Chiara Dobrinja

Radiofrequency Ablation Compared to Surgery for the Treatment of Benign Thyroid Nodules

Objective. Benign thyroid nodules are a common occurrence whose only remedy, in case of symptoms, has always been surgery until the advent of new techniques, such as radiofrequency ablation (RFA). This study aimed at evaluating RFA efficacy, tolerability, and costs and comparing them to hemithyroidectomy for the treatment of benign thyroid nodules. Design and Methods. 37 patients who underwent RFA were retrospectively compared to 74 patients surgically treated, either in a standard inpatient or in a short-stay surgical regimen. Efficacy, tolerability, and costs were compared. The contribution of final pathology was also taken into account. Results. RFA reduced nodular volume by 70% after 12 months and it was an effective method for treating nodule-related clinical problems, but it was not as effective as surgery for the treatment of hot nodules. RFA and surgery were both safe, although RFA had less complications and pain was rare. RFA costed €1,661.50, surgery costed €4,556.30, and short-stay surgery costed €4,139.40 per patient. RFA, however, did not allow for any pathologic analysis of the nodules, which, in 6 patients who had undergone surgery (8%), revealed that the nodules harboured malignant cells. Conclusions. RFA might transform our approach to benign thyroid nodules.

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 tumors 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.).

Full-Thickness Skin Burn Caused by Radiofrequency Ablation of a Benign Thyroid Nodule

Dear Editor: Today, radiofrequency ablation (RFA) represents an effective therapeutic option for symptomatic benign thyroid nodules. The advantages of this outpatient treatment modality include reduced morbidity, no risk of cosmetic damage, and decreased costs (1). In Trieste, we started using RFA for symptomatic thyroid nodule ablation in 2012, and so far, 107 patients have been treated with this approach, with overall satisfactory results and a low complication rate (3%), which is consistent with the literature (1–3). All the procedures were performed by the same operator, who is a well-trained radiologist, experienced in ultrasound (US), fine-needle aspiration biopsy, and RFA procedures. Nevertheless, in one of these patients (0.9%), the procedure unexpectedly caused (3,4) a third-degree skin burn. Here, we report our experience. A healthy 34-year-old woman with a slim body habitus presented with a thyroid nodule located in the left inferior pole of the gland, which was partly plunging (Supplementary Fig. S1; Supplementary Data are available online at www.liebertpub.com/thy). On presentation, she complained of local cosmetic concerns, seeking advice on the best treatment modality of her nodule. The nodule measured 42 mm × 40 mm × 23 mm (Supplementary Fig. S2A) and was cytologically benign. Given that she refused surgery and met all the eligibility criteria for thyroid RFA (5), we suggested that she undergo this procedure. The patient was informed and prepared as already described (1,2). Before the procedure, she underwent local anesthesia at the puncture site with 10 mL of 2% lidocaine, as well as conscious sedation with 2 mg of midazolam. To ablate the nodule, a monopolar electrode featuring a shaft length of 10 cm and an exposed tip length of 10 mm (RF AMICA_PROBE model RFH18100V1, HS Hospital Service SpA, Italy) was inserted into the thyroid nodule under US guidance. In particular, due to the position of the nodule (Supplementary Fig. S1), the electrode was inserted directly into the nodule from above (direct approach), instead of reaching it through the thyroid isthmus (transisthmic approach). We began by ablating the central areas of the nodule (Supplementary Fig. S2B) with an initial RF power of 30 W, which was then increased to 40 W. Then, in order to treat the other parts of the nodule, the electrode was moved and pulled slightly backward. Probably at that moment, the active needle tip must have come in close proximity to the skin with the power delivery possibly not switched off yet, so that a skin burn developed. The lesion was noticed by the operator immediately after it developed, and as soon as it was noticed the procedure was stopped, leaving most of the nodule untreated (Supplementary Fig. S2C). Otherwise, the patient did not perceive anything and she did not complain of pain during the skin injury because of the conscious sedation and local anesthesia. No other complications were encountered. Initially, the lesion appeared as a full-thickness burn that surrounded the electrode puncture site, with a maximum diameter of 1.5 cm and a charred white necrotic core (Fig. 1A). The patient was seen by a plastic surgeon who recommended treatment with topical gentamicin sulfate and hyaluronic acid for the first week, in order to reduce the risk of bacterial colonization of the wound and to help tissue regeneration and wound healing. The following week, the patient started applying an activated charcoal cloth with silver. Then, after surgical debridement of the wound (Fig. 1B), the skin burn was treated with a collagen wound dressing for another two weeks. Overall, although this skin burn took more than one month to heal, its final appearance looked almost like the normal skin (Fig. 1C). FIG. 1. (A) Baseline image of the radiofrequency ablation–induced full-thickness burn, which looks like a coin, with a maximum diameter of 1.5 cm and a charred white necrotic core. (B) Image of the neck after the surgical debridement of the wound. ... To our knowledge, this is the first report of a full-thickness skin burn caused by RFA of a benign thyroid nodule. The RFA-induced skin burns that have been reported so far were usually of first degree, and patients recovered within seven days (3–4). Here, we describe this clinical experience to raise awareness that RFA can also lead—although rarely—to full-thickness burns that take at least three weeks to heal and usually develop a scar, which may be severe. Patients should be informed of this extremely infrequent but regrettable possibility as well as its remedies, especially if they are undergoing RFA because of cosmetic concerns (and they want to avoid surgical scars). In order to prevent such a complication, it is important to keep the active needle tip within the nodule. To do so, it is recommended to use the transisthmic approach whenever possible. It can also be useful to inject cold fluid in the subcutaneous layers under the puncture site in order to create a wheal that will raise the skin and increase the distance from the nodule (we generally do that when injecting the lidocaine). It is also suggested (3) to apply an ice bag on the skin next to the puncture site during the ablation. In any case, it is important to keep in mind that conscious sedation may delay the detection of complications, and it is important to pay attention when treating superficial nodules in lean patients, where the active needle tip is more likely to come into contact with the skin. In cases when a skin burn develops, specific care will facilitate the wound healing process in order to achieve a satisfactory esthetic result.

