Roberta Lucchini

Surgical morbidity of cervical lymphadenectomy for thyroid cancer: A retrospective cohort study over 25 years.

INTRODUCTION Prognosis of thyroid cancer is strictly related to loco-regional metastases. Cervical lymphadenectomy has a specific oncologic role but may lead to significant increase of morbidity. Aim of the study is the analysis of surgical morbidity in cervical lymphadenectomy for thyroid cancer. METHODS We retrospectively analyzed 1.765 thyroid cancers operated over a period of 25 years at S. Maria University Hospital, Terni, University of Perugia, Italy. Type of lymphadenectomy, histology and complications were analysed. RESULTS A prevalence of differentiated and medullary cancers was observed (respectively 88% and 7.2%). Central lymphadenectomy was carried out in 425 patients, lateral modified and radical lymphadenectomy respectively in 651 and 17 cases. Following central neck dissection we observed: bilateral and unilateral temporary recurrent nerves palsy respectively of 0.7% and 3.5%, unilateral permanent palsy in 1.6% of cases, temporary and permanent hypoparathyroidism respectively in 17.6% and 4.4%. After lateral neck dissection we observed: intra and post-operative haemorrhage respectively in 2% and 0.29%, respiratory distress in 0.29%, lesions of facial nerve in 0.44%, of vagus in 0.14%, of phrenic nerve in 0.14%, of hypoglossal nerve in 0.29%, of the accessory nerve, transient in 1.34% and permanent in 0.29%, permanent lesion of cervical plexus in 0.29%, salivary fistula in 0.14% and chylous fistula in 1.04% of patients. Students t test was used to compare groups when appliable. CONCLUSION Central and lateral cervical lymph node dissection are associated to severe morbidity. Correct indication, surgical expertise, high volume of patients and early multidisciplinary management of complications is the key of an acceptable balance between oncologic benefits and surgical morbidity.

A Gelatin–Thrombin Matrix Topical Hemostatic Agent (Floseal) in Combination With Harmonic Scalpel Is Effective in Patients Undergoing Total Thyroidectomy A Prospective, Multicenter, Single-Blind, Randomized Controlled Trial

Background. Hemostasis during thyroidectomy is essential; however, the safest, most efficient, and most cost-effective way to achieve this is unclear. This randomized, multicenter, single-blind, prospective study evaluated the efficacy and safety of using different hemostatic approaches in patients undergoing total thyroidectomy. Methods. Patients aged ≥18 to 70 years were randomized to Floseal + a harmonic scalpel (HS), Floseal alone, HS alone, or standard total thyroidectomy. Primary endpoint was 24-hour drain output. Secondary endpoints included surgery duration and complications. Results. Two hundred and six patients were randomized to Floseal + HS (n = 52), Floseal alone (n = 54), HS alone (n = 50), and standard total thyroidectomy (n = 50). The 24-hour drain output was lower in the Floseal + HS group compared with standard thyroidectomy. Floseal + HS also had a shorter surgery time (P < .0001) versus the other 3 treatments. Conclusion. Floseal + HS can be effective at reducing postsurgical drain output and provides a complementary hemostatic approach in patients undergoing total thyroidectomy.

Thyroid cancer invading the airway: diagnosis and management.

INTRODUCTION Aim of this study is to analyze outcome and the decision making process to approach airway invasion by thyroid tumors. METHODS Retrospective study of 30 years experience in thyroid surgery for cancer invading airway. Clinical records, surgical and pathology reports have been analyzed to assess which principles and procedural details are significant to facilitate efficient diagnosis, staging and treatment. Medical therapy was not evaluated. RESULTS Out of a consecutive series of 2165 thyroid cancer patients, T4a cancers are 303 (14%). Airway invasion was found in 141 (6.5%) cases. Well-differentiated pattern was determined in 110 (78%) while other histology was reported in 31 (22%). Airway-related symptoms have been recorded in 111 (78%) patients. Flexible bronchoscopy was performed in all patients. Rapidly evolving disease or non-resectable airway was found in 105 (74.5%) cases. Permanent tracheotomy was performed in 43 (30.5%) cases, airway lumen restoration with or without stenting in 39 (27.7%), laryngectomy in 8 (5.7%), segmental airway resection and reconstruction in 28 (19.9%). Perioperative mortality was recorded after palliative treatment only. In resected patients, completely radical surgery was not always achievable. All patients with positive margin after resection underwent adjuvant treatment and showed comparable survival to radical surgery patients after 5 years. Tumor relapse occurred in 8 (28.6%) cases (distant or locoregional). Patients with unresectable disease require treatment for symptoms relief but survival is poor. CONCLUSION Although some patients are currently referred with a severely advanced disease, the indication for tracheotomy, salvage procedures or supportive care has decreased over time. Resection is feasible for differentiated tumors with an overall good outcome.

