Outcomes of 756 patients with differentiated thyroid cancer and excellent response to treatment: An evidence-based paradigm for long-term surveillance strategies.

BACKGROUND: The 2014 British Thyroid Association thyroid cancer guidelines recommend lifelong follow-up of all thyroid cancer patients. This is probably unnecessary, particularly for differentiated thyroid cancer (DTC) patients with an excellent response to treatment and places significant demand on health service resources. DESIGN: Single centre retrospective cohort analysis of patients diagnosed and treated at the Leeds Cancer Centre between 2001 and 2014. PATIENTS: A total of 756 patients were dynamically risk-stratified (DRS) as having 'excellent response to treatment' after total thyroidectomy and radioiodineremnant ablation (RRA) for DTC. RESULTS: Median follow-up was 11.2 (range: 6.5-18.5) years. Radiological recurrence occurred in 15/756 (2.0%) patients and was always preceded by a raised thyroglobulin or thyroglobulin antibody level. The vast majority of tumour recurrences (13/15, 85%) were identifiable within 5 years of diagnostic surgery. Patients classified as having high-risk disease as per American Thyroid Association (ATA) guidelines had an almost threefold higher recurrence rate (2/34 [5.9%] vs. 13/722 [1.8%]) than those with ATA low-risk or intermediate-risk disease. Tumour histology subtype was a significant contributing factor, with Hürthle cell cancer having a worse prognosis than papillary thyroid cancer (PTC) (5/68 [7.4%] vs. 9/582 [1.5%]; relative risk: 4.76 [95% confidence interval: 1.64-13.8]). CONCLUSIONS: The recurrence rate of DRS patients with excellent response to treatment is low. It is reasonable to consider discharge of ATA low-risk or intermediate-risk patients with PTC who remain disease-free after 5 years of secondary care follow-up. Lifelong follow-up, however, currently remains the standard for subgroups at greater risk.

Improving quality of life through the routine use of the patient concerns inventory for head and neck cancer patients: main results of a cluster preference randomised controlled trial.

PURPOSE: The patient concerns inventory (PCI) is a prompt list allowing head and neck cancer (HNC) patients to discuss issues that otherwise might be overlooked. This trial evaluated the effectiveness of using the PCI at routine outpatient clinics for one year after treatment on health-related QOL (HRQOL). METHODS: A pragmatic cluster preference randomised control trial with 15 consultants, 8 'using' and 7 'not using' the PCI intervention. Patients treated with curative intent (all sites, disease stages, treatments) were eligible. RESULTS: Consultants saw a median (inter-quartile range) 16 (13-26) patients, with 140 PCI and 148 control patients. Of the pre-specified outcomes, the 12-month results for the mean University of Washington Quality of Life (UW-QOLv4) social-emotional subscale score suggested a small clinical effect of intervention of 4.6 units (95% CI 0.2, 9.0), p = 0.04 after full adjustment for pre-stated case-mix. Results for UW-QOLv4 overall quality of life being less than good at 12 months (primary outcome) also favoured the PCI with a risk ratio of 0.83 (95% CI 0.66, 1.06) and absolute risk 4.8% (- 2.9%, 12.9%) but without achieving statistical significance. Other non-a-priori analyses, including all 12 UWQOL domains and at consultant level also suggested better HRQOL with PCI. Consultation times were unaffected and the number of items selected decreased over time. CONCLUSION: This novel trial supports the integration of the PCI approach into routine consultations as a simple low-cost means of benefiting HNC patients. It adds to a growing body of evidence supporting the use of patient prompt lists more generally.

Improving quality of life through the routine use of the patient concerns inventory for head and neck cancer patients: baseline results in a cluster preference randomised controlled trial.

PURPOSE: The main aim of this paper is to present baseline demographic and clinical characteristics and HRQOL in the two groups of the Patient Concerns Inventory (PCI) trial. The baseline PCI data will also be described. METHODS: This is a pragmatic cluster preference randomised control trial with 15 consultant clusters from two sites either 'using' (n = 8) or 'not using' (n = 7) the PCI at a clinic for all of their trial patients. The PCI is a 56-item prompt list that helps patients raise concerns that otherwise might be missed. Eligibility was head and neck cancer patients treated with curative intent (all sites, stage of disease, treatments). RESULTS: From 511 patients first identified as eligible when screening for the multi-disciplinary tumour board meetings, 288 attended a first routine outpatient baseline study clinic after completion of their treatment, median (IQR) of 103 (71-162) days. At baseline, the two trial groups were similar in demographic and clinical characteristics as well as in HRQOL measures apart from differences in tumour location, tumour staging and mode of treatment. These exceptions were cluster (consultant) related to Maxillofacial and ENT consultants seeing different types of cases. Consultation times were similar, with PCI group times taking about 1 min longer on average (95% CL for the difference between means was from - 0.7 to + 2.2 min). CONCLUSION: Using the PCI in routine post-treatment head and neck cancer clinics do not elongate consultations. Recruitment has finished but 12-month follow-up is still ongoing.

