Humanitarian Surgical Missions in Times of COVID-19: Recommendations to Safely Return to a Sub-Saharan Africa Low-Resource Setting.

BACKGROUND: Since the declaration of the pandemic, humanitarian medicine has been discontinued. Until now, there have been no general recommendations on how humanitarian surgical missions should be organized. METHODS: Based on our experience in the field of humanitarian surgical missions to Sub-Saharan Africa, a panel of recommendations in times of COVID-19 was developed. The fields under study were as follows: (1) Planning of a multidisciplinary project; (2) Organization of the infrastructure; (3) Screening, management and treatment of SARS-COV-2; (4) Diagnostic tests for SARS-COV-2; (5) Surgical priorization and (6) Context of patients during health-care assistance. We applied a risk bias measurement to obtain a consensus among humanitarian health-care providers with experience in this field. RESULTS: A total of 94.36% of agreement were reached for the approval of the recommendations. Emergency surgery must be a priority, and elective surgery adapted. For emergency surgery, we established a priority level 1a (< 24 h) and 1b (< 72 h). For an elective procedure, according our American College of Surgeon adaptation score, process with more than 60 points should be reconsidered. Due to the low life expectancy in many African countries, we consider 45-50 years as age of risk. In case of SARS-COV-2 active infection or high clinical suspicion, the screening, management and treatment should be following the international guidelines adapted to duration of the stay, available infrastructure, size of the cooperation team and medical resources. CONCLUSIONS: Humanitarian surgical mission in times of COVID-19 is a challenge that must extrapolate the established recommendations to the local cooperation environment.

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.

Factores pronósticos del carcinoma folicular de tiroides / Prognostic factors of follicular thyroid carcinoma

INTRODUCCIÓN: La mayoría de los estudios pronósticos en el carcinoma diferenciado incluyen un alto número de carcinomas papilares y pocos foliculares, por lo que no todas sus conclusiones son aplicables a este último. OBJETIVO: Analizar los factores pronósticos, tanto clínicos, histológicos como terapéuticos, del carcinoma folicular de tiroides. PACIENTES Y MÉTODOS: Criterios de selección: pacientes con el diagnóstico histológico de carcinoma folicular, sin enfermedad diseminada al diagnóstico, con cirugía potencialmente curativa, y con un seguimiento mínimo de 5 años. Variables de estudio: se consideró recidiva del tumor: a) lesiones tumorales con citología sospechosa de malignidad; y/o b) el aumento de los niveles de tiroglobulina mayor de 2 ng/ml en pacientes con tiroidectomía total. Para valorar los factores pronósticos se analizan variables clínicas, terapéuticas e histológicas. Estadística: curvas de supervivencia aplicando el test de Breslow. Modelo de regresión de Cox. RESULTADOS: Se han presentado 25 recidivas (38%) en los 66 pacientes estudiados. La mayoría eran recidivas analíticas (n=20) que fueron tratadas con I-131. En los casos restantes (n=5) se realizó exéresis de la lesión localizada y posteriormente se aplicó I131. Actualmente, dos casos (3%) presentan metástasis a distancia, y otros dos (3%) han sido éxitus por evolución de la enfermedad. El tiempo medio libre de enfermedad fue de 154 ± 14 meses, siendo las tasas de pacientes libres de enfermedad a los 5, 10, 15 y 20 años del 71, 58, 58 y 58% respectivamente. Los factores que influyen en la recidiva son: 1) la edad (p = 0,0035); 2) el sexo (p = 0,0114); 3) la clínica local (p = 0,0026); 4) la infiltración de estructuras vecinas (p = 0,0000); 5) el tipo de carcinoma (p = 0,0000); 6) el tamaño (p = 0,0162); 7) la invasión vascular (p = 0,0085); y 8) las adenopatías (p = 0,046). En el estudio multivariante persisten la clínica local (p = 0,018) y la infiltración de estructuras (p = 0,045). CONCLUSIONES: En el carcinoma folicular los principales factores predictivos son la presencia de clínica local al diagnóstico y la infiltración de estructuras vecinas

