Skip metastases to lateral cervical lymph nodes in differentiated thyroid cancer: a systematic review.

Papillary thyroid carcinoma is a slow-growing cancer with a generally good prognosis that sometimes have an aggressive behaviour. Metastases to neck lymph nodes is the first step of the diffusion. The central neck compartment is involved most commonly. The ipsilateral lateral neck compartments are usually involved afterwards, and the involvement of the contralateral one is considered a quite rare occurrence. In more rare cases, metastases to lateral neck compartment without central lymph node metastasis (so called "skip metastases") could be observed. Aim of this literature review study is to analyse the average incidence, pattern and risk factors of this occurrence.This study was performed according to PRISMA criteria. A final selection of 13 articles published in English language from 1997 to 2017 was performed. Any research article, review or meta-analysis was taken into consideration. Research was expanded considering the related references of articles.The incidence of skip metastases ranged from 1.6 to 21.8%. Risk factors such as age > 45 years, size < 5 mm and tumor located in the upper pole or isthmus of thyroid gland were found.Due to the frequency of skip metastases in thyroid cancer, a careful preoperative examination of lateral lymph nodes should be necessary.

Characterization of adrenocortical tumors by 18F-FDG PET/CT: Does steroid hormone hypersecretion status modify the uptake pattern?

BACKGROUND: adrenal tumor-to-liver uptake value (Tmx:Lmx) on 18F-FDG PET/CT is an accurate and reproducible PET parameter in the distinction between benign and malignant adrenal masses. The potential impact of steroid hormone secretion on 18F-FDG uptake is still debatable. The aim of this study was to evaluate this relationship. METHODS: 2010-2015: 73 patients who underwent adrenalectomy for adrenocortical tumors [49 secreting/(SA) and 24 non-secreting/(NSA)] were retrospectively included in the study. Fourteen were malignant. All patients underwent hormonal evaluation, functional and anatomical imaging, Weiss scoring and Ki 67 evaluation. RESULTS: malignant tumors exhibit higher SUVmax than benign tumors (median 7.75 vs 3.06 respectively, p < 0.001) and Tmx:Lmx was 2.7 vs 1.17 for benign tumors, p < 0.001. Tmx:Lmx was positively correlated to Weiss score (p < 0.001). No significant difference was observed for Tmx:Lmx between SA and NSA overall (p = 0.851), regardless of the subgroup of tumors analyzed. Tmx:Lmx was not correlated to tumor size (p < 0.508) or 24 h free urinary cortisol level (p < 0.522). CONCLUSIONS: no correlation was observed between Tmx:Lmx and hormonal status, however the correlation between ratio, malignancy and Weiss score confirm the utility of 18F-FDG PET/CT for the differentiation of benign from malignant adrenal lesions, irrespective of the hormone secretory status of the tumor. 18F-FDG PET/CT is a useful biomarker in the diagnosis of adrenal tumors, regardless of the secretion status.

The prevalence of post-thyroidectomy chronic asthenia: a prospective cohort study.

PURPOSE: Chronic asthenia (CA) is complained by some patients that have undergone thyroid surgery. We evaluate its impact in patients undergoing unilateral or bilateral thyroidectomy, the trend during a 1-year follow-up, and the possible risk factors. METHODS: A prospective, cohort study was carried out on 263 patients scheduled for thyroidectomy from 2012 and 2014. Exclusion criteria were as follows: Graves' disease, malignancies requiring radioiodine therapy, post-surgical hypoparathyroidism, laryngeal nerve palsy, abnormal pre- and post-operative thyroid hormone levels, and BMI outside the normal range. Demographics; smoking and alcoholism addiction; cardiac, pulmonary, renal, and hepatic failure; diabetes; anxiety; and depression were recorded. The Brief Fatigue Inventory (BFI) was used to evaluate CA and its possible association with these comorbidities 6 and 12 months after thyroidectomy. RESULTS: One hundred seventy-seven patients underwent total thyroidectomy (TT), 54 hemithyroidectomy (HT). Thirty-two patients were not recorded because of the onset of exclusion criteria. In the 6 months after thyroidectomy, in the TT group, 64 patients (36.16%) reported an impairment in the BFI score and only 1 in the TL group. The mean BFI score changed from 1.663(±1.191) to 2.16 (±11.148) in the TT group, from 1.584 (±1.371) to 1.171 (±1.093) in the TL group (p < 0.001). No further significant variations in BFI were reported 1 year after surgery. CONCLUSIONS: CA worsened after TT, but not after HT. Apart from operative procedure itself, no other risk factor was found be significantly associated with post-thyroidectomy asthenia. Further investigation is needed to determine the causes of CA.

