Effects of magnesium supplementation on post-thyroidectomy hypocalcemia: a prospective single-center study.

BACKGROUND: Severe and/or symptomatic hypocalcemia due to hypoparathyroidism is the main contraindication for discharge in patients who have undergone thyroid surgery. Hypomagnesemia may contribute to the onset of hypoparathyroidism and is frequently observed after thyroid surgery in hypocalcemic patients. The impact of prophylactic and postoperative Magnesium supplementation on postoperative hypocalcemia and hypomagnesemia was prospectively evaluated by comparing patients undergoing prophylactic supplementation to a control group of patients who had only received Magnesium after evidence of postoperative hypoMg. METHODS: One hundred and twenty patients who underwent a total thyroidectomy participated in the study. Seventy-three patients were included in the study group, 47 in the control group. Prior to surgery, patients in the study group were given Magnesium orally for 5 days; postoperatively, Calcium and Magnesium was administered to all patients who displayed hypocalcemia and hypomagnesemia. RESULTS: Postoperative biochemical hypocalcemia (serum Calcium<8.5 mg/dL, regardless of its clinical severity) was found in 60 patients (50%) on D1 and in 58 patients (48.4%) on D2. Among hypocalcemic patients, hypomagnesemia was recorded in 29 at D1 (48%), and in 46 at D2 (79%). A significant positive correlation was found between Magnesium, Calcium, and parathyroid hormone in the first two postoperative days, while a significant inverse correlation occurred for these same parameters and length of hospital stay (p<0.001). One hundred and five patients (87.5%) were discharged as expected on the second postoperative day (Study group = 65, Control group = 40, p = 0.724), whereas 15 patients (12.5%) required prolonged hospitalization (Study group = 8, Control group = 7, p = 0.721). The Study group only showed significantly higher Magnesium levels on the first postoperative day (p=0.03). CONCLUSIONS: Although Magnesium and Calcium levels showed the same trend after thyroidectomy, neither Magnesium prophylaxis nor Magnesium treatment influenced the clinical course of postoperative hypocalcemia.

Possible role of low magnesium levels in the onset of postoperative hypoparathyroidism following thyroidectomy.

BACKGROUND: A positive correlation between calcium and magnesium serum levels is well known and depends upon various factors. This study aims at verifying the existence of this association in a retrospective series of patients who underwent thyroid surgery. METHODS: Two hundred and eighty-five consecutive patients (202 female, 83 male, mean age 57 years) who underwent at least total thyroidectomy (TT) and had a complete clinical and biochemical pre- and postoperative evaluation were included in the study. Patients were evaluated with regard to: sex, age, indications for surgery, operative time, number of accidentally removed parathyroids, extent and time of surgery, thyroiditis, final histology, pre- and postoperative levels of calcium, magnesium, vitamin D, and creatinine, presence of symptoms of hypocalcemia. Statistical analysis was performed using the R software. RESULTS: In the postoperative period, biochemical hypocalcemia (<8.5 mg/dL) was observed in 126 patients (44%) and severe hypocalcemia (<7.5 mg/dL, a level indicating the need for longer hospitalization) was seen in 40 (14%). When analyzing patients with and without postoperative hypocalcemia, the factors affecting postoperative biochemical hypocalcemia were: older age (P=0.019), longer operative time (P=0.039), and a highly significant correlation between postoperative calcium and magnesium levels (r=0.432; P<0.001). CONCLUSIONS: The only factor among the ones we analyzed in this retrospective study that would appear to be linked to the onset of clinically relevant hypocalcemia is low magnesium levels in the postoperative period. A prospective randomized study with a group of patients undergoing magnesium replacement in the postoperative period can clarify the possible role of magnesium repletion on hypocalcemia.

An H-TERT Mutated Skin Metastasis as First Occurrence in a Case of Follicular Thyroid Carcinoma.

