Radioguided surgery with combined use of gamma probe and hand-held gamma camera for treatment of papillary thyroid cancer locoregional recurrences: a preliminary study.

BACKGROUND: Persistent differentiated papillary thyroid cancer (PTC) with metastasis followed by radical locoregional surgery is an indication for limited reoperation. Despite excellent prognosis the major challenge is controlling locoregional recurrences. AIM: To evaluate the efficacy of radioguided excision with combined use of gamma probe and an hand-held gamma camera. PATIENTS AND METHODS: From June 2009 to January 2012, we enrolled twenty-two patients with locoregional PTC recurrences, previously undergone to central and/or lateral neck dissection for PTC. The diagnosis of recurrent PTC was based on thyroglobulin (TG) evaluation [basal and after thyroid stimulating hormone (TSH) stimulation], ultrasound (US), iodine-131 (131I) whole body scan (WBS) and fine needle aspiration cytology (FNAC). In the morning of surgery, radiotracer was injected directly into the lesions by US guide. Careful dissection was carried out using gamma probe and hand held gamma camera. Metastatic lymph nodes were identified and excised. RESULTS: In all the patients recruited, 39 pathologic nodes were injected and 61 nodes were removed. Among the removed nodes, 22 (36.1%) were additional nodes (not injected by radiotracer). Of the additional lymph nodes, 7 (31.8%) were metastatic. Mean radioactive count of the lesion (28.633±9.218 counts/s) was higher than tumor bed (385.73±192.23 counts/s) (p < 0.0001). No complications were observed during radioguided excision, neither on post-operative period. CONCLUSIONS: The use of hand-held gamma camera in addition to gamma probe in our preliminary study allows a minimally invasive procedure and safer identifications of the lesions and ensures the completeness of the excision in a difficult surgical field.

Renal artery embolization in a gross kidney neoplasm. Case report.

AIM: To demonstrate the utility of the renal artery embolization (RAE) in the dissection of gross neoplasms and the reduction in blood loss and operative time. CASE REPORT: We report a case of a gross left renal neoplasm (with the diameter of about 12 cm) in a 45 years old Caucasian female who underwent to renal artery embolization 24 hours before left nephroureterectomy. This procedure has determined a reduction in operative times (about 90 minutes) because of the ligature of the renal vein was facilitated. Intraoperative blood loss was of about 100 ml and the patient didn't need of blood transfusions; the abdominal drain was removed in third postoperative day (daily drained serous fluid was about 20 ml). The patient was discharged 7 days later. CONCLUSION: RAE facilitates the dissection of gross neoplasms (diameter> than 10 cm), so causing a reduction in intraoperative blood loss and in blood transfusion. The operative times are lower because the ligature of the renal vein is less difficult and the dissection is facilitated for the presence of tissue oedema. The disadvantages are the incomplete hembolyzation, coil migration, hematomes, post-infarction syndrome (nausea, vomit, abdominal pain, leucocytosis, hyperpyrexia, hematoma); other risks include the possibility of pulmonary embolism, intestinal infarction and infections. Its reduced utilization could be due to the lack of randomized prospective studies showing its potential benefits.

Minimally invasive video-assisted thyroid surgery: how can we improve the learning curve?

OBJECTIVE: Minimally invasive video-assisted thyroidectomy (MIVAT) is a technically demanding procedure and requires a surgical team skilled in both endocrine and endoscopic surgery. A time consuming learning and training period is mandatory at the beginning of the experience. The aim of our report is to focus some aspects of the learning curve of the surgeon who practices video-assisted thyroid procedures for the first time, through the analysis of our preliminary series of 36 cases. PATIENTS AND METHODS: From September 2004 to April 2005 we selected 36 patients for minimally invasive video-assisted surgery of the thyroid. The patients were considered eligible if they presented with a nodule not exceeding 35 mm in maximum diameter; total thyroid volume within normal range; absence of biochemical and echographic signs of thyroiditis. We analyzed surgical results, conversion rate, operating time, post-operative complications, hospital stay, cosmetic outcome of the series. RESULTS: We performed 36 total thyroidectomy. The procedure was successfully carried out in 33/36 cases. Post-operative complications included 3 transient recurrent nerve palsies and 2 transient hypocalcemias; no definitive hypoparathyroidism was registered. All patients were discharged 2 days after operation. The cosmetic result was considered excellent by most patients. CONCLUSIONS: Advances in skills and technology have enabled surgeons to reproduce most open surgical techniques with video-assistance or laparoscopically. Training is essential to acquire any new surgical technique and it should be organized in detail to exploit it completely.

[The actual role of bilateral neck exploration in the treatment of primary hyperparathyroidism]. / Il ruolo attuale della esplorazione bilaterale del collo nel trattamento dell'iperparatiroidismo primario.

