Langenbecks Arch Surg DOI 10.1007/s00423-017-1566-9

ABSTRACTS

7th Symposium of the European Society of Endocrine Surgeons: Surgery for Subclinical Endocrine Disease

# Springer-Verlag Berlin Heidelberg 2017

April 6-8 2017, Oxford, UK

ESES 2017 - ORAL PRESENTATIONS

www.eses17.com

OC 01

Local Organising Committee:

Normocalcaemic Primary Hyperparathyroidism – a asymptomatic and mild disease? A Zahn, E Luu, J Kußmann 1Endocrine Surgery, SchoenKliniken.de, Hamburg, Germany

Radu Mihai, MD - Consultant Surgeon, Oxford University Hospitals NHS Trust | Honorary Clinical Senior Lecturer, Nuffield Department of Surgery, University of Oxford Greg Sadler, MD - Consultant Endocrine Surgeon, Oxford University Hospitals NHS Trust Isabel Quiroga, MD - Consultant Surgeon, Oxford University Hospitals NHS Trust David Scott-Coombes, MD - Consultant Endocrine Surgeon, University Hospital of Wales, Cardiff Congress Venue: The Mathematical Insititute University of Oxford Andrew Wiles Building Radcliffe Observatory Quarter Woodstock Road Oxford OX2 6GG

Introduction. Due to wider osteometabolic evaluation of patients in specialized centers the diagnosis of normocalcaemic primary hyperparathyroidism (NCHPT) is increasing. This study addresses the question ‘Do patients with NCHPT develop PHPT specific symptoms?’ Material and Methods. A retrospective review of our parathyroid database (2007-2016) identified 1417 patients with PHPT who underwent parathyroidectomy. Patients with secondary causes of hyperparathyroidism were excluded. Results. 81 patients presented normal serum calcium levels 2 weeks prior operation (range 2.14 – 2.58 mmol/l, PTH > 65 pg/ml). In 48 patients the serum and ionized calcium level was normal over the entire course of monitoring prior operation (NCHPT-Group I). In 26 patients the serum calcium or the ionized calcium level was at least one time elevated (NCHPT-Group II). 48 patients with “classic hypercalcemic PHPT” were enrolled for comparison (Group III).

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The median preoperative serum calcium level was lower in group I and II (I: 2.5 mmol/l, II 2.5 mmol/l, III: 2.8 mmol/l). Patients in group I and II presented similar symptoms as the hypercalcemic PHPT patients in Group III (kidney stones: 28% vs. 27% vs. 21%, osteoporosis: 36% vs. 19% vs. 29%, bone pain: 52% vs. 69% vs. 63%). Multi-gland disease seemed to occur more frequent in group I and II compared to the classic PHPT patients (15% and 12% vs. 6%). Conclusion: In our review NCHPT patients appear with similar symptoms as “classic” symptomatic PHPT patients. Parathyroidectomy can be indicated. The additional measurement of ionized calcium can discover NCHPT-patients who are not “truly” normocalcemic per definition.

OC 02 Mild primary hyperparathyroidism is overlooked and suboptimally handled J Enell1, J Hennings1, E Lundgren2 1Department of Surgical and Perioperative Sciences, Umeå University, Umeå, Sweden 2 Department of Surgical Sciences, Uppsala University, Uppsala, Sweden Background. Primary hyperparathyroidism (pHPT) is a common endocrine disease. There is a difference between the reported prevalence of the disease and the number of patients being evaluated at specialist clinics. Furthermore, there are no uniform Swedish guidelines for how to investigate and evaluate patients with mild pHPT. Allegedly many unidentified patients with biochemically determined mild pHPT are not properly evaluated. Method. Some 365 patients with a biochemical profile compatible with pHPT were identified by the laboratory results at the Department of Clinical Chemistry at Östersund’s Hospital, Sweden. All patients included met preset biochemical criteria for pHPT. 16 patients were excluded because of inaccessible medical files. The remaining patients’ medical files were scrutinized. Patients with other conditions responsible of the abnormal laboratory results were excluded: secondary hyperparathyroidism (sHPT, n=72), suspected familiar hypocalciuric hypercalcemia (FHH, n=3), previously recognized pHPT (n=13) patients being on the waiting list for bariatric surgery (n=11) or had previously undergone bariatric surgery (n=45) and other causes (n=3). Children aged less than 15 years (n=3) were also excluded from analysis Results. Of 199 included patients, 92 were referred to a specialist clinic. In 25 cases further investigation had been refrained because of severe comorbidity. Eighty-two patients with probable pHPT, whom had not been evaluated at a

specialist clinic, were identified. In this group the median age was 64 years and 80% were female. Median albumin corrected calcium was 2.54 mmol/L and PTH was 5.7 mmol/L. Eleven patients were diagnosed with pHPT in primary care, but symptoms and signs were not evaluated thoroughly. Conclusion. A large portion of patients presenting with biochemical mild pHPT are not evaluated properly. This is not in line with current research.

OC 03 Is parathyroidectomy safe and effective in patients with normocalcemic primary hyperparathyroidism? E Traini1, 2, M Raffaelli1, 2, V Caruso1, 2, S Rossi1, 2, C De Crea1, 2, CP Lombardi1, 2, R Bellantone1, 2 1 Istituto di Semeiotica Chirurgica, Università Cattolica del S. Cuore, Rome, Italy; 2 U.O. di Chirurgia Endocrina e Metabolica, Fodazione Policlinico Universitario A. Gemelli, Rome, Italy Introduction. Indications and advantages of parathyroidectomy in patients with normocalcaemic primary hyperparathyroidism (N-PHPT) are still matter of debate. We aimed to verify and compare clinical presentation and surgical outcomes between normocalcaemic and hypercalcaemic forms in our series of patients who underwent parathyroidectomy for primary hyperparathyroidism. Material and Methods. Clinical presentation and surgical outcomes of 760 consecutive patients were reviewed. Among them we retrospectively compared data of 183 normocalcemic (group A) and 577 hypercalcemic (group B) patients. Results. Sixty-four patients in group A (35%) and 256 in group B (48%) were symptomatic. No significant differences were found between the 2 groups concerning age, gender, vitamin D levels. Mean preoperative PTH levels were significantly higher in group B (252±320 pg/ml Vs 196±303; p<0.05). On the contrary mean PTH levels in the first postoperative day was significantly lower in group B (30.25±26.51 Vs 22.73±20.71, p<0.001). No significant difference in overall accuracy of sestaMIBI scan was found. US scan failed in detecting diseased glands in significantly more patients in group A (69 vs. 144; p<0.001). Significantly more patients in group A underwent bilateral explorations (113 vs. 255; p<0.001), despite the rate of multiglandular disease was similar between the 2 groups (2% vs. 4%, P=NS). At a mean follow-up period of 71±48 months all but one patient, among the 96 of group A who completed follow-up evaluation, were biochemically cured. The remaining patient had a permanent

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hypoparathyroidism. Among N-PHPT patients who had target organ disease before parathyroidectomy, improvement in bone density and in kidney stones was observed in 72% and 54%, respectively. Conclusion: In normocalcemic patients parathyroidectomy is as safe and effective as in case of the hypercalcemic patients. Among N-PHPT patients with symptomatic onset parathyroidectomy is associated with a significant improvement in bone and kidney manifestations of the disease.

OC 04 Quality of life and non-specific symptoms in normocalcemic primary hyperparathyroidism. Is surgery a ef f e c ti v e a s i n h y p erca l c e mi c m i ld p r im a r y hyperparathyroidism? S Bannani1, C Blanchard1, N Christou2, C Guerin3, A Hamy4, D Drui5, F Sebag3, M Mathonnet2, P Guillot6, C Caillard1, JB Hardouin7, E Mirallie1 1 Clinique de Chirurgie digestive et endocrinienne (CCDE), CHU Nantes, Hôtel Dieu, 44093 Nantes Cedex 1, Nantes, France; 2Chirurgie digestive, générale et endocrinienne, 8CHU de Limoges - Hôpital Dupuytren, Limoges, France; 3 AP-HM - Hôpital de La Conception, Chirurgie Générale, Hôpital La Conception, Marseille, France; 4Chirurgie digestive et endocrinienne, CHU Angers,, Angers, France; 5Service d'Endocrinologie, Hôpital Laënnec, CHU Nantes, Nantes, France; 6Service de Rhumatologie, CHU Nantes, Hôtel Dieu, Nantes, France; 77Plateforme de Biométrie, EA 4275SPHERE, CHU Nantes, Nantes, France Introduction. Normocalcemic primary hyperparathyroidism (NC-pHPT) is a clinical identity increasingly diagnosed among patients with mild pHPT. Mild pHPT patients are defined by a blood calcium level ≤2.85 mmol/L. The aim of this study was to describe quality of life and non-specific symptoms before and after surgery in patients with NC-pHPT compared to hypercalcemic mild pHPT (HC-m-pHPT) patients. Material and Methods. A prospective study, evaluating quality of life (SF-36) and 26 non-specific symptoms (autoquestionnaires) before and after surgery for mild pHPT, was conducted in four University Hospitals (Clinical Trial: NCT01776502). Results. 116 patients were included. Median age was 68 years (51-87). There were 90 females (77.6%). Median blood calcium level was 2.67mmol/L (2.50-2.85). There were 29 NCpHPT patients, median age was 69.6 years, 69% were females and the median blood calcium level was 2.52mmol/L (2.452.59). The 87 HC-m-pHPT patients had a median age of 67.8

years (80% females) with a median blood calcium level of 2.72mmol/L (2.60-2.85). Only calcium levels were statistically different (p<0.001). Preoperatively, the mental component summary (MCS) and the physical component summary (PCS) of SF-36 were 38.7/100 and 39.5/100 respectively. In NCpHPT patients, MCS and PCS were respectively 38.1/100 and 38.0/100. In HC-m-pHPT patients, MCS and PCS were 39.0/100 and 40.2/100. There were no differences between groups. One year after surgery, biochemical cure rate was 98%. Median blood calcium level of the whole population was 2.37mmol/L (2.00-2.95); NC-pHPT patients at 2.35mmol/L (2.16-2.53) and HC-m-pHPT at 2.40mmol/L (2.00-2.95). The difference was significant in both groups (p<0.001). MCS and PCS for the whole population were 41.3/100 and 42.0/100 respectively. Compared to preoperative scores, the difference was significant (p= 0.004 for PCS, p=0.036 for MCS). In NC-pHPT patients, MCS and PCS were 39.3/100 (p=0.58) and 39.3/100 (p=0.045). In HC-m-pHPT patients, MCS and PCS were 42.0/100 (p=0.043) and 43.1/100 (p=0.025). In NC-pHPT patients, 2 non-specific symptoms (fatigue and thirst) significantly improved versus 11 in HCm-pHPT patients. Conclusion Quality of life and frequency of non-specific symptoms are moderately improved postoperatively in NCpHPT patients.

OC 05 C l i n i c a l a n d p a t h o ge n e t i c v a r i e t y of p r i m a r y hyperaldosteronism from the large consecutive institutional series of patients SM Cherenko, OS Larin, LV Shchekaturova, OE Tretiak, OA Tovkai 1 Ukrainian Scientific and Practical Center for Endocrine Surgery, Kyiv, Ukraine Introduction. Study of structure of whole cohort of patients with primary hyperaldosteronism (PHA) has a particular interest concerning the shifting paradigm in understanding the pathogenesis of disease. Last two decades demonstrated not only high rate of PHA among hypertensive patients but also prevalence of non-tumorous adrenal lesions causing aldosterone hypersecretion. The aim of study was to investigate the spectrum of various pathogenetic forms of PHA on the clinical database of national referral endocrine hospital within the period of 1996-2014 years. Material and methods: Results of management of 474 patients, who underwent surgical and therapeutic treatment,

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were retrospectively studied. Patients were predominantly referred to hospital due to suspicious signs of endocrine hypertension or incidentally discovered adrenal mass. All patients were investigated by screening of serum potassium, aldosterone-renin ratio, confirmation tests, multi-spiral computed tomography. Selective adrenal vein sampling for aldosterone/cortisol ratio was performed in 63 cases. Patients with proven or suspected lateralized disease without contraindications for surgery have been directed to adrenalectomy. Results: Analysis of PHA structure demonstrated the following distribution of different forms: idiopathic (bilateral) adrenal hyperplasia – 235 (49.6%), aldosterone-producing adenoma – 195 (41.1%), primary (unilateral) adrenal hyperplasia – 21 (4.4%), asymmetrical adrenal hyperplasia with simultaneous aldosterone and cortisol secretion (mostly resulted in subclinical Cushing syndrome) due to adrenocorticotropin-independent macronodular adrenal hyperplasia (AIMAH) – 15 (3.2%), familial forms of PHA – 6 (1.3%), incl. glucocorticoidremediable aldosteronism in 4, adrenocortical carcinoma – 2 (0.4%) cases. 255 patients underwent surgery by unilateral laparoscopic adrenalectomy. Among 219 patients from the group of conservative treatment of PHA glucocorticoid-remediable aldosteronism (GRA) was suspected in 22 patients and have been confirmed by ex-uvantibus treatment with dexamethasone in 4 patients. The rest of patients received continuous treatment by antagonists of mineralocorticoid receptors as well as 22 patients from surgical group, which demonstrates persistence of PHA after unilateral adrenalectomy (with probably idiopathic bilateral adrenal hyperplasia). Conclusion: The analysis of pathogenetic structure of PHA has demonstrated variability of disease with predomination of idiopathic bilateral adrenal hyperplasia and gradually decreasing share of aldosterone-producing adenoma. Right diagnosis of distinct form of primary hyperaldosteronism allows choosing adequate mode of treatment.

OC 06 Primary Hyperaldosteronism: Non-Invasive Lateralization Studies And Outcome Of Endoscopic Adrenalectomy S Ronti1,2, M Raffaelli1,2, G D'Amato1,2, P Gallucci1,2, C De Crea1,2, CP Lombardi1,2, R Bellantone1,2 1 Istituto di Semeiotica Chirurgica, Università Cattolica del Sacro Cuore, Rome, Italy; 2U.O. Chirurgia Endocrina e Metabolica, Fondazione Policlinico Universitario A. Gemelli, Rome, Italy Introduction: Current guidelines define adrenal venous sampling (AVS) as the gold standard in differentiating unilateral

and bilateral forms of primary hyperaldosteronism (PH). This study evaluates the role of non-invasive imaging techniques in the selection of unilateral disease and the surgical outcome of endoscopic adrenalectomy (EA). Material and Methods: The medical records of all the patients who underwent endoscopic adrenalectomy (transperitoneal lateral laparoscopic, posterior retroperitoneoscopic or robotassisted adrenalectomy) for PH were reviewed. Follow-up was obtained by phone contacts or outpatients consultations. Results: Fifty-eight patients successfully underwent EA for PH. All of them underwent preoperative computer tomography and/or magnetic resonance imaging. In 28 cases dexamethasone suppression adrenal cortical scintiscan was performed. AVS was performed in two cases (3.4%). Pathological report showed an aldosterone-producing adenoma in 57 patients (98.3%) and unilateral micronodular hyperplasia in one case (1.7%). The pathological mean tumor size was 22.9±11.3 mm (range: 8-60). Follow-up was completed in 47 patients (81%). The mean follow-up time was 106.0±45.3 months (range: 12202). All but one patient were biochemically cured: the only recurrence (2.1%) occurred in a patient who developed a contralateral aldosterone-producing adenoma. Twenty-nine patients (61.7%) had complete resolution (CR) of hypertension normal blood pressure without pharmacological treatment. Seventeen patients (36.2%) had incomplete resolution (IR) normal blood pressure under treatment. However, 87.2% of patients reduced the number of anti-hypertensive drugs. At univariate analysis no significant differences were found between CR and IR patients, even if the IR group was found to be older, to have a longer story of hypertension and to take a higher number of anti-hypertensive drugs preoperatively, whilst females were prevalent in the CR group. Conclusion: In our experience non-invasive lateralization studies were able to select patients with unilateral hypersecretion in most of the cases. In order to avoid worthless complications, AVS might be used selectively. In the present series, male gender, older age and severe long dated hypertension were risk factors for persistent hypertension.

OC 07 Comparison of clinical presentation in patients with nonfunctioning adrenal tumours and patients with subclinical and clinical hypercortisolism AOJ Bergenfelz1, M Barczyński2, L Brunaud3, T Clerici4, M Iacobone5, Ö Makay6, T Musholt7, F Palazzo8, S Slycke9, J Villar del Moral10, P Riss11, MR Vriens12 1 Surgery, Skåne University Hospital, Lund, Sweden; 2 Surgery, Szpital Miejski Specjalistyczny im. Gabriela

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Narutowicza, Krakow, Polen; 3Surgery, CHU, Nancy, France; 4 Surgery, Kantonsspital, St. Gallen, Switzerland; 5Surgery, Azienda Ospedaliera, Padua, Italy; 6Surgery, Ege University Hospital, Izmir, Turkey; 7 Surgery, Universitätsmedizin Mainz, Mainz, Germany Background. Adrenal incidentalomas are common, and hypercortisolism is therefore diagnosed more frequently, most often as subclinical disease. The difference between clinical and subclinical disease is sometimes subtle, and the association between these two disease entities and non-functioning adrenal tumours is unclear. Methods. EUROCRINE is a pan European database for endocrine surgical procedures launched in 2015. Surgery for adrenal tumours is one of the entities that is registered. Age, sex, weight, systolic and diastolic blood pressure, medical treatment of hypertension, diabetes, osteoporosis, medical treatment for hypercortisolism, side of adrenal tumour, type of detection (adrenal related symptoms or incidental), size of tumour, type of operation, and postoperative adrenal insufficiency are, among other variables, registered. Results. There were 494 adrenalectomies (287 women, 58.1 per cent) registered as of November 15, 2017. The median age of the patients was 58 years, and the median tumour size 35 mm. Some 191 patients (38.7 per cent) were operated due to non-functioning tumour, 68 (13.7 per cent) patients were operated due to Cushing´s syndrome and 13 patients (2.6 per cent) due to subclinical hypercortisolism. There were differences between the three groups in age, sex, and medically treated hypertension, diabetes, and osteoporosis, side of tumour, tumour size and treatment for postoperative adrenal insufficiency. However, there was no difference in preoperatively measured blood pressure and weight of the patients between the three groups. Patients with Cushing´s syndrome and subclinical hypercortisolism differed in age (median 53 versus median 65 years, p=0.01), type of detection (incidental, 23 of 68 versus 10 of 13, p<0.01), the rate of osteoporosis (49 of 68 versus 0 of 13, p=0.032), whereas tumour size reached borderline significance (median 30 mm vs 45 mm, p=0.052). Sex, hypertension, diabetes, blood pressure, weight, side of tumour and postoperative adrenal insufficiency did not differ between the two groups.

OC 08 A Series of Patients with Subclinical Cushing’s Syndrome Undergoing Adrenalectomy AN Di Marco 1,2 , Y Grant 1,2 , P Bhatt 3 , A Sam 4,5 , FF Palazzo1,2 1 Department of Surgery, Imperial College, London, UK; 2 Department of Endocrine Surgery, Imperial College Healthare NHS Trust, London, UK; 3School of Medicine, I m p e r i a l C o l l e g e, L o n d o n , U K ; 4 D ep a r t m e n t o f Endocrinology, Imperial College Healthcare NHS Trust, London, UK; 5Department of Medicine, Imperial College, London, UK Introduction: There is debate regarding the optimum management of autonomous hypercortisolaemia without overt clinical signs of Cushing’s (‘Subclinical Cushing’s Syndrome’, SCS). SCS is present in approximately 20% of adrenal incidentalomas. Biochemical and clinical severity range from mild dysregulation of the diurnal cortisol axis to secretion significant enough to cause contralateral adrenal suppression. SCS may be the sole hormonal hypersecretion or a secondary feature in another adrenal syndrome: an under-reported phenomenon in patients undergoing adrenalectomy, which places them at risk of hypo-adrenal crisis. Methods: A retrospective analysis of 124 adrenalectomies performed between January 2013 and November 2016 was undertaken. Patients undergoing surgery for other reasons but with concomitant SCS were identified (using LDDST, ONDST) and records interrogated for demographic, clinical, biochemical, operative and outcome data.

Conclusion. Although patients with Cushing´s syndrome and subclinical hypercortisolism did not differ in sex, and the rate of diabetes and hypertension, the difference in age, tumour size and the rate of osteoporosis suggest different disease aetiologies.

Results: 21 patients (17%) (12F:9M, median age 51 years) had SCS alone (n=4) or co-secreted (n=17). 15 patients had diabetes and/or hypertension. The indication for surgery was Conn’s, phaeochromocytoma, malignancy (known or suspected) or SCS in 4, 7, 6 and 4 cases, respectively. Median tumour size was 50mm (range 15-130 mm). 14 procedures were completed laparoscopically (11 transperitoneal: 3 retroperitoneoscopic) and 7 open (including 3 conversions). 9am cortisol was checked on postoperative day 1 in 11 patients (median 34nmol/l) and SST in 2 with suspected mild disease (both passed). Median length of stay was 1 day (range 1-7 days). All patients bar those who passed SST were discharged on a reducing dose of oral steroids, continued until subsequent SST: 10 more demonstrated adrenal recovery, data was missing on 3 discharged to local follow-up, 6 remained on steroids: 4 beyond a year and 2 not yet at 1 year. Improvement in comorbidities was seen in 11 patients (52%).

Acknowledgement: Eurocrine clinics listed at www.eurocrine. eu. Supported by the Health Programme of the EU

Conclusion: The incidence of contralateral adrenal suppression in 90% of those with co-existent SCS (17% of adrenal

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tumours) underlines that despite the syndrome being ‘subclinical’ pre-operatively, it exerts important clinical effects following adrenalectomy with the risk of hypoadrenalism. This would support mandatory routine assessment of cortisol production, if not pre, then certainly post adrenalectomy. Longterm recovery of adrenal function and improvement in sequelae of SCS may be expected in over half of patients.

OC 09 Posterior retroperitoneoscopic adrenal surgery for clinical and subclinical Cushing's syndrome in patients with bilateral adrenal disease B Seeliger, AJ Lowery, PF Alesina, MK Walz 1 Klinik für Chirurgie und Zentrum für Minimal Invasive Chirurgie, Kliniken Essen-Mitte, Essen, Germany Introduction. The treatment of hypercortisolism for patients with bilateral adrenal disease (BAD) is controversial. Bilateral total adrenalectomy results in permanent hypocortisolaemia requiring lifelong steroid replacement. Less than total adrenal resection represents an alternative option however long-term outcome or recurrence data are limited. We report our experience with the surgical management of hypercortisolism caused by BAD. Methods. Between 2004 and 2016, 42 patients (12 male, 30 female; mean age 58 +/- 10 years) with clinical (CS) and subclinical (sCS) Cushing's syndrome caused by BAD underwent adrenal surgery via the posterior retroperitoneoscopic approach. Clinical, radiological and biochemical parameters were evaluated pre- and post-operatively. Results. 70 adrenal operations performed in total included unilateral resection (n=3), unilateral adrenalectomy (n=15), bilateral resection (n=9), adrenalectomy and contralateral resection (n=14), bilateral total adrenalectomy (n=3). Median operating time was 47.5 min (30 - 150) with no difference between unilateral and bilateral (synchronous included) procedures (p=0.15). Mortality was zero. Clavien-Dindo grade of post-operative complications was: I (n=5), IV (n=3). All but one patient with CS and 17/31 patients with sCS received postoperative steroid supplementation for a median duration of 20 (1.5 – 129) months. After median follow-up of 40 months (3-129) the cure rate was 93%; 11 patients required ongoing steroid supplementation. There were 3 biochemical recurrences (two underwent contralateral resection), 2 patients with new/progressive radiological nodularity are biochemically eucortisolaemic. A significant reduction in BMI (p=0.01) and anti-hypertensive requirements (p=0.04) was observed post-operatively.

Results. The optimal management of hypercortisolism, particularly sCS in patients with BAD, remains controversial. In the present series, bilateral adrenal surgery with partial resection on one or both sides led to resolution of hypercortisolism in all cases. This approach results in a lower risk of recurrence and a more marked improvement in hypercortisolism-related comorbidity when compared to unilateral adrenalectomy. Conclusion. Less than total bilateral adrenalectomy represents a suitable strategy for most of the patients. This approach avoids lifelong steroid replacement in the majority of cases with low rates of adrenal insufficiency and recurrence.

OC 10 Management of MEN1 related non-functioning pancreatic NETs: a shifting paradigm. Results from the DutchMEN1 Study Group. S Nell1, HM Verkooijen2, CRC Pieterman3, WW de Herder4, AR Hermus5, OM Dekkers6, AN van der Horst-Schrivers7, ML Drent 8 , PH Bisschop 9 , B Havekes 10 , IHM Borel Rinkes1, GD Valk3, MR Vriens1 1 Department of Endocrine Surgical Oncology and Endocrine Oncology, University Medical Center Utrecht, Utrecht, The Netherlands; 2Imaging Division, University Medical Center Utrecht, Utrecht, The Netherlands; 3Department of Endocrine Oncology, University Medical Center Utrecht, Utrecht, The Netherlands; 4Department of Internal Medicine, Erasmus Medical Center, Rotterdam, The Netherlands; 5 Department of Endocrinology, Radboud University Medical Center, Nijmegen, The Netherlands; 6 Departments of Endocrinology and Metabolism and Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands; 7 Department of Endocrinology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands Objective: To assess if surgery for Multiple Endocrine Neoplasia type 1 (MEN1) related non-functioning pancreatic neuroendocrine tumors (NF-pNETs) is effective for improving overall survival and preventing liver metastasis. Background: MEN1 leads to multiple early-onset NF-pNETs. The evidence base for guiding the difficult decision who and when to operate is meager. Methods: MEN1 Patients diagnosed with NF-pNETs between 1990-2014 were selected from the DutchMEN1 study group database, including >90% of the Dutch MEN1 population. The effect of surgery was estimated using time-dependent Cox analysis with propensity score restriction and adjustment.

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Results: Of the 152 patients, 53 underwent surgery and 99 were managed by watchful waiting. In the surgery group, tumors were larger and faster-growing, patients were younger, more often male and were more often treated in centers that operated more frequently. Surgery for NF-pNETs was not associated with a significantly lower risk of liver metastases or death, (adjusted Hazard Ratio (HR) = 0.73 (0.25 - 2.11). Adjusted HR's after stratification by tumor size were: NFpNETs <2cm = 2.04 (0.31 - 13.59) and NF-pNETs 2-3 cm = 1.38 (0.09 - 20.31). Five out of the six patients with NFpNETs >3cm managed by watchful waiting developed liver metastases or died compared with six out of the 16 patients who underwent surgery. Conclusions: MEN1 patients with NF-pNETs <2cm can be managed by watchful waiting, hereby avoiding major surgery without loss of oncological safety. The decision to operate patients with NF-pNETs between 2 to 3 cm becomes debatable. Surgery for patients with NF-pNETs >3cm seems justifiable.

a numeric pain scale was used in the subjects at the same moments described. Results.: In a one-year period, 50 patients (29 women) with a mean age of 48.5 years had the complete evaluation. The operation was ST in 19, TP+45 in 19 and TP+90 in 12 cases. In the whole cohort there were improvements in the PCS (t132.4, t2-49.8, t3 52,5) and MCS t145.8, t2 53.8 and t3 55.4). The improvement occurred irrespective to the type of operation, with no significant difference [PCS in ST (t1 27.5, t2 49.5, t3 49.9), in TP+45 (t1 33.8, t2 52.0, t3 54.9) and in TP+90 (t1 36.3, t2 46.3, t3 53.8)][MCS in ST (t1 56.3, t2 54.3, t3 55.0), in TP+45 (t1 45.8, t2 53.2, t3 56.3) and in TP+90 (t1 39.8, t2 54.1, t3 56.1)]. Severe pain was reported before the operation by 30 patients. After 12 months only one patient still complained of severe pain. Conclusion: Total parathyroidectomy with immediate autograft and subtotal parathyroidectomy are equally adequate to improve QoL of dialysis patients with advanced secondary hyperparathyroidism.

OC 11 Quality of life after parathyroidectomy in secondary hyperparathyroidism W Alves Filho 1 , SS Arap 1 , CP Nascimento Jr 1 , MDG Brescia 1, RMA Moyses 2, MR Custodio2, LM Massoni Neto1, PT Goldenstein2, V Jorgetti2, FLM Montenegro1 1 Surgery, University of Sao Paulo Medical School, Sao Paulo, Brazil; 2Nephrology, University of Sao Paulo Medical School, Sao Paulo, Brazil Introduction. Among the patients with end-stage renal disease mental and physical well-being should always figure among the main objectives of care. Several instruments have been used to measure quality of life (QoL) of patients. In dialysis patients, the Short Form 36 Health Survey Questionnaire (SF-36) proved to be a very useful tool to evaluate QoL. However, there are few studies available that analyze well-being of subjects after parathyroidectomy for secondary hyperparathyroidism. The primary goal of the present study is to determine if there is any difference in QoL of patients submitted to subtotal parathyroidectomy (ST), when comparing to those submitted to total parathyroidectomy with immediate autograft of 45 fragments (TP+45) or 90 parathyroid fragments (TP+90). Material and Methods. In a prospective randomized study (Clinical Trials.gov Identifier NCT02464072), we did the application of the SF-36 form at three different moments: preoperatively (t1), 6 months (t2) and 12 months (t3) after surgery. The physical component summary score (PCS) and the mental component summary score (MCS) were analyzed. In addition,

OC 12 Objective analysis of swallowing and voice outcomes after thyroidectomy: a prospective cohort study T Gumus1, O Makay1, S Eyigor2, K Ozturk3, Z Cetin3, B Sezgin3, Z Kolcak1, M Ozdemir1, G Icoz1, M Akyıldız1 1 General Surgery, Ege University, Izmir, Turkey; 2Physical Therapy And Rehabilitation, Ege University, Izmir, Turkey; 3 Otorhinolaryngology, Ege university, Izmir, Turkey Background: Impairment in voice and swallowing functions are common after thyroidectomy. We aimed to evaluate objective voice and swallowing changes in a series of patients undergoing thyroidectomy. Methods: A total of 40 consenting patients were prospectively recruited. Subjective evaluation of swallowing was assessed with the ‘Subjective Swallowing Evaluation Survey’, ‘Swallowing Impairment Score’ and ‘MD Anderson Dysphagia Index’. The ‘Kaypentax Swallowing Module’ was used for objective evaluation. Physiologic signals were recorded during swallowing and videostrobolaryngoscopy (VSL) was performed to evaluate residue, aspiration and/or penetration. Voice evaluation was assessed with VSL and ‘The MultiDimensional Voice Program’ for capturing and analyzing the voice samples. All evaluations were performed preoperatively and 1 day, 2 weeks and 6 months postoperatively. Results: No vocal cord palsy was experienced. Postoperative subjective swallowing impairment was found in 30% of

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patients, who complained of dysphagia (p>0,05). Although there was no difference between pre and post-operative scores for the intake of liquid and semi-solid food, there was a significant difference regarding light and moderate residual accumulation and secretion in solid food intake (p=0,013). Frequency of swallowing and swallowing functional scale showed no difference, but the functional intake scale revealed specific functional limitation (p=0,034). Subjective data showed no correlation with objective findings. Regarding voice evaluation, a significant increase was observed in standard deviation of average fundamental frequency and degree of subharmonics (p<0,01).

Results.: 118 children (42M/76F) underwent TT for hereditary MTC (77, 65%) and Graves disease (41, 35%). Transient hypocalcaemia was observed in 55 children (46.6%) of which 35 (63.6%) recovered after a mean of 41 days. Persistent hypocalcaemia was recorded in 20 children (17%). Lymph node dissection and parathyroid auto-transplantation were linked to significantly higher rates of transient hypocalcaemia (p 0.009 and < 0.001 respectively). The PGRIS score correlated significantly with transient but not persistent hypocalcaemia (p=0.009) in that the lower the PGRIS score predicted the higher the rate of postoperative transient hypocalcaemia.

Conclusion: Without evident recurrent nerve injury, besides subjective changes, also objective swallowing and voice alterations do occur after thyroidectomy.

Conclusion: Our study suggests that PGRIS score could be used to predict transient but not persistent hypocalcaemia in children undergoing TT and that parathyroid preservation in situ is better than autotransplantation in preserving normocalcaemia.

