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Background: Among surgical patients, care fragmentation (CF) is associated with worse outcomes. However, oncologic literature documents an association between high surgical volume and improved outcomes, favoring centralized cancer-surgery centers and thus predisposing to CF in patients with surgically treated tumors. We aimed to identify features associated with CF and ascertain differences in overall survival (OS) among patients with differentiated thyroid cancer (DTC). Methods: The National Cancer Database was queried for DTC patients diagnosed from 2009 to 2017. Patients experienced CF if part of their treatment was performed outside of the reporting facility or an associated office. A multivariable logistic regression analysis identified independent features associated with CF. A Cox multivariable regression analysis assessed the impact of CF on OS. A Kaplan–Meier analysis compared survival differences between patients experiencing CF or unified care (UC). Results: A total of 131,620 patients were included. Among them, 70,204 (53.3%) experienced CF and 61,416 (46.7%) experienced UC. Age < 55, residing in high-income areas, and stage 3 and 4 tumors were features independently associated with CF, whereas uninsured patients were less likely to experience CF than the privately insured. The features most strongly associated with CF were treatment at highest thyroid cancer-surgery volume institutions and traveling in the top distance quartile. While patients with CF experienced minor delays in time from diagnosis to surgery, 5-year OS was improved among patients with CF compared to UC for those with Stage 1–3 disease. Conclusions: Among patients with DTC, CF is associated with treatment at a highest thyroid cancer surgery volume facility and improved OS in a setting of minor treatment delays. [ABSTRACT FROM AUTHOR]

Background: Population-based analyses of 30-day outcomes after parathyroidectomy for renal secondary hyperparathyroidism are limited. We sought to identify risk factors associated with prolonged length of stay (LOS) and readmission in this patient population. Methods: Patients with secondary hyperparathyroidism who underwent parathyroidectomy were reviewed in the ACS-NSQIP database (2011–2016). Patients were identified by ICD codes specific to secondary hyperparathyroidism of renal origin and the ACS-NSQIP variable for current preoperative dialysis. Multivariable logistic regression was used to identify independent factors associated with prolonged LOS and 30-day readmission after parathyroidectomy. Results: The cohort included 1846 patients with secondary hyperparathyroidism on dialysis who underwent parathyroidectomy. There were 416 (22.5%) patients classified under the prolonged LOS group. On multivariable analysis, factors associated with prolonged LOS included elevated preoperative alkaline phosphatase [OR 3.13 (95%-CI 2.09–4.70), p < 0.001], decreased preoperative hematocrit [OR 1.83 (95%-CI 1.25–2.68), p = 0.002], unplanned reoperation (OR 5.02 [95%-CI 2.22–11.3], p < 0.001) and any postoperative complication [OR 6.12 (95%-CI 3.31–11.3), p < 0.001]. The overall 30-day readmission rate was 15.0%. Hypocalcemia and hungry bone syndrome accounted for 47.0% (n = 93/198) of readmissions. On multivariable analysis, patients with a history of hypertension and those undergoing unplanned reoperation were at risk of readmission [2.16 (95%-CI 1.21–3.87), p = 0.009, and 2.40 (95%-CI 1.15–5.02), p = 0.020, respectively], whereas reoperative parathyroidectomy was inversely associated with readmission (OR 0.24, 95%-CI 0.07–0.80, p = 0.021). Conclusion: In patients undergoing parathyroidectomy for renal secondary hyperparathyroidism, several readily available preoperative biochemical markers, including those of increased bone turnover and anemia, are associated with prolonged postoperative LOS. Unplanned reoperation was predictive of both increased LOS and readmission. [ABSTRACT FROM AUTHOR]

Background: Risks of thyroidectomy for multinodular goiter (MNG) in older and frail patients are unclear, particularly regarding hematoma and recurrent laryngeal nerve (RLN) palsy. Methods: MNG patients undergoing total thyroidectomy were reviewed in the ACS-NSQIP procedure-targeted database (2016–2017). Outcomes were analyzed between adult (age <65), older-adult (age ≥65 and <80), and oldest-old (age ≥80) patients. Five-factor modified frailty index (mFI-5) was calculated based on functional status, diabetes, COPD, CHF, and hypertension, and used in comparative analyses. Results: A total of 2189 adult, 635 older-adult, and 59 oldest-old patients were included. Compared to adult patients, older-adult and oldest-old patients had higher mFI-5 ≥0.4 rates (14% vs. 22% vs. 31%, respectively, p < 0.001). The overall complication rate was 17.0% and similar between groups; however, oldest-old patients had higher rates of surgical site infection (3.4% vs. 0.3% vs. 0.4%), pneumonia (5.1% vs. 0.3% vs. 0.2%), and readmission (10.2% vs. 2.4% vs. 2.6%) compared to older-adult and adult patients, respectively (p < 0.05). On multivariable analyses of thyroidectomy-specific complications, mFI-5 ≥0.4 (OR 2.5, 95%-CI 1.4–4.4) and bleeding disorder (OR 4.6, 95%-CI 1.3–16.3) were predictive of hematoma, whereas vessel-sealant device usage (OR 0.4, 95%-CI 0.3–0.7) was protective. mFI-5 ≥ 0.4 (OR 1.5, 95%-CI 1.1–2.2), bleeding disorder (OR 2.8, 95%-CI 1.04–7.8), parathyroid autotransplantation (OR 1.7, 95%-CI 1.2–2.6), and prolonged operative time (OR 1.4, 95%-CI 1.02–1.8) were predictive of RLN palsy. Age was not a significant predictor of hematoma or RLN palsy. Conclusions: Patients ≥80 years old are at increased risk for systemic complications and readmission after thyroidectomy for MNG. Frailty index better risk-stratifies patients than age for thyroidectomy-specific complications. [ABSTRACT FROM AUTHOR]

