Surgical treatment of anaplastic thyroid carcinoma. Our experience

BACKGROUND

In anaplastic thyroid carcinoma (ATC) surgical resection associated to radiotherapy and chemotherapy can ameliorate local disease control with occasional long-term survivals.

PATIENTS AND METHODS

Resection of the tumor was accomplished in 20 ATC patients, with no macroscopic (13 cases) or minimal residual neck disease infiltrating vital structures (7 cases). Ten of these patients (50%) had distant metastases. Sixteen cases were also treated with radiotherapy and chemotherapy, while in one patient only chemotherapy was possible; 2 patients refused further therapy; the last one is starting adjuvant treatment. Morbidity and survival were analysed, and compared with other 15 ATCs submitted to partial tumor debulking or not operated at all (control group).

RESULTS

Function of at least one laryngeal recurrent nerve was preserved in all 20 patients; none experienced permanent hypoparathyroidism. At last follow-up examination 17 patients had died and 3 were alive 1, 6 and 80 months after the operation, the latter being free of disease. Survival of dead patients ranged from 3 to 28 months (mean: 8 months). In the control group all patients died, survival ranging from 1 to 13 months (mean: 4 months). Actuarial analysis of survival showed a significant difference between the two groups (p = 0.0112); multivariate analysis of several prognostic factors confirmed that complete or near complete tumour resection was the most relevant.

CONCLUSIONS

Surgical resection is an important component of the multimodal treatment of ATC and should be attempted whenever possible.

Thyroidectomy for Graves' hyperthyroidism. Retrospective study of patients' appreciation

AIM OF THE STUDY

To retrospectively investigate the patients' views of surgical treatment of Graves' hyperthyroidism.

METHODS

One hundred two patients were included in the study and submitted to extensive subtotal thyroidectomy or total thyroidectomy between 1993-2003. Data were acquired from the responses to a questionnaire, that was completed by 83 patients.

RESULTS

Before the operation the working/studying ability and the social/emotional relations were impaired in 20% and 22% of cases. Preoperative information was adequate for 84% of patients. The perception of the hospital efficiency was favourable in 89% of cases, and the interpersonal relations with clinicians and nurses were very positive for 96% of patients. After the operation, all patients were hypothyroid on levothyroxine (l-T4); unexpected problems with l-T4 therapy occurred in 6% of cases. Voice changes or neck discomfort were reported by 29% and 8% of patients. The aesthetic appearance of the scar was very satisfactory for 70% of patients, but 11% were unsatisfied. The working/studying ability and the social/emotional relations improved in 63% and 59% of cases. Eye symptoms improved in 71% of the patients with endocrine ophthalmopathy, but got worse in 60%. The quality of life, expressed with a 0 to 10 scale, improved from a mean preoperative score of 4.7 to a mean score of 7.9 (P = 0.000). Only 5% of patients expressed hesitation to recommend surgery to a friend with similar disease.

CONCLUSIONS

Surgery is an effective therapy for selected cases of Graves' disease and meets the expectations of the majority of patients. Nevertheless some possible factors for dissatisfaction are pointed out.

Cytokine expression profile in human pancreatic carcinoma cells and in surgical specimens: implications for survival

Cytokine shedding by tumor cells into the local microenvironment modulates host immune response, tumor growth, and metastasis. The study aimed to verify the hypothesis that the immunological microenvironment of pancreatic carcinoma exists in a prevalently immunosuppressive state, influencing survival. We analyzed expression profiles of pro-inflammatory (IL-1beta, IL-2, IL-6, IL-8, IL-12 p40, IL-18 and IFN-gamma) and anti-inflammatory (IL-10, IL-11, IL-13 and TGF-beta isoforms) cytokines. The study was performed both in vitro, in five pancreatic carcinoma cell lines (real time RT-PCR), and in specimens from 65 patients, comparing tumoral versus non-tumoral pancreatic tissues (real time RT-PCR and immunohistochemistry). Furthermore, cytokines were measured in supernatants and sera (from patients and controls) by ELISA. All cell lines expressed IL-8, IL-18, TGF-beta1, TGF-beta2 and TGF-beta3, but not IFN-gamma and IL-2 transcripts. Expression of IL-1beta, IL-6, IL-10, IL-11, IL-13 and IL-12 mRNA was variable. All the above cytokines were detected as soluble proteins in supernatants, except IL-13. Tumor tissues overexpressed IL-1beta, IL-6, IL-8, IL-10, IL-11, IL-12 p40, IL-18, IFN-gamma, TGF-beta1, TGF-beta2 and TGF-beta3 at the mRNA level and IL-1beta, IL-18, TGF-beta2 and TGF-beta3 also at the protein level. Conversely, non-tumor tissues had stronger RNA and protein expression of IL-13. Survival was significantly longer in patients with high IL-1beta and IL-11 and moderate IL-12 expression. Serum IL-8, IL-10, IL-12, IL-18, TGF-beta1 and TGF-beta2 were higher in patients than in controls, as opposed to IL-1beta and IL-13. Patients with low circulating levels of IL-6, IL-18 and TGF-beta2 survived longer. Pancreatic cancer is characterized by peculiar cytokine expression patterns, associated with different survival probabilities.

