The incidence of carcinoma in cytologically benign thyroid cysts.

BACKGROUND: The management of cytologically benign thyroid cysts is controversial. Treatment options include observation, chemical sclerosis, and surgery. This study was undertaken to determine the incidence of carcinoma in cytologically benign thyroid cysts that recur after complete aspiration and to determine the indications for surgery in these patients. METHODS: The medical records of 1189 consecutive patients undergoing thyroid surgery between July 1995 and November 2000 were reviewed. In 34 patients the indication for surgery was a thyroid cyst with benign cytologic findings that refilled at least once after complete aspiration. These patients were selected for further study. RESULTS: The 26 women and 8 men had a median age of 42 years. Fine-needle aspiration cytology was consistent with a benign cyst in all these cases. Final pathologic findings revealed the nodule to be a papillary carcinoma in 4 patients (12%). In another 4 patients (12%) an incidental microscopic papillary carcinoma, separate from the cyst, was identified on final pathologic findings. In all 4 patients with papillary carcinoma the cyst size was greater than 3 cm (range, 3.4 to 5.0 cm). CONCLUSIONS: The incidence of malignancy in cytologically benign thyroid cysts that recur after aspiration is high enough to warrant surgical excision, especially if the cyst is greater than 3 cm in size.

Re-operation for bleeding after thyroidectomy and parathyroidectomy.

BACKGROUND: This study was undertaken to determine the frequency and timing of re-operation for bleeding following thyroidectomy (THY) and parathyroidectomy (PARA) as well as the implications of this concerning the safety of ambulatory surgery. METHODS: Patients requiring re-operation after THY and PARA were identified from a computerized database of patients undergoing surgery between 3/l/95 and 12/31/99. The medical records of these patients were reviewed in detail. RESULTS: Six of 918 THY (0.7%) and 4 of 350 PARA (1.1%) required re-operation for bleeding. In two cases the wounds were opened emergently at the bedside due to worsening airway obstruction. One patient required an emergency tracheostomy. There were no deaths. Excluding one patient who bled five days post-operatively, the time interval from the completion of surgery to the identification of postoperative hematoma ranged from 2 to 48 hours, the median being 16 hours. CONCLUSIONS: Postoperative bleeding is an uncommon but unavoidable complication of THY and PARA. If treated promptly, serious consequences can be avoided. The relatively long interval between the initial operation and the development of the hematoma needs to be considered when recommending the performance of these procedures on an ambulatory basis.

Comparacion de los umbrales de desfibrilacion ventricular en cardiodesfibriladores con caja activa implantados en la region derecha versus aquellos implantados en la region izquierda del torax / Assesment of the ventricular desfibrillation thresholds in ICD with active can, implanted in the right and left side of the thorax

Se apresentan los resultados del implante de cardiodesfibriladores con caja activa en 25 pacientes. En 19 de ellos (grupo I) el generador de caja activa fue posicionado en la región infraclavicular izquierda; en los 6 pacientes restantes (grupo II), el generador debió ser posicionado en la región infraclavicular derecha. El procedimiento de inducción de fibrillación ventricular y medición de la energia necesaria para su reversión se ajustó a un protocolo por nosotros disenado (Figura 1). Para el grupo I el menor umbral promedio de desfibrilación que se obtuvo fue de 13.82 Joules (J), SD + 3.20, SEM + 0.73. En el grupo II los valores para la desfribrilación fueron de 13.25 J, SD + 4.17, SEM + 1.7. La comparación estadística entre ambos grupos (I y II) no demostró diferencias significativas. Se concluye entonces que en el implante de cardiodesfibriladores con caja activa, y empleándo nuestro protocolo, no existen limitaciones para la elección de la zona infraclavicular derecha, cuando la región isquierda no esté en condiciones de ser utilizada.

Nonsustained ventricular tachycardia in severe heart failure. Independent marker of increased mortality due to sudden death. GESICA-GEMA Investigators.

