Background
The recent development and spread of ultrasonography and ultrasonography-guided fine needle aspiration biopsy (FNAB) has facilitated the detection of small papillary microcarcinomas of the thyroid measuring 1 cm or less (PMC). The marked difference in prevalence between clinical thyroid carcinoma and PMC detected on mass screening prompted us to observe PMC unless the lesion shows unfavorable features, such as location adjacent to the trachea or on the dorsal surface of the thyroid possibly invading the recurrent laryngeal nerve, clinically apparent nodal metastasis, or high-grade malignancy on FNAB findings. In the present study we report comparison of the outcomes of 340 patients with PMC who underwent observation and the prognosis of 1,055 patients who underwent immediate surgery without observation.

/pdf/an-observational-trial-for-papillary-thyroid-microcarcinoma-598tm08lr0.pdf

An Observational Trial for Papillary Thyroid Microcarcinoma in Japanese Patients

Objective To systematically review the current preoperative diagnostic modalities, surgical treatments, and glandular pathologies associated with primary hyperparathyroidism. Study design A systematic literature review. Results Of the 20,225 cases of primary hyperparathyroidism reported, solitary adenomas (SA), multiple gland hyperplasia disease (MGHD), double adenomas (DA), and parathyroid carcinomas (CAR) occurred in 88.90%, 5.74%, 4.14%, and 0.74% of cases respectively. Tc99m-sestamibi and ultrasound were 88.44% and 78.55% sensitive, respectively, for SA, 44.46% and 34.86% for MGHD, and 29.95% and 16.20% for DA, respectively. Postoperative normocalcemia was achieved in 96.66%, 95.25%, and 97.69% of patients offered minimally invasive radio-guided parathyroidectomy (MIRP), unilateral, and bilateral neck exploration (BNE). Intraoperative PTH assays (IOPTH) were helpful in approximately 60% of bilateral neck exploration conversion (BNEC) surgeries. Conclusion The overall prevalence of multiple gland disease (MGD and DA) was lower than often suggested by conventional wisdom. Furthermore, preoperative imaging was less accurate than it is often perceived for accurately imaging MGD. MIRP and UNE were more successful in achieving normocalcemia than is typically quoted. IOPTH was a helpful but not “fool-proof” adjunct in parathyroid exploration surgery. Significance These results support a greater role for the treatment of primary hyperparathyroidism using less invasive approaches. EMB rating: B-3.

A systematic review of the diagnosis and treatment of primary hyperparathyroidism from 1995 to 2003

Thyroid cancer nodal metastases: Biologic significance and therapeutic considerations

Papillary thyroid carcinoma: factors influencing prognosis and current therapy.

Background
Hepatic encephalopathy may be caused by a decreased plasma ratio of branched-chain amino acids (BCAA) to aromatic amino acids. Treatment with BCAA may therefore have a beneficial effect on patients with hepatic encephalopathy.

Objectives
To evaluate the beneficial and harmful effects of BCAA for patients with hepatic encephalopathy.

Search methods
We identified trials through The Cochrane Hepato-Biliary Group Controlled Trials Register (September 2002), (Issue 3, 2002), MEDLINE (1966-2002/09) and EMBASE (1980-2002/05), manual searches of bibliographies and journals, authors of trials, and pharmaceutical companies.

Selection criteria
Randomised trials comparing BCAA with any kind of control therapy for hepatic encephalopathy were included, regardless of blinding, language, or publication status.

Data collection and analysis
Trial inclusion and data extraction were made independently by two reviewers. Our primary outcome was improvement of hepatic encephalopathy. Statistical heterogeneity was tested using random effects and fixed effect models. Binary outcomes are reported as risk ratios (RR) based on a random effects model.

Main results
Eleven randomised trials (556 patients) assessing BCAA versus carbohydrates, neomycin/lactulose, or isonitrogenous control were included. The median number of patients in each trial was 55 (range 22 to 75). Follow-up after treatment was reported in four trials (median 17 days (range 6 to 30 days)). Compared to the control regimens, BCAA significantly increased the number of patients improving from hepatic encephalopathy at the end of treatment (risk ratio (RR) 1.31, 95% confidence interval (CI) 1.04 to 1.66, nine trials). We found no evidence of an effect of BCAA on survival (RR 1.06, 95% CI 0.98 to 1.14, eight trials) or adverse events (RR 0.97, 95% CI 0.41 to 2.31, three trials). Sensitivity analyses indicated that methodological quality had significant impact on the results. We found no evidence of an effect of BCAA on improvement of hepatic encephalopathy in trials with adequate generation of the allocation sequence (RR 1.01, 95% CI 0.84 to 1.23, three trials), adequate allocation concealment (RR 1.09, 95% CI 0.89 to 1.33, five trials), or adequate double-blinding (RR 1.20, 95% CI 0.83 to 1.73, three trials).

Authors' conclusions
We did not find convincing evidence that BCAA had a significant beneficial effect on patients with hepatic encephalopathy. The trials performed in this field were small with short follow-up and most had low methodological quality.

