Use of sexual abuse as a means of political suppression in Africa

Use of sexual abuse as a means of political suppression in Africa

By Dr. Abbas Azadian,

According to recent reports, 150 countries continue to use torture and ill treatment as an instrument of po­litical pressure and repression against those who challenge the prevailing order. In Africa, inter-ethnic and armed conflicts have been ongoing struggles over last few years. These conflicts continue to fuel human rights abuses. People are caught in the conflict between governments and rebel forces and suffer appalling atrocities such as abduction, rape, amputation, torture and death. According to the most current Amnesty International report, human rights were violated and detainees were tortured and ill treated[1] in at least 32 African countries.

Sexual Abuse as an Instrument for Political Suppression

Sexual abuse and rape have been frequently used as a means of suppression. In many African countries, rape, mutilation and other forms of torture have been used as weapons of war in recent conflicts and in par­ticular when ethnic issues were prominent. In particular, rape and other forms of sexual violence have been inflicted on women in many African countries. Women in custody have been subjected to many forms of torture and in particular sexual violence and rape. These women may be psychologically traumatized for life. The ill effects of rape and sexual violence continue even when these women are forced to flee their countries of origin and subsequently seek refuge in a safe country like Canada. In this paper we will re­view a few cases of women who have been sexually abused in different settings to demonstrate the pro­found and long lasting effects of sexual abuse and rape on the victims.

Sexual Abuse in Political Settings

Case 1

Politically motivated harassment of opponents remained a public policy in Angola and many other African countries where officials systematically undermine freedom of expression and suppress any criticism of the government's practices.

BC is a 21-year-old woman from Angola. Her father was a political activist writing about corruption in the government, the lack of freedom and social justice in the country. The government of Angola had been fol­lowing his activities and harassing him on a regular basis. He was arrested on several occasions. On one particular night the government forces attacked their home. They started beating everyone. They also ran­sacked the place. "To give her father a lesson" she and her mother were sexually abused in front of the rest of family; her father included. She was later blindfolded and taken to jail. She was forced to do hard labor in prison. She was repeatedly raped during the 2 years she was in jail. She was also beaten up on a regular basis. This treatment continued until she used an occasion to escape the jail and the country. She has never seen her family members since that morning when the police came to their house.

BC's emotional reaction to the ongoing sexual abuse is one of detachment and depression. She is cold and distant. She persistently tries to avoid talking about her traumatic experiences. She is confused about time and place. She dissociates and things appear unreal to her. She also reports difficulties falling sleep. When she goes to bed she would continuously think about the traumatic events and sexual abuse. She usually wakes up in the middle of the night confused after having nightmares. Her heart races and she has diffi­culty breathing. Sometimes, she is unable to get back to sleep. As a result of inadequate sleep, she ex­periences extreme fatigue and has difficulty concentrating and functioning.

Case 2

GJ is a 30-year-old woman from Rwanda. She and her family endured many types of persecution, threats, violence and killing that extended beyond the war and continued to the present day. This in­cludes her gang rape at the hands of Hutu soldiers at a refugee camp where her family fled during the war. On another occasion, someone threw a hand grenade through the window of her house. When GJ arrived, she found one family member dead and another one mortally wounded.

GJ's emotional reaction is very similar to BC. She feels she has changed for life. She describes herself as being a happy, sociable and outgoing person before these incidents, and now feels very detached from others and keeps to herself. She does not want to be in any groups and prefers to stay in her room. She does not take pleasure in anything and no longer smiles. She feels continually sad. She is also troubled by very poor concentration and memory difficulties, often forgetting scheduled activities. She has great difficulties falling asleep at night because it is at this time that the memories of her rape and the grenade attack are strongest. She lies in bed remembering her assailants' voices and laughter and sees images of the scene of her rape or the grenade attack. She tries to block these thoughts out but is not successful. Often these thoughts and images keep her awake until 4 in the morning. Her sleep is also disturbed by nightmares wherein she hears friends crying for help. She runs to save them, but arrives too late. She awakens from these dreams with a pounding heart and cannot settle back to sleep afterward. She also describes a hypersensivity to sounds in her environment. For example, she gets extremely upset by sounds on the street, which remind her alternatively of artillery fire or of a grenade blast. She reports that when she hears these loud voices she instinctively "close the door and start running", her heart pounding. She says it takes her a few minutes before she realizes that she is no longer in Rwanda and that the sounds are benign. GJ's feelings of sadness are compounded by feelings of guilt. She feels re­sponsible for her rape, even though others have told her that she could not have prevented it from hap­pening. She wonders if she could have been "firmer" or more resolute in saying "no" to her assailants. Since her rape she has had a sense of being tainted and feeling "dirty". This pattern of thinking has per­sisted to this day. She sometimes wonders if she would be better off dead. While telling her story, GJ was anxious, hesitant, upset and tearful. She was sad.

