¿Neoplasia de células de Hürtle o de células oncocíticas? Denominación actual y su manejo. Reporte de caso / Hürtle cell or oncocytic cell neoplasm? Current denomination and its management. Case report

Introducción: Las células de Hürtle fueron descritas por Max Askanazy en 1898, aunque su denominación inapropiada ha permanecido en el léxico. Pueden observarse en una amplia variedad de lesiones tiroideas, desde afecciones no neoplásicas hasta francamente malignas. Caso clínico: Femenina de 62 años de edad, asmática e hipertensa controlada, alérgica al yodo y a la penicilina, quien inicia enfermedad actual 1 año previo al presentar aumento de volumen en región anterior del cuello. Ecografía tiroidea reportó glándula aumentada de tamaño, con nódulo tiroideo derecho, complejo de 4 cm; y nódulo tiroideo izquierdo, complejo de 2 cm, TI-RADS 4C. Tomografía computarizada reportó lesión ocupantne de espacio del lóbulo tiroideo derecho de 6 cm y nódulos tiroideos izquierdos de 3 y 2 cm. Pruebas tiroideas sin alteraciones. Se realizó tiroidectomía total. Diagnóstico histopatológico: adenoma de células de Hürtle. Conclusión: En la actualidad, el término correcto es neoplasia de células oncocíticas, bien sea para el adenoma o para el carcinoma. Este tipo de tumores se presenta con mayor frecuencia en mujeres de mediana edad y con un tamaño considerable al momento del diagnóstico. Es necesario establecer un protocolo de acción ante el diagnóstico presuntivo mediante punción por aspiración por aguja fina, debido a la dificultad para diferenciar entre patología benigna y maligna, con la finalidad de garantizar una conducta terapeútica adecuada(AU)

Introduction: Hürtle cells were described by Max Askanazy in 1898, although their inappropriate name has remained in the lexicon. They can be seen in a wide variety of thyroid lesions, from non-neoplastic to frankly malignant conditions. Clinical case: A 62-year-old female, asthmatic and controlled hypertensive, allergic to iodine and penicillin, who started the current disease 1 year before presenting volume increase in the anterior region of the neck. Thyroid ultrasound reported an enlarged gland, with a 4-cm complex right thyroid nodule; and left thyroid nodule, 2 cm complex, TI-RADS 4C. Computed tomography reported a 6 cm space-occupying lesion of the right thyroid lobe and 3 and 2 cm left thyroid nodules. Thyroid tests without alterations. Total thyroidectomy was performed. Histopatological diagnosis: Hürtle cell adenoma. Conclusion: Currently, the correct term is oncocytic cell neoplasm, either for adenoma or for carcinoma. This type of tumors occurs more frequently in middle-aged women and with a considerable size at the time of diagnosis. It is necessary to establish a protocol of action before the presumptive diagnosis by means of fine needle aspiration procedure, due to the difficulty to differentiate between benign and malignant pathology, with the purpose of guaranteeing an adequate therapeutic conduct(AU)

Tiroides Ectópica Lingual: caso Clínico / Lingual Ectopic Thyroid: a clinical case

La tiroides ectópica lingual es una patología muy poco frecuente, producida por la detención en el descenso normal de la glándula durante el desarrollo embrio-nario. La localización lingual de tejido tiroideo es la más común entre las tiroides ectópicas o aberrantes. Esta enfermedad puede ser asintomática pero, cuan-do los signos y síntomas están presentes, guardan estrecha correlación con la localización de la lesión y son proporcionales a su tamaño. El diagnóstico debe realizarse clínicamente y con el complemento de es-tudios por imágenes y endocrinológicos. En los aná-lisis de laboratorio se debe incluir dosaje de las hor-monas TSH, T4 libre y T3, vinculadas con la función tiroidea. Las biopsias deben evitarse ya que causan desequilibrio en la producción hormonal de la glándu-la y peligro de profusas hemorragias. En este artículo se desarrolla una descripción de las generalidades de la tiroides ectópica lingual, y se presenta un caso clínico de un niño con un tumor lingual, que fue deri-vado por su médica pediatra a cirugía para realizar una biopsia. Asimismo, se comenta la importancia que tiene para el odontólogo conocer esta patología a fin de poder evitar sus posibles complicaciones (AU)

Lingual thyroid is a rare disorder produced by a failure in the descent of thyroid gland to its normal position during embryological development. Lingual localization of thyroid tissue is the most common among the ectopic or aberrant thyroids. This condition can be asymptomatic, although when symptoms take place, they are connected to the lesion location and depend on its size. Diagnosis should be made clinically and complemented with imaging and endocrine studies. Laboratory analysis must include dosage of TSH, free T4 and T3, thyroid function-linked hormones. Due to the possible imbalance in the gland hormone production and the risk of massive bleeding, biopsy should be avoided. In this article, a brief description of lingual ectopic thyroid generalities is developed and a clinical case of a 7-years old child is provided. Additionally, dentistry importance of knowing this condition is commented, in order to prevent its possible complications (AU)

