Primary hyperparathyroidism: can ultrasonography be the only preoperative diagnostic procedure?

PURPOSE: The purpose of our study was to assess the role of ultrasonography (US) before surgical treatment of primary hyperparathyroidism. MATERIALS AND METHODS: We retrospectively evaluated 77 patients (60 women, 17 men; mean age 59 years) with primary hyperparathyroidism who underwent parathyroid US prior to surgery. Sixty-five of 77 (84%) patients had undergone (99m)Tc- sestamibi (MIBI) scintigraphy. The results were correlated with the surgical and histopathological findings. RESULTS: Surgery revealed 85 abnormal parathyroid glands in 77 patients (70 adenomas, 15 hyperplasias). The locations of the parathyroid glands were typical cervical (n=77), thyrothymic ligament (n=3), carotid sheath (n=2), and mediastinum (n=3). In two patients, intrathyroid microadenoma was diagnosed by histopathology. Seventy-four enlarged glands in 64 patients were correctly identified at US. Per-patient sensitivity and positive predictive values, respectively, were 84% (64/76) and 99% (64/65) for US, 68% (44/65) and 100% (44/44) for scintigraphy and 91% (59/65) and 98% (59/60) for both techniques combined. We weighed 63 out of 85 glands, obtaining a value of 1,004+/-1,564 mg; 460 mg (mean+/-standard deviation; median). CONCLUSIONS: Preoperative detection and localisation of enlarged parathyroid glands can be based on US, an inexpensive and widely available method, limiting the use of scintigraphy to those cases with negative and/or doubtful findings on US.

[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.

Intra-operative testing for parathyroid hormone: the Central Laboratory option.

BACKGROUND: Intra-operative PTH testing in the operating theatre has proven to be an accurate way to verify the removal of all pathological parathyroid tissue in primary hyperparathyroidism. Its limitation is the high cost. An alternative, more cost-effective procedure is proposed: intra-operative PTH dosage at the Central Laboratory. PATIENTS AND METHODS: Fifty-four patients underwent parathyroidectomy with intraoperative dosage of PTH at the Central Laboratory. Three blood samples were taken from each patient: just after the induction of anesthesia, 5 and 10 min after parathyroidectomy. The samples were sent to the Central Laboratory and analysed simultaneously. The results were phoned back to the theatre. The procedure was considered effective when PTH drop was >/=50% from basal value, 10 min after parathyroidectomy. RESULTS: 98.1% of patients proved recovered (average follow- up 31.1 months). The procedure had 3 false negatives, 1 false positive, with sensitivity, specificity, accuracy, positive predictive value and negative predictive value of 94.0%, 75.0%, 92.6%, 97.9%, and 50.0%, respectively. DISCUSSION AND CONCLUSION: The main disadvantage of the presented procedure is the long waiting time. Nevertheless this time is the same as that required for results from intra-operative histological examination, the only alternative to determine surgery effectiveness in centres where portable instrumentation for intra-operative PTH dosage in the operating theatre is not available. The advantage of intra-operative PTH at the Central Laboratory is the very low cost. If results in terms of sensitivity, specificity, accuracy, and cost are taken into consideration, intra-operative dosage of PTH at the Central Laboratory may be deemed a viable alternative to the operating theatre.

Medullary and papillary carcinoma of the thyroid gland occurring as a collision tumour: report of three cases with molecular analysis and review of the literature.

We report the simultaneous occurrence of medullary thyroid carcinoma (MTC) and papillary thyroid carcinoma (PTC), presenting as spatially distinct and well-defined tumour components, in three cases. In the first patient, histology, immunohistochemistry and electron microscopy demonstrated an MTC in the one nodule and PTC in two additional lesions. Non-neoplastic thyroid parenchyma separated the three nodules. Metastasis from PTC was diagnosed in a regional lymph node. Genetic analysis of both tumour components showed a distinctive mutational pattern: in the MTC a Cys634Arg substitution in exon 11 of the RET gene and in the two PTC foci a Val600Glu substitution in exon 15 of the BRAF gene. The other two patients are members of a large multigenerational family affected with familial MTC due to a germline mutation of the RET gene (Ala891Ser). Both patients harboured, besides medullary cancer and C-cell hyperplasia, distinct foci of papillary thyroid cancer, which was positive for Val600Glu BRAF mutation. Review of the literature disclosed 18 similar lesions reported and allowed the identification of different patterns of clinical presentation and biological behaviour. So far, the pathogenesis of these peculiar cases of thyroid malignancy has been completely unknown, but an underlying common genetic drive has been hypothesised. This is the first report in which two mutations, in the RET and BRAF genes, have been identified in three cases of MTC/PTC collision tumour, thus documenting the different genetic origin of these two coexisting carcinomas.

Radio-guided video-assisted parathyroidectomy: a preliminary report.

