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.

PICC-PORT totally implantable vascular access device in breast cancer patients undergoing chemotherapy.

BACKGROUND AND OBJECTIVES: The increasing use of arm totally implantable vascular access devices for breast cancer patients who require chemotherapy has led to a greater risk of complications and failures and, in particular, to upper extremity deep vein thrombosis. This study aims to investigate the outcomes of the arm peripherally inserted central catheter-PORT technique in breast cancer patients. METHODS: The peripherally inserted central catheter-PORT technique is an evolution of the standard arm-totally implantable vascular access device implant based on guided ultrasound venous access in the proximal third of the upper limb with subsequent placement of the reservoir at the middle third of the arm. A prospective study was conducted on 418 adult female breast cancer patients undergoing chemotherapy. The primary study outcome was peripherally inserted central catheter-PORT failure. RESULTS: Median follow-up was 215 days. Complications occurred in 29 patients (6.9%) and failure resulting in removal of the device in 11 patients (2.6%). The main complication we observed was upper extremity deep vein thrombosis, 10 (2.4%); all patients were rescued by anticoagulant treatment without peripherally inserted central catheter-PORT removal. The main reason for removal was reservoir pocket infection: 4 (0.9%) with an infection rate of 0.012 per 1000 catheter days. Cumulative 1-year risk of failure was 3.6% (95% confidence interval, 1.3%-7.1%). With regard to the patients' characteristics, body mass index <22.5 was the only significant risk for failure (p = 0.027). CONCLUSION: The peripherally inserted central catheter-PORT is a safe vascular device for chemotherapy delivery that achieves similar clinical results as traditional long-term vascular access devices (peripherally inserted central catheter and arm totally implantable vascular access device, in particular) in breast cancer patients.

Diagnostic Value of Sural Nerve Biopsy: Retrospective Analysis of Clinical Cases From 1981 to 2017.

Nerve biopsy represents the conclusive step in the diagnostic work-up of peripheral neuropathies, and its diagnostic yield is still debated. The aim of this study is to consider the impact of nerve biopsy on reaching a useful diagnosis in different peripheral neuropathies and its changing over time. We retrospectively analyzed 1,179 sural nerve biopsies performed in the period 1981-2017 at Neurological Clinic of Policlinico San Martino (Genoa). We relied on medical records and collected both clinical and pathological data in a database. Biopsy provided univocal diagnoses in 53% of cases (with an increase over time), multiple diagnostic options in 14%, while diagnosis was undetermined in 33% (undetermined reports decreased during the years). In 57% of patients, the pre-biopsy suspicion was confirmed, while in 43% sural biopsy modified the clinical diagnosis. The highest yield was in axonal neuropathies (29% undetermined reports vs. 40% in demyelinating and 48% in mixed neuropathies). In 68% of patients with vasculitic neuropathy, this etiology was already suspected, whereas in 32% nerve biopsy modified the clinical diagnosis. During the years, the number of annually performed biopsies decreased significantly (p = 0.007), with an increase in the mean age of patients (p < 0.0001). The percentage of hereditary neuropathies had a significant decrease (p = 0.016), while the rate of vasculitic and chronic inflammatory neuropathies increased (p < 0.0001). This is the largest Italian study addressing the yield of sural nerve biopsy. During the years, we observed a progressive refinement of the indication of this procedure, which confirms its utility for interstitial neuropathies, particularly if non-systemic vasculitic neuropathy is suspected.

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.

ERBB1- and ERBB2-Positive Medullary Thyroid Carcinoma: A Case Report.

Medullary thyroid carcinomas (MTCs) are rare thyroid tumors occurring in both sporadic and hereditary forms, whose pathogenesis is related to RET proto-oncogene alterations. MTCs originate from parafollicular cells, which produce calcitonin that represents the biochemical activity of MTC. Total thyroidectomy is the main treatment for MTC and often cures patients with confined diseases. In the presence of metastasis, the therapeutic approach depends on the rate of disease progression. We report a case of a 54-year-old female with a single, incidentally discovered, thyroid nodule of 1 cm, classified as suspicious MTC after a stimulation test with intravenous (iv) calcium. After surgery, we examined the nodule using immunohistochemistry, immunofluorescence, and electron microscopy. In addition to calcitonin, we found that it expressed intracellular positivity for the tyrosine kinase RTK receptors ERBB1 and ERBB2. Consistently with MTC features, the ultrastructural examination of the tumor displayed heterogeneous spindle-shaped cells containing two groups of secretory granules. Because of the significant correlation found between high ERBB1/ERBB2 levels in MTCs and extrathyroidal growth, the detection of ERBB1 and ERBB2 expression suggests that the two oncoproteins may be involved in the tumor proliferative responses and/or in the differentiation of parafollicular C-cells. The biological, prognostic, and therapeutic significance of these patterns would merit further investigations.

