Prediction of hypocalcemia after total thyroidectomy using indocyanine green angiography of parathyroid glands: A simple quantitative scoring system.

BACKGROUND: Hypocalcemia is one of the most common complications after total thyroidectomy. Recently, indocyanine green (ICG) angiography of the parathyroid glands (PGs) has been suggested as a reliable tool for predicting postoperative hypocalcemia. The aim of our study was to evaluate the performance of a simple quantitative score based on ICG angiography of the PGs (4-ICG score) for predicting postoperative hypocalcemia. METHODS: Thirty nine consecutive patients who underwent total thyroidectomy for multinodular goiter were included. For each patient, the 4-ICG score was calculated, adding the individual viability value of the four PGs. Discrimination and correlation analyses were performed. RESULTS: In 32/39 patients, the four PGs were identified. Patients with postoperative hypocalcemia (n = 6, 19%) had a lower 4-ICG score (2.5 [1.8-3.3] vs. 4.0 [3.0-6.0]; p = 0.003). The 4-ICG score showed good discrimination in terms of predicting postoperative hypocalcemia (AUC = 0.875 (0.710-0.965); p = 0.001) and a good correlation with postoperative parathyroid function. CONCLUSIONS: The 4-ICG score predicts postoperative hypocalcemia and correlates well with postoperative parathyroid function in patients undergoing total thyroidectomy for multinodular goiter.

Perfil histológico e inmuno-histoquímico del carcinoma medular de tiroides esporádico y familiar / Histological and immunohistochemical profile of sporadic and familial medullary thyroid carcinoma

Introducción En el carcinoma medular tiroideo (CMT) el perfil histológico e inmuno-histoquímico está mal definido. El objetivo de este estudio es determinar las características clínicas, histológicas e inmuno-histoquímicas del CMT, y analizar si existen diferencias entre los carcinomas esporádicos y familiares. Material y método Se han incluido 55 tumores confirmados histológicamente. Fueron revisadas las preparaciones histológicas y se llevaron a cabo las tinciones de inmuno-histoquímica de los bloques de parafina del archivo. Resultados De los 55 carcinomas, 19 (35%) fueron esporádicos y 36 (65%) de tipo familiar. La distribución por sexo es similar, sin embargo, los carcinomas familiares tienen una mayor frecuencia de pacientes menores de 40 años (p<0,001). En la mayor parte de los casos se ha observado un patrón de crecimiento sólido y el tipo celular plasmocitoide. Son hallazgos más frecuentes en el familiar la hiperplasia de células C y la multicentricidad, mientras que en el esporádico es más frecuente la necrosis tumoral, los focos hemorrágicos, la invasión vascular y la presencia de neovascularización. Respecto a la inmuno-histoquímica, los tumores muestran positividad intensa con marcadores para calcitonina, CEA y bcl-2, y proteína p53. En cuanto al estadiaje, los carcinomas familiares son diagnósticados en estadios más iniciales, con tamaño más pequeño y sin metástasis ganglionares (p<0,01).Conclusiones Los CMT familiares presentan con más frecuencia hiperplasia de células C y multicentricidad, y los esporádicos muestran con más frecuencia focos de necrosis, hemorragia, invasión vascular y neovascularización. Ni los criterios histológicos ni los inmuno-histoquímicos son arquitecturales para diferenciar las formas familiar y esporádica (AU)

Introduction The histological and immunohistochemical profile of medullary thyroid carcinoma is ill-defined. The objective of this study was to determine the epidemiological, histological, and immunohistochemical characteristics of medullary carcinoma and to analyze whether differences exist between sporadic and familial carcinomas. Patients and methods Fifty-five histologically confirmed tumors were studied. Histological slides were reviewed and immunohistochemical staining of the archival paraffin blocks was performed. Results Nineteen of the 55 carcinomas (35%) were sporadic, and 36 (65%) familial. Sex distribution was similar, but familial carcinoma was more common in patients under 40 years of age (p<0.001). A solid growth pattern and plasmacytoid cells were found in most cases. C-cell hyperplasia and multicentricity were more frequent findings in familial carcinoma, while tumor necrosis, hemorrhagic foci, vascular invasion, and neovascularization were more common in the sporadic type. Immunohistochemical staining was positive for calcitonin, CEA, bcl-2, and p53 protein. With regard to staging, familial carcinomas were diagnosed in the earliest stages, when they were smaller and there were no lymph node metastases (p<0.01).Conclusions Familial cases were more frequent when there was more C-cell hyperplasia and multicentricity. Sporadic cases more frequently showed foci of necrosis, hemorrhage, vascular invasion, and neovascularization. Neither histopathological nor immunohistochemical criteria are useful for differentiating between familial and sporadic forms (AU)

[Histological and immunohistochemical profile of sporadic and familial medullary thyroid carcinoma]. / Perfil histológico e inmuno-histoquímico del carcinoma medular de tiroides esporádico y familiar.

