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Differentiated thyroid carcinoma accounts for 90% of all thyroid cancers and occurs as papillary carcinoma in 90% of cases. It was shown as this is characterized by an excellent long-term prognosis, although in follow-up long series, were described recurrence rates up to 35%. Although in the past has not been attributed prognostic significance to the lymph nodes, in the last decade has shown how these can affect the rate of locoregional recurrence of differentiated thyroid carcinoma. This renewed interest in lymph node metastatic disease has prompted a shift in surgical treatments more aggressive, with a view to achieving a low incidence of locoregional recurrence. Analyzing the more recent guidelines formulated at the international level, we can highlight how we gradually consolidated the role of prophylactic central compartment lymphadenectomy in the surgical treatment of patients with differentiated thyroid carcinoma. The aim of this treatment, in fact, is not only to reduce the mortality of patients, but to obtain an adequate staging, facilitate radiotherapy treatment, obtain undetectable thyroglobulin levels, avoiding the need for repeated reiterventi, made more simple follow-up. All these objectives can be achieved by careful surgery. Total thyroidectomy associated with prophylactic lymphadenectomy of the central compartment was found to achieve these objectives, although in the absence of data from randomized trials, its role remains controversial.

In this study on 28 operated patients, the Authors show that total thyroidectomy with elective central neck dissection and ipsilateral neck dissection is the most appropriate surgical treatment for medullary thyroid carcinoma. Pathologic study on lymph nodes removed in central and in latero-cervical compartments showed malignancy respectively in 75% and in 70% of the cases. However the role of elective ipsilateral lateral neck dissection remains controversial.

Advanced head & neck cancer, after a first treatment, has an high rate of relapse locally or in the lymph nodes. Aim of present study is to value the option and the results in salvage surgery of 62 patients (55 male, 7 female, mean age 53,2) with cancer of the larynx and pyriform sinus, previously treated by surgery or radiotherapy; 45,2% showed relapse on T side, 25,5% in the nodes, 29% both. During follow-up, 3,2% showed a second primitive cancer, 9,6% still present disease. Overall survival rate is 72,6% after 3 years (86,2% for early cancers, 54,5% in advanced ones), 50.6% after 5 years (65,5% for early, 36,4% in advanced). Laryngeal cancers presented better survival rate (54% at 5 years) after salvage surgery than ipopharynx (33% at 5 years). Therefore in ipophaynx cancers we think it is useful to programme aggressive treatment also in early cancer. In our experience in larynx recurrence suvracricoid surgery is really suitable.

The onset of cervicoscopy dates back to the first endoscopic parathyroidectomy in 1996. This operation, along with its several variants, has become a valid option widespread in many important centres. Later on, endoscopic or video assisted thyroidectomy was introduced in spite of the limits imposed by the mass of the gland to remove. It is indicated for a minority of patients for this reason but both parathyroidectomy and thyroidectomy showed some important advantages with respect to conventional surgery, advantages demonstrated also in prospective studies. They are mainly represented by a better cosmetic outcome and a less distressful postoperative course. These approaches proved to be safe and feasible in any surgical background: their complication rate is the same as traditional open surgery in the neck. Very promising seems to be the videoscopic access to neck lymph nodes (central and lateral compartments) whereas other fields of application such as carotid artery surgery and spine surgery still remain object of experimental studies. As far as the lateral neck dissection is concerned the technique is going to be standardized in our centre as a variant of the well known video assisted approach adding a 5 mm trocar placed in the supraclavicular space. By consequence, cervicoscopy has to be considered an important surgical tool which can be further improved but which also has an excellent potentiality.

