Surgical management of benign thyroid disease.

The most recent surgical approaches to benign uninodular, multinodular, normo and/or hyperfunctioning thyroid disease are considered.

Surgical management and follow-up of medullary thyroid carcinoma.

Between 1977 and 1990 we operated on 33 patients with medullary thyroid carcinoma. We performed total thyroidectomy in 31 patients and central node dissection and/or lateral modified node dissection in 21 patients (63.3%). Two patients underwent radiotherapy after subtotal resection and tracheostomy. No perioperative death occurred. Twenty-five patients were followed (mean follow-up, 63.8 months) and 8 others were unavailable for follow-up. Three patients (1 with multiple endocrine neoplasia type IIB, 2 sporadic with distant metastases) died of their disease at 12, 18 and 36 months after initial operation. Of the remaining 22 patients, 4 with stage II disease were normocalcitoninemic even with pentagastrin stimulation, following total thyroidectomy and bilateral modified neck dissection and central node dissection. Eighteen other patients continued to have elevated calcitonin levels postoperatively. Only 10 patients with known cervical metastatic disease were reoperated upon. We performed extensive node dissection in all. In addition we resected recurrent tumor from the thyroid bed in 4 patients. Despite these extensive reoperations no patient became normocalcitoninemic. At the completion of the study (December 1991), 22 of the 25 patients followed were alive: 4 patients with normal calcitonin levels, baseline and after pentagastrin stimulation, and 18 with persistent mildly elevated calcitonin levels but no other evidence of disease. Our experience supports a very aggressive surgical approach at the time of the first operation for patients with medullary thyroid carcinoma. A lesser operation usually resulted in residual medullary thyroid carcinoma in the neck. We demonstrate the difficulty of achieving a cure by reoperation once the tumor becomes demonstrable by localization studies.

Corticotropin-releasing hormone test: improvement of the diagnostic accuracy of simultaneous and bilateral inferior petrosal sinus sampling in patients with Cushing syndrome.

Twenty-six consecutive patients with ACTH-dependent Cushing syndrome were subjected to simultaneous, bilateral inferior petrosal sinus sampling for ACTH assay before and after ACTH-releasing hormone (CRH) stimulation. The baseline ACTH inferior petrosal sinus/periphery (IPS/P) ratio was > or = 2 in 12 of 26 patients (46%), whereas the CRH-stimulated IPS/P ratio was > or = 3 in 19 of 26 patients (73%). A pituitary adenoma, ACTH-secreting at immunostaining, was surgically proved in all of the 19 patients who had an ACTH IPS/P ratio > or = 2 basally or > or = 3 after the CRH test but also in three other patients who did not have such ratios. The value of the basal IPS/P ratio and the complete lack of ACTH increase after CRH led to the diagnosis of an ectopic ACTH syndrome in four patients: a bronchial carcinoid was found in three patients, and the site of the tumor was still unknown in the other. In conclusion, the CRH test improved the diagnostic accuracy of inferior petrosal sinus sampling from 61.5% (12 pituitary, 4 ectopic) to 92.0% (19 pituitary, 4 ectopic). Thus it should be performed during the diagnostic process.

[Medullary carcinoma of the thyroid gland]. / Il carcinoma midollare della tiroide.

The Authors, after introducing the epidemiology and physiopathology of medullary thyroid carcinoma, compare the most recent diagnostic methods and therapeutic strategies. They highlight recent progress in genetics, in diagnosis and therapy and in the role of labelled radiopharmaceuticals in diagnosis, post-operative therapy and follow-up.

Choledochal cysts in adults: a case report.

We examined a case of choledochal cyst in an adult having congenital dilatation of the bile duct classified, according to Todani's, as type I and treated by excision with hepatic-jejunostomy Roux-en Y. This procedure is recommended as the best treatment for eliminating pancreatitis by pancreaticobiliary disconnection and thus for reducing the risk of malignancy.

Hürthle cell neoplasm.

Hürthle cell neoplasms (HNC) of the thyroid gland are uncommon, but potentially malignant lesions. Opinion is divided as to their most suitable surgical treatment. In the ten-year period between 1976 and 1986, 46 patients with Hürthle cell tumor underwent surgery in our Department. Preoperative diagnosis was made by fine needle biopsy. In all cases but six, total lobectomy plus isthmusectomy was performed. In our experience HCC can be differentiated from benign forms by careful evaluation of invasive malignancy criteria performed by an experienced thyroid pathologist and by electron microscopy. In agreement with Bondeson et al. we found that lesions larger than 2 cm should not be considered potentially malignant, and do not warrant aggressive surgical treatment. Therefore, on the basis of our experience, we initially treat Hürthle cell tumors with hemithyroidectomy and isthmusectomy, and only if biopsy tissue shows histologic and electron microscopic signs of malignancy, do we resort to total thyroidectomy.

[Echotomography in scrotal pathology]. / L'ecotomografia nella patologia scrotale.

The authors reviewed their experience on 94 cases of patients suffering from scrotum diseases. This study was carried out either by means of grey-scale or real-time ultrasonography. They consider ecotomography to be an essential diagnostic aid in the clinical investigation of patients affected by this pathology, being a non invasive method and characterized by very high reliability.

[Clinico-diagnostic considerations on lymphocytic thyroiditis. Presentation of clinical cases]. / Considerazioni clinico-diagnostiche sulle tiroiditi linfocitarie. Presentazione di casi clinici.

Personal experience with autoimmune lymphocyte thyroiditis, represented by 11 cases observed between 1972 and today, is reported. After some brief aetiopathogenetic notes on the lesions in question, the problems of diagnosing the nature of the thyropathy are stressed. After reviewing the examinations that have been proposed in the literature, it is noted that the preoperative recognition of a thyroiditis with autoimmune genesis is still problematical. The institution of a diagnostic protocol based on the systematic search for antibodies, the perchlorate test, the thyrostimulation test, ESR study, the search for alpha2 and gamma-globulins, scintigraphy with positive indicators and needle biopsy as well as on scintigraphy and thyrometabolic tests (T3-T4-TSH-TRH test) is proposed. Even when such a protocol is adopted, however, it should be mentioned that only in 18% of the personal cases was it possible to diagnose thyroiditis, in the other subjects this being merely an occasional post-operative finding. In confirming the personal therapeutic approach, which at least initially is medical, for recognized forms, it is pointed out that surgical treatment is to be preferred in certain cases because of the presence of compressive phenomena, and in others it appears capable of relieving, in follow-up, the thyroiditic process, probably as a result of the removal of the antigenic tissue.