Malignant transformation in non-recurrent peritoneal cystic mesothelioma Our experience and review of the literature.

AIM: Cystic peritoneal mesothelioma is commonly regarded as a benign neoplasm at its first manifestation. It can only seldom show malignant transformation, and only after repeated postoperative recurrences. MATERIAL OF STUDY: We hereby represent a unique case of peritoneal cystic mesothelioma, malignant since its first presentation. We observed a 73 year-old man presenting with intermittent abdominal pain and periumbilical swelling. At surgery, we found an extensive, oval-shaped, multi-lobed cystic formation that was surgically removed. RESULTS: Histopathology was consistent with a malignant peritoneal cystic mesothelioma. In agreement with oncologists, we decided not to give any further therapy because of the few possibilities offered by systemic chemotherapy and the paucity of published data from the literature. We planned periodical follow-up including US scan every six and CTscan every 12 months. DISCUSSION: Several cases of malignant transformation occurring after repeated recurrences of peritoneal mesothelioma have been reported. To our knowledge, this is the first case showing "ab initio" histological features of malignancy, typical of an active, proliferating and infiltrating lesion. In addition, advanced age and male gender of our patient are extremely peculiar CONCLUSION: Our observation suggests the possibility, although very rare, that peritoneal cystic mesothelioma may present as malignant since its first manifestation. KEY WORDS: Peritoneal cystic mesothelioma.

Cancer of the thyroid gland in geriatric age: a single center retrospective study with a 10-year post-operative follow-up.

INTRODUCTION: We evaluated the characteristics of thyroid carcinoma in geriatric patients and outcomes after a 10-years follow-up. METHODS: Comparative retrospective study on a group of 31 geriatric patients and one of 224 non-geriatric, who underwent surgery for thyroid carcinoma in the period 1998-2003. We compared with Fisher's exact test: histology, multifocality, tumor size, lymph-node metastasis, distant metastasis, persistence/recurrence and mortality, including and excluding anaplastic carcinomas, in a subgroup of 26 geriatric patients and another of 223 non-geriatric patients. RESULTS: RESULTS for the geriatric and non-geriatric groups and in the geriatric and non-geriatric subgroups respectively were as follows: multifocality 9/31 vs. 74/224 (p-value 0.8382) and 9/26 vs. 74/223 (p-value 1); tumor size: 16/31 vs. 28/224 T3-T4 (p-value < 0.0001) and 11/26 vs. 27/223 T3-T4 (p-value 0.0004); lymph-node metastases: 17/31 vs. 34/224 (p-value < 0.0001) and 12/26 vs. 33/223 (p-value 0.0004); distant metastases: 8/31 vs. 3/224 (p-value < 0.0001) and 3/26 vs. 2/223 (p-value 0.0088); disease recurrence/persistence: 11/31 vs. 3/224 (p-value < 0.0001) and 6/26 vs. 2/223 (p-value > 0.0001); mortality: 7/31 vs. 2/224 (p-value < 0.0001) and 2/26 vs. 1/223 (p-value 0.0295). Anaplastic carcinomas were predominantly in the geriatric group: 5 vs. 1 (p-value < 0.0001). No statistical differences for other histotypes. DISCUSSION: Thyroid carcinoma is more aggressive in geriatric patients. This may justify a more aggressive surgical strategy with possible prophylactic lymphadenectomy, in addition to ablative therapy with (131)I and suppressive therapy with levothyroxine. CONCLUSION: It would be useful to undertake randomized prospective studies on a large cohort of patients to determine the most effective therapy for geriatric patients suffering from thyroid carcinoma.

Double probe intraoperative neuromonitoring with a standardized method in thyroid surgery.

INTRODUCTION: The purpose of this study was to evaluate the effectiveness of intraoperative neuromonitoring (IONM) of the recurrent laryngeal nerve (RLN) and the vagus nerve (VN) with a standardized approach in thyroid surgery. METHODS: Retrospective study with an experimental group with which IONM was used, both with the RLN that the VN, and a control one, each consisting of 300 total thyroidectomies. Each patient underwent a pre-and post-operative videolaryngoscopy. The number of RLNs identified and the number of transient and permanent RNL injuries for each group were assessed, and then compared with χ(2) tests. In the experimental group Sensitivity, Specificity, Positive Predictability, Negative Predictability and Accuracy of IONM were evaluated, depending on the number of true positive results, false negatives, true negatives and false positives obtained by comparing the results of IONM with the post-operative videolaryngoscopies. RESULTS: The results obtained for the experimental group vs. the control group were: RLNs identified 595 (99.1%) vs. 552 (92%) -P Value <0.0001; Permanent RLNs injuries 4 (1.33%) vs. 5 (1.67%) -P Value 1; transient RLNs injuries 1 (0.33%) vs. 8 (2.67%) -P Value 0.044. The IONM system, for the RLN and VN showed respectively: Sensitivity 66.7% vs. 83.3%; specificity 97.6% vs. 99.5%; Positive Predictability 22.2% vs. 62.5%; Negative Predictability 99.6% vs. 99.3%; Accuracy 97.3% vs. 99.3%. CONCLUSIONS: Our study highlights that using IONM with a standardized method in thyroid surgery, improves the ability to identify the RLN and a reduction in the incidence rate of transient RLN injuries.