Erica Panicucci

Transoral robotic surgery of the tongue base in obstructive sleep Apnea‐Hypopnea syndrome: Anatomic considerations and clinical experience

The purpose of our work was to describe, through cadaveric dissection, the anatomy of the tongue base with a robotic perspective and to demonstrate the feasibility of this approach in case of tongue base hypertrophy in Obstructive Sleep Apnea‐Hypopnea Syndrome (OSAHS).

Horizontal Semicircular Canal Benign Paroxysmal Positional Vertigo: Effectiveness of Two Different Methods of Treatment

The aim of this study is to compare the results obtained using 2 methods of treatment for horizontal semicircular canal benign paroxysmal positional vertigo (HSC-BPPV): the barbecue maneuver + forced prolonged position (FPP) versus the Gufoni maneuver. In a randomized prospective clinical trial, we recruited 147 patients affected by HSC-BPPV. The primary outcome was the absence of vertigo and nystagmus upon application of the supine roll test during the follow-up examination. A statistical evaluation was performed in order to assess whether any parameters (e.g. age, duration of nystagmus and symptoms) could influence in any way the results obtained with the 2 methods of treatment. One hundred and three of the 147 patients affected by HSC-BPPV had the geotropic form and 44 had the apogeotropic type. We were able to transform 29 cases of HSC-BPPV from apogeotropic to geotropic. Finally, we obtained a group of 112 patients who were randomized either to the barbecue + FPP procedure (54 patients) or to the Gufoni maneuver (58 patients). The most evident result is the higher percentage of success (statistically significant) with the Gufoni maneuver at the first session of treatment (86 vs. 61%). The final control showed that 44 out of 54 (81%) patients treated with the barbecue maneuver + FPP were symptom free compared to 54 out of 58 (93%) treated with the Gufoni maneuver. Both the barbecue maneuver + FPP and the Gufoni maneuver are valid methods for treating HSC-BPPV (geotropic forms). However, our results also indicate that the Gufoni maneuver has a significant advantage: the success rate shown at the follow-up, although without statistical significance, is undoubtedly higher (93 vs. 81%). This result, together with the fact that it is very easy to perform and that patient compliance is better, make the Gufoni maneuver the method of choice in HSC-BPPV treatment.

Papillary thyroid cancer: Pathological parameters as prognostic factors in different classes of age

OBJECTIVE: To analyze aspects of a series of papillary thyroid carcinomas and evaluate the prognostic features specific to different age classes. STUDY DESIGN: Retrospective study. SUBJECTS AND METHODS: From 2000 to 2005, 2709 patients underwent a total thyroidectomy for papillary thyroid carcinoma in our department. Patients were divided into three groups: <18 years (G1), 19 to 45 years (G2), and >46 years (G3). Histologic and clinical features were statistically evaluated. RESULTS: Tumor size was larger in G1 when compared with both G2 and G3 (P < 0.0001). Infiltration of the thyroid capsule and node metastases were higher in G1 than both G2 and G3 (P < 0.0001). The Tall-cell variant was more represented in G2 and G3. CONCLUSION: In the pediatric population, papillary carcinoma is a more aggressive disease. Because pediatric cancers have a better prognosis than their adult counterparts, this does not influence patient outcome. Age can then be considered the most important factor in determining prognosis.

Intrathyroidal Differentiated Thyroid Carcinoma: Tumor Size-Based Surgical Concepts

IntroductionTotal thyroidectomy (TT) remains the treatment of choice for differentiated thyroid carcinomas (DTCs), but a limited approach can be proposed when tumors are at an early stage and limited to a single lobe. The aim of this study was to analyze the pathologic and clinical aspects of a retrospective series of DTCs in an attempt to determine whether these features might prove useful for limiting the surgical strategy in selected cases.MethodsFrom 2000 to 2005, a total of 2798 patients (637 males, 2161 females; mean age 44.6 years) underwent TT for papillary thyroid carcinoma in our department. The histologic features considered were size, histologic subtype and capsule of the tumor, its multifocality/bilaterality, infiltration of the thyroid capsule, and the presence of nodal metastases.ResultsStatistical analysis revealed that among tumors ≤ 1 cm the presence of the tumor capsule, infiltration of the thyroid capsule, bilaterality, and the presence of node metastases were all significantly lower when the tumor size was ≤ 0.5 cm (p < 0.0001). Furthermore, patients with bilateral carcinomas demonstrated a significantly higher presence of a tumor capsule (p = 0.012), infiltration of the thyroid capsule (p < 0.0001), and node metastases (p < 0.0001) and a higher incidence of the “tall-cells” variant (p < 0.0001) when compared to the unilateral population.ConclusionsBased on these data it is suggested that tumors ≤ 1 cm cannot be considered a homogeneous class of DTCs. Nevertheless, in tumors ≤ 0.5 cm the absence of a “tall-cells” variant and the absence of infiltration of the thyroid capsule might be useful for avoiding an unnecessary completion thyroidectomy after lobectomy.

