Active Surveillance of Thyroid Microcarcinomas: a Critical View.

PURPOSE OF THE REVIEW: There has been an increasing interest on active surveillance for papillary thyroid microcarcinomas (PTMC) in the literature. We will analyze the contributions of those authors who support this approach in most patients with low-risk tumors. RECENT FINDINGS: The development of molecular methods to effectively detect aggressive PTMC at the fine-needle aspiration biopsy will enable the sound indication of immediate surgery in those patients, assuring the other individuals with the far more frequent indolent PTMC will undergo active surveillance with less anxiety. Several studies compared the quality of life between patients with PTMC who underwent active surveillance with immediate total thyroidectomy. However, thyroid lobectomy is a quite acceptable intermediate alternative for most patients with PTMC, with less surgical morbidity. It is important to wait for worldwide validation, with reports from low- and middle-income areas, before recommending the routine adoption of active surveillance for patients with PTMC, due to difficult logistic obstacles in those environments.

Injury of the external branch of the superior laryngeal nerve in thyroid surgery.

The external branch of the superior laryngeal nerve (EBSLN) innervates the cricothyroid muscle (CTM) to promote lengthening and thinning of the vocal fold, thus increasing voice pitch. The close relation with the superior thyroid vessels (STV) puts the EBSLN in risk every time the superior pole of the thyroid is dissected. It travels downward to innervate the CTM, lateral to the thyroid cartilage and to the inferior pharyngeal constrictor muscle (IPCM), being eventually covered by this muscle fibers as it approaches its entry point. During its descending course, the EBSLN curves and crosses the STV posteriorly. The lower this crossing occurs in the neck, the higher the risk of surgical damage to the nerve by transection, traction, entrapment, thermal damage or disrupted blood supply. The chances of surgical trauma are also increased by size and weight of the specimen, shorter neck length and non-white ethnicity. Voice changes following thyroid surgery are common and multifactorial. The actual rate of vocal impairment due to EBSLN injury is unclear, since changes to the everyday speaking voice can be minimal and laryngeal findings are usually subtle and controversial. CTM electroneuromyography (EMG) is the most accurate tool to diagnose abnormal EBSLN conductivity, but it is technically difficult and barely applicable in routine practice. Recommended approaches to prevent injury include: (I) individual distal ligature of the STV by the thyroid capsule; (II) visual identification of the nerve and its trajectory and (III) electrostimulation with either observation of CTM twitch or intraoperative nerve monitoring (IONM) via dedicated endotracheal tube electrodes. There is accumulating evidence that a combination of visual and standardized electrophysiological EBSLN identification with meticulous division of the STV improves preservation rates. IONM bears the additional benefits of prognostication, quantification and documentation of neural function once it allows intraoperative laryngeal EMG.

Abdominal compression: a new intraoperative maneuver to detect chyle fistulas during left neck dissections that include level IV.

BACKGROUND: Chyle fistulas may occur after left neck dissections that include level IV, due to injury of the thoracic duct or of 1 of its major branches. Despite being unusual, this complication carries substantial postoperative morbidity and even mortality. So far, no effective intraoperative maneuver has been reported to detect this fistula at the end of a neck dissection. In this cohort study, we sought to describe a simple new maneuver, intraoperative abdominal compression, which can effectively help to identify an open major lymphatic duct on level IV at the end of a neck dissection. PATIENTS AND METHODS: From March 1989 to September 2010, 206 patients underwent neck dissections involving left level IV, and underwent intraoperative abdominal compression. There were 119 men and 87 women, with ages ranging from 18 to 81 years (median, 52 years). One hundred forty-four patients had squamous cell carcinomas, 54 had thyroid carcinomas, 5 had malignant melanomas, and 3 had salivary cancers. Distribution by type of left neck dissection was: selective including levels II, III, and IV (73 cases; 35.4%), selective including levels II, III, IV, and V (55 cases; 26.6%), selective including levels I, II, III, and IV (12 cases; 5.8%), modified radical (47 cases; 22.8%), and radical (19 cases; 9.2%). In all cases, at the end of the procedure, the endotracheal tube was temporarily disconnected from the ventilator. Keeping the dissected level IV area under clear visualization, an abdominal compression was performed. At this moment, any detected lymphatic leak was carefully clamped and tied with nonabsorbable sutures. After ventilating the patient, the intraoperative abdominal compression was repeated to reassure complete occlusion of the lymphatic vessel. RESULTS: In 13 cases (6.3%), a chyle leak was detected after performing the intraoperative abdominal compression. All leaks except for 2 were successfully controlled after 1 attempt. In these 2 patients, a patch of muscle and fat tissue was applied with fibrin glue on the top. In 1 of these patients, another chyle leak in a different location was detected only at the second intraoperative abdominal compression, and was also effectively closed. Postoperatively, there were 2 (1%) chyle fistulas, both among these 13 cases, and all were successfully managed with clinical measures only. No fistulas occurred among the remaining 193 patients in whom intraoperative abdominal compression did not demonstrate lymphatic leak. CONCLUSION: To our knowledge, this is the first description of a specific maneuver to actively detect a lymphatic fistula at the end of a left neck dissection involving level IV. In this study, intraoperative abdominal compression was able to detect an open lymphatic vessel in 6.3% of the cases, as well as to assure its effective sealing in the remaining 93.7% of the patients. Moreover, no life-threatening high-volume fistula was noted in this study.

