The role of brachytherapy for margin control in oral tongue squamous cell carcinoma.

BACKGROUND: The aim of this study is to assess the feasibility and effectiveness of using peri-operative brachytherapy (BRTx) for positive/narrow margins present post primary surgical resection of oral tongue squamous cell carcinoma (OTSCC). METHODS: Prospective single-centre study of patients with OTSCC (T1-3, N0-3, M0) treated with resection of primary tumour ± regional nodal resection and intra-operative insertion of BRTx catheters. BRTx was administered twice daily at 40.8Gy/12Fr for 'Positive' (≤2 mm) margins, at 34Gy/10Fr for 'Narrow' (2.1-5 mm) margins, and not given for 'Clear' (> 5 mm) margins over the course of 5-6 days, 3-5 days post operatively. RESULTS: Out of 55 patients recruited 41 patients (74.6%) were treated with BRTx, as 12 patients had clear margins and 2 patients had unfavourable tumour anatomy for catheter insertion. EBRTx was avoided in 64.3% of patients. Overall Survival (OS) at 3 and 5 years was 75.6 and 59.1% respectively, while Disease Specific Survival (DSS) was 82.3 and 68.6% at 3 and 5 years respectively. Recurrence and survival outcomes were not associated with margin status or the use of or specific dose of BRTx on Cox regression analysis. Acute and late toxicity secondary to BRTx was minimal. CONCLUSIONS: The use of BRTx after primary OTSCC resection with positive/narrow margins ± EBRTx to the neck ± CTx achieves outcomes comparable to traditional treatment of surgery followed by re-resection or EBRTx ± CTx. Morbidity associated with oral cavity EBRTx or secondary resection and reconstruction is thus avoided. Both acute and late toxicity rates are low and compare favourably with other BRTx OTSCC studies. TRIAL REGISTRATION: Retrospectively registered. https://www.mcgill.ca/rcr-rcn/files/rcr-rcn/2017.06.05_rcn_hn.pdf . LEVEL OF EVIDENCE: 4.

Feelings of Disenfranchisement and Support Needs Among Patients With Thyroid Cancer.

PURPOSE: To offer a better understanding of the experiences, preferences, and needs of patients with thyroid cancer. PARTICIPANTS & SETTING: 17 patients with thyroid cancer receiving treatment at a university-affiliated hospital in Montreal, Québec, Canada. METHODOLOGIC APPROACH: Interviews were conducted with patients, and descriptive phenomenology was used to explore patients' lived experience. FINDINGS: Coping with uncertainty was a major theme that emerged from interviews, with some of the main concerns being difficult treatment decisions, long surgery wait times, and fears about surgical complications, potential metastases, and death. Study participants reported that without a nurse and an interprofessional team, they would be lost in a system they believed minimized their illness and offered few resources to support them in a time of crisis. IMPLICATIONS FOR NURSING: Nurses must understand how the needs of individuals with thyroid cancer are often overlooked because of the good prognosis associated with the disease and should work to meet these information and support needs.

CALCITONIN SECRETORY INDEX AND UNSUSPECTED NODAL DISEASE IN MEDULLARY THYROID CARCINOMA.

OBJECTIVE: Medullary thyroid carcinoma (MTC) is a rare thyroid malignancy originating from parafollicular C-cells with the potential for aggressive behavior. The extent of lymph node (LN) dissection at the time of surgery is controversial, with different schools of thought prevailing. Some systematically perform LN dissections, whereas others base their decision on radiologic evidence of disease and some with the assistance of pre-operative calcitonin (CT) levels. METHODS: We retrospectively assessed the correlation between pre-operative CT levels and clinico-pathologic factors among 42 patients with MTC between 1994 and 2015. Furthermore, we refined the use of pre-operative serum CT levels and explored for the first time a test called the Calcitonin Secretory Index (CSI, ng/mL/mm). RESULTS: Pre-operative CT levels correlated independently with tumor size ( P<.0001), number of metastatic LNs ( P<.01), and increased rates of distant metastasis. The CSI better predicted early LN disease ( P<.045). Patients with early LN metastasis had a CSI >30 ng/mL/mm, a representative threshold above which the surgical cure declines considerably. CONCLUSION: In our experience, pre-operative CT levels and now the CSI appear as sensitive and specific risk stratification markers for MTC. Despite negative findings on dedicated pre-operative neck imaging in addition to total thyroidectomy, a CSI >30 ng/mL/mm would prompt bilateral central node dissection. Due to the small sample size, our study provides preliminary evidence of the value of CSI in clinical practice. ABBREVIATIONS: ANOVA = analysis of variance; ATA = American Thyroid Association; CSI = Calcitonin Secretory Index; CT = calcitonin; LN = lymph node; MTC = medullary thyroid carcinoma; ROC = receiver operating characteristic.

