Complications of neck dissections in papillary thyroid carcinoma. A modified procedure to reduce parathyroid morbidity

Lymphatic metastasis develops in approximately 20% to 80% of patients with papillary thyroid carcinoma (PTC). Clinically evident pathologic nodes should be treated with therapeutic neck dissection. The extent of lymph node dissection, based on predictable drainage patterns from PTC, includes central compartment dissection with nodal clearance of level VI, and modified radical dissection of the lateral compartment with removal of levels II through V. Neck dissection, though a reliably safe procedure, carries certain potential complications.The most significant morbidity following therapeutic neck dissection for PTC is hypoparathyroidism, related to parathyroid damage leading to temporary or permanent hypocalcemia. This complication occurs most often when lateral neck dissection is combined with total thyroidectomy plus central neck dissection. That increased hypoparathyroidism appears not to be associated with incidental removal of the parathyroid glands or the number of parathyroid glands preserved, but to vascular compromise in the dissected central neck, related to the extension of nodal dissection to include the central neck to lateral cervical compartment. To reduce parathyroid morbidity we have modified the surgical procedure in the management of patients with PTC and neck nodal involvement, and approach, first, the lateral compartment via extrathyroideal space and perform the nodal basins dissection according to operation popularized by O.Suarez and named " functional neck dissection", which is based on the facial compartments and the facial envelope in the neck. KEY WORDS: Cervical lymph node metastases, Neck dissections, Papillary thyroid carcinoma.

Comparison of Chromosome Aberration Frequency before and after Administration of 131I in Two Groups of Thyroid Cancer Patients

The chromosome aberration frequencies of 10 thyroid cancer patients, before and after their first radioiodine treatment (group A), were compared to the frequencies found in another 10 subjects previously treated with two or more radioiodine administrations (group B). Our data show that the relative increase in chromosome-type aberrations was similar in the two groups: from 2.0% to 3.7% (group A) and from 4.7% to 9.0% (group B). However, the increase in the number of cells with aberrations was greater in group A. Moreover, the higher frequency of aberrations in group B, even before the radioiodine treatment, points out the effect of previous treatments and demonstrates the persistence of this type of lesion. The sister chromatid exchange frequency in the two groups was also analysed, but no effect bound to the radioiodine treatment could be demonstrated.

Complications of Neck Dissections in Papillary Thyroid Carcinoma: A Modified Procedure to Reduce Parathyroid Morbidity

BACKGROUND/AIM

Hypoparathyroidism is the most significant morbidity after neck dissection for thyroid cancer. Addition of lateral neck dissection (ND) to central ND combined with total thyroidectomy (TT) increases the risk of postoperative hypoparathyroidism compared to TT plus central ND. The aim of this study was to verify if a modified procedure and different access to the neck for lateral ND may improve safety.

PATIENTS AND METHODS

In 62 patients with papillary thyroid cancer (PTC) undergoing TT plus central and lateral ND between 2010 and 2013, lateral ND was performed as first step approaching the neck via extrathyroideal space. Calcium in serum and parathormone (PTH) were determined preoperatively, intraoperatively and during the follow-up.

RESULTS

Twenty patients (32%) developed postoperative hypocalcemia. Calcium levels and PTH completely recovered for 58 out of 62 patients from 3 to 6 months after surgery. After a mean of 12 months' follow-up, only four patients (6.5%) had developed permanent hypoparathyroidism. The incidence of parathyroid complication after TT plus central ND and lateral ND did not differ from postoperative hypoparathyroidim after TT plus central ND.

CONCLUSION

The presented surgical procedure may provide a better outcome in terms of parathyroid morbidity.

Papillary thyroid microcarcinoma: proposal of treatment based on histological prognostic factors evaluation

BACKGROUND

Papillary thyroid cancer accounts for approximately 80% of thyroid tumors and its incidence has increased over the past decades. Papillary thyroid microcarcinomas (PMCs), defined by the World Health Organization as less than 1.0 cm in size, are identified with greater frequency. The majority of patients with PMCs follows a benign clinical course, however a subgroup of these carcinomas is as aggressive as bigger tumors. Risk factors related with poor outcome have not been defined and the optimal treatment has not been proved. The authors investigated histologic prognostic factors predicting high risk patients considered for more aggressive treatment and propose reviewed therapeutic guidelines based on analysis of histopathologic features which determined the recurrence rate.

