Incidence of Head and Neck Cancers before and after 9/11 in New York City and New York State.

INTRODUCTION: The incidence of cancers in New York State (NYS) before and after 9/11 including lung, colorectal, and renal cancers has been previously described. To date, the incidence of head and neck cancers (HNCs) before and after 9/11 has not been described. METHODS: Cancers involving the oral cavity and oropharynx; the nose, nasal cavity, nasopharynx, and middle ear; larynx; and thyroid were identified using the New York State Cancer Registry (NYSCR). Age-adjusted incidence and rates per 100,000 residents from 1987 to 2015 were analyzed using joinpoint regression. Trends in incidence using annual percent changes are presented. RESULTS: The overall rate of HNC increased slightly by 0.7% (p < 0.001) from 1987 to 2003 in NYS. From 2003 to 2008, the rate increased by 5.73% (p < 0.001), and from 2008 to 2015, the rate increased by 1.68% (p < 0.001). The rate of thyroid cancer increased by 6.79% (p < 0.001) from 1987 to 2003, by 9.99% (p < 0.001) from 2003 to 2009, and by 2.41% (p = 0.001) from 2009 to 2015. The rate of thyroid cancer was higher in women at all time points. In a subset analysis of HNCs excluding thyroid cancer, the rate decreased by 2.02% (p < 0.001) from 1991 to 2001, followed by a nonsignificant increase of 0.1% (p = 0.515) from 2001 to 2015. The rate of oropharyngeal (OP) cancer significantly increased from 1999 to 2015 (2.65%; p < 0.001). The rate of oral cavity cancer significantly decreased from 1987 to 2003 (1.97%; p < 0.001), with no significant change after 2003. The rate of laryngeal cancer decreased significantly by 2.43% (p < 0.001) from 1987 to 2015, as did the rate of nasal cavity/nasopharyngeal cancer (0.33%; p = 0.03). CONCLUSIONS: In NYS, OP cancer and thyroid cancer rates increased significantly during the study period. The rate of thyroid cancer was higher in women. The rate of combined HNC increased significantly after 9/11 compared to before 9/11; however, in a subset analysis of all HNC patients excluding thyroid cancer, the rate decreased significantly prior to 9/11 and then nonsignificantly increased afterward. This suggests that the increase in thyroid cancer accounts for the increase in combined HNC in NYS. The impact of 9/11 on rates of HNC requires further research.

Giant cell tumor of bone and secondary osteoarthritis.

Giant cell tumor of bone is a commonly encountered aggressive epiphyseal bone tumor, most often treated surgically. The natural history and presentation are classically described but the histopathology is poorly understood. Intralesional curettage is the mainstay of treatment, but there is significant variation in the use of adjuvant and cavity filling modalities. No gold standard has been agreed upon for treatment, and a variety of techniques are currently in use. Given its location, secondary osteoarthritis is a known long-term complication. This review examines the natural history of giant cell tumors, treatment options and complications, and subsequent development of osteoarthritis. Arthroplasty is usually indicated for secondary osteoarthritis although data is limited on its efficacy. Further directions will likely center on improved pharmacological treatments as well as improved arthroplasty techniques.

The Role of the Gut Microbiome in Orthopedic Surgery-a Narrative Review.

PURPOSE OF REVIEW: The importance of the gut microbiome has received increasing attention in recent years. New literature has revealed significant associations between gut health and various orthopedic disorders, as well as the potential for interventions targeting the gut microbiome to prevent disease and improve musculoskeletal outcomes. We provide a broad overview of available literature discussing the links between the gut microbiome and pathogenesis and management of orthopedic disorders. RECENT FINDINGS: Human and animal models have characterized the associations between gut microbiome dysregulation and diseases of the joints, spine, nerves, and muscle, as well as the physiology of bone formation and fracture healing. Interventions such as probiotic supplementation and fecal transplant have shown some promise in ameliorating the symptoms or slowing the progression of these disorders. We aim to aid discussions regarding optimization of patient outcomes in the field of orthopedic surgery by providing a narrative review of the available evidence-based literature involving gut microbiome dysregulation and its effects on orthopedic disease. In general, we believe that the gut microbiome is a viable target for interventions that can augment current management models and lead to significantly improved outcomes for patients under the care of orthopedic surgeons.