INTRODUCTION: The histological and immunohistochemical profile of medullary thyroid carcinoma is ill-defined. The objective of this study was to determine the epidemiological, histological, and immunohistochemical characteristics of medullary carcinoma and to analyze whether differences exist between sporadic and familial carcinomas. PATIENTS AND METHODS: Fifty-five histologically confirmed tumors were studied. Histological slides were reviewed and immunohistochemical staining of the archival paraffin blocks was performed. RESULTS: Nineteen of the 55 carcinomas (35%) were sporadic, and 36 (65%) familial. Sex distribution was similar, but familial carcinoma was more common in patients under 40 years of age (p<0.001). A solid growth pattern and plasmacytoid cells were found in most cases. C-cell hyperplasia and multicentricity were more frequent findings in familial carcinoma, while tumor necrosis, hemorrhagic foci, vascular invasion, and neovascularization were more common in the sporadic type. Immunohistochemical staining was positive for calcitonin, CEA, bcl-2, and p53 protein. With regard to staging, familial carcinomas were diagnosed in the earliest stages, when they were smaller and there were no lymph node metastases (p<0.01). CONCLUSIONS: Familial cases were more frequent when there was more C-cell hyperplasia and multicentricity. Sporadic cases more frequently showed foci of necrosis, hemorrhage, vascular invasion, and neovascularization. Neither histopathological nor immunohistochemical criteria are useful for differentiating between familial and sporadic forms.

[Toxic intrathoracic goiter. Clinical profile and surgical morbidity in an endocrine surgery unit]. / Bocio intratorácico tóxico. Perfil clínico y morbilidad quirúrgica en una unidad de cirugía endocrina.

BACKGROUND: The development of postsurgical complications is exacerbated when several risk factors coincide in the same patient. OBJECTIVE: To analyze the results of surgery for toxic intrathoracic goiter in terms of (a) the need for sternotomy; (b) morbidity and mortality; and (c) remission of compressive symptoms. MATERIAL AND METHODS: A review (1980-2002) was carried out of 43 cases of toxic intrathoracic multinodular goiter according to Eschapase's definition (3 cm below the sternal manubrium) occurring in patients without previous thyroid surgery who underwent total thyroidectomy. There were 2 control groups: I (non-toxic intrathoracic goiter, without recurrence and not requiring total thyroidectomy) and II (non-intrathoracic, non-toxic goiter without recurrence, requiring total thyroidectomy). The following variables were analyzed: sociopersonal, clinical and surgical characteristics, morbidity, mortality, and outcome. RESULTS: Compared with the control groups, the patient group had longer disease duration and was older. In 6 patients (14%) 1 was difficulty in intubation, and 2 patients required fiberoptic intubation. All goiters could be extirpated through the cervical route. The morbidity rate was 37% (n=16). Notably, 4 were recurrent lesions (9%), 1 of which was definitive, and 14 were hyperparathyroidism (33%), one of which was definitive. The only difference between the control groups and the patient group was a greater incidence of transitory hypoparathyroidism in the patient group than in control group II (33% versus 15%; p=0.0103). Surgical outcomes were excellent in terms of symptom remission. CONCLUSIONS: In any unit with ample experience of endocrine surgery, total thyroidectomy in toxic intrathoracic goiter can be carried out with a low risk of postsurgical complications, a low incidence of sternotomies and complete symptom remission. In intrathoracic goiter surgery, the presence of associated hyperthyroidism does not increase postoperative morbidity.

Bocio intratorácico tóxico. Perfil clínico y morbilidad quirúrgica en una unidad de cirugía endocrina / Toxic intrathoracic goiter. Clinical profile and surgical morbidity in an endocrine surgery unit

