Tarik Terzioglu

The long term outcome of papillary thyroid carcinoma patients without primary central lymph node dissection: Expected improvement of routine dissection

BACKGROUND We investigated central compartment recurrence (CCR) and mortality rate in patients with papillary thyroid carcinoma (PTC) who had no central lymph node dissection (CLND) at the time of primary operation. METHODS The medical records of 343 patients who underwent operations for PTC between January 1988 and December 2002 with a mean postoperative follow-up period of 9 +/- 4 years, were reviewed. RESULTS Twenty-two patients (6%) had locoregional recurrence. The lateral, central, or both compartments were involved in 16, 2, and 4 of 22 patients, respectively. The rate of CCR was 2% (6/343). Five (2%) patients died from PTC due to locoregional invasion (tracheal and esophageal invasion) in 3 patients and distant metastasis in 2 patients. Older age (>or=60), initial metastatic lateral cervical lymph nodes, size of primary tumor size >or=3 cm, microscopic extrathyroidial extension, and aggressive histologic subtypes (diffuse sclerosing, tall-cell, poorly differentiated) of PTC were risk factors for CCR and mortality (P = .0001). CONCLUSION Initial CLND might be of value to prevent CCR and mortality in PTC patients with initial metastatic cervical lateral lymph nodes, older age (age >or=60), primary tumor size >or=3 cm, and agressive histopathologic features of PTC.

Excision Efficiency of Radioguided Occult Lesion Localization in Reoperative Thyroid and Parathyroid Surgery

BACKGROUND The purpose of this study was to investigate the efficiency of a radioguided occult lesion localization technique in reoperative thyroid and parathyroid procedures in patients who had undergone previous neck exploration for thyroid or parathyroid disease. METHODS Twenty-one consecutive patients who were scheduled for reoperative thyroid or parathyroid surgery were studied. The indication for reoperation was recurrent papillary thyroid cancer (PTC) in eight patients, completion thyroidectomy for PTC in eight patients who had previously undergone a bilateral subtotal thyroidectomy, recurrent goiter in two patients, primary hyperparathyroidism in two patients, and recurrent parathyroid cancer in one patient. Ninety minutes before surgery, 0.1 mL of Technetium-99m (0.2 mCi)-labeled macroaggregated albumin was injected directly into the lesion under ultrasonographic guidance. During surgery, a handheld gamma probe was used to localize and excise the lesions. The background and postexcisional site radioactivities were compared to confirm the completeness of each procedure. The radiation dose in the operating room environment, duration of surgery, and postoperative complication rates were evaluated in all patients. In patients with PTC, the change in serum thyroglobulin (Tg) following surgery was noted. RESULTS Thirty lesions were marked and excised. The postexcisional bed gamma counts (610 ± 141) were markedly decreased compared with the pre-excisional site counts (21,415.8 ± 4993.4; p = 0.0001). The ratio of the postexcisional and background counts (4.6 ± 4.3) was significantly lower than the ratio of the pre-excisional and background counts (173.7 ± 156.4; p = 0.0001). The mean operation duration was 53.3 ± 7.5 minutes. The dose absorbed by the hands of the surgeon was estimated as 0.07 ± 0.02 and 0.15 ± 0.05 millisievert/h when one or three lesions were marked, respectively. One patient developed postoperative transient hypoparathyroidism. After surgery, serum Tg levels dropped to <2 ng/mL in 86% (6/7) of the patients with PTC whose preoperative serum Tg was elevated. CONCLUSIONS The radioguided occult lesion localization technique was efficient in the perioperative identification of thyroid and parathyroid tumors in patients who were undergoing reoperation for PTC and hyperparathyroidism.

Expression of bcl-2 in Papillary Thyroid Cancers and its Prognostic Value

Abstract Purpose: Papillary thyroid cancer has a good prognosis. This favourable prognosis may be attributed to the apoptotic tendency of the cancer cells. This study aims to evaluate the expression of bcl-2, which is an antidote of apoptosis, and aims to evaluate the value of bcl-2 as a prognostic marker in papillary thyroid cancer. Material-Methods : Bcl-2 expression in the archival materials of 31 patients with papillary thyroid cancer was examined with immunohistochemical methods using bcl-2 and p-53 stains. The results were compared with 31 normal thyroid tissue specimens, which consisted of the contralateral lobes of these patients. The results were then analyzed in accordance with the clinical features of the patients. Results : Thirty (96.7%) patients of the control group were positive for bcl-2 whilst one (3.3%) was negative. The staining for bcl-2 was positive in 12 (%75) patients with microcarcinomas (p < 0.05) and 13 (86.6%) with papillary cancers (p > 0.05). Two cases of the papillary cancer group were admitted to the hospital with local recurrence (6.4%) and both were positive for bcl-2 (p > 0.05). All cases (4/31), whose MACIS scores were higher than 7 were positive for bcl-2. Twenty-one of 27 cases whose MACIS scores were lower than 7 (77.7%) were positive for bcl-2 (p > 0.05). All tumours of this series were negative for p-53 immunstaining. Conclusion : The rate of bcl-2 expression in microcarcinomas of papillary thyroid cancer decreases when compared to normal thyroid tissue. This may be an early sign of oncogenesis, and a reason for the favourable prognosis in microcarcinomas. However, bcl-2 cannot be used as a prognostic marker.

