Thyroglobulin - what is the postoperative threshold for the suspicion of thyroid cancer recurrence in the absence of anti-Tg antibody measurement?

BACKGROUND: Thyroglobulin (Tg) is used as a postoperative marker for the follow-up of patients with thyroid carcinoma, but there is no consensus regarding the value that may indicate possible recurrence. Aim. To evaluate Tg levels as a marker for recurrence of thyroid carcinoma. SUBJECTS AND METHODS: Demographics and survival of 80 patients who underwent total thyroidectomy for well-differentiated thyroid cancer were analysed and related to Tg levels. Tg measurements were performed when patients were euthyroid, after completion of treatment. RESULTS: The median Tg value was 1.3 ng/ml. Higher values were found in males, high-risk patients and patients with recurrent disease. Using the median Tg value as cut-off, patients were divided into two groups (group I ≤1.3 ng/ml and group II >1.3 ng/ml). There was a significant correlation between values >1.3 ng/ml and recurrence. When survival was related to Tg values, there was a tendency towards worse prognosis in group II. The best predictive cut-off value for recurrence was found to be 1.3 ng/ml, which had a sensitivity of 77% and a specificity of 57%. CONCLUSIONS: Although low, a cut-off Tg level of 1.3 ng/ml represents a simple indication for further investigation in patients receiving thyroxine after completion of treatment for thyroid cancer, in the absence of measurement of anti-Tg auto-antibodies.

Epidemiology and survival of patients with well-differentiated thyroid cancer subjected to total thyroidectomy in Thrace area, Northern Greece: a 20-year experience.

AIM: The aim of this study was to evaluate epidemiology and survival of patients with well-differentiated thyroid cancer (WTC) treated with total thyroidectomy (TT) in the area of Thrace, Northern Greece. METHODS: The study was conducted on 80 patients who underwent total thyroidectomy from January 1985 to December 2004 for WTC. Patients' medical records and demographics, including age, sex, histological type (papillary, follicular, mixed type papillary-follicular, Hurthle), stage according to TNM staging, coexistence or future postoperative occurrence of local recurrence or distal metastases and overall and specific survival were analyzed and survival rates were calculated. RESULTS: Papillary carcinoma was found in 56.3% and follicular in 43.8%. Statistical analysis revealed significant correlation of male gender with the high-risk population (P = 0.017), follicular carcinoma with high-risk population (P < 0.0001) and high-risk population with local recurrence or metastatic disease (P < 0.0001). Overall year, 5-year and 10-year survival were 100%, 94% and 91.8% respectively. Further analysis showed a significant reduction in survival regarding to age > 45 years (P = 0.03), follicular type (P = 0.009), high-risk population (P = 0.008), presence of local recurrence or metastatic disease (P < 0.0001) and not significant correlation with male gender (P = 0.086). CONCLUSION: In conclusion, total thyroidectomy should be the surgical treatment of choice in all cases with WTC, especially in male patients > 45 years of age since they have a higher frequency of advanced malignant disease at presentation, a fact that affects prognosis. Patients must be accurately categorized postoperatively, and follow-up must be personalized, in order to diagnose recurrence as early as possible.

Multifocality of thyroid carcinomas: a "privilege" of papillary tumors or not?

AIM: To study the frequency of multifocality in well-differentiated non-medullary thyroid carcinomas and correlate it with various epidemiological factors, as well as with patients' survival. PATIENTS AND METHODS: A retrospective study was conducted on 80 patients who underwent total thyroidectomy from January 1985 to December 2004 in the First Department of Surgery of University General Hospital of Alexandroupolis, Democritus University of Thrace, Greece, for well-differentiated non-medullary thyroid cancer (papillary and follicular). Patients' medical records and demographics, including age, gender, histological type (papillary, follicular), multiple foci of tumors, overall and specific survival were analyzed. RESULTS: Multifocality was established in 17/80 patients (21,25%). Multifocal tumors were found in 4/20 male patients (20%) and 13/60 female ones (21,67%), percentages which are almost identical. Increased rates of multifocal tumors were found in the age groups of 20-29, 30-39 and 70-79 years old, while low rates were documented in the age groups of 0-9, 10-19 and 60-69 years old. Follicular tumors had a 20% rate, similar to papillary tumors (22,2%), and an impressive multifocal rate of mixed papillary-follicular neoplasms (75%) was found. Finally, survival was not found to be influenced by the multifocality of the tumor, under the prerequisition that total thyroidectomy is applied. CONCLUSIONS: Multifocality should not be considered as a "privilege" of papillary thyroid tumors, but as a privilege of thyroid carcinomas in general. If total thyroidectomy is applied in all benign and malignant thyroid diseases, the presence of multiple foci does not affect the prognosis and the survival of the patients.

