Large non-functioning parathyroid cysts: our institutional experience of a rare entity and a possible pitfall in thyroid cytology.

OBJECTIVE: Large non-functioning parathyroid cysts represent a rare entity with a benign clinical course. They may be misdiagnosed as thyroid cystic neoplasms on fine needle aspiration cytology (FNAC), resulting in inappropriate surgical treatment. We evaluated our institutional experience in the diagnosis of large parathyroid cystic lesions underlining all the differential diagnoses and pitfalls. METHODS: In the period between 1998 and 2012, we reported the cytology of eight large (>2.5 cm) parathyroid cystic lesions (all female patients) with histological control. The aspirations were performed with a 25-gauge needle with ultrasonographic guidance. The aspirated material was processed with liquid-based cytology (LBC). All the patients had normal serum parathyroid hormone (PTH) and calcium. RESULTS: The cytological samples showed a fluid watery component without colloid and few or absent epithelial cells. The resulting negativity for thyroglobulin and positivity for PTH, carried out on the cystic fluids, suggested parathyroid lesions rather than either thyroid cystic lesions (including follicular thyroid neoplasm) or cystic malignant lesions. All the patients underwent surgery without complications. CONCLUSIONS: To the best of our knowledge, this is one of the largest series with cytohistological evaluation of large parathyroid cysts. The incidence of large parathyroid cysts remains controversial as most patients are asymptomatic. FNAC may be performed with conclusive results in the majority of cystic cases. The detection of PTH and calcium on the cystic liquid is likely to achieve a correct cytological diagnosis, allowing adequate treatment and ruling out a more frequent thyroid lesion.

EPO modulation in a 14-days undersea scuba dive.

Erythropoiesis is affected during deep saturation dives. The mechanism should be related to a downregulation of serum Erythropoietin (s-EPO) concentration or to a toxic effect of the hyperbaric hyperoxia. We evaluated s-EPO and other haematological parameters in 6 scuba divers before, during and after a 14-days guinness saturation dive (8-10 m). Athletes were breathing air at 1.8-2 ATA, under the control of a team of physicians. Serum parameters were measured before diving (T0) and: 7 days (T1), 14 days (T2) after the beginning of the dive and 2 h (T3) and 24 h (T4) after resurfacing. Hgb, and many other haematological parameters did not change whereas Ht, s-EPO, the ratio between s-EPO predicted and that observed and reticulocytes (absolute, percent) declined progressively from T0 to T3. At T4 a significant rise in s-EPO was observed. Hgb did not vary but erythropoiesis seemed to be affected as s-EPO and reticulocyte counts showed. All these changes were statistically significant. The experiment, conducted in realistic conditions of dive length, oxygen concentration and pressure, allows us to formulate some hypotheses about the role of prolonged hyperbarism on erythropoiesis. The s-EPO rise, 24 h after resurfacing, is clearly documented and related to the "Normobaric Oxygen Paradox". This evidence suggests interesting hypotheses for new clinical applications such as modulation of s-EPO production and Hgb content triggered by appropriate O2 administration in pre-surgical patients or in some anemic disease.

ENT function in a 14-days guinness scuba dive.

Scuba diving is known to affect the rhino-pharyngo-tubaric district (RPT unit). The aim of the study was to document function modifications of the RPT unit in 6 Italian divers (3 men and 3 women) who lived for 14 days consecutively at a depth of 8-10 m, breathing air (21% oxygen) at a pressure ranging between 1.8 and 2 ATA. RPT and inner ear assessment were carried out before the dive (TIME 0) and 24 h (TIME 1) after resurfacing, in order to investigate diving-related RPT and inner ear alterations. Physical examination after resurfacing revealed: fungal external otitis, otoscopic findings consistent with middle ear barotraumas and rhinosinusitis. Rhino-manometry showed a remarkable increase in inspiratory nasal flow and a substantial decrease in nasal resistance. No epithelial cell disruption was retrieved comparing pre and post resurfacing samples. Post-diving tubaric dysfunction was found. Pure tone audiometry revealed a bilateral 40 dB HL hearing loss at 4 kHz in 1 diver. Relevant PTA functions did not seem to be affected by the experiment, no remarkable changes were found at the Sensory Organisation Test and at the Motor Control Test. The 14-day underwater period had a positive effect on nasal flows and resistances.

[Endoluminal radiofrequency ablation of the great saphenous vein versus stripping. A preliminary study]. / Termoablazione con radiofrequenza della vena grande safena versus stripping. Studio preliminare.