Branched-chain amino acids for hepatic encephalopathy

OBJECTIVE To evaluate the prognosis of papillary microcarcinoma (PMC) of the thyroid. DESIGN Prospective study. SETTING Teaching hospital, Italy. SUBJECTS 89 patients treated for papillary micro carcinoma of thyroid and followed up for at least 6 years (range 6-12). INTERVENTION Total thyroidectomy and, for lymph node metastases, laterocervical lymphadenectomy. MAIN OUTCOME MEASURES Sex distribution, mode of onset of disease, diameter of tumour, histological type, histological stage, presence of lymph node metastases at the time of operation and type of operation. RESULTS When the disease presented with laterocervical lymph nodes it was histologically more aggressive and included follicular (n = 3) and sclerosing (n = 4) types. CONCLUSION Papillary microcarcinoma has an excellent prognosis if managed initially by total thyroidectomy.

Papillary microcarcinoma of the thyroid gland: analysis of prognostic factors including histological subtype.

The study aims were to characterize patients with insular thyroid cancer and to provide data on patient outcome after surgical therapy. We compared nine patients with insular thyroid cancer at the Department of Surgical Science of "La Sapienza" University of Rome with 27 patients of similar age and tumor size who had follicular and papillary cancer, for a minimum follow-up period of 24 months (range, 24-72 months). All of the patients examined underwent total thyroidectomy. Vascular invasion was observed in 44.4 per cent of insular carcinomas (P < 0.05 vs papillary carcinomas). No significant differences were observed regarding diagnostic method, multifocality, tumor nodes metastases (TNM), or stage. The death rate of patients with insular carcinoma (33.3%) was found to be higher than that of patients with follicular carcinoma (P < 0.05) and papillary carcinoma (P < 0.01). Relapsing lymph-node pathologies were observed in 4 patients (44.4%) with insular carcinoma (P < 0.05 vs those with follicular and papillary carcinomas). Distant metastases were observed in 66.6 per cent of insular carcinomas (P < 0.005 vs follicular carcinoma and P < 0.001 vs papillary carcinoma). At the end of follow-up, 2 patients (22.2%) with insular carcinoma were disease-free (P < 0.001 vs those with follicular and papillary carcinomas). Our study demonstrates an unfavorable prognostic role of the insular phenotype of thyroid cancer, such that this tumor can be classified as an autonomous clinical and pathological entity.

Prognostic factors of insular versus papillary/follicular thyroid carcinoma.

The aim of this study was to verify the reliability of the differential diagnosis between benign and malignant thyroid nodules on the basis of vascularization. The study was conducted on 108 patients with a scintigraphically "cold" thyroid nodule, including 54 carcinomas and 54 benign nodules. All patients underwent total thyroidectomy. Diagnosis based on histological examination of the surgical specimen was compared with ultrasonographic diagnosis obtained according to a personal classification proposed by the authors. Vascular ultrasonographic investigation produced 10 false positives, 6 false negatives and 92 correct diagnoses, with 88.8% sensitivity, 81.5% specificity, an 82.7% positive predictive value and an 88% negative predictive value. It can thus be used effectively to identify the larger nodules, while it is unable to provide any indication as to their histological type. Ultrasound vascular thyroid study is a non-invasive and low-cost method and is very reliable in the differential diagnosis of cold thyroid nodules. The best ultrasonographic modality is power Doppler. Ultrasound contrast media increase vascular definition but, due to their higher cost and the longhier duration of the examination, they should only be used in the case of small nodules.

Malignant thyroid nodules: comparison between color Doppler diagnosis and histological examination of surgical samples.

From November 1970 to July 1983, a total of 322 thyroid cancers were treated surgically in our clinic. Total thyroidectomy was the treatment of choice. In 131 patients, modified neck dissection (unilaterally in 23 and bilaterally in 108) was added. Of the latter patients, 33 also required upper mediastinal lymph node dissection. There were no operative deaths. No recurrent laryngeal nerve iatrogenic palsy was observed. Permanent parathyroid insufficiency developed in only about 4% of patients. The low morbidity and good long-term results justify the use of this procedure in all patients with thyroid malignancies. Despite conservative arguments in the controversial issue of lobectomy versus total thyroidectomy, skilled surgeons should be able to perform total thyroidectomy safely. It is recommended as the treatment of choice because of the well-documented multicentricity of thyroid cancers and the good prognosis of differentiated cancers associated with a near-normal life expectancy, to permit radioactive iodine therapy of possibly functioning metastases and the easier control of hypothyroidism with thyroid supplement medication.

Thyroid cancer: surgical experience with 322 cases.

The authors report a case of pancreatic malignant fibrous histiocytoma (approximately 22 cm). Clinical and instrumental approach for preoperative diagnosis is discussed and the anatomopathological features of the lesion, which is rarely localized in the pancreatic gland, are stressed. Surgical treatment is outlined as well.

Malignant fibrous histiocytoma of the pancreas

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