The goal of our study was to estimate the presence (or absence) of latero-cervical nodal metastases (pN+), in patients with squamous oropharyngeal cancer, correlating this finding with T stage. We examined 255 patients out of 329 affected by squamous oropharyngeal cancer, from 1976 to 2005. The 255 patients examined were treated surgically (both T and N). As far as clinical latero-cervical nodal metastases were concerned, 215 patients (84%) were cN+, while 40% (16%) were cN-. The result of the histological examination showed that 82% of the neck dissections (both cN+ and cN-) actually had latero-cervical metastases, while the remaining patients had reactive lymph nodes. The false-positive (cN+ -->pN-) patients, were 14% while false-negative patients (cN- -->pN+) amounted to 63%. The correlation between T and pN+ of the patients classified as cN- showed that 24% of patients were T1, 44% T2, 32% T3, and none T4; the pN+ patients, who clinically manifested latero-cervical lymph-node metastases were: T1 8%, T2 15%, T3 37%, T4 40%. Analysis of these data led us to the conclusion that, in view of the high lymphophilia of squamous cancer in the oropharyngeal district, it would be advisable to treat N metastases, both cN+ and cN-, at any T stage of cancer, surgically or with chemo- or radiotherapy, according to the patient's performance status.

Objective: To define the surgical principles of neck dissections as applied to the head and neck squamous cell carcinomas, extending their rationale to treatment of lymph nodes metastases from thyroid carcinomas., Materials and Methods: Between January 1994 and June 2002, 52 patients affected by well-differentiated thyroid cancers (1 follicular, 9 medullary, and 42 papillary cancers) underwent uni- or bilateral neck dissections at our Department, for a total of 73 neck dissections. Patients were subdivided into 2 groups: 37 simultaneously treated on the thyroid and the neck (Group A), and 15 operated elsewhere on the thyroid and for a neck recurrence and/or persistence at our Department (Group B)., Results: 48 patients underwent a regular follow-up (range: 3-86 months, mean: 38). Among patients alive with disease, 5 in Group A and 4 in Group B had a local-regional recurrence. In particular, 2 patients for each group (2 medullary and 2 papillary cancers) had a regional recurrence on the N site, at the level of one or more lymph nodes "in field" as regards the neck dissection previously performed. Moreover, in all these patients a local recurrence on the T site has been observed., Discussion: Lymph nodes metastases have a minor prognostic impact in well-differentiated thyroid cancers in respect of the rest of head and neck cancers. Nonetheless, when performing a curative or elective neck dissection, the gold standard surgical principles must be the same. As a matter of fact, a 20% incidence of lymph nodes metastases at the V level, often not specifically addressed in neck dissections for thyroid cancers, it is noteworthy. Aim of such an aggressive surgical approach of the neck is to obtain a low incidence of "in field" regional recurrences, which become no more amenable of a subsequent surgical salvage., Conclusion: Surgical techniques as lymphadenectomy or "pick-berry procedure" must be abandoned because they do not respect the basic anatomic, physiopathologic, and oncologic principles of neck dissections along cervical fasciae and spaces.

Background: In this study the authors analyze the indications and the type of surgical procedure to perform on the neck lymph nodes in cases of differentiated thyroid carcinoma., Methods: The study has been carried in a retrospective way. Between 1993 and 2001, 93 differentiated thyroid cancer were observed. There were 72 women and 21 men, with a mean age of 45.9 years (range 18-77). Patients have been divided into three groups: the first included 25 patients who underwent only thyroidectomy (24 total thyroidectomy, 1 lobectomy); the second group included 52 patients who underwent total thyroidectomy and lymphadenectomy of the central compartment. The third group included 16 patients who underwent total thyroidectomy and functional neck dissection. The median follow-up was 65.9 months., Results: The postoperative complications was similar between three groups. Follow-up has shown similar survival and recurrences between groups., Conclusions: The elective lymphadenectomy of the central could be a solution for a routine treatment of differentiated thyroid cancer without lymph node involvement. The presence of cervico-lateral node metastases imposes a functional neck dissection.

We report herein the case of a 43 year-old man who was operated 1998 of left colectomy and hepatic resection for colic adenocarcinoma metastasized in the liver. He suffers of multinodular goiter from some years; was admitted to our hospital with a 2-month history of enlargement of goiter and appearance of a new nodule. Physical and imaging examinations disclosed a new nodules in the thyroid. Was operated of total thyroidectomia and lymphoadenectomia cervical in the December 2002. Hystologic examinations revealed adenocarcinoma which was consistent with a diagnosis of metastases from the primary colon adenocarcinoma to the thyroid. The rarity, diagnosis, and prognosis of thyroid metastasis from colon carcinoma are discussed.

