Microcarcinoma papilar de tiroides: vigilancia activa. Revisión de la bibliografía / Papillary thyroid microcarcinoma: active surveillance. Literature review

El cáncer de tiroides ha aumentado en incidencia, sin embargo, la mortalidad se mantiene estable. Muchas de estas lesiones son a expensas de un microcarcinoma papilar de tiroides definido por la OMS como aquel carcinoma papilar de tiroides que en su diámetro máximo no sobrepasa los 10 mm. El avance de la imagenología sobre todo la ecografía de alta resolución y el hallazgo en pieza de anatomía patológica por lesiones benignas son las principales causas del aumento en el diagnóstico de esta entidad. La vigilancia activa surge entonces como alternativa de manejo para pacientes portadores de microcarcinoma papilar con bajo riesgo de progresión, obteniendo resultados oncológicos comparables. Independiente de su tratamiento el pronóstico de estos pacientes es excelente con sobrevida cercana al 100% en 10 años. A pesar de lo dicho la morbilidad de las distintas opciones terapéuticas es muy distinta. Será fundamental buscar elementos clínicos y paraclínicos que permitan tomar una decisión práctica, con el fin de determinar qué pacientes con microcarcinomas papilares que podrán entrar en un protocolo de vigilancia activa. Esta revisión pretende examinar la bibliografía publicada al respecto como alternativa de manejo, y su eventual aplicación en Uruguay.

Thyroid cancer has increased in incidence; however, mortality remains stable. Many of these lesions are at the expense of papillary thyroid microcarcinoma defined by the WHO as papillary thyroid carcinoma that in its maximum diameter does not exceed 10 mm. The advance of imaging, especially high-resolution ultrasound and the finding of benign lesions in pathological anatomy specimens are the main causes of the increase in the diagnosis of this entity. Active surveillance arises then as a management alternative for patients with papillary microcarcinoma with low risk of progression, obtaining comparable oncologic results. Regardless of their treatment, the prognosis of these patients is excellent with a survival rate close to 100% in 10 years. In spite of what has been said, the morbidity of the different therapeutic options is very different. It will be essential to look for clinical and paraclinical elements that will allow making a practical decision, in order to determine which patients with papillary microcarcinomas will be able to enter an active surveillance protocol. This review aims to examine the literature published on this subject as a management alternative, and its eventual application in Uruguay.

Variante células altas de cáncer papilar de tiroides: reporte de casos / Tall cell variant of papillary thyroid cancer: case report

El cáncer papilar constituye aproximadamente el 80% de todos los casos de cáncer de tiroides y el 85% de los tumores diferenciados. La variante de células altas representa el 1,3 al 12% del cáncer papilar siendo la variante agresiva más común de estos tumores. Posee un comportamiento agresivo, con mayor incidencia de invasión extratiroidea, linfovascular y metástasis a distancia, responsables de tasas de recurrencia más altas y peor pronóstico. Los casos aquí reportados reflejan las características que hacen sospechar mayor agresividad tumoral, desde el diagnóstico. Describimos dos pacientes de sexo femenino, entre 40 y 50 años, con historia de corta evolución, cuya presentación fue con síntomas de compresión locorregional y adenopatías metastásicas en cuello. Con hallazgos ecográficos e intraoperatorios de relevancia en cuanto la agresividad tumoral que hicieron sospechar la presencia de una variante agresiva del cáncer papilar. La histopatología de la variante de células altas posee una base molecular diferente respecto al papilar clásico que le confiere mayor morbi-mortalidad, constituyendo un factor de pronóstico independiente para la recurrencia. El tratamiento quirúrgico es la tiroidectomía total con vaciamiento profiláctico de los ganglios linfáticos centrales y eventualmente vaciamiento lateral de cuello según valoración preoperatoria, con posterior ablación postoperatoria de restos tiroideos mediante yodo radiactivo.

Papillary cancer constitutes approximately 80% of all thyroid cancer cases and 85% of differentiated tumors. The tall cell variant represents 1.3 to 12% of papillary cancers, being the most common aggressive variant of these tumors. It has an aggressive behavior, showing a higher incidence of extrathyroid and lymphovascular invasion and distant metastasis, responsible for higher recurrence rates and a worse prognosis. The cases reported here reflect characteristics that make us suspect tumor aggressiveness. These are female patients, between 40 and 70 years old, with a history of short evolution. They present locoregional symptoms or metastatic adenopathies, with ultrasound and intraoperative findings of relevance in terms of tumor aggressiveness that led to the suspicion of the presence of an aggressive variant of papillary cancer. The histopathology of the tall cell variant has a different molecular basis that confers its own morbidity and mortality, being an independent prognostic factor for recurrence. Total thyroidectomy is recommended with prophylactic dissection of the central lymph nodes and eventually lateral neck dissection according to preoperative evaluation followed by postoperative ablation with radioactive iodine.