OC 13 Can Parathyroid Glands Remaining In Situ (PGRIS) score predict postoperative hypocalcaemia in children undergoing total thyroidectomy H Nounou, F Prete, I Christakis, B Farquharson, T AbdelAziz, TR Kurzawinski 1 Endocrine Surgery Centre, University College London Hospitals NHS Trust, London, UK Introduction: Transient and persistent hypocalcaemia after thyroid surgery in children remain a significant problem requiring treatment, frequent monitoring and affecting the quality of life. Best surgical strategies to maintain normal calcium postoperatively are uncertain but PGRIS (Parathyroid Gland Remaining In Situ) score developed by Barcelona group for adults suggested that in situ preservation of parathyroids is better than autotransplantation. The purpose of this study was to validate whether PGRIS score can be applied in children undergoing Total Thyroidectomy (TT) to predict postoperative hypocalcaemia. Material and Methods: Children (<18 years of age) who underwent Total Thyroidectomy were enlisted in the study. Number of parathyroid glands remaining in situ, autotransplanted and found in the specimen on histology were recorded. Children were classified according to the PGRIS score into; Group 1 (one or two parathyroids in situ), Group 2 (three parathyroid in situ) and Group 3 (all four glands remaining in situ) and PGRIS score was correlated with temporary (<1month) and persistent (>1 month) hypocalcaemia defined as calcium levels < 2.1 mmol/l. Statistical analyses were done using SPSS® version 23.0 (IBM, Armonk, New York, USA).

OC 14 Incidental papillary thyroid microcarcinoma – a study of 2466 patients operated for benign thyroid disease N Slijepcevic, V Zivaljevic, A Diklic, G Zoric, K Tausanovic, M Jovanovic, B Rovcanin, I Paunovic 1 Centre for endocrine surgery, Clinical Centre of Serbia, Belgrade, Serbia Introduction. The aim of our study was to investigate the incidence, risk factors and histological characteristics of PTMC in patients operated for benign thyroid diseases (BTD). Material and Methods. A retrospective study conducted at a high volume endocrine surgery unit in a five year period. The study included 2466 patients operated for BTD, of which 403 had a PTMC incidentally discovered on definite histopathological analysis. All variables statistically related to PTMC in univariate logistic regression were further analysed in three separate multivariate logistic regression models (MLR), to determine independent risk factors for PTMC. Results. There were 2128 (86.3%) females and 338 (13.7%) males operated for BTD. PTMC was diagnosed in 345 (16.2%) females and 58 (17.2%) males. Age ranged from 14 to 85 years (mean 54). Sex and age were not related to the incidence of PTMC. The overall incidence of PTMC in BTD was 16.3%. The highest incidence was in Hashimoto thyroiditis (22.7%) and in patients with total/near-total thyroidectomy (17.7%). The lowest incidence (6.6%) was in a solitary hyperfunctional thyroid nodule. According to MLR, Hashimoto thyroiditis and a solitary hyper-functional thyroid nodule are independent risk factors. When the MLR model was adjusted

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for sex, age and extent of operation, Graves’ disease proved to be an independent risk factor, also. Most patients had a PTMC ≤5mm (69.2%). The follicular variant of PTMC was most common (54.5%). Unilateral dissemination of PTMC was found in 16.1% of cases, whereas bilateral dissemination was present in 8.7%. A multifocal PTMC was discovered in 8.4%, while a bilateral multifocal PTMC was found in 6.0%. According to MLR, size of PTMC is an independent risk factor for intraglandular dissemination, while follicular variant of PTMC and weight of the thyroid lobe are risk factors for unilateral and bilateral multifocality of PTMC. Conclusion. Incidence of PTMC in benign thyroid diseases is 16.3%. It is higher in Hashimoto thyroiditis and patients with total/near-total thyroidectomy; and lower in patients with hyperthyroidism. Independent risk factors for dissemination are size of PTMC, follicular variant of PTMC and weight of thyroid lobe.

Results: Mean nodule size was 43.2 mm (range: 30-92). 95% were solid and 5% were predominantly cystic. The risk of cancer was 22.8% (46/202) with no size threshold, or graded increase in risk observed. Based on biologic behavior 50% of cancers were considered clinically significant. Accordingly, the risk of cancer for which surgery is recommended was 11.4% (23/202). The risk of cancer requiring total thyroidectomy was 9.4% and was influenced by nodule size (19% vs. 60% in C1 and C2, respectively; p = 0.01). Predominantly cystic nodules were ≥ 40 mm with a greater risk of malignancy compared to predominantly solid nodules even after adjusting for size (40% vs. 9.9%; p= 0.01and 40% vs. 12.5%; p= 0.02, respectively). Conclusion: The risk of malignancy in Bethesda II solitary nodules ≥ 30 mm is considerable implying a need for changing the way these are approached and refining cytopathology reporting.

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Cancer masquerading as Bethesda II in solitary thyroid nodules ≥ 3cm in size: time for adjustments S Bakkar, AM Poma, M Miccoli, C Corsini, C Ambrosini, F Basolo, P Miccoli 1 Division of Endocrine Surgery, Department of Surgical Pathology, University of Pisa, Pisa, Italy; 2Division of Pathology, Department of Surgical Pathology, University of Pisa, Pisa, Italy; 3Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy; 4Division of Endocrine Surgery, Department of Surgical Pathology, University of Pisa, Pisa, Italy; 5Division of Endocrine Surgery, Department of Surgical Pathology, University of Pisa, Pisa, Italy; 6Division of Pathology, Department of Surgical Pathology, University of Pisa, Pisa, Italy; 7Division of Endocrine Surgery, Department of Surgical Pathology, University of Pisa, Pisa, Italy

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Aim: To assess the risk of cancer in solitary thyroid nodules ≥ 30 mm in size reported as Bethesda II, and its implications. Method: The clinical records of 202 patients who underwent lobectomy for solitary thyroid nodules measuring ≥ 30 mm, reported as Bethesda II on preoperative FNAC between Jan 2015-Apr 2016 were reviewed. Data collected included nodule size and consistency, and final histopathology results. The risk of cancer and the recommended management according to ATA guidelines were the outcomes of interest. Comparisons were then made between two size categories: (30-40 mm; n= 72; C1) and (>40 mm; n= 130; C2) as well as between two nodule consistencies (solid/predominantly solid and predominantly cystic).

F-DOPA PET/CT IN INITIAL STAGING OF MEDULLARY THYROID CARCINOMA T Solé1, C Guérin1, A Abdullah3, NC Paladino1, W Essamet5, J Vaillant4, F Castinetti2, D Taïeb3, F Sebag1 1 Endorcrine surgery department, La conception, University hospital, Marseille, France; 2Endocrinology department, La conception, University hospital, Marseille, France; 3Nuclear medicine department, La timone, University hospital, Marseille, France; 4Medical imaging department, La timone, University hospital, Marseille, France; 5Anatomopathology department, La timone, University hospital, Marseille, France Introduction: Surgery is the only curative option for medullary thyroid carcinoma (MTC). It relies on total thyroidectomy associated with central lymph node dissection. The role of lateral node dissection is still debated. 18F-DOPA PET/CT has been found to be a sensitive imaging modality in the follow-up of MTC patients but its role at initial diagnosis is currently unknown. The aim of our study was to evaluate the performance of 18F-DOPA PET/CT in the initial staging of MTC. Material and Methods: We retrospectively reviewed all MTC patients who underwent 18F-DOPA PET/CT at initial diagnosis. Lesion and compartment-based analysis were done. Results.: Nine patients were included (sex ratio= 0.80, median age= 54 years [35-78], preoperative Calcitonin (CTn) level median= 870 pg/ml [64 – 2522]). Nine total thyroidectomies and 13 compartmental node dissections were performed. Based on histological findings, 11 thyroid nodules and 23

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metastatic lymph nodes from 7 involved compartments were reported. 18F-DOPA PET/CT was positive in 8 patients and negative for one patient (CTn level=64 pg/ml), whereas neck US was positive in all cases. 18F-DOPA PET/CT and US detected 9 and 10 primary tumors (/11) and 7 and 4 involved lymph nodes compartments (/7), respectively. When preoperative CTn level was above 150 pg/ml, lesion and compartment based sensitivity (including thyroid tumors and compartment) were respectively 55% and 92% for 18F-DOPA PET/CT versus 52% and 85% for neck US. No significant correlation was found between CTn levels and uptake values. Conclusion: Due to its very high sensitivity for detecting metastatic LN compartments, 18F-DOPA PET/CT adds information to neck US in the preoperative staging of MTC patient, with potential implications in a tailored surgical approach to patients. These results require validation in larger studies, specifically regarding potential implications in the extent of the surgery.

OC 17 Increased annual incidence of papillary thyroid carcinoma due to a more frequent diagnosis of subclinical tumors MC González-Sánchez1, G Franch-Arcas1, M CaraballoAngeli 1 , M Rodríguez-González 2 , S Del-Carmen 2 , JR Olivo-Esteban3, B Ezurmendía-Sinisterra1, L Muñoz-Bellvís1 1 Surgery, University Hospital of Salamanca, Salamanca, Spain; 2 Pathology, University Hospital of Salamanca, Salamanca, Spain; 3 Radiology, University Hospital of Salamanca, Salamanca, Spain Introduction. Increased diagnosis rate of papillary thyroid carcinoma during the last decade has been described worldwide. Our aim is to evaluate its prevalence during the recent years at our tertiary-level hospital. Material and methods: Pathology records prospective database was used for analyzing all papillary thyroid carcinomas treated at our institution from 2009 to 2015. We compared the annual incidence per 100000 inhabitants at our health area of influence, whether the papillary carcinoma was preoperatively diagnosed or not (incidentaloma), age, gender, MACIS score and diameter of the tumor (pT form TNM classification) across the study period. Results: We retrieved 134 patients for the analysis. Annual incidence showed a significant trend towards an increase over the years studied (from 2.5 patients in 2009 to 10,3 in 2015 per 100000 inhabitants, P < 0.0005). No significant differences were observed regarding age, gender and MACIS score. Mean tumor diameter was progressively

smaller across the study period (from 18.5±5 mm in 2009 to 10.7±2 mm in 2015; P = 0.0006). Comparing pT there were significant differences, with a progressive increase in the proportion of pT1a (≤10mm; considered subclinical) from 33% in 2009 to 60% in 2015 (P = 0.011). Although no significant differences regarding the proportion of patients preoperatively diagnosed (being not postoperatively incidentalomas) were observed, a significant trend to an increase in the proportion of pT1a cases preoperatively diagnosed was observed in 2015 and 2014 when compared with grouped data from previous years 2009-2013 (83% vs. 61% vs. 55%; P = 0.048). Conclusions: 1) We observed an increase in the annual incidence of papillary thyroid tumors diagnosed at our institution during the study period. 2) This increase seems to be related with an increment in the diagnosis of subclinical tumors (≤10mm) and is not related with an increase in diagnosed postoperative incidentalomas. 3) Our hypothesis is that changes in diagnostic trends, with an increase in the use of neck ultrasound and fine needle aspiration in thyroid nodules below 10mm may account for the results observed.

OC 18 The changing landscape of clinicopathological characteristics of thyroid cancer over the last 35 years among 19,976 surgical patients A Konturek1, M Barczynski1, M Stopa Barczynska1, W Nowak1 1 Department of Endocrine Surgery, Third Chair of General Surgery, Jagiellonian University Medical College, CRACOW, POLAND Introduction: The incidence of thyroid cancer has increased fivefold over the past four decades with the vast majority of the increase noted to be among small, indolent papillary thyroid carcinomas. Substantial overdiagnosis and potential overtreatment have led to a shift in clinical practice toward less aggressive approaches and a focus on improved risk stratification. The aim of this study was to capture the changing clinicopathological characteristics of thyroid cancer over the last 35 years at our institution. Material and Methods: This was a retrospective cohort study. All potentially eligible patients undergoing thyroid surgery at our institution between 1981 and 2015 identified in the hospital register were considered for inclusion in the analysis. Exclusion criteria were incomplete follow-up data. Primary outcome was clinicopathological characteristics of thyroid cancer. Data were estimated on annual basis to identify trends in prevalence of thyroid cancer.

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Results.: During the 35-year study period 19,976 patients underwent thyroid surgery, including 1,872 (9.4%) patients with diagnosed thyroid cancer. The prevalence of thyroid cancer among all thyroid operations increased from 4.4% in 1981 to 13.8% in 2015 (p<0.001), whereas incidence of papillary thyroid cancer (PTC) increased form 38.8% in 1981 to 87.9% in 2015 (p<001). Incidental diagnosis of PTC decreased from 71.2% in 1981 to 34.1% in 2015 (p<0.001), whereas median diameter of PTC decrease from 22.3±13.7mm in 1981 to 7.5 ±16.0mm in 2015 (p<0.001).

Conclusion When analyzing the results, we identified 147 patients with a family history of thyroid disease (20%). In 8 patients (5.44%) we found a at least one relative with papillary thyroid carcinoma. However, our study does not demonstrate a difference in the aggressiveness of familial and sporadic papillary thyroid carcinoma.

Conclusions: The following trends in surgical volume for thyroid cancer were identified throughout the study period: a fivefold increase of thyroid operations for thyroid cancer, a threefold increase in incidence of PTC, a threefold decrease in the median diameter of PTC, and a twofold decrease of incidental diagnosis of PTC.

O Gonzalez1, C Iglesias 2, C Zafon3, JM Balibrea1, E Caubet1, R Vilallonga1, J Temprana2, J Mesa3, JM Fort1, M Armengol1

P02 Macro, but not micrometastases, detected by OSNA technique are related with more aggressive papillary thyroid cancer features

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Endocrine Surgery, Hospital Vall d´Hebron, Barcelona, Spain; 2Pathology, Hospital Vall d¨Hebron, Barcelona, Spain; 3Endocrinology, Hospital Vall d´Hebron, Barcelona, Spain

ESES 2017 - POSTER PRESENTATIONS P01 Family papillary thyroid carcinoma (FPTC): a retrospective analysis in a sample of the Bulgarian population for ten-year period. K Vidinov1, D Nicolova2 1

Department of Endocrine surgery, CCEG, Medical University, Sofia, Bulgaria; 2 Department of Genetics, Medical University, Sofia, Bulgaria In recent years, there are numerous reports indicating the presence of family papillary carcinoma. Unfortunately, no genetic defect can be linked directly to the disease. For these reasons, in this study we set the goal to make a retrospective analysis of the cases with papillary carcinoma in the Department of Endocrine Surgery the past ten years, to comparable the characteristics of sporadic and familial forms of the disease and to find families with hereditary papillary carcinoma. Material and methods The study included 810 patients treated for thyroid cancer in the Department of Endocrine Surgery, USBALE "Acad. Iv. Penchev" Hospital, between 01.01.2006 – 31.12.2015. We used chi square test to determine statistical significant difference. The data analysis and interpretation was performed on SPSS 20.0. Results Both groups had similar demographic distribution. We found that 587 patients have sporadic papillary carcinoma, while 147 have a relative with thyroid pathology in the first degree of kinship. In 8 patients there was a blood relative with thyroid cancer. When we compared the two groups we found statistically significant difference only in tumor size. There was no significant difference in aggressiveness of the thyroid cancer (multifocality and lymph node metastasis).

Introduction Classically, risk stratification in papillary thyroid carcinoma (PTC) assigns the same magnitude of risk to all patients with regional lymph node involvement (N1 disease). However, specific lymph node characteristics (e.g. size, number, extension, etc) will allow individualizing treatment and follow-up. One-Step Nucleic Acid Amplification (OSNA) measures the number of copies of mRNA of cytokeratin 19 (CK19) as a marker of lymph node metastasis. Thus, copy numbers between 250 and 5,000 were considered micrometastases (mM1), and more than 5,000 copies were designated as macrometastases (MM1). Objective To analyze the influence of OSNA lymph node metastasis classification in the histological characteristics of PTC in patients submitted to lymph node dissection (LND). Material and methods LND from 40 patients (28 female, mean age 49±15 years old) were evaluated. Lymph node metastases were detected using OSNA. Metastases characteristics include total tumoral load (TTL), TTL per total lymph node weight (TTL/TLNW), and mM1 versus MM1. According to the metastases status tumor related variables were studied. Results A total of 513 lymph nodes were found, with a mean (SD) of 12.8 (9.5) per patient. Thirty LND were considered positive for metastases (75%). There were no significant differences in tumor histological variables and TTL or TTL/ TLMW. According to mM1 versus MM1 status, there were 10 (25%) patients with no lymph node involvement, 11 (27.5%) with only mM1, and 19 (47.5%) with at least one MM1. Only this last group was significantly related with primary tumor size (p=0.04), vascular invasion (p = 0.03),

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extrathyroidal extension (p = 0.04) and positive margin (p =0.04). Conclusion Lymph node macrometastases detected by OSNA are related with more aggressive PTC. OSNA could be a useful technique to improve lymph node metastases characterization.

Conclusion The incidence of thyroid cancer was similar in both group. The results of routine concurrent US carotid and thyroid examinations were helpful in detecting thyroid tumors in both patient groups. P04 Emergency surgery in amiodarone-induced thyrotoxicosis

P03 Prevalence of incidental thyroid cancer detected in subjects undergoing carotid ultrasonography

E Viejo1, I Grao1, P Ciriano1, E Fernández2, JL Escat1, I Amunategui1, E Mercader1

ML Lavazza1, VP Pappalardo1, DI Inversini1, LX Xiaoli2, CWW Wu3, AA Anuwong4, HYK Kim5, RL Liu6, GWR Randolph7, GD Dionigi1

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General Surgery, Hospital General Universitario Gregorio Marañón, Madrid, Spain; 2Department of Endocrinology, Hospital General Universitario Gregorio Marañón, Madrid, Spain

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1st Division of General Surgery, Research Center for Endocrine Surgery, University of Insubria, Varese, Italy; 2 Jilin Provincial Key Laboratory of Surgical Translational Medicine, Japan Union Hospital of Jilin University, Changchun City, China; 3Department of Otolaryngology, Kaohsiung Medical University Hospital, Kaohsiung M e d i c a l U n i v e r s i t y, K a o h s i u n g C i t y, Ta i w a n ; 4 Department of Surgery, Police General Hospital, Faculty of Medicine, Siam University, Bangkok, Thailand; 5 KUMC Thyroid Center, Korea University, Seoul, Korea; 6The Third Affilated Hospital, Sun Yatsen University, Guangzhou, China; 7Division of Thyroid and Parathyroid Surgery, Department of Otolaryngology, Harvard Medical School, Boston, USA Introduction The purpose of this prospective study was to evaluate incidental thyroid cancer diagnosed by ultrasonography (US) in a population who underwent carotid echography. Material and methods Between January 2013 and March 2016, we examined thyroid glands during routine diagnostic, follow-up carotid US. A total of 3,533 subjects underwent carotid screening ultrasound (n = 2,662) or US for diagnosis or follow-up (n = 871). When a thyroid lesion was suspicious for malignancy, fine-needle aspiration was performed. We compared the cases of pathologically proven thyroid cancer in two groups: first group, including patients with carotid disease found, and a second group, including patients with negative findings. Discussion Among the 3,533 cases, 44 (1.24%) were diagnosed as thyroid cancer; all were papillary carcinomas. Pathologically proven thyroid cancers were identified in 14 (1.6%) of the 871 patients with carotid disease and in 30 (1.12%) of the 2,662 non-vascular disease patients (p>0.05). The diameters of the 44 thyroid nodules were 0.7-3.7 cm; the mean diameters in the first and second groups were 12.9 and 11.6 mm, respectively (p>0.05).

Introduction Amiodarone is a commonly used iodine-based potent antiarrhythmic drug. It is associated with thyroid dysfunction and life-threatening thyrotoxicosis. In medical refractory cases, surgery may be required. Material and Methods: We report four cases of amiodaroneinduced thyrotoxicosis in patients with complex hearth diseases that required urgent or semiurgent surgery during 2015 – 2016 in our endocrine surgery unit. Discussion All patients were males with severe cardiopathy history due to different pathologies: tetralogy of Fallot, ischemic heart disease, dilated cardiomyopathy and Marphan syndrome. They received amiodarone for ventricular arrhythmias or atrial fibrillation. Although type II thyrotoxicosis was initially diagnosed, all the cases were finally treated as mixed thyrotoxicosis due to poor evolution. Treatment included full dose of steroids and antithyroid drugs as first step, adding, later, other treatments such as perchlorate, cholestyramine, and lugol. In one case, four preoperative plasmapheresis sessions were performed. Despite intensive medical treatment managed by cardiologists and endocrinologists, there was no improvement and hearth function was at risk. Total thyroidectomy, under supervision of specialized anesthesic team, was safely performed in all cases with no mortality and no intraoperative complications. Two patients developed a transient hypoparathyroidism. At present all patients remain stable. One of them, after a period of time with a ventricular assistance dispositive, was successfully transplanted. Conclusion Amiodarone-induced thyrotoxicosis is a severe complication in patients with impaired cardiac function. Multidisciplinary team must be involved in decision-making and emergent total thyroidectomy should be taken into account as a safely and effective treatment for patients who cannot be controlled by medical treatment.

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P05 Parathyroid related positioning the capsule (PRPC) a novel classification to predicting hypocalcaemia during total thyroidectomy

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L Romano-Torres1, EM Barajas-Fregoso2

Background The mean of this study was determinate the association between the thyroid nodule size and metastatic disease in the central neck compartment, in patients with papillary thyroid cancer, who was developed a prophylactic central neck dissection.

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Unit of Thyroid and Parathyroid, Hospital General de Puebla.“Eduardo vasquez, Puebla, Mexico; 2Endocrine Surgery, Centro Medico Nacional Siglo XXI, Mexico, City, Mexico Aim To propose a novel classification that could be useful to predict postoperative hypocalcemia and hypoparathyroidism during thyroidectomy. Patients and Methods a prospective study of patients who underwent total thyroidectomy from 2013 to 2016, therapeutic central neck dissection and incidental parathyroidectomy patients were excluded. Patients were divided in 4 groups according the parathyroid gland position related to the thyroid capsule: 1)extra- capsular 2) intra- capsular 3) mixed 4) non identified gland. Frequency analysis, univariate and ROC curves were assessed. Results Thyroidectomy was performed in 30 patients, all of them were female gender. The average age was 41.89 + 12.5 yrs., nodule size 2.95 + 1.9 cm, postoperative iPTH 27.94 + 17.73 pg, postoperative serum calcium 8.17 + 0.57 g/dl, corrected serum calcium 7.90 + 0.65 g/dl. Postoperative hypoparathyroidism in 23.3% and postoperative hypocalcemia in 33.3%. At 30 days after surgery only 8.3% present hypoparathyroidism. According to our proposal classification, 69.4% of the parathyroid glands were extra-capsular position and 15% of these presented hypoparathyroidism, intra-capsular 2.8% with all cases with hypoparathyroidism (only one case with iPTH 8.4 pg/dl three months after procedure), mixed position 16.7% with 33.3% of hypoparathyroidism, and non identified gland in 11.1% with 33.3% of hypoparathyroidism. The area under de curve in patients with mixed and non-identified gland position was 0.595 and 0.589 respectively to predict hypocalcemia. Conclusion Parathyroid related position de capsule (PRPC) it is a novel and practice classification that could predict hypocalcemia after total thyroidectomy. P06 Association Between Thyroid Nodule Size and Metastatic Disease at Central Neck Compartment in Patients with Papillary Thyroid Cancer L Romano-Torres1, EM Barajas-Fregoso2

Unit of Thyroid and Parathyroid. Hospital General de Puebla "Eduardo Vasquez". Mexico; 2Endocrine Surgery. Centro Medico Nacional Siglo XXI. Mexico City

Material and Methods Was included all the patients with diagnosis by papillary thyroid cancer, in who was performed total thyroidectomy with prophylactic central neck dissection, the clinical charts of the patients was reviewed. The variables included were size of thyroid nodule, laterality of the central compartment affected, capsular involved, lymphovascular permeability, age and gender. Results Seventeen patients were included, the mean age was 38 + 14.03, all of them female gender, 52.9% present metastatic disease in central compartment, of which the 37.5% were small nodules (1-1.5 cm). We found that the 66.7% of the patients with metastatic disease in the central neck compartment have lymphoovascular permeability, and the 58.3% capsular involved. Conclusion In our study, we are not able to say that the thyroid nodule size has relation with metastatic disease in the central neck compartment in patients with papillary thyroid cancer. However, we could see 33% of metastatic disease central compartment in nodules less than 1.5 cm, and nodules largest than 1.5 cm until 66.7%, capsular involved was found in 58.3%. We recommended perform prophylactic neck dissection in all patients with papillary thyroid cancer without matter the nodule size. P07 The routine follow-up of the classical and follicular variant papillary thyroid microcarcinoma intersecting an unusual Eagle’s Syndrome with an hyoid bone variation D Sengul1, I Sengul2, O Ozer3 1

Endocrine Surgery, General Surgery, Giresun University Faculty of Medicine, Giresun, Turkey; 2Pathology, Giresun University Faculty of Medicine, Giresun, Turkey; 3 Radiology, Giresun University Faculty of Medicine, Giresun, Turkey Objectives It is aimed here in to present the case with his 3D CT imagings, diagnosed as an atypical styloid ligament calsification, Eagle’s Syndrome, during a non-contrast neck CT which was performed for the calsification detected in the neck US that was the part of the routine follow-up of the

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classical and follicular variant (CV and FV) papillary thyroid microcarcinoma (PTmC). Case report 52-year-old Turkish man underwent the total thyroidectomy on June 2014. Afterwards, 100 mCi RAI ablation was administered after his histopathology was revealed the FVPTmC of the right lobe on two focuses, 3 and 6 mm, and CVPTmC of the left lobe on one focus, 7 mm. On the routine follow-up, a 5.1 mm in diameter linear calcific echogenity among the mucsular structures at the level of 3rd compartment of the left lateral cervical region was recognized on the neck US on July 2016. Afterwards, a noncontrast CT scanning of the neck was performed due to the suspicion of the styloid ligament calsification and the patient’s complaint of the pain on the descripted area. The images were examined using 3D software program. A dense calcification 1.8 mm in lenght and 4.2 mm in width was detected in the neighborhood of the right lesser corn of hyoid bone. Both of the hyoid lesser corns were symmetrical. However, the right greater corn had higher volume compared to the left though both had the same length. Conclusions The styloid process was defined as “segmented type” in terms of morphological classification and the “completely calsified type” in terms of classification pattern regarding Langlais et al. 1986. The stylohyoid complex calsification was out of all the 12 subtypes of O’Carroll’s Classification System, suprisingly. It is extremely interesting case of Eagle’s Syndrome, detected during the routine followup of the CVPTmC, and FVPTmC, having an extremely rare stylohyoid ligament calsification, out of O’Carroll’s System, with an hyoid bone variation. P08 An axillary Schwannoma: a rare case D Sengul1, I Sengul2, U Karinoglu3, O Cuvas Apan4, H Oksuz3

(100 μg/2 mL ampoule) 1 μg.kg-1, Propofol (1%) infusion 50 μg.kg-1 min-1, and Aritmal ampoule 5 ml (2% 100 mg/5 ml), was performed for 63 year-old male with the complaints of painless lump, a 1.5×1 cm, oval, firm, mobile, non-tender mass in the left axilla deeper to pectoralis major muscle, at the axillary region for 4 months. The microscopic evaluation with Haematoxylin and Eosin (H&E), revealed the welldemarcated pseudocapsular structure, spindle shaped proliferation exhibiting hypocellular and hypercellular areas. While the hypercellular areas was showing spindle shaped cells having wavy nuclei arranged in the fascicles with focal palisading of nuclei, the hypocellular ones showed the large number of foamy macrophages and loose myxoid stroma. On the immunhistochemical analysis, the tumor cells showed diffuse cytoplasmic positivity for S-100 protein and was negative for Desmin, Actin, and CD34; confirming the diagnosis of Schwannoma. The proliferation index of Ki-67 was about 12%. The histopathological diagnosis of Schwannoma was confirmed by the immunohistochemical analysis. Conclusion Axillary Schwannoma is uncommon, but should be considered in the differential diagnosis of an axillary mass, particularly in the presence of a nerve deterioration or disability, and if malignancy can be eliminated. Surgery is indicated for the tumors leading pain, neurological dysfunction or for any rapidly growing ones, suspicious for malignancy, and the complete resection represents the cure. Awareness of this condition would be helpful in the preoperative diagnosis of the mentioned cases. P09 Clinical impact of autofluorescence-based identification of parathyroids using near-infrared light during total thyroidectomy: a comparative before-after study F Benmiloud1, G Penaranda2, A Denizot1 1

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Department of Pathology, Giresun University Faculty of Medicine, Giresun, Turkey; 2 Department of General Surgery, Giresun University Faculty of Medicine, Giresun, Turkey; 3Department of Pathology, Prof Dr A Ilhan Ozdemir State Hospital, Giresun, Turkey; 4 Department of Anesthesiology and Reanimation, Giresun University Faculty of Medicine, Giresun, Turkey Objective Schwannoma, neurilemmoma, is well capsulated, slowly growing tumor originating from benign neoplastic Schwann cells of the peripheral nerve sheath. Due to its rarity and complex anatomical location they can pose the misdiagnosis at clinical evaluation. Case Presentation A total surgical excision with a safety margin via local anesthesia and sedoanalgesia, Fentanyl citrate

Endocrine Surgery Unit, Hopital Europeen, Marseille, F r a n c e ; 2 B i o s t a t i s t i c s , A l p h a b i o L a b o r a t o r y, Marseille,France; 3 Endocrine Surgery Unit, Hopital Europeen, Marseille, France Background Near-infrared (NIR) light has recently been shown to facilitate intraoperative autofluorescence-based identification of parathyroids. However, the impact of this technique on surgical performance and patient outcome during total thyroidectomy (TT) remains unknown. Methods We conducted an observational before-after study. Between January and June 2016, an NIR light camera (Fluobeam®-Fluoptics®) was used intraoperatively to examine the surgical field in all consecutive patients who underwent TT (+/- lymph node dissection).These patients (NIR+ group) were compared with patients who underwent

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surgery without NIR from January 2015 to January 2016 (NIR- group). Patients with combined parathyroid disease were excluded from the study. The main outcomes included parathyroid identification, autotransplantation and inadvertent resection rates as well as postoperative hypocalcemia rates (corrected serum calcium < 2 mmol/l or > 2 mmol/l with calcium treatment). Other analyzed data included age, sex, Body Mass Index (BMI), extent and duration of surgery, non parathyroid-related complications, thyroid weight, size of the largest nodule and definitive diagnosis. Results We examined 237 patients: 63 in the NIR+ group and 174 in the NIR- group (252 and 696 theoretically present parathyroids, respectively). In the NIR+ group, among the 191 parathyroids visualized with the naked eye, 189 were identified using NIR light (Kappa concordance test [IC 95]: 0.98 [0.95-1.00]). NIR light enabled identification of parathyroids before they were visualized with the naked eye in 65% of patients. In the NIR+ group, more parathyroids were identified (75% of the theoretically present parathyroids vs. 65%, p=0.001) and less parathyroids were autotransplanted (0.8% vs. 6.7%, p=0.017) compared with the NIR- group. The postoperative hypocalcemia rate was 4.7% in the NIR+ group vs. 27% in the NIR- group (p<0.001). No difference was noted concerning inadvertent parathyroid resection rate (1.2% vs 1.7% in the NIR+ and NIR- groups, respectively, p=0.29), definitive hypocalcemia rate (0% and 1.5%, respectively, p=0.6) nor any other analyzed data (with the exception of BMI, higher in the NIR+ group). Conclusion With the help of autofluorescence-based visualization of parathyroids using NIR light during total thyroidectomy, we observed a significant improvement of parathyroid identification and autotransplantation rates and a diminution of postoperative hypocalcemia rate. P10 The utility of the Bethesda category and its association with BRAF mutation in the prediction of papillary thyroid cancer stage 1

