A "pilot light" of the right non-recurrent laryngeal nerve.

Total thyroidectomy was performed in a 53-year-old male, with Graves-Basedow's disease. At surgery, the vagus nerve was found to be located medially to the carotid artery associated with a non-recurrent laryngeal nerve arising directly from the cervical vagus: this association has never been described in the literature. These results indicate that a medial location of the vagus nerve may be considered as a "pilot light" of the non-recurrent laryngeal nerve.

Diagnosis, treatment, prognostic factors and long-term outcome in papillary thyroid carcinoma.

The papillary thyroid carcinoma (PTC) is the most frequent endocrine cancer and it is the most common thyroid cancer (85-95%). Potential risk factors for the incidence of the PTC include radiation exposure, iodine deficiency, family history of thyroid cancer. The PTC is usually indolent and the prognosis is favourable, with a 10 year survival generally reported to exceed 90%. The palpation and growth of thyroid nodules are the more frequent clinical manifestations of the PTC which can be evaluated by physical examination, neck ultrasound and fine needle aspiration cytology (FNAC). The therapeutic management of PTC includes surgical treatment combined with 131I therapy and life long TSH suppressive thyroid hormone replacement. The external beam radiation can be taken into account in select aggressive tumours. Nevertheless the good prognosis of the PTC, the prevalence of persistence or recurrent disease is not trans-curable. The biomolecular studies can permit to individuate the more aggressive PTC subtypes. A more significant attention of the clinical examination, US and FNAC to the thyroid nodular disease will be able to guarantee a more precocious diagnosis and a radical surgical treatment.

Surgical treatment of primary hyperparathyroidism: from bilateral neck exploration to minimally invasive surgery.

The human parathyroid glands, first described by Sandström in 1880, attracted interest because they were subject to inadvertent removal or ischemic injury during radical thyroid surgery. That this caused metabolic derangements was not known until many years later. Following on Kocher's studies, research continued to improve techniques sparing the parathyroids during thyroid surgery but without developing parathyroid surgery as such. For over a century, the lack of suitable surgical instruments, accurate preoperative localizing imaging techniques, and reliable laboratory tests hindered the evolution of parathyroid surgery, relegating it a marginal existence. Only after 1930, when it became clear that hyperparathyroidism is caused by an increased production of parathyroid hormone (PTH) by overactive parathyroid glands in the neck and/or the mediastinum, could parathyroid surgery, which shares a similar approach with thyroid surgery, be developed for treating hyperparathyroidism. The aim of parathyroid surgery is to cure hyperparathyroidism. Until advanced surgical and laboratory diagnostic technologies became available, concern about the risk of failure led surgeons to search all four glands by bilateral neck exploration, which proved unnecessary in 80% of cases. Recent years have seen parathyroid surgery evolve with the introduction of more efficacious preoperative localization imaging techniques and the use of rapid intraoperative parathormone assay, so that parathyroid surgery is now more selective and can be performed as a minimally invasive procedure in some cases.

[Papillary thyroid microcarcinoma. Long-term outcome in 587 cases compared with published data]. / Il microcarcinoma papillare della tiroide: nostra esperienza e letteratura a confronto.