Importance of ELABELA in the differential diagnosis of benign and malignant lesions of the thyroid gland

ABSTRACT Objective: This study investigated whether ELABELA plays a role in the differential diagnosis of benign and malignant lesions of the thyroid gland. Subjects and methods: Of the 87 patients included in the study, 12 had undergone surgery for benign thyroid diseases, 30 had papillary thyroid cancer without invasion and/or lymph node metastasis in the surrounding tissues in the pathology report, and 45 had papillary thyroid cancer with invasion and/or lymph node metastasis in the surrounding tissues. Results: In the macrocarcinoma group, the proportion of patients with severe ELABELA staining (61.1%) was higher than that in the adenoma (50%) and microcarcinoma (23.8%) groups, while the proportion of those with mild to moderate staining was lower (p < 0.001). In the microcarcinoma group, the proportion of patients with severe staining was lower than that in the adenoma group, while the proportion of those with mild to moderate staining was higher (p < 0.001). In papillary thyroid carcinomas, the rates of moderate and severe staining in the classical variant, mild staining in the follicular variant, severe staining in the classical + follicular variant, and severe staining in the oncocytic variant were higher. Conclusion: To the best of our knowledge, this study is the first to be conducted on this subject. In this study, ELABELA was not found to be significant in the differential diagnosis of benign and malignant lesions of the thyroid gland. In papillary thyroid carcinomas, severe ELABELA staining patterns were more common in macrocarcinoma patients than in microcarcinoma patients.

Cáncer Papilar en Quiste Tirogloso. Caso Clínico y Revisión de la literatura / Papillary Cancer in Tirogloso Cyst. Case report and review of literature

INTRODUCCIÓN: Los quistes tiroglosos son las lesiones más comunes de la línea media cervical y se ha descrito el carcinoma papilar de tiroides en el 1%. Debido a su baja incidencia no existe un consenso acerca del tratamiento óptimo. Caso clínico: Paciente mujer de 34 años de edad consulta por aumento de volumen cervical doloroso y se evidencia nódulo doloroso en región cervical media. Ecografía de tiroides visualiza una lesión quística compleja. Se completa el estudio con tomografía computada del cuello con contraste que evidencia quiste del conducto tirogloso con compromiso inflamatorio-infeccioso, por lo que se decide cirugía. Biopsia evidencia cáncer papilar de 0.25 cm en quiste del conducto tirogloso, con bordes quirúrgicos negativos. Por bajo riesgo se decide control imagenológico estricto. DISCUSIÓN: Los quistes del conducto tirogloso comprenden las lesiones cervicales congénitas más frecuentes. Se presentan como masas indolentes y asintomáticas. El diagnóstico es confirmado mediante ecografía y la tomografía es utilizada para ampliar el estudio. La aparición de cáncer tiroideo en estos quistes es poco común, y generalmente son indistinguibles de las lesiones benignas en el preoperatorio. En relación al manejo del cáncer papilar en quiste del conducto tirogloso no existe un consenso de su tratamiento óptimo. Para los casos de bajo riesgo se sugiere control anual con TSH y ecografía tiroidea. Para aquellos pacientes de alto riesgo se sugiere tiroidectomía total y ablación de los restos tiroides con yodo radioactivo, con control anual con niveles de tiroglobulina. El pronóstico es excelente, con tasas de remisión que superan el 95%. CONCLUSIONES: Los carcinomas en quistes de conducto tirogloso son poco comunes y en la mayoría de los casos son lesiones diagnosticadas de manera incidental después de la resección quirúrgica. Para definir necesidad de tiroidectomía, debe realizarse estudio individualizado por un equipo multidisciplinario con amplia experiencia.

INTRODUCTION: Thyroglossal cysts are the most common affection of the cervical midline. Papillary carcinoma has been described in 1% of this cysts. Due to its low incidence a consensus on the optimal treatment does not exist. Clinical case: A 34 year old female with no relevant past medical history, presented with a painful cervical mass of many weeks of appearance. The thyroid ecography showed a complex cystic lesion and the cervical computed tomography with contrast evidenced a cyst of the thyroglossal duct with inflammatory and infectious findings. Surgery with no incidents was performed. Biopsy reported a 0.25 cm papillary cancer in the thyroglossal duct cyst, with negativa surgical margins. Strict follow up with imaging studies was decided. DISCUSSION: the thyroglossal duct cyst are the most common congenital cervical affections. Classically, they present as indolente, asyntomatic masses on the cervical midline. The diagnosis is confirmed with ecography and computed tomography is used to extent evaluation. Thyroid cancer in thyroglossal duct cyst is uncommon and generally indistinguishable from benign lesions in the preoperative phase. A consensus regarding the optimal management of this patients does not exist. For low risk cases, an anual control with THS and thyroid ecography is suggested. For patients with high risk a Sistrunk with total thyroidectomy and radioactive ablation of thyroids remnants is recommend. Follow up with anual thyroglubin levels should be performed. The prognostic is excellent, with more than 95% remission rates. CONCLUSSIONS: Thyroglossal duct cyst carcinomas are rare. In most cases, diagnosis is made incidentally after surgical resection. To decide wheter thyroidectomy is necessary each case should be analyzed individually by a multidisciplinary team with vast experience.

Estudio patológico intraoperatorio en la cirugía tiroidea: ¿cuánto contribuye a la estrategia quirúrgica? / Intraoperative pathologic evaluation in thyroid surgery: how much does it contribute to surgical strategy?