Sexual Abuse in Domestic Settings

Case 3

As prominent as the use of sexual violence has been in armed conflicts, ethnic disputes and political re­pression, in most countries a woman's greatest risk of violence comes from people she knows. Violation of human rights against women happens not only at the hands of police and soldiers, but also at the hands of their own husbands, fathers or employers. In particular, sexual abuse may be used in domestic setting to intimidate women and force them into subversion. The following case is an example of the use of physical and sexual abuse in this setting and highlights the effect of economic hardship and poverty.

MK is a 27-year-old woman from Nigeria. She was forced to marry her husband when she was very young. Her husband was a dedicated Muslim and Imam (an Islamic religious leader). As soon as she moved to her husband's house, he started to abuse her in a variety of ways. He would beat her for not being covered properly. He would use a hot rod to inflict pain on her. On another occasion he put a hot cooking spoon on her body. This ill treatment continued until she could not tolerate it any longer and she ran away. She attempted to run away a few times but she was found every time and returned as she had very limited resources. Her punishment became worse each time she was returned. She was forced to do the chores of all four wives of the Imam. He raped her repeatedly and continued to physically abuse her. On one occasion when she had been caught and brought back, she was tied to a hook from the ceiling and a hot coal was put under her with ground, dried pepper in it to make breathing more difficult for her. Eventually she had to leave the country as she could not tolerate the pain and suffering inflicted on her and in particular she could not tolerate the sexual abuse.

Her emotional reaction to these repeated episodes of sexual abuse was what we expect from all victims of sexual abuse. She felt down and depressed. She thought of killing herself. The pain inflicted on her was so intolerable that she could not sleep, concentrate and function properly. She had a very difficult time in de­scribing the pain inflicted on her as well. She would get agitated and restless and would cry nonstop. MK' s situation is by no means unique.

Psychological Reactions to Sexual Abuse

The cases described demonstrate there is a tremendous range of frequently occurring reactions to trauma. Some people withdraw into silence; others seek out support or have a pressing need to talk about what hap­pened. Some may be preoccupied with thoughts about what they could have done differently to prevent what happened. Others may be filled with anger and rage at the injustice and feel a deep sense of hopelessness and helplessness. Abuse may affect victims physically, emotionally and behaviorally. It may affect also their thinking patterns. The physical reactions may include jitteriness, muscle tension, upset stomach, rapid heart rate, dizziness, fatigue and lack of energy. Emotional reactions may include extreme fear and inability to feel safe, sadness, grief and depression, guilt and anger, inability to enjoy anything, intense or extreme feeling at one time and a chronic feeling of emptiness at other times. As a result, the abused woman may become with­drawn or isolated from others, startle easily and avoid certain places and situations. She may also become confrontational and aggressive, change her eating habits, and become restless. The cognitive changes may include heightened awareness of surroundings at times and lessened awareness and disconnection from envi­ronment at other times. She may also think differently about herself and the world. She may have previously thought of herself as strong and independent. Subsequent to the traumatic experience she may think that she is no longer in control of her fate. She may also think the world is not a safe place to live in anymore. As a result she may not be able to trust anybody or count on people and feel more isolated as a result. This may lead to loss of self-esteem.

