Development of a tool to calculate the probability of hypocalcemia after total thyroidectomy: a prospective study.

PURPOSE: This study aimed to evaluate the ability of the percentage of decrease in serum PTH level in the first 8 h after total thyroidectomy (TT) to predict hypocalcemia requiring Ca supplementation and develop a tool to predict it. METHODS: 97 patients who underwent TT with measurement of preoperative parathyroid hormone (PTH) levels were prospectively evaluated 1 and 8 h after TT; postoperative magnesium (Mg2PO) and phosphorus levels were evaluated on the 2nd day after surgery. The percentage of decrease in PTH level 1 h (%dPTH1h) and 8 h (%dPTH8h) postoperatively and predictors of hypocalcemia requiring Ca supplementation were evaluated and an equation was developed to predict this outcome. RESULTS: %dPTH1h (p = 0.002), %dPTH8h (p = 0.001) and (Mg2PO) (p < 0.01) were isolated predictors of postoperative hypocalcemia requiring Ca supplementation. The data obtained led to the development of two tools to predict this complication. CONCLUSIONS: The percentage of decrease in PTH level 1 h and 8 h postoperatively and the magnesium level on the 2nd day after surgery were predictors of more severe hypocalcemia, and an auxiliary tool for predicting this complication was developed.

Basal or stimulated thyroglobulin in evaluating response to treatment in papillary thyroid carcinoma? A retrospective cohort study.

OBJECTIVE: It is not clear whether response to initial treatment in papillary thyroid carcinoma (PTC) patients is best evaluated by measuring thyroglobulin (Tg) in the presence of levothyroxine (BTg) or when stimulated by elevated TSH (STg). The aim of this study was to evaluate whether response to therapy 1 year after initial treatment changes with the use of STg in relation to BTg in PTC patients treated with total thyroidectomy (TT) and radioiodine (131I), and, if observed, to assess which response is better associated with clinical course. SUBJECTS AND METHODS: This is a retrospective study of 148 PTC patients submitted to TT and 131I. We analyzed the response to therapy (excellent, biochemical incomplete, or indeterminate) at 1 year after initial treatment, using BTg or STg, and compared which method was better associated with "excellent response at final evaluation." RESULTS: Twenty-eight patients (20.4%) presented change in response to therapy, with 17 of these (60.7%) presenting a worse response. Response using STg was 1.6 times better associated with proposed outcome [odds ratio (OR) = 4.61; confidence interval 95% (IC95%): 2.13-9.98] than with BTg (OR = 2.84; IC95%: 1.33-6.06). CONCLUSION: Response to therapy at 1 year using STg was altered in approximately 20% of cases and therefore proved to be a better predictor of excellent response in the last evaluation.

Postoperative serum magnesium levels as a predictor for the need for calcium replacement after total thyroidectomy: a prospective study.

Objective: Our aim was to assess the ability of serum magnesium (Mg), measured on the first postoperative day (Mg1PO), to predict the need for calcium (Ca) replacement in patients undergoing total thyroidectomy (TT). Subjects and methods: Eighty patients undergoing TT, with Mg1PO and PTH dosage in the first (PTH1h) and eighth (PTH8h) hours after TT, were evaluated for the need for Ca replacement. Data were evaluated by uni/multivariate logistic regression and Receiver Operating Characteristic (ROC) curve. Results: 32 patients (40%) required Ca replacement. Median PTH1h, PTH8h and Mg1PO were higher in the no replacement group: 17 versus (vs) 3 pg/mL (p < 0.001), 18.2 vs 3.0 pg/mL (p < 0.001) and 2 vs 1.6 mg/dL (p < 0.001), respectively. Mg1PO was the isolated predictor for this replacement (odds ratio = 0.0004, 95% confidence interval: 0.000003-0.04; p = 0.001), with the cut-off value of 1.8 mg/dL showing sensitivity and specificity of 78.1% and 87.5%, respectively. Conclusion: In this group of patients, serum Mg1PO was the isolated predictor for the need for Ca replacement.

