Reoperation in the treatment of asymptomatic metastasizing medullary thyroid carcinoma

Eleven patients who continued to have elevated calcitonin (CT) levels after thyroidectomy and central node dissection for medullary carcinoma of the thyroid gland (MCT) were subjected to additional surgery. Metastatic MCT was found in the excised tissue from each patient. Normalization of CT values was obtained in four patients who had a few microscopic, unilateral metastases. In these patients an average of 13 normal lymph nodes were excised at reoperation for each metastasis. The results of the reoperative series demonstrate that it is possible, with meticulous neck dissection, to normalize CT levels in patients with microscopic metastases from MCT. Metastases that can be seen or palpated are always associated with microscopic lymph node metastases. Removal of such microscopic metastases is probably the key to achieving normal postoperative CT levels.     

甲状腺癌的再次手术治疗

目的 探讨甲状腺癌再次手术的意义、手术时机及其手术方式。方法 回顾性分析1989年1月－2000年1月间57例甲状腺癌再次手术的临床资料。结果 首次手术方式为甲状腺肿块切除或甲状腺患叶次全切除术47例,甲状腺癌改良根治术6例,甲状腺患侧叶全切除术4例。首次手术病理类型：乳头癌32例,滤泡状癌15例,混合癌7例,未分化癌3例;再次手术的主要原因为首次手术不当致癌残存和肿瘤复发者47例,占82．5％,其次为术中漏诊6例,快速冰冻切片误诊4例。再次手术中甲状腺及周围组织中残癌率为53．7％;颈部淋巴结残癌率48．6％。再次手术后的5年生存率为92．9％,10年生存率为87．5％。结论 由于甲状腺癌的术前误诊,如首次术式选择不当,则手术后的残癌率较高,再次手术是必要的,而且两次手术间隔不要超过3个月。再次手术时宜重视选择适当手术方式,以提高病人的长期生存率。     

Improved results of cervical reoperation for medullary thyroid carcinoma.

OBJECTIVE: The purpose of the study is to determine whether reoperation for medullary thyroid carcinoma (MTC), performed with low morbidity in carefully selected patients, consistently results in improvement as determined by lowering of stimulated calcitonin levels. BACKGROUND: Persistent or recurrent elevation of stimulated plasma calcitonin levels occurs in > 50% of patients after primary operation for MTC. Success of reoperation with clearance of metastatic cervical nodal disease has been hampered by failure to identify patients with distant metastases and by inadequate removal of involved nodal groups. METHODS: Since 1992, the authors have evaluated 115 patients with recurrent or residual MTC. Fifty-three patients have not undergone operation because of extent of disease, previous extensive treatment, medical condition, or patient choice. Sixty-two patients underwent surgery. Ten patients had laparoscopic or open examination of the liver, the results of which showed liver metastases. Seven patients had palliative debulking of cervical tumor. In 45 patients without evidence of distant metastases, cervical operation was carried out with curative intent. Removal of central, upper mediastinal, and lateral nodes (levels II, III, IV, VI, and VII) was done. RESULTS: Seven of eight patients who had palliative resections are alive without symptoms. In patients who underwent curative resections, postoperative stimulated calcitonin levels were in the normal range in 17 patients (38%) and were not significantly lowered in 6 patients (13%). There were no deaths, and no transfusions were used. CONCLUSIONS: These results are a significant improvement over the authors' previous series and reflect better preoperative identification of patients with disease confined to the neck and improved operative strategy based on knowledge of the pattern of nodal spread of MTC.     

Nonfamilial medullary thyroid carcinoma

On the basis of this report and the current literature, we conclude that the familial type of medullary thyroid carcinoma can be diagnosed early using basal and poststimulation levels of calcitonin. However, most of the patients with sporadic disease present with a neck mass later in life. The tumor has a tendency to invade locally and metastasize to lymph nodes early in its course. Prognosis is negatively influenced by the extent of disease, lymph node involvement and elderly age. The surgical procedures of choice should be total thyroidectomy with clearance of central nodes of the neck as well as neck dissection when indicated. All parathyroid glands should be inspected. For patients treated for cure, the determinant 10 year survival is 48 percent, and 20 year survival is 33 percent. Recurrence of local disease should be treated aggressively, as important palliation and prolongation of life can be achieved. Radiotherapy may be helpful in the management of residual tumor or recurrent disease. Basal calcitonin assays and poststimulation studies are useful in diagnosing residual or recurrent disease. In the familial cases, the existence of other endocrinopathies has to be considered in the management of the patients.     

