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Prophylactic central compartment lymph node dissection (pCCND) results in a higher percentage of surgical-related complications. To date, no evidence of the impact of pCCND on the clinical outcome of papillary thyroid carcinoma (PTC) patients with synchronous ipsilateral cervical lymph node metastases has been reported.We evaluated all consecutive patients affected by PTC and synchronous ipsilateral cervical, but without evidence of central compartment, lymph node metastases. We selected 54 consecutive patients (group A) treated by total thyroidectomy, ipsilateral cervical lymph node dissection, and pCCND and 115 patients (group B) matched for sex, age at diagnosis, number and dimension of the metastatic lateral cervical lymph nodes, without pCCND. Clinical outcome after a median of 5 years and surgical-related complications were assessed.The two groups were completely similar in terms of clinical features. Clinical outcomes showed a higher percentage of biochemical and indeterminate but not structural response in group B. Group B required significantly more radioiodine treatments, but no difference was shown in the need to repeat surgery for recurrences. Conversely, the prevalence of permanent hypoparathyroidism was significantly higher in group A (14.8%) than in group B (4.3%).In PTC patients with synchronous ipsilateral cervical lymph node metastases, in absence of clinically evident lymph node metastases of the central compartment, performing pCCND does not improve the 5-year outcome in terms of structural disease, despite a greater number ofIQR = interquartile range; pCCND = prophylactic central compartment lymph node dissection; PTC = papillary thyroid carcinoma; Tg = thyroglobulin; US = ultrasound.

Renal cell carcinoma (RCC) has a high metastatic potential, and most commonly metastasizes via the bloodstream, although lymphatic metastases also occur. RCC is well-known for its propensity to metastasize to unusual sites, and late metastasis, even after a number of years, is common. The occurrence of RCC metastasis to the head and neck region is uncommon, and occurs primarily in the thyroid gland and in patients with widespread dissemination. Involvement of the parathyroid gland in metastatic carcinoma is extremely rare. In the present report, a case of metastasis confined to the parathyroid gland is described, likely with intrathyroidal localization, arising from a RCC that occurred 16 years after nephrectomy. A 66-year-old man was referred to the Department of Surgery of the University Hospital of Pisa (Pisa, Italy) with a preoperative fine-needle aspiration diagnosis of a follicular lesion in the context of nodular goiter of the thyroid gland. The previous medical history of the patient included a right nephrectomy for the treatment of clear cell RCC in February 1997. No other distant metastases were identified as of the latest follow-up in March 2014. At the time of thyroid surgery, the thyroid and parathyroid function tests were normal. The gross appearance of the surgical specimen was a multinodular goiter with a solid nodule measuring 33 mm on the left lobe of the thyroid gland. Microscopic examination revealed a completely encapsulated lesion consisting of clear cells arranged in a solid pattern and intermixed with fragments of parathyroid tissue. Following immunohistochemical examination, the clear cell lesion was negative for thyroid transcription factor-1 and thyroglobulin and strongly positive for epithelial membrane antigen, cluster of differentiation 10 and vimentin. To the best of our knowledge, this is the second case of metastasis to the parathyroid gland from a RCC reported in the literature.

Surgical removal is recommended for recurrent thyroid carcinomas (RTCs) unable to uptake radioiodine and/or not responsive to chemotherapy. However, repeated neck dissection is difficult for surgeons. Thus, radiofrequency ablation (RFA) was proposed for RTCs. The aim of this prospective study is to assess RTC treatment response after RFA, according to well-established criteria. Sixteen lesions in 13 patients were treated by RFA. All patients refused/were excluded from repeated surgery or other conventional therapy. CT and US examinations were performed before RFA to evaluate lesion volume and vascularization. All RFA procedures were performed under US-guidance by an 18-gauge, electrode. Treatment response was evaluated by CT, according to RECIST 1.1 and to mRECIST guidelines; CT examinations were performed during follow-up (6–18 months); the volume of residual vital tumour tissue and the percentage of necrotic tissue were estimated by contrast enhanced CT. RFA was well tolerated by all patients; in two cases laryngeal nerve paralysis was observed. Mean pre-treatment volume was 4.18 ± 3.53 ml. Vital tumour tissue and percentage of necrosis at 6, 12 and 18 months were 0.18 ± 0.25, 0.11 ± 0.13, 0.29 ± 0.40 ml and 91.9 ± 11.1, 90.4 ± 13.3, 80.8 ± 23.1%. According to RECIST 1.1, target lesion response was classified as complete response (CR) in one case, partial response (PR) in 11/16, stable disease in 4/16 cases. According to mRECIST, 11/16 cases were classified as CR and the remaining 5 as PR. RFA is a safe procedure to treat the viable tumour tissue and to reduce the RTC volume; as to the criteria to assess treatment response, mRECIST appears to be more accurate.

