Joseph N. Attie

Preservation of parathyroid glands during total thyroidectomy: Improved technic utilizing microsurgery☆

An improved technic for total thyroidectomy, utilizing magnification, is described. A method of preservation of the parathyroid glands with intact blood supply has been developed. The completeness of total thyroidectomy has been confirmed in 91 per cent of patients studied by postoperative radioactive iodine scan.

Feasibility of total thyroidectomy in the treatment of thyroid carcinoma: Postoperative radioactive iodine evaluation of 140 cases☆

The objective of this study was to evaluate our experience with so-called total thyroidectomy. Fifty cases (the retrospective group) had been operated on before the start of the study and had been on thyroid replacement therapy; this was discontinued, thyroid-stimulating hormone was administered, and iodine-131 studies were performed. Ninety cases (the prospective group) were evaluated 3 or more weeks postoperatively with no thyroid hormone having been administered. All patients were given 50 microcuries of iodine-131 and uptake studies were performed 24 hours later. All the patients were evaluated at a time when it was believed that practically all circulating hormone secreted by the thyroid gland before its removal had been metabolized or excreted from the body. If the patients with iodine-131 uptakes only in the region of the pyramidal lobe are considered to have had total thyroidectomy, we find that 85.7% of the patients studied had an uptake of less than 1.5%, and 96.4% had an uptake of less than 2.5%. There is increasing evidence to indicate that total thyroidectomy is the procedure of choice in the treatment of differentiated thyroid carcinoma. The present study indicates that with proper technique, total resection of the thyroid gland is feasible in nearly all cases of thyroid carcinoma.

Value of Fine Needle Aspiration Biopsy of Salivary Gland Masses in Clinical Decision-Making

The accuracy of fine needle aspiration biopsy (FNAB) in the diagnosis of salivary tumors has been well established. This study was undertaken to determine the impact of FNAB on patient management. One hundred one patients underwent FNAB of major salivary gland masses. The physicians initial clinical impression was compared with the FNAB diagnosis and the final diagnosis in each case. Forty patients had solitary masses thought to be benign tumors other than Warthins tumors. FNAB in 13 of these patients (33%) yielded a diagnosis permitting modification of the planned procedure. The diagnosis of Warthins tumor was suspected clinically in 23 patients. In nine of these patients (39%), FNAB resulted in a different diagnosis. Of the 10 patients believed to have malignant tumors, using FNAB, 1 was found to have sialadenitis and 1 a lymphoma. Overall, FNAB resulted in a change in the clinical approach to 35% of the patients. We recommend the performance of FNAB in almost all patients with salivary masses.

Elective radical neck dissection in epidermoid cancer of the head and neck. A retrospective analysis of 853 cases of mouth, pharynx, and larynx cancer

A retrospective analysis of 853 patients with cancer of the mouth, pharynx, and larynx operated on over a 30‐year period was performed. Four hundred fifty‐seven of them had a radical neck dissection (RND) at some point. Five hundred ninety patients had no clinically positive nodes (N‐o) necks at the time of primary treatment; 99 of these had elective neck dissection, whereas 95 others had a delayed RND when nodes became clinically involved. Twenty‐three percent of all N‐o patients had microscopically involved nodes and less than half of these were among those patients selected for elective RND. Furthermore, 58% of those patients who had elective RND did not have positive nodes. Comparative analysis of elective RND, delayed therapeutic RND after clinical appearance of nodes, and composite operations for patients with N1–N3 disease indicates little difference in disease‐free survival when the nodes in the elective RND were positive microscopically for tumors (56%, 49% and 47% respectively). It thus seems that elective RND offers no real advantage over a careful watchful waiting approach in most patients.

Initial failure of surgical exploration in patients with primary hyperparathyroidism

To determine the causes of failures of cervical exploration for primary hyperparathyroidism, we reviewed 892 patients operated on by one surgeon from 1953 to 1990. Twenty-seven patients (3%) remained hypercalcemic or developed hypercalcemia within 6 months of surgery. Of these, five patients had one adenoma removed initially; at reoperation, three patients had a second adenoma that was successfully removed, whereas the other two patients had hyperplasia and required subtotal parathyroidectomies. No enlarged parathyroid glands were identified in 22 patients. Eventually, six patients became normocalcemic spontaneously, seven patients underwent re-exploration with a successful outcome in all but one case, two patients had ectopic hyperparathyroidism associated with carcinoma elsewhere, and seven patients refused reoperation and remain hypercalcemic. The failure rate of surgical exploration for primary hyperparathyroidism can be reduced by systematically exploring all four parathyroid glands. All abnormal parathyroids should be removed with histologic verification. When no abnormal glands are found, localization studies should be performed before re-exploration.

