BACKGROUND Radiation therapy is critical for treating many solid tumors but increases the risk of secondary malignancies due to DNA damage. Radiation-associated sarcomas (RAS) occur in 0.03% to 0.8% of irradiated patients, typically 5 to 20 years after treatment. Undifferentiated pleomorphic sarcoma (UPS) is a common RAS subtype with poor 5-year survival (12%-14%). Risk rises with doses ≥50 Gy and is especially concerning in previously irradiated head and neck regions, where surgery is challenging. Germline mutations in DNA repair genes (eg, ATM) further increase susceptibility. CASE REPORT A 54-year-old man treated in 2003 for multifocal medullary thyroid carcinoma (thyroidectomy, bilateral neck dissection, adjuvant 59.4 Gy radiation) presented 22 years later with a painless neck mass. Imaging showed a 1.9-cm enhancing lesion within the prior radiation field. Excision revealed a 4-cm, FNCLCC grade 3 intramuscular UPS meeting the modified Cahan criteria for RAS. Immunohistochemistry excluded recurrent thyroid carcinoma. Margins were positive, but re-excision and re-irradiation were not feasible. The sarcoma tumor board recommended close surveillance and germline testing. This case involved high-grade UPS arising 2 decades after neck irradiation. Compared with sporadic UPS, RAS-associated UPS has worse disease-specific survival (~52% vs 76%) and higher local recurrence (~55% vs 24%), emphasizing the importance and difficulty of achieving negative margins in previously irradiated fields. CONCLUSIONS As cancer survival improves, lifelong vigilance for RAS remains essential. New masses in irradiated areas require prompt evaluation. Multidisciplinary management and consideration of genetic testing are critical, as treatment options are often limited by prior therapy.

Background Narrative operative reports (NORs) often lack key information that can guide postoperative management of thyroid disease. We aimed to develop and validate a nationally standardized synoptic operative report (SOR) for thyroid surgery. Materials and Methods Surgeons were surveyed for their opinions of current operative reporting practices. Reportable elements from thyroidectomy NORs were ranked by thyroid disease specialists and reviewed by a national advisory committee to develop a standardized SOR using the Modified Delphi Method. Six thyroid surgeons piloted the SOR. Completeness and reporting frequencies of SOR elements were compared with pre-pilot NORs using Wilcoxon rank sum, chi-squared, and Fisher's exact analyses. A post-pilot survey assessed provider satisfaction. Results Among 42 Canadian thyroid surgeons from 9 provinces, 31% expressed dissatisfaction with current reporting practices and 100% expressed interest in a SOR. In total, 109 reportable thyroidectomy elements were collected from 142 NORs and ranked by 46 thyroid disease specialists. Consensus agreed upon a 21-element SOR by a national advisory committee. Among 172 NORs and 170 piloted SORs, SORs had higher median overall completeness (100% [100-100%]) than NORs (65% [47-70%], p < 0.001). SORs improved reporting of cancer-specific elements, including the presence of gross extrathyroidal cancer extension (SOR: 100%, NOR: 43%, p < 0.001) and residual gross disease (SOR: 100%, NOR: 16%, p < 0.001). More than half of users and readers reported improved reporting completeness and impact on patient care with SORs. Conclusions Implementation of a nationally developed thyroid surgery SOR enhanced completeness, delivery of cancer-specific information, and provider satisfaction, which can improve quality of patient care.

The incidence of differentiated thyroid cancer (DTC) has increased significantly in recent decades. Following initial diagnosis, DTC patients are classified according to the American Thyroid Association (ATA) as low, intermediate, and high risk for recurrence. Patients in the ATA low recurrence-risk category have a recurrence risk of ≤5%, with 20-year disease-specific mortality of <1%. Accordingly, there has been a shift to de-escalating initial treatment, including the relaxation of thyroid-stimulating hormone suppression. In addition, fewer low-risk patients undergo total thyroidectomy or radioactive iodine therapy. However, the optimal long-term surveillance strategy remains unclear, with many patients continuing follow-up in speciality clinics for many years. In addition, emerging evidence suggests that long-term surveillance can be effectively managed in primary care settings. To enhance understanding among Canadian thyroid practitioners and to improve care for Canadian patients diagnosed with low-risk DTC, we developed this consensus statement by collecting feedback from a multidisciplinary team led by one chairperson (endocrinologist), an additional eight endocrinologists, two surgeons, and one patient partner. This consensus statement reflects current evidence and expert opinion regarding initial management and long-term surveillance of low-risk DTC patients. This work is valuable to Canadian thyroid practitioners as it provides standardized guidelines to ensure optimal care and improved outcomes for low-risk DTC patients.

