Indeterminate thyroid cytology: detecting malignancy using analysis of nuclear images.

BACKGROUND: Thyroid nodules diagnosed as 'atypia of undetermined significance/follicular lesion of undetermined significance' (AUS/FLUS) or 'follicular neoplasm/suspected follicular neoplasm' (FN/SFN), according to Bethesda's classification, represent a challenge in clinical practice. Computerized analysis of nuclear images (CANI) could be a useful tool for these cases. Our aim was to evaluate the ability of CANI to correctly classify AUS/FLUS and FN/SFN thyroid nodules for malignancy. METHODS: We studied 101 nodules cytologically classified as AUS/FLUS (n = 68) or FN/SFN (n = 33) from 97 thyroidectomy patients. Slides with cytological material were submitted for manual selection and analysis of the follicular cell nuclei for morphometric and texture parameters using ImageJ software. The histologically benign and malignant lesions were compared for such parameters which were then evaluated for the capacity to predict malignancy using the classification and regression trees gini model. The intraclass coefficient of correlation was used to evaluate method reproducibility. RESULTS: In AUS/FLUS nodule analysis, the benign and malignant nodules differed for entropy (P < 0.05), while the FN/SFN nodules differed for fractal analysis, coefficient of variation (CV) of roughness, and CV-entropy (P < 0.05). Considering the AUS/FLUS and FN/SFN nodules separately, it correctly classified 90.0 and 100.0% malignant nodules, with a correct global classification of 94.1 and 97%, respectively. We observed that reproducibility was substantially or nearly complete (0.61-0.93) in 10 of the 12 nuclear parameters evaluated. CONCLUSION: CANI demonstrated a high capacity for correctly classifying AUS/FLUS and FN/SFN thyroid nodules for malignancy. This could be a useful method to help increase diagnostic accuracy in the indeterminate thyroid cytology.

The first postoperative-stimulated serum thyroglobulin is a prognostic factor for thyroid microcarcinomas / A primeira dosagem sérica de tireoglobulina estimulada pós-operatória é um fator prognóstico para os microcarcinomas da tireoide

Abstract Introduction: Endogenous thyroid-stimulating hormone-stimulated thyroglobulin collected after total thyroidectomy is a useful predictor of better prognosis in patients with differentiated thyroid carcinomas in general, but studies with microcarcinomas are scarce. Objective: To assess whether the first postoperative stimulated thyroglobulin measurement is a prognostic factor in patients with microcarcinoma. Methods: The medical data of 150 differentiated thyroid carcinoma patients were studied retrospectively, and 54 (36%) cases with microcarcinoma were selected. The first postoperative stimulated thyroglobulin (1st stimulated thyroglobulin), measured after thyroidectomy, initial presentation data, and microcarcinomas treatment were assessed regarding outcome. Worse prognosis was defined as neoplasm persistence/recurrence. Results: Persistence/recurrence occurred in 27.8% of the cases. These patients were identified according to the following parameters: receiving more than one 131iodine dose (100% vs. 0%; p < 0.0001); accumulated 131iodine dose (232.14 ± 99.09 vs. 144 ± 33.61 mCi; p < 0.0001); presented active disease in the last assessment (53.3% vs. 0%; p < 0.0001); follow-up time (103.07 ± 61.27 vs. 66.85 ± 70.14 months; p = 0.019); and 1st stimulated thyroglobulin (19.01 ± 44.18 vs. 2.19 ± 2.54 ng/dL; p < 0.0001). After multivariate logistic regression, only the 1stSTg [odds ratio = 1.242; 95% confidence interval: 1.022-1.509; p = 0.029] and follow-up time (odds ratio = 1.027; 95% confidence interval: 1.007-1.048; p = 0.007) were independent predictors of risk of persistence/recurrence. The cutoff point of 1.6 ng/dL for the 1st stimulated thyroglobulin was significantly associated with disease persistence/recurrence [area under the curve = 0.713 (p = 0.019)]. Conclusion: The first stimulated thyroglobulin predicted disease persistence/recurrence in patients with microcarcinoma.