Surgery is the only curative treatment for primary hyperparathyroidism (pHPT). Surgical exploration is recommended for all patients with biochemically documented pHPT and signs or symptoms of the disease. Some patients are asymptomatic, others have subtle symptoms that disappear after parathyroid surgery. Felix Mandl successfully performed the first parathyroidectomy in 1925, using a bilateral neck exploration (BNE) with examination of all four glands and this remained the procedure of choice for pHPT into the 1990s. As over 80% of pHPT cases are due to a single parathyroid adenoma, many authors have questioned the need of BNE and have proposed directed unilateral approaches, termed "mini-invasive parathyroidectomies". The aim of this report is to define which is the actual role of the conventional surgical approach to pHPT.

[Intraoperative quick parathyroid hormone assay in thyroid surgery: preliminary experience on 36 cases]. / Dosaggio intraoperatorio dell'ormone paratiroideo in chirurgia tiroidea: esperienza preliminare su 36 casi.

Through the analysis of our preliminary experience on 36 consecutive cases of thyroid surgery, we assessed the feasibility of the rapid intraoperative assay of the intact parathyroid hormone (iPTH) as predictive risk factor of hypocalcemia versus seric calcium level on the first post-operative day to select the patients eligible to an early discharge. Furthermore, we managed to determine if iPTH level during thyroid surgery could point out the cases in which parathyroid autotransplantation is necessary, as the macroscopic evaluation of the parathyroid gland's viability is inadequate.

[Gastrointestinal stromal tumors: our experience]. / Tumori stromali gastrointestinali: nostra esperienza.

The authors report their experience on the treatment of GIST. They point out the importance of classification of the disease in low, medium and high risk neoplasms based on the characteristic of the tumour: site, volume and mytotic index as the Consensus Conference of Bethesda recently established. Surgical procedure remains the most important treatment in localized disease, while patients with advanced disease can benefit from imatinib, a chemotherapeutic agent recently introduced, as an adjuvant therapy.

[Treatment of hemorrhoids with circular mechanic stapler]. / Trattamento della patologia emorroidaria con suturatrice meccanica circolare.

In a pilot study undertaken in collaboration with the Department of Surgery of "San Carlo di Nancy" Hospital in Rome, over the period form January 1998 to February 2000, 128 patients with haemorrhoidal disease underwent surgery using a circular stapler to "lift" the mucous-haemorrhoidal prolapse, according to the pathogenetic theory discussed here below. We compared the results of our series with those of a retrospective series of 80 patients that undergoing traditional surgery (Khubchandani 45, Milligan-Morgan 30, Whitehead 5), evaluating length of operation, postoperative pain and complications. Our preliminary data show that the technique requires only a short learning period, reduces the length of the operation, reduces the medium- and long-term pain and allows mables the patient to resume full working activity earlier.

[Pseudosarcoma of the urinary bladder. Report of a case]. / Pseudosarcoma della vescica urinaria. Studio di un caso.

A case of myofibroblastic pseudosarcomatous tumor of the bladder occurred in a patient previously submitted to TURB is reported. Aim of this investigation is to demonstrate, on the basis of the literature, the importance of histopathology in the diagnosis of bladder pseudosarcoma, since endoscopical and radiological methods can erroneously show a neoplasm. A 65-year-old male patient with hematuria, submitted to ultrasonography and cystoscopy, revealed a bladder superficial papillary formation. A TURB was performed and the histological study showed a superficial bladder cancer (T1-G1-2). After a second hematuria episode with stranguria a new bladder formation was diagnosed and resected; the histological study revealed a bladder pseudosarcoma. The absolute benignity of the lesion and the slight difference in the symptomatology between urothelial carcinoma and pseudosarcoma are underlined. Furthermore, the importance of histopathology to obtain an accurate diagnosis is stressed. The difficulty of a preoperative diagnosis without histopathological examination is pointed out.

1,25-Dihydroxycholecalciferol-dependent calcium uptake by mouse mammary gland in culture.

Mammary explants from pregnant mice cultured in the presence of lactogenic hormones express their differentiated function by producing milk components in vitro. In the present paper radioactive calcium uptake was studied in the mammary gland during terminal differentiation, when lactogenesis was initiated. Under these conditions a relevant accumulation of calcium in the tissue was clearly demonstrable. We have characterized the calcium uptake by the tissue as a saturable and energy dependent process. When 1,25-dihydroxycholecalciferol [1,25-(OH)2D3], the major calcium regulator hormone, was added to the incubation medium the secosteroid strongly stimulated this process by increasing the maximal velocity without significantly altering the Michaelis Menten constant (Km). Detectable increases in calcium uptake could be measured after the explants were cultured with 1,25-(OH)2D3 for 30 min, with the response continuing to increase sharply over time and reaching a plateau at 3 h. The increase was not affected by the presence of actinomycin D or cycloheximide suggesting that the 1,25-(OH)2D3 stimulation of calcium uptake may be independent of de novo protein synthesis. These results provide evidence for early and direct action of the hormonal form of vitamin D in affecting calcium transport across membranes of functionally differentiated epithelial cells of the mammary gland.

