Performance of a multigene genomic classifier and clinical parameters in predicting malignancy in a Southeast Asian cohort of patients with cytologically indeterminate thyroid nodules.

BACKGROUND: Most thyroid nodules are benign. It is important to determine the likelihood of malignancy in such nodules to avoid unnecessary surgery. The primary objective of this study was to characterize the genetic landscape and the performance of a multigene genomic classifier in fine-needle aspiration (FNA) biopsies of cytologically indeterminate thyroid nodules in a Southeast Asian cohort. The secondary objective was to assess the predictive contribution of clinical characteristics to thyroid malignancy. METHODS: This prospective, multicenter, blinded study included 132 patients with 134 nodules. Molecular testing (MT) with ThyroSeq v3 was performed on clinical or ex-vivo FNA samples. Centralized pathology review also was performed. RESULTS: Of 134 nodules, consisting of 61% Bethesda category III, 20% category IV, and 19% category V cytology, and 56% were histologically malignant. ThyroSeq yielded negative results in 37.3% of all FNA samples and in 42% of Bethesda category III-IV cytology nodules. Most positive samples had RAS-like (41.7%), followed by BRAF-like (22.6%), and high-risk (17.9%) alterations. Compared with North American patients, the authors observed a higher proportion of RAS-like mutations, specifically NRAS, in Bethesda categories III and IV and more BRAF-like mutations in Bethesda category III. The test had sensitivity, specificity, negative predictive value, and positive predictive value of 89.6%, 73.7%, 84.0%, and 82.1%, respectively. The risk of malignancy was predicted by positive MT and high-suspicion ultrasound characteristics according to American Thyroid Association criteria. CONCLUSIONS: Even in the current Southeast Asian cohort with nodules that had a high pretest cancer probability, MT could lead to potential avoidance of diagnostic surgery in 42% of patients with Bethesda category III-IV nodules. MT positivity was a stronger predictor of malignancy than clinical parameters.

Posttraumatic Nasal Deformities: Correcting the Crooked and Saddle Nose.

The nose is frequently traumatized in facial injuries and this often results from motor vehicle accidents, sports-related injuries, and altercations. Subsequently, posttraumatic nasal deformity is one of the most common reasons that patients seek consultation in the doctor's office. Depending on the type of nasal deformities, this can result in functional impairment and aesthetic problems. Two challenging problems to be addressed in the posttraumatic nose include the crooked nose deformity and the saddle nose deformity. The numerous publications on these two topics attest to the exacting surgical expertise required in its treatment. The key features in management of these conditions are discussed further.

Orbital fracture in a professional diver: issues and management.

BACKGROUND: We present a case report of a professional diver who sustained a fracture of the left orbital medial wall as well as floor exceeding 50% with orbital fat herniation blocking the maxillary sinus ostium. This may result in a closed cavity within the maxillary sinus that could potentially result in barotraumas during future diving. The aim of his surgery consists of repairing the orbital fracture and to aerating the sinus at the same sitting. METHOD: A transconjunctival approach was used combined with endoscopic sinus surgery approach to the maxillary sinus. The orbital floor fracture was repaired with a titanium plate. A wide middle meatal antrostomy was performed. A size eight Foley's catheter was inserted into the maxillary sinus and the balloon inflated to elevate and support the displaced inferior orbital floor bone fragment. The balloon was left in situ for 4 weeks to support the mobile inferior orbital fragment till adequate bone healing and stability. RESULTS: Patient recovered well. At 3 months post-operatively, the maxillary antrostomy remained patent, and a hyperbaric oxygen challenge test was performed with success. A repeat orbital CT scan 1 day after hyperbaric challenge showed no signs of air leakage, and the bony inferior orbital floor fracture has healed completely with the titanium plate in situ. CONCLUSION: This is the first case report of repair of orbital floor fracture with simultaneous aeration of the maxillary sinus in a professional diver using a combined approach. The patient was able to resume his occupation as a professional diver following surgery.

Retropharyngeal lipoma with parapharyngeal extension: is transoral excision possible?

Retropharyngeal lipomas are rare tumours that are usually asymptomatic until they reach a large size. The definitive treatment is surgical excision. Since the tumours are typically large at the time of presentation, extensive surgery for complete clearance of the lipoma from the retropharyngeal and parapharyngeal regions is to be expected. Transoral excision is typically indicated for small retropharyngeal tumours, as this approach does not give good access to the parapharyngeal area laterally. Herein, we present the case of a patient who underwent transoral excision of a huge retropharyngeal lipoma, which extended into the right parapharyngeal space. The surgical technique used and the insights gained are described in this report. Even with parapharyngeal extension, transoral resection of a huge retropharyngeal lipoma can be performed. More invasive surgery, which may involve a neck incision, mandibulotomy or pharyngotomy, is not necessary. While huge retropharyngeal lipomas are usually symptomatic and require surgical intervention, transoral resection can be adequate and safe for treatment.

Esthesioneuroblastomas in an Asian population: similarities and differences.

OBJECTIVE: Esthesioneuroblastoma is an uncommon tumor that is described widely among the Caucasians. In Singapore, we see predominantly Asian patients with esthesioneuroblastomas. From our experience, we note significant and interesting differences between our data on Asian patients and the published ones on the Caucasian patients. METHODS: A retrospective review of all patients who underwent craniofacial resection for esthesioneuroblastomas was conducted from January 1997 to January 2010. Relevant data were collected and statistical analyses were carried out to determine factors that predicted mortality or complications. RESULTS: Out of a total of 48 patients who underwent craniofacial resections, half had esthesioneuroblastomas (50%). There was a peak age distribution at the sixth decade of life and 62% of our patients were male. Both local and regional recurrence rate was 50%. CONCLUSION: Majority of our Asian patients who underwent craniofacial resections had esthesioneuroblastomas. There is a male predilection, and we do not see a bimodal age distribution that is commonly reported.