Vía clínica de terapia metabólica con 131I en cáncer diferenciado de tiroides / Clinical pathway of metabolic therapy with 131I in differentiated thyroid cancer

Las vías clínicas son planes asistenciales que se aplican a procesos clínicos de curso predecible con la intención de protocolizarlos y disminuir la variabilidad en su manejo. Nuestro objetivo ha sido desarrollar una vía clínica para la terapia metabólica con 131I, proceso asistencial aplicado a los pacientes con carcinoma diferenciado de tiroides. Se organizó un equipo de trabajo formado por médicos (endocrinología y medicina nuclear), personal de enfermería (unidad de hospitalización y medicina nuclear), de radiofísica y del servicio de apoyo a la gestión clínica y continuidad asistencial. Para el diseño de la vía clínica se realizaron varias reuniones del equipo, en las que se pusieron en común las revisiones bibliográficas y se abordó el diseño y el desarrollo de la vía, respetando las guías clínicas vigentes. Este equipo ha logrado mediante consenso la elaboración del plan asistencial, estableciendo sus puntos clave y redactando los distintos documentos que componen la vía clínica: matriz temporal, documento de registro de variaciones de la vía clínica, documentos de información al paciente, encuesta de satisfacción del paciente, folleto de pictogramas, indicadores de evaluación de calidad. Por último, la vía clínica se ha presentado a todos los servicios clínicos involucrados y a la dirección médica del hospital, procediendo a su implementación en la práctica clínica (AU)

Clinical pathways are care plans that are applied to clinical processes with a predictable course, with the intention of protocolizing them, and reducing the variability in their management. Our objective was to develop a clinical pathway for 131I metabolic therapy, in its application to differentiated thyroid cancer. A work team was organised consisting of doctors (Endocrinology and Nuclear Medicine), nursing staff (Hospitalisation Unit and Nuclear Medicine), Radiophysics and the Clinical Management and Continuity of Care Support Service. For the design of the clinical pathway, several team meetings were held, in which the literature reviews were pooled and the design and development of the clinical pathway was undertook, in accordance with current clinical guidelines. This team has achieved consensus on the development of the care plan, establishing its key points and drafting the different documents that make up the clinical pathway: timeframe-based schedule, clinical pathway variation record document, patient information documents, patient satisfaction survey, pictogram brochure, quality assessment indicators. Finally, the clinical pathway was presented to all clinical departments involved and to the medical director of the hospital, and it is now being implemented in clinical practice (AU)

Clinical pathway of metabolic therapy with 131I in differentiated thyroid cancer.

Clinical Pathways are care plans that are applied to clinical processes with a predictable course, with the intention of protocolizing these processes and reducing the variability in their management. Our objective was to develop a clinical pathway for 131I metabolic therapy in its application to differentiated thyroid cancer. A work team was organized consisting of doctors (Endocrinology and Nuclear Medicine), nursing staff (Hospitalization Unit and Nuclear Medicine), Radiophysics and the Clinical Management and Continuity of Care Support Service. For the design of the clinical pathway, several team meetings were held, in which the literature reviews were pooled and the design and development of the clinical pathway was undertaken in accordance with current clinical guidelines. This team achieved consensus on the development of the care plan, establishing its key points and drafting the different documents that make up the Clinical Pathway: Timeframe-based schedule, Clinical Pathway Variation Record Document, Patient Information Documents, Patient Satisfaction Survey, Pictogram Brochure, Quality Assessment Indicators. Finally, the clinical pathway was presented to all the clinical departments involved and to the Medical Director of the Hospital and is now being implemented in clinical practice.

[Lipid lowering treatment of severe hypertriglyceridemia with acute pancreatitis caused by everolimus in a patient with a neuroendocrine tumor]. / Tratamiento hipolipemiante de la pancreatitis aguda secundaria a hipertrigliceridemia severa por everolimus en un paciente con tumor neuroendocrino.

