Biomedical subjects
Publications and source records attributed to Maria Rosa Pelizzo.
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Aim of the present study was to investigate the feasibility and long-term results of focused radioguided parathyroidectomy using a "low" 37 MBq (1 mCi) 99mTc-sestamibi dose protocol compared to conventional "high 740 MBq (20 mCi) 99mTc-sestamibi dose protocol" in patients with primary hyperparathyroidism (PHPT). The data of focused radioguided surgery obtained in a group of 320 consecutive PHPT patients with high probability of the presence of a solitary parathyroid adenoma (PA) were studied. All patients underwent preoperative imaging work-up of double-tracer 99mTc-pertechnetate/99mTc-sestamibi subtraction parathyroid scintigraphy (Sestamibi scintigraphy) and high resolution neck ultrasound (US). In 301/320 patients (96.6%) focused minimally invasive radioguided surgery was successfully performed by administering a "low" 37 MBq (1 mCi) 99mTc-sestamibi dose in the operating room 10 minutes before operation. No major intraoperative complications were recorded. Focused radioguided surgery required a mean time of 32 min and a mean hospital stay of 1.2 days. Local anesthesia was applied in 75 patients, 66 of whom (88%) were patients older than 65 years with comorbidities contraindicating general anesthesia. No case of persistent or recurrent PHPT was observed during post-surgical follow-up (range = 18-70 months; mean +/- SD = 15.3 +/- 9.1 months). Radiation exposure dose to the operating surgeon was 1.2 microSi/hour with the "low 37 MBq (1 mCi) 99mTc-sestamibi dose", and less than 1.0 microSi/hour for the other operating-room personnel. Focused low dose radioguided parathyroidectomy is a safe and effective means to localize parathyroid adenomas in patients affected by solitary PA thus reducing by 20 fold the radiation exposure dose to the patients and operating room personnel.
PURPOSE: A prerequisite for optimum minimally invasive radio-guided surgery (MIRS) for primary hyperparathyroidism (PHPT) is the demonstration of significant uptake of (99m)Tc-sestamibi in a parathyroid adenoma (PA). The aim of this study was to evaluate the clinical role or (99m)Tc-sestamibi SPECT in selecting patients for this procedure. METHODS: Fifty-four consecutive PHPT patients were evaluated by single-session (99m)Tc-pertechnetate/(99m)Tc-sestamibi planar subtraction scintigraphy, followed by (99m)Tc-sestamibi SPECT acquisition to localise hyperfunctioning PAs and assist in planning the surgical approach. RESULTS: Scintigraphy showed the presence of a solitary PA in 47/54 patients (87%) and two or more PAs in four patients (7.4%); it was negative in the remaining three patients (5.6%). The overall sensitivity of (99m)Tc-sestamibi scintigraphy was 94.6%. In 7/54 patients, the PA was located deep in the para-oesophageal/paratracheal space. So far, 22 patients with scintigraphic evidence of a solitary PA (in four of whom the PA was located deep in the neck) have undergone successful MIRS using the low 37 MBq (1 mCi) (99m)Tc-sestamibi dose protocol. Intraoperative quick parathyroid hormone (QPTH) assay demonstrated a fall in all 22 patients, thus confirming successful removal of the hyperfunctioning PA. No major surgical complications were observed. After a period of follow-up ranging between 6 and 27 months (median 13 months), no case of persistent/recurrent PHPT was recorded. When comparing the parathyroid to background (P/B) ratio measured at planar and SPECT preoperative scintigraphy with that measured intraoperatively with the gamma probe, a good linear correlation was found between the SPECT and the intraoperative gamma probe measurements (r=0.89; p<0.01) but no correlation was found with planar scintigraphic data. CONCLUSION: Our preliminary data suggest that measurement of the P/B ratio by means of (99m)Tc-sestamibi SPECT is more accurate in predicting the intraoperative measurements with the gamma probe. In this respect, a preoperative (99m)Tc-sestamibi SPECT acquisition should be recommended for better selection of PHPT patients in whom a MIRS approach can be offered.