Metástase linfática cervical no carcinoma espinocelular de vias aerodigestivas superiores: análise crítica de fatores preditivos, pelo modelo de regressão logística / Lymph node metastasis from squamous cell carcinoma of the upper aerodigestive tract: individual risk prediction by logistic regression model

Introdução: a dissecção cervical no carcinoma espinocelular (CEC) de vias aerodigestivas superiores (VADS) é preconizada com base no risco epidemiológico de metástase linfática. A indicação do esvaziamento eletivo, porém, ainda é controversa. Determinar o risco individual de metástase auxilia na escolha do tratamento mais adequado. Objetivo: verificar a possibilidade de calcular o risco individual de metástase segundo os resultados da comparação de características clínicas e anátomo-patológicas entre os doentes com e sem metástase linfática cervical do CEC de VADS. Pacientes e Método: estudo retrospectivo longitudinal de caso-controle de 209 operados no período de agosto de 2002 a janeiro de 2007, distribuídos em dois grupos: 128 casos com e 81 sem metástase (estes seguidos por mais de 12 meses). Variáveis passíveis de serem preditivas do risco de metástase linfática foram comparadas entre os grupos e analisadas pelo modelo de regressão logística. Resultados: No grupo com metástase, o CEC apresentou maior freqüência de invasão sangüínea, linfática, perineural, margem comprometida e infiltrado inflamatório escasso. Maior diâmetro e grau de diferenciação foram variáveis independentes preditivas do risco (razão de chances) de desenvolver metástase linfática respectivamente de: 4,8 vezes para o CEC moderadamente diferenciado; e 1,5 vezes para cada centímetro de aumento no diâmetro do carcinoma primário. Maior espessura e invasão sangüínea foram co-variáveis dependentes. O cálculo do risco individual revelou que tanto para o CEC T1/T2 de língua oral e soalho, bem diferenciado e com espessura a partir de 1cm, assim como para o CEC de laringe (não glótico) com diâmetro acima de 1,3cm, o risco de metástase foi maior de 20%, para esta casuística. Conclusão: O grau de diferenciação e o maior diâmetro do CEC de VADS foram variáveis independentes preditivas da ocorrência de metástase linfática cervical. O risco individual de metástase pôde ser calculado em função dessas características, segundo o modelo logístico.

Introduction: the elective neck dissection is indicated for head and neck squamous cell carcinoma (SCC) with metastasis risk higher than 20% in epidemiological investigations, but it remains controversial in some situations. To determine the individual risk to develop node metastasis would allow the surgeons to offer a more adequate treatment case by case. Objective: to verify if it is possible to obtain an individual risk prediction model based on clinical and pathological features presented by patients with SCC of the upper aerodigestive tract. Patients and methods: retrospective longitudinal case-control study of 209 patients treated from August 2002 to January 2007, divided into two groups: 128 cases with and 81 without node metastasis followed up more than 12 months. The clinical and pathological characteristics of the primary tumor were compared between the groups and analyzed by the logistic regression model. Results: Diameter and histological grade were independent predictive variables of node metastasis risk (odds ratio = 4.8 for moderately, compared to well differentiated carcinoma; 1.5 per centimeter of primary carcinoma diameter). Thickness and vascular invasion were covariates related to them. The logistic prediction model revealed that the risk of node metastasis was higher than 20% for T1/T2 well differentiated SCC of the oral tongue and floor of mouth with thickness larger than 1.0cm. Laryngeal SCC (except glottic) with diameter smaller than 1.3cm presented less than 20% of risk. Conclusion: histological grade and diameter of the upper aerodigestive tract SCC were independent predictive variables of the neck node metastasis. The individual risk could be calculated in function of these factors by the logistic regression model.

