Rocco Domenico Alfonso Bellantone

Electrophysiologic recurrent laryngeal nerve monitoring during thyroid and parathyroid surgery: International standards guideline statement

Intraoperative neural monitoring (IONM) during thyroid and parathyroid surgery has gained widespread acceptance as an adjunct to the gold standard of visual nerve identification. Despite the increasing use of IONM, review of the literature and clinical experience confirms there is little uniformity in application of and results from nerve monitoring across different centers. We provide a review of the literature and cumulative experience of the multidisciplinary International Neural Monitoring Study Group with IONM spanning nearly 15 years. The study group focused its initial work on formulation of standards in IONM as it relates to important areas: 1) standards of equipment setup/endotracheal tube placement and 2) standards of loss of signal evaluation/intraoperative problem‐solving algorithm. The use of standardized methods and reporting will provide greater uniformity in application of IONM. In addition, this report clarifies the limitations of IONM and helps identify areas where additional research is necessary. This guideline is, at its forefront, quality driven; it is intended to improve the quality of neural monitoring, to translate the best available evidence into clinical practice to promote best practices. We hope this work will minimize inappropriate variations in monitoring rather than to dictate practice options. Laryngoscope, 121:S1–S16, 2011

The Italian registry for adrenal cortical carcinoma: Analysis of a multiinstitutional series of 129 patients

BACKGROUND Adrenal cortical carcinoma is an uncommon tumor with a poor prognosis. The low incidence of this tumor makes it difficult to achieve reliable data on clinical manifestations, natural history, and the impact of therapies. The purpose of this study was to evaluate such aspects in a large series. METHODS A retrospective series of 129 cases (55 men and 74 women, mean age of 49 years) was collected from 18 surgical institutions. At the time of diagnosis 45.7% of patients had endocrine symptoms. One hundred twenty-four patients underwent surgery, which was considered curative in 91 cases and palliative in 33. Sixty-three patients had local disease, 48 had regional disease, and 43 had distant metastases. RESULTS This study confirmed a higher incidence in the 40- to 50-year-old population with a female prevalence; hormonal hyperincretion was more common in women, but it was not caused by advanced disease. The overall 5-year survival rate was 35%. Tumor stage and curative resection affected prognosis significantly. The influence of gender, side, age, and hormonal function has not been confirmed. Adjuvant therapies were ineffective in prolonging survival. Reoperated patients experienced better survival (mean, 41.5 months) than nonreoperated cases (mean, 15.6 months). CONCLUSIONS The poor prognosis of adrenal cortical carcinoma may be improved by early diagnosis and complete resection. Radical surgery is the sole effective therapy, particularly in early stages. Surgical treatment of recurrence seems to improve survival and should be attempted systematically. Adjuvant therapies obtained contrasting results, and their role should be evaluated in prospective multicentric trials.

Minimally invasive video-assisted thyroidectomy: multiinstitutional experience.

Minimally invasive video-assisted thyroidectomy (MIVAT) was described in 1998. In this study we collected the experience of four third-level referral centers that adopted this technique. A total of 336 patients (279 females, 57 males) were selected for MIVAT. Selection criteria were thyroid volume <15 ml, nodules not exceeding 3.5 cm of diameter, and an absence of thyroiditis, previous neck surgery, or previous irradiation. The procedure, totally gasless, is carried out through a 15 mm central incision above the sternal notch. Dissection is performed under endoscopic vision using conventional and endoscopic instruments. The mean operating time was 69.4 ± 30.6 minutes for lobectomy (range 20–150 minutes) and 87.4 ± 43.5 minutes for total thyroidectomy (range 30–220 minutes). The mean postoperative stay was 1.9 ± 0.8 days. Postoperative complications were 7 transient and 1 definitive recurrent nerve palsies and 11 cases of hypoparathyroidism (9 transient, 2 definitive). Conversion to open surgery was necessary in 15 patients (4.5%). This study confirms in a large number of cases the safety and feasibility of MIVAT, even in different surgical settings where similar results were achieved. The complication rate was not different from that of standard thyroidectomy. Although the operating time appears longer than with conventional procedures, the learning curve demonstrates a sharp decrease with increasing experience and the introduction of new technologies. The number of patients eligible for this approach remains low, thereby limiting its use, but it should be considered a valid option in selected surgical centers, offering some advantages to patients in terms of cosmetic results and postoperative distress.