All people have psychological defenses that in difficult and stressful times protect them against fragmentation and loss of control. At times these defenses are overwhelmed to the degree that the person not only reacts negatively to events but may also meet the criteria for a psychiatric disorder. The most common and well know disorder in trauma victims is posttraumatic stress disorder. However the reaction is not limited to this condition. A wide variety of disorders including major depressive disorder, dysthymia, generalized anxiety disorder, panic attacks and substance abuse may be observed in trauma victims.

Conclusion

The cases discussed also demonstrate that torture and violence occurs in a wide range of circumstances and serves different purposes. There is no reliable estimate of the true prevalence of torture in the world. The above data published by Amnesty International that probably reflect but a fraction of all human abuses may give some idea about the extent of the problem. It appears that there is a wide spread and regular use of tor­ture and ill treatment in many African countries. These include whipping, flogging, caning, amputations, beating, verbal abuse and threats, isolation and solitary confinement, physical abuse and use of excessive force. Sexual abuse is also widely used in a variety of settings in these countries. Physical and sexual abuse is also used in domestic settings to maintain the dominance of men and subordination of women in the family and society.

The three cases discussed in this paper demonstrate the reality that torture has long-term and disabling psy­chological effects. Torture survivors and survivors of sexual abuse have more difficulties with concentration, memory, energy and sleep. They have nightmares in which they are being followed, arrested and tortured.

They wake up confused and demonstrate symptoms of anxiety. They may feel guilty about what happened and limit their contacts with other people and so lose their social network of support. These psychological problems can cause severe psychosocial disability that may last decades or even a lifetime.

To address psychological problems of torture survivors, interaction at several levels of care may be necessary. They may benefit from pharmacotherapy. Medication may improve their sleep, increase their energy and ap­petite and lift their mood. Nightmares and flashbacks may decrease as well. Psychological treatment for ef­fective rehabilitation of torture survivors has been widely recognized and advocated[2]. Most rehabilitation centers have adopted a multidisciplinary approach in the case of survivors, involving legal, medical, social and psychological help[3]. There is ample evidence that with adequate support and treatment, torture survi­vors can return to normal life and end the cycle of mental anguish. However, it appears that prevention of tor­ture and ill treatment of political detainees is the best method of limiting psychological pain to people tor­tured and of curbing the cost to society.

Certain safeguards are necessary to end the torture and ill treatment of detainees. These include clear policies that torture and ill-treatment will not be tolerated; an end to incommunicado detention, including giving de­tainees access to independent medical examination and legal counsel; outlawing the use of confessions ex­tracted under torture as evidence in courts of law; independent inspection of places of detention; informing detainees of their rights; human rights training for law enforcement personnel; compensation for the victims of torture; medical treatment and rehabilitation for the victims of torture[4]. Governments have to ensure that prison conditions do not amount to cruel inhuman or degrading treatment or punishment, in line with interna­tional human rights standards for the treatment of prisoners. Special attention should be paid to the issues of ethnic background and gender. An emphasis on working against abuses based on gender should be at the heart of any torture campaign. This includes the use of violence and in particular sexual abuse in domestic settings. Any form of torture is indefensible and may affect individuals for the rest of their lives.

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[1] Amnesty International. Amnesty International Annual Report. London, England: Amnesty Interna­tional Publication; 2001.

[2] Vesti P, Kastrup M. Psychotherapy for torture survivors. In Basoglu M, ed. Torture and Its Conse­quences: Current Treatment Approaches. Cambridge, England: Cambridge University Press; 1992:348-362

[3] Van Willigen LHM. Organization of care and rehabilitation services for victims of torture and other forms of organized violence: a review of current issues. In Basoglu M, ed. Torture and Its Conse­quences: Current Treatment Approaches. Cambridge, England: Cambridge University Press; 1992:277-298

[4] Amnesty International. Amnesty International Annual Report. London, England: Amnesty Interna­tional Publication; 2001

AFTERMATH OF TRAUMA: HOW TO REMAIN HEALTHY

AFTERMATH OF TRAUMA: HOW TO REMAIN HEALTHY

by Dr. Abbas Azadian, MD & Jean Hackney

Over the past few months I have been frequently asked about the psychological consequences of the terror in the United States and in particular the tragedy in New York City on the 11^th September. What are the implications of the New York tragedy for teachers and learners? Are there students in your classrooms who had friends, family in New York at that time, or who are newcomers from wartorn countries in danger of retraumatization by the tragedy?

