Laparoscopic vs Open Treatment for Gastric and Non-Gastric Gastrointestinal Stromal Tumors: a Two-Center Experience.

We retrospectively reviewed the medical records of 109 patients who underwent curative laparoscopic or open resection for different types of gastrointestinal stromal tumors (GIST). Only primary GIST patients who did not receive preoperative chemotherapy or oral imatinib treatment were included in the analysis. We divided the patients into 2 groups according to the surgical approach:a laparoscopic group (LAP) and a laparotomic group (OPEN). Our aim was to confirm the feasibility and safety of laparoscopic surgery for GISTs that differed in size and location, and to assess its long-term oncologic outcome in terms of overall survival (OS) and disease-free survival (DFS). Furthermore, we performed a surgical short-term outcome analysis. The two groups did not differ with respect to age at operation, gender, BMI or comorbidities. Even the NIH and AFIP risk classifications were not significantly different between the two groups. Furthermore, in our analysis, there was no significant difference in mean tumor size or location between the two groups. Wedge resection was the most frequently performed procedure. The conversion rate was 7.8%. The operative time was 194.75 (60- 350) min for the open group and 181.70 (57-480) min for the laparoscopic group. Our data clearly indicated that the long-term oncologic outcome and DFS of laparoscopic resection were not inferior to those of traditional open operations and laparoscopic resection was still feasible in cases with large tumors: the median size of the tumor was 4.5 cm (3-25) and the tumor was larger than 4.5 cm in 47.7% of the cases in the LAP group. With regard to short-term outcomes, our study demonstrated that the LAP group had fewer complications, faster gastrointestinal recovery, reduced use of analgesic drugs and shorter postoperative hospital stay (each p<0.05). In conclusion, our experience confirms that GISTs are very uncommon cancers for which the prognosis is closely related to size, localization and class of risk. In light of our clinical data, laparoscopic resection for gastric and non-gastric GISTs is a safe, feasible and oncologically correct procedure. The most important advantage of this technique is that it ensures a better postoperative outcome compared with open surgery, without worsening the prognosis.

Conventional Total Thyroidectomy Using a Novel Single Retractor: Technical Note for Apollo®.

Despite the increasingly innovative techniques developed in thyroid surgery to offer patients minimally invasive and scarless interventions, conventional open procedures still account for most of the interventions performed in this field. The surgical incision length has been significantly reduced, from 6-9 cm to 3 cm, and therefore patients perceive the scar to be highly acceptable. In this technical note, we present the use of a new single retractor (APOLLO®; AFS MEDICAL GmbH, Teesdorf, Austria) for conventional open thyroidectomies with intraoperative neuromonitoring. This device offers several advantages: a) better exposure of the surgical field; b) less traction on skin flaps and neck muscles; and c) protection of the skin edges from the heat generated by energy-based devices/coagulating instruments, with consequent better healing.

Past and Future of the Molecular Characterization of the T Cell Repertoire: Some Highlights of Eli Sercarz's Contributions.

The contribution of Eli E. Sercarz to immunology and immunopathology has been remarkable and achieved many milestones in the understanding of the processes of the mechanisms fine-tuning immune responses. A part of his work was dedicated to the study of the deep complexity of the lymphocyte T cell repertoire and its importance during the physiologic development and disease, such as clonal heterogeneity of T cell responses. Starting from these studies, under his mentoring, we had the opportunity to implement the spectratyping method and apply it to human and experimental autoimmune diseases, obtaining intriguing results. The open question of this brief review is the possible role of this fine and complex technique, the immunoscope analysis, in the era of the big data and omics.

Drawbacks of neural monitoring troubleshooting algorithms in transoral endoscopic thyroidectomy.

