Solitary thyroid metastasis from colon cancer: a rare case report.

Malignant metastases to the thyroid are rare and are even rarer from a colorectal primary. As these metastases are often asymptomatic, they are usually discovered incidentally on imaging performed as follow-up for the primary tumour. In this report, we present a case of metastatic sigmoid adenocarcinoma to the thyroid diagnosed and treated at our institution.

Central neck dissection in differentiated thyroid cancer: technical notes.

Differentiated thyroid cancers may be associated with regional lymph node metastases in 20-50% of cases. The central compartment (VIupper VII levels) is considered to be the first echelon of nodal metastases in all differentiated thyroid carcinomas. The indication for central neck dissection is still debated especially in patients with cN0 disease. For some authors, central neck dissection is recommended for lymph nodes that are suspect preoperatively (either clinically or with ultrasound) and/or for lymph node metastases detected intra-operatively with a positive frozen section. In need of a better definition, we divided the dissection in four different areas to map localization of metastases. In this study, we present the rationale for central neck dissection in the management of differentiated thyroid carcinoma, providing some anatomical reflections on surgical technique, oncological considerations and analysis of complications. Central neck dissection may be limited to the compartments that describe a predictable territory of regional recurrences in order to reduce associated morbidities.

Ultrasound dye-assisted surgery (USDAS): a promising diagnostic and therapeutic tool for the treatment of cancer recurrences in the neck.

The evolution of new techniques for cancer surgery has led to important changes in cancer care in recent years. The endpoint of cancer treatment is now to treat the patient with minimum discomfort while respecting quality of life. New techniques, such as mini-invasive surgery, must respect the correct oncological indications, when technically feasible. The surgery for nodal spread or recurrence of disease, after previous surgery on T or T and N for neck cancer, can represent a diagnostic and therapeutic challenge, especially in the neck, which is characterized by small spaces and noble structures. Often lesions become enveloped in scar tissue and can be difficult to visualize during surgery, representing a genuine problem for the surgeon. Ultrasound dye-assisted surgery is a procedure that combines ultra-sound localization of pathological nodes with the use of methylene blue to mark diseased structures to simplify their visualization (and thus removal) in the surgical field. The technique is simple and can be used in surgically and oncologically experienced hands, even in hospitals that do not have sophisticated technology.

Role of operator experience in ultrasound-guided fine-needle aspiration biopsy of the thyroid.

PURPOSE: Thyroid nodules are commonly encountered in clinical practice, and ultrasound (US)-guided fine-needle aspiration biopsy (FNAB) is the gold standard in diagnosing the pathological nature of undetermined thyroid nodules. The aim of this study was to evaluate whether operator experience influences the diagnostic accuracy of US-guided FNAB. MATERIALS AND METHODS: A total of 700 consecutive US-guided FNAB done by a single radiologist between 2000 and 2007 were retrospectively analysed. The same freehand technique and capillary-action technique with 22- or 25-gauge needles was used for all nodules, All specimens were prepared and fixed without the cytologist on site and were subsequently analysed by two expert cytologists. The procedures were chronologically divided into seven groups and classified as diagnostic or nondiagnostic. RESULTS: The rate of nondiagnostic procedures for each group was 32% in group 1, 13% in group 2, 17% in group 3, 11% in group 4, 10% in group 5, 5% in group 6 and 8% in group 7. No major complications were recorded. CONCLUSIONS: The rate of nondiagnostic US-guided FNAB is heavily dependent on the operator's experience. We estimated that at least 200 procedures need to be performed in order to achieve the levels of diagnostic accuracy reported in the literature. We therefore suggest specific training before operators routinely perform this procedure in clinical practice.

Role of prophylactic central neck dissection in cN0 papillary thyroid cancer.

Prophylactic central neck dissection in papillary thyroid cancer is controversial. In this retrospective cohort study, the aim was to assess possible advantages of prophylactic central neck dissection with total thyroidectomy in cN0 papillary thyroid cancer. A total of 244 consecutive patients with papillary thyroid cancer, without clinical and ultrasound nodal metastases (cN0), were evaluated out of 1373 patients operated for a thyroid disease at the Istituto Europeo di Oncologia, Milan, Italy from 1994 to 2006. Of these 244 patients, 126 (Group A) underwent thyroidectomy with central neck dissection, while 118 (Group B) underwent thyroidectomy alone. Demographic, clinical and pathological features were analysed. Overall recurrence rate was 6.3% (8/126) in Group A and 7.7% (9/118) in Group B, with a mean follow-up of 47 (Group A) and 64 (Group B) months. In Group A patients, 47% were pN1a and all patients with recurrence had nodal involvement (p = 0.002). Survival rate did not differ in the two groups. Nine patients were lost to follow-up. Group A patients were older and their tumours were larger in size; according to the pT distribution, a higher extra-capsular invasion rate was observed. The two groups were equivalent as far as concerns histological high risk variants and multifocality. Nodal metastases correlated with stage: pT1-2 vs. pT3-T4a, p = 0.0036. A lower risk of nodal metastases was related to thyroiditis (p = 0.0034). In conclusion, central neck metastases were predictive of recurrence without influencing prognosis. From data obtained, possible greatest efficacy of central neck dissection in pT3-4 papillary thyroid cancer without thyroiditis is suggested.

Evolution of lung nodules < or =5 mm detected with low-dose CT in asymptomatic smokers.

