Biomedical subjects
J N Attie
Publications and source records attributed to J N Attie.
Hayes Martin Lecture. The physician (ARZT) and the arts.
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Parathyroid localization: inability to predict multiple gland involvement.
Preoperative localization using various imaging techniques can accurately predict the location of solitary parathyroid adenomas in about 75% of patients. Its value has been questioned because of the high success rate of parathyroid exploration without localization. The ability of localization studies to differentiate preoperatively between patients with solitary adenomas and those with multiple gland disease would be valuable because bilateral exploration might be avoided in many cases. Ultrasonography, thallium-201/technetium-99m subtraction scintigraphy, and magnetic resonance imaging were used to evaluate 16 patients with primary hyperparathyroidism who were ultimately found at surgery to have multiple enlarged parathyroid glands. No single imaging technique was able to identify more than 53% of enlarged glands, and only four patients were accurately predicted preoperatively to have enlargement of multiple parathyroid glands. Existing imaging techniques cannot be relied on to predict multiple gland involvement preoperatively. Bilateral surgical exploration is mandatory in all patients with primary hyperparathyroidism.
Accuracy of frozen section in the evaluation of salivary tumors.
The records of 333 patients who underwent surgery were reviewed to document the accuracy of frozen section in the evaluation of salivary gland tumors. Frozen sections were obtained in 310 patients. The final pathologic diagnoses included 210 benign tumors and 45 malignancies. The sensitivity for the detection of malignancy was 69%, and the specificity was 96%. The specific accuracy to correctly identify the type of malignancy present was only 51%. In four patients, a false-positive diagnosis of malignancy was made. Frozen section was much more accurate in the evaluation of benign salivary tumors. Forty-three of 45 Warthin's tumors were correctly identified by frozen section. Two tumors thought to be Warthin's tumors on frozen section proved to be low-grade mucoepidermoid carcinomas. One tumor reported to be a benign mixed tumor was actually a malignant mixed tumor. In this series of patients, frozen section proved to be no more accurate in the evaluation of salivary tumors than what has been reported in the literature for fine-needle aspiration biopsy.
Thyroid carcinoma presenting as an enlarged cervical lymph node.
Differentiated thyroid cancer most commonly presents as a thyroid nodule. Cervical node metastases are commonly observed. In the present report, we describe the clinical presentation, pathologic findings, surgical approach, and follow-up of 43 patients in whom the initial presentation of thyroid cancer was that of an enlarged cervical lymph node. At surgery, 65% of the patients had additional lymph node involvement. The thyroid pathology was papillary carcinoma in all patients, and, in two thirds of patients, the thyroid primary was 1 cm or smaller in size. Forty patients underwent thyroidectomy and modified neck dissection; 3 were treated by thyroidectomy alone. One patient died of disease, 7 were lost to follow-up after 4 to 27 years, 5 died of unrelated causes, and the remaining 30 are alive and free of disease 1.5 to 33.5 years after surgery (mean: 14.8 years).
Value of fine needle aspiration biopsy of salivary gland masses in clinical decision-making.
The accuracy of fine needle aspiration biopsy (FNAB) in the diagnosis of salivary tumors has been well established. This study was undertaken to determine the impact of FNAB on patient management. One hundred one patients underwent FNAB of major salivary gland masses. The physician's initial clinical impression was compared with the FNAB diagnosis and the final diagnosis in each case. Forty patients had solitary masses thought to be benign tumors other than Warthin's tumors. FNAB in 13 of these patients (33%) yielded a diagnosis permitting modification of the planned procedure. The diagnosis of Warthin's tumor was suspected clinically in 23 patients. In nine of these patients (39%), FNAB resulted in a different diagnosis. Of the 10 patients believed to have malignant tumors, using FNAB, 1 was found to have sialadenitis and 1 a lymphoma. Overall, FNAB resulted in a change in the clinical approach to 35% of the patients. We recommend the performance of FNAB in almost all patients with salivary masses.
Elective radical neck dissection in epidermoid cancer of the head and neck. A retrospective analysis of 853 cases of mouth, pharynx, and larynx cancer.
A retrospective analysis of 853 patients with cancer of the mouth, pharynx, and larynx operated on over a 30-year period was performed. Four hundred fifty-seven of them had a radical neck dissection (RND) at some point. Five hundred ninety patients had no clinically positive nodes (N-o) necks at the time of primary treatment; 99 of these had elective neck dissection, whereas 95 others had a delayed RND when nodes became clinically involved. Twenty-three percent of all N-o patients had microscopically involved nodes and less than half of these were among those patients selected for elective RND. Furthermore, 58% of those patients who had elective RND did not have positive nodes. Comparative analysis of elective RND, delayed therapeutic RND after clinical appearance of nodes, and composite operations for patients with N1-N3 disease indicates little difference in disease-free survival when the nodes in the elective RND were positive microscopically for tumors (56%, 49% and 47% respectively). It thus seems that elective RND offers no real advantage over a careful watchful waiting approach in most patients.
