[Diagnostic, therapeutic and healthcare management protocols in thyroid surgery. 2nd Consensus Conference (U.E.C. CLUB)]. / Protocolli Gestionali Diagnostico-Terapeutico-Assistenziali in Chirurgia Tiroidea. 2 feminine Consensus Conference.

AIM: To review and to update the management protocols in thyroid surgery proposed two years ago by 1st Consensus Conference called on the topic by the Italian Association of Endocrine Surgery Units (UEC Club). METHOD: The 2nd Consensus Conference took place November 30, 2008 in Pisa within the framework of the 7th National Congress of the UEC Club. A selected board of endocrinologists and endocrine surgeons (chairmans: Paolo Miccoli and Aldo Pinchera; speaker: Lodovico Rosato) examined the individual chapters and submitted the consensus text for the approval of several experts. This plain and concise text provides the rationale of the thyroid patient management and wants to be the most complete possible tool for the physicians and other professionals in the field. CONCLUSIONS: The diagnostic, therapeutic and healthcare management protocols in thyroid surgery approved by the 2nd Consensus Conference are officially those proposed by the Italian Association of Endocrine Surgery Units (UEC Club) and are subject to review by two years.

[Diagnostic, therapeutic and healthcare management protocols in parathyroid surgery. 1st Consensus Conference]. / Protocolli Gestionali Diagnostico-Terapeutico-Assistenziali in Chirurgia Paratiroidea. 1 feminine Consensus Conference.

AIM: The aim of the study was to draw up a management protocol in parathyroid surgery promoted by the Italian Association of Endocrine Surgery Units (UEC Club), based on the guidelines of the main international scientific societies and shared by the experts and applied by the operators in the sector. METHODS AND CONSENSUS: The management protocols, already presented in 2003, on the occasion of the current review were examined by the 1st Consensus Conference called on the topic by the Italian Association of Endocrine Surgery Units (UEC). The Conference comprised two distinct sessions, the first in November 2006 within the framework of the 5th National Congress of the UEC Club in Verona, and the second in September 2007 within the framework of the 10th Multidisciplinary Scanno Prize Meeting. A selected board of endocrinologists and endocrine surgeons examined the individual chapters and submitted the consensus text for the approval of several experts. CONCLUSIONS: The diagnostic, therapeutic and healthcare management protocols in parathyroid surgery approved by the 1st Consensus Conference are officially those proposed by the Italian Association of Endocrine Surgery Units (UEC Club) and are subject to review by October, 2009.

[Secondary hyperparathyroidism]. / L'iperparatiroidismo secondario.

We reviewed the results of twenty-four years' experience of parathyroidectomy for secondary hyperparathyroidism. Over the period from 1976 to 2000, we performed 171 parathyroidectomies for secondary hyperparathyroidism (91 males, 80 females; median age: 57.4). Autotransplantation was performed in 45. Of the 171 patients undergoing parathyroidectomy, 14 (8.1%) were treated for relapse. Twenty-four of the 45 patients treated with autotransplantation (53.3%) were followed up for 82 +/- 37 months. Hypoparathyroidism was observed in 33.3% of these (worse after 6 months in 21% and stable in 46%). Five patients (11.1%) experienced a relapse of hyperparathyroidism. We believe that the treatment of choice for secondary hyperparathyroidism is subtotal parathyroidectomy, the indications for autotransplantation in parathyroid surgery are rare.

Telomerase repeat amplification protocol (TRAP): A new molecular marker for parathyroid carcinoma.

Telomerase results to be active in human germ, stem cells, several malignant cell tumors and in immortalized cell lines. In order to investigate if molecular mechanisms other than Rb gene inactivation can be helpful to diagnose malignancy of parathyroid tumors, we decided to investigate the presence of active telomerase in homogenates from different pathological parathyroid tissues (hyperplastic, adenomatous, carcinomatous, and normal) and primary cell cultures. The TRAP assay was performed to detect this activity in histologically characterized normal, hyperplastic, adenomatous, and carcinomatous human parathyroid tissues, primary cell lines, and one metastatic tissue from parathyroid carcinoma. Only malignant parathyroid glands and the metastatic tissue were TRAP positive. Our findings suggest that telomerase expression could represent an important molecular mechanism underlying the acquisition and progression of an aggressive phenotype of epithelial parathyroid cells and it may help to predict their malignant potential. The TRAP assay is easy to perform and it could become an additional tool to be included in the harmamentarium for the molecular diagnosis of parathyroid carcinoma.

[Merkel-cell carcinoma. A report of 3 clinical cases]. / Carcinoma a cellule di Merkel. Osservazione di tre casi clinici.

The finding of Merkel cell carcinoma is a rare but important event owing to the highly aggressive nature of this neoplasm. The authors report three cases of Merkel cell carcinoma with different onsets which were representative of the possible range of clinical symptoms and the prognosis of this pathology. In two cases diagnosis was made by chance, but in the third case a preoperative biopsy was initially performed with subsequent radicalization. The authors examine the diagnostic and therapeutic protocols proposed by other authors and compare them to their personal experience to ensure early diagnosis and radical therapy. Surgery is the obligatory initial choice, followed by radiotherapy and an accurate follow-up. The authors evaluate the use of Octeotride therapy for tumours of neuroendocrine origin and hence its application to Merkel cell carcinoma.

Expression of the alpha- and beta-subunits of human chorionic gonadotropin by subsets of parathyroid cells in states of hyperparathyroidism.

