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Parathyroid Hormone Deficiency after Total Thyroidectomy: Incidence and Time to Resolution
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ASSOCIATION FOR ACADEMIC SURGERY AND SOCIETY OF UNIVERSITY SURGEONS
AUS (n 40), 34 were node negative on final pathology, while 6 were node positive. All 6 patients with node positive disease had a positive marker profile. Of 34 patients with node negative disease, 31 (91%) had a negative marker profile, while 3 (9%) had a positive marker pro file. In patients with a ‘‘suspicious’’ AUS (n 40), 28 (70%) had positive cytopathology and histopathology. Twenty three of 28 also had a posi tive marker profile, while 5 patients had a negative marker profile. Twelve of 40 patients with ‘‘suspicious’’ AUS (30%) had negative cyto pathology. Five were node positive on final pathology; 4 had a positive marker profile and 1 had a negative marker profile. Seven patients were node negative on final pathology; 2 had a positive marker profile and 5 had a negative marker profile. Mean size of lymph node metasta sis detected by the panel was 7.2 mm (range 3 mm 1.7 cm). A positive marker profile was associated with traditional indicators of prognosis, including histologic grade, estrogen and progesterone receptor and Her2neu status, and increasing tumor size (p < 0.05 for each). The overall sensitivity and specificity of AUS, FNAB, and RT PCR in pre dicting the final histopathologic status of the axilla was 85% and 88%, respectively. Conclusion: This is the first report to demonstrate that real time RT PCR analysis of FNAB specimens is feasible in pre dicting the final lymph node status in patients with clinically node neg ative breast cancer. Over expression of breast cancer associated genes correlates with traditional indicators of disease prognosis.
11.3. Surgical Care for Thyroid Cancer in Elderly Americans. S. A. Porter,1 A. A. Gawande,2 S. R. Lipsitz,2 C. M. Weeks,2 B. Neville,3 H. In,3 A. K. Jha,4 J. C. Weeks,3 C. C. Greenberg2; 1 Harvard Medical School, Boston, MA; 2Brigham and Women’s Hospital, Boston, MA; 3Dana Farber Cancer Institute, Boston, MA; 4Harvard School of Public Health, Boston, MA Background: In 1996, the American Thyroid Association recommen ded total thyroidectomy for papillary thyroid cancer 1.5 cm. Several recent studies have confirmed a survival advantage with this proce dure. The difference in morbidity between total thyroidectomy and less extensive resections is minimal. We sought to evaluate what per cent of elderly Americans are getting appropriate surgical care for thyroid cancer and the degree of institutional variation in perfor mance. Methods: Using SEER Medicare data we identified 1,196 pa tients who underwent surgery for papillary thyroid cancers that were 1.5 cm or node positive and were diagnosed between 2000 and 2005. We calculated the overall proportion of patients receiving total thy roidectomy in this five year period. We also examined the distribution of performance across institutions. Finally, we identified patient and institutional factors associated with receiving appropriate care. Results: From 2000 to 2005, 90.7% of patients received total thyroid
ABSTRACTS
ectomy. The distribution of performance for the 74 institutions that performed 5 or more thyroid surgeries is shown in Figure 1. Only 43% of hospitals performed appropriate surgery on all patients, but all institutions performed total thyroidectomy on at least 60%. On bi variate analysis, rates were higher among patients treated at NCI comprehensive cancer centers (96% v. 90%, p 0.02), hospitals par ticipating in an oncology cooperative group (92% v. 87%, p 0.01), ur ban hospitals (91% v. 84%, p 0.03), and teaching hospitals (93% v. 87%, p 0.0009). Living in a lower income area was associated with a lower likelihood of receiving total thyroidectomy (p 0.0001). There was no association with other patient characteristics. Conclusions: Over 90% of Medicare patients currently receive total thyroidectomy for papillary thyroid cancer. While the majority of hospitals still failed to perform this procedure in all of their elderly patients, a rate of 100% was attained at 43% of hospitals and is therefore an achievable goal. Much of the variation seems to be at the institution level, suggesting that structural and provider factors, rather than patient mix, are re sponsible for the deficiencies in care. 11.4. Parathyroid Hormone Deficiency after Total Thyroidectomy: Incidence and Time to Resolution. L. Youngwirth, J. Benavidez, R. Sippel, H. Chen; University of Wisconsin, Madison, WI Introduction: Parathyroid hormone (PTH) deficiency or hypopara thyroidism after total thyroidectomy is not an uncommon post opera tive complication. Patients who have PTH deficiency will develop profound hypocalcemia if not properly treated with oral calcium sup plementation and activated vitamin D (calcitriol). However, there is little published on the long term outcomes of these patients. The aim of this study was to determine the incidence of PTH deficiency and the time course to resolution after total thyroidectomy. Methods: We identified 271 consecutive patients who underwent total thyroid ectomy from January 2006 to December 2008. All patients had serum PTH levels tested four hours after surgery and the morning after sur gery. Patients were diagnosed with PTH deficiency if their serum PTH was <10 pg/mL. The outcomes of patients with PTH deficiency (Group 1) were then compared to patients who did not have PTH de ficiency (Group 2). Patients in Group 1 were evaluated for parathyroid function by measuring serum PTH levels as well as documenting us age of supplemental calcium and calcitriol. Results: Of the 271 pa tients, 33 (12%) were found to have PTH deficiency. In comparing PTH deficient patients (Group 1) to patients in Group 2, there were no differences in age, gender, thyroid pathology, the incidence of thy roiditis, or other factors which would predict the development of PTH deficiency post operatively. Of the 33 patients in Group 1, 24 (73%) pa tients had recovery of their PTH levels to 10 pg/mL at their one week follow up appointment while 9 (27%) patients still had PTH levels <10 pg/mL. With long term follow up, 27 (82%) patients had recovered with a PTH level of 10 pg/mL while 6 (18%) patients had a serum PTH level <10 pg/mL. However, 3 (9%) required long term calcitriol. Conclusions: We concluded that approximately 12% of patients un dergoing total thyroidectomy will develop PTH deficiency. Of the PTH deficient patients, 73% will return to normal parathyroid function within one week of surgery. Furthermore, 82% of these PTH deficient patients will return to normal parathyroid function with long term follow up. Only 1% of patients undergoing total thyroidectomy will re quire calcitriol for long term hypocalcemia.
11.5. Prior Radiation Is Not a Contraindication to Minimally Invasive Parathyroidectomy. R. Rahbari,1 I. G. Sansano,2 D. M. Elaraj,3 Q. Duh,2 O. H. Clark,2 E. Kebebew1; 1National Cancer Institute, Bethesda, MD; 2University of Callifornia San Francisco, San Francisco, CA; 3Northwestern University Feinberg School of Medicine, Chicago, IL Introduction: Most patients with primary hyperparathyroidism (PHPT) can have a minimally invasive parathyroidectomy based on
ASSOCIATION FOR ACADEMIC SURGERY AND SOCIETY OF UNIVERSITY SURGEONS
AUS (n 40), 34 were node negative on final pathology, while 6 were node positive. All 6 patients with node positive disease had a positive marker profile. Of 34 patients with node negative disease, 31 (91%) had a negative marker profile, while 3 (9%) had a positive marker pro file. In patients with a ‘‘suspicious’’ AUS (n 40), 28 (70%) had positive cytopathology and histopathology. Twenty three of 28 also had a posi tive marker profile, while 5 patients had a negative marker profile. Twelve of 40 patients with ‘‘suspicious’’ AUS (30%) had negative cyto pathology. Five were node positive on final pathology; 4 had a positive marker profile and 1 had a negative marker profile. Seven patients were node negative on final pathology; 2 had a positive marker profile and 5 had a negative marker profile. Mean size of lymph node metasta sis detected by the panel was 7.2 mm (range 3 mm 1.7 cm). A positive marker profile was associated with traditional indicators of prognosis, including histologic grade, estrogen and progesterone receptor and Her2neu status, and increasing tumor size (p < 0.05 for each). The overall sensitivity and specificity of AUS, FNAB, and RT PCR in pre dicting the final histopathologic status of the axilla was 85% and 88%, respectively. Conclusion: This is the first report to demonstrate that real time RT PCR analysis of FNAB specimens is feasible in pre dicting the final lymph node status in patients with clinically node neg ative breast cancer. Over expression of breast cancer associated genes correlates with traditional indicators of disease prognosis.
