Is there a relationship between preoperative cytological diagnosis and evolution in patients with differentiated thyroid carcinoma? A retrospective study

ABSTRACT Objective: Cytological analysis and Bethesda classification of thyroid nodules is the standard method of diagnosing differentiated thyroid carcinoma (DTC). However, even for nodules with a non-malignant cytological diagnosis, there is a not insignificant risk of cancer. There are doubts whether this lack of certainty would influence patient prognosis. Our aim was to compare patients with DTC, classified according to the preoperative cytological diagnosis, regarding their evolution. Subjects and methods: A retrospective study was carried out with 108 DTC patients submitted to total thyroidectomy (TT) between 2009 and 2015, divided into three groups according to preoperative cytological diagnosis (Bethesda classification): classes I/II, III/IV, and V/VI. Groups were compared for evolution considering response to treatment at last evaluation as well as time disease free. Statistical analysis used ANOVA, chi squared, and Kaplan-Meier curves with p<0.05 considered significant. Results: Groups differed for time between nodule puncture and TT [in months; V/VI (2.35 ± 2.48) < III/IV (7.32 ± 6.34) < I/II (13.36 ± 8.9); p < 0.0001]. There was no significant difference between groups for evolution at final evaluation (disease free status; classes I/II: 71.4%; classes III/IV: 60%; classes V/VI: 66.6%; p = 0.7433), as well as time disease free (in months; classes I/II: 34.57 ± 25.82; classes III/IV: 38.04 ± 26.66; classes V/VI: 30.84 ± 26.34; p = 0.3841). Conclusions: DTC patients classified according to preoperative cytological diagnosis did not differ for evolution. Although patients with non-malignant cytological diagnoses were submitted to TT later, this did not affect the evolution of the cases.

Gnathostomiasis acquired after consumption of raw freshwater fish in the Amazon region: a report of two cases in Brazil

Abstract Gnathostomiasis is a parasitic zoonosis caused by the helminth Gnathostoma spp., acquired through the consumption of raw or undercooked contaminated aquatic animals.The disease is endemic in Southeast Asia and Central America. Two male patients, both middle-aged, presented with single itchy erythemato-edematous plaques on the anterior thorax and left flank. Both had consumed raw fish in the Amazon region. The clinical and epidemiological examinations suggested gnathostomiasis, and treatment with albendazole caused total regression of the lesions. Health teams should be familiar with the disease to provide correct diagnosis. The control strategy should be based on health education for the population.

Contribution to characterization of skin field cancerization activity: morphometric, chromatin texture, proliferation, and apoptosis aspects,

Abstract Background: A skin field cancerization is a cutaneous area with subclinical changes resultant from chronic sun exposure, with a higher predisposition to development of pre-neoplastic and neoplastic lesions. So far, there are no well-defined objective parameters that can indicate their degree of activity. Objectives: To describe and compare morphometric aspects and expression of factors related to apoptosis and cell proliferation in actinic keratosis (AK), in both photoexposed and photoprotected epidermis. Methods: A cross-sectional study of patients with actinic keratosis in the forearms, biopsied at two points: the actinic keratosis and the axillary region. The biopsies of the actinic keratosis, perilesional area, and axilla were evaluated through keratinocyte intraepithelial neoplasia (KIN), and immunohistochemistry of p53, survivin, and Ki67. Nuclear morphometry of basal layer cells was performed through digital image analysis: entropy, area, perimeter, Ra, fractal dimension, circularity, color intensity, and largest diameter. Results: There were 13 patients included and 38 actinic keratosis biopsied. In morphometry, 1039 nuclei were analyzed, of which 228 represented axillary skin, 396 demonstrated actinic keratosis, and 415 represented the perilesional area to the actinic keratosis. There was a significant difference (p < 0.05) in all variables tested for the topographies evaluated. A significant correlation was identified between nucellar morphometric elements, KIN, proliferation markers, and apoptosis. Joint patterns of p53, Ki67, and KIN discriminated the topographies sampled. Study limitations: This was a cross-sectional study with a small number of patients. Conclusions: There are patterns of proliferation, resistance to apoptosis, and different cellular morphometrics between photoprotected skin and photoexposed skin. The joint expression of p53, Ki67, and KIN can characterize skin field cancerization activity.

