The American Thyroid Association Guidelines: Do We All Agree?

Program Description: The theme of this audience interactive miniseminar is to incorporate what is new and controversial in the management of differentiated thyroid cancer as well as to examine the level that molecular biology is incorporated into the management of thyroid neoplasms. The American Thyroid Guidelines for differentiated thyroid cancer are a widely quoted document. The level of evidence on which these recommendations are made varies extensively leaving considerable room for debate. Some aspects of surgical management such as laryngoscopy, bronchoscopy, and neuro-monitoring are left out of the document. The moderator will provide a brief background power-point presentation on the pertinent ATA guideline as a template. Expert panelists will debate case presentations germane to the given guideline and determine the level of agreement. Audience interactive opinion will be sought. The specific guidelines (where applicable) and case presentations will include: 1) Ultrasound indications for fine needle aspiration and the use of molecular markers from the FNA; 2) Laryngoscopy and neuro-monitoring; 3) Extent of initial surgical therapy for low-risk differentiated thyroid neoplasms and the potential role for molecular markers; 4) Bronchoscopy, preparation for airway management and extent of surgery for high risk patients with extra-thyroidal spread; and 5) Surgery for recurrent differentiated thyroid cancer and the role of molecular targeted therapy. Panelists and the interactive audience will give opinions on the relevance of the ATA guidelines to their thyroid surgical practice.

Educational Objectives: 1) Learn the benefits and limitations of the American Thyroid Association Guidelines. 2) Learn about molecular markers for diagnosis, prognostication, and molecular-targeted therapy. 3) Learn about ultrasound-guided FNA, management of low- and high-risk patients, and recurrence.

Selective Neck Dissection in Node Positive Squamous Cell Carcinoma of Head and Neck

Objective: Optimal type of neck dissection in head and neck squamous cell carcinoma HN(SCC) with clinically positive neck nodes has not been determined. The following study was performed to determine the rate of regional control with selective neck dissection (SND) in these patients.

Method: HNSCC patients with cervical lymph node metastases who were treated with SND in a single institution from 2000 to 2010 were selected. Demographics, tumor characteristics, extent of neck dissection, prior and adjuvant treatments, locoregional control and survival were recorded. Recurrence in the neck and disease-specific survival (DSS) were primary and secondary endpoints.

Results: A total of 130 patients underwent SND. A total of 84 (65%) were male. Median age was 62 years (range, 20-89 years). Most common primary site was oral cavity (64%). Twenty-one patients (16%) had prior treatments, 107 (82.3%) received adjuvant treatment. Median follow-up was 21 months. Fifteen patients (11.5%) had recurrence in dissected neck. Five-year neck recurrence-free survival (NRFS) was 82.5%. N2C disease patients had shorter NRFS (5-year: 64%). At the end of study 75 (58%) patients had NED and 32 (25%) had died of disease. Five-year DSS was 70%. Number of positive nodes, positive surgical margins, and perineural invasion were predictors of shorter DSS.

Conclusion: Selective neck dissection in patients with cervical lymph node metastases from head and neck SCCs is effective in controlling the disease in the neck, when performed in the setting of multi-modality treatment including post operative radiotherapy.

Anatomy of thyroid and parathyroid glands and neurovascular relations

Historically, thyroid surgery has been fraught with complications. Injury to the recurrent laryngeal nerve, superior laryngeal nerve, or the parathyroid glands may result in profound life-long consequences for the patient. To minimize the morbidity of the operation, a surgeon must have an in-depth understanding of the anatomy of the thyroid and parathyroid glands and be able to apply this information to perform a safe and effective operation. This article will review the pertinent anatomy and embryology of the thyroid and parathyroid glands and the critical structures that lie in their proximity. This information should aid the surgeon in appropriate identification and preservation of the function of these structures and to avoid the pitfalls of the operation.

Disease-related death in patients who were considered free of macroscopic disease after initial treatment of well-differentiated thyroid carcinoma

BACKGROUND

Death from well-differentiated thyroid cancer (WDTC) is rare, and over the past century there has been a trend away from local recurrence as the primary cause of death. The objective of our study was to report the cause of death from thyroid cancer in patients with WDTC treated with curative intent with surgery ± adjuvant radioactive iodine.

METHODS

An institutional database of 1811 patients with WDTC treated surgically for WDTC between 1986 and 2005 was analyzed and identified 165 (9.4%) who had died. Case records were studied to determine the cause of death in each patient.

