Citations

AbstractEighty‐nine patients underwent adrenal exploration for Cushing's syndrome at our institution during the period 1970–1979. On the basis of clinical and histological findings related to the initial adrenal operation, patients were divided into 6 major subgroups: (a) adrenocortical adenoma; (b) adrenocortical carcinoma; (c) proven ectopic ACTH adrenocortical hyperplasia; (d) Cushing's disease; (e) uncertain diagnostic group (probably ectopic ACTH syndrome—site unknown); and (f) “non‐ACTH‐dependent” hypercortisolism due to micronodular hyperplasia.Results of pathologic examination included 25 adrenal adenomas, 15 adrenocortical carcinomas, 40 bilateral adrenocortical hyperplasias, and a single case of micronodular hyperplasia. The postoperative mortality rate was 5.6%, and significant morbidity occurred in 40% of patients. Four of the 5 patients who died within 30 days of operation were in the subgroups with adrenal carcinoma (2 patients) and Cushing's disease (2 patients). Survival in patients with adrenocortical adenomas was significantly decreased at 2 years (relative adrenocortical insufficiency?), but thereafter, it paralleled the expected survival. Patients with the ectopic ACTH syndrome and adrenocortical carcinoma had significantly decreased survival, with only one‐third of carcinoma patients alive 2 years postoperatively. The survival of patients with Cushing's disease was lower than expected at both 5 and 10 years.These results confirm that the diagnosis of patients with endogenous hypercortisolism is usually straightforward and accurate, surgical intervention in this group of patients is still accompanied by significant short‐term mortality and morbidity, and long‐term survival in all subgroups is decreased.

AbstractThe cause of splenic artery aneurysms and the indications for their treatment remain controversial. Splenic artery aneurysms occur more frequently in women and are associated with pregnancy and multiparity. Whether arteriosclerosis is the cause of the aneurysm or is a secondary phenomenon is unknown. Patients not treated do well, especially if the aneurysm is less than 2 cm in diameter. The rate of rupture is approximately 3%, and it appears to be decreasing as more patients are found to have this type of aneurysm. The mortality rate for ruptured splenic artery aneurysm is greatly increased if the patient is pregnant. Indications for removal include presence of symptoms, pregnancy or plan to become pregnant, increasing size, and a diameter of 2 cm or greater. Depending on the medical condition of the patient, aneurysms that are less than 2 cm in diameter can be removed electively, or they can be left and the patient followed closely. The risk of elective removal is extremely low and has minimal morbidity. In the treatment of this type of aneurysm, the spleen should be preserved if possible; splenectomy is reserved for those aneurysms found in the hilus of the spleen or during emergency situations.

AbstractThe collective term “pancreatic cancer” should be replaced by more specific terminology indicating the histological subtype, e.g., pancreatic ductal adenocarcinoma, ampullary adenocarcinoma, duodenal carcinoma, pancreatic cystadenocarcinoma, cholangiocarcinoma, and malignant islet cell carcinoma. Each of these tumors has its own inherent prognostic and therapeutic characteristics‐95% of ampullary lesions being resectable in contrast to ±10% of pancreatic ductal malignancies and comparable 5‐year survival figures for these two subtypes are 40% and 5%, respectively.Since the results of adjuvant therapy (chemo‐ and/or radiotherapy) have been dismal, the only chance of cure remains resective therapy, either by the performance of a total or subtotal pancreatectomy (Whipple procedure). The operative mortality rate for these procedures at our institution has been 12% and 4%, respectively, with corresponding 5‐year survival rates of 2% and 4%. Despite earlier promise that total pancreatectomy only would be a superior procedure (elimination of the pancreatojejunal anastomosis, wider lymphadenectomy, irradication of multicentric disease), the operation has thus far not fulfilled these expectations.The Whipple procedure remains the resective procedure of choice at our institution—total pancreatectomy being performed principally in those patients in whom a safe pancreatojejunal anastomosis cannot be constructed.Value of early diagnosis in patients with ductal adenocarcinoma does not appear to imply improved prognosis. Energies should be diverted toward etiological identification of this lethal malignancy which is steadily increasing in incidence.

