Comparison of histopathological features and prognosis of classical and follicular variant papillary thyroid carcinoma.

PURPOSE: To compare the histopathological features and the outcomes of the follicular variant and classical variant of papillary thyroid carcinoma. MATERIAL AND THE METHODS: Demographic data, histopathological features (tumor size, thyroid capsule invasion, extrathyroidal extension, vascular invasion and multicentricity), lymph node metastasis, local recurrence, distant metastasis and mortality during the follow-up of 258 C-PTC and 153 FVPTC patients who underwent total thyroidectomy were compared. The dynamic risk assessment system was used to refine postoperative risk estimates based on the assessment of response to initial treatment. RESULTS: The demographic data showed no significant difference between the two groups. The mean tumor size showed no significant difference between the two groups. The rate of thyroid capsule invasion, extrathyroidal extension, and lymph node metastasis was significantly higher in C-PTC than in FVPTC group, whereas multicentricity and bilobar involvement were significantly higher in FVPTC group than in C-PTC group. Central lymph node metastasis was significantly more frequent in patients with C-PTC than in those with FVPTC (p < 0.0001). Local recurrence was found in 22 (5.3 %) patients overall and was significantly more common in C-PTC group than in FVPTC group. In patients ≥45 years, the local recurrence rate was significantly higher in patients with CPTC than in those with FVPTC. The local recurrence rate in patients <45 years was not significantly different between the two groups of patients. The multicentricity rate was significantly higher in the FVPTC group for both age groups. Dynamic risk assessment showed that the rate of intermediate- and high-risk groups showed no significant difference between C-PTC and FVPTC patients but the rate of low risk patients was higher in FVPTC group than in C-PTC group (p = 0.04). The recurrence rate in low-risk group was found higher in C-PTC compared to FVPTC patients (4.7 vs. 0.7 %, p = 0.04, respectively). The recurrence rate showed no significant difference in both intermediate- and high-risk groups in C-PTC and FVPTC patients. During the follow-up, the rate of distant metastasis and disease-specific mortality was not significantly different between the two groups (p = 0.25). CONCLUSION: FVPTC is a common subtype of PTC and has a higher rate of multicentricity with bilobar involvement. Although aggressive histopathologic features, such as thyroid capsule invasion, extrathyroidal extension, and lymph node metastasis, are significantly more frequent in CPTC than in FVPTC, the long-term outcome is similar in both subtypes after appropriate initial surgery and postoperative RAI ablation treatment.

Impact of total versus subtotal thyroidectomy on calcium metabolism and bone mineral density in premenopausal women.

OBJECTIVE: This study aimed to compare the impact of total versus subtotal thyroidectomy on calcium metabolism and bone mineral density in euthyroid, premenopausal women. SUBJECTS: The study included 24 premenopausal women who had undergone total (n = 10) or subtotal (n = 14) thyroidectomy and who were receiving nonsuppressive doses of thyroxine. The median post-operative period was four years. We determined, in all patients, the following parameters associated with calcium metabolism: total serum calcium, inorganic phosphate, intact parathormone, calcitonin and alkaline phosphatase. The bone mineral density of the spine and hip were measured using a Hologic QDR 4500C bone densitometer and were compared with controls matched for age and peak bone mineral density (using the t-test). RESULTS: The measured calcium metabolism parameters were normal in all patients, and none had osteoporosis. There was no significant difference in the bone mineral density measurements for the spine and hip, comparing patients who had undergone total versus subtotal thyroidectomy (using the t-test). CONCLUSION: The impact of total thyroidectomy on bone mineral metabolism is not significantly different from that of subtotal thyroidectomy, in premenopausal women with normal thyroid-stimulating hormone values.

The preoperative exclusion of thyroid carcinoma in multinodular goiter: Dynamic contrast-enhanced magnetic resonance imaging versus ultrasonography-guided fine-needle aspiration biopsy.

BACKGROUND: We compared the diagnostic values of dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) and ultrasonography (USG)-guided fine-needle aspiration biopsy (FNAB) in the detection of thyroid carcinoma associated with multinodular goiter. METHODS: USG-guided FNAB and DCE-MRI were performed consecutively on 26 patients who had multinodular goiter with dominant nodules and clinical suspicion of malignancy. DCE-MRI findings, cytodiagnosis, and final histopathologic results were correlated. We compared the sensitivity, specificity, diagnostic accuracy, and positive (PPV) and negative predictive values (NPV) of DCE-MRI and USG-guided FNAB. RESULTS: Of 57 nodules in 26 patients, 16, 37, and 4 nodules showed delayed, plateau, and rapid washout patterns, respectively. Thyroid carcinoma was found in 8 patients (31%). Delayed washout pattern in a nodule was correlated with the histologic diagnosis of thyroid carcinoma (P < .001). None of the nodules with thyroid carcinoma had a plateau or rapid washout pattern. The sensitivity and NPV of DCE-MRI to diagnose thyroid carcinoma were greater when compared with those in USG-guided FNAB (100 vs 71.4%, and 100 vs 91.7%, respectively; P < .001). CONCLUSION: When other diagnostic methods are inconclusive, DCE-MRI is superior to USG-guided FNAB to exclude thyroid carcinoma in patients with multinodular goiter.

