Dominant Nodule Research Articles

Parathyroid tissue in an adult’s cervical bronchogenic cyst

Dear Editor, Bronchogenic cysts are rare, benign, congenital lesions that occur due to aberrant tracheobronchial tree development during embryogenesis [1–3]. They usually present in childhood, in the lungs or mediastinum, while cervical cysts are infrequent [1, 2]. Neither parathyroid gland absorption by a bronchogenic cyst nor parathyroid tissue in such a lesion has been reported. An adult’s cervical bronchogenic cyst containing parathyroid tissue, incidentally found during thyroidectomy in the right superior parathyroid gland location, is presented. A 52-year-old man presented with a multinodular goitre. Thyroid function, parathormone and calcium were normal. Ultrasound demonstrated a multinodular goitre with a 3-cm dominant nodule in the left and a 4-cm dominant nodule in the right thyroid lobe; no lymphadenopathy or additional abnormal findings were identified. Fine-needle aspiration cytology of both nodules revealed follicular cells with microfollicular pattern, occasionally showing oncocytic changes and nuclear pleomorphism but no malignant changes (Thy3 according to the Classification of the Royal College of Physicians [4]). Intraoperatively, a big multinodular goitre and a cyst in the right superior parathyroid gland location, interpreted as parathyroid cyst, were identified. No lymphadenopathy was observed. Total thyroidectomy and cyst excision were performed. The other three parathyroid glands were preserved. The thyroid gland (10×8×3 cm, 87.5 g) consisted of an enlarged (8×5.5×3 cm) multinodular right and an enlarged (4.5×3×3.5 cm) nodular left lobe. The latter lobe was almost entirely replaced by a well-circumscribed, encapsulated nodule (3.5×2.4×3 cm), which consisted of follicles with microfollicular and solid architecture and, focally, Hurthle cell changes. A focus of capsular and few foci of vascular invasion were noted. No papillary pathology features were found. Ki-67 proliferative index was <1%. Minimally invasive follicular thyroid carcinoma with capsular and vascular invasion diagnosis was offered. The cyst (0.8×0.4×0.3 cm, 0.16 g) was thin-walled, unilocular. Microscopically, the inner surface was lined by ciliated, pseudostratified, cuboidal to columnar epithelium with goblet cells. The cystic wall contained smooth muscle, seromucous glands and islands of parathyroid tissue (Fig. 1). This was confirmed by immunohistochemical parathormone demonstration (Fig. 2). There was no evidence of malignancy. A diagnosis of benign bronchogenic cyst with parathyroid tissue in its wall was made. Cervical bronchogenic cysts are infrequent, usually diagnosed in children but can rarely be encountered in adults; such aberrant location could be explicable by migration of abnormal tracheobronchial tree buds during embryogenesis [1–3]. They are often asymptomatic, frequently found incidentally during radiologic evaluation or, seldom, thyroidectomy as in our patient [5]. Although rare, they should be included in the differential diagnosis of cervical masses. Characteristic histologic findings are a ciliated, respiratory-type, pseudostratified epithelial lining with smooth muscle cells, mucous glands, cartilage and fibrous connecVirchows Arch (2008) 453:307–308 DOI 10.1007/s00428-008-0655-0

Minimally Invasive Video-assisted Thyroidectomy: 2 Yrs Work

Objective The minimally invasive video-assisted thyroidectomy (MIVAT) technique was first pioneered in Europe in the 1990s. It has shown to have comparable results to traditional thyroidectomy and additional advantages such as better cosmetic results as well as faster recovery. This project aims to analyze the results from the MIVAT procedure utilizing a 2-person technique over the initial 2 years of inception at an academic training center. Methods Retrospective review of 170 cases between May 2006 and September 2007 at LLUMC. The demographic and clinical data collected includes age, sex, incision, operative times, hospitalization, identification of recurrent laryngeal nerves, pathology, size of the dominant nodule and entire gland, and postoperative complications. Results 23 male and 147 female patients underwent MIVAT by a single surgeon; of those, 59 total thyroidectomies and 111 hemithyroidectomies were performed. The mean incision length was 3.5cm. The average weight/volume on pathology was 19.25g/19cm3, 21.03g/22cm3 and 31.29g/40cm3 for the right lobe, left lobe, and entire gland respectively. Average nodule size was 3.6cm3. The mean surgical time was 91.7 minutes and the mean blood loss was 31cc. Average hospitalization stay was 1.43 days. 17 patients experienced temporary hypocalcemia, and 1 patient remained hypocalcemic for more then 6 months. Two patients experienced transient pitch problems, 7 patients experienced temporary unilateral vocal cord paresis, and 1 patient experienced mild diplophonia. Conclusions While enabling smaller surgical access for thyroidectomy, 2-surgeon technique MIVAT can be performed safely and quickly. Voice problems were the most common complications that usually resolved in 8 weeks.

