Publications by authors named "Melanie L Lyden"

36 Publications

Clinical course and imaging characteristics of benign adrenal cysts: a single-center study of 92 patients.

Eur J Endocrinol 2022 Sep 25;187(3):429-437. Epub 2022 Jul 25.

Division of Endocrinology, Diabetes, Metabolism and Nutrition.

Objective: Benign adrenal cysts are rare lesions of the adrenal glands. Limited data are available to guide management. We aimed to describe the presentation and outcomes of patients with benign adrenal cysts.

Design: Retrospective longitudinal cohort study.

Methods: Consecutive patients with histologically or radiologically confirmed adrenal cysts between 1995 and 2021 were identified. Pheochromocytomas and malignancy were excluded.

Results: Benign adrenal cysts were diagnosed in 92 patients (53, 57% women) at a median age of 45 years. Mode of discovery was incidental on imaging in 81 (88%), symptoms of mass effect in 9 (9.8%), and others in 2 (2.2%). Majority (89, 97%) of patients had unilateral cysts (45 right, 44 left) with a median size of 48 mm (range 4-200) at diagnosis. On imaging, most cysts were round/oval (85.4%), homogenous (83.2%) lesions with calcifications (64.0%) and no vascular enhancement (97.7%). During a median follow-up of 65 months (range 7-288), adrenal cysts demonstrated minimal enlargement (median size change 6 mm, median growth rate 2 mm/year). On hormonal evaluation, 10% (5/50 tested) had an abnormal overnight dexamethasone suppression test, and 9.5% (4/42 tested) had an abnormal case detection testing for primary aldosteronism. Patients treated with adrenalectomy (46, 50%) were younger (36.9 years vs 50.8 years, P = 0.0009) and had more rapidly enlarging cysts (median growth rate 5.5 mm/year vs 0.4 mm/year, P = 0.0002).

Conclusion: Benign adrenal cysts are usually incidentally discovered, non-functional, homogenous lesions without vascular enhancement that demonstrate minimal growth. Adrenalectomy should be reserved for patients with heterogeneous lesions, abnormal hormonal evaluation, or those with mass effect symptoms.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1530/EJE-22-0285DOI Listing
September 2022

Histopathology and Genetic Causes of Primary Aldosteronism in Young Adults.

J Clin Endocrinol Metab 2022 Jul 2. Epub 2022 Jul 2.

Department of Molecular and Integrative Physiology, University of Michigan, Ann Arbor, MI, USA.

Context: Due to its rare incidence, molecular features of PA in young adults are largely unknown. Recently developed targeted mutational analysis identified aldosterone-driver somatic mutations in aldosterone-producing lesions, including aldosterone-producing adenomas (APAs), aldosterone-producing nodules (APNs), and aldosterone-producing micronodules, formerly known as aldosterone-producing cell clusters.

Objective: To investigate histologic and genetic characteristics of lateralized PA in young adults.

Methods: Formalin-fixed, paraffin-embedded (FFPE) adrenal tissue sections from 74 young patients with lateralized PA (<35 years-old) were used for this study. Immunohistochemistry (IHC) for aldosterone synthase (CYP11B2) was performed to define the histopathologic diagnosis. Somatic mutations in aldosterone-producing lesions were further determined by CYP11B2 IHC-guided DNA sequencing.

Results: Based on the CYP11B2 IHC results, histopathologic classification was made as follows: 48 APAs, 20 APNs, 2 multiple aldosterone-producing nodules (MAPNs), 1 double APN, 1 APA with MAPN, and 2 non-functioning adenomas (NFAs). Of 45 APAs with successful sequencing, 43 (96%) had somatic mutations, with KCNJ5 mutations being the most common genetic cause of young-onset APA (35/45, 78%). Of 18 APNs with successful sequencing, all of them harbored somatic mutations, with CACNA1D mutations being the most frequent genetic alteration in young-onset APN (8/18, 44%). Multiple CYP11B2-expressing lesions in patients with MAPN showed several aldosterone-driver mutations. No somatic mutations were identified in NFAs.

Conclusions: APA is the most common histologic feature of lateralized PA in young adults. Somatic KCNJ5 mutations are common in APAs, whereas CACNA1D mutations are often seen in APNs in this young PA population.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1210/clinem/dgac408DOI Listing
July 2022

Comparison Between Sporadic and Multiple Endocrine Neoplasia Type 1-Associated Insulinoma.

J Am Coll Surg 2022 Jun 24. Epub 2022 Jun 24.

Department of Surgery, Mayo Clinic, Rochester, MN.

Background: The differences between sporadic and MEN-1 associated insulinoma are not well described. Herein, we compared demographics, neoplasm characteristics, presentation, and survival in patients with sporadic vs MEN-1 insulinomas including benign and malignant disease.

Methods: A retrospective study identified insulinoma patients. MEN-1 was defined based on genetic testing or clinically in patients with two or more primary MEN-1 tumor types.

Results: A total of 311 patients were identified: 84% benign and 16% malignant. The incidence of malignancy was similar (18% vs. 16%, MEN-1 vs. Sporadic, p = 0.76). Within malignant patients, the median (IQR) age was 33 (25,44) in MEN-1 vs 54 (41,70) in sporadic insulinoma, p=0.04. There was no difference in sex or tumor size between MEN-1 and sporadic malignant insulinoma, p>0.05Of the 260 patients with benign insulinoma, 7% had MEN-1 syndrome. MEN-1 patients presented with insulinoma at a younger age: median (IQR) age was 38 (24, 49) vs 52 (43, 65) years, p<0.01.Resection of benign insulinoma was performed in 78% of the MEN-1 and 94% of the sporadic group, p=0.03. Resected benign tumors were larger in the MEN-1: 2 (1.65, 2.45) cm vs 1.5 (1.2, 2.0) cm, respectively, p=0.03. Concurrent insulinomas were more common in MEN-1 (17% vs 2%), p <0.01.

Conclusion: MEN-1 patients present with insulinoma at younger age and have larger benign pancreatic lesions at the time of resection compared to sporadic neoplasms. Younger patients and those with multifocal pancreatic neuroendocrine tumor in the setting on endogenous hyperinsulinism should be evaluated for MEN-1.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/XCS.0000000000000307DOI Listing
June 2022

Informing therapeutic lymphadenectomy: Location of regional metastatic lymph nodes in adrenocortical carcinoma.

Am J Surg 2022 06 19;223(6):1042-1045. Epub 2021 Oct 19.

