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Thyroid_Cancer

Thyroid surgery in children in a single institution from Osama Ibrahim Almosallama Ali Aseerib Ahmed Alhumaida Ali S AlZahranic Saif Alsobhib Saud AlShanafeybFrom the aDepartment of Surgery College of Medicine Qassim University Buraidah Al Qassim Saudi Arabia bDepartment of Surgery King Faisal Specialist Hospital and Research Center Riyadh Saudi Arabia cDepartment of Medicine King Faisal Specialist Hospital and Research Center Riyadh Saudi Arabia Correspondence Dr Osama Ibrahim Almosallam Department of Surgery College of Medicine Qassim University PO Box Buraidah Al Qassim Saudi Arabia osama_iaahotmailcom ORCID orcid0000000290367564 Citation Almosallam OI Aseeri A Alhumaid A AlZahrani AS Alsobhi S AlShanafey S Thyroid surgery in children in a single institution from Ann Saudi Med Received January Accepted May Published August Copyright Copyright Annals of Saudi Medicine Saudi Arabia This is an access under the Creative Commons AttributionNonCommercialNoDerivatives International License CC BYNCND The details of which can be accessed at httpcreativecommons licensesbyncnd40Funding NoneBACKGROUND Data on thyroid surgery in children are scarceOBJECTIVE Analyze outcome data on thyroid surgery in a pediatric populationDESIGN Medical record reviewSETTING Tertiary health care institutionPATIENTS AND METHODS We collected demographic and clinical data on patients years or younger who had thyroid surgery in the period to Descriptive data are presentedMAIN OUTCOME MEASURES Indications for thyroidectomy thyroid pathology complications length of stay and radioactive iodine treatment and recurrencesSAMPLE SIZE RESULTS Of patients who underwent thyroidectomy procedures were females and the mean age at operation was years and were associated with multiple endocrine neoplasia type There was no history of radiation exposure Eightyone patients had fine needle aspiration FNA which correlated with the final histopathology in of cases Sixtysix patients had malignant cancer papillary of patients who had neck dissection had lymph node metastasis and had distant metastases to the lung Procedures included total thyroidectomy hemithyroidectomy completion and subtotal thyroidectomy Twentythree patients developed hypocalcemia permanent and had unilateral recurrent laryngeal nerve injury permanent Patients were followed up for a mean duration of months median months Of patients with thyroid cancer received radioactive iodine and had recurrence Malignancy is the commonest indication for thyroid surgery in children and FNA is highly diagnostic Hypocalcemia and recurrent laryngeal nerve injury are significant complications The recurrence rate in thyroid cancer is LIMITATIONS RetrospectiveCONFLICT OF INTEREST Noneoriginal ANN SAUDI MED JULYAUGUST WWWANNSAUDIMEDNET 0cThyroid diseases requiring surgery are relatively uncommon in children compared to adults The prevalence of palpable thyroid nodules in children ranges from to Sporadic welldifferentiated thyroid cancer is the most common endocrine malignancy in children accounting for of pediatric cancers in the prepubertal age group and up to of cancers in adolescents aged “ year2 The most common indication for thyroid surgery in children varies among published studies but thyroidectomy for malignant conditions is rising38 Data in children throughout the world are relatively scarce The objective of this study was to analyze the clinical data and outcome of thyroid surgery in a large series of children treated at a single center at King Faisal Specialist Hospital and Research Center KFSHRC in RiyadhPATIENT AND METHODS With the approval of the Institutional Review Board IRB at KFSHRC the medical records of all patients years old and younger who underwent a thyroid surgery between and were retrospectively reviewed We elected to include patients up to the year to ensure a reasonable followup period Patients for the study were identified by a search of the operating room log for all procedures involving the thyroid gland for the specified age groupDemographic data clinical features and surgical outcomes were collected Specific data that were obtained included age at operation gender family history presenting symptoms history of radiation exposure presence of multiple endocrine neoplasia type MEN thyroid function test presence and size of thyroid nodules by ultrasound presence of lymph nodes metastasis or distant metastasis fine needle aspiration FNA cytology surgical procedure final histopathology and length of followup Outcomes analyzed were postoperative complications including transient or permanent hypocalcemia transient or permanent recurrent laryngeal nerve paralysis wound infection and hematoma length of stay and radioactive iodine treatment and recurrences Thyroid procedures in this series included hemithyroidectomy subtotal total and completion thyroidectomy Surgeries were performed by either an endocrine adult surgeon or a pediatric surgeon No intraoperative nerve monitoring was used Early in the series procedures were performed by adult endocrine surgeons but lately a combined approach was adopted where pediatric surgeons and adult endocrine surgeons collaborated in such cases proceduresthe normal range in our laboratory regardless of symptoms Transient hypocalcemia was identified if it lasted for less than months while permanent hypocalcemia was considered if the serum calcium level remained below normal range and the patient continued on calcium supplementation after months of the surgery All patients with a family history of MEN underwent genetic testing of the RET protooncogene to confirm the diagnosis All patients who underwent completion thyroidectomy had a preoperative and postoperative vocal cords assessment at the Otolaryngology clinic Descriptive data were generated and comparisons were conducted using the t test for continuous data and the chisquare or Fisher exact tests for proportionsRESULTSBetween and patients underwent surgical procedures patients underwent two procedures for thyroid disease at our institution Eighty patients were females The mean age at operation was years median years range years The most common indication for thyroidectomy was thyroid nodule which was present in of cases Table The mean SD size of thyroid nodules was mm There were cases associated with MEN syndromes The final pathology in two patients with MEN syndrome showed medullary thyroid cancer MTC while the remaining patients had prophylactic procedures before development of MTC None of the patients had a history of radiation exposure Eightyone patients FNA which correlated with the final histopathology in of cases There were three cases of toxic adenoma and one case of Graves™ disease which did not require FNA The remaining cases underwent FNA at another institution and FNA was not repeated at our institution or they came for completion thyroidectomy with documented pathology for malignancy after they had their first surgery in another hospitalThe most common diagnoses included papillary thyroid cancer and multinodular goiter or colloid Table Indications for thyroidectomy in patients IndicationNodulen MEN prophylaxisHyperthyroidismMultinodular goiterCompletion thyroidectomy Hypocalcemia was defined by calcium levels below Data are number original PEDIATRIC THYROID SURGERYANN SAUDI MED JULYAUGUST WWWANNSAUDIMEDNET 0cnodule Table Surgical procedures included total thyroidectomy hemithyroidectomy completion thyroidectomy and subtotal thyroidectomy Neck dissection was performed in patients Operative complications were observed in patients The most common complication was hypocalcemia transient permanent and Table Thyroid pathology in the patientsPathologyn BenignNormal thyroid tissueColloid noduleCystAdenomaThyroiditisGraves™ diseaseThyroid cancerPapillaryFollicularMedullaryHurthleAnaplasticTotalData are number Table Benign and malignant lesions in patientsBenignn37Malignantn66 P value Age meanyearsGender malefemalePresence of noduleHypocalcemiaRecurrent laryngeal nerve palsyBleedinghematomaWound infectionTracheal injuryOverall complicationsMean length of stay daysMEN recurrent laryngeal nerve palsy transient permanent all were unilateral Table Of patients with malignant lesions had lymph node metastasis and patients had distant metastases to the lung None of the patients developed postoperative bleeding wound infection or tracheal injury Patients were followed up for a mean of months median range months radioactive iodine treatment was delivered to patients with malignant lesions patients had recurrences were local recurrences and were local and distant recurrences to the lung Three cases received radioactive iodine RAI before and after recurrence One case was low risk before recurrence so did not receive RAI until after recurrence One case had medullary thyroid cancer so did not receive RAI In the remaining five cases there was no clear data whether those patients received RAI before or only after a recurrence All local recurrences underwent resection except for one patient who was lost follow up There was no mortality in this study DISCUSSIONThe most common indication for thyroidectomy in this series was thyroid nodule which correlates with previously published reports in the pediatric population35 Children with thyroid nodules have an estimated fourfold higher risk of developing thyroid cancer compared to adults910 The high incidence of malignancy in this series suggests children with a thyroid nodule should be carefully evaluatedFNA is a valuablemethod for preoperative evaluation of thyroid nodules However there are limitations on the routine use of FNA in children including the need for sedation sampling errors and the limited availability of experienced cytopathologists11 Many previous studies reported high sensitivity and specificity of FNA in evaluating thyroid nodule in children1114 which correlate with our findingsOur data showed lymph node metastasis in of thyroid cancer cases which supports the notion that children with thyroid cancer frequently present with more extensive disease than adults Lymphnode involvement at diagnosis is seen in to of children compared with to of adults with differentiated thyroid cancer1523 Because our hospital is the largest referral center in Saudi Arabia especially for oncology cases this may explain the large number of lymph node and distant metastasis In this cohortThe most common complication reported after thyroidectomy in children is hypoparathyroidism with an incidence ranging between to which original PEDIATRIC THYROID SURGERYANN SAUDI MED JULYAUGUST WWWANNSAUDIMEDNET 0ccorresponds with our results of which are reported as hypocalcemia in Table One study found that total thyroidectomy central and bilateral neck dissection Graves™ disease and malignancy were risk factors for hypocalcemia after thyroid surgery3 In this cohort postoperative hypocalcemia was noted more in malignant cases but it failed to reach statistical significance Moreover there was no significant difference between benign and malignant cases in terms of mean age gender distribution recurrent laryngeal nerve injury or overall complications a finding that was reported previously26 Multiple studies in recent years have found an inverse relationship between surgeon volume and complication rates2728 but similar data in the pediatric population is lacking One study found that highvolume endocrine surgeons have better outcomes and shorter lengths of stay and lower costs after thyroidectomy and parathyroidectomy in children compared to pediatric surgeons general surgeons or otolaryngologists29 Scheumann and colleagues also concluded that a collaborative approach between pediatric and endocrine surgeons would have better outcomes This has led other authors to suggest that a combined approach with endocrine and pediatric surgeons in addition to pediatric endocrinologists may optimize the care of children with surgical thyroid disease given the low number of pediatric patients4 Our data do not allow for comparisons of different approaches given the late adoption of the combined approach The recurrence rate for thyroid cancer in children after thyroidectomy has varied widely in reported studies ranging from to while it was in this cohort Only a few studies explored the predictors of recurrence Lymph node involvement multiple nodules male gender younger age histologic subtype and advanced tumor stage were risk factors associated with recurrence17233033 In this study of patients with malignant lesions received RAI Although there are conflicting data regarding the indications of postoperative RAI treatment in lowrisk patients the current recommendation is that lowrisk patients can be treated without RAI3436There are some limitations to this study The retrospective nature may affect the validity and quality of the data The small number of cases in some categories did not enable us to compare groups and explore predictors relative to these factors On the other hand this study adds to the scarce data on thyroid surgery in pediatric age group Malignancy is the commonest indication for thyroid surgery in children and FNA is highly diagnostic Hypocalcemia and recurrent laryngeal nerve injury are significant complications Cancerrelated death is extremely rare but recurrence is not uncommon and a significant number of patients with malignant cases received RAI treatmentoriginal PEDIATRIC THYROID SURGERYANN SAUDI MED JULYAUGUST WWWANNSAUDIMEDNET 0cREFERENCES Trowbridge FL Matovinovic J McLaren GD Nichaman MZ Iodine and goiter in children Pediatrics Ries LAG Melbert D Krapcho M Stinchcomb DG Howlader N Horner MJ et al SEER Cancer Statistics Review “ Bethesda National Cancer Institute Based on November SEER data submission Chen Y[h] Masiakos PT Gaz RD Hodin RA Parangi S Randolph GW et al Pediatric thyroidectomy in a high volume thyroid surgery center Risk factors for postoperative hypocalcemia J Pediatr Surg Aug5081316 Wood JH Partrick DA Barham HP Bensard DD Travers HS Bruny JL et al Pediatric thyroidectomy a collaborative surgical approach J Pediatr Surg May4658238 Scholz S Smith JR Chaignaud B Shamberger RC Huang SA Thyroid surgery at Children™s Hospital Boston a 35year singleinstitution experience J Pediatr Surg Mar46343742 Josefson J Zimmerman D Thyroid nodules and cancers in children Pediatr Endocrinol Rev Sep611423 Hameed R Zacharin MR Changing face of paediatric and adolescent thyroid cancer J Paediatr Child Health LugoVicente H Ortiz VN Irizarry H Camps JI Pagán V Pediatric thyroid nodules management in the era of fine needle aspirationJ Pediatr Surg Mussa A De Andrea M Motta M Mormile A Palestini N Corrias A Predictors of Malignancy in Children with Thyroid Nodules J Pediatr Oct167488692 Amirazodi E Propst EJ Chung CT Parra DA Wasserman JD Pediatric thyroid FNA biopsy Outcomes and impact on management over years at a tertiary care center Cancer Cytopathol Partyka KL Huang EC2 Cramer HM Chen S Wu HH Histologic and clinical followup of thyroid fineneedle aspirates in pediatric patients Cancer Cytopathol Sinha CK Decoppi P Pierro A Brain C Hindmarsh P Butler G et al Thyroid Surgery in Children Clinical Outcomes Eur J Pediatr Surg Oct2554259 Kundel A Thompson GB Richards ML Qiu LX Cai Y Schwenk FW et al Pediatric Endocrine Surgery A 20Year Experience at the Mayo Clinic J Clin Endocrinol Metab February “ Jiang W Newbury RO Newfield RS Pediatric thyroid surgery and management of thyroid nodulesan institutional experience features and over a 10year period Int J Pediatr Endocrinol Burke JF Sippel RS Chen H Evolution of Pediatric Thyroid Surgery at a Tertiary Medical Center Surg Res “ AlQahtani KH Tunio MA Al Asiri M Aljohani NJ Bayoumi Y Riaz K et al Clinicopathological treatment outcomes of differentiated thyroid cancer in Saudi children and adults J Otolaryngol Head Neck Surg Nov Kluijfhout WP van Beek DJ Verrijn Stuart AA Lodewijk L Valk GD Van der Zee DC et al Postoperative Complications After Prophylactic Thyroidectomy for Very Young Patients With Multiple Endocrine Neoplasia Type Medicine Baltimore 20159429e1108 Raval MV Browne M Chin AC Zimmerman D Angelos P Reynolds M Total thyroidectomy for benign disease in the pediatric patient”feasible and safe J Pediatr Surg Stavrakis AI Ituarte PH Ko CY Yeh MW Surgeon volume as a predictor of outcomes in inpatient and outpatient endocrine surgery Surgery “ Sosa JA Bowman HM Tielsch JM Powe NR Gordon TA Udelsman R The importance of surgeon experience for clinical and economic outcomes from thyroidectomy Ann Surg “ Tuggle CT Roman SA Wang TS Boudourakis L Thomas D Udelsman R et al Pediatric endocrine surgery Who is operating on our children Surgery Dec144686977 Park S Jeong JS Ryu HR Lee C Park JH Kang S et al Differentiated Thyroid Carcinoma of Children and Adolescents27Year Experience in the Yonsei University Health System J Korean Med Sci Palmer BA Zarroug AE Poley RN Kollars JP Moir CR Papillary thyroid carcinoma in children risk factors and complications of disease recurrence J Pediatr Surg Wada N Sugino K Mimura T Nagahama M Kitagawa W Shibuya H et al Pediatric differentiated thyroid carcinoma in stage I risk factor analysis for disease free survival BMC Cancer D Danese Gardini A Farsetti A Sciacchitano S Andreoli M Pontecorvi A Thyroid carcinoma in children and adolescents Eur J Pediatr Astl J Chovanec M Lukes P Katra R Dvorakova M Vlcek P et al Thyroid carcinoma surgery in children and adolescents “ years experience surgery of pediatric thyroid lymph node metastases carcinoma Int J Pediatr Otorhinolaryngol Chaukar DA Rangarajan V Nair N Nadkarni MS Pai PS Dcruz AK et al Pediatric thyroid cancer J Surg Oncol Dzodic R Buta M Markovic I Gavrilo D Matovic M Milovanovic Z et al Surgical management of welldifferentiated thyroid carcinoma in children and adolescents years of experience of a single institution in Serbia Endocr J Scheumann GF Gimm O Wegener G Hundeshagen H Dralle H Prognostic significance and surgical management of locoregional in papillary thyroid cancer World J Surg Shi RL Qu N Yang SW Tumor size interpretation for predicting cervical lymph node metastasis using a differentiated thyroid cancer risk model Onco Targets Ther “ Zimmerman D Hay ID Gough IR Goellner JR Ryan JJ Grant CS et al Papillary thyroid carcinoma in children and adults longterm followup of patients conservatively treated at one institution during three decades Surgery Collini P Mattavelli F Pellegrinelli A Barisella M Ferrari A Massimino M Papillary carcinoma of the thyroid gland of childhood and adolescence Morphologic subtypes biologic behavior and prognosis a clinicopathologic study of sporadic cases treated at a single institution during a 30year period Am J Surg Pathol BorsonChazot Causeret S Lifante JC Augros M Berger N Peix JL Predictive factors for recurrence from a series of children and adolescents with differentiated thyroid cancer World J Surg Baumgarten HD Bauer AJ Isaza A MostoufiMoab S Kazahaya K Adzick NS Surgical management of pediatric thyroid disease Complication rates after thyroidectomy at the Children™s Hospital of Philadelphia highvolume Pediatric Thyroid Center Journal of pediatric surgery Oct Kurzawinski TR De Coppi P Thyroidectomy in Children InPediatric Surgery pp Springer Berlin Heidelberg Francis G Waguespack SG Bauer AJ Angelog P Benvenga S et al Management Guidelines for Children with Thyroid Nodules and Differentiated Thyroid Cancer The American Thyroid Association Guidelines Task Force on Pediatric Thyroid Cancer THYROID Volume Number original PEDIATRIC THYROID SURGERYANN SAUDI MED JULYAUGUST WWWANNSAUDIMEDNET 0c'