The Role of Cervical Disc Arthroplasty in Elite Athletes.

PURPOSE OF REVIEW: Cervical disc arthroplasty (CDA) for the treatment of symptomatic cervical disc herniations (CDH) is a promising treatment for professional athletes. In recent years, a number of high-profile athletes have returned to professional play within three months after CDA, raising important questions about the potential of this procedure within this patient group. We provide the first comprehensive review of available literature for the safety and efficacy of CDA in professional contact sport athletes. RECENT FINDINGS: CDA provides theoretical biomechanical advantages over anterior cervical discectomy and fusion (ACDF) and posterior foraminotomy (PF), as CDA is the only operation for treatment of CDH that provides neural decompression, stability and height restoration, with preserved range of motion. While the comparative long-term results from each procedure are unknown, CDA has provided encouraging promise in its use in professional contact athletes. We aim to aid ongoing discussions regarding the controversies in spine surgery for professional athletes by providing a scientific review of the available evidence-based literature involving cervical disc arthroplasty in this population. In general, we believe that CDA is a viable alternative to ACDF and PF for the contact professional athlete who requires full neck range of motion and desires an expedited return to play. For collision athletes, the short- and long-term safety and efficacy profile of this procedure is promising but still unclear.

Comparison of Pelvic Landmarks for Leg Length Discrepancy Measurement With Robotic Arm-Assisted Total Hip Arthroplasty.

Background: Leg length discrepancy (LLD) is a common complication after total hip arthroplasty (THA) leading to significant morbidity and dissatisfaction for patients. A popular system for robotic arm-assisted THA utilizes preoperative computed tomography (CT) scans for surgical planning. Accurate measurement of leg length is crucial for restoring appropriate patient anatomy during the procedure. This study investigates the interobserver and interlandmark reliability of 3 different pelvic landmarks for measuring preoperative LLD. Methods: We compiled preoperative pelvic CT scans from 99 robotic arm-assisted THAs for osteoarthritis. Radiologic leg length measurement was performed using the robotic arm-assisted THA application by 2 orthopaedic residents using reference lines bisecting the following pelvic landmarks: the anterior superior iliac spines, acetabular teardrops, and most inferior aspect of the ischial rami. Results: On multivariate analysis, there was no significant difference found (P value = .924) for leg length measurement based on the 3 different pelvic anatomical landmarks. Leg length measurements showed interobserver reliability with significant Pearson correlation coefficients (r = 1.0, 0.94, 0.96, respectively) and nonsignificant differences in LLD means between subjects on paired sample (P value = .158, .085, 0.125, respectively) as well as between landmarks on pairwise comparison. Conclusions: The 3 pelvic landmarks used in this study can be used interchangeably with the lesser trochanter as the femoral reference point to evaluate preoperative LLD on pelvic CT in patients undergoing robotic-arm assisted THA. This study is the first of its kind to evaluate the interobserver and interlandmark reliability of anatomical landmarks on pelvic CT scans and suggests interchangeability of 3 pelvic landmarks for comparing leg length differences.

Revising large scars.

Large scars in the head and neck are often the cause of significant emotional distress to patients, and often present unique challenges to the plastic and reconstructive surgeon undertaking their revision. The primary goal of scar revision is to eliminate compromise of function that may have resulted from scar contracture; a secondary goal is to improve the appearance of the scar. Special techniques for the revision of large scars include serial partial excision, rapid intraoperative or prolonged tissue expansion, split- and full-thickness skin grafting, regional flaps, and free microvascular tissue transfer. Recent research has investigated the use of artificial skin and autologous fat grafting for large scar revision.

Ultrasound-guided fine-needle aspiration biopsy of thyroid neoplasms with lipomatous stroma: Report of two cases.

