Fluorescence imaging to visualize the recurrent laryngeal nerve during thyroidectomy procedures: analysis of 65 cases and 81 nerves.

BACKGROUND: Recurrent laryngeal nerve (RLN) injury after thyroidectomy is relatively common. Locating the RLN prior to thyroid dissection is paramount to avoid injury. We developed a fluorescence imaging system that permits nerve autofluorescence. We aimed to determine the sensitivity and specificity of fluorescence imaging at detecting the RLN relative to thyroid and other background tissue and compared it to white light. METHODS: In this prospective study, 65 patients underwent thyroidectomy from January to April 2022 (16 bilateral thyroid resections) using white and fluorescent light. Fluorescence intensity [relative fluorescence units (RFU)] was recorded for RLN, thyroid, and background. RFU mean, minimum, and maximum values were calculated using Image J software. Thirty randomly selected pairs of white and fluorescent light images were independently reviewed by two examiners to compare RLN detection rate, number of branches, and length and minimum width of nerves visualized. Parametric and nonparametric statistical analysis was performed. RESULTS: All 81 RNLs observed were visualized more clearly under fluorescence (mean intensity, µ = 134.3 RFU) than either thyroid (µ = 33.7, p < 0.001) or background (µ = 14.4, p < 0.001). Forest plots revealed no overlap between RLN intensity and that of either other tissue. Sensitivity and specificity for RLN were 100%. All 30 RLNs and all 45 nerve branches were clearly visualized under fluorescence, versus 17 and 22, respectively, with white light (both p < 0.001). Visible nerve length was 2.5 × as great with fluorescence as with white light (µ = 1.90 vs. 0.76 cm, p < 0.001). CONCLUSIONS: In 65 patients and 81 nerves, RLN detection was markedly and consistently enhanced with autofluorescence neuro-imaging during thyroidectomy, with 100% sensitivity and specificity.

Nerve autofluorescence in near-ultraviolet light markedly enhances nerve visualization in vivo.

BACKGROUND: During surgery, surgeons must accurately localize nerves to avoid injuring them. Recently, we have discovered that nerves fluoresce in near-ultraviolet light (NUV) light. The aims of the current study were to determine the extent to which nerves fluoresce more brightly than background and vascular structures in NUV light, and identify the NUV intensity at which nerves are most distinguishable from other tissues. METHODS: We exposed sciatic nerves within the posterior thigh in five 250-300 gm Wistar rats, then observed them at four different NUV intensity levels: 20%, 35%, 50%, and 100%. Brightness of fluorescence was measured by fluorescence spectroscopy, quantified as a fluorescence score using Image-J software, and statistically compared between nerves, background, and both an artery and vein by unpaired Student's t tests with Bonferroni adjustment to accommodate multiple comparisons. Sensitivity, specificity, and accuracy were calculated for each NUV intensity. RESULTS: At 20, 35, 50, and 100% NUV intensity, fluorescence scores for nerves versus background tissues were 117.4 versus 40.0, 225.8 versus 88.0, 250.6 versus 121.4, and 252.8 versus 169.4, respectively (all p < 0.001). Fluorescence scores plateaued at 50% NUV intensity for nerves, but continued to rise for background. At 35%, 50%, and 100% NUV intensity, a fluorescence score of 200 was 100% sensitive, specific, and accurate identifying nerves. At 100 NUV intensity, artery and vein scores were 61.8 and 60.0, both dramatically lower than for nerves (p < 0.001). CONCLUSIONS: At all NUV intensities ≥ 35%, a fluorescence score of 200 is 100% accurate distinguishing nerves from other anatomical structures in vivo.

Consensus Conference Statement on the General Use of Near-infrared Fluorescence Imaging and Indocyanine Green Guided Surgery: Results of a Modified Delphi Study.

