Cardiothyreosis: Pathogenic Conjectures, Clinical Aspects and Surgical Approach.

INTRODUCTION: The presence of striking cardiovascular manifestations were noted in the first descriptions of hyperthyroidism owing to Parry (1825) and Basedow (1840) in his famous Merseburg triad. Hyperthyroidism may either cause cardiac complications in individuals with a normal myocardium (genuine form of disorder) or complicate preexisting cardiac troubles. MATERIAL AND METHOD: An homogenous series of 49 cardiothyreosis, 11 males and 38 females, aged 12 - 78 (mean 45) years selected between 138 thyrotoxic patients operated on in a period of two decades is herein presented. There were registered 15 Basedow diseases, 16 toxic adenomas and 18 multinodular toxic goiters. Among these were found isolated or dominating when combined together, 21 cases with rhythm troubles (4 with extrasistolic arrhythmia and one with fibrilloflutter, 10 cases with cardiac failure and 9 cases with coronary cardiac disease. To these 7 hypertensive patients and two with mitral valvulopathy were added. In hyperthyroidism clinical diagnosis was confirmed on imaging exams and hormonal determinations while cardiovascular disturbances was ascertained by interrogatory, clinical signs, EKG and echocardiography. All our cases were operated on performing 33 total or near total thyroidectomies and 16 lobectomies without morbidity recording however 5 postoperative tachyarrhythmias but finally most of them with good clinical results (87,7% cured or significantly ameliorated). DISCUSSIONS AND CONCLUSIONS: Pathogenic diagnosis of such so-called "cor thyreotoxicosis" is not always easy on account of cardiovascular syndrome which frequently overshowed the thyroid subclinical pictures or emergencies of new described entities as amidarone induced thyrotoxicosis. The single administration of a whole calculated dose of I 131 with subsequent treatment with thyrostatics and B-blockers till remission of toxicosis is achieved can be chosen opposing to thyroidectomy after short medicamentous preparation which is effective in large thyromegalies and toxic adenomas.

Thyroglossal Duct Cyst Carcinoma in Child and Adult. Two Case Reports.

Thyroglossal duct cyst carcinoma is rarely mentioned in literature representing only 0,7-1,6% of cases with these embryonic remnants. Two patients with thyroid duct cyst carcinoma, a 14-year-old girl and a 44-year-old man operated on in our department, both diagnosed postoperatively are described. In the first one a classical Sistrunk operation was performed removing a 3 cm asymptomatic mass, a milimetric papillary carcinoma being incidentally discovered at paraffin section pathology. The second case presented a 4 cm cyst with benign clinical and ultrasonic features excepting a 8 mm nodule in the right thyroid lobe. Cytology was inconclusive such as a Sistrunk procedure together with a right thyroid lobectomy were done. Pathology revealed a limited carcinomatous focus in the cyst wall but also a papillary thyroid microcarcinoma. Both cases was thereby diagnosed only after microscopic examination. Conservative approach adopted due to "œinnocent" clinical appearance, subcentimetric size and absence of any risk factor in the two cases achieved stable, verified over time healing confirming the favorable prognosis of this rare pathology.

Clinicopathological phenotype of parathyroid carcinoma: therapeutic and prognostic aftermaths.

Parathyroid carcinomas (PC) are rare and "devastating"€ causes of hyperparathyroidism (HP), frequently discovered fortuitously,with not always doubtless pathological confirmation, and dissociate post-therapeutic outcomes and prognosis even after well-performed surgery. We herein report four PT neoplasms,three of them proving to be authentic PCs, and one an atypical parathyroid adenoma. There were three females and one male, aged 32-49 (mean 44) years. In three circumstances PC was associated with primary HP and in one case the tumor had developed on a CKD-BMD (renal HP) background. All patients presented marked clinical and biochemical phenomena related to hypercalcemia with greater intensity of renal, bone, neuromuscular and psychological signs and symptoms to which in one observation specific uremic manifestations were added. Preoperative and intraoperative diagnosis was suspected only in two cases (one of them being in fact an atypical PT adenoma), but in the other two it was established by paraffin section on histological evidence of definitive stigma of malignancy. Our little experience underlines the wide and protean range of the origins, clinical aspects, course and prognosis of PC, which adds to the difficulties of pre- and intraoperative diagnosis. Awareness of this lesion must be permanent to detect its presence in any unusual eventuality, imposing a radical en bloc resection at the initial operation, assuring the best chance of cure.