Introduction: PEG is more and more used for those patients who need a medium and above all long term enteral nutrition, especially at home. This is the closest technical system to the requirements to have an ideal nutritional access; however it is burdened, on average in 32.5% of cases, with complications linked to technical mistakes of positioning or to a wrong management, such as haemorrhage and gastric perforation., Case Report: A patient, subjected to supraglottic laryngectomy, to removal of tongue's base and to bilateral laterocervical lymphadenectomy and PEG carrier for 4 months, has arrived to our observation for a clinical outline of acute abdomen for perforation of hollow internal organ, preceded by progressive anaemia due to high digestive haemorrhage. Performed an exploratory laparotomy, it was discovered on the gastric fore face, between body and antrum, in proximity to the small curvature and in front of the PEG gastric access, a perforation with max 2 cm of diameter, crossed by probe's internal disk of retention. They proceeded to remove that, to unstick the gastric stoma from the parietal peritoneum, to suture the access of gastrostomy and the perforation by omentoplasty. Finally they carried out a jejunostomy for enteral feeding., Discussion: We think we can pathogenetically identify the cause of the haemorrhage and of the stomach's perforation, occurred in a short time in the case we have examined, in the probe's movement for incorrect fixing of the plate of external anchorage or for excessive slimming of the patient due to not balanced nutritional supply, as well as in the consequent extension of its intraluminal part with continuous rubbing by internal disk on the gastric wall and with onset decubitus ulcer. Physiopathologic moments, connected with the supposed etiological factor, make both occurred complications as an unique pathologic entity, which has to be observed in the PEG carriers, in order to be able to diagnose it and treat it precociously and above all in order to be able to prevent it. Only a correct technique of positioning and of nursing and of management of nutritional supply is able not to thwart the finality of the PEG device which can be considered, in the elective indications and for the favourable requisites that marks it, a valid access to enteral nutrition realization.

Reconstruction of the oro- and hypopharynx has specific difficulties duo to their wide diameters. Thirteen patients underwent reconstruction with a free U-shaped jejunal transplant, after circular pharyngo-laryngectomy for hypopharyngeal cancer invading the oropharynx. This transplant included a side-to-side anastomosis between the two limbs of the jejunal loop and allowed reconstruction of the upper digestive tract after wide carcinologic resection of the pharynx. The U-shaped jejunal transplant facilitated the upper anastomosis, especially the upper part where the resection involved the oropharynx. It formed a reservoir behind the tongue and avoided nasal reflux. Best indication are large resections involving the oropharynx.

The purpose of the present study was to define the indications and extension for the treatment of lymph nodes in clinically NO patients with primary malignant epithelial parotid tumors. A retrospective analysis was performed on 46 cases with such tumor out of 307 parotid neoplasms (246 benign, 61 malignant) consecutively treated from 1985 to 1994. Lymph node metastases were present only in the histotypes with a high degree of malignancy (overall incidence, 24%). Two patients (5%) showed occult metastases. No correlation was found between the size of the neoplasm and the incidence of lymph node metastases. However, the latter were significantly more common in locally highly aggressive neoplasms (class "a"), 8%; class "b" 43%; P = 0.006). Due to the small number of cases, it was not possible to correlate the incidence of occult metastases with neoplasm size or local extension. As regards topographic distribution of lymph node metastases, level II was always involved, level V was never involved, and level i.v was involved only when metastases were found in the upper levels. Occult metastases were found only at level II. Over a follow-up period of 2 to 10 years, no cases were seen with cervical recurrences. Although drawn from a limited series, the results are similar to the data generally reported in the literature, showing that lymph node metastases are rare in neoplasms with a low grade of malignancy whereas there is a significant increase in the incidence of metastatic lymph nodes and occult metastases when the grade of malignancy is high. In conclusion, in clinically NO patients, a suprahomohyoid neck dissection (levels I-II-III) is indicated only when the neoplasm shows a high grade of malignancy or when it is a class "b" malignancy. In the other cases, neck dissection is determined by the clinical evidence of metastasis and can be extended to the lower levels. Neck dissection can be avoided in NO patients whenever ultrasound and fine needle biopsy are both routinely used in the preoperative evaluation of the cervical lymph nodes.