Elastografía por ondas de corte como herramienta en la evaluación de los nódulos tiroideos / Shear-wave elastography as a tool in the assessment of thyroid nodules

Resumen Introducción: La elastografía por ondas de corte (SWE) ha demostrado ser predictiva de malignidad en nódulos tiroideos. Objetivo: Determinar mediante SWE, el punto de corte de la rigidez con mayor especificidad y sensibilidad para detectar nódulos tiroideos que requieren cirugía. Métodos: Estudio transversal de pacientes con nódulos tiroideos evaluados ultrasonográficamente en un periodo de tres años; se empleó la clasificación TI-RADS y mediante SWE se determinó la rigidez de los nódulos. Con el sistema Bethesda se clasificaron las muestras histopatológicas y mediante curva ROC se obtuvo el punto de corte de la rigidez con mayor especificidad y sensibilidad. Resultados: 41 % de los nódulos fue TI-RADS 5 y 59 %, TI-RADS 1-4. En los TI-RADS 5, la mediana de rigidez de los nódulos con categoría IV-VI del sistema Bethesda fue de 35.9 kPa y en los nódulos con TI-RADS 1-4, 21.6 kPa. En los nódulos TI-RADS 5, la rigidez > 32.5 kPa tuvo especificidad de 75 % y sensibilidad de 57 % para detectar los que requieren cirugía; en los TI-RADS 1-4, el valor de corte de 21.5 kPa tuvo especificidad de 63 % y sensibilidad de 51 %. Conclusión: La rigidez determinada por SWE es útil para detectar nódulos que requerirán exploración quirúrgica.

Abstract Introduction: Shear-wave elastography (SWE) has been shown to be predictive of malignancy in thyroid nodules. Objective: To determine, by SWE, the stiffness cutoff point with the highest specificity and sensitivity to detect thyroid nodules that require surgery. Methods: Cross-sectional study of ultrasonographically-evaluated patients for thyroid nodules over a period of three years; the TI-RADS classification system was used, and nodule stiffness was determined by SWE. Histopathological specimens were classified using the Bethesda system, and the stiffness cutoff point with the highest specificity and sensitivity was obtained using ROC curves. Results: Forty-one percent of the nodules were classified as TI-RADS 5, and 59 %, as TI-RADS 1-4. In TI-RADS 5 nodules, median stiffness of those in Bethesda system IV-VI categories was 35.9 kPa; in nodules with TI-RADS 1-4, 21.6 kPa. In TI-RADS 5 nodules, a cutoff point > 32.5 kPa had a specificity of 75 % and sensitivity of 57 % to detect those requiring surgery; in TI-RADS 1 to 4 nodules, a cutoff point of 21.5 kPa had a specificity of 63 % and sensitivity of 51 %. Conclusion: SWE-determined stiffness is useful to detect nodules that require surgical evaluation.

Ligadura segregada de la arteria tiroidea superior. Minimizar la lesión posterior a la tiroidectomía en el rama externa del nervio laríngeo superior. Un nuevo enfoque práctico / Segregated ligation of the superior thyroid artery minimize post-thyroidectomy injury to the external branch of superior laryngeal nerve, a novel practical approach

External division of the superior laryngeal nerve supplies the crico-thyroid muscle to excite length and thickness of the vocal fold. Thus, increasing voice tone. The vicinity with the superior thyroid vessels sets the external branch of the superior laryngeal nerve in danger every time the superior end of the thyroid is dissected. Thus, the aim of present study is to assess the rate and complication of external branch of the superior laryngeal nerve injury post- thyroidectomy when segregated ligation of superior thyroid vessels closes to thyroid capsule without prior nerve identification and without nerve stimulator or intraoperative neuro-monitoring. The presented study is a prospective, non- randomized clinical study included 1450 patients who underwent thyroidectomy which either (total thyroidectomies, near total thyroidectomies or lobectomy and isthmectomy) in the Department of Surgery/AL-Diawania Teaching Hospital in Diawania City, Iraq, between January 2000 and February 2018. All patients underwent thyroidectomy through segregated ligation of superior thyroid artery very closely to thyroid capsule without prior nerve identification and without nerve stimulator or intraoperative neuromonitoring. Postoperative indirect laryngoscopy vocal cord examination with long term follow up through physical examination and clinical history to evaluate nerve integrity. In present study, the total cases with EBSLN injury were 38 (2.6%), in which the transient EBSLN injury occurred in 28 (1.9%) of patients and permanent injury occurred in 10 (0.7%) of patients and majority of cases with EBSLN injury were occur in patients with large size goiter 29 (2%) more than small size goiter 9 (0.6%) And these differences were statistically significant differences, (P<0.005). In addition to, the majority of cases with EBSLN injury were occur in male {25(1.7%)} more than female patients {13(0.9%)} And these differences were statistically significant differences, (P<0.005). Segregated ligation of superior thyroid artery is a safe technical option, cost effective, time preserved and need surgical skills to minimized risk of injury to the external laryngeal nerve