Role of Surgeon-Performed Ultrasound in Predicting Malignancy in Patients with Indeterminate Thyroid Nodules

Certain ultrasound features can predict malignancy in patients with thyroid nodules. The purpose of this study was to determine the value of surgeon-performed ultrasound (SUS) in predicting thyroid malignancy in patients with indeterminate fine-needle aspiration (FNA) cytology. 477 consecutive patients with dominant thyroid nodules were referred to our institution from 2002 to 2007. Of these, 180/477(38%) were judged to have indeterminate cytology: follicular neoplasm (FN, n = 108), Hürthle neoplasm (HN, n = 29), and suspicious for papillary thyroid cancer (SPTC, n = 43). SUS characteristics for thyroid nodules were recorded in a prospective database prior to thyroidectomy. Variables analyzed included patients' age and sex, nodule size, shape, echogenicity, consistency, borders, multiplicity/multicentricity, and presence of microcalcifications. SUS features of thyroid nodules were correlated with final pathology. The accuracy of individual SUS features as well as the presence of two or more adverse features in predicting malignancy was also examined. There were 144 females and 36 males. Mean age was 52 years (range 17-87 years). Mean tumor size was 2.7 cm (range 0.65-6.6 cm). Overall, final pathology revealed cancer in 92/180 (51%) patients. Malignancy was present in 40/108 (37%) FN, 12/29 (41%) HN, and 40/43 (93%) SPTC. Nodule borders (irregular), shape (height > width), hypoechogenicity, and presence of microcalcifications were significantly associated with malignancy. The presence of 2 or >/=3 adverse SUS thyroid nodule features was associated with a >/=55% or >/=78% risk of malignancy, respectively. Adverse thyroid nodule features seen on SUS may predict malignancy and help determine the initial extent of thyroidectomy in patients with indeterminate FNA cytology.

Effect of Thyroid Gland Volume in Preoperative Detection of Suspected Malignant Thyroid Nodules in a Multinodular Goiter

The detection of suspected malignant thyroid nodules by ultrasonography is associated with thyroid gland volume and tumor size. Prospective clinical trial. A tertiary referral center. Three hundred sixty-five patients with a multinodular goiter with coexistent dominant nodules. The correlation between thyroid gland volume and tumor size and the detection of suspected malignant thyroid nodules by ultrasonography. The incidence of thyroid carcinoma inside and outside the dominant nodules and thyroid gland volume and tumor size in suspected or unsuspected malignant thyroid nodules by ultrasonography were determined. Receiver operating characteristic analysis was used to identify the cutoffs of the tumor size and thyroid gland volume. One hundred thyroid carcinomas were found in 69 (18.9%) patients. Forty-one of these carcinomas were inside the dominant nodule, whereas 59 were outside the dominant nodule. Only 9 of the 59 thyroid carcinomas outside the dominant nodules were suspected of being malignant by ultrasonography. Thyroid gland volume less than 38 mL and tumor size larger than 7 mm had 48-fold (odds ratio, 48; P < .001) and 21.5-fold (odds ratio, 21.5; P < .001) increased rates, respectively, of detecting suspected malignant thyroid nodules by ultrasonography. Thyroid gland volume and tumor size were significantly associated with detection of suspected malignant thyroid nodules by ultrasonography. Small thyroid gland volume was associated with detection of suspected malignant thyroid nodules in multinodular goiters.

