Simon Grodski

The histological characteristics of follicular thyroid carcinomas (FTCs) are important predictors of prognosis, and lesions can be classified as either minimally invasive follicular carcinoma (MIFC) or widely invasive follicular carcinoma (WIFC) based on histopathological characteristics. There has been controversy surrounding the histological classification of FTC, which can present challenges to clinicians attempting to deliver accurate prognostic information to their patients. The aim of the present study was to examine cases of metastatic FTC for characteristics that may predict aggressive tumour behaviour. The Monash University Endocrine Surgery Unit database was searched for patients with FTC. The histopathology reports were collated for these patients to confirm the diagnosis of FTC, classify patients into MIFC versus WIFC, and examine for key characteristics such as the capsular and/or vascular invasion. The thyroid specimens from patients with metastatic FTC were examined by reviewing pathologists. It was hypothesized that patients with metastatic disease would likely have WIFC as their primary lesion. There were 64 patients with FTC identified during the period of 1997-2009. Of these, 10 patients were found to have metastatic disease. On review of the histopathology, three patients were found to have WIFC,four patients had MIFC and three patients did not have definite features of FTC found in the thyroid gland. Currently accepted histological classification of FTC is inadequate and fails to accurately predict patients with distant metastatic disease and a more aggressive clinical course. It is thus the policy of our unit to recommend total thyroidectomy and radioactive iodine ablation for all patients with FTC.

Summary: Objective  A new protocol for postoperative calcium management was developed with the aim of achieving an increase in the proportion of patients being safely discharged on the first postoperative day. We present our experience with the first 50 patients treated under this new protocol. Patients and design  A cohort study was performed involving the first 50 patients admitted for total or completion thyroidectomy, those data were then compared with a control group. Intact PTH (iPTH) was measured at 4‐h postoperatively and patients with iPTH in the normal range were discharged on the first postoperative day. Results  Mean age and sex distribution were similar in both groups. Mean lowest postoperative corrected calcium levels in the study group were 2·19 mmol/l and 2·15 mmol/l in the control group (P = 0·24). Parathyroid auto‐transplantaion was associated with low PTH levels (risk ratio = 0·49). Over 50% of patients (n = 27) were successfully discharged on the first postoperative day in the study group and no patient required readmission. Length of stay was significantly shorter in the study group, mean 1·64 vs. 2·20 days (P < 0·05). Conclusion  The use of iPTH accurately predicts hypocalcaemia after total thyroidectomy and can be used to facilitate safe early discharge for patients.

Background: Total thyroidectomy is now accepted worldwide as the standard surgical procedure for the management of benign bilateral nodular thyroid disease. Hypocalcemia is the most common complication of that procedure and a variety of strategies for diagnosing and managing post‐thyroidectomy hypocalcemia have been advocated. Increasingly, the use of intact parathyroid hormone (PTH) has been utilized to try to predict those patients at risk of developing post‐thyroidectomy hypocalcemia.Methods: A Medline search of English language literature was performed and we reviewed the evidence in relation to the following three issues: the accuracy of PTH in predicting hypocalcemia, the optimal timing for measuring PTH, and the routine use of oral calcium supplements.Results: Post‐thyroidectomy PTH levels accurately predict hypocalcemia but lack 100% accuracy. Progressive and severe hypocalcemia is unlikely in the setting of a normal PTH level and hence PTH can be cautiously used to facilitate discharge within 24 h for many patients. In addition, PTH levels can be used to implement early treatment with calcium and/or vitamin D supplements to reduce the incidence and severity of hypocalcemia. A single PTH measurement taken any time from 10 min to several hours postoperative will provide equally accurate results for predicting post‐thyroidectomy hypocalcemia. Routine use of oral calcium supplements may reduce the incidence and severity of post‐thyroidectomy hypocalcemia.Conclusion: Postoperative PTH can be used to stratify the risk of patients developing hypocalcemia after thyroidectomy. In addition, the routine use of oral calcium supplements can lead to decreased incidence and severity of post‐thyroidectomy hypocalcemia. Protocols based on PTH and the routine use of oral calcium supplements can lead to improved patient outcomes after thyroidectomy.

Hypertension during pregnancy is a common problem, causing significant maternal and fetal morbidity and mortality. Pre‐eclampsia is by far the most common cause, affecting 5–10% of primigravid women. Phaeochromocytoma is a rare endocrine tumour causing hypersecretion of noradrenaline, adrenaline and/or dopamine. It is extremely rare during pregnancy and may be misdiagnosed with potentially catastrophic consequences. Delayed diagnosis remains a significant source of maternal and fetal morbidity and mortality. Recognition is critical, as the majority of maternal deaths have occurred when the diagnosis has been overlooked. Diagnosis of phaeochromocytoma is achieved by detecting increased catecholamines and metabolites (metanephrine and normetanephrine) on 24‐h urine collection, as these levels are unaffected by pregnancy or pre‐eclampsia. Definitive treatment of phaeochromocytoma is surgical and the laparoscopic approach has been shown to be safe and is preferred for most phaeochromocytomas. Medical preparation and treatment of hypertension is essential for safe surgery. Timing of adrenalectomy is either during the second trimester or as a staged procedure after Caesarean section delivery.