Colorectal carcinoma: correlation between age, gender and subsite distribution.

BACKGROUND: Several studies have shown a migration in the occurrence of colorectal cancer (CRC) toward a proximal colonic location. The aim of this study was to examine the interrelationship between the anatomical distribution of CRC and gender, age at presentation, and incidence rates for the disease in the inhabitants of Thrace, Northern Greece. METHODS: A retrospective study was conducted on CRC cases diagnosed in a northern part of Greece (Evros region, 150.000 inhabitants), in the First Department of Surgery of the University General Hospital of Thrace, between 1982 and 1997. Two time periods were compared (1982-1989 and 1990-1997), at which age at diagnosis (28-88 years), gender, the incidence and subsite location of CRC were identified in the patients. Tumors were classified into right-sided cancers (from the cecum to and including the splenic flexure), left-sided cancers (located in the descending and the sigmoid colon), and rectal cancers (rectal lesions). The chi-square test and Fischer's exact test were used to compare the data. RESULTS: During the entire study period (1982-1997), 143 cases of CRC were identified in our department. This cohort comprised 71 males and 72 females, with mean ages of 66 years and 64.7 years, respectively. The population remained almost stable during this time period. The incidence of CRC was significantly higher in the latter part of the study (1990-1997 compared to 1982-1989) for both genders (p < 0.001), with this increase being higher among the female patients with CRC (by 17.32%, p = 0.474). The analysis also revealed that the disease occurred at a significantly higher frequency at a later age (p = 0.002), especially in patients with RC (p = 0.001). A proximal migration of CRC was observed in the latter part of the study (p = 0.495), with the frequency of right-sided cancers increasing significantly among the females (by 119%, p = 0.025). CONCLUSIONS: The incidence of CRC has increased in our region. In addition, a proximal migration of tumors over time was identified, especially in older and female individuals, which was linked to a decrease in the incidence of left colon cancer. These findings have important implications for the choice of CRC screening strategies.

Emergency operations for carcinoma of the colon.

The aim of this retrospective clinical study was to record and analyse the immediate and long term results obtained from emergency operation for carcinoma of the large bowel. In a 12-year period (1991-2003), 154 patients were operated on for carcinoma of the colon. In 29 patients (19%; 11 males, 18 females, m.a. 72.8 years and 67.5 years respectively), the operation was performed urgently. In 21 (72.5%) there was a complete obstruction located in 17 (81%) at the sigmoid, in 2 (9.5%) in right flexure and in 2 (9.5%) in left flexure. Five patients (17%) had developed peritonitis due to perforation proximal to the tumour and three patients (10.5%) had developed necrotic colitis and haemorrhage due to the obstruction. In 23 patients (79.5%) a radical curative operation was feasible [11 (38%) subtotal colectomies with ileo-rectal anastomosis, seven (24%) Hartman's, three (10%) right hemicolectomy and two (7%) on table bowel lavage plus colectomy with ileo-rectal anastomosis] and in six (11%) only palliative operations could be done (transverse loop colostomy). In all cases the postoperative period was uneventful. Three patients with palliative operation were submitted to a radical curative operation 2 months later and the other three patients died 6 months later from causes irrelevant to the primary disease. It is concluded that in this series of patients radical curative operations for carcinoma of the large bowel even under urgent conditions were feasible in the cases without additional complications, eliminating the necessity for reoperations later on.

Testosterone-secreting adrenal adenoma in a peripubertal girl.

A 15-year-old girl who presented with primary amenorrhea and virilization had an adrenocortical adenoma that secreted predominantly testosterone. To our knowledge, she is the first peripubertal and second youngest patient with a testosterone-secreting adrenal tumor described. Serum dehydroepiandrosterone sulfate and urinary 17-ketosteroid and 17-hydroxycorticosteroid levels were normal. A tumor was located by a computed tomographic (CT) scan and by uptake of 6-beta-[75Se] selenomethylnorcholesterol. Microscopic examination of the tumor showed typical features of an adrenocortical adenoma with no histologic features characteristic of Leydig cells. Postoperatively, her hirsutism regressed, she rapidly went through puberty, and regular monthly menstruation started four months later. Finding the source of testosterone in a virilized patient can be difficult. Eleven of the 14 previously described patients with testosterone-secreting adrenal tumors initially underwent misdirected surgery on the ovaries. Review of these cases revealed that results of hormone stimulation and suppression tests are unreliable and that these tumors are usually large. Therefore, CT scanning of the adrenal glands is recommended in all patients suspected of having a testosterone-secreting tumor. If the adrenal glands on CT scan are normal, then surgery directed at the ovaries can be undertaken. Adrenal and ovarian vein catheterization is rarely necessary.

