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Since its outbreak in early 2020, the COVID-19 pandemic has diverted resources from non-urgent and elective procedures, leading to diagnosis and treatment delays, with an increased number of neoplasms at advanced stages worldwide. The aims of this study were to quantify the reduction in surgical activity for indeterminate thyroid nodules during the COVID-19 pandemic; and to evaluate whether delays in surgery led to an increased occurrence of aggressive tumours. In this retrospective, international, cross-sectional study, centres were invited to participate in June 22, 2022; each centre joining the study was asked to provide data from medical records on all surgical thyroidectomies consecutively performed from Jan 1, 2019, to Dec 31, 2021. Patients with indeterminate thyroid nodules were divided into three groups according to when they underwent surgery: from Jan 1, 2019, to Feb 29, 2020 (global prepandemic phase), from March 1, 2020, to May 31, 2021 (pandemic escalation phase), and from June 1 to Dec 31, 2021 (pandemic decrease phase). The main outcomes were, for each phase, the number of surgeries for indeterminate thyroid nodules, and in patients with a postoperative diagnosis of thyroid cancers, the occurrence of tumours larger than 10 mm, extrathyroidal extension, lymph node metastases, vascular invasion, distant metastases, and tumours at high risk of structural disease recurrence. Univariate analysis was used to compare the probability of aggressive thyroid features between the first and third study phases. The study was registered on ClinicalTrials.gov, NCT05178186. Data from 157 centres (n=49 countries) on 87 467 patients who underwent surgery for benign and malignant thyroid disease were collected, of whom 22 974 patients (18 052 [78·6%] female patients and 4922 [21·4%] male patients) received surgery for indeterminate thyroid nodules. We observed a significant reduction in surgery for indeterminate thyroid nodules during the pandemic escalation phase (median monthly surgeries per centre, 1·4 [IQR 0·6-3·4]) compared with the prepandemic phase (2·0 [0·9-3·7]; p

Warthin like-papillary thyroid cancer (WL-PTC) is a rare malignancy; it is difficult to distinguish preoperatively a WLPTC from a classic PTC. Often it is associated with Hashimoto thyroiditis (HT) that determines a better prognosis with a very low probability of recurrence. The case concerns a 43-year-old female with a single thyroid nodule suspected for cancer; and she had multiple sclerosis (MS) from the age of 19. Thyroid hormone levels were normal such as thyroid antibodies. Total thyroidectomy with lymphadenectomy of central compartment was performed. Histological examination revealed a Warthin like-PTC without Hashimoto thyroiditis. The mechanisms involved in pathogenesis of thyroid cancer in patients with autoimmune disease are not completely clear. We hypothesized that not only a local autoimmune response, such as HT, could contribute to the determination of this type of cancer but also a systemic autoimmune disease such as MS.

The surgical treatment of the intermediate-risk DTC (1–4 cm) remains still controversial. We analyzed the current practice in Italy regarding the surgical management of intermediate-risk unilateral DTC to evaluate risk factors for recurrence and to identify a group of patients to whom propose a total thyroidectomy (TT) vs. hemithyroidectomy (HT). Among 1896 patients operated for thyroid cancer between January 2017 and December 2019, we evaluated 564 (29.7%) patients with unilateral intermediate-risk DTC (1–4 cm) without contralateral nodular lesions on the preoperative exams, chronic autoimmune thyroiditis, familiarity or radiance exposure. Data were collected retrospectively from the clinical register from 16 referral centers. The patients were followed for at least 14 months (median time 29.21 months). In our cohort 499 patients (88.4%) underwent total thyroidectomy whereas 65 patients (11.6%) underwent hemithyroidectomy. 151 (26.8%) patients had a multifocal DTC of whom 57 (10.1%) were bilateral. 21/66 (32.3%) patients were reoperated within 2 months from the first intervention (completion thyroidectomy). Three patients (3/564) developed regional lymph node recurrence 2 years after surgery and required a lymph nodal neck dissection. The single factor related to the risk of reoperation was the histological diameter (HR = 1.05 (1.00–1-09), p = 0.026). Risk stratification is the key to differentiating treatment options and achieving better outcomes. According to the present study, tumor diameter is a strong predictive risk factor to proper choose initial surgical management for intermediate‐risk DTC. © 2021, Italian Society of Surgery (SIC).

