THERE IS COMPELLING EVIDENCE THAT FREE-FLOATING endolymph particles in the posterior semicircular canal underlie most cases of benign paroxysmal positional vertigo (BPPV). Recent pathological findings suggest that these particles are otoconia, probably displaced from the otolithic membrane in the utricle. They typically settle in the dependent posterior canal and render it sensitive to gravity. Well over 90% of patients can be successfully treated with a simple outpatient manoeuvre that moves the particles back into the utricle. We describe the various techniques for this manoeuvre, plus treatments for uncommon variants of BPPV such as that of the lateral canal. For the rare patient whose BPPV is not responsive to these manoeuvres and has severe symptoms, posterior canal occlusion surgery is a safe and highly effective procedure.

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Diagnosis and management of benign paroxysmal positional vertigo (BPPV)

Primary intraosseous carcinoma of the jaws. Review and update of odontogenic carcinomas.

Objective To reexamine the age, metastases, extent, and size (AMES) risk criteria for well-differentiated thyroid cancer with the effect of therapy on outcome. Design Review of patient medical records and direct-contact follow-up. Setting Two tertiary referral centers. Main Outcome Measures Recurrence or death. Patients One thousand nineteen patients with well-differentiated thyroid cancer treated between 1940 and 1990. Results One thousand nineteen patients with well-differentiated thyroid cancer were treated between 1940 and 1990, with a mean follow-up of 13 years, including a recent group of 264 patients treated from 1980 to 1990 at 2 different institutions with a mean follow-up of 8 years. The AMES criteria were used to designate high- and low-risk patients. The entire group had 229 high- and 790 low-risk patients; the percentage of high-risk patients decreased slightly after 1960. From 1940 to 1960, 1960 to 1979, and 1980 to 1990, the high-risk groups had survival rates of 48%, 62%, and 47%, respectively. For the low-risk patients, survival rates were 96%, 98%, and 98%, respectively. Recurrences occurred in 5% of low-risk patients and were usually curable; in high-risk patients, recurrence was associated with a 75% mortality. In low-risk patients, there was no significant difference in recurrence or death according to type of operation (unilateral or bilateral) or use of radioactive iodine. In high-risk patients, there were trends toward but no significant improvement in survival with bilateral surgery and radioactive iodine therapy; thyroid replacement was associated with a significant improvement in survival. Conclusions The AMES risk criteria remain highly valid predictors of risk. They define most low-risk patients for whom radical treatment may add excess morbidity but not improve already excellent prognoses.

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Differentiated thyroid cancer: reexamination of risk groups and outcome of treatment.

Long-term outcome of patients with differentiated thyroid carcinoma: effect of therapy.

BACKGROUND
The criteria for minimally invasive (low grade) follicular carcinoma of the thyroid (MI) remain controversial, often resulting in unnecessary treatment.

METHODS
The records of 130 patients with minimally invasive (MI) follicular thyroid carcinoma were retrieved from the files of the Endocrine Tumor Registry of the Armed Forces Institute of Pathology.

RESULTS
Ninety-five patients were confirmed to have MI based on the authors' criteria of small-to-medium vessel invasion, capsular invasion of up to full thickness, no parenchymal tumor extension, and no tumor necrosis (patients with oxyphilic tumors were excluded). The remaining 35 patients had tumors that were reclassified as “not low grade” based on large vessel invasion, extension into parenchyma, and tumor necrosis (oxyphilic cases excluded). The MI patients included 67 women and 28 men, ages 20–95 years (average, 42.0 years). Nearly all patients presented with a thyroid mass (n = 90 patients). The mean tumor size was 2.8 cm. Histologic features examined for tumor classification included cellularity, capsule nature, capsular invasion, vascular invasion, extension into parenchyma, cytoplasmic oxyphilia, mitotic activity, and necrosis. All patients were treated with surgical excision. Adjuvant radioactive iodine therapy was performed in 24 patients. Five patients developed recurrent disease: four were alive or had died without evidence of disease after additional treatment (mean, 18.1 years), and one patient died with disease (MI tumor) at 15.1 years. All of the remaining patients were disease free (mean follow-up, 16.5 years).

