bluuebunny/crossref_metadata_2025 huggingface dataset:
Partial superior laryngeal nerve (SLN) lesions before and after thyroid surgery
Authors: Jansson Svante , Tisell Lars ‐Erik , Hagne Ingrid , Sanner Esbjörn , Stenborg Rune , Svensson Per
Published: May 2005

The incidence of superior laryngeal nerve (SLN) lesions and their consequences in terms of voice quality was studied in 20 patients undergoing thyroid surgery, performed by surgeons who were not specialists in endocrine surgery. The SLN function was examined by electromyography (EMG) of the cricothyroid muscles before and after surgery. Voice analysis was performed through the registration of the average pitch and range of the speaking voice and the upper pitch limit. The perceptual voice quality was judged by a panel of listeners. Voice problems were registered through a questionnaire. The larynx status was examined by indirect laryngoscopy before and after surgery. Three patients who had not previously been operated on in the neck had partial SLN lesions before surgery. According to the EMG, no SLN at risk developed a complete lesion, but 58% of the SLN's developed partial lesions which persisted 1 year after surgery in all but 1 of the examined patients. Seven of 10 patients with isolated SLN lesions had postoperative voice problems, which had disappeared after 1 year in 4 of them. Standard indirect laryngoscopy failed to diagnose an isolated partial SLN paresis. A significant correlation was found between SLN lesion and a reduction in the average pitch of the speaking voice (p < 0.05). Partial SLN lesions cannot be diagnosed exclusively on voice symptoms and standard indirect laryngoscopy. EMG registrations make a definite diagnosis possible. Measurements of the average pitch of the voice could be used as a noninvasive screening procedure.
Adenylate cyclase activity as a predictor of thyroid tumor aggressiveness
Authors: Siperstein Allan E. , Zeng Qui ‐Hua , Gum Elizabeth T. , Levin Kenneth E. , Clark Orlo H.
Published: May 2005

Prior studies in our laboratory have shown that human thyroid neoplasms have a greater adenylate cyclase activity in response to thyroid stimulating hormone (TSH) than does the adjacent histologically normal thyroid tissue. However, there is little information relating activity of the TSH receptor‐adenylate cyclase system to the type of thyroid neoplasm. Thyroid tissue from 67 patients was divided by clinical and histological criteria into 6 categories: normal (59), benign tumors (20), stage 1 carcinoma—intrathyroidal involvement only (25), stage 2 carcinomaregional lymph node involvement (6), stage 3 and 4 carcinoma—tissue invasion or distant metastasis (11), and medullary carcinoma (3). Adenylate cyclase activity in an 8,000 x g thyroid membrane preparation was determined in the basal state and when maximally stimulated with 300 mU/ml TSH. The cyclase responsiveness was the ratio of TSH stimulated adenylate cyclase activity compared to basal adenylate cyclase activity. The cyclase responsiveness by category is: normal, 2.8±0.2 (mean ± SEM); benign, 17.9±2.4; stage 1 carcinoma, 9.2±1.9; stage 2 carcinoma, 4.0±1.0; stage 3 and 4 carcinoma, 1.6±0.4; and medullary carcinoma, 1.05±0.04 (for the neoplasms,p <0.02 by ANOVA). Tumor stage was the only correlate with this trend as other prognostic risk factors (age, sex, a history of neck irradiation, or papillary versus follicular histology) showed no difference in cyclase responsiveness. These studies demonstrate a consistent inverse correlation between adenylate cyclase responsiveness and tumor stage or aggressiveness. Cyclase responsiveness appears to have clinical application for predicting which thyroid tumors will behave aggressively.
Cervical exploration for suspected primary hyperparathyroidism in renal stone formers: A challenge to the surgeon
Authors: Farnebo Lars ‐Ove , Sandersjöö Gunnar , Granberg Per ‐Ola
Published: May 2005

A retrospective analysis of 579 patients operated on for suspected primary hyperparathyroidism (PHPT) shows that male stone formers are younger, have less hypercalcemia, fewer neuromuscular symptoms, and a higher frequency of parathyroid hyperplasia or normal findings than men without renal stones. On the other hand, female stone formers do not differ from female patients without renal stones with regard to age, degree of hypercalcemia, or preoperative symptoms, but, like the male stone formers, they have a higher frequency of hyperplasia. This circumstance means that female as well as male patients present special problems at cervical exploration.
Guanyl nucleotide regulatory proteins in neoplastic and normal human thyroid tissue
Authors: Clark O. H. , Gum E. T. , Siperstein A. E. , Gerend P. L.
Published: May 2005