Introducción El desarrollo de complicaciones posquirúrgicas se acentúa cuando en un mismo paciente coinciden varios factores de riesgo. Objetivo: analizar en el bocio intratorácico tóxico los resultados quirúrgicos en cuanto a: 1) necesidad de esternotomía; 2) morbimortalidad postoperatoria, y 3) remisión de la sintomatología compresiva. Material y métodos Revisión retrospectiva (1980–2002) de 43 bocios multinodulares intratorácicos según la definición de Eschapase (3cm debajo del manubrio esternal), tóxicos, sin cirugía tiroidea previa y sometidos a una tiroidectomía total. Grupos controles: i (bocio intratorácico no tóxico ni recidivado sometido a una tiroidectomía total) y ii (bocio no intratorácico ni tóxico ni recidivado sometido a una tiroidectomía total). Se analizan variables sociopersonales, clínicas, quirúrgicas, morbimortalidad y de evolución. Resultados Comparando con los grupos control, los pacientes a estudio presentan mayor tiempo de evolución y mayor edad. En 6 casos (14%) se presentó dificultad en la intubación, precisando 2 de ellos fibrobroncoscopio para la intubación. Todos los bocios pudieron ser extirpados por vía cervical. La morbilidad fue del 37% (n=16), entre las que destacan 4 lesiones recurrenciales (9%), una de ellas definitiva, y 14 hipoparatiroidismos (33%), uno de ellos definitivo. Comparando con los grupos control, se evidencia que la única diferencia es la existencia de una mayor incidencia de hipoparatiroidismos transitorios respecto al grupo control ii (el 33 frente al 15%; p=0,0103). Los resultados en cuanto a la remisión de la (..) (AU)

Background The development of postsurgical complications is exacerbated when several risk factors coincide in the same patient. Objective: To analyze the results of surgery for toxic intrathoracic goiter in terms of (a) the need for sternotomy; (b) morbidity and mortality; and (c) remission of compressive symptoms. Material and methods A review (1980–2002) was carried out of 43 cases of toxic intrathoracic multinodular goiter according to Eschapase's definition (3cm below the sternal manubrium) occurring in patients without previous thyroid surgery who underwent total thyroidectomy. There were 2 control groups: I (non-toxic intrathoracic goiter, without recurrence and not requiring total thyroidectomy) and II (non-intrathoracic, non-toxic goiter without recurrence, requiring total thyroidectomy). The following variables were analyzed: sociopersonal, clinical and surgical characteristics, morbidity, mortality, and outcome. Results Compared with the control groups, the patient group had longer disease duration and was older. In 6 patients (14%) 1 was difficulty in intubation, and 2 patients required fiberoptic intubation. All goiters could be extirpated through the cervical route. The morbidity rate was 37% (n=16). Notably, 4 were recurrent lesions (9%), 1 of which was definitive, and 14 were hyperparathyroidism (33%), one of which was definitive. The only difference between the control groups and the patient group was a greater incidence of transitory hypoparathyroidism in the patient group than in control group II (33% versus 15%; p=0.0103). Surgical outcomes (..) (AU)

The value of various definitions of intrathoracic goiter for predicting intra-operative and postoperative complications.

BACKGROUND: Intrathoracic goiter (IG) is a pathologic and clinical entity defined by criteria that varies from one series to the next. The objective of this study was to determine the most useful definition of IG for predicting intra-operative and postoperative complications. METHODS: The study included 201 patients treated for multinodular goiter who met the following criteria: (1) they had no previous thyroid surgery; (2) they had undergone total thyroidectomy; and (3) they were diagnosed with IG according to 1 of the following definitions: (1) clinical; (2) Hsu's; (3) Kocher's; (4) Torre's; (5) Eschapase's; (6) Lahey's; (7) Lindskog's; (8) Crile's; (9) Katlic's; and (10) subcarinal. Three variables were evaluated: (1) intra-operative complications; (2) need for a sternotomy; and (3) postoperative complications. RESULTS: During orotracheal intubation, there were difficulties in 25 cases, all of which were detected using the 6 least restrictive definitions of IG (these range from the clinical definition to Lahey's definition. In 6 (3%) cases, it was necessary to carry out a sternotomy. The thoracic approach could be predicted using Katlic's definition. None of the definitions of IG was useful for predicting postoperative complications. CONCLUSION: Most definitions of IG can be ignored because they are not clinically relevant. The 6 least restrictive definitions overlap in their utility to predict intubation difficult during the anesthetic process; consequently, the clinical definition should be used because it is the simplest to calculate. Katlic's definition is the most useful for predicting a possible sternotomy for extirpating goiter.

[Spirometric evaluation of respiratory involvement in asymptomatic multinodular goiter with an intrathoracic component]. / Valoración espirométrica de la afectación respiratoria en el bocio multinodular asintomático con componente intratorácico.

