Incidental thyroid carcinoma: Correlation between FNAB cytology and pathological examination in 1093 cases

Abstract Objective To investigate Incidental Thyroid Carcinoma (ITC) by comparing the results of Fine Needle Aspiration Biopsy (FNAB) cytology and the postoperative pathological findings. Methods Data of 1479 patients who underwent total thyroidectomy were retrieved. Three hundred eighty-six patients were excluded due to insufficient data. Each surgical specimen studied received two histopathological diagnoses: the local diagnosis ‒ for the same area in which the FNAB was performed; and the final diagnosis, which includes a study of the entire surgical specimen. Results A thousand and ninety-three patients were investigated. FNAB result was malignant in 187 patients, benign in 204, suspicious or indeterminate in 668 cases, and inconclusive in 34 cases. The prevalence of ITC was 15.1%. Most of the ITC in this series was less than 0.5 cm. The incidence of ITC was higher in Bethesda III (17.5% ITC) and IV (19% ITC) than in Bethesda II cases (1.5% false negatives and 9% ITC). Conclusion Although the incidence of false-negative results in Bethesda II nodules is only 1.5%, 9% of these patients had ITC in the thyroid parenchyma outside the nodule that underwent preoperative FNAB. The incidence of ITC in the same scenario was even higher in Bethesda III (17.5%) and Bethesda IV cases (19%). Ultrasonography-guided FNAB is an excellent method for the assessment of thyroid nodules. However, biopsy sites should be carefully selected. Despite the high incidence of incidentalomas, total thyroidectomy should not always be the treatment of choice due to its rare but potentially serious complications. The findings of the present study can assist future clinical decisions towards active surveillance strategies for the management of papillary thyroid carcinoma.

Superficial cervical plexus blockade improves pain control after thyroidectomy: A randomized controlled trial

OJECTIVES: The aim was to evaluate the ability of bilateral superficial cervical plexus blockade to control pain and to reduce the side effects of general anesthesia in patients submitted to thyroidectomy. METHODS: In this randomized controlled trial, we prospectively studied 100 consecutive patients who underwent total thyroidectomy. The simple random patient sample was divided into two groups: 50 patients received general anesthesia alone (group 1 [G1]), and 50 patients received general anesthesia with bilateral superficial cervical plexus blockade (group 2 [G2]). Statistical analyses were performed, and a 5% significance level was adopted. RESULTS: The mean arterial blood pressure and heart rate were 12% lower in G2 patients than in G1 patients 60 minutes after surgery (101 mmHg for G1 vs. 92.3 mmHg for G2; p<0.001). G2 patients reported less pain than G1 patients, and opioid consumption was lower in G2 patients than in G1 patients, not upon postanesthesia care unit arrival, but at 30 minutes (2% vs. 34%; p<0.001, respectively), 45 minutes (0% vs. 16%; p=0.006, respectively), and 4 hours postoperatively (6% vs. 20%; p=0.037, respectively). The incidence of nausea and vomiting was lower in G2 patients than in G1 patients from 45 minutes (0% vs. 16%; p=0.006, respectively) to 8 hours postoperatively (0% vs. 14%; p=0.012, respectively). CONCLUSIONS: The present study demonstrated that the combination of bilateral superficial cervical plexus blockade with general anesthesia for thyroidectomy is feasible, safe, and effective for achieving pain control and improving patient outcomes.

Assessment of quality of life in patients with advanced oral cancer who underwent mandibulectomy with or without bone reconstruction

INTRODUCTION Malignant neoplasms of the head and neck, due to its anatomical location, can cause significant alterations in vital functions related to feeding, communication and social interaction of the affected patients. Objective To analyze the quality of life of patients with advanced malignant neoplasms of the oral cavity and submitted to radical operations with curative intent. Material and methods 47 patients with oral cavity squamous cell carcinoma (SCC), in stages III and IV, underwent surgical treatment with segmental mandibulectomy and complementary radiotherapy. The patients were submitted to the quality of life questionnaires after a minimum time of six months after the surgical treatment. Results Of the 183 patients, only 47 (25.7%) were able to answer the questionnaire and were included as the sample of the study. The majority of patients selected were male (39; 82.9%). The mean age was 64.4 years. The majority of the patients presented clinical stage IV (83%) and were submitted to adjuvant radiotherapy (95.4%). The mean score obtained after the questionnaires were applied was 64.6. The worst scores were found in swallowing and chewing. Conclusion There were no statistically significant differences in the domains of quality of life between the two groups studied (with bone reconstruction versus no bone reconstruction). Patients interviewed 2 years or more after treatment presented higher scores (p = 0.02).

RESUMO INTRODUÇÃO As neoplasias malignas de cabeça e pescoço, pela própria localização anatômica, podem acarretar alterações significativas em funções vitais relacionadas à alimentação, comunicação e interação social dos indivíduos afetados. OBJETIVO Analisar a qualidade de vida dos pacientes com neoplasias malignas avançadas de cavidade oral, submetidos a operações radicais com intenção curativa. MATERIAL E MÉTODOS 47 pacientes portadores de carcinoma espinocelular de cavidade oral, em estádios III e IV, foram submetidos ao tratamento cirúrgico com mandibulectomia segmentar e radioterapia complementar. Os pacientes foram submetidos ao teste de qualidade de vida após o tempo mínimo de seis meses do tratamento cirúrgico. RESULTADOS Dos 183 pacientes, com apenas 47 (25,7%) foi possível a realização da entrevista, compondo estes a amostra para o estudo. A maioria dos pacientes do grupo selecionado era do sexo masculino, total de 39 homens (82,9%). A idade média foi de 64,4 anos. A maioria dos pacientes apresentava estadiamento clínico IV (83%), sendo submetidos à radioterapia adjuvante (95,4%). A média do escore obtido após a avaliação dos questionários foi de 64,6. Os piores escores foram encontrados nos quesitos deglutição e mastigação. CONCLUSÃO Não houve diferenças estatisticamente significativas nos domínios de qualidade de vida entre os dois grupos estudados (com reconstrução óssea versus sem reconstrução óssea). Pacientes entrevistados dois anos ou mais após o tratamento apresentaram escores superiores (p=0,02).

