Emad Kandil

Tulane University, New Orleans, Louisiana, United States

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Publications (181)332.02 Total impact

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    ABSTRACT: Recurrent laryngeal nerve (RLN) injury is one of the most common complications of thyroid surgery. Injury to the external branch of the superior laryngeal nerve is less obvious and affects the voice variably; however, it can be of great significance to professional voice users. Recent literature has led to an increase in theuse of neuromonitoring as an adjunct to visual nerve identification during thyroid surgery. In our review of the literature, we discuss the application, efficacy and safety of neuromonitoring in thyroid surgery. Although intraoperative neuromonitoring (IONM) contributes to the prevention of laryngeal nerves injury, there was no significant difference in the incidence of RLN injury in thyroid surgery when IONM was used compared with visual identification alone. IONM use is recommended in high risk patients; however, there are no clear identification criteria for what constitutes “high risk”. There is no clear evidence that IONM decreases the risk of laryngeal nerve injury in thyroid surgery. However, continuous IONM provides a promising tool that can prevent imminent nerve traction injury by detecting decreased amplitude combined with increased latency.
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    ABSTRACT: The objective of this study was to describe national trends in robotic thyroid surgery from 2009 through 2013. The University HealthSystem Consortium (UHC) database was searched for patients undergoing robotic thyroidectomy (RT) from 2009 through 2013. Another US institution's RT data, not included in the UHC database, were also evaluated. Patient demographics, institutional volume, comorbid conditions, complications, and cost information were analyzed. Sixty-one institutions performed 484 RT during the study period. From 2009 through 2011, US annual RT volume increased from 39 cases to 140. Annual volume dropped to 69 cases in 2012 and 93 cases in 2013. Higher volume centers reported lower complication rates (P<0.02). Hematoma formation (3.7%) was the most common complication, and there was one death. Over ten percent of patients were obese. Brachial plexus injury and axillary skin flap perforations were reported in less than one percent of cases. Mean cost for a total RT was $13,287 ($5,125 - $42,444). From 2009 through early 2011, there was a steady increase in RT volume, especially among high volume institutions. In mid to late 2011, there was a noticeable drop in RT volume, which significantly altered the projected trajectory of the procedure in this country. Despite higher complication rates, lower volume centers perform the majority of RT and are also responsible for recent increases in RT utilization patterns in the US.
    Thyroid: official journal of the American Thyroid Association 05/2015; DOI:10.1089/thy.2015.0066 · 3.84 Impact Factor
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    ABSTRACT: Reoperation for recurrent papillary thyroid cancer (PTC) can be associated with a high rate of complications and failure to provide lasting remission. Percutaneous ethanol injection (PEI) may be an effective nonsurgical management option for locally recurrent PTC. This systematic analysis of the current literature compares the efficacy and complications related to PEI vs reoperative surgical intervention for treatment of locally recurrent PTC. Original studies were identified using the keywords "thyroid/ethanol" and "recurrent thyroid cancer/repeat surgery." Studies evaluating reoperation or PEI for lymph node metastases in patients with primary surgery of total thyroidectomy with appropriate lymph node dissection where indicated were included in the analysis for both reoperation and PEI. Animal studies, single case reports, and studies with fewer than 10 lesions were excluded. Outcomes included interval to detection of recurrence, success and failure rates, recurrence rates, complication rates, and follow-up duration. Between-group outcome differences were calculated using random-effects models, and pooled data cross-tabulation and logistic regression analysis were used. In all, 945 publications were identified, and 27 studies met the inclusion criteria. There were no studies that directly compared the 2 treatment techniques. A total of 1617 patients were included in this analysis; 168 (11.4%) were treated with PEI, and 1449 (88.6%) were treated with reoperation. Reoperation was successful in 94.8% of cases compared with an 87.5% success rate for PEI (odds ratio [OR], 2.58; 95% CI, 1.55-4.31; P < .001). The recurrence rates for PEI and reoperation at the site of the treated lesion or elsewhere in the neck were also similar (OR, 1.07; 95% CI, 0.65-1.77; P = .78). Reoperation was associated with a 3.5% pooled risk of complications, while PEI incurred a pooled risk of 1.2% (OR, 2.9; 95% CI, 0.72-12.3; P = .08). However, most studies did not report routine preoperative and postoperative laryngoscopies, an evaluation needed for accurate neural complication analysis associated with each procedure. High-quality, well-designed studies are needed to evaluate the feasibility of incorporating PEI into the treatment protocol of PTC. Although presently inferior to reoperation, PEI has the potential to be a widely accepted and effective nonsurgical treatment option for limited recurrent PTC in poor surgical candidates or patients seeking to avoid multiple reoperations.
