Long-term esophageal motility changes after thyroidectomy: associations with aerodigestive disorders.

BACKGROUND: Patients undergoing thyroidectomy often complain aerodigestive disorders. In a previous study we showed the associations between voice impairment and proximal acid reflux, swallowing impairment and Upper Esophageal Sphyncter (UES) incoordination and the decrease in UES pressure in thirty-six patients observed before and soon afterwards uncomplicated thyroidectomy. This study investigated the state of post-thyroidectomy esophageal motility changes and its associations with these disorders after 18-24 months. PATIENTS AND METHODS: The thirty-six patients prospectively recruited according to selection criteria (thyroid volume ≤60 ml, benign disease, age 18-65 years, previous neck surgery, thyroiditis, pre- or postoperative vocal cord palsy) underwent voice (VIS) and swallowing (SIS) impairment scores, esophageal manometry and pH monitoring once again. RESULTS: After 18-24 months, both VIS and SIS recovered (respectively: p=0,022; p=0,0001); UES pressure increased (p=0,0001) nearing the preoperative values. The persistence of swallowing complaints were associated with the persistence of esophageal incoordination (p=0,03); the association between voice impairment and proximal acid reflux was confirmed (p<0,001). CONCLUSIONS: Our study confirms that aerodigestive disorders after uncomplicated thyroidectomy, largely transient, are strictly connected with upper esophageal motility changes. In this viewpoint, the innervation of upper aerodigestive anatomical structures (larynx, pharynx, upper esophagus) and its variations should be focused.

Endoscopic sclerotherapy for hemostasis of acute esophageal variceal bleeding.

INTRODUCTION: Currently the most widely used methods for endoscopic control of esophageal varices bleeding are sclerotherapy and rubber band ligation. Although the superiority of band ligation (BL) over endoscopic sclerotherapy (SCL) for the secondary prophylaxis of variceal hemorrhage has been proven, the best approach for acute bleeding remains controversial. PATIENTS AND METHODS: We performed a retrospective study between January 2005 and May 2013. We selected 104 patients with gastrointestinal hemorrhage from rupture of esophageal varices treated with endoscopic sclerotherapy. The sclerosing agent used was 1% polidocanol in 89 cases, butyl-cyanoacrylate in 8 cases and sodium tetradecylsulfate in 4 cases. In 3 cases had not been carried sclerosis because it was not possible to identify the bleeding site. RESULTS: Among the 101 patients who underwent endoscopic sclerotherapy 4 presented re-bleeding within 12 hours from first treatment. Other 10 patients (9.9%) presented re-bleeding within a 5-days period. The most frequent complication was ulceration, observed in 4 cases (3.8%). There was only one case of perforation treated conservatively. CONCLUSIONS: The general improvement in the results of the treatment of variceal acute bleeding might be attributed to better clinical management of these patients. In literature no consensus exists regarding the preferred endoscopic treatment. To date, there is no single method applicable to all patients with bleeding esophageal varices, but sclerotherapy is considered effective, safe and repeatable in experienced hands.

COX-2 expression in lobular in situ neoplasia of the breast: correlation with histopathological grading system according to the Tavassoli classification.

AIMS: There is considerable evidence to link cyclooxygenase (COX)-2 to the development of cancer. The aim of this study was to assess COX-2 expression and its subcellular localization in lobular in situ neoplasia (LIN) of the breast and to verify differences in COX-2 expression between different grades of lesions according to the Tavassoli classification. METHODS AND RESULTS: We analysed the expression of COX-2 protein by immunohistochemistry in tissue samples of 51 LIN lesions classified into three grades according to the Tavassoli classification. COX-2 immunostaining was observed in 78.4% of LIN samples and showed a prevalent membranous rather than cytoplasmic pattern. COX-2 was expressed in 16/17 (94.1%) LIN1, 22/25 (88%) LIN2 and 2/9 (22.2%) LIN3. As regards COX-2 expression, a statistically significant difference was found between LIN1 and LIN3 (P = 0.001) and between LIN2 and LIN3 (P =0.001). No difference was found between LIN1 and LIN2. Moreover, a significant negative correlation was found between LIN grade and COX-2 expression (P < 0.0001). CONCLUSIONS: COX-2 is highly expressed in LIN, supporting a role for this protein in the early stage of breast carcinogenesis, representing the rationale for using COX-2 selective inhibitors in the earliest stages of breast cancer.

