Simulator Based Obstetric Ultrasound Training: A Prospective, Randomized Single-Blinded Study.

OBJECTIVE: To compare the use of simulator-based and patient-based obstetric ultrasound training. METHODS: This was a prospective, randomized, single-blinded trial. Eighteen consenting obstetric trainees with minimal previous ultrasound exposure were recruited. Enrolled patients were also fully consenting. Mid-trimester fetal brain anatomy in the standard planes (i.e., biparietal diameter and head circumference, cavum septum pellucidum, posterior fossa, and lateral ventricle) was chosen as a surrogate for all fetal anatomy ultrasound training. Trainees were randomized into two groups according to training method: simulator group (n = 9) or patient group (n = 9). All participating trainees went through the following sequence: a didactic session regarding the required planes; a "real" patient 15-minute pretest; a 45-minute training session with a dedicated ultrasound educator, using either a simulator or a "real" patient (according to the randomized group assignment); and a 15-minute post-test to obtain and label the standard four planes on a "real" patient. All images were stored and then scored by two blinded Maternal Fetal Medicine staff, according to 3 set criteria: image quality, landmarks, and measurements. Each criterion was scored 0 to 15 for a total score of 0 to 60. RESULTS: Pretest competence was similar between the two groups. For each of the two groups there was a significant score improvement following training: real patient (mean score pretest 13.3 vs. post-test 24.6; P < 0.04) and simulator group (mean score pretest 15.9 vs. post-test 28.9; P < 0.05). All trainees demonstrated significant overall score improvements (mean score pretest 14.6 vs. post-test 26.6; P < 0.04) regardless of training method. Trainees were further divided by their initial level of confidence (pretest score ≤5: very unconfident; pretest >5: unconfident). The improvement was similar for both groups, but "very unconfident" trainees' performance improved more in the simulator group (mean pretest vs. post-test score 3.5 to 35) compared with the patient group (mean pretest vs. post-test score 2.3 to 25.6) CONCLUSION: Simulator-based obstetric ultrasound training performed as well as real patient training and was found to be especially beneficial for beginner trainees. Simulator-based ultrasound training has a high rate of acceptance by trainees, does not require investment of patient or clinic resources, and warrants consideration as an educational tool for the safe and effective teaching of obstetric ultrasound.

Two-dimensional sonographic assessment of maximum placental length and thickness in the second trimester: a reproducibility study.

OBJECTIVES: To determine the most reproducible method for the sonographic measurement of placental length. METHODS: A prospective study of women with singleton pregnancies who underwent sonographic measurement of placental dimensions during mid-gestation. Two sonographers independently determined placental length using three different approaches (linear, curve-linear and panoramic) and placental thickness. Reproducibility was assessed by the Bland-Altman method and Interclass Correlation Coefficient (ICC). RESULTS: Overall 34 women were included in the study. The curve-linear approach for the measurement of placental length was associated with the highest reproducibility (mean inter-observer difference of -0.10 cm) compared to the linear and panoramic approaches (mean difference -0.15 cm and -0.29 cm, respectively). Similarly, the ICC was highest for the curve-linear length approach (0.974) compared with the linear length and panoramic length approaches (0.956 and 0.926, respectively). Measurements of maximum placental thickness was also associated with a very good ICC (0.954). CONCLUSIONS: The curve-linear method for the measurement of placental length in the 2nd trimester appears to be the most reproducible approach. This technique may prove useful as an adjunct screening method, along with uterine artery Doppler and maximum placental thickness, to screen for major placental complications of pregnancy in the second trimester.

Early anatomy ultrasound in women at increased risk of fetal anomalies.

OBJECTIVE: This study was designed to assess the accuracy of ultrasound anatomy screening before 17 weeks gestation in a population at high risk of fetal anomalies. METHODS: Retrospective review of anatomy ultrasound examinations carried out between 12-17 weeks gestation in a high-risk population. Early sonographic findings were compared with the 18-22 week anatomy ultrasound, karyotype, echocardiogram and postnatal/postmortem results. RESULTS: A complete anatomical survey was achieved in 68 of 101 screened fetuses (67%), with cardiac anatomy having the lowest completion rate (78/101; 77%). Anomalies were suspected on ultrasound in 23 fetuses. Four of these did not undergo pathologic examination but had clearly abnormal findings on ultrasound. Eighteen fetuses had a confirmed abnormal outcome. Sensitivity of early anatomy ultrasound was 83.3% (n = 15/18) and specificity 94.9% (n = 75/79). There were 3 false negative ultrasounds (16.6%: trisomy 21 with short humerus, choanal atresia and ventriculomegaly, and a ventricular septal defect). False positive rate was 4.0% (4 ventricular septal defects). CONCLUSION: The high rate of visualization of anatomic structures between 12-17 weeks gestation allows for either early detection of fetal anomalies or parental reassurance in many cases. Subtle anomalies of the heart remain difficult to diagnose.