Objective Tumor Response of Hepatocellular Carcinoma Obtained by Transarterial Radioembolization with Iodine-131-Lipiodol Versus Transarterial Chemoembolization for Patients with and without Portal Venous Thrombosis: A Controlled Interventional Trial.

RATIONALE AND OBJECTIVES: Hepatocellular carcinoma (HCC) treatment often requires transarterial chemoembolization (TACE). However, TACE efficacy is controversial in the presence of portal vein thrombosis (PVT). Although transarterial radioembolization (TARE) benefit was previously documented in PVT, neither the objective tumor response (OTR) after TARE with Iodine-131-lipiodol (131I-lipiodol) nor the PVT effect on the results of locoregional therapies was accurately measured in prospective clinical trials. The aim of this study was to compare OTR and survival obtained by TARE with 131I-lipiodol versus TACE in patients with cirrhosis and HCC, as well as between those with and without PVT. MATERIALS AND METHODS: 33 patients were included, from whom 38 tumors were assessed. OTR was quantified by a special algorithm to measure hypervascular HCC tissue. RESULTS: 19 tumors received each therapy. Nine subjects (27%) had PVT, most of them in the TARE group (p = 0.026). Mean OTR according to the tumor volumes was 24.2% ± 56% after TARE and 32.8% ± 48.9% after TACE, with no difference between the treatments (p = 0.616). Similar values were also observed between those with and without PVT (p = 0.704). Mean survival was 340 days and did not differ between the two treatments (p = 0.596), but was 194 days in PVT cases (p = 0.007). CONCLUSIONS: This is the first study in which OTR obtained by TARE with 131I-lipiodol is accurately measured. Additionally, PVT impact on survival after TARE and TACE was precisely documented. Although the TARE group had more PVT subjects (who had shorter survival), TARE and TACE achieved similar OTR and OS rates.

Thyroglobulin/thyrotropin ratio for predicting long-term response in differentiated thyroid carcinoma: a retrospective study.

OBJECTIVE: Thyrotropin-stimulated thyroglobulin (STg) after total thyroidectomy is a prognosis marker for differentiated thyroid carcinoma (DTC). As Tg level is influenced by thyrotropin (TSH), perhaps the STg/TSH ratio is also a prognosis marker for these tumours. We aimed to compare STg/TSH ratio and first STg level in differentiated thyroid carcinoma patients for their ability to predict the long-term response to initial treatment. METHODS: This retrospective study evaluated data from 181 DTC patients for first (1st) STg and STg/TSH ratio, at 1-3 months post-total thyroidectomy and before iodine-131 therapy, according to response to initial therapy [Excellent/Indeterminate or Incomplete (Biochemical/Structural)] observed at final evaluation, and with the survival time with excellent/indeterminate response. RESULTS: Cases with incomplete response presented higher STg level [225.13 ± 585.26 ng/mL versus (vs) 20.4 ± 192.9 ng/mL; p < 0.001] and STg/TSH ratio (3.01 ± 7.8 vs 0.27 ± 2.58; p < 0.001). Cutoffs of 5 ng/mL for STg and 0.085 for STg/TSH displayed sensitivities of 76.7% and 76.9%, and specificities of 79.2% and 82.6%, respectively, in predicting response to therapy. Values below these cutoffs were associated with longer survival time in excellent/indeterminate response (140.4 vs 15.9 and 144.6 vs 15.9 months, respectively). CONCLUSION: STg/TSH ratio has a similar performance to the 1st STg in predicting long-term response to initial therapy.

Postoperative serum magnesium levels as a predictor for the need for calcium replacement after total thyroidectomy: a prospective study