Papillary and follicular thyroid neoplasms have been documented to have thyrotropin (TSH) receptors and an intact receptor‐adenylate cyclase (AC) system. The AC response to TSH in most benign and malignant thyroid neoplasms is greater in the neoplasms than in the adjacent normal thyroid tissue. This increased AC response could be due to abnormal amounts of guanyl nucleotide regulatory (G) proteins, to an altered ratio of stimulating to inhibiting G proteins, or to the coupling of the G proteins—to either the receptor or to the catalytic unit of AC. To study why tumors have a greater AC response to TSH, we first extracted the G proteins from normal and neoplastic human thyroid tissue and placed them in membranes from cyclase minus S49 mouse lymphoma cells that lack a stimulating guanyl nucleotide regulatory protein (Gs). These studies demonstrated that there were comparable amounts of guanyl nucleotide regulatory protein in normal and neoplastic thyroid tissue. We next investigated whether there was an alteration in the ratio of inhibiting (Gi) to stimulating (Gs) guanyl nucleotide regulating proteins in thyroid neoplasms. Pertussis toxin (PT) (10 μg/ml) was used to study the activity of the inhibiting G protein since it stimulates AC activity by inhibiting the inhibitory regulatory protein by adenosine diphosphate ribosylating the alpha subunit of the Gi protein. Cholera toxin (CT) (10 ng/ml) was used because it selectively activates the stimulating G proteins. AC activity was determined by the conversion of [α‐32P]ATP to cAMP in pmol/mg protein per 30 minutes. In 11 patients, PT‐stimulated AC levels [8.55±1.7 SEM, (mean±standard deviation)] in normal tissues were higher than basal levels of AC (5.14±0.9,p< 0.01). However, there were no differences in basal and PT‐stimulated levels in neoplastic tissues (6.43±1.0 and 6.87 ±1.8, respectively). This suggests that there is less Gi protein in the neoplasms since the AC response to PT was greater in normal tissues by 170%, but there was no significant stimulation in neoplastic tissues. In contrast, the AC response to CT (10 μg/ml that directly activates the stimulatory guanyl nucleotide regulatory proteins was greater in neoplastic thyroid tissue (174.3±30.1) than in normal thyroid tissue (78.5±16.3) from the same patients (p<0.01).

These experiments demonstrate that most thyroid neoplasms have less Gi and more Gs protein, which probably accounts for the greater AC response to TSH in thyroid neoplasms. The greater stimulation of Gs and the greater AC response in the neoplasms may be one reason for the more rapid growth of benign and malignant thyroid tumors.
Spectrum of pheochromocytoma in the131I‐MIBG era
Authors: Cheung Polly S. Y. , Thompson Norman W. , Dmuchowski Carl F. , Sisson James C.
Published: May 2005

131I‐metaiodobenzylguanidine (131I‐MIBG) scintigraphy allows for both functional diagnosis and anatomical localization of pheochromocytoma. The spectrum of pheochromocytoma since the routine use of preoperative131I‐MIBG scan was studied.

From 1980 to 1986, a total of 34 patients were primarily diagnosed and treated at the University of Michigan Medical Center, Ann Arbor, Michigan, U.S.A. There were 16 males and 18 females. The mean age was 38 years and 4 patients (11.8%) were under 18 years of age. Six patients (17.6%) had family history of pheochromocytoma or multiple endocrine neoplasia (MEN) II syndrome. The presenting symptoms were hypertension in 29 patients (85.3%); attacks of headache, palpitation, sweating, and flushing in 4 (11.8%), and 1 patient presented with a neck mass.

Plasma catecholamines were elevated in 97% of patients while urinary catecholamines and metabolites were elevated in 93.5%.131I‐MIBG was accurate in 82.3%, partly positive in 11.8%, and false‐negative in 5.9% of patients. CT scan was accurate in 80%, partly positive in 10%, but failed to show the tumor in another 10% of patients.

At operation, extraadrenal lesions were found in 38.2% of the patients and among these, one‐third were extraabdominal. Multiple tumors occurred in 5 (14.7%), and bilateral adrenal lesions occurred in 4 patients (11.8%). Malignancy was diagnosed in 3 patients (8.8%) after an average follow‐up period of 2 years.

We conclude that the use of routine preoperative131I‐MIBG scanning improves localization of pheochromocytoma and earlier diagnosis is possible in patients with MEN II syndrome. Multiple tumors, extraadrenal and extraabdominal lesions occur more often than commonly believed. The low rate of confirmed malignancy is probably related to the short period of follow‐up.
When is total thyroidectomy indicated as a treatment of “follicular carcinoma”?
Authors: Yamashita Tomoyuki , Fujimoto Yoshihide , Kodama Takaya , Hirayama Akira , Obara Takao , Ito Yukio , Aiba Motohiko , Kusakabe Kiyoko
Published: May 2005

Clinicopathologic studies were performed to establish rational criteria for total thyroidectomy as a treatment of follicular carcinoma. During the 4‐year period from 1981 to 1984, total thyroidectomy was carried out on 23 patients in whom unequivocal vascular invasion and/or obvious extracapsular extension were disclosed on pathological study of the primary thyroid lesion. Although occult metastatic lesions were detected postoperatively in 5 patients, no distant metastases have been found in 12. Distant metastasis was clinically manifest on admission in the other 6 patients. The degree of vascular invasion at the primary lesion was not correlated with the occurrence of distant metastasis. However, 10 of the 15 patients with tumors characterized by a thick fibrous capsule had distant metastases, while all but 1 of 8 patients with a thin capsule showed no metastasis. Apparent capsular invasion seemed to increase the relative risk of distant metastasis. On the other hand, solid clusters of tumor cells containing a variable number of small follicles, which characterize “Langhans' wuchernde Struma,” were found in 6 patients, and 5 of them showed distant metastases. Thus, total thyroidectomy should be considered when (a) distant metastases are clinically apparent, (b) the primary lesion has a thick fibrous capsule with or without obvious capsular invasion, or (c) solid clusters of tumor cells are demonstrated microscopically.
Familial occurrence of differentiated, nonmedullary thyroid carcinoma
Authors: Ozaki Osamu , Ito Kunihiko , Kobayashi Kaoru , Suzuki Akira , Manabe Yoshitaka , Hosoda Yasuhiro
Published: May 2005