Distribution and postprandial release of porcine peptide YY.

Peptide YY (PYY), a thirty-six amino acid intestinal hormonal peptide with a tyrosine residue at each end (hence YY as Y represents tyrosine in the new peptide nomenclature), was found throughout the gastrointestinal tract of the pig. Concentrations were very low in the foregut (antrum, 3.4 +/- 0.3 pmol/g; duodenum, 1.1 +/- 1.5 pmol/g), higher in the distal small intestine (ileum, 100 +/- 13 pmol/g) and very high in the large bowel (descending colon, 270 +/- 45 pmol/g). Peptide YY was found to circulate in plasma and concentrations rose substantially in response to eating (fasting, 138 +/- 15 pmol/l; postprandial, 263 +/- 21 pmol/l; P less than 0.001). There was a small but significant portal/arterial gradient in postprandial PYY levels. More than 90% of the immunoreactive PYY in gut extracts eluted, on gel permeation chromatography, in an identical position to pure PYY standard, but small amounts of higher molecular weight material, possibly precursors, were detected. In contrast, plasma from fasting pigs contained a large proportion (60-70%) of these large molecular forms. These findings suggest that the putative pro-PYY may be cleared more slowly from the circulation than the 36 amino acid hormonal peptide. The high concentrations of immunoreactive PYY in the circulation of the young pig may reflect a species difference between pig and man or may indicate an important role for PYY in the developing animal.

Effect of food on porcine gut regulatory peptides in arterial and portal venous blood.

The concentrations of gut regulatory peptides were monitored simultaneously in the portal and arterial circulations of 8 healthy conscious swine in the fasted state and after a standard mixed meal. The sampling was achieved via chronic cannulations of these two vessels. Portal/arterial differences of insulin and glucagon were similar to those previously described, indicating the importance of hepatic extraction of these two hormones. Portal/arterial differences for the gastrointestinal regulatory peptides were relatively small, however, and the liver is unlikely to be of major importance in the metabolism of these peptides.

Lymph, pancreatic and gastrointestinal hormones in response to feeding in the conscious pig.

Concentrations of several gastrointestinal hormonal peptides were measured in lymph from the cisterna chyli and in arterial plasma; in healthy, conscious pigs during ingestion of a meal. Lymph concentrations of the pancreatic hormones insulin, glucagon and pancreatic polypeptide were small compared with plasma concentrations, although postprandial increments were significant. In contrast lymph concentrations of gastrin, cholecystokinin, motilin and gastric inhibitory peptide (GIP) from the foregut showed a more marked postprandial rise than the pancreatic hormones. Indeed the total integrated responses of these peptides in lymph reached about 50% of those seen in arterial plasma. It would appear unlikely that the lymphatics constitute an important transport mechanisms for these regulatory peptides. However, lymph concentrations of hormones may reflect levels in interstitial fluid better than plasma and may be of value in assessing putative physiological actions within a target tissue.

An experimental model for simultaneous chronic sampling of portal and systemic blood and gastrointestinal lymph via cannulae in conscious swine.

Surgical techniques are described whereby safe chronic cannulations of the portal vein, the external iliac artery and vein and the cisterna chyli of pigs were performed. The pigs tolerated the operations well and there was a short recovery period. They were unrestrained during the subsequent feeding experiments, when large sequential blood and lymph samples were withdrawn readily. The experimental periods varied from 3 to 46 days (mean : 13.4 days, SE: 2.0). All of 22 arterial cannulae remained patent (mean : 16 days, SE : 2.2), nineteen of 22 portal cannulae (mean : 15 days, SE : 1.8) and eighteen of 22 venous cannulae (mean : 14 days, SE : 1.9). The lymph cannula patency varied from 2 to 7 days, but lymph samples were easily obtained through all but one of them during the third postoperative day.