INTRODUCTION: Most prognostic studies in differentiated carcinoma have included a high number of papillary carcinomas and few follicular carcinomas, and not all of their conclusions therefore apply to the latter. OBJECTIVE: To analyze the prognostic factors of follicular thyroid carcinoma. PATIENTS AND METHODS: Selection criteria: Patients with histological diagnosis of follicular carcinoma who had undergone potentially curative surgery, had no disseminated disease at diagnosis, and had been followed up for at least 5 years. Study Variables: Tumor recurrence was defined as: 1) tumor lesions with cytological analysis suggesting malignancy and/or 2) patients with total thyroidectomy with thyroglobulin levels >2 ng/mL. Clinical, therapeutic, and histological parameters were analyzed to assess prognostic factors. RESULTS: Recurrence was found in 25 (38%) of the 66 study patients during a follow-up period of 99 ± 38 months. Most patients with recurrence (n=20) had increased Tg levels without anatomical location, and were initially treated with radioactive I131. In the remaining 5 cases, surgical excision of the lesion was performed, and three patients required surgery during the follow-up period. Two patients died due to the disease (3%), and two other patients (3%) currently have distant metastases. Mean disease-free interval was 154 ± 14 months, and rates of disease-free patients at 5, 10, 15, and 20 years were 71, 58, 58, and 58% respectively. Clinical factors influencing recurrence included 1) age (p = 0.0035); 2) sex (p = 0.0114); and 3) cervical pain (p = 0.0026). Histological/surgical factors associated with recurrence included 1) infiltration into neighboring structures (p = 0.0000); 2) type of carcinoma (p = 0.0000); 3) size (p = 0.0162); 4) vascular invasion (p = 0.0085); and 5) adenopathies (p = 0.046). In the multivariate study, cervical pain (p = 0.018) and extrathyroid invasion (p = 0.045) continued to be significant factors. CONCLUSIONS: In follicular carcinoma, rates of disease-free patients are 71% at 5 years and 58% at 10 years, and the main predictive factors are presence of local clinical symptoms and infiltration into neighboring structures

Prognostic factors of follicular thyroid carcinoma.

INTRODUCTION: Most prognostic studies in differentiated carcinoma have included a high number of papillary carcinomas and few follicular carcinomas, and not all of their conclusions therefore apply to the latter. OBJECTIVE: To analyze the prognostic factors of follicular thyroid carcinoma. SELECTION CRITERIA: Patients with histological diagnosis of follicular carcinoma who had undergone potentially curative surgery, had no disseminated disease at diagnosis, and had been followed up for at least 5 years. STUDY VARIABLES: Tumor recurrence was defined as: 1) tumor lesions with cytological analysis suggesting malignancy and/or 2) patients with total thyroidectomy with thyroglobulin levels >2 ng/mL. Clinical, therapeutic, and histological parameters were analyzed to assess prognostic factors. RESULTS: Recurrence was found in 25 (38%) of the 66 study patients during a follow-up period of 99 ± 38 months. Most patients with recurrence (n=20) had increased Tg levels without anatomical location, and were initially treated with radioactive I131. In the remaining 5 cases, surgical excision of the lesion was performed, and three patients required surgery during the follow-up period. Two patients died due to the disease (3%), and two other patients (3%) currently have distant metastases. Mean disease-free interval was 154 ± 14 months, and rates of disease-free patients at 5, 10, 15, and 20 years were 71, 58, 58, and 58% respectively. Clinical factors influencing recurrence included 1) age (p=0.0035); 2) sex (p=0.0114); and 3) cervical pain (p=0.0026). Histological/surgical factors associated with recurrence included 1) infiltration into neighboring structures (p=0.0000); 2) type of carcinoma (p=0.0000); 3) size (p=0.0162); 4) vascular invasion (p=0.0085); and 5) adenopathies (p=0.046). In the multivariate study, cervical pain (p=0.018) and extrathyroid invasion (p=0.045) continued to be significant factors. CONCLUSIONS: In follicular carcinoma, rates of disease-free patients are 71% at 5 years and 58% at 10 years, and the main predictive factors are presence of local clinical symptoms and infiltration into neighboring structures.

