John Th. M. Plukker

BACKGROUND Findings of mediastinal uptake of ¹³¹I after surgical treatment for differentiated thyroid carcinoma (DTC) are common, especially in young patients. Given the frequency of false‐positive findings, a protocol for diagnostic and therapeutic strategies would be useful. With the goal of accurately selecting management strategies, the authors analyzed their data and data found elsewhere in the literature for correlations with the incidence of mediastinal ¹³¹I uptake and with treatment for patients exhibiting such ¹³¹I uptake. METHODS All patients with DTC who were treated between 1978 and 2000 at Groningen University Hospital (Groningen, The Netherlands) and who received adjuvant ¹³¹I ablation therapy were included in the current analysis, which involved retrospective review of all relevant data. RESULTS Five hundred four patients with DTC initially underwent total thyroidectomy, with additional ¹³¹I ablation performed for 489 of these patients. In 48 of 489 patients (9.8%), ¹³¹I uptake was seen in the mediastinum on a posttreatment scan. Analysis of those 48 patients and of cases in the literature demonstrated that serum thyroglobulin levels, risk status, and the presence of thymus on radiologic images were important in the surgical decision‐making process. CONCLUSIONS Mediastinal uptake of ¹³¹I on posttreatment scans was found in approximately 10% of patients after total thyroidectomy for DTC. Based on the current data and the data presented in the literature, the authors developed a flow chart for determining appropriate treatment strategies, which included mediastinal dissection for high‐risk patients and for patients with serum thyroglobulin levels > 10 ng/mL. Cancer 2005. © 2004 American Cancer Society.

Background: Treatment of esophageal perforation remains controversial and recommendations vary from initially non‐operative to aggressive surgical management. Several factors are responsible for this life‐threatening event, which has led to more individualized treatment ensuring adequate pleuromediastinal drainage with sufficient irrigation. We analyzed our data, evaluating morbidity and mortality in this selective approach. Methods: During 1985 to 2001, 17 of the 38 patients with esophageal perforation treated in our hospital underwent primarily a thoracotomy, wide drainage and debridement of chest/mediastinum and enteral hyperalimentation. Twenty‐one patients (55%) initially were treated non‐operatively (NPO, nasogastric tube, hyperalimentation, antibiotics and chest tube), but surgery was required in 9 patients (43%). Results: Most perforations were iatrogenic (45%; 17/38) followed by spontaneous perforations (32%; 12/38). Cervical perforations were managed earlier (n = 23) was based on signs of sepsis, empyema and progression of pneumomediastinum/thorax. Mortality occurred in one patient (3%), initially treated conservatively. Median intensive care and duration of hospitalization were not different between the conservative (5 and 7 days, respectively) and the primary surgical approach (21 and 27 days, respectively), but were higher after secondary surgery (13 and 50 days, respectively). Conclusions: Spontaneous esophageal perforations require early surgical exploration with drainage and irrigation of mediastinum and pleural cavity, while most iatrogenic lesions can be managed conservatively. Cervical perforations can be treated adequately non‐operatively, but thoracic perforations often require surgical intervention.

Background: 18-F-fluorodeoxyglucose positron emission tomography (FDG-PET) is valuable in staging of esophageal cancer. However, FDG-PET may falsely upstage patients leading to incorrect exclusion from surgical treatment. This study was performed to determine the false-positive rate and possible causes. Methods: The rate of false-positive lesions on FDG-PET was documented in 86 out of a group of 98 patients. Lesions were defined as false positive when pathological examination was negative or as absence of tumor activity within 6 months of follow-up. To evaluate the influence of a learning curve on the false-positive rate, the PET scans were revised recently. Results: False-positive lesions were found in 13 patients (13 of 86; 15%). FDG-PET incorrectly revealed only locoregional node metastases in 5 patients in whom surgery with curative intent was performed. Ten lesions in the other 8 patients were classified as distant organ or as nonregional node metastases (M1a/1b). Finally, 5 patients upstaged to M1a/1b underwent a curative resection. The number of false-positive lesions decreased from 16 to 5 (6%) after revision. Conclusions: Proper interpretation of FDG-PET in staging esophageal cancer is impeded by false-positive results. Even after completion of the learning curve, positive FDG-PET findings still have to be confirmed by additional investigations.

Background: The present study reviewed a 30-year experience of managing carotid body paraganglioma (CBP) and analysed clinical findings associated with perioperative morbidity. Methods: Clinical records, radiological findings and pathological reports of all patients who presented with CBP between 1966 and 1997 were reviewed. There were 39 consecutive patients with 45 tumours and median follow-up was 10 years. The Shamblin classification was used to define complication rates and long-term surgical results. Results: Preoperative information derived from magnetic resonance angiography (MRA) and colour Doppler imaging (CDI) was comparable to that from standard four-vessel arteriography. Forty-one CBPs were resected in 35 patients. Six patients had bilateral tumours and seven had multicentric tumours. The median duration of operation and blood loss were substantially higher for Shamblin type III tumours. All major vascular complications (four of 39 patients) and permanent neurological complications (three of 39) were observed in type III tumours. Conclusion: Surgical planning and prediction of perioperative complications can be obtained by staging derived from MRA and CDI. Severe complications occur predominantly in type III CBPs.

Background: Surgical management of recurrent pleomorphic adenoma of the parotid gland has a considerable risk of facial nerve injury and a high re‐recurrence rate. To obtain more insight into this issue we evaluated our experiences.Methods: Medical records and histologic material of all these patients (31 women and 21 men), who had been treated from 1976–1995 were reviewed. Median interval between initial treatment and commencement of recurrences was 3 (0.8–18) years. Last surgery consisted of parotidectomy in 48 patients (92%), including 19 (40%) total procedures and wide local excision with involved skin in four patients.Results: At a median follow‐up of 9 years, eight patients (8/52; 15%) had re‐recurrences develop, including 4 of 21 patients (19%) after a previous parotidectomy (group I) and 4 of 31 patients (13%) without prior parotidectomy (group II). The chance of re‐recurrence in a group of patients with a minimal follow‐up of 10 years after salvage surgery was 17% (4 of 24). The risk of a new relapse was, respectively, 4% and 8% at 1 and 5 years after treatment of recurrent disease. Acceptable N.VII function was preserved in 45 of the 49 (92%) nerves at risk. The risk of N.VII injuy was higher and more serious in group I (29% vs 10% in group II). The function of four of the five (80%) reconstructed zygomaticotemporal branches of the N.VII was adequate.Conclusion: Surgical treatment of recurrent pleomorphic adenoma of the parotid gland, usually consisting of a parotidectomy with wide extent and eventually facial nerve reconstruction, demonstrates favorable results with acceptable morbidity. The risk of new relapse and N.VII injury was higher after previous parotidectomy. © 2001 John Wiley & Sons, Inc. Head Neck 23: 311–316, 2001.