Completion thyroidectomy for differentiated thyroid cancer (results in a consecutive series of 68 patients).

INTRODUCTION: Completion thyroidectomy plays an important role in the management of patients with thyroid cancer. The aim of this study is to determine the indications for and timing of a second surgery, as well as surgical complications. MATERIAL AND METHODS: Operative reports, as well as the hospital and outpatient records of 686 consecutive patients, who had undergone surgery for differentiated thyroid cancer, were reviewed. Among these, 68 (9,9%) patient records of a completion thyroidectomy for cancer were analyzed. RESULTS: The mean time interval between the first and second operation was 3.6 months (range: 1-9). Post-operative complications occurred in 9 patients (12,9%). Among three patients with inferior laryngeal nerve palsy (4,4%) one had definitive palsy (1.4%). Hypoparathyroidism occurred in 6 patients (8,8%) being permanent in one of them (1.4%). No significant difference either for definitive inferior laryngeal nerve lesions (p = 0.9) or for definitive hypocalcemia (p = 1) was found between the groups of patients who had a completion thyroidectomy and those who had a one-step total thyroidectomy for cancer. CONCLUSIONS: Correct indications for re-operation, total lobectomy as a primary surgical procedure as well as lateral access to the residual thyroid gland could all reduce the high risks of complications related to this kind of surgery.

[Lymphadenectomy in differentiated thyroid carcinoma]. / La linfectomia nel carcinoma differenziato della tiroide.

Differentiated thyroid carcinoma accounts for 90% of all thyroid cancers and occurs as papillary carcinoma in 90% of cases. It was shown as this is characterized by an excellent long-term prognosis, although in follow-up long series, were described recurrence rates up to 35%. Although in the past has not been attributed prognostic significance to the lymph nodes, in the last decade has shown how these can affect the rate of locoregional recurrence of differentiated thyroid carcinoma. This renewed interest in lymph node metastatic disease has prompted a shift in surgical treatments more aggressive, with a view to achieving a low incidence of locoregional recurrence. Analyzing the more recent guidelines formulated at the international level, we can highlight how we gradually consolidated the role of prophylactic central compartment lymphadenectomy in the surgical treatment of patients with differentiated thyroid carcinoma. The aim of this treatment, in fact, is not only to reduce the mortality of patients, but to obtain an adequate staging, facilitate radiotherapy treatment, obtain undetectable thyroglobulin levels, avoiding the need for repeated reiterventi, made more simple follow-up. All these objectives can be achieved by careful surgery. Total thyroidectomy associated with prophylactic lymphadenectomy of the central compartment was found to achieve these objectives, although in the absence of data from randomized trials, its role remains controversial.

Immunoreactive insulin-like growth factor I (IGF-I) and IGF-I-binding protein content in human thyroid tissue.

We measured immunoreactive insulin-like growth factor I (IGF-I) in extracts of normal and nodular thyroid tissue obtained at surgery from patients with nontoxic goiter. The nodular tissues contained a higher concentration [mean, 279.0 +/- 69.7 (+/- SE) mU/g] than paired normal tissues (115.5 +/- 17.9 mU/g; P = 0.024; n = 12); a difference was evident in all but one patient. Sephadex G-50 gel filtration of tissue extracts revealed two immunoreactive peaks, the first in the void volume of the column, and the second in the elution volume of authentic IGF-I. The first peak was identified as IGF-I-binding protein by sodium dodecyl sulfate-polyacrylamide gel electrophoresis after cross-linking with iodinated IGF-I. Isolated thyroid cell membranes contained high affinity IGF-I-binding sites of similar affinity and numbers in both normal and nodular thyroid tissue. The IGF-I content of six thyroid cancer extracts was higher than that of normal thyroid tissue, but the IGF-I content of thyroid tissue from six patients with Graves' disease and five patients with Hashimoto's thyroiditis was similar to that in normal thyroid tissue. These data suggest that the stimulatory effect of TSH on thyroid cell proliferation could be mediated through IGF-I action and suggest that an increase in IGF-I production could sustain the goitrogenic process.

Toxic thyroid adenoma: absence of DNA mutations of the TSH receptor and Gs alpha.