Thyroid tumors with abundant adipose tissue component are rare, reportedly accounting for 0.98-2.8% of all thyroid nodules, and include entities such as thyroid lipoadenoma and thyroid carcinoma with lipomatous stroma (TCLS). They may be encountered on fine-needle aspiration biopsy (FNAB), which is widely used in evaluation of thyroid nodules. However, due to their relative rarity, adipose elements rarely are recognized preoperatively in these tumors. Herein, we report two cases of thyroid tumors with abundant adipose tissue, along with cytologic, histologic, and ultrasonographic features. Although an intermixture of adipose tissue and thyroid follicular cells is the key cytologic feature of thyroid tumors with adipose stroma, other cytologic findings, such as abundant fat droplets or isolated fragments of adipose tissue, also should raise the possibility of a fat-containing tumor, particularly when a biopsy is performed by a cytopathologist under ultrasonographic guidance and adequate radiologic-pathologic correlation. Cytopathologists should be aware that overlooking lesional adipose tissue within a thyroid neoplasm might give the false impression of a non-diagnostic or sparsely cellular FNAB specimen.

A new office-based procedure for treatment of snoring: The S.I.Le.N.C.E. study.

OBJECTIVE: Demonstrate the safety and effectiveness of palatal foreshortening and stiffening in reducing snoring severity in nonobstructive sleep apnea (non-OSA) patients complaining of chronic disruptive snoring. METHODS: In a US-based 8-center, open-label, prospective, single-arm cohort study, 52 consenting adults with chronic disruptive snoring (snoring impacting a patient's life and causing patient or bed partner to seek medical intervention) were treated via office-based placement of resorbable, bidirectional, barbed suture implants into the soft palate under local anesthesia. Prior to intervention, home sleep tests (HSTs) were performed to rule out OSA and to document snoring noise level. Both subject and their bed/sleep partners (also consented) completed questionnaires including: bed/sleep partner's scored visual analog scale (VAS) for subjects' snoring severity, and subject scoring for Epworth Sleepiness Scale (ESS) and Pittsburgh Sleep Quality Index (PSQI). Following intervention, HSTs, VAS, ESS and PSQI were repeated at 30, 90 and 180 days. RESULTS: Mean baseline bed/sleep partner VAS was 7.81 ± 1.59. Mean postimplant VAS scores decreased significantly at each measured interval; to 5.77±2.35 (P < .001) at 30 days, 4.48 ± 1.81 (P < .001) at 90 days, and 5.40 ± 2.28 (P < .001) at 180 days. Post treatment improvements in daytime sleepiness and QOL were also observed. Two partial extrusions were reported. No further adverse events were identified. CONCLUSION: The current study demonstrates the safety and efficacy of the Elevoplasty procedure in reducing snoring severity over a follow-up period of 6 months. LEVEL OF EVIDENCE: 2b.

Endoscopic pituitary surgery: a systematic review and meta-analysis.

OBJECT: Surgery on the pituitary gland is increasingly being performed through an endoscopic approach. However, there is little published data on its safety and relative advantages over traditional microscope-based approaches. Published reports are limited by small sample size and nonrandomized study design. A meta-analysis allows for a description of the impact of endoscopic surgery on short-term outcomes. METHODS: The authors performed retrospective review of data from their institution as well as a systematic review of the literature. The pooled data were analyzed for descriptive statistics on short-term outcomes. RESULTS: Nine studies (821 patients) met inclusion criteria. Overall, the pooled rate of gross tumor removal was 78% (95% CI 67-89%). Hormone resolution was achieved in 81% (95% CI 71-91%) of adrenocorticotropic hormone secreting tumors, 84% (95% CI 76-92%) of growth hormone secreting tumors, and 82% (95% CI 70-94%) of prolactin secreting tumors. The pooled complication rates were 2% (95% CI 0-4%) for CSF leak and 1% (95% CI 0-2%) for permanent diabetes insipidus. There were 2 deaths reported in the literature that were both related to vascular injury, giving an overall mortality rate of 0.24%. CONCLUSIONS: The results of this meta-analysis support the safety and short-term efficacy of endoscopic pituitary surgery. Future studies with long-term follow-up are required to determine tumor control.