Resumo Introdução: A tireoglobulina estimulada pelo hormônio tireoestimulante endógeno coletada após tireoidectomia total é um preditor útil de melhor prognóstico em pacientes com carcinomas diferenciados de tireoide em geral, mas os estudos com microcarcinomas são escassos. Objetivo: Avaliar se a primeira medida pós-operatória de tireoglobulina estimulada é um fator prognóstico em pacientes com microcarcinoma. Método: Os dados clínicos de 150 pacientes com carcinoma diferenciado de tireoide foram estudados retrospectivamente e 54 (36%) casos com microcarcinoma foram selecionados. A primeira dosagem de tireoglobulina estimulada (1a TgE) pós-operatória, medida após a tireoidectomia, os dados da apresentação inicial e tratamento do microcarcinoma foram avaliados quanto ao resultado. O pior prognóstico foi definido como a persistência/recorrência da neoplasia. Resultados: A persistência/recorrência ocorreu em 27,8% dos casos. Esses pacientes foram identificados de acordo com os seguintes parâmetros: receberam mais de uma dose de iodo131 (100% vs. 0%; p < 0,0001); dose acumulada de iodo131 (232,14 ± 99,09 vs. 144 ± 33,61 mCi; p < 0,0001); apresentou doença ativa na última avaliação (53,3% vs. 0%; p < 0,0001); tempo de seguimento (103,07 ± 61,27 vs. 66,85 ± 70,14 meses; p = 0,019); e 1ªTgE (19,01 ± 44,18 vs. 2,19 ± 2,54 ng/dL; p < 0,0001). Após a regressão logística multivariada, apenas a 1ª TgE [odds ratio = 1.242; intervalo de confiança de 95%: 1,022-1,509; p = 0,029] e tempo de seguimento (odds ratio = 1,027; intervalo de confiança de 95%: 1,007-1,048; p = 0,007) foram preditores independentes de risco de persistência/recorrência. O ponto de corte de 1,6 ng/dL para a 1a TgE foi significativamente associado à persistência/recidiva da doença [área abaixo da curva = 0,713 (p = 0,019)]. Conclusão: A 1ª dosagem sérica de tireoglobulina estimulada previu a persistência/recorrência da doença em pacientes com microcarcinoma.

The first postoperative-stimulated serum thyroglobulin is a prognostic factor for thyroid microcarcinomas.

INTRODUCTION: Endogenous thyroid-stimulating hormone-stimulated thyroglobulin collected after total thyroidectomy is a useful predictor of better prognosis in patients with differentiated thyroid carcinomas in general, but studies with microcarcinomas are scarce. OBJECTIVE: To assess whether the first postoperative stimulated thyroglobulin measurement is a prognostic factor in patients with microcarcinoma. METHODS: The medical data of 150 differentiated thyroid carcinoma patients were studied retrospectively, and 54 (36%) cases with microcarcinoma were selected. The first postoperative stimulated thyroglobulin (1st stimulated thyroglobulin), measured after thyroidectomy, initial presentation data, and microcarcinomas treatment were assessed regarding outcome. Worse prognosis was defined as neoplasm persistence/recurrence. RESULTS: Persistence/recurrence occurred in 27.8% of the cases. These patients were identified according to the following parameters: receiving more than one 131iodine dose (100% vs. 0%; p<0.0001); accumulated 131iodine dose (232.14±99.09 vs. 144±33.61mCi; p<0.0001); presented active disease in the last assessment (53.3% vs. 0%; p<0.0001); follow-up time (103.07±61.27 vs. 66.85±70.14 months; p=0.019); and 1st stimulated thyroglobulin (19.01±44.18 vs. 2.19±2.54ng/dL; p<0.0001). After multivariate logistic regression, only the 1stSTg [odds ratio=1.242; 95% confidence interval: 1.022-1.509; p=0.029] and follow-up time (odds ratio=1.027; 95% confidence interval: 1.007-1.048; p=0.007) were independent predictors of risk of persistence/recurrence. The cutoff point of 1.6ng/dL for the 1st stimulated thyroglobulin was significantly associated with disease persistence/recurrence [area under the curve=0.713 (p=0.019)]. CONCLUSION: The first stimulated thyroglobulin predicted disease persistence/recurrence in patients with microcarcinoma.

Follicular thyroid lesions: is there a discriminatory potential in the computerized nuclear analysis?

BACKGROUND: Computerized image analysis seems to represent a promising diagnostic possibility for thyroid tumors. Our aim was to evaluate the discriminatory diagnostic efficiency of computerized image analysis of cell nuclei from histological materials of follicular tumors. METHODS: We studied paraffin-embedded materials from 42 follicular adenomas (FA), 47 follicular variants of papillary carcinomas (FVPC) and 20 follicular carcinomas (FC) by the software ImageJ. Based on the nuclear morphometry and chromatin texture, the samples were classified as FA, FC or FVPC using the Classification and Regression Trees method. RESULTS: We observed high diagnostic sensitivity and specificity rates (FVPC: 89.4% and 100%; FC: 95.0% and 92.1%; FA: 90.5 and 95.5%, respectively). When the tumors were compared by pairs (FC vs FA, FVPC vs FA), 100% of the cases were classified correctly. CONCLUSION: The computerized image analysis of nuclear features showed to be a useful diagnostic support tool for the histological differentiation between follicular adenomas, follicular variants of papillary carcinomas and follicular carcinomas.

