The extent of surgery in thyroglossal cyst carcinoma.

PURPOSE: The optimal management of thyroglossal cyst carcinoma, particularly the extent of surgery required is controversial. The aim of this study was to evaluate the need for routinely adding total thyroidectomy to Sistrunk's operation in the management of this condition. METHODS: The clinical records of 19 patients with a diagnosis of thyroglossal cyst carcinoma encountered in an 11-year period (2004-2015) were reviewed. All patients underwent total thyroidectomy in addition to Sistrunk's procedure. The rate of concomitant thyroglossal cyst and thyroid carcinomas was calculated and cancers were staged according to the AJCC-TNM staging system. Patients were divided into two groups: those with thyroglossal cyst carcinoma only (group A) and those with a synchronous or metachronous thyroid carcinoma as well (group B). The need for radioactive iodine ablation in group A was assessed. The ability to omit total thyroidectomy based on thyroglossal cancer size and a negative thyroid ultrasound was also evaluated. RESULTS: The rate of concomitant thyroid cancer was 63.2 % (12/19). Based on stage, three out of the seven patients in group A required radioactive iodine ablation. Total thyroidectomy was ultimately justifiable in 78.9 % (15/19) of cases. Omitting total thyroidectomy in T1 thyroglossal cyst cancers or based on a sonographically normal thyroid was associated with a 43 % risk of missing thyroid malignancy. CONCLUSION: The routine addition of total thyroidectomy to Sistrunk's procedure seems to be appropriate for comprehensive loco-regional control especially that selecting a subset of patients in which it could be omitted is a difficult task.

Advancements in the treatment of hypothyroidism with L-T4 liquid formulation or soft gel capsule: an update.

INTRODUCTION: The most recent advance concerning levothyroxine (L-T4) therapy is the development of novel oral formulations: the liquid preparation, and the soft gel capsule. Areas covered: This review evaluates the most recent clinical studies about these new formulations. The liquid formulation has been shown to overcome: the food and beverages intereference with L-T4 tablets absorption, caused by food or coffee at breakfast; malabsorption induced by the increased gastric pH, resulting from atrophic gastritis, or due to proton-pump inhibitors; and malabsorption after bariatric surgery. The use of liquid L-T4 has been studied also in pregnancy, newborns and infants, suggesting a better bioequivalence than tablets. Finally, liquid L-T4 is more active than tablets in the control of thyroid-stimulating hormone (TSH) in hypothyroid patients without malabsorption, drug interference, or gastric disorders, leading to a hypothesized higher absorption of liquid L-T4 also in these patients. Few studies have evaluated soft gel L-T4 with promising results in patients with malabsorption related to coffee or gastritis. Expert opinion: Liquid L-T4 (and soft gel capsules) are more active than the tablet L-T4 in the control of TSH in hypothyroid patients with gastric disorders, malabsorption, or drug interference, but also in patients without absorption disorders.

The safety and efficacy of vandetanib in the treatment of progressive medullary thyroid cancer.

INTRODUCTION: Traditional therapies for advanced or metastatic progressive medullary thyroid cancer (pMTC) are poor effective. Several TKIs have been tested in clinical trials in pMTC patients. Areas covered: This paper reviews efficacy and safety of vandetanib in the treatment of pMTC. Expert commentary: Vandetanib (trade name CAPRELSA® [Vandetanib]) has been shown to improve progression-free survival (30.5 vs 19.3 months in controls) in pMTC patients. Vandetanib is approved by FDA and EMA for metastatic MTC in adults; in adolescents and children with metastatic or locally advanced MTC, vandetanib seems to be effective. The most common adverse events in vandetanib-treated patients are: diarrhea, rash, folliculitis, nausea, QTc prolongation, hypertension and fatigue. In patients with aggressive differentiated thyroid cancer, vandetanib has shown promising results. Further research is needed to determine the ideal targeted therapy, based on tumor molecular characterization and host factors, to obtain the best response in terms of survival and quality of life.

The association of other autoimmune diseases in patients with autoimmune thyroiditis: Review of the literature and report of a large series of patients.

