Keith S Heller, M.D.

Importance of intraoperative parathyroid hormone measurement in the diagnosis of parathyroid lipoadenoma
Lee, Ann Y; Wang, Beverly Y; Heller, Keith S
2011 Jun;33(6):917-919, Head & neck
BACKGROUND.: Parathyroid lipoadenoma is an uncommon tumor that may be difficult to diagnose on intraoperative frozen section. Intraoperative parathyroid hormone (PTH) measurement is useful in assessing the adequacy of parathyroidectomy. This case demonstrates the value of intraoperative PTH measurement in recognizing a parathyroid lipoadenoma. METHODS AND RESULTS.: A case of a 62-year-old woman with primary hyperparathyroidism in which intraoperative PTH measurement helped confirm the diagnosis of parathyroid lipoadenoma is presented. CONCLUSIONS.: In patients with primary hyperparathyroidism, a significant decrease in intraoperative PTH confirms that an enlarged parathyroid with normal to low cellularity containing abundant fat is a lipoadenoma and that further exploration is not necessary. (c) 2010 Wiley Periodicals, Inc. Head Neck, 2011
— id: 132304, year: 2011, vol: 33, page: 917, stat: Journal Article,

Validation of the histologic risk model in a new cohort of patients with head and neck squamous cell carcinoma
Brandwein-Gensler, Margaret; Smith, Richard V; Wang, Beverly; Penner, Carla; Theilken, Andrea; Broughel, Darcy; Schiff, Bradley; Owen, Randall P; Smith, Jonathan; Sarta, Cathy; Hebert, Tiffany; Nason, Rick; Ramer, Marie; DeLacure, Mark; Hirsch, David; Myssiorek, David; Heller, Keith; Prystowsky, Michael; Schlecht, Nicolas F; Negassa, Abdissa
2010 May;34(5):676-688, American journal of surgical pathology
BACKGROUND: Half of the patients with head and neck squamous cell carcinoma (HNSCC) can be expected to fail therapy, indicating that more aggressive treatment is warranted for this group. We have developed a novel risk model that can become a basis for developing new treatment paradigms. Here we report on the performance of our model in a new multicenter cohort. DESIGN: Eligible patients from 3 institutions (Montefiore Medical Center, University of Manitoba, and New York University Medical Center) were identified and pathology slides from their resection specimens were reviewed by Margaret Brandwein-Gensler; risk category was assigned as previously published. Kaplan-Meier analysis was performed for disease progression and survival. Cox proportional hazards regression was performed, adjusted for potential confounders. A teaching module was also developed; attending pathologists were asked to score coded slides after a lecture and multiheaded microscope teaching session. Agreement was assessed by calculating Cohen unweighted kappa coefficients. RESULT: The validation cohort consisted of 305 patients, from the above institutions, with 311 primary HNSCC of the oral cavity, oropharynx, and larynx. The median follow-up period for all patients was 27 months. Risk category predicts time to disease progression (P=0.0005), locoregional recurrence (P=0.013), and overall survival (P=0.0000) by Kaplan-Meier analysis. High-risk status is significantly associated with decreased time to disease progression, adjusted for clinical confounders (P=0.015, hazard ratio 2.32, 95% confidence interval 1.18-4.58) compared with collapsed intermediate and low-risk groups. We also demonstrate substantial interrater agreement (kappa=0.64), and very good rater agreement when compared with the standard (kappa=0.87). CONCLUSIONS: We demonstrate significant predictive performance of the risk model in a new cohort of patients with primary HNSCC, adjusted for confounders. Our training experience also supports the feasibility of adapting the risk model in clinical practice
— id: 120802, year: 2010, vol: 34, page: 676, stat: Journal Article,

Is screening appropriate for occult cervical lymph node metastases in patients with well-differentiated thyroid cancer?
Heller, Keith S
2010 Aug;20(8):933-934, Thyroid
— id: 111546, year: 2010, vol: 20, page: 933, stat: Journal Article,

Impact of the 2009 American Thyroid Association guidelines on the choice of operation for well-differentiated thyroid microcarcinomas
Ogilvie, Jennifer B; Patel, Kepal N; Heller, Keith S
2010 Dec;148(6):1222-1227, Surgery
BACKGROUND: The 2009 ATA Guidelines state 'lobectomy alone may be sufficient treatment for small (<1 cm), low risk, unifocal, intrathyroidal papillary carcinomas in the absence of . . . nodal metastases.' We determined how often these criteria are satisfied, and whether tumor size alone can dictate operative management. METHODS: Medical records of 346 patients with well-differentiated thyroid cancer (WDTC) who underwent thyroidectomy from January 1, 2007 to November 10, 2009, were reviewed. There were 130 patients with tumors </=1 cm and negative lateral nodes. Pathology reports were reviewed to identify adverse features including multifocality, extrathyroidal extension, vascular invasion, and central node metastases. RESULTS: Eighty-four percent underwent total thyroidectomy and 16% central node dissection. All but 2 patients had papillary cancer. Sixty-one percent with cancers 6-10 mm (group 1) had adverse pathologic features compared with 32% with cancers <6 mm (group 2). Multifocality was most common: 55% in group 1 versus 32% in group 2 (P = .004). Positive central nodes were identified in 23% of group 1 versus 4% of group 2 (P = .004). Of patients in group 1, 88% had positive or suspicious fine-needle aspiration biopsy (FNAB) preoperatively. CONCLUSION: We recommend that total thyroidectomy be considered as the initial operation for thyroid tumors 6-10 mm in size in which the preoperative FNAB is diagnostic or suspicious for WDTC
— id: 115280, year: 2010, vol: 148, page: 1222, stat: Journal Article,

Immunohistochemical evaluation of napsin, PAX-8, beta-catenin, TIFIg, Cyclin D1, p16, and EGFR in papillary thyroid carcinoma
Sun, W.; Yee, M.; Nonaka, D.; Roses, D.; Heller, K.; Han, E. Y.; Wang, B. Y.
2010 OCT ;57(11):70-70, Histopathology
— id: 113924, year: 2010, vol: 57, page: 70, stat: Journal Article,

