Identification of the nonrecurrent laryngeal nerve during thyroid surgery: 20-year experience

The nonrecurrent laryngeal nerve, which is rarely observed during thyroidectomy, is at high risk for damage. During a 20-year period 6000 thyroidectomies were performed at our institution, and during these operations inferior laryngeal nerves were routinely identified in all the patients with a standard procedure based on the usual anatomic landmarks. A nonrecurrent laryngeal nerve was observed on the right side in 31 cases (0.51%), with no anatomic anomalies found on the left side. The nerve anomaly was diagnosed preoperatively in five patients. A vocal cord deficit, caused by a nerve lesion, was observed in four cases (12.9%). Our results suggest that the best way to avoid morbidity is routine identification of the nerve. This can be done by carefully identifying all the thyroid structures and being suspicious of the presence of the abnormality when the inferior laryngeal nerve is not found in a classic position

Preoperative assessment of thyroid nodules: the surgeon's point of view

Abstract: A selective approach to patients with thyroid nodules, in order to differentiate between negative findings and uncertain or positive results requiring surgery, has been outlined. Fine needle aspiration biopsy (FNAB) is the most reliable and cost-effective technique currently available to distinguish benign from malignant thyroid disease. In those lesions diagnosed by FNAB as 'follicular lesions', radionuclide scanning, serum calcitonin and CEA determination, color doppler ultrasonography and the response to TSH suppressive therapy may be of assistance. Despite such screening procedures. the majority of follicular lesions remain indeterminate, and surgery is therefore necessary before a correct diagnosis can be made. (C) 2000 Editions scientifiques ct medicales Elsevier SAS

Endoleak after open abdominal aortic aneurysm repair: new open repair following unsuccessful endoluminal treatment

Endoleak is not a condition exclusively confined to stent grafts, developing after abdominal aortic aneurysm open repair also. The correction of this complication by endovascular procedure may be considered, but its possible unsuccessfulness may make the subsequent open repair quite awkward

Efficacy of sequential double tracer subtraction and SPECT parathyroid imaging in the precise localization of a low mediastinal parathyroid adenoma successfully removed surgically

Abstract: The case of a 58-year-old female patient with primary hyperparathyroidism (serum calcium levels = 12.3 mg/dL, serum PTH levels = 254 pg/mL) resulting from a rare case of solitary parathyroid adenoma located in the low mediastinum is described. The sequential acquisition of planar Tc-99m pertechnetate-MIBI subtraction scan and SPECT imaging precisely localized an intra-thymic parathyroid adenoma located in the lower portion of the mediastinum anteriorly close to the body of the sternum. High-resolution 10-MHz neck ultrasonography and neck-mediastinum spiral computed tomography scan did not reveal parathyroid enlargement. A 14-mm sized intrathymic parathyroid adenoma was successfully removed through a 4-cm median cervicotomy by pulling up and excising the thymus. Thus, in this patient, the accurate preoperative scintigraphic localization of the parathyroid adenoma allowed the surgeon to avoid a sternotomy as is usually required in these cases. Intraoperative, rapid PTH levels fell to the normal range and serum calcium levels remained in the normal range in the subsequent 15-month follow up

Papillary thyroid microcarcinoma (PTMC: prognostic factors management and outcome in 403 patients.

AIM: To investigate an "optimal" therapeutic management of patients with papillary thyroid microcarcinoma (PTMC). METHODS: We evaluated a group of 403 consecutive patients affected by PTMC operated on by the same surgeon. Prognostic factors were evaluated by uni- and multivariate statistical analysis. RESULTS: After a mean follow-up of 8.5 years, 372 patients were living without disease (undetectable serum thyroglobulin levels), 24 patients were living with disease (increased serum thyroglobulin levels), 6 patients were deceased due to causes different from thyroid cancer, and 1 patient was deceased due to metastatic thyroid cancer. No statistically significant prognostic factor was found at uni- and multivariate analysis. However, it is worth noting that in patients with a larger primary tumour (size> or =5mm) and treated by partial thyroidectomy alone, the prevalence of recurrent disease was higher than in patients treated by total thyroidectomy and (131)I administration. CONCLUSION: It appears reasonable to perform total thyroidectomy (possibly associated with central compartment node dissection), (131)I whole body scan (followed by (131)I therapy when necessary) and TSH-suppressive hormonal therapy in patients with PTMC

Papillary thyroid carcinoma: 35-year outcome and prognostic factors in 1858 patients.

