Role of fine-needle aspiration biopsy and frozen section analysis in the surgical management of thyroid tumors.

INTRODUCTION: The role of fine-needle aspiration (FNA) and frozen section (FS) in the management of thyroid neoplasms continues to generate considerable controversy. We reviewed our recent experience to determine the clinical utility of FNA and FS in our surgical management and intraoperative decision-making. METHODS: All patients who had operations for thyroid disease between January 1996 and June 1999 were identified in our prospective database. Completion and incidental thyroidectomies were excluded. Data obtained from the pathology files included FNA, FS, and the final histologic diagnosis. RESULTS: Five hundred sixty-four patients, including 409 women (73%), with a median age of 50 years (range, 6-94) were identified, of whom 293 (52%) had cancer diagnosed on permanent sections. Three hundred twenty-nine patients (58%) had evaluable FNA, of which 91 (28%) were benign, 94 were malignant (28%), and 144 (44%) were suspicious (46% of these were malignant on final). Frozen section was performed in 397 (70%) patients; of these samples, 170 (43%) were found to be benign, 106 (27%) were malignant, and 121 (30%) were deferred (46% malignant on final). Fine-needle aspiration positively identified 51% of confirmed malignancies; 13% of patients with malignancy had a benign FNA result. Total thyroidectomy was performed in 64% of malignant tumors and 29% of benign thyroid disease (P < .001). Logistic regression revealed no association of extent of surgery with FNA results. A frozen section positive for malignancy was associated with total thyroidectomy (P < .001, RR 6 [CI 3-10]), and a negative frozen section report was associated with lobectomy (P < .05, RR 0.5 [CI 0.3-0.96]). Frozen sections results altered the preoperative plan in only 29 patients (5%). CONCLUSION: Results of preoperative FNA had no direct impact on the selection of the surgical procedure in this selected cohort. Intraoperative FS added very little to surgical management. The majority of thyroid operations at this institution are planned and performed based on known prognostic factors and intraoperative findings.

Dermatofibrosarcoma protuberans of the head and neck.

BACKGROUND: Dermatofibrosarcoma protuberans (DFSP) of the head and neck is a rare, locally infiltrative, low-grade sarcoma. This study defines the clinical behavior of DFSP, evaluates the role of frozen section analysis, and identifies factors that predict local control. METHODS: Hospital records and pathological slides were reviewed for 33 patients with pathologically confirmed head and neck DFSP treated at Memorial Sloan-Kettering Cancer Center between 1964 and 1999. Factors were analyzed by using Fisher's exact or chi2 tests. RESULTS: For 21 primary and 12 recurrent patients, median age and tumor size at presentation was 39 years and 2.0 cm, respectively. Thirty-two (97%) patients were alive at a median follow-up of 82 months. Three patients recurred locally, all with smaller than 2-cm resection margins. Deep tumors were more likely to have a margin-positive resection than superficial lesions (P = .03). Gross margin 2 cm or more was a significant predictor of a negative histological margin (P<.001). There was a trend toward improved recurrence-free survival for tumors treated with wide (> or =2 cm) margin resection (P = .059). Accuracy, sensitivity, specificity, and false negative rates of frozen section were 80%, 43%, 100%, and 57%, respectively. CONCLUSIONS: Wide margin resection of head and neck DFSP predicts negative histological margins and impacts favorably on local recurrence-free survival. Frozen section analysis does not assess resection margins accurately.

The association of Chlamydia pneumoniae infection and reactive airway disease in children.

OBJECTIVE: To determine the possible association of Chlamydia pneumoniae infection and reactive airway disease in children. DESIGN: Prospective observational study. SETTING: Pediatric emergency department in Children's Medical Center of Brooklyn (NY), Kings County Hospital Center. PARTICIPANTS: One hundred eighteen children with acute episodes of wheezing and 41 age- and sex-matched healthy controls, aged 5 to 16 years. INTERVENTIONS: Children with cultures positive for C pneumoniae were treated with antibiotics. MEASUREMENTS/MAIN RESULTS: Cultures for C pneumoniae and serum samples for antibody testing were obtained from subjects and healthy controls. We isolated C pneumoniae from 13 (11%) children with wheezing and from two (4.9%) controls. Seven (58.3%) of 12 children with positive cultures had no detectable antibody to C pneumoniae and only three (25%) children had serologic evidence of acute infection. Six children had positive cultures on multiple occasions, ranging from 1 to 5 months. The children with wheezing were treated with erythromycin or clarithromycin, a new macrolide antibiotic approved for use in adults; all eventually had a negative culture. Nine (75%) of these children demonstrated clinical and laboratory improvement of the reactive airway disease after the eradication of chlamydial infection. CONCLUSIONS: Infection with C pneumoniae can trigger acute episodes of wheezing in children with asthma. Treatment of C pneumoniae infection may improve the course of reactive airway disease in these patients.