Respiratory tract obstruction is underestimated in asymptomatic intrathoracic goiter. Our aim was to evaluate the involvement of the upper airway of asymptomatic patients with intrathoracic multinodular goiter, assessing the effect on respiratory function by means of spirometry. We selected 21 patients with asymptomatic intrathoracic goiter on whom a thyroidectomy had been performed. Spirometry was done in supine decubitus and in standing position before and 3 months after surgery. The preoperative study in decubitus showed mild obstruction in 4 cases (20%). In 2 of these cases this condition was also present in standing position (10%). Spirometry became normal after surgery in the 4 patients with obstruction. To conclude, spirometry in asymptomatic intrathoracic goiter shows mild obstruction of respiratory function in 10% to 20% of cases, depending on position. Surgery was associated with normalization of the abnormal parameters and an improvement in the remaining parameters. These data support the need to schedule surgery as soon as possible.

Pheochromocytoma in MEN 2A syndrome. Study of 54 patients.

BACKGROUND: Pheochromocytoma occurs in nearly 50% of MEN 2A (multiple endocrine neoplasia, type 2A) cases. Many issues related to this tumor are still the subject of debate: the diagnostic management in patients who have had positive genetic study results (RET mutation), variations related to mutation, the best surgical option, and the real relapse rate during long-term follow-up. The aim of this study is to present our experience with this unusual disease, looking for answers to some of these questions. PATIENTS AND METHODS: Of 169 patients belonging to 19 MEN 2A families, 54 (32%) presented with pheochromocytoma. The following variables have been studied: (1) clinical and diagnostic data [age, mutation, clinical features, results of catecholamines and catabolites in a 24-h urine sample, computerized tomography (CT) scan and iodine-131 meta-iodobenzylguanidine (MIBG) scintigraphy results, and the means of diagnostic, clinical, or genetic screening]; (2) surgical treatment; and (3) follow-up and recurrence. The mean follow-up time was 92.5 months (range: 12-120 months). RESULTS: The mean age of the 54 patients was 37.9 years (range: 14-71 years); 33 were women. Most (96.3%) mutations were found in exon 11. The most frequent mutations were Cys634Tyr (in 33 cases [61.1%]) and Cys634Arg (in 14 [25.9%]). The diagnosis of pheocromocytoma was made after the diagnosis of MTC in 26 cases (48.2%), simultaneously in 21 (38.9%), and prior in the 7 remaining cases (12.9%). At the time of diagnosis 28 patients (51.8%) were asymptomatic and 26 (48.2%) had clinical features related to pheochromocytoma. In 6 patients (11.1%), the values of catecholamines and catabolites in urine were normal. In the cases with high values, the most useful isolated determination was that of metanephrines (82%), followed by adrenaline (76%). The CT scan did not provide a correct diagnosis in 6 patients with bilateral lesions, and one patient with a bilateral tumor was not diagnosed by MIBG. The combination of CT scan and MIBG diagnosed 100% of cases. The pheochromocytoma was bilateral in 27 cases, with a total number of 81 pathological glands detected. A laparascopic approach was used in 30 cases and a laparotomy in 24. The mean tumor size was 4.5 cm (range: 1-18 cm). Five patients with unilateral resection relapsed (18.5%), and the mean relapse time was 43.2 months (range: 12-120 months). There was a greater frequency of pheochromocytoma in those subjects who had the Cys634Arg mutation (p < 0.03). In addition, the Cys634Arg mutation is more frequent in bilateral cases. There are no prognostic factors for recurrence. CONCLUSIONS: Pheochromocytoma in MEN 2A is related to the type of mutation, which can be early onset and is frequently asymptomatic. Its diagnosis requires catecholamines determinations as well as a CT scan. Correct diagnosis of bilaterality is established by CT and MIBG. Laparoscopic adrenalectomy is the treatment of choice.

Valoración espirométrica de la afectación respiratoria en el bocio multinodular asintomático con componente intratorácico / Spirometric evaluation of respiratory involvement in asymptomatic multinodular goiter with an intrathoracic component

La obstrucción de la vía aérea se infravalora en el bocio intratorácico asintomático. Nuestro objetivo ha sido valorar mediante espirometría la afectación de la vía aérea superior y la repercusión en la función respiratoria de pacientes asintomáticos con bocio multinodular intratorácico. Para ello se seleccionó prospectivamente a 21 pacientes con bocio intratorácico asintomático a quienes se había practicado una tiroidectomía. Se realizó la espirometría en decúbito supino y en bipedestación antes y a los 3 meses de la cirugía. El estudio preoperatorio mostró en decúbito una afectación obstructiva leve en 4 casos (20%), en 2 de los cuales persistía en bipedestación (10%). Tras la cirugía se normalizó la alteración en los 4 casos. En conclusión, la espirometría en el bocio intratorácico asintomático muestra una afectación obstructiva leve de la función respiratoria en el 10-20% de los casos, en función de la postura. La cirugía se acompaña de la normalización de los parámetros alterados y de la mejoría del resto. Estos datos apoyan la necesidad de indicar la cirugía lo antes posible (AU)