DNA point mutations of the TSH receptor and of the alpha subunit of the stimulatory GTP-binding protein (Gs alpha) have been suggested as major causes of hyperfunctioning thyroid adenomas. However, significant differences in the prevalence of these mutations (from 0.3 to 84%) have been found in different populations. The present study was designed to evaluate further the presence of mutations in discrete fragments of cDNA encoding critical regions of the TSH receptor and of the Gs alpha involved in signal transduction and cAMP production. Genomic DNA extracted from 15 thyroid adenomas and surrounding quiescent thyroid tissues was used as a template to amplify four DNA fragments of TSH receptor and one DNA fragment of Gs alpha. TSH receptor and Gs alpha DNAs were analyzed by a number of techniques. We did not detect any mutations (new or previously described) in our patients. These results confirm that the causes of solitary toxic adenomas are protean, and only some of them may be somatic DNA point mutations. Since the clinical features of solitary toxic adenoma are homogeneous, it could be important to establish the specific molecular defect underlying each case, in order to follow up the patients and to assess their clinical evolution.

Doppler evaluation of intrathyroid arterial resistances during preoperative treatment with Lugol's iodide solution in patients with diffuse toxic goiter.

BACKGROUND: The aim of this study was to ascertain the utility of echo-Doppler in the analysis of the low resistance thyroid vascularization in diffuse toxic goiter (DTG), and the effectiveness of Lugol's solution (iodine-iodide solution) in patients undergoing thyroidectomy. STUDY DESIGN: Twenty-five patients with diffuse toxic goiter were evaluated and compared with 19 normal subjects. Patients were treated with increasing doses of Lugol's solution 2% for 7 days until a total dose of 75 mg of iodine was given. Echo-Doppler was performed on the last day of treatment, 12 hours before operation. RESULTS: Mean basal Doppler Resistance Index (RI) of intrathyroid arterial flow was significantly lower in patients with DTG compared with normal controls (0.4718 +/- 0.0625 versus 0.55 +/- 0.05, range: 0.472 to 0.643; p = 0.008). Moreover, the RI was significantly increased in patients with DTG after Lugol's solution (+16.46 +/- 10.22%, range: -2.59 to +39.97; p< 0.0005). CONCLUSIONS: Echo-Doppler RI allowed documenting lower arterial resistances within the thyroid gland in patients with DTG. The use of preoperative Lugol's solution therapy induces normalization of those changes for safer thyroidectomy.

A new technique for intraoperative blood recovery in the cancer patient.

Homologous blood transfusion in the cancer patient is dangerous because of an apparent immunodepressive action. Even a program of pre-deposit and isovolemic hemodilution, for reasons of immediacy and patient conditions, is often not feasible. Likewise, the intraoperative recovery of blood, although used by some, does not prevent the possible reinfusion of suspended neoplastic cells. A system that eliminates tumor cells could enable the recovery of blood in cancer patients in non-septic operative sites. A system that seems to correspond to these requisites has been set up by inserting two filters for the elimination of leucocytes from erythrocyte concentrates into a cell separator that is normally used in clinical practice. Laboratory studies, using immunohistochemical identification of tumor cells cultivated in vitro, have demonstrated the absence of contaminating cells in blood available for reinfusion.

Combined use of urinary UGP and serum CA 125 in the diagnosis of gynecological cancers.

UGP, the beta-core fragment of human chorionic gonadotropin has been proposed as a tumor marker for gynecological malignancies. This fragment may be detected in a single morning-specimen of urine using an enzyme immunoassay. In this study, the diagnostic usefulness of urine UGP and serum CA 125 measurement for gynecological neoplasias (149 cases) was evaluated using a control group of patients with benign gynecological diseases (69 cases) and healthy females (99 cases). Considering the neoplastic patients in comparison to patients with benign diseases, the best diagnostic efficiency (78%) was found to correspond to a cut-off level of 120 pmol/mol creatinine the sensitivity being 73% and the specificity 90%. With this cut-off, an efficiency of 82% for healthy controls was obtained. Since the menopausal condition increases UGP levels, and though no significant difference for UGP was found between healthy subjects and patients with benign diseases, we decided to consider the reference populations as a single group. Thus, we evaluated the UGP performance on the basis of menopausal status. When a specificity of 95% was fixed, the cut-off values were 120 and 180 pmol/mol creatinine for pre- and postmenopausal women respectively, the sensitivity being 73% and 64%. Finally the combined evaluation of UGP and CA 125 improved their individual clinical efficiency for the diagnosis of ovarian serous cystadenocarcinomas, assuring a sensitivity of 86% and a specificity of 89%.

Cervico-mediastinal extension of thyroid cancer.