The number of thyroid cancers is increasing. Standard treatment usually includes primary surgery, thyroid-stimulating hormone suppressive therapy, and ablation of the thyroid remnant with radioactive iodine (RAI). Despite the generally good prognosis of thyroid carcinoma, about 5% of patients will develop metastatic disease, which fails to respond to RAI, exhibiting a more aggressive behavior. The lack of specific, effective and well-tolerated drugs, the scarcity of data about the association of multi-targeting drugs, and the limited role of radioiodine for dedifferentiated thyroid cancer, call for further efforts in the field of new drugs development. Rearranged during transfection (RET)/papillary thyroid carcinoma gene rearrangements, BRAF (B-RAF proto-oncogene, serine/threonine kinase) gene mutations, RAS (rat sarcoma) mutations, and vascular endothelial growth factor receptor 2 angiogenesis pathways are some of the known pathways playing a crucial role in the development of thyroid cancer. Targeted novel compounds have been demonstrated to induce clinical responses and stabilization of disease. Sorafenib has been approved for differentiated thyroid cancer refractory to RAI.

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.

Until now, no data are present in literature about the prototype Th1 chemokine (C–X–C motif) ligand 10 (CXCL10) in anaplastic thyroid cancer (ATC). This study aimed to test in “primary human ATC cells” (ANA) vs “normal thyroid follicular cells” (TFC): (a) CXCL10 secretion basally and after interferon (IFN)-γ and/or tumor necrosis factor (TNF)-α stimulation; (b) peroxisome proliferator-activated receptor (PPAR)-γ activation by thiazolidinediones, rosiglitazone or pioglitazone, on CXCL10 secretion, on proliferation and apoptosis in ANA. We demonstrate that: (a) ANA, but not TFC, produced basally CXCL10, and did so in half of cases; (b) IFN-γ stimulated dose-dependently CXCL10, in ANA and TFC; (c) TNF-α did not induce CXCL10 secretion, in ANA and TFC; (d) IFN-γ + TNF-α induced a synergistic but variable release of CXCL10 in the different ANA preparations, while it was more reproducible in TFC; (e) rosiglitazone action on CXCL10 in ANA was inhibitory in 2/6, stimulatory in 1/6 and nil in 3/6, whereas it was inhibitory in TFC; (f) rosiglitazone inhibition of proliferation in ANA was not associated with the effect on CXCL10; (g) nuclear factor-κB and ERK1/2 were basally activated in ANA, increased by IFN-γ + TNF-α, and rosiglitazone inhibited that activation. On the whole, the present data first show that ANA cells are able to produce CXCL10, basally and under the influence of cytokines. However, the pattern of modulation by IFN-γ, TNF-α or thiazolidinediones is extremely variable, suggesting that the intracellular pathways involved in the chemokine modulation in ATC have different types of deregulation.

The increasing incidence of thyroid cancer is associated with a higher number of advanced disease characterized by the loss of cancer differentiation and metastatic spread. The knowledge of the molecular pathways involved in the pathogenesis of thyroid cancer has made possible the development of new therapeutic drugs able to blockade the oncogenic kinases (BRAF V600E, RET/PTC) or signaling kinases [vascular endothelial growth factor receptor (VEGFR), platelet-derived growth factor receptors (PDGFR)] involved in cellular growth and proliferation. Some clinical trials have been conducted showing the ability of targeted therapies (sorafenib, sunitinib, axitinib, imanitib, vandetanib, pazopanib, gefitinib) in stabilizing the course of the disease. Until now, however, no consensus guidelines have been established for patient selection and more data on toxicities and side effects are needed to be collected.

