Sorafenib in metastatic thyroid cancer: a systematic review.

BACKGROUND: Sorafenib was recently approved by the U.S. Food and Drug Administration for radioiodine-resistant metastatic differentiated thyroid cancer (DTC). In addition, two drugs (vandetanib and cabozantinib) have received U.S. Food and Drug Administration approval for use in medullary thyroid cancer (MTC). Several published phase II trials have investigated the efficacy of sorafenib in thyroid cancers, but to date, results from those studies have not been compared. METHODS: A systematic review of the literature was performed to assess response rate, median progression-free survival, and adverse events associated with sorafenib therapy for metastatic thyroid cancers. RESULTS: This review included seven trials involving 219 patients: 159 with DTC (papillary, follicular, and poorly differentiated), 52 with MTC, and 8 with anaplastic thyroid cancer. No study reported complete responses to treatment. Overall partial response, stable disease, and progressive disease rates were 21%, 60%, and 20%, respectively. The median progression-free survival was 18 months for patients with all subtypes of thyroid cancer. Drug was discontinued in 16% of patients because of toxicities or intolerance, and the dose was reduced in a further 56%. Side effects with an incidence ≥ 50% were hand-foot syndrome (74%), diarrhea (70%), skin rash (67%), fatigue (61%), and weight loss (57%). Deaths not related to progressive disease occurred in nearly 4% of patients. CONCLUSION: Treatment with sorafenib in patients with progressive DTC and MTC is a promising strategy, but the adverse event rate is high, leading to a high rate of dose reduction or discontinuation. Consequently, sorafenib use in patients with metastatic thyroid cancer requires careful selection of patients and careful management of side effects.

Staining intraoperative topical solutions with fluorescein: enhancing the safety of sinus surgery.

BACKGROUND: Oxymetazoline HCl 0.05%, 1:100,000 lidocaine with epinephrine (lido+epi), and 1:1000 epinephrine are all colorless solutions employed in sinus surgery. Because lido+epi is injected whereas others are not, care must be taken to label all solutions to avoid inadvertent injection of oxymetazoline or concentrated epinephrine because of life-threatening complications. Dyes have been used to color solutions for visual identification, but efficacy and cost have never been compared. We sought to determine the effectiveness of surgical marking pen (gentian violet) and fluorescein strips as coloring agents in mediums commonly used in sinus surgery. METHODS: In this specialty techniques study, 4 liquid mediums (normal saline [NS], 0.05% oxymetazoline, 1:1,000 epinephrine, and lido+epi) and 2 coloring agents (fluorescein strip and surgical marking pen) were combined separately. Photos and absorbance of each solution were obtained at 15-minute intervals over 2 hours using a spectrophotometer. RESULTS: Peak absorbance remained stable for all solutions with fluorescein. Absorbance also remained constant for NS (0.37 absorbance units [AU] → 0.37 AU) and oxymetazoline (2.8 AU → 2.8 AU) mixed with marking pen. Absorbance decreased over 2 hours when marking pen was mixed with 1:1000 epinephrine (0.82 AU → 0.32 AU) and lido+epi (1.19 AU → 0.33 AU). Furthermore, the majority of color visibility and absorbance decreased in the first 15 minutes for concentrated epinephrine (0.82 → 0.33) and lido+epi (1.19 → 0.51). Cost of fluorescein strips ($0.14 to $0.20/strip) was less than marking pens ($13 to 46/pen). CONCLUSION: Compared to marking pen dye, solutions dyed with fluorescein retained their color and did not decay over time. We recommend fluorescein strips to label colorless materials in the operating room because of their lack of color decay and cost advantages.

Three-dimensional sinus imaging as an adjunct to two-dimensional imaging to accelerate education and improve spatial orientation.

OBJECTIVES/HYPOTHESIS: Develop a novel three-dimensional (3-D) anatomical model to assist in improving spatial knowledge of the skull base, paranasal sinuses, and adjacent structures, and validate the utilization of 3-D reconstruction to augment two-dimensional (2-D) computed tomography (CT) for the training of medical students and otolaryngology-head and neck surgery residents. STUDY DESIGN: Prospective study. METHODS: A study of 18 subjects studying sinus anatomy was conducted at a tertiary academic center during the 2011 to 2012 academic year. An image processing and 3-D modeling program was used to create a color coded 3-D scalable/layerable/rotatable model of key paranasal and skull base structures from a 2-D high-resolution sinus CT scan. Subjects received instruction of the sinus anatomy in two sessions, first through review of a 2-D CT sinus scan, followed by an educational module of the 3-D reconstruction. After each session, subjects rated their knowledge of the sinus and adjacent structures on a self-assessment questionnaire. RESULTS: Significant improvement in the perceived understanding of the anatomy was noted after the 3-D educational module session when compared to the 2-D CT session alone (P < .01). Every subject believed the addition of 3-D imaging accelerated their education of sinus anatomy and recommended its use to others. CONCLUSIONS: The impression of the learners was that a 3-D educational module, highlighting key structures, is a highly effective tool to enhance the education of medical students and otolaryngology residents in sinus and skull base anatomy and its adjacent structures, specifically in conceptualizing the spatial orientation of these structures.