Quality of life following lobectomy versus total thyroidectomy is significantly related to hypothyroidism.

OBJECTIVE: The aim of the present study was to investigate the differences in quality of life (QOL) following complete or partial thyroidectomy and with regard to thyroid hormone replacement (LT4) therapy. STUDY DESIGN: Patients who underwent thyroidectomy were asked to complete the validated thyroid-specific ThyPRO QOL questionnaire at least 6 months following surgery. SETTING: Tertiary medical center. METHODS: Thyroid specific QOL questionnaire analysis. RESULTS: A total of 190 patients completed the ThyPRO questionnaire. Of them 89 patients had complete thyroidectomy and 101 patients had unilateral thyroid lobectomy. The total thyroidectomy group had significantly worse overall QOL self-assessment score than the lobectomy patients (p < 0.0001). Patients receiving LT4 therapy regardless of the extent of surgery, reported worse QOL compared to patients not receiving LT4. CONCLUSIONS: Quality of life following thyroid surgery is significantly related to hypothyroidism and the requirement for LT4 therapy, rather to the extent of surgery. The best QOL was reported in patients treated with lobectomy who did not require LT4 therapy.

Is molecular testing in patients with low risk papillary thyroid carcinoma justified? A Markovian model.

BACKGROUND: Current guidelines consider all cases of papillary thyroid carcinoma (PTC) smaller than 4 cm and without extrathyroidal extension (ETE) and/or lymph node metastases as belonging to the same prognostic group, and therefore the recommendation is for uniform treatment. Xing draws our attention to a small subgroup with Duet Mutations (BRAF E600 and TERT 3636 genes) that are aggressive biologically and should be treated differently. Thus the aim of the present study is to test the validity of this recommendation. METHODS: A Markovian Model is used to evaluate the above hypothesis. RESULTS: A Monte Carlo sensitivity test shows a 5.6 year survival advantage for patients with low-grade PTC, who have the Duet Mutations, and were treated by total thyroidectomy rather than hemithyroidectomy. CONCLUSIONS: We conclude that there is a place for routine molecular tests in low-risk patients with PTC.

Effects of surgery for obstructive sleep apnea on cognitive function and driving performance.

BACKGROUND: Obstructive sleep apnea (OSA) is associated with a significantly increased risk of motor vehicle accidents in addition to such cognitive impairments as attention and memory deficits. The aim of the study was to examine the effect of upper airway surgery for OSA on driving and cognitive function. METHODS: Adult patients who underwent surgery for OSA at a tertiary medical center in 2016-2019 were prospectively recruited. Patients were assessed before and 3-6 months after surgery with a self-report and neurocognitive battery and a driving simulation platform. RESULTS: The cohort included 32 patients of average age 46.9 ± 11.6 years. During the 3 years before treatment, 9 patients had been involved in road accidents and 18 were detained by police for traffic violations. After surgery, there was a significant decrease in the Epworth Sleepiness Scale (13.7 vs. 8.1, p 0.043) and a significant reduction in time to completion of the Color Trail Test (part 1: 21.4 vs 18.7 s, p = 0.049; part 2: 46.8 vs 40.5 s, p = 0.038). Improvements in divided attention and selective attention response times were noted on the advanced stages of the Useful Field of Vision Scale (p = 0.013, p = 0.054). Before surgery, patients showed a high tendency to drive over the speed limit and to cross the dividing line to the opposite lane on the simulation test. Nevertheless, all considered themselves good drivers. These tendencies decreased after treatment. CONCLUSIONS: Surgery for OSA can significantly improve driving performance and cognitive function.

Is parotidectomy justified in elderly patients with pleomorphic adenoma? A decision analysis model.

PURPOSE: The value of parotidectomy in older patients is unclear. This study presents a decision model to help resolve this question. MATERIALS & METHODS: A Markov model with Monte Carlo simulation was used to compare outcomes in patients of different ages with pleomorphic adenoma of the parotid gland treated by surgery or surveillance. RESULTS: In 30-year-old patients, surgery conferred a 3.5-year gain in life expectancy whereas in 75-year-olds, it was only 0.74 months. The expected rate of malignant transformation at age 30 years was 6.5% after surgery and 26.5% after surveillance; at age 65, corresponding rates were 0.8% and 10.7%. Sensitivity analysis showed that age was the only parameter that significantly contributed to life expectancy. The benefit of surgery was restricted in older patients. CONCLUSION: Our Markov decision-analysis model suggests that patients older than 65 years with pleomorphic adenoma have a limited survival advantage with surgery compared to surveillance.