Reoperative parathyroid surgery
Heller K.S.
2009 ;20(1):66-70, Operative techniques in otolaryngology, head & neck surgery
Reoperative parathyroid surgery can be technically challenging and exposes the patient to a higher risk of complications than initial parathyroidectomy. Initial surgical failure can be avoided by thorough, bilateral exploration by an experienced parathyroid surgeon or by the use of intraoperative parathyroid hormone (PTH) monitoring if a limited exploration is planned. Before undertaking a reoperation for hyperparathyroidism the patient must be fully reevaluated including a reassessment of the need for surgery, a review of all previous surgical and pathology reports, and the performance of imaging studies to identify the location of the missing gland. An understanding of parathyroid embryology and anatomy helps identify possible locations of missing glands. The specific surgical approach is dictated by the anticipated location of the abnormal gland. Intraoperative PTH monitoring can limit the extent of reoperative surgery. Recurrent laryngeal nerve monitoring can help decrease the risk of complications. copyright 2009 Elsevier Inc. All rights reserved
— id: 100946, year: 2009, vol: 20, page: 66, stat: Journal Article,

Relation of final intraoperative parathyroid hormone level and outcome following parathyroidectomy
Heller, Keith S; Blumberg, Sheila N
2009 Nov;135(11):1103-1107, Archives of otolaryngology, head & neck surgery
OBJECTIVE: To determine if final intraoperative parathyroid hormone (IOPTH) level predicts those at risk for recurrence after parathyroidectomy. Minimally invasive parathyroid exploration guided by preoperative imaging and IOPTH level is an accepted alternative to bilateral exploration for the treatment of primary hyperparathyroidism (HPT). However, additional enlarged, hypercellular parathyroid glands are present in some patients in whom IOPTH levels fall to normal after excision of a single adenoma. At least 15% of patients are normocalcemic with elevated PTH levels (PPTH) after parathyroidectomy. In these patients, a higher risk of recurrent HPT has been found. DESIGN: Retrospective review of medical records. SETTING: University teaching hospital. PATIENTS: The records of all 194 patients who underwent successful initial parathyroidectomy for nonfamilial HPT in 2007 and 2008 by 1 surgeon were reviewed. MAIN OUTCOME MEASURES: Intraoperative PTH level was measured prior to incision (baseline); at excision of the abnormal gland; at 5, 10, 15, and 20 minutes after excision; and at various additional times as needed. Of the patients, 71% underwent minimally invasive parathyroid exploration. Calcium, PTH, and 25-hydroxyvitamin D levels were measured during the first month after surgery in all patients and after 3 months or more in 80%. Patients were divided into 5 groups depending on the following final IOPTH levels: lower than 10 pg/mL (group l) (to convert PTH to nanograms per liter, multiply by 1.0); 10 to 19 pg/mL (group 2); 20 to 29 pg/mL (group 3); 30 to 39 pg/mL (group 4); and 40 pg/mL or higher (group 5). RESULTS: Of the patients, 82% had a single adenoma, 9% had double adenomas, and 9% had 3 or more abnormal glands. The final IOPTH/baseline IOPTH value in groups 1 to 5 was 7%, 11%, 16%, 23%, and 26%, respectively. There was no significant difference in the preoperative calcium among the groups. All 3 patients with persistent HPT and 5 patients with PPTH were in group 5. One of the 96 patients in groups 1 and 2 and 5 of the 72 patients in groups 3 and 4 had PPTH at the last evaluation. CONCLUSION: Patients with a final IOPTH level of 40 pg/mL or higher are at higher risk of having persistent HPT and should be followed up closely and indefinitely following parathyroidectomy
— id: 105346, year: 2009, vol: 135, page: 1103, stat: Journal Article,

Preoperative parathyroid scintigraphic lesion localization: accuracy of various types of readings
Nichols, Kenneth J; Tomas, Maria B; Tronco, Gene G; Rini, Josephine N; Kunjummen, Biju D; Heller, Keith S; Sznyter, Laura A; Palestro, Christopher J
2008 Jul;248(1):221-232, Radiology
PURPOSE: To retrospectively compare the accuracy of various parathyroid scintigraphy readings for single-gland disease (SGD) and multigland disease (MGD) in patients with primary hyperparathyroidism, with histologic analysis as the reference standard. MATERIALS AND METHODS: Institutional review board approval was obtained for this HIPAA-compliant study. Records of 462 patients with primary hyperparathyroidism who underwent preoperative imaging with a technetium 99m ((99m)Tc) sestamibi and (99m)TcO4- protocol that consisted of early and late pinhole (99m)Tc sestamibi, pinhole thyroid imaging, image subtraction, and single photon emission computed tomography (SPECT) were retrospectively reviewed. An experienced nuclear medicine physician without knowledge of other test results or of the final diagnoses graded images on a scale from 0 (definitely normal) to 4 (definitely abnormal). Early pinhole (99m)Tc sestamibi images, late pinhole (99m)Tc sestamibi images, subtraction images, SPECT images, early and late pinhole (99m)Tc sestamibi images, all planar images, and all images--including SPECT images--were read in seven sessions. Receiver operating characteristic curves were generated for each session and were used to calculate sensitivity, specificity, and accuracy. RESULTS: A total of 534 parathyroid lesions were excised. Of the 462 patients, 409 had one lesion, whereas 53 had multiple lesions. Reading all images together was more accurate (89%, P = .001) than was reading early (79%), late (85%), subtraction (86%), and SPECT (83%) images separately; however, it was not significantly more accurate than reading planar images (88%) or early and late images together (87%). Reading all images was significantly less sensitive in the detection of lesions with a median weight of 600 mg or less than in the detection of lesions with a median weight of more than 600 mg (86% vs 94%, P = .004). Per-lesion sensitivity for reading all images was significantly higher for SGD than for MGD (90% vs 66%, P < .001). Sensitivity of reading all images together in the identification of patients with MGD was 62%. CONCLUSION: Reviewing early, late, and subtraction pinhole images together with SPECT images maximizes parathyroid lesion detection accuracy. Test sensitivity is adversely affected by decreasing lesion weight and MGD
— id: 80343, year: 2008, vol: 248, page: 221, stat: Journal Article,

Do all cancers need to be treated? The role of thyroglobulin in the management of thyroid cancer: the 2006 hayes martin lecture
Heller, Keith S
2007 Jul;133(7):639-643, Archives of otolaryngology, head & neck surgery
— id: 73078, year: 2007, vol: 133, page: 639, stat: Journal Article,

