Angiogenesis in human normal and pathologic adrenal cortex

The angiogenic phenotype of 13 normal adrenal glands (N), 13 aldosterone-producing adenomas (APA), 12 cortisol-producing adenomas (CPA), 13 nonfunctioning adrenal cortical adenomas (NFA), and 13 adrenal cortical carcinomas (CA) was investigated. Intratumoral vascular density was explored by CD34, a marker of endothelial cells, and the angiogenic status was investigated by vascular endothelial growth factor (VEGF) expression, an important angiogenic factor expressed by tumoral cells. Vascular density, quantified as the number of vessels per square millimeter, was significantly lower (P < 0.0001) in CA (110.3 +/- 27.8) than in N (336.6 +/- 14.5), APA (322.8 +/- 19.1), CPA (288.5 +/- 14.3), and NFA (274.2 +/- 19.8). VEGF expression, calculated as the percentage of positive cells, was significantly greater (P < 0.0001) in CA (85.3 +/- 2.1) than in APA (56.5 +/- 7.5), CPA (38.5 +/- 7.0), N (33.1 +/- 6.1), and NFA (0.76 +/- 0.6). In APA, a negative relation between CD34 and plasma renin activity (P < 0.0002) and a positive association between CD34 and aldosterone levels (P < 0.05) was found. In conclusion, the angiogenic phenotype of CA is characterized by VEGF overexpression but low vascularization, a finding suggesting a dissociation between angiogenic potential and neoangiogenic capabilities of these tumors. The lack of VEGF expression in NFA and the close association between angiogenesis and functional status in APA also suggest a possible influence of the angiogenic phenotype on hormonal secretion of these endocrine tumors.

Endoscopic surgery in Senegal. Benefits, costs and limits

BACKGROUND

Evaluating the introduction of endoscopic surgery in Senegal may be useful for assessing the role of this technology in developing countries.

METHODS

The endoscopic surgery performed at the Hospital Principal and the Hospital Le Dantec, Dakar, from January 1995 to December 2000 was evaluated retrospectively. Operative time, postoperative stay, patients, and hospital costs were compared in samples of 100 patients treated endoscopically and 80 patients treated with open techniques.

RESULTS

Altogether, 826 endoscopic procedures were performed (11.6% of elective surgical activity). Of these, thoracoscopic (34%) and laparoscopic (14%) vagotomy, cholecystectomy (21%), fundoplication (12%), and diagnostic laparoscopy (11%) were selected for comparisons. Operative time proved to be reduced by endoscopic surgery except for laparoscopic fundoplication (+40 min). After endoscopic surgery, postoperative hospitalization was 3.7 days shorter, and patient fees were consequently reduced. In 6 years, 87% of the hospital investment (36,000 Euro) was recovered.

CONCLUSIONS

Developing countries can benefit from endoscopic surgery. First-world countries might supply staff training.

Evaluation of telomerase mRNA (hTERT) in colon cancer

Telomerase activation, a cardinal requirement for immortalization, is a crucial step in the development of malignancy and requires the induction of the catalytic component, human telomerase reverse transcriptase (hTERT), encoded by the hTERT gene. By reverse transcription-PCR, using primers within the reverse transcriptase domain of hTERT, we investigated telomerase messenger in 8 adenomatous and 9 dysplastic polyps, and in 32 paired cancer-normal mucosa specimens, one liver and one spleen metastasis from patients resected for sporadic colorectal cancer. Telomerase messenger was absent or very low in normal mucosa and in adenomatous polyps. Dysplastic polyps and adenocarcinoma samples showed hTERT mRNA, with higher levels in cancer tissues compared to dysplastic lesions. A high telomerase messenger level was shown to be associated with late-staged cancers and with metastasis; thus, detection of telomerase messenger may be useful in the early diagnosis of colon cancer, and telomerase may be a new target for therapeutic intervention.

Graves-Basedow's disease in children and adolescents: total vs subtotal thyroidectomy

"Graves' disease" is an autoimmune pathology and is the most important cause of hyperthyroidism in children and adolescents. The treatment for this disease is controversial; there are three different options: synthetic antithyroid drugs, ablation of the thyroid gland with I 131 or surgery. Our study reports the clinical and therapeutic aspects and long-term results of 27 patients (< = 18 years old) treated with total thyroidectomy or "near-total" thyroidectomy from 1975 to August 2001. Antithyroid drugs represent the preliminary treatment of choice. For a long time in the past therapy with radioactive iodine was not recommended; now it represents an efficiently therapy with low morbility. Surgical treatment is suitable when a young patient presents a considerable enlargement of the thyroid gland or when antithyroid medical treatment does not achieve a good control of the disease, or when rapid control of hyperthyroidism is necessary. The surgical treatment can be a total thyroidectomy or a "near-total" thyroidectomy. The first is the best choice for us, because it has a low risk of relapse and a major efficacy in the ophthalmopathy.

