Contralateral Nodules Research Articles

Natural History of Contralateral Nodules After Lobectomy in Patients With Papillary Thyroid Carcinoma.

Bilateral thyroid nodularity is considered an indication for total thyroidectomy in papillary thyroid carcinoma (PTC). However, the natural history and outcome of contralateral nodules have never been studied. To investigate the natural history of nonsuspicious contralateral nodules after lobectomy for PTC. We included patients who had one or more solid nodules (≥3 mm) in the contralateral lobe with benign cytology before surgery or small nonsuspicious nodules per ultrasonography. One hundred and twelve patients were included. Median age was 57 years, and median size of the PTC (initial lobectomy) was 8 mm (range, 0.5 to 28 mm). On the contralateral side, the median size of nodules was 7 mm (range, 3 to 30 mm). Thirty-three nodules (29%) had fine-needle aspiration (FNA) before surgery, and all were benign. After a median follow-up of 6 years, median growth was zero (range, -20 to 19 mm). Twenty-six nodules (23%) increased ≥3 mm in size (median, 6 mm; range, 4 to 19 mm). Twenty patients (18%) developed new nodules. Twelve patients (11%) underwent completion thyroidectomy for growth (three), suspicious FNA (seven; Bethesda III to V), malignancy (one), or unknown reason (one). Overall, according to the completion thyroidectomy specimen, six patients (5%) were diagnosed with contralateral PTC (five micro-PTCs, one 20 mm), and all were without evidence of disease at the end of follow-up. There were no surgical difficulties or local complications during completion surgery. Lobectomy for low-risk patients with a small PTC and nonsuspicious contralateral thyroid nodule(s) is a reliable and safe initial treatment option. In the few patients who required completion thyroidectomy, treatment with surgery and radioiodine was effective.

Predictive Factors for Occult Contralateral Papillary Thyroid Carcinoma in Patients with Ipsilateral Multifocality on Frozen Biopsy

Background and Objectives Papillary thyroid carcinoma (PTC) frequently occurs as multifocal and bilateral tumors. However, multifocality and bilaterality are not easy to detect preoperatively and contralateral remnant tumor might lead to reoperation after hemithyroidectomy. We aimed to demonstrate the frequency of bilaterality and predictive factors for occult contralateral PTC when a frozen biopsy of hemithyroidectomy shows multifocal PTCs in one of the lobes. Subjects and Method One hundred and thirty patients with PTC were enrolled in this study. All patients underwent hemithyroidectomy and frozen biopsy, followed by total thyroidectomy because of ipsilateral multifocality. Medical records, pathologic results, and preoperative ultrasound results were reviewed retrospectively. Patients were divided into two groups depending on bilaterality (unilateral or bilateral). Results Bilaterality was detected in 74 of 130 patients (56.9%). Bilateral group showed more number of carcinomas (3.9±1.4 vs. 2.3±0.9) and more tendency of existence of contralateral nodule (87.8% vs. 55.3%). Tumor size of 1 cm or more and contralateral nodules were significant predictive factors for the existence of occult contralateral PTC. The suspicious sonographic feature of contralateral nodule had 75.7% sensitivity and 75% specificity for detecting bilaterality. Conclusion The incidence of bilateral PTC is high in patients with ipsilateral multiple tumors. When the frozen biopsy result shows multifocality in one of the lobes, the remnant tumor may lead to reoperation under recent guidelines on thyroid surgical extent. Characteristics of contralateral nodule can help physicians and patients to make the decision regarding surgical extent. Key words: Frozen sections ㆍ Papillary thyroid carcinoma ㆍ Thyroid nodule

Extent of surgery did not affect recurrence during 7-years follow-up in papillary thyroid cancer sized 1-4cm: Preliminary results.