A surgical series of 30 cervico-mediastinal thyroid cancer patients operated on has been retrospectively reviewed. Results were compared with those obtained in patients operated on for benign cervico-mediastinal goiter and thyroid cancer confined to cervical region. Of 4688 thyroidectomies performed, 30 patients were operated on for thyroid carcinoma with cervico-mediastinal extension. There were 15 males and 15 females. The mean age was 67 years (range, 21-86 years). Patients with cervico-mediastinal cancer were significantly older than patients with benign cervico-mediastinal goiter (P < 0.0001). Time between onset of first symptoms and surgery was significantly longer in patients with cervico-mediastinal cancer than in those with benign cervico-mediastinal goiter (P < 0.0001) and cervical thyroid cancer. Signs and symptoms at the time of surgery were cervical mass in 28 patients (93%), cervical lymphadenopathy in 20 patients (66%), dyspnea in 21 (70%), dysphagia in 9 (30%), dysphonia in 2 (7%), and venous stasis in 1 (3%). None of the patients was asymptomatic. Total thyroidectomy with functional lymphectomy was performed in 16 cases. Seven of these patients were operated on in 2 stages. In 8 cases the operation was a debulking procedure, and in 6 it was a near-total thyroidectomy. Sternotomy was performed in two cases. A differentiated thyroid cancer was found in 21 patients (70%), medullary in 5 (17%) and undifferentiated in 4 (13%). The incidence of medullary carcinoma was significantly higher compared with cervical cancer (P < 0.008). Postoperative complications were higher than those occurring in benign cervico-mediastinal goiter and similar to those occurring in cervical cancer. The actuarial survival was similar to that of cervical cancer matched for age and sex. This analysis shows that the longer clinical history of goiter is related to its endothoracic development and its neoplastic transformation. This finding should further encourage surgeons to treat any cervico-mediastinal goiter as promptly as possible.

Pseudotumor of the liver: a challenging diagnosis.

Inflammatory pseudotumors of the liver are rare, and their natural history is mostly unknown. Making the diagnosis is often difficult, and these masses are often confused with other lesions, generally either primary or secondary neoplasms. The case of a patient who had an exhaustive preoperative work-up, including ultrasonography, CT scan and MRI, is herein presented. The characteristics of each exam, particularly those of the MRI, in which the pattern is poorly described in the literature, are reported. A fine needle biopsy was not contributive, as it was performed too centrally within the nodule. Only a high degree of suspicion and the existence of this tumor might lead to a preoperative diagnosis, thus avoiding major surgery. However, as is evident from the experiences of most authors and from our own, doubt may persist even after an exhaustive work-up. Since the morbidity and mortality of liver resection of noncirrhotic livers is low, surgery should be considered the treatment of choice.

Reverse cascade filtration of ascitic fluid--preliminary results.

Refractory ascites is an infrequent complication of cirrhosis. Paracentesis and ultrafiltration of the ascitic fluid with intravenous or intraperitoneal reinfusion of the concentrated ascites has been used as therapy for this condition since 1971. The technique is cumbersome and has high morbidity and mortality rates, even if effective. In this paper we describe a new technique that couples secondary filtration for the removal of macromolecules, with ultrafiltration of ascitic fluid. In its very first application 6 patients underwent 8 treatments. No adverse effect was observed and clinical efficacy was good. Up to 60 g of albumin can be saved in a single session lasting less than 2 hours.

[Comparative evaluation of the effects of a peritoneo-venous shunt and of concentration-reinfusion on the survival of cirrhotic subjects with "intractable" ascites]. / Valutazione comparative degli effetti dello shunt peritoneo-venoso e della concentrazione-reinfusione sulla sopravvivenza dei cirrotici con ascite "intrattabile".

Two homogeneous groups of patients with ascites intractable to a traditional medical therapy and to a first concentration and reinfusion (C/R) have been studied. The first group underwent others C/R, the latter one a peritoneo-venous shunt. The survival and the quality of life of the two groups of patients have been compared. Also a correlation between the basal clinical conditions and the mortality has been tested. In both groups the survival was similar, but the patients who underwent a peritoneo-venous shunt had a better quality of life. The deaths, but for a correlation with iperbilirubinemia, were related with the logic evolution of cirrhosis. The authors conclude with some critical considerations about the treatments evaluated.

[Preliminary experience with a new tumor marker in obstetrics and gynecology: UGP (Urinary Gonadotropin Protein)]. / Esperienze preliminari con un nuovo marcatore tumorale in ostetricia e ginecologia: UGP.

