History Of Neck Irradiation Research Articles

The Treatment of Hypothyroidism in Pregnancy

Abstract Hypothyroidism is a pathologic condition generated by the thyroid hormone deficiency. The American Thyroid Association advises for the screening of hypothyroidism beginning at 35 years and thereafter every 5 years in people at high risk for this condition: females older than 60 years, pregnant women, patients with other autoimmune disease or patients with a history of neck irradiation. In pregnant women, hypothyroidism can been associated with adverse effect for both mother and child. The „Guidelines of the American Thyroid Association for the Diagnosis and Management of Thyroid Disease During Pregnancy and Postpartum“ recommends the treatment of maternal overt hypothyroidism: females with a thyrotropin (TSH) level higher than the trimester-specific reference interval and decreased free thyroxine (FT4), and females for which TSH level is higher than 10.0 mIU/L, irrespective of the FT4 value, with administration of oral levothyroxine. The goal of treatment of maternal overt hypothyroidism is to bring back the serum TSH values to the reference range specific for the pregnancy trimester. The Guidelines of the „European Thyroid Association for the Management of Subclinical Hypothyroidism in Pregnancy and in Children“ recommends treatment of pregnancy associated subclinical hypothyroidism with the following levothyroxine doses: „1.20 μg/kg/day for TSH≤4.2 mU/l, 1.42 μg/kg/day for TSH >4.2-10 and 2.33 μg/kg/day for overt hypothyroidism“. The „Guidelines of the American Thyroid Association for the Diagnosis and Management of Thyroid Disease During Pregnancy and Postpartum“ and the „European Thyroid Association for the Management of Subclinical Hypothyroidism in Pregnancy and in Children“ do not recommend the treatment of isolated hypothyroxinemia in pregnancy.

Case Report: Post-Operative Airway Obstruction in A Patient with Reinke’s Edema

Here we present the case of a 64 year old female with a history of neck radiation and Reinke’s edema that experienced unexpected respiratory failure after a sedation anesthetic. After the case terminated, the patient was noted to be hypoventilating and stridorous. Mask ventilation, laryngeal mask airway ventilation, and direct laryngoscopy failed. The patient was intubated with video laryngoscopy. Reinke's edema, a benign lesion characterized by swelling of the vocal folds, was thought to contribute to the difficulty in ventilating and intubating this patient. We present a discussion of Reinke’s edema and its potential relevance to the practice of anesthesia.

Screening for thyroid cancer in survivors of childhood and young adult cancer treated with neck radiation.

The optimal method of screening for thyroid cancer in survivors of childhood and young adult cancer exposed to neck radiation remains controversial. Outcome data for a physical exam-based screening approach are lacking. We conducted a retrospective review of adult survivors of childhood and young adult cancer with a history of neck radiation followed in the Adult Long-Term Follow-Up Clinic at Memorial Sloan Kettering between November 2005 and August 2014. Eligible patients underwent a physical exam of the thyroid and were followed for at least 1year afterwards. Ineligible patients were those with prior diagnosis of benign or malignant thyroid nodules. During a median follow-up of 3.1years (range 0-9.4years), 106 ultrasounds and 2277 physical exams were performed among 585 patients. Forty survivors had an abnormal thyroid physical exam median of 21years from radiotherapy; 50% of those with an abnormal exam were survivors of Hodgkin lymphoma, 60% had radiation at ages 10-19, and 53% were female. Ultimately, 24 underwent fine needle aspiration (FNA). Surgery revealed papillary carcinoma in seven survivors; six are currently free of disease and one with active disease is undergoing watchful waiting. Among those with one or more annual visits, representing 1732 person-years of follow-up, no cases of thyroid cancer were diagnosed within a year of normal physical exam. These findings support the application of annual physical exam without routine ultrasound for thyroid cancer screening among survivors with a history of neck radiation. Survivors with a history of neck radiation may not require routine thyroid ultrasound for thyroid cancer screening. Among adult survivors of childhood and young adult cancer with a history of radiation therapy to the neck, annual physical exam is an acceptable thyroid cancer screening strategy.

Endovascular recanalization of the common carotid artery in a patient with radio induced chronic occlusion

Recanalization of chronic occlusion of the common carotid artery (CCA) in patients with a history of neck irradiation is challenging, both for vascular surgeons and interventional neuroradiologists. We describe a...