Differentiated thyroid cancer arising from thyroid follicular epithelial cells is the most frequent endocrine malignancy, and skin metastases are very rare. We describe a case of a 70-year-old women with a history of an indeterminate thyroid nodule on cytology. A painless, erythematous skin nodule of about 7 mm diameter was removed from the scalp and diagnosed as a metastasis from thyroid cancer. After total thyroidectomy, a histological diagnosis of follicular thyroid cancer was made. Two cycles of radioactive iodine were performed. Both the follicular thyroid carcinoma (FTC) and the metastasis were investigated for the presence of BRAF/RAS and TERT promoter mutations. The results showed that the cutaneous metastasis was BRAF wild-type and TERT promoter-mutated (position g.1,295,228 C>T); in contrast, the primary thyroid lesion was negative for both molecular markers.

Neurological complications in thyroid surgery: a surgical point of view on laryngeal nerves.

THE CERVICAL BRANCHES OF THE VAGUS NERVE THAT ARE PERTINENT TO ENDOCRINE SURGERY ARE THE SUPERIOR AND THE INFERIOR LARYNGEAL NERVES: their anatomical course in the neck places them at risk during thyroid surgery. The external branch of the superior laryngeal nerve (EB) is at risk during thyroid surgery because of its close anatomical relationship with the superior thyroid vessels and the superior thyroid pole region. The rate of EB injury (which leads to the paralysis of the cricothyroid muscle) varies from 0 to 58%. The identification of the EB during surgery helps avoiding both an accidental transection and an excessive stretching. When the nerve is not identified, the ligation of superior thyroid artery branches close to the thyroid gland is suggested, as well as the abstention from an indiscriminate use of energy-based devices that might damage it. The inferior laryngeal nerve (RLN) runs in the tracheoesophageal groove toward the larynx, close to the posterior aspect of the thyroid. It is the main motor nerve of the intrinsic laryngeal muscles, and also provides sensory innervation to the larynx. Its injury finally causes the paralysis of the omolateral vocal cord and various sensory alterations: the symptoms range from mild to severe hoarseness, to acute airway obstruction, and swallowing impairment. Permanent lesions of the RNL occur from 0.3 to 7% of cases, according to different factors. The surgeon must be aware of the possible anatomical variations of the nerve, which should be actively searched for and identified. Visual control and gentle dissection of RLN are imperative. The use of intraoperative nerve monitoring has been safely applied but, at the moment, its impact in the incidence of RLN injuries has not been clarified. In conclusion, despite a thorough surgical technique and the use of intraoperative neuromonitoring, the incidence of neurological complications after thyroid surgery cannot be suppressed, but should be maintained in a low range.

Proteomics, and metabolomics: magnetic resonance spectroscopy for the presurgical screening of thyroid nodules.

We review the progress and state-of-the-art applications of studies in Magnetic Resonance Spectroscopy (MRS) and Imaging as an aid for diagnosis of thyroid lesions of different nature, especially focusing our attention to those lesions that are cytologically undetermined. It appears that the high-resolution of High-Resolution Magic-Angle-Spinning (HRMAS) MRS improves the overall accuracy of the analysis of thyroid lesions to a point that a significant improvement in the diagnosis of cytologically undetermined lesions can be expected. This analysis, in the meantime, allows a more precise comprehension of the alterations in the metabolic pathways induced by the development of the different tumors. Although these results are promising, at the moment, a clinical application of the method to the common workup of thyroid nodules cannot be used, due to both the limitation in the availability of this technology and the wide range of techniques, that are not uniformly used. The coming future will certainly see a wider application of these methods to the clinical practice in patients affected with thyroid nodules and various other neoplastic diseases.

Postoperative follow up in patients showing no evident residual disease - cut-offs for imaging/ intervention.

The European Group generally agrees with the American guidelines on the issue of the indications for additional surgery in patients with recurrence of medullary thyroid cancer. The discussions have been focused mainly on the postoperative follow-up, where some European experts feel that a postoperative calcitonin-stimulating test is of some importance in assigning the patient to the "Cured" or "Non-cured" group immediately after surgery. A part of the European group feels that a negative calcitonin-stimulating test might lead to a less intensive follow-up in the late follow-up of these patients.

Incidental versus clinically evident thyroid cancer: a 5-year follow-up study.