Quantum dot-mediated photoproduction of reactive oxygen species for cancer cell annihilation.

While semiconductor quantum dots produce little singlet oxygen, they may undergo Type I photoreactions to produce other reactive oxygen species (ROS) to kill cells. CdTe quantum dots coated with thioglycolic acid were used to test that possibility. Some thiol ligands were purposely removed to regenerate the surface electron traps that were passivated by the ligand. This allowed photoinduced electrons to dwell on the surface long enough to be gathered by nearby oxygen molecules to produce ROS. The photocytotoxicity of these quantum dots was tested on nasopharyngeal carcinoma cells. Photokilling was shown to be drug and light dose dependent. Using 0.6 mum quantum dots for incubation and 4.8 J cm(-2) for irradiation, about 80% of the cells were annihilated. These quantum dots promised to be potent sensitizers for photoannihilation of cancer cells.

Mechanisms of 2-methoxyestradiol-induced apoptosis and G2/M cell-cycle arrest of nasopharyngeal carcinoma cells.

2-Methoxyestradiol (2ME2) is an endogenous metabolite of 17beta-estradiol (E(2)). This study aims to examine the anti-tumour activities of 2ME2 on the poorly differentiated HONE-1 NPC cell line. At the concentration of 1 microM, 2ME2 was found to induce a short-term reversible G2/M cell-cycle arrest. Further 10-fold increase to 10 microM, 2ME2 induced both irreversible G2/M phase cell-cycle arrest and apoptosis. Induction of apoptosis and G2/M cell-cycle arrest was due to oxidative stress as both apoptosis and the proportion of cells arresting at G2/M phase could be reduced by the superoxide dismutase (SOD) mimetic, TEMPO. Induction of apoptosis was accompanied with proteolytic cleavage of caspase-9 and -3, but not caspase-8. Kinetics studies revealed that 2ME2 induced a time-dependent inhibition of extracellular signal-regulated protein kinase (ERK) and an activation of c-jun N-terminal kinases (JNKs). The chemical inhibitor of JNKs, SP600125, was found to reduce 2ME2-induced apoptosis of the HONE-1 cells. Confocal microscopy revealed that the induction of G2/M cell-cycle arrest was associated with the presence of immunoreactivity of p-cdc2 (Tyr15) in the nucleus. The G2/M cell-cycle arrest is also correlated with an increased level of inactive p-cdc25C (Ser216) in 2ME2-treated HONE-1 cells. Results from this study indicate that production of superoxide anions might be involved in 2ME2-induced apoptosis and G2/M cell-cycle arrest of the HONE-1 cells.

The impact of postoperative complications on long-term outcomes following curative resection for colorectal cancer.

BACKGROUND: This study aimed to investigate the impact of postoperative complications on long-term survival and disease recurrence in patients who underwent curative resection for colorectal cancer. METHOD: Patients who underwent radical resection for colorectal cancer with curative intent from January 1996 to December 2004 were included. Operative mortality and morbidity were documented prospectively. Factors that might affect long-term outcome were analyzed with multivariate analysis. RESULTS: Curative resection was performed in 1657 patients (943 men), and the median age was 70 years (range: 24-94 years). The 30-day mortality was 2.4%, and the complication rate was 27.3%. Age over 70 years (P < .001, odds ratio: 2.06, 95% CI: 1.63-2.61), male gender (P = .001, odds ratio: 1.49, 95% CI: 1.19-1.88), emergency operation (P < .001, odds ratio: 3.14, 95% CI: 2.26-4.35) and rectal cancer (P < .001, odds ratio: 1.41, 95% CI: 1.25-1.61) were associated with a significantly higher complication rate. With exclusion of patients who died within 30 days, the median follow-up of the surviving patients was 45.3 months. The 5-year overall survival was 64.9%, and the overall recurrence rate was 29.1%. The presence of postoperative complications was an independent factor associated with a worse overall survival (P = .023, hazard ratio: 1.26; 95% CI: 1.03-1.52) and a higher overall recurrence rate (P = .04, hazard ratio: 1.26; 95% CI: 1.01-1.57). CONCLUSION: The presence of postoperative complication not only affects the short-term results of resection of colorectal cancer, but the long-term oncologic outcomes are also adversely affected. Long-term outcomes can be improved with efforts to reduce postoperative complications.

