Can Thyroid Ultrasonography Predict Substernal Extension or Tracheal Compression in Goiters?

PURPOSE: To determine whether an ultrasonography (US)-defined thyroid volume can accurately predict substernal extension or tracheal narrowing. METHODS: After research ethics approval, we identified patients with thyroid nodules investigated with both US and computed tomography (CT). Reviewers assigned scores for both substernal extension and tracheal compression on CT using pre-established classification systems. Statistical analysis with receiver operating characteristic curve analysis was performed to find the US-determined thyroid volume thresholds that correlated with each substernal extension and tracheal compression. RESULTS: This study included 120 patients (mean age 63.4 years; SD ± 15.9; 67% female). Thirty-five patients (29%) had substernal extension. The mean US total thyroid gland volume in patients with and without substernal extension were 92.4 and 37.6 cm3, respectively (P < .001). 86% of patients with substernal extension had tracheal narrowing vs. 27% of patients without substernal extension (P < .0001). A cutoff dominant gland volume of ≥37.5 cm3 showed 83% sensitivity and 79% specificity for substernal extension (area under the curve [AUC] = 0.84). A total thyroid gland volume threshold of ≥37.8 cm3 showed 89% sensitivity and 87% specificity for any degree of tracheal narrowing (AUC = 0.90). CONCLUSIONS: This study suggests that US volumes may be used as a predictor to identify those patients with thyroid enlargement who are most at risk of substernal extension and tracheal compression and who may benefit from preoperative CT imaging for optimal surgical and anesthetic planning.

Contemporary surgical management of non-medullary thyroid malignancy.

This article reviews the clinical features of well differentiated thyroid cancer and examines various tools used in the evaluation of patients, in both the primary and the recurrent settings. Contemporary treatment strategies, with an emphasis placed on surgical treatment are revisited. Non-surgical modalities, including the use of radioactive iodine, external beam radiotherapy and chemotherapy are discussed.

Effect of Implementing Community of Practice Modified Thyroid Imaging Reporting and Data System on Reporting Adherence and Number of Thyroid Biopsies.

RATIONALE AND OBJECTIVES: Thyroid nodules are common in the population, although the rate of malignancy is relatively low (5%-15%). The purpose of this study was to determine if introducing a modified standardized reporting format and management algorithm (Thyroid Imaging Reporting and Data System [TI-RADS]) affects radiologist reporting adherence, number of thyroid biopsies, and other measurable outcomes. MATERIALS AND METHODS: All thyroid biopsies performed over two 6-month periods were evaluated at a tertiary care hospital with Research Ethics Board approval. The first period was before implementation of TI-RADS and the second was several months after implementation of TI-RADS (using a modified version made through a multidisciplinary collaboration). The number of biopsies performed was determined in each of the two periods as well as the percent of positive malignancy, wait times, and rates of non-diagnostic/unsatisfactory and inconclusive biopsies, which included atypia of undetermined significance (AUS) and follicular lesion of undetermined significance (FLUS). RESULTS: The average number of biopsies performed prior to implementing modified Kwak's TI-RADS was 74 thyroid biopsies per month and the average number of diagnostic ultrasounds was 271. After the introduction of modified Kwak's TI-RADS, the average number of thyroid biopsies decreased to 60 per month (an 18.9% reduction, P < .05), and the number of diagnostic ultrasound increased to 287 per month (a 5.9% increase from 2016 to 2017). The average wait time for a thyroid biopsy decreased from 5 to 3 weeks (P < .05). There was a slight increase in the rate of positive malignancy results (from 15% to 18%), although it was not statistically significant. The rate of non-diagnostic/unsatisfactory and inconclusive results (including AUS and FLUS) remained unchanged (18% AUS/FLUS/15% non-diagnostic/unsatisfactory before and 17% AUS/FLUS/15% non-diagnostic/unsatisfactory after TI-RADS introduction, P > .05). CONCLUSIONS: Introduction of a multidisciplinary-approved standardized reporting system with evidence-based management recommendations led to no statistically significant change in the number of diagnostic ultrasounds but a statistically significant reduction in the number of monthly thyroid biopsies and associated reduction in wait times.

Sublingual gland resection in squamous cell carcinoma of the floor of mouth: is it necessary?

