High-Grade Neuroendocrine Carcinoma Within a Tracheal Polyp: A Case Report.

INTRODUCTION: Primary carcinomas of the trachea are rare, with a reported annual incidence of one in a million. We present a case of a previously undescribed polypoid high-grade neuroendocrine carcinoma of the trachea. Resection of the carcinoma revealed only superficial invasion of the mucosa and without evidence of local or distant metastatic disease. Histologically, the tumor had high-grade features with necrosis and a high mitotic index. METHODS: Characterization of this rare neuroendocrine carcinoma of the trachea was performed by immunohistochemistry and whole-genome sequencing. RESULTS: Immunohistochemistry result was positive for neuroendocrine markers, p16 and an elevated Ki-67. Whole-genome sequencing of the lesion was performed and revealed a very unusual and very distinct mutational signature without relationship to other relevant neuroendocrine carcinomas. Neither known driver nor targetable mutations were found by whole-genome sequencing. Analysis of the sequence of numerous viral elements of human papillomavirus-18 suggests that the pathogenesis of the lesion is related to viral integration. The patient developed distal recurrence, which progressed to widespread pulmonary dissemination, presumably through aerogenous spread of disease. CONCLUSIONS: This is the first characterization of this type of tracheal tumor, including genomic findings, pathogenesis, and natural history.

Oncosuppressor-Mutated Cell-Based Diagnostic Platform for Liquid Biopsy Diagnoses Benign Head and Neck Masses and Predicts Malignancy in Thyroid Nodules: Results from a Consecutive Cohort of Patients.

BACKGROUND: We reported that a novel oncosuppressor-mutated cell (OMC)-based platform has the potential for early cancer detection in healthy individuals and for identification of cancer patients at risk of developing metachronous metastases. OBJECTIVE: Herein, we sought to determine the diagnostic accuracy of this novel OMC-based platform in a consecutive cohort of patients operated for suspicious head and neck masses. METHODS: OMCs (BRCA1-deficient fibroblasts) were exposed to blood serum from patients with head and neck nodules before surgical removal. These cells were analyzed for their proliferation and survival. Treated OMCs were inoculated subcutaneously in NOD/SCID mice, and tumor growth was monitored over time. RESULTS: OMCs exposed to serum from patients with malignant lesions displayed increased proliferation compared to those exposed to serum from patients with benign lesions. Only OMCs exposed to serum from patients diagnosed with malignant thyroid neoplasia generated a cancerous mass. The sensitivity of the test was 92%, with only 1 false negative out of 34 patients. Immunohistochemical staining showed that the cancerous masses were poorly differentiated adenocarcinomas with high proliferative index. CONCLUSIONS: These data show that liquid biopsy combined with an OMC-based in vivo platform has the potential to diagnose benign head and neck masses and predict whether a thyroid nodule is malignant. These results strengthen the concept that OMCs can be used to detect circulating malignant factors in cancer patients.

A thyroid gland with over 30 foci of papillary thyroid carcinoma with activating BRAF V600E mutation.

Multifocal papillary thyroid carcinoma (PTC) is common and the number of tumor foci rarely exceeds ten. The mechanism of multifocal disease is debated, with the two main hypotheses consisting of either intrathyroidal metastatic spread from a single tumor or independent multicentric tumorigenesis from distinct progenitor cells. We report the case of a 46-year-old woman who underwent total thyroidectomy and left central neck lymph node dissection after fine-needle aspiration of bilateral thyroid nodules that yielded cytological findings consistent with PTC. Final pathology of the surgical specimen showed an isthmic dominant 1.5 cm classical PTC and over 30 foci of microcarcinoma, which displayed decreasing density with increasing distance from the central lesion. Furthermore, all malignant tumors and lymph nodes harbored the activating BRAF V600E mutation. The present case highlights various pathological features that support a mechanism of intraglandular spread, namely a strategic isthmic location of the primary tumor, radial pattern of distribution and extensive number of small malignant foci and BRAF mutational homogeneity. Learning points: Multifocal papillary thyroid carcinoma (PTC) is commonly seen in clinical practice, but the number of malignant foci is usually limited to ten or less. There is no clear consensus in the literature as to whether multifocal PTC arises from a single or multiple distinct tumor progenitor cells. Strategic location of the dominant tumor in the thyroid isthmus may favor intraglandular dissemination of malignant cells by means of the extensive lymphatic network. An important pathological finding that may be suggestive of intrathyroidal metastatic spread is a central pattern of distribution with a reduction in the density of satellite lesions with increasing distance from the dominant focus. PTCs originating from the isthmus with intraglandular metastatic dissemination behave more aggressively. As such, a more aggressive treatment course may be warranted, particularly with regard to the extent of surgery.

