Management of Abdominal Paraganglioma: A Single Center's Experience

Background and Objectives: Paragangliomas (PGLs) are rare neuroendocrine extra-adrenal tumors that could be secreting mass. The symptoms are the typical triad of paroxysmal headache, hypertension and sweating, but could also be accompanied by symptoms involving multiple organs. Surgery is the gold standard treatment for both PGLs and pheochromocytomas (PHEOs). Material and Methods: We used a computerized endocrine surgery registry to record the demographic and clinical data of 153 patients who underwent surgery for PPGL between 2010 and 2023 at our hospital. Results: Thirteen patients (8.43%) with paragangliomas underwent surgery at our institute. Five patients presented symptomatic syndrome. Preoperative investigations included enhanced abdominal CT (nine patients) and enhanced MRI (seven patients). In cases of suspicious mass, we performed 131I-MIBG scans (two patients) or 68GA-DOTATOC PET-CT scans (11 patients). Laparoscopic approach was used in four cases (30.7%) and abdominal laparotomy in the other nine (69.3%). Biochemical tests were performed on all patients. Conclusions: In this retrospective study, we discuss the multidisciplinary management in our institute of this rare disease, from its challenging diagnosis to the surgical strategy for PGLs. Laparoscopic surgery is the gold standard, but a tailored approach should be adopted for each patient.

Uni- and Multivariate Analyses of Cancer Risk in Cytologically Indeterminate Thyroid Nodules: A Single-Center Experience

Every year in Italy, about 60,000 new cases of nodular thyroid pathology are diagnosed, of which almost 30% are cytologically indeterminate (TIR3A/3B). The risk of malignancy reported in the literature on thyroid nodules ranges from 5% to 15% for TIR3A and from 15% to 30% for TIR3B. It is suspected that these percentages are higher in practice. We performed univariate and multivariate analyses of clinical risk factors. The medical records of 291 patients who underwent surgery for cytologically indeterminate nodular thyroid disease were retrospectively reviewed. Clinical parameters and preoperative serum markers were then compared between the benign nodular thyroid disease and thyroid cancer groups. For each patient, clinical characteristics, comorbidities, neck ultrasonographic features, and histological reports were statistically analyzed using Chi-squared and Fisher's exact tests. A total of 134 malignant neoplasms were found (46%), divided into 55 cases (35%) in the TIR3A group and 79 cases (59%) in the TIR3B group. Statistical analysis was not significant in both populations for both sex and age (TIR3A p-value = 0.5097 and p-value = 0.1430, TIR3B p-value = 0.5191 p-value = 0.3384), while it was statistically significant in patients with TIR3A nodules associated with thyroiditis (p-value = 0.0009). In addition, the patients with TIR3A and 3B nodules were stratified by ultrasound risk for the prediction of malignancy and it was significant (p = 0.0004 and p < 0.0001). In light of these results, it emerges that surgical treatment of nodular thyroid pathology with indeterminate cytology TIR3A should always be considered, and surgery for TIR3B is mandatory.

Papillary thyroid carcinoma with fibromatosis-like stroma: a case report and review of the literature

BACKGROUND

Papillary thyroid carcinoma (PTC) is a common neoplasia with multiple variants. One of these extremely rare and poorly described variants is PTC with fibromatosis-like stroma (PTC-FMS), a peculiar entity distinguished by its predominant mesenchymal component. This paper reviews the literature, discusses the diagnostic challenges, and the clinical and surgical implications of this type of tumor which has fewer than 30 cases reported in the literature.

CASE PRESENTATION

We reported a case of PTC-FMS found in a 41-year-old Italian woman, who came to our Institute with a recent growth in the form of a mass on the neck. Further immunohistochemical examination showed β-catenin aberrant staining both in the nuclei and cytoplasm of the mesenchymal cells. The patient underwent total thyroidectomy and received radioactive iodine (RAI) 2 months after surgery.

CONCLUSION

Given the possibility of recurrence of PTC-FMS and the ineffectiveness of RAI therapy, complete surgical resection represents the main treatment for this type of tumor. Despite the fact that the specific nature of these lesions has yet to be determined, guidelines for classical PTC should be followed.

Metastatic Adrenal PEComa: Case Report and Short Review of the Literature

PEComa has become a widely accepted entity, and increased recognition has led to descriptions of this tumor in a wide variety of anatomic sites, including the adrenal gland. PEComa (perivascular epithelioid cell tumor) is a mesenchymal tumor composed of perivascular cells, and the most frequent sites of PEComas are the uterus and retroperitoneum. The incidence is <1 per 1,000,000 people. We report a case of adrenal metastatic PEComa in a 63-year-old man discovered by a spontaneous hematoma of the rectus abdominis. In our case, PEComa of the adrenal gland was a significant diagnostic dilemma as the morphologic and immunophenotypic features of this neoplasm may easily be confused with those of other more commonly encountered lesions.