Familial occurrence of differentiated, nonmedullary thyroid carcinoma in 23 patients from 11 families is reported. Five patients were male and 18 were female. The familial relationship of patients was “parent and child” in 12 cases from 6 families, and “siblings” in 11 cases from 5 families. Carcinoma of other organs was noted in other members in 8 families. Histological examination revealed 18 papillary, 2 follicular, and 2 anaplastic carcinomas (the 2 anaplastic carcinomas were considered to be transformed from preexisting differentiated carcinoma). In 1 case, the histological type was unknown. The average diameter of the primary lesion was 29.9 mm. Cervical lymph node metastasis was found in 77.8% and local recurrence in 28.6% of the patients. Solid and invasive growth was dominant. On HLA typing, phenotypes of B7 and DR1 were significantly redominant in familial patients compared with nonfamilial patients and normal Japanese. Moreover, the haplotype of B7‐Cw7‐DR1 was observed in 5 of 13 patients tested.

It is suggested from these observations that some types of differentiated, nonmedullary thyroid carcinoma may show familial occurrence and that they may have common factors with regard to the genetic and immunologic basis of the disease.
Perigraft reaction: Incompatibility of synthetic vascular grafts? new aspects on clinical manifestation, pathogenesis, and therapy
Authors: Paes E. , Vollmar J. F. , Mohr W. , Hamann H. , Brecht‐Krauss D.
Published: May 2005

Perigraft reaction can be defined as an aseptic biological incompatibility of synthetic vascular prostheses. The clinical picture is characterized by an indolent fluctuating swelling around the prosthesis, consisting of sterile fluid surrounded by a fibrous capsule. Since 1979, a total of 22 perigraft reactions in 2,554 implanted vascular grafts were observed and analyzed. The incidence of this complication is about 8/1,000 both for Dacron ® double‐velour and expanded polytetrafluoroethylene (PTFE). Including 306 reports from the literature, prostheses in the extraanatomical position comprise nearly 75% of the material analyzed.

The time interval between graft implantation and clinical manifestation is, on average, 25 months. Although the etiology is still unclear, the pathogenesis is supposed to be multifactorial: (a) there is mechanical trauma due to continuous shifting of the prosthesis in the surrounding tissue (especially in the case of extraanatomic grafts), (b) there is physicochemical irritation of the tissue bed by the graft material (velour surface, organic solvents), and (c) poor incorporation of the graft may lead to periprosthetic gap formation and fluid accumulation around the prosthesis. Infections, or immunologic or allergic causes can be excluded.

Therapy includes total or partial replacement of the affected portion of the graft and cyst wall with substitution by a prosthesis of a different synthetic material. Repeated aspiration of the periprosthetic cyst should be avoided because of the high failure rate and danger of secondary infection.
Extracranial vascular disease: Advances in operative indications and technique
Authors: Imparato Anthony M.
Published: May 2005

Although the major concern in preventing perioperative strokes incident to carotid endarterectomy has been protection of the brain from clamping ischemia, analysis of over 2,000 operative procedures performed in conscious patients in whom vigorous efforts were made to discover the cause of perioperative neurologic deficits revealed that clamping ischemia accounted for 0.5% of the neurologic deficits while rethrombosis of the operative site, cerebral embolization during or immediately postoperatively, and intracerebral hemorrhage each accounted for 0.5%. In a fifth group, the diagnosis was not clear. The total incidence of neurologic cerebral deficits was 2.5% and the incidence varied markedly with the neurologic status of the patient at the time of operation, the condition of the contralateral carotid artery, and the tolerance to clamping ischemia while awake.

Postoperative follow‐up indicates that if operative complication rates can be kept well below 3%, surgical intervention can be expected to favorably alter the natural course of ischemic stroke syndromes.
Factors contributing to success and failure of femorotibial bypass grafts
Authors: Courtney Donal F. , Flinn William R. , McCarthy Walter J. , Yao James S. T. , Bergan John J.
Published: May 2005

Femorodistal bypass grafting is an important technique in the armamentarium of vascular surgeons, and it has been found that the cost of such procedures justifies their performance in patients who have sustained critical ischemia. Graft material remains the most important factor in causation of graft failure, with all prosthetics having disadvantages when compared to the saphenous vein. In attempts to use biological materials, both bovine heterografts and human umbilical vein grafts have been seen to form aneurysms and undergo thrombosis. Meanwhile, many variations on the theme of prosthetic grafts have been tried and found wanting when used as bypasses from the femoral artery to the distal circulation. Among configurations tried have been polytetrafluoroethylene with and without external support; Dacron® in woven and knitted format, with or without internal and external velour; and combinations of these. As patency rates of these reconstructions have proven inferior to others using the saphenous vein, attempts have been made to extend the use of autogenous biologic material. Such attempts have included cephalic vein bypass grafts, short vein bypass grafts originating distal to the femoral artery, deep veins used as grafts, and the in situ bypass. Lately, it has been recognized that the in situ bypass, when compared to concurrent controls, shows no significant advantage to the popliteal level but is the technique of choice when distal anastomoses are at or distal to the midcalf. Compositesequential bypasses represent another technique developed to utilize the autogenous vein as a distal segment. While this has increased the rate of patency of distal bypass grafting, other aids to patency such as use of anticoagulants, antiplatelet agents, and adjunctive arteriovenous fistula have not. Dynamics of the coagulation system show an intrinsic change in patient status toward coagulation in the postoperative period, and although this factor is of some significance in causing early graft thrombosis, technical defects do not seem to play an important part. This review details some of these important causes of graft failure and places them in proper perspective.
The challenge of the middle mediastinal parathyroid
Authors: Curley I. R. , Wheeler M. H. , Thompson N. W. , Grant C. S.
Published: May 2005