Thyroid Nodule DNA Methylation Signatures: An Important Diagnostic Annotation.

Molecular profiling in thyroid cancer has made significant progress in part due to advances in somatic mutation profiling. Yet, differentiating benign from malignant thyroid nodules remains elusive. A unique set of DNA methylation signatures has the potential of improving thyroid cancer molecular diagnostics based on the DNA methylome.See related article by Yim et al., p. 544.

Measuring Decision-Making During Thyroidectomy: Validity Evidence for a Web-Based Assessment Tool.

BACKGROUND: Errors in judgment during thyroidectomy can lead to recurrent laryngeal nerve injury and other complications. Despite the strong link between patient outcomes and intraoperative decision-making, methods to evaluate these complex skills are lacking. The purpose of this study was to develop objective metrics to evaluate advanced cognitive skills during thyroidectomy and to obtain validity evidence for them. METHODS: An interactive online learning platform was developed ( www.thinklikeasurgeon.com ). Trainees and surgeons from four institutions completed a 33-item assessment, developed based on a cognitive task analysis and expert Delphi consensus. Sixteen items required subjects to make annotations on still frames of thyroidectomy videos, and accuracy scores were calculated based on an algorithm derived from experts' responses ("visual concordance test," VCT). Seven items were short answer (SA), requiring users to type their answers, and scores were automatically calculated based on their similarity to a pre-populated repertoire of correct responses. Test-retest reliability, internal consistency, and correlation of scores with self-reported experience and training level (novice, intermediate, expert) were calculated. RESULTS: Twenty-eight subjects (10 endocrine surgeons and otolaryngologists, 18 trainees) participated. There was high test-retest reliability (intraclass correlation coefficient = 0.96; n = 10) and internal consistency (Cronbach's α = 0.93). The assessment demonstrated significant differences between novices, intermediates, and experts in total score (p < 0.01), VCT score (p < 0.01) and SA score (p < 0.01). There was high correlation between total case number and total score (ρ = 0.95, p < 0.01), between total case number and VCT score (ρ = 0.93, p < 0.01), and between total case number and SA score (ρ = 0.83, p < 0.01). CONCLUSION: This study describes the development of novel metrics and provides validity evidence for an interactive Web-based platform to objectively assess decision-making during thyroidectomy.

Evolving Management of Zenker's Diverticulum in the Endoscopic Era: A North American Experience.

BACKGROUND: Open surgical cricopharyngeal myotomy(CM) is considered standard of care for Zenker's diverticulum(ZD). Trans-oral CM has been described using a rigid stapling device for two decades; however, this remains problematic for severely kyphotic patients. This problem can be overcome with flexible endoscopy utilizing an electrosurgical needle knife. We sought to compare clinical outcomes between these techniques to stratify patient selection. METHODS: Patients undergoing ZD treatment from 1992 to 2015 were reviewed. Demographics, diverticulum size, post-operative complications, and length of stay (LOS) were compared between open cricopharyngeal myotomy (OpenCM), rigid trans-oral stapling myotomy (RigidCM), and flexible endoscopic myotomy (FlexCM). Dysphagia scores (DS, 0:best-4:worst) and pneumonia incidence were assessed pre-operatively and post-operatively. RESULTS: 62 patients underwent OpenCM (39/62(63 %)) or endoscopic CM (23/62(37 %) (8 RigidCM/15 FlexCM)). CM significantly reduced dysphagia for all approaches [OpenCM:2(2-3)-0(0-0); RigidCM:2(2-2)-0(0-0); FlexCM:3(3-3)-0(0-0)]. FlexCM patients had significantly worse pre-operative DS. Endoscopic CM was attempted and completed in 23/35(66 %) patients. Reasons for OpenCM conversion included inability to position the diverticular retractor due to patient body habitus (RigidCM), and the inability to position the overtube due to small ZD (FlexCM). Major post-operative complications were rare and similar in all groups. Medium-to-long-term post-myotomy pneumonia was comparable between groups. LOS (days) was reduced for FlexCM (1(1-2)) versus RigidCM (3(2-6)) and OpenCM (4(3-7)). CONCLUSIONS: CM is highly effective for treating ZD. Open and endoscopic approaches offer comparable outcomes and dysphagia resolution. FlexCM is efficacious for large ZD and can be performed in most patients irrespective of body habitus. FlexCM represents an excellent approach for large ZD, while OpenCM should be reserved for small ZD for which an overtube cannot be positioned.