Department of Surgery, Mayo Clinic, 200th 1st Street, Rochester, MN, 55905, USA. Electronic address:

Background: The anatomic boundaries of lymphadenectomy for adrenocortical carcinoma (ACC) are not defined.

Methods: Adults undergoing resection of ACC were included. Locations were categorized based on positive LN locations on final pathology.

Results: Of 231 resected ACC, 6% had positive LN during initial resection. Positive LN in left ACC (n = 7) were: 2 para-aortic, 2 left renal-hilar, 1 para-aortic and left renal-hilar and 1 unknown, while for right ACC (n = 7): 2 para-caval, 1 para-caval and right renal-hilar, 1 inter-aortocaval, 1 celiac, 1 para-aortic, and 1 unknown. Of 55 resections for recurrent ACC, positive LN in left ACC (n = 2) were: 1 para-aortic, and 1 para-aortic with left renal-hilar, while LN for right ACC (n = 7): 2 inter-aortocaval, 2 right renal-hilar, 2 para-caval and one retrocrural.

Conclusion: The most common LN metastases are para-caval for right, and para-aortic and left renal-hilar for left ACC. Further studies are necessary to determine the boundaries of lymphadenectomy in ACC resection.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.amjsurg.2021.10.014DOI Listing
June 2022

Medullary thyroid cancer: What is the optimal management of the lateral neck in a node negative patient at index operation?

Surgery 2022 01 18;171(1):177-181. Epub 2021 Jul 18.

Department of Surgery, Mayo Clinic, Rochester, MN. Electronic address:

Background: Medullary thyroid cancer is a neuroendocrine malignancy that can occur sporadically or as the result of genomic rearranged during transfection mutations. Medullary thyroid cancer has a higher rate of metastasis than well-differentiated thyroid cancer. Lateral neck dissection is often performed, and its prophylactic use is controversial.

Methods: Single-center, retrospective review (2000-2017) of patients undergoing primary surgical treatment for medullary thyroid cancer who had negative lateral neck imaging preoperatively. Demographics, genetic associations, clinical, and imaging findings were analyzed. Locoregional recurrence, overall recurrence, and overall survival were examined.

Results: A total of 110 patients were identified, of which 18 underwent prophylactic lateral neck dissection and 92 did not. Age, sex distribution, preoperative calcitonin levels, and follow-up were similar among groups. Overall recurrence was 20% for no prophylactic lateral neck dissection and 39% for prophylactic lateral neck dissection (P = .46). Most recurrences were locoregional recurrence, 7.6% for no prophylactic lateral neck dissection versus 22% for prophylactic lateral neck dissection (P = .08), half of it being to the lateral neck in both groups. A total of 7 patients from the no prophylactic lateral neck dissection group required treatment for recurrences versus 4 patients in prophylactic lateral neck dissection group (P = .57). Overall survival at 5 years was similar, 43% the no prophylactic lateral neck dissection group and 31% for prophylactic lateral neck dissection group (P = .52).

Conclusion: Lateral neck dissection has no effect in decreasing locoregional or overall recurrences in medullary thyroid cancer and has no effect in overall survival when performed prophylactically at index surgical intervention.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.surg.2021.04.052DOI Listing
January 2022

Perspectives on virtual interviews-A follow-up study of the Comprehensive Endocrine Surgery Fellowship interview process.

Surgery 2022 01 13;171(1):259-264. Epub 2021 Jul 13.

Boston University School of Medicine and Boston Medical Center, MA. Electronic address:

Background: The American Association of Endocrine Surgeons Comprehensive Endocrine Surgery Fellowship interview stakeholders previously favored in-person interviews, despite time and expense. This study assessed perception changes given mandated virtual interviews because of coronavirus disease 2019.

Methods: Immediately after the 2020 Match, anonymous surveys were distributed to applicants (n = 37) and program directors (n = 22). Mixed-methods analyses were used to evaluate responses. Results were compared to data from a prior study of the 2013 to 2018 in-person interview process.

Results: Response rates were 82% (program directors) and 60% (applicants). Compared with prior applicants, 2020 applicants attended similar numbers of interviews (1-10, 32% vs 37%; P = .61), used fewer vacation days (23% vs 56%; P = .01), and most reported 0 expenses. Burdens included lack of protected time for interviews. The virtual format did not compromise applicant ability to meet faculty (mean rank = 6.8/10) or make favorable impressions (mean rank = 6.8/10). Program directors reported equivalent or improved assessments of applicants. Program directors (72%) and applicants (77%) indicated that future interviews should be partially or completely virtual.

Conclusion: In contrast to prior survey data, applicants and program directors now express interest in virtual or hybrid interview processes. Virtual interviews were less costly, less time-consuming, and met goals effectively. Integrating virtual interview components will require innovative strategies to reduce redundancies and promote equitable access.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.surg.2021.03.069DOI Listing
January 2022

Diagnostic Accuracy of Dehydroepiandrosterone Sulfate and Corticotropin in Autonomous Cortisol Secretion.

Biomedicines 2021 Jun 28;9(7). Epub 2021 Jun 28.

Division of Endocrinology, Mayo Clinic, Rochester, MN 55902, USA.

Autonomous cortisol secretion (ACS) affects up to 50% of patients with adrenal adenomas. Despite the limited evidence, clinical guidelines recommend measurement of serum concentrations of dehydroepiandrosterone-sulfate (DHEA-S) and corticotropin (ACTH) to aid in the diagnosis of ACS. Our objective was to determine the accuracy of serum concentrations of DHEA-S and ACTH in diagnosing ACS. We conducted a retrospective single center study of adults with adrenal adenoma evaluated between 2000-2020. Main outcome measure was diagnostic accuracy of DHEA-S and ACTH. ACS was defined as post-dexamethasone cortisol >1.8 mcg/dL. Of 468 patients, ACS was diagnosed in 256 (55%) patients with a median post-DST cortisol of 3.45 mcg/dL (range, 1.9-32.7). Patients with ACS demonstrated lower serum concentrations of DHEA-S (35 vs. 87.3 mcg/dL, < 0.0001) and ACTH (8.3 vs. 16 pg/mL, < 0.0001) compared to patients with non-functioning adrenal tumors (NFAT). Serum DHEA-S concentration <40 mcg/dL diagnosed ACS with 84% specificity and 81% PPV, while serum ACTH concentration <10 pg/mL diagnosed ACS with 75% specificity and 78% PPV. The combination of serum concentrations of DHEA-S <40 mcg/dL and ACTH <10 pg/mL diagnosed ACS with the highest accuracy with 92% specificity and 87% PPV. Serum concentrations of DHEA-S and ACTH provide additional value in diagnosing ACS.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.3390/biomedicines9070741DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8301396PMC
June 2021

Multiple endocrine neoplasia type 1 in children and adolescents: Clinical features and treatment outcomes.

