Celestino Pio Lombardi

Role of reoperation in recurrence of adrenal cortical carcinoma: results from 188 cases collected in the Italian National Registry for Adrenal Cortical Carcinoma.

BACKGROUND Recurrence of adrenal cortical carcinoma (ACC) after radical surgery is a common finding. Although successful reoperations have been reported with encouraging results, most published experiences are anecdotal and based on few cases. We report the results of surgical treatment for recurrent ACC in a multiinstitutional series. METHODS One hundred eighty-eight cases of ACC were collected in a national registry. A complete follow-up was obtained in 179 cases. At initial diagnosis 92 patients had local disease (stage I or II). One hundred seventy patients underwent surgical treatment, considered radical in 140; in this group, recurrent disease was observed in 52 cases (37%) after a mean disease-free interval of 21.7 months. RESULTS Adjuvant chemotherapy was ineffective in ameliorating the prognosis. The mean survival in 20 patients who underwent reoperation was significantly higher (15.85 +/- 14.9 months) than in nonreoperated cases (3.2 +/- 2.9 months). Five-year actuarial survival in reoperated patients is significantly better than in nonreoperated patients (49.7% versus 8.3%, respectively). CONCLUSIONS Although the prognosis of this tumor is still poor, surgery is the only effective therapy; reoperation allows survival comparable to that observed in patients without recurrent disease. An aggressive strategy for recurrent ACC is advisable until prospective studies demonstrate a real effectiveness for chemotherapy.

Minimally invasive, totally gasless video-assisted thyroid lobectomy

BACKGROUND Neck surgery is one of the newest fields of application of video-assisted surgery. We developed a technique for minimally invasive, totally gasless video-assisted thyroid lobectomy. METHODS The procedure was accepted by a patient with a follicular nodule of the left lobe of the thyroid. We performed a left thyroid lobectomy through a single 20-mm horizontal skin incision, just above the sternal notch, after inserting a 5-mm 30 degrees laparoscope, by using both endoscopic and conventional instrumentation. RESULTS The recurrent laryngeal nerve and the parathyroid glands were easily identified and preserved. The operating time was 2.5 hours. No complication occurred. The postoperative stay was 2 days. The cosmetic result was excellent CONCLUSIONS We concluded that our technique is feasible and safe. This makes us optimistic about the future of minimally invasive, video-assisted thyroid surgery.

Total thyroidectomy for management of benign thyroid disease: review of 526 cases

Total thyroidectomy is not frequently performed in cases of benign disease because of the associated risk of postoperative hypoparathyroidism and recurrent laryngeal nerve (RLN) damage. We chose a series of patients who had undergone total thyroidectomy (TT) for benign thyroid tumors to evaluate the safety of this approach and its role in the treatment of nonmalignant lesions of the thyroid. We considered only patients with a minimum follow-up of 24 months. Records of 526 patients who underwent TT were carefully reviewed, assessing for perioperative complications and late sequelae. The mean age was 44 ± 15.7 years; 109 patients (20.7%) were male and 417 (79.3%) were female. Altogether, 65 patients (12.3%) were operated on for toxic goiter, 429 (81.6%) for bilateral nodular goiter, and 32 (6.1%) for thyroiditis. Postoperative hemorrhage requiring reoperation occurred in 8 cases (1.5%). The incidences of permanent RLN palsy (considered as a percentage of the nerves at risk) and permanent hypocalcemia were 0.4% and 3.4%, respectively. A trend toward a decrease in the complication rate was observed during the last 5 years. There were no disease recurrences during a mean follow-up of 44 months. The results of our series show that TT can be performed safely in patients, with a low incidence of lifetime disabilities. TT has the advantage of reducing/avoiding the risk of disease recurrence and reoperation and should therefore be considered a valuable option for treating benign thyroid diseases.Résumé.La thyroïdectomie total mais n’est pas réalisée fréquemment en cas de maladie bénigne en raison du risque d’hypoparathyroïde postopératoire et de lésions du nerf récurrent. Nous avons sélectionné une série de thyroïdeectomies totales (TT) pour maladie bénigne afin d’évaluer la sécurité de cette approche et son rôle dans le traitement des lésions non malignes de la thyroïde. Nous avons pris en compte seulement les patients ayant un suivi minimum de 24 mois. Les dossiers de 526 patients ayant eu une TT ont été revus pour évaluers les complications péri-opératoires et les séquelles tardives. L’âge moyen était de 44 ± 15.7 ans. Cent neuf patients (20.7%) étaient des hommes et 417 (79.3%) des femmes. Soixante=cinq patients (12.3%) ont été opérés pour goitre toxique, 429 (81.6%) pour goitre nodulaire bilatéral et 32 (6.1%) pour thyroïdite. Une hémorragie postopératoire a nécessité une ré-intervention dans 8 cas (1.5%). L’incidence de paralysie permanente du nerf récurrent (pourcentage de nerfs récurrents à risque) et d’hypocalcémie permenente ont été, respectivement, de 0.4% et de 3.4%. On a observé une tendance vers une diminution du taux de complications pendant les cinq dernières années. Aucune récidive n’a été observée avec un suivi moyen de 44 mois. Les résultats de notre série indiquent que la TT peut être réalisée avec sécurité dans cette population avec une incidence d’incapacité permenent réduite. La TT a l’avantage de réduire/éviter le risque de récidive de la maladie et de réopération et devrait être une option valable pour le traitement de maladies bénignes de la thyroïde.ResumenLa tiroidectomia total no es un procedimiento de realización frecuente en la enfermedad benigna por razón del riesgo de hipoparatiroidismo postoperatorio y de lesión del nervio laríngeo recurrente. Tomamos una serie de tiroidectomías totales (TT) practicadas por tumores benignos con el objeto de evaluar la seguridad de esta conducta y su papel en el tratamiento de lea lesiones no malignas de la tiroides. En el presente estudio sólo fueron considerados pacientes con un seguimiento mínomo de 24 meses. Se revisaron las historias de 526 pacientes que habían sido sometidos a TT para determinar las complicaciones postoperatorias y las secuelas tardías. La edad promedio fue 44 ± 15.7 años; 109 (20.7%) eran hombres y 417 (79.3%) mujeres; 65 (12.3%) fueron operados por bocio tóxico, 429 (81.6%) por bocio nodular bilateral y 32 (6.1%) por tiroiditis. Se presentó hemorragia postoperatoria que requirió reoperación en 8 casis 91.5%). La incidencia de parálisis permamente del nervio laríngeo recurrente consierada como porcentaje de los nervios en riesgo y de hipocalcemia fue 0.4% y 3.4% respectivamente. Se observó tendencia hacia la disminución de las complicaciones en el curso de los últimos 5 años. No se registró recurrencia de la enfermedad en el seguimiento de 44 meses. Los resultados del análisis de nuestra serie indican que la TT puede ser practicada con seguridad en pacientes con enfermedad benigna de la tiroides, con una baja tasa de complicaciones permenentes. La TT tiene la ventaja de reducir o abolir tanto el riesgo de recurrencia de la enfermedad como el de una reoperación, y en consecuencia, debe ser considerada Bellantone et al.: Benign Thyroid Disease and Total Thyroidectomy como una opción valiosa en el tratamiento de la enfermedad tiroidea benigna.

