Clinicopathological features and outcomes after radioactive iodine treatment of oncocytic well-differentiated thyroid carcinomas.

OBJECTIVE: The aim of this study was to compare the clinicopathological features of Hürthle cell carcinomas (HCC) and oncocytic papillary thyroid carcinomas (OPTC) and to evaluate their response to radioactive iodine (RAI) treatment. METHODS: We retrospectively reviewed the charts of patients with histopathologically verified OPTC (group 1) and HCC (group 2), during a 17-year period. All patients underwent total thyroidectomy and received RAI adjuvant therapy. Clinicopathological characteristics of the two groups were compared. Response to initial therapy was assessed 6 to 24 months after RAI ablation according to the American Thyroid Association dynamic risk reclassification. Clinical outcomes were evaluated. RESULTS: A total of 28 patients (8 OPTC and 20 HCC) were included. There was no significant difference in clinicopathological features including sex, age, tumour size and vascular invasion. Distant metastases were absent in both groups. OPTC, however, presented more features of local invasion (50% vs. 10%, P = 0.03), extrathyroidal extension (25% vs. 0%, P = 0.07) and lymph node involvement (37.5% vs. 0%, P = 0.01). Median cumulative RAI activity administered to both groups was 200 mCi (range: 100-300 mCi). Response to RAI therapy was excellent in all HCC and 87.5% of OPTC (P = 0.28). One patient with OPTC (12.5%) presented an indeterminate response. Clinical outcomes were favourable after a median follow-up of 87.5 and 49 months, respectively. CONCLUSION: Although OPTC presented more locoregional invasion, clinicopathological characteristics of OPTC and HCC were comparable. Both OPTC and HCC were iodine responsive. We suggest that adjuvant RAI therapy after total thyroidectomy is beneficial for OPTC and HCC and may improve disease-free survival.

Comparison of clinical characteristics of patients with follicular thyroid carcinoma and Hürthle cell carcinoma. / Comparación de las características clínicas en pacientes con carcinoma folicular de tiroides y carcinoma de células de Hürthle.

INTRODUCTION: Hürthle cell carcinoma (HCC) is an uncommon thyroid cancer historically considered to be a variant of follicular thyroid carcinoma (FTC). The aim of this study was to assess the differences between these groups in terms of clinical factors and prognoses. PATIENTS AND METHODS: A total of 230 patients (153 with FTC and 77 with HCC) with a median follow-up of 13.4 years were studied. The different characteristics were compared using SPSS version 20 statistical software. RESULTS: Patients with HCC were older (57.3±13.8 years vs. 44.6±15.2 years; P<.001). More advanced TNM stages were also seen in patients with HCC and a greater trend to distant metastases were also seen in patients with HCC (7.8% vs. 2.7%, P=.078). The persistence/recurrence rate at the end of follow-up was higher in patients with HCC (13% vs. 3.9%, P=.011). However, in a multivariate analysis, only age (hazard ratio [HR] 1.10, confidence interval [CI] 1.04-1.17; P=.001), size (HR 1.43, CI 1.05-1.94; P=.021), and histological subtype (HR 9.79, CI 2.35-40.81; P=.002), but not presence of HCC, were significantly associated to prognosis. CONCLUSION: HCC is diagnosed in older patients and in more advanced stages as compared to FTC. However, when age, size, and histological subtype are similar, disease-free survival is also similar in both groups.

Favorable Outcome of Hurthle Cell Carcinoma of the Thyroid Treated With Total Thyroidectomy, Radioiodine, and Selective Use of External-Beam Radiotherapy.

OBJECTIVES: There is controversy about the prognosis of Hurthle cell carcinoma of the thyroid. The purpose of this project is to report the outcome of a well-defined group of patients treated at a single institution in the modern era. METHODS: Sixteen patients met the following inclusion criteria: Treatment with curative intent at our institution between January 1, 1997, and December 31, 2010. Primary treatment with total thyroidectomy with or without neck dissection. Age >18 years at the time of thyroidectomy. Confirmation by a pathologist of the diagnosis of a primary Hurthle cell carcinoma of the thyroid based on ≥75% Hurthle cells with extension through the tumor capsule. No areas of poorly differentiated (insular) or undifferentiated (anaplastic) carcinoma. Stage T1-3, NX-1b, M0. All patients received radioiodine immediately after thyroidectomy (remnant ablation, n=14) or as adjuvant for a recurrence (n=2). External-beam radiotherapy to the neck as adjuvant therapy after thyroidectomy was used in 2 patients and after resection of a neck recurrence in 1 patient. RESULTS: Five-year actuarial rates with a median 6 years of follow up on surviving patients were as follows:Overall and cancer-specific survival: 92% (1 death from Hurthle cell carcinoma). Relapse-free survival (no visible tumor and unstimulated thyroglobulin ≤1.0): 65%. CONCLUSIONS: Our experience suggests that the outcome of Hurthle cell carcinoma of the thyroid is favorable in adults with stage T1-3 NX-1b M0 disease who are managed with total thyroidectomy, radioiodine, and-in selected cases-external-beam radiotherapy. We do not have the ability to compare our results to other management strategies.