Respiratory tract obstruction is underestimated in asymptomatic intrathoracic goiter. Our aim was to evaluate the involvement of the upper airway of asymptomatic patients with intrathoracic multinodular goiter, assessing the effect on respiratory function by means of spirometry. We selected 21 patients with asymptomatic intrathoracic goiter on whom a thyroidectomy had been performed. Spirometry was done in supine decubitus and in standing position before and 3 months after surgery. The preoperative study in decubitus showed mild obstruction in 4 cases (20%). In 2 of these cases this condition was also present in standing position (10%). Spirometry became normal after surgery in the 4 patients with obstruction. To conclude, spirometry in asymptomatic intrathoracic goiter shows mild obstruction of respiratory function in 10% to 20% of cases, depending on position. Surgery was associated with normalization of the abnormal parameters and an improvement in the remaining parameters. These data support the need to schedule surgery as soon as possible (AU)

Results of surgical treatment in multinodular goiter with an intrathoracic component.

PURPOSE: (1) To determine the clinical profile of intrathoracic multinodular goiter (IMG); (2) to evaluate the results of surgery, and (3) to analyze the incidence of malignancy and its evolution. METHODS: Two hundred and forty-seven operated cases of IMG were reviewed. These cases of IMG had all been diagnosed according to Eschapse's definition (>3cm below the sternal manubrium). The morbidity and postoperative evolution were analyzed. A comparative study was carried out on a group of 425 cases of nonintrathoracic goiter. We applied the chi(2) test, Student's t-test, and a logistical regression analysis. RESULTS: Intrathoracic MG occurs in patients over 60 years of age, with goiter which has a long evolution time (>12 years), and more than 60% are symptomatic. Oral tracheal intubation was difficult in 10% (n = 24) of the cases, and 7 required the use of a fibrobronchoscope. In 8 cases (3%) a thoracic approach was necessary. Morbidity occurred in 24% (n = 59), most notably 29 recurring lesions (12%), of which 2 were definitive (0.8%), and 31 hypoparathyroidisms (13%), of which 1 was definitive (0.4%). No significant difference was found in the postsurgical morbidity between the intrathoracic MG and the nonintrathoracic cases. Regarding the remission of the symptoms, the results were excellent. In 14 cases (5.7%) thyroid carcinoma was related with, most of these being papillary microcarcinoma. In 10 of the 49 cases of partial surgery (20%) a relapse of the goiter was observed. CONCLUSIONS: Intrathoracic MG is usually asymptomatic and it occurs in goiter with a long time of evolution. Surgery is a good therapeutic option given that the goiter can be removed via the neck, with low morbidity, a remission of the symptoms, malignancy is ruled out, and recurrence can be avoided if a total thyroidectomy is performed.

Results of surgery for toxic multinodular goiter.

PURPOSE: We analyzed the clinical and histological features of patients operated on for toxic multinodular goiter (TMG) to determine the clinical profile and evaluate the surgical results. METHODS: We reviewed 672 patients who underwent surgery for multinodular goiter (MG), 112 (17%) of whom had hyperthyroidism, and analyzed the epidemiological, clinical, and surgical variables. RESULTS: The patients with TMG tended to be older than those with nontoxic MG, with a greater evolution time of the goiter and a higher rate of positive antithyroid antibodies. In the multivariate analysis, the only feature characteristic of TMG, as opposed to nontoxic MG, was the evolution time. Morbidity was 34%, representative of the fact that that most of the patients were seen before the establishment of our endocrine surgical unit. The hyperthyroid symptoms resolved in all patients, but 4 of 17 patients who underwent partial surgical resection showed signs of relapse within a follow-up period of 98 +/- 71 months. CONCLUSIONS: TMG is characterized by a long evolution time and is most effectively treated by total thyroidectomy, which achieves complete remission from symptoms, without relapse, and is necessary if there is associated carcinoma. However, the incidence of complications may be high if this procedure is not carried out by surgeons with experience in endocrine surgery.