Surgery 2022 01 26;171(1):77-87. Epub 2021 Jun 26.

Academic Endocrine Unit, Radcliffe Department of Medicine, University of Oxford, Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, United Kingdom. Electronic address:

Background: Clinical manifestations and treatment outcomes in children and adolescents with multiple endocrine neoplasia type 1 are not well characterized.

Methods: We conducted a retrospective cohort study of 80 patients with multiple endocrine neoplasia type 1 who commenced tumor surveillance at ≤18 years of age.

Results: Fifty-six patients (70%) developed an endocrine tumor by age ≤18 years (median age = 14 years, range = 6-18 years). Primary hyperparathyroidism occurred in >80% of patients, with >70% undergoing parathyroidectomy, in which less-than-subtotal (<3-gland) resection resulted in decreased disease-free outcomes versus subtotal (3-3.5-gland) or total (4-gland) parathyroidectomy (median 27 months versus not reached; P = .005). Pancreaticoduodenal neuroendocrine tumors developed in ∼35% of patients, of whom >70% had nonfunctioning tumors, >35% had insulinomas, and <5% had gastrinomas, with ∼15% having metastases and >55% undergoing surgery. Pituitary tumors developed in >30% of patients, and ∼35% were macroprolactinomas. Tumor occurrence in male patients and female patients was not significantly different. Genetic analyses revealed 38 germline MEN1 mutations, of which 3 were novel.

Conclusion: Seventy percent of children aged ≤18 years with multiple endocrine neoplasia type 1 develop endocrine tumors, which include parathyroid tumors for which less-than-subtotal parathyroidectomy should be avoided; pancreaticoduodenal neuroendocrine tumors that may metastasize; and pituitary macroprolactinomas.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.surg.2021.04.041DOI Listing
January 2022

Comparison of short- and long-term postoperative occurrences after robotic single-incision cholecystectomy versus multiport laparoscopic cholecystectomy.

Surg Endosc 2022 04 3;36(4):2357-2364. Epub 2021 May 3.

Department of Surgery, Mayo Clinic, 200 1st St SW, Rochester, MN, 55905, USA.

Background: Long-term outcomes of SIRC are not well established. Furthermore, SIRC is only now being considered more frequently for patients with independent risk factors for PSH, such as obesity. As such, the paucity of data on longer-term post-surgical outcomes of SIRC is particularly notable as it pertains to obese patients.

Methods: All patients undergoing cholecystectomy performed by two surgeons at our institution from 2008-2018 were reviewed. Our inclusion criteria were patients who underwent SIRC or multiport laparoscopic cholecystectomy (MPLC) and had at least one month of postoperative follow-up. Patients who underwent additional procedures at the time of cholecystectomy were excluded. Our outcomes of interest were the 30-day POC rate and the long-term PSH rate. Analysis was conducted on an intention-to-treat basis, using logistic regression analysis for POC and time-to-event analysis for PSH.

Results: We examined 584 patients who underwent either SIRC (51%) or MPLC (49%). Of the 296 patients who underwent SIRC, 15 (5%) developed a POC and 23 (8%) developed a PSH. Of the 288 patients who underwent MPLC, 11 (4%) developed a POC, and 28 (10%) developed a PSH. Procedure group and obesity was not associated with the risk of POC (p = 0.29, p = 0.21, respectively). Procedure group was not associated with an increased risk of PSH (p = 0.29). Obese patients, however, were 1.94 times more likely to develop PSH compared to non-obese patients overall (p = 0.02).

Conclusions: There is no statistically significant difference in POC and PSH rate following SIRC when compared with MPLC in patients in the same BMI group. Male gender and prior abdominal surgery are risk factors for POC, while advancing age and obesity are risk factors for PSH.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s00464-021-08513-yDOI Listing
April 2022

Preoperative Imaging in Renal Transplant Patients with Tertiary Hyperparathyroidism.

World J Surg 2021 08 27;45(8):2454-2462. Epub 2021 Mar 27.

Department of Surgery, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA.

Background: Tertiary hyperparathyroidism following kidney transplantation is most commonly characterized by 4-gland hyperplasia, but single and double adenomatous disease has been demonstrated in this population as well. It is unknown whether preoperative imaging can assist in identifying patients who may qualify for focused surgery for adenomatous disease.

Materials And Methods: We performed a retrospective review of our patient database from 1998-2018 for patients with tertiary hyperparathyroidism following renal transplant. Patient charts were reviewed for patient demographics, laboratory values, preoperative imaging, operative findings, pathology, and complications.

Results: We identified 113 patients with tertiary hyperparathyroidism following renal transplant who underwent parathyroidectomy. There were 51 females and 62 males with a mean age of 53.4 ± 13.4 years. Median preoperative calcium and PTH were 10.9 mg/dl (IQR 10.3-11.2) and 228 pg/ml (IQR 118-305). Preoperative ultrasound was performed in 60 patients. Of these, 11 (18%) were negative, 38 (63%) showed 1-2 adenomas, and 11 (18%) showed ≥ 3 adenomas. 99mTc-sestamibi parathyroid scintigraphy was performed in 101/113 patients. Of these, 11 (11%) were negative, 62 (61%) showed 1-2 areas of discordant sestamibi uptake, and 28 (28%) showed ≥ 3 areas of discordant uptake. Ultimately, 19 (17%) patients had a single adenoma removed, 16 (14%) had 2 adenomas removed, and (69%) had multi-gland disease. There were 26 ectopic glands found in 21 patients, 42.3% of which were identified on preoperative imaging. 94.1% of patients were eucalcemic at last follow-up, mean (± SD) 5.8 ± 3.6 years. Adenomas that were visualized on ultrasound were larger on pathology than those non-visualized (997 ± 120 mg (mean ± SE) vs. 388 ± 109 mg, p = 0.0003). This was also true for parathyroid scintigraphy (647 ± 41 mg vs. 355 ± 51 mg, p = 0.0001).

Conclusion: In patients with tertiary hyperparathyroidism, preoperative imaging can aid in predicting which patients will have 1-2 gland disease. In patients with 1-2 gland disease on congruent ultrasound and nuclear medicine imaging studies, the accuracy increases to 59%. Preoperative imaging can help identify ectopic glands. Larger adenomas are more likely to be identified on both imaging modalities.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s00268-021-06098-0DOI Listing
August 2021

Occurrence and Natural History of Thyroid Cancer in Patients with Cowden Syndrome.