    Archives of Otolaryngology - Head and Neck Surgery 04/2015; DOI:10.1001/jamaoto.2015.0596 · 1.75 Impact Factor
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    ABSTRACT: Robot assisted thyroid surgery has been the latest advance in the evolution of thyroid surgery after endoscopy assisted procedures. The advantage of a superior field vision and technical advancements of robotic technology have permitted novel remote access (trans-axillary and retro-auricular) surgical approaches. Interestingly, several remote access surgical ports using robot surgical system and endoscopic technique have been customized to avoid the social stigma of a visible scar. Current literature has displayed their various advantages in terms of post-operative outcomes; however, the associated financial burden and also additional training and expertise necessary hinder its widespread adoption into endocrine surgery practices. These approaches offer excellent cosmesis, with a shorter learning curve and reduce discomfort to surgeons operating ergonomically through a robotic console. This review aims to provide details of various remote access techniques that are being offered for thyroid resection. Though these have been reported to be safe and feasible approaches for thyroid surgery, further evaluation for their efficacy still remains.
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    ABSTRACT: Retained foreign bodies (RFB) after operative interventions are linked to an increased risk of morbidity and mortality, and represent a medico-legal liability. We aimed to identify associated risk factors and outcomes related to iatrogenic RFB in the United States. A cross-sectional analysis was performed on all interventions that resulted in a secondary diagnosis of RFB in the Nationwide Inpatient Sample (NIS) from 2003 to 2009. Comparative controls were randomly selected from patients who underwent similar procedures. We identified 3,045 cases of RFB, and 12,592 controls were included. The majority of incidents, 968 (31.8%), were reported after gastrointestinal interventions. Risk of RFB was higher in teaching hospitals (odds ratio [OR] 1.31, 95% CI [1.19, 1.45], p < 0.001). For abdominopelvic procedures, patients admitted with traumatic injuries did not demonstrate a higher risk of RFB compared with electively admitted patients (OR 1.70, 95% CI [0.94, 3.07], p = 0.08). However, for procedures unrelated to abdominopelvic surgery, patients admitted for trauma had a lower risk (OR 0.62, 95% CI [0.50, 0.78], p < 0.001). Obesity (BMI ≥ 30 kg/m(2)) and older age (≥65 years) were significantly associated with a higher risk only for abdominopelvic procedures (p < 0.01 for both). Retained foreign bodies were associated with a higher average cost of health services ($26,678.00 ± $769.69 vs $12,648.00 ± $192.80, p < 0.001). Retained foreign bodies have unfavorable and nationally tangible clinical and economic outcomes. The risk profile for RFB at the national level seems to demonstrate an association with demographic and clinical factors including nature of the procedure, type of admission, and trauma status. Teaching hospitals are associated with a higher risk. Targeted efforts toward identified high-risk populations are needed to avoid these morbid and costly complications. Copyright © 2015 American College of Surgeons. Published by Elsevier Inc. All rights reserved.
