[Thyroid cancer in children and adolescents. Clinical aspects, diagnostic problems and special therapeutics]. / Cancer thyroïdien chez l'enfant et l'adolescent. Aspects cliniques, problèmes diagnostiques et thérapeutiques particuliers.

Twenty-five children undergoing surgery for thyroid carcinoma, were compared in a retrospective study. Clinical characteristics and disease course were detailed in three groups. In the first of 11 patients, a lobo-isthmusectomy was performed for a thyroid nodule, except two cases of total thyroidectomy (TT). Papillary carcinoma was diagnosed on histologic findings. Preoperative cytology and peroperative frozen section examination were inadequate for diagnosis. All children had a complete remission after treatment. In the second group, 10 children had evident thyroid carcinoma with cervical lymph node metastases, and lung metastases in two. Microscopicaly, there were diffuse sclerosing variant or multifocal papillary carcinoma. A TT with central node dissection was performed in all, with a lateral lymph node dissection in 9. Treatment included radioiodine therapy and thyroxin suppression therapy. Three patients had a postoperative recurrent laryngeal palsy, one hypoparathyroidism. Reoperation was carried out in 4 for cervicomediastinal lymph node recurrence. All patients are alive, with a complete remission, except for the two patients with lung metastases. In this group of aggressive tumors, a complete cure was possible with combination of extended, sometimes repeated, surgery and radioiodine therapy. In the last group, 4 patients had a medullary carcinoma. One presented with a thyroid nodule. The others were asymptomatic with a positive pentagastrin test during biological screening for familial disease. Two patients with lymph node metastases had a persistent pathologic calcitonin test despite a TT with complete central and lateral lymph node dissection. Early genetic screening in family members is the only way to perform a curative thyroidectomy in a prepathologic stage.

[Malignant cortico-adrenal tumors with vena cava extension. Is surgical resection justified?]. / Tumeurs malignes cortico-surrénaliennes avec extension cave. L'exérèse chirurgicale est-elle justifiée?

Between January 1989 and December 1996, 6 patients (4 females and 2 males), ranging in age from 23 to 82, underwent surgery for malignant adrenocortical tumors with inferior vena cava extension. There were 5 adrenocortical carcinomas and 1 metastasis from a differentiated thyroid carcinoma. The tumor size ranges from 9 to 17 cm. 5 tumors involved the right adrenal and 1 involved the left adrenal. Four patients had a vena caval thrombus, extending into the right atrium in one case. Two patients had direct tumoral invasion of the IVC wall without thrombius. All patients underwent en bloc excision of the adrenal gland and regional nodes, with nephrectomy in 4 cases and right hepatectomy in one case. Thrombectomy was performed in 4 cases with cardio-pulmonary by-pass in one case. Venous invasion without thrombus required total resection of the infra-hepatic IVC ine one case and vascular reconstruction with prosthetic patch in another case. There were no peri-operative deaths. Two patients died from metastatic disease after 13 and 40 months respectively. Four patients were alive with a follow-up ranging from 3 to 31 months, 3 patient were free of disease. Surgical resection of adrenocortical carcinomas with IVC extension can be attempted. There is no increase in morbidity and mortality in comparison with surgical treatment of other adrenal carcinomas. In these particular cases, the risk of metastases and local recurrence is high, but long-term survival can be obtained after radical macroscopic resection.

[Results of reoperations for goiter]. / Résultats des réinterventions pour goitres.

We report 47 reoperations for benign thyroid goiters between February 1994 and October 1995 out of a total of 1125 thyroidectomies. These operations concerned 42 women and 5 men with an average age of 54 years. The mean time between the 2 operations was 19 years. On 45 occasions, the reoperation included a totalisation of the previous partial thyroidectomy. In 2 cases a near total thyroidectomy was performed leaving a minimal thyroid remnent on one side. The mean weight of the resected gland was 73 grs. The morbidity included 2 temporary recurrent laryngeal nerve palsies resolving within 2 months and 7 cases of temporary hypocalcemia without permanent hypocalcemia. In the case of repeated surgery, the risks of recurrent laryngeal nerve damage and parathyroid gland resection are typically increased. The risk varies according to the initial surgical resection: unilateral lobectomy versus bilateral subtotal lobectomy. Surgical risks can be significantly decreased with a safe surgical technique. Indications for reoperations in case of benign thyroid goiter are rare and can probably still be reduced. Treatment with thyroxin is sometimes ineffective and is questionable after sub total thyroidectomy for nodular goiter. A primary total thyroidectomy can be indicated in such selected cases.

