Daniele Pironi

Thyroid Imaging Reporting and Data System Score Combined with the New Italian Classification for Thyroid Cytology Improves the Clinical Management of Indeterminate Nodules

The new Italian cytological classification (2014) of thyroid nodules replaced the TIR3 category of the old classification (2007) with two subclasses, TIR3A and TIR3B, with the aim of reducing the rate of surgery for benign diseases. Moreover, thyroid imaging reporting and data system (TI-RADS) score appears to ameliorate the stratification of the malignancy risk. We evaluated whether the new Italian classification has improved diagnostic accuracy and whether its association with TI-RADS score could improve malignancy prediction. We retrospectively analyzed 70 nodules from 70 patients classified as TIR3 according to the old Italian classification who underwent surgery for histological diagnosis. Of these, 51 were available for cytological revision according to the new Italian cytological classification. Risk of malignancy was determined for TIR3A and TIR3B, TI-RADS score, and their combination. A different rate of malignancy (p = 0.0286) between TIR3A (13.04%) and TIR3B (44.44%) was observed. Also TI-RADS score is significantly (p = 0.003) associated with malignancy. By combining cytology and TI-RADS score, patients could be divided into three groups with low (8.3%), intermediate (21.4%), and high (80%) risk of malignancy. In conclusion, the new Italian cytological classification has an improved diagnostic accuracy. Interestingly, the combination of cytology and TI-RADS score offers a better stratification of the malignancy risk.

Unexpected granular cell tumor in abdominal wall: Case report and literature review

Granular cell tumors (GCTs) are uncommon benign neoplasms deriving from Schwann cells of the peripheral nerve fibers. Although these tumors can be found anywhere in the body, the most frequent site is the tongue, followed by the chest wall and the arm. The abdominal wall is an extremely rare site for GCTs. These tumors are generally asymptomatic and have a slow growth rate. Today, thanks to their immunoreactivity to S-100 and CD68, the differential diagnosis is more straightforward than in the past. We report on a young patient affected by a GCT located in the upper third of the right rectus abdominis muscle. En bloc excision through a diamond-shaped skin incision allowed us to make a correct histological diagnosis, which was confirmed by the immunohistochemical findings. GCT, which is very rare in abdominal wall muscles, should be considered in the differential diagnosis, and surgical excision is the treatment of choice.

Prevention of complications during reoperative thyroid surgery.

BACKGROUND Thyroidectomy performed by an experienced surgeon is associated with a low incidence of recurrent laryngeal nerve injury and permanent hypoparathyroidism. During reoperative thyroid surgery there is a higher technical risk because detection and preservation of the recurrent laryngeal nerves and parathyroid glands are more difficult than in the primary surgery. AIM Our retrospective cohort study was to assess short- and long-term complications associated with reoperative thyroid surgery in order to suggest a technical approach to lower the morbidity rate. MATERIALS AND METHODS From January 2005 to September 2013, 745 patients underwent surgery for thyroid disease. Before surgery all patients underwent clinical examination, laboratory blood tests, hormonal assays, neck ultrasound, chest radiography and indirect laryngoscopy. Patients were followed up at 1, 3, 6 months and then annually after operation with hormonal assays, blood tests and neck ultrasound. RESULTS Eighty (10.7%) out of 745 patients (mean-age= 52.5 years; age-range 18-80) underwent reoperative surgery for recurrent thyroid disease. The primary treatments were enucleoresection (11.2%), thyroid lobectomy(56,3%), thyroid lobectomy with isthmectomy(10%) and subtotal thyroidectomy (22,5%). In the reoperative surgery group (Group Re) the transient RLN complications were 1.3% compared to 0.2% in the primary surgery group (Group P) (p= 0.51). The incidence of temporary hypocalcemia was 45% in the reoperative surgery group vs. 42.7% in the primary surgery group (p=0.72). CONCLUSIONS Reoperative surgery should be reserved to experienced surgeons. However, even in this case, when surgical maneuvers reserved for primary surgery are applied, then this surgery is associated with a low complications rate.

Robotic Total Gastrectomy With Intracorporeal Robot-Sewn Anastomosis: A Novel Approach Adopting the Double-Loop Reconstruction Method