There is debate whether hemithyroidectomy is sufficient for patients with papillary thyroid cancer (PTC) sized 1-4cm. Therefore, we investigated whether hemithyroidectomy affects recurrence rate compared with thyroidectomy in patients with PTC sized 1-4cm. Retrospective observational study. We included 147 patients with 1-4cm PTC who underwent hemithyroidectomy between 2004 and 2008. They were matched with 298 patients who underwent thyroidectomy, comparing age, sex, tumour size, multiplicity, extrathyroidal extension status and lymph node (LN) metastasis status. Recurrence-free survival (RFS) was compared between hemithyroidectomy and thyroidectomy groups. Median follow-up length was 7years, during which there were nine (6.1%) and 17 (5.7%) recurrences in hemithyroidectomy and thyroidectomy groups, respectively. Recurrence-free survival in the hemithyroidectomy group was not different from that in the thyroidectomy group regardless of variant, multifocality, LN metastasis and radioactive iodine treatment. However, in subgroup analysis, hemithyroidectomy significantly increased the risk of recurrence in patients with contralateral nodules on the preoperative imaging. Recurrence after hemithyroidectomy was not different from that after thyroidectomy during a median follow-up of 7years. However, because thyroidectomy might be favoured in patients with contralateral nodules at preoperative evaluation, a thorough evaluation of the contralateral thyroid lobe is necessary.

Prediction of occult carcinoma in contralateral nodules based on the ultrasonic features of unilateral papillary thyroid carcinoma

Objective: To investigate the occurrence of occult carcinoma in contralateral lobes based on the ultrasonic features of unilateral papillary thyroid carcinoma. Methods: The study included 202 consecutives cases of unilateral papillary thyroid carcinoma with benign nodules in the contralateral lobe identified by preoperative ultrasound or fine-needle aspiration from June 2014 to December 2015. All patients received total thyroidectomies, and with postoperative pathological examination they were divided into two groups, one including 60 cases with positive occult cancer and another one consisting of 142 cases with negative occult cancer. Univariate and multivariate analyses were performed to analyze the sonographic features of unilateral papillary thyroid carcinoma relevant to the occurrence of occult carcinoma in the contralateral nodules. Results: Univariate analysis indicated occult carcinoma in the contralateral lobes was associated with Hashimoto's thyroiditis(χ(2)=3.955, P=0.047), unclear border (χ(2)=4.375, P=0.036)and multifocality in the ipsilateral(χ(2)=7.375, P=0.007), but not with tumors maximum size, location, A/T, shape, internal structure, internal echo, acoustic halo, calcification, capsular invasion and blood flow signal in the lobe with carcinoma on another side. Multivariate analysis showed unclear border (OR=2.727, P=0.010) and multifocality in the ipsilateral(OR=2.807, P=0.005)of carcinoma were independent predictive factor for contralateral occult PTC. Conclusions: Unclear border and multifocality of PTC in the ipsilateral were closely relevant to the occurrence of occult carcinoma in the contralateral nodules.

Thyroid lobectomy is an effective option for unilateral benign nodular disease.

The use of thyroid lobectomy in the treatment of unilateral, benign nodules is limited by the potential of nodular recurrence in the remaining lobe. This study aimed to assess the rate and clinical impact of nodular recurrence in the contralateral lobe after thyroid lobectomy and to identify predictive factors of recurrence. Single-centre retrospective study. Records of patients that underwent lobectomy for unilateral thyroid nodules between 1991 and 2010 were reviewed and 270 patients were included. Exclusion criteria were: presence of contralateral nodule(s) ≥5mm on preoperative ultrasound, diagnosis of cancer necessitating completion thyroidectomy or pseudonodules. Recurrence was defined as the occurrence of nodule(s) ≥5mm in the remaining lobe on at least one postoperative ultrasound. A set of clinical, imaging, histological and biochemical parameters was tested as predictors of recurrence using logistic regression. After a median follow-up of 78months (range, 12-277months), the global recurrence rate was 42% and recurrence of nodules of a size ≥1cm occurred in 19%. Reoperation rate was 1·1%. 90% of patients were treated postoperatively by levothyroxine. Median time to nodular recurrence was 4years. Preoperative contralateral lobe volume and resected thyroid weight were identified as significant predictors of recurrence (P=0·045 and P=0·03 respectively). Thyroid lobectomy is an effective therapeutic strategy for unilateral, benign nodules, resulting in a low rate of clinically relevant nodular relapse in a mildly iodine-deficient area. Patients with uninodular disease and a contralateral lobe of normal size are particularly good candidates for lobectomy.

Partial Thyroidectomy for Papillary Thyroid Microcarcinoma: Is Completion Total Thyroidectomy Indicated?