[Excision of a parathyroid adenoma of the aorto-pulmonary window under thoracoscopy]. / Exérèse sous thoracoscopie première d'un adénome parathyroïdien de la fenêtre aorto-pulmonaire.

OBJECTIVES: Neck exploration is usually required in all cases of primary hyperparathyroidism. Without a precise localization preoperatively cervicotomy may be unsuccessful, especially in case of an ectopic adenoma. CASE REPORT: A patient with primary hyperparathyroidism due to a solitary adenoma localized in the middle mediastinum was identified on preoperative computed tomography and technetium-99m-sestamibi radionuclide scan. The tumor was successfully removed at thoracoscopy without neck exploration. DISCUSSION: Preoperative localization of primary hyperparathyroid tumors is not indicated in all patients. In some selected cases (acute hypercalcemia, reoperation, serious illness) prior neck exploration would be useful in guiding the surgeon.

[Malignant adrenocortical carcinoma with atypical aspect. Value of tomodensitometry and magnetic resonance imaging. Apropos of a case]. / Corticosurrénalome malin de présentation atypique. Intérêt du scanner et de l'IRM. A propos d'un cas.

A case of large and non-functioning malignant adrenal tumor is reported. It was discovered incidentally during a check-up ordered because of sciatic pain caused by an osteolytic lesion of the sacrum. This huge abdominal tumor was suspected to be an adrenal tumor one the basis of the CT and MR findings. Histological analysis of percutaneous biopsies were unable to define the site and etiology of these two masses. Only histo-pathological examination of the surgical specimen allowed the diagnosis of adrenal cortical carcinoma.

[Role of total thyroidectomy in the treatment of benign thyroid diseases]. / Place de la thyroïdectomie totale dans le traitement des maladies thyroïdiennes bénignes.

In 1990, total thyroidectomy (T.T.) was performed in 4% of all benign thyroid diseases and in 7% in case of diffuse benign thyroid diseases, operated on in our surgical unit. In 1995, this incidence of T.T. increased to 20% and 37% respectively. Several considerations can explain this rise in T.T. indications. Currently, the incidence of reoperations on benign goiters represents 4.5% of all our thyroid surgery. It can be considered as a failure of a first incomplete operation. Furthermore, most of goiter recurrences are medically treated and the recurrence rate is higher than the reoperation rate. In Grave's disease, surgery is indicated after medical treatment failure or for acute complications. In this case, the aim of surgery is radical cure of hyperthyroidism. Because evaluation of the weight of thyroid remnant for prevention of postoperative hypothyroidism is difficult, indication of T.T. with thyroxin replacement therapy can be proposed. Surgical excision of a multinodular goiter is indicated for large size lesions, tracheal compression or thyrotoxic evolution. Over the years subtotal thyroidectomy was performed for these benign lesions. Subtotal thyroidectomy leaves a diseased remnant gland. Attempts to suppress nodular recurrence by thyroxin treatment do not guarantee success. Then T.T. can be advocated since postoperative thyroxin therapy is often given after subtotal thyroidectomy to prevent hypothyroidism. Total thyroidectomy is an appropriate operation for the management of a benign thyroid disease because it precludes patients from requiring further surgery for recurrent diseases. However, it requires two conditions. In first, the patient must have the psychologic and economic capacity for a permanent medical therapy. The other is that the procedure be performed with low risks of complications in comparison with subtotal thyroidectomies. Currently recurrential palsy and hypoparathyroidism rates are evaluated in the literature between 0 and 3%.