Epidemiological Study of Thyroid Pathology in a University Hospital.

OBJECTIVES: The incidence of papillary thyroid carcinoma increased in several countries. The purpose of this study was to quantify the changes in thyroid carcinomas in our University Hospital. STUDY DESIGN: Retrospective study. METHODS: All 1.927 thyroidectomy cases studied in the Pathology Department of Hotel-Dieu de France Hospital (Beirut, Lebanon), between 2003 and 2013, were included. RESULTS: The Female/Male Sex Ratio of the studied population was 3.7/1. The mean age of female patients was significantly lower than that of male patients. The most frequent diagnoses were multinodular goiter (78%) and papillary-carcinoma (26%). 337 cases had a single lesion on gross examination. 21 of them were diagnosed with follicular carcinoma and 59 with follicular adenoma. A statistically significant correlation was found between the unicity of the lesion on gross examination and the final diagnosis of a follicular neoplasm. Thyroid carcinoma was multifocal in 33% of the cases and bilateral in 24%. A statistically significant increase in thyroid carcinoma proportion (from 15% in 2003 to 44% in 2013) was found. Among all thyroid carcinomas, the proportion of papillary type increased from 65% in 2003 to 94% in 2013 ; this increase remained statistically significant after the exclusion of papillary micro-carcinomas, whose proportion was stable throughout the 11 years. CONCLUSIONS: In this study, we noted a statistically significant increase in the frequency of thyroid carcinoma, especially of the papillary type. The unicity of the lesion on gross examination is significantly associated with a follicular neoplasm.

Differentiated thyroid carcinoma in early adulthood patients.

BACKGROUND: This paper reviews the clinico-pathologic features and outcomes of differentiated thyroid -carcinoma in early adulthood patients. STUDY DESIGN: Retrospective study. MATERIAL: From january 2000 to december 2012, 71 patients aged between 20 and 44 years who underwent thyroidectomy for differentiated thyroid carcinoma were included. The following parameters were recorded : age, gender, pre-operative symptoms and diagnosis, thyroid hormonal status, substernal extension, operative details, preoperative and postoperative calcium and phosphorous values, perioperative complications, length of hospital stay, final histology, survival and disease progression. RESULTS: There were 59 females (83%) and 12 males with a median age of 29 years (20-44 years). None had a previous neck irradiation. Total thyroidectomy was performed on 65 patients (92%). There were 66 papillary (93%) and 5 follicular carcinomas. Extrathyroidal invasion and lymph node involvement were present in 44% and 37% of cases respectively. Transient hypocalcemia and dysphonia occurred in 15% and 4 % of cases respectively. Permanent hypocalcemia and vocal cord paralysis occurred in 1% and 0% of cases respectively. Adjuvant radioactive I(131) therapy was given to 50 patients. There were 7 cases (10%) of lymph node recurrences but no disease-related deaths. The only statistical differences between this group and all ages group were the extracapsular invasion (44% vs 20% p = 0,0014) and lymph node metastasis (37% vs 18% p = 0,0091). CONCLUSIONS: Differentiated thyroid carcinoma has a good prognosis in early adulthood patients. Although death from this condition is rare, recurrence is frequent and long term follow up is mandatory.

Morbidity of redo surgery for thyroid disease.

OBJECTIVE: Redo thyroid surgery is generally associated with more complications than firsthand surgery. The actual study reports a single center experience of redo thyroid surgery compared to primary bilateral thyroidectomy. STUDY DESIGN: Mono institutional retrospective study. METHODS: Institutional review of redo thyroid surgery patients (Group 2 : completion thyroidectomy and Group 3 : thyroidectomy for recurrent thyroid diseases) compared to Group 1 : primary bilateral thyroidectomy operated on during the same time interval. RESULTS: Demographic characteristics were not different between groups. Substernal extension and hyperthyroidism were more frequent in group 1. Weight of the resected thyroid gland was lower in groups 2 and 3. Incidence of transient hypocalcemia, permanent hypoparathyroidism, transient and permanent recurrent laryngeal palsy was not different between the groups. Hematoma occurred in 5% of cases in the 3 groups and postoperative length of stay was 1 day in 92% of cases of the 3 groups. CONCLUSIONS: Redo thyroid surgery can be performed with no excess morbidity provided strict selection criteria, having reoperation in mind while performing firsthand intervention.

Cervical neck dissection without drainage in papillary thyroid carcinoma.

OBJECTIVE: To review the safety of thyroidectomy combined with cervical neck dissection without drainage, in patients with papillary thyroid carcinoma. MATERIALS AND METHODS: Two groups were defined depending on whether cervical neck dissection was or was not performed (groups one and two, respectively). RESULTS: Group one included 153 patients with central neck dissection and 52 patients with central and lateral neck dissection. Group two included 121 patients. Post-operative drainage was not used in either group. Overall, 17 patients (5 per cent) developed post-operative haematoma and/or seroma: 12 patients (6 per cent) in group one and 5 patients (4 per cent) in group two. There were no major bleeding episodes; only minor bleeding or seroma was encountered, not requiring surgical intervention. Overall, 91 per cent of patients had a post-operative stay of 1 day. The number of peri-operative local complications and length of stay did not differ significantly between the two groups. CONCLUSION: Thyroidectomy plus cervical neck dissection without drainage is safe and effective in the treatment of papillary thyroid carcinoma.

