Recommendations for head and neck surgical procedures during the COVID-19 pandemic

The coronavirus disease (COVID-19) pandemic, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has spread exponentially worldwide. In Brazil, the number of infected people diagnosed has been increasing and, as in other countries, it has been associated with a high risk of contamination in healthcare teams. For healthcare professionals, the full use of personal protective equipment (PPE) is mandatory, such as wearing surgical or filtering facepiece class 2 (FFP2) masks, waterproof aprons, gloves, and goggles, in addition to training in care processes. A reduction in the number of face-to-face visits and non-essential elective procedures is also recommended. However, surgery should not be postponed in the case of the most essential elective indications (mostly associated with head and neck cancers). As malignant tumors of the head and neck are clinically time sensitive, neither consultations for these tumors nor their treatment should be postponed. Postponing surgical treatment can result in a change in the disease stage and alter an individual's chance of survival. In this situation, planning of all treatments must begin with the request for, in addition to routine examinations, a nasal swab polymerase chain reaction for SARS-CoV-2 and chest computed tomography. Only if the results of these tests are positive or if fever or other symptoms suggestive of COVID-19 are present should the surgical procedure be postponed until the patient completely recovers. This is mandatory not only because of the risk of contamination of the surgical team but also because of the increased risk of postoperative complications and high risk of death. During this pandemic, the most effective safety measures are social distancing for the general public and the adequate availability and use of PPE in the healthcare field. The treatment of other chronic diseases, such as cancer, should be continued, as the damming of cases of these diseases will have a deleterious effect on the public healthcare system.

Biochemical, bone and renal patterns in hyperparathyroidism associated with multiple endocrine neoplasia type 1

Primary hyperparathyroidism associated with multiple endocrine neoplasia type I (hyperparathyroidism/multiple endocrine neoplasia type 1) differs in many aspects from sporadic hyperparathyroidism, which is the most frequently occurring form of hyperparathyroidism. Bone mineral density has frequently been studied in sporadic hyperparathyroidism but it has very rarely been examined in cases of hyperparathyroidism/multiple endocrine neoplasia type 1. Cortical bone mineral density in hyperparathyroidism/multiple endocrine neoplasia type 1 cases has only recently been examined, and early, severe and frequent bone mineral losses have been documented at this site. Early bone mineral losses are highly prevalent in the trabecular bone of patients with hyperparathyroidism/multiple endocrine neoplasia type 1. In summary, bone mineral disease in multiple endocrine neoplasia type 1related hyperparathyroidism is an early, frequent and severe disturbance, occurring in both the cortical and trabecular bones. In addition, renal complications secondary to sporadic hyperparathyroidism are often studied, but very little work has been done on this issue in hyperparathyroidism/multiple endocrine neoplasia type 1. It has been recently verified that early, frequent, and severe renal lesions occur in patients with hyperparathyroidism/multiple endocrine neoplasia type 1, which may lead to increased morbidity and mortality. In this article we review the few available studies on bone mineral and renal disturbances in the setting of hyperparathyroidism/multiple endocrine neoplasia type 1. We performed a meta-analysis of the available data on bone mineral and renal disease in cases of multiple endocrine neoplasia type 1-related hyperparathyroidism.

Surgical approach to medullary thyroid carcinoma associated with multiple endocrine neoplasia type 2