Low-dose CT is widely employed for the early diagnosis of lung cancer in high-risk populations even if screening programmes have not been clinically validated yet; however, the optimum follow-up schedule for small lung nodules of uncertain status has not been defined. The aim of this study was to assess outcomes for small pulmonary nodules (diameter < or =5 mm) detected by CT in asymptomatic smokers In 2000-2001, 1035 high-risk people were enrolled in an observational study for the early detection of lung cancer by yearly CT. The prevalence, incidence and evolution of small lung solid nodules are described 238 solid lung nodules < or = 5 mm were identified at initial low-dose CT in 165 people (prevalence 15.9%). 26% of them were not detected in the following 4 years, 43.3% did not change and 10.1% grew to >5 mm; three were removed and found to be malignant (all T1N0); the remaining 21 were followed yearly In the following year, 79 new small nodules were detected (incidence 7.9%). 11.4% were not detected in the subsequent 3 years, 79.7% did not change, 2.5% grew to > 5 mm and were followed yearly In conclusion, prevalent and incident nodules < or =5 mm detected by low-dose CT screening for lung cancer can be safely checked at 1 year intervals.

Endoscopic ultrasound and Computed Tomography in the diagnosis, locoregional staging and assessment of vascular infiltration of pancreatic carcinoma.

PURPOSE: The aim of this study was to evaluate the diagnostic accuracy of colour-Doppler Endoscopic Ultrasonography (EUS), in the detection, loco-regional staging and assessment of vascular infiltration in pancreatic carcinoma, and to compare the results with those obtained by Computed Tomography (CT). MATERIALS AND METHODS: A series of 57 patients with diagnosed or suspected pancreatic carcinoma was retrospectively analysed. All patients underwent EUS and thin-slice (< 5 mm) spiral dynamic CT. The final diagnosis (carcinoma in 37 patients and benign lesion in 20) was obtained by laparotomy in 21 patients, fine-needle aspiration cytology (FNAC) in 17, and follow-up in 19. RESULTS: The specificity and sensitivity for the diagnosis of malignancy were respectively 45% and 92% for EUS and 45% and 89% for CT, with an accuracy of 75% for EUS (p <0.05) and 74% for CT (p = 0.07). The specificity and sensitivity for the diagnosis of loco-regional nodal metastases were both 100% for EUS. The specificity and sensitivity for the diagnosis of vascular infiltration were 100% and 94% for EUS and 100% and 44% for CT, giving a diagnostic accuracy of 97% for EUS vs 74% for CT (p <0.001). CONCLUSIONS: EUS proved to be more sensitive and specific than CT in the loco-regional staging of pancreatic carcinoma. Its diagnostic accuracy is especially high in assessing vascular infiltration and loco-regional nodal metastases. CT still remains the examination of choice for staging pancreatic carcinoma and for assessing its resectability as it affords a panoramic view and ability to rule out distant metastases. Candidates to resection should all be examined by EUS, as, due to its high accuracy in loco-regional staging and assessing vascular infiltration, it might allow a large proportion of patients to be spared the operation.

Schwannoma of thyroid bed. A case report and considerations on interdisciplinary collaboration.

Schwannoma of the thyroid bed is extremely rare, but is known to simulate a thyroid nodule. A retrospective review is reported of a 64-year-old female patient with a thyroid nodule who had been submitted to pre-operative fine-needle aspiration biopsy, judged inadequate, following which total thyroidectomy was performed. On histological examination, the nodule (in the thyroid bed) was found to be a schwannoma. This case report stresses the importance of interdisciplinary collaboration. Better co-operation between surgeon, pathologist and radiologist may have led to correct pre-operative diagnosis with sparing of at least half the thyroid.

[Role of high resolution color-Doppler US of the sentinel node in patients with stage I melanoma]. / Ruolo dell'ecografia del linfonodo sentinella nei pazienti con melanoma in stadio clinico I.

PURPOSE: The aims of the present work are to assess the diagnostic accuracy of high resolution color Doppler ultrasound (US) of the sentinel node (SN) in patients with cutaneous melanoma skin at stage I. The US findings of nodal involvement could spare the patient a surgical step (selective lymphaderectomy) allowing them to undergo radical lymphadenectomy directly. MATERIAL AND METHODS: From November 1998 to November 2000 94 patients (mean age 52.7 years) underwent lymphoscintigraphy in order to mark the SN site on their skin. An US scan (112 lymphatic basins) was performed within 24 hours with a 10-13 MHz electronic linear probe with color-power-Doppler (Esaote AU5 Idea Scanner, Genoa, Italy). The sonographic features we analysed were: shape (roundness index), hilum displacement, intranodal heterogenicity, eccentric cortical thickness, extranodal invasion, vessel irregularity. RESULTS: 26 nodes showed US findings consistent with malignant involvement, 86 were negative. All the nodes were surgically removed and controlled by histology. Sensitivity and specificity of US scanning were 89.4% and 90.3%, the positive and negative predictive values 65.3% and 97.6%, respectively. US correctly identified the involved SN in 15,1% cases, so that 17 patients could have avoided the selective lymphadenectomy CONCLUSION: Preoperative lymphoscintigraphy and high-resolution color-Doppler US scanning constitute a useful diagnostic tool in identifying the metastatic SN, with a low margin of error. False negatives were technically induced, even using the more recent scanners, by the low US probe resolution, unable to recognise metastatic microdeposits. The two most reliable parameters in identifying involved lymphnodes were the roundness index and the absence of hilar echo. The advent of technologically more advanced probes should allow better spatial resolution and assessment of lymph node vascularization, enabling diagnosis of metastasis measuring less than 2 mm in diameter.