Hashimoto's Thyroiditis and Papillary Cancer Thyroid Coexistence Exerts a Protective Effect: a Single Centre Experience

Papillary thyroid carcinoma (PTC) is the most common malignant tumour of the thyroid and it is often found in association with Hashimoto's thyroiditis (HT). This concomitance is still under debate. The aim of this study is to investigate the influence of Hashimoto's thyroiditis in patients with papillary thyroid carcinoma. Two thousand two hundred eighteen patients underwent thyroidectomy in our department between January 2015 and January 2020. Of these, 435 patients had surgery for papillary thyroid carcinoma and form the basis of our studies. The association between PTC and HT was found in 180 patients (41.4%), mostly represented in the female group (78.9%), with a lower median age than patients with PTC without HT. In comparison to patients with PTC alone, the PTC-HT group had less invasive and smaller tumours, as well as less lymph node involvement. Moreover, tumours of patients with PTC-HT were diagnosed earlier. Our data showed that Hashimoto's thyroiditis may be considered a protective factor when PTC develops. Furthermore, we concluded that patients with PTC and HT had a better prognosis and a lower risk of recurrence than those that did not have HT.

Adrenal surgery: Review of 35 years experience in a single centre

INTRODUCTION

The rate of adrenal disease diagnosed is progressively increasing due to the diagnostic tools improvement. We analysed patients that underwent to adrenalectomy in our centre for different adrenal pathologies and we tried to established guidelines for the surgical therapy.

METHODS

Demographic and clinical data were prospectively entered in a computerized endocrine surgery registry for all patients who underwent surgery for adrenal lesions at our institution over a 35-year period and statistical analyses was performed.

RESULTS

Between 1986 and 2020, 502 patients underwent adrenalectomy: open adrenalectomy (OA) was performed in 104 patients (28,6%), laparoscopic adrenalectomy (LA) in 398 patients (71,4%). The rate of conversion to OA was 5,9% (21 patients). The mean operating time in laparoscopic approach was 84.3 min (range 40-180) while in open approach was 121.9 min (40-210). The average length of stay (LOS) for LA was 3.6 days, while for OA was 7.4 days. The time to return to normal activity for LA was 21 days while for OA was 37 days.

CONCLUSIONS

The progressive increase in the number of adrenalectomies performed is due more to a better understanding of adrenal disease than to the availability of minimally invasive techniques. The choice of a laparoscopic approach should depend on the surgeon's experience, regardless the dimension of the lesion. Considering our long experience, we suggest OA for lesion of more of 6 cm, for malignant lesion with a diameter higher than 3 cm or with a pre-operatory evidence of invasion of the surrounding tissue.

Metastases to the thyroid gland: review of incidence, clinical presentation, diagnostic problems and surgery, our experience

PURPOSE

Metastases to the thyroid gland are uncommon and they represent 1-3% of all thyroid malignancy. The aim of this study is to analyze the diagnostic problems and the role of surgery in metastatic lesions to the thyroid.

METHODS

We retrospectively analyzed all patients who had undergone thyroidectomy at our Center. Out of more than 5000 thyroidectomies performed, only 9 cases had metastases to the thyroid gland.

RESULTS

The most common primary tumor arises from kidney and lung. Non-thyroid malignancies diagnosis was obtained with US, FNAC and PET-CT. Surgery was performed in all our series (except for one case) and the expectancy of life after surgery is related to the primary tumor and comorbidities of patients.

CONCLUSION

The thyroid gland can be a rare site of metastases for many tumors, especially in an abnormal thyroid gland. Surgery is associated with an improved survival and the extension of surgery depends on the extension of the neoplastic lesion.

The Extent of Surgery for Thyroid Medullary Cancer

Aims

Evaluation of the impact of the extent of primary surgery and reintervention on the outcome of patients with medullary thyroid carcinoma.

Methods

Seventy-two patients with medullary thyroid carcinoma (MTC) were surgically treated between 1967 and 1992.

Results

Fifty-five cases were sporadic, 5 patients had MEN 2A, 4 MEN 2B syndrome and 8 familial non-MEN MTC; 1 patient had stage I disease, 30 patients stage II, 36 stage III and 5 stage IV. Sixty-four had their initial treatment at our center, and 8 came for subsequent treatment. At first treatment, 8 patients were subjected to partial thyroidectomy, 10 to total thyroidectomy, 53 to total thyroidectomy with neck dissection, and 1 to only radical neck dissection; postoperative serum calcitonin (Ct) levels returned to normal in 3, 6 and 27 patients, respectively. In the patient with only radical neck dissection, Ct levels remained elevated. No patient with Ct normalization after surgery became responsive to pentagastrin in the follow-up. Thirteen patients had a reoperation due to nodal relapse. At a mean follow-up of 5.7 years (6-252 months), the 10-year survival rate was 84.5% with a significant difference between patients under and over 40 years of age (96.4 vs 57%), between stage I-II (100%) and stage III, IV (83.8%, 0% respectively). At the last follow-up, 36 (50%) patients were alive and disease free and 26 were alive with disease (15 with distant metastases). Of the 10 deaths, 7 were due to tumor recurrence, 3 to 120 months after surgery.

Conclusions

Data suggest that an earlier diagnosis rather than more extensive surgery could improve survival and reduce recurrences. However, the least treatment required is total thyroidectomy plus central neck and upper mediastinum clearance and in addition, according to the extent of nodal involvement, mono- or bilateral neck dissection. To avoid ineffective reoperation due to distant (mainly liver) micro-metastases, persistent residual microscopic disease requires a more aggressive restaging.

Frequency of Thyroid Carcinoma in a Recent Series of 539 Consecutive Thyroidectomies for Multinodular Goiter

Aims and background

The aim of the study was to analyze the frequency of thyroid carcinoma in a consecutive series of 539 thyroidectomies for multinodular goiter (MNG) and to assess the influence of sex and age as cancer risk factors.

