Bocio endotorácico en un adulto / Endothoracic goiter in an adult

Se presenta el caso clínico de un paciente de 48 años de edad, quien acudió a la consulta de Patología de Tiroides del Hospital Provincial Dr. Gustavo Aldereguía Lima de Cienfuegos, por presentar aumento de volumen del cuello en la región anterior, decaimiento, ocasionalmente disfagia y ligera disnea. Al examen físico se constató un tumor en la región anteroinferior y lateral derecha del cuello, movible, que se prolongaba hacia abajo a la parte superior del tórax. Se realizó hemitiroidectomía derecha con exéresis de la prolongación endotorácica. El paciente evolucionó favorablemente.

The case report of a 48 years patient is presented. He went to the Thyroid Pathology Service of Dr. Gustavo Aldereguía Lima Provincial Hospital from Cienfuegos, due to an increase of volume in the anterior region of the neck, weakness, occasionally deglutition disorders and light dyspnea. A tumor was verified in the anteroinferior and lateral right region of the neck, movable, that was prolonged downward to the superior part of the thorax when the physical exam was carried out. A right hemithyroidectomy was carried out with exeresis of the endothoracic extension. The patient had a favorable clinical course.

Perfil clínico e terapêutico dos pacientes com hipertireoidismo do ambulatório de endocrinologia de um hospital universitário do sul do Brasil / Perfil clínico e terapêutico dos pacientes com hipertireoidismo do ambulatório de endocrinologia de um hospital universitário do sul do BrasilClinical and therapeutic profile of patients with hyperthyroidism in an outpatient endocrine clinic at a university hospital in southern Brazil

.Introdução: O hipertireoidismo decorre da elevação sérica dos hormônios tireoidianos, secundária à hiperfunção da glândula tireoide, sendo as principais causas a Doença de Graves (DG) e os Bócios Nodulares Tóxicos (BNT). Objetivos: Avaliar o perfil clínico e modalidades terapêuticas aplicadas em pacientes com diagnóstico de hipertireoidismo acompanhados em um Hospital Universitário no Sul do Brasil. Métodos: Estudo observacional, transversal e descritivo, com inclusão de pacientes com diagnóstico de hipertireoidismo por DG e BNT; foram coletados dados epidemiológicos, clínicos, laboratoriais e de tratamento. Resultados: A maioria dos pacientes foi referenciada pela atenção primária e encontrava-se em uso prévio de droga antitireoidiana (DAT). A variável idade obteve diferença estatisticamente significativa entre as etiologias de DG e BNT; em ambas houve predomínio de incidência no sexo feminino. A DG apresentou maior frequência de sinais e sintomas de tireotoxicose, ao passo que o BNT mostrou mais sinais e sintomas de compressão. Houve remissão da doença em 23,2% dos pacientes com DG tratados com DAT; em 23,2% dos pacientes optou-se pela manutenção de metimazol em baixa dose por mais de 36 meses e em 16,1% foi realizado tratamento definitivo. No BNT foram preferidas terapias definitivas, principalmente a tireoidectomia, em 27,5% dos pacientes. Doses baixas de metimazol por mais de 36 meses foram utilizados também no BNT, em 22,5% dos pacientes. Conclusão: O hipertireoidismo é uma doença heterogênea, desde a clínica inicial até a terapêutica, entre suas etiologias mais prevalentes. Observou-se uma tendência de priorizar as terapias medicamentosas em longo prazo com baixas doses, tanto na DG quanto no BNT. (AU)

Perfil clínico e terapêutico dos pacientes com hipertireoidismo do ambulatório de endocrinologia de um hospital universitário do sul do BrasilClinical and therapeutic profile of patients with hyperthyroidism in an outpatient endocrine clinic at a university hospital in southern Brazil ARTIGO ORIGINALRafael Antonio Parabocz1, Renata Soares Carvalho1, Gianna Carla Alberti Schrut1, Ana Claudia Garabeli Cavalli Kluthcovsky1, Matheo Augusto Morandi Stumpf1Introduction: Hyperthyroidism results from the serum elevation of thyroid hormones, secondary to hyperfunction of the thyroid gland. The main causes are Graves' disease (DG) and Toxic Nodular Goiters (BNT). Objectives: Evaluate the clinical profile and therapeutic modalities applied in patients diagnosed with hyperthyroidism followed up at a University Hospital in Southern Brazil. Methods: Observational, cross-sectional and descriptive study, including patients diagnosed with hyperthyroidism by DG and BNT; epidemiological, clinical, laboratory and treatment data were collected. Results: Most patients were referred by primary care and had been using antithyroid drugs (DAT). The age variable obtained showed a statistically significant difference between the etiologies of DG and BNT; in both, there was a predominance of incidence in females. DG showed a higher frequency of signs and symptoms of thyrotoxicosis, while BNT showed more signs and symptoms of compression. There was remission of the disease in 23.2% of patients with DG treated with DAT; in 23.2% of the patients, low-dose methimazole was maintained for more than 36 months and in 16.1%, definitive treatment was performed. In BNT, definitive therapies were preferred, mainly thyroidectomy, in 27.5% of patients. Low doses of methimazole for more than 36 months were also used in BNT in 22.5% of patients. Conclusion: Hyperthyroidism is a heterogeneous disease, from initial clinic to therapy, among its most prevalent etiologies. There was a tendency to prioritize long-term drug therapies with low doses, both in DG and BNT. (AU)