Human pancreatic carcinoma cells secrete bioactive interleukin-18 after treatment with 5-fluorouracil: implications for anti-tumor immune response

Recently we observed that pancreatic carcinoma cell lines constitutively express Interleukin-18 (IL-18). Bioactive IL-18 induces Interferon (IFN)-gamma production, Fas Ligand (FasL) expression, and inhibits angiogenesis, raising the issue of anti-tumor effects of a tumor-derived cytokine and motivating a more detailed analysis of IL-18 production in pancreatic carcinoma cells. This analysis included the study of effects of chemotherapeutic drugs (5-fluorouracil [5-FU], gemcitabine, cisplatin) commonly used in the treatment of pancreatic cancer patients on IL-18 production and processing. IL-18 expression and post-translational processing were determined using RT-PCR, immunoblot and ELISA in pancreatic carcinoma cell lines and in tumor tissue and serum samples from pancreatic carcinoma patients in the presence and absence of chemotherapeutic drugs. We describe expression of IL-18 in pancreatic carcinoma cells and tissues associated with significantly elevated IL-18 levels in patients sera. Specifically, Capan-2 pancreatic tumor cells produced and secreted precursor IL-18 with no apparent biological activity. However, the chemotherapeutic agent 5-FU, by inducing Caspase-1 and Caspase-3 activation, induced secretion of proteolytically processed mature and degraded IL-18 species, respectively, in Capan-2 cells. Conditioned medium from 5-FU-treated but not control Capan-2 cells induced IFN-gamma production by activated T cells in an IL-18-dependent manner. Furthermore, adjuvant polychemotherapy including 5-FU significantly increased serum levels of mature, bioactive IL-18 in pancreatic carcinoma patients. Treatment of pancreatic cancer cells with 5-FU induced Caspase-dependent processing of pro-IL18 leading to the secretion of biologically active IL-18. These findings delineate a novel mechanism by which chemotherapeutic agents may modulate local anti-tumor cell-mediated immune responses.

[Post-thyroidectomy cervical hematoma]

AIM

Postoperative hematoma is a complications of thyroid surgery uncommon but potentially life threatening. It has implications for the trend toward outpatient procedures.

METHODS

Retrospective review of 1.221 thyroidectomies performed at our institution over a 6-years period, to identify patients with hematomas requiring reoperation. Symptoms, treatment and findings at reoperation were evaluated. A control group (n=120) was compared for perioperative risk factors and outcome.

RESULTS

Eighteen patients (1.5%) developed a postoperative hematoma. Symptoms included neck pain/pressure in 10 patients, respiratory distress in 9, wound drainage in 2, dysphagia in 1, agitation and sweating in 1. Mean time to symptom onset was 12 hours (range: 1.3-40 hours). Six hematomas presented between 7 and 24 hours, and 3 beyond 24 hours. Six patients required bedside hematoma evacuation. The bleeding source was identified in 15 patients. All patients recovered well, but one required a temporary tracheostomy. Case/controls comparison yielded in the study group a higher prevalence of hyperthyroidism (55.6% vs 25.8%, P=0.022) and intrathoracic goiter (50% vs 22.5%, P=0.029), and a longer mean hospital stay (5.22 vs 4.1, P=0.012); morbidity was not increased.

CONCLUSIONS

Postoperative hematoma is an uncommon complication of thyroid surgery. If treated promptly, serious consequences can be avoided. The relatively long interval between the initial operation and the hematoma development needs to be considered when establishing outpatient practice guidelines.

[Surgical treatment of Graves' disease: results in 108 patients]

AIM OF THE STUDY

To evaluate morbidity and functional results of surgical treatment in patients with Graves' disease.

METHODS

A retrospective study was performed in 108 patients operated on during 1993-2003. Main indications for surgery were failure of treatment with antithyroid drugs (80.6%), large goiter (46.3%) and/or severe ophthalmopathy (23.1%). Surgical procedures were extensive subtotal thyroidectomy (EST; n = 33; uni- or bilateral remnant of <2 g) or total thyroidectomy (TT; n=75). Functional results were established in 89 patients (27 EST patients and 62 TT patients) after a mean follow-up of 5.9 years.