Warthin-like tumor of the thyroid gland: an uncommon variant of papillary thyroid cancer
Kim, Harold H; Myssiorek, David; Heller, Keith S; Zahurullah, Fazlur; Bhuiya, Tawfiqul
2006 Jan;85(1):56-59, Ear, nose & throat journal
Several variants of papillary thyroid cancer have been described, including, most recently, Warthin-like tumor of the thyroid gland. To bring attention to this uncommon variant, we review previous reports on this entity and we add 5 new cases to the literature. We retrospectively reviewed the records of all patients who had undergone thyroidectomy at our institution during a 7-year period. Among these cases, we identified 5 patients who had had a Warthin-like tumor of the thyroid. From their charts, we compiled data on age, sex, lymphadenopathy, distant spread, and treatment. Pathologic specimens were reviewed for tumor size, capsular invasion, and vascular invasion. All 5 patients were women (mean age: 51.6 yr). Tumor size ranged from 0.9 to 2.0 cm. Multifocality was seen in 1 of the 5 patients; this patient was also the only one who experienced capsular and vascular invasion. No patient had lymph node spread or distant metastasis. Because the follow-up period among these patients was still short, we were unable to analyze long-term survival data
— id: 71066, year: 2006, vol: 85, page: 56, stat: Journal Article,

Value of positron emission tomography (PET) scan in treatment decision making for nodal metastases in head and neck squamous cell cancer
Mehrotra, B; Roy, R; Radhakrishnan, N; Gabalski, E; Myssiorek, D; Rush, S; Ebling, D; Pollack, J; Dubner, S; Heller, K
2006 JUN 20 ;24(18):299S-299S, Journal of clinical oncology
— id: 73775, year: 2006, vol: 24, page: 299S, stat: Journal Article,

Low pretreatment hemoglobin and advanced age: Important adverse prognostic factors in head and neck cancer independent of treatment modality. A large single institutional study
Mehrotra, B; Seetharamu, N; Janson, D; Heller, K; Myssiorek, D; Pollack, J; Nissel-Horowitz, S; Thomas, A; Kohn, N
2005 JUN 1 ;23(16):506S-506S, Journal of clinical oncology
— id: 73776, year: 2005, vol: 23, page: 506S, stat: Journal Article,

Persistently elevated parathyroid hormone levels after parathyroid surgery
Wang, Tracy S; Ostrower, Samuel T; Heller, Keith S
2005 Dec;138(6):1130-1135, Surgery
BACKGROUND: Persistent elevation of serum parathyroid hormone (PTH), despite normocalcemia, occurs in 8% to 40% of patients after parathyroidectomy. Explanations have included hypocalcemia owing to vitamin D deficiency or bone remineralization, and persistent hyperparathyroidism. METHODS: A retrospective chart review of 816 consecutive patients who underwent surgery for primary hyperparathyroidism was conducted. RESULTS: One hundred fourteen patients (15%) had persistently elevated PTH levels (PPTH). Patients with PPTH had higher preoperative PTH levels than those with normal PTH levels postoperatively. They also had lower postoperative Ca(++) and vitamin D levels. Multiple gland enlargement was identified in fewer patients with PPTH than in those with normal postoperative PTH levels. In patients with PPTH and a postoperative Ca(++) less than 9.6 mg/dL (group I), there was a greater decrease in IOPTH, a higher initial postoperative PTH level, and a lower postoperative vitamin D level than in PPTH patients whose postoperative Ca(++) was > or =9.6 mg/dL (group II). Postoperative Ca(++) and vitamin D levels were also lower in patients whose PPTH did not ultimately resolve. Three patients in group II had recurrent disease. CONCLUSIONS: Persistent elevation of postoperative serum PTH levels in normocalcemic patients is associated with mild hypocalcemia, probably owing to vitamin D deficiency. In some patients it may also be indicative of mild persistent hyperparathyroidism
— id: 71067, year: 2005, vol: 138, page: 1130, stat: Journal Article,

The clinical significance and anatomic distribution of parathyroid double adenomas
Bergson, Eric J; Heller, Keith S
2004 Feb;198(2):185-189, Journal of the American College of Surgeons
BACKGROUND: Parathyroid double adenomas are reported to occur in 3% to 12% of cases of primary hyperparathyroidism, but the very existence of double adenomas has been controversial. This study was undertaken to evaluate the clinical significance and anatomic distribution of parathyroid double adenomas. STUDY DESIGN: The medical records of 384 consecutive patients who underwent operation for primary hyperparathyroidism were reviewed. RESULTS: A total of 27 patients (7%) were found to have double parathyroid adenomas. Intraoperative parathyroid hormone (PTH) levels were measured in each case. Two enlarged hypercellular parathyroid glands were identified in 6 possible configurations: 10 both superior, 3 both inferior, 5 both right, 3 both left, 5 right superior and left inferior, and 1 left superior and right inferior. There was preferential distribution to the bilateral superior position (p = 0.008). In all patients intraoperative PTH levels dropped by at least 50% from baseline and into the normal range after removal of both abnormal parathyroid glands. All patients remain normocalcemic 1 to 26 months postoperatively. Two patients have persistently elevated PTH values with normal serum calcium levels. CONCLUSIONS: The drop in intraoperative PTH levels and maintenance of normocalcemia postoperatively confirm previous reports that double adenomas do exist and are not simply missed cases of four-gland hyperplasia. Their incidence is more than would be expected by chance alone. The preferential occurrence of bilateral superior double adenomas suggests the possibility that these may represent hyperplasia of parathyroids arising from the fourth branchial pouch rather than isolated neoplastic events
— id: 71068, year: 2004, vol: 198, page: 185, stat: Journal Article,

Sestamibi scans and intraoperative parathyroid hormone measurement in the treatment of primary hyperparathyroidism
Bergson, Eric J; Sznyter, Laura A; Dubner, Sanford; Palestro, Christopher J; Heller, Keith S
2004 Jan;130(1):87-91, Archives of otolaryngology, head & neck surgery
OBJECTIVE: To assess the value of preoperative sestamibi scanning and intraoperative parathyroid hormone (IOPTH) measurement in the treatment of patients with primary hyperparathyroidism due to multiple gland disease (MGD). DESIGN: Retrospective medical record review. SETTING: Tertiary care academic medical center. PATIENTS: The study population comprised 383 consecutive patients who underwent surgery for primary hyperparathyroidism at Long Island Jewish Medical Center, New Hyde Park, NY, between June 1, 1999, and January 31, 2002. INTERVENTIONS: Sestamibi scanning, IOPTH measurement, bilateral parathyroid exploration, and minimally invasive parathyroid surgery. MAIN OUTCOME MEASURES: Rate of postoperative persistent hyperparathyroidism. RESULTS: A total of 376 patients met the requirements for inclusion in the study. There were 275 women (73%) and 101 men (27%). Of the patients, 325 (86%) had single adenomas, 28 (7%) had double adenomas, 16 (4%) had 3 or more abnormal glands, and 1 had parathyroid cancer. There were 9 cases (2%) of persistent or recurrent hypercalcemia after surgery. Duration of follow-up ranged from 1 to 37 (median, 7) months. The sensitivity of sestamibi scanning for detecting MGD was 23%, and the positive predictive value was 63%. Using the requirement that the IOPTH level fall by 50% from the first baseline and into the normal range, MGD was distinguished from solitary adenoma in 36 (88%) of 41 cases. CONCLUSIONS: The combination of preoperative sestamibi scanning and IOPTH measurement is effective in identifying cases of MGD and allows successful minimally invasive parathyroidectomy in most patients
— id: 71070, year: 2004, vol: 130, page: 87, stat: Journal Article,

