Fine needle cytology pre-surgical differentiation of parathyroid neoplasms: Is it reliable?

BACKGROUND: Fine needle cytology (FNC) of a parathyroid neoplasia (PN) is reliable, but needs to be confirmed by Parathormone (PTH) and Thyroglobulin (TG) immunoassay on needle washing or by immunocytochemistry (ICC) evaluation. The differentiation between parathyroid adenoma (PA), atypical adenoma (PAA) and carcinoma (PC) is difficult on histology or even impossible on FNC. The aim of this study was to evaluate possible cytological criteria to classify FNC-PN further. METHODS: Twenty-three FNC samples of PN and parathyroid cysts were rather then have been reviewed. The series includes 18 PNs, 4 cysts and 1 Thyr3B (histologically diagnosed as PA). Cytological features were: cellularity, patterns (follicular, solid or papillary), clear, oncocytic, isolated cells, nuclear atypia, cytoplasmic inclusions, nucleoli and mitoses. Data were compared with the histological controls. RESULTS: Seventeen PNs, 2 cysts and 1 Thyr3B FNC samples were histologically diagnosed as PA (16), PAA (2) and PC (2). Two cysts and 1 PN were not confirmed histologically. Cytological features and incidences were: high cellularity (1 PA, 1 PAA, 2 PCs), follicular (8 PAs, 1 PAA), solid (5 PAs, 1 PC), papillary pattern (1PA, 1 PAA, 1 PC), clear cells (4 PAs, 1 PAA, 2 PCs), oncocytic cells (6 PAs, 1 PAA, 2 PCs), isolated cells (5 PAs, 2 PAAs, 2 PCs), nuclear atypia (2 PAs, 1 PAA, 2 PCs), cytoplasmic inclusions (4 PAs, 2 PCs), nucleoli (2 PCs) and mitoses (2 PCs). CONCLUSION: Evident nucleoli and mitoses may suggest the differentiation between PA and PC. However, further investigations are required to confirm these preliminary observations.

Surgical management of cervico-mediastinal goiters: Our experience and review of the literature.

AIM: We analyze and discuss the clinical presentation, the diagnostic procedures and the surgical technique in relation to post-operative complications and results in cervico-mediastinal thyroid masses admitted in Thoracic Surgery Unit of AOU Second University of Naples from 1991 to 2006 and in Thoracic Surgery Unit of AOU "S. Giovanni di Dio & Ruggi D'Aragona" of Salerno over a period of 3 years (2011-2014). METHODS: We reviewed 97 patients who underwent surgical treatment for cervico-mediastinal goiters. 47 patients (49.2%) had cervico-mediastinal goiter, 40 patients (40%) had mediastino-cervical goiter and 10 patients (10.8%) had mediastinal goiter. 73 cases were prevascular goiters and 24 were retrovascular goiters. We performed total thyroidectomy in 40 patients, subtotal thyroidectomy in 46 patients and in 11 cases the resection of residual goiter. In 75 patients we used only a cervical approach, in 21 patients the cervical incision was combined with median sternotomy and in 1 patient with transverse sternotomy. RESULTS: Three patients (3.1%) died in the postoperative period (2 cardio-respiratory failure and 1 pulmonary embolism). The histologic study revelead 8 (7.7%) carcinomas. Postoperative complications were: dyspnea in 9 cases (10.7%), transient vocal cord paralysis in 6 patients (9.2%), temporary hypoparathyroidism in 9 patients (9.2%) and kidney failure in 1 case (0.9%). CONCLUSIONS: The presence of a cervico-mediastinal thyroid mass with or without respiratory distress requires a surgical excision as the only treatment option. Thyroid masses extending to the mediastinum can be excised successfully by cervical incision. Bipolar approach (cervical incision and sternotomy) has an excellent outcome, achieving a safe resection, especially in large thyroid masses extending to the mediastinum with close relations to mediastinal structures and in some limited cases (carcinoma, thyroiditis, retrovascular goiter, ectopic goiter). Postoperative mortality and morbidity is very low, independent of surgical techniques. Other surgical approaches for excision of a Posterior Mediastinal Thyroid Goiter reported in literature are: VATS techniques to remove an ectopic intrathoracic goiter, robot-assisted technique for the removal of a substernal thyroid goiter, with extension into the posterior mediastinum.