RESULTS

Operative mortality was zero. There were 4 (3.7%) transient unilateral recurrent laryngeal nerve (RLN) palsies and no cases of permanent RLN palsy. Temporary hypocalcemia occurred in 15 patients (13.9%) and permanent hypoparathyroidism resulted in two (1.9%). Four patients (3.7%) developed a postoperative hematoma that required reoperation. There was no significant difference in the rate of complications between EST and TT, although temporary hypocalcemia was more common following TT than EST (17.3% vs. 6.1%) and permanent hypoparathyroidism affected only TT patients. None of the patients developed recurrent hyperthyroidism; all patients are maintained on levothyroxine.

CONCLUSIONS

Surgery is an effective therapy for selected cases of Graves' disease. When performed by experienced surgeons, it can be carried out with no mortality and minimal morbidity. EST (with uni- or bilateral remnant of <2 g) and TT are both effective in order to achieve a definitive cure of hyperthyroidism.

Tumor-associated transforming growth factor-beta and interleukin-10 contribute to a systemic Th2 immune phenotype in pancreatic carcinoma patients

In this study, we report coexpression of transforming growth factor-beta (TGF-beta) and interleukin-10 (IL-10) in pancreatic carcinoma tissue associated with significantly elevated levels of both cytokines in the sera of pancreatic carcinoma patients. Using conditioned media (CM) of pancreatic carcinoma cells, we further demonstrate that tumor cell-derived TGF-beta and IL-10 inhibited in an additive fashion both proliferation and the development of Th1-like responses in peripheral blood mononuclear cell (PBMC) preparations derived from normal donors. The antiproliferative and Th1-suppressive activities contained in CM of pancreatic carcinoma cells were due primarily to IL-10 and/or TGF-beta, as shown by the capacity of cytokine-specific neutralizing antibodies to reverse these effects. Finally, as compared to normal controls, PBMC derived from pancreatic carcinoma patients displayed a Th2-like cytokine expression pattern upon activation with either anti-CD3 antibody or Staphylococcus aureus strain Cowan I. Taken together, these results suggest that aberrant production of TGF-beta and IL-10 in pancreatic tumor patients skews T-cell cytokine production patterns in favor of a Th2 immunophenotype.

Primary hyperparathyroidism sustained by a giant adenoma of the parathyroid gland

A case of primary hyperparathyroidism sustained by an unusually large parathyroid adenoma is presented. The tumor affected a 45-year-old woman with a 15-year history of nephrolithiasis and presented as a palpable neck mass. On the basis of clinical findings and ultrasound examination, it was initially misdiagnosed as a thyroid nodule. CT scan and transesophageal endosonography gave a correct definition of the tumor, which was located behind the left thyroid lobe and expanded posterior to the pharynx and the esophagus in the prevertebral space. At surgery a parathyroid tumor measuring 8 x 7 x 3 cm and weighing 90 g was successfully removed. No signs of malignancy were observed by both morphological and cell kinetic analyses.

Oxidative damage and transforming growth factor beta 1 expression in pretumoral and tumoral lesions of human intestine

The aim of this study was to evaluate a possible relationship between oxidative stress and transforming growth factor beta 1 (TGF beta 1) expression in human colon adenocarcinoma. Crohn's disease, an inflammatory pathology of the intestine often regarded to as precancerous, was also examined. Indices of impaired redox balance were monitored in blood and in bioptic samples from 10 adult patients with adenocarcinoma of the colon and from five patients with Crohn's disease. On tissue samples TGF beta 1 mRNA expression was also determined. Ten healthy adults provided normal reference values for plasma indices of oxidative stress, and normal tissue distant from the lesions was used for comparative analysis. Fluorescent adducts with plasma proteins of malonaldehyde (MDA) and 4-hydroxynonenal (HNE) were significantly lower than controls in the plasma from cancer patients and significantly higher in the plasma from Crohn's patients. In adenocarcinoma biopsies, susceptibility to lipid peroxidation processes and TGF beta 1 expression were below the relative control; in Crohn's disease, lipid peroxidation and cytokine expression were both above the relative control. The findings obtained suggest the existence of an association between oxidative damage and fibrogenic cytokine expression in the human intestine. Further studies are needed to conclusively prove the correlation between the two events.

Ectopic aldosteronoma associated to another adrenocortical adenoma in the adrenal gland of the same side

The occurrence of tumors originating from aberrant adrenocortical tissue in ectopic site is very rare. Up to now only two cases of ectopic aldosterone-producing adenoma have been described. We have observed another case of ectopic aldosteronoma, located in the retrocaval region, laterally to the body of the 12th thoracic vertebra. This ectopic tumor was associated to another adrenocortical adenoma, in the adrenal gland of the same side. The diagnostic implications of this observation are discussed.