[Signet-ring cell carcinoma of the Vater's ampulla: report of a clinical case]. / Carcinoma a cellule ad anello con castone dell'ampolla di vater: osservazione di un caso clinico.

We report the case of a sixty-six year-old man admitted at our hospital with a suspected malignant tumor of the ampulla of Vater. The patient underwent a Pylorus-preserving pancreatico-duodenectomy. Histology showed a signet-ring cell carcinoma of the ampulla of Vater. This case is the 13th report in the literature of a signet-ring cell carcinoma of the ampulla of Vater.

Prenatal diagnosis of congenital diaphragmatic hernia in a McFadden Kalousek type 2 triploid fetus.

Triploidy is characterized by an extra haploid set. We report a rare case of a prenatally diagnosed digynic type (McFadden/Kalousek type 2) triploid fetus with congenital diaphragmatic hernia (CDH). Prenatal ultrasonographic examination allows reliable detection of CDH and it is therefore of great importance for proper parental counselling, as well as performing fetal karyotype for associated chromosomal anomalies.

Role of planimetric analysis in diagnosing thyroid follicular lesions on fine needle aspiration biopsies: a study with histologic correlation.

BACKGROUND: Follicular lesions represent a gray area of interpretation in fine needle aspiration biopsy (FNAB) of the thyroid, with as much as 25% inconclusive reports. We identified "predominantly follicular lesions" (PFLs) as the cytologic category most apt to take advantage of planimetric analysis to reach a more definitive diagnosis. STUDY DESIGN: Sixty-eight cases of FNAB were diagnosed as PFL among the 1,296 FNABs submitted to our institution between January 1994 and June 1995. These cases underwent planimetric analysis with a Leica semiautomatic image analyzer. A smear from a colloid nodule was used as a reference slide. Nuclear areas, perimeters, form factors and maximum diameters were evaluated. Cases in which nuclear areas and maximum nuclear diameters values were found to be > or = 30% higher than the corresponding values found in the reference slide were reported to the clinician as suspicious for malignancy ("flagged" by the computer). These cases required closer follow-up with repeat FNAB within a month, ultrasound and nuclear imaging studies. Nineteen of these cases underwent surgical resection. RESULTS: Histologic reports diagnosed 9 cases of follicular carcinomas, 4 cases of follicular adenomas and 6 cases of nodular hyperplasia. When nuclear areas, perimeters and maximum diameters were all utilized, all the malignant lesions were reported correctly by the computer analysis as flagged, and all the benign lesions were reported as "not flagged." The sensitivity and specificity were 100%, and statistically significant correlations were proven. CONCLUSION: Although the above data provide strong evidence for the value of planimetric analysis in differentiating between follicular lesions, we cannot reach definitive conclusions on the basis of such a limited number of cases. However, the results stimulated our current efforts in applying planimetry along with the evaluation of other biologic markers to a larger set of cases.

Management of cervical intraepithelial neoplasia of the uterine cervix: 110 cases treated by cold-knife conization.