[Modern approach to parathyroidectomy]. / Approccio chirurgico alla paratiroidectomia nel 2014: chirurgia tradizionale, mini-invasiva e tecniche "alternative"

Parathyroid surgery underwent significant innovations in the past 20 years, after both the improvement of the imaging techniques used to localize abnormal parathyroids (ultrasonography and MIBI scintiscan) and the possibility of the intraoperative PTH assay. These two tools, in experienced hands, can correctly differentiate uniglandular (more than 85% of the cases of primary hyperparathyroidism) from multiglandular disease. These technological improvements led to the possibility of limiting the surgical exploration to the single parathyroid responsible for the hyperparathyroidism in the majority of cases, avoiding unnecessary bilateral exploration that might increase both the morbidity of the surgery and its global costs. Furthermore, from a technical point of view, the philosophy of a minimally invasive surgery has also been applied to parathyroidectomy and several techniques have been described which are commonly considered minimally invasive. In this paper, the authors want to summarize their indications to perform a focused parathyroidectomy vs. a more traditional bilateral exploration, their definition of a minimally invasive parathyroidectomy and finally, it is given an overview of the techniques currently used for a parathyroidectomy.

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.

Metastases to the thyroid gland from renal cancer.

AIMS AND BACKGROUND: Metastases to the thyroid gland from renal cancer pose a challenge to physicians, due in part to the rarity of the phenomenon, the prolonged time interval between removal of the primary renal cancer and the appearance of metastases, the difficulty in diagnosis, and the uncertainty regarding long-term prognosis. We report our experience with diagnosis and management of patients affected by thyroid metastases from renal clear cell carcinoma. STUDY DESIGN: We report herein three clinical cases of thyroid metastases from renal clear cell carcinoma. We also present a review of the literature and examine common features of clinical presentation and management recommendations. RESULTS: Over the past 17 years, 918 patients underewent surgery for thyroid cancer in our institution. Histological examination demonstrated a thyroid secondary malignancy from kidney cancer in 3 cases. Two patients underwent total thyroidectomy, whereas in the third patient a palliative right lobectomy with homolateral latero-cervical lymphoadenectomy was performed. At a 5-year follow-up, only one patient survived and was disease-free. CONCLUSIONS: Thyroid metastases from renal clear cell carcinoma are a rare occurrence but should be taken into consideration in the differential diagnosis of a thyroid nodule. Preoperative diagnosis is often difficult. Nevertheless, an extensive diagnostic workup is recommended because the subsequent therapy must be tailored on the basis of the local extension of metastases. Surgical treatment of solitary thyroid metastases is recommended. However, patients with disseminated disease have a poor prognosis, and palliative care is the indicated recommendation. In these patients and in surgically untreatable patients, prolonged survival may be achieved by adjuvant medical therapy.

Pheochromocytoma during pregnancy treated by surgery. A case report and the review of the literature.

INTRODUCTION: Prenatal diagnosis of pheocromocytoma, although rare, is important as it allows a reduction in both maternal mortality and foetal loss. Pheocromocytoma operated on in the first trimester of pregnancy with survival of both patient and foetus is rare in literature. Our case was operated on with success after a correct and early diagnosis was obtained despite a chronic hypertension which existed long before pregnancy. Our case study well illustrates that a correct multidisciplinary approach involving endocrinologists, anesthesiologists, surgeons and gynecologists is fundamental for a positive outcome. CASE REPORT: The case of a white caucasian pregnant woman at 13th weeks of gestation with pheocromocytoma and severe and unstable hypertension that could not be pharmacologically controlled is described. Morphological diagnosis was safely obtained by Magnetic Resonance Imaging (MRI) without intravenous medium contrast agent. Pre-operative treatment consisted of therapy with alpha-blockers and rehydration. Adrenalectomy was performed through a laparotomy. Postoperative treatment consisted of rehydration and ephedrine continued until the fourth post-operative day. The post-operative period was uneventful and a new ultrasound (US) scan confirmed foetal vitality. The patient was discharged seven days after surgery. A live newborn was physiologically delivered after a nine-month pregnancy. CONCLUSION: A correct diagnosis in all pregnant women with severe hypertension particularly those not screened for secondary hypertension and a multidisciplinary management are mandatory to obtain optimal results and avoid deleterious effects at delivery.

Tako-tsubo cardiomyopathy as initial presentation of pheocromocytoma. A clinical case.

