Intraoperative measurement of parathyroid hormone in minimally invasive surgery for parathyroid adenoma.

INTRODUCTION: In the past bilateral neck exploration was the gold standard for successful surgical management of primary hyperparathyroidism. More restricted procedures have been introduced recently thanks to imaging techniques and intraoperative parathyroid hormone assay confirming eradication of hyperfunctioning tissue. METHODS: Thirty patients operated for parathyroid adenoma were submitted to intraoperative PTH determination with Quick Pack immunochemiluminescent assay (Nichols lab.) prior to excision and 5, 10 and 20 minutes after removal of the presumed hyperactive gland. Eleven patients were operated on by a minimally invasive procedure with videoassistance. RESULTS: Response to excision of the hyperfunctioning gland was evidenced by a significant decrease of PTH levels (50% of initial value) in 26 patients. Plasma PTH levels decreased by at least 80% of pre-excisional value after 20 minutes, 70% after 10 minutes and by 50% after 5 minutes. In 2 cases, significant decrease of PTH was obtained after 45 and 60 minutes respectively. In 2 other cases, the adenoma could not be found and there was no decrease of PTH even after extensive exploration of the neck. In the 11 patients who underwent minimal invasive surgery, 2 were converted to open neck surgery: in one case the adenoma was not accessible in the upper part of the neck, in the other case the hyperfunctioning gland remained undiscovered. CONCLUSION: intraoperative measurement of PTH should be considered a reliable and reproducible method for evaluation of the secreting activity of a parathyroid gland. The Quick Pack method has the advantage of confirming that the hyperactive gland has really been eradicated and consequently of considerably reducing operating time and avoiding extensive exploration of the neck.

Contribution of hook-guided breast biopsy to the pathological diagnosis of mammographic lesions.

This study was carried out to evaluate the reliability of a diagnostic approach with close cooperation between radiologists and surgeons for minimal breast disease. From 1993 to 1995, 152 evaluable patients with non palpable breast lesions were examined by mammography and their lesion was localized with a hook wire before being referred to the surgeon for biopsy. Comparison of mammography findings with pathological diagnosis indicated a good predictive value for benign lesions with only 8% non concordant diagnosis and a rather low predictive value in case of suspect mammograms with only 64% positive diagnosis. With hook-guided breast biopsy, a correct diagnosis was established in 93% of the cases. The remaining breast samples were either non contributory or necessitated a second biopsy. Several recommendations are proposed for improving accuracy of breast sampling such as securing the hook into the gland, orienting the limits of resection, sending specimen for X-ray study and inking the margins for the pathologist. This field experience revealed that some progress are to be made in diagnosis in particular by standardization of mammography and pathological criteria, more precise localization of the lesions with the hook and more refined surgical techniques for breast biopsy.

Chondroma of the trachea.

The case of a 76 year old man with a progressive upper respiratory distress due to a chondroma of the trachea is reported which necessitated a segmental tracheal resection with end-to-end anastomosis and restoration of the initial tracheal lumen. This case report is illustrative of a rare benign disease (10 cases described till today) originating from the cartilaginous rings of the trachea. The tumor usually appears as an upper airway obstructing syndrome and endoscopy is essential for establishing the diagnosis. Laser resection can be recommended for the treatment of limited lesions, whereas tracheal resection with end-to-end anastomosis is recommended for more advanced chondroma because it is prone to local recurrence and potentially exposed to malignant transformation into chondrosarcoma.

Carcinomas of the thyroid with unusual presentation. About two cases.

Two cases of thyroid carcinoma with unusual presentation are reported. In the first case, a follicular carcinoma was associated with hyperthyroidism from a hot nodule located in the same lobe. This condition is not so infrequent as indicated by the literature and should warrant pathological examination at the time of excision of the hot nodule. In the second case, both anaplastic and follicular carcinomas were coexisting in the same tumour of a young adult. This occurrence is rather exceptional in the early period of life and is usually the fact of elderly people with long-standing goiters. The favourable outcome of this patient is also contrasting with the bad prognosis associated with anaplastic carcinoma of the thyroid. Another interesting feature is the existence of an anaplastic carcinoma of the thyroid in a family member of this second case.

Intracarotid artery infusion of DTIC for invasive maxillofacial melanoma.

Five inoperable invasive cases of malignant melanoma of the maxillofacial region were treated with seven intracarotid artery infusions of DTIC. Total doses of 3.5-9.5 g of DTIC were continuously administered for 15-25 days. Two of the five patients experienced transient objective regression after the first DTIC infusion but not after the second. Three patients were operated on after infusion and only one had recurrence. However, all patients died with disseminated disease within 3 years after DTIC infusion. Toxicity was encountered in two of seven infusions; it consisted in reversible leukopenia plus thrombopenia and leukopenia alone. These patients had received the highest doses, 9.5 g/25 days and 8 g/20 days respectively. It is concluded that intra-arterial infusion of DTIC can be temporarily effective in the polydisciplinary treatment of invasive head and neck melanomas.

Treatment with steroids of a giant cell granuloma of the maxilla.

This case report of giant cell granuloma involving the maxilla is of particular interest for two reasons: the locally aggressive clinical course contrasting with the diagnosis of a benign disease and the spectacular, although transient, response under steroid treatment. Corticotherapy should be further tested in cases of invasive or recurring giant cell granuloma.

Regional chemotherapy of maxillofacial malignant melanoma with intracarotid artery infusion of DTIC.

Six intracarotid artery infusions of DTIC were performed in 4 patients with invasive malignant melanoma of the maxillo-facial region. A total dose of 3.5 to 7 g was well tolerated. Only 1 patient who received 9.5 g in 25 days developed a reversible bone marrow depletion. Two out of the 4 patients presented a transient 50% tumor surface regression, but no response was seen after the second infusion. Of the 2 remaining patients, 1 had no measurable effect and 1 experienced tumor progression.