Expression of bcl-2 in papillary thyroid cancers and its prognostic value.

PURPOSE: Papillary thyroid cancer has a good prognosis. This favourable prognosis may be attributed to the apoptotic tendency of the cancer cells. This study aims to evaluate the expression of bcl-2, which is an antidote of apoptosis, and aims to evaluate the value of bcl-2 as a prognostic marker in papillary thyroid cancer. MATERIAL-METHODS: Bcl-2 expression in the archival materials of 31 patients with papillary thyroid cancer was examined with immunohistochemical methods using bcl-2 and p-53 stains. The results were compared with 31 normal thyroid tissue specimens, which consisted of the contralateral lobes of these patients. The results were then analyzed in accordance with the clinical features of the patients. RESULTS: Thirty (96.7%) patients of the control group were positive for bcl-2 whilst one (3.3%) was negative. The staining for bcl-2 was positive in 12 (%75) patients with microcarcinomas (p < 0.05) and 13 (86.6%) with papillary cancers (p > 0.05). Two cases of the papillary cancer group were admitted to the hospital with local recurrence (6.4%) and both were positive for bcl-2 (p > 0.05). All cases (4/31), whose MACIS scores were higher than 7 were positive for bcl-2. Twenty-one of 27 cases whose MACIS scores were lower than 7 (77.7%) were positive for bcl-2 (p > 0.05). All tumours of this series were negative for p-53 immunstaining. CONCLUSION: The rate of bcl-2 expression in microcarcinomas of papillary thyroid cancer decreases when compared to normal thyroid tissue. This may be an early sign of oncogenesis, and a reason for the favourable prognosis in microcarcinomas. However, bcl-2 cannot be used as a prognostic marker.

Anaplastic thyroid cancer with transient thyrotoxicosis: case report and literature review.

A 55-year-old woman with anaplastic thyroid carcinoma presented with hyperthyroidism and neck swelling, hoarseness, and cervical lymphadenopathy. On physical examination, she was found to be clinically hyperthyroid with an enlarged, nontender multinodular goitre. Her serum thyroid hormone levels confirmed hyperthyroidism and technetium-99m pertechnetate scan failed to visualize the thyroid gland. Open biopsy showed an invasion of the thyroid gland by anaplastic thyroid carcinoma. The thyrotoxic phase lasted 60 days with predominantly increased thyroxine level and triiodothyronine/thyroxine (T3/T4) ratio decreased below 15. The thyrotoxic period was followed by subclinical hyperthyroidism and hypothyroidism which continued until she died of lung metastasis.

The value of DNA content in predicting the prognosis of thyroid carcinoma in an endemic iodine deficiency region.

DNA content of tumour was found to correlate with various prognostic factors and survival, especially in well differentiated thyroid carcinoma. The aim of this investigation was to evaluate the correlation between the DNA ploidy and the prognosis as well as the survival in thyroid carcinoma in our country, being an endemic iodine deficiency region. DNA flowcytometry was performed on paraffin embedded archival tissue blocs of 74 patients with thyroid carcinoma (70 well differentiated, 3 anaplastic and Hurthle cell carcinoma) and 12 patients with multinodular goitre. DNA ploidy was defined as diploidy or aneuploidy. Aneuploidy was detected in 5 (6.8%) patients with thyroid carcinoma (3 anaplastic, 1 papillary and 1 Hurthle cell carcinoma). Aneuploidy was significantly more frequent in patients with anaplastic carcinoma (n: 3/3, 100%) compared to well differentiated thyroid carcinoma (n: 1/70, 1.4%) (p < 0.0001). Aneuploid DNA content significantly correlated with advanced age (p < 0.01), large tumour size (p < 0.001), and low survival (p < 0.01). Mean survival period of patients with anaplastic carcinoma in whom aneuploidy was frequently encountered, was shorter compared to patients with diploid well differentiated tumours (p < 0.01). In conclusion, although anaplastic and follicular carcinoma are more frequently diagnosed in endemic areas, the rate on aneuploidy was found to be lower in thyroid carcinoma in our country compared to data reported to nonendemic areas. As the prognostic predictive value of DNA ploidy is reliable in well differentiated thyroid carcinoma, DNA measurement of FNA biopsy may influence the extent of surgery. Thyroid carcinoma, other than well differentiated types, require radical operations independent of the DNA content. However, adjunctive treatment methods may be used earlier postoperatively according to quantitative DNA measurement.

