Inter-Observer Variation in the Pathologic Identification of Minimal Extrathyroidal Extension in Papillary Thyroid Carcinoma

Background: Extrathyroidal extension (ETE) is a significant prognostic factor in papillary thyroid carcinoma (PTC). Minimal extrathyroidal extension (mETE) is characterized by involvement of the sternothyroid muscle or perithyroid soft tissue, and is generally identified by light microscope examination. Patients with mETE, identified pathologically, are automatically upstaged to pT3. However, the prognostic implications of mETE have been a source of controversy in the literature. Moreover, there is also controversy surrounding the identification of mETE on pathological specimens. The objective of this study was to determine the level of agreement among expert pathologists in the identification of mETE in PTC cases. Methods: Eleven expert pathologists from the United States, Italy, and Canada were asked to perform a review of 69 scanned slides of representative permanent sections of PTC specimens. Each slide was evaluated for the presence of mETE. The pathologists were also asked to list the criteria they use to identify mETE. Results: The overall strength of agreement for identifying mETE was slight (??=?0.14). Inter-pathologist agreement was best for perithyroidal skeletal muscle involvement (??=?0.46, moderate agreement) and worst for invasion around thick-walled vascular structures (??=?0.02, slight agreement). In addition, there was disagreement over the constellation of histologic features that are diagnostic for mETE, which affected overall agreement for diagnosing mETE. Conclusions: Overall agreement for the identification of mETE is poor. Disagreement is a result of both variation in individual pathologists' interpretations of specimens and disagreement on the histologic criteria for mETE. Thus, the utility of mETE in staging and treatment of PTC is brought into question. The lack of concordance may explain the apparent lack of agreement regarding the prognostic significance of this pathologic feature.Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/140271/1/thy.2015.0508.pd

Inter-Observer Variation in the Pathologic Identification of Extranodal Extension in Nodal Metastasis from Papillary Thyroid Carcinoma

Background: Extranodal extension (ENE) in lymph node metastases has been shown to worsen the prognosis of papillary thyroid cancer (PTC). Despite the clinical significance of ENE, there are no stringent criteria for its microscopic diagnosis, and its identification is subject to inter-observer variability. The objective of this study was to determine the level of agreement among expert pathologists in the identification of ENE in PTC cases. Methods: Eleven expert pathologists from the United States, Italy, and Canada were asked to review 61 scanned slides of representative permanent sections of PTC specimens from Mount Sinai Beth Israel Medical Center in New York. Each slide was evaluated for the presence of ENE. The pathologists were also asked to report the criteria they use to identify ENE. Results: The overall strength of agreement in identifying ENE was only fair (??=?0.35), and the proportion of observed agreement was 0.68. The proportions of observed agreement for the identification of perinodal structures (fat, nerve, skeletal, and thick-walled vessel involvement) ranged from 0.61 to 0.997. Conclusions: Overall agreement for the identification of ENE is poor. The lack of agreement results from both variation in pathologists' identification of features and disagreement on the histologic criteria for ENE. This lack of concordance may help explain some of the discordant information regarding prognosis in clinical studies when this feature is identified.Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/140272/1/thy.2015.0551.pd

American Head and Neck Society Endocrine Section clinical consensus statement: North American quality statements and evidence‐based multidisciplinary workflow algorithms for the evaluation and management of thyroid nodules

BackgroundCare for patients with thyroid nodules is complex and multidisciplinary, and research demonstrates variation in care. The objective was to develop clinical guidelines and quality metrics to reduce unwarranted variation and improve quality.MethodsMultidisciplinary expert consensus and modified Delphi approach. Source documents were workflow algorithms from Kaiser Permanente Northern California and Cancer Care of Ontario based on the 2015 American Thyroid Association management guidelines for adult patients with thyroid nodules and differentiated thyroid cancer.ResultsA consensus‐based, unified preoperative, perioperative, and postoperative workflow was developed for North American use. Twenty‐one panelists achieved consensus on 16 statements about workflow‐embedded process and outcomes metrics addressing safety, access, appropriateness, efficiency, effectiveness, and patient centeredness of care.ConclusionA panel of Canadian and United States experts achieved consensus on workflows and quality metric statements to help reduce unwarranted variation in care, improving overall quality of care for patients diagnosed with thyroid nodules.Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/148340/1/hed25526_am.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/148340/2/hed25526.pd

