Louise Rochon

Occult Cervical Metastases: Immunoperoxidase Analysis of the Pathologically Negative Neck:

OBJECTIVES: The purpose of this study is to better estimate the true incidence of occult regional metastases associated with stage I and II squamous cell carcinoma of the oral cavity. The clinical and prognostic significance of micrometastatic disease discovered by cytokeratin immunoperoxidase reactivity in the previously pathologically N0 neck is also evaluated. METHODS: Forty patients treated between 1985 and 1996 with T1 or T2 squamous cell carcinoma of the lip and oral cavity were studied. All had primary surgical treatment including functional neck dissection. No metastases were demonstrated on hematoxylin and eosin microscopy. All specimens were reexamined with immunoperoxidase staining for cytokeratin. RESULTS: Five percent of patients had micrometastatic disease. Retrospective analysis of patients with a minimum follow-up of 2 years has failed to show a statistically significant association between a positive cytokeratin analysis and poor locoregional control or overall survival. CONCLUSIONS: Results suggest that the true incidence of occult metastases with carcinoma of the oral cavity is significantly higher than previously documented. However, the prognostic significance of these findings remains unclear.

Sarcomatoid carcinoma of the head and neck

BACKGROUNDnSarcomatoid carcinoma (SC) of the upper aerodigestive tract is a rare malignancy of which the diagnosis, optimum treatment, and prognosis remain controversial. A series of 17 patients with SC is presented, along with an analysis of potential prognostic factors, outcome following treatment, and patterns of failure.nnnMATERIALS AND METHODSnHospital charts and pathology material were reviewed in all cases. The end points chosen were overall survival (OS), disease-free survival, and local control above the clavicles.nnnRESULTSnThere were 15 male and 2 female patients with a median age of 70 years. With a median follow-up length of 29 months, the median survival time was 32 months with an actuarial survival of 72% and 42% at 2 and 5 years, respectively.nnnCONCLUSIONnAll recurrences were detected within 30 months from diagnosis. There was an OS advantage for patients with early-stage disease, patients with extralaryngeal presentations, and patients treated with surgery.

Skin Metastases in Squamous Cell Carcinoma of the Head and Neck

Distant metastases in squamous cell carcinoma of the head and neck (SCCHN) are most often to the lung, liver, and bone. SCCHN rarely metastasizes to skin sites. OBJECTIVE: To ascertain the significance of skin metastases (SM) on the prognosis of patients with SCCHN. METHODS: A retrospective review of all patients between 1987 and 1999 with SCCHN was conducted. Patients in whom SM developed were identified. Data pertaining to demographics, primary tumor staging, SM development, and outcome were investigated. RESULTS: In 798 consecutive patients diagnosed with SCCHN between 1987 and 2000, 19 developed SM. The average time of onset of the SM was 17.65 months. The average survival time was 7.2 months after the development of SM. The overall survival time of patients who developed SM from the initial presentation of the primary tumor was 24.85 months. The 1-year survival rate from the time of development of SM was 0%. CONCLUSIONS: Metastasis to skin sites is an uncommon feature of SCCHN. SM may represent the first clinical evidence of impending loco-regional recurrence or distant metastasis. The development of SM is an ominous sign associated with an extremely poor prognosis, similar to the development of distant metastasis at more typical sites. Both the development of SM and survival of patients developing SM are independent of primary tumor stage. Current treatment options of SM are limited in their efficacy.

Carcinoma in situ of the glottic larynx: excision or irradiation?

The management of glottic carcinoma in situ (CIS) is controversial, with vocal cord stripping (S) generally accepted as the standard treatment, and radiotherapy (RT) as an alternative. We present our experience with 34 patients treated by either stripping or RT.

Coexistence of Malignant Struma Ovarii and Cervical Papillary Thyroid Carcinoma

CONTEXTnStruma ovarii is an uncommon monodermal teratoma in which thyroid tissue is the predominant element. Malignant transformation of struma ovarii is an even rarer occurrence.nnnCASE PRESENTATIONnWe describe a 42-year-old woman who underwent a total abdominal hysterectomy and bilateral salpingo-oophorectomy for a symptomatic left pelvic mass. Histology revealed malignant struma ovarii with classical papillary thyroid carcinoma expression. Ultrasonography of the cervical neck showed thyroid micronodules and a dominant 1-cm nodule in the left thyroid lobe. As the ovarian tumor was large, the patient underwent a total thyroidectomy with the intention of administering ¹³¹I therapy in an adjuvant setting. Histology of the cervical thyroid gland revealed bilateral multifocal papillary thyroid carcinoma with extrathyroidal extension and perithyroidal lymph node metastasis.nnnMETHODSnMorphological (microscopy), immunohistochemical (Hector Battifora mesothelial cell 1, cytokeratin-19, galectin-3), and molecular (BRAF V600E, RAS, RET-PTC) characteristics and clonality analysis of the cervical thyroid and ovarian tumors were explored to distinguish them as separate malignancies.nnnRESULTSnThe thyroid-type tumors from the cervical gland and ovary were discordant in terms of tissue histology and level of cytokeratin-19 expression. The clinical features and tumor profile results supported the independent existence of these two embryologically related, although topographically distinct, malignancies.nnnCONCLUSIONnOur findings provided support for synchronous, albeit distinct, primary tumors in the ovary and cervical thyroid. Field cancerization and early genomic instability may explain multifocality in all thyroid-type tissue. In this regard, patients with malignant struma ovarii should undergo imaging of their thyroid gland for coexisting disease and thyroidectomy recommended for suspected malignancy or in preparation for radioiodine therapy.

