Grey-scale analysis improves the ultrasonographic evaluation of thyroid nodules

Ultrasonography is the main imaging method for the workup of thyroid nodules. However, interobserver agreement reported for echogenicity and echotexture is quite low. The aim of this study was to perform quantitative measurements of the degree of echogenicity and heterogeneity of thyroid nodules, to develop an objective and reproducible method to stratify these features to predict malignancy.A retrospective study of patients undergoing ultrasonography-guided fine-needle aspiration was performed in an University hospital thyroid center. From January 2010 to October 2012, 839 consecutive patients (908 nodules) underwent US-guided fine-needle aspiration. In a single ultrasound image, 3 regions of interest (ROIs) were drawn: the first including the nodule; the second including a portion of the adjacent thyroid parenchyma; the third, the strap muscle. Histogram analysis was performed, expressing the median, mean, and SD of the gray levels of the pixels comprising each region. Echogenicity was expressed as a ratio: the nodule/parenchyma, the nodule/muscle, and parenchyma/muscle median gray ratios were calculated. The heterogeneity index (HI) was calculated as the coefficient of variation of gray histogram for each of the 3 ROIs. Cytology and histology reports were recorded.Nodule/parenchyma median gray ratio was significantly lower (more hypoechoic) in nodules found to be malignant (0.45 vs 0.61; P = 0.002) and can be used as a continuous measure of hypoechogenicity (odds ratio [OR] 0.12; 95% confidence interval [CI] 0.03-0.49). Using a cutoff derived from ROC curve analysis (<0.46), it showed a substantial inter-rater agreement (k = 0.74), sensitivity of 56.7% (95% CI 37.4-74.5%), specificity of 72.0% (67.8-75.9%), positive likelihood ratio (LR) of 2.023 (1.434-2.852), and negative LR of 0.602 (0.398-0.910) in predicting malignancy (diagnostic odds ratio 3.36; 1.59-7.10). Parenchymal HI was associated with anti-thyroperoxidase positivity (OR 19.69; 3.69-105.23). The nodule HI was significantly higher in malignant nodules (0.73 vs 0.63; P = 0.03) and, if above the 0.60 cutoff, showed sensitivity of 76.7% (57.7-90.1%), specificity of 46.8% (42.3-51.4%), positive LR of 1.442 (1.164-1.786), and negative LR of 0.498 (0.259-0.960).Evaluation of nodule echogenicity and echotexture according to a numerical estimate (nodule/parenchyma median gray ratio and nodule HI) allows for an objective stratification of nodule echogenicity and internal structure

Thyroid papillary carcinoma arising in ectopic thyroid tissue within a neck branchial cyst

BACKGROUND: Thyroid gland derives from one median anlage at the base of the tongue, and from the two fourth branchial pouches. A number of anomalies may occur during their migration. These can be in form of ectopic tissues, which are frequently found along the course of thyroglossal duct and rarely in other sites, many of these may develop same diseases as the thyroid gland. CASE PRESENTATION: A 36-years-old female presented with a 3 month history of left side neck mass. The mass disappeared following aspiration of brown colored fluid, which on cytological examination showed cells with nuclear irregularities that warranted the resection of the lesion. The histology demonstrated a thyroid papillary carcinoma arising within the branchial cyst. Thereafter, the patient underwent a total thyroidectomy with central lymph nodes dissection. Histology showed a multifocal papillary carcinoma with central lymph nodes metastases. Only four cases of primary thyroid carcinomas in neck branchial cyst have been described so far. CONCLUSION: In a lateral cystic neck mass, although rare, occurrence of ectopic thyroid tissue and presence of a papillary thyroid carcinoma should be kept in mind

Combined Inhibition of CDK4/6 and PI3K/AKT/mTOR Pathways Induces a Synergistic Anti-Tumor Effect in Malignant Pleural Mesothelioma Cells.

