Giuseppe Pisano

Intraoperative recurrent laryngeal nerve monitoring in thyroid surgery: is it really useful?

AIM The aim of this study was to evaluate the ability of intraoperative recurrent laryngeal nerve monitoring to predict the postoperative functional outcome and the potential role of this technique in reducing the postoperative nerve palsy rate. MATERIALS AND METHODS Between June 2007 and December 2011, 1693 consecutive patients who underwent thyroidectomy by a single surgical team were evaluated. We compared patients who have had a neuromonitoring and patients who have undergone surgery with the only visualization. Patients in which NIM was not utilized (Group A) were 942 against the others 751 (group B). RESULTS In group A there were 28 recurrent laryngeal nerve injuries (2.97%) of which 21 were transients (2.22%) and 7 were permanents (0.74%). In group B there were 20 recurrent laryngeal nerve injuries (2.66%) of which 14 (1.86%) transients and 6 (0.8%) permanents. Differences between the two groups were not statistically significative. CONCLUSIONS The technique of intraoperative neuromonitoring in thyroid surgery is safe and reliable in excluding postoperative recurrent laryngeal nerve palsy; it has high accuracy, specificity, sensitivity and negative predictive value. Neuromonitoring is useful to identify the recurrent laryngeal nerve and it can be a useful adjunctive technique for reassuring surgeons of the functional integrity of the nerve but it does not decrease the incidence of injuries compared with visualization alone. Its application can be particularly recommended for high-risk thyroidectomies.

Identification alone versus intraoperative neuromonitoring of the recurrent laryngeal nerve during thyroid surgery: experience of 2034 consecutive patients

BackgroundThe aim of this study was to evaluate the ability of intraoperative neuromonitoring in reducing the postoperative recurrent laryngeal nerve palsy rate by a comparison between patients submitted to thyroidectomy with intraoperative neuromonitoring and with routine identification alone.MethodsBetween June 2007 and December 2012, 2034 consecutive patients underwent thyroidectomy by a single surgical team. We compared patients who have had neuromonitoring and patients who have undergone surgery with nerve visualization alone. Patients in which neuromonitoring was not utilized (Group A) were 993, patients in which was utilized (group B) were 1041.ResultsIn group A 28 recurrent laryngeal nerve injuries were observed (2.82%), 21 (2.11%) transient and 7 (0.7%) permanent. In group B 23 recurrent laryngeal nerve injuries were observed (2.21%), in 17 cases (1.63%) transient and in 6 (0.58%) permanent. Differences were not statistically significative.ConclusionsVisual nerve identification remains the gold standard of recurrent laryngeal nerve management in thyroid surgery. Neuromonitoring helps to identify the nerve, in particular in difficult cases, but it did not decrease nerve injuries compared with visualization alone. Future studies are warranted to evaluate the benefit of intraoperative neuromonitoring in thyroidectomy, especially in conditions in which the recurrent nerve is at high risk of injury.

Total thyroidectomy without prophylactic central neck dissection in clinically node-negative papillary thyroid cancer: is it an adequate treatment?

BackgroundCervical lymph node metastases in papillary thyroid cancer are common. Although central neck dissection is indicated in clinically nodal-positive disease, it remains controversial in patients with no clinical evidence of nodal metastasis. The aim of this retrospective study was to determine the outcomes of clinically lymph node-negative patients with papillary thyroid cancer who underwent total thyroidectomy without a central neck dissection, in order to determine the rates of recurrence and reoperation in these patients compared with a group of patients submitted to total thyroidectomy with central neck dissection.MethodsTwo-hundred and eighty-five patients undergoing total thyroidectomy with preoperative diagnosis of papillary thyroid cancer, in the absence of suspicious nodes, were divided in two groups: those who underwent a thyroidectomy only (group A; n = 220) and those who also received a central neck dissection (group B; n = 65).ResultsSix cases (2.1%) of nodal recurrence were observed: 4 in group A and 2 in group B. Tumor histology was associated with risk of recurrence: Hürthle cell-variant and tall cell-variant carcinomas were associated with a high risk of recurrence. Multifocality and extrathyroidal invasion also presented a higher risk, while smaller tumors were at lower risk.ConclusionsThe role of prophylactic central lymph node dissection in the management of papillary thyroid cancer remains controversial. Total thyroidectomy appears to be an adequate treatment for clinically node-negative papillary thyroid cancer. Prophylactic central neck dissection could be considered for the more appropriate selection of patients for radioiodine treatment and should be reserved for high-risk patients only. No clinical or pathological factors are able to predict with any certainty the presence of nodal metastasis. In our experience, tumor size, some histological types, multifocality, and locoregional infiltration are related to an increased risk of recurrence. The potential use of molecular markers will hopefully offer a further strategy to stratify the risk of recurrence in patients with papillary thyroid cancer and allow a more tailored approach to offer prophylactic central neck dissection to patients with the greatest benefit. Multi-institutional larger studies with longer follow-up periods are necessary to draw definitive conclusions.