Background Intraoperative Neurophysiological Monitoring (IONM) reduces the incidence of Recurrent Laryngeal Nerve (RLN) injuries during thyroid surgery. To preserve nerve function, long acting neuromuscular blocking agents (NMBA) should be avoided. However, NMBA are necessary for laryngoscopy and endotracheal intubation. We designed this double-blinded, randomized, placebo-controlled trial to assess if a low-dose of rocuronium given at intubation would affect the IONM data recorded before the thyroid dissection. Methods Hundred patients undergoing elective thyroid surgery were randomized to receive either 0.3 mg kg−1 of low dose rocuronium (intervention) or no-NMBA (control). Intubation was performed with video-laryngoscopy. IONM was placed on RLN and nerve stimulation was performed before and after thyroid dissection. The presence of a valid amplitude prior to dissection was defined when the IONM signal was >100 μV. Occurrence of difficult laryngoscopy was reported together with intubation details including time, difficulty and failure. The lowest peripheral saturation (SpO2) and the number of desaturation episodes during the intubation were also registered. Results No patients showed impaired IONM signal before dissection in both groups. Cormack-Lehane grade was higher in the intervention group (1 1 ; 2 ) compared to control one (1 1 ; 1 ; P = 0.046). No-NMBA patients had increased number of difficult laryngoscopies (21% versus 6%, P = 0.041) and intubations (34% versus 8%; P = 0.003) as well as a longer time to intubation (78 [55; 175] versus 55 [31; 110] sec; P = 0.006). Lower values of peripheral SpO2 during intubation attempt were registered in the no NMBA group (99 [97; 100] versus 99 [99; 100] %; P = 0.020). However, the number of intubation failure was similar between groups (p=0.495). Conclusions Low-dose of rocuronium does not compromise pre-dissection IONM signal and improves intubation condition when compared to a relaxant free strategy.

Background: The recurrent laryngeal nerve (RLN) can be injured during thyroid surgery, which can negatively affect a patient's quality of life. The impact of intraoperative anatomic variations of t...

L’identificazione routinaria e la visualizzazione diretta del nervo laringeo ricorrente (NLR) sono riconosciute in tutto il mondo come i gold standard nella tecnica di dissezione della tiroide. Il neuromonitoraggio intraoperatorio (IONM) puo completare l’informazione offerta dall’identificazione diretta attraverso un’analisi funzionale. L’esperienza oramai decennale in Italia con il neuromonitoraggio ha notevolmente contribuito a una piu estesa comprensione della fisiopatologia della paralisi del NLR. Il vantaggio principale dello IONM, tuttavia, e la possibilita di riconoscere una paralisi del NLR visivamente non rilevabile, identificando i potenziali meccanismi di danno e, talvolta, riducendo il rischio di un danno nervoso bilaterale. Poiche la perdita del segnale intraoperatorio puo richiedere una modifica della strategia chirurgica preoperatoriamente pianificata, le presenti raccomandazioni forniscono informazioni sulle possibilita e sui limiti dello IONM nel momento decisionale di una perdita del segnale intraoperatoria. Ci si augura, comunque, che ulteriori studi, il progressivo affinamento della tecnologia e la corretta applicazione dello IONM nella chirurgia tiroidea si evolvano in modo significativo nei prossimi anni.