Safety of video‐assisted thyroidectomy versus conventional surgery

Thyroid gland manipulation, surgical stress response, and postoperative outcome in cases of video‐assisted thyroidectomy (VAT) and conventional thyroidectomy were compared to verify the safety of VAT.

Follicular thyroid neoplasms can be classified as low- and high-risk according to HBME-1 and Galectin-3 expression on liquid-based fine-needle cytology

DESIGN Fine-needle aspiration biopsy (FNAB) is the most reliable diagnostic tool in the diagnosis of thyroid nodules. A cytologic diagnosis of follicular neoplasm with atypical cells of undetermined significance (FN/AUS) implies that the selection of patients between surgery and follow-up is difficult. In this setting immunocytochemical stainings might be helpful. The efficacy of a panel made up of HBME-1 and Galectin-3 antibodies is evaluated in cases processed by liquid-based cytology (LBC). METHODS Out of 7091 thyroid FNAB processed by LBC method, 120 cases undergoing surgery successively were selected. These cases were classified as benign lesion (BL, eight cases), FN, including the ACUS category of the Bethesda classification (FN/AUS, 50 cases), suspicious for malignancy (SM, 59 cases), and malignant neoplasm (MN, three cases). Immunostains for HBME-1 and Galectin-3 were carried out on the LBC slides. RESULTS All MN and BL were histologically confirmed. FN/AUS and SM showed a malignancy risk of 24 and 72.9% respectively. The complete immunocytochemical panel was positive in 83.3% of the cases resulting in malignancy and negative in 87.5% of cases resulting in benign histology. Among the FN/AUS, the complete positive immunocytochemical panel was detected in 76.9% of cases resulting as malignant and the complete negative immunocytochemical panel was observed in 96.8% of cases resulting as benign at histology. CONCLUSIONS The expression of HBME-1 and Galectin-3 in cases classified as FN/AUS on LBC-processed FNABs can effectively distinguish lesions, which need immediate surgery (high risk or FNH or Thy 3h) from those which can be followed-up (low risk or FNL or Thy 3l).

Long-term outcome of functional post-thyroidectomy voice and swallowing symptoms.

BACKGROUND Voice and swallowing symptoms are frequently reported early after thyroidectomy even in the absence of laryngeal nerves injury. We evaluated the short-term and long-term outcomes of these functional alterations. METHODS Consenting patients undergoing total thyroidectomy (TT) were enrolled. Videolaryngostroboscopy (VSL), acoustic voice analysis (AVA), and maximum phonation time (MPT) were performed pre-operatively, 3 months postoperatively, and >1 year postoperatively. Subjective evaluation of voice (Voice Impairment Score=VIS) and swallowing (Swallowing Impairment Score=SIS) were obtained pre-operatively, as well as 1 week, 1 month, 3 months, and >1 year postoperatively. RESULTS The long-term evaluation was completed in 110 patients. The percentage of patients with symptoms 1 week after operation was significantly higher than preoperatively, whereas it was significantly lower at long-term evaluation. VIS was significantly worse than pre-operatively, 1 week, 1 month, and 3 months after surgery, but it was similar to pre-operative >1 year after TT. SIS was significantly worse 1 week after thyroidectomy but not 1 month and 3 months after thyroidectomy, and it was significantly lower than the pre-operative >1 year after TT. CONCLUSION Vocal and swallowing symptoms are frequent after TT. In the absence of laryngeal nerve injury, after an initial impairment, late after operation, patients experienced subjective amelioration of their voice and swallowing performances, which may be related to the resolution of compressive symptoms.

