Transoral video assisted thyroidectomy: a systematic review.

INTRODUCTION: The aim of this study is to perform a review of the English-language international literature concerning thyroid surgery performed through the transoral vestibular approach, to evaluate its flessibility and safety in terms of complications. MATERIALS AND METHOD: The review was carried out on 17 studies of 17 different Authors. The following variables were taken into consideration: first Author's name, nationality, year of publication, number of cases, hospital stay, conversion rate, type of surgical approach, total number of total thyroidectomies and loboisthmectomies, operative time range, intraoperative blood loss range, number and percentage of complications. RESULTS: 736 procedures were performed: 289 total thyroidectomies and 447 loboisthmectomies. Surgical approach was trivestibular in 15 cases and combined (oro-vestibular) in 2 cases. The operative time varies from 43 minutes for a loboisthmectomy to 345 for a total thyroidectomy. Intraoperative blood loss ranges from 3 to 300 ml. Ten cases were converted into open surgery. The hospital stay varies from 1 to 10 days. Complications were: transient recurrent laryngeal nerve palsy in 34 cases, permanent in 2 cases; transient hypoparathyroidism in 62 cases. One case of postoperative bleeding, 22 postoperative seroma, 20 cases of mental nerve injury, 8 cases of operative wound infection. CONCLUSIONS: Transoral endoscopic thyroidectomy vestibular approach (TOETVA) is a new surgical method, the use of which exclusively meets the aesthetic needs of some patients. Its specific complication is the injury of the mental nerves. Further studies, however, seem to be necessary, on numerically broader cases, to ascertain the real validity of the method.

D’Andrea’s disease (angiomegaly): a currently well-defined nosological entitys.

In 1997 D’Andrea et al. described a new nosological entity the characteristics of which consisted of lengthening, dilation and tortuosity of blood vessels, arteries or veins, less prominent, but also less circumscribed than an aneurysm. This condition does not necessarily imply specific aneurysm formation although aneurysms at multiple sites are a frequent observation. The term used by authors for angiomegaly of the venous system was venomegaly and the analogous condition of the arterial system was termed arteriomegaly. Although tortuosity and dilation of arteries and veins have been widely reported, suggesting a systemic disorder which affects the structural integrity of all vessels, most papers dealing with this intriguing condition did not describe any alterations in the components of vessel walls. In the present paper, the authors describe a well-defined condition, D’Andrea’s Disease (or DD, in this article), analyzing its salient morphological and clinical features and clarifying this pathological condition as a distinct and now well-defined nosological entity.

Agenesis of the internal carotid artery: a family pathology?

The internal carotid artery agenesis is a rare malformation disorder. We report the case of a 12-year-old boy suffering migraine, who had presented an episode featuring amaurosis fugax, spontaneously regressed. CT angiography images show hypoplasia of the left common carotid artery with loss of opacification of the left internal carotid artery consistent to agenesis. Moreover CT scans through the skull base demonstrate absence of left petrous carotid canal and an hypertrophic left middle cerebral artery originating from an aberrant artery arising from the right cavernous carotid. All diagnostic examinations confirmed the presence of the internal carotid artery agenesis, as Lie's type IV. We started an annual follow up that over the next 7 years did not reveal any change in magnetic resonance angiography images.

Incidental thyroid carcinomas. A retrospective study.

AIM: The aim of the present study is to report our series of incidental thyroid carcinomas in the last 15 years and their follow-up, discussing therapeutics indications and surgical choices. PATIENTS AND METHODS: We have considered 1793 patients operated on Surgical Sciences Department of "Sapienza" University of Rome from January 1, 2001 to December 31, 2015. The study was conducted on 83 totally thyroidectomized patients with a real incidental thyroid carcinoma, by clinical, laboratory and instrumental controls. Whole-body scan was the most important test in postoperative evaluation. RESULTS: In our series, the incidence of incidental carcinomas was 4.62%. Compared to the total number of cancer patients, the percentage is 21,9%. In 15.66% of cases there was multifocality and in 7.23% also bilaterality. Regarding the histological type, in all cases they were papillary carcinoma. The size of the neoplastic lesions ranged from a minimum of 3 to a maximum of 10 mm. Whole-body scan revealed lymph node metastasis in 57.69% of patients. DISCUSSION: Comparing these data with our previous studies we have seen a significant increase in incidence of incidental thyroid carcinomas over the years. Our therapeutical choice is total thyroidectomy and complection thyroidectomy after lobectomy, because of a relevant percentage of multifocality and/or bilaterality of these tumors. Many Authors on the contrary prefer a more conservative approach invoking the good prognosis of these tumors. The 57.69% of lymph node metastasis at postoperative whole-body scan comfort us in our setting. CONCLUSION: Incidental thyroid carcinomas are not uncommon. We consider only tumors until 1 cm in diameter. Multifocality and bilaterality are often present such as occult lymph node metastasis. Our therapeutical choice is total thyroidectomy in order to conduct a proper follow-up.

