Tracheal varices caused by mediastinal compression of a large intrathoracic goiter: report of a case.

INTRODUCTION: Tracheal varices are a rare condition but they can be an important source of massive or recurrent haemoptysis. Usually they are related to increased pressure in the pulmonary veins. Mediastinal goiter is often associated to compressive effects on the surrounding structures, including mediastinal vessels with potential superior vena cava syndrome. CASE REPORT: We describe a case, not previously reported in literature, of mediastinal goiter with hemoptysis as first clinical manifestation. Bleeding was attributed to a superior vena cava syndrome associated to a tracheal fragile mucosa with an easily bleeding intramural nodule which was diagnosed as tracheal varices after total thyroidectomy. The nodule in fact disappeared together with the venous hypertensive signs after venous decompression of the mediastinum. CONCLUSIONS: Compressive symptoms including tracheal varices, related to mediastinal goiter, can be treated surgically by total thyroidectomy via cervicotomy and when required with associated median sternotomy.

Thyroid anaplastic carcinoma: the impact of multimodality treatment on survival. The experience of a referral center for endocrine surgery.

AIM: Anaplastic thyroid carcinoma (ATC) is characterized by local invasiveness, risk of recurrence and very poor prognosis. METHODS: We retrospectively reviewed 79 consecutive patients treated between 1996 and 2012. We analysed the multimodality treatment of ATC considering the impact of surgery and radiotherapy on survival. RESULTS: Patients were divided in groups A and B (tumor less and larger than 5 cm). Surgery was carried out in 44 patients, radiotherapy in 48 patients. Tracheostomy and endoprosthesis were used respectively in 48.1% and in 25.3% of patients. The mean survival was 5.35 (± 3.2) months with no significant difference in group A vs. group B. Considering patients undergone surgery, significant impact on survival was observed comparing A vs. B (P=0.013). Combination of surgery and radiotherapy significantly improves outcome comparing A vs. B (P=0.017). Improvement in survival compared to no treatment at all was observed in both groups respectively for surgery (P=0.001 and P=0.0001) and radiotherapy (P=0.047 and P=0.0001). CONCLUSION: Although the severity of prognosis of ATC, multimodality treatment still significantly improves local control of the disease achieving acceptable survival in selected patients and adequate palliation of symptoms for the others. Surgery is still a fundamental treatment.

Total thyroidectomy and central lymph node dissection. Experience of a referral centre for endocrine surgery.

AIM: Thyroid cancer prognosis is determined by several variables, even with extremely elevated survival rate. The most debated issues are the type of thyroidectomy and extension of lymphadenectomy. Aim of the study is the analysis of benefits of level VI lymphadenectomy associated to total thyroidectomy in the treatment of thyroid cancer. PATIENTS AND METHODS: 316 total thyroidectomy with central node dissection were carried out in the Unit of Endocrine Surgery, University of Perugia. Direct parathyroid auto-implantation was carried out if damage or accidental excision occurred. High risk patients received radioiodine treatment. RESULTS: Lymph node metastases in the VI level were observed in 42% of cases with a significant difference (p 0.0042) of positive lymph node in level VI comparing tumor larger than 1 cm vs smaller than 1 cm. No significant differences were observed when considering difference of sex, and age. Significant difference (p 0.005) was shown when considering over 45 years old male patients with tumor larger than 1 cm vs smaller ones. The 78% of patients underwent iodine ablation after surgery. Recurrence rate in these patients was 3.2%, with no significant difference compared to not treated patients. Bilateral temporary recurrent nerves palsy were observed in 0.6% of cases, unilateral temporary recurrent nerves palsy in 3.4%, unilateral permanent palsy in 1.5%, temporary hypoparathyroidism in 17%, permanent hypoparathyroidism in 4.4%. CONCLUSIONS: Total thyroidectomy combined to central node dissection, even in absence of risk factors and without clinical evident nodes, is the treatment of choice offering clear indications to radioiodine ablation.

Micro HTA as a tool for clinical governance: the experience of the Breast Unit in "Santa Maria" Terni Hospital.

The last decade has witnessed the affirmation of the paradigm Health Technology Assessment (HTA) as a tool for government innovation technology in health care. As is known, this is an approach of evaluation oriented policy making that, in addition to provide for the disclosure of its results, it is proposed to consider simultaneously the clinical, economic, organizational, ethical and social issues arising from the introduction or disposal of a health technology, understood in the broadest sense of the term. In order to reconstruct a realistic picture of its level of implementation we have reproduced a micro HTA which served to assess the Harmonic Focus® device usefulness in breast surgery.

