[Which lymphadenectomy in papillary thyroid gland carcinoma?]. / Welche Lymphadenektomie bei papillärem Schilddrüsenkarzinom?

BACKGROUND: The optimal treatment of papillary thyroid carcinoma (PTC) is still debated, also with respect to nodal treatment. METHOD: Retrospective analysis of a personal series of 159 patients with PTC, with respect to nodal disease, follow up 1-27 (mean 8) years. RESULTS: In 42 patients with clinical, macroscopic nodal disease (cN1) a therapeutic lymphadenectomy was performed, with pN1 status in 41 (98%) patients. 117 patients had no clinical or intraoperative suspicion of nodal involvement (cN0), with occult nodal disease in 5/29 (17%) patients undergoing prophylactic (elective) lymphadenectomy, and in 2/88 (2.3%) patients without primary lymphadenectomy (metachronous nodal disease) (p < 0.005). Nodal recurrences were observed (1-5 years after primary treatment for cure) in 5/42 (12%) pN1 and in 3/114 (2.6%) cN0, pN0 tumors (p = 0.009), with unfavourable outcome in 2 and 1 patients, respectively. The 20-year tumor specific survival was 100% in TNM I + II (low risk) patients (including pN1 and N0 tumors); the survival rate was deteriorated by stage pN1 vs. N0 in TNM high risk patients (50% vs. 86%; p = 0.03). DISCUSSION: The intraoperative macroscopic staging (cN) remains important:--clinical nodal disease warrants a systematic node dissection (microdissection), for preventing (curable or serious) nodal recurrences. Occult nodal disease does not evolve frequently in clinical nodal recurrence. A less radical (and only central) prophylactic lymphadenectomy, avoiding surgical morbidity, may be oncologically adequate. More sensitive detection of nodal positivity (frozen section of sampling tissue or sentinel nodes, immunohistochemistry) appears not rationale. In pN0, cN0 tumors use of prophylactic 131I may represent overtreatment, and follow up controls may be conducted less rigorously.

[Differential gene expression signatures in well differentiated thyroid carcinomas]. / Differentielle Genexpression in gut differenzierten Schilddrüsenkarzinomen.

Despite their common origin from follicular epithelial cells, papillary and follicular thyroid carcinomas differ in their histology and clinical course. In this study the transcriptional profiles of these tumors in comparison with normal thyroid tissue were established. The aim was the development of a molecular tool providing additional information to current histopathological diagnosis and allowing further insight into tumorigenesis. Genome wide expression profiling was performed using Human Unigene Set--RZPD 2 high density cDNA macroarrays comprising 76,000 genes as probes and radioactively labeled cDNA targets retrotranscribed from the isolated RNA of three papillary and three follicular thyroid carcinomas as well as three normal thyroid tissues. 8600 genes differing in their expression between the three groups were selected and printed onto subarrays. Radioactively labeled cDNA targets obtained from 16 papillary carcinomas, 13 follicular carcinomas and 17 normal thyroid tissues were hybridized to these subarrays. 200 genes exhibited a statistically significant expression difference between the two tumor types (p <0.01). In a hierarchical cluster analysis of 124 of these genes (46 known genes and 78 ESTs) the algorythm divided the tumor samples into two groups corresponding to the papillary and follicular thyroid carcinomas. The clearcut diagnostic potential of this method has to be corroborated in a prospective study. Several of the differentiallly expressed genes are known to play a role in tumor development and metastasis. Some of the genes up- or down-regulated in both tumor types are members of known oncogenic pathways in thyroid carcinomas. The complete understanding of complex genome wide expression profiles however awaits a longstanding advancement of hypothesis driven research.

[Differentiated thyroid carcinoma. Surgery and significance of lymph node involvement]. / Differenziertes Schilddrüsenkarzinom. Zur Chirurgie und Bedeutung von Lymphknotenbefall.