Anastomotic leakage is associated with poor long-term outcome in patients after curative colorectal resection for malignancy.

The impact of anastomotic leakage on long-term outcomes after curative surgery for colorectal cancer has not been well documented. This study aimed to investigate the effect of anastomotic leakage on survival and tumor recurrence in patients who underwent curative resection for colorectal cancer. Prospectively collected data of the 1,580 patients (904 men) of a median age of 70 years (range: 24-94), who underwent potentially curative resection for colorectal cancer between 1996 and 2004, were reviewed. Cancer-specific survival and disease recurrence were analyzed using Kaplan Meier method, and variables were compared with log rank test. Cox regression model was used in multivariate analysis. The cancer was situated in the colon and the rectum in 933 and 647 patients, respectively. Anastomotic leakage occurred in 60 patients (clinical leakage: n = 48; radiological leak: n = 12). The leakage rate was significantly higher in patients with surgery for rectal cancer (6.3 vs 2.0%, p < 0.001). The 5-year cancer-specific survivals were 56.9% in those with leakage and 75.9% in those without leakage (p = 0.012). The 5-year systemic recurrence rates were 48.4 and 22.6% in patients with and without anastomotic leak, respectively (p = 0.001), whereas the 5-year local recurrence rates were 12.9 and 5.7%, respectively (p = 0.009). Anastomotic leakage remained an independent factor associated with a worse cancer-specific survival (p = 0.043, hazard ratio: 1.63, 95% CI: 1.02-2.60) and a higher systemic recurrence rate (hazard ratio: 1.94, 95% CI: 1.23-3.06, p = 0.004) on multivariate analysis. In rectal cancer, anastomotic leakage was an independent factor for a higher local recurrence rate (hazard ratio: 2.55, 95% CI: 1.07-6.06, p = 0.034). In conclusion, anastomotic leakage is associated with a poor survival and a higher tumor recurrence rate after curative resection of colorectal cancer. Efforts should be undertaken to avoid this complication to improve the long-term outcome.

Impact of laparoscopic resection for colorectal cancer on operative outcomes and survival.

OBJECTIVE: This study aimed to compare the outcomes of patients who underwent laparoscopic and open resections for colorectal cancer. Comparison of colectomy in 2 consecutive periods (period 1: January 1996-May 2000; period 2: June 2000-December 2004), with laparoscopic surgery being a surgical option in period 2, was also performed. SUMMARY BACKGROUND DATA: Prospective data of 1134 patients (448 in period 1; 656 in period 2) who underwent elective resection for colon and upper rectal cancer (above 12 cm from anal verge) were analyzed. METHODS: The operative outcome and survival were compared between patients who underwent laparoscopic and open resection in period 2. The outcomes of colorectal resections in the 2 periods were also compared. RESULTS: During period 2, the operative mortality rates of patients with laparoscopic (n = 401) and open resection (n = 255) were 0.8% and 3.7%, respectively (P = 0.022), and the morbidity rates were 21.7% and 15.7%, respectively (P = 0.068). The patients who underwent laparoscopic resection had significantly earlier return of bowel function, earlier resumption of diet, and shorter hospital stay. The 3-year overall survivals in those with nondisseminated disease were 74.4% and 78.8% for open and laparoscopic resection, respectively (P = 0.046). The operative morality rates were 4.4% and 2.6% in period 1 and period 2, respectively (P = 0.132). The 3-year overall survivals for patients with nondisseminated disease were 69.7% and 76.1% for period 1 and period 2, respectively (P = 0.019). The overall survivals in patients who underwent open resection in the 2 periods were similar (P = 0.284). CONCLUSIONS: The short-term favorable outcome of laparoscopic resection for colorectal cancer was confirmed and improvement of survival was observed with the practice of laparoscopic resection.

Early outcomes of surgery for small bowel obstruction: analysis of risk factors.