“Minimally invasive video-assisted thyroidectomy. Initial experience in a general surgery department”

The aim of this study is to analyze our preliminary results from minimally invasive video-assisted thyroidectomy (MIVAT) and demonstrate the feasibility of MIVAT also in non-referral centers. We report our initial experience based on a series of 47 patients selected for MIVAT at General Surgery Department of University of Trieste during a period from May 2005 to February 2007. The eligibility criteria were rigorously observed. Age, goiter volume, major diameter of the dominant nodule, operative times, pathologic findings, postoperative pain, length of hospital stay, cosmetic results, and complications were retrospectively analyzed. Thyroid lobectomy was successfully accomplished in 33 cases, total thyroidectomy in 14. Conversion to standard cervicotomy was required in three patients (6%). Mean operative time of lobectomy was 82.6 min and 118.7 for total thyroidectomy. Postoperative complications included 11 (23.4%) transient hypocalcemias, 2 (4.2%) hematomas, and 2 (4.2%) temporary laryngeal nerve palsies. None-recurrent nerve palsies was observed. The cosmetic result was excellent in most cases. Our experience demonstrates that MIVAT, after adequate training, is feasible and safe, with results comparable to conventional thyroidectomy, also in a General Surgery Department, from a dedicated team, with a sufficient and specific activity volume.

Prospective Trial Evaluating Electrical Impedance Scanning of Thyroid Nodules Before Thyroidectomy

Electrical impedance scanning (EIS) identifies tissue impedance changes associated with malignancy. Methods to distinguish benign from malignant thyroid nodules, particularly in patients with indeterminate cytology are lacking. To determine the diagnostic accuracy of EIS in the preoperative evaluation of thyroid nodules. From September 2002 to December 2006, 216 patients underwent thyroid fine needle aspiration (FNA) and EIS prethyroidectomy in this prospective cohort study. EIS, either positive or negative for malignancy, was correlated with final histopathology. A focal bright spot over a thyroid nodule correlating with increased conductivity and/or capacitance >25% baseline sternocleidomastoid muscle impedance defined positive EIS. Study endpoints were EIS accuracy, sensitivity (Sn), specificity (Sp), positive predictive value (PPV), and negative predictive value (NPV). This study has been registered in the National Institutes of Health's public trials registry at ClinicalTrials.gov. The registration number is NCT00571077. EIS correctly diagnosed 96 of 110 patients with malignant and 75 of 106 patients with benign dominant thyroid nodules: Sn = 87%, Sp = 71%, PPV = 76%, NPV = 84%: overall EIS accuracy = 79%. Pretest cancer probability of 51% (110 of 216) increased to 76% (96 of 127) post-EIS, and preoperative use of EIS would result in a significant reduction (71%, 75 of 106) in number of operations performed for benign nodules. EIS performance was similar for 109 patients with indeterminate FNA: Sn = 83%, Sp = 67%, PPV = 61%, NPV = 87%, accuracy = 73%. Pretest probability of cancer increased from 39% (42 of 109) to 61% (35 of 57) post-EIS. The use of EIS would result in a significant reduction (67%, 45 of 67) in the number of purely diagnostic thyroidectomy for indeterminate FNA. EIS shows promise in differentiating thyroid nodules. Further EIS hardware and software optimization is warranted to improve upon the already favorable negative predictive value in indeterminate thyroid nodules.

Molecular Classification of Thyroid Nodules by Cytology

Fine needle aspiration (FNA) biopsy of thyroid nodules provides cytologic specimens whose interpretation can direct patients toward either thyroidectomy or observation. Approximately 20% of FNA specimens yield an indeterminate result. Recent studies have characterized differences in gene expression between benign and malignant conditions, most often using whole tissue. Our goal was to determine the feasibility of quantitative polymerase chain reaction (qPCR)-based gene expression analysis in cytologic samples. For five genes shown to be over-expressed in thyroid carcinomas (fibronectin, galectin-3, Met/HGFR, MUC1, and GA733-precursor), we compared expression among pathologic states. Prospective laboratory analysis of 20 thyroidectomy specimens. Routine microscopy was performed. Cytologic samples were obtained from the dominant nodules, and RNA was extracted. Preliminary analysis using fluorometry and reverse-transcriptase (RT)-PCR was performed. Expression levels of the test genes in nodules and from control samples were measured by real-time qPCR. Fold changes in gene expression were compared. Only one specimen did not yield sufficient intact RNA for gene expression analysis. RT-PCR revealed satisfactory RNA recovery in all other specimens. qPCR showed significant over-expression of fibronectin in the papillary carcinomas compared with the goiters (P = .0013), follicular adenomas (P = .0014), and follicular carcinomas (P = .0001). Differences in both fibronectin and MUC1 expression between the follicular carcinomas and the follicular adenomas were also significant (P = .025 and .045, respectively). Cytologic specimens were a satisfactory source of tissue for qPCR-based gene expression analysis. Both fibronectin and MUC1 were differentially expressed in follicular adenomas and follicular carcinomas, and fibronectin expression differed in papillary carcinomas compared with the other lesions. These results may form the basis of a clinical predictor for lesions with indeterminate or suspicious cytology.