AIM: Papillary thyroid microcarcinoma (PTMC), a tumor measuring =or<1 cm according to the World Health Organization (WHO) histologic classification, is the most common histologic variant of thyroid cancer. The aim of this study was to evaluate the long-term outcome of surgical treatment for PTMC at a single institution with a view to differentiate therapy options based on risk of progression of disease by comparing our results with those reported in the literature. METHODS: The study sample was a total of 587 cases of PTMC treated surgically at our institution between 1990 and 2006. PTMC was an incidental finding (PTMC-I) in 325 (55.4%) cases, diagnosed preoperatively (PTMC-D) at echography and needle-aspiration biopsy in 229 (39%), and occult with metastasis (PTMC-O) in 33 (5.6%). Patients were grouped into two classes (PTMC diameter =or>5 mm or <5 mm) and compared against prognostic factors: sex, age, type of PTMC (PTMC-I, PTMC-D, PTMC-O), extent of surgery, lymph node dissection, lymph node metastasis, iodine-131 (131-I) therapy, state of disease, relapses. These parameters were then compared against tumor size (PTMC diameter =or>5 mm or <5 mm), excluding cases of PTMC-O with metastasis. RESULTS: Comparison of the two groups divided by tumor size, across the entire sample and after PTMC-O cases were excluded, revealed significant differences in the type of PTMC, frequency of partial thyroidectomy, presence of lymph node metastasis, iodine-131 therapy, life status and recurrence rate. CONCLUSION: Published PTMC studies were analyzed for definition of the disease, incidence, therapy, prognosis, and follow-up results and compared with our data. The results of our analysis argue against use of the term ''microcarcinoma'' in the wider sense since the three PTMC categories (PTMC-I, PTMC-D, PTMC-O) present different behaviour patterns. When cases of PTMC-O with clinically manifest metastasis were excluded, none of the patients with PTMC <5 mm in diameter were reoperated for tumor recurrence and all are currently free of disease. In conclusion In PTMC <5 mm in diameter, whether PTMC-I and PTMC-D, and without evidence of lymph node involvement, partial thyroidectomy may be a viable approach to treatment. By contrast, occult PTMC with metastasis is prognostically important and should therefore be treated like tumors =or>5 mm in diameter.

Natural history, diagnosis, treatment and outcome of medullary thyroid cancer: 37 years experience on 157 patients.

AIM: The analysis of a 37-year retrospective study on diagnosis, prognostic variables, treatment and outcome of a large group of medullary thyroid cancer (MTC) patients was conducted, in order to plan a possible evidence-based management process. METHODS: Between Jan 1967 to Dec 2004, 157 consecutive MTC patients underwent surgery in our centre: 60 males and 97 females, mean age 47.3 years (range 6-79). Total thyroidectomy was performed in 143 patients (91.1%); central compartment (CC) node dissection (level VI) in 41 patients; central plus lateral compartment (LC) node dissection (levels II, III, and IV) in 82 patients. Subtotal thyroidectomy was initially performed in 14 cases: 10 of them were re-operated because of persistence of elevated serum calcitonin levels. RESULTS: After a median post-surgical follow-up of 68 months (range 2-440 months), 42.9% of patients were living disease-free, 39.8% were living with disease, 3.1% were deceased due to causes different from MTC, and 3.2% were deceased due to MTC. The overall 10-year survival rate was 72%. At uni-variate statistical analysis (a) patient's age at initial treatment (>45 years; >/=45 years), (b) sporadic vs. hereditary MTC, (c) disease stage, and (d) the extent of surgical approach resulted as significant variables. Instead, at multivariate statistical analysis, only (a) patient's age at initial diagnosis, (b) disease stage, and (c) the extent of surgery resulted as significant and independent prognostic variables influencing survival. CONCLUSION: The presence of lymph node and distant metastases at first diagnosis significantly worsened prognosis and survival rate in our series. Early diagnosis of MTC is very important, allowing complete surgical cure in Stages I and II patients. Due to the relatively bad prognosis of MTC, especially for disease Stages III and IV, it appears reasonable to recommend radical surgery including total thyroidectomy plus CC lymphoadenectomy as the treatment of choice, plus LC lymphoadenectomy in patients with palpable and/or ultrasound enlarged neck lymph nodes.

Papillary thyroid microcarcinoma (PTMC): prognostic factors, management and outcome in 403 patients.

AIM: To investigate an "optimal" therapeutic management of patients with papillary thyroid microcarcinoma (PTMC). METHODS: We evaluated a group of 403 consecutive patients affected by PTMC operated on by the same surgeon. Prognostic factors were evaluated by uni- and multivariate statistical analysis. RESULTS: After a mean follow-up of 8.5 years, 372 patients were living without disease (undetectable serum thyroglobulin levels), 24 patients were living with disease (increased serum thyroglobulin levels), 6 patients were deceased due to causes different from thyroid cancer, and 1 patient was deceased due to metastatic thyroid cancer. No statistically significant prognostic factor was found at uni- and multivariate analysis. However, it is worth noting that in patients with a larger primary tumour (size> or =5mm) and treated by partial thyroidectomy alone, the prevalence of recurrent disease was higher than in patients treated by total thyroidectomy and (131)I administration. CONCLUSION: It appears reasonable to perform total thyroidectomy (possibly associated with central compartment node dissection), (131)I whole body scan (followed by (131)I therapy when necessary) and TSH-suppressive hormonal therapy in patients with PTMC.

