Expression of vascular endothelial growth factor in follicular cell-derived lesions of the thyroid: Is NIFTP benign or precancerous?

Objective: Vascular endothelial growth factor (VEGF) is an angiogenic factor that plays an important role in physiological and pathological angiogenesis of the thyroid. The aim of the current study was to determine the expression characteristics of VEGF in follicular cell-derived lesions of the thyroid and to assess whether a new entity noninvasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTP) is precancerous. Material and Methods: Patients diagnosed with 33 follicular adenomas (FA), 41 invasive follicular variant papillary thyroid cancer (IN-FVPTC), and 40 NIFTP in surgical resection materials were evaluated retrospectively. Immunostaining was performed on 5-µm paraffin tissue sections. The percentages of immunostaing for VEGF were evaluated on pathological materials. We used a percentage of labeled thyrocytes score (0, no labeling; 1, <30%; 2, 31-60%; 3, >60%) and an intensity score (0, no staining; 1, weak; 2, intermediate; 3, strong). The sum of two scores were accepted as the total score. Results: Mean ages of the FA, IN-FVPTC, and NIFTP groups were 44.7 ± 11.7 years, 46.9 ± 13.6 years, 43.2 ± 15.4 years, respectively and the mean VEGF immunostaining scores were 44.7 ± 29.3, 50.2 ± 32.54, 4 ± 26.3 respectively. Although there was no statistically significant difference (p= 0.347), the total score of the NIFTPs was higher than the scores of the FA (mean= 3.9 ± 1.8) and IN-FVPTC(mean= 4.3 ± 1.9) groups with a mean value of 4.6 ± 1.7. This result was remarkable. There was no statistically significant difference between tumor diameters and staining percentages (p= 0.750). Conclusion: Even if there were no statistical differences for VEGF immunostaining, it was high in NIFTPs. Since we know the role of VEGF in tumorigenesis, we can hypothesize that NIPTP can be precancerous. Our argue should be corroborated by a large prospective study.

Hypoparathyroidism in Total Thyroidectomy due to Benign Thyroid Diseases.

PURPOSE: Our aim was to compare the effects of exposing the recurrent laryngeal nerve throughout its entire course with exposing the nerve only at its entry to the larynx in patients undergoing total thyroidectomy due to benign thyroid diseases, and to evaluate the effects of these methods on the risk for hypoparathyroidism. METHODS: The medical records of 437 patients who had undergone total thyroidectomy at the ear, nose, and throat clinic between 2001 and 2015 for benign thyroid diseases were evaluated retrospectively. Mean patient age was 46.7 years (range 18-79 years). Eighty-six patients were male and 351 were female. Patients were divided into 2 groups according to recurrent laryngeal nerve exposure during surgery. In the first group, the nerve was observed as it entered the larynx, and its course was not completely exposed. In the second group, the nerve was identified in the tracheoesophageal groove, and its course was fully exposed. Group 1 consisted of 256 patients (47 male and 209 female) and group 2 consisted of 181 patients (39 male and 142 female). There were no statistically significant differences between the groups in terms of age and gender, and the groups were homogeneously distributed. FINDINGS: Transient hypoparathyroidism was observed in 15 (5.8%) patients and permanent hypoparathyroidism was observed in 3 (1.1%) patients in group 1, and transient hypoparathyroidism was observed in 23 (12.7%) patients and permanent hypoparathyroidism was observed in 7 (3.8%) patients in group 2. The rates of both transient and permanent hypoparathyroidism were higher in the patients in group 2, and the difference was statistically significant (P < 0.001). Transient recurrent nerve palsy was seen in 1 patient in each group. Permanent recurrent nerve palsy occurred in 1 patient in group 2, although the difference between groups was not statistically significant (P = 0.28). IMPLICATIONS: Transient and permanent hypoparathyroidism were less common in thyroidectomies that involved detection of the recurrent laryngeal nerve at the site of entry to the larynx and keeping its dissection minimal; this technique was also more reliable.

Proposal of a Budget-Friendly Camera Holder for Endoscopic Ear Surgery.