Health technology assessment and thyroid surgery.

The growth of technological innovation, the request for assistance, the rising patient's expectations and the interest of the industry have led to a rise in the cost of health care systems. In this context the role of the National Health System is not to delay the development or adoption of new technologies, but rather to drive the development selecting priorities and promoting its use. Health Technology Assessment (HTA) is a multidisciplinary and multidimensional approach for analyzing the medical-clinical, social, organizational, economic, ethical and legal implications of a technology (devices, drugs, procedures) through the assessment of multiple parameters such as effectiveness, safety, costs of the social and organizational impact. A health technology assessment is a comprehensive, systematic evaluation of the prerequisites for estimating the consequences of using health technology. Main characteristic of HTA is that the problem is tackled using an approach focused on four main elements: - technology; - patient; - organization; - economy. The authors have applied the HTA method for the analysis of the ultrasonic focus dissector on thyroid surgery. They compared the cost of the surgical procedure using the ultrasonic dissector and without it in a case study of 440 patients who underwent thyroidectomy.

Differentiated thyroid tumors: surgical indications.

Thyroid gland tumors represent 1% of malignant tumors. In Italy their incidence is in constant growth. The aggressiveness depends on the histological type. The relative non-aggressive grade of different forms of tumors is the basis for discussing the treatment of choice: total thyroidectomy vs lobectomy with or without lymphadenectomy of the sixth level in the absence of metastasis. Authors report about their experience, and they advocate, given the high percentage of multicentric forms, total thyroidectomy as treatment of choice.

Myoblastoma of the breast: Our experience and review of literature.

INTRODUCTION: Breast myoblastoma or granular cell tumor involving the breast parenchyma has been described in detail for the first time since Abrikossoff in 1931. The location of this injury to the breast is very rare, accounting for between 5% and 15% of all cases of cancer of the granular cells. We present our experience regarding the identification of two cases because of the relative rarity of this tumor. It is often confused with breast cancer on clinical and radiological, and its diagnosis can then be difficult for physicians, radiologists and pathologists. PRESENTATION OF CASES: We report the cases of two young women who came to our attention because of the presence of mass shoveled breast, mobile and accompanied by pain cycle independent. In both cases, mammography and ultrasound revealed the presence of heterogeneous mass and irregular, but in one of two such mass located at the Union of external quadrants of the left breast and was in contact with his serratus anterior and suspicion for malignancy. In both cases the 'histology combined with immunohistochemical study proved to be a granular cell tumor. CONCLUSION: Although a granular cell tumor of the breast is a rare tumor breast, should be considered in the differential diagnosis of benign and malignant lesions. Surgeons and pathologists should keep in mind when considering a granular cell tumor cells with abundant granular cytoplasm containing materials to avoid misdiagnosing breast cancer, which could lead to unnecessary surgery.

Male breast cancer, clinical presentation, diagnosis and treatment: Twenty years of experience in our Breast Unit.

BACKGROUND: The male breast cancer (MBC) is a rare and represents less than 1% of all malignancies in men and only 1% of all breast cancers incident. We illustrate the experience of our team about the clinico-pathological characteristics, treatment and prognostic factors of patients treated over a period of twenty years . RESULTS: Forty-seven patients were collected 1995-2014 at the Breast Unit of the Hospital of Terni, Italy. The average age was 67 years and the median time to diagnosis from the onset of symptoms was 16 months. The main clinical complaint was sub areolar swelling in 36, 76% of cases. Most patients have come to our attention with advanced disease. The histology of about ninety percent of the tumors were invasive ductal carcinoma. Management consisted mainly of radical mastectomy; followed by adjuvant radiotherapy and hormonal therapy with or without chemotherapy. The median follow-up was 38 months. The evolution has been characterized by local recurrences; in eight cases (17% of all patients). Metastasis occurred in 15 cases (32% of all patients). The site of bone metastases was in eight cases; lung in four cases; liver in three cases; liver and skin in one case and pleura and skin in one case. CONCLUSION: The male breast cancer has many similarities to breast cancer in women, but there are distinct functions that need to be appreciated. Future research for a better understanding of the disease should provide a better account of genetic and epigenetic characteristics of these forms; but, above all, epidemiological and biological cohorts numerically more consistent.