CONTEXT: Medullary thyroid carcinoma (MTC) is a rare tumor originating from thyroid parafollicular C cells. We previously demonstrated that somatostatin (SRIH) reduces cell growth in the human MTC cell line, TT, which expresses all SRIH receptor (SSTR) subtypes and responds differently to selective SSTR agonists. OBJECTIVE: To clarify the possible effects of SRIH analogs on hormone secretion and proliferation in MTC primary cultures, we evaluated SSTR expression and assessed the in vitro effects on calcitonin (CT) and chromogranin A secretion as well as cell viability of SRIH analogs interacting with SSTR1, SSTR2, and SSTR5. DESIGN: Thirty-five patients affected by MTC were recruited from 2003 to 2005. After total thyroidectomy, the samples were examined for CT, chromogranin A, and SSTR expression by RT-PCR. Primary cultures were developed and tested with SRIH analogs interacting with SSTR1, SSTR2, and SSTR5. RESULTS: We selected 18 MTC tumor samples, expressing SSTR1, SSTR2, and SSTR5. Two different groups were identified according to CT secretion inhibition by the clinically available SRIH analog, lanreotide. In the responder group, CT secretion was reduced by compounds interacting with SSTR1, SSTR2, and SSTR5, whereas cell viability was not affected. On the other hand, in the nonresponder group, CT secretion was reduced by the SSTR1 selective agonist, whereas cell viability was inhibited by SSTR2 selective agonists. CONCLUSIONS: Our data suggest that SRIH analogs might be useful in medical therapy of MTC because they could have antiproliferative effects despite the lack of antisecretory activity and vice versa.
We reported here the data on minimally invasive radio-guided parathyroidectomy (MIRP) in a large group of 253 patients enrolled from the whole series of 355 consecutive patients affected by primary hyperparathyroidism (P-HPT) referred to our center. On the basis of preoperative imaging including Sestamibi scintigraphy and neck ultrasound (US), 263 patients (74% of the whole series) with evidence of a solitary parathyroid adenoma (PA) and a normal thyroid gland were addressed to MIRP and in 253 (96%) of them this minimally invasive neck exploration was successfully performed. The MIRP protocol developed in our center consisted of a very low 1 mCi Sestamibi injection in the operating room a few minutes before the start of intervention, thus minimizing the radiation exposure dose to the patient and personnel. No major intraoperative complication was recorded in patients treated by MIRP and only a transient hypocalcemia in 8.5% of cases. The mean duration time for MIRP was 35 min and the mean hospital stay 1.2 days. Local anesthesia was also performed in 62 patients, 54 of whom were elderly patients with concomitant invalidating diseases contraindicating general anesthesia. No HPT relapse was observed during subsequent follow-up. The gamma probe was used also during bilateral neck exploration in the group of 92 patients excluded from MIRP. The most frequent cause of exclusion from MIRP in our series was the presence of concomitant Sestamibi avid thyroid nodules (68.5% of cases) that can give false positive results at radio-guided surgery. In conclusion, MIRP is an effective treatment in patients with a high likelihood of a solitary PA and a normal thyroid gland at scintigraphy and US so that an accurate preoperative localizing imaging is required for MIRP. A low 1 mCi Sestamibi dose appears sufficient to perform MIRP. Patients with concomitant Sestamibi avid thyroid nodules should be excluded from MIRP.
OBJECTIVE: Primary aldosteronism is the most common endocrine form of secondary hypertension, but no single test or imaging method always identifies it. Identification of a unilateral overproduction of aldosterone due to Conn's adenoma or unilateral hyperplasia is of utmost importance to the surgeon. MATERIALS AND METHODS: We reviewed our experience with primary aldosteronism in 46 consecutive patients who had undergone adrenalectomy at the Surgical Pathology Institute, University of Padua since 1993. All the patients underwent a CT scan. Adrenal venous sampling was performed in those patients with negative or equivocal findings on imaging studies. RESULTS: Computed tomography was non-contributory in 12 patients and frankly misleading in 2 patients, demonstrating a probable mass lesion in the contralateral but not in the ipsilateral adrenal. Eighteen patients had selective venous sampling that was successful in altering the management of 14 cases. Eleven patients who biochemically had an adrenal adenoma, had normal/equivocal CT, while the remaining 3 had bilateral or contralateral adrenal masses. Venous sampling localized aldosterone secretion and an adenoma, less than 1 cm in diameter, was removed, curing their hypertension. Eleven patients were treated by open adrenalectomy and 35 by the lateral transperitoneal laparoscopic approach. Histological examination revealed 45 Conn's adenomas, of which 13 had a diameter of less than 1 cm (range 0.3-0.8), and 1 case of nodular hyperplasia. CONCLUSIONS: Patients who have equivocal or unexpected CT findings should proceed to hormonal localization. Adrenal venous sampling is essential in patients with equivocal CT scans to avoid unnecessary and inappropriate adrenalectomy.
