[Reproductive history, contraceptives and cigarette smoke as risk factors for cancer of the thyroid in women. Case-control study]. / Storia riproduttiva, contraccettivi e fumo di sigaretta come fattori di rischio del cancro della tiroide nel sesso femminile.

BACKGROUND: Evaluation of the influence of hormonal and reproductive factors and the role of cigarette smoking in the onset of thyroid carcinoma. METHODS: Comparison between a group of 78 female patients all living in the district of Lazio, operated for thyroid follicular or papillary carcinoma at the Third Clinical Surgery Dept., Policlinico Umberto I, Rome (Italy) from 1990 to 1997, and a group of 150 women free from neoplastic and/or hormonal pathology, recruited by the compilation of a questionnaire. RESULTS: Cigarette smoking can be associated with risk reduction of developing thyroid neoplasia. On the contrary, no risk variation has been associated with the number of normal pregnancies, with pregnancy interruption both spontaneous and voluntary and with anthropometric characteristics of the analysed individuals. The first pregnancy at very young age and the use of contraceptives seem to determine a risk increase of thyroid cancer, at the limit of statistical significance. CONCLUSIONS: The antiestrogenic action of cigarette smoking exerts a protective action for thyroid carcinomas. Spontaneous or volontary interruption of pregnancy did not show a significant effect as risk factor.

[Familial papillary carcinoma of the thyroid: biogenetic identification and clinical assessment of 4 families]. / Il carcinoma papillifero della tiroide a carattere familiare: determinazioni biogenetiche e valutazioni cliniche su quattro gruppi familiari.

The Authors report 9 patients who were affected by familial papillary carcinoma of thyroid These patients were members of 4 families and they were selected in a general group of 97 patients affected by papillary cancer of the thyroid who underwent surgery from 1991 to 1998. The 9 patients were 1st degree relatives: two sisters, two sisters, two sisters and three brothers. The clinical course was similar in patients whether familiar or sporadic group, but average age in first was 10 yrs lower than in the latter group. Functional cervical dissection was needed only one time by lymphatic metastasis. Observed survival was 100% (follow up 92-16 months) and no specific complication was reported. Thyreoglobulin value was less than normal in every patients. Ret linkage analysis was always performed and no rearrangement was found; in 4 patients APC gene was detected but it was never seen. Case studies are consistent with an autosomal dominant trait that shows an high penetrance if associated with a permissive codominant trait. The authors believe that are necessary further studies on this occurrence. In papillary thyroid cancer familiarity was observed in 9.6%, than authors propose that relatives of thyroid papillary cancer should be underwent to screening.

Familial papillary carcinoma of the thyroid: a report of nine first-degree relatives of four families.

The authors report the occurrence of papillary carcinoma of the thyroid in nine first-degree relatives of four families among a consecutive series of 97 patients with papillary carcinoma of the thyroid who were operated on from 1991 to 1998. Total thyroidectomy was performed in all cases. All patients are alive without evidence of disease after a mean follow-up period of 43 months. Since in our series familial papillary carcinoma of the thyroid was found in 9.3% of patients, we suggest an adequate screening among first-degree relatives of all patients with papillary thyroid carcinoma. Because of reported aggressive behaviour of familial papillary carcinoma of the thyroid, aggressive surgical treatment plus post-operative thyroid remnant ablation with radio-iodine should be warranted in all patients.

[The inferior nonrecurrent laryngeal nerve: a report of 7 cases observed since 1987]. / Il nervo laringeo inferiore non ricorrente: descrizione di 7 casi osservati dal 1987.

The non-recurrent inferior laryngeal nerve is a rare anomaly (0.34% on th right side, extremely rare on the left side) that increases the risk of damage to the nerve during thyroid and parathyroid surgery. Seven cases of non-recurrent laryngeal nerve are reported, emphasizing the diagnostic accuracy of angio-MR for the anatomical identification of the vascular anomaly that invariably occurs with the nerve malformation.

[Recurrences after thyroid lobectomy for benign thyroid diseases: analysis of a clinical-instrumental follow up]. / Le recidive dopo lobectomia per tireopatia benigna: analisi di un follow up clinico-strumentale.

