Thyroid Hyalinizing Trabecular Tumor: A Case Series

Aim: Hyalinizing Trabecular Tumor (HTT) of the thyroid gland is an unusual and rare follicular derived neoplasm, which was first described from Carney and colleagues in 1987. We aim to present two cases of HTT diagnosed as papillary thyroid carcinomas in preoperative FNA cytological findings, although the postoperative histological examinations revealed the presence of Hyalinizing Trabecular tumors. Moreover, a short review regarding the diagnostic and clinical aspects of this rare thyroid tumor is also presented. Cases Presentation: A 30 year old and a 33 year old females were referred as having papillary thyroid carcinomas on preoperative FNA. Total thyroidectomy was offered in both. Histologic sections revealed the presence of HTT with the characteristic trabecular arrangement of polygonal/spindle cells and positive staining for MIB-1. Both patients remain disease free at a follow up of 5 years. Discussion: Although HTT diagnosis and differentiation from other thyroid tumors remains a topic of controversy, immunochemistry and molecular analysis may provide adequate information for HTT distinction from papillary thyroid carcinoma (PTC), medullary thyroid cancer (MTC) and paragaglioma. Therefore, suspicious cases based on preoperative FNA, require careful evaluation and cooperation of pathologists, endocrinologists and endocrine surgeons for optimal diagnosis and treatment. Conclusions: HTT is a rare, mostly benign neoplasm with favorable prognosis Preoperative identification of HTT is significant since its extremely low malignant potential and its favorable prognosis may lead to less extended operations and avoidance of postoperative radioiodine administration

Use of a diathermy system in thyroid surgery

Hypothesis: New hemostatic methods have been widely used in open and laparoscopic surgery. The LigaSure Precise diathermy system (Valleylab, Boulder, Colo) has been recently used in thyroid surgery. We hypothesized that its use could lead to reduced operative time and fewer complications compared with conventional knot tying in total or near-total thyroidectomy. Design Prospective case-controlled study. Setting Tertiary care private hospital. Patients Eighty patients underwent total or near-total thyroidectomy by 1 surgeon. Interventions Forty patients underwent thyroidectomy with the conventional knot tying technique and 40 patients with the LigaSure diathermy system. Main Outcome Measures Demographics, histopathological diagnosis, operative time, intraoperative blood loss, complications, and cost, using 2 test and Wilcoxon rank sum test. Results: The study groups had similar demographic and histopathological characteristics. The mean \ub1 SD operative time was nonsignificantly reduced in the LigaSure group compared with the conventional knot tying group (84 \ub1 6 vs 89 \ub1 7 minutes, P =3D .60). The mean \ub1 SD intraoperative blood loss was less for the LigaSure group (30 \ub1 5 vs 35 \ub1 8 mL, P =3D .36). There was 1 case of transient recurrent laryngeal nerve palsy in the LigaSure group. One patient from this group and 2 patients from the other group exhibited transient hypocalcemia; permanent postoperative hypocalcemia was not encountered in either group. The cost of the LigaSure diathermy system was significantly greater than that of conventional knot tying. Conclusion: Use of the LigaSure in thyroid surgery did not significantly reduce operative time, blood loss, or complication rates compared with conventional knot tying, but it increased operative cost

Thyroid paraganglioma: a case series of a rare head and neck tumor

Thyroid paragangliomas are rare neuroendocrine tumors. We present two cases analyzing their clinical presentation and pathology findings. A 44-year-old woman presented with a 33 mm left thyroid lobe mass. A 27-year-old male presented with a 27-mm right thyroid lobe mass and a FNA biopsy suggesting a follicular thyroid tumor. Both patients underwent total thyroidectomy. Vigorous bleeding was noted on the first case. Histologic sections revealed encapsulated tumors, whereas immunochemical stains were positive for chromogranin A, synaptophysin and NSE and negative for thyroglobulin, calcitonin, CEA and S-100. After an 18- and 12-month follow-up, respectively, both patients have no signs of local recurrence or distantmetastasis. Preoperative diagnosis of thyroid paragangliomas was never attained in this series. Immunohistochemistry is mandatory for proper differential diagnosis. For the surgeon, the operation is technically demanding mainly due to the increased vascularity and friability of the tumor