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A Beiša , M Kvietkauskas , V Beiša , M Stoškus , E Ostanevičiūtė3, E Jasiūnas5, L Griškevičius2,4, K Strupas1

clinicopathological factors that could facilitate better prediction of patient prognosis and planning of appropriate treatment. We hypothesized that preoperative determination of Bethesda category of fine-needle aspiration (FNA) biopsy specimens and its association with BRAF mutation would be an informative for predicting the stage of papillary thyroid cancer (PTC), and it could assist in defining the optimal scope of initial surgical and medical managements for PTC. Material and Methods A prospective study analyzed patients, who had US suspicious thyroid nodule, underwent FNA and cytological examination, and were classified according to Bethesda system. Patients from AUS/FLUS, FN/SFN, SMC and PMC groups were examined for the BRAF mutation, had a thyroid surgery from January 2013 till June 2016. Demographical, histological features and stage of the disease were evaluated for PTC patients in accordance to Bethesda category and its association with BRAF mutation. Discussion Out of all, 308 patients underwent operation. 143 (46.4%) of them were diagnosed with PTC. In 14 (9.8%) PTC cases, FNA biopsy were classified as AUS/FLUS, 23 (16.1%) as FN/SFN, 41 (28.7%) as SMC, and 65 (45.5%) as PMC. I-II stage of PTC was diagnosed for 88 (61.5%) patients, and IIIIVA for 55 (38.5%). SMC and PMC group patients had a statistically significantly larger tumor, higher incidence of lymph node metastases, classical PTC type, BRAF positive, and III-IVA stage cancer, than AUS/FLUS and FN/SFN group patients. When comparing 27 (18.9%) BRAF negative patients from AUS/FLUS and FN/SFN group with 116 (81.1%) BRAF negative patients from SMC and PMC group and all BRAF positive patients, prediction of more aggressive histological features and stage was slightly improved. Conclusions We have found that higher Bethesda categories are associated with higher stages of PTC. Association of Bethesda category with BRAF mutation can slightly improve value of stage prediction. P11 Small Pheochromocytomas: clinical, diagnostic and perioperative issues of disease SM Cherenko, OS Larin, OA Tovkai

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Centre of Abdominal Surgery, Vilnius University, Vilnius, Lithuania; 2 Centre of Haematology, Oncology and Transfusion Medicine, Vilnius University, Vilnius, Lithuania; 3 Centre of Laboratory Medicine, Vilnius University, Vilnius, Lithuania; 4Centre of Internal, Family Medicine and Oncology, Vilnius University, Vilnius, Lithuania; 5Mykolas Romeris University, Vilnius, Lithuania Introduction Approximately 10% of all thyroid cancers have a poor prognosis, making it important to identify

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Endocrine Surgery, Ukrainian Scientific and Practical Center for Endocrine Surgery, Kyiv, Ukraine Introduction Pheochromocytoma (P) is considered as relatively rare adrenal tumor with clinical manifestation after reaching the size of 4-6 cm. Meanwhile, it’s supposing that small P can be not rare found within different diagnostic imagination. Some of these, being clinically silent, can cause serious cardio-vascular risk undergoing unrelated medical

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procedures. We compared clinical course, peculiarities of diagnostics and treatment of small P (less than 3 cm) and bigger P among patients underwent adrenalectomy on proven or suspected P. Material and Methods Group of small P comprised by 14 patients aged from 21 to 62 years with mean size of tumor 23 mm (range: 4-29 mm). Control group consisted of 35 patients corresponded on age (23-75 years) with mean P diameter of 56 mm (range: 30-127 mm). Small P comprised 8% of all 175 patients with P operated on by authors during the last 19 years from the whole group of 967 adrenalectomies. Prevalence of women and right side lesions characterized both groups. Discussion Principal differences between groups were less prominent clinical activity (any symptoms were detected in half of small P) with less level of catecholamines and metanefrines in serum and urea of small P patients. Computed tomography was often the first but not targeted diagnostic step. Silent clinical course was the main reason that small P have been discovered predominantly incidentally with no blockage of alpha-adrenergic receptors before surgery in 6 of 14 patients. Most of them had a critical elevation of blood pressure during operation (43% against 9% in control group; p<0.05). Despite small size and mild catecholamine excess 4 from 14 patients (29%) experienced episodes of potentially harmful hypertensive crisis during unrelated medical procedures in the past. All small P were treated successfully by laparoscopic adrenalectomy. Most of patients became free from hypertension. Conclusion Small P may carry actual risk of unexpected hypertensive crisis during any unrelated medical procedures. The clinical course of small P is hidden in half of patients and laboratory investigations are interfered with mild elevation of biochemical markers. Laparoscopic adrenalectomy is safe mode of treatment of small P in case of adequate preparation. P12 Baseline neutrophil-to-lymphocyte ratio can not predict occults papillary thyroid microcarcinomas in benign multinodular goiters DK Manatakis, VN Soulou, D Balalis, L Tzelves, DP Korkolis, GH Sakorafas, G Plataniotis, E Gontikakis

surgery for presumably benign disease. Our study aimed to evaluate the role of neutrophil-to-lymphocyte ratio (NLR), a surrogate index of systemic inflammation, as a potential biomarker in predicting the presence of papillary microcarcinomas in clinically asymptomatic, FNA-negative thyroid nodules. Material and Methods Consecutive adult patients who underwent total thyroidectomy between 2008-2015 were identified from a prospectively maintained thyroid surgery database and categorised in 4 groups (group A - multinodular goitres, group B - Hashimoto lymphocytic thyroiditis, group C - papillary microcarcinomas, group D - papillary carcinomas). Analysis and comparison of clinical characteristics (age, gender, thyroid specimen weight, dominant nodule size) and biochemical tests (TSH, total WBC, neutrophil and lymphocyte differential counts, NLR) was performed. NLR was calculated as the absolute neutrophil count divided by the absolute lymphocyte count, based on the preoperative complete blood cell count. Specificity, sensitivity, positive and negative predictive values as well as accuracy were calculated, using NLR median and mean as cut-off values. Discussion In total, 397 patients fulfilled the inclusion criteria (94 male, 303 female). Final diagnoses included 160 MNG (group A), 30 HLT (group B), 113 PTMC (group C) and 94 PTC (group D). Although total WBC counts were similar, NLR was significantly increased in PTMC and PTC cases, compared to benign pathology (group A 2.14±0.85, group B 2.26±0.79, group C 2.40±0.96, group D 2.54±1.10, p=0.026). With a cut-off of 2.05 (NLR median), sensitivity and specificity were 55.6% and 54%, PPV 49.1% and NPV 60.4%. With a cut-off of 2.40 (NLR mean), sensitivity decreased to 40.4%, specificity increased to 66.1%, PPV was 48.8% and NPV 58.2%. With both values, overall accuracy was only 44.7%. Conclusion Whereas NLR exhibited an association with malignancy, low specificity and sensitivity, as well as low PPV and NPV, practically preclude its use in predicting occult papillary microcarcinomas during the diagnostic work-up of thyroid nodules. P13 Is medical treatment of "mild" primary hyperparathyroidism cost- effective? P Riss1, R Kefurt1, A Selberherr1, C Bichler1, L Brammen1, C Scheuba1, B Niederle1

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Department of Surgical Oncology, Agios Savvas Anticancer Hospital, Athens, Greece

Introduction With an incidence up to 20%, occult papillary microcarcinomas (≤1cm) constitute the majority of incidentally discovered thyroid malignancies in patients undergoing

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Department of Surgery, Medical University of Vienna, Vienna, Austria Background Surgery is the only curative treatment of primary hyperparathyroidism (PHPT). However, calcimimetic drugs

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can effectively decrease parathyroid hormone (PTH) and serum calcium in patients with PHPT. As cost effective treatment is of increasing importance there is ongoing discussion about the use of calcimimetics instead of surgery in “mild” PHPT. Aim of this study was to compare the costs of medical and surgical treatment in patients with PHPT. Methods The cost for parathyroid surgery was calculated using two different presumptions. The overall “economical costs” were calculated on the basis of the refund costs paid from the public healthcare insurance to the hospital in Austria. The “real costs” for the hospital were calculated according to the actual expenses for consumable supplies and intraoperative PTH- monitoring. Results Overall “economical costs” for parathyroid surgery were €1.925 at most. The “real costs” for the surgical procedure were €1.787. Based on a bidaily intake, the costs for cinacalcet 30mg were €1.97 per day. Therefore, the costs for surgery were reached after a cinacalcet treatment of 88 and 82 days, respectively. Conclusions Long term intake of calcimimetics instead of surgery is not cost effective. However, it remains an option for “palliative treatment” and “bridging” to surgery in selective patients. P14 Follow-up of low-risk PTC patients without immediate Surgery-Bulgarian experience R Pandev, M Kermedchiev, T Pirdopska, I Tersiev, T Hagieva, B Nonchev, N Raikov, P Bochev, Z Cherkesov

BRAF examinations of FNA specimen were performed in 2 cases. All Patients were followed every 6 months with Neck ultrasound. Between 2011–2016- 33 patients (age 26-58 years) chose observation without immediate surgery. Follow up time: 6-60 months Discussion: 8 patients underwent surgery for size enlargement or ultrasound suspected lymph nodes. Surgery performed: Hemi-Tx (n=5), Hemi-Tx + central neck dissection (n=2) and isthmusectomy (n=1). Final histology revealed in 7 cases PTC, and in one benign lesion. TNM Patients Details: pT1aNoMo (n= 3); pT1bNoMo (n= 2); pT1apN1aMo (n=1); pT1bpN1aMo (n=1) The Size of removed LN metastases was between 0.5- 1cm, or micro-metastasis. 25 patients were just followed and remained clinically disease free. None of the patients showed distant metastases or died during follow-up. Conclusion: Our experience of low risk PTC patients showed that active surveillance without immediate surgery remains a proper decision for these patients. It might be not too late to perform surgery after disease progression. P15 Primary Hyperparathyroidism in Teenagers - presentation of 9 cases T Cvasciuc 1 , G Sadler 2 , R Squire 3 , P Johnson 4 , M Lansdown1, R Mihai2 1

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University Clinic of Surgery, Medical University, Sofia, Bulgaria; 2University Clinic of Surgery, Medical University, Sofia, Bulgaria; 3 Department of Pathology, Medical University, Sofia, Bulgaria; 4Department of Pathology, Medical University, Sofia, Bulgaria; 5Nuclear Medicine Department, City Hospital, Sofia, Bulgaria; 6Department of Endocrinolology, Medical University, Plovdiv, Bulgaria; 7 Department of Endocrinolology, Hospital, Varna, Bulgaria Introduction The incidence of Papillary thyroid cancer is increasing and most patients present an indolent course of the disease. In this study, we analyzed the cohort of patients, who were observed without immediate surgery. Material and Methods: Study design: retrospective - survey performed in four Endocrine and Surgery Centers in Bulgaria. Patients selection: patients with FNA evidence of low-risk PTC classical variant d<15mm (Category V—suspicious for malignancy, Category VI—malignant), without initial surgical treatment.

Endocrine Surgery, Leeds Teaching Hospitals, Leeds, UK; Pediatric Surgery, Leeds Teaching Hospitals, Leeds, UK; 3 Endocrine Surgery, Oxford University Hospitals, Oxford, UK; 4 Pediatric Surgery, Oxford University Hospitals, Oxford, UK 2

Introduction: Just over 270 cases of primary hyperparathyroidism (PHPT) in young patients (<20 years) have been reported in literature since 1966. Incidence may be under appreciated. The aim of this report is to present outcome of treatment for nine cases of PHPT in teenagers operated in two teaching hospitals in the UK. Methods: Retrospective analysis of unselected patients with PHPT diagnosed before being 20 years old. Results: Five girls and four boys aged 12-18 years (median 16) presented either with known familial disease (MEN1, n=3 and HPT-JT syndrome, n=1) or with sporadic disease (n=5). The later group had significant neuropsychiatric symptoms. Six patients had positive Sestamibi scans. Four patients had

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minimally invasive parathyroidectomy and five had bilateral neck exploration. Six months postoperatively eight patients had normal calcium levels. Of the MEN1 patients, one is being investigated for recurrent hypercalcaemia 4 years after initial subtotal parathyroidectomy and one is cured after redo parathyroidectomy for recurrent hypercalcaemia 5 years after scan-directed single gland excision. Conclusions: PHPT in teenagers remains very rare but should not be overlooked, as untreated hypercalcemia can affect growth and development. Majority but not all young patients with PHPT have familial disease. Timing and extent of first operation for PHPT in MEN1 patients continues to be challenging. The cure rate should be as in adult population >95%. P16 Adrenocorticotropin- Independent macronodular adrenal hyperplasia: From literature analysis to initial clinical experience in Ukraine SM Cherenko, OE Tretiak, LV Shchekaturova, OA Tovkai 1

Ukrainian Scientific and Practical Center for Endocrine Surgery, Kyiv, Ukraine Introduction: Bilateral ACTH-independent macronodular adrenal hyperplasia (AIMAH) is considered as a rare cause of Cushing’ syndrome (CS). AIMAH is interesting issue for clinicians and researchers due to unique mechanism of cortisol secretion stimulation not by ACTH, but next to the action of other humoral agents, which activate ectopic (aberrant) adrenocortical receptors triggering steroidogenesis. We analyzed literature information and studied own clinical data concerning diagnosis and treatment of AIMAH patients. Material and Methods: Published and electronic resources were analyzed. Own data were retrieved from institutional computed database. Relevant laboratory investigations became available since 2009, so we selected all cases of adrenal hyperplasia (34) as a pathologic form of ACTH independent CS (166 patients) within period 2009-2015 years yielded 634 adrenalectomies. Discussion: AIMAH is not casuistic condition among endogenous adrenal CS. It comprised 22.1% in our consecutive series of surgically treated CS. Average age of patients was 53±7 years (42-71 years) with female prevalence 76.7%. Clinical presentation of disease comprised with predominantly subclinical CS accompanied by arterial hypertension, diabetes mellitus, osteoporosis, obesity.We found high percentage of primary hyperaldosteronism (44.1%; 15 from 34) among patients with AIMAH and CS. All patients after confirmation of CS, ACTH-independancy and positive visualization were undergone unilateral (prominent gland)

laparoscopic adrenalectomy. Follow-up was available for 30 from 34 patients: 1-5.5 years for 25; 0.5-1 year after surgery – for 5 patients. Clinical improvement of symptoms has been established for 84% and 100% correspondingly. All patients demonstrated normalization of serum level of cortisol at overnight dexametasone test. We detected one case of laboratory relapse of subclinical CS 3 years after adrenalectomy followed by full reconvalescence from overt CS. Patient refused completion adrenalectomy. Conclusion: Incidentally discovered bilateral hyperplastic lesions of adrenals with low radiologic density on computed tomography should be considered as possible AIMAH and underwent investigation on occult CS. Laparoscopic adrenalectomy on the side of prominent hyperplasia leads to longterm remission in most of patients and doesn’t accompanied with adrenal insufficiency. Relapse of CS needs for search the intrinsic kind of ectopic adrenocortical receptors and specific way of their blockage to avoid adrenal insufficiency after total adrenalectomy. P17 Feasibility of thyroid imaging reporting and data system (TIRADS) classification in predicting thyroid malignancy NA Sahbaz1, AC Dural1, C Akarsu1, S Akbulut1, R Turkay2, HF Baytekin3, H Alis1 1

General Surgery, Bakirkoy Dr. Sadi Konuk Training and Research Hospital, Istanbul, Turkey; 2Radiology, Bakirkoy Dr. Sadi Konuk Training and Research Hospital, Istanbul, Turkey; 3Pathology, Bakirkoy Dr. Sadi Konuk Training and Research Hospital, Istanbul, Turkey Introduction: We aimed to determine the feasibility of TIRADS classification in differentiating benign from malignant thyroid nodules. Methods: Consecutive ultrasound imaging records of patients with multinodular goiter from January 2010 and December 2015 who underwent surgery were retrospectively reviewed. The risk of malignancy of each TIRADS category was determined and correlation with pathology was assessed. The patients with malignant cytology findings (Bethesda 6) who were categorized TIRADS 6 were excluded from the study. The positive and negative predictive values, sensitivity, specificity and accuracy of the TIRADS classification was calculated on 2x2 table with their own formulas. Results: A total of 949 nodules were evaluated and 917 of these were included to study. The risk of malignancy for nodules evaluated as TIRADS 2 was 0%, for TIRADS 3 it was 8.9%, for TIRADS 4A it was 10.9%, for TIRADS 4B it was

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64.7% and for TIRADS 5 it was 95% (p<0.001). The positive predictive value of TIRADS classification was found 70.3%, negative predictive value was found 94.9%, sensitivity was found 64.9%, specificity was found 96% and accuracy was found 92% for our institution. Conclusion: The TIRADS classification based on suspicious ultrasound findings is reliable in predicting thyroid malignancy and can be routinely used in daily practice. P18 Intraoperative tissue distinction during robotic adrenalectomy using indocyanine green fluorescence: A Case Report AC Dural 1 , C Akarsu 1 , NA Sahbaz 1 , B Kankaya 1, M Karabulut1, H Alis1 1

Bakirkoy Dr. Sadi Konuk Training and Research Hospital, Department of General Surgery, Istanbul, Turkey Introduction: Indocyanine green dye with near-infrared fluorescent (ICGNIRF) imaging has been used to identify tumoral tissue and its resection margins in robotic surgery. We aimed to describe our initial experience with ICGNIRF imaging during robotic right adrenalectomy in a patient with Cushing’s syndrome. Case Presentation: A 36 year old female patient was referred for adrenalectomy from Endocrinology with a diagnosis of Cushing’s Syndrome. Computed tomography imaging of the adrenal gland revealed a 13x10 mm sized adrenal mass on the right side. Robotic lateral transabdominal adrenalectomy for the right adrenal mass was planned. She was positioned in the left lateral decubitus position. Four trocars were placed on the upper right quadrant. The robot was docked and using a Maryland grasper and Cadiere forceps, the gland was circumferentially dissected. Two mL (2.5 mg/mL) dose of ICG solution was administered intravenously and the robot toggled to NIRF mode. Seconds later, the adrenal parenchyma became fluorescent and approximately at 4th minute, has become optimal for tissue distinction. The adrenal vein was isolated, clipped, and divided. Robotic adrenalectomy was successfully performed with no fluorescent tissue left behind. Adrenal tissue was removed using a specimen bag and the robot was undocked. The total procedure time was 110 minutes. The patient was discharged uneventfully at postoperative day 2. Conclusion: The ICGNIRF imaging during robotic adrenalectomy might be useful especially in patients with Cushing’s syndrome. A real-time image guidance may help identify the borders of the adrenal gland especially in patients with bulky adipose tissue.

P19 The role of adrenal tumor boards in disease management and decision making D Guzey1, H Alis1, HA Kabuli1, NA Sahbaz1, AC Dural1, C Akarsu1, I Halicioglu1, M Mert2 1

Bakirkoy Dr. Sadi Konuk Training and Research Hospital, Department of General Surgery, Istanbul, Turkey; 2Bakirkoy Dr. Sadi Konuk Training and Research Hospital, Department of Endocrinology, Istanbul, Turkey Introduction: The aim of our study is to investigate the impact of adrenal tumor board (ATB) in the management of adrenal gland diseases. Methods: The data of patients with adrenal diseases evaluated in the ATB rounds between May 2013 and November 2016 were reviewed retrospectively in terms of demographics, diagnostic, laboratory, imaging, surgery and histopathology results from the hospital records. Results: The mean age of 109 patients was 54.1±12.2 and the F/M ratio was 70/39. Twentyfive patients were presented to the ATB by endocrinology, 63 by surgery and 21 by pathology department. A total of 34 patients were presented twice, 12 were presented three times to the ATB. In the first round, a decision for surgery was taken for 41 patients and followup decision without any intervention was taken for 15 patients. Additional tests were requested from 50 patients and 14 of them underwent surgery as a result of these investigations. Also, surgery decision was made for 2 of 9 patients whom imaging was requested at the first round. In 6 of 46 patients (13%) the ATB has changed the decision in favor of surgical intervention in second or third rounds, during their followup or their further investigation. Conclusion: Today, multidisciplinary boards are located in the center of modern disease management. The discussion of the cases in these meetings may lead to change the management of patients. Similarly, in our series, 13% of reevaluated patients resulted in management changes following the ATB rounds. P20 Thyroglobulin after surgery in differentiated thyroid cancer. When does thyroglobulin help us to identify relapse? I Osorio Silla1, J Gómez Ramírez1, S Rivas Fidalgo1, P Tejedor1, I López Rojo1, A Gómez Valdazo1, M DíazMiguel Maseda1

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Neck and Breast Surgery Department, Fundactión Jimenez Díaz, Madrid, Spain

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Introduction: Risk stratification in differentiated thyroid cancer (DTC) is based on a continuous and dynamic evaluation. Nowadays, not base only on histopathological findings and TNM classification, but also clinical factors including thyroglobulin (TG) concentration both stimulated and on LT4, therapeutic management, and the response to treatment administered are considered. However, which prognostic factors are the most reliable to adequately assess the risk of relapse in DTC is still ongoing. The aim to this study was to evaluate the utility of TG concentration at different times of follow-up in DTC to predict tumor recurrence. Material and methods: Retrospective study of 141 DTC staged pT1-T4NO-N1M0, in whom total thyroidectomy +/lymphadenectomy and complementary radioiodine (RAI) treatment were carried out between 2010 and 2014. Patients were divided according to tumor recurrence, and were compared TG concentration (postsurgical, post RAI and at first year of follow up). Median follow-up was 3 years (2-4,2). Discussion: 15 patients (11%) presented with tumour relapse. The TG level post-surgical, post RAI and at year of follow up were found to be statistically significant in univariate analysis. Stimulated TG level, evaluated before adjuvant RAI treatment, were statistically significant in both univariate and multivariate analyses. The patients with relapse shown, 92% TG postsurgical on LT4 > 1.19 ng/ml, 73% stimulated TG postsurgical >10.4 ng/ml, 72% TG on LT4 > 0,55 ng/ml and 73% stimulated TG > 3,08 ng/ml at first year of follow up. Patients with stimulated TG postsurgical >10.4 ng/ml, unspecified neck ultrasound and vascular invasion shown increased risk of recurrence. Conclusion: TG concentration at different times of follow-up is useful for predicting early tumor recurrence. TG level postsurgical on LT4 provides greater sensitivity, while stimulatedTG post-surgical and in a year provides greater specificity. According to multivariate analysis, stimulated-TG postsurgical is an independent predictor of relapse, significantly increasing recurrence risk if its value was> 10.4 ng/ml. P21 Delta calcium as a reliable predictor of early post thyroidectomy hypocalcaemia for early safe discharge WA Abo Elwafa1, AS Nabawi1, HF Al Wagih1, MH Fayad1 1

Deprtment of Head, Neck and Endocrine Surgery, Alexandria University, Faculty of Medicine, Alexandria, Egypt Background: Hypocalcaemia is the most common complication after total thyroidectomy, It is usually manifests itself (2472h) postoperatively, which interfere with early safe

postoperative discharge. The aim of our study was to assess sensitivity and specificity of delta calcium (Δ Ca = preoperative Ca - 20h postoperative Ca) in early prediction of post thyroidectomy hypocalcemia. Methods: The study included 116 patients who were subjected to total thyroidectomy. Preoperative and postoperative corrected serum calcium levels were measured at 6, 20 and 48 hours, hypocalcemia was defined as Ca level below 8.4 mg/dl at any time point and/or patient experiencing symptoms of hypocalcaemia. Ca levels and their differences between time points were compared. All hypocalcaemic patients were followed up at one and 6 months post-operatively. Results: 26 patients (22.4%) developed postoperative hypocalcaemia, 20 patients of them (17.24%) with transient hypocalcaemia and 6 patients (5.17%) with permanent hypocalcaemia. The number of patients with Ca levels < 8.4mg/dl at 20h and 48h were more than at 6h (p<0.001). The Δ Ca (preoperative ca - 20h postoperative ca) had the best area under the ROC curves (AUC = 0.87), and Δ Ca (>0.5) was significantly more frequent in cases of hypocalcemia (p < 0.001) with 80.77% sensitivity and 77.78% specificity. In our study the Δ Ca (preoperative ca - 6h postoperative ca) was significant if Δ Ca (>0.3) with (AUC = 0.82) and (p < 0.001) with 92.3% sensitivity and 63.3% specificity. Conclusions: Post thyroidectomy hypocalcaemia always occurs when ΔCa (preoperative ca - 20h postoperative ca) > (0.5). However, Δ Ca (preoperative ca - 6h postoperative ca) > (0.3) has a higher sensitivity with lower specificity compared to 20h one. The Δ Ca enabled us for early detection of patients with post thyroidectomy hypocalcaemia, and it can be a useful and cost-effective tool for early, safe discharge without routinely prophylactic calcium and vitamin D supplementation or PTH assay. P22 Thyroid petomas and malignancy S Ros1, C López2, F Herrerías1, A Lecube2, MC De La Fiente1, JA Baena1, JJ Olsina1 1

Endocrine Surgery, Hospital Arnau De Vilanova, Lleida, Spain; 2Endocrine, Hospital Arnau De Vilanova, Lleida, Spain Introduction: We have reviewed the thyroid petomas with focal uptake studied in our unit. We aimed to evaluate the possible associated factors of risk malignancy and a correlation between them. Material and methods: Twenty-six patients with thyroid Petomas were referred to our unit. We have reviewed the

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clinical charts, ultrasonographic (US) findings, FNA diagnostics and pathology reports of the patients who were operated on. We have analyzed the correlation between the different parameters and the SUV max uptake values of the PET. Discussion: Regarding to ultrasound findings, there were 3 patients without nodules. Thyroid malignancies were identified in 5 of the 21 patients who underwent cytologic correlation; these had a nodule size >2cm in 80%. Most of the u.s petomas features comparing the malignant and benign group didn’t show significant statistic differences, nevertheless the calcifications (macro and micro) almost reached it. In order to find correlation between the petomas and histopathology, we divided patients into two groups: Benign (B) and malignant (M); Two patients denied FNA so they were excluded. Five patients proved to be malignant (M) and 19 benign (B). In the B group 79.2% were female, the mean age was 63,4 years-old (M: 68,4), the majority of both groups had a neoplastic extrathyroidal past history. The SUV max median value in (B) was 5.4 (2.9-36.3) and in the (M) was 4.1 (3.7-5.9); The FNA results were benign in 57% of the cases and seven patients were operated on with a specimen malignancy outcome in 71% of them (medullary carcinoma: 28.5%, papillary carcinoma: 28.5% and in one case a thyroid invasion for squamous larynx carcinoma). Conclusion: According to our data there was no correlation between the SUV max and the histopathology results. Just a 21% of petomas’ patients resulted to have thyroid malignancy. Of all the US features of the petomas, calcifications only had a tendency to have a statistical significance. Additionally, in a small group with focal SUV uptake there weren’t any nodules or thyroid pathology.

database and classified in 2 groups (group AI and group NoAI). Patient history and staging abdominal CT scans were reviewed for associated comorbidities (arterial hypertension, diabetes mellitus, dyslipidaemia, cardiovascular disease, cardiac arrhythmias) and the presence and radiological characteristics of AI. Laboratory tests for hormone hypersecretion in cases of AI were additionally retrieved from patient files. Functioning adenomas, tumours >4 cm or with suspicious radiological features were resected, with serial follow-up offered to the rest of the patients. Discussion: In total, 303 patients were eligible for inclusion (157 males, 146 females, mean age 63±14 years, range 21-91 years), with 51 adrenal tumours discovered (16.8%). The two groups were comparable in terms of age, gender and prevalence of comorbidities, with the exception of arterial hypertension (67% in group AI vs 46% in group NoAI, p<0.01). Mean lesion size was 2.4±1.9 cm, while in 10 patients (19.6%) bilateral AI were found. Biochemical work-up revealed 3 cases of phaeochromocytoma (5.9%), 3 cases of subclinical Cushing’s syndrome (5.9%) and 1 case of aldosteronoma (1.9%). Indications for adrenalectomy included hormone hypersecretion (7 patients, 13.7%), suspicious radiology (4 patients, 7.8%) and increase in size >4 cm (6 patients, 11.8%). Final pathology confirmed the preoperative diagnosis in all patients, except for a haemorrhagic cyst initially described as metastasis. Conclusion: Prevalence of AI on CT scans is reported at 4% and up to 8% in autopsy series. Our cohort of oncological patients showed a much higher percentage of AI (16.8%), however only 16% represented functioning adenomas and 6% were malignant, with 78% being small, hormonally nonactive cortical adenomas, findings in agreement with those of the general population.

P23 Incidental Adrenal Lesions In Oncological Patients DK Manatakis, L Tzelves, D Balalis, A Tzortzopoulou, VN Soulou, DP Korkolis, GH Sakorafas, E Gontikakis, G Plataniotis 1

Department of Surgical Oncology, Agios Savvas Anticancer Hospital, Athens, Greece Introduction: The classic definition of adrenal incidentaloma (AI) excludes oncological patients. Our study investigated the prevalence and characteristics of AI in a cohort of unselected cancer patients, based on the hypothesis that a higher incidence of both AI and metastases would be expected.

Material and Methods: All consecutive adult patients admitted in our department with diagnosis of malignancy, either for primary treatment or follow-up, between January and October 2016, were identified from a prospectively maintained

P24 Early risk factors for start symptoms of postoperative hypocalcemia after total thyroidectomy L Romano-Torres1, EM Barajas-Fregoso2 1

Unit of Thyroid and Parathyroid, Hospital General de Puebla "Eduardo Vasquez", Mexico; 2Endocrine Surgery, Centro Medico Nacional Siglo XXI, Mexico City Background: Hypocalcemia is a common complication after total thyroidectomy. The symptoms are varied,and often presented with serum calcium below 8 mg/dl to 24 hrs after thyroidectomy. The purpose of this study is to determine early factors associated with these symptoms to total thyroidectomy (8 - 12hrs later) Materials and methods: Patients were included after total thyroidectomy for benign and malignant disease. measurements

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were: albumin, iPTH, calcium, phosphorus,magnesium were performed at 8-12 hrs post- surgical procedure and fast, in addition to demographic, clinical and biochemical variables of patients, documenting the presence or absence of symptoms of hypocalcemia, univariate and multivariate analysis was performed to identify factors associated with postoperative hypocalcemia symptoms. Results: Forty patients after total thyroidectomy for benign (57.5%) and malignant disease (42.5%) were included, mean age was 40.3+- 12.7 years, 32.5% (n= 13) of patients had symptoms of hypocalcemia, iPTH average was 26.45 +18.15 pg/ml, corrected calcium 7.88 +- 0.62 mg/dl. In 28.1% of the patients had postoperative hypoparathyroidism and 27.5% required intravenous calcium replacement. 53.9% of the cancer patients had symptoms of hypocalcemia. In the multivariate analysis: age (p = 0.038), nodule size (p= 0.30), central neck dissection (p=0.046), parathyroid manipulation (p = 0.022), iPTH (P = 0.001) and the corrected calcium (p = 0.001), were strong factors associated with symptoms of hypocalcemia. Conclusions: Predictors factors for symptomatic hypocalcemia were: iPTH less than 10pg/dl, Ca C under 7.4, and manipulation parathyroid. We recommend administer exogenous calcium intravenously to patients with these risk factors after thyroidectomy and fast, also add calcium and calcitriol for management of hypocalcemia after discharge. P25 Surgical Or Medical Treatment For Tertiary Hyperparathyroidism: A Systematic Review RR Dulfer1, GJH Franssen1, DA Hesselink2, EJ Hoorn2, CHJ van Eijck1, TM van Ginhoven1 1

Surgery, Erasmus MC, University Medical Center, Rotterdam, The Netherlands; 2 Nephrology and Kidney Transplantation, Erasmus MC, University Medical Center, Rotterdam, The Netherlands Introduction: A significant portion of patients with chronic kidney disease and secondary hyperparathyroidism (sHPT) remain hyperparathyroid after kidney transplantation, a state known as tertiary hyperparathyroidism (tHPT). Without treatment, tHPT can lead to diminished kidney allograft and patient survival. Parathyroidectomy was commonly performed to treat tHPT until the introduction of the calcimimetic drug cinacalcet. Currently it is unknown which treatment is superior. Methods: A systematic review was performed and medical literature databases were searched for studies written in English and published after 2003 (cinacalcet was approved in 2004) regarding the treatment of tHPT.