Long-term monitoring of cell-mediated immunity in disease-free breast cancer patients: a preliminary retrospective study

In 102 N- and 44 N+ disease-free breast cancer patients, lymphocytic populations and skin reaction of delayed hypersensitivity (SRDH) were monitored up to 266 months after mastectomy to find out whether they were similar or different from control values. In two selected groups of 34 N- and 11 N+ breast cancer patients, the whole 10 year follow-up was divided into three subintervals, each of them lasting 40 months and the time course of lymphocytic populations was evaluated. In the 102 N- patients, mean CD4+, CD8+, CD3+ values were lower (P < 0.01, P < 0.001, P < 0.01, respectively) while CD4+/CD8+ ratio was higher (P < 0.05) than in controls. Fifteen N- breast cancer patients (16%) were anergic compared to 30(32%) of controls (P < 0.05). In the 34 selected N- breast cancer patients soon after mastectomy the mean value of CD4+, CD8+, CD3+ T subpopulations was lower (P < 0.01, P < 0.001, P < 0.01, respectively) than in controls. Successively their mean value increased so that in the last subinterval they were not or were only slightly lower (P n.s., P < 0.05, P < 0.05, respectively) than in controls. In the 44 N+ patients, mean CD4+, CD8+, CD3+ values were lower (P < 0.001, v < 0.05, P < 0.01, respectively) and CD19+ lymphocytes higher (P < 0.001) than in controls. Five N+ breast cancer patients (13%) were anergic compared to 32% of controls (P < 0.05). In the 11 selected N+ breast cancer patients soon after mastectomy, the mean value of CD4+, CD8+ T subpopulations and CD16+56+ cells was significantly lower (P < 0.001, P < 0.001, P < 0.01, respectively) than in controls. Successively their mean value constantly increased so that in the last subinterval, no or slight (P n.s., P < 0.05, P n.s., respectively) significant difference compared to controls occurred. The mean CD4+/CD8+ ratio value of N- patients was significantly higher than in controls. However in the last subinterval, the significance was lower than in the first one (P < 0.05 and P < 0.01, respectively). In the N+ patients, the mean value of CD4+/CD8+ ratio was constant, although not significantly, lower than in controls; however it progressively increased from the first to the last subinterval. Therefore the significance of the difference of the mean CD4+/CD8+ ratio between N- and N+ patients strongly decreased from the first to the last subinterval (P < 0.001 and P < 0.05, respectively). These data indicate that in breast cancer patients, following mastectomy, a significant activation of memory and CD4+ T cells and long-term decrease of the circulating immunocompetent CD4+, CD8+ and CD16+56+ cells occurs. The prolonged disease-free interval observed in the 34 N- and 11 N+ breast cancer patients can be correlated with the restoration of the normal state of cell-mediated immunity.

Calcium-sensing receptor gene polymorphisms in primary hyperparathyroidism

The calcium-sensing receptor (CaR) polymorphism A986S has been found to be associated with higher serum calcium levels in normal subjects, suggesting that this amino acid change might decrease the inhibitory activity of the mutated receptor, render the parathyroid cells more prone to proliferate, and eventually increase the risk of developing primary hyperparathyroidism (PHPT). The aim of the present study was to investigate the frequency of this and other 2 known CaR polymorphisms (R990G and Q1011 E) in patients with PHPT and their effect on its phenotype. We studied 103 Italian patients with PHPT and 148 healthy Italian subjects and we compared the results in 50 pairs matched for sex, age and geographic provenience. A fragment of exon 7 of the CaR gene, containing the 3 polymorphic loci of interest (A986S, R990G, and Q1011E), was amplified by PCR and sequenced. Serum calcium and PTH levels, BMD and other biochemical and clinical parameters were evaluated. The frequency distribution of the A9865, R990G, and Q1011 E polymorphisms in the 103 PHPT patients was 39.8%, 5.8%, and 2.0%, respectively. There was no difference in the frequency of the 3 CaR polymorphisms in the 50 matched pairs of patients and controls. We found no significant difference in several clinical and biochemical parameters between PHPT patients carrying or not the 986S allele. Finally, no relationship was observed between the 986S genotype and total and ionized serum calcium in control subjects. The A986S CaR polymorphism is the most common in Italian PHPT patients and the allotype AS does not appear to play a relevant role in the pathogenesis of PHPT and its severity. The A986S polymorphism does not correlate with serum calcium levels in normal Italian subjects.

Adrenal surgery before and after the introduction of laparoscopic adrenalectomy

BACKGROUND

The widespread introduction of laparoscopic adrenalectomy (LA) may have broadened the indications for a surgical approach to adrenal lesions. The aim of this study was to evaluate how the introduction of the laparoscopic technique changed the profile of patients referred for adrenal surgery.

METHODS

Some 243 patients, who underwent adrenal surgery between November 1986 and December 1999, were divided in two groups: patients in group 1 underwent surgery before the introduction of LA (November 1986 to May 1993) and those in group 2 were operated on after the introduction of LA (June 1993 to December 1999). The groups were compared with respect to gender, age, preoperative diagnosis and lesion size.

RESULTS

There were 88 patients in group 1 and 155 in group 2. The mean number of adrenal operations per month was 1.1 during the first period and 2.0 during the second. No differences were found in gender and lesion size. The statistical analysis showed a significant difference in indications for surgery (P = 0.005). The patients in group 2 were older but, after excluding those with metastases, the difference between the two groups was not significant.

