Biochemical cure - is this enough?

Abstract Purpose Repeat surgery in patients with primary hyperparathyroidism (pHPT) is associated with an increased risk of complications and failure. This stresses the need for optimized strategies to accurately localize a parathyroid adenoma before repeat surgery is performed. However, evidence on the extent of required diagnostics for a structured approach is sparse. Methods A retrospective single-center evaluation of 28 patients with an indication for surgery due to pHPT and previous thyroid or parathyroid surgery was performed. Diagnostic workup, surgical approach, and outcome in terms of complications and successful removement of parathyroid adenoma with biochemical cure were evaluated. Results Neck ultrasound, sestamibi scintigraphy, C11-methionine PET-CT, and selective parathyroid hormone venous sampling, but not MRI imaging, effectively detected the presence of a parathyroid adenoma with high positive predictive values. Biochemical cure was revealed by normalization of calcium and parathormone levels 24–48h after surgery and was achieved in 26/28 patients (92.9%) with an overall low rate of complications. Concordant localization by at least two diagnostic modalities enabled focused surgery with success rates of 100%, whereas inconclusive localization significantly increased the rate of bilateral explorations and significantly reduced the rate of biochemical cure to 80%. Conclusion These findings suggest that two concordant diagnostic modalities are sufficient to accurately localize parathyroid adenoma before repeat surgery for pHPT. In cases of poor localization, extended diagnostic procedures are warranted to enhance surgical success rates. We suggest an algorithm for better orientation when repeat surgery is intended in patients with pHPT.

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Surgical management of pediatric Cushing's disease: an analysis of 15 consecutive cases at a specialized neurosurgical center

Arquivos Brasileiros de Endocrinologia & Metabologia ◽

10.1590/s0004-27302010000100004 ◽

2010 ◽

Vol 54 (1) ◽

pp. 17-23 ◽

Cited By ~ 17

Author(s):

Ricardo Santos de Oliveira ◽

Margaret de Castro ◽

Sonir Roberto Rauber Antonini ◽

Carlos Eduardo Martinelli Júnior ◽

Ayrton Custódio Moreira ◽

...

Keyword(s):

Cushing’S Disease ◽

Transsphenoidal Surgery ◽

Pediatric Patients ◽

Serum Cortisol ◽

Plasma Cortisol Level ◽

Hormone Deficiency ◽

Cushing's Disease ◽

Specialized Center ◽

Biochemical Cure

OBJECTIVE: The aim of this study was to review the results of surgery for pediatric patients with Cushing's disease who were less than 18 years old and underwent transsphenoidal surgery in a specialized center during a 25-year period. SUBJECTS AND METHODS: Retrospective study, in which the medical records, histology and pituitary imaging of 15 consecutive pediatric patients with Cushing's disease (mean age: 13 years) were evaluated by the same team of endocrinologists and a neurosurgeon from 1982 to 2006. Patients were considered cured when there was clinical adrenal insufficiency and serum cortisol levels were below 1. 8 µg/dL or 50 nmol/L after one, two, three, or seven days following surgery; they therefore required cortisone replacement therapy. Follow-up was for a median time of 11.5 years (range: 2 to 25 years). RESULTS: Clinical and biochemical cure was achieved in 9/15 patients (60%) exclusively after transsphenoidal surgery. Hypopituitarism was observed in four patients; growth hormone deficiency, in two; permanent diabetes insipidus, in one case. CONCLUSIONS: Cushing's disease is rare in children and adolescents. Transsphenoidal surgery is an effective and safe treatment in most of these patients. Plasma cortisol level < 1. 8 µg/dL following surgery is the treatment goal and is a good predictive factor for long-term cure of Cushing's disease.

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Outcomes after a purely endoscopic transsphenoidal resection of growth hormone–secreting pituitary adenomas

Neurosurgical FOCUS ◽

10.3171/2010.7.focus10153 ◽

2010 ◽

Vol 29 (4) ◽

pp. E5 ◽

Cited By ~ 53

Author(s):

Peter G. Campbell ◽

Erin Kenning ◽

David W. Andrews ◽

Sanjay Yadla ◽

Marc Rosen ◽

...

