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Aim: Surgery for mediastinal goiters (MG) is indicated for compression symptoms and risk of malignancy. Total thyroidectomy by cervicotomy is universally considered the standard surgical approach to MG. In selected cases sternotomy or a thoracotomy are used. Options of the operative technique and practical surgical problems are analysed., Methods: A retrospective analysis of twenty-eight-years on 1767 cases of MG in a referral centre for endocrine surgery was carried out. All patients underwent standard preoperative study and CT based surgical planning. Surgery was performed by an experienced surgical team with standard technique via cervical approach or in selected case via sternotomy or thoracotomy. Clinical records were examined., Results: Total thyroidectomy was performed in all cases. A cervical approach was used in almost 99% of patients. Significant shorter surgical time was observed for surgery via the cervical approach vs sternotomy and thoracotomy. Benign struma was observed in 1503 patients and a carcinoma in 264. We observed postoperative bleeding in 0.5% of cases, permanent monolateral recurrent laryngeal nerve palsy occurred in 1.3%, bilateral palsy in 0.6%, transient and permanent hypoparathyroidism in 14% and 4.1% respectively., Conclusion: MG may be approached by a cervicotomic access only with a clear knowledge of potential risk and complications of the surgical manoeuvres. Sternotomy or of a thoracotomy are indicated only in selected cases but their inapplicability may be really dangerous in those MG not otherwise resectable. MG should be referred only to specialized centre., (Copyright © 2015 IJS Publishing Group Limited. Published by Elsevier Ltd. All rights reserved.)

Introduction: Thoracic duct fistula at the cervical level is a severe but rare complication following thyroid surgery, particularly associated to lateral dissection of the neck and to mediastinal goiter., Methods: we retrospectively analyzed chylous fistulas observed in a cohort of 13.224 patients underwent surgery for thyroid disease since 1986 to 2014, in the Unit of Endocrine Surgery, S. Maria University Hospital, Terni, Italy., Results: We observed 20 cases of chylous fistula. Thirteen patients underwent primary surgery in our institution while the remaining 7 cases had been referred to our Department from other hospitals for an already diagnosed lymphatic leak. Surgical procedures carried out included total thyroidectomy for mediastinal goiter in 4 patients, total thyroidectomy for cancer in 2 patients, unilateral functional lymphadenectomy in 11 patients and bilateral in 3. Intraoperative repair was carried out in 4 cases. Of the remaining 16 cases, 4 of the 6 fistulas with low flow leakage healed in about 30 days of conservative treatment, 2 cases instead required surgical repair. All 10 patients with "high-flow" fistula underwent surgery. Despite surgery was performed later, postoperative course in patients with late surgical repair is similar to what observed in those patients with early surgical repair. Both groups underwent cervical drainage removal in post-operative day 4., Conclusion: Healing of a cervical chylous fistula can be achieved by conservative medical therapy (nutritional and pharmacological) but in case of therapeutic failure with rapid decrease of general condition, the surgical approach is necessary. In our experience, duct ligation after unsuccessful conservative treatment, is the only resolutive treatment., (Copyright © 2015 IJS Publishing Group Limited. Published by Elsevier Ltd. All rights reserved.)

Introduction: Prognosis of thyroid cancer is strictly related to loco-regional metastases. Cervical lymphadenectomy has a specific oncologic role but may lead to significant increase of morbidity. Aim of the study is the analysis of surgical morbidity in cervical lymphadenectomy for thyroid cancer., Methods: We retrospectively analyzed 1.765 thyroid cancers operated over a period of 25 years at S. Maria University Hospital, Terni, University of Perugia, Italy. Type of lymphadenectomy, histology and complications were analysed., Results: A prevalence of differentiated and medullary cancers was observed (respectively 88% and 7.2%). Central lymphadenectomy was carried out in 425 patients, lateral modified and radical lymphadenectomy respectively in 651 and 17 cases. Following central neck dissection we observed: bilateral and unilateral temporary recurrent nerves palsy respectively of 0.7% and 3.5%, unilateral permanent palsy in 1.6% of cases, temporary and permanent hypoparathyroidism respectively in 17.6% and 4.4%. After lateral neck dissection we observed: intra and post-operative haemorrhage respectively in 2% and 0.29%, respiratory distress in 0.29%, lesions of facial nerve in 0.44%, of vagus in 0.14%, of phrenic nerve in 0.14%, of hypoglossal nerve in 0.29%, of the accessory nerve, transient in 1.34% and permanent in 0.29%, permanent lesion of cervical plexus in 0.29%, salivary fistula in 0.14% and chylous fistula in 1.04% of patients. Student's t test was used to compare groups when appliable., Conclusion: Central and lateral cervical lymph node dissection are associated to severe morbidity. Correct indication, surgical expertise, high volume of patients and early multidisciplinary management of complications is the key of an acceptable balance between oncologic benefits and surgical morbidity., (Copyright © 2015 IJS Publishing Group Limited. Published by Elsevier Ltd. All rights reserved.)