    Journal of the American College of Surgeons 04/2015; 220(4):749-59. DOI:10.1016/j.jamcollsurg.2014.12.015 · 4.45 Impact Factor
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    ABSTRACT: Introduction: Fine needle aspiration cytology (FNA) of thyroid nodules can lead to changes that extensively replace cytologically confirmed thyroid lesions. These replaced thyroid lesions are called vanishing tumors, and can be challenging to pathologists, endocrinologists and surgeons, rendering the final pathological diagnosis difficult to interpret. We performed a retrospective analysis focusing on the issues that tend to compromise management plans for these vanishing tumors. Study Design: Retrospective review Methods: Data of 609 patients referred to our institution for thyroid surgery were reviewed. Patients with suspicious lesions on neck ultrasound underwent FNA biopsy. We compared FNA cytological and surgical pathological findings to identify patients with vanishing tumors. FNA-induced reactive changes such as cystic degeneration, hemorrhage, calcification, cholesterol crystals, fibrosis and granulation tissue were identified. Results: Seventeen patients (2.7%) were identified with vanishing tumors in specimen pathology. Preoperative FNA cytology was indeterminate in seven (41.1%) and benign in ten (58.8%) patients. The mean size of vanishing tumors was 2.4±1.5 cm in greatest dimension. On surgical pathology, all nodules showed regressive changes partially or entirely replacing the tumor. There were seven nodules (41.1%) that were entirely replaced while remaining ten nodules showed partial replacement of tumors by regressive changes. Three (23%) nodules presented with focal areas of optically clear nuclei suspicious of PTC; one showed an additional focus of follicular neoplasm of uncertain malignant potential. Conclusions: FNA-induced secondary changes can lead to obliteration of nodules, leading to surgical pathology diagnosis with no evidence of benign or malignant lesions. Pathologists and surgeons should be aware of this challenging scenario. In the presence of expert opinions, FNA cytology can provide a definitive diagnosis for these vanishing tumors.
    Society of Surgical Oncology, Houston, Texas; 03/2015
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    ABSTRACT: Background. BRAF V600E mutation is associated with poor prognosis in patients with papillary thyroid carcinoma (PTC). PTC is often multifocal, and there are no guidelines on how many tumors to test for BRAF mutation in multifocal PTC. Methods. Fifty seven separate formalin-fixed and paraffin-embedded PTCs from twenty-seven patients were manually macrodissected and tested for BRAF mutation using a commercial allele-specific real-time polymerase chain reaction-based assay (Entrogen,WoodlandHills, CA). Data related to histologic characteristics, patient demographics, and clinical outcomes were collected. Results. Allmutations detected were BRAF V600E. Seventeen patients (63%) had concordant mutation status in the largest and second-largest tumors (i.e., both were positive or both were negative). The remaining ten patients (37%) had discordantmutation status. Six of the patients with discordant tumors (22% overall) had a BRAF-negative largest tumor and a BRAF-positive second-largest tumor. No histologic feature was found to help predict which cases would be discordant. Conclusions. Patients with multifocal PTC whose largest tumor is BRAF-negative can have smaller tumors that are BRAF-positive. Therefore, molecular testing of more than just the dominant tumor should be considered. Future studies are warranted to establish whether finding a BRAF mutation in a smaller tumor has clinical significance.
    BioMed Research International 03/2015; · 2.71 Impact Factor
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    ABSTRACT: Fine needle aspiration (FNA) cytology, being the mainstay to diagnose thyroid nodules, does not provide definitive results in a subset of patients. The use of molecular markers testing has been described as a useful aid in differentiation of thyroid nodules that present with an indeterminate cytodiagnosis. Molecular tests, such as the Afirma gene classifier, mutational assay and immunohistochemical markers have been increasingly used to further increase the accuracy and defer unnecessary surgeries for benign thyroid nodules. However, in light of the current literature, their emerging roles in clinical practice are limited due to financial and technical limitations. Nevertheless, their synergistic implementation can predict the risk of malignancy and yield an accurate diagnosis. This review discusses the clinical utility of various molecular tests done on FNA indeterminate nodules to avoid diagnostic thyroidectomies and warrant the need of future multi-Institutional studies.