Técnica EXIT como manejo de la vía aérea en masas gigantes congénitas de cuello / Ex-Utero Intrapartum Treatment for airway management in congenital giant neck masses

Resumen: Introducción: Las masas congénitas de cabeza y cuello se asocian a asfixia perinatal e injuria cerebral con elevada mortalidad. La técnica EXIT (Ex Útero Intrapartum Treatment) consiste en asegurar la vía aérea del neonato, sin interrumpir la oxigenación y perfusión materno-fetal a través del soporte placentario. Esta técnica no ha sido estandarizada en países de medianos ingresos. Objetivo: Describir el caso clínico de 2 neonatos manejados mediante la técnica EXIT. Caso Clínico: Se reportan dos casos, uno con malformación linfática diagnosticada a la semana 20 gestación y el segundo con tiromegalia y polihidramnios diagnosticados a la semana 35 de gestación. En ambos casos, duran te la cesárea se realizó la técnica EXIT con un equipo conformado por neonatólogo, ginecólogo, anestesiólogo, cirujano pediatra, otorrinolaringólogo, enfermero y terapeuta respiratorio. En los dos pacientes se logró asegurar la vía aérea mediante intubación orotraqueal al primer intento. En el caso 1 se confirmó la malformación linfática y recibió escleroterapia, y en el caso 2 se diagnosticó hipotiroidismo congénito asociado a bocio, que fue manejado con levotiroxina. Los pacientes se mantuvieron 7 y 9 días con ventilación mecánica invasiva respectivamente y egresaron sin complicaciones respiratorias. Conclusiones: La técnica EXIT en estos casos fue un procedimiento seguro, llevado a cabo sin inconvenientes. Se necesita un equipo multidisciplinario y la disponibilidad de una unidad de cuidados intensivos neonatales, con el objetivo de reducir potenciales complica ciones y garantizar el manejo postnatal. Para lograr su ejecución, es indispensable el diagnóstico prenatal oportuno.

Abstract: Introduction: Congenital head and neck masses are associated with perinatal asphyxia and brain injury, increasing the risk of death. The EXIT (Ex Utero Intrapartum Treatment) technique con sists of ensuring the newborn's airway while is still receiving placental support. This technique has not been standardized in developing countries. Objective: To describe the clinical outcomes of two infants who underwent the EXIT technique. Clinical Case: We present two cases, one with lymphatic malformation diagnosed at 20 weeks of gestational age (WGE) and the second one, a preterm newborn with thyromegaly and polyhydramnios, diagnosed at 35 WGE. In both cases, during the C-section, the EXIT technique was performed with a team of a neonatologist, a gyne cologist, an anesthesiologist, a pediatric surgeon, an otolaryngologist, a nurse, and a respiratory therapist. In both patients, the neonatologist achieved to secure the airway through orotracheal intubation at the first attempt. In the first case, lymphatic malformation was confirmed and re ceived sclerotherapy, and the second one was diagnosed with congenital hypothyroidism which was managed with levothyroxine. The patients needed invasive mechanical ventilation for 7 and 9 days, respectively, and were discharged without respiratory complications. Conclusions: In these patients, the EXIT technique was a safe procedure, carried out without inconvenience. A multi disciplinary approach and the availability of a neonatal intensive care unit are needed to reduce potential complications and ensure postnatal management. Timely prenatal diagnosis is essential to perform this technique.

Use of strain ultrasound elastography versus fine-needle aspiration cytology for the differential diagnosis of thyroid nodules: a retrospective analysis

OBJECTIVE: Fine-needle aspiration cytology is the risk stratification tool for thyroid nodules, and ultrasound elastography is not routinely used for the differential diagnosis of thyroid cancer. The current study aimed to compare the diagnostic parameters of ultrasound elastography and fine-needle aspiration cytology, using surgical pathology as the reference standard. METHODS: In total, 205 patients with abnormal thyroid function test results underwent ultrasound-guided fine-needle aspiration cytology on the basis of the American College of Radiology Thyroid Imaging-Reporting and Data System classification and strain ultrasound elastography according to the ASTERIA criteria. Histopathological examination of the surgical specimens was performed according to the 2017 World Health Organization classification system. Moreover, a beneficial score analysis for each modality was conducted. RESULTS: Of 265 nodules, 212 measured ≥1 cm. The strain index value increased from benign to malignant nodules, and the presence of autoimmune thyroid diseases did not affect the results (p>0.05 for all categories). The sensitivities of histopathological examination, ultrasound elastography, and fine-needle aspiration cytology for detection of nodules measuring ≥1 cm were 1, 1, and 0.97, respectively. The working area for detecting nodule(s) in a single image was similar between strain ultrasound elastography and fine-needle aspiration cytology for highly and moderately suspicious nodules. However, for mildly suspicious, unsuspicious, and benign nodules, the working area for detecting nodule(s) in a single image was higher in strain ultrasound elastography than in fine-needle aspiration cytology. CONCLUSION: Strain ultrasound elastography for highly and moderately suspicious nodules facilitated the detection of mildly suspicious, unsuspicious, and benign nodules.