BACKGROUND: The incidence of differentiated thyroid cancer in patients undergoing surgery for presumed benign thyroid disease (incidental thyroid cancer) is not negligible. The purpose of this study was to verify if incidental thyroid cancers have a different clinical course than the clinically evident thyroid cancer. METHODS: A group of patients with incidental thyroid cancer (n = 95) has been compared to a control group with clinically evident thyroid cancer (n = 93). Both the histology and the outcome after a 5-year follow-up have been compared. RESULTS: At the univariate analysis, the groups demonstrated significant differences in many pathologic features, remnant ablation (p < .001), and persistent disease (p = .006). Nevertheless, the multivariate analysis revealed that the outcome was not influenced by the preoperative or the incidental diagnosis. CONCLUSION: Incidental thyroid cancers show a different pathological pattern when compared to clinically evident thyroid cancers. Nonetheless, the final outcome is not influenced by preoperative or postoperative diagnosis. Hence, patients with incidental thyroid cancer should follow the same postoperative protocols of patients with clinically evident thyroid cancer.

Metabolomics approach to thyroid nodules: a high-resolution magic-angle spinning nuclear magnetic resonance-based study.

BACKGROUND: Proton magnetic resonance spectroscopy of operative specimens has been reported to successfully differentiate normal tissue from malignant thyroid tissue. We used a new high-resolution magnetic resonance spectroscopy technique for the differentiation of benign and malignant thyroid neoplasms. METHODS: Histological specimens from 72 patients undergoing a total thyroidectomy were processed into a 4-mm ZrO(2) high-resolution magic angle spinning (HRMAS) rotor with 5 µL of D(2)O. A Bruker Avance spectrometer operating at 400 MHz for the (1)H frequency and equipped with a (1)H/(13)C/(31)P HRMAS probe was used. RESULTS: Normal and neoplastic thyroid tissues could be discriminated from each other by different relative concentrations of several amino acids and lipids, as well as benign and malignant neoplasms, that differed in terms of a greater lactate and taurine and a lesser lipid choline, phosphocholine, myo-inositol, and scyllo-inositol levels in malignant samples. A statistical analysis with a receiver operating characteristic curve revealed that 77% of the samples were accurately predicted. Similar results were obtained with specimens obtained from ex vivo aspirates. CONCLUSION: A further development of this project will be to use the metabolomics approach on specimens obtained from aspirates in vivo after the resolution of technical problems attributable to possible contamination.

Minimally invasive video-assisted thyroidectomy: an analysis of results and a revision of indications.

BACKGROUND: The first report of minimally invasive video-assisted thyroidectomy (MIVAT) was published in 1999, and the indications were progressively implemented: from cytologically undetermined thyroid nodules to intermediate-risk differentiated thyroid cancers. The aim of this study was to review the entire series of patients who underwent a MIVAT, critically analyzing its indications and contraindications and trying to figure out how the indications might be extended. METHODS: From 1998 to 2009, a total of 1,946 patients (1,659 females, 287 males; mean age = 40.2 years) underwent MIVAT in our department. Inclusion criteria were benign thyroid nodules <35 mm, malignant nodules <20 mm, and an ultrasonographically estimated thyroid volume (ETV) <25 cc. The presence of suspicious or metastatic lymph nodes and the presence of severe thyroiditis were considered a contraindication for MIVAT. RESULTS: A total thyroidectomy was performed in 1,435 patients (72.3%). A total lobectomy was performed in 511 cases (26.3%), and a central neck node sampling was associated with total thyroidectomy in 104 cases. Final histology revealed benign disease in 979 cases (51.5%) and a malignancy was diagnosed in 915 cases (48.5%). Unexpected thyroiditis was found on final histology in 17.9% of the patients with benign disease and 30.9% of patients with malignancy. The incidence of thyroiditis was significantly different in these two populations (p < 0.0001). CONCLUSION: Our data confirm the validity of the traditional indications for MIVAT: low-risk differentiated thyroid cancer (DTC), cytologically undetermined nodules, and small-volume benign thyroid disease. The indications may be further and safely extended to those patients with associated thyroiditis and those with intermediate-risk DTC. MIVAT can be proposed on a much larger scale than it was at its onset and cannot be considered an option for only a limited number of patients.