Acinic Cell Carcinoma of the Parotid Gland in Children and Adolescents.

Acinic cell carcinoma of the parotid gland is a rare low-grade malignant neoplasm. Data on children are sparse. For the present study, the database of a tertiary pediatric medical center was reviewed for all patients with parotid gland acinic cell carcinoma diagnosed and treated between 2004 and 2013. Clinical, histologic, treatment, and outcome parameters were collected from the medical files. Four patients were identified, 3 female and 1 male, aged 13.5 to 18 years (median 15.7) at diagnosis. One patient had a family history of parotid tumor and 1 of hypothyroidism/hyperthyroidism. Two patients had L-thyroxin-treated Hashimoto thyroiditis, and 1 had a thyroid nodule. All presented with a localized parotid mass and negative lymph nodes. Treatment consisted of partial parotidectomy, with no damage to the facial nerve. Histology confirmed the diagnosis of acinic cell carcinoma with low proliferation rate (Ki67 immunostaining 1% to 8%). No evidence of disease was found on any patient with a median follow-up at 83 months (range, 32 to 93 mo) from presentation. In our experience, the prognosis of pediatric parotid gland acinic cell carcinoma is good, and surgery alone is sufficient for treatment of early stage tumors. This is the first report of findings of a family history of thyroid disease and/or thyroid abnormalities in patients with parotid gland acinic cell carcinoma.

Heat shock proteins HSP90, HSP70 and GRP78 expression in medullary thyroid carcinoma.

BACKGROUND: Medullary thyroid carcinoma management consists mainly of surgical resection and is largely chemoresistant. There is ongoing effort to discover novel therapies for medullary thyroid carcinoma. Increased levels of heat shock proteins have been associated with multiple cancers and are being studied as potential therapeutic targets. The purpose of this study was to determine the expression levels of heat shock proteins 90 and 70 and of glucose related protein 78 in medullary thyroid carcinoma tissues compared with normal thyroid tissues. METHODS: 20 tissue specimens of medullary thyroid carcinoma and 10 specimens of thyroids without malignancy were analyzed by immunohistochemistry. RESULTS: Medullary thyroid carcinoma specimens showed 27% higher expression level of heat shock protein 90 immunostaining, and a 43% higher expression level of heat shock protein 70 immunostaining versus normal controls. These differences, however, were not statistically significant. A significantly higher expression level was noted for glucose related protein 78 in the medullary thyroid carcinoma specimens than in the controls. CONCLUSION: This study indicates increased expression levels of heat shock proteins 90 and 70 and glucose related protein 78 levels in medullary thyroid carcinoma. These findings, though preliminary imply that these proteins may have a role in medullary thyroid carcinoma's tumor biology and may have and future therapeutic options. Larger cohorts are needed to corroborate these results.

ROBOTIC-ASSISTED TRANSAXILLARY THYROID SURGERY - THE RABIN MEDICAL CENTER EXPERIENCE

AIMS: To review the experience of a single-center with RATS and to assess its outcome, feasibility and safety. BACKGROUND: With the advent of minimally invasive techniquesin thyroid surgery, robot-assisted transaxillary thyroid surgery (RATS) has become one of the most popular approaches. Its main advantages are improved cosmetic outcome, thereby increasing patient satisfaction, improved visualization and range of motion. Several large-scale studies, have demonstrated its safety and feasibility. METHODS: A retrospective review of all RATS consecutive cases at Rabin Medical Center. RESULTS: A total of 38 RATS procedures were performed between July 2012 and May 2015. The mean age of patients was 39 years (22-74); all patients were females; the average BMI was 25 (18-32). Thirty-seven patients underwent partial thyroidectomy and one - total thyroidectomy. The average maximal diameter of nodules pre-operatively was 2.5 cm (0.5- 5). Seventeen patients (44%) had papillary carcinoma; 13 (33%) - hyperplastic nodules and 8 (20%) - benign thyroid adenomas or goiters. The average total operative time was 166 minutes. One case was converted to open due to a large tumor; there were 6 (15.7%) cases of vocal cord paresis, of which 1 (2.6%) was permanent; there were 8 (21%) cases of hypoesthesia - all resolved within 4-12 weeks. There were no cases of permanent brachial plexus injury. CONCLUSIONS: In skilled hands, RATS is a safe alternative to conservative thyroidectomy, and should be presented to patients with aesthetic concerns. As with any new emerging technique, careful patient selection is crucial and further evidence must be sought to confirm its indications over time.

