Clinicopathological phenotype of parathyroid carcinoma: therapeutic and prognostic aftermaths.

Parathyroid carcinomas (PC) are rare and "devastating"€ causes of hyperparathyroidism (HP), frequently discovered fortuitously,with not always doubtless pathological confirmation, and dissociate post-therapeutic outcomes and prognosis even after well-performed surgery. We herein report four PT neoplasms,three of them proving to be authentic PCs, and one an atypical parathyroid adenoma. There were three females and one male, aged 32-49 (mean 44) years. In three circumstances PC was associated with primary HP and in one case the tumor had developed on a CKD-BMD (renal HP) background. All patients presented marked clinical and biochemical phenomena related to hypercalcemia with greater intensity of renal, bone, neuromuscular and psychological signs and symptoms to which in one observation specific uremic manifestations were added. Preoperative and intraoperative diagnosis was suspected only in two cases (one of them being in fact an atypical PT adenoma), but in the other two it was established by paraffin section on histological evidence of definitive stigma of malignancy. Our little experience underlines the wide and protean range of the origins, clinical aspects, course and prognosis of PC, which adds to the difficulties of pre- and intraoperative diagnosis. Awareness of this lesion must be permanent to detect its presence in any unusual eventuality, imposing a radical en bloc resection at the initial operation, assuring the best chance of cure.

Thyroid and thymic exeresis in surgery of hyperparathyroidism.

BACKGROUND: Owing to close anatomical and embryological connexions between the thyroid, parathyroids and thymus,manifold coexisting pathology can be identified during the surgery of hyperparathyroidism (Hp). MATERIAL AND METHODS: In this retrospective study we report the incidence, clinical forms, histology and management of thyroid and thymic synchronous lesions encountered in as eries of 82 consecutive patients with various types of Hp operated on in the last three decades. Demography, clinical records, biochemical data, imaging procedures, pathology reports and surgical protocols were revised. RESULTS: Between 1984-2013, 82 cases of Hp, 20 primary and 62 renal (27 secondary and 35 tertiary), 57 women and 25 males (sex ratio: 2.3 1) of 15-72 (mean 46.5) years, under went surgery in our clinic. Concomitant thyroid exereses were performed in 32 patients (2 subtotal thyroidectomies, 12 lobectomies, 8 atypical resections and 10 diagnosis biopsies), foruni- or bilateral (multi)nodular goiters or different €œminutelesions. Pathology showed 11 colloid goiters, 3 follicular adenomas,5 nodular hyperplasias and 6 thyroiditis cases, 3 papillary microcarcinomas and 4 specimens with normal thyroid tissue.Excision of the fibrofatty retromanubrial tissue in total parathyroidectomies for renal Hp (19 cases) revealed one nonmyastenicthymoma, one thymic cyst and thymic remnants in 6 patients.Morbidity in these extended operations was not significantly increased, comparing to the parathyroid exploration alone. DISCUSSIONS AND CONCLUSIONS: Meticulous pre- and intraoperative evaluation in all cases of Hp enables the actual shift from bilateral neck exploration to minimally invasive surgery,increasing however the potential risk of missing thyroid or thymic coexistent significant lesions. The surgeon dedicated to this pathology must be aware of the possibility of encountering such synchronous association and make generous efforts to wards their complete cure in a single operation.

Unusual malignant tumors of the thyroid gland.