11.3. Surgical Care for Thyroid Cancer in Elderly Americans. S. A. Porter,1 A. A. Gawande,2 S. R. Lipsitz,2 C. M. Weeks,2 B. Neville,3 H. In,3 A. K. Jha,4 J. C. Weeks,3 C. C. Greenberg2; 1 Harvard Medical School, Boston, MA; 2Brigham and Women’s Hospital, Boston, MA; 3Dana Farber Cancer Institute, Boston, MA; 4Harvard School of Public Health, Boston, MA Background: In 1996, the American Thyroid Association recommen ded total thyroidectomy for papillary thyroid cancer 1.5 cm. Several recent studies have confirmed a survival advantage with this proce dure. The difference in morbidity between total thyroidectomy and less extensive resections is minimal. We sought to evaluate what per cent of elderly Americans are getting appropriate surgical care for thyroid cancer and the degree of institutional variation in perfor mance. Methods: Using SEER Medicare data we identified 1,196 pa tients who underwent surgery for papillary thyroid cancers that were 1.5 cm or node positive and were diagnosed between 2000 and 2005. We calculated the overall proportion of patients receiving total thy roidectomy in this five year period. We also examined the distribution of performance across institutions. Finally, we identified patient and institutional factors associated with receiving appropriate care. Results: From 2000 to 2005, 90.7% of patients received total thyroid
ABSTRACTS
ectomy. The distribution of performance for the 74 institutions that performed 5 or more thyroid surgeries is shown in Figure 1. Only 43% of hospitals performed appropriate surgery on all patients, but all institutions performed total thyroidectomy on at least 60%. On bi variate analysis, rates were higher among patients treated at NCI comprehensive cancer centers (96% v. 90%, p 0.02), hospitals par ticipating in an oncology cooperative group (92% v. 87%, p 0.01), ur ban hospitals (91% v. 84%, p 0.03), and teaching hospitals (93% v. 87%, p 0.0009). Living in a lower income area was associated with a lower likelihood of receiving total thyroidectomy (p 0.0001). There was no association with other patient characteristics. Conclusions: Over 90% of Medicare patients currently receive total thyroidectomy for papillary thyroid cancer. While the majority of hospitals still failed to perform this procedure in all of their elderly patients, a rate of 100% was attained at 43% of hospitals and is therefore an achievable goal. Much of the variation seems to be at the institution level, suggesting that structural and provider factors, rather than patient mix, are re sponsible for the deficiencies in care. 11.4. Parathyroid Hormone Deficiency after Total Thyroidectomy: Incidence and Time to Resolution. L. Youngwirth, J. Benavidez, R. Sippel, H. Chen; University of Wisconsin, Madison, WI Introduction: Parathyroid hormone (PTH) deficiency or hypopara thyroidism after total thyroidectomy is not an uncommon post opera tive complication. Patients who have PTH deficiency will develop profound hypocalcemia if not properly treated with oral calcium sup plementation and activated vitamin D (calcitriol). However, there is little published on the long term outcomes of these patients. The aim of this study was to determine the incidence of PTH deficiency and the time course to resolution after total thyroidectomy. Methods: We identified 271 consecutive patients who underwent total thyroid ectomy from January 2006 to December 2008. All patients had serum PTH levels tested four hours after surgery and the morning after sur gery. Patients were diagnosed with PTH deficiency if their serum PTH was <10 pg/mL. The outcomes of patients with PTH deficiency (Group 1) were then compared to patients who did not have PTH de ficiency (Group 2). Patients in Group 1 were evaluated for parathyroid function by measuring serum PTH levels as well as documenting us age of supplemental calcium and calcitriol. Results: Of the 271 pa tients, 33 (12%) were found to have PTH deficiency. In comparing PTH deficient patients (Group 1) to patients in Group 2, there were no differences in age, gender, thyroid pathology, the incidence of thy roiditis, or other factors which would predict the development of PTH deficiency post operatively. Of the 33 patients in Group 1, 24 (73%) pa tients had recovery of their PTH levels to 10 pg/mL at their one week follow up appointment while 9 (27%) patients still had PTH levels <10 pg/mL. With long term follow up, 27 (82%) patients had recovered with a PTH level of 10 pg/mL while 6 (18%) patients had a serum PTH level <10 pg/mL. However, 3 (9%) required long term calcitriol. Conclusions: We concluded that approximately 12% of patients un dergoing total thyroidectomy will develop PTH deficiency. Of the PTH deficient patients, 73% will return to normal parathyroid function within one week of surgery. Furthermore, 82% of these PTH deficient patients will return to normal parathyroid function with long term follow up. Only 1% of patients undergoing total thyroidectomy will re quire calcitriol for long term hypocalcemia.
11.5. Prior Radiation Is Not a Contraindication to Minimally Invasive Parathyroidectomy. R. Rahbari,1 I. G. Sansano,2 D. M. Elaraj,3 Q. Duh,2 O. H. Clark,2 E. Kebebew1; 1National Cancer Institute, Bethesda, MD; 2University of Callifornia San Francisco, San Francisco, CA; 3Northwestern University Feinberg School of Medicine, Chicago, IL Introduction: Most patients with primary hyperparathyroidism (PHPT) can have a minimally invasive parathyroidectomy based on