We have evaluated prospectively the prevalence of other autoimmune disorders in outpatient clinic in 3069 consecutive patients with diagnosed chronic autoimmune thyroiditis (AT), with respect to two age- and sex-matched control groups: a) a control group of 1023 subjects, extracted from a random sample of the general population without thyroid disorders; b) 1023 patients with non-toxic multinodular goiter extracted from the same random sample of the general population, with similar iodine intake. The results of our study demonstrate a significant increase of the prevalence of autoimmune disorders in AT patients (with respect to both controls), for the following diseases: chronic autoimmune gastritis (CAG), vitiligo (Vit), rheumatoid arthritis, polymialgia rheumatica (Polym), celiac disease, diabetes, sjogren disease, multiple sclerosis, systemic lupus erythematosus, sarcoidosis, alopecia, psoriathic arthritis, systemic sclerosis, and HCV-related cryoglobulinemia. While the statistical analysis reached near the significance for Addison's disease and ulcerative colitis. Interestingly, the association of three autoimmune disorders was observed almost exclusively in AT patients, and the most frequent associations were AT+CAG+Vit and AT+CAG+Polym. We suggest that patients with AT who remain unwell, or who develop new not specific symptoms (despite adequate treatment) should be screened for other autoimmune disorders, avoiding the delay in the diagnosis of these disorders.

Minimally invasive video-assisted thyroidectomy (MIVAT) from A to Z.

A minimal access procedure does not necessarily mean that it is minimally invasive. However, as its name implies, MIVAT is a truly minimally invasive treatment modality. The advantages it offers over its conventional counterpart are indeed related to its minimally invasive nature. Furthermore, this nature has not compromised its ability to accomplish its purpose both safely and effectively. Ever since its introduction in the late 1990s, MIVAT has been progressively evolving. The indications for this procedure, which was initially surrounded by skepticism, have been expanding. Benign thyroid pathology is now considered only one of its indications among others. This article provides a detailed description of this minimally invasive, maximally effective and patient satisfying procedure so that it may be adopted by more surgeons around the globe for better patient care and to also encourage the development of further future advancements.

Sentinel node radioguided biopsy in surgical management of the medullary thyroid carcinoma A case report.

INTRODUCTION: Medullary thyroid cancer is a rare carcinoma. Surgery is the only curative treatment and since cervical lymphnodes metastases are frequent and can occur at an early stage, a standardized central lymphnode dissection is associated to total thyroidectomy. However, the extent of lymphadenectomy to the lateral neck lynphnodes remains debated. To reduce the extent of lymphnode excision, the sentinel node biopsy has been used as an accurate technique to assess the status of the lymphnodes in the regional drainage basin in solid tumors, and more recently, in thyroid carcinoma. In this case report, we show the utility of the radioguided biopsy of the sentinel lymphnode in the surgical management of the medullary thyrod cancer. CASE REPORT: We present the case of a 24-year-old Caucasian, Italian woman with a sporadic medullary thyroid microcarcinoma occasionally detected by neck ultrasound and diagnosed by high serum calcitonin level and fine needle aspiration cytology. There was no ultrasound evidence of lymphnode involvement both in central and lateral compartment of the neck. We performed a preoperative mapping of the the sentinel lymphnodes by the injection of technetium-99m radiolabelled albumin nanocolloids in the thyroid nodule. Then our patient underwent total thyroidectomy combined with radioguided biopsy of the sentinel lymphnodes. Histology confirmed the presence of the medullary thyroid cancer and revealed micrometastases only in two sentinel lymphnodes detected in right lateral compartment of the neck so an ipsilateral lateral neck dissection besides the central neck dissection was performed at the end of operation. Basal and pentagastrin-stimulated serum calcitonin level was undetectable during the follow-up investigations. CONCLUSION: This is the first reported case that shows the utility of the radioguided SLN biopsy for the accurate staging of the cervical lymphnode involvement in patient with sporadic medullary thyroid microcarcinoma. Total thyrodectomy and central neck dissection is recommended for all patients with medullary thyroid carcinoma, but the indication for the lateral neck dissection is still controversial. The radioguided SLN biopsy technique could be a useful tool to perform the dissection only in those patients with proven lateral neck lymphnode involvement and reduce the extention of the lateral lymphnode excision and the incidence of related complications.

Performance of chloride/phosphate test in patients with primary hyperparathyroidism. Is it related to calcium level?