Tiroidectomía y paratiroidectomía endoscópica transoral con abordaje vestibular(TOETVA TOEPVA): Experiencia inicial en el Hospital Universitario Austral / Transoral endoscopic thyroidectomy and parathyroidectomy vestibular approach (TOETVA TOEPVA): intial experience in Hospital Universitario Austral

RESUMEN Antecedentes: la cervicotomía de Kocher ha sido el abordaje clásico para la cirugía tiroidea y paratiroidea. El aumento en la preocupación por la cicatriz cervical ha generado un interés creciente por disminuir su tamaño o trasladarla a lugares menos visibles. Anuwong publica 60 casos de TOETVA/TOEPVA en 2016, con resultados óptimos. Objetivos: comunicar la experiencia con la tiroidectomía y paratiroidectomía transoral endoscópica con abordaje vestibular en el Hospital Universitario Austral. Material y métodos: análisis retrospetivo, sobre base prospectiva, de 18 procedimientos, entre mayo de 2019 y marzo de 2020. Se realizaron 2 paratiroidectomías, 13 lobectomías, 4 tiroidectomías totales, una con linfadenectomía central; una paciente presentó 2 patologías (adenoma paratiroideo y nódulo tiroideo). Citología según Bethesda: categoría II: 7; indeterminada: 1 y categoría VI: 9. Resultados: 18 pacientes femeninas. Mediana de edad: 41 años. Media del tamaño nodular: 30 mm. Volumen glandular medio: 24 mL. Conversión: 1 caso. Promedio de tiempo quirúrgico: lobectomía, 260 minutos; tiroidectomía total, 262 minutos. Histología definitiva: carcinoma papilar, 11; bocio nodular, 6; adenoma paratiroideo, 2. Complicaciones: equimosis leve, 12 pacientes; hipoparatiroidismo transitorio, 1 caso; paresia recurrencial transitoria, 1 caso; hiposensibilidad mentoniana transitoria, 1 caso. Dos casos de tiroidectomía total por cáncer: tiroglobulina a las 6 semanas < 0,1 μUI/mL. Conclusiones: 1) Es un abordaje seguro y ofrece resultados cosméticos excelentes. 2) Puede implementarse con equipamiento endoscópico convencional, con curva de aprendizaje corta y escasa morbilidad. 3) Alternativa para el tratamiento del carcinoma papilar de bajo riesgo. 4) Es prioritario garantizar la seguridad del paciente.

ABSTRACT Background: Kocher's cervicotomy has been the classic approach for thyroid and parathyroid surgery. The greater concern about neck scarring has generated an increasing interest in reducing scar size or leaving the scar in less visible places. In 2016 Anuwong published 60 cases of TOETVA/TOEPVA with optimal outcomes. Objectives: The aim of this study is to report the initial experience with transoral endoscopic thyroidectomy and parathyroidectomy vestibular approach in Hospital Universitario Austral. Material and methods: We conducted a retrospective analysis of 18 prospective procedures performed between May 2019 and March 2020. The procedures performed were 2 parathyroidectomies, 13 lobectomies, 4 total thyroidectomies, 1 with central lymph node dissection; one patient presented a parathyroid adenoma and a benign thyroid nodule. Cytology report according to the Bethesda system: category II in 7 cases, VI in 9 and indeterminate in 1. Results: 18 female patients. Median age: 41 years. Mean nodule size: 30 mm. Mean gland volume: 24 mL. Conversion. 1 case. Mean operative time: lobectomy, 260 minutes; total thyroidectomy, 262 minutes. Definite histology: papillary thyroid carcinoma,11; benign nodular goiter, 6; parathyroid adenoma, 2. Complications: mild ecchymosis, 12 patients; temporary hyperparathyroidism, 1 case; temporary recurrent laryngeal palsy, 1 case; temporary numbness of the mental region in 1 case. In the two cases undergoing total thyroidectomy due to cancer, thyroglobulin level 6 weeks after surgery was < 0.1 μIU/mL. Conclusions: 1) The transoral approach is a safe and feasible procedure that offers excellent cosmetic results. 2) It can be implemented using conventional endoscopic equipment, has a short learning curve and low morbidity rate. 3)It constitutes an alternative for the treatment of low-risk papillary thyroid carcinoma. 4) Patient's safety should be guaranteed.

Neoplasias foliculares del tiroides. Correlación citopatológica / Follicular thyroid neoplasia. Cytopathological correlations

RESUMEN Introducción: la citología con aguja fina se mantiene como el estudio fundamental ante un nódulo tiroideo, pero el diagnóstico de neoplasia folicular es aún su punto débil para definirlo. Se mantiene como conducta su extirpación quirúrgica para alcanzarlo. Objetivo: determinar la correlación citopatológica en las neoplasias foliculares del tiroides. Materiales y métodos: se realizó un estudio prospectivo y descriptivo que incluyó a 80 pacientes operados con diagnóstico citológico de neoplasia folicular del tiroides, en el Hospital "Comandante Faustino Pérez" de la ciudad de Matanzas, de marzo del 2012 a febrero del 2016. Se evaluaron las variables: edad, sexo, tamaño, localización, número de nódulos y diagnóstico histológico definitivo. Resultados: predominaron las lesiones benignas con 56 para el 70 % dentro de ellas, los bocios multinodulares con 33,75 % y los adenomas foliculares con el 31,25 %. Los tumores malignos ocuparon el 30 %. El carcinoma papilar, variedad folicular con 12 para el 15 %, seguido del carcinoma papilar clásico con 10 para el 12,50 %. Conclusiones: el porcentaje de malignidad de este estudio fue del 30 % con predominio del carcinoma papilar variedad folicular y el carcinoma papilar clásico. Entre las lesiones benignas predominaron los bocios multinodulares y los adenomas foliculares (AU).

