Presentación atípica de cáncer de tiroides en Hospital Escuela Universitario, Honduras / Atypical Thyroide Cancer, University School Hospital, Honduras

A las masas o protuberancias en la glándula tiroides se les llama nódulos tiroideos, la mayoría son benignos, pero alrededor de 2-3 de 20 son cancerosos. El carcinoma anaplásico, representa alrededor del 2%, es más frecuente en el sexo femenino (proporción 3:1). Objetivo: presentar un caso atípico de tumor canceroso en tiroides, técnicas diagnósticas y tratamiento aplicado. Presentación decaso clínico: paciente femenina de 51 años, procedente de Tegucigalpa, evangélica, ama de casa, con historia de masa en región anterior del cuello de un año de evolución, crecimiento progresivo, dolorosa a la palpación, que presentaba úlcera sangrante de un mes de evolución y 8 cm de diámetro. Examen físico: masa de 15 x 15 cm, móvil, asimétrica, bordes irregulares, consistencia dura, adherida a planos profundos. Exámenes complementarios: T4 libre 1.14 ng/dL, hormona estimulante tiroidea 2.10 mU/mL. Ultrasonido de cuello + Doppler:masa sólida, lóbulos aumentados de tamaño y con microvascularidad. Tomografía contrastada: masa en cartílago tiroides de 7.6 x 6.9 cm, bordes definidos, múltiples calcificaciones, sin áreas de necrosis, sin compresión de estructuras adyacentes; ganglios bilaterales aumentados de tamaño. Biopsia por Aspiración con Aguja Fina:carcinoma anaplásico de tiroides con focos de neoplasia papilar y variante de células altas. Tratamiento: tiroidectomía total, mostrando glándula tiroides aumentada de tamaño, peso aproximado de 200 g; levotiroxina 100 µg vía oral c/día de por vida, calcio 2 tabletas vía oral c/día por un mes. Conclusión: El estudio confirmatorio de cáncer anaplásico de tiroides es la biopsia por aspirado con aguja fina; sin embargo, la biopsia por disección, confiere un diagnóstico definitivo cuando existen dudas sobre la toma de muestra o cuando la clínica del paciente no corresponda con el diagnóstico de la biopsia por aspiración con aguja fina...(AU)

Multifocal papillary carcinoma of the thyroid with heterotopic ossification and extramedullary hematopoiesis associated with a lipomatous follicular nodule

Heterotopic ossification has been described in papillary thyroid carcinoma in association with high incidence of extrathyroidal invasion, multifocality, lymph node metastasis, and older age. Nevertheless, it has not been described as a specific subtype of papillary thyroid carcinoma, because of its rarity. We described the case of an 80-year-old female patient, with familial history of papillary thyroid carcinoma. In the annual screening examination, she was diagnosed with thyroid nodules. The patient was submitted to a thyroidectomy because the fine needle aspiration cytology was positive for malignancy according to the Bethesda classification. The surgical specimen analyses showed a multifocal papillary carcinoma with one major lesion in the left lobe measuring 0.9 cm, and two small lesions (0.4 cm and 0.2 cm) in the right lobe. Only the biggest lesion in the right lobe had the osteoid matrix with rare osteoclasts and fat metaplasia with progenitor cells. There was perineural invasion, but vascular invasion was not identified. The margins were free and there was no extrathyroidal extension. In the left lobe there was an oncocytic nodule and a lipomatous follicular nodule. In recent years there has been a significant increase in the diagnosis of thyroid cancer, mainly because of the finding of microcarcinomas as a result of many requests for cervical image exams. Future studies may define (i) whether papillary thyroid carcinoma with heterotopic ossification is a true histological variant; (ii) the causes of that alteration; and (iii) eventual follow-up implications.

Autopercepção da deglutição em pacientes com doença tireoidiana benigna não cirúrgica / Self-perception of swallowing by patients with benign nonsurgical thyroid disease

RESUMO Objetivo verificar a frequência de queixa para deglutir em pacientes com doença tireoidiana benigna não cirúrgica e comparar a autopercepção de intensidade da alteração de deglutição em diferentes tipos de doença tireoidiana. Método a amostra do estudo foi composta por 39 mulheres com idades entre 19 e 58 anos (38,54 ± 10,74 anos) e diagnóstico de hipotireoidismo (n=22; 56,4%) ou nódulos tireoidianos (n=17; 43,6%). Investigou-se a presença de queixa, tipo de queixa e autopercepção da intensidade da alteração de deglutição por meio da escala analógico-visual de 100 milímetros. Os dados foram analisados de forma descritiva e para comparar a autopercepção entre os diferentes diagnósticos clínicos utilizamos o teste não paramétrico de Mann-Whitney. O nível de significância foi de 5%. Resultados vinte e seis (66,7%) participantes relataram queixa para deglutir. As queixas referidas foram sensação de estase em região laringofaríngea (37,15%), engasgo (34,29%) e odinofagia (28,57%). O valor médio da autopercepção de intensidade da alteração de deglutição por meio da escala analógico-visual foi 59,35 (± 27,38) milímetros. A autopercepção não foi diferente entre os diagnósticos clínicos de doença tireoidiana. Conclusão nessa amostra, queixas para deglutir foram frequentes em mulheres com doenças tireoidianas benignas não cirúrgicas. Essas pacientes percebem a alteração de forma moderada, independentemente do diagnóstico clínico da patologia tireoidiana.