Thyroid cancer patients receiving an interdisciplinary team-based care approach (ITCA-ThyCa) appear to display better outcomes: Program evaluation results indicating a need for further integrated care and support.

BACKGROUND: Thyroid cancer (ThyCa) is generally associated with a favorable prognosis and excellent surgical outcomes. Consequently, its treatment is medically focused and current guidelines recommend interdisciplinary care including access to a nurse for complex cases alone. To date, no studies have evaluated the need for and impact of an Interdisciplinary Team-based Care Approach (ITCA-ThyCa) for general thyroid cancer patients, including a dedicated nurse as part of a larger interdisciplinary team, as well as patient-reported outcomes, as is recommended worldwide in cancer care. Our aim was to evaluate such a program. METHODS: The ITCA-ThyCa was evaluated within a quasi-experimental design using the Centers for Disease Control Framework for Program Evaluation, including process and outcome measures. Patients eligible were adults with a biopsy indicating confirmed or highly suspicious ThyCa (TNM-Classification + Bethesda score of V/VI). The intervention group (IG) received ITCA-ThyCa and the comparison group (CG), usual care alone. RESULTS: In our sample comprised of 200 participants (122 IG; 78 CG), ITCA-ThyCa patients appeared to show significantly better outcomes than CG patients, namely, higher levels of overall well-being (P = .001) and fewer physical (P = .003) and practical (P = .003) issues and concerns. More satisfied with their overall care (P = .028), including care coordination (P = .049), they reported their health care provider as more approachable (P = .007), respectful (P = .005), and trustworthy (P = .077; trend) and were more likely to recommend their hospital (P = .02). Ninety-eight percent of IG patients recommended ITCA-ThyCa. CONCLUSION: Data from our program illustrates that hospital resources should not be allocated based on medical trajectory alone and challenges the idea that ThyCa is "straightforward." ThyCa patients seem to experience symptom distress at a level comparable to-or exceeding-that of general oncological patients despite their promising medical outcomes, indicating that better integrated care and support are in order.

Clinical parameters predicting development of pulmonary malignancies in patients treated for head and neck squamous cell carcinoma.

BACKGROUND: As the locoregional control rates in head and neck squamous cell carcinoma (HNSCC) have increased, these patients may suffer distant metastasis in a higher proportion of cases. Clinicopathological characteristics allowing prediction of high-risk profile would allow adapting posttreatment surveillance to individual risk. METHODS: A retrospective review of all patients with HNSCC treated at the Jewish General Hospital, McGill University, Montreal, Quebec, Canada, between 1999 and 2008 was conducted for this study. RESULTS: The study included 428 patients with a mean follow-up of 65 months (±SEM 1.7). Eighty patients (18.6%) developed pulmonary malignancy during follow-up. In multivariate Cox-regression analysis, locoregional failure and current smoking were associated with higher risk of pulmonary malignancy (p < .001 and p = .008, respectively). CONCLUSION: Locoregional failure and smoking persistence are predictors of pulmonary malignancy in patients with HNSCC. © 2015 Wiley Periodicals, Inc. Head Neck 38: E1277-E1280, 2016.

Computerized tomography based tumor-thickness measurement is useful to predict postoperative pathological tumor thickness in oral tongue squamous cell carcinoma.

BACKGROUND: Tumor thickness has been shown in oral tongue squamous cell carcinoma (OTSCC) to be a predictor of cervical metastasis. The postoperative histological measurement is certainly the most accurate, but it would be of clinical interest to gain this information prior to treatment planning. This retrospective study aimed to compare the tumor thickness measurement between preoperative, CT scan, and surgical specimens . METHODS: We retrospectively included 116 OTSCC patients between 2001 and 2013. Thickness was measured on computer tomography imaging and again surgical specimens. RESULTS: The median age was 66 years. 62.8 % of patients were smokers with a mean of 31.4 pack-years. Positive nodal disease was reported in 41.2 %. Mean follow-up time was 33.1 months. The correlation between CT scan-based tumor thickness and surgical specimens based thickness was significant (Spearman rho = 0.755, P < 0.001). CONCLUSION: Tumor thickness assessed by CT scan may provide an accurate estimation of true thickness and can be used in treatment planning.