cancer0

You are a medical assistant specializing in cancer diagnosis. Based on the given information, you must classify the cancer type as one of the following three options: 'Thyroid_Cancer', 'Colon_Cancer', or 'Lung_Cancer'. Please choose the most appropriate category based on the provided text. Do not include any other cancer types or responses outside of these three categories. Text: Thyroid surgery in children in a single institution from Osama Ibrahim Almosallama Ali Aseerib Ahmed Alhumaida Ali S AlZahranic Saif Alsobhib Saud AlShanafeybFrom the aDepartment of Surgery College of Medicine Qassim University Buraidah Al Qassim Saudi Arabia bDepartment of Surgery King Faisal Specialist Hospital and Research Center Riyadh Saudi Arabia cDepartment of Medicine King Faisal Specialist Hospital and Research Center Riyadh Saudi Arabia Correspondence Dr Osama Ibrahim Almosallam Department of Surgery College of Medicine Qassim University PO Box Buraidah Al Qassim Saudi Arabia osama_iaahotmailcom ORCID orcid0000000290367564 Citation Almosallam OI Aseeri A Alhumaid A AlZahrani AS Alsobhi S AlShanafey S Thyroid surgery in children in a single institution from Ann Saudi Med Received January Accepted May Published August Copyright Copyright Annals of Saudi Medicine Saudi Arabia This is an access under the Creative Commons AttributionNonCommercialNoDerivatives International License CC BYNCND The details of which can be accessed at httpcreativecommons licensesbyncnd40Funding NoneBACKGROUND Data on thyroid surgery in children are scarceOBJECTIVE Analyze outcome data on thyroid surgery in a pediatric populationDESIGN Medical record reviewSETTING Tertiary health care institutionPATIENTS AND METHODS We collected demographic and clinical data on patients years or younger who had thyroid surgery in the period to Descriptive data are presentedMAIN OUTCOME MEASURES Indications for thyroidectomy thyroid pathology complications length of stay and radioactive iodine treatment and recurrencesSAMPLE SIZE RESULTS Of patients who underwent thyroidectomy procedures were females and the mean age at operation was years and were associated with multiple endocrine neoplasia type There was no history of radiation exposure Eightyone patients had fine needle aspiration FNA which correlated with the final histopathology in of cases Sixtysix patients had malignant cancer papillary of patients who had neck dissection had lymph node metastasis and had distant metastases to the lung Procedures included total thyroidectomy hemithyroidectomy completion and subtotal thyroidectomy Twentythree patients developed hypocalcemia permanent and had unilateral recurrent laryngeal nerve injury permanent Patients were followed up for a mean duration of months median months Of patients with thyroid cancer received radioactive iodine and had recurrence Malignancy is the commonest indication for thyroid surgery in children and FNA is highly diagnostic Hypocalcemia and recurrent laryngeal nerve injury are significant complications The recurrence rate in thyroid cancer is LIMITATIONS RetrospectiveCONFLICT OF INTEREST Noneoriginal ANN SAUDI MED JULYAUGUST WWWANNSAUDIMEDNET 0cThyroid diseases requiring surgery are relatively uncommon in children compared to adults The prevalence of palpable thyroid nodules in children ranges from to Sporadic welldifferentiated thyroid cancer is the most common endocrine malignancy in children accounting for of pediatric cancers in the prepubertal age group and up to of cancers in adolescents aged “ year2 The most common indication for thyroid surgery in children varies among published studies but thyroidectomy for malignant conditions is rising38 Data in children throughout the world are relatively scarce The objective of this study was to analyze the clinical data and outcome of thyroid surgery in a large series of children treated at a single center at King Faisal Specialist Hospital and Research Center KFSHRC in RiyadhPATIENT AND METHODS With the approval of the Institutional Review Board IRB at KFSHRC the medical records of all patients years old and younger who underwent a thyroid surgery between and were retrospectively reviewed We elected to include patients up to the year to ensure a reasonable followup period Patients for the study were identified by a search of the operating room log for all procedures involving the thyroid gland for the specified age groupDemographic data clinical features and surgical outcomes were collected Specific data that were obtained included age at operation gender family history presenting symptoms history of radiation exposure presence of multiple endocrine neoplasia type MEN thyroid function test presence and size of thyroid nodules by ultrasound presence of lymph nodes metastasis or distant metastasis fine needle aspiration FNA cytology surgical procedure final histopathology and length of followup Outcomes analyzed were postoperative complications including transient or permanent hypocalcemia transient or permanent recurrent laryngeal nerve paralysis wound infection and hematoma length of stay and radioactive iodine treatment and recurrences Thyroid procedures in this series included hemithyroidectomy subtotal total and completion thyroidectomy Surgeries were performed by either an endocrine adult surgeon or a pediatric surgeon No intraoperative nerve monitoring was used Early in the series procedures were performed by adult endocrine surgeons but lately a combined approach was adopted where pediatric surgeons and adult endocrine surgeons collaborated in such cases proceduresthe normal range in our laboratory regardless of symptoms Transient hypocalcemia was identified if it lasted for less than months while permanent hypocalcemia was considered if the serum calcium level remained below normal range and the patient continued on calcium supplementation after months of the surgery All patients with a family history of MEN underwent genetic testing of the RET protooncogene to confirm the diagnosis All patients who underwent completion thyroidectomy had a preoperative and postoperative vocal cords assessment at the Otolaryngology clinic Descriptive data were generated and comparisons were conducted using the t test for continuous data and the chisquare or Fisher exact tests for proportionsRESULTSBetween and patients underwent surgical procedures patients underwent two procedures for thyroid disease at our institution Eighty patients were females The mean age at operation was years median years range years The most common indication for thyroidectomy was thyroid nodule which was present in of cases Table The mean SD size of thyroid nodules was mm There were cases associated with MEN syndromes The final pathology in two patients with MEN syndrome showed medullary thyroid cancer MTC while the remaining patients had prophylactic procedures before development of MTC None of the patients had a history of radiation exposure Eightyone patients FNA which correlated with the final histopathology in of cases There were three cases of toxic adenoma and one case of Graves™ disease which did not require FNA The remaining cases underwent FNA at another institution and FNA was not repeated at our institution or they came for completion thyroidectomy with documented pathology for malignancy after they had their first surgery in another hospitalThe most common diagnoses included papillary thyroid cancer and multinodular goiter or colloid Table Indications for thyroidectomy in patients IndicationNodulen MEN prophylaxisHyperthyroidismMultinodular goiterCompletion thyroidectomy Hypocalcemia was defined by calcium levels below Data are number original PEDIATRIC THYROID SURGERYANN SAUDI MED JULYAUGUST WWWANNSAUDIMEDNET 0cnodule Table Surgical procedures included total thyroidectomy hemithyroidectomy completion thyroidectomy and subtotal thyroidectomy Neck dissection was performed in patients Operative complications were observed in patients The most common complication was hypocalcemia transient permanent and Table Thyroid pathology in the patientsPathologyn BenignNormal thyroid tissueColloid noduleCystAdenomaThyroiditisGraves™ diseaseThyroid cancerPapillaryFollicularMedullaryHurthleAnaplasticTotalData are number Table Benign and malignant lesions in patientsBenignn37Malignantn66 P value Age meanyearsGender malefemalePresence of noduleHypocalcemiaRecurrent laryngeal nerve palsyBleedinghematomaWound infectionTracheal injuryOverall complicationsMean length of stay daysMEN recurrent laryngeal nerve palsy transient permanent all were unilateral Table Of patients with malignant lesions had lymph node metastasis and patients had distant metastases to the lung None of the patients developed postoperative bleeding wound infection or tracheal injury Patients were followed up for a mean of months median range months radioactive iodine treatment was delivered to patients with malignant lesions patients had recurrences were local recurrences and were local and distant recurrences to the lung Three cases received radioactive iodine RAI before and after recurrence One case was low risk before recurrence so did not receive RAI until after recurrence One case had medullary thyroid cancer so did not receive RAI In the remaining five cases there was no clear data whether those patients received RAI before or only after a recurrence All local recurrences underwent resection except for one patient who was lost follow up There was no mortality in this study DISCUSSIONThe most common indication for thyroidectomy in this series was thyroid nodule which correlates with previously published reports in the pediatric population35 Children with thyroid nodules have an estimated fourfold higher risk of developing thyroid cancer compared to adults910 The high incidence of malignancy in this series suggests children with a thyroid nodule should be carefully evaluatedFNA is a valuablemethod for preoperative evaluation of thyroid nodules However there are limitations on the routine use of FNA in children including the need for sedation sampling errors and the limited availability of experienced cytopathologists11 Many previous studies reported high sensitivity and specificity of FNA in evaluating thyroid nodule in children1114 which correlate with our findingsOur data showed lymph node metastasis in of thyroid cancer cases which supports the notion that children with thyroid cancer frequently present with more extensive disease than adults Lymphnode involvement at diagnosis is seen in to of children compared with to of adults with differentiated thyroid cancer1523 Because our hospital is the largest referral center in Saudi Arabia especially for oncology cases this may explain the large number of lymph node and distant metastasis In this cohortThe most common complication reported after thyroidectomy in children is hypoparathyroidism with an incidence ranging between to which original PEDIATRIC THYROID SURGERYANN SAUDI MED JULYAUGUST WWWANNSAUDIMEDNET 0ccorresponds with our results of which are reported as hypocalcemia in Table One study found that total thyroidectomy central and bilateral neck dissection Graves™ disease and malignancy were risk factors for hypocalcemia after thyroid surgery3 In this cohort postoperative hypocalcemia was noted more in malignant cases but it failed to reach statistical significance Moreover there was no significant difference between benign and malignant cases in terms of mean age gender distribution recurrent laryngeal nerve injury or overall complications a finding that was reported previously26 Multiple studies in recent years have found an inverse relationship between surgeon volume and complication rates2728 but similar data in the pediatric population is lacking One study found that highvolume endocrine surgeons have better outcomes and shorter lengths of stay and lower costs after thyroidectomy and parathyroidectomy in children compared to pediatric surgeons general surgeons or otolaryngologists29 Scheumann and colleagues also concluded that a collaborative approach between pediatric and endocrine surgeons would have better outcomes This has led other authors to suggest that a combined approach with endocrine and pediatric surgeons in addition to pediatric endocrinologists may optimize the care of children with surgical thyroid disease given the low number of pediatric patients4 Our data do not allow for comparisons of different approaches given the late adoption of the combined approach The recurrence rate for thyroid cancer in children after thyroidectomy has varied widely in reported studies ranging from to while it was in this cohort Only a few studies explored the predictors of recurrence Lymph node involvement multiple nodules male gender younger age histologic subtype and advanced tumor stage were risk factors associated with recurrence17233033 In this study of patients with malignant lesions received RAI Although there are conflicting data regarding the indications of postoperative RAI treatment in lowrisk patients the current recommendation is that lowrisk patients can be treated without RAI3436There are some limitations to this study The retrospective nature may affect the validity and quality of the data The small number of cases in some categories did not enable us to compare groups and explore predictors relative to these factors On the other hand this study adds to the scarce data on thyroid surgery in pediatric age group Malignancy is the commonest indication for thyroid surgery in children and FNA is highly diagnostic Hypocalcemia and recurrent laryngeal nerve injury are significant complications Cancerrelated death is extremely rare but recurrence is not uncommon and a significant number of patients with malignant cases received RAI treatmentoriginal PEDIATRIC THYROID SURGERYANN SAUDI MED JULYAUGUST WWWANNSAUDIMEDNET 0cREFERENCES Trowbridge FL Matovinovic J McLaren GD Nichaman MZ Iodine and goiter in children Pediatrics Ries LAG Melbert D Krapcho M Stinchcomb DG Howlader N Horner MJ et al SEER Cancer Statistics Review “ Bethesda National Cancer Institute Based on November SEER data submission Chen Y[h] Masiakos PT Gaz RD Hodin RA Parangi S Randolph GW et al Pediatric thyroidectomy in a high volume thyroid surgery center Risk factors for postoperative hypocalcemia J Pediatr Surg Aug5081316 Wood JH Partrick DA Barham HP Bensard DD Travers HS Bruny JL et al Pediatric thyroidectomy a collaborative surgical approach J Pediatr Surg May4658238 Scholz S Smith JR Chaignaud B Shamberger RC Huang SA Thyroid surgery at Children™s Hospital Boston a 35year singleinstitution experience J Pediatr Surg Mar46343742 Josefson J Zimmerman D Thyroid nodules and cancers in children Pediatr Endocrinol Rev Sep611423 Hameed R Zacharin MR Changing face of paediatric and adolescent thyroid cancer J Paediatr Child Health LugoVicente H Ortiz VN Irizarry H Camps JI Pagán V Pediatric thyroid nodules management in the era of fine needle aspirationJ Pediatr Surg Mussa A De Andrea M Motta M Mormile A Palestini N Corrias A Predictors of Malignancy in Children with Thyroid Nodules J Pediatr Oct167488692 Amirazodi E Propst EJ Chung CT Parra DA Wasserman JD Pediatric thyroid FNA biopsy Outcomes and impact on management over years at a tertiary care center Cancer Cytopathol Partyka KL Huang EC2 Cramer HM Chen S Wu HH Histologic and clinical followup of thyroid fineneedle aspirates in pediatric patients Cancer Cytopathol Sinha CK Decoppi P Pierro A Brain C Hindmarsh P Butler G et al Thyroid Surgery in Children Clinical Outcomes Eur J Pediatr Surg Oct2554259 Kundel A Thompson GB Richards ML Qiu LX Cai Y Schwenk FW et al Pediatric Endocrine Surgery A 20Year Experience at the Mayo Clinic J Clin Endocrinol Metab February “ Jiang W Newbury RO Newfield RS Pediatric thyroid surgery and management of thyroid nodulesan institutional experience features and over a 10year period Int J Pediatr Endocrinol Burke JF Sippel RS Chen H Evolution of Pediatric Thyroid Surgery at a Tertiary Medical Center Surg Res “ AlQahtani KH Tunio MA Al Asiri M Aljohani NJ Bayoumi Y Riaz K et al Clinicopathological treatment outcomes of differentiated thyroid cancer in Saudi children and adults J Otolaryngol Head Neck Surg Nov Kluijfhout WP van Beek DJ Verrijn Stuart AA Lodewijk L Valk GD Van der Zee DC et al Postoperative Complications After Prophylactic Thyroidectomy for Very Young Patients With Multiple Endocrine Neoplasia Type Medicine Baltimore 20159429e1108 Raval MV Browne M Chin AC Zimmerman D Angelos P Reynolds M Total thyroidectomy for benign disease in the pediatric patient”feasible and safe J Pediatr Surg Stavrakis AI Ituarte PH Ko CY Yeh MW Surgeon volume as a predictor of outcomes in inpatient and outpatient endocrine surgery Surgery “ Sosa JA Bowman HM Tielsch JM Powe NR Gordon TA Udelsman R The importance of surgeon experience for clinical and economic outcomes from thyroidectomy Ann Surg “ Tuggle CT Roman SA Wang TS Boudourakis L Thomas D Udelsman R et al Pediatric endocrine surgery Who is operating on our children Surgery Dec144686977 Park S Jeong JS Ryu HR Lee C Park JH Kang S et al Differentiated Thyroid Carcinoma of Children and Adolescents27Year Experience in the Yonsei University Health System J Korean Med Sci Palmer BA Zarroug AE Poley RN Kollars JP Moir CR Papillary thyroid carcinoma in children risk factors and complications of disease recurrence J Pediatr Surg Wada N Sugino K Mimura T Nagahama M Kitagawa W Shibuya H et al Pediatric differentiated thyroid carcinoma in stage I risk factor analysis for disease free survival BMC Cancer D Danese Gardini A Farsetti A Sciacchitano S Andreoli M Pontecorvi A Thyroid carcinoma in children and adolescents Eur J Pediatr Astl J Chovanec M Lukes P Katra R Dvorakova M Vlcek P et al Thyroid carcinoma surgery in children and adolescents “ years experience surgery of pediatric thyroid lymph node metastases carcinoma Int J Pediatr Otorhinolaryngol Chaukar DA Rangarajan V Nair N Nadkarni MS Pai PS Dcruz AK et al Pediatric thyroid cancer J Surg Oncol Dzodic R Buta M Markovic I Gavrilo D Matovic M Milovanovic Z et al Surgical management of welldifferentiated thyroid carcinoma in children and adolescents years of experience of a single institution in Serbia Endocr J Scheumann GF Gimm O Wegener G Hundeshagen H Dralle H Prognostic significance and surgical management of locoregional in papillary thyroid cancer World J Surg Shi RL Qu N Yang SW Tumor size interpretation for predicting cervical lymph node metastasis using a differentiated thyroid cancer risk model Onco Targets Ther “ Zimmerman D Hay ID Gough IR Goellner JR Ryan JJ Grant CS et al Papillary thyroid carcinoma in children and adults longterm followup of patients conservatively treated at one institution during three decades Surgery Collini P Mattavelli F Pellegrinelli A Barisella M Ferrari A Massimino M Papillary carcinoma of the thyroid gland of childhood and adolescence Morphologic subtypes biologic behavior and prognosis a clinicopathologic study of sporadic cases treated at a single institution during a 30year period Am J Surg Pathol BorsonChazot Causeret S Lifante JC Augros M Berger N Peix JL Predictive factors for recurrence from a series of children and adolescents with differentiated thyroid cancer World J Surg Baumgarten HD Bauer AJ Isaza A MostoufiMoab S Kazahaya K Adzick NS Surgical management of pediatric thyroid disease Complication rates after thyroidectomy at the Children™s Hospital of Philadelphia highvolume Pediatric Thyroid Center Journal of pediatric surgery Oct Kurzawinski TR De Coppi P Thyroidectomy in Children InPediatric Surgery pp Springer Berlin Heidelberg Francis G Waguespack SG Bauer AJ Angelog P Benvenga S et al Management Guidelines for Children with Thyroid Nodules and Differentiated Thyroid Cancer The American Thyroid Association Guidelines Task Force on Pediatric Thyroid Cancer THYROID Volume Number original PEDIATRIC THYROID SURGERYANN SAUDI MED JULYAUGUST WWWANNSAUDIMEDNET 0c' Answer:

Thyroid_Cancer

" The adopted strategy was the same as that used in prior years [] and is based on four exclusive queries that return four disjoint citation subsets The first query QPub_plain is based on a plaintext search in PubMed titles and s using keywords The second query QPub_indexed relies on the PubMed indexing scheme using MeSH terms and results are made exclusive of the previous set The third one QWoS_restricted is based on a plaintext search in WoS restricted to the two research areas œMedical Informatics and œHealth Care Sciences Services The fourth query QWoS_filtered is based on the same plaintext search used in WoS but filtered by nonrelevant research areas eg Archeology Dance Zoology etc and the two research areas of the previous query It is of note that the two WoS queries select only nonPubMedindexed papers that are supposed to be caught by the two PubMed queriesA first review of the four subsets of retrieved citations was performed by the two section editors to select candidate best papers Following the IMIA Yearbook protocol these candidate best papers were then individually reviewed and rated by both section editors the chief editor of the Decision Support section and external reviewers from the international Medical Informatics community Based on the reviewers™ ratings and comments the Yearbook editorial committee then selected the best papers of the year in the decision support domainIMIA Yearbook of Medical Informatics IMIA and Ge Thieme Verlag KG 0cReview Results The literature search has been performed on January A total of unique references were obtained distributed as follows for QPub_plain for QPub_indexed for QWoS_restricted and for QWoS_filtered yielding subtotals of references from PubMed and from WoS Compared to the previous year the global query retrieved more papers After a first individual screening independently performed by both section editors based on the title and of papers not rejected by both section editors were discussed by the two editors to achieve a final selection of candidate best papers After the external review of these s the editorial committee finally selected three of them as best papers for [“] Table They are discussed in the next section and summaries of their contents are available in the AppendixDiscussion and OutlookIn the first paper Hendriks [] propose an approach to the modeling of clinical practice guidelines which certainly builds on already existing approaches but which is systematically conducted in order to be scalable and used to represent complex guidelines They promote the formalism of clinical decision trees CDTs as they are both clinically interpretable by healthcare professionals and computerinterpretable thus suitable for implementation in datadriven CDSSs The disambiguation of textual guidelines is supported first by the formal unequivocal specification of data items used as decision criteria using international coding systems to enforce interoperability and second by the representation of guideline knowledge as CDTs The method is applied to the Dutch breast cancer guidelines Sixty CDTs were built involving a total of data items among which could not be linked to standard terminologies The authors report the ambiguity of certain criteria which could be subjective or had multiple definitions The resulting knowledge base was implemented in a decision support application where it can be interactively browsed or automatically executed By modeling guidelines in such a way this work is a step forward in the sharing of encoded knowledgeIn the second paper KamiÅ¡alić [] tackled the issues linked to the formalization of the medical processes used for managing chronic diseases and their execution in CDSSs They analyzed the decisionmaking dimensions of the therapeutic management of chronic diseases like those known to increase the cardiovascular risk and identified three basic levels therapy strategy dosage adaptation and intolerance management To handle these different aspects consistently they propose a formalism called extended Timed Transition Diagram eTTD With eTTDs they illustrate the multilevel and finegrained modeling required to capture the contents of arterial hypertension management guidelines This detailed demonstration on how procedural knowledge for hypertension management can be formalized to develop a CDSS could certainly be used in other medical domainsThe third paper by Khalifa [] presents a conceptual and practical framework to help assess confidence in predictive tools GRASP for Grade and Assess Predictive Tools is both a method to look for evidence from the published literature and an analysis grid It standardizes the assessment of the available literature associated to a predictive tool and the grading of its level of proof Three phases of evaluation are considered i before the implementation of the tool to assess both its internal and external validity ii during the implementation to assess its potential effect and usability and iii after the implementation to assess its effectiveness and safety In each phase the level of evidence can be assessed from the study design A qualitative summarizes the direction of evidence positive negative mixed This grid can be considered as similar to existing grids for instance the CONSORT statement for clinical trials However it gives a rigorous methodology for a critical appraisal of predictive tools and could be extended to all kind of CDSSs It might be a useful tool to extend the evidencebased culture in the field of medical informaticsBesides the three best papers selected for the Decision Support section of the edition of the IMIA Yearbook several other works retrieved from the literature review deserve to be cited Some of them deal with the personalization of decisions Laleci [] propose a scientific and technical approach to develop personalized care plans that comply with clinical practice guidelines for the management of complex polypathology situations Jafarpour [] propose a solution to dynamically manage the conflicts that can rise in this type of complex contexts Ben Souissi [] introduce the use of health information technology involving multiple criteria decision to support the choice between antibiotics alternatives Interestingly other works promote the creation and sharing of operational knowledge bases as exemplified by Hendriks [] Thus Huibers [] transform the textual STOPPSTART criteria into unambiguous definitions mapped to medical terminologies Canovas et al [] formalize EUCAST expert rules as an ontology and production rules to detect antimicrobial therapies at risk of failure M¼ller [] propose an diagnostic knowledge base that can compete with commercial ones Replacing humans is another topic of research and Spnig [] work on two aspects to virtualize a doctor the automatic acquisition of data through sensors and speech recognition and the automation of diagnostic reasoning Rozenblum et al[] propose a machine learning method to generate clinically valid alerts to detect errors in prescriptions Acceptability of CDSS is another key point Kannan [] propose a method for a CDSS design to best meet a precisely specified and assessable user purpose Design alerts may also avoid rejection of CDSSs by caregivers Fernandes [] created algorithms able to aggregate filter and reduce the notifications delivered to healthcare professionals Amrose et al [] tried to understand in real life the impact of alerts on users and to find the actions they triggered Finally it is always interesting to obtain varied evaluation results of controversial CDSSs In this respect Kim [] evaluated Watson for Oncology in thyroid carcinoma and reported a concordance rate with local practices considered as too low to adopt the tool As evidenced by the number and the variety of works around decision support research in the field is very active This year™s selection highlighted pragmatic works that promote the transparency and sharing of the IMIA Yearbook of Medical Informatics 2020Duclos 0cTable Best paper selection of s for the IMIA Yearbook of Medical Informatics in the section 'Decision Support' The s are listed in alphabetical order of the first author™s surname Section Decision Support\uf0a7 Hendriks MP Verbeek XAAM van Vegchel T van der Sangen MJC Strobbe LJA Merkus JWS Zonderland HM Smorenburg CH Jager A Siesling S Transformation of the National Breast Cancer Guideline Into DataDriven Clinical Decision Trees JCO Clin Cancer Inform \uf0a7\t KamiÅ¡alić\tA\tRia±o\tD\tKert\tS\tWelzer\tT\tNemec\tZlatolas\tL\tMultilevel\tmedical\tknowledge\tformalization\tto\tsupport\tmedical\tpractice for chronic diseases Data Knowledge Engineering “\uf0a7 Khalifa M Magrabi F Gallego B Developing a framework for evidencebased grading and assessment of predictive tools for clinical decision support BMC Med Inform Decis Mak knowledge bases used by decision support tools as well as the grading of their utility The ultimate goal is that users could trust such tools to then use themAcknowledgementWe would like to thank all the present and past editorial boards of the IMIA Yearbook especially Martina Hutter and Adrien Ugon for their support as well as the reviewers for their participation to the selection of the best papers for the Decision Support section We cannot end this synopsis without a meaningful thought for our colleague and friend Vassilis Koutkias who started this year again to tackle the tasks of a Decision Support section coeditor but passed away in last December and unfortunately could not finishReferences Jankovic I Chen JH Clinical Decision Support and Implications for the Clinician Burnout Crisis Yearb Med Inform Koutkias V Bouaud J Contributions on Clinical Decision Support from the Literature Yearb Med Inform Aug2811357 Hendriks MP Verbeek XAAM van Vegchel T van der Sangen MJC Strobbe LJA Merkus JWS Transformation of the National Breast Cancer Guideline Into DataDriven Clinical Decision Trees JCO Clin Cancer Inform KamiÅ¡alić A Ria±o D Kert S Welzer T Nemec Zlatolas L Multilevel medical knowledge formalization to support medical practice for chronic diseases Data Knowledge Engineering “ Khalifa M Magrabi F Gallego B Developing a framework for evidencebased grading and assessment of predictive tools for clinical decision support BMC Med Inform Decis Mak Laleci GB Yuksel M Sarigul B Arvanitis TN Lindman P Chen R A Collaborative Platform for Management of Chronic Diseases via GuidelineDriven Individualized Care Plans Comput Struct Biotechnol J “ Jafarpour B Raza Abidi S Van Woensel W Raza Abidi SS Executiontime integration of clinical practice guidelines to provide decision support for comorbid conditions Artif Intell Med Ben Souissi S Abed M El Hiki L Fortemps P Pirlot M PARS a system combining semantic technologies with multiple criteria decision aiding for supporting antibiotic prescriptions J Biomed Inform Huibers CJA Sallevelt BTGM de Groot DA Boer MJ van Campen JPCM Davids CJ Conversion of STOPPSTART version into coded algorithms for software implementation A multidisciplinary consensus procedure Int J Med Inform C¡novasSegura B Morales A Juarez JM Campos M Palacios F Impact of expert knowledge on the detection of patients at risk of antimicrobial therapy failure by clinical decision support systems J Biomed Inform M¼ller L Gangadharaiah R Klein SC Perry J Bernstein G Nurkse D An access medical knowledge base for community driven diagnostic decision support system development BMC Med Inform Decis Mak Spnig S EmbergerKlein A Sowa JP Canbay A Menrad K Heider D The virtual doctor An interactive clinicaldecisionsupport system based on deep learning for noninvasive prediction of diabetes Artif Intell Med Rozenblum R RodriguezMonguio R Volk LA Forsythe KJ Myers S McGurrin M Using a Machine Learning System to Identify and Prevent Medication Prescribing Errors A Clinical and Cost Analysis Evaluation Jt Comm J Qual Patient Saf Kannan V Basit MA Bajaj P Carrington AR Donahue IB Flahaven EL User stories as lightweight requirements for agile clinical decision support development J Am Med Inform Assoc Fernandes CO Miles S Lucena CJP Cowan D Artificial Intelligence Technologies for Coping with Alarm Fatigue in Hospital Environments Because of Sensory Overload Algorithm Development and Validation J Med Internet Res 20192111e15406 Amroze A Field TS Fouayzi H Sundaresan D Burns L Garber L et al Use of Electronic Health Record Access and Audit Logs to Identify Physician Actions Following Noninterruptive Alert ing Descriptive Study JMIR Med Inform 201971e12650 Kim M Kim BH Kim JM Kim EH Kim K Pak K Concordance in postsurgical radioactive iodine therapy recommendations between Watson for Oncology and clinical practice in patients with differentiated thyroid carcinoma Cancer Correspondence toPr Catherine DuclosLIMICS INSERM Facult© L©onard de Vinci rue Marcel Cachin Bobigny FranceEmail catherineduclosaphpfr IMIA Yearbook of Medical Informatics 2020Pragmatic Considerations on Clinical Decision Support from the Literature 0cAppendix Content Summaries of Best Papers for the Decision Support Section of the IMIA YearbookHendriks MP Verbeek XAAM van Vegchel T van der Sangen MJC Strobbe LJA Merkus JWS Zonderland HM Smorenburg CH Jager A Siesling STransformation of the National Breast Cancer Guideline into datadriven clinical decision treesJCO Clin Cancer Inform May3114Since clinical practice guidelines are still narrative and described in large textual documents the aim of this work was to model complex guidelines as datadriven clinical decision trees CDTs that could be still humaninterpretable while computerinterpretable for implementation in decision support systems The Dutch national breast cancer guidelines were translated into CDTs Data items which characterize the patient and the tumor and represent decisional criteria were encoded unambiguously using existing classifications and coding systems related to breast cancer when feasible In total CDTs were necessary to cover the whole guidelines driven by data items Of all data items could be coded using existing classification and coding systems All CDTs represented unique patient subpopulations Complex guidelines could be transformed as systematically constructed modular datadriven CDTs that are clinically interpretable and executable in a decision support applicationKamiÅ¡alić A Ria±o D Kert S Welzer T Nemec Zlatolas LMultilevel medical knowledge formalization to support medical practice for chronic diseasesData Knowledge Engineering “This research is focused on knowledge representation to support the medical processes involved in chronic diseases management which can be viewed as a procedural and sequential application of knowledge An intuitive easy and effective mechanism for medical knowledge formalization is proposed through a formalism called extended Timed Transition Diagram eTTD This formalism allows for the consistent representation of three basic levels of decision making that should be taken into account in the prescription and adaptation of longterm treatment therapy strategy dosage and intolerances The methodology can be manually applied to build eTTDs from clinical practice guidelines eTTDs implementation is demonstrated by modeling clinical practice guidelines for the therapeutic management of arterial hypertension The obtained models can be used as a baseline framework for the development of decision support systems involving medical proceduresKhalifa M Magrabi F Gallego BDeveloping a framework for evidencebased grading and assessment of predictive tools for clinical decision supportBMC Med Inform Decis Mak Oct Deciding to choose a clinical predictive tool in clinical practice should be guided by its correctly assessed effectiveness The objective of this work is to developp a conceptual and practical framework to Grade and Assess Predictive tools GRASP and provide clinicians with a standardised evidencebased system to support their search for and selection of efficient predictive tools The GRASP framework grades predictive tools based on published evidence across three dimensions phase of evaluation level of evidence and direction of evidence The final grade of the tool is based on the phase of evaluation that gets the hightest grade supported by the highest level of positive or mixed evidence that supports a positive This framework was successfully applied to five predictive tools GRASP report updates could be a way to maintain a data base that documents the evidence of predictive tools IMIA Yearbook of Medical Informatics 2020Duclos 0c"

