Thyroid Diseases: Mandel SJ

Abalovich M, Amino N, Barbour LA, Cobin RH, De Groot LJ, Glinoer D, Mandel SJ, Stagnaro-Green A. · Endocrinology Division, Durand Hospital, Buenos Aires, Argentina. · J Clin Endocrinol Metab. · Pubmed #17948378 links to  free full text

Abstract: OBJECTIVE: The objective is to provide clinical guidelines for the management of thyroid problems present during pregnancy and in the postpartum. PARTICIPANTS: The Chair was selected by the Clinical Guidelines Subcommittee (CGS) of The Endocrine Society. The Chair requested participation by the Latin American Thyroid Society, the Asia and Oceania Thyroid Society, the American Thyroid Association, the European Thyroid Association, and the American Association of Clinical Endocrinologists, and each organization appointed a member to the task force. Two members of The Endocrine Society were also asked to participate. The group worked on the guidelines for 2 yr and held two meetings. There was no corporate funding, and no members received remuneration. EVIDENCE: Applicable published and peer-reviewed literature of the last two decades was reviewed, with a concentration on original investigations. The grading of evidence was done using the United States Preventive Services Task Force system and, where possible, the GRADE system. CONSENSUS PROCESS: Consensus was achieved through conference calls, two group meetings, and exchange of many drafts by E-mail. The manuscript was reviewed concurrently by the Society's CGS, Clinical Affairs Committee, members of The Endocrine Society, and members of each of the collaborating societies. Many valuable suggestions were received and incorporated into the final document. Each of the societies endorsed the guidelines. CONCLUSIONS: Management of thyroid diseases during pregnancy requires special considerations because pregnancy induces major changes in thyroid function, and maternal thyroid disease can have adverse effects on the pregnancy and the fetus. Care requires coordination among several healthcare professionals. Avoiding maternal (and fetal) hypothyroidism is of major importance because of potential damage to fetal neural development, an increased incidence of miscarriage, and preterm delivery. Maternal hyperthyroidism and its treatment may be accompanied by coincident problems in fetal thyroid function. Autoimmune thyroid disease is associated with both increased rates of miscarriage, for which the appropriate medical response is uncertain at this time, and postpartum thyroiditis. Fine-needle aspiration cytology should be performed for dominant thyroid nodules discovered in pregnancy. Radioactive isotopes must be avoided during pregnancy and lactation. Universal screening of pregnant women for thyroid disease is not yet supported by adequate studies, but case finding targeted to specific groups of patients who are at increased risk is strongly supported.

Frates MC, Benson CB, Charboneau JW, Cibas ES, Clark OH, Coleman BG, Cronan JJ, Doubilet PM, Evans DB, Goellner JR, Hay ID, Hertzberg BS, Intenzo CM, Jeffrey RB, Langer JE, Larsen PR, Mandel SJ, Middleton WD, Reading CC, Sherman SI, Tessler FN, Anonymous00094. · No affiliation provided · Radiology. · Pubmed #16304103 links to  free full text

Abstract: The Society of Radiologists in Ultrasound convened a panel of specialists from a variety of medical disciplines to come to a consensus on the management of thyroid nodules identified with thyroid ultrasonography (US), with particular focus on which nodules should be subjected to US-guided fine needle aspiration and which thyroid nodules need not be subjected to fine-needle aspiration. The panel met in Washington, DC, October 26-27, 2004, and created this consensus statement. The recommendations in this consensus statement, which are based on analysis of the current literature and common practice strategies, are thought to represent a reasonable approach to thyroid nodular disease.

Layfield LJ, Cibas ES, Gharib H, Mandel SJ. · University of Utah School of Medicine, University of Utah Hospital and Clinics, Salt Lake City, UT, USA. · CA Cancer J Clin. · Pubmed #19278960 links to  free full text

Abstract: In the adult population, thyroid nodules are common and are increasingly detected by ultrasound examination or other scanning techniques. Depending on their size and ultrasonographic features, these nodules may require further investigation, including tissue diagnosis. Fine-needle aspiration (FNA) has become the predominant method to obtain tissue for microscopic analysis. In October 2007, the National Cancer Institute sponsored a conference to review the state of the science for the use of FNA in the management of thyroid nodules. This conference reviewed indications for thyroid FNA and pre-FNA requirements, training and credentialing, techniques for thyroid FNA, diagnostic terminology and morphologic criteria, utilization of ancillary studies, and post-FNA testing and treatment options. The results of those discussions have been published in both print and electronic versions. The aim of the current article was to discuss indications for FNA, diagnostic terminology, and post-FNA options, issues that are important to physicians who are managing patients with thyroid nodules.