INTRODUCTION: Tako-tsubo cardiomyopathy is a rapidly reversible form of acute heart failure triggered by stressful events that occur more frequently in postmenopausal women. A central role is supposed to be played by catecholamines and the association with pheocromocytoma is rare. CASE PRESENTATION: We describe a patient admitted for abdominal pain and suffering of hypertension pharmacologically treated. During hospitalization the patient presented cephalea and precordial pain with nausea and profuse sweating. ECG showed ST elevation and deep negative T wave. Blood tests were moderately elevated. Echo-cardiography reported a left ventricular apex akynesia and hyperkynesia of the base while coronarography was negative. As hypertension persisted the suspicion of pheocromocytoma arose. Urinary and blood catecholamines were mildly elevated and echography and Magnetic Resonance revealed a left adrenal gland mass. The diagnosis of pheocromocytoma was thus confirmed Left laparoscopic adrenalectomy was performed after adequate stabilization and preoperative pharmacological preparation by hydration, a-and f-blockers. Intraoperatively blood pressure was controlled by nitroprussiate, rapid half life beta-blockers (esmolol cloridrate). Post-operative course was uneventful and arterial pressure returned to normal as well as catecholamines values. Patient was discharged on the 5th post-operative day Five months afterwards the patient had normal arterial pressure without anti-hypertensive therapy and symptom free. CONCLUSION: The case confirmed that tako-tsubo cardiomyopathy could be the first manifestation of tumors secreting catecholamines and that pheocromocytoma should be considered in patients with hypertension and acute stress-induced cardiomiopathy without evidence of acute coronary disease and with negative coronarography.

Anal metastasis from recurrent breast lobular carcinoma: a case report.

We report a case of isolated gastrointestinal metastasis from breast lobular carcinoma, which mimicked primary anal cancer. In July 2000, an 88-year-old woman presented with infiltrating lobular cancer (pT1/G2/N2). The patient received postoperative radiotherapy and hormonal therapy. Four years later, she presented with an anal polypoid lesion. The mass was removed for biopsy. Immunohistochemical staining suggested a breast origin. Radiotherapy was chosen for this patient, which resulted in complete regression of the lesion. The patient died 3 years after the first manifestation of gastrointestinal metastasis. According to the current literature, we consider the immunohistochemistry features that are essential to support the suspicion of gastrointestinal breast metastasis, and since we consider the gastrointestinal involvement as a sign of systemic disease, the therapy should be less aggressive and systemic.

Rectal hepatoid carcinoma with liver metastases in a patient affected by ulcerative colitis.

BACKGROUND: Hepatoid tumors (HTs) are rare extra-hepatic neoplasms with the histological features, biochemical profile and, sometimes, even clinical course of hepatocellular carcinoma. We present a case of rectal hepatoid adenocarcinoma with metachronous liver metastases. METHODS: Four months after total procto-colectomy for a rectal adenocarcinoma (Astler-Coller C2), a 42-year-old man with ulcerative colitis showed hypoechoic masses in the hepatic parenchyma by abdominal ultrasonography. Carcinoembryonic antigen was normal, but alpha-fetoprotein was 32,000 microg/L. Fine-needle biopsy revealed that liver masses were positive for hepatocellular carcinoma. The patient underwent left hepatectomy and alcoholisation of a small deep nodule in segment 8. RESULTS: Immunohistochemistry and albumin mRNA in situ hybridization suggested that the nodules were metastases of a HT. The patient was well during the first 6 months and refused any adjuvant chemotherapy. He died from liver failure 19 months after initial diagnosis. CONCLUSIONS: HT is a rare colon cancer. The preoperative diagnosis of this tumor requires a high degree of suspicion, the availability of a panel of immunohistochemical markers, and a certain amount of luck. The prognosis is poor despite an aggressive and multimodal therapeutic strategy. So far, none of the hypotheses proposed about the origin and the biology of these tumors is convincing.

Neurinoma originating from the recurrent nerve: report of a case.

Schwannoma is an uncommon, peripheral nerve sheath tumor of the neck that can occur either as an isolated lesion or multiple lesions. Multiple schwannomas, as seen in neurofibromatosis, occur less frequently. The rare occurrence and poorly defined symptoms of these tumors often make their preoperative diagnosis difficult. This report describes an unusual case of recurrent nerve Schwannoma which was successfully identified by color Doppler sonography.

The bowel cleansing for colonoscopy. A randomized trial comparing three methods.

