R. Dzodic

Sentinel lymph node concept in differentiated thyroid cancer

Introduction: Differentiated thyroid carcinoma (DTC) account up to 90% of all thyroid malignacies, and represents the most common malignant tumors of endocrine system. The incidence of papillary thyroid carcinoma (PTC), especially small tumors is rapidly increasing during past three decades. At the time of diagnosis, the incidence of lymph node metastases (LNM) ranges from 80 to 90%. During the last 15 years, LNM were recognized as bad prognostic factor for both local-regional relapse (LRR) and cancer specific survival. There is general agreement that neck dissections are indicated in cases of clinically apparent LNM. The subject of the current controversy is the surgical treatment of occult LNM that remain unrecognized on preoperative diagnosis (cN0). The extent of operations of the lymph nodes ranges from “wait and see” so-called “Western school” principle substantiated the role of applying ablative I131therapy and frequency peroperative complications (recurrent laryngeal nerve injury and hypoparathyroidism), especially for less experienced teams to mutual prophylactic dissection of the central and lateral compartments so-called “Japanese school” due to the limited use of radioactive iodine therapy and significantly lower operating morbidity if dissetion was done during primary operation. Despite high prevalence of occult LNM, existing controversies regarding diagnosis, longterm prognostic impact and extent of lymph node surgery, motivated some authors to apply consept of sentinel lymph node biopsy (SLNb) in DTC, taking into account excellent results of SLN concept in breast cancer and skin melanoma. This review presents the summarized results of relevant studies and three meta-analysis of accuracy and applicability of SLN concept in patients with differentiated thyroid carcinoma.

