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Near-infrared autofluorescence and indocyanine green fluorescence are 2 recent tools introduced to improve postoperative parathyroid function during thyroid surgery.We conducted a randomized prospective study. Patients undergoing total thyroidectomy were randomly assigned either to the fluorescence group, in which near-infrared autofluorescence and indocyanine green fluorescence were used, or to the control group. The primary outcomes of the study were the rate of postoperative transient and symptomatic hypocalcemia.A significantly higher number of parathyroid glands were identified in the fluorescence group (3.83 vs 3.64, P = .028). The rate of postoperative symptomatic hypocalcemia was significantly lower in the fluorescence group (6% vs 17%, P = .015), as was the dosage (1.53 vs 1.91 g, P = .007) and the duration of calcium therapy (32.30 vs 45.66 days, P = .003). Having at least 2 well-vascularized parathyroid glands correlates to lower rates of transient hypocalcemia (7.4% vs 21.9%, P = .037) as well as to higher serum calcium (8.70 vs 8.42 mg/dL, P = .027) and parathyroid hormone levels (19.15 vs 11.4 pg/mL, P = .0002) on postoperative day 1.Near-infrared autofluorescence and indocyanine green fluorescence are novel tools that may support the endocrine surgeon in preserving and predicting post-thyroidectomy parathyroid gland function.

Purpose To evaluate the efficacy and safety of radiofrequency (RF) ablation in the treatment of benign thyroid nodules (BTNs) by applying a modification of the moving-shot technique. Materials and Methods Fifty-one BTNs in 46 patients for whom surgery was contraindicated or who refused surgery were treated with RF ablation: 31 had lesion volumes 3 (group A) and 20 had volumes ≥ 20 cm 3 (group B). The solid component percentage of each lesion was assessed, and any present fluid component was aspirated. Symptomatic scores and cosmetic scores (CSs) were assessed. All RF ablations were performed under ultrasound (US) guidance with an 18-gauge electrode. Treatment response was evaluated by contrast-enhanced US at 6-month intervals for 18 months in group A. In group B, after the 6- and 12-month follow-up assessments, a second treatment was performed in selected cases, and the 6-month contrast-enhanced US follow-up was started again. Volume reduction rate (VRR) was evaluated at each follow-up examination. Results No permanent paralysis of the laryngeal nerve was observed; 2 patients experienced transient hoarseness. In all nodules treated with a single RF ablation session, the VRRs at 6, 12, and 18 months were 69.4%, 78.7%, and 84% in group A, respectively, and 66.6%, 79.4%, and 81.5% in group B, respectively. The VRRs of group B nodules treated with a second RF ablation procedure (n = 6) were 86.4% and 88.2% at 6 and 12 mo after the second treatment, respectively. All patients reported symptom relief and CS improvement. Conclusions RF ablation is a reliable alternative to surgery in patients affected by BTNs and can be safely repeated in selected cases.

Background Robot-assisted transaxillary thyroidectomy is a well-established remote-access thyroid procedure that has been demonstrated to be as safe and effective as its time-honored conventional clamp-and-tie counterpart. However, it has been incriminated for a set of unprecedented complications that surgeons need to be aware of and deal with appropriately. Patient findings The patient is a young woman who underwent robot-assisted thyroid lobectomy for a sizeable nodule that was reported as benign after fine-needle aspiration cytology. She presented 3 years later with subcutaneous nodules along the surgical track that were found to represent seeding of benign thyroid tissue. This is the first report of benign thyroid tissue seeding after a gasless transaxillary procedure. Summary Seeding along the surgical track is a potential complication of gasless remote-access thyroid surgery, even in case of benign disease, that surgeons need to be acquainted with. Conclusions Surgeons should be aware of the potential for benign seeding after remote-access thyroid procedures. Accordingly, adequate precautions should be taken, patients should be counseled in this regard, and alternative medical strategies to control local seeding of thyroid tissue could be suggested.

We report the antineoplastic and anti-angiogenic activity of the pyrazolo[3,4-d]pyrimidine derivative CLM3 and the cyclic amide CLM94, both multiple tyrosine kinase inhibitors (TKIs), in human primary medullary thyroid cancer (P-MTC) cells, and in vitro in the medullary thyroid cancer (MTC) cell lines TT (harboring a RET C634W activating mutation) and MZ-CRC-1 (carrying the MEN2B RET mutation Met891Thr).The antiproliferative and proapoptotic effects of CLM3 and CLM94 (1, 5, 10, 30, and 50 μmol/L) were tested in P-MTC cells obtained at operation, and in TT cells. In addition, the antiproliferative effects of CLM3 and CLM94 (0.005, 0.05, 0.5, and 5 μmol/L) were tested in TT and MZ-CRC-1 cells after 7 days of treatment to compare the results with those previously reported in the literature.CLM3 and CLM94 (30 or 50 μmol/L) inhibited (P.01) the proliferation of the P-MTC cells, TT cells, and MZ-CRC-1 cells and increased the level of apoptosis in a dose-dependent manner at 10, 30, and 50 μmol/L (P.001), while having no effect on migration or invasion. The inhibition of proliferation by CLM3 and CLM94 was similar among P-MTC cells with/without RET mutations, and similar effects were observed regarding the increased level of apoptosis. Furthermore, CLM3 and CLM94 significantly decreased vascular endothelial growth factor-A expression in TT cells.The antitumor activities of the multiple TKIs CLM3 and CLM94 were demonstrated in both primary MTC cultures as well as 2 established MTC cell lines in vitro, opening an avenue for future clinical evaluations.