Malignancy rates for Bethesda III subcategories in thyroid fine needle aspiration biopsy (FNAB)

OBJECTIVES: Most thyroid diseases are nodular and have been investigated using ultrasound-guided fine needle aspiration biopsy (FNAB), the reports of which are standardized by the Bethesda System. Bethesda category III represents a heterogeneous group in terms of lesion characteristics and the malignancy rates reported in the literature. The objective of the present study was to evaluate the differences in the malignancy rates among Bethesda III subcategories. METHODS: Data from 1,479 patients who had thyroid surgery were reviewed. In total, 1,093 patients (89.6% female, mean age 52.7 (13-89) years) were included, and 386 patients were excluded. FNAB results (based on Bethesda Class) and histopathological results (benign or malignant) for coincident areas were collected. Bethesda III patients were subcategorized according to cytopathological characteristics (FLUS: follicular lesion of undetermined significance, Bethesda IIIA; AUS: atypia of undetermined significance, Bethesda IIIB). Data were correlated to obtain the malignancy rates for each Bethesda category and the newly defined subcategory. RESULTS: FNAB results for these patients were as follows: Bethesda I: 3.1%; Bethesda II: 18.6%; Bethesda III: 35.0%; Bethesda IV: 22.1%; Bethesda V: 4.1%; and Bethesda VI: 17.1%. The malignancy rates for Bethesda Class IIIB were significantly higher than those for Bethesda Class IIIA (p<0.001) and Bethesda Class IV (p<0.001). Bethesda Class IIIA showed significantly lower malignancy rates than Bethesda Class III overall (p<0.001) CONCLUSIONS: Improvements of the Bethesda System should consider this subcategorization to better reflect different malignancy rates, which may have a significant impact on the decision-making process.

Substernal goiter and laryngopharyngeal reflux

ABSTRACT Objective This study aims to compare the prevalence of laryngopharyngeal reflux signs between two groups of patients undergoing thyroidectomy for voluminous goiter: substernal goiters and voluminous cervical goiter without thoracic extension. Subjects and methods A retrospective case-control study was performed with data retrieved of the charts of the patients submitted to thyroidectomies occurred at a tertiary care center (Head and Neck Surgery Department, University of São Paulo Medical School) between 2010 and 2014. The selected thyroidectomies were allocated in two groups for study: patients with substernal goiters and patients with voluminous cervical goiter without thoracic extension. Cervical goiters were selected by ultrasonography mensuration. Clinical criterion was used to define substernal goiter. Results The average thyroid volume in patients with substernal goiter was significantly greater than the average volume in patients with only cervical goiter (p < 0.001). The prevalence of signs of reflux laryngitis at laryngoscopy was significantly greater in substernal goiter patients (p = 0.036). Moreover, substernal goiter was considered as the unique independent variable for high reflux laryngitis signs at laryngoscopy (OR = 2.75; CI95%: 1.05-7.20; p = 0.039) when compared to only cervical goiter patients. Conclusion This study shows a significant association between substernal goiters and signs of laryngopharyngeal reflux at preoperative laryngoscopy. Therefore, when compared with voluminous cervical goiters, the substernal goiters increase the chance of reflux laryngitis signs in patients.

Postoperative calcium levels as a diagnostic measure for hypoparathyroidism after total thyroidectomy

ObjectiveThe aim of the present study was to identify a fast, efficient and low-cost method to diagnose hypoparathyroidism after total thyroidectomy.Materials and methodsOne hundred and forty medical records, which contained patients’ clinical and laboratory data, were retrospectively analyzed. Patient parathyroid hormone values, which were obtained immediately following operation, were compared with their ionized calcium levels the morning after surgery. This comparison was used to examine the correlation between the two variables in predicting hypoparathyroidism because measuring calcium levels is low-cost and more available in the hospitals compared to measuring parathormone (PTH) levels.ResultsThere was a positive and statistically significant correlation between PTH and ionized calcium values (Pearson correlation coefficient, r = 0.456; p < 0.0001). The values of first postoperative day ionized calcium levels (stratified by the 1.10 mmol/l cut-off value) were tested as a diagnostic measure for hypoparathyroidism, and a PTH < 15 pg/mL obtained immediately following operation served as a reference. This analysis showed that ionized calcium levels measured on the first postoperative day had a sensitivity of 45.6% (95% CI 30.9-61.0%), a specificity of 88.9% (95% CI 80.5-94.5%) and an accuracy of 76.7% (95% CI 68.7-83.5%) as a diagnostic measure for hypoparathyroidism.ConclusionIn conclusion, we demonstrated that patients who had high ionized calcium levels on the first postoperative day also had high PTH levels immediately following operation and, therefore, they had lower rates of hypoparathyroidism.