Defining competencies for safe thyroidectomy: An international Delphi consensus.

BACKGROUND: Current methods for teaching and assessing competencies that characterize expert intraoperative performance are inconsistent, subjective, and lack standardization. This mixed-methods study was designed to define and establish expert consensus on the most important competencies required to perform a thyroidectomy safely. METHODS: Cognitive task analyses for thyroidectomy were performed with semistructured interviews of experts in thyroid surgery. Verbal data were transcribed verbatim, coded, and categorized according to themes that were synthesized into a list of items. Once qualitative data reached saturation, 26 experts were invited to complete 2-round online Delphi surveys to rank each item on a Likert scale of importance (1-7). Consensus was predefined as a Cronbach's α ≥ 0.80. RESULTS: Sixty items were synthesized from 5 interviews and categorized into 8 sections: preparation (n = 8), incision/exposure (n = 11), general considerations (n = 4), middle thyroid vein (n = 1), superior pole (n = 5), inferior pole (n = 5), posterolateral dissection (n = 19), and closure (n = 7). Eighteen (69%) experts from 3 countries participated in the Delphi survey. Consensus was achieved after 2 voting rounds (Cronbach's α = 0.95). Greatest weighted sections included "Superior Pole Dissection" and "Posterolateral Dissection." CONCLUSION: Consensus was achieved on defining the most important competencies for safe thyroidectomy. This blueprint serves as the basis for instructional design and objective assessment tools to evaluate performance.

Rare metastases of well-differentiated thyroid cancers: a systematic review.

BACKGROUND: A minority of metastatic well-differentiated thyroid cancer (WDTC) patients present with end-organ disease other than in the lung, bone or lymph nodes. These metastases tend to be overlooked because of their low incidence, and this results in delayed diagnosis. The purpose of this study was to perform a systematic review of the clinical and histologic features of unusual WDTC metastases. METHODS: A systematic literature search of bibliographic databases, reference lists of articles, and conference proceedings was performed up to 2013. Studies were included if they reported on adult patients with WDTC and pathology-proven metastases to end-organs other than lung, bone, or lymph nodes. A total of 238 studies were included in a qualitative analysis. Data is expressed as N (%) and median [interquartile range]. RESULTS: A total of 492 patients (median age, 62 years [50-70 years]) were identified in 197 case reports and 42 case series. There were 22 different end-organ metastatic sites documented with either papillary [255 (57 %)], follicular [172 (39 %)], or Hürthle-cell [18 (4 %)] histology. A total of 181 (41 %) patients presented with solitary metastasis and 54 (93 %) with elevated serum thyroglobulin. Positron emission tomography and whole-body radioactive iodine scans revealed hypermetabolic foci in 28 (97 %) and 50 (81 %) cases, respectively. Disease-free interval following the initial diagnosis of the primary thyroid cancer was highly variable, ranging from synchronous presentation [66 (33 %)] to metachronous disease after 516 months [mean 86 months (SD 90)]. CONCLUSIONS: WDTC can manifest with highly variable and unusual clinical features. Rare sites of metastases should be considered in the absence of the more common extra-cervical disease recurrence locations.

Parathyroid hormone levels 1 hour after thyroidectomy: an early predictor of postoperative hypocalcemia.

