Post-thyroidectomy hypocalcemic syndrome: predictive value of early PTH. Preliminary results.

AIM: The aim of this study is to determine an early measured serous PTH cut-off value below which it's possible to predict post-thyroidectomy hypocalcaemia outbrake. MATERIALS OF STUDY: Ninety-three consecutive patients having a benign thyroid pathology were submitted to total thyroidectomy. In all the patients serous post-surgery intact PTH and total calcium were measured within an hour from weaning. 65 patients were measured a second time 18 hours from surgery. We searched for a correlation between the post-surgery PTH values at 1 and 18 hours from surgery with the calcemia at 1 and 18 hours from surgery. We carried out a one-year follow-up for each patient. Hypocalcemia developed in 26 patients (27.95%). It was transitory in twenty-two patients (23.65%) and permanent in 4 patients (4.3%). No correlation was found between PTH1 and Cal (p = 0.8). Statistically relevant correlation (p = 0.008) was found between PTH1 and Ca2. The correlation between PTH2 and Ca2 (p = 0.001) turns out to be even more relevant. We also calculated a found that 9.5 pg/dl was PTH1 cut-off value below which it is possible to predict hypocalcemia onset (p = 0.001). DISCUSSION AND CONCLUSIONS: Early post-surgery PTH measuring is a highly predictive test of post-surgery hypocalcemia. We identified a PTH1 cut-off value of 9.5 pg/dl, below which hypocalcemia onset is extremely frequent. This assessment permits us to establish an adequate drug prophylaxis, thus avoiding the related symptoms. We can also perform one-day surgery thyroidectomy in patients showing normal PTH values.

Simultaneous medullary carcinoma and differentiated thyroid cancer. Case report.

BACKGROUND: Medullary thyroid cancer (MTC) is an uncommon and aggressive tumour representing only 5-10% of all thyroid malignancies. MTC arises from parafollicular thyroid cells (C-cells) producing calcitonin hormone. Differentiated thyroid cancer (DTC) is the most frequent thyroid tumour (papillary or follicular), representing 80% of all thyroid cancer. DTC derives from follicular thyroid cells, that come from the central thyroid sketch. The association between medullary and papillary thyroid cancer is rare. Several cases have been reported of mixed carcinomas. CASE REPORT: We report two cases of associated medullary and papillary carcinomas in two different foci in patients with respectively Graves' disease and multinodular goiter. A young woman affected by Grave's disease and multinodular goiter under pharmacological treatment with antithyroidal drugs underwent total thyroidectomy. The histopathological examination revealed the presence of a medullary carcinoma of the middle third of right lobe (1.1 cm) with an adjacent papillary microcarcinoma (0.5 cm). A 72-years-old woman, affected by euthyroid multinodular goiter, underwent total thyroidectomy. The pathological findings were two microcarcinomas, medullary (0.44 cm) in the left lobe and papillary (0.22 cm) in the right lobe. CONCLUSION: We can speculate that this coexistence is inferred, not having shown a specific cause that justifies the association between the two types of tumour and the high prevalence of papillary carcinoma.

Giant mediastinal parathyroid adenoma: a case report.

A 65 year old female patient suffering from multinodular goitre and from hypercalcaemic syndrome which had been and was being treated with drugs for a number of years. The patient undergoes total thyroidectomy. Surgical neck and anterior mediastinum exploration was negative for sick parathyroids. Neck and chest TC and 'TC sestamibi scintigraphy showed the presence of a 7 cm hyperfunctional ectopic parathyroid tissue in the postero-superior mediastinum infiltrating oesophagus. Video bronchoscopy revealed an extrinsic compression of the trachea. The patient underwent surgery. Through right postero-lateral thoracotomy and mediastinal pleura incision, the adenoma excision was carried out. The histological examination revealed a potentially malignant parathyroid adenoma with infiltration, without over-reaching the capsule. The surgical treatment resulted in an immediate resolution of the clinical symptomatology. One year later, the follow up was shown no observable relapse with normal calcium and PTH values. Today, the tendency to minimally invasive surgery, an accurate preoperative localization of the adenoma and the use of techniques such as intra-surgical nuclear mapping through manual gamma probes, selective angiography, venous intraoperative dosage of PTH and intra-surgical ultrasound scan.

Klebsiella pneumoniae pulmonary infection with thyroid abscess: report of a case.

Thyroid abscess is a rare clinical entity, usually associated with a pyriform sinus fistula. A prompt diagnosis is important because it may progress rapidly into a life-threatening condition. We report a very unusual case of thyroid abscess associated with a lung infection, both caused by Klebsiella pneumoniae. The patient was treated successfully with a culture-appropriate antibiotic and an uneventful thyroid lobectomy. A delay in diagnosis of morbidities associated with a thyroid abscess may result in rapid exacerbation of this condition; therefore, prompt and appropriate treatment is mandatory for a successful outcome.

[Thyroid diseases in elderly patients]. / Disfunzioni tiroidee in età geriatrica.