Laparoscopic or open hemicolectomy for elderly patients with right colon cancer? A retrospective analysis.

AIM: The aim of this study was to compare the short-term surgical outcomes of laparoscopically-assisted right hemicolectomy (LRH) and open right hemicolectomy (ORH) in elderly patients. Patients and methods-Results. Seventy-five patients underwent right hemicolectomy for cancer during the study period, with 41 patients aged ≥ 70 years old. Twenty-four patients underwent ORH and seventeen patients had a LRH (58% vs 42%).We found no differences between ORH and LRH in terms of mean operative time :89,5 minutes in open vs 80 minutes in laparoscopic group and return of bowel function (2,76 vs 2,54 days). Also the length of hospital stay did not differ significantly between the two groups (8,5 days in ORH vs 7 days in LRH - p 0,06). Postoperative morbidity was higher in ORH (25% vs 5%) though not statistically significant and the incidence of anastomotic leakage was similar between the two groups (8% vs 5%). CONCLUSION: Laparoscopic RH in an elderly population is feasible and safe. However, we found no evidence to suggest that it is better than open RH and think that the decision regarding the method of operation should reflect surgeon expertise, patient co-morbidities and the necessity to perform extended resections.

Multi-organ resection for locally advanced adrenocortical cancer: surgical strategy and literature review.

Adrenocortical carcinoma (ACC) is a rare and aggressive endocrine malignancy with an estimated worldwide incidence of 0.5-2 per million/year. Complete surgical removal of ACC represents the current treatment of choice for this tumor. A disease-free resection margin (R0) is an important predictor of long-term survival: surgery is demanding and must be performed by a highly experienced surgical team. We report the surgical strategy adopted in a patient with locally advanced ACC and virilization to obtain a R0 resection.

[Prognostic factors in colorectal adenocarcinoma]. / Fattori prognostici dell'adenocarcinoma colorettale.

Aim of this study was to analyse prognostic factors of improved survival after resection of colorectal cancer. We studied 715 patients by retrospective review operated for colorectal adenocarcinoma. Survival was analyzed by the Kaplan-Maier method. Comparisons were made by log rank analysis. The overall survival is 75% at 1 years, 41.0% at 5 years, 29.7% at 10 years. A significant difference was noted in the survival rate according to age of the patients (p < 0.01), preoperative serum level of carcinoembryonic antigen (CEA) (p < 0.05), the performance status (p < 0.05), intestinal obstruction (p < 0.01), clinicopathological stage of the tumour (p < 0.05). Other factors including the sex, the clinical diagnosis of anaemia, the site of the tumour and histological grade had no apparent influence on survival. To define high-risk groups of recurrence is important for adjuvant therapy and follow-up study.

[A diagnostic strategy in persistent hyperparathyroidism]. / Strategia diagnostica nell'iperparatiroidismo persistente.

BACKGROUND: Primary operations for hyperparathyroidism performed by experienced surgeons has a success rate of about 95% without any preoperative localization. After unsuccessful cervicotomy, localization studies must be performed in order to define the surgical approach. The objective of our retrospective studies was to determine the accuracy of non invasive and invasive localization studies in patients with persistent hyperparathyroidism. METHODS: The present reoperative series involved 7 patients with persistent hyperparathyroidism. Six patients came from a series of 140 operated on at the department of Prof. J. Marescaux from 1991 to 1993 (success rate of 95.7% in cervical exploration). Patient n. 7 came from another department. RESULTS: After negative initial cervicotomy, non invasive localization procedure are undertaken, but with a high incidence of false-positive results (9% to 75%). Among available invasive techniques, it has been chosen to sample blood from large veins in the neck and mediastinum for Parathyroid Hormone (1-84 PTH) determination and to realise angiography for locating parathyroid adenomas as well as for vein mapping. Their combination permitted to localize all lesions. CONCLUSIONS: The specificity of serum concentration of 1-84 PTH determination by catheterization of cervical and mediastinal veins (100%) combined to the sensitivity of angiography (82%) allowed to obtain good result in parathyroid localization in persistent hyperparathyroidism.