Antecedentes: el papel del estudio patológico intraoperatorio (EPI) en cirugía tiroidea ha sido discutido largamente y es todavía motivo de controversia. Objetivo: estimar los resultados del EPI en el diagnóstico de malignidad, su relación con la biopsia por punción-aspiración preoperatoria con aguja fina (PAAF) y el estudio patológico diferido (EPD), así como su contribución al cambio en la estrategia quirúrgica en cirugía tiroidea. Material y métodos: revisión retrospectiva de las historias clínicas de 773 pacientes operados por patología tiroidea entre enero de 2014 y diciembre de 2015. En todos se efectuó EPI y EPD; a 686 (89%) pacientes también se les efectuó la biopsia por PAAF preoperatoria. Resultados: los resultados del EPI fueron benigno en 215 pacientes (27,8%), maligno en 419 (54,2%) y no definitivo en 139 (18,0%). Cuando estos resultados fueron comparados con la EPD se encontraron 19 casos (8,8%) de falsos negativos y 4 (0,95%) de falsos positivos. Considerando solo los resultados definitivos, el EPI tuvo sensibilidad 95%, especificidad 98%, valor predictivo positivo 99%, valor predictivo negativo 91% y exactitud 91%. Cuando se comparó el EPI con la PAAF preoperatoria, los valores de sensibilidad más bajos (44%) correspondieron a las categorías de Bethesda III y IV. El EPI influyó en la estrategia quirúrgica en 95 pacientes (12,28%): en 53 (6,8%), la hemitiroidectomía cambió a tiroidectomía total; en 37 (4,8%), el diagnóstico de metástasis ganglionares permitió realizar un vaciamiento modificado de cuello, y en 5 (0,6%) ocurrieron ambas situaciones. Conclusión: el EPI tuvo altos valores de utilidad diagnóstica cuando se compararon con el EPD. También se correlacionó con la PAAF preoperatoria, pero tuvo menos utilidad en las categorías Bethesda III y IV. El EPI contribuyó a cambiar la decisión de técnica quirúrgica en un grupo de pacientes y evitar una segunda operación.

Background: the role of intraoperative pathologic evaluation (IPE) in thyroid surgery has largely been discussed and it is still controversial. Objective: to estimate the results of IPE in diagnosis of malignancy, its correlation with preoperative fine needle aspiration (FNA) biopsy and permanent pathologic evaluation (PPE), and its contribution to change surgical strategy in thyroid surgery. Materials and methods: retrospective chart review of 773 patients operated on for thyroid disease between January 2014 and December 2015. All patients underwent IPE and PPE; 686 (89%) patients had also preoperative FNA biopsy. Results: IPE resulted benign in 215 patients (27.8%), malignant in 419 (54.2%) and non definitive in 139 (18.0%). When these results were compared with PPE, 19 cases were false negative (8.8%) and 4 false positive (0.95). Considering only definitive results, IPE had sensitivity 95%, specificity 98%, positive predictive value 99%, negative predictive value 91% and accuracy 91%. When IPE was compared with preoperative FNA biopsy, lowest values of sensitivity (44%) corresponded with Bethesda categories III and IV. IPE influenced surgical strategy in 95 patients (12.28%): in 53 (6.8%) hemithyroidectomy changed to total thyroidectomy, in 37 (4.8%) lymph node metastases diagnosis allowed to perform modified neck dissection, and in 5 (0.6%) both situations occurred. Conclusion: IPE had high values of diagnostic utility when compared with PPE. It also correlated with preoperative FNA biopsy, but had less utility in Bethesda categories III and IV. IPE contributed to change surgical technical decision in a subset of patients and avoid a second operation.

Preoperatively undiagnosed papillary thyroid carcinoma in patients thyroidectomized for benign multinodular goiter

ABSTRACT Objective Incidental thyroid cancers (ITCs) are often microcarcinomas; among them, the most frequent histotype is the papillary one. The purpose of this study was to evaluate the rate of papillary thyroid cancer (PTC) in patients thyroidectomized for benign multinodular goiter. Subject and methods We retrospectively evaluated the histological incidence of PTC in 207 consecutive patients who, in a 1-year period, underwent thyroidectomy for benign multinodular goiter. All patients came from an iodine-deficient area (Orleans, France) with three nuclear power stations located in the neighboring areas of the county town. Results Overall, 25 thyroids (12.1%) harbored 37 PTC, of which 31 were microcarcinomas. In these 25 PTC patients, mean age was 55 ± 10 years (range 30-75), female:male ratio 20:5 (4:1). In 10 patients (40% of 25 and 4.8% of 207), PTCs were bilateral, and in 7 (2 with microPTCs) the thyroid capsule was infiltrated. These 7 patients underwent central and lateral cervical lymph node dissections, which revealed lymph node metastases in one and two cases, respectively. Radioiodine treatment was performed in 7 cases. Neither mortality nor transient and permanent nerve injuries were observed. Four (16%) transient hypocalcaemias occurred as early complications. At last follow-up visit (mean length of follow-up 17.2 ± 3.4 months), all patients were doing well and free of any clinical local recurrence or distant metastases. Conclusion With a 12% risk that multinodular goiter harbors preoperatively unsuspected PTCs, which can have already infiltrated the capsule and that can be accompanied by PTC foci contralaterally, an adequate surgical approach has to be considered.