Polyamines and the catalytic domain of protein kinase C.

The effect of polyamines on the catalytic domain of protein kinase C from rat brain was investigated. It was found that the addition of spermine strongly inhibited phosphorylation activity toward histone H1 as substrate. This tetramine, at millimolar concentrations, was most potently effective while triamines and diamines were almost uneffective, therefore the inhibitory action appeared to be structural specific. Data shown here suggest that polyamine by interacting with the catalytic domain of the enzyme may contribute to its regulation.

Inhibitory action of polyamines on protein kinase C association to membranes.

Physiological activation of protein kinase C requires the interaction of this enzyme with cellular membranes [Nishizuka (1986) Science 233, 305-312]. In the present work a reconstituted system of protein kinase C and human inside-out erythrocyte vesicles was utilized to study the effect in vitro of naturally occurring polyamines on the activation process of protein kinase C. The active membrane-associated complex was conveniently determined by its ability to bind radioactive phorbol ester with an exact 1:1 stoichiometry. The association reaction of the enzyme to membrane was rapid, being complete within 1 min at 25 degrees C. The addition of polyamines, particularly spermine, greatly decreased in a dose-dependent manner the amount of protein kinase C bound to membranes (i.e. in the activated form). The effect observed was quite specific, since it was dependent on the chemical structure of the polyamine and it was manifest at micromolar concentrations of the polycation; the order of potency was spermine greater than spermidine greater than putrescine. A characterization of this effect is presented and possible physiological implications are discussed.

1,25-Dihydroxycholecalciferol receptor regulation in hormonally induced differentiation of mouse mammary gland in culture.

Mammary explants from pregnant mouse cultured in the presence of insulin, cortisol, and PRL express their differentiated function by producing milk proteins such as casein. Sucrose density gradient analysis of high salt extract of cultured explants showed the presence of 1,25-dihydroxycholecalciferol (1,25-(OH)2D3 specific binding activity sedimenting at 3.3 S. Specific 1,25-(OH)2D3 binding activity in mammary explants varied as a function of the hormonal milieu in culture. The highest activity was found in explants cultured in the presence of insulin, cortisol, and PRL, whereas only a marginal activity was present in explants cultured with insulin. The comparison of 1,25-(OH)2D3 binding activity in explants cultured with insulin and with the three hormone combination by Scatchard plot analysis indicated that the synergistic actions of insulin, cortisol, and PRL increased the number of 1,25-(OH)2D3 specific binding proteins as much as 6-fold; however, the affinity constant of the binding protein was relatively constant in the two systems. Time course studies showed that the increase in 1,25-(OH)2D3 binding activity was detectable as early as 12 h after the addition of cortisol and PRL to insulin-primed explants. The increase was inhibited by the presence of actinomycin D and cycloheximide, suggesting that the hormonal stimulation of 1,25-(OH)2D3 binding activity involves both transcriptional and translational process. These results indicate that insulin, cortisol, and PRL stimulate the specific 1,25-(OH)2D3 binding activity during the induction of mammary functional differentiation when milk protein synthesis takes place.

Phorbol esters, but not the hormonal form of vitamin D, induce changes in protein kinase C during differentiation of human histiocytic lymphoma cell line (U-937).

Human histiocytic lymphoma cells (U-937) undergo similar differentiation when incubated with the phorbol ester 12-0-tetradecanoyl phorbol-13-acetate (TPA) and 1,25-dihydroxycholecalciferol. In this action, TPA somehow implicates calcium-sensitive and phospholipid-dependent protein kinase (protein kinase C), which is rapidly and significantly affected by this inducer. On the contrary, 1,25-dihydroxycholecalciferol in its differentiating action does not involve protein kinase C thus suggesting that the secosteroid induces monocytic differentiation possible through a different mechanism of that of phorbol ester.

Loss of plasma-generated vitamin D-binding protein in explants of mouse mammary gland in culture.

Selective removal of 6S plasma-generated vitamin D-binding protein from mouse mammary gland was achieved by a simple tissue culture technique. This binder was totally diluted out from the mammary explant in a time-dependent manner within 2 days of tissue culture, allowing conditions most suitable for 1,25-dihydroxyvitamin D3-receptor studies. In comparison with other methods to eliminate 6S plasma-generated vitamin D-binding protein the present technique is easy, simple and does not require the use of other vitamin D metabolites to study differential displacement of 1,25-dihydroxyvitamin D3 binding to the heterogeneous binding sites.