[The diagnostic and therapeutic challenges of bilateral renal oncocytosis : Illustrative case presentations and a review of the literature]. / Die bilaterale renale Onkozytose als diagnostische und therapeutische Herausforderung : Falldarstellung und Literaturreview.

Bilateral oncocytosis along with multiple tumours in both kidneys represents a very rare pathology that is accompanied by diagnostic and therapeutic challenges. We report the case of a 60-year old male patient who underwent computer tomography with incidental detection of multiple bilateral and contrast enhancing renal tumours of different size. Subsequently the patient underwent nephron-sparing tumor resection, first on the right side and 4 weeks later on the left side. The histology of all removed tumors showed evidence of pure oncocytoma. There were no postoperative complications and renal function reached a stable state within 6 months follow-up. The major challenge regarding diagnostic process and therapy of this pathology is to distinguish benign oncocytoma from chromophobe renal cell carcinoma and hybrid tumours, which can all be associated with renal oncocytosis. Because of limitations concerning imaging processes and biopsy, all patients should undergo nephron-sparing surgery as far as possible. On the other hand alternative therapies should - regarding to therapy-associated morbidity and the basically benign prognosis of oncocytoma - be well discussed to obtain informed consent. In this case report different therapy options and the international literature concerning renal oncocytosis will be discussed.

Oncocytoma of the parotid gland causing false-positive result on I-131 whole-body scintigraphy.

A 50-year-old patient underwent near-total thyroidectomy in 1997 because of a T1N0M0 follicular carcinoma in the right lobe of the thyroid gland, followed by I-131 ablation (3700 MBq). Follow-up of I-131 whole-body scintigraphy after 9 years showed pathologic uptake at the left side of the neck. Histopathologic analyses of the resected specimen suggested a cystic metastasis within the parotid gland, probably originating from thyroid carcinoma. However, the patient had been disease-free for over 9 years and thyroglobulin was undetectable in plasma. Revision of the specimen with complementary immunohistochemical staining revealed histopathologic aspects more typical of oncocytoma.

Clinicopathological characteristics and long-term outcome in patients with distant metastases from differentiated thyroid cancer.

BACKGROUND: Distant metastases are seen in a minority of patients with differentiated thyroid carcinoma (DTC) but account for most of its disease-specific mortality. Studies on the long-term outcome of patients with distant metastases are controversial. MATERIALS AND METHODS: We retrospectively reviewed the medical records of 660 patients with differentiated thyroid carcinoma followed at our institution from 1994 to 2004. Forty-four patients (6.7%) had distant metastases, with a prevalence of 4.8% for papillary thyroid cancer, 21% for follicular thyroid cancer, and 10% for Hurthle cell cancer. Primary near-total thyroidectomy followed by I(131) radiation was performed in 97% of patients with metastases (86% operated on in 1980-2003). Mean age at thyroidectomy was 49+/-19 years, and the female-to-male ratio was 1.9:1. RESULTS: The distant metastasis occurred synchronously with the primary tumor in 45.5% and after a median follow-up of 9 years in the others. Affected sites were lungs (n=24), bones (n=11), lungs and bones (n=9), brain (n=3), and uterus (n=1). Median duration of follow-up was 12 years (range: 1-42 years) from thyroidectomy and 5.5 years (range: 1-24 years) from diagnosis of distant metastases. The 5- and 10-year survival rates (all causes) after diagnosis of distant metastases were 88% and 77%, respectively. No significant differences in survival curves were found by age, sex, metastasis site, histopathology, or interval to distant metastasis. CONCLUSIONS: We conclude that complete resection of the thyroid gland at diagnosis and high-dose adjuvant radioactive iodine are associated with improved survival in patients with metastatic DTC.

Locally advanced thyroid cancer.

PURPOSE OF REVIEW: The purpose of this review is to summarize existing literature with respect to locally advanced thyroid cancer and define the intricacies of preoperative evaluation, surgical management of involved sites and postoperative treatment. RECENT FINDINGS: Locally invasive thyroid cancer is an uncommon disease process, which carries significant morbidity and mortality. Current treatment modalities include appropriate surgery, radioactive iodine treatment and external beam radiation therapy. Proper evaluation of the extent of disease, with complete gross tumor removal, is paramount in managing this difficult problem. Surgical treatment is still the mainstay for locally advanced thyroid cancer. SUMMARY: Little progress has been made in advancing the treatment of locally advanced thyroid cancer. Patient identification, evaluation and proper surgical management with adjuvant therapy, still remain the most effective course of treatment. Aggressive surgical treatment including removal of all gross tumor and still preserving vital structures along with adjuvant therapy is likely to offer the best results. There is a very high incidence of locoregional and distant failure in this group of patients. The understanding and recognition of histopathological variations, such as poorly differentiated thyroid cancer is also important. New molecular markers are needed to help identify and predict aggressive tumor behavior.