Carcinoma bem diferenciado de tireoide: perfil epidemiológico, resultados cirúrgicos e resposta oncológica / Well-differentiated tireoid carcinoma: epidemiological profile, surgical results and oncological response

RESUMO Objetivo: conhecer o perfil epidemiológico dos pacientes submetidos à cirurgia do carcinoma bem diferenciado da tireoide no Hospital Universitário Cassiano Antônio Moraes da Universidade Federal do Espírito Santo, assim como os resultados oncológicos e as principais complicações pós-operatórias. Métodos: estudo transversal e retrospectivo de pacientes portadores de carcinoma bem diferenciado da tireoide operados no período de janeiro de 2008 a dezembro de 2015. Resultados: no período do estudo, dos 353 pacientes submetidos a tratamento cirúrgico da glândula tireoide, 95 eram portadores de CBDT. O carcinoma papilífero da tireoide foi o mais frequente (91,57%). A tireoidectomia total não associada a esvaziamento cervical foi o procedimento cirúrgico mais frequente (65,26%). As complicações pós-operatórias ocorreram em 6,31% dos pacientes, sendo o hematoma a mais frequente. O tempo médio de seguimento foi de 36,9 meses. A recidiva ocorreu em quatro pacientes (4,21%), sendo locorregional em todos os casos. Os fatores prognósticos analisados, como sexo, idade, tamanho do tumor, acometimento linfonodal, estadiamento, tipo de cirurgia, histologia e iodoterapia complementar não demonstraram significância estatística. Conclusão: o carcinoma papilífero da tireoide foi a neoplasia maligna mais frequente, acometendo o sexo feminino na faixa etária dos 49 anos mais frequentemente. A recidiva locorregional ocorreu em quatro pacientes. O hematoma foi a complicação mais frequente.

ABSTRACT Objective: to know the epidemiological profile of patients undergoing surgery for well-differentiated thyroid carcinoma at the Cassiano Antônio Moraes University Hospital of the Federal University of Espírito Santo, as well as the oncological results and the main postoperative complications. Methods: we conducted a cross-sectional, retrospective study of patients with well-differentiated thyroid carcinoma (WDTC) operated from January 2008 to December 2015. Results: During the study period, 95 of the 353 patients undergoing surgical treatment of the thyroid gland had WDTC. Papillary carcinoma was the most frequent (91.57%). Total thyroidectomy not associated with cervical emptying was the most frequent surgical procedure (65.26%). Postoperative complications occurred in 6.31% of patients, hematoma being the most frequent. The mean follow-up time was 36.9 months. Relapse occurred in four patients (4.21%), being locoregional in all cases. The prognostic factors analyzed, such as gender, age, tumor size, lymph node involvement, staging, type of surgery, histology and complementary iodine therapy did not show statistical significance. Conclusion: papillary carcinoma was the most common thyroid malignant neoplasm, affecting women in the 49-year-old age group more frequently. Loco-regional recurrence occurred in four patients. Hematoma was the most frequent complication.

Carcinoma familiar de tiroides no medular: reporte de un caso clínico y revisión de la literatura / Familial non medullary thyroid carcinoma: report of a case and literature review

El carcinoma tiroideo familiar no medular (CFTNM) representa aproximadamente entre el 3,2% y 9,6% de todos los cánceres de tiroides, y se define por la presencia de cáncer diferenciado de tiroides en 2 o más familiares, en ausencia de otros síndromes familiares conocidos o exposición a radiación. Si bien su fisiopatología es aún incierta, algunos investigadores postulan un patrón de herencia dominante con penetrancia incompleta, no habiendo aún un gen específico responsable. Esta entidad suele presentarse a una menor edad y con características más agresivas que en su forma esporádica. Dado el interés por conocer la presentación de esta enfermedad y las recomendaciones para su manejo, se presenta el caso de una paciente diagnosticada con cáncer papilar de tiroides con el antecedente de 4 familiares con la misma patología. Actualmente el tamizaje mediante ecografía cervical y biopsia por punción aspiración con aguja fina de los nódulos tiroideos es el examen de elección ante la presencia del antecedente de CFTNM, ya que aún no hay estudios genéticos disponibles. La tiroidectomía total más disección ganglionar es el tratamiento de elección. Debido al comportamiento más agresivo y peor pronóstico del CFTNM, es necesaria un alto índice de sospecha y una investigación completa en la presencia de un componente familiar.

The non-familial medullary thyroid carcinoma (FNMTC) represents approximately between 3.2 and 9.6% of all thyroid cancers, and is defined by the presence of differentiated thyroid cancer in 2 or more families in the absence of other known familial syndromes or radiation exposure. Although the pathophysiology is still uncertain, some investigators posit a dominant pattern of inheritance with incomplete penetrance, but still there is no specific gene responsible. It occurs at a younger age and with more aggressive characteristics than the sporadic form. Because of the interest in learning about the presentation of this disease and its recommendations, we present the case of a patient diagnosed with papillary thyroid cancer with a history of 4 family with the same pathology. Actually cervical screening by ultrasound and the fine needle aspiration biopsy (FNAB) of thyroid nodules is the examination of choice in the presence of a history of FNMTC, since no genetic studies yet available. Total thyroidectomy with lymph node dissection is the treatment of choice. Because the more aggressive behavior and poor prognosis of FNMTC, a high index of suspicion and a full investigation is required in the presence of a familial component.