Total thyroidectomy is a well-established surgical approach for the management of papillary thyroid cancer (PTC). However, the best surgical approach for papillary microcarcinoma is nowadays still debated. Both total thyroidectomy and simple lobectomy are used. We report the experience of a single University center in the treatment of thyroid microcarcinoma. A retrospective analysis on all patients who underwent thyroid surgery at our institution over a 24-year period (1991-2015) was performed. Patients were grouped according to whether they received total thyroidectomy (Group 1) or lobectomy (Group 2). Follow-up was made by routine clinical and ultrasound examination. Specific outcomes such as recurrence and need for reoperation as well as complications (transient vocal cord paralysis and hypocalcemia) were analyzed. During the study period 880 patients underwent surgery for PTC. Group 1 and 2 consisted, respectively, of 756 and 124 patients. A micro PTC (<10 mm) was present in 251 and 69 specimen of Group 1 and 2. No evidence of disease recurrence in the follow-up was reported in patients with microPTC in Group 1 and in 57 patients of Group 2. In the remaining 12 patients completion thyroidectomy was carried out due to ultrasound findings of contralateral nodules (10), lymphadenopathy (1), and capsular invasion (1). Five of these patients had a contralateral papillary carcinoma on final histopathologic examination. Thus recurrence rate for patients of Group 2 was 7.3%. Morbidity rates were, respectively, for Group 1 and 2: transient nerve palsy 81 and 5 (11 vs. 7.3%, p = ns), transient hypoparathyroidism (Calcium <2.00 mmol/L) 137 (18.6%) and 0 (p < 0.0001). Three of the 12 patients of Group 2 undergoing further surgery had a transient hypoparathyroidism. Thyroid lobectomy is an effective surgical strategy to manage papillary microcarcinomas with low complications. Routine completion thyroidectomy is not mandatory. Appropriate selection excluding high-risk patients is of paramount importance in order to achieve the best results.

Prediction of occult carcinoma in contralateral nodules for unilateral papillary thyroid carcinoma

To investigate the risks for occult carcinoma in contralateral nodules for unilateral papillary thyroid carcinoma. The study included 157 consecutive cases of unilateral papillary thyroid carcinoma with benign nodules in the contralateral lobe identified by preoperative ultrasound or fine-needle aspiration from January 2011 to December 2013. The patients received total thyroidectomies and neck lymph node dissections. The frequency and predictive factors for contralateral occult carcinoma in these patients were analyzed. A total of 68 patients (43.3%) had occult papillary thyroid carcinoma in the contralateral lobe and the maximum diameter of contralateral occult papillary carcinoma ranged from 0.1 to 1.2 cm, including ≤ 0.5 cm in 56 patients, 0.5-1.0 cm in 9 patients and >1.0 cm in 3 patients respectively. In univariate analysis, occult carcinoma in the contralateral lobe was associated with patient age (χ(2) = 7.266, P = 0.007) and pathologically multifocality in the ipsilateral lobe (χ(2) = 5.090, P = 0.024), but not with family history, tumor size, thyroid function, Hashimoto's thyroiditis, perithyroidal invasion, multifocality in the ipsilateral lobe, clinically or pathologically node-negative neck. In multivariate Logistic an analysis, age (OR = 1.054, P = 0.001) and multifocality in the ipsilateral lobe on final pathology (OR = 2.443, P = 0.021) were independent predictive factors for contralateral occult papillary thyroid carcinoma. Occult carcinoma is common in the contralateral "benign" nodules in patients with unilateral papillary thyroid carcinoma especially in young patients or the cases with multifocal tumors.

66IN - Optimal Assessment of an Additional Lung Nodule in a Patient with Potential for Cure

