Langenbecks Arch Surg DOI 10.1007/s00423-017-1622-5

ABSTRACTS

36th Annual Meeting of the German Association of Endocrine Surgeons (CAEK) 36. Arbeitstagung der Chirurgischen Arbeitsgemeinschaft Endokrinologie (CAEK) November 2th – 4th 2017, Bern, Switzerland www.caek2017.ch

Organizing Committee Prof. Dr. Christian A. Seiler Dr. Reto Kaderli Inselspital Bern Universitätsspital Bern Universitätsklinik für Viszerale Chirurgie und Medizin Freiburgstr. 10 3010 Bern | Schweiz Congress Venue Fabrikhalle 12 Fabrikstr. 12 3012 Bern | Schweiz www.eventfabrikbern.ch

the donor nor the recipient showed any complications. In the postoperative course clinical symptoms of hypocalcemia significantly improved whereas serum calcium and parathyroid hormone (PTH) levels progressively increased into the normal range. Former intense replacement therapy could be discontinued completely in a stepwise fashion. To date, four years after transplantation, the patient remains asymptomatic with normal serum levels of calcium and PTH. Conclusions: Successful living-donor parathyroid allotransplantation for postsurgical hypoparathyroidism represents an innovative therapeutic strategy that could provide the definitive treatment in those patients in which the disease is therapy-refractory. The procedure can be justified even in nontransplant recipients. Retrieval of parathyroid glands from healthy donors is feasible and safe. [email protected]

1 2 Living-donor parathyroid allotransplantation for therapy-refractory postsurgical persistent hypoparathyroidism in a nontransplant recipient – four year results: a case report Ayman Agha1, Marcus Nils Scherer 2 , Christian Moser1, Thomas Karrasch3, Christiane Girlich3, Fabian Eder3, Ernst-Michael Jung4, Hans Juergen Schlitt2, Andreas Schaeffler4 1 Klinik für Allgemein-, Viszeral-, Endokrine- und Minimalinvasive Chirurgie, Klinikum Bogenhausen, Städtisches Klinikum München GmbH; 2Klinik und Poliklinik für Chirurgie, Universitätsklinikum Regensburg; 3 Klinik und Poliklinik für Innere Medizin I, Universitätsklinikum Regensburg; 4Institut für Röntgendiagnostik, Universitätsklinikum Regensburg Objective: Therapy-refractory persistent hypoparathyroidism after extensive neck surgery is a rare but severe complication. Parathyroid allotransplantation may represent a definitive treatment option. Results: We report the case of a 32-year-old female, referred to our hospital with intractable persistent hypocalcemia after neck surgery for papillary thyroid cancer. Despite optimal medical treatment including calcium and vitamin D supplementation and even hormonal replacement therapy hypocalcemic symptoms failed to improve. The quality of life was considered very low. In light of the unsuccessful medical therapy and the young age of the patient parathyroid allotransplantation seemed an attractive treatment option to restore normal calcium homeostasis despite of the need for immunosuppressive therapy after the procedure. Therefore, we performed living-donor allotransplantation of two healthy parathyroid glands to the recipient’s left forearm. The surgical intervention was successful. Neither

Hyperglycaemia after insulinoma resection - a rare problem indicating diabetes mellitus Aycan Akca, Achim A. R. Starke, Peter E. Goretzki Department of Visceral and Endocrine Surgery, Lukaskrankenhaus Neuss, Germany Objective: No systematic study is known investigating the adaptive gap of function for beta cells of the pancreas after insulinoma operation. Methods: We analyzed serum glucose during a postoperative fasting period of 48 hours in all patients with insulinoma operated on between 2001 and 2017 retrospectively. Results: 39 (59.1%) of 66 patients with insulinoma were operated on by enucleation, left resection was performed in 19 (28.8%) and pancreatic resection in 8 (12.1%) patients. Two of these patients suffered from malignant insulinoma. In 28 cases (42.2%) postoperative serum glucose was between 140 and 200 mg/dl. In 15 (22.7%) patients the glucose value reached > 200mg/dl. Four of these patients needed postoperative insulin therapy, but only 2 (3%) developed diabetes mellitus. Conclusions: Postoperative fasting glucose levels in insulinoma patients showed significant hyperglycaemia in only few patients (22.7%) in between first 48 h after pancreatic resection. Therefore beta cell adaptation after insulinoma resection is fast, and does not present a problem of postoperative metabolism. [email protected]

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Repetitive Pancreatic Surgery in Multiple Endocrine Neoplasia Type 1 Max B. Albers, Jerena Manoharan, Carmen Bollmann, Detlef K. Bartsch Klinik für Viszeral-, Thorax- und Gefäßchirurgie, Universitätsklinikum Gießen und Marburg, Standort Marburg Objective: Pancreatic neuroendocrine neoplasms (pNEN) are one of the most common manifestations and causes of death in MEN1 patients. The indication and type of surgery is still highly controversial. Aim of the present study was to evaluate the frequency and outcome of reoperations in MEN1-pNEN. Methods: A since 1999 prospectively collected database of 92 MEN1 patients treated at our institution was retrospectively analyzed for first and redo-pancreatic resections and their outcome. Redo-Surgery was indicated for functioning tumors causing an endocrine syndrome or non functioning pNEN exceeding 20mm. Results: Of 92 MEN1 patients, 59 (64%) underwent at least one surgical treatment for pNEN (30 for non functioning pNEN, 11 for Insulinoma and 18 for ZES). Initial surgery included 11 enucleations, 26 distal pancreatic resections (DPR), 9 DPR plus enucleation, 1 middle pancreatic resection (MPR) and 9 partial pancreatoduodenectomies (PPD). All patients with Inuslinoma were biochemically cured after initial surgery. During a mean follow up period of 155 months (12,9 years) 12 (13%) patients underwent reoperations (5 enucleations, 4 DPR, 1 DPR plus enucleation, and 2 PPD) for either new NF-pNENs >1-2cm (n=6), recurrent ZES (n=4) or new developed insulinoma (n=2). 4 of 6 patients with a functional tumor were cured and the reoperation resulted in completion pancreatectomy in only 2 patients. Three (5%) patients had to undergo a third operation (3 DPR), which resulted in completion pancreatectomy in 1 patient. Overall, second and third operations resulted in completion pancreatectomy in only 3 patients (3,3%). The complication rate, including pancreatic fistulas, did not differ significantly between the first operation and reoperations. Conclusions: Reoperations for pancreatic manifestations of MEN1 are relatively safe and completion pancreatectomy can be avoided for a long time. [email protected]

4 Results of surgery for Graves’ disease after failed radioiodine therapy Per F. Alesina, Beate Meier, Jakob Hinrichs, Wazma Mohmand, Martin K. Walz Klinik für Chirurgie und Zentrum für Minimal Invasive Chirurgie, Kliniken Essen-Mitte, Essen Objective: Thyroidectomy remains the only treatment option in case of failure of non-surgical therapies. In this study we present the results of thyroidectomy performed in patients that underwent thyroidectomy after failed radioiodine treatment. Methods: Between January 2000 and June 2017, 1022 patients (832 w, 190 m; mean age 41±14 years) with Graves’ disease have been operated at our department. Among them, 30 patients (26 w, 4 m; mean age: 50 ± 9,6 years) were referred to surgery after failed radioiodine therapy and recurrent hyperthyroidism. The remaining patients served as a control group. The data, including postoperative complications rate, were collected from a prospectively maintained database. Pre- and postoperative laryngoscopy was routinely performed. Symptomatic patients for postoperative hypocalcaemia underwent calcium and/or PTH level control and were substituted with calcium and/or Vitamin D.

Results: Postoperative complications in the study group included four postoperative recurrent laryngeal nerve palsies and three cases of postoperative symptomatic hypocalcaemia requiring vitamin D supplementation. There was no bleeding. The mean operating time was 70 minutes (range: 40-135 minutes). The mean hospital stay was 2,1 days (range: 2-4 days). The incidence of nerve palsy calculated for nerves at risk was significant higher than in the control group (6,6% vs. 1,6%) [p=0,01]. The rate of patients with postoperative hypocalcaemia was similar in the groups (10% vs. 15%) [p=0,6]. All recurrent laryngeal nerve palsies in the study group were transient and recovered within 6 months. One patient still requires vitamin D supplementation at last follow-up. Conclusions: Surgery for Graves’ disease after radioiodine therapy is associated with a significant higher incidence of transient recurrent laryngeal nerve palsy. Nevertheless, the long-term results of surgery should not discourage the use of surgery as a definitive therapy for recurrent hyperthyroidism after radiometabolic treatment. [email protected]

5 Management of diagnostics and therapy of intrathoracic parathyroid adenoma in primary hyperparathyroidism Mona Besmens, Nina Sehnke, Bernhard J. Lammers, Katharina Schwarz, Peter E. Goretzki Chirurgische Klinik I, Lukaskrankenhaus Neuss Objective: We illustrate the diagnostic requirements and surgical options in treating intrathoracic adenoma. Methods: From 02/2011 to 04/2017 we retrospectively analysed all our cases of intrathoracic parathyroid adenoma in regards of diagnostics and surgical requirements. Results: In 588 patients with primary hyperparathyroidism (PHPT) 43 intrathoracic adenomas were found. 8 adenomas were located by MiBi-scintigraphy alone. 15 adenomas could not be found via ultrasound or scintigraphy, but in a cervical exploration. In 14 cases, the diagnostic was extended to CT (8) or MRI scan (6). Six patients with negative standard imaging (4 with recurrent disease, 2 with high perioperative risk) underwent PTH venous sampling. These 37 adenomas were situated in the upper mediastinum. 5 of 6 adenomas in the aorto-pulmonary window or lower mediastinum were detected by scintigraphy. Additionally, a CT or MRI scan was performed for diligent planning of the surgical procedure. One adenoma could only be detected by MRI scan. 36 intrathoracic parathyroid adenomas were resected via a cervical approach. In 3 of these, a manubriotomy was necessary. Only one of the 43 patients received a total thymectomy via video-assisted thoracoscopy (VATS) and a cervical approach, due to parathyreomatosis. 6 patients were resected via VATS alone (4 adenomas in the aorto-pulmonary window, 2 in the lower mediastinum). Only one of these had a sternotomy due to bleeding out of the ascending aorta. All 43 patients with intrathoracic adenoma were treated successfully. Conclusions: Patients with intrathoracic parathyroid adenoma are a heterogenous group when diagnostic and therapeutic challenges are addressed. Most parathyroid adenomas in the upper ventral mediastinum can easily be explored by a cervical approach alone or with help of VATS. Adenomas located more distally and especially those in the aortopulmonary window require experience in thoracic surgery. This must be considered, when endocrine surgeons are primarily addressed because of the diagnosis of PHPT. [email protected]

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6 Analysis of out-patient vs in-patient urinary calcium excretion in patients with primary hyperparathyroidism Lindsay Brammen1, Barbara Curik1, Angelika Geroldinger2, Andreas Selberherr1, Christian Scheuba1, Philipp Riss1 1 Section “Endocrine Surgery”, Division of General Surgery, Department of Surgery 2 Section for Clinical Biometrics, CeMSIIS Medical University Vienna, Waehringer Guertel 18-20, Vienna, Austria Objective: The most important differential diagnosis in patients with primary hyperthyroidism (PHPT) is familial hypocalciuric hypercalcemia (FHH). In order to differentiate between the two diseases, a 24h-urinary calcium excretion is essential. In patients with FHH, calcium excretion is usually decreased, whereas in PHPT patients, it is normal or increased. In the out-patient setting, the collection of urine over 24 hours sometimes poses problems for the patients, which can lead to inaccurate results. This study was conducted to observe and determine differences between outpatient and in-patient 24-hour urinary calcium excretion analyses. Methods: Data of PHPT patients who collected 24-hour urine on an outpatient as well as in-patient basis and who were operated on between 2004 and 2009 was analyzed. Patient characteristics, as well as 24-hour urinary calcium excretion were evaluated. Results: The study included 56 patients (40 female: 16 male), mean age 59 years, that fulfilled our criteria. Statistical analysis demonstrated no significance between age and sex and 24-hour urine calcium excretion when comparing out-patient to in-patient collection (p=0.055). Furthermore, a multivariate analysis confirmed no statistical significance in the ability to predict calcium excretion in an in-patient setting when the out-patient 24-hour calcium excretion, as well as age and sex are known. Conclusions: Our study showed no significant difference in calcium excretion when collecting urine on an in-patient versus out-patient setting. Furthermore, when an out-patient calcium excretion, as well as age and sex are known, it is not possible to predict an in-patient calcium excretion value. Thus, when an out-patient calcium excretion value is known, it may not be required to repeat the process as an in-patient. Further studies are needed to better understand the factors influencing 24-hour urine calcium excretion and the possible misdiagnosis of FHH. [email protected]

