Gianluca Donatini

Endoscopic bilateral neck exploration versus quick intraoperative parathormone assay (qPTHa) during endoscopic parathyroidectomy: A prospective randomized trial

BackgroundQuick intraoperative parathormone assay (qPTHa) during paratyroidectomy has become a standard procedure for patients with primary hyperparathyroidism (PHPT). This paper aims to compare endoscopic bilateral neck exploration (BE) versus focused parathyroidectomy plus qPTHa during minimally invasive video-assisted parathyroidectomy (QM). The endpoints of the study are the mean operative time and outcome of the surgical procedure (PTH and calcemia normalization at one and six months postoperatively).MethodsForty patients with PHPT, positive to preoperative localization studies (ultrasonography evaluation and 99Tc-MIBI scan) for a single parathyroid adenoma, were randomly allotted into two groups. In the first group (QM), 20 patients (17 women, three men, mean age 57.6 years) underwent focused endoscopic parathyroidectomy (MIVAP tecnicque) plus qPTHa . In the second group (BE) 20 patients (17 women, three men, mean age 59.6 years) underwent endoscopic parathyroidectomy plus bilateral exploration in order to check the integrity of the remaining glands.ResultsThere were no significant differences between groups at baseline. No conversion to cervicotomy was required. No postoperative complications were reported. The mean operative time was 32.0 vs 33.1 min [BE and QM group respectively, p = not significant (ns)]. A second macroscopically enlarged gland was removed in four patients in the BE group. Only one out of four glands was reported to be hyperplastic in the final histology. All patients were discharged on the first postoperative day. Calcemia levels were normalized in all patient of both groups, despite persistently high level of serum PTH in one patient in the QM group.ConclusionsBE can be performed endoscopically, avoiding both the time necessary for qPTHa and its cost, with the same effectiveness, but might in few cases lead to the unjustified removal of parathyroid glands slightly enlarged but not necessarily pathologic.

Video-assisted central compartment lymphadenectomy in a patient with a positive RET oncogene: initial experience

BackgroundProphylactic surgery for patients carrying a positive RET proto-oncogene proved to be highly effective in curing those likely to experience the development of a medullary carcinoma. Video-assisted procedures have been proved feasible for central compartment dissection.MethodsA total of 15 patients (7 men and 8 women) with a positive RET proto-oncogene underwent total thyroidectomy and central compartment lymphadenectomy via a video-assisted approach. The mean age of the patients was 32.5 years. The echographically estimated mean volume was 10.3 ml, and the mean diameter of the main nodule was 8.8 mm. Preoperative ultrasound showed an absence of lateral neck lymph node involvement in all cases. No drain was used. Direct laryngoscopy was performed in all cases 1 month after surgery.ResultsThe mean operative time was 67.3 min. A transient hypoparathyroidism occurred in one patient, and a permanent hypoparathyroidism occurred in another patient. No laryngeal nerve palsy was present. All the patients were discharged on postoperative day 1. Histology showed a medullary carcinoma in 10 patients and diffuse C-cell hyperplasia in 5 patients. The mean number of lymph nodes removed was 5.1. None of these nodes proved to be metastatic. Calcitonin levels were undetectable in all six patients who had a follow-up period longer than 1 year.ConclusionVideo-assisted central compartment lymphadenectomy was proved to be effective and safe. The procedure demonstrated a complication rate comparable with that for the conventional procedure, a better cosmetic outcome, and less postoperative pain. Although the video-assisted access proved to be a valid option for the treatment of patients carrying a positive RET proto-oncogene, a greater number of cases with a longer follow-up period is necessary to estimate the impact of the video-assisted approach on central neck lymphadenectomy.

Invisible Scar Endoscopic Dorsal Approach Thyroidectomy: A Clinical Feasibility Study

Background The aim of the present study was to test the safety and feasibility of the dorsal approach endoscopic thyroidectomy procedure in a prospective trial in humans, after the procedure had been developed ex vivo in human cadavers.

