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Medullary thyroid cancer is a rare carcinoma. Surgery is the only curative treatment and since cervical lymphnodes metastases are frequent and can occur at an early stage, a standardized central lymphnode dissection is associated to total thyroidectomy. However, the extent of lymphadenectomy to the lateral neck lynphnodes remains debated. To reduce the extent of lymphnode excision, the sentinel node biopsy has been used as an accurate technique to assess the status of the lymphnodes in the regional drainage basin in solid tumors, and more recently, in thyroid carcinoma. In this case report, we show the utility of the radioguided biopsy of the sentinel lymphnode in the surgical management of the medullary thyrod cancer.We present the case of a 24-year-old Caucasian, Italian woman with a sporadic medullary thyroid microcarcinoma occasionally detected by neck ultrasound and diagnosed by high serum calcitonin level and fine needle aspiration cytology. There was no ultrasound evidence of lymphnode involvement both in central and lateral compartment of the neck. We performed a preoperative mapping of the the sentinel lymphnodes by the injection of technetium-99m radiolabelled albumin nanocolloids in the thyroid nodule. Then our patient underwent total thyroidectomy combined with radioguided biopsy of the sentinel lymphnodes. Histology confirmed the presence of the medullary thyroid cancer and revealed micrometastases only in two sentinel lymphnodes detected in right lateral compartment of the neck so an ipsilateral lateral neck dissection besides the central neck dissection was performed at the end of operation. Basal and pentagastrin-stimulated serum calcitonin level was undetectable during the follow-up investigations.This is the first reported case that shows the utility of the radioguided SLN biopsy for the accurate staging of the cervical lymphnode involvement in patient with sporadic medullary thyroid microcarcinoma. Total thyrodectomy and central neck dissection is recommended for all patients with medullary thyroid carcinoma, but the indication for the lateral neck dissection is still controversial. The radioguided SLN biopsy technique could be a useful tool to perform the dissection only in those patients with proven lateral neck lymphnode involvement and reduce the extention of the lateral lymphnode excision and the incidence of related complications.Il carcinoma midollare della tiroide è raro. Il suo trattamento è chirurgico e consiste in una tiroidectomia totale associata a dissezione dei linfonodi centrali. L’opportunità della linfoadenectomia dei linfonodi cervicali laterali è argomento controverso. Per ridurre l’estensione della dissezione dei linfonodi laterocervicali ai casi in cui tale procedura sia effettivamente necessaria abbiamo eseguito la tecnica della biopsia del linfonodo sentinella, già praticata in altra patologia tumorale, in un caso di carcinoma midollare, sporadico, diagnosticato con ecografia, determinazione dei livelli di calcitonina serica e citologia dell’agoaspirato. All’ecografia non si evidenziavano linfonodi cervicali centrali o laterali. Abbiamo eseguito mappaggio preoperatorio dei linfonodi sentinella iniettando Tecnezio 99-m nel nodulo tiroideo. La paziente è stata poi sottoposta a tiroidectomia totale e biopsia radioguidata dei linfonodi sentinella. L’esame istologico ha confermato la presenza di un carcinoma midollare della tiroide e di micrometastasi in due linfonodi sentinella situati nel compartimento laterale destro. Dopo la tiroidectomia l’intervento è stato completato con dissezione dei compartimenti centrale e laterala destro. Al followup non sono stati rilevati livelli di calcitonina serica nè basali nè dopo stimolazione con pentagastrina. Si tratta del primo caso, riportato in letteratura, che dimostra l’utilità della biopsia radioguidata del linfonodo sentinella nella stadiazione linfonodale e del trattamento chirurgico del microcarcinoma midollare della tiroide. Tale biopsia può essere utile ad eseguire la dissezione linfonodale laterale solo nei pazienti con provato coinvolgimento dei linfonodi laterali del collo e quindi a ridurre l’entità della dissezione e delle relative complicanze.

The Authors report a rare case of duodenal neoplasia in a 17 year old boy. The patient was admitted in an emergency setting for hemorrhagic shock and duodenal perforation. Laparotomy was performed and a huge perforated neoplasia of the duodenum was found. Conservative approach was preferred, since the intraoperative histology was unuseful in choosing the better procedure: thus just a tumorectomy and closure of the duodenum were performed. Pathology examination demonstrated a neuroendocrine primitive duodenal tumors not well differentiated and with high grade of malignancy. The Authors discuss the role of the elements, clinical features and pathology, as well as emergency and postoperative management.

To review the patients treated at our Institute over the past 22 years and to evaluate the behaviour of 14 atypical carcinoids on the basis of Capella's classification (1994), defining the most suitable surgical approach.A total of 118 patients undergoing surgery for lung neuroendocrine tumours were reanalyzed on the basis of their anatomic and pathological characteristics, surgical treatment and survival.The 5-year survival rate was 96.5% for typical forms and 74.5% for atypical forms; the 10-year survival rate was 92.4% for typical forms and 49.8% for atypical forms (p0.001). Lymph node metastatic involvement was also an important contributing factor for survival (p0.05). A review of the series of 19 patients treated over the past 6 years, diagnosed with so-called atypical carcinoid based on Capella's anatomic and pathological classification, showed that 5 were well differentiated neuroendocrine tumours (WDNT), 8 well differentiated neuroendocrine carcinomas (WDNC) and 1 small-cell lung neuroendocrine carcinoma (SLCL). From a surgical point of view, 10 cases underwent demolitive surgery and 9 conservative surgery. The overall actuarial survival rate in this series was 78% at 5 years, 100% for WDNT and 75% for WDNC. The only case of SCLC died after a few months.The authors conclude that the 5 and 10-year probability of survival are closely linked to the histological type of the lung neuroendocrine tumour and the presence of lymph node metastasis. Capella's new anatomic and pathological classification helps to establish a more precise prognosis for so-called atypical carcinoids. Lastly, given the malignant potential of these tumours, preference should be given to radical exeresis.