Thyroidectomy with ultrasonic dissector: a multicentric experience.

INTRODUCTION: We have conducted a clinical controlled trial (CCT) on patients who had undergone thyroidectomy for goitre or thyroid carcinoma. The endpoint of this study was to evaluate the benefits of ultrasonic dissector vs conventional technique (vessel ligation and tight) in patients undergoing thyroid surgery. PATIENT AND METHODS: Between January 2007 and December 2009 a CCT was conducted on 2.736 consecutive patients admitted to our clinical wards, who had undergone thyroidectomy for goitre or thyroid carcinoma. They were divided in two group: 1.021 patients (203 male and 818 female) underwent thyroidectomy with ultrasonic dissector (UAS) and 1.715 patients (369 male and 1.346 female) underwent throidectomy with conventional technique (vessel ligation and tight) (CT). RESULTS: The operative time (UAS 80 minutes mean, 50 to 120 min., vs CT 120 minutes, 70 to 180 minutes) was much lower in the thryoidectomy with UAS group. The incidence of transient laryngeal nerve palsy (UAS 17/1.021 patients. 1.6% vs CT 16/1.715 patients, 0.9%) was higher in the thyroidectomy with UAS group; the incidence of permanent laryngeal nerve palsy was similar in two groups(UAS group; there are no relevant difference in the incidence of permanent hypocalcemia (UAS 26/1.021 patients, 2.5% vs 35/1.715 patients, 2%) which was similar in two groups. Also the average post-operative hospitalization was similar in two groups (2 days). CONCLUSIONS: Actually, the only significant advantage shown from this CCT is represented in terms of cost-effectiveness (reduction of the usage of operating room and hospitalization) for patients treated with UAS, subsequent to the significant reduction of operative duration. Although the analysis showed that the patients who were treated with ultrasonic dissection don't present more favourable results in incidence of post-operative transient complication:transient laryngeal nerve palsy (1.6% in UAS vs 0.9% in CT) and transient hypocalcaemia (9.5% in UAS vs 7.7% in CT). There is no significant difference in the incidence of permanent laryngeal nerve palsy (0.9% in UAS vs in 1% CT). The experience of surgeon is the only important factor which can influence the appearance of these complications; the usage of Ultrasonic dissector can only help surgical action but can't repair the experience of the operator.

[Diagnostic, therapeutic and healthcare management protocols in parathyroid surgery. 1st Consensus Conference]. / Protocolli Gestionali Diagnostico-Terapeutico-Assistenziali in Chirurgia Paratiroidea. 1 feminine Consensus Conference.

AIM: The aim of the study was to draw up a management protocol in parathyroid surgery promoted by the Italian Association of Endocrine Surgery Units (UEC Club), based on the guidelines of the main international scientific societies and shared by the experts and applied by the operators in the sector. METHODS AND CONSENSUS: The management protocols, already presented in 2003, on the occasion of the current review were examined by the 1st Consensus Conference called on the topic by the Italian Association of Endocrine Surgery Units (UEC). The Conference comprised two distinct sessions, the first in November 2006 within the framework of the 5th National Congress of the UEC Club in Verona, and the second in September 2007 within the framework of the 10th Multidisciplinary Scanno Prize Meeting. A selected board of endocrinologists and endocrine surgeons examined the individual chapters and submitted the consensus text for the approval of several experts. CONCLUSIONS: The diagnostic, therapeutic and healthcare management protocols in parathyroid surgery approved by the 1st Consensus Conference are officially those proposed by the Italian Association of Endocrine Surgery Units (UEC Club) and are subject to review by October, 2009.

Evaluation of the surgical completeness after total thyroidectomy for differentiated thyroid carcinoma.