Thyroidectomy in patients at high-risk of bleeding: can it be safely performed?

AIM: This study evaluated the safety of thyroid surgery in patients where anticoagulation was unavoidable or in patients with coagulopathy. METHODS: The records of all patients having high risk of bleeding at the time of thyroidectomy (July 2000 and March 2005) were retrospectively reviewed to evaluate intraoperative and postoperative bleeding. RESULTS: Ten patients were studied. Thyroid lobectomy with isthmusectomy (N=3) and bilateral thyroidectomy (N=7) were performed. Intraoperative surgical hemostasis was meticulous using ligasure vessel sealing system. Patients were divided in 3 groups. Group I (N=2) had small-vessel vasculitis, underwent thyroidectomy under full heparinization. Heparin therapy was continued until full anticoagulation by oral anticoagulants. Group II (N=2) had a documented congenital coagulation defect, had a pre and postoperative special protocols. Group III (N=6) underwent simultaneous thyroid and cardiac surgery (e.g.: intraoperative full heparinization and postoperative antiplatelet therapy in some cases). No extra-bleeding was noted on surgical reports. In the postoperative period, one patient developed a superficial small hematoma in the neck that resolved spontaneously. Transient unilateral laryngeal nerve palsy and transient hypocalcemia were seen in one and two patients respectively. CONCLUSIONS: Thyroidectomy in patients with coagulopathy is feasible with low risk of bleeding if meticulous hemostasis, particularly using ligasure vessel sealing system, is respected.

Predictors of intra-operative parathyroid hormone decline in subjects operated for primary hyperparathyroidism by minimally invasive parathyroidectomy.

BACKGROUND: The predictors of intra-operative PTH (IOPTH) decline during minimally invasive parathyroidectomy (MIP) for primary hyperparathyroidism have been but poorly studied. MATERIALS AND METHODS: This retrospective study included 108 patients who underwent MIP for a single adenoma. Serum calcium and phosphorus were measured before surgery and 1 day post-operatively. IOPTH was measured before (intra-operative preincision or PTHt0) and 10 min after removal of the adenoma (PTHt10). The Modification of Diet in Renal Disease (MDRD) equation was used to estimate the glomerular filtration rate. The weight of the adenoma was assessed in all the subjects. RESULTS: The sex ratio female/male was 5.37 with a mean age of 57.3 yr. The mean pre- and postoperative values were for calcium 2.80 and 2.19 mmol/l, respectively (p<0.0001) and for phosphorus 0.90 and 1.16 mmol/l, respectively (p<0.0001). The PTH dropped from a mean value of 184.8 to 50.8 pg/ml 10 min after adenoma resection with a mean drop of 69.7%. Thirteen patients (12%) did not achieve a PTH fall of more than 50%. In a bivariate analysis, age, an MDRD<60 ml/min and weight of adenoma were inversely associated with IOPTH fall (p=0.009, p=0.004, and p<0.001, respectively) while gender, body mass index, hypertension, diabetes, pre-operative phosphorus and calcium had no significant effects. In the multivariate analysis, age, weight of adenoma, and MDRD were still independent negative predictors of the IOPTH fall (p=0.01, p=0.018, and p<0.001, respectively). CONCLUSION: Our results suggest that during MIP the presence of a parathyroid adenoma with a high weight, in an elderly subject or in a subject with altered renal function, will result in a lesser degree of IOPTH fall.

[Synchronous sigmoid colon and breast cancers in man]. / Association synchrone d'un cancer du sigmoïde chez l'homme et d'un cancer du sein.

We report the case of 72-year-old man with sigmoid colon cancer associated with synchronous right breast cancer. However, in the present case, we found breast cancer insidiously at physical exam. The patient died after six months after the dissemination of the breast cancer.

[Unusual location of a parathyroid adenoma: the carotid sheath]. / Localisation atypique d'un adénome parathyroïdien: la gaine carotidienne.

We report the imaging features of an occult parathyroid adenoma with unusual location in the carotid sheath. Our patient presented with primary hyperparathyroidism. Following negative neck ultrasound and scintigraphy, exploratory neck dissection with partial thyroidectomy was performed twice over a 2 day period without biological response. Cervical and mediastinal CT and MRI were performed with no result. Digital angiography showed a tumoral blush supplied by the left inferior thyroid artery and located in close contact with the carotid artery. Venous sampling of the neck confirmed the left location of the adenoma and a third surgical intervention found the adenoma embedded in the left carotid sheath. This is an unusual case of parathyroid adenoma that necessitated the use of several imaging techniques.

[Parathyroid adenoma localized in the mediastinum. Case report and review of the literature]. / Adénome parathyroïdien de localisation médiastinale. Rapport d'un cas et revue de la littérature.