Langer JE, Mandel SJ. · Department of Radiology, University of Pennsylvania School of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA 19104, USA. · Neuroimaging Clin N Am. · Pubmed #18656029 No free full text.

Abstract: Sonography plays an important role in the evaluation of patients who have thyroid carcinoma by identifying metastatic disease to the regional cervical lymph nodes. The sonographic appearance of lymph node metastases may vary from subtle alterations in echogenicity or vascular patterns to more obvious findings of calcifications and cystic changes within an affected node. Identification of metastatic disease to lateral cervical lymph nodes by sonography may affect the extent of surgical resection at the time of diagnosis. In patients who have had thyroidectomy for cancer, sonographic evaluation has proved to be the most sensitive imaging technique to detect thyroid cancer recurrence in the neck.

Fish SA, Langer JE, Mandel SJ. · Department of Medicine, University of Pennsylvania School of Medicine, 1 Maloney, Endocrinology, HUP, 3400 Spruce Street, Philadelphia, PA 19104, USA. · Endocrinol Metab Clin North Am. · Pubmed #18502334 No free full text.

Abstract: The initial application of sonography for the evaluation of the neck, more than 30 years ago, was to differentiate cystic and solid thyroid nodules. With improvements in technology, ultrasound has been applied to characterize distinct features in the appearance of thyroid nodules. More recently, its function has been expanded to assess cervical lymph nodes for metastatic thyroid cancer. This article discusses the sonographic features of thyroid nodules associated with malignancy and the role of ultrasound in the management of patients with thyroid cancer.

Chan GW, Mandel SJ. · Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia, PA, USA. · Nat Clin Pract Endocrinol Metab. · Pubmed #17515891 No free full text.

Abstract: The diagnosis of Graves' disease in pregnancy can be complex because of normal gravid physiologic changes in thyroid hormone metabolism. Mothers with active Graves' disease should be treated with antithyroid drugs, which impact both maternal and fetal thyroid function. Optimally, the lowest possible dose should be used to maintain maternal free thyroxine levels at or just above the upper limit of the normal nonpregnant reference range. Fetal thyroid function depends on the balance between the transplacental passage of thyroid-stimulating maternal antibodies and thyroid-inhibiting antithyroid drugs. Elevated levels of serum maternal anti-TSH-receptor antibodies early in the third trimester are a risk factor for fetal hyperthyroidism and should prompt evaluation of the fetal thyroid by ultrasound, even in women with previously ablated Graves' disease. Maternal antithyroid medication can be modulated to treat fetal hyperthyroidism. Serum TSH and either total or free thyroxine levels should be measured in fetal cord blood at delivery in women with active Graves' disease, and those with a history of (131)I-mediated thyroid ablation or thyroidectomy who have anti-TSH-receptor antibodies. Neonatal thyrotoxicosis can occur in the first few days of life after clearance of maternal antithyroid drug, and can last for several months, until maternal antibodies are also cleared.

LeBeau SO, Mandel SJ. · Division of Endocrinology and Metabolism, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA. · Endocrinol Metab Clin North Am. · Pubmed #16310645 No free full text.

This publication has no abstract.

Mandel SJ. · Division of Endocrinology, Diabetes, and Metabolism, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania 19104, USA. · Endocr Pract. · Pubmed #15310543 No free full text.

