Carlo Enrico Ambrosini

Is Elastography Actually Useful in the Presurgical Selection of Thyroid Nodules with Indeterminate Cytology

BACKGROUND Although fine-needle aspiration cytology remains the mainstay of the preoperative workup of thyroid nodules, those with follicular proliferation still represent a diagnostic challenge. Real-time elastography (RTE) estimates the stiffness/elasticity of lesions and is regarded as a promising technique for the presurgical selection of thyroid nodules (including those with indeterminate cytology). AIM Our aim was to verify the potential role of RTE in the presurgical diagnosis of cancer in a large cohort of consecutive patients with follicular thyroid nodules. PATIENTS AND METHODS One hundred two patients were submitted to conventional ultrasonography and RTE evaluation before being operated on for thyroid nodule with indeterminate cytology (54% single nodules). Tissue stiffness on RTE was scored from 1 (greatest elasticity) to 4 (no elasticity). RESULTS At conventional ultrasonography examination, the nodules (median diameter 2.2 cm) were solid (cystic areas < 10%); microcalcifications were detected in 56% of them and a hypoechoic pattern in 64%. Elasticity was high in eight cases only (score 1-2) although low in 94 (score 3-4). Cancer was diagnosed in 36 nodules (35%), being associated with microcalcifications (P < 0.0001) and inversely related to nodule diameter (P < 0.01). Malignancy was detected in 50% of the nodules with RTE score 1-2 and in 34% of those with score 3-4. Therefore, either the positive (34%) or the negative predictive value (50%) was clinically negligible. CONCLUSIONS The current study does not confirm the recently reported usefulness of RTE in presurgical selection of nodules with indeterminate cytology and suggest the need for quantitative analytical assessment of nodule stiffness to improve RTE efficacy.

Minimally invasive video-assisted thyroidectomy versus conventional thyroidectomy in pediatric patients.

BACKGROUND Minimally invasive video-assisted thyroidectomy (MIVAT) proved to be safe and effective in the treatment of both benign and malignant disease. The aim of the present study is to compare MIVAT approach with conventional approach for total thyroidectomy in a group of 99 pediatric patients operated in the Department of General Surgery of the University of Pisa between March 2007 and July 2012. PATIENTS A total of 99 pediatric patients under the age of 18 years with thyroid disease referred to our Department to undergo total thyroidectomy. Patients were divided into two groups according to the surgical technique performed: 34/99 (34.3%) patients (MIVAT group [MG]) and 65/99 (65.7%) patients, (conventional group [CG]) who underwent total thyroidectomy, respectively, with MIVAT approach and conventional approach. RESULTS In MG mean operative time for total thyroidectomy was 40 ± 6.57 minutes (range 30-60 min); postoperative hospital stay was 1 day for 18 patients (53%), 2 days for 12 patients (35.25%), 3 days for 4 patients (11.8%); transient hypoparathyroidism (hypoPTH) was observed in 12 cases (35.3%) and permanent hypoPTH in 2 cases (5.9%); transient postoperative unilateral vocal cord palsy was observed in 2 patients (5.9%). In CG mean operative time for total thyroidectomy was 49.3 ± 12.9 minutes (range 30-80 min); postoperative hospital stay was 1 day for 16 patients (24.6%), 2 days for 40 patients (61.5%), 3 days for 8 patients (12.3%), and 4 days for 1 patient (1.6%); transient hypoPTH was observed in 23 cases (35.4%) and permanent hypoPTH in 4 cases (6.1%), who needed therapy with calcitriol and calcium carbonate; transient postoperative unilateral vocal cord palsy was observed in 4 patients (6.1%). There were no cases of permanent vocal cord paralysis in both groups. The correlation between two groups of patients showed that mean operative time was significantly lower in MG (p = 0.0007). CONCLUSION Pediatric patients of MG showed a significantly lower operative time and postoperative hospital stay with respect to pediatric patients of CG if compared with conventional technique. This result with the evidence of similar degree of completeness and rate of postoperative complications make MIVAT a valid option for the treatment of pediatric patients when performed by a well-trained staff in a third referral center.

Quale ruolo per la chirurgia nel carcinoma anaplastico della tiroide

Il carcinoma anaplastico della tiroide (ATC) è il tumore maligno più aggressivo e più letale della tiroide ed è uno dei tumori solidi dalla mortalità più alta nell’uomo. L’ATC ha una progressione tipicamente molto rapida, tanto che si sono osservati casi in cui il volume della massa è raddoppiato in tre giorni. La sopravvivenza mediana dei pazienti trattati varia tra i 3 e 5 mesi, anche se una terapia multimodale aggressiva può incrementare significativamente la sopravvivenza nei casi di tumori inizialmente resecabili mentre, se non si riesce a ottenere un buon controllo locale della massa primitiva, la crescita dell’ATC è inesorabile e provoca rapidamente la morte. A cominciare dai primi anni 2000 si è osservato che un trattamento multimodale combinante chirurgia, radioterapia esterna e chemioterapia può aumentare considerevolmente la sopravvivenza dei pazienti, specialmente quelli stadio IV-A e stadio IV-B. Con questi presupposti, è necessario che, una volta completato il percorso stadiativo, un team multidisciplinare che coinvolge il chirurgo, il radioterapista e l’oncoendocrinologo si riunisca al fine di delineare e pianificare accuratamente il percorso terapeutico [1]. È necessario che i componenti del team abbiano notevole esperienza nei complessi trattamenti che questa patologia richiede; è opportuno, quindi, che in mancanza di tali competenze i pazienti vengano rapidamente riferiti a centri di alta specializzazione, evitando ritardi o procedure chirurgiche inadeguate che potrebbero facilmente compromettere il risultato finale. È importante considerare che scelte chirurgiche azzardate potrebbero richiedere tempi di guarigione prolungati ritardando l’esecuzione degli ulteriori trattamenti e compromettere, quindi, la raggiungibilità dei migliori risultati. Una

Minimally Invasive Video-Assisted Parathyroidectomy; A Detailed Illustration and Highlighting an Additional Potential Advantage Over Other Targeted Parathyroid Surgeries

Targeted parathyroid surgery also referred to as minimally invasive parathyroidectomy has replaced full neck exploration as the preferred surgical approach to primary hyperparathyroidism. This is attributed to the ability to accurately localize enlarged parathyroid glands preoperatively and obtain objective evidence of adequate resection intraoperatively. The two most widely used minimally invasive parathyroid surgeries are the non-endoscopic miniincision parathyroidectomy and the minimally invasive video-assisted parathyroidectomy. The aim of this article is to provide a detailed illustration of the latter supplemented with an animated video of the procedure, and to highlight a potential advantage it offers over other targeted parathyroid procedures; the ability to perform a full neck exploration and/or a concomitant thyroid surgery without the need to convert to a standard cervicotomy.