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These differences have been attributed to selection bias, geographical location (iodine deficiency) [1. The epithelial tumours arise either from follicular cells or from parafollicular C cells, while the various sarcomas and malignant lymphomas comprise the non-epithelial tumours. The main pathologic features and biologic behaviour will be reviewed, including ancillary procedures which may aid in the his to logical typing of problematic cases. His to pathology and immunohis to chemistry of thyroid cancer are important in the actual classification. Follicular carcinoma Follicular carcinoma is a malignant epithelial tumour that shows follicular cell differentiation not belonging to any other distinctive type of thyroid malignancy [2. These are more common in iodide-deficient areas, where they make up 25 to 40% of thyroid cancers. Not all tumours which form follicles should be classified under this category, because of differences not only in morphologic features, but also in biologic behaviour. For example, some variants of papillary carcinoma exhibit follicular structure, but pursue a clinical course similar to conventional papillary carcinoma. Some authors consider oncocytic carcinoma separate from the usual follicular carcinoma. There are two types of follicular carcinoma: minimally invasive and widely invasive [2. Minimally invasive follicular carcinoma is indistinguishable grossly from follicular adenoma. It presents as a solitary, well circumscribed nodule with a complete, usually thick capsule and a homogeneous, bulging, grey cut surface (Fig. Diagnosis of malignancy requires demonstration of 10 capsular or vascular invasion (Fig. Full thickness invasion of the capsule is necessary to fulfil the criterion of capsular invasion. At least 10 blocks are recommended to be taken around the nodule that will include the capsule and surrounding thyroid tissue. Widely invasive follicular carcinoma grossly exhibits extensive invasion of the surrounding tissue (Fig. Microscopically, these tumours tend to be more obviously malignant than the minimally invasive category. Nuclear pleomorphism is usually evident, mi to tic activity is prominent, and necrosis is more likely to be present. Neoplasms composed of Hurthle cells are still controversial with regard to their classification and biologic behaviour. Some consider it a subtype of follicular neoplasm and the criteria for differentiating benign from malignant are the same as in the other follicular tumours, including demonstration of invasion. Others, however, consider thyroid neoplasms composed of this cell type as a separate entity with different pathologic and behavioural features [2. Most studies recognize benign and malignant forms, with invasion as the most important determining fac to r. Papillary carcinoma Papillary carcinoma is the most common type of thyroid cancer. It is a malignant epithelial tumour with evidence of follicular cell differentiation forming papillae and/or a set of distinctive nuclear features [2.
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If the trocar of a primary cannula penetrates the bowel, the condition is usually diagnosed when the mucosal lining of the gastrointestinal tract is visualized. However, the injury may not be recognized immediately because the cannula may not stay within the bowel or may pass through the lumen. Such injuries usually occur when a single loop of bowel is adherent to the anterior abdominal wall. The injury may not be recognized until peri to nitis, abscess, enterocutaneous fistula, or death occurs (123,124). Therefore, at the end of the procedure, the removal of the primary cannula must be viewed either through the cannula or an ancillary port, a process facilitated by routine direct visualization of closure of the incision of the primary port. Trocar-related injuries to the s to mach and bowel require repair as soon as they are recognized. If the injury is small, a trained opera to r can repair the defect under laparoscopic direction using a double layer of running 2-0 or 3-0 absorbable sutures. Extensive lesions may require resection and reanas to mosis, which in most instances requires at least a small laparo to my. The preoperative use of mechanical bowel preparation in selected high-risk cases minimizes the need for laparo to my or colos to my, but recent evidence suggests that bowel surgery, if necessary, may be safely performed in unprepared bowel (125). Dissection and Thermal Injury When mechanical bowel trauma is recognized during the dissection, treatment is the same as that described for trocar injury. Should the injury involve radiofrequency electrical energy, it is important to recognize that the zone of desiccation and coagulation may exceed the area of visual damage. This is especially true if the exact mechanism of the thermal injury is unknown or if injury results from contact with a relatively large surface area electrode that would be more likely to create a large coagulation injury. Conversely, bowel injury created under direct vision with a radiofrequency needle or blade electrode is associated with little collateral coagulation effect and can be managed similar to a mechanically induced lesion. Consequently, surgical repair should be implemented considering these fac to rs, and should include, if necessary, resection of ample margins around the injury. Thermal injury may be handled expectantly if the lesion seems superficial and confined, such as when fulguration (noncontact arcing of high-voltage current) involves bowel. In a study of 33 women with such injuries who were managed expectantly in the hospital, only 2 required laparo to my for repair of perforation (126). Urologic Injury Damage to the bladder or ureter may occur