Langenbecks Arch Surg (2014) 399:1083–1096 DOI 10.1007/s00423-014-1251-1

ABSTRACTS

33rd Annual Meeting of the German Association of Endocrine Surgeons (CAEK) 33. Arbeitstagung der Chirurgischen Arbeitsgemeinschaft Endokrinologie (CAEK) November 20–22, 2014, Basel, Switzerland

Organizing Committee Prof. Dr. Daniel Oertli Universitätsspital Basel Klinik für Allgemeinchirurgie Viszeralchirurgie Spitalstr. 21 4031 Basel Switzerland Dr. Christof Kull Kantonsspital Baselland–Standort Liestal Klinik für Viszeral-, Allgemein-, Thorax- und Gefäßchirurgie Rheinstr. 26 4410 Liestal Switzerland

Methods: Dual center retrospective analysis of mediastinal PA in pHPT preoperatively investigated with MIBI-scintigraphy. Biochemical and clinical data of MIBI-negative and MIBI-positive PA were compared. Results: In center A 8/1075 (0.7 %), center B 5/547 (0.9 %) pHPT patients had mediastinal PA localization. Six were MIBI-positive, six negative. There were no significant differences between MIBI-positive and negative regarding preoperative calcium, PTH levels and PA weight (median Ca 2.9 mmol/l; PTH 456.6 pg/ml in MIBI-positive vs.3.1 mmol/l; 310.6 pg/ml in MIBI-negative; median specimen weight MIBI-positive was 5351 mg vs. negative 17,705 mg). Successful parathyroidectomy resulted in postoperative median calcium/PTH levels of 1.86 mmol/l and 49.8 pg/ml. Conclusion: Comparison of biochemical and clinical criteria of mediastinal PA in pHPT in two centers did not reveal reliable determinants to prognosticate MIBI-performance. In order to assess true incidence of MIBInegative mediastinal PA and to preclude bias due to underpowered data, multicentric study of this clinically important phenomenon is desired.

Dr. Thomas Clerici Kantonsspital St. Gallen Klinik für Chirurgie Chirurgische Abteilung Rorschacherstr. 95 9007 St. Gallen Switzerland

FR.02.04

Congress Venue Universitätsspital Basel Zentrum für Lehre und Forschung Hebelstr. 20 4031 Basel www.unispital-basel.ch

Claudia Bures, V. Zielinski, L. Preldzic, Friedrich Kober, E. Klug, Michael Hermann 2nd Department of Surgery, Krankenanstalt Rudolfstiftung, Vienna, Austria

Parathyroid gland identif ication during thyroidectomy: noticed and missed by the endocrine surgeon — data for court-appointed experts

[email protected]

FR.02.03 Mediastinal parathyroid adenoma in primary hyperparathyroidism: what determines positive MIBI scintigraphy?

Kerstin Lorenz1, Thomas Clerici2, Sebastian Bailer1, Carsten Sekulla1, Phuong Nguyen Thanh1, Henning Dralle1 1 Department for General, Visceral, and Vascular Surgery, University of Halle-Wittenberg, Halle an der Saale, Germany; 2Department for Surgery, Kantonsspital St. Gallen, St. Gallen, Switzerland [email protected] Background: Methoxyisobutylisonitrile (MIBI) scintigraphy can localize parathyroid adenomas (PA) in primary hyperparathyroidism (pHPT) and stratify surgical approach, especially relevant for mediastinal localization, possibly requiring open or endoscopic mediastinal approach. Incidence of MIBI-negative mediastinal PA and determinants for positive MIBI findings are indistinct.

Background: Legal aspects of thyroidectomy focus on recurrent nerve injury, postoperative bleeding, and hypoparathyroidism. Court-appointed experts often claim that the identification of four parathyroid glands during thyroid surgery has to be mandatory. The aim of this study was to evaluate how many parathyroid glands (PG) are identified by an experienced thyroid surgeon. Methods: More than 300 thyroidectomies were analyzed according to a prospective protocol. The number of intraoperatively identified, accidentally removed parathyroid glands and the clinical outcome were evaluated. Results: Median dissected number of parathyroid glands (PGs) was 2.3. Four, three, two, one, and zero PGs were found in 12, 31, 35, 16, and 6 % of patients, respectively. In the histopathologic examination, a single accidentally removed PG was found in 9 %, two PGs in 1 %. The incidence of latent permanent and manifest permanent hypoparathyroidism was 2.8 and 0.3 % (1/357), respectively. Conclusion: An experienced surgeon does not identify all parathyroid glands in the majority of cases; however, the specimen itself should be examined thoroughly by the surgeon after removal. A low number of

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identified PGs does not necessarily impact the outcome. The visualization of all four PGs cannot be demanded by court-appointed experts.

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death=7.0, 95 % CI: 1.6–30.6 %) were identified as a significant prognosticator for long-term survival. Conclusion: Long-term survival is not significantly depreciated after the curative resection of appendiceal NET.

FR.02.05 Our experience comparing MRI, EUS, and CT in the diagnosis of insulinoma

Aycan Akca, Anastasia Melin, Achim A. R. Starke, Bernhard J. Lammers, Peter E. Goretzki Department of Visceral and Endocrine Surgery, Lukaskrankenhaus Neuss, Germany [email protected] Background: Different imagings are used to localize insulinoma. Endoscopic ultrasonography (EUS) is accepted as the best diagnostic tool to detect insulinoma, but holds a strong interobserver variability. Methods: We analyzed all patients with insulinoma, who underwent EUS, computed tomography (CT), and magnetic resonance imaging (MRI) between 2001 and 2014 retrospectively. Results: Sixty nine of our 232 patients with neuroendocrine tumors suffered from insulinoma, including 10 cases of malignancy. EUS, CT, and MRI were positive in 30 (43.5 %), 29 (42 %), and 26 (37.7 %) patients, respectively. In 20 (30 %), 14 (20.3 %), and 6 (8.7 %) patients, EUS, CT, and MRI were negative. In 14 patients (46.7 %), MRI and EUS were positive. MRI localized the tumor in 10 (33.3 %) patients with negative EUS. Whereas, EUS detected the tumor in 4 (13.3 %) patients with negative MRI. Twenty patients in our collective underwent all three examinations. MRI was positive in 14 patients, while EUS or CT was positive in 10. Conclusion: Our data shows that MRI has the best diagnostic performance in detection and localization of insulinoma. EUS has interobserver variability, and the exact localization in the pancreas is not always possible.

FR.06.01 Long-term survival is not impaired after the complete resection of neuroendocrine tumors of the appendix

Thomas Steffen1*, Sabrina M. Ebinger1*, René Warschkow1,2, Cornelia Lüthi1, Bruno M. Schmied1, Thomas Clerici1 1 Department of Surgery, Kantonsspital St. Gallen, St. Gallen, Switzerland; 2Institute of Medical Biometry and Informatics, University of Heidelberg, Heidelberg, Germany *Both authors contributed equally. [email protected] Background: aNET are a common entity in routine medical care, with a rate per appendectomy as high as 0.3 to 0.9 %. Considering the relatively young age at diagnosis for these patients, exact information about the long-term prognosis of aNET is required. Methods: Between 1990 and 2003, the 10-year survival rates of 79 patients was analyzed using risk-adjusted Cox proportional hazard regression models adjusted for population-based baseline mortality. Additionally, prognostic factors for the oncologic outcomes were assessed. Results: The median follow-up of all patients was 12.1 and 13.7 years for those alive. All patients underwent curative R0 resections. No distant metastases were diagnosed. A total of 31 (39.2 %), 29 (36.7 %), 18 (22.8 %), and 1 (1.3 %) patients had stage I, IIA, IIB, and IIIB aNET, respectively, according to the latest classification by the European Neuroendocrine Tumor Society (ENETS). The 10-year overall and relative survival rates were 83.6 % (95 % CI: 75.5–92.6 %) and 96.7 % (95 % CI 87.5–107 %), respectively. Second primary malignancies (hazard ratio of

FR.06.02 Minichromosome maintenance expression in slow-growing gastroenteropancreatic neuroendocrine neoplasms

Simon Schimmack1,2, Ben Lawrence1, Barton Kenney3, Hubertus Schmitz-Winnenthal2, Oliver Strobel2, Irvin M. Modlin1, Mark Kidd1 1 Gastrointestinal Pathobiology Research Group, Department of Gastrointestinal Surgery, Yale University School of Medicine, CT, USA; 2 University Hospital of General, Visceral, and Transplantation-Surgery of Heidelberg, Heidelberg, Germany; 3Department of Pathology, Division of Gastrointestinal and Hepatic Pathology, Yale University School of Medicine, New Haven, CT, USA [email protected] Background: Small intestinal neuroendocrine neoplasms (SI-NENs) often are characterized by a low Ki67 index. We hypothesized that expression of minichromosome maintenance proteins (MCMs), which are essential replication licensing markers, may provide information to augment standard Ki-67 expression in these tumors. Methods: We conducted immunohistochemical (IHC) staining, Western blot analysis, quantitative PCR, and copy number variations of MCM2, MCM3, and Ki-67 in small intestinal NENs (n=22). MCM and Ki67 expression was compared by Kaplan-Meier survival analysis (tissue microarray, independent set [n=55]). We used 43 pancreatic NENs and 14 normal tissues as control groups. Results: In SI-NENs, MCM2 and MCM3 were detected in significantly (10×, p<0.01) more cells than Ki67; expression trended toward higher levels than in normal small intestine (p=0.06). MCM2 mRNA correlated with Ki-67 IHC (p<0.05). MCM3 expression in proliferating cells significantly predicted survival (p<0.002). Combinations of Ki67 and MCM2/3 in algorithms differentiated low proliferative lesions (overall survival 12 years) and high proliferating tumors (OS: 6.1 years). Conclusion: MCMs are expressed in a higher proportion of NEN cells than Ki67 in slow growing lesions and correlates with survival. Assessment can be used to augment Ki-67 to improve prognostic classification in low-grade lesions.