ABSTRACT A significant number of patients present with a dominant pulmonary mass or presumptive lung cancer with an additional radiologically visible intra-pulmonary nodule. The IASLC stage classification of T3 (nodule within same lobe), T4 (nodule within other ipsilateral lobe) and M1a (contralateral nodule) is applied for these patients. It is very difficult to say what the frequency is of early lung cancer with an additional pulmonary nodule. Several studies estimated the prevalence of an additional nodule coexisting with potentially operable lung cancer on imaging between 20 and 25% of patients, in whom 25-30% is malignant. Additional nodules account for only 2.5% of cases included in the 7th edition of the IASLC staging database. It is unclear what proportion is grossly detectable instead of only pathologically reported. In addition, the T3/T4/M1a additional nodule stage classification should not be applied to synchronous second primary lung cancers (SPLC) or lesions that are imaged but most likely benign such as subcentimeter intrapulmonary lymph nodes. The distinction between synchronous SPLC and intrapulmonary metastatic disease has relied upon Martini and Melamed's approach. More recently, the hypothesis of field cancerization in the lung has made acceptance of synchronous SPLC easier. Additional nodules judged as synchronous SPLC should be staged with separate TNM designations. Patients with an additional lung nodule should be evaluated by an experienced multidisciplinary tumour board. The biological relationships between the lesions does matter in terms of our traditional thinking around staging and therapy. A careful evaluation for distant and mediastinal metastases is strongly recommended. The evaluation for possible extrathoracic metastases should be carried out by an integrated PET/CT and brain MRI/CT. In the absence of extrathoracic distant metastases, an invasive mediastinal evaluation either by mediastinoscopy or endosonography should be carried out. No further invasive diagnostic workup of the T3 or T4 additional nodule is undertaken for an operable patient. Patients unable or equivocal to undergo a contralateral surgical resection should undergo an endoscopic or percutaneous biopsy of the M1a additional nodule. Disclosure: The author has declared no conflicts of interest.

Impact of Contralateral Tumor Nodules on Survival in Non-Small Cell Lung Cancer: A SEER Database Analysis

Purpose/Objective(s): We explored the prognostic implications of contralateral tumor nodules in patients with non-small cell lung cancer (NSCLC) using the SEER database. We hypothesized that many such cases represent a second primary tumor and exhibit a favorable prognosis compared to other types of metastatic disease. Materials/Methods: We analyzed overall survival (OS) in SEER data from 2004-2009 for patients age 25-85 with malignant primary tumors of the lung or bronchus and non-small cell histology. Patients were categorized as M0, M0 with ipsilateral nodule in separate lobe, M1a with contralateral nodule, M1a without contralateral nodule, or M1b with distant metastasis. We used Kaplan-Meier estimates and the log-rank test to compare OS between groups. Using a proportional hazards model, risk of death for patients with tumor nodules in a contralateral lobe was compared to what would be expected from a synchronous second primary tumor. Results: Of 208,691 patients who met inclusion criteria, 10,548 had contralateral tumor nodules without other metastatic disease. Median and 2 yr OS for these patients was 7 mo and 18%, respectively. This was greater than that observed in patients with other forms of M1a disease (4 mo and 8%; p < 0.001) but less than that with an ipsilateral nodule in a separate lobe (11 mo and 27%; p < 0.001). This pattern persisted when patients were stratified by N-stage and primary tumor size. Not unexpectedly, patients with ipsilateral nodules received more definitive treatment relative to those with contralateral nodules (21% surgery, 30% radiation vs 6% surgery, 23% radiation). Interestingly, patients with T1-2a N0-1 disease and a contralateral nodule achieved greater OS than those with no additional pulmonary nodule but with N3 disease. Patients with T1-2N0 disease and a contralateral nodule had a hazard for death that was not significantly different from that expected from a synchronous stage IA primary tumor. Patients with more advanced T and N stages had OS intermediate between that estimated for concurrent primaries and M1b disease. Conclusions: Contralateral tumor nodules in NSCLC carry a prognosis more favorable than other M1a or M1b disease but less favorable than no additional nodule or an ipsilateral nodule in a separate lobe. Collectively, our analyses suggest that M1a contralateral nodules represent two distinct biological subgroups: hematogenous metastatic disease and synchronous, early stage second primaries. This study points to (1) an opportunity for improvement in the current staging system, (2) a rationale for definitive treatment of T1-2N0 patients with contralateral nodules, and (3) a need for molecular pathologic sub-classification of contralateral pulmonary nodules in patients with more advanced disease in order to identify those who may benefit from aggressive loco-regional treatments. Author Disclosure: Z.S. Morris: None. D.M. Cannon: None. S.M. Bentzen: None. K.R. Kozak: None.