Minimally invasive video-assisted thyroidectomy in pediatric patients

BACKGROUND Minimally invasive video-assisted thyroidectomy (MIVAT) proved to be safe and effective in the treatment of both benign diseases and malignancies. We report our experience in thyroid surgery in pediatric patients. METHODS From October 1998 to December 2005, 35 patients (27 females and 8 males) underwent MIVAT for thyroid disease. The mean age was 14.0 years (range, 8-18 years); mean ecographically estimated thyroid volume was 11.13 mL (range, 8-25 mL). RESULTS A total thyroidectomy was performed in 22 patients, whereas lobectomy was performed in 13. Two patients of the latter group had a second lobectomy for a false-negative result at frozen section during the first operation. One patient underwent also a prophylactic central neck dissection for positive RET oncogene. The histologic examination found a papillary carcinoma in 11 patients, a microfollicular nodule in 7 patients, and multinodular goiter in 17 patients. The mean operative time was 54.1 minutes for thyroidectomy (range, 25-110 minutes) and 38.5 minutes for lobectomy (range, 20-65 minutes). All patients but one was discharged on the first postoperative day. One transient hypoparathyroidism was observed in the patient who underwent total thyroidectomy plus central neck lymphadenectomy. CONCLUSIONS The MIVAT technique proved to be as safe and effective as conventional thyroidectomy with Kocher approach to treat patients with both benign and malignant diseases of the thyroid gland. The advantages of MIVAT are represented by a better and faster postoperative course and an improved aesthetic result, which is particularly important in this group of patients.

The impact of thyroidectomy on psychiatric symptoms and quality of life

Introduction: Existing trials investigated the impact of medical treatment of thyroid disorders on health-related quality of life (QOL) and psychiatric symptoms. The aim of this prospective study is to analyze the impact of thyroid surgery on QOL and severity of psychiatric symptoms. Materials and methods: Forty-seven patients undergoing thyroid surgery (TS) were assessed before thyroidectomy (T0) and 37 also after surgery, ≥6 months after euthyroidism was achieved (T1). QOL and psychiatric symptoms were evaluated at T0 and T1 using the Medical Outcomes Study Short Form Survey (SF-36) and the Symptom Checklist-90 (SCL-90-R). Scores at T0 were compared with those of patients undergoing surgery for non-thyroidal disease and the SF-36 scores were also compared with the normative Italian sample. Changes in QOL and psychiatric symptoms between T0 and T1 were also examined. Results: Health-related QOL in TS patients before surgery was poorer than in the comparison group on the SF-36 mental component summary measure and social functioning. Mental health improved significantly after surgery but social functioning remained markedly impaired. A significant reduction in the severity of psychiatric symptoms was observed. Discussion: Our results indicate that even long after euthyroidism is achieved after surgery, patients show a significant improvement of mental health and a reduction of psychiatric symptoms. Nevertheless, patients continue to have a poorer QOL compared to the Italian normative sample.

Proteomic analysis of human thyroid fine needle aspiration fluid

The aim of this study was to determine the protein pattern of human thyroid fine needle aspiration fluid (FNA) using a proteomic approach. FNA proteins were separated using 2-dimensional gel electrophoresis (2DE), digested and then analyzed by peptide mass fingerprinting. For the first time, we provided an image of the protein components of the FNA, in which approximately 220 protein spots can be identified. The proteome analysis revealed a specific fingerprint of FNA with proteins appertaining to various functional systems. Our preliminary results of FNA protein pattern could be a starting point in studying the presence of potential markers implicated in thyroid diseases.

The endoscopic approach to the neck: a review of the literature and an overview of the various techniques

We thank Dr. Muenscher and collegues for their review of our article on the underlying pros and cons of endoscopic and video-assisted surgical approaches for neck surgery. In our opinion, some points have not been stressed properly. Since its initiation in 1999, the minimally invasive videoassisted thyroidectomy (MIVAT) approach has been widely used for both benign and malignant thyroid lesions in both adult and pediatric patients [1–3]. Although listed as a disadvantage, the operative time for MIVAT resembles that for conventional thyroidectomy after an adequate learning curve period [3]. Both the operative time and the complications rate for MIVAT equal those for open surgery [1–3]. A major criticism is the author’s reported absence of clinical studies investigating the completeness of videoassisted techniques in thyroid cancer. In fact, at least two clinical trials involving patients with lowand intermediate-risk papillary thyroid carcinomas (PTCs) have been reported by our university [4, 5]. We demonstrated that PTC patients who underwent MIVAT had a good outcome during a 5-year follow-up period. The outcome was similar to that for patients treated with conventional thyroidectomy and the same degree of exposure to post-surgical radioactive iodine treatment (I) [5]. Disclosures G. Donatini, G. Materazzi, and P. Miccoli have no conflicts of interest or financial ties to disclose.