Eur Thyroid J 2020 Sep 12;9(5):243-246. Epub 2020 Mar 12.

Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA.

Introduction: Cowden syndrome patients are at an increased risk of developing differentiated thyroid carcinoma (DTC). There are limited studies of thyroid cancer biology within this population. We aimed to describe the frequency and progression of DTC in this population.

Method: We reviewed all patients with clinically or genetically confirmed Cowden syndrome treated at our institution between 1979 and 2017. Presentation, operative details, pathology, and adjuvant treatment for all thyroid diseases were analyzed.

Results: Forty-seven patients were identified. Thirty-seven received a clinical diagnosis while 10 tested positive on genetic testing for the gene. Average follow-up time was 10 years. Twenty-three patients underwent a total thyroidectomy. Nine patients were diagnosed with thyroid cancer, with a mean age of 28.5 years, 4 cases of the follicular variant of papillary thyroid cancer (PTC), 4 of PTC, and 1 of cystic PTC. One patient required an interval lateral neck dissection but no patients developed distant metastasis. Fourteen patients underwent thyroidectomy, 12 due to follicular adenoma, Hürthle cell adenoma, or multinodular goiter, 1 due to Graves' disease, and 1 who elected to undergo a prophylactic thyroidectomy. No mortality was associated with thyroid cancer in these patients.

Conclusion: Patients with Cowden syndrome are at a significantly increased risk of developing DTC and have a younger age of onset. In this study, 20% of the patients with Cowden syndrome were diagnosed with DTC, but distant metastasis and overall mortality were absent. Clinical features were similar to those of sporadic DTC, proving that, apart from screening, Cowden syndrome-related DTC can be treated in similar fashion.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1159/000506422DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7548836PMC
September 2020

Positive Lymph Nodes in Adrenocortical Carcinoma: What Does It Mean?

World J Surg 2021 Jan 9;45(1):188-194. Epub 2020 Oct 9.

Department of Surgery, Mayo Clinic, Rochester, MN, USA.

Background: The role of lymphadenectomy in adrenocortical carcinoma resection is controversial. Therefore, we conducted a population-based study to assess the association between positive lymph nodes (LN) and survival.

Methods: The Surveillance, Epidemiology, and End Results set of cancer registries were utilized. The associations between positive lymph nodes and tumor size, grade and laterality were assessed. Cancer specific survival (CSS) trends and factors affecting survival were analyzed.

Results: A total of 2170 adult patients were identified; 60% underwent resection. Among those resected, LN were examined in 23% and were positive in 25% of patients with LN examined. Patients with positive LN tended to have smaller tumors compared to those with negative LN (12 ± 5 vs 15 ± 11 cm, p = 0.02). The rate of positive LN was higher in right ACC, p = 0.03. Median overall CSS was 21 months, with significant differences between resection (42 months) and no resection (4 months), p < 0.01. Median CSS did not change over time when comparing ACC patients who underwent surgery before 2000, 2000-2009, and 2010-2016. On multivariable analysis including resection group, advanced age, grades III and IV, regional and distant stage, in addition to positive LN were associated with worse survival, p < 0.05.

Conclusion: Lymphadenectomy is infrequently performed during ACC resection, and when performed, regional LN involvement tends to be associated with worse survival. Neoplasm size and grade were not associated with LN involvement and therefore, do not inform lymphadenectomy need. Further studies are needed to assess the indications for, and value of lymphadenectomy in ACC.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s00268-020-05801-xDOI Listing
January 2021

Is same-day discharge associated with increased 30-day postoperative complications and readmissions in patients undergoing laparoscopic adrenalectomy?

Surgery 2021 02 30;169(2):289-297. Epub 2020 Sep 30.

Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN.

Background: Advances in minimally invasive surgery and perioperative care have decreased substantially the duration of time that patients spend recovering in hospital, with many laparoscopic procedures now being performed on an ambulatory basis. There are limited studies, however, on same-day discharge after laparoscopic adrenalectomy. The objectives of this study were to investigate the outcomes and trends of ambulatory laparoscopic adrenalectomy in a multicenter cohort of patients.

Methods: Adult patients who underwent elective laparoscopic adrenalectomy between 2005 and 2016 were identified in the database of the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP). Baseline demographics and 30-day outcomes were compared between patients who underwent ambulatory laparoscopic adrenalectomy and those who were discharged after an inpatient stay. Multivariable logistic regression and Cox proportional hazards modelling were used to investigate the association between same-day discharge and 30-day complications and unplanned readmissions.

Results: Of the 4,807 patients included in the study, 88 (1.8%) underwent ambulatory laparoscopic adrenalectomy and 4,719 (98.2%) were admitted after the adrenalectomy. The same-day discharge group contained fewer obese patients (37.2% vs 50%; P = .04), a lesser proportion of American Society of Anesthesiologists class III patients (45.5% vs 61%; P = .003), and more patients with primary aldosteronism (14.8% vs 6%; P = .002) compared with the inpatient group. After adjustment for confounders, same-day discharge was not associated with 30-day overall complications (OR 1.17, 95% CI 0.35-3.85; P = .80) or unplanned readmissions (HR 2.77, 95% CI 0.86-8.96; P = .09). The percentage of laparoscopic adrenalectomies performed on an ambulatory basis at hospitals participating in the ACS NSQIP remained low throughout the study period (0-3.1% per year) with no evidence of an increasing trend over time (P = .21).

Conclusion: Ambulatory laparoscopic adrenalectomy is a safe and feasible alternative to inpatient hospitalization in selected patients. Further study is needed to determine the cost savings, barriers to uptake, and optimal selection criteria for this approach.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.surg.2020.08.018DOI Listing
February 2021

Differences in outcomes of bilateral adrenalectomy in patients with ectopic ACTH producing tumor of known and unknown origin.

Am J Surg 2021 02 5;221(2):460-464. Epub 2020 Sep 5.

Mayo Clinic, Department of Surgery, 200 1st Street, 55905, Rochester, MN, USA. Electronic address:

Background: Endogenous Cushing syndrome (CS) can be caused by ectopic corticotropin-producing tumors of known (EK) and unknown origin (EU). Bilateral adrenalectomy (BA) can be used as definite treatment of hypercortisolism in such cases. This study compared patients undergoing BA for CS secondary to EK vs EU.