A Thyroglossal Duct Cyst Presenting as a Thyroid Nodule in the Lateral Neck

The patient is a 55-year-old female with a history of multinodular goiter. She was followed for several years for a dominant left-sided superior pole thyroid nodule. Several prior fine needle aspiration biopsies had been performed. All were consistent with the diagnosis of degenerative colloid nodule. Eventually she developed symptoms of intermittent choking and shortness of breath and presented for surgical evaluation. On physical examination, including ultrasound, a left-sided superior thyroid nodule was noted. At operation, the nodule was found to be completely separate from the thyroid. Dissection revealed a thyroglossal duct cyst (TDC) located lateral to the superior pole of the thyroid gland, attached to the mid portion of the hyoid bone by a pedicle. The standard Sistrunk procedure was performed. Here we describe an unusual late presentation of a TDC located lateral to a multinodular goiter and producing compressive symptoms.

High Prevalence of Carcinoma in Ultrasonography-guided Fine Needle Aspiration Cytology of Thyroid Nodules

The purpose of this study was to assess the rate of malignancy in thyroid nodules incidentally detected at sonography and to determine the diagnostic value of ultrasonography-guided fine needle aspiration cytology (USgFNAC) in thyroid nodules. Five hundred patients (84 men and 416 women) who had thyroid incidentalomas underwent USgFNAC at Konkuk University Hospital between August 2005 and July 2006. Thyroid sonography and guided aspiration was performed on all single nodules and on dominant nodules with suspected malignancy in cases of multinodular goiter. Five hundred fifty-eight nodules from 500 patients were aspirated using ultrasonography guidance. The USgFNAC results for all patients were as follows: 307 (61.4%) benign, 108 (21.6%) suggestive of malignancy, 56 (11.2%) indeterminate, and 29 (5.8%) inadequate for cytologic diagnosis. The rate of malignancy was significantly higher in women than in men (23.6% in women vs 11.9% in men, p<0.01). Ultrasonographic characteristics that had a significant association with thyroid malignancy included solid echocomponent, hypoechogenecity, ill defined margin, and presence of microcalcifications (p<0.05). Eighty-eight patients underwent surgical resection. The positive predictive value of USgFNAC was 90.2% (74/82), and the accuracy index was 84.1% (74/88). In 80 patients with well-differentiated thyroid carcinoma after surgery, 49% (39/80) had lesions smaller than 1 cm. The rate of malignancy in incidental thyroid nodules on USgFNAC was 21.6%. Ultrasonographic features could be useful in differentiating between benign and malignant nodules.

The preoperative exclusion of thyroid carcinoma in multinodular goiter: Dynamic contrast-enhanced magnetic resonance imaging versus ultrasonography-guided fine-needle aspiration biopsy