Case for diagnosis. Noninfectious suppurative panniculitis induced by mesotherapy with deoxycholate

Abstract A 28-year-old white female patient presented with multiple erythematous-to-violaceous, painful, suppurative nodules on the buttocks and thighs that appeared after two weeks of mesotherapy with deoxycholate, caffeine, sunflower liposomes, and sinetrol for localized fat. She was treated for atypical mycobacteriosis, but with no satisfactory response after antibiotic therapy. Bacterial, mycobacterial, and fungal culture were all negative. Histopathologic examination of the biopsy showed noninfectious suppurative panniculitis. It resolved after treatment with methotrexate, prednisone, and hydroxychloroquine. This report highlights the rarity of this complication, the importance of its early recognition, and differentiation with atypical fast growing mycobacterioses.

Lepromatous leprosy, melanoma, and basal cell carcinoma: clinical-histopathologic association

Abstract Cutaneous neoplasms frequently occur in leprosy, but there are few reports of the coexistence of leprosy and basal cell carcinoma in the same lesion. This case reports a 49-year-old male with an ulcerated plaque on the right lateral nasal wall, bright papules on the sternal region, and a blackened plaque on the right temporal region. The nasal and temporal lesions were diagnosed by histopathology as basal cell carcinoma and melanoma, respectively. The sternal lesions were excised with the repair of the "dog ear" which histopathological examination showed macrophages in the dermis parasitized with acid-fast bacilli, confirming the diagnosis of lepromatous leprosy with Fite-Faraco staining. This case report highlights the importance of referring the dog-ear specimen for histopathologic analysis.

American tegumentary leishmaniasis: severe side effects of pentavalent antimonial in a patient with chronic renal failure

Abstract: Pentavalent antimonials are the first-line drug treatment for American tegumentary leishmaniasis. We report on a patient with chronic renal failure on hemodialysis who presented with cutaneous lesions of leishmaniasis for four months. The patient was treated with intravenous meglumine under strict nephrological surveillance, but cardiotoxicity, acute pancreatitis, pancytopenia, and cardiogenic shock developed rapidly. Deficient renal clearance of meglumine antimoniate can result in severe toxicity, as observed in this case. These side effects are related to cumulative plasma levels of the drug. Therefore, second-line drugs like amphotericin B are a better choice for patients on dialysis.

The first postoperative-stimulated serum thyroglobulin is a prognostic factor for thyroid microcarcinomas / A primeira dosagem sérica de tireoglobulina estimulada pós-operatória é um fator prognóstico para os microcarcinomas da tireoide

Abstract Introduction: Endogenous thyroid-stimulating hormone-stimulated thyroglobulin collected after total thyroidectomy is a useful predictor of better prognosis in patients with differentiated thyroid carcinomas in general, but studies with microcarcinomas are scarce. Objective: To assess whether the first postoperative stimulated thyroglobulin measurement is a prognostic factor in patients with microcarcinoma. Methods: The medical data of 150 differentiated thyroid carcinoma patients were studied retrospectively, and 54 (36%) cases with microcarcinoma were selected. The first postoperative stimulated thyroglobulin (1st stimulated thyroglobulin), measured after thyroidectomy, initial presentation data, and microcarcinomas treatment were assessed regarding outcome. Worse prognosis was defined as neoplasm persistence/recurrence. Results: Persistence/recurrence occurred in 27.8% of the cases. These patients were identified according to the following parameters: receiving more than one 131iodine dose (100% vs. 0%; p < 0.0001); accumulated 131iodine dose (232.14 ± 99.09 vs. 144 ± 33.61 mCi; p < 0.0001); presented active disease in the last assessment (53.3% vs. 0%; p < 0.0001); follow-up time (103.07 ± 61.27 vs. 66.85 ± 70.14 months; p = 0.019); and 1st stimulated thyroglobulin (19.01 ± 44.18 vs. 2.19 ± 2.54 ng/dL; p < 0.0001). After multivariate logistic regression, only the 1stSTg [odds ratio = 1.242; 95% confidence interval: 1.022-1.509; p = 0.029] and follow-up time (odds ratio = 1.027; 95% confidence interval: 1.007-1.048; p = 0.007) were independent predictors of risk of persistence/recurrence. The cutoff point of 1.6 ng/dL for the 1st stimulated thyroglobulin was significantly associated with disease persistence/recurrence [area under the curve = 0.713 (p = 0.019)]. Conclusion: The first stimulated thyroglobulin predicted disease persistence/recurrence in patients with microcarcinoma.

