Encapsulated papillary thyroid carcinoma: is it a distinctive clinical entity with low-grade malignancy?

BACKGROUND: Encapsulated papillary thyroid carcinoma (EPTC) is commonly retained as a tumor with indolent clinical courses. Herein we focused on the search for factors predicting biological behavior and influencing prognosis of EPTC in comparison with the non-encapsulated counterpart of papillary thyroid carcinoma (NEPTC). METHODS: From January 1998 to May 2009, 348 patients underwent thyroidectomy in our surgical department because of papillary thyroid carcinoma (PTC). A cross-sectional study of 52 patients with EPTC and 296 patients with NEPTC was carried out: demographic data, tumor characteristics, diagnostic results, patient management, post-operative and follow-up results were evaluated. RESULTS: EPTC patients were significantly younger than patients with NEPTC (44.5 vs 48.8 yr, p<0.04). Mean tumor size was significantly greater for EPTC than for NEPTC (2.36 vs 1.41 cm, p<0.001). Tumor multifocality, thyroid capsular invasion, and lymph node involvement at diagnosis were significantly associated with NEPTC (p=0.0001, p<0.0001, and p=0.027, respectively). Multivariate analyses showed that NEPTC classical variant were at risk for both thyroid capsular invasion and nodal involvement (odds ratio 6.870 and 9.514, respectively) while EPTC were not. Nodal metastasis at diagnosis was the only factor influencing recurrence. CONCLUSIONS: The majority of EPTC had risk-free clinical courses as a result of their low risk of locoregional spread. However, definitive recommendations need a longer follow-up and a comparison with a lesser treated group of patients belonging to the same category of risk at diagnosis.

Expression of ATP7B in normal human liver.

ATP7B is a copper transporting P-type ATPase, also known as Wilson disease protein, which plays a key role in copper distribution inside cells. Recent experimental data in cell culture have shown that ATP7B putatively serves a dual function in hepatocytes: when localized to the Golgi apparatus, it has a biosynthetic role, delivering copper atoms to apoceruloplasmin; when the hepatocytes are under copper stress, ATP7B translocates to the biliary pole to transport excess copper out of the cell and into the bile canaliculus for subsequent excretion from the body via the bile. The above data on ATP7B localization have been mainly obtained in tumor cell systems in vitro. The aim of the present work was to assess the presence and localization of the Wilson disease protein in the human liver. We tested immunoreactivity for ATP7B in 10 human liver biopsies, in which no significant pathological lesion was found using a polyclonal antiserum specific for ATP7B. In the normal liver, immunoreactivity for ATP7B was observed in hepatocytes and in biliary cells. In the hepatocytes, immunoreactivity for ATP7B was observed close to the plasma membrane, both at the sinusoidal and at the biliary pole. In the biliary cells, ATP7B was localized close to the cell membrane, mainly concentrated at the basal pole of the cells. The data suggest that, in human liver, ATP7B is localized to the plasma membrane of both hepatocytes and biliary epithelial cells.

Hypocalcemia following total thyroidectomy: early factors predicting long-term outcome.

Hypocalcemia following total thyroidectomy (TT) must be considered permanent in patients requiring calcium replacement after one year. The aim of this study was to identify early risk factors predicting long-term outcome of postoperative hypocalcemia. Among 453 patients who underwent TT from January 1998 to May 2003, a cross-sectional study between 44 patients with transient hypocalcemia (9.7%) and 3 patients with permanent hypocalcemia (0.7%) was carried out. Both low serum calcium level (< 8 mg/dl) and high serum phosphorus level (> 4.5 mg/dl), measured on postoperative day 7, were predictive for outcome. Central neck lymph node dissection, performed for thyroid carcinoma, also correlated with outcome. Serum phosphorus level > 4.5 mg/dl on postoperative day 7 resulted the only independent factor predicting permanent hypoparathyroidism. Therefore indication for central dissection would be very strict. When serum phosphorus level is unfavorable a correct replacement therapy is mandatory to prevent the consequences of permanent hypocalcemia.

Meta-analysis and review of prospective randomized trials comparing laparoscopic and Lichtenstein techniques in recurrent inguinal hernia repair.