Laryngeal Framework Surgery in the Irradiated Neck: A Retrospective Matched Cohort Study.

Laryngeal framework surgery (LFS) remains a cornerstone treatment in the management of glottic insufficiency. Traditionally, a history of radiation to the neck has been considered a relative contraindication to LFS. A retrospective matched cohort study was performed to study LFS outcomes in patients with and without a history of radiation. Variables studied included radiation specifics, surgical time, operative difficulty, complications, need for revision surgery, and Voice Handicap Index-10 (VHI-10) scores. A total of 298 patients were studied. Fourteen patients with a history of neck irradiation were matched with 14 nonirradiated controls. No complications were encountered in the nonirradiated cohort. In the irradiated cohort, there were 2 minor wound complications and 1 admission for stridor treated medically. No cases of implant extrusion were observed. The VHI-10 scores were improved in both cohorts relative to preoperative baseline (P = .001). Posttreatment VHI-10 scores were better in the nonirradiated cohort (P = .03). There was no difference between cohorts with respect to complication rates, surgical time, surgical difficulty, length of stay, use of a surgical drain, or need for revision surgery. Laryngeal framework surgery is safe and associated with improved voice outcomes in patients with a history of neck irradiation.

English

Numerous studies on Ultrasonographic (US) findings of Thyroid malignancy have been conducted (1-6). The main pathologic types of thyroid carcinoma are papillary, follicular, medullary, and anaplastic. Papillary and follicular thyroid carcinomas both have an excellent prognosis, with a 20-year survival of 90%-95% and 75%, respectively (7-9). Medullary thyroid carcinoma is more aggressive, with a 10-year survival of 42%-90% (10-11). Anaplastic thyroid carcinoma has an extremely poor prognosis, with a 5-year survival of 5% (10-11). Risk factors for thyroid carcinoma include age of less than 20 years or more than 60 years, a history of neck irradiation, and a family history of thyroid cancer (11.).Thyroid lymphoma, usually of the non-Hodgkin type, is uncommon. It may occur as part of generalized lymphoma or as a primary tumor, usually in the setting of Hashimoto thyroiditis. Metastases to the thyroid are rare and usually originate from primary lung, breast, and renal cell carcinomas. Metastatic disease should be suspected when a solid thyroid nodule is found in a patient with a known non-thyroid malignancy. AIMS & OBJECTIVE: In this study we planned to differentiate different type of thyroid malignancies based on Ultrasonography from one another due their different prognosis. MATERIAL & METHOD: We took 120 patients showing palpable neck masses out of which 40 patients were found to have malignant neoplasm of Thyroid gland. Further differentiation of different type of Thyroid neoplasm was done by Ultrasonography. RESULT: Out of 40 malignant neoplasm, 24 patients had papillary carcinoma and 4 patients had medullary carcinoma Thyroid. Rest 16 patients were kept in other type of thyroid malignancies. CONCLUSION: We concluded our study with the fact that just keeping the patient under category of thyroid neoplasm is just not sufficient, rather we should be able to differentiate each type of thyroid malignancy from one another due to different prognosis of each type.

Validating common carotid stenosis by duplex ultrasound with carotid angiogram or computed tomography scan

No consensus exists for duplex ultrasound criteria in the diagnosis of significant common carotid artery (CCA) stenosis. In general, peak systolic velocity (PSV) >150 cm/s with poststenotic turbulence indicates a stenosis >50%. The purpose of our study is to correlate CCA duplex velocities with angiographic findings of significant stenosis >60%. We reviewed the carotid duplex records from 2008 to 2011 looking for patients with isolated CCA stenosis and no ipsilateral internal or contralateral carotid artery disease who received either a carotid angiogram or a computed tomography scan. We identified 25 patients who had significant CCA disease >60%. We also selected 74 controls without known CCA stenosis. We performed receiver operating characteristics analysis to correlate PSV and end-diastolic velocity (EDV) with angiographic stenosis >60%. The degree of stenosis was determined by measuring the luminal stenosis in comparison to the proximal normal CCA diameter. Most patients had a carotid angiogram (21/25), four only had a computed tomography angiography and four had both. Eighteen patients had history of neck radiation. The CCA PSV ≥250 cm/s had a sensitivity of 98.7% (81.5%-100%) and a specificity of 95.7% (92.0%-99.9%), CCA PSV ≥300 cm/s had a sensitivity of 90.9% (69.4%-98.4%) and a specificity of 98.7% (92.0%-99.9%). The CCA EDV ≥40 cm/s had a sensitivity of 95.5% (95% confidence interval of 75.1-99.8%) and specificity of 98.7% (92.0%-99.9%), EDV ≥60 cm/s had a sensitivity of 100% (75.1%-99.8%) and specificity of 87% (94.1-100%), and EDV ≥70 cm/s had a sensitivity of 86.4% (64.0%-96.4%) and specificity of 100% (94.1%-100%). The presence of both PSV <250 cm/s and EDV <60 cm/s had a 98.7% negative predictive value, and the presence of both PSV ≥250 cm/s and EDV ≥60 cm/s had 100% positive predictive value. Establishing CCA duplex criteria to screen patients with significant stenosis is crucial to identify those who will need further imaging modality or treatment. In our laboratory, CCA PSV ≥250 cm/s and EDV ≥60 cm/s are thresholds that can be used to identify significant (>60%) CCA stenosis with a high degree of accuracy.