A associação dos níveis séricos de TSH com o risco de câncer bem diferenciado de tireoide e sua relação com a agressividade da doença / The association of serum TSH with the risk of well-differentiated thyroid cancer and its relation with disease aggressiveness

Introdução: O câncer de tireoide é a neoplasia endócrina de maior prevalência, e sua incidência vem aumentando nos últimos anos. Estudos anteriores sugeriram que o nível sérico de Hormônio Estimulante de Tireoide (TSH) é um fator de risco independente para o desenvolvimento de cânceres bem diferenciados de tireoide. Além disso, alguns desses estudos demonstraram que altos níveis de TSH estão relacionados a estágios mais avançados de doença. Objetivos: O objetivo do presente estudo é averiguar se os níveis de TSH, mesmo dentro da faixa da normalidade, se correlacionam com maior incidência e maior agressividade dos carcinomas bem diferenciados de tireoide. Métodos: Analisamos os dados de 1180 pacientes submetidos a tireoidectomia total pela equipe da Disciplina de Cirurgia de Cabeça e Pescoço do HC-FMUSP, sendo 57,9% devido a doenças benignas e 42,1% a neoplasias malignas de tireoide. Para cada paciente, adotamos os valores absolutos de TSH referentes à última coleta antes da cirurgia, e os resultados dos exames anatomopatológicos (AP). Resultados: A comparação dos níveis de TSH estratificado nos pacientes com doenças benignas e com neoplasias malignas demonstrou uma associação estatisticamente significativa (p < 0,0001), nos permitindo inferir que pacientes com valor de TSH sérico maior de 1,16 µIU/mL tem maior risco de serem portadores de câncer bem diferenciado de tireoide do que aqueles que tem níveis de TSH menor ou igual a este valor. Porém, quando comparamos o estadio final dos CBT com os níveis de THS estratificado não houve associação significativa (p = 0,585), e assim pelos nossos resultados não podemos afirmar que valores de TSH maiores de 1,16 µIU/mL estão associados a maior gravidade no câncer de tireoide.

Introduction: The thyroid cancer is the most common endocrine malignancy, and its incidence has increased in recent years. Previous studies have suggested that serum Thyroid Stimulating Hormone (TSH) is an independent risk factor for the development of well differentiated thyroid cancer. Furthermore, some of these studies showed that high TSH levels are related to more advanced stages of disease. Objective: The aim of the present study is to investigate if serum THS levels, even whitin the normal range, are related with higher incidence and increased aggressiveness of well-differentiated thyroid carcinomas. Methods: We analyzed data of 1180 patients who underwent total thyroidectomy by the Discipline of Head and Neck Surgery from Hospital das Clinicas of University of São Paulo (HC-FMUSP). 57.9% was due to benign diseases and 42,1% was due to malignant neoplasms. For each patient, we adopted the value of serum TSH reference to the last collection before surgery, and the results of the pathologic exams. Results: The comparison of the stratified TSH levels in the patients with benign diseases and malignant neoplasms showed a statistically significant association (p < 0,0001), allowing us to infer that patients with TSH levels higher than 1,16 µIU/mL have higher risk of being carriers of well differentiated thyroid cancer than those who TSH levels less than or equal to this value. But when we compared the final stage of CBT with the stratified TSH levels, there was no significant association (p = 0,585), and so by our results we cannot say that THS levels higher then 1,16 µIU/mL are associated with more advanced stage of disease.

Malignant solitary fibrous tumor of the thyroid: a case-report and review of the literature / Tumor fibroso solitário maligno da tiroide: relato de caso e revisão da literatura

Solitary fibrous tumor (SFT) is an uncommon spindle-cell neoplasm that most often involves the pleura, rarely occurring in extra-thoracic locations. Twenty-six cases of SFT arising in the thyroid gland have been described. We report a case of a 60-year-old woman presenting an 8-month history of enlargement of the neck associated with dysphagia. The patient underwent a right hemithyroidectomy and SFT of the thyroid was diagnosed. Immunohistochemistry showed positivity for CD34 marker, and the high number of mitoses and the presence of cellular atypia suggested that the tumor was malignant. To our knowledge, this is the second case of malignant SFT of the thyroid gland ever reported. Due to the rarity of these tumors, the indication of adjuvant therapy and prognosis are uncertain. Long-term follow-up after surgical resection seems to be advisable.

O tumor fibroso solitário (SFT) é uma neoplasia rara de células fusiformes que mais frequentemente envolve a pleura, raramente ocorrendo em áreas extratorácicas. Já foram descritos 26 casos de SFT da tiroide. Relatamos o caso de uma paciente de 60 anos de idade com um histórico de 8 meses de aumento do pescoço associado à disfagia. A paciente foi submetida a uma hemitiroidectomia direita e foi diagnosticado um SFT de tiroide. A imuno-histoquímica mostrou resultados positivos para o marcador CD34, e o grande número de mitoses e a presença de atipia celular sugerem que o tumor era maligno. Em nosso conhecimento, este é o segundo caso de STF da tiroide maligno já relatado. Dada a rara ocorrência desses tumores, a indicação de tratamento adjuvante e o prognóstico são incertos. Recomenda-se o acompanhamento de longo prazo depois da ressecção cirúrgica.