CONCLUSION

The introduction of LA resulted in an increase in the number of patients referred. The criteria for patient selection did not change, but more patients with adrenal metastases and incidentaloma were operated on laparoscopically.

A quick intraoperative parathyroid hormone assay in the surgical management of patients with primary hyperparathyroidism: a study of 206 consecutive cases

OBJECTIVE

The traditional surgical approach for patients with primary hyperparathyroidism (PHPT) consists of the identification of at least four glands and in the removal of all hyperfunctioning parathyroid tissue.

DESIGN

To evaluate whether intraoperative parathyroid hormone (PTH) monitoring will allow a more limited surgical procedure by confirming complete removal of all hyperfunctioning tissue.

METHODS

Plasma samples were obtained from 206 consecutive patients with sporadic PHPT before skin incision, during manipulation of a suspected adenoma, and 5 min (T-5) and 10 min after removal of abnormal parathyroid tissue. PTH was measured by a quick immunochemiluminescent assay (QPTH). The operative success was defined by a decrease of PTH greater than 50% of the highest pre-excision value.

RESULTS

A >50% decrease of PTH occurred in 203 patients and was evident at T-5 in the majority of cases. All but three had normal serum calcium the day after surgery and afterwards. PTH concentration did not show a >50% decrease in the remaining three cases after completion of surgery. One patients had negative neck exploration and remained hypercalcemic; the other two had normal serum calcium at follow-up. Thus, the intraoperative QPTH correctly predicted the outcome of surgery in 201 patients (97.5%) (200 true positive and 1 true negative), and provided three false positive and two false negative results.

CONCLUSIONS

The intraoperative QPTH measurement represents a useful tool to assist the surgeon during parathyroidectomy. It indicates whether all hyperfunctioning parathyroid tissue has been removed, limiting the procedure to a unilateral neck exploration in most cases.

MEN1 gene alterations do not correlate with the phenotype of sporadic primary hyperparathyroidism

Loss of heterozygosity (LOH) in the MEN1 region on chromosome 11q13 and MEN1 gene mutations have been found in a subset of sporadic parathyroid tumors. The question of whether these genetic abnormalities in the parathyroid tumors might influence the clinical and biochemical characteristics of primary hyperparathyroidism (PHPT) remains to be elucidated. The aim of the present study was to correlate the presence of MEN1 gene alterations in PHPT tumors with the clinical phenotype. Using microsatellite analysis for LOH at 11q13 and DNA sequencing of the coding exons, the MEN1 gene was studied in 38 parathyroid tumors of patients with sporadic PHPT. Fourteen tumors showed LOH at 11q13, and mutations of MEN1 gene were detected in 7 cases. The clinical and biochemical characteristics of patients were unrelated to the presence or absence of LOH and/or MEN1 gene mutations. In conclusion, MEN1 gene alterations are rather common in sporadic PHPT and their presence does not correlate with the clinical manifestations of the disease.

Apoptosis control and proliferation marker in human normal and neoplastic adrenocortical tissues

We evaluated by immunohistochemistry the expression of the Bcl-2 and p53 proteins, as markers of apoptosis control, and of MIB-1, as a marker of cell proliferation, in a series of normal and neoplastic adrenocortical tissues. The specimens were 13 normal adrenals, 13 aldosterone-producing adenomas, 13 non-functioning adenomas and 16 carcinomas. Results were calculated as percentage of immunostained cells by using specific antibodies. No p53 protein was detected in any of the adrenocortical adenomas (functioning and non functioning) or normal adrenals, while p53 was overexpressed in 15 out of 16 carcinomas. In particular, 10 adrenal cancer specimens (62.5%) showed strong staining in a high percentage (range 10-50%) of the malignant cells. The percentage of Bcl-2 positive cells was higher (P<0.05 or less) in non-functioning adenomas (8.1+/-1.9%) and in carcinomas (14.9+/-5.6%) than in normals (2.9+/-0.9%) and aldosterone-producing adenomas (5.3+/-1.3%) since four specimens of the non-functioning adenomas-group (30.7%) and six of the carcinomas-group (37.5%) showed over 10% positivity (cut-off for normal values, set at 90th percentile of our controls). MIB-1 positivity was 0.50+/-0.36% in normals, 0.54+/-0.08% in non-functioning adenomas and 0.54+/-0.08% in aldosterone-producing adenomas. MIB-1 was expressed in all carcinomas with values (13.7+/-3.1%) significantly (P<0.0006) higher than in the other groups. In conclusion, the present data indicate that the apoptosis control and proliferation activity evaluated by the p53 and MIB-1 proteins are impaired in adrenal carcinomas but preserved in adenomas, independently of their functional status. Therefore, these immunohistochemical markers, overexpressed in carcinomas only, may be useful in the diagnosis of malignancy in adrenocortical tumours. Whether Bcl-2 positivity found in some carcinomas and non-functioning adenomas may constitute, in the latter, a negative prognostic marker is still unknown.