Incidence of metastatic well-differentiated thyroid cancer in cervical lymph nodes
Wang, Tracy S; Dubner, Sanford; Sznyter, Laura A; Heller, Keith S
2004 Jan;130(1):110-113, Archives of otolaryngology, head & neck surgery
OBJECTIVE: To determine the incidence of clinically positive lateral cervical nodes at presentation and after initial treatment in patients with well-differentiated thyroid cancer. DESIGN: Retrospective chart review. SETTING: University-affiliated teaching hospitals. PATIENTS: A total of 508 patients who underwent a thyroidectomy as part of their initial treatment for well-differentiated thyroid carcinoma between January 1978 and December 1999. Neck dissections were performed only for clinically palpable cervical nodes. MAIN OUTCOME MEASURES: Recurrence in the neck and survival. RESULTS: Forty-four patients (9%) had palpable lateral cervical lymph nodes at the time of surgery. All 31 patients younger than 45 years presenting with palpable positive nodes are alive and free of disease; 4 of 13 patients 45 years or older have died of thyroid cancer. Only 16 (3%) of 464 patients who did not undergo initial neck dissection had recurrence in lateral cervical nodes. Recurrence is more likely when the initial tumor is larger than 4 cm. In 216 patients younger than 45 years, there were 5 (2%) recurrences in lateral cervical nodes; these patients remain alive and free of disease. In 248 patients 45 years or older, there were 11 (4%) with recurrent disease in the lateral neck; 4 of these patients have died of thyroid cancer. CONCLUSIONS: An aggressive approach to detecting and treating occult lateral cervical nodes by techniques such as jugular node sampling, sentinel node biopsy, or image-guided needle biopsy is not necessary in most patients. Attempts to detect and remove occult lateral cervical lymph node metastases might be considered in older patients with large primary tumors
— id: 71069, year: 2004, vol: 130, page: 110, stat: Journal Article,

The training of head and neck surgeons: the care of head and neck patients: 2002 Presidential Address, American Head and Neck Society
Heller, Keith S
2003 Jan;129(1):9-13, Archives of otolaryngology, head & neck surgery
— id: 71071, year: 2003, vol: 129, page: 9, stat: Journal Article,

Hurthle cell neoplasms of the thyroid
Dahl, Linda D; Myssiorek, David; Heller, Keith S
2002 Dec;112(12):2178-2180, Laryngoscope
OBJECTIVES/HYPOTHESIS: Hurthle cell tumors are a variant of follicular cell neoplasms. The purpose of the study was to determine the reliability of intraoperative frozen-section analysis for diagnosing Hurthle cell carcinoma and Hurthle cell neoplasm and to evaluate age, gender, and tumor size differences in the incidence of Hurthle cell carcinoma. STUDY DESIGN: Retrospective chart review. METHODS: The records of all patients undergoing thyroid surgery at Long Island Jewish Medical Center (Long Island Campus of the Albert Einstein College of Medicine, New Hyde Park, NY) from 1990 to 2000 were reviewed. Patients were identified whose final pathological finding was Hurthle cell neoplasm or Hurthle cell carcinoma. Age at diagnosis, gender, tumor size, and correlation between frozen-section analysis and final pathological finding was determined. RESULTS: One hundred sixteen patients had Hurthle cell tumors on final pathological finding (49 had Hurthle cell carcinoma and 67 had Hurthle cell neoplasm). Eleven of these patients had incidental papillary carcinoma. There were 24 men and 92 women. Sixty-seven percent of the men (16 of 24) and 36% of the women (33 of 92) had Hurthle cell carcinoma on final pathological finding. The mean ages for Hurthle cell neoplasm and Hurthle cell carcinoma groups were 53 (median age, 50 y) and 58 years (median age, 61 y), respectively. One hundred eleven patients had intraoperative frozen-section analysis. Of the 49 patients with Hurthle cell carcinoma, 9 (19%) were diagnosed by frozen-section analysis, 36 (75%) had indeterminate frozen-section analysis, 3 (6%) were discovered to have papillary carcinoma on frozen-section analysis, and 1 did not have a frozen-section analysis. Multivariate analysis indicated that size correlated with malignancy and that gender did not (P =.0015). CONCLUSIONS: In the study population, only 19% of patients were discovered to have Hurthle cell carcinoma on frozen-section analysis. Sixty-seven percent of men with Hurthle cell neoplasm had malignancies, compared with 36% of women, and this difference was statistically significant
— id: 71072, year: 2002, vol: 112, page: 2178, stat: Journal Article,