Análise comparativa da incidência de câncer em pacientes operados com e sem hipertireoidismo / Comparative analysis of cancer incidence in patients operated with and without hyperthyroidism

Introdução: A incidência de câncer de tireóide em pacientes operados por hipertireoidismo vem aumentando nos últimos anos. A maioria desses casos é composta por tumores pequenos que são achados no resultado anátomo-patológico, o que implica em grande desafio ao cirurgião de cabeça e pescoço. Objetivo: Avaliar a relação entre hipertireoidismo e câncer de tireóide. Materiais e Métodos: Estudo retrospectivo de pacientes operados em uma única instituição entre 2004 e 2010. Foram identificados 1133 pacientes submetidos à tireoidectomia dos quais 761 foram analisados. Os pacientes foram divididos em 2 grupos, com e sem diagnóstico de hipertireoidismo. Foi realizada revisão de prontuário com avaliação de variáveis clínicas e patológicas. Realizada análise estatística dos dados. Resultados: Do total de pacientes do estudo 8,3% tinham diagnóstico pré-operatório de hipertireoidismo. Desses, 39,7% tinham doença de Graves, 49,2% bócio multinodular tóxico e 11,1% doença de Plummer. A incidência de câncer foi de 20,6% no grupo com hipertireoidismo e 38,7% no grupo sem (p=0,024). Os pacientes com hipertireoidismo apresentaram maior incidência de carcinoma micropapilífero (p=0,011) e tireoidite (p=0,02), menor sensibilidade para detecção de doença maligna na punção biópsia (50%) e congelação (25%). A maioria dos pacientes foi submetido à tireoidectomia total, à exceção dos pacientes com doença de Plummer (p<0,01). Conclusão: Em nossa casuística os pacientes com hipertireoidismo operados apresentaram incidência de malignidade menor que a de pacientes sem hipertireoidismo, sendo acometidos preferencialmente por microcarcinomas. Em grande parte dos casos o diagnóstico foi realizado apenas no anátomo-patológico. Punção biópsia e exame de congelação mostraram baixa sensibilidade para diagnóstico de doença maligna nesse grupo.

Background: The incidence of thyroid cancer in patients surgically treated for hyperthyroidism has increased in recent years. Most of these cases are composed of small tumors that are found only in the pathological analyze, which implies a big challenge for the head and neck surgeon. Objective: To evaluate the relationship between hyperthyroidism and thyroid cancer. Methods: A retrospective study of patients operated in a single institution between 2004 and 2010. We identified 1133 patients underwent thyroidectomy of whom 761 cases were analyzed. Patients were divided into two groups, with and without diagnosis of hyperthyroidism. Chart review was performed with assessment of clinical and pathological variables. Statistical analysis of data was performed. Results: Among the patients studied, 8.3% had diagnosis of hyperthyroidism. Of these, 39.7% had Graves' disease, 49,2% toxic multinodular goiter and 11.1% Plummer's disease. The incidence of cancer was 20.6% in patients with hyperthyroidism and 38.7% in patients without (p=0.024). Patients with hyperthyroidism showed higher incidence of papillary thyroid microcarcinoma (p=0.011) and thyroiditis (p=0.02), lower sensitivity for detecting malignancy in fine needle aspiration (50%) and frozen section (25%). Most patients underwent total thyroidectomy, except for patients with Plummer's disease (p<0.01). Conclusion: In our series the patients with hyperthyroidism had lower incidence of malignancy, and were mainly affected by papillary thyroid microcarcinoma. In most cases diagnose was done only in pathological analyses. Fine needle aspiration and frozen section examination showed low sensitivity for diagnosis of malignancy in this group.

Congelação intra-operatória em tireoidectomias / Frozen section exam in thyroidectomy

Objetivo: Analisar a eficácia da congelação intra-operatória (CIP) em tireoidectomias. Método: Análise retrospectiva dos resultados da CIP, da punção aspirativa por agulha fina (PAAF) e do anátomo-patológico (AP) em 114 tireoidectomias. Resultados: a CIP mostrou especificidade de 100% e sensibilidade de 89%. A sensibilidade foi menor em casos de PAAF indicativa de neoplasia folicular (57%). Conclusão: a CIP é uma ferramenta importante que auxilia no diagnóstico e tratamento de pacientes submetidos a tireoidectomia e somos favoráveis à sua utilização.

Objective: Study the efficiency of operative frozen section examination in thyroid surgery. Method: retrospective medical recording review of frozen section examination results, fineneedle aspiration biopsies and final pathologic examinations in 114 thyroid surgeries. Results: the frozen section examination showed a specificity of 100% and sensitivity of 89%. The sensitivity was lower in cases of cytology of follicular neoplasm (57%). Conclusion: The frozen section examination is an important tool for diagnoses and treatment of patients submitted to thyroid surgery.

Paratireoidectomia como modelo de avaliação do aprendizado de médicos residentes em cirurgia: resultados iniciais de estudo prospectivo / Parathyroidectomy as a model of learning evaluation of surgery residents: initial results of a prospective study

Introdução: O hiperparatireoidismo foi considerado uma doença rara no Brasil, mas o incremento no diagnóstico tem ocasionado aumento na demanda de tratamento. Apesar do desenvolvimento de novos medicamentos, o tratamento cirúrgico ainda é considerado importante. Mesmo com os avanços tecnológicos de localização, a experiência do cirurgião prevalece como fator determinante dos resultados da operação. Desse modo, a avaliação da aquisição de competência do médico residente nesse tipo de operação é uma obrigação da instituição de ensino. Ela deve criar instrumentos para essa avaliação. Objetivo: Descrever o instrumento de avaliação do ensino de operações de paratireóide desenvolvido em uma instituição universitária e seus resultados preliminares. Métodos: Analisaram-se os resultados dos instrumentos aplicados aos médicos residentes no ano de 2007. Os formulários foram preenchidos por diferentes supervisores com a análise de aspectos psicomotores, cognitivos e afetivos. Durante o período analisado, houve a aplicação de dois instrumentos diferentes, em etapas seqüenciais. Resultados: Houve nove avaliações em cada instrumento. No formulário com três conceitos (fraco, regular e bom), quanto aos aspectos psicomotores houve 82,5% de regular e 17,5% de bom. Nos aspectos afetivos, 29,6% de regular e 70,4% de bom. No protocolo com cinco conceitos (muito fraco, fraco, regular, bom, muito bom), nos aspectos psicomotores observaram-se 22,2% de regular, 58,7% de bom e 19,1% de muito bom. Em relação aos aspectos afetivos, houve 1,6% de muito fraco, 4,8% de fraco, 14,3% de regular, 47,6% de bom e 31,7% de muito bom. Conclusões: A mudança no protocolo de avaliação aparentemente permitiu discriminação melhor dos aspectos afetivos.