[Video-assistive minimally invasive surgical procedures in the treatment of thyroid in children and adolescents]

Minimally invasive video-assisted (MIVA) surgery of the thyroid is now widely accepted by endocrinel surgeons, especially in adult age. This report describes indications, limits, technical aspects and results of MIVA in 10 young patients (mean age 16 years, range 11-18) enrolled in a study of 213 patients (mean age 45 years, range 11-81) operated with this technique, from October 1998 to August 2001, in the Department of Surgery at the University of Pisa. Young patients were submitted to surgery: 8 lobectomies (6 for microfollicular lesions and 2 for adenomas functionally autonomous) and 2 total thyroidectomies for papillary carcinoma. No case has been converted in "open" surgery and no post-operatory complications have been observed. Elective indications of MIVA are the volume of the nodule and the istological type. This technique cannot be performed in voluminous goiters, in medullary carcinomas and in scarcely differentiated carcinomas. Minimally invasive video-assisted surgery of the thyroid, in our experience, represents a reliable technique also in pediatric age.

Neoangiogenesis in colon cancer: correlation between vascular density, vascular endothelial growth factor (VEGF) and p53 protein expression

Angiogenesis is an essential requirement for the development, progression and metastasis of malignant tumors. Vascular endothelial growth factor (VEGF) plays an essential role in the development of angiogenesis of numerous solid malignancies, including colon cancer. The tumor suppressor gene p53 is a potent transcriptional regulator of genes which are involved in many cellular activities, including cell-cycle arrest, apoptosis and angiogenesis. In order to better understand the relation among p53 status, VEGF expression and microvessels count (MVC) in colon cancer, we evaluated immunoreactivity for CD34 endothelium-associated antigen, VEGF and p53 proteins in 43 cases of colon adenocarcinoma. Our results demonstrated an association between VEGF expression, p53 status and angiogenesis, suggesting that mutant p53 plays a central role in promoting angiogenesis in colon cancer progression.

GH secretion is impaired in patients with primary hyperparathyroidism

The activity of the GH/IGF-I axis as a function of parathyroid activity and calcium metabolism in humans has never been assessed. To address this issue, we studied 18 patients (5 men, 13 women; age range, 23-76 yr; mean, 61 yr) with primary hyperparathyroidism (PHP) due to solitary parathyroid adenoma. GH secretion was evaluated by serum IGF-I levels, spontaneous mean GH secretion over two morning hours, and GH response to arginine (ARG) alone or combined with GHRH. In five patients, serum GH concentrations were measured every 20 min for 24 h, and deconvolution analysis was performed. A group of 35 age- and sex-matched normal subjects served as controls. Mean serum IGF-I levels in PHP were lower than in normal controls, and in six PHP patients individual serum IGF-I levels were below the age-related normal range. The mean (+/-SE) peak GH response to ARG alone in PHP patients was significantly lower than in normal subjects (4.0 +/- 1.0 vs. 22.0 +/- 1.3 microg/liter; P < 0.001). Likewise, the mean (+/-SE) peak GH response to ARG plus GHRH was reduced in PHP patients (9.9 +/- 0.9 vs. 38.0 +/- 3.5 microg/liter; P < 0.001). The mean GH concentration over two morning hours in PHP was lower (0.20 +/- 0.05 vs. 1.34 +/- 0.31 microg/liter; P < 0.001). The mean GH concentration over 24 h in five PHP patients was lower than in six normal controls (0.3 +/- 0.1 vs. 0.7+/- 0.1 microg/liter; P < 0.05); the deconvolution analysis showed that 24-h GH production rate (3.0 +/- 1.7 vs. 28.2 +/- 4.7 microg/liter.d; P < 0.05) and mean secretory burst mass (1.2 +/- 0.7 vs. 10.5 +/- 2.6 microg/liter; P < 0.05), but not pulse frequency, were lower in PHP patients than in normal controls. GH half-life and approximate entropy values of 24-h GH profiles were similar in PHP patients and normal controls. No correlation was found between serum-ionized calcium or PTH levels and spontaneous or stimulated GH levels in PHP patients. In conclusion, this study demonstrates that PHP patients have a reduction in both spontaneous and stimulated GH secretion. Accordingly, PHP should be mentioned as a further example of a metabolic condition in which GH secretion in adults is reduced.

Impact of harmonic scalpel on operative time during video-assisted thyroidectomy

BACKGROUND

Minimally invasive video-assisted thyroidectomy (MIVAT) has been practiced in our department since 1998. It has some advantages over conventional surgery in terms of postoperative pain and cosmetic result. The aim of this study was to evaluate the use of the Harmonic scalpel (HS) on the performance of this procedure.

METHODS

Between October 1998 and January 2001, 116 patients underwent MIVAT. The HS was used for the last 26 operations. We compared this group of patients (HS-G) with a control group (C-G) of 26 patients who had undergone MIVAT before the introduction of the HS. The following parameters were considered: age, gender, preoperative diagnosis, size of the lesion, type of operation (lobectomy or total thyroidectomy), operative time, complication rate, and postoperative hospital stay.