In most cases of persistent or recurrent hyperparathyroidism (HPT), the pathological parathyroid (PT) will be in the neck or accessible through the cervical approach, and in only a small percentage will median sternotomy be required. We present 3 cases of persistent HPT where the PT tissue was in the middle mediastinum. We acknowledge that this is a rare occurrence and that it cannot be explained adequately by standard embryological teaching. In cases requiring formal mediastinal exploration, the mediastinal exploration is not complete unless the middle mediastinum is carefully explored to exclude ectopic PT tissue.
Modified neck dissection for patients with nonadvanced, differentiated carcinoma of the thyroid
Authors: Ozaki Osamu , Ito Kunihiko , Kobayashi Kaoru , Suzuki Akira , Manabe Yoshitaka
Published: May 2005

To determine if it is truly unnecessary to perform modified neck dissection in nonadvanced, differentiated thyroid carcinoma, the extent of metastases in regional lymph nodes in 586 patients were studied. Four hundred and fifteen patients (70.8%) underwent neck dissections, and lymph node metastasis was disclosed in 339 cases (81.7%). Of the 78 cases judged as stage N0 during the operation, histological examination revealed metastasis in 34 cases (43.6%). Metastatic nodes were found in the central region in 300 cases (72.3%) and within the jugular region in 278 cases (67.0%). Neck dissections were carried out in 277 of 401 nonadvanced cases and in 138 of 185 advanced cases. In the former, metastasis was disclosed in the central region in 68.6% and within the jugular region in 62.1%. In the latter, on the contrary, the percentages were 79.7% and 76.8%, respectively.

It is evident from these data that it is not reasonable to judge the presence of lymph node metastasis during operation, and that lymph node metastases are found in patients with nonadvanced disease as frequently as in patients with advanced disease. It is suggested that adequate modified neck dissection should be performed even in patients with nonadvanced, differentiated carcinoma of the thyroid.
Prospective comparison of radionuclide, ultrasound, and computed tomography in the preoperative localization of parathyroid glands
Authors: Carmalt Hugh L. , Gillett David J. , Chu John , Evans Richard A. , Kos Susan
Published: May 2005

A total of 51 patients undergoing neck exploration for primary (n=29) or secondary (n=22) hyperparathyroidism were studied by 3 localization techniques: high‐resolution computed tomography (CT) scanning, ultrasonography (US), and thallium‐technetium subtraction scanning (TTS). The accuracy for locating single adenomas was 93% by CT, 88% by US, and 86% by TTS. The sensitivity for each test was 77%, 52%, and 58%, respectively. At surgery, the mean measurement of the long axis of these glands was 20 mm. The accuracy for locating diffusely hyperplastic glands was 37% by CT, 49% by US, and 31% by TTS. The sensitivity was 33%, 50%, and 26%, respectively. The longest axis averaged 11 mm. No advantage was shown by the use of multiple tests.

Our results show that CT is the single most effective localization technique in patients with primary disease; however, in hyperplastic disease, the tests gave such poor results that further studies will be required to develop a technique with acceptable sensitivity.
In situ breast carcinomas: A population‐based study on frequency, growth pattern, and clinical aspects
Authors: Blichert‐Toft M. , Graversen H. P. , Andersen J. , Dyreborg U. , Green A.
Published: May 2005

This study comprises 78 consecutive women, within situ carcinoma of the breast and no evidence of invasion, who were diagnosed and treated surgically from October, 1979 to June, 1986. Lobular carcinoma in situ (LCIS) was found in 30 patients (38%) and ductal carcinoma in situ (DCIS) was identified in 48 patients (62%). The series is a study based in the county of Funen, which has a total female population of 230,028 inhabitants.

Epidemiological calculations were carried out in 5 municipalities in the area of Odense University Hospital with 77,477 female inhabitants 20+ years of age according to a predetermined referral scheme and diagnostic procedures. This sub‐study revealed a frequency of 9.0 cases ofin situ carcinomas per 105 woman‐years and a cumulated risk of 0.53% of havingin situ carcinoma demonstrated within the age range of 20–75 years.In situ lesions made up about 6% of all newly diagnosed breast carcinomas in the region. Furthermore, in about 3% of all breast biopsies and in about 0.3% of all women having mammography due to breast symptoms, anin situ finding was the only malignant change.

Pathoanatomically, a distinction could be made between 3 different growth patterns: microfocal, tumor‐forming, and diffuse growths. Microfocal lesions comprised a major part (60%) of in situ carcinomas. With one exception, the microfocal cases were chance findings in an otherwise benign breast biopsy, whereas the more aggressive growth patterns (tumor‐forming and diffuse) were predominantly clinical and/or mammographic findings, all belonging to the DCIS type. Excisional biopsy or partial mastectomy was performed in 85% of the women with microfocal cases, while such breast preservation procedures were used in only 27% of patients with tumor‐forming or diffuse growths.
Carotid body tumors at high altitudes: Quito, Ecuador, 1987
Authors: Pacheco‐Ojeda Luis , Durango Enrique , Rodriquez Clara , Vivar Nicolas
Published: May 2005