[Sentinel lymph node procedure in thyroid carcinoma patients. Our experience]. / La procedura del linfonodo sentinella nel paziente con cancro della tiroide Nostra esperienza.

AIM: How far to extend surgical treatment of papillary thyroid carcinoma (PTC) is still an open question. A contribution may derive from intraoperative lymphatic mapping because, in other malignancies, the procedure has become an important aid in defining lymph node status. The aim of this study was to evaluate the feasibility of sentinel lymph node (SLN) mapping performed by intratumoural injection of vital blue dye to guide nodal dissection in PTC. METHODS: One hundred and ten patients were selected for the study, all of them had a preoperative diagnosis of PTC, but no clinical or ultrasonographic evidence of nodal involvement. Following cervicotomy and exposition of the thyroid gland, vital blue dye was injected into the malignant thyroid nodule. Subsequently, total thyroidectomy and lymph node dissection were carried out, and the thyroid, the SLN(s) and the other lymph nodes were sent for frozen section and definitive histologic evaluation. RESULTS: Intraoperative lymphatic mapping located sentinel lymph nodes in 74 cases (67.3%); the SLN was detected in the laterocervical compartment (LC) in 4 cases (5.4%), with the ''sick'' of the CC. In 23 of these 74 patients (31.1%) the SLN(s) were positive for micro-metastases and in 15 cases (65.2%) both the SLN and other resected nodes were found positive. In the 51 cases in whom the SLN was disease-free, the other nodes were also negative. Of the 36 cases in whom the SLN was not detected, in 4 cases (11.1%) a parathyroid gland was stained and in 1 case (2.8%) fibroadipous tissue was stained. To date, of the 23 patients with positive-SLN 22 patients are living without disease (95.6%), 1 patient is living with disease (4.4%); all patients with negative SLN are living without disease; of the 36 patients without staining of the SLN, 35 are living without disease (97.2%) and 1 patient is deceased for reasons different from PTC (2.8%). CONCLUSIONS: On the basis of this study, we underline some disadvantages in using Blue Patent V dye in SLN biopsy procedure as: a) the risk of disruption and interruption of the lymphatics from the tumour; b) blue dye uptake by a parathyroid gland which is successively mistakenly removed; c) the ''seak'' of the CC that doesn't permit to disclose SLN that lies outside the central compartment.

[Cervical lymphorrea after nodal dissection: role of fasting based on clinical evidence]. / Linforrea cervicale dopo svuotamento linfonodale: ruolo del digiuno basato sull'evidenza clinica.

The management of chylous fistula, subsequent to neck nodal dissection, includes either unstandardized conservative procedures and reoperation. The main reason of controversy in literature is probably due to the rarity (1-2.5%) of such troublesome complication due to inadvertent disruption of the thoracic duct itself or of its tributary branches. We report one case of severe cervical chylous fistula, occurred after left lateral dissection for advanced papillary thyroid carcinoma, and successfully restored by a conservative approach. None of the following treatment modalities was effective: pressure dressing, low-fat diet, octreotide, etilefrine, and local tetracycline sclerotherapy. Instead, fasting combined with total venous nutritional replacement was successful in curing the leak. It may be hypothesized that the beneficial effect on chyle production observed in the present patient in fasting condition, could be explained by a decrease of splancnic blood flow consequent to intestinal feeding rest. The other treatment procedures can be adjunctive methods with impredictable effect. As a standard approach with the aim to prevent and treat cervical lymphorrea, we suggest preoperatory fat meal, intraoperative search for milky leak by positive respiratory pressure, ligation of the thoracic duct (a mesh coverage when necessary) if inadvertently damaged, but not a systematic search for it. Moreover, according to the amount and the duration of the leakage, fasting combined with venous supplement by central or peripheral access, in combination with local treatment by sclerosing agents appears to be efficacious. In our opinion, neck reoperation or intrathoracic ligation of the thoracic duct represent the last therapeutic option of unresponsive or untractable cases.

