Goiter surgery recommendations in sub-Saharan Africa in humanitarian cooperation.

Background: The standard treatment for endemic goiter is usually total thyroidectomy. In low- and middle-income countries, the management of thyroid disease, which is commonplace in fully developed countries, is not always possible. The purpose of this study is to establish a treatment algorithm to calculate the extent of thyroidectomy based on the risk factors of each patient. Methods: This is a retrospective observational study conducted during the period between 2017 and 2019. A total of 287 patients with thyroid pathology were treated in Maragua Hospital (Kenya). The results of surgical treatment were analyzed after the implementation of an individualized treatment protocol. Results: One hundred and sixty patients with different types of goiter underwent surgery: solitary nodule (54.4%), multi-nodular goiter (30.6%), diffuse goiter (10.6%), and intrathoracic goiter (3.8%). The techniques used were hemithyroidectomy (78.8%), Dunhill thyroidectomy (9.4%), bilateral subtotal thyroidectomy (6.9%), and total thyroidectomy (3.1%). There was no mortality. The surgical morbidity rate was 16% (only one major complication (3b)). Two cases of dysphonia were resolved in the first week. There were three cases of symptomatic hypocalcaemia, two of which resolved in the first week and the other of which was definitive. The follow-up at 6 months was 67%. The cancer rate found in the resection specimens was 5%. Discussion: The implementation of individualized surgical protocols for thyroid surgery in sub-Saharan Africa can improve outcomes. The cooperation projects can increase access to complex surgical treatment for patients with limited resources in low- and middle-income countries.

Malignant prediction in paragangliomas: analysis for clinical risk factors.

INTRODUCTION: Paragangliomas are infrequent neuroendocrine tumours whose only criterion for malignancy is presence of metastases; thus, all paragangliomas show malignant potential. Actually, different risk factors have been analyzed to predict metastases but they remain unclear. PURPOSE: To analyze clinical, histological, and genetic factors to predict the occurrence of metastasis. PATIENTS AND METHOD: A multicentre retrospective observational analysis was performed between January 1990 and July 2019. Patients diagnosed with paraganglioma were selected. Clinical, histological, and genetic features were analyzed for the prediction of malignancy. RESULTS: A total of 83 patients diagnosed with paraganglioma were included, of which nine (10.8%) had malignant paraganglioma. Tumour size was greater in malignant tumours than in benign (6 cm vs. 4 cm, respectively; p = 0.027). The most frequent location of malignancy was the thorax-abdomen-pelvis area observed in six cases (p = 0.024). No differences were observed in histological differentiation, age, symptoms, and catecholaminergic production. The most frequent genetic mutation was SDHD followed by SDHB but no differences were observed between benign and malignant tumours. In the univariate analysis for predictive factors for malignancy, location, tumour size, and histological differentiation showed statistical significance (p = 0.025, p = 0.014, and p = 0.046, respectively); however, they were not confirmed as predictive factors for malignancy in the multivariate analysis. CONCLUSION: In this study, no risk factors for malignancy have been established; therefore, we recommend follow-up of all patients diagnosed with paraganglioma.

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.

Fístula quilosa como complicación de la cirugía tiroidea en patología maligna / Chyle fistula as complication of thyroid surgery in malignant pathology

Introducción: La fístula quilosa (FQ) cervical es excepcional y no existe consenso sobre su tratamiento. El objetivo es analizar la eficacia de los tratamientos conservador y quirúrgico en esta patología. Método: Población a estudio constituida por pacientes con cirugía tiroidea que presentan en la evolución posquirúrgica una FQ. Grupos a estudio: 1) Grupo con tratamiento conservador, formado por FQ con débito inferior a 300cm3/día, tardías o coleccionadas en el cuello; y 2) Grupo con tratamiento quirúrgico, formado por FQ precoces con débito superior a 300cm3/día. Variables a estudio: Se analizan los resultados en cuanto a tasas de curación y la tasa de reconversión a tratamiento quirúrgico. Resultados: Nueve pacientes presentaron una FQ. Todos iniciaron tratamiento conservador; de ellos, el 67% (n=6) con intención curativa, resolviéndose el 50% de los casos (n=3). Los restantes, tras más de 150 días de tratamiento, fueron ingresados para añadir dieta absoluta y nutrición parenteral. Uno de ellos se resolvió, siendo los otros 2 casos remitidos a cirugía. En los casos restantes (33%; n=3) se indicó la cirugía como tratamiento definitivo inicial. El abordaje fue cervical con ligadura y punto transfixivo del conducto torácico. En uno de los pacientes, que asociaba un quilotórax, se asoció una toracoscopia. En los 2 casos en quienes fracasó el tratamiento conservador, se indicó la cirugía mediante cervicotomía, identificando el punto de reflujo linfático. Todos los operados han presentado resolución de la fístula. Conclusiones: El tratamiento conservador es efectivo en el 66% de las FQ de bajo débito. En las fístulas de débito alto, o donde el tratamiento conservador no es efectivo, la cirugía ofrece una resolución efectiva y rápida del cuadro