An operative approach to the treatment of refractory cutaneous nasal sarcoid: a case report and review of the literature.

The treatment of cutaneous sarcoid is often frustrating, because lesions may be refractory to treatment, or recurrent. There is little information in the literature regarding the surgical treatment of cutaneous sarcoid. Such treatment may become necessary in cases that do not respond to systemic treatments and create functional impairments. We present a 7-year follow-up of a patient with cutaneous nasal sarcoid that was successfully treated surgically.

Facial nerve rerouting in skull base surgery.

Facial nerve rerouting techniques were developed to facilitate re-section of extensive tumors occupying the skull base. Facial nerve rerouting has its own limitations and risks, requiring microsurgical expertise, additional surgical time, and often some degree of facial nerve paresis. This article presents different degrees of anterior and posterior facial nerve rerouting, techniques of facial nerve rerouting, and a comprehensive review of outcomes. It then reviews anatomic and functional preservation of the facial nerve in acoustic neuroma resection, technical aspects of facial nerve dissection, intracranial facial nerve repair options, and outcomes for successful acoustic neuroma surgery.

Minimally invasive brow suspension for facial paralysis.

OBJECTIVE: To report a new technique for unilateral brow suspension for facial paralysis that is minimally invasive, limits supraciliary scar formation, does not require specialized endoscopic equipment or expertise, and has proved to be equal to direct brow suspension in durability and symmetry. DESIGN: Retrospective survey of a case series of 23 patients between January 1997 and December 2000. SETTING: Metropolitan tertiary care center. PATIENTS: Patients with head and neck tumors and brow ptosis caused by facial nerve paralysis. MAIN OUTCOME MEASURE: The results of the procedure were determined using the following 3-tier rating system: outstanding (excellent elevation and symmetry); acceptable (good elevation and fair symmetry); and unacceptable (loss of elevation). RESULTS: The results were considered outstanding in 12 patients, acceptable in 9 patients, and unacceptable in only 1 patient. One patient developed a hematoma, and 1 patient required a secondary adjustment. CONCLUSIONS: The technique has proved to be superior to standard brow suspension procedures with regard to scar formation and equal with respect to facial symmetry and suspension. These results have caused us to abandon direct brow suspension and to use this minimally invasive method in all cases of brow ptosis due to facial paralysis.

Temporal morphomics as a model for determining preoperative risk of blood transfusion in nonsyndromic craniosynostosis patients.

BACKGROUND: Estimates of blood loss during craniosynostosis surgeries have ranged from 42 to 126 percent of infant's total blood volume. Currently, no risk model has been developed to determine the likelihood of needing a blood transfusion. The authors propose an objective model, based on patients' three-dimensional anatomical characteristics, to stratify the likelihood of needing perioperative packed red blood cells. METHODS: High-throughput image analysis from already ordered preoperative computed tomographic scans was used to reconstruct the three-dimensional anatomy of the temporalis muscle and overlying temporal fat pad. Using these morphomic measurements, the authors created a risk assessment model of the amount of packed red blood cells infused based on morphomic variations in temporal soft tissue. RESULTS: The authors evaluated 139 infants with nonsyndromic craniosynostosis from the University of Michigan Health System. Results show the need for blood transfusion ranged from 94.1 percent among patients in the smallest quartile for temporal fat pad volume compared with 65.7 percent among the group with the largest quartile for temporal fat pad volume (p = 0.0057). Using multivariable linear regression, temporal fat pad volume (p = 0.012) and fat pad thickness (p = 0.036) were independent predictors for amount of packed red blood cells required. CONCLUSIONS: The authors demonstrate that patients with diminished temporal fat pad volume are significantly more likely to need increased packed red blood cell transfusions. In addition, by use of multivariable linear regression, their data suggest that temporal fat pad volume and thickness were independent predictors for the amount of required transfusion of packed red blood cells.

Methodology for intra-operative recording of the corticobulbar motor evoked potentials from cricothyroid muscles.