Abstract: OBJECTIVE: To review the published reports pertaining to the diagnostic utility of ultrasonography for evaluation of thyroid nodules. METHODS: Various roles for diagnostic thyroid ultrasonography and screening ultrasound studies of the thyroid are discussed, and ultrasound characteristics of thyroid nodules and their association with malignant potential are described. RESULTS: In two studies that correlated ultrasound findings with physical examination findings in patients with a solitary thyroid nodule detected by palpation, 16% of such patients had no corresponding nodule evident on ultrasonography, and 45% of such patients had an additional nodule detected by ultrasonography. Similarly, approximately 18% of patients with a palpable multinodular thyroid had no nodules larger than 1 cm in diameter on ultrasound studies. Thyroid nodules larger than 1 cm have been found by ultrasonography to be present in from 2 to almost 5% of the population with normal findings on examination of the thyroid. Use of screening ultrasound study of the thyroid has been suggested for patients with a history of childhood irradiation to the head and neck or a family history of thyroid cancer. Numerous investigations that have evaluated ultrasound features of thyroid nodules have suggested five characteristics as suggestive of malignant potential--hypoechogenicity, microcalcifications, irregular or microlobulated border, absent or irregular thick halo, and increased intranodular vascularity. CONCLUSION: Correlation of ultrasound and palpation findings will provide a comprehensive evaluation of nodular thyroid disease. Moreover, real-time ultrasonography facilitates characterization of features associated with an increased risk of a malignant lesion. High-resolution thyroid ultrasonography is a dynamic tool for endocrinologists.

Mandel SJ. · University of Pennsylvania School of Medicine, 1 Maloney, Endocrinology, HUP, 3400 Spruce Street, Philadelphia, PA 19104, USA. · Best Pract Res Clin Endocrinol Metab. · Pubmed #15157837 No free full text.

Abstract: Hypothyroidism during pregnancy is associated with adverse outcomes that can be ameliorated or prevented by adequate therapy with thyroxine. Currently, there are no guidelines for universal screening for thyroid dysfunction in pregnant women or in women of reproductive age. Therefore, it is important to recognize those groups of women who may be at higher risk for development of hypothyroidism so that serum TSH testing may be performed with appropriate initiation of thyroxine therapy. In addition, the thyroxine therapy of women with established hypothyroidism should be optimized prior to conception and during pregnancy when the thyroxine dosage requirement generally increases early in gestation. The diverse etiologies of maternal hypothyroidism may require different increments in thyroxine dose during pregnancy, and generally the postpartum dosage requirement returns to pre-pregnancy levels.

Mandel SJ, Mandel L. · Division of Endocrinology, Diabetes, and Metabolism, University of Pennsylvania Medical School, Philadelphia, Pennsylvania 19104, USA. · Thyroid. · Pubmed #12729475 No free full text.

Abstract: Radioactive iodine ((131)I) targets the thyroid gland and has been proven to play an effective role in the treatment of differentiated papillary and follicular cancers. Simultaneously, this radioisotope hones in on the salivary glands where it is concentrated and secreted into the saliva. Dose related damage to the salivary parenchyma results from the (131)I irradiation. Salivary gland swelling and pain, usually involving the parotid, can be seen. The symptoms may develop immediately after a therapeutic dose of (131)I and/or months later and progress in intensity with time. In conjunction with the radiation sialadenitis, secondary complications reported include xerostomia, taste alterations, infection, increases in caries, facial nerve involvement, stomatitis, candidiasis, and neoplasia. Prevention of the (131)I sialadenitis may involve the use of sialogogic agents to hasten the transit time of the radioactive iodine through the salivary glands. However, studies are not available to delineate the efficacy of this approach. Recently, amifostine has been advocated to prevent the effects of irradiation. Treatment of the varied complications that may develop encompass numerous approaches and include gland massage, sialogogic agents, duct probing, antibiotics, mouthwashes, good oral hygiene, and adequate hydration.

Mandel SJ, Cooper DS. · Division of Endocrinology, Diabetes, and Metabolism, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania 19104, USA. · J Clin Endocrinol Metab. · Pubmed #11397822 links to  free full text

This publication has no abstract.

Cooper DS, Doherty GM, Haugen BR, Kloos RT, Lee SL, Mandel SJ, Mazzaferri EL, McIver B, Sherman SI, Tuttle RM, Anonymous00638. · Sinai Hospital of Baltimore and Johns Hopkins University School of Medicine, MD, USA. · Thyroid. · Pubmed #16420177 No free full text.

This publication has no abstract.

Gupta-Abramson V, Troxel AB, Nellore A, Puttaswamy K, Redlinger M, Ransone K, Mandel SJ, Flaherty KT, Loevner LA, O'Dwyer PJ, Brose MS. · Developmental TherapeuticsProgram of the Abramson CancerCenter, University of Pennsylvania,Philadelphia, PA 19104, USA. · J Clin Oncol. · Pubmed #18541894 No free full text.