RESULTS

The two groups were well matched for age, gender, preoperative diagnosis, lesion size, and type of operation. The mean operative time was significantly reduced in the HS-G for both lobectomy (37.3 +/- 8.4 vs 49.4 +/- 18.0 min) and total thyroidectomy (53.8 +/- 16.3 vs 90.6 +/- 22.1 min). No differences were found for postoperative stay. One patient in the C-G experienced a transient recurrent nerve palsy. There were no other complications.

CONCLUSIONS

This study showed that the utilization of the HS for MIVAT is safe and associated with a shorter operative time. A reduction of the rates for such complications such as hypoparathyroidism and recurrent nerve injuries was not possible to demonstrate in the present study. Much larger series are needed for further evaluation of this instrument.

Iopanoic acid rapidly controls type I amiodarone-induced thyrotoxicosis prior to thyroidectomy

Amiodarone-induced thyrotoxicosis (AIT) may develop either in apparently normal thyroid glands (Type II AIT) or in the presence of sub-clinical thyroid abnormalities (either autonomous goiter or latent Graves' disease; Type I AIT). Mixed forms also occur. While Type I AIT is due to iodine-induced excess thyroid hormone synthesis, Type II AIT is a form of amiodarone (possibly iodine) -induced destructive thyroiditis. Type I AIT is usually treated by combined thionamide and potassium perchlorate therapy, but may be resistant to therapy. On the other hand, Type II AIT often responds favorably to glucocorticoids and may not require further therapy once euthyroidism has been restored. Not infrequently, however, AIT (especially Type I) is resistant to conventional treatment, and several weeks or months may elapse before euthyroidism is restored. Thyroidectomy has been carried out in Type I AIT patients, but thyroid surgery in thyrotoxic patients, especially those with underlying cardiac problems, carries a high surgical risk. In this study we describe 3 patients with Type I AIT, who were successfully treated with a short course of iopanoic acid (IOP), an oral cholecystographic agent, which is rich in iodine and is a potent inhibitor of 5'-deiodinase, resulting in a marked decrease in the peripheral tissue conversion of T4 to T3, in preparation for thyroid surgery. Euthyroidism was rapidly restored in 7-12 days, allowing a subsequent safe and uneventful thyroidectomy in all cases. These patients were then treated with L-T4 for their hypothyroidism and amiodarone was safely re-instituted. We suggest that IOP is the drug of choice in the rapid restoration of euthyroidism prior to definitive thyroidectomy in patients with drug resistant Type I AIT.

[Prophylactic total thyroidectomy in children and adolescents with genetic mutations in the RET-protooncogene]

Medullary thyroid cancer (C.M.T.) can be a sporadic form generally in adults or a heredofamilial form where the first symptom appears in pediatric and adolescent age. The hereditary form can be isolated or associated with others endocrine neoplasias of type 2: MEN2a (with or without cutaneous lichen amyloidosis) and MEN2b. The responsible gene of the transmission has been identified in proto-oncogene RET localized on chromosome 10. Point form mutations of this proto-oncogene have been found on exons 10 and 11 in MEN2a and on 16 in MEN2b. In our study on 64 subjects, who belong 11 familiar groups, affected by MEN2a, MEN2b and familiar C.M.T., underwent a genetic research to look for point form mutations of proto-oncogene RET with PCR followed by the analysis of restriction. A genetic mutation has been revealed in 25 subjects: 18 were already known affected by MEN2 and so surgical treated and 7 seemed healthy (mean age 17.4 years, range 10-25). These 7 patients has been undergone clinical research and surgical treatment: a total thyroidectomy associated a lymphectomy of the central compartment. In all cases the histological exam showed C.M.T. moreover a patient had metastasis in lymph nodes of the central compartment. Another had hyperparathyroidism and pheochromocytoma treated with total thyroidectomy, parathyroidectomy and bilateral laparoscopic adrenalectomy. The identification in a very early age of carrier subjects of hill's gene inside an affected family, permits the execution of a prophylactic total thyroidectomy to prevent the C.M.T.. The penetrance of this neoplasia in hereditary form is 100%.

Minimally invasive surgery for thyroid and parathyroid diseases

During the past 4 years, some minimally invasive procedures for thyroid and parathyroid surgery have been described. All these techniques have been demonstrated as feasible and safe. Nevertheless, the surgeon should be well trained to obtain the best results with these approaches. Moreover, not all patients are eligible for minimally invasive procedures. At the moment, they can be proposed for most patients with sporadic primary hyperparathyroidism, but only for a minority of patients with thyroid nodules. The results from minimally invasive procedures are almost comparable with those of conventional surgery, but they have additional advantages in terms of cosmetic result and postoperative pain. Therefore, these procedures should be considered a valid option by surgeons dealing with neck endocrine surgery.

Anterior, lateral, and posterior retroperitoneal approaches in endoscopic adrenalectomy

BACKGROUND

Three approaches are currently used for endoscopic adrenalectomy-the lateral (transperitoneal), the posterior (retroperitoneal), and the anterior (transperitoneal). Both the lateral and posterior approaches are performed with the patient placed in the flank decubitus position; in the anterior approach the patient is supine. This study was designed to compare these three types of access in a relatively large series of patients undergoing adrenalectomy at three different institutions.