FR.06.03 Outcome of enucleations for pancreatic neuroendocrine neoplasms

Oliver Strobel, Simon Schimmack, Annia Cherrez, Ulf Hinz, Lars Fischer, Thilo Hackert, Markus W. Büchler Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Germany [email protected] Background: Pancreatic enucleations are increasingly performed for pancreatic neuroendocrine neoplasms (pNENs) but little is known about perioperative and long-term results. Methods: From a prospective database including 303 patients undergoing pancreatic resection for pNENs between October 2001 and February 2013, patients with enucleations were identified and perioperative morbidity as well as follow-up results were assessed. Results: Enucleations were performed in 60 (19.8 %) patients with pNENs. Thirty-four (57 %) pNENs were located in the pancreatic head/uncinate process and 26 (43 %) in the body/tail. The median tumor size was 1.3 cm (IQR: 0.9–1.7). There were 47 (78 %) G1 and 13 (22 %) G2 tumors. The median duration of the operation was 137 min (IQR:

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101–172), and the median postoperative stay was 8 days (IQR: 7–10). Morbidity was 35 %. Eighteen patients (30 %) developed postoperative pancreatic fistula (POPF). Ten patients developed grade A POPF (ISGPFdefinition). Only 8 (13 %) patients developed clinically relevant POPF (n= 3 grade B, n=5 grade C). Mortality was 0 %. After a median follow-up time of 26 months (IQR: 7–46), all patients were still alive resulting in an actuarial 5-year survival rate of 100 %. Conclusion: In context of the high morbidity of formal pancreatic resections, enucleation for G1/G2 pNENs is a safe procedure with favorable outcome.

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Results: In 106 patients, lymph nodes were resected as a part of the main oncological resection of the primary. After a median follow-up of 48 months (range 1–157), 63 patients are still alive whereas 43 patients died. Patients still alive had a mean lymph node ratio of 0.158, whereas patients who died had a lymph node ratio of 0.488 (p=0.000). Conclusion: Survival is statistically significantly higher in patients with lower lymph node ratio. An early and aggressive surgical approach could reduce the amount of lymph node metastases and consecutively could approve survival.

SA.02.01 FR.06.04 Bronchopulmonary neuroendocrine tumors in multiple endocrine neoplasia type 1

Max B. Albers1, Caroline Lopez-Lopez1, Jens Waldmann1, Volker Fendrich1, Emily P. Slater1, Jonas C. Apitzsch2, Detlef K. Bartsch1 1 Klinik für Viszeral-, Thorax- und Gefäßchirurgie, 2 Klinik für diagnostische und interventionelle Radiologie, Universitätsklinikum Gießen und Marburg, Standort Marburg [email protected] Background: This study aimed to determine the prevalence, potential precursor lesions, course of disease, and prognosis of BNENs in MEN1. Methods: A prospectively collected database of MEN1 patients was retrospectively analysed for BNENs. Results: Five of 75 MEN1 patients developed histologically confirmed BNENs. Two patients had multiple lung lesions. All patients underwent surgery (four anatomic resections, one wedge resection). Histopathology revealed carcinoids G1 sized 7 to 32 mm. Lymph node metastases were found in 3 patients. Four patients had tumorlets as well as diffuse pulmonary neuroendocrine cell hyperplasia. CT scans revealed bronchopulmonary lesions >3 mm in 16 of 53 patients. After a median of 48-month follow-up, these were stable in 12 patients (75 %) and slightly progressive in 4 patients (25 %). Hypergastrinemia was the only feature more common in patients with pulmonary nodules and BNENs compared to patients without pulmonary nodules (p=0072). One patient deceased of BNEN during long-term follow-up. Conclusion: BNENs in MEN1 might be more common than previously reported, and pulmonary neuroendocrine cell hyperplasia is a potential precursor. The natural course seems rather benign, but lesions >2 cm tend to metastasize. These data should be considered for screening, therapy, and follow-up strategies.

Efficacy of a single preoperative dexamethasone dose to prevent nausea and vomiting after thyroidectomy (tPONV): a randomized, double-blind, placebo-controlled clinical trial

Ignazio Tarantino1, Rene Warschkow1, Ulrich Beutner1, Walter Kolb1, Andreas Lüthi2, Cornelia Lüthi1, Bruno M. Schmied1, Thomas Clerici1 1 Klinik für Chirurgie, 2Klinik für Anästhesiologie, Intensiv-, Rettungs- und Schmerzmedizin, Kantonsspital St. Gallen, St. Gallen, Switzerland [email protected] Background: PONV is an unsettling problem that commonly occurs in patients after thyroidectomy. Various preventive measures have been studied, such as a single administration of steroids. However, many of these studies have been criticized for their biases (e.g., use of opioids, gender selection) or were retracted. Therefore, we performed a randomized-controlled trial to investigate the effect of dexamethasone on PONV after thyroidectomy while carefully controlling for known biases. Methods: This single-institution, randomized, double-blind, placebo-controlled, superiority study was performed between January 2011 and May 2013. Patients undergoing thyroidectomy for benign disease were randomly allocated to receive a single dose of dexamethasone (8 mg) or placebo before surgery. The primary endpoint was the incidence of PONV. Results: The total incidence of PONV was 65 of 152 patients (43 %, 95 % CI: 35–51 %). In the ITT analysis, PONV occurred in 22 of 76 patients (29 %, 95 % CI: 20–40 %) in the treatment arm and in 43 of 76 patients (57 %, 95 % CI: 45–67 %) in the control arm (p=0.001; OR=0.31, 95 % CI: 0.16–0.61 %). The number needed to treat was four. No severe dexamethasone-related adverse events were observed during the study. Conclusion: A single preoperative dexamethasone administration is an effective, safe, and economical measure to reduce PONV incidence after thyroidectomy.

FR.06.05

SA.02.02

Lymph node ratio has a signif icant influence on survival in neuroendocrine neoplasia of the ileum

I nfl ue nce o f in traop er at ive neu romoni tori ng (I ON M) in postoperative nausea and vomiting (PONV) in thyroid surgery — analysis of a standardized drug regime

Anna E. Heverhagen, M. Schuchmann, Dominik Wiese, Jens Waldmann, Detlef K. Bartsch, Volker Fendrich Department of Visceral, Thoracic and Vascular Surgery, Philipps University, Marburg, Germany

Christian Vorländer1, Romuald Kazmierczak2, P. Yadev1, Robert H. Lienenlüke1 1 Klinik für Endokrine Chirurgie, Bürgerhospital Frankfurt am Main; 2 Klinik für Anästhesiologie, Bürgerhospital Frankfurt am Main

[email protected] [email protected] Background: The aim of this study was to evaluate the role of resected lymph node metastases ratio in patients who underwent surgery due to a neuroendocrine neoplasia of the ileum between 1999 and 2014 in our institution. Methods: One hundred twenty patients that underwent surgery for ileal NEN between 1999 and 2014 at our institution were retrospectively evaluated regarding their survival and their lymph node ratio at time of surgery.

Background: IONM is established in thyroid/parathyroid surgery nowadays to reduce the rate of recurrent laryngeal nerve palsy. PONV as a side effect of this procedure is known. Postoperative bleeding is a complication which might be influenced by PONV. A standardized PONV prophylaxis might lower the rate of these complications Methods: In 2010, 151 female patients were observed using IONM without standardized prophylaxis for PONV but using the total

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intravenous technique (TIVA) as anaesthesia (Group A). In 2014, a total of 200 patients were observed using TIVA and PONV prophylaxis (granisetron and dexamethasone) (Group B). The rate of early (up to 2 h), midtime (2–6 h) and late (6–24 h) nausea and vomiting was recorded prospectively in both groups using the Apfel score. Results: Analysis showed an early rate of 53 % in Group A (Apfel 2–4) vs. 5 % in Group B (p<0001). For midtime and late PONV rate, the results were 35 and 8 % in Group A and 30 and 15 % in Group B, respectively (n.s.). No postoperative bleeding was observed in both cohorts. Conclusion: IONM is connected with a higher rate of postoperative nausea and vomiting. A standardized prophylaxis can lower the PONV rate in the most vulnerable period early postoperatively. This regime makes thyroid surgery more safely.

SA.02.03 Is postoperative laryngoscopy mandatory after thyroid surgery in times of IONM?

Susanne H. Estourgie, Katharina Schwarz, Peter E. Goretzki Klinik für Allgemein-, Viszeral-, Thorax- und Gefäßchirurgie, Lukaskrankenhaus Neuss [email protected] Aim: What is the role of laryngoscopy after thyroid-surgery regarding long-term laryngeal nerve paralysis (LNP) in times of intraoperativeneuromonitoring (IONM). Methods: Six hundred eighty-four patients (1038 nerves-at-risk) were studied retrospectively. Vocal cord function was assessed by laryngoscopy pre- and postoperatively. Permanent LNP was defined as impairment of active vocal cord mobility exceeding 1-year post-surgery. Results: Fifty nine patients had postoperative (unilateral) vocal cord dysfunction (VCD). There was one false positive result. Eighteen of 59 patients had no IONM loss (false negative). Permanent VCD occurred in nine patients (incidence 0.87 %). Sensitivity, specificity, and predictive values of IONM for predicting permanent VCD were 100, 96, 25, and 100 % and for ENT-findings were 100, 94, 18, and 100 %. In case of a normal IONM, no permanent VCD were seen. Only one patient had VCD up to 5 months and had clinical symptoms of hoarseness. The other 14 patients recovered within 3 months. Conclusion: This study confirms that IONM alone can predict permanent VCD with high sensitivity. Preoperative laryngoscopy and IONM remain standard for (para-)thyroid surgery. In case of IONM loss, two-stage thyroidectomy and postoperative laryngo(strobo)scopy is recommended. Patients with normal IONM but laryngeal symptoms should also be examined by the ORL specialist. Patients with normal IONM and no laryngeal symptoms exceeding the common laryngeal discomfort after intubation do not require postoperative laryngoscopy.

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Methods: A European Prospective Evaluation Multicenter Study was conducted between July 2010 and July 2012. Overall, 22,011 patients with surgery for thyroid diseases were evaluated. Two thousand four hundred eighty-seven patients received surgery thyroiditis (Graves disease’ (n=1141) and thyroiditis de Quervain and Hashimoto (n=1347)). A logistic regression analysis was performed for recurrent laryngeal nerve palsy and hypoparathyroidism. Results: General complications did not differ significantly. The incidence of temporary and permanent recurrent laryngeal nerve (RLN) palsy ranged for both groups between 3.44–3.86 % and 0.50–0.86 % and were not statistically significant. Logistic regression analysis revealed larger extent of resection and no intraoperative RLN identification as risk factors for transient and permanent RLN palsy. Onset of thyroiditis, extended thyroid resections, number of identified parathyroid glands, and no performed autotransplantion evolved as independent risk factors for the onset of transient and permanent hypoparathyroidism. Conclusion: The presented data demonstrated that surgery for thyroiditis is saved and not generally accompanied with an increased risk of postoperative complications. To save parathyroid glands seems to be mandatory in surgery for thyroiditis.