INTRODUCTION: The application of intraoperative neural monitoring (IONM) trouble-shooting algorithms procedures in transoral endoscopic thyroidectomy vestibular approach (TOETVA) was investigated. METHODS: Loss of signal (LOS) is defined as a loss of the primary electromyographic (EMG) normal biphasic waveform with reduced amplitude response to less than 100µV with a stimulation level intensity of 1-2mA. A systematic review of the IONM system at LOS was covered methodically: (i) correct endotracheal tube verification, (ii) stimulation of the recurrent laryngeal nerve (RLN) at entry point, (iii) ipsilateral or contralateral vagal nerve (VN) stimulation, and (iv) laryngeal twitch (LT). RESULTS: The function of 223 nerves at risk (NAR) was recorded with IONM. Twenty-seven (12%) NAR experienced a suspected LOS. LT could not be appreciated. In 15/27 (55%) cases, the application of the IONM trouble-shooting algorithm revealed upward displacement of the EMG tube (all orotracheal intubations). In 9 (4%) NAR, VN stimulation was not accomplished. In detail, there were n.5 left and n. 4 right VNs. Two VNs were ipsilateral, and 7 VNs contralateral. For EMG tube displacement, because the oral/nasal area is included in the aseptic field, it is less possible to re-check by the laryngoscope or fiberscope. CONCLUSIONS: A limit for applying the IONM trouble-shooting algorithm to TOETVA is determined by (a) inability to appreciate the LT, (b) difficulty in stimulating the ipsilateral and contralateral VN, and (c) remodeling EMG endotracheal tube position. A modified IONM trouble-shooting algorithm for TOETVA is proposed.

Use of Vivostat® Autologous Fibrin Sealant in Thyroid Surgery.

INTRODUCTION: Post-thyroidectomy hemorrhage is a rare but potentially life-threatening and unpredictable complication of thyroid surgery. Therefore, intraoperative bleeding control and hemostasis are crucial. However, the most efficient, cost-effective, and standardized way to achieve this is not clear. This study aimed to evaluate the outcome of total thyroidectomy (TT) and partial thyroidectomy (PT) performed using the Vivostat® hemostatic system (Vivostat A/S, Lillerød, Denmark). METHODS: Patients underwent TT and PT for benign and malignant diseases (multinodular goiter, Graves' disease, differentiated thyroid carcinoma). The primary endpoint was 1st-day postoperative drain output and bleeding that required reintervention. Secondary endpoints included surgery duration and postsurgical complications (vocal fold palsy, hypocalcemia, seroma, wound infection). RESULTS: Between October 2020 and December 2020, 56 patients were enrolled; 69.6% female; mean age 49.5 years. The mean 24-h drain output was 40 ml. No redo surgery was needed. Seroma was present in 5.3% of cases; no permanent vocal palsy or hypocalcemia was observed. CONCLUSION: This study shows that the Vivostat® system is both safe and effective for hemostasis during thyroid surgery.

C2 Xplore® for Intermittent and Continuous Laryngeal Nerve Monitoring: Technical Note.

Due to the direct anatomical relationship between the recurrent laryngeal nerve (RLN) and the thyroid gland, the function and anatomical integrity of the RLN is fundamentally at risk in every thyroid operation. While a RLN morbidity rate of less than 5% is achieved in specialized clinics, the morbidity rates are significantly higher in non-specialized centers. Thus, the aim is to reduce the complication rate by establishing standardized interventions. Exact knowledge of the anatomical course of the RLN, the nerve-sparing dissection technique and the supportive use of intraoperative neuro-monitoring (IONM) to identify anatomical variations are the basis for nerve-sparing surgery. We tested the new C2 Xplore® system (inomed Medizintechnik GmbH, Emmendingen, Germany) as a tool for performing intermittent and continuous laryngeal nerve monitoring during thyroid surgery. The C2 Xplore® helps to enhance surgeon-IONM interaction, and provides comprehensive digital EMG documentation with EMG quantification. EMG artifacts are removed. Image quality and EMG feedback are highly acceptable for intraoperative monitoring. The C2 Xplore® system does not have a deleterious impact on the proper function of other surgical instruments. C2 Xplore® is effective for intraoperative monitoring, optimizing RLN dissection, and supporting surgical deliberations, and for forensic use and research. A step-by-step C2 Xplore® procedure is described.

Energy-Based Devices Affect the Aesthetic Outcome of Cervical Thyroidectomy and Parathyroidectomy. A Retrospective Study.