Hipocalcemia e hipoparatireoidismo clínico após tireoidectomia total / Hypocalcemia and clinical hypoparathyroidism after total thyroidectomy

OBJETIVO: O hipoparatireoidismo que se sucede à tireoidectomia total é uma complicação relativamente freqüente, porém, em geral, assintomática. O presente estudo foi realizado a fim de correlacionar níveis séricos pós operatórios de cálcio com sinais e sintomas de hipocalcemia. MÉTODO: Cinqüenta e sete pacientes submetidos à tireoidectomia total foram estudados retrospectivamente na Disciplina de Cirurgia de Cabeça e Pescoço do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo. A dosagem sérica de cálcio, total ou ionizado,foi correlacionado com a presença, ou não, de sinais e sintomas de hipocalcemia, no pós-operatório imediato e tardio. RESULTADOS: A hipocalcemia precoce ocorreu em 37 por cento dos casos e em 18 por cento na fase tardia. Após seis meses da cirurgia, 50 por cento dos pacientes sintomáticos não eram hipocalcêmicos e do total de hipocalcêmicos 57 por cento eram assintomáticos. CONCLUSÕES: A avaliação clínica exclusiva pós-operatória não se mostrou confiável para o diagnóstico de hipocalcemia. A dosagem de cálcio deve ser feita como rotina após tireoidectomias totais.

BACKGROUND: Hypoparathyroidism after total thyroidectomy is a common complication although the majority of cases are asymptomatic. The present study was prompted in order to correlate postoperative serum calcium levels and clinical signs and symptoms of hypocalcemia. METHODS: Fifty-seven patients operated on for total thyroidectomy were retrospectively studied at Hospital das Clínicas of São Paulo University. Serum calcium levels were measured 48 hours and six months after surgery and were correlated with signs or symptoms of hypocalcemia. RESULTS: Transient hypocalcemia occurred in 37 percent and permanent hypocalcemia in 18 percent. After six months, 50 percent of symptomatic patients were not hypocalcemic and 57 percent of hypocalcemic patients were asymptomatic. CONCLUSION: The diagnosis of hypocalcemia after total thyroidectomy based solely on clinical evaluation is not reliable; therefore, serum calcium levels should be monitored routinely after total thyroidectomies.

Salivary gland tumors in a Brazilian population: a retrospective study of 124 cases

Salivary gland tumors constitute a highly heterogeneous histopathologic group. There are few epidemiological studies of large series of benign and malignant salivary gland tumors in Brazil. MATERIAL AND METHODS: Hospital records of 124 patients with salivary gland tumors diagnosed from January 1993 to December 1999 were reviewed. The patients were analyzed according to gender, age, size, location, and histopathology of the tumor. RESULTS AND CONCLUSIONS: Patients with benign and malignant tumors presented with a mean age of 47.7 and 48.8 years, respectively. The frequency of benign tumors was 80 percent (n = 99) and malignant tumors 20 percent (n = 25). Tumors were localized in the parotid gland 71 percent (n = 88), in the submandibular gland 24 percent (n = 30), and in the minor salivary glands 5 percent (n = 6). The most common benign tumors were pleomorphic adenoma in 84 percent (n = 84) and Warthin's tumor in 13 percent (n = 13). Among malignant tumors, mucoepidermoid carcinoma was the most common in 52 percent (n = 13), adenoid cystic carcinoma occurred in 20 percent (n = 5), and carcinoma ex pleomorphic adenoma was detected in 12 percent (n = 3)

Salivary gland tumors in a Brazilian population: a retrospective study of 124 cases.

UNLABELLED: Salivary gland tumors constitute a highly heterogeneous histopathologic group. There are few epidemiological studies of large series of benign and malignant salivary gland tumors in Brazil. MATERIAL AND METHODS: Hospital records of 124 patients with salivary gland tumors diagnosed from January 1993 to December 1999 were reviewed. The patients were analyzed according to gender, age, size, location, and histopathology of the tumor. RESULTS AND CONCLUSIONS: Patients with benign and malignant tumors presented with a mean age of 47.7 and 48.8 years, respectively. The frequency of benign tumors was 80% (n = 99) and malignant tumors 20% (n = 25). Tumors were localized in the parotid gland 71% (n = 88), in the submandibular gland 24% (n = 30), and in the minor salivary glands 5% (n = 6). The most common benign tumors were pleomorphic adenoma in 84% (n = 84) and Warthin's tumor in 13% (n = 13). Among malignant tumors, mucoepidermoid carcinoma was the most common in 52% (n = 13), adenoid cystic carcinoma occurred in 20% (n = 5), and carcinoma ex pleomorphic adenoma was detected in 12% (n = 3).