Introduction: Cervical chyle fistula (CF) is exceptional, and there is no agreement on its treatment. The study objective was to assess the efficacy of conservative and surgical treatment in this condition. Method: Study population: Patients undergoing thyroid surgery who experience CF after the procedure. Study groups: 1) Group with conservative treatment: CF with flow rates less than 300cm3/day, late or collected in the neck; and 2) Group with surgical treatment: early CF with flow rates greater than 300 cm3/day. Study variables: Cure rates and rate of conversion to surgery were analyzed. Results: Nine patients experienced CF. Conservative treatment was started in all of them, in 67% (n=6) with curative intent. Fifty percent of treated cases were resolved (n=3). The remaining patients were hospitalized after more than 150 days of treatment to add absolute diet and parenteral nutrition. The condition resolved in one patient, and the other two were referred for surgery. In the remaining patients (33%, n=3), surgery was indicated as the initial definitive treatment. A cervical approach, with ligature and transfixion stitch of the thoracic duct, was used. In one of the patients, who also had chylothorax, thoracoscopy was also performed. In the two patients where conservative treatment failed, cervicotomy was indicated, identifying in both the lymphatic reflux point. Fistula resolved in all operated patients. Conclusions: Conservative treatment was effective in 66% of low flow CFs. Surgery effectively and rapidly resolves fistulas with a high flow or not responding to conservative treatment

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.

Chyle fistula as complication of thyroid surgery in malignant pathology. / Fístula quilosa como complicación de la cirugía tiroidea en patología maligna.

INTRODUCTION: Cervical chyle fistula (CF) is exceptional, and there is no agreement on its treatment. The study objective was to assess the efficacy of conservative and surgical treatment in this condition. METHOD: Study population: Patients undergoing thyroid surgery who experience CF after the procedure. Study groups: 1) Group with conservative treatment: CF with flow rates less than 300cm3/day, late or collected in the neck; and 2) Group with surgical treatment: early CF with flow rates greater than 300 cm3/day. STUDY VARIABLES: Cure rates and rate of conversion to surgery were analyzed. RESULTS: Nine patients experienced CF. Conservative treatment was started in all of them, in 67% (n=6) with curative intent. Fifty percent of treated cases were resolved (n=3). The remaining patients were hospitalized after more than 150 days of treatment to add absolute diet and parenteral nutrition. The condition resolved in one patient, and the other two were referred for surgery. In the remaining patients (33%, n=3), surgery was indicated as the initial definitive treatment. A cervical approach, with ligature and transfixion stitch of the thoracic duct, was used. In one of the patients, who also had chylothorax, thoracoscopy was also performed. In the two patients where conservative treatment failed, cervicotomy was indicated, identifying in both the lymphatic reflux point. Fistula resolved in all operated patients. CONCLUSIONS: Conservative treatment was effective in 66% of low flow CFs. Surgery effectively and rapidly resolves fistulas with a high flow or not responding to conservative treatment.

Prophylactic thyroidectomy in multiple endocrine neoplasia 2 (MEN2) patients with the C634Y mutation: A long-term follow-up in a large single-center cohort.

BACKGROUND: Medullary thyroid carcinoma (MTC) is the main cause of death in multiple endocrine neoplasia 2A (MEN2A) patients. It is therefore important to treat this disease at an early stage. The mutation in codon 634 is considered to be associated with an aggressive clinical course, whereas the C634Y mutation may result in a more indolent course. Prophylactic thyroidectomy is performed before thyroid disease occurs. However, controversy surrounds this disease regarding levels of calcitonin (Ct) and age. In this context, few studies have investigated this mutation over a long period. OBJECTIVE: To analyze a large cohort of patients with the C634Y mutation who received prophylactic thyroidectomy. MATERIALS AND METHODS: In a group of 110 MEN2 patients, we analyzed those with the C634Y mutation who had received prophylactic thyroidectomy (absence of clinical and radiological thyroid disease) treated in a tertiary referral hospital between 1983 and 2016. MTC is related to age and Ct. Statistical analysis was performed using the χ2 test, partial correlations, and logistic regression. RESULTS: Fifty patients with a mean age of 12 ±â€¯9 years were analyzed; 56% of these had MTC (100% stage I). There was no case of hypoparathyroidism or permanent recurrent damage. MTC was associated mainly with age (OR 1.38). One 5-year-old patient presented with MTC. Mean follow-up time was 16 ±â€¯6 years, and no cases of recurrence were observed. CONCLUSIONS: Performing prophylactic thyroidectomy in patients with the C634Y mutation allows us to cure the disease without causing long-term complications. Our results support the notion that age <5 years should be a criterion for carrying out prophylactic thyroidectomy in these patients.