Malignant pleural mesothelioma (MPM) is a progressive malignancy associated to the exposure of asbestos fibers. The most frequently inactivated tumor suppressor gene in MPM is CDKN2A/ARF, encoding for the cell cycle inhibitors p16INK4a and p14ARF, deleted in about 70% of MPM cases. Considering the high frequency of alterations of this gene, we tested in MPM cells the efficacy of palbociclib (PD-0332991), a highly selective inhibitor of cyclin-dependent kinase (CDK) 4/6. The analyses were performed on a panel of MPM cell lines and on two primary culture cells from pleural effusion of patients with MPM. All the MPM cell lines, as well as the primary cultures, were sensitive to palbociclib with a significant blockade in G0/G1 phase of the cell cycle and with the acquisition of a senescent phenotype. Palbociclib reduced the phosphorylation levels of CDK6 and Rb, the expression of myc with a concomitant increased phosphorylation of AKT. Based on these results, we tested the efficacy of the combination of palbociclib with the PI3K inhibitors NVP-BEZ235 or NVP-BYL719. After palbociclib treatment, the sequential association with PI3K inhibitors synergistically hampered cell proliferation and strongly increased the percentage of senescent cells. In addition, AKT activation was repressed while p53 and p21 were up-regulated. Interestingly, two cycles of sequential drug administration produced irreversible growth arrest and senescent phenotype that were maintained even after drug withdrawal. These findings suggest that the sequential association of palbociclib with PI3K inhibitors may represent a valuable therapeutic option for the treatment of MPM

The size criteria in minimally invasive video-assisted thyroidectomy

BACKGROUND: Thyroid size is a very important criteria of MIVAT exclusion because the working space provided by the technique is limited. The aim of this work has been to verify the suitability of MIVAT and its applicability in clinical practice, not only in patients with a thyroid volume up to 25 ml but also in patients with a thyroid volume included from 25 to 50 ml. METHODS: From January 2003 to February 2006, 33 patients have been selected for MIVAT. A completely gasless procedure was carried out through a central 20 to 35 mm skin incision performed "high" between the cricoid and jugular notch. RESULTS: The patients were separated in 2 groups. The first group (less than 25 ml) included 23 patients, the second group (from 25 to 50 ml) included 10 patients. The skin incision performed was from 20 to 25 mm (mean 23.61 mm ± 1.83) long in the first group and from 25 to 35 mm (mean 27.8 mm ± 2.20) long in the second one; this difference is significant (t test p < 0.001). CONCLUSION: Our study suggest that the MIVAT using for thyroids bigger than 25 ml and up to 50 ml in volume is feasible and safe. This way allows more patients, excluded before, to take the advantages of minimally invasive approach

The minimally invasive open video-assisted approach in surgical thyroid diseases

BACKGROUND: The targets of minimally invasive surgery (MIVA) could be summarised by: achievement of the same results as those obtained with traditional surgery, less trauma, better post-operative course, early discharge from hospital and improved cosmetic results. The minimally invasive techniques in thyroid surgery can be described as either endoscopic "pure" approach (completely closed approach with or without CO(2 )insufflation), or "open approach" with central neck mini-incision or "open video-assisted approach". Traditionally, open thyroidectomy requires a 6 to 8 cm, or bigger, transverse wound on the lower neck. The minimally invasive approach wound is much shorter (1.5 cm for small nodules, up to 2–3 cm for the largest ones, in respect of the exclusion criteria) upon the suprasternal notch. Patients also experience much less pain after MIVA surgery than after conventional thyroidectomy. This is due to less dissection and destruction of tissues. Pathologies treated are mainly nodular goiter; the only kind of thyroid cancer which may be approached with endoscopic surgery is a small differentiated carcinoma without lymph node involvement. The patients were considered eligible for MIVA hemithyroidectomy and thyroidectomy on the basis of some criteria, such as gland volume and the kind of disease. In our experience we have chosen the minimally invasive open video-assisted approach of Miccoli et al. (2002). The aim of this work was to verify the suitability of the technique and the applicability in clinical practice. METHODS: A completely gasless procedure was carried out through a 15–30 mm central incision about 20 mm above the sternal notch. Dissection was mainly performed under endoscopic vision using conventional endoscopic instruments. The video aided group included 11 patients. All patients were women with a average age of 54. RESULTS: We performed thyroidectomy in 8 cases and hemithyroidectomy in 3 cases. The operative average time has been 170 minutes. CONCLUSION: Nowadays this minimally invasive surgery, in selected patients, clearly demonstrates excellent results regarding patient cure rate and comfort, with shorter hospital stay, reduced postoperative pain and most attractive cosmetic results