Role of reoperation in recurrence of adrenal cortical carcinoma: results from 188 cases collected in the Italian National Registry for Adrenal Cortical Carcinoma.

BACKGROUND Recurrence of adrenal cortical carcinoma (ACC) after radical surgery is a common finding. Although successful reoperations have been reported with encouraging results, most published experiences are anecdotal and based on few cases. We report the results of surgical treatment for recurrent ACC in a multiinstitutional series. METHODS One hundred eighty-eight cases of ACC were collected in a national registry. A complete follow-up was obtained in 179 cases. At initial diagnosis 92 patients had local disease (stage I or II). One hundred seventy patients underwent surgical treatment, considered radical in 140; in this group, recurrent disease was observed in 52 cases (37%) after a mean disease-free interval of 21.7 months. RESULTS Adjuvant chemotherapy was ineffective in ameliorating the prognosis. The mean survival in 20 patients who underwent reoperation was significantly higher (15.85 +/- 14.9 months) than in nonreoperated cases (3.2 +/- 2.9 months). Five-year actuarial survival in reoperated patients is significantly better than in nonreoperated patients (49.7% versus 8.3%, respectively). CONCLUSIONS Although the prognosis of this tumor is still poor, surgery is the only effective therapy; reoperation allows survival comparable to that observed in patients without recurrent disease. An aggressive strategy for recurrent ACC is advisable until prospective studies demonstrate a real effectiveness for chemotherapy.

Minimally invasive, totally gasless video-assisted thyroid lobectomy

BACKGROUND Neck surgery is one of the newest fields of application of video-assisted surgery. We developed a technique for minimally invasive, totally gasless video-assisted thyroid lobectomy. METHODS The procedure was accepted by a patient with a follicular nodule of the left lobe of the thyroid. We performed a left thyroid lobectomy through a single 20-mm horizontal skin incision, just above the sternal notch, after inserting a 5-mm 30 degrees laparoscope, by using both endoscopic and conventional instrumentation. RESULTS The recurrent laryngeal nerve and the parathyroid glands were easily identified and preserved. The operating time was 2.5 hours. No complication occurred. The postoperative stay was 2 days. The cosmetic result was excellent CONCLUSIONS We concluded that our technique is feasible and safe. This makes us optimistic about the future of minimally invasive, video-assisted thyroid surgery.

Total thyroidectomy for management of benign thyroid disease: review of 526 cases

