Risk Factors of Esophageal Squamous Cell Cancer Specific for Different Macroscopic Types.

Objective: To further explore risk factors of esophageal squamous cell cancer specific for different macroscopic types.Methods: A total of 423 patients and 423 age (±3 years) and gender matched controls were recruited. Multinomial logistic regression and multivariable logistic regression analysis were used to evaluate the risk factors of ESCC specific for different macroscopic types.Results: In this study, we found that drinking hot tea (OR = 1.98, 95% CI:1.14-3.43) and higher intake of hard food (OR = 1.64, 95% CI:1.05-2.58) positively associated with ulcerative type of ESCC, but not with medullary type or other types. Although alcohol drinking and lower intake of fresh vegetable appeared to be more harmful to the ulcerative-type ESCC, the discrepant risks were not significantly different in ulcerative type and medullary type. Moreover, tobacco smoking, intake of hot food, spicy food, fresh fruit, scallion and garlic were related to ESCC risk, whereas no significant difference in magnitude of their associations with respect to macroscopic type was observed. Furthermore, significant multiplicative interaction between tobacco smoking and alcohol drinking was found in ulcerative-type and medullary-type ESCC.Conclusion: Drinking hot tea and higher intake of hard food were associated with increased risk of ulcerative type of ESCC. However, the mechanism for this difference needs to be further studied.

Unusual malignant tumors of the thyroid gland.

BACKGROUND: Although situated on the last places among the statistical hierarchy of human malignancies, thyroid cancers (TC) are the most common tumors of the endocrine system. Follicular epithelium neoplasms account for more than 90% of these lesions with a favourable prognosis, while resting tumors (medullary, anaplastic, lymphoma, sarcoma etc) generally present a rapid unfavorable evolution with a low rate of survival. PATIENTS AND METHODS: In a series of 464 thyropathies personally treated, 72 cases of TC (15.5%) were identified. Fifty-seven patients presented epithelial TC a 34 papillary variant, 20 follicular variant and 8 mixed forms. Alongside these there were two medullary TC, 9 anaplastic TC and insular TC, and primary lymphoma and metastasis to the thyroid of a lung carcinoma each single case. Four cases have been described in patients who were aged 2-6 years at the time of the Chernobyl disaster. Out of the common types, based on our own taxonomic criteria, we selected a group of 36 TC with unusual clinical, histological and behavioural characteristics or particular pathological associations. RESULTS: Seven cases of occult TC, 7 cases with precessive adenopathy TC and 11 patients with TC associated with hyperthyroidism were registered. All of them underwent adapted thyroidectomies in which the presence of cancer was decisive for the extent of surgery. Medullary, insular and anaplastic TC were the most aggressive lesions and even extended surgery and complementary therapy failed to improve the prognosis of these patients. In the same category we included the cases presenting the coexistence of two TC types, pathologic dedifferentiation in recurrences and concurrent presence of another endocrine or nonendocrine cervical lesion. The a surgical dogma of total thyroidectomy cannot always be respected, so complementary therapeutic solutions must be applied. RESULTS were complex, registering steady recoveries in occult, hyperfunctioning and even in coexisting pathological lesions, but many recurrences and reinterventions with poor survival rates (a few weeks up to 2 years) in cases with reduced or absent histologic differentiation were also noted. Some lesions were inoperable. DISCUSSIONS AND CONCLUSIONS: Increasing clinician, surgeon and pathologist awareness of these distinct, but not rare anatomoclinical contingencies could contribute to their adequate diagnosis and treatment. Recent progress in knowledge of molecular carcinogenesis and promising successes of targeted chemotherapy trials with new drugs offer promising perspectives in the management of advanced or metastatic TC. Surgery still remains the cornerstone treatment for thyroid cancers.

Carcinoma medular de tiroides: experiencia de 20 años / Medullary thyroid carcinoma: 20 years experience