[Current role of abdomino-perineal amputation]

In Italy 6.5% of cancer deaths can be attributed to localized colorectal cancer of which rectal cancer alone accounts for 33%. The introduction of mechanical staplers and new techniques (colo-anal anastomosis) into colon surgery has led to a drastic reduction in indications for Miles' operation in favour of techniques which aim to conserve the sphincter. From October 1987 to March 1991 the Surgical Clinical of the Ospedale Maggiore in Novara operated 75 patients with rectal cancer. Twenty-eight patients underwent APA (abdominoperineal amputation) whereas 47 underwent conservative surgery, referred to as SSR (sphincter-saving resection). Of the 28 APA patients, 19 revealed a localisation in the lower rectum (0-5), 7 in the mid rectum (6-8) and 2 in the upper rectum (9-15). In the latter two cases the considerable size of the tumour mass and the extraparietal diffusion of the tumour led the authors to prefer APA rather than SSR. In SSR the minimum distal safety margin from the tumour was 2 cm, whereas the mean distance of the tumour from the anal margin in APP patients was 4 cm, and that in SSR patients 11 cm. The stage of cancer was not taken into consideration when choosing the type of surgery. Postoperative mortality was 3.5% for APA and 2% for SSR. The overall incidence of recidivation was 20%, equivalent to 11 patients. Recidivation was found to be more frequent in the lower rectum (6 cases) compared to the upper rectum (1 case).(ABSTRACT TRUNCATED AT 250 WORDS)

[The surgical approach to adrenal incidentaloma]

In this paper the Authors analyse the indications for treatment of adrenal incidentaloma by making a retrospective review of this series. These indications are compared with recent trends which have emerged in the literature.

[Transverse mesocolon herniation. Description of a clinical case]

A case of herniation of small bowel through a defect of the transverse meso-colon with secondary herniation through the gastrocolic ligament and re-entry into the greater peritoneal cavity is reported. This form of lesser sac hernia is rare and only one hundred half cases have been reported in literature.

[The autologous splenic reimplant in the rat]

In order to evaluate the clinical utility of autologous splenic transplantation in the omental pouch, a pneumococcal challenge was performed in 3 groups of rats, after demonstration of vitality of the intraperitoneal inoculum: Group A: splenectomized rats; Group B: reimplanted rats; Group C: sham operation. No statistically significant difference was found between the first two groups regarding resistance against infection (p less than 0.982), while normal rats proved more resistant (p less than 0.031). Between group A and B significant differences (p less than 0.001) exists only for a more precocious mortality in the first group. The poor clinical utility of the technique is demonstrated.

[Percutaneous correction of benign stenosis of the bile ducts and biliary-digestive anastomosis. Percutaneous transhepatic biliplasty]

The authors describe their experience in nine cases of transhepatic percutaneous dilatation of bile ducts benign stenosis by a Gruntzig catheter inflated at the stenotic level in order to stretch the sclerotic lesion. Despite the brief follow-up, the first results are satisfying; for this reason percutaneous dilatation of bile ducts benign stenosis could be a new procedure in the treatment of these lesions in selected cases.

[Instrumental follow-up of patients treated by internal biliary drainage]

The various radiological techniques available for the long-term follow-up of patients given definitive percutaneous trans-hepatic biliary implants (DTBI) are evaluated on the basis of personal experience. After a rapid examination of the available technics it is concluded that direct X-ray, echotomography and sequential hepatobiliary scintigraphy are more than sufficient for an accurate follow-up of the disease in such patients.

[Surgical treatment of endocrine tumors of the pancreas]

Following a brief review of the literature dealing with the rarity of this disease, and the diagnostic progress made to date, the surgical techniques applicable to the various locations of the neoplasia are described. Personal experience with 8 insuloma patients is reported.

[Immune complex monitoring in Echinococcus infections]

In two patients with hepatic echinococcosis, we studied the in vivo interaction between circulating immune complexes and polymorphonuclear neutrophil surface receptors according to our previously described technique and quantitated the amount of circulating immune complexes by the C1q binding assay. Both tests were positive prior to surgical removal of the cysts, to gradually become negative to weeks later, and are persistently negative at two months after complete asportation. The application of the two tests may be of value in assessing surgical radicality and consequently the prompt disappearance of circulating parasite antigens. In particular, failure of these two tests two turn negative or the occurrence of further, new positivities may suggest either uncomplete eradication of the cyst or reinfection. These immunologic techniques appear to provide a better monitoring of echinococcosis than all the other well-known immunological tests which detect specific immunoglobulins present in serum for a long time and therefore unable to indicate the persistence or the new appearance of the parasite antigens.

[Diagnosis of primary and secondary tumors of the liver]

A brief epidemiological and clinical introduction is followed by an examination of the most useful methods for the diagnosis of primary and secondary tumours of the liver: alpha protein values, scintiscanning, arteriography of the coeliac artery, splenoportography, and laparotomy with directed biopsy. The diagnostic specificity and percent positivity of each method are illustrated.