The role of surgery in the treatment of thyroid anaplastic carcinoma in the elderly

INTRODUCTION Anaplastic thyroid carcinoma (ATC) is characterized by local invasiveness, risk of recurrence and very poor prognosis. METHODS We retrospectively analysed the multimodality treatment of ATC in 79 patients considering the impact of surgery on survival. RESULTS Patients were divided in two age groups A and B (cut-off 75 years) and in two size subgroups (cut-off 5 cm). Surgery was performed in 78.5% patients of group A and 32.4% of B (p < 0.05). Radiation respectively in 73.8% and 43.2% (p < 0.05). Tracheostomy and endoprosthesis were used in 45.2% and 16.6% in group A and in 43.2% and 35.1% in group B. The use of tracheostomy was significantly higher (p < 0.05) in larger tumours. In group B comparing operated and not operated patients significant difference in survival was observed for larger tumours (p = 0.043). In Kaplan Meir analysis significant difference in survival was observed comparing surgical and no surgical patients of all four subgroups. Surgery plus radiotherapy offered a significant better outcome in smaller tumours (p = 0.017). Considering the effect of the single treatment, compared to no treatment at all, survival is significantly improved by surgery for smaller and larger tumours respectively with 4.42 (p = 0.001) and with 3.5 months (p = 0.0001) and by radiotherapy respectively with 3.44 and with 3.28 months (p = 0.047 and p = 0.0001). CONCLUSION In elderly patients with ATC, although poor prognosis, surgery is still fundamental in the multimodality treatment with significant advantage in selected patients. Nevertheless most of elderly patients with large tumours are suitable only for palliative management.

Breast cancer micrometastasis and axillary sentinel lymph nodes frozen section. Our experience and review of literature

BACKGROUND Sentinel lymph node (SLN) biopsy plays a major role in the surgical management of primary breast cancer. The aim of this study was to assess the diagnostic accuracy of the assessment of axillary frozen sections of SLNs for micrometastasis diagnosis. PATIENTS AND METHODS This study focused on 250 SLNs from 137 patients. Each lymph node was fully analyzed by frozen section. After fixation, serial sections were cut and stained by hematoxylin and eosin (HE) and for pan-cytokeratins by immunohistochemistry (IHC). RESULTS Tumor cells were detected in 57 SLNs, 37 on frozen sections and 20 on controls. Of these 57 positive SLNs, 38 contained metastases, 9 contained micrometastases and 10 contained isolated tumor cells. The specificity and positive predictive value of SLN frozen sections for micrometastasis was 100%. The sensitivity was 83.3% for metastasis, 40% for micrometastasis; the false-negative rate was 16.7% for metastasis and 60% for micrometastasis. CONCLUSION Analysis of frozen section of SLNs is an accurate method for metastasis detection, allowing concurrent axillary dissection when positive. The protocol for SLN analyses described herein shows good sensitivity for micrometastasis detection.

The forgotten goiter: casuistic contribution and considerations for the choice of surgical approach

Aim. A residual mediastinal thyroid (“forgotten goiter”) is a well-known, though uncommon, complication of total thyroidectomy. Materials of study. The authors analyze their experience with three cases of goiter forgotten, observed in a series of 2946 thyroid resections in the period 2005–2010. In the study, a preoperative CT of the chest with three-dimensional reconstruction was always performed to examine the topographical relationships of the lesion. Excision was performed through cervicotomy, cervicosternotomic approach and cervicosternotomy, and posterolateral right thoracotomy. Results. There were no complications. Histological examination was suggestive of malignancy in one case (follicular carcinoma with pulmonary metastases). Discussion. The indication for surgery in cases of forgotten goiter is intrinsic to the diagnosis. Preoperative evaluation with accurate topographic imaging is required in all cases in order to understand the nature and location of mediastinal pathological tissue and to identify the most suitable access route. The cervicotomy is the ideal access for low surgical trauma and is easily extendable into a partial or complete sternotomy. A thoracotomy, on the other hand, which is usually reserved for the right side, must be planned preoperatively.