Carotid body tumors seem to be encountered more frequently in people living at high altitudes. Twenty lesions operated in 19 patients at a general hospital in Quito, Ecuador over a period of only 5 years are reported. All patients lived in the highlands of the Andean region. There was no operative mortality, and morbidity was comparable to other series. No malignant cases were found. A higher degree of suspicion to recognize tumors and to operate at an earlier stage of development and thereby diminish operative morbidity is recommended. The great reliability of contrast angiogram and the development of other noninvasive diagnostic techniques is stressed. A study of the incidence of this lesion in the entire country should be made in the future.
Results of adrenal surgery for cushing's syndrome: 10 Years' experience
Authors: Watson Ronald G. K. , van Heerden Jon A. , Northcutt Robert C. , Grant Clive S. , Ilstrup Duane M.
Published: May 2005

Eighty‐nine patients underwent adrenal exploration for Cushing's syndrome at our institution during the period 1970–1979. On the basis of clinical and histological findings related to the initial adrenal operation, patients were divided into 6 major subgroups: (a) adrenocortical adenoma; (b) adrenocortical carcinoma; (c) proven ectopic ACTH adrenocortical hyperplasia; (d) Cushing's disease; (e) uncertain diagnostic group (probably ectopic ACTH syndrome—site unknown); and (f) “non‐ACTH‐dependent” hypercortisolism due to micronodular hyperplasia.

Results of pathologic examination included 25 adrenal adenomas, 15 adrenocortical carcinomas, 40 bilateral adrenocortical hyperplasias, and a single case of micronodular hyperplasia. The postoperative mortality rate was 5.6%, and significant morbidity occurred in 40% of patients. Four of the 5 patients who died within 30 days of operation were in the subgroups with adrenal carcinoma (2 patients) and Cushing's disease (2 patients). Survival in patients with adrenocortical adenomas was significantly decreased at 2 years (relative adrenocortical insufficiency?), but thereafter, it paralleled the expected survival. Patients with the ectopic ACTH syndrome and adrenocortical carcinoma had significantly decreased survival, with only one‐third of carcinoma patients alive 2 years postoperatively. The survival of patients with Cushing's disease was lower than expected at both 5 and 10 years.

These results confirm that the diagnosis of patients with endogenous hypercortisolism is usually straightforward and accurate, surgical intervention in this group of patients is still accompanied by significant short‐term mortality and morbidity, and long‐term survival in all subgroups is decreased.
DNA distribution pattern in intestinal carcinoid tumors
Authors: Cohn Gabriella , Erhardt Kerstin , Cedermark Björn , Hamberger Bertil , Auer Gert
Published: May 2005

The DNA distribution pattern has been suggested to be of prognostic value in several malignant tumors in which diploidy is indicative of low malignancy potential. The present study retrospectively evaluates the DNA content in intestinal carcinoid tumors. The charts of 27 patients treated for carcinoid tumors between 1965 and 1984 were reviewed. Paraffin‐embedded specimens from 22 primary tumors were available. The DNA content in individual cells was measured on histological sections of 4‐μm thickness, according to a cytophotometric method based on light transmission measurements of Feulgen‐stained nuclei. Seventeen tumors were localized to the small intestine, 1 to the appendix, 3 to the colon, and 1 to the rectum. There were 13 men and 9 women with a mean age of 59 years. Nine patients died of disseminated disease, with survival times ranging from 3 to 12 years (median: 5 years). For the 13 living patients, the follow‐up times ranged from 8 months to 16 years and 8 months. All but 1 tumor showed a majority of their nuclear DNA values around the diploid level. One tumor had 87% nondiploid cells and 14% aneuploid cells. The patient underwent a radical operation and is disease free 2 years after surgery. According to this preliminary study, intestinal carcinoid tumors are rarely aneuploid. The patients also had fairly long survival times. Thus, these observations are in agreement with the fact that carcinoid tumors often have a relatively benign course compared to other malignant tumors of the intestinal tract.
Clinical management of persistent and/or recurrent primary hyperparathyroidism
Authors: Grant Clive S. , van Heerden Jon A. , Charboneau J. William , James E. Meredith , Reading Carl C.
Published: May 2005

Persistent or recurrent hypercalcemia following operation for benign hyperparathyroidism (HPT) remains a surgical challenge. From 1978 to 1984 at the Mayo Clinic, 157 patients underwent reexploration. This included 110 cervical, 38 combined cervical and mediastinal, and 9 mediastinal explorations. A total of 197 previous operations (range 1–5) had been performed, including 136 patients for sporadic disease, 14 for multiple endocrine neoplasia, and 7 for familial HPT. Preoperative localizing studies were employed in 137 patients (87%), Cervical ultrasonography had an accuracy of 76% (sensitivity, 82%; positive predictive value, 81%), while mediastinal computed tomography was accurate in 76% (sensitivity, 57%; positive predictive value, 80%). Arteriography, venography, and venous sampling were not used. Guided by high‐resolution, small parts ultrasonography, fine‐needle aspiration biopsy confirmed localization of parathyroid tissue in 3 patients. Successful resolution of hypercalcemia occurred in 139 patients (89%) with a mean follow‐up of 22 months. There were no operative deaths; 12 patients (8%) had temporary neuropraxia of the recurrent laryngeal nerve, 6 patients (4%) suffered permanent unilateral paralysis, and 20 (13%) became permanently hypoparathyroid. Two of 4 hypoparathyroid patients who were autotransplanted with cryopreserved parathyroid tissue have become eucalcemic. The results indicate that the disease site is usually in the neck, that noninvasive localizing techniques have superseded arteriography and venous sampling, and that reoperative parathyroid surgery can be performed with rare mortality and acceptable morbidity. Although these refinements have led to improved success, reoperative parathyroid surgery should not be performed by the occasional parathyroid surgeon.
Bone histomorphometry and serum bone gla‐protein in the diagnosis of primary hyperparathyroidism
Authors: Delmas Pierre D. , Meunier Pierre J. , Faysse E. , Saubier E. C.
Published: May 2005

