Thyroid nodular disease in pregnancy: current diagnosis and management.
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Algorithms↗
Biomedical subjects
I B Rosen
Publications and source records attributed to I B Rosen.
Prognostic features in tall cell papillary carcinoma and insular thyroid carcinoma.
Tall cell papillary carcinoma (TCPC) and insular carcinoma (IC) are variants of thyroid carcinoma that are considered to be more aggressive than well differentiated papillary or follicular carcinoma. To determine the clinical significance of these diagnoses, we evaluated 65 patients with these tumors. There were 30 TCPCs, 27 ICs, and 8 ICs or TCPCs with focal anaplastic carcinoma (FAC). Forty-two patients (27 TCPCs, 14 ICs, and 1 FAC) are alive and free of disease. Nine patients with IC are alive with distant metastases. Ten patients (2 TCPCs, 2 ICs, and 7 FACs) died of disease. Univariate analysis of disease-free interval determined that, as for all thyroid carcinomas, patient age, tumor size, extrathyroidal extension, and lymph node metastases were significant for prognosis. ICs did significantly worse than TCPCs. Focal anaplastic dedifferentiation predicted a worse prognosis. Multivariate analysis for disease-free interval showed age, number of lymph node metastases, and tumor type to be significant. Analysis of the same factors for prediction of mortality showed that TCPC and IC were not significantly different. These data suggest that TCPC is less aggressive than IC, which often results in disseminated disease. Focal AC predicts poor survival.
Adult↗
Evaluation of single isotope technetium 99M-sestamibi in localization efficiency for hyperparathyroidism.
BACKGROUND: Regardless of surgical effectiveness, ongoing activity in parathyroid localization in hyperparathyroidism (HPT) is an established enterprise. Sestamibi (MIBI), the most recent new modality, is being assessed in this regard. METHODS: Twenty mCI of 99 TC Sestamibi was administered intravenously in patients with prospective HPT. Images were assessed by pinhole and full-field gamma camera at 20 minutes and 2 hours. Dual-phase one isotope only was utilized. Patients were then studied for pathology and MIBI correlation. RESULTS: Sixty-three cases underwent MIBI scanning, 50, or 79%, of which were due to a single adenoma. Sensitivity showed in 41 of 50 adenomas and was 82% correct. Quadrant localization was 97%. Eleven patients showed hyperplasia with MIBI sensitivity of 82% on a case basis but only 31% for multiglandular disease. Overall MIBI sensitivity is 80%. One false-positive and one true-negative case were observed. All patients achieved eucalcemia. No operative morbidity of significance occurred. CONCLUSION: Scanning with 99M Sestamibi dual-phase technique is the preferred mode of parathyroid localization in current practice. It is of assistance in primary HPT, essential in recurrent HPT, and of use in ectopic gland detection. It can support surgical intervention in the marginal HPT patient. Scanning still requires bilateral exploration for complete assessment.
Adenoma↗
ret/PTC-1, -2, and -3 oncogene rearrangements in human thyroid carcinomas: implications for metastatic potential?
The ret/PTC oncogene is unique to papillary thyroid cancer. Three forms of this oncogene, formed by translocation of three different genes to the tyrosine kinase domain of the ret protooncogene, result in constitutive kinase activation. Correlation with clinical outcome is controversial; ret/PTC-1 has been suggested to predict aggressive behavior. There is no morphological description of ret/PTC-positive tumors. We analyzed 60 thyroid carcinomas for ret/PTC expression to determine correlation with clinical history, disease stage, or tumor morphology. Ribonucleic acid extracted from frozen tissue was reverse transcribed; PCR was performed to amplify ret/PTC-1, 2, and -3. The TPC-1 cell line was the positive control for ret/PTC-1. All tumors were characterized morphologically. Clinical data were collected. The 57 papillary and 3 follicular carcinomas were resected from 44 female patients and 15 males. The average age at diagnosis was 46.2 yr (range. 24-83 yr). Three patients had a history of neck irradiation. At diagnosis, 11 patients had extrathyroidal tumor extension, 20 had lymph node metastases, and 1 had lung metastasis. Thirteen patients had tall cell papillary carcinomas; 3 tumors had focal insular or anaplastic dedifferentiation. The average follow-up was 13.4 months, during which 4 patients had recurrent disease. No deaths occurred. One papillary carcinoma (1.7%) was positive for ret/PTC-1, none was positive for ret/PTC-2, and 2(3.4%) were positive for ret/PTC-3. Although all 3 patients who had tumors containing ret/PTC rearrangements were under the age of 45 yr (range, 26-44 yr) and had small tumors (< 1.2 cm), 2 of these 3 patients presented with lymph node metastases, and the third had lymphatic invasion. ret/PTC oncogene expression did not correlate with radiation history. In summary, ret/PTC oncogene rearrangements were found in 3 of 60 (5%) thyroid carcinomas and were not present in tumors with aggressive morphological features. However, we found ret/PTC rearrangements in young patients (< 45 yr of age) with small thyroid carcinomas showing a predisposition for lymphatic involvement, suggesting a possible role in the development of this subgroup of tumors.