Recurrent pleomorphic adenoma of the parotid gland: Institutional experience and review of the literature.

BACKGROUND: Recurrent pleomorphic adenoma (PA) of the parotid gland is a challenging surgical issue with controversy regarding management and long term outcome. METHODS: All patients who were operated for recurrent PA of the parotid gland between the years 1991 and 2013 were reviewed. Patient demographics, clinicopathologic variables, and operative details were collected retrospectively. RESULTS: A total of 22 patients were operated for recurrent PA of the parotid gland. Mean interval between recurrences was 7 and 6 years for first recurrence and second recurrence, accordingly. Second recurrence was significantly influenced by younger age at initial treatment (P = 0.009). Only two patients (9%) with a recurrence developed facial nerve paralysis following surgery. Adjuvant radiotherapy was given to nine patients with no evidence of disease progression or recurrence. There were no cases of malignant transformation. CONCLUSIONS: Recurrent PA of the parotid gland tends to occur in long intervals in a multifocal pattern. Adjuvant radiotherapy could be suggested as an alternative for surgery. J. Surg. Oncol. 2016;114:714-718. © 2016 Wiley Periodicals, Inc.

Is There Justification for Total Thyroidectomy in Low-Risk Papillary Thyroid Carcinoma? A Decision-Analysis Model.

BACKGROUND: Low-risk papillary thyroid carcinoma is commonly treated surgically. However, uncertainties exist in regard to the optimal extent of surgery. We approached this question using a decision-analysis model. METHODS: A Markov model was used to compare outcome between patients with small (1-2 cm) low-risk PTC treated by hemithyroidectomy or total thyroidectomy. Probabilities and utilities were derived from the literature. The model was evaluated with Monte Carlo simulation. Sensitivity analysis was used to determine which variables most affected the model. RESULTS: Hemithyroidectomy was associated with a minor increase in mortality risk. After incorporation of mortality risk, complications, and quality-of-life measures, hemithyroidectomy was found to be superior to total thyroidectomy, with an increasing benefit over time. Quality-of-life measures, especially disutility of disease recurrence and undergoing surgery, had the greatest effect on the incremental benefit of hemithyroidectomy. CONCLUSION: Based on our decision-analysis model, hemithyroidectomy is the preferred option in low-risk PTC.

Value of ultrasound in detecting central compartment lymph node metastases in differentiated thyroid carcinoma.

The value of ultrasound in detecting central compartment lymph node metastasis in patients with well-differentiated thyroid carcinoma (WDTC) is unclear. Prospective patients with WDTC attending a university-affiliated tertiary medical center between July 2010 and June 2011 underwent neck ultrasound for detection of central compartment lymph node metastases prior to surgery. Central lymph node dissection was performed during the initial surgery regardless of ultrasound findings. The sensitivity and specificity of preoperative ultrasound in detecting central lymph node metastases were calculated according to the final histopathological results. Sixty-four patients met the study criteria. Twenty-four had pathologic central compartment lymph nodes according to preoperative ultrasound, 20 of which were confirmed by histological examination. One patient was found to have pathological central lymph nodes by histology which was not detected by US. Sensitivity of preoperative ultrasound was 95%, specificity 90%, and negative and positive predictive values 97 and 83%, respectively. Preoperative ultrasound may serve as an accurate and important tool for deciding the extent of surgery in WDTC.

Treatment decisions and adherence to guidelines in the treatment of low risk papillary carcinoma of the thyroid.

BACKGROUND: Treatment guidelines for well-differentiated papillary thyroid carcinoma (PTC) are based on retrospective studies and vary among professional thyroid associations. OBJECTIVES: To evaluate physician adherence to guidelines, overall and by specialty. METHODS: Questionnaires on the approach to low risk PTC were distributed among 51 surgeons and endocrinologists treating patients with PTC in tertiary medical centers. RESULTS: A wide range of answers was recorded among physicians regarding the danger posed by low risk PTC to the patient's life, urgency with which treatment should be administered, type of treatment, and risks associated with this treatment. There was a significant between-group difference in treatment preference: endocrinologists chose total thyroidectomy with radioactive iodine, while surgeons favored hemithyroidectomy alone. CONCLUSIONS: There is a wide difference in treatment recommendations between treating physicians and different specialties with regard to low risk PTC. The wide variation within and between soecialties may be explained by biases.