BACKGROUND: Parathyroid dysfunction leading to symptomatic hypocalcemia is not uncommon following a total or completion thyroidectomy and is often associated with significant patient morbidity and a prolonged hospital stay. A simple, reliable indicator to identify patients at risk would permit earlier pharmacologic prophylaxis to avoid these adverse outcomes. We examined the role of intact parathormone (PTH) levels 1 hour after surgery as a predictor of post-thyroidectomy hypocalcemia. METHODS: We prospectively reviewed the cases of consecutive patients undergoing total or completion thyroidectomy. Ionized calcium (Ca(2+)) and intact PTH levels were measured preoperatively and at 1-, 6- and 24-hour intervals postoperatively. The specificity, sensitivity, negative and positive predictive values of the 1-hour PTH serum levels (PTH-1) in predicting 24-hour post-thyroidectomy hypocalcemia and eucalcemia were determined. RESULTS: We reviewed the cases of 149 patients. Biochemical hypocalcaemia (Ca(2+) < 1.1 mmol/L) developed in 38 of 149 (25.7%) patients 24 hours after thyroidectomy. The sensitivity, specificity, positive and negative predictive values of a low PTH-1 were 89%, 100%, 97% and 100%, respectively. CONCLUSION: We found that PTH-1 levels were predictive of symptomatic hypocalcemia 24 hours after thyroidectomy. Routine use of this assay should be considered, as it could prompt the early administration of calcitriol in patients at risk of hypocalcemia and allow for the safe and timely discharge of patients expected to remain eucalcemic.

CONTEXTE: Il n'est pas rare qu'un dysfonctionnement des glandes parathyroïdes entraînant une hypocalcémie symptomatique s'observe après une thyroïdectomie totale ou de complétion et il est souvent associé à une importante morbidité chez les patients et à un séjour hospitalier prolongé. Un indicateur simple et fiable permettant de reconnaître les patients à risque pourrait favoriser une prophylaxie pharmacologique précoce afin d'éviter ces complications. Nous avons examiné le rôle des taux de parathormone (PTH) intacte une heure après la chirurgie comme prédicteurs de l'hypocalcémie post-thyroïdectomie. MÉTHODES: Nous avons passé en revue de manière prospective des cas consécutifs de patients soumis à une thyroïdectomie totale ou de complétion. Les taux de calcium ionisé (Ca2+) et de PTH intacte ont été mesurés avant l'intervention, puis 1 heure, 6 heures et 24 heures après. Il a ainsi été possible de déterminer la spécificité, la sensibilité, la valeur prédictive négative et positive des taux sériques de PTH 1 heure après l'intervention (PTH-1) pour ce qui est de prédire l'hypocalcémie et l'eucalcémie 24 heures après la thyroïdectomie. RÉSULTATS: Nous avons analysé 149 cas. L'hypocalcémie biochimique (Ca2+ < 1,1 mmol/L) a été observée chez 38 patients sur 149 (25,7 %) 24 heures après la thyroïdectomie. La sensibilité, la spécificité, la valeur prédictive positive et négative d'un taux de PTH-1 faible ont été respectivement de 89 %, 100 %, 97 % et 100 %. CONCLUSION: Nous avons noté que les taux de PTH-1 étaient prédictifs d'une hypocalcémie symptomatique 24 heures après la thyroïdectomie. L'utilisation d'emblée de ce test est à envisager puisqu'elle permettrait l'administration précoce de calcitriol chez les patients exposés à un risque d'hypocalcémie et un congé sécuritaire et rapide chez les patients dont on s'attend à ce qu'ils demeurent eucalcémiques.

Determinants of urolithiasis before and after parathyroidectomy in patients with primary hyperparathyroidism.