SA.02.05 Objective and subjective scar aesthetics after MIVAT vs. conventional thyroidectomy

Maik Sahm1,2, Matthias Pross1, Hans Lippert2 1 DRK Klinken Berlin-Köpenick, Department of Surgery; 2Institute for Quality Control in Operative Medicine, University Magdeburg [email protected] Background: The scar analysis needs a long-term follow-up period because the scar remodeling is most active during the first 6 months after operation. Data of examinations of the long-term results after minimally invasive video-assisted thyroidectomy (MIVAT) and conventional thyroidectomy (CT) are rare. Methods: Between 2004 and 2011, 143 patients underwent MIVAT. In 2011, 134 patients underwent CT. We performed a cohort study with a follow-up examination and included 117 vs. 102 patients (MIVAT vs. CT) with a follow-up period of 23.1 vs. 23.6 months. We used the valid Patient and Observer Scar Assessment Scale (PSAS/OSAS). Results: The measurable scar length was 19.7 vs. 39.7 mm (MIVAT vs. CT) (p<0.001). The score of PSAS was 10.4 vs. 9.9 (p=0.666), and the score of OSAS was 8.5 vs. 9.9 (p=0.010). Conclusion: In terms of long-term cosmetic results, MIVAT shows compared with CT no significant difference in PSAS but a significant difference in OSAS. This is the first long-term examination of this question.

SA.05.01 SA.02.04 Thyroiditis and surgery: multivariate analysis of risk prof ile and incidence of postoperative complications: a prospective multicenter study of Europe

Oliver Thomusch1, Carsten Sekulla2, Henning Dralle2, Kerstin Lorenz2, and the PETS Study Team 1 Abteilung für Allgemein- und Viszeralchirurgie, Universitätsklinikum Freiburg; 2Klinik für Allgemein-, Viszeral- und Gefäßchirurgie, Klinikum der Martin-Luther-Universität Halle-Wittenberg Background: Risk profiles and incidence of complications have not systematically been investigated for surgery of thyroiditis. This study was performed to clarify the topic and to receive evidence-based data regarding surgery for thyroiditis. [email protected]

Impact of EMG tracing of postoperative vocal cord function in CNM guided thyroidectomy

Rick Schneider, Carsten Sekulla, Kerstin Lorenz, Phuong Nguyen Thanh, Andreas Machens, Henning Dralle Department of General, Visceral, and Vascular Surgery, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany [email protected] Background: This prospective study was undertaken to evaluate the impact of intraoperative EMG signal tracing in continuous neuromonitoring (CNM) on postoperative vocal cord palsy (VCP). Methods: Nine hundred sixty-two nerves at risk (NAR) were continuously stimulated. Changes of EMG signal parameters amplitude (AMP) and latency (LAT) were analysed within defined subgroups: (1) uneventful

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EMG tracing; (2) severe combined event (SCE); (3) SCE and loss of signal (LOS); (4) LOS without SCE. Results: LOS was registered in 36 NAR (3.7 %), 21 LOS in (3) and 15 LOS in (4). Early postoperative VCP was seen in (1) 3, (2) 0, (3) 7, and (4) 14 NAR. There was no permanent VCP. Subgroup analysis showed significant shorter mean CNM session time in (1) 40.7±24.1 min, compared to (2) 58.1±42.8 min. (3) 68.1±37.1 min, and (4) 55.8±31.6. Relative numbers of AMP<50 % of baseline and AMP<100 μV were significantly higher in (3) 2.43, 0.47 and (4) 2.75, 1.02, compared to (1) 0.25, 0.04 and (2) 0.95, 0.01, respectively. In contrast, relative number of LAT>110 % of baseline was comparable in all groups. Conclusion: Severe changes of AMP or LAT from baseline frequently occur in CNM. To prevent false positive results, EMG artefacts have to be excluded by real-time correlation of EMG tracing with surgical manoeuver. However, AMP<50 % from baseline or AMP<100 μV are significantly indicative for impending nerve injury with subsequent VCP.

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65 pg/ml) was diagnosed (group I). Fifty-eight patients with hypercalcemic pHPT were enrolled for comparison (group II). An incidentaloma (normocalcemic) was found in 26 patients initially referred for thyroid operation (group III). Secondary causes for hyperparathyroidism were excluded. Results: The median preoperative serum calcium levels (group I: 2.5 mmol/l, group II: 2.9 mmol/l, group III: 2.4 mmol/l) and the median gland weights (group I: 470 mg, group II: 900 mg, group III: 170 mg) were different. Patients presented kidney stones in group I in 33 %, group II in 31 %, and group III in 4 %. The symptoms “mood swings” (group I: 43 %, group II: 55 %) and “bone pain” (group I: 53 %, group II: 55 %) were indicated quite similar. Adenomas were found in group I in 73 %, group II in 84 %, and in group III in 35 %. The presence of multigland disease tended to be higher in group I: 17 % versus group II: 9 %. Single gland disease occurred in group I in 83 %, group II in 91 %, and group III in 100 %. Conclusion: In our review, patients with normocalcemic pHPT presented the same signs and symptoms as the symptomatic pHPT patients. Parathyroidectomy should be considered. Particularly, when thyroid operation is planned, it might prevent a potential reoperation.

SA.05.02 Changes of laryngeal mobility and symptoms following thyroid surgery — 6 months follow-up

Antje E. Gohrbandt, Anna Aschoff, Hauke Lang, Thomas J. Musholt Department of Endocrine Surgery, University Hospital Mainz, Germany [email protected] Background: Swallowing disorders are frequent complains after thyroidectomy even in absence recurrent laryngeal nerve pareses. The aim of this study was to assess the laryngeal movement following thyroidectomy in relation to dysphagia. Methods: Fifty-three patients (mean age 52.4±12.5 yrs; 36 female) with benign pathologies and intact recurrent nerve function were prospectively evaluated. Laryngeal movement was analyzed by ultrasound preoperatively and 1, 3, and 6 months postoperatively. Additionally, a dysphagia and voice-specific quality of life questionnaire was evaluated. Results: Mean laryngeal movement differed between genders preoperatively and postoperatively resulting in a recovery predominantly in women (differences preoperatively to 1, 3, and 6 months postoperatively in females 6.0, 3.7, and 1.5 mm, in males 13.8, 11.7, and 10.3 mm). Hoarseness (9 females), impaired swallowing (1 female, 2 males), and cervical discomfort (7 females, 3 males) were mainly reported by women 1 month postoperatively. After 6 months, these complaints resolved (cervical discomfort 1 female). Quality of life was only affected in 1 female 1 month after surgery. Conclusion: Laryngeal movement was postoperatively significantly impaired, and only females revealed a recovery nearly to baseline after 6 months. Though showing only a small grade of recovery of laryngeal movement, clinical symptoms are rare in male patients.

SA.05.03

The normocalcemic primary hyperparathyroidism — the early phase of a symptomatic pHPT?

Alexandra Zahn, E. Schmitz, Jochen Kußmann Schön Klinik Hamburg Eilbek, Abteilung für endokrine Chirurgie, Hamburg [email protected] Background: Routine measurement of PTH has lead to an increased identification of patients with normocalcemic pHPT. Is there an indication for parathyroidectomy? Methods: In this retrospective review of our parathyroid database (2007– 2012), parathyroidectomy was performed in 660 patients with pHPT. In 58 patients, a normocalcemic pHPT (serum calcium 2.14–2.58 mmol/l, PTH>

SA.05.04 Calcitonin stimulation testing and the risk of pancreatitis

Kerstin Lorenz, Mohammed Abuazab, Carsten Sekulla, Henning Dralle Department of General-, Visceral, and Vascular Surgery, University of Halle-Wittenberg, Halle an der Saale, Germany [email protected] Background: Calcitonin stimulation testing serves preoperative discrimination of C-cell hyperplasia from MTC and directing extension of surgery. Adverse reactions involve flush, sweating, tachycardia, and nausea; however, severe side effects are rarely reported. Pancreatitis following calcitonin stimulation testing may evolve undiagnosed. Rationale of calcitonin stimulation testing needs to be rigorously verified for this potentially severe complication. Methods: Patients undergoing pre- and intraoperative calcitonin stimulation testing using pentagastrin or calcium were retrospectively investigated for development of associated pancreatitis. Results: Of 198 patients with calcitonin stimulation test, 6 (3 %) (female 3, male 3; mean age 43, 5 years) developed pancreatitis thereafter. Mean preoperative basal calcitonin was 5001 pg/ml; maximum stimulation level was mean 107, 683 pg/ml. Mean postoperative levels for amylase and lipase were 15.4 and 8.9 μmol/, respectively. Sonography and CT revealed edematous pancreatitis in 4, necrotizing pancreatitis in 2. All patients were managed conservatively; however, hospital stay was prolonged (mean 9, 3 days). Conclusion: Calcitonin stimulation testing is unpleasant for the patient, intricate for the investigator, and may induce pancreatitis. No cut-off or predisposing criteria for development of pancreatitis were identified. In the absence of reliable cut-offs for preoperative calcitonin, risk of pancreatitis calls for rigorous indication for calcitonin stimulation testing in considerably elevated basal calcitonin.

P 01 Discordance in histopathologic findings of papillary microcarcinoma in thyroid specimens — interobserver variations of two institutes of pathology

Claudia Bures1, V. Zielinski1, Tobias Klatte2, Nikolaus Neuhold3, Andrea Schultheis3, Friedrich Kober1, S. Neumann3, Michael Hermann1 1 2nd Department of Surgery, Krankenanstalt Rudolfstiftung, Vienna, Austria; 2Department of Urology, Medical University of Vienna, Vienna, Austria; 3Department of Pathology and Bacteriology, Krankenanstalt Rudolfstiftung, Vienna, Austria [email protected]

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Background: According to the literature, the incidence of thyroid microcarcinomas has increased in the last decades. The detection rate is, however, significantly determined by the accuracy of the histological examination. Methods: Up to 2012, our department was situated in a clinic specialized in thyroid surgery and pathology. In 2013, the surgical department but not the institute of pathology was moved and integrated into a maximum care hospital. In this study, we compared the detection rate of papillary microcarcinomas in the two different institutes of pathology in a time frame of 6 months during two consecutive years (2012 and 2013). Results: In 2012, 597 thyroid surgeries were performed of which 60 (i.e., 10 %) showed a microcarcinoma. In 2013, 509 thyroid surgeries were performed and 29 (i.e., 5.7 %) microcarcinomas were identified. The difference is highly significant (p<0008). An analysis of tumor size, number of microcarcinomas, lymph node metastases, etc. will be presented. Conclusion: Pathologic identification of microcarcinoma is highly observer dependent. The pathologist and the standardization of specimen work-up are of paramount importance for the accurate diagnosis of papillary microcarcinoma, which has a significant clinical impact.