Clinical Features, Treatment, and Long‐Term Outcome of Papillary Thyroid Cancer in Children and Adolescents Without Radiation Exposure

Cancer of the thyroid gland is rare in children and adolescents. A history of neck irradiation is a well-established risk factor for tumor development, and most previous reports focused on cases that were induced by radiation exposure. We present here a retrospective review of the clinical features, treatment, and long-term outcome of children and adolescents with papillary thyroid cancer (PTC) without a history of radiation exposure who were treated at our institution over a period of ~50years. We retrospectively investigated 142 PTC patients without an irradiation history who were younger than 20years of age when treated from 1961 to 2005 (17 males and 125 females; mean age=16.3±2.7years; follow-up=21.8±12.0years). The clinicopathological results were evaluated using the medical records. Disease-free survival (DFS) and cause-specific survival (CSS) were assessed with the Kaplan-Meier method and compared with the log-rank test. Parametric analyses were performed using Student's t test and nonparametric analyses were performed using the Mann-Whitney U test. At diagnosis, three patients had distant lung metastasis and 33 had gross neck lymph node (LN) metastasis. All patients were treated with surgery (hemi/partial thyroidectomy in 45 patients, subtotal thyroidectomy in 85, total thyroidectomy in 12, no LN dissection in 50, central compartment dissection in 20, and modified radical neck dissection in 72), and postoperative external beam radiation therapy was administered to 59. Postoperative ablative therapy using I(131) was not performed in this series. Recurrence was found for regional LN (n=25), lung (n=9), remnant thyroid (n=5), and others (n=4). DFS and CSS at 40years were 74.1 and 97.5%, respectively. DFS was significantly worse in patients aged <16years with a family history of thyroid cancer, preoperative neck gross LN metastasis, maximum tumor diameter, and extrathyroidal invasion. Preoperative gross neck LN metastasis and distant metastasis at diagnosis were significant factors for CSS. No other factors contributed to DFS and CSS. When the clinical features of children and adolescents were compared, the incidence of preoperative gross neck LN metastasis and distant metastasis at diagnosis and tumors with a maximum diameter >10mm were significantly higher in the children group than in the adolescent group. DFS was significantly shorter in the children group than in the adolescent group, but no significant difference was found in CSS between these two groups. The prognosis of PTC in children and adolescents is excellent, regardless of the extent of thyroidectomy and LN dissection. We recommend that only children or adolescents with preoperative gross neck LN metastasis and distant metastasis at diagnosis should be subjected to postoperative ablative therapy.