12-month efficacy of a single radiofrequency ablation on autonomously functioning thyroid nodules.

PurposeRadiofrequency ablation has been advocated as an alternative to radioiodine and/or surgery for the treatment of autonomously functioning benign thyroid nodules. However, only a few studies have measured radiofrequency ablation efficacy on autonomously functioning benign thyroid nodules. The aim of this work was to evaluate the 12-month efficacy of a single session of radiofrequency ablation (performed with the moving shot technique) on solitary autonomously functioning benign thyroid nodules.MethodsThirty patients with a single, benign autonomously functioning benign thyroid nodules, who were either unwilling or ineligible to undergo surgery and radioiodine, were treated with radiofrequency ablation between April 2012 and May 2015. All the patients underwent a single radiofrequency ablation, performed with the 18-gauge needle and the moving shot technique. Clinical, laboratory, and ultrasound evaluations were scheduled at baseline, and after 1, 3, 6, and 12 months from the procedure.ResultsA single radiofrequency ablation reduced thyroid nodule volume by 51, 63, 69, and 75 % after 1, 3, 6, and 12 months, respectively. This was associated with a significant improvement of local cervical discomfort and cosmetic score. As for thyroid function, 33 % of the patients went into remission after 3 months, 43 % after 6 months, and 50 % after 12 months from the procedure. This study demonstrates that a single radiofrequency ablation allowed us to withdraw anti-thyroid medication in 50 % of the patients, who remained euthyroid afterwards.ConclusionThis study shows that a single radiofrequency ablation was effective in 50 % of patients with autonomously functioning benign thyroid nodules. Patients responded gradually to the treatment. It is possible that longer follow-up studies might show greater response rates.