Utilidad para médicos no radiólogos de la clasificación tirads y las características ecográficas de los nódulos tiroideos / Usefulness for non radiologist physicians of tirad classification and ecographic characteristics of thyroid nodules

Dada la mayor accesibilidad a la ecografía tiroidea, se diagnostican más nódulos de forma incidental aumentando su prevalencia al 65% en las tres últimas décadas. Todo ello ha supuesto un aumento de punciones innecesarias. El objetivo de nuestro estudio es identificar la utilidad de la clasificación TIRADS y de las características ecográficas de los nódulos tiroideos para establecer la probabilidad de malignidad de los mismos y seleccionar aquellos sospechosos para realizar la punción y aspiración con aguja fina (PAAF). Se encontró una relación estadísticamente significativa entre la malignidad y nódulo sólido, hipoecogenicidad, márgenes irregulares y microcalcificaciones. Sin embargo, no se encontró relación estadísticamente significativa entre malignidad y número de nódulos, tamaño nodular, diámetro craneocaudal y vascularización central. Asimismo, un 26.1% de los nódulos TIRADS-2 (todos ellos microcarcinomas), un 30% de los TIRADS-3 y un 54 % de los TIRADS-4 fueron malignos (p 0.027). Tanto el TIRADS como las características ecográficas aisladas son útiles para identificar nódulos sugerentes de malignidad.

Owed to the easier accessibility to thyroid ecography, more incidental nodules are discovered reaching their prevalence the 65 % of population in the last three decades. All of it has resulted in a growth of unnecessary fine needle aspirations (FNA). Our study objective is to identify the TIRADS classification utility and the nodules sonographic characteristics to establish their probability of malignancy and to select those suspicious susceptible of FNA. We found a statistically significant relationship between malignancy and solid nodule, hypoechogenicity, irregular margins and microcalcifications. However we didn´t find a relation between malignancy and number, size, shape (taller than wide) and central vascularity. With respect to TIRADS classification, 26,1% of TIRADS-2 (all of them microcarcinomas), 30% of TIRADS-3 and 54% of TIRADS-4 were malignant (p: 0,027). Both of them, TIRADS and individual sonographic characteristics are useful to identify nodules suspicious of malignancy.

Associations between thyroid-stimulating hormone and hypertension according to thyroid cyst status in the general population: a cross-sectional study

BACKGROUND@#The absence of thyroid cysts may indicate latent thyroid damage, as demonstrated in our previous study. However, the association between the absence of thyroid cysts and latent functional damage of the thyroid is unknown. At low thyroid hormone productivity, which may be associated with latent functional damage of the thyroid, the association between thyroid-stimulating hormone (TSH) and hypertension might be enhanced. Therefore, we evaluated the association between TSH level and hypertension stratified by thyroid cyst status.@*METHODS@#We conducted a cross-sectional study of 1724 euthyroid Japanese individuals aged 40-74 years who participated in an annual health checkup in 2014.@*RESULTS@#In the study population, 564 and 686 participants had thyroid cysts and hypertension, respectively. A significant positive association was observed between TSH and hypertension in subjects without a thyroid cyst but not in subjects with thyroid cysts. There was a significant positive association between hypertension and TSH in subjects without a thyroid cyst (odds ratio [OR] 1.27; 95% confidence intervals [CI] 1.01, 1.61) but not in subjects with thyroid cysts (OR 0.79; CI 0.57, 1.09) in the model fully adjusted for known confounding factors. The correlation between the TSH and free triiodothyronine (fee T3) levels (simple correlation coefficient [r] = - 0.13, p < 0.01) was stronger in the subjects without thyroid cysts than in those with thyroid cysts (r = - 0.03, p = 0.525).@*CONCLUSIONS@#TSH is positively associated with hypertension only in individuals without thyroid cysts. The correlation between the TSH and free T3 levels was stronger in the subjects without thyroid cysts than in those with thyroid cysts. Therefore, the absence of thyroid cysts could be related to the association between TSH level and hypertension, possibly by indicating that the subjects without thyroid cysts had limited thyroid hormone reserves. Therefore, the absence of thyroid cysts could indicate the latent functional damage of the thyroid.