The Continuing Saga of Postpartum Thyroiditis

Postpartum thyroiditis (PPT) is characterized by the development of postpartum thyroid dysfunction (PPTD), which may occur up to 12 months after delivery. Usually the syndrome presents as transient hyperthyroidism (median time of onset, 13 wk) followed by transient hypothyroidism (median time of onset, 19 wk). Clinically, women are relatively asymptomatic during the hyperthyroid phase, although some may notice palpitations requiring treatment with -adrenergic blocking agents. In contrast, patients experience persistent and troublesome symptoms related to the hypothyroid period, which usually must be treated with levothyroxine, normally for up to 1 yr (1, 2). Several studies from different countries have shown that about 12–61% of women who develop postpartum hypothyroidism go on to a permanent hypothyroid state when assessed 1 yr or more after delivery (2–4); these women then require lifelong levothyroxine replacement therapy. In those women who do not develop permanent hypothyroidism, the chance of experiencing a recurrence of PPTD after a previous episode is around 70% (5). The incidence of PPTD has been the subject of much debate. Although most reviews cite a range from 4–9% (6), there is considerable variation in these figures due to sample bias, frequency of blood sampling, and definition of the syndrome. For example, an incidence of 16.7% quoted by Fung et al. (2) was later shown to be erroneous due to the inclusion of the large denominator of thyroid peroxidase (TPO) antibody-negative persons used in the calculation. Nevertheless, the wider incidence has ranges from 1.1 to 21.1%. PPTD is an immunological disorder occurring more frequently in women with certain human leukocyte antigen haplotypes and being usually characterized by the presence of circulating TPO antibodies (7). Indeed, the condition occurs in up to 50% of women found to be TPO antibody positive at the end of the first trimester of gestation (i.e. before the titers start to decline during pregnancy). The other 50% of TPO antibody-positive women who have no thyroid dysfunction are considered to have PPT but not PPTD. Furthermore, there is evidence that the TPO antibody titer at 16 wk gestation is related to the severity of the PPTD (8). The prospective study of PPT by Stagnaro-Green et al. (9) is an important contribution to the epidemiology of postpartum thyroid disease and adds to the debate in several ways. They took advantage of a previously reported study of screening for thyroid function in pregnancy that examined 4562 pregnant women from southern Italy (Puglia) in the first trimester (10). In that study, women were randomly assigned to a universal screening group or a case-finding group. In addition, women in both groups were grouped as high risk if they had one of the following: family history of autoimmune thyroid disease, presence of goiter, signs and symptoms suggestive for thyroid dysfunction, personal history for type 1 diabetes or other autoimmune disease, and history of neck irradiation, previous miscarriages, or preterm deliveries. A total of 4384 women were tested at 6 and 12 months postpartum for thyroid function (TSH and TPO antibodies), with free T4 being measured if hyperthyroidism was suspected. They were also screened in the first trimester, and those with thyroid dysfunction at that time were not studied further for this analysis. PPTD was defined by the usual criteria (2). The incidence of PPT was low at 3.9%. This figure should be compared with two studies from northern Italy that reported incidences of 8.7 and 18%, respectively (11, 12). However the base population in both studies did not exceed 400. Although women who were TPO antibody positive or women in the high-risk groups reported by Stagnaro-Green et al. (9) were significantly more likely to

Symptomatic carotid artery stenosis: what is the preferred treatment?

Stroke is a major cause of mortality, morbidity, and disability. Carotid artery disease is the etiology for 15% to 20% of stroke. Carotid endarterectomy (CEA) reduces the risk of ipsilateral stroke and death in symptomatic patients with 50% to 99% carotid artery stenosis when the operative risk of stroke or death is less than 6%. Treatment benefit is greater with earlier surgery, more severe stenoses, and older age. Recently, carotid artery stenting (CAS) has emerged as a treatment option, especially in patients with high surgical risk due to anatomic or clinical variables. Nondisabling stroke risk may be higher with CAS than CEA, but the difference is narrowed with the use of embolic protection devices. The risk for myocardial infarction is lower with CAS than CEA. There is no difference in risk for disabling stroke or death. Worse results with new or low-volume CAS operators is a concern. CEA and CAS are complementary revascularization strategies. CEA may be preferred in older patients with complex anatomy or bulky plaques. CAS may be preferred in younger patients and those with restenosis, history of neck radiation, surgical contraindications, or surgically inaccessible lesions. The role for optimal medical therapy as an alternative treatment strategy remains to be defined. Nevertheless, all patients should be treated with lifestyle interventions and secondary risk factor control to target levels to reduce the risk of subsequent atherosclerotic events.

Endocrine Society of India management guidelines for patients with thyroid nodules: A position statement

Thyroid nodules are common. Thyroid cancer is rarer. No guidelines exist for management of thyroid nodules in the Indian context and these recommendations are intended for this purpose. The consensus committee reviewed important articles, including previously published consensus statements. Management points were scored according to the level of evidence. These guidelines cover the clinical evaluation and include the interpretation of imaging and fine needle aspiration cytology of thyroid nodules. The guidelines also cover the management of special situations like thyroid incidentalomas, cystic thyroid lesion and nodules detected during pregnancy. The consensus guidelines represent a summary of current medical evidence for thyroid nodule management and the committee has attempted to optimize the guidelines for the clinical practice setting in India.

