Endocrine papers

Value of serum thyroglobulin measurement in patients operated on for well differentiated thyroid carcinoma. Ruter A, Smeds S, Lennquist S. Eur J Surg 1998; 164: 665-671.

Thyroglobulin is a protein synthesized by the thyroid follicles of both benign and malignant thyroid tissue. Under physiological conditions only small amounts can be detected in the serum. Both benign and malignant thyroid neoplasms can result in increased serum thyroglobulin levels. After total thyroidectomy levels should fall to undetectable levels if no thyroid or neoplastic tissue remains. The aim of this study was to assess the value of measuring thyroglobulin concentrations in the detection of recurrent carcinomas in a series of patients undergoing total thyroidectomy. In total, 194 patients with well differentiated thyroid cancer were operated on over a 15 year period. Of these patients, 181 were followed up by a standard protocol with regular thyroglobulin assessments. Six patients had increasing levels that lead to the detection and successful treatment of recurrent disease. Six patients had rising levels without signs of recurrence. Twelve patients had persistently high levels presumed to be due to persistence of disease. No clinical evidence of recurrence was seen without an increase in serum thyroglobulin. It was concluded that serum thyroglobulin is valuable in the follow up of patients with well differentiated thyroid cancer and that increasing serum levels are often the first sign of recurrence.

Natural course of adrenal incidentalomas: seven-year follow-up study. Siren J, Tervahartiala P, Sivula A, Haapiainen R. World J Surg 2000; 24: 579-582.

Adrenal tumours are identified as an incidental finding during approximately 1% of abdominal CT scans. Most adrenal 'incidentalomas' are non-functioning cortical adenomas and need no surgical intervention. No consensus exists regarding their management but few surgeons would offer surgery for incidentalomas less than 5 cm in diameter. Surgery is however indicated if the tumours shows radiological features of malignancy, are hormonally active or rapidly increase in size. This study was a retrospective study of 30 adrenal incidentalomas identified in 27 patients between 1981 and 1992. Patients were invited to be re-examined in 1997. The mean follow-up was 7 years. Two patients refused and 9 had died from unrelated causes. Sixteen patients underwent clinical, radiological and hormonal assessment. Hormonal evaluation involved a low-dose dexamethasone suppression test, 24-hour urinary catecholamine metabolite excretion and serum potassium. MRI scanning was used to measure the tumour size. In none of the patients were there clinical or radiological features of malignancy. No tumour showed hormonal activity. It was concluded that adrenal incidentalomas were slow growing and hormonally inactive and that conservative management was justified.

Medullary thyroid cancer: multivariate analysis of prognostic factors influencing survival. Hyer S L, Vini L, A'Hern A, Harmer C. Eur J Surg Oncol 2000; 26: 686-690.

Medullary thyroid carcinoma (MTC) is a rare tumour arising from the parafollicular C cells of the thyroid gland. It accounts for between 5 and 10% of all thyroid malignancies and occurs in both sporadic and familial forms. The familial forms can occur alone or as part of the multiple endocrine neoplasia syndrome (MEN IIa or MEN IIb). As many as 25% of all cases are inherited. The initial surgical treatment usually involves total thyroidectomy often associated with a modified neck dissection. Radiotherapy following surgery may help in the local control of disease. A number of factors have been suggested to influence prognosis such as age, sex, sporadic vs. familial disease and the extent of tumour at presentation, but the relative importance of these factors is unclear. The aim of this study was to assess the long-term results of treatment of MTC and to define prognostic factors. A retrospective analysis of all patients diagnosed with MTC between 1949 and 1998 in a large tertiary referral centre was performed. In total, 162 patients (87 female, 75 male) were identified with 52 (32%) having familial disease. The median follow-up was 9 years (range 2-20 years). The majority of patients (90%) presented with a thyroid mass or cervical lymphadenopathy. Total or subtotal thyroidectomy was performed in 147 patients. Of these patients 45 patients also underwent a neck dissection. Radiotherapy was given to 76 patients with advanced disease present at initial presentation. Overall survival was 72% at 5 years and 56% at 10 years. In multivariate analysis the factors that significantly predicted survival were age at diagnosis, extent of nodal disease, extent of surgery and metastases at presentation. Radiotherapy significantly reduced local relapse in patients with ipsilateral nodal disease. It was concluded that MTC can be associated with prolonged survival. The best prognosis is seen in young patients undergoing total thyroidectomy and neck dissection. External beam radiotherapy significantly reduces local relapse in patients with limited nodal disease.

