Disease Severity at Presentation in Patients with Disease-Related Mortality from Differentiated Thyroid Cancer: Implications for the 2015 ATA Guidelines.

BACKGROUND: The current trend of less aggressive treatment of low-risk differentiated thyroid cancer (DTC) patients was recently challenged by a study reporting >10% disease-related mortality (DRM) in low-risk patients ablated with radioiodine activities below 54 mCi. However, this study and others were limited by incomplete data on disease severity at presentation. Whether patients presenting with low-risk disease are at risk for disease-related mortality is crucial for planning current treatment strategies. METHODS: Patients with documented DRM from DTC were included from the Rabin thyroid cancer registry and the Davidoff Head and Neck cancer service databases. Disease characteristics at presentation, treatments, disease course, and cause of death were analyzed. RESULTS: Of 1374 patients whose charts were reviewed, 56 were confirmed to have died of DTC, and 53 had sufficient data for analysis. Median time from diagnosis to death was 9 years (range 1-36). Cause of death was related to distant metastases in 46 patients and aggressive neck disease in 7 patients. The median age at diagnosis was 62 years (range 22-83, 83% older than 45), and were initially categorized as American Thyroid Association high risk in 89% of cases (in 4 cases due to high thyroglobulin levels), intermediate risk in 6% (3 older patients with N1b disease), misclassification as benign in one case, and none was low risk. Most patients had an advanced disease stage (stage IV, 88%; III, 2%; II, 2%; I, 8%). All patients with stage I disease were <45 years, with aggressive features (1 poorly differentiated, 3 gross extrathyroidal extension). One patient with stage II disease was <45 years and had distant metastases. Detection of distant metastases occurred within the first year in 25 patients and during subsequent follow-up in 25 patients. Overall, aside from one patient who was misdiagnosed as having a benign follicular adenoma at presentation, all patients had aggressive disease features at presentation. CONCLUSION: None of the patients with DRM had low-risk features at presentation, supporting the current paradigm of less aggressive approach in the low-risk group. Studies analyzing mortality from thyroid cancer should stratify patients into the various risk categories based on full baseline data, including postoperative thyroglobulin levels.

The role of elective neck dissection in patients undergoing salvage laryngectomy.

BACKGROUND: We investigated the risk of neck metastases in patients undergoing salvage total laryngectomy in association with previous radiotherapy. METHODS: The medical records of 42 patients (51 neck specimens) with clinical N0 classification who underwent salvage total laryngectomy in 2 cancer centers were reviewed. Fourteen patients had previous radiotherapy to the central neck and 28 to the central and lateral neck. RESULTS: Staging before salvage total laryngectomy was similar in both groups. The risk of neck metastases in the central and central/lateral radiation groups was 12% and 18%, respectively (p = .69). Subgroup analysis revealed that 4 of 8 patients initially presenting with clinically N+ had neck metastases before surgery, versus 2 of 26 for those with clinically N0 (p = .015; relative risk [RR] = 4.67). The risk or metastases in the contralateral neck was 0 of 9. CONCLUSION: The risk of neck metastases in patients who undergo either central or central/lateral neck radiotherapy is similar. Elective neck dissection seems appropriate in patients undergoing SLR.

Hyperfunctioning intrathyroid parathyroid gland: a potential cause of failure in parathyroidectomy.

BACKGROUND: The surgical success rate of parathyroidectomy is 95%. However, in rare patients, ectopic hyperfunctioning parathyroid glands may be located in the thyroid but missed on imaging studies or during surgery. The aim of the present study was to evaluate the perioperative findings in 6 patients with intrathyroid parathyroid glands treated for hyperparathyroidism in our center over a 5-year period and to review the relevant literature. METHODS: Of the 426 patients who underwent parathyroidectomy for hyperparathyroidism between 1998 and 2003 in our center, 6 (1.4%) were found to have intrathyroid glands. Their files were reviewed for clinical features, surgical approach, intraoperative findings, parathyroid gland location, and morphologic and histopathologic characteristics. RESULTS: The group included 2 men and 4 women of mean age 66 years. The diagnosis in all patients was based on an increase in serum calcium concentration (10.1-13 mg/100 mL) and parathyroid hormone level (102-320 pg/mL). The clinical symptoms were kidney stones, gastrointestinal complaints, hypertension, and osteopenia. Localization studies included ultrasonography in all patients and sestamibi in 4. When the parathyroid glands were not identified, bilateral neck and mediastinum were explored. Adenoma was diagnosed histologically in 4 patients; 2 had a double adenoma. CONCLUSION: Intrathyroid parathyroid gland is a rare condition in patients with hyperparathyroidism. In these patients, imaging may miss the pathologic gland. Despite its rarity, the possibility of an intrathyroid parathyroid should be kept in mind, and, when meticulous bilateral exploration of the neck fails to identity the hyperfunctioning gland, the surgeon should consider hemithyroidectomy.

Acute parotitis as a complication of fine-needle aspiration in Warthin's tumor. A unique finding of a 3-year experience with parotid tumor aspiration.