BACKGROUND: The surgical management of primary hyperparathyroidism is changing both in terms of the extent of cervical exploration and in technique. There are many new mini-invasive procedures for neck surgery. We describe our preliminary experience with a technique that combines two mini-invasive procedures--radio-guided and video-assisted parathyroidectomy. METHODS: Six consecutive patients with no recurrent or persistent primary hyperparathyroidism, no previous cervical operations, and no thyroid pathologies were selected to undergo radio-guided video-assisted parathyroidectomy. RESULTS: One case was converted. There was no morbidity or mortality in the postoperative period. Six parathyroids were removed; the histological diagnosis was adenoma in all cases. All patients were discharged on the 1st postoperative day. Calcium serum levels normalized in all cases, with only one case of transient postoperative hypocalcemia. All patients were normocalcemic after 6 months. CONCLUSION: Radio-guided video-assisted parathyroidectomy is feasible in selected patients. However, longer follow-up and more cases are necessary before this procedure can be applied routinely.

[Follicular neoplasm of the thyroid: usefulness of extemporaneous histologic study of frozen sections]. / Neoplasia follicolare della tiroide: utilità dell'esame istologico estemporaneo al congelatore.

PURPOSE: The role of frozen section (FS) in determining thyroidectomy extent in patients with follicular neoplasms is debated. The Authors consider FS usefulness through experience retrospective review. MATERIAL AND METHODS: From January 1980 to June 1999, 1252 Fine Needle Aspirations (FNA) were performed in patients with thyroid nodules. Out of these, 155 (12.4%) resulted follicular neoplasms. All these patients were operated on: 54 had total thyroidectomy because of both lobes disease and 101 had emithyroidectomy with FS. FS results were compared to definitive histological examination. Sensitivity, specificity, accuracy, positive predictive value (PPV) and negative predictive value (NPV) of frozen section have been estimated. RESULTS: Out of 155 follicular neoplasms, 15 resulted malignant at definitive histological examination: 6 were diagnosed by FS. All 6 patients had a total thyroidectomy during the same operation. Of the rimanenti 9, 6 had a second operation for radicalization within 2-3 days. FS sensitivity was 42.9%, specificity 100%, accuracy 92.0%, PPV 100% and NPV 8.5%. DISCUSSION: Some Authors consider FS useful because it allows to radicalize the operation immediately, in case of positivity for malignancy. Even if only few patients, the possibility to solve the problem in a one-step procedure is a great advantage. Other Authors consider FS useless because to diagnose a poor number malignant neoplasms, a lot of intra-operative examination have to be done. Costs are higher than benefits. CONCLUSIONS: The Authors believe that both attitudes are correct and the decision of using or not FS cannot be standardized.

Post-thyroidectomy hypocalcemia and feasibility of short-stay thyroid surgery.

AIM: To study the feasibility of thyroid surgery in a short-stay hospitalization regimen, with particular reference to postoperative hypocalcemia. METHODS: The clinical files of 696 patients operated on from January 1977 to January 2000 for thyroid diseases were analyzed. They were divided into groups on the basis of extent of operation and type of disease. Hypocalcemia incidence was compared between the different groups of patients. Data were analyzed statistically using the chi-square and Fisher's exact tests. RESULTS: There were 74 temporary (10.6%) and 12 (1.7%) persistent hypocalcemia cases. None of these occurred in patients undergoing lobectomy. The incidence of hypocalcemia was higher in two-lobe vs. single-lobe operations (p < 0.05), in total thyroidectomy with lymphadenectomy vs. total thyroidectomy (p < 0.05) and in hyperthyroidism vs. patients with normal serum hormone levels (p < 0.05). 84.9% of hypocalcemia cases developed on postoperative day 1, with only one tetanic crisis. CONCLUSIONS: Thyroid surgery in the short-stay hospitalization regimen is feasible for all patients undergoing lobectomy. Patients undergoing subtotal or total thyroidectomy may be treated in a short-stay regimen, only if they are affected with non-hyperfunctioning benign diseases and if they have normal serum calcium levels on postoperative day 1.

Mixed follicular and parafollicular thyroid carcinoma.

A rare case of mixed follicular-parafollicular thyroid carcinoma which occurred in a 50-year-old man, is reported. The ultrastructural aspects of the tumor showed: a biphasic growth pattern with microfolliculi and solid areas; the coexpression of thyroglobulin and calcitonin antigens in the same follicle-like structures; the presence of neuroendocrine granules, microvilli and intracytoplasmic canaliculi bordered by microvilli. These characteristics lead us to a diagnosis of mixed follicular-parafollicular thyroid carcinoma.

[Pneumocystosis of splenic localization in the course of HIV infection: a new indication for splenectomy. Description of a case]. / Pneumocistosi a localizzazione splenica in corso di infezione da HIV: una nuova indicazione alla splenectomia. Descrizione di un caso.