Surgical treatment of secondary hyperparathyroidism in elderly patients: an institutional experience

BackgroundSecondary hyperparathyroidism in elderly fragile patients presents clinical difficulties due to severity of symptoms and related comorbidity. The optimal surgical approach for this group of patients is still debated.AimThe aim of the study was to define the optimal technique of parathyroidectomy in elderly patients with secondary hyperparathyroidism.MethodsRetrospective analysis in a series of 253 patients including 35 elderly individuals at a single institution was carried out. Postoperative parathyroid hormone decrease, surgical complications and symptoms control were analyzed for all patients in relation to the types of parathyroidectomy performed.Results In elderly patients, total parathyroidectomy was the most used approach. Subtotal parathyroidectomy was mostly reserved for younger patients suitable for kidney transplantation. No elderly patients treated with total parathyroidectomy were autotransplanted. No significant difference in surgical complications was observed between younger and elderly patients and considering the different procedures. Adequate symptom control after surgery was achieved in almost 90% of patients. A limited rate of recurrence requiring repeat surgery was observed only after subtotal parathyroidectomy.DiscussionConsidering the features of all types of parathyroidectomy, very low recurrence rate, contained postoperative hypocalcemia and limited complications following total parathyroidectomy, might represent specific advantages for elderly patients.ConclusionsTotal parathyroidectomy without parathyroid transplantation is safe for elderly patients with secondary hyperparathyroidism and a good alternative to the well-established total parathyroidectomy with autografting.

Surgical approach to mediastinal goiter: An update based on a retrospective cohort study

AIM Surgery for mediastinal goiters (MG) is indicated for compression symptoms and risk of malignancy. Total thyroidectomy by cervicotomy is universally considered the standard surgical approach to MG. In selected cases sternotomy or a thoracotomy are used. Options of the operative technique and practical surgical problems are analysed. METHODS A retrospective analysis of twenty-eight-years on 1767 cases of MG in a referral centre for endocrine surgery was carried out. All patients underwent standard preoperative study and CT based surgical planning. Surgery was performed by an experienced surgical team with standard technique via cervical approach or in selected case via sternotomy or thoracotomy. Clinical records were examined. RESULTS Total thyroidectomy was performed in all cases. A cervical approach was used in almost 99% of patients. Significant shorter surgical time was observed for surgery via the cervical approach vs sternotomy and thoracotomy. Benign struma was observed in 1503 patients and a carcinoma in 264. We observed postoperative bleeding in 0.5% of cases, permanent monolateral recurrent laryngeal nerve palsy occurred in 1.3%, bilateral palsy in 0.6%, transient and permanent hypoparathyroidism in 14% and 4.1% respectively. CONCLUSION MG may be approached by a cervicotomic access only with a clear knowledge of potential risk and complications of the surgical manoeuvres. Sternotomy or of a thoracotomy are indicated only in selected cases but their inapplicability may be really dangerous in those MG not otherwise resectable. MG should be referred only to specialized centre.

Surgical management of mediastinal goiter in the elderly

AIM Mediastinal goiter (MG) is characterized by compression symptoms such choking, dyspnea, sleeping apnea and dysphagia. It is significantly observed in elderly patients who due to comorbidity are associated to increased surgical risk. Total thyroidectomy is indicated to treat tracheal compression. Cervicotomy is the most used surgical access. AIM of the study was the evaluation of the role of surgery in the treatment of MG in the elderly. METHODS A retrospective analysis of twenty-eight-years on 1721 (390 over 80-years-old) cases of MG in a referral center for endocrine surgery was carried out. CT was used as a standard in the preoperative study. Surgery was performed by an experienced surgical team with standard technique via cervical approach or in selected cases via sternotomy or thoracotomy. Clinical records were examined. RESULTS Patients were divided into two groups: older and younger than 80-years-old. Total thyroidectomy was performed in all cases and via a cervical approach in almost 99% of patients. Tracheal dislocation and tracheomalacia were prevalent in elderly patients and were treated conservatively. Benign struma was observed in 1463 patients and a carcinoma in 258. Larger thyroid weight was observed in the elderly. The rate of complications was similar between groups. CONCLUSION Total thyroidectomy via cervical approach is the treatment of choice for MG in the elderly. It should be treated only in referral centers with adequate caution for elderly patients to achieve complete cure with limited complications.

Persistent hypercalcitoninemia in patients with medullary thyroid cancer

Medullary thyroid carcinoma is a highly malignant and progressive disease. Surgery is the only effective treatment. Calcitonin is a significant marker for medullary thyroid carcinoma, and due to its sensitivity it represents a useful tool for the follow-up. The outcome of patients affected by medullary thyroid carcinoma depends on tumor size, lymph node involvement, and adequacy of primary surgical management. In the present study, the authors reviewed their own experience in the cure of medullary thyroid carcinoma. Forty-one patients operated for sporadic medullary thyroid carcinoma were included. Indications for surgery, inclusive of lymphectomy techniques, timing of redo surgery, and the meaning of calcitonin levels in highlighting disease are extensively discussed. Patients with elevated calcitonin levels and favorable outcome are considered, together with the various diagnostic tools to be employed during patient workup.