ABSTRACT Introduction: fine needle cytology is still the main study against a thyroidal nodule, but the follicular neoplasia diagnosis is still its weak point to define it. The surgical removal keeps being used to reach it. Objective: to determine the cytopathological correlation in follicular thyroid neoplasia. Materials and methods: a prospective, descriptive study was carried out including 80 patient with diagnosis of follicular thyroid neoplasia in the Hospital "Comandante Faustino Pérez" of Matanzas, who underwent a surgery from March 2012 to February 2016. The assessed variables were age, sex, size, location, quantity of nodes and final histological diagnosis. Results: benign lesions predominated, with 56 for 70 %; among them, multinodular goiters with 33.75 % and follicular adenomas with 31.25 %. Malignant tumors were 30 %: papillary carcinoma, follicular variety with 12 for 15 %, followed by the classical papillary carcinoma with 10 for 12.50 % Conclusions: the malignity percent of this study was 30 % with the predominance of the papillary carcinoma, follicular variant and the classic papillary carcinoma. Multinodular goiters and follicular adenomas predominated among the benign lesions (AU).

Bocio Intratorácico / Intrathoracic goiter

El bocio intratorácico se define como aquel bocio que se encuentra parcial o totalmente en el mediastino; su incidencia está en relación con el bocio multinodular. Es asintomático entre el 20­30%. Su diagnóstico se hace por pruebas de imagen; su Gold estándar es la tomografía axial computarizada. El tratamiento más efectivo y recomendado es la cirugía, sobre todo para pacientes con síntomas opresivos o con sospecha de malignidad y bocios hiperfuncionantes en quienes el tratamiento farmacológico no fue exitoso. Se detalla el caso de una paciente de 59 años de edad, quien, con síntomas opresivos esternales, a quien se le diagnostica masa mediastínica, la cual se resuelve con indicación quirúrgica, siendo resolutiva para la paciente, con mejoras en la sintomatología y diagnostico de benignidad. (AU)

Intrathoracic goiter is defined as partially or totally in the mediastinum; its incidence is related to multinodular goiter. It is asymptomatic in 20-30%. Its diagnosis is made by imaging tests; the gold standard is computerized axial tomography. Treatment can be pharmacological with risk of recurrence; the most effective and recommended is surgery, especially for patients with oppressive symptoms or with suspected malignancy. We present the case of a 59-year-old patient with sternal oppressive symptoms, who is diagnosed with a mediastinal mass, which resolved by surgery, with improvements in symptoms and a diagnosis of benignity. (AU)

Hepatotoxicidade induzida por azatioprina em portadora da síndrome de Vogt-Koyanagi-Harada / Azathioprine-induced hepatotoxicity in a Vogt-Koyanagi-Harada syndrome patient

Este relato teve como objetivo apresentar um caso de hepatotoxicidade colestática induzida por azatioprina em portadora da síndrome de Vogt-Koyanagi-Harada. À admissão, apresentava icterícia +3/+4, acolia fecal e colúria, além de aumento de marcadores hepáticos, sendo compatível com síndrome colestática, cuja etiologia foi confirmada após exclusão de outras causas possíveis e retirada da azatioprina. A paciente evoluiu, após 1 semana de retirada do fármaco, com diurese livre de coloração menos escura e evacuação presente, sem acolia. Além disso, houve melhora nos exames que precederam a alta hospitalar

This report aimed at presenting a case of azathioprine-induced cholestatic hepatotoxicity in a patient with Vogt-Koyanagi-Harada syndrome. On admission, she presented with jaundice +3/+4, acholic feces, and choluria, as well as increased hepatic markers, all consistent with cholestatic syndrome, the etiology of which was confirmed after other possible causes were ruled out and azathioprine was discontinued. After 1 week of the drug discontinuation, the patient progressed with free diuresis of lighter color and defecation, with no acholia. In addition, tests performed before discharge were improved.

Thyroid gland changes in patients with acromegaly

ABSTRACT Objective Acromegaly is characterized by high neoplastic morbidity as a side effect of growth hormone (GH) hypersecretion. Increased incidence of goiter, thyroid carcinoma, and thyroid dysfunction is also reported. The aim of the present study was to find the prevalence of thyroid dysfunction and goiter in patients with acromegaly and determine its relationship to disease activity, disease duration, and the presence of secondary hypothyroidism. Subjects and methods In a cross-sectional study of the period 2008-2012 were included 146 patients with acromegaly (56 men, 90 women) of mean age 50.3 ± 12.4 years. Acromegaly disease activity and thyroid function were evaluated in all patients. Thyroid ultrasonography was performed to calculate thyroid volume and detect the presence of nodular goiter. Results Ninety-one patients were determined to have an active disease, and 55, a controlled disease. The mean thyroid volume in patients without previous thyroid surgery was 37.6 ± 38.8 mL. According to disease activity, thyroid volume was significantly higher in patients with active disease (38.5 ± 45.4 mL vs. 27.2 ± 18.4 mL, p = 0.036). A weak positive correlation was found between thyroid volume and insulin-like growth factor 1 (IGF-1) in the whole group and in females (R = 0.218; p = 0.013, and R = 0.238; p = 0.037, respectively). There was no significant correlation of thyroid volume with disease duration and GH level in the whole group and in both sexes. The patients with secondary hypothyroidism had twofold smaller thyroid volume, relative to the rest of the group. The prevalence of thyroid dysfunction was 39%, with a female to male percentage ratio of 1.73. Goiter was diagnosed in 87% of patients, including diffuse goiter (17.1%) and nodular (69.9%), with no significant difference between patients with active and controlled disease or the presence of secondary hypothyroidism. Conclusions Thyroid volume in patients with acromegaly depends on disease activity and the presence of secondary hypothyroidism as a complication. The increased prevalence of nodular goiter determines the need of regular ultrasound thyroid evaluation in the follow-up of patients with acromegaly. Arch Endocrinol Metab. 2020;64(3):269-75