Abstract Disclosure: I. Albanese: None. N. Nicolas: None. S.S. Wing: Grant Recipient; Self; Pfizer Global R&D. Other; Self; Almac Discovery (Independent Contractor). E. Mitmaker: None. L. Vautour: None. Background: Primary hyperparathyroidism is rarely diagnosed in pregnancy as symptoms may overlap with those of pregnancy and biochemical diagnosis may be masked by physiologic changes in calcium homeostasis. Hyperparathyroidism in pregnancy is associated with increased maternal and fetal complications. While mild disease is treated conservatively, moderate to severe disease is generally treated surgically in the second trimester. Safe pharmacotherapy options are limited in pregnancy. Case: A 35-year-old woman G3P1 at 10 weeks presented to our institution with polyuria, bone pain and weakness with labs demonstrating severe hypercalcemia (Calcium total: 3.82mmol/L (normal: 2.12-2.62); PTHi: 12pmol/L (normal: 1.5-9.3)). PTHrP was suppressed. She had a prior history of PTH-mediated hypercalcemia in her first pregnancy. She previously underwent three exploratory surgeries in which only three parathyroid glands were found and removed. The hyperparathyroidism and hypercalcemia persisted post-operatively thus she also required intravenous fluids, calcitonin and cinacalcet. The pregnancy was otherwise uncomplicated. Post-partum, she developed hypoparathyroidism and hypocalcemia. Throughout this current pregnancy, multiple imaging modalities were used (ultrasound, MRI and parathyroid sestamibi), none of which were unable to localize any hyperfunctioning parathyroid tissue. Thus, management was limited to medical therapy. Despite aggressive hydration, calcitonin and cinacalcet, total calcium and PTH levels consistently rose reaching peaks of 4.06mmol/L and 45.4pmol/L, respectively. Given hypercalcemia severity and associated neurological symptoms, she was also given bisphosphonates (pamidronate 60mg and zoledronic acid 4mg). She underwent C-section at 25+3 weeks due to fetal decelerations and placental insufficiency. She again developed hypoparathyroidism and hypocalcemia 1-week post-partum. Genetic testing was negative for any causes of hyperparathyroidism. Discussion: This is a unique case of severe PTH-mediated hypercalcemia in that the exact mechanism is unknown but appears to be pregnancy-mediated and reversible such that it only occurs in pregnancy with subsequent hypoparathyroidism post-partum. Investigations to better elucidate the mechanism of this are ongoing. Presentation: Saturday, June 17, 2023

# 01. Operative classification of ventral abdominal hernias: new and practical classification {#article-title-2} Ventral hernias of the abdomen are defined as a noninguinal, nonhiatal defect in the fascia of the abdominal wall. Unfortunately, there is not currently a universal classification system

INTRODUCTION: Information documented in narrative surgical reports influences the management of thyroid disease but often lacks consistency. This study aimed to investigate national perceptions of current thyroid surgical reporting practices and identify frequently reported items. METHODS: Surgeons who perform thyroidectomy were surveyed for their opinions on current surgical reporting practices and asked to provide de-identified narrative reports dictated for benign and/or malignant disease. Survey results and report elements were summarized using descriptive statistics. RESULTS: Forty-two surgeons from 9 Canadian provinces were surveyed with 89% performing >16 thyroidectomies annually. Narrative reporting was used by 88% of surgeons, of whom 35% expressed dissatisfaction and 100% expressed interest in using a synoptic template if available. Those who already used synoptic templates (12%) reported 100% satisfaction (Fig. 1). Among 142 narrative reports evaluated, 76% were dictated for thyroid operation performed for possibly malignant or malignant disease and 30% for benign disease. Essential surgical reporting elements including the status of parathyroid glands (75% to 79%) and recurrent laryngeal nerve(s) (100%) were adequately reported, but disease extent (46%) and tumor size (13%) were not. Additionally, the presence/absence of gross extrathyroidal cancer extension (36%) and the presence of residual cancer (6%) were inconsistently documented in reports for malignant disease. Nonessential elements such as incision placement (100%) were routinely reported.Figure 1.: Summary of current reporting options and surgeon satisfaction.CONCLUSION: Narrative surgical reporting dominates current practice but fails to document important prognostic information. Development of an accepted standardized national synoptic operative template would benefit quality of patient care, improve consistency and patient outcomes, and boost user satisfaction.