Lobectomy versus total thyroidectomy in children with post-Chernobyl thyroid cancer: a 15 year follow-up.

In 1994, 21 Belarus children presenting papillary thyroid cancer (PTC) diagnosed after the Chernobyl disaster, and already submitted to subtotal surgery, underwent thyroid re-operation and post-operative radioiodine (131(I)) therapy. All were re-evaluated after a 15-year follow-up, to evaluate the results of partial versus total thyroidectomy. Nineteen out of 21 children (mean age 9.2 years) had previously undergone a lobectomy. All cases underwent re-operation in 1994. Histology revealed a PTC in the residual lobe in three cases, three had lymph node metastases. After surgery, 20 patients underwent 131(I) therapy. The post-131(I) whole body scan was negative in seven cases, showed neck node metastases in five, lung metastases in three, multiple associated metastases in six. The follow-up was performed with rhTSH-stimulated serum thyroglobulin (Tg) evaluation and ultrasonography. Twenty patients showed Tg <1 ng/ml and negative ultrasonography; the patient who refused 131(I) therapy showed a thyroid remnant and a Tg of 32 ng/ml. Chi-square analysis showed significantly higher prevalences of residual cancer in the neck or lung, lymph node metastases, and re-operations (before completion) in patients who had undergone lobectomy than in those who had undergone completion thyroidectomy and 131(I) therapy. The surgical complications after lobectomy were similar to those after completion thyroidectomy. A less-than-total thyroidectomy should not be indicated in patients with radiation-induced PTC, due to the high risk of residual cancer in the thyroid left in situ. The results of this study favor total thyroidectomy as the initial treatment for thyroid cancer in children exposed to fallout radiation.

Standard versus video-assisted thyroidectomy: objective postoperative pain evaluation.

BACKGROUND: This prospective, randomized study was designed to objectively demonstrate that minimally invasive video-assisted thyroidectomy (MIVAT) improves postoperative pain compared with standard thyroidectomy, via the dosage of biochemical mediators measured before and after surgery. METHODS: Forty-nine patients undergoing total thyroidectomy were allotted to MIVAT (n = 23) or traditional thyroidectomy (OPEN) (n = 26) groups. At hospitalization (T0), interleukin (IL)-1, -2, -4, -6, -10, -3, tumor necrosis factor (TNF)-α, TGF-ß, and MCP-1 were measured. The basal pain tolerance also was evaluated by VAS. Blood samples for interleukin measurement and VAS evaluations were obtained from all patients in the recovery room (T1) and 24 h after surgery (T2). RESULTS: At T0, the MIVAT and the OPEN groups were not different in terms of basal pain tolerance and biochemical profile. At T1, VAS scores were significantly higher (p = 0.04), whereas TGF-ß (p = 0.03) and MCP-1 (p = 0.03) levels were significantly lower in the OPEN than in the MIVAT group. No significant difference was demonstrated for other interleukins. A significant inverse relationship between VAS and TGF-ß was demonstrated and confirmed through the correlation (p = 0.003) and regression (p = 0.003, p < 0.0001, R (2) = 0.172) coefficients; the stepwise regression also demonstrated that TGF was the most predictive factor of postoperative pain (p = 0.0038) through an inverse relationship. No statistically significant difference has been demonstrated at T2. CONCLUSIONS: TGF-ß serum levels immediately after surgery seem to correlate with pain evaluation, confirming that reduced postoperative distress is an objective outcome of MIVAT. This result confirms the results of studies based only on subjective pain evaluations.

Clinicopathologic and molecular disease prognostication for papillary thyroid cancer.