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Background: Postoperative paralysis of recurrent laryngeal nerve (RLNP) is one of the major complications in thyroid and parathyroid surgery. A control of vocal cord mobility should be conducted after each thyroid or parathyroid operation. But does the date of the examination influence the rate of RLNP? Methods: Between September 2012 and March 2014, 1960 patients underwent surgery of the thyroid or parathyroid glands in our hospital. From September 2012 up to August 2013 (group A, n=1224), patients were sent to the ENT examination 1 day after surgery. From September 2013 up to March 2014 (group B, n = 736), ENT examination was performed 5 to 8 days after surgery. Data was recorded prospectively using a Microsoft Access database and analyzed retrospectively. Results: Nineteen out of 1224 patients in group A showed a decrease or loss of vocal cord movement (0.9 % related to 1943 nerves at risk, while 15 out of 736 patients (1.3 % related to 1148 nerves at risk) showed the same result in group B. Conclusion: Since there was no significant difference between both groups, patients can be send to postoperative ENT check on the first day after surgery to facilitate the postoperative management and enable early discharge.

P 02

“Indeterminated” (follicular) thyroid nodules: is a simplif ied cytological classification of value to plan lymph node surgery

Stephanie Strobl, Philipp Riss, Andreas Selberherr, Christoph Bichler, Christian Scheuba, Bruno Niederle Section Endocrine Surgery, Division General Surgery, Department of Surgery, Medical University, Vienna [email protected] Background: According to the guidelines of “Austrian Society of Cytology (ÖGZ)” and simplifying the Bethesda System for Reporting Thyroid Cytopathology, cytodiagnosis was divided into four categories: nondiagnostic (0), benign (A), follicular neoplasia (B) (with subclassifications (B1): suspicious/indeterminate or follicular neoplasm and (B2): follicular neoplasm suspicious for papillary thyroid cancer), or malignant (C). B1 and B2 tumours were of interest analyzing the prediction of malignancy and the incidence of lymph node metastasis. Methods: Within 5 years 278 (27.6 %) fine needle aspirations were performed in 1008 patients. Ninety eight (35.2 %) were classified ÖGZ B. (B1: 75 (76.5 %) B2: 23 (23.5 %)). In all patients with B tumors, total thyroidectomy and initial (first step) unilateral central neck dissection was performed. Results: The overall malignancy was 25 (25.5 %) of 98 B tumors. Definitive histology revealed cancer in 14 (18.7 %) B1 and in 11 (47.8 %) B2 nodules. Nine (12.0 %) B1 tumors were classified papillary thyroid cancer (PTC [9/14: 64.3 % of malignant B1]; one patient pN1) and 5 (6.7 %; [5/14: 35.7 % of malignant B1]) follicular thyroid cancer (FTC). All 11 malignant B2 tumors [11/23: 47.8 %] were classified PTC, 5 (45.5 %) patients with pN1. Conclusion: In the absence of a clear cytological diagnosis, the simplified cytopathological ÖGZ classification is a helpful planning surgery in the “indeterminated” (follicular) thyroid nodule. ÖGZ B1 does not exclude PTC. In thyroid nodules classified B2 PTC was documented in 43 %. “First step central (level 6) neck dissection” may be considered in B2 tumors because in 45.5 %, lymph node metastasis were demonstrated.

P 04 First experiences with robotic-assisted hemithyroidectomy via axillary single incision

Sabine Eckhardt, Elisabeth Maurer, Volker Fendrich, Detlef K. Bartsch Klinik für Viszeral-, Thorax- und Gefäßchirurgie, Standort Marburg, Universitätsklinikum Gießen und Marburg GmbH [email protected] Background: We report our first experiences with robotic-assisted hemithyroidectomy (RAHT). Acceptance of this new technique, operating time, hospital stay, and patients’ satisfaction including the cosmetic result were recorded. Results: RAHT was offered to 58 patients. Twenty (34 %) patients decided for RAHT. The median operation time was 160 min (range 106 to 300 min). The learning curve was impressive, since operating time could be reduced to 120 min in the last five operations. Two patients (10 %) had a T1 thyroid cancer (1 PTC, 1 MFTC). There occurred no surgical site infection, no permanent dysaesthesia of the breast/thoracic skin, no postoperative hemorrhage, and no postoperative hypoparathyroidism. Two of the first five patients had a transient upper plexus palsy that lasted 5 and 28 days until complete restitution. Therefore, positioning of the arm was changed to a horizontal position. Two patients (10 %) had a transient recurrent laryngeal nerve palsy (RLNP), most likely due to heat irritation. Median postoperative stay was 3 (range 2–5) days. All 20 patients were highly satisfied with the cosmetic result. Conclusion: Robotic-assisted thyroid surgery is yet not well accepted by eligible patients. There is a significant learning curve. Special attention is required to avoid plexus palsy by optimal patient positioning and transient RLNP due to the use of vessel sealing instruments. Cosmetic outcome is valued very well and patients’ satisfaction is high.

P 03

P 05

Does the date of postoperative ENT check influence the rate of early postoperative recurrent laryngeal nerve paralysis?

Predicting the risk for postoperative hypoparathyroidism after thyroid surgery: results of a prospective study

Robert H. Lienenlüke, Halil Altindag, Heidrun Kufleitner, Christian Vorländer Klinik für Endokrine Chirurgie, Bürgerhospital Frankfurt am Main

Giulia Manzini1, Florian Malhofer1, Theresia Weber2 1 Klinik für Allgemein- und Viszeralchirurgie, Universitätsklinikum Ulm; 2 Abteilung für endokrine Chirurgie, Katholisches Klinikum Mainz

[email protected]

[email protected]

Langenbecks Arch Surg (2014) 399:1083–1096

Background: Postoperative hypoparathyroidism is a common complication after total thyroidectomy. The aim of our study was to identify specific risk factors for transient and permanent hypoparathyroidism. Methods: Prospective study on 361 patients undergoing near-total (Dunhill) or total thyroidectomy (TT) with or without lymph node dissection (ND). Serum calcium and parathyroid hormone (PTH) levels were measured on the first postoperative day and during a mean followup of 4.8 months. A multivariate logistic regression analysis was used to identify risk factors for transient and permanent hypoparathyroidism. Results: Surgery was performed for 224 patients with multinodular goiter, 40 with Graves’ disease and 97 thyroid carcinomas. In 124 patients (34 %), a transient hypoparathyroidism (PTH≤10 pg/ml) was treated with calcium and vitamin D regardless of symptoms. The rate of permanent hypoparathyroidism was 3.6 % and correlated with the extent of surgery (1.4 % Dunhill operation, 7.9 % TT plus ND). On univariate analysis extent of surgery, autotransplantation, postoperative PTH, and histopathology were the strongest predictors of hypoparathyroidism. Vitamin D deficiency (≤10 ng/ml) showed only a trend towards a higher risk for transient (p= 0.0514) but failed to predict permanent hypoparathyroidism. Conclusion: Postoperative PTH accurately identifies patients at risk for hypoparathyroidism. High preoperative Vitamin D levels could not prevent permanent hypoparathyroidism.

P 06 Does normotension at the end of thyroidectomy prevent postoperative haemorrhage?

Susanne Bock, Walter Kolb, Thomas Clerici Klinik für Chirurgie, Kantonsspital St. Gallen, St. Gallen, Switzerland [email protected] Background: Postoperative haemorrhage is reported in around 1–2 % after thyroid surgery. The known risk factors can hardly be influenced. We hypothesize that postoperative haemorrhage might partly be due to an inadequate surgical haemostasis as a result of hypotonic blood pressure intraoperatively, preventing a proper identification of potential sources of haemorrhage. Methods: Having set up this hypothesis in 2010, we started to ask our anaesthetists to provide normotension during haemostasis in the final phase of surgery. We present a retrospective analysis covering the last 10 years, focusing on the rate of postoperative bleeding before and after the introduction of normotension, as well as pre- and intraoperative blood pressure values. Results: One thousand eight hundred seventy patients underwent thyroid surgery from 2003 to 2013; 1204 before the introduction of normotension and 666 afterwards. The rate of postoperative haemorrhage decreased from 1.7 to 0.5 % (p=0.017). The median difference in blood pressure between the preoperative value and the value during haemostasis decreased by 20 mmHg (systolic) and 10 mmHg (diastolic), respectively (p<0.002). Conclusion: Normotension during final haemostasis seems to be a valuable method to minimize postoperative haemorrhage and is easy to implement. We therefore highly recommend this as a standard of care in thyroid surgery.

P 07 Thyroid nodules: guideline compliance in preoperative diagnostics in Germany

Alexander Reinisch, Patrizia Malkomes, Nils Habbe, Wolf-Otto Bechstein, Katharina Holzer Department of General and Visceral Surgery, Goethe-University Hospital and Clinics, Frankfurt am Main, Germany [email protected]

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Background: Since 2006 several guidelines regarding the preoperative diagnostics in surgery for thyroid nodules were published. The aim of this study was to determine guideline compliance depending on the institution initiating these diagnostics. Methods: Preoperative diagnostic measures of patients who underwent thyroid surgery for nodular goiter between 2006 and 2013 were recorded and analyzed based on their assignation through the University Medical Centre (UMC), a specialized endocrinologist (ENP), or a general practitioner (GP). Postoperative malignancy rates were analyzed. Results: Of 677 patients enrolled, 62 % were assigned by UMC, 18.5 % by ENP and 19.5 % by GP. Ultrasonography was preformed between 97.6 % in UMC and 90.9 % in GP (p<0.0001). The rates of fine-needle aspiration cytology bestrode between 47.6 % in UMC and 23.2 % in ENP (p<0.0001). Rates for analysis of thyroid-stimulating hormone and thyronine were above 93 % in all groups (n.s.) whereas rates for calcitonin were found between 75 % in GP and 66.4 % in ENP (n.s.). Malginancy rates were 11.82 % for differentiated thyroid cancer and 1.03 % for medullary thyroid cancer. Conclusion: Evidence-based guidelines may optimize the therapeutic outcome and allow target-oriented and economic diagnostics. Efforts should be undertaken to reduce deficits in guideline adherence and hereby reduce variations in care.

P 08 Cryopreservation of parathyroids in sHPT under GCP-like conditions: will the demanding procedure be justified in the future?