Thyroid and thymic exeresis in surgery of hyperparathyroidism.

BACKGROUND: Owing to close anatomical and embryological connexions between the thyroid, parathyroids and thymus,manifold coexisting pathology can be identified during the surgery of hyperparathyroidism (Hp). MATERIAL AND METHODS: In this retrospective study we report the incidence, clinical forms, histology and management of thyroid and thymic synchronous lesions encountered in as eries of 82 consecutive patients with various types of Hp operated on in the last three decades. Demography, clinical records, biochemical data, imaging procedures, pathology reports and surgical protocols were revised. RESULTS: Between 1984-2013, 82 cases of Hp, 20 primary and 62 renal (27 secondary and 35 tertiary), 57 women and 25 males (sex ratio: 2.3 1) of 15-72 (mean 46.5) years, under went surgery in our clinic. Concomitant thyroid exereses were performed in 32 patients (2 subtotal thyroidectomies, 12 lobectomies, 8 atypical resections and 10 diagnosis biopsies), foruni- or bilateral (multi)nodular goiters or different €œminutelesions. Pathology showed 11 colloid goiters, 3 follicular adenomas,5 nodular hyperplasias and 6 thyroiditis cases, 3 papillary microcarcinomas and 4 specimens with normal thyroid tissue.Excision of the fibrofatty retromanubrial tissue in total parathyroidectomies for renal Hp (19 cases) revealed one nonmyastenicthymoma, one thymic cyst and thymic remnants in 6 patients.Morbidity in these extended operations was not significantly increased, comparing to the parathyroid exploration alone. DISCUSSIONS AND CONCLUSIONS: Meticulous pre- and intraoperative evaluation in all cases of Hp enables the actual shift from bilateral neck exploration to minimally invasive surgery,increasing however the potential risk of missing thyroid or thymic coexistent significant lesions. The surgeon dedicated to this pathology must be aware of the possibility of encountering such synchronous association and make generous efforts to wards their complete cure in a single operation.

Unusual malignant tumors of the thyroid gland.

BACKGROUND: Although situated on the last places among the statistical hierarchy of human malignancies, thyroid cancers (TC) are the most common tumors of the endocrine system. Follicular epithelium neoplasms account for more than 90% of these lesions with a favourable prognosis, while resting tumors (medullary, anaplastic, lymphoma, sarcoma etc) generally present a rapid unfavorable evolution with a low rate of survival. PATIENTS AND METHODS: In a series of 464 thyropathies personally treated, 72 cases of TC (15.5%) were identified. Fifty-seven patients presented epithelial TC a 34 papillary variant, 20 follicular variant and 8 mixed forms. Alongside these there were two medullary TC, 9 anaplastic TC and insular TC, and primary lymphoma and metastasis to the thyroid of a lung carcinoma each single case. Four cases have been described in patients who were aged 2-6 years at the time of the Chernobyl disaster. Out of the common types, based on our own taxonomic criteria, we selected a group of 36 TC with unusual clinical, histological and behavioural characteristics or particular pathological associations. RESULTS: Seven cases of occult TC, 7 cases with precessive adenopathy TC and 11 patients with TC associated with hyperthyroidism were registered. All of them underwent adapted thyroidectomies in which the presence of cancer was decisive for the extent of surgery. Medullary, insular and anaplastic TC were the most aggressive lesions and even extended surgery and complementary therapy failed to improve the prognosis of these patients. In the same category we included the cases presenting the coexistence of two TC types, pathologic dedifferentiation in recurrences and concurrent presence of another endocrine or nonendocrine cervical lesion. The a surgical dogma of total thyroidectomy cannot always be respected, so complementary therapeutic solutions must be applied. RESULTS were complex, registering steady recoveries in occult, hyperfunctioning and even in coexisting pathological lesions, but many recurrences and reinterventions with poor survival rates (a few weeks up to 2 years) in cases with reduced or absent histologic differentiation were also noted. Some lesions were inoperable. DISCUSSIONS AND CONCLUSIONS: Increasing clinician, surgeon and pathologist awareness of these distinct, but not rare anatomoclinical contingencies could contribute to their adequate diagnosis and treatment. Recent progress in knowledge of molecular carcinogenesis and promising successes of targeted chemotherapy trials with new drugs offer promising perspectives in the management of advanced or metastatic TC. Surgery still remains the cornerstone treatment for thyroid cancers.

