Biomedical subjects

Jonathan W Serpell

Publications and source records attributed to Jonathan W Serpell.

12 recordsLinked to original sources

PubMed2006

Thyroidectomy is safe and effective for retrosternal goitre.

BACKGROUND: Retrosternal goitre was defined as any thyroid enlargement identified below the thoracic inlet at operation, with the patient's neck held in extension. The aim of this study was to determine the characteristics of the patients, the goitres, the surgery and its morbidity (including tracheomalacia, recurrent laryngeal nerve palsy and hypocalcaemia) and the incidence of malignancy in order to establish guidelines for managing patients with a retrosternal goitre. METHODS: Data were collected prospectively on all thyroidectomies carried out by a single surgeon over 14 years. Patients underwent appropriate preoperative assessment and thyroidectomy was carried out using a standardized capsular dissection technique. There were 199 cases of retrosternal extension. RESULTS: Retrosternal extension was significantly more common on the left side than on the right side (ratio 3:2, P < 0.05). Most patients (83.4%) had significant symptoms that were relieved by surgery. Of the 199 thyroidectomies, none required a sternal split. The rate of malignancy was low (2.5%). Postoperative morbidity was 30%, the majority being asymptomatic temporary hypocalcaemia. There were no patients with permanent recurrent laryngeal nerve palsies or permanent hypoparathyroidism. There was one case of tracheomalacia. There was no death. CONCLUSION: Retrosternal goitre is a frequently symptomatic condition, with a low but definite rate of malignancy. Surgery is usually possible through a cervical incision and with an acceptable risk of significant morbidity. Thyroidectomy should be recommended as the treatment of choice.

Adolescent↗

PubMed2006

Extralaryngeal bifurcation of the recurrent laryngeal nerve: a common variation.

Extralaryngeal bifurcation and trifurcation of the recurrent laryngeal nerve (RLN) is not well described in anatomical texts. This significant anatomical variation is important because prevention of vocal cord paralysis requires preservation of all branches of the RLN. The aim of this study was to examine the prevalence of extralaryngeal bifurcation of the RLN seen during thyroid/parathyroid surgeries. All patients undergoing total thyroidectomy, hemithyroidectomy and parathyroidectomy (excluding all minimally invasive procedures) carried out by a single endocrine surgeon from November 2003 to December 2004 were included. Operative data obtained prospectively included the location of the nerve, number of branches and the distance in millimetres from the inferior border of the cricothyroid to the point of bifurcation. A total of 213 (right = 114, left = 99) RLN in 137 patients were studied. Seventy-seven (36%) nerves bifurcated or trifurcated before entry into the larynx. Bifurcations were more common on the right (43%) than on the left (28%) (P = 0.05). Trifurcations were seen in eight nerves, seven on the right and one on the left (P = 0.05). Bilaterally branched RLN were observed in 14 (18%) of 77 patients undergoing a bilateral procedure. One non-RLN was identified on the right. The median distance from the cricothyroid to the point of division was 18 mm on the right and 13 mm on the left. Extralaryngeal division of the RLN is a common anatomical variant occurring more frequently on the right. Unseen branches of the RLN are at risk of injury during surgery. Therefore, great care is required following presumed identification of the RLN to ensure that there are no other unidentified branches.

Adolescent↗

PubMed2005

Thyroid cancer in the renal transplant population: epidemiological study.

BACKGROUND: The epidemiology of thyroid neoplasms in the renal transplant population has not been widely published. The present study compares the behaviour of thyroid cancer in the transplant cohort with that of the general population. It also documents the transplantation outcomes of patients with thyroid and non-thyroid cancers. METHODS: All recipients of renal grafts are registered with the Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry. Data were obtained from this institution and analysed using Microsoft Excel and Stata statistical software. Risk ratio, attributable risk, Mann-Whitney test, and the Kaplan-Meier survival probability were calculated. RESULTS: Between 1963 and 31 March 2002, 23 (0.22%) patients were diagnosed with thyroid cancer from a cohort of 10,689 renal transplant recipients. The median age in the renal-transplant thyroid cancer group was 48.2 years (range: 23-67 years), and there were 11 (48%) male patients, compared to 26% of thyroid cancer patients in the general population (P = 0.02). The median time to thyroid cancer diagnosis after transplantation was 68 months (range: 3-253 months) compared to 102 months (range: 3-363 months; P = 0.004) in non-thyroid cancers. Ten patients (43%) were found to have lymphatic metastasis, eight of whom presented at the time of primary diagnosis. The risk ratio (RR) was 5.2 (95% confidence interval: 2.0-16.6), with an attributable risk of 17.4 cases per 10,000. There were two cancer-related deaths resulting in a survival probability of 89% at 5, 10 and 15 years. CONCLUSIONS: There is a higher incidence of thyroid cancer and an altered sex distribution in the renal transplant population. A significant proportion presents with lymphatic metastasis requiring lymph node dissection and radioactive iodine treatment.