OBJECTIVE: To assess the determinants of urolithiasis in patients with primary hyperparathyroidism (PHPT) before and after parathyroidectomy (PTX). METHODS: Institutional Research Ethics approval was obtained. A retrospective review was performed for patients presenting with PHPT to the stone, surgical oncology, and otolaryngology clinics at 2 tertiary-care centers from January 2006 to November 2011. Demographic, clinical, and surgical data were collected together with 24-hour urine collections before and after PTX. RESULTS: Of 332 patients undergoing PTX, 255 (68.2% female patients) had PHPT. Mean age was 60.3 years (range, 18-91). Before PTX, renal calcification was detected in 51 (20%) patients, nephrolithiasis in 48 (18.8%), and nephrocalcinosis in 3 (1.2%) patients. Compared with PHPT patients without stones, PHPT patients with stones were significantly younger (56.4 vs 61.3 years, P=.02), less likely to be female (54.9% vs 71.9%, P=.03), and had significantly lower levels of vitamin D (19.7 vs 23.5 ng/mL, P=.03). Nine patients (3.5%) developed stones after PTX and were found to have significantly higher post-PTX total serum calcium levels when compared with those without stones. Although hypercalciuria was detected in 62% of pre-PTX stone formers, none of those who tested had post-PTX hypercalciuria (P<.001). On multivariate regression analysis, post-PTX stone formation was associated with male gender (adjusted odds ratio [95% confidence interval]: 6.8 [5.3-7.2], P=.01) and post-PTX hypercalcemia (adjusted odds ratio [95% confidence interval]: 1.48 [1.33-2.12], P=.02). CONCLUSION: Pre-PTX urolithiasis was associated with younger age, male gender, and lower levels of vitamin D, whereas post-PTX urolithiasis was independently predicted by male gender and hypercalcemia.

Cost-effectiveness of molecular testing for thyroid nodules with atypia of undetermined significance cytology.

CONTEXT: Novel molecular diagnostics, such as the gene expression classifier (GEC) and gene mutation panel (GMP) testing, may improve the management for thyroid nodules with atypia of undetermined significance (AUS) cytology. The cost-effectiveness of an approach combining both tests in different practice settings in North America is unknown. OBJECTIVE: The aim of the study was to determine the cost-effectiveness of two diagnostic molecular tests, singly or in combination, for AUS thyroid nodules. DESIGN AND SETTING: We constructed a microsimulation model to investigate cost-effectiveness from US (Medicare) and Canadian healthcare system perspectives. PATIENTS: Low-risk patients with AUS thyroid nodules were simulated. INTERVENTIONS: We examined five management strategies: 1) routine GEC; 2) routine GEC + selective GMP; 3) routine GMP; 4) routine GMP + selective GEC; and 5) standard management. MAIN OUTCOME MEASURES: Lifetime costs and quality-adjusted life-years were measured. RESULTS: From the US perspective, the routine GEC + selective GMP strategy was the dominant strategy. From the Canadian perspective, routine GEC + selective GMP cost and additional CAN$24 030 per quality-adjusted life-year gained over standard management, and was dominant over the other strategies. Sensitivity analyses reported that the decisions from both perspectives were sensitive to variations in the probability of malignancy in the nodule and the costs of the GEC and GMP. The probability of cost-effectiveness for routine GEC + selective GMP was low. CONCLUSIONS: In the US setting, the most cost-effective strategy was routine GEC + selective GMP. In the Canadian setting, standard management was most likely to be cost effective. The cost of these molecular diagnostics will need to be reduced to increase their cost-effectiveness for practice settings outside the United States.

A multi-institutional international study of risk factors for hematoma after thyroidectomy.

BACKGROUND: Cervical hematoma can be a potentially fatal complication after thyroidectomy, but its risk factors and timing remain poorly understood. METHODS: We conducted a retrospective, case-control study identifying 207 patients from 15 institutions in 3 countries who developed a hematoma requiring return to the operating room (OR) after thyroidectomy. RESULTS: Forty-seven percent of hematoma patients returned to the OR within 6 hours and 79% within 24 hours of their thyroidectomy. On univariate analysis, hematoma patients were older, more likely to be male, smokers, on active antiplatelet/anticoagulation medications, have Graves' disease, a bilateral thyroidectomy, a drain placed, a concurrent parathyroidectomy, and benign pathology. Hematoma patients also had more blood loss, larger thyroids, lower temperatures, and higher blood pressures postoperatively. On multivariate analysis, independent associations with hematoma were use of a drain (odds ratio, 2.79), Graves' disease (odds ratio, 2.43), benign pathology (odds ratio, 2.22), antiplatelet/anticoagulation medications (odds ratio, 2.12), use of a hemostatic agent (odds ratio, 1.97), and increased thyroid mass (odds ratio, 1.01). CONCLUSION: A significant number of patients with a postoperative hematoma present >6 hours after thyroidectomy. Hematoma is associated with patients who have a drain or hemostatic agent, have Graves' disease, are actively using antiplatelet/anticoagulation medications or have large thyroids. Surgeons should consider these factors when individualizing patient disposition after thyroidectomy.