BACKGROUND: The goal of the study was to determine the prognostic value of nonsustained ventricular tachycardia (NSVT) in total mortality in severe congestive heart failure (CHF) and in death modes. NSVT is associated with an increased mortality in CHF. However, the predictive value of NSVT as a marker for sudden death or death due to progressive heart failure has not been determined. METHODS AND RESULTS: Five hundred sixteen patients from the GESICA trial (33.4% with NSVT) were initially studied with the results of 24-hour Holter and 2 years of follow-up. Within 2 years, 87 of 173 patients (50.3%) with NSVT and 106 of 343 patients (30.9%) without NSVT died. Relative risk (RR) was 1.69 (95% confidence interval [CI], 1.27 to 2.24; P < .0002), and Cox proportional hazard analysis was 1.62 (95% CI, 1.22 to 2.16; P < .001). Sudden death increased from 8.7% (30 of 343) to 23.7% (41 of 173) in patients with NSVT (RR, 2.77; 95% CI, 1.78 to 4.44; P < .001). Progressive heart failure death was also increased from 17.5% (60 of 343) to 20.8% (36 of 173) (P = .22). Quantitative analysis of 24-hour Holter (first 295 patients) demonstrated that couplets had a similar RR to that of NSVT for both total mortality (RR, 1.81; 95% CI, 1.22 to 2.66; P < .002) and sudden death (RR, 3.37; 95% CI, 1.57 to 7.25; P < .0005). Couplets and/or NSVT (ventricular repetitive beats) were even more predictive for sudden death (RR, 10.1; 95% CI, 1.91 to 52.7; P < .01). CONCLUSIONS: In patients with CHF, NSVT is an independent marker for increased overall mortality rate and sudden death. The absence of NSVT and ventricular repetitive beats in a 24-hour Holter indicates a low probability of sudden death.

Long-term evaluation of patients undergoing immediate mandibular reconstruction.

BACKGROUND: Immediate reconstruction following segmental mandibulectomy is an accepted surgical technique. The benefits and patient selection criteria need to be established. PATIENTS AND METHODS: Forty-seven patients who underwent immediate reconstruction of the mandible were followed for up to 14 years. Survival, complication rates, and functional results were analyzed. RESULTS: Median survival was 39 months and actuarial 5-year survival was 40%. Two patients died in the postoperative period, and 9 suffered major reconstruction-related complications. The majority of these complications were related to the use of reconstruction plates, and occurred when the mandibular defect included the arch or when the plates were covered by pectoralis flaps. Half of the patients interviewed were able to eat a regular diet. CONCLUSIONS: Mandibular reconstruction can be performed safely and expeditiously in nearly all patients undergoing segmental mandibulectomy. Functional results and long-term survival will be acceptable in many cases.

Life-threatening arrhythmias and RV dysfunction after surgical repair of tetralogy of Fallot. Comparison between transventricular and transatrial approaches.

BACKGROUND: Late postoperative arrhythmias and right ventricular dysfunction may occur after classic repair of tetralogy of Fallot. METHODS AND RESULTS: During a mean follow-up of 8.9 years (range, 5 to 14 years), 24-hour ambulatory electrocardiographic studies were done in 107 patients after repair of tetralogy of Fallot. Radionuclide angiography was performed in 97, and 78 patients also underwent postoperative heart catheterization. The patients were divided into two groups: group A consisted of 71 patients aged 2 months to 61 years (mean, 6.8 years) in whom the right ventricular approach was used; group B included 36 patients aged 8 months to 39 years (mean, 7.9 years) whose repair was through the right atrium. A transannular patch was employed in 42 (59.2%) patients in group A and in 23 (63.9%) patients in group B. Eighteen patients were adults (> 18 years old) at the time of surgery: 13 (18.3%) in group A and 5 (13.8%) in group B. During a mean follow-up of 9.7 years, 57 (80.3%) group A patients were in New York Heart Association (NYHA) functional class I. Atrial flutter was present in 3 (4.2%) patients, and 28 (39.4%) had significant ventricular arrhythmias (> or = Lown grade 2). Postoperative heart catheterization showed good hemodynamic results in 36 of 54 group A patients studied (12 of whom had ventricular arrhythmias); moderate-to-severe pulmonary regurgitation was present in 14 (25.9%) patients; only 2 (3.7%) patients had right ventricular hypertension. On electrophysiological study, 8 of 28 (28.6%) patients in group A had inducible sustained ventricular tachycardia. Despite antiarrhythmic therapy, 2 of these patients died suddenly, presumably from ventricular arrhythmias. Two other late deaths in group A were caused by heart failure. During a mean follow-up of 7.2 years, 33 of 36 (91.7%) patients in group B were in NYHA functional class I. Atrial flutter was not found in any patient in this group. Only 1 (2.8%) patient, who had moderate-to-severe pulmonary regurgitation, had significant ventricular arrhythmias (> or = Lown grade 2). Postoperative catheterization showed good hemodynamic results in 20 of 24 patients; 3 (12.5%) had moderate-to-severe pulmonary regurgitation, and 1 (4.2%) patient had right ventricular hypertension. Sustained ventricular tachycardia could not be induced in any of the 5 adult patients who underwent electrophysiological studies. One late death (caused by endocarditis) occurred in group B. CONCLUSIONS: The right atrial approach significantly reduced the risk of life-threatening ventricular arrhythmias after repair of tetralogy of Fallot (P < .001) without increasing the incidence of supraventricular arrhythmias. Right ventricular dysfunction and severe pulmonary regurgitation were also more prevalent (P < .01) when the right ventricular approach was used.

