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To quantify how frequently intraoperative parathyroid hormone levels increase during thyroid surgery and to explore a possible relationship between secondary hyperparathyroidism due to vitamin D deficiency and elevation in intraoperative parathyroid hormone.Case series with chart review.Tertiary academic center.A total of 428 consecutive patients undergoing completion and total thyroidectomy by the senior author over a 7-year period were included for analysis. All patients had baseline and postexcision intraoperative parathyroid hormone levels as well as vitamin D levels from the same laboratory. Institute of Medicine criteria were employed for vitamin D stratification (30, normal; 20-29.9, insufficient;20, deficient) . Other data analyzed include sex, age, neck dissection status, and parathyroid autotransplantation.A total of 118 patients (27.6%) had an intraoperative parathyroid hormone elevation above baseline. Patients with vitamin D deficiency were significantly more likely to experience hormone elevation ( P = .04). When parathyroid hormone rose, it did so by a mean 32.1 pg/mL. Patients with vitamin D deficiency demonstrated significantly larger hormone increases ( P = .03).Elevation in intraoperative parathyroid hormone levels above baseline after completion and total thyroidectomy occurs in over one-fourth of cases and is significantly associated with vitamin D deficiency. This study is the first to report this observation. We hypothesize that vitamin D deficiency in these patients may create a subclinical secondary hyperparathyroidism that leads to intraoperative parathyroid hormone elevation when the glands are manipulated. Additional studies will be needed to explore this physiologic mechanism and its clinical significance.

Background The purpose of this study was to define and characterize the thyroid tumor-draining lymph nodes in genetically engineered mice harboring thyroid-specific expression of oncogenic BrafV600E with and without Pten insufficiency. Methods After intratumoral injection of methylene blue, the lymphatic drainage of the thyroid gland was visualized in real time. The thyroid gland/tumor was resected en bloc with the respiratory system for histological analysis. Results Although mice harboring BrafV600E mutations were smaller in body size compared with their wild-type (WT) littermates, the size of their thyroid glands and deep cervical lymph nodes were significantly larger. Additionally, the tumor-draining lymph nodes showed increased and enlarged lymphatic sinuses that were distributed throughout the cortex and medulla. Tumor-reactive lymphadenopathy and histiocytosis, but no frank metastases, were observed in all mice harboring BrafV600E mutations. Conclusions The tumor-draining lymph nodes undergo significant structural alterations in immunocompetent mice, and this may represent a primer for papillary thyroid carcinoma (PTC) metastasis.

Objectives To measure the effect of proton pump inhibitors (PPIs), with and without concurrent bisphosphonates, on parathyroid hormone (PTH), vitamin D, and calcium. Design Retrospective chart review of individuals 60 years and older. Subjects with reduced renal function (creatinine >1.3 mg/dL) and low vitamin D (

ObjectiveTo determine differences in the mean parathyroid hormone (PTH) levels for normocalcemic and hypocalcemic total thyroidectomy patients who were tested for PTH during the intraoperative or early postoperative period.Data SourcesMEDLINE, the Cochrane Database, and other databases from 1960 to 2014 in the English language and specific to humans for relevant articles.Review MethodsStudies were included if PTH was obtained within 24 hours of thyroidectomy. Studies were excluded (1) if only a hemithyroidectomy was performed, (2) if means of studied PTH values were not reported in the article, or (3) if the time of the PTH draw fell outside of defined “intraoperative” or “early postoperative” windows. PTH values were divided into 3 groups: preoperative (control group), intraoperative (ie, discharge decisions were based on PTH values drawn in the operating room), and early postoperative (ie, PTH values at 1 to 4 hours after surgery were used as a guide).ResultsThe reported means of perioperative PTH level...

To compare the cost of same-day vs 23-hour observation outpatient thyroidectomy at US academic medical centers.Cross-sectional analysis of a national database.The University HealthSystem Consortium (UHC) data collected from discharge summaries.Discharge data were collected from the first quarter of 2009 through the second quarter of 2013. The UHC database, compiled from more than 200 affiliated hospitals, was searched based on diagnosis codes for outpatient thyroid procedures. Cost data, calculated based on reported charges, were collected in addition to demographics. Comparisons were made between same-day vs 23-hour observation based on cost. Additional stratification was performed based on the extent of thyroidectomy.During the study period, 49,936 outpatient thyroidectomies were performed. Overnight observation (63%) was more common than same-day discharge (37%). The overall mean cost of outpatient thyroidectomy was $5617, with a mean cost of same-day surgery of $4642 compared with $6101 for overnight observation (P.0001). When stratifying by extent of thyroidectomy, the cost of same-day surgery was consistently lower than that for overnight observation.Outpatient thyroidectomy is commonly performed in the United States. It is most commonly performed on a 23-hour overnight observation basis. Overnight stay and complications were chief among other factors associated with higher cost, independent of the type of thyroid procedure performed. In appropriately selected patients, same-day thyroidectomy is a safe and cost-effective alternative to overnight observation or inpatient thyroid procedures.