Despite its increasing incidence over the last 30 years, the mortality rate of papillary thyroid cancer (PTC) has decreased significantly. Nevertheless, a minority of patients still present with an aggressive form of PTC that can lead to death, even after a prolonged period of survival. Many classifications exist that allow one to stratify the clinical risk of recurrence and death in patients with PTC; however, the parameters upon which they are established are pathological and molecular and, therefore, are revealed only after surgery. The preoperative identification of these aggressive variants of PTC would allow one to schedule a more aggressive operation (e.g., total thyroidectomy together with central and/or mono- or bi-lateral node dissections) in patients with high-risk PTC. This article reviews the parameters used most commonly to differentiate low-risk PTCs from their more aggressive variants and describes some of the newest molecular therapies for this latter group of tumors.

Papillary thyroid cancer: pathological parameters as prognostic factors in different classes of age.

OBJECTIVE: To analyze aspects of a series of papillary thyroid carcinomas and evaluate the prognostic features specific to different age classes. STUDY DESIGN: Retrospective study. SUBJECTS AND METHODS: From 2000 to 2005, 2709 patients underwent a total thyroidectomy for papillary thyroid carcinoma in our department. Patients were divided into three groups: <18 years (G1), 19 to 45 years (G2), and >46 years (G3). Histologic and clinical features were statistically evaluated. RESULTS: Tumor size was larger in G1 when compared with both G2 and G3 (P < 0.0001). Infiltration of the thyroid capsule and node metastases were higher in G1 than both G2 and G3 (P < 0.0001). The Tall-cell variant was more represented in G2 and G3. CONCLUSION: In the pediatric population, papillary carcinoma is a more aggressive disease. Because pediatric cancers have a better prognosis than their adult counterparts, this does not influence patient outcome. Age can then be considered the most important factor in determining prognosis.

Minimally invasive video-assisted thyroidectomy for benign thyroid disease: an evidence-based review.

BACKGROUND: A decade after nearly all surgical disciplines developed minimally invasive techniques, the first report of a single case of minimally invasive thyroidectomy was published. Minimally invasive video-assisted thyroidectomy (MIVAT) is now considered the most widely practiced and most easily reproducible minimally invasive procedure for thyroidectomy. The aim of this review was to analyze the treatment of benign thyroid diseases by MIVAT. METHODS: A systematic evidence-based literature review focusing on three questions was carried out. Additional data were obtained on the basis of our personal experience. (1) Are minimally invasive procedures indicated in the treatment of thyroid diseases? (2) Is MIVAT a safe technique and what are the demonstrated advantages? (3) Since different thyroid diseases may be treated by MIVAT, is it of any value in the treatment of benign thyroid diseases? RESULTS: MIVAT can be considered an appropriate treatment of some thyroid diseases; it represents a safe procedure with the same incidence of complications as traditional surgery, and also has advantages in terms of both cosmetic result and postoperative distress. CONCLUSIONS: In spite of an increasing trend toward performing more extensive procedures other than thyroidectomy alone during videoscopic procedures, the current literature seems to reaffirm that the main and safest indication for MIVAT is benign disease.

Clinically unpredictable prognostic factors in the outcome of medullary thyroid cancer.

Total thyroidectomy and central neck dissection are the procedures of choice in patients affected with medullary thyroid cancer. It is known that a medullary thyroid cancer with node metastases can be rarely cured, and therefore the utility of a modified radical neck dissection in the absence of suspicious node metastases still needs further evidence. The study aims to verify whether other epidemiological and pathological parameters could affect the prognosis of medullary thyroid cancer patients. We prospectively studied 70 medullary thyroid cancer patients consecutively operated on (from 2000 to 2004) at the same institution and analysed by the same pathologists. All patients underwent total thyroidectomy and central lymphadenectomy. In 27 cases, the ipsilateral (n=19) or bilateral (n=8) modified radical neck dissection was performed in the presence of suspicious lateral neck node metastases. After surgical treatment, basal and stimulated serum calcitonins (Cts) were measured in all patients. Follow-up ranged between 1 and 4 years. Patients were considered 'cured' when stimulated Ct was undetectable. Age, sex, tumour size, tumour capsule, multicentricity, nodes in the central neck and mean number of positive nodes were analysed in 'cured' and 'not-cured' patients. The presence of node metastases in the central compartment was significantly correlated with the outcome of the patients, being present in 9 and 72% of cured and not-cured patients respectively (P<0.000001). Tumour size was also significantly correlated with the outcome of the disease (P<0.00006). The presence of the tumour capsule correlated with better prognosis (P=0.0005) and absence of node metastases (P=0.0080). By multivariate analysis, the presence of node metastasis remained the most significant variable affecting the outcome of the disease (P=0.000014). Our results show that the outcome of encapsulated cancer is significantly better regardless of tumour size and node metastases. Although the early diagnosis and the extensive surgical treatment may favour the good outcome of medullary thyroid cancer, they do not always guarantee the definitive cure of the disease, being the capsular infiltration an independent bad prognostic factor.