La tecnica del monitoraggio intraoperatorio continuo (CIONM) del nervo laringeo ricorrente (NLR) e riconosciuta come uno strumento utile per riconoscere le lesioni nervose imminenti e interrompere la relativa manovra chirurgica per prevenire le lesioni permanenti durante la tiroidectomia. Il CIONM fornisce costantemente preziose informazioni in tempo reale, il che e molto utile durante interventi chirurgici complessi della tiroide, specialmente in contesti di anatomia insolita. Il CIONM supera la limitazione metodologica inerente al neuromonitoraggio intermittente (IINOM). L’evento elettromiografico (EMG) combinato clinicamente importante (riduzione ampiezza e aumento latenza del segnale EMG), indicativo di imminente lesione del NLR, previene la maggior parte delle lesioni legate alla trazione del NLR anatomicamente intatto consentendo la modifica della manovra chirurgica che ne e causa nell’80% dei casi. Come ulteriore estensione, il CIONM aiuta anche a identificare il recupero del nervo funzionale intraoperatorio, qualora avvenga una ripresa del valore di ampiezza ≥50% rispetto ai valori della baseline iniziale; cio consente di continuare la resezione del lato controlaterale. Il CIONM facilita un’azione correttiva precoce prima che sia stato fatto un danno permanente al NLR. Il CIONM e una tecnica recente ma in rapida evoluzione, in via di perfezionamento da vari studi incentrati sul miglioramento della sua attuazione e interpretazione, nonche sull’eliminazione degli ostacoli tecnici.

Highlights • In patients with CRF it’s difficult to diagnose parathyroid carcinoma. • The concomitant presence of metastases should lead us to suspect malignant parathyroid lesions. • In literature there are no cases of parathyroid carcinoma in patients with CRF (chronic renal failure) diagnosed by means of pulmonary metastasis., Introduction Parathyroid carcinoma is a rare malignancy. Our case report is unusual for its presentation. The patient referred symptoms compatible with CRF; nodular lesions to parathyroid glands and an elevated PTH induced physician to hypothesize secondary hyperparathyroidism. The presence of haemoptysis gave us suspicion for malignant neoplasm but only histological examination allowed us to recognize the nature of the lesion, because even PET-CT didn’t detect, an hypercaptation in the parathyroids. Presentation of the case The case concerns a 59 years old female with the following symptoms: asthenia, oliguresis, nausea, haemoptysis and very high levels of calcium and PTH. Laboratory findings (PTH 570 pg/ml; Ca 12.20 mg/dl; P 1.8 mg/dl), ultrasound, CT scan and parathyroid scintigraphy, associated with clinical data, indicated a parathyroid carcinoma with single pulmonary metastasis of the upper lobe of the left lung, confirmed by histological examination and immunochemistry. Cytology performed with bronchoscopy was negative. Surgery (“en bloc” parathyroidectomy on adjacent structures, lymph node dissection near recurrent nerve and atypical lung resection) was effective, with normalization of calcium and PTH levels and disappearance of symptoms after 48 h. After six months, no signs of local recurrence or metastases were observed. Discussion No clinical or bio-humoral data allows a preoperative diagnosis of parathyroid carcinoma. Only with definitive pathology and immunochemistry it is possible to differentiate an adenoma from a carcinoma. Conclusion In patients with CRF it’s difficult to diagnose parathyroid carcinoma, because its presentation mimics the most common secondary hyperparathyroidism; the concomitant presence of metastases should lead us to suspect malignant parathyroid lesions. Surgery is the only effective therapy and therefore should be always performed.

Intraoperative neuromonitoring identifies recurrent laryngeal nerve (RLN) injury and gives prognostic information regarding postoperative glottic function. Loss of the neuromonitoring signal (LOS) signifies segmental type 1 or global type 2 RLN injury. This study aimed at identifying risk factors for RLN injury and determining vocal fold (VF) function initially and 6 months after definitive LOS.