Adult↗
Dr. Norman Bethune as a surgeon.
Dr. Norman Bethune's recognition as a Canadian of renown resulted from his devoted work in China during the late 1930s. He had received a general surgical training, but his personal illness with tuberculosis led him to specialize in thoracic surgery. A surgical program at McGill University under Dr. Edward Archibald, a pioneer thoracic surgeon, was initially successful, but by the mid-1930s Bethune was rejected by McGill and Dr. Archibald. He became chief of thoracic surgery at the Hôpital du Sacré-Coeur outside Montreal. H developed thoracic surgical instruments and wrote numerous scientific papers. The outbreak of civil war in Spain in 1937 attracted Bethune to oppose what he viewed as fascist aggression. He went to Spain, where he established the value of mobile blood banking. On his return to Canada in 1937 he became aware of the escalating war between China and Japan. He joined the Chinese communist forces in northern China and spent 18 months doing Herculean mobile war surgery, while improving the state of medical services in primitive, depressing conditions. He died in 1939 at the age of 49 years of septicemia as a result of accidental laceration of his finger during surgery. The Chinese have venerated Norman Bethune and stimulated his memorialization in Canada. His surgical record can be viewed as mixed in quality, but overall his performance remains impressive for its achievement.
Canada↗
Occult micropapillary carcinoma associated with benign follicular thyroid disease and unrelated thyroid neoplasms.
Surgically resected thyroids from 425 patients with thyroid disease other than carcinoma of follicular cell derivation were thoroughly examined for occult micropapillary carcinoma (MPC). There were 317 cases of nodular hyperplasia, 36 of thyroiditis, 44 follicular adenomas, and 28 others. Glands were sectioned at 2- to 3-mm intervals and fixed in formalin. Every section was examined histologically. There were 71 cases (16.7%) of MPC containing 118 tumors. Among 343 women, 51 (14.9%) had MPC; among 82 men, 20 (24.4%) had MPC. The average age of all of the patients was 46.9 years and of those with MPC, 50.5 years. The occurrence of MPC peaked between 40 and 70 years and declined in older patients. MPC was found in 8.9% of patients who underwent lobectomies, 10.8% who had hemithyroidectomies, and 24.1% of those who had total thyroidectomies. Logistic regression analysis revealed significant associations between the presence of MPC and the patient sex, age, and extent of surgery; in contrast, there was no association between the occurrence of MPC and the underlying thyroid disease. These data indicate that MPC is present in up to 24.1% of thyroids removed for unrelated thyroid disease. The predominance of this lesion in men is in striking contrast to the occurrence of clinically significant thyroid cancer. This suggests that the initiation of carcinogenesis is not sexually dimorphic, whereas promoters of tumor growth are. A rational management of this common disease awaits the results of careful controlled trials.
Adolescent↗
Secondary malignancy of the thyroid gland and its management.