Surgical management of medullary thyroid carcinoma

Medullary thyroid cancer (MTC) is a malignant tumor of the parafollicular C cells of the thyroid and comprises only 1–2% of all thyroid cancer cases. Unlike most differentiated thyroid cancer, MTC is associated with a mean survival of 8.6 years and accounts for a disproportionate 8.6% of thyroid cancer deaths. Surgery is the mainstay of treatment for loco-regional disease and the only current means of cure for MTC. The relatively low incidence of MTC has made the comprehensive study of this disease difficult and most research to date has been based largely on single institution, retrospective, and/or non-randomized studies. Despite various professional organizations such as the American Thyroid Association establishing guidelines for the diagnosis and treatment of patients with MTC, there is still significant variation in actual practice patterns with regard to the extent of surgery, as well as the management of persistent or recurrent disease. The purpose of this review is to discuss the latest updates in the surgical treatment of MTC, as well as the management of locally advanced, recurrent, and metastatic disease based on the most recent data and expert consensus guidelines.     

Immuno-histochemical study of medullary thyroid carcinoma

Five peptide hormones including calcitonin (CT) and gastrin-releasing peptide (GRP), serotonin (5HT), CEA, nervous tissue specific proteins and monoclonal antibody Leu-7 were immuno-histochemically studied on 60 cases of medullary thyroid carcinoma (MTC). In addition, localization of varied products in the tumor cells and its relations with the clinical features in some cases were evaluated. MTC contains a variety of products in many cases, and CT and CEA were positive in all cases. In 50 of the 57 cases (87.7%), GRP was positive, which suggested that GRP could be a novel tumor marker for this tumor. Furthermore, in tumor cells and C-cell hyperplastic foci, identical cells were sometimes revealed to possess both CT and GRP. Existence of somatostatin (SS), substance-P (SP), beta-MSH, 5 HT, Leu-7 and NSE in the tumor cells were confirmed. NSE was positive in 32 of the 47 cases (61.8%) which could confirm that MTC possesses neuroendocrine nature. In two cases of autopsy in which the tumors were highly malignant in clinical course and undifferentiated in histology, most tumor cells showed poor stainability for peptide hormones, suggesting that specific qualities as neuroendocrine tumor had been lost. In familial cases, the tumor tended to contain multiple substances.     

Hormone-dependent medullary carcinoma of the thyroid

An unusual case of complete regression of pulmonary metastases of medullary carcinoma of the thyroid after oral administration of thyroid extract is presented. The patient has remained free of disease for three and a half years. This treatment has few side effects and may be as effective as is the administration of radioactive iodine or external radiation. For these reasons, it should be tried despite adverse pathologic indications.     

Treatment of familial medullary thyroid carcinoma

Medullary thyroid carcinoma (MTC) is a rare thyroid malignancy, which is familial in 25-29% of cases. Familial MTC is due to germ-line mutations in the RET proto-oncogene. It can occur either alone or as the thyroid manifestation of MEN 2 syndromes; the disease is inherited in an autosomal dominant fashion with age-related penetrance. The treatment of choice is surgery. Early diagnosis and an adeguate initial operation provide the best chance of cure. Hence, the diagnosis should be made preoperatively. Genetic testing can identify almost all affected individuals with hereditary disease and permits prophylactic/early thyroidectomy in gene carriers. Total thyroidectomy and lymphadenectomy of the cervicocentral compartment is mandatory in all patients. In addition, bilateral dissection of the cervicolateral compartment should be done in all cases with more than microscopic disease. Plasma calcitonin is an excellent marker for postoperative follow-up. Treatment of persistent/recurrent disease is primarily surgical. Hence, a reoperative cervical lymphadenectomy should be considered in patients with persistently elevated calcitonin levels and no signs of distant metastases. Chemotherapy and external radiotherapy have little impact on the course of avanced disease; more promising is metabolic radiotherapy with Y90-DOTATOC in patients with somatostatin receptor-positive tumours.     

Surgical therapy of medullary thyroid carcinoma

This study describes the findings of a retrospective study of 57 medullary thyroid cancer patients observed at the main Sicilian centres for endocrine surgery. Six of these patients were observed locally in order to add a further dimension to the discussion of surgical therapies for medullary thyroid carcinoma. A review of the literature on sporadic forms of medullary thyroid carcinoma and hereditary neoplastic syndromes is followed by presentation of the authors' series. Diagnostic protocols, surgical therapies and pathological observations are discussed. Particular attention is paid to patterns of metastases of medullary thyroid carcinoma and to the differing opinions regarding the extent of lymph-node dissection required and the treatment of recurrent disease. Total extracapsular thyroidectomy with lymph-node dissection is identified as the gold standard of surgical therapies for this form of cancer.     