Estudio multivariable de los factores de riesgo para desarrollar complicaciones en la cirugía del bocio multinodular / Multivariate study of risk fators for developing complications after multinodular goiter surgery

Introducción. El bocio multinodular (BM) supone un alto volumen de pacientes en los servicios de cirugía endocrina. Sin embargo, los factores de riesgo de morbilidad tras la cirugía no han sido investigados sistemáticamente. El objetivo es analizar, mediante un análisis estadístico multivariable, los resultados quirúrgicos, en cuanto a morbimortalidad, para poder determinar los factores de riesgo de la cirugía del BM. Pacientes y método. Se han revisado retrospectivamente 672 BM intervenidos. Las variables analizadas fueron la edad, el sexo, la cirugía previa, el tiempo de evolución, la sintomatología, el componente intratorácico, la gradación cervical del bocio, la duración de la cirugía, la experiencia del cirujano, la técnica quirúrgica, la identificación de estructuras, el carcinoma tiroideo asociado y el peso de la pieza tiroidea. Se aplicaron el test de la ÷2 y el de la t de Student, así como un análisis de regresión logística. Resultados. El índice de morbilidad fue del 22% (n = 147), la mayoría correspondiente a hipoparatiroidismos y lesiones recurrenciales transitorias. Los factores de riesgo para desarrollar estas complicaciones fueron la presencia de sintomatología (p = 0,0131), el hipertiroidismo (p = 0,0333), la sintomatologíacompresiva (p = 0,0158), la gradación clínica del bocio (p = 0,0482), la técnica quirúrgica realizada (p < 0,00001) y el peso del tiroides (p = 0,0302); como factores de riesgo independiente persistieron la técnica quirúrgica, el hipertiroidismo y la gradación del bocio. El índice de complicaciones definitivas fue del 2,2% (n = 15), que corresponden a 6 hipoparatiroidismos (0,9%) y 10 lesiones recurrenciales (1,5%). El factor de riesgo para su desarrollo es el hipertiroidismo (p = 0,0037; riesgo relativo [RR] = 2,8). Conclusiones. El principal factor de riesgo independiente para el desarrollo de complicaciones en la cirugía del BM es el hipertiroidismo (AU)

Introduction. Multinodular goiter (MG) accounts for a large volume of procedures performed in endocrine surgery departments. However, risk factors for postoperative complications have not been systematically investigated. The aim of the present study was to evaluate surgical outcomes in terms of morbidity and mortality through multivariate statistical analysis with a view to determining risk factors in MG surgery. Patients and method. A total of 672 patients who underwent surgery for MG were retrospectively reviewed. The variables analyzed were age, sex, prior surgery, disease duration, symptomatology, intrathoracic component, the surgeon’s experience, surgical technique, identification of structures, associated thyroid carcinoma and thyroid specimen weight. The chi-squared test, Student’s t-test and logistic regression analysis were performed. Results. Morbidity was 22% (n = 147) and mostly corresponded to hypoparathyroidisms and transitory recurrent lesions. Risk factors for developing these complications were symptomatic disease (p = 0.0131), hyperthyroidism (p = 0.0333), compressive symptoms (p = 0.0158), clinical grade of the goiter (p = 0.0482), surgical technique (p < 0.00001) and thyroid weight (p = 0.0302). Independent risk factors were surgical technique, hyperthyroidism and goiter grade. The definitive complication rate was 2.2% (n = 15), corresponding to six hypoparathyroidisms (0.9%) and 10 recurrent lesions (1.5%). The risk factor for their development was hyperthyroidism (p = 0.0037; RR = 2.8). Conclusions. The main independent risk factor for complications after MG surgery is hyperthyroidism (AU)

[Multivariate study of risk factors for developing complications after multinodular goiter surgery]. / Estudio multivariable de los factores de riesgo para desarrollar complicaciones en la cirugía del bocio multinodular.

INTRODUCTION: Multinodular goiter (MG) accounts for a large volume of procedures performed in endocrine surgery departments. However, risk factors for postoperative complications have not been systematically investigated. The aim of the present study was to evaluate surgical outcomes in terms of morbidity and mortality through multivariate statistical analysis with a view to determining risk factors in MG surgery. PATIENTS AND METHOD: A total of 672 patients who underwent surgery for MG were retrospectively reviewed. The variables analyzed were age, sex, prior surgery, disease duration, symptomatology, intrathoracic component, the surgeons experience, surgical technique, identification of structures, associated thyroid carcinoma and thyroid specimen weight. The chi-squared test, Students t-test and logistic regression analysis were performed. RESULTS: Morbidity was 22% (n = 147) and mostly corresponded to hypoparathyroidisms and transitory recurrent lesions. Risk factors for developing these complications were symptomatic disease (p = 0.0131), hyperthyroidism (p = 0.0333), compressive symptoms (p = 0.0158), clinical grade of the goiter (p = 0.0482), surgical technique (p < 0.00001) and thyroid weight (p = 0.0302). Independent risk factors were surgical technique, hyperthyroidism and goiter grade. The definitive complication rate was 2.2% (n = 15), corresponding to six hypoparathyroidisms (0.9%) and 10 recurrent lesions (1.5%). The risk factor for their development was hyperthyroidism (p = 0.0037; RR = 2.8). CONCLUSIONS: The main independent risk factor for complications after MG surgery is hyperthyroidism.