Incidental lesions of the thyroid are increasingly discovered as the prevalence of medical imaging escalates. The likelihood of malignancy must be assessed for each of these incidentalomas. The utility of the metabolic data derived from the identification of these lesions on PET/CT imaging is unclear. The overall rate of detection of thyroid incidentalomas on PET/CT is estimated at 1.5％-4.2％. However, this rate varies by the pattern of uptake. Several studies have evaluated predictive measures such as maximal standardized uptake value (SUVmax) and radiomics. However, no definitive conclusion has been reached. Given that the majority of PET/CT scans are performed in the context of malignancy, we recommend first assessing the general condition and life expectancy of patients when PET-detected thyroid incidentalomas are unveiled. We also recommend considering observation versus diagnostic workup with further imaging and/or fine-needle aspiration and cytology.

Background: Although the current gold standard for diagnosing thyroid nodule malignancy is ultrasound-guided fine-needle aspiration (FNA) cytology, about 20-25% of cytological evaluations are considered indeterminate for malignancy. This limitation has led to the emergence of next-generation sequencing panels, for example, ThyroSeq v3 (TSv3), which recognize highly diagnostic genetic mutations of common thyroid carcinomas in FNA samples and classify them as test-negative or test-positive, helping optimize treatment for indeterminate thyroid nodules (ITNs). Our goals were to evaluate the benign call rate (BCR) of TSv3 and assess its diagnostic performance and clinical utility while highlighting the points of consideration for a public Canadian institution. Methods: This is a single-center study conducted at the Royal Victoria Hospital (McGill University Health Centre) in Montreal, Canada, between January and February 2019. Patients were offered TSv3 following the McGill algorithm for ITN workup, a novel protocol developed at our institution to select only diagnostic surgery candidates to minimize waste of public resources, considering the single-payer health care system. Patient demographics, cytopathology results, TSv3 data, treatment plan, and final histopathology result were reviewed. Results: A total of 50 ITNs underwent TSv3 testing; molecular analysis yielded 20 (40%) "positive" results and 24 (48%) "negative" results. Six (12%) results were classified as "currently negative" or "negative but limited." "Currently negative" results indicate a low-risk mutation that alone is insufficient for development of a malignant lesion. "Negative but limited" results indicate a sample that is nondiagnostic for malignancy due to low cell count. BCR was calculated as ("negative" and "currently negative")/total, resulting in a BCR of 58%. Twenty-three (46%) patients were scheduled for surgery and 27 (54%) patients continued with surveillance. Ninety-one percent (20 of 22) of the resected target nodules were malignant on final pathology. Conclusions: TSv3 proved beneficial in classifying ITNs as positive or negative, avoiding surgery in the latter cases. We found a lower reduction rate in surgery and BCR than the previously published studies, which is attributable to the criteria of the McGill algorithm. In the Canadian public health care system, preventing unnecessary surgery represents significant cost savings for the provincial government while also improving patient quality of life.

We read with much interest the paper,[1] “Clinical significance of thyroid incidentalomas detected on fluorodeoxyglucose positron emission tomography scan (PETomas): An Indian experience” by Kumar et al. published in the July–September 2019 issue of your journal. In April 2011, our team published our findings on this topic, at which time we suggested that this thyroid entity should be called “PETomas.”[2] We are, therefore, extremely surprised that Kumar et al. did not cite our publication and acknowledge our role in initiating the use of the term “PETomas.”