AbstractGastric cancer constitutes a major health problem. Robotic surgery has been progressively developed in this field. Although the feasibility of robotic procedures has been demonstrated, there are unresolved aspects being debated, including the reproducibility of intracorporeal in place of extracorporeal anastomosis.Difficulties of traditional laparoscopy have been described and there are well-known advantages of robotic systems, but few articles in literature describe a full robotic execution of the reconstructive phase while others do not give a thorough explanation how this phase was run.A new reconstructive approach, not yet described in literature, was recently adopted at our Center.Robotic total gastrectomy with D2 lymphadenectomy and a so-called “double-loop” reconstruction method with intracorporeal robot-sewn anastomosis (Parisis technique) was performed in all reported cases.Preoperative, intraoperative, and postoperative data were collected and a technical note was documented.All tumors were located at the upper third of the stomach, and no conversions or intraoperative complications occurred. Histopathological analysis showed R0 resection obtained in all specimens. Hospital stay was regular in all patients and discharge was recommended starting from the 4th postoperative day. No major postoperative complications or reoperations occurred.Reconstruction of the digestive tract after total gastrectomy is one of the main areas of surgical research in the treatment of gastric cancer and in the field of minimally invasive surgery.The double-loop method is a valid simplification of the traditional technique of construction of the Roux-limb that could increase the feasibility and safety in performing a full hand-sewn intracorporeal reconstruction and it appears to fit the characteristics of the robotic system thus obtaining excellent postoperative clinical outcomes.

Vitiligo and Autoimmune Thyroid Disorders

Vitiligo represents the most common cause of acquired skin, hair, and oral depigmentation, affecting 0.5–1% of the population worldwide. It is clinically characterized by the appearance of disfiguring circumscribed skin macules following melanocyte destruction by autoreactive cytotoxic T lymphocytes. Patients affected by vitiligo usually show a poorer quality of life and are more likely to suffer from depressive symptoms, particularly evident in dark-skinned individuals. Although vitiligo is a non-fatal disease, exposure of affected skin to UV light increases the chance of skin irritation and predisposes to skin cancer. In addition, vitiligo has been associated with other rare systemic disorders due to the presence of melanocytes in other body districts, such as in eyes, auditory, nervous, and cardiac tissues, where melanocytes are thought to have roles different from that played in the skin. Several pathogenetic models have been proposed to explain vitiligo onset and progression, but clinical and experimental findings point mainly to the autoimmune hypothesis as the most qualified one. In this context, it is of relevance the strong association of vitiligo with other autoimmune diseases, in particular with autoimmune thyroid disorders, such as Hashimoto thyroiditis and Graves’ disease. In this review, after a brief overview of vitiligo and its pathogenesis, we will describe the clinical association between vitiligo and autoimmune thyroid disorders and discuss the possible underlying molecular mechanism(s).

Distal pancreatectomy with splenic preservation: A short-term outcome analysis of the Warshaw technique

INTRODUCTION Spleen-preserving left pancreatectomy (SPDP) with splenic vessels preservation (SVP) or without (Warshaw technique, WT) has been described with robotic, laparoscopy and open surgery. Nevertheless, significant data on medium- and long-term follow-up are still not available, since data in literature are scarce and the level of evidence is low. METHODS In this retrospective study, we describe and compare short and medium term results of spleen-preserving distal pancreatectomy in eight patients. RESULTS In WT group the duration and the intraoperative bleeding was superior than SVP group. The incidence of perigastric collateral vessels and presence of submucosal varices evidenced at CT scan was 66% in WT group, while only one case occurred in SVP group. DISCUSSION The limit of laparoscopic approach is the fact that it needs advanced laparoscopic skills, which might result in intraoperative bleeding and splenectomy. The most of literature considered salvage WT intraoperatively performed in case of classical SVP and not only elective WT. The consequence is that there is no difference in immediate postoperative results (operative time, intraoperative bleeding, hospital stay) that are in favour of SVP because WT is performed only in case of failure in preserving the splenic vessels. In fact when this intervention is performed electively, the procedure time is reduced as well as the intraoperative bleeding. CONCLUSIONS WT is safe and feasible, even if there are not definitive evidences that demonstrate it is superior to classic SVP. RCTs are needed to determine advantages and disadvantages of WT compared to the classic SVP.

A Retrospective Case-Control Study Evaluating the Bowel Preparation Quality during Surveillance Colonoscopy after Colonic Resection

Purpose. Bowel preparation for surveillance endoscopy following surgery can be impaired by suboptimal bowel function. Our study compares two groups of patients in order to evaluate the influence of colorectal resection on bowel preparation. Methods. From April 2010 to December 2011, 351 patients were enrolled in our retrospective study and divided into two homogeneous arms: resection group (RG) and control group. Surgical methods were classified as left hemicolectomy, right hemicolectomy, anterior rectal resection, and double colonic resection. Bowel cleansing was evaluated by nine skilled endoscopists using the Aronchick scale. Results. Among the 161 patients of the RG, surgery was as follows: 60 left hemicolectomies (37%), 62 right hemicolectomies (38%), and 33 anterior rectal resections (20%). Unsatisfactory bowel preparation was significantly higher in resected population (44% versus 12%; P value = 0.000). No significant difference (38% versus 31%, P value = ns) was detected in the intermediate score, which represents a fair quality of bowel preparation. Conclusions. Our study highlights how patients with previous colonic resection are at high risk for a worse bowel preparation. Currently, the intestinal cleansing carried out by 4 L PEG based preparation does not seem to be sufficient to achieve the quality parameters required for the post-resection endoscopic monitoring.

