic (LA) and open (OA) adrenalectomy for malignant disease. METHODS: The American College of Surgeons NSQIP database was queried from 2010-2014 to identify LA and OA performed for
academic institution. Patients were allocated into 2 groups according to LSJ or HF use. All patients underwent vocal cord assessment using laryngoscopy preoperatively and postoperatively.
A Contemporary Analysis of The Incidence of Adrenocortical Cancer in Adrenal Incidentalomas Nisar Zaidi, MD, Khalil Tamrgha, Zaid Yaqoob, Sonya K Patel, MD, Emre Bucak, MD, Zanati M Ahmed, MD, Alexis K Okoh, MD, Cem Dural, Eren Berber, MD, FACS Cleveland Clinic Foundation, Cleveland, OH INTRODUCTION: Guidelines for the management of adrenal incidentalomas (AI) put forth by the NIH and AAES/AACE were largely based on studies utilizing old generation CTs. These guidelines recommend adrenalectomy vs observation predominantly based on tumor size. It is unknown whether the classic rates about the incidence of adrenocortical cancer (ACC) based on tumor size apply to the modern series. The objective of this study is to analyze the incidence of ACC in a contemporary series of AI.
RESULTS: Five hundred thirty patients were randomized into 2 groups (HF group, N ¼ 206 (38.86 %) LSJ instrument group, N ¼ 324(61.13 %)). Seven (2.16%) LSJ patients developed transient postoperative hypocalcaemia compared to 17 (8.25%) patients in HF group (p 0.002). Operative times were not significantly different (HF 122.4 46.94 min vs. LSJ 117.8 55.41 min; p ¼ 0.09). The LSJ use was associated with slightly more intraoperative Bood loss when compared to HF (LSJ 17.95 52.38 ml vs HF 15.7517.04 ml; p¼ 0.24). no significant difference in rate of transient laryngeal nerve injury between both groups (LSJ: 3.70% vs HF: 5.34%; p¼ 0.39. Overall postoperative complications rate was similar (LSJ: 15.17% vs HF 20.90%; p¼ 0.11).
METHODS: All patients who presented to Cleveland Clinic between 1992 and 2015 with a diagnosis of adrenal disorders (15,000 patients) were reviewed from a hospital electronic medical record database. The patients with AI were identified. This study reports an interim analysis of the first 10,000 patients reviewed.
CONCLUSIONS: Both LigasureÔ and HarmonicÒ procedures provide surgeons ergonomics and no significant differences were shown in operative time and rate of complications. However there is a trend for transient postoperative hypocalcemia in patients operated using HF compared to those with LSJ.
RESULTS: Out of 10,000 patients, 3269 patients met the criteria for AI. Hormonal workup demonstrated pheochromocytoma in 6%, primary hyperaldosteronism in 4.2% and Cushing’s syndrome in 3.5%. Four hundred fifteen patients underwent adrenalectomy. The incidence of ACC for tumors less than 4 cm was 3.7%, for tumors 4-6 cm, 4.1%, and for tumors > 6 cm, 21.1%.
Fusion Imaging: Optimal Localization for Ectopic Parathyroid Adenoma Phillip K Pellitteri, DO, James Biery Guthrie Clinic, Sayre, PA, Geisinger Medical Center, Danville, PA INTRODUCTION: Parathyroidectomy enjoys a success rate in excess of 95% for definitive cure of primary hyperparathyroidism. Approximately 10% of patients will exhibit the presence of parathyroid gland(s) in a verified ectopic location. Targeted surgery requires accurate localization. This discussion presents a dual institutional experience utilizing computed tomographyeTc99m fusion imaging with or without SPECT/CT for identification and accurate localization of ectopic parathyroid glands in patients undergoing neck exploration for primary hyperparathyroidism.
CONCLUSIONS: This interim analysis represents one of the largest contemporary analyses on the incidence of ACC in AIs. The results show that if non-operative patients with stable tumors are also accounted for, the incidence of ACC across tumor sizes is less than currently reported in the guidelines. We believe that a complete analysis of our data will generate a more accurate incidence of ACC and provide for modern recommendations in the management of AI. Comparing the Efficacy and Surgical Outcomes of HarmonicÒ Scalpel vs LigaSureÔ Small Jaw in Thyroid and Parathyroid Surgery. Taha A Hassoon, MD, Fadi Murad, Daniah Bu Ali, MD, Muhammad Anwar, MBBS, Roostam Kholmatov, MD, Zaid Al-Qurayshi, MD, Rizwan Aslam, Emad Kandil, MBBCh, FACS Tulane Medical School-Tulane University, New Orleans, LA
METHODS: A retrospective review of patients undergoing exploration for primary hyperparathyroidism at 2 academic tertiary care institutions over a 7-year period (2008-2015) was conducted. The primary objective of the study was to evaluate the localization of ectopic parathyroid glands utilizing fusion imaging and correlate the accuracy of these results with surgical findings at exploration.
INTRODUCTION: Location and rich vascularity of thyroid gland poses a challenge for a surgeon to achieve good hemostasis and minimize postoperative complications. This study aims to compare LSJ vs HF in terms of operative time, intraoperative blood loss, RLN injury, and postoperative complications.
RESULTS: Fifty-nine ectopic parathyroid glands were identified: 9 within the mediastinum, 21 within the thymus, 5 in an undescended location above the superior pole of the thyroid gland, 13 in a true retro-esophageal location and 11 within the thyroid parenchyma. Fusion imaging accurately identified the location of 54 of 59 ectopic glands, including all glands located in mediastinal, undescended, and thymic locations. Imaging failed to identify 3 intra-thyroidal glands and 2 glands in retro-esophageal locations.
