Citations

AbstractThe prediction of outcome in the rare Hürthle cell tumor of the thyroid continues to present a problem to surgeons and pathologists. To better clarify the distinctions between benign and malignant tumors, we have measured DNA content by flow cytometry on isolated cell nuclei derived from archival paraffin‐embedded tissue blocks of 125 Hürthle cell tumors operated from 1943 to 1985 at the Mayo Clinic, Rochester, Minnesota, U.S.A. Nuclear DNA ploidy patterns were divided into 3 groups. A DNA normal (diploid) pattern was found in 55% of 75 Hürthle cell adenomas and in 26% of 50 Hürthle cell cancers; a DNA tetraploid/polyploid pattern was found in 11% of benign, and 14% of malignant tumors. An abnormal DNA stemline was detected in 34% of benign and 60% of malignant tumors. Hürthle cell cancer was the histologic diagnosis in 24% of the DNA normal, 47% of the DNA tetraploid/polyploid, and 54% of the DNA aneuploid tumors. None of the patients with adenomas developed tumor recurrence. However, 20% of the euploid and 40% of the aneuploid tumors developed local or distant recurrences. Survival to thyroid cancer death was significantly correlated with DNA ploidy status (p=0.02) but did not correlate with either tumor size or histologic grade. To date, deaths from thyroid cancer have been confined to patients whose tumors were DNA aneuploid. We would conclude that determination of DNA ploidy status may not aid the surgical pathologist in the diagnosis of Hürthle cell cancer. However, when a patient's Hürthle cell cancer is DNA aneuploid, there is significant risk of death from thyroid cancer.

AbstractThe records of patients treated at the Mayo Clinic for toxic multinodular goiter during 1950–1954, 1960–1964, and 1970–1974 were reviewed to compare results of surgical and131I therapy, to define trends in treatment policy and outcome, and to attempt to elucidate factors associated with posttreatment hypothyroidism. The series involved 446 patients who underwent thyroidectomy as initial treatment and 89 who initially received131I. The time to success was significantly shorter (p=0.001) in surgically treated patients than in patients initially receiving131I. Compared with patients treated medically, patients treated initially with surgery were much less likely to require a second treatment (0% versus 24%) during the first year after initial treatment. The probability of postthyroidectomy hypothyroidism increased from approximately 12% in the 1950s to more than 70% in the 1970s at 2 years after surgery. Neither more aggressive surgery nor use of more sensitive tests to diagnose hypothyroidism accounted for the increased probability in recent years.

AbstractPersistent or recurrent hypercalcemia following operation for benign hyperparathyroidism (HPT) remains a surgical challenge. From 1978 to 1984 at the Mayo Clinic, 157 patients underwent reexploration. This included 110 cervical, 38 combined cervical and mediastinal, and 9 mediastinal explorations. A total of 197 previous operations (range 1–5) had been performed, including 136 patients for sporadic disease, 14 for multiple endocrine neoplasia, and 7 for familial HPT. Preoperative localizing studies were employed in 137 patients (87%), Cervical ultrasonography had an accuracy of 76% (sensitivity, 82%; positive predictive value, 81%), while mediastinal computed tomography was accurate in 76% (sensitivity, 57%; positive predictive value, 80%). Arteriography, venography, and venous sampling were not used. Guided by high‐resolution, small parts ultrasonography, fine‐needle aspiration biopsy confirmed localization of parathyroid tissue in 3 patients. Successful resolution of hypercalcemia occurred in 139 patients (89%) with a mean follow‐up of 22 months. There were no operative deaths; 12 patients (8%) had temporary neuropraxia of the recurrent laryngeal nerve, 6 patients (4%) suffered permanent unilateral paralysis, and 20 (13%) became permanently hypoparathyroid. Two of 4 hypoparathyroid patients who were autotransplanted with cryopreserved parathyroid tissue have become eucalcemic. The results indicate that the disease site is usually in the neck, that noninvasive localizing techniques have superseded arteriography and venous sampling, and that reoperative parathyroid surgery can be performed with rare mortality and acceptable morbidity. Although these refinements have led to improved success, reoperative parathyroid surgery should not be performed by the occasional parathyroid surgeon.

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.