BACKGROUND: In recent decades, the use of near-infrared light and fluorescence-guidance during open and laparoscopic surgery has exponentially expanded across various clinical settings. However, tremendous variability exists in how it is performed. OBJECTIVE: In this first published survey of international experts on fluorescence-guided surgery, we sought to identify areas of consensus and nonconsensus across 4 areas of practice: fundamentals; patient selection/preparation; technical aspects; and effectiveness and safety. METHODS: A Delphi survey was conducted among 19 international experts in fluorescence-guided surgery attending a 1-day consensus meeting in Frankfurt, Germany on September 8th, 2019. Using mobile phones, experts were asked to anonymously vote over 2 rounds of voting, with 70% and 80% set as a priori thresholds for consensus and vote robustness, respectively. RESULTS: Experts from 5 continents reached consensus on 41 of 44 statements, including strong consensus that near-infrared fluorescence-guided surgery is both effective and safe across a broad variety of clinical settings, including the localization of critical anatomical structures like vessels, detection of tumors and sentinel nodes, assessment of tissue perfusion and anastomotic leaks, delineation of segmented organs, and localization of parathyroid glands. Although the minimum and maximum safe effective dose of ICG were felt to be 1 to 2 mg and >10 mg, respectively, there was strong consensus that determining the optimum dose, concentration, route and timing of ICG administration should be an ongoing research focus. CONCLUSIONS: Although fluorescence imaging was almost unanimously perceived to be both effective and safe across a broad range of clinical settings, considerable further research remains necessary to optimize its use.

Comparación entre los melanomas de cabeza y cuello con los de tronco y extremidades / Comparison between head and neck melanomas with trunk and extremity melanomas

Antecedentes: los melanomas en cabeza y cuello (MCC) han sido asociados con factores pronósticos diferentes de aquellos en otras localizaciones. Objetivo: comparar características demográficas, clínicas y resultados del tratamiento quirúrgico de pacientes con MCC y pacientes con melanomas en tronco y extremidades (MTE). Material y métodos: se llevó a cabo una revisión retrospectiva de las historias clínicas de pacientes operados por melanoma entre enero de 2012 y diciembre de 2017. Quince pacientes (22,3%) tuvieron MCC y 52 (77,7%) MTE. Resultados: ambos grupos tuvieron edad similar (63,8 ± 21,1 versus 58,5 ± 16), pero los MCC mostraron una tendencia con predominio masculino (80% versus 61,3%). Los MCC tuvieron menor espesor tumoral que los MTE (2,07 versus 5,5 mm) y mayor porcentaje de melanoma in situ, 5 (33,3%) versus 8 (15,3%), pero requirieron vaciamientos ganglionares más a menudo (33% versus 25%) así como reconstrucción del defecto primario con colgajos locales y miocutáneos. Durante el seguimiento, en el grupo de MCC, dos pacientes desarrollaron recidivas locales que fueron extirpadas, y otros tres desarrollaron metástasis a distancia en pulmón, intestino delgado y abdomen y fallecieron por la enfermedad; en el grupo de MTE un paciente tuvo recidiva local y cinco fallecieron de metástasis sistémicas. El tamaño de la muestra no permitió aplicar pruebas de significación entre las diferencias encontradas. Conclusión: los MCC se presentan en un amplio rango de edad y estadios, y tuvieron algunas diferencias clínicas con el MTE. Los defectos producidos por la extirpación de la lesión primaria requieren procedimientos reconstructivos más complejos la mayoría de las veces y se aconseja un abordaje multidisciplinario.

Background: Head and neck melanomas (HNMs) have been associated with prognostic factors different from those on other locations. Objective: The goal of the present study was to compare the demographic and clinical characteristics and the outcomes of surgical treatment between patients with HNM and those with trunk and extremity melanoma (TEM). Material and methods: The clinical records of patients undergoing surgery for melanoma between October 2014 and April 2018 were retrospectively reviewed. Fifteen patients (22.3%) had HNM and 52 (77.7) presented TEM. Results: There were no differences in age between both groups (63.8 ± 21.1 versus 58.5 ± 16), but there was a trend toward higher percentage of men in the HNM group (80% versus 61.3%). Patients with HNM had lower tumor thickness than those with TEM (2.07 versus 5.5 mm), higher incidence of melanoma in situ [5 (33.3%) versus 8 (15.3%)]; lymph node resection was more common (33% versus 25%) as well as reconstruction of the primary defect with local and musculocutaneous flaps. During follow-up, two patients in the HNM group developed local recurrences that were excised and three presented distant metastases in the lung, small bowel and abdomen and finally died due to the disease. In the TEM group, one patient had local recurrence and five died due to systemic metastases. The sample size was not sufficient to assess statistically significant differences. Conclusion: Head and neck melanomas occur in a wide age range and stages and has some clinical differences with TEM. The defects produced after the excision of the primary lesion often require more complex procedures and should be managed with a multidisciplinary approach.

Estudio patológico intraoperatorio en la cirugía tiroidea: ¿cuánto contribuye a la estrategia quirúrgica? / Intraoperative pathologic evaluation in thyroid surgery: how much does it contribute to surgical strategy?