ABSTRACT Purpose To verify the frequency of swallowing complaints in patients with benign nonsurgical thyroid disease and compare the self-perception of swallowing disorder intensity between different types of thyroid disease. Methods The study sample comprised 39 women aged 19-58 years (38.54 ± 10.74) with hypothyroidism (n=22; 56.4%) or thyroid nodules (n=17; 43.6%). Presence and type of swallowing complaint and self-perception of swallowing disorder intensity were investigated by means of self-ratings recorded on a 100-millimeter visual analog scale. The data were analyzed by descriptive measures and the Mann-Whitney nonparametric test was used to compare the self-perception of swallowing disorder intensity between both clinical diagnoses of thyroid disease. The level of 5% was adopted for statistical significance. Results Twenty-six (66.7%) individuals reported the following swallowing complaints: pharyngolaryngeal stasis sensation (37.15%), chocking (34.29%), and odynophagia (28.57%). The mean value of self-perception of swallowing disorder intensity by the visual analog scale was 59.35 (± 27.38) millimeters. No difference in self-perception was reported between the clinical diagnoses of thyroid disease. Conclusion In this sample, swallowing complaint was frequently observed in patients with benign nonsurgical thyroid disease. Moderate self-perception of swallowing disorder intensity was reported regardless of the clinical diagnosis of thyroid disease.

Painless thyroiditis associated to thyroid carcinoma: role of initial ultrasonography evaluation

Even though it is a rare event, most associations of thyroid carcinoma with subacute thyroiditis described in the literature are related to its granulomatous form (Quervain’s thyroiditis). We present a patient with subacute lymphocytic thyroiditis (painless thyroiditis) and papillary thyroid cancer that was first suspected in an initial ultrasound evaluation. A 30-year old female patient who was referred to the emergency room due to hyperthyroidism symptoms was diagnosed with painless thyroiditis established by physical examination and laboratory findings. With the presence of a palpable painless thyroid nodule an ultrasound was prescribed and the images revealed a suspicious thyroid nodule, microcalcification focus in the heterogeneous thyroid parenquima and cervical lymphadenopathy. Fine needle aspiration biopsy was taken from this nodule; cytology was assessed for compatibility with papillary thyroid carcinoma. Postsurgical pathology evaluation showed a multicentric papillary carcinoma and lymphocytic infiltration. Subacute thyroiditis, regardless of type, may produce transitory ultrasound changes that obscure the coexistence of papillary carcinoma. Due to this, initial thyroid ultrasound evaluation should be delayed until clinical recovery. We recommended a thyroid ultrasound exam for initial evaluation of painless thyroiditis, particularly in patients with palpable thyroid nodule. Further cytological examination is recommended in cases presenting with suspect thyroid nodule and/or non-nodular hypoechoic (> 1 cm) or heterogeneous areas with microcalcification focus.

An uncommon case of Marine-Lenhart syndrome / Um caso incomum de síndrome de Marine-Lenhart

The term Marine-Lenhart syndrome describes the association between Graves’ disease and autonomously functioning thyroid nodules (AFTN), such as toxic adenoma or toxic multinodular goiter. The two diseases may coexist or may be present at different moments in the same patient. In the literature, there are many reports on the development of Graves’ disease after radioiodine treatment for AFTN, but very little information may be found on the occurrence of AFTN after radioiodine therapy for Graves’ disease. We describe here the case of a female patient with Graves’ disease who was successfully treated with radioiodine for Graves’ disease, returning to normal thyroid function. Three years later, biochemical analysis and ultrasound examination identified a thyroid nodule that progressively increased in size. The 99mTc-pertechnetate scintigraphy showed avid uptake in the right lobule, which corresponded to a nodular lesion consistent with AFTN.