Keyword(s):

Growth Hormone ◽

Pituitary Adenomas ◽

Remission Rate ◽

Csf Leak ◽

Oral Glucose ◽

Cure Rate ◽

Cavernous Sinus Invasion ◽

Remission Criteria ◽

Biochemical Cure ◽

Transsphenoidal Resection

Object Using strict biochemical remission criteria, the authors assessed surgical outcomes after endoscopic transsphenoidal resection of growth hormone (GH)–secreting pituitary adenomas and identified preoperative factors that significantly influence the rate of remission. Methods A retrospective review of a prospectively maintained database was performed. The authors reviewed cases in which an endoscopic resection of GH-secreting pituitary adenomas was performed. The cohort consisted of 26 patients who had been followed for 3–60 months (mean 24.5 months). The thresholds of an age-appropriate, normalized insulin-like growth factor–I concentration, a nadir GH level after oral glucose load of less than 1.0 μg/l, and a random GH value of less than 2.5 μg/l were required to establish biochemical cure postoperatively. Results Overall, in 57.7% of patients undergoing a purely endoscopic transsphenoidal pituitary adenectomy for acromegaly, an endocrinological cure was achieved. The mean clinical follow-up duration was 24.5 months. In patients with microadenomas (4 cases) the cure rate was 75%, whereas in patients harboring macroadenomas (22 cases) the cure rate was 54.5%. Cavernous sinus invasion (Knosp Grades 3 and 4) was associated with a significantly lower remission rate (p = 0.0068). Hardy Grade 3 and 4 tumors were also less likely to achieve biochemical cure (p = 0.013). The overall complication rate was 11.5% including 2 incidents of transient diabetes insipidus and 1 postoperative CSF leak, which were treated nonoperatively. Conclusions A purely endoscopic transsphenoidal approach to GH-secreting pituitary adenomas leads to similar outcome for noninvasive macroadenomas compared with traditional microsurgical techniques. Furthermore, this approach may often provide maximal visualization of the tumor, the pituitary gland, and the surrounding neurovascular structures.

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Article Commentary: Zollinger–Ellison Syndrome: A Personal Perspective

The American Surgeon ◽

10.1177/000313480807400701 ◽

2008 ◽

Vol 74 (7) ◽

pp. 563-571 ◽

Cited By ~ 3

Author(s):

E. Christopher Ellison

Keyword(s):

Peptic Ulcer ◽

Total Gastrectomy ◽

Malignant Potential ◽

Personal Perspective ◽

Surgical Removal ◽

Tumor Removal ◽

Ulcer Disease ◽

Zollinger Ellison Syndrome ◽

Biochemical Cure ◽

The Impact

The odyssey of Zollinger-Ellison Syndrome is one of the most interesting in surgery. From the initial recognition of two patients with severe peptic ulcer disease in 1955 sprung an international dialogue on this unique disease culminating in discovery that gastrin was the hormone secreted by these pancreatic and duodenal tumors. The impact was the birth of a new area of science, “gastrointestinal endocrinology.” Initially, surgeons were challenged by the complexity of the patients and the need to perform total gastrectomy to prevent death from complications of the severe ulcer disease. Later, after the discovery of proton pump inhibitors, total gastrectomy was no longer needed and the surgeon could focus treatment on tumor removal added by radioimmunoassay for gastrin and new imaging modalities. Today, we recognize that all gastrinomas have malignant potential; early surgical removal can reduce the incidence of metastases and improve survival, independent of biochemical cure, in both sporadic and familial forms of the disease.

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Shortening Postoperative Stay after Parathyroidectomy - A District General Hospital Experience

International Archives of Otorhinolaryngology ◽

10.1055/s-0039-1698777 ◽

2019 ◽

Vol 24 (03) ◽

pp. e313-e318

Author(s):

Sidhartha Sinha ◽

Matthew Fok ◽

Ijaz Ahmad ◽

Mustafa Al-Sheikh ◽

Christopher Backhouse

Keyword(s):