Diagnóstico perioperatorio de malignidad asociada al bocio multinodular / Perioperative diagnosis of malignancy in multinodular goiter

Introducción. La incidencia de malignidad en el bocio multinodular (BM) oscila entre el 1 y el 10 por ciento; su diagnóstico es difícil, excepto si se dispone de una histología definitiva. Los objetivos de este trabajo son: a) determinar los factores clínicos de riesgo de malignidad del BM, y b) valorar la utilidad de la ecografía, la citología (PAAF) y la biopsia intraoperatoria (BIO) en el BM para detectar malignidad. Pacientes y método. Se revisan 672 BM intervenidos, de los cuales 59 (8,8 por ciento) presentan un carcinoma tiroideo asociado. Se analizan diferentes variables, como los factores pronósticos, y los resultados de la ecografía, la PAAF y la BIO para descartar malignidad. El diagnóstico de estas exploraciones fue clasificado como positivo (indicativo de malignidad) y negativo (resto de diagnósticos) y se comparó con el de la histología definitiva con el fin de calcular el valor de dichas técnicas para el diagnóstico de malignidad. Resultados. Las variables independientes asociadas a la presencia de carcinoma sobre un bocio son los antecedentes familiares de enfermedad tiroidea (riesgo relativo [RR] = 1,6), el antecedente de radioterapia cervical (RR = 1,8), el bocio recidivado (RR = 2,1) y las adenopatías cervicales (RR = 1,6). La ecografía presentó una sensibilidad del 14 por ciento para descartar malignidad, con un valor predictivo positivo del 29 por ciento y una seguridad diagnóstica del 89 por ciento. La PAAF presentó una sensibilidad del 17 por ciento, una especificidad del 96 por ciento y una seguridad diagnóstica del 88 por ciento, con un valor predictivo positivo del 32 por ciento y negativo del 88 por ciento. Por último, la BIO mostró una sensibilidad del 19 por ciento, una especificidad del 100 por ciento, un valor predictivo positivo del 100 por ciento, un valor predictivo negativo del 93 por ciento y una seguridad diagnóstica del 93 por ciento. Conclusiones. La ecografía, la PAAF y la BIO tienen una baja sensibilidad para el diagnóstico de BM por lo que, ante la sospecha de malignidad, deben tenerse en cuenta los criterios clínicos en la toma de decisiones (AU)

Cáncer epidermoide de mama en el varón. ¿Primario o secundario? / Squamous cell cancer of the breast in the male. Primary or secondary?

El cáncer epidermoide de mama es una enfermedad poco frecuente y representa el 0,06-1,1 por ciento de las neoplasias malignas de mama; raramente aparece en varones. Puede ser un tumor primario, cuyo origen es controvertido (absceso, quiste, etc.), o secundario a un tumor epidermoide de otra localización (pulmonar, laringe, esófago, vejiga y cérvix), por lo que es importante realizar endoscopia, tomografía axial computarizada toracoabdominal y exploración ginecológica en las mujeres, con el fin de diagnosticar posibles lesiones primarias. Su tratamiento no difiere del resto de tumores de mama, aunque suele presentar un curso rápido y agresivo, con tasas de recurrencia de alrededor del 25 por ciento (AU)

Manejo de la vía aérea en la cirugía del bocio multinodular con afección traqueal / Airway management in the surgery of multinodular goiter with tracheal involvement