Adult↗

PubMed2004

Development of a parathyroid database in Melbourne and review of the last 50 cases.

BACKGROUND: Minimally invasive parathyroidectomy (MIP) is only possible if preoperative localization studies accurately identify the abnormal parathyroid tissue. The aim of the present paper was to evaluate the accuracy of these studies in our geographical region and the consequences on MIP. METHODS: A Filemaker Pro database was designed and a retrospective analysis was carried out on the last 50 parathyroidectomies. RESULTS: There were a total of 49 patients who underwent parathyroidectomy; with one patient having two operations. Forty-nine preoperative ultrasound localization studies were performed. Ultrasound sensitivity of correct localization of abnormal parathyroids was 41% with a false positive rate of 25%. Twenty-two sestamibi scans identified 14 abnormal parathyroids. Sestamibi scanning had a sensitivity of 32% for correct localization and a false positive rate of 32%. There were 16 different radiologists or nuclear medicine physicians involved with the nuclear medicine scans, and 22 different radiologists involved in the preoperative ultrasound scans. Forty-seven patients were cured of hyperparathyroidism after a primary operation, with a total of 48 patients in all being cured following re-exploration. One patient was lost to follow up. The success of primary exploration was therefore 96% and following re-exploration this increased to 98%. CONCLUSION: We found preoperative localization studies to have low sensitivities and high false positive rates. To move successfully towards MIP, we need to identify a radiologist with a special interest in localization studies to achieve greater accuracy.

Adult↗

PubMed2003

Fine needle aspiration in the management of benign thyroid cysts.

BACKGROUND: Resolution of cystic thyroid lesions after aspiration occurs in 8-45% of cases, the remainder require treatment for residual tumour or recurrent cysts. The aim of this study was to identify patient characteristics that predict cyst recurrence to enable these patients to undergo early surgery. METHODS: A retrospective analysis of 123 patients with benign thyroid cysts that were suitable for conservative management was undertaken. Demographic, clinical, ultrasound and fine needle aspiration cytology data were collated for patients who underwent surgery or were managed conservatively. Univariate and multivariate analyses were performed to identify factors predictive of cyst recurrence. RESULTS: Of the 123 patients, 43 underwent surgery consequent on cyst recurrence or persistent symptoms after aspiration, and 80 were treated by aspiration alone. There were 17 males and 106 females, of mean age 45.5 years. The mean cyst size was 27 mm. Those undergoing surgery had a significantly greater mean cyst size (P = 0.001). The only factor predicting cyst recurrence on univariate analysis was absence of follicular cells on initial aspiration (P = 0.005). Multivariate analysis confirmed absence of follicular cells as an independent characteristic predicting recurrence, the odds ratios for recurrence was 3.18 (95%CI 1.39-7.29). CONCLUSION: The present study suggests consideration of early surgery for patients with thyroid cysts with absence of follicular cells on initial cytology.

Biopsy, Fine-Needle↗

PubMed2003

Fine-needle aspiration cytology of thyroid nodules: how useful is it?

BACKGROUND: Thyroid nodules are common and the principal method of diagnosis is fine-needle aspiration cytology (FNAC). METHODS: To determine the value of FNAC in the diagnosis of thyroid nodules, thyroid cytology of 253 patients with definitive histology after surgery was analyzed from 1992 to 2002. FNAC was correlated with histology and the sensitivity, specificity and likelihood ratios were calculated. The method of FNAC and number of non-diagnostic aspirates were noted. The frequency of thyroid cancer was investigated in male and females who presented with a solitary thyroid nodule. RESULTS: The overall sensitivity of FNAC detecting thyroid neoplasia was 55.0%, specificity 73.7% and accuracy 67.2%. Likelihood ratios indicate that a 'malignant' or 'suspicious for malignancy' cytology dramatically increase the pretest probability of thyroid neoplasia. There were no false positive 'malignant' FNAC. Ultrasound guided FNAC had a significantly lower non-diagnostic rate compared to freehand FNAC (P < 0.02). Of 22 males, 22.7% who proceeded to surgery for their solitary nodule had thyroid carcinoma compared with 11.9% of 167 females (P = 0.02). CONCLUSIONS: FNAC was essential to management in this series of patients. 'Malignant' or 'suspicious for malignancy' cytology are absolute indicators for thyroidectomy. FNAC should be undertaken with ultrasound guidance and if possible with a pathologist in attendance to assess sample adequacy. We recommend a high index of suspicion of thyroid cancer in the male patient who presents with a solitary nodule. If solitary nodules are to be observed, repeat FNAC should be undertaken because of the high false negative rate.