New perspectives in the diagnosis of thyroid follicular lesions

Thyroid nodules are very common, affecting 19%-67% of the adult population. However, about 10% of them harbor a malignant lesion. Consequently, the first aim in their clinical evaluation is to exclude malignancy. Fine-needle aspiration cytology (FNAC) represents the main diagnostic tool for the evaluation of thyroid nodules. However, FNAC has a main diagnostic limit, namely cellular atypias of indeterminate significance, which require surgical excision and histological examination to differentiate benign from malignant lesions. Histology reports show that approximately 80% of these patients harbor a benign lesion. Therefore, in order to reduce unnecessary thyroidectomy, over the last years, the cytological classification of thyroid nodules has been revised and a number of new instrumental and molecular approaches have been proposed. In the present article, we will attempt to summarize the most recent cytological, molecular and echographic strategies to enhance the diagnostic accuracy of preoperative thyroid follicular lesions. In particular, we will discuss the new cytological classifications from the Bethesda System for Reporting Thyroid Cytopathology (BSRTC), the British Thyroid Association-Royal College of Pathologists (PTA-RCPath) and the new Italian Society for Anatomic Pathology and Cytology (SIAPEC 2014. We will review molecular tests evaluated to ameliorate follicular lesion diagnosis as well as the clinical utility of the new echographic Thyroid Imaging Reporting and Data System (TI-RADS) score.

Expression and prognostic value of the cell polarity PAR complex members in thyroid cancer

Establishment and maintenance of the apical-basal cell polarity, required for proper replication, migration, specialized functions and tissue morphogenesis, relies on three evolutionary conserved complexes: PAR, CRUMBS and SCRIBBLE. Loss of cell polarity/cohesiveness (LOP/C) is implicated in cancer progression, and members of the polarity complex have been described as either oncogenes or oncosuppressors. However, no information on their role in thyroid cancer (TC) progression is available. In the present study, we evaluated the gene expression of the PAR complex members aPKCι, PARD3α/β and PARD6α/β/γ in 95 papillary TC (PTC), compared to their normal matched tissues and in 12 anaplastic TC (ATC). The mRNA and protein levels of investigated genes were altered in the majority of PTC and ATC tissues. In PTC, univariate analysis showed that reduced expression of aPKCι, PARD3β and PARD6γ mRNAs is associated with increased tumor size, and the reduced expression of PARD3β mRNA is associated also with recurrences. Multivariate analysis demonstrated that the presence of lymph node metastasis at diagnosis and the reduced expression of PARD3β are independent risk factors for recurrences, with hazard ratio, respectively, of 8.21 (p=0.006) and 3.04 (p=0.029). The latter result was confirmed by the Kaplan-Meier analysis, which evidenced the association between decreased PARD3β mRNA levels and shorter disease-free interval. In conclusion, we demonstrated that the expression of PAR complex components is deregulated in the majority of PTC and there is a general trend towards their reduction in ATC tissues. Moreover, a prognostic value for the PARD3β gene in PTCs is suggested.

Urgency surgical treatment for duodenal GISTs: analysis of aged patients and review of the literature

IntroductionGastrointestinal stromal tumours (GISTs) are the most common mesenchymal neoplasms (85%) of the gastrointestinal (GI) tract; duodenal GISTs constitute 3–5% of all GISTs and represent 10–30% of all malignant tumours of the duodenum. Rarely, patients present severe bowel obstruction, perforation or severe bleeding. The radical resection with complete removal of the tumour remains the main therapeutic approach. We performed a local resection in patients with suspected GIST admitted for emergency treatment for GI bleeding.CasesWe present three cases of patients admitted for GI bleeding. The cause could be a GIST bleeding. In all cases, local resection was performed without a pancreaticoduodenectomy. Histological examination on surgical preparations showed that in two cases it was a GIST and in one case, it was a leiomyoma.DiscussionSurgery remains the treatment of choice in the case of a GIST primitive without evidence of metastases, even for patients who are hospitalized for a bleeding emergency. Wide resections are not needed; it is important to remove completely the disease. In the case of duodenal GIST, it is important to get negative margins near the head of the pancreas, and this could take a PD. According to our experience and to the literature review, we believe that if the duodenal papilla or the periampullary region is not interested, you must perform a local resection. This is also because non-malignant tumours may present as GISTs and in these cases it is not recommended to run a PD.ConclusionThe treatment of choice for duodenal GISTs is complete surgical resection with negative resection margins. When the papilla or the periampullary region is involved we choose to perform pancreaticoduodenectomy; otherwise it is better to perform a local resection. In fact, local resection has lower morbidity and mortality, with a comparable outcome.