AIM: To evaluate the use of UGP (urinary gonadotropin protein) as a tumor marker in gynaecologic and obstetric malignant diseases. MATERIALS AND METHODS: The study was carried out in the division of Gynaecology and Obstetrics of the Ospedali Riuniti in Bergamo. 63 patients, with obstetric or gynaecologic benign or malignant diseases, entered the study. 66 healthy volunteers were examined as a group-control. In both the groups UGP levels were determined in morning urine, using an immunoenzymatic commercial kit. RESULTS: Results, expressed in fmol UGP/ml of urin, show that UGP is produced by several neoplasms, but the false-positive percentage is still high; a higher precision can be obtained with an accurate choice of the cut-off value and with a standardization of the analytical technics. Besides, the contemporary determination of UGP and CA 125 levels reduces the possibility of false-positive and false-negative results. CONCLUSIONS: More studies must be carried out to confirm the value of UGP as a tumor marker in obstetrics and gynaecology. Anyway, this recently purified protein can already be useful, in combination with the usual tumor markers, in the prompt diagnosis and management of primary neoplasms or recurrences, with a higher sensibility in comparison with traditional clinical and radiological examinations.

Serum levels of tumor-associated trypsin inhibitor (TATI) in benign and malignant gynecological diseases.

The behavior of tumor-associated trypsin inhibitor (TATI) as a marker for gynecological cancer was studied in a control population and in patients with different benign and malignant diseases. When a cut-off level of 21.4 micrograms/l was used the specificity was 100% in patients with benign diseases. The sensitivity in patients with malignant tumors was low for cervical and corpus cancer, 13% and 14%, respectively, whereas it was 33% in all the ovarian malignant tumors, reaching 60% in the mucinous type. There was a clear correlation between TATI level and stage.

[Intraoperative manometry during functional surgery of the esophagus]. / La manometria intraoperatoria nella chirurgia funzionale dell'esofago.

The purpose of this investigation was to verify the suitability of intra-operative manometry in the course of functional surgery of the esophagus, especially with reference to the results obtained in terms of sphincter functionality, related to the overall changes in symptoms and pH-metry. The practice disclosed herein refers solely to the Heller-Dor operation for esophageal achalasia and to the Nissen Rossetti operation for gastro-esophageal reflux. The promising results obtained using this method to achieve a complete myotomy during Heller's operation, in our opinion testify in favor of its usefulness with this type of surgical procedure. On the contrary, for preparing a fundoplication we feel that method is of orientative value only, since there is no correspondence between the values obtained at the end of the fundoplication and those recorded 18 to 24 months after surgery. The predictive nature of the examination is thus denied.

[The use of different suture materials in thyroid surgery. A statistical evaluation of the immediate and long-term results]. / Utilizzo di differenti materiali di sutura in chirurgia della tiroide. Valutazione statistica dei risultati immediati e a distanza.

Six groups of patients for a total of 120 cases were examined for cervical wound suture results. Different synthetic absorbable sutures and different suture techniques were employed. Good aesthetic results were always obtained in long-term follow-up. The patients sutured with Polydioxanone, a monofilament with prolonged breaking strength retention, had a lower incidence of local complications.

[13 cases of angiodysplasia of the digestive system]. / Su 13 casi di angiodisplasia dell'apparato digerente.

OBJECTIVE: This clinical study assesses the diagnostic and therapeutic problems entailed in so-called gastrointestinal angiodysplasias. Summary back ground data: the topic presents numerous, still unresolved, issues: classification (its clinical presentation and classification); anatomo-pathological identification; diagnosis and localization; treatment of patients with acute massive bleeding; long-term outcomes. MATERIALS AND METHODS: Thirteen patients, equally distributed between both sexes an with a mean age of 54 years (range = 23-75), were observed and operated over a nearly 20 year period. All patients had acute massive bleeding localized to the stomach, duodenum, ileum, colon and rectum. Diagnosis and localization were previously obtained in nine patients, mostly using selective angiography. With the exception of two rectal localizations treated with embolization, all patients underwent surgical resection. In two cases operated on without previous diagnosis, (rebleeding occurred). CONCLUSION: The data available in the literature are broadly substantiated, even if the mean age reported seems somewhat lower (54 yrs). Localizations were detected in nearly all segments of the gastrointestinal tract, and the indication to surgical resection possibly after detection of the angiodysplasia and source of bleeding is confirmed. The best diagnostic technique is selective angiography.