Background: Medullary thyroid carcinoma (MTC) is a rare malignant tumor that arise from C cells. Surgical treatment and its results are controversial, so we decided to study it. Aim: To describe clinically MTC, treatment and outcomes in the long term. Material and Method: We retrospectively reviewed medical records of patients with MTC operated in our hospital between the years 1987 and 2007. We analyzed the cli-nical characteristics, treatment, morbidity and long-term follow up. Results: There were 24 patients operated with a mean age of 46.1 +/- 16.6 years. The main form of presentation was painless increased cervical volume (56.2 percent). In 15 percent this pathology was part of a MEN 2b. All of them have had a total thyroidectomy, which was extended in 50 percent of cases. The 35.2 percent were multifocal, 29.4 percent bilateral and 62.5 percent had metastatic lymph node involvement. Five patients remained higher calcitonin levéis in the postoperative period and 9 patients recurred clinically on average 4.5 years after surgery. The presence of persistent disease was significantly associated with hereditary MTC (p = 0.0088) and the clinical recurrence was significantly determined by the presence of not expanded total thyroidectomy (p = 0.0196). The probability of surviving more than 19 years was 66.6 percent (95 percent CI = 0.24 to 0.89). Conclusions: The MTC is a rare tumour and treatment of choice is surgery. The persistent disease is associated with hereditary MTC form, and the clinical recurrence is associated with not expanded total thyroidectomy. We recommend total thyroidectomy with central voiding and radical modified jugular dissection.

Antecedentes: El carcinoma medular de tiroides (CMT) es un tumor maligno poco frecuente, originado a partir de las células C. Su tratamiento quirúrgico y resultados son controvertidos, por lo que hemos decidido estudiarlo. Objetivo: Describir clínicamente el CMT, tratamiento y resultados a largo plazo. Material y método: Se revisaron retrospectivamente las fichas clínicas de pacientes con CMT operados en nuestro hospital entre 1987 y el 2007. Se analizaron las características clínicas, tratamiento, morbilidad y seguimiento a largo plazo. Resultados: Se operaron 24 pacientes, cuya edad media fue 46,1 +/- 16,6 años. La principal forma de presentación fue aumento de volumen cervical (56,2 por ciento). Un 15 por ciento formaba parte de una NEM 2b. A todos se les realizó una tiroidectomía total, ampliada en el 50 por ciento de los casos. El 35,2 por ciento eran multifocales, el 29,4 por ciento bilaterales y el 62,5 por ciento tenía metástasis ganglionar. Cinco pacientes mantuvieron niveles de calcitonina elevados en el postoperatorio y nueve pacientes recurrieron clínicamente, en promedio, a los 4,5 años. La enfermedad persistente se asoció significativamente con CMT hereditario (p = 0,0088) y la recurrencia clínica a tiroidectomía total no ampliada (p = 0,0196). La probabilidad de sobrevivir más de 19 años fue 66,6 por ciento (IC 95 por ciento = 0,24 a 0,89). Conclusiones: EL CMT es un tumor raro cuyo tratamiento de elección es la cirugía. La persistencia de enfermedad se asocia con la forma hereditaria, y la recurrencia clínica con la tiroidectomía total no ampliada, lo que nos hace recomendar una tiroidectomía total asociada a vaciamiento central y disección yugular radical modificada.

Thyroid cancer in young adults.

The incidence of thyroid cancer in young adults is rising. Differentiated carcinoma (ie, papillary, follicular, and their variants) and medullary thyroid carcinoma (MTC) represent the two most common subtypes, with differing etiologies, prognoses, and management strategies. Ultrasound (US)-guided fine needle aspiration (FNA) is the best initial test for evaluating a nodule or mass suspicious for malignancy. Tumor histology, in addition to radiographic findings and clinical presentation, guides surgical management, the need for adjuvant therapies, and the optimal approach to long-term follow-up. Radioactive iodine (RAI) is used to reduce recurrence and improve survival for differentiated thyroid carcinomas (DTCs). Emerging systemic therapies provide options for patients with progressive metastatic MTC or radio-resistant DTC. Overall, the prognosis for the most common thyroid malignancy, papillary thyroid carcinoma (PTC), is excellent. The treatment of young adult thyroid cancer patients occurs optimally as part of a multidisciplinary coordination of care.

Iodine intake and incidence of thyroid cancer in Denmark.

OBJECTIVE: Iodine intake is suspected to be a risk factor for thyroid cancer. Eastern Denmark is characterized by mild and western Denmark by moderate iodine deficiency, and this difference is associated with a 50% difference in the occurrence of goitre and thyrotoxicosis. The objective of the study was to determine whether the incidence of thyroid cancer differs between these two regions, as any difference would have important safety implications for the national iodine supplementation programme. DESIGN AND METHODS: We studied all thyroid cancers notified to the Danish Cancer Registry in the period 1973-1997, focusing on the four most frequent subtypes: papillary, follicular, anaplastic and medullary thyroid cancer. A Poisson regression model was used with models of goodness-of-fit for age, period, sex. RESULTS: No regional difference was found in the overall incidence of follicular (0.3% 100 000 person-years) or papillary (0.7% 100 000 person-years) thyroid cancer. A slight but nonsignificant increase in total incidence, resulting mainly from a significant increase in the incidence for the papillary subtype, was observed in both regions. CONCLUSION: The results suggest that modest differences in iodine intake do not affect thyroid cancer incidence or the distribution of subtypes.

