Risk of Malignancy in FDG-Avid Thyroid Incidentalomas on PET/CT: A Prospective Study.

BACKGROUND: Due to a substantial risk of malignancy, patients with focal FDG-avid thyroid incidentalomas (FFTIs) on PET/CT are in most of Denmark referred to Head and Neck Cancer (HNC) fast track programs. The aim of this study was to determine the risk of malignancy in FFTI managed in a HNC fast track program. METHODS: A prospective cohort study including all patients with FFTI referred to the HNC fast track program, Odense University Hospital between September 1, 2016 and August 31, 2017. Ultrasonography (US) and fine-needle aspiration biopsy (FNAB) were intended to be done in all patients. Nodules with cytology of Bethesda 1, 3, 4, 5, or 6 were planned for surgical removal. RESULTS: A total of 104 patients were included. All patients had US and 101 patients (97%) had FNAB. Forty-two patients had benign cytology classified as Bethesda 2. The remaining 62 patients underwent surgery except from 11 patients, mainly due to comorbidity. The overall risk of malignancy for patients with FFTI referred to our HNC fast track program was calculated to be 24% (23/95) based on patients with unequivocal cytology and/or histology. The only statistically significant US characteristic to predict malignancy was the appearance of irregular margins with a sensitivity of 47% and specificity of 96%. CONCLUSION: The risk of malignancy of FFTIs handled in our HNC fast track program is 24%.

Inter- and Intrarater Reliability and Agreement Among Danish Head and Neck Pathologists Assessing Extranodal Extension in Lymph Node Metastases from Oropharyngeal Squamous Cell Carcinomas.

BACKGROUND: Extranodal extension (ENE) in lymph node metastases is one of the most important prognostic factors in head and neck squamous cell carcinomas. Studies have shown inconsistency among pathologists in the assessment of ENE. The aims of this study were: (1) to determine the interrater and intrarater reliability and agreement in the assessment of ENE among Danish pathologists and (2) to test if a standardized assessment method may increase interrater agreement. METHODS: Four Danish head and neck pathologists assessed ENE presence or absence in 120 histological slides from lymph nodes with oropharyngeal squamous cell carcinoma metastases (first round). Subsequently, guidelines were introduced to the pathologists and a new assessment was performed (second round). Finally, two of the pathologists assessed the slides to determine intrarater reliability and agreement (third round). RESULTS: Interrater kappa coefficients varied between 0.57 and 0.67 in the first round and between 0.59 and 0.72 in the second round. The intrarater agreement between round 2 and 3 was 0.88 for pathologist 1 and 0.92 for pathologist 2 with resulting kappa coefficients of 0.76 (95% CI 0.64-0.88) and 0.84 (95% CI 0.74-0.94), respectively. CONCLUSION: We found a moderate level of reliability and agreement among pathologists for ENE in lymph node metastases from oropharyngeal squamous cell carcinomas. The intrarater reliability and agreement was generally higher than interrater measures. Interrater agreement was slightly improved by standardized assessment.

Diagnostic accuracy of imaging modalities in detection of histopathological extranodal extension: A systematic review and meta-analysis.

OBJECTIVE: To present an up to date systematic review and meta-analysis evaluating the diagnostic accuracy of the most used imaging modalities in detection of histopathological extra nodal extension (ENE) in head and neck squamous cell carcinoma. MATERIALS AND METHODS: Medline, Embase, and Cochrane databases were systematically searched on March 27th 2020. Screening, inclusion, quality assessment, and data extraction were done by two reviewers. Meta-analysis was conducted using the bivariate model approach after pooling the studies according to imaging modality. Heterogeneity was explored by meta-regression. Comparison was done by meta-regression and sub-group analyses. RESULTS: Out of 476 initial hits, 25 studies were included for analysis. Of these, 14 dealt with CT, nine with PET/CT, four with MRI, two with ultrasound, and none with PET/MRI. Meta-analysis based on a total sample size of 3391 showed that CT had a sensitivity of 76% [67-82%] and specificity of 77% [69-83%], MRI a sensitivity of 72% [64-79%] and specificity of 78% [57-90%], and PET/CT a sensitivity of 80% [76-84%] and specificity of 83% [74-90%] in the ability to predict ENE. No meta-analysis could be done on ultrasound. There were no significant differences between modalities in overall accuracy; however, PET/CT had significantly higher sensitivity than CT and MRI. CONCLUSION: There was no significant difference in the ability of CT, MRI, and PET/CT to diagnose histopathological ENE, except that PET/CT had a significantly higher sensitivity than CT and MRI.

Histopathological Definitions of Extranodal Extension: A Systematic Review.

Extranodal extension (ENE) is a very strong prognostic factor in head and neck squamous cell carcinoma. However, significant variance in reported incidence of ENE suggests discordance in perception of ENE among pathologists. This study aims to map the different definitions of histopathological ENE used in the literature. A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Statement. Guided by the research question: "How is histopathological ENE defined?" the databases Medline, Embase, and Cochrane were systematically searched. All retrieved studies were reviewed and qualitatively analyzed. Three categories of existing definitions were formed. The systematic literature search yielded 1786 studies after removal of duplicates. Nine hundred and thirty-four full text articles were assessed for inclusion and 44 unique ENE definitions were identified and categorized 1-3; (1) simple definitions only describing a breach in the capsule (48%), (2) definitions also including a description of the perinodal tissue (43%), and (3) definitions adding a description of a specific reaction in the perinodal structure (9%). No consensus definition of ENE exists, but based on the level of details in the identified definitions, three overall categories of ENE definitions were established.

[Acute upper airway obstruction caused by a multinodular goitre after tracheotomy].

This case report illustrates how a multinodular goitre caused acute airway obstruction in a multitrauma 66-year-old male after tracheotomy. The patient had no symptoms of the goitre before the tracheotomy but developed subglottic airway obstruction at the time of decannulation. He underwent a subacute total thyroidectomy which removed the obstructive symptoms. A weakening of the tracheal tube followed by the tracheotomy possibly caused the tracheal stenosis in combination with the goitre.

Post-operative parathyroid hormone can be used as a predictor of normocalcaemia after total thyroidectomy.

INTRODUCTION: Development of hypocalcaemia is a serious complication to total thyroidectomy (TT). The measurement of intact plasma parathyroid hormone (iPTH) has been internationally described as a good predictor of hypocalcaemia. Despite this, consensus in the field has yet to be reached among clinicians. We aimed to evaluate if measurement of iPTH 24 hours post-operatively (24-iPTH) can identify patients who do not subsequently develop clinically significant hypocalcaemia (CSH), thereby allowing for early discharge after TT. METHODS: This was a historic cohort study of all patients who had a TT in the period from January 2013 to March 2014 at the Department of Oto-rhino-laryngology, Aarhus University Hospital, Denmark. Only patients with 24-iPTH measurements were included. Post-operative treatment with calcium or activated vitamin D analogue was defined as CSH. Data were collected from medical records. RESULTS: A total of 69 patients were included, 80% were women, the median age was 47 and 83% had a malignant disease. A total of 35% developed CSH and the median hospitalisation period was four days. The sensitivity, specificity and positive predictive value of 24-iPTH ≥ 2.8 pmol/l to exclude CSH were 76%, 92% and 94%, respectively. In addition, we found that a body mass index > 25 kg/m(2) significantly increased the risk of developing CSH. CONCLUSIONS: The measurement of 24-iPTH ≥ 2.8 pmol/l can be used to predict patients who will not develop CSH after TT and allow for early discharge of more than 50% of the patients. FUNDING: none. TRIAL REGISTRATION: not relevant.