BACKGROUND: Although situated on the last places among the statistical hierarchy of human malignancies, thyroid cancers (TC) are the most common tumors of the endocrine system. Follicular epithelium neoplasms account for more than 90% of these lesions with a favourable prognosis, while resting tumors (medullary, anaplastic, lymphoma, sarcoma etc) generally present a rapid unfavorable evolution with a low rate of survival. PATIENTS AND METHODS: In a series of 464 thyropathies personally treated, 72 cases of TC (15.5%) were identified. Fifty-seven patients presented epithelial TC a 34 papillary variant, 20 follicular variant and 8 mixed forms. Alongside these there were two medullary TC, 9 anaplastic TC and insular TC, and primary lymphoma and metastasis to the thyroid of a lung carcinoma each single case. Four cases have been described in patients who were aged 2-6 years at the time of the Chernobyl disaster. Out of the common types, based on our own taxonomic criteria, we selected a group of 36 TC with unusual clinical, histological and behavioural characteristics or particular pathological associations. RESULTS: Seven cases of occult TC, 7 cases with precessive adenopathy TC and 11 patients with TC associated with hyperthyroidism were registered. All of them underwent adapted thyroidectomies in which the presence of cancer was decisive for the extent of surgery. Medullary, insular and anaplastic TC were the most aggressive lesions and even extended surgery and complementary therapy failed to improve the prognosis of these patients. In the same category we included the cases presenting the coexistence of two TC types, pathologic dedifferentiation in recurrences and concurrent presence of another endocrine or nonendocrine cervical lesion. The a surgical dogma of total thyroidectomy cannot always be respected, so complementary therapeutic solutions must be applied. RESULTS were complex, registering steady recoveries in occult, hyperfunctioning and even in coexisting pathological lesions, but many recurrences and reinterventions with poor survival rates (a few weeks up to 2 years) in cases with reduced or absent histologic differentiation were also noted. Some lesions were inoperable. DISCUSSIONS AND CONCLUSIONS: Increasing clinician, surgeon and pathologist awareness of these distinct, but not rare anatomoclinical contingencies could contribute to their adequate diagnosis and treatment. Recent progress in knowledge of molecular carcinogenesis and promising successes of targeted chemotherapy trials with new drugs offer promising perspectives in the management of advanced or metastatic TC. Surgery still remains the cornerstone treatment for thyroid cancers.

[Indications for surgery in thyroiditis]. / Indicatii ale tratamentului chirurgical în tiroidite.

INTRODUCTION: Inflammatory processes of the thyroid represents a main proportion of the gland's pathology but the majority of them are treated by medical methods, surgery being indicated. PATIENTS AND METHODS: In 14 cases (3%) from 464 operations for different thyroid conditions we have encountered authentic inflammatory lesions in 9 cases of Hashimoto's thyroiditis (two associated with papillary thyroid carcinoma and one with malignant lymphoma), two cases of Riedel's thyroiditis and respectively de Quervain thyoiditis, tuberculous thyroiditis and actynomicosis one case each. The common lymphoplasmacytic infiltration in Basedow's disease was not considered likewise as the inflammatory nespecific lesions encountered in benign and malignant pathology of the gland. The clinical and imagistic data, biological evaluation and titer of anticorps but particularly the paraffine examination together with intraoperative estimations are decisive for the diagnosis. RESULTS AND DISCUSSIONS: Firm diagnosis of thyroiditis was rarely affirmed before operation, surgical indication being formulated on clinical criterions dominated by cancer suspicion. Among these are diffuse or (multi)nodular thyromegaly with a dominant nodule with recent appearance and rapid growing in temporal and geographic proximity of Chemobyl disaster, with hard consistence, celsian or compressive features and adenopathy. More added the imagistic signs but especially suspect aspects of the FNAB (follicular or with Hürthle cells smears) and also of the frozen sections. Certainty diagnosis was established by paraffine examination not always without hesitations or reexamination (Hashimoto's thyroiditis diagnosed in one case was finally a malignant lymphoma). Large removal decided after intraoperative findings induced for the most of patients a definitive hypothyroidism. CONCLUSION: All the diagnosis resources must be exhausted for the diagnosis of the inflammatory lesions of the thyroid to avoid unnecessary surgery. On the other side the chronic overstimulation by the TSH of the glandular tissue affected by the immune process, represent an important factor of producing neoplasia.

Parathyromatosis coexisting with papillary thyroid microcarcinoma.