OBJECTIVE: To establish the methodology for recording corticobulbar motor evoked potentials (CoMEPs) from cricothyroid muscles (CTHY) elicited by transcranial electrical (TES) and direct cortical stimulation (DCS). METHODS: Six healthy subjects and 18 patients undergoing brain surgery were included in the study. In six healthy subjects as well as in nine patients under general anaesthesia, CoMEP was obtained by TES. In three patients under general anaesthesia and in six patients during awake craniotomy, CoMEP was obtained by DCS. We used three methods of electrical stimulation for eliciting responses from CTHY muscles: (1) TES over C3/Cz or C4/Cz (in six healthy subjects and nine patients under general anaesthesia), (2) DCS with a strip electrodes placed over exposed cortex in two patients, and (3) DCS with a hand-held probe in seven patients. For recordings, we percutaneously placed hook-wire electrodes in CTHY muscle (76 µm diameter) passing through 27-gauge needles, guided by electromyogram (EMG) feedback. In anaesthetised patients, recording electrodes were placed before patients were put to sleep. RESULTS: Recordings of CoMEPs by TES was successfully performed in all but one healthy subject and all patients. Either method of stimulation resulted in recordings of short- and long-latency responses (SLRs and LLRs) in CTHY muscle. After DCS, SLRs were recorded in all patients but two, in whom only LLR was obtained; in patient No. 1 (Table 3) LLR was elicited by a strip electrode, while in patient No. 4 (Table 3), LLR was elicited by a hand-held electrode. The possible explanation for eliciting only LLR in patient No. 1 was that the strip electrode did not cover the primary motor cortex. In patient No. 4, only LLR but not SLR was recorded, due to the underlying pathology which displaced M1 for cricothyroid muscle not being accessible to the DCS with the hand-held electrode. As each CTHY muscle is innervated from both hemispheres, CoMEPs were recorded from the left or right CTHY muscle during TES or DCS over either the left or right hemisphere. In healthy subjects, TES elicited SLR with a latency of 13.25 ± 1.38 ms, while in patients the latency was 12.73 ± 0.64 ms. In healthy subjects, TES elicited LLR with a latency of 40.53±4.66ms, and in patients, it elicited LLR with a latency of 44.70±4.61ms. The group of patients in whom the responses were elicited by DCS, SLR and LLR had similar latencies as responses elicited by TES; in the patient's group the values were 13.97±1.11ms versus 12.73±0.64ms and 45.91±3.88ms versus 44.70±4.61ms, respectively. CONCLUSIONS: Together with the existing methodology for intra-operatively eliciting CoMEPs in the vocal muscles, a new methodology for eliciting CoMEPs in CTHY muscle has the potential to continuously monitor the functional integrity of the structures involved in conveying signals from the motor cortex to the CTHY muscle. It is highly probable that SLR is a neurophysiological marker for the primary motor cortex (M1) and it is equal to CoMEP for laryngeal muscle, while LLR is a marker for the opercular part of Broca's area. SIGNIFICANCE: This new and rather simple method adds a new tool in exploration of the functional organisation of motor cortex and corticobulbar pathways for laryngeal muscles. Furthermore, it has great potential to intra-operatively monitor its functional integrity.

Predictors of short-term outcomes following endoscopic pituitary surgery.

OBJECTIVE: Refinement of endoscopic pituitary surgery requires an understanding of the impact of demographic and surgical variables on outcomes. METHODS: Multivariate logistic regression and ANOVA models were used to explore variables for association with outcomes in a consecutive series of 57 patients undergoing endoscopic pituitary surgery. RESULTS: The mean duration of surgery was 177 min and was longer in patients with larger tumor size (p=0.03) and presentation with visual symptoms (p=0.02) in univariate analyses. The median duration of hospitalization was 3 days and was longer in patients with larger tumors (p=0.0005). Gross tumor removal was achieved in 89%. Tumor size correlated with extent of tumor removal with an almost 3-fold decrease in complete tumor removal for every 1cm increase in tumor size (p=0.047). High rates of hormonal control (90%) and improvement in visual symptoms (92%) were noted. CONCLUSIONS: High rates of gross tumor removal, hormonal cure and visual field improvement were noted in this series. Markers including tumor size and visual symptoms may be used to stratify patients.