The value of frozen section examinations in determining the extent of thyroid surgery in patients with indeterminate fine-needle aspiration cytology
Roach, Jeffrey C; Heller, Keith S; Dubner, Sanford; Sznyter, Laura A
2002 Mar;128(3):263-267, Archives of otolaryngology, head & neck surgery
OBJECTIVES: To determine the usefulness of intraoperative frozen section (FS) examinations in establishing the diagnosis of thyroid cancer in patients undergoing thyroidectomy for nodules with indeterminate cytological features and to determine the cost-effectiveness of FS examinations in this situation. DESIGN: Retrospective medical record review. The results of fine-needle aspiration biopsies (FNABs), FS examinations, and final pathologic examinations are compared. A cost-effectiveness analysis of routine FS examinations compared with the cost of additional surgical procedures is performed. SETTING: A private surgical practice in a medical school-affiliated teaching hospital. PATIENTS: The records of all 480 patients undergoing thyroidectomy between January 1, 1998, and September 30, 2000, were reviewed. All 199 patients with a dominant thyroid nodule and FNAB results either highly suggestive of papillary cancer or indeterminate were studied. RESULTS: Of the patients with FNAB results highly suggestive of papillary cancer, 95% had cancer according to the final pathologic examination results. The diagnosis of cancer was made by FS examination results in 67% of these patients. Of the remaining 178 patients whose FNAB result was indeterminate, 64 (36%) had thyroid cancer. Malignancy was diagnosed by FS examination results in 30 (47%) of these patients. If FS examinations had not been performed, these 30 patients would have required a second operation to complete a total thyroidectomy. The cost savings of routine FS examinations in patients with indeterminate FNAB results is 1298 US dollars per patient. CONCLUSIONS: The routine performance of FS examinations in patients with thyroid nodules with indeterminate cytological features is a cost-effective way of avoiding a second surgical procedure if a total thyroidectomy is indicated. In patients with FNAB results highly suggestive of papillary cancer, FS examinations are not useful. In these patients, the definitive operation can be based on the results of the FNAB
— id: 71073, year: 2002, vol: 128, page: 263, stat: Journal Article,

Re-operation for bleeding after thyroidectomy and parathyroidectomy
Abbas, G; Dubner, S; Heller, K S
2001 Jul;23(7):544-546, Head & neck
BACKGROUND: This study was undertaken to determine the frequency and timing of re-operation for bleeding following thyroidectomy (THY) and parathyroidectomy (PARA) as well as the implications of this concerning the safety of ambulatory surgery. METHODS: Patients requiring re-operation after THY and PARA were identified from a computerized database of patients undergoing surgery between 3/l/95 and 12/31/99. The medical records of these patients were reviewed in detail. RESULTS: Six of 918 THY (0.7%) and 4 of 350 PARA (1.1%) required re-operation for bleeding. In two cases the wounds were opened emergently at the bedside due to worsening airway obstruction. One patient required an emergency tracheostomy. There were no deaths. Excluding one patient who bled five days post-operatively, the time interval from the completion of surgery to the identification of postoperative hematoma ranged from 2 to 48 hours, the median being 16 hours. CONCLUSIONS: Postoperative bleeding is an uncommon but unavoidable complication of THY and PARA. If treated promptly, serious consequences can be avoided. The relatively long interval between the initial operation and the development of the hematoma needs to be considered when recommending the performance of these procedures on an ambulatory basis
— id: 71354, year: 2001, vol: 23, page: 544, stat: Journal Article,

The incidence of carcinoma in cytologically benign thyroid cysts
Abbas, G; Heller, K S; Khoynezhad, A; Dubner, S; Sznyter, L A
2001 Dec;130(6):1035-1038, Surgery
BACKGROUND: The management of cytologically benign thyroid cysts is controversial. Treatment options include observation, chemical sclerosis, and surgery. This study was undertaken to determine the incidence of carcinoma in cytologically benign thyroid cysts that recur after complete aspiration and to determine the indications for surgery in these patients. METHODS: The medical records of 1189 consecutive patients undergoing thyroid surgery between July 1995 and November 2000 were reviewed. In 34 patients the indication for surgery was a thyroid cyst with benign cytologic findings that refilled at least once after complete aspiration. These patients were selected for further study. RESULTS: The 26 women and 8 men had a median age of 42 years. Fine-needle aspiration cytology was consistent with a benign cyst in all these cases. Final pathologic findings revealed the nodule to be a papillary carcinoma in 4 patients (12%). In another 4 patients (12%) an incidental microscopic papillary carcinoma, separate from the cyst, was identified on final pathologic findings. In all 4 patients with papillary carcinoma the cyst size was greater than 3 cm (range, 3.4 to 5.0 cm). CONCLUSIONS: The incidence of malignancy in cytologically benign thyroid cysts that recur after aspiration is high enough to warrant surgical excision, especially if the cyst is greater than 3 cm in size
— id: 71353, year: 2001, vol: 130, page: 1035, stat: Journal Article,

Cytologic determinants of well-differentiated thyroid cancer
Charles, M A; Heller, K S
1997 Nov;174(5):545-547, American journal of surgery
OBJECTIVE: Fine-needle aspiration biopsy (FNAB) is the preferred diagnostic study for evaluating thyroid nodules. Despite its accuracy, many patients undergo thyroidectomy for benign nodules. This study was undertaken to identify risk factors that might increase the specificity of FNAB. METHODS: Medical records of 422 patients who underwent thyroid surgery between 1986 and 1996 were reviewed. All patients had FNAB prior to surgery. RESULTS: Of the 422 patients, 36% had benign cytology, 46% had indeterminate cytology, and 13% had cancer. In the indeterminate group, 29% of patients had cancer at surgery. Of patients with papillary cytology, 84% had malignancies. Five percent of FNABs were nondiagnostic. Neither age, gender, nor tumor size was associated with increased specificity of FNAB. CONCLUSION: There is no subpopulation of patients with indeterminate FNAB cytology at increased risk of having well-differentiated thyroid cancer
— id: 71355, year: 1997, vol: 174, page: 545, stat: Journal Article,

The accuracy of clinical examination versus frozen section in the diagnosis of parotid masses : DISCUSSION
Heller, Keith
1997 ;55(1):32-32, Journal of oral & maxillofacial surgery
— id: 71376, year: 1997, vol: 55, page: 32, stat: Journal Article,

Long-term evaluation of patients undergoing immediate mandibular reconstruction
Heller, K S; Dubner, S; Keller, A
1995 Nov;170(5):517-520, American journal of surgery
BACKGROUND: Immediate reconstruction following segmental mandibulectomy is an accepted surgical technique. The benefits and patient selection criteria need to be established. PATIENTS AND METHODS: Forty-seven patients who underwent immediate reconstruction of the mandible were followed for up to 14 years. Survival, complication rates, and functional results were analyzed. RESULTS: Median survival was 39 months and actuarial 5-year survival was 40%. Two patients died in the postoperative period, and 9 suffered major reconstruction-related complications. The majority of these complications were related to the use of reconstruction plates, and occurred when the mandibular defect included the arch or when the plates were covered by pectoralis flaps. Half of the patients interviewed were able to eat a regular diet. CONCLUSIONS: Mandibular reconstruction can be performed safely and expeditiously in nearly all patients undergoing segmental mandibulectomy. Functional results and long-term survival will be acceptable in many cases
— id: 71356, year: 1995, vol: 170, page: 517, stat: Journal Article,

