Reliable sonographic features for nodal thyroglobulin to diagnose recurrent lymph node metastasis from papillary thyroid carcinoma.

OBJECTIVES: Ultrasound-guided aspiration cytology (US-FNAC) was previously used to diagnose lymph node metastasis of papillary thyroid carcinoma (PTC). Combined US-FNAC with nodal thyroglobulin (LN-FNA-Tg) significantly improved the diagnostic rate. However, diagnostic accuracy depends on proper node selection. Therefore, it is crucial to choose the nodes with reliable sonographic features to guide clinician for confirmation. DESIGN AND SETTING: Retrospective cohort study was carried out in one medical centre from 2011 to 2014. PARTICIPANTS: A total of 148 patients with PTC, being treated by total thyroidectomy and radioiodine, were assessed for potential nodal metastases by ultrasound. MAIN OUTCOME MEASURES: Lymph nodes with cystic content, peripheral hypervascularity, calcification, hyperechoic content, the absence of hilum and Solbiati index < 2 indicated risk of malignancy. US-FNAC and LN-FNA-Tg were both performed. Positive nodal metastasis was further confirmed by dissection. Risk impact of these sonographic features on LN-FNA-Tg to diagnose nodal metastasis was tested by logistic regression analysis based on the significance in both univariate and multivariate models. RESULTS: Overall, 49 lymph nodes were documented as recurrent nodal metastasis. LN-FNA-Tg greater than serum thyroglobulin and higher than 1 ng/mL achieved 100% of diagnostic rate for recurrent nodal metastasis. The malignant sonographic features that significantly cohered with positive LN-FNA-Tg were cystic and hyperechoic content and lack hilum, in sequence. CONCLUSIONS: LN-FNA-Tg is an excellent tool to quantitatively diagnose nodal metastasis. To achieve ideal diagnosis, the most reliable sonographic features were cystic content, hyperechoic content and the absence of hilum in lymph nodes, but not calcification or Solbiati index < 2.

Recurrent laryngeal nerve injury in video-assisted thyroidectomy: lessons learned from neuromonitoring.

INTRODUCTION: The objective of the study was to assess the mechanism of recurrent laryngeal nerve (RLN) injury during video-assisted thyroidectomy (VAT). METHODS: The study examined 201 nerves at risk (NAR). VAT with laryngeal neuromonitoring (LNM) was outlined according to this scheme: (a) preparation of the operative space; (b) vagal nerve stimulation (V1); (c) ligature of the superior thyroid vessels; (d) visualization, stimulation (R1), and dissection of the RLN; (e) extraction of the lobe; (f) resection of the thyroid lobe; (g) final hemostasis; (h) verification of the electrical integrity of the RLN (V2, R2). The site, cause, and circumstance of nerve injury were elucidated with the application of LNM. Laryngeal nerve injuries were classified into type 1 injury (segmental) and 2 (diffuse). RESULTS: Fourteen nerves (6.9 %) experienced loss of R2 and V2 signals. 80 percent of lesions occurred in the distal 1 cm of the course of the RLN. The incidence of type 1 and 2 injuries was 71 and 29 % respectively. The mechanisms of injury were traction (70 %) and thermal (30 %). Traction lesions were created during the extraction of the lobe from the mini-incision [point (e)]. Thermal injury occurred during energy-based device use in (f) and (g) circumstances. CONCLUSIONS: RLN palsy still occurs with routine endoscopic identification of the nerve, even combined with LNM. LNM has the advantage of elucidating the mechanism of RLN injury. Traction and thermal RLN injuries are the most frequent lesions in VAT.

Implementation of systematic neuromonitoring training for thyroid surgery.

Neural monitoring is increasingly applied to thyroid surgery and yet few surgeons have received formal training in intraoperative neuromonitoring (IONM). Standardized application of neural monitoring is an expected outcome of formal training programs in IONM. This study was designed to document a systematic training course that focuses on standardized state-of-art IONM knowledge. Seventeen 1-day courses were organized by the Department of Surgical Sciences, University of Insubria Medical School (Varese-Como, Italy), between 2009-2010. The course included didactic and practical training sessions. Some specific steps and checklist identified for courses included: knowledge of IONM technology and troubleshooting algorithms; IONM anesthetic perspectives, standards of IONM equipment set up and technique. A total of 75 trainees completed a questionnaire after completion of the respective courses. Questions probed demographic data, operative IONM experience and evaluation of course content. Data gathered showed that 97% of participants had no prior experience with the standardized approach of IONM technique (i.e. stimulation of the vagal nerve). The most useful parts of the course were judged to be (a) algorithms for perioperative IONM problem solving (30%), (b) live surgery with hands-on training (25%), (c) standardization of IONM technique (25%), and (d) IONM equipment set-up (20%). Poor reimbursement for hospital thyroid procedures is the main reason of limitation of IONM technology. The course offered participants novel knowledge and training and gave participants a systematic and standard approach to IONM technique.

Lower ataxia telangiectasia mutated (ATM) mRNA expression is correlated with poor outcome of laryngeal and pharyngeal cancer patients.

