Thyroid and Parathyroid Surgery: Achieving Optimal Outcomes

Allan Siperstein, M.D.Chair Surgery InstituteDirector, Endocrine Surgery CenterCleveland Clinic

May 2009

ThyroidThyroid

Greek word Greek word thyreosthyreos-- shield shapedshield shaped

Histology of normal thyroidHistology of normal thyroid

Characteristics of Malignant Characteristics of Malignant

Thyroid NodulesThyroid Nodules

•• solitary nodulesolitary nodule

•• hard, fixedhard, fixed

•• rapidly enlargingrapidly enlarging

•• ipsilateral adenopathyipsilateral adenopathy

•• hoarseness with vocal chord paralysishoarseness with vocal chord paralysis

•• development of nodule at age less than development of nodule at age less than 14 or greater than 65 years14 or greater than 65 years

•• history of low dose ionizing radiationhistory of low dose ionizing radiation

Evaluation of Solitary or Dominant Evaluation of Solitary or Dominant

Thyroid NodulesThyroid Nodules

Hx X-ray Therapy

FNA

Observe

Total Thyroidectomy

yesno

ColloidNodule

“Benign”

FollicularNeoplasm

“Suspicious”

PapillaryCancer

“Cancer”

InadequateSpecimen

LobectomyTotal

Thyroidectomy

Radioiodine scansRadioiodine scans

Thyroid sono in 35yo manThyroid sono in 35yo man

ThyroidLeft jugular

noncompressed

Left jugular

compressed

Sono guided needle placementSono guided needle placement

Equipment for FNAEquipment for FNA

3cm incision marked3cm incision marked

Specimen and incisionSpecimen and incision

Location of parathyroidsLocation of parathyroids

DeDe--Evolution of disease severity in Evolution of disease severity in

HyperparathyroidismHyperparathyroidism

•• Classically patients presented with CaClassically patients presented with Ca++++ >12 >12 and significant symptomsand significant symptoms

•• Routine Routine chemchem panels detected panels detected ““asymptomaticasymptomatic”” patients with mildly patients with mildly elevated elevated calciumscalciums

•• Use of CaUse of Ca++++ and PTH screening in patients and PTH screening in patients with osteoporosis and kidney stones is with osteoporosis and kidney stones is detecting disease with high normal or detecting disease with high normal or minimally elevated minimally elevated calciumscalciums

Nice big parathyroid adenomaNice big parathyroid adenoma

Parathyroid disease in 2009Parathyroid disease in 2009

Difficulties in diagnosis of mild Difficulties in diagnosis of mild

hyperparathyroidismhyperparathyroidism

•• 11°° HP HP vsvs 2 2 °° HP HP vsvs normalnormal

•• Use of ionized Ca, albumin, Use of ionized Ca, albumin, VitVit D levelsD levels

•• 24h urinary Ca to exclude BFHH24h urinary Ca to exclude BFHH

•• Pts on Pts on bisphosphonatesbisphosphonates

•• May need serial studies to establish May need serial studies to establish diagnosisdiagnosis

2002 NIH Criteria for Surgery2002 NIH Criteria for Surgery

•• Blood calcium level more than 1.0 mg/Blood calcium level more than 1.0 mg/dLdLabove normalabove normal

•• 2424--hour urinary calcium excretion greater hour urinary calcium excretion greater than 400 mg/daythan 400 mg/day

•• Kidney function reduced by 30% below Kidney function reduced by 30% below normalnormal

•• Bone mineral density reduced by 2.5 Bone mineral density reduced by 2.5 standard deviations below young, healthy standard deviations below young, healthy controlscontrols

•• Age less than 50Age less than 50

VanderWalde, L. H. et al. Arch Surg 2006;141:885-891.

Fracture-free survival of 1569 patients with primary hyperparathyroidism

Minimally Invasive Parathyroid Surgery = Minimally Invasive Parathyroid Surgery =

MIPSMIPS

•• This is a marketing term used to make This is a marketing term used to make patients think one approach to parathyroid patients think one approach to parathyroid surgery has significantly better outcomes than surgery has significantly better outcomes than anotheranother

•• Surgeons should define their operations in Surgeons should define their operations in technical terms:technical terms:

•• Single gland exploration through 2cm incisionSingle gland exploration through 2cm incision

•• 4 gland exploration through a 2.5cm incision4 gland exploration through a 2.5cm incision

•• Single gland exploration using videoscopic Single gland exploration using videoscopic instrumentationinstrumentation

Extent of Parathyroid ExplorationExtent of Parathyroid Exploration

•• Bilateral explorationBilateral exploration-- look for all 4 look for all 4 glandsglands

•• Unilateral explorationUnilateral exploration-- look for 2 glands look for 2 glands on one sideon one side

•• Focal explorationFocal exploration-- look for single look for single abnormal glandabnormal gland

•• Select cases based on localizing studiesSelect cases based on localizing studies

•• End procedure based on rapid intraop PTHEnd procedure based on rapid intraop PTH

Key to the success of focal exploration:Key to the success of focal exploration:

•• What is the incidence of multiple gland What is the incidence of multiple gland diseasedisease

•• How good are localizing studies in How good are localizing studies in predicting single gland diseasepredicting single gland disease

•• How good is intraop PTH measurement in How good is intraop PTH measurement in determining that all pathology has been determining that all pathology has been removedremoved

•• How good is the long term followHow good is the long term follow--upup

•• What is an acceptable failure rate balanced What is an acceptable failure rate balanced by the proposed benefitsby the proposed benefits

Incidence of multiple gland diseaseIncidence of multiple gland disease

•• Retrospective review at 2 endocrine Retrospective review at 2 endocrine

surgery centers: Emory and CCFsurgery centers: Emory and CCF

•• 828 patients with 1828 patients with 1o o hyperparathyroidismhyperparathyroidism

•• Bilateral neck explorationBilateral neck exploration

•• Disease patterns:Disease patterns:

single adenomas single adenomas 7171%%

double adenomas double adenomas 15%15%

hyperplasia hyperplasia 1313%%

0

10

20

30

40

50

% D

A P

ati

en

ts

1 2 3 4 5 6

Distribution of Double AdenomasDistribution of Double Adenomas

Both

Superior

Both

Inferior

Right

Superior

Left

Inferior

Left

Superior

Right

Inferior

Both

Left

Both

Right

*P<.001*

Sestamibi Iodine subtraction scan Sestamibi Iodine subtraction scan

with SPECT imagingwith SPECT imaging

Tc sestamibi I 123 Subtraction

Surgeon PreformedSurgeon Preformed

Parathyroid UltrasoundParathyroid Ultrasound

•• 7.5 MHz or higher 7.5 MHz or higher transducertransducer

•• Curved or small Curved or small footprint linearfootprint linear

•• Patient positioned Patient positioned supine with neck supine with neck hyperextendedhyperextended

Experience and Outcomes Experience and Outcomes

•• Importance of experience is intuitiveImportance of experience is intuitive

•• Many published reports confirm thisMany published reports confirm this

•• Clinician volumeClinician volume

•• Hospital volumeHospital volume

•• What about thyroid/parathyroid surgery?What about thyroid/parathyroid surgery?

•• Sosa Sosa et al, et al, Annals of Surgery 1998Annals of Surgery 1998

•• StavrakisStavrakis et al, et al, Surgery 2007Surgery 2007

•• PieracciPieracci et al, et al, World J. of Surgery 2008World J. of Surgery 2008

ReRe--operative Surgeryoperative Surgery

•• Significant percentage of our practiceSignificant percentage of our practice

•• Some unavoidableSome unavoidable

•• Many felt to be avoidableMany felt to be avoidable

•• Can reCan re--operations be reliably classified as operations be reliably classified as

avoidable or unavoidable?avoidable or unavoidable?

AimsAims

1. Create a set of criteria for classifying re1. Create a set of criteria for classifying re--

operations as avoidable or unavoidableoperations as avoidable or unavoidable

2. Determine the incidence of avoidable re2. Determine the incidence of avoidable re--

operations in thyroid and parathyroid operations in thyroid and parathyroid

surgerysurgery

3. Determine whether clinical volume 3. Determine whether clinical volume

affects the incidence of avoidable reaffects the incidence of avoidable re--

operationsoperations

MethodsMethods

•• All patients undergoing reAll patients undergoing re--operative thyroid operative thyroid and parathyroid surgery 1999and parathyroid surgery 1999--20072007

Pre-op imaging

Intra-op findings

Histopathology

Objective criteria

+

Avoidable or Unavoidable?

MethodsMethods

•• Hospital volume obtained using inpatient & Hospital volume obtained using inpatient &

outpatient dataoutpatient data

•• < 20 cases/year = low< 20 cases/year = low--volume centervolume center

•• ≥≥ 20 cases/year = high20 cases/year = high--volume centervolume center

•• Each reEach re--operation treated as separate case operation treated as separate case

Criteria for Avoidable Criteria for Avoidable vsvs

Unavoidable OperationsUnavoidable Operations

•• Example for Thyroid CasesExample for Thyroid Cases

•• UnavoidableUnavoidable �� Completion thyroidectomy after Completion thyroidectomy after

lobectomylobectomy for follicular neoplasm on FNAfor follicular neoplasm on FNA

•• AvoidableAvoidable �� Selective LN excision (Selective LN excision (““berry berry

pickingpicking””) with recurrence in same compartment) with recurrence in same compartment

•• Example for Parathyroid CasesExample for Parathyroid Cases

•• UnavoidableUnavoidable �� Persistent 1Persistent 1ºº HPT due to ectopic gland HPT due to ectopic gland

inaccessible through standard incisioninaccessible through standard incision

•• AvoidableAvoidable �� Persistent 1Persistent 1ºº HPT due to missed gland in normal HPT due to missed gland in normal

anatomic locationanatomic location

Study GroupStudy Group

280 patients underwent re-operative surgery

227 single re-operations

53 multiple re-operations

395 total re-operations

335 cases with initial hospital data

available

Number of % of TotalCases

Type of Re-operationThyroid 189 56%

Parathyroid 146 44%

Hospital Volume

High-Volume Center 167 50%Low Volume Center 168 50%

Re-operation ClassificationAvoidable 134 40%Unavoidable 201 60%

Case DistributionCase Distribution

Incidence of Avoidable ReIncidence of Avoidable Re--operations:operations:

Thyroid Thyroid vs.vs. Parathyroid SurgeryParathyroid Surgery

70%Unavoidable

Avoidable30%

47%Unavoidable

Avoidable53%

Thyroid Re-operations

189 cases

Parathyroid Re-operations

146 cases

Thyroid Cases: Thyroid Cases:

Low Low vs.vs. HighHigh--Volume CentersVolume Centers

High-Volume Centers

103 cases

Low-Volume Centers

86 cases

54% 46%

CCF

Avoidable Thyroid ReAvoidable Thyroid Re--operationsoperations

High-Volume Centers

103 cases

Low-Volume Centers

86 cases

UnavoidableAvoidable

57%*

85%

15%*

43%

* p < 0.001

Avoidable

Unavoidable

Thyroid Cancer CasesThyroid Cancer Cases

High-Volume Centers

72 cases

Low-Volume Centers

62 cases

55%*

88%

12%*

45%Unavoidable

Avoidable

* p < 0.001

Unavoidable

Avoidable

Benign Thyroid CasesBenign Thyroid Cases

High-Volume Centers

31 cases

Low-Volume Centers

24 cases

* p = NS

33%*

81%

19%*

67%Unavoidable

Avoidable

Unavoidable

Avoidable

Hospital Volume and Incidence ofAvoidable Thyroid Re-operations

< 5 5-20 20-50 50-100 > 1000

20

40

60

80

100%

Avo

idab

le R

efe

rrals

Annual Number of Thyroid Cases

High-Volume Centers

Low-Volume Centers

56%

Parathyroid Cases: Parathyroid Cases:

Low Low vs.vs. HighHigh--Volume CentersVolume Centers

High-Volume Centers

64 cases

Low-Volume Centers

82 cases

44%56%

CCF

Avoidable Parathyroid ReAvoidable Parathyroid Re--operationsoperations

High-Volume Centers

64 cases

Low-Volume Centers

82 cases

78%*

78%

22%*22%

* p < 0.001

Unavoidable

Avoidable

Avoidable

Unavoidable

Persistent 1Persistent 1ºº HPTHPT CasesCases

High-Volume Centers

62 cases

Low-Volume Centers

34 cases

* p < 0.001

95%*

59%

41%*

5%

Avoidable

Unavoidable

Avoidable

Unavoidable

Persistent 1Persistent 1ºº HPTHPT Cases: Cases:

Impact of Initial Sestamibi ScanImpact of Initial Sestamibi Scan

0

20

40

60

80

100

70

%

100%*

* p < 0.001

% Correct

Imaging% Avoidable

36%

17%

*% Correct

Imaging% Avoidable

Low-Volume Center

High-Volume Center

Hospital Volume and Incidence of

Avoidable Parathyroid Re-operations

< 5 5-20 20-50 50-100 > 1000

20

40

60

80%

Avo

idab

le R

efe

rrals

Annual Number of Parathyroid Cases

High-Volume Center

Low-Volume Center

Complications

0

3

6

9

High-Volume

Center

Low-Volume

Center

% R

LN

In

jury

p < 0.05

3%

9%

Initial Operations Re-operations

p < 0.001

% C

om

pli

cati

on

s

RLN Injury after Initial Operation: High vs. Low-Volume Center

Complication Rates in Our Practice: Initial vs. Re-operative Surgery

0

3

6

9

1%

4%

ConclusionsConclusions

•• ReRe--operative thyroid & parathyroid surgery can be operative thyroid & parathyroid surgery can be

reliably classified as avoidable or unavoidablereliably classified as avoidable or unavoidable

•• A significant number of reA significant number of re--operative thyroid and operative thyroid and

parathyroid surgeries are avoidableparathyroid surgeries are avoidable

•• Most avoidable reMost avoidable re--operations originate from lowoperations originate from low--

volume centers volume centers �� Persistent 1Persistent 1ºº HPT, Thyroid CancerHPT, Thyroid Cancer

•• Provides further evidence for concentrating the Provides further evidence for concentrating the

treatment of thyroid & parathyroid disease to hightreatment of thyroid & parathyroid disease to high--

volume centers volume centers

Keys to successful high volume Keys to successful high volume

Endocrine Surgery programEndocrine Surgery program

•• 4 surgeons4 surgeons-- group practice modelgroup practice model

•• Dedicated RNs & NPDedicated RNs & NP

•• ““One stop shoppingOne stop shopping””

•• Pre visit record reviewPre visit record review

•• Lab studiesLab studies

•• ConsultConsult

•• UltrasoundUltrasound

•• Needle biopsyNeedle biopsy

Challenging Parathyroid LocalizationChallenging Parathyroid Localization