Cancer recurrence in papillary thyroid microcarcinoma: a multivariate analysis on 231 patients with a 12-year follow-up.

AIM: Papillary thyroid microcarcinoma (PMC) is considered a common disease with a good prognosis and low rate of recurrence but the extension of initial surgical treatment and the need of completion thyroidectomy are still controversial. Aim of this study is the assessment of the prognostic factors that are predictive of cancer recurrence on a large controlled series of patients with a prolonged follow-up. METHODS: A total of 231 patients with PMC were followed up for a median period of 12 years (range 5-35 years). The patients included 54 males and 177 females, with a mean age at the time of first diagnosis of 45.7±12.7 years. RESULTS: At presentation 158 patients had no metastases, whereas 73 had lymph node metastases and 1 had bone metastases. Surgery included 177 total thyroidectomies and 54 lobectomies. Eighty-four patients underwent lymph node dissection, and 131 patients were treated with radioiodine therapy. The disease recurred in 15 patients (6.5%): 5 cases of local recurrence, all of which in the contralateral lobe after lobectomy, 13 cases of lymph-node metastases, and 2 cases of lung metastases. Multivariate analysis showed that two parameters were predictive for local recurrence: age <45 years (P=0.05; RR: 6.9; 95% CI: 1.59-29.9) and evidence of lymph-node metastases at presentation (P=0.03; RR: 3.24; 95% CI: 1.17-8.55) CONCLUSION: Total or near-total thyroidectomy seems to reduce the risk of local recurrences in non-incidental PMC. Prophylactic dissection of central compartment nodes in the absence of clinically evident metastases seems not to change the risk of recurrence. In incidental PTMC without multifocality, extracapsular extension or histologically-proven lymph node metastases, lobectomy is associated with a very low risk of recurrence. Follow-up with neck ultrasonography seems advisable at yearly intervals, as recurrences may present from less than one year until several years after thyroidectomy. Radioiodine ablation of thyroid remnants should be considered only in young patients in presence of multifocal tumors, histologically-proven metastatic lymph nodes to the significantly higher risk of recurrence.

Dosimetry in the therapy of metastatic differentiated thyroid cancer administering high 131I activity: the experience of Busto Arsizio Hospital (Italy).

AIM: The purpose of the present work was to evaluate the impact of 131I high activity therapy treatments of metastatic differentiated thyroid cancer (MDTC) in terms of feasibility, tolerance, efficacy, and the impact of dosimetry in order to optimize the process. METHODS: Seventeen MDTC patients underwent 27 treatments with 131I, with activity ranging from 6.2 GBq to 24.1 GBq. Red marrow (RM) peritherapy dosimetry was based on the Standard Operating Procedure of European Association of Nuclear Medicine (EANM SOP), while metastases dosimetry on the guidelines of Italian Association of Physicists in Medicine and Italian Association of Nuclear Medicine. In 12 cases prospective dosimetry was performed too, with the purpose of evaluating the possibility of maximizing the therapeutic activity, complying the 2 Gy red marrow (RM) dose constraint. The absorbed dose to 45 lesions was evaluated. The severity of myelotoxic effects was monitored during the follow-up. RESULTS: Treatments were generally well tolerated, also at the highest RM absorbed doses. RM absorbed doses ranged from 0.49 to 6.67 Gy, lesion doses from 1.1 Gy to 778 Gy. In case of repeated treatments on the same site, in 13 cases on a total of 15, an absorbed dose reduction was observed. RM prospective and peritherapeutic dosimetry differed somewhat: absorbed doses measured during therapy ranged from -7% to +40% with respect to provisional absorbed doses. CONCLUSION: In our experience high activity treatments were well-tolerated. Prospective dosimetry needs further investigation to become sufficiently reliable in order to comply the 2 Gy constraint. Lesions became progressively less iodine-avid in case of repeated treatments, so the "first big-shoot" treatment with the highest safe activity seems to be desirable to obtain the maximum efficacy.

Anaplastic thyroid carcinoma. Practical aspects of multimodal therapy and data emerging from a 40-year experience at a single Italian institution.