The diagnosis of primary hyperparathyroidism (PHP) may be difficult, especially in the case of asymptomatic hypercalcemia. Since bone is the major target organ of parathyroid hormone (PTH), the hypersecretion of PTH in patients with PHP can be assessed by bone biopsy and by measured markers of bone turnover. In a first study, a transiliac bone biopsy was performed in 184 patients with surgically proven parathyroid adenoma (159 cases) or parathyroid hyperplasia (25 cases), and quantitative measurements were compared with age‐and sex‐matched controls. In patients with parathyroid adenoma, there was a marked and significant increase of the resorption surfaces, the area of the periosteocytic lacunae, and the osteoid surfaces measured on the trabecular bone. Similar results were found in patients with parathyroid hyperplasia. Only 4 patients (2.2% of cases) had a normal bone biopsy, indicating that bone histomorphometry is a sensitive method for detecting an increase of bone turnover in PHP. However, this method is not specific and does not differentiate between primary and secondary hyperparathyroidism.

In a second study, we measured serum bone gla‐protein (sBGP), also called osteocalcin, which is a new specific marker of bone turnover, in 25 patients with primary hyperparathyroidism: sBGP was increased (14.2±9.6 ng/ml versus 6.2±2.4 ng/ml in controls, p<0.001) and was significantly correlated with serum PTH, serum calcium, and adenoma weight. In the patients who had a simultaneous bone biopsy, sBGP was found to be significantly correlated with the parameters reflecting bone formation. In conclusion, bone histomorphometry and measurement of sBGP are 2 sensitive methods for detecting increased bone turnover in patients with PHP. These methods may be useful for the diagnosis of PHP when other biochemical tests fail.
Current results of conservative surgery for differentiated thyroid carcinoma
Authors: Rossi Ricardo L. , Cady Blake , Silverman Mark L. , Wool Marvin S. , Horner Tia A.
Published: May 2005

From 1961 to 1980 at the Lahey Clinic, 309 patients had initial surgical therapy for differentiated thyroid carcinoma. Review of this experience in comparison with previous decades revealed a progressive increase in the incidence of the disease in men, an increase in less extensive forms of the disease, an increase in use of bilateral subtotal thyroidectomy (77% of patients), the discontinuation of use of prophylactic nodal dissection, and the progressive replacement of radical neck dissections by modified and limited neck dissections. In this series, with a median follow‐up period of 13 years, 11% of patients had recurrence, and 7% died of disease. Determinants of outcome were shown to be risk groups as defined by age and sex, extent of disease (size of tumor and extent of extraglandular involvement), capsular invasion, blood vessel invasion, ability to remove all tumor at operation, and, to a lesser extent, pathologic type. Presence of nodes affected recurrence rate but did not have any deleterious effects on survival. Multifocal involvement did not appear to be an adverse prognostic factor. Treatment was successful in 73% of patients with nodal recurrences, in 53% with local recurrences, and in 27% with distant recurrences. Recurrences more often were treated successfully in low‐risk patients than in high‐risk patients. None of the deaths from local recurrence could have been prevented by initial total thyroidectomy. Recurrent nerve paralysis and hypoparathyroidism each occurred in only 1 patient (0.4%) who underwent bilateral subtotal or near‐total thyroidectomy. We conclude that a selective approach using lesser operations than total thyroidectomy is sufficient for management of patients with well‐differentiated thyroid carcinoma and that total thyroidectomy is not required.
False‐negative errors in fine‐needle aspiration biopsy of dominant thyroid nodules: A prospective follow‐up study
Authors: Boey John , Hsu C. , Collins Robert J.
Published: May 2005

Reluctance to adopt fine‐needle aspiration (F‐NA) of dominant thyroid nodules stems largely from fear of overlooking a malignancy in a nodule diagnosed as benign on FNA (false‐negative error). Published error rates have been derived from surgical series without regard to the outcome of those who were followed without operation. In order to ascertain the overall false‐negative error rate, we conducted a prospective study in 600 patients who underwent FNA. Among the 482 study patients who had a benign FNA diagnosis or inadequate specimens, 117 underwent surgery because of the concurrent large‐needle biopsy result or a clinical suspicion of malignancy. Eight false‐negative errors were identified in this group, 5 of which were detected by large‐needle biopsy. Among the remaining 365 patients who were followed for an average of 2 1/2 years, 2 patients were found to have well‐differentiated carcinomas in recurrent cysts. The overall false‐negative error rate of FNA alone in all 482 patients was 2.1%. This was reduced to 1.0% by the use of concurrent large‐needle biopsy. Properly applied, FNA can reduce unnecessary surgery among patients with clinically benign nodules without incurring an unacceptably high false‐negative error rate. Furthermore, this error rate may be reduced substantially by combining large‐needle biopsy with FNA and by close follow‐up with surgery performed later in patients who manifest clinical features suggestive of malignancy.
99mTc(V)‐dimercaptosuccinic acid scintigraphy for medullary thyroid carcinoma
Authors: Miyauchi Akira , Endo Keigo , Ohta Hitoya , Torizuka Kanji , Matsuzuka Fumio , Kobayashi Akira , Kuma Kanji , Maeda Masazumi
Published: May 2005