Risk stratification and consecutive prognosis progresses in childhood Wilms tumors. Two cases report.

BACKGROUND: Even if Wilms' tumour is the commonest primary malignant neoplasia in children, it maintained a continuous interest due to actual therapeutic successes contrasting with the customary delayed diagnosis, malignancy and specific risk factors. PATIENTS AND METHODS: Two recent illustrative cases from our clinic are presented. The first one - a little girl of 22 months with repeated admissions for habitual constipation and psychomental disturbances revealed at abdominal ultrasonography a hypo-echoic mass at the superior pole of the right kidney. CT confirmed the presence of a solid homogeneous mass of 23/25 mm without node or distant metastases, suggestive for Wilms' tumour. Conforming to SIOP protocol she received chemotherapy and after 4 weeks a superior polar nephrectomy was performed. Pathology confirmed the diagnosis of triphasic nephroblastoma of intermediary risk. Postoperative chemotherapy according to the protocol SIOP assured the cure with a disease free period of 23 months. The second case - also a girl, of 3 years, is admitted for constipation, pain in the left flank and mental retard (QI=40). Ultrasonography determined a huge mass (Ø~6 cm) situated at the superior pole of the left kidney. CT attested a nonhomogeneous, encapsulated tumour image of 6.2/5.4/7.2 cm in large posterolateral contact with the renal parenchyma out of which it appears to be developed. The diagnosis of WT is strongly suggested and after chemotherapy a radical left nephrectomy with initial vessels ligature was performed. Pathology: stage IIb nephroblastoma with focal epithelial anaplasia. After surgery she continued the chemotherapy (HR regime), was cured and excepting a medullar aplasia is in a good health after 24 months. DISCUSSIONS: Our both cases were girls under 3 years, presenting nonspecific features: constipation and psychic troubles, the tumour being incidentally discovered by the abdominal ultrasonography. CT established the diagnosis. Conventional chemotherapy framing adapted to the tumour's stage and surgery conducted to a stable cure of about two years in both cases. CONCLUSIONS: Conforming to the SIOP protocols preoperative chemotherapy was applicable, well-tolerated and efficacious for two recent cases presented in our clinic, determining the shrinkage of tumour volume and stage and consecutive reduction of the surgical risks.

Mesenchymal (non-epithelial) "non-GIST" tumors of the digestive tract.

Morphological, immunohistochemical and ultrastructural but also clinical and prognostic differences between multiple types of mesenchimal (stromal, nonepithelial) tumors of the gastrointestinal tract prompted us the remembrance of an anecdotic series of sixteen observations of mesenchymal "nonstromal" gastrointestinal tumors (MNSGIT) encountered in four decades of surgical practice. The diagnosis was mainly established on clinical grounds (dyspepsia, pains, digestive hemorrhage or obstruction, palpable tumor) - some lesions being incidentally discovered - and confirmed by radiology, endoscopy, intraoperative exploration and microscopic pathology examination which revealed 9 schwannomas, three leiomyomas, two lipomas, fibroma and "mixoma" one case each. Our cases were located on the stomach (n=12), small bowell (n=1) and right colon (n=3). All the cases were operated on being practiced tumor exeresis with mucous or parietal ruff excision, atypical, conservative and standard (segmentar or sectorial) visceral resection. There was no postoperative morbidity or mortality in our series. Median follow-up for our cases was 24 (range 6 - 60) months and there are not evidence of recurrences or metastatic disease. Even if the actual concerns are prioritary oriented towards the study of GIST, the current nosology of the tiny subgroup of mesenchymal (non-epithelial) "non-GIST" lesions of the digestive tract must be reloaded helping the practioner which can be confronted with this pathology to a better evaluation and optimal therapy.