PURPOSE: The hypothesis of this meta-analysis was to assess whether laparoscopic approach shows real benefits over Lichtenstein technique in recurrent inguinal hernia repair. METHODS: A literature search for prospective randomized trials comparing laparoscopic and Lichtenstein procedure in recurrent inguinal hernia repair was performed. Trials were reviewed for primary outcome measures: re-recurrence, chronic inguinal pain and ischemic orchitis; and for secondary outcome measures. Standardized mean difference (SMD) was calculated for continuous variables and odds ratio for dichotomous variables. RESULTS: Seven studies comparing laparoscopic and Lichtenstein technique were considered suitable for the pooled analysis. Overall 647 patients with recurrent inguinal hernia were randomized to either laparoscopic repair (333, 51.5 %, transabdominal preperitoneal approach, TAPP and totally extraperitoneal approach, TEP) or anterior open repair (314, 48.5 %, Lichtenstein operation). Patients who underwent laparoscopic repair experienced significantly less chronic pain (9.2 % vs. 21.5 %, p = 0.003). Patients of the laparoscopic group had a significantly earlier return to normal daily activities (13.9 vs. 18.4 days, SMD = -0.68, 95 % CI = -0.94 to -0.43, p < 0.000001). Operative time was significantly longer in laparoscopic operations (62.9 vs. 54.2 min, SMD 0.46, 95 % CI 0.03, 0.89; p = 0.04). No other differences were found. CONCLUSIONS: Laparoscopy showed reduced chronic inguinal pain and an earlier return to normal daily activities but significantly longer operative time. Despite the expected advantages, the choice between laparoscopy and other techniques still depends on local expertise availability. Only dedicated centers are able to routinely offer laparoscopy for recurrent inguinal hernia repair.

The usefulness of 99mTc-SestaMIBI scan in the diagnostic evaluation of thyroid nodules with oncocytic cytology.

OBJECTIVE: To assess the relevance of (99m)Tc-SestaMIBI (MIBI) scan in the diagnostic evaluation of thyroid nodules with oncocytic cytology. SUBJECTS AND METHODS: Twenty-four patients with a single (or prevalent) 'cold' solid nodule with Hurthle cells (HC) at fine needle aspiration cytology (FNAC) were studied. Cytological diagnosis of oncocytic metaplasia (OM) or HC tumor (HCT) was made when HC on the smear were comprised 10-75%, or >75%. Nodules concentrating MIBI at early and late (2 h after washout) stages were considered MIBI-positive. In all cases histological findings were obtained after total thyroidectomy. RESULTS: FNAC was malignant or suspect for malignancy in 16 cases (six HCT and 10 OM) and not suspect in eight (two HCT and six OM). Histological examination revealed 14 malignant tumors (11 HCT and three OM), and 10 benign thyroid lesions (three HCT and seven OM). Sensitivity of FNAC for malignancy was 92.8% and specificity was 70.0%; HCT were identified by FNAC in only 35.7% and OM in 70.0% of cases. No significant difference in MIBI positivity was found between malignant and benign thyroid nodules. The highest percentage of MIBI positivity was found in HCT (78.5%), but MIBI-positive nodules were also observed in thyroid lesions with HC metaplasia (40.0%). CONCLUSIONS: MIBI scintiscan has no value in differentiating malignant from benign HC thyroid neoplasias. Most HCT are MIBI-positive, but this scan is not sufficiently specific to differentiate true HC neoplasias from other thyroid lesions showing HC at FNAC, although an MIBI-negative scan strongly supports the absence of true HCT.

The "ultraperipheral" revascularization in arteriosclerotic obstruction of tibial vessels. Experimental study.

In arteriosclerotic obstruction of the main tibial arteries, the tibial collateral vessels are usually patent, and about 70% of these arteries are potentially suitable for surgical revascularization. The present study aimed at investigating the practical feasibility of a selective revascularization procedure on these tibial muscular arteries (ultraperipheral revascularization). Six lower limbs amputated at thigh level for arteriosclerotic gangrene with complete obstruction of the main tibial arteries, were studied: the tibial collateral muscular vessels showed patency in 65% of cases. The authors propose a surgical technique for the revascularization of these peripheral vessels with the use of a vascular prosthesis. The "post-operative" angiographic studies showed that revascularization of these peripheral muscular arteries was possible.

Inflammatory pseudotumor of the liver. A report of two cases with unusual histologic picture.

Two cases of inflammatory pseudotumor (IPT) of the liver are reported. Clinical presentation was vague and aspecific. Laboratory tests and data from imaging techniques provided no specific information on the actual nature of the lesions and were misleading, suggesting a malignant lesion in one patient and a complicated hydatid cyst in the other. On gross examination, the tumors appeared yellowish ore grey-yellow in color, with a firm cut surface and well circumscribed from the surrounding parenchyma, although a true capsule was not evident. Variability in the histological pattern was also observed, even though the major finding was in both cases an admixture of lymphocytes, plasmacells, granulocytes and monocytes. Lymphocytes were immunohistochemically heterogeneous; monocytes showed in one case large hyperchromic atypical nuclei, confirming the previously, reported possibility that some cases of IPT may be mistaken for sarcomas. Further evidence is added in support of the hypothesis that some liver IPT may result from the evolution of cholangitic abscesses.