Cough syncope and tracheal compression secondary to a retrosternal goitre: looking for a pulmonary embolism.

A 51-year-old man presented acutely with recurrent bouts of coughing associated with transient and brief loss of consciousness consistent with cough syncope, mild stridor and a recent history of a respiratory tract infection. A chest X-ray demonstrated tracheal narrowing. His D-dimer was negative. A non-contrast CT scan of the chest demonstrated a large retrosternal goitre causing tracheal compression, and further investigation with a contrast-enhanced CT scan of the neck and chest demonstrated an incidental finding of a large pulmonary embolus (PE). The full extent of the PE was determined through performing a CT pulmonary angiography. Doppler ultrasound demonstrated a left leg deep vein thrombosis as the primary cause of the PE. His cough syncope improved in response to anticoagulation treatment, to the point where he could be safely discharged home. He had a further significant improvement in symptoms following an elective hemithyroidectomy for retrosternal goitre.

Metastasis of carcinoma of the lung to a carotid body paraganglioma.

Tumour-to-tumour metastasis is a rare phenomenon, but has been described in the literature in just over 100 cases. It can be particularly puzzling for the reporting pathologists, when encountered unexpectedly in a tumour showing abrupt transition from the usual morphology to another unusual pattern. The literature reports a variety of combinations with carcinoma-to-carcinoma being the most common; and renal cell carcinomas appear to the most common recipient tumours with common donor tumours being breast, lung and renal cell carcinomas. The authors report a case of poorly-differentiated lung carcinoma metastasising into a carotid body paraganglioma. Our case is unique and in our knowledge the first described case of carotid body paraganglioma with metastasis from a lung primary. To the best of our knowledge this is the first report of this interesting biological phenomenon in this combination.

Intraoperative parathyroid hormone monitoring to determine long-term success of total parathyroidectomy for secondary hyperparathyroidism.

BACKGROUND: Use of intraoperative parathyroid hormone (ioPTH) monitoring during total parathyroidectomy for secondary hyperparathyroidism is common, although its ability to predict long-term normoparathyroid state is not known. METHODS: Prospective evaluation of 57 consecutive patients undergoing total parathyroidectomy for renal hyperparathyroidism with ioPTH monitoring and follow-up PTH assays were used to categorize the patients into 3 groups: success, adequate biochemical control, and failure. RESULTS: There was no statistically significant difference in percentage reduction of ioPTH between the 3 groups (p = .07), although there was a moderate negative correlation between percentage reduction of ioPTH and percentage reduction of PTH at follow-up (R = 0.57). CONCLUSIONS: When used under current guidelines, ioPTH monitoring is of no use in predicting long-term cure for these patients because it does not predict success. Patients that undergo total parathyroidectomy are required to have long-term calcium and PTH assay follow-up because normoparathyroidism cannot be assumed. Using the regression equation calculated, success may be predicted for future patients.

Extramedullary plasmacytoma of the tongue base: a case report and clinical review of head and neck plasmacytoma.

Plasmacytomas of the head and neck are rare tumors characterized by a monoclonal proliferation of plasma cells. Very few cases of plasmacytoma of the tongue base have been reported. We present a new case of extramedullary plasmacytoma of the tongue base, we discuss its diagnosis and management, and we review the literature on plasmacytomas of the head and neck.

Diagnostic biopsy of lymph nodes of the neck, axilla and groin: rhyme, reason or chance?

INTRODUCTION: Improving patient pathways of care is becoming increasingly important in the delivery of timely, appropriate surgical care. With this aim, we analysed the referral and management pathway of patients undergoing diagnostic superficial lymph node biopsy. PATIENTS AND METHODS: A retrospective review of case notes of patients undergoing diagnostic superficial lymph node biopsy over 3 years, 1998-2000 at the Bradford Hospitals NHS Trust. Indication for surgical biopsy was based on clinical suspicion following assessment in the out-patient clinic for the majority, and arrangement of investigations as deemed appropriate. There were no clinical algorithms in use during the study period. RESULTS: There was no evidence for the use of explicit protocols for referral or management. Biopsy was often delayed. Of 268 patients referred from primary care, referral was made to any of 14 hospital Department with 39% (105 of 268) attending more than one outpatient appointment, and 155 (41 of 268) attending more than one department. Eighteen percent (47 of 268) of patients were informed of their diagnosis within 6 weeks of referral and 42% (113 of 268) within 3 months of referral. Nine percent (24 of 268) underwent pre-operative fine needle aspiration cytology. Of patients with enlarged neck nodes, 29% (52/180) had examination of the upper aero-digestive tract. CONCLUSIONS: The study supports the introduction of co-ordinated problem-based referral and management pathways for the management of patients with enlarged superficial lymph nodes supported by regular audits of practice.