    Anticancer research 03/2015; 35(3):1237-1241. · 1.87 Impact Factor
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    ABSTRACT: Studies have shown that the risk of malignancy in follicular neoplasms is as high as 30%. Often, surgery is recommended for such lesions, not for therapeutic purposes but as a diagnostic method, leading to increased hospital costs and related morbidities. Recent studies have suggested that tumor size predicts malignant potential of these follicular neoplasms. Our aim was to identify the impact of nodule size on the risk of malignancy for such lesions. A retrospective medical chart review was undertaken for patients who underwent thyroid surgery at a single academic North American Institution. A total of 120 follicular lesions, follicular neoplasms (Bethesda category IV) or follicular lesions of undetermined significance (Bethesda category III) in 110 patients undergoing thyroid surgery were evaluated. Nodule size as measured by ultrasound, fine-needle aspiration cytological results, and final histopathology reports were reviewed. Analysis was performed by classification according to nodule size: <3 cm, ≥3 cm, <4 cm and ≥4 cm. Out of the 120 nodules, 48 (40%) were reported to be malignant on final pathological examination. The malignancy rate in nodules <3 cm and ≥ 3cm was 41% and 37.8%, respectively (p=0.84). When 4 cm was used as the cut-off, the rate in nodules <4 cm and ≥4 cm was 40.6% and 37.5%, respectively (p=0.82). Increased thyroid nodule size does not increase the malignancy rate for follicular neoplasms. Hence, we recommend against routine total thyroidectomy for patients with follicular neoplasms based on the size criteria. Copyright© 2015 International Institute of Anticancer Research (Dr. John G. Delinassios), All rights reserved.
    Anticancer research 03/2015; 35(3):1635-9. · 1.87 Impact Factor
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    ABSTRACT: Objectives/HypothesisNew approaches for robotic-assisted thyroidectomy, including the retroauricular approach, were recently described. We have modified the established surgical approach for retroauricular robotic thyroidectomy. Herein, we report our initial experience to identify challenges and limitations of this new surgical approach.Study DesignProspective case series.Methods This study was performed under institutional review board approval for patients who underwent retroauricular robotic hemithyroidectomy at an academic North American institution. The retroauricular approach was modified by using the space between the two heads of the sternocleidomastoid muscle as our working space. Additionally, selected patients underwent concomitant neck lift surgery with robotic thyroid surgery. Clinical characteristics, total operative time, blood loss, surgical outcomes, and length of hospital stay were evaluated.ResultsTwelve female patients were included in this study. Mean age was 45 ± 4.43 years, and mean body mass index was 28.6 ± 2.15. Mean thyroid nodule size was 1.15 ± 0.26 cm3. All cases were completed successfully via single retroauricular incision. There was no conversion to an open approach. Four out of 12 patients (33%) underwent additional concomitant neck lift surgery, with a mean total operative time of 156 ± 15.88 minutes. The mean operative time for the remaining eight patients who underwent the robotic approach without additional neck lift surgery was 145.4 ± 10.08 minutes. There were no cases of permanent vocal cord paralysis or permanent hypoparathyroidism. Mean blood loss was 22.4 ± 4.32 mL. Four patients (33%) were discharged home on the same day of surgery, and the remaining eight patients were discharged after an overnight stay.Conclusions Single-incision retroauricular robotic hemithyroidectomy can be a safe and feasible alternative to other remote access techniques. Neck lift surgery can be performed safely in a select group of patients. However, future studies are warranted to further evaluate the benefits and limitations of this novel approach.Level of Evidence4. Laryngoscope, 125:767-771, 2015
    The Laryngoscope 03/2015; 125(3). DOI:10.1002/lary.24786 · 2.03 Impact Factor
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    ABSTRACT: Fine needle aspiration (FNA) cytology, being the mainstay to diagnose thyroid nodules, does not provide definitive results in a subset of patients. The use of molecular markers testing has been described as a useful aid in differentiation of thyroid nodules that present with an indeterminate cytodiagnosis. Molecular tests, such as the Afirma gene classifier, mutational assay and immunohistochemical markers have been increasingly used to further increase the accuracy and defer unnecessary surgeries for benign thyroid nodules. However, in light of the current literature, their emerging roles in clinical practice are limited due to financial and technical limitations. Nevertheless, their synergistic implementation can predict the risk of malignancy and yield an accurate diagnosis. This review discusses the clinical utility of various molecular tests done on FNA indeterminate nodules to avoid diagnostic thyroidectomies and warrant the need of future multi-Institutional studies. Copyright© 2015 International Institute of Anticancer Research (Dr. John G. Delinassios), All rights reserved.