INTRODUCTION: Thyroid and parathyroid diseases are very common. Most of these cases are in women and may be amenable to surgery. The patient's perception that these are not life-threatening diseases leads them to expect an excellent aesthetic result, since the surgical incision area is clearly visible. OBJECTIVE: To evaluate different scarring outcomes using three different energy-based devices (Harmonic Focus®, Johnson & Johnson, New Brunswick, NJ; Thunderbeat Open Fine Jaw®, Olympus Medical, Tokyo, Japan; LigaSure Small Jaw®, Medtronic, Dublin, Ireland) and to determine the impact of post-thyroidectomy/parathyroidectomy scars on the patient's quality of life. METHODS: One hundred female patients who underwent thyroidectomy or parathyroidectomy between September 2017 and September 2019 at the Endocrine and Minimally Invasive Surgery Department of Messina University Hospital were recruited. A retrospective analysis assessed the thickness of the cervical scar via ultrasound imaging, and the patient's degree of satisfaction through the Patient and Observer Scar Assessment Scale (POSAS) and the Body Dysmorphic Disorder Questionnaire (BDDQ). RESULTS: The patients were divided into three groups according to the energy-device used: group A (LigaSure SJ (n=38), group B (Harmonic F, n=32) and group C (Thunderbeat OFJ, n=30). The three groups were homogeneous with respect to number of patients, age and surgical procedures. The best aesthetic result, which correlated with the lowest scar thickness, was observed in group A; these patients were more satisfied than those in the other two groups. Moreover, correlations between scar thickness and quantitative variables (such as age or BMI) were not found in any of the groups. CONCLUSIONS: Based on the data collected and our experience, the LigaSure Small Jaw® (Medtronic) seems to offer the best aesthetic outcome in patients who undergo transverse cervicotomy for thyroid and parathyroid diseases. However, further prospective studies involving a greater number of cases are needed.

Status of Alternative Approaches for Thyroidectomy: Is There Any Evidence to Substitute in Place of Conventional Surgery?

Over the past 20 years, various alternative cervical minimally invasive (partly endoscopically assisted) and extracervical endoscopic (partly robot-assisted) approaches have been developed. All of these alternative access methods aim at optimizing the cosmetic results. In principle, the indication for the use of alternative access procedures does not differ from that for conventional surgery. Nonetheless, appropriate experience in traditional thyroid surgery and suitable patient selection, taking into account thyroid volumes and the underlying pathology, are important prerequisites. General contraindications for an alternative approach are large goiter with symptoms of compression, advanced thyroid carcinoma, recurrent interventions or previous radiotherapy in the operating area. The alternative surgical approaches to the thyroid can be divided into cervical minimally invasive, extracervical endoscopic (robot-assisted) and transoral procedures. This article gives an overview of the clinically used alternative approaches in thyroid surgery. The desire for an optimal cosmetic result should not be prioritized over patient safety. Only a few alternative procedures (minimally invasive video-assisted thyroidectomy, transaxillary robot-assisted thyroidectomy) can currently be viewed as a useful addition to conventional thyroid surgery, even when in responsible, experienced hands for a selected group of patients.

An Improved Recurrent Laryngeal Nerve-Monitoring Device: Technical Note for Nim Vital™.

A new device for monitoring the laryngeal nerves during thyroid surgery has been developed. NIM Vital™ (Medtronic Xomed, Inc., Jacksonville, FL, USA) incorporates (a) a new wireless design, (b) NIM NerveTrendTM (Medtronic Xomed) EMG reporting, (c) intelligent noise-reduction technology that suppresses artifacts, (d) smart troubleshooting pop-up alerts, and (e) NIM Nervassure ™ (Medtronic Xomed) for continuous monitoring. This device offers enhanced stability and flexibility for both intermittent and continuous laryngeal nerve monitoring. The new NIM NerveTrend ™ EMG reporting makes it possible to track the recurrent laryngeal nerve condition throughout a procedure, even when using intermittent nerve monitoring. During both continuous and intermittent monitoring, green, yellow and red status bars provide visual information and associated tones provide audible cues, making it easy to monitor nerve function and interpret EMG trends. This new tool for laryngeal nerve monitoring has the potential to augment nerve dissection during surgery. Measurements of long-term outcome are needed to establish their efficacy.

The Laboratory Role in anti-TNF Biological Therapy Era.

Along years, the advent of biological therapy widely modified treatment of rheumatic diseases and other disorders. However, many agents may elicit in anti-drug antibodies (ADAbs) upon consecutive infusions, with a loss of response. For the right strategy of a personalized medicine, the therapeutic monitoring of TNF-α inhibitors and ADAbs represents an important effort in diagnostic-therapeutic pathway, to improve overall patient management and favoring an appropriate clinical approach. A raising number of diagnostic tests have been designed to elucidate the efficacy and/or safety of a specific drug or class of drugs for a targeted patient's group. Our paper reviewed the current understanding of the immunogenicity of biological drugs employed in the treatment of inflammatory diseases underlying the laboratory role.

Strategies for superior thyroid pole dissection in transoral thyroidectomy: a video operative guide.