Methods: Retrospective review (1995-2017) of patients undergoing BA due to EK or EU. We analyzed demographic characteristics, laboratory values, intraoperative variables, surgical outcomes, and survival.

Results: 48 patients (26 EU, 22 EK) were identified. Serum cortisol and ACTH concentrations were similar. 92% of BA for EU were performed minimally invasively vs 77% for EK, P = 0.22. Complications occurred in 19% of EU and 4.5% EK, P = 0.2. Mean survival was 4.3 years for EU and 4.0 years for EK without difference in all-cause mortality P = 0.63.

Conclusion: BA cure rate was 100% for CS in EU and EK. Morbidity, long term and all-cause mortality differences were not statistically significant between EK and EU.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.amjsurg.2020.08.047DOI Listing
February 2021

Comparison of benign and malignant insulinoma.

Am J Surg 2021 02 16;221(2):437-447. Epub 2020 Aug 16.

Department of Surgery, Mayo Clinic, 200th 1st Street, Rochester MN, 55905, USA. Electronic address:

Background: How malignant insulinomas present relative to benign insulinomas is unknown.

Methods: A single-institution retrospective study identified patients with insulinoma. Malignancy was defined by distant metastases, positive lymph node(s), T stage of 4, direct invasion into surrounding peripancreatic tissue, or presence of lymphovascular invasion. Wilcoxon Rank Sum tests and Kaplan-Meier analysis were used.

Results: A total of 311 patients were identified: 51 malignant and 260 benign. Patients with malignant insulinoma presented with higher levels of insulin, proinsulin, and c-peptide. Malignant lesions were larger: 4.2 ± 3.2 vs 1.8 ± 0.8 cm in benign lesions, p < 0.01. Overall survival at 5 years was 66.8% vs 95.4% for malignant and benign insulinoma respectively, p < 0.01.

Conclusions: Larger size of insulinoma and increased serum β-cell polypeptide concentrations were associated with malignancy. Malignant insulinoma has poorer survival. Further work-up to rule out malignancy may be indicated for larger pancreatic lesions and for patients with higher pre-operative insulin and pro-insulin.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.amjsurg.2020.08.003DOI Listing
February 2021

Optimizing the fellowship interview process: Perspectives from applicants and program directors of the comprehensive endocrine surgery fellowship program.

Surgery 2021 03 25;169(3):488-495. Epub 2020 Aug 25.

Department of Surgery, Medical College of Wisconsin, Milwaukee, WI.

Background: Approximately 80% of general surgery residents undertake some form of fellowship training. Our objective was to characterize goals and burdens of the interview process among applicants to Comprehensive Endocrine Surgery Fellowship programs.

Methods: Participants included trainees from 2013 to 2019. Results for ranking questions are presented as a mean rank reported out of the total number of selections.

Results: Response rate was 54% (n = 75). The most important goal for interviews was meeting the faculty (mean rank 2.4/9), followed by "behind the scenes information" and "make a good impression" (mean rank 3.6 and 3.7, respectively). The most substantial burden for the applicant was expense (mean rank 2.1/7), followed by time away from residency (mean rank 3.1/7). The economic burden of 51% of the applicants was $2,500 to $7,500. Geographic location and expense were the top 2 reasons applicants declined offers of interviews. Despite the process, 76% of respondents indicated that no improvements to the interview process are necessary. Alternative strategies such as videoconferencing or centralized interviews received little support (<10%).

Conclusion: Despite identifying several burdens, survey respondents believed that in-person interviews are an integral component of the fellowship application process. Indeed, 70% of applicants do not have a first-choice program before interviews, and meeting the faculty is ranked as the greatest priority goal. Our data illustrate the importance of individual specialties evaluating and optimizing their own processes for fellowship interviews.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.surg.2020.06.037DOI Listing
March 2021

Impact of opioid prescribing guidelines on prescribing at discharge from endocrine surgery.

Am J Surg 2021 02 18;221(2):455-459. Epub 2020 Aug 18.

Department of Health Services Research, Mayo Clinic, 200th 1st Street, Rochester MN, 55905, USA; Mayo Clinic Robert D and Patricia E Kern Center for the Science of Health Care Delivery, 200th 1st Street, Rochester MN, 55905, USA. Electronic address:

Introduction: In 2018, our institution implemented opioid prescribing guidelines for endocrine surgery.

Methods: We evaluated prescribing trends before and after the guidelines (60 MME following adrenal procedures and 37.5 MME for thyroid/parathyroid procedures) using chi-squared and Wilcoxon Rank-Sum tests.

Results: We identified 357 patients in the pre-guideline and 397 in the post-guideline period. The proportion discharged with any opioid prescription decreased from 96.1% to 77.3%, p < 0.01, and the median (IQR) prescribed amount decreased from 150.0 (100.0, 200.0) to 50.0 (25.0, 75.0), p < 0.01 overall and within each category. The proportion receiving prescription above the upper guidelines limit also decreased, while opioid refills within 30-day of discharge remained stable (2.8% before and 4.5% after the guidelines, p = 0.21).

Conclusion: Opioid prescribing guidelines for endocrine surgical procedures decreased both the proportion of patients receiving opioids and the amount when prescribed, therefore further supporting the utility of opioid prescribing guidelines in decreasing over-prescription.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.amjsurg.2020.08.004DOI Listing
February 2021

Parathyroidectomy improves hypercalciuria in patients with primary hyperparathyroidism.

Surgery 2020 10 15;168(4):594-600. Epub 2020 Aug 15.

Department of Surgery, Mayo Clinic, Rochester, MN. Electronic address:

Background: Hypercalciuria is an important manifestation of primary hyperparathyroidism and may contribute to the risk of nephrolithiasis. This study examined the impact of parathyroidectomy on 24-hour urinary calcium (24-hour U) levels and rates of resolution of hypercalciuria after surgery.

Methods: A retrospective cohort study was performed of patients who underwent curative parathyroidectomy for primary hyperparathyroidism from 2007 to 2017. Baseline and postoperative urine and serum biochemistry levels were analyzed. The relationship between preoperative 24-hour U levels and the absolute decrease in postoperative U excretion was assessed using Spearman's rank correlation coefficient.