Comorbidity in newly diagnosed thyroid cancer patients: a population-based study on prevalence and the impact on treatment and survival.

BACKGROUND: Comorbidity may be an important contributory factor to differences in the treatment and outcome of cancer, especially in older patients. It might also provide information on the aetiology of the cancer in cases of high or low frequency. The aim of this study was to describe the spectrum of comorbidity and the possible impact on treatment and survival in newly diagnosed thyroid cancer (TC). DESIGN: A population-based observational study. SETTING: The Eindhoven Cancer Registry, Comprehensive Cancer Centre South (IKZ), the Netherlands. METHODS: Demographic, histological and treatment data on all 417 TC patients diagnosed between 1 January 1993 and 31 December 2002 were collected and followed up till 2004. An adapted version of the list of Charlson was used for registration of clinically relevant concomitant disorders. The prevalence of comorbidity at diagnosis was analysed according to gender, age, histological type and therapy. Crude 6-month and 1- and 5-year survival rates were determined. A regression analysis was performed to identify independent variables related to survival. RESULTS: Information on comorbidity was available for 378 patients (91%). Comorbidity was present in 32% of the patients; 23% had one and 12% had two or more concomitant diseases. The prevalence of comorbidity increased with age. Hypertension was the most frequent comorbidity (18%), followed by 'other cancers' (7%), cardiovascular diseases (6%) and diabetes mellitus (6%). The prevalence of hypertension was twice as high as expected at all age groups. Six patients > 60 years had had tuberculosis. Initial surgical treatment was negatively related to the presence of concomitant diseases in patients < 70 years (P = 0.02), but not in patients > or = 70 years. Comorbidity was not independently associated with crude survival up to 5 years. CONCLUSIONS: A previous diagnosis of hypertension was associated with TC. The use of external radiation for diagnostic and therapeutic procedures for tuberculosis probably explains the high prevalence of former tuberculosis in elderly TC patients. Treatment choices appeared to be influenced by the presence of comorbidity. Comorbidity did not affect survival up to 5 years; a study with a longer period of follow-up is needed.

A prospective study of thyroid nodular disease in children and adolescents in western Poland from 1996 to 2000 and the incidence of thyroid carcinoma relative to iodine deficiency and the Chernobyl disaster.

BACKGROUND: In Poland, where soil is deficient in iodine, supplementation of iodine was introduced in 1935, discontinued in 1980, and then re-introduced in 1997. One of the effects of inadequate iodine intake, prior to 1997, was an increase in the prevalence of thyroid nodular disease (TND) in children. Chernobyl, located in the neighbouring country of Ukraine, suffered a catastrophic nuclear explosion in April 1986. PROCEDURE: A total of 411 children with TND (an incidence of 7.53/100,000) were diagnosed and registered in western Poland between 1996 and 2000 and further evaluated as a population-based study. RESULTS: Based on the patient's clinical status, ultrasound examination, scintiscan, laboratory tests, cytology and the family history, many of the patients qualified for surgery and, as a result, histopathologic data were obtained from 155 of the 411 patients operated on to date (37.7% of all TND). Thyroid carcinoma was detected in 37 of the operated children, i.e. 23.9% or 9.0% of all children with TND with a median incidence of 0.68/100,000. Papillary carcinoma was the predominant histologic type (26-70.3%) compared to follicular carcinoma (10-27.0%) and medullary carcinoma (1-2.7%). Retrospective analysis of the figures for the 23 years (1972-1995) showed that in that period a total of 23 thyroid carcinomas were registered. However, only 12 of these were detected in the 20-year period between 1972 and 1991, none in the years 1992-1993 and, significantly, 11 from 1994 to 1995. CONCLUSIONS: Thyroid carcinoma appears to be an ongoing and increasing problem in the children and adolescents of our region, and it is developing more intensively when compared, both to other parts of Poland and to previous statistics (2000 vs. 1985; P<0.002). Iodine deficiency and radiation resulting from the Chernobyl disaster might be important risk factors in the development of thyroid carcinoma in the young population analysed in our region in the period since 1994. The high percentage of follicular carcinoma and follicular adenoma with an undetermined prognosis (19 out of 46) indicates that the long-term iodine deficiency in our region may be more significant in the pathogenesis of malignant transformation than has previously been postulated.