RESULTS

Of the 165 deaths, 17 (10%) patients were confirmed to have died of thyroid cancer and 6 (4%) died of an unknown cause but had thyroid cancer present at the time of last follow-up. The remaining 142 (86%) died from other causes and were considered free of thyroid cancer at their last follow-up. We therefore identified only 23 cause-specific deaths from the entire cohort (1.3%). Of the 17 patients known to have died of thyroid cancer, all had distant recurrence. Ninety-four percent had pulmonary metastases. Of these, 47% also had bony metastasis at the time of death. Two patients had recurrent disease in the neck at the time of death, but both also had distant disease. Of the six patients (4%) who died of unknown causes but had thyroid cancer at last follow-up, four (67%) had distant disease alone, one (17%) had local and regional recurrence, and one had local and distant recurrence at last follow-up.

CONCLUSION

After successful resection of WDTC, we report a low disease-specific death rate (1.3%). In contrast to earlier reports, death caused by central compartment disease in this recent series is very rare, with metastatic disease accounting for almost all fatalities.

Nutrition management of patients with malignancies of the head and neck

The importance of nutrition and the prognostic impact of malnutrition in patients with head and neck cancer are not fully appreciated in the surgical world where a pervasive attitude exists that weight loss during treatment is inevitable and nutritional expertise or intervention may be dismissed out of ignorance. In this article, the authors explore the nutritional requirements of these patients and the impact of a multidisciplinary therapeutic approach to head, neck, and skull base cancer care.

Prognostic implication of sentinel lymph node biopsy in cutaneous head and neck melanoma

BACKGROUND

Current therapy for intermediate thickness melanoma involves wide local excision with sentinel lymph node biopsy (SLNB). SLNB provides important prognostic information and immediate regional lymphadenectomy for a positive sentinel lymph node (SLN) may improve survival and identifies patients who are candidates for adjuvant therapy and/or clinical trials. The head and neck site is unique because of its complex lymphatic drainage pattern to multiple nodal basins and because of the risk of site-specific morbidity associated with regional lymphadenectomy when compared to other body sites. The goal of this study is to report the results of SLNB for head and neck cutaneous melanoma in locating the sentinel node and to report on the prognostic implications of SLNB for this cohort of patients.

METHODS

A prospectively entered melanoma database was used to review consecutive patients with head and neck cutaneous melanoma undergoing SLNB at Memorial Sloan-Kettering Cancer Center between 1996 and 2007. The database, along with a retrospective chart review, was used to evaluate the success of SLNB at locating an SLN and the success rate of frozen section and permanent section analysis at diagnosing metastatic disease. Recurrence at all sites including the nodal basin and status at last follow-up was recorded. Characteristics of the patients' primary melanoma were included. Descriptive statistics along with univariate and multivariate survival analysis were performed.

RESULTS

Between 1996 and 2007, 234 patients with a diagnosis of head and neck cutaneous melanoma underwent SLNB and had at least 1 month of follow-up. At least 1 SLN was identified in 218 of these patients (93%) by lymphoscintigraphy. In 16 patients, no SLN was found. These patients had a much shorter time to recurrence (4.75 months) than either the SLN-positive group (10.7 months) or the SLN-negative group (26.0 months). They had a disease-specific survival (DSS) in between the SLN-positive and SLN-negative group. Of the patients in whom an SLN was identified, 28 patients (12%) had at least 1 positive SLN. Of these, the SLNs of 14 patients (50%) were identified on frozen section; 14 (50%) could only be identified after further sectioning or immunohistochemical analysis postoperatively. Among 190 patients with a negative SLNB, 12 patients had recurrences in the nodal basin. This resulted in a sensitivity of 70%, a negative predictive value of 94%, and a false-negative rate of 30%. The 3-year disease-free survival for SLN-negative and SLN-positive patients was 84% (p < .031) and 58% (p < .102), respectively. The 3-year melanoma-specific survival was 98% (p < .012) and 75% (p < .201), respectively.

CONCLUSION

The SLN status is an important predictor of survival. The technique, performed in the head and neck is complex and associated with a high false-negative rate.

Rising incidence of second cancers in patients with low-risk (T1N0) thyroid cancer who receive radioactive iodine therapy

BACKGROUND

American Thyroid Association guidelines currently recommend the selective use of radioactive iodine (RAI) therapy in patients with well differentiated thyroid cancer (WDTC). Despite these guidelines, RAI ablation has been used routinely in all but the very lowest risk patients with thyroid cancer over the last 30 years. The objective of this study was to evaluate patterns of RAI use and elevated risk of secondary primary malignancies (SPM) in patients with low-risk (T1N0) WDTC.