Ten patients with medullary thyroid carcinoma (MTC) and 2 patients with papillary carcinoma of the thyroid were investigated by scintigraphy using99mTc(V)‐dimercaptosuccinic acid [99mTc(V)‐DMS], a new radiopharmaceutical agent for imaging MTC. At surgery, a tracer dose of the agent was administered intravenously, and the distribution of the agent was studied in the surgically removed tissues. Among the patients with MTC, 7 had clear scintigraphic images of tumors, 2 had faint images, and 1 patient with a recurrent tumor in a lymph node had no significant image. In 3 patients, mediastinal involvements were clearly demonstrated, and mediastinal dissection confirmed the scintigraphic findings. No significant images were obtained in the patients with papillary carcinoma. The tissue distribution studies of99mTc(V)‐DMS revealed specific accumulation of the agent in MTC tissue and low uptake in other tissues. This new scintigraphy for MTC is of great value in deciding the surgical approach and follow‐up.
Reoperation for secondary hyperparathyroidism in hemodialysis patients
Authors: Dubost Claude , Kracht Matthias , Assens Pierre , Sarfati Emile , Zingraff Johanna , Drüeke Tilman
Published: May 2005

Parathyroidectomy (PTx) in uremic patients is only performed in case of severe hyperparathyroidism. In some instances, PTx may be either insufficient or, on the contrary, lead to intolerable hypoparathyroidism. Recurrence is always possible because of persistent renal failure. Reoperations may, therefore, be necessary. We report here on 25 reoperations done in 21 patients who are part of a series of 248 patients operated on for secondary hyperparathyroidism. Nine patients had initial parathyroidectomy (PTx) at another institution. Six patients underwent reoperation after initial surgery, which was incomplete leaving 1–3 glands in place. In 7 patients reoperation was done after initially successful, subtotal PTx. In these we found hypertrophic remnants and a supernumerary gland in 1. Seven patients had total PTx, with immediate parathyroid reimplantation in 5 instances. Reoperation on the graft was judged necessary in 5 patients, but hypertrophy of grafted fragments was observed in only 3 of them. In 3 patients secondary autografting was performed with cryopreserved tissue. The analysis of our cases shows the difficulties of localizing unique or multiple sites of parathyroid hormone overproduction despite the availability of many diagnostic approaches. From a practical point of view, we try at present to resect all parathyroid tissue in case of reoperation for recurrent hyperparathyroidism. If hypoparathyroidism results by this procedure or in case of hypoparathyroidism obtained unexpectedly, we then proceed to delayed parathyroid autotransplantation with cryopreserved tissue.
Serum calcium as an early indicator for surgical treatment of hyperparathyroidism after renal transplantation
Authors: Sitges‐Serra A. , Gores P. , Hesse U. , Fryd D. S. , Najarian J. S. , Sutherland D. E. R.
Published: May 2005

In an attempt to find out if a particular group of patients with hyperparathyroidism after renal transplantation (HRT) are at risk of developing complications, 14 patients with overt untreated HRT who had at least 1 serum calcium determination ≥ 12 mg/100 ml were evaluated and compared retrospectively with 11 normocalcemic transplant recipients at 6 and 30± 8 months after successful renal allografting. Serum calcium was ≥ 12 mg/100 ml within 6 months of transplantation in 13 of the 14 HRT patients. At 6 months significant differences were found between HRT and controls in mean serum calcium (11.6 versus 9.2 mg/100 ml) and alkaline phosphatase (228 versus 120 U/l). At 30±8 months differences were found in serum calcium (10.2 versus 9.4 mg/100 ml), phosphate (2.8 versus 4.8 mg/100 ml), and alkaline phosphatase (180 versus 88 U/l). Serum creatinine levels were similar in the 2 groups. A significant correlation was found between early and late determinations of alkaline phosphatase when all 25 patients were studied as a single group (r=0.72, p<0.001). Bone pain and/or radiological evidence of hyperparathyroid bone disease were significantly associated with HRT (8 versus 1 and 7 versus 0, respectively). A higher but not significant incidence of vascular calcifications (5 versus 1) and acute pancreatitis (2 versus 0) was found in HRT. Patients who develop moderate to severe HRT as defined by at least 1 serum calcium determination ≥ 12 mg/100 ml do so within 6 months of renal transplantation, have increased morbidity, particularly involving the skeleton, and might benefit from early subtotal parathyroidectomy.
Treatment of toxic multinodular goiter (hummer's disease): Surgery or radioiodine?
Authors: Jensen Michael D. , Gharib Hossein , Naessens James M. , van Heerden Jon A. , Mayberry W. Eugene
Published: May 2005

The records of patients treated at the Mayo Clinic for toxic multinodular goiter during 1950–1954, 1960–1964, and 1970–1974 were reviewed to compare results of surgical and131I therapy, to define trends in treatment policy and outcome, and to attempt to elucidate factors associated with posttreatment hypothyroidism. The series involved 446 patients who underwent thyroidectomy as initial treatment and 89 who initially received131I. The time to success was significantly shorter (p=0.001) in surgically treated patients than in patients initially receiving131I. Compared with patients treated medically, patients treated initially with surgery were much less likely to require a second treatment (0% versus 24%) during the first year after initial treatment. The probability of postthyroidectomy hypothyroidism increased from approximately 12% in the 1950s to more than 70% in the 1970s at 2 years after surgery. Neither more aggressive surgery nor use of more sensitive tests to diagnose hypothyroidism accounted for the increased probability in recent years.
Thyroid function after hemithyroidectomy for benign nodules
Authors: Cheung Polly , Boey John , Wong John
Published: May 2005