Prognostic significance of nodal ratio in cutaneous squamous cell carcinoma of the head and neck.

The TNM classification is not specific for head and neck skin cancer and makes no allowance for disease extent. Studies have shown that the relative number of metastatic-to-examined lymph nodes, termed the Nodal ratio, is a reliable independent prognosticator in several types of cancer. The study was designed as a retrospective analysis in a university affiliated tertiary care center setting. The files of all patients (n = 71) with cutaneous head and neck squamous cell carcinoma and regional lymph node metastasis who attended a tertiary medical center between 1990 and 2008 were reviewed for clinical variables and outcome, and Nodal ratio was calculated. Data were analyzed for impact on survival. On multivariate analysis Nodal ratio and age were found to be significant predictors of overall survival. The N-ratio was the only significant predictor of disease-specific survival. Age, type of treatment (selective/modified neck dissection), pathologic N stage, and radiotherapy had no effect. The Nodal ratio is a potentially valuable prognostic index in cutaneous squamous cell carcinoma. The minimal number of nodes that need to be excised has to be determined.

Smoking habits among Israeli hospital doctors: a survey and historical review.

BACKGROUND: Smoking is a serious health issue worldwide. Smoking trends among physicians predict similar trends in the general population. Little is known about current smoking rates among physicians. OBJECTIVES: To investigate current smoking trends a Israeli physicians. METHODS: All practicing physicians at a tertiary university-affiliated medical center in central Israel were invited to complete a Web-based questionnaire on smoking habits and smoking-related issues via the institutional email. Findings were compared to those in the general population and between subgroups. RESULTS: Of the 90 responders (53 male, 88 Jewish), 54 (60%) had never smoked, 21 (23.3%) were past smokers, and 15 (16.7%) were current smokers. The rate of current smokers was lower than in the general population. The proportion of current smokers was higher among residents than attending physicians and among physicians in surgical compared to medical specialties. Past smokers accounted for 17.9% of the residents (average age at quitting 26.2 years) and 28.1% of the attending hysicians (average age at quitting 33.0 years). Non-smokers more frequently supported harsh anti-smoking legislation. CONCLUSIONS: The rate of smoking is lower in physicians than in the general population but has not changed over the last 15 years. Anti-smoking programs should particularly target physicians in surgical specialties.

Novel grading system for quantifying upper-airway obstruction on sleep endoscopy.

BACKGROUND: The aim of this study was to present a novel anatomically comprehensive and clinically applicable system for the quantification of sleep endoscopy findings in patients with obstructive sleep apnea/hypopnea syndrome (OSAHS). METHODS: Fifty-five adult patients with a polysomnographic diagnosis of OSAHS were referred for midazolam-induced sleep endoscopy following failure of continuous positive airway pressure. Five anatomical sites of possible obstruction along the upper airway were documented: nose/nasopharynx (N), uvulopalatine plane (P), tongue base (T), larynx (L), and hypopharynx (H). Each involved site was assigned a severity grade of 1 (partial obstruction) or 2 (complete obstruction). The digits representing the obstruction pattern at each level were then added to yield a severity index (SI). The SI for each patient was determined by two independent observers. Findings were correlated with the respiratory disturbance index (RDI) and body mass index (BMI). RESULTS: The SI was significantly correlated with the RDI (R=0.746, Pearson; P<0.0001) and predicted disease severity with 65% accuracy. There was no association with BMI. By site, the tongue base and hypopharynx were significantly correlated with obstruction severity; obstruction in the tongue base predicted disease severity with a sensitivity of 68.8 and sensitivity of 81.1. CONCLUSION: Our easy-to-use endoscopic grading system provides physicians with an accurate picture of the pattern of the upper-airway system obstruction in patients with obstructive sleep apnea/hypopnea syndrome. It is a promising tool for estimating the location and severity of upper airway disease and may have implications for treatment planning.

Early death from papillary thyroid carcinoma.

