RESUMO
Importance: Tall cell morphology (TCM) is a rare and aggressive variant of papillary thyroid carcinoma (PTC) that has been associated with poor outcomes; however, the risk factors for worse survival are not well characterized. Objective: To identify prognostic factors associated with cancer recurrence and death in patients with PTC-TCM. Design, Setting, and Participants: All patients treated for PTC-TCM at a single tertiary-level academic health care institution from January 1, 1997, through July 31, 2018, were included. Tall cell variant (TCV) was defined as PTC with TCM of 30% or more; and tall cell features (TCF) was defined as PTC with TCM of less than 30%. Patients with other coexisting histologic findings and/or nonsurgical management were excluded. Clinicopathologic features associated with worse outcomes were identified using Kaplan-Meier and Cox proportional-hazards model. Data were analyzed from March 1, 2018, to August 15, 2018. Main Outcomes and Measures: Locoregional recurrence-free survival (LRRFS), distant recurrence-free survival (DRFS), and overall survival (OS) after surgery. Results: A total of 365 patients (median [range] age, 51.8 [15.9-91.6] years; 242 [66.3%] female) with PTC-TCM (TCV, 32%; TCF, 68%) were evaluable. Total thyroidectomy was performed in 336 (92%) patients; 19 (5.2%) received radiotherapy; and 15 (4.1%) received radioactive iodine. Clinical features were pT3 or T4, 65%; node-positive, 53%; and positive surgical margins, 24%. LRRFS at 1-, 3-, 5-, and 10-year was 95%, 87%, 82%, and 73%, respectively. On multivariable analysis, male sex and age were not independent predictors of inferior 5-year LRRFS, whereas positive surgical margins (HR, 3.5; 95% CI, 2.0-6.3), positive lymph nodes (HR, 2.8; 95% CI, 1.4-5.8), and primary tumor size of 3 cm or more (HR, 3.3; 95% CI, 1.4-7.8) were strongly associated with worse LRRFS. Age 55 years or older (HR, 3.2; 95% CI, 1.5-7.0), male sex (HR 4.5; 95% CI, 2.1-10.0), positive surgical margins (HR, 2.7; 95% CI, 1.2-6.0), nodal positivity (HR, 3.1; 95% CI, 1.3-7.7), tumor diameter of 1.5 cm or more (HR, 20.6; 95% CI, 2.8-152.1), and TCV vs TCF (HR, 3.1; 95% CI, 1.5-6.7) were associated with worse DRFS. Male sex (HR, 3.1; 95% 1.4-6.8) and tumor diameter of 1.5 cm or more (HR, 2.8; 95% CI, 1.0-7.4) were associated with worse OS. A findings-based nomogram was constructed to predict 10-year LRRFS (C index, 0.8). Conclusions and Relevance: This retrospective cohort study found that in patients with PTC-TCM, positive surgical margins, node positive disease, and tumor size of 3 cm or more were risk factors for worse LRRFS. Intensified locoregional therapy, including adjuvant radiation, may be considered for treating these patients.