The detection of Castleman's disease in the neck is uncommon. However, it must be included in the differential diagnosis of a neck mass, together with other lymphoproliferative disorders or thyroid diseases. In 1999, three patients underwent resection of a neck mass of uncertain cytological diagnosis. Frozen-section examinations and immunohistochemical studies using primary antibodies directed against B- and T-cell markers were performed. Very similar features were observed in all cases and the diagnosis of Castleman's disease was based on Frizzera's histological morphological criteria; all cases were of the hyaline vascular type. After surgical resection, the patients remained symptom-free after 51, 50 and 46 months, respectively, without clinical or radiographic signs of local or diffuse recurrence. Surgical removal of a mass of unknown origin located in the central part of the neck is mandatory because it allows a correct diagnosis to be made and is curative when the disease is limited to one site.
OBJECTIVE: In this paper we report in a larger series the use of radio-probe-guided surgery (RGS) in nonradioiodine avid, well-differentiated thyroid cancer (DTC). DESIGN: Thirty-seven patients with locoregional recurrent, nonradioiodine avid DTC were studied with (99m)Tc-sestamibi directed RGS using a handheld gamma probe as an intraoperative detector. OUTCOME: Twenty-three women and 14 men were followed after RGS for 35.4 +/- 12.5 months (range 9-57). There were 33 papillary (one "tall" cell variant), 2 follicular, and 2 Hürthle cell cancers. In 7 patients, thyroid cancer recurred in the neck while cervical lymph node metastases were found in 31 patients (one patient had papillary cancer in both the thyroid bed and cervical lymph nodes). Sixty-six discrete nodules ranging from 6 to 45mm (mean tumor diameter, 18.4 +/- 8.5mm) were identified by both high-resolution ultrasound and (99m)Tc-sestamibi probe-guided RGS. After RGS, Tg (thyroglobulin) fell in 33 of 37 patients and mean target=nontarget sestamibi uptake ratios decreased in all 37 patients ( p < 0.0001). CONCLUSION: These data confirm our earlier observations that a (99m)Tc-sestamibi intraoperative gamma probe can be used to identify and guide resection of recurrent tumor and involved lymph nodes in locoregional metastases of nonradioiodine-avid thyroid cancer.
The classical therapeutic approach to patients with differentiated thyroid cancer (DTC) is based on total or near-total thyroidectomy, followed by (131)I treatment and thyroid-stimulating hormone suppressive therapy. This approach allows complete cure in many patients, especially when the tumour is diagnosed at an early stage; it also allows long-term survival in patients with locoregional recurrences or distant metastases if they can be treated with (131)I. In contrast, when metastatic DTC deposits lose their ability to trap (131)I (non-functioning metastases), a worse prognosis is expected. Nevertheless, in patients with locoregional non-functioning recurrences, an early diagnosis and prompt surgical extirpation can lead to a favourable prognosis. In these cases, radical surgery is needed. This can be achieved with radio-guided surgery using a hand-held gamma probe and a tumour-seeking radiotracer to detect, intraoperatively, the smallest metastatic lesions. In this paper, we discuss the two principal techniques proposed in the literature for radio-guided surgery of non-functioning DTC metastatic recurrences, the first using high doses of (131)I and the second using low doses of 99mTc-Sestamibi.
Judging from recent data, heritable forms account for 30-40% of pheochromocytomas. The molecular basis for the familial pheochromocytoma has been largely elucidated and the role of germline mutation of the VHL, RET, SDHB, and SDHD genes has been established. However, on genotyping a group of 172 sporadic or familial pheochromocytomas, we characterized four unrelated probands with familial pheochromocytomas without any sequence variants of RET (exons 8, 10, 11, 13, 14, 15, and 16) or the entire coding sequence of VHL, SDHB, SDHC, SDHD, and EGLN3 (exon-intron boundaries included). The proband of family 1 is a man who had a bilateral pheochromocytoma at the age of 32 and a local recurrence at the age of 48 years. His brother died of malignant pheochromocytoma and his nephew died suddenly of an undiagnosed pheochromocytoma. The proband of family 2 is a female who had a 5-cm benign adrenal pheochromocytoma at the age of 34 years, while her cousin (maternal branch) had a monolateral pheochromocytoma at the age of 42 years. No other tumors had been reported in either family. The proband of family 3 is a female who had a bilateral pheochromocytoma at the age of 66 years. Her sister had a bilateral pheochromocytoma and breast cancer at the age of 54 years. Several other tumors were recorded in this family, including laryngeal cancer, leukemia, and a case of medullary thyroid carcinoma (MTC) in one brother. MTC was naturally ruled out in the proband and her sister. In family 4, the proband was a female who had a bilateral pheochromocytoma at the age of 46 years and a local recurrence a few years later, with liver metastases from the pheochromocytoma. Her brother had a monolateral benign pheochromocytoma. The proband also had a melanoma and bilateral renal cysts. This case revealed a VHL sequence variant IVS2+43 A>G, which was also found in one other unrelated sporadic pheochromocytoma. VHL mRNA integrity is currently being evaluated. The proband had no cerebellar or spinal NMR findings or retinal alterations. In family 5, the proband was a female who had a right adrenal pheochromocytoma at the age of 50 years and a breast cancer at 49 years of age. Her mother had had a right adrenal pheochromocytoma at 61 years of age. Although other molecular mechanisms, such as particular variants in untranslated regions or partial gene deletions, cannot be ruled out, we think finding families with nonsyndromic pheochromocytoma without any RET, VHL, SDHB, SDHC, SDHD, or EGLN3 mutation may argue in favor of the presence of other pheochromocytoma susceptibility genes.