STUDY DESIGN

One hundred forty nine patients with PMC who underwent surgery were retrospectively analyzed. Clinical and histopathologic parameters potentially predicting patient outcome and recurrent disease were statistically investigated, after a minimum follow-up of 5 years.

RESULTS

After a median follow-up of 5.4 years 28 of 149 patients experienced recurrent disease. All of them were reoperated on and newly treated with radioiodine administration. The multivariate statistical analysis identified extrathyroidal invasion (Odds Ratio, OR, 58.54; P=0.013), the solid pattern (OR,25.77; P>0.001), the tumor multifocality (OR, 15.80; P= 0.005), and the absence of tumor capsule (OR, 9.74; P=0.015) as significant and indipendent risk factors for the appearance of PMCs recurrences. Of note, none of the PMC "incidentally" discovered at histopathological examination alone experienced recurrent disease during follow-up.

CONCLUSIONS

Although most PMC have favourable long-term prognosis, some patients (19% in our series) presented aggressive clinical course strongly correlated with some histopathologic features (extrathyroidal invasion, tumor multifocality, solid pattern and absence of capsule) who need to be investigated and for whom a radical therapeutic approach is recommended based on total thyroidectomy and regional lymphadenectomy followed by radioiodine administration.

Radioguided parathyroidectomy in forearm graft for recurrent hyperparathyroidism

We report a peculiar case of recurrent hyperparathyroidism caused by hyperplasia of a forearm graft implanted following a total parathyroidectomy in a 38-year-old patient with chronic renal failure. The forearm graft hyperplasia was detected using (99)Tc(m)-sestamibi scanning, which identified hyperplastic transplanted parathyroid tissue in the forearm of the patient. During the initial surgery, the surgeon failed to mark the parathyroid tissue with sutures or clips to facilitate locating it. Therefore, we referred the patient for radioguided surgery. This surgical procedure allowed us to locate and completely remove the hyperfunctioning transplanted parathyroid tissue.

Immunohistochemical evaluation of inflammatory and proliferative markers in adjacent normal thyroid tissue in patients undergoing total thyroidectomy: results of a preliminary study

Background

Total thyroidectomy is the treatment of choice in the majority of thyroid malignancies, preventing the risk of reoperative surgery due to recurrences. In order to assess the usefulness of such an approach, expression levels of inflammatory and proliferative markers were evaluated immunohistochemically in non-lesional adjacent thyroid tissues from a group of patients who underwent total thyroidectomy for different thyroid diseases.

Methods

Nineteen consecutive patients treated by total thyroidectomy for different thyroid diseases entered the study. IL-6Rb gp130 component of the IL-6 cytokine family members receptor complexes, STAT3 cytokine signalling transduction and transcription activation factor, p53 as tumour suppressor and CK19 cytokeratin as proliferation marker were analyzed in non-lesional thyroid tissues.

Results

Gp 130 expression was detected in all tissue samples with a scattered distribution while STAT3 and p53 positivity was observed in 17 out of 19 patients with a prevailing cytoplasmic localization. Cytokeratin 19 positivity was found in patients with papillary carcinoma, in one case of follicular adenoma, 3 multinodular goiters and one Basedow disease.

Conclusion

Based on the results of this preliminary study, it may be concluded that the presence of a persisting cytokine-mediated activation associated with cytoplasmic localization of p53 is frequently observed in different thyroid diseases. Such a process seems to occur in the thyroid gland as a whole. Moreover, STAT3 activation as well as mutant p53 are risk factors for the development of neoplastic diseases. Total thyroidectomy may be supported as an adequate therapeutic approach for all the patients in whom overexpression of cytokine-dependent markers is detected.

Thyroidectomy with ultrasonic dissector: a multicentric experience

INTRODUCTION

We have conducted a clinical controlled trial (CCT) on patients who had undergone thyroidectomy for goitre or thyroid carcinoma. The endpoint of this study was to evaluate the benefits of ultrasonic dissector vs conventional technique (vessel ligation and tight) in patients undergoing thyroid surgery.

PATIENT AND METHODS

Between January 2007 and December 2009 a CCT was conducted on 2.736 consecutive patients admitted to our clinical wards, who had undergone thyroidectomy for goitre or thyroid carcinoma. They were divided in two group: 1.021 patients (203 male and 818 female) underwent thyroidectomy with ultrasonic dissector (UAS) and 1.715 patients (369 male and 1.346 female) underwent throidectomy with conventional technique (vessel ligation and tight) (CT).