BACKGROUND: Secondary cancer of the thyroid gland is widely acknowledged as infrequent but is a persistent problem requiring ongoing awareness, particularly with respect to clinical recognition and treatment. METHODS: From 1978 to 1993, a 15-year period, patients demonstrating secondary involvement of the thyroid gland as a surgical problem were collected and analyzed with regard to pathology, demography, behavior of primary and secondary disease, treatment, and patient outcome. RESULTS: In the 15-year span, 11 patients with secondary involvement of the thyroid gland were recognized, consisting of 3 men and 8 women with primary lesions occurring in oral cavity, esophagus, stomach, colon, pancreas, breast, skin, unknown, kidney, and lung. Needle biopsy produced a 90% malignancy rate but in only half of such cases was the diagnosis specific for secondary malignancy. Eight of 11 underwent palliative surgery, usually total thyroidectomy. No patient survived > 2 years. There was no undue surgical morbidity. One patient died of pulmonary embolus postoperatively. CONCLUSIONS: Secondary cancer of the thyroid is rare and can be detected by fine-needle aspiration biopsy in the face of clinical findings. Where indicated, palliative thyroidectomy can be effective, because other methods of treatment appear ineffective.
Aged↗
Management of the hot thyroid nodule.
BACKGROUND: Solitary hyperfunctioning nodules of the thyroid gland are usually viewed as benign. They may present with autonomous euthyroidism but are of concern for potential progression to hyperthyroidism. Various methods of treatment are worthy of consideration. PATIENTS AND METHODS: Forty-five patients with solitary hot thyroid nodules verified by radioisotope scintiscanning were selected for treatment. Thirty-one underwent surgery, usually partial thyroidectomy. Eight euthyroid patients received no treatment, 5 underwent therapy with radioactive iodine (RAI), and 1 received thyroid suppression treatment. The cases were assessed retrospectively. RESULTS: Thyroidectomy patients had no morbidity, were well, and showed 1 Hürthle cell tumor and 5 coincidental small malignancies associated with benign hot nodules, including a contralateral cancer. Untreated patients showed continuance of good health, but nodules persisted and 1 Graves' orbititis occurred. The RAI-treated patients had persistent nodularity, improved function, and 1 case of hyperparathyroidism. Thyroid feeding only caused iatrogenic toxicity and was discontinued. CONCLUSIONS: There are various techniques for managing the hot nodule. Nonsurgical methods may be effective, but can result in persistent nodularity and iatrogenic sequelae. Excision had no morbidity in this series and was effective in providing immediate relief of problems present and potential.
Adenocarcinoma↗
Management considerations in Hürthle cell carcinoma.
BACKGROUND: Hürthle cell tumors still pose issues concerning diagnosis and management. METHODS: From 1984 to 1993 forty-seven patients underwent thyroidectomy, and they were diagnosed after operation to have presumptive Hürthle cell tumors. The surgical pathologic findings were reviewed. In the neoplastic group the chart was reviewed for clinical features and outcome. RESULTS: Thirty-one patients had nonneoplastic Hürthle cell nodules. Eleven (69%) of the 16 tumors were malignant affecting 11 women and five men ranging in age from 22 to 86 years. Two patients died of cancer for a 18% rate; one patient is alive with disease. Operations were uncomplicated. Factors for adverse outcome include tumor size greater than 4 cm, woman older than 60 years of age, and complete capsular invasion on surgical pathologic findings. CONCLUSIONS: Fine-needle aspiration biopsy demonstration of Hürthle cell lesion is an indication for operation, providing Hashimoto's thyroiditis is excluded. Our surgical practice (I.B.R.) is to perform total thyroidectomy for all Hürthle cell neoplasms, as well as jugular node sampling and adjuvant radioiodine for cancer. Stringent histologic interpretation is possible and necessary for true appreciation of Hürthle cell tumor incidence and behavior. Cancer mortality of 18% is greater than the rate (2%) of our well-differentiated thyroid cancer group.
Adenoma, Oxyphilic↗
Congenital thyroid hemiagenesis.