BACKGROUND: Laparoscopic sleeve gastrectomy (LSG), initially described by Gagner's group as the first stage of the laparoscopic duodenal switch in super-obese patients, is now gaining wide diffusion among bariatric surgeons as a new restrictive operation. METHODS: From January 2005 to January 2006, 8 obese patients with BMI 37-74 kg/m(2) underwent LSG for conversion from a prior complicated or failed laparoscopic adjustable gastric banding (LAGB). Three patients had severe symptomatic esophageal dilation, while 5 patients had unsuccessful weight loss with poor "band compliance". After de-banding, LSG was calibrated upon a 34-Fr gastric bougie, and blue and green linear staplers were used. The staple-line was buttressed by placing a sero-serosal running suture in all but one patient, and methylene blue dye was used to test for leaks. All the patients underwent upper GI series with water-soluble contrast medium 2 days after the surgery. RESULTS: The average operating-time for LSG was 90 minutes (range 60-120 min). The average hospital stay was 4 days (range 3-7). There were no perioperative complications, no conversion, and no mortality. No intraoperative or postoperative blood transfusions were required. CONCLUSIONS: LSG proved to be feasible and safe after LAGB. Longer follow-up and larger series are needed to assess weight loss results.
AIM: Debate exists in the literature about the optimal treatment to be adopted in patients with locally advanced differentiated thyroid carcinoma. We aimed to better define the most appropriate diagnostic and therapeutic protocol for this type of tumour. METHODS: The clinical and histopathological records of 280 consecutive patients with locally advanced differentiated thyroid carcinoma, studied and operated on by the same surgical team in the period between 1967 and 2002, were reviewed. RESULTS: With regard to overall survival, at univariate statistical analysis, the patient's age at diagnosis (threshold, 45 years), primary tumour size, local cancer extension at diagnosis (subtypes of T4), extent of thyroidectomy, performance of lymph node dissection and performance of post-surgical external radiotherapy were found to be significant prognostic variables. With regard to the appearance of recurrent disease during follow-up, at univariate statistical analysis, the patient's age at initial diagnosis (threshold, 45 years), primary tumour size, local cancer extension at diagnosis (subtypes of T4), extent of thyroidectomy, performance of lymph node dissection, presence of metastatic lymph nodes, performance of post-surgical 131I therapy and performance of post-surgical external radiotherapy were found to be significant prognostic variables. At multivariate statistical analysis, the patient's age at initial diagnosis, extent of tumour, extent of thyroidectomy and performance of lymph node dissection were the only independent prognostic variables. CONCLUSIONS: In our experience, an aggressive surgical approach at first diagnosis appears to offer a better prognosis in terms of both overall survival and disease-free time interval in patients with locally advanced differentiated thyroid carcinoma, especially those over 45 years of age.
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BACKGROUND: For some patients, especially those with a higher BMI, a non-selective Lap-Band placement using the pars flaccida approach with application of the small-diameter bands (9.75 and 10 cm) may be too tight or may require significant gastroesophageal junction dissection and thinning. In such a case, the major perioperative complication is acute obstruction immediately after surgery. We review the etiology of obstructive complications that present postoperatively in the first 24 hours. CASE REPORTS: Acute postoperative stoma obstruction (esophageal outlet stenosis) was observed in 5 patients who underwent 9.75-cm Lap-Band placement for morbid obesity. 2 of these patients had a postoperative upper GI series showing a misplaced band with gastric slippage, and repeat operation was required. 3 patients had gastric obstruction without slippage. Of the latter, 1 patient insisted that the band be removed rather than being replaced with a longer one, and the remaining 2 were managed with conservative treatment, involving extended hospitalization until the edema subsided and the patient slowly regained the ability to swallow. CONCLUSION: Obstructive symptoms associated with the Lap-Band using the pars flaccida approach can be addressed conservatively in most patients or by minimally invasive surgery; however we believe that routine use of the 11-cm Lap-Band for the pars flaccida approach could easily prevent this early complication.