Everolimus is an mTOR inhibitor, approved as a treatment for cancer and as an immunosuppressant agent in solid organ transplantation; it frequently produces toxic metabolic effects, particularly of the most severe kind. Its use can cause hyperglycemia, hypercholesterolemia and hypertriglyceridemia; thus, metabolic values should be monitored regularly to prevent these adverse events. We present the case of a woman with an intestinal neuroendocrine tumor who developed two episodes of acute pancreatitis, secondary to severe hypertriglyceridemia caused by everolimus. After treatment with fibrates and omega-3, triglyceride levels returned to baseline, without developing new metabolic or digestive complications. Targeted levels of triglyceride for cancer patients treated with everolimus, should be below 500 or 300 mg/dL, depending on whether life expectancy is less or longer than one year, respectively.

Tratamiento hipolipemiante de la pancreatitis aguda secundaria a hipertrigliceridemia severa por everolimus en un paciente con tumor neuroendocrino / Lipid lowering treatment of severe hypertriglyceridemia with acute pancreatitis caused by everolimus in a patient with a neuroendocrine tumor

Everolimus es un inhibidor de mTOR, empleado en oncología y como inmunosupresor en el trasplante de órgano sólido. Sus efectos adversos a nivel metabólico son muy frecuentes, especialmente los más severos. Puede ocasionar hiperglucemia, hipercolesterolemia e hipertrigliceridemia, por lo que la monitorización de los parámetros metabólicos en las sucesivas visitas es vital para detectar e iniciar tratamientos que puedan prevenir las complicaciones. Se presenta el caso de una mujer con diagnóstico de tumor neuroendocrino intestinal que desarrolló dos pancreatitis agudas secundarias a hipertrigliceridemia severa por everolimus. Tras inicio de tratamiento con fibratos y omega-3, se normalizó la cifra de triglicéridos sin presentar nuevas complicaciones metabólicas ni digestivas secundarias al fármaco. La recomendación en pacientes con cáncer en tratamiento activo con everolimus es mantener los triglicéridos por debajo de 500 o 300 mg/dL, dependiendo de si la esperanza de vida es inferior o superior a un año, respectivamente

Everolimus is an mTOR inhibitor, approved as a treatment for cancer and as an immunosuppressant agent in solid organ transplantation; it frequently produces toxic metabolic effects, particularly of the most severe kind. Its use can cause hyperglycemia, hypercholesterolemia and hypertriglyceridemia; thus, metabolic values should be monitored regularly to prevent these adverse events. We present the case of a woman with an intestinal neuroendocrine tumor who developed two episodes of acute pancreatitis, secondary to severe hypertriglyceridemia caused by everolimus. After treatment with fibrates and omega-3, triglyceride levels returned to baseline, without developing new metabolic or digestive complications. Targeted levels of triglyceride for cancer patients treated with everolimus, should be below 500 or 300 mg/dL, depending on whether life expectancy is less or longer than one year, respectively

Prognostic value of change in anti-thyroglobulin antibodies after thyroidectomy in patients with papillary thyroid carcinoma

Purpose: Anti-thyroglobulin antibodies (TgAb) can be used as a surrogate tumor marker in the follow-up of papillary thyroid carcinoma (PTC). We try to determine if the change in TgAb levels in the first post-operative year is a good predictor of persistence/recurrence risk in TgAb-positive PTC patients. Methods/patients: 105 patients with PTC who underwent thyroidectomy between 1988 and 2014 were enrolled. We calculated the percentage of change in TgAb levels with the first measurement at 1-2 months after surgery and the second one at 12-14 months. Results: TgAb negativization was observed in 29 patients (27.6%), a decrease of more than 50% was observed in 57 patients (54.3%), less than 50% in 12 patients (11.4%) and in 7 patients (6.7%) the TgAb level had increased. The percentage of persistence/recurrence was 0, 8.8, 16.7 and 71.4% in each group, respectively (p < 0.001). In the multivariate analysis, only the percentage of change in TgAb showed a significant association with the risk of persistence/recurrence, regardless of other factors such as age, size and TNM stages. Conclusions: Changes in TgAb levels in the first year after surgery can predict the risk of persistence/recurrence of TgAb-positive PTC patients. Patients who achieved negativization of TgAb presented an excellent prognosis

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Prognostic value of change in anti-thyroglobulin antibodies after thyroidectomy in patients with papillary thyroid carcinoma.