AIM: To compare the postoperative courses of patients subjected to closure procedure or stripping of the great saphenous vein (GSV). METHODS: We examined 2 groups of 15 patients with ostial and truncular saphenous insufficiency matched for CEAP clinical and anatomic classes. Group A patients underwent saphenous closure; short stripping was performed on those of Group B. In the Group A surgery was performed under spinal (12) or local (3) anesthesia; the procedure was preceded by crossotomy (5), crossectomy (1) or saphenous ligation (8); in 11 cases micro-phlebotomies were associated. In the Group B surgery was performed under general (5), spinal (7) or local (3) anesthesia; the procedure always was preceded by crossectomy (1); in 11 cases micro-phlebotomies were associated. RESULTS: Group A patients were discharged 6-18 hours after surgery. None presented ecchymosis, hyperemia or skin lesions. Five complained of mild aching thigh pain, which did not require pain medication. All resumed normal daily activities the day after surgery and returned to work after 4.9 days. Six months after surgery, none of the patients had evidence of saphenous vein re-channeling. Group B patients were discharged 12-18 hours after surgery. Nine had ecchymosis on the thigh. Five reported mild thigh pain requiring analgesics. Normal daily activities and work were resumed 2.7 and 9.3 days after surgery. CONCLUSIONS: This retrospective study seems to confirm that endoluminal radiofrequency ablation of the GSV provides good immediate results with no significant complications and can reduce postoperative pain and the length of convalescence with respect to those of stripping.

Doppler ultrasonography before thyroidectomy is not useful to prevent cerebrovascular accident.

Surgical manipulation of the cervical vascular bundle during neck surgery may promote a thromboembolic event. We evaluated if thyroid surgery is associated with any alterations in the carotid artery wall that would imply an augmented risk of cerebrovascular accident (CVA). A prospective evaluation of a consecutive series of patients who underwent total thyroidectomy was performed. High resolution Doppler ultrasonography (HR-DU) was performed the day before and three days after surgery in asymptomatic consenting patients scheduled for total thyroidectomy. Two hundred patients were recruited. Preoperatively, no hemodynamically significant stenosis (> 70%) was observed. Surgery was delayed in one patient because of asymptomatic subclavian steal syndrome. The remaining 199 patients underwent total thyroidectomy. No modification of preoperative findings was observed at the postoperative HR-DU evaluation. No CVA was observed. In the absence of any significant stenosis, thyroid surgery does not affect the presence and extent of arterial wall disease and the consequent risk of CVA. Thus, screening with HR-DU does not seem beneficial in a generally asymptomatic population without significant risk factors.

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.

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.

[Venous angiodysplasias with endoral manifestation. The problems of therapy]. / Angiodisplasie venose ad estrinsecazione endorale. Problemi di terapia.

Five oral venous angiodysplasia cases are presented by the authors. Besides subjective aesthetic and psychological factors, the treatment of these lesions depends on objective chewing problems and on haemorrhagic risk. This can be either spontaneous or in relation with dental surgery during teeth extraction or third molar pathology therapy. In two patients the lesions affected the tongue and cheek mucosa including the submandibular and masseter region. In one patient there was just one localization at the tongue apex. In another patient the lesion affected only the cheek mucosa and in another the cheek was affected in all its thickness at the left hemimandibular level. Three patients were treated surgically, another with sclerotherapy and another one didn't undergo any treatment, as the lesion didn't present any haemorrhagic risk and the symptomatology was only related to salivary lithiasis. During a three year follow up the patients surgically treated recovered completely, the patient treated with sclerotherapy showed a progressive reduction of the swellings ending in an almost complete recovery. The clinical experience and the literature review show that the correct oral venous angiodysplasia diagnosis and a right sclerotherapy or operation, preventive if necessary, nearly always allow dental surgery in the time required for the ongoing dental pathology.

[Venous angiodysplasias of the cheek. The problems of therapy]. / Angiodisplasie venose della guancia. Problemi di terapia.

Four cases of cheek venous malformations observed and treated in different ways are discussed by the authors. In this region angiodysplasias may cause chewing problems or an increased haemorrhagic risk during dental surgery. The therapeutic troubles are due to the muscular connections where there are many recesses and infiltration ways close to the motor and sensitive nervous trunk. Aesthetic restrictions may oblige to a minor operation or partial excision. Particular care must be taken to the lesion access. In this experience two patients have been surgically treated with venous angioma differentiation: one of these with sclerotherapy of the residual angioma As the extent of the lesion caused reconstructing problems, one patient underwent plastic surgery. The other patient was treated with sclerotherapy. After two years the patients surgically treated recovered while the patients treated with sclerotherapy turned out to be asymptomatic. In conclusion, this experience and the literature review show that the correct diagnosis and a right sclerotherapy or surgery, preventive if necessary, allow any dental surgery in due time for dental diseases without any higher haemorrhagic risk.