Introduction: Hyperparathyroidism was considered a rare disease in Brazil, but the increment in diagnosis has increased the need for treatment. Although new drugs have been developed, surgery is still considered an important therapy. Albeit the improvement in parathyroid localizing imaging studies, results of the operation are still affected by the experience of the surgeon. Thus, evaluation of residents' skills in this of operation is mandatory to teaching institutions. The institution should develop instruments for this evaluation. Objective: To report the initial experience with a rating system for evaluating parathyroid surgery teaching. Methods: The results of evaluation forms applied to head and neck surgery residents in the year of 2007 were analyzed. The evaluation was performed by different supervising surgeons and it included cognitive, operative skills and behavioral aspects. There were two different forms, developed consecutively. Results: Nine forms were filled for each type of chart. Regarding the chart with three possible options (poor, regular and good) the results for operative skills were 82.5% of regular and 17.5% of good. In behavioral aspects there were 29.6% of regular and 70.4% of good. In the forms with five possibilities (very poor, poor, regular, good, very good) there were 22.2% of regular, 58.7% of good and 19.1% of very good for technical skills aspects. In behavioral aspects, there were 1.6% of very poor, 4.8% of poor, 14.3% of regular, 47.6% of good and 31.7% of very good. Conclusion: The modification of the evaluation chart apparently improved the analysis of the behavioral aspects.

Estudo epidemiológico de 230 casos de carcinoma basocelular agressivos em cabeça e pescoço / Epidemiologic study of 230 aggressive basal cell carcinomas in head and neck

Introdução: o câncer da pele é a neoplasia maligna mais comum entre os caucasianos. No Brasil, o número de casos novos de câncer de pele não melanoma estimados para 2006 é de 55.480 casos em homens e de 61.160 em mulheres. O tipo mais comum de tumor maligno da pele é o carcinoma basocelular (CBC), responsável por 70% desses casos, seguido pelo carcinoma espinocelular e pelo melanoma. Cerca de 80% dos CBC são da região de cabeça e pescoço, em especial, da face. Objetivo: caracterização epidemiológica dos casos de CBC operados no serviço. Pacientes e Método: foram revistos os prontuários dos pacientes operados por CBC da pele entre 1987 e 2006. Foram analisados os dados referentes a gênero, idade, raça, local do tumor primário, tipo histológico, classificação T e invasão de estruturas profundas. Resultados: 230 pacientes foram operados, sendo 122 homens (53,1%) e 108 mulheres (46,9%). A idade variou de 31 a 95, com média de 63 anos (desvio padrão de 12,0) e o grupo mais acometido foi a sétima década. A raça caucasiana compreendeu 203 (88,2%) pacientes, seguido pela parda (11,3%) e um caso na raça amarela (0,5%). O local do tumor primário mais acometido foi nariz, com 32,5% dos casos, seguido por órbita (12,5%), pavilhão auricular (11,8%), malar (10,5%), perioral (7%), temporal (6,5%), mento (1,5%) e couro cabeludo (1,5%). Mais de uma variante histológica esteve presente no mesmo tumor em 59% dos casos. A variante esclerodermiforme foi a mais prevalente, estando presente em 57,3% dos casos, seguido pelo tipo sólido/nodular (54,7%), tipo ulcerado (26,8%), pela variante metatípica em 12,6% e superficial em 5,7%. Quanto ao estádio T, houve 28,7%% de T1, 29,3% de T2, 4,8% de T3 e 37,2% de T4. A invasão tumoral em estruturas profundas ocorreu na cartilagem nasal em 12 casos, cartilagem de orelha externa em 10 casos, tecidos periorbitários em nove casos, parótida em nove casos, osso temporal em cinco casos, osso nasal em quatro casos, osso frontal em quatro casos, maxila em quatro casos e mandíbula em dois casos. Houve invasão perineural documentada em 21,3% dos casos.

Introduction: skin cancer is the most common malignant neoplasm among Caucasians. In Brazil there were estimated 55480 new cases in men and 61160 in women in 2006. Basal cell carcinoma (BCC) is the most common skin cancer, accounting for 70%, followed by squamous cell carcinoma and melanoma. 80% of BCC are located in the head and neck region, especially in the face. Objective: epidemiological characterization of BCC cases operated in our Head and Neck Service. Patients and Methods: It was a retrospective study. The charts of the patients undergoing surgery between 1986 and 2006 and data reporting gender, age, race, primary tumor site, hystologic subtype, T stage, and perineural invasion were analyzed. Results: 230 patients were enrolled, being 122 men (53.1%) and 108 women (46.9%). The age varied between 31 and 95, median 63 (SD=12). Caucasians accounted for 203 (88.2%), and non-Caucasians for 27 (11.8%). The primary tumor sites were: nose (32.5%), periorbital (12.5%), auricular (11.8%), malar (10,5%), perioral (7%), temporal (6,5%), mental (1,5%) and scalp (1,5%). More than one histological subtype were seen in 59%. Morpheaform subtype was seen in 57.3% of the cases, followed by nodular (54.7%), ulcerated (26.8%), metatypical(12.6%), and superficial (5,7%). There were 28.7% of T1, 29.3% of T2, 4.8% of T3 and 37.2% of T4. Invasion of structures occurred in nasal cartilage in 12 cases, auricular cartilage in 10 cases, periorbital tissue in 9 cases, parotid gland in 9 cases, temporal bone in 5 cases, nasal, frontal, maxilla in 4 cases, mandible in 2 cases, dura-mater in 2 cases.