7 Analysis of the course of intraoperative parathyroid hormone in patients with primary hyperparathyroidism and uncharacteristically low (<100 pg/ml) or high (>400 pg/ml) basal PTH values Lindsay Brammen1, Carmen Maria Bereuter1, Angelika Geroldinger2, Andreas Selberherr1, Christian Scheuba1, Philipp Riss1 1 Section “Endocrine Surgery”, Division of General Surgery, Department of Surgery 2 Section for Clinical Biometrics, CeMSIIS Medical University Vienna, Waehringer Guertel 18-20, Vienna, Austria Objective: Quick intraoperative monitoring of parathyroid hormone (QPTH) is useful in patients with primary hyperparathyroidism (PHPT). The implementation of this tool has led to the performance of minimally invasive parathyroidectomy on patients with localized single-gland disease. There is disagreement concerning the established criteria and its prediction of complete resection of hyper-functioning parathyroid tissue in patients with uncharacteristically low (<100 pg/ml) or high (>400 pg/ ml) basal serum parathyroid hormone (PTH). The aim of this study was to

investigate the applicability of QPTH in patients with low or high basal PTH. Methods: In this study, 1021 patients (816 female:205 male) with PHPT were analyzed. They were divided into three groups: low (<100 pg/ml), medium (100-400 pg/ml) and high (>400 pg/ml) basal serum PTH. Sensitivity, specificity, positive and negative predictive value, as well as accuracy were calculated between the different groups using the intraoperative "Vienna Criterion". Results: For the "low group" (296 patients), sensitivity and specificity were calculated to be 84% and 94%, in the "medium group" (638 patients) 91% and 82%, and in the "high group" (87 patients) 96% and 67%. Positive predictive values were 99.5%, 98.5% and 95% for the "low", "medium", and "high" groups, respectively. Negative predictive values for the "low group" was 26%, for the "medium group" 40% and for the "high group" 73%. The overall accuracy was calculated to be 84%, 90%, and 92% for the "low", "medium" and "high" groups, respectively. Conclusions: The established "Vienna Criterion" can be used in patients with low and medium baseline PTH. The specificity is very low in patients with a baseline PTH >400 pg/ml, which could result in untimely termination of surgeries, thus giving rise to higher postoperative persistence rates. Therefore, additional criteria need to be identified for this patient population. [email protected]

8 Postoperative hypoparathyroidism in thyroid surgery: anatomicsurgical mapping of the parathyroids and implications for thyroid surgery Florian Burger1, Hannes Stofferin1, Rupert Prommegger2, Marko Konschake1 1 Division for Clinical and Functional Anatomy; Department for Anatomy, Histology and Embryology; Medical University of Innsbruck, Austria; 2General and Endocrine Surgery, Sanatorium Kettenbrücke, Innsbruck, Austria Objective: Hypoparathyroidism remains one of the most common complications in thyroid and parathyroid surgery. This study aims for an improved understanding of the complexity and topography of the blood supply as well as the localization of the parathyroid glands compared to the two most important intraoperative landmarks: the inferior laryngeal nerve and Zuckerkandl’s tubercle. Methods: We examined 71 laryngeal compounds to classify the blood supply and the location of the parathyroid glands compared to the inferior laryngeal nerve and Zuckerkandl's tubercle (ZT). For intraoperative localization and orientation, we defined in a Cartesian coordinate system the ZT plane as x-axis and the course of the inferior laryngeal nerve as y-axis. Results: Like expected, the parathyroids are mainly supplied by the inferior thyroid artery, whereas the superior thyroid artery provides a backup supply. It must be pointed out that 7,8 % of parathyroids receive their blood directly from the thyroid gland, making preservation during e.g. thyroidectomy impossible. We discovered that 74,6 % of all parathyroid glands lie within 1 cm of the inferior laryngeal nerve and 1 cm cranial or 2,5 cm caudal to the ZT plane. Conclusions: Our described perimeters mark the most crucial areas during surgery to preserve the parathyroids glands and the inferior laryngeal nerve – providing the surgeon with a blueprint where special carefulness is needed. Since the inferior thyroid artery provides blood in the most cases, preoperative identification with sonography is advisable, whereas during surgery the vessel should be identified and all branches handled with care. [email protected]

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9 Contrast enhanced ultrasound: a new tool for identification of szintigraphy-negativ parathyroid adenoma Francesca Di Cerbo1, M. Sohn1, Matthias Hornung2, A. Mamilos3, Igors Iesalnieks1, Ayman Agha1 1 Klinik für Allgemein-, Viszeral-, Endokrine- und Minimalinvasive Chirurgie, Klinikum Bogenhausen, Städtisches Klinikum München GmbH; 2Klinik und Poliklinik für Chirurgie, Universitätsklinikum Regensburg; 3Institut für Pathologie, Universitätsklinikum Regensburg Objective: Preoperative accurate localization of parathyroid adenomas (PA) in primary hyperparathyreoidism (pHPT) is crucial for realizing successful state of the art minimally invasive videoassisted parathyreoidectomy. To date Technetium 99m sestamibi scanning is the commonly accepted method. The main intracellular sestamibi-activity was detected intramitochondrial so that the mitochondrial content of the cell is supposed to correlate with the level of radionuclide storing. Sensitivity of the method is reported to be around 90%. Nevertheless parathyroid localization remains challenging, especially in case of concomitant goiter, multiple gland disease and after previous neck surgery. The study is conducted to evaluate wether contrast enhanced ultrasound (CEUS) can bridge the diagnostic gap in case of szintigraphy negative pHPT. Besides the rate of oxyphil cells was correlated with false negative findings in Technetium 99m sestamibi scans. Methods: Consecutive patients with pHPT and negative sestamibi-scans were retrospectively identified in two surgical centers. Results of szintigraphy and CEUS were compared. Moreover, rate of mitochondria-rich oxyphil cells in PA was correlated with the diagnostic sensitivity. Results: Between 2009 and 2017, 37 patients with false negative szintigraphy in pHPT were identified. CEUS was applied in 30 patients. In all of them, preoperative localization was correct. Conclusions: CEUS is an effective tool for the identification of PA in patients with negative szintigraphy. Advantageously, the method is accurate, independent from the mitochondrial content and cheap wherefore its general use could be recommended. [email protected]

10 Are there differences between single session and two time session lymphadenectomy in thyroid cancer? Marc Goebel, Benjamin M. Leu, Hans Udo Zieren St. Agatha-Krankenhaus Köln, Schilddrüsenzentrum Köln, Abteilung für Chirurgie, Köln Objective: In the German Guidelines for the surgical treatment of thyroid cancer there are controversial discussions about the benefit of prophylactic lymphadenectomy in thyroid cancer, especially considering the recommendations for the indication of single session and two time lymphadenectomy. Methods: A retrospective analysis of our patient population between the 01.01.2006 until the 31.12.2016. The stuff surgeons in the St. Agatha Hospital in Cologne performed 6645 thyroid operations during that time. We detected thyroid cancer in 534 patients, from that we conducted 157 single sessions oncological operations (total thyroidectomy and central cervical lymphadenectomy) and 177 two time session oncological operations (4,19 days between the two operations). Results: We found no statistical significant differences between the two groups, regarding patient population, tumor types, tumor stadium,

intraoperative complications and especially permanent nerve palsy and permanent hypoparathyroidism. Conclusions: For high-volume thyroid surgeons complication rates do not differ regarding single sessions and two time sessions oncological thyroid operations. Therefor there is no reason to recommend single session oncological thyroid operations and not two time session oncological thyroid operations. [email protected]

11 Frequency of postoperative dysphagia and vocal changes after thyroid and parathyroid gland operations Andreas Hillenbrand, Gregor Cammerer, Lisa Dankesreiter, Doris Henne-Bruns Department of General and Visceral Surgery, University Hospital Ulm, Ulm, Germany Objective: Swallowing difficulties and vocal changes are one of the most frequent postoperative side effects after thyroid and parathyroid gland operations in the medium to long term. The prevalence and influence of possible risk factors were investigated in patients undergoing surgery at Ulm University Hospital. Methods: Between May 2013 and October 2014, 399 patients with thyroid and parathyroid glands were operated at Ulm University Hospital. Excluded from the evaluation were 27 patients with already preoperatively existing (n = 10) or postoperative (n = 17) temporary or permanent paralysis of the recurrent nerve, since swallow complaints and vocal changes are to be expected in these patients. Patients were questioned at least 6 months post-operatively using a questionnaire. The age, the BMI, the diagnosis, the type of operation, the size of the resected tissue, the nicotine consumption and the subjective postoperative swallowing and vocal changes were examined. Results: 222 of 372 questionnaires returned, 198 of them were complete filled. 219 sheets could be included in the evaluation. The median age of the patients was 56 years (range: 17 to 92 years), 73% were female and 26% male. Long-term postoperative dysphagia were reported by 17.6% of respondents. There was no relationship between postoperative swallowing problems with age, sex, nicotine abuse, resected tissue volume or BMI. The extent of the intervention and the diagnosis, however, had an influence on the postoperative swallowing difficulties. A third of the patients reported postoperative swallowing difficulties after lymph node dissection and 40% in Graves' disease. Vocal changes were reported postoperatively by 23% (mostly quieter or deeper voice and hoarseness). Conclusions: Postoperative dysphagia and vocal changes are frequent. Particularly after lymph node dissection and surgical treatment for Graves' disease, postoperative dysphagia occurs. [email protected]

12 Malignant metastatic insulinoma – Two long-term follow-ups Hannes Irmer, Aycan Akca, Achim A. R. Starke, Peter E. Goretzki Lukaskrankenhaus Neuss, Chirurgische Klinik I, Neuss, Germany Objective: We present two long-terms of a 53-year female Patient (P1) and a 78-year female Patient (P2) suffering from malignant hepaticmetastatic insulinoma.

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Methods: P1 (NET-TNM: pT1 pN1 (0/1) cM1 (HEP)) got operated in 1997 via Enucleation of an 15mm pancreatic corpal insulinoma. 15 y later symptomatic, multiple hepatic metastasis got diagnosed and treated via TACE/TAE (2013,14,15,16). P2 (NET-TNM: pT4 p N 1 p M 1 ( H E P ) r e c e i v e d a P P P D ( Tr a v e r s o ) i n 1 9 9 7 . Asymptomatic hepatic metastases got treated through TACE/TAE (3x 97-99; 2x 03+06). Routine checks let to the diagnosis of multiple hypervascularized, hepatic metastases via MRT in 2010. A resection was done in 11/10. P2 was asymptomatic till 2013 when phases of hypoglycaemia were detected. MRT showed progress in abdominal lymph nodal metastases. Due to patients age and general condition no surgery took place. A conservative treatment with mTOR-Inhibitor Everolimus (=AFINITOR) was started. Results: Due to primary surgery and consequent treatment of the metastases with TACE/TARP/TAE satisfactory gradients was reached in both cases. Two Pat. are presented who survived for more than 20 years after primary diagnosis. Conclusions: We suggest surgery on the tumour and trans arterial chemoembolization on the hepatic metastasis. Resection of hepatic metastasis can be an opportunity. A conservative alternative could be the AFINITOR. [email protected]

13 Constant growth of bilateral adrenal myelolipoma despite normal ACTH levels in congenital adrenal hyperplasia. A case report. Jann Tabitha1, Arampatzis Spyridon2, Worni Mathias1, Gloor Beat1, Trepp Roman3 1 University Clinic of Visceral Surgery and Medicine, Inselspital, Bern, Switzerland; 2 University Clinic of Nephrology, Inselspital, Bern, Switzerland; 3 University Clinic of Diabetology, Endocrinology, Nutritional Medicine and Metabolism, Inselspital, Bern, Switzerland Objective: Myelolipomas are circumscribed benign masses composed of mature fat and bone marrow elements. They are frequently found among patients with congenital adrenal hyperplasia due to 21-hydroxylase deficiency. Several case reports and small case series suggested that their growth is stimulated by chronic exposure to high levels of ACTH, most commonly associated with low adherence to glucocorticoid replacement therapy. Methods: We describe the clinical presentation, imaging and intraoperative findings of a patient with giant bilateral myelolipomas in congenital 21-hydroxylase deficiency. Results: The 21-hydroxylase deficiency of this 43-year-old man had been detected at birth and he was treated with hydrocortisone, prednisone and fludrocortisone ever since. As long as the patient remembers he was treated with supraphysiologic glucocorticoid doses. Accordingly, our records of the last 10 years show ACTH levels constantly within the lower reference range. Despite normal ACTH levels, the right-sided adrenal mass continuously grew from 13 cm to 26 cm in 6 years and became increasingly symptomatic. In addition, multiple lumps of identical imaging characteristic developed on his arms and thorax wall. Given abdominal discomfort and complete adrenal function loss, an interdisciplinary decision was made to resect both adrenal glands. Intraoperative findings were consistent with preoperative imaging, both sides (26 cm right-, 15 cm left side) were histologically confirmed to be myelolipomas. The patient recovered well and left hospital after 5 days. Conclusions: Growth of myelolipomas in congenital adrenal hyperplasia due to 21-hydroxylase deficiency is not necessarily mediated through chronically elevated ACTH levels, other reasons have to be considered. [email protected]

14 Intraoperative detection of parathyroid glands with near-infrared autofluorescence imaging Roland Ladurner1, Ufuk Guendogar1, Norah Al Arabi1, Herbert Stepp2, Julia K. Gallwas3. Klaus Hallfeldt1 1 Department of Surgery, Ludwig Maximilians University Munich, Innenstadt Medical Campus, Nussbaumstrasse 20, 80336, Munich, Germany; 2 Laser-Research Laboratory, LIFE-Center, Ludwig Maximilians University Munich, Grosshadern Medical Campus, Feodor-Lynen-Str. 19, 81377, Munich, Germany; 3Department of Obstetrics and Gynecology, Ludwig Maximilians University Munich, Grosshadern Medical Campus, Marchioninistr. 15, 81377, Munich, Germany Objective: The reliable identification of parathyroid glands during thyroid surgery may prevent their inadvertent surgical removal. The objective of this study was to evaluate a new technique to identify parathyroid glands by exposing their autofluorescence. Methods: Fluorescence imaging was carried out during thyroid surgery. After identification, the parathyroid glands as well as the surrounding tissue were exposed to near-infrared (NIR) light with a wavelength of 690-770 nm using a modified Karl Storz near-infrared/indocyanine green (NIR/ICG) endoscopic system. Parathyroid tissue was expected to show near-infrared autofluorescence, captured in the blue channel of the camera. Whenever possible the visual identification of parathyroid tissue was confirmed histologically. Results: In preliminary investigations, using the standard NIR/ICG endoscopic system we noticed considerable interference of light in the blue channel overlying the autofluorescence. Therefore, we had to modify the light source by interposing additional filters. Following these modifications we investigated 52 parathyroid glands from 25 patients undergoing thyroid surgery. 47 glands were identified correctly based on NIR autofluorescence. Neither adipose tissue nor lymph nodes revealed substantial autofluorescence and nor did thyroid tissue. Conclusions: Parathyroid tissue is characterized by showing a unique autofluorescence in the near-infrared spectrum. This highly sensitive, label-free effect can be used to identify and preserve parathyroid glands during thyroid surgery. [email protected]