secondary to mechanical or thermal trauma incurred during laparoscopic procedures. Ideally, such injury should be prevented; otherwise, as is the case for most complications, it is preferable to identify the trauma intraoperatively. Bladder Injury Bladder injury can result from the perforation of the undrained bladder by an insufflation needle or trocar, or it may occur while the bladder is being dissected from adherent structures or from the anterior uterus (127,128). Estimates of the frequency of unintentional cys to to my associated with laparoscopic hysterec to my range from 0. A2 bladder laceration can be confirmed by injecting sterile milk or a diluted methylene blue solution through a transurethral catheter. Thermal injury to the bladder, however, may not be apparent initially and, if missed, can present as peri to nitis or a fistula. Routine preoperative bladder drainage usually prevents trocar-related cys to to mies. Separation of the bladder from the uterus or other adherent structures requires good visualization, appropriate retraction, and excellent surgical technique. Sharp mechanical dissection is preferred, particularly when relatively dense adhesions are present. Very small-caliber injuries to the bladder (1 to 2 mm) may be treated with bladder catheterization for 3 to 7 days. When a larger injury is identified, it can be repaired laparoscopically (127,128,131).
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The use of colour Doppler imaging identifies multiple small vessels within and adjacent to the thyroid [5. The major advantages of ultrasound are that it is accessible, inexpensive, and non-invasive. Because of the relatively short examination time required for ultrasound and the ability to image while the patient is taking thyroid hormonal supplementation, it is more convenient than scintigraphy for follow-up of patients with prior or increased risk of cancer. Improved grey scale and Doppler sonography have increased the accuracy and specificity of ultrasound 45 for thyroiditis and other diffuse glandular diseases [5. In spite of these attributes, retrotracheal and mediastinal lesions remain difficult for ultrasound evaluation because of acoustic shadowing from overlying air or bone [5. Another limitation of ultrasound is that it is inferior to cross-sectional imaging techniques in identifying lymphadenopathy or in evaluating for extension of thyroid disease in to the soft tissues of the neck or chest [5. These modalities also play a critical role in the detection of lymph node metastases as well as in extension of thyroid disease to adjacent tissues in the neck like paraspinal muscles. Contiguous 5 mm-thick axial sections are obtained at the level of the cavernous sinus superiorly and extend inferiorly in to the superior mediastinum to include the aortic arch. The injection of iodinated contrast material intravenously increases the density of the gland diffusely. Although iodinated contrast material may provide additional information about lesions in the thyroid, it alters radioactive iodine uptake measurements for 6 to 8 weeks because of the iodine content. Therefore, contrast should not be administered to patients who will also undergo scintigraphic evaluation. This configuration provides high-quality images with a high signal- to -noise ratio and the best soft tissue resolution. Multiple pulse sequences are obtained including un-enhanced sagittal and axial T1-weighted images, as well as axial fast spin-echo T2-weighted imaged with the application of fat saturation. On T1-weighted images, the normal thyroid gland shows homogeneous signal intensity slightly greater than that of the musculatue in the neck. On T2-weighted images, the thyroid gland is hyperintense relative to the neck musculature [5. It offers the advantage of precisely targeting solid components within complex lesions [5. Malignant neoplasms Thyroid carcinoma arises from both follicular and prafollicular C cells. The potential of malignancy range from low grades (papillary/follicular carcinoma) to aggressive (anaplastic carcinoma). The major his to logical classification of thyroid carcinoma includes papillary, 46 follicular, medullary, and anaplastic. The majority of carcinomas (60 to 80%) are papillary, followed by 15-20% follicular, medullary and anaplastic types account from 5 to 10 per cent each of thyroid cancers [5. Most thyroid malignancy is hypoechoic (63%) or isoechoic (26%) on sonography; hyperechoic thyroid lesions tend to be benign [5. Calcification causing bright hyperechoic foci, which if large enough cause acoustic shadowing, occurs in both benign and malignant disease [5. Most commonly, thyroid cancer is a localized intrathyroidal hypoechoic or isoechoic discrete mass which is similar to more common benign lesions. Malignant invasion of the thyroid rarely may cause direct invasion of the carotid artery or local invasion of the adjacent muscles with loss of the normal tissue boundaries. Papillary carcinoma Papillary carcinoma is a low-grade malignancy occurring most commonly in adolescent girls and young adults. Frequently, papillary carcinoma is multi-focal in the thyroid gland and is thought to represent intraglandular spread rather than multiple synchronous tumours. It has the highest incidence among thyroid malignancies for cervical lymph node spread [5. Metastatic lymph nodes may be normal in size and may be cystic, calcified or haemorrhagic, or they may contain colloid (Figs 5. Follicular carcinomas Follicular carcinomas are well-differentiated, relatively low-grade malignancies. Pathologically, they are characterized by capsular and vascular invasion and are usually solitary lesions. Distant metastases to the lung and bone, related to haema to genous seeding, are more common than lymph node spread [5.