OBJECTIVES: The study aimed to review the etiologies of patients who underwent surgery for small bowel obstruction (SBO) and to evaluate the risk factors affecting the early postoperative outcomes. MATERIALS AND METHODS: A case series of 430 patients (252 men) with a mean age of 64.5 years, who underwent 437 operations for SBO, were retrospectively reviewed. RESULTS: Peritoneal adhesions and hernia were the most common causes of SBO, contributing 42.3 and 26.8% of all cases, respectively. Strangulation occurred in 27.7% and caused nonviable bowel in 13.0% of obstructing episodes. Old age (age >/= 70 years), female patient, nonadhesive obstruction, and hernia were the independent significant factors associated with bowel strangulation. The 30-day mortality was 6.5%, and the median postoperative hospital stay was 8 days. Old age, the presence of premorbid pulmonary disease, and malignant obstruction were the independent factors associated with operative mortality. The overall complication rate was 35.5%, and old age was the only significant factor associated with postoperative complications. CONCLUSIONS: Surgery for SBO is still associated with significant mortality and morbidity. As old age is significantly associated with an increased incidence of strangulation, operative mortality, and complications, this group of patients should be managed with extra cautions to avoid unfavorable outcome of surgery.

Laparoscopic and open anterior resection for upper and mid rectal cancer: an evaluation of outcomes.

PURPOSE: This study was designed to compare the outcomes of laparoscopic anterior resection with open operation for mid and upper rectal cancer. METHODS: A total of 265 patients who underwent elective laparoscopic or open anterior resection for cancer of the mid and upper rectum from June 2000 to December 2004 were included. Data about the patients' demographics, operative details, postoperative outcome, and disease status were collected prospectively. Comparison of the outcome between laparoscopic and open resection was performed. RESULTS: The median age of the 265 patients was 69 (range, 27-91) years, and laparoscopic anterior resection was performed in 98 patients (37 percent). There was no difference in the age, gender, comorbidities, and level of tumor between the two groups. The operating time was longer in the laparoscopic group (200 vs. 127 minutes; P < 0.01), but the blood loss was less (200 vs. 250 ml; P = 0.027). The overall operative mortality was 1.8 percent, and the complication rate was 27.9 percent. Significantly more patients with early diseases (Stage I and Stage II) were operated with laparoscopic approach. There was no difference in the mortality or morbidity between the two groups. Anastomotic leakage occurred in five patients with open resection and one with laparoscopic resection (P = 0.418). Patients with laparoscopic resection had an earlier return of bowel function and earlier resumption of diet as well as a shorter median hospital stay (7 vs. 8 days; P < 0.001). With the median follow-up of the surviving patients for 21.2 months, the three-year local recurrence rates for those with open and laparoscopic resection were 4.9 and 3.3 percent, respectively (P = 0.513). In patients with Stage I and Stage II disease, the three-year cancer-specific survivals for open and laparoscopic resection were 89.8 and 88.6 percent, respectively (P = 0.882), whereas those of patients with Stage III disease were 65.6 and 55.5 percent, respectively (P = 0.911). CONCLUSIONS: Laparoscopic anterior resection for mid and proximal rectal cancer is a safe option with short-term advantages compared with open operation. The oncologic outcomes of patients who underwent laparoscopic anterior resection were not compromised, with similar local recurrence rate and the cancer-specific survival rate as patients who underwent open resection.

Self-expanding metallic stent as a bridge to surgery versus emergency resection for obstructing left-sided colorectal cancer: a case-matched study.

This study aimed to compare the outcomes of patients who suffered from obstructing left-sided colorectal cancer, treated with self-expanding metallic stent (SEMS) as a bridge to surgery, with those who underwent emergency operation. Twenty patients who had acute obstruction due to left-sided colorectal cancer underwent surgical resection after insertion of SEMS (group I) were matched to 40 patients with emergency colonic resection (group II). The two groups were compared for the incidence of primary anastomosis, stoma rate, hospital stay, duration of intensive care, postoperative morbidity, and mortality. Both groups had similar preoperative comorbidity and stage of disease, but the tumors in group I were more distally located (P < 0.001). In group I, one patient developed colon perforation and required Hartmann's operation. All the other patients underwent elective operation with primary anastomosis. In group II, primary anastomosis was performed in 29 patients (72.5%; P = 0.047). The operative mortality of group I and group II was 5% and 12.5%, respectively (P = 0.653). Significantly shorter median postoperative hospital stay and median stay in the intensive care unit (ICU) were observed in group I (9 days [range, 5-39 days] vs. 12 days [range, 8-49 days], P = 0.015 and 0 day [range, 0-17 days] vs. 0.5 day [range, 0-18 days], P = 0.022, respectively). There were no differences in hospital mortality (P = 0.653) or 30-day mortality (P = 0.653). Both groups had similar reoperation rates, surgical complications, and medical complications. When compared with emergency resection, insertion of SEMS as a bridge to surgery for obstructing left-sided colorectal cancer is associated with a higher rate of primary anastomosis as well as a better outcome in terms of hospital stay and stay in the ICU. The wider application of this treatment option for obstructing colorectal cancer warranted further studies.