AIM OF THE STUDY: To evaluate the differences about incidence, kind and clinical features of thyroid diseases in young and elderly patients. MATERIALS AND METHODS: Our study has been conducted in Endocrine Surgery Unit, "S. Luigi and S. Currò" Hospital in Catania, from January 2001 to December 2003. In this period 621 patients affected with different thyroidopathies were observed. They were divided in two groups: elderly (65 years or older), named Group A, and young subjects (under 65 years old), named Group B. Group A included 147 people aged between 65 and 89, with F:M = 3.9:1. Our study was founded on clinical and laboratory evaluation of thyroid hormones and antibodies (AAT, AMT) and subsequently an ultrasonographical evaluation, that has been completed, in some cases, with cytologic examination (FNAc). CONCLUSION: The main aspect about thyroid diseases is the different and atypical presentation in the elderly in comparison to young patients, with subsequent difficult diagnosis due to common symptoms to thyroidopathies rather than to physiological ageing. The most common thyroid dysfunctions in elderly are the autoimmune thyroidopathies, responsible of hypothyroidism. Such condition, in elderly, is often clinically irrelevant.

[Some ecomorphologic aspects of nodular goiter]. / Su alcuni aspetti ecomorfologici dei noduli tiroidei.

AIM OF THE STUDY: Determine microcalcifications' rule in nodular goiter, to classify those calcifications and identify US features suspect for tumoral pathology. MATERIAL AND METHODS: In Endocrine Surgery Unit we ultrasonographically detected 655 patients in a period of twelve months (Jan to Dec 2005). Patients aged from 22 to 75 years. Multinodular goiter were 42% and solitary nodular 33.8%, higher than other studies, as we checked selected patients. We determined microcalcification' incidence in nodular goiter and thyroiditis and studied their correlations with tumours. We also studied other US features suspect for malignant lesions. We divided microcalcifications in four groups. Thyroiditis prevalence was 55.8%. Microcalcifications' prevalence was 32.3%, divided as follow: Type I 18.1%, type II 4%, type III 81.8%, type IV 9%. In 9% of patients was present more than one kind of calcifications. Microcalcification rate was 28.9% in inflammatory disease, 55.17% in multinodular goiter and 18, 18% in single thyroid nodules. "Suspect" microcalcifications were present in 9% of whole thyroid pathology and in 12% of MNG. The majority of microcalcifications belonged to type III and their nature is questionable. Several Authors mentioned microcalcifications as a sensitive and highly specific feature for tumour diagnosis. Microcalcifications have a 59.2% sensitivity rate and a specificity rate of 85.8-95%. Their diagnostic accuracy is 77.4%. Other us suspect features are hypoecogenicity and irregular nodule outline. CONCLUSIONS: Ultrasonography remains an operator-dependent exam and it's necessary a correct interpretation of morphological data. Meticulous characterization of all ultrasonographic criteria enounced above is useful to reach satisfactory results and identify suspect lesions.

[Papillary carcinoma in an isthmic thyroglossal duct cyst: clinical considerations]. / Il carcinoma papillifero in cisti del dotto tireoglosso a sviluppo istmico: considerazioni su un' osservazione clinica.

Cancer in a thyroglossal duct cyst is uncommon (incidence: approximately 1%). There are about 250 reported cases in the literature, most of which are papillary cancers or, less frequently, squamous or follicular carcinomas. The preoperative diagnosis of thyroglossal duct cyst carcinoma may be facilitated by an ultrasound neck examination or fine needle aspiration cytology (FNAc). As reported in the literature, however, the diagnosis is often obtained only at histopathological examination. We describe a case of a 43-year-old male patient with a papillary carcinoma in an isthmic thyroglossal duct cyst. Ultrasound of the neck demonstrated a nodular hypo-anechogenic cystic neoformation of the isthmus of the thyroid, while Fnac was not diagnostic. An isthmectomy of the thyroid was initially performed. Frozen examination of the cystic lesion revealed a papillary carcinoma in the thyroglossal duct cyst. A total thyroidectomy with central lymphectomy was therefore performed. Carcinoma in the thyroglossal duct has a low mortality (5-year mortality: < 2%), but a long-term follow-up is mandatory, due to the low, short-and medium-term recurrence rate.

[Hashimoto thyroiditis. Possible cause or consequence of a malignant thyroid tumor]. / Tiroidite di Hashimoto: possibile causa o conseguenza del tumore tiroideo maligno.

AIM OF THE STUDY: The Authors performed a retrospective study on their case records in order to analyze the epidemiological aspects of association between Hashimoto thyroiditis and differentiated thyroid carcinoma. MATERIALS AND METHODS: From January 2004 to December 2005 the Authors performed 282 total thyroidectomy for any thyroid pathology. All patients were studied preoperatively even dosing antithyroid antibodies. In the study are included patients who presented histological finding of both Hashimoto thyroiditis and carcinoma. RESULTS: Eleven patients (23.9%) of 46 patients operated on for differentiated thyroid carcinoma also presented histological finding of thyroiditis. Association of thyroiditis and carcinoma was present in 39.2% of histologically detecied thyroiditis (28 patiems). CONCLUSIONS: Pathophysiological relationship between Hashimoto thyroiditis and DTC are still unclear, although a certain association of theese two anatomo-clinic entity has been demonstrated. We can't yet say if Hashimoto thyroiditis advance and facilitale tumour arising or thyroiditis is a reaction to neoplasia or these two pathologies are indipendeni each other, although both are present in the same patient.