METHODS

The Surveillance, Epidemiology, and End Results (SEER) database was used to analyze trends in RAI use over time in the United States. To determine the excess risk of SPM, the standardized incidence ratio (SIR) and excess absolute risk (EAR) of various cancers were calculated in the 2 cohorts. Between 1973 and 2007, 37,176 patients with WDTC were followed in the SEER Program, equating to 408,750 person-years at risk (PYR). In total, 14,589 patients received RAI, and SPMs were observed in 3223 patients.

RESULTS

During the study period, the rate of RAI use in patients with low-risk (T1N0) WDTC increased from 3.3% to 38.1%. For low-risk patients, the SIR of SPM was 1.21 (95% confidence interval [CI], 0.93-1.54), and the EAR was 4.6 excess cases per 10,000 PYR. SPM with significantly elevated risk because of RAI were salivary gland malignancies (SIR = 11.13; 95% CI, 1.35-40.2) and leukemia (SIR = 5.68; 95% CI, 2.09-12.37). The excess risk of leukemia was significantly greater in patients aged <45 years (SIR = 5.32; 95% CI, 2.75-9.30) compared with the excess risk in older patients (SIR = 2.26; 95% CI, 1.43-3.39).

CONCLUSIONS

The increased risk of a SPM in patients with low-risk (T1N0) WDTC, along with a lack of data demonstrating improved survival outcomes with adjuvant RAI, provide a compelling argument in favor of rationing the use of RAI in this patient population.

Lymph node metastasis in nasal vestibule cancer: a review

BACKGROUND

Squamous cell carcinoma of the nasal vestibule (SCCNV) is an uncommon malignancy. Our purpose is to define the incidence of simultaneous and delayed regional metastasis in SCCNV according to the available literature.

METHODS

Articles discussing SCCNV and addressing the issue of regional lymph node metastases were reviewed.

CONCLUSION

SCCNV is an uncommon form of cancer, possibly originating in the mucocutaneous junction. The incidence of lymph node metastasis is variably reported. The data in the literature do not provide a solid basis for recommendations on elective treatment of the neck. Thorough examination of the neck is recommended, preferably with modern imaging techniques.

Current concepts in the management of primary hyperparathyroidism

Primary hyperparathyroidism is the commonest cause of hypercalcemia in the ambulatory setting. Widespread use of routine laboratory screening has resulted in a large number of patients presenting with subclinical disease. In truly asymptomatic patients, consensus guidelines have been developed to determine which patients need definitive treatment. The most common pathologic finding is parathyroid adenoma, followed by hyperplasia, double adenomas and parathyroid carcinoma. The mainstay of treatment is surgery. While there is still an important role for four gland exploration and evaluation, there is now considerable interest in a more focused surgical approach. This paradigm shift is based on localizing studies that combine sestamibi scanning with anatomic imaging, most commonly ultrasound scanning. A range of minimally invasive approaches have been developed to treat parathyroid adenomas, including unilateral and single gland explorations as well as a number of different endoscopic techniques. Intra-operative rapid parathormone assay has replaced histologic examination as a more effective method to confirm the adequacy of surgery in most cases. Functional localization and exploration using a gamma probe has also been described. The management of patients with persistent or recurrent hyperparathyroidism is difficult and requires a multidisciplinary approach.

Current trends in initial management of hypopharyngeal cancer: the declining use of open surgery

Squamous cell carcinoma of the hypopharynx represents a distinct clinical entity. Most patients present with significant comorbidities and advanced-stage disease. The overall survival is relatively poor because of high rates of regional and distant metastasis at presentation or early in the course of the disease. A multidisciplinary approach is crucial in the overall management of these patients to achieve the best results and maintain or improve functional results. Traditionally, operable hypopharyngeal cancer has been treated by total (occasionally partial) laryngectomy and partial or circumferential pharyngectomy, followed by reconstruction and postoperative radiotherapy in most cases. Efforts to preserve speech and swallowing function in the surgical treatment of hypopharyngeal (and laryngeal) cancer have resulted in a declining use of total laryngopharyngectomy and improved reconstructive efforts, including microvascular free tissue transfer. There are many surgical, as well as nonsurgical, options available for organ and function preservation, which report equally effective tumor control and survival. The selection of appropriate treatment is of crucial importance in the achievement of optimal results for these patients. In this article, several aspects of surgical and nonsurgical approaches in the treatment of hypopharyngeal cancer are discussed. Future studies must be carefully designed within clearly defined populations and use uniform terminology and standardized functional assessment and declare appropriate patient or disease endpoints. These studies should focus on improvement of results, without increasing patient morbidity. In this respect, technical improvements in radiotherapy such as intensity-modulated radiotherapy, advances in supportive care, and incorporation of newer systemic agents such as targeted therapy, are relevant developments.

