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.

Detección inmunohistoquímica de parafibromina en patología de paratiroides / Immunohistochemical detection of parafibromin in parathyroid pathology

Introduction: The definitive diagnosis of parathyroid cancer is extremely difficult, from the clinical approach to the molecular diagnosis. A gene mutation was detected recently in patients with parathyroid cancer. It is a suppressor tumor gene called HRPT2, which codifies for a protein that participates in PAF1 complex, the parafibromin. It has been observed that the expression of this protein it's altered in parathyroid cancer, what would serve like method of diagnosis by immunohystochemistry, with a sensitivity and specificity of 73-96 percent and 99-100 percent respectively. Material and Method: The anti-parafibromin immunohysto-chemistry staining was made in 23 parathyroids tissue samples (5 adenomas, 6 hyperplasia, 7 normal and 5 carcinomas). Results: A positive pattern is observed in almost 100 percent of benign pathology and 100 percent in normal tissue. In the cases of carcinoma only 2 of 5 had a strong positivity. Conclusions: The pathological clinical correlation does not allow the association of the loss of parafibromin immunoreactivity in some unequivocal cases of parathyroid cancer. The parafibromin immunostaining does not allow to discriminate between benign or malign pathologies.

Introducción: El diagnóstico definitivo de cáncer de paratiroides es extremadamente difícil, desde el acercamiento clínico hasta el diagnóstico molecular. Se detectó recientemente en pacientes con cáncer de paratirodes un gen supresor de tumor mutado (HRPT2), que codifica para una proteína que participa en el complejo PAF1, la parafibromina. Se ha observado que la expresión de esta proteína está alterada en los casos de cáncer de paratiroides, lo que serviría como método de diagnóstico por inmunohistoquímica, con una sensibilidad y especificidad de 73-96 por ciento y 99-100 por ciento, respectivamente. Material y Método: Se realizó tinción inmunohistoquímica anti parafibromina en 23 muestras de tejido paratiroideo (5 adenomas, 6 hiper-plasias, 7 normales y 5 carcinomas). Resultados: Se observa un patrón positivo fuerte en casi 100 por ciento de la patología benigna y 100 por ciento en tejido normal. En los casos de carcinoma sólo 2 de 5 tenían positividad fuerte. Conclusiones: La correlación clínico patológica no permite asociar la pérdida de tinción de parafibromina en algunos casos de cáncer inequívocos. La tinción de parafibromina no permite discriminar entre patología benigna y maligna.

Carcinoma medular de tiroides: experiencia de 20 años / Medullary thyroid carcinoma: 20 years experience

Background: Medullary thyroid carcinoma (MTC) is a rare malignant tumor that arise from C cells. Surgical treatment and its results are controversial, so we decided to study it. Aim: To describe clinically MTC, treatment and outcomes in the long term. Material and Method: We retrospectively reviewed medical records of patients with MTC operated in our hospital between the years 1987 and 2007. We analyzed the cli-nical characteristics, treatment, morbidity and long-term follow up. Results: There were 24 patients operated with a mean age of 46.1 +/- 16.6 years. The main form of presentation was painless increased cervical volume (56.2 percent). In 15 percent this pathology was part of a MEN 2b. All of them have had a total thyroidectomy, which was extended in 50 percent of cases. The 35.2 percent were multifocal, 29.4 percent bilateral and 62.5 percent had metastatic lymph node involvement. Five patients remained higher calcitonin levéis in the postoperative period and 9 patients recurred clinically on average 4.5 years after surgery. The presence of persistent disease was significantly associated with hereditary MTC (p = 0.0088) and the clinical recurrence was significantly determined by the presence of not expanded total thyroidectomy (p = 0.0196). The probability of surviving more than 19 years was 66.6 percent (95 percent CI = 0.24 to 0.89). Conclusions: The MTC is a rare tumour and treatment of choice is surgery. The persistent disease is associated with hereditary MTC form, and the clinical recurrence is associated with not expanded total thyroidectomy. We recommend total thyroidectomy with central voiding and radical modified jugular dissection.