Introduction: Anaplastic thyroid carcinoma (ATC) is characterized by local invasiveness, risk of recurrence and very poor prognosis., Methods: We retrospectively analysed the multimodality treatment of ATC in 79 patients considering the impact of surgery on survival., Results: Patients were divided in two age groups A and B (cut-off 75 years) and in two size subgroups (cut-off 5 cm). Surgery was performed in 78.5% patients of group A and 32.4% of B (p < 0.05). Radiation respectively in 73.8% and 43.2% (p < 0.05). Tracheostomy and endoprosthesis were used in 45.2% and 16.6% in group A and in 43.2% and 35.1% in group B. The use of tracheostomy was significantly higher (p < 0.05) in larger tumours. In group B comparing operated and not operated patients significant difference in survival was observed for larger tumours (p = 0.043). In Kaplan Meir analysis significant difference in survival was observed comparing surgical and no surgical patients of all four subgroups. Surgery plus radiotherapy offered a significant better outcome in smaller tumours (p = 0.017). Considering the effect of the single treatment, compared to no treatment at all, survival is significantly improved by surgery for smaller and larger tumours respectively with 4.42 (p = 0.001) and with 3.5 months (p = 0.0001) and by radiotherapy respectively with 3.44 and with 3.28 months (p = 0.047 and p = 0.0001)., Conclusion: In elderly patients with ATC, although poor prognosis, surgery is still fundamental in the multimodality treatment with significant advantage in selected patients. Nevertheless most of elderly patients with large tumours are suitable only for palliative management., (Copyright © 2014 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.)

Aim: Mediastinal goiter (MG) is characterized by compression symptoms such choking, dyspnea, sleeping apnea and dysphagia. It is significantly observed in elderly patients who due to comorbidity are associated to increased surgical risk. Total thyroidectomy is indicated to treat tracheal compression. Cervicotomy is the most used surgical access. AIM of the study was the evaluation of the role of surgery in the treatment of MG in the elderly., Methods: A retrospective analysis of twenty-eight-years on 1721 (390 over 80-years-old) cases of MG in a referral center for endocrine surgery was carried out. CT was used as a standard in the preoperative study. Surgery was performed by an experienced surgical team with standard technique via cervical approach or in selected cases via sternotomy or thoracotomy. Clinical records were examined., Results: Patients were divided into two groups: older and younger than 80-years-old. Total thyroidectomy was performed in all cases and via a cervical approach in almost 99% of patients. Tracheal dislocation and tracheomalacia were prevalent in elderly patients and were treated conservatively. Benign struma was observed in 1463 patients and a carcinoma in 258. Larger thyroid weight was observed in the elderly. The rate of complications was similar between groups., Conclusion: Total thyroidectomy via cervical approach is the treatment of choice for MG in the elderly. It should be treated only in referral centers with adequate caution for elderly patients to achieve complete cure with limited complications., (Copyright © 2014 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.)

Background: Sentinel lymph node (SLN) biopsy plays a major role in the surgical management of primary breast cancer. The aim of this study was to assess the diagnostic accuracy of the assessment of axillary frozen sections of SLNs for micrometastasis diagnosis., Patients and Methods: This study focused on 250 SLNs from 137 patients. Each lymph node was fully analyzed by frozen section. After fixation, serial sections were cut and stained by hematoxylin and eosin (HE) and for pan-cytokeratins by immunohistochemistry (IHC)., Results: Tumor cells were detected in 57 SLNs, 37 on frozen sections and 20 on controls. Of these 57 positive SLNs, 38 contained metastases, 9 contained micrometastases and 10 contained isolated tumor cells. The specificity and positive predictive value of SLN frozen sections for micrometastasis was 100%. The sensitivity was 83.3% for metastasis, 40% for micrometastasis; the false-negative rate was 16.7% for metastasis and 60% for micrometastasis., Conclusion: Analysis of frozen section of SLNs is an accurate method for metastasis detection, allowing concurrent axillary dissection when positive. The protocol for SLN analyses described herein shows good sensitivity for micrometastasis detection., (Copyright © 2014. Published by Elsevier Ltd.)