[Papillary carcinoma of the thyroid. A uni- and multivariate analysis of the factors affecting the prognosis inclusive of surgical treatment]. / Carcinoma papillare della tiroide. Analisi uni e multivariata dei fattori influenti la prognosi incluso il trattamento chirurgico.

METHODS: A total of 463, out of 677 patients operated on for papillary thyroid carcinoma between 1967-1995, were selected, on the basis of a 5-year minimal follow-up (max 28, mean 11.15 +/- 5.29), for uni and multivariate analysis of survival curves. Patient sex, age over and under 45 years, tumour size smaller and larger than 15 mm, stage, any TNM parameter, histological variety, surgical procedure on the thyroid and nodes were the factors assessed in order to express the prognosis. RESULTS: Male:female ratio was 1:3, the mean age 42.2 years; only 25.9% of patients presented with smaller than 15 mm tumor, about 57% with positive nodes and 8.85% with distant metastases; total or near total thyroidectomy was performed in 86% and nodal dissection in 70% of patients. The 5, 10, 15, 20 year survival rate resulted to be 96.94%, 94.36%, 91.38% and 88.69%; 23 patients, but none aged less than 45 years, died (poorly differentiated and locally advanced carcinoma). Age over 45 years, T4 and M+ stages resulted of high prognostic importance while nodal involvement, interrelated with T and M, showed no independent impact; stage gradually worsened but no difference was found between stage I and II. Adverse effect of male sex resulted from its interrelation with more advanced stages. The relapse rate was found higher in male sex and in patients aged over 45 years, interrelated with T and N extension: no tumor smaller than 15 mm recurred and no relation was found between recurrence and surgical procedure. CONCLUSIONS: Longer follow-up is needed to compare the higher curative effectiveness of total thyroidectomy and nodal dissection versus more conservative treatments.

[Hypoparathyroidism after thyroidectomy. Analysis of a consecutive, recent series]. / Ipoparatiroidismo dopo tiroidectomia. Verifica di una serie consecutiva e recente.

We analyzed a recent and consecutive series of 254 thyroidectomies performed during the last year to verify the incidence of post-thyroidectomy hypoparathyroidism. 249 patients were included in the study and were divided into 2 groups according to the extension of the thyroidectomy. In the first group of 49 patients treated by lobectomy no one developed hypoparathyroidism. In the second group of 200 patients, of which 53 were treated by subtotal and 147 by total thyroidectomy, postoperative hypoparathyroidism was found in 28 (14%) patients, but it was persistent (lasting six months or longer) in 8 (4%). Global incidence of postoperative hypoparathyroidism was statistically higher in total thyroidectomy vs subtotal thyroidectomy (17% vs 5.66%; p < 0.05); however persistent hypoparathyroidism incidence wasn't statistically higher in total thyroidectomy (5.4% vs 0%; p = n.s.). As far as thyroid disorders that require bilateral thyroidectomy Chi 2-test showed a trend of persistent hypoparathyroidism to be more frequent in patients operated on for Graves' disease and thyroid cancer than in other thyroid disorders.

Surgical treatment of papillary thyroid carcinoma: uni- and multivariate analysis of prognostic factors (TNM staging system included).

Out of 677 patients, who underwent surgery for papillary thyroid carcinoma between '67-'95, we selected for survival uni and multivariate analysis 463 patients with over 5 years of minimal follow up (max 28, mean 11.15 +/- 5.29). Patient's sex, age (over and under 45) tumour size (smaller and larger than 15 mm), stage, any TNM parameter, hystological variety, surgical procedure on the thyroid and nodes were the factors assessed in order to establish the prognosis. Male:female ratio was 1:3, average age 42.2 +/- 0.68; only 25.9% of the patients presented smaller than 15 mm tumors, about 57% positive nodes and 8.85% distant metastases; total or near total thyroidectomy was performed in 86% of the cases and nodal dissection in 68.47%. The 10, 15, 20 year survival rate resulted to be 94.36%, 91.38% and 88.69%; 23 patients (4.96%) died of poorly differentiated and locally advanced carcinoma, but none of them was younger than 45. Age over 45, T4 and M+ stage parameters and dedifferentiated histotype resulted of high value while nodal involvement, interrelated with T and M, showed no independent impact; stage gradually got worse but no difference was found between stage I and II, or T1 and T2. Surgical treatment has not resulted to affect survival, whereas lymphnodes involvement is correlated with complications. Adverse effect of male sex resulted from its interrelation with more advanced stages. A significantly higher relapse rate was found in males and in patients over 45, interrelated with T and N extension: no tumor smaller than 15 mm recurred and no relation was found between recurrence and surgical procedure. Longer follow-up is needed to compare the more conservative treatments with total thyroidectomy and nodal dissection.

[A case of forgotten giant goiter]. / Su di un caso di gozzo oublié gigante.