Targeted parathyroid surgery also referred to as minimally invasive parathyroidectomy has replaced full neck exploration as the preferred surgical approach to primary hyperparathyroidism. This is attributed to the ability to accurately localize enlarged parathyroid glands preoperatively and obtain objective evidence of adequate resection intraoperatively. The two most widely used minimally invasive parathyroid surgeries are the non-endoscopic miniincision parathyroidectomy and the minimally invasive video-assisted parathyroidectomy. The aim of this article is to provide a detailed illustration of the latter supplemented with an animated video of the procedure, and to highlight a potential advantage it offers over other targeted parathyroid procedures; the ability to perform a full neck exploration and/or a concomitant thyroid surgery without the need to convert to a standard cervicotomy.

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.

CLM29 (a pyrazolo[3,4-d]pyrimidine, that inhibits RET, epidermal growth factor receptor, vascular endothelial growth factor receptor, and has an anti-angiogenic activity) has anti-neoplastic activity in papillary dedifferentiated thyroid cancer. Here we tested CLM29 in medullary thyroid cancer (MTC), in primary MTC cells (P-MTC) obtained at surgery, and in TT cells harboring (C634W) RET mutation. CLM29 (10, 30, 50 μM) inhibited significantly (P

The occurrence of carcinoma of the thyroglossal duct remnant (TDRCa) is reported to be less than 1%. We retrospectively analyzed 18 cases (14 females, 4 males; mean age, 38.17 years) of TDRCa who underwent surgery in our department, to evaluate the correct workup for diagnosis and treatment. Nine patients underwent a total thyroidectomy and a Sistrunk procedure (SP) whereas 8 underwent a completion total thyroidectomy after a postoperative diagnosis of TDRCa. One patient was diagnosed with TDRCa several years after total thyroidectomy for goiter. Postoperatively all patients were given radioiodide and levothyroxine therapy. Mean follow-up was 85 months. No patient died of tumor-related disease. Thyroglossal duct neoplasms were represented by papillary carcinoma in 16 cases; thyroid histology demonstrated papillary carcinoma in 6 cases (33.3%). Three patients demonstrated single regional node metastasis and only one of them demonstrated the presence of malignant thyroid disease. When clinical diagnosis of thyroglossal duct cyst is made, the workup should be completed by ultrasound (US) scan and fine-needle aspiration cytology (FNAC) in order to plan the correct surgery for a possible TDRCa. Total thyroidectomy should always be considered with SP to permit the correct treatment and follow-up in those patients. Long-term survival of patients with cTDRCa is excellent.

OBJECTIVES Patients with SSc have an increased risk of malignancy compared with the general population. Before now, no study has evaluated the risk of thyroid cancer (TC) in SSc patients. The aim of the study was to evaluate the prevalence of TC in SSc patients. METHODS We studied the prevalence of TC in 327 unselected SSc patients in comparison with two population-based, gender- and age-matched control groups (654 subjects from an iodine-deficient area and 654 subjects from an iodine-sufficient area). Thyroid status was assessed by measurement of circulating thyroid hormones and autoantibodies, thyroid ultrasonography and fine-needle aspiration cytology (when necessary). RESULTS Circulating thyroid-stimulating hormone, anti-thyroglobulin and anti-thyroperoxidase antibody levels, and the prevalence of hypothyroidism were significantly higher in SSc patients (P < 0.01, for all). Six patients with papillary TC (PTC) were detected among SSc patients, whereas only one case was observed in each of controls 1 and 2 (P = 0.007, for both). In SSc all patients with TC had evidence of thyroid autoimmunity vs 40% of the other SSc patients (P = 0.001). CONCLUSION These data suggest a high prevalence of papillary TC in SSc patients, in particular in the presence of thyroid autoimmunity; careful thyroid monitoring would be opportune during the follow-up of these patients.

