Surgical itinerary in parathyroid hyperfunction: 63 cases operated on

Universitatea de Medicină și Farmacie ”Gr. T. Popa”, Iași, Clinica IV-a Chirurgie, Clinica V-a Pediatrie, Al XI-lea Congres al Asociației Chirurgilor „Nicolae Anestiadi” din Republica Moldova și cea de-a XXXIII-a Reuniune a Chirurgilor din Moldova „Iacomi-Răzeșu” 27-30 septembrie 2011Introducere: Multiplele aspecte etiopatogenice și anatomo-clinice ale hiperparatiroidismului (HP): pri-mar (HPP), renal (HPR), familial, din NEM etc. constituie o patologie care realizează o continuă provocare. În afara fenotipului și simptomatologiei polimorfe, a noilor achiziții diagnostice și terapeutice, frapează contrastul dintre incidența/prevalența sindromului în creștere în tările dezvoltate – mai ales pe seama observațiilor asimptomatice - și seriile limitate numeric sau cazurile izolate cu manifestări “istorice”, publicate în literatura națiunilor “în tranziție” sau subdezvoltate. Material și metoda: Din 1986 în clinica noastră au fost operate 63 observații de HP: 20 HPP – adenoame =17, carcinoame=2, paratiromatoza=1 și 43 HPR – HP secundar (HPS)=23 și tertiar=20. Am înregistrat 44 femei și 19 bărbati (raport 2,3/1) cu limite de vârstă 15 – 67 (medie 47) ani. Diagnosticul și indicația chirurgicală au fost stabilite clinic prin prezența suferinței renale – urolitiaza multipla sau recidivata în HPP – insuficiența renală cronică în regim de hemodializa în HPR, sindrom osos manifest – osteoporoza, dureri osoase, chisturi și fracturi, manifestări neuromusculare, psihonevrotice, digestive și cardiovasculare în ambele varietăți. Datele de laborator au obiectivat valori anormale ale calciului seric total și ionizat, fosforului și fosfatazei alcaline și în special ale iPTH iar explorarile localizatoare au inclus ultrasonografia – mai puțin concludentă în leziunile multiglandulare și mai recent scintigrafia cu 99mTc-tetrophosmin. Rezultate: Toate cazurile au fost operate practicându-se exereza simplă în 17 adenoame și “în bloc” cu lobul tiroidian ipsilateral în două cancere (unul fiind o recidivă la 4 ani după indepărtarea unui adenom), într-un adenom chistic intratiroidian ca și în cazul de paratiromatoza (de asemenea recidiva după exere-za extra muros a unui adenom). În observațiile de HPR au fost executate 24 paratiroidectomii subtotale (în 20 observatii reușindu-se exereza standard a 3 si ½ glande, în rest indepartandu-se 3 sau doar 2 paratiroide) si respectiv 19 paratiroidectomii totale (6 cu autotransplant glandular și 13 simple). Din considerente tactice sau pentru leziuni asociate explorarea/exereza chirurgicală a fost extinsă la tiroida (29 cazuri) sau timus (20 cazuri). Examenul anatomopatologic a precizat diagnosticul final în toate obser-vațiile. Rezultatele imediate și în timp au fost bune în special în HPP. Nu au fost hipocalcemii persistente chiar în cazul paratiroidectomiilor extinse dar am notat o paralizie recurentială, un hematom al lojei și recidiva în două cazuri de autotransplant antibrahial ca și cea a unui cancer la 4 ani după extirparea unui adenom (leziune noua ?). Concluzii: Paratiroidectomia – cu rafinamentele sale recente: minim invazivă, endoscopică sau asistată robotic – este singurul tratament eficace și definitiv în HPP și constituie o terapie simptomatică impor- tantă, deși suboptimal, în cazurile de HPR (a căror tratament ideal este transplantul renal). Exerezele paratiroidiene trebuie practicate doar de specialiști antrenați în această chirurgie.Background: Hyperparathyroidism (HP) is a constantly evolving entity with multiple clinical varieties i.e.: primary (HPP), renal (HPR), familial, in MEN etc., proteiform phenotype and symptomatology, continous modernizing diagnosis and therapeutic methods and striking differences in epidemiology between developed nations and the 3rd world’s or “in transition” countries. Material and methods: The study population comprised 63 patients with HP operated on from 1986 in our clinic. There were 20 cases with PHP (17 adenomas, 2 carcinomas and one parathyromatosis) and 43 cases with RHP (23 secondary and 20 tertiary). The series included 44 women and 19 men (ratio 2,3/1), aged 15-67 (range 47) years. As a rule the documentation of signs and symptoms as well as recording of the surgical indications were consistently thorough. The presence of multiple and recurrent urolithiasis in HPP and renal failure on hemodialysis in HPR as well as bone, muscular, neuropsychiatric, digestive and cardiovascular manifestation in both syndromes are constantly described. Laboratory data indicated abnormally levels of serum calcium, phosphorus, alkaline phosphatase but especially of the iPTH. Localisation procedures included ultrasonography less valuable for multiglandular lesions and recently 99mTc-tetrophosmin scan. Results: All the cases were operated on: 17 simple exeresis for adenomas and 4 “en bloc” resections to-gether with the thyroid lobe for two carcinomas, intrathyroid cystic adenoma and parathyromatosis one case each. In HPR 20 patients underwent standard subtotal parathyroidectomy (3 and ½ glands) but in 3 cases only 3 or even 2 glands were founded and 19 total parathyroidectomy respectively (6 with auto- transplantation). Thyroid (n=29) and thymus (20) resections were practiced for associated lesions or tac- tical reasons. Pathology established the final diagnosis. Immediate and late results were good especially in HPP. Persistent hypocalcemia was not encountered even in extended resections but we avow a cervi-cal hematoma,a recurrent laryngeal nerve palsy, two antibrahial recurrences and a carcinoma developed four years after resection of an adenoma (new lesion ?). Conclusions: Parathyroidectomy with its recent refinements in minimally invasive, endoscopic, video- and robotic techniques constitutes the gold standard therapy for HPP and still remains the only permanently effective method offering an improved quality of life in HPR. These operations must be done by high-specialised surgeons