We compared the diagnostic values of dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) and ultrasonography (USG)-guided fine-needle aspiration biopsy (FNAB) in the detection of thyroid carcinoma associated with multinodular goiter. USG-guided FNAB and DCE-MRI were performed consecutively on 26 patients who had multinodular goiter with dominant nodules and clinical suspicion of malignancy. DCE-MRI findings, cytodiagnosis, and final histopathologic results were correlated. We compared the sensitivity, specificity, diagnostic accuracy, and positive (PPV) and negative predictive values (NPV) of DCE-MRI and USG-guided FNAB. Of 57 nodules in 26 patients, 16, 37, and 4 nodules showed delayed, plateau, and rapid washout patterns, respectively. Thyroid carcinoma was found in 8 patients (31%). Delayed washout pattern in a nodule was correlated with the histologic diagnosis of thyroid carcinoma (P < .001). None of the nodules with thyroid carcinoma had a plateau or rapid washout pattern. The sensitivity and NPV of DCE-MRI to diagnose thyroid carcinoma were greater when compared with those in USG-guided FNAB (100 vs 71.4%, and 100 vs 91.7%, respectively; P < .001). When other diagnostic methods are inconclusive, DCE-MRI is superior to USG-guided FNAB to exclude thyroid carcinoma in patients with multinodular goiter.

Radioactive iodine therapy in poorly differentiated thyroid cancer

A 55-year-old male was diagnosed with poorly differentiated thyroid cancer after total thyroidectomy, which was performed because of progressive enlargement of a dominant thyroid nodule. He developed an early cervical recurrence that was treated with modified neck dissection. He subsequently developed biopsy-proven progressive pulmonary metastases. Neck and chest CT scans, laboratory tests, CT-guided fine-needle aspiration biopsy, [18F]-2-fluoro-2-deoxy-D-glucose-PET scan, lesional dosimetry using 124I PET scan, diagnostic radioactive iodine (RAI) scanning, whole-body and blood RAI dosimetry, and single-photon-emission CT. Stage IV poorly differentiated thyroid cancer. Surgical resection of cervical recurrence, RAI therapy.

Incidence of thyroid carcinoma in fluorodeoxyglucose positron emission tomography-positive thyroid incidentalomas

Fluorodeoxyglucose (FDG) whole body positron emission tomography (PET) scan may show clinically occult second lesions. Such lesions in the thyroid are increasingly common. There are several recent reports of a high probability of malignancy in these lesions ranging from 14% to 63%. This is a retrospective review of 15,711 PET scans at a multi-disciplinary thyroid clinic at a tertiary care university medical center. Twenty-two patients were referred with thyroid PET "incidentalomas." The review included 18 FDG-PET scans, ultrasound guided fine needle aspiration biopsies, and thyroid surgery pathology. Aspiration cytology or pathology were the main outcome measures. Three patients had malignancy of the PET-positive thyroid lesions. Papillary thyroid micro carcinomas were detected in four of the specimens that showed a benign pathology of the dominant nodule. Our experience shows a 14% malignancy rate for the dominant (imaged) nodule and a total malignancy rate of 32% when the incidental micro carcinomas are included. Both of these rates are significantly lower than results published previously.

Management of Thyroid Dysfunction during Pregnancy and Postpartum: An Endocrine Society Clinical Practice Guideline

The objective is to provide clinical guidelines for the management of thyroid problems present during pregnancy and in the postpartum. The Chair was selected by the Clinical Guidelines Subcommittee (CGS) of The Endocrine Society. The Chair requested participation by the Latin American Thyroid Society, the Asia and Oceania Thyroid Society, the American Thyroid Association, the European Thyroid Association, and the American Association of Clinical Endocrinologists, and each organization appointed a member to the task force. Two members of The Endocrine Society were also asked to participate. The group worked on the guidelines for 2 yr and held two meetings. There was no corporate funding, and no members received remuneration. Applicable published and peer-reviewed literature of the last two decades was reviewed, with a concentration on original investigations. The grading of evidence was done using the United States Preventive Services Task Force system and, where possible, the GRADE system. Consensus was achieved through conference calls, two group meetings, and exchange of many drafts by E-mail. The manuscript was reviewed concurrently by the Society's CGS, Clinical Affairs Committee, members of The Endocrine Society, and members of each of the collaborating societies. Many valuable suggestions were received and incorporated into the final document. Each of the societies endorsed the guidelines. Management of thyroid diseases during pregnancy requires special considerations because pregnancy induces major changes in thyroid function, and maternal thyroid disease can have adverse effects on the pregnancy and the fetus. Care requires coordination among several healthcare professionals. Avoiding maternal (and fetal) hypothyroidism is of major importance because of potential damage to fetal neural development, an increased incidence of miscarriage, and preterm delivery. Maternal hyperthyroidism and its treatment may be accompanied by coincident problems in fetal thyroid function. Autoimmune thyroid disease is associated with both increased rates of miscarriage, for which the appropriate medical response is uncertain at this time, and postpartum thyroiditis. Fine-needle aspiration cytology should be performed for dominant thyroid nodules discovered in pregnancy. Radioactive isotopes must be avoided during pregnancy and lactation. Universal screening of pregnant women for thyroid disease is not yet supported by adequate studies, but case finding targeted to specific groups of patients who are at increased risk is strongly supported.