RESULTS

The operative time (UAS 80 minutes mean, 50 to 120 min., vs CT 120 minutes, 70 to 180 minutes) was much lower in the thryoidectomy with UAS group. The incidence of transient laryngeal nerve palsy (UAS 17/1.021 patients. 1.6% vs CT 16/1.715 patients, 0.9%) was higher in the thyroidectomy with UAS group; the incidence of permanent laryngeal nerve palsy was similar in two groups(UAS group; there are no relevant difference in the incidence of permanent hypocalcemia (UAS 26/1.021 patients, 2.5% vs 35/1.715 patients, 2%) which was similar in two groups. Also the average post-operative hospitalization was similar in two groups (2 days).

CONCLUSIONS

Actually, the only significant advantage shown from this CCT is represented in terms of cost-effectiveness (reduction of the usage of operating room and hospitalization) for patients treated with UAS, subsequent to the significant reduction of operative duration. Although the analysis showed that the patients who were treated with ultrasonic dissection don't present more favourable results in incidence of post-operative transient complication:transient laryngeal nerve palsy (1.6% in UAS vs 0.9% in CT) and transient hypocalcaemia (9.5% in UAS vs 7.7% in CT). There is no significant difference in the incidence of permanent laryngeal nerve palsy (0.9% in UAS vs in 1% CT). The experience of surgeon is the only important factor which can influence the appearance of these complications; the usage of Ultrasonic dissector can only help surgical action but can't repair the experience of the operator.

The role of fine-needle aspiration performed with liquid-based cytology in the surgical management of thyroid lesions

BACKGROUND

The aim of this retrospective study was to assess the accuracy and usefulness of cytological classification of fine-needle aspirates in determining the appropriate surgical treatment for thyroid lesions studied with conventional smears (CS) and liquid-based cytology (LBC) in a split-sample method.

PATIENTS AND METHODS

A total of 353 patients were studied with both CS and LBC. The cytological diagnoses were classified according to the British Thyroid Association into 5 groups: Thy1, inadequate; Thy2, non-neoplastic or benign group including goiter, thyrocytic hyperplasia without nuclear atypia and thyroiditis; Thy3 or indeterminate/follicular proliferation, including follicular neoplasm not otherwise specified and oxyphilic follicular neoplasm; Thy4, suspicious for malignancy, including follicular lesion with nuclear pleomorphism; Thy5, diagnostic for malignancy including papillary carcinoma and medullary carcinoma. The efficacy of thyroid fine-needle aspiration processed by CS with LBC in a split-sample method was evaluated.

RESULTS

Overall 164 patients were included in the Thy2, 97 in the Thy3, 49 in the Thy4, and 43 in the malignant Thy5 group. The percentage of unnecessary thyroidectomies decreased from 58.5 to 42% in our series.

CONCLUSION

Our subclassification, according to the British Thyroid Association classification, attempts to reduce the number of Thy3 who undergo surgery. The comparison between the traditional management of thyroid lesions and our morphological categories with the use of CS and LBC together allows the number of unnecessary thyroidectomies to be reduced.

[Diagnostic, therapeutic and healthcare management protocols in parathyroid surgery. 1st Consensus Conference]

AIM

The aim of the study was to draw up a management protocol in parathyroid surgery promoted by the Italian Association of Endocrine Surgery Units (UEC Club), based on the guidelines of the main international scientific societies and shared by the experts and applied by the operators in the sector.

METHODS AND CONSENSUS

The management protocols, already presented in 2003, on the occasion of the current review were examined by the 1st Consensus Conference called on the topic by the Italian Association of Endocrine Surgery Units (UEC). The Conference comprised two distinct sessions, the first in November 2006 within the framework of the 5th National Congress of the UEC Club in Verona, and the second in September 2007 within the framework of the 10th Multidisciplinary Scanno Prize Meeting. A selected board of endocrinologists and endocrine surgeons examined the individual chapters and submitted the consensus text for the approval of several experts.

CONCLUSIONS

The diagnostic, therapeutic and healthcare management protocols in parathyroid surgery approved by the 1st Consensus Conference are officially those proposed by the Italian Association of Endocrine Surgery Units (UEC Club) and are subject to review by October, 2009.