PURPOSE: Anti-thyroglobulin antibodies (TgAb) can be used as a surrogate tumor marker in the follow-up of papillary thyroid carcinoma (PTC). We try to determine if the change in TgAb levels in the first post-operative year is a good predictor of persistence/recurrence risk in TgAb-positive PTC patients. METHODS/PATIENTS: 105 patients with PTC who underwent thyroidectomy between 1988 and 2014 were enrolled. We calculated the percentage of change in TgAb levels with the first measurement at 1-2 months after surgery and the second one at 12-14 months. RESULTS: TgAb negativization was observed in 29 patients (27.6%), a decrease of more than 50% was observed in 57 patients (54.3%), less than 50% in 12 patients (11.4%) and in 7 patients (6.7%) the TgAb level had increased. The percentage of persistence/recurrence was 0, 8.8, 16.7 and 71.4% in each group, respectively (p < 0.001). In the multivariate analysis, only the percentage of change in TgAb showed a significant association with the risk of persistence/recurrence, regardless of other factors such as age, size and TNM stages. CONCLUSIONS: Changes in TgAb levels in the first year after surgery can predict the risk of persistence/recurrence of TgAb-positive PTC patients. Patients who achieved negativization of TgAb presented an excellent prognosis.

Acromegalia ectópica por carcinoide bronquial / Ectopic acromegaly due to a bronchial carcinoid

Los tumores que causan acromegalia ectópica pueden hacerlo a través de la secreción de GH o de GHRH. Se han descrito un centenar de casos de acromegalia ectópica por secreción de GHRH. Dado la rareza de esta patología presentamos un caso clínico con el objetivo de aportar nuestra experiencia diagnóstico-terapéutica y de seguimiento posterior. Se presenta el caso de una paciente con rasgos físicos acromegaloides de varios años de evolución. Deforma concomitante también presentaba otros síntomas acompañantes sugestivos de posible origen bronquial. Ante la sospecha clínica de acromegalia se optó por confirmarlo bioquímicamente y posteriormente mediante estudio de imagen. Se descartó el origen hipofisario por lo que se realizó el despistaje de un tumor neuroendocrino bronquial y/o gastrointestinal por serlas localizaciones más frecuentes. El tratamiento de elección fue la resección quirúrgica (AU)

Tumours that cause ectopic acromegaly can do so through the secretion of GH or GHRH. A hundred cases of ectopic acromegaly due to secretion of GHRH have been described. Given the rarity of this pathology, we present a clinical case with the aim of contributing our diagnostic-therapeutic experience and the subsequent follow-up. We present the case of a patient with acromegaloid physical features that had evolved over several years. Concomitantly, he also presented other accompanying symptoms that suggestive of a possible bronchial origin. Facing the clinical suspicion of acromegaly, we opted to confirm it biochemically and subsequently through image study. A hypophysary origin was ruled out, so we carried out screening for a bronchial neuroendocrine and/or gastrointestinal tumor as they are the most frequent localizations. The treatment of choice was surgical resection (AU)

[Ectopic acromegaly due to a bronchial carcinoid]. / Acromegalia ectópica por carcinoide bronquial.