Steven Dralle, Anneliese Uckermark, Michael Linnebacher, Ernst Klar Allgemeine Chirurgie, Thorax-, Gefäß- und Transplantationschirurgie, Universitätsmedizin Rostock [email protected] Background: In 2008, the German Department of Health (BMG) has finally finished a long discussion by defining that cryopreservation of parathyroid glands (PG), and subsequent retransplantation is not subject to the German pharmaceutical law (AMG). Nevertheless, the procedure has to be performed under good clinical practice (GCP)-like conditions. It is the aim of this study to give an update of a standard operating procedure for PG cryopreservation that complies with GCP and shows the clinical impact of cryopreservation in the long run in our department. Methods: Since 2003, we have been processing and cryopreserving 103 samples of surgically removed PGs. Currently, we are performing a longterm follow-up of all patients suffering from secondary hyperparathyroidism (sHPT) who have been treated surgically and whose PG have been cryopreserved. Parameters: patient’s sex and age by the time of operation, diagnosis that lead to chronic end-stage renal failure, status post renal transplantation, follow-up in months, number of removed PG, no/immediate/subsequent retransplantation of PG, intraoperative PTH-monitoring, and other laboratory findings (PTH, CA2+, PO4, AP, Crea) in the follow-up. Results: So far, 72 of 103 patients have been analyzed (39 men, 33 women). The average age by the time of operation was 52.6 (23–80) years. The average time between first dialysis and parathyroidectomy is 81.5 (5–273) months. The long-term follow-up is 83.4 (6–133) months. Sixteen patients were operated after renal transplantation and on average, 3.6 PG were removed. Seven patients were operated due to a recurrence of sHPT. Twenty-four patients did not undergo a retransplantation of PG at all, and 37 patients were retransplanted immediately. Seven patients underwent a subsequent retransplantation of PG, whereby the average time between removal and subsequent retransplantation of PG varied from 4 days to 20 months. Conclusion: Together, subsequent retransplantation of PG was performed rarely (7 of 72 patients). More than 50 % of all patients (37 of 72) underwent an immediate retransplantation. PG of every patient was cryopreserved. Is it still worthwhile to keep the strategy of cryopreservation despite a low retransplantation rate?

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P 09

P 11

Postoperative hypoparathyroidism after thyroid surgery in the elderly

Thyroid micro-carcinoma with lymph node metastasis

Nina Sehnke, Katharina Schwarz, Bernhard J. Lammers, Peter E. Goretzki Chirurgische Klinik I, Lukaskrankenhaus Neuss

Andrea Bradatsch, Gerhard Wolf Department für Endokrine Chirurgie, Klinische Abteilung für Allgemeinchirurgie, Universitätsklinik für Chirurgie, Medizinische Universität Graz

[email protected]

[email protected]

Background: Postoperative hypoparathyroidism is the most frequently complication of thyroid surgery. Most of the literature deals with postoperative hypoparathyroidism in younger patients, but there is little information about this complication in the elderly. Methods: We analyzed 4467 patients retrospectively, who underwent thyroid surgery between 2007 and August 2012. Results: One hundred ninety-six patients were older than 75 years, and 24 of those patients suffered a complication like postoperative hypoparathyroidism (PTH <15 pg/ml). The transient rate of postoperative hypoparathyroidism was 12 % (24/196) and 3 % (24/705) of all patients with reduced parathyroid function. Everyone was substituted with calcium and rocaltrol. Only 20 % were symptomatic, but 32 % in the comparison group under 74 years. Retention time (7 days) was longer than in the comparison group (<75 years; 4 days). Two patients were readmitted because of hypercalcaemia. Conclusion: The elderly were rarely symptomatic, but the retention time was longer than in the comparison group under 74 years. Calcium substitution must be more strictly controlled in the elderly, because of the risk of hypercalcaemia (renal failure).

Background: Papillary micro-carcinoma are considered to be “benign diseases”. However, lymph node metastasis can still be found in a small cohort of patients. In some cases, lymph node enlargement is the first sign of disease. Prognosis seems, however, to be favorable and identical to non-metastatic micro-PTC. Methods: We analyzed the data of all patients who were diagnosed with micro-PTC (<1 cm) through cervical lymph node enlargement and biopsy. The smallest focus measured 0.2 mm, 60 % presented with 3 to 6 mm, 15 % were multifocal. In one case with lymph node involvement, no thyroid tumor could be identified. Results: In contrast to treatment of micro-PTC, where non-radical surgical treatment is advocated, all cases presenting with lymph node metastases were treated by thyroidectomy, completing lymphadenectomy, and radio-iodine ablation. In this group, no recurrent or metastatic disease was observed. Conclusion: A small cohort of patients with micro-PTC presents primarily with lymph node enlargement and are diagnosed as by lymph node biopsy. They represent a sub-group of micro-carcinoma, which is normally considered to be a negligible disease. After surgical treatment, they seem to have the same favorable prognosis as micro-PTC without metastasis. It seems that the primary tumour size is the most important prognostic factor, despite the presence of lymph node metastasis.

P 10 Management of papillary carcinoma of thyroglossal duct carcinoma according to the CAEK guidelines on surgical treatment of malignant thyroid diseases

P 12

Hans Bittscheidt1, Georg Richter2, Jörg Müller3, Rainer Lück1 1 Abteilung für Viszeralchirurgie, Sanaklinikum Hameln-Pyrmont; 2 Abteilung für Pathologie, Sanaklinikum Hameln-Pyrmont; 3Abteilung für Nuklearmedizin, Medizinische Hochschule Hannover

Frauke Schuster1, Renan Viola Rasche1, Ana Karena Neukirch1, Anke Meyer1, Marios Papadakis1, Kurt Rasche2, Cornelia Dotzenrath1 1 Helios Klinikum Wuppertal, Abteilung für Endokrine Chirurgie; 2Helios Klinikum Wuppertal, Abteilung für Pneumologie, Allergologie, Schlaf- und Beatmungsmedizin

Sleeping disturbances in patients with primary hyperparathyroidism — a prospective, case-control study

[email protected] [email protected] Background: Thyroglossal duct cysts are aberrations in thyroid development. A malignant transformation is rare and present in only 1 %. Methods: We describe two patients (female 42 and 59 years) with a PTC of a thyroglossal duct cyst. The first patient underwent local excision of a PTC (pT1a) next to hyoidal bone in 2008. No further action was taken until 2013. At this time, a suspect solitary nodule in the thyroid and cervical lymphadenopathy was found. We performed thyroidectomy with selective neck dissection. Histology confirmed pT1a pN0 PTC. Radioiodine therapy was done. The second patient underwent resection of a thyroglossal duct cyst, histology showed a PTC (pT1b). Due to the tumor size, further suspect nodules of the thyroid gland and local lymphadenopathy thyroid resection and selective neck dissection were performed. Histology showed no further tumor manifestation or lymph node metastasis. Radioiodine therapy was done. Conclusion: Due to the small number of cases of malignancies in thyroglossal duct cysts, strict recommendations of treatment are missing. A malignant thyroid carcinoma of the thyroglossal duct can be judged as primary thyroidal and therefore be treated according to the CAEK guidelines.

Background: Studies about cognitive changes in patients with primary hyperparathyroidism showed a decreased concentration level. The aim of this study was to find out if there is a relationship between primary hyperparathyroidism and sleeping disturbances. Methods: In a prospective, case-control study with matching pairs, sleeping quality was examined in 30 patients with primary hyperparathyroidism and 30 patients with non-toxic nodular goiter. Our testing battery consisted of four different tests: the Landauer Inventar, the Epworth sleepiness scale, the berlin questionnaire and the PSQI. Results: Early results show that patients with primary hyperparathyroidism have a lower sleeping quality and have more sleeping disturbances as for example, insomnia, nightmares, restless legs, and body rocking compared a match control group.

P 13 Comparative diagnostic value of ultrasound, ultrasound-guided fine needle aspiration and sestamibi scintigraphy for the correct preoperative localisation of parathyroid adenomas

Stefan Bilz1, Natalie Rogowski-Lehmann1, Ina Krull1, René Oettli2, Michael Brändle1, Walter Kolb3, Thomas Clerici3

Langenbecks Arch Surg (2014) 399:1083–1096 1 Division of Endocrinology and Diabetes, Department of Internal Medicine, Kantonsspital St. Gallen, Switzerland; 2Department of Radiology and Nuclear Medicine, Kantonsspital St. Gallen, Switzerland; 3 Department of Surgery, Kantonsspital St. Gallen, Switzerland

[email protected] Background: Open minimally invasive parathyroidectomy (OMIP) has become the standard surgical therapy for patients with primary hyperparathyroidism (pHPT) and requires exact preoperative localisation procedures. This study prospectively assessed the sensitivity and positive predictive value (PPV) of ultrasound (US), ultrasound-guided fine needle aspiration with PTH measurement in the needle washout (US-FNA) and sestamibi scintigraphy (SS) for the localisation of parathyroid adenomas in patients with pHPT. Methods: Forty consecutive patients with pHPT were included. US and USFNA were performed by two endocrinologists using high-resolution ultrasound and a free hand technique. Double isotope scanning with 99mTc pertechnetate and 99mTc sestamibi was used during the scintigraphic studies. A localisation procedure was considered correct if surgical removal of a parathyroid gland at this localisation resulted in biochemical cure of the pHPT at 6 weeks and/or 6 months postoperatively. All surgeries were performed by two experienced endocrine surgeons using intraoperative PTH monitoring. Results: The sensitivities for correctly identifying the localisation of a hyperfunctioning adenoma were 69 % (SS), 97 % (US), 69 % (US-FNA), 100 % (combination of SS or US) and 85 % (combination of SS or USFNA). The respective PPVs were 96 % (SS), 92 % (US), 100 % (USFNA), 93 % (combination of SS or US) and 100 % (combination of SS or US-FNA). Surgical cure was achieved by a minimally invasive approach in 35 patients. A bilateral neck exploration was performed in three cases, and one adenoma was located ectopically in the anterior mediastinum and correctly localised by SS. US-FNA confirmed an adenoma in 42 % of the scintigraphically negative lesions. Hemorrhagic and/or fibrotic changes following US-FNA were detectable intraoperatively in 33 % and complicated surgery in three cases. Conclusion: US, US-FNA and SS correctly localise parathyroid adenomas and allow OMIP in the vast majority of patients with pHPT. Due to its high sensitivity, US is superior to SS and recommended as first-line investigation. Both SS and US-FNA may be reserved for sonographically equivocal cases. US-FNA, although highly predictive, is complicated by a high rate of hemorrhagic and/or fibrotic changes in the biopsied adenoma and should be used cautiously.