Anaplastic thyroid carcinoma is a rare malignant neoplasia with high biological aggressiveness and rapid and lethal clinical course. In selected patients, an aggressive multimodal therapy could decrease illness progression both in the neck e in other sites. However, it is not clear if these combined treatments improve survival. In our institution, the Department of Nuclear Medicine has a 40-year experience in monitor and treatment of a group of 48 patient with ATC confirmation that clinical presentation could overlap pre-existent nodular goitre or rapid enlarging mass of recent onset. At onset, age do not change final poor prognosis and the survival seems most favorable in patients with a primary tumor size <6 cm. A better mean survival was noticed in those patients who respond to the multimodal therapy (8 months vs 4.6 months). Radioiodine (131 I) therapy is unnecessary due to the loss of NIS expression of the ATC cells. Therefore, after quick clinical and instrumental work up, our experience and the literature data suggest that the first line therapy is represented from external radiotherapy combined also with cisplatin or doxorubicin, followed by "curative" surgical procedure of the primary lesion in the neck and subsequent chemotherapy. For those patients who show distant metastasis at onset chemotherapy is the first line therapy followed by external radiotherapy and when possible subsequent surgical procedure.

Prevalence, clinical significance and prognostic value of anti-thyroglobulin antibodies in the follow-up of patients with differentiated thyroid carcinoma: a retrospective study.

AIM: Elevated persistent value of antithyroglobulin antibodies (Ab-Tg) in differentiated thyroid carcinoma (DTC) patients may interfere with Tg determination. The aim of the study was to evaluate the use of Ab-Tg as tumor marker as a replacement for thyroglobulin (Tg). METHODS: From 1990 al 2004 767 patients have been treated and followed, mean follow-up years 6.9+/-2.4. Thirty-two patients Ab-Tg positive after radioiodine ablation, who had showed during the follow-up stable indosable value di Tg, have undergone analysis. RESULTS: The recurrences were statistically more significant when Ab-Tg were increased, than when Ab-Tg were stable or diminished during the time (P<0.0001). Lymphocytic thyroditis was found in thirteen patients (40.6%) at histological specimen after thyroidectomy. The persistence of lymphocytic thyroditis has not modified the value of Ab-Tg as tumor marker (P<0.001). The 10/32 (31.2%) patients Tg negative have been compared to the 61/712 patients Ab-Tg positive (8.6%) who relapse. The recurrence rate was significantly higher for the first group of patients than that for the second (P<0.0001). Multivariate analisys showed N1 (P<0.001; OR 2.51) and Ab-Tg positive (P<0.001; OR: 6.15) associated with recurrences. CONCLUSIONS: Ab-Tg must be determined, in concomitance with Tg, during the follow-up of DTC, to establish the accuracy of Tg, in order to use it as tumour marker. It must be kept in mind that the strongest indication for relapse due to Ab-Tg is an increasing of level in the same patient measured in the long time. Persistent elevated Ab-Tg levels are prognostic of future recurrences.

[Treatment of patient having thyroid nodules: dimension of disease, diagnostic choices and guide-lines]. / La gestione del paziente con nodulo tiroideo: dimensioni della patologia, scelte diagnostiche e linee guida.

UNLABELLED: The demand of nodule thyroid diagnosis has increased very much in the last years, because of large diffusion of medical information among the population, the increased use and improvement of medical technology that evidences more and more morphology alterations of the gland. The prevalence of palpable thyroid nodule is 2.1-4.2%, but when the ultrasonography is used the prevalence can reach in average 67%. The thyroid cancer however is a rare event: 1% of all malign tumours. The medium incidence is 2.1 for 100,000 men per year, and 5.19 for 100,000 women per year. pretest illness low probability presents a necessity of a very accurate diagnostic test. The introduction of FNA in the 70 has changed the diagnosis, and allowed to spare time and money. The patient with thyroid nodules should be evaluated by experienced physicians in the thyreopathy field, using efficient remote and family anamnesis, by an accurate palpation of the thyroid and the neck, cl AIM: ing necessary diagnostic controls. The physician should perform the FNA with a cytopathologist and should convey to him all the clinical and biotumoral information. He should be able to interpret correctly the results of the FNA and to suggest the diagnostic and therapeutical follow-up. This review reveals the best compromise between cost-effectiveness, based on the evidence results taken from international literature, taking into consideration various diagnostic opportunities at our disposal. Guide-lines for the treatment of patients with thyroid nodule are proposed.