Tumours that cause ectopic acromegaly can do so through the secretion of GH or GHRH. One hundred cases of ectopic acromegaly due to secretion of GHRH have been described. Given the rarity of this pathology, we present a clinical case with the aim of contributing our diagnostic-therapeutic experience and the subsequent follow-up. We present the case of a patient with acromegaloid physical features that had evolved over several years. Concomitantly, he also presented other accompanying symptoms that were suggestive of a possible bronchial origin. Facing the clinical suspicion of acromegaly, we opted to confirm it biochemically and subsequently through image study. A hypophysary origin was ruled out, so we carried out screening for a bronchial neuroendocrine and/or gastrointestinal tumor as they are the most frequent localizations. The treatment of choice was surgical resection.

[Recurrence and prognostic factors after treatment with antithyroid agents in Graves-Basedow disease. Multicenter study in Northern Spain]. / Recidiva y factores pronósticos tras tratamiento con antitiroideos en la enfermedad de Graves-Basedow. Estudio multicéntrico en el norte de España.

Therapy with anti-thyroid drugs is the initial option mostly used in our country for the treatment of hyperthyroidism due to Graves-Basedow disease. To evaluate the long term results of this kind of therapy, a total of 773 patients were studied who were diagnosed from 1975 to 1994 in three hospitals in Northern Spain (Hospital Central de Asturias, Hospital de Cruces and Hospital de Navarra) after a mean follow-up time after anti-thyroid drug withdrawal of 46 +/- 33.1 months. The results showed a likelihood of hyperthyroidism relapse of 42.9%, 59.8%, 67.9% and 78.9% at one, three, five and ten years, respectively. Goitre size was correlated very significantly with the likelihood of relapse (p < 0.0001). In contrast, only TBII positivity at the end of therapy among the remaining parameters (age, sex, goitre size, length of therapy, positivity of anti-thyroid antibodies and TBII) influenced significantly on the relapse likelihood (p < 0.05). In conclusion, after a long term follow-up after anti-thyroid therapy, a high relapse rate of hyperthyroidism in Graves-Basedow disease, which amounts up to 79% at ten years, was observed. Goitre size was the main predictive factor for this relapse.

Recidiva y factores pronósticos tras tratamiento con antitiroideos en la enfermedad de Graves-Basedow. Estudio multicéntrico en el norte de España / Relapse and prognostic factors after anti-thyroid therapy for Graves-Basedow disease. Multicentric study in Northern Spain

Recidiva y factores pronósticos tras tratamiento con antitiroideos en la enfermedad de Graves-Basedow. Estudio multicéntrico en el norte de España El tratamiento con fármacos antitiroideos es la opción inicial más utilizada en nuestro país para el tratamiento del hipertiroidismo por enfermedad de Graves-Basedow. Para evaluar el resultado a largo plazo de este tipo de tratamiento hemos estudiado 773 pacientes diagnosticados entre 1975 y 1994 en tres hospitales del norte de España (Hospital Central de Asturias, Hospital de Cruces y Hospital de Navarra) después de un tiempo medio de seguimiento tras la retirada de los antitiroideos de 46 ñ 33,1 meses. Los resultados mostraron una probabilidad de recidiva del hipertiroidismo del 42,9 por ciento al año, del 59,8 por ciento a los 3 años, del 67,9 por ciento a los 5 años y del 78,9 por ciento a los 10 años. El tamaño del bocio se correlacionó muy significativamente con la probabilidad de recidiva (p < 0,0001), mientras que del resto de las variables estudiadas (edad, sexo, tamaño del bocio, duración del tratamiento, positividad de los anticuerpos antitiroideos y de los TBII) sólo la positividad de los TBII al final del tratamiento influyó de forma muy significativa (p < 0,05). En conclusión, tras un seguimiento a largo plazo después del tratamiento con antitiroideos se observa una alta tasa de recidiva del hipertiroidismo en la enfermedad de Graves-Basedow, que llega a ser del 79 por ciento a los 10 años, siendo el tamaño del bocio el factor fundamental a la hora de predecir esta recidiva (AU)