Ultrasonography is supposed to provide a reliable preoperative estimate of thyroid volume. This prospective study compares the estimated thyroid volume (EV) to real volume (MV), obtained by measuring the excised gland after surgery. One hundred one patients undergoing total thyroidectomy were selected for the study. Indications for surgery were: multinodular goiter, diffuse toxic goiter (DTG), uninodular disease. In all cases, ultrasound was repeated 1 month after surgery to verify complete thyroid removal. EV was underestimated in 89 cases; it perfectly matched the MV in 5 and was overestimated in 7. Mean EV was 28.3 mL (range, 7-50) and mean MV 36.2 mL (range, 7-76); this difference was statistically significant (p0.0001). Patients were then divided in groups according to EV (orthan 25 mL) and thyroid morphology. Highly significant differences were found between all groups (p0.0001) except the DTG population, where the difference was less significant (p0.042). The study demonstrates that a correct preoperative measurement of the thyroid gland is not achievable because the volume estimated by ultrasound is largely underestimated in comparison to the real volume of the excised gland. Nevertheless ultrasound is more reliable in DTG than in other thyroid diseases. Increasing the number of cases may help to verify a new mathematical model.

Background: The diagnosis of incidental thyroid carcinoma (ITC) in patients operated on for a benign disease is frequent. This study aims to determine both its clinical effect and the possibility of identifying this class of patients preoperatively. Methods: A total of 998 consecutive patients (697 women and 301 men; mean age, 49.5 years) undergoing surgery for benign thyroid pathology in a single institution were studied. The mean time between first diagnosis of thyroid disease and operation was 9.0 years (range, 0–50 years). All patients underwent at least one ultrasonography before surgery, and 678 patients underwent fine-needle aspiration cytology. Patients with undetermined cytology or follicular nodules were excluded from the study. Results: Histology revealed an ITC in 104 patients (10.4%): 99 had a papillary carcinoma. Mean and median diameters of ITC were 1.4 and 0.7 cm, respectively (range, 0.1–7.5 cm). In 43 patients, the tumour size was greater than 1 cm, whereas it exceeded 2 cm in 25 patients. Tumours were multicentric in 19.8% of the patients and occurred in 8.2% of patients with nodular toxic goiter, 8.7% of patients with toxic diffuse goiter and 13.8% of patients with multinodular goiter. Discussion: The results confirm the high frequency of ITC. ITC was more frequent in euthyroid patients than in thyrotoxic patients (P

We evaluated in primary human thyrocyte cultures the effect of interferon (IFN)-alpha and -beta on the expression of thyroid peroxidase (TPO), sodium/iodide symporter (NIS), and thyroglobulin (Tg) as well as T(4) release. Human thyrocyte cultures were carried out with fresh normal thyroid tissue. Gene and protein expression of Tg, TPO, and NIS were assessed by RT-PCR and Western blot analysis after 24, 48, and 72 h of treatment with TSH alone (10 mIU/ml) and in combination with IFN alpha or -beta (10(4) U/ml). IFN inhibited the TSH-stimulated gene expression of Tg, TPO, and NIS in a time-dependent manner without significant differences between IFN alpha and -beta. Moreover, the addition of both type I IFNs clearly reduced the TSH-stimulated protein expression of Tg, TPO, and NIS after 72 h of exposure. Finally, this down-regulation was associated with a reduction of T(4) release by almost 50%. In conclusion, our study shows that both IFN alpha and -beta down-regulate the TSH-stimulated expression of Tg, TPO, and NIS as well as T(4) release. Indeed, the development of hypothyroidism during type I IFN therapy may be related, at least in part, to an abnormal expression and function of key proteins involved in iodine uptake and organification.

Ever since the introduction of video-assisted thyroidectomy (VAT), Graves' disease has represented a contraindication. This study aimed to demonstrate that VAT can be proposed also for Graves' disease.From January 2002 to March 2003, 21 patients (20 women and 1 man) with Graves' disease underwent VAT. One patient showed positive test results for gene RET. The mean age of the patients was 36.4 years.No conversions of procedure were necessary. The mean operative time was 56.9 min. The RET-positive patient underwent total thyroidectomy and central compartment lymphadenectomy. Postoperative bleeding occurred in the patient with the largest gland. Histology showed goiter in 18 cases, medullary carcinoma in 1 case, and papillary carcinoma in 2 cases. No cases of vocal cord palsy but three cases of transient hypocalcemia were registered.Graves' disease can be treated safely using VAT only if selection criteria are carefully respected. The young age of the patients with this disease encourages us to propose VAT for its good cosmetic and postoperative outcome.