BACKGROUND: The dissection of the superior thyroid gland pole is challenging when using the in TransOral Endoscopic Thyroidectomy Vestibular Approach (TOETVA) due to (a) the cranio-caudal approach, (b) cranial-caudal view, and (c) the restriction of maneuverability inside the narrow neck air pocket. METHODS: In this paper and operative video guide, a series of TOETVA's tips and tricks are presented with an emphasis on the strategies for a safe approach to the superior thyroid gland pole structures. RESULTS: Management of the upper thyroid pole structures includes: (a) use of a 5 mm/30°-45° endoscope; (b) retraction ports up to the limit of the lower jaw edge; (c) lateral retraction of 1/3 of the cranial strap muscles; (d) isthmectomy; (e) cutting the sternothyroid muscle cranially for 1 cm; (f) retraction of the thyroid upwards and laterally; (g) monitoring the external branch of the superior laryngeal nerve, and (h) sealing individual vessel branches. CONCLUSION: Access to the superior thyroid pole space through the TOETVA approach presents some challenges, particularly when accessing thyroid vessels or nodules located or displaced more cranially. Strategies that enhance a critical view of the superior thyroid gland structures can protect them from damage and have the potential to improve the safety of the TOETVA and decrease potential conversion rates.

How to Avoid and Manage Mental Nerve Injury in Transoral Thyroidectomy.

Transoral endoscopic thyroidectomy by vestibular approach (TOETVA) represents an innovative and scarless technique for thyroid surgery. The procedure is conducted via a three-port technique at the oral vestibule using a 10mm port for the 30° endoscope and two additional 5mm ports for the dissecting and coagulating instruments. Patients meeting the following criteria can be considered as candidates for TOETVA: (a) an ultrasonographically (US) estimated thyroid diameter =10cm; (b) US-estimated gland volume =45mL; (c) nodule size =50mm; (d) presence of a benign tumor, such as a thyroid cyst or a single- or multinodular goiter; (e) Bethesda 3 and/or 4 categories, and (f) papillary microcar-cinoma without the evidence of metastasis. Beyond the classic complications of thyroid surgery, namely cervical hematoma, recurrent laryngeal nerve injury and hypoparathyroidism, novel consequences can occur as mental nerve (MN) injury. In this paper, leading experts in the field report on their current clinical experience with the TOETVA approach for thyroid gland surgery, with emphasis given to tips and tricks to avoid and manage MN injury.

New Paradigms for Neural Monitoring in Thyroid Surgery.

Intraoperative neuromonitoring (IONM) in thyroid gland surgery provides real-time feedback to the endocrine surgeon regarding the electrophysiological consequences of surgical manipulation of the laryngeal nerves. The goal of monitoring modalities is to detect surgical or physiological insults to the recurrent laryngeal nerve (RLN) while they are still reversible or, in cases where prevention is not an option, to minimize the damage done to these structures during thyroidectomy. In recent decades, monitoring of the RLN has become a fundamental part of endocrine surgery. IONM is a feasible procedure in both open and endoscopic, robotic thyroidectomy. Experts in IONM have organized a working group of general, endocrine, head and neck ENT surgeons and endocrinologists (International Neural Monitoring Study Group; INMSG) to develop standards for practicing this technique in endoscopic and robotic thyroidectomy. This paper presents recent clinical and research experience with intraoperative neural monitoring for thyroid gland surgery.

Bacterial Colonization on Endoscopic Materials and Surgical Field Without Infections After Transoral Endoscopic Thyroidectomy.

INTRODUCTION: Our aim was to determine whether bacteria contamination occurred within the surgical field or on endoscopic equipment during surgery using the transoral endoscopic thyroidectomy vestibular approach (TOETVA). MATERIALS AND METHODS: Participants were recruited from patients planned for TOETVA between May 2017 and December 2019. Bacterial samples were taken before and at the conclusion of the TOETVA procedure. The preoperative and postoperative samples were taken from the endoscopic materials and inferior oral vestibulum using a sterile flocked swab. RESULTS: The study resulted in 480 samples (80 TOETVAs). No vestibular, port site, or neck infections occurred in any of the patients. Three (3.7%) out of 80 patients developed postoperative fever. Our results show different microbial communities during TOETVA. The most prevalent species detected were S treptococcus species. Multivariate logistic regression analyses revealed that the degree of contamination depended on the sampling site (inferior vestibulum > equipment) ( P =0.03). In addition, the abundance of bacteria was affected by operative time ( P =0.013). There were no significant differences observed in isolation frequencies of bacteria in malignancy ( P =0.34). CONCLUSIONS: TOETVA surgery is categorized as a "clean-contaminated" operation. A swab identified the common colonizers of oral microbiota on the endoscopic equipment and within the surgical field.