Antecedentes: El carcinoma medular de tiroides (CMT) es un tumor maligno poco frecuente, originado a partir de las células C. Su tratamiento quirúrgico y resultados son controvertidos, por lo que hemos decidido estudiarlo. Objetivo: Describir clínicamente el CMT, tratamiento y resultados a largo plazo. Material y método: Se revisaron retrospectivamente las fichas clínicas de pacientes con CMT operados en nuestro hospital entre 1987 y el 2007. Se analizaron las características clínicas, tratamiento, morbilidad y seguimiento a largo plazo. Resultados: Se operaron 24 pacientes, cuya edad media fue 46,1 +/- 16,6 años. La principal forma de presentación fue aumento de volumen cervical (56,2 por ciento). Un 15 por ciento formaba parte de una NEM 2b. A todos se les realizó una tiroidectomía total, ampliada en el 50 por ciento de los casos. El 35,2 por ciento eran multifocales, el 29,4 por ciento bilaterales y el 62,5 por ciento tenía metástasis ganglionar. Cinco pacientes mantuvieron niveles de calcitonina elevados en el postoperatorio y nueve pacientes recurrieron clínicamente, en promedio, a los 4,5 años. La enfermedad persistente se asoció significativamente con CMT hereditario (p = 0,0088) y la recurrencia clínica a tiroidectomía total no ampliada (p = 0,0196). La probabilidad de sobrevivir más de 19 años fue 66,6 por ciento (IC 95 por ciento = 0,24 a 0,89). Conclusiones: EL CMT es un tumor raro cuyo tratamiento de elección es la cirugía. La persistencia de enfermedad se asocia con la forma hereditaria, y la recurrencia clínica con la tiroidectomía total no ampliada, lo que nos hace recomendar una tiroidectomía total asociada a vaciamiento central y disección yugular radical modificada.

Tumor fibromixoide osificante simulando un cáncer anaplásico de tiroides: reporte de un caso / Ossifying fibromyxoid tumor of the neck: case report

El tumor fibromixoide osificante corresponde a una neoplasia infrecuente, de comportamiento benigno pero que presenta recurrencia en un tercio de los casos, comportándose como un sarcoma de bajo grado. Se reporta el caso de una paciente operada de tiroides en dos oportunidades en 9 años, cuyo diagnóstico final fue tumor fibromixoide osificante.

Ossifying fibromyxoid tumor of soft parts in an uncommon tumor with a benign behavior but with a tendency to relapse. We report a 76 years old female presenting with a growing mass located in the anterior portion of the neck that was excised. The pathological study disclosed an anaplastic thyroid cancer. The patient received chemotherapy and was lost from follow up. Nine years later, she presented with progressive dysphagia. A neck CT scan showed a mass in the left thyroid base that completely included the cervical esophagus. The patient was operated and the mass was excised. The pathological diagnosis disclosed an ossifying fibromyxoid tumor.

Linfoma primario de tiroides: reporte de cuatro casos / Primary thyroid lymphoma: report of four cases

Primary thyroid lymphoma is uncommon and usually of non-Hodgkin type. We report four female patients with thyroid lymphoma. An 81 year-old patient that was operated and received three cycles of chemotherapy and was lost from follow up. A 16 year-old patient that is operated and received full chemotherapy and was discharged free of disease. A 80 year-old patient that was operated and died due to a multiple organ failure, 50 days after hospital admission and a 54 year-old female that was operated but rejected chemotherapy and was lost from follow up.

Sarcoma sinovial intraoral primario monofásico / Monophasic synovial sarcoma of the oral cavity: report of one case

El sarcoma sinovial es un tumor maligno de partes blandas, bien diferenciado y que representa entre 5.6 por ciento a 10 por ciento de todos los sarcomas. Su localización en cabeza y cuello no es común, y representa cerca de un 9 por ciento, con menos de 100 casos reportados en la literatura. La localización intraoral es muy peculiar, existiendo 32 casos previamente descritos en el mundo, de los cuales 3 corresponden al tipo monofásico. Se presenta un caso de un paciente varón de 16 años con un caso de sarcoma sinovial intraoral monofásico y una revisión de la literatura disponible.

Synovial sarcoma is a well-differentiated malignant tumor of soft tissues, that corresponds approximately 10 percent of all soft tissue sarcomas. Its location in the head and neck uncommon and the location in the oral cavity is really peculiar, with only 32 previously described cases, of which only three corresponded to the monophasic type. We report a 16 years old male patient consulting for a lump in the right oral mucosa. The patient was operated in two occasions excising the tumor with radical lymph node dissection and parotid gland excision. The pathological diagnosis was a monophasic intraoral synovial sarcoma. Postoperative radiotherapy was recommended but not done. After 16 months of follow up the patient is without evidence of relapse.

Tiroidectomia sin ligaduras: evaluando Ligasure Precise® / Ligasure® for hemostasis during thyroidectomy