Metástase linfática cervical no carcinoma espinocelular de vias aerodigestivas superiores: análise crítica de fatores preditivos, pelo modelo de regressão logística / Lymph node metastasis from squamous cell carcinoma of the upper aerodigestive tract: individual risk prediction by logistic regression model

Introdução: a dissecção cervical no carcinoma espinocelular (CEC) de vias aerodigestivas superiores (VADS) é preconizada com base no risco epidemiológico de metástase linfática. A indicação do esvaziamento eletivo, porém, ainda é controversa. Determinar o risco individual de metástase auxilia na escolha do tratamento mais adequado. Objetivo: verificar a possibilidade de calcular o risco individual de metástase segundo os resultados da comparação de características clínicas e anátomo-patológicas entre os doentes com e sem metástase linfática cervical do CEC de VADS. Pacientes e Método: estudo retrospectivo longitudinal de caso-controle de 209 operados no período de agosto de 2002 a janeiro de 2007, distribuídos em dois grupos: 128 casos com e 81 sem metástase (estes seguidos por mais de 12 meses). Variáveis passíveis de serem preditivas do risco de metástase linfática foram comparadas entre os grupos e analisadas pelo modelo de regressão logística. Resultados: No grupo com metástase, o CEC apresentou maior freqüência de invasão sangüínea, linfática, perineural, margem comprometida e infiltrado inflamatório escasso. Maior diâmetro e grau de diferenciação foram variáveis independentes preditivas do risco (razão de chances) de desenvolver metástase linfática respectivamente de: 4,8 vezes para o CEC moderadamente diferenciado; e 1,5 vezes para cada centímetro de aumento no diâmetro do carcinoma primário. Maior espessura e invasão sangüínea foram co-variáveis dependentes. O cálculo do risco individual revelou que tanto para o CEC T1/T2 de língua oral e soalho, bem diferenciado e com espessura a partir de 1cm, assim como para o CEC de laringe (não glótico) com diâmetro acima de 1,3cm, o risco de metástase foi maior de 20%, para esta casuística. Conclusão: O grau de diferenciação e o maior diâmetro do CEC de VADS foram variáveis independentes preditivas da ocorrência de metástase linfática cervical. O risco individual de metástase pôde ser calculado em função dessas características, segundo o modelo logístico.

Introduction: the elective neck dissection is indicated for head and neck squamous cell carcinoma (SCC) with metastasis risk higher than 20% in epidemiological investigations, but it remains controversial in some situations. To determine the individual risk to develop node metastasis would allow the surgeons to offer a more adequate treatment case by case. Objective: to verify if it is possible to obtain an individual risk prediction model based on clinical and pathological features presented by patients with SCC of the upper aerodigestive tract. Patients and methods: retrospective longitudinal case-control study of 209 patients treated from August 2002 to January 2007, divided into two groups: 128 cases with and 81 without node metastasis followed up more than 12 months. The clinical and pathological characteristics of the primary tumor were compared between the groups and analyzed by the logistic regression model. Results: Diameter and histological grade were independent predictive variables of node metastasis risk (odds ratio = 4.8 for moderately, compared to well differentiated carcinoma; 1.5 per centimeter of primary carcinoma diameter). Thickness and vascular invasion were covariates related to them. The logistic prediction model revealed that the risk of node metastasis was higher than 20% for T1/T2 well differentiated SCC of the oral tongue and floor of mouth with thickness larger than 1.0cm. Laryngeal SCC (except glottic) with diameter smaller than 1.3cm presented less than 20% of risk. Conclusion: histological grade and diameter of the upper aerodigestive tract SCC were independent predictive variables of the neck node metastasis. The individual risk could be calculated in function of these factors by the logistic regression model.

Hipocalcemia e hipoparatireoidismo clínico após tireoidectomia total / Hypocalcemia and clinical hypoparathyroidism after total thyroidectomy

OBJETIVO: O hipoparatireoidismo que se sucede à tireoidectomia total é uma complicação relativamente freqüente, porém, em geral, assintomática. O presente estudo foi realizado a fim de correlacionar níveis séricos pós operatórios de cálcio com sinais e sintomas de hipocalcemia. MÉTODO: Cinqüenta e sete pacientes submetidos à tireoidectomia total foram estudados retrospectivamente na Disciplina de Cirurgia de Cabeça e Pescoço do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo. A dosagem sérica de cálcio, total ou ionizado,foi correlacionado com a presença, ou não, de sinais e sintomas de hipocalcemia, no pós-operatório imediato e tardio. RESULTADOS: A hipocalcemia precoce ocorreu em 37 por cento dos casos e em 18 por cento na fase tardia. Após seis meses da cirurgia, 50 por cento dos pacientes sintomáticos não eram hipocalcêmicos e do total de hipocalcêmicos 57 por cento eram assintomáticos. CONCLUSÕES: A avaliação clínica exclusiva pós-operatória não se mostrou confiável para o diagnóstico de hipocalcemia. A dosagem de cálcio deve ser feita como rotina após tireoidectomias totais.