METHODS

Laparoscopic adrenalectomy was performed in 216 patients with a variety of adrenal disorders, including 66 patients with Conn's syndrome, 55 with incidentaloma, 58 with Cushing's syndrome, 33 with pheochromocytoma, two with virilizing adrenogenital syndrome, and two with other lesions. Seventy-two adrenalectomies were performed using the lateral access, 67 via the posterior approach, and 77 via the transperitoneal anterior approach. There were 111 right and 105 left lesions.

RESULTS

One patient in the lateral access group and three patients in the posterior group required conversion to open surgery. No conversions were needed in the anterior group. The learning curve was statistically significant only in the anterior access group. In both of the transperitoneal approaches (lateral and anterior), a statistically significant correlation was found between the operative time and the patient's body mass index (BMI). The postoperative hospital stay and time needed to return to normal activities were similar for the three groups. One patient who underwent retroperitoneal adrenalectomy for Cushing' disease died in the postoperative period of Candida sepsis and peritonitis.

CONCLUSIONS

The anterior access route requires that the surgeon be skilled in advanced laparoscopic surgery. Both of the transperitoneal approaches (anterior and lateral) are suitable to remove larger adrenal masses. The posterior access may represent a better option in obese patients or in cases with small lesions.

Comparison between minimally invasive video-assisted thyroidectomy and conventional thyroidectomy: a prospective randomized study

BACKGROUND

Endoscopic procedures for thyroid surgery have been introduced since 1998, but their diffusion has remained limited because their advantages were never demonstrated.

METHODS

Forty-nine patients undergoing surgery for either a thyroid nodule or a small papillary carcinoma were allotted to 1 of these procedures, minimally invasive video-assisted thyroidectomy (MIVAT) or conventional thyroidectomy (CT). Exclusion criteria were nodules greater than 35 mm, presence of thyroiditis, and thyroid volume greater than 20 mL. Preoperative diagnosis, operative time, postoperative pain, complications, and cosmetic result were evaluated.

RESULTS

MIVAT group included 25 patients and the CT group 24 patients. Operative time was 66 +/- 24 minutes for MIVAT and 45 +/- 15 minutes for CT (P = .001). Postoperative course was significantly less painful in the patients who underwent MIVAT (P = .003). Cosmetic result evaluated by verbal response scale and numeric scale was in favor of MIVAT (P = .003 and P = .01, respectively). One recurrent nerve palsy and 1 transient hypoparathyroidism were present in CT patients; MIVAT patients experienced 2 transient palsies.

CONCLUSIONS

Despite some MIVAT advantages in terms of postoperative pain and cosmesis, CT still offers an advantage in terms of operative time and its safety should not differ. Larger series of patients are needed before deciding whether endoscopic thyroidectomy can offer important advantages.

RET protein expression has no prognostic impact on the long-term outcome of papillary thyroid carcinoma

BACKGROUND

RET proto-oncogene rearrangements (RET/PTC) are causative events in the pathogenesis of a subset of papillary thyroid cancer (PTC). The prevalence of RET/PTC varies in different countries and according to specific clinical features: it is higher after radiation exposure and it is claimed to be higher in young patients. Conflicting results are reported regarding the prognostic role of RET/PTC activation.

OBJECTIVE

To investigate the prognostic meaning of RET/PTC rearrangement on the long term outcome of PTC.

METHODS

We have studied the expression of the RET encoded protein in 127 papillary thyroid carcinomas by immunohistochemistry using a polyclonal antibody against the tyrosine-kinase domain of the RET protein. These cases have been collected during 1970-1985, and have a mean (+/-S.D.) period of follow-up of 18.6+/-3.7 years (range 12-27 years). The results have been compared with the patients' outcome.

RESULTS

The tyrosine-kinase domain of RET was expressed in 82 (64.6%) papillary carcinomas. Among them, RET was highly expressed in 65 (51.2%) cases and moderately expressed in 17 (13.4%). RET expression was absent in 45 (35.4%) cases. No correlation was found between RET expression and other parameters such as sex, age at diagnosis, tumor class and histological variant. Follow-up analysis showed no influence of RET expression on patients' outcome. By multivariate analysis, age (>45 years) and tumor class IV, but not sex and RET expression were adverse prognostic indicators of death.

CONCLUSION

In conclusion, our analysis indicates that RET expression is frequently found in PTC, and has no influence on tumor outcome.

[Video-assisted parathyroidectomy: learning curve]

STUDY AIM

Minimally invasive video-assisted parathyroidectomy (MIVAP) was introduced in 1997 for the treatment of sporadic primary hyperparathyroidism (sPHPT). The study aim was to review the entire series of patients operated on in order to analyse the learning curve of this procedure.

PATIENTS AND METHODS

Between February 1997 to January 2001, 185 patients underwent MIVAP. All these patients were divided into three groups: group A (GA) included 63 patients operated on between February 1997 and September 1998; group B (GB) 64 patients operated on between October 1998 and January 2000; Group C (GC) 64 patients operated on between January 2000 and January 2001. Mean operative time, complications and conversions rates of the three groups were compared.

