Thyroid microcarcinoma approach: a ten year experience.

AIM: To optimize thyroid microcarcinoma approach, through a retrospective examination of Authors' experience and literature review. MATERIALS: Characteristics, treatment and outcomes of patients affected with thyroid microcarcinoma were examined: among 1733 patients operated on for thyroid diseases at Endocrine Surgery Unit of San Paolo Hospital in Milan, from 2001 to 2011, 104 (6.0%) resulted affected with microcarcinoma. Twenty (19.2%) had pre-operative and 84 (80.8%) post-operative diagnosis, 11 with (N+) and 93 without (N0) lymph node metastasis. Eighty-five patients underwent total thyroidectomy, 11 (N+) total thyroidectomy with lymphoadenectomy and 8 lobectomy, 2 radicalized in thyroidectomy. All patients underwent Levo-thyroxine suppressive therapy, 25 (24.0%) 131I ablation. Differences between N0 and N+ patients were researched. RESULTS: Neither recurrences nor death at a mean follow-up of 5.6 years. Tumour was multifocal and in thyroid with no other diseases in N+, in a greater rate than in N0 patients. DISCUSSION: Microcarcinoma generally has an indolent course, but sometimes it presents with nodal metastasis. For this reason its treatment in literature is still largely debated. CONCLUSION: In cases of pre-operative diagnosis of microcarcinoma without lymph node metastasis, we propose total thyroidectomy; otherwise, total thyroidectomy with lymphoadenectomy. In cases of post-operative diagnosis, after a partial resection, only selected cases on the basis of patients' and tumour features require a completion total thyroidectomy. We propose Levo-thyroxine suppressive therapy to all patients, 131I ablation in cases of lymphatic metastasis and only in selected cases without metastasis, on the basis of patients' and tumour aspects (age, sex, histological variant, multifocality).

[Hashimoto's thyroiditis and medullary carcinoma in the same gland: a purely random occurrence?]. / Tiroidite di Hashimoto e carcinoma midollare della tiroide coesistenti nella medesima ghiandola: una coincidenza?

In this paper the authors describe the case of 64-year-old woman who had been suffering from poorly defined thyroid disease for 30 years and Hashimoto's thyroiditis for 3 years, with recent detection of high serum calcitonin and CEA. Her family history was negative for endocrinological diseases and her general medical history was not significant for any diseases, except for mild hypertension. There were no pathological findings at physical examination. Cervical ultrasound showed 2 nodular lesions of the right lobe of the thyroid and the isthmus. FNABs of these nodules were performed under ultrasound control and proved non-diagnostic. The patient underwent total thyroidectomy. Intra-operative frozen sections were negative for cancer. Definitive histological examination was positive for medullary carcinoma of the right thyroid lobe (diameter 0.6 cm) in Hashimoto's thyroiditis. The association between thyroid cancers deriving from follicular cells and Hashimoto's thyroiditis is documented in the literature and would appear to determine a better prognosis. Cases such as the one presented in this paper, however, are rare and it is debated whether lymphocyte infiltration may predispose to the onset of medullary carcinoma or whether it is a defence against the tumour.

Management of calcium refilling post-parathyroidectomy in end-stage renal disease.

BACKGROUND: Management of post-parathyroidectomy hypocalcemia in dialysis patients is not well defined. We reviewed published approaches to treatment in an effort to define a clinical algorithm for controlling serum calcium levels post-operatively. METHODS: We conducted a PubMed search for the years 1980-2003 with the keywords "hypocalcemia" and "parathyroidectomy". Only English language and human subject abstracts were analyzed, and only those articles dealing with secondary or tertiary hyperparathyroidism (HPTH) were reviewed further. Other articles were extracted from cross-referencing. RESULTS: We initially examined 146 articles. This review summarizes the findings of the relevant articles along with our own practice regarding post-parathyroidectomy hypocalcemia management in dialysis patients. The vast majority of patients require intravenous (i.v.) calcium supplements after surgery. There are no available controlled studies on calcium supplementation for post-parathyroidectomy hypocalcemia in this patient population. Calcitriol supplementation proved valuable in two studies. CONCLUSIONS: Post-parathyroidectomy hypocalcemia is a common complication, which can be prevented and treated with oral and i.v. calcium supplementation and/or active vitamin D metabolites. Daily follow-up of both serum calcium and phosphorus are mandatory to prevent this major post-operative complication. Based on the available evidence, we propose a protocol for the prevention and treatment of post-parathyroidectomy hypocalcemia, for use in clinical practice. This approach requires validation by a controlled clinical trial.

Geometry and bone mass in primary hyperparathyroidism assessed by peripheral Quantitative Computed Tomography (pQCT).

PURPOSE: Non-invasive measurement by peripheral quantitative computed tomography (pQCT) of bone geometry, biomechanics, and mineral content in patients (pts) with primary hyperparathyroidism (PHPT). MATERIALS AND METHODS: Total, trabecular and cortical mineral density (totBMD, cortBMD, trab BMD), bone geometrical properties (total area, trabecular area, cortical area, cortical/total area) and cortical thickness as biomechanical parameters, were assessed by pQCT at distal radius in 38 (32 F; 6 M) consecutive patients with PHPT (mean age: 62 yrs; range: 30-77). In a subgroup of 12 patients, bone mineral density (BMD) was also measured by means of dual X-ray absorptiometry (DXA) at the lumbar spine (L2-L4). RESULTS: Serum biochemical characteristics were: iPTH (269+/-214 pg/ml; range: 107-1438, normal: 30-65), Calcium (11.4+/-1.1 mg/dl; range: 10.6-13.5, normal: 8.1-10.4) and Alkaline Phosphatase (398+/- 392 U/L; range:173-1174, normal: 98-279). Compa-red with 87 healthy age-matched subjects, total, trabecular and cortical bone densities were reduced in all patients (TotBMD: 216+/-92 mg/cm(3) vs ctr 342+/-94, -37%, p<0.05; TrabBMD: 93+/-51 mg/cm(3) vs ctr 140+/-54, -34%, p <0.01; CorBMD: 711+/-178 mg/cm(3) vs ctr 802+/-175, -11%, p<0.02), such as cortical thickness (0.143+/-0.02 cm vs ctr 0.157+/-0.03, -9%, p<0.02). Among geometrical parameters, only cortical/total area was significant different in the two groups (0,29 vs 0.31; p<0.04). A strong correlation was found between peripheral trabecular bone density assessed by pQCT and axial bone mineral density measured by DXA at L2-L4 (r=0.80; p<0.01). CONCLUSIONS: pQCT measurements in PHPT showed: 1) osteopoenia in all bone compartments partly related to age and menopause; 2) reduced cortical density and cortical thickness consistent with "cancellization" of the inner cortex and lower ability of bone to absorb loading forces. DXA measurements showed osteopoenia also at the lumbar spine, a site rich in trabecular bone. PQCT allowing selective assessment of true volumetric cortical and trabecular bone density such as bone geometry, is proposable in clinical practice, in order to evaluate presurgical bone "status" and to monitor the response to parathyroidectomy.