INTRODUCTION: Nodal treatment in papillary (PTC) and in follicular (FTC) thyroid carcinoma is still a subject of debate. METHODS: 1974-95 therapeutic lymphadenectomy (30/95), 1996-1999 frequent prophylactic lymphadenectomy (32/57; P = 0.005) was used for PTC, with therapeutic lymphadenectomy for FTC (15/115). 131I was used selectively for pN1-tumours. RESULTS: PTC: The incidence of pN0-, but not of pN1-status increased significantly (P = 0.03). Nodal recurrence was observed in 5/89 (6%) with therapeutic, vs. 1/54 (2%) with prophylactic lymphadenectomy (P = NS), i.e. in 1/107 (0.9%) patients without evidence of nodal disease, vs. 5/36 (14%) of those with pN1-status (P = 0.0004). Survival at 25 yrs. in stages TNM I and II was 100%, i.e., independent of N-status. FTC: No nodal recurrence was observed. CONCLUSION: Occult untreated nodal disease represented no major clinical problem. Selective nodal treatment may offer optimal results; meticulous nodal dissection is indicated for N1-tumours.

[Basedow disease. From subtotal to total thyroidectomy]. / Morbus Basedow. Von subtotaler zu totaler Thyreoidektomie.

BACKGROUND: Surgical treatment of Graves' disease is based on modern pathophysiolic understanding and adequate surgical tactic and technique. STUDY: This is an audit from one institution about 81 consecutive, prospectively documented patients, undergoing subtotal (remnant < 6 g) or total thyroidectomy, by the technique of capsular dissection. RESULTS: Patients were female in 89%, aged 11-79 (median 35) years. They constitute 9% of all thyroid operations, i.e. 47% of those performed for hyperthyroidism. Indications were persistence and recurrence of disease, orbitopathy, large goiter, nodule formation, refusal of radioiodine, preconception control. Preoperative treatment was thyrostatic (97%), iodine (87%), propranolol (50%). During the study period use of total thyroidectomy increased from 0% to 87% (p < 0.0001), and the remnant size decreased from median 3.5 g to 0 g (p < 0.0001). Goiter weight was 20-255 g, median 70.28 (23%) patients had concomitant colloid or adenomatous nodules, 5 (6%) had an incidental microcarcinoma, and 3 (4%) had a clinical papillary or follicular carcinoma, 1 patient had a parathyroid adenoma. Mortality was 0; surgical morbidity was early postoperative haemorrhage (n = 2 (2.5%)), permanent nerve palsy (1 patient with recurrence after previous resection (1.2%; 0.6% of nerves at risk)); no case of permanent hypoparathyroidism occurred. Functional results: In 6 patients (8%; 15% of those with subtotal resection) recurrent hyperthyroidism developed, 1 month to 8 years postoperatively, necessitating reablative treatment (surgical in 2 instances). 1 further patient developed preclinical hyperthyroidism 11 years postoperatively. Postoperative thyroxine substitution was found to be inadequate in 16/73 (20%) patients, as demonstrated by suppressed or elevated TSH values. Recurrence-free survival at 10 years was 100% in patients with a remnant measuring < 3 g, vs. 55.8% in those with a remnant size > or = 3-6 g (p = 0.002). Ophthalmopathy improved in 33/47 (70%) and deteriorated in 5 (10%) patients postoperatively, independently of the procedure (total or subtotal). CONCLUSIONS: Extensive or total thyroidectomy is necessary for late recurrence-free survival.--Variation of the spontaneous remnant function may occur and contribute to inadequate substitution.--(Near) total thyroidectomy has a low morbidity and is considered the treatment of choice, also with the theoretical advantage of complete autoantigene removal.--Surgical progress is based on capsular dissection with fine preparatory operative technique.

Differentiated thyroid carcinoma. Follow-up of 264 patients from one institution for up to 25 years.