A survey on pulmonary screening practices among otolaryngology-head & neck surgeons across Canada in the post treatment surveillance of head and neck squamous cell carcinoma.

BACKGROUND: Post treatment lung screening for head and neck cancer patients primarily focuses on the distant metastasis and a high rate of second primary can also be expected. The best screening tool and timing for this purpose is controversial. We sought out to assess the current practice and beliefs among Canadian Head and Neck Surgeons. METHODS: After Ethical Board approval, a nationwide survey was conducted through the Canadian Society of Otolaryngology (CSO) among head and neck surgeons regarding their practices for pulmonary screening in HNSCC patients. RESULTS: Our CSO survey among Otolaryngology-head and neck surgeons showed that 26 out of 32 respondents perform routine lung screen, out of which 23 (88%) feel that chest radiography should be preferred. The majority of respondents felt that lung screening could impact beneficially on mortality. For symptomatic patients, low-dose spiral CT was the preferred modality (48%), followed by PET/CT scan (14%) and sputum cytology (14%). In high-risk asymptomatic patients (current smoker, radiation exposure, family history and advanced HNSCC), 31% of respondents performed a CXR. The same percentage performed a low dose CT, while 19% relied on PET scan. A further 19% of respondents did not perform any screening in high-risk patients. Most respondents (77%) had more than 10 years practice since graduation from medical school and came from the provinces of Quebec, Ontario and Alberta. CONCLUSION: Chest radiography remains the preferred modality for lung screening and was believed to be impacting beneficially on lung mortality. The recent literature does not seem to be in agreement with those beliefs. Further studies to establish which modality is best and concurrent nation-wide education are warranted.

Intraoperative parathyroid hormone level in parathyroidectomy: which patients benefit from it?

BACKGROUND: Intraoperative parathyroid hormone level (IOPTH) is withdrawn during parathyroidectomy to confirm the success of the procedure. Recently, the importance of IOPTH has been put to question. The purpose of this study is to determine whether IOPTH is necessary for all patients undergoing parathyroidectomy in the presence of frozen section. MATERIALS AND METHODS: A cohort study of parathyroidectomies was performed in three university affiliated hospitals during 2007-2012. The patients were divided into two groups. Group 1: Patients with two preoperative concordant imaging localizing a hyperactive gland. Group 2: Patients without two concordant imaging. A comparison of benefit of IOPTH was carried out. Frozen section results were also analyzed to determine sensitivity and predictability of a parathyroid adenoma. RESULTS: The study considered 221 patients having parathyroidectomies for primary hyperparathyroidism (PHPT). Of them, 10 were excluded due to incomplete data. Among the remaining, 186 had 2 concordant imaging preoperatively localizing an adenoma. 93.5% of whom were found intraoperatively in that location. IOPTH was not found to be of importance in 98.92% of the preoperative localized adenomas in the presence of frozen section. IOPTH added an estimate of 30.9 minutes on average to the surgery time. CONCLUSION: This study demonstrates that the added operating time associated with IOPTH may not be justified for patients undergoing parathyroidectomy who have 2 concordant imaging preoperatively in the presence of frozen section. This study suggests a simple algorithm, The McGill Parathyroid Protocol (MPP), to help in approaching PHPT patients undergoing parathyroidectomy.

Female gender as a risk factor for transient post-thyroidectomy hypocalcemia.