Resumo Introdução: A tireoglobulina estimulada pelo hormônio tireoestimulante endógeno coletada após tireoidectomia total é um preditor útil de melhor prognóstico em pacientes com carcinomas diferenciados de tireoide em geral, mas os estudos com microcarcinomas são escassos. Objetivo: Avaliar se a primeira medida pós-operatória de tireoglobulina estimulada é um fator prognóstico em pacientes com microcarcinoma. Método: Os dados clínicos de 150 pacientes com carcinoma diferenciado de tireoide foram estudados retrospectivamente e 54 (36%) casos com microcarcinoma foram selecionados. A primeira dosagem de tireoglobulina estimulada (1a TgE) pós-operatória, medida após a tireoidectomia, os dados da apresentação inicial e tratamento do microcarcinoma foram avaliados quanto ao resultado. O pior prognóstico foi definido como a persistência/recorrência da neoplasia. Resultados: A persistência/recorrência ocorreu em 27,8% dos casos. Esses pacientes foram identificados de acordo com os seguintes parâmetros: receberam mais de uma dose de iodo131 (100% vs. 0%; p < 0,0001); dose acumulada de iodo131 (232,14 ± 99,09 vs. 144 ± 33,61 mCi; p < 0,0001); apresentou doença ativa na última avaliação (53,3% vs. 0%; p < 0,0001); tempo de seguimento (103,07 ± 61,27 vs. 66,85 ± 70,14 meses; p = 0,019); e 1ªTgE (19,01 ± 44,18 vs. 2,19 ± 2,54 ng/dL; p < 0,0001). Após a regressão logística multivariada, apenas a 1ª TgE [odds ratio = 1.242; intervalo de confiança de 95%: 1,022-1,509; p = 0,029] e tempo de seguimento (odds ratio = 1,027; intervalo de confiança de 95%: 1,007-1,048; p = 0,007) foram preditores independentes de risco de persistência/recorrência. O ponto de corte de 1,6 ng/dL para a 1a TgE foi significativamente associado à persistência/recidiva da doença [área abaixo da curva = 0,713 (p = 0,019)]. Conclusão: A 1ª dosagem sérica de tireoglobulina estimulada previu a persistência/recorrência da doença em pacientes com microcarcinoma.

Melanoma: clinical, evolutive and histopathological characteristics of a series of 136 cases

Abstract: BACKGROUND: The incidence of melanoma has been increasing in Brazil and all over the world. Despite improvements in diagnosis and treatment, mortality remains unchanged. OBJECTIVE: To associate clinical and histopathological aspects with the evolution of 136 cases of cutaneous melanoma. METHODS: Retrospective cohort study that analyzed all patients diagnosed with melanoma during the period from 2003 to 2011, with at least 4 years follow up. Archived slides were analyzed to study histopathological variables (Breslow, ulceration, mitoses and histological regression). Medical records were used to retrieve clinical variables (age, sex, localization, time of appearance, diameter) and progression (metastases or death). Association measures were assessed by statistical analysis. RESULTS: There was no statistically significant difference between groups according to age. Superficial spreading subtype showed lower Breslow (0.5mm) than acral lentiginous and nodular subtypes (2 and 4.6mm respectively), less ulceration and metastases (9.4% against 50 and 70.6%). Nodular subtype had higher mitoses' median (5.0/mm2) than superficial spreading and lentigo maligna (0.0/mm2, for both). Regression was more frequent in superficial spreading and lentigo maligna subtypes. There were only deaths by melanoma in the acral group, however, there were deaths for other reasons in groups superficial spreading one, acral lentiginous one and lentigo maligna two. STUDY LIMITATIONS: Use of medical records as a source of data to the study. CONCLUSIONS: Superficial spreading subtype presents better prognosis indicators. Histological subtype should be considered in follow-up and treatment protocols of patients with cutaneous melanoma.