Outcomes of surgery for mid and distal rectal cancer in the elderly.

BACKGROUND: This study aimed to evaluate the surgical strategies, operative results, and oncological outcomes of elderly patients who underwent curative resection for mid and distal rectal cancer. Comparison was made with patients of younger age. STUDY DESIGN: Of the 612 patients who underwent curative resection for rectal cancer, 133 were older than 75 years of age. Comparisons were made between the young and elderly patients in the aspects of operative strategies, operative results, and long-term outcomes. RESULTS: Resection resulting in a permanent end colostomy was performed in 96 patients (15.7%), and there was no difference between young and elderly patients. There was a female predominance in the elderly group. Elderly patients also had a higher incidence of comorbid medical diseases, especially cardiovascular and neurological diseases. The operative time, blood loss, and incidence of intraoperative complications did not differ in the two groups. However, significantly fewer elderly patients underwent adjuvant radiation and/or chemotherapy. The overall 30-day mortality was 1.14%. There was no difference between the elderly patients and younger patients in hospital mortality (P = 0.178). The complication rates of the elderly and young patients were 36.8% and 30.1%, respectively (P = 0.141). Comparison between the individual complications in the elderly and young patients revealed significantly more cardiovascular complications in the elderly patients. With the median follow up of the surviving patients of 45.1 months, the overall 5-year survival of the elderly and younger groups was 47.7% and 70.1%, respectively (P < 0.001). The 5-year cancer-specific survival was 75.4% and 67.5% in the young and elderly patients, respectively (P = 0.061). CONCLUSIONS: Curative resection for mid and distal rectal cancer for the elderly can be performed safely with the same strategies of sphincter preservation used for younger patients. The postoperative complications and the 5-year cancer-specific survival rates were similar to those of younger patients.

Laparoscopic colectomy for obstructing sigmoid cancer with prior insertion of an expandable metallic stent.

We report a patient with obstructing cancer of the sigmoid colon initially treated with a self-expanding metallic stent. The metallic stent successfully relieved the intestinal obstruction, and laparoscopic anterior resection was performed subsequently. The use of this approach in the management of patients with obstructing colorectal cancer is discussed.

Palliation for advanced malignant colorectal obstruction by self-expanding metallic stents: prospective evaluation of outcomes.

PURPOSE: This study was designed to evaluate the outcomes of self-expanding metallic stents as a palliative treatment for malignant obstruction of the colon and rectum. METHODS: The insertion of self-expanding metallic stents was attempted for palliation in 52 patients (33 males; mean age, 66.5 +/- 16.4 years) with colorectal obstruction caused by advanced malignancies. The stents were inserted under endoscopic and fluoroscopic guidance. The data on the success of the procedure, the complications, and the outcomes of the patients were collected prospectively. RESULTS: Thirty patients had locally advanced or disseminated primary colorectal cancers, and 22 had recurrent cancer of colorectal or other primaries. Successful insertion of the stent was achieved in 50 patients. The median survival of the patients was 88 (range, 3-450) days. Complications occurred in 13 patients (25 percent). These included perforation of the colon (n=1), migration or dislodgement of the stents (n=8), severe tenesmus (n=1), colovesical fistula (n=1), and tumor ingrowth (n=2). Insertion of a second stent was required in eight patients. Subsequent operations were performed in nine patients, and stoma creation was required in seven patients. CONCLUSIONS: Self-expanding metallic stents are highly effective in relieving malignant colorectal obstruction. The complication rate is acceptable and palliation can be achieved in the majority of the patients without a stoma.

