Prophylactic central neck dissection for papillary thyroid cancer.

BACKGROUND: Prophylactic central neck dissection (CND) for papillary thyroid cancer (PTC) remains controversial. The aim of this study was to examine whether prophylactic CND for PTC affected long-term survival and locoregional control. METHODS: This was a retrospective cohort study of patients who underwent total thyroidectomy (TT) with bilateral prophylactic CND. They were compared with patients who had TT without CND. Personalized adjuvant radioiodine treatment was used in both groups. Primary outcomes were overall and disease-specific survival, and locoregional control. Secondary outcomes were number of patients with negative serum thyroglobulin levels, and morbidity. RESULTS: Of 640 patients with PTC included in this study, 282 (treated in 1993-1997) had TT without CND and 358 (treated in 1998-2002) underwent TT with CND. The 10-year disease-specific survival rate for patients who had TT without CND was 92·5 per cent compared with 98·0 per cent in patients with CND (P = 0·034), and the locoregional control rate was 87·6 and 94·5 per cent respectively (P = 0·003). In multivariable analysis, extrathyroidal extension was an independent predictive factor for locoregional recurrence (odds ratio 12·47, 95 per cent confidence interval 6·74 to 23·06; P < 0·001), whereas CND was an independent predictive factor for improved locoregional control at 10 years after surgery (odds ratio 0·21, 0·11 to 0·41; P < 0·001). No differences were seen in the rates of permanent hypoparathyroidism or recurrent laryngeal nerve injury between the groups. CONCLUSION: Bilateral prophylactic CND for staging of the neck in PTC, followed by personalized adjuvant radioiodine treatment, improved both 10-year disease-specific survival and locoregional control, without increasing the risk of permanent morbidity. REGISTRATION NUMBER: NCT01510002 (http://www.clinicaltrials.gov).

Randomized clinical trial of bilateral subtotal thyroidectomy versus total thyroidectomy for Graves' disease with a 5-year follow-up.

BACKGROUND: The extent of thyroid resection in Graves' disease remains controversial. The aim of this study was to evaluate long-term results of bilateral subtotal thyroidectomy (BST) compared with total thyroidectomy (TT) in patients with Graves' disease and mild active ophthalmopathy. METHODS: Participants were assigned randomly to BST or TT, and followed for 5 years after surgery. The primary endpoints of the study were the prevalence of recurrent hyperthyroidism and changes in Graves' ophthalmopathy. Secondary endpoints were postoperative transient and permanent paresis of the recurrent laryngeal nerve, and postoperative hypocalcaemia and hypoparathyroidism. RESULTS: Two hundred patients were included, of whom 191 (BST 95, TT 96) completed the 5-year follow-up. Recurrent hyperthyroidism occurred in nine patients after BST and in none after TT (P = 0·002). Progression of Graves' ophthalmopathy was observed in nine patients after BST compared with seven following TT (P = 0·586). Transient hypoparathyroidism occurred in 13 and 24 patients respectively (P = 0·047). Permanent hypoparathyroidism was diagnosed in no patient after BST and in one after TT (P = 0·318). No differences were noted in transient or permanent recurrent laryngeal nerve injury. CONCLUSION: TT for Graves' disease prevented recurrent hyperthyroidism but did not prevent the progression of ophthalmopathy compared with BST.

Randomized clinical trial of visualization versus neuromonitoring of recurrent laryngeal nerves during thyroidectomy.

BACKGROUND: The aim of this study was to test the hypothesis that identification of the recurrent laryngeal nerve (RLN) during thyroid surgery reduces injury, and that intraoperative nerve monitoring may be of additional benefit. METHODS: One thousand consenting patients scheduled to have bilateral thyroid surgery were randomized to standard protection or additional nerve monitoring. The primary outcome measure was prevalence of RLN injury. RESULTS: Of 1000 nerves at risk in each group, transient and permanent RLN injuries were found respectively in 38 and 12 nerves without RLN monitoring (P = 0.011) and 19 and eight nerves with RLN monitoring (P = 0.368). The prevalence of transient RLN paresis was lower in patients who had RLN monitoring by 2.9 per cent in high-risk patients (P = 0.011) and 0.9 per cent in low-risk patients (P = 0.249). The negative and positive predictive values of RLN monitoring in predicting postoperative vocal cord function were 98.9 and 37.8 per cent respectively. CONCLUSION: Nerve monitoring decreased the incidence of transient but not permanent RLN paresis compared with visualization alone, particularly in high-risk patients. REGISTRATION NUMBER: NCT00661024 (http://www.clinicaltrials.gov).

Superiority of preemptive analgesia with intraperitoneal instillation of bupivacaine before rather than after the creation of pneumoperitoneum for laparoscopic cholecystectomy: a randomized, double-blind, placebo-controlled study.