The effect of prostaglandin E1 on colonic anastomotic healing

In an attempt to show the effect of prostaglandin E1 (PGE1) on colonic anastomotic healing the authors measured collagen synthesis and counted inflammatory cells (polymorphonuclear leukocytes “PMN” histiocytes, lymphocytes, and plasma cells) and compared the results to those of aprotinin and control groups. The authors performed colonic anastomoses on 45 male albino rats, which were divided into three groups. Measurements of collagen synthesis and counts of inflammatory cells in the first group were evaluated as control data. They administered 2000 units aprotinin daily for two days in the second group and 2μg PGE1 daily for two days in the third group. Collagen content as hydroxyproline in the resected anastomotic part of the colon was measured and the inflammatory cells were counted on the first, third, fifth, and tenth days. The results showed that PGE1-administered rats had significantly higher collagen levels (5.21±1.35μghydroxyproline/mgr tissue,P<0.05and 3.81±0.63μg/mg, P<0.05)on the third and fifth days, respectively, compared with the control and aprotinin groups. The aprotinin group also had higher collagen levels (3.34±0.27μg/mg, P<0.05and 3.07±0.40μg/mg, P<0.05) on the third and fifth days, respectively, compared with the control group. There were no statistically important differences in the collagen contents of the control, aprotinin, and PGE1 groups on the tenth day and there was an increase in the collagen content in all groups(P<0.05). The inflammatory cells, including PMNs, histiocytes, lymphocytes, and plasma cells, which play an important role in the inflammatory stage of colonic anastomotic healing, were also counted. The cells were counted on the third, fifth, and tenth days and the results were evaluated as (+) positive and more positive. The results of the control and aprotinin groups were found as (+++), (+++), and (++) on the third, fifth, and tenth days, respectively. In the PGE1-administered group the inflammatory cells were counted as (+), (++), and (++) on the third, fifth, and tenth days, respectively. In addition, there was an increase in fibroblast synthesis and new vessel formation on the tenth day. Thus, it was shown that PGE1 decreased inflammatory cells and increased collagen synthesis in the early stage of colonic anastomoses and fibroblasts in the late stage more effectively when compared with the control and aprotinin groups. Aprotinin also was found to be more effective in decreasing the anti-inflammatory effect compared with the control group. It is concluded that PGE1 stimulates the colonic anastomotic healing resulting in a remarkable improvement in collagen synthesis and a decrease of inflammatory cells in the early stage of colonic anastomoses.

Efficiency of gamma probe and dual-phase Tc-99m sestamibi scintigraphy in surgery for patients with primary hyperparathyroidism.

Purpose The purpose of this study was to determine the value of the intraoperative gamma probe and the efficacy of dual-phase Tc-99m sestamibi imaging in patients with primary hyperparathyroidism. Methods Twenty-one patients with primary hyperparathyroidism were examined prospectively. Results of same-day dual-phase Tc-99m sestamibi scintigraphy and intraoperative gamma probe evaluations were compared with the intraoperative findings and histopathologic diagnoses. A 15-mm handheld gamma probe was used to measure gamma activity in the neck and upper mediastinum. Nuclear mapping by gamma probe showed a single quadrant of neck that emitted gamma radiation significantly greater than the other three quadrants, which correlated with the sestamibi scan. Results Dual-phase Tc-99m sestamibi scintigraphy determined and localized parathyroid lesions in 20 patients (sensitivity, 94%). Of the 20 parathyroid lesions removed, 15 were located in normal positions, whereas five were explored in ectopic sites (one within the thyroid, one in the anterior mediastinum, one in a retrotracheal position, one in the carotid sheath, and one in the retroesophageal region). Although the index of thyroid nodules varied from 15.8% to 22.9%, the index for parathyroid lesions was 77.3% to 112.8%. Conclusions These results confirm that parathyroid lesions, especially at ectopic sites, can be treated successfully in shorter operative times with minimal complications with the help of the intraoperative gamma probe.

Impact of total versus subtotal thyroidectomy on calcium metabolism and bone mineral density in premenopausal women.