Methods

In a 2-year period, 539 patients underwent subtotal or total thyroidectomy for MNG at the Institute of General Surgery, University of Padova, Padova, Italy: 455 were females and 84 males (F/M = 5.5/1); mean age was 46 years (min. 17, max 78). Only 17 patients (3.1%) (16 females and 1 male) were aged 21 years or less.

Results

A malignancy was found in 41 patients: 38 females and 3 males; 39 older and 2 younger than 21 years. The frequency of cancer in MNG was 7.6%: 8.3% in females and 3.6% in males; 7.5% in patients older than 21 and 11.7% under 21 years.

Conclusions

The combination of MNG and carcinoma should always be carefully considered but not overemphasized, and the policy of surgically treating all patients with MNG is not justified. Sex and age cannot be considered as factors of a higher risk of cancer.

Effects of preoperative statin use on perioperative outcomes of carotid endarterectomy

OBJECTIVES

Several studies have shown the beneficial role of statins in reducing the risk of major perioperative complications and death associated with noncardiac vascular surgery, but few have focused on their effects in the event of carotid endarterectomy (CEA). This study analyzes the effects of preoperative statin use on perioperative outcomes in patients undergoing CEA.

MATERIALS AND METHODS

Data from all consecutive patients who underwent primary CEA for symptomatic and asymptomatic carotid disease between 2002 and 2014 at a single institution were prospectively stored in a vascular surgery registry, recording risk factors, medication, and indication for surgery. Endpoints of the study were perioperative (30-day) stroke and death.

RESULTS

Overall, 784 patients were on statins (825 CEAs, Group I), while 494 were not (545 CEAs, Group II). There were two perioperative strokes in Group I (0.24%) and four in Group II (0.73%; p = .22), and no deaths. The only nonfatal cardiac complication occurred in Group II (0.18%, p = .39). A neurologist assessed patients at 1, 6, and 12 months after CEA, and every 2 years thereafter. Follow-up (range: 0.1-13 years; mean, 6.3 ± 3.7 years) was obtained for 1,239 patients (1,326 CEAs). Because 165 patients (166 CEAs) crossed over from Group II to Group I during the follow-up time, long-term data were stratified by postoperative statin treatment rather than by preoperative statin use. The 5- and 10-year restenosis/occlusion and survival rates did not differ significantly between the two groups.

CONCLUSIONS

Taking statins prior to CEA did not seem to affect the risk of major perioperative ischemic events and death, most likely due to the extremely low overall incidence of perioperative complications.

Estrogen and thyroid cancer is a stem affair: A preliminary study

Gender influences Papillary Thyroid Cancer (PTC) with an incidence of 3:1 when comparing women to men with different aggressiveness. This gender discrepancy suggests some role of sex hormones in favoring the malignant progression of thyroid tissue to cancer. Estrogens are known to promote Stem Cell self-renewal and, therefore, may be involved in tumor initiation. The goals of these studies are to investigate the underlying causes of gender differences in PTC by studying the specific role of estrogens on tumor cells and their involvement within the Cancer Stem Cell (CSC) compartment. Exposure to 1nmoll^-1 Estradiol for 24h promotes growth and maintenance of PTC Stem Cells, while inducing dose-dependent cellular proliferation and differentiation following Estradiol administration. Whereas mimicking a condition of hormonal imbalance led to an opposite phenotype compared to a continuous treatment. In vivo we find that Estradiol promotes motility and tumorigenicity of CSCs. Estradiol-treated mice inoculated with Thyroid Cancer Stem Cell-enriched cells developed larger tumor masses than control mice. Furthermore, Estradiol-pretreated Cancer Stem cells migrated to distant organs, while untreated cells remained circumscribed. We also find that the biological response elicited by estrogens on Papillary Thyroid Cancer in women differed from men in pathways mediated. This could explain the gender imbalance in tumor incidence and development and could be useful to develop gender specific treatment of (PTC).

A very rare bilateral adrenal tumor

We report a case of very rare adrenal tumor. A 54-year-old patient was classified as affected by bilateral adrenal incidentaloma that surprisingly, on histology resulted solitary fibrous tumors. Solitary fibrous tumor (SFT) is an uncommon mesenchymal neoplasm. Only five cases of localization of SFT in adrenal gland are reported in the literature, while the frequency of retroperitoneum localization is more frequent, about 30 cases. Immunohistochemically, SFT can be positive for CD34 antigen, vimentin, CD99, and bcl-2 and usually negative for cytokeratins, chromogranin A, NSE, neurofilaments, synoptophysin, and S-100. Surgical excision remains the main treatment in fact the recurrence is locoregional and correlated with positive margins due to incomplete excision, while distant metastases are correlated with atypical or malignant features.