BACKGROUND: Ataxia telangiectasia mutated (ATM) kinase is a critical regulator in initiating DNA damage response and activating DNA repair. However, the correlation between ATM expression and the outcome of laryngopharyngeal cancer patients is unknown. We hypothesize that ATM expression is correlated with a worse outcome in laryngopharyngeal cancer patients. PATIENTS AND METHODS: The ATM messenger RNA (mRNA) expression of 80 tumors of laryngeal and pharyngeal cancer was examined by real-time quantitative RT-PCR. Overall survival rates were measured using Kaplan-Meier estimates and the log-rank tests. The adjusted hazard rate ratios (HRRs) were computed by multivariate Cox regressions. RESULTS: Reduced ATM mRNA was found in 65 of 80 studied cases. Lower ATM expression [tumor/normal <0.3, HRR = 2.49; 95% confidence interval (CI) 1.27-4.88], younger age (<55 years, HRR = 2.71; 95% CI 1.16-6.32), and larger tumor (T(3)/T(4), HRR = 2.21; 95% CI 1.10-4.44) were independent risk factors for survival. Patients with lower ATM and younger age (HRR = 6.51; 95% CI 2.05-20.66) or with lower ATM and T(3)/T(4) tumor (HRR = 5.23; 95% CI 2.04-13.40) exhibited the poorest outcome. CONCLUSION: The expression of ATM mRNA, which is frequently downregulated in laryngeal and pharyngeal cancers, could be a valuable prognostic marker.

Tissue polypeptide antigen, carcinoembryonic antigen, carbohydrate antigen, and CA125 levels as tumor markers in squamous cell carcinoma of the head and neck.

Ninety-eight untreated patients with squamous cell carcinoma of the head and neck of different localizations (larynx 36, oral cavity 48, nasal cavity 14) were selected for a study to measure TPA, CEA, CA 19-9, CA125 pre- and post-therapy. Fifty healthy individuals and 42 patients with benign lesions were as normal and disease controls. The positive rates were 22.3%, 27.8%, 5.6% and 0% respectively in TPA, CEA, CA 19-9 and CA125 markers in laryngeal cancer patients. The positive rates of TPA level was higher with significant difference in advanced stage group than in early stage group; conversely, the positive rate of CEA levels were somewhat high in early stages of laryngeal cancer. Meanwhile, the positive rates were 25.0%, 18.8%, 14.6% and 4.2% individually in the same order in oral cancer patients. There was no relationship between the marker levels and progression of the oral cancer. The tumor markers were almost of no use in detecting nasal cancer. It also seemed there was no relationship between the various serum levels and the tumor or nodal burden in laryngeal and oral cancer. Only TPA level decreased significantly after therapy in patients with laryngeal and oral cancer who had originally elevated marker levels. Conclusively, only TPA and CEA markers are of some clinical use in the disease.

Lymphoepithelial cyst of the parotid gland--a case report.

The lymphoepithelial cyst has been commonly termed branchial cleft cyst or branchial cyst. Although many theories, including the branchial apparatus theory, thymic duct theory, and inclusion theory, have been put forward, the etiology is still controversial. Parotid lymphoepithelial cysts are rare and could be divided into two groups, AIDS-related and non-AIDS related, by the relationship with HIV infection. A non-AIDS related lymphoepithelial cyst of left parotid gland in an 81-year-old man presenting as a parotid tumor is described. A left partial parotidectomy was carried out to remove the lesion. There was no recurrence after 2 years. Lymphoepithelial cysts of the parotid gland are often misdiagnosed as other benign tumors in spite of detailed preoperative investigations. Thus a pathological proof is needed for precise diagnosis. In addition, we also need to take the possibility of HIV infection into consideration, although Taiwan is not an AIDS epidemic area.

The management of advanced subglottic carcinoma with stomal invasion: a case report.

Primary subglottic carcinoma is rare. The initial stage is usually asymptomatic and the carcinoma is advanced when the symptoms are in evidence. Because the trachea and thyroid gland adjoin to the subglottic area, the tumor invades them along with the superior mediastinum and lung by the way of paratracheal lymph drainage. To resuscitate a severe airway obstruction, an emergency tracheotomy is required, which, however, results in a higher frequency of stomal recurrence later. We treated a case with advanced subglottic carcinoma and performed extended radical neck dissection with the resection of total larynx, thyroid gland, and involved trachea with peristomal skin en bloc. In order to completely remove the paratracheal and superior mediastinal lymph nodes, the sternal manubrium and its adjoining clavicles and ribs were cut off. This was necessary to optimize the field of vision, and to prevent injury to the great vessels and pleura. Because of its availability, its thickness, and its skin paddle, the pectoralis major myocutaneous flap was formed to the skin defect and to protect the great vessels. Postoperative stoma was at the sternal level and did not compress the great vessels. Parathyroid gland, after chopping, was reimplanted into muscle tissue to prevent hypocalcemia. No more postoperative radiotherapy or chemotherapy was necessary because the lymph nodes were spared. There were no postoperative complications and the patient was discharged 2 weeks later. No recurrence occurred in the 28 months follow-up period.