PURPOSE OF INVESTIGATION: The purpose of this study was to evaluate treatment by cold-knife-conization in women carriers of cervical intraepithelial neoplasia (CIN). METHODS: The histologic findings of pre-clinical neoplasia of the cervix after conization were compared to the previous findings of cytology, colposcopy and punch-biopsy in 110 women examined between 1985 and 1995. The chi square test (chi2) was used for the statistical analysis. RESULTS AND CONCLUSIONS: A close correlation is clinically important where complementary roles of these three methods are used to identify lesions suitable for local ablative therapy. The Pap test alone is no longer sufficient for the screening of the pre-cancerous lesion of the cervix and colposcopy is compulsory each time the smear is inadequate or altered. Conization permitted us to single out 13 (11.8%) cases of carcinoma. After cold-knife conization we had six (5.4%) recurrences within two years and two (1.8%) within three years. Our data show that conservative therapy by conization in women with CIN reduces the risk of invasive cancer of the cervix but careful follow-up of these patients is essential.

Cytology, histology, and colposcopy in the diagnosis of neoplastic non-invasive epithelial lesions of the cervix.

The purpose of our study was to examine the concordance among colposcopy, cytology, and histology in the diagnoses of intraepithelial lesions of the uterine cervix. We compared the results of Pap tests, biopsies, and colposcopy in 190 patients, who had histologically proven CIN and/or HPV infection, using histology as "the gold standard". The chi 2 (chi square) test was used for the statistics analysis. The sensitivity of cytology for the detection of CIN was 70%, and was lower for LGL (low grade lesions) than for HGL (high grade lesions): 61.2% versus 88.5%, respectively (p < 0.0001). We obtained a high rate of false negative smears (30%), with a relatively high rate of inadequate samples (59.6%). The sensitivity of colposcopy was 92%. Our results suggest that the Pap test alone is no longer sufficient for the screening of precancerous lesions of the cervix, and colposcopy is compulsory each time the smear is inadequate or altered.

Morphologic and planimetric diagnosis of follicular thyroid lesions on fine needle aspiration cytology.

During 1989-1992, 2,729 fine needle aspiration biopsies were performed; 585 with histologic controls were reviewed. The aim of the study was to demonstrate the incidence of carcinoma in follicular-structured smears without nuclear enlargement, evaluated with planimetric techniques, and to suggest a new cytodiagnostic classification. Of 398 follicular-structured smears, 188 were colloid nodules, 38 were thyreocytic hyperplasias without nuclear atypia, 146 were predominantly follicular lesions (PFL) and 26 were follicular lesions with nuclear pleomorphism. The last showed a high incidence of neoplasia (69.2%) and carcinoma (46.1%) and the largest planimetric values for nuclear area, perimeter and maximum diameter. The second and third categories showed only a difference in the incidence of benign neoplasms (32.9 vs. 15.8%). These results suggest that six months of expectant management might be useful in simple follicular lesions, whereas a follicular pattern with nuclear enlargement requires surgical treatment for the strong possibility of carcinoma.

[Preoperative cytodiagnosis by needle aspiration of follicular thyroid lesions]. / La citodiagnosi preoperatoria su agoaspirato nelle lesioni follicolari tiroidee.

In the period 1989-92, 2729 F.N.A.B. were performed: 585 with an histological control were reviewed. The aim of the study was to evaluate the risk of carcinomatous occurrence in the follicular-structured smears and to suggest a new cytodiagnostic classification. Out of 398 follicular-structured smears, 188 were colloid nodules (CN), 38 thyreocytic hyperplasias without nuclear atypia (THWNA), 146 predominantly follicular lesions (PFL), 26 follicular lesions with nuclear pleomorphism (FLWNP). The last one showed a high incidence of neoplasia (69.2%) and carcinoma (46.1%); the second and the third only a difference in the incidence of benign neoplasms (32.9 vs. 15.8%), with almost the same percentage of occurrence of malignancies (2.6 vs. 2.1%). Such results suggest that a six-months dilatory strategy might be useful in simple follicular lesions (THWNA and PFL) whereas a cytological follicular pattern with nuclear pleomorphism requires a surgical treatment for the high risk of carcinomatous occurrence.