Results: A total of 1669 articles were identified of which 47 were included in the review. After subtotal and total parathyroidectomy initial cure rates were 98.7% and 100%, respectively, however in 7.6% and 4.2% of patients tHPT recurred. After treatment with cinacalcet, 81% of the patients achieved normocalcaemia. Due to side effects, 6.4% of the patients discontinued cinacalcet treatment. Although literature regarding graft function and survival is very limited, however renal graft survival after surgical treatment seems comparable to therapy with cinacalcet. Conclusion: Surgical treatment for tHPT has higher cure rates than medical treatment. Side effects and complications of both treatment modalities were mild and occurred in a minority of patients. Data regarding clinical endpoints is scarce. This systematic review suggests that (sub)total parathyroidectomy is the preferred treatment for tHPT. P26 Impact of continuous vagus stimulation on surgical technique in emergency thyroidectomy due to compressive goiter R Schneider 1 , M Elwerr 1 , C Sekulla 1 , K Lorenz 1 , A Machens1, H Dralle1,2 1

Department of General, Visceral, and Vascular Surgery, Martin Luther University Halle-Wittenberg, Halle/Saale, Germany; 2 Department of General, Visceral and Transplantation Surgery, Section of End, University of Duisburg-Essen, Essen, Germany Background: Emergency thyroidectomy (ET) due to compressive goiter constitutes a minute percentage requiring distinguished agility. Continuous vagus stimulation (CVS) alerts the surgeon to the imminent risk of traction induced recurrent laryngeal nerve (RLN) damage and thereby decreases the risk of permanent nerve damage. This lack of data regarding the use of intraoperative neural monitoring in patients with ET prompted this study, which aimed the impact of CVS on surgical technique in such extreme cases based on the experience of 214 patients with elective retrosternal and mediastinal goiter thyroidectomy. Methods: A series of 7 emergency thyroidectomies with CVS in a life-threatening setting were performed between January 2011 and June 2016, which fulfilled the following criteria: Severe tracheal compression with intubation on standby, or global respiratory insufficiency due to tracheal compression requiring intubation. Discussion: In 5 patients (71%) total thyroidectomy, in 2 patients (29%) lobectomy was performed using adjusted craniocaudal thyroid approach; of which transsternal approach

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was necessary in 1 case. Median baseline amplitude was significantly lower compared to elective retrosternal and mediastinal goiter thyroidectomy (552 μV vs. 900 μV, p<0.001) without differences in latency baseline (6.82 ms vs. 6.04 ms). No postoperative complications as transient hypoparathyroidism, bleeding, postoperative infections or new cases of RLN palsy nerve were documented. No postoperative mortality occurred. Median hospital stay in ET was 25 days (range: 9 to 42 days). Conclusions: In a high volume center, immediate ET in an impending or manifesting respiratory failure due to tracheal compression is a safe procedure with an excellent postoperative outcome. CVS offered highest safety for the RLN function in transcervical removal of extended retrosternal and mediastinal goiter using adjusted craniocaudal thyroid approach, which might diminished the number of transsternal approaches. P27 A rare case of hyperparathyroidism in a teenage boy MLMG Matthey Gie1, MM Matter1, ND Demartines1, MH Hauschild2, TB Bouthors2, AP Pfenniger2

surgery with oral calcium and calcitriol (asymptomatic hypocalcemia). The anatomopathology confirmed a parathyroid adenoma. There was no family history. Discussion and Conclusion: In the last four decades less than 400 cases of paediatric PHPT were reported in the literature, representing only a few percent of all PHPT patients. In the present case, as showed in previous reports, young patients are more symptomatic compared with adult patients requiring in hospital medical management. In adults, a parathormone level higher than 3-10 times above the upper normal limit is highly suspicious for malignancy, but is regularly seen in children. PHPT should be suspected in young patients suffering from recurrent nephrolithiasis. Investigations and surgical managements are similar for paediatric patients and adults including scintigraphy, cervical exploration and in case focused surgery. P2811C-Methionine PET/CT role in a selected sample of patients with primary hyperparathyroidism and inconclusive preoperative work-up D Maccora1, C Caldarella2, A Giordano1, I Bruno3 1

1

Visceral surgery, University Hospital, CHUV, Lausanne, Switzerland; 2Paediatric Unit, University Hospital, CHUV, Lausanne, Switzerland Introduction: Primary hyperparathyroidism (PHPT) in children is rare. Few reports are listed in the literature. In such patients, symptoms seem to be more severe than in adult affecting first the kidneys and bones. We report a case of a teenage boy who was diagnosed with a PHPT found after a first episode of nephrolithiasis. Case Report: A 14-year-old boy was admitted in a regional hospital for a first episode of nephrolithiasis and screened for phosphocalcic disorders. The blood tests showed a disquieting parathormone level (PTH 527pg/ml, N: 15-70) suspect for malignancy and a severe hypercalcemia (4.19mmol/l) with hypophosphatemia (0.82mmol/l). The ultrasound showed a nodule (1.6 x 1.1 x 1.8 cm) behind the left thyroid lobe and 99mTc MIBI with SPECT-CT suggested a left posterior parathyroid adenoma. Following his transfer in a paediatric unit, he suffered from a symptomatic hypercalcemia (nausea, vomiting, acute renal failure and QT shortening) requiring iv fluids, diuretics, calcimimetics and synthetic calcitonin. At cervical focused exploration in the left side a large posterior parathyroid adenoma was removed en bloc with the left thyroid lobe due to the vascular anatomy and in order to protect the laryngeal nerve. Intraoperative PTH level decreased more than 50% (T0=743pg/ml; T10=133pg/ml) from baseline after 10 minutes. The patient was discharged at home 6 days after

Institute of Nuclear Medicine, Università Cattolica del S. Cuore “A. Gemelli”, Rome, Italy; 2 PET-CT Center, Policlinico “A. Gemelli”, Rome, Italy; 3Nuclear Medicine Unit, Policlinico “A. Gemelli”, Rome, Italy Introduction: Surgical strategy in patients with primary hyperparathyroidism (pHPT) needs pre-operative imaging. Accuracy of MIBI scan in detecting abnormal parathyroid glands is well-known; PET/CT using 11C-Methionine (CMET) is a promising method in this field. Aim of the study was to evaluate the role of additional C-MET on the surgical planning in patients with difficult diagnostic work-up (normocalcaemic pHPT, inconclusive or contradictory results at conventional imaging). Material and Methods: We included all the patients with pHPT who underwent parathyroid surgery having C-MET in our hospital after an inconclusive/contradictory preoperative conventional work-up (MIBI or ultrasound). Histological diagnosis, postoperative normalization of serum calcium and parathyroid hormone (PTH) were the reference standard. Diagnostic performance of C-MET alone and of the integration of the two techniques were compared. Analysis was based on the identification of the correct side of the neck and of each abnormal gland. Discussion: Eighteen patients were included: 16 had a parathyroid adenoma removed, 2 had negative surgical exploration. Median calcium and PTH values were 11.30 mg/dl [interquartile range (IQR) 10.47-11.97] and 159.80 pg/ml (IQR 99 .9 5-2 29 .1 5) , r es pe ct i v el y. S ev en pat i ent s ha d

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normocalcaemic pHPT. The median weight of the excised glands was 0.50 g (IQR 0.27-1.32). MIBI correctly detected the side in 2 patients, the abnormal parathyroid gland in 5 patients; C-MET correctly detected the side in one patient, the abnormal gland in 11 patients. Sensitivity, specificity and accuracy for C-MET in detecting the correct side of the abnormal gland were 80%, 67% and 78%, respectively; in detecting each abnormal gland were 79%, 50% and 72%, respectively. The integration of MIBI and C-MET correctly identified the side of the abnormal gland with sensitivity, specificity and accuracy of 88%, 100% and 89%, respectively; and correctly identified each abnormal gland with 86%, 50% and 78%, respectively. Clinical data showed no significant correlation with either MIBI or C-MET results. Conclusion: According to these preliminary results, the integration of both MIBI and C-MET in patients with inconclusive/contradictory results at standard diagnostic work-up, as for normocalcaemic pHPT, showed the highest accuracy in detecting hyperfunctioning parathyroid glands. To date, clinical data could not guide in choosing which single method should be preferred. P29 Follicular Thyroid Carcinoma Presenting As Skull Metastasis: A Case Report And Literature Review A Gómez Valdazo, I López Rojo, J Gómez Ramirez, I Osorio Silla, M Sánchez de Molina, S Rivas Fidalgo, M Díaz-Miguel

Discussion: FTC are slowly growing in nature and tend to metastasize in advanced stage by haematogenous route, being the lung and bone the most common sites. Bone metastases tend to be multiple and more often to ribs, vertebrae, and sternum, but involvement of the skull is unusual. Radical resection of bone metastasis is associated with improved survival. Although there is no evidence of the impact of surgical debulking of skull metastasis on outcome of FTC, it is currently accepted that the best therapy includes complete excision of the thyroid gland and removal of as much of the metastatic focus as possible. Internal radioactive iodine therapy is recommended; external radiation is generally reserved for cases where uptake of I-131 by the metastastatic site is weak. Finally, chronic suppression of endogenous TSH should be induced by the administration of thyroid hormone to prevent tumor growth. Measurements of circulating thyroglobulin to predict recurrences might be useful. P30 Comparison of Effects of Energy Based Devices on Quality of Life After Sutureless Thyroidectomy AE Arikan1, S Teksoz1, O Dulgar2, D Teksoz3, M Ozcan1, R Ozgultekin1, Y Bukey1, MA Ozyegin1 1

Department of General Surgery, Istanbul University, Cerrahpasa Medical Faculty, Istanbul, Turkey; 2Department of Internal Medicine, Istanbul University, Cerrahpasa Medical Faculty, Istanbul, Turkey; 3 Department of Biochemistry, Istanbul University, Cerrahpasa Medical Faculty, Istanbul, Turkey

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Cirugía General, sección Cuello y Mama, Fundación Jiménez Díaz, Madrid, Spain Background: Follicular thyroid carcinoma (FTC) is associated with a favourable long-term survival. However, the prognosis is known to be worse for patients with distant metastases. Skull is a rare site for metastases; and in most of the reported cases, this occurs long after the diagnosis and institution of treatment for primary cancer. There have been only a few cases reported in literature with skull metastasis as the presenting feature of an occult FTC. Case presentation: A 69-year-old male patient presented with a rapidly growing, soft, painless lump in the occipital region of skull. Magnetic resonance imaging of the brain demonstrated a 3 cm homogeneous, enhancing mass, centred in the posterior calvarium, which extended partially into the surrounding soft tissue and the superior sagittal sinus, but without any invasion of the brain parenchyma. Histopathological analysis after partial resection was consistent with FTC metastasis. Thyroid ultrasound showed a 13 mm hypoechoic nodule in the right lobe and a 55 mm heterogeneous nodule in the left lobe, without lymph node affectation. The patient underwent a total thyroidectomy and internal radioactive iodine therapy.

Introduction: With developing technology, treatment of diseases is also eased along with diagnosis of diseases. Energybased vessel-sealing-devices(EBVSD) are leading technology that shortens duration of operation and helps to surgeon. Examples of EBVSDs are:Ligasure™(Medtronic,MN), Harmonic (Ethicon Endo Surgery,CN), and Thunderbeat (Olympus Co Inc, Tokyo,Japan). Even though, benign thyroid diseases are not life-threating, they disrupt quality-of-life (QoL). In literature, it was shown that after thyroidectomy QoL of patients get better, however effect of EBVSDs is not assessed yet. Material and methods: ThyPRO-39 was translated to Turkish according to method of WHO. ThyPRO-39-TR was applied to 200 patients, who underwent sutureless total thyroidectomy(STT) with either two EBVSDs (100 for each:Ligasure™ LF1212 and Harmonic Focus®) in our department for benign thyroid diseases and does not fall into exclusion criteria. All patients received 50mcg levothyroxine sodium, 75mg diclofenac sodium, 1000mg calcium, and 880IU Vitamin-D3 post-operatively. This study is registered on ClinicalTrials.gov with number of NCT02683551. Authors have no conflict of interest.

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Results: Patient files, hospital-information-system-records, operative-notes, pathology-reports of 1032 patients who underwent to STT between January 2014 – May 2016 were assessed. Eight hundred thirty-two patients were excluded due to malignancy, simultaneous another operation, vocal-cord palsy, co-existing systemic/psychiatric disease, non-hypo/hyper-thyroidism or incidental parathyroidectomy. While there was no dropped cases in Harmonic group, seven of Ligasure™ group patients dropped due to change of contact information. There was no statistical difference between groups for age, gender, body-mass-index, and tobacco use. Demographics and distribution of diagnosis are given in table. Only “Eye symptoms” and “Cognitive functions” domains of that 13 domains of ThyPRO-39-TR were better in Harmonic group. Values and domains are given in Table. Discussion: Each question in eye symptoms showed significant improvement in Harmonic group while there was nonsignificant decline in Ligasure™ group. This difference may be related with existence of more Graves patients in Harmonic group. Two-of-three questions related with cognitive functions were improved in Harmonic group and the other question showed decline in Ligasure™ group. This difference may be related to disruption of regional-homogeneity in brain due to electrical activity of Ligasure™.

respect to clinical manifestations, extent of disease, distant metastasis, treatment modality and cause of death. Results: Mean age was64.5 years, and male/female ratio was 19/33. Most of the patients (59.6%) presented with a growing mass at the point of diagnosis, followed by hoarseness (26.9%) and pain (21.2%). Extrathyroidal extension (Stage T4b) was seen in 33 (63.5%) patients. In 32 patients, metastasis was observed with lung metastasis being the frequently seen (96.9%). As treatment modalities, surgery (33 patients 63.5%), chemotherapy (27, 51.9%), targeted therapy (16, 31.4%) and radiotherapy (32, 61.5%) was performed, whereas combination therapy was observed in 45 patients. In KaplanMeier analyses, multimodality treatment showed better survival than no treatment (p<0.005). Furthermore, multimodality treatment showed prolonged survival in T4b cancer and in cases with distant metastasis. Conclusion: ATC is an aggressive cancer with advanced stage at time of presentation. Active multimodality treatment may be considered to prolong survival in T4b and M1 cases. P32 Management of advanced thyroid cancer with mediastinal metastasis SY Kim1, SM Kim1, YS Lee1, TI Yun2, HS Chang1, CS Park1

Conclusion: When Harmonic is used during STT for benign thyroid diseases, cognitive functions and eye symptoms get better than Ligasure™ was used.

1

Thyroid Cancer Center, Department of Surgery, Gangnam Severance Hospital, Yonsei Universtiy College of Medicine, Seoul, Korea; 221st Women's Clinic, Gyeonggi-do, Korea

P31 Multi-modality treatment in anaplastic thyroid cancer SY Kim1, SM Kim1, YS Lee1, TI Yun2, HS Chang1, CS Park1 1

Thyroid Cancer Center, Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea; 2Department of Surgery, 21st Women's Clinic, Gyeonggi-do,South Korea Introduction: Anaplastic cancer is the most aggressive and rapidly progressing malignant human neoplasms with a grave prognosis. An aggressive treatment may be attempted for tumors at an early stage, but the optimal management of this disease remains controversial especially for cancer at advanced stage with distant metastasis. The aim of this study was to introduce the outcome of multi-modality treatment in 52 cases of ATCs over a 13-year period in our institution. Material and Methods: Between January 2003 and October 2016, 52 patients of ATC who were treated at the Thyroid Cancer Center, Gangnam Severance Hospital, Yonsei University College of Medicine were enrolled in this study. These patient’s records were retrospectively analyzed with

Background: In thyroid cancer, mediastinal lymph node metastases are extremely rare. But the invasiveness of the disease leads often to significant morbidity and also to frequent cause of death. As treatment options, surgery, radio-iodine therapy, external beam radiation and targeted therapy is known, but as non-surgical therapy are not effective, only surgery can provide the only change for these patients. Material and Methods: Between October 2000 and November 2016, 195 patients who underwent mediastinal dissection for thyroid cancer metastasis at the Thyroid Cancer Center, Gangnam Severance Hospital, Yonsei University College of Medicine were enrolled in this study and retrospectively analyzed. Chart and imagings were reviewed for clinical characteristic, extent of surgery, pathology and follow-up. Results: There were 80 male (41.0%) and 115 female (59.0%) patients with a mean age of 49.9 ±15.1 years. 118 patients (60.5%) presented with synchronous mediastinal metastasis and the most common cancer type was papillary thyroid cancer (165 patients, 84.6%). In 35 patients (18.3%) there was distant metastasis observed at time of surgery, whereas 13

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(6.7%) developed distant metastasis during follow-up. In 46 cases, combined resection of either trachea (8, 4.1%), lung (5, 2.6%), major vessel (12, 6.2%) or nerve (21, 10.8%) was performed. Transcervical approach was the most common (126 cases, 64.6%), followed by full sternotomy (40, 20.5%) and partial sternotomy (24, 12.3%). Median follow-up was 40.6 months [18.8; 64.9] with overall survival of 91.3% of the patients. In 17 (8.7%) patients, disease related death occurred. Recurrence was observed in 47 (24.1%) patients with median time to recurrence of 19 month [8.4; 31.7].

Conclusion: There is a significant number of patients with concomitant thyroid and parathyroid disease which justifies the routine analyses of calcemia and PTH level in these patients because they are only reliable parameters of potential hyperparathyroidism diagnosis in patients undergoing thyroidectomy. Furthermore, we believe that it is reasonable to perform simultaneous parathyroidectomy in normocalcemic patients with primary hyperparathyroidism during thyroidectomy in order to prevent the development of hypercalcemia and other symptoms.

Conclusion: Aggressive surgical treatment for locally advanced well- differentiated thyroid carcinoma may offer improved local control of disease, prolonged palliation and opportunity for cure in selected patients.

P34 4D-CT: additional alternative for localization of undetected parathyroid adenoma – a case series

P33 Operations On Parathyroid Glands In Patients Who Underwent Thyroid Surgery B Rovcanin1, V Zivaljevic1, M Jovanovic1, G Zoric1, N Slijepcevic1, K Tausanovic1, A Diklic1, I Paunovic1 1

Center for endocrine surgery, University of Belgrade, Faculty of medicine, Belgrade, Serbia Introduction: Primary hyperparathyroidism is A disease characterized by increased serum calcium levels which are associated with inappropriately high PTH concentration. Nevertheless, some patients have normocalcemic primary hyperparathyroidism in which the blood parathyroid hormone (PTH) levels are higher than normal but the blood calcium level is normal. Criteria for diagnosing normocalcemic hyperparathyroidism include increased serum PTH values, normocalcemia, no previous episodes of hypercalcemia, normal values of serum vitamin D and excluded secondary hyperparathyroidism. In most cases, diagnosis is obtained incidentally, during the thyroid disease evaluation or preparation for surgery. Material and Methods: We present the results of the retrospective study that evaluated the incidence of normocalcemic primary hyperparathyroidism in the group of 4033 patients who underwent thyroidectomy from 2009 to 2014 in the Center for Endocrine Surgery, Clinical Center of Serbia. Discussion: Out of 4033 patients in 114 (2.8%) of them, the parathyroidectomy was simultaneously performed due to the concomitant disease. In the group of these 114 patients, 42 patients (37%) were identified to have normocalcemic primary hyperparathyroidism. Among them the mean serum PTH values were 120.2 ± 57 pg/ L. In all cases the parathyroidectomy of a single parathyroid gland has been performed.

FW Watzka1, JT Theurer1, KO Oberholzer2, HL Lang1, TJM Musholt1 1

Endocrine Surgery Section, University Medical Center University Mainz, Mainz, Germany; 2Radiology, University Medical Center University Mainz, Mainz, Germany Backround: The preoperative localization of parathyroid adenomas in case of a hyperparathyreoidism is challenging. In 25% the traditional sonography and nuclear scintigraphy techniques fail in localisation of the adenoma. A novel method of multiphase CT imaging (4D-CT) seems to promise higher diagnostic accuracy. In our study we analysed our first patients with 4D-CT in view to accuracy of the preoperatively and the surgically/pathologically proved localization of parathyroid adenomas. Materials and Methods: A total of 23 pathologically cases of parathyroid adenoma were retrospectively reviewed between october 2014 and july 2016. Patients with negative sonography and nuclear scintigraphy results or following unsuccessful neck-exploration were subjected to preoperative 4D-CT and included in the study. Results: In all of the 23 pathologically proved cases collected over the study period the parathytoid adenoma could be located preoperative using the 4D-CT, including 4 cases of multigland disease. In 4 cases the 4D-CT was used after a cervical exploration in which the adenoma remained undiscovered. In our patient collective the 4D-CT showed an accuracy of 100% for single-gland- and for multigland disease. Conclusion: 4D-CT demonstrated a very high diagnostic accuracy for single and multigland disease in our study group. We recommend performing 4D-CT in case of a hyperparathyroidism with uncertain localization of the adenoma. With an exact preoperative localisation, a focussed approach can be performed and unnecessary cervical exploration can be avoided.

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P35 Update on neuroendocrine pancreatic tumors – a retrospective single center analysis of 134 cases over a 26year period FW Watzka1, FM Meyer1, CS Schwarz1, CF Fottner2, HL Lang1, TJM Mushot1 1

Endocrine Surgery Section, University Medical Center University Mainz, Germany; 2Endocrinology and Metabolic Diseases, University Medical Center University Mainz, Germany Background: Pancreatic neuroendocrine tumors (PNET) are rare tumors, but have been increasing in incidence. Compared to exocrine pancreatic carcinomas treatment and prognosis are significantly different. Methods: In a retrospective single-centre study from 1990 to 2016 134 patients with PNETs were analyzed. Clinical data were collected in the MaDoc database of the university medical center Mainz. Results: According to the NET classification by the WHO in 2010, 43% (n=58) of patients were grade-1, 37% (n=49) were grade-2, and 20% (n=27) were grade-3. In 65 patients hepatic metastasis were present, 59 patients had lymph node metastasis. An R0-resection was achieved in 77 cases, an R1 situation in 7 cases. 6 times a tumor debulking was carried out (R2) and 7 times the operation was aborted without any resection because of the advanced tumor stage. A relapse occurred in 9 patients. Different prognostic factors (stage, grade, tumor size, age) were analyzed. Grade-dependent 10-year survival rates were 93.7% (grade 1), 66.0% (grade 2) and 13.8% (grade 3). Conclusion: PNETs have a good prognosis, if they are welldifferentiated and resected completely. In case of hepatic metastasis and advanced tumor stage a tumor reduction can reduce the hormonal symptoms and improve the survival time, even so the prognosis remains very poorly.

of AI to exclude functionality and malignancy. This has been shown to be poorly done in secondary care. This audit was undertaken to assess the impact of general clinician feedback and education on the investigation of AI in secondary care. Materials and Methods: A keyword search of abdominal computed tomography (CT) scans performed in one NHS Foundation Trust from 1st January - 31st December2010 and 2015 was undertaken. Case notes were reviewed to determine subsequent investigation and management. The results from the 1st audit (2010) were fed back to general clinicians and radiologists at departmental meetings with the expectation that this would improve the investigation of these lesions. Discussion: 4028 and 6205 CT scans were reviewed from 2010 and 2015 respectively. AI were reported ina significantly higher percentage of CT scans (p<0.0001)in 2015than 2010 735/6205 (11.8%) v 75/4028 (1.9%). Excluding oncology patients with concurrent primary malignancy in another organ and those who died within 3 months of their scan, 49 patients in 2010 and 486 in 2015 should have been investigated.There was no difference in the percentage of AI referred for specialist work-up 13/49 (26.5%) and 119/486 (24.5%) or received no further investigation36/49 (73.5%) and 338/486 (69.5%), but a smaller percentage (p=0.01) underwent further imaging without biochemical investigation in 2015 29/486 (6.0%) versus 8/49 (16.3%). Conclusion: Feedback of the 2010 audit to radiologists resulted in significantly more AI being reported in 2015. The higher (11.8%) prevalence of AI seen in 2015 is consistent with prospective studies from tertiary care, and the lower (1.9%) prevalence in 2010, with retrospective studies from routine clinical practice. General clinician feedback at departmental meetings has had no impact on the investigation of AI. Different strategies need to be adopted to improve AI investigation. P37 Diagnosis And Management Of Thyroid Incidentaloma

P36 Impact Of Clinician Feedback On The Investigation Of Adrenal Incidentalomas

R Fedor1, D Kovács1, M Andrási1, S Barna2, EV Nagy3, F Győry1

B Searle1, SR Aspinall1

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General Surgery, Northumbria Healthcare NHS Foundation Trust, Newcastle Upon Tyne, UK Introduction: Incidentalomas are lesions found coincidentally on radiological investigation of an unrelated condition. The prevalence of adrenal incidentalomas (AI) is rising with increased cross sectional imaging. Guidelines universally recommend clinical, biochemical and radiological investigation

University of Debrecen, Clinical Center, Institute of Surgery, University of Debrecen, Debrecen, Hungary; 2Scanomed LTD, Scanomed diagnosctic LTD, Debrecen, Hungary; 3 Institute of Internal Medicine, University of Debrecen, Debrecen, Hungary Introduction: Thyroid incidentalomas are detected by imaging investigations unrelated to the thyroid gland. With the increasing use of cross-sectional imaging and screeening measurements, the prevalence of these lesions increases. These

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nodules are always asymptomatic, mostly benign, but rarely malignant disease or the suspicion of malignancy could occure. The management of these lesions is controversial and the optimal strategy for treatment is unknown. Material and methods: We investigated a five years period from january 2011 to december 2015. We evaluated the diagnostic steps, the operational methods and analyzed the histological results and the complications. Discussion: In the investigated period 2323 thyroid operations were performed in our institution, including 276 cases (11,88%) of asymptomatic incidentalomas. The ultrasonography was positive in almost all cases, while „cold nodule” was shown in 71 cases (25,72%) on 99mTc scintigraphy. The 99m Tc-MIBI scan was positive in 9,78%. The nodules were smaller than 3cm in almost 70% of the cases, and the lesion was uninodular in 51,81%. During the diagnostic process ultrasonography guided aspiration and cytology was performed in 162 cases (58,7%). The indication for surgery was based on the suspicion of malignancy in more than 60% of these cases. Lobectomy or thyroidectomy/near-total thyroidectomy was performed in almost all cases. The final histology was malignant in 44 cases (15,94%). Postoperative complication occured in 13 patient (4,71%). Recurrent laryngeal nerve paresis was found in only one case (0,36%), and 6 patient suffered from postoperative hypocalcaemia (2,17%), but only one was permanent. Conclusion: The prevalence of the thyroid incidentaloma is increasing. During the diagnostic procedures our aim is to detect the malignant or the suspected lesions. The indication for surgery are based on ultrasonographic signs (including the patterns for malignancy) and the results of the cytologic- and scintigraphic measurements. Definitive operational treatment is suggested in consideration of the low complication rate.

Material and Methods: The aim of a study was to assess usefullness of laparoscopic procedures for treating adrenal cancer. Results. During 48 months, 209 adrenalectomies were done. In 27 patients (12,9%) in histopatological examination carcinoma of adrenal gland was found. In 11 patients (40,8%) primary carcinoma of adrenal cortex. In 12 patients (44,4%) metastatic tumors were found in remaining 4 patients other rare carcinomas were diagnosed. All patients were operated on: 23 (85,2%) of them had laparoscopic adrenalectomy and in 4 cases (14,8%) an open adrenalectomy was performed, among them one conversion to an open method was done. There was no serious complications and no deaths were observed. Average time of hospitalization was 9.8 days. Longer hospitalization was due to patient transfer to other medical center for combined therapy. Average time for open method was 140 minutes and for laparoscopy was 190 minutes with statistical significance (p=0,02). There was no statistical significance in duration of laparoscopic adrenalectomy in cases of tumors with median diameter 50mm and larger (p=0,16). Conclusions: Laparoscopic adrenalectomy is safe and effective method of treatment for adrenal gland carcinoma. For well trained teams is comparative to classical method in aspect of oncological radical treatment P39 Association Of Preoperative Neutrophil-ToLy m p h o c y t e R a t i o W i t h C l i n i c o p a t h o l o g i c a l Characteristics Of Papillary Thyroid Microcarcinoma D Balalis, DK Manatakis, VN Soulou, L Tzelves, A Tzortzopoulou, DP Korkolis, GH Sakorafas, G Plataniotis, E Gontikakis 1

P38 Laparoscopic adrenalectomy as a treatment of adrenal carcinoma – single center study 1

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S Toutounchi , E Krajewska , R Pogorzelski , P Fiszer , K Celejewski1, N Wrzesinska1, M Legocka1 1

Department of General and Endocrine Surgery, Medical University of Warsaw, Warsaw, Poland

Introduction: Adrenal carcinoma is found in 10% of all cases of adrenal gland tumors. It is difficult diagnostic problem and therapeutic as well. Many metastatic tumors may be found in adrenal glands. In some patients with different carcinomas such metastases may be found in 25% of all cases. They may be treated with open surgery as well as with laparoscopy.

Department of Surgical Oncology, Agios Savvas Anticancer Hospital, Athens, Greece Introduction: The prognosis of papillary thyroid microcarcinoma (PTMC) is generally excellent; however there is a small percentage of tumours with aggressive clinical and pathological characteristics. Our study assessed the association of the preoperative neutrophil – to – lymphocyte ratio (NLR), a surrogate inflammatory response marker, with clinicopathological characteristics of PTMC. Material and Methods: Adult patients diagnosed with PTMC from 2011-2015 were identified from a prospectively maintained thyroid surgery database. Patient files and histopathology reports were retrospectively reviewed. Comparison of clinical and pathological characteristics (age, gender, thyroid specimen weight, dominant nodule size, presence of

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lymphocytic thyroiditis) as well as biochemical tests (TSH, total WBC, neutrophil and lymphocyte differential counts) was performed. NLR was calculated as the absolute neutrophil count divided by the absolute lymphocyte count, based on the preoperative complete blood cell count. Discussion: In total, 113 PTMC were included in the analysis (31 males, 82 females, mean age 52±11 years). Baseline NLR was significantly increased in patients ≥45 years (2.68±0.99 vs 2.29±0.93, p=0.03) and in those with multifocal and bilateral lesions (2.65±1.05 vs 2.25±0.88, p=0.02, and 2.79±1.14 vs 2.28±0.87, p=0.01, respectively). Follicular variant exhibited higher NLR compared to the classic papillary carcinoma (2.55±1.10 vs 2.19±0.67, p=0.03). On the contrary, NLR was not found to be associated with patient gender, tumour size or the presence of thyroiditis in the final histology. Conclusion: Our study found that NLR, an index of systemic inflammatory response, is generally higher in patients with poorer tumour profiles. Interestingly however, the NLR was not significantly elevated in cases of PTMC in the context of Hashimoto thyroiditis, as initially expected. P40 A confusing situation in thyroid surgery: silk suture reaction S Soylu, AE Arıkan, S Teksoz, M Ozcan, Y Bukey

thyroid region. Due to suspicion of thyroid malignancy, a fine needle aspiration biopsy was performed and foreign body reaction was revealed cytologically. Discussion: A suture reaction can vary from an erythematous swelling to chronic granulomatous reaction. The time interval between the operation and formation of suture reaction was six years in both of the cases thus these patients were considered as chronic patients. Foreign body reaction diagnosis was confirmed with fine needle aspiration biopsy. It is important to diagnose chronic inflammations since these cases can mimic recurrence in thyroid malignancies. Because recurrence of thyroid malignancy is highly suspected, surgical excision of the lesion should be performed. In last decade, rather than silk, absorbable synthetic sutures were used. With these absorbable polymers less foreign body reaction is encountered. Furthermore, use of ligation is discontinued with facilitation of energy based devices and sutureless thyroidectomy is preferred choice for thyroidectomy. Conclusion: A suture reaction after thyroid surgery can be diagnosed cytologically with fine needle aspiration biopsy. Successful treatment of this chronic inflammation is achieved with surgically removal of silk suture. This doubtful situation can be prevented with use of sutureless technique. P41 Special issues in laparoscopic surgery for phaeochromocytoma

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General Surgery, Istanbul University, Cerrahpasa Medical Faculty, Istanbul,Turkey; 2 General Surgery, Istanbul University, Cerrahpasa Medical Faculty, Istanbul, Turkey; 3 General Surgery, Istanbul University, Cerrahpasa Medical Faculty, Istanbul, Turkey; 4 General Surgery, Istanbul University, Cerrahpasa Medical Faculty, Istanbul, Turkey; 5 General Surgery, Istanbul University, Cerrahpasa Medical Faculty, Istanbul, Turkey Introduction: Silk suture reaction (i.e. a benign granulomatous inflammatory foreign body reaction) is a rare complication of thyroid surgery. Here, two cases of post-thyroidectomy suture reaction are presented. Both of the patients were female, one was the 48 and the other was 34 years old.~ Material and methods: The patients were presented with neck swelling and leakage of serous fluid from the Kocher’s incision. Both patients had normal free T4, free T3, and TSH values. The 48 year-old female patient had a right subtotal and left near-total thyroidectomy six years ago and the other had bilateral total thyroidectomy six years ago. In the physical examination a mobile, painless, red, swelling was palpated in front of neck. In the ultrasound of both patients, a heterogenous nodule with hypoechoic rim was seen, however, in scintigraphy no radiopharmaceutical involvement was observed in

C Aggeli 1 , AM Nixon 1 , T Choreftaki 2 , G Vletsis 1 , C Tserkezis1, C Parianos1, GN Zografos1 1

Third Department of Surgery, Athens General Hospital "G. Gennimatas", Athens, Greece; 2Department of Pathology, Athens General Hospital "G. Gennimatas", Athens, Greece Background: Laparoscopic adrenalectomy is the gold standard for the treatment of benign adrenal tumors. Resection of pheochromocytomas is a challenging procedure due to potential life-threatening hemodynamic instability. Pheochromocytomas have a rich network of high-pressure vessels, and thus have an increased risk of intraoperative bleeding. A perceived increased risk of malignancy renders laparoscopic surgery even more challenging. Material and methods: A total of 72 adrenalectomies for pheochromocytoma were performed between June 1997 and November 2016. Ten abdominal paragangliomas, operated in the same period are not included in this series. Preoperative diagnosis, operative details, complications, length of hospital stay, morbidity and follow-up were documented from hospital records of 511 patients who underwent 520 adrenalectomies for benign and malignant adrenal tumors in the same period.