Is [18F]-2-fluoro-2-deoxy-d-glucose (FDG) scintigraphy with non-dedicated positron emission tomography useful in the diagnostic management of suspected metastatic thyroid carcinoma in patients with no detectable radioiodine uptake?

OBJECTIVE: Dedifferentiation of thyroid cancer leads to an inability of thyroid cells to concentrate iodine. In these cases, imaging methods that allow an accurate detection of recurrence and/or metastases at an early stage are essential for an adequate management of patients. Positron emission tomography using [18F]-2-fluoro-2-deoxy-d-glucose and a dedicated (dPET-FDG) or non-dedicated (nPET-FDG) camera has been suggested as a potential tool for the detection of tumour foci. DESIGN AND METHODS: This prospective study was undertaken to evaluate nPET-FDG in 51 consecutive patients (18 men, 33 women) with differentiated thyroid cancer (33 papillary, 11 follicular, four insular and three oncocytic (Hurthle-cell) thyroid carcinomas). Selection criteria were high thyroglobulin (Tg) levels (>10 ng/ml off-levothyroxine treatment) and no detectable radioiodine uptake, on a whole body scan performed with a high dose, in the absence of iodine contamination. RESULTS: Results were interpreted in terms of assumed presence of tumoral tIssue. Sensitivity of nPET-FDG was similar to that of conventional imaging modalities (67%). False negative nPET-FDG (n=16) were observed mostly in cases of micro-lesions (lymph nodes or lung metastases). Conversely, nPET-FDG identified new tumoral sites in 11 cases. Better sensitivity was found for nPET-FDG in patients with Tg levels higher than 15 microg/l (P<0.05). On a patient basis, results of nPET-FDG were equivalent to that of dPET-FDG. Finally, nPET-FDG changed treatment strategy in seven patients. CONCLUSIONS: nPET-FDG has a high sensitivity for the detection of tumour sites in patients when pathological iodine uptake cannot be demonstrated and appears to be a useful method in patients with elevated Tg levels, especially when dedicated PET is either unavailable or impractical.

Hürthle cell carcinoma.

Patients with Hürthle cell carcinoma (HCC) of the thyroid often have aggressive tumors and generally have a worse prognosis than those with papillary or follicular thyroid carcinomas. A total thyroidectomy with ipsilateral central neck lymphadenectomy and a modified radical neck dissection, if central or lateral nodes are positive, are indicated for HCC. The completeness of this procedure should be assessed by radioiodine scan 3 to 4 months after surgery. Any thyroid remnant should be ablated with radiolabeled iodine 131 to eliminate all tissue at risk and to facilitate the use of serum thyroglobulin in surveillance for tumor recurrence. Fewer than 10% of these cancers take up radioiodine. Recurrent disease is treated surgically with good palliation and appreciable prolongation of life. Local excision and neck dissection for recurrent neck disease or pulmonary wedge resection for lung metastasis has been shown to be effective. All patients with HCC should be given thyroid hormone because most of these tumors have thyrotropin receptors. External beam radiation may be considered for patients with unresectable disease, but this is considered palliative.

Malignant oncocytoma of major salivary glands. Report of a post-irradiation case.

The fourth case of malignant oncocytoma arising in the submandibular gland is here reported. This tumor arose in a 48-year-old man after radiation exposure, a finding never described before for malignant oncocytoma. In addition, several regional metastatic lymph nodes were found. The diagnosis was confirmed by histochemical and ultrastructural findings. The tumor cells showed easily recognizable mucus production and, ultrastructurally, abundant mitochondria, intracytoplasmic lumina lined by microvilli and lipid droplets. These last features have only seldom been described in malignant oncocytoma. Furthermore, the neoplastic cells were alpha-1-antitrypsin positive and S100, thyroglobulin, carcinoembryonic antigen, and smooth muscle actin negative. A thorough review of the literature is also presented.

Pancreatic pseudocyst resolution after parathyroidectomy for hyperparathyroidism.

Hyperparathyroidism is a rare cause of pancreatic inflammatory disease. Appropriate treatment of coexistent hyperparathyroidism and pancreatitis, especially when complicated by pseudocyst formation, is unsettled. We describe two patients with primary hyperparathyroidism who developed pancreatitis associated with multiple pseudocysts. The largest cyst in each patient was 9 and 5 cm, respectively. After correction of hyperparathyroidism and normalization of serum calcium levels by removal of a parathyroid adenoma, the pseudocysts resolved in both patients, as documented with computed tomography. We conclude that uncomplicated pancreatic pseudocysts in patients with primary hyperparathyroidism can be treated expectantly. Surgical correction of hyperparathyroidism and normalization of serum calcium levels should precede pancreatic intervention when possible, since pseudocyst resolution is likely and the risks of postoperative hypercalcemia are avoided.