To better understand relationships of parathyroid hormone (PTH) production, adenoma gamma counts, and adenoma mass in patients undergoing minimally radioguided invasive parathyroidectomy for primary hyperparathyroidism from single-gland disease.A prospective review of 104 patients operated on by a single surgeon.University tertiary hospital.Adults who have primary hyperparathyroidism due to a single gland.There were 23 men and 81 women with an average age of 63 years. The mean (SD) adenoma mass was 0.78 (0.69) g (median, 0.57 g). The mean (SD) percent of background for the adenoma was 120.2 (90.5). Preoperative PTH and percent of background gamma count of the adenoma showed a likely correlation with a Spearman ρ value of 0.2039 and a P value of .037. There were significant correlations between both percent of background of the adenoma and adenoma mass (Spearman ρ = 0.4991 and P.0001). Preoperative PTH and adenoma mass also showed a significant positive correlation (Spearman ρ = 0.308 and P = .002).There exist correlations between gland mass, radioactivity, and PTH level. Adenoma radiation counts do not appear to be a proxy for changes in PTH levels measured during surgery as has been reported. Intraoperative PTH has been shown by others not to be necessary when doing radioguided parathyroid surgery if the Norman rule is observed. However, a radioguided technique and intraoperative PTH can provide complementary information in making an assessment of completion of parathyroid procedures.

To determine if standardized uptake values (SUV) on positron emission tomography (PET) are predictive of thyroid pathology and the significance of serial SUV measurements of thyroid nodules over time.Case series with chart review.Academic health center.In total, 23,384 PET and PET/computed tomography (CT) scans were performed between December 2001 and April 2011.Patients with incidental thyroid uptake were identified. SUV(max), age, sex, size of thyroid lesion, indication for PET scan, and cytology/pathology were collected.Incidental thyroid uptake was noted in 1309 PET scans (5.60%), focal uptake in 690 (2.95%), and diffuse uptake in 619 (2.65%). Complete data were available for 359 PET scans from 103 patients. Malignancy was identified in 28 patients (27%). Twenty-five of the 28 lesions (89%) were primary thyroid malignancies. A significant difference between malignant SUV(max) and benign SUV(max) was found (mean ± SD, 7.04 ± 7.88 for malignancies vs 3.85 ± 3.06 for benign tumors, P = .0292). Receiver operating characteristics curves were constructed on patients with PET data within 3 months of diagnosis and indicated that a SUV(max) of 4.2 differentiated maximally between benign and malignant lesions. Serial SUV uptake had no significant change over time.All thyroid nodules with focal uptake on (18)F-fluorodeoxyglucose-PET/CT should be considered at higher risk of malignancy than those discovered incidentally by other imaging modalities. Higher SUV(max) values are more indicative of malignant lesions. All lesions should be evaluated with ultrasonography ± fine-needle aspiration if no clinical contraindications exist. Size of the primary nodule does not influence SUV(max) uptake.

Medullary thyroid carcinoma (MTC) is a rare malignancy arising from the parafollicular C cells within the thyroid gland. The majority of cases are sporadic, but at least 30% are hereditary in nature. Inherited forms of MTC occur as familial MTC or as a manifestation of multiple endocrine neoplasia type 2. Early diagnosis and aggressive surgical management, including prophylactic thyroidectomy, improve the prognosis of patients with hereditary MTC. Several issues regarding the diagnosis and treatment of MTC remain controversial. Genetic penetrance and virulence are variable. We present an index case of familial MTC to illustrate common difficulties in the initial diagnosis and dilemmas in the surgical approach, followed by a review of current literature relevant to the management of hereditary MTC.

