Carcinoma papilar tiroideo con invasión locorregional: reporte de caso / Papillary thyroid crcinoma with locoregional invasion: case report

El cáncer diferenciado de tiroides incluye el tipo papilar y folicular que representan más del 80% de los casos y tienen un excelente pronóstico. Existen varios subtipos histológicos y las variantes foliculares son probablemente las más comunes. La incidencia de cáncer papilar variante folicular ha ido en aumento. En un reporte de un solo centro, cerca del 40% de los cánceres papilares eran variantes foliculares1. El subtipo infiltrativo de la variante folicular presenta sectores que invaden el parénquima tiroideo no neoplásico y carece de una cápsula tumoral bien definida. Tiene un comportamiento biológico y un perfil molecular que es más similar al tumor papilar clásico2. Existen características clínicas y patológicas asociadas con riesgo más alto de recurrencia tumoral y mortalidad; entre ellos se describen el tamaño del tumor primario y la presencia de invasión de tejidos blandos3. En la invasión de estructuras adyacentes, los sitios más comprometidos incluyen los músculos pretiroideos, el nervio laríngeo recurrente, el esófago, la faringe, laringe y la tráquea. Además, puede haber otras estructuras involucradas como: la vena yugular interna, la arteria carótida y los nervios vago, frénico y espinal4. El compromiso de los ganglios linfáticos y la incidencia de metástasis ganglionares en adultos depende de la extensión de la cirugía. Entre los que se realizan una disección radical modificada del cuello, hasta el 80% tienen metástasis en los ganglios linfáticos y el 50% de ellas son microscópicas5. Clínicamente los tumores localmente avanzados cursan con disfonía, disfagia, disnea, tos o hemoptisis, pero la ausencia de síntomas no descarta la invasión local. Según las guías de la American Thyroid Association6 son variables de mal pronóstico: la edad del paciente, el tamaño del tumor primario, la extensión extra tiroidea y la resección quirúrgica incompleta.

Differentiated thyroid cancer includes papillary and follicular types that represent more than 80% of cases and have an excellent prognosis. There are several histologic subtypes, and follicular variants are probably the most common. The incidence of papillary follicular variant cancer has been increasing. In a singlecenter report, about 40% of papillary cancers were follicular variants1. The infiltrative subtype of the follicular variant presents sectors that invade the non-neoplastic thyroid parenchyma and lacks a well-defined tumor capsule. It has a biological behavior and a molecular profile that is more similar to the classic papillary tumor2. There are clinical and pathological characteristics associated with a higher risk of tumor recurrence and mortality; These include the size of the primary tumor and the presence of soft tissue invasion3. In the invasion of adjacent structures, the most compromised sites include the pre-thyroid muscles, the recurrent laryngeal nerve, the esophagus, the pharynx, larynx and trachea. In addition, there may be other structures involved such as: the internal jugular vein, the carotid artery and the vagus, phrenic and spinal nerves4. The involvement of the lymph nodes and the incidence of lymph node metastases in adults depends on the extent of the surgery. Among those who undergo a modified radical neck dissection, up to 80% have lymph node metastases and 50% of them are microscopic5. Clinically locally advanced tumors present with dysphonia, dysphagia, dyspnea, cough, or hemoptysis, but the absence of symptoms does not rule out local invasion. According to the American Thyroid Association guidelines6, there are variables with a poor prognosis: the age of the patient, the size of the primary tumor, the extra-thyroid extension, and incomplete surgical resection.

Diagnostic performance of thyroid ultrasound in Hürthle cell carcinomas

ABSTRACT Objective Hürthle cell carcinomas (HCCs) of the thyroid have been recently reclassified as a separate entity due to their distinct clinical and molecular profiles. Few studies have assessed the ability of preoperative characteristics in differentiating HCCs from Hürthle cell adenomas (HCAs) due to the low prevalence of both lesions. This study aimed to compare the preoperative features of HCCs and HCAs and evaluate the diagnostic performance of ultrasound in distinguishing between both. Subjetcs and methods Retrospective study including 101 patients (52 HCCs and 49 HCAs) who underwent thyroid surgery from 2000 to 2016. Clinical, ultrasonographic, and histological data were reviewed. Diagnostic performance of suspicious sonographic features was analyzed in 51 cases (24 HCCs and 27 HCAs). Results Hürthle cell neoplasms were predominant in females. Subjects ≥ 55 years represented 58% of the cases of HCCs and 53% of those of HCAs. Carcinomas were significantly larger (p < 0.001), and a tumor size ≥ 4 cm significantly increased the risk of malignancy (odds ratio 3.67). Other clinical, cytologic, and sonographic data were similar between HCCs and HCAs. Among the HCCs, the lesions were purely solid in 54.2%, hypoechoic in 37.5%, and had coarse calcifications in 12.5%, microcalcifications in 8.3%, irregular contours in 4.2%, and a taller-than-wide shape in 16.7%. Predominantly/exclusive intranodular vascularization was observed in 52.6%. Overall, 58% of the HCCs were classified as TI-RADS 4 or 5 compared with 48% of the HCAs. TI-RADS 4 or 5 had a specificity of only 51.8% and a positive likelihood ratio of 1.21. Conclusions Apart from the lesion size, no other preoperative feature adequately distinguished HCCs from HCAs. Sonographic characteristics raising suspicion for malignancy, which are mostly present in papillary carcinomas, were infrequent in HCCs. New tools must be developed to improve preoperative diagnosis and deferral of surgery in cases of adenomas.