Pneumocystis carinii is a common cause of interstitial pneumonitis in AIDS patients: it affects 85% of patients with cell-mediated immunodeficiencies. Extrapulmonary infection is much more infrequent and it is observed only in these patients who receive aerosolized pentamidine prophylaxis because of minimal systemic distribution of the drug. No case of extrapulmonary disease was observed in patients receiving systemic prophylaxis for Pneumocystis carinii with cotrimoxazole. The pathogenesis of extrapulmonary infection is not clear: it is probably connected with hematogenous or lymphatic dissemination from the lung. In a small number of case is due to reactivation of extrapulmonary foci or to a new infection. The management of disseminated infection of Pneumocystis carinii is medical: only recently a combination of medical and surgical approach was proposed for a patient with extrapulmonary infection. We report a case of 29 years old patient with AIDS with a demonstrated pulmonary and splenic localisation of pneumocystis carinii submitted to surgical splenectomy. The surgical decision was taken for several reasons: no response to medical therapy, the relative good general condition of the patient despite the immunological status, the presence of thrombocytopenia and abdominal pain in the left upper quadrant, and the risk of rupture of spleen. The post-operative course was eventful. We support splenectomy for splenic infection of Pneumocystis carinii in very small selected cases and only with palliative intent.

Ultrasonographic surveillance after surgery for euthyroid goitre in patients treated or not with thyroxine.

OBJECTIVE: To assess the efficacy of postoperative treatment with I-thyroxine in patients operated on for euthyroid goitre after precise definition of extent of goitre disease preoperatively and postoperatively by ultrasound. DESIGN: Retrospective study in a selected population. SETTING: University hospital, Italy. SUBJECTS: 53 patients operated on from 1984 to 1994 for euthyroid goitre. INTERVENTIONS: 13 patients who had contralateral disease had lobectomy and contralateral enucleation and were treated postoperatively with suppressive doses of thyroxine. 22 patients underwent lobectomy with no medication. 18 patients underwent subtotal thyroidectomy followed by thyroxine in substitution doses. All patients had regular clinical assessments and ultrasound examination for evidence of recurrent disease. RESULTS: There were no significant differences in the incidence of relapses between those who had lobectomy and those who had lobectomy plus enucleation (p > 0.05). CONCLUSIONS: We found no significant evidence that postoperative suppressive treatment had any effect on recurrence of goitre. Subtotal thyroidectomy gave the lowest recurrence rate (p = 0.14).

[Asymptomatic hyperparathyroidism. Influence of PTH values on the therapeutic decision]. / Iperparatiroidismo asintomatico. Influenza dei valori di PTH sulle decisioni terapeutiche.

The majority of patients affected by primary hyperparathyroidism present now in surgical series are little or totally asymptomatic. This is due to widespread use of multiphasic screening for hypercalcemia as far as to more liberal indications for parathyroid exploration. The debate about the need for parathyroidectomy is open in these patients, having few or no signs at all of primary hyperparathyroidism, because conservative treatment has yielded confused results. The authors analyzed preoperative biochemical values and surgical outcome from 26 patients affected by primary hyperparathyroidism. Thirteen cases had overt primary hyperparathyroidism (group A) and 13 had asymptomatic disease (group B). Patients in group A had higher preoperative PTH values than patients in group (p < 0.05). After surgery, the patients in group A showed parathyroid glands which weighted significatively more than ones in group B (p +/- 0.01). Further, a significant correlation between preoperative PTH value and glandular weight was demonstrated in all cases. The authors conclude surgery for patients having mild primary hyperparathyroidism may give some problems related to the very small size of abnormal glands found during operation. We advise a close follow-up for these patients initially without treatment: surgery should be recommended for those showing PTH values higher than 150 pg/ml.

Recurrence of goitre after operation in euthyroid patients.

OBJECTIVE: To try and resolve some of the problems associated with the treatment of goitre in euthyroid patients. DESIGN: Retrospective open study SETTING: University hospital SUBJECTS: 106 out of a total of 161 euthyroid patients operated on for goitre from 1974-1988. Those who underwent total thyroidectomy (n = 14), in whom the histological diagnosis was thyroiditis (n = 10), or who were lost to follow up (n = 31) were excluded from the study. MAIN OUTCOME MEASURES: Recurrence of goitre, and correlation with type of operation, age, and histological type. RESULTS: 62 Patients underwent unilateral, and 44 bilateral resections. There were 24 recurrences (23%), 13 of which were subclinical; 19 occurred after unilateral, and 5 after bilateral, resections (p = 0.02). There were no significant associations between recurrence and age or histological type. CONCLUSION: Subtotal thyroidectomy is the treatment of choice for goitre in euthyroid patients.

Ovarian and cervical thyroid struma. A case report.

A case of associated ovarian and cervical thyroid struma in a 24-year old female, is reported. The patient was affected by a right thyroid cold nodule which at fine needle aspiration biopsy showed the cytological pattern of benign follicular adenoma; as the nodule was increasing after one year of suppressive therapy, the patient was selected for surgery. At admission during routine physical examination a previously undetected left pelvic mass was discovered: at laparotomy it proved to be a cystic tumor consisting of benign thyroid tissue at the level of left ovary. Histology confirmed the diagnosis of follicular adenoma of the right thyroid nodule after right lobectomy. Albeit cases of thyroid tissue in the ovary have been reported, true struma ovarii is a rare occurrence. A concomitant hyperthyroidism is seen in only 1/4 of cases and the patients can be divided into three groups: hyperthyroid, ascitic and asymptomatic: our patient was in the asymptomatic group.