Secretome of primary cultures is an accessible source of biological markers compared to more complex and less decipherable mixtures such as serum or plasma. The protonation state (PS) of secretome reflects the metabolism of cells and can be used for cancer early detection. Here, we demonstrate a superhydrophobic organic electrochemical device that measures PS in a drop of secretome derived from liquid biopsies. Using data from the sensor and principal component analysis (PCA), we developed algorithms able to efficiently discriminate tumour patients from non-tumour patients. We then validated the results using mass spectrometry and biochemical analysis of samples. For the 36 patients across three independent cohorts, the method identified tumour patients with high sensitivity and identification as high as 100% (no false positives) with declared subjects at-risk, for sporadic cancer onset, by intermediate values of PS. This assay could impact on cancer risk management, individual’s diagnosis and/or help clarify risk in healthy populations., Diagnostics: Proton state of secreted proteins in blood helps identify cancer A blood test that measures whether molecules secreted by cells contain titratable proton atoms can accurately discriminate between patients who have cancer and those who don’t. Titratable species may in turn influence the protonation state of a solution, i.e. the number of protons added to and the net charge of that solution. A team led by Natalia Malara from University Magna Graecia in Catanzaro, Italy and Enzo Di Fabrizio from the King Abdullah University of Science and Technology in Thuwal, Saudi Arabia, Francesco Gentile from the University Federico II in Naples, Italy, and Nicola Coppedè from the Institute of Materials for Electronics and Magnetism in Parma, Italy, created an eletrochemical device that can detect faulty metabolism by quantifying the proportion of secreted proteins with and without extra protons—an indicator of abnormal cell division, proliferation and invasion. The researchers tested the device on blood samples from patients with solid tumors and healthy controls. The method identified cancer patients with a high degree of accuracy. If the findings are confirmed in larger trials, the test could help with the screening, diagnosis and management of cancer.

Hypoparathyroidism is a rare disease characterized by low serum calcium levels and absent or deficient parathyroid hormone level. Regarding the epidemiology of chronic hypoparathyroidism, there are limited data in Italy and worldwide. Therefore, the purpose of this study was to build a unique database of patients with chronic hypoparathyroidism, derived from the databases of 16 referral centers for endocrinological diseases, affiliated with the Italian Society of Endocrinology, and four centers for endocrine surgery with expertise in hypoparathyroidism, to conduct an epidemiological analysis of chronic hypoparathyroidism in Italy. The study was approved by the Institutional Review Board. A total of 537 patients with chronic hypoparathyroidism were identified. The leading etiology was represented by postsurgical hypoparathyroidism (67.6%), followed by idiopathic hypoparathyroidism (14.6%), syndromic forms of genetic hypoparathyroidism (11%), forms of defective PTH action (5.2%), non-syndromic forms of genetic hypoparathyroidism (0.9%), and, finally, other forms of acquired hypoparathyroidism, due to infiltrative diseases, copper or iron overload, or ionizing radiation exposure (0.7%). This study represents one of the first large-scale epidemiological assessments of chronic hypoparathyroidism based on data collected at medical and/or surgical centers with expertise in hypoparathyroidism in Italy. Although the study presents some limitations, it introduces the possibility of a large-scale national survey, with the final aim of defining not only the prevalence of chronic hypoparathyroidism in Italy, but also standards for clinical and therapeutic approaches.

The diagnostic, therapeutic and health-care management protocol (Protocollo Gestionale Diagnostico-Terapeutico-Assistenziale, PDTA) by the Association of the Italian Endocrine Surgery Units (U.E.C. CLUB) aims to help treat the patient in a topical, rational way that can be shared by health-care professionals. This fourth consensus conference involved: a selected group of experts in the preliminary phase; all members, via e-mail, in the elaboration phase; all the participants of the XI National Congress of the U.E.C. CLUB held in Naples in the final phase. The following were examined: diagnostic pathway and clinical evaluation; mode of admission and waiting time; therapeutic pathway (patient preparation for surgery, surgical treatment, postoperative management, management of major complications); hospital discharge and patient information; outpatient care and follow-up. A clear and concise style was adopted to illustrate the reasons and scientific rationales behind behaviors and to provide health-care professionals with a guide as complete as possible on who, when, how and why to act. The protocol is meant to help the surgeon to treat the patient in a topical, rational way that can be shared by health-care professionals, but without influencing in any way the physician–patient relationship, which is based on trust and clinical judgment in each individual case. The PDTA in thyroid surgery approved by the fourth consensus conference (June 2015) is the official PDTA of U.E.C. CLUB.