Relationships between serum levels of vitamins and papillary thyroid cancer: a single center case-control study.

Background: Vitamins are involved in various human physiological and biochemical mechanisms due to their antioxidant properties and their ability to enhance the immune response. Deficiency of some serum vitamins has been reported to be associated with an increased risk of developing cancer, including thyroid cancer. However, medical literature dealing with cholecalciferol supplementation was not able to show the potential of this intervention in cancer prevention. The aim of this paper is to highlight the association between lower serum vitamins levels and papillary thyroid cancer occurrence. Methods: This case-control study was conducted between September 2018 and October 2019. Cases were defined as patients with histologically diagnosed papillary thyroid cancer who underwent thyroidectomy were retrospectively recruited and serum levels of various vitamins were assessed by examining their relationships with clinical, pathological and molecular data (n=51). Controls matched on sex and thyroid surgery were randomly selected from the same population (n=49). Results: In this study, serum concentrations of vitamins A and E in neoplastic patients were significantly lower than in controls (1.40 vs. 1.78, P<0.003 and 23.9 vs. 29.1, P<0.003, respectively). Serum concentrations of vitamin D and methylmalonic acid were borderline significantly low (15.6 vs. 17.9, P=0.06 and 100.3 vs. 110.4, P=0.055, respectively), while homocysteine was statistically similar in the two groups. Furthermore, serum vitamin levels were compared with the pathological characteristics of cancer patients, and vitamin D concentrations were significantly lower in BRAF-positive than in BRAF-negative neoplastic patients (8.2 vs. 16.0, P=0.021). On the other hand, no significant differences were observed in the correlation between serum levels of vitamins and other pathological characteristics, in particular with regard to lymph node metastases. Conclusions: In conclusion, albeit with the analysis of a limited sample, this study highlighted the phenomenon that deficiencies in vitamins A and E can be associated with a higher frequency of occurrence of papillary thyroid cancer.

Subcutaneous implantation of oncocytic thyroid cell aggregates nine years later from thyroidectomy. A case report.

INTRODUCTION AND IMPORTANCE: Subcutaneous implantation of thyroid tissue is a rare clinical condition that involves the head and neck region and occurs after surgery, diagnostic procedures or cervical trauma. CASE PRESENTATION: A 90-year old woman with two skin nodules on her thyroidectomy scar was hospitalized and treated by two surgical excisions. Histologically, these lesions were two aggregates of cutaneous oncocytic thyroid cells. In the patient's clinical history there was a total thyroidectomy for multinodular goiter, performed 9 years previously and at which a well-encapsulated subcapsular oncocytic adenoma of the left lobe was also incidentally discovered. At 12 months of follow-up, the patient is showed well and her wounds healed. CLINICAL DISCUSSION: Subcutaneous colonization or seeding of thyroid tissue is a rare occurrence reported in the literature for both benign and malignant pathologies; among the malignant ones, the implantation of follicular carcinoma cells is the most frequent. Only in one previous case, to our knowledge, subcutaneous colonization originating from oncocytic thyroid (or Hurthle) cell neoplasms has been described. CONCLUSION: We report an unusual case of double subcutaneous implantation of oncocytic thyroid cells on the cervical scar of an elderly woman, nine years after total thyroidectomy.

Granular cell tumor of the trachea mimicking an infiltrating thyroid cancer. A case report.

INTRODUCTION AND IMPORTANCE: Granular cell tumor (GCT) is a rare neurogenic neoplasm originating from Schwann cells that predominantly affects women and can involve skin and mucousae. In the respiratory system it most frequently involves bronchi and larynx, while it is rare in the trachea. CASE PRESENTATION: A 26-year old female smoker was hospitalized for a suspected hypoechoic nodule in the right thyroid lobe closely adherent to the trachea. At preoperative computed tomography tracheal lumen was totally clear. The patient underwent a total thyroidectomy with lymph node dissection and tracheal shaving. The postoperative course was complicated by an extensive subcutaneous bilatreral emphysema associated with respiratory distress appeared on the fifth day. Bronchoscopy revealed a right anterolateral subcentimeter lesion near the second tracheal ring. Histologically, the diagnosis was consistent with a tracheal GCT developing into the thyroid parenchyma. The patient was discharged on the twentieth postoperative day. At the follow-up bronchoscopy the lesion was completely healed and at the last 12 month follow-up the patient is doing well. CLINICAL DISCUSSION: Tracheal tumors are uncommon neoplasms accounting for about 2% of the total respiratory tree tumors. In literature we found <50 papers concerning tracheal GCT and in almost all of the cases patients complained about respiratory symptoms. CONCLUSION: We report here a rare case of benign GCT of the trachea with extraluminal development, in a young patient who did not complain about preoperative respiratory symptoms, presented on ultrasound as a thyroid nodule with suspected cytology.