ABSTRACT Objective: Our aim was to assess the ability of serum magnesium (Mg), measured on the first postoperative day (Mg1PO), to predict the need for calcium (Ca) replacement in patients undergoing total thyroidectomy (TT). Subjects and methods: Eighty patients undergoing TT, with Mg1PO and PTH dosage in the first (PTH1h) and eighth (PTH8h) hours after TT, were evaluated for the need for Ca replacement. Data were evaluated by uni/multivariate logistic regression and Receiver Operating Characteristic (ROC) curve. Results: 32 patients (40%) required Ca replacement. Median PTH1h, PTH8h and Mg1PO were higher in the no replacement group: 17 versus (vs) 3 pg/mL (p < 0.001), 18.2 vs 3.0 pg/mL (p < 0.001) and 2 vs 1.6 mg/dL (p < 0.001), respectively. Mg1PO was the isolated predictor for this replacement (odds ratio = 0.0004, 95% confidence interval: 0.000003-0.04; p = 0.001), with the cut-off value of 1.8 mg/dL showing sensitivity and specificity of 78.1% and 87.5%, respectively. Conclusions: In this group of patients, serum Mg1PO was the isolated predictor for the need for Ca replacement.

Which of the branched-chain amino acids increases cerebral blood flow in hepatic encephalopathy? A double-blind randomized trial.

Branched-chain amino acids increase the brain perfusion of patients with hepatic encephalopathy (HE), but the amino acid and the mechanisms involved are still unknown. This study compared brain perfusion and clinical improvement during leucine or isoleucine supplementation. After randomization, 27 subjects with cirrhosis and HE received leucine or isoleucine supplements for one year. Brain single Photon Emission Computed Tomography (SPECT) and dynamic brain scintigraphy (DBS) were performed pretreatment and at 1, 8 and 12 months of supplementation. Brain perfusion was increased only in the isoleucine group at 8 months of treatment by both SPECT and DBS (p < 0.001 and p = 0.05, respectively) and by SPECT at the 12th month (p < 0.05). This was associated with hepatic encephalopathy improvement at 8 and 12 months (p = 0.008 and 0.004, respectively), which was not observed in the leucine group (p = 0.313 and 0.055, respectively). Isoleucine supplementation achieved a better impact on brain perfusion restoration in HE.

Arm lymphoscintigraphy after axillary lymph node dissection or sentinel lymph node biopsy in breast cancer.

PURPOSE: Compare the lymphatic flow in the arm after breast cancer surgery and axillary lymph node dissection (ALND) versus sentinel lymph node biopsy (SLNB) using lymphos-cintigraphy (LS). PATIENTS AND METHODS: A cross-sectional study with 39 women >18 years who underwent surgical treatment for unilateral breast cancer and manipulation of the axillary lymph node chain through either ALND or SLNB, with subsequent comparison of the lymphatic flow of the arm by LS. The variables analyzed were the area reached by the lymphatic flow in the upper limb and the sites and number of lymph nodes identified in the ALND or SLNB groups visualized in the three phases of LS acquisition (immediate dynamic and static images, delayed scan images). For all analyses, the level of significance was set at 5%. RESULTS: There was a significant difference between the ALND and SLNB groups, with predominant visualization of lymphatic flow and/or lymph nodes in the arm and axilla (P=0.01) and extra-axillary lymph nodes (P<0.01) in the ALND group. There was no significant difference in the total number of lymph nodes identified between the two groups. However, there was a significant difference in the distribution of lymph nodes in these groups. The cubital lymph node was more often visualized in the immediate dynamic images in the ALND group (P=0.004), while the axillary lymph nodes were more often identified in the delayed scan images of the SLNB group (P<0.01). The deltopectoral lymph node was only identified in the ALND group, but with no significant difference. CONCLUSION: The lymphatic flow from the axilla was redirected to alternative extra-axillary routes in the ALND group.

Lymphoscintigraphy detecting alterations of upper limb lymphatic flow following early sentinel lymph node biopsy in breast cancer.