Pheochromocytoma: a changing perspective and current concepts

This article aims to review current concepts in diagnosing and managing pheochromocytoma and paraganglioma (PPGL). Personalized genetic testing is vital, as 40–60% of tumors are linked to a known mutation. Tumor DNA should be sampled first. Next-generation sequencing is the best and most cost-effective choice and also helps with the expansion of current knowledge. Recent advancements have also led to the increased incorporation of regulatory RNA, metabolome markers, and the NETest in PPGL workup. PPGL presentation is highly volatile and nonspecific due to its multifactorial etiology. Symptoms mainly derive from catecholamine (CMN) excess or mass effect, primarily affecting the cardiovascular system. However, paroxysmal nature, hypertension, and the classic triad are no longer perceived as telltale signs. Identifying high-risk subjects and diagnosing patients at the correct time by using appropriate personalized methods are essential. Free plasma/urine catecholamine metabolites must be first-line examinations using liquid chromatography with tandem mass spectrometry as the gold standard analytical method. Reference intervals should be personalized according to demographics and comorbidity. The same applies to result interpretation. Threefold increase from the upper limit is highly suggestive of PPGL. Computed tomography (CT) is preferred for pheochromocytoma due to better cost-effectiveness and spatial resolution. Unenhanced attenuation of >10HU in non-contrast CT is indicative. The choice of extra-adrenal tumor imaging is based on location. Functional imaging with positron emission tomography/computed tomography and radionuclide administration improves diagnostic accuracy, especially in extra-adrenal/malignant or familial cases. Surgery is the mainstay treatment when feasible. Preoperative α-adrenergic blockade reduces surgical morbidity. Aggressive metastatic PPGL benefits from systemic chemotherapy, while milder cases can be managed with radionuclides. Short-term postoperative follow-up evaluates the adequacy of resection. Long-term follow-up assesses the risk of recurrence or metastasis. Asymptomatic carriers and their families can benefit from surveillance, with intervals depending on the specific gene mutation. Trials primarily focusing on targeted therapy and radionuclides are currently active. A multidisciplinary approach, correct timing, and personalization are key for successful PPGL management

Posterior retroperitoneoscopic versus laparoscopic adrenalectomy in sporadic and MENIIA pheochromocytomas

Retroperitoneal adrenalectomy (PRA) comprises an alternative approach in the management of adrenal tumors that has been set as the treatment of choice in our Institution. We assess the impact of PRA the management of hereditary and sporadic pheochromocytomas comparing its outcomes to the laparoscopic technique, in a case-controlled setting. From May 2008 to January 2013, 17 patients [5 males and 12 females, mean age: 51 yrs (range 26-73)] with pheochromocytomas underwent PRA. Demographics, tumor characteristics, operative time, complications, hospital stay, and postoperative pain (based on VAS score at days 1 and 3) were compared to 17 selected laparoscopic patient controls [7 males and 10 females, mean age 49 yrs (range 25-64)]. 17 patients, 11 with the sporadic form and 6 with MENIIA associated pheochromocytomas, comprised the retroperitoneoscopic group. 19 pheochromocytomas with a mean size 3.7 cm (range 1.7-7.0) at a mean operative time: 105.6 min (range 60-180) were accordingly excised. In the laparoscopic group, 13 patients had sporadic pheochromocytomas, whereas 4 patients had MENIIA syndrome. Mean tumor size of the laparoscopic series was 5.1 cm (range 1.7-8.5) at a mean operative time of 137 min (range 75-195). No mortality or conversions were encountered in both groups. No blood transfusions were needed. Mean visual analog scale pain scores were significantly lower for the retroperitoneoscopic group both on days 1 and 3 [0.94 (0-3) vs 4.15 (3-6), p < 0.001 and 0.06 (0-1) vs 3.5 (2-6) p < 0.001] respectively. Mean hospital stay for the patients of the retroperitoneoscopic group was significantly better than the laparoscopic group [(2.1 +/- A 0.24 days vs 40 +/- A 0.70 days) p < 0.001]. Retroperitoneoscopic adrenalectomy is associated with excellent clinical results in the management of sporadic and hereditary pheochromocytomas. Moreover, it appears to be superior to the laparoscopic approach, because it is faster and affords the patient with less pain and shorter hospital stay