Thyroid primary cancer involves 1.5% of malignant tumors and it causes yearly 0.5% cancer mortality. It is usually related to eu- or hypothyroidism, whereas it is rarely associated with hyperthyroidism. The Authors deal with controversial issues concerning thyroid oncogenesis and surgical strategies. However, they have not ignored epidemiological data and clinical features most peculiar to various neoplastic histotypes. They also report on their own experience with 156 cases of thyroid CA, out of 2.510 surgically treated thyroid diseases, which were being investigated from 1969 to 1998. The Authors recognize that an appropriate approach to thyroid neoplastic diseases arises from a careful evaluation of all parameters (T, N, M, histotype, patient's, age, intraoperative assessment etc.) characterizing their polymorphism.

The operative treatment of thyroid pathology has to be distinguished for benign and malignant pathology. The major complications associated with thyroid surgery are injury to the recurrent laryngeal nerve and hypoparathyroidism. Postoperative hypoparathyroidism is rarely the result of inadvertent removal of all parathyroid glands but, non commonly, is due to disruption of their blood supply. Postoperative hypoparathyroidism results in patients with symptomatic hypocalcemia, transitory and permanent hypoparathyroidism. Subtotal thyroidectomy is used for the treatment of benign thyroid pathology while tumors are treated by total thyroidectomy with neck dissection.

The authors report their experience and surgical treatment of 440 patients with differentiated carcinoma of the thyroid (DCT) from 1970 to 1990 in the III Surgical Dept. at the University of Rome "La Sapienza". Considering 305 cases of papillary carcinoma, 103 Total Thyroidectomy (TT), 118 TT with Functional Regional Lymphadenectomy (FRL), 32 TT with Node-Picking, 51 TT with curative FRL and one TT with Radical Neck dissection were performed. In 135 cases of follicular carcinoma TT associated with Node-picking were performed on two patients, TT associated with FRL on 8 patients and TT associated with RND on 2 patients. Overall survival to 10 years was 90%; 98% for N- papillary carcinoma and 66% for N+ follicular carcinoma. There were no permanent recurrence of disease. Out of the patients who did not undergo cervical lymphadenectomy 30% developed temporary hypocalcemia; 53% (mediastinal lymphadenectomy) to 87% (FRL) of the patients submitted to lymphadenectomy developed temporary hypocalcemia with permanent hypoparathyroidism in 0.9%-23% of the cases. On the base of what has been observed by Pasieka and Grant, the Authors believe TT as the absolute solution for patients with DCT because it allows the removal of both the original tumor and the possible neoplasms in the residual gland tissue, and enables early identification of other metastases which can be treated efficaciously with I131.

Marginal mandibulectomy is a compromise between preserving the mandibular structure and radical oncological surgery. In order to evaluate the correctness of the indications for this operation, a group of 47 patients with oral carcinoma underwent direct surgery or associated chemoradiotherapy and surgery. Surgery was programmed on the basis of clinical and radiological examinations and the specific evaluation of the distance of the tumour mass from the mandibular surface. This approach was justified by the lack of correlation, in anatomic and clinical terms, between tumoral infiltration of the mandible and metastatic recurrence in the cervical lymph nodes. Lastly, the varying pattern of tumoral invasion of the various mandibular regions (thickness of cortical bone, presence of foramen) induced the authors to distinguish the indications for conservative treatment by segments. According to international literature and on the basis of the authors' past experience, marginal mandibulectomy represents an extremely interesting method since it associates a satisfactory aesthetic-functional level with a radical oncological approach, in particular with regard to the symphyseal and parasymphyseal region owing its structural characteristics and reconstructive importance. The indications for this type of surgery are therefore in theory based primarily on oncological aspects, and subsequently on the various anatomic and reconstructive aspects of the various mandibular segments.