Prognostic factors in atypical meningiom

Atypical meningioma represent an intermediary group between the benign meningioma (grade I) and anaplastic meningioma (grade III), and are known for high recurrence rate and short life expectancy. After modification of the classification World Health Organization in 2007, subsequent studies have tried to find prognostic factors for recurrence and survival, which are inconstant from author to author. This paper aims to present a short review of the most important prognostic factors in atypical meningioma

Selective maternal seeding and environment shape the human gut microbiome

Vertical transmission of bacteria from mother to infant at birth is postulated to initiate a life-long host-microbe symbiosis, playing an important role in early infant development. However, only the tracking of strictly defined unique microbial strains can clarify where the intestinal bacteria come from, how long the initial colonizers persist, and whether colonization by other strains from the environment can replace existing ones. Using rare single nucleotide variants in fecal metagenomes of infants and their family members, we show strong evidence of selective and persistent transmission of maternal strain populations to the vaginally born infant and their occasional replacement by strains from the environment, including those from family members, in later childhood. Only strains from the classes Actinobacteria and Bacteroidia, which are essential components of the infant microbiome, are transmitted from the mother and persist for at least 1 yr. In contrast, maternal strains of Clostridia, a dominant class in the mother's gut microbiome, are not observed in the infant. Caesarean-born infants show a striking lack of maternal transmission at birth. After the first year, strain influx from the family environment occurs and continues even in adulthood. Fathers appear to be more frequently donors of novel strains to other family members than receivers. Thus, the infant gut is seeded by selected maternal bacteria, which expand to form a stable community, with a rare but stable continuing strain influx over time.Peer reviewe

The tumour volume influence on tumour recurrence and progression-free survival in the case of atypical meningiomas: Our experience on a series of 81 cases

Objective: The objective of our study was to evaluate a possible relation between the volume of atypical meningiomas (AMs) and the risk of tumour recurrence, as well as progression-free survival (PFS). Material and methods: We evaluated 81 patients diagnosed with AMs (WHO grade II meningioma) who have undergone surgery at the "Prof. Dr. N. Oblu" Emergency Clinical Hospital Iasi between January 1, 2010, and December 31, 2019. The recorded data were demographic and imagistic (MRI, contrast-enhanced T1WI). We calculated the tumour volume prior to the surgery and evaluated the tumour recurrence using MRI at 12, 24, 36, 48 and 60 months after the surgery. Results: 50.6% of patients had meningioma volume < 26.4 cm3. Women had larger tumour volumes than men (52.6%). Patients of age ? 60 years old, had tumour volumes ? 26.4 cm3 in 58.5% of cases and meningiomas with volumes ? 26.4 cm3 recurred earlier (p=0.010). Also, patients who had tumour volumes ? 26.4 cm3, had a shorter PFS (40.976 months), compared to patients with tumour volumes < 26.4 cm3, who had better PFS (53.4 months). Conclusions: the tumour volume of AMs ? 26.4 cm3 represents a negative prognostic factor for both early tumour recurrence and reduced PFS

Mirror, mirror on the wall, who’s the fairest of them all? Atypical meningioma associated with multiple meningiomas

The incidence of multiple meningiomas (MMs) without stigmata of neurofibromatosis or family history of meningiomatosis is rare. MMs with atypical histology are even rarer, since most of them have benign histology. The authors report three cases of MMs, of which the symptomatic meningioma removed was an atypical meningioma (AM). We also review their possible pathogenesis and histopathology. Although there has not been established any MMs management and therapy strategy so far, our recommendation is to treat symptomatic and accessible lesions or growing tumours and also to prefer a conservative approach consisting of the imaging follow-up of asymptomatic lesions