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.

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.

Relación entre la forma de presentación y el pronóstico del microcarcinoma papilar tiroideo / Relation between clinical presentation and prognosis of patients with papillary thyroid microcarcinoma

FUNDAMENTO Y OBJETIVO: Analizar a los pacientes con microcarcinoma papilar (MCP) de tiroides para intentar establecer su pronóstico al diferenciar los diagnosticados pre y postoperatoriamente. PACIENTES Y MÉTODO: Estudio retrospectivo de 83 pacientes con MCP, estableciendo dos grupos en función del momento del diagnóstico. Se compararon su clínica, histología y seguimiento, y se analizaron la supervivencia y el intervalo libre de enfermedad (ILE) entre los dos grupos. RESULTADOS: El grupo A (pacientes diagnosticados preoperatoriamente) incluyó a 30 pacientes (36,1 por ciento) y el grupo B (de diagnóstico postoperatorio) a 53 (63,9 por ciento). Se detectó recurrencia en 5 pacientes, todos del grupo A. La supervivencia global fue del 98,8 por ciento y el ILE global del 94 por ciento (83,3 por ciento para el grupo A y el 100 por ciento para el B, con diferencias significativas; p = 0,01). CONCLUSIONES: Es útil separar a los pacientes con MCP de tiroides diagnosticados pre o postoperatoriamente, ya que su evolución es diferente y, por lo tanto, requieren un tratamiento y seguimiento diferente (AU)

Prophylactic thyroidectomy in MEN 2A syndrome: experience in a single center.

BACKGROUND: Genetic study of the RET proto-oncogene has modified the management, treatment, and prognosis of medullary thyroid carcinoma (MTC), multiple endocrine neoplasia 2A (MEN 2A), for patients with less advanced tumor stages. Classically, the diagnosis was based on an increase in basal and poststimulus peak calcitonin (bCT and pCT). Prophylactic thyroidectomy, based on results of genetic testing, may reduce recurrences in MTC. STUDY DESIGN: Of 82 MTC (MEN 2A) patients genetically diagnosed and surgically treated at our center, 22 received a prophylactic thyroidectomy (RET +, bCT and pCT with normal values and asymptomatic). We analyzed age, gender, phenotype, RET mutation, cervical ultrasound, laboratory tests (bCT, pCT, and CEA), surgery, histologic data, TNM, and followup. RESULTS: The 22 patients belonged to 8 families with MTC (MEN 2A). Mean age was 15.2 years (range 5 to 36 years). The RET mutation in 21 patients was Cys-->Tyr and in the remaining patient both in codon 634 in exon 11. The median values of bCT and pCT were 38 pg/mL (range < 15 to 75 pg/mL) and 148.5 pg/mL (range < 15 to 250 pg/mL), respectively. Total thyroidectomy was performed in 8 patients (age < or = 10 years) and associated central neck dissection in 14 patients (age> 10 years). Histologic study showed 7 C-cell hyperplasias and 15 MTCs (8 bilateral); the median size was 0.2 cm (range < 0.1 to 0.7cm); 1 patient had metastatic adenopathies. According to TNM, 7 were stage 0, 14 were stage I, and 1 was stage III. Postsurgery bCT and pCT values were normal in all patients, with a curative rate of 100%. MTC patients compared with C-cell hyperplasia patients were older on average, had higher mean bCT, mean pCT, and mean CEA. CONCLUSIONS: Prophylactic thyroidectomy based on genetic testing allows identification and treatment of patients at an early stage of the disease and decreases recurrence rates. pCT values above the upper limit of normal may be markers for the presence of MTC and should be considered in selecting operative procedures for these patients.