Nodular Thyroid Disease

We investigated the evolution of thyroid nodules ≤1 cm without suspicious ultrasonographic characteristics and hot nodules detected by 131I scintigraphy (that do not require cytologic evaluation) in patients who are at low risk for malignancy. A total of 148 patients with 290 nodules ≤1 cm without suspicious characteristics and 32 subjects with low thyroid stimulating hormone and 55 hot nodules were studied. Thirty-six of the 290 nodules ≤1 cm without suspicious characteristics exhibited growth during follow-up and were punctured. Cytology was interpreted as benign in 28 cases, insufficient in 6, indeterminate in 1, and suspicious of malignancy in another (papillary carcinoma). Ten patients with hot nodules were treated with radioiodine because of progression to hyperthyroidism. Twenty patients with 35 hot nodules were followed and none had significant nodule growth. Therefore, malignancy was observed in only 1 of 345 nodules (0.3%) without an initial indication for cytology. Cytology is not necessary in the case of nodules ≤1 cm that have no suspicious radiologic features or hot nodules in patients without a history of neck radiation during childhood or a family history of thyroid carcinoma.

A Case of Coexistence of Parathyroid and Papillary Thyroid Carcinoma

Primary hyperparathyroidism is usually caused by a parathyroid adenoma, occasionally by primary parathyroid hyperplasia and rarely by parathyroid carcinoma. Coincidental occurrence of thyroid carcinoma in parathyroid adenoma is not uncommon, but synchronous parathyroid and thyroid carcinoma is extremely rare. Here, we describe a case of synchronous parathyroid carcinoma and papillary thyroid carcinoma. A 68-year-old female with no history of neck irradiation presented with hyperparathyroidism by parathyroid mass that was observed during the treatment of bronchiolitis obliterans organizing pneumonia. During the preoperative evaluation thyroid nodules were also observed. Therefore, she underwent surgery at Konyang University Hospital and was diagnosed with coexisting parathyroid and papillary thyroid carcinoma. (J Korean

Carotid angioplasty and stenting in anatomically high-risk patients: Safe and durable except for radiation-induced stenosis

Carotid angioplasty and stenting (CAS) is used in patients considered high-risk for carotid endarterectomy (CEA). Patients qualify as high-risk because of medical comorbid conditions or for anatomic considerations (previous CEA, radical neck dissection, radiation). We compared the technical feasibility and durability of CAS in medically high-risk patients (MED) vs anatomically high-risk patients (ANAT). A retrospective review was performed of all consecutive patients undergoing CAS by a single vascular surgery group. All patients were high risk and evaluated with duplex ultrasound imaging and angiography. Primary end points were technical success, 30-day stroke, myocardial infarction (MI), death, and in-stent restenosis. Standard statistical analysis included Kaplan-Meier life tables. From January 2003 to December 2007, 230 CAS (98 ANAT, 132 MED) procedures were attempted. The ANAT cohort comprised 84 patients with a single anatomic risk factor: 71 with a previous ipsilateral CEA, 6 high lesions, 6 history of neck radiation, and 1 with a tracheostomy. Ten patients had two or three anatomic risk factors: nine with radical neck dissection and radiation and one with neck radiation and ipsilateral CEA. The mean age was 71.1 years for ANAT vs 73.9 years for MED (P = .021). Technical success rates were 98% in ANAT and 98.5% in MED (P = .76). Thirty-day stroke rate was 1.0% in ANAT and 5.3% in MED (P = .14); the mortality rate was 2.0% in ANAT and 0.8% in MED (P = .79). The 2-year survival free from stroke was MED, 93.6% and ANAT, 98.9% (P = .118); and from restenosis was MED, 91.9%; and ANAT, 91.0% (P = .98). Two-year overall survival was significantly better in ANAT (84.6%) vs MED (70.1%; P = .026). Four of the seven restenoses in the ANAT group occurred in patients with previous neck radiation. The restenosis rate for radiation-induced (RAD) stenosis treated with CAS was significantly higher at 22.2% (4 of 18) compared with 3.8% (3 of 78) in ANAT group patients without a history of radiation (non-RAD; P = .028). The 2-year restenosis-free survival was 72.7% in the RAD group vs 95.9% in the non-RAD group (P = .017). CAS is as technically feasible, safe, and durable in anatomically high-risk patients as in medically high-risk patients, with similar rates of periprocedural stroke and death and late restenosis. However, patients with radiation-induced stenosis appear to be at an increased risk for restenosis.