OBJECTIVES: Transient post-thyroidectomy hypocalcemia is a common complication following thyroid surgery. Studies have identified risk factors and possible ways to help predict post-thyroidectomy hypocalcemia with the intent of ultimately limiting its incidence. This study evaluates the role of patient gender as a potential risk factor. STUDY DESIGN: A retrospective case series with chart review of 270 consecutive total thyroidectomy patients was conducted. SETTING: Jewish General Hospital, a McGill University-affiliated hospital in Montreal, Canada. SUBJECTS AND METHODS: 219 women and 51 men were included. Postoperative hypocalcemia was defined as any 1 of the following: total serum calcium 1.90 mmol/L or less, or signs and symptoms of hypocalcemia. The following were evaluated as potential confounding factors in the study: age, menopause, preoperative calcium, parathyroid hormone, magnesium and phosphate levels, presence of carcinoma in the surgical specimen, number of parathyroid glands preserved in situ, thyroid gland volume, and nodule size. RESULTS: Female patients experienced transient postoperative hypocalcemia in 24.7% (54/219) of cases, which was significantly greater than the 11.8% (6/51) incidence detected in men (P < .05). This represents a female/male relative risk ratio of 2.1 (confidence interval, 1.0-4.6). There was no significant difference in rates of hypocalcemia between premenopausal and postmenopausal women (22.7% vs 26.6%). CONCLUSION: These findings suggest that being female is likely a risk factor for transient post-thyroidectomy hypocalcemia. Although this association is statistically significant, its magnitude and clinical relevance are uncertain and may be trivial. Additional research is needed to ascertain the physiologic mechanisms underlying this gender difference.

What are thyroidectomy patients really concerned about?

OBJECTIVE: To better appreciate perioperative concerns affecting patients considering thyroidectomy and to understand how they may vary according to patient characteristics. STUDY DESIGN: Cross-sectional analysis. SETTING: Tertiary referral center. SUBJECTS AND METHODS: The authors recruited patients scheduled for thyroid surgery at the McGill University Thyroid Cancer Center. A total of 148 patients completed the 18-item Western Surgical Concern Inventory-Thyroid (WSCI-T) questionnaire. Psychometrics of the WSCI-T were assessed through a principal component analysis with varimax rotation and reliability analyses. Independent-samples t tests and 2-tailed Pearson correlations were ran, identifying areas of elevated concerns and their relationship to gender, age, and surgical procedure (total vs hemithyroidectomy). RESULTS: The principal component analysis revealed the presence of 3 domains of presurgical concerns on the WSCI-T:Surgery-Related Concerns, Psychosocial Concerns, and Daily-Living Concerns. Reliability coefficients for the WSCI-T Total and subscales were satisfactory. Responses on the WSCI-T indicated on average a moderate overall level of concerns before thyroidectomy. Surgery-Related Concerns was the highest domain of concerns, followed by Daily-Living and Psychosocial Concerns, respectively. Patients were mainly worried about the nodule being cancerous, experiencing a change in voice, and surgical complications. Areas of minor concern included being judged or treated differently, becoming depressed, and feeling embarrassed. Women had higher overall levels of concern than men did. Although there were no significant differences in overall levels of concern according to age and surgical procedure, differences were noted at a subscale and item level. CONCLUSION: This study establishes a mean that will permit adequate physician counseling and a better management of patients' perioperative worries.

McGill Thyroid Nodule Score (MTNS): "rating the risk," a novel predictive scheme for cancer risk determination.

OBJECTIVE: There are presently a great number of publications pertaining to the clinical risk factors associated with thyroid cancer. These studies deal mostly with a single feature from either patient demographics, physical examination, laboratory values, imaging, or cytology. We sought to create a novel scoring system that integrates the diagnostic indices of each of these clinical features for carcinoma. METHODS: A retrospective analysis of 1047 consecutive thyroidectomy patients was performed. Each patient was assigned a cancer risk score according to a newly devised 22-variable scoring scheme termed the McGill Thyroid Nodule Score (MTNS). The MTNS was developed by a multidisciplinary team of endocrinologists, thyroid surgeons, and pathologists using already established evidence-based risk factors for thyroid cancer. RESULTS: The exact incidence of malignancy was calculated for each MTNS score based on final pathology. The incidence for scores of 1 to 3 was 27%, of 4 to 7 was 32%, of 8 was 39%, of 9 to 11 was 63%, of 12 to 13 was 88%, and of 14 to 18 was 93%. All (130 of 130) patients with a score ≥ 19 had carcinoma. A score ≤ 8 correlated with a 32% (115 of 357) risk of thyroid cancer, whereas a score > 8 implied an 86% (417 of 487) risk. CONCLUSION: Our data suggest that a combined scoring system, the MTNS, can serve as an accurate predictor of the risk for thyroid cancer in a specific thyroid nodule. This will help physicians better formulate management decisions accordingly.

Preoperative parathyroid hormone levels as a predictor of postthyroidectomy hypocalcemia.