PURPOSE: To evaluate early variations in lymphatic circulation of the arm pre- and post-sentinel lymph node biopsy (SLNB) and conservative breast surgery by lymphoscintigraphy (LS). PATIENTS AND METHODS: Between 2005 and 2012, 15 patients underwent LS before and after the SLNB (total=30 studies). The pre-SLNB study was considered the control. Early images within twenty minutes (dynamic and static images) and delayed images within ninety minutes of arms and armpits were acquired using a gamma camera. The LS images before and after the SLNB of each patient were paired and compared to each other, evaluating the site of lymphatic flow (in the early phase) and identifying the number of lymph nodes (in the late phase). These dynamic images were subjected to additional quantitative analysis to assess the lymphatic flow rate using the slope assessed by the angular coefficient of the radioactivity × time curves in areas of interest recorded in the axillary region. The variations of lymphatic flow and the number of lymph nodes in the post-SLNB LS compared to the pre-SLNB LS of each patient were classified as decreased, sustained or increased. The clinical variables analyzed included the period between performing the SLNB and the subsequent LS imaging, age, body mass index, number of removed lymph nodes, type of surgery and whether immediate oncoplastic surgery was performed. RESULTS: The mean age was 54.53±9.03 years (36-73 years), the mean BMI was 27.16±4.16 kg/m2 (19.3-34.42), and the mean number of lymph nodes removed from each patient was 1.6±0.74 (1-3). There was significant difference in the time between surgery and the realization of LS (p=0.002; Mann-Whitney U test), but in an inverse relationship, the higher was the range, the smaller was the lymphatic flow, indicating a gradual reduction of lymphatic flow after surgery (Spearman's p=0.498, with p=0.013). CONCLUSION: Upper limb lymphatic flow gradually decreased after the SLNB and conservative breast surgery in this study, but these results are exploratory because of the small sample size. Further studies are needed to confirm and to investigate more in depth these findings.

Evaluation of mammographic density and (99m)Tc-sestamibi scintimammographic uptake in postmenopausal women on hormone replacement therapy.

OBJECTIVE: To evaluate changes in mammographic density and (99m)Tc-sestamibi scintimammographic uptake in postmenopausal women on hormone replacement therapy (HRT). METHODS: Seventy-five postmenopausal women were prospectively studied and allocated into three groups: 50 women were randomized to either Group 1 (G1, n=25), which received 2mg of 17beta-oestradiol continuously combined with 1mg of norethisterone acetate (E2/NETA, Kliogest, Medley) or Group 2 (G2), which received 2.5mg/day of tibolone (Livial, Organon). The remaining 25 women, who were asymptomatic and had no desire to undergo HRT, constituted the control group (G3). Each patient was submitted to both mammography and scintimammography at baseline and after six months. Mammographic density was evaluated by using the BI-RADS classification system. The classification system of Barros et al. was used in the interpretation of scintimammography. For statistical analysis, the Chi-square test, ANOVA and Pearson's correlation were used. RESULTS: At six months, increased mammographic density was observed in 48% of G1, 12% of G2 and 16% of G3 patients (p<0.001). The increase in sestamibi uptake was 56% in G1, 28% in G2 and 24% in G3 (p<0.001). Increases in both density and uptake were significantly higher in the group on E2/NETA than among tibolone users and the controls. CONCLUSION: In postmenopausal women, HRT with E2/NETA was associated with increased mammographic density and increased (99m)Tc-sestamibi scintimammographic uptakes, suggesting greater mithochondrial activity in the cells of the mammary duct. This was not observed in users of 2.5 mg of tibolone, demonstrating that the effects on the breast were reduced. The same was observed in the control group.

Lutetium 177-DOTA-TATE therapy for esthesioneuroblastoma: A case report.

Esthesioneuroblastoma (ENB), also known as olfactory neuroblastoma, is a rare malignant tumor that accounts for 3% of all tumors of the nasal cavity. The incidence of ENB is 0.4 cases per million in the general population, and the most common symptoms are nasal obstruction and epistaxis. Previous studies have indicated the presence of somatostatin receptors in this tumor type. Common treatment strategies for ENB include resection and adjuvant radiotherapy and/or chemotherapy (combined treatment); however, the rate of recurrence is high. Treatment of neuroendocrine tumors using radionuclides bound to somatostatin analogues is well established in clinical practice. However, a standard and effective therapeutic approach has not been reported for ENB. The current study described the case of a 74-year-old female with numerous recurrences of ENB following multiple treatments and without possibility of resection. The patient was treated with the radiolabeled-somatostatin analogue, 177Lutetium-DOTA-octreotate (177Lu-DOTA-TATE), which successfully controlled the disease. This suggests that 177Lu-DOTA-TATE is a potential treatment for ENB and may represent an effective alternative and novel therapeutic strategy for this disease.