The reconstruction of the loss of substance from the oral floor following demolitive cancer surgery aims to guarantee adequate tongue movement and the consequent preservation of phonatory and swallowing functions, as well as the possibility of using prosthetic rehabilitation. Large defects are resolved using musculocutaneous or free vascularised flaps, whereas smaller defects may be closed by first intention using alveolo-lingual suture. There are a number of drawbacks to this method: occurrence of fistulas immediately after surgery and secondary ankyloglossia. It is then necessary to resort to a second operation using dermoepidermic graft and plastic surgery of the oral floor to liberate the tongue. These problems may be resolved using a nasolabial flap. The flap can be prepared using either an upper or lower peduncle, it is relatively simple to perform and does not significantly prolong operating times. The contemporary dissection of the neck with ligature of the facial artery does not in our experience significantly influence flap vascularisation. The main drawback is the limited size of the flap (on average it is 6-7 cm long with a maximum width of 3-4 cm at the base. The upper edge is equally placed 7-10 mm from the medial side). The flap must be sufficiently thick to ensure an adequate blood supply to subcutaneous tissue, but the dissection plane must be sufficiently near the surface to preserve the facial nerve. It is important to prepare the graft bed so as to avoid creating tension after suture.(ABSTRACT TRUNCATED AT 250 WORDS)

Secondary tumours of the kidney are becoming an increasingly frequent pathology due to the accurate follow-up and longer survival of cancer patients. The paper reports a rare case of renal metastasis from a thyroid carcinoma, which started as a Hürthle cell adenoma and was transformed into a carcinoma with a follicular appearance after 26 years. The suspicion of a secondary site was based on the high serum levels of HTG (human thyroglobulin); metastasis was identified following scintigraphic tests using a dual marker (99mTC, 201TL) and renal scintigraphy with 123I Hippuran. The definitive diagnosis was obtained following histological tests; conservative surgery was performed to treat the metastasis (tumorectomy with removal of healthy pericapsular tissue).

The paper discusses current views on the subject of the treatment of salivary gland tumours, based on the largest and most important studies reported in the literature. In particular, it takes into consideration the role of preoperative biopsy, the extension to be given to operations, the opportunity of using surgical and/or radiotherapeutic treatment for the neck, and factors which influence prognosis.

CT can be considered the most reliable technique in detecting nodal metastases of the cervical district. The Authors have studied 170 patients with laryngeal cancer (104 N0, 21 N1, 21 N2 and 24 N3 clinically) with CT of the cervical region during infusion of contrast material. All patients underwent radical neck dissection with pathological examination of the nodes. CT diagnosis and pathological findings were correlated. Our findings show that CT has an overall accuracy of 91.8% (100% in groups N2 and N3) and fed false positives and false negatives.

In this work the Authors show their own operative technique, attained in the surgical treatment of the neoplasms of the vestibule of the mouth. This operative technique also shows the possibility of reducing two surgical treatments to one. In other words it is possible to remove the primitive lesion and carry out, at the same time, the emptiness of those lymphonodulos chains the lymphtic vessels of the region are tributary to. In such a way the time elapsed between the operation and the following nuclear therapy is considerably reduced. Besides, though the exeresis implies an aesthetical injury, not considerable anyway, no functional deficiencies are shown since all the mouth functions, mastication, phonation, language, deglutition etc. are promptly recovered.