OBJECTIVES: The goal of the present study is to determine whether a decline in the 1-hour postoperative parathyroid hormone (PTH) level relative to the preoperative level is predictive of hypocalcemia. METHODS: This is a retrospective study involving 142 consecutive patients who underwent total thyroidectomy. Changes in preoperative PTH levels were then compared with the 1-hour levels. RESULTS: Thirty-four of 142 patients (23.9%) who underwent total thyroidectomy developed hypocalcemia. Thirty-one of the 34 patients who became hypocalcemic had a 1-hour postoperative PTH drop of 70% or more when compared with the preoperative value (sensitivity = 91%, specificity = 98%, positive predictive value = 94%, and negative predictive value = 97%). CONCLUSION: A decline in the preoperative PTH level of 70% or greater at 1 hour following total thyroidectomy appears to be a reliable predictor of patients at risk of developing hypocalcemia. By allowing thyroid surgeons to identify these patients in the early postoperative period, calcium supplementation can be initiated sooner.

Head and neck incidentalomas on positron emission tomographic scanning: ignore or investigate?

BACKGROUND AND OBJECTIVE: Incidental head and neck abnormalities are increasingly detected with 18F-fluorodeoxyglucose positron emission tomography (FDG-PET). Incidental thyroid lesions on PET are described in many studies; however, no reports have definitively identified incidental findings in multiple head and neck sites. The aim of this study was to (1) review the related literature, (2) identify the incidence and significance of head and neck incidentalomas on PET/computed tomography (CT) scanning, and (3) attempt to establish management recommendations for head and neck PET incidentalomas. STUDY DESIGN: Retrospective study. SETTING: Tertiary care centre. METHODS: Head and neck incidentaloma cases from whole-body 18F-FDG PET/CT scans were reviewed based on specific inclusion criteria from January 2009 to January 2010 at the Jewish General Hospital. The patients had been scanned for known or suspected malignant lesions in non-head and neck sites. Patients with incidental head and neck abnormalities were identified. RESULTS: The scans of 38 of 1565 (2.43%) subjects who underwent FDG-PET scanning for known or suspected cancer demonstrated head and neck incidentalomas. In 8 of 38 cases (21.05%), malignancies were discovered in the incidentaloma lesion (5 thyroid, 2 parotid, and 1 cervical lymph node), and all were new primary malignancies. Five of the 8 (62.5%) demonstrated significantly high standard uptake value (SUV). CONCLUSION: Head and neck PET/CT incidentalomas are quite common. A significantly high SUV strongly suggests the presence of malignancy. Head and neck incidentalomas merit consultation and further evaluation.

Serum thyroglobulin predicts thyroid remnant ablation failure with 30 mCi iodine-131 treatment in patients with papillary thyroid carcinoma.

BACKGROUND: Most patients with differentiated thyroid cancer are treated with radioiodine (131-I) after thyroidectomy. The characteristics predictive of successful remnant ablation with low activities of 131-I are ill defined and could help stratify patients into those who should receive higher activities. METHODS: In a case series of 193 consecutive patients with papillary thyroid cancer who underwent total thyroidectomy and received 30 mCi (1110 MBq) of 131-I, we assessed the percentage of successful radioremnant ablation as defined by a composite of scintigraphic and biochemical endpoints. Clinical, histological, scintigraphic, and biochemical covariables were analyzed to identify associations with treatment failure. RESULTS: Successful radioremnant ablation with low-activity 131-I was obtained in 78% of the entire cohort of patients. The presence of limited microscopic extrathyroidal extension, nodal micrometastases, or an elevated stimulated ablation was associated with failure to ablate the remnant. While accounting for other factors in a multivariable analysis, patients with an ablation thyroglobulin of at least 6 µg/l were at a more than five times greater risk (P<0.001) to fail 30 mCi 131-I remnant ablation. CONCLUSION: The majority of patients with papillary thyroid carcinoma experienced successful ablation. However, elevated-stimulated ablation thyroglobulin levels were strongly predictive of ablation failure, suggesting that this biochemical marker correlates with a more aggressive tumor profile and identifies those patients who might benefit from additional therapy.

Preoperative serum calcium levels as an indicator of postthyroidectomy hypocalcemia.