[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.

[Drainage in thyroid surgery]. / Il drenaggio nella chirurgia della tiroide.

Bleeding represents a rare complication of thyroid surgery but when it occurs it may be life-threatening. To prevent this complication drainage is widely used. However no study has demonstrated the drains' value and recent reports have questioned its benefits. Therefore we have analyzed our experience of a 10 year-period in which 1.217 thyroidectomies were performed by the same surgical team and prophylactic routine drainage was always adopted. In 13 patients (1.06%) a benign hematoma occurred with spontaneous remission. In 6 patients the bleeding was severe and compressive hematoma occurred; it required surgical re-exploration. Such a complication is unusual in the neck surgery (0.49% in the authors' series) performed by experienced surgeons and when life-threatening hematomas do occur they depend on various uncontrolled factors and drainage is often not helpful. Otherwise a meticulous haemostatic technique is necessary and patients should be observed very closely during the few first hours following surgery on the thyroid gland. Therefore on the basis of the analysis of their series, although it is not always possible to prove the benefit of the drainage, the authors suggest its indication in the neck surgery, as in other fields with dead space, to remove blood and secretions reducing postoperative complications. They have never observed wound infections and patients were discharged within 72 hours.

[Vascular cysts of the adrenals. Association with aneurysm of the abdominal aorta]. / Cisti vascolare del surrene. Associazione con un aneurisma dell'aorta addominale.

A rare case of an adrenal vascular cyst associated to an abdominal aorta aneurysm is reported. Adrenal cysts are an uncommon clinical finding, in most cases incidentally discovered for nonspecific abdominal pain, during US, TC or RM evaluation or at autopsy. Small adrenal mass are clinically silent. They may be symptomatic (lumbar tension, pain) for dimensions over 10 centimetres. Cysts of large size can cause displacement and compression of adjacent organs. They present a difficult problem of differentiation between benign and malignant lesions. Non-neoplastic adrenal cysts have been divided into four categories: parasitic (7%), epithelial (9%), endothelial (45%) and haemorrhagic or pseudocystic (39%). Vascular adrenal cysts may be a traumatic consequence of an hamartomatous vascular anomaly. The aim of this paper is to discuss, on the basis of the literature, the etiology, diagnosis and treatment of the adrenal mass. Surgical timing is discussed for the concomitant vascular lesion. The elective treatment was left adrenalectomy performed through transperitoneal approach. Surgery for abdominal aorta aneurysm was differed because the adrenal mass was suspected to be an infected neoplastic lesion and for the feasibility of endovascular procedure. The adrenal specimens contained a cystic structure with fluid blood, fibrin and calcifications. Normal adrenal cortical tissue was found in the cystic wall. This lesion (arising from vascular anomalies) require separation from haemorrhagic adrenal neoplasm. Awareness of adrenal pseudocysts and careful attention to the hystological features aids this distinction.

Radioguided parathyroidectomy in forearm graft for recurrent hyperparathyroidism.

We report a peculiar case of recurrent hyperparathyroidism caused by hyperplasia of a forearm graft implanted following a total parathyroidectomy in a 38-year-old patient with chronic renal failure. The forearm graft hyperplasia was detected using (99)Tc(m)-sestamibi scanning, which identified hyperplastic transplanted parathyroid tissue in the forearm of the patient. During the initial surgery, the surgeon failed to mark the parathyroid tissue with sutures or clips to facilitate locating it. Therefore, we referred the patient for radioguided surgery. This surgical procedure allowed us to locate and completely remove the hyperfunctioning transplanted parathyroid tissue.

Neuroendocrine and psychological assessment in a guinness 10 days scuba dive.

This study was designed to evaluate physiological and psychological stress parameters in 2 professional trained scuba divers, using a unique physiopathologic model, offered by the guinness 240 hours scuba dive. Two scuba dive masters have spent 240 hours at 6 - 8 meters depth (26.4 ft) in Ponza Island water (Italy). Blood samples were collected daily in the underwater bell; samples were carried out of water in waterproof bags. Breath samples were collected, measuring ethylene release. Psychological assessment was performed using the State and Trait Anxiety Inventory and the Zung self-rating depression scale. In the studied subjects, cortisol and prolactin showed physiological pulsatile secretion. Breath ethylene didn't exceed normal values. At the start of the study, no subjects showed high levels of state anxiety, trait anxiety and current depression. Psychometric scales scores remained steady during the diving period and no subjects showed anxiety and/or depression and/or panic symptoms during the time of observation. The present study shows that, although the long-time diving, well trained professional divers did not develop anxiety and/or depression. No subject discontinued the diving due to occurred psychological disorders or systemic events. The present report shows that the long-term diving permanence is possible, at least in well trained scuba divers.

