[Endoscopic and surgical treatment of acute bleeding gastroduodenal ulcers]

One of the basic problems of the treatment of acute bleeding from gastroduodenal ulcers concerns the correct timing of individual therapeutic steps. From 1992 to 1990 the I. Surgical Clinic in Brno performed the total of 438 urgent gastrofibroduodenoscopies, the most frequent finding being bleeding from the lesions in the area of the duodenal bulb. Endoscopic stoppage of bleeding was successful in 87.7% of patients. Failures in stopping the bleeding occurred in 18 cases and lead to urgent surgical intervention. On the basis of gained experience we recommend the following algorhithm in patients with acute bleeding from gastroduodenal ulcers: urgent endoscopy-endoscopic stoppage of bleeding. Relapse of bleeding requires endoscopic control with a new attempt of endoscopic therapy, in the case of failure it is urgent to intervene surgically. (Tab. 4, Ref. 14.)

Surgical treatment strategy for thyroid gland carcinoma nodal metastases

The authors present their experience with surgical treatment for nodal metastases of thyroid carcinoma based on neck dissections. The specificity of the surgical approach to the lymph nodes was determined by the biologic behavior of each thyroid tumor. Using the available literature on metastases from thyroid tumors, an opinion is supported that surgery for differentiated carcinomas (papillary and follicular neoplasms) can be more conservative and can be safely limited to modified neck dissections. In contrast, a more extended type of selective neck dissection, and only rarely a comprehensive neck dissection, is needed for medullary carcinoma. Because of its rapid spread to distant sites local aggressivity, extirpation of individual lymph nodes or neck dissection is not justified in patients with anaplastic thyroid carcinoma.

[The effect of gender on prevalence and survival in thyroid carcinoma]

Based on their own experience with a large group of patients with thyroid cancers, the authors confirm the higher prevalence of differentiated thyroid cancers both papillary and follicular (1 : 3,5) in females, while the differences in anaplastic and medullary cancers are much less prominent. Survival of females in univariate studies is much higher in both papillary and follicular cancers compared to males, in multivariate studies these differences lose their significance and only in papillary cancers under the age of 40 years at diagnosis and in a subgroup of papillofollicular cancers the differences retain their significance. The authors therefore deduce that differences found in univariate studies are significantly influenced by other factors such as age at the diagnosis and the spread of disease at the diagnosis.

Positive thyroid cancer scintigraphy using technetium-99m methoxyisobutylisonitrile

The aim of the study was to evaluate the possibility of detecting thyroid cancer recurrences without the need for withdrawal of thyroid suppressive treatment. Upper-body or whole-body scintigraphy was performed in a group of 200 patients evaluated for differentiated thyroid cancers in 1993 and 1994 using technetium-99m sestamibi. Scans were performed 20-30min following i.v. administration of 500MBq of 99mTc-methoxyisobutylisonitrile (MIBI). Bone and lung metastases were detected with very high sensitivity and specificity, with a very high predictive value of negative results and a somewhat lower predictive value of positive results. The sensitivity and specificity of findings in the neck were lower but the predictive value of negative results was high. Whole-body scans with 99mTc-MIBI are a useful tool in the follow-up of patients with differentiated thyroid cancer, for the detection of distant metastatic lesions.

Positive thyroid cancer scintigraphy using 99Tcm-tetrofosmin (Myoview): a preliminary report

99Tcm-tetrofosmin imaging was performed in 23 thyroid cancer patients and compared with whole-body 131I scans, neck ultrasonography and plasma thyroglobulin levels. Of 22 patients with differentiated thyroid cancer, 8 showed identical images on 131I scan and tetrofosmin; 1 patient with medullary cancer had identical images with 99Tcm-DMSA and 99Tcm-tetrofosmin, the findings being confirmed by sonography. The potential usefulness of 99Tcm-tetrofosmin imaging in the follow-up of thyroid cancers is discussed.

[What does the radicality of thyroidectomy depend on?]

Reflections on the radicality of thyroidectomy are based on the persisting lack of uniformity as regards terminology, indications and techniques of thyroid surgery. The authors emphasize four basic factors involved in the solution of thyroid diseases: A. respecting the preoperative examination and recommendations of the endocrinologist, B. philosophy of the surgeon and his workplace, C. experience and skill of the surgeon, D. postoperative follow-up and treatment of patients. The necessity of multidisciplinary collaboration emphasized under A is followed under B by a detailed analysis of principles of the workplace as regards indications and technical and tactical aspects. In part C necessary theoretical and personal problems of the thyroid surgeon are summarized. Without careful postoperative check-up examinations and evaluation of the results of operations mentioned under D we cannot speak of radicality of thyroid surgery.

[Use of immunoreactive calcitonin and sonography in the diagnosis of medullary carcinoma of the thyroid gland]

In a group of 94 patients with a histologically verified medullary thyroid carcinoma were 59 patients with the sporadic form and 35 patients with the familial form. After radical surgery and subsequent actinotherapy in all patients the values of immunoreactive calcitonin were monitored along with the sonographic examination. In all with calcified thyroid residues confirmed on sonography, or when metastases were detected in the liver, elevated or high levels of immunoreactive calcitonin were found. The authors emphasize the importance of this examination for the early detection of relapses of medullary thyroid carcinoma.