The forgotten goiter is most often the consequence of the incomplete removal of a "plunging" goiter, but it can sometimes be attributed to a concomitant, unrecognised mediastinal goiter which is not connected to the thyroid. Differential diagnosis must be made with other mediastinal masses and with plunging relapses of a previously operated struma. Radiological analysis of persisting mediastinal involvement before and immediately after surgery is the only decisive means of diagnosis, but this is not always available in practice. In this paper the authors report a case of considerable size observed in a series of 346 mediastinal goiters operated between 1967 and 1994. They examine the pathogenetic aspects and the nosological, diagnostic and therapeutic problems related to forgotten goiter, and lastly they list the recommendations that several surgeons have made in an attempt to reduce the incidence. In conclusion, the systematic use of CAT or NMR in the diagnosis of mediastinal opacity may help to reduce the risk of forgetting glandular residue in the mediastinum.

[Which thyroidectomy in Basedow disease?]. / Quale tiroidectomia per il morbo di Basedow?

One hundred and seventy patients with Graves' disease underwent thyroidectomy between 1987 and 1994 (10.5% of all thyroidectomies performed in the same period). Female/male ratio was 9/1; mean age 55.2 years and average period between diagnosis and surgical treatment 5.3 years. The average thyroid weight was 230 g (range 90-950 g). Thyroidectomy was subtotal in 110 and total in 60 patients, 5 of which had been previously treated elsewhere from 5 to 33 years before. Malignancy was incidentally found in 2.35% of patients. The complication rate resulted higher in total thyroidectomies than in subtotal procedures (bleeding 0.9% vs 5.4%, transient hypoparathyroidism 4.5% vs 12.7%, recurrent nerve lesion 0.45% vs 2.72%) however the differences were not statistically significant; this probably because both the procedures were carried out with the same technique for parathyroid gland and recurrent nerve safety. The need of repeated surgery increased the risk. In opposition to total thyroidectomy, subtotal thyroidectomy does not doom to complete and permanent replacement therapy (96.4% of hypothyroidism at 2 months, 72.6% at 4 years), but in this series it failed to achieve remission in 2 patients who maintained a mild hyperthyroidism and in one more patient who developed a relapse 4 years later. Serum TSI meaning is not clear, but preoperative positivity suggests a wider resection and postoperative persistence a closer follow-up by functional assessment. In conclusion surgical procedures for Graves' disease range from subtotal to total thyroidectomy but for a safe outcome the choice depends more on the intraoperative troubles of each single case than on theoretic advantages.

[Post-thyroidectomy hypocalcemia and ligation of the inferior thyroid artery trunk]. / Ipocalcemia post-tiroidectomia e legtura al tronco dell'arteria tiroidea inferiore.

The effect of bilateral truncal ligation of the inferior thyroid artery on parathyroid function is prospectively analyzed in two homogeneous groups of 10 patients treated by total thyroidectomy, with (G1) and without (G2) truncal ligation, comparing immediately postoperative and late serum calcium levels. A significant decrease in mean calcemic levels (minimal ones 2.1, with n.v. 2.1-2.6 mmol/l) was observed in both groups no longer than in the first postoperative days. There was no significant difference in global (clinical + laboratory) hypocalcemia rate (G1 = 0-30% vs G2 = 10-40% respectively); nevertheless hypocalcemia was noted paradoxically to occur more frequently in G-2 patients, out of which one developed a permanent hypoparathyroidism.

[Description of two cases of retrobrachiocephalic thymus gland]. / Descrizioni di due casi di timo retrobrachiocefalico.

We report two rare cases of thymus gland found behind the left brachiocephalic vein, in young women undergoing thymectomy for myasthenia gravis. Our observations are included among the thymic anatomical variants. After a review of the literature on the subject, we discuss both the diagnostic role of new radiological techniques (CT, NRM) and the choice of surgical approach to these variants.

[Efficacy of immunomodulating treatment in patients with different degrees of immunosuppression]. / Efficacia del trattamento immuno-modulante nei soggetti con diverso grado di immunodepressione.

Immunodepression is a common condition in patients undergoing elective operations and it constitutes a high risk for the onset of postoperative infective complications. The use of immunomodulatory drugs has proved useful in the prophylaxis of these complications, although the precise indications for each drug have not yet been clearly codified. The present study aimed to assess the effects of thymostimulin in patients with different degrees of immunodepression, by evaluating both the incidence of postoperative infections and the changes induced in various immunological parameters. The results obtained indicated that those subjects with the highest degree of immunodepression (hypo-anergic) benefited most from drug therapy in comparison to those with a lesser degree of immunodepression (relatively hypo-ergic). The advantages were evident in hypo-anergic subjects both with regard to the frequency of early postoperative infections, and with regard to immunological parameters. On the other hand, in relatively hypo-ergic subjects, benefits were limited to the improvement of some immunological parameters. In our opinion, the use of thymostimulin is of particular use only in those subjects with marked immunodepression since the incidence of post-operative sepsis is highest in this group.