Differentiated thyroid tumors: surgical indications.

Thyroid gland tumors represent 1% of malignant tumors. In Italy their incidence is in constant growth. The aggressiveness depends on the histological type. The relative non-aggressive grade of different forms of tumors is the basis for discussing the treatment of choice: total thyroidectomy vs lobectomy with or without lymphadenectomy of the sixth level in the absence of metastasis. Authors report about their experience, and they advocate, given the high percentage of multicentric forms, total thyroidectomy as treatment of choice.

A useful ultrasound score to select thyroid nodules requiring fine needle aspiration in an iodine-deficient area.

BACKGROUND: The high prevalence of thyroid nodules in iodine-deficient areas is a practical problem because of the large number of patients requiring fine needle aspiration (FNA) to detect malignant nodules. AIM: To obtain an ultrasound (US) score for predicting malignant nodules and reduce the number of unnecessary and expensive FNA. SUBJECT AND METHOD: All nodules observed from September 2001 to March 2006 were evaluated by US: echostructure, echogenicity, halo, microcalcifications and ratio between antero-posterior and transversal diameters (AP/TR). Two thousand six hundred and forty-two consecutive patients underwent US-guided FNA for a total of 3645 nodules. RESULTS: Logistic regression analysis showed a potent predictive role for solitary nodules and absence/ incomplete halo (p=0.000). A significant predictive role for microcalcifications and AP/TR ratio was also observed. A 10-point score was constructed using the standardized regression coefficient. Nodules with US score or=5.5 had a frequency of malignancy of 0.4, 1.1 and 5.6% (p<0.001), respectively. Nodules with >or=5.5 US score were characterized by a 66% sensitivity and a 76% specificity compared to the diagnostic values of single parameters which were either sensitive or specific. CONCLUSIONS: According to our data, we suggest FNA for nodules reaching a >5.4 US score, whereas a clinical judgement should be used for the intermediate category nodules. When the score is lower than 2.5 we do not recommend FNA. The practical use of this US score can help reduce unnecessary and expensive FNA in iodine-deficient areas.

Surgical treatment of sporadic medullary thyroid carcinoma: strategy and outcome.

BACKGROUND: Medullary Thyroid Carcinoma (MTC) originates from the thyroid C cells and accounts for approximately 5-9% of all thyroid cancers. Aim of this study was to retrospectively evaluate the outcomes of 41 patients with MTC who underwent treatment at our institution. PATIENTS AND METHODS. We reviewed the records of 41 patients who underwent surgery between 1995 and 2004. The patients were divided into two groups: A) patients (n 30) without any previous surgery. B) patients (n 11) previously thyroidectomized and high calcitonin levels with or without radiological evidence of local regional or distant metastases. We performed total thyroidectomy with central compartment lymphadenectomy and ipsilateral modified radical neck dissection in group A patients. Group B patients underwent re-excision of the central neck compartment and bilateral modified radical neck dissection if it had not been previously performed. RESULTS: Most patients had major reduction in postoperative calcitonin levels. Compartmental dissection of the cervical node significantly improved the results of primary surgery and calcitonin returned to normal levels in approximately 60% of the patients in group A, but only the 30% of the patients in group B. CONCLUSIONS: The extent of the primary surgical resection and the evidence of local or distant metastases significantly influence the outcome of MTC patients. An extensive lymphadenectomy performed early in the treatment and re-operative cervical lymphadenectomy in patients with persistently high calcitonin levels after thyroidectomy significantly improved the outcome, although re-operation rarely results in normalized calcitonin levels and is associated with a higher incidence of complications.

Fine needle aspiration cytology of thyroid nodules: conventional vs thin layer technique.

OBJECTIVE: Liquid-based cytology using the thin layer technique has recently been introduced in thyroid fine needle aspiration cytology together with or in substitution of direct smears, but its usefulness is still controversial and relatively few studies have been published in this field. The aim of the present study was to compare the results obtained from conventional smears with those from thin layer smears. DESIGN: In 3875 thyroid nodules, a double cytologic sampling was taken in randomized order, to prepare conventional or thin layer smears. MAIN OUTCOME: The diagnoses agreed in 2934 (75.7%) cases and disagreed in 941 (24.3%). The analysis of discordant data showed there were fewer non-diagnostic cases in the thin layer smears (377 vs 541, p<0.001) whereas in conventional smears there were more cases positive for carcinoma (27 vs 4, p<0.001). The cytohistologic correlation was available for 194 cases and showed that conventional smears had a greater capacity for revealing carcinomas (44 vs 31). Finally, diagnoses based on conventional smears were more sensitive than thin layer smears (93.6% vs 65.9%) whereas specificity was constant. CONCLUSIONS: From our experience, the conventional smear offers a greater possibility of diagnosis when suspecting malignancy or diagnosing malignancy cases, whereas thin layer smears significantly reduce the number of non-diagnostic cases. For this reason, we suggest combining the two techniques in routine cytologic diagnosis.