Background. The effectiveness of minimally invasive video-assisted thyroidectomy (MIVAT) in papillary thyroid carcinoma is still debated. Some are concerned about this procedure in patients with thyroid cancer. This prospective study aimed to demonstrate that near-total thyroidectomy can be performed by MIVAT with similar results compared with open thyroidectomy. Methods. A total of 33 patients with a thyroid nodule proven to be a papillary thyroid carcinoma underwent a near-total thyroidectomy. They were randomly assigned to group A (n = 16) or group B (n = 17) who were treated either by MIVAT or conventional near-total thyroidectomy, respectively. Iodine-131 thyroid bed uptake and serum thyroglobulin were measured 1 month after operation. Data were analyzed by unpaired t test and Mann-Whitney statistic methods. Results. Mean iodine-131 uptake was 5.1 ± 4.9% in group A and 4.6 ± 6.7% in group B. Mean thyroglobulin serum levels were 5.3 ± 5.8 ng/mL in group A and 7.6 ± 21.7 ng/mL in group B. The differences were not statistically significant. Conclusions. The results of this study showed that the completeness obtained with MIVAT is similar to that obtained with open thyroidectomy, with the great advantage of a minimal neck wound. No conclusions can be drawn in terms of influence of MIVAT on the outcome of the patients with small papillary thyroid carcinoma. (Surgery 2002;132:1070-4.)

Telomerase activation, a cardinal requirement for immortalization, is a crucial step in the development of malignancy and requires the induction of the catalytic component, human telomerase reverse transcriptase (hTERT), encoded by the hTERT gene. By reverse transcription-PCR, using primers within the reverse transcriptase domain of hTERT, we investigated telomerase messenger in 8 adenomatous and 9 dysplastic polyps, and in 32 paired cancer-normal mucosa specimens, one liver and one spleen metastasis from patients resected for sporadic colorectal cancer. Telomerase messenger was absent or very low in normal mucosa and in adenomatous polyps. Dysplastic polyps and adenocarcinoma samples showed hTERT mRNA, with higher levels in cancer tissues compared to dysplastic lesions. A high telomerase messenger level was shown to be associated with late-staged cancers and with metastasis; thus, detection of telomerase messenger may be useful in the early diagnosis of colon cancer, and telomerase may be a new target for therapeutic intervention.

Minimally invasive video-assisted thyroidectomy (MIVAT) has been practiced in our department since 1998. It has some advantages over conventional surgery in terms of postoperative pain and cosmetic result. The aim of this study was to evaluate the use of the Harmonic scalpel (HS) on the performance of this procedure.Between October 1998 and January 2001, 116 patients underwent MIVAT. The HS was used for the last 26 operations. We compared this group of patients (HS-G) with a control group (C-G) of 26 patients who had undergone MIVAT before the introduction of the HS. The following parameters were considered: age, gender, preoperative diagnosis, size of the lesion, type of operation (lobectomy or total thyroidectomy), operative time, complication rate, and postoperative hospital stay.The two groups were well matched for age, gender, preoperative diagnosis, lesion size, and type of operation. The mean operative time was significantly reduced in the HS-G for both lobectomy (37.3 +/- 8.4 vs 49.4 +/- 18.0 min) and total thyroidectomy (53.8 +/- 16.3 vs 90.6 +/- 22.1 min). No differences were found for postoperative stay. One patient in the C-G experienced a transient recurrent nerve palsy. There were no other complications.This study showed that the utilization of the HS for MIVAT is safe and associated with a shorter operative time. A reduction of the rates for such complications such as hypoparathyroidism and recurrent nerve injuries was not possible to demonstrate in the present study. Much larger series are needed for further evaluation of this instrument.

Figure 1. The external branch of the superior laryngeal nerve (SLN) lying on the surface of the cricothyroid muscle before the ligation of the upper pedicle (SP) of the thyroid. Figure 2. The anastomotic branch (AB) of the external branch of the superior laryngeal nerve with the recurrent laryngeal nerve (RN) before its entrance in the larynx. The endoscope allows a straight, close, and magnified view of the area after the section of the right upper pedicle of the thyroid.