Interplay of TGFβ signaling and microRNA in thyroid cell loss of differentiation and cancer progression

ABSTRACT Thyroid cancer has been rapidly increasing in prevalence among humans in last 2 decades and is the most prevalent endocrine malignancy. Overall, thyroid-cancer patients have good rates of long-term survival, but a small percentage present poor outcome. Thyroid cancer aggressiveness is essentially related with thyroid follicular cell loss of differentiation and metastasis. The discovery of oncogenes that drive thyroid cancer (such as RET, RAS, and BRAF), and are aligned in the MAPK/ERK pathway has led to a new perspective of thyroid oncogenesis. The uncovering of additional oncogene-modulated signaling pathways revealed an intricate and active signaling cross-talk. Among these, microRNAs, which are a class of small, noncoding RNAs, expanded this cross-talk by modulating several components of the oncogenic network - thus establishing a new layer of regulation. In this context, TGFβ signaling plays an important role in cancer as a dual factor: it can exert an antimitogenic effect in normal thyroid follicular cells, and promote epithelial-to-mesenchymal transition, cell migration, and invasion in cancer cells. In this review, we explore how microRNAs influence the loss of thyroid differentiation and the increase in aggressiveness of thyroid cancers by regulating the dual function of TGFβ. This review provides directions for future research to encourage the development of new strategies and molecular approaches that can improve the treatment of aggressive thyroid cancer.

Modelo ambulatorial de atendimento de nódulo de tireoide / Ambulatory care model thyroid nodule

A prevalência de detecção de nódulos na tireoide através da palpação é de aproximadamente 5%. Essa prevalência sobe para 19 a 67% quando utilizada a avaliação ecográfica. A importância da avaliação clínica dessa entidade está na necessidade de diagnosticar o câncer de tireoide que ocorre em 5 a 10% dos casos. O relato descreve o perfil dos atendimentos realizados no ambulatório de nódulos de tireoide do Hospital Municipal Dr. Mário Gatti no período de 01/05/17 a 27/07/18 de pacientes que tiveram diagnóstico ultrassonográfico de nódulo de tireoide e realizaram punção aspirativa por agulha fina, a fim de inferir a respeito da capacidade de resolutividade do ambulatório interdisciplinar (endocrinologia e cirurgia de cabeça e pescoço) no diagnóstico e tratamento do câncer de tireoide. A organização do ambulatório com atendimento integral e por equipe multidisciplinar, possibilita uma melhora na qualidade assistencial além de ser elemento facilitador para o ensino, aprendizado e pesquisa. (AU)

The rate of thyroid node detection by touch is approximately 5%. This rate goes up to a range between 19 and 67% when a sonographic evaluation is used. The importance of the clinical evaluation of those thyroid nodes is within the need of diagnosing the cancer that occurs in 5 to 10% of the cases. This paper describes the profile of consultations performed at the Outpatient Clinic Thyroid Node Unit of the Municipal Hospital Dr. Mário Gatti (HMMG) from 01/05/17 to 07/27/18, of patients who had ultrasonographic diagnostics of thyroid node and underwent fine-needle aspiration, in order to draw conclusions about the capacity of the interdisciplinary clinic (Endocrinology and Head and Neck surgery) to diagnose and treat thyroid cancer effectively. The organization of the outpatient clinic, with comprehensive care and multidisciplinary team, enables an improvement in medical assistance as well as facilitating teaching, learning and research. (AU)

Hypothyroid offspring replacement with euthyroid wet nurses during lactation improves thyroid programming without modifying metabolic programming

ABSTRACT Objective Determine the milk quality effect during lactation on the metabolic and thyroid programming of hypothyroid offspring. Materials and methods Ten-week-old female Wistar rats were divided into two groups: euthyroid and thyroidectomy-caused hypothyroidism. The rats were matted and, one day after birth, the pups were divided into three groups: euthyroid offspring (EO), hypothyroid offspring (HO) and hypothyroid with a euthyroid replacement wet nurse (HRO). During lactation, the milk quality and offspring body length were evaluated. The body weight and energy intake were determined on a weekly basis, as well as the metabolic profile at the prepubertal (P35-36) and postpubertal (P55-56) ages. At P56, the animals were sacrificed, the adipose tissues were weighed and the thyroid glands were dissected for histological processing. Results The milk of the hypothyroid wet nurse decreases proteins (16-26%), lipids (22-29%) and lactate (22-37%) with respect to euthyroid. The HO has a lower body weight gain (23-33%), length (11-13%) and energy intake (15-21%). In addition, HO presents impaired fasting glucose and dyslipidemia, as well as a reduction in seric thyroid hormone (18-34%), adipose reserves (26-68%) and thyroid gland weight (25-34%). The HO present thyroid gland cytoarchitecture alteration. The HRO develop the same metabolic alterations as the HO. However, the thyroid gland dysfunction was partially prevented because the HRO improved under about 10% of the serum thyroid hormone concentration, the thyroid gland weight although histological glandular changes presented. Conclusions The replacement of hypothyroid offspring with a euthyroid wet nurse during lactation can improve the thyroid programming without modifying metabolic programming.

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.