Abstract: PURPOSE: Given the molecular pathophysiology of thyroid cancer and the spectrum of kinases inhibited by sorafenib, including Raf kinase, vascular endothelial growth factor receptors, platelet-derived growth factor receptor, and RET tyrosine kinases, we conducted an open-label phase II trial to determine the efficacy of sorafenib in patients with advanced thyroid carcinoma. PATIENTS AND METHODS: Eligible patients with metastatic, iodine-refractory thyroid carcinoma received sorafenib 400 mg orally twice daily. Responses were measured radiographically every 2 to 3 months. The study end points included response rate, progression-free survival (PFS), and best response by Response Evaluation Criteria in Solid Tumors. RESULTS: Thirty patients were entered onto the study and treated for a minimum of 16 weeks. Seven patients (23%; 95% CI, 0.10 to 0.42) had a partial response lasting 18+ to 84 weeks. Sixteen patients (53%; 95% CI, 0.34 to 0.72) had stable disease lasting 14 to 89+ weeks. Seventeen (95%) of 19 patients for whom serial thyroglobulin levels were available showed a marked and rapid response in thyroglobulin levels with a mean decrease of 70%. The median PFS was 79 weeks. Toxicity was consistent with other sorafenib trials, although a single patient died of liver failure that was likely treatment related. CONCLUSION: Sorafenib has clinically relevant antitumor activity in patients with metastatic, iodine-refractory thyroid carcinoma, with an overall clinical benefit rate (partial response + stable disease) of 77%, median PFS of 79 weeks, and an overall acceptable safety profile. These results represent a significant advance over chemotherapy in both response rate and PFS and support further investigation of this agent in these patients.

Mandel SJ. · Division of Endocrinology, Diabetes, and Metabolism, Hospital of the University of Pennsylvania, Philadelphia, USA. · JAMA. · Pubmed #15572721 No free full text.

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Kaplan SL, Mandel SJ, Muller R, Baloch ZW, Thaler ER, Loevner LA. · University of Pennsylvania School of Medicine, Philadelphia, PA 19104, USA. · AJNR Am J Neuroradiol. · Pubmed #19039052 No free full text.

Abstract: BACKGROUND AND PURPOSE: One of the dilemmas facing clinicians treating patients with thyroid cancer is the evaluation of postthyroidectomy patients with rising serum thyroglobulin levels and indeterminate or normal findings on neck sonography. In this study, we examine the role of MR imaging in this subgroup of patients. MATERIALS AND METHODS: We retrospectively reviewed MR images of patients with thyroid cancer with abnormal lymph nodes in the retropharyngeal and parapharyngeal spaces and determined the size and signal-intensity characteristics of these nodes. We reviewed patient charts for the following history: 1) thyroidectomy, 2) rising thyroglobulin levels, 3) iodine-131 radiation therapy, 4) neck dissection, and 5) pathology on neck sonography and chest CT. We reviewed pathology findings to determine if thyroid cancer metastases were present in these lymph nodes. RESULTS: Eight patients had abnormal retropharyngeal space nodes, and 1 patient had a parapharyngeal space mass. Lymph nodes ranged from 7 to 25 mm. On MR imaging, 1 patient had a cystic node, 2 had complex nodes, and 6 had solid nodes. Eight patients had rising serum thyroglobulin levels and a history of thyroidectomy, radioiodine therapy, and neck dissection. Two of these patients had no pathologic nodes on sonography and normal findings on chest CT. Six patients had tissue sampling of their skull base node, and metastatic thyroid cancer was present in 5. CONCLUSIONS: MR imaging of the neck should be considered in thyroidectomy patients with rising serum thyroglobulin levels and a history of radioiodine therapy and neck dissection. Radiologists should carefully examine the retropharyngeal and parapharyngeal spaces in these patients because nodal metastases may occur there more commonly than realized.

Cibas ES, Alexander EK, Benson CB, de Agustín PP, Doherty GM, Faquin WC, Middleton WD, Miller T, Raab SS, White ML, Mandel SJ. · Department of Pathology, Brigham and Women's Hospital, Boston, Massachusetts 02115, USA. · Diagn Cytopathol. · Pubmed #18478607 No free full text.