Antecedentes: el papel del estudio patológico intraoperatorio (EPI) en cirugía tiroidea ha sido discutido largamente y es todavía motivo de controversia. Objetivo: estimar los resultados del EPI en el diagnóstico de malignidad, su relación con la biopsia por punción-aspiración preoperatoria con aguja fina (PAAF) y el estudio patológico diferido (EPD), así como su contribución al cambio en la estrategia quirúrgica en cirugía tiroidea. Material y métodos: revisión retrospectiva de las historias clínicas de 773 pacientes operados por patología tiroidea entre enero de 2014 y diciembre de 2015. En todos se efectuó EPI y EPD; a 686 (89%) pacientes también se les efectuó la biopsia por PAAF preoperatoria. Resultados: los resultados del EPI fueron benigno en 215 pacientes (27,8%), maligno en 419 (54,2%) y no definitivo en 139 (18,0%). Cuando estos resultados fueron comparados con la EPD se encontraron 19 casos (8,8%) de falsos negativos y 4 (0,95%) de falsos positivos. Considerando solo los resultados definitivos, el EPI tuvo sensibilidad 95%, especificidad 98%, valor predictivo positivo 99%, valor predictivo negativo 91% y exactitud 91%. Cuando se comparó el EPI con la PAAF preoperatoria, los valores de sensibilidad más bajos (44%) correspondieron a las categorías de Bethesda III y IV. El EPI influyó en la estrategia quirúrgica en 95 pacientes (12,28%): en 53 (6,8%), la hemitiroidectomía cambió a tiroidectomía total; en 37 (4,8%), el diagnóstico de metástasis ganglionares permitió realizar un vaciamiento modificado de cuello, y en 5 (0,6%) ocurrieron ambas situaciones. Conclusión: el EPI tuvo altos valores de utilidad diagnóstica cuando se compararon con el EPD. También se correlacionó con la PAAF preoperatoria, pero tuvo menos utilidad en las categorías Bethesda III y IV. El EPI contribuyó a cambiar la decisión de técnica quirúrgica en un grupo de pacientes y evitar una segunda operación.

Background: the role of intraoperative pathologic evaluation (IPE) in thyroid surgery has largely been discussed and it is still controversial. Objective: to estimate the results of IPE in diagnosis of malignancy, its correlation with preoperative fine needle aspiration (FNA) biopsy and permanent pathologic evaluation (PPE), and its contribution to change surgical strategy in thyroid surgery. Materials and methods: retrospective chart review of 773 patients operated on for thyroid disease between January 2014 and December 2015. All patients underwent IPE and PPE; 686 (89%) patients had also preoperative FNA biopsy. Results: IPE resulted benign in 215 patients (27.8%), malignant in 419 (54.2%) and non definitive in 139 (18.0%). When these results were compared with PPE, 19 cases were false negative (8.8%) and 4 false positive (0.95). Considering only definitive results, IPE had sensitivity 95%, specificity 98%, positive predictive value 99%, negative predictive value 91% and accuracy 91%. When IPE was compared with preoperative FNA biopsy, lowest values of sensitivity (44%) corresponded with Bethesda categories III and IV. IPE influenced surgical strategy in 95 patients (12.28%): in 53 (6.8%) hemithyroidectomy changed to total thyroidectomy, in 37 (4.8%) lymph node metastases diagnosis allowed to perform modified neck dissection, and in 5 (0.6%) both situations occurred. Conclusion: IPE had high values of diagnostic utility when compared with PPE. It also correlated with preoperative FNA biopsy, but had less utility in Bethesda categories III and IV. IPE contributed to change surgical technical decision in a subset of patients and avoid a second operation.

Autofluorescencia: un método innovador en la identificación intraoperatoria de adenomas paratiroideos / Autofluorescence: an innovative method in the intraoperative identification of parathyroid adenomas