[Indications for surgery in thyroiditis]. / Indicatii ale tratamentului chirurgical în tiroidite.

INTRODUCTION: Inflammatory processes of the thyroid represents a main proportion of the gland's pathology but the majority of them are treated by medical methods, surgery being indicated. PATIENTS AND METHODS: In 14 cases (3%) from 464 operations for different thyroid conditions we have encountered authentic inflammatory lesions in 9 cases of Hashimoto's thyroiditis (two associated with papillary thyroid carcinoma and one with malignant lymphoma), two cases of Riedel's thyroiditis and respectively de Quervain thyoiditis, tuberculous thyroiditis and actynomicosis one case each. The common lymphoplasmacytic infiltration in Basedow's disease was not considered likewise as the inflammatory nespecific lesions encountered in benign and malignant pathology of the gland. The clinical and imagistic data, biological evaluation and titer of anticorps but particularly the paraffine examination together with intraoperative estimations are decisive for the diagnosis. RESULTS AND DISCUSSIONS: Firm diagnosis of thyroiditis was rarely affirmed before operation, surgical indication being formulated on clinical criterions dominated by cancer suspicion. Among these are diffuse or (multi)nodular thyromegaly with a dominant nodule with recent appearance and rapid growing in temporal and geographic proximity of Chemobyl disaster, with hard consistence, celsian or compressive features and adenopathy. More added the imagistic signs but especially suspect aspects of the FNAB (follicular or with Hürthle cells smears) and also of the frozen sections. Certainty diagnosis was established by paraffine examination not always without hesitations or reexamination (Hashimoto's thyroiditis diagnosed in one case was finally a malignant lymphoma). Large removal decided after intraoperative findings induced for the most of patients a definitive hypothyroidism. CONCLUSION: All the diagnosis resources must be exhausted for the diagnosis of the inflammatory lesions of the thyroid to avoid unnecessary surgery. On the other side the chronic overstimulation by the TSH of the glandular tissue affected by the immune process, represent an important factor of producing neoplasia.

Parathyromatosis coexisting with papillary thyroid microcarcinoma.

UNLABELLED: The aim of this report is to describe a fortuitely discovered association between parathyromatosis and papillary thyroid microcarcinoma. CASE DESCRIPTION: A 56-year-old woman presented with a pyelic relapsed stone, bone pains, neurovegetative com-plaints and iPTH = 348 ng/l as manifestations of recurrent primary hyperparathyroidism after a right inferior parathyroid adenoma exeresis done elsewere six years ago. Ultrasonography showed a 5 mm hypoechoic zone at the lower pole of the right lobe of the thyroid. At the operation an irregular, unbounded, white-yellowish mass 5 mm in diameter was identified lateral and below the thyroid pole together with 15-20 nodules of 1-2 mm scattered on the distal surface of the gland and also in the areolar fibrofatty surrounding atmosphere. Excision and biopsy of the mass and of two main nodules showed the presence of parathyroid issue and the operation is finally completed to a thyroid lobectomy. Definitive paraffin examination evidencied multiple poorly outlined nests of benign parathyroid tissue but also a minute foci of papillary thyroid carcinoma. Two years after the operation the patient is symptom free without any local recurrence and in normal biological parameters. DISCUSSION: Coexistence between parathyromatosis - a rare but challenging cause of hyperparathyroidism - and thyroid (micro)carcinoma a more frequent encountered lesion is an entirely coincidental occurrence. The preoperative diagnosis of both conditions - particularly of the latter one - is rarely anticipated. In such intraoperative fortuitous finding the intervention must include an en bloc thyroid lobectomy together with periglandular and retro-sternal fibrofatty tissue. This strategy is beneficent also for the eventually nonidentified thyroid microcarcinoma. CONCLUSIONS: Preoperative and intraoperative evaluation for recurrent primary and renal hyperparathyroidism must be exhaustive considering possible coexisting thyroid lesions. Indeed in our knowledge there have been no reports in the literature mentioning this unprecedented entity.

