Paul C. Bryson

Immunohistochemical Distinction of Follicular Thyroid Adenomas and Follicular Carcinomas

OBJECTIVES To use immunohistochemical (IHC) evaluation of proteins encoded by genes that were differentially expressed in follicular thyroid adenomas (FAs) vs follicular thyroid carcinomas (FTCs) to distinguish benign vs malignant follicular thyroid lesions. Multiple gene microarray studies suggest that benign and malignant follicular thyroid neoplasms have different gene expression profiles. DESIGN Immunohistochemical analysis of thyroid neoplasms, including FA (n = 62), FTC (n = 62), and follicular variant of papillary thyroid carcinoma (n = 58), using tissue microarrays. We evaluated antibodies galectin-3, autotaxin, intestinal trefoil factor 3 (TFF3), extracellular matrix metalloproteinase inducer (EMMPRIN), and growth arrest and DNA damage-inducible protein 153 (GADD153). We analyzed data for quantitative differences in IHC intensity and the percentage of positive cells between FAs and combined follicular carcinomas. Sensitivity and specificity analysis are reported, along with a dual-protein clinical algorithm. SETTING Academic tertiary care center. PATIENTS Adults with known follicular and papillary thyroid lesions that were surgically resected during the past 15 years. MAIN OUTCOME MEASURES Sensitivity and specificity of individual and combined antibodies for detecting benign from malignant lesions. RESULTS Quantitative analysis showed IHC validation of the gene expression differences noted in previously published microarray reports. A significantly higher percentage of FTC cells stained with galectin-3, EMMPRIN, and GADD153. Galectin-3 and EMMPRIN also showed a significantly higher intensity of staining in FTC cells. Compared with malignant lesions, TFF3 stained a greater cell percentage in FAs. Galectin-3 (sensitivity, 0.72; specificity, 0.62) and EMMPRIN (sensitivity, 0.63; specificity, 0.49) had the most promising diagnostic potential with a dual-protein sensitivity of 0.80 and specificity of 0.70. Autotaxin and GADD153 had overall higher sensitivities (0.88 and 0.82, respectively) but very poor specificities (0.02 and 0.21, respectively). CONCLUSIONS Protein expression data validate the pooled gene expression results that differentiate FTC from FA. Our results show promise for multiple-protein IHC analysis algorithms and their diagnostic ability. Future studies should focus on clinical translation of these molecular differences for the diagnosis of follicular thyroid neoplasms.

Type I gore-tex laryngoplasty for glottic incompetence in mobile vocal folds

OBJECTIVE To determine the effectiveness of gore-tex medialization thyroplasty for the management of glottic incompetence (GI) in patients with mobile vocal folds. METHODS Twenty patients with glottic incompetence (GI) and mobile vocal folds were retrospectively analyzed after gore-tex medialization laryngoplasty. Pre- and postoperative outcome measures including grade, roughness, breathiness, asthenia, strain of the voice (GRBAS), glottal function index (GFI), and voice-related quality of life (VRQOL) were compared to detect surgical effectiveness. Two anesthetic subgroups were identified and compared: general anesthesia, via laryngeal mask airway (LMA) anesthetic, and local anesthesia. RESULTS Statistically significant differences were identified between pre- and postoperative VRQOL (P<0.0001), GFI (P<0.01), and composite GRBAS (P<0.0001) after a mean follow-up time of 7.8 months. Both the LMA and the local anesthetic subgroups demonstrated similar significance across these measures. GFI and VRQOL scores demonstrate a moderate correlation (ρ=0.71). Perceptual voice quality (GRBAS) correlates slightly better with VRQOL scores (ρ=-0.6; P<0.01) than qualitative measures of glottal function (GFI) (ρ=0.43). CONCLUSION Gore-tex thyroplasty provides reliable medium-term improvement in both perceptual and subjective voice parameters in the setting of GI with mobile vocal folds.

High-Resolution Ultrasound in the Evaluation of Pediatric Recurrent Respiratory Papillomatosis

OBJECTIVES To characterize the ultrasonographic appearance of laryngeal papillomatosis and to compare ultrasound with direct laryngoscopy and bronchoscopy, the criterion standard, for airway evaluation. DESIGN Prospective, nonrandomized analysis of preoperative and postoperative airway ultrasound images. SETTING Tertiary, university-based medical center. PARTICIPANTS Eight patients (4 females and 4 males) with recurrent respiratory papillomatosis, with a mean age of 10.25 years and a mean of 14 surgical papilloma resections (range, 3-35). INTERVENTION The patients underwent planned papilloma resections with ultrasound evaluation before formal endoscopic resection. Preresection ultrasound images of respiratory papillomas were evaluated. MAIN OUTCOME MEASURES The ultrasonographic appearance of respiratory papillomas and pediatric airway anatomy. RESULTS Respiratory papillomas appeared as discrete, hyperechoic lesions on the relatively hypoechoic background of the true vocal folds. CONCLUSIONS Recurrent respiratory papillomas have a characteristic ultrasonographic appearance that seems to correlate with endoscopic findings. It seems that this modality holds promise for identifying pedunculated papillomas. Although direct laryngoscopy and bronchoscopy are the criterion standard, airway ultrasound may have a role in the early diagnosis of, surveillance of, and operative planning for recurrent respiratory papillomatosis. To our knowledge, this is the first study to describe the ultrasonographic appearance of papillomas and the first comparison of ultrasonographic and endoscopic airway images. This modality merits further study, and further investigation is ongoing.