Supraomohyoid neck dissection as a staging procedure for squamous cell carcinomas of the oral cavity and oropharynx
Henick, D H; Silver, C E; Heller, K S; Shaha, A R; El, G H; Wolk, D P
1995 Mar-Apr;17(2):119-123, Head & neck
BACKGROUND. A multi-institutional retrospective study was performed to evaluate the efficacy of the supraomohyoid neck dissection (SOHND) for detection of occult cervical metastasis in squamous cell carcinoma of the oral cavity and oropharynx. METHODS. Seventy-five previously untreated patients with clinically negative necks were studied. Seventeen (23%) neck specimens revealed occult metastatic disease, and 58 (77%) were histologically negative. Postoperative irradiation was received by 94% of the patients with positive specimens and 22% with negative specimens. Patients were followed until recurrence of neck disease, or for a period of 2 years or longer. RESULTS. Cervical metastasis subsequently developed in 25% of treated positive specimen patients, none of the untreated positive specimen patients, 8% of the treated negative specimen patients, and 11% of the untreated negative specimen patients. The sensitivity of SOHND for cervical metastasis was 82%, negative predictive value 91%, and accuracy 94%. CONCLUSIONS. The authors conclude that SOHND is a useful procedure for detection of occult cervical metastatic disease in cancer of the oral cavity and oropharynx
— id: 71357, year: 1995, vol: 17, page: 119, stat: Journal Article,

Local control of squamous cell carcinoma following marginal and segmental mandibulectomy
Dubner, S; Heller, K S
1993 Jan-Feb;15(1):29-32, Head & neck
The records of 130 consecutive patients undergoing marginal or segmental mandibulectomy for squamous cell carcinoma of the oral cavity or oropharynx were reviewed. An attempt was made to correlate incidence of recurrence with characteristics of the primary tumor and extent of mandibulectomy. The local recurrence rate was 19% following marginal mandibulectomy and 6% following segmental mandibulectomy. The incidence of local recurrence was independent of the size of the primary tumor or the extent of lymph node metastases. Neither mandibular invasion by tumor nor the addition of radiotherapy influenced local recurrence. Ten of 15 patients recurring locally after marginal mandibulectomy were salvaged by further surgery. This study suggests that local control following marginal mandibulectomy is comparable to that following segmental mandibulectomy regardless of the size of the tumor. Segmental mandibulectomy should be reserved for those tumors invading deeply into the mandible or wrapping around it
— id: 71360, year: 1993, vol: 15, page: 29, stat: Journal Article,

Accuracy of frozen section in the evaluation of salivary tumors
Heller, K S; Attie, J N; Dubner, S
1993 Oct;166(4):424-427, American journal of surgery
The records of 333 patients who underwent surgery were reviewed to document the accuracy of frozen section in the evaluation of salivary gland tumors. Frozen sections were obtained in 310 patients. The final pathologic diagnoses included 210 benign tumors and 45 malignancies. The sensitivity for the detection of malignancy was 69%, and the specificity was 96%. The specific accuracy to correctly identify the type of malignancy present was only 51%. In four patients, a false-positive diagnosis of malignancy was made. Frozen section was much more accurate in the evaluation of benign salivary tumors. Forty-three of 45 Warthin's tumors were correctly identified by frozen section. Two tumors thought to be Warthin's tumors on frozen section proved to be low-grade mucoepidermoid carcinomas. One tumor reported to be a benign mixed tumor was actually a malignant mixed tumor. In this series of patients, frozen section proved to be no more accurate in the evaluation of salivary tumors than what has been reported in the literature for fine-needle aspiration biopsy
— id: 71358, year: 1993, vol: 166, page: 424, stat: Journal Article,

Parathyroid localization: inability to predict multiple gland involvement
Heller, K S; Attie, J N; Dubner, S
1993 Oct;166(4):357-359, American journal of surgery
Preoperative localization using various imaging techniques can accurately predict the location of solitary parathyroid adenomas in about 75% of patients. Its value has been questioned because of the high success rate of parathyroid exploration without localization. The ability of localization studies to differentiate preoperatively between patients with solitary adenomas and those with multiple gland disease would be valuable because bilateral exploration might be avoided in many cases. Ultrasonography, thallium-201/technetium-99m subtraction scintigraphy, and magnetic resonance imaging were used to evaluate 16 patients with primary hyperparathyroidism who were ultimately found at surgery to have multiple enlarged parathyroid glands. No single imaging technique was able to identify more than 53% of enlarged glands, and only four patients were accurately predicted preoperatively to have enlargement of multiple parathyroid glands. Existing imaging techniques cannot be relied on to predict multiple gland involvement preoperatively. Bilateral surgical exploration is mandatory in all patients with primary hyperparathyroidism
— id: 71359, year: 1993, vol: 166, page: 357, stat: Journal Article,

Reinnervated radial forearm free flaps in head and neck reconstruction
Dubner, S; Heller, K S
1992 Nov;8(6):467-468, Journal of reconstructive microsurgery
The radial forearm flap has proved to be a reliable free flap for intraoral reconstruction after major head and neck ablative surgery for cancer. In contrast to the myocutaneous flap, it is thin and flexible, and as a result, it is better suited to conforming to the irregular surface which remains over an intact or restored mandible. A criticism of both techniques however, is that while the flap effectively fills the defect, it serves as an insensate reservoir in which food and saliva can collect. A modification of the reinnervated radial forearm free flap is presented, with discussion of its use in three patients, following extensive resection of the floor of the mouth and tongue
— id: 71362, year: 1992, vol: 8, page: 467, stat: Journal Article,

Value of fine needle aspiration biopsy of salivary gland masses in clinical decision-making
Heller, K S; Dubner, S; Chess, Q; Attie, J N
1992 Dec;164(6):667-670, American journal of surgery
The accuracy of fine needle aspiration biopsy (FNAB) in the diagnosis of salivary tumors has been well established. This study was undertaken to determine the impact of FNAB on patient management. One hundred one patients underwent FNAB of major salivary gland masses. The physician's initial clinical impression was compared with the FNAB diagnosis and the final diagnosis in each case. Forty patients had solitary masses thought to be benign tumors other than Warthin's tumors. FNAB in 13 of these patients (33%) yielded a diagnosis permitting modification of the planned procedure. The diagnosis of Warthin's tumor was suspected clinically in 23 patients. In nine of these patients (39%), FNAB resulted in a different diagnosis. Of the 10 patients believed to have malignant tumors, using FNAB, 1 was found to have sialadenitis and 1 a lymphoma. Overall, FNAB resulted in a change in the clinical approach to 35% of the patients. We recommend the performance of FNAB in almost all patients with salivary masses
— id: 71361, year: 1992, vol: 164, page: 667, stat: Journal Article,