Human papillary dedifferentiated thyroid cancer (HPDTC) represents a therapeutic dilemma. Targeted therapy (RET proto-oncogene or BRAF-targeting drugs) are promising treatments for HPDTC. Also PPARg agonists are another exciting field for redifferentiating therapy of HPDTC. However, even if many new approaches for the therapy of HPDTC are emerging, until now a significant clinical impact on survival by the use of these drugs is still lacking. In the future, the identification of patients who are likely to benefit from each therapeutic option will be important. In this view particular importance should be given to development of primary cells from the single patient by fine needle aspiration samples, as recently observed in anaplastic thyroid cancer. In fact, chemosensitivity tests in primary tumoral cells may help in detecting responsive patients and in preventing the administration of inactive drugs to those unresponsive.

Many different minimally invasive procedures have been proposed for the surgical treatment of primary hyperparathyroidism (pHPT). The “pure” endoscopic approach [1, 2] was the first operation presented by M. Gagner in 1996 and it was characterized by a steady gas flow insufflated at low pressure. Other approaches were then introduced, ranging from video-assisted gasless techniques [3, 4] to open minimally invasive parathyroidectomy (OMIP) either guided by an intraoperative scan [5] or just relying on preoperative localization studies [6, 7]. In 1997, we reported on a personal technique [4, 8] named minimally invasive video-assisted parathyroidectomy (MIVAP) that has been adopted by several centers during the last years [8, 9, 10, 11]. In spite of the favor encountered by these operations among the patients, many endocrine surgeons are still reluctant to accept these minimally invasive procedures because they might be too time consuming, too expensive and not viable for all the patients presenting pHPT. With regard to this last point, it is of paramount importance to define very carefully the exact indications to this minimally invasive surgery.

Resumen El origen de la cervicoscopia tuvo lugar cuando se realizo la primera paratiroidectomia laparoscopica en 1996. Con sus diversas variantes, esta intervencion se ha convertido, hoy dia, en una opcion terapeutica valida en numerosos centros hospitalarios importantes. Posteriormente, se introdujo la tiroidectomia endoscopica o videoasistida a pesar de los limites que impone el gran volumen del tiroides para su extraccion. Esta tecnica esta indicada en una pequena proporcion de pacientes, dado que la paratiroidectomia y la tiroidectomia muestran ventajas importantes con respecto a la cirugia convencional, ventajas que tambien se han demostrado en estudios con diseno prospectivo. Las ventajas se refieren, principalmente, al mejor resultado estetico y a la disminucion de complicaciones en el postoperatorio. Ambos abordajes quirurgicos han demostrado ser seguros y factibles en cualquier contexto quirurgico, y su tasa de complicaciones es similar a la de la cirugia abierta tradicional en el cuello. El acceso videoscopico a los ganglios linfaticos del cuello (compartimientos central y externo) parece muy prometedor, mientras que otras posibles aplicaciones, como la cirugia sobre la arteria carotida y sobre la columna vertebral, todavia permanecen en fase de estudio experimental. En consecuencia, la cervicoscopia debe ser considerada una herramienta quirurgica importante que ya en este momento muestra grandes posibilidades pero que todavia mejorara mas en el futuro.

Background. Endoscopic procedures for thyroid surgery have been introduced since 1998, but their diffusion has remained limited because their advantages were never demonstrated. Methods. Forty-nine patients undergoing surgery for either a thyroid nodule or a small papillary carcinoma were allotted to 1 of these procedures, minimally invasive video-assisted thyroidectomy (MIVAT) or conventional thyroidectomy (CT). Exclusion criteria were nodules greater than 35 mm, presence of thyroiditis, and thyroid volume greater than 20 mL. Preoperative diagnosis, operative time, postoperative pain, complications, and cosmetic result were evaluated. Results. MIVAT group included 25 patients and the CT group 24 patients. Operative time was 66 ± 24 minutes for MIVAT and 45 ± 15 minutes for CT ( P =.001). Postoperative course was significantly less painful in the patients who underwent MIVAT ( P =.003). Cosmetic result evaluated by verbal response scale and numeric scale was in favor of MIVAT ( P =.003 and P =.01, respectively). One recurrent nerve palsy and 1 transient hypoparathyroidism were present in CT patients; MIVAT patients experienced 2 transient palsies. Conclusions. Despite some MIVAT advantages in terms of postoperative pain and cosmesis, CT still offers an advantage in terms of operative time and its safety should not differ. Larger series of patients are needed before deciding whether endoscopic thyroidectomy can offer important advantages. (Surgery 2001;130:1039-43.)