UNLABELLED: The aim of this report is to describe a fortuitely discovered association between parathyromatosis and papillary thyroid microcarcinoma. CASE DESCRIPTION: A 56-year-old woman presented with a pyelic relapsed stone, bone pains, neurovegetative com-plaints and iPTH = 348 ng/l as manifestations of recurrent primary hyperparathyroidism after a right inferior parathyroid adenoma exeresis done elsewere six years ago. Ultrasonography showed a 5 mm hypoechoic zone at the lower pole of the right lobe of the thyroid. At the operation an irregular, unbounded, white-yellowish mass 5 mm in diameter was identified lateral and below the thyroid pole together with 15-20 nodules of 1-2 mm scattered on the distal surface of the gland and also in the areolar fibrofatty surrounding atmosphere. Excision and biopsy of the mass and of two main nodules showed the presence of parathyroid issue and the operation is finally completed to a thyroid lobectomy. Definitive paraffin examination evidencied multiple poorly outlined nests of benign parathyroid tissue but also a minute foci of papillary thyroid carcinoma. Two years after the operation the patient is symptom free without any local recurrence and in normal biological parameters. DISCUSSION: Coexistence between parathyromatosis - a rare but challenging cause of hyperparathyroidism - and thyroid (micro)carcinoma a more frequent encountered lesion is an entirely coincidental occurrence. The preoperative diagnosis of both conditions - particularly of the latter one - is rarely anticipated. In such intraoperative fortuitous finding the intervention must include an en bloc thyroid lobectomy together with periglandular and retro-sternal fibrofatty tissue. This strategy is beneficent also for the eventually nonidentified thyroid microcarcinoma. CONCLUSIONS: Preoperative and intraoperative evaluation for recurrent primary and renal hyperparathyroidism must be exhaustive considering possible coexisting thyroid lesions. Indeed in our knowledge there have been no reports in the literature mentioning this unprecedented entity.

Surgical management of renal hyperparathyroidism: a preliminary series report.

BACKGROUND: Renal hyperparathyroidism (RHPT) is a frequent complication of uremic patients on hemodialysis and despite various advances in medical therapy parathyroidectomy is necessary in a semnificative number of cases. PATIENTS AND METHODS: We reviewed our experience (first in Romania) regarding fortythree patients with RHPT operated on in our clinic between 1994 and 2009 evaluating the diagnosis methods, surgical indications, techniques and results together with the evolution of our own therapeutical concept. The study included 22 men and 21 women of median age of 48 (range 15-67) years, performing hemodialysis (n=41) or peritoneal dialysis (n=2) from 7,7 (range 3-13) years respectively. Three patients received an unsuccessful renal graft. The diagnosis was established by anamnesis, clinical complaints (mainly osteoarticular pains, osteoporosis, fractures and skeletal deformities, muscle weakness, severe itching and mental troubles), completed by abnormal values of calcemia, phosphatemia alkaline phosphatasis and intact PTH. Ultrasonography and parathyroid scan were useful in "adenomised" parathyroids and coexistent thyroid pathology. RESULTS: All the patients were operated on. Twentyfour sub-total parathyroidectomies and 19 total parathyroidectomies (6 with autotransplantation), were performed (two video-assisted). There were no deaths and the operative morbidity was 20,9% (vocal cord hemiparesis and postoperative bleeding--each one case, mild transitory hypocalcemia three cases and recurrences four cases). Pathology revealed that RHTP was due to four gland diffuse hyperplasia (n = 23) or nodular hyperplasia (n = 19). One parathyroid carcinoma (in the fourth parathyroid gland), one thymoma and two papillary thyroid microcarcinoma was identified. Clinical and biochemical cure was achieved at median term control of 38 (range 6-165) months in 79.0% (n = 34) of cases. CONCLUSION: Parathyroidectomy is effective for long intervals as symptomatic therapy in cases of RHPT appearing in uremic patients on hemodialysis or after renal transplant but the optimal technique must be individualized on each case and still to be debated.