Multifocal papillary thyroid carcinoma (PTC) is common and the number of tumor foci rarely exceeds ten. The mechanism of multifocal disease is debated, with the two main hypotheses consisting of either intrathyroidal metastatic spread from a single tumor or independent multicentric tumorigenesis from distinct progenitor cells. We report the case of a 46-year-old woman who underwent total thyroidectomy and left central neck lymph node dissection after fine-needle aspiration of bilateral thyroid nodules that yielded cytological findings consistent with PTC. Final pathology of the surgical specimen showed an isthmic dominant 1.5 cm classical PTC and over 30 foci of microcarcinoma, which displayed decreasing density with increasing distance from the central lesion. Furthermore, all malignant tumors and lymph nodes harbored the activating BRAF V600E mutation. The present case highlights various pathological features that support a mechanism of intraglandular spread, namely a strategic isthmic location of the primary tumor, radial pattern of distribution and extensive number of small malignant foci and BRAF mutational homogeneity.

Background: Safe performance of laparoscopic transabdominal adrenalectomy requires the application of a complex body of knowledge and skills, which are difficult to define, teach, and measure. This qualitative study aims to characterize expert behaviors, decisions, and other cognitive processes required to perform laparoscopic transabdominal adrenalectomy. Method: Hierarchical and cognitive task analyses for right and left laparoscopic transabdominal adrenalectomy were performed using semi-structured interviews and field observations of experts. Verbal data was supplemented with published literature, coded and thematically analyzed using constructivist grounded-theory by 2 independent reviewers. Results: A conceptual framework was synthesized. Sixty-eight tasks, 46 cognitive behaviors, and 52 potential errors were identified and categorized into 8 procedural steps and 8 fundamental principles: anticipation, exposure, teamwork or communication, physiology, dissection techniques, oncologic margins, tactical modification, and error recovery. Experts emphasized the importance of creating a 3-dimensional mental model of the anatomy or pathology (eg, aberrant vessels, tumor location) that is consistently fine-tuned throughout the operation, with conscious awareness of danger zones (eg, medial arc). Despite variations in dissection techniques, experts highlighted 2 themes: macrodissection and microdissection, with emphasis on nonlinear motions and effective transitions between the 2 when appropriate. Conclusion: This study defines behaviors and competencies that are essential to performing laparoscopic transabdominal adrenalectomy effectively and safely. (C) 2019 Elsevier Inc. All rights reserved.

Importance:In addition to biochemical cure, clinical benefits after surgery for primary aldosteronism depend on the magnitude of decrease in blood pressure (BP) and use of antihypertensive medications with a subsequent decreased risk of cardiovascular and/or cerebrovascular morbidity and drug-induced adverse effects.Objective:To evaluate the change in BP and use of antihypertensive medications within an international cohort of patients who recently underwent surgery for primary aldosteronism.Design, Setting, and Participants:A cohort study was conducted across 16 referral medical centers in Europe, the United States, Canada, and Australia. Patients who underwent unilateral adrenalectomy for primary aldosteronism between January 2010 and December 2016 were included. Data analysis was performed from August 2017 to June 2018. Unilateral disease was confirmed using computed tomography, magnetic resonance imaging, and/or adrenal venous sampling. Patients with missing or incomplete preoperative or follow-up data regarding BP or corresponding number of antihypertensive medications were excluded.Main Outcomes and Measures:Clinical success was defined based on postoperative BP and number of antihypertensive medications. Cure was defined as normotension without antihypertensive medications, and clear improvement as normotension with lower or equal use of antihypertensive medications. In patients with preoperative normotensivity, improvement was defined as postoperative normotension with lower antihypertensive use. All other patients were stratified as no clear success because the benefits of surgery were less obvious, mainly owing to postoperative, persistent hypertension. Clinical outcomes were assessed at follow-up closest to 6 months after surgery.Results:On the basis of inclusion and exclusion criteria, a total of 435 patients (84.6%) from a cohort of 514 patients who underwent unilateral adrenalectomy were eligible. Of these patients, 186 (42.3%) were women; mean (SD) age at the time of surgery was 50.7 (11.4) years. Cure was achieved in 118 patients (27.1%), clear improvement in 135 (31.0%), and no clear success in 182 (41.8%). In the subgroup classified as no clear success, 166 patients (91.2%) had postoperative hypertension. However, within this subgroup, the mean (SD) systolic and diastolic BP decreased significantly by 9 (22) mm Hg (P < .001) and 3 (15) mm Hg (P = .04), respectively. Also, the number of antihypertensive medications used decreased from 3 (range, 0-7) to 2 (range, 0-6) (P < .001). Moreover, in 75 of 182 patients (41.2%) within this subgroup, the decrease in systolic BP was 10 mm Hg or greater.Conclusions and Relevance:In this study, for most patients, adrenalectomy was associated with a postoperative normotensive state and reduction of antihypertensive medications. Furthermore, a significant proportion of patients with postoperative, persistent hypertension may benefit from adrenalectomy given the observed clinically relevant and significant reduction of BP and antihypertensive medications.