Iodine-131 radio-guided surgery in differentiated thyroid cancer: Outcome on 31 patients and review of the literature

In the present study we investigated the role of radio-guided surgery with Iodine-131 (I-131) in a group of 31 patients with differentiated thyroid cancer (DTC) and loco-regional recurrent disease. The principal inclusion criterion for I-131 radio-guided surgery in our protocol was the presence of an I-131 positive loco-regional disease relapse after previous total thyroidectomy and at least 2 ineffective conventional I-131 treatments. The protocol we used consisted of the following steps. Day 0: all patients were hospitalized and received a therapeutic 3.7 GBq (100 mCi) dose of I-131 after thyroid hormone therapy withdrawal in condition of overt hypothyroidism (serum TSH levels>30 microUI/ml). Day 3: a whole body scan following the therapeutic I-131 dose (TxWBS) administration was acquired. Day 5: neck surgery was performed through a wide bilateral neck exploration using a 15-mm collimated gamma probe, measuring the absolute intra-operative counts and calculating the lesion to background (L/B) ratio. Day 7: post-surgery TxWBS was performed using the remaining radioactivity to evaluate the completeness of tumoral lesions extirpation. The final histologic examination showed the presence of 184 metastatic foci; among them, 98 (53.2%) were evident by both TxWBS and gamma probe evaluation, 76 (41.3%) were demonstrated only by gamma probe, and 10 (5.4%) were negative by both TxWBS and gamma probe evaluation. During follow-up (8 months to 4.9 years, mean 2.8 years), DxWBS, serum Tg levels off l-T4, and US showed absence of loco-regional disease in 25 patients (80.6%) while 6 patients had persistent disease. In conclusion, this protocol allowed us to identify neoplastic foci with high sensitivity and specificity, enabling us to remove loco-regional I-131 disease recurrences resistant to previous conventional I-131 therapies. Furthermore, the gamma probe allowed detection of some additional tumoral foci in sclerotic areas or located behind vascular structures that were not visualized at the pre-surgery TxWBS evaluation.

Evaluation of the surgical completeness after total thyroidectomy for differentiated thyroid carcinoma

BACKGROUND

To quantify the rate of patients without thyroid remnants, to identify predictive factors for the absence of residual thyroid tissue and to evaluate number, site, size and function of thyroid remnants after total thyroidectomy for differentiated thyroid carcinoma (DTC).

METHODS

Thousand one hundred and seventy-eight patients who underwent total thyroidectomy for DTC were evaluated; 343 patients with lymph node or distant metastases and 115 patients with detectable thyroglobulin autoantibodies (TgAb) were excluded. (131)I ablative treatment (RAI) without preliminary diagnostic (131)I whole body scans (DxWBS), and 24-h (131)I quantitative neck uptake (RAIU test) and thyroglobulin (Tg) off L-T4 evaluation were performed in the remaining 720 pts. In 252 patients a 99mTc-pertechnetate pre-operative thyroid scan (99mTc-scan) was used for comparison with (131)I neck scans after RAI to evaluate site of thyroid remnants. Only patients with thyroid remnants were evaluated for successful ablation 6-10 months after RAI.

RESULTS

Post-treatment whole body scan (TxWBS) demonstrated lack of thyroid remnants in 50/720 patients and the best predictive factors for the absence of residual thyroid tissue were RAIU <1% and undetectable Tg off L-T4. Thyroid remnants were present in 670/720 patients. In 252 patients with (99m)Tc-scan, 617 sites of functioning thyroid tissue were found: 381 within and 236 outside the thyroid bed. Complete successful ablation was achieved in 610/670 patients with thyroid remnants.

CONCLUSIONS

This study confirms that most patients (93.1%) have thyroid remnant after total thyroidectomy for DTC. Most thyroid remnants were contralateral to tumour site and were even observed outside thyroid bed. However, a real total thyroidectomy, demonstrated by negative TxWBS, RAIU <1% and undetectable Tg off L-T4, was achieved in 6.9% of patients.