Modulation of cyclic nucleotide-independent protein kinase from chick intestine by naturally occurring polyamines and mucopolysaccharides.

Chick duodenal mucosa contains an endogenous factor which is capable to inhibit selectively a homologous polyamine-sensitive protein kinase. The inhibitor was partially purified and characterized, and it was found to contain typical mucopolysaccharidic components. Glycosidases digestion studies, selective degradation analysis and spectrophotometric titrations with metachromatic dyes indicated that the inhibitor preparation contained two major moieties identified as heparin-like and heparan sulfate-like structures. In chick intestine the inhibitor was specific for polyamine-sensitive protein kinase since selectively interacted with it and was inert towards other cAMP-independent and cAMP-dependent protein kinases. The inhibitory effect of the endogenous factor was counteracted by naturally occurring polyamines such as spermine. The order of potency of various polyamines was: spermine greater than thermine much greater than spermidine much greater than diamines. The release of inhibition by addition of physiological concentrations of spermine was also apparent when using cytosolic proteins as endogenous phosphate acceptors. These results suggest that a possible role of polyamine in the regulation of polyamine-sensitive protein kinase in the intestine is to protect the enzyme from the inhibitory action of endogenous heparinoids.

Polyamine-sensitive protein kinase from chick intestinal mucosa.

A cyclic nucleotide-independent protein kinase which phosphorylates preferentially acidic proteins such as casein or phosvitin was isolated from cytosol of chick duodenal mucosa. The enzyme was purified more than 633 fold to apparent homogeneity by ammonium sulfate fractionation, column chromatography on DEAE-cellulose, phosphocellulose, hydroxylapatite and by sucrose density gradient centrifugation. The native enzyme has a molecular weight of 131 000 as measured by gel filtration. The enzyme is a complex protein containing three polypeptides of molecular weight of 39 000, 36 000 and 27 000. It behaves as a complex throughout its purification and gel filtration but its components are readily separated by electrophoresis in denaturing buffer. The 27 000 molecular weight band was selectively autophosphorylated when the enzyme was incubated in the presence of [gamma-32P]ATP. When casein was used as substrate, physiological concentrations of naturally occurring polyamines such as spermine and spermidine markedly stimulated enzyme activity. However with phosvitin as substrate polyamines were strong inhibitors of the enzyme activity. This contrasting effect on intestinal kinase activity was also apparent using cytoplasmic proteins as endogenous phosphate acceptors. A characterization of this differential effect is presented and some possible physiological implications are discussed.

1 alpha, 25-dihydroxycholecalciferol and human histiocytic lymphoma cell line (U-937): the presence of receptor and inhibition of proliferation.

Human histiocytic lymphoma cells (U-937) contain high affinity binding protein for 1 alpha, 25-dihydroxycholecalciferol. The Kd (0.2 nM) and sedimentation coefficient on sucrose gradients (3.7 S) are similar to those reported for 1 alpha, 25-dihydroxycholecalciferol receptor in other tissues. This secosteroid added to the culture was able to inhibit cell proliferation in a dose dependent manner. Differentiation-associated properties such as phagocytic ability, C3 rosette formation, positive reaction for alpha- naphtyl acetate esterase as well as electron microscopy examination indicate that 1 alpha, 25-dihydroxycholecalciferol induces in vitro monocyte-macrophage differentiation in this monoblast-like cell line.

Peptide-chain initiation in duodenal mucosa of rachitic chicks after 1 alpha-,25-dihydroxycholecalciferol administration.

The post-ribosomal fraction of chick duodenal mucosa contains Met-tRNAMetf-binding protein(s) that behaves like the eukaryotic initiation factor (eIF-2) in protein synthesis. The binding activity of cytosol protein can be measured by retention of the radioactive complex formed on a nitrocellulose membrane. Complex-formation requires Met-tRNAMetf and GTP or guanosine [beta, gamma-methylene] triphosphate, and is inhibited by aurintricarboxylic acid. The ternary initiation complex thus formed can bind to ribosomal particles from chick intestine. By sucrose-density-gradient centrifugation, [35S]Met-tRNAMetf was found to bind exclusively to 40S and not to 60S ribosomal subunit particles. In the duodenal mucosa of rachitic chicks the ability of the cytosol proteins to promote the binding of Met-tRNAMetf to ribosomal particles via ternary-complex formation is detectably increased by 3 h after injection of 1 alpha,25-dihydroxycholecalciferol, the active form of vitamin D. Cholecalciferol and ergocalciferol under the same experimental conditions failed to stimulate Met-tRNAMetf-binding activity.