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Many microorganisms produce superantigens that activate an entire family of T cells. Some members of the T cell family may be committed to responding to au to antigens and could thereby initiate an au to immune response. The infectious process itself can act like an adjuvant: it can drive B cells to differentiate in to antibody-producing cells that produce the natural au to antibodies so often seen following infection. There are instances, moreover, where class switching results in IgG antibodies, indicating that helper T cells may also be activated, perhaps through the infectious process. Inadequate affinity matura tion of adaptive responses can be harmful, as the host responds not only to the infectious agent, but also to closely related au to antigens. Moreover, self-reactive effec to r T cells may also be generated and induce au to immune disease. These effects may even be apparent in dealing with memory T cells, suggesting that an infection occurring long after the initial sensitization of the host to au to antigen can cause an enhanced au to immune response. The mechanisms described above are likely to be involved in the induction of organ-localized au to immune diseases, where damage is largely confined to a single organ or cell target, such as seen in diabetes mellitus type 1, chronic lymphocytic thyroiditis, or multiple sclerosis. An alternative mechanism by which au to immu nity may arise is a defect in negative selection in the thymus and a failure of clonal deletion to rid the periphery of self-reactive T cells. Such a defect in clonal deletion is most likely to give rise to multiple au to immune responses, such as seen in the generalized or systemic au to immune diseases. These animals character istically produce a large spectrum of au to antibodies similar to those seen in human cases of lupus. The amplification mechanisms include epi to pe spread, which involves the recruitment of additional antigenic determinants on the self-reactive antigen molecule. We distinguish this intramolecular epi to pe spreading from immune esca lation, which describes the extension of the au to immune response to other antigenic molecules in the same target organ. It is charac teristic of almost all of the au to immune diseases that multiple au to antibodies are produced after the disease is under way, probably reflecting an adjuvant effect. Thus, the use of animal models, where the disease can be induced under controlled conditions, can provide important insights in to this process. In addition, prospective epidemiological studies that examine the development, persistence, and progression of au to antibodies before the clinical expression of disease can also advance our understanding of the etiology of au to immune diseases in humans. Several studies of this type are now being conducted in diabetes mellitus type 1 research (Parks et al. The important fac to rs deter mining the cy to to xic mechanisms involved in any situation include the accessibility of the antigen to the immune effec to rs as well as the quality and quantity of the immune response itself. There is some heuristic value in distinguishing Th1 responses from Th2 responses, although this dicho to my is rarely clear-cut or complete. This dicho to my is largely based on mouse studies that may not entirely apply to human beings or all animal species. Thus, broadly speaking, Th1 responses are thought of as cell-mediated, whereas Th2 responses are associated with antibody-mediated effec to r mechanisms. Among the au to immune diseases, a direct demonstration of pathogenetic mechanisms has been possible until now only with antibody-mediated disorders. Antibodies to blood cells are responsible for the haemolytic anaemias and thrombocy to penias, either through enhanced phagocy to sis by reticuloendothelial cells or by complement-mediated lysis. Pemphigus vulgaris and bullous pemphigoid are due to antibodies that destroy intercellular substances that hold to gether cells of the skin, inducing blister or bullous formation. The most important antibodies from a clinical point of view are directed to components of the cell nucleus.
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