P 14 Functional evaluation of parathyroid grafts after total parathyroidectomy for secondary hyperparathyroidism with autotransplantation into the tibialis anterior muscle

Chrysanthi Anamaterou1, Simon Schimmack2, Matthias Lang1, G. Rudofsky1, Oliver Strobel2, Peter Nawroth1, Markus W. Büchler2, Hubertus Schmitz-Winnenthal2 1 Department of Medicine I and Clinical Chemestry, 2Department of General, Visceral and Transplantation Surgery University Hospital of Heidelberg, Germany [email protected] Background: At our institution, total parathyroidectomy with heterotopic autotransplantation into the tibialis anterior muscle is the preferred procedure for renal HPT. The aim of this study was to assess the long-term function of autotransplanted parathyroid tissue. Methods: We reviewed the medical records of a consecutive series of 42 patients who underwent total parathyroidectomy with autotransplantation into the tibialis anterior muscle. In these patients, we examined the function of the autograft using a modified Casanova test of the leg bearing the parathyroid tissue.

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Results: The ischemic blockade led to a marked reduction in the plasma concentration of intact PTH (≥50 % of the baseline value) in 19 patients indicating well-functioning autografts (45 %). In 11 patients, ischemia of the graft site did not cause any change in the concentration of PTH indicating functioning residual parathyroid tissue in the neck (26 %). During the median follow-up time of 8.2 years, two patients developed graft-dependent recurrent hyperparathyroidism (5 %) without therapeutic consequence and three patients suffered from persistent symptomatic hypoparathyroidism (7 %). Conclusion: Our results indicate that total parathyroidectomy with autotransplantation into the tibialis anterior muscle was successful in 88 % and provides therefore an alternative surgical treatment of secondary hyperparathyroidism.

P 15 Failed parathyroid operation: high serum calcium levels do not exclude FHH

Anke Meyer1, Natalie Meurer1, Marios Papadakis1, Imke Meyer, Norbert Weyerbrock1, Marco Tosch2, Cornelia Dotzenrath1 1 Klinik für Endokrine Chirurgie, Helios Klinikum Wuppertal; 2Klinik für Nuklearmedizin, Helios Klinikum Wuppertal [email protected] Methods: A 61-year-old male was admitted for surgery of primary hyperparathyroidism (pHPT). His intact PTH level was 108 pg/ml (normal range: 12–65 pg/ml), and serum calcium level was 3.2 mmol/l (2.1–2.6). Urine calcium was 4.3(normal range 2.5–8.0), and a ratio of calcium creatinine clearance was >0.01. He had a history of stroke with complete recovery, but no further pHPT associated symptoms. US of the neck was negative and 99mTc MIBI scintigraphy was slightly positive on the left side. Results: Intraoperatively, only the right superior parathyroid gland which was slightly enlarged was removed. Histology confirmed the diagnosis of an adenoma. All other parathyroid glands were not enlarged. Transcervical thymectomy was performed. Ten minutes after removal of the adenoma, intraoperative PTH was 35.4 pg/ml. Serum calcium level was 2.64 mmol/l at the first postoperative day but was 2.94 mmol/l after 1 week with a PTH level 89.2 pg/ml indicating persistent pHPT. 99mTc MIBI scintigraphy was redone and was negative. MRI did not show an adenoma. Genetic testing for MEN-I- mutation and for calcium-sensing receptor (CaSR) mutation was performed. Surprisingly, a missense mutation of the CaSR was detected which was not described yet (c.1651A> G for p.Arg551Gly (Exon 6). Therefore, we recalculated the ratio of calcium creatinine clearance which was 0.0093, indicated a former miscalculation. Conclusion: Familial hypocalciuric hypercalcemia (FHH) is a rare disease with usually mildly elevated serum calcium levels. In our case, a new mutation associated with very high calcium level was detected. Therefore, we conclude:

1. FHH should be considered in all patients with elevated calcium 2. 3.

levels. FHH should be considered in all patients with persisting pHPT. FHH can also be associated with calcium levels >3.1 mmol/l.

P 16 Can pre-operative vitamin D treatment prevent postoperative hypocalcemia in primary hyperparathyroidism?

Hannah Ebner1, Florian Herrle2, Kai Nowak2, Stefanie Nittka3, Klaus Wasser4, Alexander Lammert1

1092 1 Fifth Medical Clinic (Department of Nephrology, Endocrinology), University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany; 2Department of Surgery, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany; 3Institute for Clinical Chemistry, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany; 4Institute of Clinical Radiology and Nuclear Medicine, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany

[email protected] Background: Postoperative hypocalcemia in primary hyperparathyroidism (pHPT) is a common problem. This may cause severe clinical symptoms and increase hospital stay. We analysed if preoperative vitamin D substitution mitigates postoperative hypocalcemia. Methods: We retrospectively analysed all patients which were referred and diagnosed via our endocrinology outpatient department. Surgery was performed by endocrine surgeons. Results: We retrieved 70 cases of pHPT. Thirty-one were operated (19 without, 12 patients with preoperative Vitamin D substitution). Anthropometrical and biochemical data were comparable between groups. Vitamin D substitution was started at mean 107.8 days prior to operation with a mean daily dosage of 2178 units per day. On day one, postoperatively, more patients presented without hypocalcemic symptoms in the vitamin D-treated group (33.3 vs. 50 %, p=0.20). In patients without preoperative vitamin D therapy, postoperative calcium dropped to a lower nadir (mean 2.17 mmol/l vs. 2.31 mmol/l, p=0.06) even though PTH levels were comparable in both groups (19.7 ng/ml vs. 15.4 ng/l, p= 0.47). Furthermore, need for treatment with oral calcium supplementation was reduced in patients receiving preoperative vitamin D substitution (41.6 vs. 66.6 %, p=0.27). Conclusion: Preoperative Vitamin D substitution proved save in our population and may reduce symptomatic as well as biochemical hypocalcemia.

P 17 Insuff icient decrease of intraoperative parathyroid hormone after parathyroidectomy: is extended cervical exploration necessary?

Ann-Kathrin Müller1, Kirsten Lindner1, Christina Lenschow1, Norbert Senninger1, Mario Colombo-Benkmann2 1 Klinik für Allgemein-und Viszeralchirurgie, Universitätsklinikum Münster, Germany; 2Klinik für Allgemein-und Viszeralchirurgie, Ruppiner Kliniken GmbH, Neuruppin, Germany [email protected] Background: In focused parathyroidectomy (PTx), intraoperative parathyroid hormone monitoring (ioPTH) is helpful to confirm surgical success. In case of insufficient decrease, defined by <50 % from baseline level, literature recommends re-measurement of ioPTH for avoiding unnecessary exploration. The objective of the study was to evaluate whether continuation of exploration shows an improved outcome compared to re-measurement. Methods: We conducted a retrospective study on 122 patients (m:w= 36:86) operated on for pHPT between 2007 and February 2014. Blood samples were collected before surgery at gland excision and 10 min after PTx. Results: Twelve patients (9.8 %) with parathyroid hyperplasia showed an insufficient decrease (range 2–48 %). Subsequently, seven patients were explored leading to the diagnosis of a second adenoma in all cases. Preoperatively, two patients were diagnosed a singular adenoma, in three patients diagnosis was inconclusive and two patients had thyroid nodules. In five cases, surgery was not continued because of sufficient PTHdecrease after re-measurement (n=4) and loss of signal of intraoperative

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neuromonitoring. Preoperative localization was unambiguous in four patients. Conclusion: In case of insufficient PTH-decrease, we recommend remeasurement before initiating an extended exploration if localization diagnostic was unambiguous. In case of discordant localization diagnostic or thyroid nodules, we consider cervical exploration for detection of a possible second adenoma useful.

P 18 Intraoperative bilateral jugular venous sampling and rapid p a r a t h y ro i d h o r m o n e t e s t i n g i n p a t i e n t s u n d e r g o i n g parathyroidectomy for primary hyperparathyroidism

Naja-Norina Pluto1, Wolf-Otto Bechstein2, Katharina Holzer2 1 Klinik für Plastische und Ästhetische Chirurgie, Florence-NightingaleKrankenhaus, Düsseldorf; 2Klinik für Allgemein- und Viszeralchirurgie, Universitätsklinikum Frankfurt [email protected] Background: A successful focused parathyroidectomy is based on an accurate preoperative localization technique. In some cases, preoperative imaging is negative. Some surgeons think that bilateral internal jugular venous sampling (BIJV) is a helpful tool to localize the side of the parathyroid adenoma. Methods: Fifty patients with primary hyperparathyroidism had bilateral internal jugular venous sampling during surgery. Lateralizing PTH levels were determined by comparing the left with the right sample. A difference of 5 % or more was defined as lateralisation. Results: Of the 50 patients, 41 demonstrated a single adenoma, three had double adenomas and six patients had four-gland hyperplasia. Sensitivity of BIJV in all 50 patients was 84.4 %, positive predictive value was 65.1 %. Localization was correctly predicted in 28 of 50 patients. Falsepositive results were observed in 15 patients. Twenty patients had a negative preoperative imaging (ultrasound and/or Tc-99 m sestamibi scan). Of these, BIJV successfully localized the adenoma in 12 cases (60 %) so that a focused approach could be still possible. Conclusion: BIJV is helpful in detecting parathyroid adenoma especially in the event of negative localization studies.

P 19 Experience in 129 patients with pancreatic neuroendocrine neoplasia (pNEN): large procedure variety with low morbidity

Aycan Akca, Peter E. Goretzki, Anastasia Melin, Achim A. R. Starke Department of Visceral and Endocrine Surgery, Lukaskrankenhaus Neuss, Germany [email protected] Background: Resection is indicated in most patients with pNEN. Treatment varies from conservative procedure to pancreatectomy. Methods: We analyzed all patients with neuroendocrine tumors treated between 2001 and 2014 retrospectively. Results: Of 232 patients with NEN, 129 (55.6 %) demonstrated with pNEN. Sixty-nine (53.5 %) patients suffered from insulinoma, followed by functional pNEN n=26 (20.2 %), non-functional pNEN n=19 (14.7 %), and noninsulinoma pancreatogenous hypoglycemia syndrome (NIPHS) n=15 (11.6 %). Three of 129 (2.3 %) patients without symptoms of pNEN and NIPHS refused surgical treatment. Two patients (1.6 %) with non-resectable non-functional pNEN were operated on gastroenterostomy. Pancreatic mid-resection was performed in n=5, subtotal pancreatectomy in n = 3, pancreatectomy in n = 5, modified Whipple’s procedure in n=23, enucleation in n=42, and distal pancreatectomy in n=45, with one case of unknown procedure. Sixty-four

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patients (49.6 %) had no postoperative complications. The most common complications were pancreatic fistulas n=8 (6.2 %), postoperative bleeding n=7 (5.4 %), and diabetes mellitus n=7 (5.4 %). The median hospital stay was 15.9 days (range 4–60). Conclusion: Our data demonstrates that resection even in patients with advanced disease can lead to an improvement of symptoms, associated with less morbidity. However, not all patients (with mild symptoms) require surgical treatment.