Gastroesophageal reflux and a comparison of the different antireflux procedures following esophagomyotomy: an experimental study in rabbits.

The surgical options for achalasia remain controversial regarding the surgical access route, whether it be transthoracic or transabdominal, the need of, and the type of an added antireflux procedure following an esophagomyotomy. These questions were investigated in an experimental study that used 30 albino rabbits divided into six groups, as follows: transabdominal Heller's esophagomyotomy (TAHE), transthoracic Heller's esophagomyotomy (TTHE), TAHE and Nissen total fundoplication (NF), TAHE and partial fundoplication (PF), TAHE and modified fundoplication (MF), and a control group. Esophageal transit time (ETT) and gastroesophageal reflux (GER) were evaluated by scintigraphy on the seventh postoperative day. When an esophagomyotomy was performed either with a transabdominal or transthoracic approach, a significantly increased GER rate was found in comparison to the controls. All types of antireflux procedures performed prevented GER effectively. Although NF and PF groups showed a significant delay in ETT when compared to the control group (P < 0.001), no such finding was observed in the MF group. In conclusion, an antireflux procedure following an esophagomyotomy is recommended. A modified fundoplication was thus found to be as effective as the other techniques in preventing GER, and was even a safer method when obstructive findings following a total or partial fundoplication were considered.

Great cervical vein invasion of thyroid carcinoma.

Intraluminal tumor thrombus in great cervical veins as a result of thyroid carcinoma is extremely rare. Three patients (2 Hürthle cell, 1 papillary carcinoma) were surgically treated for thyroid carcinoma associated with tumor thrombus in the great cervical veins. Tumor thrombus in the internal jugular vein due to extension of thyroid carcinoma was found in these 3 patients. Segmental resection of the internal jugular vein was performed in all cases and a tumor thrombectomy from subclavian vein was accomplished in 1 patient. Histological examination verified intraluminal tumor thrombus resulting from invasion of thyroid carcinoma in all patients. The postoperative follow-up period ranged from 1 to 2 years. Of 2 patients undergoing completion thyroidectomy, 1 died of distant metastasis, the other underwent reoperation for local recurrence. The patient who had a definitive primary surgical procedure is free of recurrence. Appropriate initial surgical procedure in rare cases of thyroid carcinoma associated with intraluminal tumor thrombus in great cervical veins seems to improve the clinical outcome of the disease.

Multiple vascular leiomyomas involving bilateral adrenal glands, spleen, and epicardium, associated with bilateral testicular microlithiasis and empty sella turcica.

Leiomyomas can arise from any tissue having smooth muscle as one of its constituents, especially gastrointestinal and genitourinary systems, less frequently in the skin, and rarely in deep soft tissue. An unusual case of multiple vascular leiomyomas involving bilateral adrenal glands, spleen, and epicardium, associated with bilateral testicular microlithiasis, and empty sella turcica is reported in a 15-year-old boy. The adrenal masses were incidentally discovered by ultrasonography. These three findings, taken individually are rare, and the constellation of the three, to the best of our knowledge, is the first recorded example. Furthermore, bilateral involvement of the adrenal glands with leiomyomas is, by itself, very uncommon. The tumors considered benign were surgically removed. Orchiectomy wasn't performed. The boy is well after 1.5-year follow-up under cortisone, 9alpha-fludrocortisone, and testosterone therapy.

Steroid cell tumor of the ovary as a rare cause of virilization.