Fine needle aspiration cytology of 650 thyroid nodules operated for multinodular goiter: a cyto-histological correlation based on the new Italian cytological classification (siapec 2014).

The new Italian cytological classification (SIAPEC 2014) of thyroid nodules, in line with those of Bethesda and BTA-RCPath, replaces the previous TIR3 class with two new classes (TIR3A and TIR3B), which correspond to different risks of malignancy and clinical actions required. The present study was conducted to evaluate the diagnostic accuracy of the new SIAPEC classification as opposed to its previous version (SIAPEC 2007). Preoperative cytology was compared with the final histology obtained from 650 consecutive patients who underwent total thyroidectomy for multinodular goiter. Of this total, 434 patients (group A) had their cytological diagnosis based on the old SIAPEC 2007 classification and 216 patients (group B) had their cytological diagnosis based on the SIAPEC 2014 classification. In group A 111 patients (25.6%) had a TIR3 diagnosis, while in group B 52 patients (24.1%) received a TIR3 diagnosis, of whom 30 had TIR3A and 22 had TIR3B. In group A, 46 (41.4%) out of the 111 patients with TIR3 diagnosis had, based on histology, a thyroid carcinoma. In group B, only 2 (6.7%) out of 30 patients with TIR3A diagnosis had a thyroid carcinoma. This rate of malignancy was significantly lower (p less than 0.001) than that observed in patients with TIR3B diagnosis, in which 12 (54.5%) out of 22 patients had a carcinoma. The observations here reported show that, in respect to the previous version, the new Italian cytological classification provides greater diagnostic accuracy for detecting thyroid nodule malignancy.

Early discharge after total thyroidectomy: a retrospective feasibility study.

AIM: The continued hospitalization after total thyroidectomy is often due to the onset of hypocalcemic complications more than 24 hours after surgery. So it would be important to predict which patients will not develop the hypocalcemic complication to discharge them early. This was the aim of our study. PATIENTS AND METHODS: Our retrospective study was conducted on 327 consecutive thyroidectomized patients, operated on for benign and malignant diseases. We evaluated the values of preoperative serum calcium levels (Cal0) and of the first postoperative day (Cal1) and two new variables were calculated (dCal and dCaln). The same thing was made on a subgroup of 111 patients in whom also parathiroyd hormone (PTH) values were detected. Statistical analysis was performed with the goal of determining if we could establish a safe criterion for discharge at 24 hours after surgery and if there is a correlation between suitability for discharge and diagnosis. RESULTS: As to discharge, the predictive power of the discriminant function applied was significant both on the total of patients and in the subgroup of 111 patients, but it was clinically unacceptable because it would expose us to a 21% to 27% error rate. It is not possible to identify a threshold, below which to consider patients surely dischargeable. The diagnosis does not appear correlated with the suitability for discharge. CONCLUSION: On the basis of serum calcium and PTH levels in the first postoperative day, it is impossible to predict which patients can be discharged 24 hours after surgery without incurring in hypocalcemic complications.

Duplex ultrasound and magnetic resonance imaging of the supra-aortic arches in patients with non recurrent inferior laryngeal nerve: a comparative study.