Surgical and pathological changes after radiofrequency ablation of thyroid nodules

Background. Radiofrequency ablation (RFA) has been recently advocated as an effective technique for the treatment of symptomatic benign thyroid nodules. It is not known to what extent it may affect any subsequent thyroid surgery and/or histological diagnosis. Materials and Methods. RFA was performed on 64 symptomatic Thy2 nodules (benign nodules) and 6 symptomatic Thy3 nodules (follicular lesions/follicular neoplasms). Two Thy3 nodules regrew after the procedure, and these patients accepted to undergo a total thyroidectomy. Here we present how RFA has affected the operation and the final pathological features of the surgically removed nodules. Results and Conclusions. RFA is effective for the treatment of Thy2 nodules, but it should not be recommended as first-line therapy for the treatment of Thy3 nodules (irrespective of their mutational status), as it delays surgery in case of malignancy. Moreover, it is unknown whether RFA might promote residual tumor progression or neoplastic progression of Thy3 lesions. Nevertheless, here we show for the first time that one session of RFA does not affect subsequent thyroid surgery and/or histological diagnosis.

Primary hyperparathyroidism in older people: surgical treatment with minimally invasive approaches and outcome.

Introduction. Elderly patients with primary hyperparathyroidism (pHPT) are often not referred to surgery because of their associated comorbidities that may increase surgical risk. The aim of the study was to review indications and results of minimally invasive approach parathyroidectomy in elderly patients to evaluate its impact on outcome. Materials and Methods. All patients of 70 years of age or older undergoing minimally approach parathyroidectomy at our Department from May 2005 to May 2011 were reviewed. Data collected included patients demographic information, biochemical pathology, time elapsed from pHPT diagnosis to surgical intervention, operative findings, complications, and results of postoperative biochemical studies. Results and Discussion. 37 patients were analysed. The average length of stay was 2.8 days. 11 patients were discharged within 24 hours after their operation. Morbidity included 6 transient symptomatic postoperative hypocalcemias while one patient developed a transient laryngeal nerve palsy. Time elapsed from pHPT diagnosis to first surgical visit evidences that the elderly patients were referred after their disease had progressed. Conclusions. Our data show that minimally invasive approach to parathyroid surgery seems to be safe and curative also in elderly patients with few associated risks because of combination of modern preoperative imaging, advances in surgical technique, and advances in anesthesia care.

Minimally invasive video-assisted parathyroidectomy. Initial experience in a General Surgery Department

Background: The aim of this study is to analyze our preliminary results from minimally invasive video-assisted parathyroidectomy (MIVAP) and demonstrate the feasibility of MIVAP also in non-referral centers. Material and methods: During a period from June 2005 to January 2008, in the General Surgery Department of University of Trieste, we operated on 39 patients with primary hyperparathyroidism (pHPT). MIVAP by an anterior approach was proposed for 23 (59%) patients with sporadic pHPT and one unequivocally enlarged parathyroid gland on pre-operative ultrasound and 99mTc-SestaMIBI scintigraphy without associated goiter and without previous neck surgery. Intra-operatively, a quick parathyroid assay was used during the last 11 surgical procedures. All patients underwent pre-operative and post-operative investigations of calcemia, phoshoremia and PTH levels and vocal cord function. Age, operative times, pathologic findings, post-operative pain, calcemia, length of hospital stay, cosmetic results, and complications were retrospectively analyzed. Results: MIVAP was successfully accomplished in 22 cases. Conversion to standard cervicotomy was required in one patient (4.34%). Mean operative time was 67 min. Post-operative complications included 1 (4.34%) transient hypocalcemia. No laryngeal nerve palsies, no definitive hypocalcemias, no persistent pHPT and no recurrent pHPT were observed. The cosmetic result was excellent in all cases. Conclusions: Our preliminary results demonstrate that MIVAP for localized single-gland adenoma, after adequate training, seems to be feasible with significant advantages, especially in terms of cosmetic results, post-operative pain, and post-operative recovery even in a General Surgery Department, if performed by a dedicated team, with a sufficient and specific activity volume.