[Coverage of pointed acute coronary syndromes in the general hospital centers]. / Prise en charge des syndromes coronariens aigus dans les centres hospitaliers généraux. Résultats du registre RICA 2000.

This study presents data on the management of acute coronary syndromes collected in a national registry organized by the french Collège national des cardiologues des hôpitaux généraux in September 2000. In all 86 institutions participated and data from 607 patients (mean age: 67 years; 413 men) were analysed. The final diagnosis was unstable angina in 38%, non-Q wave myocardial infarction in 21% and Q-wave myocardial infarction in 40.5%. Median time to admission was 4 h. At symptom onset, patients called their general practitioners in 46% of cases, emergency ambulatory units in 31% of cases and arrived to the hospital on their own in 23% of cases. Observance of the European Society of Cardiology guidelines was good for patients without ST segment elevation. In patients with ST segment elevation, 9% had pre-hospital thrombolysis, 28% hospital thrombolysis, and 27% had angioplasty within 48 h of admission, including 9% with rescue angioplasty. Overall, 57% of patients with ST segment elevation received reperfusion therapy. In hospital mortality was 6% for the whole cohort, and 11% for patients with acute myocardial infarctions. By multivariate analysis, predictors of in-hospital mortality were age, type of acute coronary syndrome, absence of beta-blocker therapy, and absence of coronary angiography.

Fourier amplitude image circumferential profile analysis in the evaluation of the dipyridamole test.

The aim of this study was to evaluate a circumferential profile method of analysis (CPA) of the Fourier image of amplitude (FA), obtained by equilibrium gated radionuclide angiocardiography (EGRA) in the assessment of the response to the dipyridamole (DIP) test in patients with previous myocardial infarction. The changes in regional wall motion (RWM) induced by DIP in a group of 29 patients with previous MI were compared with those of a ten-patient control group. On the basis of SPECT thallium-201 standard stress-rest scintigraphy the infarcted patients were divided into 9 patients with fixed perfusion defects at four hours and 20 patients with both fixed and reversible perfusion defects. The quantitative CPA was carried out on the FA image normalized by the mean amplitude calculated for the left ventricle (LV) area. A circular ROI was drawn around the FA left ventricle image and two curves (basal and post-DIP) with 60 points were obtained. We compared this method with a five-sector method of analysis applied to the same FA images. An increase of 2 or more SD in the basal post-DIP ratio curve, compared with the average of the ratios in the control group, was found in 16 of 20 patients with reversible perfusion defects (sensitivity: 80%) and an increase in the same ratio was found in 2 of 9 MI patients with fixed perfusion defects (specificity: 78%). A sensitivity and specificity of 60% and 78% respectively were found using sectorial analysis.

[Changes in lipid status during pravastatin treatment]. / Modificazioni del quadro lipidico durante trattamento con pravastatina.

Reduced cholesterolemia lowers the risk of ischemic cardiopathy, especially if LDL cholesterol levels are reduced. Today this effect can be achieved using drugs following the discovery of a new class of molecules: statins are specific inhibitors of HMG-CoA-reductase, a key enzyme in cholesterol biosynthesis. These molecules act by modifying the intracellular quota of cholesterol, especially at a hepatocytic level, thus enabling an enhanced expression of those genes responsible for forming receptors for membrane LDL with an increased number of receptors. This leads to a modulation of receptor activity which interferes with LDL uptake, promoting more rapid clearance. The aim of this study was to confirm the efficacy and tolerability of pravastatin when used for long periods in patients with high cholesterol levels, and to compare its activity to that of gemfibrozil.

[Relationship between reproductive patterns and infant mortality: alternative interpretations]. / Relación entre patrones reproductivos y mortalidad infantil: interpretaciones alternativas.