O termo “síndrome de Marine-Lenhart” descreve a associação da doença de Graves e nódulos tireoidianos de funcionamento autônomo (AFTN), como no adenoma tóxico ou bócio multinodular tóxico. As duas doenças podem coexistir ou podem estar presentes em diferentes momentos no mesmo paciente. Na literatura, existem muitos relatos sobre o desenvolvimento da doença de Graves após radioiodoterapia para AFTN, mas muito poucos dados podem ser encontrados em relação ao aparecimento de AFTN após radioiodoterapia para doença de Graves. Descrevemos o caso de uma paciente do sexo feminino com doença de Graves que realizou com sucesso o tratamento com iodo radioativo, com a normalização da função da tireoide. Três anos depois, uma análise bioquímica e um exame de ultrassonografia identificaram o aparecimento de um nódulo na tireoide que progressivamente aumentou de tamanho. A cintilografia com 99mTc-pertecnetato revelou uma captação ávida no lóbulo direito, correspondente à lesão nodular, consistente com uma AFTN.

Hyperfunctioning thyroid cancer: a five-year follow-up / Carcinoma de tireoide hiperfuncionante: seguimento de cinco anos

Differentiated thyroid cancer rarely occurs in association with hyperfunctioning nodules. We describe a case of a 47-year-old woman who developed symptoms of hyperthyroidism associated with a palpable thyroid nodule. Thyroid scintigraphy showed an autonomous nodule, and fine-needle aspiration biopsy was suggestive of papillary carcinoma. Laboratorial findings were consistent with the diagnosis of hyperthyroidism. The patient underwent thyroidectomy and a papillary carcinoma of 3.0 x 3.0 x 2.0 cm, follicular variant, was described by histological examination. The surrounding thyroid tissue was normal. Postoperatively, the patient received 100 mCi of 131I, and whole body scans detected only residual uptake. No evidence of metastasis was detected during five years of follow-up. Hot thyroid nodules rarely harbor malignancies, and this case illustrated that, when a carcinoma occurs the prognosis seems to be very good with no evidence of metastatic dissemination during a long-term follow-up.

O câncer diferenciado de tireoide raramente ocorre em associação a nódulos hiperfuncionantes. Foi descrito aqui o caso de uma paciente de 47 anos de idade que desenvolveu sintomas de hipertireoidismo associados a um nódulo tireoidiano palpável. A cintilografia da tireoide mostrou tratar-se de um nódulo autônomo, e a biópsia por punção aspirativa por agulha fina foi sugestiva de carcinoma papilar. Os achados laboratoriais foram consistentes com o diagnóstico de hipertireoidismo. A paciente foi submetida à tireoidectomia e um carcinoma papilar de 3,0 x 3,0 x 2,0 cm, variante folicular, foi descrito por exame histopatológico. O tecido tireoidiano circunjacente era normal. No pós-operatório a paciente recebeu 100 mCi de 131I, e a cintilografia de corpo inteiro mostrou apenas captação residual. Nenhuma metástase foi identificada ao longo de cinco anos de acompanhamento. Nódulos quentes raramente albergam doença maligna, e este caso demonstrou que, quando ocorre carcinoma, o prognóstico parece ser muito bom, sem evidência de disseminação metastática em longo prazo.

High prevalence of thyroid nodules in patients with achrocordons (skin tags): Possible role of insulin-resistance / Alta prevalencia de nódulos tiroideos en pacientes con acrocordones (fibromas blandos): Posible papel de la insulino-resistencia

Due to the observation of a great number of patients having achrocordons, when they underwent fine needle biopsies for thyroid nodules, we decided to perform a prospective study to investigate the relationship between this finding and the presence of insulin resistance (IR), since achrocordons are commonly seen in hyperinsulinemic subjects. A total of 120 consecutive women, aged 18-35 yrs were studied. All subjects were also evaluated by thyroid ultrasound (US) for measuring thyroid volume and the presence of nonpalpable nodules. Basal and post-prandial serum insulin was measured in all of them, as well as the Homeostasis Model Assessment (HOMA). Subjects were divided in two groups: Group A, with achrocordons (n = 44) and Group B, without achrocordons (n = 76). Group A showed 24 patients (54.5%) with thyroid nodules, whereas Group B only 13 subjects (17.1%); p = 0.0087. When we considered, as having high normal thyroid volume, the glands weighting more than 16 grams by US, without nodules, it was found that 8/44 cases from Group A (18.6%) and 3/76 from Group B (3.9%) fitted in such category, p = 0.0076. In patients with nodules and/or bigger thyroids, IR was observed in 36/44 (81.8%) of Group A and 14/76 (18.4%) of Group B, p = 0.0069, while the overall prevalence of IR was 0.47 in Group A and 0.05 in Group B, p = 0.00094. It is concluded that patients with achrocordons have a higher prevalence of US-detected thyroid nodules and larger thyroid glands. Then, it may be beneficial to search for thyroid abnormalities in those subjects with skin tags.