Differentiated Thyroid Cancer: Indications and Extent of Central Neck Dissection—Our Experience

The aim of this retrospective study was to determine the rate of metastases in the central neck compartment and examine the morbidity and rate of recurrence in patients with differentiated thyroid cancer treated with or without a central neck dissection. Two hundred and fifteen patients undergoing total thyroidectomy with preoperative diagnosis of differentiated thyroid cancer, in the absence of suspicious nodes, were divided in two groups: those who underwent a thyroidectomy only (group A; n = 169) and those who also received a central neck dissection (group B; n = 46). Five cases (2.32%) of nodal recurrence were observed: 3 in group A and 2 in group B. Tumor histology was associated with a risk of recurrence: Hürthle cell-variant and tall cell-variant carcinomas were associated with a high risk of recurrence. Multifocality and extrathyroidal invasion also presented a higher risk, while smaller tumors were at lower risk. The results of this study suggest that prophylactic central neck dissection should be reserved for high-risk patients only. A wider use of immunocytochemical and genetic markers to improve preoperative diagnosis and the development of methods for the intraoperative identification of metastatic lymph nodes will be useful in the future for the improved selection of patients for central neck dissections.

Renal cell carcinoma metastasis to thyroid tumor: a case report and review of the literature

IntroductionMetastatic neoplasms to the thyroid gland are rare in clinical practice. Clear cell renal carcinoma is the most frequent site of origin of thyroid metastases and represents 12 to 34% of all secondary thyroid tumors. Tumor-to-tumor metastases, in which a thyroid neoplasm is the recipient of a metastasis, are exceedingly rare. We report a case of clear cell renal carcinoma metastatic to a follicular adenoma. This is the tenth case of renal cell carcinoma metastasis to thyroid tumor reported in the literature.Case presentationA 62-year-old Caucasian woman with a history of clear cell renal carcinoma was admitted to our institution for multinodular goiter. A histological examination after total thyroidectomy revealed clear cell renal carcinoma metastasis to a thyroid follicular adenoma.ConclusionsPreoperative diagnosis of secondary thyroid neoplasm is difficult to achieve. The diagnosis of metastatic disease should be taken into account if patients have a history of clear cell renal carcinoma or if there is a multifocal growth pattern and clear cell appearance of the cytoplasm.

Intraoperative parathyroid hormone assay during focused parathyroidectomy: the importance of 20 minutes measurement

BackgroundParathyroid hormone (PTH) monitoring during the surgical procedure can confirm the removal of all hyperfunctioning parathyroid tissue, as the half-life of PTH is approximately 5 min. The commonly applied Irvin criterion is reported to correctly predict post-operative calcium levels in 96-98% of patients. However, the PTH baseline reference concentration is markedly influenced by surgical manipulations during preparation of the affected glands, interindividual variability of the PTH half-life and modifications in the physiological state of the patient during surgery. The aim of this study was to evaluate the possible impact of the measurement of intraoperative PTH 20 minutes after surgery.MethodsBetween 2003 and 2012, 188 patients underwent a focused parathyroidectomy associated to rapid intraoperative PTH assay monitoring. Blood samples were collected: 1) at pre-incision time, 2) at 10 min after gland excision and 3) at 20 min after excision, if a sufficient reduction of PTH value was not observed. On the bases of the Irvin criterion, an intra-operative PTH drop>50% from the highest either pre-incision or pre-excision level after parathyroid excision was considered a surgical success.ResultsA >50% decrease of PTH after gland excision compared to the highest pre-excision value occurred in 156/188 patients (83%) within 10 min and in further 12/188 after 20 minutes (6.4%). In the remaining 20 patients (10.6%) values of PTH remained substantially unchanged or decreased less than 50% and for this reason bilateral neck exploration was performed. An additional pathologic parathyroid was removed in 9 cases, a third in one. In the other 10 cases further neck exploration by a standard cervical approach was negative and in four of these persistent postoperative hypercalcemia was demonstrated. The overall operative success was 97.3%. Intraoperative PTH monitoring was accurate in predicting operative success or failure in 96.3% of patients.ConclusionsThe 20 minutes PTH measurement appears very useful, avoiding unnecessary bilateral exploration and the related risk of complications with only a slight increase of the duration of surgery and of the costs. PTH values decreasing appeared to be influenced by surgical manipulations during minimally invasive parathyroidectomy.

Role of intraoperative neuromonitoring of recurrent laryngeal nerves in the outcomes of surgery for thyroid cancer.