Comportamiento quirúrgico de las patologías del tiroides / Surgical behavior of thyroid pathologies

RESUMEN Introducción: La enfermedad nodular tiroidea es motivo de consulta médica, la decisión quirúrgica viene marcada por la sospecha de malignidad, el aumento de tamaño, presencia de clínica compresiva, e incluso motivos estéticos. Objetivo: Describir las características clínicas y quirúrgicas, de los pacientes con patología tiroidea, operados en el hospital "Comandante Pinares". Métodos: Se realizó un estudio descriptivo, ambispectivo de los pacientes intervenidos quirúrgicamente del tiroides en el Hospital "Comandante Pinares", en el período comprendido desde enero 2014 a diciembre 2018. Se tomó una muestra de 85 pacientes que cumplieron los criterios de inclusión. Los datos fueron obtenidos de las historias clínicas en un formulario diseñado para la investigación. Se midieron variables demográficas, epidemiológicas, clínicas, paraclínicas y quirúrgicas utilizándose métodos estadísticos para variables cuantitativas y cualitativas. Resultados: Las afecciones quirúrgicas de tiroides fueron más frecuentes en el sexo femenino, entre 50 y 59 años, predominándose los nódulos benignos. La forma clínica más frecuente de presentación fue la nodular sólida y los nódulos malignos se presentaron mayormente en tumores menores de 2 cm. El diagnóstico definitivo según resultados de la biopsia por parafina mostró que la mayoría de las lesiones fueron benignas, predominándose el bocio nodular y en la biopsia aspirativa con aguja fina. El resultado más frecuente fue el negativo. La técnica quirúrgica más empleada fue la Tiroidectomía total en un tiempo. La mayoría de los pacientes no presentaron complicaciones. Conclusiones: El tratamiento de las afecciones quirúrgicas del tiroides muestra resultados satisfactorios, predominándose las afecciones en el sexo femenino, de etiología benigna(AU)

ABSTRACT Introduction: Nodular thyroid disease is a reason for medical consultation, the surgical decision is marked by the suspicion of malignancy, an increase in size, the presence of a compression symptoms, and even aesthetic reasons. Objective: To describe the clinical and surgical characteristics of patients with thyroid disease, operated at the "Comandante Pinares" hospital. Methods: A descriptive, ambispective study of patients undergoing thyroid surgery at the "Comandante Pinares" Hospital was performed in the period from January 2014 to December 2018. A sample was taken of 85 patients who met the inclusion criteria. Data was obtained from medical records in a form designed for research. Demographic, epidemiological, clinical, paraclinical and surgical variables were measured using statistical methods for quantitative and qualitative variables. Results: Surgical thyroid conditions were more frequent in females, between 50 and 59 years of age, with benign nodules prevailing. The most frequent clinical form of presentation was solid nodular, and malignant nodules appeared mainly in tumors smaller than 2 cm. The definitive diagnosis according to the results of the paraffin biopsy showed that the majority of the lesions were benign, with a predominance of nodular goiter and fine needle aspiration biopsy. The most frequent result was negative. The most widely used surgical technique was Total Thyroidectomy at one time. Most of the patients did not present complications. Conclusions: The treatment of surgical thyroid conditions shows satisfactory results, predominating the conditions in the female sex, of benign etiology(AU)

Resultados a corto plazo del tratamiento con 131I en el bocio multinodular: valor adicional de la estimulación previa con rhTSH / Short-term results of treatment with 131I in multinodular goiter: additional value of previus stimulation with Recombinant human thyrotropin

OBJETIVO: El yodo radiactivo (131I) es una opción terapeútica segura y eficaz cuando se utiliza solo o con la estimulación previa de TSH recombinante humana (rhTSH) en el tratamiento del bocio multinodular (BMN). En espera de ensayos clínicos que determinen la dosis óptima, demuestren seguridad y confirmen la eficacia, diferentes protocolos se utilizan para aplicar la dosis de 131I. Analizamos la respuesta al tratamiento con una dosis calculada por protocolo mixto (dosis fijas y cálculo por porcentaje de captación) en pacientes con BMN toxico y no toxico en nuestro hospital, en el periodo 2010-2013. MATERIALES Y MÉTODOS: Estudio prospectivo en pacientes con BMN no quirúrgico (BMNNQ) que requerían reducción del volumen glandular y/o tratamiento del hipertiroidismo. Se evaluaron 134 pacientes, 14 cumplieron con los criterios de inclusión (13mujeres) de edad media 71.08 años. Un grupo con BMN toxico, otro grupo con BMN no toxico, un tercer grupo con BMN no toxico estimulado con 0,1 mg de rhTSH previo a la dosis. Se evaluó, función tiroidea, captación tiroidea de 99ᵐTc, volumen tiroideo y síntomas compresivos. Se siguió a los pacientes durante 12 meses. RESULTADOS: Se aplicaron dosis entre 15 y 30 mCi de 131I. Remitió el hipertiroidismo en 6 de 7 pacientes. Hubo una reducción del volumen glandular (p<0.01).Los pacientes con estímulo de 0,1 mg rhTSH, aumentaron el porcentaje de captación de 99ᵐTc a las 24 h en un 32.43±10.61 permitiendo aplicar menor dosis de 131I. La tasa de aparición de hipotiroidismo fue de 7.41 por cada 100 pacientes.mes, mayor en pacientes con BMN toxico tratados con dosis bajas (p-=0.03). Hubo una mejoría subjetiva de la clínica compresiva en todos los pacientes. No hubo eventos adversos. CONCLUSIONES: Una dosis de 131I calculada por protocolo mixto es efectiva y segura para la reducción del volumen glandular y control del hipertiroidismo asociado. La estimulación con rhTSH logra el mismo efecto con una menor dosis administrada.