Assuntos
Carcinoma Papilar , Neoplasias da Glândula Tireoide , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Carcinoma Papilar/cirurgia , Estudos de Coortes , Radioisótopos do Iodo/uso terapêutico , Margens de Excisão , Recidiva Local de Neoplasia/patologia , Nomogramas , Prognóstico , Estudos Retrospectivos , Fatores de Risco , Câncer Papilífero da Tireoide/cirurgia , Neoplasias da Glândula Tireoide/cirurgia , Neoplasias da Glândula Tireoide/patologia , Tireoidectomia , Adolescente , Adulto Jovem , Adulto , Idoso , Idoso de 80 Anos ou maisRESUMO
OBJECTIVE: To present a case series on biotin interference in parathyroid hormone (PTH) level measurement. METHODS: We review the presentation and management of patients at our institution evaluated for unexpectedly low PTH levels while taking biotin supplements in the setting of high or normal serum calcium. RESULTS: Two patients presented with surprising low parathyroid levels--one during preoperative evaluation for hyperparathyroidism and another during postoperative follow-up after subtotal parathyroidectomy. The patients were found to be taking 1,500 mcg and 5,000 mcg of biotin per day, respectively. The role of biotin interference was confirmed in one of the patients when she was retested off biotin, and PTH levels responded appropriately. Biotin supplements remain as unbound molecules in the serum, thus interfering with PTH enzyme-linked immunosorbent assay (ELISA) results and falsely depressing the PTH level. CONCLUSION: Biotin supplement use has expanded over the years, ranging from medically endorsed therapies to home remedies. Review of the 2 ELISA systems used at our institution demonstrates that free biotin mimics the biotinylated antibody used in the detection process. Screening for biotin use prior to PTH measurement and automatic biotin levels for clinically aberrant PTH levels provide the clinician with a true PTH level--lowering the disease burden of untreated hyperparathyroidism while avoiding unnecessary work-ups for other processes.
Assuntos
Biotina/uso terapêutico , Hormônio Paratireóideo/sangue , Bioensaio , Feminino , Humanos , Hiperparatireoidismo/sangue , Hiperparatireoidismo/cirurgia , Pessoa de Meia-Idade , Modelos Biológicos , ParatireoidectomiaRESUMO
BACKGROUND: Although the utility of the harmonic scalpel (HS) in thyroidectomy has been extensively demonstrated, there is little experience regarding its use for neck dissections. METHODS: Within 10 years, 119 patients underwent modified radical neck dissection (MRND) for thyroid cancer. In 51 patients, MRND was performed using conventional knot tying and in 68 using the HS. The number of lymph nodes (LNs) removed, operative time, estimated blood loss (EBL), drain output, duration of the drainage, and complications were compared for 47 patients undergoing first-time unilateral MRND without concomitant additional surgical procedures. RESULTS: The number of LNs removed, operative time, duration of drainage, and rate of lymphatic leak were similar between groups. For the HS group, EBL (5 ± 3 vs 32 ± 10; P = .006) and drain output on postoperative day 1 (51.7 ± 6.2 vs 78.9 ± 11.9; P = .02) and at 1 week (6.1 ± 1.2 vs 10.2 ± 1.8, respectively; P = .03) were significantly less. CONCLUSION: Despite the limitations of its retrospective nature, this study shows that the HS reduces EBL and the amount of lymphatic drainage compared to knot tying after MRND.
Assuntos
Esvaziamento Cervical/instrumentação , Esvaziamento Cervical/métodos , Instrumentos Cirúrgicos , Vibração/uso terapêutico , Análise de Variância , Feminino , Humanos , Linfonodos/cirurgia , Masculino , Pessoa de Meia-Idade , Esvaziamento Cervical/estatística & dados numéricos , Complicações Pós-Operatórias , Hemorragia Pós-Operatória , Estudos Retrospectivos , Neoplasias da Glândula Tireoide/cirurgia , Fatores de TempoRESUMO
OBJECTIVE: To assess factors affecting long-term survival of patients undergoing radiofrequency ablation (RFA) of colorectal hepatic metastases, with attention to evolving chemotherapy regimens. METHODS: Prospective evaluation of 235 patients with colorectal metastases who were not candidates for resection and/or failed chemotherapy underwent laparoscopic RFA. Preoperative risk factors for survival and pre- and postoperative chemotherapy exposure were analyzed. RESULTS: Two hundred and thirty-four patients underwent 292 RFA sessions from 1997 to 2006, an average of 8 months after initiation of chemotherapy. Twenty-three percent had extrahepatic disease preoperatively. Patients averaged 2.8 lesions, with a dominant diameter of 3.9 cm. Kaplan-Meier actuarial survival was 24 months, with actual 3 and 5 years survival of 20.2% and 18.4%, respectively. Median survival was improved for patients with