KIT gene molecular analysis distinguishes multiple primary GIST from metastatic disease

10048 Background: The occurrence of multiple primary GIST (MPG) has been reported exclusively in children and in NF1 patients. However, sometimes adult GIST patients present at onset with double lesions raising the problem of the differential diagnosis between metastatic and MPG. Morphologic features might help in recognizing MPG. A clear cut distinction is much less obvious when dealing with simultaneous high risk lesions. Molecular analysis of KIT gene may represent an important tool to discriminate among these two possibilities, allowing proper therapeutic strategies. Methods: From a series of 200 GIST we selected 5 non NF1 adult GIST patients, presenting double lesions at onset. Genomic DNA was extracted from both the nodules of each patients and exons 9, 11, 13, 14 and 17 of KIT gene were sequenced. Cases were also investigated for KIT exon 10 and intron 10 and PDGFRA exons 12 and 18. Results: Age ranged from 48 to 82 years. Four patients had a dominant nodule, ranging in size between 3 and 10 cm, and a peritoneal/hepatic nodule ranging in size between 0.8 and 3 cm. One patient had one gastric and one small intestinal nodules of 6 cm. No significant differences in mitotic rate and morphology were seen between the two nodules in each case. In two cases, both nodules showed same molecular profile, confirming the metastatic nature of the disease. In one case, the same KIT mutation was detected in both lesions, but an additional mutation was present only in the intestinal tumor. In contrast, in one case, different KIT mutations were found, suggesting the occurrence of two synchronous GIST. In an additional case, while a PDGFRA mutation was found in the tumor located in the stomach, no mutations were detected in the tumor located in the liver. Conclusions: 1. Molecular analysis proves the existence of exceptional cases of multiple primary GIST in non children, non NF1 patients. 2. Since discrimination between metastatic disease at onset and multiple primaries impacts over therapeutic strategies, it might be useful also in the routine practice to perform molecular analysis of both nodules in cases of double GIST. No significant financial relationships to disclose.

Multifocality and multicentricity are not contraindications for sentinel lymph node biopsy in breast cancer surgery.

BackgroundAfter the availability of the results of validation studies, the sentinel lymph node biopsy (SLNB) has replaced routine axillary dissection (AD) as the new standard of care in early unifocal breast cancers. Multifocal (MF) and multicentric (MC) tumors have been considered a contraindication for this technique due to the possible incidence of a higher false-negative rate. This prospective study evaluates the lymphatic drainage from different tumoral foci of the breast and assesses the accuracy of SLNB in MF-MC breast cancer.Patients and methodsPatients with preoperative diagnosis of MF or MC infiltrating and clinically node-negative (cN0) breast carcinoma were enrolled in this study. Two consecutive groups of patients underwent SLN mapping using a different site of injection of the radioisotope tracer: a) "2ID" Group received two intradermal (ID) injections over the site of the two dominant neoplastic nodules. A lymphoscintigraphic study was performed after each injection to evaluate the route of lymphatic spreading from different sites of the breast. b) "A" Group had periareolar (A) injection followed by a conventional lymphoscintigraphy. At surgery, both radioguided SLNB (with frozen section exam) and subsequent AD were planned, regardless the SLN status.ResultsA total 31 patients with MF (n = 12) or MC (n = 19) invasive, cN0 cancer of the breast fulfil the selection criteria. In 2 ID Group (n = 15) the lymphoscintigraphic study showed the lymphatic pathways from two different sites of the breast which converged into one major lymphatic trunk affering to the same SLN(s) in 14 (93.3%) cases. In one (6.7%) MC cancer two different pathways were found, each of them affering to a different SLN. In A Group (n = 16) lymphoscintigraphy showed one (93.7%) or two (6.3%) lymphatic channels, each connecting areola with one or more SLN(s). Identification rate of SLN was 100% in both Groups. Accuracy of frozen section exam on SLN was 96.8% (1 case of micrometastasis was missed). SLN was positive in 13 (41.9%) of 31 patients, including 4 cases (30.7%) of micrometastasis. In 7 of 13 (53.8%) patients the SLN was the only site of axillary metastasis. SLNB accuracy was 96.8% (30 of 31), sensitivity 92.8 (13 of 14), and false-negative rate 7.1% (1 of 14). Since the case of skip metastasis was identified by the surgeon intraoperatively, it would have been no impact in the clinical practice.ConclusionOur lymphoscintigraphic study shows that axillary SLN represents the whole breast regardless of tumor location within the parenchyma. The high accuracy of SLNB in MF and MC breast cancer demonstrates, according with the results of other series published in the literature, that both MF and MC tumors do not represent a contraindication for SLNB anymore.