Incidental medullary thyroid microcarcinoma revealed by mild increase of preoperative serum calcitonin levels: therapeutic implications

To investigate whether further, diagnostic procedures should be recommended in patients with slight increase of preoperative serum basal calcitonin (bCT) levels in whom surgical treatment can be recommendable. Fourteen consecutive patients with nodular thyroid disease underwent thyroidectomy in our center for suspected medullary thyroid microcarcinoma (MTC) because their serum bCT levels were slightly higher than the upper limit of normal range. Serum bCT was measured by radioimmunoassay, normality range = 0-20 ng/L. Surgical specimens were examined by the same pathologist using histologic and immunohistochemistry techniques. An extensive search for parafollicular C-cell hyperplasia (CCH) and/or microscopic MTC foci was performed. At preoperative ultrasound, a single thyroid nodule was depicted in three patients while a multinodular goiter in 11. The bCT values ranged between 24.4 and 94.6 ng/L, median 42.2 ng/L while the pentagastrin-stimulated CT (sCT) values by pentagastrin test ranged between 61.5 and 1,262 ng/L, median 245.0 ng/L. Total thyroidectomy was performed in 13 patients, and lobectomy in the other one; central node dissection was also performed in eight cases. At histology, MTC was diagnosed in nine patients (64.3 %), showing a median maximum diameter of 6.1 mm (range, 1.5-17 mm); CCH was diagnosed in the other five patients (35.7 %). The pentagastrin stimulation test was obtained in all patients. It is worth noting that a very high increase of sCT >100 ng/mL was observed in 5/9 patients with MTC and in 2/4 patients with HCC, therefore suggesting the absence of a relationship between the entity of response to pentagastrin test with a specific pathology (MTC vs. HCC). In six patients, the MTC was the nodule on which preoperative FNAC had been performed, while in other three patients preoperative FNAC had been performed on a different nodule from the MTC. Based on our experience, in case of the pentagastrin stimulation test with sCT <100 ng/L and a single nodule, the CT assay on FNAC may be useful, subsequently lobectomy with definitive histological diagnosis is recommended. In case of the Pg test with sCT <100 ng/L and bilateral goiter, total thyroidectomy with histological diagnosis is recommended. In this way, as for the surgical procedure, total thyroidectomy is recommended in cases of bilateral goiter, while lobectomy can be offered for cases with single nodes with serum dosage of bCT in the strict follow up. In case of the pentagastrin stimulating test with sCT <100 ng/L and bilateral goiter, total thyroidectomy with histological diagnosis is recommended.

The role of BRAF(V600E) mutation as poor prognostic factor for the outcome of patients with intrathyroid papillary thyroid carcinoma

BACKGROUND

BRAF(V600E) mutation, which represents the most frequent genetic mutation in papillary thyroid carcinoma (PTC), is widely considered to have an adverse outcome on PTC outcome, however its real predictive value is not still well stated. The aim of the present study was to evaluate if BRAF(V600E) mutation could be useful to identify within patients with intrathyroid ultrasound-N0 PTC those who require more aggressive treatment, by central neck node dissection (CLND) or subsequent postoperative (131)I treatment.

METHODS

Among the whole series of 931 consecutive PTC patients operated on at 2nd Clinical Surgery of University of Padova and at General Surgery Department of University of Trieste during a period from January 2007 to December 2012, we selected 226 patients with an intrathyroid tumor and no metastases (preoperative staging T1-T2, N0, M0). BRAF(V600E) mutation was evaluated by PCR-single-strand conformation polymorphism analysis and direct genomic sequencing. We analyzed the correlation between the presence/absence of the BRAF(V600E) mutation in the fine-needle aspiration (FNA) and the clinical-pathological features: age, gender, extension of surgery, node dissection, rate of cervical lymph node involvement, tumor size, TNM stage, variant of histotype, mono/plurifocality, association with lymphocitary chronic thyroiditis, radioactive iodine ablation doses, and outcome.

RESULTS

The BRAF(V600E) mutation was present in 104 of 226 PTC patients (47.8%). BRAF(V600E) mutation correlated with multifocality, more aggressive variants, infiltration of the tumoral capsule, and greater tumor's diameter. BRAF(V600E) mutation was the only poor prognostic factor in these patients.

DISCUSSION

In our series, BRAF(V600E) mutation demonstrated to be an adverse prognostic factor indicating aggressiveness of disease and it could be useful in the management of low-risk PTC patients, as supplementary prognostic factor to assess the preoperative risk stratification with the aim to avoid unnecessary central neck node dissection (BRAF pos.) or to perform complementary (131)I-therapy (BFAF neg.).

Durability of eversion carotid endarterectomy

OBJECTIVE

Carotid endarterectomy (CEA) remains the gold standard for treating carotid disease in selected symptomatic and asymptomatic patients, though carotid angioplasty and stenting has emerged as a safe alternative. The aim of this study was to assess the durability of CEA in a large series of patients followed up according to a strict clinical and ultrasonographic protocol.

METHODS

Over a 23-year period (1990-2012) a total of 1773 patients (1251 men and 522 women) with a mean age of 75.2 years (range, 31 to 96 years) who underwent 2007 consecutive primary eversion CEAs performed by the same surgeon under general anesthesia with electroencephalographic monitoring and selective shunting were prospectively followed up with ultrasonography at 1, 6, and 12 months, then yearly. A long-term follow-up (median, 11.2 years; mean, 12.9 years) was obtained for 1680 patients (94.8%). End points were perioperative (30-day) stroke and death and late carotid restenosis/occlusion rates.