Cáncer diferenciado de tiroides en tiroides lingual, presentación de un caso / Differentiated thyroid cancer in the lingual thyroid, presentation of a case

The lingual thyroid carcinoma is very uncommon neoplasia with an incidence of less than 1 percent. The papillary variant is the most frequent. Cervical MRI helps differentiate muscle from thyroid tissue. The definitive diagnosis is given by histology. Management is similar to that of orthotopic thyroid cancer. We present the case of a 23-year-old woman with hypothyroidism undergoing treatment with dysphagia and sensation of pharyngeal foreign body and malodorous oral bleeding. Nasopharyngoscopy showed a rounded mass at the base of the tongue; the biopsy was compatible with thyroid neoplasia. Image study with ultrasound confirms empty thyroid bed with presence of lingual ectopic thyroid. The team of surgeons performed surgery with Trotter Technique, they removed a tumor of 4 centimeters of diameter. The definitive biopsy concludes minimally invasive follicular carcinoma. The treatment was completed with 100 mCi of radioiodine. Systemic screening at 7 days was negative, as the post-operative thyroglobulin (Tg)

Extremely Well-Differentiated Papillary Thyroid Carcinoma Resembling Adenomatous Hyperplasia Can Metastasize to the Skull: A Case Report

We describe herein histologic, immunohistochemical, and molecular findings and clinical manifestations of a rare case of an extremely well differentiated papillary thyroid carcinoma (EWD-PTC). Similarly, it is also difficult to diagnose follicular variant papillary thyroid carcinoma (FVPTC), whose diagnosis is still met with controversy. A recently reported entity of well-differentiated tumor of uncertain malignant potential (WDT-UMP) is added to the diagnostic spectrum harboring EWD-PTC and FVPTC. We report this case, because EWD-PTC is different from FVPTC in its papillary architecture, and also from WDT-UMP in its recurrence and metastatic pattern. These morphologically deceptive entities harbored diagnostic difficulties in the past because the diagnosis depended solely on histology. However, they are now diagnosed with more certainty by virtue of immunohistochemical and molecular studies. We experienced a case of EWD-PTC, which had been diagnosed as adenomatous hyperplasia 20 years ago and manifested recurrence with lymph node (LN) metastasis 7 years later. After another 7 years of follow-up, a new thyroid lesion had developed, diagnosed as FVPTC, with LN metastasis of EWD-PTC. One year later, the patient developed metastatic FVPTC in the skull. Immunohistochemically, the EWD-PTC was focally positive for CK19, negative for galectin-3, and focally negative for CD56. Molecular studies revealed BRAF-positivity and K-RAS negativity. The FVPTC in the left thyroid showed both BRAF and K-RAS negativity. In conclusion, EWD-PTC and FVPTC share similar histologic features, but they are different tumors with different molecular biologic and clinical manifestations. A large cohort of EWD-PTC should be included in further study.

Horner syndrome as a manifestation of thyroid carcinoma: a rare association / Síndrome de Horner como manifestação clínica de carcinoma da tireoide: uma associação rara

An 82-year-old patient presented a progressively growing hard thyroid nodule, and left ptosis. Additionally, ophthalmologic evaluation revealed ipsilateral miosis, diagnostic findings of Horner syndrome. Computerized tomography revealed a 7.5-cm thyroid mass infiltrating the main neck vessels. Although clinical and imaging data were suggestive of poorly differentiated thyroid carcinoma, fine-needle aspiration led to the diagnosis of papillary carcinoma. Paliative care was proposed to the patient due to the advanced stage of the neoplasm and to significant comorbidities. Horner syndrome is an infrequent manifestation of thyroid disorders and benign etiologies are more often implied. Malignant thyroid neoplasms represent a rare cause of Horner syndrome. However, an appropriate and prompt diagnosis is paramount for timely treatment of rare thyroid malignancies.