Trefoil Factor 3 Immunohistochemical Characterization of Follicular Thyroid Lesions From Tissue Microarray

OBJECTIVES To characterize trefoil factor 3 (TFF3) expression in normal thyroid tissue samples compared with that in follicular adenoma, follicular carcinoma, and follicular variant of papillary thyroid carcinoma using immunohistochemistry on tissue microarrays. DESIGN Immunohistochemical analysis of 83 normal thyroid tissue and of 83 follicular neoplasms (26 follicular adenomas, 25 follicular variant of papillary thyroid carcinoma, 23 follicular thyroid carcinomas, and 9 papillary thyroid carcinomas) was performed using an antibody to TFF3 on tissue microarray sections composed of formalin-fixed, paraffin-embedded tissue samples. SETTING Academic research. PATIENTS Thyroid tissue samples collected from patients over a 15-year period were obtained from the University of North Carolina Hospitals Division of Surgical Pathology archives. MAIN OUTCOME MEASURES Thyroid tissue samples were graded by a pathologist based on intensity of antibody staining and on percentage of cells stained. Localization of TFF3 antibody was noted. Data were analyzed for semiquantitative differences in immunohistochemical intensity of antibody staining and in percentage of cells stained among normal thyroid tissue samples, follicular adenoma, follicular thyroid carcinoma, follicular variant of papillary thyroid carcinoma, and papillary thyroid carcinoma. RESULTS Semiquantitative analysis demonstrated that immunohistochemistry detects significant levels of TFF3 expression in normal thyroid tissue samples compared with that in follicular lesions based on intensity of antibody staining (P < .05). Only follicular thyroid carcinoma demonstrated a significant reduction in percentage of cells stained compared with that in normal thyroid tissue samples (P = .03). No significant differences in intensity of antibody staining or in the percentage of cells stained were noted among follicular adenoma, follicular thyroid carcinoma, follicular variant of papillary thyroid carcinoma, or papillary thyroid carcinoma. Trefoil factor 3 staining localized to the cytoplasm. CONCLUSIONS Protein expression data validate gene expression findings that follicular neoplastic lesions have decreased expression of TFF3 compared with that in normal thyroid tissue samples. These findings contribute to evidence suggesting that TFF3 may have a role in normal thyroid tissue function and that thyroid carcinomas may have reduced expression of TFF3, in contradistinction to other carcinomas that overexpress TFF3.

Cordotomy by Coblation in Bilateral Vocal Fold Immobility

Objective: 1) Understand the presentation, etiology, and management of bilateral vocal fold immobility. 2) Understand the utility, technique, and advantage of endoscopic coblation vocal cordotomy for patients with bilateral vocal fold immobility. 3) Compare the use of the laryngeal coblator with the laser. Method: Case series using endoscopic coblation to perform vocal cordotomy in patients with bilateral vocal fold immobility is presented. Seven patients underwent suspension microlaryngoscopy with either initial or revision vocal cordotomy with or without partial arytenoidectomy. Routine follow-up was performed and wound healing was documented via distal chip videolaryngoscopy. Results: Seven patients underwent suspension microlaryngoscopy with vocal cordotomy as part of airway management for bilateral vocal fold immobility. The laryngeal coblator was used to perform a transverse cordotomy. The procedure was completed in approximately 5 minutes. No laser protection is required reducing operative set-up and procedure time versus the laser. Two patients had a prior tracheotomy. No patients required a tracheotomy with this procedure. Patients were seen between 1 day and 1 month postoperatively. Patients had minimal granulation tissue at the cordotomy site and appeared to have quicker healing. The glottic airway and stridor were improved in all patients. Conclusion: Initial outcomes of endoscopic coblation vocal cordotomy reveal this technique to be safe and efficient. Coblation increased the glottic airway with minimal granulation tissue and rapid healing. This represents the first described use of coblation for bilateral vocal fold immobility. Long-term data will be forthcoming.

Markers Differentiating Follicular Thyroid Neoplasms on FNA

ical (microscopic) perineural tumor spread is significant in determining the site of nerve sacrifice. Achieving negative margins intraoperatively has favorable prognostic value, while the presence of nodal disease at the time of diagnosis confers a dismal prognosis. Long-term measures of facial function and appearance are acceptable with the addition of static and reconstructive procedures. This is the largest series to date to comprehensively analyze outcomes in this disease process.

P086: Laryngoscopic Findings in Unilateral Vocal Fold Paresis

27 men were examined in the Serviço de Otorrinolaringologia do Hospital Universitário Pedro Ernesto, Rio de Janeiro, Brazil, in a period of 11 years. The vocal nodules were diagnosed through telescopic laryngoscopy (70° or 90°) and the nasal examination consisted of an anterior rinoscopy and endoscopic evaluation after mucosal retraction with a vasoconstrictor solution 1:80000. A naso-sinusal CT scan was made if necessary. RESULTS: Some 113 of 208 patients (54.3%) were found to have nasal obstructive abnormalities. The fibrous nodules occurred in 72 patients (63.8%) and the edematous nodules in 41 (36.2%); 56 patients (49.5%) referred nasal obstruction complaints, 15 bilateral and 41 unilateral. The nasal obstructive abnormalities were septal deviation (50.4%), allergic rhinitis (36.3%), osseous abnormalities of the turbinates (15.9%), vasomotor rhinitis, adenotonsillar hypertrophy, nasal polyposis and Killian antrochoanal polyp. In the patients with fibrous nodules the more common nasal abnormalities were septal deviation, osseous abnormalities of the turbinates, and vasomotor rhinitis. In the edematous nodules patients: allergic rhinitis and septal deviation. CONCLUSIONS: Nasal obstruction was found in 54.3% of the patients with vocal nodules. The clinical suspicion exists that nasal obstruction could be a predisposing factor in the nodules arousal though the primordial factor is the vocal abuse.