Debido a la alta frecuencia de acrocordones en pacientes que concurrían a nuestro servicio para realizar punciones aspirativas de nódulos tiroideos, realizamos un estudio prospectivo para investigar la relación entre este hallazgo y la presencia de insulino resistencia (IR), dado que los acrocordones son frecuentemente observados en pacientes hiperinsulinémicos. Se incluyeron 120 pacientes consecutivas, con edades entre 18 y 35 años. Todas fueron evaluadas con una ecografía tiroidea para determinar su volumen y la presencia de nódulos no palpables. Se midió insulinemia basal y post prandial, así como el índice Homeostasis Model Assessment (HOMA). Las pacientes se dividieron en 2 grupos: Grupo A, con acrocordones (n = 44) y Grupo B, sin acrocordones (n = 76). En el Grupo A se encontraron 24 (54.5%) con nódulos tiroideos, mientras que el Grupo B, sólo 13 (17.1%); p = 0.0087. Cuando consideramos la presencia de una glándula tiroides de tamaño elevado pero dentro de los límites normales, medida por ecografía (peso mayor a 16 gramos sin nódulos), encontramos que 8/44 casos del Grupo A (18.6%) y 3/76 del Grupo B (3.9%) entraron en esta categoría, p = 0.0076. En aquellas pacientes con nódulos tiroideos o glándula tiroides de mayor tamaño, observamos IR en 36/44 (81.8%) del Grupo A y en 14/76 (18.4%) del Grupo B, p = 0.0069, mientras que la prevalencia total de IR fue del 0.47 en el Grupo A y del 0.05 en el Grupo B, p = 0.00094. En conclusión, las pacientes con acrocordones tuvieron mayor prevalencia de nódulos tiroideos detectados por ecografía, glándula tiroides de mayor tamaño y mayor proporción de insulino resistencia.

Incidência de malignidade na doença nodular da tiróide com baixa suspeita clínica: estudo observacional prospectivo por dois anos numa coorte de 50 pacientes / Incidence of malignant lesions in patients with clinically benign thyroid nodules: observational and prospective study in a cohort of 50 patients followed during two years

OBJETIVOS: Verificar a ocorrência de lesões malignas em pacientes com nódulos tiroidianos clinicamente benignos e o valor da repetição da citologia aspirativa da tiróide (PAAF). MÉTODOS: Estudo observacional prospectivo por 2 anos em coorte de 50 mulheres com nódulos tiroidianos clinicamente benignos, com exame clínico, ultra-sonografia (US) e PAAF inicial, seguidas por acompanhamento clínico, US e repunção dos mesmos nódulos (PAAF2). RESULTADOS: A palpação não é bom método para o seguimento dos nódulos quando comparada ao US. O quadro clínico foi parâmetro de confiança, pois 47/50 pacientes (94 por cento) evoluíram sem malignidade durante o seguimento. PAAF1 e PAAF2 concordaram em 33/39 pacientes quando PAAF1 foi negativa (85 por cento); 11 pacientes foram operadas, 8 por PAAF suspeita e 3 por aumento do volume nodular durante o seguimento. O anátomo-patológico (AP) foi benigno nas lesões suspeitas (8 adenomas e 3 bócios colóides). Houve 2 casos de microcarcinoma papilífero não invasivo em área distante dos nódulos e 1 caso de carcinoma papilífero não invasivo em bócio multi-nodular. CONCLUSÕES: Houve concordância entre características clínicas de benignidade com PAAF, US e acompanhamento clínico ou cirurgia; numa paciente encontramos carcinoma papilífero. O US deve ser considerado em pacientes com suspeita de nódulos de tiróide ao exame clínico; na maioria das vezes quando o resultado da PAAF1 é negativo para malignidade, o segundo exame citológico confirma o primeiro.

Parasitic thyroid nodule in a patient with Hashimoto's chronic thyroiditis

A case of parasitic thyroid nodule is presented. The patient was a non symptomatic 53-year-old white woman, on irregular course of L-thyroxine to treat hypothyroidism due to Hashimoto's thyroiditis. Without a history of thyroid trauma or surgery, she presented a 1.6 x 0.7 x 0.5cm right pre-laryngeal lymph node-like mass which, on ultrasonography, appeared distinct from the gland. TSH, thyroid peroxidase antibody and thyroglobulin antibody serum levels were elevated and T4-free level was normal. Thyroid and total body 99mTc isonitrile scintiscan showed a topic thyroid without radionuclide uptake in the nodule. Fine-needle aspiration of the nodule showed epithelial cells with nuclear atypia and oncocytic changes plus intense lymphoid infiltration and germinative center formation, simulating lymph node metastasis of papillary thyroid carcinoma. Conventional biopsy revealed a parasitic thyroid nodule with Hashimoto's chronic thyroiditis. Parasitic thyroid nodule must always be remembered so that unnecessary surgical assessment and undesirable sequels may be avoided