Results: Of 110 patients, 84 (76.4%) experienced a ≥20% decrease in 24-hour U level postoperatively. These patients had a higher baseline median 24-hour U level (293.5 vs 220.5 mg/24-hour; P = .001), higher baseline mean serum parathyroid hormone (106.5 vs 83; P = .05) and were more likely to have single gland disease (85.7% vs 65.4%, P = .04) compared with patients in whom 24-hour U excretion did not improve. Of the 28 patients (25%) who were hypercalciuric (24-hour U >400 mg/day) at baseline, 22 (79%) became normocalciuric postoperatively. A linear correlation was observed between preoperative 24-hour U levels and the decline in 24-hour U excretion after surgery (R = 0.59, P < .0001) such that the degree of improvement could be predicted using the following equation: absolute decrease in postoperative 24-hour U = 0.68 × preoperative 24-hour U-68.

Conclusion: Parathyroidectomy reduces 24-hour U excretion in the majority of patients with PHPT and restores normocalciuria in 79% of patients with hypercalciuria at baseline.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.surg.2020.07.010DOI Listing
October 2020

Not all adrenal incidentalomas require biochemical testing to exclude pheochromocytoma: Mayo clinic experience and a meta-analysis.

Gland Surg 2020 Apr;9(2):362-371

Department of Surgery, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA.

Background: Excluding a pheochromocytoma is important when a patient presents with an incidentally discovered adrenal mass. However, biochemical testing for pheochromocytoma can be cumbersome, time consuming, or falsely positive. Our objective was to determine if unenhanced computed tomography (CT) imaging alone can be used to rule out pheochromocytoma.

Methods: We performed a retrospective study of all patients with a pathologically confirmed pheochromocytoma and unenhanced CT imaging who were treated at the Mayo Clinic between 1998 and 2016. Additionally, we performed a systematic review and meta-analysis of original studies published after 2005 with patients who had adrenal masses, more than 10 patients with pheochromocytomas, and reported attenuation on unenhanced CT imaging in Hounsfield units (HU).

Results: In the Mayo cohort, we identified 186 patients and 199 pheochromocytomas with unenhanced CT imaging. The mean unenhanced CT attenuation was 35±9 HU (range, 15-62), and only 15 tumors had attenuation ≤20 HU. The systematic review identified 26 studies (1,217 tumors), and 23 studies provided a mean unenhanced CT attenuation. The overall mean unenhanced CT attenuation across the studies was 35.6 HU (95% CI, 22.0-49.1 HU). A cutoff of >10 HU had a 100% sensitivity (95% CI, 1.00-1.00) for pheochromocytoma with low heterogeneity between the 21 qualified studies (I=0%). Sensitivity for pheochromocytoma was 100% and 99% for an unenhanced CT attenuation cutoff of >15 and >20 HU.

Conclusions: Biochemical testing may not be required to exclude pheochromocytoma if an incidental adrenal mass has low attenuation (<10 HU) on unenhanced CT images.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.21037/gs.2020.03.04DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7225448PMC
April 2020

Bilateral Adrenalectomy: Differences between Cushing Disease and Ectopic ACTH-Producing Tumors.

Ann Surg Oncol 2020 Oct 9;27(10):3851-3857. Epub 2020 May 9.

Department of Surgery, Mayo Clinic, Rochester, MN, USA.

Background: Bilateral adrenalectomy (BA) is a curative treatment for hypercortisolism in patients with corticotropin (ACTH)-dependent Cushing syndrome. Indications include refractory Cushing's disease (CD) following failed pituitary surgery, and occult or unresectable ectopic ACTH-producing neoplasms (EA).

Methods: This was a single-center, retrospective review (1995-2017) of patients undergoing BA for CD or EA. Demographics, laboratory findings, and intraoperative and postoperative variables were analyzed.

Results: Of 137 patients, 83 (61%) had CD and 54 (39%) had EA; 87% of CD patients were female versus 46% of EA patients (p < 0.0001). Mean age at diagnosis was 40 ± 15 years for CD and 49 ± 18 years for EA (p = 0.004). Preoperative serum cortisol concentrations were higher in the EA cohort (63 ± 40 μg/dL) versus the CD cohort (33 ± 19 μg/dL) [p < 0.001], with no significant differences in serum ACTH. Time from diagnosis until adrenalectomy was 54 ± 69 months for CD versus 4 ± 13 for EA (p = 0.002). Most patients underwent minimally invasive surgery (MIS; 86% CD vs. 75% EA; p = 0.19). There was no difference between the rates of conversion to an open approach, intraoperative blood loss, or operative time between groups, and no difference between complications in CD versus EA (p = 1.0). Five-year survival was significantly shorter among the EA cohort (30% for EA vs. 80% for CD; p < 0.001).

Conclusion: Patients with EA presented with higher serum cortisol levels compared with patients with CD. EA patients were more likely to require intraoperative transfusion and postoperative intensive care. BA in patients with CD and EA can be performed safely in an MIS fashion, with similar morbidity; however, survival at 5 years was significantly less in the EA cohort.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1245/s10434-020-08451-4DOI Listing
October 2020

Clinical course of adrenal myelolipoma: A long-term longitudinal follow-up study.

Clin Endocrinol (Oxf) 2020 07 23;93(1):11-18. Epub 2020 Apr 23.

Division of Endocrinology, Diabetes, and Nutrition, Mayo Clinic, Rochester, MN, USA.

Objective: We aimed to describe clinical course of myelolipoma and to identify predictors of tumour growth and need for surgery.

Design: A retrospective study.

Patients: Consecutive patients with myelolipoma.

Results: A total of 321 myelolipomas (median size, 2.3 cm) were diagnosed in 305 patients at median age of 63 years (range, 25-87). Median follow-up was 54 months. Most myelolipomas were incidentally detected (86%), whereas 9% were discovered during cancer staging and 5% during workup of mass effect symptoms. Thirty-seven (12%) patients underwent adrenalectomy. Compared to myelolipomas <6 cm, tumours ≥6 cm were more likely to be bilateral (21% vs 3%, P < .0001), cause mass effect symptoms (32% vs 0%, P < .0001), have haemorrhagic changes (14% vs 1%, P < .0001) and undergo adrenalectomy (52% vs 5%, P < .0001). Among patients with ≥6 months of imaging follow-up, median size change was 0 mm (-10, 115) and median growth rate was 0 mm/y (-6, 14). Compared to <1 cm growth, ≥1 cm growth correlated with larger initial size (3.6 vs 2.3 cm, P = .02), haemorrhagic changes (12% vs 2%, P = .007) and adrenalectomy (35% vs 8%, P < .0001).