Modified lateral neck lymphadenectomy: Prospective randomized study comparing harmonic scalpel with clamp-and-tie technique

OBJECTIVE: To compare the use of harmonic scalpel (HS) with clamp-and-tie technique to evaluate their comparative merits in modified lateral lymphadenectomy (LL). STUDY DESIGN: Prospective and randomized. SUBJECTS AND METHODS: Thirty-seven patients were recruited and divided into Group A (conventional; n = 20) and Group B (HS; n = 17). Thyroid volume, neck circumference, operative time, diameter of the tumor and lymph node, drainage volume, pain, and complications were compared. Operation consisted of thyroidectomy and LL. RESULTS: Groups were homogeneous for thyroid volume, diameter of thyroid nodule and lymph node, and neck circumference. Operative time was shorter in Group B than in Group A. The fluid collection in the vacuum between 24 and 48 hours and the increase of neck circumference were lower in Group B. Pain was significantly lower in Group B after 12 hours and decrease was faster in Group B. CONCLUSION: The use of HS during LL is as safe as conventional technique and may allow shorter operative time, lower lymphatic spillage, and faster decrease of pain.

Prognostic Value of N-Terminal Pro–Type-B Natriuretic Peptide and Doppler Left Ventricular Diastolic Variables in Patients With Chronic Systolic Heart Failure Stabilized by Therapy

Prognostication of patients with chronic heart failure (HF) stabilized by therapy may be difficult. Therefore, the aim was to evaluate whether combined assessment of plasma N-terminal pro-B natriuretic peptide (NT-pro-BNP) and Doppler left ventricular (LV) diastolic variables was relevant to the prognosis of patients with stable HF. Outpatients with LV systolic HF (ejection fraction < or =45%), classified using clinical criteria as decompensated (n = 94) and stable HF (n = 219), underwent a complete Doppler echocardiographic study. NT-pro-BNP was measured together with mitral wave velocities, E wave deceleration time, and tissue Doppler early septal annular velocity. Median follow-up was 22 months. Freedom from all-cause mortality or HF hospitalization at 24 months was worst (44%) in patients with decompensated HF, intermediate (58%) in patients with stable HF with NT-pro-BNP higher than the median (>1,129 pg/ml), and best (92%) in patients with lower NT-pro-BNP (log-rank p <0.0001). In patients with stable HF, NT-pro-BNP >1,129 pg/ml (hazard ratio [HR] 2.84, p = 0.003), E wave deceleration time <150 ms (HR 2.31, p = 0.004), and tissue Doppler early septal annular velocity <8 cm/s (HR 2.18, p = 0.01) were predictors of the end point at multivariate analysis. The addition of Doppler LV diastolic variables and NT-pro-BNP significantly improved the chi-square test for outcome prediction (from 14.4 to 46.4). In conclusion, NT-pro-BNP and spectral and tissue Doppler variables of LV diastolic dysfunction added independent and incremental contributions to prognostic stratification of patients with stable HF.

New trends in the treatment of undifferentiated carcinomas of the thyroid.