Paciente de 82 anos apresentando-se com nódulo tireoidiano de crescimento progressivo e ptose palpebral esquerda. O exame oftalmológico revelou ainda miose ipsilateral e achados diagnósticos de síndrome de Horner. A tomografia computadorizada mostrou massa tireoidiana de 7,5 cm infiltrando os grandes vasos do pescoço. Apesar dos dados clínicos e imagiológicos sugestivos de um carcinoma pouco diferenciado da tireoide, a citologia aspirativa foi diagnóstica de carcinoma papilar. Em função do estádio avançado da neoplasia e das comorbilidades significativas, foi proposta para terapêutica paliativa. A síndrome de Horner é uma manifestação clínica infrequente em tumores tireoidianos, estando as condições benignas maioritariamente implicadas. As neoplasias malignas da tireoide representam uma causa rara de síndrome de Horner. Contudo, um diagnóstico adequado e expedito é fundamental para o tratamento atempado nos raros casos de malignidade da tireoide.

Contribuição da análise de textura do núcleo celular para o diagnóstico diferencial de lesões foliculares da tireoide: comparação com marcadores imunoistoquímicos / Contribution of nuclear texture analysis for the differential diagnosis of follicular lesions of the thyroid: comparison to immunohistochemical markers

OBJETIVO E MÉTODOS: Com o propósito de investigar a contribuição do exame da cromatina nuclear no diagnóstico diferencial das lesões foliculares da glândula tireoide, foram estudadas 76 amostras previamente submetidas à análise de expressão proteica de HBME-1, CK-19 e galectina-3. RESULTADOS: HBME-1 confirmou-se como o mais sensível marcador imunoistoquímico de malignidade. Uma série de variáveis morfométricas, densitométricas e de textura foram úteis na distinção entre os diferentes tipos de lesão folicular. Entre essas variáveis, o r², parâmetro relacionado à granularidade do núcleo, apresentou a melhor acurácia, sensibilidade, especificidade, valor preditivo positivo e negativo, diferenciando lesões benignas de malignas. CONCLUSÃO: A morfometria analítica de imagem da cromatina nuclear pode acrescentar acurácia ao diagnóstico diferencial das lesões de padrão folicular.

OBJECTIVE AND METHODS: To investigate the utility of nuclear chromatin texture assessment in the differential diagnosis of follicular patterned lesions, by means of examining 76 samples previously submitted to the immunohistochemical protein analysis of HBME-1, CK-19 and galectina-3. RESULTS: HBME-1 confirmed to be the most sensitive marker of malignancy. A series of morphometric, densitometric and texture variables were useful in the discrimination of the different types of follicular lesions. Among these variables, r², a parameter related to the granularity of the nucleus presented the best accuracy, sensitivity, specificity and positive and negative predictive values, distinguishing benign from malignant lesions. CONCLUSION: The morphometric analysis of nuclear chromatin images may add accuracy to the differential diagnosis of follicular patterned lesions.

Thyroid cancer in toxic and non-toxic multinodular goiter.

BACKGROUND: Many authors have claimed that hyperthyroidism protects against thyroid cancer and believed that the incidence of malignancy is lower in patients with toxic multinodular goiter (TMG) than in those with non-toxic multinodular goiter. But in recent studies, it was reported that the incidence of malignancy with TMG is not as low as previously thought. AIM: To compare the thyroid cancer incidence in patients with toxic and non-toxic multinodular goiter. SETTINGS AND DESIGN: Histology reports of patients treated surgically with a preoperative diagnosis of toxic and non-toxic multinodular goiter were reviewed to identify the thyroid cancer incidence. Patients having a history of neck irradiation or radioactive iodine therapy were excluded from the study. MATERIALS AND METHODS: We reviewed 294 patients operated between 2001-2005 from toxic and non-toxic multinodular goiter. One hundred and twenty-four of them were toxic and 170 were non-toxic. Hyperthyroidism was diagnosed by elevated tri-iodothyroinine / thyroxine ratios and low thyroid-stimulating hormone with clinical signs and symptoms. All patients were evaluated with ultrasonography and scintigraphy and fine needle aspiration biopsy. STATISTICAL ANALYSIS USED: Significance of the various parameters was calculated by using ANOVA test. RESULTS: The incidence of malignancy was 9% in the toxic and 10.58% in the non-toxic multinodular goiter group. Any significant difference in the incidence of cancer and tumor size between the two groups could not be detected. CONCLUSIONS: The incidence of malignancy in toxic multinodular goiter is not very low as thought earlier and is nearly the same in non-toxic multinodular goiter.