[Pancreaticoduodenectomy in surgical treatment of malignant tumors of Vater's region]. / Duodenopancreatectomia cefalica in tratamentul tumorilor maligne ale regiunii vateriene.

BACKGROUND: The optimal treatment of tumors of Vater's region represents a permanent interest of every physician involved in the treating of malignant diseases with such localization. AIM: This presentation proposes a pancreaticoduodenectomy (DPC) evaluation in the surgical treatment of tumors of Vater's ampulla. MATERIALS AND METHODS: Between 1999 - 2009 our clinic has treated a number of 37 cases with mechanic jaundice by malignant diseases (JMN). Out of these, 5 cases (13.5%) have been hospitalized with JMN (preoperative diagnose) by malignant tumors of Vater' region: 4 men and a woman, aged 46 to 72, from rural medium, who represent the aim of this paper. RESULTS. DISCUSSION: In 4 cases (10,.8%), intra-operatory exploration confirms the existence of tumors of Vater's ampulla or duodenal papilla (diagnosis having been established by preoperatory duodenoscopy) using DPC (Child Procedure). Postoperative evolution, either immediate or distanced, was favorable, implying no deaths. The microscopic exam of the extirpated piece confirms Vater's Ampulloma in two cases (5.4%); in the other two cases, the above mentioned exam reveals the small bowel's carcinoma at duodenal papilla. In the last 2.7% cases intra-operatory lymph node and visceral metastases have been observed, choledochoscopy revealing cholangiocarcinoma (confirmed by microscopic exam), the patient having suffered only a choledochoduodenostomy. CONCLUSIONS: Without being endowed with great experience in the field, the results of DPC treatment in these first cases of malignant tumors of Vater's region allow us to found the reasoning of the righteousness of surgical indication. DPC draws the hope of radical healing intention in the cancer with this localization.

[Cutaneous dissemination of visceral neoplasms in women -reported to a clinical situation]. / Diseminarile cutanate ale cancerelor viscerale la femeie--în legatura cu un caz clinic.

The subject of this case report is a 65 years old female hospitalized for firm, raised, pseudoinflammatory and pseudoangiomatous painless nodular lesions, confluent in large plaques that were localized on the anterior, posterior and left sides of the neck, the anterior and postero-superior areas of the left thorax. These lesions developed in a 3 months period. Histopathological examination of the skin bioptical specimen revealed morphological aspects of an ovarian serous cystadeno-carcinoma metastasis.

[Hyperfunctional parathyroid carcinoma]. / Carcinomul paratiroidian hiperfunctional.

The parathyroid cancer is mentioned in literature with an incidence of 0.5-5% in the etiology of the primary hyperparathyroidism. The authors present the case of a 45 year old female with diagnosis of "primary hyperparathyroidism" based on clinical, ultrasonographic and biochemical investigations. A right superior adenoma of 3 x 2 x 1 cm (150 mg) has been found and extirpated. The histological examination showed an adenoma with predominant "chief" cells. Three years after surgery the patient had a recurrence of the clinical and hypercalcemie syndrome (with more severe damages). The surgical reexploration showed the right thyroid lobe with a nodular aspect and in its inferior pole a enlarged parathyroid gland of one cm size was found. An en-block exeresis including the right thyroid lobe with isthmus as well as the mentioned lesion and the half of left superior parathyroid, the left inferior one together with retrosternal fat tissue have been performed. Frozen sections completed by paraffin examination established the diagnosis of hyperfunctioning parathyroid carcinoma. We have emphasize the issues that could suggest the initially preoperative true diagnosis: the large size of excised adenoma and the relatively quick recurrence of the phenomena of parathyroid hyperfunction. The surgical principles and strategies in the treatment of parathyroid cancer are also discussed.