OBJECTIVE/HYPOTHESIS: Fine needle aspiration (FNA) is an accurate, cost-effective tool for the study of salivary gland lesions. Although complications are extremely rare, salivary gland FNA can lead to hemorrhage, facial nerve injury, and cellulitis at the needle puncture site. Some studies suggest that FNA can cause infarction or metaplastic transformation of benign Warthin's tumors. We review our recent experience with FNA of the parotid gland, focusing on possible complications and pitfalls. STUDY DESIGN AND SETTING: The medical records of all patients who underwent FNA of the parotid gland from 2000 to 2002 in the Department of Otolaryngology-Head and Neck Surgery of a major tertiary-care referral center were reviewed. Cytological results were compared to the histological diagnosis and complications were recorded. RESULTS: Of the 256 lesions aspirated, 99 patients (39%), were cytologically diagnosed as benign tumors, including 31 (12%) Warthin's tumors, of which 16/17 resected and confirmed histologically. Five patients with Warthin's tumor had post-FNA parotitis and were treated accordingly. CONCLUSIONS: The combination of cystic spaces surrounded by oncocytic cells and a poor blood supply makes the tumor susceptible to infarction and inflammation. Our findings indicate that FNA is a strong and reliable tool in the investigation of the salivary glands. Nevertheless, when Warthin's tumor is clinically suspected on the basis of its location (tail of the parotid gland), cystic texture, patient sex (male) and age, one should consider parotitis as a possible complication. EBM RATING: C-4.

Expression of EGFR and Cerb-B2 as prognostic factors in cancer of the tongue.

Squamous cell carcinoma (SCC) of the tongue is sometimes associated with local recurrence and regional metastases despite adequate surgical excision. The present study sought to determine if epidermal growth factor receptor (EGFR) and Cerb-B2 expression has prognostic or predictive value in SCC of the tongue, as with other epithelial malignancies. The study sample comprised of 27 patients with carcinoma of the tongue who underwent partial glossectomy and neck dissection between 1990 and 1999. Average follow-up was 54 months. Specimens from 23 patients were analyzed for growth factor expression using monoclonal antibodies specific for EGFR and Cerb-B2. Findings were correlated with the clinical course. EGFR and Cerb-B2 were expressed in 34% and 17% of the specimens, respectively. There was a statistically significant correlation between EGFR expression and tumor differentiation, and a borderline correlation between Cerb-B2 expression and T stage. No association was found between growth factor expression and tumor depth, lymph node status, extracapsular invasion, recurrence, or survival. Overexpression of EGFR and Cerb-B2 cannot serve as a prognostic factor or predictor of survival and treatment success in SCC of the tongue.

The cytological and clinical value of the thyroid "follicular lesion".

BACKGROUND: The main limitation of fine-needle aspiration (FNA) is its limited distinction between neoplastic and benign lesions. We summarize our experience with thyroid nodules that were defined as follicular lesions by comparing the clinical and cytological features of the thyroid follicular lesions that were examined histologically to define the most reliable criteria of malignancy. METHODS: The medical records of all patients who underwent thyroid aspiration at Rabin Medical Center from 1999 to 2000 were reviewed for a diagnosis of follicular lesion that warranted surgery (N = 58). The cytology and pathology reports of the patients who met these criteria were reviewed and compared with the original reports. RESULTS: The incidence of malignancy in follicular lesions of the thyroid is about 26%. There was a significant correlation between a histologic diagnosis of carcinoma and the cytologic findings of nuclear grooves (P =.041), solid arrangement (P =.019), hypercellularity (P =.01), and hypercellularity to colloid amount ratio (P =.016). Nodular size was predictive of malignancy. No correlation was found between patient age or gender and tendency toward malignancy. CONCLUSIONS: The combination of cytological characteristics and the size of the nodule aspirate are predictive values of malignancy. We believe that every follicular lesion should be excised to obtain a definitive histological diagnosis based on capsular or vascular invasion.

Basaloid squamous carcinoma of the larynx.

BACKGROUND: Basaloid squamous cell carcinoma (BSCC) is a distinct variant of squamous cell carcinoma that was first described by Wain et al in 1986. Since then, about 160 cases have been reported in the literature. Only 40 cases have been described in the larynx. METHODS: Four cases of BSCC of the larynx treated in our department between 1986 and 2000 are presented. The clinical features, biological behavior, and histopathological and immunohistochemical characteristics of this uncommon tumor are described, and the relevant literature is reviewed. RESULTS: The main clinical presentation did not differ from other histological types of laryngeal carcinoma. The clinical course, however, was much more aggressive. All the patients received aggressive therapy including radical surgery and radiation. Two patients received chemotherapy. Two of the 4 patients presented died of distant metastasis shortly after diagnosis and treatment. CONCLUSIONS: The finding of this study with a limited number of patients supports previous reports suggesting that BSCC is a highly aggressive tumor that presents in older population with male predominance. The frequency of associated regional as well as distant metastases suggests that aggressive treatment is indicated and that systemic chemotherapy should be contemplated.

[Subglottic carcinoma].

Subglottic malignancies are rare. They constitute about 1% of laryngeal cancer. Most of these malignancies are squamous cell carcinoma. In this article were describe various definitions concerning the borders of the subglottic region. A summary of pathophysiology and behavior of cancer in this location is presented. The incidence of primary subglottic carcinoma is low. The origin of most cancers in this area is the glottic cancer that extends into the subglottic region. The tumor tends to spread through lymphatic channels to the paraglottic and preglottic (delphian) nodes and secondary to the jugular chain. The delayed diagnosis is due to the lack of symptoms in the early stage of the disease and the hidden location of the tumor. The presenting symptoms are usually dyspnea and stridor. Direct laryngoscopy is essential for early detection of the tumor and the use of CT and MRI is advocated. Therapy is usually radical. Total laryngectomy and radiation therapy have both been advocated. Between 1995 and 2000, 126 patients with laryngeal squamous cell carcinoma were presented to our department. Our experience in diagnosing and treating subglottic cancer in 4 patients is hereby described. The latest literature on the subject is reviewed.