Total thyroidectomy: the treatment of choice in differentiated thyroid carcinoma.

INTRODUCTION: Clinically detectable thyroid carcinoma constitutes less than 1% of human cancers. Ninety percent of all thyroid malignancies are differentiated papillary and follicular carcinoma. Surgery plays a key role in differentiated thyroid carcinoma as it carries excellent prognosis, lower recurrence rate and low mortality rate but controversy persists for extent of surgery and optimal surgical management of lymph node metastasis. PATIENT AND METHOD: A retrospective analysis was done for the cases that underwent total thyroidectomy with lymph node dissection for differentiated carcinoma of thyroid in Kathmandu Medical College during two year periods (Oct 2001 to Oct 2003). RESULT: In our experience with 18 cases of Differentiated Thyroid Carcinoma (DTC) treated with total thyroidectomies and lymph node dissection, papillary carcinoma was predominant with 83% incidence. Disease was prevalent in 50 to 60 year age group. Except two cases of transient hypocalcaemia and few wound related complications, there have been no other complications. CONCLUSION: Total thyroidectomy with lymph node dissection is safe and effective, so, the treatment of choice in cases of differentiated thyroid carcinoma.

Postoperative Findings and Risk for Malignancy in Thyroid Nodules with Cytological Diagnosis of the so-called "Follicular Neoplasm"

BACKGROUND: Malignant follicular lesion is not differentiated from benign lesions cytologically. The objective of this study was to assess the rate and the risk of malignancy in thyroid nodules which were cytologically diagnosed as follicular neoplasm by fine-needle aspiration (FNA) cytology. METHODS: All the patients who had undergone surgery with cytological diagnosis of follicular neoplasm from January 1996 through December 2001 in Asan Medical Center were studied retrospectively. Patients' and nodule characteristics were analyzed for factors associated with the presence of cancer. Two hundred and fifteen patients (196 females, 19 males) were included and their mean age was 39.4 years (range: 12~76). RESULTS: About half of the patients (102 out of 215, 47.4%) had malignancy with 29 papillary carcinomas, 57 follicular carcinomas, 15 H rthle cell carcinomas and 1 medullary carcinoma. Previously suggested factors associated with risk for malignancy, such as male gender, large tumor size (> 4 cm) or age of patients (> 45 years), were not associated with increased risk. Diagnosis of H rthle cell neoplasia on FNA was also not associated with increased risk. Only the extremes in age of the patients (below 20 or above 60 years) were associated with increased risk for malignancy. CONCLUSION: In our findings, prevalence of carcinoma in thyroid nodule patients with cytological diagnosis of follicular neoplasm was much higher than those reported. Clinical characteristics, such as male gender, age and nodule size, are not useful predictors for the presence of malignancy. Thyroid nodules with cytological diagnosis of follicular neoplasm warrant immediate surgery.

The pathology of thyroid neoplasms at the University Hospital of the West Indies: a 10-year analysis

Thyroid neoplasms were diagnosed in 93 patients (79 women and 14 men) between January 1986 and December 1995. 52 tumors were benign and 41 were malignant. An unusual finding was that there were 16 cases each of follicular and papillary carcinomas: that is, more patients with follicular carcinomas than expected. The significance is discussed.

Tumores papilares y quísticos del páncreas: estudio clínicopatológico, citopatológico, inmunohistoquímico y de ploidía nuclear / Papillary cystic tumors of the pancreas: clinico-pathological, cytopathological, immunohistochemical, and nuclear ploidy study

Se presentam 7 casos de tumores papilares y quísticos del páncreas (TPQ): 5 se presentaron en mujeres y 2 em hombres con edades entre 21 y 68 años (media 39). Clínicamente todos tenían una massa abdominal palpable, 3 tumores estaban localizados en la cabeza, 2 en el cuerpo, 1 en el istmo y el restante en la cola del órgano; 5 casos fueron tratados con resecciones quirúrgicas radicales y 2 sólo biopsias. En 4 casos se realizó punción aspiración preoperatoria, realizándose el diagnóstico en 3 de ellos. inmunohistoquímicamente tenían marcadores endocrinos y exocrinos apoyando estos datos la hipótesis de la diferenciación dual de estos tumores. La ploidía nuclear demostró 4 tumores diploides, 2 diploides-tetraploides y 1 aneuploide. Los TPQ son neoplasia de bajo grado factibles de ser diagnosticados por punción aspiración, con un fenotipo mixto (endocrino-exocrino) y con una predominancia de tumores diploides