INCIDENTAL PARATHYROIDECTOMY DURING TOTAL THYROIDECTOMY AS A POSSIBLE RISK FACTOR OF HYPOCALCEMIA. EXPERIENCE OF A SINGLE CENTER AND REVIEW OF LITERATURE.

CONTEXT: Post-operative clinical and biochemical hypocalcemia is a common complication of thyroid surgery and the correlation with incidental parathyroidectomy (IP) remains controversial. OBJECTIVE: To evaluate the incidence of IP during TT, its correlation to early post-surgery hypocalcemia, and its potential risk factors. PATIENTS AND METHODS: 77 consecutive patients submitted to thyroid surgery between January 2018 and December 2019. Demographic, clinical, biochemical, surgical and histopathological factors were assessed. Statistical multivariate analysis was performed to identify the risk of IP. RESULTS: IP was evident in 22 (28.5%) patients who underwent TT, TT with lymph node dissection of the central compartment (CLND) and reoperation for previous hemithyroidectomy with CLND. Early symptomatic hypocalcemia 24 hours after TT was demonstrated in 12/22 (54.5%) patients, with PTH value of <14pg/mL in 7/12 (58.3%) patients, and in 6 of these 7 patients (85.7%) the PTH value was <6.3pg/mL. In 5/22 (22.7%) patients the IP was associated with biochemical hypocalcemia <8.4mg/dL, and in 5/22 (22.7%) patients anatomical damage was not associated with a reduction in plasma calcium levels. The severity of early post-op hypocalcemia was not correlated with the number of parathyroid glands left in situ. The multivariate analysis did not show statistically significant values between the clinical-pathological variables and increased risk of IP. CONCLUSIONS: No IP clinical-pathological risk factors have been identified during thyroid surgery. In all cases of TT, with or without CLND, the meticulous identification of the parathyroid glands, whose incidental removal is frequently associated with clinical and biochemical hypocalcemia, is recommended.

Proton vs photon: A model-based approach to patient selection for reduction of cardiac toxicity in locally advanced lung cancer.

PURPOSE/OBJECTIVE: To use a model-based approach to identify a sub-group of patients with locally advanced lung cancer who would benefit from proton therapy compared to photon therapy for reduction of cardiac toxicity. MATERIAL/METHODS: Volumetric modulated arc photon therapy (VMAT) and robust-optimised intensity modulated proton therapy (IMPT) plans were generated for twenty patients with locally advanced lung cancer to give a dose of 70 Gy (relative biological effectiveness (RBE)) in 35 fractions. Cases were selected to represent a range of anatomical locations of disease. Contouring, treatment planning and organs-at-risk constraints followed RTOG-1308 protocol. Whole heart and ub-structure doses were compared. Risk estimates of grade⩾3 cardiac toxicity were calculated based on normal tissue complication probability (NTCP) models which incorporated dose metrics and patients baseline risk-factors (pre-existing heart disease (HD)). RESULTS: There was no statistically significant difference in target coverage between VMAT and IMPT. IMPT delivered lower doses to the heart and cardiac substructures (mean, heart V5 and V30, P < .05). In VMAT plans, there were statistically significant positive correlations between heart dose and the thoracic vertebral level that corresponded to the most inferior limit of the disease. The median level at which the superior aspect of the heart contour began was the T7 vertebrae. There was a statistically significant difference in dose (mean, V5 and V30) to the heart and all substructures (except mean dose to left coronary artery and V30 to sino-atrial node) when disease overlapped with or was inferior to the T7 vertebrae. In the presence of pre-existing HD and disease overlapping with or inferior to the T7 vertebrae, the mean estimated relative risk reduction of grade⩾3 toxicities was 24-59%. CONCLUSION: IMPT is expected to reduce cardiac toxicity compared to VMAT by reducing dose to the heart and substructures. Patients with both pre-existing heart disease and tumour and nodal spread overlapping with or inferior to the T7 vertebrae are likely to benefit most from proton over photon therapy.

Bilateral hydrocele. Uncommon clinical presentation of primary testicular lymphoma in the elderly.

Primary testicular lymphoma (PLT) represents 5% of testis tumors, the incidence increases in patients older than 60 years of age. Bilateral hydrocele is an unusual clinical presentation. Relapse in the central nervous system and in the contralateral testis is often observed. The US shows hypoechoic nodular lesions with a complete structural involvement of didymus and hypervascularization at Color Doppler. Orchiectomy should be performed in all cases as it is indispensable for the histopathological diagnosis and to characterize the immunophenotypic features. The most common histotype is diffuse large-B cell lymphoma. Combined biological approach and chemotherapy with rituximab and doxorubicin has radically changed the prognosis of disease. The authors report two patients of 81 and 82 years-old who referred for evaluation of massive bilateral hydrocele causing severe limitation of deambulation. Negative cytological findings for neoplastic cells in the scrotal effusion made difficult the differential diagnosis between inflammatory and malignant disease. Histopathologic findings made a diagnosis of high grade diffuse large B-cell NHL, respectively stage IV-E and stage III-E. The 82 years old patient was treated with 6 chemotherapy cycles of rituximab, cyclophosphamide, vincristine, prednisone. The exitus was dued to the umbilical hernia complications. In the 81 years old patient, cognitive deficit and severe impairment of general conditions constituted an absolute contraindication to polychemotherapy treatment. Rapid tumor progression led the patient to exitus 2 months after diagnosis. In both patients the delayed diagnosis of PLT was probably due to the reduction of welfare protection in the elderly with adverse social conditions.