Thyroglobulin/thyrotropin ratio for predicting long-term response in differentiated thyroid carcinoma: a retrospective study

ABSTRACT Objective: Thyrotropin-stimulated thyroglobulin (STg) after total thyroidectomy is a prognosis marker for differentiated thyroid carcinoma (DTC). As Tg level is influenced by thyrotropin (TSH), perhaps the STg/TSH ratio is also a prognosis marker for these tumours. We aimed to compare STg/TSH ratio and first STg level in differentiated thyroid carcinoma patients for their ability to predict the long-term response to initial treatment. Subjects and methods: This retrospective study evaluated data from 181 DTC patients for first (1st) STg and STg/TSH ratio, at 1-3 months post-total thyroidectomy and before iodine-131 therapy, according to response to initial therapy [Excellent/Indeterminate or Incomplete (Biochemical/Structural)] observed at final evaluation, and with the survival time with excellent/indeterminate response. Results: Cases with incomplete response presented higher STg level [225.13 ± 585.26 ng/mL versus (vs) 20.4 ± 192.9 ng/mL; p < 0.001] and STg/TSH ratio (3.01 ± 7.8 vs 0.27 ± 2.58; p < 0.001). Cutoffs of 5 ng/mL for STg and 0.085 for STg/TSH displayed sensitivities of 76.7% and 76.9%, and specificities of 79.2% and 82.6%, respectively, in predicting response to therapy. Values below these cutoffs were associated with longer survival time in excellent/indeterminate response (140.4 vs 15.9 and 144.6 vs 15.9 months, respectively). Conclusion: STg/TSH ratio has a similar performance to the 1st STg in predicting long-term response to initial therapy.

[Intramammary lymph node sentinel metastasis without metastasis in axilla. Axillary lymph node dissection or conservative surgery?]. / Linfonodo sentinela intramamário comprometido e axila livre. Esvaziamento axilar ou conduta conservadora?

The sentinel lymph node biopsy is a standard treatment for patients with breast cancer and clinically negative axilla lymph node. The presence of an extra-axillary and intra-axillary (IM) sentinel lymph node (SLN) occurs in up to 2.6% of cases. In the presence of a metastatic IM SLN, axillary positivity may occur in up to 81% of cases. Due to the limited number of cases reported, there is no standard treatment for the association of metastatic SLN IM and non-metastatic axillary SLN . We add here two cases to the literature, one of them with metastatic disease in the axilla. The use of a nomogram demonstrated that the risk of axillary metastasis was less than 10% and the addition of these cases to the literature showed that in this situation the rate of axillary metastasis is 6.25%. We discuss the pros and cons of further axillary dissection in this situation.

Carotid artery rupture following radioiodine therapy for differentiated thyroid carcinoma.

INTRODUCTION: Radioiodine therapy for patients with differentiated thyroid cancer aims at reducing tumor recurrence by eradicating residual macro- and microscopic foci. Side effects are generally rare, tenuous and transient, with little clinical significance. OBJECTIVE: To report a rare case of differentiated thyroid carcinoma presenting a large expansive solid mass at the base of the skull, with invasion of the left masticatory muscle and adjacent subcutaneous tissue, and without invasion of the carotid space, which evolved to carotid artery rupture following radioiodine therapy. DISCUSSION: Side effects are uncommon after radioiodine therapy and when present, have mild intensity. Serious adverse events are very rare, especially those arising from structures not directly invaded by metastatic tissue with radioiodine uptake, as occurred in this case. This occurrence serves to raise awareness of the need for increased care when using radioiodine therapy on high-avidity masses located close to important structures.

Accuracy of (99m)Tc-sestamibi scintimammography for breast cancer diagnosis.