Patient Education ◽

Length Of Stay ◽

District General Hospital ◽

Unplanned Readmission ◽

Short Stay ◽

Retrospective Audit ◽

Parathyroid Adenomas ◽

Biochemical Cure ◽

Postoperative Length ◽

Preoperative Patient

Introduction Historically, concerns about complications following parathyroid surgery, such as airway compromise, bleeding and hypocalcemia, have precluded its consideration as a short-stay surgical procedure. Recent advancements in perioperative care have resulted in several publications demonstrating that parathyroidectomy can be safely performed as a short-stay procedure. Objectives The aim of the present study was to describe the process of implementing a short-stay protocol focusing on preoperative patient education and postoperative calcium management for those undergoing surgery for primary hyperparathyroidism (PHP). Method A retrospective audit of consecutive parathyroidectomies performed for PHP over the period between 2010 and 2013 was performed. A short-stay protocol (SSP) was introduced focusing on postoperative calcium management. Results were reaudited over the period between 2013 and 2015. Results Consecutive parathyroidectomies in 76 patients were included in the study. A total of 42 patients underwent parathyroidectomy prior to the introduction of the protocol. A total of 26.2% of these patients were symptomatic from hypercalcemia. A total of 40 out of 42 (95.2%) patients had a biochemical cure. A total of 36 out of 42 (85.7%) cases were due to parathyroid adenomas. A total of 34 patients underwent surgery following the introduction of the protocol. A total of 13 out of 34 (38.2%) of the patients had symptomatic hypercalcemia. A total of 33 out of 34 (97.1%) had a biochemical cure. A total of 32 out of 34 (94.1%) cases were due to parathyroid adenomas.The length of stay decreased from a median of 3 days (range 2–9 days; mean 3.32) preprotocol to a median of 2 days (range 2–3 days; mean 2.16) postprotocol (p < 0.0001) with no difference in the 30-day unplanned readmission rate (4.8 versus 2.9%; p = 0.999). Conclusions The postoperative length of stay after parathyroidectomy for PHP can be safely reduced through patient education and by rationalizing postoperative calcium management without adversely affecting outcomes.

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Surgical management of medullary thyroid cancer: which guidelines should we follow?

The Journal of Laryngology & Otology ◽

10.1017/s0022215115000237 ◽

2015 ◽

Vol 129 (5) ◽

pp. 478-483 ◽

Cited By ~ 2

Author(s):

A Bowen ◽

N Mani ◽

S Penney ◽

S Loughran ◽

B Yap

Keyword(s):

Thyroid Cancer ◽

Surgical Management ◽

Medullary Thyroid Cancer ◽

Stage I ◽

Disease Stage ◽

American Thyroid Association ◽

Cure Rate ◽

Aggressive Approach ◽

Medullary Thyroid ◽

Biochemical Cure

AbstractBackground:Surgery is currently the only curative treatment for medullary thyroid cancer. Unfortunately, the surgical strategy that will offer patients at each disease stage the best chance of a biochemical cure remains unclear. The American Thyroid Association and British Thyroid Association guidelines offer different strategies.Methods:A retrospective analysis of the surgical management of 47 patients with medullary thyroid cancer diagnosed between 1994 and 2013 was performed. Surgical management was compared with current American Thyroid Association and British Thyroid Association guidelines. Outcome was defined as the first post-operative calcitonin measurement.Results:All patients with stage I–III disease achieved a post-operative biochemical cure regardless of the guidelines followed. The overall biochemical cure rate for patients with stage IVa disease was significantly reduced to 10 per cent (p < 0.01), but the biochemical cure rate for stage IVa disease patients who underwent bilateral lateral lymph node dissection was 33.3 per cent.Conclusion:The conservative, surveillance-driven approach recommended by the American Thyroid Association is appropriate for stage I–III disease. However, the more aggressive approach advocated by the British Thyroid Association might provide stage IVa disease patients a greater chance of achieving a biochemical cure.

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Prognostic Factors for Biochemical Cure in Patients with Medullary Carcinoma of Thyroid

The Korean Journal of Endocrine Surgery ◽

10.16956/kjes.2003.3.2.121 ◽

2003 ◽

Vol 3 (2) ◽

pp. 121

Author(s):

Jeong-Han Kim ◽

Sang-wook Kim ◽

Seok-Jin Nam ◽

Jeong-meen Seo ◽

Jung-Hyun Yang

Keyword(s):

Prognostic Factors ◽

Medullary Carcinoma ◽

Biochemical Cure

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The outcome of surgery in 668 patients with acromegaly using current criteria of biochemical ‘cure’

Acta Endocrinologica ◽

10.1530/eje.1.01863 ◽

2005 ◽

Vol 152 (3) ◽

pp. 379-387 ◽

Cited By ~ 312

Author(s):