Evaluación del nódulo tiroideo con ecografía y elastografía de alta resolución sin la punción-aspiración con aguja fina / Evaluation of the thyroid nodule with high-resolution ultrasonography and elastography without fine needle aspiration biopsy

Introducción: La punción-aspiración con aguja fina (PAAF) es la técnica diagnóstica gold standard en el protocolo diagnóstico del nódulo tiroideo. Sin embargo, no está exenta de complicaciones. Objetivo: Establecer los nódulos tiroideos en los que se podría evitar la PAAF en el protocolo diagnóstico con la inclusión de la ecografía de alta definición y la elastografía. Material y método: Se realiza un estudio prospectivo no aleatorizado. Se incluyen nódulos tiroideos solitarios y los nódulos dominantes del bocio multinodular. Se excluyeron los pacientes con cirugía tiroidea previa. A todos los pacientes se les realiza primero una ecografía de alta resolución y una elastografía, y posteriormente una PAAF. Se analizan las variables ecográficas en 2D y doppler, las elastográficas, y el resultado de la PAAF según Bethesda. Para correlacionar los datos, los nódulos se clasifican como benignos o malignos. Para el análisis estadístico se aplica el test de la t de Student, el test de Chi-cuadrado y un análisis de regresión logística. Resultados: Se analizan 221 nódulos tiroideos, de los cuales 32 fueron malignos (14%). Los hallazgos ecográficos más predictores de malignidad (p<0,05) son la ecoestructura hipoecoica o compleja (OR=11,832), las microcalcificaciones (OR=9,637) y la vascularización caótica con el doppler (OR=46,464). Respecto a la elastografía, el patrón elastográfico I y II se asocian a benignidad (p=0,0004 y p<0,0001, respectivamente). Cuando se combina la elastografía tipo I o II, y la ecografía con ecoestructura no hipoecoica ni compleja, sin microcalcificaciones y sin vascularización caótica en la ecografía doppler, el 100% de los casos eran benignos, con una especificidad del 100% y una sensibilidad del 14%. Conclusiones: La combinación de la ecografía de alta resolución y la elastografía permite seleccionar casos donde no es necesario realizar una PAAF. Los casos susceptibles de seguimiento periódico sin realización de PAAF son aquellos que no presentan ecoestructura hipoecoica o compleja, que no muestran microcalcificaciones y en los que la vascularización no es caótica, junto con una elastografía tipo I y II

Introduction: Fine needle aspiration biopsy (FNAB) is the gold standard screening technique used in the diagnostic protocol for thyroid nodules. However, it is not free of complications. Objective: To identify thyroid nodules in which FNAB could be avoided during the diagnostic process by means of the use of a high-resolution ultrasonography or elastography. Material and method: A prospective, non-randomized study was carried out. Single thyroid nodules and dominant nodules of multinodular goiter were included. Patients who had undergone thyroid surgery in the past were excluded. All patients underwent a high-resolution ultrasound and elastography, and, subsequently, a FNAB. We analyzed the ultrasound variables in 2D and Doppler, followed by the elastographic variables, and the results of the FNAB according to Bethesda. To correlate the data, the nodules were classified as benign or malignant. Student's t test, the Chi-square test and a logistic regression analysis were applied for the statistical analysis. Results: A total of 221 thyroid nodules were analyzed, 32 of which were malignant (14%). The most predictive ultrasound findings of malignancy (P<.05) were a hypoechoic or complex echostructure (OR=11.832), the presence of microcalcifications (OR=9.637) and chaotic vascularization observed in the Doppler (OR=46.464). With regard to the elastography, elastographic patterns I and II were seen to be associated with benignity (P=.0004 and P<.0001, respectively). When type I or II elastography was combined with an ultrasound showing a non-hypoechoic nor complex echostructure, without microcalcifications nor chaotic vascularization in the Doppler ultrasound, 100% of the cases were benign with a specificity of 100% and a sensitivity of 14%. Conclusions: The combination of a high-resolution ultrasound with an elastography makes it possible to select cases where a FNAB does not have to be performed. Cases susceptible to a periodic follow-up without the use of a FNAB are those without a hypoechoic nor complex structure, no microcalcifications, non-chaotic vascularization and a type I or II elastography

Evaluation of the thyroid nodule with high-resolution ultrasonography and elastography without fine needle aspiration biopsy. / Evaluación del nódulo tiroideo con ecografía y elastografía de alta resolución sin la punción-aspiración con aguja fina.