BACKGROUND AND AIM: Papillary thyroid carcinoma (PTC) is universally regarded as a curable malignancy with a favorable prognosis. However, a minority of patients may present, or subsequently develop, locoregional and distant metastases that may adversely affect survival. The value of the various staging methods is complicated by different approaches to diagnostic, therapeutic and follow-up strategies. We aimed at assessing the prognostic factors and survival rate in a large cohort of patients treated and followed up in the same center. MATERIALS AND METHODS: A total of 1858 patients with PTC operated on by the same surgeon, and followed in the same center over a period of 35 years, were included. Total thyroidectomy was performed in the majority of patients after I-131 diagnostic scans and thyroglobulin assays. When the latter 2 were positive, therapy with I-131 was given. Follow-up was performed periodically and further therapy doses were administered when necessary. All patients were maintained on life-long thyroxine. RESULTS: Ninety-three patients (5%) developed evidence of locoregional or distant metastases after an average follow-up period of 7.9 years (range 1.53-30.5 years). Univariate analysis showed all variables (except for gender) to be significantly correlated with disease recurrence and survival. Multivariate analysis showed 4 variables to be significant and independent prognostic factors: patient age at first treatment, extent of disease, extent of surgery, and the presence of I-131 positive metastases. DISCUSSION AND CONCLUSION: Our data agree with other scoring systems in that patient age at first treatment and the extent of disease are significant and independent prognostic factors. However, and at variance with other methods, we found that the extent of primary surgery and the presence of I-131 positive or negative metastases have similar prognostic significance. In high risk patients, total thyroidectomy and lymphadenectomy followed by I-131 treatment and TSH-suppressive hormonal therapy are recommended

Natural history, diagnosis, treatment and outcome of medullary thyroid cancer: 37 years experience on 157 patients.

Aim: The analysis of a 37-year retrospective study on diagnosis, prognostic variables, treatment and outcome of a large group of medullary thyroid cancer (MTC) patients was conducted, in order to plan a possible evidence-based management process. Methods: Between Jan 1967 to Dec 2004, 157 consecutive MTC patients underwent surgery in our centre: 60 males and 97 females, mean age 47.3 years (range 6-79). Total thyroidectomy was performed in 143 patients (91.1%); central compartment (CC) node dissection (level VI) in 41 patients; central plus lateral compartment (LC) node dissection (levels II, III, and IV) in 82 patients. Subtotal thyroidectomy was initially performed in 14 cases: 10 of them were re-operated because of persistence of elevated serum calcitonin levels. Results: After a median post-surgical follow-up of 68 months (range 2-440 months), 42.9% of patients were living disease-free, 39.8% were living with disease, 3.1% were deceased due to causes different from NITC, and 3.2% were deceased due to MTC. The overall 10-year survival rate was 72%. At uni-variate statistical analysis (a) patient's age at initial treatment (> 45 years; > 45 years), (b) sporadic vs. hereditary MTC, (c) disease stage, and (d) the extent of surgical approach resulted as significant variables. Instead, at multivariate statistical analysis, only (a) patient's age at initial diagnosis, (b) disease stage, and (c) the extent of surgery resulted as significant and independent prognostic variables influencing survival. Conclusion: The presence of lymph node and distant metastases at first diagnosis significantly worsened prognosis and survival rate in our series. Early diagnosis of MTC is very important, allowing complete surgical cure in Stages I and II patients. Due to the relatively bad prognosis of MTC, especially for disease Stages III and IV, it appears reasonable to recommend radical surgery including total thyroidectomy plus CC lymphoadenectomy as the treatment of choice, plus LC lymphoadenectomy in patients with palpable and/or ultrasound enlarged neck lymph nodes. (c) 2006 Elsevier Ltd. All rights reserved

Natural history , diagnosis, treatmente and outcome of medullary thyroid cancer: 37 yars experience on 157 patients.

AIM: The analysis of a 37-year retrospective study on diagnosis, prognostic variables, treatment and outcome of a large group of medullary thyroid cancer (MTC) patients was conducted, in order to plan a possible evidence-based management process. METHODS: Between Jan 1967 to Dec 2004, 157 consecutive MTC patients underwent surgery in our centre: 60 males and 97 females, mean age 47.3 years (range 6-79). Total thyroidectomy was performed in 143 patients (91.1%); central compartment (CC) node dissection (level VI) in 41 patients; central plus lateral compartment (LC) node dissection (levels II, III, and IV) in 82 patients. Subtotal thyroidectomy was initially performed in 14 cases: 10 of them were re-operated because of persistence of elevated serum calcitonin levels. RESULTS: After a median post-surgical follow-up of 68 months (range 2-440 months), 42.9% of patients were living disease-free, 39.8% were living with disease, 3.1% were deceased due to causes different from MTC, and 3.2% were deceased due to MTC. The overall 10-year survival rate was 72%. At uni-variate statistical analysis (a) patient's age at initial treatment (>45 years; >/=45 years), (b) sporadic vs. hereditary MTC, (c) disease stage, and (d) the extent of surgical approach resulted as significant variables. Instead, at multivariate statistical analysis, only (a) patient's age at initial diagnosis, (b) disease stage, and (c) the extent of surgery resulted as significant and independent prognostic variables influencing survival. CONCLUSION: The presence of lymph node and distant metastases at first diagnosis significantly worsened prognosis and survival rate in our series. Early diagnosis of MTC is very important, allowing complete surgical cure in Stages I and II patients. Due to the relatively bad prognosis of MTC, especially for disease Stages III and IV, it appears reasonable to recommend radical surgery including total thyroidectomy plus CC lymphoadenectomy as the treatment of choice, plus LC lymphoadenectomy in patients with palpable and/or ultrasound enlarged neck lymph nodes