Conclusions: Most myelolipomas are incidentally discovered on cross-sectional imaging. Myelolipomas ≥6 are more likely to cause mass effect symptoms, have haemorrhagic changes and undergo resection. Tumour growth ≥1 cm is associated with larger myelolipoma and haemorrhagic changes. Adrenalectomy should be considered in symptomatic patients with large tumours and when there is evidence of haemorrhage or tumour growth.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1111/cen.14188DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7292791PMC
July 2020

Predicting Postthyroidectomy Hypocalcemia: Improving Predictive Ability of Parathyroid Hormone Level.

Am Surg 2020 Feb;86(2):121-126

We performed a retrospective study of our large patient cohort aiming to examine the ability to predict postthyroidectomy hypocalcemia. A retrospective review of patients who underwent total or near-total thyroidectomy at our institution between 2008 and 2018 was performed. Postoperative hypocalcemia was defined as Ca level <8.0 mg/dL (reference range: 8.9-10.1 mg/dL) within 30 days of operation. Logistic regression was used to develop models for prediction of the occurrence of postoperative hypocalcemia. Inclusion criteria were met by 1463 patients. Hypocalcemia was documented in 223 patients (15%). Models based on parathyroid hormone (PTH) levels alone had an associated receiver operator characteristic with an areas under the curve (AUC) of 0.79. There was an inverse relationship between time of measurement and PTH levels within the first two hours after thyroidectomy ( < 0.01). When measured two to six hours after closure, the predictive ability of PTH compared favorably (AUC = 0.82) with either earlier (within the first two hours after closure, AUC = 0.79) or later measurement (6-24 hours after closure, AUC = 0.77). When measured between two and six hours postoperatively, PTH < 19 pg/mL had a sensitivity of 90 per cent and negative predictive value of 96 per cent for postoperative hypocalcemia. The model that included the PTH level, concurrently measured total blood calcium level, and time of measurement had an improved predictive ability with an AUC of 0.87. PTH level of 19 pg/mL measured two to six hours after thyroidectomy had a sensitivity of 90 per cent and a negative predictive value of 96 per cent in our cohort. The model including postoperative PTH level, calcium level, and time of measurement may further improve the ability to predict postthyroidectomy hypocalcemia.
View Article and Find Full Text PDF

Download full-text PDF

Source
February 2020

Adrenalectomy for non-neuroblastic pathology in children.

Pediatr Surg Int 2020 Feb 5;36(2):129-135. Epub 2019 Nov 5.

Department of Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.

Background: Adrenalectomy for non-neuroblastic pathologies in children is rare with limited data on outcomes. We reviewed our experience of adrenalectomy in this unique population.

Methods: Retrospective study of children (age ≤ 18) who underwent adrenalectomy with non-neuroblastic pathology from 1988 to 2018. Clinical and operative details of patients were abstracted. Outcomes included length of stay and 30-day postoperative morbidity.

Results: Forty children underwent 50 adrenalectomies (12 right-sided, 18 left-sided, 10 bilateral). Six patients (15%) presented with an incidental adrenal mass while 4 (10%) had masses found on screening for genetic mutations or prior malignancy. The remaining 30 (75%) presented with symptoms of hormonal excess. Nineteen patients (48%) underwent genetic evaluation and 15 (38%) had genetic predispositions. Diagnoses included 9 patients (23%) with pheochromocytoma, 8 (20%) with adrenocortical adenoma, 8 (20%) with adrenocortical carcinoma, 7 (18%) with adrenal hyperplasia, 2 (5%) with metastasis, and 6 (14%) with additional benign pathologies. Of 50 adrenalectomies, twenty-five (50%) were laparoscopic. Median hospital length of stay was 3 days (range 0-11). Post-operative morbidity rate was 17% with the most severe complication being Clavien-Dindo grade II.

Conclusion: Adrenalectomy for non-neuroblastic pathology can be done with low morbidity. Its frequent association with genetic mutations and syndromes requires surgeons to have knowledge of appropriate pre-operative testing and post-operative surveillance.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s00383-019-04589-9DOI Listing
February 2020

Comparison between functional and non-functional adrenocortical carcinoma.

Surgery 2020 01 19;167(1):216-223. Epub 2019 Sep 19.

Department of Surgery, Mayo Clinic, Rochester, MN. Electronic address:

Background: While roughly half of adrenocortical carcinomas are functional, whether functional status impacts outcomes remains controversial. We compared presentation and survival for functional and nonfunctional neoplasms.

Methods: Adult patients presented with adrenocortical carcinomas at the Mayo Clinic were included. Tumor characteristics and outcomes were analyzed.

Results: The 266 identified patients presented with stage I (6%), II (33%), III (26%), and IV disease (32%); stage was unknown in 3%. Fifty-three percent of tumors were functional; patients with functional adrenocortical carcinomas were younger, more likely to be female, and more likely to present with metastatic disease. Surgical resection was undertaken in 84% of patients with 69% having R0 resection. While 30-day morbidity was similar between functional and nonfunctional adrenocortical carcinomas, median overall survival was better for nonfunctional adrenocortical carcinomas (median 66 vs 22 months, P = .01). Functional adrenocortical carcinomas was independently associated with shorter survival after adjusting for age, sex, grade, stage, and resection attempt: hazard ratio = 1.5 (95% confidence interval, 1.04-2.14, P = .03).

Conclusion: In our cohort, long term survival was worse for all patients with functional tumors. However, when analyzing patients with R0 resection, there was no survival difference between functional and nonfunctional adrenocortical carcinomas, signaling need for better understanding of adrenocortical carcinomas behavior to individualize and optimize treatment strategies.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.surg.2019.04.066DOI Listing
January 2020

Optimizing Opioid-Prescribing Practices After Parathyroidectomy.

J Surg Res 2020 01 12;245:107-114. Epub 2019 Aug 12.

Mayo Clinic, Surgical Outcomes Program, Robert D and Patricia E Kern Center for The Science of Health Care Delivery, Rochester, Minnesota. Electronic address:

Background: To help control opioid overprescription, we conducted a large institutional, 3-site initiative to provide discharge prescribing guidelines for different procedures. Our aim is to refine institutional guidelines for parathyroidectomy.

Methods: Patients undergoing parathyroidectomy completed a 28-question survey about opioid consumption. Discharge opioid prescription amounts were converted into morphine milligram equivalents (MMEs) and reported as median and interquartile range (IQR). Consumption was dichotomized into top quartile MME users (Q4) versus standard users (Q1, Q3). Univariate analysis compared opioid consumption.