BACKGROUND: To quantify the rate of patients without thyroid remnants, to identify predictive factors for the absence of residual thyroid tissue and to evaluate number, site, size and function of thyroid remnants after total thyroidectomy for differentiated thyroid carcinoma (DTC). METHODS: Thousand one hundred and seventy-eight patients who underwent total thyroidectomy for DTC were evaluated; 343 patients with lymph node or distant metastases and 115 patients with detectable thyroglobulin autoantibodies (TgAb) were excluded. (131)I ablative treatment (RAI) without preliminary diagnostic (131)I whole body scans (DxWBS), and 24-h (131)I quantitative neck uptake (RAIU test) and thyroglobulin (Tg) off L-T4 evaluation were performed in the remaining 720 pts. In 252 patients a 99mTc-pertechnetate pre-operative thyroid scan (99mTc-scan) was used for comparison with (131)I neck scans after RAI to evaluate site of thyroid remnants. Only patients with thyroid remnants were evaluated for successful ablation 6-10 months after RAI. RESULTS: Post-treatment whole body scan (TxWBS) demonstrated lack of thyroid remnants in 50/720 patients and the best predictive factors for the absence of residual thyroid tissue were RAIU <1% and undetectable Tg off L-T4. Thyroid remnants were present in 670/720 patients. In 252 patients with (99m)Tc-scan, 617 sites of functioning thyroid tissue were found: 381 within and 236 outside the thyroid bed. Complete successful ablation was achieved in 610/670 patients with thyroid remnants. CONCLUSIONS: This study confirms that most patients (93.1%) have thyroid remnant after total thyroidectomy for DTC. Most thyroid remnants were contralateral to tumour site and were even observed outside thyroid bed. However, a real total thyroidectomy, demonstrated by negative TxWBS, RAIU <1% and undetectable Tg off L-T4, was achieved in 6.9% of patients.

Iodine-131 radio-guided surgery in differentiated thyroid cancer: outcome on 31 patients and review of the literature.

In the present study we investigated the role of radio-guided surgery with Iodine-131 (I-131) in a group of 31 patients with differentiated thyroid cancer (DTC) and loco-regional recurrent disease. The principal inclusion criterion for I-131 radio-guided surgery in our protocol was the presence of an I-131 positive loco-regional disease relapse after previous total thyroidectomy and at least 2 ineffective conventional I-131 treatments. The protocol we used consisted of the following steps. Day 0: all patients were hospitalized and received a therapeutic 3.7 GBq (100 mCi) dose of I-131 after thyroid hormone therapy withdrawal in condition of overt hypothyroidism (serum TSH levels>30 microUI/ml). Day 3: a whole body scan following the therapeutic I-131 dose (TxWBS) administration was acquired. Day 5: neck surgery was performed through a wide bilateral neck exploration using a 15-mm collimated gamma probe, measuring the absolute intra-operative counts and calculating the lesion to background (L/B) ratio. Day 7: post-surgery TxWBS was performed using the remaining radioactivity to evaluate the completeness of tumoral lesions extirpation. The final histologic examination showed the presence of 184 metastatic foci; among them, 98 (53.2%) were evident by both TxWBS and gamma probe evaluation, 76 (41.3%) were demonstrated only by gamma probe, and 10 (5.4%) were negative by both TxWBS and gamma probe evaluation. During follow-up (8 months to 4.9 years, mean 2.8 years), DxWBS, serum Tg levels off l-T4, and US showed absence of loco-regional disease in 25 patients (80.6%) while 6 patients had persistent disease. In conclusion, this protocol allowed us to identify neoplastic foci with high sensitivity and specificity, enabling us to remove loco-regional I-131 disease recurrences resistant to previous conventional I-131 therapies. Furthermore, the gamma probe allowed detection of some additional tumoral foci in sclerotic areas or located behind vascular structures that were not visualized at the pre-surgery TxWBS evaluation.

Cytogenetic monitoring of hospital workers exposed to low-level ionizing radiation.

In the present study the cytogenetic effects in hospital workers exposed to low-level radiation were evaluated. Samples of peripheral blood were collected from 63 subjects working in radiodiagnostics and from 30 subjects, working in the same hospitals, who were used as controls. A higher number of cells with chromosome-type aberrations (CA) was observed in the exposed workers vs. the controls and the difference was statistically significant (p less than 0.05). No correlation was, on the contrary, found between CA and years of exposure. A significant difference was observed in the incidence of cells with CA between smokers and non-smokers, but in the control group only. In contrast, in the workers exposed to ionizing radiation, the frequency of cells with CA was very similar in smokers and non-smokers.

Sister-chromatid exchange rates in XX and XY cells of ten chimeric Callithrix jacchus individuals.