IntroductionMalignant tumours of the thyroid are generally classified as either well-differentiated thyroid carcinoma, which is composed of papillary and follicular carcinoma, or undifferentiated/anaplastic thyroid carcinoma (ATC). ATC is not only the most lethal disease in the field of endocrine surgery but also one of the most aggressive tumours characterized by an almost invariable fatal outcome, which only very rarely exceeds a 1-year course.DiscussionThe impact of surgical resection in association with external beam radiation on ATC outcome has been extensively investigated also in studies based on multicentric database, and there is a general agreement on the significance of a complete resection of the tumour. It has been difficult up to now to collect data regarding chemotherapy adjuvant treatment. In spite of the lack of an extensive review about the results of this kind of treatment by itself or as part of a multimodal approach, it seems that among the several chemotherapy agents experienced, none proved to influence significantly ATC prognosis. Neither doxorubicin (the most commonly used) nor other drugs, such as cisplatin, bleomycin, fluorouracil or cyclophosphamide, showed any real efficacy in controlling the disease.ConclusionThe most recent development in this field seems to be represented by the possibility offered by PPARg agonists; even more promising might be the use of adenovirus-mediated p53 tumour suppressor gene therapy or BMP-7. All these new therapies need further confirmation coming from ongoing clinical trials such as those involving the use of vascular and growth factor-targeted agents.

Prognostic significance of tricuspid annular motion and plasma NT-proBNP in patients with heart failure and moderate-to-severe functional mitral regurgitation

The role of the right ventricle has been relatively neglected proportionate to its importance. We sought to evaluate the impact of right ventricular (RV) and NT‐proBNP on the outcome of patients with heart failure (HF) and functional mitral regurgitation (MR).

Plasma Homocysteine, Folate, and Vitamin B12 Levels in Patients With Laryngeal Cancer

OBJECTIVE To determine plasma levels of homocysteine, folate, and vitamin B12 in patients with laryngeal cancer and a control group. DESIGN Analysis of homocysteine, folate, and vitamin B12 levels in 25 consecutive untreated patients with laryngeal carcinoma and 80 healthy control participants. The study and control groups were subdivided into smokers, ex-smokers, and nonsmokers, as well as drinkers and nondrinkers. INTERVENTION The AxSYM system was used to measure total homocysteine levels, and the ARCHITECT system (both Abbott-Diagnostics Division) was used to measure folate and vitamin B12 levels. MAIN OUTCOME MEASURES Homocysteine, folate, and vitamin B12 levels. RESULTS The mean (SD) level of total homocysteine in patients with laryngeal carcinoma was 2.84 (1.62) mg/L vs 0.99 (0.24) mg/L in the control group (P <.001). The mean (SD) folate plasma level was 4.3 (2.2) ng/mL vs 7.9 (2.4) ng/mL (P <.001). CONCLUSIONS Metabolic alterations in homocysteine, folate, and vitamin B12 levels, especially hypofolatemia, could be associated with laryngeal cancer. Lengthier follow-up studies and larger groups of patients will help determine the real role of these metabolic alterations.

The impact of thyroidectomy on parathyroid glands: A biochemical and clinical profile

Introduction: An evaluation of PTH levels during thyroid surgery may reflect the functional status of the parathyroids and be useful in identifying patients at risk for hypocalcemia. This study aims to monitor the parathyroid function during total thyroidectomy through intra-operative serial samples for calcium and PTH. Materials and methods: Forty-seven patients undergoing total thyroidectomy for different diseases were selected for the study. Patients underwent serum PTH and calcium sampling at the induction of anesthesia (T0) and after the first (T1) and the second (T2) lobectomy. Serum calcium was also drafted 24 h after the operation. Results: Mean PTH at T0, T1, and T2 was, respectively: 32.1 pg/ml, 19.6 pg/ml, and 11.5 pg/ml. PTH was significantly higher at T0 when compared to T1 (p<0.0001). It was also significantly higher at T1 than at T2 (p<0.0001). At T1 PTH levels were below the normal range in 20/47 cases (42.5%) and at T2 in 31/47 cases (66%). Twenty-four h after surgery, 8 patients (17%) demonstrated a biochemical hypocalcemia. A PTH value at T0 in the upper (>70 pg/ml) or in the lower (<20 pg/ml) limits of the normal range was statistically related to post-operative hypocalcemia (p=0.017). Discussion: The study seems to confirm that serum PTH during thyroidectomy does not represent a sensitive tool in precociously identifying hypocalcemic patients. Nevertheless, before surgery, a PTH concentration at the higher or lower normal limit may help to identify patients “at risk” of developing hypocalcemia.