In order to assess the need for thyroxine therapy to maintain normal thyroid function in patients who have undergone hemithyroidectomy for benign solitary nodules, pre‐ and postoperative serum thyroxine (T4) and serum thyrotropin (TSH) concentrations were measured in a prospective study on 103 patients. Thyroid function measurements were normal before the operation. Postoperative thyroid function tests showed a significant reduction of serum T4 at 3 years and a significant elevation of serum TSH between 6 months and 3 years after surgery, but the altered levels remained within the normal range. Thirteen patients had abnormal postoperative thyroid function tests. Eight patients had subnormal T4 levels, which were accompanied by concomitant increases in TSH levels above normal in 3 individuals. Five patients had supranormal TSH values associated with normal T4 levels, but only 1 of them showed clinical recurrence of a goiter. These observations suggest that most patients remain clinically and biochemically euthyroid after hemithyroidectomy. Thus, routine replacement thyroxine therapy is not necessary to prevent biochemical hypothyroidism, but it may be indicated in the few patients in whom a subnormal T4 level develops. The clinical significance of these subtle changes in serum T4 and TSH within the normal range is not clear especially with respect to goiter recurrence.
Secretory pattern and blood pressure in pheochromocytoma
Authors: Gröndal Staffan , Hamberger Bertil , Telenius‐Berg Margaretha
Published: May 2005

The diagnostic accuracy of urinary and plasma catecholamines was studied in 16 patients with pheochromocytoma. Five of 16 patients had 1 or more plasma samples within the normal range, while all 16 patients had increased urinary samples. Urinary catecholamines, therefore, have a higher diagnostic specificity than plasma catecholamines. No diurnal rhythm of catecholamine secretion was found in 7 patients in whom plasma catecholamines and blood pressure were followed for 24 hours. No correlation was found between blood pressure and plasma catecholamines in patients at rest.
Surgical pathology of bone sarcomas
Authors: Huvos Andrew G.
Published: May 2005

Malignant tumors arising from the skeleton are uncommon neoplasms, comprising only a small proportion of the malignant lesions in the body. Despite their rarity, they are of great clinicopathologic interest because of their prevalence in all age groups, the manifold histologic and radiographic presentations, and the complexities of treatment. This article addresses some of the problems the surgical pathologist faces in the diagnosis of the more important bone tumors with an aggressive clinical behavior.
Management of bone sarcomas at Memorial Sloan‐Kettering Cancer Center
Authors: Gebhart Michael J. , Lane Joseph M.
Published: May 2005

Survival of bone sarcoma patients has markedly improved during the last 20 years. This was followed by a new trend toward limb‐sparing procedures instead of amputations.

This article will review the current preoperative approach, the biopsy techniques, the surgical treatments in different anatomical locations and their indications as well as the results in osteogenic sarcoma patients treated at Memorial Sloan‐Kettering Cancer Center, New York, New York, U.S.A.
Isolation perfusion of the lower limb with platinum
Authors: Vaglini M. , Belli F. , Santinami M.
Published: May 2005

From August, 1983 to February, 1986, a total of 14 patients affected by osteogenic sarcoma of the limbs have been treated at the National Cancer Institute, Milan, Italy. For all patients, due to the size of tumor and the extracompartmental invasion, the only possible treatment was an amputation or disarticulation and, for this reason, it was decided to submit the patients to combined treatments according to this schedule: 2 subsequent intraarterial infusions of cis‐platinum (CDDP) + systemic high‐dose methotrexate (MTX), followed by hyperthermic antiblastic perfusion in extracorporeal circulation and 2 more cycles of systemic high‐dose MTX + CDDP.

This schedule of treatment is reasonably well tolerated by the patients, despite the side effects and the length of the entire presurgical period. No significant complications have been observed, either local or systemic.
The role of the pathologist in the management of soft tissue sarcomas
Authors: Hajdu Steven I. , Shiu Man H. , Brennan Murray F.
Published: May 2005

We have described the diagnostic handling of surgical specimens from patients with soft tissue sarcomas and summarized our experience with 244 patients with soft tissue sarcomas in 1985. Of the 244 patients admitted with soft tissue sarcomas, 157 had primary lesions, 60, recurrent lesions, and 27, metastatic lesions. Eight tumors were biopsied, 133 excised, 56 resected, and 20 patients were treated with amputation. In 24 cases, the gross specimen margins were positive for sarcoma, and in 22, the microscopic margins were positive for sarcoma. Bone was included with 43 surgical specimens, 16 of which showed microscopic evidence of bone invasion and 4 of which showed periosteac involvement. Six sarcomas metastasized to lymph nodes and 7 invaded blood vessels. Primary sarcomas included 78 liposarcomas, 44 myosarcomas, 41 malignant fibrous histiocytomas, 27 tendosynovial sarcomas, 19 fibrosarcomas, 13 angiosarcomas, 11 malignant peripheral nerve tumors, and 11 other sarcomas. While 75% of the sarcomas were histologically high‐grade and 54% were advanced (stage III and stage IV tumors), 21% were small (less than 5 cm) and 14% were early (stage 0 and stage I) lesions. Histologic variation of tumor type, grade, and cellular components were observed in 84 of the 244 patients.