UNLABELLED: The optimum treatment for differentiated thyroid carcinoma (DTC) is still debated. Results obtained using a selective treatment strategy for papillary (PTC) and follicular (FTC) thyroid carcinoma over 25 years in one institution are reported. 149 patients (mean age 46 yrs) had PTC in TNM stages I-IV in 58%, 26%, 15% and 1% respectively. Total thyroidectomy and remnant 131I ablation (43%) were carried out in TNM high-risk patients (stages III and IV) and in low-risk patients (I and II) at risk for a (curable) recurrence (stages pN1 and/or pT4). Hemi- or total thyroidectomy, without radioiodine, was used in 76% of pT1-3 N0 tumours (68%). Central and/or lateral lymphadenectomy was performed in 42% of patients (electively in the last 4 years). The mean follow-up was 7 years. RESULTS: 6 patients died of PTC and 8/143 patients treated for cure had a recurrence (6 nodal, 1 contralateral, 1 local). In low-risk patients--including 68% of patients aged > or = 45 yrs--the cause specific 25-year survival rate was 100%, vs. 62% (at 15 years) (p < 0.0001) in high-risk patients. In stage I and stage II the recurrence-free survival rates at 25 years were 95% and 100% respectively. Risk factors for recurrence were macroscopic (p < 0.0001) but not microscopic local invasion (pT4); stage pN1 (p = 0.0004). Only 1/107 patients initially judged node-negative had a nodal recurrence. FTC (n = 115; mean age 56 yrs; mean follow-up 8 yrs): Cause-related death (n = 8) or serious recurrence (n = 3) occurred in 10/53 grossly invasive FTC, in 1/45 minimally invasive FTC with vascular invasion, and in none of 17 FTC with capsular invasion (CI) alone, under radical treatment (131I) in 75%, 33%, and 12% respectively. 20-year disease-free survival in grossly and in minimally invasive FTC was 78% and 95.5% respectively (p = 0.0007). Patients aged < 45 yrs and patients with minimally invasive FTC with CI alone (all ages) had 100% 20-year disease-free survival vs. 80% (p = 0.013) in the remainder. There was no curable recurrence in FTC. The ratio of grossly invasive FTC decreased (p < 0.0001) during the study period. CONCLUSIONS: Risk-0 groups may be defined and selected for a reduced extent of treatment (PTC pT1-3 N0; FTC < 45 yrs, or CI alone). Older (> or = 45 yrs) patients with PTC in stages I and II have an excellent prognosis (risk 0). With selective (therapeutic) lymphadenectomy the risk of nodal recurrence may be very low in node negative tumours, without use of radioiodine. Meticulous lymphadenectomy is indicated in pN1 tumours with nodal recurrences despite 131I (5/36 patients). The technique of capsular dissection for extracapsular total uni- or bilateral thyroidectomy provides excellent oncological and surgical results. A decrease in the incidence of FTC parallels a decrease in endemic goitre in Switzerland.

[Therapy concept in differentiated thyroid gland carcinoma--results of 25 years with 257 patients]. / Therapiekonzept bei differenziertem Schilddrüsenkarzinom--Resultate über 25 Jahre bei 257 Patienten.

BACKGROUND: Differentiated thyroid carcinoma is a unique tumour in that a low risk-patient population with a tumour-related death rate of near 0% can be found. Yet in these patients the risk and risk factors of curable recurrences must be considered. The question therefore arises, whether in defined subgroups of low risk-patients a reduced extent of treatment (hemithyroidectomy, total thyroidectomy without 131I ablation) may result in cure without recurrence, including low morbidity of treatment and reduced costs. STUDY DESIGN: In a consecutive series of 257 patients suffering from papillary (146) or follicular (111) carcinomas operated by one surgeon over a period of 25 years, a reduced extent of treatment was carried out essentially in subgroups of minimally invasive follicular carcinoma, namely in pT1,2-tumors of young patients, or in those with capsular invasion alone, and in pT1,2 N0 papillary tumors, representing a subgroup of TNM stage I and II tumors. For N-staging selective lymphadenectomy was carried out at the beginning of the study, but elective lymphadenectomy was used since 1996 for papillary carcinoma. Follow-up was 1-25 (mean = 8) years. All excised tumors were examined by one pathologist. RESULTS: 167 (approximately 2/3) of the patients presented with a single nodule, whereas in 1/3 a concomitant benign nodular goiter or an immunothyropathy was found. The percentage of grossly invasive follicular carcinoma decreased during the 25 year period from 41 to 10% of all patients (p < 0.0005), whereas the percentage of papillary cancer rise from 35% to 66% (p < 0.005). Hemithyroidectomy, total thyroidectomy without, and with 131I ablation respectively, were performed in 32%, 24%, and 44% of patients. In papillary carcinoma N1-status was found in 21 (23%)/ 92 patients with selective, and in 18/54 patients (33%) with elective lymphadenectomy, respectively (n.s.). One (0.4%) patient died postoperatively. Permanent hypoparathyroidism occurred in 1.9% (3% for total thyroidectomy), permanent recurrent nerve lesion in 1.6% of patients (1% of nerves at risk). PAPILLARY CARCINOMA: No tumour-related death and no serious recurrence occurred in the low risk-group (TNM stages I and II) (n = 112 (84%)), including a T4-, N1-, M1-status in 9%, 20% and 3% of patients, respectively. 4/112 patients (3.6%) developed a recurrence (3 nodal, 1 contralateral, following 131I ablation in 2 instances). Only one (1%) instance of a nodal recurrence occurred in N0-tumors (n = 97). In TNM stages III and IV (high risk) patients (with T4-, N1-, M1-status in 79%, 58%, and 8% respectively), residual and recurrent disease occurred in 7 (33%) patients, leading to 6 (29%) tumor-related deaths. Follicular carcinoma: One 74-year old patient (1.6%) died from minimally invasive follicular carcinoma (n = 54 (51%); mean age 48 years). In 44 (81%) patients treatment did not include remnant ablation. 7 (13%) patients died from widely invasive follicular carcinoma (n = 53 (49%); mean age 64 years) and 3 (6%) further patients are alive with a serious recurrence. No curable recurrence was observed in follicular carcinoma. CONCLUSIONS: The decrease in goiter endemicity during the last decades in Switzerland paralleled a decrease in the incidence of grossly invasive follicular carcinoma over the 25 year period of the study. Following selective treatment, low risk TNM stage I and II-patients with papillary carcinoma had a tumor-related death rate of 0% and a low (3.6%) recurrence rate. N1-status represents a risk factor for nodal recurrence (even with remnant ablation). Elective vs. selective lymphadenectomy lead to slight stage migration but it presented no advantage in terms of recurrence and death which were rare events. No death occurred in the subgroups of minimally invasive follicular carcinoma of young (< 45) patients (41%) and in the patients without vascular invasion (28%), even without remnant ablation in most instances. No curable recurrence occurred in foll