OBJECTIVES: Little evidence exists to guide surgeons in the management of the sublingual glands (SLG) not macroscopically involved by squamous cell carcinoma of the floor of mouth and oral tongue. This study aims to determine the frequency with which the SLG is invaded, to identify variables predicting for SLG invasion and the morbidity associated with it's resection in entirety. STUDY DESIGN: Retrospective cohort study. METHODS: A review of 164 patients treated for oral cavity cancer at a tertiary institution with a large volume of head and neck malignancy was performed. Demographic data, rates of surgical complications and follow up information was recorded. Pathologic review of resected material in this group yielded 134 specimens in the region of the SLG. A detailed analysis of 63 specimens in which the SLG was included was carried out. RESULTS: The median age was 58 years, mean follow up was 2.2 years, and there were 44 males and 19 females. Seventeen cases (27%) demonstrated histopathological SLG invasion. In patients with SLG involvement, this was evident at the time of surgery in 15 patients (88%). Microscopic SLG invasion, without macroscopic evidence at surgery, was present in only 4.2% of patients undergoing SLG resection. Clinical and pathological T stage (p = 0.023 and 0.005) and tumor thickness (p = 0.015) predicted for SLG invasion. Total SLG resection significantly increased the post-operative wound complication rate from 14% in patients without SLG resection to 25% (p = 0.05). CONCLUSION: Total SLG resection in early stage and thin squamous cell carcinoma of the floor of mouth and oral tongue provides minimal oncologic benefit and is associated with increased perioperative morbidity due to neck wound complications.

Prognostic variables and calcitonin in medullary thyroid cancer.

OBJECTIVES/HYPOTHESIS: Medullary thyroid cancer (MTC) is a nonepithelial, neuroendocrine tumor with a more aggressive clinical behavior than differentiated thyroid cancer. The purpose of the study was to review a single institution's experience with MCT since 1969. STUDY DESIGN: Retrospective cohort study. METHODS: A retrospective review of 30 patients treated for MTC at a tertiary care referral center between 1969 and 2000. There were 17 female and 13 male patients, median age at presentation was 38 years, and median follow-up for survivors was 12.4 years. RESULTS: Seventy percent of patients had sporadic MTC, 6.7% had familial MTC, 16.7% had multiple endocrine neoplasia syndrome type IIA, and 6.7% had multiple endocrine neoplasia syndrome type IIB. The cumulative overall survival rates at 5, 10, and 20 years were 97%, 88%, and 84%, respectively; disease-free survival rates were 97%, 74%, and 29%, respectively. Advanced tumor stage (P = .014) and multiple endocrine neoplasia syndrome type IIB predicted decreased disease-specific survival. Variables affecting disease-free survival were post-thyroidectomy calcitonin level (P = .001), vascular invasion (P = .005), perineural invasion (P = .010), extrathyroidal extension (P < .001), and the presence of nodal metastases (P = .001). Locoregional control rates were 83% at 5 years and 70% at 10 years. Vascular invasion (P = .004), extrathyroidal extension (P = .008), and post-thyroidectomy basal calcitonin level (P = .003) predicted locoregional failure. Many patients in the series experienced prolonged survival despite elevated calcitonin levels. CONCLUSION: Long-term disease-free survival is uncommon in MTC, but the study data indicate that the majority of patients with MTC live for prolonged periods, despite biochemical evidence of persistent disease. Adverse pathological features such as extrathyroidal extension and vascular and perineural invasion were predictors of disease recurrence. The use of serum markers in the follow-up of patients with MTC must be interpreted within the clinical context.

Selectively false-positive radionuclide scan in a patient with sarcoidosis and papillary thyroid cancer: a case report and review of the literature.

BACKGROUND: Radioiodine and Tc-99 m pertechnetate scans are routinely relied upon to detect metastasis in papillary thyroid cancer; false-positive scans are relatively rare. To our knowledge, no published reports exist of sarcoidosis causing such selectively false-positive scans. METHODS: We present a case of a 41-year-old woman with known metastatic papillary thyroid cancer (T1bN1aMx) in whom sarcoidosis-affected cervical and mediastinal lymph nodes demonstrated uptake of thyroid-targeting radionuclides. Only the minority of these nodes demonstrated radionuclide uptake, raising the suspicion of adjacent or coexisting sarcoid and metastatic involvement. Selective uptake of thyroid-targeted radionuclides by isolated sarcoidosis is, to our knowledge, a previously undocumented occurrence. RESULTS: Biopsies of uptake-negative mediastinal nodes revealed sarcoidosis. Pathology from a subsequent neck dissection excising uptake-positive cervical nodes also showed sarcoidosis, with no coinciding malignancy. CONCLUSIONS: We document a case of sarcoidosis causing a selectively false-positive thyroid scintigraphy scan. It is useful for clinicians to be aware of potential false-positives and deceptive patterns on radionuclide scans when managing patients with both well-differentiated thyroid cancer and a co-existing disease affecting the nodal basins draining the thyroid gland.