A randomized controlled trial to evaluate the efficacy of ultrasound-guided laser photocoagulation for treatment of benign thyroid nodules.

This randomized controlled study was designed to test the efficacy and safety of percutaneous ultrasound (US)-guided laser photocoagulation (PLP) for treatment of subjects with compressive symptoms due to benign thyroid nodules and/or at high surgical risk. Twenty six subjects were randomized to the intervention (no. 13, age 68+/-3 yr, mean+/-SEM) or observation (no. 13, age 71+/-2 yr) groups. In the control group, the volume of nodules did not significantly change over the 30 week period of observation. In the intervention group, median nodule volume at baseline was 8.2 ml (range 2.8-26.9) and was not significantly different from that of the control group. Nodules decreased significantly (p<0.0001) by 22% after 2 weeks (6.5 ml; range 2.4-16.7) and by 44% after 30 weeks (4.6 ml; range 0.69-14.2). Energy given was correlated (p<0.05) with the reduction of thyroid nodule volume. All patients tolerated the treatment well and reported relief from compressive and cosmetic complaints (p<0.05). At the time of enrolment 7/13 (54%) and 6/13 (46%) of patients in the intervention and control groups, respectively, had sub clinical hyperthyroidism. PLP normalized thyroid function at 6 and 30 weeks after treatment. In conclusion, PLP is a promising safe and effective procedure for treatment of benign thyroid nodules in patients at high surgical risk.

[Male breast cancer. Five years experience and literature review]. / Il cancro della mammella maschile. La nostra esperienza di 5 anni e confronto con la letteratura internazionale.

Male breast cancer is an uncommon disease and its aetiology, clinical behaviour and treatment is not well-known . Retrospective studies show that age and stage-matched breast cancer in men and women are compared. Nevertheless, the poor mammary tissue in man allow a rapid local infiltration, late diagnosis and poor survival rate. The Authors report their five years experience and with a short literature review they summarise what is currently known about this uncommon neoplasm in terms of prognostic factors, therapy and survival.

[Lymphectomy in differentiated thyroid cancers: our experience]. / La linfectomia nelle neoplasie differenziate della tiroide: nostra esperienza.

INTRODUCTION: At present we are still debating on which is the most adequate therapeutic strategy concerning the size of the thyroidectomy and the extension of the lymphectomy in differentiated thyroid tumors. PATIENTS AND METHODS: From January 2000 to December 2005, 334 operations for thyroid neoplasms have been performed; 304 (91%) for differentiated tumors. In 124 cases (37%) the latero-cervical and/or the central compartment lymphectomy have been associated with thyroidectomy: 79 monolateral and central compartment lymphectomies (ML and CCL) (64%), 11 bilateral and central compartment lymphectomies (BL and CCL) (8%), and 34 central compartment lymphectomies (CCL) (28%) have been performed. RESULTS: Out of the 124 lymphectomies, in 44 cases (35.5%) we found the presence of metastasis in the lymph nodes of latero-cervical and central compartments, in 10 cases (8%) absence of metastasis in the lymph nodes of the latero-cervical and central compartments, in 25 cases (20%) presence of metastasis in the latero-cervical lymph nodes and absence of metastasis in the lymph nodes of the central compartment. In 11 cases of bilateral and central compartment lymphectomies, 5 of them (4%) had positive lymph nodes of the latero-cervical and central compartments, while the other, only 6 (5%), had positive latero-cervical lymph nodes on the same side as the neoplasia. In 34 central compartment lymphectomies there was absence of metastasis. Mortality rate was zero. There was one case (0.8%) of recurrent laryngeal nerve temporary bilateral palsy (RTBP); 4 cases (3.2%) of recurrent temporary monolateral palsy (RTMP); 2 cases (1.6%) of definitive monolateral palsy (DMP); 29 cases (23.5%) of temporary hypoparathyroidism (TH); 7 cases (5.5%) of definitive hypoparathyroidism (DH). CONCLUSIONS: Latero-cervical lymphectomy should be performed by necessity when clinical tests or pre-diagnostic exams show suspect lymph nodes, whereas central compartment lymphectomy should be performed in any case of thyroid neoplasia.