P 20 Long-term results after surgery for pheochromocytoma

Jens Waldmann1, Anna-Lena Nuttebaum1, Volker Fendrich1, Annette Ramaswamy2, Detlef K. Bartsch1 1 Department of Visceral-, Thoracic- and Vascular Surgery, 2Department of Pathology, University Hospital Giessen and Marburg, Marburg, Germany [email protected] Background: Risk for recurrency and metastases in patients with pheochromocytoma is unreliable to predict after surgery. Methods: A consecutive patient cohort after surgery for pheochromocytoma/paraganglioma from 1988 to 2014 was retrospectively analyzed. Clinical presentation, surgery, hormone levels, tumor size, diagnostic imaging, recurrency, capsular disrupture, metastases, and death were analyzed. Risk factors for recurrency were analyzed by univariate analysis. Results: A total of 85 consecutive patients were included in the present study. Forty open and 53 laparoscopic adrenalectomies, including eight bilateral and four subtotal procedures were performed. No in-hospital mortality occurred. Six patients (7 %) presented with malignant pheochromocytoma. Fifteen RET and 1 succinate dehydrogenase B (SDHB) mutation were identified in 45 patients. Five of 18 patients (28 %) revealed lymph node metastases. After a median follow-up of 110 months, only one of 79 benign and three of six malignant pheochromocytomas recurred. At final follow-up, 73 patients were disease-free, three were alive with disease, two succumbed to disease, and seven for other reasons. Kaplan-Meyer estimates for 5/10-years survival after surgery were 95/ 90 % with an estimated median overall-survival of 234 months. Malignant disease, SDHB mutation, and vascular invasion were predictors for recurrency at univariate analysis while all other evaluated parameters including capsular disrupture failed. Conclusion: Recurrency in benign pheochromocytomas seems to be overestimated in historic cohorts while it occurs frequently in patients with malignant pheochromocytomas.

P 21

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Results: Seventeen patients, 10 with a typical and 7 with an atypical neuroendocrine neoplasias of the lung patients were identified. Eighteen operations in 17 patients were performed; atypical resection of the tumor and lobectomy both with radical lymph node dissection were the main type of operations. Preoperative imaging modalities showed no evidence of suspicious lymph node metastases. Overall, 374 lymph nodes were resected. Only one patient with an atypical multifocal tumor had lymph node metastases (6/18); all other patients with a neuroendocrine tumor of the lung had no lymph node metastases during the time point of operation. After a median follow-up of 31 months (range 1–142), all 17 patients are alive and without any signs of tumor recurrence. Conclusion: The management of neuroendocrine neoplasias of the lung is still limited by missing randomised trials. We suggest that lymph node metastases are a rare event in patients with sporadic neuroendocrine tumor of the lung. The influence of systemic lymph node dissection on overall survival remains questionable.

P 22 Coincidence of two mutations in a patient presenting with multiple endocrine neoplasia type 1 — is the clinical course more aggressive?

Magnus Melin, Aycan Akca, Denis Wirowski, Katharina Schwarz, Achim A. R. Starke, Peter E. Goretzki Department for General and Endocrine Surgery, Lukaskrankenhaus Neuss, Germany [email protected] Background: Patients with multiple endocrine neoplasia type 1 (MEN1) are known to develop primary hyperthyroidism in 90–95 %, pancreatic tumors in 40–50 %, and pituitary tumors in 10–60 %. Bronchial or thymic carcinoids are rare with a prevalence of 10 %. Primary hyperparathyroidism is the most common first symptom. Methods: We performed a retrospective analysis of the clinical course of a MEN1 family presenting with two different mutations, including the coincidence of both in the index patient. Results: The index patient was a young female presenting with multifocal pancreatic gastrinoma and hepatic metastasis at the age of 21. The following molecular genetic diagnostics showed two mutations, the paternal on exon 3 and the maternal on intron 1 of the MEN1 gene. The paternal mutation has been associated with disease, while the maternal mutation has not. The index patient further developed primary hyperparathyroidism, a bronchial carcinoid and multiple pulmonary, hepatic and lymphatic metastases. The father developed primary hyperparathyroidism and a bronchial carcinoid, however, at a later age. The mother and the second daughter, who only showed the maternal mutation, were disease free. Conclusion: The question remains, whether the sequence variation IVS12A>G could aggravate the clinical symptoms of the MEN1 mutation on exon 3.

The outcome of patients with neuroendocrine neoplasias of the lung — experience with 17 patients

Christian Meyer, Andreas Kirschbaum, Detlef K. Bartsch, Volker Fendrich Department of Surgery, Universitätsklinik Gießen und Marburg, Standort Marburg, Germany [email protected] Background: To evaluate the outcome of patients with neuroendocrine neoplasias of the lung in a tertiary referral center. Methods: All patients that underwent surgery for neuroendocrine neoplasias of the lung between 2000 and January 2014 at our institution were retrospectively evaluated. The diagnosis of neuroendocrine neoplasias of the lung was based on clinical symptoms, CT-Scan, bronchoscopy, histopathology, and by Octreotid-Scan.

P 23 Roboter-assisted surgical management of neuroendocrine tumors of the pancreas

Volker Fendrich, Elisabeth Maurer, Detlef K. Bartsch Klinik für Visceral-, Thorax- und Gefäßchirurgie, Philipps-Universität Marburg [email protected] Background: To evaluate the first experiences using the DaVinci robotic system for resection of neuroendocrine tumors of the pancreas. Methods: All patients which underwent surgery for neuroendocrine tumors of the pancreas between February and June 2014 by using the roboter-assisted DaVinci device were evaluated.

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Results: In the time period mentioned above, five patients were evaluated. Three patients underwent distal pancreatic resection and in two patients, the tumor was enucleated. There was no conversion. The mean operation time was 175 min (120–195). One patient developed a pancreatic fistula type B after enucleation. Conclusion: Using the DaVinci robotic system for resection of neuroendocrine tumors of the pancreas is feasible. If there is an advantage for the patients has to be evaluated in clinical trials.

P 24 Effect of combined antiangiogenic therapy at different points of tumorangiogenesis in RIP1-TAg5-transgenic mice

Hendrik Strothmann, Simon Schimmack, S. Schoelch, U. Scherer, Thomas Schmidt, Markus W. Buechler, F. Hubertus Schmitz-Winnenthal Department of Surgery, University of Heidelberg, Germany

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surface markers, chemokine ligand 20 (CCL20) and Treg transcription factor FoxP3 were analyzed by immunohistochemistry. Results: Infiltrating cells were mostly CD4+ T cells with a predominant memory-effector phenotype CD4+CD45RO+CD27+. Infiltrating CD4+ T cells upregulated the expression of chemokine receptors CCR5 (5.5 %), CCR6 (9.6 %), and CXCR3 (9.3 %), producing high amounts of IFN gamma (41.3 %) and IL-17 (4.0 %) compared to circulating CD4+ T cells. High numbers of CD4+CD25+CD127-FoxP3+ (Tregs) were found in infiltrating cells (2.9 %) compared to peripheral blood. Immunohistological analysis of the thyroid gland demonstrated the abundance of CD4+CD45RO+CD27+ T cells, the expression of CCL20 and expression of FoxP3. Conclusion: Our findings suggest that infiltrating T cells, possibly driven by chemokine receptors, belong to the Th1/Th17 effector T cell phenotype producing high amounts of IFN gamma and IL-17. The presence of Tregs within inflammatory tissue indicates a role of these cells in modulating inflammation.

[email protected] Background: Hypervascularisation as a common feature of pancreatic neuroendocrine neoplasms (pNEN) has promoted antiangiogenic therapy to the center of attention in the treatment of this entity. This study aims to assess the effect of combination of different antiangiogenic agents on early and late tumor formation of pNEN in RIP1-TAg5-transgenic mice. Methods: RIP1-TAg5-transgenic mice developing beta cell neoplasms at defined points in time were treated with four antiangiogenically acting substances—VXM01 (oral DNA-vaccine encoding VEGFR-2), sunitinib (multi-targeted tyrosine-kinase inhibitor), everolimus (mTOR-Inhibitor), and DC101 (monoclonal antibody against murine VEGFR-2/flk-1 receptor)—solely and in combination at defined stages of tumorangiogenesis. IHC staining for CD31 and survival analyses were performed to determine the effects of preemptive, interventional, and regressive therapies. Results: Everolimus and VXM01/everolimus treatment led to a significant 1.8-fold (1.6-fold) increase of CD31-positive vessels (p<0.01) in the preemptive group, co-administration of sunitinib negated this effect. Combined VXM01/DC101 treatment resulted in significantly reduced CD31-positive vessels (48 % of control, p<0.05) in the regressive group. Kaplan-Meier-analyses showed a significantly longer survival of mice under VXM01/DC101, everolimus, sunitinib/everolimus, VXM01/ everolimus treatment (p<0.05). Conclusion: Our study confirms the potential of antiangiogenic therapy in the treatment of pNEN and supports the combined use of different agents to increase treatment efficiency.

P 25 Hashimoto Thyroiditis is dominated by infiltrating Th1/Th17 cells

Martin Gasser1, Giovanni Almanzar2, Jochen Schreiner2, Kerstin Höfner”, Vanessa Wild3, Andreas Rosenwald3, Christoph-Thomas Germer1, Ana Maria Waaga-Gasser1, Martina Prelog2 1 Department of General, Vascular, and Pediatric Surgery, University of Würzburg, Würzburg, Germany; 2Laboratory of Pediatric Rheumatology, Special Immunology and Osteology, Department of Pediatrics, University of Würzburg; 3Institute of Pathology, University of Würzburg [email protected] Background: The role of infiltrating T cells in the pathogenesis of Hashimoto’s thyroiditis (HT) is still under debate. Here we characterized the phenotype and function of isolated T cells (Th1/Th17 versus Tregs) from the thyroid gland. Methods: Thyroid tissue and peripheral blood mononuclear cells (PBMCs) were obtained from HT patients who underwent thyroidectomy. After in vitro expansion, cytokine production profiles of isolated infiltrating T cells and PBMCs were assessed by flow cytometry. Cell

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Two cases of renal neuroendocrine tumor — case report and review of the literature

Anastasia Melin1, C. Otto2, Aycan Akca1, Achim A. R. Starke1, Peter E. Goretzki1 1 Department of Visceral and Endocrine Surgery, Lukaskrankenhaus Neuss, Germany; 2Department of Urology, Gemeinschaftsklinikum Koblenz-Mayen [email protected] Background: 0.3 % of all renal tumors are neuroendocrine, and 1 % of NET are localized in the urogenital tract, where neuroendocrine cells do not exist. The origin of these tumors remains unclear. In 18–26 %, there is an association with a horseshoe kidney. 27 % of the patients remain symptomless. Methods: We analyzed the patient data retrospectively and compared with the literature on renal NET. Results: Our first case was a 20-year-old male patient with a horseshoe kidney and a renal NET of the left kidney, which was operated in June 2012. A year after first diagnosis, the patient came to us with a metastasis in the renal pedicle, showing up in a DOTATOC-PET-CT. We resected a lymph node metastasis, showing infiltration of a NET with a proliferation of 5 %. The second case was a 57-year-old male patient, diagnosed with a renal tumor coincidentally. He was operated in June 2013. The tumor showed synaptophysin positivity. Follow-up examinations showed no recurrence. Conclusion: 45.6 % of renal neuroendocrine tumors have already metastasized at initial diagnosis. It is important to include this rare tumor into the differential diagnosis of renal tumors. Due to its rareness, a standardized therapy does not yet exist.

