Ultrasound guided fine needle aspiration and thyroid disease

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OtolaryngologyHead and Neck Surgery August 1999

Scientific Sessions--Wednesday

cases are presented, each of which required extensive reconstruction following traumatic or surgically created defects in the facial skeleton. The defects reconstructed were the result of orbital and mandibular trauma or oncologic resections. Methods: SL allows the accurate reproduction of both internal and external anatomy of body structures. The individuals were scanned using 3-dimensional CT preoperatively, and data from these scans was used to create SL models of the patients' defect. In some cases it was used for evaluating the physical dimensions and 3-dimensional relationship for surgical planning. In other cases it was used to actually prefabricate a custom-fit prosthesis or reconstruction plating for intraoperative implantation. Results: In the cases where the model was used for simple evaluation, it is difficult to actually quantify the benefits. Subjectively, in the surgeons' experience, the models enhanced the preoperative planning in better estimating both the extent of a procedure and the required support (operating room time, equipment, plating sets, hydroxy appetite cement, etc). In the cases where the model was used for prefabrication of implants or plating, this method unquestionably decreased the intraoperative time, by several hours in some cases, while providing more accurate reconstruction prosthesis. Conclusions: The SL model provides highly accurate 3dimensional models that can be utilized for preoperative evaluation and planning as well as prefabrication of the prosthesis and plating while decreasing operative times and enhancing results. 8:08 AM

Optical Coherence Tomography and Fluorescence Spectroscopy of Transformed Oral Tissue MASSOUD M9 PHD (presenter); MOUWAFAK MUFLIH AL-RAWI MD; EW J VAN DER BREGGEN MS; KAREN H CALHOUN MD; H K M STERENBORG PHD; ASHLEYJ WELCH; Galveston TX; Galveston TX; Haarlem Netherland; Galveston TX; Capelle D Ijssel Netherlands; Austin TX

Objectives: To investigate the biochemical and morphological changes in oral tissue during benign and malignant transformation in 2 hamster models by employing a combination of fluorescence spectroscopy and optical coherence tomography (OCT), a new optical imaging technique with near-microscopic spatial resolution. Methods: The fiberoptic autofuorescence and bench-optic OCT measurements were done almost simultaneously. Quantification methods involved ratio analysis to quantify fluorescence spectral (red/orange) and measurements of the thickness of mucosa in the OCT images to quantify changes in the tissue architecture. Results: OCT provides details visible up to 2 mm mucosal thickness. Mucosal thickness ranged from 75 _+ 9 ~tm in normal tissue to 130 _+ 30 l.tm in both benign and premalignant lesions and could differentiate between treated and untreated

mucosa (P < 0.05). The red/orange ratio showed an increase in normal (0.49 _+0.07) versus premalignant tissue (1.3 _+0.8) and was unchanged in the benign lesions (0.492 _+0.007). The blue tumor-to-normal ratio was decreased in premalignant tissue (0.5 -+ 0.3) compared with normal tissue (0.9 -+ 0.3), whereas it was similar to normal in the benign lesions (1.1 _+ 0.2). During development from normal to premalignant there was an increase in both the thickness of mucosa and the redorange ratio, with the correlation factor between these two being 0.8. No such correlation in increase was noted in the benign lesions. Conclusion: This study suggests that in the early stage of mucosal epithelial lesion development, a combination of OCT and autofluorescence could provide a high tumor sensitivity. The loss of stratified architecture in the OCT images suggests a role for this technique in tumor detection. The application of fuorescence detection, on the other hand, is more practical in the fast scanning of large surface areas of mucosa and provides information on biochemical changes in tissue. 8:16 AM

Ultrasound Guided Fine Needle Aspiration and Thyroid Disease KENNETH A NEWKIRK MD (presenter); KENNETH D BURMAN MD; MATTHEW D RINGEL MD; JAMES JELINEK MD; ZIAD E DEEB MD; ALEXANDER S MARK MD; Fairfax VA; Washington DC; Washington DC; Washington DC; Washington DC; Washington DC

Objectives: Fine-needle aspiration (FNA) is a valuable part of the diagnosis and management of thyroid disease. The unity of ultrasound-guided FNA (USFNA) as an effective diagnostic tool has increased over the past 2 decades. However, as an evolving technology, standardization of indications for its use has not been fully addressed. This study attempts to address the issues of accuracy of USFNA and to determine indications for its use. Methods: A retrospective chart review was performed in 166 patients (139 women and 27 men) undergoing USFNA at a tertiary care medical center. Sensitivity, specificity, accuracy, positive predictive (PPV), and negative predictive (NPV) values; the inadequacy rate; the complication rate; and the cancer yield were assessed. Results: The mean ages for women and men were 52.1 (SD _+ 14.8) and 58.4 (SD -+ 15.4) years. Comparing final cytopathologic diagnosis to the preliminary reading at the time of the biopsy, the sensitivity was 88%, the specificity was 98%, and the PPV, NPV, and accuracy were 82%, 98%, and 96%, respectively. Comparing cytopathology to histologic diagnosis (N = 25), sensitivity was 86%, specificity was 89%, the PPV was 75%, the NPV was 94%, and the accuracy was 88%. The mean nodule size was 2.2 cm (SD _+ 1.1, range 0.56.2 cm), with an average of 4.7 passes (SD + 2.1) per biopsy. The cancer yield was 24% (6/25), and the inadequacy rate was