Abstract: The National Cancer Institute (NCI) sponsored the NCI Thyroid Fine-Needle Aspiration (FNA) State of the Science Conference on October 22-23, 2007 in Bethesda, MD. The 2-day meeting was accompanied by a permanent informational website and several on-line discussions between May 1 and December 15, 2007 (http://thyroidfna.cancer.gov). This document summarizes the indications for performing an FNA of a nodule discovered by physical examination or an imaging study; the indications for using ultrasound versus palpation for guidance when performing a thyroid FNA; the issues surrounding informed consent for thyroid FNA; and the information required on a requisition form that accompanies a thyroid FNA specimen. (http://thyroidfna.cancer.gov/pages/info/agenda/)

Urhan M, Dadparvar S, Mavi A, Houseni M, Chamroonrat W, Alavi A, Mandel SJ. · Division of Nuclear Medicine, Department of Radiology, Department of Medicine University of Pennsylvania Medical Center, Philadelphia, PA 19104, USA. · Eur J Nucl Med Mol Imaging. · Pubmed #17256140 No free full text.

Abstract: PURPOSE: Using 123I for diagnostic purposes avoids the risk of stunning for subsequent radioiodine treatment and affords an excellent image quality. In this study we assessed the role of 123I in comparison with 131I post-treatment imaging in patients with thyroid cancer. METHODS: We compared a total of 292 123I scans with their corresponding post-treatment 131I images. Patients received a therapeutic dose of 131I following diagnostic scanning with 50-111 MBq of 123I. All patients were in a hypothyroid state (>30 microIU/l) before radioiodine administration for either diagnostic or therapeutic purposes. RESULTS: In 228 out of 263 patients with a positive diagnostic scan, 123I whole-body scan findings were concordant with those of corresponding post-treatment 131I images (concordance rate 87%). However, there were 44 additional foci of abnormal uptake on post-treatment 131I scans in 22 discordant cases with no impact on therapeutic management of the patients. In 13 patients, there was at least one new site on post-treatment images that had been missed on pretreatment 123I images. Twenty-nine patients with a negative diagnostic scan were treated with 131I owing to a high serum thyroglobulin level (range 11.3-480 ng/ml). Radioiodine uptake sites were seen in eight post-treatment scans. In 21 pairs of whole-body scans, both the pre- and the post-treatment scan were negative (concordance rate 72.4%). CONCLUSION: 123I scanning is comparable to high-dose 131I post-treatment imaging in thyroid carcinoma patients, and 123I offers excellent image quality as a diagnostic agent. It avoids disadvantages such as stunning before treatment and delivery of a high radiation dose to patients.

Mandel SJ, Mandel L. · Division of Endocrinology, Diabetes, and Metabolism, University of Pennsylvania Medical School, Philadelphia, PA, USA. · Oral Surg Oral Med Oral Pathol Oral Radiol Endod. · Pubmed #17095255 No free full text.

Abstract: Radioactive iodine (131I), used in the treatment of differentiated thyroid carcinoma, is known to cause both short-term and long-term radiation damage to the salivary glands. The injury appears as glandular swellings and/or decreased salivation with 131I dosage and passage of time playing significant roles. A case report is presented to alert the profession to the existence of patients who have received 131I therapy and who complain shortly thereafter of xerostomia, but following a thorough examination are found to represent a group of false-positives. Emphasis is placed on the diagnostic techniques used in the differential diagnosis.

Langer JE, Luster E, Horii SC, Mandel SJ, Baloch ZW, Coleman BG. · Department of Radiology, University of Pennsylvania Medical Center, 3400 Spruce St., Philadelphia, PA 19104, USA. · AJR Am J Roentgenol. · Pubmed #16247162 links to  free full text

Abstract: OBJECTIVE: The purpose of this report is to describe the imaging appearance of granulomatous inflammation in the neck presenting as a late complication in patients who have undergone thyroidectomy for differentiated thyroid carcinoma. CONCLUSION: Granulomatous inflammation can occur as a palpable mass in the operative bed of asymptomatic patients who have undergone thyroidectomy for thyroid carcinoma. The diagnosis may be suggested when the lesion shows the sonographic appearance of a poorly defined hypoechoic lesion or lesions with a central echogenic nonshadowing focus, often within the sternocleidomastoid muscle. These lesions may appear as complex cystic masses on CT and MRI and may have increased activity on PET. Percutaneous biopsy can establish the diagnosis of an inflammatory lesion and can exclude underlying active infection and malignancy.