Potential use of acupuncture in the treatment of first bite syndrome.

OBJECTIVES: First bite syndrome (FBS) is an early postoperative pain syndrome characterized by the sudden onset of pain in the parotid region at the first bite of each meal. The etiology is not certain, hence a standardized therapy does not exist. METHODS: A 50-year old woman referred to us complaining of a swelling in the right parotid region. Fine-needle aspiration biopsy (FNAB) was diagnostic for pleomorphus adenoma of the deep lobe of the parotid gland. A 50-year old man presented with a mass in the right side of the neck, FNAB was diagnostic for parapharyngeal space neurinoma. The first patient was submitted to total parotidectomy with facial nerve preservation, the second to extracapsular dissection of the tumor. A week after surgery both patients developed FBS. A qualitative/quantitative description of pain was obtained by means of a self-coded questionnaire. The score ranges from 8 to 44, corresponding to the lowest and the highest discomfort possible, respectively. Acupuncture was used to treat these 2 patients. The treatment protocol comprised 6 sessions, one per week, lasting 30 minutes each. RESULTS: Our questionnaire was administered before and after treatment and the score dropped from 33 to 25 in the female, from 30 to 15 in the male patient. CONCLUSION: FBS is a complication of upper cervical surgery with a high morbidity rate. We describe the first two cases of FBS that were successfully treated with acupuncture in our ENT department. We believe that this procedure may represent a valid therapeutic alternative in the future.

Under-response correction for EBT3 films in the presence of proton spread out Bragg peaks.

We present a study of the under-response of the new Gafchromic EBT3 films and a procedure to accurately perform 2D and 3D proton dosimetry measurements for both pristine and spread out Bragg peaks (SOBP) of any energy. These new films differ from the previous EBT2 generation by a slightly different active layer composition, which we show has not effected appreciably their response. The procedure and the beam quality correction factor curve have been benchmarked using 29 MeV modulated proton beams. In order to show the correction to apply when EBT3 films are used as treatment verification tools in anthropomorphic phantoms, two simulation studies involving clinical energies are presented: a SOBP for eye treatments and a SOBP to treat 20 cm deep and 5 cm thick tumours. We find maximum under-responses of 37%, 30% and 7.7% for the modulated 29 MeV beam, eye and deep tumour treatment, respectively, which were attained close to the end of the peak tails, due to a higher proportion of very low energy protons. The maximum deviations between corrected and uncorrected doses were for the three cases, respectively, 20.7%, 8.3% and 2.1% of the average dose across flat region of the SOBP. These values were obtained close to the distal edge of the SOBPs, where the proportion of low energy protons was not as high as on the tail, but there still was a number of protons high enough to deposit a reasonable amount of dose in the films.

Prognostic role of internal jugular vein preservation in neck dissection for head and neck cancer.

BACKGROUND AND OBJECTIVES: Sparing internal jugular vein (IJV) in neck dissection for head and neck cancer is controversial. We aimed at evaluating the prognostic impact of IJV preservation. METHODS: We examined 206 files of head and neck cancer patients who underwent radical or modified radical neck dissection at the Otolaryngology University of Florence. The site of primary tumor was larynx and hypopharynx in 44.66%, oropharynx in 25.24%, oral cavity in 23.3%, unknown in 4.85%, salivary glands and rhinopharynx in 0.97%. In 60.19% the IJV was resected, in 39.81% preserved. Prognostic impact of IJV preservation was assessed by Kaplan-Meier and multivariate analysis. RESULTS: Neck recurrence occurred in 25.2%: the IJV was resected in 42.31%, in 57.69% preserved (P = 0.02). At multivariate analysis, neck recurrence resulted significantly associated to extracapsular spread (ECS) (P = 0.009), IJV preservation (P = 0.01), positive margins (P = 0.02). In ECS positive patients, a higher risk of neck recurrence was documented for IJV preservation (P = 0.012). A worse prognosis was observed for patients with IJV spared (P = 0.06). CONCLUSIONS: IJV preservation is associated with an increased risk of neck failure and a worse outcome, mainly in patients with ECS of nodes.

