Utilidad de la PTH intraoperatoria como predictor de curación quirúrgica en hiperparatiroidismo primario / Usefulness of intraoperative parathormone measurement to predict surgical cure in primary hyperparathyroidism

Background: The aim of the surgical treatment of primary hyperparathyroidism (PHPT) is to achieve its complete cure, evidenced by normal serum calcium in the postoperative period. Measurement of intraoperative serum parathormone (PTH) can be useful to predict complete cure of the disease. Aim: To assess the usefulness of intraoperative PTH measurement to predict complete cure of PHPT Material and methods: Serum PTH was measured to all patients operated for PHPT between 2003 and 2008, before and five and ten minutes after the excision of the parathyroid gland causing the disease. The criteria for complete cure were normal serum calcium at 24 hours and 6 months after surgery and the pathological confirmation of parathyroid gland excision. Results: Eighty-eight operated patients, aged 58±15 years (72 females) were studied. Sixty four percent were asymptomatic and their preoperative serum calcium was 11.6± 1.2 mg/dl. A normal serum calcium was achieved in 86 patients (98 percent) at 24 hours and 50 of 52 patients followed for six months (96 percent). The pathological study disclosed an adenoma in 69 (78 percent), and multiglandular disease in 16 (18 percent), a parathyroid cancer in one and a normal gland in one patient. Intraoperative PTH predicted early and definitive cure in 97 percent and 100 percent of patients with a single adenoma, respectively. Among patients with multiglandular disease, the predictive figures were 94 percent and 100 percent, respectively. Conclusions: Intraoperative PTH measurement efficiently predicts early and definitive surgical cure of PHPT.

[Usefulness of intraoperative parathormone measurement to predict surgical cure in primary hyperparathyroidism]. / Utilidad de la PTH intraoperatoria como predictor de curación quirúrgica en hiperparatiroidismo primario.

BACKGROUND: The aim of the surgical treatment of primary hyperparathyroidism (PHPT) is to achieve its complete cure, evidenced by normal serum calcium in the postoperative period. Measurement of intraoperative serum parathormone (PTH) can be useful to predict complete cure of the disease. AIM: To assess the usefulness of intraoperative PTH measurement to predict complete cure of PHPT. MATERIAL AND METHODS: Serum PTH was measured to all patients operated for PHPT between 2003 and 2008, before and five and ten minutes after the excision of the parathyroid gland causing the disease. The criteria for complete cure were normal serum calcium at 24 hours and 6 months after surgery and the pathological confirmation of parathyroid gland excision. RESULTS: Eighty-eight operated patients, aged 58+/-15 years (72 females) were studied. Sixty four percent were asymptomatic and their preoperative serum calcium was 11.6+/- 1.2 mg/dl. A normal serum calcium was achieved in 86 patients (98%) at 24 hours and 50 of 52 patients followed for six months (96%). The pathological study disclosed an adenoma in 69 (78%), and multiglandular disease in 16 (18%), a parathyroid cancer in one and a normal gland in one patient. Intraoperative PTH predicted early and definitive cure in 97% and 100% of patients with a single adenoma, respectively. Among patients with multiglandular disease, the predictive figures were 94% and 100%, respectively. CONCLUSIONS: Intraoperative PTH measurement efficiently predicts early and definitive surgical cure of PHPT.

Impact of preoperative ultrasonographic staging of the neck in papillary thyroid carcinoma.

OBJECTIVE: To determine the frequency of occult macroscopic metastasis detected by preoperative US evaluation of the neck in patients with PTC. Papillary thyroid carcinoma (PTC) is a malignancy with a high rate of lymph node metastasis. The findings of routine thyroid ultrasonography (US) and physical examination may underestimate metastatic disease. Thus, we propose that patients diagnosed as having PTC undergo preoperative US staging of the neck. DESIGN: This prospective study included 60 patients diagnosed as having PTC from January 1 through June 30, 2006. Patients had undergone previous thyroid US evaluation with no palpable adenopathy. Lymph nodes were deemed suspicious by US findings with a minor axis greater than 10 mm, a minor axis greater than 50% of the major axis, or hyperechogenicity with or without microcalcifications. Metastasis was confirmed by fine-needle aspiration biopsy or frozen section analysis. Patients with confirmed metastasis underwent a neck dissection. The location of adenopathy reported by US was correlated with the pathological report. RESULTS: The US evaluation identified 12 of 60 patients (20%) with adenopathy suggestive of metastasis. Metastasis was confirmed in 11 of 12 patients (92%). Metastasis was found in 1 of 48 patients who had a negative US finding. Overall, sensitivity, specificity, and positive and negative predictive values were 92%, 98%, 92%, and 98%, respectively. All neck levels with suspicious adenopathy detected by US evaluation, with 1 exception, were confirmed by pathological findings. Nine patients had additional neck levels involved with microscopic disease undetected by the US evaluation. CONCLUSIONS: In patients with PTC, preoperative US evaluation of the neck is effective in detecting nonpalpable metastasis. Therefore, routine preoperative neck US evaluation is recommended to optimize primary surgical planning.

[Clinical features of 17 patients with familial non medullary thyroid carcinoma]. / Carcinoma familiar del tiroides no medular (CFTNM): características de presentación en 17 casos.