The authors propose to verify the therapeutical role of lobectomy in confronting monolobar nodular thyroid disease. In a period of 4 years (1990-1993), forty-four patients (30 women, 14 men) underwent thyroid lobectomy for a benign disease and follow-up treatment for 3 years on a semestral basis. All patient were studied both before the operation and during the follow-up using US and measuring the levels of T3, T4 and TSH; 34 patients (77.2%) had undergone a scintigraphy before surgery. The indication towards surgical intervention was, in 16 patients, consequent to the diagnosis of monolobar uninodular goiter and in 28 patients to monolobar plurinodular goiter. The operation involves thyroidal extracapsular lobectomy with isthmectomy. There were no temporary and/or permanent recurrential lesions, nor there were any significant hypocalcaemic alterations. The US description of the follow-up has been classified in four groups: normal, non-homogeneity (presence of simple parenchymal non-homogeneity), recurrence/non-homogeneity (presence of both pseudonodular forms and parenchymal non-homogeneity), recurrence (presence of recurrence with nodule(s) whose diameter is greater than 5 mm.). From the US follow-up examination, it was shown that 14 out of 44 patients (31.8%) presented alterations in the residual lobe wich were not identifiable in the pre-operative US examination (3 recurrences = 6.81%; recurrence/non-homogeneity = 2.27%; 10 non-homogeneity = 22.7%). Thirteen out of 14 patients are treated with substitutive ormonal therapy Out of these 30 patients whose residual lobe shows no alterations using US, 23 (70.6%) are treated with substitutive ormonal therapy. The authors have underlined a substantial percentage difference between the incidence of normality of the residual lobe during follow-up to lobectomy due to adenoma (normality 88.8%) and to lobectomy due to goiter-related lesions (normality 60%). During US follow-up examinations, abnormality percentages equal or superior to 30%--as those noticed after lobectomy due to goiter-related lesions underline the doubts wich characterize any form of partial thyroidal asportation (4 recurrence in 35 cases of monolobar uni- or plurinodular goiter = 11.4%); also, in the authors' experience, substitutive ormonal therapy has seemingly no effect on the recurrence incidence. According to the authors, the lobectomy can occupy a therapeutical role in thyroid diseases with monolobar expression, but to avoid an elevated number of recurrences, a rigorous evaluation of the real extension of the nodular disease is indispensable.

[Submandibulectomy in the treatment of pathology of the submandibular gland: our experience 1970-1995]. / La sottomandibulectomia nel trattamento delle patologie della ghiandola sottomandibolare: nostra esperienza 1970-1995.

Submandibular gland excision is proposed in the treatment of neoplastic and non neoplastic diseases; this surgical procedure can be performed by transoral or transcervical approach. The aim of the study is to demonstrate that cervical approach must be preferred because it is safer and allows a wider exposition of the surgical field. From 1970 to June 1995, 54 patients (47 with chronic sialadenitis, 7 with benign tumors and 7 with malignant tumors) were submitted to excision of the submaxillary gland. Of the 54 resections performed, 2 were completed with "functional" cervical lymphadenectomy and 1 with Radical Neck Dissection in pts. with malignant neoplasms. There were no postoperative deaths; complications occurred in 1 patient (1/54 = 1.8%) as a iatrogenic permanent lesion of the maxillary branch of the facial nerve (in detail 0/47 patients with benign disease and 1/7 (14.7%) patients with malignant disease). The cervical approach for the resection of the submaxillary gland is preferred to the transoral approach for the lower risk of iatrogenic lesions of the lingual and hypoglossal nerves and the possibility of curative resections in case of malignant neoplasms. A regulated and experimented technique through the cervical approach also lowers the risk of a lesion of the maxillary branch of the facial nerve.

[Paraganglioma in the case records of the III Surgical Clinical Institute]. / I paragangliomi nella casistica dell'istituto di III Clinica Chirurgica (1970-1995).