15 Navigating through uncertainty: an illustrative case of parathyroid carcinoma and initiative for multicentre study Christina Lenschow 1, S. Schrägle1, Julia Wendler2, R. Kickuth4, C. Lapa 3 , Christoph-Thomas Germer1 , Martin Fassnacht 2 , Nicolas Schlegel1, Matthias Kroiss2 on behalf of the German study group for rare tumours of the thyroid and parathyroid glands 1 University Hospital Würzburg, Department of General, Visceral, Vascular and Pediatric Surgery; 2 University Hospital Würzburg, Department of Internal Medicine I, Division of Endocrinology and Diabetology; 3University Hospital Würzburg, Department of Nuclear Medicine; 4University Hospital Würzburg, Institute of Diagnostic and Interventional Radiology Objective: Parathyroid carcinoma (PCa) is a rare disease (0,5-1% of all parathyroid tumours) and treatment options beyond surgery are limited. We present an illustrative case of PCa with metastatic spread to an abdominal lymph node, which demonstrates the need for management in an interdisciplinary setting. The lack of expertise even in large endocrine

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centres necessitates multicentre efforts. This may improve diagnostic work-up, clinical decision making and treatment. Methods: A 45-year-old woman presented with hypercalcemia (calcium 3.4 mmol/l) and increased parathyroid hormone (PTH) levels 12 years after primary therapy (left parathyroidectomy, left hemithyroidectomy and central lymph node dissection, external beam radiation therapy (50.4 Gy)). Cervical ultrasound, [99mTc]-sestamibi SPECT (including CT) and [11C]-methionine PET/CT were inconclusive. Dissection of the medial and lateral cervical compartments did not reveal cervical tumour tissue. Treatment with cinacalcet and ibandronic acid were initiated with limited efficacy. Results: In this case, [18F]-FDG-PET/CT revealed high focal abdominal FDG-uptake corresponding to a pathologic lymph node in the hepatic hilus indicative of tumours aggressiveness. Selective venous sampling revealed highest PTH production in the hepatic vein sample. The tumour was surgically removed. Histology demonstrated a lymph node metastasis of parathyroid carcinoma. Postoperatively, calcium levels were normalized and PTH levels decreased by nearly half. Calcium was well controlled with cinacalcet. Conclusions: Diagnosis, localization, and treatment of PCa are challenging, especially in recurrent cases. To improve management of PCa patients, we propose a multicentre registry study. Time to biochemical recurrence and disease specific death will be modelled by the Kaplan-Meier method. Clinical and pathological risk factors of prognosis will be identified by Cox Proportion Hazard Modelling. A minimum of 100 PCa patients will be enrolled. Currently, 15 centres in Germany and Canada have agreed to participate. We would like to encourage additional expert centres to contribute to this study [email protected]

16 Delayed completion thyroidectomy does not affect disease specific survival in patients with differentiated thyroid cancer Christina Lenschow1, Nicolas Schlegel1, Uwe Mäder2, ChristophThomas Germer1, Christoph Reiners3, Frederik A. Verburg4 1 University of Wuerzburg, Department for General, Visceral, Vascular and Pediatric Surgery; 2CCC Mainfranken; 3University of Wuerzburg, Department of Nuclear Medicine; 4University of Marburg, Department for Nuclear Medicine Objective: In patients with differentiated thyroid cancer (DTC) late histopathological diagnosis or unilateral recurrent laryngeal nerve palsy (RLNpalsy) leads to delayed completion thyroidectomy. Due to the excellent prognosis of DTC it is widely assumed that such delay of completion thyroidectomy is not associated with adverse oncological outcome of these patients although this has hardly been addressed in previous studies. Methods: We performed a retrospective database study using the Wuerzburg thyroid cancer database. From this database we examined 2113 patients with pT1a-pT3 tumours who were operated for DTC between 1980 and 2016. Patient characteristics, registered surgical complications and the disease specific survival (DSS) were extracted from the database. Results: 1124 patients underwent a single thyroidectomy (TTx) and 989 completion TTx in a two-stage procedure. Patients with papillary thyroid cancer (n=1614) more frequently had a single operation TTx than patients with follicular thyroid cancer (n=499) patients (56.9% vs. 41.1%; p<0.001). Patients undergoing two operations significantly more frequently suffered from transient surgical complications (single vs. twostage procedure: transient hypoparathyroidism 11% vs. 13%, transient RLN-palsy 7.8% vs 10.8%; p<0.001). In univariate Kaplan-Meier analysis, patients who underwent a single operation TTx had a lower longterm survival than those undergoing two-stage procedure (30 year DSS: 92.1 ± 1.6% vs. 94.1± 2.3%; p=0.003). Multivariate Cox-regression entering known prognostically relevant variables from our collective

showed that the presence of distant metastases, T-stage and age at diagnosis were determinants for DSS, but not the number of operations independent of the time point when completion TTx was performed. Conclusions: If possible thyroidectomy in two operations should be avoided as this is associated with a higher rate of recurrent laryngeal nerve palsy and hypoparathyroidism. However, if for clinical reasons it is unavoidable to perform a thyroidectomy as a two-stage procedure, this will not negatively affect DSS. [email protected]

17 Risk factors for recurrent laryngeal nerve paralysis in endocrine neck surgery in a high volume centre Robert H. Lienenlueke, Christian Vorlaender Klinik für Endokrine Chirurgie Bürgerhospital Frankfurt am Main Objective: Permanent Recurrent Laryngeal Nerve Paralysis (RLNP) is rare in specialized endocrine surgical centres (below 1%). Nevertheless also transient RLNP can be very stressful to the patient. The aim of this study is to rule out risk factors for RLNP in a high volume centre. Methods: From January 2014 up to December 2015 2964 patients underwent surgery of the thyroid or parathyroid glands in our clinic. We retrospectively analyzed all data due to RLNP paying attention on age, sex, indication for surgery and weight of resected tissue. Results: 72 out of 2964 Patients suffered from RLNP (2,4%). No difference was found between the patients with or without RLNP according to age or sex. Median operation time was 24% longer in patients with RLNP (96 min {38-323} vs. 77 min {18-419}). Also median weight of the resected tissue was 14% heavier in patients with RLNP (24g {1-178g} vs. 21g {1-510g}. Relating to indication for surgery RLNP was more often found in patients with mechanical indication like manifestly enlarged goiters (3,1%) than in cases with suspected cancer (2,4%). Conclusions: Sex or age is no risc factor for suffering from RLNP after endocrine neck surgery. Extended time of operation does not have to be the cause of RLNP but can also be the consequence of intraoperative recognized damage of the recurrent laryngeal nerve by loss of signal in neuromonitoring. Although no significance could be detected RLNP was more frequent in patients who underwent surgery due to manifestly enlarged goiters. Continous intraoperative neuromonitoring of the vagal nerve may help to avoid RLNP in selected operations of large thyroids. [email protected]

18 Multifocal papillary thyroid microcancer mPMTC - special importance of forecast? Ellen Luyven, Katharina Schwarz, Bernhard J. Lammers, Peter E. Goretzki Lukaskrankenhaus Neuss, Chirurgische Klinik I, Klinik für Allgemein-, Viszeral-, Thorax- und Gefäßchirurgie, Neuss Objective: Multifocal papillary thyroid cancer mPTC is not unusual in the daily clinic routine also in papillary microcancer ( tumor size up to 10 mm (T1a)). We questioned, whether there is a different outcome and therapy compare to single PTMCs. Methods: We retrospectively analysed 87 patients with PTMC (2011 – 2014) and compared mPTMC (T1am) with PTMC (T1a). Than we classified

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these two groups into three subgroups (A) up to 5mm (T1a; n=41), (B) 610mm (T1a; n=29), and (C) up to 10mm with capsular infiltration (T3; n=17). Results: 0% patient in subgroup (A) and 0% in subgroup (B) showed multifocal tumor. Whereas in subgroup (C) 35% (6/17) multifocal papillary microcancer (T3m) were detected. 84% (5/6) patients were male and between 43y and 56 y. There are currently no cases of relapse within the three groups. (median follow-up: 33 months) Conclusions: Based on our results, it is perhaps possible to link microcancer mPTMC with male gender and with early capsular infiltration, but it does not demonstrate increased local recurrence. So there is no need for extensive therapy in mPTMC cases. [email protected]

19 Chemoprevention with enalapril and aspirin in Men1(+/T) knockout mouse model Jerena Manoharan1, Caroline L. Lopez1, Barbara Joos1, Pietro Di Fazio1, Ioannis Mintziras1, Annette Ramaswamy2, Emily P. Slater1, Detlef K. Bartsch1, Volker Fendrich3 1 Department of Visceral, Thoracic and Vascular Surgery, Philipps University Marburg, Marburg, Germany; 2Department of Pathology, Philipps University Marburg, Marburg, Germany; 3Clinic for Endocrine Surgery, Schoen-Klinik, Hamburg Eilbek, Hamburg Objective: Chemopreventive agents have not been evaluated for the hereditary syndrome MEN1. Evaluation of aspirin and enalapril as chemopreventive therapy options in pancreatic neuroendocrine neoplasias (pNEN) in Men1(+ /T) knockout mouse model. Methods: Men1(+/T) mice will be treated either with aspirin, enalapril or placebo as chemopreventive agents for 6,9,12,15 and 18 months. After the study period, Men1(+/T) mice will be euthanized and evaluated regarding pancreatic tumor development and progress. Pancreatic neuroendocrine neoplasia size and amount was analysed in each group in haematoxylin stained probes with a microscope. To evaluate the expression of caspase-3, Ki 67 index and VEGF of treated and non-treated Men1(+/T) mice pancreata, immunohistochemical staining was performed. Furthermore, a real-time PCR was carried out to evaluate REL A (NFKB) expression in treated and non-treated Men1(+/T) mice. Results: In total 75 Men1(+/T) mice were treated in this study either with placebo (n=25), aspirin (n=25) or enalapril (n=25). In aspirin and enalapril treated Men1(+/T) mice a significant growth reduction of pNEN was observed compared to the control group. Aspirin lead to a pNEN size reduction of 80% (838876 μm2 vs 167518,12μm2, p<0,001). A treatment with enalapril reached a tumor growth reduction of 79% (838876 vs 174758,24μm2, p < 0,00). According to the tumor size the amount of pNEN was evaluated. In treated Men1(+/T) mice with aspirin (33,4%) or enalapril (41%) a significant pNEN amount reduction was achieved. Regarding the Ki 67 index no significant difference could be obtained. Furthermore, the evaluation of the apoptosis marker caspase 3 revealed a higher positive expression in pNEN of treated Men1(+/T) mice. Immunohistostaining of VEGF in pNEN detected a lower positive staining in treated Men1(+/T) mice compared to the control group. Real time PCRs showed that REL A expression was downregulated in 18-month treated enalapril Men1(+/T) mice, but not in aspirin treated Men1(+/T) mice. Conclusions: This study could reveal a significant antiproliferative effect of enalapril and aspirin in pNENs in the Men1(+/T) knockout mouse model. Therefore, enalapril and aspirin might be useful as chemopreventive agents, which should be tested in clinical trials. [email protected]

20 Do we have to wait for the result of the intraoperative quick parathormon test in preoperative localized sporadic parathyroid adenoma? Elisabeth Maurer, Sabine Wächter, Detlef K. Bartsch Department of Visceral, Thoracic and Vascular Surgery University Hospital Giessen and Marburg GmbH, Location Marburg, Marburg Objective: Open minimally invasive parathyroidectomy (OMIP) is the procedure of choice to treat primary hyperparathyroidism (pHPT) caused by a preoperatively localized adenoma. In case of this focused approach frozen section analyses and intraoperative quick parathyroid hormone (qPTH) test confirm a successful resection. Since qPTH test is time consuming and costly, we analysed, whether it has disadvantages not to await its result before terminating the procedure. Methods: Between 2009 to 2017 415 patients underwent parathyroidectomy for sporadic pHPT. Patients with a diagnosed solitary parathyroid adenoma based on concordant positive results in 99mTc-sestamibi scintigraphy and neck ultrasound were scheduled for OMIP. In all patients frozen section and qPTH-test (base line and 15 minutes after adenoma resection) were performed, but in patients with a macroscopic clear parathyroid adenoma the result of qPTH test was not awaited before finishing surgery. Patients were informed that in case of persisting high PTH levels a reexploration has to be performed the same or next day. Results: 198 (48%) patients had solitary parathyroid adenomas based on concordant 99mTc-sestamibi scan and ultrasound results. Of those 175 patients underwent OMIP and 23 patients unilateral exploration with simultaneous thyroid resection because of ipsilateral benign goiter. 179 (90,4%) procedures were finished without waiting for the qPTH test result. The operation time was median 63 (range 16-190) minutes. In all patients the qPTH test was received after extubation and confirmed successful excision of the adenoma by a PTH drop of at least 50%. In 19 patients with a non convincing parathyroid adenoma lesion and/or no confirmation of adenoma by frozen section the qPTH result was waited for. The median operation time was significantly longer with 108 (range 65-287) minutes, the median time to receive the qPTH value was 38 (30-45) minutes. In 11 patients the operation was extended to unilateral or bilateral exploration because of inadequate qPTH drop. Overall, 1 of 198 (0,5%) patients had persistent disease after this approach that required reexploration to cure the disease. Conclusions: In patients with a preoperative concordantly localized (neck ultrasound, 99mTc-sestamibi scintigraphy) solitary parathyroid adenoma and the intraoperative identification of a convincing adenoma the result of the intraoperative qPTH test has not to be waited for. This approach is safe and spares operative time and money. [email protected]