Dysphagia with a thyroid nodule: is there a primary aerodigestive malignancy?

Three cases of laryngopharyngeal primary squamous cell carcinoma presenting with thyroid nodules are described. The key message to take away from these cases is that patients with advanced malignancy of the upper aerodigestive tract can present with a thyroid nodule.

Growth hormone abuse and bodybuilding as aetiological factors in the development of bilateral internal laryngocoeles. A case report.

A 36-year-old man presented with hoarseness and stridor. He was an elite professional bodybuilder and admitted to having abusing anabolic steroids and growth hormone in the recent past. A CT scan showed bilateral laryngocoeles. The patient was initially managed with intravenous corticosteroids and broad-spectrum antibiotics, and the stridor resolved sufficiently to permit discharge from the hospital. He proceeded to undergo endoscopic marsupialisation of his laryngocoeles and to date has made a full recovery. This is the first reported case where anabolic steroid and growth hormone abuse combined with an elite bodybuilder's exercise regime has been implicated in the aetiology of bilateral laryngocoeles.

Mucinous intestinal type adenocarcinoma of the sinonasal tract secondary to passive wood dust inhalation: case report.

A 76-year-old female patient with a mucinous intestinal type adenocarcinoma of the sinonasal tract is described. The probable aetiology of passive hard wood dust inhalation, investigations carried out and subsequent surgical treatment using a transfacial access approach and a temporoparietal fascial composite free flap in conjunction with free auricular cartilage are described.

Upper aerodigestive tract squamous cell carcinoma: distribution of extracapsular spread and soft tissue deposits in the neck.

OBJECTIVE: Extracapsular spread (ECS) and soft tissue deposits (STD) of squamous cell carcinoma (SCC) in the neck of patients with metastatic SCC of the upper aerodigestive tract have been shown to adversely affect actuarial and disease-free survival. No studies to date have detailed the distribution of ECS and STD within the neck. MATERIAL AND METHODS: A total of 215 neck dissections from 155 patients were prospectively collected and analysed for the presence of both STD and ECS. As no classification for STD exists, their distribution was classified according to the nodal levels used for classification of cervical lymph nodes as described by the Memorial Sloan-Kettering Cancer Center. RESULTS: A total of 81 neck dissections from 59 patients were found to have either metastatic lymph nodes with ECS, STD or both. The distribution of lymph node metastasis, ECS and STD was very similar. Level II was most frequently affected, with Levels III and IV being affected less frequently. There were very few lymph node metastases to Level V, and this level contained no evidence of either ECS or STD. CONCLUSION: The method of pathological assessment of neck dissection specimens and reporting on the presence of ECS and STD has not been formalized. By analysing neck dissection specimens in the manner described we can report on the presence or absence of ECS and STD with increased accuracy. This has considerable implications for patient management.

Soft tissue deposits in neck dissections of patients with head and neck squamous cell carcinoma: prospective analysis of prevalence, survival, and its implications.

BACKGROUND: Soft tissue deposits of squamous cell carcinoma in the necks of patients with squamous cell carcinoma of the upper aerodigestive tract may represent either total effacement of a lymph node by carcinoma or extralymphatic deposits of carcinoma. There are few reports of their clinical or prognostic significance. METHODS: Data from 215 neck dissections from 155 patients with squamous cell carcinoma of the upper aerodigestive tract were studied prospectively to assess the prevalence of soft tissue deposits within the neck. The case notes of these patients were subsequently reviewed to analyze the effect on both the overall survival and recurrence-free survival. RESULTS: The prevalence rate for soft tissue deposits occurring alone was 10.3%; the prevalence rate for soft tissue deposits occurring with extracapsular spread was 13.5%. The overall prevalence rate for soft tissue deposits was 23.9%. There was a statistically significant reduction in actuarial and recurrence-free survival in patients with soft tissue deposits compared with patients with pathologically node-negative necks (P=.001), and in patients with soft tissue deposits compared with those with pathologically node-positive necks without extracapsular spread (P=.001). No statistically significant differences were found between patients with soft tissue deposits and patients with pathologically node-positive necks with extracapsular spread, for actuarial survival or recurrence-free survival. CONCLUSIONS: In this series, soft tissue deposits were associated with an aggressive clinical course and poor survival. It is therefore important that histopathologists agree on a uniform terminology when reporting soft tissue deposits and actively look for their presence when examining neck dissection specimens.