BACKGROUND: Papillary thyroid carcinoma can have familial aggregation. AIM: To compare retrospectively familial non medullary thyroid carcinoma (FNMTC) with sporadic papillary thyroid carcinoma (PTC). MATERIAL AND METHODS: Retrospective analysis of medical records of patients with thyroid carcinoma. An index case was defined as a subject with the diagnosis of differentiated thyroid carcinoma with one or more first degree relatives with the same type of cancer. Seventeen such patients were identified and were compared with 352 subjects with PTC. RESULTS: The most common affected relatives were sisters. Patients with FNMTC were younger than those with PTC. No differences were observed in gender, single or multiple foci, thyroid capsule involvement, surgical border involvement, number of affected lymph nodes and coexistence of follicular hyperplasia. Patients with FNMTC had smaller tumors and had a nine times more common association with lymphocytic thyroiditis. Five patients with FNMTC had local recurrence during 4.8 years of follow up. CONCLUSIONS: Patients with FNMTC commonly have an associated chronic thyroiditis, are younger and have smaller tumors than patients with PTC.

Carcinoma familiar del tiroides no medular (CFTNM): características de presentación en 17 casos / Clinical features of 17 patients with familial non medullary thyroid carcinoma

Background: Papillary thyroid carcinoma can have familial aggregation. Aim: To compare retrospectively familial non medullary thyroid carcinoma (FNMTC) with sporadic papillary thyroid carcinoma (PTC). Material and methods: Retrospective analysis of medical records of patients with thyroid carcinoma. An index case was defined as a subject with the diagnosis of differentiated thyroid carcinoma with one or more first degree relatives with the same type of cancer. Seventeen such patients were identified and were compared with 352 subjects with PTC. Results: The most common affected relatives were sisters. Patients with FNMTC were younger than those with PTC. No differences were observed in gender, single or multiple foci, thyroid capsule involvement, surgical border involvement, number of affected lymph nodes and coexistence of follicular hyperplasia. Patients with FNMTC had smaller tumors and had a nine times more common association with lymphocytic thyroiditis. Five patients with FNMTC had local recurrence during 4.8 years of follow up. Conclusions: Patients with FNMTC commonly have an associated chronic thyroiditis, are younger and have smaller tumors than patients with PTC.

[Pathological characteristics of thyroid microcarcinoma. A review of 402 biopsies]. / Características de presentación del microcarcinoma papilar del tiroides. Experiencia retrospectiva de los últimos 12 años.

BACKGROUND: Thyroid microcarcinoma is a tumor of 10 mm or less, that should have a low risk of mortality. However, a subgroup of these carcinomas is as aggressive as bigger tumors. AIM: To describe the pathological presentation of these tumors, and compare them with larger tumors. MATERIAL AND METHODS: All pathological samples of thyroid carcinoma that were obtained between 1992 and 2003, were studied. In all biopsies, the pathological type, tumor size, the focal or multifocal character, the presence of lymph node involvement and the presence of lymphocytic thyroiditis or thyroid hyperplasia, were recorded. RESULTS: One hundred eighteen microcarcinomas and 284 larger tumors were studied. The mean age of patients with microcarcinoma and larger tumors was 42.7+/-14 and 49.3+/-16 years respectively (p <0,001) and 83% were female, without gender differences between tumor types. Mean size of microcarcinomas was 8.6 mm and 116 (98%) were papillary carcinomas. Of these, 109 (94%) were well differentiated and seven (6%) were moderately differentiated. Thirty six (31%) were multifocal and in 10 (8,6%), there was lymph node involvement. The mean size of larger tumors was 23.8 mm and 241 (85%) were papillary carcinomas. Of these, 200 (83%) were well differentiated, and 41 (17%) were moderately differentiated. Eighty five (35%) were multifocal and in 44 (18%) there was lymph node involvement. The prevalence of thyroiditis and hyperplasia was significantly higher among microcarcinomas than in larger tumors (15 and 2.5%, respectively, p <0.001, for the former; 32.4 and 1.7%, respectively, p <0.001, for the latter). CONCLUSIONS: In this series, one third of microcarcinomas were multifocal and 10% had lymph node involvement. Therefore, the aggressiveness of these tumors is higher than what is reported in the literature and they should be treated with total thyroidectomy.

[Missed diagnosis of osteoporosis and failure to treat adults with hip fracture in Chile]. / Falta de reconocimiento de osteoporosis y omisión de tratamiento en adultos mayores con fractura de cadera en Chile.

BACKGROUND: Hip fractures are the most severe complication of osteoporosis, yet patients who suffer hip fracture rarely receive adequate treatment. AIM: To assess diagnosis and treatment of osteoporosis in patients with hip fracture. PATIENTS AND METHODS: A retrospective study in 203 patients admitted for hip fracture surgery at two medical institutions in Santiago, Chile. Clinical data from 101 patients from the Hospital Clínico Pontificia Universidad Católica de Chile (a university tertiary care hospital, HCPUC) and 102 patients from Hospital de Urgencia de la Asistencia Pública (a public emergency hospital, HUAP) were reviewed. We also evaluated incidence of new fractures, further treatment of osteoporosis and functionality, by means of a telephonic survey of 48% of patients (n = 99) 12.3 +/- 5.3 months after hip fracture in HCPUC and 16.5 +/- 3.0 months for HUAP. RESULTS: A previous diagnosis of osteoporosis was present in 2.9% and 1% of cases, and treatment prior to fracture in 3.9% and 0% of cases from HCPUC and HUAP, respectively. None of the patients in HUAP were diagnosed with osteoporosis during hospital stay or given treatment for this condition at discharge, in comparison to 0.9% (n = 1) and 2% (n = 2), respectively, in HCPUC. Seven and six percent of cases presented prior hip fractures. Telephonic follow up of patients revealed that 75.6% persisted without treatment for osteoporosis. At follow up, 2.9% and 3% of patients in HCPUC and HUAP had presented new hip fractures. At the time of survey 30.9% and 34% of patients, respectively, were considered invalid. CONCLUSIONS: Missed diagnosis and failure to treat osteoporosis occurred in over 90% of patients admitted for hip fracture, regardless of the different complexities in the hospitals of admission. The data suggest that lack of medical action on these issues may play a role in failure to prevent new hip fractures.