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Medullary Thyroid Cancer: Are Practice Patterns in the U.S. Discordant from ATA Guidelines?
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ASSOCIATION FOR ACADEMIC SURGERY AND SOCIETY OF UNIVERSITY SURGEONS—ABSTRACTS
thyroidectomies, primarily in women (11.7% male). From these 253, 27% had a final pathologic diagnosis of cancer (81.7% papillary, 11% follicular, and 3.6% medullary or Hurthle cell). No relationship between gender and tumor status was noted (p ¼ 0.17), though women presented with tumor approximately 8 years earlier than men (p ¼ 0.002). Complications were infrequent (3.56%) and were not related to tumor status (p ¼ 0.72). Twelve percent of specimens contained parathyroid tissue. Of those with calcium measurements available (53%), eighty-three percent had transient hypocalcemia; a single patient (1%) had permanent hypocalcemia. Hypocalcemia was not related to tumor status (p ¼ 0.90). The total thyroidectomy rate in this series is higher than that in 1986 (11.8%), the incidence of cancer higher (18% in 1986), and the incidence of transient hypocalcemia the same with that of permanent hypocalcemia lower (4% in 1986). Conclusions: This retrospective study of 291 consecutive thyroid surgeries performed over five years by a single surgeon describes a high rate of transient postoperative hypocalcemia along with a low rate of other complications, comparing favorably with prior studies of thyroid resection including that performed at the same institution more than 20 years ago. The data supports the performance of total thyroidectomy by an experienced surgeon for both benign and malignant disease, as complication rates in each remained low and individual complications were not related to tumor status.
29.16. Medullary Thyroid Cancer: Are Practice Patterns in the U.S. Discordant from ATA Guidelines? B. Panigrahi, C. T. Tuggle, S. Roman, J. A. Sosa; Yale University School of Medicine, New Haven, CT Objective: To benchmark national practice patterns against 2009 American Thyroid Association (ATA) guidelines for medullary thyroid cancer (MTC) regarding use of thyroidectomy, lymphadenectomy, radioactive iodine (RAI), and external beam radiation (EBRT). Background: Surgery is the mainstay of treatment for MTC, with long-term patient outcomes associated with adequacy of resection. Guidelines for the clinical management of MTC have been published by several professional societies. The most comprehensive guidelines were put forth by the ATA in 2009, bringing together evidence-based recommendations and expert opinion. Methods: This is a cross-sectional, retrospective cohort study of MTC patients in the Surveillance, Epidemiology and End Results (SEER) database, 1973-2006. ATA Recommendations 61-66 (extent of surgery), 85 (RAI), and 93 (EBRT) were analyzed. The outcome of interest was practice accordance with these recommendations. Predictors of compliance were identified. c2, ANOVA, Kaplan Meier survival, and multivariate logistic regression analyses were used. Results: 2033 patients with MTC were identified. 59% were women; average age at diagnosis was 52 years (SEM 18 yrs). 78% were white. 16% had additional malignancies. 79% underwent total thyroidectomy, 13% partial thyroidectomy, and 8% had no surgery. 25% had extrathryoidal tumor extension. 19% had tumor size 1 cm, 24% > 1 cm and 2 cm, 37% >2 cm and 4 cm, and 19% >4 cm. 24% had multifocal MTC. Overall 5- and 10-year survival rates were 78% and 68%, respectively, and diseasespecific survival rates were 86% and 80%. 41% of patients did not receive appropriate surgical therapy (Rec. 61-63); patients whose care was out of compliance were diagnosed at an older age (54 vs. 50 yrs, p<.001). Patients who had thyroidectomy in compliance with recommendations had more lymph nodes resected than patients who had partial thyroidectomy (19 vs. 12, p<.01). Patients >65 yrs received less aggressive surgery (p<.001) and had more advanced disease (p<.005) than younger patients; 68% underwent total thyroidectomy, 15% partial thyroidectomy, and 16% had no surgery. 32% had extrathryoidal tumor extension, and 25% had tumor size >4 cm. Most patients with distant metastatic disease were treated appropriately (Recs. 64-66). Patients with distant metastases were older (57 vs. 52 yrs, p<.005), and received more EBRT (p<.001). 4% of patients received inappropriate RAI (Rec. 85). 209 patients had gross incomplete
resections, with 33% receiving postoperative EBRT (Rec. 93). 21 patients received EBRT as primary treatment, 67% of which had distant metastases. Significant predictors of surgery being performed out of accordance with ATA recommendations in multivariate analysis were patient age >65 (OR 3.1, p< .001), female gender (OR 1.5, p<.005), earlier year of diagnosis (1988-1997)(OR 1.7, p<.001), geographic region (p<.005), intrathyroidal tumor extent (OR 2.6, p<.001), and tumor size 1 cm (OR 1.6, p<.05) Conclusion: Variation in practice patterns exist in the U.S. with regard to extent of surgery and lymphadenectomy for MTC. The elderly are more likely to receive care out of compliance with ATA guidelines. Dissemination of standardized guidelines is important to ensure optimal treatment with less variation in quality of care.
