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Background Current guidelines consider all cases of papillary thyroid carcinoma (PTC) smaller than 4 cm and without extrathyroidal extension (ETE) and/or lymph node metastases as belonging to the same prognostic group, and therefore the recommendation is for uniform treatment. Xing draws our attention to a small subgroup with Duet Mutations (BRAF E600 and TERT 3636 genes) that are aggressive biologically and should be treated differently. Thus the aim of the present study is to test the validity of this recommendation. Methods A Markovian Model is used to evaluate the above hypothesis. Results A Monte Carlo sensitivity test shows a 5.6 year survival advantage for patients with low-grade PTC, who have the Duet Mutations, and were treated by total thyroidectomy rather than hemithyroidectomy. Conclusions We conclude that there is a place for routine molecular tests in low-risk patients with PTC.

Purpose The value of parotidectomy in older patients is unclear. This study presents a decision model to help resolve this question. Materials & methods A Markov model with Monte Carlo simulation was used to compare outcomes in patients of different ages with pleomorphic adenoma of the parotid gland treated by surgery or surveillance. Results In 30-year-old patients, surgery conferred a 3.5-year gain in life expectancy whereas in 75-year-olds, it was only 0.74 months. The expected rate of malignant transformation at age 30 years was 6.5% after surgery and 26.5% after surveillance; at age 65, corresponding rates were 0.8% and 10.7%. Sensitivity analysis showed that age was the only parameter that significantly contributed to life expectancy. The benefit of surgery was restricted in older patients. Conclusion Our Markov decision-analysis model suggests that patients older than 65 years with pleomorphic adenoma have a limited survival advantage with surgery compared to surveillance.

Background: Basaloid squamous cell carcinoma (BSCC) is a distinct variant of squamous cell carcinoma that was first described by Wain et al in 1986. Since then, about 160 cases have been reported in the literature. Only 40 cases have been described in the larynx. Methods: Four cases of BSCC of the larynx treated in our department between 1986 and 2000 are presented. The clinical features, biological behavior, and histopathological and immunohistochemical characteristics of this uncommon tumor are described, and the relevant literature is reviewed. Results: The main clinical presentation did not differ from other histological types of laryngeal carcinoma. The clinical course, however, was much more aggressive. All the patients received aggressive therapy including radical surgery and radiation. Two patients received chemotherapy. Two of the 4 patients presented died of distant metastasis shortly after diagnosis and treatment. Conclusions: The finding of this study with a limited number of patients supports previous reports suggesting that BSCC is a highly aggressive tumor that presents in older population with male predominance. The frequency of associated regional as well as distant metastases suggests that aggressive treatment is indicated and that systemic chemotherapy should be contemplated.

Purpose: The standard treatment for patients with early glottic carcinoma in Israel has been radiotherapy. In recent years, encouraging results with laryngo-microscopic carbon dioxide laser surgery as a treatment for early glottic carcinoma has changed our treatment strategy. We conducted a retrospective study to investigate the results of carbon dioxide laser excisional technique for early glottic carcinoma (T1, T2). Materials and Methods: Twenty-six had squamous cell carcinoma (SCC), (21 patients with T1 and 5 patients with T2 lesions), 3 had carcinoma in situ, (CIS) and 3 had verrucous carcinoma (VC). Results: All patients were free of disease after salvage treatment at the most recent follow-up. Conclusions: Careful patient selection with endoscopic staging and strict follow-up are essential to secure good results in the treatment of carbon dioxide laser for early laryngeal carcinoma. (Am J Otolaryngol 2003;24:28-33. Copyright 2003, Elsevier Science (USA). All rights reserved.)

Purpose: This study presents our experience with 728 patients treated in our department for well-differentiated thyroid carcinoma between 1954–1994. Materials and Methods: The retrospective evaluation of the prognostic implications of the clinical and pathological findings was performed. Age, sex, histological variants, tumor size, and locoregional and distant spread were evaluated as risk factors in relation to the prognosis. Results: During follow-up, which ranged from 1 to 31 years, 125 locoregional and/or distant metastases developed (17.2% of the patients), 87 of which occurred in the first 10 years after initial therapy. Thirty-two patients with papillary cancer and 20 with follicular cancer died of causes related to malignancy of the thyroid. Conclusion: The experience gained in our department has led us to adopt an aggressive approach in the treatment of patients with well-differentiated carcinoma of the thyroid gland.