    Anticancer research 03/2015; 35(3):1237-1241. · 1.87 Impact Factor
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    ABSTRACT: The Bethesda criteria are proposed for appropriate stratification of malignancy risk in thyroid nodules, but controversy exists regarding their accuracy and reliability in decision making. Additionally, previous studies have suggested higher rates of both malignancy and false negative fine needle aspiration biopsy (FNA) associated with increasing nodule size. This study aims to determine the accuracy of ultrasound (US)-guided FNA using the current Bethesda criteria in surgical practice. We also aimed to investigate the relationship between nodule size and malignancy. A retrospective analysis of US-guided FNAs by a single surgeon during a 4.5 year period. FNA results using Bethesda criteria were compared to final surgical pathology. 611 patients with thyroid nodules underwent US-guided FNA. FNA results in 375 subsequently excised thyroid nodules were recorded according to the Bethesda criteria: 192 (51%) benign, 65 (17%) atypia of unknown significance/follicular lesion of undetermined significance (AUS/FLUS), 42 (11%), suspicious for follicular neoplasm (SFN), 17 (5%) suspicious for malignancy (SM), 28 (8%) malignancy, and 31 (8%) non-diagnostic. Malignancy was confirmed by surgical pathology in 15%, 34%, 50%, 88%, 100%, and 39% of the above groups respectively. Sensitivity, specificity, and false-negative rate were 61%, 99%, and 15% respectively. No correlation existed between the size of nodules with indeterminate FNA results and malignancy rate (p=0.89), or size of nodules with non-diagnostic FNA and malignancy rate (p=0.50). The current Bethesda risk stratification system underestimated malignancy rates in benign, indeterminate and non-diagnostic cytopathologic categories in our experience. There was no positive linear correlation between nodule size and malignancy rate in these cytopathologic categories. Copyright © 2015. Published by Elsevier GmbH.
    Pathology - Research and Practice 02/2015; 211(5). DOI:10.1016/j.prp.2015.02.005 · 1.56 Impact Factor
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    ABSTRACT: This review is intended to provide an updated role of molecular genetics and various targeted therapies that have been developed to treat advanced stages of melanoma. Because of the declining success in melanoma therapy, the curative treatment for advanced stage melanoma has been a challenge for clinicians. Several mutations such as N-RAS, p53, BRAF including mutant-BRAF that lead to activation of kinase pathway, are implicated in the development of malignant melanoma. However, the current literature depicts that the prognostic role of BRAF mutation in disease progression is still controversial. While its higher level in advanced stage disease is associated with decreased overall survival (OS), some studies show that it failed to confer as an independent prognostic predictor of the disease. This has also led researchers to accomplish newer therapeutic strategies that lead to improved disease-response and grant survival benefits. Vemurafenib, a BRAF inhibitor agent, is one of the few available targeted therapies that is FDA approved and provides promising results in metastatic disease. However, its resistance at an early stage is of great concern. Recent implementation of combinational therapies including " targeted therapy " , immunotherapy, and biological agents has appealed many researchers to define the adjunctive role of available therapies and their limitations in advanced stage and metastatic melanoma. This commends the need for future multi-institutional studies to confirm the clinical validity of different therapeutic strategies on a large scale population.
