Hisanori Sasai

Incidences of Unfavorable Events in the Management of Low-Risk Papillary Microcarcinoma of the Thyroid by Active Surveillance Versus Immediate Surgery

Background: The incidence of papillary microcarcinoma (PMC) of the thyroid is rapidly increasing globally, making the management of PMC an important clinical issue. Excellent oncological outcomes of active surveillance for low-risk PMC have been reported previously. Here, unfavorable events following active surveillance and surgical treatment for PMC were studied. Methods: From February 2005 to August 2013, 2153 patients were diagnosed with low-risk PMC. Of these, 1179 patients chose active surveillance and 974 patients chose immediate surgery. The oncological outcomes and the incidences of unfavorable events of these groups were analyzed. Results: In the active surveillance group, 94 patients underwent surgery for various reasons; tumor enlargement and the appearance of novel lymph node metastases were the reasons in 27 (2.3%) and six patients (0.5%), respectively. One of the patients with conversion to surgery had nodal recurrence, and five patients in the immediate surgery group had a recurrence in a cervical node or unresected thyroid lobe. All of these recurrences were successfully treated. None of the patients had distant metastases, and none died of the disease. The immediate surgery group had significantly higher incidences of transient vocal cord paralysis (VCP), transient hypoparathyroidism, and permanent hypoparathyroidism than the active-surveillance group did (4.1% vs. 0.6%, p < 0.0001; 16.7% vs. 2.8%, p < 0.0001; and 1.6% vs. 0.08%, p < 0.0001, respectively). Permanent VCP occurred only in two patients (0.2%) in the immediate surgery group. The proportion of patients on L-thyroxine for supplemental or thyrotropin (TSH)-suppressive purposes was significantly larger in the immediate surgery group than in the active surveillance group (66.1% vs. 20.7%, p < 0.0001). The immediate surgery group had significantly higher incidences of postsurgical hematoma and surgical scar in the neck compared with the active surveillance group (0.5% vs. 0%, p < 0.05; and 8.0% vs. 100%, p < 0.0001, respectively). Conclusions: The oncological outcomes of the immediate surgery and active surveillance groups were similarly excellent, but the incidences of unfavorable events were definitely higher in the immediate surgery group. Thus, active surveillance is now recommended as the best choice for patients with low-risk PMC.

Validation of the Acoustic Voice Quality Index in the Japanese Language

OBJECTIVES The Acoustic Voice Quality Index (AVQI) is a multivariate construct for quantification of overall voice quality based on the analysis of continuous speech and sustained vowel. The stability and validity of the AVQI is well established in several language families. However, the Japanese language has distinct characteristics with respect to several parameters of articulatory and phonatory physiology. The aim of the study was to confirm the criterion-related concurrent validity of AVQI, as well as its responsiveness to change and diagnostic accuracy for voice assessment in the Japanese-speaking population. STUDY DESIGN This is a retrospective study. METHODS A total of 336 voice recordings, which included 69 pairs of voice recordings (before and after therapeutic interventions), were eligible for the study. The auditory-perceptual judgment of overall voice quality was evaluated by five experienced raters. The concurrent validity, responsiveness to change, and diagnostic accuracy of the AVQI were estimated. RESULTS The concurrent validity and responsiveness to change based on the overall voice quality was indicated by high correlation coefficients 0.828 and 0.767, respectively. Receiver operating characteristic analysis revealed an excellent diagnostic accuracy for discrimination between dysphonic and normophonic voices (area under the curve: 0.905). The best threshold level for the AVQI of 3.15 corresponded with a sensitivity of 72.5% and specificity of 95.2%, with the positive and negative likelihood ratios of 15.1 and 0.29, respectively. CONCLUSIONS We demonstrated the validity of the AVQI as a tool for assessment of overall voice quality and that of voice therapy outcomes in the Japanese-speaking population.

Long-term histological outcomes of injected autologous fat into human vocal folds after secondary laryngectomy

OBJECTIVE: To histologically evaluate the long-term outcomes of autologous fat grafts after injection laryngoplasty in the human larynx. STUDY DESIGN AND SETTING: We injected liposuctioned fat for vocal fold augmentation in patients with vocal fold paralysis. We suctioned autologous fat from the low abdomen with an 18-G disposable needle and a 20-mL disposable syringe under negative pressure. This is different from the conventional liposuction technique and avoids the use of special equipment. In this article, we report the histological evaluation of 2 patients (patient 1: 12 months, patient 2: 41 months) who required total laryngectomy after autologous fat injection into the vocal folds. RESULTS: Histological examination revealed normal-appearing viable adipocytes with minimal inflammatory response in both patients. CONCLUSIONS: Our liposuctioned autologous fat injection histologically offered long-term improvement in patients with impaired glottal closure from vocal fold paralysis. (Otolaryngol Head Neck Surg 2005;132:685-688.)