OBJECTIVE: Radioactive iodine (131I) is a safe and effective therapeutic option when used alone or with prior stimulation of recombinant human Thyrotropin (rhTSH) in the treatment of multinodular goiter (MNG). In absence of clinical trials that determine the optimal dose, demonstrate safety and confirm efficacy, different protocols are used to apply the dose of 131I. We analyze the response to treatment with a dose calculated by mixed protocol (fixed doses and calculation by percentage of uptake) in patients with toxic and non-toxic MNG in our hospital, in the period 2010-2013. MATERIALS AND METHODS: Prospective study in patients with non-surgical MNG that required glandular volume reduction and / or treatment of hyperthyroidism. 134 patients were evaluated, 14 met the inclusion criteria (13 women) of average age 71.08 years. One group with toxic MNG, another group with non-toxic MNG and a third with non-toxic multinodular goiter stimulated with 0.1 mg of rhTSH prior to the dose. Patients were followed for 12 months. Upon following, we assessed Thyroid function, 99ᵐTc thyroid uptake, thyroid volume and compressive symptoms. RESULTS: Doses between 15 and 30 mCi of 131I were applied. We observed hyperthyroidism remission in 6 of 7 patients. There was a reduction in glandular volume (p <0.01) considering all patients. Patients with a stimulus of 0.1 mg rhTSH, increased the percentage of uptake of 99ᵐTc at 24 h by 32.43 ± 10.61, allowing a lower dose of 131I to be applied. The rate of onset of hypothyroidism was 7.41 per 100 patients-month, and was higher in patients with toxic MNG treated with low doses (p = 0.03). There was a subjective improvement of the compression clinic in all patients. No adverse events were observed. CONCLUSIONS: A dose of 131I calculated by a mixed protocol is effective and safe for achieving glandular volume reduction and associated hyperthyroidism control. Stimulation with rhTSH produces the same effect with a lower administered dose.

Bocio multinodular gigante. Revisión de la literatura a propósito de un caso / Giant multinodular goiter. Case report and literature review

Introducción. La patología tiroidea abarca desde procesos benignos hasta cánceres. El manejo médico-quirúrgico del bocio gigante implica la realización de estudios citológicos y de imagen. El objetivo de este artículo fue hacer una revisión de la literatura y presentar un caso atendido de bocio multinodular gigante. Métodos. En el presente artículo se revisa la literatura sobre el tema en cuestión a propósito del caso de una paciente de 54 años de edad, intervenida quirúrgicamente por bocio multinodular, con evolución satisfactoria.Resultados. Se interviene la paciente de manera electiva, realizando exéresis a un tiroides de 658 gramos, conservando los nervios laríngeos recurrentes y las glándulas paratiroides; se realizó una meticulosa hemos-tasia y se trasladó la paciente a la Unidad de Cuidados Intensivos. A los 3 días se retiraron ambos drenajes cervicales, y se dio alta hospitalaria definitiva a los 8 días. La biopsia por parafina corroboró el diagnóstico preoperatorio. Discusión. Las indicaciones de tratamiento quirúrgico del bocio incluyen: crecimiento rápido de la glándula, síntomas compresivos y sospecha de malignidad. Las complicaciones son mínimas cuando se realiza una técnica muy meticulosa.Conclusión. El bocio multinodular gigante es infrecuente, y en todos los casos, requiere de intervención quirúrgica

Introduction. Thyroid pathology ranges from benign processes to cancers. The medical-surgical management of the giant goiter involves performing cytological and imaging studies. The objective of this article was to review the literature and present a treated case of giant multinodular goiter.Methods. This article reviews the literature on the subject in question regarding the case of a 54-year-old female patient who underwent surgery for multinodular goiter, with satisfactory evolution.Results. The patient was intervened electively, excising a 658 gram thyroid, preserving the recurrent laryngeal nerves and the parathyroid glands. A meticulous hemostasis was performed and the patient was transferred to the Intensive Care Unit. After 3 days, both cervical drains were removed, and the patient was discharged after 8 days. The paraffin biopsy corroborated the preoperative diagnosis.Discussion. Indications for surgical treatment of goiter include: rapid gland growth, compressive symptoms, and suspected malignancy. Complications are minimal when a very meticulous technique is performed. Conclusion. Giant multinodular goiter is rare, and in all cases, requires surgical intervention

Bocio multinodular tóxico por intoxicación con monóxido de carbono / Toxic multinodular goiter due to poisoning by carbon monoxide