Laparoscopic sleeve gastrectomy in morbidly obese patients. Technique and short term results

Objective : To evaluate the efficacy of Laparoscopic Sleeve Gastrectomy (LSG) as a definitive procedure for morbidly obese patients. Design : This constitutes a prospective study carried out in a tertiary care private hospital and included 15 morbidly obese patients who underwent LSG. The operation was performed through two 12 mm and two 5 mm ports, using the Endo-GIA stapler to create a lesser curve gastric tube over a 36-Fr bougie. Results : Operative time, complication rates, hospital length of stay, Body Mass Index (BMI), % of Excess Weight Loss (EWL) and appetite were evaluated. There were six females and nine males, aged (mean +/- SD) 40.5 +/- 10.5 yrs and preoperative BMI 47.8 +/- 7.5 kg/m(2). The operative time was 147.7 +/- 43.2 min. There was one conversion to open surgery and one gastric leak with haemorrhage that led to gastric tube stenosis, ultimately requiring revision surgery. All patients, except these two, were discharged on the 2nd postoperative day after an upper GI series and the initiation of a clear liquid diet. At the follow-up (7.5 +/- 4.4 months post operatively), the % EWL was 35.7 +/- 10.1. Eight patients who received regular postoperative dietician counselling at follow-up did better than the others who did not (% EWL 40.4 +/- 3.8 vs 30.2 +/- 4.1, respectively). All patients reported significant loss of appetite. Conclusions : Although the number of patients is relatively small, the data of this study indicate that laparoscopic sleeve gastrectomy is effective in weight reduction, being an acceptable surgical option for morbidly obese patients. A higher number of patients and longer follow-up period will be necessary to evaluate long-term efficacy

Surgical and clinicopathologic implications of the pyramidal lobe of the thyroid gland

BACKGROUND: The pyramidal lobe (PL) represents an upward extension of the thyroid gland with remarkable variability in terms of presence. location and size. This prospective study analyzes the significance of the PL. METHODS: From January 2013 to September 2015, 538 patients were prospectively enrolled in the study. Descriptive statistics, differences of patients with and without PL, differences in PL size (Kruskal-Wallis/ANOVA tests) and correlations of PL size with age, BMI and thyroid weight were computed. Odds ratios for the probability of observing PL size above the median value were analyzed using multivariate analysis. RESULTS: Out of 538 patients, 272 (50.6%) had pyramidal lobe, average size 1.82 cm. Statistically significant higher proportion of patients with PL was observed for patients with Delphian node presence (P=0.017). PL size was significantly larger for patients with greater thyroid weight (P=0.014); male gender (P=0.011) and Delphian node presence (P=0.021). No difference was found regarding age or BMI. Patients with multifocal papillary thyroid cancer (PTC)>10 mm had smaller PL size than patients with minimal multifocal PTC (<10 mm). After adjusting for age, gender, BMI, and thyroid weight, the odds of observing PL size above the sample median was significantly lower for patients with Multifocal PTC>10 mm (P=0.023) and for patients with cervical LN malignancy (P=0.014). CONCLUSIONS: PL occurs in 50.6% of patients. Larger size correlates strongly with big thyroids, male gender and Delphian nodes presence. Thorough anatomic knowledge and meticulous surgical technique are required for PL excision and a truly “total thyroidectomy.