Guglielmo Ardito

Radio-guided surgery for lymph node recurrences of differentiated thyroid cancer

The objectives of this study were to assess the reliability of radioiodine (131I) and a gamma probe for radio-guided surgery (RGS) to detect and then radically dissect lymph node recurrences (LNRs) in 10 patients with differentiated thyroid cancer (DTC). The major inclusion criterion was the presence of an iodine-positive LNR after previous total thyroidectomy and at least two ineffective 131I treatments. The protocol was designed as follows. Day 0: all patients were hospitalized and received 3.7 GBq of 131I in the hypothyroid condition. Day 3: presurgery whole-body scan with a therapeutic dose (TxWBS). Day 5: neck surgery using a gamma probe (Navigator GPS, AutoSuture, Italy), recording the absolute counts and the lesion/background (L/B) counts ratio. Day 7: post-surgery TxWBS performed using the remaining radioactivity. The presurgery TxWBS was positive in all patients, and the post-surgery TxWBS showed a negative pattern in 7 of 10 patients, suggesting the efficacy of the surgical procedure in most of the patients. After RGS the mean decrease in the absolute counts and the L/B counts ratio were 77.6% (52.7% minimum, 94.6% maximum) and 77.4% (52.3% minimum, 94.8% maximum), respectively. After operation the surgeon judged the procedure to be decisive in two patients, favorable in six, and irrelevant in two. The final histologic examination showed the presence of 78 lymph node metastases (mean of 8 per patient). There were 33 neoplastic lesions found by both TxWBS and gamma probe evaluations; 41 were shown only by gamma probe, and 4 were negative by both TxWBS and gamma probe evaluations. This protocol permitted us to look for neoplastic foci with high sensitivity and specificity, and we were able to remove lymph node metastases resistant to radioiodine therapy at a single session. The protocol also allowed detection of some additional tumoral foci in sclerotic areas or behind vascular structures that are difficult to identify and were not seen at the presurgery TxWBS evaluation. However, because of the possible false-negative results, complete excision must be undertaken in high risk patients with a local recurrence to eradicate the largest number of lymph nodes, independent of the counts measured by the gamma probe.

Aggressive papillary thyroid microcarcinoma: prognostic factors and therapeutic strategy.

Background and Aim Papillary thyroid carcinomas smaller than 1 cm are classified as papillary microcarcinomas (PMCs). Papillary microcarcinomas are usually considered low-risk tumors; however in some cases, PMCs behave aggressively and metastasize early, giving rise to clinically metastatic disease. Debate exists in the literature about prognostic factors and therapeutic management to PMC. We report here the long-term experience of our referral center for malignant thyroid disease. Methods We retrospectively analyzed 149 consecutive patients with PMC who underwent surgery at our institution between 2000 and 2005; 49 of them (33% of cases) were treated also with radioiodine therapy. Clinical and histopathological parameters potentially predicting patient outcome and recurrent disease were statistically investigated, after a minimum follow-up of 5 years. Results After a median follow-up of 5.4 years (range, 5–11 years), 28 (19%) of 149 patients experienced recurrent disease. All of them were reoperated on and newly treated with radioiodine administration. Of these 28 patients, 27 are living without disease, whereas 1 patient died due to metastatic thyroid cancer to lungs. The multivariate statistical analysis identified extrathyroid invasion (odds ratio [OR], 58.54; P = 0.013), the solid pattern (OR, 25.77; P < 0.001), the tumor multifocality (OR, 15.80; P = 0.005), and the absence of tumor capsule (OR, 9.74; P = 0.015) as significant and independent risk factors for the appearance of PMC recurrences. Of note, in most patients who experienced recurrent disease, the PMC had been diagnosed preoperatively and often for the presence of cervical clinically evident lymphadenopathy. On the other hand, none of the PMC “incidentally” discovered at histopathological examination alone experienced recurrent disease during follow-up. Conclusions Although most PMCs have an indolent course, there is a fraction (19% in our series) of patients with PMC and aggressive behavior strongly correlated with some histopathological features (extrathyroid invasion, solid pattern, tumor multifocality, and absence of a capsule) who need to be individualized and for whom a radical therapeutic approach is recommended based on total thyroidectomy and lymphadenectomy followed by radioiodine administration.

Fine needle aspiration of a Warthin-like thyroid tumor : Report of a case with differential diagnostic criteria vs. other lymphocyte-rich thyroid lesions

BACKGROUND Warthin-like papillary carcinoma of the thyroid (WLT), a recently described entity, should be included among lymphocyterich lesions of the thyroid. The diffuse sclerosing variant of papillary carcinoma (DSV), the oxyphilic variant of Hashimoto thyroiditis (OHT) and primary lymphoplasmacytic lymphoma (PLT), the FNA appearances of which have many similarities, belong to the same category. CASE REPORT A case of WLT occurred in a 31-year-old female, who was admitted with a 1.5-cm, nodular lesion of the thyroid; fine needle aspiration (FNA) yielded a diagnosis of papillary carcinoma. Histologic examination revealed the characteristic picture of WLT, with papillae lined with large, oxyphilic thyreocytes, with nuclear pseudoinclusions and grooves filled with lymphocytes, mostly mature plasma cells. The FNA picture of WLT was compared with those of the other lymphocyticrich lesions of the thyroid--DSV, OHT and PLT. CONCLUSION The differences between these forms provide diagnostic criteria that could be useful for the preoperative management of patients affected by suspicious, inflammation like thyroid lesions.

Radioguided parathyroidectomy in forearm graft for recurrent hyperparathyroidism

We report a peculiar case of recurrent hyperparathyroidism caused by hyperplasia of a forearm graft implanted following a total parathyroidectomy in a 38-year-old patient with chronic renal failure. The forearm graft hyperplasia was detected using (99)Tc(m)-sestamibi scanning, which identified hyperplastic transplanted parathyroid tissue in the forearm of the patient. During the initial surgery, the surgeon failed to mark the parathyroid tissue with sutures or clips to facilitate locating it. Therefore, we referred the patient for radioguided surgery. This surgical procedure allowed us to locate and completely remove the hyperfunctioning transplanted parathyroid tissue.

Diagnostic Lobectomy for Unilateral Follicular Nodules of the Thyroid Gland

We describe our technique of diagnostic lobectomy (DL) and the rationale it is based on. We define DL as a minimally invasive procedure consisting of total lobectomy and isthmusectomy, with preservation of the omolateral recurrent laryngeal nerve and parathyroid glands, but without digital exploration of the contralateral lobe. The fact that re-entry into the previously explored field to complete thyroidectomy increases the risk of complications must be taken into consideration. The subjects were 63 consecutive patients who underwent surgery for unilobar follicular neoplasms of the thyroid gland between January 1997 and December 2002. There were 49 follicular adenomas and 14 carcinomas. In the 14 patients with thyroid cancer, total thyroidectomy was performed within 2 weeks after the first operation in a sterile environment with normal anatomical cleavage plains, avoiding any risk of injury to the laryngeal nerves and parathyroid glands. It is concluded that DL is a safe and suitable surgical procedure for patients with follicular-structured lesions of the thyroid gland.