Effect of primary treatment on survival in anaplastic thyroid carcinoma. Besic N, Auersperg M, Us-Krasovec M, Golouh R, Frkovic-Grazio, Vodnik A. Eur J Surg Oncol 2001; 27: 260-264.

Anaplastic thyroid carcinoma (ATC) is a rare tumour with an invariably poor prognosis irrespective of the treatment modalities used. There is insufficient data in the literature regarding the optimal combination of surgery, radiotherapy and chemotherapy. Some centres perform initial surgery followed by radiotherapy and chemotherapy and vice versa. The aim of this retrospective non-randomised study was to determine whether survival of patients treated by primary surgery followed by chemotherapy and radiotherapy was better than patients having surgery as a secondary treatment modality. Between 1972 and 1998, 162 patients with ATC were treated at the Institute of Oncology in Ljubljana, Slovenia. Overall. 79 patients (26 men, 53 women; mean age 65 years) were included in the study. The 83 patients with distant metastases on admission, with survival shorter than one month or who did not undergo any treatment were excluded. The 79 patients were classified into a primary surgery group (n=26) and a primary chemotherapy or radiotherapy group (n=53), including 12 patients who underwent secondary surgery. The survival of both groups were compared by the log-rank test. In comparison to the primary surgery group, those patients undergoing primary chemotherapy and radiotherapy were older, and had larger and more rapidly growing tumours. There was no difference in survival between the two groups. Survival for greater than one year was seen in 25% patients with primary surgery and 21% of patients with primary chemotherapy and radiotherapy. The best results (50% survival at one year) were obtained in patients in whom the tumour was surgically excised after primary chemotherapy and radiotherapy. It was concluded that timing of the different treatment modalities might have an impact on survival and that treatment should start with chemotherapy and radiotherapy, with surgery to follow if possible.

Impact of timing on completion thyroidectomy for thyroid cancer. Tan M P, Agarwal G, Reeve T S, Barraclough B H, Delbridge L W. Br J Surg 2002: 89: 802-804.

Completion thyroidectomy plays an important role in the management of patients with thyroid cancer. Although one-stage total thyroidectomy is preferable, the characteristics of certain types of thyroid cancer, particular follicular lesions, renders the preoperative and intraoperative diagnosis of malignancy a challenge. This situation often necessitates a second operation. Completion thyroidectomy carries an inherent risk of complications which has been reported to be higher than that of the primary operation. It is thought that the timing of reoperation is a contributory factor and that completion thyroidectomy should be undertaken either within 10 days of the initial lobectomy or only after 3 months. To date there is no published data to support this argument. The aim of this study was to review the impact of timing of follow-up surgery on the rate of complications following completion thyroidectomy. Data were obtained retrospectively from a thyroid database to which the records of all patients had been entered since 1957. A group of patients who had the last 100 consecutive completion thyroidectomies for thyroid cancer comprised the study group. Overall, 66 patients had their second operation performed within 10 days or more than 90 days after the initial operation (Group 1). The other 37 patients had reoperation between 10 and 90 days after the first procedure (Group 2). One patient in Group 1 and one patient in Group 2 suffered a permanent complication. It was concluded that there was no definite impact of the timing of surgery on the rate of complications after completion thyroidectomy.