Adrenal cystic lesions: Report of 12 surgically treated cases and review of the literature

Adrenal cysts are rare (0, 064%–0, 18% in autopsy series) and less than 500 cases have been reported in the western literature. Incidental diagnosis of adrenal cysts, however, is reported with increasing rates. We observed 12 patients with adrenal cyst. Each of them had a careful laboratory and instrumental evaluation; all the patients were operated. In our series about 67% of the patients were symptomatic (6 patients with abdominal pain, 1 with palpable mass, 1 with hemorrhagic shock). No biochemical alteration was observed. Conversely we observed an unusual subclinically hyperfunctioning cystic adenoma, potentially progressive to a clinically recognizable endocrine syndrome. US, CT and MRI had a sensitivity of 66, 7%, 80% and 100% respectively. Adrenalectomy was performed in all patients. The pathological findings were: 1 epithelial cyst (cystic adenoma), 2 endothelial cysts (vascular cystic ectasia with adenomatous adrenocortical hyperplasia and 1 vascular cyst) and 9 pseudocysts. On the basis of these results, we conclude that a careful hormonal, morpho-functional and instrumental evaluation is indicated in all adrenal cysts, even if the available diagnostic procedures, even when combined, cannot always define their nature. Surgical excision, when possible by laparoscopic approach, is indicated in presence of symptoms, endocrine abnormalities (even when subclinic), complications, suspicion of malignancy and/or large size (>5 cm). Adrenal gland must be excised en bloc, also because of the possible presence of other adrenal lesions.

Simultaneous immunohistochemical expression of HBME-1 and galectin-3 differentiates papillary carcinomas from hyperfunctioning lesions of the thyroid

Aims : The histological diagnosis is critical for the postsurgical management and follow‐up of thyroid malignancies. The differential diagnosis between papillary carcinoma and hyperfunctioning lesions, either with papillary hyperplasia or with a follicular architecture, can create real diagnostic difficulty. The aim of this study was to evaluate the expression of several antibodies considered to be markers of malignancy in malignant and hyperfunctioning thyroid neoplasms and to include the most effective of them in a diagnostic panel.

BRAF (V600E) mutation analysis on liquid-based cytology-processed aspiration biopsies predicts bilaterality and lymph node involvement in papillary thyroid microcarcinoma

Activating mutations in the valine‐to‐glutamic acid substitution at position 600 of the v‐raf murine sarcoma viral oncogene homolog B1 (BRAF‐1) gene are detected frequently in patients with papillary thyroid carcinoma (PTC). These mutations have been identified in approximately 29% to 69% of PTCs and in >80% of PTCs of the tall cell variant, whereas they have not been detected in benign lesions or in the majority of those (80%) with the follicular variant of PTC. The objective of the current study was to evaluate the role of liquid‐based cytology (LBC) for the detection of BRAF mutations in the outcome of patients who have thyroid PTC measuring ≤1 cm and, hence, in guiding their clinical and surgical management.

Management of Cystic or Predominantly Cystic Thyroid Nodules: The Role of Ultrasound-Guided Fine-Needle Aspiration Biopsy

OBJECTIVE Conventional fine-needle aspiration biopsy (FNAB) for cystic thyroid nodules (CTNs) has a high rate of nondiagnostic and false-negative results. Ultrasound-guided FNAB (UG-FNAB) permits direct sampling of the wall and/or the solid portion of CTNs, increasing the possibility of a representative sample. In this study we evaluated the role of UG-FNAB in CTNs management. METHODS Five-hundred-seventy-five UG-FNAB of CTNs were performed. Thyroidectomy was carried out in 119 of these cases. The medical records of these 119 patients were reviewed and form the basis of this report. RESULTS The nondiagnostic smear rate was 9.2%. Cytological diagnosis was benign nodule in 42 cases, predominantly follicular lesion in 50 cases, and suspicious or malignant lesion in 16 cases. The final pathology revealed a benign nodule in 98 cases (82.4%) and a carcinoma in 21 (17.6%). The overall accuracy of UG-FNAB was 88.0%. No significant differences were found in age, sex, lesion size, or echographic pattern (p = NS) comparing patients with benign CTNs to patients with malignant CTNs. CONCLUSION UG-FNAB has a low rate of nondiagnostic smears and a high overall accuracy in CTNs. All CTNs should undergo UG-FNAB to select patients for surgery, since the malignancy rate is not negligible and no clinical parameter can reliably predict it.