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Results: 72 tumors were removed from 70 patients (33men, 37 women, mean age 52,7years, range 16-73 years). Two patients with MEN IIA underwent bilateral resection of pheochromocytomas one patient in two stages and the other patient underwent cortical sparing bilateral adrenalectomy in one stage. Tumor size in laparoscopic procedures ranged from 2.2cm to 11.1 cm (mean 4.97 cm). Operative time was 55 to 210 minutes (mean 110 minutes). 61 patients had sporadic disease (31 potentially malignant based on PASS score), and 9 in the context of a familial syndrome (6 MEN IIA syndrome, 2 Von Hippel Lindau syndrome and 1 von Recklinghausen disease respectively). 54 patients successfully underwent laparoscopic adrenalectomy. 8 patients had an open approach from the start due to large tumor size and concerns regarding oncological margins. In one case open approach was chosen due to a large concurrent pancreatic mass. 8 patients had conversions from laparoscopic to open procedure. The mean hospital stay was 2.1 days (range 1-3) for the laparoscopic procedures. Nine patients developed hypertensive crises lasting longer than 10 minutes which were adequately addressed with administration of sodium nitroprusside. One patient postoperatively developed pulmonary embolism, and succumbed 1 month later.

(androstenedione, free testosterone and DHEA sulfate) with normal ATCH, cortisol and metanefrines. A MR found a 13.5 cm adrenal mass so she was diverted to Surgery. In block left adrenalectomy was done and she was discharged 7 days later without unexpected events. Histology showed a well differentiated adrenal adenocarcinoma with necrotic and hemorrhagic areas, less than 2 mitosis and KI67<1% and no capsular or lymphovascular invasion. Even though it was completely resected and there was no evidence of tumour aggressiveness, she started mitotane treatment to prevent recurrence.

Conclusions: Laparoscopic resection of pheochromocytomas, despite its greater difficulty compared to that of other adrenal tumors, is a safe and effective procedure, beneficial for the patient in the hands of experienced surgical teams.

I López Rojo, A Gómez Valdazo, J Gómez Ramírez, I Osorio Silla, P Tejedor Togores, ML Sánchez de Molina, S Rivas Fidalgo, D Cortés Guiral, M Díaz Miguel

Conclusion: Virilizing adrenal carcinoma is an uncommon cause of adrenal mass. Clinical suspicion is usually followed by biochemical tests and image studies, aimed to establish hormone origin (ovarian, congenital, adrenal cause etc). Once diagnosis is made, surgery seems to be the best treatment, usually followed by steroidogenesis inhibitors. Our case had typical progressive signs of androgen excess, virilization and large size. But atypically, even though it had a big size, pathology revealed good prognosis. P43 Houdini Test. Could we predict our morbidity?

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P42 Virilizing adrenal carcinoma I López Rojo, A Gómez Valdazo, J Gómez Ramírez, I Osorio Silla, ML Sánchez de Molina, S Rivas Fidalgo, M Díaz Miguel

General Surgery, Fundación Jiménez Díaz, Madrid, Spain; General Surgery, Fundación Jiménez Díaz, Madrid, Spain; 3 General Surgery, Fundación Jiménez Díaz, Madrid, Spain; 4 General Surgery, Fundación Jiménez Díaz, Madrid, Spain; 5 General Surgery, Fundación Jiménez Díaz, Madrid, Spain; 6 General Surgery, Fundación Jiménez Díaz, Madrid, Spain; 7 General Surgery, Fundación Jiménez Díaz, Madrid, Spain 2

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General Surgery, Fundación Jiménez Díaz, Madrid, Spain; General Surgery, Fundación Jiménez Díaz, Madrid, Spain; 3 General Surgery, Fundación Jiménez Díaz, Madrid, Spain; 4 General Surgery, Fundación Jiménez Díaz, Madrid, Spain; 5 General Surgery, Fundación Jiménez Díaz, Madrid, Spain 6 General Surgery, Fundación Jiménez Díaz, Madrid, Spain; 7 General Surgery, Fundación Jiménez Díaz, Madrid, Spain 2

Introduction: Adrenal cortical carcinoma is a rare disease, with a bimodal age distribution and women predominance. They are mostly functioning tumours and therefore suspected due to hormone production. We present the case of a 49 year old woman with a virilizing adrenal carcinoma. Case Presentation: A 49 year old woman was referred to the Hospital in order to study frontal alopecia. She recounted rising corporal hair within the last 10 years, with no voice changes or muscular growth. She had increased blood androgen

Introduction: Daily endocrine surgery is nearly always elective and routine surgery, ideally done by expert neck surgeons. Even then, could we use our experience to predict complications related to our procedures? Could we anticipate to these complications due to intraoperatory findings and our final impression? Houdini test plan on comparing expected morbidity after thyroidectomies done by expert surgeons with real morbidity observed during postoperative surveillance and follow up. Final aim is to check if morbidity could be foreseeable by expert endocrine surgeons. Material and Methods: From May 2016, we asked expert endocrine surgeons to fill in a questionnaire after each total thyroidectomy. We collected surgical details and we asked them for expected morbidity: transient/permanent hypoparathyroidism, dysphonia and recurrent palsy, risk of reintervention, haematoma and features of malignancy on

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histology. We review patients progress and compare expected and real outcomes. Discussion: 40 patients are included. Real and estimated hypocalcemia were surprisingly similar (40%). Dysphonia was suspected in 38.5% patients and in 22.2% of recurrent monitored patients, while it was observed in 16.6% and 5.5% respectively. We encountered 2 recurrent palsy 4 weeks after surgery. They expect 5.1% non asfictic hematoma but we unfortunately registered 17.9% (none redo required). Regarding malignancy on histology, it was suspected on 12.8% and diagnosed in 20.5% (microcarcinoma included). Conclusion: Thyroid Surgery done by expert surgeons in high specialization Hospitals is the only way we could prevent and minimize post thyroid surgery complications. Our results show that even when done by experts, morbidity could be hardly predictable by surgeons’ opinion upon surgery is completed. Intraoperative recurrent nerve monitoring helps with making a distinction between patients at dysphonia’s risk. Despite surgeon’s experience has shown a reduction of morbidity, we aren’t able yet to estimate whom is at risk of complications. Therefore, including experts, we need to keep a high level of alertness when doing a total thyroidectomy. P44 Adrenal mass hemorrhage. A report of 10 cases AM Nixon, C Aggeli, C Tserkezis, C Parianos, G Vletsis, GN Zografos

retroperitoneal mass. 3 patients were referred for elective surgery of adrenal incidentaloma and one for pheochromocytoma where the pathology report revealed the presence of a large adrenal hematoma. In these cases neither pheochromocytoma nor cortical adenocarcinoma could be excluded as the definitive diagnosis. In 3 cases spontaneous bleeding was attributed to adrenal metastasis from lung cancer and patients were referred to the oncology department for treatment. In one case, spontaneous bleeding occurred in a known adrenal incidentaloma. The patient underwent laparoscopic right adrenalectomy after initial hemodynamic stabilization and after examination of her medical record excluded the likelihood of pheochromocytoma. One patient underwent open right adrenalectomy due to high suspicion of cortical adenocarcinoma (pathology report pending). The patient with traumatic adrenal hemorrhage was revealed to have upon further investigation a history of congenital adrenal hyperplasia. None of the patients required immediate surgical intervention due to persistent hemodynamic instability. Conclusions: Acute abdominal and flank pain is the most prevalent symptom in spontaneous and traumatic adrenal mass hemorrhage. Spontaneous hemorrhage in an adrenal mass should prompt a high clinical suspicion of underlying malignancy. In our experience there is no contraindication for prompt surgical treatment if pheochromocytoma and metastatic disease can be ruled out. Delayed intervention may render the pathology report non-diagnostic and thus influence medical management.

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Third Department of Surgery, Athens General Hospital "G. Gennimatas", Athens, Greece

P45 Preoperative predictors of multiglandular disease in patients with primary hyperparathyroidism

Background: Hemorrhage in pre-existing adrenal tumors is a rare clinical condition. Hemorrhage may occur either spontaneously or in the presence of blunt abdominal trauma. Immediate surgical intervention is reserved for persistent hemodynamic instability. The likelihood of an undiagnosed pheochromocytoma renders emergency surgery extremely precarious.

A Bergenfelz1, M Almquist1, M Thier1, S Daudi1

Material and methods: Data was collected prospectively from 10 patients that were managed in our department from July 2010 to November 2017. Patients with adrenal hemorrhage in the absence of an adrenal mass were not included in this study. Results: 9 out of 10 patients had spontaneous adrenal hemorrhage in the absence of recent abdominal trauma. 5 of these patients presented with acute abdominal and flank pain and sought immediate medical care. One patient was referred to our department after a motor vehicle collision due to severe abdominal pain and after imaging revealed a bleeding right

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Department of Clinical Sciences, Lund University, Lund, Sweden Background: Primary hyperparathyroidism (pHPT) is caused by single or multiglandular disease (MGD). Patients with MGD have an increased risk of complications during surgery and of persistence and recurrence after surgery. The study evaluated whether preoperative clinical and biochemical characteristics could predict MGD in patients with pHPT. Methods: We retrospectively evaluated patients operated upon in the period 1989-2013 for first-time, non-hereditary pHPT. MGD was defined in patients with more than one pathological gland excised at surgery, or with persistent hypercalcemia after the excision of a single pathological parathyroid gland, confirmed by histopathology. Clinical and biochemical variables were compared in patients with single- and multiglandular disease. Logistic regression was used to identify

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variables predicting MGD, yielding odds ratios (OR) with 95% confidence intervals (CI). Results: There were 707 patients, of which 79 (11%) had MGD. Patients with MGD were more likely to have negative sestamibi scintigraphy than patients with single gland disease, 15 of 49 (31%) vs. 70 of 402 (17%; p=0.03), to suffer from diabetes (12 of 74, 16%) vs. 45 out of 626 patients (7.2%; p<0.01), and had lower preoperative levels of urinary calcium; 3.80 mml/L vs. 4.44 mmol/L; p=0.04 (0.095 mg/dl vs. 0.11 mg/dl). Multivariable analysis identified negative scintigraphy (OR 2.42; 95% CI 1.18 to 4.79), diabetes (OR 2.75; 95% CI 1.31 to 4.97) and elevated levels of osteocalcin (OR 3.79, 95% CI: 1.75 to 8.21) as predictors of MGD. Conclusion: Negative sestamibi scintigraphy, diabetes and elevated osteocalcin levels were predictors of MGD. P46 Subclinical “second” tumours of thyroid cancer patients

in cases of ovarian cancer (5.5) and endometrial cancer (3.97). As regards other tumours, their high relative risk could not be conclusively proved. It was found if thyroid goitre was appeared after extrathyroid malignant neoplasms, the course it was more favourable. Conclusions: Relative risk of endometrial and ovarian tumours development after thyroid TCP is higher than in the overall population. Typical duration period of time between the extrathyroid tumours and TC appearance was one decade till and after appearance of thyroid pathology. Prognosis as regards neoplasms in TCP was determined in the basic character and clinical course of other tumour. P47 Incidental Papillary Thyroid Cancer In Patients Who Have Undergone Parathyroid Surgery M Jovanovic1, V Zivaljevic1, 2, A Diklic1, 2, G Zoric1, K Tausanovic1, N Slijepcevic1, B Rovcanin1, N Kalezic1, 2, V Sabljak1, 2, A Toskovic1, B Odalovic1, 3, N Vujacic1, I Paunovic1, 2

AF Romanchishen1, KV Vabalayte1, DV Makharoblishvili1 1

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Hospital Surgery Department, St.Petersburg State Pediatric Medical University, St.Petersburg, Russia Objective: Many experimental and clinical observations have shown that such combinations may be due to the following mechanisms: disturbance of neurohormonal regulation; exposure to ionising radiation; genetic defects (Gardner’s syndrome, Cowden’s disease, Carney’s complex end others). Material and methods: 1828 thyroid cancer patients (TCP) were treated during 1973-2004 and observed for a period from 1 to 27 years (in average 17 years).Age of patients ranged between 21 and 80 years (mean age made 55.8 years). An absolute majority of patients constituted of women - 98.1%, while men constituted 1.9%.The control group was constituted of 99 women with thyroid pathology, but without any other tumours. Age of the subjects in control group ranged from 24 years to 82 years, the average age made 53 years. Main outcome measures - relative risk, localisation of “second” malignancies. Results: The most part (77.7%) of multiple tumours were found to be metachronus. Extrathyroid malignant neoplasms were found for the greater part in organs of female reproductive system. Radio-induced type of polyneoplasia was found in one case (1.8%) only. Clinical course of thyroid cancer was not differ in both study and control groups. Hormone dependent extrathyroid tumours lasted relatively favorably. Average free interval was calculated to be 7.5 years. It was showed that statistically significant increased relative risk was found only

Center for Endocrine Surgery, Clinical Center of Serbia, Belgrade, Serbia; 2 School of Medicine, University of Belgrade, Belgrade, Serbia; 3School of Medicine, University of Pristina, Kosovska Mitrovica, Serbia Introduction: Incidence of thyroid diseases is far higher in patients with primary hyperparathyroidism (pHPT) than in general population. The aim of this study was to present incidence and clinical characteristics of incidental papillary thyroid carcinoma in patients who have undergone parathyroid surgery. Material and Methods: We have analyzed patients who have undergone parathyroid surgery and have had concomitant thyroid disease requiring surgery at our Institution during the period from 2008 to 2015. Patients with papillary thyroid carcinoma were particularly analyzed. Discussion: During the study period, a total of 849 patients have undergone parathyroidectomy. The mean age of those patients was 57.6 years. Out of this number, 224 (26.4%) had concomitant thyroid diseases that required surgery. Among patients with concomitant pHPT and thyroid diseases that required surgery there were 17 patients (7.5%) with subclinical hyperthyroidism and 38 (17%) with hypothyroidism. The most common procedures on thyroid gland were lobectomy (in 55%) and total thyroidectomy (in 36%). Thyroid gland histopathology analyses revealed benign goiter in 59%, Hashimoto thyroiditis in 19%, benign adenoma in 12% and thyroid carcinoma in 10%. Papillary thyroid carcinoma was found in 20 patients and one patient had Hurthle cell carcinoma. These 20

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Conclusion: Among patients operated due to pHPT there was a significant number of patients with concomitant thyroid diseases that required surgery (26.4%). The incidence of papillary thyroid carcinoma in patients operated due to pHPT was 6.6%. Based on the results of our study we believe that thyroid gland should be examined in patients with pHPT.

Discussion: We have retrospectively analyzed 286 consecutive patients operated due to adrenal tumors, with mean age of 51.3 years. Open approach was conducted in 115 patients and laparoscopic approach in 154 patients. Hybrid approach was used in 17 patients (9 for left-sided and 8 for right-sided tumors). Mean tumor’s diameter in patients operated using open, laparoscopic and hybrid approach was 4.9 cm, 4.3 cm and 9.5 cm, respectively. Clinical aspect of pheochromocytoma was present in 6 patients, Cushing’s syndrome in 2 patients, 3 patients had subclinical Cushing’s syndrome and 6 patients had incidentaloma. Histopathological analyses have revealed that 6 patients had pheochromocytoma, 8 patients had cortical adenoma, one patient had myelolipoma, one patient had ganglioneurinoma and one patient had metastatic renal carcinoma. There was no intraoperative and postoperative mortality. Postoperative hemodialysis was applied in one patient (with renal carcinoma). In 2 patients wound seroma was present.

P48 Surgery For Large Adrenal Tumros – A Hybrid Approach

Conclusion: Hybrid approach might be considered as gold standard for adrenalectomy in adrenal tumors larger than 6 cm.

I Paunovic1, 2, M Jovanovic1, B Rovcanin1, V Zivaljevic1, 2, G Zoric1, K Tausanovic1, N Slijepcevic1, N Kalezic1, 2, V Sabljak1, 2, A Toskovic1, B Odalovic1, 3, N Vujacic1, A Diklic1, 2

P49 Fungating Thyroid Cancer: A Complex Clinical Scenario

patients with papillary thyroid carcinoma represented 2.4% out of all patients operated due to pHPT. Micropapillary thyroid carcinoma was present in 16% of patients who had concomitant pHPT and thyroid diseases, i.e. in 4.2% out of all patients operated due to pHPT. Overall, incidental papillary thyroid carcinoma was present in 6.6% operated due to pHPT. Several studies have shown that hypercalcemia represents a goitrogen and that there is an increased incidence of concomitant pHPT and thyroid diseases. Furthermore, hypercalcemia is connected with increased incidence of several cancers – with thyroid carcinoma, among others.

AS Nabawi1, HF Al Wagih1, ME Hemeida1, TY Koraitim1, M Mousa1, TM Ezzat2

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Center for Endocrine Surgery, Clinical Center of Serbia, Belgrade, Serbia; 2 School of Medicine, University of Belgrade, Belgrade, Serbia; 3School of Medicine, University of Pristina, Kosovska Mitrovica, Serbia Introduction: Laparoscopic, as well as open approach can be used for adrenal tumors. Both of these approaches have advantages and disadvantages. Still laparoscopic adrenalectomy represents a gold standard for small functional and nonfunctional adrenal tumors nowadays. The aim of this study was to present our experience regarding hybrid approach i.e. laparoscopic to open adrenalectomy for adrenal tumors larger than 6 cm. Material and Methods: A retrospective study was conducted during the five years period (2012-2015) and included patients who underwent adrenalectomy at our Institution. Patients in whom a hybrid approach was applied were analyzed particularly, i.e. special cases with large adrenal tumors. A hybrid approach implies lateral laparoscopic approach via three ports, regardless of the tumor’s position. Good lightening and zoom are used in order to get access to the structures that cannot be easily reached during open approach. After maximal tumor mobilization adrenal vein is clipped and cut, if accessible. The procedure ends throughout mini subcostal laparotomy, not greater than 10 cm. This allows extirpation of intact tumor, in order to provide further histopathology analyses.

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Head Neck and Endocrine, Alexandria University Hospital, Alexandria, Egypt; 2Division of Surgery and Interventional Science, University College London, London, UK In the literature most articles discussing advanced thyroid cancer focus on major aero digestive system or vessel involvement and management. In this study our aim was to investigate patients who presented with a fungating thyroid cancer (FTC) as regards pathology, possible reasons behind such an aggressive presentation and the outcome of managing these patients by different modalities including radical resection and reconstruction, radioactive iodine ablation or external beam radiation. Methods: Collection of clinical, laboratory, imaging and pathological data of all patients admitted to the head and neck and endocrine surgery unit, Main University Hospital. Results: A total of 11 patients presented with a FTC, 8 of which were previously operated. The final pathological diagnosis showed that 4 patients had a well differentiated thyroid cancer (DTC), 4 had a poorly DTC, 2 with anaplastic cancer and 1 with medullary thyroid cancer. Although extensive resections and reconstructions using flaps were undertaken, clear safety margins were impossible to achieve. The three patients who were not operated died within one month of presentation.

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Conclusions: If there is no distant metastasis, a curative resection should be the goal unless complete tumor excision results in unwanted peri operative morbidity and mortality. Patients with gross residual disease, after surgical resection, may benefit from postoperative external radiotherapy for local control of complications, namely bleeding. P50 Factors associated with risk of remnant disease in patients with papillary microcarcinoma - is there a cause for concern regarding undertreatment? R Kralik1, E Takacsova2, I Waczulikova3, M Sabol1, D Dyttert1, V Rekeň1 1

Department of Oncological Surgery, St. Elisabeth Cancer Institute, Bratislava, Slovakia; Department of Nuclear Medicine, St. Elisabeth Cancer Institute, Bratislava, Slovakia; 3Department of Nuclear Physics and Biophysics, FMPI Comenius University, Bratislava, Slovakia Introduction: optimal treatment for papillary thyroid microcarcinoma (PTMC) lacks consensus and it seems of importance to take the risk factors of remnant disease into account when performing surgery to avoid undertreatment. We have focused on identifying factors associated with risk of remnant/persistent disease in a group of patients with PTMC. Material and Methods: All PTMC patients (size of 10 mm or less) who underwent thyroid surgery in our clinical setting between 2007-2015, were analysed. Remnant/persistent disease was defined in cases with postoperative, stimulated thyreoglobulin level above 5ngml, with lymph node metastases and with the need repeated treatment (re-operation and/or radioactive iodine (RAI)). The outcomes and different risk groups were evaluated by bivariable and multivariable analyses. Discussion: A total of 163 cases with thyroid surgery were included. 85(52%) patients were diagnosed before surgerythe 1st group patients treated with total thyroidectomy (TTE) with central neck dissection (CND), 44(27%) patients had the cancer identified during surgery from frozen section procedure - 2 nd group patients treated with TTE+CND, and 34(21%) patients were diagnosed based on histology- 3rd group patients treated with lobectomy or TTE without CND. In bivariable analysis we did not found differences between the 1st and 2nd groups (treated in the same way) in median age, median tumor size (8 vs. 7 mm), extrathyroidal propagation (12.94% vs. 13.64%), multifocality (25.88% vs. 22.73%), and persistence rates (21.18% vs. 22.73%). However, differences were identified in angioinvasion (17.65% vs. 6.82%) and nodal metastasis presence (36.91% vs. 26.83%). The 3rd group – tumor size of 4.75 mm, extrathyroidal propagation 2.94%,

multifocality 8.82%, angioinvasion 2.94% – exbibited the lowest risk of persistence (14.71%). Age below 45, extrathyroidal propagation and nodal metastases, were independently associated with persistence in multivariable analysis. Conclusion: based on our findings the risk of undertreatment (21.7% of cases) is an important issue in PTMC patients diagnosed before and during surgery, who would otherwise be missed for subsequent therapy. Incorporating the ipsilateral central neck dissection into the thyroid gland surgery would allow for better stratification of patients. P51 A Perspective From Turkey On Management Of Papillary Microcarcinoma Of The Thyroid Ö Makay1, M Özdemir1, Y Giles Şenyürek2, F Tunca2, M Düren3, M Uludağ4, M Hacıyanlı5, G İçöz1, A İşgör6, S Özbaş7, Z Özcan8, S Tezelman9 General Surgery, Ege University Medicine Faculty, İzmir, Turkey; 2General surgery, İstanbul University Medicine Faculty,Çapa, İstanbul, Turkey; 3General Surgery, İstanbul University Medicine Faculty,Cerrahpaşa, İstanbul, Turkey; 4 General Surgery, Şişli Etfal Traning and Research Hospital, İstanbul, Turkey; 5General Surgery, Katip Çelebi Universtiy, İzmir, Turkey; 6General Surgery, Bahçeşehir University Medicine Faculty, İstanbul, Turkey; 7 General Surgery, Güven Hospital, Ankara, Turkey 1

Introduction: Hereby, we present internet-based questionnaire study results performed by the Turkish Association of Endocrine Surgery with the purpose of stating the treatment approaches to papillary microcarcinomas in Turkey. Material and Methods: The questionnaire consisted of 13 questions in total and was designed for easy completion and data collection. The questions of the survey mainly addressed the surgical treatment management of the thyroid cancer of <1cm in diameter. Nevertheless, patient management before, during and after surgical intervention was also questioned; additionally, the propensity for active surveillance was evaluated. Discussion: There were 420 responders in total who were of multidisciplinary origin (endocrinologists, surgeons, nuclear medicine specialists, pathologists and oncologists). Total thyroidectomy was the predominating treatment approach (65%) for the classical type microcarcinomas limited in one lobe. Whereas, in the cases of microcarcinomas diagnosed incidentally during hemithyroidectomy, the propensity for complementary surgery was of 40%. A great proportion of the responders considered capsule invasion of the tumor (86%) and patient-based management (94%) of utmost importance. The

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ratio of the responders who recommend radioactive iodine ablation in incidental cancers having no aggressive criteria was 51%. Nevertheless, 73% of the responders were against routine central dissection in these cases. The recommendation for active surveillance of these cases - without any interventional therapy - was limited with only 9%. Conclusion: This survey demonstrated that there have been varieties in the approach of the papillary microcarcinoma case in Turkey. P52 Can the ‘intraoperative freehand spect’ technique be an alternative for image-guided parathyroid surgery? M Özdemir1, O Makay1, A Oral2, T Gümüş1, Z Burak2, G İçöz1, M Akyıldız1 General Surgery, Ege University Medicine Faculty, İzmir, Turkey; 2 Nuclear Medicine, Ege University Medicine Faculty, İzmir, Turkey

P53 Routine single-photon emission computed tomography in primary hyperparathyroidism? V Korwar, L Naureen, A Zarka, A Edwards, J Morgan 1

Endocrine & Transplant Surgery, North Bristol NHS Trust, Bristol, UK

Introduction: SPECT/CT (Single-photon emission computed tomography/Computed tomography) is useful for ectopic parathyroid glands and in differentiating between physiologic and pathologic uptake. It’s sensitivity is significantly lower in multiglandular disease (MGD). 99mTc-sestamibi (MIBI) and ultrasound (USS) have good sensitivity in localising single adenomas. Our study aimed to assess the benefit of SPECT/ CT in preoperative localization of parathyroid glands in patients with primary hyperparathyroidism (PHPT).

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Introduction: Freehand SPECT (F-SPECT) is a system that has been used to monitor body's radioactivity intraoperatively. Herein, we aimed to evaluate the feasibility of F-SPECT for intraoperative 3-D mapping in parathyroid surgery. Material and Methods: Six consecutive patients diagnosed with parathyroid adenomas scanned intraoperatively using F-SPECT to localize parathyroid adenomas before surgical procedure. In two patients, the procedure could not be completed due to the technical problems. F-SPECT images were acquired i ntraoperatively using declipse SPECT (SurgicEyeTM). Discussion: The SPECT protocol was performed successfully in 4 patients. 746 MBq 99mTc-MIBI was injected to patients intravenously before surgery. Mean time of scanning was 3 minutes before surgery. Conventional parathyroidectomy was performed in 3 patients and minimally invasive parathyroidectomy was performed in 1 patient. In one case, the parathyroid adenoma was successfully located. Nevertheless, it was observed that the depth, distance from the skin of the adenoma was deviated 8 mm. In the second case, a 20 mm lateral and a 10 mm depth deviation was observed. In the third case, localization was successful, while there was 15 mm depth deviation. In the fourth case, 5 mm lateral deviation was observed, while the depth of adenoma was estimated correctly. The procedure extended the mean operation time not more than 13 minutes. Conclusion: Although we could demonstrate that the FSPECT technology can be helpful in localizing the parathyroid adenoma, extension of data of this preliminary report is warranted.

Material and Methods: A retrospective analysis of 118 patients treated between Dec 2014 to May 2016 for PHPT was performed. 95 female and 23 male patients with a mean age of 61 years were included. Diagnosis was based on biochemical tests, excluding other causes for hypercalcaemia. Preoperative localization studies; USS in 115, MIBI in 112 and SPECT/CT in 68 patients were performed. Imaging results were correlated with histology. The cost of USS, MIBI and SPECT/CT in our hospital are £250, £800 and £600 respectively. We noticed an increased incidence of MGD in our series compared to published studies (36/118). USS and MIBI had higher sensitivity with localization both in case of adenoma (82.4, 80.5) and MGD (58.2, 38.2). SPECT/CT had lower sensitivity (78.7 in adenoma and 28 in MGD) and was useful in one case of intra-thoracic parathyroid gland. The success rate of parathyroidectomy in our series was 97% with a mean follow up of 7.5 months. Discussion: Our approach to surgical management of PHPT is unilateral or bilateral exploration based on localization studies, gross and frozen section findings. Published incidence of ectopic Parathyroid glands (PTG) is 6-16%, out of which 12% are intra-thoracic where SPECT/CT is very useful. There is no universal approach in preoperative localisation studies. The reported benefit of routine SPECT/CT from previous studies in PHPT has been variable. Conclusion: In surgery for PHPT, USS and MIBI scans are useful in localizing the hyperactive gland. SPECT/CT increases the cost of treatment, and involves exposure to radiation without significant increase in sensitivity to identify PTG especially in cases of MGD. We suggest a step wise approach to localising PTG in PHPT with USS, MIBI and SPECT/CT in that order as needed.

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P54 Management of Subclinical Cushings Disease N Chidumije, J Yuan, W Elsaify

P55 Comparison of immunohistochemistry and direct sequencing methods for identify BRAFV600E mutation in papillary thyroid carcinoma

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Breast and Endocrine Surgery, James Cook University Hospital, South Tees NHS Trust, Middlesbrough, UK

JW Yi1, JK Kim1, CY Seong1, IE Bae2, HW Yu2, SJ Kim1, YJ Chai3, JY Choi2, KE Lee1

Introduction: With routine use of ultrasound and computer tomography (CT), adrenal masses are increasingly detected. A significant percentage of these incidental masses are hormonally active, with up to 20% of these producing glucocorticoids. However, management of incidental adrenal masses without apparent clinical symptoms remains a controversial topic. Between 2011 and 2016, 52 laparoscopic/Open adrenalectomies were performed for several indications including pheochromocytomas, Conn’s syndrome, MEN Type 1 syndrome, B-cell Lymphoma, metastatic renal cell carcinoma, metastatic melanoma, ganglioneuroma and cushings syndrome. Out of the 52 cases, 5 subclinical cushings disease were identified. Currently, the preferred management of subclinical cushings disease is with adrenalectomy. This study discusses the findings of these 5 patients diagnosed with subclinical cushings disease and their management.

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Methods: A retrospective study was done on 5 subclinical adrenalectomies performed at a single center in the UK. Clinical data was collected on these cases from the time of incidental adrenal mass findings, baseline biochemical screening tests, decision to operate and follow up post adrenalectomy. Discussion: All 5 patients in this study had high but not excessive amounts of cortisol but failed the dexamethasone suppression test. Patients were aged between 50–75 years and comprised of 3 males and 2 females. They were all fit for surgery (Open/laparoscopic adrenalectomies) with hospital stays between 48-96 hours, intraoperative blood loss of less than 500 mls and no surgical complications recorded. The histology were all adrenocortical adenomas with an average specimen weight and size of 62 g and 70 mm respectively. The author recommends a surgical approach to subclinical cushings disease. Conclusion: Abdominal CT scan and biochemical evaluation including but not limited to serum electrolytes, catecholamines, baseline ACTH, cortisol and dexamethasone suppression tests should be performed in all patients with incidentalomas. This helps determine functionality of the adrenal mass. Additionally, a multi-disciplinary team meeting is advised for discussion on management. Further randomized trials are needed in the future to gain more knowledge and expertise on the potential management for subclinical cushings disease.

Department of Surgery, Seoul National University Hospital and College of Medicine, Seoul, Korea; 2Department of Surgery, Seoul National University Bundang Hospital and College of Medicine, Seongnam, Korea; 3Department of Surgery, Seoul Metropolitan Government Seoul National University Boramae Hospital, Seoul, Korea Introduction: BRAFV600E mutation is the most common somatic variant in papillary thyroid carcinoma(PTC) and it is known to be associated with aggressive prognostic factors. Classic detection method for BRAF mutation is Sanger sequencing with polymerase chain reaction. Recently, immunohistochemistry (IHC) method using BRAFV600E specific antibody (VE1) had been developed and widely used in clinics. However, there are lack of evidence whether the IHC method is comparable with Sanger sequencing method or not. Materials and methods: Our institution had begun BRAF V600E IHC test since January 2013. From the August 2015, we routinely perform both Sanger sequencing and IHC stain to all PTC specimen after surgery. We retrospectively evaluated 217 results which were tested both methods at the same time and compared consistency of Sanger and IHC methods. IHC results were described as three variables: negative, weak positive and strong positive. Discussion: BRAF mutation was detected 89.4% (194/217) in IHC and 78.8% (171/217) in Sanger sequencing. Diagnostic parameters of IHC compared with Sanger sequencing were as follows: 100% sensitivity (171/171), 50% specificity (23/46), 88.1% positive predictive value (171/194) and 100% negative predictive value (23/23). No false negative result was detected in IHC. Overall concordance rate between two methods was 89.4% (194/217). Discordant results were found in 23 samples (10.6%): Seven cases had small size tumors less than 6mm, eight cases were low tumor cellularity and eight tissues were low quality of DNA. Conclusion: IHC using VE1 antibody is a reliable and highly sensitive method to detect BRAFV600E mutation in PTC. Advantages of IHC are faster and cheaper than direct sequencing, can be conducted in small pathologic labs, easily quantify BRAF V 6 0 0 E protein expression and assess tumor homo/heterogeneity.