BACKGROUND: Non-recurrent inferior laryngeal nerve (NRILN) is usually discovered during thyroid surgery. It is often associated with vascular abnormalities that can be detected with magnetic resonance imaging (MRI) or duplex ultrasound scan. The aim of this study was to compare the diagnostic sensitivity of ultrasonography with MRI to identify the vascular abnormalities associated to NRILN. PATIENTS AND METHODS: We revised 2713 total thyroidectomies to select patients with NRILN. The NRILN was identified in 17 patients (0,6%). A postoperative ultrasonic duplex scanning and a MRI was performed in 15 cases as 2 patients refused to submit to the exams. RESULTS: At MRI an unique origin of common carotid trunk and a concomitant aberrant retroesophageal subclavian right artery was showed in 11 patients. In 2 cases vascular abnormality consisted in separated origin of supra-aortic arteries. At duplex ultrasound scan only in 2 patients was impossible to identify vascular abnormalities detected at MRI. Tthe diagnostic sensitivity of duplex ultrasound was 84,6%. CONCLUSIONS: Preoperative duplex ultrasound is a non invasive method with high diagnostic sensitivity that can easily complete the preoperative thyroid ultrasonography.

Randomized study on the effects of different strategies of intermittent pneumatic compression for lower limb claudication.

BACKGROUND: The aim of the present study was to evaluate the efficacy of different strategies of intermittent pneumatic compression (IPC) for the treatment of lower limb claudication. METHODS: Five study groups were prospectively studied. Group 1: 9 patients not undergoing IPC; Group 2; six patients undergoing IPC 1 hour/thrice-a-day/4 months; Group 3: six patients undergoing IPC 2 hours/once-a-day/4 months; Group 4; six patients undergoing IPC 1 hour/thrice-a-day/2 months; Group 5: six patients undergoing IPC 2 hours/once-a-day/2 months. RESULTS: All patients completed the planned treatment schedule and stated a compliance of 33% in group 2, 83% in group 3, 66% in group 4 and 100% in group 5. Peak systolic velocity of the popliteal artery blood flow increased over baseline values particularly when IPC lasted 4 months (group 2: 85%, group 3: 81% vs. group 4: 76%, group 5: 73%). These beneficial effects lasted 10 months and vanished 14 months after the end of IPC treatment. The absolute claudication distance increased at the end of the treatment of 101% in group 2, 94% in group 3, 86% in group 4, and 83% in group 5, and it was still increased over the baseline values 14 months after the end of the treatment. No differences have been observed whether the treatment was performed once- or thrice-a-day. CONCLUSIONS: ICP treatment performed two hours once-a-day for four months provide excellent results with satisfactory treatment compliance. However, these effects are not durable and vanish about one year after the end of IPC treatment.

Uni-centric localization of Castleman's disease treated with laparoscopic and traditional approach. Report of two cases.

Castleman's disease (CD) is a rare lymphoproliferative disorder. Clinically CD has been subdivided in two forms: uni-centric and multicentric. The uni-centric type is limited to a single anatomic lymph-node-bearing region. The present report describes two cases of uni-centric CD: the first was an abdominal localization treated with a laparoscopic approach; the second was a submaxillary localization treated with a classical approach. In case 1 the laparoscopic approach permitted to reach diagnosis, not clear after diagnostic imaging procedures, and enabled a total and excellent resolution of the pathology because our patient, after eight months of follow up, has had no evidence of recurrence of the disease. In case 2 we want to highlight that CD should be considered in the differential diagnosis of a solitary neck mass and that the surgical treatment is diagnostic and curative at the same time.

Prevalence of chronic cerebrospinal venous insufficiency in multiple sclerosis: a blinded sonographic evaluation.

OBJECTIVES: To verify the prevalence of chronic cerebrospinal venous insufficiency in patients affected by different clinical forms of multiple sclerosis and in healthy subjects using the Zamboni ultrasound protocol combined with M-mode ultrasound examination. MATERIALS AND METHODS: We enrolled 112 patients with multiple sclerosis and 67 healthy subjects from 20 to 67 years of age. All the patients underwent Duplex and color-Doppler sonography of the neck vessels, transcranial colour duplex sonography, M-mode study of the valve system and of venous abnormalities. Subjects were positive for chronic cerebrospinal venous insufficiency when at least two of five hemodynamic criteria of the Zamboni protocol were fulfilled. Chronic cerebrospinal venous insufficiency condition was further analyzed by a multivariate analysis including age, sex, disease duration, subtypes of multiple sclerosis and expanded disability status scale score as independent variables. RESULTS: No healthy subjects was positive for chronic cerebrospinal venous insufficiency, while in the sample of patients affected by multiple sclerosis the diagnosis was made in 59.8% of cases (p < 0.0001). The first criterion was the most frequent in patients affected by multiple sclerosis and chronic cerebrospinal venous insufficiency (respectively 54.4% and 76.1%, p < 0.001). The second, third and fourth criteria were never present in healthy subjects but were detected in patients with multiple sclerosis. The positivity of the second criterion was associated with diagnosis of chronic cerebrospinal venous insufficiency in 100% of cases. The third criterion had a prevalence of 52.2% in the subgroup of chronic cerebrospinal venous insufficiency patients. It was positive in 36 multiple sclerosis patients and was associated with chronic cerebrospinal venous insufficiency diagnosis in all cases except one. The multivariate analysis showed that age, disease duration, sex, subtypes of multiple sclerosis and expanded disability status scale score were not considered predictors of this haemodynamic condition. CONCLUSION: Chronic cerebrospinal venous insufficiency is a haemodynamic condition strongly associated with multiple sclerosis and is not found in normal controls. The addition of M-mode ultrasound to the diagnostic protocol allows improved observation of venous valve abnormalities.