Lymphoepithelioma-like carcinoma of the skin

Abstract: Primary cutaneous lymphoepithelioma-like carcinoma is a rare disease with low metastatic potential. Its morphologic and pathological features are similar to those of nasopharyngeal lymphoepithelial carcinoma. We report the case of a 60-year-old man with an infrapalpebral pearly papule, measuring 0.6 cm in diameter. The lesion was excised with a clinical hypothesis of basal cell carcinoma or squamous cell carcinoma. Histopathological analysis revealed a malignant neoplasm with syncytial arrangement of cells with vesicular nuclei, associated with dense lymphocytic infiltrate. Immunohistochemistry revealed cytokeratin-positive cells (AE1/AE3) and p63 protein, indicating epithelial histogenesis and squamous differentiation. A negative Epstein-Barr virus test result was achieved by immunohistochemistry. Primary lymphoepithelioma-like carcinoma of the skin is a differential diagnosis of lesions with prominent inflammatory infiltrates.

Melanoma primário múltiplo sincrônico em mulher jovem: relato de caso e revisão da literatura / Multiple synchronous primary melanoma in young women: case report and literature review

Contexto: Melanoma corresponde a apenas 3% dos cânceres da pele, porém, tem alta letalidade. Pacientes diagnosticados com melanoma têm risco de 1% a 8% de desenvolver um segundo melanoma, o que se denomina de melanoma primário múltiplo (MPM). Até 30% dos casos de MPM são sincrônicos. Descrição do caso: Mulher, de 39 anos, com duas lesões melanocíticas no membro inferior. Exame histopatológico evidenciou serem ambos melanomas primários, sendo, portanto, diagnosticados como MPM sincrônicos. Discussão: MPM sincrônico é raro e há poucos relatos na literatura, sendo as características da doença pouco conhecidas pelos dermatologistas. Principais fatores de risco para desenvolvimento de MPM são história pessoal de nevo displásico e antecedente familiar de melanoma. Conclusões: Pacientes com MPM devem ter seguimento clínico regular minucioso, por apresentarem maior risco que a população geral de desenvolver outros melanomas. Com o aumento da incidência do melanoma, casos de MPM devem tornar-se mais frequentes na prática clínica.

Granuloma facial mimetizando carcinoma basocelular / Facial granuloma mimicking basal cell carcinoma

Contexto: Granuloma facial é dermatose rara, benigna, localizada e crônica, com características histopatológicas de vasculite leucocitoclástica. Seu diagnóstico muitas vezes é um desafio para o dermatologista, pois a morfologia da lesão pode simular outras doenças dermatológicas, como carcinoma basocelular. Descrição do caso: Mulher, de 45 anos, fototipo 1 com lesão nasal assintomática há um ano, apresentou-se para exame clínico e dermatoscópico. A lesão assemelhava-se ao carcinoma basocelular, porém o exame histopatológico confirmou tratar-se de granuloma facial. Discussão: As lesões de granuloma facial localizam-se principalmente na face e fazem diferencial com eritema elevatum diutinum,carcinoma basocelular, linfoma cutâneo, pseudolinfoma, entre outros. O exame anatomopatológico é característico, com a presença de infiltrado inflamatório misto predominantemente perivascular. Conclusões: O diagnóstico de granuloma facial deve ser sempre lembrado diante de lesões faciais que se apresentam como placas eritêmato-acastanhadas, sendo necessário, além de exame clínico e dermatoscópico, a avaliação histopatológica.

Aryl hydrocarbon receptor overexpression in miniaturized follicles in female pattern hair loss

Abstract The etiopathogenesis of female pattern hair loss is still poorly understood. In addition to genetic and hormonal elements, environmental factors could be involved. The aryl hydrocarbon receptor is expressed in keratinocytes and can be activated by environmental pollutants leading to alterations in the cell cycle, inflammation, and apoptosis. Here we demonstrate the overexpression of nuclear aryl hydrocarbon receptors in miniaturized hair follicles in female pattern hair loss.