We briefly review the surgical approaches to medullary thyroid carcinoma associated with multiple endocrine neoplasia type 2 (medullary thyroid carcinoma/multiple endocrine neoplasia type 2). The recommended surgical approaches are usually based on the age of the affected carrier/patient, tumor staging and the specific rearranged during transfection codon mutation. We have focused mainly on young children with no apparent disease who are carrying a germline rearranged during transfection mutation. Successful management of medullary thyroid carcinoma in these cases depends on early diagnosis and treatment. Total thyroidectomy should be performed before 6 months of age in infants carrying the rearranged during transfection 918 codon mutation, by the age of 3 years in rearranged during transfection 634 mutation carriers, at 5 years of age in carriers with level 3 risk rearranged during transfection mutations, and by the age of 10 years in level 4 risk rearranged during transfection mutations. Patients with thyroid tumor >5 mm detected by ultrasound, and basal calcitonin levels >40 pg/ml, frequently have cervical and upper mediastinal lymph node metastasis. In the latter patients, total thyroidectomy should be complemented by extensive lymph node dissection. Also, we briefly review our data from a large familial medullary thyroid carcinoma genealogy harboring a germline rearranged during transfection Cys620Arg mutation. All 14 screened carriers of the rearranged during transfection Cys620Arg mutation who underwent total thyroidectomy before the age of 12 years presented persistently undetectable serum levels of calcitonin (<2 pg/ml) during the follow-up period of 2-6 years. Although it is recommended that preventive total thyroidectomy in rearranged during transfection codon 620 mutation carriers is performed before the age of 5 years, in this particular family the surgical intervention performed before the age of 12 years led to an apparent biochemical cure.

Post-surgical follow-up of primary hyperparathyroidism associated with multiple endocrine neoplasia type 1

The bone mineral density increments in patients with sporadic primary hyperparathyroidism after parathyroidectomy have been studied by several investigators, but few have investigated this topic in primary hyperparathyroidism associated with multiple endocrine neoplasia type 1. Further, as far as we know, only two studies have consistently evaluated bone mineral density values after parathyroidectomy in cases of primary hyperparathyroidism associated with multiple endocrine neoplasia type 1. Here we revised the impact of parathyroidectomy (particularly total parathyroidectomy followed by autologous parathyroid implant into the forearm) on bone mineral density values in patients with primary hyperparathyroidism associated with multiple endocrine neoplasia type 1. Significant increases in bone mineral density in the lumbar spine and femoral neck values were found, although no short-term (15 months) improvement in bone mineral density at the proximal third of the distal radius was observed. Additionally, short-term and medium-term calcium and parathyroid hormone values after parathyroidectomy in patients with primary hyperparathyroidism associated with multiple endocrine neoplasia type 1 are discussed. In most cases, this surgical approach was able to restore normal calcium/parathyroid hormone levels and ultimately lead to discontinuation of calcium and calcitriol supplementation.

Associação de carcinoma papilífero da tireóide e hiperparatireoidismo / Association of papillary thyroid carcinoma and hyperparathyroidism

OBJETIVO: A ocorrência de carcinoma papilífero da tireóide (CPT) em doentes com hiperparatireoidismo (HPT) suscita dúvidas quanto a ser apenas coincidência ou apresentar relação causal. O objetivo deste trabalho é verificar se a incidência de CPT em diferentes formas de HPT é semelhante entre si e à incidência de CPT em achados de necropsias, assim como em doentes submetidos à tireoidectomia na mesma região. MÉTODO: Os dados de 222 pacientes consecutivos tratados por HPT foram revistos e foi analisada a incidência de CPT. Os pacientes foram estratificados em HPT primário (107) e HPT secundário (115). Os laudos anatomopatológicos foram revistos, a incidência de CPT foi pesquisada e suas características nesses indivíduos foram estudadas. Esses dados foram comparados a dados encontrados em casos de necrópsia e em 89 casos de bócio compressivo/mergulhante. Empregou-se o teste exato de Fisher e o teste t não pareado. RESULTADOS: Os laudos foram passíveis de análise em 103 casos de HPT primário, com 10 pacientes com CPT (9,7 por cento) e em 111 portadores de HPT secundário, com três CPT associados (2,7 por cento). Houve diferença entre o HPT primário e HPT secundário (p=0,04). Essa diferença também foi significativa em relação aos 1 por cento de CPT achados em necrópsia na região (p=0,0001). Não houve diferença com relação à incidência de 11,2 por cento de CPT no grupo operado por compressão e também em relação às características dos tumores, apesar de haver 80 por cento de multicentricidade no CPT de doentes com HPT primário. CONCLUSÕES: A ocorrência de CPT em HPT primário é maior que em HPT secundário e que em achados de necropsia.