INTRODUCTION The aim of this retrospective study was to evaluate the ability of intraoperative neuromonitoring to predict the postoperative functional outcome and its role in reducing the postoperative recurrent laryngeal nerve palsy rate during thyroidectomy for thyroid malignancy. METHODS Between June 2007 and March 2013, 656 consecutive patients with thyroid cancer underwent thyroidectomy by a single surgical team. We compared 357 patients who have had neuromonitoring (Group A) to 299 patients who have undergone surgery with nerve visualization alone (group B). RESULTS In group A 7 recurrent laryngeal nerve paralysis were observed (1.96%), 6 (1.68%) transient and 1 (0.28%) permanent; a bilateral recurrent laryngeal palsy was observed in 1 of the 7 cases (0.28%). In group B 6 recurrent laryngeal nerve paralysis were observed (2.01%), 5 (2.01%) transient and 1 permanent (0.33%); bilateral palsy was observed in 1 of the 6 cases (0.33%). Differences were not statistically significative. CONCLUSIONS Routine visual nerve identification remains the gold standard of recurrent laryngeal nerve management in surgery for thyroid cancer. Intraoperative neuromonitoring is safe, effective, reliable, and easy to perform in excluding postoperative recurrent laryngeal palsy. It helps to identify the nerve in thyroid cancer, but it did not decrease the injuries compared with visualization alone in this study; however, its use can change the operative strategy in order to prevent the risk of bilateral damage in case of signal loss. Future studies are needed to evaluate the benefit of intraoperative neuromonitoring in thyroidectomy for thyroid cancer.

Late bleeding after total thyroidectomy; report of two cases occurring 13 days after operation.

Postoperative hematoma is a rare but potentially life-threatening and unpredictable complication of thyroid surgery. We report two cases of very late postoperative bleeding occurring on the 13th postoperative day in patients treated with low-molecularweight heparin and acenocoumarol. Patient 1 was readmitted with complaints of progressive anterior neck swelling and bleeding from the cervical wound without respiratory distress. The patient had restarted therapy with Acenocoumarol associated with Nadroparin one day before. Under general anesthesia, cervical exploration allowed detection of a superficial hematoma. Patient 2 returned to our institution with subhyoid ecchymosis and moderate blood loss from the left drainage wound. The patient underwent drainage and was treated conservatively. Although most bleeding occurs within 24 hours, caution should be taken in patients on oral anticoagulants and low-molecular weight heparin and close monitoring should also be advised at home after discharge, particularly if anticoagulant therapy has restarted.

Surgery for Primary Hyperparathyroidism in Patients with Preoperatively Negative Sestamibi Scan and Discordant Imaging Studies: The Usefulness of Intraoperative Parathyroid Hormone Monitoring

The aim of this study was to evaluate the impact of intraoperative parathyroid hormone (PTH) monitoring on surgical strategy, intraoperative findings, and outcome in patients with negative sestamibi scintigraphy and with discordant imaging studies. We divided our 175 patients into 3 groups: group A was methoxyisobutylisonitrile (MIBI)-positive and ultrasonography positive and was concordant (114 patients), group B was MIBI-positive and ultrasonography-negative (50 patients), and group C was MIBI–-and ultrasonography-negative (11 patients). The overall operative success was 99.12% in group A, 98% in group B, and 90.91% in group C, with an incidence of multiglandular disease of 3.5% in group A, 12% in group B, and 9.09% in group C. Intraoperative PTH monitoring changed the operative management in 2.63% of patients in group A and 14% in group B. The use of intraoperative PTH achieves to obtain excellent results in the treatment of primary hyperparathyroidism in high-volume centers, even in the most difficult cases, during MIBI-negative and discordant preoperative imaging studies.

Differentiated thyroid cancer in the elderly: our experience.

INTRODUCTION The objective of this retrospective study was to investigate clinical and pathologic characteristics of differentiated thyroid cancer in elderly patients and to evaluate the results of surgical treatment in this age group. METHODS The clinical records of patients who underwent total thyroidectomy between 2002 and 2012 with histopathological diagnosis of differentiated thyroid cancer were analyzed. Patients were divided into two groups: those 65 years old or older were included in group A (101), those younger in group B (354). RESULTS The mean surgical time was 100.9 ± 30.5 min in group A and 100.7 ± 27.6 in B. Postoperative stay was significantly longer in group A (2.8 ± 1.5 days vs 2.4 ± 0.7; p < 0.01). Classic papillary carcinoma was more frequent in group B, whereas follicular variant of papillary carcinoma and tall cell carcinoma in A. In group B node metastases were nearly twice. In Group A transient hypoparathyroidism occurred in 25 patients (24.8%), permanent hypoparathyroidism in 4 (4%), hematoma in 6 (5.9%), recurrent nerve palsy in 2 (2%), and wound infection in 2 (2%). In group B transient and permanent hypoparathyroidism occurred in 48 and 7 patients respectively (13.6% and 2%), hematoma in 4 (1.1%), recurrent nerve palsy in 5 (1.4%), and wound infection in 1 (0.3%). CONCLUSIONS Differentiated thyroid carcinoma is more aggressive in elderly patients for biological causes connected to age and to histotype but also for the diagnostic delay. Thyroid surgery in elderly patients is safe when the procedure is carried out by experienced staff. Total thyroidectomy is the surgical operation of choice.