Hounsfield unit value has null effect on thyroid nodules at 18F-FDG PET/CT scans

ABSTRACT Objectives: Detection rate of thyroid nodules is increasing with the use of new imaging modalities, especially in screening for malignancies. Positron emission tomography/computed tomography (PET/ CT)-positive thyroid nodules should be differentiated for malignancy to avoid unnecessary operations and further follow-up. Most trials evaluate the role of SUVmax, but there is no definitive information about the utility of Hounsfield unit (HU) values for prediction of malignancy. This study aimed to evaluate the HU values beside SUVmax for detecting malignancy risk of PET/CT-positive thyroid nodules. Subjects and methods: Results of 98 cancer patients who had fine needle aspiration biopsy (FNAB) for thyroid nodules detected on PET/CT between January 2011 and December 2015 were assessed. The FNABs and surgical pathological results were recorded. Results: FNABs revealed benign results in 32 patients (32.7%), malignant in 18 (18.4%), non-diagnostic in 20 (20.4%), and indeterminate in 28 (28.5%). Twenty-four patients underwent thyroidectomy. The mean HU values were not significantly different in benign and malignant nodules (p = 0.73). However, the mean SUVmax was significantly higher (p < 0.001) in malignant ones. Area under curve (AUC) was 0.824 for SUVmax; the cut-off value was over 5.55 (p < 0.001), with 80% sensitivity, 84.5% specificity. Conclusions: Our current study demonstrated that HU value does not add any additional valuable information for discriminating between malignant and benign thyroid nodules. We also defined a SUV cut-off value of 5.55 for malignant potential of thyroid nodules detected on PET/CT Arch Endocrinol Metab. 2018;62(4):460-5

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.

Linfonodos do nível VI: estudo anatômico dos linfonodos localizados entre o nervo laríngeo recorrente e a artéria carótida comum direita / Level VI lymph nodes: an anatomic study of lymph nodes located between the recurrent laryngeal nerve and the right common carotid artery

RESUMO Objetivo: descrever a presença de linfonodos e suas relações com características demográficas e antropométricas em uma região específica ainda não descrita pelos compêndios de anatomia, por nós denominada de Recesso Carotídeo Recorrencial (RCR), localizada entre o nervo laríngeo recorrente direito, a artéria carótida comum direita e a artéria tireoidea inferior direita. Métodos: foram dissecadas 32 regiões cervicais à direita de cadáveres com até 24 horas de post mortem. O tecido fibrogorduroso do RCR foi ressecado e preparado com fixação em formol. Em seguida, foi submetido a uma sequência crescente de álcoois (70%, 80% e 90%), posteriormente a uma solução de Xilol e, por fim, a uma solução de Salicilato de Metila, respeitando o tempo necessário de cada etapa. O estudo macroscópico foi realizado na peça diafanizada, observando a presença ou não de linfonodos. Quando presentes, foram fotografados e suas medidas foram aferidas com um paquímetro digital. No estudo microscópico, foi utilizada a coloração hematoxilina-eosina para confirmação do linfonodo. Resultados: observou-se a presença de linfonodos em 22 dos 32 espécimes (68,75%), com o número de linfonodos por cadáver variando de zero a seis (média de 1,56±0,29) e tamanho com média de 7,82mmx3,86mm (diâmetros longitudinal x transversal). Conclusão: a relação entre dados antropométricos e presença de linfonodos no RCR (teste exato de Fischer) foi significante para indivíduos normolíneos (p=0,03) e também significante entre a etnia branca (p=0,04).

ABSTRACT Objective: to describe the presence of lymph nodes and their relationships with demographic and anthropometric characteristics in a specific region, not yet described in anatomy compendiums, called by us Recurrent Carotid Recess (RCR) and located among the right recurrent laryngeal nerve, the right common carotid artery, and the right inferior thyroid artery. Methods: 32 right cervical regions were harvested from cadavers within 24 hours post-mortem. The fibro-fatty tissue of the RCR was resected and prepared with formalin fixation. It was then subjected to an increasing sequence of alcohols (70%, 80%, and 90%), subsequently to a solution of Xylol, and finally to a solution of Methyl Salicylate, respecting the time required for each step. The macroscopic study was carried out on the diaphanized piece, observing the presence or not of lymph nodes. When present, they were photographed and their measurements were gauged with a digital caliper. In the microscopic study, hematoxylin-eosin staining was used to confirm the lymph node. Results: the presence of lymph nodes was observed in 22 (68.75%) of the 32 specimens. The number of lymph nodes ranged from zero to six (mean of 1.56±0.29), per cadaver, and their mean size was 7.82mmx3.86mm (longitudinal x transversal diameters). Conclusion: the relationship between anthropometric data and presence of lymph nodes in the RCR (Fisher's exact test) was significant for medium-height individuals (p=0.03) and also white ones (p=0.04).