Safety of low-dose intrathecal fluorescein in endoscopic cranial base surgery.

OBJECTIVE: Intraoperative identification of cerebrospinal fluid (CSF) leakage is critical in successful closure after endoscopic cranial base surgery. Intrathecal injection of fluorescein is quite useful in identifying CSF leaks. However, complications have been reported with various doses and the technique has fallen out of favor. We explored the safety of low-dose intrathecal fluorescein administered to patients undergoing endoscopic cranial base surgery. METHODS: A retrospective chart review and postoperative patient survey were performed. The nature and incidence of complications and subjective complaints were recorded in 54 patients who underwent endoscopic, endonasal approaches to the anterior cranial base and received intrathecal fluorescein after premedication with dexamethasone and diphenhydramine. RESULTS: Intraoperative CSF leak was identified with fluorescein in 46.3% of the patients and helped determine the reconstruction technique. Postoperative CSF leak occurred in 9.3% of the patients and resolved with lumbar drainage. There were no seizures. Most side effects were nonspecific, transient, and likely not caused by fluorescein including malaise (57.4%), headache (51.9%), dizziness (31.5%), or nausea/vomiting (24.1%). Three patients (5.6%) experienced persistent subjective lower extremity weakness (n = 2) and numbness (n = 2) postoperatively; however, two of them had undergone lumbar drainage. CONCLUSION: Low-dose injection of intrathecal fluorescein after premedication with steroid and antihistamine agents is generally safe. Most symptoms are nonspecific and transient, likely caused by the surgery or lumbar drainage. However, fluorescein should be administered with some caution because it may be responsible for occasional lower extremity weakness and numbness.

Endoscopic transphenoidal pituitary surgery with real-time intraoperative magnetic resonance imaging.

BACKGROUND: The aim of this study was to report and show the technique, results, and complications of combined endoscopic and intraoperative magnetic resonance imaging (IMRI) surgical treatment of pituitary disease from both a technical and a surgical perspective. METHODS: We performed a retrospective chart review of 10 endoscopic, endonasal resections of 10 pituitary macroadenomas using the Polestar N-10 IMRI system in a tertiary health care facility. The patient demographics, tumor measurements, and postoperative symptoms and complications were assessed. The effect of the magnetic field on the video screen, the image quality of the IMRI images, and IMRI detection of residual tumor were evaluated also. RESULTS: IMRI images were obtained in all cases and were of sufficiently high quality to indicate adequate decompression of the optic chiasm and the removal of all suprasellar tumor. However, there was significant distortion of the video monitor regardless of the viewing angle. This was overcome with a wall-mounted plasma screen. Residual tumor was found with IMRI and resected endoscopically in three cases. In two other cases, suspected residual tumor on IMRI was examined endoscopically and found to be a normal postoperative change. In two cases no tumor was seen on the IMRI. Five patients who had preoperative progressive visual loss preoperatively improved postresection and two patients who had increased insulin growth factor 1 preoperatively normalized postoperatively. No delayed cerebrospinal fluid leaks or any other complications occurred. CONCLUSION: Combining intraoperative endoscopy and IMRI is an effective surgical modality for pituitary surgery. Each technology provides complimentary information, which can assist the surgeon in safely maximizing the extent of resection.

Prognostic factors of recurrence in encapsulated Hurthle cell carcinoma of the thyroid gland: a clinicopathologic study of 50 cases.