The natural history of papillary thyroid carcinoma (PTC) is characterized by a slow growth rate and an excellent prognosis at 20 and 30 years. However, there is a small subset of patients with poorer outcome.Twenty patients who died of PTC within 10 years of diagnosis were studied to identify prognostic indicators and biological markers of early death. Findings were statistically compared with a previous review of all patients with PTC treated in the same institute and studies in the literature.The study group included 6 men and 14 women with a mean age of 65 years at diagnosis. Average tumor size was 3.6 cm; 16 patients had extracapsular extension. All tumor samples studied histologically stained poorly for p53, Ki67, and CD34. Regional metastases were present in half the patients, and distal metastases in all. All patients had an advanced disease stage (Tumor, Node, Metastases classification), and only 4 had a low score on the Metastases, Age, Completeness of resection, local Invasion, tumor Size risk stratification. Analysis of the findings against data in the literature for the whole population of patients with PTC, who had a considerably better survival (8% mortality within 8-15 years vs 100% within 10 years in our sample), yielded significant differences for rates of extrathyroidal extension (P = .0001), regional metastases (P = .016), and distant metastases (P = .0001).Extrathyroid extension, late regional metastases, and distant metastases may be risk factors for early death from PTC.

Purpose The clinical course of patients with squamous cell carcinoma (SCC) of the tongue is often unpredictable. Some patients have a fair course with good response to treatment, whereas others have aggressive locoregional disease despite diagnosis at an early stage. The purpose of the present study was to determine if histochemical staining for cytokeratins of the negative neck nodes obtained in prophylactic neck dissection could predict treatment failure in patients with SCC of the tongue. Materials and methods Between 1990 and 2000, 18 patients with early squamous cell carcinoma of the tongue (T1,T2N0M0) underwent partial glossectomy with neck dissection at the Rabin Medical Center in Israel. All had clear resection margins and no evidence of neck metastasis and were expected to do well. Nevertheless, 6 patients had an aggressive course and died of disease shortly after presentation because of local or regional failure. In an attempt to predict failure of treatment and patients’ outcome, paraffin-embedded blocks from the pathologically negative lymph nodes were subjected to immunohistochemical staining for cytokeratin using polyclonal antibodies. The antigen-antibody complex was identified by using the biotinylated secondary antibody and followed by the streptavidin-peroxidase detection method. Results None of the 142 sections from pathologically negative lymph nodes stained positive for keratin. On multivariate analysis, a statistically significant relationship was found between disease-free survival, early recurrence (P = .03), and metastasis to the neck (P = .008). Conclusions Keratin staining failed to yield evidence of micrometastasis. Further studies with more samples are needed to confirm these findings.

Background: The main limitation of fine-needle aspiration (FNA) is its limited distinction between neoplastic and benign lesions. We summarize our experience with thyroid nodules that were defined as follicular lesions by comparing the clinical and cytological features of the thyroid follicular lesions that were examined histologically to define the most reliable criteria of malignancy. Methods: The medical records of all patients who underwent thyroid aspiration at Rabin Medical Center from 1999 to 2000 were reviewed for a diagnosis of follicular lesion that warranted surgery (N = 58). The cytology and pathology reports of the patients who met these criteria were reviewed and compared with the original reports. Results: The incidence of malignancy in follicular lesions of the thyroid is about 26%. There was a significant correlation between a histologic diagnosis of carcinoma and the cytologic findings of nuclear grooves (P = .041), solid arrangement (P = .019), hypercellularity (P = .01), and hypercellularity to colloid amount ratio (P = .016). Nodular size was predictive of malignancy. No correlation was found between patient age or gender and tendency toward malignancy. Conclusions: The combination of cytological characteristics and the size of the nodule aspirate are predictive values of malignancy. We believe that every follicular lesion should be excised to obtain a definitive histological diagnosis based on capsular or vascular invasion.

Purpose: To discuss unusual facial injuries resulting from a bomb blast. Materials and Methods: In March 1997, a bomb consisting of a bag of nails was detonated in a coffee shop in Tel Aviv. Two of the wounded were brought to our level 1 Trauma Center with unique facial injuries. Computed tomography (CT) scan and CT angiogram were performed. Results: The blast occurred to the immediate right of the victims who were sitting in an open cafe. Both had tympanic perforation. The first patient showed indirect damage to the facial nerve from a piece of shrapnel located anterior to the carotid artery and medial to the right mandibular angle. The second had a piece of shrapnel lodged in the parapharyngeal space that was initially missed and discovered only on reexamination 3 days later after the patient complained of pain in the temporomandibular joint; there was no facial nerve deficit. The port of entry was probably a small wound in the anterior wall of the external ear canal. Conclusions: The wounds are probably attributable to the spalling effect of the shrapnel passing through the parotid gland, which has mixed-density tissue. These cases show that nerves are susceptible to damage even in the absence of direct engagement and that the emergency room physician should be alert to even small skin imperfections in blast victims to avoid missing penetrating wounds. (Am J Otolaryngol 2003;24:75-77. Copyright 2003, Elsevier Science (USA). All rights reserved.)