cancer1

You are a medical assistant specializing in cancer diagnosis. Based on the given information, you must classify the cancer type as one of the following three options: 'Thyroid_Cancer', 'Colon_Cancer', or 'Lung_Cancer'. Please choose the most appropriate category based on the provided text. Do not include any other cancer types or responses outside of these three categories. Text: " The adopted strategy was the same as that used in prior years [] and is based on four exclusive queries that return four disjoint citation subsets The first query QPub_plain is based on a plaintext search in PubMed titles and s using keywords The second query QPub_indexed relies on the PubMed indexing scheme using MeSH terms and results are made exclusive of the previous set The third one QWoS_restricted is based on a plaintext search in WoS restricted to the two research areas œMedical Informatics and œHealth Care Sciences Services The fourth query QWoS_filtered is based on the same plaintext search used in WoS but filtered by nonrelevant research areas eg Archeology Dance Zoology etc and the two research areas of the previous query It is of note that the two WoS queries select only nonPubMedindexed papers that are supposed to be caught by the two PubMed queriesA first review of the four subsets of retrieved citations was performed by the two section editors to select candidate best papers Following the IMIA Yearbook protocol these candidate best papers were then individually reviewed and rated by both section editors the chief editor of the Decision Support section and external reviewers from the international Medical Informatics community Based on the reviewers™ ratings and comments the Yearbook editorial committee then selected the best papers of the year in the decision support domainIMIA Yearbook of Medical Informatics IMIA and Ge Thieme Verlag KG 0cReview Results The literature search has been performed on January A total of unique references were obtained distributed as follows for QPub_plain for QPub_indexed for QWoS_restricted and for QWoS_filtered yielding subtotals of references from PubMed and from WoS Compared to the previous year the global query retrieved more papers After a first individual screening independently performed by both section editors based on the title and of papers not rejected by both section editors were discussed by the two editors to achieve a final selection of candidate best papers After the external review of these s the editorial committee finally selected three of them as best papers for [“] Table They are discussed in the next section and summaries of their contents are available in the AppendixDiscussion and OutlookIn the first paper Hendriks [] propose an approach to the modeling of clinical practice guidelines which certainly builds on already existing approaches but which is systematically conducted in order to be scalable and used to represent complex guidelines They promote the formalism of clinical decision trees CDTs as they are both clinically interpretable by healthcare professionals and computerinterpretable thus suitable for implementation in datadriven CDSSs The disambiguation of textual guidelines is supported first by the formal unequivocal specification of data items used as decision criteria using international coding systems to enforce interoperability and second by the representation of guideline knowledge as CDTs The method is applied to the Dutch breast cancer guidelines Sixty CDTs were built involving a total of data items among which could not be linked to standard terminologies The authors report the ambiguity of certain criteria which could be subjective or had multiple definitions The resulting knowledge base was implemented in a decision support application where it can be interactively browsed or automatically executed By modeling guidelines in such a way this work is a step forward in the sharing of encoded knowledgeIn the second paper KamiÅ¡alić [] tackled the issues linked to the formalization of the medical processes used for managing chronic diseases and their execution in CDSSs They analyzed the decisionmaking dimensions of the therapeutic management of chronic diseases like those known to increase the cardiovascular risk and identified three basic levels therapy strategy dosage adaptation and intolerance management To handle these different aspects consistently they propose a formalism called extended Timed Transition Diagram eTTD With eTTDs they illustrate the multilevel and finegrained modeling required to capture the contents of arterial hypertension management guidelines This detailed demonstration on how procedural knowledge for hypertension management can be formalized to develop a CDSS could certainly be used in other medical domainsThe third paper by Khalifa [] presents a conceptual and practical framework to help assess confidence in predictive tools GRASP for Grade and Assess Predictive Tools is both a method to look for evidence from the published literature and an analysis grid It standardizes the assessment of the available literature associated to a predictive tool and the grading of its level of proof Three phases of evaluation are considered i before the implementation of the tool to assess both its internal and external validity ii during the implementation to assess its potential effect and usability and iii after the implementation to assess its effectiveness and safety In each phase the level of evidence can be assessed from the study design A qualitative summarizes the direction of evidence positive negative mixed This grid can be considered as similar to existing grids for instance the CONSORT statement for clinical trials However it gives a rigorous methodology for a critical appraisal of predictive tools and could be extended to all kind of CDSSs It might be a useful tool to extend the evidencebased culture in the field of medical informaticsBesides the three best papers selected for the Decision Support section of the edition of the IMIA Yearbook several other works retrieved from the literature review deserve to be cited Some of them deal with the personalization of decisions Laleci [] propose a scientific and technical approach to develop personalized care plans that comply with clinical practice guidelines for the management of complex polypathology situations Jafarpour [] propose a solution to dynamically manage the conflicts that can rise in this type of complex contexts Ben Souissi [] introduce the use of health information technology involving multiple criteria decision to support the choice between antibiotics alternatives Interestingly other works promote the creation and sharing of operational knowledge bases as exemplified by Hendriks [] Thus Huibers [] transform the textual STOPPSTART criteria into unambiguous definitions mapped to medical terminologies Canovas et al [] formalize EUCAST expert rules as an ontology and production rules to detect antimicrobial therapies at risk of failure M¼ller [] propose an diagnostic knowledge base that can compete with commercial ones Replacing humans is another topic of research and Spnig [] work on two aspects to virtualize a doctor the automatic acquisition of data through sensors and speech recognition and the automation of diagnostic reasoning Rozenblum et al[] propose a machine learning method to generate clinically valid alerts to detect errors in prescriptions Acceptability of CDSS is another key point Kannan [] propose a method for a CDSS design to best meet a precisely specified and assessable user purpose Design alerts may also avoid rejection of CDSSs by caregivers Fernandes [] created algorithms able to aggregate filter and reduce the notifications delivered to healthcare professionals Amrose et al [] tried to understand in real life the impact of alerts on users and to find the actions they triggered Finally it is always interesting to obtain varied evaluation results of controversial CDSSs In this respect Kim [] evaluated Watson for Oncology in thyroid carcinoma and reported a concordance rate with local practices considered as too low to adopt the tool As evidenced by the number and the variety of works around decision support research in the field is very active This year™s selection highlighted pragmatic works that promote the transparency and sharing of the IMIA Yearbook of Medical Informatics 2020Duclos 0cTable Best paper selection of s for the IMIA Yearbook of Medical Informatics in the section 'Decision Support' The s are listed in alphabetical order of the first author™s surname Section Decision Support\uf0a7 Hendriks MP Verbeek XAAM van Vegchel T van der Sangen MJC Strobbe LJA Merkus JWS Zonderland HM Smorenburg CH Jager A Siesling S Transformation of the National Breast Cancer Guideline Into DataDriven Clinical Decision Trees JCO Clin Cancer Inform \uf0a7\t KamiÅ¡alić\tA\tRia±o\tD\tKert\tS\tWelzer\tT\tNemec\tZlatolas\tL\tMultilevel\tmedical\tknowledge\tformalization\tto\tsupport\tmedical\tpractice for chronic diseases Data Knowledge Engineering “\uf0a7 Khalifa M Magrabi F Gallego B Developing a framework for evidencebased grading and assessment of predictive tools for clinical decision support BMC Med Inform Decis Mak knowledge bases used by decision support tools as well as the grading of their utility The ultimate goal is that users could trust such tools to then use themAcknowledgementWe would like to thank all the present and past editorial boards of the IMIA Yearbook especially Martina Hutter and Adrien Ugon for their support as well as the reviewers for their participation to the selection of the best papers for the Decision Support section We cannot end this synopsis without a meaningful thought for our colleague and friend Vassilis Koutkias who started this year again to tackle the tasks of a Decision Support section coeditor but passed away in last December and unfortunately could not finishReferences Jankovic I Chen JH Clinical Decision Support and Implications for the Clinician Burnout Crisis Yearb Med Inform Koutkias V Bouaud J Contributions on Clinical Decision Support from the Literature Yearb Med Inform Aug2811357 Hendriks MP Verbeek XAAM van Vegchel T van der Sangen MJC Strobbe LJA Merkus JWS Transformation of the National Breast Cancer Guideline Into DataDriven Clinical Decision Trees JCO Clin Cancer Inform KamiÅ¡alić A Ria±o D Kert S Welzer T Nemec Zlatolas L Multilevel medical knowledge formalization to support medical practice for chronic diseases Data Knowledge Engineering “ Khalifa M Magrabi F Gallego B Developing a framework for evidencebased grading and assessment of predictive tools for clinical decision support BMC Med Inform Decis Mak Laleci GB Yuksel M Sarigul B Arvanitis TN Lindman P Chen R A Collaborative Platform for Management of Chronic Diseases via GuidelineDriven Individualized Care Plans Comput Struct Biotechnol J “ Jafarpour B Raza Abidi S Van Woensel W Raza Abidi SS Executiontime integration of clinical practice guidelines to provide decision support for comorbid conditions Artif Intell Med Ben Souissi S Abed M El Hiki L Fortemps P Pirlot M PARS a system combining semantic technologies with multiple criteria decision aiding for supporting antibiotic prescriptions J Biomed Inform Huibers CJA Sallevelt BTGM de Groot DA Boer MJ van Campen JPCM Davids CJ Conversion of STOPPSTART version into coded algorithms for software implementation A multidisciplinary consensus procedure Int J Med Inform C¡novasSegura B Morales A Juarez JM Campos M Palacios F Impact of expert knowledge on the detection of patients at risk of antimicrobial therapy failure by clinical decision support systems J Biomed Inform M¼ller L Gangadharaiah R Klein SC Perry J Bernstein G Nurkse D An access medical knowledge base for community driven diagnostic decision support system development BMC Med Inform Decis Mak Spnig S EmbergerKlein A Sowa JP Canbay A Menrad K Heider D The virtual doctor An interactive clinicaldecisionsupport system based on deep learning for noninvasive prediction of diabetes Artif Intell Med Rozenblum R RodriguezMonguio R Volk LA Forsythe KJ Myers S McGurrin M Using a Machine Learning System to Identify and Prevent Medication Prescribing Errors A Clinical and Cost Analysis Evaluation Jt Comm J Qual Patient Saf Kannan V Basit MA Bajaj P Carrington AR Donahue IB Flahaven EL User stories as lightweight requirements for agile clinical decision support development J Am Med Inform Assoc Fernandes CO Miles S Lucena CJP Cowan D Artificial Intelligence Technologies for Coping with Alarm Fatigue in Hospital Environments Because of Sensory Overload Algorithm Development and Validation J Med Internet Res 20192111e15406 Amroze A Field TS Fouayzi H Sundaresan D Burns L Garber L et al Use of Electronic Health Record Access and Audit Logs to Identify Physician Actions Following Noninterruptive Alert ing Descriptive Study JMIR Med Inform 201971e12650 Kim M Kim BH Kim JM Kim EH Kim K Pak K Concordance in postsurgical radioactive iodine therapy recommendations between Watson for Oncology and clinical practice in patients with differentiated thyroid carcinoma Cancer Correspondence toPr Catherine DuclosLIMICS INSERM Facult© L©onard de Vinci rue Marcel Cachin Bobigny FranceEmail catherineduclosaphpfr IMIA Yearbook of Medical Informatics 2020Pragmatic Considerations on Clinical Decision Support from the Literature 0cAppendix Content Summaries of Best Papers for the Decision Support Section of the IMIA YearbookHendriks MP Verbeek XAAM van Vegchel T van der Sangen MJC Strobbe LJA Merkus JWS Zonderland HM Smorenburg CH Jager A Siesling STransformation of the National Breast Cancer Guideline into datadriven clinical decision treesJCO Clin Cancer Inform May3114Since clinical practice guidelines are still narrative and described in large textual documents the aim of this work was to model complex guidelines as datadriven clinical decision trees CDTs that could be still humaninterpretable while computerinterpretable for implementation in decision support systems The Dutch national breast cancer guidelines were translated into CDTs Data items which characterize the patient and the tumor and represent decisional criteria were encoded unambiguously using existing classifications and coding systems related to breast cancer when feasible In total CDTs were necessary to cover the whole guidelines driven by data items Of all data items could be coded using existing classification and coding systems All CDTs represented unique patient subpopulations Complex guidelines could be transformed as systematically constructed modular datadriven CDTs that are clinically interpretable and executable in a decision support applicationKamiÅ¡alić A Ria±o D Kert S Welzer T Nemec Zlatolas LMultilevel medical knowledge formalization to support medical practice for chronic diseasesData Knowledge Engineering “This research is focused on knowledge representation to support the medical processes involved in chronic diseases management which can be viewed as a procedural and sequential application of knowledge An intuitive easy and effective mechanism for medical knowledge formalization is proposed through a formalism called extended Timed Transition Diagram eTTD This formalism allows for the consistent representation of three basic levels of decision making that should be taken into account in the prescription and adaptation of longterm treatment therapy strategy dosage and intolerances The methodology can be manually applied to build eTTDs from clinical practice guidelines eTTDs implementation is demonstrated by modeling clinical practice guidelines for the therapeutic management of arterial hypertension The obtained models can be used as a baseline framework for the development of decision support systems involving medical proceduresKhalifa M Magrabi F Gallego BDeveloping a framework for evidencebased grading and assessment of predictive tools for clinical decision supportBMC Med Inform Decis Mak Oct Deciding to choose a clinical predictive tool in clinical practice should be guided by its correctly assessed effectiveness The objective of this work is to developp a conceptual and practical framework to Grade and Assess Predictive tools GRASP and provide clinicians with a standardised evidencebased system to support their search for and selection of efficient predictive tools The GRASP framework grades predictive tools based on published evidence across three dimensions phase of evaluation level of evidence and direction of evidence The final grade of the tool is based on the phase of evaluation that gets the hightest grade supported by the highest level of positive or mixed evidence that supports a positive This framework was successfully applied to five predictive tools GRASP report updates could be a way to maintain a data base that documents the evidence of predictive tools IMIA Yearbook of Medical Informatics 2020Duclos 0c" Answer:

Thyroid_Cancer

coronary arterybypass grafting thrombosis fibrin fibrinogen mutationIntroduction Intraoperative thrombosis of saphenous veins SV during harvesting is very rareCase Report We present a case of a 60yearold male patient with multivesselcoronary artery disease and a history of a nonST elevation acute coronary syndromeand type2 diabetes mellitus admitted for coronary artery bypass grafting in whombilateralintraoperative SV thrombosis occurred during graft harvesting Routinethrombophilia screening showed no abnormalities and cancer was excluded Compared with healthy controls we observed prolonged fibrin clot lysis time and increasedthrombin generation reflected by endogenous thrombin potential Scanning electronmicroscopy of the thrombosed material revealed compact and thick fibrin layer on theclot surface with a solid mass of unusually compressed platelets and erythrocytesunderneath The patient was tested for fibrinogen and factor F XIII polymorphismsand was found to be heterozygous for fibrinogen HaeIII 455G A and FXIIIVal34Leu 100G TConclusion fibrinogen HaeIII and FXIII Val34Leu polymorphisms are reflected inreduced clot permeability and susceptibility to lysis and might contribute to intraoperative SV thrombosis during vascular grafting procedures Carriers of those are atrisk of primary venous graft failure after bypass proceduresIntroductionCoronary artery bypass grafting CABG is a method of choicefor revascularization in patients with multivessel disease anddiabetes mellitus DM Although arterial grafts are preferredin selected scenarios the common practice is to use leftinternal thoracic artery LITA to bypass the left anteriordescending artery LAD and to place venous conduits toother target vessels An often chosen vascular graft the greatsaphenous vein SV offers decent durability and is easy toharvest SV graft occlusion may occur in up to of caseswithin the first months and as many as may occludewithin first to weeks1 SV harvesting dramaticallychanges the vein™s environment with disruption of bloodflow in vasa vasorum damage to the adventitia hypoxia andhyponutrition of the vessel wall along with focal endothelialdisruption2 Acute SV graft failure is usually a result of graftthrombosis which among other factors like technical failuregrafttarget vessel disproportion etc may be caused byhypercoagulabilityreceivedMarch acceptedJuly 101055s00401715657ISSN Ge Thieme Verlag KGStuttgart · New York 0ce198Bilateral Saphenous Vein Thrombosis during CABG Mazur et alCase ReportA 60yearold male patient with multivessel coronary arterydisease who suffered from a nonST elevation acute coronarysyndrome NSTEACS month prior to admission a nonsmoker with type2 DM on metformin peptic ulcer diseaseand a history of alcohol abuse was admitted to our institutionfor CABG Just after the NSTEACS a left ventricle LV thrombus was seen on one echocardiographic examination but itwas absent during followup There was no deep venousthrombosis or bleeding diathesis history On admission thepatient was on aspirin mg once daily and enoxaparin mg once daily Routine laboratory tests were withinnormal ranges –ºTable There were no abnormalities onphysical examination apart from obesity body mass index kgm2 when the patient was admitted The lower extremities appeared normal There were no varicose veins nosigns or symptoms of venous insufficiency and the pastmedical history was negative for both personal and familyhistory of chronic venous insufficiency or varicose veins Thepatient was operated on following the standard proceduresDuring LITA harvest a cardiac surgery resident harvested theright SV using the technique The wall of the SV lookedgrossly normal Upon dissection the side branches were tiedoff and clipped and a needle was placed at the distal end whilethe proximal end was still not separated An attempt was madeTable Results of initial and followup laboratory testingVariableCoagulation testsRed blood count 103µLHemoglobin gdLWhite blood count 103µLPlatelet count 103µLAPTT sPT sPT INRPlatelet aggregation mmolL arachidonic acid µmolL ADP Thrombophilia screeningFibrinogen gLAntithrombin III Ddimer µgLantiXa IUmLHomocysteine µmolLProtein C Protein S Factor VIII Leiden c1601G A 0397G AProthrombin cfibrinogen 455G AFactor XIII 100G TLupus anticoagulant ratioLupus anticoagulant ratio APTTAnticardiolipin IgGAnticardiolipin IgMAnti2glycoprotein I IgG antibodyAnti2glycoprotein I IgM antibodyNormal rangesPreoperativePostoperative day Postoperative day “““““““““““““““““““““““““““““““““““““““““““ GG no mutationGG no mutation““ GPL MPL SGU SMU““““““““““““GG no mutationGG no mutationGA heterozygoteGT heterozygote GPL MPL SGU SMUAbbreviations APTT activated partial thromboplastin time GPL IgG phospholipid unit Ig immunoglobulin INR international normalized ratioMPL IgM phospholipid unit PT prothrombin time SGU standard IgG 2 glycoprotein unit SMU standard IgM 2 glycoprotein unitTH Vol No 0cBilateral Saphenous Vein Thrombosis during CABG Mazur et ale199to flush the vein with a solution containing blood mLheparin IU and normal saline mL while the distalend was closed with an atraumatic vascular clamp and veinthrombosis was noted Upon the separation of the distal end aluminal thrombus was visible The left SV was then taken downusing the same protocol by an experienced staff cardiacsurgeon with the same result Presence of a luminal thrombuswas confirmed upon separation of the proximal end Systemicheparin was administered and normal LITA outflow wasconfirmed Concerns regarding safety of cardiopulmonarybypass use were raised due to suspected thrombotic issueand the approach was modified The LITA“LAD anastomosiswas completed offpump on a beating heartThe postoperative course was uneventful On postoperative day the patient received dual antiplatelet therapy withaspirin and clopidogrel and was discharged on day with nosigns of thrombosis or myocardial ischemia Elective angioplasty of nongrafted vessels was scheduled and a completethrombophilia screening was done –ºTable On the and12month followup the patient did wellDiagnostic ApproachBecause a thrombophilia was suspected screening wasinitiated showing no abnormalities –ºTable Cancer was excluded as a cause of thrombosis Positiveantibodies against neutrophil cytoplasm antigens pANCAand cANCA were excluded as a cause of vasculitis We thenproceeded to analyze fibrin phenotype using the previouslydescribed methodology34 Briefly plasma fibrin clot permeability was determined in a hydrostatic pressure systemTubes containing fibrin clots formed from adding mmolLcalcium chloride and UmL human thrombin Sigma tocitrated plasma were connected through plastic tubing to abuffer reservoir M TrisHCl M NaCl pH Thevolume flowing through the gel was measured within minutes A permeation coefficient Ks reflecting poresize was calculated from equation Ks ¼ Q 02 L ηt 02 A 02 Δpwhere Q is the flow rate in time t L is the length of a fibrin gelη is the viscosity of liquid A is the cross section area and Δp isa differential pressure in dynecm2 Lower Ks values indicated reduced permeability Fibrinogen was determined usingthe Clauss method Even though the followup fibrinogenlevel was normal we identified strongly decreased fibrin clotpermeability Ks ¼ 06 02 9cm2 compared withhealthy controls from our previous report n ¼ Ks ¼ 9cm23 samples collected during late follow[“] up appointment on postoperative day Compared withhealthy controls n ¼ we observed prolonged clot lysistime CLT 06 vs 06 minutes and increasedthrombin generation reflected by endogenous thrombinpotential ETP in the studied subject ETP ¼ 06 vs 06 nM 02 min respectively measurement ofthe thrombin generation was done with calibrated automated thrombography thrombinoscope BV Maastricht theNetherlands according to the manufacturer™s instructionsin the 96well plate fluorometer Ascent Reader Thermolabsystems OY Helsinki Finland equipped with the filter set at a temperature of °C Briefly microliters of plateletpoor plasma were diluted with µL of the reagent containing pmolL recombinant tissuefactor micromolar phosphatidylserinephosphatidylcholinephosphatidylethanolamine vesicle and µL of FluCasolution Hepes pH nmolL CaCl2 mgmL bovinealbumin and mmolL ZGlyGlyArg7amino4methylcoumarin Each plasma sample was analyzed in duplicateFor analysis the maximum concentration of thrombin generated was used3Cryosectioned tissue sections were fixed in icecold methanol“acetone mixture peroxidase activity was quenchedwith H2O2 and unspecific background was blocked with bovine albumin BSA Sigma Co St Louis Missouri UnitedStates Primary adequate antibodies against fibrin or tissuefactor TF were applied both Abcam Cambridge UnitedKingdom Primary antibodies were followed by thecorresponding secondary antibodies conjugated with fluorochrome Abcam as previously described5 Images were analyzed using Olympus BX microscope SVs immunostainingrevealed thick layer of fibrin directly on the vessel endothelium–ºFig 1A and high TF –ºFig 1B activity Within the thrombuswe found abundant blood nuclear cells nuclei stained usingDAPI suggesting the presence of proinflammatory monocyteswhich are known source of TF Unfortunately we were not ableto immunostain CD68 due to high unspecific backgroundresulting from large amounts of fibrin The microscopic analysisshowed abundant adventitial vessels –ºFig 1C D Withinalmost every single vessel we found thrombi rich in bothprothrombin –ºFig 1C and TF –ºFig 1DProthrombotic fibrin clot phenotype reflected by reducedKs and prolonged CLT along with enhanced thrombin generation and unusualimages obtained from the immunostaining of the SVs prompted us to perform analysis ofwhole blood clot morphology using scanning electron microscopy SEM as previously described6 After washing thethrombus was fixed with glutaraldehyde phosphatebuffered saline solution Specimens were dehydrated goldcoated and photographed digitally with a JEOL JSM JEOL Tokyo Japan The analysis revealed compact and thickfibrin layer on the clot surface with a solid massof unusually compressed platelets and erythrocytes underneath This observation suggested veryhigh contractileforces during clot formation in a plateletdriven fibrinmediated mechanism of clot contraction and prompted usto study common fibrinogen and factor F XIII polymorphisms The patient was heterozygous for fibrinogen HaeIII455G A and FXIII Val34Leu 100G TDiscussionA dramatic intraoperative SV thrombosis provoked by graftharvesting for CABG lead to change in revascularizationstrategy but its cause remained unknown following thestandard thrombophilia screening The cases of acute SVgraft thrombosis in the perioperative period are very rareand as few as of grafts occlude within first to weeks17TH Vol No 0ce200Bilateral Saphenous Vein Thrombosis during CABG Mazur et alFig Representative images of SV graft immunostaining after massive thrombosis A“D prothrombin stained red TF stained green nucleistained blue using DAPI and scanning electron microscopic images E F of the surface of whole blood clot formed in vitro from citrated bloodobtained from the patient undergoing CABG Box and arrow represent magnification of the fragment in the box Arrows show pertinent stainedfragments see text CABG Coronary artery bypass grafting SV saphenous veins TF tissue factorA normal SV is composed of the intima the media and theadventitia8 The intima is built of the layer of endothelial cellson the luminal side the media consists of smooth musclecells and the adventitia forms the outer part8 In a normalsetting the endothelium is crucial for vein integrity andprevention of thrombosis9 and its focal disruption maypredispose to vessel thrombosis2 SV manipulation andimplantation leads to loss of endothelial integrity and elicitsan inflammatory response with platelet adhesion and leukocyte recruitment Notwithstanding an overt thrombosis isextremely rare in the operating room SV dissection results inblood flow disruption in vasa vasorum and causes adventitial damage hypoxia and vessel wall hyponutrition10 Acuteperioperative saphenous vein graft failure is almost always aresult of graft thrombosis but this very uncommonly occursprior to graft placement Surgical factorslike technicalanastomotic failure or severe disproportion between thetarget vessel and the graft may lead to thrombosis butvessel injury and hypercoagulability are among potentialcauses as well11There was no evident inflammatory process in microscopy inour patient but even if an inflammatory process was presentTH Vol No 0cBilateral Saphenous Vein Thrombosis during CABG Mazur et ale201preoperatively in our patient™s SVs the inflammatory background alone could not explain the dramatic intraoperativethrombosis We hypothesized that increased thrombin generation and prothrombotic fibrin clot phenotype were responsiblefor the clinical presentation Conversion of fibrinogen to fibrinfacilitated by thrombin is a concluding step of coagulation Ithas been shown that fibrin clots with small pores betweentightly packed thin fibrin fibers are relatively lysis resistant12Such clot phenotype has been evidenced in multiple thromboticpathologies such as myocardial infarction6 ischemic stroke13and venous thromboembolism4 The prothrombotic clotphenotype reflected by a tendency to form dense fibrin clotsresistant to lysis has been previously reported in patients withinstent thrombosis14 While routine thrombophilia screeningresults in a high almost detection rate of commonhypercoagulable states15 there are prothrombotic conditionsthat escape routine diagnostic approach The overall microscopic clot appearance and prothrombotic fibrin properties lead tothe discovery of two mutations in our patient that are notroutinely tested during thrombophilia screening namely fibrinogen 455G A and FXIII100G TElevated fibrinogen was postulated as one of the riskfactors for early graft failure after CABG1116 Epidemiologicalstudies have established that elevated fibrinogen is stronglyassociated with cardiovascular diseases17 A metaanalysis of individual records of participants from prospective studies revealed that age and sexadjustedhazard ratio per gL increase in usual fibrinogen level forcoronary heart disease was confidence interval [CI]“ while for stroke the hazard ratio was as high as 95CI “ Risk of coronary disease progression wasalso linked to genetic polymorphisms of the fibrinogen geneDe Maat et al found that A allele of fibrinogen 455G Awas associated with more severe progression of coronarydisease as documented angiographically18 Gu and colleagues in a metaanalysis of studies with patientsfound that A allele of the fibrinogen 455G A is associated with susceptibility to coronary disease and also withischemic stroke odds ratio for stroke ¼ [ CI “]for AA þ GA vs GG19 In a recent study of patients with atrialfibrillation Hu and colleagues found that the A allele of fibrinogen 455G A was a risk factor for cardioembolicstroke probably by elevating the level of plasma fibrinogen20 On the other hand in a metaanalysis of studies involving cases and controls FXIIIVal34Leu polymorphism was shown to be associated withrisk myocardial infarction21 FXIII is crucial to thrombusstabilization and changes of its plasma concentration reflectnonspecifically the extent of thrombosis as shown by Li et alin a study on patients with cerebral venous thrombosis22Interesting associations of FXIII Val34Leu polymorphism andthrombotic disorders have been reported Jung et al reportedin a metaanalysis of studies that FXIII Val34Leu polymorphism is associated with recurrent pregnancy loss23Although no association with the incidence of ischemicstroke was found for this polymorphism24 apparentlywhen the stroke occurs Val34Leu polymorphism of FXIIIaffects the severity of its outcome25 Furthermore Kreutzand colleagues suggested in that FXIII Val34Leu polymorphism may increase risk of recurrent MI and death inpatients with angiographically established coronary arterydisease26 In our group has shown in a study of patients that in patients undergoing CABG FXIII Leu34 alleleis associated with decreased fibrin clot permeability andefficiency of fibrinolysis27ConclusionOur extensive workup showed that fibrinogen HaeIII andFXIII Val34Leu polymorphisms are reflected in reduced clotpermeability and susceptibility to lysis These mutationslikely contributed to intraoperative saphenous graft thrombosis Further studies are needed to elucidate the role ofthese polymorphisms in early graft failure after bypassgrafting procedures however their contributory role seemsevidentFundingThis study was funded by a grant from the JagiellonianUniversity Medical College no KZDS007961 to PMConflict of InterestNone declaredReferences Bourassa MG Fate of venous grafts the past the present and thefuture J Am Coll Cardiol “ Roubos N Rosenfeldt FL Richards SM Conyers RA Davis BBImproved preservation of saphenous vein grafts by the use ofglyceryl trinitrateverapamil solution during harvesting Circulation 19959209II31“II36 Mazur P Sokołowski G HubalewskaDydejczyk A PłaczkiewiczJankowska E Undas A Prothrombotic alterations in plasma fibrinclot properties in thyroid disorders and their posttreatmentmodifications Thromb Res “ Undas A Zawilska K CieslaDul M et al Altered fibrin clotstructurefunction in patients with idiopathic venous thromboembolism and in theirrelatives Blood “ Natorska J Marek G Hlawaty M Sadowski J Tracz W Undas AFibrin presence within aortic valves in patients with aorticstenosis association with in vivo thrombin generation and fibrinclot properties Thromb Haemost “ Undas A Szułdrzynski K Stepien E et al Reduced clot permeability and susceptibility to lysis in patients with acute coronarysyndrome effects of inflammation and oxidative stress Atherosclerosis “ Fitzgibbon GM Kafka HP Leach AJ Keon WJ Hooper GD BurtonJR Coronary bypass graft fate and patient outcome angiographicfollowup of grafts related to survival and reoperation in patients during years J Am Coll Cardiol “ Kim FY Marhefka G Ruggiero NJ Adams S Whellan DJ Saphenous vein graft disease review of pathophysiology preventionand treatment Cardiol Rev “ Allaire E Clowes AW Endothelial cell injury in cardiovascularsurgery the intimal hyperplastic response Ann Thorac Surg“ McGeachie JK Meagher S Prendergast FJ Veintoartery graftsthe longterm development of neointimal hyperplasia and itsTH Vol No 0ce202Bilateral Saphenous Vein Thrombosis during CABG Mazur et alrelationship to vasa vasorum and sympathetic innervation Aust NZ J Surg “ Harskamp RE Lopes RD Baisden CE de Winter RJ Alexander JHSaphenous vein graft failure after coronary artery bypass surgerypathophysiology management and future directions Ann Surg“ Undas A Fibrin clot properties and their modulation in thrombotic disorders Thromb Haemost “ Undas A Podolec P Zawilska K et al Altered fibrin clotstructurefunction in patients with cryptogenic ischemic strokeStroke “ Undas A Zalewski J Krochin M et al Altered plasma fibrin clotproperties are associated with instent thrombosis ArteriosclerThromb Vasc Biol “ GoldmanMazur S Wypasek E Karpiński M Stanisz A Undas AHigh detection rates of antithrombin deficiency and antiphospholipid syndrome in outpatients aged over years using thestandardized protocol for thrombophilia screening Thromb Res“ Moor E Hamsten A Blombäck M Herzfeld I Wiman B Rydén LHaemostatic factors and inhibitors and coronary artery bypassgrafting preoperative alterations and relations to graft occlusionThromb Haemost “ Danesh J Collins R Appleby P Peto R Association of fibrinogen Creactive protein albumin or leukocyte count with coronary heartdisease metaanalyses of prospective studies JAMA “ de Maat MP Kastelein JJ Jukema JW et al 455GA polymorphismof the betafibrinogen gene is associated with the progression ofcoronary atherosclerosis in symptomatic men proposed role foran acutephase reaction pattern of fibrinogen REGRESS groupArterioscler Thromb Vasc Biol “ Gu L Liu W Yan Y et al Influence of the fibrinogen455GApolymorphism on development of ischemic stroke and coronaryheart disease Thromb Res “ Hu X Wang J Li Y et al The fibrinogen gene 455GA polymorphism associated with cardioembolic stroke in atrial fibrillationwith low CHA2DS2VaSc score Sci Rep Jung JH Song GG Kim JH Seo YH Choi SJ Association of factor XIIIVal34Leu polymorphism and coronary artery disease a metaanalysis Cardiol J “ Li B Heldner MR Arnold M et al Coagulation Factor XIIIin Cerebral Venous Thrombosis TH e227“e229 Jung JH Kim JH Song GG Choi SJ Association of the F13A1Val34Leu polymorphism and recurrent pregnancy loss a metaanalysis Eur J Obstet Gynecol Reprod Biol “ Shemirani AH Pongrácz E Antalfi B Adány R Muszbek L FactorXIII A subunit Val34Leu polymorphism in patients sufferingatherothrombotic ischemic stroke Thromb Res “ Shemirani AH Antalfi B Pongrácz E Mezei ZA Bereczky Z Csiki ZFactor XIIIA subunit Val34Leu polymorphism in fatal atherothrombotic ischemic stroke Blood Coagul Fibrinolysis “ Kreutz RP Bitar A Owens J et al Factor XIII Val34Leu polymorphism and recurrent myocardialinfarction in patients withcoronary artery disease J Thromb Thrombolysis “ Stepień E Plicner D Kapelak B Wypasek E Sadowski J UndasA Factor XIII Val34Leu polymorphism as a modulator of fibrinclot permeability and resistance to lysis in patients withsevere coronary artery disease Kardiol Pol 2009678A“TH Vol No 0c'