Role of prophylactic central neck dissection in cN0-papillary thyroid carcinoma: results from a high-prevalence area.

BACKGROUND: Prophylactic, compartment-oriented central neck dissection (CND) for cN0 papillary thyroid carcinoma (PTC) is not widely practiced. We examined our results with this surgical approach. METHODS: A cohort of 158 patients operated on for the classical variant of PTC at a follow-up of 1-22 years (mean: 6.6) were enrolled. The patients with a preoperative diagnosis of cN0 PTC (group A, 59 patients) underwent total thyroidectomy (TT) + CND. In the patients with incidental postoperative diagnosis of malignancy (group B, 99 patients) a TT alone was performed. RESULTS: Ninety-six T1, 36 T2, 26 T3/T4 PTC patients were enrolled. The overall biochemical/scintigraphic recurrence rate (15 patients, 9.49%), was significantly higher in group B. Disease-free survival and need for postoperative radioiodine ablative treatment were more favorable in group A (P<0.05; P<0.001, respectively). The median radioiodine ablative treatment in the T2 cluster alone was lower in group A (P<0.001). The morbidity rate was similar in both groups. CONCLUSION: Considering the acceptable morbidity, prophylactic CND seems to be advantageous in terms of recurrence rate and need for radioiodine treatment in this variant of PTC, at least in T2 or more advanced stages. The indolent behavior of PTC does not allow for reliable prognostic evaluations.

A case of splenic rupture: a rare event after laparoscopic cholecystectomy.

BACKGROUND: Laparoscopic cholecystectomy (LC) is generally safe and well-accepted. In rare cases, it is associated with complications (intra- e postoperative bleeding, visceral injury and surgical site infection). Splenic lesion has been reported only after direct trauma. We report an unusual case of splenic rupture presenting after "uncomplicated" LC. CASE PRESENTATION: A 77-year-old woman presented with distended abdomen, tenderness in the left upper quadrant and severe anemia 12 hours after LC. Clinical examination revealed hypovolemic shock. Abdominal computed tomography confirmed the diagnosis of splenic rupture, and the patient required an urgent splenectomy through midline incision. The post-operative course was uneventful and the patient was discharged on 7th postoperative day.Splenic injury rarely complicates LC. We postulate that congenital or post-traumatic adhesions of the parietal peritoneum to the spleen may have been stretched from the splenic capsule during pneumoperitoneum establishment, resulting in subcapsular hematoma and subsequent delayed rupture. CONCLUSIONS: Splenic rupture is an unusual but life-threatening complication of LC. Direct visualization of the spleen at the end of LC might be a useful procedure to aid early recognition and management in such cases.

Carcinoma showing thymus-like differentiation (CASTLE): a case report.

INTRODUTION: Carcinoma showing thymus-like differentiation (CASTLE) is a rare malignant thyroid cancer. We report a case of CASTLE treated with surgery and adjuvant external neck radiation therapy. MATERIALS AND METHODS: We experienced a case of CASTLE in a 63-year-old man, who presented with a neck mass due to enlarged and hard thyroid gland, most notably in the right lobe, without palpable cervical nodes. RESULTS: Total thyroidectomy was performed for both diagnostic and therapeutic purposes. Histologic examination of the specimen showed a "thymus like" thyroid cancer; the tumor, partially circumscribed, lobulated, involved both lobes, and in more points reached the capsule of the organ and infiltrated perithyroid muscle tissue. After immunohistochemical assay (CK19 +, CK20 -, thyroglobulin -, calcitonin -, CD5 +, CD117 +), a diagnosis of CASTLE was made. DISCUSSION: CASTLE is a rare, malignant tumour of the thyroid gland, with histopathological features similar to squamous cell carcinoma, but with a more favourable prognosis. Preoperative diagnosis is difficult. CASTLE is usually cured surgically with total thyroidectomy and selective neck dissection, followed by radiotherapy. CONCLUSIONS: Surgery and radiotherapy are effective to manage thyroid CASTLE tumors.