Aesthetics in Thyroid Surgery: The Patient Perspective.

Objectives To define characteristics that influence patient perceptions of thyroidectomy scar cosmesis. Study Design Prospective cohort study. Setting Tertiary endocrine surgery practice in an academic medical center. Subjects and Methods Institutional review board-approved trial in which 136 subjects were recruited from a population of patients being seen for either thyroid or sinus surgery and evaluated standardized photographs, superimposed with computer-generated thyroidectomy scars of varying lengths (2, 4, and 6 cm) and widths (1 and 2 mm), and graded their perception of the scars using the observer scar assessment scale (OSAS) domains of the patient and observer scar assessment scale. Results There were 69 subjects in the thyroid group and 67 in the nonthyroid group. Controlling for width, longer scars were perceived as worse than shorter scars; controlling for length, thicker scars were perceived as worse than thinner scars ( P < .01). Beyond 2 cm, thick scars were judged to be worse than thin scars, even when they were shorter. There was no difference in the mean overall OSAS scores between surgery, sex, or age groups. Nonwhites tended to judge scars as being worse than whites did ( P < .01). Conclusion As expected, patients of all demographics prefer shorter scars compared with longer scars and thinner scars over thick scars. Ethnic differences in scar perception were identified and deserve additional study. Surgeons should endeavor to perform thyroid surgery through the smallest incision that allows the operation to be performed safely to minimize the cosmetic impact of the operation.

Continuous Vagal Nerve Monitoring is Dangerous and Should not Routinely be Done During Thyroid Surgery.

INTRODUCTION: Laryngeal nerve monitoring has been increasingly embraced as a mechanism for mitigating the risk of nerve damage during thyroid and parathyroid surgery. Vagal nerve monitoring has recently been introduced as a potentially increased level of nerve integrity scrutiny. We sought to define the risks and benefits of this technology in a prospective analysis of a series of patients undergoing neck endocrine surgery. SETTING: High-volume academic endocrine surgery practice. METHODS: A prospective, non-controlled trial of continuous vagal nerve monitoring (CVNM) in a projected cohort of 20 non-randomly selected patients undergoing thyroid and parathyroid surgery was planned. A commercially available nerve monitoring system with automatic periodic stimulation was utilized for both laryngeal nerve monitoring and CVNM. Demographic data were obtained, and outcome variables included surgical procedures performed, pathology, complications, incremental time required to achieve CVNM, and benefits of monitoring and stimulation. RESULTS: The patient accrual was aborted after 9 surgeries (12 nerves monitored) because of two serious adverse events (hemodynamic instability and reversible vagal neuropraxia attributable to the monitoring apparatus). No other complications occurred. The time to establish monitoring ranged from 3 to 26 min, with a median of 6 min (representing 2.9-12.2 % of the total surgical procedural time). The stimulation clamp became dislodged 11 times in 5 cases and was replaced in 7 of those instances. Benefits of CVNM included recognition of reduced amplitude and increased nerve latency in two patients. CONCLUSIONS: We report the first evidence that CVNM may cause serious patient harm. This novel approach is invasive and threatens patient safety. Although it may occasionally provide meaningful information, the risk-benefit ratio does not favor widespread adoption.

Contemporary surgical techniques.

Recent technologic advances have engendered alternative and innovative approaches to thyroid surgery aimed at reducing cosmetic sequelae. Minimally invasive techniques via small anterior cervical incisions hidden in natural skin creases and remote access approaches that eliminate anterior neck incisions entirely have emerged as viable options for patients who regard cosmesis as a priority. The safe application of these techniques to both benign and malignant thyroid disease has been evaluated.

Advancements in computed tomography management of chronic rhinosinusitis.

BACKGROUND: Advances in cone beam computed tomography (CBCT) technology have allowed for reduction in radiation dosages as well as the miniaturization of CT scanner units. This has given rise to new applications for CT scanning, including point-of-care (POC) in-office and intraoperative applications. METHODS: A review of recent changes to radiological modalities as applied to otolaryngology-head and neck surgery was performed. A discussion of the physics, applications, and role of diagnostic imaging in the evaluation of chronic rhinosinusitis (CRS) is conducted. RESULTS: The adaptation of cone beam technology has allowed for the practical implementation of CT scanning at the bedside, be it in the clinic or operating room setting. CONCLUSION: Given their relative low cost, ease of storage, and low-dose radiation exposure, POC-CT scanners have become an indispensable tool in the diagnosis and treatment of CRS. In the setting of increasing antibiotic costs, overtreatment with antibiotics, and fewer required return visits, POC-CT challenges the conventional role of empiric medical therapy before progression to imaging for the diagnosis of CRS.