Background: The incidence of papillary thyroid microcarcinoma (PTMC) has increased over the past decade. The American Thyroid Association (ATA) suggests that these patients may undergo either thyroid lobectomy or active surveillance. It remains unclear whether there exists a subgroup of PTMC patients who may benefit from more aggressive treatment due to increased risk of recurrence. Methods: We retrospectively reviewed 357 patients with PTMC who underwent surgery at a single institution from 2004 to 2016. Patients were classified according to 2015 ATA risk stratification for structural disease recurrence. Demographic, oncologic, and clinicopathologic data were compared between groups. Results: Out of 357 patients, 246 were classified as low-risk PTMC, 93 were intermediate-risk, and 18 were high-risk. There were more male patients in the high-risk group (38.9%) than the intermediate- (31.2%) or low-risk groups (15.4%) (p < 0.001). Patients with low-risk microcarcinomas were more likely to have an incidental PTMC when compared to intermediate- or high-risk groups (98[39.8%], 15[16.1%], 1[5.6%], respectively, p < 0.001). Patients with high-risk PTMCs, compared to those with intermediate- and low-risk PTMCs, were more likely to have rising postoperative thyroglobulin levels after total thyroidectomy (6[40.0%], 4[5.1%], 9[5.7%], respectively, p = 0.001) and structural recurrence after lobectomy or total thyroidectomy (3[16.7%], 0[0%], 0[0%], respectively, p < 0.001). The median follow-up time was 17.5 (IQR 3–55) months. Conclusions: Patients with high-risk PTMC have an increased risk of recurrence when compared to low- and intermediate-risk microcarcinomas, whereas intermediate-risk PTMC may behave similarly to low-risk tumors. ATA risk stratification may inform clinical decision making for patients with PTMC. [ABSTRACT FROM AUTHOR]

Background: Primary squamous cell carcinoma of the thyroid (ThySCC) is a rare cancer, primarily described only in case reports. We aimed to characterize the prognosis of ThySCC and compare its oncologic behavior to other thyroid malignancies. Methods: The National Cancer Database was queried to identify patients with ThySCC, papillary, tall cell variant, poorly differentiated (PDTC), and anaplastic (ATC) subtypes of thyroid cancer treated from 2004 to 2015. Demographics, tumor characteristics, and treatments were compared by tumor type and assessed to identify independent predictors of overall survival (OS). Results: Of 123,684 patients included, 314 had ThySCC. ThySCC patients had a 5-year OS of 17.7%, more closely resembling ATC (8.3%) than PDTC or PTC. ThySCC and ATC patients had similar demographics, except ThySCC patients who were younger (68.0 vs. 70.2 years, p < 0.01). ThySCC tumors were smaller (mean 53.5 ± 45.7 vs. 69.5 ± 75.2 mm) with less frequent extrathyroidal extension (ETE) (64.0% vs. 73.8%), lymphovascular invasion (8.3% vs. 12.3%), and positive margins (22.0% vs. 28.3%) compared to ATCs (p < 0.05). ETE [HR 3.1 (95% CI 1.5–6.4), p < 0.05] and lymph node metastases [HR 2.2 (95% CI 1.2–4.0) p < 0.05] were independently associated with worse OS for ThySCC patients. Both ThySCC and ATC patients had similar surgical success rates, with R1 resection possible in 37.3% versus 35.0% of patients, respectively (p < 0.05). However, in contrast to ATC patients, adjuvant therapy was not associated with improved OS for ThySCC patients after complete resection. Conclusions: ThySCC has a poor prognosis, similar to ATC, but with fewer aggressive features and no apparent survival benefit with adjuvant therapy after complete macroscopic surgical resection. [ABSTRACT FROM AUTHOR]