Total thyroidectomy is not frequently performed in cases of benign disease because of the associated risk of postoperative hypoparathyroidism and recurrent laryngeal nerve (RLN) damage. We chose a series of patients who had undergone total thyroidectomy (TT) for benign thyroid tumors to evaluate the safety of this approach and its role in the treatment of nonmalignant lesions of the thyroid. We considered only patients with a minimum follow-up of 24 months. Records of 526 patients who underwent TT were carefully reviewed, assessing for perioperative complications and late sequelae. The mean age was 44 ± 15.7 years; 109 patients (20.7%) were male and 417 (79.3%) were female. Altogether, 65 patients (12.3%) were operated on for toxic goiter, 429 (81.6%) for bilateral nodular goiter, and 32 (6.1%) for thyroiditis. Postoperative hemorrhage requiring reoperation occurred in 8 cases (1.5%). The incidences of permanent RLN palsy (considered as a percentage of the nerves at risk) and permanent hypocalcemia were 0.4% and 3.4%, respectively. A trend toward a decrease in the complication rate was observed during the last 5 years. There were no disease recurrences during a mean follow-up of 44 months. The results of our series show that TT can be performed safely in patients, with a low incidence of lifetime disabilities. TT has the advantage of reducing/avoiding the risk of disease recurrence and reoperation and should therefore be considered a valuable option for treating benign thyroid diseases.Résumé.La thyroïdectomie total mais n’est pas réalisée fréquemment en cas de maladie bénigne en raison du risque d’hypoparathyroïde postopératoire et de lésions du nerf récurrent. Nous avons sélectionné une série de thyroïdeectomies totales (TT) pour maladie bénigne afin d’évaluer la sécurité de cette approche et son rôle dans le traitement des lésions non malignes de la thyroïde. Nous avons pris en compte seulement les patients ayant un suivi minimum de 24 mois. Les dossiers de 526 patients ayant eu une TT ont été revus pour évaluers les complications péri-opératoires et les séquelles tardives. L’âge moyen était de 44 ± 15.7 ans. Cent neuf patients (20.7%) étaient des hommes et 417 (79.3%) des femmes. Soixante=cinq patients (12.3%) ont été opérés pour goitre toxique, 429 (81.6%) pour goitre nodulaire bilatéral et 32 (6.1%) pour thyroïdite. Une hémorragie postopératoire a nécessité une ré-intervention dans 8 cas (1.5%). L’incidence de paralysie permanente du nerf récurrent (pourcentage de nerfs récurrents à risque) et d’hypocalcémie permenente ont été, respectivement, de 0.4% et de 3.4%. On a observé une tendance vers une diminution du taux de complications pendant les cinq dernières années. Aucune récidive n’a été observée avec un suivi moyen de 44 mois. Les résultats de notre série indiquent que la TT peut être réalisée avec sécurité dans cette population avec une incidence d’incapacité permenent réduite. La TT a l’avantage de réduire/éviter le risque de récidive de la maladie et de réopération et devrait être une option valable pour le traitement de maladies bénignes de la thyroïde.ResumenLa tiroidectomia total no es un procedimiento de realización frecuente en la enfermedad benigna por razón del riesgo de hipoparatiroidismo postoperatorio y de lesión del nervio laríngeo recurrente. Tomamos una serie de tiroidectomías totales (TT) practicadas por tumores benignos con el objeto de evaluar la seguridad de esta conducta y su papel en el tratamiento de lea lesiones no malignas de la tiroides. En el presente estudio sólo fueron considerados pacientes con un seguimiento mínomo de 24 meses. Se revisaron las historias de 526 pacientes que habían sido sometidos a TT para determinar las complicaciones postoperatorias y las secuelas tardías. La edad promedio fue 44 ± 15.7 años; 109 (20.7%) eran hombres y 417 (79.3%) mujeres; 65 (12.3%) fueron operados por bocio tóxico, 429 (81.6%) por bocio nodular bilateral y 32 (6.1%) por tiroiditis. Se presentó hemorragia postoperatoria que requirió reoperación en 8 casis 91.5%). La incidencia de parálisis permamente del nervio laríngeo recurrente consierada como porcentaje de los nervios en riesgo y de hipocalcemia fue 0.4% y 3.4% respectivamente. Se observó tendencia hacia la disminución de las complicaciones en el curso de los últimos 5 años. No se registró recurrencia de la enfermedad en el seguimiento de 44 meses. Los resultados del análisis de nuestra serie indican que la TT puede ser practicada con seguridad en pacientes con enfermedad benigna de la tiroides, con una baja tasa de complicaciones permenentes. La TT tiene la ventaja de reducir o abolir tanto el riesgo de recurrencia de la enfermedad como el de una reoperación, y en consecuencia, debe ser considerada Bellantone et al.: Benign Thyroid Disease and Total Thyroidectomy como una opción valiosa en el tratamiento de la enfermedad tiroidea benigna.