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P56 Robot-Assisted Endoscopic Mediastinal Parathyroidectomy: A Video-Poster Presentation Ö Makay1, SF Durmaz2, M Özdemir1, I Şimşir3, G İçöz1, M Akyıldız1 General Surgery, Ege University Medicine Faculty, İzmir, Turkey; 2Department of Surgery,University Medical Center Rotterdam, Rotterdam, Netherlands; 3Internal Medicine, Ege University Medicine Faculty, İzmir, Turkey

P57 Intra-Operative Parathyroid Hormone Monitoring Outperforms Pre-Operative Ultrasound And Mibi In Patients With Mild Primary Hyperparathyoidism MS Shawky1, T Ezzat Abdel-Aziz1, T Beale2, S Morley2, J Bomanji3, J Smart4, J Honour1, TR Kurzawinski1

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Introduction: The parathyroid glands are generally located in the cervical region, just behind the thyroid gland. Ectopic parathyroid glands can be located at any anatomical location from the base of the tongue to the mediastinum. One-third of the ectopic parathyroid glands migrate deep into the mediastinum or chest which are not accessible with a low cervical incision. Herein, we described the robotic approach to an ectopic mediastinal parathyroid adenoma. Case Report: A 45-year-old man admitted to an outside hospital with a history of nephrolithiasis, diffuse joint pain and problems with walking, lasting for a year. The patient had normal findings on physical examination. Blood tests revealed elevated serum calcium, alkaline phosphatase, parathyroid hormone (PTH) and a decreased phosphate level. Ultrasound of the neck showed no evidence of parathyroid adenoma. Subsequently, a computed tomography scan of the thorax showed a hypervascular solitary nodule of 2cm in the anterior mediastinum, at the level of the anterior aspect of the ascending aorta. 99mTc-MIBI scintigraphy confirmed the presence of an adenoma. Surgery was performed thoracoscopically with the da Vinci Si robotic system. Four ports were used for the operation, three of them for the robotics arms and one for assistance. Postexcision PTH level was used for intraoperative confirmation of success. The total operative time was 119 minutes. Intraoperative blood loss was minimal and no complications occurred during the operation. The patient was discharged without any complications on the fourth postoperative day. Conclusion: The robotic technique provides excellent visualization with three-dimensional view, better color resolution, better contrast, precision, and enhanced skills in order to ensure an affective, safe, and accurate operation. The robotic approach is our preferred method for mediastinal located parathyroid glands. Besides, accurate localization of the ectopic parathyroid gland(s) due to preoperative screening, is an important aspect for the robotic approach.

Endocrine Surgery; 2 Radiology, 3 Nuclear Medicine; Anaesthesia, University College Hospital, London, UK

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Introduction: Performance of Ultrasound and MIBI in primary hyperparathyroidism (PHPT) patients with normal calcium or parathyroid hormone (PTH) is lower than in cases where both of these biochemical indices are clearly elevated. This can lead to either patients being not considered for minimally invasive parathyroidectomy (MIP) or tendency to order more scans in attempt to improve localisation. Ability of intraoperative PTH (IOPTH) monitoring to predict cure during surgery could maximise opportunity to perform MIP in patients with single positive scan without compromising cure rate. The aim of this study is to evaluate the performance of these tests in patients with either normal or elevated calcium and PTH. Methods: Patients who had parathyroidectomy for PHPT between 2011 and 2016 were categorised into 2 groups. Group 1 (mild PHPT) included patients with either normal calcium or inappropriately suppressed PTH (i.e. PTH within normal range). Group 2 (classic PHPT) had both calcium and PTH elevated. Sensitivity and accuracy of US and MIBI were calculated for both groups, with operative and histopathology findings as ‘gold standard’. Operations were considered successful when PTH dropped at least 50% from highest levels. Sensitivity and accuracy of IOPTH monitoring were determined with ‘cure’ as gold standard. Operations were classified as Bilateral Neck Exploration (BNE) or MIP. Cure was defined as normocalcaemia for at least three months post-operatively. Discussion: 290 patients (72 male, 218 female, median age: 58 years) had surgery, 88 BNE and 202 MIP with 35 conversions dictated either by insufficient PTH drop (14) or inability to see or to dissect enlarged gland (21). 27 patients had mild and 263 patients had classic PHPT. Sensitivity of US, MIBI and IOPTH was 80%, 70.9%, 99% for classic and 47.6%, 57.1% and 100% for mild PHPT respectively. Accuracy of US, MIBI and IOPTH was 81.2%, 80.7%, 95.7% for classic and 75%, 77.1% and 100% for mild PHPT respectively. Overall cure rate in the entire series was 96.2%. Conclusion: US and MIBI have similar ability to localize abnormal glands and are less useful in mild than in classic PHPT. Superior performance of IOPTH in predicting cure highlights its particular value in mild disease.

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P58 Rare Thyroid Incidentaloma Starting With Liver Metastasis

P59 Thoracic Duct Injury During Thyroid Cancer Operation

F Gyory1, M Andrasi1, L Buris1, R Fedor1, L Toth2, L Bidiga2, S Barna3, É Pasztor4, M Bodor5

F Gyory, M Andrasi, D Kovacs, R Fedor Institute of Surgery, Clinical Center, University of Debrecen

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Surgery, 2Pathology, 3Scanomed Ltd, 4Radiology, 5Internal Medicine, University of Debrecen Clinical Center, Debrecen, Hungary Introduction: Thyroid incidentaloma is an asymptomatic, unsuspected thyroid lesion that is discovered mostly on imaging studies or rarely during surgery unrelated to the thyroid gland. Liver metastasis of the thyroid cancer is rarely published in case reports.

Material and Methods: 591 patients were operated in our institute for thyroid cancer from January 2005 to December 2015. One case from this 10-year period presented thyroid incidentaloma starting with liver metastasis. In 2009 a solitary liver nodule was discovered in a 51-year-old female patient without any complains. Repeated USs then a liver CT scan showed progression in size. A growing cavernous haemangioma was suspected based on the detailed gastrointestinal and imaging investigations. In 2010 the VII. liver segment was resected. Histology and immunohistochemistry revealed a 35 mm liver metastasis of follicular thyroid cancer. Neck US showed a 28 mm cystic, partially calcified solitary nodule in the thyroid. Thyroidectomy was performed, histology verified a pT 2 N 0 M 1 follicular cancer. 3700MBq 131I therapy was given four times, and posttherapy WBS (whole body scan) was performed after every treatment. As per protocol, imaging included neck and abdominal US, PET-CT scan, 99m Tc-MIBI whole body scan. On and off thyroxin levels were taken regularly during follow-up. Discussion: Post-therapy 131I WBS revealed various sites of metastases including small lymph nodes in the pelvic, neck region and in one of the ribs. Repeated high dose 131 I therapy effectively controlled the disease, no further progression was detected, and no further surgical intervention was necessary. Thyroglobuline level decreased under suppression dose administration of thyroxine (latest sTSH: <0.005 mU/l hTG: 26.5 ug/l, anti–Tg AB 10.9IU/ ml as of 21/Nov/2016). Conclusion: Progression free survival can be reached in this very rare type of metastatic follicular thyroid cancer by multimodal treatment including endocrinology, surgery, nuclear medicine, radiology and pathology.

Introduction: Postoperative bleeding, inferior or superior laryngeal nerve paresis, and hypoparathyreosis are rare possible complications after thyroid operations. Injury of the thoracic duct or its branches occurs more rarely, mainly during extensive neck dissection for metastatic thyroid cancer. Sequelae ranging from severe fluid, protein and electrolyte loss, skin necrosis, fistula formation or even carotid artery necrosis may be potentially lethal. Detailed anatomical knowledge is essential to avoid injury or to successfully control chyle leakage.If not diagnosed intraoperatively, the large amount of drain output, particularly if milky, may suggest leakage in the postoperative period. Conservative or surgical treatment is based mainly on the daily amount of fluid loss. Material and methods: 591 patients were operated in our institute for thyroid cancer from January 2005 to December 2015. Two cases from this 10-year period are presented with thoracic duct injury. Discussion: Patient 1: A 45-year male patient underwent completion thyroidectomy and modified radical neck dissection for papillary thyroid cancer (pT3N1bM0). On the 3. postoperative day more than 300 ml milk-like fluid was drained from the operating field. The injured thoracic duct was successfully discovered, and ligated during reoperation. No more leakage occurred during the following postoperative period. Patient 2: Total thyroidectomy and central neck dissection was performed in a 40-year-old female patient for pT3N1aM0 papillary cancer. On the 3. postoperative day 130 ml milky fluid was collected in the drain. Immediate fat and protein free diet was applied, and octreotide was given intravenously as part of the conservative treatment. Discharge was gradually decreased and then stopped after 10 days. Both patients were hospitalized for more than 10 days and no severe complication of chyle leakage occurred. Conclusion: Delayed hospitalization time and elevated costs are also emphasized on the basis of these two presented cases. P60 The Effect of sentinal lymph node biopsy with 99mTCNanocolloid for the management of prophylactic central neck dissection in patients with papillary thyroid cancer O Bayram1, O Agcaoglu1, I Bayram2, IC Sormaz3, F Tunca3, Y Giles3

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General Surgery, Koc University School of Medicine, Istanbul, Turkey; 2Radiology, Liv Hospital, Istanbul, Turkey; 3 General Surgery, Istanbul University School of Medicine, Istanbul, Turkey Aim : to evaluate the effect of intraoperative pathological examination for sentinel lymph node (SLN) metastasis diagnosed by preoperative lymphoscintigraphy in deciding for a prophylactic central ganglion.Cases between January 2013– March 2014 with a clinical diagnosis of N0 papillary cancer and their preoperative lymphoscintigraphy were reviewed. All patients had preoperatively an ultrasonography-guided 99m Tcnanocolloid injection in malign nodules, followed by lymphoscintigraphy. Following thyroidectomy, a gamma probe scan was performed and lesions with highest counts were considered as sentinel lymph node (SLN). These lesions were excised and sent for frozen section, followed by a routine prophylactic ipsilateral central lymph node dissection. Final pathology results were retrospectively reviewed and assessed. Data was evaluated for sensitivity, specificity, positive and negative prediction value with regard to prediction of metastatic disease in central neck area.A total of 21 patients were involved; with an average age of 44 (16 – 67). SLN detection rate by lymphoscintigraphy was 71% (n=15). One SLN in 14 (93%) patients and 2 SLN’s in one (7%) patient were detected and excised. Metastatic SLN was detected at frozen section examination of SLN’s that were excised from 15 patients. The group had an average tumour diameter of 15 ± 7,5 mm. A total of 162 lymph ganglions were dissected from central area, of which 35 (21,6%) were metastasic. Central lymph node metastasis was detected in 6 (28%) patients. Among the 6 patients where a SLN couldn’t be detected intraoperatively, 1 patient had metastasis in all 10 dissected central nodes. For detection of ipsilateral central area involvement of SLN biopsy by lymphoscintigraphy, the accuracy, sensitivity and specificity values were 81%, 33% and 100% respectively; PPV and NPV were 100% and 79%. The specificity and positive prediction values of lymphoscintigraphy with 99mTC-nanocolloid and SLN biopsy on clinical N0 PTC patients to detect central area involvement was found to be high, however, the sensitivity rate of this technique was 33%. For a better evaluation of SLN biopsy’s effect on N0 PTC patients in determining a SND decision, further studies with a greater number of patients are needed. P61 The value of fine needle aspiration of thyroid nodules in an endemic goiter region SS Strobl1, KO Koperek2, SA Selberherr1, BC Bichler1, BL Brammen1, SC Scheuba1, NB Niederle1, RP Riss1 1

Surgery, 2Pathology, Medical University Vienna, Vienna, Austria

Background: Fine needle aspiration (FNA) is a standard procedure in the evaluation of solitary thyroid nodules. However, the feasibility of FNA in an endemic goiter region with predominantly multinodular disease is questionable. This study aims to evaluate if FNA is reasonable in these patients to set indication for surgery and extent of possible prophylactic lymph node dissection. Method. All patients operated for nodular goiter with preoperative FNA of the dominant nodule in a five-year period were included. Cytology was assessed using the Bethesda classification. An analysis was performed regarding operative procedures performed, results of the final histological examination of the thyroid gland and lymph node involvement. Results: 307 of 936 patients (32.8%) operated, in the period between 2009 – 2013, had preoperative FNA and were included. In 39/307 patients (12.8%) FNA was nondiagnostic (Bethesda[B]I). Final report revealed a differentiated thyroid cancer in 8 of 39 patients (20.5%). 136 (51%) showed BII (33 patients with DTC, 24.3%), 11 (4.1%) BIII (2 DTC, 18.2%), 62 patients (23.1%) BIV (19 DTC, 30.6%) and 21 (7.8%) BV (13 DTC, 62%). BVI was diagnosed in 38 patients (14.1%). All but one patients (37/38, 97.4%) had a DTC. Prophylactic central neck dissection was performed in 119/121 patients (98.3%) with BIV-VI and revealed lymph node metastases in 32 patients (26.9%) of whom all but one patient was classified as BV-VI. Conclusion: Even in an endemic goiter region and in patients with multinodular goiter, FNA of the dominant nodule adds valuable information to the surgeon allowing more extensive surgery (i.e. first-step prophylactic central neck dissection). This may be considered especially in patients with BV-VI cytology. P62 The influence of parathyroidectomy on postural parameters in patients with primary hyperparathyroidism a preliminary report. W Chudzinski1, M Wolska2, A Lazar2, N Wrzesinska1, E Ciolak1, Z Galazka1, W Rongies2 Department of General and Endocrine Surgery, 2Department of Rehabilitation, Physiotherapy Division, Medical University of Warsaw, Warsaw, Poland

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Background: The calcium ion influences neural conductibility and muscular contractibility. It is widely accepted, that patients with primary hyperparathyroidism (PHPT) do not have any overt abnormalities in neurological examination and electromyography. However, their ability to maintain a stable, erect body posture has not been investigated.

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Methods: Aim of the study was to examine the quality of static balance in patients with PHPT before and after parathyroidectomy, based on posturography. Results: The study group consisted of 29 patients undergoing surgery for symptomatic PHPT, between 27 and 76 years (mean±SE) 56.6±2,5 years. After surgery hypercalcemia was remedied in all patients. A posturography examination was done twice for each patient: on the day before surgery and in the early postoperative period (2-4 days after surgery). Every evaluation consisted of four 30 seconds-long tests: twice in a balanced stance on two feet with open eyes and twice with closed eyes. The tests were performed using a PEL 38 pedo-barograph and WINPOD software version 3.81. All values are expressed as mean ±SE; (median). Statistical analyses were performed by using the Statistica 12 PL program. After parathyroidectomy we noted reduced COD (Center Of Gravity) sways compared to preoperative in tests with closed eyes: length of sway 201±17, (180) vs 226±21, (218); area of sway (mm2) 137±23, (110) vs 214±42, (148) (p<0,05); velocity of sway (mm/s) 6.1±0.5, (5.5) vs 6,9±0.6 (6.6). Conclusion: We observed the tendency to improve the stability of erect body posture in the early postoperative period in patients undergoing surgery for PHPT. Further investigations should be performed to assess the durability of this effect. P63 Large Asymptomatic Parathyroid Mass- A Difficult Challenge PCH Ciriano Hernandez, IGT Grao Torrente, CR Ruiz Moreno, EMC Enrique Mercader Cidoncha, IAP Iñaki Amunategui Prats, JLEC Jose Luis Escat Cortes

Image test showed a left parathyroid mass with doubtful infiltration of oesophagus and lytic lesion in left scapula. PET-CT proved increased SUVand percutaneous biopsy of the scapula evidenced high osteoclast concentration. After intense medical treatment we got control of calcium levels. Due to doubtful diagnosis we held our surgical strategy as an oncological procedure, performing total thyroidectomy, rigth lower parathyroidectomy and ipsilateral central lymph node dissection (no surrounding tissues infiltration was observed). She developed hipocalcemia and hungry bone syndrome, requiring intravenous infussion of calcium gluconate. Normal levels of calcium and PTH were reached before hospital discharge. Pathological report informed of giant PA, although size and some celular atypias were worrisome. One year after surgery, patient remains asymptomatic, presents normal levels of calcium and PTH, and improvement of bone lessions. No recurence has been proved during follow up. Discussion: Differenciate PA and PC can represent a challenge in case of large parathyroid mass. Length, severity of symptoms and marked hypercalcemia and PTH, increase the likelihood of PC, while invasion of surrounding tissues and metastasis are diagnostic of PC. Preoperative image evaluation is sometimes hard to interprete. Also brown tumors can mimic metastasis, difficulting even more a correct differential diagnose. Conclusion: In those cases associating large parathyroid mass and severe hypercalcemia, PC should always be suspected. Surgery is the only curative treatment for PC, making sure of performing an oncological procedure, to assure a complete removal of the tumor.

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General And Digestive Surgery, Hgugm, Madrid, Spain

Introduction: Parathyroid adenoma (PA) is the main cause of prymary hiperparatiroidism (PH). Severity of symptoms relates to degree of hypercalcemia and tumor size. Althought rare, large parathyroid masses can remain asymptomatic and debut as hypercalcemic crisis. In those cases, parathyroid carcinoma (PC) should be taken into account. Severe hyperparathyroidism, when mantained can cause bone reabsorption and fibrosis, leading to brown tumors, that can be missinterpreted as metastasis. Material and Methods: A 50 year old woman, asymptomatic up to admission to emergency area with nausea, abdominal and left shoulder pain. Physical examination confirmed articular tenderness. Blood test showed increased levels of calcium 14,1 (8,7-10,2) and PTH 1366 (14-60).

P64 Thyroid Lobectomy For Unifocal Clinically Node Negative Papillary Thyroid Microcarcinoma: Role of Ipsilateral Prophylactic Central Neck Dissection C. De Crea1, 2, M. Raffaelli1, 2, L. Sessa1, 2, S.E. Tempera1, 2, C.P. Lombardi1, 2, R. Bellantone1, 2 1

Istituto di Semeiotica Chirurgica, Università Cattolica del S. Cuore, Rome, Italy; 2 U.O. di Chirurgia Endocrina e Metabolica, Fondazione Policlinico Universitario A. Gemelli, Rome, Italy Introduction: Thyroid lobectomy is a valid alternative to total thyroidectomy (TT) in low risk, unifocal cN0 papillary thyroid carcinoma (PTC). Patients with extracapsular extension and/or central neck nodal metastases may require TT because of the increased risk of recurrence. However, it is hard to pre-

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operatively define central neck nodal status. We aimed to verify if ipsilateral central neck nodes dissection (IpsiCNND) and frozen section examination (FSE) of the removed nodes can identify patients who could benefit from TT and central neck dissection (CND). Material and Methods: Between October 2014 and June 2016, ten clinically unifocal cN0 microPTC (≤1cm) patients underwent thyroid lobectomy plus IpsiCNND with FSE (TL-Group). If FSE was positive for metastases, TT and bilateral CND was accomplished during the same procedure. TLGroup was compared to 10 controls (C-Group) who underwent TT plus IpsiCNND with FSE (if FSE was positive a bilateral CND was performed). Discussion: The TL-Group and C-Group were well matched for mean age, sex and mean tumor size (6.2Vs6.8 mm, respectively) (P=NS). Mean operative time was 59.5±17.8 for TL-Group and 65.8±21.5 minutes for C-Group (P=NS). Complications rate was similar between the two groups (P=NS). FSE identified occult nodal metastases (>2mm) in 4 patients: 2 in the TL-Group and 2 in the C-Group (P=NS). Final histology showed occult micrometastases (≤2mm) not detected at FSE in 6 patients: 3 in the TL-Group and 3 in the C-Group (P=NS). Overall in the TL-Group 6 patients underwent TT (60%): 2 during the first surgery after positive FSE on IpsiCCND, 4 as completion thyroidectomy after final histology showing pT3 and/or multifocal tumors and/or micrometastases. At a mean follow up of 19 months no patient showed local and/or nodal recurrence in the TL-Group or in the C-Group. Conclusion: Sixty per cent of the patients with microPTC selected for thyroid lobectomy had to be converted to TT. FSE of IpsiCNND correctly identified one third of these patients during the operation avoiding the need for further surgery. In the remaining patients, IpsiCNND was useful to establish the subsequent patient’s management protocol. P65 Thyroid Lobectomy For Unifocal Clinically Node Negative Papillary Thyroid Microcarcinoma: Role Of Ipsilateral Prophylactic Central Neck Dissection C De Crea1, 2, M Raffaelli1, 2, L Sessa1, 2, SE Tempera1, 2, CP Lombardi1, 2, R Bellantone1, 2 1

Istituto di Semeiotica Chirurgica, Università Cattolica del S. Cuore, Rome, Italy; 2 U.O. di Chirurgia Endocrina e Metabolica, Fondazione Policlinico Universitario A. Gemelli, Rome, Italy Introduction: Thyroid lobectomy is a valid alternative to total thyroidectomy (TT) in low risk, unifocal cN0 papillary thyroid carcinoma (PTC). Patients with extracapsular extension and/or central neck nodal metastases may require TT because

of the increased risk of recurrence. However, it is hard to preoperatively define central neck nodal status. We aimed to verify if ipsilateral central neck nodes dissection (IpsiCNND) and frozen section examination (FSE) of the removed nodes can identify patients who could benefit from TT and central neck dissection (CND). Material and Methods: Between October 2014 and June 2016, ten clinically unifocal cN0 microPTC (≤1cm) patients underwent thyroid lobectomy plus IpsiCNND with FSE (TL-Group). If FSE was positive for metastases, TT and bilateral CND was accomplished during the same procedure. TLGroup was compared to 10 controls (C-Group) who underwent TT plus IpsiCNND with FSE (if FSE was positive a bilateral CND was performed). Discussion: The TL-Group and C-Group were well matched for mean age, sex and mean tumor size (6.2Vs6.8 mm, respectively) (P=NS). Mean operative time was 59.5±17.8 for TLGroup and 65.8±21.5 minutes for C-Group (P=NS). Complications rate was similar between the two groups (P=NS). FSE identified occult nodal metastases (>2mm) in 4 patients: 2 in the TL-Group and 2 in the C-Group (P=NS). Final histology showed occult micrometastases (≤2mm) not detected at FSE in 6 patients: 3 in the TL-Group and 3 in the C-Group (P=NS). Overall in the TL-Group 6 patients underwent TT (60%): 2 during the first surgery after positive FSE on IpsiCCND, 4 as completion thyroidectomy after final histology showing pT3 and/or multifocal tumors and/or micrometastases. At a mean follow up of 19 months no patient showed local and/or nodal recurrence in the TL-Group or in the C-Group. Conclusion: Sixty per cent of the patients with microPTC selected for thyroid lobectomy had to be converted to TT. FSE of IpsiCNND correctly identified one third of these patients during the operation avoiding the need for further surgery. In the remaining patients, IpsiCNND was useful to establish the subsequent patient’s management protocol. P66 Diagnosis and surgical management of 61 patients with insulinoma – a retrospective analysis of the IENET Mainz FW Watzka1, FM Meyer1, JS Staubitz1, CF Fottner2, HL Lang1, TJM Musholt1 1

Endocrine Surgery Section, 2Endocrinology and Metabolic Diseases, University Medical Center University Mainz, Germany Background: Most insulinomas attain clinical relevance by hypoglycaemic hyperinsulinism at an early tumor stage

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(Diameter < 1cm). The localization is relevant for the further surgical approach but also demanding because of the small tumor size. Methods: In a retrospective study 61 patients with hypoglycaemic hyperinsulinism treated in our department between 1990 and 2016, were included. The results of preoperative diagnostic imaging procedures were analyzed. Results: Out of the 61 patients 3 were diagnosed with MEN 1 syndrome, 2 with (hereditary) insulinomatosis and 56 with sporadic insulinoma. A correct localization of the tumor was achieved by EUS in 85.1%, by CT in 79.1%, by MRI in 63.4%. EUS appeared to be the most accurate tool locating the tumor prior to an operation. Particular in localization of very small tumors the EUS is superior compared to CT and MRI. EUS should be performed by a trained Examiner additionally to a CT in case of an insulinoma. Enucleation was performed in 62% of cases (38/61), distal pancreatic resection in 21% (13/61), partial pancreatic resection in 10% (6/61). 5 resections were performed laparoscopically. 6 patients had a recurrence after R0 resection and 4 patients developed distant metastasis. Conclusion: About 10% of insulinoma cannot be located before operation. Therefore, the intraoperative palpation and ultrasound stays decisive for a successful therapy. Parenchymasparing- and minimal-invasive resection should be performed whenever it is possible. P67 Prevalence of ligament of Berry lymph node metastasis in thyroid cancer NY Hur1, JS Kim1,2, JH Kim1,2, JH Choe1,2

Discussion: From October 2009 through May 2016, a total of 4751 patients had been operated for thyroid cancer in a single institution by a single surgeon. A total of 100 subjects (2.1%) had enlarged ligament of Berry lymph nodes. Those were excised and 14 cases turned out as metastasis (14%). Their gender and age were similar to those of the subjects without ligament of Berry lymph node metastasis.The proportions of BRAF mutation, central lymph node metastasis, lateral lymph node metastasis, T stage, tumor margin positivity and extrathyroidal extension were not significantly different among subjects with LBLN metastasis and those without LBLN metastasis. The subjects with LBLN metastasis had a higher proportion of multiplicity and the parathyroid retrieval count (p-value : 0.001, 0.031 respectively) Conclusion: From this cross-sectional study of the patients having thyroid surgery, we can assume the prevalence of ligament of Berry lymph node metastasis in the thyroid cancer patients which was not reported in any other studies. Surgical strategies aimed at the treatment of ligament of Berry lymph node metastasis are needed. P68 Incidental Papillary Thyroid Carcinoma: 1-Year Results R Niciporuka1, A Abolins3, A Ozolins1,2, Z Narbuts1,2 1

Department of Surgery, Pauls Stradins Clinical University hospital, Riga, Latvia; 2 Department of Surgery, Riga Stradins University, Riga, Latvia; 3Department of Pathology, Pauls Stradins Clinical University hospital, Riga, Latvia Introduction: Papillary thyroid carcinoma (PTC) is most common thyroid cancer and incidence increases worldwide. Papillary thyroid microcarcinomas (PTMC) are defined as PTC in size 10mm or less.

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Department of Endocrine Surgery, Samsung Medical Center, Seoul, Korea ; 2 Sungkyunkwan University School of Medicine, Seoul, Korea Introduction: The prevalence of ligament of Berry lymph node metastasis among patients operated for the thyroid cancer is not well documented, and current guidelines pay little attention to a surgical extent for ligament of Berry lymph node in the thyroid cancer. Material and Methods: We conducted a retrospective review of medical records to evaluate the prevalence of ligament of Berry lymph node metastasis among patients who were operated for the thyroid cancer. Ligament of Berry lymph node is defined as lymph nodes around ligament of Berry and excised during the thyroidectomy when it is enlarged or has suspicious features.

Material and Methods: Retrospective one year thyroid patients' data from EUROCRINE database introduced in daily practice since October 2015 were analysed. All together 237 patients underwent thyroid operation due to various reasons. Morphology revealed 60 (25.3%) cases of PTC. Data were analysed regarding to morphology, tumour size, thyroid weight and indications for operation. Discussion: Twenty-one (35.0%) patient was operated due to compression symptoms (13/21) and thyrotoxicosis (8/21); PTC were found incidentally in morphology – Group A. Thirty-nine (65.0%) of PTC were operated due to suspected or proved malignancy - Group B. Fine needle aspiration was performed in 11 (52.4%) patients from Group A, and in 38 (97.4%) – Group B (p<0.05). In Group A mean tumour size was smaller compared to Group B - 11.8mm vs 16.5mm

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(p<0.05). PTMC was found in 15/21 patients in Group A and 14/39 patients in Group B (p<0.05). Nevertheless, in 6/21 patients in Group A mean tumour size was 36.3mm (1170mm). Multifocal PTC in Group A were in 3 (14.3%) and in Group B - 16 (41.0%) cases (p<0.05). Among 60 PTC cases 16 (26.7%) were follicular variant of PTC. Mean thyroid weight in Group A was 103.5g vs 28.8g in Group B (p<0.05). Conclusion: PTC is not rare incidental finding in patients operated due to benign thyroid disorders. Mostly incidental PTC are PTMC but in some cases it could be large carcinomas. Follicular variant of PTC could be found in cases of incidental PTC including noninvasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTP).

suspicion of TC. In the last two groups, the rate of glucose avidity in the target nodules was 78.5% and 83.9%, respectively. The rate of malignancy was 57.1% in thyroid incidentalomas, 36.2% in Bethesda IV glucose-avid nodules (32.7% if we exclude Hürthle cell neoplasms), and 85.2% in nodules suspicious of TC with glucose uptake (p<0.001). Conclusion: Thyroid PET-scan incidentaloma should be fully evaluated and probably resected due to a non-negligible risk of malignancy. However the likelihood of malignancy in Bethesda IV nodules is low. P70 Incidentally found large asymptomatic adrenocortical carcinoma. Case report

P69 How worrying should be a focal thyroid uptake in pet scan? A comparison between different clinical scenarios.

R Niciporuka1, N Fokina3, A Ozolins1,2, Z Narbuts1,2, J Gardovskis1,2

AB Vico Arias, J Triguero Cabrera, P Notario, A Vilchez Rabelo, N Sarabia, MA García Martínez, N Muñoz Pérez, JA Jiménez Ríos, JI Arcelus Martínez, JM Villar del Moral

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General Surgery. Endocrine Surgery Unit, Complejo Hospitalario Universitario de Granada, Granada, Spain Introduction: Today, positron emission tomography (PET) scan, mainly associated with computed-tomography (PETCT) images is a very useful tool in many fields of oncology. Its role in thyroid cancer (TC) is not clearly defined, particularly in the preoperative workup. But the detection of a thyroid PET-incidentaloma generates some concerns regarding its potential malignancy. Our aim was to explore the clinical relevance of a thyroid focal uptake in various clinical settings. Material & Methods: We performed a retrospective unicentric study based on a prospectively-maintained specific database. We tested the risk of malignancy linked to a focal thyroid uptake of 18-Fluorodeoxyglucose (FDG) in PET-CT scan in three different situations: subclinical condition (PET incidentaloma during preoperative or follow-up workup of any extrathyroidal neoplasm), preoperative study of cytologically indeterminate thyroid nodules, and preoperative investigation of patients with clinical, sonographic or cytologic suspicion of having TC. Data were analyzed through Pearson chisquare and Fisher’s exact test. Discussion: During the period January of 2006 to December of 2014, 1484 patients underwent thyroidectomy in our institution. Of them, 163 had a preoperative 18-FDG PET-CT scan: 11.9% because of pretreatment staging or follow-up of an extrathyroid malignancy, 46.3% for preoperative workup of a cytologically Bethesda IV thyroid nodule, and 41.8% patients with clinical, ultrasonographical or cytological

Department of Surgery, Pauls Stradins Clinical University hospital, Riga, Latvia; 2 Department of Surgery, Riga Stradins University, Riga, Latvia ; 3 Department of Endocrinology, Pauls Stradins Clinical University hospital, Riga, Latvia Introduction: Adrenocortical carcinoma (ACC) is malignant tumor arising from adrenal cortex. ACC has an incidence of ∼0.5–2 new cases per million people per year, prevalence of 2.7% among adrenal incidentalomas. 18-25% of ACC are > 6cm. Occult adrenal masses varies depending on the composition of the hormonal activity and size. Material and Methods: Case report of 50 years old male is presented to highlight possible development of large ACC without any specific adrenal symptoms. Discussion: Fifty years old male patient incidentally diagnosed with left adrenal mass in 2014. Patient refused from further examination. Two years later was admitted due to fever without any specific reason. Abdominal CT revealed excessive augmentation of adrenal tumor - 400 to 1000ml (10x12x15 cm) compared to year 2014. Increased dopamine level was noticed- 527mkg/24hU. Due to diagnosed mitral valve regurgitation III-IV and pulmonary hypertension valvuloplasty was performed month later. Five month after valvuloplasty patient was admitted to surgical department for adrenalectomy. At the time of admission patient revealed new complain - mild left side back pain. Left side lumbolaparotomy was performed. Large adrenal tumor dislocating, but not invading surrounding structures was visualized. During operation tumor capsule ruptured. Morphology revealed ACC with necrosis and invasive growth T3NxM0Rx. Tumor size was 17.4x14x8.5 cm and weight 1320 grams. Patient received radiation therapy. Five month

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Endocrine Surgery and 2Endocrinology, Central Clinic of Athens, Athens, Greece

after operation abdominal CT revealed no metastatic or recurrent process in abdominal cavity.