RESULTS

The three groups were well matched for age and gender. Mean operative time was significantly shorter in patients of GC (28.3 +/- 13.6 min) when compared with GA (62.3 +/- 24.6 min) and GB (48.4 +/- 18.1 min). Conversion was required in 3 cases of GA (4.8%), in 8 cases of GB (12.8%) and in 4 cases of GC (6.5%). One transient postoperative recurrent nerve palsy and 4 cases of transient postoperative hypocalcemia were observed among patients of GA. No complications were registered in the other groups.

CONCLUSIONS

This study shows that with increasing experience, the operative time of MIVAP was dramatically reduced, as well as postoperative complications rate. The higher percentage of conversion in groups B and C may be explained by the fact that, with increasing experience, more difficult and ambiguous cases were operated with this technique.

Contralateral papillary thyroid cancer is frequent at completion thyroidectomy with no difference in low- and high-risk patients

Total (or near-total) thyroidectomy (TT) is considered by many as the most adequate treatment for papillary thyroid carcinoma (PTC). In patients who have undergone lobectomy, the necessity of performing a completion thyroidectomy (CT) is still discussed. The aim of this retrospective study was to evaluate tumor bilaterality in patients initially treated with partial thyroidectomy for PTC and who then underwent CT. We studied 182 patients treated with CT after lobectomy and/or isthmectomy for PTC diagnosed from 1969-1998. Mean age at diagnosis was 40+/-14.5 years and mean interval between partial thyroidectomy and CT was 19.8+/-56.8 months. At CT, 80 of 182 patients (44%) had one or more foci of tumor in the remaining thyroid lobe, always of the same papillary histotype, associated with ipsilateral lymph node metastases in 22 cases. In addition, 10 patients with no tumoral foci in the thyroid specimen had evidence of lymph node metastases. The rate of bilateral tumor was not different when patients were analyzed according to the classification of "low-" or "high-risk." Among several clinical features, the presence of lymph node metastases at the first surgical treatment and time interval between first treatment and CT were correlated with higher frequency of bilaterality (p = 0.033 and p = 0.044, respectively). The postsurgical 131I whole-body scan revealed the presence of persistent lymph node metastases or diffuse micronodular lung metastases in 7 and 6 patients, respectively. In conclusion, PTC was frequently bilateral in our series and this bilaterality was independent from the "low-" or "high-risk" classification. On these bases, we believe that PTC should be treated with TT when diagnosed before surgery and submitted to CT, if partial surgery was the initial intervention.

Minimally invasive video-assisted parathyroidectomy: multiinstitutional study

Unilateral and minimally invasive parathyroidectomies with endoscopic and video-assisted technique have been introduced. Most of these procedures utilize preoperative localization and intraoperative monitoring of parathyroid hormone. There are only a few reports on these procedures. The objective of this study was to evaluate video-assisted parathyroidectomy (MIVAP) for surgery in patients with primary hyperparathyroidism (pHPT). From February 1997 to June 1999 a series of 123 consecutive patients with pHPT at four surgical centers were evaluated. The patients' ages ranged from 18 to 77 years (median 50 years). Preoperatively, sestamibi scintigraphy and ultrasonography for localization were performed for all patients. Selection criteria for a MIVAP procedure excluded patients with negative localization, suspicion of multiglandular disease (MGD) or thyroid malignancy, a large thyroid mass, and prior surgery or irradiation to the neck. MIVAP was performed with a 1.5 cm suprasternal incision; the operation was then done through this incision with a 30 degree 5 mm endoscope and microsurgical instruments with brief CO2 insufflation for adenoma identification. We then proceeded with an open technique through the small incision under video-assistance. Intraoperative monitoring of intact parathyroid hormone (iPTH) assays was used in all patients. Among the 123 patients in whom MIVAP was attempted, the procedure was accomplished in 109 (89%). Conversion to conventional cervicotomy was required in 14 (11%) patients because of failed localization, failure of the iPTH level to fall appropriately, or technical problems. There was no persistent or recurrent HPT during the 3 to 12-month follow-up. Oral calcium replacement for symptomatic hypocalcemia postoperatively was given in 7 (6%) cases. A unilateral transient laryngeal nerve palsy, resolving within 6 months postoperatively, occurred in two (2%) patients. The median hospital stay was 1.5 days (range 0.5-5.0 days). This study showed the feasibility of MIVAP as an alternative surgical treatment for pHPT in a selected group of patients. Further studies are necessary to evaluate the efficacy and rationale of MIVAP compared to other techniques for parathyroidectomy in pHPT patients.