Renal arteriovenous fistula simulating hydronephrosis: A case report.

INTRODUCTION: Acquired renal arteriovenous fistulas (AVFs) include those that occur as a complication of renal biopsy. CASE REPORT: The authors report the case of a woman with recent-onset grade I hypertension, who was referred to our staff for sonographic studies of the kidneys and urinary tract. Laboratory data revealed microhematuria and proteinuria <0.5 g/24 h, and renal function was borderline (MDRD GFR 58 mL/min). Renal sonography of the left kidney revealed an anechoic, arboriform area at the level of the pelvis, which was suggestive of hydronephrosis. The color Doppler examination showed turbulent flow within the anechoic area, with high-velocity arterial flow and arterialization of the venous waveform at spectral analysis. Selective renal angiography later confirmed the presence of a middle renal AVF with pseudoaneurysm, which had been provoked by a renal biopsy performed over 10 years earlier in another center. Since the patient was currently in good health, the prescribed management consisted solely of close clinical and US follow-up. DISCUSSION: AV fistulas are among the most commonly diagnosed renovascular malformations. The case reported here underlines the importance of using color Doppler ultrasound when obstructive uropathy is suspected, especially in patients who have undergone renal biopsy.

Doppler ultrasound and renal artery stenosis: An overview.

Renovascular disease is a complex disorder, most commonly caused by fibromuscular dysplasia and atherosclerotic diseases. It can be found in one of three forms: asymptomatic renal artery stenosis (RAS), renovascular hypertension, and ischemic nephropathy. Particularly, the atherosclerotic form is a progressive disease that may lead to gradual and silent loss of renal function. Thus, early diagnosis of RAS is an important clinical objective since interventional therapy may improve or cure hypertension and preserve renal function. Screening for RAS is indicated in suspected renovascular hypertension or ischemic nephropathy, in order to identify patients in whom an endoluminal or surgical revascularization is advisable. Screening tests for RAS have improved considerably over the last decade. While captopril renography was widely used in the past, Doppler ultrasound (US) of the renal arteries (RAs), angio-CT, or magnetic resonance angiography (MRA) have replaced other modalities and they are now considered the screening tests of choice. An arteriogram is rarely needed for diagnostic purposes only. Color-Doppler US (CDUS) is a noninvasive, repeatable, relatively inexpensive diagnostic procedure which can accurately screen for renovascular diseases if performed by an expert. Moreover, the evaluation of the resistive index (RI) at Doppler US may be very useful in RAS affected patients for predicting the response to revascularization. However, when a discrepancy exists between clinical data and the results of Doppler US, additional tests are mandatory.

Obstructive uropathy and acute renal failure due to ureteral calculus in renal graft: a case report.

INTRODUCTION: Obstructive uropathy caused by kidney stones is quite rare in transplant kidneys. CLINICAL CASE: The authors report the case of a patient, previously gastrectomized for gastric carcinoma. He underwent renal transplantation using uretero-ureterostomy, and presented an episode of acute renal failure 7 years after surgery. Ultrasound (US) examination showed no sign of rejection but allowed detection of moderate hydronephrosis in the transplant kidney. Subsequent computed tomography (CT) revealed a kidney stone in the middle ureter at the crossing of the iliac vessels. The patient therefore urgently underwent percutaneous nephrostomy of the graft and recovered diuresis and renal function. The patient was transferred to the Transplant Center where he underwent ureterotomy with removal of the stone and subsequent ureteropyelostomy. Also transureteral resection of the prostate (TURP) was performed due to urinary retention of prostatic origin. Histological examination showed prostate carcinoma, Gleason stage 3, which was treated conservatively using radiotherapy without suspension of the administered low dose of immunotherapy. DISCUSSION: Calculosis is one of the least common causes of obstructive uropathy in transplant kidneys. In the described case, US examination performed after onset of renal insufficiency led to subsequent radiological investigation and resulting interventional procedures (nephrostomy and surgical removal of the stone) with complete recovery of pre-existing renal function.

The role of ultrasonography in the study of medical nephropathy.

Diagnostic techniques in nephrology include clinical history, physical examination, laboratory tests, scintigraphy, diagnostic imaging techniques as well as renal biopsy. In kidney diseases, ultrasonography is used as a first-line imaging technique, and its role in medical nephropathy is to exclude urological pathologies, to differentiate between acute and chronic renal failure, to follow-up on the course of a disease, to guide needle biopsy, etc. Ultrasound images are useful at characterizing the pelvis, assessing renal dimensions and parenchymal echogenicity, sampling color-power Doppler signals and evaluating their characteristics and distribution as well as measuring parenchymal resistive index. Taken together, these data can provide useful clues to the diagnosis and help to reduce the number of possible differential diagnoses.

[A 'pretty' surprise...]. / Una 'bella' sorpresa...