Scintimammography using (99m)Tc-sestamibi is a noninvasive and painless diagnostic imaging method that is used to detect breast cancer when mammography is inconclusive. Because of the advantages of labeling with (99m)Tc-sestamibi and its high efficiency in detecting carcinomas, it is the most widespread agent for this purpose. Its accumulation in the tumor has multifactorial causes and does not depend on the presence of architectural distortion or local or diffuse density variation in the breast. The objective of this study was to evaluate the accuracy of scintimammography for detecting breast cancer. One hundred and fifty-seven patients presenting 158 palpable and non-palpable breast nodules were evaluated. Three patients were male and 154 were female, aged between 14 and 81 years. All patients underwent scintimammography, and the nodule was subjected to cytological or histological study, i.e., the gold standard for diagnosing cancer. One hundred and eleven malignant and 47 benign nodules were detected, with predominance of ductal carcinomas (n=94) and fibroadenoma/fibrocystic condition (n=11/n=11), respectively. The mean size was 3.11 cm (7-10 cm) among the malignant nodules and 2.07 cm among the benign nodules (0.5-10 cm). The sensitivity, specificity, positive predictive value, negative predictive value and accuracy were 89, 89, 95, 78 and 89%, respectively. Analysis on the histological types showed that the technique was more effective on tumors that were more aggressive, such as ductal carcinoma. In this study, (99m)Tc-sestamibi scintimammography was shown to be an important tool for diagnosing breast cancer when mammography was inconclusive.

Physiotherapeutic stimulation: Early prevention of lymphedema following axillary lymph node dissection for breast cancer treatment.

The aim of this study was to confirm the effectiveness of early physiotherapeutic stimulation for lymphatic flow progression in patients with breast cancer undergoing axillary dissection. This was a randomized experimental study on 22 patients who underwent lymphoscintigraphy in their arms on two different occasions, firstly without stimulation and secondly after randomization into two groups: without physiotherapeutic stimulation (WOPS; n=10) and with physiotherapeutic stimulation (WPS; n=12). The lymphoscintigraphy scan was performed with (99m)Tc-phytate administered into the second interdigital space of the hand, ipsilaterally to the dissected axilla, in three phases: dynamic, static, and delayed whole body imaging. Physiotherapeutic stimulation was carried out using Földi's technique. In both groups, images from the two examinations of each patient were compared. Flow progression was considered positive when, on the second examination, the radiopharmaceutical reached areas more distant from the injection site. Statistical analysis was used to evaluate frequencies, percentages and central trend measurements, and non-parametric tests were conducted. Descriptive analysis showed that the WPS and WOPS groups were similar in terms of mean age, weight, height, body mass index and number of lymph nodes removed. There were statistically significant associations between physiotherapeutic stimulation and radiopharmaceutical progression at all three phases of the study (p<0.0001). Early physiotherapeutic stimulation in breast cancer patients undergoing radical axillary dissection is effective, and can therefore be indicated as a preventive measure against lymphedema.

(99m)Tc-sestamibi scintigraphy used to evaluate tumor response to neoadjuvant chemotherapy in locally advanced breast cancer: A quantitative analysis.

To evaluate the tumor response to neoadjuvant chemotherapy, (99m)Tc-sestamibi breast scintigraphy was proposed as a quantitative method. Fifty-five patients with ductal carcinoma were studied. They underwent breast scintigraphy before and after neoadjuvant chemotherapy, along with clinical assessment and surgical specimen analysis. The regions of interest on the lesion and contralateral breast were identified, and the pixel counts were used to evaluate lesion uptake in relation to background radiation. The ratio of these counts before to after neoadjuvant chemotherapy was assessed. The decrease in uptake rate due to chemotherapy characterized the scintigraphy tumor response. The Kruskal-Wallis test was used to compare the mean scintigraphic tumor response and histological type. Dunn's multiple comparison test was used to detect differences between histological types. The Mann-Whitney test was used to compare means between quantitative and qualitative variables: scintigraphic tumor response vs. clinical response and uptake before chemotherapy vs. scintigraphic tumor response. The Spearman's test was used to correlate the quantitative variables of clinical reduction in tumor size and scintigraphic tumor response. All of the variables compared presented significant differences. The change in (99m)Tc-sestamibi uptake noted on breast scintigraphy, before to after neoadjuvant chemotherapy, may be used as an effective method for evaluating the response to neoadjuvant chemotherapy, since this quantification reflects the biological behavior of the tumor towards the chemotherapy regimen. Furthermore, additional analysis on the uptake rate before chemotherapy may accurately predict treatment response.