Intraoperative parathyroid hormone level in parathyroidectomy: which patients benefit from it?

BackgroundIntraoperative parathyroid hormone level (IOPTH) is withdrawn during parathyroidectomy to confirm the success of the procedure. Recently, the importance of IOPTH has been put to question. The purpose of this study is to determine whether IOPTH is necessary for all patients undergoing parathyroidectomy in the presence of frozen section.Materials and methodsA cohort study of parathyroidectomies was performed in three university affiliated hospitals during 2007-2012. The patients were divided into two groups. Group 1: Patients with two preoperative concordant imaging localizing a hyperactive gland. Group 2: Patients without two concordant imaging. A comparison of benefit of IOPTH was carried out. Frozen section results were also analyzed to determine sensitivity and predictability of a parathyroid adenoma.ResultsThe study considered 221 patients having parathyroidectomies for primary hyperparathyroidism (PHPT). Of them, 10 were excluded due to incomplete data. Among the remaining, 186 had 2 concordant imaging preoperatively localizing an adenoma. 93.5% of whom were found intraoperatively in that location. IOPTH was not found to be of importance in 98.92% of the preoperative localized adenomas in the presence of frozen section. IOPTH added an estimate of 30.9xa0minutes on average to the surgery time.ConclusionThis study demonstrates that the added operating time associated with IOPTH may not be justified for patients undergoing parathyroidectomy who have 2 concordant imaging preoperatively in the presence of frozen section. This study suggests a simple algorithm, The McGill Parathyroid Protocol (MPP), to help in approaching PHPT patients undergoing parathyroidectomy.

The Mcgill thyroid nodule score - does it help with indeterminate thyroid nodules?

BackgroundUltrasound guided fine-needle aspiration (USFNA) biopsy of thyroid nodules often gives a result of indeterminate pathology, placing thyroid specialists in difficult management situations. The aim of this study is to evaluate the incidence of malignancy in patients undergoing surgery and to correlate these results with the McGill Thyroid Nodule Score (MTNS).MethodsWe performed a retrospective study comparing USFNA results, MTNS and histopathology of patients undergoing thyroid surgery between 2010 and 2012. Pre-operative USFNA results were divided into three subgroups: benign, indeterminate and suspicious for/malignant. The indeterminate USFNA subgroup comprised of Bethesda type III (atypia of undetermined significance) and Bethesda type IV (follicular neoplasms, including Hurthle cell neoplasms) lesions. Post-operative histopathology was divided into benign or malignant groups.ResultsOf the 437 patient charts reviewed, 57.0% had an indeterminate USFNA biopsy. Within the indeterminate group, the malignancy rate was 39.8%. For indeterminate USFNA, the median MTNS was 7 (32% risk of malignancy) for benign nodules and 9 (63% risk of malignancy) for malignant nodules on post-operative histopathology (pu2009<u20090.05).ConclusionThe rate of malignancy in operated patients with an indeterminate USFNA result was 39.8%. The MTNS can be of value to thyroid specialists in pre-operative decision-making when dealing with an indeterminate result of a thyroid nodule on USFNA.

The McGill Thyroid Nodule Score’s (MTNS+) role in the investigation of thyroid nodules with benign ultrasound guided fine needle aspiration biopsies: a retrospective review

BackgroundUltrasound guided fine needle aspiration (USFNA) biopsies of thyroid nodules sometimes create a decision-making dilemma for surgeons as they may yield falsely benign results. The McGill Thyroid Nodule Scoreu2009+u2009(MTNS+) was developed to aid in clinical guidance regarding the management of patients with these USFNA results. The aim of this study was to assess the MTNS+ as a clinical tool in patients with benign preoperative thyroid nodule USFNAs and to analyze the relationship between nodule size and malignancy in these patients.MethodsWe conducted a retrospective chart review of 1312 patients who underwent thyroidectomies between 2010 and 2015 at the McGill University Teaching Hospitals. Patients with Bethesda II (benign) USFNA results, calculated MTNS+, and nodule size evaluated on ultrasound were included in the study. The false-negative rate was calculated, and MTNS+ and nodule size were each compared to final pathology results. Binary logistic regression was used for statistical analysis.ResultsOf the 1312 patients, 101 met the inclusion criteria and together had an average MTNS+ score of 6.83, which corresponds to a predicted malignancy rate between 25 and 33xa0%. Final pathology revealed malignancy in 16 (15.8xa0%) subjects. The average MTNS+ of patients with malignant nodules on surgical pathology was 8.25, while that of patients with benign nodules was 6.56.Patients with nodule size 1–1.9xa0cm (a) and 2–2.9xa0cm (b) each had an equal rate of malignancy of 2.97xa0% (nu2009=u20093), nodule size 3–3.9xa0cm (c) had a rate of 1.98xa0% (nu2009=u20092), and nodule size ≥4xa0cm (d) a rate of 7.92xa0% (nu2009=u20098).ConclusionThe rate of malignancy (15.8xa0%) is higher than expected when reviewing the risk of malignancy in nodules considered as Bethesda class 2. On the other hand, the rate is lower than the 25–33xa0% predicted by the MTNS+. We also found a higher malignancy rate for nodules above 4xa0cm in size, but size was a poor predictor of malignancy when used alone. Therefore, while the MTNS+ may be helpful at helping to identify USFNAs that are incorrectly classified as benign, the percentage risk of malignancy is lower than expected.