21 Procalcitonin as a tumour marker for MTC? Julian Mittermeier, Robert Lienenlüke, Christian Vorländer Bürgerhospital Frankfurt am Main Objective: Procalcitonin (PCT) is a prepeptide of the hormone Calcitonin, which is produced in the neuroendocrine cells (c-cells) of the thyroid. Calcitonin is being used as a tumour marker for the medullary thyroid carcinoma. Procalcitonin is being used for the detection and as a marker for the seriousness of a bacterial infection. We would like to discuss the significance of procalcitonin in preoperative diagnostics for the detection of medullary thyroid carcinoma, the risk for a differential diagnosis (C-Cell-hyperplasia), and the positive prediction accuracy of

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the postoperative tumour stadium in comparison to calcitonin. Because of its significance as an infection parameter, Procalcitonin is easily available. The results will be available sooner and the costs will be lower. Methods: Retrospective comparison of inhouse patients: 39 patients with MTC vs. 29 patients with c-cell-hyperplasia with a positive procalcitonin result Results: - Cut off MTC at PCT > 0,1ng/ml - Cut off positive lymph nodes > 0,5 ng/ml (7/27, 26%); (6/7 with positive lymph nodes at PCT >5ng/ml) - With low PCT < 0,5ng/ml all MTC pT1a (12patients) - Maximal PCT for C-Cell-Hyperplasia 0,8ng/ml (27/29 patients <0,2ng/ml) PCT <0,1ng/ ml: 0(0%)MTC, 19(100%)CCH PCT 0,1-0,2ng/mll: 3(27%)MTC, 8(73%)CCH PCT 0,2-0,5ng/ml: 9(90%)MTC, 1(10%)CCH PCT >0,5ng/ml: 27(96%)MTC, 1(4%)CCH Conclusions: There was no c-cell-carcinoma without a positive test for procalcitonin. When the PCT-level lies below 0,5ng/ml, a thyroidectomy is adequate. A lymph-node-dissection is not necessary, if there is no macroscopic lymph node-metastasis. When the PCT-level lies above 0,5ng/ml a dissection of the lymph-nodes should be performed. Procalcitonin could replace Calcitonin in the diagnosis of a medullary thyroid carcinoma. A study with more patients would be necessary to confirm our results. [email protected]

22 Preclincal Fine Needle Aspiration Cytology for suspicious thyroid nodules – a critical appraisal of their clinical utility Ali Naddaf1, K. Tischler2, Constantin Smaxwil1, Andreas Zielke1 1 Endocrine Center Stuttgart, Department of Endocrine Surgery, Diakonie-Klinikum Stuttgart; 2 Section of Medical Controlling, Diakonie-Klinikum Stuttgart Objective: Although the number of thyroid surgeries is declining, a fair number is done to rule out malignant disease. In this context the usefulness of preoperative Fine Needle Aspiration Cytology (FNAC) has been challenged. Here we report the results of external FNAC for suspicious thyroid nodules. Methods: Retrospective analysis of prospectively documented data from the Thyroid Center Data Registry at the Endocrine Center, DiakonieKlinkum Stuttgart. All patients with thyroid procedures treated between 1/2013 and 6/2017 were reviewed to identify those with preoperative FNAC. Individual cases were reclassified according to Bethesda I-VI and compared to the final histopathology findings. Descriptive parameter of FNAC-utility and performance were calculated. Results: Of 5510 patients with 651 cases of thyroid cancer (11,8%), 656 had preoperative FNAC (492 external FNAC, 75%) with 189 thyroid cancer diagnoses (28,8%). FNAC was classified BI&II in 254 patients (38,7%), BIII&IV in 302 patients (46%) and BV&VI in 100 (15%). Increasing Bethesda group rank was related to increasing cancer prevalence from 13% for BI&II to 21 % for BII&IV 21% and 91% for patients with BV&VI, as well as higher TNM stages. Of all cancers in this cohort, FNAC detected 149, for an overall true positive rate of > 80%. Intraoperative frozen sections were most useful in patients for Bethesda I and II cytology, with a false negative rate of 2,5%. However, frozen sections did not add significant information in Bethesda BV&VI, due to the high cancer prevalence in this group. Conclusions: These data suggest preoperative FNAC to be useful in the evaluation of suspicious thyroid nodules, even when a majority of these FNAs are done externally. Moreover, the likelihood of a cancerous lesion of nodules with Bethesda V and VI cytology is very high, suggesting the routine use of intraoperative frozen sections to be not useful. [email protected]

23 Duodenal and ampullary neuroendocrine neoplasms Anna Nießen, Simon Schimmack, Ulf Hinz, Markus W. Büchler, Oliver Strobel Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Germany Objective: Neuroendocrine neoplasms of the gastroenteropancreatic system (GEP-NEN) are a heterogeneous entity of increasing incidence. Duodenal NEN (dNEN) are extremely rare and account for about 4% of all GEP-NEN. Clinical management of dNEN remains controversial. In this study we aimed to assess the outcome of surgical management, with a focus on small-sized and well differentiated (G1) dNEN. Methods: We conducted a retrospective study on all patients undergoing surgery for dNEN at our institution between 2002 and 2017. Clinicopathologic features, perioperative outcome and survival were analyzed. Results: A total of 27 patients were identified. Out of 25 patients presenting with their primary tumor, 22 patients (88%) underwent formal oncological resection whilst 3 patients (12%) received local resection. One (3.7%) patient presented with recurrent disease after endoscopic resection and one with diffuse metastatic disease. Surgical 90-day mortality was 1 of 27 (3.7%). The 5-year overall survival rate was 71% in the entire cohort, 74% in patients undergoing resection for primary pNEN, 79% for patients undergoing formal oncological resection, 100% after formal resection for pN0 and 73% for pN1 tumors. Out of 22 patients undergoing formal lymphadenectomy, 17 (77%) patients had lymph node metastasis (pN1). The rate of metastases correlated with the size of the tumor. Of patients presenting with tumors <1cm, 1-2cm, >2cm, 2 of 5 (40%) patients, 9 of 11 (82%) patients, and 6 of 6 (100%) patients had metastases (pN1 or pM1), respectively. Furthermore, 8 of 13 (62%) patients with G1 dNEN had lymph node metastases and 2 of 13 (15%) had liver metastases. Conclusions: Our data show that even well differentiated and small dNEN have a considerable risk of metastases. These data challenge the concept of surveillance or of local resection even for small and/or well differentiated dNEN. [email protected]

24 Correlation of perioperative biochemical variables with parathyroid adenoma weight in primary hyperparathyroidism Marios Papadakis, Theodora Margariti, Emmanouil Kotzampasakis, Frauke Schuster, Norbert Weyerbrock, Cornelia Dotzenrath Department of Endocrine Surgery, Helios University Clinic, Wuppertal, Germany. Objective: Aim of this study is to investigate the relationship between perioperative biochemical markers and parathyroid adenoma size in patients treated surgically for primary hyperparathyroidism. Methods: We retrospectively reviewed the medical records of 339 patients, who underwent surgery for primary hyperparathyroidism in our department between 2009 and 2016. Data regarding perioperative calcium, parathyroid hormone and phosphate levels, as well as adenoma weight and specimen dimensions was obtained for each patient. The Spearman's Rho correlation was applied as the data was not normally distributed. Results: Median age at presentation was 60 years. The median preoperative calcium and PTH levels were 2,83 mmol/l (range 2,3-4) and 122,3 pg/mL (range 45-2740), respectively, falling by 16,6% and 80,6% postoperatively. The median adenoma weight was 1g (range 0,1-11).

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The adenoma weight was moderately correlated with the preoperative PTH value (r=0,44, p<0,01) and highly correlated with the adenoma max. diameter (r=0,72, p<0,01). There was a weak correlation between the adenoma weight and the preoperative and postoperative changes in parathormone levels (r=0,27, p<0.01). Conclusions: Perioperative biochemical parameters do not significantly correlate with adenoma weight. [email protected]

25 A novel rapid detection system for intraoperative PTH-monitoring in pHPT: does the added cost add value to the perioperative management? Maxim Parkhach1, Verena Quantius1, Constantin Smaxwil1, Mirjam Busch1, Joachim Wagner1, Ali Naddaf1, Barbara Leitner2, Andreas Zielke1 1 Endocrine Center Stuttgart, Department of Endocrine Surgery, Diakonie-Klinikum Stuttgart; 2Outcomes Research Unit, Endocrine Center Stuttgart, Diakonie-Klinikum Stuttgart Objective: Intraoperative parathyroid hormone monitoring is standard of care in surgeries for primary hyperparathyroidism. Different technologies are available and their respective utilization of OR-time and -personnel are important variables of health care expenditure. Here we report data from a cost minimization analysis (CMA) using a novel rapid detection system when compared to the institutional standard assay. We aimed to identify the potential of this novel assay to optimize parameter of OR personnel utilization. Methods: During a prospective study (DRKS #11066) the biochemical and procedural data of 60 consecutive cases of primary HPT who underwent either focused or planned bilateral cervical exploration between 6/2016 and 6/2017 were used for time-driven cost analysis on the basis of actual capacity cost rates for personnel resource. Total (assay) turn-over-time was defined as the time needed “blood to value” in minutes. Results: Differences of assay turnover times were 32 ± 6 (range 8-76, median 28) minutes. Results from the standard assay were not available in one case, because of a KIS-failure. Capacity cost rates for OR personnel use were reduced by € 203.4 ± 7.9 per procedure using the rapid detection system. When calculating the “Best of 10” assay results, differences of turnover time were 18 ± 4 (range 8-26, median 19) minutes and differences in OR personnel capacity cost rate were € 110,8 ± 2.0 per procedure. Conclusions: Our data suggest the potential of a rapid PTH detection system to reduce OR-personnel utilization time and cost during parathyroid surgeries. Time Driven Activity Based Costing (TD-ABC) is a powerful tool to define the exact costs involved with innovative technologies and allows for rational decisions to be made. [email protected]

26 Completion thyroidectomy for recurrent goiter and risk of postoperative hypoparathyroidism Alberto Posabella, Markus Von Fluee, Beatrice Kern Department of Visceral Surgery, St. Claraspital, Basel Objective: Post-operative hypoparathyroidism is a well-recognized complication in thyroid surgery, but limited data exists about this related risk after a completion thyroidectomy procedure for recurrence goiter.

Methods: Data of patients with completion thyroidectomy between 8/2011 and 7/2016 were analyzed and the results compared to patients with primary total thyroidectomy for benign goiter. Results: 21 patients underwent a re-intervention for recurrence goiter and 156 patients a primary total thyroidectomy for benign goiter. Demographic data and time of hospitalization's stay showed no differences (p= 0.556). Operation time was 140 min in the primary operated group and 116 min in the recurrent group (p<0.01). More parathyroid glands were visualized intraoperative in the primary group (2.8 vs 1.8 p<0.01). The histopathological examination didn't show any difference in presence of parathyroid tissue on the specimen (p=0.723). Parathormon level pre- and postoperative were 45.8 pg/ml / 27.9 pg/ml in the primary group and 56 pg/ml / 40.1 pg/ml in the recurrent group (p=0.037/0.012). Calcium level 24 hours postoperative were 2.17 mmol/l and 2.16 mmol/l respectively (p=0.455). None of the 21 patients with thyroidectomy for recurrence had a hypoparathyroidism postoperative. In the primary operated group 36 patients (23%) had a PTH level below normal, and 6 patients (4%) presented with a symptomatic hypocalcemia. In the follow-up 10/36 patients are still under calcium supplementation, 17/36 could stop and 9/36 are lost to follow-up. Conclusions: A completion thyroidectomy for recurrent goiter is safe concerning parathyroid function. Our data showed no higher risk for post-operative hypoparathyroidism compared to primary total thyroidectomy. [email protected]

27 Localization of recurrence of primary hyperparathyroidism in MEN 1 – a case report Lenka Rados1, Fabian Haupt1,2, Sabine Weidner1,2, Christian A. Seiler3, Roman Trepp1 1 University Clinic of Diabetology, Endocrinology, Nutritional Medicine and Metabolism, Inselspital, Bern, Switzerland; 2 University Clinic of Nuclear Medicine, Inselspital, Bern, Switzerland; 3 University Clinic of Visceral Surgery and Medicine, Inselspital, Bern, Switzerland Objective: There are different surgical options of primary hyperparathyroidismus in multiple endocrine neoplasia Typ 1 (MEN 1), mainly subtotal parathyroidectomy (removal of three and a half glands) or total parathyroidectomy with autotransplantation. With both strategies localization of recurrent adenomas/hyperplasias can be a challenge. Results: The 45-year-old patient was diagnosed with primary hyperparathyroidism associated with MEN 1 at the age of 32 years. The same year he was diagnosed with a neuorendocrine tumor of the pancreas and a hormonal inactive pituitary microadenoma. Due to severe hypercalcemia (max. 3.4 mmol/L) and recurrent symptomatic renal stones total parathyroidectomy with autotransplantation of one and a half parathyroid glands into the left tibialis anterior muscle was performed. In the following 6 years, calcium values remained normalized and the patient was free of further renal stones. Seven years ago recurrence of hypercalcemia was found, initially mild and in the course moderate (max. 2.88 mmol/L). In addition, symptomatic renal stones started to recur 4 years ago. Ultrasound was suspicious for a parathyroid adenoma behind the right lower thyroid lobe, 99mTc-Sestamibi SPECT-CT on the other hand showed increased activity at the left tibialis anterior muscle, although without correlation in the native CT-Scan. 18F-Cholin-PET/CT suggested parathyroid glands at both mentioned sites. Therefore, we performed a simultaneous venous sampling at the left inguinal and the right brachiocephalic vein. As there was a marked difference of iPTH (498 vs 89 pg/mL)