RESUMEN Paciente masculino de 53 años con antecedentes de alergia, trabajador artesanal que realiza serigrafías, con alta exposición a productos químicos que, al someterse a altas temperaturas desprenden gran cantidad de vapor. Acude a consulta refiriendo que desde aproximadamente 2 meses antes presenta decaimiento con calambres musculares, palpitaciones, enrojecimiento de la cara y, aumento de tamaño de la glándula tiroides. Se diagnostica un bocio multinodular tóxico, por cifras hormonales elevadas. Se realiza ultrasonido de tiroides que informa bocio multinodular, una biopsia por aspiración con aguja fina, con atipia de significado incierto, y lesión folicular del tiroides. Se separa de su centro de trabajo y se logra revertir la sintomatología a los 15 días del tratamiento. Frecuentemente aparecen enfermedades asociadas a intoxicaciones por químicos y medicamentos, donde la presencia de hipertiroidismo no es habitual. Se requiere una anamnesis exhaustiva y exámenes complementarios específicos para un diagnóstico y tratamiento adecuados(AU)

ABSTRACT 53 years old male patient with a history of allergy; he works as a craft worker (producing serigraphs) very exposed to chemicals, which when subjected to high temperatures emit large amount of steam. The patient attends to the consultation referring that from approximately 2 months before he has been presenting weakness with muscle cramps, palpitations, flushing of the face and, increase in the size of the thyroid glands. It is diagnosed by the high hormonal figures a toxic multinodular goiter. Thyroid ultrasound is performed that shows multinodular goiter; it is also conducted a biopsy by fine-needle aspiration resulting in atypia of uncertain significance, and follicular lesion of the thyroid. The patient was separated from his workplace and there were reversed the symptoms after 15 days of treatment. Frequently appear diseases associated to poisonings caused by chemicals and medicines, where the presence of hyperthyroidism is not usual. It requires a comprehensive anamnesis and complementary tests that are specific for a proper diagnosis and treatment(AU)

Hipotireoidismo congênito como fator de risco para os transtornos do processamento auditivo central / Congenital hypothyroidism as a risk factor for central hearing process disorders

RESUMO Objetivo: Investigar a manifestação de sintomas do transtorno do processamento auditivo central em crianças com hipotireoidismo congênito. Métodos: Estudo de caráter exploratório, descritivo e transversal com 112 pacientes com hipotireoidismo congênito com idade ≥5 anos. Realizou-se entrevista com os pais/cuidadores no momento da espera da consulta médica. Portadores de outras afecções médicas foram excluídos. Como instrumento de pesquisa utilizou-se o protocolo estruturado de anamnese para avaliação do processamento auditivo rotineiramente empregado por audiologistas. A análise estatística utilizou o teste Qui-quadrado. Resultados: A distribuição por sexo foi semelhante (meninas: 53,3%). Os casos não-disgenesia constituíram a forma fenotípica mais prevalente para o hipotireoidismo congênito (88,4%), e verificou-se que 65,3% das crianças apresentavam algum episódio de níveis séricos irregulares de hormônio tireoestimulante. Dentre as manifestações mais frequentes dos sintomas do transtorno do processamento auditivo central, as queixas relaciondas às funções cognitivas auditivas, como: figura-fundo (83,0%), atenção auditiva (75,9%) e memória auditiva (33,0%) foram as mais evidentes. Reclamações relacionadas ao rendimento escolar foram reportadas em 62,3%. Conclusões: Os dados obtidos evidenciaram altas frequências de sintomas de defasagem nas funções cognitivas relacionadas ao processamento auditivo central, em especial na atenção auditiva, figura-fundo e memória auditiva nos portadores do hipotireoidismo congênito.

ABSTRACT Objective: To investigate the presence of central auditory processing disorder symptoms in children with congenital hypothyroidism. Methods: An exploratory, descriptive, cross-sectional study of 112 patients with congenital hypothyroidism aged ≥5 years old. An interview was held with the parents/caregivers at the time of the medical consultation. Patients with other medical conditions were excluded. As a research instrument, the structured protocol of anamnesis was used to evaluate the auditory processing routinely used by audiologists. For statistical analysis, the chi-square test was used. Results: Sex distribution was similar in both boys and girls (girls: 53.3%). The most prevalent phenotypic form of congenital hypothyroidism was no dysgenesis (88.4%), and 65.3% of the children had an episode of irregular serum thyroid-stimulating hormone (TSH) levels. Among the manifestations of the most frequent central auditory processing disorder symptoms, problems were reported with regard to cognitive functions, as they related to hearing, such as figure-background ability (83.0%), auditory attention (75.9%) and auditory memory (33.0%). Complaints related to school performance were reported in 62.3% of the cases. Conclusions: The data obtained show a high frequency of lag symptoms in cognitive functions related to central auditory processing, particularly with regard to auditory attention, figure-background ability and auditory memory in patients with congenital hypothyroidism.

High-intensity focused ultrasound ablation as a treatment for benign thyroid diseases: the present and future

High-intensity focused ultrasound (HIFU) is a promising ablation technique for benign thyroid nodules. Current evidence has found good short- to medium-term outcomes, similar to those of better-established ablation techniques such as radiofrequency and laser ablation. The fact that it does not require insertion of a needle into the target makes HIFU a truly non-invasive treatment. Although it is not without risks, its low risk profile makes it an attractive alternative to surgery. There is much room for future development, starting from expanding the current indications to enhancing energy delivery. Relapsed Graves disease and papillary microcarcinoma are diseases that can benefit from HIFU treatment. Its role in the mediation of immune responses and synergistic effects with immunotherapy are promising in the fight against metastatic cancers.