Primitive neuroectodermal tumor (PNET) as somatic-type malignancy arising from an extragonadal germ-cell tumor: clinical, pathological and molecular features of a case.

We report a rare case of a 34-year-old man with a right axillary mass. Ten years previously, he had been diagnosed with a right scapular nonseminomatous germ-cell tumor consisting of teratoma, completely resected without any further treatment. Presently he was found to have a metastatic malignant small round cell tumor consistent with a secondary somatic malignancy arising in the background of nonseminomatous germ-cell tumor, teratoma, yolk sac tumor, and primitive neuroectodermal tumor with distinct chromosome 22 translocation. Although the patient initially responded well to chemotherapy with etoposide, cisplatin, ifosfamide and mesna, he relapsed shortly after.

Incidental thyroid "PETomas": clinical significance and novel description of the self-resolving variant of focal FDG-PET thyroid uptake.

BACKGROUND: Recent series of incidental thyroid activity on fluorodeoxyglucose positron emission tomography (FDG-PET) in patients evaluated for nonthyroidal malignancy, which we refer to as a "PEToma," have suggested that such lesions are associated with a significant incidence of primary thyroid cancer. METHODS: We retrospectively reviewed 6457 FDG-PET scans performed on 4726 patients from May 2004 to March 2007. We reviewed the cases of patients whose PET or computed tomography (CT) radiology reports described PET uptake within the thyroid to identify incidence and malignant potential of PETomas and evaluate their clinical and histopathologic features. RESULTS: We found that 160 patients (3.4%) had incidental, abnormal FDG uptake in the thyroid gland, 103 of whom had focal uptake (the PEToma group). Of these patients, 50 (48%) underwent further investigations, including ultrasonography in 48, fine-needle aspiration cytology in 38 and computed tomography in 3. Ten patients underwent surgery, and papillary thyroid cancer was identified in 9. The remaining 53 patients with PETomas underwent no further investigation. Interestingly, 5 patients who had focal uptake within the thyroid showed either spontaneous resolution on repeat FDG-PET (self-resolving) or no focal lesion on subsequent ultrasonography (false-positive). CONCLUSION: The incidence of papillary thyroid cancer in the present series is similar to that in the literature. Although some patients will show self-resolving or false-positive focal thyroid uptake on FDG-PET, we believe that, if the patient's clinical status permits, the evaluation of patients with incidental thyroid PEToma should include ultrasonographic confirmation and fine-needle aspiration cytology.

The role of sentinel lymph node biopsy in differentiated thyroid carcinoma.

OBJECTIVE: To determine whether sentinel lymph node (SLN) biopsy can accurately predict central compartment metastasis in patients with differentiated thyroid carcinoma. DESIGN: Prospective clinical study. SETTING: Academic tertiary care center. PATIENTS: Ninety-eight patients (82 women and 16 men; mean age, 48.3 years) underwent a total thyroidectomy and central compartment dissection. INTERVENTION: Peritumoral injection of methylene blue dye, 1%, followed by SLN biopsy. MAIN OUTCOME MEASURES: The final pathology report established the presence of metastasis among SLNs and lymph nodes that did not stain blue (non-SLNs [NSLNs]). RESULTS: Differentiated thyroid carcinoma was found in 75 of 98 patients (77%). Seventy of 75 patients with differentiated thyroid carcinoma presented with SLNs and/or NSLNs within the central compartment. Fifteen of 70 patients had metastasis-positive SLNs, while 55 had metastasis-negative SLNs. Six of 15 patients with positive SLNs also had positive NSLNs. No patients with negative SLNs were found to have positive NSLNs. Sentinal lymph node status was a highly significant predictor of NSLN result (Fisher exact test, P < .001). The accuracy, sensitivity, specificity, and positive and negative predictive values of SLN biopsy were 87%, 100%, 86%, 40%, and 100%, respectively. CONCLUSIONS: To our knowledge, this is the largest series of SLN biopsy in patients with differentiated thyroid carcinoma. Our experience suggests that this is an accurate and noninvasive means to identify subclinical lymph node metastasis. Because negative SLNs correlate strongly with a negative central compartment (100% in this study, P < .001), this technique can be used as an intraoperative guide when determining the extent of surgery necessary in cervical level VI.