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suggesting that mainly the autotransplanted glands in the leg are responsible for the recurrence, we abstained form additional selective venous sampling of the thyroid veins and the patient was sent to remove the autotransplanted parathyroid glands in the left tibialis anterior muscle. Conclusions: In addition to ultrasound, 99mTc-sestamibi SPECT-CT and 18F-Cholin-PET/CT, selective venous sampling can be a valuable localization tool in recurrent primary hyperparathyroidism, especially in the case of autotransplanted parathyroid glands. [email protected]

28 Thyroid cancer patient survey Germany & France 2016 - Cancer Journey and quality of life Harald Rimmele1, Beate Bartès2, Matthias Büttner3 1 Bundesverband Schilddrüsenkrebs – Ohne Schilddrüse leben e.V., Germany; 2Association Vivre sans Thyroïde, France; 3Institut für Medizinische Biometrie, Epidemiologie und Informatik (IMBEI), Universitätsklinikum Mainz, Germany Objective: In 2016, the German and the French patient organization performed a bilingual survey on the cancer journey and quality of life of thyroid cancer patients, inspired by the international patient survey done in 2010 by seven patient organizations (Hormones, Banach et al. 2013). AIM: Evaluate the impact of a thyroid cancer diagnosis on the patient’s quality of life. Identify differences between treatment protocols. Point out aspects needing improvement. Identify changes with regard to the 2010 survey. Methods: Anonymous online questionnaire with 70 questions, March to June 2016. Participants: 1,217 (85.1% women), recruited via the German and French discussion forums, newsletters and social media. 50.8% were from Germany, 31.8% from France. Results: Only 35% received clear written information on their disease and on treatment options at the time of diagnosis. 80% searched for information on the Internet. The responders indicated that the information provided by patient organizations was the most useful information found during their cancer journey. Many patients report an altered quality of life. 36.3% take dietary supplements (complementary or alternative treatments), with the main aim to relieve increased fatigue. The survey brought up a huge amount of additional results regarding the details of diagnosis, treatment and follow-up of thyroid cancer patients, pointing out various differences between the two countries: reasons for consulting, specialist in charge of the follow-up, use of fine needle aspiration. In Germany more patients had more surgeries than in France. Only 11% of the patients in Germany and Austria had their surgery in a CAEK certified clinic. [email protected]

29 Mixed exocrine-endocrine neoplasms of the pancreas Simon Schimmack1, T. Weber2, F. Bergmann3, Ulf Hinz1, Anna Nießen1, Thilo Hackert1, Makus W. Büchler1, Oliver Strobel1 1 University Hospital of General, Visceral and Transplantation Surgery, Heidelberg, Germany; 2Department of Radiology, University Heidelberg 3Institute of Pathology, University Heidelberg Objective: Mixed adeno-endocrine neoplasms (MANECs) of the pancreas are extremely rare malignancies. Only 50 MANECs have been published in the English literature, most of them as case reports focusing on

histological and immunohistochemical characterization. Here, we aimed to characterize mixed exocrine-endocrine neoplasms of the pancreas with respect to pathological and radiological features as well as the outcome after surgical resection. Methods: Our prospective database was screened for mixed exocrineendocrine neoplasms. Histological, radiological and clinical features were determined. Survival was analyzed and compared to matched pure neuroendocrine neoplasms and adeno/acinar carcinomas. Matching criteria were gender, age, grading and TNM stage. MEN1 cases were excluded. Results: Of 3034 primary pancreatic malignancies (adeno, neuroendocrine, acinar) resected between 10/2001 and 12/2015, we identified 11 (0.4%) neoplasms that were mixed exocrine-endocrine, including 5 acinarneuroendocrine and 6 adeno-neuroendocrine carcinoma. All six adeno–neuroendocrine neoplasms were G3 carcinoma but non presented with distant metastasis, while 60% of acinar-neuroendocrine neoplasms had metastasized to liver or lung at presentation. All adeno-neuroendocrine neoplasms showed radiological features of pancreatic adenocarcinoma while 60% of acinarneuroendocrine tumors exhibited mainly neuroendocrine radiologic features. 5-year survival rate in MANECs was 50.0%, in matched PDAC 37.5% and in matched pNENs 64.2%. 5-year survival was better in pure acinar carcinoma (41.5%) in comparison to acinar-neuroendocrine MANECs (20%). Conclusions: MANECs are rare and difficult to preoperatively distinguish from pure pancreatic adeno- or neuroendocrine carcinoma. Based on the presented survival of MANEC, resection is the therapy of choice. [email protected]

30 Prognostic impact of lymph node involvement in pancreatic neuroendocrine neoplasms Simon Schimmack1, D. Fliegner1, Ulf Hinz1, F. Bergmann2, Anna Nießen1, Thilo Hackert1, Markus W. Büchler1, Oliver Strobel1 1 University Hospital of General, Visceral and Transplantation Surgery, Heidelberg, Germany; 2Institute of Pathology, University Heidelberg Objective: The impact of lymph node metastasis (LNM) on survival in pancreatic neuroendocrine neoplasms (pNEN) as well as their best surgical treatment is controversial. We aimed to determine the frequency and prognostic impact of lymph node involvement in pNEN. Methods: Patients who underwent pancreatic resections for pNEN between 10/2001 and 03/2016 were identified from a prospective database. Exclusion criteria were G3, M1, non-formal resections, in-hospital mortality and missing information. Clinicopathological parameters such as TNM stage, grading and tumor size as well as overall (OS) and diseasefree survival (DFS) were analyzed. Results: Of a total of 223 patients with G1/G2 pNEN (=pNET) 73 had LNM (32.7%). LNM were more frequent in G2 (51.0%) than in G1 pNET (16.8%) (p<0.0001). In cases with at least 12 examined lymph nodes (ELN), pN0 was associated with a longer DFS (92.7% 8-year rate) compared to pN1 (51.0% 8-year rate) (p<0.0001). In patients with pNET in the pancreatic head 32 of 76 (42.1%) had LNM; significantly more frequently than patients with body and tail pNET (41 of 147; 27.9%; p<0.05). Patients with body/tail pNET showed a better OS (95.4% 8year rate) and DFS (76.9% 8-year rate) compared to head pNET (OS: 85.1%, DFS: 69.7% 8-year rate). The extent of lymph node involvement was significantly associated with DFS in body/tail pNET (0 LNM: 95% 8-year rate, 1-3 LNM: 61.4% 8-year rate, >4 LNM: 30% 8-year rate; p<0.01). LNM occurred very rarely in G1 pNET <1.8cm (3.4%), while 43.8% of G1 pNET larger than 4 cm had LNM (p<0.0001). The smallest G2 pNET (<1.8cm) already presented 27.3% LNM (p<0.001). Conclusions: The presence and extent of lymphnode involvement has considerable prognostic impact in pNET (G1/G2). Based on lymphnode

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involvement, pNET should be addressed by formal resections but enucleations may be adequate in G1 tumors below 2 (1.8) cm. [email protected]

31 Targeting hypoxia inducible Carbonic-Anhydrase-IX suppresses tumor-initiating cells in thyroid cancer Jennifer Schmidt, Elsie Oppermann, Wolf Otto Bechstein, Katharina Holzer, Patrizia Malkomes University Hospital of Frankfurt/ Main, Department for General Surgery, Frankfurt/Main Objective: Growing evidence suggests that thyroid cancer is a stem cell driven malignancy, in which tumor growth and therapy resistance is dependent on a small population of cancer cells, simplified as tumor-initiating cells (TICs). The hypoxia-inducible enzyme, Carbonic-Anhydrase-IX (CAIX) has been shown to be essential for tumor cell survival in different tumor entities. The aim of the study is to investigate the role of CAIX in thyroid TIC activity and the impact of targeting CAIX on TIC eradication. Methods: The expression of CAIX in monolayer and thyrosphere cultures was analyzed in 3 thyroid cancer cell lines (BCPAP, FTC-133, 8505C) using flow cytometry (FACS) and immunofluorescence. To investigate the role of CAIX in cancer cell proliferation and TIC activity, CAIX was inhibited using the inhibitor Methazolamide and proliferation, apoptosis as well as tumorsphere assays were performed. All experiments were additionally completed by exposing cells to hypoxia. Finally, results were validated by a genetic knockdown of CAIX using shRNAs. Results: We could detect an increased expression of CAIX in thyrospheres in comparison to monolayers in FACS and immunofluorescence, suggesting its role in the stemness ablitiy to form thyrospheres. Hypoxia led to an additional induction of CAIX expression and cell proliferation. The treatment of thyroid cancer cells with Methazolamide resulted in a strong inhibition of cell proliferation under normoxia as well as under hypoxia. Using apoptosis assay, we detected a 3-fold increase of early apoptosis rate in anaplastic thyroid cancer cells after Methazolamide treatment. An inhibition of CAIX caused a significant reduction of tumorsphere formation capacity in all cell lines. Accordingly, a genetic CAIX-knockdown resulted in a significant inhibition of cell proliferation. Conclusions: Our data revealed that CAIX is a critical mediator of cancer cell proliferation and thyroid TIC activity. Targeting CAIX represents a potential therapeutic strategy to eliminate TICs in thyroid cancer. [email protected]

32 Time course and risk factors of post-thyroidectomy vocal cord dysfunction – how long does it take the nerve to recover? Sina Schmidt1, Constantin Smaxwil1, Barbara Leitner2, K. Tischler3, Andreas Zielke1 1 Endocrine Center Stuttgart, Department of Endocrine Surgery, Diakonie Klinikum-Stuttgart; 2Endocrine Center Stuttgart, Quality Management, Diakonie Klinikum-Stuttgart; 3Departement of Controlling, Diakonie Klinikum-Stuttgart Objective: Vocal cord dysfunction (VCD) after thyroidectomy is a dreaded surgical complication. Although logopedic therapy is helpful, it is often postponed but would be initiated earlier, if the expected time until

VC-recovery could be predicted. However, such data is not available. We analyzed the time course of VCD aiming to identify risk factors for longlasting recovery. Methods: Retrospective analysis of prospectively documented data of a registry of a specialized high-volume center. Follow-up data of patients with thyroid procedures (6/2015 - 5/2016) were analyzed excluding preexisting unilateral or bilateral VCD. All patients had pre- and postoperative VC-tests by direct laryngoscopy. Patients with newly diagnosed VCD were subjected to a detailed follow-up program using structured telephone interviews to assess course of voice alteration as well as VC status. Results: 1100 thyroid surgeries (578 bilateral, 517 unilateral, 5 central thyroidectomies: 1673 NAR) were analyzed. 141 patients had cancer (12,8%), with 68 region VI lymphadenectomies (6,2%); 86 patients had Graves’ disease (7,8%), 57 recurrent goiter (5,2%). 86 patients had postsurgical VCD (5,2% NAR) and their demographic data were similar to the entire group. 64.1% had a complete recovery, 17.9% had a markedly improved VC-mobility with a fully recovered voice and 14.1% patients denied further tests because of their fully regained quality of voice. 3 patients had persistent VCD (0,18 % NAR); 6 were lost. Mean recovery time was 4.4 months. 46.2% had loss-of-signal (LOS) during surgery, but recovery times were similar to those without. Type of LOS (primary vs. secondary) had no apparent influence on recovery time, nor had the reason for surgery (recurrent goiter, Graves ’, carcinoma or lymphadenectomy). Conclusions: The majority of vocal cord palsies recovered within the first year. We were unable to reliably relate clinic-pathological parameter to duration of recovery. Therefore, early initiation of logopedic treatment for all patients with VCD may be advisable. [email protected]

33 Time course and risk factors associated with post-thyroidectomy hypoparathyroidism – how long does it take to recover? Sina Schmidt1, Constantin Smaxwil1, Barbara Leitner2, K. Tischler3, Andreas Zielke1 1 Endocrine Center Stuttgart, Department of Endocrine Surgery, Diakonie Klinikum-Stuttgart; 2Endocrine Center Stuttgart, Quality Management, Diakonie Klinikum-Stuttgart; 3Departement of Controlling, Diakonie Klinikum-Stuttgart Objective: Post-thyroidectomy hypoparathyroidism (PH) is a frequent event. Patients with severe PH benefit from early medical support. Data regarding the exact time course of PH are currently not available. Therefore, this study conducted a detailed time course analysis of treatment and biochemical recovery of PH and aimed to identify risk factors for long-lasting PH. Methods: Retrospective analysis of prospectively documented data of a registry of a specialized high-volume center. Follow-up data of all thyroid procedures (6/2015 - 5/2016, excluding simultaneous parathyroid surgery) were analyzed. Patients with biochemical parameter of PH or need for calcium-supplementation were subjected to a detailed follow-up program based on structured telephone interviews for at least one year. During the interviews medication, lab-parameters and symptoms were assessed. Results: 1100 thyroid surgeries (578 bilateral, 517 unilateral, 5 central thyroidectomies: 3346 PAR) were analyzed. 141 patients had cancer (12,8%), 68 region VI lymphadenectomies (6,2%); 86 patients had Graves’ (7,8%) and 57 recurrent goiter (5,2%). 143 patients with new calcium-supplementation were evaluated. Their demographic data were similar to the entire group. 57,3 % were symptomatic; 35.6% had a calcium lower than 2.0 mmol/l (2.0-2.75) and 76.9% had a PTH less than 15