  • The Laryngoscope 01/2015; DOI:10.1002/lary.25133 · 2.03 Impact Factor
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    ABSTRACT: Objective The aim of the study is to examine the correlation between weight, gender, and race with external branch of superior laryngeal nerve (EBSLN) visualization. Furthermore, we compared normative EBSLN neural-monitoring values to those of the recurrent laryngeal nerve (RLN).Study DesignRetrospective study.SettingNorth American tertiary academic hospital.Subjects and MethodsA retrospective, institutional review board-approved review was carried out on patients undergoing thyroid surgery by a single surgeon over 3.5 years. Preoperative and postoperative laryngoscopy was done on all patients in accordance with recently published American Academy of Otolaryngology voice optimization at thyroidectomy guidelines, and patients' clinical and operative relevant data were collected.ResultsA total of 447 nerves were at risk in 371 thyroidectomy patients. Of these nerves at risk, 237 (53.02%) were visualized and stimulated. The average amplitude and latency for the EBSLN were significantly lower when compared to the amplitude and the latency of RLN stimulation (P < 0.0001, P < 0.0001, respectively). There was no gender or racial disparity. Out of our study population, the EBSLN was identified in 64.56% in nonobese patients, whereas it was only 40.00% in obese patients (P < 0.001). Additionally, of the 56 patients in whom the EBSLN was visualized on one side and who further underwent bilateral neck exploration, 41 (73%) had visualization of the nerve on the contralateral side as well.ConclusionEBSLN is less likely to be visualized in obese patients; however, there was no gender or racial disparity. Stimulation of EBSLN was felt to be a useful adjunct during superior pole dissection to assure the nerve integrity.Level of Evidence4. Laryngoscope, 2015
    The Laryngoscope 01/2015; DOI:10.1002/lary.25139 · 2.03 Impact Factor
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    Emad Kandil, Ahmad Saeed, Joseph Buell
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    ABSTRACT: Liver is the commonest site for metastasis in patients with neuroendocrine tumors (NETs); it occurs in 45-95% of patients. Available treatment options include surgical resection, liver transplantation, chemotherapy and biotherapy. Surgery is the gold standard for curative therapy. Typically, a multidisciplinary approach is a cornerstone for decision making while dealing with this aggressive disease. This review will focus on the performance and safety of open, laparoscopic, and liver transplant surgical approaches in NETs patients with liver metastases.
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    ABSTRACT: The aim of this study is to compare the safety and efficacy of conventional laparotomy with those of robotic and laparoscopic approaches to hepatectomy. Independent reviewers conducted a systematic review of publications in PubMed and Embase, with searches limited to comparative articles of laparoscopic hepatectomy with either conventional or robotic liver approaches. Outcomes included total operative time, estimated blood loss, length of hospitalization, resection margins, postoperative complications, perioperative mortality rates, and cost measures. Outcome comparisons were calculated using random-effects models to pool estimates of mean net differences or of the relative risk between group outcomes. Forty-nine articles, representing 3702 patients, comprise this analysis: 1901 (51.35%) underwent a laparoscopic approach, 1741 (47.03%) underwent an open approach, and 60 (1.62%) underwent a robotic approach. There was no difference in total operative times, surgical margins, or perioperative mortality rates among groups. Across all outcome measures, laparoscopic and robotic approaches showed no difference. As compared with the minimally invasive groups, patients undergoing laparotomy had a greater estimated blood loss (pooled mean net change, 152.0 mL; 95% confidence interval, 103.3-200.8 mL), a longer length of hospital stay (pooled mean difference, 2.22 days; 95% confidence interval, 1.78-2.66 days), and a higher total complication rate (odds ratio, 0.5; 95% confidence interval, 0.42-0.57). Minimally invasive approaches to liver resection are as safe as conventional laparotomy, affording less estimated blood loss, shorter lengths of hospitalization, lower perioperative complication rates, and equitable oncologic integrity and postoperative mortality rates. There was no proven advantage of robotic approaches compared with laparoscopic approaches.