Summary Objectives The aim of the present study had been to examine the relationships between menstrual dysphonia and measures of psychosocial distress, in a sample of female professional voice users. Design and Methods This is a prospective study of 52 consecutive professional voice users, aged 18–40 years, affected by transient dysphonia related to the menstrual cycle and recruited in the Division of Phoniatrics and Audiology of the Second University of Naples, from April 2011 to September 2014. The following evaluation protocol was used: videoendoscopy, the GIRBAS scale, the Voice Handicap Index, and the determination of sexual hormonal plasma levels both during the menstrual and the luteal phase of the cycle. Furthermore, we measured, in all patients, the levels of perceived disability and quality of life during and after the dysphonia episodes by means of the Manchester Short Assessment of Quality of Life and the Sheehan disability scale. Results Laryngoscopic evaluation revealed that only minor morphologic changes were present during the first days of the follicular phase, usually returning to normal morphology after the menstrual period was over. However, we found that dysphonia episodes of varying degree were present in most evaluated subjects; women with a moderate degree of dysphonia also had a lower quality of life and greater overall disability, during menses. Conclusions Despite minimal morphologic signs of laryngeal pathology, menstrual dysphonia might represent a disease which is frequent among female professional voice users, which in turn is associated with a certain degree of disability and lower quality of life during premenstrual and menstrual phases.

Intraoperative neuromonitoring identifies recurrent laryngeal nerve (RLN) injury and gives prognostic information regarding postoperative glottic function. Loss of the neuromonitoring signal (LOS) signifies segmental type 1 or global type 2 RLN injury. This study aimed at identifying risk factors for RLN injury and determining vocal fold (VF) function initially and 6 months after definitive LOS.Prospective study encompassing 21 hospitals from 13 countries.Included in this study were patients with persistent intraoperative LOS.At first postoperative laryngoscopy, early VF palsy was present in 94 of all 115 patients with LOS (81.7%): in 53 of 56 patients (94.6%) with type 1 injury and 41 of 59 patients (69.5%) with type 2 injury. In LOS type 1, women outnumbered men5-fold. Traction produced LOS type 1 in 38 of 56 patients (67.9%) and LOS type 2 in 54 of 59 patients (91.5%). Course of the RLN posterior and/or anterior to the inferior thyroid artery, extralaryngeal branching, or tuberculum of Zuckerkandl did not increase VF palsy rates. Permanent VF palsy rates were also lower (P = .661) after LOS type 2 than after LOS type 1: 6.8% (four of 59 patients) versus 10.7% (six of 56 patients). Intraoperative administration of steroids did not diminish postoperative VF palsy rates.LOS type 1 entails more severe nerve damage than LOS type 2, affecting women disproportionately. Both LOS types, being primarily associated with traction injury, are unaffected by variant neck anatomy in expert hands and unresponsive to steroids.2b Laryngoscope, 126:1260-1266, 2016.

Hypocalcemia, the most common complication of thyroidectomy, is a transient condition in up to 27% of patients and a permanent condition approximately 1% of patients. The aim of this prospective study was to evaluate reliability of postoperative intact parathyroid hormone (iPTH) assessment for predicting clinically relevant postthyroidectomy hypocalcemia for a safe early discharge of patients with no overtreatment.Seventy-five consecutive patients (age 51 ± 13 years [mean ± SD]) undergoing total or completion thyroidectomy with no concomitant parathyroid diseases or renal failure were included in the present study. Serum iPTH level was determined before and 2 hours after thyroidectomy. Serum calcium concentration was determined 1 day before and 2 days postoperatively.The occurrence of postoperative hypocalcemia was correlated both with the absolute and relative iPTH decrease, determined as a ratio of the preoperative value (P.0001). There was a greater difference in relative decrease in iPTH between patients remaining normocalcemic and those with hypocalcemia present on the second postoperative day. Hypocalcemic patients on the second postoperative day had a 62% relative decrease in iPTH 2 hours after thyroidectomy.The relative decrease in serum iPTH was greater in patients with hypocalcemia arising on the second postoperative day rather than in patients who remained normocalcemic. The relative decrease in iPTH determined 2 hours after total thyroidectomy together with the serum calcium concentration 24 hours after thyroidectomy proved to be useful predictors of sustained hypocalcemia and might change the clinical management of patients after thyroid surgery to support a longer hospitalization in these selected patients.

