Faculty Bibliography

Objective: To determine how to triage patients with a follicular neoplasm (FN), without nuclear atypia reported by fine-needle aspiration, on the basis of risk factors. Methods: The age, sex, tumor size, and cell type of 397 patients who underwent thyroidectomy for follicular carcinoma (FC) or follicular adenoma between 1991 and 2001 were analyzed statistically. The likelihood ratio and probability of FC for various combinations of tumor size, sex, and cell type were estimated with use of Bayes' theorem. Results: FC was significantly associated with tumor size >2.1 cm (P = 0.048), male sex (P = 0.0007), and Hurthle cell type (P<0.0001). The mean size of minimally invasive FC was significantly smaller (2.9 cm versus 4.8 cm; P = 0.004) and the mean patient age was significantly younger (47.6 years versus 61.0 years; P = 0.003) than for widely invasive FC. The lowest probability (0.31%) for FC was in female patients with a small ( 2.1 cm) micro-follicular FN reported by a cytopathology practice with 10% accuracy of true FN at surgical intervention, whereas the highest probability (29.5%) for FC was in male patients with a large (>2.1 cm) Hurthle cell neoplasm reported by a cytopathology practice with 70% accuracy of true FN at surgical intervention. Conclusion: Although an estimate of probability for FC based on age, sex, thyroid nodule size, and cell type is provided in this study for patients diagnosed with FN without nuclear atypia on fine-needle aspiration, the variability of the accuracy in cytopathology practice makes it difficult to change the current treatment paradigm, which requires carefully planned prospective studies with long-term follow-up. (Endocr Pract. 2003;9:510-516)

We investigated how frequently the imaging procedure we use immediately prior to radiosurgery--triple-dose gadolinium-enhanced MR performed with the patient immobilized in a nonrelocatable head frame and 1-mm-thick MPRAGE (magnetization-prepared rapid gradient echo) images (SRS3xGado)-identifies previously unrecognized cerebral metastases in patients initially imaged by conventional MR with single-dose gadolinium (1xGado). Between July 1998 and July 2000, the diagnoses established for 47 patients who underwent radio-surgical procedures for treatment of cerebral metastases at The Gamma Knife Center of New York University were based initially on the 1xGado protocol. In July 1998, we began using SRS3xGado as our routine imaging protocol in preparation for targeting lesions for radio-surgery, using triple-dose gadolinium and acquisition of contiguous 1-mm Tl-weighted axial images. Because our SRS3xGado scans sometimes unexpectedly revealed additional metastases, we sought to learn how frequently the initial 1xGado scans would underestimate the number of metastases. We therefore reviewed the number of brain metastases identified on the SRS3xGado studies and compared the results to the number found by the 1xGado protocol, which had initially identified the brain metastases. Additional metastases, ranging from 1 to 23 lesions per patient, were identified on the SRS3xGado scan in 23 of 47 patients (49%). In 57% of the 23 patients, only one additional lesion was identified. The mean time interval between the 1xGado and the SRS3xGado scans was 20.6 days (range, 4-83 days), and the number of additional lesions detected and the time interval between two scans were negatively correlated (-0.11). The number of lesions detected on the SRS3xGado was associated only with the number of lesions on the 1xGado and not with any other patient or tumor pretreatment characteristics such as age, gender, largest tumor volume on the 1xGado, or number of days between the 1xGado and the SRS3xGado or prior surgery. The identification of additional lesions with SRS3xGado MR may have implications for patients who are treated with stereotactic radiosurgery alone (without whole-brain irradiation) with single-dose gadolinium imaging, in that unidentified lesions may go untreated. As a result of these findings we continue to use and advocate SRS3xGado scans for radiosurgery