[Diagnostic, therapeutic and healtcare management protocols in thyroid surgery. I consensus conference (UEC club)]

The aim of the study was to draw up a management protocol in thyroid surgery promoted by the Italian Association of Endocrine Surgery Units (Club delle UEC), shared by the experts and applied by the operators in the sector. The management protocols already presented in February 2002 and drawn up by the first Author of the present publication on the occasion of the current review were examined by the I Consensus Conference called on the topic by the Italian Endocrine Surgery Units. The conference comprised two distinct sessions, the first on 18 June 2005 within the framework of the 4th National Congress of the Club delle UEC in Naples, and the second on 17 September 2005 within the framework of the 8th Multidisciplinary Scanno Prize Meeting. A selected board of endocrinologists and endocrine surgeons, chaired by Aldo Pinchera and comprising the first nine Authors of this paper, examined the individual chapters in close collaboration with the other Authors, comparing their findings with the opinions of the experts cited in the text and submitting the consensus text for the approval of all those present. The diagnostic, therapeutic and healtcare management protocols in thyroid surgery approved by the I Consensus Conference are officially those proposed by the Italian Association of Endocrine Surgery Units (Club delle UEC) and are subject to review by October 1, 2007.

Treatment of local and regional recurrences of differentiated thyroid cancer by radio-guided surgery with iodine-131

BACKGROUND/MATERIAL AND METHODS: The aim of this study was to assess the reliability of radioiodine ((131)I) and a gamma probe for radio-guided surgery (RGS) to detect and radically dissect lymph node recurrence (LNR) in 15 patients with differentiated thyroid cancer (DTC). The major inclusion criterion was the presence of a radioiodine-positive LNR after previous total thyroidectomy and at least two ineffective (131)I treatments. The protocol was designed as follows: Day 0--all patients were hospitalized and received 3.7 GBq of (131) I while clinically hypothyroid. Day 3--pre-surgery whole-body scan with a therapeutic (131)I dose (TxWBS) was acquired. Day 5--neck surgery using a gamma probe (Navigator GPS, AutoSuture, Italy), recording the absolute counts and the lesion/background (L/B) counts ratio was performed. Day 7--post-surgery TxWBS was performed using the remaining radioactivity.

RESULTS AND CONCLUSIONS

This protocol permitted us to identify neoplastic foci with high sensitivity and specificity, enabling us to remove lymph node metastases resistant to radioiodine therapy in a single session. The protocol also allowed detection of some additional tumoural foci in sclerotic areas or behind vascular structures that were not seen at the pre-surgery TxWBS evaluation.

A less invasive, selective, functional neck dissection for papillary thyroid carcinoma

HYPOTHESIS

To describe an alternative lateral neck access in order to perform neck dissection in papillary thyroid carcinoma (PTC) with lymph node involvement.

DESIGN

Prospective (January 2000 to December 2003), 36-month study.

SETTING

Catholic University of Rome and University of "Tor Vergata", Rome, Italy.

PATIENTS AND METHODS

Twenty-four consecutive patients with PTC and cervical lymph node metastases were included. Functional neck dissection (FND), unilateral or bilateral, was performed acceding via a lateral dissection through a traditional Kocher incision, running along the superficial fascia of the neck and posteriorly to the sternocleidomastoideus muscle.

RESULTS

Mean age was 39.04+/-13.69 years. Twenty patients were women and four were men. Mean tumour size was 2.5+/-1 cm, while the greatest metastatic lymph node size was 4.5 cm. Minimally invasive, selective FND was performed in all patients associated to total thyroidectomy and central compartment lymph node clearance. Metastatic lymph nodes were found in 142 out of 340 of the lymph nodes dissected.

CONCLUSIONS

Minimally invasive neck dissection seems to carry a lower risk in terms of specific morbidity and allows a quicker recovery and a better aesthetic result. This access has to be considered as a less invasive procedure compared to the other surgical accesses for the radical or modified lateral neck dissection.

[Differentiated tumor of the thyroid in children and adolescents]

Differentiated thyroid carcinoma (DTC) is rare in young patients and represents 0,5 to 3,0% of childhood carcinomas. The incidence increases with age: a peak incidence is observed between 15 and 19 years of age. DTC in children is frequently associated with greater risk of cervical lymph node involvement (60-80% of cases) and lung metastases at diagnosis in 20% of patients. However the prognosis for these patients is better when compared with that of adults, despite a high incidence of relapse, leading to reoperation. Young age (<16 years), lymph node involvement or distant metastases at diagnosis and some histopathologic characteristics have been suggested as predictive factors of recurrences. The records of 33 patients with DTC in a 14-year period (1990-2004) were reviewed. There were 31 females and 2 males who ranged from 11 to 21 years. At the diagnosis 15 patients had disease confined to the thyroid, 18 had additional lymph node metastases in the neck; one of them had also lung metastases. Total thyroidectomy (TT) was the elective approach in all patients (4 cases videoassisted). TT was associated to functional neck dissection in 21 cases. 131I was administrated to 28 patients (3,7 GBq as ablative dose): 11 of this received further radioiodine treatments (mean 7,4 GBq) because of elevated serum thyroglobulin levels and presence of loco-regional or lung metastasis at diagnostic total body scan after 131I treatment. The overall survival rate was 100% at a follow up of 4 months to 14 years.