Failure of embryologic development of a lobe of the thyroid gland is a rare anomaly. In order to characterize this unusual entity, we report our experience in seven patients with thyroid hemiagenesis involving the left lobe in five and the right lobe in two patients. The diagnosis was made as a result of evaluation and treatment of a thyroid nodule (4), diffuse thyroid enlargement with thyrotoxicosis (2), and a simple goiter in a patient with a prior history of radiation treatment for facial acne. In five patients thyroid scintigraphy demonstrated unilateral absence of function, four of whom had an ultrasound exam of the neck that revealed a corresponding absence of thyroid tissue. In one patient the diagnosis was made incidentally on a screening ultrasound exam of the neck. Thyroid hemiagenesis was unsuspected preoperatively in one patient with Graves' disease because of marked hyperplasia of a single thyroid lobe and isthmus. Thyroid hemiagenesis was confirmed in four patients who underwent thyroidectomy. The presence of a thyroid isthmus was established in six patients. Postoperatively, all patients were treated with thyroid hormone. Associated thyroid pathology included adenoma (1), follicular carcinoma (1), colloid nodule (2), Graves' disease (2), and a simple goiter (1). In conclusion, the diagnosis of thyroid hemiagenesis should be considered in any patient with unilateral absence of function on thyroid scintigraphy and confirmed by ultrasonography. Recognition of this rare congenital anomaly is important to avoid unnecessary contralateral neck exploration with its potential morbidity and to insure that all patients receive careful follow-up and appropriate thyroid hormone therapy when necessary.
Adenocarcinoma, Follicular↗
The through-and-through oromandibular defect: rationale for aggressive reconstruction.
Through-and-through oral cancer (T4+) involving contiguous mucosa, mandible, and skin is a devastating disease with poor prognosis and represents one of the most difficult reconstructive challenges in head and neck surgery. Thirty-eight patients underwent immediate microvascular reconstruction following surgical tumor ablation. The purpose of the present review was to assess the value of microvascular reconstruction in these essentially palliative reconstructive efforts. The iliac crest osteocutaneous flap was used in the majority of patients and was found to be ideal for the reconstruction of large bony and soft-tissue defects present in this group of patients. Other methods, including pectoralis major, forehead, and latissimus dorsi flaps, also were used in the soft-tissue reconstruction. The mean follow-up was 16 +/- 2 months, and the mean hospitalization was 43 +/- 22 days. The majority of patients succumbed to recurrent or related diseases, yet a few went on to survival despite the initial advanced stage of disease. A number of complications were observed. However, most patients developed normal or easily intelligible speech (65 percent), and most (78 percent) had their tracheostomies closed and sustained themselves on an oral soft diet (84 percent). Bony union was noted in the majority of patients (73 percent). Although the prognosis in full-thickness oral carcinoma is grim, it appears that palliative surgery in these cases is well justified. The goals are to shorten the duration of hospitalization, reduce morbidity, and improve the remaining quality of life. Microvascular tissue transfer offers a means to achieve these goals in a single, reliable procedure. We feel that immediate one-stage bone and soft-tissue reconstruction restores dignity and relieves suffering in this unfortunate group of individuals.
Adult↗
Parathyroid cancer: clinical variations and relationship to autotransplantation.
OBJECTIVE: To identify the clinical and pathological characteristics of parathyroid cancer to determine the best method of treatment and to prevent the use of malignant tissue for autotransplantation. DESIGN: A chart review over a 20-year period (1973 to 1993). SETTING: Two tertiary-care referral centres in Ontario with specialty interest in disease of the thyroid and parathyroid glands. PATIENTS: Sixteen patients, identified as has having parathyroid cancer (equivocal diagnosis in 9 and definitive diagnosis in 7). MAIN OUTCOME MEASURES: The clinical and histologic features, treatment, morbidity and mortality of parathyroid cancer. RESULTS: Some patients with an equivocal diagnosis had postoperative recurrent hyperparathyroidism characterized by multiple soft-tissue implants of parathyroid that persisted after reoperation. The others had infiltrative attachment of parathyroid lesions to the thyroid gland and were eucalcemic and disease free up to 12 years after treatment. Three of the seven patients with a definitive diagnosis of parathyroid cancer were treated for a neck mass; the others were treated for hypercalcemia and multiple lytic bone lesions, hypercalcemia and renal disease and secondary hyperparathyroidism. En-bloc resection, carried out in all but one case, was curative in five cases. The patient with secondary hyperparathyroidism underwent total parathyroidectomy and autotransplantation but died of metastatic parathyroid cancer 1 year later. CONCLUSIONS: Because of the difficulty in making a histologic diagnosis of parathyroid cancer, en-bloc resection of the thyroid and parathyroid glands and locally invaded structures is the appropriate treatment to avoid tumour spillage. Caution should be exercised in the use of donor parathyroid tissue for autotransplantation.
