Emanuela Varaldo

Neurological complications in thyroid surgery: a surgical point of view on laryngeal nerves.

The cervical branches of the vagus nerve that are pertinent to endocrine surgery are the superior and the inferior laryngeal nerves: their anatomical course in the neck places them at risk during thyroid surgery. The external branch of the superior laryngeal nerve (EB) is at risk during thyroid surgery because of its close anatomical relationship with the superior thyroid vessels and the superior thyroid pole region. The rate of EB injury (which leads to the paralysis of the cricothyroid muscle) varies from 0 to 58%. The identification of the EB during surgery helps avoiding both an accidental transection and an excessive stretching. When the nerve is not identified, the ligation of superior thyroid artery branches close to the thyroid gland is suggested, as well as the abstention from an indiscriminate use of energy-based devices that might damage it. The inferior laryngeal nerve (RLN) runs in the tracheoesophageal groove toward the larynx, close to the posterior aspect of the thyroid. It is the main motor nerve of the intrinsic laryngeal muscles, and also provides sensory innervation to the larynx. Its injury finally causes the paralysis of the omolateral vocal cord and various sensory alterations: the symptoms range from mild to severe hoarseness, to acute airway obstruction, and swallowing impairment. Permanent lesions of the RNL occur from 0.3 to 7% of cases, according to different factors. The surgeon must be aware of the possible anatomical variations of the nerve, which should be actively searched for and identified. Visual control and gentle dissection of RLN are imperative. The use of intraoperative nerve monitoring has been safely applied but, at the moment, its impact in the incidence of RLN injuries has not been clarified. In conclusion, despite a thorough surgical technique and the use of intraoperative neuromonitoring, the incidence of neurological complications after thyroid surgery cannot be suppressed, but should be maintained in a low range.

Is euthyroidism the goal of surgical treatment of diffuse toxic goitre

OBJECTIVE To find out by studying a homogeneous group of patients whether euthyroidism is achievable by surgical treatment of diffuse toxic goitre. DESIGN Retrospective study. SETTING Teaching hospital, Italy. SUBJECTS 128 of the 152 patients operated on for diffuse toxic goitre during the period January 1971-December 1994 and followed up for a median of 83 months (range 6-289). INTERVENTION. Standard subtotal thyroidectomy. MAIN OUTCOME MEASURES Operative mortality, recurrence, hypothyroidism and late complications. RESULTS There were no operative deaths. After 10 years follow up, 11 patients (9%) had developed recurrences and 61 (48%) were euthyroid. In the univariate analysis the risk of hypothyroidism was significantly associated with the year of operation (p = 0.04), the duration of symptoms (p < 0.01), and the degree of lymphocytic infiltration (p < 0.01). The last two were confirmed by multivariate analysis. CONCLUSION Subtotal thyroidectomy seems to be an effective treatment of diffuse toxic goitre as a stable euthyroid state can be achieved in nearly half the patients after a prolonged follow up.

Neurinoma Originating from the Recurrent Nerve : Report of a Case

Schwannoma is an uncommon, peripheral nerve sheath tumor of the neck that can occur either as an isolated lesion or multiple lesions. Multiple schwannomas, as seen in neurofibromatosis, occur less frequently. The rare occurrence and poorly defined symptoms of these tumors often make their preoperative diagnosis difficult. This report describes an unusual case of recurrent nerve Schwannoma which was successfully identified by color Doppler sonography.

EPIDEMIOLOGY OF PERITONITIS

Summary The most relevant epidemiological data concerning different form of peritonitis are reviewed taking into account that secondary peritonitis are those of major interest for surgeons. A review of the literature concerning the epidemiology of peritonitis secondary to peptic ulcer perforation, appendicitis, hollow viscus perforation after endoscopic procedures, colonic perforation and postoperative peritonitis is given. Some details about primary peritonitis and peritonitis occurring in AIDS patients are discussed as well.

Definition and classification of peritonitis

Summary Peritonitis is defined as the inflammation of the peritoneum or of a part thereof, which may not necessarily be due to infection. Authors review the classifications proposed in the light of current etiopathogenetic, microbiologic and pathophysiologic concepts. The classification suggested herein stems directly from the outline that was stated in Hamburg in 1987. A definition of primary, secondary and tertiary peritonitis is given. At moment a thorough classification should be based on a integrated etiopathogenetic and pathologic approach.

ERBB1- and ERBB2-Positive Medullary Thyroid Carcinoma: A Case Report

Medullary thyroid carcinomas (MTCs) are rare thyroid tumors occurring in both sporadic and hereditary forms, whose pathogenesis is related to RET proto-oncogene alterations. MTCs originate from parafollicular cells, which produce calcitonin that represents the biochemical activity of MTC. Total thyroidectomy is the main treatment for MTC and often cures patients with confined diseases. In the presence of metastasis, the therapeutic approach depends on the rate of disease progression. We report a case of a 54-year-old female with a single, incidentally discovered, thyroid nodule of 1 cm, classified as suspicious MTC after a stimulation test with intravenous (iv) calcium. After surgery, we examined the nodule using immunohistochemistry, immunofluorescence, and electron microscopy. In addition to calcitonin, we found that it expressed intracellular positivity for the tyrosine kinase RTK receptors ERBB1 and ERBB2. Consistently with MTC features, the ultrastructural examination of the tumor displayed heterogeneous spindle-shaped cells containing two groups of secretory granules. Because of the significant correlation found between high ERBB1/ERBB2 levels in MTCs and extrathyroidal growth, the detection of ERBB1 and ERBB2 expression suggests that the two oncoproteins may be involved in the tumor proliferative responses and/or in the differentiation of parafollicular C-cells. The biological, prognostic, and therapeutic significance of these patterns would merit further investigations.

Metastases to the thyroid gland from renal cancer

AIMS AND BACKGROUND Metastases to the thyroid gland from renal cancer pose a challenge to physicians, due in part to the rarity of the phenomenon, the prolonged time interval between removal of the primary renal cancer and the appearance of metastases, the difficulty in diagnosis, and the uncertainty regarding long-term prognosis. We report our experience with diagnosis and management of patients affected by thyroid metastases from renal clear cell carcinoma. STUDY DESIGN We report herein three clinical cases of thyroid metastases from renal clear cell carcinoma. We also present a review of the literature and examine common features of clinical presentation and management recommendations. RESULTS Over the past 17 years, 918 patients underewent surgery for thyroid cancer in our institution. Histological examination demonstrated a thyroid secondary malignancy from kidney cancer in 3 cases. Two patients underwent total thyroidectomy, whereas in the third patient a palliative right lobectomy with homolateral latero-cervical lymphoadenectomy was performed. At a 5-year follow-up, only one patient survived and was disease-free. CONCLUSIONS Thyroid metastases from renal clear cell carcinoma are a rare occurrence but should be taken into consideration in the differential diagnosis of a thyroid nodule. Preoperative diagnosis is often difficult. Nevertheless, an extensive diagnostic workup is recommended because the subsequent therapy must be tailored on the basis of the local extension of metastases. Surgical treatment of solitary thyroid metastases is recommended. However, patients with disseminated disease have a poor prognosis, and palliative care is the indicated recommendation. In these patients and in surgically untreatable patients, prolonged survival may be achieved by adjuvant medical therapy.