Carcinoma papilar de tiroides: úlcera sangrante de piel / Thyroid cancer and bleeding skin ulcer

Background: Differentiated thyroid cancer has a good prognosis. If there is local tumor infiltration, the prognosis depends on its complete excision. Case report: We report a 67 years old woman with a papillary thyroid cancer and a bleeding skin ulcer. The initial assessment disclosed local tumor infiltration of neck structures and cervical lymph nodes. She was subjected to a radical thyroidectomy, radical neck dissection and dissection of involved structures. She was also treated with radioiodine and levothyroxine and remains asymptomatic after two years of follow up.

Introducción: Los cánceres tiroideos, de la variedad diferenciada, son tumores malignos con buen pronóstico. Los subtipos más comunes son el carcinoma papilar y el carcinoma folicular. Incluso cuando infiltran localmente, tienen un pronóstico relativamente bueno cuando se pueden resecar completamente. Caso clínico: Presentamos un caso de cáncer papilar de una señora mayor que se presentó con una úlcera sangrante de piel. En la evaluación se encontró que tenía infiltración de estructuras del cuello locales y de los ganglios linfáticos cervicales. Fue tratada con tiroidectomía total y disección radical de cuello modificada, así como la resección de las estructuras involucradas. Más tarde fue tratada con yodo radiactivo y levo tiroxina. A pesar de la infiltración local permanece asintomática a los dos años de seguimiento.

Carcinoma papilar de tiroides en quiste del conducto tirogloso / Thyroglossal duct cyst with papillary carcinoma

Introduction: In about 1-2 percent of cases of thyroglossal cyst may be neoplastic changes, mostly correspond to papillary thyroid carcinoma (75-85 percent). The aim of this paper is to present 9 cases of papillary thyroid carcinoma in thyroglossal duct cyst. Materials and Methods: Data were recorded retrospectively from patients diagnosed with papillary thyroid carcinoma in thyroglossal duct cyst treated at Hospital Clínico Universidad de Chile between 1999 2014. Results: From 142 cases operated for thyroglossal duct cyst, 9 cases of papillary cancer (6.34 percent) were recorded. The average age was 32 years. The average diameter of the lesion was 4.4 cm (SD 2.2 cm). 8 patients underwent total thyroidectomy; a simultaneous thyroid cancer was diagnosed in 3 of them. In 6 cases was added iodine therapy. In only one patient a lymph nodal dissection was performed. We do not observe any surgical complication. A solid component in preoperative ultrasonographic study is suspicious of malignancy. The average follow-up time was 85 months. There is no recurrence or mortality in this group of patients. Conclusions: Although the safest long term management is Sistrunk surgery associated with thyroidectomy and radioiodine in selected cases, these patients must be evaluated by a multidisciplinary group and thyroidectomy should be considered in high surgical volume center, in order to minimize complications.

Introducción: En alrededor de 1-2 por ciento de los casos de quiste tirogloso pueden existir cambios neoplásicos, en su mayoría corresponden a carcinoma papilar de tiroides (75-85 por ciento). El objetivo de este trabajo es presentar 9 casos de carcinoma papilar de tiroides en quiste del conducto tirogloso, en cuanto a su forma de presentación y manejo. Material y Método: Se registraron en forma retrospectiva datos de pacientes condiagnóstico de carcinoma papilar de tiroides en quiste del conducto tirogloso atendidos en el Hospital Clínico de la Universidad de Chile entre 1999 2014. Resultados: De 142 casos de pacientes operados por quiste del conducto tirogloso, se registraron 9 casos de cáncer papilar (6,34 por ciento). El promedio de edad de los pacientes fue de 32 años. El diámetro promedio de la lesión fue de 4,4 cm (DS 2,2 cm). Del total, 8 pacientes fueron sometidos a tiroidectomía total, se diagnosticó cáncer de tiroides en 3 de ellos, en 6 se asoció tratamiento con radioyodo. En sólo 1 paciente se realizó una disección linfonodal. El tiempo promedio de seguimiento fue de 85 meses; a la fecha la serie no ha presentado recurrencia ni mortalidad. Conclusiones: Si bien el manejo más seguro a largo plazo es la cirugía de Sistrunk, asociado a una tiroidectomía y eventual radioyodo, la resolución quirúrgica con tiroidectomía asociada debe ser considerada cuando la morbilidad no sea mayor que el beneficio teórico.