Speech patterns following partial glossectomy for small tumors of the tongue
Heller, K S; Levy, J; Sciubba, J J
1991 Jul-Aug;13(4):340-343, Head & neck
To determine the type and extent of speech impairment to be expected following partial glossectomy, pre- and postoperative speech evaluations were performed on 10 patients undergoing surgery for carcinomas of the mobile tongue less than 3 cm in size. In addition, audiotapes of standardized speech samples were made at each evaluation. Preoperative speech evaluation revealed normal rates of verbal diadochokinesis without distortion in all 10 patients. Phonologic analysis was also normal in 9 of these patients. Postoperative evaluation revealed normal rates of verbal diadochokinesis in 6 patients and mild lingual distortion in 4. At 3 weeks postoperatively 1 patient had sibilant distortion and 1 patient overall slurring of speech. Evaluation of both of these patients at 6 months revealed that speech had returned to normal. Blinded comparison of the pre- and postoperative audiotapes revealed no change in 8 patients. In 2 patients the early postoperative tape was thought to 'sound different' but the final postoperative tapes in all patients were judged to be normal. This study demonstrates that partial glossectomy for early carcinomas of the tongue can be performed with minimal, if any, permanent speech impairment
— id: 71363, year: 1991, vol: 13, page: 340, stat: Journal Article,

Computed tomography of the clinically negative neck
Stern, W B; Silver, C E; Zeifer, B A; Persky, M S; Heller, K S
1990 Mar-Apr;12(2):109-113, Head & neck
Members of the New York Head and Neck Society conducted a multi-institutional review correlating preoperative computed tomography (CT) of the neck with postoperative pathology in 59 patients with squamous cell carcinoma of the oral cavity, pharynx, and larynx, without palpable lymphadenopathy. All underwent CT followed by surgery that included partial or complete cervical lymphadenectomy. Sixteen (28%) patients had occult cervical metastases including 6 (17%) of 36 patients with 'early stage' (T1 and T2) primary tumors and 10 (44%) of 23 patients with 'advanced' (T3 or T4) lesions. There was agreement of CT scan findings with presence or absence of metastatic disease in 41 (69%) of 59 studies, with sensitivity 38%, and with specificity 81%. Findings of central lucency and nodal confluence were highly reliable indicators of malignancy, whereas nodal size bore a less direct relationship. Intravenous contrast medium was useful for anatomical delineation, but not for identification of malignancy. Review of films by a single radiologist did not produce greater diagnostic accuracy than the original interpretations. The authors conclude that while it is not possible to identify all instances of cervical node involvement, employment of CT in addition to physical examination and prognostication based on primary tumor stage will facilitate appropriate selection of patients for elective treatment of the neck
— id: 71364, year: 1990, vol: 12, page: 109, stat: Journal Article,

Treatment of Warthin's tumor by enucleation
Heller, K S; Attie, J N
1988 Oct;156(4):294-296, American journal of surgery
Among 162 patients with Warthin's tumor, 113 had removal by enucleation. The others, in whom parotidectomy and facial nerve dissection were performed, were not suspected of having Warthin's tumor preoperatively or had tumor too close to the facial nerve to be safely enucleated. Patients were generally older and more likely to be male than patients with other benign parotid tumors. Fifteen patients had multiple Warthin's tumors at the time of initial presentation; in an additional 12 patients, Warthin's tumor developed in the opposite parotid gland after the initial operation. In only two patients did an additional tumor develop in a gland from which a Warthin's tumor had previously been enucleated. No permanent injuries to the facial nerve occurred. Because of the safety and efficacy with which enucleation can be performed and because the risk of malignant transformation of Warthin's tumors is extremely small, we believe that enucleation is the treatment of choice in most cases
— id: 71365, year: 1988, vol: 156, page: 294, stat: Journal Article,

An unusual presentation of lymphoma in a homosexual man
Dubner, S; Heller, K S
1987 May;87(5):302-303, New York state journal of medicine
— id: 71370, year: 1987, vol: 87, page: 302, stat: Journal Article,

The syndrome of inappropriate secretion of antidiuretic hormone (SIADH) following neck dissection
Wenig, B L; Heller, K S
1987 Apr;97(4):467-470, Laryngoscope
The syndrome of inappropriate secretion of antidiuretic hormone (SIADH) is characterized by hyponatremia and urinary osmolality generally greater than serum osmolality. It is due to inappropriate water retention resulting from excessive release of antidiuretic hormone (ADH). Seventeen patients undergoing neck dissection were studied. Six developed SIADH and two became symptomatic due to profound hyponatremia. Five of the six patients who developed SIADH had previously undergone a neck dissection and/or had received radiation therapy. A suggested pathophysiologic mechanism for this phenomenon is discussed. The syndrome can usually be prevented by fluid restriction during and after surgery
— id: 71371, year: 1987, vol: 97, page: 467, stat: Journal Article,

Metastatic trichomatricial carcinoma
Mir, R; Cortes, E; Papantoniou, P A; Heller, K; Muehlhausen, V; Kahn, L B
1986 Jul;110(7):660-663, Archives of pathology & laboratory medicine
Trichomatricial carcinoma has been recently recognized as a rare malignant variant of pilomatricoma with a potential for local recurrence and, rarely, for distant metastases. We describe such a tumor in a 52-year-old man who developed local recurrence and axillary lymph node metastases within six months of local excision, followed by bilateral pulmonary metastases and 2 1/2 years later by death due to disseminated tumor. This, to our knowledge, is the second reported case of metastasizing trichomatricial carcinoma
— id: 71372, year: 1986, vol: 110, page: 660, stat: Journal Article,