In the primary hyperparathyroidism the vast majority of enlarged parathyroid glands may be excised by cervicotomy. Rarely the excision of ectopic mediastinal parathyroid adenoma, not accessible by cervical incision, necessitates another approach for parathyroidectomy. We report herein the case of primary hyperparathyroidism due to mediastinal adenoma treated by sternotomy with review of the literature for different modalities of treatment for mediastinal localization.

[Castelman's disease. Report of two cases with review of the literature]. / Maladie de Castelman. Apropos de deux cas et revue de la littérature.

Castelman's disease, an unusual condition of unknown cause, consisting of a massive proliferation of lymphoid tissue. Three histologic variants (hyaline vascular, plasma-cell, and mixed) and two clinical types (localized and multicentric) of Castelman's disease have been described. Localized disease can be cured with surgery or radiotherapy, but complete remission in patients with multicentric disease have been achieved only with prednisone or chemotherapy given at the time of diagnosis. The aim of this study is to report two cases of retroperitoneal Castelman's disease with review of the literature. The first patient, of 36 years old, presented for abdominal pain with anorexia and weight loss. The abdomino-pelvic CT scan showed a 6 cm retroperitoneal mass. The biopsy of this lesion suspected a lymphoproliferative disease. At laparotomy total excision of mass was made and the final histology revealed a hyalino-vascular type of Castelman's disease. The second patient, of 26 years old, presented for left lombar pain with weight loss. The abdominopelvic CT Scan showed a 6.5 cm retroperitoneal mass. The biopsy of this lesion showed a Castelman's disease. At laparotomy total excision of mass was made and the final histology confirmed a hyalino-vascular type of Castelman's disease.

Substernal goitre: a rare cause of pulmonary hypertension and heart failure.

Benign substernal goitres usually extend into the upper anterior mediastinum and are easily extractable through a cervical approach. Very infrequently these tumours extend into the thoracic cavity causing compression of mediastinal structures. The authors report a case of pulmonary hypertension and severe cardiac failure secondary to a long-standing substernal goitre, and support the surgical management of this disease.

[Hemostatic embolization of hepatocellular carcinoma complicated by hemoperitoneum. Apropos of 2 cases and review of the literature]. / Embolisation hemostatique de carcinome hepatocellulaire complique D'hemoperitoine. A propos de deux cas et revue de la littérature.

Rupture of hepatocellular carcinoma is a severe complication that occurs in about 10% of patients. It may occur as a terminal event in patients with advanced disease or it may be the first presentation in a healthy individual. Various treatment options have been proposed, which include conservative treatment, transarterial embolization and operative hemostasis or liver resection. We report intraperitoneal hemorrhage and hypovolemia in two patients with spontaneous rupture of an hepatocellular carcinoma treated successfully by transarterial hepatic embolization. On follow-up, these patients died 7 and 8 months after this treatment respectively.

[Epidermoid carcinoma developing in a chronic anal fistula]. / Carcinome épidermoïde développé sur fistule anale chronique.

BACKGROUND: Malignant degeneration of anal fistula is a rare occurrence in the course of a common disease. Abdominoperineal resection offers the only hope of cure. CASE REPORT: A 41-year-old patient who was operated 14 years earlier for anal fistula presented recurrence treated by fistulectomy. Histology revealed a well-differentiated squamous-cell carcinoma. Radiotherapy (45 Gy) was added postoperatively. Five months later, local recurrence was treated by chemotherapy and abdominoperineal resection. Two months later the patient died from cachexia with local recurrence. DISCUSSION: Biopsies of anal fistula tract and histology of all fistulectomies are required for early diagnosis of possible carcinoma. Abdominoperineal resection offers the only hope of cure.

[Necrotizing fasciitis in sacrococcygeal pilonidal sinus in a patient with bone marrow aplasia. Treatment by large excision and closing by local flaps]. / Fasciite nécrosante sur sinus pilonidal sacro-coccygien chez un patient en aplasie médullaire. Traitement par excision large et fermeture par lambeaux locaux.

Pilonidal sinus is a frequent, benign disease with either an acute or a chronic course. The treatment of this common disease is essentially surgical. Necrotizing fasciitis is a rare complication of this disease that can be life-threatening, especially in immunocompromised subjects. The authors report the case of a 35-year-old woman with bone marrow aplasia following chemotherapy for type 2 acute myeloblastic leukaemia, who developed necrotizing fasciitis of a pre-existing sacrococcygeal pilonidal sinus and present a review of the literature.

Benign disease of the thyroid gland and vocal fold paralysis.

Development of vocal fold paralysis in the presence of thyroid disease is strongly indicative of thyroid cancer, and requires surgical exploration. At the same time, vocal fold paralysis does not relieve the surgeon of his obligation to identify and preserve the recurrent laryngeal nerves, since the cause of the paralysis may be a benign disease, with a fair chance of functional recovery after surgery. We hereby report a case of recurrent laryngeal nerve palsy secondary to a multinodular goitre.