Neck lesions mimicking thyroid pathology

IntroductionNodular lesions within the neck may origin from several structures. A misdiagnosed origin may expose the surgeon to inappropriate procedures. These lesions are paradoxically frequent in high specialised centre for endocrine surgery.Patients and methodsIn the year 2006, three patients were first admitted to our department with a diagnosis of thyroid nodule (1) or lymphatic metastases of thyroid carcinoma (2). The first patient had ultrasound (US) and Tc-99-m scan orienting for thyroid nodule. The two other patients, presented with lateral neck lesion in ipsilateral sincronous and previous diagnosis of papillary thyroid carcinoma, respectively, with US and computed tomography scan confirmed lesion but with a FNA cytology negative for tumoural cells.ResultsAll three patients underwent surgical exploration. In the first two cases, a whitish tender nodule (4 and 4.5cm), cleavable from surrounding structures, was removed with final histology of Schwannoma and Paraganglioma, respectively. Both patients experienced Bernard Horner Syndrome. In the last patients, a firm grey nodule of 5cm strictly adherent to muscular planes was removed with diagnosis of Castleman’s Disease.ConclusionsNodular neck lesions mimicking a thyroid pathology (thyroid nodules or metastatic lymph nodes) are rare but can represent a tough challenge for surgeons who might fall into incorrect surgical approaches, resulting in high morbidity. Pre-operative work-up would help the surgeon to obtain the correct diagnosis, thus, to follow the better surgical approach. Nevertheless, a careful approach would be used for that neurogenic tumour amenable of resection without jeopardising nervous structures.

Diagnosis of an Unusual Case of Castleman's Disease

Castleman disease (CD) is a benign angiofollicular lymph node hyperplasia usually found in the mediastinum, but the pelvis is rarely affected. Descriptions of the pelvic CD mainly involve computed tomography (CT) features and focal well-defined masses, while descriptions based on magnetic resonance imaging (MRI) patterns and infiltrating masses are rare. Through a case of a pelvic CD, unusual in its radiological appearance, the authors analyse imaging features as suggested by CT and MRI in order to improve the recognition of this rare disease. 2011 The College of Radiographers. Published by Elsevier Ltd. All rights reserved.

Proteomic approach used in the diagnosis of Riedel's thyroiditis: a case report.

IntroductionRiedels thyroiditis, a rare thyroid disease, can be difficult to diagnose prior to surgical removal and can be confused with malignancy both clinically and cytologically.Case presentationWe report the case of a 72-year-old Caucasian woman who presented with a goiter, which showed a rapid increase in size at ultrasound check, suggesting malignancy. Because of inconclusive cytology, a total thyroidectomy was performed. Fine-needle aspiration of the removed thyroid was processed by two-dimensional electrophoresis, and the proteome was compared with both anaplastic cancer and control samples. Significant differentially expressed protein spots were identified by Western blot analysis by using specific antibodies.ConclusionsThe protein pattern of Riedels fine-needle aspiration revealed a superimposition with that of the control samples. The comparison of the protein pattern of Riedels thyroiditis fine-needle aspiration with that of anaplastic cancer showed evidence of a different expression of ferritin heavy chains, ferritin light chains, and haptoglobins, as previously reported in thyroid cancers. Therefore, we performed Western blot analysis of these proteins and validated that their expression levels were low or absent in Riedels thyroiditis and control samples despite the high concentrations present in fine-needle aspiration anaplastic samples. The concurrent absent or low expression levels of haptoglobin, ferritin light chain, and ferritin heavy chain in Riedels thyroiditis fine-needle aspiration samples strongly indicate the benign nature of the thyroid lesion. These results suggest the potential applicability of fine-needle aspiration proteome analysis for Riedels thyroiditis diagnosis.