BACKGROUND: Hypoparathyroidism after total thyroidectomy is a common complication although the majority of cases are asymptomatic. The present study was prompted in order to correlate postoperative serum calcium levels and clinical signs and symptoms of hypocalcemia. METHODS: Fifty-seven patients operated on for total thyroidectomy were retrospectively studied at Hospital das Clínicas of São Paulo University. Serum calcium levels were measured 48 hours and six months after surgery and were correlated with signs or symptoms of hypocalcemia. RESULTS: Transient hypocalcemia occurred in 37 percent and permanent hypocalcemia in 18 percent. After six months, 50 percent of symptomatic patients were not hypocalcemic and 57 percent of hypocalcemic patients were asymptomatic. CONCLUSION: The diagnosis of hypocalcemia after total thyroidectomy based solely on clinical evaluation is not reliable; therefore, serum calcium levels should be monitored routinely after total thyroidectomies.

Salivary gland tumors in a Brazilian population: a retrospective study of 124 cases

Salivary gland tumors constitute a highly heterogeneous histopathologic group. There are few epidemiological studies of large series of benign and malignant salivary gland tumors in Brazil. MATERIAL AND METHODS: Hospital records of 124 patients with salivary gland tumors diagnosed from January 1993 to December 1999 were reviewed. The patients were analyzed according to gender, age, size, location, and histopathology of the tumor. RESULTS AND CONCLUSIONS: Patients with benign and malignant tumors presented with a mean age of 47.7 and 48.8 years, respectively. The frequency of benign tumors was 80 percent (n = 99) and malignant tumors 20 percent (n = 25). Tumors were localized in the parotid gland 71 percent (n = 88), in the submandibular gland 24 percent (n = 30), and in the minor salivary glands 5 percent (n = 6). The most common benign tumors were pleomorphic adenoma in 84 percent (n = 84) and Warthin's tumor in 13 percent (n = 13). Among malignant tumors, mucoepidermoid carcinoma was the most common in 52 percent (n = 13), adenoid cystic carcinoma occurred in 20 percent (n = 5), and carcinoma ex pleomorphic adenoma was detected in 12 percent (n = 3)

Carcinoma folicular de tireóide: estudo retrospectivo / Follicular thyroid carcinoma: retrospective study

OBJETIVOS: Abordar o diagnóstico, tratamento e evolução do carcinoma folicular da tireóide. MÉTODOS: Análise retrospectiva dos dados de 38 pacientes submetidos à tireoidectomia por carcinoma folicular puro, num período de 10 anos no HC-FMUSP. O tempo médio de seguimento foi de três anos e três meses. Nove pacientes eram do sexo masculino (23,7 por cento) e 29 do sexo feminino (76,3 por cento), com idades entre 19 e 87 anos (média=49,5). RESULTADOS: Em 17 (58,6 por cento) dos doentes, observou-se nódulo único à ultra-sonografia, e 23 (79,3 por cento) tinham nódulos frios à cintilografia. Sintomatologia esteve presente em 33 pacientes (86,8 por cento). A punção aspirativa por agulha fina (PAAF), realizada em 27 pacientes, revelou padrão folicular em 24 (88,9 por cento), carcinoma papilífero em 2 (7,4 por cento) e bócio em 1 (3,7 por cento). Tireoidectomia total foi o tratamento final em 34 pacientes e esvaziamento cervical foi realizado em três casos. Apenas 5 (13,1 por cento) obtiveram confirmação diagnóstica ao exame de congelação intra-operatória. Houve 2 (5,2 por cento) óbitos pela doença e 5 (13,1 por cento) pacientes apresentam-se vivos com doença. O aumento da tireoglobulina (TG) correlacionou-se com o aparecimento de metástase em 100 por cento dos casos. CONCLUSÕES: Concluímos que pacientes com carcinoma folicular de tireóide geralmente apresentam-se com nódulo único ou predominante ao primeiro exame, cuja PAAF é de padrão folicular. O exame de congelação raramente confirma o diagnóstico. Em nosso serviço, o tratamento de escolha é a tireoidectomia total, permitindo um seguimento mais adequado e confiável do paciente e prevenindo o crescimento de lesões subclínicas no lobo contralateral. A evolução geralmente é favorável.

BACKGROUND: Unlike papillary carcinoma, there are limited data regarding diagnosis, treatment and follow-up of patients with follicular thyroid carcinoma. METHODS: We retrospectively analyzed data on 38 patients submitted to thyroidectomy for exclusive follicular carcinoma over a 10 years period. Mean follow-up was 39 months (114 months the longest). Nine patients were males (23,7 percent) and 29 females (76,3 percent). Mean age was 49.5 (19 to 87 years). RESULTS: Thirty-three (86,8 percent) patients presented at least one symptom such as dyspnea, dysphagia or hoarseness. Seventeen (58,6 percent) patients had a solitary nodule shown by ultrasonography and 23 (79,3 percent) had "cold" nodules by scintigraphy. Twenty-seven patients underwent were submitted to fine-needle aspiration biopsy (FNA), which revealed a follicular neoplasm (benign or malignant) in 24 (88,9 percent) patients, goiter in 1(3,7 percent) and papillary carcinoma in 2 cases (7,4 percent). Total thyroidectomy was the final treatment in 34 patients and neck dissection operation was required in 3 cases. Only 13,1 percent of the patients were diagnosed as having follicular carcinoma by intraoperative frozen section. Two patients died from the tumor and 5 patients remain alive with the tumor all of them with distant metastasis. Elevation of serum levels of thyroglobulin correlated with metastasis in 100 percent of those cases. CONCLUSIONS: We conclude that follicular thyroid carcinoma usually presents as a solitary nodule diagnosed as a follicular neoplasm by FNA biopsy. Intra-operatory frozen section rarely confirms the diagnosis. O treatment of choice for thyroid follicular cancer total thyroidectomy followed by complementary therapy (radioiodine therapy) if necessary. We advocate total thyroidectomy because it is assumited with a better follow-up and avoids growth of subclinical lesions on the opposite lobe. Outcome is good in the majority of cases.