[Thyroid microcarcinoma: our experience]. / Microcarcinoma tiroideo: nostra esperienza.

Differentiated thyroid cancer had an excellent prognosis; the diagnosis of sub-centimetric differentiated cancer (microcarcinoma) is more and more frequently. Clinical evolution of microcarcinoma could be various: microcarcinoma can represent an autoptic finding or can evolve with locoregional lymph node involvement or metastasis. Various clinical and genetic factors have been considered to predict the aggressiveness of this neoplasm. From 2001 to 2004, 74 patients with diagnosis of thyroid microcarcinoma underwent surgical treatment. By a retrospective survey we evaluated risk factors and the choice of surgical treatment. The aggressiveness appear to be related mainly to multifocality and size. Our therapeutic strategy is to perform total thyroidectomy for benign pathologies, total thyroidectomy with lymphadenectomy in cases with preoperative diagnosis of microcarcinoma.

Breast surgery and sentinel node biopsy. Our experience.

Massive campaigns of screening of breast pathologies improved early diagnosis of breast cancers. Most of these cancers are small-sized (T1) and seldom show intraoperative nodal involvement. Sentinel node biopsy is the elective choice in the above mentioned cases because, if negative, it avoids axillary dissection. International literature reports rates of false negative sentinel node biopsy ranging among 4.5 and 12%; results in our experience account for almost 6%. As a consequence, there is the definite risk of potentially positive axilla that will not be dissected with subsequent risk of axillary recurrence within 24 months. The reason of that could be related to the fact that in Referral Centers this technique is performed in strictly selected patients, so as to gain a diagnostic accuracy of 98%. The rate of axillary recurrences does not justify the routine axillary dissection, since this is just a staging, not a therapeutic procedure. In case of doubt, it can be recommended a close and careful follow-up of the axilla.

[Granulomatous mastitis: diagnostic and therapeutic problems. Case report and review of the literature]. / Mastite granulomatosa: problemi di diagnosi e terapia. Presentazione di un caso e revisione della letteratura

The granulomatous mastitis is uncommon inflammatory disease of the breast of unknown etiology. The diagnosis is obtained only through hystopathology. We report a case of woman, 41 years old, showing lesions of the breast, that caused strong pain with ulcerations sero-haematic secretion and axillary omolateral lymphadenopathy. The diagnostic workup (sonography, mammography, multiples FNAB of single lesions, the culture of cells and hormonal profile) showed an inflammatory aspecific lesions with presence of atipic cells in nipple's secretion and in FNAB of periareola lesion. We performed an excisional biopsy. The hystopathologic diagnosis showed a granulomatous mastitis, confirming the validity of our diagnostic and therapeutic choices. The excisional biopsy has allowed to avoid an overtreatment and obtain a good aesthetic result.

[Bile leakage after laparoscopic cholecystectomy: report of three cases in our experience]. / Coleperitoneo dopo colecistectomia laparoscopica: descrizione di tre casi nella nostra esperienza.

Laparoscopic cholecystectomy (LC) is associated with an higher incidence of bile duct injury than open cholecystectomy. There has been concern and the reason why bile leakages are more frequent with LC is yet unclear. Bile collections can occurr because of major about (75%) or minor (about 25%) injuries. Anyway, external biliary decompression is a key factor in the treatment, in order to avoid an emergency intervention. The Authors report their experience concerning 3 cases of bile leakages among a series of 458 LC. Only in one of the three cases the subhepatic space was not drained and an emergency laparotomy was performed. The Authors, on the basis of their own experience and of the data reported in literature, suggest the routinary intraoperative placement of a drainage into the subhepatic space, to be removed, if no complications occur, one day after surgery.

[Interstitial laser photocoagulation in liver tumours: our experience]. / Laserterapia interstiziale nell'epatocarcinoma su cirrosi: nostra esperienza.