Chemotherapy for head and neck cancer relapsing after radiotherapy
Cortes, E P; Kalra, J; Amin, V C; Attie, J; Eisenbud, L; Khafif, R; Wolk, D; Aral, I; Sciubba, J; Akbiyik, N; Heller, K
1981 Apr 15;47(8):1966-1970, Cancer
Thirty-nine patients (28 men and 11 women, ages 43 to 83 years) with advanced head and neck epidermoid carcinoma (33 had relapsed from previous radiotherapy) were treated with a three-day bleomycin administration (30 by continuous intravenous infusion and nine by subcutaneous route) followed on the fifth day by intravenous administration of cyclophosphamide + methotrexate + 5-fluorouracil (Bleo-CMF). This drug schedule was based on the cell cycle synchrony principle. Twenty-one of 39 patients (54%) responded (seven complete, 14 partial remission) lasting from 4 to 20 months. The median duration of survival for complete remission, partial remission, and disease progression was 15, ten, and four months, respectively. The Bleo-CMF was well tolerated with minimal toxicity. The effectiveness of this regimen in previously irradiated patients compels us to pursue its application in a randomized study as an adjuvant for Stages III and IV head and neck cancer following maximum eradication of the local disease by surgery and/or radiotherapy
— id: 71374, year: 1981, vol: 47, page: 1966, stat: Journal Article,

Adult Burkitt's lymphoma: report of a case
Wasserman, B S; Capasso, V P; Heller, K S; Gluck, M J
1981 Jul-Sep;36(3):73-75, Journal of oral medicine
— id: 71373, year: 1981, vol: 36, page: 73, stat: Journal Article,

Carcinoma of the lip
Heller, K S; Shah, J P
1979 Oct;138(4):600-603, American journal of surgery
(1) Carcinoma of the lip occurs predominantly in men in their seventh and eighth decades of life. (2) Epidermoid carcinoma is the most common malignant lip tumor. (3) Metastases to cervical lymph nodes are uncommon. (4) Elective neck dissection is not indicated. (5) Therapeutic radical neck dissection can benefit the patient in the presence of proved suprahyoid lymph node metastases. (6) The five year survival rate for epidermoid carcinoma of the lip is higher than the rate for epidermoid carcinoma of other sites in the oral cavity or pharynx. (7) Local recurrence does not correlate with the size of the primary tumor. (8) Initial treatment failures can frequently be salvaged surgically
— id: 71367, year: 1979, vol: 138, page: 600, stat: Journal Article,

Carotid arterial hemorrhage after radical head and neck surgery
Heller, K S; Strong, E W
1979 Oct;138(4):607-610, American journal of surgery
From 1960 to 1974, 63 patients treated by the Head and Neck Service of Memorial Hospital underwent carotid arterial ligation for control of actual or threatened carotid rupture. Twenty-one of these patients died without leaving the hospital. Fourteen of these deaths were the direct result of carotid ligation or hemorrhage. Five of the surviving patients suffered permanent neurologic damage. Factors predisposing to carotid rupture included a history of radiation, advanced disease, the presence of an oral or pharyngeal suture line in continuity with a dissected neck, and the postoperative development of skin necrosis or fistulas. Because elective carotid ligation did not prevent the consequences of carotid rupture and because reestablishment of vascular continuity is almost never possible, all attempts should be made to avoid the conditions that are precursors to this most serious complication of radical head and neck surgery
— id: 71366, year: 1979, vol: 138, page: 607, stat: Journal Article,

cis-Dichlorodiammineplatinum(II)-based chemotherapy as initial treatment of advanced head and neck cancer
Wittes, R; Heller, K; Randolph, V; Howard, J; Vallejo, A; Farr, H; Harrold, C; Gerold, F; Shah, J; Spiro, R; Strong, E
1979 Sep-Oct;63(9-10):1533-1538, Cancer treatment reports
During the past 2--3 years, a total of 73 patients with advanced head and neck cancer (mostly stage IV) were treated with cis-dichlorodiammineplatinum(II) (cis-platinum) as initial therapy, either alone or in combination with other agents. After chemotherapy, the patients received surgery and/or radiation therapy in standard fashion. Major degrees of tumor regression were seen in 40%--71% of the patients. cis-Platinum and bleomycin given by infusion gave the highest response rate (71%). The addition of high-dose methotrexate to cis-platinum plus bleomycin produced an unacceptable level of toxicity. Similarly, a four-drug regimen in which low-dose methotrexate and vinblastine were added to cis-platinum and bleomycin resulted in increased toxicity without additional therapeutic effect. Initial chemotherapy does not compromise subsequent surgery or increase either the immediate complications of surgery or the acute toxicity of radiation therapy. It seems unlikely that initial chemotherapy has altered the grim prognosis of an advanced, inoperable presentation. The effect of initial chemotherapy on advanced, operable disease will have to be assessed by suitable controlled trials
— id: 71375, year: 1979, vol: 63, page: 1533, stat: Journal Article,

Male breast cancer: a clinicopathologic study of 97 cases
Heller, K S; Rosen, P P; Schottenfeld, D; Ashikari, R; Kinne, D W
1978 Jul;188(1):60-65, Annals of surgery
From 1949 through 1976, 97 men have been treated at Memorial Hospital for primary operable breast cancer. Seven per cent had intraductal carcinoma. Of the patients with invasive carcinoma 30% were pathologic stage I, 54% stage II, and 16% stage III. Fourty-six per cent had pathologically negative axillary lymph nodes. The most common type of tumor was infiltrating duct carcinoma. Fourty per cent of the patients had microscopic gynecomastia. None of the eight patients with intraductal or intracystic carcinoma died of cancer. Survival of the entire group of men with invasive carcinoma was 40% after ten years. The ten year survival for men with negative nodes was 79%, for men with positive nodes 11%. Comparison with a series of 304 women with breast cancer operated on at Memorial Hospital in 1960 revealed no difference with regard to incidence of positive axillary lymph nodes or stage of disease. There was, however, a significantly lower survival rate for men. This poorer prognosis was limited to those men with pathologically positive axillary nodes
— id: 71368, year: 1978, vol: 188, page: 60, stat: Journal Article,

Use of a questionably viable flap as a full thickness skin graft after mastectomy
Heller KS; Slattery LR; Harris MN
1976 Jul;143(1):94-96, Surgery, gynecology & obstetrics
Questionably viable skin flaps may be used as full thickness grafts after mastectomy. It is suggested that the procedure described can help reduce the incidence of flap necrosis after mastectomy and yield a more acceptable cosmetic result
— id: 25240, year: 1976, vol: 143, page: 94, stat: Journal Article,

Effect of tolerance and of antibody mediated immune suppression on the avidity of the cellular and humoral immune response
Heller, K S; Siskind, G W
1973 Jan;6(1):59-65, Cellular immunology
— id: 71369, year: 1973, vol: 6, page: 59, stat: Journal Article,