The role of repeat fine needle aspiration in the management of indeterminate thyroid nodules

BackgroundManagement decisions are not straightforward when the Ultrasound Guided Fine Needle Aspiration (USFNA) demonstrates a Bethesda score of either category III or IV, and a diagnostic hemi-thyroidectomy or a repeat USFNA (r-USFNA) could be performed. The aim of this study is to assess the effectiveness of r-USFNA in the management of indeterminate thyroid nodules by evaluating the likelihood of obtaining a definite diagnosis.MethodsWe reviewed the medical records of all patients with thyroid nodules between 2011 and 2015 at the Jewish General Hospital (Montreal, Canada). Three hundred fifty-one patients who had undergone a surgical procedure (hemi or total thyroidectomy) and a diagnosis of B3 or B4 on the primary USFNA (p-USFNA) were included in the study. Ninety-six of the included patients also had a repeat USFNA prior to the surgery. Demographic data, type of procedure, and McGill Thyroid Nodule Score (MTNS) were obtained from the medical records. Malignancy rates were calculated based on the final surgical histopathology report.ResultsUpon r-USFNA, an average 76xa0% of patients did not change Bethesda categories, 7.4xa0% downgraded to a benign category. The results showed that, on an average 17.3xa0% of patients with p-USFNA of B3 and 20xa0% of patients with p-USFNA of B4, upgraded to a malignant or suspicious for malignancy category, thus changing the clinical management to total thyroidectomy. Our data demonstrates that r-USFNA facilitates choosing the correct surgery of total thyroidectomy in about 20xa0% of nodules that have upgraded from B3/B4 to a more definite malignant category.Conclusionsr-USFNA in patients with indeterminate diagnoses (B3 or B4) increases categorization into more definite categories. Approximately 20xa0% of patients are found to have malignant thyroid nodules and suspicious for malignancy thyroid nodules upon repeating the biopsy, hence a diagnostic hemi-thyroidectomy was avoided and a more definitive surgery could be performed. Furthermore, repeat USFNA results in a fewer number of hemi-thyroidectomy and completion thyroidectomy procedures.

Ultrasound-guided fine-needle aspiration of thyroid nodules: Does size matter?

PURPOSEnSome authors have questioned the benefit of fine-needle aspiration (FNA) of thyroid nodules ≥ 4 cm. They report that the results of the FNA are not as reliable when compared to nodules <4 cm. The aims of this study are to evaluate the accuracy and predictive values of ultrasound-guided FNA (USFNA) of thyroid nodules ≥ 4 cm and compare these findings to nodules <4 cm.nnnMETHODSnA retrospective study of 998 patients who underwent thyroid surgery between 2006 and 2012 at the McGill University Thyroid Cancer Center was performed. USFNA and post-operative pathology diagnoses of nodules ≥ 4 cm versus those <4 cm were compared. Pre-operative USFNA results were divided into three groups: benign, indeterminate, and malignant/suspicious for malignancy subgroups. Post-operative results were separated into benign and malignant groups.nnnRESULTSnThere were 225 patients with nodules ≥ 4 cm and 773 patients with nodules <4 cm. The sensitivity, specificity, positive predictive value and negative predictive value for USFNA of nodules ≥ 4 cm were 84.62% (CI 71.91-93.10), 91.49% (CI 79.6-97.58), 91.67% (CI 80.0-97.63) and 84.31% (CI 71.4-92.95), respectively. The sensitivity, specificity, positive predictive value and negative predictive value for USFNA of nodules <4 cm were 90.48% (CI 86.1-93.8), 85.92% (CI 75.6-93.02), 95.8% (CI 92.41-97.96) and 71.76% (CI 60.95-81.0), respectively. The difference in diagnostic accuracy of USFNA between both groups was not statistically significant (p>0.05).nnnCONCLUSIONnThis study shows that the sensitivity, specificity, positive predictive value and negative predictive value for USFNA of nodules ≥ 4 cm are similar to that of smaller nodules. It is therefore suggested that these nodules undergo USFNA.