People wonder what kind of psychologi­cal reactions they should expect. They wonder how long the effects are going to last and how severe they are going to be. To provide an honest answer I have to say that we do not know. In North America, we have never been in a similar situation in terms of the magnitude of the tragedy and losses and the degree of coverage by the media. We know that the closeness of people to the source of trauma affects their reactions.

One man who escaped the tragedy said: "I am traumatized for life!" He may not have a degree in psychology or may not be a psychiatrist but he is right in his cynical anticipation. People who observed the trauma first hand and those who escaped it narrowly may be traumatized for life. Who can forget those horrifying scenes?

One woman was in a business meeting on the 70th floor when the first plane crashed. "We could not see the plane coming toward us but we saw fire, smoke and papers", she said. She made it to the 44th floor when the second plane hit the opposite side of the building. "The building swayed probably about two feet. I thought at that point it was going to topple over. That was the moment I was probably the most scared."

She may remain scared for the rest of her life when she is walking up or down any stairwells. These people not only observed the most terrible scenes possible, they narrowly escaped certain death as well. The closeness to trauma and the magnitude of what they observed will put them at major risk of a psychi­atric disorder.

People are different and have different characters and backgrounds. They react to events differently. In general, the immediate behavioral reactions may include anxiety, depression, irritability, numbness and detachment. These people may feel that they are walking in a void. They may not be able to connect to others. There may be a sense of loss of time and space as though they are walking in space and daydreaming. They may be confused and not able to recognize where they are and who they are.

This confusion may lead to a more distressing phenomenon. Being confused about time and place, the victims may think that the events are happening again. They re-experience the events as though they are occurring. For the victim this experience is as real as the original event. During these times they may react with horror. Their heart may start racing and they may have difficulties breathing. They could become nervous and develop muscle tension. They may scream and try to run away. They will be detached from their environment.

These behavioral and physiological responses will not be limited to when they are awake. They may have difficulty falling asleep. They review the events again and again. Eventually when they sleep they re-experience the events in their dreams. They wake up from night­mares screaming and drenched in sweat. They may be confused or look frightened. They do not know where they are. Their heart starts racing again. They may not be able to go back to sleep for the rest of the night. This is going to affect their ability to concentrate and think. Their memory will be slow. They feel tired and cannot function or relate to others easily.

Victims of a tragedy as horrifying as this are going to react to these terrible events emotionally as well. The feeling of terror will continue. They feel unsafe. This includes a sense of being unable to protect themselves. The experience leaves a deep sense of distrust in them and they may not be able to rely on others when they need to. They cannot trust others. They feel helpless and think that their actions cannot change or influence current situations. They feel numb, empty and used up. They may have a dull sense of terror, horror, and rage about what happened and may not be able to express these feelings. These events will change the way they look at themselves, the world and others.

These reactions will not be limited to people who observed the tragedies first hand or were within the vicinity of the events and so at risk. They may happen in people who have been repeatedly watching these events on television. The risk is lower, the severity of reaction less and the length of reaction is shorter. Nevertheless the risk exists and we all have to be watchful and try to protect ourselves.

People react to stress in differ­ent ways; however, there are common behaviors that teach­ers might see in the classroom as a result of such a tragedy.

There may be disruptions that learners experience around the tragedy, and this may mean that:

• Some learners may not be prepared to learn. They may be apathetic, being uninterested in learning. Their emotional distress may get in the way of academic progress

• Some learners might be unusually quiet or withdrawn

• There might be increased absenteeism (complaints of headaches, stomach­aches, or other symptoms of illness)

• There might be outbursts of anger, irritability or sudden changes in mood

• Learners might appear more distracted than usual; have poor concentrations, attention problems, restlessness, or daydreaming

• Some learners might be lethargic, tired and perhaps sleep in class

• Classroom management may be more difficult; teachers may have to deal with regressive, withdrawn or disruptive behavior.