A case of acquired renal cystic disease (ACDK) with oncocytosis, a dominant nodule (oncocytoma), multiple adenomas and a microscopic papillary renal cell carcinoma associated with crescentic glomerulonephritis

Sir, A 76-year-old female patient suffering from long-term arterial hypertension had a nephrotic syndrome in 1997, being diagnosed of membranous glomerulonephritis clinically and with biopsy. She was resistant to steroids and azathioprine. Then, her treatment was changed to Mycophenolate Mofetil. In 2005, she had anuria, abdominal discomfort and acral edema. Serologic studies were negative. Hemodyalisis, besides steroids and cyclofosphamide treatment were started. Her renal function was worsening and a new biopsy showed a crescentic glomerulonephritis with epithelial crescents, severe tubulointerstitial changes and focal tubular hyperplasia. IF studies were identical to the previous biopsy and consistent with membranous glomerulonephritis (granular peripheral glomerular deposits of Ig G, C3 and C1q). EM is not available. CT scan and MRI displayed multiple renal cysts suggesting ACDK with a 2.5 cm solid nodule and a total right nephrectomy was performed. The removed kidney (Fig. 1) had multiple cysts, numerous minute nodules and a tangreen 2.5 cm mass. Studied by routine methods and immunohistochemistry (cytogenetics and EM are not available), a crescentic GN with many obsolescent glomeruli was found (Fig. 2). There were prominent tubulointerstitial changes: severe tubular atrophy, frequent tubular hyperplasia and oncocytic changes, sometimes papillary; Virchows Arch (2007) 450:365–367 DOI 10.1007/s00428-006-0324-0

Is bronchoscopic lung biopsy helpful in the management of patients with diffuse lung disease?

Few studies have evaluated how the results of bronchoscopic lung biopsy (BLB) affect clinical management. The objective of the present study was to evaluate the clinical usefulness of BLB in the overall management of patients with diffuse pulmonary diseases. The study was a retrospective analysis of patients who underwent fluoroscopy-guided BLB over a 2-yr period. Patients whose biopsy was of a lung mass or single dominant lung nodule were excluded. The usefulness of BLB was assessed to determine whether the results affected the clinical management of these patients. During the study period, 603 patients underwent 651 BLB procedures. The results of BLB were clinically helpful in 494 (75.9%) out of 651 procedures. No diagnostic abnormality was identified in 107 (16.4%) out of the 651 biopsy procedures. This finding was clinically helpful in 59 (55.1%) out of 107 procedures, as the results excluded specific processes suspected before BLB. In 52 procedures (8% of all BLB), no lung parenchyma was obtained. In conclusion, bronchoscopic lung biopsy is a clinically useful test in approximately 75% of procedures. In the 25% of bronchoscopic lung biopsies that were clinically unhelpful, the reason for failure in approximately one-third of patients was the failure of the procedure to obtain an adequate quantity of lung parenchyma for a meaningful histological analysis.