Results: A total of 91 patients were included; 90% were opioid-naive. While the median prescribed was 75 (IQR 75, 150) MME, the median consumed was 0 (IQR 0, 20). Top users reported higher pain scores [median (IQR): 2 (2, 4)] compared to standard users [1 (0, 3), P = 0.01]. However, there was no difference in opioid consumption between unilateral neck exploration, bilateral exploration, or thyroidectomy and parathyroidectomy, P = 0.11. There was no difference in opioid consumption by age, sex, or BMI (all P > 0.05). Of those receiving a prescription, 94.6% had left-over opioids at the time of survey, resulting in 82% of prescribed opioids being unused.

Conclusions: Over half of patients undergoing parathyroidectomy did not consume any opioid, and very few needed more than 2 d of opioid. Moreover, most patients did not dispose the unused opioids, which put these pills at risk of diversion and misuse. Surgical approach did not change consumption, illustrating that these guidelines are applicable to thyroidectomy given the similarity between techniques. We recommend prescribing nonopioid analgesics for patients undergoing parathyroidectomy.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jss.2019.07.039DOI Listing
January 2020

Primary Aldosteronism: Does Underlying Pathology Impact Clinical Presentation and Outcomes Following Unilateral Adrenalectomy?

World J Surg 2019 10;43(10):2469-2476

Department of Surgery, Mayo Clinic, 200 First Street S.W., Rochester, MN, 55905, USA.

Introduction: Patients undergoing unilateral adrenalectomy for primary aldosteronism (PA) may have a solitary adenoma, unilateral hyperplasia, or multiple adenomas on final pathology. This study investigated whether the underlying pathological diagnosis was associated with differences in clinical presentation and postoperative outcomes.

Methods: A retrospective cohort study of patients undergoing unilateral adrenalectomy for PA from 2004 to 2015 at our institution was performed. Baseline clinical and laboratory parameters, as well as postoperative biochemical and hypertension cure rates, were compared across the three aforementioned pathological groups.

Results: Of 206 patients who met criteria for inclusion, 152 (73.8%) had a single adenoma, 33 (16%) had unilateral hyperplasia, and 21 (10.2%) had multiple unilateral adenomas. Patients with unilateral hyperplasia were more likely to be male (81.2% vs 57.9%, P = .03), undergo left-sided adrenalectomy (78.8% vs 47.4%, P < .01), and had a lower median adrenal venous sampling lateralization index (9.8 vs 19.8, P = .04) compared to those with solitary, but not multiple unilateral adenomas. No differences were seen in age, duration of hypertension, preoperative plasma aldosterone levels, plasma renin activities, 24-h urinary aldosterone excretion, serum potassium concentrations, and the number of preoperative antihypertensive medications across all three pathological groups. All patients achieved biochemical cure following adrenalectomy, and no significant differences in the rates of hypertension cure or improvement were observed in comparisons across pathological subtype.

Conclusions: Clinical presentation and postoperative outcomes are similar regardless of underlying pathology in patients with PA. Because one in four patients may harbor unilateral hyperplasia or multiple adenomas, total unilateral adrenalectomy should be performed as the operation of choice over adrenal-sparing approaches.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s00268-019-05059-yDOI Listing
October 2019

Cushing syndrome: uncovering Carney complex due to novel PRKAR1A mutation.

Endocrinol Diabetes Metab Case Rep 2019 Mar 21;2019. Epub 2019 Mar 21.

Departments of Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, Minnesota, USA.

Carney complex (CNC) is a rare multiple neoplasia syndrome characterized by spotty pigmentation of the skin and mucosa in association with various non-endocrine and endocrine tumors, including primary pigmented nodular adrenocortical disease (PPNAD). A 20-year-old woman was referred for suspected Cushing syndrome. She had signs of cortisol excess as well as skin lentigines on physical examination. Biochemical investigation was suggestive of corticotropin (ACTH)-independent Cushing syndrome. Unenhanced computed tomography scan of the abdomen did not reveal an obvious adrenal mass. She subsequently underwent bilateral laparoscopic adrenalectomy, and histopathology was consistent with PPNAD. Genetic testing revealed a novel frameshift pathogenic variant c.488delC/p.Thr163MetfsX2 (ClinVar Variation ID: 424516) in the PRKAR1A gene, consistent with clinical suspicion for CNC. Evaluation for other clinical features of the complex was unrevealing. We present a case of PPNAD-associated Cushing syndrome leading to the diagnosis of CNC due to a novel PRKAR1A pathogenic variant. Learning points: PPNAD should be considered in the differential for ACTH-independent Cushing syndrome, especially when adrenal imaging appears normal. The diagnosis of PPNAD should prompt screening for CNC. CNC is a rare multiple neoplasia syndrome caused by inactivating pathogenic variants in the PRKAR1A gene. Timely diagnosis of CNC and careful surveillance can help prevent potentially fatal complications of the disease.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1530/EDM-18-0150DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6432981PMC
March 2019

Primary Hyperparathyroidism: Redefining Cure.

Am Surg 2019 Feb;85(2):214-218

Primary hyperparathyroidism is the most common cause of hypercalcemia. Follow-up can be resource-intensive and costly. The aim of this study was to determine if there is a subset of patients who can be defined cured earlier than six months. This was a retrospective study of patients who underwent parathyroidectomy between January 2012 and March 2014. Patients with a history of multiple endocrine neoplasia syndrome, and secondary or tertiary hyperparathyroidism were excluded. Patients with normal preoperative calcium and parathyroid hormone (PTH) and those without six months follow-up were excluded. Patients were divided into two groups: cured and not cured. Data analysis was performed between the two groups. A total of 509 patients were screened, and 214 met our inclusion criteria: 202 in the cured category and 12 in the not cured category (94% cure rate). There was no significant difference between age, gland weight, or preoperative PTH. There was a statistically significant difference between final intraoperative PTH (IOPTH) (37 55, = 0.008) and per cent PTH decrease (69 43%, < 0.0001). There was a significant difference between intraoperative cure rate ( < 0.0006), imaging concordance ( = 0.0115), and solitary multiglandular disease ( = 0.0151). Subgroup analysis in patients with concordant imaging, solitary parathyroid adenoma, and IOPTH decrease by 50 per cent to normal or near-normal correlated with a six-month cure rate of 97 per cent. Patients with primary hyperparathyroidism with concordant imaging, single-adenoma pathology, and IOPTH decrease by 50 per cent to normal or near-normal levels (15-65 pg/mL) can be considered cured and may need less frequent follow-up.
View Article and Find Full Text PDF

Download full-text PDF

Source
February 2019
-->