cancer2

You are a medical assistant specializing in cancer diagnosis. Based on the given information, you must classify the cancer type as one of the following three options: 'Thyroid_Cancer', 'Colon_Cancer', or 'Lung_Cancer'. Please choose the most appropriate category based on the provided text. Do not include any other cancer types or responses outside of these three categories. Text: coronary arterybypass grafting thrombosis fibrin fibrinogen mutationIntroduction Intraoperative thrombosis of saphenous veins SV during harvesting is very rareCase Report We present a case of a 60yearold male patient with multivesselcoronary artery disease and a history of a nonST elevation acute coronary syndromeand type2 diabetes mellitus admitted for coronary artery bypass grafting in whombilateralintraoperative SV thrombosis occurred during graft harvesting Routinethrombophilia screening showed no abnormalities and cancer was excluded Compared with healthy controls we observed prolonged fibrin clot lysis time and increasedthrombin generation reflected by endogenous thrombin potential Scanning electronmicroscopy of the thrombosed material revealed compact and thick fibrin layer on theclot surface with a solid mass of unusually compressed platelets and erythrocytesunderneath The patient was tested for fibrinogen and factor F XIII polymorphismsand was found to be heterozygous for fibrinogen HaeIII 455G A and FXIIIVal34Leu 100G TConclusion fibrinogen HaeIII and FXIII Val34Leu polymorphisms are reflected inreduced clot permeability and susceptibility to lysis and might contribute to intraoperative SV thrombosis during vascular grafting procedures Carriers of those are atrisk of primary venous graft failure after bypass proceduresIntroductionCoronary artery bypass grafting CABG is a method of choicefor revascularization in patients with multivessel disease anddiabetes mellitus DM Although arterial grafts are preferredin selected scenarios the common practice is to use leftinternal thoracic artery LITA to bypass the left anteriordescending artery LAD and to place venous conduits toother target vessels An often chosen vascular graft the greatsaphenous vein SV offers decent durability and is easy toharvest SV graft occlusion may occur in up to of caseswithin the first months and as many as may occludewithin first to weeks1 SV harvesting dramaticallychanges the vein™s environment with disruption of bloodflow in vasa vasorum damage to the adventitia hypoxia andhyponutrition of the vessel wall along with focal endothelialdisruption2 Acute SV graft failure is usually a result of graftthrombosis which among other factors like technical failuregrafttarget vessel disproportion etc may be caused byhypercoagulabilityreceivedMarch acceptedJuly 101055s00401715657ISSN Ge Thieme Verlag KGStuttgart · New York 0ce198Bilateral Saphenous Vein Thrombosis during CABG Mazur et alCase ReportA 60yearold male patient with multivessel coronary arterydisease who suffered from a nonST elevation acute coronarysyndrome NSTEACS month prior to admission a nonsmoker with type2 DM on metformin peptic ulcer diseaseand a history of alcohol abuse was admitted to our institutionfor CABG Just after the NSTEACS a left ventricle LV thrombus was seen on one echocardiographic examination but itwas absent during followup There was no deep venousthrombosis or bleeding diathesis history On admission thepatient was on aspirin mg once daily and enoxaparin mg once daily Routine laboratory tests were withinnormal ranges –ºTable There were no abnormalities onphysical examination apart from obesity body mass index kgm2 when the patient was admitted The lower extremities appeared normal There were no varicose veins nosigns or symptoms of venous insufficiency and the pastmedical history was negative for both personal and familyhistory of chronic venous insufficiency or varicose veins Thepatient was operated on following the standard proceduresDuring LITA harvest a cardiac surgery resident harvested theright SV using the technique The wall of the SV lookedgrossly normal Upon dissection the side branches were tiedoff and clipped and a needle was placed at the distal end whilethe proximal end was still not separated An attempt was madeTable Results of initial and followup laboratory testingVariableCoagulation testsRed blood count 103µLHemoglobin gdLWhite blood count 103µLPlatelet count 103µLAPTT sPT sPT INRPlatelet aggregation mmolL arachidonic acid µmolL ADP Thrombophilia screeningFibrinogen gLAntithrombin III Ddimer µgLantiXa IUmLHomocysteine µmolLProtein C Protein S Factor VIII Leiden c1601G A 0397G AProthrombin cfibrinogen 455G AFactor XIII 100G TLupus anticoagulant ratioLupus anticoagulant ratio APTTAnticardiolipin IgGAnticardiolipin IgMAnti2glycoprotein I IgG antibodyAnti2glycoprotein I IgM antibodyNormal rangesPreoperativePostoperative day Postoperative day “““““““““““““““““““““““““““““““““““““““““““ GG no mutationGG no mutation““ GPL MPL SGU SMU““““““““““““GG no mutationGG no mutationGA heterozygoteGT heterozygote GPL MPL SGU SMUAbbreviations APTT activated partial thromboplastin time GPL IgG phospholipid unit Ig immunoglobulin INR international normalized ratioMPL IgM phospholipid unit PT prothrombin time SGU standard IgG 2 glycoprotein unit SMU standard IgM 2 glycoprotein unitTH Vol No 0cBilateral Saphenous Vein Thrombosis during CABG Mazur et ale199to flush the vein with a solution containing blood mLheparin IU and normal saline mL while the distalend was closed with an atraumatic vascular clamp and veinthrombosis was noted Upon the separation of the distal end aluminal thrombus was visible The left SV was then taken downusing the same protocol by an experienced staff cardiacsurgeon with the same result Presence of a luminal thrombuswas confirmed upon separation of the proximal end Systemicheparin was administered and normal LITA outflow wasconfirmed Concerns regarding safety of cardiopulmonarybypass use were raised due to suspected thrombotic issueand the approach was modified The LITA“LAD anastomosiswas completed offpump on a beating heartThe postoperative course was uneventful On postoperative day the patient received dual antiplatelet therapy withaspirin and clopidogrel and was discharged on day with nosigns of thrombosis or myocardial ischemia Elective angioplasty of nongrafted vessels was scheduled and a completethrombophilia screening was done –ºTable On the and12month followup the patient did wellDiagnostic ApproachBecause a thrombophilia was suspected screening wasinitiated showing no abnormalities –ºTable Cancer was excluded as a cause of thrombosis Positiveantibodies against neutrophil cytoplasm antigens pANCAand cANCA were excluded as a cause of vasculitis We thenproceeded to analyze fibrin phenotype using the previouslydescribed methodology34 Briefly plasma fibrin clot permeability was determined in a hydrostatic pressure systemTubes containing fibrin clots formed from adding mmolLcalcium chloride and UmL human thrombin Sigma tocitrated plasma were connected through plastic tubing to abuffer reservoir M TrisHCl M NaCl pH Thevolume flowing through the gel was measured within minutes A permeation coefficient Ks reflecting poresize was calculated from equation Ks ¼ Q 02 L ηt 02 A 02 Δpwhere Q is the flow rate in time t L is the length of a fibrin gelη is the viscosity of liquid A is the cross section area and Δp isa differential pressure in dynecm2 Lower Ks values indicated reduced permeability Fibrinogen was determined usingthe Clauss method Even though the followup fibrinogenlevel was normal we identified strongly decreased fibrin clotpermeability Ks ¼ 06 02 9cm2 compared withhealthy controls from our previous report n ¼ Ks ¼ 9cm23 samples collected during late follow[“] up appointment on postoperative day Compared withhealthy controls n ¼ we observed prolonged clot lysistime CLT 06 vs 06 minutes and increasedthrombin generation reflected by endogenous thrombinpotential ETP in the studied subject ETP ¼ 06 vs 06 nM 02 min respectively measurement ofthe thrombin generation was done with calibrated automated thrombography thrombinoscope BV Maastricht theNetherlands according to the manufacturer™s instructionsin the 96well plate fluorometer Ascent Reader Thermolabsystems OY Helsinki Finland equipped with the filter set at a temperature of °C Briefly microliters of plateletpoor plasma were diluted with µL of the reagent containing pmolL recombinant tissuefactor micromolar phosphatidylserinephosphatidylcholinephosphatidylethanolamine vesicle and µL of FluCasolution Hepes pH nmolL CaCl2 mgmL bovinealbumin and mmolL ZGlyGlyArg7amino4methylcoumarin Each plasma sample was analyzed in duplicateFor analysis the maximum concentration of thrombin generated was used3Cryosectioned tissue sections were fixed in icecold methanol“acetone mixture peroxidase activity was quenchedwith H2O2 and unspecific background was blocked with bovine albumin BSA Sigma Co St Louis Missouri UnitedStates Primary adequate antibodies against fibrin or tissuefactor TF were applied both Abcam Cambridge UnitedKingdom Primary antibodies were followed by thecorresponding secondary antibodies conjugated with fluorochrome Abcam as previously described5 Images were analyzed using Olympus BX microscope SVs immunostainingrevealed thick layer of fibrin directly on the vessel endothelium–ºFig 1A and high TF –ºFig 1B activity Within the thrombuswe found abundant blood nuclear cells nuclei stained usingDAPI suggesting the presence of proinflammatory monocyteswhich are known source of TF Unfortunately we were not ableto immunostain CD68 due to high unspecific backgroundresulting from large amounts of fibrin The microscopic analysisshowed abundant adventitial vessels –ºFig 1C D Withinalmost every single vessel we found thrombi rich in bothprothrombin –ºFig 1C and TF –ºFig 1DProthrombotic fibrin clot phenotype reflected by reducedKs and prolonged CLT along with enhanced thrombin generation and unusualimages obtained from the immunostaining of the SVs prompted us to perform analysis ofwhole blood clot morphology using scanning electron microscopy SEM as previously described6 After washing thethrombus was fixed with glutaraldehyde phosphatebuffered saline solution Specimens were dehydrated goldcoated and photographed digitally with a JEOL JSM JEOL Tokyo Japan The analysis revealed compact and thickfibrin layer on the clot surface with a solid massof unusually compressed platelets and erythrocytes underneath This observation suggested veryhigh contractileforces during clot formation in a plateletdriven fibrinmediated mechanism of clot contraction and prompted usto study common fibrinogen and factor F XIII polymorphisms The patient was heterozygous for fibrinogen HaeIII455G A and FXIII Val34Leu 100G TDiscussionA dramatic intraoperative SV thrombosis provoked by graftharvesting for CABG lead to change in revascularizationstrategy but its cause remained unknown following thestandard thrombophilia screening The cases of acute SVgraft thrombosis in the perioperative period are very rareand as few as of grafts occlude within first to weeks17TH Vol No 0ce200Bilateral Saphenous Vein Thrombosis during CABG Mazur et alFig Representative images of SV graft immunostaining after massive thrombosis A“D prothrombin stained red TF stained green nucleistained blue using DAPI and scanning electron microscopic images E F of the surface of whole blood clot formed in vitro from citrated bloodobtained from the patient undergoing CABG Box and arrow represent magnification of the fragment in the box Arrows show pertinent stainedfragments see text CABG Coronary artery bypass grafting SV saphenous veins TF tissue factorA normal SV is composed of the intima the media and theadventitia8 The intima is built of the layer of endothelial cellson the luminal side the media consists of smooth musclecells and the adventitia forms the outer part8 In a normalsetting the endothelium is crucial for vein integrity andprevention of thrombosis9 and its focal disruption maypredispose to vessel thrombosis2 SV manipulation andimplantation leads to loss of endothelial integrity and elicitsan inflammatory response with platelet adhesion and leukocyte recruitment Notwithstanding an overt thrombosis isextremely rare in the operating room SV dissection results inblood flow disruption in vasa vasorum and causes adventitial damage hypoxia and vessel wall hyponutrition10 Acuteperioperative saphenous vein graft failure is almost always aresult of graft thrombosis but this very uncommonly occursprior to graft placement Surgical factorslike technicalanastomotic failure or severe disproportion between thetarget vessel and the graft may lead to thrombosis butvessel injury and hypercoagulability are among potentialcauses as well11There was no evident inflammatory process in microscopy inour patient but even if an inflammatory process was presentTH Vol No 0cBilateral Saphenous Vein Thrombosis during CABG Mazur et ale201preoperatively in our patient™s SVs the inflammatory background alone could not explain the dramatic intraoperativethrombosis We hypothesized that increased thrombin generation and prothrombotic fibrin clot phenotype were responsiblefor the clinical presentation Conversion of fibrinogen to fibrinfacilitated by thrombin is a concluding step of coagulation Ithas been shown that fibrin clots with small pores betweentightly packed thin fibrin fibers are relatively lysis resistant12Such clot phenotype has been evidenced in multiple thromboticpathologies such as myocardial infarction6 ischemic stroke13and venous thromboembolism4 The prothrombotic clotphenotype reflected by a tendency to form dense fibrin clotsresistant to lysis has been previously reported in patients withinstent thrombosis14 While routine thrombophilia screeningresults in a high almost detection rate of commonhypercoagulable states15 there are prothrombotic conditionsthat escape routine diagnostic approach The overall microscopic clot appearance and prothrombotic fibrin properties lead tothe discovery of two mutations in our patient that are notroutinely tested during thrombophilia screening namely fibrinogen 455G A and FXIII100G TElevated fibrinogen was postulated as one of the riskfactors for early graft failure after CABG1116 Epidemiologicalstudies have established that elevated fibrinogen is stronglyassociated with cardiovascular diseases17 A metaanalysis of individual records of participants from prospective studies revealed that age and sexadjustedhazard ratio per gL increase in usual fibrinogen level forcoronary heart disease was confidence interval [CI]“ while for stroke the hazard ratio was as high as 95CI “ Risk of coronary disease progression wasalso linked to genetic polymorphisms of the fibrinogen geneDe Maat et al found that A allele of fibrinogen 455G Awas associated with more severe progression of coronarydisease as documented angiographically18 Gu and colleagues in a metaanalysis of studies with patientsfound that A allele of the fibrinogen 455G A is associated with susceptibility to coronary disease and also withischemic stroke odds ratio for stroke ¼ [ CI “]for AA þ GA vs GG19 In a recent study of patients with atrialfibrillation Hu and colleagues found that the A allele of fibrinogen 455G A was a risk factor for cardioembolicstroke probably by elevating the level of plasma fibrinogen20 On the other hand in a metaanalysis of studies involving cases and controls FXIIIVal34Leu polymorphism was shown to be associated withrisk myocardial infarction21 FXIII is crucial to thrombusstabilization and changes of its plasma concentration reflectnonspecifically the extent of thrombosis as shown by Li et alin a study on patients with cerebral venous thrombosis22Interesting associations of FXIII Val34Leu polymorphism andthrombotic disorders have been reported Jung et al reportedin a metaanalysis of studies that FXIII Val34Leu polymorphism is associated with recurrent pregnancy loss23Although no association with the incidence of ischemicstroke was found for this polymorphism24 apparentlywhen the stroke occurs Val34Leu polymorphism of FXIIIaffects the severity of its outcome25 Furthermore Kreutzand colleagues suggested in that FXIII Val34Leu polymorphism may increase risk of recurrent MI and death inpatients with angiographically established coronary arterydisease26 In our group has shown in a study of patients that in patients undergoing CABG FXIII Leu34 alleleis associated with decreased fibrin clot permeability andefficiency of fibrinolysis27ConclusionOur extensive workup showed that fibrinogen HaeIII andFXIII Val34Leu polymorphisms are reflected in reduced clotpermeability and susceptibility to lysis These mutationslikely contributed to intraoperative saphenous graft thrombosis Further studies are needed to elucidate the role ofthese polymorphisms in early graft failure after bypassgrafting procedures however their contributory role seemsevidentFundingThis study was funded by a grant from the JagiellonianUniversity Medical College no KZDS007961 to PMConflict of InterestNone declaredReferences Bourassa MG Fate of venous grafts the past the present and thefuture J Am Coll Cardiol “ Roubos N Rosenfeldt FL Richards SM Conyers RA Davis BBImproved preservation of saphenous vein grafts by the use ofglyceryl trinitrateverapamil solution during harvesting Circulation 19959209II31“II36 Mazur P Sokołowski G HubalewskaDydejczyk A PłaczkiewiczJankowska E Undas A Prothrombotic alterations in plasma fibrinclot properties in thyroid disorders and their posttreatmentmodifications Thromb Res “ Undas A Zawilska K CieslaDul M et al Altered fibrin clotstructurefunction in patients with idiopathic venous thromboembolism and in theirrelatives Blood “ Natorska J Marek G Hlawaty M Sadowski J Tracz W Undas AFibrin presence within aortic valves in patients with aorticstenosis association with in vivo thrombin generation and fibrinclot properties Thromb Haemost “ Undas A Szułdrzynski K Stepien E et al Reduced clot permeability and susceptibility to lysis in patients with acute coronarysyndrome effects of inflammation and oxidative stress Atherosclerosis “ Fitzgibbon GM Kafka HP Leach AJ Keon WJ Hooper GD BurtonJR Coronary bypass graft fate and patient outcome angiographicfollowup of grafts related to survival and reoperation in patients during years J Am Coll Cardiol “ Kim FY Marhefka G Ruggiero NJ Adams S Whellan DJ Saphenous vein graft disease review of pathophysiology preventionand treatment Cardiol Rev “ Allaire E Clowes AW Endothelial cell injury in cardiovascularsurgery the intimal hyperplastic response Ann Thorac Surg“ McGeachie JK Meagher S Prendergast FJ Veintoartery graftsthe longterm development of neointimal hyperplasia and itsTH Vol No 0ce202Bilateral Saphenous Vein Thrombosis during CABG Mazur et alrelationship to vasa vasorum and sympathetic innervation Aust NZ J Surg “ Harskamp RE Lopes RD Baisden CE de Winter RJ Alexander JHSaphenous vein graft failure after coronary artery bypass surgerypathophysiology management and future directions Ann Surg“ Undas A Fibrin clot properties and their modulation in thrombotic disorders Thromb Haemost “ Undas A Podolec P Zawilska K et al Altered fibrin clotstructurefunction in patients with cryptogenic ischemic strokeStroke “ Undas A Zalewski J Krochin M et al Altered plasma fibrin clotproperties are associated with instent thrombosis ArteriosclerThromb Vasc Biol “ GoldmanMazur S Wypasek E Karpiński M Stanisz A Undas AHigh detection rates of antithrombin deficiency and antiphospholipid syndrome in outpatients aged over years using thestandardized protocol for thrombophilia screening Thromb Res“ Moor E Hamsten A Blombäck M Herzfeld I Wiman B Rydén LHaemostatic factors and inhibitors and coronary artery bypassgrafting preoperative alterations and relations to graft occlusionThromb Haemost “ Danesh J Collins R Appleby P Peto R Association of fibrinogen Creactive protein albumin or leukocyte count with coronary heartdisease metaanalyses of prospective studies JAMA “ de Maat MP Kastelein JJ Jukema JW et al 455GA polymorphismof the betafibrinogen gene is associated with the progression ofcoronary atherosclerosis in symptomatic men proposed role foran acutephase reaction pattern of fibrinogen REGRESS groupArterioscler Thromb Vasc Biol “ Gu L Liu W Yan Y et al Influence of the fibrinogen455GApolymorphism on development of ischemic stroke and coronaryheart disease Thromb Res “ Hu X Wang J Li Y et al The fibrinogen gene 455GA polymorphism associated with cardioembolic stroke in atrial fibrillationwith low CHA2DS2VaSc score Sci Rep Jung JH Song GG Kim JH Seo YH Choi SJ Association of factor XIIIVal34Leu polymorphism and coronary artery disease a metaanalysis Cardiol J “ Li B Heldner MR Arnold M et al Coagulation Factor XIIIin Cerebral Venous Thrombosis TH e227“e229 Jung JH Kim JH Song GG Choi SJ Association of the F13A1Val34Leu polymorphism and recurrent pregnancy loss a metaanalysis Eur J Obstet Gynecol Reprod Biol “ Shemirani AH Pongrácz E Antalfi B Adány R Muszbek L FactorXIII A subunit Val34Leu polymorphism in patients sufferingatherothrombotic ischemic stroke Thromb Res “ Shemirani AH Antalfi B Pongrácz E Mezei ZA Bereczky Z Csiki ZFactor XIIIA subunit Val34Leu polymorphism in fatal atherothrombotic ischemic stroke Blood Coagul Fibrinolysis “ Kreutz RP Bitar A Owens J et al Factor XIII Val34Leu polymorphism and recurrent myocardialinfarction in patients withcoronary artery disease J Thromb Thrombolysis “ Stepień E Plicner D Kapelak B Wypasek E Sadowski J UndasA Factor XIII Val34Leu polymorphism as a modulator of fibrinclot permeability and resistance to lysis in patients withsevere coronary artery disease Kardiol Pol 2009678A“TH Vol No 0c' Answer:

Thyroid_Cancer

Solitary plasmacytoma SP of the skull is an uncommon clinical entity that is characterized by alocalized proliferation of neoplastic monoclonal plasma cells This case report describes a50yearold male that presented with a headache and an exophytic soft mass on the occiputThe diagnosis of SP was based on the pathological results and imaging examinations The patientunderwent occipital craniotomy skull reconstruction and lower trapezius myocutaneous flapLTMF transplantation under general anaesthesia The tumour was capsulized and extended tothe subcutaneous and the subdural space through the dura mater with skull defects The neoplasm of the occipital bone involved large areas of scalp and subcutaneous tissue which resultedin a large postoperative scalp defect that was repaired using LTMF transplantation All of thetumour was removed and the transplanted flap grew well Followup at months identified anaggressive mass lesion on the right frontallobe The patient received six cycles of the PADchemotherapy regimen bortezomib doxorubicin and dexamethasone and the lesion was significantly reduced This case demonstrates that LTMF is an alternative approach for the repair ofscalp and subcutaneous soft tissue defects caused by the excision of a large malignant tumourof the occipital region Chemotherapy is the choice of treatment for neoplastic recurrenceKeywordsSolitary plasmacytoma lower trapezius myocutaneous flap scalp reconstruction plasma cellsDate received July accepted March 1Department of Neurosurgery Hunan Cancer Hospitaland the Affiliated Cancer Hospital of Xiangya School ofMedicine Central South University Changsha HunanProvince China2Department of Head and Neck Surgery Hunan CancerHospital and the Affiliated Cancer Hospital of XiangyaSchool of Medicine Central South University ChangshaHunan Province ChinaCorresponding authorsLei Wang and ZhengWen He Department ofNeurosurgery Hunan Cancer Hospital and the AffiliatedCancer Hospital of Xiangya School of Medicine CentralSouth University Tongzipo Road Yuelu DistrictChangsha Hunan Province ChinaEmails wangsengyi163com hezhw2001163comCreative Commons Non Commercial CC BYNC This is distributed under the terms of the CreativeCommons AttributionNonCommercial License creativecommonslicensesbync40 which permitsnoncommercial use reproduction and distribution of the work without further permission provided the original work is attributedas specified on the SAGE and Access pages ussagepubcomenusnam accessatsage 0cIntroductionSolitary plasmacytoma SP is the pathological manifestation of the proliferationof monoclonal plasma cells and an SPthat originates in bone tissue is called a solitary plasmacytoma of bone SPB1 Bonedestruction may occur in any osseous location but the most common sites are thepelvis spine femur humerus and ribs2“An SPB of the skull is rare and a hugegrowth in the occipital bone is rarely mentioned in the literature34 Complete tumourremoval is the first and best approach forpatients with no lesions in other parts of thebody3 This current case report describes arare case of SPB of the occipital bone withscalp involvement in which the patient underwent radical resection and reconstruction ofJournal of International Medical Researchthe large scalp defects through lower trapeziusmyocutaneous flap LTMF transplantationCase reportA 50yearold male patient presented inOctober to the Department ofNeurosurgery Hunan Cancer Hospitaland the Affiliated Cancer Hospital ofXiangya School of Medicine CentralSouth University Changsha HunanProvince China with a headache and an exophytic mass on the occiputaTheexaminationphysicalshowed no findings Computed tomographyCT showed a large mass with homogeneousenhancement on the occiput compressing thebilateral occipital lobe b and theneurologicalFigure Preoperative imaging examinations a preoperative appearance of the tumour b preoperativeenhanced computed tomography scan c preoperative enhanced magnetic resonance imaging MRId preoperative enhanced MRI scan “ axial view e preoperative digital subtraction angiographyThe colour version of this figure is available at httpimrsagepubcom 0cWang et alresonanceandbone window revealed a solitary osteolyticlesion involving the whole entire of the occipital bone MagneticimagingMRI showed an intra and extracerebralexpansile osseous lesion 02 mm themass was mostly isointense with the brainparenchyma on both T1 and T2weightedimagesenhancedFigures 1c and 1d Digital subtraction angiography DSA demonstrated that all of thetumour had hypervascularity that was supplied from the occipital artery In order todecrease bleeding volume and shorten thesurgery time the feeding blood vessel wasembolized during DSA ehomogeneouslyThe patient underwent occipital craniotomy skull reconstruction and LTMF transplantation under general anaesthesia Thetumour was capsulized and extended tothe subcutaneous and the subdural spacethrough the dura mater with skull defectsGrossly the tumour had a fishmeat likeappearance mixed with hard cartilage andbroken bone a The tumour had arich blood supply and despite embolizationof the main blood supply artery duringDSA before surgery there was a lot ofblood loss during the operation Thetumour mass underwent extended resectionincluding the marginal bone and involvedscalp forming an 02 cm bone windowand a 02 cm scalp defect The skulldefect was reconstructed using titaniummesh and the scalp defect was transplantedusing LTMF The trapezius and the skinisland 02 cm and the supplying vesselsof the transverse cervical artery and thedorsal scapular artery were marked on theskin b The island flap was excisedand its muscle pedicle dissected up to theFigure Perioperative procedures and imaging examinations a the tumour was fishmeat soft tan inappearance b the trapezius and the skin island and the supplying vessels of the transverse cervicalartery and the dorsal scapular artery marked out on the skin c the island flap and its muscle pedicle wereexcised d the flap was set into the defect with a wellperfused distal end e the stiches were removedafter surgery f postoperative enhanced magnetic resonance imaging MRI scan “ sagittal viewg postoperative enhanced MRI scan “ axial view The colour version of this figure is available at httpimrsagepubcom 0crotation point at the medialsuperior edgeof the scapula c The LTMF wasrotated vertically into the occipital scalpdefect through the neck posterior subcutaneous tunnel d Two weeks afterthe operation the transplanted skin islandwas vital and wound healing undisturbedFigurethattheremovedtumour wasFigures 2f and 2g2e MRIcompletelyindicatedHaematoxylin and eosin staining of thetumour showed the presence of atypicalplasma cells with typical eccentric roundnucleistainingshowed the following staining patterncytokeratinP “ epithelial membrane antigen “ melanA “ CD38 ¾ CD138ImmunohistochemicalJournal of International Medical Research¾ CD20 “ Kappa ¾ Lambda ¾glial fibrillary acidic protein “ S100“CD68 ¾ thyroid transcription factor1“ Vim “ CD3 “ and Ki67 Figure The patient refused further radiotherapyfor financial reasons After a followupperiod of around months he was symptom free and had no clinical evidence ofdisease At the 5month followup visitMRI revealed no eld recurrence butan aggressive mass lesion with enhancementwaslobeFigures 4a and 4b Chemotherapy PADregimen bortezomib pegylated liposomaldoxorubicindexamethasone wasadministered from April in thefound on thefrontalrightandFigure Representative photomicrographs of the tumour a haematoxylin and eosin stained sectionshowing diffuse sheets of plasma cells b immunohistochemical staining for CD138 showing strong positivity in the tumour cells c immunohistochemical staining for CD38 showing strong positivity in thetumour cells d the positive expression of Ki67 was The colour version of this figure is available athttpimrsagepubcom Scale bar mm 0cWang et alFigure Magnetic resonance imaging scans of the patient during followup a b at the 5month followup visit showing no recurrence in situ but an aggressive mass lesion with enhancement on the right frontallobe c d after six consecutive cycles of chemotherapy showing no recurrence in situ and the lesion onthe right frontal lobe was significantly reducedDepartmentof Haematology HunanCancer Hospital and the Affiliated CancerHospital of Xiangya School of MedicineCentralSouth University ChangshaHunan Province China After six consecutive cycles of chemotherapy the lesion on hisright frontal lobe was significantly reducedFigures 4c and 4d Postoperative reviewafter months showed no tumour recurrence in situ of the original SPBAs this was a case report the InstitutionalReview Board of Hunan Cancer Hospitalwaived the need for ethical approval Thepatient provided written informed consentfor publication that was approved by theInstitutional Review Board and the detailsof the patient have been anonymizedDiscussionHuge intra and extracranial SPs of theoccipital bone are very rare and few caseshave been reported34 SPB is characterizedby the presence of a solitary lytic lesion dueto monoclonal plasma cell ltration withsofttissue extension5 SPBsor withoutaccount for of all SP cases and theyoccur primarily in red marrowcontainingbones6 Plasma cells are highly sensitive toradiation78 Radiation therapy remains the 0cJournal of International Medical Researchtreatment of choice for patients after surgery According to recommendations froma European expert panel a total fractionated dose of “ Gy should be given anda margin of atleast cm should beemployed6 In this current caseit wasunfortunate that the patient refused radiationreasonsA review was performed months afterthe operation and a new mass was foundon the right frontal lobe After six cyclesof chemotherapy the tumour had reducedin size significantly which suggests that chemotherapy has a positive impact on thegrowth of recurrent tumourseconomictherapyforThe imaging characteristics of SPB in theskull are complex and can easily lead tomisdiagnosis Enhanced CT scanning combined with observation of the bone windoware credible means by which to diagnoseSPB and they could provide more information about osteolytic lesions In the currentcase the MRI examination allowed for theidentification of the location size and shapeof the tumour as well as its relationship tothe surrounding structures In our opinionpreoperative DSA is necessary for the identification of the blood supply vessels and tofacilitate vessel embolizationDuringthetumourrecurrencecurrent operationthetumour was found to involve the scalpand subcutaneous tissue To reduce theprobability oftheinvolved scalp underwent an extendedresection LTMF was used to facilitateoccipital scalp reconstruction LTMF provides available muscle compartments transferred on a reliable vascular pedicle to thedorsal suprascapular and neck regions9The benefits of LTMF include well vascularized tissue ease of harvest and the provision of a large flap located far enoughaway from the damaged area10 The mainblood supply to the LTMF originates fromthe transverse cervical artery and the dorsalscapular artery1112 This method couldsolve the problem ofinsufficient bloodsupply caused by titanium plate implantation In additionthe musculocutaneouspedicle could fill the subcutaneous cavitycreated by the huge tumourresectionpreventing occipitalia scalp hydrops andsecondary infection LTMF is an alternative approach for the repair of scalp andsubcutaneous soft tissue defects caused byexcision of a malignanttheoccipital regiontumour ofAuthors™ contributionsLW studied the case collected the referencesand wrote the paper ZH designed the reportand wrote the paper HC and HZ wrote thepaper XP analysed the data NR served as thefirst chief during surgery and wrote the paperAll authorsread and approved the finalmanuscriptDeclaration of conflicting interestThe authors declare that there are no conflicts ofinterestFundingThis project was supported by grants from theScientific Research Project of Hunan ProvincialHealth Commission No20200709 the HunanProvincial Natural Science Foundation of ChinaNo2019JJ40182 and the Sailing Programme ofHunan Provincial Cancer Hospitalorcid000000021069ORCID iDLei WangReferences Sabattini E Bacci F Sagramoso C et alWHO classification of tumours of haematopoietic and lymphoid tissues in anoverview Pathologica “ Gee ED and Sadovsky R Multiple myeloma recognition and management AmFam Physician “ Rizea RE Popescu M Ghehit¸ 15a KLet al Neurosurgical rare disease solitary 0cWang et alplasmacytoma of the skull “ case report andliterature review Rom J Morphol Embryol “ Chang MY Shih LY Dunn P et al Solitaryplasmacytoma of bone J Formos Med Assoc “ Weber DM Solitary bone and extramedullary plasmacytoma Hematology Am SocHematol Educ Program “ Caers J Paiva B Zamagni E et alDiagnosis treatment and response assessment in solitary plasmacytoma updated recommendations from a European ExpertPanel J Hematol Oncol Knobel D Zouhair A Tsang RW et alPrognostic factors in solitary plasmacytomaof the bone a multicenter Rare CancerNetwork study BMC Cancer Liebross RH Ha CS Cox JD et alSolitary bone plasmacytoma outcome andprognostic factors following radiotherapyInt J Radiat Oncol Biol Phys “ Mohos G Vass G Kemeny L et alExtended lowertrapezius myocutaneousflap to cover a deep lateral neck defect onirradiated skin a new application J PlastSurg Hand Surg “ U 15gurlu K Ozc¸ elik D Hu¨ thu¨ t I et alExtended vertical trapezius myocutaneousflap in head and neck reconstruction as asalvage procedure Plast Reconstr Surg “ Baek SM Biller HF Krespi YP et al Thelower trapezius island myocutaneous flapAnn Plast Surg “ Netterville JL and Wood DE The lower trapezius flap Vascular anatomy and surgicaltechnique Arch Otolaryngol Head NeckSurg “ 0c'