BACKGROUND: Virilization is associated with either ovarian causes, including polycystic ovary syndrome, hyperthecosis, and ovarian tumor, or with adrenal causes, including tumors and congenital adrenal hyperplasia. In establishing the diagnosis, levels of dehydroepiandresterone sulfate, testosterone, and 17 alpha-hydroxyprogesterone (17-OHP), with their response to dexamethasone treatment, should be assessed; and, where indicated, computerized tomography, ultrasound, and selective venous catheterization should be undertaken. CASE REPORT AND RESULTS: A 21-year-old woman presented with a 17-year history of early accelerated linear growth and virilization. During this time, a putative diagnosis of nonclassic congenital adrenal hyperplasia had been made, and she had been treated with glucocorticoids, with no regression in virilization, for 8 years. On presentation to our group, the failure of low- and high-dose dexamethasone suppression tests to decrease blood levels of testosterone and 17-OHP, combined with a relatively low blood level of corticotropin, led us to investigate an androgen-secreting tumor of ovarian origin. When ultrasonography and computerized tomography of the ovaries and adrenal glands displayed no abnormality, selective venous catheterization was performed, revealing an abnormal ovarian-peripheral gradient for testosterone, 17-OHP, estradiol, and androstenedione in the right ovarian vein. On exploratory laparotomy, a neoplasm adjacent to the right ovary was resected and was found to be a steroid cell tumor of the ovary not otherwise specified, one of the rarest tumors causing virilization in children. Symptomatic resolution followed tumor removal. CONCLUSION: Selective ovarian and adrenal venous catheterization for hormone assays is an efficient method of identification and localization of an androgen source in virilizing syndromes when noninvasive methods fail.

The effect of prostaglandin E1 on experimental colitis in the rat.

Prostaglandin E1 (PGE1) is known to have a strong vasodilator effect and to block coagulation and inflammation in high concentrations. The aim of this study has been to investigate whether PGE1 has an inhibitory effect on inflammation in experimental colitis. Experimental colitis was produced by rectal instillation of 10% acetic acid in 60 rats. These were divided into prostaglandin (PG) (n = 30) and control groups (n = 30). Twelve hours later, an intraperitoneal injection of 2 micrograms PGE1 in 1 ml saline was given to the PG group and 1 ml saline to the control group. This was repeated daily and the animals were sacrificed in groups of 10 on the 3rd, 7th and 10th day. Histopathological examination and hydroxyproline determination for assessment of collagen synthesis were performed. PGE1 significantly decreased inflammation on third day with the hydroxyproline level significantly higher in the PG group compared with the control group (p < 0.05). This difference was however not significant at the 7th and 10th day. The present study supports a beneficial role for prostaglandin E1 in reducing the severity of colonic inflammation following chemically induced colitis but only in the early stages of development.

Cyproheptadine treatment in Cushing's disease.

Cyproheptadine, a nonselective 5-hydroxytryptamine receptor blocking agent, reduces ACTH and beta-endorphin secretion from the ACTH-producing tumors. A 35-year-old female suffering from Cushing's disease due to microadenoma of the pituitary gland has been followed since the age of 15. Subtotal adrenalectomy followed by total adrenalectomy, pituitary irradiation, and transsphenoidal hypophysectomy, combined with second radiotherapy of the pituitary, were unsuccessful in achieving remission of the disease. Remission was achieved with cyproheptadine up to a dosage of 24 mg/day. Every attempt to discontinue cyproheptadine treatment was accompanied by recurrence of the disease. This is the first case of Cushing's disease in which cyproheptadine treatment has been the only efficacious therapy for a period of 11 yr. Cyproheptadine may be an alternative long-term therapy for Cushing's disease when other methods of treatment fail.

Comparison of preoperative imaging techniques (thallium technetium scan and ultrasonography) and intraoperative staining (with methylene blue) in localizing the parathyroid glands.

We carried out a prospective study to compare the predictive value of preoperative thallium technetium scan, ultrasound (US) and intraoperative staining of the parathyroid glands (with methylene blue) in patients with parathyroid adenoma, parathyroid hyperplasia, thyroid carcinoma and thyrotoxicosis, in the Istanbul School of Medicine, Department of General Surgery. Methylene blue was given at a dose of 5 mg/kg/body weight in a 500 ml 5% Dextrose +0.9% saline solution 1 hour before surgery. All adenomas (10 patients), hyperplastic parathyroid glands (12 patients) and 45 of 52 suppressed glands (82%) were stained. In patients with thyroid carcinoma (7) and thyrotoxicosis (5), 42 of 48 normal parathyroid glands (87%) were stained. There were no maneuver-related complications. Thallium technetium scan (TT) accurately identified 10 of 10 (100%) parathyroid adenomas and 13 of 26 (50%) hyperplastic parathyroid glands. US successfully localized 10 of 10 (100%) adenomas and 18 of 26 (66%) hyperplastic glands. Neither technique was successful in identifying normal glands. The intraoperative identification of the parathyroid glands with methylene blue was found to be an effective, safe and cost-effective technique which helps the surgeon in the dissection and shows abnormal parathyroid glands more accurately than preoperative imaging techniques.

Concurrent hyperthyroidism and thyroid carcinoma.