Surgical management of metastases to the thyroid gland

BACKGROUND

Metastases to the thyroid gland are uncommon, with rates reported between 0.02% and 1.4% of surgically resected thyroid specimens. Our goal was to present our experience with surgical management of metastases to the thyroid gland.

METHODS

Twenty-one patients with metastatic disease to the thyroid were identified from a database of 1,992 patients with thyroid cancer who had surgery during 1986-2005. Patient, tumor, treatment, and outcome details were recorded by analysis of charts. The median age at time of surgery was 68 (range, 39-83) years; 12 were men and 9 were women.

RESULTS

All patients were managed by surgery, including lobectomy in ten patients, total thyroidectomy in six, completion thyroidectomy in two, and subtotal thyroidectomy in one. In two patients, the thyroid lesion was found to be unresectable at the time of surgery. Histopathology revealed renal cell carcinoma in ten, malignant melanoma in three, gastrointestinal adenocarcinoma in three, breast cancer in one, sarcoma in one, and adenocarcinoma from an unknown primary site in three patients. Seventeen patients have died. The cause of death in all 17 was widespread metastatic disease from their respective primary tumors. The median survival from surgery to death or last follow-up was 26.5 (range, 2-114) months.

CONCLUSIONS

In patients with metastases to the thyroid gland, local control of metastatic disease in the central compartment of the neck can be successfully achieved with minimal morbidity with surgical resection in selected patients.

Thyroid and parathyroid surgery in pregnancy

The consideration of surgery during pregnancy requires weighing the benefit of urgent surgery against the risk to mother and fetus. Surgery during pregnancy involves an increase in both maternal and fetal risks. Thyroid and parathyroid surgery involves physiological risks to both mother and fetus specific to the disease and function of these endocrine glands. Evaluation of a thyroid mass is similar in pregnant patients with ultrasound and fine-needle aspiration biopsy providing the most important information, while the use of radiographic imaging is severely constrained except when specifically required. In general, thyroid surgery can be delayed until after delivery except in cases of airway compromise or aggressive cancer. In contrast, parathyroid surgery is recommended during pregnancy to avoid adverse effects to the neonate.

Current treatment options for recurrent nasopharyngeal cancer

Loco-regional control rate of nasopharyngeal carcinoma (NPC) has improved significantly in the past decade. However, local recurrence still represents a major cause of mortality and morbidity in advanced stages, and management of local failure remains a challenging issue in NPC. The best salvage treatment for local recurrent NPC remains to be determined. The options include brachytherapy, external radiotherapy, stereotactic radiosurgery, and nasopharyngectomy, either alone or in different combinations. In this article we will discuss the different options for salvage of locally recurrent NPC. Retreatment of locally recurrent NPC using radiotherapy, alone or in combination with other treatment modalities, as well as surgery, can result in long-term local control and survival in a substantial proportion of patients. For small-volume recurrent tumors (T1–T2) treated with external radiotherapy, brachytherapy or stereotactic radiosurgery, comparable results to those obtained with surgery have been reported. In contrast, treatment results of advanced-stage locally recurrent NPC are generally more satisfactory with surgery (with or without postoperative radiotherapy) than with reirradiation.

Delphian node metastasis in head and neck cancers--oracle or myth?

Delphian node (DN) refers to the pre-laryngeal or pre-cricoid nodal tissue often identified during laryngeal or thyroid surgery. The original nomenclature is based on the assumption that metastasis to this node was predictive of aggressive disease and poor outcome for patients. In this article, we review the existing literature on the topic to determine the significance of DN metastasis in laryngeal, hypopharyngeal and thyroid cancers.

Retropharyngeal lymph node metastases in head and neck malignancies

Retropharyngeal lymph node (RPLN) metastasis of primary head and neck cancer often receives less consideration than lymph node metastasis in the neck. With improvements in imaging techniques and reports of surgical pathology, there is an improved understanding of the risk and subsequently the need for treatment of RPLNs. The rates of RPLN metastasis from carcinomas of the nasopharynx, oropharynx, hypopharynx, postcricoid region, maxillary sinus, and cervical esophagus are sufficiently high to warrant routine treatment, either electively or therapeutically, of this region. Through improved diagnostic techniques and heightened awareness of RPLN metastasis, patients at risk of having these metastases can be treated more effectively.