Carcinoma papilar en quiste tirogloso. Propuesta de algoritmo diagnóstico y terapéutico / Papillary carcinoma in a thyroglossal duct cyst. Proposal of an algorithm for diagnosis and treatment / Carcinoma papilar em cisto tirogloso: proposta de algoritmo diagnóstico e terapêutico

Antecedentes: el carcinoma diferenciado de tiroides en quiste tirogloso (CaQT) es una entidad rara. La incidencia de CaQT es de 1 a 2%. Usualmente su forma de presentación clínica es indistinguible de una lesión benigna y el diagnóstico definitivo es postquirúrgico. No hay en la actualidad un consenso sobre la indicación de tiroidectomía total, radioablación con iodo y/o terapia supresiva con levotiroxina luego de ser extirpado quirúrgicamente...

Introduction: the development of well -differentiated thyroid carcinoma in thyroglossal duct cysts (TGDCa) is uncommon. The incidence of TGDCa lies within 1 to 2%. Usually the clinical appearance is indistinguishable from a benign thyroglossal duct cyst. The definitive diagnosis is post-operative. After the surgery of choice, the other alternative treatments such as thyroidectomy, radioiodine and L-T4 therapy are controversial...

Antecedentes: o carcinoma diferenciado de tireoide em cisto tirogloso (CaQT) é uma entidade rara. A incidência de CaQT é de 1 a 2 por cento. Em geral, a sua forma de apresentação clínica é indistinguível de uma lesão benigna e o diagnóstico definitivo é pós-cirúrgico. Não existe atualmente um consenso sobre a indicação de tiroidectomia total, radioablação com iodo e/ou terapia supressiva com levotiroxina após ser extirpado cirurgicamente...

Estruma ovarii maligno / Malignant struma ovarii

The Malignant Struma ovarii (SO) is a thyroid carcinoma generated in a mature teratoma, constitutes 0.8-3percent of ovarian tumors. Then, two cases will be reviewed. Case 1: 46 year old woman with no known morbid consulted for right iliac fossa pain requiring exploratory laparotomy with findings of an ovarian tumor, the biopsy reported mature ovarian teratoma SO type microfocus papillary thyroid carcinoma. Case 2: 59 year old female with a history of dyslipidemia and knee osteoarthritis in controls in gynecology since 2010 on the right adnexal mass of cystic type of 5x3 cm. The study showed only free fluid dissemination ovarian, oofectomía bilateral was performed and biopsy showed minimally invasive follicular carcinoma (2.8 cm) developed by SO, serosa without invasion of the ovary. Is derived of endocrinology and the study showed: thyroid stimulating hormone (TSH) 3.3 uIU/ ml; Peroxidase antibody (anti-TPO) and thyroglobulin antibody (antiTG) negative. Ultrasonography exhibited thyroid nodule of 0.8 x 0.6 cm, hipovascularizado with normal thyroid cintigraphy and cytology negative for neoplastic cells in fine needle aspiration (FNA). Discussion: It’s a rare condition, which requires a multidisciplinary approach to treatment...

Características clínicas, ultrasonográficas y anatomopatológicas de pacientes operados por sospecha de malignidad tiroidea / Clinical, ultrasonographic and anatomopathological characteristics of patients operated on for suspected thyroid malignancy

Introducción: El carcinoma tiroideo se caracteriza por su lenta evolución y elevado porcentaje de curación. Objetivo: describir las características clínicas, ultrasonográficas y anatomopatológicas de los pacientes operados. Métodos: estudio descriptivo, retrospectivo. Se utilizaron para obtener el dato primario las historias clínicas de los pacientes que cumplieron con los criterios de inclusión: operados por sospecha de malignidad tiroidea, mayores de 18 años de edad que contaron con datos completos demográficos, clínicos, sonográficos y anatomopatológicos, y que estuviesen inscritos en el hospital. Se confeccionaron tablas de distribución de frecuencias. Se aplicó la prueba de comparación de proporciones para describir la significación estadística de las variables estudiadas en relación con la malignidad tiroidea. Resultados: el 81,8 por ciento de los pacientes afectados de malignidad tiroidea correspondió al género femenino. El 39,4 por ciento de estos correspondieron al grupo de edad entre 41 y 50 años, el 75,8 por ciento de este grupo de pacientes correspondió al examen sonográfico con un área del nódulo tiroideo mayor de 10 mm, el 53,3 por ciento de estos pacientes presentó como morfología tiroidea el nódulo único, y el 75,8 por ciento presentó como resultado de la citología con aguja fina un carcinoma de tiroides. El 91 por ciento presentó como clasificación histológica carcinoma papilar. Conclusiones: la mayor frecuencia de carcinoma fue la variante papilar. Se encontró de forma predominante en mujeres con edades entre los 41 y 50 años que tenían nódulos mayores de 1 cm(AU)

Introduction: Thyroid carcinoma is characterized by slow progression and high recovery percentage. Objective: to describe the clinical, ultrasonographic and anatomopathological characteristics of patients operated on for thyroid malignancy. Methods: retrospective and descriptive study for which the primary data were collected from the medical histories of patients who met the inclusion criteria. These criteria comprised surgery for suspected thyroid malignancy, age over 18 years, and complete demographic, clinical, ultrasonographic and anatomopathological data and registration at the hospital. Frequency distribution tables were drawn up. The ratio comparison test was applied to describe the statistical significance of the studied variables with respect to the thyroid malignancy. Results: in the group of patients with thyroid malignancy, 81.8 percent were females, 39.4 percent aged 41 to 50 years. The ultrasonographic test showed that 75.8 percent of them had a thyroid nodule area greater than 10 mm, 53.3 percent presented solitary nodule morphology whereas the result of the fine needle aspiration cytology was thyroid carcinoma. The histological classification yielded papillary carcinoma in 91 percent of patients. Conclusions: the papillary carcinoma was the most common, particularly in females aged 41 to 50 years who had over 1 cm nodules(AU)