OtolaryngologyHead and Neck Surgery Volume 121 N u m b e r 2

11% (19/166). Minor complications occurred in 8.5% of patients. Conclusion: USFNA is a safe and effective diagnostic modality in the management of thyroid disease, especially for nodules that are difficult to palpate. 8:30 AM

Cancer without Surface Atypia: Why Surface Markers Are Not Reliable PAUL W BAUER MD (presenter); CHARLES W VAUGHAN MD FACS; GERARD F DOMANOWSKI MD; ERROL BAKER PHD; Waltham MA; Boston MA; Boston MA; Boston MA

Objective: Techniques of mucosal epithelial observation require that atypia develop into a full-thickness process upward from the basement membrane prior to invading the submucosal connective tissue. We raised the following questions: Is full-thickness atypia a necessary precondition for invasion? Does the lack of surface atypia preclude invasion? Methods: A retrospective, randomized review of histologic specimens of head and neck squamous cell carcinoma. Ninety patients were selected randomly from the tumor registry of the past 17 years of patients who have undergone surgical excision. All slides with mucosal epithelium present were reviewed for each patient. Observations from each slide selected were analyzed by calculating ~2 against a priori expected values for atypical surface epithelium with invasion, atypical surface epithelium without invasion, normal surface epithelium with invasion, and normal surface epithelium without invasion. Results: Generated a study population of 77 patients, represented by 371 pathology slides, and 730 data points. There were 69 instances of normal surface epithelium with underlying invasion. The observed frequency of invasion given a normal surface was significantly (P < 0.00001) greater than what would have been predicted. Conclusion: The hypothesis that normal surface precludes invasion was not supported by these data. Full-thickness atypia is not a necessary precondition for invasion. Techniques that rely on surface observation of atypia are not reliable guides to predicting invasion. 8:38 AM

Risk Factors Associated with Hypothyroidism Following Laryngectomy THOMAS T GAL JR MD (presenter); ROBIN L GAL MSPH; DOUGLAS W KLOTCH MD FACS; ALAN B CANTOR PHD; Tampa FL

Objectives: Hypothyroidism is a well-documented complication following treatment of head and neck cancer, and it is particularly significant in patients undergoing laryngectomy. The objective of this study was the identification of factors associated with the development of hypothyroidism in this population. Methods: Records of 136 patients treated with laryngectomy were retrospectively reviewed in an attempt to define a risk

Scientific Sessions--Wednesday

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factor profile for patients who are most likely to develop hypothyroidism following laryngectomy. The Cox proportional hazards model was used to identify factors significantly related to an increased risk for development of hypothyroidism. The actuarial method was used to estimate the period of greatest risk for the development of hypothyroidism. Results: Increased risks were found for patients who were female (P = 0.0049), received preoperative radiation therapy (P = 0.0022), had invasion of the thyroid gland by tumor (P = 0.0003), had presence of cervical metastases (P = 0.0022), and developed postoperative fistula (P = 0.0095). From the actuarial method, we estimate that the period of time when patients are at greatest risk for development of hypothyroidism is between 0 and 14 months after surgical intervention. Wound complications were twice as frequent in hypothyroid patients. Conclusion: Perioperative awareness of risk factors associated with the development of hypothyroidism in patients undergoing laryngectomy allows for early recognition and management of hypothyroidism and may reduce the number of complications related to wound healing and fistula. 8:46 AM

Evaluation of Advanced Directives in Head and Neck Oncology Patients WAYNE E BERRYHtLL MD (presenter); GEORGE L ADAMS MD; Saint Paul MN; Minneapolis MN

Objectives: Advanced directives (ADs) are means by which patients can express their desires concerning treatment and care. In order for these directives to be effective, the patient must fully understand the individual components of the directive. Most ADs do specifically address issues effecting head and neck (H&N) patients and are therefore ineffective. This study queries H&N oncology patients concerning AD issues, evaluates their understanding, and implements an AD specific to H&N patients that addresses unique issues such as carotid rupture and airway obstruction. Methods: Thirty-eight H&N oncology patients, at various stages of disease course and treatment, were interviewed and given a 10-question survey evaluating their understanding of ADs, components of CPR, ventilation, intubation, artificial nutrition, tracheostomy, management of carotid blowout, and other methods of support. The survey also evaluated the efficacy of the provider's ability to communicate these issues. Patients were given the opportunity to complete a specific H&N AD. Results: Twenty-three of the patients surveyed had an AD on the patient record. Patients with advanced stages and longer courses were more likely to have an AD in place. All patients had some misconception regarding the performance of CPR and its components. Eighty-three percent of patients did not understand principles of intubation, ventilation, and the use of a ventilator. Development of a life-threatening con-