RESULTS

More than two in three of the lesions (1446 of 2007, 72.1%) were symptomatic at the time of surgery, with a 25% rate of preoperative stroke. Preoperative antiplatelet or anticoagulant therapy was used by 1675 patients (94.4%), whereas 918 (51.8%) were receiving statin treatment. Overall, there were eight (0.4%) perioperative strokes and no deaths. During the follow-up, there were nine (0.47%) asymptomatic late carotid restenoses (six moderate [50%-69%] and three severe [≥ 70%]) and one (0.05%) carotid occlusion. Nine patients (0.47%) had late ipsilateral strokes, none of them related to restenosis/occlusion. Overall, there were 159 late deaths (9.4%).

CONCLUSIONS

The results of this study show that eversion CEA can be performed in symptomatic and asymptomatic patients with an extremely low perioperative stroke/death risk and a negligible incidence of late restenosis/occlusion, thus assuring a persistently good protection against the risk of cerebral ischemia.

Solitary fibrous tumor of the thyroid gland: a report of two cases with an analysis of their clinical and pathological features

Solitary fibrous tumors of the thyroid gland are rare soft-tissue neoplasms and only 24 cases have been reported in the literature to date. We describe two patients who underwent surgery for rapidly growing thyroid nodes of uncertain nature on cytology. At the final histological examination, they proved to be fibrous tumors of the thyroid gland that were CD-34, BCL2, CD-99, and Ki-67 positive, like other known cases. Neither of these two cases have recurred so far.

Features of papillary thyroid carcinoma in patients older than 75 years

The aim of this study was to evaluate the prognosis in elderly patients affected by papillary thyroid carcinoma. A retrospective review was conducted on 1,407 patients operated on for papillary thyroid carcinoma at our Department from 1990 to 2007. We analyzed the frequency, the stage, the treatment, the recurrence and the survival in a group of patients aged 75 years or more when compared with a group of patients younger. Among 1,407 patients affected by papillary thyroid carcinoma, 117 (8.3%) were older than 75 years while 1,290 (91.7%) patients were younger. There was no statistical difference between the two groups in frequency of papillary histotype and type of surgery. In the older group, the incidence of anaplastic cancer was higher, p < 0.001. The rate of IV stage was 3.8% in younger versus 15.4% in older patients, p < 0.001. The incidence of recurrence was 6.1% versus 17.9%, p < 0.001, in young and elderly patients, respectively. At a mean follow-up of 8.7 years (range 2-19 years) the overall 10 and 15-year survival in younger patients was 91.3 and 88.7%, while in the older group was 71.8 and 63.9%, respectively. The Kaplan-Meier curve showed a statistically significant difference of survival rate in the two groups (p < 0.0001). Although papillary thyroid cancer is widely considered a lymph-tropic tumor, it seems to have a stronger attitude to distant metastases in elderly patients with a worse prognosis due to a more advanced stage.

Rapid intraoperative parathyroid hormone assay in fine needle aspiration for differential diagnosis in thyroid and parathyroid surgery

BACKGROUND

The purpose of our study was to investigate the efficacy of rapid intraoperative parathyroid hormone (rIO-PTH) analysis performed using material collected by fine needle aspiration as a parameter to distinguish anatomical structures which the surgeon is not able to identify clearly as parathyroid or lymph node during thyroid/parathyroid surgery. Before surgery, all patients gave written, informed consent.

METHODS

We measured the rIO-PTH on 50 anatomical structures, 32 presumed parathyroids and 18 presumed lymph nodes from 22 patients, who underwent thyroid/parathyroid surgery between May and September 2009.

RESULTS

The rIO-PTH values obtained on parathyroids ranged from 85.4 pmol/L to more than 2106 pmol/L, with a rIO-PTH median of 263.25 pmol/L. Results obtained on lymph nodes ranged from <0.52 pmol/L up to 20.4 pmol/L, with a rIO-PTH median equal to 1.31 pmol/L. Results of the Mann-Whitney test showed a rIO-PTH median significantly different (p<0.0001) between samples obtained from parathyroid glands and lymph node tissue.

CONCLUSIONS

We demonstrated that rapid intraoperative measurement of parathyroid hormone is a good parameter for the differential diagnosis of parathyroid vs. lymph node tissue. We suggest extending the use of this technique to the field of parathyroid preservation during thyroid/parathyroid surgery in those cases where the parathyroids prove difficult to recognize on the basis of topographic or morphologic criteria.

Pitfalls in adrenal surgery. Report of two cases

Pitfalls in diagnosis and treatment of adrenal diseases are frequent and not properly reported in literature. Among more than 51 adrenalectomies for incidentaloma performed during a l0 years period, we present 2 cases of diagnostic errors that a very formative opportunity in the approach to adrenal diseases. A precise and careful preoperative diagnosis is of utmost importance in the management of adrenal disease to avoid therapeutic pitfalls.

Surgical therapeutic planning options in nodular goiter

Nodular goiter encompasses a spectrum of diseases from the incidental asyntomatic small solitary nodule to the large intrathoracic goiter causing pressure symptoms as well as functional complaints. The mainstay in the diagnostic evaluation is related to functional and morphological characterization with serum thyroid-stimulating hormone (TSH), ultrasound (US) and other imaging procedures and cytology by fine needle aspiration (FNA) on the basis of the different diseases. A clinical classification considering solitary cyst, adenomatous functioning nodule, follicular lesion and multinodular goiter may be proposed to consider the alternative therapies other than surgery as TSH suppressive or thyrostatic treatment, 131I therapy, percutaneous ethanol injection therapy (PEIT) or the only clinical exam in benignant lesions. Surgery should be advocated for the treatment of thyroid nodules whenever a patient presents with either pressure symptoms, hyperthyroidism or follicular/indeterminate cytology. Surgical approach, intraoperatory strategy and the extension of surgical treatment are correlated to the different clinical categories. At surgery the frozen section analysis in case of hemithyroidectomy is of aid to rule out malignancy and to prevent the reoperation. The surgical treatment of choice in case of uninodular goiter is lobectomy, total thyroidectomy or near total thyroidectomy is the correct treatment of multinodular bilateral goiter. The choice of the treatment must be condivided with the patient.