This is a clinical history of hypertensive chronic renal failure patients who first presented at our hypertension ambulatory for control. The possibility of performing routine echography permitted the precocious diagnosis of bilateral kidney neoplasm and urothelial cancer.

Hemodiafiltration with online regeneration of the ultrafiltrate.

The concept of regeneration of dialysis fluids and of ultrafiltrate in particular has been recently revisited. Hemodiafiltration with online regeneration of the ultrafiltrate allows the concomitant infusion of sodium, calcium, and bicarbonate. Here, we studied the adsorptive characteristics of an integrated two-step sorbent system relative to different solutes present in the ultrafiltrate: sodium, calcium, phosphate, bicarbonate, uric acid, creatinine, and beta2-microglobulin. In vitro studies were performed in order to differentiate the relative roles for each sorbent (mineral-activated charcoal or hydrophobic resin) in adsorbing a given solute. Ex vivo studies were performed in order to evaluate the presence of cytokines (interleukin-1 beta and tumor necrosis factor-alpha), of cytokine (interleukin-1 beta and tumor necrosis factor-alpha)-inducing activities, and of the cytokine release in response to exogenous bacterial lipopolysaccharide by normal whole blood incubated with ultrafiltrate samples obtained at 15, 120, and 240 minutes after the start of treatment. The results of the present studies show the presence of immunomodulatory substances in the ultrafiltrate and the significant (P < 0.01) increase in the lipopolysaccharide-induced release of both interleukin-1 beta and tumor necrosis factor-alpha. The biological relevance of the ultrafiltrate and the possible relevance of the online, endogenous reinfusion are discussed.

[Renal involvement in multiple myeloma. Physiopathology and therapy]. / Patologia renale nel mieloma multiplo. Fisiopatologia e terapia.

Renal failure (RF) is a common accompaniment of multiple myeloma and is identified in over half of patients at presentation. RF is usually related to the presence of Bence-Jones protein (immunoglobulin light chain) which damages all the compartments of the kidney: glomerule, tubulo-interstitium and vasculature. The most common renal lesion is cast nephropathy, named "myeloma kidney": Cast are produced by two mechanisms: proximal tubule damage and intratubular cast formation. The predominant pathophysiologic mechanism of tubule damage appears to be a precipitation of Bence-Jones protein and Tamm-Horsfall glycoprotein produced by cells of ascending limb of Henle's loop in the tubule lumen. The therapeutic maneuvers to reduce renal damage and preserve renal function are reduction of plasma concentration of light chain with chemotherapy, elimination of factors which favour coprecipitation of Tamm-Horsfall protein with light chain (hypercalcemia, acid urine, radiocontrast material, furosemide, oliguria). At last, colchicine (1.2 mg/day) will also be efficacious in the acute management of patients with cast nephropathy.

Endothelin stimulates steroid secretion by frog adrenal gland in vitro: evidence for the involvement of prostaglandins and extracellular calcium in the mechanism of actin of endothelin.

Endothelin (ET-1) is a pleiotropic regulatory peptide which exerts multiple endocrine actions on the cardiovascular system. In the present study, we have investigated the possible role of ET-1 in the regulation of adrenocortical cells using perifused frog interrenal (adrenal) slices. Graded doses of ET-1 from 10(-11)-10(-9) M stimulated both corticosterone and aldosterone production in a dose-dependent manner. Repeated 20-min pulses of ET-1 (10(-9) M), given at the frequency of one pulse per 90 min, resulted in a marked reduction of the secretory response after the second pulse. Prolonged administration (3 h) of ET-1 induced a rapid increase in corticosterone and aldosterone output, followed by a gradual decline of corticosteroid secretion. Perifusion of frog adrenal tissue with ET-1 (10(-9) M) caused a significant increase in the release of prostaglandin E2 (PGE2) and 6-keto-PGF1 alpha, the stable metabolite of the prostacyclin PGI2. The enhancement of PG biosynthesis preceded by 10 min the peak of corticosteroids. When repeated pulses of ET-1 were administered, a significant diminution of the production of PGE2 and 6-keto-PGF1 alpha was observed after the second pulse. The cyclooxygenase inhibitor indomethacin (5 microM) totally suppressed the stimulatory effect of ET-1 on corticosterone and aldosterone secretion; in contrast, indomethacin did not affect ACTH-evoked corticosteroid secretion. Perifusion of adrenal slices with a calcium-free solution or addition of cobalt (4 mM) induced total inhibition of the stimulatory effect of ET-1. These results demonstrate that ET-1 is a potent stimulator of corticosterone and aldosterone secretion from frog adrenal gland in vitro. Our data show that repeated or prolonged administration of ET-1 induces a rapid desensitization phenomenon. The data also indicate that ET-1-evoked corticosteroid secretion is mediated by an increase in PG biosynthesis and requires the presence of extracellular calcium.