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pg/ml (15-65). Mean recovery time of PH was 3.16 months, 6 patients (4.2% of the cohort, 0.5% of all thyroid surgeries) required calcium after 12 months. Of all intra- and postoperative parameter, only the event of lymphadenectomy and low PTH plus hypocalcaemia were associated with longer postoperative recovery. Conclusions: The most important biochemical marker of a swift recovery from PH after thyroidectomy is a PTH-level above the lower limit of norm indicating that preservation of parathyroid vitality during surgery is the single most decisive factor. This is underscored by the fact, that patients with RVI-lymphadenectomies are at a risk for long lasting PH. Surgical technique dominates all other parameter. [email protected]

34 Characteristics of loss of signal and intraoperative recovery during thyroid surgery Rick Schneider1, Kerstin Lorenz 1, Henning Dralle2 1 Department of Visceral, Vascular and Endocrine Surgery, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany; 2Department of General, Visceral and Transplantation Surgery, Section of Endocrine Surgery, University of Duisburg-Essen, Essen, Germany Objective: The characteristics of localized type 1 and global type 2 injuries to the recurrent laryngeal nerve (RLN) and the extent and dynamics of intraoperative nerve recovery are poorly understood. Methods: A prospective approach aimed at identifying risk factors for RLN injury, exploring the dynamics of loss and intraoperative recovery of electromyographic signal and its relationship to early postoperative and permanent vocal fold (VF) palsy. Results: Of 115 patients with persistent loss of signal (LOS) early VF palsy was present in 95% of patients with type 1 injury and 70% of patients with type 2 injury. Traction produced LOS type 1 in 68%, and in LOS type 2 in 92%. Permanent VF palsy rates were also lower after LOS type 2 than LOS type 1: 6.8% vs. 10.7%. Of 62 patients with LOS and intraoperative recovery of signal early VF palsy was present in 65% of patients with type 1 injury and in 26% with type 2 injury. Signal recovery <50% identified 88% of patients with LOS type 1 and 44% of patients with LOS type 2 early VF palsy rate. Signal recovery ≥50% always signified normal VF function. Conclusions: : LOS type 1 entails more severe nerve damage than LOS type 2. Both types are primarily associated with traction injury. In contrast to persistent LOS heralding VF palsy in most patients, signal recovery during surgery ≥50% of the nerve baseline amplitude always signified normal postoperative VF function, which allows moving on with completion thyroidectomy on the unaffected side. [email protected]

35 Liver resection in patients with neuroendocrine liver metastases – A propensity score matching analysis Teresa Schreckenbach1, Helga Hübert1, Jörg Bojunga2, Christine Koch2, Wolf Otto Bechstein1, Katharina Holzer1 1 University Hospital Frankfurt, Department of General and Visceral Surgery; 2University Hospital Frankfurt, Medical Clinic I Objective: Neuroendocrine tumors (NET) often develop liver metastases. Until today there is no clear evidence that liver resection is superior to

other non-operative therapies. Aim of this study was to compare patients with NET liver metastases undergoing surgery and conservative therapies or conservative treatment alone. Methods: Patients undergoing liver resection due to NET metastases between 2002 and 2014 were included in this retrospective study. Through propensity score matching 32 patients with surgery were compared to 31 patients with conservative therapy. Parameter used for matching were age, tumor grading, localization of the primary tumor, number of metastases, extra-hepatic tumor manifestations and the Charlson-Comorbidity-Index. Results: From all patients, 35 patients (55.6%) were male. 42 patients (66.7%) had synchronous metastases. 71.4% of all patients had diffused metastases. The median age of patients with liver resection was 60 years (range, 34 – 82 years), of patients undergoing conservative treatment 62 years (range, 46 – 71 years). Of the patients undergoing resection 20 patients (64.5%) had major liver resections. 6 patients (18.8%) received debulking surgery and 1 patient (3.1%) underwent liver transplantation. In 16 cases (50%) R0-resection was achieved. 56.2% of the patients undergoing liver resection had no or minor complications (ClavienDindo-Score ≤ 2). Compared with the patients in the conservative treatment group (OS, 140 months; 95% CI, 96 – 184 months) patients with liver resections (OS, 166 months; 95% CI, 117 – 214 months) showed a significant increase of overall survival (P = 0.045). Conclusions: Liver surgery results in a superior overall survival for patients with NET liver metastases. It is a safe and feasible therapy option and should be always considered in context of multimodal interdisciplinary treatment. [email protected]

36 Recurrent multinodular goiter with continuous and intermittend neuromonitoring – Comparison of two periods Katharina Schwarz, Peter E. Goretzki Lukaskrankenhaus Neuss, Chirurgische Klinik I, Klinik für Allgemein-, Viszeral-, Thorax- und Gefäßchirurgie, Neuss Objective: Surgery for recurrent multinodular goiter (rMNG) had been demonstrated with a decreased risk for permanent recurrent laryngeal nerve palsy (pRLNP) using intraoperative neuromonitoring (IONM). In this study we The question occurs, wether continuous IONM (cIONM) may be helpful to further reduce RLNP in case of recurrent goiter. Methods: We analysed our data of 415 (517 nerves at risk) patients with rMNG between 2002 – 2010 (period 1) based on intermittent IONM (Medtronic ®) and data of 169 (209 nerves at risk) patients from 2014 – 2016 (period 2) treated with cIONM (Dr. Langer ®). We always utilize vessel sealing and magnifying glasses. Results: In period 1 17 patients (3,3%) had a transient and 5 had a permanent (0,9%) RLNP. One of these patients (0,2%) with a pRLNP had a bilateral vocal cord palsy since of a preexisting pRLNP contralateral. During period 2 we saw five transient (2,4%) RLNP causal traction; identified by decreased or loss of IONM signal. Two patients (0,9%) incurred pRLNP. One patient suffered injury of a branching nerve, the second patient had a transient bilateral RLNP despite a normal signal after operation of the first side and a permanent vocal cord palsy on the second side (decreased signal). Conclusions: Further reduction of RLNP below 0,9% using cIONM could not be accomplished. Both pRLNP were shown during 2014, in 2015 and 2016 none of our patients developed a permanent vocal cord palsy. All pRLNP in period 1 + 2 were detected by IONM. [email protected]

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37 cIONM in intrathoracic goiter – its influence on decision for sternotomy Nina Sehnke, Katharina Schwarz, Peter E. Goretzki Department of Visceral and Endocrine surgery, Lukaskrankenhaus Neuss, Germany Objective: In about 1-15% of thyroidectomies goiters are located intrathoracical with higher rates of complications and a somewhat different management. In the literature sternotomy should only be performed in cases of previous cervical thyroidectomy, invasive carcinoma and truly intrathoracic location. Methods: We retrospectively analyzed 160 patients (269 nerves at risk) with thyroid surgery for intrathoracic goiter between 2001 – 06/2017. Intrathoracic goiter was defined when the retrosternal part exceeded 50% of the whole goiter. There were 83 women (52%) and 77 men (48%) with a median age of 63 years (range 34 to 98 years). 32 patients (20%) presented with a recurrent goiter. cIONM was used in 26 patients (16,2%). Results: A cervical approach was used in 126 patients (75%). 38 patients required median sternotomy and in two patients a lateral thoracotomy was performed (25%). Most recurrent intrathoracic goiters were located in the left posterior mediastinum, in our patients. In patients with intermittent IONM and transsternal approach (25/35) indication for sternotomy was defined preoperatively in 70%, because of an “endangered nerve” on the right side or a huge goiter on the left. In patients with continuous IONM sternotomy had to be performed in 19% patients, which was defined preoperatively in 1/5 already. Postoperative complications in these 160 patients were 6 transient hypocalcaemias, 10 transient and 3 permanent recurrent nerve palsies and 3 patients with collar secondary bleeding. There was no increased complication rate in recurrent, when compared to primary surgery for intrathoracic goiters. Conclusions: cIONM doesn’t reduce the rate of sternotomy actually, but it changed the operation strategy of sternotomy. It reduced the preoperative decision of sternotomy in case of intrathoracic goiter. The transsternal approach for expected nerve problems may be reduced, today, when using continuous IONM. [email protected]

38 Diagnostic assessment of dignity of thyroid nodules: the role of scintigraphy and FNAB with application of TIRADS Dietmar Simon1, P. Hetkamp2, J. Farahati1, H. Hautzel3, R. Görges2,4 1 Bethesda Duisburg; 2Univ.klinik Essen; 3Uniklinik Düsseldorf; 4Praxis Nuklearmedizin Duisburg Objective: In the past years standardized sonographic assessment of thyroid nodules has been developed (TIRADS). In Germany specific epidemiological characteristics have to be considered. Therefore a multicentric study was initiated to evaluate the significance of complementary or redundant information of scintigraphy, FNAB and ultrasound. Methods: In a prospective trial all patients with thyroid nodules >1cm were characterized by ultrasound and scintigraphy. In hypofunctional nodules FNAB was performed. The distribution of sonographic criteria according to TIRADS (Kwak 2011) was evaluated and compared with FNAB. 305 hyperfunctional and 385 hypofunctional nodules were examined, including 40 thyroid carcinomas. Results: The distribution of sonographic criteria of malignancy in hyperfunctional / hypofunctional / malignant nodules was as follows: hypoechoic 51.2/39.2/62.5%, complex echogenicity 2/17.9/22.5%, irregularity 18.4/28.6/47.5%, calcifications 39.6/26.3/35%, taller than wide

shape 11.8/12.7/22.5%. In 266 sonographically classified nodules according to TIRADS 4.6% were malignant in TIRADS 4a, 15.1% in TIRADS 4c, 100% in TIRADS 5. In hyperfunctional nodules 59.4% were TIRADS ≥4b. FNAB in 292 hypofunctional nodules showed class I in 20.8%, II in 59.6% (1 malignant), III in 16.8% (12% malignant), IV in 3% (67% malignant), 0.3 in V. Conclusions: TIRADS classification can be helpful in preselection of patients for further diagnostic or operation. The high rate of suspect TIRADS categories in hyperfunctioning nodules is remarkable. Therefore scintigraphy has to be integrated in diagnostic algorithm. This study demonstrates potential for improvement in FNAB. [email protected]

39 Navigating through uncertainty II: another illustrative case of parathyroid carcinoma and a plea to support an initiative for a multicenter study Constantin Smaxwil1, O. Ploner2, P. Aschoff3, G. Friedel4, Andreas Zielke1 (on behalf of all of the German surgeons with a special interest in surgery of the thyroid and parathyroid glands) 1 Endocrine Center Stuttgart, Department of Endocrine Surgery, Diakonie Klinikum-Stuttgart; 2 Endocrine Center Stuttgart, Division of Endocrinology and Diabetology, Diakonie Klinikum-Stuttgart; 3 Endocrine Center Stuttgart, Nuclear Medicine and PET-Institute, Diakonie Klinikum-Stuttgart; 4Center of Pneumology, Thoracic Surgery and Respiratory Medicine, Klinik Schillerhöhe, Gerlingen Objective: Parathyroid carcinoma (PCa) is an orphan disease and besides from surgery, external beam therapy and symptomatic calcinacet – options are limited. We present an illustrative case of PCa with metastatic spread to the lungs, highlighting the need for structured, long-term, mutidisciplinary and multilevel treatment. Methods: Case review of a 42-year-old patient with the clinical presentation of recurrent pHPT, following resection of a solitary parathyroid clear cell adenoma 9 years earlier. At reoperation en-bloc thyreoparathyroidektomy was performed and local lymphadenectomy. However, hypercalcaemia and hyperparathormonaemia persisted (PTH 782 vs. 885ng/ml, Calcium 2,7 vs. 3.1mmol/L). CT-scan, MIBI and FDG-PET/CT revealed bilateral metastases to the lung and pleura. The patient was placed on cinacalcet and underwent two-stage resection of pulmonary and pleural lesions (12/2012 and 01/2014), confirming metastases of PCa. Cinacalcet was discontinued after the last operation (PTH 67ng/ml, Calcium1.9mmol/L). PTH was recently determined 101 ng/ml with a serum calcium of 3.0mmol/l, prompting re-initiation of cinacalcet. CT confirmed “recurrent” bifocal lesions to the lung. Results: In this case, presence of parathyroid carcinoma, albeit inconclusive histopathology of the specimen retrieved during the second neck operation, is evidenced by presence of bilateral pulmonary metastases. Following multi-step surgical eradication of all accessible tumour, normalization of PTH and calcium levels were observed. In this case, PTH served as a sensitive tumour-marker. Conclusions: Extent of initial surgery, histopathologic confirmation and, ultimately, long term treatment of PCa remain a challenge. This case underscores the need for multiinstitutional efforts to gain more insights into the strikingly different clinical presentations, molecular genetics and to enable the development of effective antiproliferative therapies. Recently, a multicenter registry study aiming to improve diagnosis and management of PCa patients has been initiated. We would like to encourage all of the expert centers attending this meeting to consider contributing to this study. [email protected]