[Thyroid microcarcinoma in benign thyroid diseases]. / Il microcarcinoma tiroideo nelle tireopatie benigne.

INTRODUCTION: Thyroid microcarcinoma is a malignant thyroid tumor with potential multifocality and a maximum of 1 cm of diameter. This carcinoma has been discovered more frequently like incidentaloma. AIM OF THE STUDY: To appraise the incidence of MCT in the benign thyroid diseases and the advantages offered from the total thyroidectomy, performed for benign diffused thyroid diseases, which surgical treatment "therapeutic" performed for these malignant tumors. MATERIALS AND METHODS: The study was conducted on 600 patients operated with total thyroidectomy for benign thyroid disease, admitted from 1999 to 2003. RESULTS: All patients were alive and free of disease at last control. DISCUSSION: The MCT is a carcinoma that presents frequently a behavior little malignant and a good prognosis. His principal characteristic is the absence of clinical demonstrations. Therefore his discovery, almost always accidental on a thyroid removed for other pathology, it has signaled by histologic study CONCLUSIONS: Thyroid microcarcinoma is a slow growing tumor, with a good prognosis and with a good disease-free survival. It can present a better aggressiveness for his multifocal localization and invasion. Therefore total thyroidectomy can be considered best treatment and also be surgical treatment oncologically correct for this tumor.

[The lobe of Zuckerkandl: an important sign of recurrent laryngeal nerve]. / Il lobo di Zuckerkandl: faro del nervo laringeo ricorrente.

INTRODUCTION: The accurate acquaintance of the anatomy of the thyroid gland allows reduction of complications to interventions of thyroidectomy, where for the existing topography, the nervous and vascular structures could result vulnerable. The identification of Zuckerkandl's tuberculum could reduce the lesions to the recurrent laryngeal nerve, for constant relationship between the recurrent laryngeal nerve and tuberculum. MATERIALS AND METHODS: The Authors have studied 605 patients underwent to thyroid surgery for benign or malignant thyroid diseases. The aim was to verify if the incidence of recurrent nerve lesions can be reduced with the identification of the Zuckerkandl's tuberculum and with a knowledge of its anatomical relationships with vascular, nervous and glandular structures near the thyroid. RESULTS: The Zuckerkandls tuberculum was found in the majority of the cases, with prevalence to the right. Its identification has allowed an immediate and safe identification of recurrent laryngeal nerve, with setting of time of the operation and especially with setting of possible injury to the recurrent nerves. DISCUSSION: The lobe of Zuckerkandl is the extension of the lateral lobes of the thyroid, composed of thyroid tissue only and so it can be interested in thyroid lesions. This tubercle is considered a constant anatomical landmark for the recurrent laryngeal nerve and the superior parathyroid glands. The knowledge of the lobe of Zuckerkandl is essential to perform "safety thyroidectomy", without injury for the vascular and nervous structures. CONCLUSIONS: TZ identification is not always easy and/or possible but, when that happens become aware of possible, systematically, the isolation of the recurrent nerve and of the superior parathyroid gland, preserve such structures from possible lesions in surgery of the thyroid gland.

[Zuckerkandl's tuberculum: could it be useful in thyroid surgery?]. / Il tubercolo di Zuckerkandl: è un ausilio nella chirurgia della tiroide?

A thorough knowledge of thyroid anatomy could reduce the incidence of lesions to the inferior laryngeal nerve. In view of its relationship with the recurrent laryngeal nerve and the parathyroid gland, Zuckerkandl's tuberculum should be considered an anatomical landmark for the recurrent laryngeal nerve in thyroid surgery. The aim of the study was to verify whether the identification of Zuckerkandl's tuberculum could be useful to reduce the incidence of recurrent laryngeal nerve lesions. Four hundred and thirty-two patients underwent thyroid surgery over the period from January 2001 to December 2003 for benign (377 patients) or malignant disease (55 patients). Three-hundred and forty-eight (81%) underwent total thyroidectomy. Zuckerkandl's tuberculum was found in 74.5% of patients, with a high prevalence in the right lobe: in 5% of patients it was grade I, in 50% grade II and in 45% grade III. Its presence was associated with the recurrent laryngeal nerve in almost all cases. Eight of the patients undergoing total thyroidectomy suffered recurrent nerve paralysis, only 4 of which proved definitive. Identification of Zuckerkandl's tuberculum allows safer isolation of the recurrent laryngeal nerve and superior parathyroid gland dissection.