Investigation prior to thyroglossal duct cyst excision

INTRODUCTION

Investigation of the anterior midline neck lump has been debated over the years with little agreement on best practice. Thyroglossal duct cysts (TDCs) are the most common aetiology. A TDC may contain ectopic thyroid tissue, which may affect the decision to excise.

METHODS

A computerised survey was sent to a representative sample of UK-based ENT surgeons to determine current practice in investigation of presumed TDCs and the incidence of ectopic thyroid tissue.

RESULTS

Overall, 95% of those surveyed use ultrasonography, with 32% also arranging thyroid function tests. Fifteen per cent had encountered absent normal thyroid tissue in the presence of a midline neck swelling. In 64% of cases this represented the only functioning thyroid tissue. Thyroid function tests were normal in all but two cases.

CONCLUSIONS

The results show a significant change in practice over the last decade. All surgeons would arrange some form of investigation of a presumed TDC, with the vast majority using ultrasonography. Radioisotope scanning should only be used if the ultrasonography or thyroid function tests are abnormal. The incidence of ectopic thyroid tissue in this survey was higher than previously calculated, with a 0.17% prevalence of midline neck lumps representing the only functioning thyroid tissue.

Galvanic stimulation of the vestibular periphery in guinea pigs during passive whole body rotation and self-generated head movement

Irregular vestibular afferents exhibit significant phase leads with respect to angular velocity of the head in space. This characteristic and their connectivity with vestibulospinal neurons suggest a functionally important role for these afferents in producing the vestibulo-collic reflex (VCR). A goal of these experiments was to test this hypothesis with the use of weak galvanic stimulation of the vestibular periphery (GVS) to selectively activate or suppress irregular afferents during passive whole body rotation of guinea pigs that could freely move their heads. Both inhibitory and excitatory GVS had significant effects on compensatory head movements during sinusoidal and transient whole body rotations. Unexpectedly, GVS also strongly affected the vestibulo-ocular reflex (VOR) during passive whole body rotation. The effect of GVS on the VOR was comparable in light and darkness and whether the head was restrained or unrestrained. Significantly, there was no effect of GVS on compensatory eye and head movements during volitional head motion, a confirmation of our previous study that demonstrated the extravestibular nature of anticipatory eye movements that compensate for voluntary head movements.

Outcomes of continuously infused 5-fluorouracil, doxorubicin, and mitomycin-C (iFAM) as salvage regimen in patients with biliary tract cancer

282

Background: In advanced biliary tract cancer, after failure of first-line chemotherapy, salvage chemotherapy has not yet been established and the prognostic factors in salvage setting have not been widely known. The purpose of this study was to evaluate the efficacy and safety of iFAM as salvage chemotherapy in biliary tract cancer and to reveal the prognostic factors.

Methods: Eligibility included: 1) age 18-75, 2) histologically confirmed biliary tract cancer, 3) previously treated with palliative first-line chemotherapy, 4) ECOG PS 0-2, 5) adequate organ function. iFAM consisted of 5-FU 800 mg/m2 over 12 hour on days 1-5, doxorubicin 30 mg/m2 on day 1, and mitomycin-C 8 mg/m2 on day 1, every 4 weeks.

Results: Between February 2003 and August 2009, 50 patients (pts) were enrolled. The median age was 57.3 yrs (range: 26.0-71.5 yrs), and there were 33 men (66%). 32 pts (64%) had ECOG PS 0-1 and 18 pts (36%) had PS 2. Biliary tract cancers were extrahepatic cholangiocarcinoma (30%), intrahepatic cholangiocarcinoma (30%) and gallbladder cancer (40%). Previous chemotherapy mainly consisted of gemcitabine-based and 5-FU-based regimens. Median cycles of iFAM were 2 (range: 1-6). Best responses to iFAM were PR in 2 (4%) pts and SD in 9 (18%), that is response rate was 4% and disease control rate was 22% (95% CI: 7.35-28.65). The median PFS and OS were 2.2 (95% CI: 2.0–2.4) months and 5.0 (95% CI: 3.3–6.7) months, respectively. Grade 3/4 hematologic toxicities were neutropenia (10%), anemia (2%), and thrombocytopenia (8%). Frequent nonhematologic toxicities were alopecia (34%), stomatitis (28%), vomiting (24%), and diarrhea (12%), which were grade 1/2. ECOG PS (0-1 vs 2) was significant prognostic factor for both PFS (p=0.029) and OS (p=0.025). Poor response to previous chemotherapy (p=0.031) were poor prognostic factors for OS.