[Perforated peptic ulcer and laparoscopic treatment]. / Ulcera peptica perforata e laparoscopia.

BACKGROUND: The purpose of this study is to evaluate the possibility, safety and advantages of laparoscopic approach in the diagnosis and therapy of perforated peptic ulcer. METHODS: This is a retrospective study including 69 cases of gastroduodenal perforation initially treated laparoscopically. The safety (morbidity and mortality) was estimated according to the two mortality rates fixed for laparotomies, APACHE II and Mannheimer Peritonitis Index (MPI). Sixty-nine patients (average age: 52 years), 23% of whom being over 70 years old, suffering from gastroduodenal perforation, were initially treated with laparoscopy. RESULTS: The laparoscopic diagnosis was done in 91% of cases. When the perforation was localized, the laparoscopic treatment was possible in 94% of cases. In 93% of cases a simple closure of the ulcerated perforation was performed. The conversion ratio was of 16%. One-hundred minutes (55-180) was the average operating. The morbidity was of 13%. One septic shock was reported in a patient with general purulent peritonitis diagnosed with laparoscopy and, after having converted, it was treated with laparotomy. No malignant iperCO2 was relieved. The reported mortality was of 4.3%, the theoretical mortality estimated was of 6% (MPI) and of 14% (Score APACHE II). The 3 deceased (87, 87 and 93 years old) had ASA index superior to 3. The remarkable advantage of laparoscopic approach is, in addition to diagnostic contribution, the absence of wall complications when the operation is not converted. CONCLUSIONS: The laparoscopic approach is suggested in gastroduodenal perforation, since it allows an etiological diagnosis and a treatment without conversion in 84% of cases.

[Sequential treatment of lithiasis of the common bile duct]. / Il trattamento sequenziale della litiasi della via biliare principale.

The purpose of this study is to evaluate the sequential endoscopic-laparoscopic approach for clearance of common bile duct (CBD) and removal of gallbladder in patients with simultaneous cholecystolithiasis and choledocholithiasis. A data base of 990 patients undergoing Laparoscopic Cholecystectomy (LC) was compiled during an 5 years period. 88 patients were suspected of having CBD stones based upon clinical, biological and ultrasound evidence. The CBD cannulation rate was 93% (82/88). CBD stones were found in 43 patients (49%). The stones were removed preoperatively by Endoscopic Sphincterotomy (ES) in 37 patients of these 43 cases (86%). LC was performed in all patients after endoscopic retrograde cholangiopancreatography (ERCP). This treatment had showed no mortality and a morbidity of 14%. Efficacy of this sequential method of treatment of LVBP was 86%. With inclusion of laparoscopic extractions, the efficacy rate was 91%. The rate of residual stones was 1% (1/88). Experience with ERCP and ES before LC has been growing. ERCP-SE in the treatment of choice to clear the CBD before LC in high risk elderly patients (26) as well as in complicated stones. However, in this era of laparoscopic surgery, CBD stone can be removed laparoscopically in specialized centres with the advantage of a non-invasive single procedure for the patient. Laparoscopic CBD desobstruction and ES are not opposite but complementary. Preoperative ERCP and ES should be reserved for patients with serious illness. All other patients should be managed laparoscopically; in this case the future of sequential treatment resides in a one step-approach: preoperative ERCP if cholangiography is positive.