Low-Energy Interstitial Laser Photocoagulation for Treatment of Nonfunctioning Thyroid Nodules: Therapeutic Outcome in Relation to Pretreatment and Treatment Parameters

Interstitial laser photocoagulation (ILP) is a recently proposed therapeutic procedure for the ablation of benign thyroid nodules, which has already proven to be safe and effective. However, results supporting the routine use of ILP are still limited. The aim of the study was to evaluate the efficacy and safety of ILP treatment in benign nonfunctioning thyroid nodules and to establish whether the therapeutic outcome may be predicted by any clinical parameter at baseline. Twenty-three patients with either a solitary nodule or a dominant nodule within a multinodular goiter underwent ILP and were evaluated 1 and 3 months later. In order to assess the efficacy of low-energy ILP, the procedure was performed with an output power of 3 W, delivering a mean energy of 33.4 +/- 12.7 Joule/mL of nodule volume, which is much lower than previously reported. Nodule volume significantly decreased after ILP as assessed after 1 and 3 months (analysis of variance; F = 5.37; p = 0.007). Patients with multinodular goiter showed a greater reduction at 3 months compared with patients bearing a solitary thyroid nodule (38.6 +/- 5.3 vs. 30.9 +/- 6.5%; p < 0.01). Age, sex, ultrasound pattern (isoechogenous/hypoechogenous), pretreatment volume, number of ILP treatments, and total energy delivered did not show any significant correlation with treatment outcome. Our results demonstrate that ILP can produce a significant reduction of thyroid nodule volume even when a much lower energy than previously reported is delivered. ILP constitutes a minimally invasive technique, which can be carried out on an outpatient basis and could represent a valid nonsurgical alternative for thyroid nodule management. Dominant nodules within a multinodular goiter appear to be more responsive to ILP compared with solitary thyroid nodules.

Mcm‐2 and Ki‐67 Have Limited Potential in Preoperative Diagnosis of Thyroid Malignancy

Minichromosome maintenance protein 2 (Mcm-2) is essential for DNA replication and serves as a useful biomarker of cell-cycle state in human tissue samples. Ki-67 is an established proliferation marker. Because Mcm-2 expression has not previously been assessed in thyroid tissue, the aim of this study was to assess the expression of both proteins in a range of thyroid lesions to determine their potential value as preoperative markers of thyroid malignancy. Mcm-2 and Ki-67 protein expression were assessed by immunohistochemistry in formalin-fixed, paraffin-embedded thyroid tissues from 128 patients with histologic diagnoses of papillary carcinoma (n = 38), follicular carcinoma (n = 22), follicular adenoma (n = 33), and dominant nodules of multinodular goitre (n = 35). Mcm-2 and Ki-67-labeling indices (LIs) were both higher in follicular and papillary carcinomas than in follicular adenomas or dominant nodules. The Ki-67 LI discriminated better between follicular carcinomas and follicular adenomas (P < .0001) than Mcm-2 (P = .0273). However, the Mcm-2 and Ki-67 LIs overlapped widely between the four histologic groups, and the expression of these proteins was also noted to be heterogenous within these lesions. Neither Mcm-2 or Ki-67 can currently be reliably applied as preoperative markers to distinguish benign from malignant thyroid lesions.

Updated Protocol for the Examination of Specimens From Patients With Carcinomas of the Prostate Gland

T protocol is intended to assist pathologists in providing clinically useful and relevant information as a result of the examination of surgical specimens. Use of this protocol is intended to be entirely voluntary. If equally valid protocols or similar documents are applicable, the pathologist is, of course, free to follow those authorities. Indeed, the ultimate judgment regarding the propriety of any specific procedure must be made by the physician in light of the individual circumstances presented by a specific patient or specimen. It should be understood that adherence to this protocol will not guarantee a successful result. Nevertheless, pathologists are urged to familiarize themselves with the document. Should a physician choose to deviate from the protocol based on the circumstances of a particular patient or specimen, the physician is advised to make a contemporaneous written notation of the reason for the procedure followed. The College recognizes that this document may be used by hospitals, attorneys, managed care organizations, insurance carriers, and other payers. However, the document was developed solely as a tool to assist pathologists in the diagnostic process by providing information that reflects the state of relevant medical knowledge at the time the protocol was first published. It was not developed for credentialing, litigation, or reimbursement purposes. The College cautions that any uses of the protocol for these purposes involve considerations that are beyond the scope of this document.