Fine-needle aspiration cytology of Castleman disease: case report with review of the literature.

Organs involved by Castleman disease (CD) may be investigated by fine-needle aspiration cytology. No specific cytomorphological criteria are currently described for a definitive diagnosis. The cytological features of three fine-needle aspirations from three different lymph nodes of a patient with histologically confirmed CD of the hyaline-vascular type are herein reported, with a review of the literature. The fine-needle aspirations showed branching capillaries associated with fragments of germinal center. Review of the literature yielded 12 other case reports with over half describing similar findings. Because branching hyalinized small blood vessels penetrating follicular germinal center are characteristic of CD of the hyaline-vascular type on histology, this finding in fine-needle aspirates should raise that diagnostic possibility.

Radio-guided minimally invasive parathyroidectomy under local anesthesia.

BACKGROUND: Despite the high success rate of the complete bilateral neck exploration to treat primary hyperparathyroidism, less invasive alternatives have been emerging. In an attempt to reduce operative time and decrease perioperative morbidity, we reported our experience with radio-guided minimally invasive parathyroidectomy (RMIP) under local anesthesia. STUDY DESIGN: A retrospective chart review was carried out to study 55 consecutive patients, in an adult tertiary care hospital (Montreal General Hospital), who underwent RMIP under local anesthesia over a 30-month period. Charts were reviewed for operative information, radiological and pathological diagnoses and post-operative course. The main outcome measures were the accuracy of localizing the parathyroid adenoma, operative time, achievement of normocalcemia post-operatively and perioperative morbidity. RESULTS: Of the 55 patients we studied, 51 were cured as defined by normocalcemia following a single intervention, for an overall cure rate of approximately 93%. Four patients required an additional procedure: In two because of failure to remove a diseased gland, and in two because of multiglandular disease. The preoperative sestamibi scan accurately predicted the location of all abnormal parathyroid glands in 53 cases. In the remaining two cases, the scan failed to predict multiglandular disease. Average total operative time was 39 minutes. There were no major complications. CONCLUSIONS: RMIP under local anesthesia is a safe and effective modality to treat primary hyperparathyroidism. The short operative time, the use of local anesthesia and the low complication rate make this technique a viable alternative.

Large remnant 131I ablation as an alternative to completion/total thyroidectomy in the treatment of well-differentiated thyroid cancer.

BACKGROUND: An alternative to completion thyroidectomy for well-differentiated thyroid carcinoma is to ablate the remnant lobe with 131 I. The purpose of this study is to review our own experience with large remnant ablation. METHODS: A retrospective review of 169 patients with well-differentiated thyroid cancer treated at one institution over a 14-year period was undertaken. Seventy-one patients who underwent partial thyroidectomy (PT) followed by 131 I ablation were identified. This group was compared to 98 patients treated with total thyroidectomy (TT). RESULTS: Mean follow-up was 6.2 years for the 71 PT + 131 I versus 4.7 years for the 98 TT patients (P = .184). Recurrence occurred in 4 of 71 PT + I 131 patients (5.6%) versus 9 of 98 TT patients (9.2%) (P = .393). Other than a tendency for the size of the primary to be slightly larger and for the histology to be follicular carcinoma in the PT + 131 I patients, the 2 groups were nearly identical in age, gender, and other prognostic factors such as capsular invasion and metastases. CONCLUSIONS: Large-dose ablation with 131 I is a viable alternative to completion thyroidectomy. Recurrence rates over an average 6-year period are similar to TT. Long-term monitoring of these cohorts is required.