In order to ascertain whether or not sister-chromatid exchange (SCE) differs in relation to sex, SCE rates in XX and XY cells from 10 specimens of marmoset (Callithrix jacchus) were examined. The choice of this primate is particularly suitable for three reasons: most individuals have a chimeric constitution, the X chromosome is quite large and the Y chromosome is particularly small. Therefore, the influence of possible differences in their exposure to the external environment can be eliminated. The results obtained did not reveal any significant difference between SCE rates in male and female cells in any of the examined individuals.

Cell kinetics and sister-chromatid-exchange frequency in human lymphocytes.

Repeated cultures from 5 healthy donors were set up in 3 tissue-culture media: TC109, TC199 and TC1640. For each donor, 3 blood samples were taken at 1-week intervals, making a total of 5 x 3 x 3 = 45 cultures. Our results show a large variability in the individual SCE base-line frequency. This variability can be partly attributed to the different tissue-culture media or to the donors themselves. Our results, however, stress the importance of the proliferating rate of the culture in determining the SCE frequency.

Baseline and mitomycin C (MMC)-induced sister-chromatid exchanges in XX and XY cells of Callithrix jacchus chimeric twins.

Lymphocytes from chimeric individuals of the species Callithrix jacchus (Primates) were examined to evaluate differences in the frequency of sister chromatid exchanges (SCE) between XX and XY cells. The aim was to discover whether SCE differ according to genetic sex and whether XX and XY cells show a different sensitivity to SCE inducing agents. This experimental model has enabled us to eliminate the possible differences caused by environmental factors. The results obtained do not reveal significant differences between male and female cells, in either the baseline SCE frequency or that induced by mitomycin C at concentrations of 0.01 and 0.03 microgram/ml. No significant differences were observed in the distribution of high SCE frequency cells (HFC), even if it is possible to observe a higher level of exchanges in XX cells in each trial. With regard to the phenotypic sex, there appears to be a trend towards slightly higher SCE rates in females, even if results are not statistically significant.

Chromosomal aberrations, sister chromatid exchanges and high frequency cells in young patients with neurofibromatosis 1 (NF1).

Chromosomal aberrations (CAs), sister chromatid exchanges (SCEs) and high frequency cells (HFCs) have been assessed in peripheral blood lymphocytes of 10 neurofibromatosis (NF1) patients and 10 healthy controls. In both groups, the spontaneous rates and the induced (bleomycin for CA and MMC for SCE) frequencies were analyzed. No differences between cells from NF1 patients and controls were observed with respect to spontaneous or bleomycin induced CA. Spontaneous or MMC induced SCE frequencies were also similar in NF1 patients and controls. HFCs, on the contrary, were statistically lower in NF1 patients.

Modified radical neck dissection via extra-thyroideal space (MRND vets) in papillary thyroid carcinoma.

The purpose of this study was to describe an alternative lateral neck access to perform lymph nodes sampling and/or neck dissection via extra-thyroideal space (MRND vets) in papillary thyroid carcinoma with lymph nodes involvment. Twenty-four consecutive patients with papillary thyroid carcinoma were included. Lymph nodes sampling and modified radical neck dissection, unilateral or bilateral, were performed acceding via a lateral dissection through a traditional Kocher incision, running along the medial fascia of the neck, posteriorly to the sterno-cleido-mastoideus muscle (SCM). Mean age was 39.04 +/- 13.69 years. Twenty patients were women, and 4 were men. Mean tumor size was 2.5 +/- 1 cm.. Total thyroidectomy with lymph nodes dissection of the central compartment associated to modified radical neck dissection was performed in 17 patients: among these, nine patients had a preoperative diagnosis of the latero-cervical lymph nodes metastases, and eight had a perioperative diagnosis of metastases of the extensive sampling of the lower third of the jugular chain. Metastatic lymph nodes were found in 107 out of 615 lymph nodes dissected. The MNRD vets access for modified lateral neck dissection seems to carry a lower risk in terms of specific morbility and allows a quicker recovery and a better cosmetic result. This access has to be considered as a less invasive procedure compared to other surgical accesses for the radical modified lateral neck dissection.

Follicular adenoma of the thyroid gland with extensive bone metaplasia.