cancer3

You are a medical assistant specializing in cancer diagnosis. Based on the given information, you must classify the cancer type as one of the following three options: 'Thyroid_Cancer', 'Colon_Cancer', or 'Lung_Cancer'. Please choose the most appropriate category based on the provided text. Do not include any other cancer types or responses outside of these three categories. Text: Solitary plasmacytoma SP of the skull is an uncommon clinical entity that is characterized by alocalized proliferation of neoplastic monoclonal plasma cells This case report describes a50yearold male that presented with a headache and an exophytic soft mass on the occiputThe diagnosis of SP was based on the pathological results and imaging examinations The patientunderwent occipital craniotomy skull reconstruction and lower trapezius myocutaneous flapLTMF transplantation under general anaesthesia The tumour was capsulized and extended tothe subcutaneous and the subdural space through the dura mater with skull defects The neoplasm of the occipital bone involved large areas of scalp and subcutaneous tissue which resultedin a large postoperative scalp defect that was repaired using LTMF transplantation All of thetumour was removed and the transplanted flap grew well Followup at months identified anaggressive mass lesion on the right frontallobe The patient received six cycles of the PADchemotherapy regimen bortezomib doxorubicin and dexamethasone and the lesion was significantly reduced This case demonstrates that LTMF is an alternative approach for the repair ofscalp and subcutaneous soft tissue defects caused by the excision of a large malignant tumourof the occipital region Chemotherapy is the choice of treatment for neoplastic recurrenceKeywordsSolitary plasmacytoma lower trapezius myocutaneous flap scalp reconstruction plasma cellsDate received July accepted March 1Department of Neurosurgery Hunan Cancer Hospitaland the Affiliated Cancer Hospital of Xiangya School ofMedicine Central South University Changsha HunanProvince China2Department of Head and Neck Surgery Hunan CancerHospital and the Affiliated Cancer Hospital of XiangyaSchool of Medicine Central South University ChangshaHunan Province ChinaCorresponding authorsLei Wang and ZhengWen He Department ofNeurosurgery Hunan Cancer Hospital and the AffiliatedCancer Hospital of Xiangya School of Medicine CentralSouth University Tongzipo Road Yuelu DistrictChangsha Hunan Province ChinaEmails wangsengyi163com hezhw2001163comCreative Commons Non Commercial CC BYNC This is distributed under the terms of the CreativeCommons AttributionNonCommercial License creativecommonslicensesbync40 which permitsnoncommercial use reproduction and distribution of the work without further permission provided the original work is attributedas specified on the SAGE and Access pages ussagepubcomenusnam accessatsage 0cIntroductionSolitary plasmacytoma SP is the pathological manifestation of the proliferationof monoclonal plasma cells and an SPthat originates in bone tissue is called a solitary plasmacytoma of bone SPB1 Bonedestruction may occur in any osseous location but the most common sites are thepelvis spine femur humerus and ribs2“An SPB of the skull is rare and a hugegrowth in the occipital bone is rarely mentioned in the literature34 Complete tumourremoval is the first and best approach forpatients with no lesions in other parts of thebody3 This current case report describes arare case of SPB of the occipital bone withscalp involvement in which the patient underwent radical resection and reconstruction ofJournal of International Medical Researchthe large scalp defects through lower trapeziusmyocutaneous flap LTMF transplantationCase reportA 50yearold male patient presented inOctober to the Department ofNeurosurgery Hunan Cancer Hospitaland the Affiliated Cancer Hospital ofXiangya School of Medicine CentralSouth University Changsha HunanProvince China with a headache and an exophytic mass on the occiputaTheexaminationphysicalshowed no findings Computed tomographyCT showed a large mass with homogeneousenhancement on the occiput compressing thebilateral occipital lobe b and theneurologicalFigure Preoperative imaging examinations a preoperative appearance of the tumour b preoperativeenhanced computed tomography scan c preoperative enhanced magnetic resonance imaging MRId preoperative enhanced MRI scan “ axial view e preoperative digital subtraction angiographyThe colour version of this figure is available at httpimrsagepubcom 0cWang et alresonanceandbone window revealed a solitary osteolyticlesion involving the whole entire of the occipital bone MagneticimagingMRI showed an intra and extracerebralexpansile osseous lesion 02 mm themass was mostly isointense with the brainparenchyma on both T1 and T2weightedimagesenhancedFigures 1c and 1d Digital subtraction angiography DSA demonstrated that all of thetumour had hypervascularity that was supplied from the occipital artery In order todecrease bleeding volume and shorten thesurgery time the feeding blood vessel wasembolized during DSA ehomogeneouslyThe patient underwent occipital craniotomy skull reconstruction and LTMF transplantation under general anaesthesia Thetumour was capsulized and extended tothe subcutaneous and the subdural spacethrough the dura mater with skull defectsGrossly the tumour had a fishmeat likeappearance mixed with hard cartilage andbroken bone a The tumour had arich blood supply and despite embolizationof the main blood supply artery duringDSA before surgery there was a lot ofblood loss during the operation Thetumour mass underwent extended resectionincluding the marginal bone and involvedscalp forming an 02 cm bone windowand a 02 cm scalp defect The skulldefect was reconstructed using titaniummesh and the scalp defect was transplantedusing LTMF The trapezius and the skinisland 02 cm and the supplying vesselsof the transverse cervical artery and thedorsal scapular artery were marked on theskin b The island flap was excisedand its muscle pedicle dissected up to theFigure Perioperative procedures and imaging examinations a the tumour was fishmeat soft tan inappearance b the trapezius and the skin island and the supplying vessels of the transverse cervicalartery and the dorsal scapular artery marked out on the skin c the island flap and its muscle pedicle wereexcised d the flap was set into the defect with a wellperfused distal end e the stiches were removedafter surgery f postoperative enhanced magnetic resonance imaging MRI scan “ sagittal viewg postoperative enhanced MRI scan “ axial view The colour version of this figure is available at httpimrsagepubcom 0crotation point at the medialsuperior edgeof the scapula c The LTMF wasrotated vertically into the occipital scalpdefect through the neck posterior subcutaneous tunnel d Two weeks afterthe operation the transplanted skin islandwas vital and wound healing undisturbedFigurethattheremovedtumour wasFigures 2f and 2g2e MRIcompletelyindicatedHaematoxylin and eosin staining of thetumour showed the presence of atypicalplasma cells with typical eccentric roundnucleistainingshowed the following staining patterncytokeratinP “ epithelial membrane antigen “ melanA “ CD38 ¾ CD138ImmunohistochemicalJournal of International Medical Research¾ CD20 “ Kappa ¾ Lambda ¾glial fibrillary acidic protein “ S100“CD68 ¾ thyroid transcription factor1“ Vim “ CD3 “ and Ki67 Figure The patient refused further radiotherapyfor financial reasons After a followupperiod of around months he was symptom free and had no clinical evidence ofdisease At the 5month followup visitMRI revealed no eld recurrence butan aggressive mass lesion with enhancementwaslobeFigures 4a and 4b Chemotherapy PADregimen bortezomib pegylated liposomaldoxorubicindexamethasone wasadministered from April in thefound on thefrontalrightandFigure Representative photomicrographs of the tumour a haematoxylin and eosin stained sectionshowing diffuse sheets of plasma cells b immunohistochemical staining for CD138 showing strong positivity in the tumour cells c immunohistochemical staining for CD38 showing strong positivity in thetumour cells d the positive expression of Ki67 was The colour version of this figure is available athttpimrsagepubcom Scale bar mm 0cWang et alFigure Magnetic resonance imaging scans of the patient during followup a b at the 5month followup visit showing no recurrence in situ but an aggressive mass lesion with enhancement on the right frontallobe c d after six consecutive cycles of chemotherapy showing no recurrence in situ and the lesion onthe right frontal lobe was significantly reducedDepartmentof Haematology HunanCancer Hospital and the Affiliated CancerHospital of Xiangya School of MedicineCentralSouth University ChangshaHunan Province China After six consecutive cycles of chemotherapy the lesion on hisright frontal lobe was significantly reducedFigures 4c and 4d Postoperative reviewafter months showed no tumour recurrence in situ of the original SPBAs this was a case report the InstitutionalReview Board of Hunan Cancer Hospitalwaived the need for ethical approval Thepatient provided written informed consentfor publication that was approved by theInstitutional Review Board and the detailsof the patient have been anonymizedDiscussionHuge intra and extracranial SPs of theoccipital bone are very rare and few caseshave been reported34 SPB is characterizedby the presence of a solitary lytic lesion dueto monoclonal plasma cell ltration withsofttissue extension5 SPBsor withoutaccount for of all SP cases and theyoccur primarily in red marrowcontainingbones6 Plasma cells are highly sensitive toradiation78 Radiation therapy remains the 0cJournal of International Medical Researchtreatment of choice for patients after surgery According to recommendations froma European expert panel a total fractionated dose of “ Gy should be given anda margin of atleast cm should beemployed6 In this current caseit wasunfortunate that the patient refused radiationreasonsA review was performed months afterthe operation and a new mass was foundon the right frontal lobe After six cyclesof chemotherapy the tumour had reducedin size significantly which suggests that chemotherapy has a positive impact on thegrowth of recurrent tumourseconomictherapyforThe imaging characteristics of SPB in theskull are complex and can easily lead tomisdiagnosis Enhanced CT scanning combined with observation of the bone windoware credible means by which to diagnoseSPB and they could provide more information about osteolytic lesions In the currentcase the MRI examination allowed for theidentification of the location size and shapeof the tumour as well as its relationship tothe surrounding structures In our opinionpreoperative DSA is necessary for the identification of the blood supply vessels and tofacilitate vessel embolizationDuringthetumourrecurrencecurrent operationthetumour was found to involve the scalpand subcutaneous tissue To reduce theprobability oftheinvolved scalp underwent an extendedresection LTMF was used to facilitateoccipital scalp reconstruction LTMF provides available muscle compartments transferred on a reliable vascular pedicle to thedorsal suprascapular and neck regions9The benefits of LTMF include well vascularized tissue ease of harvest and the provision of a large flap located far enoughaway from the damaged area10 The mainblood supply to the LTMF originates fromthe transverse cervical artery and the dorsalscapular artery1112 This method couldsolve the problem ofinsufficient bloodsupply caused by titanium plate implantation In additionthe musculocutaneouspedicle could fill the subcutaneous cavitycreated by the huge tumourresectionpreventing occipitalia scalp hydrops andsecondary infection LTMF is an alternative approach for the repair of scalp andsubcutaneous soft tissue defects caused byexcision of a malignanttheoccipital regiontumour ofAuthors™ contributionsLW studied the case collected the referencesand wrote the paper ZH designed the reportand wrote the paper HC and HZ wrote thepaper XP analysed the data NR served as thefirst chief during surgery and wrote the paperAll authorsread and approved the finalmanuscriptDeclaration of conflicting interestThe authors declare that there are no conflicts ofinterestFundingThis project was supported by grants from theScientific Research Project of Hunan ProvincialHealth Commission No20200709 the HunanProvincial Natural Science Foundation of ChinaNo2019JJ40182 and the Sailing Programme ofHunan Provincial Cancer Hospitalorcid000000021069ORCID iDLei WangReferences Sabattini E Bacci F Sagramoso C et alWHO classification of tumours of haematopoietic and lymphoid tissues in anoverview Pathologica “ Gee ED and Sadovsky R Multiple myeloma recognition and management AmFam Physician “ Rizea RE Popescu M Ghehit¸ 15a KLet al Neurosurgical rare disease solitary 0cWang et alplasmacytoma of the skull “ case report andliterature review Rom J Morphol Embryol “ Chang MY Shih LY Dunn P et al Solitaryplasmacytoma of bone J Formos Med Assoc “ Weber DM Solitary bone and extramedullary plasmacytoma Hematology Am SocHematol Educ Program “ Caers J Paiva B Zamagni E et alDiagnosis treatment and response assessment in solitary plasmacytoma updated recommendations from a European ExpertPanel J Hematol Oncol Knobel D Zouhair A Tsang RW et alPrognostic factors in solitary plasmacytomaof the bone a multicenter Rare CancerNetwork study BMC Cancer Liebross RH Ha CS Cox JD et alSolitary bone plasmacytoma outcome andprognostic factors following radiotherapyInt J Radiat Oncol Biol Phys “ Mohos G Vass G Kemeny L et alExtended lowertrapezius myocutaneousflap to cover a deep lateral neck defect onirradiated skin a new application J PlastSurg Hand Surg “ U 15gurlu K Ozc¸ elik D Hu¨ thu¨ t I et alExtended vertical trapezius myocutaneousflap in head and neck reconstruction as asalvage procedure Plast Reconstr Surg “ Baek SM Biller HF Krespi YP et al Thelower trapezius island myocutaneous flapAnn Plast Surg “ Netterville JL and Wood DE The lower trapezius flap Vascular anatomy and surgicaltechnique Arch Otolaryngol Head NeckSurg “ 0c' Answer:

Thyroid_Cancer

" This study aimed to investigate serum matrix metalloproteinase MMP2 and MMP9levels in patients wit(...TRUNCATED)

cancer4

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Thyroid_Cancer

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Thyroid_Cancer

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cancer8

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