Treatment of Warthin's tumor by enucleation

Among 162 patients with Warthins tumor, 113 had removal by enucleation. The others, in whom parotidectomy and facial nerve dissection were performed, were not suspected of having Warthins tumor preoperatively or had tumor too close to the facial nerve to be safely enucleated. Patients were generally older and more likely to be male than patients with other benign parotid tumors. Fifteen patients had multiple Warthins tumors at the time of initial presentation; in an additional 12 patients, Warthins tumor developed in the opposite parotid gland after the initial operation. In only two patients did an additional tumor develop in a gland from which a Warthins tumor had previously been enucleated. No permanent injuries to the facial nerve occurred. Because of the safety and efficacy with which enucleation can be performed and because the risk of malignant transformation of Warthins tumors is extremely small, we believe that enucleation is the treatment of choice in most cases.

Differential oncogenic expression in thyroid follicular and Hürthle cell carcinomas

Although Hürthle cell tumors are considered to be variants of follicular neoplasms, they have distinct cytologic and behavioral characteristics. To elucidate the basis for these differences, the expression of 5 oncogenes and growth factors (Pan-ras, N-myc, transforming growth factor-alpha [TGF-alpha], transforming growth factor-beta [TGF-beta], and insulin-like growth factor 1 [IGF-1]) was compared between 12 follicular carcinomas and 8 Hürthle cell carcinomas by immunocytochemistry. The percentage of follicular carcinomas and Hürthle cell carcinomas that stained positively for the different oncogenes was as follows and respectively: Pan-ras 8% versus 63%; TGF-alpha 17% versus 63%; TGF-beta 25% versus 88%; IGF-1 17% versus 88%; and N-myc 17% versus 100%. All these differences were highly significant by the chi 2 test. This difference in the expression of oncogenes between Hürthle cell carcinomas and follicular carcinomas suggests that these two tumors could, in fact, represent separate entities.

Parathyroid localization: Inability to predict multiple gland involvement

Preoperative localization using various imaging techniques can accurately predict the location of solitary parathyroid adenomas in about 75% of patients. Its value has been questioned because of the high success rate of parathyroid exploration without localization. The ability of localization studies to differentiate preoperatively between patients with solitary adenomas and those with multiple gland disease would be valuable because bilateral exploration might be avoided in many cases. Ultrasonography, thallium-201/technetium-99m subtraction scintigraphy, and magnetic resonance imaging were used to evaluate 16 patients with primary hyperparathyroidism who were ultimately found at surgery to have multiple enlarged parathyroid glands. No single imaging technique was able to identify more than 53% of enlarged glands, and only four patients were accurately predicted preoperatively to have enlargement of multiple parathyroid glands. Existing imaging techniques cannot be relied on to predict multiple gland involvement preoperatively. Bilateral surgical exploration is mandatory in all patients with primary hyperparathyroidism.

Preoperative localization of parathyroid adenomas

During a 12-month period, 64 patients were operated on for primary hyperparathyroidism. Sixty-one had single adenomas and 3 had double adenomas. Preoperative imaging was used to localize the adenomas. Half of the patients (32 of 64) had magnetic resonance, thallium-201/technetium-99m subtraction scintigraphy, and high-resolution ultrasonography; the other 32 patients had 1 or 2 of the imaging modalities. Sensitivity and specificity of magnetic resonance imaging was 82 percent and 97 percent, respectively; the sensitivity and specificity of the other two modalities was 59 and 98 percent for subtraction scintigraphy and 73 and 98 percent for ultrasonography. The use of preoperative imaging facilitated surgical exploration, reduced operating time, and resulted in an increased number of successful operations. There were no negative explorations in this series as compared with 19 negative explorations (2.6 percent) in our prior experience with 720 operations.

Thyroid carcinoma presenting as an enlarged cervical lymph node.

Differentiated thyroid cancer most commonly presents as a thyroid nodule. Cervical node metastases are commonly observed. In the present report, we describe the clinical presentation, pathologic findings, surgical approach, and follow-up of 43 patients in whom the initial presentation of thyroid cancer was that of an enlarged cervical lymph node. At surgery, 65% of the patients had additional lymph node involvement. The thyroid pathology was papillary carcinoma in all patients, and, in two thirds of patients, the thyroid primary was 1 cm or smaller in size. Forty patients underwent thyroidectomy and modified neck dissection; 3 were treated by thyroidectomy alone. One patient died of disease, 7 were lost to follow-up after 4 to 27 years, 5 died of unrelated causes, and the remaining 30 are alive and free of disease 1.5 to 33.5 years after surgery (mean: 14.8 years).