Introducción: En tiroidectomia total se están evaluando métodos de hemostasia distintos a la ligadura habitual. Objetivo: Presentar nuestra experiencia inicial en la tiroidectomia total sin ligaduras, al utilizar el método de sellado de vasos a través de Ligasure Precise®. Material y método: Se consignaron en forma prospectiva, los datos de 129 pacientes: Datos personales, fecha de operación, antecedentes mórbidos, síntomas, función tiroidea, examen físico, ecografía, punción con aguja fina, tipo de operación, cirujano, tiempo operatorio, estadía postoperatoria, débito de drenajes, biopsia intraoperatoria y definitiva, complicaciones. Se utilizó un p < 0.05 como significativo para los cálculos estadísticos. Resultados: Se realizaron 129 tiroidectomías entre Enero y Agosto del 2005. Se operaron 65 pacientes deforma tradicional y 64 con Ligasure. No hubo mortalidad operatoria. Edad promedio 42,7 y 46,9 para cada grupo (p >0.05). Biopsia definitiva informó carcinoma en 34 y 32 por ciento respectivamente. Hospitalización promedio de 2,63 días y 2,26 días (p 0.02). El débito de drenajes fue 78 ce para el grupo Ligasure y 63,2 ce para el grupo tradicional. Tiempo operatorio promedio de 94 minutos (grupo tradicional) y 92 minutos (Ligasure) (p= 0.6). Las complicaciones fueron hematoma (1 caso por grupo), Lesión de recurrente laríngeo (1 caso en el grupo de ligadura tradicional) e hipocalcemia transitoria (6 casos en el grupo Ligasure y 1 caso en el grupo control). Conclusión: La tiroidectomia con Ligasure Precise es un método cómodo para el cirujano y tan seguro como la tiroidectomia con ligaduras. Su aplicación, indicación y reales beneficios deben ser evaluados en el futuro con mayor número de casos.

Background: Traditionally, hemostasis during thyroidectomy is done using clamp ligation of vessels. There is a new hemostasis method based on thermal coagulation and pressure that be used in this type of surgery. Aim: To report the experience with Ligasure Precise® thermal hemostasis system. Material and methods: Prospective evaluation of patients subjected to thyroidectomy with or without the use of Ligasure®. The choice of patients for each type of hemostasis was not randomized. Operative time, surgical complications and postoperative evolution were assessed. Results: During the study period, 64 patients aged 43 + 15 years were operated using Ligasure® and 65, aged 47 + 12, were operated using traditional hemostasis. Among patients with and without use of Ligasure®, operative time was 92 and 94 minutes respectively (p=NS), wound drainage volume was 78 and 63 ml respectively (p=NS) and hospital stay was 2.6 and 2.3 days respectively (p = 0.02). One patient in each group had a hematoma, one patient operated with Ligasure® had a lesion of the recurrent laryngeal nerve. Six patients operated using Ligasure® and one operated without it, had transient hypocalcaemia. Conclusions: Ligasure® hemostasis system is safe in thyroidectomy.

Tumor cervical por enfermedad de Kikuchi: Una entidad clínica a la que no estamos habituados. Caso clínico / Histiocytic necrotizing lymphadenitis: Report of three cases

Histiocytic necrotizing lymphadenitis (HNL), also known as Kikuchi 5 disease is a rare condition of unknown etiology. Patients present with cervical lymph node enlargement, fever and malaise. The diagnosis is made by excision biopsy. However, this entity must be distinguished from both reactive processes and malignant tumors such as lymphoma. The clinical course is self limited with spontaneous resolution within a few months. We report three patients with the disease. A 37 year-old woman with a 4 months history of a painless submaxillary mass of 2.5 cm diameter, attached to the deep tissues of the neck. The mass was excised and the biopsy report was HNL. After 26 months of follow up, the patient is asymptomatic. A 30 year-old woman with a history of 2 months of a painless lateral cervical mass and aspiration biopsy was reported as suspicious for lymphoma. An excision biopsy was performed, that was reported as HNL. In both patients, lymphoma was ruled out by immunohistochemistry. A 33 year-old woman with a 3 weeks history of an asymptomatic lateral cervical mass. Biopsy was reported as HNL. This condition must be included in the differential diagnosis of cervical asymptomatic masses. The clinician must be aware of it to avoid long-term, costly treatments.

Incidencia de hipocalcemia pos tiroidectomía total / Incidence of hypocalcemia after total thyroidectomy

Background: Postoperative hypocalcemia is one of the most common complications of thyroid surgery. It is related to the type of disease (malignant or benign), the number of identified parathyroid glands during the surgical procedure, and the surgeon's experience. Total thyroidectomy is the procedure of choice in our hospital for benign and malignant thyroid disease, but it can increase the incidence of complications. Aim: To evaluate the incidence of postoperative hypocalcemia in patients subjected to a total thyroidectomy. Material and methods: Two studies were performed. A retrospective review of medical records of 448 patients subjected to total thyroidectomy, looking for serum calcium levels of less than 8 mg/dl and clinical signs of hypocalcemia. In a second study, 45 patients were followed with measurements of preoperative and postoperative serum calcium levels. Results: In the retrospective study, only 136 records had reliable information. Clinical signs of hypocalcemia were registered in 14 percent of patients and a low serum calcium level was detected in 50 percent. In the prospective study, 42 percent of patients had a postoperative low serum calcium level and seven patients (15 percent) had symptoms. Patients were handled with oral calcium and calcitriol in some cases. Ninety nine percent of patients had normal serum calcium levels two moths after surgery. Conclusions: In this series, the rate of postoperative hypocalcemia after total thyroidectomy is similar to internaitonal reports.