BACKGROUND: our group has previously demonstrated that serum calcium levels measured in conjunction with parathyroid hormone (PTH) levels early in the postoperative period can help identify and prophylactically treat patients at significant risk for postthyroidectomy hypocalcemia. This study evaluated whether preoperative serum calcium levels can similarly be used as a reliable indicator of a patient's risk for developing postoperative hypocalcemia. MATERIALS AND METHODS: this was a retrospective review of 1000 consecutive total thyroidectomy patients (2004-2008), with multiple exclusion criteria considered. Postoperative hypocalcemia was defined as total serum calcium of ≤ 1.90 mmol/L up to 1 month following surgery, a PTH ≤ 8 ng/L, or signs and symptoms of hypocalcemia. Laboratory values were drawn at various intervals according to our institution's protocol. RESULTS: the pertinent data were analyzed for 247 of 1000 patients and indicated that patients with a preoperative corrected calcium level below 2.27 mmol/L had a postthyroidectomy hypocalcemia rate of 63%, whereas those with a calcium level above 2.27 mmol/L experienced hypocalcemia 24% of the time (p < .0001*). This threshold calcium value yielded a specificity of 93% and a likelihood ratio of 4.2. CONCLUSION: our data suggest that preoperative serum calcium levels may correlate with the development of postoperative hypocalcemia. A serum calcium level of 2.27 mmol/L is an important threshold separating patients with an elevated risk of hypocalcemia from those who will likely remain normocalcemic. These data are relevant and useful clinically in identifying patients at risk for hypocalcemia. Current studies are investigating whether patients below our critical threshold of 2.27 mmol/L would benefit from early prophylactic supplementation.

Preoperative serum thyroglobulin as an adjunct to fine-needle aspiration in predicting well-differentiated thyroid cancer.

BACKGROUND/PURPOSE: when fine-needle aspiration biopsy (FNAB) of a thyroid nodule yields indeterminate pathology, management decisions become complex, and other preoperative predictors of thyroid cancer must be employed to assess the risk of malignancy. Although thyroglobulin (Tg) is currently accepted as the serum marker of choice in the detection of well-differentiated thyroid cancer (WDTC) recurrence, its preoperative role in the workup of a thyroid nodule remains controversial. The purpose of this study was to evaluate the potential role for Tg as a preoperative indicator of primary WDTC, specifically in patients with indeterminate FNAB. METHODS: this was a retrospective review of 861 consecutive thyroidectomy patients; 297 patients had indeterminate FNAB, of which 68 had serum levels of Tg measured prior to surgery. The predictive value of various threshold levels of preoperative Tg for WDTC was evaluated. Patients with nonindeterminate FNAB or final pathology containing medullary carcinoma, anaplastic carcinoma, or lymphoma were excluded. RESULTS: eighty-one percent (25 of 31) of patients with both indeterminate FNAB and preoperative Tg ≥ 75 microg/L had well-differentiated cancer on final pathology compared to 58% (172 of 297) of patients with indeterminate cytology alone (p = .014, RR = 1.4). In addition, mean preoperative Tg levels were found to be significantly higher in patients with WDTC compared to those with benign pathology (223 vs 53 microg/L, p = .007). DISCUSSION/CONCLUSION: our results imply that elevated preoperative serum Tg levels may be predictive of WDTC. This marker may be useful as an aid when making management decisions in patients with indeterminate cytology.

Location of parathyroid adenomas: 7-year experience.

OBJECTIVE: To determine the most common location of parathyroid adenomas. METHODS: Data from 147 patients who underwent parathyroidectomy for primary hyperparathyroidism in Montreal at a McGill University teaching hospital between January 2001 and January 2008 were reviewed retrospectively. Patients with histopathologic confirmation of parathyroid hyperplasia were excluded from the study (n = 26). The 121 patients with confirmed adenomas were grouped according to the locations of the tumour into right superior, right inferior, left superior, left inferior, and ectopic. RESULTS: The left inferior parathyroid glands were the most common site of adenomas. This was the case for 50 patients (41.32% [mean 0.41; 95% CI 0.324-0.506]). The right inferior parathyroid glands were the site in 40 patients (33.06% [mean 0.33; 95% CI 0.248-0.422]). The remainder of the adenomas were distributed as follows: the left superior in 19 patients (15.7% [mean 0.157; 95% CI 0.097-0.234]), the right superior in 10 patients (8.26% [mean 0.0826; 95% CI 0.040-0.147]), and the ectopic in 2 patients (1.65% [mean 0.0165; 95% CI 0.002-0.058]). CONCLUSIONS: In this study, the most common site of adenoma was the left inferior parathyroid gland. This information provides parathyroid surgeons with a starting point when imaging fails to localize the site of the adenoma, which allows for the possibility of minimally invasive surgery especially if used in conjunction with intraoperative parathyroid hormone.