Interstitial lasertherapy (ILT) is one of the percutaneous thermal procedures allowing the ablation of primary or secondary hepatic lesions. This technique can be performed without general anaesthesia, since the patient is completely painless, in spite of the high temperatures reached, because there are no sensitive fibers around the lesion. This study includes patients with small hepatocarcinomas (< 2 cm) non peripherically sited, far from the gallbladder and the hepatic hilum. Twenty patients suffering from 24 cirrhotic hepatocarcinomas (two patients showed two nodules) have been enrolled for the present study. Mean diameter of lesions was 1.8 cm (1.3-2 cm). One or more 21 G (length 20 cm) Chiba's needles were inserted under sonographic view into the lesions. The laser energy was switched on at 4 Watts for 4-6 minutes, until an amount of energy of 900-1800 Joule was reached. All the patients were discharged 48 hours after the procedure. Triphasic CT-scan with contrast were performed 7 to 14 days after ILT, in order to check its efficacy. CT-scan showed complete necrosis in all the nodules ranging from 1.5 to 3 cm. All the patients received only one IL T session, whose longest duration was 20 minutes. No major complications occurred. ILT of small hepatocarcinomas is a safe, efficient procedure, also feasible without anaesthesia. Differently from percutaneous radiofrequency, in fact, it shows the advantage of less pain, that can avoid the need for general anaesthesia.

Which therapy to prevent post-thyroidectomy hypocalcemia?

Hypocalcemia is one of the most frequent complications after total extracapsular thyroidectomy (TET). In most of cases it is a transient phenomenon. The aim of this study is to evaluate if and how the oral administration of calcium or calcium combined with D-vitamin could effectively prevent post-thyroidectomy hypocalcemia. A randomized prospective study was performed, recruiting 120 patients who underwent total thyroidectomy. The patients in our series were randomly assigned to one of two groups: group A--patients who received calcium lactogluconate/calcium carbonate (mg 300 per day); group B--patients who received calcium carbonate/cholecalciferol therapy (calcium carbonate: 1500 mg per day; cholecalciferol 400 UI per day). The groups were well matched for age, sex and pathologies. Patients of both A and B groups were divided in two subgroups: those operated on for benign thyroid diseases (A1 and B1) and those operated on for malignancy (A2, B2). Serum calcium assays, performed 24, 48 and 72 hours after surgery, showed mean values of calcemia higher in patients of the B1 and B2 group. Statistical analysis was performed using a Student's t test. Mean serum calcium concentrations on post-operative day one, two and three were higher in patients of the group B (p<<0.01). Early and combined oral administration of both calcium and vitamin D seemed to prove major efficacy in preventing and treating post-operative hypocalcemia, showing mean serum calcium levels higher than those of patients who received only oral calcium administration. Nevertheless, further studies are necessary to validate these data.

Major complications in thyroid surgery: utility of bipolar vessel sealing (Ligasure Precise).

In the present study the Authors tried and assess the advantages of the standard sutureless thyroidectomy performed by the Ligasure Vessel Sealing System, thanks to the use of the dedicated Precise handle. The Authors compared the efficacy of haemostasis and the economical impact of the device, in terms of drug administration and costs. The Authors comparatively analyzed 120 total extracapsular thyroidectomies (TET) performed by the standard operative technique (Group A, control) and 70 TET achieved by the "sutureless technique" (Group B, case). There was a statistically significant decrease of transient postoperative hypocalcemia (5.71% vs 7.5%) and also of mean operative time (about 20 minutes) in patients of the group B. Non significant decrease of other kind of complications (postoperative hemorrhage, transient and permanent inferior laryngeal palsy, stupor of the superior laryngeal nerve, seromas) were also observed. The use of the Ligasure Precise resulted easy, safe and efficient in the Authors' experience. It allowed the decrease of postoperative haemorrhages and mean operative time.

[Neoplastic residues in the trocar tract in oncologic laparoscopic surgery]. / Recidive neoplastiche in sede di trocar nella chirurgia oncologica laparoscopica.