Endoscopic ear surgery (EES) is increasingly a preferred technique in otologic society. It offers excellent visualization of the anatomical structures directly and behind the corners with variable angled telescopes. It also provides reduced operative morbidity due to being able to perform surgical interventions with less invasive approaches. Operative preparation and setup time and cost of endoscopy system are less expensive compared with surgical microscopes. On the other hand, the main disadvantage of EES is that the surgery has to be performed with 1 single hand. It is certainly restrictive for an ear surgeon who has been operating with 2 hands under otologic microscopic views for years and certainly requires a learning period and perseverance. Holding the endoscope by a second surgeon is not executable because of insufficient surgical space.Endoscope/camera holders have been developed for those who need the comfort and convenience afforded by double-handed microscopic ear surgery. An ideal endoscope holder should be easy-to-set up, easily controlled, providing a variety of angled views, allowing the surgeon to operate with 2 hands and, budget-friendly. In this article, a commercially available 11-inch magic arm camera holder is proposed by the authors to be used in EES due to its versatile, convenient, and budget-friendly features. It allows 2-handed EES through existing technology and is affordable for surgeons looking for a low-cost and practical solution.

Olfactory Dysfunction Associated With Neuro-Behçet Disease.

INTRODUCTION: Neurologic involvement associated with Behçet disease (BD) is defined as a different entity: Neuro-Behçet disease (NBD). Behçet disease presents with olfactory dysfunction. It is not known whether this is the consequence of mucosal involvement or neurologic involvement. OBJECTIVE: The aim of this study was to investigate whether olfactory dysfunction was further aggravated as the result of neurologic involvement. METHODS: Sixteen patients diagnosed with NBD and 16 healthy control patients with similar demographic characteristics were recruited as the healthy control group. Expanded Disability Status Scale (EDSS) scoring was used for quantification of neurological disability. All diagnoses were confirmed and categorized with magnetic resonance imaging studies in all patients individually: parenchymal or nonparenchymal. A well-established test of orthonasal olfaction developed at the CCCRC was used. Correlation analysis was carried out. RESULTS: The mean CCCRC score of NBD patients was 4.60 out of 7, and this group was diagnosed to be moderately hyposmic, whereas the average score of the control group was 6.5; the difference was significant (P < 0.0001). CCCRC scores of NBD patients were significantly lower compared both healthy control patients and those of BD patients reported in the literature. Mean EDSS score of NBD patients was 1.75 ±â€Š1.0 out of 10 (0-no neurologic disability and 10-worst neurologic disability). Magnetic resonance imaging of NBD patients revealed 4 nonparenchymal and 12 parenchymal patients. Neuro-Behçet disease patients with parenchymal involvement presented with (worse) EDSS scores. Mean olfactory CCCRC score of this group was 4.38 whereas the average olfactory score of the vascular group was 5.25 out 7. Average EDSS score of vascular group was 0.75, much better compared to higher average neurologic disability score of 2.08 for the parenchymal group. Significant correlation existed between the duration of NBD and both olfactory and neurologic dysfunction scores. CONCLUSION: Neuro-Behçet disease present with aggravated olfactory dysfunction compared to BD. Neurologic involvement-especially parenchymal involvement-seems to deteriorate the olfactory dysfunction. Duration of disease is correlated with this severity of dysfunction.

BRAFV600E Mutation: Has It a Role in Cervical Lymph Node Metastasis of Papillary Thyroid Cancer?

BACKGROUND: The BRAFV600E mutation is common in papillary thyroid cancer (PTC). Lymph node metastasis (LNM) may be associated with poor prognosis. However, the LNM mechanism remains unclear. OBJECTIVES: Our aim was to evaluate the prevalence of the BRAFV600E mutation in primary tumors and accompanying LNM at the time of diagnosis. METHODS: This retrospective study included 51 PTC patients (40 women, 11 men; mean age 40.0 ± 16.5 years; range 6-81) who underwent total thyroidectomy accompanied by a lateral neck dissection due to preoperatively detected LNM. Real-time PCR was used for the detection of the BRAFV600E mutation in specimens from primary thyroid tumors and metastatic lymph node tumors. RESULTS: The prevalence of the BRAFV600E mutation was 64.7% (n = 33) in primary tumors and 47.1% (n = 24) in metastatic lymph nodes. Of 33 patients with BRAFV600E-positive primary tumors, 18 (54.5%) had BRAFV600E-positive metastatic lymph nodes. Of 18 patients with BRAFV600E-negative primary tumors, 6 (33.3%) had BRAFV600E-positive metastatic lymph nodes. The presence of the BRAFV600E mutation in the primary tumor did not affect the tumor size, but the diameter of metastatic lymph nodes significantly increased (by nearly 3 mm) with the presence of BRAFV600E in LNM (p = 0.01). CONCLUSIONS: In our study, the BRAFV600E mutation did not show a one-to-one correspondence. This indicates that the presence of BRAFV600E in the primary tumor is not clonal and addresses the role of intratumor heterogeneity in PTC tumorigenesis. This supports the theses that mutations occur in the later stages of tumorigenesis, might be subclonal, and develop de novo, or that some other factors may be involved in the development of metastasis.