A National Cancer Data Base report on 53,856 cases of thyroid carcinoma treated in the U.S., 1985-1995 [see commetns].

BACKGROUND: The National Cancer Data Base (NCDB) represents a national electronic registry system now capturing nearly 60% of incident cancers in the U. S. In combination with other Commission on Cancer programs, the NCDB offers a working example of voluntary, accurate, cost-effective "outcomes management" on a both a local and national scale. In addition, it is of particular value in capturing clinical information concerning rare cancers, such as those of the thyroid. METHODS: For the accession years 1985-1995, NCDB captured demographic, patterns-of-care, stage, treatment, and outcome information for a convenience sample of 53,856 thyroid carcinoma cases (1% of total NCDB cases). This article focuses on overall 10-year relative survival and American Joint Committee on Cancer (AJCC) (3rd/4th edition) stage-stratified 5-year relative survival for each histologic type of thyroid carcinoma. Care patterns also are discussed. RESULTS: The 10-year overall relative survival rates for U. S. patients with papillary, follicular, Hürthle cell, medullary, and undifferentiated/anaplastic carcinoma was 93%, 85%, 76%, 75%, and 14%, respectively. For papillary and follicular neoplasms, current AJCC staging failed to discriminate between patients with Stage I and II disease at 5 years. Total thyroidectomy +/- lymph node sampling/dissection represented the dominant method of surgical treatment rendered to patients with papillary and follicular neoplasms. Approximately 38% of such patients receive adjuvant iodine-131 ablation/therapy. At 5 years, variation in surgical treatment (i.e., lobectomy vs. more extensive surgery) failed to translate into compelling differences in survival for any subgroup with papillary or follicular carcinoma, but longer follow-up is required to evaluate this. NCDB data appeared to validate the AMES prognostic system, as applied to papillary cases. Younger age appeared to influence prognosis favorably for all thyroid neoplasms, including medullary and undifferentiated/anaplastic carcinoma. NCDB data also revealed that unusual patients diagnosed with undifferentiated/anaplastic carcinoma before age of 45 years have better survival. CONCLUSIONS: The NCDB system permits analysis of care patterns and survival for large numbers of contemporaneous U. S. patients with relatively rare neoplasms, such as thyroid carcinoma. In this context, it represents an unsurpassed clinical tool for analyzing care, evaluating prognostic models, generating new hypotheses, and overcoming the volume-related drawbacks inherent in the study of such neoplasms. [See editorial on pages 2434-6, this issue.]

[Surgical treatment of multinodular goiter at the Instituto Nacional de la Nutrición Salvador Zubirán]. / Tratamiento quirúrgico de bocio multinodular en el Instituto Nacional de la Nutrición Salvador Zubirán.

BACKGROUND: Surgical treatment is the first option for patients with obstructive multinodular goiter. The extent of the resection and the use of postoperative hormonal therapy are, on the other hand, still under debate. OBJECTIVE: To analyze the results of surgical treatment in 101 patient with multinodular goiter seen from 1980 to 1995. MATERIALS AND METHODS: The clinical/pathologic charts of all patients were reviewed with emphasis to the clinical diagnosis, extent of resection, final histology, type and number of complications, and long-term follow-up. The mean follow-up was three years (range 0.5-12). RESULTS: Ten males and 91 females with a mean age of 46 years were included. Surgery was recommended for a nodule suspicious of malignancy in 60 patients, for airway compression in 33, and for cosmetic reasons in eight. Unilateral lobectomy was performed in 30, bilateral subtotal thyroidectomy in 55 and total thyroidectomy in 16. Postoperative hormone therapy was administrated to 83 patients. Surgical complications occurred in six patients. Four developed permanent hypoparathyroidism and two vocal cord paralysis. There was no operative mortality. A final diagnosis of multinodular goiter was established in 89 whereas 12 had cancer. There were three asymptomatic recurrences in the group with benign lesions (they had undergone unilateral lobectomy followed by hormonal therapy). CONCLUSION: Bilateral subtotal thyroidectomy was the best treatment for multinodular goiter in our series. This procedure had few complications and there was no recurrence of the disease.