Current Readings: The Most Influential and Recent Studies Regarding Resection of Lung Cancer in M1a Disease

M1A disease is a recent concept appearing in the 7th TNM classification of lung cancer. M1A encompasses two different entities, malignant pleural or pericardial effusions and separate tumor nodules in the contralateral lung, who constitute very different diseases, with very different management and prognoses. On one hand, patients with pleural dissemination have extremely poor survival, with median and 5-year survivals of 4 months and 3.1%, respectively. Only selected patients whose limited pleural extension has been diagnosed at the time of thoracotomy and completely resected, may experience prolonged survival. On the other hand, recent progress in molecular biology still failed to establish whether a contralateral lesion is a second primary or a metastasis. These contralateral lesions are now gathered as multiple lung cancers in the surgical literature, and misleadingly classified as M1A disease in the TNM classification. Patients with contralateral nodules may experience prolonged survival after the surgical treatment of both localizations. Changing the staging by establishing the diagnosis of metastasis is probably an important issue warranting further biologic research, but according to current results this diagnosis must not in any case preclude surgery.

Thyroid Hormone Replacement Therapy, Surveillance Ultrasonography, and Fine-Needle Aspiration after Hemithyroidectomy

We undertook a retrospective analysis of a single surgeon's experience at a tertiary care teaching hospital to determine the rates of surveillance ultrasound, fine-needle aspiration (FNA), and the need for thyroid hormone replacement therapy (THRT) after hemithyroidectomy. The study population comprised 120 consecutive patients who underwent hemithyroidectomy by one surgeon from January 2008 to June 2011. The medical records were reviewed for preoperative and postoperative calcium levels, fiberoptic direct laryngoscopy examination of vocal fold mobility, postoperative complications, final pathology, and postoperative follow-up. Fifteen patients required completion thyroidectomy for malignancy and were excluded from the surveillance analysis. Of the remaining 105 patients, 10 (9.5%) required postoperative THRT. The likelihood for THRT was significantly associated with increased age (p = 0.01) and the presence of thyroiditis (p = 0.04). Other factors, such as gender, body mass index, residual thyroid volume, and presence of contralateral lobe nodules, were not significantly associated with this likelihood (p > 0.05). Twenty-three patients (21.9%) were followed with surveillance ultrasound, of whom 12 (11.4%) underwent FNA for nodule(s) in the contralateral lobe. Seventy-eight percent of patients did not require any long-term postoperative surveillance. There were no instances of permanent recurrent laryngeal nerve injury or hypoparathyroidism. Hemithyroidectomy is an effective and efficient option for the management of benign and suspicious thyroid nodules. However, patients of increased age and/or with thyroiditis are at higher risk for postoperative hypothyroidism, and should be counseled to consider total thyroidectomy to avoid the need for long-term surveillance and the possible need for a second operation.

A Randomized Trial of Hemithyroidectomy Versus Dunhill for the Surgical Management of Asymmetrical Multinodular Goiter

To assess the immediate and long-term clinical results of 2 different surgical procedures for the treatment of asymmetrical multinodular goiter (AMG). Half of the patients presenting with a single benign thyroid nodule have contralateral subclinical disease. There is a controversy whether these patients should be treated with hemithyroidectomy (HMT) or with a more extensive procedure. Adult patients with a benign unilateral dominant nodule and contralateral nodule(s) with a diameter of less than 10 mm detected on neck ultrasonography were randomized to HMT or Dunhill (DUN). Rates of complications, remnant growth, incidental carcinoma, and reoperation were assessed. A total of 118 patients (F/M:110/8, mean age 43 years) were included and randomized: 65 to HMT and 53 to DUN. After randomization, 28 patients were excluded leaving 47 HMT and 43 DUN long-term (55 ± 35 months) evaluable patients. Mean nodule size was 38 and 6 mm for the dominant and contralateral nodules, respectively. No differences were found in operative time, accidental parathyroidectomy, parathyroid autotransplantation, or wound complications. Transient hypocalcemia was more common in DUN (30% vs 8%; P < 0.001). No permanent complications were observed. At the last follow-up visit, thyroid-stimulating hormone was similar in both groups. Remnant growth (20 vs 0%; P < 0.001), appearance of new nodules (55 vs 14%; P < 0.001), and overall reoperation rate (9.2 vs 1.8%, P = 0.2) were more common in HMT, mostly because of undiagnosed cancer requiring completion thyroidectomy. Thirty percent of HMTs developed hypothyroidism and required long-term T4 supplementation. DUN appears superior to HMT for the treatment of AMG in terms of early reoperation for missed carcinomas and disease progression. Both procedures have a similarly uneventful postoperative course.