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Conclusion: Large adrenal tumors rarely are asymptomatic, more often presented with symptoms due to increased activity. Frequently ACC symptoms are unspecific and mimicking wide range of different disorders.

Introduction: The diagnosis of primary hyperparathyroidism (pHPT) is based on biochemical findings, with the most important of them being the elevated serum calcium and parathormone levels. In some cases the PTH levels are within normal range. This exceptional biochemical profile could lead to delayed diagnosis and treatment.

P71 Is serum TSH concentration a risk factor for thyroid malignancy in patients with a solitary nodule? J Triguero Cabrera1, AB Vico Arias1, S González1, A Vilchez Rabelo1, E Calcerrada1, MA García Martínez1, JI Arcelus Martínez1, JM Villar del Moral 1, JA Jiménez Ríos1, N Muñoz Pérez1 1

General Surgery. Endocrine Surgery Unit, Complejo Hospitalario Universitario de Granada, Granada, Spain Introduction: TSH is well known as the most important growth factor for thyroid follicular cells. However, its role in the development of thyroid cancer is still not clear. Our objective is to assess the role of serum TSH as a risk factor for thyroid cancer (TC).

Material and Methods: Retrospective study of 363 patients underwent thyroid surgery for solitary nodule in a regional hospital. The data of patients were collected prospectively. Variables analysed included age, sex, preoperative TSH levels, ultrasound features, cytology reports, and final pathology reports, both for the entire series and for indeterminate cytology group. Discussion: 24.2% of patients had an indeterminate cytology. The rate of TC was 27% in the whole sample and 21.4% in the subgroup of indeterminate cytology. The median of serum TSH is higher in case of TC (1.61 [12.49] vs 2.16 [1.19-3.22]; p= 0.006). Although seems to be a trend, this difference does not persist in case of patients with indeterminate cytology (1.7 [1.09-2.75] vs 2.6[1.57-3.4]; p=0.060). Risk of malignancy increased when higher TSH level (odds ratio: 1.119 [0.9991.254]), however in multivariate analysis does not reach statistical significance. Conclusion: There is a relationship between TC and levels of TSH, showing higher risk as TSH levels increases. P72 Primary Hyperparathyroidism characterized by Parathormone within Normal Range K Vamvakidis 1 , C Christoforides 1 , I Papandrikos 1 , F Tshijanu1, G Misichronis2

Purpose: Our aim is to determine the patients with pHPT without increase in intact parathormone value. Methods: This is a retrospective analysis of prospective collected data between 2010 and 2016 in our department. During this period 188 patients (160 females, mean age 58, 15min., 85 max.) underwent parathyroidectomy for symptomatic primary hyperparathyroidism (179 first operations, 9 reoperations). The preoperative evaluation included serum calcium, parathormone, albumin, phosphorus and in most of them urine calcium. Preoperative imaging studies included ultrasound in all patients and MIBI – Scintigraphy in the vast majority. In rare cases a fine needle aspiration for PTH levels evaluation was performed. Results: Among those patients, 7 had parathormone values within normal ranges (7/188, 3,72%). 7/7 patients had osteopenia or osteoporosis, 3/7 nephrolithiasis, all patients referred fatigue symptoms and mental disorders in form of depression or/and memory disturbances. Conclusion: Normohormonal pHPT is not rare and must be considered in the diagnostic evaluation of each patient with suspicion of pHPT. P73 Paraganglioma Presentation Genetic Analysis and Management: Single Centre Experience A Elsaify, R Hanna, N Chidumije, W Elsaify, J Yuan 1

Breast and Endocine Surgery, South Tees NHS Trust, Middlesbrough, UK Introduction: Paragangliomas and pheochromocytomas are relatively rare tumours of neuroectodermal origin arising from chromaffin cells. Paragangliomas constitutes 15% of adults and 30% of paediatric pheochromocytomas, they can be found along the paravertebral and para-aortic axes. Approximately 85% of paragangliomas are intra-abdominal and adjacent to the adrenal, whereas fewer than 15% are intrathoracic and 13% is cervical. The majority occur as sporadic tumours; however up to 25% of cases are familial. Familial paragangliomas have been well described in carriers of mutations of the

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succinate dehydrogenase (SDH) gene encoding subunits B, C and D. Familial syndromes include von Hippel-Lindau syndrome, neurofibromatosis type 1, tuberous sclerosis, SturgeWeber syndrome and multiple endocrine neoplasia (MEN) type 2. However, a particular MAX genetic variant has never been reported in patients with paragangliomas/ phaeochromocytoma. Method: Between 2011 and 2016, fifty-three laparoscopic/ open adrenalectomies were performed on patients aged between 24 and 77. The indications were: pheochromocytoma, Conn’s syndrome, MEN Type 1 syndrome, B-cell lymphoma, metastatic renal cell carcinoma, metastatic melanoma, ganglioneuroma and Cushing’s syndrome. Clinical data was collected from baseline biochemical screening tests, radiological evidence and histology results. Discussion: Two patients were identified to have paraganglioma. We present clinical presentation, radiological diagnosis, histopathological finding, underlying genetic mutation and surgical management. The sizes of the specimens were 40mm and 70mm. In both cases, the 24 hour urine catecholamine was raised. However, only one patient had a positive MIBG iodine 123 scan. Mutation analysis has revealed the genotype c.298C>T MAX gene in one patient, this particular genetic variant has never been reported in patients with paraganglioma. The MAX gene is detected 1 in 120,000 apparently normal individuals, this variant result in a significant amino acid exchange in a highly conserved part of the MAX gene. Conclusion:To our knowledge this is the first case report in the English literature describing the c.298C>T MAX mutation causing paraganglioma. A multi-disciplinary approach is highly recommended involving the geneticist, endocrinologist and surgeon in managing such a rare tumour. P74 Incidental Micropapillary carcinoma after Surgery for AUS/FLUS nodule. Experience of one center SS Silva, AMA Rafael, RMR Marques, LFV Fernandes 1

Surgery II, Egas Moniz Hospital, CHLO, Lisbon, Portugal

Introduction: Because there is a controversy regarding the management of AUS/FLUS FNAs from Thyroid nodule, and what to do with a final diagnosis of incidental micropapilar carcinoma (MPTC), the authors purpose analyze the data from one center to find the best way to achieve a definitive therapy. Despite very low mortality associated with micropapillary thyroid cancer, locoregional recurrence is common and controversy exists regarding optimal surgical treatment and the role of adjunctive radioiodine.

Methods: Retrospective review of patients assessed between January 2012 and June 2015 whose FNAs were classified as AUS/FLUS and went to surgery. Results: Of 4549 thyroid FNAs performed 671 (14.8%) were initially classified as AUS/FLUS and selected for further analysis. In our sample of 558 patients, 216 went to surgery. We perform 125 lobectomies and 91 total thyroidectomy, 30 patients had incidental micropapilar carcinoma has final histology in another nodule. In the group of lobectomies 30 patients perform thyroidectomy totalization, 13,9% of re-intervention. The main histology of the initial nodule was: hyperplasia, papilar carcinoma (PTC), adenoma and goiter, in decreased order. Therapeutic after surgery was decide at endocrinology department after analyse size, nodule microscopic findings and main histology of the thyroid. Only 8 patients were indicated to I 131. All patients maintained follow-up at our center. Discussion: In our sample the thyroidectomy totalization was the major conduct in MPTC induced by the size and microscopic findings, because lobectomy is associated with contralateral remnant lobe recurrence, without improving morbidity, lobectomy may be a safe operative option for select patients with papillary thyroid microcarcinoma without multifocality The follow-up of this group has showed that loco-regional recurrence is inexistent. Adjunctive radioiodine as been kept for MPTC in thyroidectomy totalization for PTC in principal nodule, rules of managing PTC overlaps the finding of MPTC. This a challenge because it was an AUS/FLUS FNA that indicate to initial surgery, mixing two grey areas of thyroid lesions. Exhaustive ecographic evaluation should be included in first approach to these patients and all cases discuss in multidisciplinary team. Conclusion: Size nodule, microscopic findings and multifocality have been the major criteria for adjuvant therapy or surveillance. These findings increased the necessity of multidisciplinary team to approach thyroid disease. P75 Preoperative prognostic factor in adrenocortical carcinoma : is 18F-FDG TEP/CT useful? C Guerin1, A Archier2, NC Paladino1, W Essamet3, J Villeret4, A Loundou5, D Taieb2, F Sebag1 Endocrine Surgery, 2 Nuclear Medicine, 3 Pathology, Pathology, Chu Nord, Marseille, France; 5Public Health, Aix Marseille University, Marseille, France

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Background: Adrenocortical carcinoma (ACC) is a rare malignant tumor with a very poor prognostic.Most prognostic parameters are determinate post operatively. The major role of 18F-FDG TEP/CT (FDG) in the diagnosis of ACC is well

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established but its role for prognosis is still debatable. The aim of the present study was to evaluate the potential role of FDG at diagnosis as a prognosticator for ACC in comparison with other prognostic factors and clinical outcomes (disease free survival (DFS) and cancer-related death (DCD)). Material and methods: We have retrospectively reviewed all patients (2004-2014) who have been evaluated FDG at diagnosis and underwent adrenalectomy in our tertiary referral center for ACC (Weiss score (WS) above or equal to 3). Results: Twenty-seven patients were included (18 women/9 men) with a median age of 49 years (22-78). Eleven/27 had biological hypercorticism, 17/27 were stage I-II and 7/27 were stage III-IV. Fourteen/27 are DFS and 13/27 are DCD with a median follow up of 37 months. In univariate analysis, hypercorticism (Hazard ratio(HR) 2,6 95%confidential interval (CI) 0,7-9,4 p= 0,14), metastasis (HR 3,8 CI 1,03-14,4 p=0,045), IVC invasion (HR 7,2 CI 1,6-32,1 p=0,01), ACC stage III/IV (HR5,5 CI 1,5-20,5 p=0,012) and WS (HR 1,8 CI 1,1-2,8 p= 0,013) were statistically associated with low DFS and low overall survival (OS). KI67% above 10% and tumor size were not statistically correlated with ultimate deaths. In the DCD patients median SUV max and uptake ratio were respectively 7,5 (4-21,4) versus 8,25 (3,3-57,48) in the DFS patients and 4 (2,17-8,33) versus 3,46 (1,3-17,68). There was no statistical association between FDG and hypercorticism, OS or DFS although there was a good correlation with the size of the tumor (p=0,009, correlation coefficient (CC) 0,49). There was no correlation with FDG uptake ratio and WS (CC 0,275 p=0,16). High KI67 expression was not statistically associated with high FDG uptake even though FDG value tended to be higher (p= 0,907). Limited number of subjects and quality of surgery should be taken in consideration to analyze our results. Conclusion: Beside its high diagnosis value, FDG uptake ratio at diagnosis should not be used as a prognosticator. P76 Does preoperative vitamin D levels relate with the risk of hypocalcemia at post-operative day 1 following total thyroidectomy? A Deffain1, M Castagnet1, F Scipioni1, JL Kraimps1, G Donatini1 1

General and Endocrine Surgery, CHU Poitiers, Poitiers, France Background: Hypocalcemia is the most common complication following total thyroidectomy. Few factors may relate with increase risk of post-operative hypocalcemia. Preoperative vitamin D values have been evaluated in previous

studies, but reports present conflicting data. This prospective cohort study evaluates the association of pre-operative vitamin D values and hypocalcemia following total thyroidectomy. Methods: Between November 2012 and November 2015, 368 patients from an initial group of 1509 patients underwent total thyroidectomy in the CHU of Poitiers, France. Exclusion criteria were: need of central neck dissection, re-do surgery, unilateral procedure, incomplete pre-operative assessment of calcium homeostasis and failure to identify four parathyroid glands at surgery. Result: Mean age of patients was 56.2 years (±14.0) and sex ratio (F:M) was 4.3:1. Sixty-four patients (17.4%) had preoperative vitamin D insufficiency (x< 25 nmol/L), 138 patients (37.5%) vitamin D deficiency (2550 nmol/L). Following total thyroidectomy for both benign or malignant pathology, 66 patients (17.9%) had symptomatic hypocalcemia (x< 2.0 mmol/L) requiring medical treatment (Group 1), 64 patients (17.4%) biochemical hypocalcemia (2 2.1 mmol/L, Group 3). No statistical correlation between post-operative serum calcium and pre-operative vitamin D values (R = -0.001, p = 0.9849) was found nor association was found regarding age, sex, type of thyroid disease or BMI of this group of patients. Conclusion: Preoperative vitamin D levels do not relate with the risk of hypocalcemia following total thyroidectomy. P77 Is outpatients in hemithyroidectomy really safe? B De Rienzo1, G Donatini1, L Lacoste2, M Castagnet1, JL Kraimps1 1

Department of General and Endocrine Surgery, CHU Poitiers, Poitiers, France; 2Department of Anesthesiology, CHU Poitiers, Poitiers, France Background: Ambulatory thyroidectomy has been proposed as a feasible procedure with the risk of hematoma being its most limiting factor. Endocrine Surgeon's Associations have advised caution in patient selection, paying close attention to the extent of surgery, thyroid pathology and patient's characteristics. The aim of this study was to evaluate the rate of hematoma and time of presentation in patients undergoing hemithyroidectomy to determine outpatient feasibility in this population. Methods: A retrospective of a prospectively maintained database identified 1384 patients undergoing isthmo-lobectomy in a single institution (January 2005 to December 2015) We

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selected patients who presented a hematoma analysing demographic and pathologic characteristics, time to hematoma development, as well as concomitant risk factors. Results: Twelve patients (0.86%) presented a hematoma, all requiring reoperation; one patient being re-operated twice. There were eight female and four male patients, with a median age of 56 years. Six patients had no compressive symptoms, 5 dysphagia and 2 mild dyspnea. The median lobe size and weight were 4.5 x 3.0 c, and 13.44 g respectively. Nine patients developed a hematoma within the first 8 post-operative hours (5 out of these 9 within the first p.o. hour), while three patients between 8 and 24 h. Seven out of the 12 patients had risk factors that would make them illegible for outpatient surgery (one kidney transplant on anticoagulants, one chronic obstructive pulmonary disease, one substernal goiter and three previous subtotal thyroidectomies, one with a concomitant neck dissection). The remaining 5 patients (0.36%), eligible for ambulatory surgery, developed a hematoma within 8 hours, which is the usual interval for observation in an outpatient setting Conclusion: Isthmo-lobectomy carries a considerable risk for post-surgical hematoma (0.86%). This is a potentially fatal complication requiring immediate evaluation and treatment. We advise caution and a careful patient selection when considering outpatient surgery for thyroid hemithyroidectomy. P78 Predictive Factors of Operative Hemodynamic Instability for Pheochromocytoma N Aksakal1, O Agcaoglu2, O Albuz 3, A Saracoglu4, C Ercetin5, S Dogan1, B Ozcinar1, A Yavru6, U Barbaros1, Y Erbil1 1

Department of General Surgery, Istanbul University, Istanbul School of Medicine, Istanbul,Turkey; 2Department of General S u r g e r y, K o c U n i v e r s i t y S c h o o l o f M e d i c i n e , Istanbul,Turkey; 3Department of General Surgery, Beytepe Military Hospital, Istanbul, Turkey; 4 Department of Anesthesiology, Bilim University Faculty School of Medicine, Istanbul, Turkey; 5 Department of General Surgery, Bagcilar Training and Research Hospital, Istanbul, Turkey; 6Department of Anesthesiology, Istanbul University, Istanbul School of Medicine, Istanbul, Turkey Background: Pheochromocytoma is an uncommon catecholamine secreting tumor in which resection is often associated with hemodynamic instability. In this study, we aim to clarify the factors affecting surgical hemodynamic instability in patients who underwent surgery with the diagnosis of pheochromocytoma.

Methods: A total of 37 patients who underwent surgery with the diagnosis of pheochromocytoma between 2008 - 2015 were analyzed retrospectively. Patients with inconsistent diagnosis or missing outcomes and follow-up data were excluded. Patient demographics, operative time, tumor size, period of medical treatment, catecholamine levels in urine, and hemodynamic instability patterns were analyzed. Results: There were 23 (62%) male and 14 (35%) female patients. Hemodynamic instability was occurred in 13 (35%) patients. Overall hemodynamic instability was higher in patients with tumor size ≤ 6cm (p<0.02), moreover, urine catecholamine levels were detected significantly higher (>2000mg) as a cut-off value in hemodynamically instable group. Conclusion: In this study, tumor diameter of <6cm and urine catecholamine levels were associated with hemodynamic instability. Preoperative management is essential for preventing hypertensive crisis and hemodynamic instability before or during surgery. P79 (Sub)total Parathyroidectomy Is a Safe and Effective Procedure for Patients with Secondary or Tertiary Hyperparathyroidism in The Netherlands WY van der Plas1, R Dulfer2, L Vogt3, RA Pol1, TM van Ginhoven2, EJ Hoorn4, EJM Nieveen van Dijkum5, AF Engelsman6, MH de Borst7, S Kruijff1 1

Surgery, University Medical Center Groningen, Groningen, Netherlands;;2Surgery, Erasmus Medical Center, Rotterdam, Netherlands; 3 Nephrology, Academic Medical Center, Amsterdam, Netherlands; 4Nephrology, Erasmus Medical Center, Rotterdam, Netherlands; 5 Surgery, Academic Medical Center, Amsterdam, Netherlands; 6 Endocrine Surgery, Royal Northshore Hospital, Sydney, Australia; 7 Nephrology, University Medical Center Groningen, Groningen, Netherlands Background: Secondary and tertiary hyperparathyroidism (HPT) is a common abnormality in patients with end-stage renal disease (ESRD), and has been associated with severe bone disorders, cardiovascular complications and increased mortality. Since the introduction of cinacalcet in 2004, a dramatic shift from surgery towards predominantly medical treatment has occurred. Surgery is thought to be associated with more complications than oral medication. However, evidence on the perioperative risk of parathyroidectomy (PTx) performed in specialized, high-volume centers is poorly documented. Therefore, the aim of this study was to evaluate 30day outcomes and effectiveness of PTx in ESRD patients in the Netherlands.

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Methods: We collected data via the Dutch Hyperparathyroid Study Group (DHSG) who established a national retrospective database in the Netherlands. Data from four academic medical centers of patients with ESRD-related HPT undergoing PTx between 1994 and 2015 were extracted. Descriptive statistics were performed. Endpoints were pre- and postoperative parathormone (PTH) levels and 30-day complication rate, including mortality, recurrent laryngeal nerve damage, surgical site problems, pneumonia and intensive care admission. Furthermore, re-operation rate and time until reoperation was recorded. Results: 206 HPT patients undergoing PTx were included, of which 68.7% was classified ASA III or higher. The median preoperative PTH level was 866.7 pg/mL (interquartile range [IQR] 407.1 – 1547.6 pg/mL). PTH levels decreased significantly after PTx: at 3 months, the median PTH drop from baseline was 93% (IQR, 71 – 98%) to a median serum level of 61.0 pg/mL (IQR, 22.6 – 147.9 pg/mL). Only 17 patients (10.1%) required re-exploration for persistent hypercalcaemia. Median time from first to second PTx was 6 months (IQR, 1 – 25 months). Thirty-day mortality and postoperative complication rate were 0.0% and 7.9% respectively. Conclusions: In The Netherlands, parathyroid surgery, remains a safe and effective procedure even in a fragile ESRD population. These data show that there should be no reluctance for surgical intervention and when indicated, nephrologists can refer these patients for PTx safely. P80 A Systematic Review of the Effect of Parathyroidectomy and Cinacalcet on Quality of Life in Patients with End-Stage Renal Disease Related Hyperparathyroidism WY van der Plas1, R Dulfer2, AF Engelsman3, L Vogt4, MH de Borst5, TM van Ginhoven2, S Kruijff1

calcimimetic agent. However, it is of paramount importance to assess the QoL that is associated with both interventions. We therefore performed a systematic review to evaluate the impact of cinacalcet and PTx on QoL. Methods: A systematic literature search is performed using PubMed and Embase databases to identify relevant articles. The search is based on the following keywords: “parathyroidectomy” or “cinacalcet”, “secondary hyperparathyroidism” or “renal hyperparathyroidism” combined with “quality of life” or SF-36” or “symptomatology”. Only studies reporting on QoL before and after both interventions are included. QoL scores were extracted from the selected manuscripts and weighted means were calculated. Due to lack of available data on QoL improvement in patients using cinacalcet, a metaanalysis could not be performed. Results: Eight articles reached our inclusion criteria. Five articles report on the effect of PTx on QoL. The physical component scores (PCS) of SF-36 increased significantly with a weighted mean of 35.5% (p<0.05). Mental component scores (MCS) increased with 13.7% (p<0.05). Parathyroidectomy Assessment of Symptoms (PAS) scores improved from 561.47 preoperatively to 302.30 postoperatively (decrease of 259 points; 46.2%). Visual Analogue Scale (VAS) scores reduced significantly for skin itching (46.6%), joint pain (30.4%) and muscle weakness (28.7%) (p<0.05). Three studies on the effect of cinacalcet on QoL were included. None of these studies showed significant improvement of PCS and MCS scores. Conclusions: Although medical treatment might correct biochemical disturbances, outcomes measured by QoL should be weighed as more important. Surgical treatment by means of PTx improves QoL significantly and should be considered as first treatment in line even in a fragile patient population. P81 Evaluation of utility of indocyanine green in viability of parathyroids in total thyroidectomy in multinodular goiter

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Surgery, University Medical Center Groningen, Groningen, Netherlands; 2Surgery, Erasmus Medical Center, Rotterdam, Netherlands; 3Surgery, Royal North Shore Hospital, Sydney, Australia; 4 Nephrology, Academic Medical Center, Amsterdam, Netherlands; 5Nephrology, University Medical Center Groningen, Netherlands Backgound: Patients with end-stage renal disease (ESRD) have a decreased quality of life (QoL). In particular, hyperparathyroidism (HPT) secondary to ESRD is associated with a decreased health status caused by bone disorders and cardiovascular disease leading to an increased risk of mortality. Since the introduction of cinacalcet, treatment has shifted significantly from parathyroidectomy (PTx) to the use of a

JM Rodriguez Gonzalez1, S Galvez-Pastor2, NM Torregrosa Perez2, A Rios Zambudio1, R Gonzalez-Costea2, A García López2, MD Balsalobre Salmeron2, B Febrero Sánchez1, PA Sánchez Fuentes1, E Romera Barba2, MI Navarro Garcia2, JL Vazquez Rojas2 1

Department of Endocrine Surgery, Hospital Universitario Virgen de la Arrixaca, Murcia, Spain; 2 Department of Endocrine Surgery, Hospital General Universitario Santa Lucía, Cartagena, Spain Background: The postoperative hypocalcaemia remains one of the most frequent complication following thyroidectomy.

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The evaluation of the injury or viability of the parathyroids glands has been done visually by the surgeon, traditionally. Angiography with indocyanine Green (IGA) is a useful technique to value tissue perfusion. Recently, it has been used to visualize vascularization of identified parathyroid glands, but the published experience is limited. Objective: 1. To assess the utility of indocyanine green to the evaluation of the vascularization of parathyroid glands after total thyroidectomy. 2. To analyze the use of angiography in predicting postoperative hypocalcaemia. Patients and Method: Prospective study with 39 patients with multinodular goitre undergoing total thyroidectomy. Excluded patients with malignant thyroid pathology, hyperthyroidism, hepatic impairment and allergy to iodine contrast. Variables: 1) preoperative: symptoms, blood test; 2) intraoperative: viability of parathyroid glands with and without indocyanine green and PTH; 3) postoperative: calcaemia and PTH after 4h, 24h, one week and one month. Registration of hypoparathyroidism when calcaemia < 8mg/dl. Results: Transient hypocalcaemia was detected in 7 of the 39 patients that underwent the operation (18%). The visual evaluation of parathyroid glands indicated that 6 of 7 of these patients had two or more parathyroid glands well vascularized. In contrast, IGA did not show any patient with hypocalcaemia with more than one well vascularized gland. Conclusion: IGA is useful to assess the vascularization of parathyroid glands, more than without IGA. Moreover, IGA could help us predict the postoperative hypoparathyroidism. We need more experience with more patients to confirm these results. P82 Incidental Thyroid Carcinoma in 1375 Thyroidectomies for Benign Preoperative Diagnosis IC Christakis 1,5 , SD Dimas 2,5 , IK Kafetzis 3,5 , NK Roukounakis4,5 1

Endocrine Surgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK; 2 Endocrine Surgery, Mediterraneo Hospital, Athens, Greece; 3Endocrine Surgery, Errikos Dunant Hospital Center, Athens, Greece; 4General Surgery and Transplantation, Evangelismos General Hospital, Athens, Greece; 5General and Endocrine Surgery, Polikliniki General Hospital, Athens, Greece

Materials and Methods: Retrospective review of all thyroidectomy operations performed in a single institution (January 2004-January 2009). We excluded patients with a preoperative diagnosis of thyroid or parathyroid malignancy. Pathology reports were screened to identify a diagnosis of ITC and the clinical records were accessed for patient demographic data, preoperative diagnosis and operative details. Discussion: 1375 patients met the inclusion criteria. The male to female ratio was 1:5.5 and a mean age at date of operation of 52 years (SD:13.2). The mean weight of the thyroid gland that was removed was 43.8 gr (SD:41.7) (Range: 4-442 gr). ITC was diagnosed in 288 patients (21%). There was no statistically significant difference between groups (ITC group versus benign pathology group) in regards to sex, preoperative diagnosis, hyperthyroidism, type of operation and the weight of the thyroid gland (p=0.053, p=0.737, p=0.074, p=0.857 and p=0.851 respectively). The most usual type of thyroid carcinoma was papillary thyroid carcinoma (224 patients-77.8%). The tumor was multifocal in 32.8% of the patients. The mean tumor size was 0.7 cm (SD:0.9).(Table) According to the 2015 American Thyroid Association Guidelines 166 patients with T1AN0M0 in our study do not need postoperative radioactive iodine treatment (RAI), RAI should be considered in 43 patients with T1bN0M0/T2N0M0/T3N0M0 and should be given in 2 patients with T2N1M0/T3N1M0. There was no statistically significant difference between groups in regards to the mean number of all lymph nodes (LN) removed, the mean number of normal LN removed and the mean size (in cm) of normal LN removed (p=0.232, p=0.244 and p=0.888 respectively). Conclusion: This is the largest series single-institution reported on this field so far, to our knowledge. ITC is diagnosed in 20% of patients operated for a benign thyroid condition. Patients should be counselled preoperatively about this risk. Thyrotoxicosis, thyroiditis, weight and size of thyroid gland are not related to the incidence of ITC. Further RAI treatment is needed in a small percentage of patients with ITC (21% of patients with ITC). P83 Predicting postoperative hypocalcemia after total thyroidectomy: reducing hospital stay, keeping the patient safe JG Graziani1, CG Guerin1, NCP Paladino1, ES Slotema1, CR Rochette1, FR Romain1, AL Loundou1, LM Marie1, MLR Le Roux1, FS Sebag1 1

Introduction: The purpose of this study was to evaluate the incidence of incidental thyroid carcinoma (ITC) in thyroid operations for a benign preoperative diagnosis and to identify the risk factors involved.