29.17. Adrenal Incidentalomas; Does a Thorough Workup Rule Out Surprises? R. H. Grogan, M. R. Vriens, E. J. Mitmaker, I. Suh, A. Harari, J. Gosnell, O. H. Clark, W. T. Shen, Q. Y. Duh; UCSF, San Francisco, CA Background: Adrenal incidentalomas are identified in 1-5% of imaging studies during work-up for non-adrenal disorders. Imaging characteristics, size, and hormonal testing are used to rule-out malignancies or functioning tumors. We review our experience to determine how often we are surprised by the final histopathological outcome after following the current recommendations for work-up. Methods: Between January 1993 and August 2009, 504 patients underwent adrenalectomy at our institution. We retrospectively reviewed our institutional experience with adrenalectomy to identify patients operated on for incidentaloma. Demographics, tumor size, radiographic characteristics, operation type, pre-operative diagnosis, and final histopathology were compared. Results: Sixty-nine (14%) of the 504 patients that underwent adrenalectomy presented initially with an incidental adrenal tumor and had the recommended work up. All sixty-nine patients underwent laparaoscopic adrenalectomy. Of those, forty-eight were diagnosed as a non-functional adenoma and were resected mainly based on size criteria. The fourty-eight patients in the adenoma group were mostly men (50%, p < 0.0001), and their median tumor size was 4 cm. The final pathology were all adrenal cortical adenoma. The other 21 patients had a definitive preoperative diagnosis other than cortical adenoma. More specficially there were 8 pheochromocytomas, 7 cortisol secreting tumors, 2 myelolipomas, 2 ganglioneuromas, and 2 aldosteronomas. There was an equal gender distribution and the median tumor size was 4.5 cm. Postoperative pathological diagnosis differed from preoperative diagnosis in 20%. Median follow-up was 18 months. Conclusion: In a high-volume institute with significant experience with adrenal masses currently recommended work-up accurately differentiates functional from non-functional tumors. However, the pre-operative work-up may not distinguish benign from malignant lesions, and may incorrectly identify the type of tumor. Our findings also raise the question of whether size should remain an indication for adrenalectomy.