A new classification of varicose veins to compare various surgical strategies.

Considering the presupposition that chronic venous insufficiency (CVI) and varicose veins classifications are extremely difficult, and that none of those presently in use are sufficiently complete, the authors propose the classification of the haemodynamic venous disease (HVD) and of the varicose veins from the clinical, anatomotopographical, etiopathogenetical and haemodynamical point-of-view. This type of classification allows us to closely follow the disease's evolution, to distinguish the benign forms from the more aggressive ones, and to evaluate the results of the medical, surgical and schlerotherapical treatments, from the efficiently, functional, instrumental and aesthetically point-of-view.

Paragangliomas of the carotid body and other rare localisation.

Cervical paragangliomas are uncommon benign or malignant neoplasms, originated by stem cells of neural crest. It is not easy nowadays to define properly their biological behaviour, the possible multiple location and the association with Multiple Endocrine Neoplasms. After a wide review about recent diagnostic, pathological and clinical acquisition, authors report their caseload of 10 patients affected by sporadic paragangliomas and 1 by familial multiple neoplasm localised in carotid bodies of both sides, left vagus nerve and left hypoglossus nerve. All patients but one were treated by a curative resection of the neoplasm. In one case only an explorative laparatomy was possible because of the visceral and vascular involvement.

Classification of the subclavian steal syndrome with transcranial Doppler.

Ultrasound has provided a highlight of the different types of subclavian steal. The authors report epidemiological and clinical data concerning 40,000 ultrasound examinations performed on epiaortic arteries and particularly the last 12,000 in which Doppler c.w., duplex scanner and transcranial Doppler were used. Various types of steal are described; five types of subclavian steal have been classified and patients stratified as being symptomatic and asymptomatic. The neurological symptoms are divided as follows: generalized cerebral ischemia, vertebro-basilar ischemia and hemispheric ischemia. Based on this clinical and haemodynamic outline, surgical therapy is indicated and type of surgery suggested.

Control of the operated carotid with ultrasound. Anatomical and hemodynamical modifications, both local and intracranial.

BACKGROUND: A study has been done on the operated carotid monitoring the modifications of the wall and of the flow in the site of the operation and at the intracranial level. METHODS: 146 operated carotids were studied using transcranial Doppler, duplex and color. The pre-surgical data were confronted with the postsurgical ones on the 4th day, one month later, 3 months later and every 6 months. RESULTS: The cerebrovascular reactivity (CR) and the cerebral hemodynamic latency time (CHLT), improved in more than half of the patients with stenosis >80%. When the stenosis is of minor entity, the improvement appears in 10% of the cases. The VCR and CHLT modifications appear within 1 month following the operation. Kinkings are more frequent with the patch (6%) than with the direct suture (3%). The symptomatic restenosis is 2%, while the asymptomatic one is 11%. The restenosis is present in 8% of the cases with direct suture and in 3% of those with suture with patch. CONCLUSIONS: The local and intracranial modifications after carotid revascularization depend on new anatomical and hemodynamical situation due to surgery. The response of the wall which can be of four types: myointimal reaction, is a "physiological" response to the trauma and its thickness does not exceed 3 mm; myointimal hyperplasia, with thickness exceeding 3 mm; early restenosis (12 to 18 months); late restenosis (after 2 years). Substantial differences in velocity between systole and diastole and the systolic stress favor hyperplasia more than low velocities with smaller differences.