[Legal contentions in thyroid surgery. Kind of preoperative information to the patients]

The question of patients information and the achievement of an informed consent to medical and/or surgical treatment by the patient still represents one of the main issue of the medical profession, having greater importance nowadays in respect to the past regarding the relationship doctor-patient and to the diagnostic-therapeutic approach to the patient. Written informed consent is a pre requisite for surgical intervention as it provides the forum for the patient to appreciate implications of the procedure and the doctor to explain details and effects of the surgery. Patients refusal is, nowadays, according to the latest orientation of the Italian Supreme Court, the major limitation to medical or surgical intervention. For these reason we have thought better to propose a written form of informed consent regarding the thyroid surgery, which implies, more than other surgery's act, the exposition of the patient to adverse iatrogenic risks and as a consequence it can expose the surgeon to criminal or civil liabilities.

Diagnostic Lobectomy for Unilateral Follicular Nodules of the Thyroid Gland

We describe our technique of diagnostic lobectomy (DL) and the rationale it is based on. We define DL as a minimally invasive procedure consisting of total lobectomy and isthmusectomy, with preservation of the omolateral recurrent laryngeal nerve and parathyroid glands, but without digital exploration of the contralateral lobe. The fact that re-entry into the previously explored field to complete thyroidectomy increases the risk of complications must be taken into consideration. The subjects were 63 consecutive patients who underwent surgery for unilobar follicular neoplasms of the thyroid gland between January 1997 and December 2002. There were 49 follicular adenomas and 14 carcinomas. In the 14 patients with thyroid cancer, total thyroidectomy was performed within 2 weeks after the first operation in a sterile environment with normal anatomical cleavage plains, avoiding any risk of injury to the laryngeal nerves and parathyroid glands. It is concluded that DL is a safe and suitable surgical procedure for patients with follicular-structured lesions of the thyroid gland.

In vivo and in vitro effects of different anaesthetics on platelet function

Different effects of thiopental, propofol and sevoflurane on platelets have been reported. Patients undergoing thyroid surgery were anaesthetized with thiopental-fentanyl-sevoflurane (n = 11) or propofol-fentanyl-sevoflurane (n = 9). Platelet aggregation and thromboxane A2 generation were studied at baseline, and at the end of anaesthesia induction and surgery. Dose-response experiments were also performed in vitro with single agents. Thiopental-fentanyl-sevoflurane significantly reduced collagen-induced aggregation by the end of induction, while ADP-induced aggregation and thromboxane generation were unaffected. Propofol-fentanyl-sevoflurane had no effect on platelets. Thiopental dose-dependently inhibited platelets in vitro, while fentanyl or propofol did not. In conclusion, thiopental reduces platelet function both ex vivo and in vitro and propofol might be considered haemostatically safer.

Revisited anatomy of the recurrent laryngeal nerves

BACKGROUND

The most frequent postthyroidectomy complication is recurrent laryngeal nerve (RLN) damage with subsequent vocal cord palsy.

METHODS

We have undertaken an intraoperative study aimed to determine the course, distribution, and RLN's anatomical relationships with adjacent structures. Only its identification and its careful exposure allow prevention of iatrogenic injuries.

RESULTS

The RLN was always routinely exposed and identified in 1,543 thyroidectomies. All patients underwent laryngoscopic evaluation before surgery and at the time of discharge. A total of 2,626 RLN were observed. The number of nerves exposed to risk was 673 (25.6%). In the whole series, of 2626 nerves controlled, there were 11 (0.4%) permanent palsies.

CONCLUSIONS

Our study confirms that damage to the RLN or to one of its branches may be avoided only by identification and careful exposure of the nerve itself. An experienced surgeon with good knowledge of the anatomy of the RLN and its anatomical variations is required for uncomplicated treatment of thyroid disease.