Objective The purpose of this study was to determine the cost considerations and strategies for incorporating ultrasound (US) in a head and neck practice. Study design and setting A retrospective chart review of office-based US procedures from 2001 to 2005 was completed at our academic medical center. Billing and coding for US and US guided fine needle aspiration (USFNA) were examined. Results The appropriate CPT codes are 76536 for US and 76942 and 10022 for USFNA-related procedures. The USFNA codes should be used repeatedly for correct coding of biopsies from multiple sites. Cost (equipment) sharing between specialties is a potential strategy for office-based US incorporation. Conclusion Based on practice volume, specific CPT coding, and Medicare reimbursements, office-based US equipment and certification costs could be offset in 1 year. Significance Office-based US can be readily incorporated with significant benefits to patients. Billing and usage strategies were identified that would improve the economics of providing office-based US.

Background The purpose of this study was to demonstrate a role for observation of patients with differentiated thyroid cancer (DTC) with persistent, nonlocalizable disease. Methods Our study was conducted on outpatients seen at our institution from 1999 to 2009 having total thyroidectomy, radioactive iodine (RAI) ablation, measurable serum thyroglobulin (Tg), and no evidence of disease on whole body or positron emission tomography (PET) scans. Results Nineteen patients in our study group aged 20 to 73 with an average follow-up of 5.5 years (range, 2–12 years); all were treated with postoperative RAI (99–210 mCi, average 119). Mean Tg ranged from 0.41 to 4.34. Tg levels remained stable or gradually decreased in all patients. Conclusion After total thyroidectomy and RAI therapy, patients may present with mildly elevated Tg values without localizable disease. These patients may have additional RAI treatments based on the Tg elevation. However, our clinical experience has shown that many of these patients will have Tg levels that either achieve stability or decrease over time without further treatment. © 2013 Wiley Periodicals, Inc. Head Neck 36: 155–157, 2014

Objectives:(1) Present the application of 4-dimensional (4D) computed tomography (CT) in preoperative localization of parathyroid adenomas that do not localize with technetium-99 (Tc-99) single-photon emission computed tomography (SPECT)/CT or ultrasound. (2) Present indications for 4D-CT use. (3) Understand radiologic dosimetry issues of 4D-CT.Methods:A retrospective review of over 15 consecutive patients at an academic medical center with primary hyperparathyroidism who underwent preoperative 4D-CT after nonlocalizing preoperative ultrasound and Tc-99 SPECT-CT scans between November 2013 and June 2014. This was a mixture of patients presenting for their first operations and others requiring revision surgery. Intraoperative radioguided parathyroidectomy results, excised gland weight, patient demographics, and parathyroid hormone levels were recorded. Sensitivity, specificity, and positive and negative predictive values of 4D-CT for preoperative adenoma localization were calculated.Results:4D-CT resulted ...

Objectives:(1) Analyze radiographic findings of thyroidectomy specimens. (2) Correlate intraoperative radiography to preoperative ultrasound and its guided fine-needle aspiration biopsy, intraoperative impression, and final pathology. (3) Describe a new intraoperative tool to help identify malignant characteristics of thyroid tissue.Methods:Prospective study comprised of consecutive patients undergoing hemi- or total thyroidectomy in a tertiary referral center. This is an ongoing study of patients treated from the months of November 2013 to June 2014. After obtaining ultrasound-guided fine needle aspiration biopsies that were indeterminate or confirmed malignancy, all patients received either a hemi- or total thyroidectomy. Prior to pathologic processing, the specimens were passed off the field and underwent intraoperative specimen radiography (IOSR) by the Faxitron Biovision (Tucson, Arizona), generating a plain radiograph. Radiographic characteristics were analyzed by a surgeon and radiologist and corre...

Context: Lysine supplementation may have a positive influence on the regulation of glucose metabolism but it has not been evaluated in older individuals. Objective: We evaluated the impact of acute lysine supplementation using three randomized experimental scenarios: 1) oral glucose alone (control), 2) oral glucose and low-dose lysine (2 g), and oral glucose and high dose lysine (5 g) lysine in 7 older (66±1 years/age), overweight (BMI = 31±2 kg/m2) individuals. Methods: We utilized a dual tracer technique (ie., [1-13C] glucose oral ingestion and [6,6-2H2] glucose infusion) during an oral glucose tolerance test (OGTT) to examine differences in hepatic and peripheral insulin sensitivity under all three scenarios. Results: Plasma glucose and insulin data were not different between the control, 2 g lysine and 5 g of lysine trials. The results of the Matsuda index were also not different between the three trials. As an index of hepatic insulin sensitivity, there were no significant differences in the endogeno...