A "pilot light" of the right non-recurrent laryngeal nerve

Total thyroidectomy was performed in a 53-year-old male, with Graves-Basedow's disease. At surgery, the vagus nerve was found to be located medially to the carotid artery associated with a non-recurrent laryngeal nerve arising directly from the cervical vagus: this association has never been described in the literature. These results indicate that a medial location of the vagus nerve may be considered as a "pilot light" of the non-recurrent laryngeal nerve.

Dual PET/CT with (18)F-DOPA and (18)F-FDG in metastatic medullary thyroid carcinoma and rapidly increasing calcitonin levels: Comparison with conventional imaging

BACKGROUND

To evaluate the role of a multi-imaging PET with (18)F-DOPA and (18)F-FDG in comparison with conventional imaging (CI) in recurrent medullary thyroid carcinoma (MTC).

METHODS

18 MTC patients who had thyroidectomy were included; they presented with elevated and rapidly increasing calcitonin levels during follow up. CI had revealed metastatic deposits in 9 patients. Patients were referred to us for a PET/CT with (18)F-DOPA and (18)F-FDG. Histologic/cytologic confirmation of recurrent MTC was obtained in at least one PET-positive lesion in all patients.

RESULTS

Foci of abnormal uptake were observed in 15 patients at (18)F-DOPA and in 11 at (18)F-FDG; 8 patients showed the same number of positive lesions with both tracers, 2 showed more lesions on (18)F-FDG, 1 was positive at (18)F-FDG alone and 5 at (18)F-DOPA alone. In 3 patients with a DOPA-positive loco-regional relapse a re-operation with curative intent was offered. SUV(max) values were higher for (18)F-FDG compared to (18)F-DOPA (mean 12.7+/-4.1 vs. 5.5+/-2.1, p<0.05). Calcitonin was higher in PET-positive patients compared to PET negative ones, while no significant differences were observed between (18)F-DOPA and (18)F-FDG positive patients.

CONCLUSIONS

In MTC patients with rapidly increasing calcitonin levels during follow up, (18)F-DOPA has a good sensitivity and a complementary role with (18)F-FDG PET/CT in detecting metastatic deposits. In our experience, the sensitivity of a multi-imaging (18)F-DOPA &(18)F-FDG PET/CT approach is greater than that obtained with CI. The higher SUV(max) values found with (18)F-FDG in some patients may reflect more aggressive tumors.

99Tc nanocolloid sentinel node procedure in papillary thyroid carcinoma: our mono-institutional experience on a large series of patients

The sentinel lymph node was defined as the first lymph node to receive drainage from a primary cancer. The aims of this study were to investigate the efficacy of radiocolloid lymphoscintigraphy and of the hand-held gamma probe procedure for sentinel lymph node biopsy in papillary thyroid carcinoma and to evaluate these results in clinical staging. A total of 99 consecutive papillary thyroid carcinoma patients entered the study. Patients underwent radiocolloid lymphoscintigraphy before surgery. Intra-operative sentinel lymph node localization was performed using a hand-held gamma probe. Patients were observed at follow-up at 2 and 6 months and, thereafter, yearly. Sequential lymphoscintigraphy was able to identify at least one sentinel lymph node in 98/99 cases (99%), using intra-operative hand-held gamma probe, the surgeon was able to detect at least one sentinel lymph node in all cases. Sentinel lymph node metastases were diagnosed in 49%. Overall, 79 patients underwent ablative (131)I therapy. The median value of thyroglobulin in N0 vs. N1 patients was 1 ng/ml vs. 1.9 ng/ml (p = 0.03) and 0.2 ng/ml vs. 1 ng/ml (p = 0.001) before and after (131)I therapy, respectively. The pre-operative lymphoscintigraphy and the intra-operative gamma probe offer significant advantages over the vital dye technique, described in our previous experience. The rate of nodal involvement (49%) is very high considering that no patients had clinically palpable nodes or suspected at echography. (131)I whole body scan and thyroglobulin measurements confirmed sentinel lymph node in papillary thyroid carcinoma as a reliable procedure. In patients classified N0, by sentinel lymph node biopsy, ablative (131)I therapy could be avoided.

Can we avoid inadvertent parathyroidectomy during thyroid surgery?

OBJECTIVES

To identify risk factors of inadvertent parathyroidectomy (IP) during thyroid surgery with the aim of decreasing the incidence of this unpleasant complication and to evaluate the impact on temporary and permanent hypocalcaemia following bilateral thyroidectomy.