Effectiveness of radiotherapy with radical neck dissection in cancers of the head and neck.
A retrospective analysis of 457 radical neck dissections performed over a 30-year period for cancers of the oral cavity, pharynx, and larynx was carried out. Two hundred thirteen patients underwent radiotherapy to the primary cancer site and/or to the neck. Of these, 164 underwent perioperative adjuvant radiotherapy and 24 underwent definitive radiation for cure and were followed up by salvage surgery. Thus, 188 patients received radiotherapy for nonrecurrent disease. Twenty-five additional patients underwent radiation for surgical failure following radical neck dissection. The goal of the study was to determine whether radiotherapy altered the course or end result of the disease. The T and N stage at onset of disease was similar for the radiotherapy and nonradiotherapy groups. Preoperative radiotherapy was effective in down staging the disease at the primary site and, to a lesser extent, in the lymph nodes, but had limited impact on survival. Failure to control the disease in the neck occurred in 60 (32%) of the 188 patients who received radiotherapy for primary disease; recurrence rates were lower in the combined therapy group than in the surgical group of patients with N2 and N3 stages of disease. The 3-year disease-free survival was 45%; this was no better than the 63% survival rate in patients who did not receive radiotherapy, although survival was better in the combined therapy group for patients with N3 stage of disease. The worst results were in those patients who were irradiated for surgical failure (14% survival); the 24 patients who required salvage radical neck dissection following failure of definitive radiotherapy for cure had a 42% survival.
Initial failure of surgical exploration in patients with primary hyperparathyroidism.
To determine the causes of failures of cervical exploration for primary hyperparathyroidism, we reviewed 892 patients operated on by one surgeon from 1953 to 1990. Twenty-seven patients (3%) remained hypercalcemic or developed hypercalcemia within 6 months of surgery. Of these, five patients had one adenoma removed initially; at reoperation, three patients had a second adenoma that was successfully removed, whereas the other two patients had hyperplasia and required subtotal parathyroidectomies. No enlarged parathyroid glands were identified in 22 patients. Eventually, six patients became normocalcemic spontaneously, seven patients underwent re-exploration with a successful outcome in all but one case, two patients had ectopic hyperparathyroidism associated with carcinoma elsewhere, and seven patients refused reoperation and remain hypercalcemic. The failure rate of surgical exploration for primary hyperparathyroidism can be reduced by systematically exploring all four parathyroid glands. All abnormal parathyroids should be removed with histologic verification. When no abnormal glands are found, localization studies should be performed before re-exploration.
Completion thyroidectomy for initially misdiagnosed thyroid cancer.
Intraoperative frozen sections fails to diagnose thyroid carcinoma accurately in 16% of cases. In such instances, we recommend that completion thyroidectomy be performed in the patient who has invasive carcinoma, is less than 70 years old, and has a reasonable life expectancy. The procedure should be carried out immediately if the error in diagnosis is discovered within a week; otherwise the procedure should be delayed until 3 to 4 months later. At that time, the recurrent laryngeal nerves and at least two parathyroid glands should be dissected and preserved. A paratracheal lymph node dissection should also be performed and the lower jugular lymph nodes should be sampled. If these jugular lymph nodes are found to be positive, a modified radical neck dissection should be added. The morbidity associated with the completion thyroidectomy is minimal. Postoperatively, a 131I scan of the neck should be carried out and ablative doses of radioactive iodine can be given if the uptake in the thyroid bed is greater than 1.5%. Subsequently, all patients are given thyroid suppressive therapy and are monitored closely. This approach will reduce the local recurrence rate and improve the long-term survival.
Multiple parathyroid adenomas: report of thirty-three cases.
An increasing number of patients with primary hyperparathyroidism are found to have two or three enlarged parathyroid glands. Of 865 patients successfully operated on by one surgeon (J.N.A.), multiple enlarged parathyroid glands (adenomas) were found and resected in 33 cases (3.8%), with resulting normocalcemia lasting from 1 to 22 years (mean 5.8). Twenty-nine patients had two adenomas and four had three adenomas. In 28 patients the multiple adenomas were synchronous. Twenty-five patients underwent removal of all of the enlarged parathyroid glands in one operation; in three patients one adenoma was removed, reoperation for persistent hypercalcemia was performed, and a second adenoma was resected with cure. In five patients one adenoma was removed, normocalcemia ensued for 3 to 18 years, and a second (metachronous) adenoma occurred and was resected successfully. Although 10 of 70 enlarged parathyroid glands removed were labeled hyperplasia, cure in all but one of our patients by selective resection of only enlarged parathyroid glands emphasizes the unreliability of histologic criteria in differentiating between parathyroid adenoma and hyperplasia. Based on this study, we support the existence of multiple adenomas and advocate removal of only macroscopically enlarged parathyroid glands in patients with primary hyperparathyroidism.