PURPOSE: The natural history of papillary thyroid carcinoma (PTC) is characterized by a slow growth rate and an excellent prognosis at 20 and 30 years. However, there is a small subset of patients with poorer outcome. METHODS: Twenty patients who died of PTC within 10 years of diagnosis were studied to identify prognostic indicators and biological markers of early death. Findings were statistically compared with a previous review of all patients with PTC treated in the same institute and studies in the literature. RESULTS: The study group included 6 men and 14 women with a mean age of 65 years at diagnosis. Average tumor size was 3.6 cm; 16 patients had extracapsular extension. All tumor samples studied histologically stained poorly for p53, Ki67, and CD34. Regional metastases were present in half the patients, and distal metastases in all. All patients had an advanced disease stage (Tumor, Node, Metastases classification), and only 4 had a low score on the Metastases, Age, Completeness of resection, local Invasion, tumor Size risk stratification. Analysis of the findings against data in the literature for the whole population of patients with PTC, who had a considerably better survival (<8% mortality within 8-15 years vs 100% within 10 years in our sample), yielded significant differences for rates of extrathyroidal extension (P = .0001), regional metastases (P = .016), and distant metastases (P = .0001). CONCLUSION: Extrathyroid extension, late regional metastases, and distant metastases may be risk factors for early death from PTC.

Chondrosarcoma of the larynx.

BACKGROUND: Chondrosarcoma of the larynx is a rare tumor. The most common symptom is hoarseness. Treatment is controversial. OBJECTIVES: To describe six patients with laryngeal chondrosarcoma from a single center. METHODS: The medical records of a major tertiary hospital were reviewed for all patients with laryngeal chondrosarcoma diagnosed and treated from 1959 to 2010. Data on background, clinical treatment and outcome were collected. RESULTS: Six patients, all males with a mean age of 53.3 years, were identified. Partial laryngectomy was performed in three patients, and total laryngectomy, local excision, and partial cricoidectomy in one patient each. Four patients had a permanent tracheostomy after surgery. One patient required postoperative chemotherapy and one radiotherapy. Follow-up time was 12-216 months (mean 102 months). Recurrence developed in two patients 2 and 8 years after initial treatment and was treated by salvage surgery in both patients. One patient died during the follow-up from an unrelated cause. The others are currently alive. CONCLUSIONS: This study supports earlier reports recommending initial treatment with partial or total laryngectomy for laryngeal chondrosarcoma. Long-term follow-up for recurrence is advised. We recommend preserving the larynx, if possible, even if a permanent tracheostomy is necessary.

[Minimally invasive video-assisted thyroidectomy].

BACKGROUND: During the last decade the surgical technique of minimally invasive video-assisted thyroidectomy [MIVAT) has evolved worldwide. This approach provides Less morbidity and better cosmetic results with the same clinical outcome. PURPOSE: The aim of this study was to assess the feasibility and efficacy of MIVAT, a new minimally invasive technique for thyroid surgery. METHODS: A retrospective analysis of patients who underwent MIVAT between 2007 and 2009 was conducted. For control, we used a demographically and clinically similar group of patients who underwent conventional open thyroidectomy. RESULTS: During the study period 18 patients with a solitary thyroid nodule underwent MIVAT. Indication for surgery was a hyperplastic nodule in all cases. The mean nodule diameter was 1.8 cm in the final pathological examination. Mean operating time was 80.3 minutes compared to 50.27 minutes in the open approach group (p < 0.001). Hospitalization time was significantly shorter in the MIVAT group compared to the open thyroidectomy group, 3.2 versus 4.5 days (p < 0.001). There were no major complications, but 4 patients developed transient vocal cord paralysis and two had wound infection in the MIVAT group, compared to none and one respectively in the control group. CONCLUSIONS: MIVAT is a technically feasible and safe procedure that leads to an improved cosmetic result and a quicker recovery. The prolonged operation time and minor complications warrant further experience in our institution.

Nonmelanoma skin cancer of the head and neck region in solid organ transplant recipients.

BACKGROUND: Nonmelanoma skin cancers (NMSC) are the most common malignancies in solid organ recipients. We investigated the incidence, clinical features, and outcome of solid organ recipients with NMSC of the head and neck. METHODS: A retrospective chart review was conducted for solid organ recipients who were treated from 1992 to 2015 and who developed NMSC of the head and neck. RESULTS: Of 3339 organ recipients, 259 patients developed 697 head and neck NMSC. Squamous cell carcinoma was the most common malignancy (55%). The overall 5-year and 10-year survival was 68% and 45%. Kidney recipients had better survival outcome than other organ recipients (10 vs 7 years). Advanced-stage cancers (10%), aggressive patterns of tumors (21%), and treatment with Prograf and Cellcept were associated with increased disease-specific mortality. CONCLUSION: Solid organ transplant increases the risk of NMSC of the head and neck. Aggressive tumors decrease patient survival and warrant more decisive and multidisciplinary approach.