A secondary analysis of the data of the Mexican National Fertility and Health Survey of 1987 (ENFES for its spanish acronym) was undertaken in order to study the relationship between reproductive patterns and child mortality. A total of 13,216 births and 711 infant deaths occurred 1 to 15 years previous to the survey were studied. The main conclusions are: 1) it is the adverse social, economic and environmental conditions surrounding young mothers (15 to 19 years) which are responsible for the excess mortality found in their children; 2) children of older women (35 and more years) experience increased mortality only in the late fetal period, this suggesting that a biological mechanism is mainly at stake; 3) the relative risks of death of first births, as compared to subsequent ones are generally smaller than one, indicating that first births have a lower probability of dying. The relative risk of death of first born relative to subsequent births, on the other hand, decreases with increasing age at death, suggesting that biological factors such as low birthweight and intrapartum complications are possibly important as well; 4) relative risks of death for short-spaced as compared to well spaced births were found, in general, to decrease from the late fetal to the neonatal and to the postneonatal periods. This points to a biological pathway, possibly via maternal nutrition, for the effect of spacing on child mortality.

[Limitations of infant mortality as a health indicator]. / Limitaciones de la mortalidad infantil como indicador de salud.

Infant mortality is usually accepted as a sensitive indicator of living conditions, and of the coverage and quality of health care in a specific country. However, the validity of this indicator in middle-income countries presents some important limitations. First, underegistration of infant deaths is a common feature. In second place, the national figures hide the great inequalities that may exist among different social sectors and regions. In this paper, the limitations of Mexico's infant mortality rate are analyzed. Underegistration is demonstrated by comparing infant mortality rates obtained from vital statistics data and national health surveys. Differences among social sectors are evident when specific infant mortality rates are compared. Inequalities have been increasing in the last years.

[A database for research in public health]. / Base de datos para la investigación en salud pública "BISP".

Epidemiological and health system research projects are often delayed due to the difficulties to build validated data basis in personal computers. This papers presents a new computer interactive program for handling numeric data from a given questionnaire to a structured archive. The questionnaire includes the basic variables of the dwelling and of the members of the household. A list of sociodemographic and health variables are selected, although other variables can be easily added, according to special needs. All the intermediate steps regularly needed to construct a data base are included in the package: capture, verification, validation and record linkage. The package is equipped with the basic procedures needed to produce tabulations and basic statistical analysis.

[Health measurement: theoretical and methodologic perspectives]. / La medición de salud: perspectivas teóricas y metodológicas.

The present article consists of a revision of the different ways health has been measured and was ordered according to the historic evolution of the health concept and conditions. The development of health measures has paralleled the changes occurred in the epidemiologic profiles and the many refinements in the conceptualization and interpretation of health. Along the years, the meaning of health has become increasingly wider. Initially, only infectious diseases were considered; later, degenerative processes were included. Nowadays, health is viewed as multifactorial and as a reflection of the life style and conditions. This essay contains a description of the theoretical postulates upon which the different health measures are based, their strategies and some of their limitations. It is divided into five main sections: morbidity, disability, and mortality indicators; measures of the health of the populations; sociomedical indicators, including measures of physical and mental health, as well as of the social component of health, positive health indicators and, finally a revision of measures of health need. It is of the utmost importance to be aware of the perspective used in the different public health research efforts since it has direct repercussions for the planning and evaluation of the health services and, in particular, for the quality of health care.

[A computerized manual for assessing the dosage absorbed by breast tissue in mammography]. / Manuale computerizzato per la valutazione della dose assorbita dal tessuto ghiandolare mammario in mammografia.

The computerized translation of "Handbook of glandular tissue doses in mammography" (HHS publication FDA 85-8239) is presented. It is registered on floppy disk and suitable for use in MS-DOS on IBM personal computer, Olivetti or compatible. The manual collects data published by many authors and suggests a method to estimate the dose released to the glandular tissue (considered at risk for breast cancer) in the most commonly used conditions for mammography. Besides translation manual, the program holds an algorithm developed by the authors, which allows the dose to the glandular tissue to be evaluated, given the following data: projection: craniocaudal or mediolateral; compression level: firm or moderate; breast size: small, medium or large; breast composition: percentage of glandular tissue content (by weight); X-ray beam quality: HVL mm Al. The algorithm is obtained from a bidimensional fit of the original data and is based on the terms contained in the manual. The program flow is guided by menus that make the procedure suitable for inexperienced operators too, both for consulting and printing and for computing program.