[Comparison of basic somatometric characteristics in randomly selected populations from Prague and Vsetín]

In 1991-1992 in the Czech Republic an epidemiological survey was conducted focused on prevention of iodine deficiency and the incidence of some thyropathies. The authors examined samples of the Prague and Vsetín population selected at random. The clinical examination comprised also somatometric assessment. In a group of 1,100 subjects from Prague and Vsetín anthropometry of basic somatometric characteristics was performed (height, body weight, BMI and four skinfolds). From comparison of the two groups ensues that the Vsetín population is shorter, as compared with the Prague population, the BMI values are significantly higher and so is the percentage of subcutaneous body fat.

[The significance of the ultrasound examination in surgery of the thyroid gland]

The authors emphasize the importance of ultrasonographic examination of the thyroid gland for the diagnosis of disease as well as for planning and implementation of the operation. They evaluate the importance of 154 sonographic examinations which were made during the last three years in 545 operations of the thyroid. For the surgeon anatomical parameters of the pathological tissue are important with special emphasis on the relation with surrounding tissues and affection of the lymphatic system. The examination is irreplaceable, in particular in reoperations of the thyroid gland and nodular syndrome.

[Multiple endocrine neoplasia type 2: familial variant of medullary carcinoma of the thyroid gland]

In addition to a brief characteristic of the syndrome of multiple endocrine neoplasia type 2 and medullary thyroid carcinoma with a familial incidence which is a prerequisite of the syndrome, the authors submit an account on a group of 53 patients who were on the authors' records during the past 12 years. During this period the disease is systematically searched for in the families of newly diagnosed patients by examining the immunoreactive calcitonin level of relatives. Familial variants account for 28% of all medullary thyroid carcinomas. Patients who are on the records so far belong to 24 families. Approximately twice as often an isolated variant of the familial type of medullary carcinoma is involved, as compared with association with another endocrine affection, in particular pheochromocytoma (Sipple's syndrome), but associated forms will increase in number perspectively (multiple endocrine neoplasia 2A). The syndrome of multiple endocrine neoplasia 2B is very malignant but in view of the typical phenotype the disease should be diagnosed already before the change to malignancy--once the disease develops into the clinical stage the course is very adverse. From the original number of all familial tumours 38 subjects survive (72%), incl 22 who were subjected to bilateral total thyroidectomy based on screening in the preclinical stage. The prognosis of these individuals is very favourable, the calcitonin levels are throughout the follow-up period (2-10 years) repeatedly negative. With regard to the possible association with another endocrinopathy (pheochromocytoma or hyperparathyroidism) all must be followed up systematically (screening) with regard to the manifestation of an associated endocrinopathy frequently only after a longer time interval.

[Iodine status and incidence of thyropathies in the Czech population]

Based on clinical experience on the rising incidence of some thyropathies in our population, the authors examined a random sample of the Prague population. They assessed and evaluated iodinuria, the sonographic finding of the thyroid gland, the palpation finding of the thyroid and a clinical examination which comprised a detailed case-history (a questionnaire checked during the examination) and a clinical and anthropometric examination. The results indicate that iodinuria (which reflects the iodine intake) reaches the recommended optimum (above 150 micrograms iodine/l) only in 11.4% of boys, 14% men, 6.3% girls and 5.4% women. A quite inadequate intake (less than 50 g iodine/l) was recorded in 13.2% boys, 15.2% men, 17% girls and 33.1% women. When evaluating the thyroid volume, an enlarged volume is found in 20.4-58.3% and on evaluation by palpation pathological changes are found in a considerable proportion of the examined population. The findings suggest that the iodine supply of the Prague population is inadequate and the incidence of abnormal findings on the thyroid gland is high. It will be necessary to verify these findings in other random population samples from other localities. If the adverse position will be confirmed, this will call for an urgent solution, i.e. a better iodine supply of the population.

[Medullary carcinoma of the thyroid gland. Personal experience]

The authors present their experience with the diagnosis and treatment of medullary thyroid carcinoma (MTC) in a group of 175 patients in the records of the RI in Motol. From the above number 106 are alive, 69 of the patients who died were diagnosed at the time of the clinical manifestation of the disease, frequently an advanced stage of the disease. Of the living patients one third was treated by total thyroidectomy after active screening. MTC accounts under our conditions in recent years for 8.6% of all thyroid malignancies. The familial variant with autosomal dominant heredity accounts for 26.5% of the above number. Within the framework of the familial variant the most frequent finding is non-MEN MTC, only 30% MTC are part of the MEN 2A or MEN 2B syndromes. MTC in childhood belongs practically always to the familial variant. At present the authors' group comprises 13 children and adolescents under 18 years, incl. one boy with the MEN 2B syndrome who succumbed to the disease. In 8 children based on active screening total thyroidectomy was indicated, incl. 5 patients were by histological examination only hyperplasia of the C-cells, i.e. a precancerous condition, was detected. After operation repeatedly in all these patients the level of immunoreactive calcitonin is low which indicates an excellent prognosis. The authors draw attention to the importance of active screening in families of all direct relations of the patient where MTC was diagnosed. Complete removal of thyroid tissue at the time of hyperplasia of C-cells or the presence of tumourous microfoci has a marked positive effect on the subsequent fate of the patients.(ABSTRACT TRUNCATED AT 250 WORDS)