Cervical paragangliomas are uncommon benign or malignant neoplasms, originated from the stem cells of the neural crest. Up to date it is still not easy to define properly their biological behaviour, the possible multicentric location and the association with Multiple Endocrine Neoplasias. After a wide review of recent diagnostic, pathological and clinical notions, the Authors report their experience, from 1970 to 1995, of 10 patients affected by sporadic paraganglioma and 1 by familial multicentric neoplasm localized on carotid bodies of both sides, left vagus nerve and left hypoglossus nerve. All patients but one were treated by a curative resection of the neoplasm; in one case only an explorative laparotomy was possible because of the visceral and vascular involvement.

[Thyroid carcinoma. Retrospective analysis of case records of the III. Surgery Department at the Umberto I Clinics in Rome in the years 1990-93]. / Il carcinoma tiroideo. Analisi retrospettiva da una casistica della III Clinica Chirurgica (anni 1990-1993) del Policlinico Umberto I di Roma.

BACKGROUND: The aim of this investigation was to ascertain: 1) temporal trends in the incidence of thyroid carcinoma between 1990-1993; 2) regional differences in the incidence and histotype among the five provinces of Latium; 3) identification of risk factors, particularly of a preexisting thyroid tumour (goitre). METHODS: Records of patients submitted to thyroid surgery at the Istitute of III Clinica Chirurgica dell'Università "La Sapienza" di Roma have been reviewed and a questionnaire filled-in. RESULTS: In the period 1990-1993, 144 cases of thyroid carcinomas were operated; 77.7% of those resided in the Latium region. Average age was 43 +/- 16.2, F:M = 3:1. During the four years observation period there was an increase in all surgical interventions and proportionally increased also thyroid surgery (hyperplasia, thyroiditis, hyperthyroidism and thyroid cancer). Thyroid cancer was found in 10% of thyroid patients, this proportion remains constant in the period 1990-1992, in 1993 rising to 14% (p = 0.032). Differences of incidence although not significant were found in the five provinces of Latium. A higher proportion of follicular histotypes was found in the province of Frosinone (FR vs RM, 20 vs 13.5% p = 0.45). A previous goitre, standing for period of three or more years, was reported in the records of 25% of patients. Seven percent of patients have been previously submitted to a partial thyroidectomy for benign thyroid disease, most of those being operated for thyroid adenoma (8 out 10 cases). CONCLUSION: During a four year period of observation an increase of thyroid carcinoma was observed only in 1993. This increase cannot be attributed to an increase in the incidence of thyroid carcinoma. The province of Frosinone, known to be an endemic area, shows a proportion of the follicular histotype higher than that of other provinces. Goiter precedes malignant thyroid neoplasia in a high proportion of patients (25%). Follicular adenoma found frequently at the histology of patients operated for benign thyroid disease suggesting a transformation from benign to a malignant condition.

[Total thyroidectomy technique: suggestions and proposals of surgical practice]. / Tecnica della tiroidectomia totale. Suggerimenti e proposte di pratica chirurgica.

Total thyroidectomy at present depicts a diffuse surgical procedure in the management of benign and malignant disease of thyroid gland. It is followed by a low incidence of iatrogenic damages (nervous lesions or permanent hypoparathyroidism), just like subtotal thyroidectomy and lower than surgery for nodular recurrences. Authors present the surgical technique they follow to perform total thyroidectomy, used in over 400 cases of benign thyroid diseases operated since 1986. The most important points of this surgical procedures are represented by exposure and sparing of inferior laryngeal nerve and by preservation of parathyroid function. Parathyroid glands can be exposed to direct surgical trauma but, more often, they are injured by damage of their vascular supply. To avoid this complication, vascular ligations of inferior thyroid artery have to be done never on the trunk of the artery, but on its branches just near the glandular capsula. Sparing of inferior laryngeal nerves comports the exposure of this structure for all its cervical course especially in the terminal edge, when the nerve is nearest to the gland. Systematical application of illustrated procedure has produced no operative mortality, no inferior laryngeal nerve permanent palsy, transient hoarseness in 0.5%, and transient symptomatic hypocalcemia in 2.7%.