Linfonodo sentinela intramamário comprometido e axila livre: esvaziamento axilar ou conduta conservadora? / Intramammary lymph node sentinel metastasis without metastasis in axilla: axillary lymph node dissection or conservative surgery?

A pesquisa do linfonodo sentinela constitui tratamento padrão para pacientes portadoras de câncer de mama e axila clinicamente negativa. A presença do linfonodo sentinela (LS) extra-axilar e intramamário (IM) ocorre em até 2,6% dos casos, e na presença do LS IM metastático, a positividade axilar pode alcançar até 81%. Na associação do LS IM metastático ao LS axilar não metastático, não há conduta padronizada, visto um limitado número de casos descritos. Adicionamos dois casos à literatura, observando, em um deles, a presença de doença metastática axilar na linfadenectomia complementar. A utilização de nomograma demonstrou que o risco de doença metastática axilar era inferior a 10%, e a adição destes casos à literatura mostrou que, nesta situação, a taxa de doença metastática axilar é de 6,25%. Discutimos os prós e contras da linfadenectomia axilar complementar nesta situação.

The sentinel lymph node biopsy is a standard treatment for patients with breast cancer and clinically negative axilla lymph node. The presence of an extra-axillary and intra-axillary (IM) sentinel lymph node (SLN) occurs in up to 2.6% of cases. In the presence of a metastatic IM SLN, axillary positivity may occur in up to 81% of cases. Due to the limited number of cases reported, there is no standard treatment for the association of metastatic SLN IM and non-metastatic axillary SLN . We add here two cases to the literature, one of them with metastatic disease in the axilla. The use of a nomogram demonstrated that the risk of axillary metastasis was less than 10% and the addition of these cases to the literature showed that in this situation the rate of axillary metastasis is 6.25%. We discuss the pros and cons of further axillary dissection in this situation.

Carotid artery rupture following radioiodine therapy for differentiated thyroid carcinoma / Ruptura de carótida pós-iodoterapia em carcinoma diferenciado de tireoide

INTRODUCTION: Radioiodine therapy for patients with differentiated thyroid cancer aims at reducing tumor recurrence by eradicating residual macro- and microscopic foci. Side effects are generally rare, tenuous and transient, with little clinical significance. OBJECTIVE: To report a rare case of differentiated thyroid carcinoma presenting a large expansive solid mass at the base of the skull, with invasion of the left masticatory muscle and adjacent subcutaneous tissue, and without invasion of the carotid space, which evolved to carotid artery rupture following radioiodine therapy. DISCUSSION: Side effects are uncommon after radioiodine therapy and when present, have mild intensity. Serious adverse events are very rare, especially those arising from structures not directly invaded by metastatic tissue with radioiodine uptake, as occurred in this case. This occurrence serves to raise awareness of the need for increased care when using radioiodine therapy on high-avidity masses located close to important structures.

INTRODUÇÃO: Iodoterapia em pacientes com carcinoma diferenciado da tireoide tem o objetivo de reduzir a recorrência tumoral erradicando focos residuais macro e microscópicos. Os efeitos colaterais, em geral, são raros, tênues e transitórios, com pouca repercussão clínica. OBJETIVO: Relatar um caso raro de carcinoma diferenciado da tireoide apresentando grande massa sólida expansiva na base do crânio, com invasão da musculatura mastigatória esquerda e do tecido subcutâneo adjacente, sem invasão do espaço carotídeo que evoluiu com ruptura de carótida pós-iodoterapia. DISCUSSÃO: Os efeitos colaterais pós-iodoterapia são pouco frequentes e, quando presentes, de intensidade discreta. Os eventos adversos graves são muito raros, em especial, aqueles decorrentes de estruturas não invadidas diretamente pelo tecido metastático iodocaptante, como nesse caso, alertando também para a necessidade do aumento dos cuidados na terapia de grandes massas ávidas pelo radioiodo próximas às estruturas nobres.