The role of clinicians in determining radioactive iodine use for low‐risk thyroid cancer

BACKGROUND: There is controversy regarding the optimal management of thyroid cancer. The proportion of patients with low‐risk thyroid cancer who received radioactive iodine (RAI) treatment increased over the last 20 years, and little is known about the role played by clinicians in hospital‐level RAI use for low‐risk disease. METHODS: Thyroid surgeons affiliated with 368 hospitals that had Commission on Cancer‐accredited cancer programs were surveyed. Survey data were linked to data reported to the National Cancer Database. A multivariable analysis was used to assess the relation between clinician decision makers and hospital‐level RAI use after total thyroidectomy in patients with stage I, well differentiated thyroid cancer. RESULTS: The survey response rate was 70% (560 of 804 surgeons). The surgeon was identified as the primary decision maker by 16% of the surgeons; the endocrinologist was identified as the primary decision maker by 69%, and a nuclear medicine, radiologist, or other physician was identified as the primary decision maker by 15%. In a multivariable analysis controlling for hospital case volume and hospital type, when the primary decision maker was in a specialty other than endocrinology or surgery, there was greater use of RAI at the hospital ( P < .001). A greater number of providers at the hospital where RAI was administered and having access to a tumor board also were associated with increased use of RAI ( P < .001 and P = .006, respectively). CONCLUSIONS: The specialty of the primary decision maker, the number of providers administering RAI, and having access to a tumor board were associated significantly with the use of RAI for stage I thyroid cancer. The findings have implications for addressing nonclinical variation between hospitals, with a marked heterogeneity in decision making suggesting that standardization of care will be challenging. Cancer 2013. © 2012 American Cancer Society. There is heterogeneity in clinician decision making for the management of patients with thyroid cancer. The specialty of the primary decision maker, the number of providers administering radioactive iodine, and access to a tumor board are associated significantly with the use of radioactive iodine for stage I thyroid cancer.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/96331/1/27721_ftp.pd

Radical palliative surgery: new limits to pursue

This case report describes the radical subtotal palliative resection of a massive recurrent desmoid tumor encompassing the abdomen, pelvis, and groin in a child who was 13 years old at the time of initial resection. Given the extensive distribution of the tumor en bloc resection, which is the standard treatment of desmoid tumors, would have meant performing a hemipelvectomy and repair of a large abdominal wall defect, likely with skin grafts and mesh. The patient’s personal goals however were to alleviate the pain and limited mobility that would allow her to re-attend high school and appear normal to her peers. Therefore, palliative surgery was pursued and currently the patient is 5 years out from her last surgery doing well. We believe that the option of surgical palliation in this case was warranted and should be an option for similar cases in the future

Barriers to mental health service use and preferences for addressing emotional concerns among lung cancer patients

OBJECTIVE: This study examined barriers to mental health service use and preferences for addressing emotional concerns among lung cancer patients (N=165) at two medical centers in the Midwestern United States. METHODS: Lung cancer patients completed an assessment of anxiety and depressive symptoms, mental health service use, barriers to using these services, and preferences for addressing emotional concerns. RESULTS: Only 45% of distressed patients received mental health care since their lung cancer diagnosis. The most prevalent patient-reported barriers to mental health service use among non-users of these services (n=110) included the desire to independently manage emotional concerns (58%) and inadequate knowledge of services (19%). In addition, 57% of distressed patients who did not access mental health services did not perceive the need for help. Seventy-five percent of respondents (123/164) preferred to talk to a primary care physician if they were to have an emotional concern. Preferences for counseling, psychiatric medication, peer support, spiritual care, or independently managing emotional concerns also were endorsed by many patients (range=40-50%). Older age was associated with a lower likelihood of preferring to see a counselor. CONCLUSIONS: Findings suggest that many distressed lung cancer patients underuse mental health services and do not perceive the need for such services. Efforts to increase appropriate use of services should address patients' desire for autonomy and lack of awareness of services

A rare combination of an endocrine tumour of the common bile duct and a follicular lymphoma of the ampulla of Vater: a case report and review of the literature