[Radio-guided surgery in primary hyperparathyroidism: clinical indications and technical procedure]. / La chirurgia radioguidata nell'iperparatiroidismo primitivo. Indicazioni cliniche e procedura tecnica.

AIM: The purpose of the present study was to assess the utility of the intraoperative gamma probe technique in a group of 128 patients suffering from primary hyperparathyroidism (PH). METHODS: In view of surgery, these patients were homogeneously subjected to a diagnostic protocol comprising double tracer scintigraphy ((99mTc)-Pertecnetate/(99mTc)-MIBI) and neck echotomography, carried out in a single session. They were then all operated on by the same surgical team. RESULTS: In 97 patients with scintigraphic and echographic evidence of single parathyroid enlargement and normal thyroid gland, mini-invasive radio-guided surgery (MRS) was planned. In 94 of these 97 patients (96%) MRS was carried out successfully by removal of a single parathyroid adenoma (PA) through a small cutaneous incision of 2-2.5 cm; in the remaining 3/97 patients (3.1%), it proved necessary to convert to bilateral surgical exploration of the neck following intraoperative diagnosis of a parathyroid carcinoma in 2 cases and of multiglandular pathology (MGP) suggested by the persistence of elevated values of intraoperative parathormone (PTH) in 1 case. It should be pointed out that the use of IGP enabled us to carry out limited surgical exploration in 18 of 23 patients who had previously undergone operation on the thyroid and/or parathyroids. In a second group of 31 patients with presumed preoperative diagnosis of MGP (5 cases) or nodular goitre concomitant with PH (26 cases), IGP was used in the course of standard bilateral surgical exploration of the neck and enabled us to locate: an ectopic parathyroid gland in the thymus in 1 case of MGP, a PA in the deep levels of the neck in 2 cases with goitre and an ectopic PA at the bifurcation of the carotid in 1 other case with goitre. It should however be specified that in certain other patients with goitre it proved difficult intraoperatively to distinguish thyroid nodes from a PA adhering to the thyroid. CONCLUSIONS: On the basis of the data to emerge from the present study we can conclude that: 1) in patients with PH presenting a scintigraphic and echographic picture indicating single PA and normal thyroid with high probability, the IGP technique proves effective in carrying out an MRS; 2) 37 MBq of (99mTc)-MIBI are an adequate dose for the correct performance of MRS; 3) a rapid intraoperative dose of PTH is to be recommended so as to confirm complete removal of the hyperfunctioning parathyroid tissue; 4) MRS may be employed successfully also in those patients previously subjected to thyroid or parathyroid surgery for the purpose of limiting the surgical trauma connected to reintervention and, therefore, to reducing the risk of complications; 5) IGP would not appear to be recommendable in patients with PH and concomitant goitre, with the possible exception of ectopic PA.

[PTH assay in the first postoperative day after thyroidectomy early predictor postoperative hypocalcemia?]. / Dosaggio del PTH in prima giornata dopo tiroidectomia: precoce indicatore di ipoparatiroidismo postoperatorio?