METHODS: This study was conducted under IRB approved protocol to compare efficacy of LSJ vs the HF. We evaluated (530) patients who underwent surgery by a surgeon at a North American
e95
http://dx.doi.org/10.1016/j.jamcollsurg.2016.08.240 ISSN 1072-7515/16
e96
Scientific Poster Presentations: 2016 Clinical Congress
Imaging results altered the approach to exploration for glands localized to mediastinal and undescended locales. CONCLUSIONS: CTeMIBI fusion imaging represents an effective localization modality for identification of ectopic parathyroid glands, determining candidacy for, and capability of a targeted surgical approach in patients with primary hyperparathyroidism. Impact of Micro- and Macroscopically Positive Surgical Margins on Survival after Resection of Adrenocortical Carcinoma Kevin L Anderson, Linda M Youngwirth, MD, Sanziana A Roman, MD, Julie A Sosa, MD, FACS Duke University School of Medicine, Durham, NC INTRODUCTION: Adrenocortical carcinoma (ACC) is a rare, aggressive cancer; complete surgical resection offers the best chance for long-term survival. The impact of surgical margin status on survival is poorly understood. Our objective was to determine the association of margin status with overall survival (OS). METHODS: Patients with ACC were identified from the National Cancer Data Base, 1998-2012, and stratified based on surgical margin status (negative vs microscopically positive vs macroscopically positive [+]). Univariate/multivariate regression/survival analysis was utilized to determine factors associated with margin status and OS. RESULTS: A total of 1,763 patients underwent surgery at 625 institutions: 88% had negative, 10% microscopic, and 2% macroscopic(+) margins. Those with micro(+) and macro(+) margins received more adjuvant chemotherapy (33% micro(+) vs 33% macro(+) vs 22% negative margins, p¼0.005). Distant metastases were seen more often in patients with positive margins (15% micro(+) vs 24% macro(+) vs 7% negative margins, p0.02). In unadjusted analysis, there was a significant difference in OS between the groups (p<0.0001), with median survival times of 62 months (IQR 19-176) for those with negative margins, 21 months (IQR 8-68) micro(+), and 7 months (IQR 2-26) macro(+) margins. After adjustment, both micro(+) [HR 1.96, p<0.0001] and macro(+) [HR 1.81, p<0.0001] margin status were associated with compromised survival. Use of chemotherapy was an independent predictor of compromised overall survival (HR 1.52, p<0.0001). CONCLUSIONS: Having either micro- or macroscopically positive margin status after ACC resection is associated with compromised survival. These results underscore the importance of achieving negative surgical margins for optimizing long-term patient outcomes. Laparoscopic Adrenalectomy for Metastatic Disease: Prospective Case Series from a High- Volume Center Frederick T Drake, MD, MPH, Toni M Beninato, MD, Maggie X Xiong, Nirav Shah, Wouter P Kluijfhout,
J Am Coll Surg
Insoo Suh, MD, FACS, Jessica E Gosnell, MD, FACS, Wen T Shen, MD, FACS, Quan-Yang Duh, MD, FACS University of California-San Francisco, San Francisco, CA INTRODUCTION: Several malignancies are known to metastasize to the adrenal gland, especially non-small cell lung cancer, renal cell carcinoma (RCC), and melanoma. Several small series have investigated both open and laparoscopic adrenalectomy (LA) in the management of adrenal metastases, and, among appropriately selected patients this has been shown to improve survival compared to nonoperative management alone. A minimally invasive approach remains somewhat controversial. METHODS: Our institution has prospectively maintained a patient registry for all adrenalectomies since 1993. Through February 2016, 41 patients underwent adrenalectomy for metastatic disease. Primary endpoints of interest were complications and median survival. Descriptive results including demographics, primary cancer, tumor size, and operative approach were also generated. RESULTS: Forty-one adrenalectomies were performed for metastatic disease. In all but one case (synchronous RFA of hepatocellular carcinoma and LA), the indication was resection after definitive treatment of a primary lesion. There were no deaths within a 30-day period. Four patients suffered complications, including 1 patient who required take back for a retroperitoneal hematoma. There was 1 conversion to open. Two patients had bilateral adrenalectomies. NSCLC (N ¼ 11), melanoma (N ¼ 9), and RCC (N¼8) were the 3 most common adrenal metastases treated by surgery. In this series, median survival after adrenalectomy for RCC was 34 months, for NSCLC was 23 months, and for melanoma was 16 months. CONCLUSIONS: LA for metastases is safe when performed by experienced surgeons. Among the 3 most common primary cancer types, there was an association with survival: RCC was improved over NSCLC, which was improved over melanoma. Laparoscopic and Open Adrenalectomy Performed for Malignant Adrenal Tumors: An Analysis of the American College of Surgeons NSQIP Database Monica Jain, MD, Edward H Phillips, MD, FACS, Miguel A Burch, MD, FACS, Daniel Shouhed, MD, Rodrigo F Alban, MD, FACS Cedars-Sinai Medical Center, Los Angeles, CA INTRODUCTION: There is controversy regarding the optimal surgical approach to malignant adrenal tumors because of differing outcomes in retrospective series and the lack of randomized trials. Consequently, an analysis of non-oncologic outcomes was undertaken to study laparoscopic (LA) and open (OA) adrenalectomy for malignant disease. METHODS: The American College of Surgeons NSQIP database was queried from 2010-2014 to identify LA and OA performed for