Non-curative surgery for colorectal cancer: critical appraisal of outcomes.

BACKGROUND AND AIMS: The value of surgery for patients with incurable colorectal cancer is controversial. This study evaluated outcomes in patients undergoing non-curative surgery for colorectal cancer and aimed to identify patients who would benefit from palliative surgery. PATIENTS AND METHODS: Demographics, tumour characteristics, operating details and outcomes were reviewed for 180 patients undergoing surgery for incurable colorectal cancer; palliative resection was performed in 150 cases. Seventeen patients died in the postoperative period. Risk factors for postoperative mortality and poor survival were analysed with univariate and multivariate analysis. RESULTS: Multivariate analysis showed that operative mortality was significantly higher in patients with non-resection surgery and in those with ascites. Median survival of patients with resection was significantly longer than in those without resection (30 vs. 17 weeks). Other independent factors that were significantly associated poor survival were the presence of ascites, presence of bilobar liver metastasis and absence of chemotherapy and/or radiation therapy. CONCLUSION: Non-curative surgery is associated with high mortality in patients without resection and in the presence of ascites. These two factors, together with the presence of bilobar liver metastasis and the absence of chemotherapy and/or radiation therapy, are associated with poor survival. In the presence of these factors the balance between the benefit and risk of surgery should be carefully considered before decision for operative treatment.

Evaluation of an automated immunochemical fecal occult blood test for colorectal neoplasia detection in a Chinese population.

BACKGROUND: Most commercial fecal occult blood tests (FOBT) used for colorectal carcinoma screening of Western populations are guaiac-based, manually developed, subjective, and sensitive to dietary components. Preliminary studies demonstrated the unsuitability of these tests for screening a Chinese population. The goal of the current study was to evaluate the performance characteristics of a human hemoglobin-specific automated immunochemical FOBT, the Magstream 1000/Hem SP (Fujirebio, Inc., Tokyo, Japan), in a Chinese population referred for colonoscopy. METHODS: Two hundred fifty consecutive patients who were referred for colonoscopy and met the study inclusion criteria provided samples for the immunochemical FOBT (without dietary restrictions) from two successive stool specimens. Tests were developed with an automated instrument that had an adjustable sensitivity threshold. The sensitivity, specificity, and positive predictive value for detecting colorectal adenomas and carcinomas were calculated according to the manufacturer's instructions over a range of sensitivity levels. RESULTS: At the optimal threshold level, the sensitivity, specificity, and positive predictive value for detection of significant colorectal neoplasia (adenomas >or= 1.0 cm and carcinomas) were 62%, 93%, and 44%, respectively. The test was easy to use, and results did not depend on operator experience. CONCLUSIONS: The automated immunochemical FOBT used in the current study was a robust, convenient, and useful tool for colorectal carcinoma screening in the study population.

Well-differentiated thyroid carcinoma in Hong Kong Chinese patients under 21 years of age: a 35-year experience.

BACKGROUND: Sporadic well-differentiated thyroid cancer is an uncommon condition in children, adolescents, and young adults. It is associated with distinct clinicopathologic features and prognosis. The present study reviews our experience in management of this condition in ethnic Chinese in Hong Kong. STUDY DESIGN: A retrospective study was performed to review the clinicopathologic features and outcomes of 34 patients less than 21 years of age with well-differentiated thyroid carcinoma over a 35-year period. Median followup was 15.2 years (range 1 to 32.5 years). RESULTS: There were 27 girls and 7 boys with a median age of 19 years (range 10 to 21 years). None had previous history of irradiation. Twenty-eight patients had papillary and six had follicular carcinomas. Operative procedures included total thyroidectomy (n = 27) and unilateral lobectomy (n = 7) with concomitant neck dissection performed in nine patients. The median tumor size was 2 cm and extrathyroidal invasion was present in 19 tumors. Adjuvant radioactive iodine treatment was administered to 18 patients after total thyroidectomy. Disease progression or recurrence rate was 24% and 27% at 5 and 10 years, respectively. The presence of lymph node metastases was associated with a higher incidence of disease recurrence. One patient with advanced local disease died from tumor bed recurrence with anaplastic transformation 18 years after the initial operation. CONCLUSIONS: Well-differentiated thyroid carcinoma is a relatively indolent tumor associated with good prognosis in young patients. Although death from this condition is rare, recurrence is frequent and longterm followup is necessary.