Irradiation-Induced Carotid Artery Stenosis: A Preventable Complication of Neck Radiotherapy?

Shichita et al in this issue of Angiology compare the angiographic characteristics of radiation-induced carotid artery stenosis with those of nonirradiated, atherosclerotic carotid stenosis. All established risk factors for carotid artery disease (ie, smoking, hypertension, diabetes mellitus, and hyperlipidemia) tended to be less frequent in the radiotherapy compared with the atherosclerotic group. Despite that, the radiation-induced carotid lesions were longer than the nonirradiated atherosclerotic carotid lesions (27.7 + 13.3 vs. 15.9 + 9.5 mm, respectively; P < .01). The conclusion reached is that local radiotherapy is as strong a risk factor for carotid artery stenosis as the established vascular risk factors. This Editorial deals with some additional issues regarding irradiation-induced carotid artery stenosis. The effect of radiation on normal tissues has been investigated since the early 1940s when the widespread use of irradiation therapy began. In 1942, Warren presented a detailed discussion of the irradiation-induced changes on the cardiovascular system; the similarity of radiation-induced changes in the vessel lumen with the atherosclerotic plaques in arteries was noted in this early report. The similarity of irradiation-induced plaque-like intimal thickening with arterial changes occurring during the atherosclerotic process was also reported by others. Animal work suggested that elevated serum cholesterol and hyperlipidemia may contribute to the development of radiation-induced carotid artery stenosis. A high-cholesterol diet induces early atheromatous changes; the addition of irradiation at even low dosage accelerates this effect. The association between hypercholesterolemia/hyperlipidemia and a faster progression of irradiation-induced carotid atherosclerosis was reported in humans three decades ago. Nine patients with irradiation-induced documented carotid stenosis were compared with 40 patients having carotid artery disease without previous history of neck irradiation. The irradiated group was younger and had less peripheral vascular and coronary heart disease but an increased incidence of localized carotid artery disease. It was proposed that elevated serum cholesterol and hyperlipidemia contribute to the development of radiation-induced carotid artery stenosis. Extrapolation from the results of the above studies suggested that irradiated carotid arteries are more susceptible to hypercholesterolemia. Therefore, even normal blood cholesterol levels may be harmful for these patients. Aggressive blood cholesterol lowering should thus be initiated at the time of neck irradiation (if not before). Statins comprise an essential component in the management of vascular From the Department of Vascular Surgery, Red Cross Hospital, Athens, Greece (KIP); Department of Vascular Surgery, University Hospital of Larissa, University of Thessaly Medical School, Larissa, Greece (ADG); Department of Clinical Biochemistry (Vascular Disease Prevention Clinic), Royal Free Hospital Campus, University College Medical School, University College London (UCL), London, UK (DPM).