Bilateral papillary thyroid cancer and associated histopathologic findings.

OBJECTIVE: To determine the incidence of bilateral papillary thyroid cancer (PTC) at total thyroidectomy (TT) and compare demographic risk factors (gender and age) and histopathologic findings (tumour size, extrathyroidal extension [ETE], T staging, and multifocality) between patients with PTC in both thyroid lobes and those with PTC limited to the ipsilateral lobe and/or isthmus. DESIGN: Retrospective study. SETTING: University teaching hospital. METHODS: The pathology results of 1047 consecutive patients who underwent TT between 2002 and 2008 were reviewed. Statistical significance was obtained using the chi-square test. MAIN OUTCOME MEASURES: Incidence of bilateral PTC and its association with demographic risk factors and histopathologic findings. RESULTS: Among 592 patients with PTC, 13.2% had bilateral PTC and 86.8% had unilateral and/or isthmian PTC. Bilaterality was present in 12.4% of women and 16.7% of men (p = .24) and in 12.9% of patients aged > or = 45 years and 13.5% < 45 years (p = .83). Bilateral PTC was found in 12.6% of patients with a primary tumour < or = 2 cm and 13.5% > 2 cm (p = .75); 23.6% of tumours with ETE demonstrated bilaterality compared to 9.7% without (p < .0001), and 8.7% of pT1 (p = .08), 9.2% of pT2 (p = .02), 23.0% of pT3 (p < .0001), and 12.5% of pT4 (p = .87) tumours were bilateral, respectively. Among bilateral PTC patients, 43.2% had multifoci in at least one lobe compared to 6.4% when nonbilateral (p < .0001). CONCLUSIONS: After TT, 13.2% of patients had bilateral PTC. No significant correlation was established between bilaterality and gender, age, and tumour size. Bilaterality was more commonly found in patients with ETE, advanced T stage, and at least one multifocal lobe.

Sternoclavicular joint osteomyelitis following head and neck surgery.

OBJECTIVES/HYPOTHESIS: To review all reported cases of sternoclavicular joint (SCJ) osteomyelitis following head and neck surgery. STUDY DESIGN: Retrospective case review. METHODS: PubMed search and one additional case from our institution. RESULTS: Twelve cases were reviewed, and the following recommendations are suggested: risk factors for SCJ osteomyelitis should be identified; early and prompt diagnosis of SCJ osteomyelitis is warranted; tracheostoma care and careful examination of the skin should not be neglected; meticulous screening for cancer recurrence is imperative; if SCJ infection is suspected, cancer recurrence must be ruled out with biopsies; and surgical debridement is considered the gold standard of treatment. Administration of newer-generation antibiotics is a reasonable choice when the infection is detected early, as is maintaining a low threshold for surgical treatment if disease persists or progresses. CONCLUSIONS: Osteomyelitis of the SCJ following head and neck surgery is uncommon and must be distinguished from malignancy with biopsies. Early diagnosis and treatment are imperative. Laryngoscope, 2010.

Prediction of hypocalcemia after using 1- to 6-hour postoperative parathyroid hormone and calcium levels: an analysis of pooled individual patient data from 3 observational studies.

BACKGROUND: Parathyroid hormone (PTH) levels up to 6 hours postthyroidectomy have been shown to have excellent predictive power in determining hypocalcemia. In this study, we investigate the usefulness of combining calcium and PTH to increase the predictive power. METHODS: Individual patient data were obtained from 3 studies (152 patients) that fulfilled our criteria (using PTH assay within hours postthyroidectomy to predict symptomatic hypocalcemia). RESULTS: Changes in combined PTH and calcium threshold levels checked 1 to 6 hours after thyroidectomy were excellent in predicting postoperative hypocalcemia. A decrease in PTH of 60%, coupled with a simultaneous decrease in calcium of 10%, 5 to 6 hours postoperatively resulted in a sensitivity and specificity of 100%. However, combined PTH and calcium threshold changes were not significantly better than using PTH threshold changes alone. CONCLUSIONS: Threshold changes in serum calcium and PTH, checked hours after surgery, can be used together to accurately predict whether a patient will become hypocalcemic after thyroidectomy.