BACKGROUND: The purpose of our study is to verify if PTH assay on the first postoperative day is a reliable early predictor of the onset of hypocalcemia. METHODS: Between October 1999 and May 2000, a prospective trial involved 162 patients who underwent total or near total thyroidectomy at our institute. On the basis of PTH assay on first day we divided the patients in three groups: group A 28 patients with PTH < 10 pg/ml; group B 34 patients with PTH between 10 and 16 pg/ml; group C 100 patients with PTH > 16 pg/ml. RESULTS: In group A: 22 of 28 patients (78.5%) developed postoperative hypocalcemia and 20 (71.4%) needed replacement therapy; in group B: 14 of 34 (41.1%) had postoperative hypocalcemia and 10 (29.4%) received treatment; in group C: 23 of 100 (23%) became hypocalcemic after surgery but only 5 (5%) require calcium-vitamin therapy. A statistically significant correlation (p = 0.0017) was identified between post-operative PTH levels and lowest blood calcium values detected after surgery. The correlation between the drop in blood calcium levels after surgery and postoperative PTH (delta Ca) was statistically even more significant (p = 0.0002); the lower the postoperative PTH, the higher the absolute value of the delta Ca. CONCLUSION: The authors suggest a clinical approach and pharmacological treatment protocol based on the outcome of PTH assay on the first post-operative day; a solution that is only apparently more costly because it in fact aims to ensure a more timely recourse to blood calcium monitoring or replacement therapy and also an earlier discharge of the patient.

99mTc-MIBI radio-guided surgery in primary hyperparathyroidism: a prospective study of 128 patients.

UNLABELLED: AIMS AND STUDY DESIGN: We investigated the role of an intraoperative gamma probe (IGP) technique in 128 patients with primary hyperparathyroidism (HPT). The patients were evaluated before surgery by 99mTc04/MIBI scintigraphy and neck ultrasound and then operated on by the same surgical team. The IGP technique consisted of the injection of a low dose (37 MBq) of 99mTc-MIBI in the operating room shortly before the start of surgery. Quick parathyroid hormone (QPTH) was routinely measured during the operation. RESULTS: In 94/97 patients (96.9%) with a preoperative diagnosis of solitary parathyroid adenoma (PA) minimally invasive radioguided surgery (MIRS) was successfully performed; in the other 3/97 patients (3.1%) conversion to bilateral neck exploration (BNE) was required because of the intraoperative diagnosis of parathyroid carcinoma in two cases and multiglandular disease (MGD) in one. MIRS was successfully performed also in 23 patients who had undergone previous thyroid or parathyroid surgery. In 31 patients with a preoperative diagnosis of MGD (n = 5) or concomitant nodular goiter (n = 26) the IGP technique was used during a bilateral neck exploration. Among these patients IGP was useful in localizing an ectopic parathyroid gland in the thymus in one case of MGD and a PA located deep in the neck (n = 2) or ectopic at the carotid bifurcation (n = 1) in three cases with nodular goiter. However, in several other patients with nodular goiter it was difficult for the probe to distinguish intraoperatively between thyroid nodules and PA located close to the thyroid gland. CONCLUSIONS: It can be concluded that a) in primary HPT patients with a high likelihood (according to scintigraphic and ultrasound findings) of being affected by a single PA and with a normal thyroid gland, the IGP technique appears useful in MIRS; b) a 99mTc-MIBI dose as low as 37 MBq appears to be adequate to perform MIRS; c) the measurement of QPTH is strongly recommended in HPT patients selected for MIRS to confirm the radicality of parathyroidectomy; d) MIRS can be useful also in HPT patients who underwent previous parathyroid or thyroid surgery to limit the surgical trauma of reoperation and minimize complications; e) with the exception of PAs located at ectopic sites or deep in the neck, the IGP technique does not seem to be recommendable in HPT patients with concomitant nodular goiter.

Ectopic parathyroid adenomas located at the carotid bifurcation: the role of preoperative Tc-99m MIBI scintigraphy and the intraoperative gamma probe procedure in surgical treatment planning.