Objetivos. Determinar el mejor manejo de la vía área para la intervención del bocio multinodular con síndrome compresivo traqueal y/o compresióndesviación traqueal, y valorar las complicaciones en la vía aérea derivadas de dicha compresión. Pacientes y método. Se revisaron 672 bocios multinodulares intervenidos, de los que 238 cumplían alguno de los siguientes criterios: a) sintomatología derivada de la compresión de la vía aérea (n = 87), o b) bocios asintomáticos con compresión-desplazamiento traqueal en la radiografía simple cervicotorácica (n = 151). El tiempo medio de evolución del bocio superaba los 10 años y el 76 por ciento presentaba un componente intratorácico. Se valora la intubación/ orotraqueal (IOT), que se agrupa en normal, dificultosa, por fibrobroncoscopia o traqueotomía, así como la presencia de traqueomalacia y su manejo postoperatorio. Resultados. En 3 pacientes (1,3 por ciento) se indicó directamente una intubación bajo control de fibrobroncoscopio, dadas las características del bocio y de los pacientes. Del resto, en 25 (11 por ciento) hubo algún tipo de dificultad y 7 (3 por ciento) precisaron la utilización de un fibrobroncoscopio. No fue preciso realizar ninguna traqueotomía. No se presentaron diferencias en la IOT entre los pacientes con sintomatología y los asintomáticos. En 3 (1,3 por ciento) casos, las características de la tráquea hicieron sospechar una traqueomalacia, aunque sólo se confirmó 1 caso, que se resolvió mediante IOT prolongada (36 h).Conclusiones. En los bocios multinodulares con compresión-desviación traqueal la IOT presenta dificultades en más del 10 por ciento, por lo que el quirófano debe estar preparado para una intubación de emergencia e incluso una traqueotomía. Sin embargo, no es necesaria una fibrobroncoscopia o traqueotomía sistemáticas, pues en la mayoría de los casos la IOT se realizará simplemente disminuyendo el calibre del tubo de intubación (AU)

Resultados del tratamiento quirúrgico en 247 pacientes con bocio multinodular con componente intratorácico / Results o surgical treatment in 247 patients with multinodular goiter with intrathoracic development

Objetivos. a) Determinar el perfil clínico de los bocios multinodulares intratorácicos; b) valorar los resultados de la cirugía, y c) analizar la incidencia de malignidad y su evolución. Pacientes y método. Se revisan 247 bocios multinodulares intratorácicos, según la definifición de Eschapase ( 3 cm por debajo del manubrio esternal), operados. Se analiza la morbilidad y la evolución postoperatoria. Se realiza un estudio comparativo con un grupo de 425 bocios multinodulares no intratorácicos. Se aplican los tests de la 2, de la t de Student y de regresión logística. Resultados. El bocio multinodular intratorácico se presenta en pacientes con más de 60 años de edad y con un bocio de larga evolución (> 12 años); más del 60 por ciento presenta manifestaciones clínicas. Hubo dificultades en la intubación orotraqueal en el 10 por ciento (n = 24) de los casos, y en 7 de ellos fue preciso utilizar el fibrobroncoscopio. En 8 casos (3 por ciento) hubo que realizar un abordaje torácico. La morbilidad fue del 24 por ciento (n = 59) y destacan 29 lesiones recurrenciales (12 por ciento), 2 definitivas (0,8 por ciento) y 31 hipoparatiroidismos (13 por ciento), 1 de ellos definitivo (0,4 por ciento). No se han obtenido diferencias significativas en la morbilidad posquirúrgica entre los bocios multinodulares intratorácicos y los no intratorácicos. Los resultados en cuanto a la remisión de la sintomatología fueron excelentes. En 14 casos (5,7 por ciento) se asociaba un carcinoma tiroideo, la mayoría microcarcinomas papilares. En diez de las 49 cirugías parciales (20 por ciento), el bocio recidivó. Conclusiones. El bocio multinodular intratorácico suele ser sintomático y se presenta en bocios de larga evolución. La cirugía es una buena opción terapéutica, ya que el bocio se puede extirpar por vía cervical con una baja morbilidad, con lo que remite la sintomatología, se descarta su posible malignidad y, si se realiza una tiroidectomía total, se evitan las recurrencias (AU)

Tratamiento definitivo del hipoparatiroidismo persistente: alotrasplante de paratiroides / Definitive treatment of persistent hyperparathyriidism: parathyroid allotrans-plantation

La hipocalcemia posquirúrgica normalmente es una complicación transitoria de la cirugía del tiroides y paratiroides que se suele resolver en no demasiado tiempo; si el problema se hace persistente la solución es más delicada. El tratamiento de elección sería el trasplante de paratiroides, pero la necesidad de inmunosupresión y sus efectos secundarios hacen discutible su indicación. Se presenta un caso de trasplante de tejido paratiroideo de un paciente con hiperparatiroidismo secundario a otro con trasplante renal e hipocalcemia grave resistente a tratamiento médico. El injerto es funcionante después de 2 años (AU)