Surgical management of renal hyperparathyroidism: a preliminary series report.

BACKGROUND: Renal hyperparathyroidism (RHPT) is a frequent complication of uremic patients on hemodialysis and despite various advances in medical therapy parathyroidectomy is necessary in a semnificative number of cases. PATIENTS AND METHODS: We reviewed our experience (first in Romania) regarding fortythree patients with RHPT operated on in our clinic between 1994 and 2009 evaluating the diagnosis methods, surgical indications, techniques and results together with the evolution of our own therapeutical concept. The study included 22 men and 21 women of median age of 48 (range 15-67) years, performing hemodialysis (n=41) or peritoneal dialysis (n=2) from 7,7 (range 3-13) years respectively. Three patients received an unsuccessful renal graft. The diagnosis was established by anamnesis, clinical complaints (mainly osteoarticular pains, osteoporosis, fractures and skeletal deformities, muscle weakness, severe itching and mental troubles), completed by abnormal values of calcemia, phosphatemia alkaline phosphatasis and intact PTH. Ultrasonography and parathyroid scan were useful in "adenomised" parathyroids and coexistent thyroid pathology. RESULTS: All the patients were operated on. Twentyfour sub-total parathyroidectomies and 19 total parathyroidectomies (6 with autotransplantation), were performed (two video-assisted). There were no deaths and the operative morbidity was 20,9% (vocal cord hemiparesis and postoperative bleeding--each one case, mild transitory hypocalcemia three cases and recurrences four cases). Pathology revealed that RHTP was due to four gland diffuse hyperplasia (n = 23) or nodular hyperplasia (n = 19). One parathyroid carcinoma (in the fourth parathyroid gland), one thymoma and two papillary thyroid microcarcinoma was identified. Clinical and biochemical cure was achieved at median term control of 38 (range 6-165) months in 79.0% (n = 34) of cases. CONCLUSION: Parathyroidectomy is effective for long intervals as symptomatic therapy in cases of RHPT appearing in uremic patients on hemodialysis or after renal transplant but the optimal technique must be individualized on each case and still to be debated.

[The surgical treatment of parathyroid hyperfunction; comments on 16 cases]. / Tratamentul chirurgical al hiperfunctiei paratiroidiene; consideratii în legatura cu 16 observatii.

16 cases of primary (13 cases) or secondary (3 cases) parathyroid hyperfunction are presented. The diagnostic circumstances are described: the tumor were incidentally discovered in patients with skeletal or urinary symptoms and following the artificial dialysis in patients with send failure. The treatment consisted in 12 adenoma excision and 3 subtotal paratyroidectomies (in 3 patients with hyperparathyroidism of renal origin. Associated operations on the thyroid gland (tactical or for removing thyroid nodules) and the operations for urinary lithiasis or skeletal disease were also presented. There was no postoperative morbidity or mortality.

[Secondary hyperparathyroidism]. / Hiperparatiroidismul secundar.

Secondary (renal) hyperparathyroidism appears in chronic renal failure, sometimes in patients on chronic dialysis. Other causes includes rickets and osteomalacia. These diseases are associated with poor calcium and vitamin D absorbtion from the small bowel. Two patients with chronic renal failure maintained on chronic haemodialysis from two and three years, respectively underwent subtotal parathyroidectomy: removal of three glands and preserving a half of a gland in situ. The diagnosis and surgical indication was made upon clinical (bone pain and severe itching), radiological (demineralisation, ectopic calcifications) and biochemical (hypercalcemia, hyperphosphoremia, increased values of alkaline phosphatases) arguments. Postoperatively the improvement is defined by a return to normal in the clinical, laboratory and radiological parametres. The most appropriate operation for secondary hyperparathyroidism is still unresolved one of two techniques is performed according to the preference of the surgeon: subtotal parathyroidectomy or total parathyroidectomy with autotransplantation of parathyroid fragments into forearm muscle.