[Predictive factors for malignancy in Hürthle-cell thyroid neoplasia. Effect of surgical treatment]. / Fattori predittivi di malignità nelle neoplasie tiroidee a cellule di Hürthle. Influenza sul trattamento chirurgico.

The aim of this study has been to evaluate factors predicting malignancy in patients with Hürthle cell neoplasms. Medical records from 36 patients who underwent thyroidectomy for Hürthle cell neoplasms between January 1998 and December 2002 were analyzed. Of the 36 patients, 19 had carcinomas and 17 had adenomas, resulting in a 52.7% prevalence of malignancy. Both fine-needle aspiration and intraoperative frozen section had low sensitivities in cancer detection (22.2% and 33.3% respectively). Hürthle cell carcinomas were significantly larger than adenomas (30.3 mm +/- 3.9 vs 17.6 mm +/- 2.3, P = 0.012), however 42% of carcinomas had a diameter between 10 and 20 mm. Size of Hürthle cell tumors is predictive of malignancy, but it is not the only factor to make surgical decision effective. Because of these uncertainties, authors believe that total thyroidectomy is the treatment of choice of all Hürthle cell neoplasms.

[Immunosuppressive therapy in ulcerative rectocolitis. Long-term assessment of results]. / La terapia immunosoppressiva nella rettocolite ulcerosa.

The short and long-term efficacy of the combined administration of azathioprine and sulphasalazine in the treatment of ulcerative colitis was evaluated. A complete and durable remission of the clinical, the endoscopic and the histological signs of the disease was achieved in all the patients but one, who did not follow the domiciliary therapeutic regimen. No adverse effects referable to the long-term assumption of the azathioprine have been noted.

[The choice of the intervention in the surgical treatment of nontoxic diffuse multinodular goiter]. / La scelta dell'intervento nel trattamento chirurgico del gozzo multinodulare diffuso non tossico.

The choice between sub-total (STT) and total (TT) thyroidectomy in surgical management of multinodular goitre should be based on the disease pathophysiology and the critical review of short and long-term results of these treatments. In order to make a comparative evaluation the authors carried out a retrospective analysis on a series of patients operated from 1970 to 1993 and on the results of a 16.3 years mean follow-up. Of 551 patients operated on the thyroid gland, 389 (70.6%) affected by multinodular goitre were considered. 340 were female and 49 male (39 years medium age). 341 (87.6%) underwent STT and 48 (12.4%) TT. Post-operative opotherapy was adjusted according to hormonal assays. Post-operative vocal cord motility and calcemia were assessed. A routine endocrinological follow-up protocol has been carried out on all patients since 1980. Transitory vocal cord palsy and hypocalcemia were significantly more frequent in TT, while permanent damage was not. Of 40 TT (complete 5 years mean follow-up, 97.5% of the patients reached euthyroidism with replacement therapy. Of 189 STT (complete 16.3 years mean follow-up), 61.4% of the patients received opotherapy. A recurrent goitre was ascertained in 39.1% of the total (73.3% in the patients not receiving opotherapy) and operated in 16.2% of the cases. According to the authors their results support the choice of TT as it matches the rationale of surgical treatment of multinodular non-toxic goitre based on the pathophysiology of the disease. Moreover it allows easy achievement of euthyroidism avoiding goitre relapse and subsequently re-operation, with an incidence of permanent recurrent nerve palsy and hypoparathyroidism not significantly different from that after STT.

[Digestive hemorrhages and intestinal metastases of chorioepithelioma]. / Emorragie digestive e metastasi intestinali da corionepitelioma.

An unusual case of digestive haemorrhage due to colic metastasis of choriocarcinoma is reported. Reference is made to the fact that the literature contains only three other cases of intestinal metastasis from choriocarcinoma and one from haemorrhagic destructive mole. Note is taken of the fact that the multiplicity of secondary sites may lead to haemorrhage in other districts, particularly the brain. Even so, the digestive haemorrhage is often the introductory sign of the primary neoplasia. The various ways of preoperatively diagnosing its nature and site are discussed. It is also shown that surgical management can be combined with suitable chemotherapy to achieve encouraging results.