Single dose of azithromycin for the treatment of genital chlamydial infections in adolescents.

We compared a single 1 gm dose of azithromycin with the standard 7-day course of doxycycline for the treatment of uncomplicated chlamydial genital infection in sexually active adolescents. Seventy-three adolescents (65 female) with a cervical or urethral culture positive for Chlamydia trachomatis were enrolled in the study; 46 received azithromycin and 27 received doxycycline. Follow-up evaluations were done 1, 2, and 4 weeks after treatment with azithromycin or initiation of treatment with doxycycline. There were four treatment failures (8.7%) among the patients who received azithromycin and four in the doxycycline-treated group (14.8%); all were female. Six of these girls (three treated with azithromycin and three with doxycycline) gave histories of unprotected intercourse with an untreated partner and were probably reinfected. Almost half the patients were clinically symptom free. The clinical response rate for the remaining patients with symptoms was 97.4% at 4 weeks. Nineteen percent of the azithromycin-treated patients and 33.3% of those treated with doxycycline had mild to moderate drug-related side effects, which were predominantly gastrointestinal. We conclude that treatment with a single oral dose of azithromycin appears to be as safe and efficacious as a 7-day course of doxycycline for the treatment of uncomplicated genital chlamydial infection in adolescents.

Use of HEp-2 cells for improved isolation and passage of Chlamydia pneumoniae.

Chlamydia pneumoniae has proved to be difficult to isolate and propagate in cell culture. We compared the growth of three strains of C. pneumoniae, TW-183 and two clinical isolates from Brooklyn, N.Y., in five cell lines, including HeLa 229, McCoy, HL, HEp-2, and HTED, an immortalized human tracheal cell line. HEp-2 was the most sensitive cell line tested. When 10-fold dilutions of three C. pneumoniae strains at known titers were inoculated into the different cell lines, the mean number of inclusion-forming units per milliliter was 1 to 2 log units higher in the HEp-2 than in the other cell lines. This difference was statistically significant. Omission of pretreatment with DEAE-dextran resulted in larger inclusions than those seen in pretreated cells, with the exception of McCoy and HTED cells. Retrieval of clinical specimens previously cultured on HeLa 229 cells and comparison of mean inclusion counts in fresh clinical specimens simultaneously inoculated on HeLa 229 and HEp-2 cells suggested that culture in HEp-2 cells may require only the initial inoculation and one passage, compared with three to four passages, as required by culture in HeLa 229 cells.

Comparison of a chemiluminometric immunoassay with culture for diagnosis of chlamydial infections in infants.

The performance of Magic Lite (CIBA-Corning), a chemiluminescent immunoassay (CIA), was compared with that of culture for the diagnosis of neonatal chlamydial conjunctivitis and respiratory infection. We performed a retrospective evaluation of 51 ocular and 96 nasopharyngeal specimens previously collected for culture testing with the CIA. The sensitivities for the ocular and the nasopharyngeal specimens were 91 and 91.7%, respectively. The specificities for both sites were 100%. A subsequent prospective study evaluating 71 ocular and 38 nasopharyngeal specimens revealed sensitivities of 83.3 and 20%, respectively. The specificities for both sites were 100%. The CIA performed favorably, compared with culture, for the diagnosis of chlamydial conjunctivitis; however, the CIA appeared less sensitive for the diagnosis of respiratory infection, including pneumonia.

Persistent infection with Chlamydia pneumoniae following acute respiratory illness.

Chlamydia pneumoniae is emerging as a significant cause of respiratory disease, including pneumonia and bronchitis, in humans. In this recently completed study of infection due to C. pneumoniae in patients presenting with pneumonia to SUNY Health Science Center at Brooklyn, we identified two individuals for whom cultures were positive on multiple occasions over a 1-year period. To determine the frequency of persistent respiratory infection with C. pneumoniae, follow-up specimens were obtained from nine individuals with culture-documented C. pneumoniae infection. Five of these individuals had persistent infection: four had a flulike illness characterized by pharyngitis, and one had bronchitis with prominent bronchospasm. All five individuals appeared to have acute C. pneumoniae infection as determined by results of serologic tests (titers of IgM antibody for all individuals were greater than or equal to 1:16). For three patients, cultures remained positive for 11 months despite therapy with 10- to 21-day courses of tetracycline or doxycycline. These observations suggest that persistent infection with C. pneumoniae may follow acute infection and may persist for many months. Infection with C. pneumoniae may be very difficult to eradicate with use of currently available antibiotics even if there is a clinical response to therapy.