    01/2015; 19(1). DOI:10.4293/JSLS.2014.00186
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    ABSTRACT: Black thyroid pigmentation is a rare entity. The risk of malignancy is higher in black thyroid compared to non-black thyroid glands. We aimed to examine the effect of age and race on the risk of malignancy in black thyroid glands. We identified a series of consecutive patients who underwent thyroidectomy at an academic institution between January 1998 and May 2013. Patient demographics, clinical characteristics, and histopathology data were reviewed. Among 925 patients who underwent thyroidectomy, 112 (12.1%) patients with black thyroid glands were identified. The incidence of thyroid cancer was 55.4% in black thyroid glands compared to 32.8% in non-black thyroid glands (p < 0.0001). The incidence of papillary thyroid cancer among the black and non-black thyroid glands was 34.8 and 20%, respectively (p < 0.001). The mean age (±SD) for patients with black thyroid glands and those with non-black thyroid was 54.3 ± 12.8 and 51.2 ± 15.7 years, respectively (p = 0.05). Black thyroid glands were also associated with a higher incidence of microcarcinomas (76 vs. 59%, p = 0.02). Among patients with black thyroid glands, Caucasians had a higher malignancy rate (63.4%) than African-Americans (37%; p = 0.03). The incidence of malignancy is higher in black thyroid compared to non-black thyroid glands, specifically in Caucasians. © 2015 S. Karger AG, Basel.
    ORL 01/2015; 77(1):33-8. DOI:10.1159/000363188 · 0.67 Impact Factor
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    E M Mannina, Z Xiong, R Self, E Kandil
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    ABSTRACT: Paragangliomas are rare tumors originating outside of the adrenal medulla which can be associated with catecholamine secretion or mass effect, one of which typically leads to their discovery. The differences between these tumors and traditional intra-adrenal pheochromocytomas are a subject of recent investigations. Standard of care therapy is medical management and surgical resection of the tumor. When tumors are biochemically active, medical optimization of the autonomic nervous system is a critical component to a safe, definitive resection. Tumors arising in the retroperitoneum present technical challenges for the surgeon as they are often large and difficult to access, making an oncologic resection much more difficult. Lastly, these tumors are mostly benign and rarely invade adjacent structures-an operative finding not always predicted by preoperative imaging-which, if present, adds significant complexity and risk to the resection. A case illustrating these challenges in the management of a biochemically active retroperitoneal paraganglioma invading the inferior vena cava follows.
    12/2014; 2014:837054. DOI:10.1155/2014/837054

Publication Stats

828 Citations
332.02 Total Impact Points

Institutions

  • 2009–2015
    • Tulane University
      • • Department of Surgery
      • • Section of Nephrology & Hypertension
      New Orleans, Louisiana, United States
    • Johns Hopkins University
      • Department of Surgery
      Baltimore, MD, United States
  • 2014
    • University of Chicago
      Chicago, Illinois, United States
  • 2013
    • Scott & White
      TPL, Texas, United States
  • 2012
    • Changsha Medical University
      Ch’ang-sha-shih, Hunan, China
  • 2011
    • Louisiana State University Health Sciences Center New Orleans
      New Orleans, Louisiana, United States
  • 2008–2010
    • Johns Hopkins Medicine
      • Department of Surgery
      Baltimore, Maryland, United States
  • 2006–2008
    • State University of New York Downstate Medical Center
      • Department of Surgery
      Brooklyn, NY, United States
  • 2003
    • Weill Cornell Medical College
      New York, New York, United States
    • Albert Einstein College of Medicine
      New York, New York, United States