Malignancy rates for Bethesda III subcategories in thyroid fine needle aspiration biopsy (FNAB)

OBJECTIVES: Most thyroid diseases are nodular and have been investigated using ultrasound-guided fine needle aspiration biopsy (FNAB), the reports of which are standardized by the Bethesda System. Bethesda category III represents a heterogeneous group in terms of lesion characteristics and the malignancy rates reported in the literature. The objective of the present study was to evaluate the differences in the malignancy rates among Bethesda III subcategories. METHODS: Data from 1,479 patients who had thyroid surgery were reviewed. In total, 1,093 patients (89.6% female, mean age 52.7 (13-89) years) were included, and 386 patients were excluded. FNAB results (based on Bethesda Class) and histopathological results (benign or malignant) for coincident areas were collected. Bethesda III patients were subcategorized according to cytopathological characteristics (FLUS: follicular lesion of undetermined significance, Bethesda IIIA; AUS: atypia of undetermined significance, Bethesda IIIB). Data were correlated to obtain the malignancy rates for each Bethesda category and the newly defined subcategory. RESULTS: FNAB results for these patients were as follows: Bethesda I: 3.1%; Bethesda II: 18.6%; Bethesda III: 35.0%; Bethesda IV: 22.1%; Bethesda V: 4.1%; and Bethesda VI: 17.1%. The malignancy rates for Bethesda Class IIIB were significantly higher than those for Bethesda Class IIIA (p<0.001) and Bethesda Class IV (p<0.001). Bethesda Class IIIA showed significantly lower malignancy rates than Bethesda Class III overall (p<0.001) CONCLUSIONS: Improvements of the Bethesda System should consider this subcategorization to better reflect different malignancy rates, which may have a significant impact on the decision-making process.

Resultados del tratamiento quirúrgico del hiperparatiroidismo primario en un país en vías de desarrollo / Outcomes of Primary Hyperparathyroidism Surgical Treatment in a Low-Middle Income Country

Introducción: El hiperparatiroidismo primario es una enfermedad común y con una distribución similar en todo el mundo. El propósito del estudio fue establecer si la presentación clínica y bioquímica, así como los resultados de su tratamiento quirúrgico, difieren en un país en vías de desarrollo, que no cuenta con todos los recursos diagnósticos y terapéuticos recomendados actualmente. Metodología: Análisis retrospectivo de pacientes operados por un mismo equipo, entre 1992 y 2015. Se obtuvo información sobre presentación clínica, resultados de estudios preoperatorios, procedimientos quirúrgicos, diagnóstico histopatológico y evolución postoperatoria. Resultados: Se operaron 55 pacientes con edad promedio de 45 años, 78% mujeres. El 65% eran sintomátcos. El valor promedio preoperatorio de calcio sérico fue 11.2 mg/dl, PTH 167.1 pg/ml, fósforo 2.6 mg/ dl, 25-hidroxi vitamina D 17.3 ng/ml y calcio urinario de 24 horas 294.7 mg. Al 59% se realizó estudios de localización preoperatoria. La sensibilidad del ultrasonido fue 57.14% y 75% para centellografa con tecnecio sestamibi. La positividad de los estudios de localización determinó el tipo de exploración quirúrgica (p=0.02). Se practcaron 27 (49%) exploraciones unilaterales y 28 (51%) bilaterales, resecando 47 (85.5%) adenomas solitarios y 3 ½ glándulas en 7 (12.7%) casos de hiperplasias. En 27 (36%) coexista patología tiroidea. Las tasas de curación, persistencia y recurrencia fueron 94.5%, 5.5% y 3.6% respectivamente. Conclusiones: La mayoría de nuestros pacientes operados son jóvenes y sintomátcos. La estrategia quirúrgica fue condicionada por los estudios de localización. Nuestras tasas de curación, persistencia y recurrencia son comparables a las reportadas.

Background: Primary hyperparathyroidism (HPTP) is a common disease with widespread distribution around the world. The aim of this study was to establish if clinical and biochemical disease characteristics and long term results differ in patents with HPTP in a low-middle income country without all recommended diagnostc and therapeutc resources. Methods: Retrospective collection of clinical diagnosis, biochemical, operative details, histology and long term results of all surgically treated patents with HPTP, from 1992 to 2015, by the same surgical team. Results: 55 patents with HPTP were analyzed. Average age is 45 years old with 78% of female patents. Sixty five percent were symptomatic. The mean preoperative serum calcium level was 11.2 mg/dl, PTH 167.1 pg/ml, phosphorus 2.6 mg/ dl, vitamin D 17.3 ng/ml and 24 hour urinary calcium 294.7 mg. Fifty nine percent of the patents had preoperative imaging. Ultrasound and sestamibi scan sensitivity was 57.1% and 75% respectively. Unilateral localization in preoperative imaging determined surgical exploration (p=0.02). Unilateral approach was used in 27 (49%) patents and bilateral in 28 (51%); 47 (85.5%) solitary adenomas and 7 (12.7%) 3 ½ gland resections of hyperplastic glands were performed. Thyroid pathology co-existed in 27 (36%) patients. Cure, persistence and recurrence rates were 94.5%, 5.5% y 3.6% respectively. Conclusions: In this study most of the patents were young and symptomatc. Surgical strategy was determined by preoperatve imaging. Cure, persistence and recurrence rates were comparable to published literature.