Airway management for symptomatic benign thyroid goiters with retropharyngeal involvement: Need for a surgical airway with report of 2 cases

Background: Intubation prior to surgical intervention for thyroid goiters is typically straightforward and uneventful. However, retropharyngeal extension of thyroid goiters is a unique entity which is characterized by displacement of the hypopharynx and laryngeal deviation. Methods: Two patients presented with progressive compressive symptoms due to enlarging thyroid goiters. Imaging revealed thyroid goiters with significant retropharyngeal involvement causing anterior displacement of the larynx and hypopharynx. Results: Both patients were unsuccessfully intubated by direct laryngoscopy, GlideScope laryngoscopy and flexible fiberoptic laryngoscopy. Tracheostomy was performed to safely establish the airway, and thyroidectomy was subsequently performed uneventfully. Formalization of the tracheal stoma was performed on both patients to prevent soilage of the thyroid bed with tracheal secretions. Conclusions: Retropharyngeal involvement of thyroid goiters can pose significant difficulty with intubation. Airway compromise can be avoided by directly proceeding with a surgical airway. Management of the tracheal stoma is an important step in preventing postoperative infection

Bilateral carotid body and cervical sympathetic chain paragangliomas: A case report and review of the literature

Background: Paragangliomas are rare neuroendocrine tumors which develop at the site of extra-adrenal paraganglia of the autonomic nervous system, originating in the neural crest. Case presentation: We report the extremely rare finding of 4 concurrent paragangliomas arising bilaterally and simultaneously involving the carotid bodies and superior cervical ganglia of the sympathetic trunk in a 53-year-old man. These tumors were large enough to cause unilateral sympathetic chain dysfunction resulting in Horner's syndrome, in addition to oropharyngeal compression causing obstructive sleep apnea. The patient's clinical course, surgical treatment, and management considerations are discussed here. Conclusion: The morbidity associated with Horner's syndrome is relatively low; therefore, resection of these tumors is less controversial. However, the surgical access to large masses in the parapharyngeal space is more difficult and, in some cases, requires mandibulotomy to ensure that critical neurovascular structures are preserved during the resection. Keywords: Paraganglioma, Parapharyngeal space, Cervical sympathetic chain, Carotid body tumor, Horner's syndrom

Epidemiological Trends of Head and Neck Cancer in the United States: A SEER Population Study

PURPOSE: This study represents the most recent epidemiologic trends of head and neck cancer (HNC) in the United States. It provides an important discussion on oropharyngeal cancer and cancers related to the human papillomavirus. The objective was to identify trends in HNC (2002 to 2012) within the United States. MATERIALS AND METHODS: This study is a retrospective analysis of the US National Cancer Institute\u27s Surveillance, Epidemiology, and End Results (SEER) submission. Using the November 2014 submission of the SEER database and SEER-18 data files, data from 2002 to 2012 were analyzed to determine the most recent epidemiologic trends. HNCs of all subtypes were analyzed together. Laryngeal cancers were further analyzed separately. Oropharyngeal cancers of the base of tongue and tonsil were analyzed independently to attempt to trend HPV-related cancers. RESULTS: From 2002 to 2012, there were 149,301 cases of HNC recorded in the SEER database. The HNC rate decreased by 0.22% per year (P = .0549) and the rate of laryngeal cancer decreased by 1.9% per year (P \u3c .0001). The rate of oropharyngeal (HPV-related) cancer increased by 2.5% per year (P \u3c .0001). HNC rates increased significantly in Kentucky and Connecticut and decreased in California (P \u3c .05). HPV-related cancers increased significantly in all states except Georgia, Hawaii, and Michigan (P \u3c .05). Laryngeal cancer rates decreased in California, Georgia, New Jersey, and New Mexico (P \u3c .05). CONCLUSIONS: The overall incidence of HNC is decreasing in the United States. There is an increasing incidence of HPV-related cancers of the oropharynx. Meaningful differences in cancer incidence and rate of change exist between men and women. Furthermore, younger groups have a greater decrease of overall HNC, with an overall increase in HPV-related cancer in patients older than 50 years