Primary squamous cell carcinoma of the thyroid diagnosed as anaplastic carcinoma: failure in fine-needle aspiration cytology?

A case of primary squamous-cell carcinoma (SCC) of the thyroid which had been initially diagnosed as an anaplastic carcinoma (ATC) is described: female, 73 years old, with a fast-growing cervical nodule on the left side and hoarseness for 3 months. Ultrasonography showed a 4.5 cm solid nodule. FNA was compatible with poorly differentiated carcinoma with immunoreactivity for AE1/AE3, EMA. Thyroidectomy was performed. Histopathological examination showed a nonencapsulated tumor. Immunohistochemistry disclosed positivity for AE1/AE3, p53,p63, and Ki67. The diagnosis was ATC. A second opinion reported tumor consisting of squamous cells, with intense inflammatory infiltrate both in tumor and in the adjacent thyroid, with final diagnosis of SCC, associated with Hashimoto thyroiditis. No other primary focus of SCC was found. Patient has shown a 48-month survival period. Clinically, primary SCCs of the thyroid and ATCs are similar. The distinction is often difficult particularly when based on the cytological analysis of FNA material.

Achados endoscópicos em crianças com estridor / Endoscopic findings in children with stridor

Doenças congênitas e adquiridas das vias aéreas podem causar dispnéia e estridor em crianças. Nas UTIs tem-se registrado maior sobrevida de prematuros, porém também elevada incidência de complicações relacionadas à intubação. OBJETIVO: Analisar retrospectivamente os achados endoscópicos em crianças com estridor. TIPO DE ESTUDO: Corte transversal. MATERIAL E MÉTODOS: Foram revisados 55 prontuários de crianças com estridor, submetidas aos exames endoscópicos de janeiro de 1997 a dezembro de 2003. Endoscopias foram: estridor pós-extubação (63,63 por cento) e avaliação de estridor neonatal (21,82 por cento). Observou-se alto índice de doenças associadas, como pulmonares (60 por cento), neurológicas (45,4 por cento) e DRGE (40 por cento). Os principais achados endoscópicos e as indicações de traqueotomia foram: estenose subglótica (27,27 por cento) e processos inflamatórios das vias aéreas (21,82 por cento), principalmente em crianças com menos de cinco anos. Lesões congênitas foram mais freqüentes em crianças com menos de um ano. CONCLUSÕES: O estridor na infância possui múltiplas etiologias, sendo as relacionadas à intubação traqueal as mais freqüentes em hospitais com atendimento de doenças complexas. Pediatras e otorrinolaringologistas devem conhecer as causas de estridor, realizando avaliação clínica detalhada para determinar a gravidade do caso. O exame endoscópico deverá ser minucioso e detalhado.

Congenital and acquired airway diseases are responsible for upper respiratory distress and stridor in children. In neonatal intensive care units, we have seen increased survival in premature babies, but also a high incidence of airway complications related to intubation, which present as stridor. AIM: To review endoscopic findings in children with stridor. STUDY DESING: a cross-sectional cohort study. METHODS: A retrospective analysis was done of 55 cases of children with stridor who underwent endoscopic exams, between January 1997 and December 2003. RESULTS: 69 percent were aged below one year. The main indications for endoscopy were post-extubation stridor (63.63 percent) and evaluation of neonatal stridor (21.82 percent). Many associated diseases were seen, including lung diseases (60 percent), neurological condition (45.4 percent), and GERD (40 percent). The main endoscopic findings and indications for tracheotomy were subglottic stenosis (27.27 percent) and airway inflammatory process (21.82 percent) occurring in children under five years old. Congenital disorders were more frequent in children under age one year. CONCLUSION: Neonatal stridor has many causes; those related to tracheal intubation are more frequent in hospitals that treat more complex diseases. Pediatricians and otorhinolaryngologists should know the main causes of stridor and perform detailed clinical evaluations to determine case severity. The endoscopic examination, must be meticulous.

Endoscopic findings in children with stridor.