Nasopharyngeal Mass Diagnosed as Transsphenoidal Encephalocele in an Adult Patient.

Transsphenoidal encephalocele, a rare congenital malformation, is generally diagnosed during childhood when investigating the reason for complaints such as nasal obstruction and recurring cerebrospinal fluid fistula. In this adult patient, the authors identified an asymptomatic transsphenoidal encephalocele after requested monitoring of a pedunculated mass detected in the nasopharynx during nasal endoscopy. After evaluation, the authors decided to follow the patient. Few cases of transsphenoidal encephalocele have been reported, and even fewer have been reported in older patients, with no other anomaly or symptoms. The success of surgical treatment for these masses is debatable. The authors did not consider surgery for this asymptomatic case. With this case presentation, the authors wish to emphasize that without making radiologic assessments of any masses identified in a nasopharyngeal examination, it would be inappropriate to perform a biopsy or any intervention.

Effects of Open Technique Rhinoplasty on Mimicry: Electroneurographic Evaluation.

OBJECTIVE: This study was designed to investigate the effects of open technique rhinoplasty on facial nerve terminal branches more concerned with mimicry via electroneurography (ENoG). METHODS: Twenty patients ages between 24 and 36 years were included in the study. Five nasal mimicry muscles were used to evaluate axonal loss of the facial nerve: bilateral transverse nasal, levator labii superioris alaeque nasi (LLSAN), and procerus muscles of all patients were evaluated preoperatively and postoperative third month by ENoG. The patients that have abnormalities regarding the amplitude and latency at third month were reevaluated at sixth month postoperatively. RESULTS: Mean latencies of the facial nerve were calculated to be increased for all muscles at third postoperative month, but this increase was significant only for left LLSAN (P = 0.002). Amplitudes of the facial nerve decreased in all of the groups, but this decrease was not significant (P > 0.05). Two patients with exceptionally long latency facial nerve response of transverse nasal muscle and 11 muscle recordings with abnormal low amplitudes of the facial nerve at the third month was reevaluated at sixth postoperative month and the values were improved. CONCLUSIONS: This study demonstrated that facial nerve integrity is minimally affected after rhinoplasty, yet all affected muscles were recovered on the long term.

The relationship between the fistula tract and the facial nerve in type II first branchial cleft anomalies.

OBJECTIVE: To share our experience involving seven patients with type II first branchial cleft anomalies (hereafter, type II anomalies), to determine whether the location of the external fistula openings of the anomalies are associated with the location of the facial nerve tract, and elucidate the relationship between the location of the fistula opening and the facial nerve. METHODS: The medical records of seven patients who underwent surgery from 2005 to 2013 for type II anomalies were retrospectively examined. The relationship between the fistula opening and the facial nerve was evaluated in each patient with respect to whether the fistula opening was superior or inferior to the mandibular angle. All patients underwent partial parotidectomy, facial nerve exposure, and total excision of the mass together with connection of a small cuff of the external auditory canal skin to the fistula tract. RESULTS: The fistula tracts were located medially to the facial nerve in two patients, and both fistulae had openings inferior to the mandibular angle. The fistula tracts were located laterally to the facial nerve in the remaining five patients: one patient had no external opening, one had an opening inferior to the mandibular angle, and the remaining three had openings superior to the mandibular angle. CONCLUSION: Because type II anomalies are rare, their diagnosis is difficult. Surgery of such lesions is challenging and associated with a high risk due to their proximity to the facial nerve. We believe that the location of the fistula opening may help to identify the relationship between the anomalous lesion and facial nerve. Studies involving larger series of cases are needed to confirm our hypothesis; however, because of the rarity of this specific anomaly, it will not be easy to compile a large number of cases. We believe that our study will encourage further investigation on this subject.