OBJECTIVE: To examine the sensitivity of the chloride/phosphate (Cl/PO4) ratio with a cut-off point of >33 as a diagnostic test for primary hyperparathyroidism (pHPT) in surgically proven patients, and its performance at different calcium levels. METHODS: This is a retrospective medical records based study. Data of 120 patients diagnosed with pHPT, already operated in the Department of Surgery, Cisanello Hospital, Pisa, Italy between March 2010 and June 2011 were reviewed. They were divided into 4 subgroups according to their calcium levels. The Cl/PO4 ratio was measured for each patient, with a cut-off point of 33, sensitivity of Cl/PO4 test was measured. Test sensitivity was calculated for each subgroup, and a correlation with the parathyroid hormone (PTH) level was investigated. Performance of the equation was tested for the normocalcemic patients with a suitable control group. RESULTS: The sensitivity of Cl/PO4 ratio for the whole group was 0.883 (0.809-0.932). The sensitivity was 0.9340 (0.857-0.973) for patients with serum calcium above normal levels. A similar result of 0.933 (0.830-0.978) was demonstrated for the subgroup with hypercalcemia <1 (mg/dL) above normal level. Normocalcemic patients constituted 24%; for this subgroup, the sensitivity test was 0.724 (0.562-0.887), specificity was 0.763 (0.628-0.898), positive predictive value was 0.700 (0.536-0.864), and negative predictive value was 0.784 (0.651-0.916). No correlation was identified between the performance of formula and serum PTH level. CONCLUSION: The Cl/PO4 test seems to be a good tool to anticipate pHPT and showed a fair performance in normocalcemic patients.

Radioguided localization of occult colonic lesions during open or laparoscopic surgery: an update.

The applications of radioguided surgery, an approach to oncologic surgery involving a multidisciplinary team, are expanding at a rapid pace. The technique of radioguided occult lesion localization (ROLL) was originally introduced in the mid- 90s for applications in breast surgery, and later adapted also to other tumor lesions such as solitary pulmonary nodules (during either open or laparoscopic surgery) and colonic lesions. Concerning the latter, in particular, the technique called radioguided occult colonic lesion identification (ROCLI) consists of identifying, with the aid of intraoperative gammaprobe counts, small lesions that may escape colic intraoperative palpation, after prior tagging of the lesions performed endoscopically through peri- or intra-lesional injection of Technetium-99m-labeled human albumin macroaggregates (99mTc- MAA), a particulate radiopharmaceutical (25-100 µm) that does not migrate from the site of interstitial administration. Since September 2001, ROCLI has been employed in 12 patients, using a collimated gamma- probe measuring 11 mm in external diameter (Scintiprobe MR100 Pol.Hi.Tech.). All patients underwent preoperative colonoscopy in order to inject 0.2 mL of a 99mTc-MAA suspension (10-20 MBq) into the submucosa or intra-perilesionally; such tagging required only a few minutes. Eight of the 12 patients were then submitted to open laparotomy, while laparoscopic access was utilized in the remaining 4 patients. In all 12 patients, localization of the lesion with the ROCLI technique was technically feasible, safe, efficient and highly accurate, enabling quick detection of the lesion during surgery, with a 100% success rate. No complications occurred, and there was no risk of contamination by ionizing radiation.

Colorectal carcinoma and folate.

More than a million people a year worldwide develops colorectal cancer (CRC), with a mortality rate close to 33%. Most of the CRC cases are sporadic, only 25% of the patients have a family history of the disease, and major genes causing syndromes predisposing to CRC only account for 5-6% of the total cases. The following subtypes can be recognized: MIN (microsatellite instability), CIN (chromosomal instability), and CIMP (CpG island methylator phenotype). CRC arises from an accumulation of genetic and epigenetic alterations such as DNA methylation, which is able to modulate gene expression. Several studies in the literature show a possible correlation between an altered methylation in the promoter of tumor suppressor genes, proto-oncogenes, genes involved in DNA repair and the CRC risk; it has also been observed a global DNA hypomethylation, especially in the presence of a low folate uptake. Epigenetic changes are reversible, then could be interesting to evaluate on their relationship with dietary factors (as well as folates) and the genetic background of the individuals, for the development of novel strategies for cancer prevention.