INTRODUCTION: Fine needle aspiration biopsy (FNAB) is the gold standard screening technique used in the diagnostic protocol for thyroid nodules. However, it is not free of complications. OBJECTIVE: To identify thyroid nodules in which FNAB could be avoided during the diagnostic process by means of the use of a high-resolution ultrasonography or elastography. MATERIAL AND METHOD: A prospective, non-randomized study was carried out. Single thyroid nodules and dominant nodules of multinodular goiter were included. Patients who had undergone thyroid surgery in the past were excluded. All patients underwent a high-resolution ultrasound and elastography, and, subsequently, a FNAB. We analyzed the ultrasound variables in 2D and Doppler, followed by the elastographic variables, and the results of the FNAB according to Bethesda. To correlate the data, the nodules were classified as benign or malignant. Student's t test, the Chi-square test and a logistic regression analysis were applied for the statistical analysis. RESULTS: A total of 221 thyroid nodules were analyzed, 32 of which were malignant (14%). The most predictive ultrasound findings of malignancy (P<.05) were a hypoechoic or complex echostructure (OR=11.832), the presence of microcalcifications (OR=9.637) and chaotic vascularization observed in the Doppler (OR=46.464). With regard to the elastography, elastographic patterns i and ii were seen to be associated with benignity (P=.0004 and P<.0001, respectively). When type i or ii elastography was combined with an ultrasound showing a non-hypoechoic nor complex echostructure, without microcalcifications nor chaotic vascularization in the Doppler ultrasound, 100% of the cases were benign with a specificity of 100% and a sensitivity of 14%. CONCLUSIONS: The combination of a high-resolution ultrasound with an elastography makes it possible to select cases where a FNAB does not have to be performed. Cases susceptible to a periodic follow-up without the use of a FNAB are those without a hypoechoic nor complex structure, no microcalcifications, non-chaotic vascularization and a type i or ii elastography.

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.

Fe de errores de «Valor pronóstico de las características clínicas, histopatológicas e inmunohistoquímicas en el carcinoma medular de tiroides» / Erratum in «Prognostic value of clinical, histopathological and immunohistochemical features in medullary thyroid cancer»

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Valor pronóstico de las características clínicas, histopatológicas e inmunohistoquímicas en el carcinoma medular de tiroides / Prognostic value of clinical, histopathological and immunohistochemical features in medullary thyroid cancer

Fundamento y objetivo: Analizar el valor pronóstico en cuanto a supervivencia de las diferentes características clínicas, histopatológicas e inmunohistoquímicas del carcinoma medular tiroideo (CMT) resecado. Pacientes y método: Se han revisado un total de 55 casos de CMT intervenidos consecutivamente y confirmados histológicamente. Los datos referentes a las características clínicas se recogieron de la historia clínica del paciente. Las características histopatológicas e inmunohistoquímicas se obtuvieron del informe anatomopatológico. Resultados: La supervivencia media (DE) al año fue del 96 (2)%; a los 5 años 91 (4)%; a los 10 años 88 (6)%; a los 15 años 83 (7)%, y a los 20 años 61 (14)%. En el análisis de las curvas de supervivencia se obtienen como variables significativas: entre las epidemiológicas, el tipo de tumor (mejor pronóstico el familiar; p=0,035), entre las histopatológicas, la presencia de hiperplasia de células C (p=0,0391) y la presencia de necrosis tumoral (p=0,0005), entre las inmunohistoquímicas, la positividad para p53 (p=0,0223) y para c-erb-b2 (p=0,023), y por último, entre los datos de estadificación, el estadio clínico TNM (p=0,0155), el tamaño (p=0,046) y la presencia de metástasis a distancia (p=0,002). Según el modelo de regresión de Cox, las únicas variables determinantes de mal pronóstico son: la existencia de necrosis (p=0,0391; odds ratio OR 6,5137) y el tamaño tumoral>4cm (p=0,027; OR 14,19659). Conclusiones: La tasa global de supervivencia del carcinoma medular de tiroides es del 82% y viene determinada principalmente por el tamaño tumoral y por la presencia de necrosis tumoral. Ningún marcador inmunohistoquímico tiene importancia significativa en la supervivencia (AU)