Prognostic factors for recurrence and survival in head and neck soft tissue sarcomas.

BACKGROUND: Soft tissue sarcomas of the head and neck represent uncommon malignant neoplasms. With the exception of orbital and parameningeal sites, the treatment of sarcomas in the head and neck has not been standardized. The authors used a prospectively collected database of adult soft tissue sarcomas to identify prognostic factors for local control and survival. METHODS: A prospectively collected database of adult soft tissue sarcoma from 1982 to 1989 was analyzed for the impact of prognostic factors on local control and survival. Factors examined included histologic type, tumor grade, size, and resection margins. RESULTS: The overall and disease free survival at 5 years was 71 and 60%, respectively. Local control was 70% at 5 years. On univariate analysis, grade and margin status were predictors for local control. Analysis based on the Cox proportional hazard model revealed that margin status was the only significant factor in predicting local control. Grade and margin status were significant prognostic indicators for survival both on univariate analysis and in the Cox proportional hazard model. CONCLUSION: Patients with head and neck sarcomas should undergo wide excision with the removal of all gross disease and the acquisition of negative, microscopic surgical margins. Patients with positive margins should receive adjuvant radiotherapy for local control. High grade lesions place patients at risk for local recurrence and distant dissemination. Investigational regimens designed to prevent metastatic disease should be performed.

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.

Accuracy of frozen section in the evaluation of salivary tumors.

The records of 333 patients who underwent surgery were reviewed to document the accuracy of frozen section in the evaluation of salivary gland tumors. Frozen sections were obtained in 310 patients. The final pathologic diagnoses included 210 benign tumors and 45 malignancies. The sensitivity for the detection of malignancy was 69%, and the specificity was 96%. The specific accuracy to correctly identify the type of malignancy present was only 51%. In four patients, a false-positive diagnosis of malignancy was made. Frozen section was much more accurate in the evaluation of benign salivary tumors. Forty-three of 45 Warthin's tumors were correctly identified by frozen section. Two tumors thought to be Warthin's tumors on frozen section proved to be low-grade mucoepidermoid carcinomas. One tumor reported to be a benign mixed tumor was actually a malignant mixed tumor. In this series of patients, frozen section proved to be no more accurate in the evaluation of salivary tumors than what has been reported in the literature for fine-needle aspiration biopsy.

Local control of squamous cell carcinoma following marginal and segmental mandibulectomy.

The records of 130 consecutive patients undergoing marginal or segmental mandibulectomy for squamous cell carcinoma of the oral cavity or oropharynx were reviewed. An attempt was made to correlate incidence of recurrence with characteristics of the primary tumor and extent of mandibulectomy. The local recurrence rate was 19% following marginal mandibulectomy and 6% following segmental mandibulectomy. The incidence of local recurrence was independent of the size of the primary tumor or the extent of lymph node metastases. Neither mandibular invasion by tumor nor the addition of radiotherapy influenced local recurrence. Ten of 15 patients recurring locally after marginal mandibulectomy were salvaged by further surgery. This study suggests that local control following marginal mandibulectomy is comparable to that following segmental mandibulectomy regardless of the size of the tumor. Segmental mandibulectomy should be reserved for those tumors invading deeply into the mandible or wrapping around it.

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 physician's 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 Warthin's tumors. FNAB in 13 of these patients (33%) yielded a diagnosis permitting modification of the planned procedure. The diagnosis of Warthin's 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.

Reinnervated radial forearm free flaps in head and neck reconstruction.