Epidermal growth factor receptor in human breast cancer: correlation with steroid hormone receptors and axillary lymph node involvement

Epidermal growth factor (EGF-R) estrogen (ER) and progesterone (PR) receptors were evaluated in 89 primary breast cancers and 23 axillary lymph node metastases. About 57% of primary and 72.2% of metastatic tumors were EGF-R positive and median EGF-R levels were higher in metastatic deposits than in primary breast tumors (P less than 0.05). An inverse distribution of EGF-R and steroid hormone receptor positive tumors was found (chi 2 = 10.87; P less than 0.001 for PR and chi 2 = 5.01; P less than 0.05 for ER) and an interesting correlation between EGF-R expression in primary tumor and axillary lymph node involvement was demonstrated (chi 2 = 21.4; P less than 0.001). Immunohistochemical studies with a monoclonal antibody against EGF-R revealed the presence of EGF-R only in malignant cells. Our data suggest that EGF-R could identify a class of more aggressive breast tumors endowed with a higher metastatic potential and may therefore represent an unfavorable prognostic parameter in breast cancer.

Safety of video‐assisted thyroidectomy versus conventional surgery

Thyroid gland manipulation, surgical stress response, and postoperative outcome in cases of video‐assisted thyroidectomy (VAT) and conventional thyroidectomy were compared to verify the safety of VAT.

Long-term outcome of functional post-thyroidectomy voice and swallowing symptoms.

BACKGROUND Voice and swallowing symptoms are frequently reported early after thyroidectomy even in the absence of laryngeal nerves injury. We evaluated the short-term and long-term outcomes of these functional alterations. METHODS Consenting patients undergoing total thyroidectomy (TT) were enrolled. Videolaryngostroboscopy (VSL), acoustic voice analysis (AVA), and maximum phonation time (MPT) were performed pre-operatively, 3 months postoperatively, and >1 year postoperatively. Subjective evaluation of voice (Voice Impairment Score=VIS) and swallowing (Swallowing Impairment Score=SIS) were obtained pre-operatively, as well as 1 week, 1 month, 3 months, and >1 year postoperatively. RESULTS The long-term evaluation was completed in 110 patients. The percentage of patients with symptoms 1 week after operation was significantly higher than preoperatively, whereas it was significantly lower at long-term evaluation. VIS was significantly worse than pre-operatively, 1 week, 1 month, and 3 months after surgery, but it was similar to pre-operative >1 year after TT. SIS was significantly worse 1 week after thyroidectomy but not 1 month and 3 months after thyroidectomy, and it was significantly lower than the pre-operative >1 year after TT. CONCLUSION Vocal and swallowing symptoms are frequent after TT. In the absence of laryngeal nerve injury, after an initial impairment, late after operation, patients experienced subjective amelioration of their voice and swallowing performances, which may be related to the resolution of compressive symptoms.

Adrenal cystic lesions: Report of 12 surgically treated cases and review of the literature

Adrenal cysts are rare (0, 064%–0, 18% in autopsy series) and less than 500 cases have been reported in the western literature. Incidental diagnosis of adrenal cysts, however, is reported with increasing rates. We observed 12 patients with adrenal cyst. Each of them had a careful laboratory and instrumental evaluation; all the patients were operated. In our series about 67% of the patients were symptomatic (6 patients with abdominal pain, 1 with palpable mass, 1 with hemorrhagic shock). No biochemical alteration was observed. Conversely we observed an unusual subclinically hyperfunctioning cystic adenoma, potentially progressive to a clinically recognizable endocrine syndrome. US, CT and MRI had a sensitivity of 66, 7%, 80% and 100% respectively. Adrenalectomy was performed in all patients. The pathological findings were: 1 epithelial cyst (cystic adenoma), 2 endothelial cysts (vascular cystic ectasia with adenomatous adrenocortical hyperplasia and 1 vascular cyst) and 9 pseudocysts. On the basis of these results, we conclude that a careful hormonal, morpho-functional and instrumental evaluation is indicated in all adrenal cysts, even if the available diagnostic procedures, even when combined, cannot always define their nature. Surgical excision, when possible by laparoscopic approach, is indicated in presence of symptoms, endocrine abnormalities (even when subclinic), complications, suspicion of malignancy and/or large size (>5 cm). Adrenal gland must be excised en bloc, also because of the possible presence of other adrenal lesions.