OBJECTIVE: To assess the effectiveness of advances in supportive centralized care on survival and function in patients with familial dysautonomia (FD). STUDY DESIGN: From September l, 1969 through January 1, 2001. Five hundred fifty-one patients with FD entered the Dysautonomia Center. We divided the group into two cohorts: the first cohort (n = 227) entered until March 1, 1981, and the second cohort (n = 324) entered after March 1, 1981. Survival curves were compared by using log-rank tests. Demographic and disease characteristics were examined, including gender, geographic location, age at entry, birth weight, breath-holding history, age of walking, causes of death, and social data. RESULTS: For both cohorts age at entry was the primary variable that influenced survival; mortality increased by 3% per year. Survival time lengthened for cohort 2 when survival time was defined as time from entry into the Center to last observation or death; in cohort 2, mortality was 73% that of cohort 1 even after adjustment for age at entry. Although survival improved, causes of death were unchanged; sleep deaths and sudden deaths remained frequent. CONCLUSION: Our data indicate that the more recent cohort patients were younger at the time of entry and had improved survival, which suggests that early access to centralized and more advanced treatment appreciably benefits patients with familial dysautonomia

Mutations in the p53 gene have been implicated to play an important role in the development of various human cancers. To evaluate the importance of p53 in lung cancer, a transgenic mouse model was established by utilizing the Clara cell secretory protein (CCSP) promoter to target the expression of a dominant-negative mutant form of p53 (dnp53) in the lung. In two transgenic CCSP-dnp53 founder lines, the dnp53 protein was expressed exclusively in the lungs. The incidence of spontaneous lung cancer in 18-month-old transgenic mice was 45%, whereas that in age-matched control mice was 20%. The relative risk of lung tumors in CCSP-dnp53 mice was 2.3 times that of wild-type mice (exact confidence limits of 0.69, 17.5). In addition to the increased incidence of spontaneous lung tumor, these mice were more susceptible to the development of lung adenocarcinoma after exposure to benzo(a)pyrene (BaP). Six months after intratracheal instillation of benzo(a)pyrene, the tumor incidence in wild-type and CCSP-dnp53 mice was 39% and 73%, respectively. The risk of lung tumors was 25.3 times greater in BaP-treated mice adjusted for transgene expression (95% confidence limits of 3.29, 678, mid-p corrected). These results suggest that p53 function is important for protecting mice from both spontaneous and BaP-induced lung cancers

OBJECTIVE: This study reviews the 223 consecutive mitral valve operations for ischemic mitral insufficiency performed at New York University Medical Center between January 1976 and January 1996. The results for mitral valve reconstruction are compared with those for prosthetic mitral valve replacement. METHODS: From January 1976 to January 1996, 223 patients with ischemic mitral insufficiency underwent mitral valve reconstruction (n = 152) or prosthetic mitral valve replacement (n = 71). Coronary artery bypass grafting was performed in 89% of cases of mitral reconstruction and 80% of cases of prosthetic replacement. In the group undergoing reconstruction, 77% had valvuloplasty with a ring annuloplasty and 23% had valvuloplasty with suture annuloplasty. In the group undergoing prosthetic replacement, 82% of patients received bioprostheses and 18% received mechanical prostheses. RESULTS: Follow-up was 93% complete (median 14.6 mo, range 0-219 mo). Thirty-day mortality was 10% for mitral reconstruction and 20% for prosthetic replacement. The short-term mortality was higher among patients in New York Heart Association functional class IV than among those in classes I to III (odds ratio 5.75, confidence interval 1.25-26.5) and was reduced among patients with angina relative to those without angina (odds ratio 0.26, confidence interval 0.05-1.2). The 30-day death or complication rate was similarly elevated among patients in functional class IV (odds ratio 5.53; confidence interval 1.23-25.04). Patients with mitral valve reconstruction had lower short-term complication or death rates than did patients with prosthetic valve replacement (odds ratio 0.43, confidence interval 0.20-0.90). Eighty-two percent of patients with mitral valve reconstruction had no insufficiency or only trace insufficiency during the long-term follow-up period. Five-year complication-free survivals were 64% (confidence interval 54%-74%) for patients undergoing mitral valve reconstruction and 47% (confidence interval 33%-60%) for patients undergoing prosthetic valve replacement. Results of a series of statistical analyses suggest that outcome was linked primarily to preoperative New York Heart Association functional class. CONCLUSIONS: Initial mortalities were similar among patients undergoing prosthetic replacement and valve reconstruction. Poor outcome was primarily related to preexisting comorbidities. Patients undergoing valve reconstruction had fewer valve-related complications. Valve reconstruction resulted in excellent durability and freedom from complications. These findings suggest that mitral valve reconstruction should be considered for appropriate patients with ischemic mitral insufficiency