Cáncer tiroideo papilar: reporte de 4 casos familiares / Papillary thyroid cancer: case reports of four family cases

Introducción: El cáncer papilar del tiroides (CPT) es la neoplasia endocrina más frecuente, siendo el 80% de los casos de la variedad papilar; sólo el 10 por ciento se manifiesta antes de los 21 años y tiene una incidencia estimada en este grupo de 0,54:100.000. Su comportamiento en la edad pediátrica se caracteriza por el diagnóstico en una etapa más avanzada de la enfermedad pero con buena respuesta terapéutica y muy baja mortalidad. Objetivo: Presentar 4 casos familiares de CPT, discutir las características particulares y la importancia del diagnóstico precoz en pacientes. Casos clínicos: Se presentan 4 familias con sujetos portadores de un carcinoma papilar familiar de Tiroides, en todas ellas el caso pediátrico se presentó con posterioridad a un caso de un adulto familiar directo, por lo que su búsqueda fue más precoz, y a pesar de un tratamiento oportuno ya tenían enfermedad avanzada al diagnóstico. Los casos pediátricos corresponden a 3 mujeres y 1 varón de edades promedio de 12 años 6 meses al momento del diagnóstico. Discusión: La variedad familiar del carcinoma papilar de tiroides (2 o más familiares de primer grado afectados), representa el 5 por ciento de los cánceres papilares. Se transmite a través de herencia autosómica dominante con penetrancia incompleta y expresividad variable. Se manifiesta a menor edad que el esporádico, es más agresivo con mayor invasión local (32 por ciento), recurrencia (20-50 por ciento) y metástasis linfática (57 por ciento), y se asocia a enfermedades tiroídeas benignas. Con frecuencia es multifocal. Conclusión: El cáncer familiar papilar de tiroides es una patología con peor pronóstico que la variedad esporádica por lo que se requiere una alto índice de sospecha en las familias afectadas para un diagnóstico y tratamiento precoz.

Introduction: Papillary thyroid cancer (PTC) is the most common endocrine malignancy, representing 80 percent of all thyroid cancers; only 10 percent of cases are manifested before age 21 and have an estimated incidence of 0.54 cases per 100,000 people. In children it is diagnosed at a more advanced stage of the disease but with good therapeutic response and very low mortality. Objective: To present four family cases with PTC, discuss the particular characteristics and the importance of early diagnosis. Case reports: 4 families with members affected by family papillary thyroid carcinoma are presented, all pediatric cases were manifested after a direct member adult case was diagnosed, therefore pediatric patients were early detected, but despite a timely treatment, the disease was advanced at the time of diagnosis. The pediatric cases are 3 females and 1 male with an average age of 12 ½ years old at diagnosis. Discussion: The family variety of papillary thyroid carcinoma (2 or more direct members affected), represents 5 percent of papillary cancers. It is transmitted through autosomal dominant inheritance with incomplete penetrance and variable expressivity. It occurs at a younger age than the sporadic type, and it is more aggressive with greater local invasion (32 percent), recurrence (20-50 percent) and lymphatic metastases (57 percent), and it is associated with benign thyroid diseases and often, it is multifocal. Conclusion: The family papillary thyroid cancer is a disease with worse prognosis than the sporadic variety; therefore, a high index of suspicion is required in affected families for early diagnosis and treatment.

Immunohistochemical analysis of thyroid follicular neoplasms and BRAF mutation correlation.

BACKGROUND: The accurate diagnosis of benign and malign thyroid tumors is very important for the clinical management of patients. The distinction of thyroid papillary carcinoma follicular variant and follicular adenoma can be difficult. AIM: To investigate the alternative methods like immunohistochemistry and exon 15 in the BRAF gene 1799 T/A mutation analyses for distinguishing thyroid tumors. MATERIALS AND METHODS: We applied immunohistochemical markers; CK19, HMWCK, Galectin‑3, HBME‑1 and Fibronectin and mutant allelespecific PCR amplification technique was used to determine 1799 T/A mutation within the BRAF gene. Formalin‑fixed parafin embedded tissues from 45 surgically total resected thyroids, included 26 thyroid papillary carcinoma follicular variant (FV‑TPC), 8 Follicular Adenoma (FA), 6 Minimal invasive follicular carcinoma (MIFC) and 5 Follicular Carcinoma (FC). STATISTICAL ANALYSES USED: Pearson Chi‑Square and Kruskal Wallis tests were performed. RESULTS: There was a positive correlation between FV‑TPC and HMWCK, CK 19, HBME1, Galectin 3, fibronectin (P < 0.05), but there was no correlation with FV‑TPC and BRAF gene mutation (P > 0.05). HBME‑1 and CK 19 stained strong and diffuse positive in FV‑TPCs but weak and focal in FAs. CONCLUSION: Our study suggests that morphologic features combined with immunohistochemical panel of HMWCK, CK19, HBME‑1, Galectin‑3 and fibronectin can help to distinguish benign and malign thyroid neoplasms and FV‑TPC from follicular adenomas. BRAF gene 1799 T/A mutation has been non‑specific but its detection can be a useful tool combined with immunohistochemistry for diagnosing FV‑TPC.