Surgical treatment of paragangliomas of the carotid body and other rare localisations.

BACKGROUND: Cervical paragangliomas are uncommon benign or malignant neoplasms, deriving from stem cells of the neural crest. Compared to all the tumors of the head and neck, they occur less frequently. They can be found in any part of the body where there are sympathetic ganglia including chemoreceptors, suprarenal medulla, retroperitoneal ganglia and the extreme branches of the vagus nerves. It is not easy nowadays to define properly their biological behaviour, the possible multicentric location and the association with Multiple Endocrine Neoplasms; this is considered particularly important and occurs in 42 per cent of the cases of familial neoplasms of the paraganglion system. METHODS: After a review of recent diagnostic, pathological and clinical findings, the authors report their experience, between 1970-1995, of 10 patients affected by sporadic paraganglioma and 1 by familial multicentric neoplasm localised in the carotid bodies of both sides, left vagus nerve and left hypoglossus nerve. All patients but one were treated by a curative resection of the neoplasm. In one case only an explorative laparatomy was possible because of visceral and vascular involvement. RESULTS: There is no mortality. There are no modifications in arterial blood pressure and catecholamine values in all patients. The complications were a recurrential palsy in a patient operated on for vagal paraganglioma; a recurrential palsy and temporary dysarthria in the patient affected by multiple familial paraganglioma; another patient operated on for carotid body paraganglioma showed a cerebral ischemic lesion which caused a slightly transitory facial-brachial motor deficit on the right side and speech impairment. CONCLUSIONS: We can venture to say that any type of cervical, mediastinal or retroperitoneal swelling in persons belonging to a genetically prone family must be first of all considered a possible paraganglioma. For this reason the patient with more than one growth of this type, whether synchronous or not, must undergo genetic investigation, along with the rest of his family.

[Observations on the vertebro-basilar system studied by ultrasound]. / Considerazioni ed osservazioni sul sistema vertebro-basilare studiato con ultrasuoni.

Vertebro-basilar circulation is complex because conditioned by several factors. Ultrasounds allow the study of many of its aspect, both hemodynamic and anatomical. Data were obtained from the examination of 50,000 patients over 25 years, of which the last 1,000 patients were examined by means of transcranial Doppler, duplex scanner color and power. 40% of these patients were found normal, 20% only had arterial thickening, 26% various types of stenosis, 10.6% subclavian steal, 14% short vertigo. The basilar artery (BA) flow (230 ml/min +/- 40) is similar to that of the internal carotid (245 ml/min +/- 50). In elderly patients, the absence of a posterior communicating artery (28%) or of both arteries (13%) is more frequent than the absence of the anterior communicating artery (7%). In normal patients decubitus variations do not modify the BA flow. In patients with vertigo due to decubitus variations, BA flow velocity increases from 20% to 40% during vertigo. Subclavian steal completely modifies the hemodynamics of vertebral arteries, while in the BA it can vary in part or completely. In conclusion, vertebral hemodynamics is different from BA hemodynamics. BA must be considered as one side of the Willis' polygon because it is an anastomosis between the vertebral arteries and is a "hemodynamic damper" between intracranial and extracranial circulation.

[Postural vertigo and basilar artery flow increment]. / Surcroît du flux dans l'artère basilaire durant le vertige de position.

PURPOSE: Research was focused on cerebral arterial flow in normal individuals and in patients suffering from short-term vertigo when sitting up rapidly from a lying position. PATIENTS AND METHODS: The research was performed in normal subjects and 46 patients affected by short term vertigo who underwent transcranial Doppler 32. In normal subjects (16 with an average age of 25 and 16 with an average age of 61) cerebral artery flow was recorded in a sitting and lying position, in Trendelenburg position and during transition from one position to another. In subjects suffering from short-term vertigo, arterial flow was recorded at baseline and during short-term vertigo. RESULTS: In normal subjects the flow remained unchanged in all body positions as well as during transition from one position to another. In subjects with short-term vertigo basilar artery flow increased with the onset of dizziness and returned to normal when dizziness ceased. CONCLUSIONS: In normal subjects cerebral self-regulation maintains constant flow in any body position. Increased basilar artery flow during short term vertigo is probably either due to altered self-regulation or its reduction in the carotid area with compensatory basilar artery hyperflow, or else to over-response in vertebro-basilar territory.