Fatores que levam à negligência quanto aos cânceres da pele não melanoma / Factors leading to neglect of non-melanoma skin cancers

Contexto: Câncer da pele não melanoma é o mais prevalente no Brasil, sendo o carcinoma basocelular (CBC) e o espinocelular (CEC) os subtipos de maior ocorrência. Apesar das estratégias de conscientização da população sobre os riscos da fotoexposição e da campanha anual da Sociedade Brasileira de Dermatologia para diagnóstico precoce e capacitação dos médicos da atenção primária em saúde para diagnóstico do câncer da pele, ainda são muitos os casos de diagnóstico tardio dos cânceres da pele, dificultando a realização do tratamento adequado e comprometendo, inclusive, o prognóstico do paciente. Descrição dos casos: Caso 1 ­ homem de 86 anos, analfabeto, com úlcera inguinal esquerda há dois anos, de 15 centímetros de diâmetro, friável, bem delimitada. Biópsia incisional revelou: CBC. Realizada exérese com linfadenectomia locorregional. O paciente evoluiu bem, mas perdeu seguimento. Caso 2 ­ mulher de 93 anos, analfabeta, hipertensa e diabética, há três anos com tumoração de oito centímetros, friável, localizada na fronte e glabela. Biópsia incisional revelou: CEC. Tendo em vista a idade avançada e suas comorbidades, optou-se por realização de radioterapia. Entretanto, a paciente perdeu seguimento. Discussão: Negligência quanto aos cânceres da pele não melanoma se relaciona, principalmente, a pobreza e baixo nível educacional do paciente, hábitos inadequados de higiene, desconhecimento sobre tumores de pele, idade avançada, moradia longe dos centros urbanos e ausência de dor. Conclusões: Ocorrência de câncer da pele de grandes dimensões ainda é uma realidade no Brasil. Negligência sobre os cânceres de pele e o atraso no diagnóstico/conduta pode alterar a história natural da doença, aumentando os riscos de recidiva, metástase e óbito.

Initial basal cell carcinomas diagnosed in the National Campaign for Skin Cancer Prevention are smaller than those identified by the conventional medical referral system

Abstract: BACKGROUND: Basal cell carcinoma is the malignant tumor most often diagnosed in the National Campaign for Skin Cancer Prevention (NCSCP). Little is known about the profile of these lesions compared to the profile of lesions diagnosed by conventional routes of public dermatological care. OBJECTIVE: To identify if basal cell carcinomas identified in prevention campaigns and referred to surgery are smaller than those routinely removed in a same medical institution. METHODS: Cross-sectional study including tumors routed from 2011-2014 campaigns and 84 anatomopathological reports of outpatients. RESULTS: The campaigns identified 223 individuals with suspicious lesions among 2,531 examinations (9%), with 116 basal cell carcinomas removed. Anatomopathological examinations revealed that the primary lesions identified in the national campaigns were smaller than those referred to surgery by the conventional routes of public health care (28 [13-50] x 38 [20-113] mm2, p <0.01). On the other hand, after a mean follow-up of 15.6 ± 10.3 months, 31% of cases identified in campaigns showed new basal cell carcinoma lesions. STUDY LIMITATIONS: Retrospective study and inaccuracies in the measurements of the lesions. CONCLUSIONS: The NCSCP promotes an earlier treatment of basal cell carcinomas compared to patients referred to surgery by the conventional routes of public health care, which can result in lower morbidity rates and better prognosis.