Unilateral Surgery for Medullary Thyroid Carcinoma: Seeking for Clinical Practice Guidelines.

Optimized preoperative diagnostic tools with calcitonin tests, ultrasound features, functional imaging modalities, and genetic testing to detect hereditary forms have led to an increased rate of earlier diagnosis and surgery for medullary thyroid cancer (MTC). This helps to adapt the primary surgery to the tumor stage and avoid surgical overtreatment for localized tumor growth, i.e., deviating from the regularly recommended thyroidectomy with bilateral central lymph node dissection in favor of a limited unilateral approach. To limit primary surgical therapy, it is crucial that the MTC is clinically unifocal, sporadic, and confined to the thyroid, and that calcitonin levels indicate biochemical recovery after surgery. The main requirement for such a limited approach is the availability of frozen section studies that reliably indicate (i) R0 resection of the MTC, (ii) absence of infiltration of the organ capsule, (iii) lack of desmoplasia (i.e., evidence of the metastatic potential of the MTC), (iiii) absence of contralateral disease or precancerous lesions. Informed consent is mandatory from the patient, who has been fully informed of the advantages, disadvantages, and potential risks of not undergoing the "classic" surgical procedure. The aim of this article is to review the guidelines for the management of early-stage MTC.

Optimal Monitoring Technology for Pediatric Thyroidectomy.

This retrospective study aimed to describe, firstly, characteristics and outcomes of the intraoperative neural monitoring technology in the pediatric population, and secondarily the recurrent laryngeal nerve complication rate. Thirty-seven patients (age <18 years) operated on from 2015 to 2021 by conventional open thyroid surgery were included. Twenty-four (64.9%) total thyroidectomies and 13 (35.1%) lobectomies were performed. Seven central and six lateral lymph node dissections completed 13 bilateral procedures. Histology showed malignancy in 45.9% of the cases. The differences between the electromyographic profiles of endotracheal tubes or electrodes for continuous monitoring were not statistically significant. In our series of young patients, both adhesive (even in 4- or 5-year-olds) and embedded endotracheal tubes were used, while in patients 3 years old or younger, the use of a more invasive detection method with transcartilage placement recording electrodes was required. Overall, out of 61 total at-risk nerves, 5 (8.2%) recurrent laryngeal nerves were injured with consequent intraoperative loss of the signal; however, all these lesions were transient, restoring their normal functionality within 4 months from surgical procedure. To our knowledge, this is the first study of intraoperative neural monitoring management in a cohort of Italian pediatric patients.

Metastatic thyroid carcinoma mimicking as a primary neoplasia of the kidney: A case report.

The unfavorable behavior of primary thyroid carcinoma (PTC) has been revealed by the hematogenous distant metastases in ~20-25% of cases with frequent localizations in lungs and bones, but infrequently in kidney. A 69-year-old male patient was admitted to Department of Human Pathology in Adulthood and Childhood 'G. Barresi', University Hospital G. Martino, (Messina, Italy) for an incidentally detected parenchymal mass involving the right kidney. A partial nephrectomy was done; at the post-surgical examination, a large nodular grayish mass was documented. Microscopically, a diffuse proliferation with solid/follicular pattern with some colloid-filled spaces was appreciable. An intense immunopositivity was revealed for thyroglobulin, thyroid transcription factor-1 (TTF-1), paired-box gene 8 (PAX-8) and cytokeratin 7, while CD10 and renal cell carcinoma marker were negative. A diagnosis of the metastatic thyroid follicular carcinoma localized in the kidney was made. At ultrasound examination, a hyperechoic mass extending from the left thyroid lobe to the isthmus, to which TIR4 diagnostic category according to the Italian reporting system for thyroid cytology was attributed. After thyroid surgical procedure, the final diagnosis of primitive differentiated follicular thyroid carcinoma with foci of poorly differentiated component was made.