Intraoperative ultrasonography is useful in surgical management of neck metastases in differentiated thyroid cancers.

Differentiated thyroid carcinomas are the most common malignancies of endocrine organs. Metastases to cervical lymph nodes occur in 20-50% of cases. Recurrence and survival rates are closely related to the type of surgery performed. High-resolution ultrasonography (USG) is a sensitive imaging method used to detect occult lymph node metastases in patients with thyroid cancer. We evaluated how intraoperative USG affected surgical success. This was a retrospective study comparing two groups of patients with thyroid carcinoma who underwent cervical lymph node dissection. A total of 101 patients (33 males and 68 females) were included. Group 1 included 53 patients who underwent surgery with intraoperative USG guidance. Group 2 included 48 patients who underwent surgery without the use of USG. All patients were followed up (mean 23 months; range 5-44 months) with thyroglobulin measurements and USG evaluations. Group 1 (intraoperative USG) had a residual/recurrent tumor rate of 1.9% (1/53 patients). Group 2 had a residual/recurrent tumor rate of 12.5% (6/48 patients). A statistically significant difference appeared between the residual/recurrent tumor rates in Groups 1 and 2 (p<0.05). In addition to its classical use in diagnosis and follow-up, intraoperative use of high-resolution USG can improve surgical success and may decrease the number of residual/recurrent tumors encountered during follow-up.

Open functional neck dissection: surgical efficacy and electrophysiologic status of the neck and accessory nerve.

OBJECTIVE: To compare a novel functional neck dissection technique that offers wider exposure and reduced morbidity compared to classic functional neck dissection, which is the gold standard for neck treatment of squamous cell carcinoma of the head and neck. STUDY DESIGN: A prospective, double-blind, controlled clinical study. SETTING: Fifty surgical neck dissections were performed on 25 patients diagnosed with laryngeal cancer. SUBJECTS AND METHODS (MAIN OUTCOME MEASURES): The open neck dissection technique was used on the primary tumour side (study group) and functional neck dissection was used on the other side (control group). Electromyographic measurements of the trapezius and sternocleidomastoid muscles and neurologic evaluations were performed preoperatively and at 1 and 6 months postoperatively. Also, the number and tumour stages of lymph nodes excised during neck dissection were evaluated by histopathologic examination as a measure of surgical efficacy. RESULTS: The electromyographic measurements of the study group at 1 and 6 months postoperatively were found to be superior to those of the control group, although the difference between the groups was not significant. The mean number of dissected lymph nodes was significantly higher in the study group than in the control group. CONCLUSION: The open functional neck dissection procedure described in this study allows wider exposure, reduces the acute morbidity associated with the spinal accessory nerve compared to classic modified neck dissection, and offers improved surgical efficacy with respect to lymphadenectomy.

[Total thyroidectomy in benign thyroid diseases]. / Selim tiroid hastaliklarinda total tiroidektomi.

OBJECTIVES: In this retrospective study, we reviewed the data from patients who had total thyroidectomy for benign thyroid disease and evaluated the safety of this surgery. PATIENTS AND METHODS: Three hundred and twenty three patients (49 males, 274 females; mean age 42.6+/-14.1 years; range 13 to 80 years) who underwent total thyroidectomy between 2002 and 2008 were included in the study. In the preoperative studies, patients with suspicion of thyroid cancer were excluded. Indications for total thyroidectomy, cancer incidence and complication rates were evaluated. Two hundred and eighty three patients (87.6%) were operated on due to bilateral multinodular goiter, 17 (5.3%) due to toxic goiter, 23 (7.1%) due to thyroiditis. RESULTS: In our study, it was found that the incidences of permanent recurrent laryngeal nerve palsy and permanent hypoparathyroidism were 0.6% and 1.86%, respectively. Postoperative hemorrhage requiring repeat surgery occurred in 0.6% of the patients. There was no recurrence during follow-up. CONCLUSION: The present study shows that total thyroidectomy is a safe procedure with a low incidence of permanent complications. Total thyroidectomy is an acceptable surgical alternative for benign multinodular or diffuse goiters.