Ultrasound as a safe and reliable guidance for subarachnoid puncture in rabbits

Abstract Purpose: To evaluate a model for studying the toxicity in nervous tissue and meninges using ultrasound to guide needle insertion into the subarachnoid space of rabbits, with the objective of avoiding injuries triggered by the puncture and by intraneural injection of solutions. Methods: Forty-five adult female rabbits were divided into 3 groups (G): G1 underwent subarachnoid puncture, G2 underwent subarachnoid injection of saline solution and G3 underwent subarachnoid injection of 0.5% hyperbaric bupivacaine. A needle was inserted into the S1-S2 subarachnoid space guided by ultrasound. The sensitivity and motility of the animals were evaluated for 3 days, after which the animals were sacrificed for removal of lumbar and sacral portions of the spinal cord for histological examination by light microscopy and immunohistochemistry. Results: All animals had motor function and pain sensitivity on the evaluation period. No animal had complication during or after the procedures. Conclusion: Ultrasound is a useful and safe method for the correct identification of the subarachnoid space of rabbits.

Exenteração orbitária: série de casos / Orbital Exenteration: a series of cases

RESUMO Objetivo: Descrever os casos de exenteração orbitária de um hospital terciário brasileiro. Métodos: Estudo retrospectivo, envolvendo pacientes submetidos à exenteração orbitária no Hospital das Clínicas da Faculdade de Medicina de Botucatu, entre os anos de 1993 a 2016. As cirurgias foram realizadas sob anestesia geral, por equipe multidisciplinar composta por oftalmologistas, otorrinolaringologistas e cirurgiões de cabeça e pescoço. Resultados: Foram estudados 14 casos de exenteração orbitária, com média de idade de 63,36 ± 13,18 anos e nove homens (64,3%). Todas cirurgias foram realizadas para tratamento de tumores malignos, sendo mais frequente o carcinoma espinocelular (7 casos - 50,0%). Os sítios primários mais frequentes foram as pálpebras (50,0%), seguida pela conjuntiva (28,6%). A maioria das cirurgias foram do tipo exenteração estendida (57,1%), com cicatrização por granulação espontânea (64,3%). A sobrevida em 1 ano foi de 78,6% e em 5 anos de 71,4%. Conclusão: O carcinoma espinocelular foi a principal causa de indicação de exenteração orbitaria, sendo as pálpebras o sítio primário mais frequente. O procedimento mais realizado foi a exenteração estendida, com a grande maioria alcançando margens livres.

ABSTRACT Objective: To describe causes of orbital exenteration in a Brazilian tertiary hospital. Methods: A retrospective study was done, involving patients submitted to orbital exenteration at the Clinical Hospital of Botucatu Medical School, between the years of 1993 to 2016. The surgeries have been performed under general anesthesia, by a multidisciplinary team, composed by ophthalmologists, otolaryngologists and head and neck surgeons. Results: Fourteen cases of orbital exenteration occurred in the period of the study, with a mean age of 63.36 ± 13.18 years and nine were men (64.3%). All exenteration were due to malignant tumors, being more frequent the squamous cell carcinoma (7 cases - 50.0%). The most common primary sites were the eyelids (50.0%) followed by the conjunctiva (28.6%). The majority of the surgeries was extended exenteration type (57.1%) and most of the reconstructions was made by spontaneous granulation (64.3%). The survivor rate in 1 year was 78,6% and in 5 years was 71.4%. Conclusion: The main cause of orbital exenteration was squamous cell carcinoma and the most frequent primary site was the eyelids. Extended exenteration was necessary for the majority of cases, most of them with free margins.

Granuloma faciale: clinical, morphological and immunohistochemical aspects in a series of 10 patients

Abstract Granuloma faciale is a chronic, benign, cutaneous vasculitis with well-established clinical and morphological patterns, but with an unknown etiology. This study describes clinical and pathologic aspects of patients diagnosed with granuloma faciale. The authors analyzed demographic, clinical, morphological and immunohistochemical data from patients with a final diagnosis of granuloma faciale, confirmed between 1998 and 2012. There was a proportional and mixed inflammatory infiltrate, Grenz zones were present in almost all the samples. Immunophenotyping confirmed a higher intensity of T lymphocytes than B lymphocytes in thirteen samples, with a predominance of T CD8 lymphocytes in 64% of cases, in contrast to the literature, which indicates that the major component is T CD4 lymphocytes. All cases were positive for IgG4 but the majority (12/14) had less than 25% of stained cells. The pathogenesis of granuloma faciale remains poorly understood, making studies of morphological and immunohistochemical characterization important to better understand it.