Aim To update the Diagnostic-Therapeutic-Healthcare Protocol (Protocollo Diagnostico-Terapeutico-Assistenziale, PDTA) created by the U.E.C. CLUB (Association of the Italian Endocrine Surgery Units) during the I Consensus Conference in 2008. Methods In the preliminary phase, the II Consensus involved a selected group of experts; the elaboration phase was conducted via e-mail among all members; the conclusion phase took place during the X National Congress of the U.E.C. CLUB. The following were examined: diagnostic pathway and clinical evaluation; mode of admission and waiting time; therapeutic pathway (patient preparation for surgery, surgical treatment, postoperative management, management of major complications); hospital discharge and patient information; outpatient care and follow-up. Conclusions The PDTA for parathyroid surgery approved by the II Consensus Conference (June 2013) is the official PDTA of the U.E.C. CLUB.

Reporting our experience with NIM-response 2.0 and 3.0 system in a series of 127 thyroidectomies.127 patients were operated at the "Magna Graecia" University (Catanzaro) from 2009 September to 2010 December, using the technique of IntraOperative NeuroMonitoring (IONM). For each patient the surgeon charge filled in a "questionnaire" assessing his/her compliance with the apparatus.We report 0.8% permanent and 0.4% transient recurrent laryngeal nerve paralysis. All surgeons have been fully satisfied from IONM technique.A recurrent laryngeal nerve lesion may occur in patients operated on total thyroidectomy between 5-8% for transient palsies and 1-3% for the permanent ones. The use of IONM seems to contribute to a reduction of transient paralysis, even if this method is still not widely accepted Nevertheless the compliance of the surgeons with IONM seems to develop very highly.NIM-response is helpful in protecting recurrent laryngeal nerve function. Advantages were observed in reduction of postoperative dysphonia and in improving the surgeon's confidence in performing a total thyroidectomy.

In the evaluation of multinodular goitre, finding a malignant neoplasia is often an unexpected result of the histological diagnosis. TRIMprob (Tissue Resonance Interaction Method Probe) is a portable system for non-invasive diagnosis, that utilises the different electromagnetic properties of healthy and pathological tissues, producing a low-power magnetic field that interacts with the molecular structure of tissues. The interference levels are detected by a receiver device and are elaborated with software in a graph consisting of 3 easily interpretable bands. The objective of our study was to assess the usefulness of the TRIMprob system in the preoperative diagnosis of carcinoma in patients with multinodular goitre. Over the period from January 2005 to March 2006 we used TRIMprob to screen 51 patients with a clinical diagnosis of multinodular goitre, later operated on by total thyroidectomy. We then compared the TRIMprob response with the histological diagnosis on the surgical specimen. The TRIMprob results suggested 46 cases compatible with non-malignant goitre and 5 suspected cancers. The final histological diagnosis confirmed these results with 46 cases of multinodular goitre and 5 papillary carcinomas. The sensitivity, specificity and diagnostic accuracy of the procedure were all 100%. On the basis of these preliminary results, TRIMprob seems to be a highly accurate method for the detection of suspected carcinomas in the context of multinodular goitre. If these results are confirmed, new prospects could be opened up in the diagnosis of thyroid diseases.

Background In Western society, the percentage of elderly people is continually growing. The prevalence of goiter increases with the age and it is estimated that 90% of women over 60 years old and 60% of men over 80 years old have a relief of thyroid nodules. This has great importance for these patients, because the incidence of malignant transformation is higher than younger ones and these are often tumor very aggressive patterns. If thyroidectomy is indicated for patients with suspected neoplasm and severe obstructive symptoms, their surgery should not be delayed since a late urgent operation could raise morbidity and mortality risk. The main indications for young patients are due to obstructive and metabolic causes over and above suspected cancer. Total thyroidectomy is considered by many authors as the treatment of choice.