[Lymphocytic infiltration in thyroid neoplasms. Preliminary prognostic assessments]. / L'infiltrato linfocitario nelle neoplasie tiroidee. Preliminari valutazioni prognostiche.

INTRODUCTION: It is known that the immune system is involved in several thyroid diseases and in the reaction against cancer progression. We have therefore evaluated lymphocytic infiltration in the slices of surgically removed thyroids in patients affected by thyroid carcinomas, to further clarify the anatomic and clinical characteristics of this pathology and the possible prognostic correlations. MATERIALS AND METHODS: Thirty-eight patients, 7 men and 31 women, aged 23-73 years, were studied. They underwent total or subtotal thyroidectomy for thyroid carcinoma. The histopathological findings were: papillary carcinomas (P): 22 cases; follicular carcinomas (F): 10 cases; undifferentiated carcinomas (U): 3 cases; other types (e.g., medullary carcinoma, M): 3 cases. RESULTS: The lymphocytic infiltration was evaluated in 4 different grades. The following results, regarding the different histological types, were found: grade 0 (no lymphocytic infiltration) in 10 cases (6 P, 2 F, 1 U, 1 mixed); grade 1 (poor lymphocytic infiltration, equivalent to a non specific inflammatory reaction) in 21 cases (11 P, 6 F, 2 U, 1 M); grade 2 (moderate lymphocytic infiltration) in 4 cases (2 P, 2 F); grade 3 (plentiful lymphocytic infiltration) in 3 cases (2 P, 1 trabecular carcinoma). In 3 patients a lymphocytic (Hashimoto's) thyroiditis was also present. The follow-up, 2 years after surgery, showed, among 17 patients examined, local recurrence and/or lymph node localization in 8 cases (the lymphocytic infiltrations was: grade 1: n = 6; grade 0: n = 2; no one exhibited a higher grade) and apparent remission in 9 (grade 3: n = 2; grade 2: n = 1; grade 1: n = 6; no one exhibited a grade 0 lymphocytic infiltration). DISCUSSION: In most patients a poor or absent infiltration was found. In 7 cases, however, the infiltration was moderate or high. In our experience, no correlation between the histologic type and the infiltration grade was observed. However, in no patient with recurrence of neoplasia a relevant (grade 2-3) infiltration could be observed; patients without recurrence often showed a grade 2-3 infiltration, and no one of them showed a grade 0. The significance of lymphocytic infiltration in thyroid carcinoma is not well clarified. In fact, a few studies underline a possible unfavourable role, since a relevant infiltration seems to be associated with a weak cell-mediated immunity, mostly in follicular and anaplastic carcinomas. However, most data support the hypothesis that the lymphocytic infiltration is a good prognostic feature: in fact, it can be often found in papillary carcinomas and in juvenile thyroid carcinomas, both characterized by a good long-term prognosis. CONCLUSIONS: Our preliminary data underline the opportunity of comparing the clinical course of the disease, the histologic grading and the tumour staging with the lymphocytic infiltration grade, an easily available pathologic datum, for a better prognostic evaluation of patients.

Resection of relevant nerve roots in surgery of spinal neurinomas without persisting neurological deficit.

In 42 patients with a spinal neurinoma or neurofibroma, resection of the affected nerve root was necessary in 24 cases for complete removal of the tumour. In 10 of these the resected nerve root was relevant for upper or lower limb function. Of this subgroup of 10 patients with a resection of a relevant motor root, only 4 showed an initial slight impairment of motor function, which was followed by complete recovery in two cases by the time of discharge from hospital. A persisting relevant motor impairment was not observed in any case. Recommendations given in the literature for the resection of spinal neurinomas vary from radical resection to strict microsurgical resection with preservation of as much of the nerve root as possible. This report together with the publication of Kim et al. suggests, that radical resection is possible without neurological deficit, if microsurgical preservation of unaffected nerve fibres is impossible or if the risk of recurrence is judged to be unduly high.