BACKGROUND: This study aimed to evaluate the optimal timing of preemptive analgesia with bupivacaine peritoneal instillation in a prospective, randomized, double-blind, placebo-controlled trial. METHODS: In this study, 120 patients qualified for laparoscopic cholecystectomy were randomized to four groups. Group A received 2 mg/kg of bupivacaine in 200 ml of normal saline before creation of pneumoperitoneum. Group B received 2 mg/kg of bupivacaine in 200 ml of normal saline after creation of pneumoperitoneum. Group C received 200 ml of normal saline before creation of pneumoperitoneum. Group D received 200 ml of normal saline after creation of pneumoperitoneum. Local wound infiltration with bupivacaine was used before skin incisions. The primary end points of the study were postoperative pain intensity on a visual analog scale and incidence of shoulder tip pain. The secondary end points included the latency of nurse-controlled analgesia activation, the analgesia request rate, and analgesic consumption. RESULTS: Significantly lower visual analog scores were observed in group A versus groups C and B versus group D during the initial 48 and 24 h, respectively. The patients in group A versus group B reported significantly lower pain at 4 h (p < 0.001) and 8 h (p = 0.003) postoperatively, but the difference was not significant after 12, 24, and 48 h. None of the group A patients reported shoulder tip pain, whereas it was reported by 3 patients in group B, 6 patients in group C, and 7 patients in group D (p < 0.01). The latency of nurse-controlled analgesia activation was 426.8 +/-57.2 min in group A, as compared with 307 +/- 39.8 min in group B, 109.3 +/- 51 min in group C, and 109 +/- 46.5 min in group D (p < 0.001). A significantly lower analgesia request rate was observed in group A versus C, as compared with group B versus D, throughout the entire study period (p < 0.05). CONCLUSIONS: Preemptive analgesia with bupivacaine peritoneal instillation is much more effective for pain relief if used before creation of pneumoperitoneum. Although the effect of bupivacaine peritoneal instillation is also noticeable when used after creation of pneumoperitoneum, it confers significantly lower benefits.

[Medullary thyroid carcinoma--personal observations]. / Rak rdzeniasty tarczycy--obserwacje wlasne.

The paper presents the rules of surgical treatment in medullary carcinoma of the thyroid gland based on own experience and survey of literature. Changing trends in diagnostic and therapeutic approach were described. The results achieved encouraged authors to find some conclusions. Long term results of therapy depend mostly on stage of disease in time of initial surgery, radicality of primary operation and further supportive treatment. Systematic follow-up after surgery makes it possible to early detect the recurrence and has an influence on survival rate. In cases of poorly differentiated medullary thyroid cancer even radical surgical procedure followed by the appropriate supportive treatment results in a not satisfactory survival.

[H"urthle cell thyroid neoplasms]. / Nowotwory tarczycy z komórek Hürthla.

The paper presents up to date knowledge about oncocytic neoplasms (Hürtle cell tumor). The following paper is based on the biggest study group in Poland. Most of these tumors were benign. The histopathological diagnosis was usually very difficult. The authors pointed out that the most important problem in the treatment process was the histopathological examination. Even intraoperative pathological diagnosis is not discriminative for the diagnosis. All diagnoses were based on paraffin-embedded samples examination. In the authors' opinion treatment process should be individualised according to all clinical and histopathological results.

[Acute mesenteric ischemia--current diagnostic and therapeutic problems]. / Ostre niedokrwienie jelit--wspólczesne problemy diagnostyczne i lecznicze.

The paper presents current views of the acute mesenteric ischemia pathophysiology. The etiology and pathogenesis with all clinical symptoms were discussed. There were presented up to date methods of diagnosis and treatment. Special attention was paid to the nonocclusive mesenteric ischemia and its prophylaxis. The diagnostic algorithm applied to all acute mesenteric ischemia was presented.

[Diagnosis and treatment approach in anaplastic thyroid carcinoma]. / Rozpoznanie i taktyka postepowania w raku anaplastycznym tarczycy.

The paper presents diagnosis and treatment of anaplastic thyroid cancer based on the own experience and literature review. There were presented up to date diagnosis and treatment which included radical thyroidectomy and radio-, chemio-, and hormonotherapy. The results of radical thyroidectomy and teleradiotherapy in anaplastic thyroid carcinoma are not satisfactory.

[Treatment approach for substernal and intrathoracic goiter. Personal experience]. / Taktyka postepowania w wolu zamostkowym i sródpiersiowym. Doswiadczenia wlasne.