Paroxysmal hypertension due to baroreflex failure

CASE PRESENTATION A 78-year-old Caucasian male was referred to our hypertension clinic in February 2005 for severe blood pressure (BP) lability. He had a diagnosis of hypertension for about 10 years, but had been previously well controlled. Over the preceding 14 months, he had noticed fluctuations in BP that became progressively more severe. Based on self-monitored home BP readings, he reported systolic BP peaks of 220–240 mmHg and systolic BP nadirs of 80–90 mmHg, often happening within the same day. He also described that the rise in BP was associated with significant diaphoresis of the head and palms and facial flushing, analogous to a ‘thermometer rising inside his face and head’. Occasionally he also experienced palpitations. He had erectile dysfunction but no history of urinary incontinence or retention, or any other genitourinary complaints. He had no other cardiopulmonary, digestive, neurological or psychiatric symptoms. At the time of the initial visit, his hypertension was managed with labetalol 50 mg that he took irregularly, on average once daily. In the past, he had experienced symptomatic hypotension and fatigue with diltiazem, metoprolol, and diuretics. He did not abuse alcohol or any illicit substances and did not use any over-the-counter medications or nutriceuticals. In addition to hypertension, he had a history of squamous cell carcinoma of the left pyriform sinus (treated with extensive radiation to the neck and chemotherapy in 1998), coronary artery disease (coronary artery bypass grafting in 2000), nonproteinuric chronic kidney disease stage 3 (clinically presumed to be due to hypertensive nephrosclerosis), gastroesophageal reflux, and well-controlled hypothyroidism. In addition to labetalol, his medications included aspirin, levothyroxine, lovastatin, omeprazole, and fish oil. On examination, the patient appeared well and calm. BP averaged 184/84 mmHg in the supine position, 152/ 78 mmHg when seated, and 140/74 mmHg after 5 min of orthostasis. His heart rate was 68 b.p.m. and there were no changes with posture. Fundoscopic examination revealed arteriolar narrowing and occasional abnormal arteriovenous crossings. The skin overlying his neck was taut from previous radiation exposure. There was no jugular venous distension at 30 degrees. Bilateral carotid bruits were heard; carotid pulsations were normal. Examination of the heart, lungs, abdomen, and extremities were normal. The neurological examination showed normal focused sensory and motor examination, without any Parkinsonian or cerebellar features. Laboratory tests were significant for an elevated serum creatinine (1.9 mg dl ), with an associated estimated glomerular filtration rate of 38 ml per min per 1.73 m. Relevant laboratory tests, all of which were unremarkable, are listed in Table 1. A renal sonogram was unremarkable. A renal magnetic resonance angiogram was normal. Duplex ultrasound of the carotid arteries revealed hemodynamically significant bilateral carotid stenosis, confirmed by magnetic resonance angiography. A magnetic resonance scan of his brain was remarkable only for deep white matter ischemic lesions; there was no evidence of a brain stem lesion or infarct. Owing to the patient’s history of neck irradiation and clinical presentation, bedside evaluation of baroreflex pathway integrity was performed after he had been off antihypertensive drugs for 5 days. BP averaged 158/ 72 mmHg in the supine position, 158/64 mmHg when seated, and 156/80 in standing. The heart rate was 84 b.p.m. in all positions. The RR interval was unchanged (0.63 s) during slow deep breathing and throughout the Valsalva maneuver. We did not use a beat-to-beat monitor, so we were unable to assess the BP response to the Valsalva maneuver. The cold pressor test (hand/ forearm immersion) showed an unexpected response: he had a decline in both heart rate (93–70 b.p.m.) and BP (154/78–98/60 mmHg), both of which recovered to baseline levels after 5 min of monitoring. His 24 h ambulatory BP monitoring is displayed in Figure 1, demonstrating marked BP lability. t h e r e n a l c o n s u l t http://www.kidney-international.org

Risk Factors for In-Stent Restenosis After Vertebral Ostium Stenting

To determine whether vascular risk factors, underlying vessel diameter, and/or the type of stent affect restenosis rates for vertebral ostium stents. A single-center retrospective analysis was conducted of 44 patients (31 men; mean age 61 years, range 32-81) who underwent stenting of 48 ostial lesions in the vertebral arteries between 1999 and 2005. Only patients who underwent angiographic follow-up were included in the analysis. Cox regression analysis was utilized for risk factor association with binary restenosis (> or =50% versus <50%). Stent types and stent categories were compared for differences in binary restenosis rates and lumen gain at follow-up angiography. Twenty-three (48%) of 48 lesions had > or =50% stenosis at a mean follow-up of 7.7 months. Cigarette smoking was associated with higher binary restenosis rates (p=0.025), while hypertension, diabetes, hyperlipidemia, history of neck radiation, and known coronary artery and/or peripheral vascular disease were not. Reduced binary restenosis rates and improved lumen gain were seen in cobalt chromium balloon-expandable stents compared to non-cobalt chromium stents (p=0.002 and p=0.002, respectively), stainless steel balloon-expandable stents (p=0.005 and p=0.005), and the S670 stent (p=0.069 and p=0.069). The size of stent used was not associated with risk of restenosis (p=0.756). Cobalt chromium stents were associated with reduced restenosis, while smoking was associated with increased restenosis risk.

Can a Lightbulb Sestamibi SPECT Accurately Predict Single‐Gland Disease in Sporadic Primary Hyperparathyroidism?

