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Purpose: Minimally invasive parathyroidectomy (MIP) has become the procedure of choice to treat primary hyperparathyroidism. The role for intra-operative parathyroid hormone measurement (IOPTH) is controversial. Some experts indicate that IOPTH is a requirement for MIP while others feel it not needed. We reviewed a 10 year history of MIP at a single institution without use of IOPTH to determine reasons for failure. Methodology: This study is a retrospective review of the University of Sydney Endocrine Surgery Database from May of 1998 to August of 2008. The database was queried for MIPs performed as well as for failed operations. Patient record analysis was completed to determine the reason for failure of the operation. Results: 1020 MIPs were performed with 23 (2.2%) failures. 1 patient was found to have benign familial hypercalcaemia, 5 were lost to follow up. Of the remaining 17 patients, average age was 62, and 76% were female. Reasons for failure in these patients were: 10 patients (59%) found to have double adenomas, 3 (17%) patients with hyperplasia and 4 (24%) patients with single gland disease missed at initial operation. All 17 were cured on repeat exploration. Of these 11 (65%) had repeat Sestamibi scans that correctly localized remaining hyperfunctioning gland(s). Conclusion: MIP can be performed safely without the need for IOPTH. The most common cause of failure after MIP is an occult double adenoma. Given that repeat Sestamibi scan correctly identifies persistent disease consideration can be given to MIP as a choice of procedure for repeat operation. [ABSTRACT FROM AUTHOR]

Introduction: Primary aldosteronism (Conn's syndrome) due to an aldosterone producing adenoma is a frequent cause of surgically correctable hypertension. It is unknown exactly which patients will have improved blood pressure (BP) control following resection. This study was undertaken to determine if histology correlated to post operative BP control in Conn's adenoma patients. We hypothesized that degree of zona glomerulosa hyperplasia would predict response to surgery. Methods: The University of Sydney Endocrine Surgery Database was queried for 20 consecutive patients who did and 20 consecutive patients who did not have improved BP control following surgery for Conn's Syndrome. Histology was reviewed to identify presence and degree of zona glomerulosa hyperplasia as well as dominate adenoma cell type: glomerulosa (G), reticularis (R) or fasciculata (F). Responders were defined as taking no BP medication or reduction of more than 2 medications 3 months after surgery. Student's t and Fischer's Exact tests were used to determine significance (p < 0.05 significant). Results: 20 responders and 13 non-responders had histology available for review. Age and sex between groups were not significantly different. Glomerulosa hyperplasia was present in 65% and 77% of responders and non-responders respectively (p = 0.7). Percentage cell type in responder tumours: 0% G, 35% F, 0% R, 65% mixed. Percentage cell type of non-responders, 0%G, 38% F, 0% R, 62% mixed with no significant difference in cell type between groups. Conclusion: Tumour histology does not influence clinical outcome following resection of Conn's adenomas. Improvement in BP following resection is unlikely related to local tumour characteristics. [ABSTRACT FROM AUTHOR]

Background: Recurrent laryngeal nerve paralysis (RLNP) is well recognized as a presenting symptom of thyroid malignancy, however RLNP is more commonly due to other aetiologies such as post-viral paralysis. The onset of a hoarse voice in a patient with a presumed benign multinodular goiter can thus present diagnostic difficulties and may lead to significant delays in the diagnosis of thyroid cancer. Methods: Data were obtained from the University of Sydney Endocrine Surgical Unit database. The study group comprised all patients presenting with a pre-operative diagnosis of RLNP prior to thyroid surgery in the 10 year period 1999 to 2008. Results: During the study period there were 44 thyroidectomies performed in cases of preoperative RNLP. 16 of these patients (36%) had cancer on final pathology with 14 having well differentiated thyroid cancer. In 3 (18%) of these patients the diagnosis was markedly delayed due to associated multinodular goiter. Mean delay from onset of RLNP to diagnosis of cancer in these 3 patients was 7 years (range 3 to 9 years). Each of these patients had normal neck CT, thyroid nodules of < 8 mm on initial imaging and initial benign FNA. In all 3 patients intra-operative findings noted tumour posteriorly at the Tubercle of Zuckerkandl and histopathology confirmed invasion of the nerve by papillary carcinoma. Conclusion: RLNP may be a sign of occult malignancy in the Tubercle of Zuckerkandl. Small tumour size and posterior location on the gland make reliable imaging and FNA difficult. Patients in whom malignancy is initially excluded should have close follow up and reassessment as there is a significant false negative rate in this patient cohort. [ABSTRACT FROM AUTHOR]