Carcinoma papilífero de tireóide em doença de graves / Papillary carcinoma in graves'disease

OBJETIVO: Verificar a incidência de carcinoma papilífero associado à doença de Graves e sua evolução. MÉTODO: Estudamos retrospectivamente os prontuários de 90 pacientes com doença de Graves submetidos a tratamento cirúrgico nos últimos 13 anos. RESULTADOS: Encontramos carcinoma papilífero de tireóide em sete pacientes (7,8 por cento), sendo cinco mulheres e dois homens, com idade média de 43 anos. Em apenas dois casos havia diagnóstico prévio. O tratamento foi tireoidectomia total em cinco casos. Na evolução, apenas um paciente apresentou metástase mediastinal detectada à pesquisa de corpo inteiro. O tempo de seguimento médio foi de 39 meses, estando todos os pacientes vivos e sem sinais de doença. CONCLUSÃO: Nossos dados confirmam a baixa incidência de carcinoma papilífero em doença de Graves, e sugerimos o tratamento cirúrgico precoce em pacientes com nódulos no bócio difuso tóxico.

BACKGROUND: The aim of the present study is to evaluate the incidence of papillary carcinoma in Graves' disease and it's clinical course. METHOD: We retrospectively studied 90 patients with Graves' disease operated on the last 13 years. RESULTS: Seven had papillary cancer (7,8 percent) and five were females. Only two of them had previous diagnosis. Total thyroidectomy was performed in five patients. Only one developed mediastinal metastasis. Average follow-up was 39 months, and all patients are alive and disease-free. CONCLUSIONS: Our data are in agreement with literature reports and we recommend early surgical treatment for patients with nodular diffuse toxic goiter.

Validade da punção biópsia por agulha fina nas doenças da glândula parótida / Fine needle aspirative biopsy in parotid gland diseases

OBJETIVO: Avaliar o método de punção biópsia aspirativa por agulha fina (PBAAF), técnica relativamente simples, de conhecida importância em cirurgia de cabeça e pescoço. Sua indicação em doenças das glândulas salivares, no entanto, especialmente na parótida, ainda é muito controversa na literatura. O diagnóstico pela PBAAF permite o adequado planejamento terapêutico e preparo do paciente. Muitos, porém, alegam que seu emprego acrescenta muito pouco à conduta terapêutica, além de ser procedimento doloroso e elevar o custo do tratamento. MÉTODO: Os autores analisaram os prontuários de 247 pacientes submetidos a parotidectomias, realizadas entre 1986 e 1998, comparando a punção aspirativa por agulha fina com o anatomopatológico definitivo. Isso foi possível em 211 casos. Houve predomínio do sexo feminino, com idade variando de dez a 84 anos. RESULTADOS: Os tumores benignos foram os mais prevalentes, correspondendo a 85,3 por cento dos casos, com predomínio do adenoma pleomórfico. A punção por agulha fina permitiu diferenciar tumores benignos de malignos em 165 casos (78,1 por cento) e acertou o diagnóstico histológico em 77,6 por cento. CONCLUSÕES: Concluímos que a PBAAF é um método eficiente e simples que fornece ao cirurgião diagnóstico das neoplasias na grande maioria das vezes e deve fazer parte, sempre que possível, da documentação pré-operatória.

BACKGROUND: Fine needle aspirative biopsy (FNAB) is an easy and reliable diagnotic method for head and neck tumors. However, its indication in salivary gland diseases is controversial. The knowledge of the histological tumor type allows a better therapeutic planning. On the other hand, for some authors, FNAB is a painful procedure that increases cost with little impaction treatment decision. METHODS: This is a retrospective study, including 247 cases of parotidectomies performed, from 1986 to 1998. We compared FNAB to histopathological diagnosis, in 211 patients in which comparison was possible. RESULTS: There were 57.8 percent female patients. Eigthy five percent were benign tumors, most of them pleomorfic adenoma. FNAB made a correct distinction between benign and malignant tumors in 165 cases, offering an exact histological diagnosis in 77.6 percent. CONCLUSIONS: FNAB is a reliable, sensitive and specific diagnostic method. Based in to our experience, we recommend its use.

The importance of the ligation of the inferior thyroid artery in parathyroid function after subtotal thyroidectomy

We prospectively studied the effects of the ligation of the inferior thyroid artery (ITA) on postoperative hypoparathyroidism in 48 patients who underwent functional subtotal thyroidectomy. Patients were randomized into two groups: A, with bilateral ligation of the ITA and B, without ligation of the ITA. Parathyroid function was checked preoperatively and after surgery by clinical examination and measurement of total calcium, intact PTH, urinary calcium, and AMPc. RESULTS: A significant incidence of postoperative hypocalcemia occurred: 17 percent in group A and 13 percent in B on the 4th postoperative day. Six months later, the incidence was 5 percent in Group A and 0 percent in Group B. These differences were not statistically significant between the two groups, and neither were any of the other clinical and laboratory observations. CONCLUSION: The ligation of the ITA was not an important causal factor for the occurrence of postoperative hypocalcemia after subtotal thyroidectomy