Single-stage repair of subglottic stenosis using the radial forearm free flap as a vascularized carrier.

BACKGROUND: We present a case report of a patient with history of subglottic carcinoma who underwent chemoradiation and subsequently developed subglottic stenosis (SGS). METHODS AND RESULTS: She was treated with an anterior cricoid split maintained by septal cartilage wrapped in a partially deepithelialized radial forearm free flap (RFFF). To date, with a follow-up of 6 months, the patient has been fully decannulated and has not experienced airway collapse or any other complications. CONCLUSIONS: Upper airway reconstruction using a single-stage autogenous cartilage graft wrapped in a vascularized carrier is a real option for those patients with extensive SGS in the setting of an irradiated and devascularized tissue bed.

Microvascular reconstruction of major lip defects.

Reconstruction of extensive lip defects is a challenging task for reconstructive microsurgeons. This article reviews the goals of lip reconstruction after major ablative or traumatic lip losses and outlines the free flap options available to achieve these goals.

Postoperative monitoring in free tissue transfer patients: effective use of nursing and resident staff.

OBJECTIVES: To compare the outcomes of two different free flap monitoring protocols and determine whether nursing staff can safely and effectively monitor free flaps. STUDY DESIGN: Historical cohort study on all head and neck free tissue transfer patients from August 2003 to August 2007. SETTING: Tertiary care teaching institution. SUBJECTS AND METHODS: The patients were divided into two groups according to monitoring protocol. Group A (n = 49) had free flaps monitored primarily by resident physicians, while Group B patients (n = 45) were evaluated primarily by nursing staff. Demographic and outcomes data, including complications, reoperations, length of hospital stay, and flap viability, were then compared. RESULTS: Overall, 28 (57%) patients in Group A and 16 (37%) in Group B had at least one complication (P = 0.05). Only eight patients in each group had major complications. There were 25 (27%) patients who required further intervention in the operating room: 18 (37%) in Group A and seven (16%) in Group B (P = 0.03). Only 12 (13%) patients returned to the operating room for concerns of flap viability: seven from Group A and five from Group B. The median length of hospital stay was 11 days for both groups (P = 0.76). The flap success rate was 95 percent, with three failures in Group A and two in Group B (P = 0.72). CONCLUSIONS: A monitoring protocol utilizing trained nursing staff has no detrimental effect on free tissue transfer outcomes. This may be used to optimize resident time within the current duty-hour restrictions.

Parotid surgery in an outpatient setting: the Vancouver Hospital experience.

OBJECTIVE: The goal of the present study was to review our experience with parotid surgery in an outpatient setting. Particular attention was given to examining the demographics of the population suitable for this approach as well as to evaluating complication and readmission rates. Waiting times for surgery were reviewed. Our experience is then compared with that of other researchers reported in the literature. METHODS: A retrospective chart review of 76 patients undergoing parotid surgery by a single surgeon in a free-standing surgical centre associated with Vancouver General Hospital, a tertiary teaching facility, was undertaken for the following: age, gender, American Association of Anesthesiology classification, time between initial visit and surgery, type of procedure, pathology, operative and recovery times and rates of complications, emergency department visitation, and readmission. RESULTS: Thirty-seven males and 39 females with a mean age of 44.8 +/- 16.2 years were reviewed. Mean operative and recovery times were 109.8 +/- 20 and 268.6 +/- 58 minutes, respectively. The minor complication rate was 6.6%. One patient (1.3%) required readmission and two others (2.6%) visited the emergency department. CONCLUSIONS: Parotid surgery is possible on an outpatient basis, given appropriate patient selection. Our rates of complications, emergency department visitation, and hospital admission compare favourably with those reported in the literature.