Saqi A, Livolsi V, Mandel SJ, Baloch Z. · Department of Pathology, New York Presbyterian Hospital, Columbia-Presbyterian Medial Center, New York, 10032, USA. · Diagn Cytopathol. · Pubmed #15830368 No free full text.

Abstract: Chordomas are rare neoplasms of notochord derivation that arise along the craniospinal axis. Their incidence along the cervical spine and close proximity to the thyroid can pose diagnostic pitfalls. We report a case of a paraspinal mass juxtaposed adjacent to the thyroid with intranuclear inclusions of papillary carcinoma, abundant eosinophilic cytoplasm of an oncocytic lesion, and pleomorphism of anaplastic carcinoma that expressed thyroglobulin and emulated a malignant thyroid neoplasm. However, subsequent histological examination revealed a chordoma with perithyroidal soft-tissue invasion. This case highlights the significance of including chordoma in the differential diagnosis of a thyroid neoplasm and interpreting thyroglobulin reactivity warily, because its inadvertent tracking during fine-needle aspirates (FNAs) can produce false positive staining of nonthyroidal cells.

Mandel SJ, Spencer CA, Hollowell JG. · Division of Endocrinology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA. · Thyroid. · Pubmed #15687823 No free full text.

Abstract: A workshop entitled, "The Impact of Maternal Thyroid Diseases on the Developing Fetus: Implications for Diagnosis, Treatment, and Screening," was held in Atlanta, Georgia, January 12-13, 2004. The workshop was sponsored jointly by The National Center on Birth Defects and Developmental Disabilities of The Centers for Disease Control and Prevention (CDC) and The American Thyroid Association. This paper reports on the individual session that examined the ability to detect and treat thyroid dysfunction during pregnancy. For this session, presented papers included: "Laboratory Reference Values in Pregnancy" and "Criteria for Diagnosis and Treatment of Hypothyroidism in Pregnancy." These presentations were formally discussed by invited respondents and by others in attendance. Salient points from this session about which there was agreement include the following: thyrotropin (TSH) can be used as marker for hypothyroidism in pregnancy, except when there is iodine deficiency usually evidenced by elevated serum thyroglobulin (Tg). We need more longitudinal studies of TSH during pregnancy in iodine-sufficient populations without evidence of autoimmune thyroid disease to develop trimester-specific TSH reference ranges. Current free thyroxine (FT4) estimate methods are sensitive to abnormal binding-protein states such as pregnancy. There is no absolute FT4 value that will define hypothyroxinemia across methods. Total thyroxine (TT4) changes in pregnancy are predictable and not method-specific. TT4 below 100 nmol/L (7.8 microg/dL) is a reasonable indicator of hypothyroxinemia in pregnancy. Women with known hypothyroidism and receiving levothyroxine (LT4) before pregnancy should plan to increase their dosage by 30% to 60% early in pregnancy. Women with autoimmune thyroid disease prior to pregnancy are at increased risk for thyroid insufficiency during pregnancy and postpartum thyroiditis and should be monitored with TSH during pregnancy.

Kupferman ME, Patterson M, Mandel SJ, LiVolsi V, Weber RS. · Department of Otolaryngology-Head and Neck Surgery, University of Pennsylvania School of Medicine, Philadelphia, USA. · Arch Otolaryngol Head Neck Surg. · Pubmed #15262763 links to  free full text

Abstract: BACKGROUND: Although lymphatic metastasis does not affect overall survival for patients with differentiated thyroid carcinoma, locoregional control can be improved with cervical lymphadenectomy. The major morbidity of neck dissection (ND) for the management of regional metastases is spinal accessory (cranial nerve XI) dysfunction. To avoid this complication, some surgeons have advocated a limited ND. OBJECTIVE: To establish the patterns of lateral cervical metastases in differentiated thyroid carcinoma and the role of comprehensive ND, we performed a review of our experience with comprehensive ND. STUDY DESIGN: Retrospective chart review. PATIENTS AND METHODS: Between 1997 and 2002, a total of 39 consecutive patients (31 women and 8 men) underwent 44 NDs for the management of lateral cervical metastases. Preoperative cytologic analysis revealed papillary carcinoma in all 39 patients (100%). All specimens were labeled and mapped by the operating surgeon to identify each level. The incidence of positive disease was determined in relation to the extent of lymphadenectomy for all dissected levels. RESULTS: All patients underwent ND at levels II through V; 7 (17%) of the 44 ND specimens included level I nodes. The incidence of metastatic disease in level II nodes was 52% (23/44 specimens). Similarly, 25 specimens (57%) contained histologic metastases at level III. Metastatic disease was noted in 18 level IV nodes (41%) and 9 level V nodes (21%). One (14%) of the 7 specimens with level I nodes contained tumor. CONCLUSIONS: Cervical metastases from papillary thyroid carcinoma occur in predictable patterns, with disease commonly present at levels II through V. We believe that a comprehensive ND, including removal of transverse cervical and spinal accessory nodes, is necessary for the complete clearance of lateral metastases.