You might not be aware of the effects of long-term disruptions immediately. Problems might not surface until weeks, months, or even longer after the disaster. As teachers, there are things you can do in the classroom around the tragedies of the past few months. Provide classroom activities that will help to learn how to cope with difficulties:

• Provide activities that encourage learners to share experiences and express feelings

• Introduce a study unit that focuses on learning about disasters

• Prepare a study project on health and safety to give students a feeling of competence, confidence and control in being able to handle disaster tragedies

Teachers may face greater strains if they are having disaster related difficulties of their own. Take care of yourself. You might find that the classroom activities create stresses for you as well. You will be a greater help to students and your colleagues if you can acknowledge your own experiences and feelings.

Teachers are continual learners. Some general knowledge around trauma can be helpful to yourself and the learners. Trauma can be isolating and people may feel separated from one another. To avoid this, try to share your feelings and thoughts with others. Seek support from friends, family and co-workers on the one hand and help them to deal with this tragedy on the other. Allow yourself to cry; it provides a good relief and release. Write, draw or use any other medium to record your thoughts and emotions. Spend more time with your loved ones. Plan some outdoor activities. Go for a walk. Listen to music. Do exercises. You do not have to follow the news channels all day long. Give yourself a break.

In particular, be mindful of children. Make yourself available to them so that they know they could talk to you. There is nothing wrong with showing emotions, like crying, in front of children. It tells them that you are a normal human being who cares for the well being of others and feel hurt when others are hurt. But remember not to show excessive distress and anxiety in front of them. Remind them that despite isolated events like this, no matter how horrible the event, they are still living in a relatively safe place in this country. And remember that disasters may also provide an opportunity to change and grow and become stronger. Tragedies may bring us closer to each other. The last thing to remember is that if you did all of these and you still experi­ence difficulties, then you should talk to professionals. In particular, talk to your family doctor.

Many people who experience tragedy so closely could be affected for the rest of their life. They are going to love but not the way they used to. They are going to live but not how they used to. They are going to work but not the way they used to. They have changed for life. They may even become stronger.

Thyroid Disease

Title: Ultrasound-guided fine-needle aspiration biopsy in the management of thyroid disease

Author(s ) ROSEN I. B. (1) ; ABBAS AZADIAN (1) ; WALFISH P. G. ; SHIA SALEM; LANSDOWN E. ; BEDARD Y. C

Author(s) Affiliation(s) (1) Univ. Toronto, Mount Sinai hosp., dep. surgery, Toronto ON, CANADA

Abstract
During a 23-month period, 59 patients were referred for ultrasound (US)-guided tine-needle aspiration biopsy (FNAB) of the thyroid gland because of inadequate orthodox (office) FNAB, a clinically small lesion, or an occult lesion. Seventy percent of the group (41 patients) was referred for surgery, which revealed cancer in 37% of patients, adenoma in 19%, and benign disease in 44%. US-guided FNAB yielded fase-positive reports in 0% of patients, false-negative reports in 5% to 12%, and inadequate aspirates in 32%. The US-guided FNAB technique had a sensitivity of 60% to 90%, a specificity of 100%, a positive predictive value of 100%, a negative predictive value of 80%, and an accuracy of 85%

Journal Title
The American journal of surgery ISSN 0002-9610 CODEN AJSUAB

Cross-sensitivity between paroxetine and sertraline

Cross-sensitivity between paroxetine and sertraline
CA Warnock and AG Azadian

OBJECTIVE: To report a case of possible cross-sensitivity between selective serotonin-reuptake inhibitors (SSRIs). CASE SUMMARY: A 20-year-old Southeast Asian man developed a maculopapular rash soon after starting paroxetine. Following resolution of this rash, another skin reaction with the same distribution and appearance occurred after sertraline therapy was started. DISCUSSION: Cross-reactivity between drugs with similar structures has been reported; however, cross-reactivity among SSRI antidepressants is unexpected given their differences in chemical structure. CONCLUSIONS: The possibility of cross-reactivity between SSRI antidepressants should be considered by clinicians who wish to switch from one SSRI to another due to a dermatologic reaction.