BACKGROUND: Follicular carcinomas of the thyroid gland, including its oncocytic variant (so-called Hurthle cell carcinoma), are subdivided into the indolent encapsulated ("minimally invasive") and the clinically aggressive widely invasive tumors. There are, however, cases of encapsulated follicular carcinoma that recur and metastasize. Identifying these cases at the time of diagnosis is crucial for prognostic and therapeutic considerations. Because to the authors' knowledge most studies do not focus exclusively on the encapsulated Hurthle cell carcinoma (EHC), the current study attempted to identify predictors of recurrence in EHC. METHODS: A tumor was defined as EHC if it was encapsulated, macroscopically well defined with microscopic but no macroscopic evidence of vascular or capsular invasion, and composed of > 75% follicular oncocytic cells. Retrospective chart review and microscopic examination identified 50 primary tumors meeting the above criteria at the Memorial Sloan-Kettering Cancer Center between 1967 and 2005. The cases were analyzed for various histologic and clinical parameters. Each parameter was correlated with recurrence-free survival (RFS). RESULTS: Seven of 50 (14%) patients developed disease recurrence. All patients who developed recurrence were found to have a high number of foci of vascular invasion (> or = 4). In univariate analysis, > or = 4 foci of vascular invasion (P <.0001), tumor size > 4 cm (P = .049), the presence of mitosis (P = .018), and a solid/trabecular growth pattern (P = .009) were found to be correlated with a decreased RFS. Extensive capsular invasion, gender, and age did not confer a statistically higher recurrence rate. The finding of a solid/trabecular growth and mitosis correlated with the presence of numerous foci (> or = 4) of vascular invasion (P = .01 and P = .005, respectively). CONCLUSIONS: A diligent search for vascular invasion is recommended in EHC that display mitosis or a solid/trabecular growth pattern. The presence of > or = 4 foci of vascular invasion should alert the pathologist and the clinician to a significantly higher risk of recurrence in EHC.

Poorly differentiated thyroid carcinomas defined on the basis of mitosis and necrosis: a clinicopathologic study of 58 patients.

BACKGROUND: Poorly differentiated thyroid carcinomas (PDTC) occupy an intermediate position at the prognostic level on the spectrum of thyroid carcinoma progression. However, their histologic definition is controversial. The objective of the current study was to assess the prognostic significance of PDTC defined on the basis of mitosis and necrosis and search for prognostic markers within this group of tumors that are predictive of overall survival (OS) and progression-free survival (PFS). METHODS: PDTC was defined as thyroid carcinoma with follicular cell differentiation at the histologic and/or immunohistochemical levels and displaying tumor necrosis and/or > or = 5 mitoses per 10 high-power fields (x400). Retrospective chart review and microscopic examination identified 58 patients with primary tumors meeting the above criteria and seen at the Memorial Sloan-Kettering Cancer Center between 1992 and 2004. These 58 patients were analyzed for various histologic, clinical, and imaging parameters. Each parameter was correlated with OS and PFS. RESULTS: Of the 58 patients studied, 22 (38%) patients died of disease with a 5-year OS rate of 60%. Forty-three of the 58 patients (74%) developed disease recurrence or disease progression, with a 5-year PFS rate of 25%. The median follow-up for the entire patient population was 42.6 months (range, 4-205 mos). A tumor size > 4 cm was found to be correlated with a decreased PFS time (P < 0.001). Those tumors with a capsule demonstrated a significantly improved OS compared with unencapsulated tumors (P = 0.001). The extent of capsular invasion was found to be a significant adverse factor for PFS (P = 0.05). The presence of extrathyroid extension into perithyroid soft tissue was found to be correlated with a decreased OS (P = 0.001) and PFS (P = 0.004). Of 27 patients with distant metastasis, 19 (70%) had concentrated radioactive iodine (RAI) at their metastatic sites. On multivariate analysis, extrathyroid extension and tumor size emerged as the only significant variables in predicting PFS (P = 0.04 and P = 0.01, respectively) whereas extrathyroid extension was found to be the sole independent prognostic factor for OS (P = 0.01). Growth pattern and cell type did not appear to influence outcome. CONCLUSIONS: PDTC defined on the basis of mitosis and necrosis constitutes a group of tumors that is more aggressive and homogeneous than PDTC defined by growth pattern. Within this group of patients, microstaging (tumor size, the extent of capsular invasion, and, especially, extrathyroid extension), and not growth pattern or cell type, is able to stratify patients into different prognostic categories. RAI uptake occurs in a significant number of patients with PDTC.