[Current trends of complementary therapy in radical surgery of colo-rectal cancer]. / Moderni orientamenti di terapia complementare nella chirurgia radicale del cancro colo-rettale.

Large surgical series are agreed on the fact that the prognosis for radically operated colorectal cancer has improved little in the last twenty years. Reasons for these failures are, of course, local or remote recurrences. To improve the number of stable cures, experiments have been carried out with complementary or coadjuvant techniques whose purpose is to limit intra-operative dissemination of the tumour and to monitor the number of cancer cells that might remain after radical surgery. Such techniques have been applied at preoperative, intra-operative and post-operative phases. Results obtained so far have been uncertain but seem to point to the usefulness of intraoperative procedures in reducing the number of local recurrences and of postoperative chemotherapy with 5 FU which has improved five-year survival indices by 5-7%.

[Anicteric calculosis of the common bile duct]. / La calcolosi anitterica dell'epato-coledoco.

In a series of 158 patients who underwent surgical treatment for biliary lithiasis, we have had 109 (69%) lithiasis of the gallbladder (CC) and 48 (31%) lithiasis of the common bile duct. In the last group 19 (38%) were without jaundice (CAEC) and 30 (62%) with jaundice (CIEC). We have compared the three group of patients (CC, CAEC and CIEC). It has come out that CAEC is between CC and CIEC and that attacks of biliary fever and high levels of alkaline phosphatase and transaminases in the serum are the helpful findings for preoperative diagnosis. Intravenous cholangiograms can confirm the diagnosis in 80% of one series but the operative cholangiography remains the definitive test. Finally CAEC seems to be the "benign" lithiasis of the common bile duct, a first stage that getting worse will became CIEC.

[The choice of operation in perforated gastroduodenal ulcer]. / La scelta dell'intervento nell'ulcera gastro duodenale perforata.

The main point for a surgeon treating a perforated peptic ulcer is to choose between a simple treatment of the complication and a treatment both of complication and ulcer disease. So, the A. have analysed their series of 58 patients with perforated peptic ulcer: one patient underwent nasogastric suction as suggested by Taylor, 16 patients underwent suture plication of the perforation, 41 underwent immediate gastrectomy. A fully follow-up was performed: in the suture-plication group only 28.5% was symptonfree, the remaining 71.5% had recurrent dyspepsia or underwent definitive gastrectomy. Follow-up results of the immediate gastrectomy patients and elective gastrectomy patients are the same. The A. discuss the different procedures of treatment and their specific indications. Surgical treatment is the selected one and simple suture and immediate gastrectomy are not opposite.

[Stomach cancer in the elderly patient]. / Il cancro dello stomaco nell'anziano.

Gastric cancer is a typical disease of old age, in fact about one half of the patients affect by it are aged over 65. Elderly patients imply a problematical choice of surgical treatment due to the general and specific risk and to life expectancy. In order to evaluate the specific features of gastric cancer in aged people and to share their experience in choosing the surgical treatment, a series of 50 patients with gastric cancer selected on the age > or = 75 years and observed from 1970 to 1993, was reviewed by the authors. Some features have been settled such as sex ratio approaching the unity, a prevalence of tumors located in the distal third of the stomach, the higher incidence of intestinal type and a wide incidence of intestinal type and a wide incidence of patients in III or IV stage. No surgical procedure was undertaken in eleven patients. The remaining 39 patients (78%) underwent a surgical procedure. In 22 patients (56.4) a resection was performed: 17 (77.3%) underwent a subtotal gastric resection, 11 curative and 6 palliative, and 5 (22.7%) a total gastrectomy out of necessity for tumor localization. In 17 patients (43.6%) a bypass procedure was carried out, while in 7 (17.9%) the surgical procedure was a simple laparatomy. Postoperative morbidity incidence was 17.9%, mortality rate 10.2%. Actuarial 5 years survival rate for curative resection was 41.5%. Median survival time was 13 months for patients who underwent a palliative resection and 6 months after bypass procedures. The data suggest that subtotal gastrectomy, also as palliative procedure, fits better to geriatric patients' requirements and is able to offer a satisfactory quality of life, to prevent cancer complications and to determine a longer survival.

[A difficult diagnosis: retroperitoneal rupture of the duodenum caused by closed trauma of the abdomen]. / Una diagnosi difficile: la rottura retroperitoneale del duodeno da trauma chiuso nell'addome.