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40 Combined 18F-PET-CT and 4D- CT for the localization of parathyroid adenomas in complex clinical scenarios - initial results Constantin Smaxwil1, P. Aschoff2, Mirjam Busch1, Joachim Wagner1, Sina Schmidt1, S. Moritz3, O. Ploner4, Andreas Zielke1 1 Diakonie-Klinikum Stuttgart, Klinik für Endokrine Chirurgie, Endokrines Zentrum Stuttgart, Stuttgart, Germany, [email protected]; 2Diakonie-Klinikum Stuttgart, PET-CT-Zentrum des Instituts für Diagnostische und Interventionelle Radiologie, Stuttgart, Germany; 3Diakonie-Klinikum Stuttgart, Endokrines Zentrum Stuttgart, Stuttgart, Germany; 4Diakonie-Klinikum Stuttgart, Klinik für Innere Medizin, Endokrines Zentrum Stuttgart, Stuttgart, Germany. Objective: In primary hyperparathyroidism (pHPT) persistent, recurrent or multiglandular disease and ectopic parathyroid adenomas (PAs) are demanding clinical scenarios. Ultrasonography and MIBI-scintigraphy may not localize and C-11-methionine (t1/2 20min) is difficult to handle. We therefore assessed the diagnostic ability of 18F-Fluoroethylcholine(FCH)-PET-CT and fourdimensional (4D)-CT for the localization of PAs in patients with complex clinical scenarios. Methods: Six patients with pHPT (two with persistent, one with recurrent non-MEN and MEN-HPT each, one with suspicion of two adenomas including an intrathoracic site and one with biochemical findings indeterminate for HPT vs. bFHH) underwent FCH-PET-CT 60 min after administration of 250 MBq of 18F-FCH. 4D-CT was included into the examination (precontrast, post contrast arterial and venous phase, 70 ml Iopamidol 300 followed by 25 ml saline chase). Results: In all of our patients combined FCH-PET-CT and 4D-CT allowed for localization of PAs. In the two patients with persistent disease FCH-PET-CT was positive in both, whereas 4D-CT was positive in one. In the two patients with recurrent disease, two PAs were found in the MEN-case whereas in the non-MEN patient, FCH-PET-CT suggested parathyreomatosis and a mass within the sternocleidoid muscle (autotransplant). The intrathoracic adenoma was clearly visible with FCH-PET-CT, not with 4D-CT. However in this case peribronchial und infrahilar FCH-tracer-retention detected by FCH-PET-CT were confirmed lymphnodes during 4D-CT. In the patient with indeterminate laboratory findings FCH-PET-CT and 4D-CT showed a localised cervical retention suggestive of small PA. Conclusions: These initial results highlight the potential of this novel combination of diagnostic tests in complex clinical scenarios of pHPT. It appears that FCH-PET-CT is superior to 4D-CT alone. However, the combination of both achieved the highest diagnostic utility, because 4DCT allowed to rule out lesions suggested by FCH-PET. We, therefore, suggest combining FCH-PET-CT with 4D-CT for localisation of PAs in complex cases. [email protected]

41 Incomplete thermo-ablated follicular thyroid cancer requiring twostep thyroidectomy in regional anaesthesia Constantin Smaxwil1, R. Eichholz2, D. Gendig3, Andreas Zielke1 1 Endocrine Center Stuttgart, Department of Endocrine Surgery, Diakonie Klinikum-Stuttgart, Stuttgart, Germany, [email protected]; 2 medizi., Medizinisches Versorgungszentrum GbR, Haus der Gesundheit, Stuttgart, Germany; 3 Berufsgenossenschaftliche Unfallklinik Tübingen, Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, Tübingen, Germany

Objective: Surgery of thyroid nodules after locally ablative procedures such as radiofrequency (RFA) or microwave ablation (MA) can be demanding, comparable to reoperation of the thyroid gland. We present an illustrative case of incompletely ablated follicular thyroid cancer operated by two step thyroidectomy using regional anaesthesia (RA) in a patient refusing general anaesthesia due to a childhood medical trauma. Methods: Case review of a 32 year old woman with a dominant thyroid nodule. When the initially 2.5 cm nodule was first detected, it had grown in only 16 months and surgery was recommended. The patient had fine needle cytology (FNC) with an unsuspicious result, but still surgery was recommended due to positive MiBi-scintigraphy. However, the patient was unwilling to have general anaesthesia so the nodule was treated once with MA (4,1kJ) and twice with RFA (6kJ and 5,8 kJ), because the nodule had grown again in between treatments. Post-RFA-FNC revealed nonspecific granulocytic inflammation. Continuous growth of the nodule prompted reevaluation for surgery. Results: Hemithyroidectomy was performed in RA using an ultrasoundguided bilateral block of the cervical nerves pathway – a technique commonly used for carotid endarterectomies. Histology findings showed a large, widely invasive follicular thyroid carcinoma and completion thyroidectomy was performed - in RA. Both intra- and postoperative courses were unremarkable. During the procedures laryngeal nerve function was continuously assessed by encouraging the awake patient to speak (video clip). Conclusions: Complex operations using RA require excellent cooperation of anaesthesia- and surgical team. In the awake patient, vocal cord function can be checked as well as in general anaesthesia using continuous neuromonitoring. This case also exemplifies that it is of paramount importance to determine the dignity of nodules before local ablative treatment is initiated. Finally, despite all the new local ablative treatment possibilities thyroid surgery using RA should not be forgotten. [email protected]

42 A plea for focused parathyroidectomy with PTH-sampling for localized pHPT-adenomas using regional anaesthesia Constantin Smaxwil1, R. Eichholz2, Mirjam Busch1, Andreas Zielke1 Diakonie-Klinikum Stuttgart, Endokrines Zentrum Stuttgart, Klinik für Endokrine Chirurgie, Stuttgart, Germany [email protected]; 2 medizi., Medizinisches Versorgungszentrum GbR, Haus der Gesundheit, Stuttgart 1

Objective: In primary hyperparathyroidism (pHPT) the current standard to remove a localized parathyroid adenoma (PA) is focused unilateral exploration using general anaesthesia. In particular, the removal of PA in one of the lower parathyroid glands can be efficiently done in ultrasound-guided regional anaesthesia of the cervical nerves pathway (RA). In the setting of a focused approach intraoperative parathyroid hormone(PTH)-assay is mandatory, but prolongs the duration of the procedure. Methods: A retrospective analysis was made of all primary parathyroidectomies for solitary PAs without synchronous thyroidectomy, from January to June 2017. Patients with congruent localization using MiBi-scintigraphy and ultrasound were evaluated. When congruent localization suggested an adenoma of a lower parathyroid gland, the patient was offered surgery using RA. Results: During this period unilateral primary parathyroidectomy was performed in 68 patients. Congruent localization of a lower parathyroid gland adenoma was documented in 17 cases. Four patients were operated using RA, with an operating-theatre-utilization time of 58±13min vs. 94 ±24min in similar operations in general anaesthesia. During procedures in RA, patients were awake and stimulated to speak to check laryngeal nerve function, without further technical equipment. Intraoperative PTH-assay was performed in all cases. Patients operated using RA, however, did not have to wait in the operating theatre until the assay-results were available.

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Conclusions: Surgery using RA avoids risks associated with primary intubation. It requires less operating-theatre time. Patients do not have to wait for the results of the PTH-assay while intubated and the surgical team on standby. This feasibility study shows that in patients with pHPT and congruent localized adenomas of the lower parathyroid glands using RA is an attractive option and can be discussed with the patient. [email protected]

43 How to avoid postoperative hypoparathyroidism in graves’ disease – a comparison of two time periods of surgical treatment Lotte Tong, Katharina Schwarz Lukaskrankenhaus Neuss Objective: Postoperative hypoparathyroidism is the most frequent complication of thyroid surgery. Most of the literature deals with postoperative hypoparathyroidism after thyroidectomy, but there is less information on postoperative hypocalcaemia in patients with graves’ disease. Methods: We analyzed all patients retrospectively, who underwent thyroidectomy due to graves’ disease between 2011 and 2016 and compared them to data from 2002-2007. Pre- and postoperative calcium levels were routinely documented. Whereas in the earlier years there were multiple surgeons performing the thyroidectomy using vessel sealing devices even close to the parathyroid glands, this practice was altered in the later years. We especially looked at the surgical outcome in terms of postoperative hypoparathyroidism depending on gender, age, volume of the resected thyroid tissue, relative postoperative drop in parathyroid hormone and preoperative hyperthyroidism. Results: In the years 2015/16 it showed, that age did not make a difference in the postoperative calcium level (>/< 30 years). The volume of the resected thyroid did influence the outcome. Also gender and preoperative hyperthyroidism affected the likelihood of postoperative hypoparathyroidism. Orthotope autotransplantation of one parathyroid gland made no significant difference in the outcome. The dismissal of the use of vessel sealing devices close to the parathyroid glands as well as having only few expert surgeons perform the thyroidectomie have hugely improved the overall outcome. Permanent hypoparathyroidism was reduced to less than 0,5 % in 2015-16 compared 2,7 % in the early 2000s. Conclusions: Positive predictive factors for postoperative hypoparathyroidism in patients with graves’ disease include a thyroid volume of >50 ml, male gender and preoperative hyperthyroidism. However the most important factors seem to be an experienced surgeon and the avoidance of thermal damage to the parathyroid glands. [email protected]

44 18F-Choline-PET-CT has the potential to predict a parathyromatosis as cause of recurrent hyperparathyroidism Martha Trujillo1, Ole Maas2, Tilman.Drescher3, Wolfram Jochum4, Thomas Clerici1 1 K l i n i k f ü r A l l g e m e i n - , Vi s z e r a l - , E n d o k r i n - u n d Transplantationschirurgie, 2Klinik für Radiologie und Nuklearmedizin, 3 Klinik für Endokrinologie, Diabetologie, Osteologie und Stoffwechselerkrankungen, 4Institut für Pathologie, Kantonsspital St. Gallen, St. Gallen, Switzerland

Objective: Parathyromatosis is an extremely rare cause of recurrent primary hyperparathyroidism (pHPT) consisting of multiple micro- and macroscopic foci of benign autonomous parathyroid tissue. It is caused by the rupture of an adenoma during first-time surgery leading to a spread of fragmented hyperfunctioning parathyroid tissue in the surgical field. As the autonomous foci grow with time, biochemically or clinically manifest recurrent pHPT will develop. 18F-Choline PET-CT is a new imaging modality for the localization of pathological parathyroid glands in pHPT which according to preliminary reports seems to be more sensitive that the widely used (99m) Tc-sestamibi-scintigraphy Results: We report on a 70-year-old patients referred to us for reexploration in recurrent pHPT 20 years after initial surgery. According to the operating report a posteriorly descended adenoma of the superior right parathyroid had been removed without mentioning any surgical problems. In order to localize preoperatively the actual source of the parathyroid autonomy we had 18F-Choline-PET-CT performed showing a dominant focus possibly corresponding to the right inferior parathyroid gland and some more and smaller foci surrounding it. Intraoperatively we found a normal inferior parathyroid and multiple dispersed “micro-adenomas” from 0.5 to 10mm in size consistent with a parathyromatosis. The biggest “micro-adenomas” corresponded perfectly with the foci described in the 18F-Choline-PET-CT preoperatively. Conclusions: In reoperative pHPT-surgery the preoperative localisation of the pathological parathyroid gland is essential to enable a targeted surgical approach. The fact that 18F-Choline-PET-CT was even able to detect minimal amounts of autonomous parathyroid tissue in a case of a parathyromatosis confirms the most promising results of 18F-CholinePET-CT in detecting pathological parathyroid glands in recent literature and therefore should be recommended in every case of persistent or recurrent pHPT in the preoperative workup. [email protected]

45 Sexual-medicine survey on endocrine surgeons self-assessing patients‘ sexual-medical irritations / problems‘ treatment in Austria Lucia Ucsnik, Andrea Kotmel, Theresa Körbel, Thomas Dorner, Johannes Bitzer, Bela Teleky, Philipp Riss Medical University Vienna, Dpt for Visceral Surgery J. Bitzer: former Swiss University Basel, Dpt for Obstetrics and Gynaecology Objective: Endocrine surgery has an impact on the hypothalamuspituary-gonadal axis and thus on the hormone-feedback-loop relevant for sexual health and reproductive health. Therefore a survey was done on endocrine surgeons self-asessing patients‘ sexual-medical irritations / problems‘ treatment. Methods: During the Austrian Surgeons’s Congress 2017 the survey was also done in the Endocrine Surgeons‘ Sessions. The questionnaire used consits of questions diveded into three sections: the patients treated (A), the offer for treatment (B), the surgeons‘ profile (C). Results: 31 surgeons participated in the survey (return rate 25,8%) – 63% men, 13% women, 26% no information, 13% aged 40 to 50 years, 25% aged 30 to 40 as well as 50 to 60 years. 50% are surgeons for more than 20 years, 13% 5 to 10 years – 13% endocrine surgeons less than 2 years, 25% between 10 and 20 years or more than 20 years. Nobody had training in sexual medicine. 88% of the participatns asked up to 20% of the patients about their sexual-medical irritations/ problems. 25% suggested that patients have no sexual-medical irritations/ problems, 38% estimated that up to 20% of the patients and 21 to 40% have sexual health issues without adressing them. The docturs rated the reason for non-adressing: other problems more important (100%), lack of time (50%), language-barrier (34%), religion and culture (each 25%), age and inconveniant topic

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(13%). 50% of the participants recommended the patients to specialists for urology, gynaecology, psychotherapy, stoma- and continence-consultant. 25% of the doctors suggested to have been of help to 21-40% of the patients‘ sexual-medical issues. Conclusions: 20% of the patients are asked about sexual-medical irrations/problems by endocrine surgeons. At least 80% of the patients thus stay non-treated. Reasons rated for non-adressment are: other problems more important, lack of time, language-barrier. No endocrien surgeon had training in sexual medicine. [email protected]

46 High intensity focused ultrasound (HIFU) in thyroid nodules. Indication and results. Data of a prospective study in Germany Christian Vorländer, Halil Altindag, Lula Gebrehiwot, Ralf Kupper, J. Engler, Robert H. Lienenlüke Bürgerhospital Frankfurt am Main, Klinik für Endokrine Chirurgie, Frankfurt/Main Objective: To date surgery and radioiodinetherapy are the standard procedures for the definitive treatment of thyroid nodules. High-intensity focused ultrasound (HIFU) is a recently developed non-invasive technique in treating benign thyroid nodules. Ultrasound (US) is used to produce heat to the targeted tissue. In Germany so far only small study groups were analysed. Methods: The study is conducted as a prospective multi-center analysis. The study was approved by the ethics-committee, a written informed consent was acquired. Results were documented at baseline, day 1, 3 weeks and 3 months after the treatment. Results: Since July 2016 18 patients (14f/4m) median age 52yrs (26-77) were treated with HIFU using the EchoPulse®system (Theraclion SA, Malakoff, France). Indication for the treatment were an autonoumus adenoma is 6 cases and progressive nodules in 12 cases. In all patients malignancy was excluded by FNAC/MIBI-scintigraphy prior to the treatment. No vocal cord palsis were observed after the treatments. No opioids were needed in the post treatment course. The average volume reduction of the targeted nodules was 52% after 3 months. In all cases but one with hyperthyroidism a normal thyroid function was achieved. Conclusions: HIFU is promising and safe for selected patients especially with autonomous adenomas. Up to date the treatment should be carried out only under controlled trial conditions to achieve long term results. [email protected]

47 The role of MIBI scintigraphy in the work up of thyroid nodules Christian Vorländer, N. Wachsmuth, Halil Altindag., Lula Gebrehiwot, Ralf Kupper, J. Engler, Robert H. Lienenlüke Klinik für Endokrine Chirurgie, Bürgerhospital Frankfurt am Main Objective: Technetium 99m-methoxyisobutylisonitrile (MIBI) was found to be taken up by a variety of tumors including thyroid cancer. So far studies suggest that the incidence of thyroid carcinoma is up to 20% in MIBI positive nodules. Larger cohorts are not available in prospective trials.