Managements of small thyroid nodules with contralateral papillary thyroid microcarcinoma

To study the diagnoses and treatments of small thyroid nodules (maximum diameter < 1 cm) with contralateral papillary thyroid microcarcinoma (PTMC). A total of 253 patients with unilateral PTMC and contralateral thyroid benign nodules identified by ultrasound before thyroidectomy was retrospectively analysed. All patients underwent near-total or total thyroidectomy. Chi-square test was used for univariate analysis and logistic regression test for multivariate analysis. In 53 (20.9%) of 253 patients with unilateral PTMC, the contralateral thyroid benign nodules identified by ultrasound were confirmed pathologically as PTMC. Univariate analysis showed multifocality of the primary tumor and Hashimoto's thyroiditis were correlated with contralateral PTMC (χ(2) = 24.834, χ(2) = 5.182, P < 0.05). However, there were no significant differences for the existence of contralateral PTMC in age, sex, tumor size, capsule invasion, lymph node metastasis, the number of nodules and Tg-level. Multivariate analysis showed only multifocal PTMC was an independent predictive factor for contralateral PTMC (OR = 5.352, P < 0.05). The patients with unilateral multifocal PTMC have a high rate of PTMC in contralateral small thyroid nodules. However, it is very difficulty to define by ultrasonography preoperatively. The total thyroidectomy maybe serve as a useful treatment.

Different Clonal Origin of Bilateral Papillary Thyroid Carcinoma, with a Review of the Literature

Papillary thyroid carcinoma (PTC) often presents with two or more anatomically separate foci. A long-standing argument is whether this multifocality is the result of multiple independent tumors ("multicentricity") or of intrathyroidal spread originating from a single tumor mass, presumably through permeation of intrathyroidal lymph vessels. We reexamined this issue with a clonality assay and compared our results with those in the literature. A total of 27 nodules from 11 female patients with bilateral PTC treated with total thyroidectomy were investigated for clonality using the HUMARA assay. Eight of 11 cases were informative (72.7 %). All but one of tumor foci showed a monoclonal population. The outlier sample gave a value indicative of balanced X-inactivation in one nodule. The monoclonality was concordant in three patients, discordant in three, and mixed in two (with both concordant and discordant results). Interestingly, in both of the latter cases (composed of over two samples per case), the contralateral nodules were discordant. Moreover, all four ipsilateral nodules were concordant. The results of our study suggest that some cases of multifocal PTC are the result of true multicentricity, whereas others are the consequence of intrathyroid spread by an originally single tumor mass. These conclusions support those made in the past years on the basis of morphologic considerations. Specifically, the incidental finding of two or more microscopic foci of PTC widely separate from each other was felt to favor multicentricity, whereas the finding of multiple ipsilateral foci of PTC within vascular spaces, often accompanied by multiple lymph node metastases, suggested intrathyroid spread; the most striking manifestation of this phenomenon being seen in the diffuse sclerosing variant of PTC.

Surveillance and Intervention After Thyroid Lobectomy

After thyroid lobectomy, many patients require ongoing care. This study sought to quantify the rates of surveillance and intervention after thyroid lobectomy. One hundred one consecutive patients who underwent a thyroid lobectomy for nodular disease were evaluated. Clinical and follow-up data were obtained by a review of patient charts and included an evaluation of resource utilization related to thyroid disease. Nineteen patients required completion thyroidectomy for thyroid cancer, and 11 had hypothyroidism before lobectomy. Of the remaining evaluable patients, 30 (42.2%) of 71 required thyroid hormone replacement after lobectomy, with 24 patients having elevated thyroid-stimulating hormone and 6 suppression of nodules in the contralateral lobe. The likelihood of thyroid hormone replacement demonstrated a trend with a contralateral nodule (9 of 14 vs. 21 of 57, P=0.06) and a significant association with thyroiditis on surgical pathology (10 of 11 vs. 20 of 60, P<0.001). Of the 82 patients who did not undergo completion lobectomy, 10 (12%) of 82 underwent postoperative fine-needle aspiration of the contralateral lobe, and 25 (30%) of 82 were followed with ultrasound surveillance. Only 27% of patients treated with lobectomy required no further surveillance or intervention. There were no instances of permanent recurrent laryngeal nerve injury. After thyroid lobectomy, most patients require continued surveillance and intervention. With a near-zero complication rate, total thyroidectomy may be a more effective and efficient option for management of nodular thyroid disease.