AIM: The laparoscopic approach to malignant diseases runs up against both old and new problems: respect for the principles of radicality, operating times, the postoperative course and surgical complications, long-term oncological results in terms of survival and recurrence of the disease. One of the problems which has received most attention regards the onset of a metastasis on a trocar scar or a mini-laparotomy recurrence. Trocar site tumor recurrences have been described in the literature following laparoscopic surgery in almost all abdominal malignant pathologies (colorectal, gynaecological, pancreatic, etc.) and even after thoracoscopy. The real frequency is currently of the order of 1% (0-2%) in colic surgery and of 14% (10-17%) after cholecystectomy for occult gallbladder carcinoma. METHODS: A retrospective survey was carried out of our laparoscopic experience; between 1994 and 2002 213 colic resections were carried out for cancer; we also observed 18 occult carcinomas of the gallbladder in 2386 laparoscopic cholecystectomies for lithiasis. RESULTS: Respectively 2 cases (11%) of trocar site neoplastic recurrences in gallbladder carcinoma and 2 cases (0.9%) from colon carcinoma were observed. CONCLUSIONS: The real extent of the problem would appear to be on a much lesser scale at the moment than was initially thought, especially as regards colic surgery. The multifactorial aetiology of the problem explains the importance of their prevention, on the basis above all of rigorous respect for the rules and protocols of laparoscopic technique.

[Laparoscopic right hemicolectomy with intracorporeal anastomosis. Technical aspects and personal experience]. / Emicolectomia destra laparoscopica con anastomosi intracorporea. Aspetti tecnici e nostra esperienza.

BACKGROUND: Laparoscopic colo-rectal surgery has gained wide acceptance as a treatment in a variety of benign and malignant diseases. The reproducibility and safety of all the principal colo-rectal procedures has been demonstrated, but some indications are still controversial. A great part of surgeons perform right hemicolectomy by laparo-assisted technique and consider it more difficult than left hemicolectomy. METHODS: A retrospective analysis of a series of 180 laparoscopic colon resections performed between 1994 and 2001 is presented. Surgical indications were: 46 cases of benign disorders and 134 colonic malignancy. The right hemicolectomy were 27 (15%): 2 benign and 25 malignant diseases. The technical aspects of completely laparoscopic right hemicolectomy is described in details. A completely mechanical intra-corporeal anastomosis is always performed. To remove the bowel specimen from the abdominal cavity it is put it in a large bag and pull it out of a 3-4 cm enlargement of a trocar-site (in the umbilical scar). RESULTS: Data of the 27 laparoscopic right hemicolectomy were analysed: there was 1 conversion to open surgery; no intra-operative complications were observed; the postoperative period was complicated by 1 anastomotic fistula. The median operative time was of 150 minutes. No case of port-site recurrence was observed. CONCLUSIONS: The laparoscopic colo-rectal surgery can reproduce in selected patients, the techniques performed in open surgery with minimally invasive treatment. It is possible to perform a completely laparoscopic right hemicolectomy after an adequate training in advanced laparoscopy, anyway there are many advantages: less postoperative pain, short-term postoperative ileus, earlier return to daily activity.

Influence of menstrual factors and dietary habits on menstrual pain in adolescence age.

OBJECTIVES: The aim of this study was to determine the frequency of the primary dysmenorrhea in adolescence age and investigate correlation between menstrual factors, dietary habits and this pathology. STUDY DESIGN: The sample was constituted from 356 students that were subjected to questionnaire, abdominal ultrasound, and in some cases, hormonal dosing. RESULTS: The frequency of the primary dysmenorrhea was 85%. Early menarche was related to an increase of its prevalence and its severity. A long and heavy menstrual flow was related to an increase of its severity. As far as dietary habits, it was noted that a higher consumption of fish, eggs, fruit and a lower consumption of wine is correlated with a lower frequency. CONCLUSION: Primary dysmenorrhea is very common in young women. The risk factors for this pathology are early menarche, long and heavy menstrual flow, and lower consumption of fish, eggs, and fruit.

[Medullary carcinoma of the thyroid gland]. / Il carcinoma midollare della tiroide.

The Authors, after introducing the epidemiology and physiopathology of medullary thyroid carcinoma, compare the most recent diagnostic methods and therapeutic strategies. They highlight recent progress in genetics, in diagnosis and therapy and in the role of labelled radiopharmaceuticals in diagnosis, post-operative therapy and follow-up.

Choledochal cysts in adults: a case report.

We examined a case of choledochal cyst in an adult having congenital dilatation of the bile duct classified, according to Todani's, as type I and treated by excision with hepatic-jejunostomy Roux-en Y. This procedure is recommended as the best treatment for eliminating pancreatitis by pancreaticobiliary disconnection and thus for reducing the risk of malignancy.