BACKGROUND:The effects of chronic lymphocytic thyroiditis (CLT) on the presentation and outcome of papillary thyroid carcinoma (PTC) have long been a topic of controversy. OBJECTIVE:To evaluate the effect of coexistent CLT on the clinicopathological features of PTC. DESIGN:Retrospective study. PATIENTS:All patients with PTC who had been followed by the 2 co-investigators (Juan Rivera and Richard J. Payne) between 2006 and 2011 were included. RESULTS:CLT was present in 35% (166) of the included patients and was associated with a higher proportion of patients with TNM stage I (p = 0.027) and fewer patients with persistent disease (p = 0.014) in comparison with the PTC-only group. Analysis of the data based on age (<45 or >45 years) revealed that in the older group, the presence of CLT was associated with fewer patients with persistent disease (p = 0.03) and capsular invasion (p = 0.05). However, in patients <45 years of age, the presence of CLT was associated with more capsular invasion (p = 0.003) and extrathyroidal extension (p = 0.004) compared with the PTC-only group. CONCLUSIONS:CLT in patients with PTC was associated with lower-stage disease and less disease persistence in patients >45 years of age. In patients <45 years, the presence of CLT appeared to be associated with unfavorable pathological features.

Molecular profiling in thyroid cancer has made significant progress in part due to advances in somatic mutation profiling. Yet, differentiating benign from malignant thyroid nodules remains elusive. A unique set of DNA methylation signatures has the potential of improving thyroid cancer molecular diagnostics based on the DNA methylome. See related article by Yim et al., p. 544

OBJECTIVE:To determine the validity of hospital administrative databases compared to prospective collection of medical data assessing thyroid surgery complications.BACKGROUND:Administrative data are increasingly used to track surgical outcomes.METHODS:All patients undergoing thyroid surgery at three French university hospitals between April 2008 and April 2009 were prospectively included. Using diagnosis and procedural codes from hospital administrative database, we designed three indicators for measuring complications of thyroid surgery: recurrent laryngeal nerve palsy, postoperative hypoparathyroidism, and postoperative hemorrhage. Gold standard was obtained from a prospective collection of medical data after systematically screening each patient for the above-mentioned complications. Their ability to monitor surgical outcomes over time within individual hospitals was estimated using control charts. Spatial comparison between hospitals was performed by funnel plots.RESULTS:A total of 1909 patients were included. Complication rates extracted from administrative data were significantly lower compared to medical data (nerve palsy 2.4% vs. 6.7%, hypoparathyroidism 10.6% vs. 22.3%, p<0.0001). Indicator sensitivity was 30.4% for nerve palsy, 45.4% for hypoparathyroidism and 71.4% for postoperative hemorrhage. Corresponding positive predictive values were 84.4%, 95.1% and 68.2%. In two of the three hospitals, administrative data were not able to track temporal variations in complications rates. Regarding inter-hospital comparisons, 2 out of 3 hospitals were considered outliers according to administrative data despite having an average performance based on medical data.CONCLUSIONS:The ability of indicators extracted from administrative databases to measure thyroid surgery outcomes depends on the quality of underlying data coding. Validation in every center should be a prerequisite before implementing such metrics for tracking performance.

Errors in judgment during thyroidectomy can lead to recurrent laryngeal nerve injury and other complications. Despite the strong link between patient outcomes and intraoperative decision-making, methods to evaluate these complex skills are lacking. The purpose of this study was to develop objective metrics to evaluate advanced cognitive skills during thyroidectomy and to obtain validity evidence for them.