Functional MRI interactions between dysplastic nodules and overlying cortex in periventricular nodular heterotopia

Periventricular nodular heterotopia (PVNH) is a malformation of cortical development associated with epilepsy. It is unclear whether the epileptogenic focus is the nodule, overlying cortex, or both. We performed electroencephalography (EEG)–functional magnetic resonance imaging (fMRI) in a patient with bilateral PVNH, capturing 45 “left temporal” epileptiform discharges. The relative time at which fMRI-involved regions became active was assessed. Additionally, nodule–cortex interactions were explored using fMRI functional connectivity. There was EEG–fMRI activity in specific periventricular nodules and overlying cortex in the left temporoparietal region. In both nodules and cortex, the peak BOLD response to epileptiform events occurred earlier than expected from standard fMRI hemodynamic modeling. Functional connectivity showed nodule–cortex interactions to be strong in this region, even when the influence of fMRI activity fluctuations due to spiking was removed. Nonepileptogenic, contralateral nodules did not show connectivity with overlying cortex. EEG–fMRI and functional connectivity can help identify which of the multiple abnormal regions are epileptogenic in PVNH.

Enlarged Benign-Appearing Cervical Lymph Nodes by Ultrasonography Are Associated with Increased Likelihood of Cancer Somewhere Within the Thyroid in Patients Undergoing Thyroid Nodule Evaluation

Benign-appearing cervical lymph nodes (CLN) are easy to assess during an ultrasonography (US) evaluation for a guided fine-needle aspiration biopsy of a suspicious thyroid nodule, but their clinical significance regarding thyroid cancer risk is not known. Non-malignant-appearing nodes may be an indicator of early malignancy in the thyroid. We hypothesize that there is an increased prediction of thyroid cancer when benign-appearing enlarged CLN (ECLN) > 1 cm in any dimension are present during an US evaluation of thyroid nodules. A review of 269 consecutive patients' charts sent for thyroid nodule assessment that underwent thyroidectomy was conducted to compare ECLN, with the presence of thyroid cancer during an ultrasound-guided fine-needle aspiration biopsy of the thyroid nodule. Surgical excision pathology confirmed all abnormal cytology reports. From the final 265 charts reviewed, 213 had benign thyroid pathology and 52 had thyroid cancer. Sex, number, and size of the biggest thyroid nodule were not different between groups. Patients with cancer were on average 10 years younger and had higher thyroid-stimulating hormone (TSH) values (p < 0.003) as well as a 10-fold increase in enlarged non-malignant-appearing lymph nodes than their peers without cancer. The presence of ECLN had an 82% sensitivity, 90% specificity, and a 68% positive predictive value for thyroid cancer. There was also an 80% negative predictive value when enlarged lymph nodes were not present. In 8 of the 37 (21.6%) patients with malignancy and ECLN, the primary dominant thyroid nodule was negative on cytologic evaluation, but malignancies were confirmed on surgical specimen, in contralateral nodules on the same side as the ECLN. These nodules were mostly subcentimeric, ranging from 0.2 to 1.14 cm and were not biopsied due to their inconspicuous appearance. After multiple logistic regression analysis, enlarged lymph nodes had a 53.8 odds ratio for cancer (20.49-141.33, p < 0.01). Discovering the presence of ECLN in routine assessment of thyroid nodules is an easy and fast surveillance technique that increases the predictive value in diagnosing thyroid cancer, especially when the enlarged lymph nodes are on the same side as the thyroid nodule.