UNLABELLED: This study evaluated the accuracy of (99m)Tc-sestamibi scintigraphy and neck ultrasonography in patients with primary hyperparathyroidism (PHPT) and the role of intraoperative hand-held gamma-probes in minimally invasive radioguided surgery (MIRS) of patients with a high likelihood of a solitary parathyroid adenoma (PA). The study was undertaken under the aegis of the Italian Study Group on Radioguided Surgery and Immunoscintigraphy (GISCRIS). METHODS: Clinical records were reviewed for 384 consecutive PHPT patients undergoing radioguided surgery using a low dose of (99m)Tc-sestamibi. Selection of patients for MIRS instead of traditional bilateral neck exploration was based on preoperative imaging indicating a solitary PA. (99m)Tc-Sestamibi (37-110 MBq, or 1-3 mCi) was injected in the operating theater 10-30 min before the start of the intervention. Either 11-mm collimated (309 patients) or 14-mm collimated (75 patients) gamma-probes were used. Intraoperative quick parathyroid hormone (IQPTH) assay was used on 308 patients (80.2%). RESULTS: MIRS was successfully performed on 268 (96.8%) of 277 patients. Conversion to bilateral neck exploration was necessary in 9 patients (3.3%) because of either persistently high IQPTH levels after removal of the preoperatively visualized PA (4 patients), intraoperative frozen-section diagnosis of parathyroid carcinoma (2 patients), or hard-to-remove PA (3 patients). MIRS, which was performed under locoregional anesthesia in 72 patients, required a mean operating time of 37 min and a mean hospital stay of 1.2 d. MIRS was successfully performed also on 32 (78.0%) of 41 patients who had previously undergone thyroid or parathyroid surgery. No major surgical complications were observed in the MIRS group, and there were only 24 cases (11%) of transient postoperative hypocalcemia. The probe was of little help in patients with concomitant (99m)Tc-sestamibi-avid thyroid nodules and not helpful at all in patients with negative scan findings preoperatively. IQPTH measurement helped to disclose some cases of multigland parathyroid disease. CONCLUSION: (99m)Tc-Sestamibi scintigraphy, especially if combined with neck ultrasonography, is highly accurate in selecting PHPT candidates for MIRS. The low-dose (99m)Tc-sestamibi protocol (which entails a low-to-negligible radiation exposure to the surgical team) is safe and effective for MIRS. MIRS plays a limited role in patients with concomitant (99m)Tc-sestamibi-avid thyroid nodules and should be discouraged in patients with negative (99m)Tc-sestamibi finding preoperatively. IQPTH can be recommended during MIRS to facilitate intraoperative identification of previously undiagnosed multigland parathyroid disease.
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.
Complication rates associated with thyroid surgery can be evaluated only through analysis of case studies and follow-up data. This study covers postoperative data from 14,934 patients subjected to a follow-up of 5 years. Among them, 3130 (20.9%) underwent total lobectomy (TL), 9599 (64.3%) total thyroidectomy (TT), 1448 (9.7%) subtotal thyroidectomy with a monolateral remnant (MRST), and 757 (5.1%) subtotal thyroidectomy with bilateral remnants (BRST). A total of 6% of the patients had already been operated on. Persistent hypoparathyroidism occurred after 1.7% of all the operations, and temporary hypoparathyroidism was noted in 8.3%. Permanent palsy of the laryngeal recurrent nerve (LRN) occurred in 1.0% of patients, transient palsy in 2.0%, and diplegia in 0.4%. The superior laryngeal nerve was damaged in 3.7%; dysphagia occurred in 1.4% of cases, hemorrhage in 1.2%, and wound infection in 0.3%. No deaths were reported. A significant rate of LRN damage was noted, which has an important impact on the patient's social life. Hypoparathyroidism after total thyroidectomy is an important complication that can be successfully treated by therapy, although it is not always easily managed in special circumstances such as in young persons or pregnant women. The complications associated with thyroid surgery must be kept in mind so the surgeon can carefully evaluate the surgical and medical therapeutic options, have more precise surgical indications, and be able to give the patient adequate information.
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