Adenoma↗
Parathyroid crisis of unusual features in a child.
BACKGROUND: A case of familial parathyroid crisis resulting from presumptive cancer in a 14-year-old boy impressed the authors with its rarity and need for recognition. METHODS: The authors performed a retrospective review of the relevant literature and described the case. RESULTS: The case report cited is the eighth example of parathyroid cancer occurring in a child younger than 16 years of age. It represents the first example of malignant parathyroid crisis because of familial hyperparathyroidism and illustrates the demand for appropriate diagnosis and methods of management in parathyroid cancer. CONCLUSIONS: Familial hyperparathyroidism may become manifest in young patients, which justifies screening among affected families to avoid serious sequelae of disease. Parathyroid cancer is an example of a malignant neoplasm in the young and is managed best by en bloc resection of primary disease, appropriate neck dissection for nodal involvement, and aggressive resection for recurrence, if possible, to control the lethal effects of hypercalcemia; this permits prolonged survival even in discouraging situations.
Adolescent↗
Ultrasound-guided fine-needle aspiration biopsy in the management of thyroid disease.
During a 23-month period, 59 patients were referred for ultrasound (US)-guided fine-needle aspiration biopsy (FNAB) of the thyroid gland because of inadequate orthodox (office) FNAB, a clinically small lesion, or an occult lesion. Seventy percent of the group (41 patients) was referred for surgery, which revealed cancer in 37% of patients, adenoma in 19%, and benign disease in 44%. US-guided FNAB yielded false-positive reports in 0% of patients, false-negative reports in 5% to 12%, and inadequate aspirates in 32%. The US-guided FNAB technique had a sensitivity of 60% to 90%, a specificity of 100%, a positive predictive value of 100%, a negative predictive value of 80%, and an accuracy of 85%. US-guided FNAB provides cytologic information in 60% of patients in whom a diagnosis cannot be established by orthodox (office) means, thus enhancing the diagnostic ability of clinicians who can recommend a treatment program with confidence.
Adenoma↗
Influence of fine-needle aspiration biopsy and frozen section examination on the management of thyroid cancer.
In order to delineate the influence of fine-needle aspiration biopsy (FNAB) and frozen section examination (FS) on the management of patients with thyroid cancer, a review of 310 patients with thyroid cancer, seen in follow-up during a 3-year period, was completed. Combined FNAB and FS examination were assessed in 225 patients, 172 (76%) with papillary carcinoma, 36 (16%) with follicular carcinoma, 13 (6%) with Hürthle cell carcinoma, and 4 (2%) with medullary carcinoma. The diagnosis according to FNAB was malignant in 78 patients (35%), cellular in 135 (60%), and benign in 12 (5%). All 78 patients with a malignant FNAB diagnosis had papillary cancer. The results of FS examination correlated with the FNAB findings in 74 patients (95%), whereas 4 patients (5%) had a false-negative FS diagnosis of "adenoma." Of the 135 patients with a cellular FNAB diagnosis, FS examination showed cancer in 75 (56%): 58 with papillary carcinoma, 7 with follicular carcinoma, and 10 with Hürthle cell carcinoma. Sixty patients (44%), 30 with papillary carcinoma, 27 with follicular carcinoma, and 3 with Hürthle cell carcinoma, had a cellular FNAB diagnosis and a FS diagnosis of a follicular neoplasm. Twelve patients (5%), 6 with papillary carcinoma, 4 with medullary carcinoma, and 2 with follicular carcinoma, had both false-negative FNAB and FS. From these results, we conclude that FS examination is indicated for intraoperative decision-making in patients with a cellular FNAB diagnosis but is unnecessary when the FNAB diagnosis is either benign or malignant. In order to avoid possible reoperation, near-total thyroidectomy should be presented as an alternative for the treatment of a hypofunctioning thyroid nodule when both FNAB and FS results are consistent with "follicular neoplasm."
Adenocarcinoma↗
Non-diagnostic fine needle aspiration biopsy: a dilemma in management of nodular thyroid disease.