Endocrine surgery, Aix-Marseille University, APHM, Marseille, France Background: Hypocalcemia occurs in 10 to 15% after total thyroidectomy. It is the main immediate postoperative

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complication which lengthens hospitalization. However, predictive factors of hypocalcemia and their management are not consensually defined. As most surgical teams watch over patients at least one night, postop day 1 calcemia and PTH levels are easy and cheap to obtain. The aim of this study was to predict the risk of postoperative hypocalcemia requiring treatment based on postoperative calcemia and PTH levels after a total thyroidectomy at day 1. Methods: This is a monocentric study including 477 consecutive patients who underwent a total thyroidectomy from January to December 2014 in our tertiary referral center. We excluded patients who underwent simultaneous parathyroid surgery. Corrected calcemia (/albumin level) and PTH levels were systematically and prospectivelly sampled and collected for every patient at day 1. Symptomatic patients were treated on day 1 or 2 with oral and/or intravenous calcium and 1alpha. Results: Seventy of 477 patients (14.7%) required a treatment for postoperative hypocalcemia. No patients with a corrected calcemia strictly greater than 2.16 mmol/l and a PTH strictly greater than 1.9 pmol/l were treated and could have been discharged at day 1 (Sp 100%). On the opposite, all patients with a calcemia lower or equal to 1.89 mmol/l required treatment regardless the PTH rates (10/70) (Sp = 100%). For calcium value between 2.16mmol/l and 1.9mmol/l with a PTH strictly greater than 4.7pmol/l, no patient required treatment. Finally with a calcemia between 2.16 mmol/l and 1.9 mmol/l and a PTH strictly greater than 1.9 pmol/l 44/50 patients did not develop symptom and did not required treatment with a sensitivity of 83% and a specificity of 88.5% (p<0.0001). Based on this algorithm, 70% of our patients could have been discharged at day 1 safely, without over or under treatment regarding hypocalcemia. Conclusions: At day 1, the association of corrected calcemia and PTH is efficient for predicting postoperative hypocalcemia. It is a reliable tool for the clinical management of patient after thyroid surgery, by decreasing in-hospital stay without taking risk for the patients. It will helps optimizing economical health resources. P84 Patterns of recurrence, response to treatment and mortality in patients with malignant phaeochromocytomas and paragangliomas T Ezzat Abdel-Aziz1, F Prete1, M Shawky1, M Gaze2, J Bomanji3, T Kurzawinski1

Introduction: Histology is a poor predictor of the malignant potential of the phaeochromocytomas and paragangliomas (p&p) and only presence of distant metastasis, which could present insidiously as vague symptoms, confirms malignancy. This study reviews patterns of recurrence, treatment and mortality in patients with malignant p&p. Materials and Methods: Retrospective review of 128 patients with p&p revealed 26 (20%) with malignant tumours (M=14, age 43 years (5–71). 8 (5 paragangliomas, 3 phaeochromocytomas) had synchronous and 18 (10 paragangliomas, 8 phaeochromocytomas) metachronous metastases. There was no correlation between histology and potential for malignant disease. The duration between operation and the diagnosis of metastatic disease was 38 months (22– 228) for paragangliomas and 78 months (11–299) for phaeochromocytomas. Symptoms included pain (13), new hypertension (9) and weight loss/anemia (4). The sites of metastases in paragangliomas were bone (9), liver (6), lung (4) and in phaeochromocytomas were liver (7), lung (6), bone (4). Local recurrence/persistence disease was associated with distant metastasis in 18 (70%) patients. MIBG scans were positive in 6/15(40%) patients with paragangliomas and in 10/11(91%) patients with phaeochromocytomas. 22 patients received radio-targeted treatment with 131I-MIBG and/or 90Y-DOTA-octreotate/ LuDO. 131I-MIBG treatment stabilized disease in 7/8(87%) phaeochromocytomas and in 2/7(29%) paragangliomas. 90YDOTA-octreotate was associated with a much better response rate in paragangliomas, with stabilisation in 7/9 (78%) patients. External beam radiotherapy was used in four (18%) patients who had aggressive disease with bone metastasis. During the follow up of 80 months (5-300), 7 patients (27%) died of recurrent disease (5 Paraganglioma, 2 phaeochromocytoma). Discussion and Conclusion: In our series 1/5 of patients with p&p had malignant disease with recurrence developing earlier in patients with paragangliomas but symptoms and patterns of metastases was similar for both tumours. I131-MIBG was effective in Phaeochromocytomas but 90Y-DOTAoctreotate/LuDO was a better treatment for paragangliomas, however 1/3 of patients with malignant p&p died of disease. Strict long term follow-up is recommended for all patients with p&p for early detection of disease recurrence. P85 Experience of Sutureless Thyroidectomy MS Malik1, AH Qureshi1

1

Centre for Endocrine Surgery, University College London Hospital and Great Ormond Street Hospital, London, UK; 2 Department of Medical Oncology, University College London Hospital, London, UK; 3Department of Nuclear Medicine, University College London Hospital, London, UK

1

General Surgery, Military Hospital, Rawalpindi, Pakistan

Objective: Ligasure is a bipolar diathermy system, which achieves vessel sealing with reduced thermal spread. We

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compared the frequency of RLN Injury, Hypocalcemia and Operative Time in patients who were undergoing thyroid surgery with conventional Suture and Clamp technique and Ligasure small jaw Vessel sealing system. The aim of the study was to evaluate the applications and efficacy of Ligasure by analyzing the duration the surgery and the rate of complications of this surgical technique. Methodology: A total of 100 consecutive thyroidectomies were included in the study. Patients were allocated into two groups according to the Thyroid Surgery technique. In Group A Conventional Suture and Clamp technique was used. In Group B Ligasure small jaw Vessel sealing system was used. All patients underwent Preoperative Indirect Laryngoscopy. Postoperatively patients were examined with a help of an anesthetist by direct laryngoscopy for the assessment of vocal cords. Patients blood calcium values were checked preoperatively and at postoperative 24, 48 and 72 hours. We evaluated the demographic features, histopathological diagnosis, operating times and relevant postoperative complications. Results: The two study groups had similar histopathological and demographic features. In Group A, 50 patients were included in which there were 39 NTT and 11 Total thyroidectomies. In Group B, 50 Patients constituted 36 NTT and 14 total thyroidectomies. In both groups bilateral RLN were identified respectively. Among the patients 99 (99%) were females and 1(1%) was males. Their mean age was 42.5 years (range 3-69 years). In Group A no RLN palsy was observed. In Group B RLN injury occurred in 1 patients (2%). Her voice and cord movements were restored in 06 months. In Group A, 22 patients (40%) had Hypocalcemia. Among these, 14 patients had Laboratory hypocalcemia whereas 8 had Symptomatic Hypocalcemia. In Group B 32 patients (64%) had hypocalcemia. Among these 18 patients had Laboratory hypocalcemia whereas 14 had Symptomatic hypocalcemia. The Mean operative time for GROUP A was 104 +/- 15 mins whereas in GROUP B it was 89 +/- 13 mins. Conclusion: In this study, Ligasure provided a statistically significant decrease in the operative time however the rate of Hypocalcemia is more by this technique. Apart from it there was no difference in the rate of complications between the two techniques. P86 Reliability of intraoperative angiography with indocyanin green after thyroid resection for the evaluation of postoperative parathyroid function Vidal Fortuny J, Sa do w sk i SM , Ka re no vic s W, Triponez F

Thoracic and endocrine surgery, University Hospital of Geneva, Geneva, Switzerland Background: There are currently no per-operative methods to reliably predict the function of each parathyroid gland (PG) visualized during thyroid surgery. We have previously demonstrated that Intra-Operative Angiography with the fluorescent dye Indocyanin Green (ICG) was feasible. We present here the results of patients who underwent total thyroidectomy, and in whom the four PGs characterized with ICG-angiography. Methods: Parathyroid angiography with intravenous administration of 3.5mL of ICG was performed in consecutive patients undergoing thyroid surgery. A near-infrared imaging endoscopic system (PinPoint, NOVADAQ) was used to characterize the vascularization of the identified PG after thyroid resection. Patients in whom four PGs were identified represent the study cohort. Data collection was done prospectively. Results: Between September 2014 and September 2015, four PGs were visualized in 67 of 278 patients undergoing total thyroidectomy. At least one well-perfused PG was demonstrated by ICG-angiography in 52 patients (77.6%). None of these patients developed postoperative hypoparathyroidism. In the other 15 patients, ICG-angiography did not show a good vascularization in any of the four PGs, despite the fact that at least one PG was visually considered well preserved in 8 of these 15 patients. Eleven of the 15 patients (including 2/4 with visually well preserved PGs) were hypoparathyroid at POD1 and six of them at POD10. One patient was still hypoparathyroid after 6 months; the others recovered a good parathyroid function. In nine patients the PGs were autotransplanted. The Positive Predictive Value of ICG-angiography (absence of hypoparathyroidism with well vascularized PG) was 100% and the Negative Predictive Value (hypoparathyroidism when no PG is well vascularized) was 73.3%. Conclusion: ICG-angiography evaluation of the PG function is reliable and better than visual evaluation alone. ICGangiography could help the surgeon decide which PG should be autotransplated and could be a reliable tool to adapt the post-operative management of patients according to the ICG-angiography results. P87 A case report of autofluorescence of metastatic lymph nodes of papillary thyroid cancer Vidal Fortuny J, Sadowski SM, Karenovics W, Triponez F Department of Thoracic and Endocrine Surgery, University Hospital of Geneva, Geneva, Switzerland

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Background: Papillary cancer is characterized by lymphatic spread, present in 10-80% of patients. Prophylactic central neck dissection is a matter of debate and the risk-benefit ratio of this procedure is controversial. No methods are still available to predict the presence of metastatic lymph nodes prior to prophylactic central lymph node dissection. Patient: A 46 year old patient underwent tonsillectomy and lateral neck dissection for squamous cell cancer. In the specimen, 2 lymph nodes were positive for papillary thyroid cancer. The PET-CT (done for the squamous cell cancer) and ultrasound of the neck did not show any thyroid pathology. He underwent total thyroidectomy and central neck dissection. Methods: Four lymph nodes were macroscopically suspicious of malignancy. Parathyroid glands were not seen during the surgical procedure ; they were searched with a device detecting auto-fluorescence (Fluobeam® Class IIa, Fluoptics, 38040 Grenoble Cedex 9, France). Parathyroid glands were not found, but the four macroscopic pathologic lymph nodes, described previously, showed clearly auto-fluorescence properties. Results: The histological results for the left side showed an infiltrative papillary microcarcinoma of 0.6 cm with BRAFV600E mutation, with minimally local extension. 12 lymph nodes were examined, 5 of them metastatic from the papillary carcinoma. Four of theses metastatic lymph nodes corresponded to the 4 macroscopic suspicious lymph nodes showing auto-fluorescence properties. A papillary microcarcinoma of 0.3 cm was found on the right side. No parathyroid glands were found. Conclusion: To our knowledge, this is the first described case reporting metastatic lymph nodes of papillary thyroid carcinoma with auto-fluorescence properties. If this result is reproducible in other patients, auto-fluorescence could be used as a tool to decide whether or not to perform a prophylactic central or lateral neck dissection, reducing the risk of unnecessary procedures. P88 Total parathyroidectomy and autotransplantation as an early postoperative two-step-procedure in renal, lithium-induced or MEN1-associated HPT: a subgroup analysis

Background: Treatment of multiglandular disease in hyperparathyroidism remains challenging. Total parathyroidectomy with simultaneous autotransplantation or subtotal parathyroidectomy are considered the preferred procedures. We question if a two-step-procedure including total parathyroidectomy with kryopreservation and deferred autotransplantation in case of aparathyroidism in the early postoperative course can avoid unnecessary autotransplantation in presence of persistent residual parathyroid-hormon-(PTH)-production and nevertheless ensure adequate systemic PTH-levels later. Methods: Retrospective subgroup analysis of patients treated for hereditary, lithium-induced (pHPT) or renal hyperparathyroidism (rHPT) from January 2000 until December 2014 undergoing total parathyroidectomy and early autotransplantation in case of postoperative complete or near-complete PTH-deficiency. Results: 13 patients with rHPT and 5 patients with pHPT of our 145 patients–cohort were treated with a two-step total parathyroidectomy and autotransplantation. The postponed autotransplantation followed 5 days (median) after parathyroidectomy. 3 patients in rHPT-group were lost in the follow-up. At 6 months the rHPT-group had median calciumlevels of 2mmol/l (1.6-2.4mmol/l) and PTH-levels of 21.6ng/l (11.7-142.9ng/l). The pHPT-group showed PTHlevels of 55.7ng/l (median, range 22.6-1676ng/l). 8/10 patients in the rHPT-group had a PTH-level at intended levels; 2 patients failed to achieve adequate PTH-levels and developed partial parathyroid insufficiency. In the pHPT-group 4 patients were cured and one had recurrent disease. Conclusion: In 12/15 patients early transplanted kryopreserved parathyroid tissue provided correct systemic PTH-levels at midterm follow-up in renal, lithium-induced and multiple-endocrine-neoplasia-1-(MEN1)-associated HPT. No complete parathyroid insufficiency (graft failure) was seen. Given that kyropreservation is available two-stepautotransplantation after total parathyroidectomy may represent a valid third surgical option in the treatment of multiglandular disease. P89 Incidence and prognosis of contralateral vocal fold palsy after hemithyroidectomy in previously unoperated patients

FC Grafen1, C Scheuba2, T Clerici3 FC Grafen1, W Kolb2, J Rosenfeld3, T Clerici2 1

Chirurgische Klinik, Spital Limmattal, Schlieren, Switzerland; 2 Chirurgische Endokrinologie, Klinische Abteilung für Allgemeinchirurgie, Medizinische Universität Wien, Wien, Austria; 3Klinik für Allgemein-, Viszeral-, Endokrin- und Transplantationschirurgie, Kantonsspital St.Gallen, St.Gallen, Switzerland

1

Chirurgische Klinik, Spital Limmattal. Schlieren, Switzerland; 2Klinik für Allgemein-, Viszeral-, Endokrinund Transplantationschirurgie, Kantonsspital St.Gallen, St.Gallen, Switzerland; 3 Hals-Nasen-Ohren-Klinik, Kantonsspital St.Gallen, St.Gallen, Switzerland

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Background: An injury of the recurrent laryngeal nerve during thyroid surgery with consecutive palsy of the ipsilateral vocal fold is a known complication. A vocal fold paralysis (VFP) of the contralateral, not-operated side is a rare event. Little is known about its causes, incidence and prognosis. Methods: Between January 2012 to December 2015 a cohort of 467 patients with hemithyroidectomies was analyzed who had no previous thyroid or parathyroid surgery (women 366, men 101}. All patients underwent laryngoscopy preoperatively and prior to discharge. As standard of care intraoperative neuromonitoring is used and a nasogastric tube placed in the proximal esophagus. While performing a hemithyroidectomy the contralateral thyroid lobe was neither explored nor dissected. A permanent palsy was defined as partial or complete persistent VFP 6 months after hemithyroidectomy. Results: 466 patients had preoperative laryngoscopy (99.8%). 461 had laryngoscopic evaluation of the vocal cord function within the first postoperative days (98.7%). One preexisting VFP was detected on procedural side. Following surgery 17 patients (3.6%) showed an ipsilateral VFP resolving completely within 6 postoperative months. In 4 patients one partial and three complete VFP of the contralateral, nonoperated side were detected (0.8%). VFP was equally distributed on both sides. Clinical symptomatology varies and the VFP resolved completely in all cases. Conclusion: Contralateral VCP is unexpected after hemithyroidectomy and cannot be explained since there are no direct surgical manipulations close to nerve. Nevertheless, it may be underestimated without postoperative laryngoscopy as a standard of care. Fortunately VFP seems to have a good prognosis.

nodules in the contralateral lobe. All underwent total thyroidectomy. Demographic data, fine needle aspiration biopsy (FNAB) results and pathology outcomes were evaluated. Discussion: A total of 135 patients; 103 (76%) women and 32 (24%) men were included. Postoperative histopathology of the dominant nodule revealed follicular nodular disease in 91 (67%), papillary carcinoma (PTC) in 37 (27%) and PmTC in 7 (6%) patients. Postoperative histopathological examination of the sub-centimeter nodules in the contralateral lobe reported follicular nodular disease in 71 (52%) and PmTC in 64 (48%) patients. Nearly half of those cases with follicular nodular disease in the dominant nodule had a PmTC in the opposite lobe. In addition, regarding the contralateral lobe of patients with PTC in the dominant nodule, PmTC was present in 14 (38%). Of those cases being reported to have PmTC in the dominant nodule, 5 (71%) of them had bilobar malignant disease. Conclusion: The sub-centimeter nodule located in the contralateral lobe of the multinodular thyroid case is highly likely to be malignant. For this reason, total thyroidectomy should be the preferred procedure in a multinodular thyroid tissue requiring surgery. P91 Minimal risk of persistent or recurrent hypoglycemia after MEN1-related insulinoma surgery. A large international cohort study S Nell1, P Goudet2, A Vella3, DK Bartsch4, ND Perrier5, ML Brandi 6 , R Zarnegar 7 , E Kebebew 8 , L Brunaud 9 , JD Pasternak10, C Sturgeon11, HM Verkooijen12, IHM Borel Rinkes13, GD Valk14, MR Vriens15 1

P90 What would we leave behind in the bilobar multinodular goiter patient if hemithyroidectomy was performed with subcentimeter nodule(s) in the remnant lobe? M Özdemir1, O Makay1, K Erözkan1, G İçöz1, M Akyıldız1 1 General Surgery, Ege University Medicine Faculty, İzmir, Turkey Introduction: Decision for thyroidectomy in patients with multinodular goiter is based on the characteristics of the nodules. Small nodules located in the contralateral lobe are generally considered clinically insignificant after preoperative work-up. However, even being sub-centimeter nodules, these may not be innocent. We aimed to investigate the results and frequency of papillary microcarcinoma (PmTC) in the contralateral lobe of the multinodular thyroid tissue. Material and Methods: We retrospectively investigated thyroidectomized multinodular goiter cases with sub-centimeter

Department of Endocrine Surgical Oncology and Endocrine Oncology, University Medical Centre Utrecht, Utrecht, The Netherlands; 2On behalf of the French Endocrine Tumor Study Group, Department of Digestive and Endocrine Surgery, Centre Hospitalier Universitaire de Dijon, Dijon, France; 3Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Minnesota, USA; 4Department of Visceral, Thoracic and Vascular Surgery, Philipps University Marburg, Marburg, Germany; 5Department of Surgical Oncology, The University of Texas, MD Anderson Cancer Centre, Texas, USA; 6Department of Surgery and Translational Medicine, University of Florence, Florence, Italy; 7Department of Surgery, New York Presbyterian Hospital Weill Cornell Medical Centre, New York, USA Objective: To determine the optimal surgical strategy to treat MEN1 patients with an insulinoma. Background: Current literature states that 15-30% of the Multiple Endocrine Neoplasia type 1 (MEN1) patients have

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persistent or recurrent hypoglycemia after insulinoma surgery, depending on the surgical procedure. Methods: A total of 96 MEN1 patients with insulinomas underwent surgery between 1990-2015 at one of the 46 participating hospitals from Europe and North America. Postoperative hypoglycemia, complications, and pancreatic insufficiency were captured. Results: Seven percent of the patients suffered from persistent or recurrent hypoglycemia; one patient was not cured, four patients developed new insulinomas in the remaining pancreas, and two patients developed insulin-producing liver metastases. None of the 9 patients who were operated for a proximal insulinoma developed hypoglycemia. Of the 54 patients with a distal insulinoma, one patient had persistent disease after a distal pancreatectomy (1/41), and one patient developed a new insulinoma after an enucleation (1/13). Of the 33 patients operated for multiple insulinomas, 1/26 patients developed an insulin producing liver metastasis after a distal pancreatectomy combined with surgery of the pancreatic head. Four out of seven patients developed recurrent disease after other surgical approaches for multiple insulinomas. Patients who underwent an enucleation did not develop pancreatic insufficiency. Conclusions: MEN1 related insulinoma surgery is more successful than previously thought. In MEN1 patients with a solitary insulinoma, an enucleation seems reasonable, if surgically feasible. A distal pancreatectomy combined with surgery of the pancreatic head is favorable for MEN1 patients with multiple insulinomas throughout the pancreas.

retrospectively applied to two population, control group (18 thyroid lobectomy (TL)) and study group (68 total thyroidectomy (TT)). Hypoparathyroidism was determined by PTH levels ≤ 14 pg/ml. Best cut-off point was assessed through receiver operating characteristics (ROC) curves and applied in a third group, composed of next 32 TT, in order to indicate selective CS. Results No hypocalcaemia was observed in 18 TL (highest %PTHioD: 61%). Best cut-off points for %PTHioD, to detect hypoparathyroidism/hypocalcaemia development, for 68 TT was 71,31% (AUC:0.938; S:0.9; E:0.895). Hypoparathyroidism rate was 38%. PTH at skin closure, 21.50 pg/ml, was also an excellent predictor of hypocalcaemia (AUC: 0.971; S: 0.9; E: 0.921). Applying cut-off levels on the third group, we achieve 19 TT discharged with CS and 13 TT discharged without CS. No readmission or emergency consultations. Conclusion %PTHioD is an excellent postoperative hypoparathyroidism predictor avoiding the costs and discomfort of unnecessary calcium supplementation. In our center, %PTHioD<71,3% and PTH skin-closure>21.5 pg/ml allows an early and safe discharge without CS in 40% of TT. P93 Kidney graft survival after total parathyroidectomy and autograft in tertiary hyperparathyroidism FLM Montenegro1, SS Arap1, CP Nascimento Jr1, MDG Brescia1, FF Magnabosco1, LM Massoni Neto1, W Nahas2, E David Neto2, LE Ianhez2

P92 Intraoperative Parathyroid Hormone Assay an excellent predictor of Hypocalcemia after total Thyroidectomy

1

I Grao Torrente 1 , E Viejo Martinez 1 , E Fernández Fernández2, J.L Escat Cortés 1, I Amunategui Prats1, E Mercader Cidoncha1

Introduction: Hyperparathyroidism after renal transplantation may require parathyroidectomy. The operation is often associated with an acute reduction of kidney function. Recovery is seen in most cases, but the kidney graft survival is a matter of concern. Some authors consider total parathyroidectomy a risk factor for graft loss. We studied renal function after parathyroidectomy.

1

General surgery, Gregorio Marañón Hospital, Madrid, Spain; Endocrinology, Gregorio Marañón Hospital, Madrid, Spain

2

Introduction Postoperative hypocalcaemia, due to parathyroid damage, is the most common complication after total thyroidectomy (0,3-49%). Postoperative routine calcium supplementation (CS) allows early discharge and avoids readmission, although is costly and has collateral effects. Intraoperative PTH decline is an useful method to predict hypoparathyroidism/hypocalcaemia development. Material and Methods Percentage of intraoperative PTH decline (%PTHioD) was defined as [(PTHpre-incision – PTH at skin closure)/(PTHpre-incision) X 100]. This test was

Department of Surgery; 2Kidney Transplant Unit, University of Sao Paulo Medical School, Sao Paulo, Brazil

Material and Methods: Analysis of renal function and kidney graft survival in a single centre cohort of renal transplant patients submitted to total parathyroidectomy and autograft treated from 1994 to 2013. The analysis included preoperative age and values of Total Calcium (Ca, normal 8.6-10.2mg/dL), Phosphorus (P, normal 2.7-4.5mg/dL), Parathormone (PTH, normal 10-65pg/mL), and Estimated Glomerular Filtration Rate (eGFR) calculated from Creatinine (Cr). Receiver operator Curve (ROC), Kaplan-Meier curves and Log-rank tests were employed.

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Discussion: There were 74 cases (46 female), with mean age of 50.6 (SD 9.6) years. Median preoperative and interquartile ranges of laboratory values were Ca 11.1 mg//dL, (10.6-12.0), P 2.5mg/dL (2.1-2.9), PTH 230pg/mL (135-446), and Cr 1.24mg/dL (1.0-1.53). Mean preoperative eGFR of 54.2 mL/ min dropped to 37.4 mL/min right after the operation. At one year, mean eGFR was 47.6 ml/min. Eighteen patients (10 female) lost their kidney grafts from 12 to 132 months after parathyroidectomy (median 49). Compared to patients with functioning graft, there were no differences in preoperative values of Ca, P, PTH and age. Conversely, there were significant differences in preoperative Cr 1.18 vs. 1.60 mg/dL (p<0.0001) and eGFR 56.5 vs. 36.5 mL/min (p=0.002). Using a ROC curve, the cut off value of eGFR was 43.5 mL/min. Using this threshold of preoperative eGFR, kidney graft survival curves were different (Log-rank, p=0.02). At 60 months, 70% of the patients with preoperative eGFR superior to 43.5 mL/min had a functioning kidney, compared to 50% if the eGFR was below this limit. Conclusion: Total parathyroidectomy with immediate autograft is rather safe in patients with good preoperative renal function, but may be an additional risk to kidney loss in patients with low preoperative eGFR.

Discussion: Overall 82 patients (44.1%) showed occult CNM. The rate of CNM did not significantly differ among different sizes cut off (≤5mm: 8/104 pN0 Vs 4/82 pN1a, respectively, P=NS; ≤10 mm: 46/104 pN0 Vs 31/82 pN1a, P=NS; ≤20 mm: 83/104 pN0 Vs 69/82 pN1a, respectively, P=NS). Significantly more pN1a than pN0 patients had pT3 tumors (35/82Vs26/104) (P<0.05), extracapsular invasion (35/ 82Vs22/104) (P<0.01) and microscopic multifocal disease (50/82Vs47/104) (P<0.05). At multivariate analysis independent risk factor for CNM were extracapsular invasion and microscopic multifocal disease. The mean number of removed and occult metastatic nodes did not significantly differ between micro- and macro-PTC pN1 patients (11.5±6.4 and 2.3±1.7, 13.2±5.9 and 2.7±1.6, respectively, P=NS). Among 77 microPTC risk factors for CNM were extracapsular invasion (10/46 pN0 Vs 16/31 pN1, P<0.05) and microscopic multifocal disease (16/46 pN0 Vs 21/31 pN1, P<0.01). Among 109 macroPTC risk factors for CNM were presence of angioinvasion at final histology (7/58 pN0 Vs 15/51 pN1, P<0.05) and histology showing classic PTC (Vs follicular variant PTC Vs tall cell variant PTC) (P<0.05).

P94 Risk Factors For Central Neck Lymph Node Metastases In Micro- Vs Macro- Clinically Node Negative Papillary Thyroid Carcinoma

Conclusion: Independent risk factors for CNM differ between micro- and macroPTC (extracapsular invasion and microscopic multifocal disease Vs angioinvasion and histological subtypes, respectively) but no preoperatively available clinical parameter is predictor of CNM in clinically unifocal cN0 PTC.

L Sessa1, 2, M Raffaelli1, 2, C De Crea1, 2, CP Lombardi1, 2, R Bellantone1, 2

P95 Cardiovascular events after parathyroidectomy in patients on renal replacement therapy

1

KM Ivarsson 1, S Akaberi2, E Isaksson3, E Reihnér4, T Czuba5, KG Prütz6, N Clyne7, M Almquist8

Istituto di Semeiotica Chirurgica, Università Cattolica del S. Cuore, Rome, Italy; 2 U.O. di Chirurgia Endocrina e Metabolica, Fondazione Policlinico Universitario A. Gemelli, Rome, Italy

1

Clinical Sciences, Lund University, Lund, Sweden; Department of Nephrology, Skane University Hospital Lund, Lund, Sweden; 3Department of Urology, University Hospital Malmö, Malmö, Sweden; 4 Department of Molecular Medicine and Surgery, Karolinska University Hospital, Stockholm, Sweden; 5National Registry Centre, Skane University Hospital Lund, Lund, Sweden; 6 Department of Internal Medicine, Helsingborg Hospital, Helsingborg, Sweden; 7Department of Nephrology, Skane University Hospital Lund, Lund, Sweden 2

Introduction: The demographic and clinical factors predictive of central lymph node metastases (CNM) in patients with clinically node negative (cN0) papillary thyroid carcinoma (PTC) remain uncertain. Despite tumor size (microPTC -≤10mm-Vs macroPTC ->10mm) has been advocated as possible risk factors for occult CNM in PTC patients, the studies available report discordant results. We aimed to prospectively evaluate factors that could identify clinically unifocal and cN0 PTC patients at higher risk of occult CNM especially comparing microPTC and macroPTC. Material and Methods: One hundred and eighty-six consecutive patients with clinically unifocal, cN0 PTC who underwent total thyroidectomy plus prophylactic bilateral central neck dissection between March 2008 and July 2012 were prospectively recruited. Risk factors for occult CNM in patients with microPTC and macroPTC were assessed.

Introduction: A majority of patients with end stage renal disease suffers from secondary hyperparathyroidism, which is associated with osteoporosis and cardiovascular disease. Parathyroidectomy (PTX) is often necessary despite improved medical treatment of the condition, and has been associated with better survival among dialysis patients. The aim of this study was to evaluate the effect of PTX on risk of cardiovascular events in patients on renal replacement therapy.

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Material and Methods: We performed a nested index-referent study within the Swedish Renal Registry (SRR), and matched PTX patients on dialysis or with functioning renal allograft with up to five non-PTX referents for age, sex and underlying renal diseases. In order to calculate time to cardiovascular events i.e. myocardial infarct, stroke and transient ischemic attack, indexes and referents were assigned the calendar date (d) of the PTX of the index patient. Crude and adjusted proportional hazards regressions with adjustment for random effects, frailty, were used to calculate hazard ratios for cardiovascular events. Discussion: Our study cohort included 20 056 patients in the SRR between 1991 and 2009, among these 579 patients had undergone PTX, 423 during dialysis and 156 during time with functioning renal allograft. These patients were matched with 1234/892 non-PTX patients. The adjusted relative risk of cardiovascular events was HR (95% CI) 1.54 (1.22-1.92) for dialysis patients at d who had undergone PTX, compared with matched patients who had not. Corresponding results for patients with renal allograft at d was HR (95% CI) 0.64 (0.470.89). Conclusion: PTX patients on dialysis at d ran a higher risk of cardiovascular events than non-operated patients. Among patients with renal allograft at d on the other hand, the risk was lower.

Sensibility, specifity, positive and negative predictive value of several cutoff points of these decline are studied. These values are related to symptoms of hypocalcemia. With data obtained from these patients a protocol is elaborated and apply to predict and prevent hypocalcaemia. After inclusion and exclusion criteria, a prospective group (group 2, N=60) of patient is enrolled using this algorithm in order to give oral calcium + vitamin D (if needed) to facilitate safe next day surgery discharge. Discussion: In group one symptomatic hypocalcemia occurs in 27.2%. Best cutoff value in terms of S, E is 60% of PTHq decline plus 24h calcemia of 7,35 mg/dl. The protocol with the 60% decline in PTH and next morning calcemia is applied to group 2 patients. 100% of these cases could be discharge with no problem. Some 11% had mild hypocalcemia symptoms at home, all of them were taking calcium supplements and these symptoms were all self-limited. Costs for intervention are clearly reduced if stay is limited to one night. Some protocols for short stay or same day surgery give oral calcium to all patients. We believe is unnecessary. Conclusions: Short stay for total thyroidectomies is safe and possible. Routine PTH assay is a keystone to discharge patient safely. Cost savings added to patient benefits should encourage endocrine surgeons to establish these kinds of protocols.

P96 Short stay thyroidectomy based in quick parathyroid hormone determination

P97 Can Precision Medicine be done with Surgical Precision: Prophylactic Thyroidectomy in Children with MEN2 in the United Kingdom

G Gutierrez1, J Garcia1, E Toledo1, A del Castillo1, M Cañon1, D Casanova1

H Nounou, F Prete, T Abdel-Aziz, C Morkane, C Brain, TR Kurzawinski

Endocrine Unit.General Surgery Department, Hospital Universitario Marques de Valdecilla, Santander, Spain

1

Introduction: Thyroidectomy has been traditionally an inpatient surgery procedure. In the last two decades it trends toward a short stay or even day surgery. Complications have been determinant for the way these patients are managed. Hypocalcemia is the most common complication and results in prolonged length of stay. We present a protocol for short stay surgery (24 hours) based in parathyroid hormone (PTH) determination.

Introduction: Genetic testing in MEN2 families offers early diagnosis, stratifies risks of developing MTC. To maximise benefits of Precision Medicine, treatment has to be delivered timely and with Surgical Precision minimising risks of complications and achieving best outcomes. This study evaluates the management of children with MEN2 in the UK and assesses its timeliness (age at DNA test and surgery), safety (complications and LOS) and effectiveness (histology, calcitonin levels, recurrence).

Material and Methods: The study has two groups of patients in two parts. Group one N=302 total thyroidectomies, prospective collective data of patients with usual care, with determination of basal and 10 minutes after thyroidectomy quick PTH (PTHq), serum calcemias, postoperative symptoms and complications. PTH percentage descent is calculated. PTHq is measured using electrochemiluminescence immunoassay.

Endocrine Surgery Centre, University College London Hospitals NHS Trust, London, UK

Material and Methods: 79 children (36M/43F) with MEN2 were stratified into ATA 2009 risk categories. Median age at DNA testing was 4.29 and at surgery 6.24 years, only 52.7% and 54.4% within recommended age. Operations beyond recommended age correlated with a late DNA test and with abnormal calcitonin and children in high risks groups had

Langenbecks Arch Surg

increased the risk of MTC. 54 children (68.5%) had total thyroidectomies (TT) and 25 (46.3%) had lymph nodes dissection (22 central, 3 lateral), 88.9% and 44% were in keeping with ATA 2009 recommendations, respectively. Discussion: Lymph node dissection (LND) was associated with higher risk of parathyroid excision (1vs.0.39, p<0.001), postoperative hypocalcaemia (76%vs.37%, p=0.001). 2 children had RLN neuropraxia, 1 phrenic nerve injury, 2 respiratory and 1 wound infection. Median LOS was 3.15 days and was longer in LND group (4.2vs.2.67 days p=0.018). There was no association between rate of complications and age of children at the time of surgery. 10 children had normal thyroid, 39 C-cell hyperplasia and 30 MTC. MTC was more frequent, multifocal and >1cm in higher risk groups (p< 0.001). Post op calcitonin was available in 71 children (mean F/U 75.7 months), 27 had undetectable, 20 detectable but in normal range and 24 at least one basal calcitonin above normal. Only one child (MEN2b) had positive LN, calcitonin > 40 and developed clinical recurrence. Conclusion: Late genetic testing and operation in half of the children resulted in ¾ of them having abnormal calcitonin and ½ developing MTC by the time of surgery. Routine LND is not necessary when children are operated within the recommended age. Significance of detectable postoperative calcitonin is uncertain but worrying as it might indicate persistent disease or incomplete removal of thyroid tissue. P98 Two novel molecular markers of thyroid cancer N Munoz Perez1, S Gonzalez Martinez1, P Notario1, N Sarabia1, E Calcerrada1, JI Arcelus Martínez1, JA Jiménez Ríos1, JM Villar del Moral1, P Bueno Laraño2 1

General Surgery. Endocrine Surgery., Complejo Hospitalario Universitario de Granada, Granada, Spain; 2Research Unit,

Complejo Hospitalario Universitario de Granada, Granada, Spain Introduction: The objective of this study is to find a gene expression profile, using microarrays methodology, to discriminate benign from malignant lesions when cytology report is undetermined. Material and Methods: From January 2008 to January 2011, 34 patients with clinical, radiological or cytological suspicion of thyroid cancer were analyzed using CodeLinkTM UniSet Human Whole Genome Bioarray in thyroid pathological tissue and in peripheral blood. Afterwards, the profile obtained was validated by quantitative polymerase chain reaction in a second group of patients. Statistical analysis was done with SPSS® 22.0 software. Qualitative variables were analyzed by Fisher exact test while quantitative ones were compared with Student-t test, if normal distribution was confirmed, or UMann Whitney test otherwise. A predictive model was constructed by logistical regression and this was evaluated calculating the sensitivity, specificity, positive and predictive values, and the area under ROC curve. Discussion: Over-expression of HMGN2 in thyroid tissue was related to malignant neoplasm (p= 0,001) while overexpression of NLRC3 in peripheral blood was associated to benign lesions (p= 0,011). The likelihood of thyroid cancer is 0.98 when HMGN2 is expressed and NLRC3 is not. By contrast, the opposite combination reduces this probability to 0.14. The application of this model to the subgroup of undetermined cytology correctly identified malignant tumors with an area under curve of 0.983. Both genes are inversely related. Conclusion: Over-expression of HMGN2 in pathological thyroid tissue besides under-expression of NLRC3 in peripheral blood of patients with thyroid nodules predicts malignant thyroid neoplasms.