Sigmoid Colon Metastasis from Sarcomatoid Renal Cell Carcinoma

The sarcomatoid histological type of renal cell carcinoma is a clinically aggressive variant of parenchymal tumor, typically resistant to systemic treatment. We report the case of a 65-year-old female patient who had undergone a left radical nephrectomy for a sarcomatoid renal cell carcinoma together with enucleation of a mass of the right kidney and a contralateral nodule diagnosed as clear cell carcinoma. One year later lung, adrenal and sigmoid colon metastases from sarcomatoid renal cell carcinoma were detected and the patient was started on systemic immunotherapy with interleukin-2 and interferon-alpha. Computed tomography showed marked disease progression and the patient died 3 weeks later. Sigmoid colon metastasis from a primary sarcomatoid renal cell carcinoma has never been described in the literature.

Sonographic detection of multifocality in breast carcinoma.

The aim of this study was to evaluate the diagnostic accuracy and clinical value of preoperative sonographic detection of multifocality in breast carcinoma. Between November 1, 1999, and November 30, 2000, we prospectively compared the sonographic and histopathologic findings for all nodules measuring 1 cm or less in the longest dimension on sonography in 19 consecutive patients diagnosed with breast carcinoma. For each nodule, the final histopathologic diagnosis, size, and, in cases of nodules in the same breast as the primary lesion, the distance from that lesion were evaluated. The 19 patients examined, all of whom were women, had a mean age of 42.1 years (range, 28-62 years). Thirty nodules were detected on sonography: 15 patients had a total of 24 nodules in the ipsilateral breast, 2 patients each had 1 nodule in the contralateral breast, and 2 patients each had 1 nodule in the ipsilateral breast and 1 nodule in the contralateral breast, for a total of 26 ipsilateral and 4 contralateral nodules. Of the 30 lesions, 20 (67%) appeared to be malignant (ie, satellite nodules) on sonography. Histopathologic examination showed that of these malignant-looking lesions, 15 (75%), which were found in 10 patients, were malignant and 5 (25%), which were found in 4 patients, were benign. For 7 (70%) of the 10 patients whose nodules appeared malignant on sonography, the initial treatment plan was changed because of the sonographic findings. Ten lesions were assessed as benign on sonography; histopathologic examination confirmed that all 10 were benign. Sonography had a sensitivity of 100%, a specificity of 67%, a positive predictive value of 75%, a negative predictive value of 100%, and an accuracy rate of 83%. The mean size of the nodules was 0.8 cm (range, 0.3-1.4 cm). The mean distance of the 26 ipsilateral nodules from the primary lesion was 1.8 cm (range, 0.5-6 cm). Preoperative sonography is accurate and reliable for detecting small satellite nodules and can have an important role in the preoperative evaluation of patients for whom breast-conserving surgery is planned.

Estudo comparativo da microvascularização das pregas vocais humanas acometidas por cisto e reação nodular contra-lateral sob endoscopia rígida

OBJETIVO: O objetivo desse estudo foi analisar as alterações microvasculares que ocorrem na prega vocal (PV) humana, quando acometida por cisto e reação nodular contra-lateral. FORMA DE ESTUDO: Clínico prospectivo. MATERIAL E MÉTODO: Através de laringoscopia de suspensão as PVs foram analisadas sob endoscopia rígida em suas porções anterior, média, posterior e sub-glótica. As alterações da microvascularização foram classificadas em quatro grandes grupos: Paralelo, Transversal, Ramificado e Puntiforme. Estas foram subdivididas em doze subtipos. RESULTADOS: Nas PVs acometidas por cisto as alterações microvasculares foram mais freqüentes (93,1%) do que nas PVs contra-laterais acometidas por reação nodular (6,9%). Na presença de cisto também foram observadas múltiplas alterações microvasculares (10 subtipos), havendo predominância de microvasos tortuosos e ectásicos, enquanto nas acometidas por reação nodular contra-lateral essas alterações foram menos variadas (3 subtipos). Quando diretamente relacionadas à lesão nodular, foram com exclusividade puntiformes. CONCLUSÃO: Nossos achados sugerem que a presença do cisto na lâmina própria interfere no arranjo dos microvasos das PVs, enquanto a reação nodular, por acometer o epitélio, que é mais superficial aos vasos, interfere em menor grau em relação à arquitetura vascular. Deste modo na presença de microvasos alterados devemos suspeitar mais do diagnóstico de cisto do que de reação nodular.