[Jugular lymph node metastasis of papillary thyroid gland carcinoma 10 years later]. / Juguläre Lymphknotenmetastase von papillärem Schilddrüsenkarzinom vor zehn Jahren. Ein Fallbericht.

We present a patient with occult papillary thyroid carcinoma, in whom a single nodal metastasis had been excised. Ten years later a nodal recurrence was diagnosed by ultrasound and fine needle aspiration cytology. The diagnosis of recurrence was erroneous, and we discuss the differential diagnostic problems, the natural course, and the adequate treatment of occult papillary microcarcinoma.

Manifold manifestations of ergotism.

Vasospastic side effects leading to organic manifestations are rare in ergotamine therapy. To our knowledge, combinations of more than two signs of ergotism have rarely been described in the literature so far. We present a 65-year-old male patient who as a consequence of severe migraine had developed ergotamine abuse. He was admitted to our hospital after one week of increasing abdominal pain. During laparotomy, necrotic areas of the small intestine and the sigmoid colon were resected, which on histopathologic examination revealed severe hypertrophy of the smooth musculature of mesenteric arteries, resulting from chronic vasospasms. Postoperatively, the patient developed ischaemia of the limbs which was confirmed by angiography. Before death, the patient also showed ischaemic signs in the acrae and necrosis of the tongue.

[Small thyroid carcinomas: biological characteristics, diagnosis and therapy]. / Kleine Schilddrüsenkarzinome: Besonderheiten der Biologie, Diagnostik und Therapie.

Small thyroid carcinomas (< or = 1.5 cm), including microcarcinomas (< or = 1.0 cm) (n = 39), were found in 53 patients (41%) with a papillary (n = 130) and in 4 cases (4%) with a follicular (n = 110) carcinoma. The tumour was clinically manifested by palpability or by the presence of nodal metastases in 1/3 of patients. Concomitant diagnoses were colloid goitre (n = 24), cellular adenoma (n = 11), Graves' disease (n = 6), and Hashimoto's thyroiditis (n = 4). Nodal involvement, multifocal tumour, and extrathyroidal extent (pT4) were present in 9%, 19%, and 8% of cases respectively. Small follicular carcinomas were minimally invasive in all instances. According to the age-related prognostic TNM-classification, 52 patients (91%) were in the low risk category. 18% of the patients underwent uni- or bilateral partial lobectomy, 35% hemithyroidectomy, and 47% total thyroidectomy, according to the extent and nature of the concomitant benign disease, whereas hemi- or total thyroidectomy was performed in the patients with known cancer. Four of 5 patients with stage pT4 cancer and all patients with nodal involvement underwent total thyroidectomy with radioiodine (n = 8 [14%]). Postoperative morbidity was 0%. During the follow-up period of 1-17 (x = 5.5) years no tumour-related death and no serious recurrence was noted. One node recurrence was removed 1 year following treatment of a stage III pT1aN1b papillary carcinoma; the patient died 4 years later accidentally without residual disease. These results confirm that cases with a potentially favourable course can be defined and treated selectively by less radical measures. Small carcinomas (< or = 1.5 cm) belong to these favourable tumours with a cancer mortality rate of virtually 0%, and the aim of treatment is to prevent curable recurrences: node positivity is an important risk factor, and therefore radioiodine is reserved for carcinomas with nodal involvement and also for the occasional small pT4-tumour.