Carcinoma folicular de tireóide: estudo retrospectivo / Follicular thyroid carcinoma: retrospective study

OBJETIVOS: Abordar o diagnóstico, tratamento e evolução do carcinoma folicular da tireóide. MÉTODOS: Análise retrospectiva dos dados de 38 pacientes submetidos à tireoidectomia por carcinoma folicular puro, num período de 10 anos no HC-FMUSP. O tempo médio de seguimento foi de três anos e três meses. Nove pacientes eram do sexo masculino (23,7 por cento) e 29 do sexo feminino (76,3 por cento), com idades entre 19 e 87 anos (média=49,5). RESULTADOS: Em 17 (58,6 por cento) dos doentes, observou-se nódulo único à ultra-sonografia, e 23 (79,3 por cento) tinham nódulos frios à cintilografia. Sintomatologia esteve presente em 33 pacientes (86,8 por cento). A punção aspirativa por agulha fina (PAAF), realizada em 27 pacientes, revelou padrão folicular em 24 (88,9 por cento), carcinoma papilífero em 2 (7,4 por cento) e bócio em 1 (3,7 por cento). Tireoidectomia total foi o tratamento final em 34 pacientes e esvaziamento cervical foi realizado em três casos. Apenas 5 (13,1 por cento) obtiveram confirmação diagnóstica ao exame de congelação intra-operatória. Houve 2 (5,2 por cento) óbitos pela doença e 5 (13,1 por cento) pacientes apresentam-se vivos com doença. O aumento da tireoglobulina (TG) correlacionou-se com o aparecimento de metástase em 100 por cento dos casos. CONCLUSÕES: Concluímos que pacientes com carcinoma folicular de tireóide geralmente apresentam-se com nódulo único ou predominante ao primeiro exame, cuja PAAF é de padrão folicular. O exame de congelação raramente confirma o diagnóstico. Em nosso serviço, o tratamento de escolha é a tireoidectomia total, permitindo um seguimento mais adequado e confiável do paciente e prevenindo o crescimento de lesões subclínicas no lobo contralateral. A evolução geralmente é favorável.

BACKGROUND: Unlike papillary carcinoma, there are limited data regarding diagnosis, treatment and follow-up of patients with follicular thyroid carcinoma. METHODS: We retrospectively analyzed data on 38 patients submitted to thyroidectomy for exclusive follicular carcinoma over a 10 years period. Mean follow-up was 39 months (114 months the longest). Nine patients were males (23,7 percent) and 29 females (76,3 percent). Mean age was 49.5 (19 to 87 years). RESULTS: Thirty-three (86,8 percent) patients presented at least one symptom such as dyspnea, dysphagia or hoarseness. Seventeen (58,6 percent) patients had a solitary nodule shown by ultrasonography and 23 (79,3 percent) had "cold" nodules by scintigraphy. Twenty-seven patients underwent were submitted to fine-needle aspiration biopsy (FNA), which revealed a follicular neoplasm (benign or malignant) in 24 (88,9 percent) patients, goiter in 1(3,7 percent) and papillary carcinoma in 2 cases (7,4 percent). Total thyroidectomy was the final treatment in 34 patients and neck dissection operation was required in 3 cases. Only 13,1 percent of the patients were diagnosed as having follicular carcinoma by intraoperative frozen section. Two patients died from the tumor and 5 patients remain alive with the tumor all of them with distant metastasis. Elevation of serum levels of thyroglobulin correlated with metastasis in 100 percent of those cases. CONCLUSIONS: We conclude that follicular thyroid carcinoma usually presents as a solitary nodule diagnosed as a follicular neoplasm by FNA biopsy. Intra-operatory frozen section rarely confirms the diagnosis. O treatment of choice for thyroid follicular cancer total thyroidectomy followed by complementary therapy (radioiodine therapy) if necessary. We advocate total thyroidectomy because it is assumited with a better follow-up and avoids growth of subclinical lesions on the opposite lobe. Outcome is good in the majority of cases.

Nervo laringeo inferior näo-recorrente / Nonrecurrent laryngeal nerve

Apesar de sua relativa raridade, a ocorrencia do nervo laringeo inferior nao-recorrente e uma anomalia de grande importancia cirurgica, merecendo sempre ser lembrada, pois nestes casos o nervo corre grande risco de lesao em cirurgia das glandulas tiroide e paratiroides. Os autores apresentam sua casuistica de sete casos e tecem comentarios sobre a anatomia e embriologia do nervo laringeo inferior, enfatizando a necessidade da disseccao deste nervo em tireoidectomias

Reconstruçäo craniofacial microcirúrgica / Microsurgical cranofacial reconstruction

De 1981 a 1988, 10 pacientes portadores de extensas lesöes tumorais em Cabeça e Pescoço foram submetidos a ressecçöes craniofaciais oncológicas, seguidos de reconstruçäo com retalhos transplantados com microcirurgia vascular. Foram executados 11 retalhos microcirúrgicos: cinco do músculo grande dorsal, três do músculo reto abdominal, um do omento maior e um paraescapular. Bons resultados foram obtidos em nove pacientes (90%) e nove retalhos (82%). Num mesmo doente, houve perda total dos dois retalhos microcirúrgicos empregados (um grande dorsal e um omento maior), provavelmente devido a uma somatória de fatores desfavoráveis. Após a apresentaçäo detalhada de um caso representativo e da análise crítica, algumas conclusöes säo delineadas em relaçäo a estas técnicas reconstrutivas