Journal title:
The Annals of Pharmacotherapy: Vol. 36, No. 4, pp. 631-633. DOI 10.1345/aph.1A262

Adverse aspects of small thyroid cancer and need for treatment

Adverse aspects of small thyroid cancer and need for treatment

Dr. Irving B. Rosen, MD *, Abbas Azadian, Paul G. Walfish, MD

Combined Endocrine Tumor Clinic, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada

^*Correspondence to Irving B. Rosen, 600 University Avenue, Suite 478, Toronto, Ontario, Canada M5G 1X5

Abstract

Background. Small, well-differentiated thyroid cancer (tumor <1.5>

Methods. A total of 382 thyroid cancer patients were reviewed. Of these, 99 patients had tumors that were < class="blsp-spelling-error" id="SPELLING_ERROR_4">extrathyroidal invasion, or metastatic disease were studied.

Results. Thirty-five patients (one-third of the <1.5 class="blsp-spelling-error" id="SPELLING_ERROR_5">thyroidectomy and neck dissection as well as orthopedic procedures for metastatic bone disease. Radioiodine ablation was used in 33 patients, external radiation in 5. Thirty-one patients are well without disease, 3 are alive with disease, 1 died of disease.

Conclusions. Small, well-differentiated thyroid cancer is infrequently aggressive, but it may be a source for metastatic morbidity and recurrence and can be viewed as potentially lethal. Need for treatment should not be ignored based solely on the size of the tumor. © 1995 Jons Wiley & Sons, Inc.

Journal Title:

Head & Neck Volume 17 Issue 5, Pages 373 - 376

Immunohistochemical localization of p53 in human thyroid neoplasms: Correlation with biological behavior

Immunohistochemical localization of p53 in human thyroid neoplasms: Correlation with biological behavior

Sefik A. Hosal¹ , Robyn L. Apel², Jeremy L. Freeman¹, Abbas Azadian³, Irving B. Rosen³, Virginia A. LiVolsi⁴ and Sylvia L. Asa²

(1)	Department of Otolaryngology Mount Sinai Hospital, University of Toronto, 600 University Avenue, M5G 1X5 Toronto, Canada

(2)	Department of Pathology Mount Sinai Hospital, University of Toronto, 600 University Avenue, M5G 1X5 Toronto, Canada

(3)	Department of Surgery Mount Sinai Hospital, University of Toronto, 600 University Avenue, M5G 1X5 Toronto, Canada

(4)	Department of Pathology, University of Pennsylvania Medical Center, Philadelphia, PA

Abstract Molecular analyses of thyroid tumors have documented mutations in the tumor suppressor p53 gene almost exclusively in anaplastic carcinomas. In contrast, immunohistochemistry has localized p53 in differentiated papillary and follicular thyroid cancers. To establish the significance of p53 immunolocalization in these lesions, 78 thyroid tumors of follicular derivation were examined. All tumors were classified by strict criteria and the extent of tumor was determined morphologically. Immunohistochemical staining for p53 was performed on paraffin sections of formalin-fixed tumor tissue. The results of staining were correlated with diagnosis, tumor extent and clinical outcome. Immunopositivity for p53 was diffuse and strong in all five anaplastic carcinomas examined. There was no staining in five of six follicular adenomas. Four of nine follicular carcinomas had some degree of nuclear staining, but this was focal; all nine tumors were confined to the thyroid at the time of examination. Of 49 papillary carcinomas, 26 were intrathyroidal, and 7 of these were occult; there was no p53 positivity in any occult lesion and only 5 of the 19 palpable lesions stained. In contrast, among 23 papillary carcinomas with extrathyroidal extension or metastases, only 9 were negative for p53 immunoreactivity. Five of seven tall cell papillary carcinomas and one of two insular carcinomas had p53 immunopositivity and this correlated with aggressive behavior. These results support the tumorigenic role of p53 mutations postulated for anaplastic thyroid carcinomas and indicate that localization of p53 by immunohistochemistry is a useful prognostic index of clinical behavior in differentiated thyroid carcinomas of follicular cell derivation.