29.18. Reduced GFI1 Transcription Factor Expression in Small Intestinal Neuroendocrine Tumor Metastases. E. K. Nakakura, M. Zuraek, D. Donner, E. Bergsland, R. Warren, Y. Wang; UC San Francisco, San Francisco, CA Introduction: Neuroendocrine (NE), or carcinoid, tumors of the small intestine frequently metastasize and produce hormones, such as serotonin, causing significant morbidity and mortality. The molecular events underlying NE tumor progression and hormone production remain largely unknown. The growth factor-independent 1 (GFI1) zinc finger transcription factor is a transcriptional repressor implicated in normal development and cancer. The intestines of Gfi (-/-) mice have increased numbers of endocrine cells. This led us to investigate GFI1 expression in human small intestinal NE tumors in which serotonin
ASSOCIATION FOR ACADEMIC SURGERY AND SOCIETY OF UNIVERSITY SURGEONS—ABSTRACTS
thyroidectomies, primarily in women (11.7% male). From these 253, 27% had a final pathologic diagnosis of cancer (81.7% papillary, 11% follicular, and 3.6% medullary or Hurthle cell). No relationship between gender and tumor status was noted (p ¼ 0.17), though women presented with tumor approximately 8 years earlier than men (p ¼ 0.002). Complications were infrequent (3.56%) and were not related to tumor status (p ¼ 0.72). Twelve percent of specimens contained parathyroid tissue. Of those with calcium measurements available (53%), eighty-three percent had transient hypocalcemia; a single patient (1%) had permanent hypocalcemia. Hypocalcemia was not related to tumor status (p ¼ 0.90). The total thyroidectomy rate in this series is higher than that in 1986 (11.8%), the incidence of cancer higher (18% in 1986), and the incidence of transient hypocalcemia the same with that of permanent hypocalcemia lower (4% in 1986). Conclusions: This retrospective study of 291 consecutive thyroid surgeries performed over five years by a single surgeon describes a high rate of transient postoperative hypocalcemia along with a low rate of other complications, comparing favorably with prior studies of thyroid resection including that performed at the same institution more than 20 years ago. The data supports the performance of total thyroidectomy by an experienced surgeon for both benign and malignant disease, as complication rates in each remained low and individual complications were not related to tumor status.
29.16. Medullary Thyroid Cancer: Are Practice Patterns in the U.S. Discordant from ATA Guidelines? B. Panigrahi, C. T. Tuggle, S. Roman, J. A. Sosa; Yale University School of Medicine, New Haven, CT Objective: To benchmark national practice patterns against 2009 American Thyroid Association (ATA) guidelines for medullary thyroid cancer (MTC) regarding use of thyroidectomy, lymphadenectomy, radioactive iodine (RAI), and external beam radiation (EBRT). Background: Surgery is the mainstay of treatment for MTC, with long-term patient outcomes associated with adequacy of resection. Guidelines for the clinical management of MTC have been published by several professional societies. The most comprehensive guidelines were put forth by the ATA in 2009, bringing together evidence-based recommendations and expert opinion. Methods: This is a cross-sectional, retrospective cohort study of MTC patients in the Surveillance, Epidemiology and End Results (SEER) database, 1973-2006. ATA Recommendations 61-66 (extent of surgery), 85 (RAI), and 93 (EBRT) were analyzed. The outcome of interest was practice accordance with these recommendations. Predictors of compliance were identified. c2, ANOVA, Kaplan Meier survival, and multivariate logistic regression analyses were used. Results: 2033 patients with MTC were identified. 59% were women; average age at diagnosis was 52 years (SEM 18 yrs). 78% were white. 16% had additional malignancies. 79% underwent total thyroidectomy, 13% partial thyroidectomy, and 8% had no surgery. 25% had extrathryoidal tumor extension. 19% had tumor size 1 cm, 24% > 1 cm and 2 cm, 37% >2 cm and 4 cm, and 19% >4 cm. 24% had multifocal MTC. Overall 5- and 10-year survival rates were 78% and 68%, respectively, and diseasespecific survival rates were 86% and 80%. 41% of patients did not receive appropriate surgical therapy (Rec. 61-63); patients whose care was out of compliance were diagnosed at an older age (54 vs. 50 yrs, p<.001). Patients who had thyroidectomy in compliance with recommendations had more lymph nodes resected than patients who had partial thyroidectomy (19 vs. 12, p<.01). Patients >65 yrs received less aggressive surgery (p<.001) and had more advanced disease (p<.005) than younger patients; 68% underwent total thyroidectomy, 15% partial thyroidectomy, and 16% had no surgery. 32% had extrathryoidal tumor extension, and 25% had tumor size >4 cm. Most patients with distant metastatic disease were treated appropriately (Recs. 64-66). Patients with distant metastases were older (57 vs. 52 yrs, p<.005), and received more EBRT (p<.001). 4% of patients received inappropriate RAI (Rec. 85). 209 patients had gross incomplete
resections, with 33% receiving postoperative EBRT (Rec. 93). 21 patients received EBRT as primary treatment, 67% of which had distant metastases. Significant predictors of surgery being performed out of accordance with ATA recommendations in multivariate analysis were patient age >65 (OR 3.1, p< .001), female gender (OR 1.5, p<.005), earlier year of diagnosis (1988-1997)(OR 1.7, p<.001), geographic region (p<.005), intrathyroidal tumor extent (OR 2.6, p<.001), and tumor size 1 cm (OR 1.6, p<.05) Conclusion: Variation in practice patterns exist in the U.S. with regard to extent of surgery and lymphadenectomy for MTC. The elderly are more likely to receive care out of compliance with ATA guidelines. Dissemination of standardized guidelines is important to ensure optimal treatment with less variation in quality of care.