BACKGROUND: Association of papillary thyroid carcinoma (PTC) and hyperparathyroidism (HPT) has not been clearly defined. The incidence of PTC in different types of HPT and necropsy or patients submitted to thyroidectomy in the same region is analyzed to verify if this association is casual or not. METHODS: Data of 222 consecutive patients operated for HPT were reviewed and incidence of PTC was defined. Patients were analyzed as primary HPT (107) and secondary (115). The incidence of PTC was compared to that found in necropsy and to that observed in 89 patients with compressive multinodular goiter submitted to thyroidectomy. Statistical analysis included Fisher's exact test and Student's t test. RESULTS: Pathology reports were available in 103 cases of primary HPT, and in 10 patients PTC was detected (9.7 percent). In 111 secondary HPT patients, PTC was found in three (2.7 percent), with statistical significant difference between primary and secondary HPT (p=0.04). This difference was also significant of the 1 percent incidence of PTC found in necropsy in the same area (p=0.0001). No difference was observed in relation to the incidence of 11.2 percent of PTC found in patients operated for compressive goiter. Tumor characteristics were not statistically different, although multicentricity was detected in 80 percent of PTC of patients with primary HPT. CONCLUSION: The incidence of PTC was elevated in patients with primary HPT, in relation to necropsy or secondary HPT cases.

Consideraçöes sobre o tratamento cirúrgico do bócio nodular tóxico autônomo / Considerations about the surgical treatment of toxic autonomic nodular goiter

Alguns autores têm proposto a injeçäo percutânea de etanol, guiada por ultrassonografia, para tratamento do bócio nodular tóxico autônomo, ao invés de cirurgia ou radio-iodoterapia. A fim de oferecer elementos para a comparaçäo entre esses métodos terapêuticos, é apresentado o estudo retrospectivo de portadores de bócio nodular autônomo operados em 5 anos no Serviço de Cirurgia de Cabeça e Pescoço de um hospital de ensino. Foram analisados dados clínicos, laboratoriais, cirúrgicos e anatomopatológicos, além de duraçäo da operaçäo, resultados, complicaçöes e tempo de parmanência hospitalar. De 26 operados por bócio nodular autônomo, nesse período, e que tinham prontuários passíveis de análise, sete possuíam bócio uninodular. Todos eram mulheres, com idade média de 38 anos e sem outra doença associada. A ultrassonografia, realizada em seis, coincidiu com o achado operatório em 66 por cento dos casos e a punçäo biópsia aspirativa, feita em cinco, ofereceu conclusäo diagnóstica em 20 por cento. O diâmetro nodular médio foi de 3,7cm. A média do tempo cirúrgico, 122 minutos. O período médio de internaçäo, 1,7 dias. Foram realizadas nodulectomias e lobectomias. Näo houve complicaçäo perioperatória com a exceçäo de um caso de hipotireoidismo subclínico. Os nódulos eram benignos, mas em um houve associaçäo com microcarcinoma papilífero. A cirurgia, portanto, constitui método eficaz de tratamento dos bócios uninodulares, implica em baixa morbidade e na resoluçäo imediata da doença. Difere, assim, de métodos näo cirúrgicos, nos quais a literatura demonstra persistência de nodularidade e seqüelas.

Metastase cerebral de carcinoma papilifero de tireoide como apresentacao inicial da doenca: relato de caso e revisäo da literatura / Brain metastases from papillary thyroid carcinoma: case report

O carcinoma papilifero e a neoplasia maligna da tireoide mais comum (70 a 80 por cento), apresentando habitualmente um curso clinico indolente e bom prognostico. Metastases usualmente ocorrem para linfonodos regionais, incluindo os cervicais e mediastinais superiores. Metastase a distancia e incomum, sendo pulmao e ossos os locais mais frequentes. Metastases cerebrais sao extremamente raras, descritas em cerca de 1 por cento dos carcinomas papiliferos da tireoide (CPT). Apresentamos, nesse artigo, os detalhes clinicos de um caso com manifestacao neurologica inicial devido a metastase cerebral de CPT, histologicamente comprovada. Tambem apresentamos uma revisao da literatura que trata dessa rara entidade clinica