The Authors report two cases of sub-peritoneal rupture of the duodenum following blunt abdominal trauma. The diagnostic difficulties are explained in detail. Emphasis is placed on the importance of prompt recognition of the duodenal injury and early surgical treatment to ensure a successful outcome.

[Carotid body tumour. Case report and literature review]. / Il tumore del glomo carotideo. Presentazione di un caso clinico e revisione della letteratura.

The tumour of the carotid body is rare. About 1000 cases had been reported in the literature. It may occur sporadically in 90% of cases and it affects both sexes in the same proportion and in the middle age. This tumour may be misdiagnosed if it is not suspected. Ultrasono-graphy and color-Doppler scan show a hypervascular tumour between the internal and external carotid arteries. CT-scan defines the tumour s extent on the surrounding structures. Angiography is the gold standard for diagnosis, showing a hypervascular mass displacing the bifurcation of the carotid arteries. Sometimes radiotherapy and embolization are indicated but the surgical excision of carotid body tumours is the therapy of choice. The surgical approach through incision like carotid artery operation is performed. If the subadventitial plane between tumour and arterial wall is not identified, resection of carotid artery and insertion of a shunt is required. Although the diagnosis and the surgical technique advances, the incidence of postoperative nerve injury is high in the different series. The clinical suspect and the early diagnosis are very important because low morbidity rate occurs with resection of a small chemodectoma. The surgical excision can be followed by postoperative respiratory depression or dyspnea both with regional and general anesthesia. The authors report a case of a medium size tumour operated on and developing a mild transient weakness of cranial nerve VII. Recent trends in evaluation and therapy are analysed and the literature is reviewed.

[Colorectal cancer in old age. Our experience]. / Il cancro colorettale in età geriatrica. Nostra esperienza.

Two hundred and thirty-three patients treated for colorectal cancer during the period 1976-1991 were divided into three groups (A: < 65 yr; B: 65-74 yr; C: > 74 yr) in order to perceive possible statistically significant differences in patients older than 75 years. Epidemiological features are similar among the three groups, while a greater diagnostic delay (p = 0.013), a higher incidence of emergency procedures (p = 0.006) and a more advanced AP stage were found in group C. The high anesthesiological risk determined a conservative surgical approach only in 4.1% of patients, while a curative resection was performed on 51% of group C vs 72.7% of group A (p = 0.016). Postoperative complications and mortality for curative resections were 28% and 12% in group C vs 24.6% and 2.9% in group A (p = n.s.); the overall 5 years survival rate was 62.9%, 51.7% and 42.2% in groups A, B, and C. It is concluded that age alone should not be considered as a contraindication to curative surgery for colorectal cancer, for life expectancy and quality are considerably worse in the elderly undergoing derivative surgery.

[Primary lymphoma of the rectum]. / Il linfoma primitivo del retto.

Observation of a case of primary rectal lymphoma (123 cases described) led to a discussion of certain aspects of the condition. Although the clinical picture points to a straightforward general diagnosis of cancer, it is possible to achieve correct diagnosis using deep and multiple perendoscopic biopsy, considering the submucous origin of the lymphomas. The therapeutic approach should allow for correct staging which is only obtained by means of diagnostic studies aimed at excluding multicentric localisations. Surgery must be considered elective in stage I and II or in cases of need. Sensitivity to radiotherapy has led some authors to propose it as a primary treatment. Chemotherapy is indicated alone or in association with radiotherapy or surgery. It is also pointed out that treatment modalities are still debated because data are not homogeneous and so few cases have been reported.

[Long-term evaluation of the treatment of perforated gastroduodenal ulcer using a median suture]. / Valutazione a distanza del trattamento dell'ulcera gastro-duodenale perforata mediante rafia.

Simple suture associated with treatment using H2-antagonists has replaced gastroduodenal resection in the treatment of peptic ulcer. Forty-four patients were submitted to rafia suture for perforated gastric or duodenal ulcer (1972-1986). Fourteen were treated in the pre-H2-antagonist period and 30 in the post-H2 antagonist period. Patients were followed up: Vissick classes I and II represent 58.3% of cases in the pre-H2-antagonist period and 95.8% in the post-H2-antagonist period. Two patients from the first period were subjected to gastroduodenal resection. In no patient of the second period was further ulcer therapy necessary. In patients of the first period, oesophagogastroduodenoscopy evidenced duodenal ulcer in one case and erosive duodenitis in two cases; erosive duodenitis was present in one patient of the second period. The choice of rafia would appear to be a valid one. Follow-up after a longer period should provide confirmation.