Intrathyroidal differentiated thyroid carcinoma: tumor size-based surgical concepts.

INTRODUCTION: Total thyroidectomy (TT) remains the treatment of choice for differentiated thyroid carcinomas (DTCs), but a limited approach can be proposed when tumors are at an early stage and limited to a single lobe. The aim of this study was to analyze the pathologic and clinical aspects of a retrospective series of DTCs in an attempt to determine whether these features might prove useful for limiting the surgical strategy in selected cases. METHODS: From 2000 to 2005, a total of 2798 patients (637 males, 2161 females; mean age 44.6 years) underwent TT for papillary thyroid carcinoma in our department. The histologic features considered were size, histologic subtype and capsule of the tumor, its multifocality/bilaterality, infiltration of the thyroid capsule, and the presence of nodal metastases. RESULTS: Statistical analysis revealed that among tumors < or = 1 cm the presence of the tumor capsule, infiltration of the thyroid capsule, bilaterality, and the presence of node metastases were all significantly lower when the tumor size was < or = 0.5 cm (p < 0.0001). Furthermore, patients with bilateral carcinomas demonstrated a significantly higher presence of a tumor capsule (p = 0.012), infiltration of the thyroid capsule (p < 0.0001), and node metastases (p < 0.0001) and a higher incidence of the "tall-cells" variant (p < 0.0001) when compared to the unilateral population. CONCLUSIONS: Based on these data it is suggested that tumors < or = 1 cm cannot be considered a homogeneous class of DTCs. Nevertheless, in tumors < or = 0.5 cm the absence of a "tall-cells" variant and the absence of infiltration of the thyroid capsule might be useful for avoiding an unnecessary completion thyroidectomy after lobectomy.

Incidental thyroid carcinoma in a large series of consecutive patients operated on for benign thyroid disease.

BACKGROUND: The diagnosis of incidental thyroid carcinoma (ITC) in patients operated on for a benign disease is frequent. This study aims to determine both its clinical effect and the possibility of identifying this class of patients preoperatively. METHODS: A total of 998 consecutive patients (697 women and 301 men; mean age, 49.5 years) undergoing surgery for benign thyroid pathology in a single institution were studied. The mean time between first diagnosis of thyroid disease and operation was 9.0 years (range, 0-50 years). All patients underwent at least one ultrasonography before surgery, and 678 patients underwent fine-needle aspiration cytology. Patients with undetermined cytology or follicular nodules were excluded from the study. RESULTS: Histology revealed an ITC in 104 patients (10.4%): 99 had a papillary carcinoma. Mean and median diameters of ITC were 1.4 and 0.7 cm, respectively (range, 0.1-7.5 cm). In 43 patients, the tumour size was greater than 1 cm, whereas it exceeded 2 cm in 25 patients. Tumours were multicentric in 19.8% of the patients and occurred in 8.2% of patients with nodular toxic goiter, 8.7% of patients with toxic diffuse goiter and 13.8% of patients with multinodular goiter. DISCUSSION: The results confirm the high frequency of ITC. ITC was more frequent in euthyroid patients than in thyrotoxic patients (P < 0.03). Sex, age, thyroid volume and interval between diagnosis and surgery did not significantly influence its incidence. The majority of ITC was represented by microcarcinomas, but in approximately 25% of patients, the tumour size was greater than 2 cm. The role played by FNAC in excluding malignancies proved to be fairly inconclusive.

Ultrasonography estimated thyroid volume: a prospective study about its reliability.