OBJECTIVE This study aimed to compare the impact of total versus subtotal thyroidectomy on calcium metabolism and bone mineral density in euthyroid, premenopausal women. SUBJECTS The study included 24 premenopausal women who had undergone total (n = 10) or subtotal (n = 14) thyroidectomy and who were receiving nonsuppressive doses of thyroxine. The median post-operative period was four years. We determined, in all patients, the following parameters associated with calcium metabolism: total serum calcium, inorganic phosphate, intact parathormone, calcitonin and alkaline phosphatase. The bone mineral density of the spine and hip were measured using a Hologic QDR 4500C bone densitometer and were compared with controls matched for age and peak bone mineral density (using the t-test). RESULTS The measured calcium metabolism parameters were normal in all patients, and none had osteoporosis. There was no significant difference in the bone mineral density measurements for the spine and hip, comparing patients who had undergone total versus subtotal thyroidectomy (using the t-test). CONCLUSION The impact of total thyroidectomy on bone mineral metabolism is not significantly different from that of subtotal thyroidectomy, in premenopausal women with normal thyroid-stimulating hormone values.

The rate of operative success achieved with radioguided occult lesion localization and intraoperative ultrasonography in patients with recurrent papillary thyroid cancer

BACKGROUND To investigate the rate of operative success in excision of nonpalpable lymph nodes with metastatic disease achieved with radioguided occult lesion localization (ROLL) and intraoperative ultrasonography (IOUS) in patients with papillary thyroid cancer (PTC). METHODS Twenty consecutive PTC patients with nonpalpable lymph nodes with metastatic disease localized in previously operated fields were randomized to receive ROLL (n = 11) or IOUS (n = 9). Nodes were excised along with adjacent soft tissue to accomplish a compartment-oriented dissection. The duration of operation, rate of postoperative complications, pre- and postoperative serum thyroglobulin (Tg) levels, and the findings of postoperative neck ultrasonography and postablation scan were recorded in all patients. Measures of operative success included a postoperative Tg level <50% of preoperative Tg level and no abnormal lesions on postoperative imaging. RESULTS Histopathologic examination confirmed the excision of all preoperatively identified metastatic nodes. Additional nodes also were excised (2.3 ± 3.3 per specimen in the ROLL group and 1.6 ± 1.8 per specimen in the IOUS group), 23% of which were metastatic. No postoperative complications occurred in either group. The duration of operation was similar in the 2 groups (P = .4). Postoperative imaging confirmed the clearance of suspicious nodes in all patients. The rate of operative success in ROLL and IOUS group were 100% and 89%, respectively. CONCLUSION In patients with recurrent PTC, a high rate of operative success in excision of nonpalpable metastatic lymph nodes was achieved by both ROLL and IOUS. We recommend compartment-oriented dissection; this approach may maximize the removal of metastatic nodes not identified by preoperative imaging.

Does intraoperative radioguided surgery influence the complication rates and completeness of completion thyroidectomy

BACKGROUND To investigate whether radioguided surgery (RGS) has any beneficial effects on the complication rates and the completeness of completion thyroidectomy (CT) in a center experienced in endocrine surgery. METHODS Thirty-three patients scheduled for CT for thyroid carcinoma were randomly selected for 2 types of intervention. CT was performed by RGS following administration of 5 mCi technetium-99m in 15 patients (group 1) and with conventional surgical exploration without RGS in 18 patients (group 2). The duration of the CT, thyroid function tests, iodine-131 uptake at 24 hours at the third postoperative week, and complication rates were compared between groups 1 and 2. RESULTS In groups 1 and 2, the duration of CT (63.3 +/- 7.5 vs 65 +/- 10.8 minutes, P = .7), postoperative serum thyrotropin-stimulating hormone (TSH) levels (43.9 +/- 17.5 mIU/L vs 36.8 +/- 8.6 mIU/L, P = .2), postoperative (131)I uptake at 24 hours (6.86 +/- 1.7 vs 7.0 +/- 1.3, P = .8), and complication rates (13.3% vs 5.6%, P = .6) showed no significant differences. CONCLUSION RGS during CT offers no benefit over conventional surgical exploration with respect to operation time, complication rates, or completeness of surgery in a center experienced in endocrine surgery. However, it might be helpful for general surgeons who are less familiar with re-operative thyroid surgery.

Adrenal Neuroblastoma in an Adult: Report of a Case

Neuroblastomas comprise a major part of adrenal tumors in children. However, they are seldom reported in adults. In this report we present the case of a 30-year-old woman who was operated on for an incidentaloma. Following an adrenalectomy, she was put on a chemoradiotherapy regimen. A histopathologic assessment of the specimen revealed Homer-Wright rosettes against a background of fibrillary matrix, which indicated a diagnosis of a neuroblastoma. In spite of a low incidence in adulthood, it should be emphasized that all adrenal tumors without any particular characteristics may be a neuroblastoma, which tends to show a very poor prognosis. Hence, such patients should undergo postoperative chemoradiotherapy, which may improve both the remission rates and survival.

False-positive uptake of I-131 MIBG

A patient with a clinical suspicion of pheochromocytoma was studied with MIBG labeled I-131. The patient had marked uptake of the radiopharmaceutical in the mediastinum, which was found to be the thymus gland at excisional biopsy. While interpreting I-131 MIBG imaging, possible MIBG uptake of normal thymic tissue must be considered to avoid a false-positive diagnosis of primary metastatic tumors.