Journal Title:
Endocrine Pathology Volume 8, Number 1 / March, 1997 Page 21-28

Management considerations in Hürthle cell carcinoma

Management considerations in Hürthle cell carcinoma^*

References and further reading may be available for this article. To view references and further reading you must purchase this article.

Abbas Azadian^{a, b, c, d,} , MDIrving B. Rosen^{a, b, c, d}, MDPaul G. Walfish^{a, b, c, d} and MDSylvia L. Asa^{a, b, c, d}

^aCombined Endocrine Tumor Clinic Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada

^bDepartment of Surgery, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada

^cDepartment of Endocrinology, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada

^dDepartment of Pathology, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada

Available online 31 May 2006.

Background. Hürthle cell tumors still pose issues concerning diagnosis and management.

Methods. From 1984 to 1993 forty-seven patients underwent thyroidectomy, and they were diagnosed after operation to have presumptive Hürthle cell tumors. The surgical pathologic findings were reviewed. In the neoplastic group the chart was reviewed for clinical features and outcome.

Results. Thirty-one patients had nonneoplastic Hürthle cell nodules. Eleven (69%) of the 16 tumors were malignant affecting 11 women and five men ranging in age from 22 to 86 years. Two patients died of cancer for a 18% rate; one patient is alive with disease. Operations were uncomplicated. Factors for adverse outcome include tumor size greater than 4 cm, woman older than 60 years of age, and complete capsular invasion on surgical pathologic findings.

Conclusions. Fine-needle aspiration biopsy demonstration of Hürthle cell lesion is an indication for operation, providing Hashimoto's thyroiditis is excluded. Our surgical practice (I.B.R.) is to perform total thyroidectomy for all Hürthle cell neoplasms, as well as jugular node sampling and adjuvant radioiodine for cancer. Stringent histologic interpretation is possible and necessary for true appreciation of Hürthle cell tumor incidence and behavior. Cancer mortality of 18% is greater than the rate (2%) of our well-differentiated thyroid cancer group.

^*Presented at the Fifty-second Annual Meeting of the Central Surgical Association, Cleveland, Ohio, March 9–11, 1995.

Journal title:

Surgery Volume 118, Issue 4, October 1995, Pages 711-715

Ultrasound-guided fine-needle aspiration biopsy in the management of thyroid disease

Ultrasound-guided fine-needle aspiration biopsy in the management of thyroid disease

Dr. Irving B. Rosen, MD *, Abbas Azadian, Paul G. Walfish, MD
Combined Endocrine Tumor Clinic, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada

*Correspondence to Irving B. Rosen, 600 University Avenue, Suite 478, Toronto, Ontario, Canada M5G 1X5

Abstract
Background. Small, well-differentiated thyroid cancer (tumor <1.5 cm) is frequently dismissed as biologically inconsequential, although varied reports have offered differing experiences.
Methods. A total of 382 thyroid cancer patients were reviewed. Of these, 99 patients had tumors that were < 1.5 cm. Thirty-five patients in this group with positive nodes, extrathyroidal invasion, or metastatic disease were studied.
Results. Thirty-five patients (one-third of the <1.5 cm group) showed other sites of involvement: nodes, 28; lung, 1; muscle, 7; nerve, 5; and bone, 2. Six patients had residual cancer following surgery. Surgery included thyroidectomy and neck dissection as well as orthopedic procedures for metastatic bone disease. Radioiodine ablation was used in 33 patients, external radiation in 5. Thirty-one patients are well without disease, 3 are alive with disease, 1 died of disease.
Conclusions. Small, well-differentiated thyroid cancer is infrequently aggressive, but it may be a source for metastatic morbidity and recurrence and can be viewed as potentially lethal. Need for treatment should not be ignored based solely on the size of the tumor. © 1995 Jons Wiley & Sons, Inc.

Journal Title:
Head & Neck Volume 17 Issue 5, Pages 373 - 376