Thirty-year experience with 457 radical neck dissections in cancer of the mouth, pharynx, and larynx.
A retrospective analysis of 457 radical neck dissections (RNDs) performed for epidermoid cancers of the head and neck was performed. There was a 27 percent overall neck recurrence rate, 17 percent being confined to the neck. Only 5 percent occurred in the ipsilateral dissected neck. Failure in the neck correlated well with the node stage at the time of surgery, but was not affected by the size of the primary tumor, the timing of the RND, or the type of RND performed. Treatment of neck recurrences was predominantly surgical, with a 56 percent local control and a 24 percent disease-free survival rate. Overall disease-free survival was 53 percent, ranging from 68 to 29 percent according to the node stage. Survival was further affected by the size of the primary tumor and failure to control disease in the neck; it was not affected by the type of RND or its timing, or the addition of radiotherapy. Overall recurrence after modified RND was 28 percent. Increased neck recurrences were noted only in N2 and N3 cases, although survival was not affected even in these late stages.
Modified neck dissection in treatment of thyroid cancer: a safe procedure.
Differentiated carcinoma of the thyroid metastasizes early and frequently to cervical lymph nodes. Radical neck dissection performed electively or therapeutically results in high cure rates. Modified neck dissection consisting of a single transverse incision, resection of the jugular chain of nodes and those in the posterior triangle of the neck with preservation of the sternomastoid muscle, the spinal accessory nerve and the submandibular salivary gland provides a cosmetic, functional result with minimal morbidity. In a series of 313 neck dissections for thyroid carcinoma, only three patients with papillary or follicular carcinoma, which was resectable, treated by thyroidectomy and modified neck dissection died of disease.
Treatment of Warthin's tumor by enucleation.
Among 162 patients with Warthin's tumor, 113 had removal by enucleation. The others, in whom parotidectomy and facial nerve dissection were performed, were not suspected of having Warthin's tumor preoperatively or had tumor too close to the facial nerve to be safely enucleated. Patients were generally older and more likely to be male than patients with other benign parotid tumors. Fifteen patients had multiple Warthin's tumors at the time of initial presentation; in an additional 12 patients, Warthin's tumor developed in the opposite parotid gland after the initial operation. In only two patients did an additional tumor develop in a gland from which a Warthin's tumor had previously been enucleated. No permanent injuries to the facial nerve occurred. Because of the safety and efficacy with which enucleation can be performed and because the risk of malignant transformation of Warthin's tumors is extremely small, we believe that enucleation is the treatment of choice in most cases.
Preoperative localization of parathyroid adenomas.
During a 12-month period, 64 patients were operated on for primary hyperparathyroidism. Sixty-one had single adenomas and 3 had double adenomas. Preoperative imaging was used to localize the adenomas. Half of the patients (32 of 64) had magnetic resonance, thallium-201/technetium-99m subtraction scintigraphy, and high-resolution ultrasonography; the other 32 patients had 1 or 2 of the imaging modalities. Sensitivity and specificity of magnetic resonance imaging was 82 percent and 97 percent, respectively; the sensitivity and specificity of the other two modalities was 59 and 98 percent for subtraction scintigraphy and 73 and 98 percent for ultrasonography. The use of preoperative imaging facilitated surgical exploration, reduced operating time, and resulted in an increased number of successful operations. There were no negative explorations in this series as compared with 19 negative explorations (2.6 percent) in our prior experience with 720 operations.
Osseointegrated denture in a vascularized bone transfer: functional jaw reconstruction.
Total functional reconstruction of the lower jaw often falls short of ideal goals. While reconstructive techniques are available to close large defects with both hard and soft tissue, the insertion of a prosthetic dental appliance and the return to normal masticatory function are often technically impossible or not even attempted. Presented here is a case report of a patient successfully rehabilitated with a fixed dental appliance supported by jaw fixtures osseointegrated into a vascularized iliac crest mandibular reconstruction. At present, 6 additional patients have had mandibular reconstructions and are in various phases of functional dental rehabilitation. When these data are complete, a series report will be presented for publication.
The occurrence of multiple endocrine neoplasia type IIb, in two children of an affected mother.
Two children with multiple endocrine neoplasia syndrome, Type IIb, (MEN IIb), whose natural mother died from complications of general anesthesia, due to undiagnosed bilateral pheochromocytomas, are described. Of particular interest is the fact that the daughter presented with many stigmata of the syndrome, including the typical facies, while her brother had no obvious clinical manifestations of the syndrome. Both children to date have undergone total thyroidectomy, and pathology reports have confirmed the presence of medullary thyroid carcinoma.