[Surgical treatment of cervico-mediastinal goiter]. / Il trattamento chirurgico del gozzo cervico-mediastinico.

Over the last decades definitions and classifications of cervico-mediastinal goiters have been proposed. According to the definition of Valdoni and Tonelli, from 1968 to 1991 237 patients were operated on for cervico-mediastinal goiter. There were 168 simple forms (141 anterior and 27 posterior) and 69 complex forms according to Borrelly's classification. We analyse and discuss the clinical presentation, the diagnostic procedures and the surgical technique in relation to post-operative complications and long term results. The mean duration of symptoms before surgery in patients with cervico-mediastinal goiter was longer than in subjects with cervical goiters. All but 8 operations were performed through a cervical incision. Two patients, both with advanced tumor, died postoperatively. Post-operative complications were: hemorrhage 0.8%, dysphonia 4.6% and transient hypoparathyroidism 2.9%. A clinical follow-up was available for 194 patients. Permanent dyspnea was observed in 1.0%, dysphonia in 4.6% and transient hypoparathyroidism in 2.9%. Tracheotomy was necessary in 5 cases. Complications were more frequent after total thyroidectomy than after partial resection (p < 0.05), after surgery for malignancy than for benign disease (p < 0.05) and in complex than in simple forms (p < 0.05). Almost all cervico-mediastinal goiters can be treated by a cervical incision. Sternotomy, when required, does not influence mobility and mortality. The lacking of an alternative treatment, the relatively high incidence of malignancy and the risk of acute airway obstruction should induce the early removal of all substernal goiters.

[Recurrent goiter: analysis of 134 reinterventions]. / Il gozzo recidivato: analisi di 134 reinterventi.

Reoperative surgery for thyroid disease still plays a predominant role in the treatment of goiter recurrences. At the moment, neither useful biological nor clinical indicators exist to prevent such recurrences. The effectiveness of TSH-suppressive therapy is still debatable and some authors have proposed total thyroidectomy for this benign disease in order to eliminate the risk of relapse. We analyzed 134 patients who underwent reintervention for recurrence of goitre in order to: 1) study possible clinical or epidemiological characteristics that could influence recurrence, 2) to verify the indications to reoperation, and 3) to evaluate the incidence of complications. For the study of complications, we adopted as a control group a series of 361 patients operated on by the same medical staff and undergoing subtotal thyroidectomy for multinodular goitre, with a minimal follow-up of 10 years. The surgical technique is described and several peculiarities are discussed. In the group of patients who had reoperation two cases (1.5%) of laryngeal palsy and two cases (1.5%) of hypoparathyroidism were recorded and this was not significantly different from the control group. A positive correlation was found between recurrence and young age at the time of first surgery (p < 0.006), female sex (p = 0.045) and esthetic results (p = 0.013). No further clinical recurrence was found in 101 patients after a mean follow-up of 122 months, while in 16 cases the echography revealed nodules in the residual parenchyma. In our opinion total thyroidectomy is not justified as a first standard procedure for this benign disease caused by the activity of various not yet well understood, growth factors.

[Surgical treatment of multinodular goiter]. / Il trattamento chirurgico del gozzo multinodulare.

A homogeneous series of 361 patients operated on for multinodular goitre was analyzed. Minimum and mean follow-up were 10 and 18.6 years, respectively. In most cases a subtotal or near total thyroidectomy was performed, while total thyroidectomy was reserved for patients with cancer. The goal of the study was to verify the long term outcome of this therapeutic strategy in terms of complications, disease recurrence, need of complementary therapies (TSH-suppressive or substitutive) and reinterventions. Global recurrences were 14.7%, and 4.9% of these needed a second operation for indications similar to those of the first operation. Long term complications were vocal cord palsy 1.1% and permanent hypoparothyroidism 0.3%, while the global complications of reinterventions were 3% (n.s.). Nearly half of the patients had not followed any functional or instrumental check-up for at least 5 years nor undergone any hormonal therapy. Among the patients who had a TSH-suppressive therapy, the recurrence rate was not significantly different compared to the group that had no treatment. On the basis of these data, it seems that subtotal thyroidectomy is adequate intervention for multinodular goitre, as long as the number of clinical recurrences is not significantly high. On the contrary, it might be expected that total interventions, performed in non specialized centers, would introduce a higher rate of complications. The need for TSH-suppressive therapy to reduce recurrences was not proven.