Radio-guided surgery is an established means for surgeons to identify a target of interest for biopsy or excision. This technique is used for a variety of malignancies as well as minimally invasive parathyroid surgery. The primary radionuclide used for these procedures is technetium-99m (Tc-99m), but others have been used. Use of (18)fluorine-fluorodeoxyglucose ((18)F-FDG) in oncology has proliferated. This has created the opportunity to use (18)F-FDG as a potential radio tracer in the operating room. A pilot study of three patients with non-iodine avid thyroid cancers undergoing (18)F-FDG-guided revision thyroid cancer surgery is reported. Radiation exposure to operating room personnel was measured. Radiation exposure to the surgeon and staff members of an operating room is well below the limits of the National Regulatory Commission. Therefore, utilization of this radiopharmaceutical intraoperatively should not be limited in the future because of concern regarding exposure of operating room personnel to radiation.

Objectives:Thyroid surgery has traditionally been performed as an inpatient procedure due to the risk of postoperative hematoma and hypocalcaemia, but it is evolving into a safe outpatient procedure in selected patients. However, there is little in the literature about which patients require prolonged observation after planned same day surgery.Methods:A retrospective chart review was performed on patients from 2005 to 2012. We analyzed patients who underwent total thyroidectomy, completion thyroidectomy, or revision total thyroidectomy who were kept overnight or longer at a tertiary care center.Results:Two hundred thirty-one cases qualified and planned for same day surgery. Eighty-six patients were not discharged (37%). Twenty-three of 86 patients were admitted for parathyroid hormone (PTH)

Objectives:Compare the cost of outpatient and inpatient thyroidectomy at US academic medical centers.Methods:Discharge data were collected from the first quarter of 2009 through the fourth quarter of 2012 from the University Health System Consortium (UHC) on over 50,000 patients. The UHC database, compiled from over 100 academic health centers and their 200 affiliated hospitals, was searched based on diagnosis codes for outpatient and inpatient thyroid procedures. The Agency for Healthcare and Research Quality (AHRQ) chronic conditions were collected in addition to demographic, length of stay (LOS), and cost data. Comparisons were made between inpatient and outpatient thyroidectomy stratified by number of chronic conditions.Results:The cost of outpatient thyroidectomy was consistently less than that for inpatient thyroidectomy. More outpatient thyroidectomies were performed on patients with 0 or 1 chronic condition, while more inpatient thyroidectomies were performed on patients with 2 or greater chronic ...

Objectives:Vitamin D deficiency is endemic in the USA. Vitamin D deficiency has been observed in many cohorts of cancer patients and thought to be a possible risk factor. We sought to compare the 25-hydroxyvitamin D levels between a cohort of patients undergoing completion and total thyroidectomy for benign and malignant thyroid diseases.Methods:A retrospective institutional review board (IRB) approved study with chart review was done at a tertiary referral academic medical center. Data were retrospectively collected on consecutive patients who underwent completion and total thyroidectomy at the University of Arkansas for Medical Sciences between October 2005 and December 2012. Postoperative 25-hydroxyvitamin D levels were collected universally and reported when available. Statistical analysis was performed to determine if vitamin D levels varied based on pathology, categorized as either benign or malignant.Results:A total of 220 total and completion thyroidectomies were performed during the study period....

Objective: Better understand the relationships of parathyroid hormone production (PTH), adenoma gamma counts, and adenoma weight in patients undergoing minimally invasive parathyroidectomy for prim...

Objective: Determine demographics and cost analysis for outpatients undergoing thyroid surgery at hospitals belonging to the University Health System Consortium (UHC).Method: The University Health System Consortium (UHC), Oak Brook, Illinois, was formed in 1984 and consists of 107 academic medical centers and 232 of their affiliated hospitals. This represents 90% of non-profit academic medical centers in the United States (www.uhc.edu). Data were compiled from discharge summaries into a secure data base.Results: There were 28,648 patients who had outpatient thyroid surgery. A total of 19,487 patients had thyroid surgery for benign disease. A total of 8,909 patients had surgery for thyroid cancer. A total of 36.2% of surgeries were hemithyroidectomy and 44.5% were totals. A total of 1,333 of the thyroid cancer patients had a simultaneous neck dissection (5%). A total of 252 patients had neck dissection for thyroid cancer as a separate procedure. The average age was 48.7 (14.7) years and 71.8% of patients w...