Estimation of the lifetime probability of disease progression of papillary microcarcinoma of the thyroid during active surveillance

Background. We reported that a minority of patients with low‐risk papillary microcarcinoma of the thyroid showed disease progression during active surveillance and that older patients had significantly lower disease progression rates than younger patients. Here, we estimated lifetime (≤85 years old) probabilities of disease progression during active surveillance according to the age at presentation based on age decade‐specific disease progression rates. Methods. From 1993–2013, 1,211 low‐risk papillary microcarcinoma patients aged 20–79 years underwent active surveillance at Kuma Hospital. We calculated the disease progression rate at the 10‐year point of active surveillance for each age‐decade group (20s to 70s) with the Kaplan‐Meier method. The lifetime disease progression probability for each age group was calculated as (1 − cumulative probability of progression‐free survival calculated with age decade‐specific disease progression rates) until the patients reached their 80s (i.e., 85 years on average). Results. The age decade‐specific disease progression rates at 10 years of active surveillance were 36.9% (20s), 13.5% (30s), 14.5% (40s), 5.6% (50s), 6.6% (60s), and 3.5% (70s); the respective lifetime disease progression probabilities were 60.3%, 37.1%, 27.3%, 14.9%, 9.9% and 3.5% according to the age at presentation. Conclusion. The estimated lifetime disease progression probabilities of papillary microcarcinoma during active surveillance vary greatly according to the age at presentation.

The Acoustic Voice Quality Index Version 03.01 for the Japanese-speaking Population

OBJECTIVES We aimed to determine the most appropriate syllable number for analyzing the Acoustic Voice Quality Index for the Japanese-speaking population (AVQIv3-JP) and to validate AVQIv3-JP using the determined syllable number. METHODS First, we counted how many syllables should be included in each continuous speech (CS) sample to achieve time-balanced analysis between CS and sustained vowel samples using our previous dataset including 336 CS samples with 58 syllables. From the descriptive statistics of the counted syllable numbers, the most appropriate syllable number was identified. Subsequently, we performed validation procedures of AVQIv3-JP using our latest dataset including 455 recordings. RESULTS Thirty Japanese syllables were judged to be the most appropriate syllable number. The concurrent validity of the AVQIv3-JP using 30 syllables was confirmed by Spearmans rho of 0.873. Subsequently, the receiver operating characteristic analysis demonstrated the excellent discriminative capability of AVQIv3-JP, showing the area under the curve of 0.915. The AVQIv3s original threshold of 2.43 in the Dutch language corresponded to sensitivity and specificity of 64.6% and 97.3%, respectively. In the present study, a threshold of 1.41 achieved the best accuracy with balanced sensitivity and specificity of 84.4% and 85.6%, respectively. Furthermore, the 95th percentile of the control participants exhibited a threshold of 2.06, showing sensitivity and specificity of 72.1% and 93.8%, respectively, as well as reasonable positive and negative likelihood ratios of 11.7 and 0.298, respectively. CONCLUSION The AVQIv3 using 30 Japanese syllables is a reliable measurement tool for estimating the severity of voice quality and detecting abnormal voices.

Prognostic value of the 8th tumor-node-metastasis classification for follicular carcinoma and poorly differentiated carcinoma of the thyroid in Japan

Follicular thyroid carcinoma (FTC), a form of differentiated thyroid carcinoma, is the second most common malignancy arising from thyroid follicular cells. Recently, the tumor-node-metastasis (TNM) classification for differentiated thyroid carcinoma was revised from the 7th to the 8th edition. The diagnostic criteria for poorly differentiated carcinoma (PDC) were also updated in the latest World Health Organization (WHO) classification. In this study, we investigated whether these changes are appropriate for accurately predicting prognosis. Three hundred and twenty-nine patients diagnosed with postoperative pathologically confirmed FTC, who underwent initial surgery at our hospital between 1984 and 2004, were enrolled. For this study, patients were re-evaluated and diagnosed with FTC (N = 285) or PDC (N = 44) without typical nuclear findings of papillary thyroid carcinoma. For FTC, the 8th TNM classification was a more accurate predictor of prognosis than the 7th TNM classification. In the 8th TNM classification, cause-specific survival became significantly poorer from Stage I to IVB. The cause-specific survival of PDC based on the latest WHO classification was worse than, but did not significantly differ from, that of PDC based only on the former WHO classification. For PDC, neither of the TNM classifications could accurately predict prognosis. Taken together, we conclude that (1) the 8th TNM classification more accurately reflects the prognosis of FTC than the 7th TNM classification; (2) PDC based on the former WHO classification should be retained, at least in Japan; and (3) the TNM classification may not be suitable for predicting the prognosis of PDC.

A Case of Adult Otitis Media Presenting with Bone Conduction Hearing Loss Due to Mucoid Type Penicillin-resistant Streptococcus Pneumoniae

A 65-year-old man complained of severe otalgia, occipital pain, hearing loss and otorrhea was referred to our hospital. Otoscopic examination demonstrated hyperemia and bulging of the left ear drum. The bacteria isolated from otorrhea was a mucoid type of Streptococcus pnemoniae. It was also penicillin-resistant Streptococcus pneumoniae (PRSP). The patient was diagnosed as having mucoid otitis media. Intravenous administration of piperacillin sodium (PIPC) diminished otalgia, occipital pain and otorrhea. However, the patient continued complain of hearing loss and a sensation of ear fullness. Due to acute sensorineural hearing loss, the patient was administered steroids. Nevertheless, bone conduction hearing loss persisted. This is the first report of otitis media demonstrating not only the mucoid type of Streptococcus pnemoniae but also PRSP.