The retrospective analysis of 489 cases of substernal and intrathoracic goiters among 4122 patients undergoing surgical treatment between 1984 and 1996 due to various thyroid gland diseases including clinical data, surgical technics and early postoperative complications was performed. The surgical procedures of substernal and intrathoracic goiter amounted to 11.9% of all thyroid gland surgery. In 468 (95.5%) patients goiter was situated substernally, in 22 (4.5%) intrathoracicaly. The mean age and time of goiter growth in that location exceeded over 10 years the location of goiter within the neck. In preoperative examination the X-ray of chest and trachea were essential. Routine ultrasonography and thyroid gland scyntigraphy were scarcely helpful as the retrosternal and mediastinal region were often omitted. The jugular access was dominant (98.6%), sternotomy was performed in 1.4% of cases due to big disproportion between size of the goiter and size of the upper inlet into the chest. The surgical complications, similarly as in goiter within the neck (no cases of pneumothorax were observed), included the single-side paresis of recurrent laryngeal nerve in 3.7% of patients, in 0.2% hypoparathyroidism, in 1% bleeding requiring reoperation and in 0.2% esophageal fistula (self-healed). The surgical treatment of retrosternal and intramediastineal goiter was safe and a total number of complications was comparable to that one in a group of patients under-going surgery due to goiter within the neck. Most of surgical procedures was possible to perform using the jugular access. In a small number of cases because of difficulties related to the anatomical conditions the access was reached through the oblong sternotomy.

[Hodgkin's disease in the thyroid gland]. / Ziarnica zlosliwa gruczolu tarczowego.

The paper presents one case with diagnosed the primary extra-nodular Hodgkin's disease in the thyroid gland. Patient was operated on. Hodgkin's disease was diagnosed postoperatively in the paraffin-embedded tissues. In authors' opinion progress in the imaging technics with fine-needle aspiration biopsy allows to formulate diagnosis, and treatment which includes chemo- and radiotherapy, improves survival.

[Chromosome aberrations in patients with papillary thyroid cancer and other neoplasms]. / Aberracje chromosomalne u chorych z rakiem brodawkowatym tarczycy i innymi nowotworami.

Cancer is essentially a genetic disease resulting from congenital or acquired alterations in some cells of the patient. Such changes may occur in particular oncogens and are responsible for the tumour phenotype of the affected population of cells. In contrast, unaltered tumour-suppressor genes are responsible for suppressing the neoplastic phenotype, and their inactivation by deletion or mutation permits cancerous development in the affected cells. The genetic model of carcinogenesis is based on the idea mutations at the DNA level, what creates a functional imbalance between the oncogenes and the tumour-suppressor genes, resulting in uncontrolled clonal proliferation. The ret/PTC oncogene is unique to papillary thyroid cancer. The paper presents a correlation analysis between chromosomal changes in papillary thyroid cancer and abnormalities of chromosomes in patients with breast cancer and chronic lymphocytic leukemia.

[Neurilemmoma in the thyroid region]. / Nerwiak oslonkowy okolicy gruczolu tarczowego.

In the paper we present the group of 3 patients with neurilemmoma. Patients were operated on because of simple nodular goiter transformed into the thyroid carcinoma. In all cases final diagnosis was based on postoperative paraffin-embedded tissues. In the authors' opinion modern imaging technics strictly allows to formulate the preoperative diagnosis. Total resection with special attention paid to the postoperative examination including ultrasound diagnostics improve survival.

[Metastasis of clear cell carcinoma of the kidney to the thyroid gland]. / Przerzuty jasnokomórkowego raka nerki do tarczycy.

We preset three patients operated on at our hospital with diagnosed metastasis clear cell carcinoma of the kidney to the thyroid gland 5, 6, and 9 years after nefrectomy. Patients were operated on because of nodular goiter and metastases were diagnosed intraoperatively (frozen section) at two cases and postoperatively in the remaining care (diagnosis made by pathologist-microscopic examination). A radical thyroidectomy was employed without chemio- or radiotherapy which is now recommended as a method of treatment of clear cell carcinoma metastasis.

[Primary malignant lymphoma of the thyroid gland--diagnosis and treatment tactics]. / Pierwotny chloniak zlosliwy gruczolu tarczowego--rozpoznanie i taktyka postepowania.

The paper presents clinical signs, diagnosis, treatment and therapeutic results in the group of 10 patients with at primary malignant lymphoma of the thyroid gland. There were presented up to date methods of diagnosis and treatment with includes chemio- and radiotherapy. In authors opinion progress in imaging technics cyto- and histopathology, and potentiality of complex treatment allows us to avoid from surgery in most cases of malignant lymphoma of the thyroid.

[Acute intestinal ischemia in material of the III Clinic of General Surgery, Collegium Medicum at the Jagellonian University]. / Ostre niedokrwienie jelita cienkiego w materiale III Kliniki Chirurgii Ogólnej CM UJ.

The research work below focuses on a retrospective analysis of a group of 28 patients who suffered from acute intestinal ischaemia caused by upper mesenteric artery embolism of thrombus. The analysis is based on Clinic's own data in the years 1991-1995. The above mentioned patients constituted 3.4% of the 828 patients suffering from acute diseases of the abdominal cavity, accepted and treated in our Clinic. Their age ranged from 38 to 89 and average age was 72.4 y. There were 18 women (64.3%). Mesenteric embolism was the cause of intestinal ischaemia with 21 patients, whereas mesenteric thrombus with 7. Twenty four patients were operated on, the remaining 4 patients were disqualified from the operative procedure, 27 patients died. A considerable progression of the necrotic lesions of the intestines was found in all the patients operated on.