Chronology of medullary carcinoma of the thyroid

In order to study the chronological progress of medullary carcinoma of the thyroid, clinical records and histological findings of 62 patients with the tumor were reviewed. Postoperative plasma calcitonin levels were examined in 54 patients. Among the patients with the disease of the hereditary type, those of 30 years of age younger with no lymph node involvement and a tumor weight less than 5 g were most likely to have normal plasma calcitonin levels postoperatively, provided total thyroidectomy were performed. The peak of age distribution of patients of the hereditary type without lymph node involvement was 15 years less than that of those with nodal involvement. In the sporadic type, there was no correlation between teh age and the nodal nodal involvement. Plasma calcitonin levels in the patients with residual tumor showed exponential increase according to the time course. The regression lines, log y = log a + bx (y: plasma calcitonin level, x: years after operation), were calculated in 23 patients followed 6 months or longer. The doubling time of the plasma calcitonin level (T2), given as 1/b log 2, correlated well with the tumor progression rate. T2 for patients of the hereditary type were 0.8 years or longer except for one. Four patients of the sporadic type with T2 of 0.1-0.3 year within 3 years after operation.     

Management of medullary carcinoma of the thyroid

Total thyroidectomy is universally advised for the familial variety of MCT. Although total thyroidectomy is also recommended for sporadic cases, partial thyroidectomy may be adequate. Cervical and upper mediastinal nodes should be sampled for microscopic study, even when they are small and appear to be normal. Appropriate neck or mediastinal nodes should be sampled for microscopic study, even when they are small and appear to be normal. Appropriate neck or mediastinal dissection is done if metastasis is present. External radiation is a valuable adjuvant to surgical excision following the apparent complete resection of the tumor, and is beneficial in the management of unresectable disease. Despite local control, patients continue to die from disseminated disease; therefore, there must be a continued search for an effective chemotherapeutic program. Much remains to be learned from calcitonin monitoring of MCT patients.     

误以良性肿瘤处理的甲状腺癌再手术问题

甲状腺癌是头颈部最常见的恶性肿瘤之一,大多数(80%~90%)表现为分化型,恶性程度相对较低。由于分化型甲状腺癌尤其不伴有颈淋巴结转移者,其临床特征与良性瘤极为相似,目前又缺乏特异性的检测方法,致使若干甲状腺癌首次手术时被当做良性肿瘤处理,以致于患者不得不再次接受手术[1]。山东大学齐鲁医院普通外科2001年1月~2004年4月甲状腺癌手术切除132例,其中48例在外院以良性肿瘤首次手术,术后病理确诊后转来再次手术,占手术病例的36.4%。再次手术后我们对切除的标本做详细的病理检查。根据病理检查结果,我们对该类病例再次手术应注意的问题、…     

甲状腺髓样癌的诊断与治疗

甲状腺髓样癌(MTC)来源于滤泡旁C细胞,占甲状腺癌的5%～10%,其中25%具有遗传性.MTC能够较早的出现淋巴结及远处转移,故早期诊断及治疗尤为重要.本文描述了MTC实验室及影像学等方面的主要表现,并对最新的治疗手段及预防性措施进行了阐述.     

Reoperation for aortofemoral graft limb occlusion: optimal methods and long-term results

To determine optimal methods of reoperation, experience with 157 secondary procedures for unilateral aortofemoral graft limb occlusion in 110 patients during a 16-year period was reviewed. In earlier years, inflow was reestablished by direct replacement of the graft limb or entire graft (11%); more recently, graft limb thrombectomy has been used most frequently (68%) with equal success, durability, and less morbidity. Femorofemoral grafts from the patent contralateral graft limb were employed in 18% of patients, usually those in whom thrombectomy was not attempted. Thrombolytic therapy (3%) appears to offer little advantage, is time-consuming, and occasionally causes significant complications. In addition to reestablishment of inflow, most patients also required revision of the femoral anastomosis to improve profunda femoris runoff; this was usually best accomplished by short segmental extension of the graft limb to the more distal deep femoral artery. Concomitant femoropopliteal bypass was done in 32% of patients and is indicated when preoperative angiography or specific intraoperative findings suggest inadequate profunda femoris outflow. An aggressive approach to reoperation appeared justified by long-term results (mean follow-up 37 months). Despite the need for repetitive reoperation in 26% of patients (two to five reoperations), graft limb patency was ultimately maintained in 78% and limb salvage achieved in 67% of patients, with an operative mortality rate of only 1.9%.