Panagiotis Nomikos ◽

Michael Buchfelder ◽

Rudolf Fahlbusch

Keyword(s):

Transsphenoidal Surgery ◽

Tumour Size ◽

Secretory Activity ◽

Primary Treatment ◽

Oral Glucose ◽

Consecutive Series ◽

Primary Therapy ◽

Cure Rate ◽

Repeat Surgery ◽

Biochemical Cure

Background and aim: The aim of this study was to illustrate the present role of transsphenoidal surgery as primary therapy in GH-secreting adenomas, and to compare the results concerning control of disease with previous series using older criteria of cure. Method: We report on a consecutive series of 688 acromegalic patients treated over a time period of 19 years. Biochemical cure was defined as normalisation of basal GH level, suppression of GH levels to below 1 ng/ml during an oral glucose load and normalisation of IGF-I levels. Of the 506 patients undergoing primary transsphenoidal surgery, a total of 57.3% postoperatively fulfilled the criteria used. Results: The rate of biochemical ‘cure’ correlated with the magnitude of the initial GH levels, the tumour size and invasion. The overall complication rate was below 2%. Mortality in this series was 0.1% (1 of 688). During a follow-up period of 10.7 years only two recurrences (0.4%) occurred. However, in the patients treated by transcranial surgery and by repeat surgery the cure rate was found to be relatively low (5.2 and 21.3% respectively). Conclusions: These data suggest that surgery remains with very few exceptions the primary treatment of acromegaly for (i) a high cure rate, (ii) low morbidity, (iii) low recurrence rate and (iv) immediate decline of GH. Based on current criteria of cure, recurrences are uncommon. However, cure by surgery alone is improbable in patients harbouring extended, invasive tumours with high secretory activity, in whom further adjuvant treatment is mandatory.

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Megavoltage pituitary irradiation lowers but seldom leads to safe GH levels in acromegaly: a long-term follow-up study

Acta Endocrinologica ◽

10.1530/eje.0.1380160 ◽

1998 ◽

pp. 160-163 ◽

Cited By ~ 27

Author(s):

NC Thalassinos ◽

S Tsagarakis ◽

G Ioannides ◽

I Tzavara ◽

C Papavasiliou

Keyword(s):

Additional Data ◽

External Beam ◽

Follow Up Study ◽

Long Term Follow Up ◽

Biochemical Cure ◽

Definition Of ◽

Pituitary Irradiation ◽

Tsh Deficiency

Radiotherapy (RT) has long been used in the treatment of acromegaly, but confusion regarding the definition of biochemical cure has hampered interpretation of previous reports on the outcome of this treatment. In the present study we present additional data using the currently accepted criteria of biochemical cure in a large group of patients followed up by our department. Forty-six acromegalic patients were treated with external beam megavoltage RT and followed up for a mean of 7.6 years (range 2-22 years). Only four patients had had previous surgical treatment by either transsphenoidal or transfrontal routes. Following RT, mean basal GH levels decreased from 30.9 ng/ml (5-96 ng/ml) to 11.5 ng/ml (1-36 ng/ml) at 10 years of follow up with a further fall to 6.1 ng/ml (1-29 ng/ml) in those patients followed up for more than 10 years. As a result, although mean GH levels of less than 5 ng/ml were achieved in 9/28 (30.1%) at 5 years, 6/19 (31.6%) at 10 years, and in 6/11 (54.5%) of those patients followed up for more than 10 years post-RT, only 0/28 (0%), 7/28 (25%), 4/19 (21%) and 1/11 (1%) achieved GH levels of <2.5 ng/ml at 2, 5. 10 and >10 years following RT. Thus, in the whole series only 10/48 (20.8%) patients showed a decrease of GH level to less than 2.5 ng/ml at their latest follow up. Hypopituitarism as a result of RT was only infrequently observed in this series; gonadal deficiency developed in 12 (26.6%) patients, thyrotrophin (TSH) deficiency in 3 (6.6%) and adrenocorticotrophin deficiency in 2 (4.4%). In conclusion, megavoltage RT is an effective treatment for the control of GH hypersecretion in acromegaly, with a continuing lowering effect for several years following RT but seldom leads to safe GH levels.

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