PURPOSE: The prevalence of ectopic parathyroid adenoma (PA) is relatively low, despite some studies in which it has been reported to be as high as 20%. Ectopic PA is a frequent cause of surgical failure, and therefore some authors recommend preoperative imaging to localize the condition in patients with primary hyperparathyroid (HPT) disease before initial surgery. METHODS: Two unusual cases of primary HPT caused by an ectopic PA located at the carotid bifurcation are reported. The patients were examined before operation using Tc-99m MIBI scintigraphy and then underwent radioguided surgery using the intraoperative gamma probe technique with injection of a low dose (37 MBq; 1 mCi) of Tc-99m MIBI. RESULTS: The first patient had a history of primary HPT and coexisting multinodular goiter. She had undergone total thyroidectomy in another center, but no enlarged parathyroid gland was found at bilateral neck exploration and serum calcium and parathyroid hormone levels remained elevated after intervention. The patient was referred to our center. A Tc-99m MIBI scan showed a focus of abnormal tracer uptake in the superior left laterocervical region that was thought to be a PA. The next day she underwent radioguided surgery and an 18-mm PA located at the left carotid bifurcation was easily removed through a 2.5-cm skin incision. The second patient was examined in our center before surgery. A neck ultrasound showed a multinodular goiter but no enlarged parathyroid glands. A pertechnectate-MIBI subtraction scan revealed a focus of abnormal Tc-99m MIBI uptake in the right superior laterocervical region that was thought to be a PA. One week later, at radioguided surgery, a 25-mm PA was identified at the right carotid bifurcation and removed successfully. CONCLUSIONS: These data strongly support the utility of preoperative imaging with Tc-99m MIBI in patients with primary HPT before initial neck exploration with the aim of avoiding surgical failure. Furthermore, the intraoperative gamma probe technique seems to be useful to reduce surgical trauma and, possibly, complications in patients with ectopic PA.

Technique and results of laparoscopic adrenalectomy.

The aim of this report is to evaluate the benefits of laparoscopic adrenalectomy in terms of perioperative morbidity, complications and patients recuperation. We reviewed our experience with laparoscopic adrenalectomy in 47 consecutive patients who underwent adrenalectomy over a 4-year period. We used the lateral transperitoneal approach in all cases. The indications for adrenalectomy were Conn's adenoma in 24 patients, pheochromocytoma in 11, Cushing's syndrome in 3 and incidental adrenal tumour in 9. The average duration of surgery was 130 min (range, 60-300 min) and average adrenal gland size was 3.4 cm (range, 1.2-8 cm). Conversion from laparoscopy to laparotomy was necessary in three patients (6.4%), and postoperative complications occurred in two patients. There was no mortality. Laparoscopic adrenalectomy can be considered the method of choice for managing almost all adrenal masses, because of its low morbidity and short postoperative recovery. The main difficulty is to identify the adrenal gland, so several technical procedures are suggested.

[Primary hyperparathyroidism in patients treated for non-medullary thyroid carcinoma]. / Iperparatiroidismo primitivo in pazienti trattati per carcinoma non midollare della tiroide.

The authors report three cases of primary hyperparathyroidism (HPT) in patients with differentiated thyroid carcinoma (DTC) developed a few years after initial surgical and radiometabolic treatment of DTC. The early diagnosis of HPT in these patients was made possible because of laboratory tests performed during follow-up, including the assay of serum calcium and serum phosphorus levels. Scinti-graphy using 99mTc-MIBI enabled the correct preoperative localisation of a single parathyroid adenoma in two of these patients and multiglandular pathology in the third.

[Prevention and treatment of intra- and post-operative complications in thyroid surgery]. / Prevenzione e trattamento delle complicanze intra- e post-operatorie in chirurgia tiroidea.

Frequency of complications in thyroid surgery is evaluated in a series of patients treated during a recent period lasting one year (1997). The records of 455 patients consecutively operated on were analyzed: 396 patients were affected by benign disorders and 59 by thyroid carcinoma. Total thyroidectomy was performed in 158 cases, near subtotal thyroidectomy in 94, thyroid totalization for recurrent disease in 21 and lobectomy in 182 ones. Post-operative haemorrhage, such to require surgical re-exploration of the thyroid bed, occurred in 2 patients (0.4%), both after total thyroidectomy for hyperfunctioning goiter. Recurrent laryngeal lesion has been observed in 2 patients (0.4% of all patients), both after total thyroidectomy for cervico-mediastinal goiter. Transient hypoparathyroidism occurred in 48 patients (10.5%), while definitive one in 9 (1.9%), of which 5 after total thyroidectomy, 2 after subtotal thyroidectomy and 2 after reoperation. Haemorrhage nearly always occurs in the first postoperative hours and gravity is conditioned by tracheal compression exercised by the haematoma. An aspirative drainage located in thyroid bed and a not hermetic closure of the middle line help a precocious diagnosis and sometimes avoid a surgical re-exploration. Some technical surgical devices permit to reduce the risk of inferior laryngeal nerve palsy. Hypoparathyroidism, often transient, is a complication of bilateral thyroid surgery, but unavoidable when more extensive thyroid surgery is required.