Resume But de l'etude : La parathyroidectomie videoassistee (MIVAP : minimally invasive video-assisted parathyroidectomy ) dans le traitement de l’hyperparathyroidie primaire sporadique (sHPT1) a ete decrite en 1997. Nous avons deja demontre que ses resultats sont comparables a ceux de la chirurgie conventionnelle avec des avantages en termes de douleur postoperatoire et de resultat esthetique. Le but de cette etude etait de revoir la serie complete des patients qui ont ete operes pour analyser la courbe d’apprentissage de la technique de MIVAP. Patients et methodes : Entre fevrier 1997 et janvier 2001, 191 patients ont ete operes par la MIVAP. Les patients ont ete divises en trois groupes : le groupe A (GA) comprenait 63 patients operes entre fevrier 1997 et septembre 1998 ; le groupe B (GB) 64 patients operes entre octobre 1998 et janvier 2000 ; le groupe C (GC) 64 patients operes entre fevrier 2000 et janvier 2001. Le temps operatoire moyen, le taux de conversions et de complications postoperatoires des trois groupes ont ete compares. Resultats : Les trois groupes etaient comparables en ce qui concerne l’âge moyen et le sexe. Le temps operatoire moyen etait significativement inferieur chez les patients du GC (27,6 ± 12,2 minutes) par rapport a ceux du GA (62,3 ± 24,6 minutes) et du GB (48,4 ± 18,1 minutes). Une conversion en chirurgie conventionnelle a ete necessaire chez trois patients du GA (4,8 %), chez neuf du GB (14,1 %) et chez quatre du GC (6,2 %). Parmi les patients du GA, une paralysie du nerf recurrent et quatre cas d’hypocalcemie postoperatoire transitoire ont ete observes. Une cervicotomie pour la revision de l’hemostase six heures apres la MIVAP a ete necessaire chez une patiente du GC. Conclusion : La parathyroidectomie videoassistee peut etre consideree comme une technique efficace dans le traitement de l’hyperthyroidie primaire, mais elle necessite une periode d’apprentissage pour obtenir les meilleurs resultats. Cette etude a demontre qu’avec l’experience, le temps operatoire diminuait de facon significative, en meme temps que le taux des complications postoperatoires. Le taux de conversion plus important chez les patients des groupes B et C pourrait s’expliquer par le fait qu’avec l’experience, des cas plus difficiles et plus ambigus ont ete operes avec cette technique.

The first endoscopic procedures proposed to reduce the invasiveness of surgery in the neck were the endoscopic and video-assisted parathyroidectomies because it was quite evident that parathyroid adenomas were ideal candidates for a minimal access surgery, being these tumors mostly benign and characterized by their limited size. Later on, the same accesses proved to be suitable also for removing small thyroid nodules, and new approaches were soon proposed, in some cases, also modifying the old ones. At present, some controversies still exist about what should be considered a real minimally invasive operation for thyroid. Although the concern raised by some about the possible adverse effect of CO2 insufflation in the neck was probably over evaluated, the procedure we set up in 1998, minimally invasive video-assisted thyroidectomy (MIVAT), was characterized by the use of an external retraction avoiding any gas inflation which is not necessary to create an adequate operative space in the neck. This approach to the thyroid has been used in our Department of Surgery for the last 8 years on more than 2,500 patients with results that can successfully rival those of standard open surgery also in terms of operative time. Of course, this is not an operation which might be proposed for any patient: its main limit is represented by the necessity of a severe selection of the patients undergoing surgery. Only 10–30% of the cases, according to different authors, fulfill the inclusion criteria for a MIVAT.

Central compartment lymph node dissection is mandatory in several thyroid tumors together with total thyroidectomy: medullary thyroid carcinoma and high-risk papillary carcinomas are the most common indications. Minimally invasive video assisted thyroidectomy is not indicated for high risk carcinomas; only low-risk papillary carcinomas and prophylactic thyroidectomy in RET gene mutation carriers, among malignancies, should be approached endoscopically. For this reason it was presumed that, if surgeons also are prone to perform minimally invasive video assisted thyroidectomy in these cases, it was necessary to remove the lymph nodes of level VI via the same access, at least in selected cases where this was possible. Here we describe and discuss the minimally invasive video assisted technique for central compartment lymph node dissection.