Papillary Microcarcinoma of the Thyroid: How Should It Be Treated?

We previously demonstrated that (1) most papillary microcarcinomas can be followed without surgical treatment and (2) when surgery is performed, patients with lateral lymph node metastasis detected on preoperative ultrasonography (US) are more likely to develop recurrence. In this study, we further investigated the application of these strategies. To date, we have observed 211 patients (average follow-up 47.9 months). In more than 70% of these patients the tumor size did not increase during the follow-up period. There were no clinicopathologic features linked to tumor enlargement except in tumors 7 mm, which tended to enlarge in patients followed for 4 years. To evaluate not only whether observation can continue but also how to dissect the lymph nodes optimally at surgery, US diagnosis for lateral node metastasis is essential because the presence of US-diagnosed lateral metastasis is an even stronger predictive marker for recurrence than the presence of pathologically confirmed node metastasis. The positive predictive value (PPV) was 80.6% for US but reached 100% if fine-needle aspiration biopsy (FNAB) of nodes or FNAB-thyroglobulin measurement is added. Furthermore, carcinomas occupying the upper region of the thyroid more frequently showed US-diagnosed and pathologically confirmed lateral metastasis, and those measuring 7 mm were more likely to show pathologically confirmed lateral metastasis. These findings suggest that, for papillary microcarcinoma: (1) US-diagnosed lateral metastasis is a strong marker predicting a worse relapse-free survival; (2) FNAB of nodes and FNAB-thyroglobulin measurement are useful tools for evaluating lymph node metastasis; and (3) careful US evaluation for lateral metastasis is necessary in patients with a tumor measuring 7 mm or that is located in the upper region of the thyroid both during observation and preoperatively.This article was presented at the International Association of Endocrine Surgeons meeting, Uppsala, Sweden, June 14–17, 2004.     

Tracheostomy: How and When Should It Be Done in Cardiovascular Surgery ICU?

Abstract   Background: The aim of this study was to assess the effect of timing and techniques of tracheostomy on mortality and morbidity in cardiovascular surgery patients. Methods: Between January 2000 and October 2007, a total of 19,559 cardiac and vascular operations were performed in our hospital, and 205 of these patients (1.04%) who underwent a tracheostomy procedure were included in this retrospective study. Results: Surgical tracheostomy (ST) was employed in 134 (65.4%) and percutaneous tracheostomy (PT) in 71 (34.6%) of the cases. There were 17 complications related to all tracheostomy procedures in 15 (7.3%) patients. Bleeding, requiring surgical intervention, occurred in five (3.7%) ST patients and in one (1.4%) PT patient. Cardiac arrest related to the procedure occurred in two (1.5%) ST patients. Pneumothorax occurred in three (2.2%) ST patients and in one (1.4%) PT patient, subcutaneous emphysema in three (2.2%) ST patients and in one (1.4%) PT patient, and tracheoesophageal fistula in one (0.7%) ST patient (p > 0.05). The postoperative infection rate was significantly lower, and cooperation of the patients, postoperative patient mobilization, and oral feeding rates were higher in the early tracheostomy group. The multifactorial mortality rates of early (相似文献   

How Wide Should Margins Be for Phyllodes Tumors of the Breast?

The surgical management of phyllodes tumors (PTs) is still controversial. Some studies have suggested surgical margins ≥1 cm, but recent studies suggested that negative margins could be appropriate regardless of their width. To evaluate recurrence rates of PTs following surgery according to margins. Retrospective study of women who attended a tertiary breast cancer reference center between 1998 and 2010: 142 patients with a PT diagnosis, either at minimally invasive breast biopsy or at surgery, were identified. Clinical, pathologic and follow‐up characteristics were assessed. Among 140 patients who underwent surgery, 64.3% of biopsies accurately predicted the final PT diagnosis at surgery. Forty‐two (42/87, 48.3%) PTs had positive margins. Twenty‐one (21/42, 50.0%) patients had a surgical revision of margins. Only one (1/42, 2.4%) had margins greater or equal to 1 cm. After a median follow‐up of 1.29 years in benign PTs, 4.99 years in borderline PTs, and 5.42 years in malignant PTs, there were five local recurrences, three in originally benign PTs and two in borderline PTs. All were managed with surgery. Four had initial margins ≤1 mm. One patient with borderline PT had a local recurrence and later progressed to regional recurrence and metastasis. Free surgical margins are necessary to treat PT, and margins of at least 1 mm might be sufficient to prevent recurrence. Core needle biopsy might not be the best diagnostic tool for PTs.