[Visceral pain in acute abdomen]. / Viszeraler Schmerz bei akutem Abdomen.

Visceral pain is caused by either distension or contraction of the visceral muscular wall or obstruction of hollow gastrointestinal organs. Unlike the somatic pain due to peritonitis, visceral pain is diffuse, epigastric, periumbilical and is often accompanied by nausea, vomiting and restlessness. We demonstrate the significance of visceral pain in the differential diagnosis of the acute abdomen presenting five cases of appendicitis and cholecystitis. A correct early diagnosis of the acute abdomen while signs of local peritonitis are still absent (appendicitis in atypical location, recurrent acute appendicitis, spontaneous reopening of an occlusion) is facilitated by the awareness for the characteristics and symptoms of visceral pain, and therefore careful taking of the patient's history. A history lacking visceral pain on the other hand represents an important clue for the diagnosis of other conditions (gynecological, diverticulititis, etc.) with acute pelvic peritonitis.

[Megacolon and megarectum in adults. Abdominal proctectomy with colo-anal anastomosis]. / Megakolon und Megarektum beim Erwachsenen. Abdominale Proktektomie mit koloanaler Anastomose.

Severe constipation in adults with megarectum may be a manifestation of Hirschsprung's disease or idiopathic megarectum. The differential diagnosis is discussed in the light of two case histories. Total abdominal proctectomy with coloanal anastomosis eliminated the aganglionic rectal segment in Hirschsprung's disease and the adynamic distal colorectum of idiopathic megarectum respectively. The surgical and functional results of a hand-sewn transanal end-to-end-anastomosis were excellent in both patients.

[Esophageal surgery in the regional hospital]. / Osophaguschirurgie am Regionalspital.

In a small series of surgically treated patients with esophageal cancer (n = 22) modern trends are observed, namely--the frequent occurrence of adenocarcinoma (50% of cases) and of early stage (pT1) (36% of cases),--a low operative mortality (5%),--favorable oncological results for tumors not penetrating the esophageal wall (pT1, 2)(64% of patients at life without recurrence 2-7 1/2 years after surgery). For curative or palliative resection of distal tumors the abdomino-cervical (transhiatal) resection was favored (n = 17) with no instance of anastomotic insufficiency and with 2 cases only of locoregional recurrence. In a case of spontaneous esophageal perforation (Boerhaave) primary suture through an abdomino-transhiatal approach was successful. The interdisciplinary intensive care, necessary in surgery of the esophagus, may be of a high standard in the district hospital.

[Surgery of rectal carcinoma: 1997 status assessment]. / Die Chirurgie des Rektumkarzinoms: eine Standortbestimmung 1997.

The rectum and mesorectum are enclosed in a fascial sheath, the fascia propria, and represent an anatomical entity of abdominal origin. This package is a well-known anatomical and oncological base for radical rectal cancer excision. It is at present under discussion again under new aspects: The surgical and oncological quality of rectal cancer excision is largely surgeon-dependent. Modern rectal surgery is refined, with sharp, very precise dissection respecting the relevant fascial planes, identifying and protecting the autonomous pelvic nerves and achieving radical locoregional tumor clearance, thus virtually eliminating the serious problem of pelvic recurrence. In this overview the concept of total mesorectal excision (TME) is explained and open questions are discussed. It remains to be determined whether a refined and anatomically precise operative technique or the oncologic concept of TME are of primary importance, and also whether patient selection influences the results to some degree.