Radiofrequency ablation for benign thyroid nodules

Benign thyroid nodules are an extremely common occurrence. Radiofrequency ablation (RFA) is gaining ground as an effective technique for their treatment, in case they become symptomatic. Here we review what are the current indications to RFA, its outcomes in terms of efficacy, tolerability, and cost, and also how it compares to the other conventional and experimental treatment modalities for benign thyroid nodules. Moreover, we will also address the issue of treating with this technique patients with cardiac pacemakers (PM) or implantable cardioverter-defibrillators (ICD), as it is a rather frequent occurrence that has never been addressed in detail in the literature.

Primary bilateral adrenal non-Hodgkin's Burkitt-like lymphoma: a rare cause of primary adrenal insufficiency. Case report and literature review.

Aims and background Primary bilateral adrenal non-Hodgkins lymphoma is an extremely rare entity. Only 44 cases have been reported in the literature. The most common presenting symptoms are abdominal pain, fever, asthenia, constipation, weight loss or typical symptoms of adrenal insufficiency, hypertension, darkening of skin, orthostatic hypotension or an addisonian crisis. Methods The case is presented of a 57-year-old man suffering from primary bilateral adrenal lymphoma with symptoms of adrenal insufficiency syndrome associated with bilateral, stabbing lumbar pain and a palpable mass on the left side. Laboratory tests revealed a considerable increase in lactate dehydrogenase levels, adrenal insufficiency, and high corticotropin levels. Results Abdominal CT scan showed two large adrenal masses. A CT-guided fine needle aspiration biopsy revealed a large B-cell non-Hodgkins lymphoma. Combination chemotherapy according to the CHOP protocol with cyclophosphamide, doxorubicin, vincristine and prednisolone was initiated, which caused a slight reduction in size of the two adrenal masses. The patient underwent a bilateral adrenalectomy with almost complete excision of the tumors. Replacement therapy with cortisone acetate was initiated postoperatively. Adjuvant combination chemotherapy according to the CHOP protocol was started but renal failure gradually emerged and the treatment could not be completed. The patient died seven months after surgery due to acute bronchial pneumonia and progression of disease. Conclusions Primary bilateral adrenal non-Hodgkins lymphoma mainly affects adult men. Diagnosis is based on histological examination. Whether associated or not with radiotherapy, chemotherapy is the most recommended treatment. Surgery, where possible, seems to lead to an increase in survival rates, but it is not possible to draw any definite conclusions on its effectiveness as yet.

Modifiable and non-modifiable risk factors for surgical site infection after colorectal surgery: a single-center experience

PurposeSurgical site infection (SSI) is the most common complication of colorectal surgery, resulting in significant burden in terms of morbidity and length of hospital stay. The aims of this study were to establish the incidence of SSI in patients undergoing colorectal surgeries and to identify potentially modifiable risk factors to reduce overall SSI rates.MethodsThis retrospective study analyzed patients who underwent colorectal resection at our Department. Patients were identified using a prospective SSI database. Univariate and multivariate analyses were used to identify risk factors.ResultsA total of 687 patients were enrolled in the study and the overall SSI rate was 19.9% (137 patients). Superficial incisional surgical site infections (SSSIs) developed in 52 (7.6%) patients, deep incisional surgical site infections (DSSIs) developed in 15 (2.2%), and organ/space infections (OSIs) developed in 70 (10.1%). Univariate and multivariate analyses confirmed that age, diabetes, emergency surgery, and a high infection risk index are risk factors for SSI.ConclusionsThere are some modifiable and non-modifiable risk factors for SSI. IRI and age are non-modifiable, whereas the timing of surgery and diabetes can be modulated by trying to defer some emergency procedures to elective ones and normalizing the glycemia of diabetic patients.