In a retrospective and not randomized clinical study we have selected 175 cases of squamous carcinoma of the anterior 2/3 of the tongue treated by interstitial radium therapy on the primary from January 1959 to December 1970. At the end of the treatment 64 patients (36.6%) were operated by radical neck dissection in homolateral lymphatic areas and 111 underwent no operation on the neck. The incidence of false negative is 25% (16/64 cases operated) and 3 patients showed lymph nodal and perilymph nodal metastasis (4.7% of the whole number of operated cases). In the following evolution the homolateral lymph nodal relapse are 2 among the 64 operated patients (3.1%) (both were N+) and 36 among the 101 non operated ones of whom a sufficient follow-up is available (greater than or equal to 3 years) (35.6%); in this last group 9 patients initially were T1, 24 were T2, 3 were T3. The data about the clinical evolution and the analysis of survival curves, in the two groups that underwent or not the neck dissection, permit to draw useful parameters for therapeutic planning.

Fifty-nine patients with head and neck carcinoma were examined with 67Ga scintigraphy. All patients had undergone lymph node dissection of the neck. They were followed for a minimum of 2 years after the examination. The primary tumor, treated prior/contemporaneously to the lymph node dissection, did not evolve in this interval. Metastatic involvement of the lymph node capsule was observed in all 44 cases with metastatic lymph nodes; macroscopic radicality was surgically obtained since involvement of the capsule was only microscopic. Nevertheless, complementary radiotherapy was given. The whole of 17 recurrences in the soft tissues of the neck were found, within 2 years, in the group of 26 patients who had undergone dissection of lymph nodes with metastatic capsular involvement and whose postoperative 67Ga scintigraphy was positive. On the contrary, no recurrences in the soft tissues of the neck were observed in the group of 18 patients who had undergone dissection of lymph nodes with metastatic capsular involvement and whose scintigraphy was negative. This result proves (P less than 0.001) 67Ga capable of evidencing eventual microscopic diffusion. Such a possibility has not yet been realized in vivo with any other investigation technique. Scintigraphy was negative in a control group of 15 patients who had undergone lymph node dissection, and with nonmetastatic lymph nodes. This finding leads us to exclude that the use of 67Ga might result in misinterpreted findings in the exploration of relatively superficial tissues. In fact, the eventual accumulation of radioisotope in nonneoplastic pathologies is quite easily recognizable in the neck. We can therefore conclude that in those 9 cases with positive scintigraphy and in whom no recurrence was found, microscopic diffusion was probably present, but local recurrence of the disease was prevented by complementary radiotherapy.

The treatment of patients with occult primary tumors presenting cervical metastases is still controversial. Thus the treatment of 10 patients with cervical metastases from unknown primary sites observed from 1978 to 1987 is reviewed. The average age of these patients was 56 years with a male: female ratio of 9:1. Any patients previously treated for cephalic or extracephalic neoplasms were excluded from the study as were those with lymphomas. According to TNM classification (1978) 7 cases (70%) were N1, one (10%) was N2 and two (20%) were N3. Only in one case were the cervical metastases multiple and unilateral, in one case (N2) they were bilateral. Histopathological diagnosis was performed with open biopsy in all cases prior to radical or conservative neck dissection. Five patients (50%) had metastases from epidermoid carcinoma, two (20%) from undifferentiated carcinoma (non nasopharyngeal), one (10%) from a papillary thyroid carcinoma, one (10%) from undifferentiated nasopharyngeal carcinoma and one (10%) from adenocarcinoma. The neck locations of the metastases were as follows: 3 (30%) at the upper cervical nodes (as was the N2 case), 3 (30%) at the mid-jugular nodes, 1 (10%) at the lower cervical nodes, 1 (10%) at the supra-clavicular nodes and 1 (10%) at the jugulo-digastric node. In the only case of multiple and unilateral nodes (10%) a contemporary involvement of the mid-jugular and lower cervical nodes was observed. A complete history was taken and a general physical and E.N.T. examination, X-ray, radioisotope and endoscopic studies were performed for all patients. In all cases treatment was: surgery on N + radiation therapy on the most common sites of unknown primary tumors. In particular, 7 conservative neck dissections (bilateral in one case), 2 radical neck dissections and 1 modified radical neck dissection were performed. The survival rate was 60% at 3 years and 40% at 5 years; it may be due to the radical treatment and to the high number of N1 and epidermoid carcinomas. In conclusion some considerations about the treatment of this pathology were reported.