AbstractUltrasound and computed tomography have had an enormous impact on the imaging procedures used in the detection of tumors of the parathyroids, pancreas, and adrenals. Ultrasound is now the examination of choice in localizing parathyroid adenomas in the neck prior to cervical exploration or after unsuccessful exploration. Its role as a screening test in patients without biochemical confirmation of hyperparathyroidism awaits further study. Computed tomography is useful in identifying mediastinal parathyroid adenomas in patients who have had unsuccessful neck explorations and islet‐cell tumors of the pancreas if they are sufficiently large (greater than 2 cm). Angiography remains the most accurate method of localizing insulinomas prior to surgery. Computed tomography scanning has become the procedure of choice in localizing adrenal tumors and has sufficient sensitivity to be used as a screening test in patients without biochemical confirmation of an adrenal abnormality.

AbstractSymptomatic hypercalcemia is a medical emergency. Knowledge of the alteration in the factors that control normal calcium homeostasis permits selection of a plan of treatment, which includes general supportive measures along with therapeutic agents directed at the specific alteration in calcium homeostasis. The rationale for the selection of various modes of treatment and treatment schedules and the untoward side effects of the therapeutic agents are reviewed.Acutely developing hypocalcemia often requires emergency treatment. Relief of symptoms can be achieved with intravenous calcium preparations. Knowledge of the underlying cause permits selection of appropriate medications when long‐term treatment is required. When vitamin D is needed, measurement of serum calcium and phosphate at regular intervals is essential. Hypoparathyroidism may be temporary after thyroid or parathyroid surgery, and efforts should be made 6 to 12 months after operation to determine whether the abnormality is permanent.

AbstractSuccessful therapy for pituitary apoplexy depends on prompt recognition of the clinical syndrome, accurate anatomic evaluation of the lesion with the CT scan, intensive steroid replacement therapy, and effective transphenoidal decompression of the tumor. Successful long‐term management of patients who have suffered pituitary apoplexy requires recognition by the complex interrelationships of the pituitary with adrenal, thyroid, gonadal, pancreatic, and gut physiology. Such patients often require multiple medications for replacement therapy. Surgical treatment is often supplemented with radiation therapy, and prolactin‐ and growth hormone‐secreting adenomas may require long‐term management with bromocriptine. Careful follow‐up evaluations and appropriate post‐surgical therapy enable most of these patients to live normal lives.

Abstract The ability to differentiate benign from malignant Hürthle cell thyroid neoplasms has provoked considerable controversy. This has significant therapeutic implications, since some have advocated total thyroidectomy for all of these lesions. The principal objectives of this study were: (a) to determine whether the histologic diagnosis of Hürthle cell adenoma could be reliably made, (b) to quantitate the risk of inappropriately labelling a Hürthle cell cancer as an adenoma, and (c) to ascertain whether the type of operative procedure affected the clinical course . We reviewed 272 patients who had undergone thyroid resection for benign Hürthle cell neoplasms at the Mayo Clinic from 1960 to 1980. All pathologic sections were rereviewed. Postoperative follow‐up was available on 233 patients (86%), with a mean of 8.9 years. A minimum of 5 years of follow‐up was obtained on 10% of the patients. Nodules ranged in size from 0.3 to 11 cm; 195 (55%) were 2 cm or larger. Surgical resection was limited to one side in 137 (50%) patients and involved both sides in 135 patients. No total thyroidectomies were performed. Evidence of malignancy—a local recurrence—developed in only 1 patient, and she died of unrelated causes. None of the 272 patients died of thyroid cancer, and none showed evidence of metastases. Our data is in agreement with most published reports, with only 6 (0.9%) of 642 reported patients being diagnosed incorrectly. These tumors can be accurately separated into benign and malignant. Routine total thyroidectomy for Hürthle cell adenomas is not justified .