RET/PTC rearrangements in thyroid nodules: studies in irradiated and not irradiated, malignant and benign thyroid lesions in children and adults

Rearrangements of the RET proto-oncogene may occur in both naturally occurring and radiation-induced papillary thyroid carcinomas. Conflicting results on the frequency and type of RET/PTC rearrangements have been reported in relation to age, radiation exposure, and histological tumor variant. We designed the present study to evaluate in a single laboratory, using the same methodologies, the pattern of RET/PTC activation in thyroid tumors from different groups of patients (exposed or not exposed to radiation, children or adults, with benign or malignant tumors) in relationship to the above mentioned variables. We studied 154 patients with benign nodules (n = 65) or papillary thyroid cancer (n = 89). In the last group, 25 were Belarus children exposed to the post-Chernobyl radioactive fallout, 17 were Italian adults exposed to external radiotherapy for benign diseases, and 47 were Italian subjects (25 children and 22 adults) with no history of radiation exposure. Among patients with benign thyroid nodules, 21 were Belarus subjects (18 children and 3 adults) exposed to the post-Chernobyl radioactive fallout, 8 were Italian adults exposed to external radiation on the head and neck, and 36 were Italian adults with naturally occurring benign nodules. The overall frequency of RET/PTC rearrangements in papillary thyroid cancer was 55%. The highest frequency was found in post-Chernobyl children and was significantly higher (P = 0.02) than that found in Italian children not exposed to radiation, but not significantly higher than that found in adults exposed to external radiation. No difference of RET/PTC rearrangements was found between samples from irradiated (external x-ray) or not irradiated adult patients, as well as between children and adults with naturally occurring, not irradiated, thyroid cancer. When analyzing the type of RET/PTC rearrangement (RET/PTC1 or RET/PTC3), no major difference was apparent. In addition, eight cases with an unknown RET/PTC rearrangement and three cases with the concomitant expression of RET/PTC1 and RET/PTC3 were found. No significant correlation was observed between the frequency and/or the type of RET/PTC rearrangement and clinical-epidemiological features of the patients such as age at diagnosis, age at exposure, histological variant, gender and tumor-node-metastasis (TNM) categories. RET/PTC rearrangements were also found in 52.4% of post-Chernobyl benign nodules, in 37.5% of benign nodules exposed to external radiation and in 13.9% of naturally occurring nodules (P = 0.005, between benign post-Chernobyl nodules and naturally occurring nodules). The relative frequency of RET/PTC1 and RET/PTC3 in rearranged benign tumors showed no major difference. In conclusion, our results indicate that the presence of RET/PTC rearrangements in thyroid tumors is not restricted to the malignant phenotype, is not higher in radiation-induced tumors compared with those naturally occurring, is not different after exposure to radioiodine or external radiation, and is not dependent from young age. Other factors, probably influenced by ethnic or genetic background, may act independently from or in cooperation with radiation, to trigger the DNA damage leading to RET proto-oncogene activation.

RET/PTC rearrangements in thyroid nodules: studies in irradiated and not irradiated, malignant and benign thyroid lesions in children and adults

Rearrangements of the RET proto-oncogene may occur in both naturally occurring and radiation-induced papillary thyroid carcinomas. Conflicting results on the frequency and type of RET/PTC rearrangements have been reported in relation to age, radiation exposure, and histological tumor variant. We designed the present study to evaluate in a single laboratory, using the same methodologies, the pattern of RET/PTC activation in thyroid tumors from different groups of patients (exposed or not exposed to radiation, children or adults, with benign or malignant tumors) in relationship to the above mentioned variables. We studied 154 patients with benign nodules (n = 65) or papillary thyroid cancer (n = 89). In the last group, 25 were Belarus children exposed to the post-Chernobyl radioactive fallout, 17 were Italian adults exposed to external radiotherapy for benign diseases, and 47 were Italian subjects (25 children and 22 adults) with no history of radiation exposure. Among patients with benign thyroid nodules, 21 were Belarus subjects (18 children and 3 adults) exposed to the post-Chernobyl radioactive fallout, 8 were Italian adults exposed to external radiation on the head and neck, and 36 were Italian adults with naturally occurring benign nodules. The overall frequency of RET/PTC rearrangements in papillary thyroid cancer was 55%. The highest frequency was found in post-Chernobyl children and was significantly higher (P = 0.02) than that found in Italian children not exposed to radiation, but not significantly higher than that found in adults exposed to external radiation. No difference of RET/PTC rearrangements was found between samples from irradiated (external x-ray) or not irradiated adult patients, as well as between children and adults with naturally occurring, not irradiated, thyroid cancer. When analyzing the type of RET/PTC rearrangement (RET/PTC1 or RET/PTC3), no major difference was apparent. In addition, eight cases with an unknown RET/PTC rearrangement and three cases with the concomitant expression of RET/PTC1 and RET/PTC3 were found. No significant correlation was observed between the frequency and/or the type of RET/PTC rearrangement and clinical-epidemiological features of the patients such as age at diagnosis, age at exposure, histological variant, gender and tumor-node-metastasis (TNM) categories. RET/PTC rearrangements were also found in 52.4% of post-Chernobyl benign nodules, in 37.5% of benign nodules exposed to external radiation and in 13.9% of naturally occurring nodules (P = 0.005, between benign post-Chernobyl nodules and naturally occurring nodules). The relative frequency of RET/PTC1 and RET/PTC3 in rearranged benign tumors showed no major difference. In conclusion, our results indicate that the presence of RET/PTC rearrangements in thyroid tumors is not restricted to the malignant phenotype, is not higher in radiation-induced tumors compared with those naturally occurring, is not different after exposure to radioiodine or external radiation, and is not dependent from young age. Other factors, probably influenced by ethnic or genetic background, may act independently from or in cooperation with radiation, to trigger the DNA damage leading to RET proto-oncogene activation.