Modified radical neck dissection via extra-thyroideal space (MRND vets) in papillary thyroid carcinoma

The purpose of this study was to describe an alternative lateral neck access to perform lymph nodes sampling and/or neck dissection via extra-thyroideal space (MRND vets) in papillary thyroid carcinoma with lymph nodes involvment. Twenty-four consecutive patients with papillary thyroid carcinoma were included. Lymph nodes sampling and modified radical neck dissection, unilateral or bilateral, were performed acceding via a lateral dissection through a traditional Kocher incision, running along the medial fascia of the neck, posteriorly to the sterno-cleido-mastoideus muscle (SCM). Mean age was 39.04 +/- 13.69 years. Twenty patients were women, and 4 were men. Mean tumor size was 2.5 +/- 1 cm.. Total thyroidectomy with lymph nodes dissection of the central compartment associated to modified radical neck dissection was performed in 17 patients: among these, nine patients had a preoperative diagnosis of the latero-cervical lymph nodes metastases, and eight had a perioperative diagnosis of metastases of the extensive sampling of the lower third of the jugular chain. Metastatic lymph nodes were found in 107 out of 615 lymph nodes dissected. The MNRD vets access for modified lateral neck dissection seems to carry a lower risk in terms of specific morbility and allows a quicker recovery and a better cosmetic result. This access has to be considered as a less invasive procedure compared to other surgical accesses for the radical modified lateral neck dissection.

Radio-guided surgery for lymph node recurrences of differentiated thyroid cancer

The objectives of this study were to assess the reliability of radio-iodine (131I) and a gamma probe for radio-guided surgery (RGS) to detect and then radically dissect lymph node recurrences (LNRs) in 10 patients with differentiated thyroid cancer (DTC). The major inclusion criterion was the presence of an iodine-positive LNR after previous total thyroidectomy and at least two ineffective 131I treatments. The protocol was designed as follows. Day 0: all patients were hospitalized and received 3.7 GBq of 131I in the hypothyroid condition. Day 3: presurgery whole-body scan with a therapeutic dose (TxWBS). Day 5: neck surgery using a gamma probe (Navigator GPS, AutoSuture, Italy), recording the absolute counts and the lesion/background (L/B) counts ratio. Day 7: post-surgery TxWBS performed using the remaining radioactivity. The presurgery TxWBS was positive in all patients, and the post-surgery TxWBS showed a negative pattern in 7 of 10 patients, suggesting the efficacy of the surgical procedure in most of the patients. After RGS the mean decrease in the absolute counts and the L/B counts ratio were 77.6% (52.7% minimum, 94.6% maximum) and 77.4% (52.3% minimum, 94.8% maximum), respectively. After operation the surgeon judged the procedure to be decisive in two patients, favorable in six, and irrelevant in two. The final histologic examination showed the presence of 78 lymph node metastases (mean of 8 per patient). There were 33 neoplastic lesions found by both TxWBS and gamma probe evaluations; 41 were shown only by gamma probe, and 4 were negative by both TxWBS and gamma probe evaluations. This protocol permitted us to look for neoplastic foci with high sensitivity and specificity, and we were able to remove lymph node metastases resistant to radioiodine therapy at a single session. The protocol also allowed detection of some additional tumoral foci in sclerotic areas or behind vascular structures that are difficult to identify and were not seen at the presurgery TxWBS evaluation. However, because of the possible false-negative results, complete excision must be undertaken in high risk patients with a local recurrence to eradicate the largest number of lymph nodes, independent of the counts measured by the gamma probe.

Coexistence of a parathyroid adenoma and parathyroid cyst causing primary hyperparathyroidism

The association of a functional parathyroid cyst with a parathyroid adenoma is an uncommon finding. In this report we describe the clinical history of a 60-yr-old man, presenting with the following findings: hypercalcemia (18.9 mg/dl), elevated serum parathormone levels (1320 pg/dl), hypercalciuria (228 mg/dl), and hyperphosphaturia (155 mg/dl). Neck ultrasound, magnetic resonance imaging (MRI) and 99Tc Sestamibi scintigraphy led to the identification of a left parathyroid adenoma, located at the lower pole of the left thyroid gland lobe, associated with a parathyroid cyst, located at the upper extremity of the same thyroid lobe. Parathyroidectomy was performed and the histological examination confirmed the diagnosis of a parathyroid adenoma with aspects of cystic degeneration and an upper parathyroid cyst. Analysis of the crystal clear intracystic fluid showed elevated parathyroid hormone (PTH) levels (137.000 pg/ml). The patient is normocalcemic at 2 yr after surgery without signs of recurrent parathyroid enlargements. Aetiology, diagnosis and management of parathyroid cyst will be discussed.