Between 1986 and 1991, thyroidectomy was performed on 138 patients with hyperthyroidism. Thyroid carcinoma was found in eight patients (5.8 per cent). Eighty (58.0 per cent) of the 138 patients had toxic nodular goitre, 33 (23.9 per cent) toxic diffuse goitre and 25 (18.1 per cent) toxic adenoma. Concurrent carcinoma was more frequent in patients with toxic adenoma (8 per cent) than in those with Graves' disease (6 per cent) and toxic nodular goitre (5 per cent). Papillary carcinoma was found in seven patients and follicular carcinoma in one. Three papillary carcinomas were occult with a diameter less than 1.5 cm. Five patients received 100 mCi 131I after operation. There was no morbidity. During follow-up of 10-45 months, there was neither death nor recurrence.

Transhiatal oesophagectomy for oesophageal carcinoma.

Between 1979 and 1990 transhiatal oesophagectomy and reconstruction with stomach was performed in 148 patients with carcinoma of the oesophagus. Ninety-seven patients were men and 51 were women; ages ranged from 21 to 88 years with a mean of 57.4 years. Dysphagia and weight loss were the usual clinical symptoms. The mean duration of symptoms was 14 weeks. Squamous cell carcinoma was present in 129 patients (87.2 per cent), 18 patients (12.2 per cent) had adenocarcinoma, and one had lymphoma (0.7 per cent). In two-thirds of the patients tumours were located in the middle thoracic (50 of 148 patients) or distal thoracic oesophagus (59 of 148 patients). Three-quarters of the patients had tumours determined as stage III. The mean length of hospital stay after operation was 12.8 days. Anastomotic leakage occurred in 15 cases (10.1 per cent). Pulmonary complications other than pneumothorax were observed in 36 cases (24.3 per cent). The 30-day postoperative mortality rate was 8.1 per cent (12 of 148 patients). Respiratory insufficiency was observed as the major cause of death (six of 12 patients). Mediastinitis due to necrosis of the transposed stomach in the mediastinum was the cause of death in three cases. Two-year actuarial survival rates in patients with cervical, upper, middle and lower thoracic tumours were 20, 22, 26 and 30 per cent respectively. Transhiatal oesophagectomy is safe and offers limited morbidity and mortality, although pulmonary complications and anastomotic leakage in the early postoperative period still pose a significant risk, especially for elderly patients in poor condition.

The effect of prostaglandin E1 on colonic anastomotic healing. A comparison study.

In an attempt to show the effect of prostaglandin E1 (PGE1) on colonic anastomotic healing the authors measured collagen synthesis and counted inflammatory cells (polymorphonuclear leukocytes "PMN," histiocytes, lymphocytes, and plasma cells) and compared the results to those of aprotinin and control groups. The authors performed colonic anastomoses on 45 male albino rats, which were divided into three groups. Measurements of collagen synthesis and counts of inflammatory cells in the first group were evaluated as control data. They administered 2000 units aprotinin daily for two days in the second group and 2 micrograms PGE1 daily for two days in the third group. Collagen content as hydroxyproline in the resected anastomotic part of the colon was measured and the inflammatory cells were counted on the first, third, fifth, and tenth days. The results showed that PGE1-administered rats had significantly higher collagen levels (5.21 +/- 1.35 micrograms hydroxyproline/mgr tissue, P less than 0.05 and 3.81 +/- 0.63 micrograms/mg, P less than 0.05) on the third and fifth days, respectively, compared with the control and aprotinin groups. The aprotinin group also had higher collagen levels (3.34 +/- 0.27 micrograms/mg, P less than 0.05 and 3.07 +/- 0.40 micrograms/mg, P less than 0.05) on the third and fifth days, respectively, compared with the control group. There were no statistically important differences in the collagen contents of the control, aprotinin, and PGE1 groups on the tenth day and there was an increase in the collagen content in all groups (P less than 0.05). The inflammatory cells, including PMNs, histiocytes, lymphocytes, and plasma cells, which play an important role in the inflammatory stage of colonic anastomotic healing, were also counted. The cells were counted on the third, fifth, and tenth days and the results were evaluated as (+) positive and more positive. The results of the control and aprotinin groups were found as ( ), ( ), and (++) on the third, fifth, and tenth days, respectively. In the PGE1-administered group the inflammatory cells were counted as (+), (++), and (++) on the third, fifth, and tenth days, respectively. In addition, there was an increase in fibroblast synthesis and new vessel formation on the tenth day. Thus, it was shown that PGE1 decreased inflammatory cells and increased collagen synthesis in the early stage of colonic anastomoses and fibroblasts in the late stage more effectively when compared with the control and aprotinin groups.(ABSTRACT TRUNCATED AT 400 WORDS)