Head and neck surgery by Har-El, Gady

By Har-El, Gady

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7 Finally, several large, retrospective studies have shown improved survival in patient treated with extensive surgery and radioiodine treatment over patients treated with less extensive procedures. , extension to sternothyroid muscle or perithyroid soft tissues) • T4a • T4b Moderately advanced disease; tumor of any size extending beyond the thyroid capsule to invade subcutaneous soft tissues, larynx, trachea, esophagus, or recurrent laryngeal nerve Very advanced disease; tumor invades prevertebral fascia or encases carotid artery or mediastinal vessels Regional lymph nodes (N)a • Nx Regional lymph nodes cannot be assessed • N0 No regional lymph-node metastasis • N1 Regional lymph-node metastasis(-es) • N1a Metastasis(-es) to level VI (pretracheal, paratracheal, and prelaryngeal/Delphian lymph nodes) • N1b Metastasis(-es) to unilateral, bilateral, or contralateral cervical (levels I, II, III, IV, or V) or retropharyngeal or superior mediastinal lymph nodes (level VII) Distant metastasis(-es) (M) • M0 No distant metastasis • M1 Distant metastasis(-es) a Regional lymph nodes are central compartment, lateral cervical, and upper mediastinal lymph nodes.

Hürthle cell carcinoma or oncocytic variant of FTC comprises approximately 5% of the malignant thyroid tumors, and in contrast to FTC, the frequency of nodal metastases in this neoplasm is approximately 30%. There is no evidence that pathogenesis of Hürthle cell carcinoma is different from that of conventional FTC, although H-Ras mutations are more often found in this type of tumor than in FTC. 2 Histological Variants of PTC and FTC and Their Respective Prognosis Type Prognosis PTC subtypes • Classical PTC (the most frequent; presents typical papillary architecture) Good • Follicular PTC Similar as in the classical type • Macrofollicular PTC Similar to other follicular variants, with lymph-node metastases present in ~20% and distant metastases in 7% of the cases • Oncocytic cell Not known • Clear cell Not known • Diffuse sclerosing Similar as in the classical type (despite high incidence of regional lymph-node and distant metastases) • Tall cell Poor • Columnar cell Poor • Solid Poor • Cribriform Not known (usually associated with FAP or Gardner syndrome) • With fascitis-like stroma Similar as in the classical type • With focal insular component Not known • With squamous cell or mucoepidermoid carcinoma Poor • With spindle and giant cell carcinomas Not known • Combined papillary and medullary carcinomas Not known • Papillary microcarcinoma Good (but in up to 11% cases, lymph-node metastasis can be present) FTC subtypes • Encapsulated FTC with microscopic capsular invasion (no vascular invasion is present) = minimally invasive follicular carcinoma Very low probability (less than 5% of the cases) of metastases, recurrences, or tumor-associated mortality • Encapsulated FTC with angioinvasion (capsular invasion is present or absent) Metastases, recurrences, or tumor-associated mortality in 5–30% of the cases • Widely invasive follicular carcinoma Metastases, recurrences, or tumor-associated mortality in 50–55% of the cases • Oncocytic cell (Hürthle cell) Nodal metastases in ~30% of the cases • Clear cell Not known • Mucinous variant Not known • FTC with signet-ring cells Not known PTC, papillary thyroid carcinoma; FAP, familial adenomatous polyposis; FTC, follicular thyroid carcinoma.

And therefore the diagnosis of FTC requires a histological proof of capsular invasion and/or vascular invasion. If the FNAB result suggests follicular neoplasm, thyroid lobectomy should be performed to permit full histological evaluation of the tumor. In approximately 20% of the lobectomy specimens in patients operated on because of FNAB suggesting follicular neoplasm, the final diagnosis confirms FTC. Undetermined or insufficient FNAB requires repetition of FNAB (see algorithm in Fig. 3). Computed tomography (Fig.

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