Background and objective: To analyze the importance of various clinical, histopathological and immunohistochemical features in the prognosis of resected medullary thyroid carcinoma. Patients and methods: A total of 55 cases of medullary thyroid carcinoma consecutively operated were investigated. The data referring to clinical features were collected in the patient's clinical history. The histopathological and immunohistochemical features of the tumors were taken from their pathological anatomy report. Results: Survival at one year was 96±2%; at 5 years 91±4%; at 10 years 88±6%; at 15 years 83±7%; and at 20 years 61±14%. Among epidemiological features, tumor type was significantly related with the disease (best familial prognosis; P=.035); among histopathological features, the presence of C cell hyperplasia and the presence of tumor necrosis had a significant relationship (P=.0005 and P=.039); among immunohistochemical features, positivity for p53 and for c-erb-b2 (P=.023 and P=.022); and finally, among staging data, TNM clinical staging (P=.015), size (P=.046) and the presence of distant metastases (P=.002). According to Cox's regression model, the only variables indicating a poor prognosis were: the existence of necrosis (P=.039; OR=6.513) and tumor size>4cm (P=.027; OR=14.196). Conclusions:The survival rate was mainly determined by tumor size and the presence of tumor necrosis. None of the immunohistochemical markers had a significant influence on survival (AU)

[Prognostic value of clinical, histopathological and immunohistochemical features in medullary thyroid cancer]. / Valor pronóstico de las características clínicas, histopatológicas e inmunohistoquímicas en el carcinoma medular de tiroides.

BACKGROUND AND OBJECTIVE: To analyze the importance of various clinical, histopathological and immunohistochemical features in the prognosis of resected medullary thyroid carcinoma. PATIENTS AND METHODS: A total of 55 cases of medullary thyroid carcinoma consecutively operated were investigated. The data referring to clinical features were collected in the patient's clinical history. The histopathological and immunohistochemical features of the tumors were taken from their pathological anatomy report. RESULTS: Survival at one year was 96 ± 2%; at 5 years 91 ± 4%; at 10 years 88 ±6%; at 15 years 83 ± 7%; and at 20 years 61 ± 14%. Among epidemiological features, tumor type was significantly related with the disease (best familial prognosis; P=.035); among histopathological features, the presence of C cell hyperplasia and the presence of tumor necrosis had a significant relationship (P=.0005 and P=.039); among immunohistochemical features, positivity for p53 and for c-erb-b2 (P=.023 and P=.022); and finally, among staging data, TNM clinical staging (P=.015), size (P=.046) and the presence of distant metastases (P=.002). According to Cox's regression model, the only variables indicating a poor prognosis were: the existence of necrosis (P=.039; OR=6.513) and tumor size>4 cm (P=.027; OR=14.196). CONCLUSIONS: The survival rate was mainly determined by tumor size and the presence of tumor necrosis. None of the immunohistochemical markers had a significant influence on survival.

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.

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.

Protamine 2 precursors, protamine 1/protamine 2 ratio, DNA integrity and other sperm parameters in infertile patients.

BACKGROUND: The protamine 1-to-protamine 2 ratio (P1/P2) is altered in the sperm cells of some infertile patients. Also, evidence for increased protamine 2 precursors (pre-P2) in a few patients has been reported. But so far, there have been no studies measuring simultaneously these two variables in a large number of patients. METHODS: We measured the P1/P2 ratio and the presence of pre-P2 using, for the first time, an antibody specific to the precursor pre-P2, together with other sperm parameters in 224 infertile patients. Additionally, the DNA integrity was assessed by terminal transferase dUTP nick-end labelling (TUNEL) in a subset of the samples. RESULTS: Pre-P2 levels show a significant positive correlation with the P1/P2 ratio, with the presence of other proteins and, at low pre-P2 levels, with TUNEL-positive sperm. An inverse correlation with sperm count, normal morphology and motility was detected. CONCLUSIONS: The levels of pre-P2 may provide clues into the pathogenic mechanisms of infertility. The increased proportion of pre-P2 in some patients with increased P1/P2 ratio suggests an involvement of pre-P2 processing. The positive correlation between TUNEL-positive sperm and pre-P2 at low pre-P2/P2 ratios also suggests a link between deficient protamine processing and decreased DNA integrity.