Solid Pancreatic Tumors with Unilocular Cyst-Like Appearance on CT: Differentiation from Unilocular Cystic Tumors Using CT

OBJECTIVE: To describe the computed tomography (CT) features of neuroendocrine tumors (NETs) and solid pseudopapillary tumors (SPTs) with unilocular cyst-like appearance, and to compare them with those of unilocular cystic tumors of the pancreas. MATERIALS AND METHODS: This retrospective study was approved by our Institutional Review Board, and informed consent was waived. We included 112 pancreatic tumors with unilocular cyst-like appearance on CT (16 solid tumors [nine NETs and seven SPTs] and 96 cystic tumors [45 serous cystadenomas, 30 mucinous cystic neoplasms, and 21 branch-duct intraductal papillary mucinous neoplasms]). Two radiologists reviewed the CT images in consensus to determine tumor location, long diameter, morphological features, wall thicknesses, ratio of wall thickness to tumor size, wall enhancement patterns, intratumoral contents, and accompanying findings. Fisher's exact test was used to analyze the results. RESULTS: All 16 solid tumors had perceptible walls (mean thickness, 2.7 mm; mean ratio of wall thickness to tumor size, 7.7%) with variable enhancement. Four NETs and seven SPTs had hemorrhage, calcifications, and/or mural nodules. Six CT findings were specific for solid tumors with unilocular cyst-like appearance: a thick (> 2 mm) wall, uneven thickness of the wall, high ratio of wall thickness to tumor size, hyper- or hypo-attenuation of the wall in the arterial and portal phase, and heterogeneous internal contents. When three or more of the above criteria were used, 100% specificity and 87.5-92% accuracy were obtained for solid tumors with unilocular cyst-like appearance. CONCLUSION: A combination of CT features was useful for distinguishing solid tumors with unilocular cyst-like appearance from unilocular cystic tumors of the pancreas.

Role of 18F-fluorodeoxy glucose PET-CT in asymptomatic epithelial ovarian cancer with rising serum CA-125: A pilot study.

Background. We evaluated the role of 18F-fluorodeoxy glucose (FDG) PET-CT scan in the diagnosis of early relapse in patients with epithelial ovarian cancer (EOC) who were asymptomatic but had a rising serum CA-125 level. Methods. Between May 2006 and July 2008, 16 patients with advanced EOC (stages III and IV) who had achieved complete response after cytoreductive surgery and platinumbased chemotherapy were included. These patients were asymptomatic but had a rising serum CA-125 level with normal physical examination and contrast-enhanced CT scan of the abdomen and pelvis. Patients were evaluated with 18F-FDG PET-CT scan. Written informed consent was taken. Patients with a positive PET-CT scan were advised ultrasoundguided fine-needle aspiration cytology (FNAC) from the area showing increased uptake. Patients in whom FNAC was negative or inconclusive or those with negative PET-CT scan were followed up closely for the next 6 months with repeat clinical evaluation and CT scan. Results. Fifteen patients (15/16) had a positive PET-CT scan. In 9 patients the positive PET lesion was confirmed on FNAC, while in 5 patients this was confirmed on follow-up CT scan after 6 months. One patient who had a single positive lesion in the pelvis on PET-CT was initially considered falsepositive because a follow-up CT scan at 6 months did not show the lesion. However, on regular follow-up after 2 years, she was detected to have an isolated lesion in the PET-positive area which was confirmed on secondary cytoreduction. This patient was considered as true-positive in the current analysis. One patient, who had a negative PET-CT scan and a negative CT scan at 6 months’ follow-up was considered true-negative. The sensitivity and specificity of PET-CT scan was 100%. We could confirm positivity on histopathology/FNAC in 10 of the 15 (66.7%) true-positive cases. Conclusion. 18F-FDG PET-CT scan is a sensitive and specific technique for early diagnosis of relapse in asymptomatic EOC patients with rising CA-125. However, its role in the management of recurrent ovarian cancers needs further evaluation.

Carcinoma tiroideo papilar oncocítico variante Warthin-like tumor: caso clínico y revisión de la literatura / Oncocytic variant of papillary thyroid carcinoma with lymphocytic stroma (Warthin-like variant): report of one case

Recently, an oncocytic variant of papillary thyroid carcinoma with lymphocytic stroma, called Warthin like tumor, has been described. Its evolution is similar to the usual papillary carcinoma. We report a 61 years old female with a multinodular goiter and a predominant nodule in the right lobe. A fine needle aspiration biopsy was compatible with a papillary thyroid carcinoma. A total thyroidectomy was performed and the pathological examination revealed a Warthin tumor of 2.2 cm. The patient was treated posteriorly with radioiodine and after six months of follow up, there is no evidence of disease...