Biopsy, Fine-Needle↗

PubMed2003

Does neck extension elevate the thyroid gland cephalad to potentially improve access during thyroidectomy?

BACKGROUND: Patients undergoing thyroidectomy are positioned with the neck extended to facilitate exposure of the neck. Computed tomography (CT) scanning of the thyroid, without i.v. contrast, is often used preoperatively to investigate the extent of large goitres. Currently, patients are scanned in the neutral position rather than the surgical position of neck extension. The aim of the present study was to determine the degree, if any, of movement of the thyroid, as measured by CT, achieved by neck extension. METHODS: A trial was designed using CT scanning of the neck. Fourteen patients were studied. Patients attended for the usual CT thyroid. In addition, they were then rescanned with their neck extended. The position of the inferior aspect of the gland in relation to the sternal notch was measured in both positions. The degree of neck extension was measured and correlated with the extent of thyroid gland movement. The data were analysed with the Wilcoxon signed rank test and Spearman correlation coefficients. RESULTS: Results showed a median difference between the two positions of 5 mm (P = 0.0002). CONCLUSION: The minimal cephalad movement of the thyroid achieved by neck extension, although statistically significant, is of doubtful clinical use, and overextension of the neck should be avoided because of its associated risks of pain, vomiting and spinal damage.

Adult↗

PubMed2003

Radical lymph node dissection for melanoma.

BACKGROUND: Therapeutic lymph node dissection for melanoma aims to achieve regional disease control. Radical lymphadenectomy (RLND) can be a difficult procedure associated with significant postoperative morbidity. The aims of the present study were to review regional disease control and morbidity in a series of lymphadenectomies performed within a specialist unit. METHODS: The present study involved the analysis of 73 lymphadenectomies in 64 patients, from 1995 to 2001. RESULTS: The overall wound complication rate after inguinal lymphadenectomy (71%) was higher than after axillary lymphadenectomy (47%; P = 0.05). After inguinal lymphadenectomy, the wound infection rate was higher (25.0%vs 5.9%; P = 0.03), delayed wound healing was more frequent (25.0%vs 5.9%; P = 0.03), and the mean time that drain tubes remained in situ was longer (12.5 vs 8.2 days; P = 0.05). There were no significant differences in seroma (46%vs 32%) rates. Lymphoedema was more common after inguinal lymphadenectomy (P < 0.02). Multivariate analysis identified inguinal RLND (P = 0.002) and increasing tumour size (P = 0.045) as predictors of wound morbidity. More patients received postoperative radiotherapy after neck RLND compared to inguinal or axilla RLND (P = 0.03). Six (8%) patients developed local recurrence after lymphadenectomy. At a median follow up of 22 months, 34 (53%) patients have died, from disseminated disease. CONCLUSIONS: Radical lymphadenectomy for melanoma is associated with significant morbidity. Inguinal node dissection has a higher rate of complications than axillary dissection. Low local recurrence rates can be achieved, limiting the potential morbidity of uncontrolled regional metastatic disease.

Adult↗

PubMed2003

Tumour involvement of the re-excision specimen following clear local excision of breast cancer with positive margins.

BACKGROUND: Breast conservation surgery and subsequent radiotherapy is an acceptable method of treating breast cancer. Complete excision of the primary tumour is important to minimize the risk of local recurrence. Re-excision is usually carried out if the initial primary tumour excision shows positive margins. However, a significant proportion of re-excision specimens are negative for tumour. The aim of the present study was to identify factors predicting a histologically positive re-excision specimen. METHODS: The case records of all patients with invasive and in situ breast cancer referred to the William Buckland Radiotherapy Centre between January 1996 and December 2001 were reviewed. The factors evaluated were patient age, whether or not tumours were detected by screening mammography, use of hook-wire needle localization, whether tumours were marked with orientating sutures, histopathological characteristics of the tumour and involvement of axillary nodes. Univariate analysis was performed. RESULTS: In the study period, a total of 1128 patients were reviewed. Of these, 742 underwent breast conservation surgery. Twenty-nine (3.9%) of the 742 had positive surgical margins and underwent re-excision. Data were insufficient for six, leaving 23 patients eligible for the study. The number of patients entering the study was small, limiting the statistical analysis. Of these, 21 patients had invasive cancer and two patients had ductal carcinoma in situ only. Of 23 re-excisions, 11(48%) contained residual tumour. Univariate analysis of the data revealed no significant factors that were likely to predict tumour in the re-excision specimen. The local recurrence after re-excision in patients with positive margins was 4.3%. CONCLUSION: The results suggest that it is not possible to predict which patients will have tumour in the re-excision specimen. However, approximately 50% of re-excision specimens showed residual cancer. Therefore it is recommended that all excisions with positive margins need further surgery.