Cirugía mayor ambulatoria de la glándula tiroides y paratiroides: resultados tras 6 años de experiencia / Major outpatient surgery of the thyroid and parathyroid glands: results after 6 years experience

Objetivo: La cirugía mayor ambulatoria (CMA) y con estancia inferior a 24 horas (overnight stay) se ha consolidado en muchas patologías aunque en cirugía tiroidea y paratiroidea resulta controvertido. El objetivo es valorar nuestros resultados en cirugía del tiroides y paratiroides en régimen de CMA durante un periodo de 6 años. Material y Métodos: Estudio observacional prospectivo de pacientes con indicación de hemitiroidectomía o paratiroidectomía enfocada en régimen CMA entre enero de 2011 y diciembre de 2016. Los pacientes cumplían criterios de CMA. En los primeros años se excluyeron los nodulos tiroideos mayores de 3 cm y los pacientes ASA III. Los pacientes ingresaron la mañana de la intervención, tras el acto quirúrgico pasaron a la Unidad de Recuperación Posquirúrgica y posteriormente a sala de hospitalización. Tras 8 h, si cumplían criterios, fueron dados de alta. Resultados: Se intervinieron 270 pacientes, la tasa de aplicabilidad global fue del 59%, la tasa de aceptabilidad global del 83,6% y el índice de sustitución del 49,2%. El índice de ingresos no deseados fue del 10,4% para la paratiroidectomía y del 17,6% en la cirugía del tiroides. Ningún paciente presentó complicaciones mayores en su domicilio. El grado de satisfacción fue alto o muy alto en el 94% de los pacientes. Conclusiones: La paratiroidectomía enfocada y la hemitiroidectomía realizada por cirujanos expertos en pacientes seleccionados, es segura y efectiva en régimen ambulatorio. Es posible mejorar el índice de sustitución ambulatorio aumentando la tasa de aplicabilidad y aceptabilidad.

Objetive: Ambulatory or overnight stay surgery have been consolidated in many different procedures. However, its use in thyroid and parathyroid surgery is still controversial. The aim of this report is to present the results of 6 years of ambulatory patients undergoing surgery of the thyroid or parathyroid glands. Material and Methods: Prospective observational study of patients who underwent hemithyroidectomy or selective parathyroidectomy in the ambulatory program from January 2011 to December 2016. All patients included met the general criteria of ambulatory surgery. During the first years nodules bigger than 3 cm and patients classified as ASA III were excluded. Patients arrive at hospital the morning of surgery. After the operation, patients pass to the post-anesthesia care unit and then to the hospitalization room. 8 hours after surgery patients are discharged home if they meet the criteria. Results: 270 patients were operated, 159 of them met the inclusion criteria. The overall applicability rate was 59%. The acceptance rate was 83.6% and the substitution index was 49.2%. The unwanted hospital admission was 10.4% for the parathyroidectomy and 17.6% for the hemithyroidectomy. Any patient presented major complications at home. The satisfaction rate was high or very high for 94% of the patients. Conclusion: Selective parathyroidectomy and hemithyroidectomy performed by experienced surgeons in selected patients can be safely and effectively carried out in ambulatory surgery (outpatient). It would be possible to improve the substitution index by increasing the application and acceptability ratios.

Preoperatively undiagnosed papillary thyroid carcinoma in patients thyroidectomized for benign multinodular goiter

ABSTRACT Objective Incidental thyroid cancers (ITCs) are often microcarcinomas; among them, the most frequent histotype is the papillary one. The purpose of this study was to evaluate the rate of papillary thyroid cancer (PTC) in patients thyroidectomized for benign multinodular goiter. Subject and methods We retrospectively evaluated the histological incidence of PTC in 207 consecutive patients who, in a 1-year period, underwent thyroidectomy for benign multinodular goiter. All patients came from an iodine-deficient area (Orleans, France) with three nuclear power stations located in the neighboring areas of the county town. Results Overall, 25 thyroids (12.1%) harbored 37 PTC, of which 31 were microcarcinomas. In these 25 PTC patients, mean age was 55 ± 10 years (range 30-75), female:male ratio 20:5 (4:1). In 10 patients (40% of 25 and 4.8% of 207), PTCs were bilateral, and in 7 (2 with microPTCs) the thyroid capsule was infiltrated. These 7 patients underwent central and lateral cervical lymph node dissections, which revealed lymph node metastases in one and two cases, respectively. Radioiodine treatment was performed in 7 cases. Neither mortality nor transient and permanent nerve injuries were observed. Four (16%) transient hypocalcaemias occurred as early complications. At last follow-up visit (mean length of follow-up 17.2 ± 3.4 months), all patients were doing well and free of any clinical local recurrence or distant metastases. Conclusion With a 12% risk that multinodular goiter harbors preoperatively unsuspected PTCs, which can have already infiltrated the capsule and that can be accompanied by PTC foci contralaterally, an adequate surgical approach has to be considered.