The alpha-subunit of human chorionic gonadotropin (hCG-alpha) has previously been found to be expressed in hyperplasias and tumours of numerous endocrine tissues including all those involved in MEN-I syndrome except the parathyroid glands. In the present immunohistochemical investigation of 86 patients with various states of hyperparathyroidism, expression of hCG-alpha by subsets of parathyroid cells was shown in 46 cases (54 per cent) including all states of hyperparathyroidism investigated: primary adenoma (n = 34, 44 per cent); uraemic secondary hyperplasia (n = 34, 53 per cent); MEN-I (n = 13, 77 per cent); MEN-II (n = 2, 100 per cent); and parathyroid carcinoma (n = 3, 100 per cent). Although the number of parathyroid cells expressing hCG-alpha was in general low, the occurrence of numerous immunoreactive cells appeared to be concentrated in primary adenoma and MEN-I (20 and 33 per cent of positive cases, respectively). No expression was found in ten normal control glands, except for very rare cells in one case. Expression of hCG-alpha was in part associated with that of hCG-beta, which appeared to be more commonly expressed than hCG-alpha in cases of secondary hyperparathyroidism. In separate experiments, Bouin fixation was found to preserve the immunoreactivity of hCG-alpha and hCG-beta better than the formalin fixation used in this study, suggesting that the figures may be underestimates. These immunohistochemical results are in agreement with a previous biochemical study showing hCG-alpha and hCG-beta in extracts of parathyroid tumours and extend to the parathyroid glands the otherwise ubiquitous finding of hCG-alpha expression in MEN-I-related neoplasms.

[Laparocele in the aged]. / Il laparocele nell'anziano.

Especially in the old patients (over 70 years) the incisional hernias represents an invalidating pathology whose treatment, for the high incidence of associated diseases of respiratory and cardiocirculatory apparatus in the aged, offers difficulties connected both to surgical methods and to the perioperative evaluation and preparation of patients. The infections of the surgical incision are very important in the pathogenesis of these diseases. In order to reduce the incidence of incisional hernias the systematic use of perioperative antibiotic therapy is desirable in every operation of abdominal surgery. In order to offer the best guarantees of recovery and to improve the postoperative course of patients, the perioperative antibiotic prophylaxis, together with the use of synthetic prosthesis material, is also essential at the moment of surgical correction of incisional hernia. Although the incisional hernia may sometimes stay silent and asymptomatic for years, it inevitably ends sup by representing a reason for acute and subacute pathologic events; an early surgical treatment is therefore desirable once the incisional hernia has been diagnosed. By this way it is possible to avoid the treatment in the old patients, as the old age is a less favourable period for people who have to be subjected to a surgical operation.

Hormonal studies in a patient with PP-producing tumors.

Five years after the removal of pure pancreatic polypeptide (PP) producing tumors, concentrations of circulating levels of PP, insulin, glucagon, and growth hormone in the basal state, after insulin-induced hypoglycemia, and after a protein-rich meal were determined in a patient with previous truncal vagotomy and Billroth II gastrectomy. Basal plasma levels of PP ranged between 2180 and 2660 pg/ml suggesting persistence or recurrence of PP producing tumors. Concentrations of the other hormones were within normal values. After insulin injection (0.1 U/Kg) levels of PP and glucagon were not modified while those of GH rose from 3.2 to 22.6 ng/ml. After a protein meal (450 gms. of cooked ground beef meat) a sharp rise of plasma PP was observed to a peak of 11310 pg/ml at 10 min. Moreover, plasma levels of immunoreactive insulin also showed an equally prompt rise to a peak of 532 microU/ml while plasma glucagon rose simultaneously to 448 pg/ml. The cause of the abnormal PP, insulin and glucagon responses could not be ascertained but we postulate that they are derived from pancreatic tumors of mixed cell type.

Effects of lymph stasis on healing of rat intestinal anastomosis.

The effects of lymphatic drainage on ileal anastomotic healing using interrupted polyglycolic acid sutures were studied in rats after division and obstruction of celiac-mesenteric lymphatics, and the data compared with sham-operated controls. In 4 of 20 rats with lymph stasis, but not sham-controls, anastomotic leakage was associated with generalized peritonitis and death. Histologic examination of the anastomotic site at 7 and 14 days revealed prolonged exudation with acute inflammatory reaction and less prominent granuloma formation where lymphatics were interrupted. Whereas foreign body giant cell reaction predominated at 14 days with lymph stasis, histiocytic and fibroblastic proliferation dominated in sham-controls. The data suggest that an intact lymphatic system favors optimal intestinal healing and repair.

Dose-response study with indoprofen i.v. as an analgesic in postoperative pain.

A double-blind, placebo-controlled parallel-group study was carried out in 100 patients with postoperative pain. The analgesic activity of indoprofen given in a single dose as an i.v. bolus followed by a 2-h infusion, at total doses of 100, 200, and 400 mg was investigated. The highest dose of 400 mg was given additionally as an i.v. bolus alone. Intensity of pain was assessed before, and 30 min, 1, 2, 4, 6 and 8 h after treatment on a 0-4 point scale. An overall assessment was made at the end of treatment by the investigator and the patient using a 0-4 point scale and a visual analogue scale. Statistical analyses according to a multiple regression model on rating scale scores at fixed times and on overall assessments showed: (i) indoprofen was always more active than placebo in providing pain relief; (ii) there was a significant dose--response relationship; and (iii) there was no difference between the two schedules of administration of the largest dose.

[Diagnostic protocol for the identification of parathyroid neoplasms]. / Protocollo diagnostico per l'identificazione delle neoformazioni paratiroidee.

The Authors after a review of literature and on the basis of their direct experience, emphasize the importance of right protocol for diagnosis of parathyroid tumors. The techniques investigated, continuously evolving and with different sensitivity, permit improving diagnosis in order to right surgery.