Combined diagnostic imaging of upper gastrointestinal tract in a patient with dysphagia and suspected gastroesophageal reflux disease (GERD).

The case of a patient with intermittent dysphagia and suspected GERD is discussed. Pharyngoesophageal scintigraphy was performed. Reflux test was negative. To better define the lesion and establish the diagnosis the study was completed with an X-ray of the upper digestive tract. The finding of a barium collection and a tear in the posterior wall of the pharyngoesophageal tract was suggestive of the diagnosis of Zenker's pseudodiverticulum.

Thyroid carcinomas with a variable insular component: prognostic significance of histopathologic patterns.

BACKGROUND: An insular growth pattern may be observed focally both in papillary and follicular thyroid carcinoma. The aim of the current study was to determine whether a greater extension of the insular component (IC) influences different clinical and histologic features at diagnosis, and a different tumor aggressiveness in terms of frequency in the occurrence of metastases as well as survival. METHODS: Thirty-three patients with histopathologic findings consistent with IC were included in the study. IC was focal (<50% of the tumor area) in 16 patients and predominant (>50% of the tumor area) in 17 patients. These 2 groups were compared with a control group of 66 patients with differentiated thyroid carcinoma. RESULTS: At diagnosis, carcinomas with predominant IC differed from those with focal IC with regard to greater tumor size and a higher frequency of extrathyroidal extension and distant metastases. Patient follow-up ranged from 5 to 188 months. The cumulative rate of distant metastases was significantly higher in patients with predominant IC. At the time of last follow-up, carcinomas with predominant IC demonstrated a lesser frequency of disease-free outcome (P = .002) and a higher number of tumor-related deaths (P = .002), either when distant metastases were present (P = .03) or absent (P = .05) at the time of diagnosis. CONCLUSIONS: The presence of predominant IC is associated with a poor prognosis in terms of ongoing disease or death. Predominant IC should be considered a separate entity from not only the classical papillary or follicular carcinomas but also the focal IC tumor.

Are there disadvantages in administering 131I ablation therapy in patients with differentiated thyroid carcinoma without a preablative diagnostic 131I whole-body scan?

OBJECTIVE: To evaluate the risk of performing inappropriate (131)I ablative therapies for thyroid carcinoma in patients lacking thyroid remnants or metastases, using a strategy of treatment without a preliminary iodine-131 diagnostic whole-body scan (DxWBS). DESIGN: Retrospective evaluation of post-therapy whole-body scans to assess the prevalence of thyroid remnants or metastases after total thyroidectomy. Comparison of (131)I uptake test and thyroglobulin (Tg) off levothyroxine (L-T4) performed before therapy with post-therapy scans, in order to evaluate the ability to predict inappropriate treatments. PATIENTS: A group of 875 consecutive patients with previous total or near-total thyroidectomy for differentiated thyroid carcinoma underwent (131)I ablative therapy without a preliminary (131)I-DxWBS. All patients were clinically free of distant metastases and macroscopic residual tumour. MEASUREMENTS: Whole-body scans were performed 2-5 days after the treatment as gold standard for thyroid remnants and metastases; 24-h (131)I quantitative neck uptake test and Tg off L-T4 were performed before (131)I therapy. RESULTS: The majority of patients (94%) were found to have thyroid remnants or metastases at post-therapy scans, in most cases (91.2%) with detectable Tg off L-T4 and positive 24-h neck uptake. 14 patients (1.6%) with tiny lymph-node metastases positive at post-therapy scans showed undetectable Tg off L-T4. In 30 patients (3.6%) faint positive post-therapy images for thyroid remnants have been classified as false-positive results on the basis of both negative 24-h neck uptake and undetectable Tg off L-T4. CONCLUSIONS: This study confirms that most patients have residual thyroid tissue after total thyroidectomy and that it seems reasonable to omit routine diagnostic whole-body scans before (131)I treatment with clinical, managerial and economic advantages.

Radio-guided surgery for lymph node recurrences of differentiated thyroid cancer.

The objectives of this study were to assess the reliability of radio-iodine (131I) and a gamma probe for radio-guided surgery (RGS) to detect and then radically dissect lymph node recurrences (LNRs) in 10 patients with differentiated thyroid cancer (DTC). The major inclusion criterion was the presence of an iodine-positive LNR after previous total thyroidectomy and at least two ineffective 131I treatments. The protocol was designed as follows. Day 0: all patients were hospitalized and received 3.7 GBq of 131I in the hypothyroid condition. Day 3: presurgery whole-body scan with a therapeutic dose (TxWBS). Day 5: neck surgery using a gamma probe (Navigator GPS, AutoSuture, Italy), recording the absolute counts and the lesion/background (L/B) counts ratio. Day 7: post-surgery TxWBS performed using the remaining radioactivity. The presurgery TxWBS was positive in all patients, and the post-surgery TxWBS showed a negative pattern in 7 of 10 patients, suggesting the efficacy of the surgical procedure in most of the patients. After RGS the mean decrease in the absolute counts and the L/B counts ratio were 77.6% (52.7% minimum, 94.6% maximum) and 77.4% (52.3% minimum, 94.8% maximum), respectively. After operation the surgeon judged the procedure to be decisive in two patients, favorable in six, and irrelevant in two. The final histologic examination showed the presence of 78 lymph node metastases (mean of 8 per patient). There were 33 neoplastic lesions found by both TxWBS and gamma probe evaluations; 41 were shown only by gamma probe, and 4 were negative by both TxWBS and gamma probe evaluations. This protocol permitted us to look for neoplastic foci with high sensitivity and specificity, and we were able to remove lymph node metastases resistant to radioiodine therapy at a single session. The protocol also allowed detection of some additional tumoral foci in sclerotic areas or behind vascular structures that are difficult to identify and were not seen at the presurgery TxWBS evaluation. However, because of the possible false-negative results, complete excision must be undertaken in high risk patients with a local recurrence to eradicate the largest number of lymph nodes, independent of the counts measured by the gamma probe.