Efecto combinado de la interacción genética sobre el desarrollo del bocio nodular con tiroiditis autoinmune y adenoma tiroideo en los habitantes de Bucovina del Norte / Combined effect of gene-gene interaction on the development of nodular goiter with autoimmune thyroiditis and thyroid adenoma in the inhabitants of Northern Bukovyna

ABSTRAC This article presents the results of a comprehensive analysis of the combined influence of genetic polymorphisms associated with various links of apoptosis regulation (BCL-2, CTLA-4 and APO-1/Fas) on the development of nodular goiter with autoimmune thyroiditis and thyroid adenoma in the studied population. The analysis was performed using the Multifactor Dimensionality Reduction (MDR) method by calculating the prediction potential. Graphic models of gene-gene interaction with the highest cross-validation consistency created by the MDR method showed complex "synergistic or independent" impact of polymorphic loci of the CTLA-4 (+49G/A), Fas (-1377G/A) and BCL-2 (63291411 A>G) genes on the onset of thyroid pathology in general, or its individual types (nodular goiter with autoimmune thyroiditis and thyroid adenoma) in the population of Northern Bukovyna.

RESUMEN Este artículo presenta los resultados de un análisis exhaustivo de la influencia combinada de polimorfismos genéticos asociados a diversos enlaces en la regulación de la apoptosis (BCL-2, CTLA-4 y APO-1/FAS) sobre el desarrollo de bocio nodular con tiroiditis autoinmune y adenoma tiroideo en la población estudiada. Para ello, se utilizó el método de reducción de dimensionalidad multifactorial (MDR) mediante el cálculo de los potenciales de predicción. Los modelos gráficos de interacción gen-gen con la mayor consistencia de validación cruzada creada por el método MDR mostraron un complejo impacto «sinérgico o independiente¼ de los loci polimórficos de los genes CTLA-4 (+49G/A), FAS (-1377G/A) y BCL-2 (63291411A>G) en el inicio de la patología tiroidea en general, o sus tipos individuales (bocio nodular con tiroiditis autoinmune y adenoma tiroideo) en la población de Bucovina septentrional.

The efficacy and safety of high-intensity focused ultrasound ablation of benign thyroid nodules

High-intensity focused ultrasound (HIFU) is a promising form of thermal ablation of benign thyroid nodules, but evidence supporting its use is scarce. The present review evaluated the efficacy and safety of single-session HIFU treatment of benign thyroid nodules. As reported in the literature, the extent of nodule shrinkage following treatment ranged from 48.8% to 68.8%. Like other forms of ablation, the shrinkage rate was greatest in the first 3-6 months, and the best responders were patients with small (≤10 mL) nodules. Complications were uncommon, but temporary vocal cord palsy occurred in 3%-4% of patients, and was related to the distance between the HIFU beam and the recurrent laryngeal nerve. Despite being safe and efficacious, a larger-scale prospective trial is required.

Malignant melanoma with synchronous thyroid metastases: case report and literature review

SUMMARY Thyroid metastases are rare in clinical practice. We describe the case of an 85-year-old woman who was referred to our department due to a multinodular goiter with compressive symptoms and subclinical hyperthyroidism. The patient was also undergoing evaluation for a polyp in her left nasal cavity, which was then diagnosed as a malignant melanoma of the nasal mucosa. A thoracoabdominal magnetic resonance imaging obtained for cancer staging revealed a > 50% tracheal obstruction caused by the goiter. The patient underwent simultaneous total thyroidectomy and melanoma excision. Histological analysis of the thyroid showed the presence of multiple metastatic foci from the melanoma. Due to the patient’s age, a decision was made to maintain her under surveillance and administer palliative treatment if necessary. Although metastases to the thyroid are rare, they should be considered in the differential diagnosis of thyroid lesions in patients with a known primary tumor. The thyroidectomy, performed in this patient’s case, allowed the diagnosis of the metastases and relief of compressive symptoms caused by the goiter.

Mutation screening of the SLC26A4 gene in a cohort of 192 Chinese patients with congenital hypothyroidism

ABSTRACT Objective Pendred syndrome (PS) is an autosomal recessive disorder characterised by sensorineural hearing loss and thyroid dyshormonogenesis. It is caused by biallelic mutations in the SLC26A4 gene encoding for pendrin. Hypothyroidism in PS can be present from birth and therefore diagnosed by neonatal screening. The aim of this study was to examine the SLC26A4 mutation spectrum and prevalence among congenital hypothyroidism (CH) patients in the Guangxi Zhuang Autonomous Region of China and to establish how frequently PS causes hearing impairment in our patients with CH. Subjects and methods Blood samples were collected from 192 CH patients in Guangxi Zhuang Autonomous Region, China, and genomic DNA was extracted from peripheral blood leukocytes. All exons of the SLC26A4 gene together with their exon-intron boundaries were screened by next-generation sequencing. Patients with SLC26A4 mutations underwent a complete audiological evaluation including otoscopic examination, audiometry and morphological evaluation of the inner ear. Results Next generation sequencing analysis of SLC26A4 in 192 CH patients revealed five different heterozygous variations in eight individuals (8/192, 4%). The prevalence of SLC26A4 mutations was 4% among studied Chinese CH. Three of the eight were diagnosed as enlargement of the vestibular aqueduct (EVA), no PS were found in our 192 CH patients. The mutations included one novel missense variant p.P469S, as well as four known missense variants, namely p.V233L, p.M147I, p.V609G and p.D661E. Of the eight patients identified with SLC26A4 variations in our study, seven patients showed normal size/location of thyroid gland, and one patients showed a decreased size one. Conclusions The prevalence of SLC26A4 pathogenic variants was 4% among studied Chinese patients with CH. Our study expanded the SLC26A4 mutation spectrum, provided the best estimation of SLC26A4 mutation rate for Chinese CH patients and indicated the rarity of PS as a cause of CH.