Follicular adenomas of the thyroid account for over 90% of benign neoplasms of the gland. They exhibit a wide range of morphological structures, from the classical follicular pattern to the peculiar hyalinizing trabecular pattern. Although follicular adenomas grow slowly, they are nonetheless subject to degenerative, most often hemorrhagic changes in their central portion. These hemorrhagic areas undergo further regressive changes such as sclerosis and calcification. However, the detection of a true bone formation with a trabecular structure and the presence of marrow is a very rare occurrence. A follicular adenoma with central cartilaginous metaplasia has been reported in literature but, to our knowledge, a follicular adenoma with bone metaplasia has never been described.

Banded karyotypes of 20 Papionini species reveal no necessary correlation with speciation.

The G-banded karyotypes of 20 species of the tribe Papionini are remarkably similar, and the amount of phylogenetic interpretation permitted is limited. The genera Mandrillus and Cercocebus may be linked by a derived chromosome 10. T. gelada may be linked to the macaques by chromosome 2. Chromosome 5, which differs in M. fascicularis, makes this species an unlikely ancestor of the Sulawesi (Celebes) macaques. An alternate hypothesis, which takes into consideration the possibility that ancestral populations may be polymorphic for these chromosome variants, suggests that different chromosome variants have become fixed in different lines. These chromosomes would therefore not reflect phylogenetic relations. In the Papionini the karyotype has not played a major role in diversification and speciation.

Comparison of chromosome aberration frequency before and after administration of 131I in two groups of thyroid cancer patients.

The chromosome aberration frequencies of 10 thyroid cancer patients, before and after their first radioiodine treatment (group A), were compared to the frequencies found in another 10 subjects previously treated with two or more radioiodine administrations (group B). Our data show that the relative increase in chromosome-type aberrations was similar in the two groups: from 2.0% to 3.7% (group A) and from 4.7% to 9.0% (group B). However, the increase in the number of cells with aberrations was greater in group A. Moreover, the higher frequency of aberrations in group B, even before the radioiodine treatment, points out the effect of previous treatments and demonstrates the persistence of this type of lesion. The sister chromatid exchange frequency in the two groups was also analysed, but no effect bound to the radioiodine treatment could be demonstrated.

Fine needle aspiration of a warthin-like thyroid tumor. Report of a case with differential diagnostic criteria vs. other lymphocyte-rich thyroid lesions.

BACKGROUND: Warthin-like papillary carcinoma of the thyroid (WLT), a recently described entity, should be included among lymphocyterich lesions of the thyroid. The diffuse sclerosing variant of papillary carcinoma (DSV), the oxyphilic variant of Hashimoto thyroiditis (OHT) and primary lymphoplasmacytic lymphoma (PLT), the FNA appearances of which have many similarities, belong to the same category. CASE REPORT: A case of WLT occurred in a 31-year-old female, who was admitted with a 1.5-cm, nodular lesion of the thyroid; fine needle aspiration (FNA) yielded a diagnosis of papillary carcinoma. Histologic examination revealed the characteristic picture of WLT, with papillae lined with large, oxyphilic thyreocytes, with nuclear pseudoinclusions and grooves filled with lymphocytes, mostly mature plasma cells. The FNA picture of WLT was compared with those of the other lymphocyticrich lesions of the thyroid--DSV, OHT and PLT. CONCLUSION: The differences between these forms provide diagnostic criteria that could be useful for the preoperative management of patients affected by suspicious, inflammation like thyroid lesions.

Thyroid tumors in children and adolescents: preoperative study.

Several studies indicate that in young patients (less than 21 years of age at the time of diagnosis), the prognosis of thyroid carcinoma (TC) is more favorable than in older patients. However, a more radical treatment approach is recommended in children and adolescents due to the higher prevalence of local lymph-node involvement in these cases. Since the extent of primary surgical treatment is closely related to the overall prognosis, preoperative diagnosis becomes essential in the management of thyroid neoplasms in young patients. In this retrospective study (1987-1998), we analyzed a surgical series of 50 children and adolescents with thyroid nodules in an attempt to establish the role of diagnostic studies in detecting malignant lesions prior to surgery. Our diagnostic protocol for evaluating thyroid nodules was based on clinical evaluation, measurement of thyroid-hormone and thyroglobulin (TG) levels, anti-TG and anti-TPO antibody titers, calcitonin, CEA, and TPA levels, sonography, scintigraphy, and fine-needle aspiration cytology (FNAC) of the thyroid nodules and any enlarged lymph nodes. Eleven of the 15 cases of histologically confirmed carcinoma were preoperatively identified as malignant lesions with the aid of FNAC. The authors conclude that the preoperative work-up of children and adolescents with thyroid nodules requires the collaboration of an experienced team of professionals, and recommend FNAC as the initial test.