Kupferman ME, Patterson DM, Mandel SJ, LiVolsi V, Weber RS. · Department of Otolaryngology-Head and Neck Surgery, University of Pennsylvania School of Medicine Philadelphia, Pennsylvania 19104, USA. · Laryngoscope. · Pubmed #15091209 No free full text.

Abstract: OBJECTIVES/HYPOTHESIS: The management of cervical metastases from differentiated thyroid carcinoma (DTC) remains controversial. Most surgeons perform a neck dissection (ND) for clinically apparent disease. The extent of nodal dissection varies from regional to comprehensive. Morbidity from ND in the setting of DTC remains high, particularly when performed in the setting of a thyroidectomy (TT). To determine complications from ND for DTC, we retrospectively reviewed our surgical experience of modified radical neck dissection for nodal metastases. STUDY DESIGN: Retrospective chart review. METHODS: Between 1997 and 2002, 39 consecutive patients (31 females and 8 males) underwent 44 comprehensive NDs of levels II-V for DTC. Central compartment dissection (CCD) (levels VI and VII) was also performed during 23 of these procedures. Twenty (45.5%) patients had prior treatment elsewhere. Preoperative pathology revealed papillary carcinoma in 22 patients (56.4%), tall cell variant in 11 (28.2%), and follicular variant in 6 (15.4%). RESULTS: Ten patients (20%) underwent ND alone, whereas 6 (14%) underwent simultaneous ND and TT. Fifteen patients underwent simultaneous ND, TT, and CCD (30%). Temporary hypocalcemia occurred after 21% of NDs that were performed in the setting of either TT or CCD or both. There were no cases of permanent hypoparathyroidism. Transient regional lymph node (RLN) paresis occurred in two patients and was associated with a concomitant central compartment nodal dissection; there were no permanent RLN palsies. Transient spinal accessory nerve paresis developed after 27% of NDs performed. Two patients developed chyle leaks. CONCLUSIONS: When ND is necessary for the treatment of thyroid malignancies, the procedure can be performed safely with acceptable morbidity.

Rickels MR, Langer JE, Mandel SJ. · Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania 19104, USA. · J Clin Endocrinol Metab. · Pubmed #15001584 links to  free full text

This publication has no abstract.

Kesmodel SB, Terhune KP, Canter RJ, Mandel SJ, LiVolsi VA, Baloch ZW, Fraker DL. · Department of Surgery, Division of Endocrinology, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA. · Surgery. · Pubmed #14668734 No free full text.

Abstract: BACKGROUND: Given the difference in surgical management between follicular neoplasms and papillary thyroid carcinoma (PTC), we sought to determine the sensitivity of fine-needle aspiration (FNA) and intraoperative pathologic study (IP), frozen section and cytologic study, in establishing a diagnosis of follicular variant of papillary thyroid carcinoma (FVPTC) and how these techniques impact operative management. METHODS: A retrospective chart review was performed of patients who underwent thyroidectomy for nodular disease between June 1997 and June 2002 identifying patients with a final diagnosis of FVPTC. FNA and IP results were reviewed in this group of patients and correlated with those of final histopathologic study. The sensitivity of FNA and IP was calculated. RESULTS: Eighty-two patients had a final diagnosis of FVPTC. Eighty-six preoperative FNAs were obtained in 80 patients, leading to a diagnosis of PTC in 7 (sensitivity 9%). Intraoperative pathologic study was performed in 31 patients with suspicious FNA results, of which 13 were definitive for PTC (sensitivity 42%). Overall, IP was obtained in 42 patients, of which 15 were positive for PTC (sensitivity 36%). CONCLUSION: Although the sensitivity of FNA in establishing a diagnosis of FVPTC is low, FNA identifies patients with suspicious lesions in whom IP is important in guiding operative management.