Carcinoid tumours of the common bile duct represent an extremely rare entity. Similarly, primary follicular lymphomas of the ampulla of Vater constitute an infrequent neoplasia. Herein, we report the first case of a synchronous development of a carcinoid tumour of the common bile duct and an ampullary follicular lymphoma that was treated surgically with a Whipple's procedure, due to inability to establish definitive preoperative diagnosis despite the extensive diagnostic investigation

Intrathoracic fire during preparation of the left internal thoracic artery for coronary artery bypass grafting

A surgical fire is a serious complication not previously described in the literature with regard to the thoracic cavity. We report a case in which an intrathoracic fire developed following an air leak combined with high pressure oxygen ventilation in a patient with severe chronic obstructive pulmonary disease. The patient presented to our institution with diffuse coronary artery disease and angina pectoris. He was treated with coronary artery bypass graft surgery, including left internal thoracic artery harvesting. Additionally to this rare presentation of an intrathoracic fire, a brief review of surgical fires is included to this paper

How to train surgical residents to perform laparoscopic roux-en-Y gastric bypass safely

Background As a result of increasing numbers of patients with morbid obesity there is a worldwide demand for bariatric surgeons. The Roux-en-Y gastric bypass, nowadays performed mostly laparoscopically (LRYGB), has been proven to be a highly effective surgical treatment for morbid obesity. This procedure is technically demanding and requires a long learning curve. Little is known about implementing these demanding techniques in the training of the surgical resident. The aim of this study was to evaluate the safety and feasibility of the introduction of LRYGB into the training of surgical residents. Methods All patients who underwent LRYGB between March 2006 and July 2010 were retrospectively analyzed. The procedure was performed by a surgical resident under strict supervision of a bariatric surgeon (group I) or by a bariatric surgeon (group II). The primary end point was the occurrence of complications. Secondary end points included operative time, days of hospitalization, rate of readmission, and reappearance in the emergency department (ED) within 30 days. Results A total of 409 patients were found eligible for inclusion in the study: 83 patients in group I and 326 in group II. There was a significant difference in operating time (129 min in group I vs. 116 min in group II; p<0.001) and days of hospitalization. Postoperative complication rate, reappearance in the ED, and rate of readmission did not differ between the two groups. Conclusions Our data suggest that under stringent supervision and with sufficient laparoscopic practice, implementation of LRYGB as part of surgical training is safe and results in only a slightly longer operating time. Complication rates, days of hospitalization, and the rates of readmission and reappearance in the ED within 30 days were similar between the both groups. These results should be interpreted by remembering that all procedures in group I were performed in a training environment so occasional intervention by a bariatric surgeon, when necessary, was inevitable

Clear cell carcinoid tumor of the distal common bile duct

BACKGROUND: Carcinoid tumors rarely arise in the extrahepatic bile duct and can be difficult to distinguish from carcinoma. There are no reports of clear cell carcinoid (CCC) tumors in the distal bile duct (DBD) to the best of our knowledge. Herein, we report a CCC tumor in the DBD and review the literature concerning extrahepatic bile duct carcinoid tumors. CASE PRESENTATION: A 73-old man presented with fever and occult obstructive jaundice. Ultrasonography, computed tomography (CT) and magnetic resonance cholangiopancreaticography (MRCP) demonstrated a nodular tumor projection in the DBD without regional lymph node swelling. Under suspicion of carcinoma, we resected the head of the pancreas along with 2(nd )portion duodenectomy and a lymph node dissection. The surgical specimen showed a golden yellow polypoid tumor in the DBD (0.8 × 0.6 × 0.5 cm in size). The lesion was composed of clear polygonal cells arranged in nests and a trabecular pattern. The tumor invaded through the wall into the fibromuscular layer. Immunohistochemical stains showed that neoplastic cells were positive for neuron-specific enolase (NSE), chromogranin A, synaptophysin, and pancreatic polypeptide and negative for inhibin, keratin, CD56, serotonin, gastrin and somatostatin. The postoperative course was uneventful and he is living well without relapse 12 months after surgery. CONCLUSION: Given the preoperative difficulty in differentiating carcinoid from carcinoma, the pancreaticoduodenectomy is an appropriate treatment choice for carcinoid tumors located within the intra-pancreatic bile duct