Thyroid lymphoma: a rare tumor requiring combined management

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Late-Onset Metastasis of Renal Cell Carcinoma into a Hot Thyroid Nodule: An Uncommon Finding Not to Be Overlooked

We report the case of a 74-year-old man with a four-year history of right nephrectomy for clear cell renal carcinoma (CCRC) who was diagnosed with hyperthyroidism. On ultrasound (US), a 5 cm solid isohypoechoic nodule with intranodular vascularization was found in the left thyroid lobe. The nodule was deemed autonomous on T99mc thyroid scan. Methimazole was started and serum thyroid hormone levels quickly normalized; euthyroidism was maintained with a very low dosage of antithyroid drug. Over time, compressive symptoms and local pain occurred and US revealed growth of the nodule. Total thyroidectomy was performed and the combined histological and immunohistochemical evaluation deemed the nodule compatible with metastasis of CCRC; on 2-year follow-up, no tumor relapse was ascertained. In patients with a history of cancer, a thyroid nodule, even if hyperfunctioning, must be suspected of being a metastasis and investigated. Hot nodules, which are largely benign, may be vulnerable to metastatic colonization owing to their rich vascularization. In these cases, surgery may be curative

Radio-guided occult lesion localization of cervical recurrences from differentiated thyroid cancer

Background: The aim of this work was to evaluate the application of he concept of ROLL (radio-guided occult lesion localisation) in order to identify non-palpable recurrences in the cervical region by differentiated hyroid cancer (DTC). This procedure makes it possible to perform minimally- invasive radio-guided surgery in a number of selected cases. Material and Methods: The new ROLL procedure was used in 32 DTC patients with loco-regional recurrent lesions. Three of the patients were subjected twice to the procedure. The patients had undergone total thyroidectomy and post-thyroidectomy 131I-ablation, and in somecases had been subjected to one or more cervical lymphadenectomies. Pre-operative labelling consists of ultrasound-guided intra-lesional administration of 99mTc-labeled human albumin macroaggregates (99mTc-MAA, 5e10MBq in 100e200 mL of saline), and was followed by scintigraphy of the cervical region, 2 to 18 hours before programmed surgery. A hand-held gamma-probe used intra-operatively made it possible to identify the labelled lesions. ROLL was employed by means of two different approaches: the former consisted of a selective minimally invasive excision of radiolabelled lesions in 12 patients (s-ROLL); the latter consisted of a modified radical neck dissection (MRND) after excision of radiolabelled lesions in 20 patients (d-ROLL). Results: A total of 59 lesions detected by ultrasound examination were radio-labelled by intra-lesional injection of 99mTc-MAA: of the 59 lesions, 41 were metastatic lymph nodes located in the latero-cervical regions, while 17 recurrent metastatic lesions were spotted in the suprajugular region (at VI level) and 1 lesion was in the high mediastinum. The mean echographic size of the lesions was 11.1_4.1 mm. Using the ROLL procedure, it was possible to localise and remove 59 out of 59 lesions (identification rate 100%), including those of 3 patients previously subjected to non-radioguided surgery, which had failed. Leakage of 99mTc-MAA in to the surrounding tissues during pre-operative labelling relatively hindered precise gamma-probe-guided identification of 3 lesions (in 2 patients). However, these lesions were identified and surgically removed on the basis of both radioactivity and palpation. Histopathological examination confirmed metastatic involvement in all the lesions and further metastases in the other nodes that had been removed. Furthermore, ROLL allows the extent of the cervical dissection to be maintained at a minimum. In our case, the procedure was particularly useful in the paratracheal region as there was no injury of the nerve or parathyroidectomy. After a median follow-up of 29 months, 19 patients showed no evidence of disease, whereas 12 patients developed loco-regional recurrences (in sites near to and/or different from those operated with ROLL), and 2 patients presented distant metastases. Statistical analyses showed no differences between the two surgical applications with regard to in-field relapse, diseasefree survival and overall survival. Conclusions: Radio-guided surgery carried out withROLLis possible in selected patients presenting with recurrent loco-regional DTC (including iodine- negative lesions). The ROLL procedure permits lesions that can be removed with limited invasiveness to be identified, in particular in patients who have already undergone cervical dissections. ROLL has proved to be particularly suitable in those cases in which the lesions were small, nonpalpableand/ or situated in sites that were surgically difficult to reach. Therefore, it is possible to use minimally invasive approaches, followed by shorter operating times and with reduced morbidity complications. Similar to other ROLLprocedures, the low radioactivity dose used does not produce significant radiation exposure either to the patients or to the staff members. In order to obtain optimal performance of the procedure, it is necessary to dispense with experts in ultrasound-guided tissue sampling in the cervical region, and to ensure close collaboration of a team that includes nuclear medicine specialists, surgeons and pathologists. The clinical importance of the ROLLprocedure in managing recurrentDTC should be debated, taking into account the information concerning the prognostic factors of the disease

Thyroid nodules with indeterminate cytology: prospective comparison between 18F-FDG-PET/CT, multiparametric neck ultrasonography, 99mTc-MIBI scintigraphy and histology

to evaluate the role of 18F-FDG-PET/CT in predicting malignancy of thyroid nodules with indeterminate cytology

Protocolli gestionali-diagnostico-terapeutico-assistenziali in chirurgica tiroidea. 2° Consensus Conference.

Aim. To review and to update the management protocols in thyroid surgery proposed two years ago by 1st Consensus Conference called on the topic by the Italian Association of Endocrine Surgery Units (UEC Club). Method. The 2nd Consensus Conference took place November 30, 2008 in Pisa within the framework of the 7th National Congress of the UEC Club. A selected board of endocrinologists and endocrine surgeons (chairmans: Paolo Miccoli and Aldo Pinchera; speaker: Lodovico Rosato) examined the individual chapters and submitted the consensus text for the approval of several experts. This plain and concise text provides the rationale of the thyroid patient management and wants to be the most complete possible tool for the physicians and other professionals in the field. Conclusions. The diagnostic, therapeutic and healthcare management protocols in thyroid surgery approved by the 2nd Consensus Conference are officially those proposed by the Italian Association of Endocrine Surgery Units (UEC Club) and are subject to review by two years