Extracorporeal shockwave lithotripsy in the management of salivary calculi. Escudier M P, Brown J E, Drage N A et al. Br J Surg 2003; 90: 482-485

The submandibular gland is the commonest site for the formation of salivary gland calculi. Over 80% of stones are found in this gland compared with 10% in the parotid and less than 5% in the sublingual and other minor salivary glands. Approximately 40% of submandibular stones lie in the distal portion of the duct and can be removed by simple intraoral procedures performed under local anaesthesia. For calculi that lie in the proximal duct or gland the treatment of choice has been sialoadenectomy. The role of extracorporeal shock lithotripsy is in the management of salivary calculi is at present unclear. The aim of this study was to assess the safety and efficacy of the technique in patients who would otherwise would have required sialoadenectomy for proximal duct or intraglandular calculi. Overall, 122 salivary calculi (84 submandibular and 38 parotid) were treated using a sialolithotriptor. Complete success was achieved in 40 (33%) procedures. This consisted of 27 of 84 submandibular and 13 of 38 parotid calculi, respectively. A further 43 (35%) were rendered asymptomatic although some stone debris remained in the duct. Failure (retention of stone debris and continued symptoms) occurred in 39 (32%) patients. The chance of failure increased with the size of the calculus and increasing duration of symptoms. It was concluded that extracorporeal shockwave lithotripsy may provided a useful option for the management of salivary calculi, particularly for stones less than 7mmm in diameter.

Phaeochromocytoma - views on current management. Williams D T, Dann S, Wheeler M H. EJSO 2003; 29: 483-490.

Phaeochromocytomas are functioning tumours of chromaffin cells. They produce catecholamines and most (more than 80%) occur in the adrenal medulla. The remainder occur in the extra-adrenal paraganglionic system which extends from the pelvis to the base of the skull. Tumours can be multiple and bilateral. Multiple, bilateral and extra-adrenal tumours are more common in children. The aim of this study was to evaluate the investigation and management of phaeochromocytomas in a tertiary referral centre. Overall, 47 patients (24 female, 23 male) were studied. Preoperative diagnosis was established by measurement of urinary catecholamines (HMMA, metadrenalines and fractionated catecholamines). Tumours localisation was achieved by ultrasound, CT, MRI and MIBG scanning. Preoperative medical preparation and control of hypertension was achieved in the majority of cases alpha-adrenergic blockade with phenoxybenzamine and beta-blockade with propanolol. Surgery was performed by a variety of approaches including laparotomy, posterior extracapsular approach and laparoscopic methods. Overall, 70% presented with hypertension but on 21% gave a history of paroxysmal hypertension. CT scanning and MRI proved to be the most sensitive localisation method. Excellent preoperative control of hypertension was achieved but induction of anaesthesia, rather than handling of the tumour, was noted to be associated with most hypertensive surges in blood pressure. There was no postoperative mortality but 10 complications occurred in 8 patients. Cure of hypertension was achieved in 80% of patients. Attempts to perform cortex-sparing procedures in patients with familial disease and multiple tumours was not successful in the long term. It was concluded that surgical excision of phaeochromocytoma can be performed with zero mortality, low morbidity and a high cure rate of hypertension. Adequate preoperative pharmacological control of hypertension is mandatory. Localisation techniques permit a focussed approach with increasing use of laparoscopy. For an optimum and satisfactory outcome a planned multidisciplinary approach is required.

Comparison of completion thyroidectomy and primary surgery for differentiated thyroid carcinoma. Erdem E, Gulcelik M A, Kuru B et al. EJSO 2003; 29: 747-749.

Disagreement exists regarding the extent of surgical treatment for differentiated thyroid carcinoma. Total thyroidectomy may be the treatment of choice as completion thyroidectomy may carry a significant risk of complications including hypoparathyroidism and recurrent laryngeal nerve palsy. The aim of this study was to report complication rates of completion thyroidectomy after primary surgery and to examine the outcomes of completion thyroidectomy for differentiated thyroid cancer. The outcomes of patients with differentiated thyroid cancer who were operated on over an eight year period were evaluated. Overall, 141 patients underwent completion thyroidectomy and 92 had primary total thyroidectomy. The two groups were comparable in respect to clinical variables. Residual tumour was found in 66 of the 141 patients (47%) undergoing completion thyroidectomy. The rate of the two most important complications, permanent recurrent laryngeal nerve palsy and permanent hypoparathyroidism were 3.5% and 4.2% in the completion thyroidectomy group and 3.3 and 4.3% in the primary thyroidectomy group. The complication rates were not significantly different between the groups. It was concluded that completion thyroidectomy can be performed safely in specialised centre with acceptable morbidity rates.