UNLABELLED: Congenital and acquired airway diseases are responsible for upper respiratory distress and stridor in children. In neonatal intensive care units, we have seen increased survival in premature babies, but also a high incidence of airway complications related to intubation, which present as stridor. AIM: To review endoscopic findings in children with stridor. STUDY DESIGN: a cross-sectional cohort study. METHODS: A retrospective analysis was done of 55 cases of children with stridor who underwent endoscopic exams, between January 1997 and December 2003. RESULTS: 69% were aged below one year. The main indications for endoscopy were post-extubation stridor (63.63%) and evaluation of neonatal stridor (21.82%). Many associated diseases were seen, including lung diseases (60%), neurological condition (45.4%), and GERD (40%). The main endoscopic findings and indications for tracheotomy were subglottic stenosis (27.27%) and airway inflammatory process (21.82%) occurring in children under five years old. Congenital disorders were more frequent in children under age one year. CONCLUSION: Neonatal stridor has many causes; those related to tracheal intubation are more frequent in hospitals that treat more complex diseases. Pediatricians and otorhinolaryngologists should know the main causes of stridor and perform detailed clinical evaluations to determine case severity. The endoscopic examination, must be meticulous.

Estenose congênita da abertura piriforme / Congenital nasal pyriform aperture stenosis

A estenose congênita da abertura piriforme é uma rara causa de obstrucão nasal que pode ocorrer no recém-nascido. É provocada pelo crescimento excessivo do processo nasal medial da maxila causando um estreitamento do terco anterior da fossa nasal. Inicialmente foi relatada uma deformidade isolada, posteriormente a estenose congênita da abertura piriforme foi considerada como apresentacão de forma menor da holoprosencefalia. Neste artigo relatamos um caso de recém-nascido do sexo masculino que apresentava desde o parto dispnéia, cianose e episódios de apnéia. O paciente foi submetido a cirurgia com alargamento da abertura piriforme por acesso sublabial. No seguimento apresentou boa evolucão durante o acompanhamento. O relato desta deformidade mostra sua importância como causa de obstrucão nasal congênita e diagnóstico diferencial de atresia coanal. A estenose congênita da abertura piriforme pode ser reparada adequadamente, quando necessário, através de procedimento cirúrgico.

Congenital nasal pyriform aperture stenosis.

The congenital stenosis of pyriform aperture is an unusual cause of neonatal nasal obstruction. It is due to bony overgrowth of the nasal lateral process of the maxilla. Initially this narrowest part of nasal airway was considered an isolated deformity; subsequently the congenital Stenosis of pyriform aperture was thought to represent a microform of holoprosencephaly. In this report a male neonate had respiratory distress, cyclic cyanosis and apnea after delivery. The patient underwent surgical correction of pyriform stenosis by sublabial access. In the follow up, the patient had good evolution. The report of this deformity shows an important cause of neonatal nasal obstruction and its differential diagnosis with bilateral choanal atresia. Congenital stenosis of nasal pyriform aperture can be surgically corrected when necessary.

Complicações das vias aéreas relacionadas à intubação endotraqueal / Airway complications associated with endotracheal intubation

Descrevemos as principais complicações das vias aéreas relacionadas à intubação endotraqueal, por meio de revisão da literatura e apresentação dos resultados de pesquisas clínicas e experimentais realizadas pelo nosso grupo de estudo. Procuramos alertar os profissionais de saúde quanto à alta incidência de complicações secundárias à intubação, as quais podem ser reduzidas com a adoção de medidas profiláticas simples e de cunho prático, estabelecidas após a compreensão da fisiopatologia das lesões.

Fenda cervical mediana / Midline cervical cleft

A fenda mediana congênita do pescoço é anomalia rara da parte ventral do pescoço. Em torno de 100 casos foram relatados na literatura, sendo o primeiro caso descrito por Bailey em 1924. Este defeito é relatado em associação com fenda mediana do lábio inferior, fenda da mandíbula e da língua, e hipoplasia de outras estruturas cervicais medianas. Acredita-se que seja uma malformação originada dos dois primeiros arcos branquiais. O tratamento da lesão consiste na excisão vertical da lesão e reparação do defeito resultante. A maioria dos autores recomenda evitar a reparação simples da lesão, preferindo a fechamento com a utilização de zetaplastia múltiplas, com o intuito de evitar fibrose e retração local. Neste artigo relatamos dois casos dessa anomalia e realizamos revisão bibliográfica.

Estenose subglótica / Stenosis subglottic

No presente trabalho, relatamos 19 casos de estenose laringotraqueal. Destes casos, 15 eram de estenose subglótica, 1 de traquéia e, em outros 2 casos, observamos comprometimento de estensas áareas da laringe e traquéia devido às alteraçöes causadas por doenças inflamatórias crônicas. Em 11 pacientes, foi realizada a reconstruçäo laringotraqueal com a técnica de enxerto de cartilagem costal, laringofissura e colocaçäo de molde. As dificuldades maiores, em relaçäo à técnica, foram observadas, principalmente em crianças, quando da retirada da cânula de traqueostomia devido à formaçäo de tecido de granulaçäo no orifício e na luz traqueal, e a estenose parcial subglótica.