Preoperative assessment of thyroid nodules: the surgeon's point of view.

A selective approach to patients with thyroid nodules, in order to differentiate between negative findings and uncertain or positive results requiring surgery, has been outlined. Fine needle aspiration biopsy (FNAB) is the most reliable and cost-effective technique currently available to distinguish benign from malignant thyroid disease. In those lesions diagnosed by FNAB as 'follicular lesions', radionuclide scanning, serum calcitonin and CEA determination, color doppler ultrasonography and the response to TSH suppressive therapy may be of assistance. Despite such screening procedures, the majority of follicular lesions remain indeterminate, and surgery is therefore necessary before a correct diagnosis can be made.

[Papillary carcinoma of the thyroid. A uni- and multivariate analysis of the factors affecting the prognosis inclusive of surgical treatment]. / Carcinoma papillare della tiroide. Analisi uni e multivariata dei fattori influenti la prognosi incluso il trattamento chirurgico.

METHODS: A total of 463, out of 677 patients operated on for papillary thyroid carcinoma between 1967-1995, were selected, on the basis of a 5-year minimal follow-up (max 28, mean 11.15 +/- 5.29), for uni and multivariate analysis of survival curves. Patient sex, age over and under 45 years, tumour size smaller and larger than 15 mm, stage, any TNM parameter, histological variety, surgical procedure on the thyroid and nodes were the factors assessed in order to express the prognosis. RESULTS: Male:female ratio was 1:3, the mean age 42.2 years; only 25.9% of patients presented with smaller than 15 mm tumor, about 57% with positive nodes and 8.85% with distant metastases; total or near total thyroidectomy was performed in 86% and nodal dissection in 70% of patients. The 5, 10, 15, 20 year survival rate resulted to be 96.94%, 94.36%, 91.38% and 88.69%; 23 patients, but none aged less than 45 years, died (poorly differentiated and locally advanced carcinoma). Age over 45 years, T4 and M+ stages resulted of high prognostic importance while nodal involvement, interrelated with T and M, showed no independent impact; stage gradually worsened but no difference was found between stage I and II. Adverse effect of male sex resulted from its interrelation with more advanced stages. The relapse rate was found higher in male sex and in patients aged over 45 years, interrelated with T and N extension: no tumor smaller than 15 mm recurred and no relation was found between recurrence and surgical procedure. CONCLUSIONS: Longer follow-up is needed to compare the higher curative effectiveness of total thyroidectomy and nodal dissection versus more conservative treatments.

[A case of forgotten giant goiter]. / Su di un caso di gozzo oublié gigante.

The forgotten goiter is most often the consequence of the incomplete removal of a "plunging" goiter, but it can sometimes be attributed to a concomitant, unrecognised mediastinal goiter which is not connected to the thyroid. Differential diagnosis must be made with other mediastinal masses and with plunging relapses of a previously operated struma. Radiological analysis of persisting mediastinal involvement before and immediately after surgery is the only decisive means of diagnosis, but this is not always available in practice. In this paper the authors report a case of considerable size observed in a series of 346 mediastinal goiters operated between 1967 and 1994. They examine the pathogenetic aspects and the nosological, diagnostic and therapeutic problems related to forgotten goiter, and lastly they list the recommendations that several surgeons have made in an attempt to reduce the incidence. In conclusion, the systematic use of CAT or NMR in the diagnosis of mediastinal opacity may help to reduce the risk of forgetting glandular residue in the mediastinum.