Surgery最新文献

Background: Multiple artificial intelligence (AI) systems have been approved to risk-stratify thyroid nodules through sonographic characterization. We sought to validate the ability of one such AI system, Koios DS (Koios Medical, Chicago, IL), to aid in improving risk stratification of indeterminate thyroid nodules.

Methods: A retrospective single-institution dataset was compiled of 28 cytologically indeterminate thyroid nodules having undergone molecular testing and surgical resection, with surgical pathology categorized as malignant or benign. Nodules were retrospectively evaluated with Koios DS. After nodule selection, automated and AI-adapter-derived Thyroid Imaging Reporting and Data System (TI-RADS) levels were recorded, and agreement with radiologist-derived levels was assessed using Cohen's κ statistic. The performance of malignancy classification was compared between the radiologist and AI-adapter. Biopsy thresholds were re-evaluated using the AI-adapter.

Results: In this cohort, 7 (25%) nodules were malignant on surgical pathology. The median nodule size was 2.4 cm (interquartile range: 1.8-2.9 cm). Median radiologist and automated TI-RADS levels were both 4, with κ 0.25 ("fair agreement"). Malignancy classification by the radiologist provided sensitivity 100%, specificity 33.3%, positive predictive value (PPV) 33.3%, and negative predictive value (NPV) 100%, compared with the AI-adapter's performance with sensitivity 85.7%, specificity 76.2%, PPV 54.5%, and NPV 94.1%. Using the AI-adapter, 14 of 28 biopsies would have been deferred, 13 of which were surgically benign.

Conclusion: Koios automated and radiologist-derived TI-RADS levels were in consistent agreement for indeterminate thyroid nodules. Malignancy reclassification with the AI-adapter improved PPV at minimal cost to NPV. Risk stratification with the addition of the AI-adapter may allow for more accurate patient counseling and the avoidance of biopsies in select cases that would otherwise be cytologically indeterminate.

Background: With the advent of peptide receptor radionuclide therapy, the timing and sequence of surgery in the treatment of metastatic gastroenteropancreatic neuroendocrine tumors merits further study. We hypothesized that surgery before peptide receptor radionuclide therapy might enhance its effectiveness in patients with metastatic gastroenteropancreatic neuroendocrine tumors.

Methods: Eighty-nine patients with metastatic well-differentiated gastroenteropancreatic neuroendocrine tumors treated with ¹⁷⁷Lutetium-dotatate peptide receptor radionuclide therapy between 2018 and 2023 were included. Fifty-six patients underwent surgery (primary tumor resection and/or liver debulking) before peptide receptor radionuclide therapy and 33 patients did not. Primary outcome was progression-free survival according to Response Evaluation Criteria in Solid Tumors. Pretreatment dotatate positron emission tomography/computed tomography was used to calculate tumor volumes.

Results: The surgery and no-surgery groups were well-matched. Median progression-free survival after peptide receptor radionuclide therapy was 15.6 months (interquartile range, 9.1-22.7 months) in the no-surgery group compared with 26.1 months (interquartile range, 12.7-38.1 months) in the surgery group (P = .04). On subgroup analysis, median progression-free survival was 18.1 months (interquartile range, 11.9-38.4 months) in patients who underwent primary tumor resection only compared with 26.2 months (interquartile range, 14.0-38.1 months) in patients who underwent liver debulking (P = .04). Tumor volume was lowest in patients who underwent liver debulking (median 146.07 mL³) compared with no surgery (median 626.42 mL³) (P = .001). On univariable analysis, a tumor volume <138.8 mL³ was associated with longer progression-free survival (hazard ratio, 2.03; 95% confidence interval, 0.95-4.34, P = .05), with a median progression-free survival of 38.1 months (interquartile range, 16.9-41.3 months) compared with 17.8 months (interquartile range, 10.8-28.7 months).

Conclusion: Surgery may enhance the effectiveness of ¹⁷⁷Lutetium-dotatate in the treatment of metastatic well-differentiated gastroenteropancreatic neuroendocrine tumors. This positive effect may be the result of a lower tumor volume in patients after surgery. Our findings fortify the concept of using surgical debulking to improve systemic therapies such as peptide receptor radionuclide therapy.

Background: Medicaid expansion has been associated with improved access to surgical care at high-volume centers. Its impact on parathyroidectomy, however, is unclear. We evaluated the association between Medicaid expansion and parathyroidectomy at high- and low-volume centers.

Methods: The Vizient Clinical Data Base was queried for parathyroidectomies. Patients were grouped by insurance status and pre- and post-Medicaid expansion periods. Hospitals were stratified into tertiles (T1-T3) by operative volume (T1 = highest-volume centers). Odds of parathyroidectomy and a difference-in-differences analysis were conducted.

Results: In total, 31,983 patients were identified. Patients were predominantly privately insured (49.9%). Uninsured and Medicaid patients had increasing odds of operation at lower-tertile centers (odds ratio: T1 = ref; uninsured: T2 = 10.0, T3 = 15.8; Medicaid: T2 = 6.2, T3 = 13.5; P < .001). Medicare patients, however, were less likely to undergo operation at lower-volume centers (odds ratio: T2 = 0.89, P < .001; T3 = 0.92, P = .002). Privately insured patients were the least likely to receive care at low-volume centers (odds ratio: T3 = 0.7, P < .001). Medicaid patients in nonexpansion states had 12-16 times higher odds of parathyroidectomy at lower-volume hospitals than their counterparts in expansion states (expansion/nonexpansion states: pre-expansion T3 = 2.3/28.0; postexpansion T3 = 1.3/21.4). Expansion was associated with an increase in the proportion of parathyroidectomy for Medicaid patients, with larger gains seen at higher-volume centers (T1 = 5.0%, P = .01; T2 = 3.1%, P = .001; T3 = 2.7%, P = .03). Expansion was not associated with changes in payor distribution for uninsured, Medicare, or privately insured patients.

Conclusions: Medicaid expansion was associated with an increase in parathyroidectomy for Medicaid patients at high-volume centers. However, in nonexpansion states, access to surgical treatment at high-volume centers remains limited for uninsured and underinsured patients.