PATIENTS AND METHODS

All consecutive thyroid surgical procedures performed at the Special Surgical Pathology Department of Padova General Hospital and Padova University during one year (January-December 2005) were retrospectively reviewed. Demographic data as well as data on diagnosis, operative reports, pathology findings, and postoperative serum calcium values were collected. A total of 882 patients (F=685 M=197) were included in the study. The patients were divided into 2 groups: those with IP and those without IP, and their data were compared to find factors affecting the occurrence of IP. The impact of IP on residual early and late postoperative parathyroid function was assessed. Hypercalcaemic (calcium level below 2.10 mMol/L) patients were followed from 1 week to 3 years.

RESULTS

Seventy of 882 patients (7.9%) were found to have IP. In 11 cases (16% of IP cases and 1.2 % of entire series) the parathyroid glands were completely intrathyroidal. The results of bivariate analysis showed young age (p=0.037), malignant disease (p<0.0001), total thyroidectomy with lymph node dissection (p<0.0001), low weight of thyroid specimen (p<0.0001), and non-visualisation of any parathyroid gland at operation (p<0.0001) as predictive factors for IP. Multivariate analysis revealed significant correlation between IP and malignant disease (p=0.004), and between lymph node dissection and permanent postoperative hypocalcaemia (p=0.018). The incidence rate of transient and permanent hypocalcaemia was higher in IP than in those without. The mean diameter of excised parathyroid glands was 3.2 mm, suggesting more extended or difficult surgical procedures.

CONCLUSION

IP is not uncommon during thyroidectomy and is associated with a higher, though not statistically significant, incidence of transient and permanent postoperative hypocalcaemia. Malignant disease, lymph node dissection, non-visualization of any parathyroid gland at operation and younger age seem to be risk factors and should be considered by the surgeon. Further efforts must be taken to reduce the incidence beginning by avoiding parathyroid fragmentation.

Diagnosis, treatment, prognostic factors and long-term outcome in papillary thyroid carcinoma

The papillary thyroid carcinoma (PTC) is the most frequent endocrine cancer and it is the most common thyroid cancer (85-95%). Potential risk factors for the incidence of the PTC include radiation exposure, iodine deficiency, family history of thyroid cancer. The PTC is usually indolent and the prognosis is favourable, with a 10 year survival generally reported to exceed 90%. The palpation and growth of thyroid nodules are the more frequent clinical manifestations of the PTC which can be evaluated by physical examination, neck ultrasound and fine needle aspiration cytology (FNAC). The therapeutic management of PTC includes surgical treatment combined with 131I therapy and life long TSH suppressive thyroid hormone replacement. The external beam radiation can be taken into account in select aggressive tumours. Nevertheless the good prognosis of the PTC, the prevalence of persistence or recurrent disease is not trans-curable. The biomolecular studies can permit to individuate the more aggressive PTC subtypes. A more significant attention of the clinical examination, US and FNAC to the thyroid nodular disease will be able to guarantee a more precocious diagnosis and a radical surgical treatment.

Factors influencing the rising rates of adrenal surgery: analysis of a 25-year experience

BACKGROUND

Adrenal surgery has been radically changed by laparoscopy and it is reasonable to wonder whether the increase in the number of adrenalectomies is entirely justified. There is still debate on the transperitoneal versus the retroperitoneal approach, the advantages and drawbacks of which are discussed here.

METHODS

Between 1983 and 2007, we performed 279 adrenalectomies in 264 consecutive patients, divided into two groups: before and after the advent of laparoscopic adrenalectomy (LA). We analyzed the factors that increased the number of adrenalectomies in recent years. The LAs were further divided into three consecutive periods and the morbidity and conversion rates, and mean operating times were compared.

RESULTS

More procedures were performed after the advent of LA, i.e., 55 (19.7%) beforehand versus 224 (80.3%) afterwards, irrespective of the type of disease, for instance: incidentaloma, 17.6% versus 82.4% (p \ 0.0001); pheochromocytoma, 20.7% versus 79.3% (p\0.0001); Conn's disease, 19.8% versus 80.2% (p \ 0.0001); Cushing's disease, 17.2% versus 82.8% (p\0.0001); cortical carcinoma, 30% versus 70% (p\0.001). Analyzing the three LA periods, operating times were the only statistically significant variable (p\0.0001).

CONCLUSIONS

The progressive increase in the number of adrenalectomies performed is due more to a better understanding of adrenal disease than to the availability of minimally invasive techniques. The choice of a laparoscopic approach (trans- or retroperitoneal) should depend on the surgeon's experience.

Characterization of a novel complex BRAF mutation in a follicular variant papillary thyroid carcinoma

INTRODUCTION

Activating mutations of the BRAF oncogene are frequently detected in papillary thyroid carcinoma (PTC) and have been associated with a worse prognosis. The amino acid substitution V600E accounts for 90% of all oncogenic BRAF mutations and is typically detected in classic PTCs, whereas other less frequent BRAF mutations seem to be associated with other PTC histotypes.

CASE

Screening for activating BRAF mutations in a series of 83 PTCs identified the most common V600E mutation in 39 cases (histologically, 38 classic PTCs and 1 sclerosing variant PTC) and a complex in-frame mutation involving amino acids V600-S605 in a stage III multicentric follicular variant PTC, occurring in a 50-year-old female patient, who was affected by hypothyroidism in autoimmune thyroiditis and had a family history of PTC and autoimmune thyroiditis. Since the identified BRAF mutation was novel in the literature, bioinformatic modeling was performed to predict its impact on BRAF activity. Although the mutation resulted in loss of a phosphorylation site in the activation loop of BRAF, it was predicted to increase BRAF kinase activity by mimicking an activating phosphorylation.