Technetium-99m sestamibi scintigraphy with single photon emission computed tomography (SPECT) is widely used to guide minimally invasive exploration in patients with sporadic primary hyperparathyroidism (SPH), although its sensitivity in multiglandular disease is limited. We examined the incidence of missed multiglandular disease and associated anatomic findings when sestamibi SPECT was positive for a single intense focus of delayed tracer uptake, termed a lightbulb scan (LBS). Prospectively entered data from 764 patients with SPH treated with initial parathyroid exploration from March 5, 2000, to December 31, 2006, were reviewed. A single radiologist performed blinded interpretation of 585 available sestamibi SPECT images, classifying 167 (28.5%) patients with a LBS. Clinical findings were compared among LBS patients with a single adenoma (true positive) and LBS patients with multiglandular disease (false negative). One hundred fifty of 167 (89.8%) LBS patients had a single adenoma and 3 (1.8%) had carcinoma. Multiglandular disease was anatomically present in 14 of 167 (8.4%) LBS patients compared with 60 of 418 (15.6%) non-LBS patients (p=0.05). Parathyroid hyperplasia occurred less frequently in LBS patients [5/167 (3%)] compared with non-LBS patients [36/418 (8.6%)], (p=0.02), while double adenomas occurred equally often in LBS patients [9/167 (5.4%)] compared with non-LBS patients [24/418 (5.7%)], (p=0.87). Double adenomas in LBS patients were more likely ipsilateral (7/9, p=0.005) and left-sided (7/7, p=0.008). LBS patients with multiglandular disease were more likely to have a history of neck irradiation, prior neck exploration, and concomitant thyroid pathology. In patients with SPH, sestamibi SPECT studies show a single bright focus of uptake in only 29% of patients. LBS findings do not exclude multiglandular disease. To avoid unacceptable rates of failure at initial parathyroid exploration, the expert surgeon should use validated adjuncts such as intraoperative PTH monitoring or four-gland exploration.

Long-term follow-up after parathyroidectomy for radiation-induced hyperparathyroidism

External radiation is associated with a risk of hyperparathyroidism. We reviewed the outcomes after operation for radiation-induced hyperparathyroidism (R-HPT). We conducted a retrospective review of all patients who had operative therapy for R-HPT from 1980 to 2003 in our department with a minimum of 3 years of follow-up after operative therapy. Between 1980 and 2003, 1932 patients underwent parathyroidectomy for primary hyperparathyroidism. Thirty-seven (1.92%) patients had a history of neck irradiation. Thirty-two patients underwent a bilateral exploration (BE), and 5 patients had a focused approach (FA). Thirty-five patients presented with single gland disease, and 2 patients had multiple gland disease. In the BE group, 26 patients remained cured biochemically after a median follow-up of 10.3 years (range, 3-21 years), and 6 patients had recurrence after a median of 13.2 years (range, 7-22 years). In the FA group, all 5 patients remained cured biochemically; however, the median follow-up remained shorter (6.4 years; range, 3-8 years). In R-HPT, the incidence of multiple gland disease at the time of initial operation was comparable with sporadic HPT. In the absence of thyroid disease, an FA may be proposed for R-HPT. Metachronous pathologic glands may develop several years after successful parathyroidectomy in R-HPT. Hence, lifelong follow-up of these patients is essential.

Restenosis after Carotid Stent Placement in Patients with Previous Neck Irradiation or Endarterectomy

Placement of a carotid artery stent (CAS) is an appealing treatment option for patients who have undergone neck irradiation or endarterectomy. Early outcomes and restenosis rates in these patients were analyzed and compared with those in de novo lesions. Single-center, retrospective review of 269 CAS procedures that used cerebral embolic protection and nitinol stents was conducted from May 2001 through July 2006. In this cohort, 66 procedures were performed in patients with a history of external-beam neck irradiation (n=26) or carotid endarterectomy (CEA; n=40), designated as the "hostile neck" group. Mean follow-up was 16 months. The 30-day event rate for the entire group included major ipsilateral stroke (1.1%), minor posterior stroke (1.1%), and myocardial death (0.4%); none occurred in the hostile neck group. The rate of restenosis or occlusion for all 269 arteries was 2.6%. There was no significant difference in restenosis or occlusion rates between de novo lesions (2.0%, four of 203) and the hostile neck group (4.5%, three of 66; P=.17). Repeat angioplasty with or without stent implantation was employed for all patients with restenosis and resulted in no periprocedural stroke, death, or subsequent restenosis. Periprocedural outcomes of CAS procedures are similar in de novo lesions as in patients with a history of neck irradiation or CEA. Importantly, restenosis requiring repeat intervention remains uncommon, and its incidence is comparable between groups.