Methods: A prospective analysis of patients with MBI positive nodules was carried out. All nodules had to be "cold" on (99m)Tc-pertechnetate scintigraphy and positive at the same location in MIBI scintigraphy („MIBI-miss-match“). All patients underwent surgery with final histology. The results in histology were correlated to the imaging results. Results: From May 2015 to April 2017a total of 123 patients with a MIBI-miss-match were included (92f/31m) within the study. The average age was 54 years (30-79). 19 cases of thyroid cancer were diagnosed, 8 cases matched correct to the targeted nodule by the MIBI-scintigraphy (6,5% of all MIBI positive nodules). 39 cases (32%) presented with a follicular adenoma. One case was diagnosed as a parathyroid adenoma. All MIBI-miss-match cases with thyroid cancer (N=8) were diagnosed as papillary thyroid cancer. Conclusions: MIBI is able to detect thyroid malignancies but in a population with nodular goiter a large variety of histologies is possible. The risk of thyroid cancer is relatively low in cases of MIBI-miss-match. According to the results of this larger series the MIBI scintigraphy it is not recommended as a routine diagnostic tool in the work up of thyroid nodules. [email protected]

48 Changing trends in surgical treatment for anaplastic thyroid cancer Sabine Wächter S.1, Christian Vorländer2, Jochen Schabram3, Ioannis Mintziras1, Detlef K. Bartsch1, Elisabeth Maurer1 1 Department of Surgery, Philipps-University of Marburg, Germany 2 Department of Surgery, Bürgerhospital Frankfurt am Main, Germany 3 Department of Surgery, Asklepios Klinik Lich, Germany Objective: Despite various attempts to modify common treatment modalities including surgery, external beam radiation (EBRT) and chemotherapy (CTX), the prognosis of anaplastic thyroid cancer (ATC) is poor and still no standardized treatment is available. This study aimed to analyse the changing trends in treatment of ATC in the last 20 years Methods: A retrospective chart analysis was conducted on 50 patients with histologically confirmed ATC who had been treated between 1994 and 2016 in 3 institutions. The outcome measures included the evaluation of clinical characteristics, operative and other managment and the overall survival (OS) based on most recent follow-up. Results: Fifty patients (23 female, 27 male) with a median age of 64 years (range 41-89)were analysed. At initial diagnosis the tumor stage was IVA in 3 patients, IVB in 21 patients and IVC in 26 patients, respectively. Overall, the 1-year OS was 100%, 43% and 12% for stage IVA, IVB and IVC (P<0,001). 44 patients underwent surgery, 6 patients underwent palliative nonoperative treatment. Of the 44 operated patients 16 patients underwent only surgery, 13 patients surgery and EBRT, 13 patients surgery, CTX and EBRT and 2 patients surgery and radioactive iodine (RAI) therapy. In addition to surgery, EBRT and CTX 5 patients also received tyrosine kinase inhibitors (TKIs) and 2 patients RAI. A multimodal treatment strategy including surgery, EBRT, CTX and TKIs was associated with a significant survival benefit compared to surgery alone (median 12 months vs. 6 months, P<0.001). We evaluated 6 patients, who were treated before the year 2000. Every patient received a thyreoidectomy including a radical neck dissection and resections of infiltrated nerves, vessels or muscles. Three sternotomies were done. Since the year 2000 instead of radical resections multimodal treatment strategies were chosen in advanced stages of disease.

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Conclusions: The treatment of ATC has changed in the last 20 years. Less radical operative resections with the addition of multimodal treatment strategies resulted in an improved OS.

50 Impact of preoperative Vitamin-D on postoperative hypocalcaemia in patients with total thyroidectomy

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49 Thyroid surgery in Graves’ disease should be center-based Corinna Wicke, Arnold Trupka Klinikum Starnberg, Endokrine Chirurgie Referenzzentrum für Schilddrüsen- und Nebenschilddrüsenchirurgie, Starnberg

Stefanie Wolak1, Mandy Scheunchen, Constantin Smaxwil2, Peter Langer 1 , Heimo Weih 3 , Inessa Ruecker 4 , Christian Vorländer 5 , Katharina Holzer6, Andreas Zielke2 1 Klinikum Hanau GmbH, 2Diakonie-Klinikum Stuttgart, 3Asklepios Klinik Seligenstadt, 4 KRH Klinikum Robert-Koch Gehrden, 5 Bürgerhospital Frankfurt am Main, 6Universitätsklinikum Frankfurt

Objective: The incidence of postoperative complications in patients with Graves’ disease is increased compared to other thyroid disease entities. Postoperative follow-up in the event of disease specific complications has been shown to be time-intensive and frequently incomplete. The objective of this study was to optimize surgical care and postoperative follow-up. Methods: We included all patients undergoing thyroid surgery for Graves’ disease in our reference center for thyroid and parathyroid surgery between July 2010 and June 2016. All procedures were exclusively performed by two high-volume surgeons. Patients were monitored prospectively for the disease specific quality control parameters (recurrent laryngeal nerve palsy, hypoparathyroidism, postoperative hemorrhage, and surgical site infection) with individualized telephone interviews by the operating surgeons and an electronically-based perioperative documentation system. Results: 314 patients were included into the prospective cohort study. The standard surgical procedure was total thyroidectomy. A two-stage procedure was necessary in 6 patients due to loss of signal during intraoperative neuromonitoring. The incidence of hemorrhage or infection requiring reoperation was 0.3% and 0.9% respectively. Histologically, 13 patients had malignant disease ranging from papillary microcarcinomas to multifocal and diffuse sclerosing manifestation with one case of concurrent lymphoma. 26 patients required postoperative follow-up. The follow-up rate was 100%. The overall incidence of permanent recurrent laryngeal nerve palsy and hypoparathyroidism was 0.3% and 0.6% respectively. Conclusions: Surgical care and postoperative management of patients’ with Graves’ disease can be further optimized in specialized centers. Lifelong and life-changing complications for the patient can be minimized. Complete follow-up allows benchmarking.

Objective: Total thyroidectomy is a standard procedure for many thyroid conditions. Postoperative hypocalcaemia is a frequent complication, affecting quality of life and hospital stay. Low vitamin D is a known risk factor, however, the utility of preoperative Vitamin-D to prevent postoperative hypocalcaemia is unclear. This study compares the clinical outcome of routine preoperative to selective postoperative Vitamin D administration in cases of total thyroidectomy Methods: During a multicenter, prospective, randomized, clinical observational trial patients scheduled for total thyroidectomy received Calcitriol 2x0.5μg for 3 days prior to surgery (interventional group), while the control group did not. The primary endpoint, i.e. the number of patients with postoperative hypocalcaemia, was defined as serum-calcium <2.1 mmol/l on any day of the postoperative course prior to discharge. Patients were followed to address secondary endpoints, such as number of days in hospital, duration of postoperative hypocalcaemia and quality of life. Results: Between July 2014 and October 2016 6 study sites recruited 287 patients; 246 were included into final analysis. Pooled postoperative hypocalcaemia rates were not different between groups (29.2% i n t e r v e n t i o n v s . 3 3 . 6 % c o n t r o l g r o u p , C h i -s q u a r e t es t ) . Hypocalcaemia rates of individual study sites varied greatly: average 31.3%, range 16% - 64%. Duration of postoperative hypocalcaemia was significantly shorter in the intervention group: 5.4 versus 9.7 days for controls (p<0.02, Wilcoxon-Mann-Whitney-U-Test). The average number needed to treat to achieve normocalcaemia during the third postoperative day was calculated with 12.5 and as low as 3.0 for study sites with higher hypocalcaemia rates. Conclusions: Routine Calcitriol prior to thyroidectomy does not affect overall hypocalcaemia rates, but significantly reduces its duration. Hypocalcemia rates varied greatly between study sites, highlighting the impact of surgical technique. Study sites with higher hypocalcaemia rates may benefit from the effect of faster calcium convalescence.

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Index of Authors Agha A. 1, 9 Akca A. 2, 12 Albers M. B. 3 Alesina P. F. 4 Altindag H. 46, 47 Arampatzis S. 13 Aschoff P. 39, 40 Bartsch D. K. 3, 19, 20, 48 Bechstein W.-O. 31, 35 Bergmann F. 29, 30 Besmens M. 5 Bitzer J. 45 Bojunga J. 35 Bollmann C. 3 Brammen L. 6, 7 Büchler M. W. 23, 29, 30 Burger F. 8 Busch M. 25, 40, 42 Cammerer G. 11 Clerici T. 44 Dankesreiter L. 11 Di Cerbo F. 9 Di Fazio P. 19 Dorner T. 45 Dotzenrath C. 24 Dralle H. 34 Drescher T. 44 Eder F. 1 Eichholz R. 41, 42 Engler J. 46, 47 Farahati J. 38 Fassnacht M. 15 Fendrich V. 19 Fliegner D. 30 Friedel G. 39 Gebrehiwot L. 46, 47 Gendig D. 41 Germer C.-T. 15, 16 Girlich C. 1 Gloor B. 13 Goebel M. 10 Goretzki P. E. 2, 5, 12, 18, 36, 37 Görges R. 38 Hackert T. 29, 30 Haupt F. 27 Hautzel H. 38 Henne-Bruns D. 11 Hetkamp P. 38

Hillenbrand A. 11 Hinrichs J. 4 Hinz U. 23, 29, 30 Holzer K. 31, 35, 50 Hornung M. 9 Iesalnieks I. 9 Irmer H. 12 Jann T. 13 Joos B. 19 Jung E.-M. 1 Karrasch T. 1 Kern B. 26 Kickuth R. 15 Konschake M. 8 Körbel T. 45 Kotmel A. 45 Kroiß M. 15 Kupper R. 46, 47 Ladurner R. 14 Lammers B. J. 5, 18 Langer P. 50 Lapa C. 15 Leitner B. 25, 32, 33 Lenschow C. 15, 16 Lienenlüke R. H. 17, 21, 46, 47 López-López C. 19 Lorenz K. 34 Luyven E. 18 Mäder U. 16 Mamilos A. 9 Manoharan J. 3, 19 Margariti T. 24 Maurer E. 20, 48 Meier B. 4 Mintziras I. 19, 48 Mittermeier J. 21 Mohmand W. 4 Moritz S. 40 Moser C. 1 Naddaf A. 22, 25 Nießen A. 23, 29, 30 Papadakis M. 24 Parkhach M. 25 Ploner O. 39, 40 Posabella A. 26 Prommegger R. 8 Quantius V. 25 Rados L. 27 Ramaswamy A. 19

Reiners C. 16 Rimmele H. 28 Riss P. 6, 7, 45 Rücker I. 50 Schabram J. 48 Scherer M. N. 1 Scheuba C. 6, 7 Schimmack S. 23, 29, 30 Schlegel N. 15, 16 Schlitt H. J. 1 Schmidt J. 31 Schmidt S. 32, 33, 40 Schneider R. 34 Schrägle S. 15 Schreckenbach T. 35 Schuster F. 24 Schwarz K. 5, 18, 36, 37, 43 Sehnke N. 5, 37 Seiler C. A. 27 Selberherr A. 6, 7 Simon D. 38 Slater E. P. 19 Smaxwil C. 22, 25, 32, 33, 39, 40, 41, 42 Sohn M. 9 Starke A. A. R. 12 Strobel O. 23, 29, 30 Teleky B. 45 Tischler K. 22, 32, 33 Tong L. 43 Trepp R. 13, 27 Trujillo M. 44 Trupka A. W. 49 Ucsnik, MAS, L. 45 Verburg F. A. 16 Vorländer C. 17, 21, 46, 47, 48, 50 Wachsmuth N. 47 Wächter S. 20, 48 Wagner J. 25, 40 Weber T. 29 Weidner S. 27 Weih H. 50 Wendler J. 15 Weyerbrock N. 24 Wicke C. 49 Wolak S. 50 Worni M. 13 Zielke A. 22, 25, 32, 33, 39, 40, 41, 42, 50 Zieren H. U. 10