DEAR1 is a dominant regulator of acinar morphogenesis and an independent predictor of local recurrence-free survival in early-onset breast cancer.

BACKGROUND: Breast cancer in young women tends to have a natural history of aggressive disease for which rates of recurrence are higher than in breast cancers detected later in life. Little is known about the genetic pathways that underlie early-onset breast cancer. Here we report the discovery of DEAR1 (ductal epithelium-associated RING Chromosome 1), a novel gene encoding a member of the TRIM (tripartite motif) subfamily of RING finger proteins, and provide evidence for its role as a dominant regulator of acinar morphogenesis in the mammary gland and as an independent predictor of local recurrence-free survival in early-onset breast cancer. METHODS AND FINDINGS: Suppression subtractive hybridization identified DEAR1 as a novel gene mapping to a region of high-frequency loss of heterozygosity (LOH) in a number of histologically diverse human cancers within Chromosome 1p35.1. In the breast epithelium, DEAR1 expression is limited to the ductal and glandular epithelium and is down-regulated in transition to ductal carcinoma in situ (DCIS), an early histologic stage in breast tumorigenesis. DEAR1 missense mutations and homozygous deletion (HD) were discovered in breast cancer cell lines and tumor samples. Introduction of the DEAR1 wild type and not the missense mutant alleles to complement a mutation in a breast cancer cell line, derived from a 36-year-old female with invasive breast cancer, initiated acinar morphogenesis in three-dimensional (3D) basement membrane culture and restored tissue architecture reminiscent of normal acinar structures in the mammary gland in vivo. Stable knockdown of DEAR1 in immortalized human mammary epithelial cells (HMECs) recapitulated the growth in 3D culture of breast cancer cell lines containing mutated DEAR1, in that shDEAR1 clones demonstrated disruption of tissue architecture, loss of apical basal polarity, diffuse apoptosis, and failure of lumen formation. Furthermore, immunohistochemical staining of a tissue microarray from a cohort of 123 young female breast cancer patients with a 20-year follow-up indicated that in early-onset breast cancer, DEAR1 expression serves as an independent predictor of local recurrence-free survival and correlates significantly with strong family history of breast cancer and the triple-negative phenotype (ER(-), PR(-), HER-2(-)) of breast cancers with poor prognosis. CONCLUSIONS: Our data provide compelling evidence for the genetic alteration and loss of expression of DEAR1 in breast cancer, for the functional role of DEAR1 in the dominant regulation of acinar morphogenesis in 3D culture, and for the potential utility of an immunohistochemical assay for DEAR1 expression as an independent prognostic marker for stratification of early-onset disease.

Glutathione S-transferase polymorphisms and risk of second primary malignancy after index squamous cell carcinoma of the head and neck.

Glutathione S-transferases (GST) detoxify carcinogens in tobacco smoke, which plays a major role in development of not only squamous cell carcinoma of the head and neck (SCCHN) but also second primary malignancy (SPM) after index SCCHN. We hypothesized that GSTM1 null, GSTT1 null, GSTP1 Ile(105)Val, and GSTP1 Ala(114)Val polymorphisms would individually and, more likely, collectively show an association with risk of SPM after index SCCHN. One thousand three hundred seventy-six incident SCCHN patients were prospectively recruited between May 1996 and December 2006, genotyped, and followed for SPM development. One hundred ten patients (8%) developed SPM: 43 (39%) second SCCHN, 38 (35%) other tobacco-associated sites, and 29 (26%) other non-tobacco-associated sites. Patients with GSTP1 Ile(105)Val polymorphism had a statistically significant association with risk of SPM development (adjusted hazard ratio, 1.7; 95% confidence interval, 1.1-2.5). However, no statistically significant associations were observed with GSTM1, GSTT1, or GSTP1 Ala(114)Val polymorphisms. After combining risk genotypes for all four polymorphisms, rates of SPM development with 0 to 1, 2, 3, and 4 risk genotypes were 6.4%, 8.4%, 10.9%, and 15.1%, respectively, and a stepwise increase in SPM risk was observed with increasing number of risk genotypes (P = 0.004 for trend). Patients with 3 to 4 risk genotypes had a 1.7-fold increased risk for SPM compared with patients with 0 to 2 risk genotypes (hazard ratio, 1.70; 95% confidence interval, 1.2-2.5). This large prospective cohort study supports a modestly increased risk of SPM after index SCCHN with GSTP1 Ile(105)Val polymorphism and an even greater risk of SPM with multiple combined GST risk genotypes.