CONCLUSIONS

This study, which reports a new BRAF mutation, highlights the usefulness of bioinformatic modeling in the prediction of functional effects of new mutations and indicates that mutation-specific screening tests might miss some rare BRAF mutations. These facts should be taken into consideration in the molecular diagnosis of thyroid cancer and in the design of therapeutic protocols based on inhibitors of the BRAF pathway.

Surgical treatment of primary hyperparathyroidism: from bilateral neck exploration to minimally invasive surgery

The human parathyroid glands, first described by Sandström in 1880, attracted interest because they were subject to inadvertent removal or ischemic injury during radical thyroid surgery. That this caused metabolic derangements was not known until many years later. Following on Kocher's studies, research continued to improve techniques sparing the parathyroids during thyroid surgery but without developing parathyroid surgery as such. For over a century, the lack of suitable surgical instruments, accurate preoperative localizing imaging techniques, and reliable laboratory tests hindered the evolution of parathyroid surgery, relegating it a marginal existence. Only after 1930, when it became clear that hyperparathyroidism is caused by an increased production of parathyroid hormone (PTH) by overactive parathyroid glands in the neck and/or the mediastinum, could parathyroid surgery, which shares a similar approach with thyroid surgery, be developed for treating hyperparathyroidism. The aim of parathyroid surgery is to cure hyperparathyroidism. Until advanced surgical and laboratory diagnostic technologies became available, concern about the risk of failure led surgeons to search all four glands by bilateral neck exploration, which proved unnecessary in 80% of cases. Recent years have seen parathyroid surgery evolve with the introduction of more efficacious preoperative localization imaging techniques and the use of rapid intraoperative parathormone assay, so that parathyroid surgery is now more selective and can be performed as a minimally invasive procedure in some cases.

Papillary thyroid carcinoma: factors influencing recurrence and survival

BACKGROUND

The prognosis of patients with papillary thyroid carcinoma (PTC) is usually favorable; however, a subset of patients can develop local recurrence or distant metastases. The aim of this study was to evaluate the prognostic factors influencing the recurrence and the survival rate in 950 PTC patients.

MATERIALS AND METHODS

From 1990 to 2005, 950 consecutive patients affected by PTC were operated on at our Department. We analyzed the prognostic role of the following parameters: gender, age at initial treatment, extent of thyroid surgery, node dissection, tumor size, node metastases, distant metastases, stage, and 131-I therapy.

RESULTS

Seventy-nine patients (8.3%) developed locoregional or distant metastases after an average follow-up of 7.8 years (range 2-17 years); in particular local recurrence was observed in 25 cases and distant metastases in 54 cases. The global 10- and 15-year survival rates were 91.38% and 88.69%, respectively. At univariate analysis, all variables were significantly correlated with recurrence (P = .001) except gender (P = .3); moreover, gender (P = .2), node dissection (P = .5), and node metastases (P = .06) were not significant on 10- and 15-year survival. At multivariate analysis the age at first treatment, T4, M+, stage IV, the extent of thyroid surgery, and the 131-I therapy resulted to be significant and independent prognostic factors (P < .001).

CONCLUSION

Our data, in disagreement with other staging systems, suggest that gender does not play a significant role both in recurrence and survival. Moreover, the 131-I therapy was a statistically significant prognostic factor at univariate and multivariate analyses.

[The surgical treatment of the nodular goiter]

BACKGROUND

The simple nodular goiter, the etiology of which is multifactorial, encompasses the spectrum from the incidental asymptomatic small solitary nodule to the large intrathoracic goiter, causing pressure symptoms as well as cosmetic complaints. The mainstay in the diagnostic evaluation is related to functional and morphological characterization with serum TSH and (some kind of) imaging. Because malignancy is just as common in patients with a multinodular goiter as patients with a solitary nodule, the increasing use of fineneedle aspiration biopsy (cytology) is supported Its management is still the cause of considerable controversy. Prevalence of nodular goiter and results of surgical treatment in a large series of patients operated on at our center are reported.

METHODS

From January to December 2004, 1009 out of 1580 patients admitted to our Center underwent surgical treatment for thyroid disease.

RESULTS

Nodular goiter accounted for 80% of the whole series. More in detail, toxic multinodular goiter was found in 13.5% of the patients, euthyroid multinodular goiter in 46.6%, single hyperplastic nodule in 2.3%, follicular lesion in 14%, Plummer's adenoma in 4.4%, relapsing goiter in 2.6% and thyroid cyst in 0.12%. Thyroid lobectomy was carried out in 20.8% of patients, while the remaining 79.2% underwent to total thyroidectomy. A carcinoma was incidentally found in 7.6% of the multinodular goiters.

CONCLUSIONS

Surgery should be advocated for the treatment of thyroid nodules whenever a patient presents with either pressure symptoms, hyperthyroidism or follicular cytology. Serum TSH measurement, ultrasounds and fine needle aspiration cytology are the main diagnostic tools. Bilateral surgical exploration of the gland should be always carried out to assess the extension of the disease. Total or near total thyroidectomy in order to minimize the risk of recurrent nerve palsy and hypoparathyroidism represents the treatment of choice for bilateral goiter. Thyroid lobectomy with frozen section should be limited to unilateral nodular goiter.