Adult↗

PubMed2002

Does frozen section have a role in the intraoperative management of thyroid nodules?

BACKGROUND: Frozen section in thyroid surgery is used to make an intraoperative pathological diagnosis of malignancy in a thyroid nodule at the time of hemithyroidectomy. A positive diagnosis allows completion of thyroidectomy, thus avoiding reoperation. However, the use of fine needle aspiration cytology in making a preoperative diagnosis of cancer has resulted in the lack of a defined role for frozen section. We examined the role of frozen section as an adjunct to fine needle aspiration cytology in determining which cytological subset will benefit from frozen section. METHODS: All patients who underwent thyroidectomy between 1992 and 2000 by a single endocrine surgeon were reviewed. RESULTS: Two hundred and nine frozen sections were performed, of which 144 underwent preoperative fine needle aspiration cytology. Frozen sections reported 135 benign nodules, 59 follicular neoplasms, five specimens with suspicious histology and 10 cancers. Ten out of 20 thyroid cancers were correctly identified by frozen section (sensitivity: 50%; specificity: 100%), eight cancers were reported on frozen section as indeterminate and two benign. Of 144 fine needle aspiration cytological procedures, frozen section on seven suspicious aspirates identified two cancers, and frozen section on 70 follicular aspirates identified four cancers, allowing intraoperative conversions to total thyroidectomy. Frozen section on seven malignant aspirates confirmed four cancers but resulted in reoperation for three because of the indeterminate frozen section reports. There were no cancers found on 135 benign aspirates. CONCLUSIONS: Frozen section on benign aspirates is unhelpful in the management of thyroid nodules. It need not be performed for cytologically proven malignant thyroid nodules. Selective use of frozen section complements fine needle aspiration cytology findings of suspicious or follicular lesions, especially in the subset with papillary cancer, allowing one-stage total thyroidectomy.

Adolescent↗

PubMedDate not supplied

Extra-nodal lymphoma presenting as a mimic of soft-tissue sarcoma.

BACKGROUND: A variety of soft-tissue tumours result in soft-tissue masses, which are all differential diagnoses of soft-tissue sarcomas. A rare cause is extra-nodal lymphoma which, unlike a soft-tissue sarcoma which it mimics, should not be excised, but rather treated by chemotherapy and/or radiotherapy. The aim of the present study was to identify clinical, radiological, biopsy and management features of lymphoma when presenting as a soft-tissue mass. METHODS: A review of 17 cases of soft-tissue lymphoma presenting as a soft-tissue mass from a total database of 295 soft-tissue tumours was undertaken. Lymphomas arising in cervical, axillary and inguinal nodes were excluded. RESULTS: All patients presented with a soft-tissue mass but none had the symptoms of lymphoma. Computed tomography scanning identified seven (54%) of 13 with regional lymphadenopathy, six (46%) of 13 with encasement of major vascular structures and three with invasion across major soft-tissue boundaries. Core biopsy established a diagnosis in 13 patients (sensitivity 93%). All patients were treated with either chemotherapy and/or radiotherapy and all are alive with a mean follow up of 19 months. None underwent major resectional surgery. CONCLUSION: The present series highlights a rare subgroup of patients with extra-nodal soft-tissue lymphoma mimicking soft-tissue sarcoma. Core biopsy is accurate in their diagnosis. Computed tomography scanning may show features suggesting the diagnosis.

Adult↗

PubMedDate not supplied

Palpable parathyroid adenomas presenting as clinical solitary thyroid nodules and cytologically as follicular thyroid neoplasms.

BACKGROUND: A palpable parathyroid mass, in a patient with primary hyperparathyroidism, is presumed to be parathyroid carcinoma until proven otherwise, with other less common causes including parathyroid cysts and adenomas. These parathyroid pathologies can be more difficult to interpret with concomitant thyroid disease. METHODS: A retrospective review was undertaken of a series of three patients with palpable parathyroid adenomas mimicking thyroid nodules. RESULTS: Two of three patients had preoperative biochemical evidence of primary hyperparathyroidism. Sestamibi scanning confirmed the presence of parathyroid pathology in one case. Fine-needle aspiration cytology revealed probable follicular neoplasms of the thyroid in all three cases. Only one of three parathyroid adenomas was diagnosed at neck exploration; the others were diagnosed at subsequent histopathology. CONCLUSION: Parathyroid and thyroid disease often occur simultaneously. Concomitant parathyroid pathology should be considered, even in the absence of biochemical and radiological evidence, at neck exploration for thyroid disease. Macroscopic identification of parathyroid disease at neck exploration can be difficult when within the thyroid gland capsule. Cytology and imaging of parathyroid adenomas may, on occasion, mimic follicular thyroid neoplasms.

Adenocarcinoma, Follicular↗