Background: Until recently the diagnosis of parathyroid cancer has been based upon difficult to interpret criteria and traditional indicators of malignancy such as mitotic activity and cellular atypia are unreliable. It is estimated that up to 50% of parathyroid carcinomas with biologically malignant behaviour may be considered benign. The aim of this study was to examine the impact of parafibromin immunohistochemistry (PI) on achieving a late diagnosis of parathyroid cancer. Methods: This is a case series with data obtained from the University of Sydney Endocrine Surgical Unit database. PI was performed on the cases identified. Results: Three patients were identified where an initial diagnosis of parathyroid adenoma had been made but where subsequent PI enabled a late diagnosis of parathyroid carcinoma. The mean age and sex distribution of the three patients at initial diagnosis was 38.3 years, M : F 2:1 (range 29–57); mean delay in diagnosis was 22 years (range 7–30). There were no statistically significant differences in patient age, sex distribution, serum calcium, and tumour weight between the three patients in the series and all other patients who have undergone parathyroidectomy for primary hyperparathyroidism. At follow-up, one patient appears cured with a normal serum calcium, one has permanent hypoparathyroidism, and one has persistent hypercalcaemia with control of serum calcium by Cinacalcet therapy. Conclusions: Diagnosis of parathyroid cancer may well be missed due to lack of clear histological criteria. PI in selected cases of parathyroid tumours will enable the accurate diagnosis of parathyroid carcinoma. [ABSTRACT FROM AUTHOR]

Purpose: Norcholesterol adrenal scintigraphy (Norchol) and computed tomography (CT) are frequently utilised in the investigation of hyperfunctioning adrenal lesions. In primary hyperaldosteronism where venous sampling has been unsuccessful and in Cushing's syndrome these modalities may help in the lateralisation of adrenal pathology. The aim of this study is to compare the accuracy of Norchol scintigraphy with that of high resolution CT in the lateralisation of hyperfunctioning adrenal tumours. Methodology: A prospective study comparing Norchol with CT was performed. Patients with primary hyperaldosteronism and failed venous sampling underwent evaluation with Norchol scintigraphy and 64 slice multidetector CT. Patients with adrenal Cushing's syndrome were also included and similarly evaluated. Imaging results were correlated with histopathology and clinical outcome after surgery. Results: In the period 2004 to 2007, 23 patients underwent Norchol and CT assessment. 20 patients had laparoscopic adrenalectomy and median follow up was 1 yr. Of these 10 had hyperaldosteronism with failed venous sampling and 10 had Cushing's syndrome. In patients with primary hyperaldosteronism Norchol correctly lateralised pathology in only 60% of cases compared to CT which was correct in 70%. In patients with Cushing's syndrome both Norchol and CT were 100% accurate in detecting the site of cortisol excess. Conclusion: In hyperaldosteronism with failed venous sampling Norchol scintigraphy offers no advantage over high resolution CT for lateralisation of pathology. In Cushing's syndrome both Norchol and CT are highly accurate and equivalent. [ABSTRACT FROM AUTHOR]

Introduction: Follicular thyroid carcinoma (FTC) includes a spectrum of neoplasms with varying propensity for metastasis. The aim of this study is to describe outcomes for FTC following multimodality treatment, with particular reference to the degree of capsular and vascular invasion and to recommend a rational management approach based on these characteristics., Methods: Patients with histologically confirmed FTC were identified from a prospectively maintained database. Details of intervention and long-term outcomes were obtained. Outcomes were compared between patients with minimally invasive follicular carcinoma (MI FTC) without vascular invasion (Group 1); angioinvasive MI FTC (Group 2); and those with widely invasive FTC (Group 3)., Results: Between May 1983 and December 2008, 124 patients with FTC were identified. The overall disease-free survival rate was 85% at a median of 40 months follow-up. Disease-free survival was 97%, 81% and 46%, respectively, in Groups 1, 2 and 3, and significantly different between groups (p<0.001). Thirteen patients in this series developed distant metastases including 2 in Group 1 and 6 in Group 2. Only patients <45 years of age with MI FTC and no vascular invasion had 100% disease-free survival. After multivariate linear regression, age (p=0.03) and the presence of vascular invasion (p=0.03) were the most powerful predictors of distant metastasis., Conclusions: Survival is improved in those with minimally invasive compared with widely invasive FTC. In patients <45 years with MI FTC without vascular invasion, hemithyroidectomy may be adequate treatment. All other patients with FTC should undergo total thyroidectomy and radioactive iodine ablation., (Copyright © 2010 Elsevier Ltd. All rights reserved.)