[Differentiated tumor of the thyroid in children and adolescents]. / Tumore differenziato della tiroide nel bambino e nell'adolescente.

Differentiated thyroid carcinoma (DTC) is rare in young patients and represents 0,5 to 3,0% of childhood carcinomas. The incidence increases with age: a peak incidence is observed between 15 and 19 years of age. DTC in children is frequently associated with greater risk of cervical lymph node involvement (60-80% of cases) and lung metastases at diagnosis in 20% of patients. However the prognosis for these patients is better when compared with that of adults, despite a high incidence of relapse, leading to reoperation. Young age (<16 years), lymph node involvement or distant metastases at diagnosis and some histopathologic characteristics have been suggested as predictive factors of recurrences. The records of 33 patients with DTC in a 14-year period (1990-2004) were reviewed. There were 31 females and 2 males who ranged from 11 to 21 years. At the diagnosis 15 patients had disease confined to the thyroid, 18 had additional lymph node metastases in the neck; one of them had also lung metastases. Total thyroidectomy (TT) was the elective approach in all patients (4 cases videoassisted). TT was associated to functional neck dissection in 21 cases. 131I was administrated to 28 patients (3,7 GBq as ablative dose): 11 of this received further radioiodine treatments (mean 7,4 GBq) because of elevated serum thyroglobulin levels and presence of loco-regional or lung metastasis at diagnostic total body scan after 131I treatment. The overall survival rate was 100% at a follow up of 4 months to 14 years.

A less invasive, selective, functional neck dissection for papillary thyroid carcinoma.

HYPOTHESIS: To describe an alternative lateral neck access in order to perform neck dissection in papillary thyroid carcinoma (PTC) with lymph node involvement. DESIGN: Prospective (January 2000 to December 2003), 36-month study. SETTING: Catholic University of Rome and University of "Tor Vergata", Rome, Italy. PATIENTS AND METHODS: Twenty-four consecutive patients with PTC and cervical lymph node metastases were included. Functional neck dissection (FND), unilateral or bilateral, was performed acceding via a lateral dissection through a traditional Kocher incision, running along the superficial fascia of the neck and posteriorly to the sternocleidomastoideus muscle. RESULTS: Mean age was 39.04+/-13.69 years. Twenty patients were women and four were men. Mean tumour size was 2.5+/-1 cm, while the greatest metastatic lymph node size was 4.5 cm. Minimally invasive, selective FND was performed in all patients associated to total thyroidectomy and central compartment lymph node clearance. Metastatic lymph nodes were found in 142 out of 340 of the lymph nodes dissected. CONCLUSIONS: Minimally invasive neck dissection seems to carry a lower risk in terms of specific morbidity and allows a quicker recovery and a better aesthetic result. This access has to be considered as a less invasive procedure compared to the other surgical accesses for the radical or modified lateral neck dissection.

Coexistence of a parathyroid adenoma and parathyroid cyst causing primary hyperparathyroidism.

The association of a functional parathyroid cyst with a parathyroid adenoma is an uncommon finding. In this report we describe the clinical history of a 60-yr-old man, presenting with the following findings: hypercalcemia (18.9 mg/dl), elevated serum parathormone levels (1320 pg/dl), hypercalciuria (228 mg/dl), and hyperphosphaturia (155 mg/dl). Neck ultrasound, magnetic resonance imaging (MRI) and 99Tc Sestamibi scintigraphy led to the identification of a left parathyroid adenoma, located at the lower pole of the left thyroid gland lobe, associated with a parathyroid cyst, located at the upper extremity of the same thyroid lobe. Parathyroidectomy was performed and the histological examination confirmed the diagnosis of a parathyroid adenoma with aspects of cystic degeneration and an upper parathyroid cyst. Analysis of the crystal clear intracystic fluid showed elevated parathyroid hormone (PTH) levels (137.000 pg/ml). The patient is normocalcemic at 2 yr after surgery without signs of recurrent parathyroid enlargements. Aetiology, diagnosis and management of parathyroid cyst will be discussed.