CONCLUSIONS
There are reproducible histologic criteria to diagnose patients with MI follicular carcinoma. The overall excellent long term prognosis and a good patient outcome suggests that no additional surgery is necessary. Cancer 2001;91:505–24. © 2001 American Cancer Society.

A clinicopathologic study of minimally invasive follicular carcinoma of the thyroid gland with a review of the English literature.

Background

Prognostic parameters for papillary carcinoma of the thyroid have been defined by several groups. However, no such study has been reported for follicular carcinoma.



Methods

We undertook a retrospective study of well-differentiated carcinoma of the thyroid operated at the Tata Memorial Hospital during the period 1970–1985. In our series, follicular carcinoma formed 48% of the well-differentiated carcinomas of the thyroid. The variables age, sex, size, extrathyroidal spread, distant metastases, and lymph node metastases were evaluated. The survival was plotted according to the Kaplan-Meier method, and graphs compared by log-rank test. Univariate and multivariate analyses were performed.



Results

Based on our experience we stratified the cases into low-risk and high-risk groups. The low-risk group included: age below 40 years, tumor size less than 5 cm, and no extrathyroidal extension or metastases. This low risk group had 100% survival at 15 years, compared with 40% survival for the high-risk group (P < .001). Seventy-three percent (73%) of our cases were in the high-risk group.



Conclusions

Based on our findings that the majority of our patients were in the high-risk group, we advocate a total or near-total thyroidectomy in treatment of follicular carcinoma of the thyroid. There is a need to arrive at a universally acceptable classification of risk groups in follicular carcinoma of the thyroid gland. HEAD & NECK 1996;18:118–126 © 1996 John Wiley & Sons, Inc.

Prognostic factors in follicular carcinoma of the thyroid: a study of 198 cases.

Primary intra-alveolar squamous-cell carcinoma of the mandible: Report of a case

We have reviewed the charts of 149 patients who underwent completion thyroidectomies for cancer of the thyroid. The purpose of the study was to evaluate extent of residual disease in the thyroid, and morbidity and mortality of the operation. Residual cancer was found in 58% of the cases, the morbidity was low, and there was no operative mortality.

Completion thyroidectomy for thyroid carcinoma

SUMMARY

A case of muco-epidermoid carcinoma of the penis in a Hindu male aged 40 is reported because of its rarity. It is the first case seen at the Tata Memorial Hospital during the past 30 years.

Muco-epidermoid Carcinoma of the Penis

Differentiated carcinoma of the thyroid has good prognosis, even in patients presenting in the late stage and with distant metastasis. In India, the incidence of papillary carcinoma and follicular carcinoma are in the ratio of 60∶40. A retrospective study was carried out to determine the impact of patient and tumor factors on survival, and to develop a simple rish group staging system to predict survival in patients with differentiated thyroid carcinomas. Four hundred and seventeen (417) patients undergoing primary treatment at our hospital between 197–1985, were entered to the study. There were 198 follicular carcinomas and 219 papillary carcinomas. Impact of patient and tumor variables were studied by drawing Kaplan Meier curves and comparing them by the Chi Sq Test. Age<=40 years (p=0.00001), tumor size <5cms (p=0.01), extrrathyroidal spread (p=0.001) and distant metastasis (p=0.00001) had significant impact on survival. These finding were true for a subset analysis follicular and papillary carcinomas separately. A Cox Regression Analysis was also performed and this showed the above factors to impact significantly on survival. Basing on the regression analysis we devised a simple risk group system and classified the patients as high and low risk. Low risk group patients had a significant survival advantage. Our findings show that the incidence of follicular carcinoma is significantly high in india (48%) and that 65% of our patients are in the high risk group. Incidence of contralateral lobe disease on completion thyroidectomy is as high as 53%. Hence, a more aggressive treatment policy is warranted and total thyroidectomy is the appropriate treatment of choice in our patients.

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Sumati S. Shrikhande

Papers

Prognostic factors in follicular carcinoma of the thyroid: a study of 198 cases.

Primary intra-alveolar squamous-cell carcinoma of the mandible: Report of a case

Completion thyroidectomy for thyroid carcinoma

Muco-epidermoid Carcinoma of the Penis

Prognosticators of survival in differentiated thyroid carcinoma.