P 27 Interdisciplinary treatment of a high malignant gastric neuroendocrine carcinoma (NEC) with hepatic metastasis in multiple endocrine neoplasia type I syndrome: a case report

Felix M. Watzka, Arno Schad, Christian Fottner, Matthias Miederer, Matthias M. Weber, Hauke Lang, Thomas J. Musholt Clinic of General, Visceral- and Transplantation Surgery, University Medical Center University Mainz, Mainz, Germany [email protected] Background: In this case report, we present a patient with a gastric neuroendocrine carcinoma in association with multiple endocrine

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neoplasia type I (MEN I) and discuss the interdisciplinary treatment concept in this individual case. Methods: We report the clinical and laboratory data, including histopathologic and immunocytochemical findings, for our current patient and also review the literature on gastric neuroendocrine neoplasia and MEN I syndromes. Results: In focus was a 53-year-old female patient with family history of multiple endocrine neoplasia type I. The patient had a gastric NEC grade 3 (Ki-67 index>70 %), located in the antrum, with hepatic metastasis. A pancreatic NEN with a diameter of 1.5 cm existed additionally. In an interdisciplinary concept after two cycles of neoadjuvant chemotherapy (carboplatin/etoposid), a gastrectomy with systematic lymphadenectomy and resection of the liver metastases was carried out. The final TNM clasification: T3, N0 (0/23), M1 (hep), R0. Postoperatively, an adjuvant chemotherapy was suggested. Conclusion: Curative surgery for patients with MEN1-associated malignant NEC should only be performed in an interdisciplinary context. Even patients with advanced disease surgery can be part of the therapy because of effective neoadjuvant chemotherapy concepts and the improved surgical outcome.

P 28 A rare cause of a solitary thyroid nodule

Stephanie Trum, Detlef Krenz Abteilung für Allgemein-, Viszeral-, Gefäß- und Thoraxchirurgie, Klinikum Dritter Orden München-Nymphenburg [email protected] Introduction: 3–15 % of all solitary thyroid nodules are malignant. Papillary thyroid carcinoma (PTC) is the most common type of thyroid cancer. Sometimes, however, rare types of malignancies can be found.

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Case report: We report the case of a 29-year-old female patient that presented with an enlarged neck mass of the left lobe of the thyroid gland. Neck ultrasound showed a singular hypoechoic nodule in the left lobe of the thyroid gland. The right lobe didn’t show any abnormality. Additionally, conspicuous lymph nodes were found on the left side of the neck. Due to the suspicious ultrasound, we performed a hemithyroidectomy. Postoperatively, histology showed primary thyroid lymphoma arising from mucosa-associated lymphoid tissue (MALT lymphoma), on the background of autoimmune Hashimoto’s thyroiditis. In order to complete the staging of the disease, the patient underwent further evaluation with panendoscopy, PET-CT, and bone marrow biopsy, which were all negative. The potential benefits of being further treated by radiotherapy and/or chemotherapy were discussed with our oncologists, and the final decision was a radiotherapy with 30Gy. One year after the radiotherapy, she is well, with no evidence of local or systematic disease, adequately replaced with L-thyroxine. Discussion: MALT lymphomas, which account for 25 % of primary lymphomas, arise mainly in the stomach (60–70 %). Primary thyroid lymphoma, however, is a really rare malignancy, representing 2–8 % of all thyroid malignancies and 1–2 % of all extranodal lymphomas. The existing data support that autoimmune thyroiditis seems to be a risk factor for the development of thyroid MALT lymphoma due to an acquired pathological transformation of the intrathyroidal lymphoid tissue. In the absence of randomized clinical trials to compare different treatment options (thyroidectomy, radiotherapy, chemotherapy) in patients with thyroid MALT lymphoma, there are no widely accepted guidelines. Surgery and radiotherapy as well as a combination of both is being discussed. In conclusion, our case of a concurrence of primary thyroid MALT lymphoma and autoimmune thyroiditis is trying to emphasize the need of a careful evaluation of any palpable thyroid mass. Moreover, this case, in addition to the existing published cases, illustrates that the nature of follow-up care and long-term results of treatment of patients with primary thyroid MALT lymphomas are not fully established yet.

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Index of Authors

Abuazab M. SA.05.04 Akca A. FR.02.05, P 19, P 22, P 26 Albers M. B. FR.06.04 Almanzar G. P 25 Altindag H. P 03 Anamaterou C. P 14 Apitzsch J. C. FR.06.04 Aschoff A. SA.05.02

Klatte T. P 01 Klug E. FR.02.04 Kober F. FR.02.04, P 01 Kolb W. SA.02.01, P 06, P 13 Krenz D. P 28 Krull I. P 13 Kufleitner H. P 03 Kußmann J. SA.05.03

Ramaswamy A. P 20 Rasche R. V. P 12 Reinisch A. P 07 Richter G. P 10 Riss P. P 02 Rogowski-Lehmann N. P 13 Rosenwald A. P 25 Rudofsky G. P 14

Bailer S. FR.02.03 Bartsch D. K. FR.06.04, FR.06.05, P 04, P 20, P 21, P 23 Bechstein W.-O. P 07, P 18 Beutner U. SA.02.01 Bichler C. P 02 Bilz S. P 13 Bittscheidt H. P 10 Bock S. P 06 Bradatsch A. P 11 Brändle M. P 13 Büchler M. W. FR.06.03, P 14, P 24 Bures C. FR.02.04, P 01

Lammers B. J. FR.02.05, P 09 Lammert A. P 16 Lang H. SA.05.02, P 27 Lang M. P 14 Lawrence B. FR.06.02 Lenschow C. P 17 Lienenlüke R. H. SA.02.02, P 03 Lindner K. P 17 Linnebacher M. P 08 Lippert H. SA.02.05 López-López C. FR.06.04 Lorenz K. FR.02.03, SA.02.04, SA.05.01, SA.05.04 Lück R. P 10 Lüthi A. SA.02.01 Lüthi C. FR.06.01, SA.02.01

Sahm M. SA.02.05 Schad A. P 27 Scherer U. P 24 Scheuba C. P 02 Schimmack S. FR.06.02, FR.06.03, P 14, P 24 Schmidt T. P 24 Schmied B. M. FR.06.01, SA.02.01 Schmitz E. SA.05.03 Schmitz-Winnenthal H. FR.06.02, P 14, P 24 Schneider R. SA.05.01 Schölch S. P 24 Schreiner J. P 25 Schuchmann M. FR.06.05 Schultheis A. P 01 Schuster F. P 12 Schwarz K. SA.02.03, P 09, P 22 Sehnke N. P 09 Sekulla C. FR.02.03, SA.02.04, SA.05.01, SA.05.04 Selberherr A. P 02 Senninger N. P 17 Slater E. P. FR.06.04 Starke A. A. R. FR.02.05, P 19, P 22, P 26 Steffen T. FR.06.01 Strobel O. FR.06.02, FR.06.03, P 14 Strobl S. P 02 Strothmann H. P 24

Cherrez A. FR.06.03 Clerici T. FR.02.03, FR.06.01, SA.02.01, P 06, P 13 Colombo-Benkmann M. P 17 Dotzenrath C. P 12, P 15 Dralle H. FR.02.03, SA.02.04, SA.05.01, SA.05.04 Dralle S. P 08 Ebinger S. FR.06.01 Ebner H. P 16 Eckhardt S. P 04 Estourgie S. SA.02.03 Fendrich V. FR.06.04, FR.06.05, P 04, P 20, P 21, P 23 Fischer L. FR.06.03 Fottner C. P 27 Gasser M. P 25 Germer C.-T. P 25 Gohrbandt A. E. SA.05.02 Goretzki P. E. FR.02.05, SA.02.03, P 09, P 19, P 22, P 26 Habbe N. P 07 Hackert T. FR.06.03 Hermann M. FR.02.04, P 01 Herrle F. P 16 Heverhagen A. FR.06.05 Hinz U. FR.06.03 Höfner K. P 25 Holzer K. P 07, P 18 Kazmierczak R. SA.02.02 Kenney B. FR.06.02 Kidd M. FR.06.02 Kirschbaum A. P 21 Klar E. P 08

Machens A. SA.05.01 Malhofer F. P 05 Malkomes P. P 07 Manzini G. P 05 Maurer E. P 04, P 23 Melin A. FR.02.05, P 19, P 26 Melin M. P 22 Meurer N. P 15 Meyer A. P 12, P 15 Meyer C. P 21 Meyer I. P 15 Miederer M. P 27 Modlin I. M. FR.06.02 Müller A.-K. P 17 Müller J. A. P 10 Musholt T. J. SA.05.02, P 27

Tarantino I. SA.02.01 Thomusch O. SA.02.04 Tosch M. P 15 Trum S. P 28 Uckermark A. P 08

Nawroth P. P 14 Neuhold N. P 01 Neukirch A. K. P 12 Neumann S. P 01 Nguyen-Thanh P. FR.02.03, SA.05.01 Niederle B. P 02 Nittka S. P 16 Nowak K. P 16 Nuttebaum A.-L. P 20 Oettli R. P 13 Otto C. P 26 Papadakis M. P 12, P 15 PETS Study Team SA.02.04 Pluto N.-N. P 18 Preldzic L. FR.02.04 Prelog M. P 25 Pross M. SA.02.05

Vorländer C. SA.02.02, P 03 Waaga-Gasser A. M. P 25 Waldmann J. FR.06.04, FR.06.05, P 20 Warschkow R. FR.06.01, SA.02.01 Wasser K. P 16 Watzka F. P 27 Weber T. P 05 Weyerbrock N. P 15 Wiese D. FR.06.05 Wild V. P 25 Wirowski D. P 22 Wolf G. P 11 Yadev P. SA.02.02 Zahn A. SA.05.03 Zielinski V. FR.02.04, P 01