539. Recurrent Laryngeal Nerve Reconstruction After Resection During the Operation of Locally Advanced Thyroid Cancer

S 887 MNGs,31 adenomas and 9 cysts.Out of 165 cancer cases 109 were papillary,20 follicular,46 mixed type and 5 medullary.18 had intrathorasic extensions.Using single ipsilateral incision 40 hemithyroidectomies,70 total thyroidectomies of benign and 55 early cancers were done.Central compartment clearance done in cancers. Bilateral approach used in 110 cases of carcinomas requiring bilateral node dissection and for 8 cases of bilateral intrathorasic extensions. Parathyroids were dissected pulvurised and injected into Sternocleidomastoid muscle before dissection. Results: Blood loss was 10-15 ml and hospital stay 24 hrs.There were no nerve injuries.Parathyroid deficiency was reported in 10/283. 165 thyroidectomies (115 total) were performed with single lateral incision. Within 6 months scar disappeared, sensory stimuli returned to normal giving excellent cosmesis and quality of life. Conclusions: ’Minimally invasive open Thyroidectomy’*’Thomas technique’, is a novel method applicable for all thyroid neoplasms . Avoidance of ’handling’ of the gland upfront,better accessibility and direct vision of nerves, ligation of vascular pedicles upfront, makes this approach unique and ’bloodless’.New technique facilitate better lymph adenectomy than anterior approach, is safest for intrathorasic extensions and even forTotal thyroidectomy with single lateral incision. Complications described in the literature are minimised with superior cosmetic results compared to Kocher~ Os technique. 539. Recurrent Laryngeal Nerve Reconstruction After Resection During the Operation of Locally Advanced Thyroid Cancer I. Markovic, R. Dzodic, I. Djurisic, M. Buta, M. Oruci, S. Nikolic, S. Petrovic, M. Mitrovic, M. Jevric, G. Pupic 1 Institute of Radiology and Oncology, Surgery, Belgrade, Serbia Background: Recurrent laryngeal nerve (RLN) palsy is a major obstacle in thyroid and parathyroid surgery. Permanent RLN paralysis was reported in 0.5 to 10% of cases. RLN injuries are more frequent during the operation and reoperations of cancer and recurrent goiter. In locally advanced thyroid cancer RLN could be infiltrated by tumor or lymph node metastases in paratracheal region. Primary objective is to achieve complete resection of tumor and lymph nodes. Resection of RLN in length of infiltration is sometimes necessary. Secondary goal during the operations is to improve phonation. A method of RLN reconstruction depends on type of injury. If end-to-end suture is not possible, anastomosis of proximal end of RLN with ansa cervicalis (ARA) using Miyauchi technique could be performed. Patient and Methods: A female patient in middle forties who was admitted to our Institute due to locally advanced multifocal papillary thyroid cancer with bulk lymph node metastases in both central and lateral neck compartments. Total thyroidectomy, central and bilateral modified radical neck dissections were performed using classic neck and modified McFee incisions. Right RLN was infiltrated about 3 cm in length up to its entrance into the larynx. Block resection of right lobe and paratracheal LNM was performed. Immediate ARA reconstruction with 6-0 resorbable sutures followed the operation. Results: The rate of RLN recovery was verified by postoperative direct laryngoscopy. It is important to underline that if the nerves were reconstructed by sutures vocal cords don‘t regain normal movement and are usually fixed in the median position. The patient‘s voice improves because reinervated cords recover from atrophy and restore tension during phonation which is shown on audio recording. Conclusion: Nerve reconstruction is strongly suggested in cases of planed or accidental resection. The ultimate method to evaluate quantitatively the voice recovery is the maximum phonation time. 541. Incidental Parathyroidectomy During Total Thyroidectomy G. Katsouli, O. Ignatova, G. Chinari, N. Perrakis, G. Tassopoulos, N. Petridis, P. Sarof, J. Nomikos, P. Arapantoni, K. Ntatsis Metaxa Cancer Hospital, Surgery, Piraeus, Greece Metaxa Cancer Hospital, Pathology, Piraeus, Greece Metaxa Cancer Hospital, Head and Neck Surgery, Piraeus, Greece Objectives: A retrospective study of the Second Department of Surgery and ENT Department of METAXA Cancer Hospital, in order to identify the degree of correlation of the presence parathyroid tissue in the thyroid specimens after elective total thyroidectomy. Patients-Methods: 183 cases of total thyroidectomy have been evaluated between 10/2009 and 10/2011.Preoperative calcium, phosphorus, PTH, FT3, FT4, TSH levels, Ultrasound, CT, R* Chest and FNA were reviewed in this patients. 36 of the 183 were males between 22 to 85 years old and 147 were females between 20 to 82 years old. This study evaluated the histopathological findings of total thyroidectomy. The presence or absence of parathyroid gland in the surgical thyroid specimen is reviewed. Results: 78 cases out of 183 patients confirmed thyroid malignancy. Among these 78 cases of thyroid malignancy, parathyroid tissue was found in 25 thyroid specimens. Among the 105 patients with benign disease, 14 with parathyroid tissue have been detected. Statistical evaluation with the X test proves a statistically significant relationship between malignancy and inadverted parathyroidectomy in total thyroid resection (0,001<P<0,01). Conclusion: The inadverted parathyroidectomy is noted frequently after total thyroidectomy with underlying malignancy. The suspicion of malignancy probably influences the surgeon to more radical resection.In literature is confirmed the findings of this study. There are also opposite results. 543. Evaluation of Effective Clinicopathologic Factors on Patients Outcome with Well Differentiated Thyroid Carcinoma A. Fanipakdel, H. Saidisaedi, S. Shahidsales, S.S. Roodbari 1 Omid Hospital, Radiotherapy-Oncology, Mashad, Iran 2 Razi Hospital, Radiotherapy-Oncology, Rasht, Iran Kowsar Hospital, Surgery, Astaneh Ashrafieh, Iran Introduction: Thyroid cancer is the most common cancer of endocrine system. Clinical, pathological and therapeutic factors affect patients’ outcome with differentiated thyroid carcinoma. The aim of this study was evaluation of the effective clinicopathologic factors on patients’ outcome with well differentiated thyroid carcinoma. Materials and Methods: In this retrospective analytic-descriptive study, patients’ files with thyroid carcinoma who referred to radiology-oncology departments in Omid and Ghaem hospital of Mashhad,Iran, were assessed from 1996-2006. Cases with pathologic report of papillary and follicular carcinoma were considered and a specific questionnaire including age, sex,time of admission, pathologic subtype, tumor size and metastases, adjuvant treatment, recurrence time, patient’s condition in the last visit and death time were recorded. Results: The patients’ mean age was 50.14 and median age was 52 years. Sixty patients (85.7%) had papillary and 11 cases (14.3%) had follicular carcinoma. End condition in 43 cases (55.8%) was good and in 34 cases (44.2%) was bad. Mean survival time was 44.1 and median survival time was 36 months. There was a significant association between T stage with end condition (P1⁄40.037) but there was no significant association between N stage with end condition (P1⁄40.665). Metastases at the time of the first visit had a significant correlation with patients outcome. 41patients (59.4%) from 69 cases with M0 disease had a good end condition versus only one patient (16.7%) from 6 cases with M1 disease with a good outcome

230. The significance of HER-2 amplification and the size and type of pathological unicentric, initially operable clinical stage I and IIA/IIB breast cancer, in determining the treatment strategy

PURPOSE In order to determine the initial treatment strategies for primary operable unicentric breast cancer, the possible relationships of the amplification of human epidermal growth-factor receptor-2 (HER-2), with age, menstrual status, tumor pathological size (pT), histopathological tumor type (HP) and kind of surgical treatment were studied. METHODS Analysed were 301 patients treated initially by surgery in the period 2006-2009. HP tumor type, pT and HER-2 status (using firstly immunohistochemistry and then chromogenic in situ hybridization/CISH) were determined. The patients were divided into 2 subgroups according to the presence (CISH+)/absence (CISH-) of HER-2 amplification. RESULTS Data on pT and HER-2 analyses were available for 293/301 (98.3%) patients with ductal (DC) and lobular carcinoma (LC). Amplification of HER-2 was found in 66 (21.9%) patients. No significant difference between the two subgroups regarding age (p=0.08), menstrual status (p>0.05) and kind of operation (p>0.05) was found. HP showed statistically significant difference between DC (55; 83.3%) and LC (11; 16.7%) patients with HER-2 amplification (p<0.01). Further HP analysis of the type of cancer within the pT category as a subgroup showed significantly higher frequency of HER-2 amplification in DC patients for pT1 (p<0.01) and in pT2 + pT3pN0 (p<0.05) compared with patients with LC. CONCLUSION This study showed a significantly higher incidence of HER-2 amplification in DC tumors, especially in pT1 and pT2, than in LC, which may influence the options in treatment strategies in primary unicentric operable DC type of breast cancer.