Aims: To determine the changing trends and current role of surgery for the management of thyroid lymphoma., Methods: A retrospective review of 50 surgical patients with a final diagnosis of thyroid lymphoma over a 35-year period., Results: All patients presented with an enlarging mass, with half having compressive symptoms on presentation. Two-thirds of patients had co-existent histological features of Hashimoto's thyroiditis. Surgery for patients with thyroid lymphoma peaked in the late 1970s (0.79% of all thyroid operations performed) followed by a significant decline in the 1980s with a current frequency of only 0.16% (p=0.009). A larger number of thyroid resections intended as a curative procedure was performed during the first half of this series compared to the latter half (p=0.05). There was no difference in disease-free survival between patients treated by thyroid resection when compared with an open biopsy (p=0.4875)., Conclusion: The surgical management of thyroid lymphoma has changed with time. Currently a larger proportion of patients are undergoing surgery in order to achieve a histological diagnosis rather than with therapeutic intent, however, an important role for surgery still exists in the management of a patient with severe airways obstruction.

Introduction: Laparoscopic adrenalectomy has surpassed open adrenalectomy as the gold standard for excision of benign adrenal lesions. The size threshold for offering laparoscopic adrenalectomy is controversial as the prevalence of adrenocortical carcinoma increases with increasing tumour size. The aim of this paper was to assess the safety of laparoscopic adrenalectomy for large adrenal tumours (tumours > or = 60 mm)., Methods: A retrospective cohort study of patients who underwent adrenalectomy in a single unit during the period 1995-2005 was undertaken., Results: One hundred and seventy patients with 173 tumours were included in this study. Of these, 29 were > or = 60 mm in size, and 16 of these patients underwent laparoscopic adrenalectomy. There were 8 adrenocortical carcinomas in the group with tumours > or = 60 mm in size. Five of these patients underwent an open adrenalectomy, while 2 and 1 patients had laparoscopic and laparoscopic converted to open adrenalectomy respectively. Four of the patients undergoing open adrenalectomy died of their disease while 1 is alive with recurrence 3 years later. The 3 patients who underwent either laparoscopic or laparoscopic converted to open adrenalectomy are alive without evidence of disease after 18 months follow up., Conclusion: Our data show that patients with tumours > or = 60 mm with no preoperative or intraoperative evidence of malignancy can undergo laparoscopic adrenalectomy without evidence of recurrence on short term follow up. These findings are concordant with the growing body of literature supporting laparoscopic adrenalectomy for potentially malignant tumours > or = 60 mm in size without preoperative or intraoperative features of malignancy.

Aims: Lymphadenectomy in the management of papillary thyroid cancer (PTC) has evolved. The aim of this study was to examine the changing role of neck dissection as reflected in the practice of a large thyroid unit over four decades., Methods: A retrospective cohort study of patients that underwent primary thyroid surgery for papillary cancer in a single unit in the period 1958-2002. Nine 5-year periods were considered and the data relevant to the treatment of the regional lymph nodes reviewed., Results: Nine hundred patients with PTC underwent surgery between 1958 and 2002 of whom 32.7% underwent lymph node dissection (LND). The use of lymphadenectomy increased from 21.4% in 1958-1962 to 48.1% in 1998-2002 of which 84% underwent a selective lymph node dissection (SLND)-a dissection where the LND is determined by the extent of the disease encountered. The mean number of nodes removed during SLND was 12.6 (range 1-56) of which a mean of 3.1 (24.8%) (0-19) were involved by the disease. Cervical levels 6 and level 4 were those most frequently dissected. There was no statistically significant difference in the complication rates in patients undergoing neck dissection and those not., Conclusion: The four decade experience reflects a move away from modified radical neck dissection and cherry picking towards SLND. Growing evidence suggests that lymphadenopathy in adult PTC is an adverse prognostic factor. SLND, a lymphadenectomy tailored to the extent of the disease process, is the coherent treatment for PTC since it serves the dual purpose of staging as well as control of local disease. This can be achieved with little morbidity when performed in a specialist centre.