29.17. Adrenal Incidentalomas; Does a Thorough Workup Rule Out Surprises? R. H. Grogan, M. R. Vriens, E. J. Mitmaker, I. Suh, A. Harari, J. Gosnell, O. H. Clark, W. T. Shen, Q. Y. Duh; UCSF, San Francisco, CA Background: Adrenal incidentalomas are identified in 1-5% of imaging studies during work-up for non-adrenal disorders. Imaging characteristics, size, and hormonal testing are used to rule-out malignancies or functioning tumors. We review our experience to determine how often we are surprised by the final histopathological outcome after following the current recommendations for work-up. Methods: Between January 1993 and August 2009, 504 patients underwent adrenalectomy at our institution. We retrospectively reviewed our institutional experience with adrenalectomy to identify patients operated on for incidentaloma. Demographics, tumor size, radiographic characteristics, operation type, pre-operative diagnosis, and final histopathology were compared. Results: Sixty-nine (14%) of the 504 patients that underwent adrenalectomy presented initially with an incidental adrenal tumor and had the recommended work up. All sixty-nine patients underwent laparaoscopic adrenalectomy. Of those, forty-eight were diagnosed as a non-functional adenoma and were resected mainly based on size criteria. The fourty-eight patients in the adenoma group were mostly men (50%, p < 0.0001), and their median tumor size was 4 cm. The final pathology were all adrenal cortical adenoma. The other 21 patients had a definitive preoperative diagnosis other than cortical adenoma. More specficially there were 8 pheochromocytomas, 7 cortisol secreting tumors, 2 myelolipomas, 2 ganglioneuromas, and 2 aldosteronomas. There was an equal gender distribution and the median tumor size was 4.5 cm. Postoperative pathological diagnosis differed from preoperative diagnosis in 20%. Median follow-up was 18 months. Conclusion: In a high-volume institute with significant experience with adrenal masses currently recommended work-up accurately differentiates functional from non-functional tumors. However, the pre-operative work-up may not distinguish benign from malignant lesions, and may incorrectly identify the type of tumor. Our findings also raise the question of whether size should remain an indication for adrenalectomy.
29.18. Reduced GFI1 Transcription Factor Expression in Small Intestinal Neuroendocrine Tumor Metastases. E. K. Nakakura, M. Zuraek, D. Donner, E. Bergsland, R. Warren, Y. Wang; UC San Francisco, San Francisco, CA Introduction: Neuroendocrine (NE), or carcinoid, tumors of the small intestine frequently metastasize and produce hormones, such as serotonin, causing significant morbidity and mortality. The molecular events underlying NE tumor progression and hormone production remain largely unknown. The growth factor-independent 1 (GFI1) zinc finger transcription factor is a transcriptional repressor implicated in normal development and cancer. The intestines of Gfi (-/-) mice have increased numbers of endocrine cells. This led us to investigate GFI1 expression in human small intestinal NE tumors in which serotonin