[Therapeutic and prognostic possibilities in primary lymphoma of the thyroid]. / Prospettive terapeutiche e prognostiche nel linfoma primitivo della tiroide.

Personal experience with small cell thyroid tumours is reviewed in the light of recent developments in diagnosis and treatment. All cases were examined by means of immunohistochemical investigation of the lymphocytic and epithelial antigens. In 7 cases in which the production of lymphocytic antigens was confirmed, a primary lymphoma of the thyroid was diagnosed. Immunohistochemical studies of the lymphocytic and epithelial antigens are essential in all small cell thyroid tumours, in order to differentiate between small cell anaplastic carcinomas and thyroid lymphomas. This differentiation is indispensable for the correct choice of treatment and an accurate prognostic assessment. In the case of lymphomas, combined surgical and radiation treatment adjusted to the clinical stage of the tumour is recommended.

[Advanced age and clinical staging in the prognostic evaluation of differentiated carcinoma of the thyroid gland]. / Età avanzata e stadio clinico nella valutazione prognostica del carcinoma differenziato della tiroide.

The prognostic significance of age in differentiated thyroid tumours is assessed via the analysis of 156 cases of differentiated thyroid carcinoma surgically treated in 1967-85. A statistical analysis was performed on a sample of 120 patients under observation since their operation. The results indicate that the negative influence of old age is due more to the higher incidence of advanced tumours among the elderly than to more aggressive behaviour by the tumour.

[The non-recurrent inferior laryngeal nerve. Surgical experience]. / Il nervo laringeo inferiore non ricorrente. Esperienza chirurgica.

During the performance of 1018 thyroid operations, 1497 recurrent laryngeal nerves were identified and exposed. Of the 773 visualized nerves on the right side, 2 were found to be non recurrent (0.26%). This abnormality may represent a pitfall during thyroidectomy even for very experienced thyroid surgeons. We emphasize that the exposure and preservation of this vital structure is the standard of care and an essential component of routine dissection in thyroid surgery.

[Papillary microcarcinoma [correction of carcinoma] of the thyroid: clinical experience and prognosis factors]. / Il microcarcinoma [corrected] papillifero della tiroide: esperienza clinica e fattori prognostici.

Thyroid neoplasm of less than 10 mm in the largest diameter are defined as minimal thyroid cancer (MTC). These tumors are a common incidental finding at autopsy and in thyroid glands excised for other pathology. These tumors can metastasize and can cause significant morbidity and mortality. Clinical significance and optimal operative procedures of these lesions are still questioned. We studied 35 MTC in order to identify clinical and histologic characteristics as prognostic factors and to establish therapeutic management strategies. From January 1988 to December 1998, 177 patients with a primary thyroid cancer underwent surgery in the Department of endocrine-surgery of Catholic University in Rome: 35 of them (19.7%) had a MTC. In the post-operative follow-up 13 of the patients with MTC had a lymph node recurrency and/or distant metastases. Careful histologic examination showed multifocality in 12 patients, capsular infiltration in 10 patients and a solid tumor in 9 patients. MTC are common and they are associated with a good prognosis. Our multifactorial analysis has identified as important risk factors: capsular infiltration, solid lesion and multifocal disease. In these cases total thyroidectomy is mandatory.

Surgery of differentiated thyroid carcinoma, lymph node metastases and locoregional recurrence.

Surgery of differentiated thyroid carcinoma is burdened with risk factors that significantly impact on prognosis, as age at diagnosis and tumor stage. Problems involved concern the extent of surgical resection and the indication for regional lymphadenectomy. As for the former, the most popular approach is total thyroidectomy "on principle" with neck lymphadenectomy. Lobectomy may represent an alternative to total thyroidectomy in low risk patients with unifocal papillary carcinoma 1 cm or less in size, or minimally invasive follicular carcinoma. As for lymphadenectomy, most authors do not agree with surgery "on principle" but rather "of necessity", that is, in presence of clinically evident lymphadenopathy and neck lymphadenectomy is the preferred surgical strategy. In most cases surgery is the treatment of choice of locoregional recurrence. Careful preoperative work-up and accurate surgical procedure are mandatory.