INTRODUCTION: Colonoscopy is the procedure of choice for the detection and ablation of small lesions o the colonic mucosa. A proper bowel cleansing is mandatory. So far several regimens have been proposed but rather none has shown a clear-cut advantage over the others. Aim of this study was to compare cleansing ability and patients' compliance of three oral regimens. PATIENTS AND METHODS: Two-hundred and seventy-three patients were block randomised into three groups. Group A (92 patients) received tablets containing senna 12 mg and Magnesium Sulphate 15 mg the day before colonoscopy. Group B (98 patients) received a Polyethylene Glycol-based solution of two litres plus 4 tablets of Bisacodyl the day before the exam. Group C (83 patients) received Sodium Phosphate 40 milliliters the day before and the day of colonoscopy. Results of 265 patients were available for the analysis. Eight patients were excluded because inability to follow prescription. The lower incidence of constipation in group C was not significant. The other parameters were homogeneously distributed in the three groups. RESULTS: The 79 patients of the group C achieved a better bowel cleansing as compared with the 90 of group A (p = 0.0003) and the 96 of group B (p = 0.034). Constipated patients had a significantly better cleansing with Sodium Phosphate preparation compared with senna plus Magnesium Sulphate (p = 0.017), but not significantly better compared with Golytely solution. Compliance and rate of total colonoscopy performed were not statistically different in the three groups. CONCLUSIONS: Sodium Phosphate solution gave better bowel preparation, with the same compliance, than either senna or Polyethylene solution. In constipated patients Sodium Phosphate showed good efficacy resulting in good cleansing rates similar to that of non-constipated patients. The poor results obtained by Polyethylene were related to the little amount of solution taken even if associated to Bisacodyl.

DNA fragmentation and DNA repair synthesis induced in rat and human thyroid cells by chemicals carcinogenic to the rat thyroid.

Five chemicals that are known to induce in rats thyroid follicular-cell adenomas and carcinomas were assayed for their ability to induce DNA damage and DNA repair synthesis in primary cultures of human thyroid cells. Significant dose-dependent increases in the frequency of DNA single-strand breaks and alkali-labile sites, as measured by the same Comet assay, were obtained after a 20-h exposure to the following subtoxic concentrations of the five test compounds: methimazole from 2.5 to 10mM; nitrobenzene, potassium bromate, N,N'-diethylthiourea and ethylenethiourea from 1.25 to 5mM. Under the same experimental conditions, DNA repair synthesis, as evaluated by quantitative autoradiography, was present in potassium bromate-exposed thyroid cells from all the three donors and in those from two of three donors with either nitrobenzene or ethylenethiourea, but did not match the criteria for a positive response in thyroid cells from any of the donors with methimazole and N,N'-diethylthiourea. Consistently with their ability to induce thyroid tumors, all the five test compounds, administered p.o. in rats in a single dose corresponding to 1/2 LD50, induced a statistically significant degree of DNA fragmentation in the thyroid. These findings suggest that the five test compounds might be carcinogenic to thyroid in humans.

Gastrointestinal stromal tumors: clinical pathological review of a personal series.

The Authors report their experience on the management of gastrointestinal stromal tumors (GISTs). In addition to recent cases immediately diagnosed as GISTs, a pathological review of stored material from non-epithelial tumors of the gastrointestinal tract operated on over the past 20 years was performed. Twenty-three out of a total of 31 cases were shown to be positive for the immunophenotypic characteristics (CD117/CD34) of GISTs. Most cases (approximately 60%) were symptomatic, with hemorrhage being the most common presenting sign, followed by occlusion, pain and perforation. Asymptomatic cases were detected incidentally during procedures for other conditions. Diagnostic techniques (ultrasound, endoscopy, endoscopic ultrasound, X-ray, CT, MRI) allowed only the detection of wall (extraluminal) involvement. Apart from differentiating between benign and malignant, preoperative biopsy was seldom valuable. All cases were treated surgically, with intervention tailored to location and anatomical/surgical and anatomical/pathological features. Long-term follow-up was conducted in all patients and for most is still ongoing: five patients died from recurrent disease at varying intervals after surgery (from 17 to 102 months). Relationships between observed aggressiveness and risk were studied. Parameters that may prove useful for the early detection and appropriate management of these lesions are discussed.

[Inguinal hernia recurrence. Report of our personal experience]. / La recidiva erniaria. Osservazioni su casistica personale.

In our previous studies, we reasserted the concept regarding the fundamental role of the transversalis fascia in securing and maintaining restraint on the abdominal wall in correspondence with the "inguinal fissure", which is considered a hiatus and a weak point. The role played by the transversalis fascia was first proposed by Edoardo Bassini and later reaffirmed by other authors, surgeons and anatomists. This concept led to the belief that the procedures deemed effective in treating inguinal hernia were those capable of strengthening or substituting the transversalis fascia. In a recent study we compared the immediate and long-term results of three techniques: Bassini, Lichtenstein and preperitoneal prosthesis by inguinal way. A lower number of recurrences was noted in the latter as compared to the others. Based on the aforementioned points, the same verification was carried out regarding recurrent inguinal hernia. The results concerning the incidence of relapse were similar, proving once again the effectiveness of the preperitoneal prosthesis (2.5% vs 6.6% for Lichtenstein). We have also attempted to identify the factors which were considered possible causes of recurrence in the previous cases we examined, allowing us to reach useful conclusions in the prevention of hernia recurrence.