Conclusions: iFAM is an effective and safe treatment option in refractory biliary tract cancer and can be considered as salvage regimen, especially for patients with good PS and good response to previous chemotherapy.

No significant financial relationships to disclose.

The Singapore liver cancer recurrence (SLICER) score for relapse prediction in patients with resected hepatocellular carcinoma

169

Background: Hepatocellular carcinoma (HCC) is a common worldwide cancer associated with extremely poor survival, with surgery the only option for cure in patients with localized disease. Current prognostic models for HCC are algorithms developed on datasets of mainly patients with metastatic or unresectable cancer, and may be less relevant to resectable HCC. Nomograms provide individualized outcome estimates. We constructed a postoperative nomogram, the Singapore liver cancer recurrence (SLICER) score, to predict outcomes of HCC patients who have undergone surgical resection.

Methods: Records for Singaporean patients undergoing first-line curative surgery for localized HCC in one institution between 1992 and 2007 were retrospectively reviewed (n=405). Freedom from relapse (FFR) was the primary outcome measure. An outcome-blinded modeling strategy including clustering, data reduction and transformation, was used. Calibration was tested with bootstrapping (n=200). We compared the performance of this model with other alternative models including CLIP, CUPI, BCLC, and Okuda scores using c-indices and likelihood analysis.

Results: A nomogram (SLICER score) predicting FFR was designed, incorporating vascular invasion, tumor size, multifocality, ECOG status, pre-operative AFP, Childs-Pugh score and cirrhosis. Bootstrap estimates show good calibration at 1, 2, 3, and 5 years postsurgery Comparison of the SLICER score with alternative prognostic models shows superior performance (Table).

Conclusions: The SLICER score enables individualized relapse predictions for patients following curative resection of localized HCC. It permits optimal patient selection for adjuvant therapy trials, biomarker development, and individual counseling.

[Table: see text]

No significant financial relationships to disclose.

Preparation technique for cytologic study of EUS-guided FNA samples when onsite cytopathologist is absent: Cell block, smear, or both?

176

Background: Smearing EUS-guided fine-needle aspiration (FNA) samples, with or without cell block, is most commonly performed for cytologic study in centers without onsite cytology. The diagnostic yield of such technique is often low (35%-50%) and may be related to loss of diagnostic material during the smearing process. Cell block technique captures not only aspirated cells but also small tissue fragments, improving diagnostic yield and enabling additional ancillary studies. This study aimed to compare the diagnostic yield of cell block alone against conventional smear (±cell block) technique in the EUS-guided FNA evaluation of pancreatic solid mass without onsite cytological assessment.

Methods: Data on the diagnostic yield of cell block alone technique performed over the last 12 months were prospectively collected and were compared to the yield of conventional smear ± cell block technique. A positive diagnostic yield was defined by the presence of adenocarcinoma and/or FNA findings consistent with the final surgical diagnosis.

Results: Data were available for 96 patients, of which 66 had cell block alone and 30 had smear +/-cell block preparation. The diagnostic yield of cell block alone was significantly higher that that of smear +/- cell block (53/66 vs 13/30; P=0.003). The addition of cell block after smearing did not improve the diagnostic yield (smear: 42% vs. both: 45%, p=0.88). Of patients who had smear +/-cell block, the diagnostic yield was significantly higher when the smearing was performed by cytopathologist as compared to that by nurse (10/16 vs. 3/14, p=0.02). There was a direct relationship between the rate of diagnostic yield and the number of FNA passes performed. The yield was highest when 4 or more FNA passes was performed (85%) as compared to that of 3 passes (63%, p=0.049) and 2 or less passes (38%, p<0.0001).

Conclusions: In the absence of onsite cytology services, the diagnostic yield from cell block alone was high (80%) and was superior to smear technique whether cell block was added to the evaluation of smears. In order to obtain adequate tissue material to maximise the diagnostic yield EUS-guided FNA of pancreatic mass, at least 4 FNA passes should be performed.

No significant financial relationships to disclose.