The radial forearm flap has proved to be a reliable free flap for intraoral reconstruction after major head and neck ablative surgery for cancer. In contrast to the myocutaneous flap, it is thin and flexible, and as a result, it is better suited to conforming to the irregular surface which remains over an intact or restored mandible. A criticism of both techniques however, is that while the flap effectively fills the defect, it serves as an insensate reservoir in which food and saliva can collect. A modification of the reinnervated radial forearm free flap is presented, with discussion of its use in three patients, following extensive resection of the floor of the mouth and tongue.

Postoperative radioactive iodine evaluation of total thyroidectomy for thyroid carcinoma: reappraisal and therapeutic implications.

The records of 430 patients who underwent total thyroidectomy with radioactive iodine (RAI) uptake studies performed postoperatively were reviewed. Indications for the administration of an ablative dose of iodine 131 are given. The majority (85.4%) had no or low (less than 2%) evidence of focal uptake and therefore were not treated with ablative doses of iodine 131. RAI scanning is necessary postoperatively to determine the completeness of the surgical procedure and to detect residual or metastatic disease. Small foci of residual disease or occult distant metastases can be adequately treated with therapeutic doses of RAI. Nodal or distant metastases that become clinically evident following thyroidectomy are usually not successfully treated with RAI.

Patterns of regional lymph node metastases from cutaneous melanomas of the head and neck.

A consecutive series of 111 patients treated between 1964 and 1989 with primary cutaneous malignant melanoma of the head and neck and histologically proven regional metastases was reviewed to determine the patterns of nodal metastases. The primary sites were grouped in the following categories: face (34), anterior scalp (25), anterior neck (16), posterior scalp (15), ear (11), and posterior neck (10). All patients underwent radical neck dissection: 80 of the procedures were therapeutic and 31 elective. A total of 106 specimens were positive for metastases. Thirty-three of the 57 patients undergoing parotidectomy had positive results for metastases (14 of 20 in therapeutic parotidectomies and 19 of 37 in elective parotidectomies). Based on the incidence of involvement of the parotid gland and the patterns of lymph node metastases from levels I through V, three observations are made. Patients undergoing regional lymphadenectomy for primary melanomas on the ear, face, and anterior scalp should be considered for parotidectomy. The use of selective limited neck dissection for elective regional lymphadenectomy appears justified based on the location of the primary site. In patients undergoing therapeutic neck dissection, a complete neck dissection should be performed due to the unpredictable distribution of lymph node metastases to the cervical lymph nodes.

Median mandibulotomy: a critical assessment.

Median mandibulotomy (mandibular "swing") has supplanted mandibular resection for access to oral and oropharyngeal tumors when there is intervening grossly normal tissue between the tumor and bone. It has also proved useful for exposure in selected patients with deep lobe parotid or parapharyngeal space tumors. We have reviewed our experience with 313 mandibulotomies performed between 1959 and 1988 with emphasis on indications, complications, and modifications in technique. Most of our mandibulotomy patients had an uncomplicated recovery, but osteotomy-related complications occurred in 20%. These complications were usually minor and no instances of nonunion were recorded. There was no apparent relationship to antecedent or postoperative radiotherapy. Dental splints were used only in selected patients (40%). The technique of osteotomy has been evolving in recent years. Paramedian, rather than median mandibulotomy, minimizes trauma to the genioglossus, geniohyoid, and digastric muscles. Miniplates offer a useful alternative to conventional wire fixation. Preoperative dental assessment has facilitated better occlusion postoperatively in dentulous patients.

The accuracy of computed tomography in the diagnosis of retroperitoneal blood in the presence of abdominal aortic aneurysm.

The use of computed tomography (CT) in the management of patients who are hemodynamically stable with symptoms suggestive of ruptured abdominal aortic aneurysm and in hemodynamically unstable patients without palpable or known aortic aneurysms was analyzed in a retrospective study. One hundred forty-two CT scans were performed; 48 patients had abdominal aortic aneurysms and 35 had no evidence of rupture or retroperitoneal blood. Ten patients had CT scans that showed evidence of rupture, and three patients had CT scans that were thought to be indeterminate for rupture, probably inflammatory. Forty patients underwent laparotomy. Excluding the three patients with inflammatory aneurysms, the results of CT scanning were compared with the findings at laparotomy. The sensitivity of CT scanning for the diagnosis of retroperitoneal blood in the presence of abdominal aortic aneurysm was 77% and the specificity was 100%, with an overall accuracy of 92%. An algorithm for the management of the patient with symptoms suggestive of a ruptured aneurysm is presented.