Estudio y manejo de nódulos tiroideos por médicos no especialistas. Consenso SOCHED / Study and management of thyroid nodes by non specialist physicians: SOCHED consensus

The thyroid nodule is a frequent cause of primary care consultation. The prevalence of a palpable thyroid nodule is approximately 4-7%, increasing up to 67% by the incidental detection of nodules on ultrasound. The vast majority are benign and asymptomatic, staying stable over time. The clinical importance of studying a thyroid nodule is to exclude thyroid cancer, which occurs in 5 to 10% of the nodules. The Board of SOCHED (Chilean Society of Endocrinology and Diabetes) asked the Thyroid Study Group to develop a consensus regarding the diagnostic management of the thyroid nodule in Chile, aimed at non-specialist physicians and adapted to the national reality. To this end, a multidisciplinary group of 31 experts was established among university academics, active researchers with publications on the subject and prominent members of scientific societies of endocrinology, head and neck surgery, pathology and radiology. A total of 14 questions were developed with key aspects for the diagnosis and subsequent referral of patients with thyroid nodules, which were addressed by the participants. In those areas where the evidence was insufficient or the national reality had to be considered, the consensus opinion of the experts was used through the Delphi methodology. The consensus was approved by the SOCHED board for publication.

Thyroid gland invasion in advanced squamous cell carcinoma of the larynx and hypopharynx / Invasão da glândula tireoide no carcinoma espinocelular avançado de laringe e hipofaringe

Abstract Introduction: Squamous cell carcinoma of the larynx and hypopharynx has the potential to invade the thyroid gland. Despite this risk, the proposition of either partial or total thyroidectomy as part of the surgical treatment of all such cases remains controversial. Objectives: To evaluate the frequency of invasion of the thyroid gland in patients with advanced laryngeal or hypopharyngeal squamous cell carcinoma submitted to total laryngectomy or pharyngolaryngectomy and thyroidectomy; to determine whether clinic-pathological characteristics can predict glandular involvement. Methods: A retrospective case series with chart review, from January 1998 to July 2013, was undertaken in a tertiary care university medical center. An inception cohort of 83 patients with larynx/hypopharynx squamous cell carcinoma was considered. All patients had advanced stage disease (clinically T3-T4) and underwent total laryngectomy or total pharyngolaryngectomy in association with thyroidectomy. Adjuvant therapy was indicated when tumor or neck conditions required. Frequency of thyroid cartilage invasion was calculated; univariate and multivariate analysis of demographic, clinical and pathological characteristics associated with cartilage invasion were performed. Results: The overall frequency of invasion of the thyroid gland was 18.1%. Glandular involvement was associated with invasion of the following structures: anterior commissure (odds ratio = 5.13; 95% confidence interval 1.07-24.5), subglottis (odds ratio = 12.44; 95% confidence interval 1.55-100.00) and cricoid cartilage (odds ratio = 15.95; 95% confidence interval 4.23-60.11). Conclusions: Invasion of the thyroid gland is uncommon in the context of laryngopharyngeal squamous cell carcinoma. Clinical and pathological features such as invasion of the anterior commissure, subglottis and cricoid cartilage are more associated with glandular invasion.

Resumo Introdução O carcinoma espinocelular de laringe e hipofaringe tem potencial para invadir a glândula tireoide. Apesar desse risco, a proposição de tireoidectomia parcial ou total como parte do tratamento cirúrgico de todos esses casos permanece controversa. Objetivos Avaliar a frequência de invasão da glândula tireoide em pacientes com carcinoma espinocelular avançado de laringe ou hipofaringe submetidos a laringectomia total ou faringolaringectomia e tireoidectomia; determinar se características clínico‐patológicas podem prever o envolvimento glandular. Método Uma série de casos retrospectivos com revisão de prontuários, entre janeiro de 1998 e julho de 2013, foi feita em um centro médico universitário de cuidados terciários. Uma coorte inicial de 83 pacientes com carcinoma espinocelular de laringe/hipofaringe foi considerada. Todos os pacientes tinham doença em estágio avançado (clinicamente T3‐T4) e foram submetidos a laringectomia total ou faringolaringectomia em associação com tireoidectomia. Foi indicada terapia adjuvante quando o tumor ou as condições do pescoço exigiram. A frequência de invasão de cartilagem da tireoide foi calculada; análises univariada e multivariada das características demográficas, clínicas e patológicas associadas à invasão de cartilagem foram feitas. Resultados A frequência global de invasão da glândula tireoide foi de 18,1%. O envolvimento glandular foi associado à invasão das seguintes estruturas: comissura anterior (odds ratio = 5,13; intervalo de confiança 95%, 1,07‐24,5), subglote (odds ratio = 12,44; intervalo de confiança 95%, 1,55‐100,00) e cartilagem cricoide (odds ratio = 15,95; intervalo de confiança 95%, 4,23‐60,11). Conclusões A invasão da glândula tireoide é rara no contexto de carcinoma espinocelular laringofaríngeo. As características clínicas e patológicas, como a invasão da comissura anterior, subglote e cartilagem cricoide, estão mais associadas a invasão glandular.