Ultrasonography is supposed to provide a reliable preoperative estimate of thyroid volume. This prospective study compares the estimated thyroid volume (EV) to real volume (MV), obtained by measuring the excised gland after surgery. One hundred one patients undergoing total thyroidectomy were selected for the study. Indications for surgery were: multinodular goiter, diffuse toxic goiter (DTG), uninodular disease. In all cases, ultrasound was repeated 1 month after surgery to verify complete thyroid removal. EV was underestimated in 89 cases; it perfectly matched the MV in 5 and was overestimated in 7. Mean EV was 28.3 mL (range, 7-50) and mean MV 36.2 mL (range, 7-76); this difference was statistically significant (p < 0.0001). Patients were then divided in groups according to EV (< or > than 25 mL) and thyroid morphology. Highly significant differences were found between all groups (p < 0.0001) except the DTG population, where the difference was less significant (p < 0.042). The study demonstrates that a correct preoperative measurement of the thyroid gland is not achievable because the volume estimated by ultrasound is largely underestimated in comparison to the real volume of the excised gland. Nevertheless ultrasound is more reliable in DTG than in other thyroid diseases. Increasing the number of cases may help to verify a new mathematical model.

Results of video-assisted parathyroidectomy: single institution's six-year experience.

Endoscopic surgery for primary hyperparathyroidism (PHPT) started in 1996 with a parathyroidectomy performed by Michel Gagner. The technique we propose and have been using for 6 years is based on a unique central access and external retraction. From February 1997 to October 2003, 370 of 520 patients affected with PHPT (71%) underwent minimally invasive video-assisted parathyroidectomy (MIVAP). There were 72 men and 298 women, with a mean age of 55.8 years. Twenty-four patients (6.5%) of the 370 in this series underwent MIVAP under loco-regional anesthesia, and the others had general anesthesia. Eleven patients were lost to follow-up. Surgical cure of PHPT was achieved in 353 patients (98,3%), as confirmed by a median follow-up of 35.1 months (range: 2-82 months). Video-assisted exploration was successfully performed in 350 patients (94%). The mean operative time was 36.2 minutes. In 21 cases (5.6%) a concomitant procedure was performed: a thyroid lobectomy in 14 cases and a total thyroidectomy in 7 cases. Patients were generally discharged the day after surgery. Most of the patients (91%) were satisfied with the cosmetic result 6 or more months after the procedure. Complications developed in 14 cases: 10 cases (2.7%) of transient hypoparathyroidism 3 cases (0.8%) of definitive palsies of the recurrent nerve, and 1 case of postoperative bleeding (0.27%). After 6 years of experience, MIVAP appears to be as safe and curative as traditional surgery, with better cosmetic results and better postoperative outcome.

Extent of surgery in thyroglossal duct carcinoma: reflections on a series of eighteen cases.

The occurrence of carcinoma of the thyroglossal duct remnant (TDRCa) is reported to be less than 1%. We retrospectively analyzed 18 cases (14 females, 4 males; mean age, 38.17 years) of TDRCa who underwent surgery in our department, to evaluate the correct workup for diagnosis and treatment. Nine patients underwent a total thyroidectomy and a Sistrunk procedure (SP) whereas 8 underwent a completion total thyroidectomy after a postoperative diagnosis of TDRCa. One patient was diagnosed with TDRCa several years after total thyroidectomy for goiter. Postoperatively all patients were given radioiodide and levothyroxine therapy. Mean follow-up was 85 months. No patient died of tumor-related disease. Thyroglossal duct neoplasms were represented by papillary carcinoma in 16 cases; thyroid histology demonstrated papillary carcinoma in 6 cases (33.3%). Three patients demonstrated single regional node metastasis and only one of them demonstrated the presence of malignant thyroid disease. When clinical diagnosis of thyroglossal duct cyst is made, the workup should be completed by ultrasound (US) scan and fine-needle aspiration cytology (FNAC) in order to plan the correct surgery for a possible TDRCa. Total thyroidectomy should always be considered with SP to permit the correct treatment and follow-up in those patients. Long-term survival of patients with cTDRCa is excellent.