[Ultrasonic quantification, value of color and contribution of transcranial Doppler sonography in carotid artery surgery]. / Quantificazione ultrasuonografica, utilità del colore ed apporto del Doppler transcranico nella chirurgia della carotide.

The authors briefly report their experience regarding the opportunities offered by the use of current ultrasound methods in carotid surgery. They describe: a system for the quantification of athcromasic plaque used to monitor non-operated patients over time; ultrasound methods used to analyse the carotid wall to establish whether it can be utilised as an index of vascular aggression in hypertension, diabetes and atherosclerosis; the use of transcranial Doppler; criteria for the definition of high risk plaque; the applications of eco-color Doppler. The paper also illustrates a new pathology identified by the authors, defined as primary intimal fibrous hyperplasia, and the evolution of the carotid wall after endarterectomy. The structural characteristics of primary hyperplasia can only be shown using ultrasound given that arteriography cannot distinguish it from atheromatic stenosis. After endarterectomy the carotid wall is subject to hematic and hemodynamic stimuli which determine the type of evolution of the wall itself. The authors therefore examine the myointimal reaction, myointimal hyperplasia, early restenosis and late restenosis as different facets of the same phenomenon.

[Recurrence of varicose veins after treatment. Multicenter study by the Italian Doppler Club, Clinical and Technological Society]. / La comparsa di varici dopo loro trattamento. Studio multicentrico del Doppler Club Italiano Società di Clinica e Tecnologia.

BACKGROUND: The first results of a multicentric study dealing with recurrent varicose veins after surgery are presented. The aims of the study are: identifying the type of varicose vein, specifying the most frequent complaints (esthetical or functional), locating the causes of recurrence, establishing the causes and the most frequent seat of recurrence, clarifying whether it is enough to call recurrent all the varicose veins which appear after surgery or whether it is necessary to distinguish various typologies. METHODS: 194 patients (139 women and 55 men) aged 51.6 average (range 28-87), have been studied up to now with duplex and color scanner following a precise protocol which consisted of three stages: before treatment, within 2 months from treatment and after recurrence of varicose veins or venous insufficiency symptoms. RESULTS: Recurrent varicose veins represented 65.7%, residual ones 14.3%, new ones 2.5%. It has not been possible to identify the type of varicose vein in 8.3% of cases. Stripping of the great saphenous veins was carried out in 88% of cases, short stripping in 4.1%, stripping of the short saphenous veins in 6.9%. Recurrent varicose veins were due to technical error in 78.7% of cases, to diagnostic error in 9.2%, to unidentifiable causes in 12% of cases. CONCLUSIONS: Data relating to the prospective study of the research will be published in subsequent papers.

[Surgical treatment of differentiated thyroid carcinomas: results in 440 cases operated between 1970 and 1994]. / Trattamento chirurgico dei carcinomi differenziati della tiroide: risultati su 440 casi operati dal 1970 al 1994.

The authors report their experience and surgical treatment of 440 patients with differentiated carcinoma of the thyroid (DCT) from 1970 to 1990 in the III Surgical Dept. at the University of Rome "La Sapienza". Considering 305 cases of papillary carcinoma, 103 Total Thyroidectomy (TT), 118 TT with Functional Regional Lymphadenectomy (FRL), 32 TT with Node-Picking, 51 TT with curative FRL and one TT with Radical Neck dissection were performed. In 135 cases of follicular carcinoma TT associated with Node-picking were performed on two patients, TT associated with FRL on 8 patients and TT associated with RND on 2 patients. Overall survival to 10 years was 90%; 98% for N- papillary carcinoma and 66% for N+ follicular carcinoma. There were no permanent recurrence of disease. Out of the patients who did not undergo cervical lymphadenectomy 30% developed temporary hypocalcemia; 53% (mediastinal lymphadenectomy) to 87% (FRL) of the patients submitted to lymphadenectomy developed temporary hypocalcemia with permanent hypoparathyroidism in 0.9%-23% of the cases. On the base of what has been observed by Pasieka and Grant, the Authors believe TT as the absolute solution for patients with DCT because it allows the removal of both the original tumor and the possible neoplasms in the residual gland tissue, and enables early identification of other metastases which can be treated efficaciously with I131.