Douglas L. Fraker

The presence of lymph node (LN) metastases in papillary thyroid cancer (PTC) has limited prognostic utility for predicting disease-specific survival. Pathologic features of the LNs beyond their presence and location do not factor into the AJCC staging system. Most LN metastases are microscopic. The natural history of patients with PTC and clinically evident LN metastases (CELNM) has not been well characterized. Patients with CELNM from PTC undergoing lymph node dissection (LND) by a single surgeon were identified (1999-2009). Patients with and without recurrence were compared by clinical and pathological factors using Student's t test, Fisher's exact test, and Chi-squared test. Logistic regression was used to determine the association between recurrence and CELNM after adjustment for confounders. Ninety-two patients were identified who underwent surgery for CELNM. With a median follow-up of 27.5 months, 27 patients (29%) developed regional nodal recurrence with no disease-related deaths. Patients with and without recurrence were similar with respect to all clinical and pathologic variables analyzed except for the number of metastatic LNs. With a similar number of LNs sampled in both groups, the mean number of metastatic LNs was significantly higher in the group of patients with recurrence versus those without recurrence (12 vs. 6, p = 0.03) and remained significantly associated with the likelihood of recurrence (p = 0.009) in the logistic regression model. Patients with CELNM have an appreciable incidence of early regional cervical recurrence but not distant metastases. Among clinical and pathological factors evaluated, the number of metastatic LNs is associated with recurrence.

Surgery is the only curative treatment for primary hyperparathyroidism. Initial parathyroidectomy procedures fail due to ectopic gland location and unappreciated multigland disease. An evidence-based literature review was performed, which surveyed all human studies in PubMed, searching for parathyroidectomy in humans between 1990 and 2009. Between 10 and 30% of patients have multigland disease caused by double adenomas or hyperplasia. Use of preoperative imaging studies and intraoperative PTH monitoring helps parathyroid surgeons overcome these obstacles. Sestamibi nuclear scan and neck ultrasound identify 70–80% of abnormal glands in patients with single adenomas. The sensitivity of ultrasound or sestamibi to identify all abnormal glands in patients with multigland disease is extremely low. Intraoperative PTH monitoring should be utilized in all patients who undergo neck exploration for primary hyperparathyroidism to reduce failures due to multigland disease. Blood samples should be drawn from peripheral veins only and a postresection level 10–15 min after gland removal should have a >50% decrease from baseline preoperative levels, and also must go to the normal range for the PTH assay being used. Contemporary prospective studies (level of evidence III/IV) show that by combining preoperative imaging and IOPTH it is possible to maximize performance of successful outpatient minimally invasive parathyroidectomy.