The Treatment of Advanced Thyroid Cancer in the Age of Novel Targeted Therapies.

Until recently, patients with advanced thyroid cancers had limited options for systemic treatment. With the introduction of tyrosine kinase inhibitors (TKIs) as a promising new class of targeted therapies for thyroid cancer, suddenly patients with advanced disease were given new options to extend survival. Guidelines worldwide have been updated to include general indications for these newer agents, but questions remain regarding which agent(s) to select, when to begin treatment, and how long therapy should continue. Additionally, the true impact of TKIs on overall survival and quality-of-life in thyroid cancer patients needs further clarification. As familiarity with approved agents and longer-term data become available, better strategies for implementation of these targeted drugs will evolve to optimize benefit for patients living with metastatic disease.

Frozen section analysis in the post-Bethesda era.

BACKGROUND: The utility of frozen section (FS) for indeterminate thyroid nodules is controversial. In 2009, the Bethesda System for Reporting Thyroid Cytopathology was established to further subcategorize indeterminate fine-needle aspiration results (follicular lesions, FL) into Bethesda category 3 (BC3) and Bethesda category 4 (BC4). We hypothesize that FS will have less utility in the evaluation of BC3 lesions when compared to BC4. MATERIALS AND METHODS: A total of 479 patients who underwent thyroid lobectomy from January 2008 to July 2014 were retrospectively reviewed. Patients without appropriate Bethesda categorization were excluded. A total of 135 patients (65 FL, 45 BC3, 25 BC4) comprised the study groups. The sensitivity and specificity of FS within these three categories were determined. RESULTS: In the FL group, 6 of 65 patients were found to have thyroid cancer. Three were identified on frozen section (FS) resulting in a sensitivity and specificity of 50% and 100%, respectively. Thus, FS changed the operation in 3 of 65 cases (4.6%). In the BC3 group, 5 of 45 patients were found to have cancer. One was identified on FS resulting in a sensitivity and specificity of 20% and 100%, respectively. Thus, FS changed the operation in 1 of 45 patients (2.2%). In the BC4 group, 4 of 25 patients were found to have cancer. Two were identified on FS resulting in a sensitivity and specificity of 50% and 100% respectively. Thus, FS changed the operation in 2 of 25 patients (8%). CONCLUSIONS: There is improved utility of FS in BC 4 patients as 8% avoided reoperation. However, this benefit hinges on surgeon practice regarding the management of differentiated thyroid cancer >1 cm and <4 cm.

Patterns of use of topical skin adhesives in the emergency department.

OBJECTIVES: The objective was to determine patterns of use of topical skin adhesives (TSA) for laceration repair. The authors hypothesized that TSA use would be more common in children and facial lacerations. METHODS: This was a structured retrospective chart review. The setting was a suburban, university-based emergency department (ED) with an emergency medicine (EM) residency; the annual census is 85,000 visits. Charts from consecutive patients presenting with lacerations in the summer of 2008 (June 2008 through August 2008) were reviewed. Demographic, clinical, and wound characteristics were extracted from electronic medical records by trained investigators using structured data collection forms. Characteristics of lacerations repaired with TSA or other closure devices were compared with bivariate and multivariate analyses using odds ratios (ORs) and 95% confidence intervals (CIs). RESULTS: A total of 755 patients presented to the ED with lacerations over the study period, of whom primary closure was used in 667; nine were excluded because the method of closure was unknown. The most common methods of laceration closure were sutures (485), adhesives (88), and staples (86). Adhesives were used to close 27% of facial lacerations, compared to 4% of all other body locations (difference = 23%, 95% CI = 18% to 29%), and in 20% of pediatric versus 8% of adult lacerations (difference = 13%, 95% CI = 7% to 18%). Adjustment for other potential patient and wound characteristics showed that adhesives were more likely to be used to close facial lacerations (OR = 10.0 CI, 95% CI = 5.5 to 18.0) and lacerations in children (OR = 1.8, 95% CI = 1.1 to 3.0) and less likely to be used as laceration length increased (OR = 0.6, 95% CI = 0.4 to 0.8). Adhesive use was not statistically associated with patient sex or race, laceration edges or shape, or the need for deep sutures. Forty-three percent of adhesive wounds were closed with no anesthetic, and a topical agent was used in another 48%. In contrast, a local anesthetic agent was injected in 87% of sutured wounds (p < 0.001) and 73% of stapled wounds (p < 0.001). CONCLUSIONS: Topical skin adhesives are used more often for children, facial lacerations, and short lacerations. Use of adhesives may improve patient comfort as need for injecting a local anesthetic is reduced.