The implications of a persistent "non-diagnostic" fine needle aspiration biopsy (FNAB) has yet to be defined in patients with a solitary thyroid nodule. Four hundred and eleven patients from 1986 to 1990 with a solitary cold thyroid nodule underwent thyroidectomy, including 92 with a "non-diagnostic" FNAB, despite a minimum of two repeat samples. Pathology revealed cancer in eight (9%)--six papillary, one lymphoma, and one squamous cell--follicular adenoma in 38 (41%), Hurthle cell adenoma in two (2%), colloid nodule in 41 (45%), epithelial cyst in two (2%), and thyroiditis in one patient (1%). The operation was uncomplicated by hypoparathyroidism or nerve dysfunction. Age, sex, nodule size, and a history of neck irradiation were examined as possible predictors of cancer risk. Male sex, previous neck irradiation and larger nodules were more common among thyroid cancer patients, but only male sex was statistically significant (P < 0.05). Persistent "nondiagnostic" cytology is a significant limitation of FNAB associated with a 52% neoplasia rate and a 9% incidence of malignancy. "Non-diagnostic" FNAB should be repeated and, if necessary, performed under ultrasound guidance. In order to avoid a missed carcinoma, surgical treatment of persistent "non-diagnostic" FNAB in a dominant hypofunctioning nodule is indicated for the male patient, radiation-associated nodular thyroid disease, recurrent cysts, compression symptoms, and failure of a 6-month trial of thyroid suppression. Lack of needle biopsy and operative morbidity justifies the aggressive exclusion of cancer.
Adolescent↗
Postparathyroidectomy transient thyrotoxicosis.
Three patients are described who had spontaneously resolving transient thyrotoxicosis after resection of a parathyroid adenoma without thyroidectomy or an apparent thyroid abnormality before or during surgery. All had documented thyrotoxicosis that developed within 2 weeks after surgery, which was clinically symptomatic in two of three patients. The thyrotoxicosis was associated with subnormal radioactive iodine thyroid uptake when performed in the two symptomatic patients and was consistent with a postsurgical inflammatory etiology secondary to thyroid gland trauma during parathyroidectomy. In all patients, the clinical and biochemical evidence of thyrotoxicosis resolved within 2 months. Antithyroglobulin and antimicrosomal antibodies were not detected in the two patients who had a complete recovery 3 months after surgery. However, in the patient who had autoimmune thyroiditis, hyperthyroidism due to Graves' disease subsequently developed 19 months after parathyroidectomy and was associated with increasing titers of antithyroglobulin and antimicrosomal thyroidal autoantibodies. From these observations, we conclude that 1) spontaneously resolving transient thyrotoxicosis of varying severity may occur in some patients after parathyroidectomy, which could be secondary to intraoperative thyroid gland manipulation, and 2) while the occurrence of subsequent Graves' hyperthyroidism in a patient with underlying autoimmune thyroiditis may have been a coincidence, this observation also raises the possibility that thyroidal autoantigen released during parathyroidectomy may trigger the reactivation of autoimmune thyroid disease in a predisposed subject.
Adolescent↗
Surgical treatment in non-neoplastic parotid disease: indications and results.
Non-neoplastic disease of the parotid gland is an important entity, requiring differential diagnosis and management. The incidence of non-neoplastic parotid disease (NNPD) is increasing and makes up about 25% of cases for which parotidectomy is indicated. NNPD can be categorized as type I (asymptomatic soft diffuse enlargement or circumscribed firm nodular enlargement) or type II (inflammatory lesions with recurrent pain and swelling, obstructive or nonobstructive). Concern over possible malignancy is highest in type I nodular lesions and least in type II lesions. Operative treatment may be indicated for exclusion of tumour, relief of recurrent pain and swelling and patient anxiety. In 62 patients with NNPD who were operated on, the relevant clinical factors included radiation, diabetes, tuberculosis, Sjögren's syndrome and pulmonary sarcoidosis. Superficial parotidectomy was effective, being associated with low morbidity, and can be recommended as acceptable treatment, providing there is a complete patient history and operation is carried out by a surgeon experienced in parotid surgery.
Adolescent↗