The importance of central compartment elective lymph node excision in the staging and treatment of papillary thyroid cancer.

OBJECTIVE: To determine the incidence of nodal involvement and assess the role of elective lymph node (LN) exploration and/or dissection in staging of tumors and treatment of patients with papillary thyroid cancer. DESIGN: Retrospective medical chart review. SETTING: Academic tertiary care medical center. PATIENTS: One hundred patients diagnosed with papillary thyroid cancer by fine-needle aspiration or intraoperative frozen section who underwent total thyroidectomy with central compartment cervical LN exploration. MAIN OUTCOME MEASURE: Incidence of positive LNs in patients 45 years or older (group A) vs those younger than 45 years (group B). RESULTS: Sixteen (39%) of 41 patients in group A had positive LN status following LN exploration and/or dissection. Seventeen (29%) of 59 patients in group B were found to have positive LNs. According to the American Joint Committee on Cancer staging system, the tumors of 11 patients (28%) in group A would be restaged from stage I/II to stage III after establishment of the positive pathologic nodal status. CONCLUSIONS: Lymph node metastasis was present in the central compartment in 39% of patients in group A. Presence of LN metastasis in older patients has been reported to increase the risk of recurrence of papillary thyroid carcinoma. Furthermore, recurrence and reoperation in the central compartment is associated with a higher risk of vocal cord paralysis. In patients in group A diagnosed with papillary thyroid carcinoma, routine central compartment LN exploration and/or dissection at the time of thyroidectomy is advocated, which allows more accurate staging of tumors and appropriate treatment. Elective excision of central compartment LNs in this older age group may improve locoregional control and possibly reduce morbidity in the long run.

Surgical anatomy of the recurrent laryngeal nerve revisited.

OBJECTIVES: Previous anatomic studies of the recurrent laryngeal nerves (RLNs) have described the variability in the course of the RLN. The anatomy of the nerve appears more constant along its distal segment near the cricothyroid joint, which is our surgical approach to the initial identification of the nerve. Understanding the topographical anatomy of the nerve in this region facilitates quick and safe nerve identification. The surgical topographical anatomy of the nerve in this region has not been studied in detail, which is the focus of this study. METHODS: A total of 278 RLNs in 190 patients were dissected during thyroidectomy and/or parathyroidectomy. The course of the nerve was recorded, paying particular attention to the directional course along its distal portion. The angle in which it coursed in relationship to a line paralleling the tracheoesophageal groove was determined. RESULTS: All 278 nerves were identified. Seventy-eight percent of the right-sided nerves coursed between 15 and 45 degrees, and 77% of the left-sided nerves coursed between 0 and 30 degrees. It appears that the nerve is more likely to travel at a more obtuse angle with right-sided RLNs and in patients with a low-lying cricoid. There was no permanent postoperative RLN palsy, and the incidence of temporary palsy was 1%. CONCLUSIONS: Approaching the nerve along its distal portion is safe and effective. The surgical topographical anatomy in this region is described in detail. Some of the potential advantages of identifying the nerve more distally include less chance of disrupting the blood supply to the inferior parathyroid gland, dissection along a shorter portion of the nerve, and less variability of the nerve.

Improvement in the detection of locoregional recurrence in head and neck malignancies: F-18 fluorodeoxyglucose-positron emission tomography/computed tomography compared to high-resolution contrast-enhanced computed tomography and endoscopic examination.

OBJECTIVES/HYPOTHESIS: To compare the diagnostic efficacy of positron emission tomography (PET) with F-18 fluorodeoxyglucose (FDG-PET)/computed tomography (CT) to that of contrast-enhanced high-resolution CT (HRCT) and assess the value of a combinatorial approach in detection of recurrent squamous cell cancer of the head and neck (HNC) and to assess the efficacy of FDG-PET/CT with and without HRCT in comparison to standard-of-care follow-up--physical examination (PE) and endoscopy (E)--in determination of locally recurrent HNC. STUDY DESIGN: Retrospective study. METHODS: A total of 103 patients with HNC underwent FDG-PET/CT and neck HRCT. There were two groups of patients: Group A had an FDG-PET study acquired with low-dose CT, and group B had an FDG-PET study acquired with HRCT. The PET data obtained with or without HRCT were compared on a lesion and patient basis with the results of the PE/E. RESULTS: On a lesion basis, both groups combined had higher sensitivity and negative predictive value (NPV) than the HRCT. Specificity and positive predictive value (PPV) for group B were higher than for group A. On a patient basis, both groups combined had a higher sensitivity and NPV than PE/E, respectively, although specificity of PE/E was higher than that of either group. PET data obtained with either protocol directly influenced treatment. CONCLUSIONS: HRCT increases the specificity and PPV of PET/CT when acquired simultaneously with PET. FDG-PET/CT acquired with either LDCT or HRCT has higher accuracy than HRCT alone and increases the sensitivity and NPV of PE/E.

Facial transplantation: the next frontier in head and neck reconstruction.

Facial reconstruction poses a unique surgical challenge-restoring the aesthetic form and function of the face. Established techniques for reconstruction include skin grafts, local cutaneous tissue flaps, and free flap autografts. The anatomic complexity of the face renders it challenging, however, to obtain a successful cosmetic and functional result. The success of recent hand, knee joint, and larynx allotransplantation and advances in immunosuppressive regimens have pushed the technical frontiers of composite tissue transfer to include partial facial transplantation. This article reviews current techniques for reconstruction of facial defects, with a focus on the microsurgical, immunologic, and ethical considerations of facial allotransplantation.

The diagnostic and prognostic utility of positron emission tomography/computed tomography-based follow-up after radiotherapy for head and neck cancer.

BACKGROUND: The detection of subclinical head and neck cancer recurrence or a second primary tumor may improve survival. In the current study, the authors investigated the clinical value of a follow-up program incorporating serial (18)F-fluorodeoxyglucose-positron emission tomography integrated with computed tomography (PET/CT) in the detection of recurrent disease in patients with head and neck cancer. METHODS: A total of 240 PET/CT scans were reviewed in 80 patients with head and neck cancer who were treated with radiotherapy (RT) from July, 2005 through August, 2007. All patients were followed with clinical examination, PET/CT, and correlative imaging for a minimum of 11 months (median follow-up, 21 months). RESULTS: The sensitivity, specificity, and positive and negative predictive values of PET/CT-based follow-up for detecting locoregional recurrence were 92%, 82%, 42%, and 98%, respectively. Corresponding values for distant metastases or second primary tumors were 93%, 96%, 81%, and 98%, respectively. Eight patients (10%) developed disease recurrences or second primary tumors that were amenable to salvage surgery with negative surgical margins. The 2-year progression-free survival and 2-year overall survival rates were significantly different between patients who had a negative and those with a positive PET/CT result within 6 months of the completion of RT (93% vs 30% [P<.001] and 100% vs 32% [P<.001], respectively). CONCLUSIONS: Although post-therapy follow-up using PET/CT is reportedly associated with a high false-positive rate in the irradiated head and neck, PET/CT appears to be a highly sensitive technique for the detection of recurrent disease. Furthermore, negative PET/CT results within 6 months of the completion of RT offer significant prognostic value.