RESUMEN Introducción El tratamiento definitivo del hiperparatiroidismo primario es la resección quirúrgica de la glándula paratiroidea anómala. Su identificación resulta un desafío aun para cirujanos expertos. Hasta el momento no se han descripto métodos inocuos y efectivos para la identificación intraoperatoria de las glándulas. Tenemos como objetivo reportar la experiencia del uso de autofluorescencia en la identificación de las glándulas paratiroideas. Método Se incluyeron pacientes con hiperparatiroidismo primario evaluados preoperatoriamente con laboratorio, ecografía cervical y centellografía con Tc-99 MIBI. Durante el acto operatorio se utilizó un método de autofluorescencia (VINFLUO-P) para identificar las glándulas paratiroides (GP). Se analizó la intensidad lumínica de las (GP) normales y anómalas (AP) y distintas covariables. Se dosó PTH ultra rápida post resección del AP y se evaluó la histopatología de la pieza intraoperatoriamente. Resultados Se incluyeron 59 pacientes. La ecografía preoperatoria predijo la ubicación correcta en el 68% y el centellograma Tc-99 MIBI el 75% de los AP. La localización más frecuente fue inferior derecha (29%). El VINFLUO-P facilitó la visualización de las GP y los AP en el 100% de los pacientes con un aumento del 27% respecto a la luz blanca. Se evidenció un descenso postoperatorio de PTH del 76,44% y de la calcemia en 1,8 mg/dl. La intensidad de la luz reflejada por los AP fue mayor que la de las GP normales (p <0,001). Se observó una relación lineal entre PTH e intensidad lumínica de AP. (CC = 0,448; p = 0,045). El patrón arquitectural sólido de los AP evidenció una asociación negativa (CC = -0,4709 p = 0,03). Conclusión La utilización del VINFLUO-P demostró ser efectivo para la identificación de las GP normales y patológicas. Las glándulas anómalas resultaron con mayor fluorescencia que los tejidos normales.

ABSTRACT Introduction The treatment of primary hyperparathyroidism consists on the resection of the abnormal parathyroid gland (PG). Identification of PGs is challenging even for expert surgeons. Currently, there are no effective and harmless methods for intraoperative identification of PGs. The aim of this study is to report our experience with the identification of PGs using autofluorescence. Materials and methods Patients with diagnosis of primary hyperparathyroidism were included in the study. Patients were preoperatively worked up with labs [parathyroid hormone (PTH), serum calcium], neck ultrasound (US) and Technetium (99mTc) sestamibi. The parathyroid gland Intraoperative fluorescent visualization (PG-IFV) method was used during the surgery to identify PGs. The fluorescent intensity ratio of normal PGs and parathyroid adenomas (PA) was analyzed and correlated to different variables. All patients underwent a post-resection rapid PTH analysis and frozen section. Results Fifty-nine patients were included in the study. The US accurately predicted the location of the PA in 68% of the cases, while 99mTc sestamibi was accurate in 75% of the cases. The most frequently reported localization of the adenoma was right inferior (29%). PG-IFV facilitated the visualization of the PGs in 100% of the cases, with a 27% increase in the visualization of the PGs when compared to white light. The postoperative PTH decreased 76.4% and the calcium 1.8 mg/dl. The fluorescent intensity ratio of the PAs was significantly higher than normal PGs (44.4 vs 27.2, p <0.001). There was positive correlation between the PTH and the fluorescent intensity ratio of the PAs [Spearman's correlation coefficient (SCC) = 0.448; p = 0.045]. The solid histoarchitectural pattern of the PAs presented a negative correlation with fluorescent intensity ratio (SCC = -0.4709, p = 0.03). Conclusion The use of PG-IFV is an effective method for intraoperative identification of normal and abnormal PGs. The fluorescent intensity ratio of abnormal PGs was significantly higher than normal PGs.

Increased identification of parathyroid glands using near infrared light during thyroid and parathyroid surgery.

BACKGROUND: Parathyroid gland (PG) identification during thyroid and parathyroid surgery is challenging. Accidental parathyroidectomy increases the rate of postoperative hypocalcaemia. Recently, autofluorescence with near infrared light (NIRL) has been described for PG visualization. The aim of this study is to analyze the increased rate of visualization of PGs with the use of NIRL compared to white light (WL). MATERIALS AND METHODS: All patients undergoing thyroid and parathyroid surgery were included in this study. PGs were identified with both NIRL and WL by experienced head and neck surgeons. The number of PGs identified with NIRL and WL were compared. The identification of PGs was correlated to age, sex, and histopathological diagnosis. RESULTS: Seventy-four patients were included in the study. The mean age was 48.4 (SD ±13.5) years old. Mean PG fluorescence intensity (47.60) was significantly higher compared to the thyroid gland (22.32) and background (9.27) (p < 0.0001). The mean number of PGs identified with NIRL and WL were 3.7 and 2.5 PG, respectively (p < 0.001). The difference in the number of PGs identified with NIRL and WL and fluorescence intensity was not related to age, sex, or histopathological diagnosis, with the exception of the diagnosis of thyroiditis, in which there was a significant increase in the number of PGs visualized with NIRL (p = 0.026). CONCLUSION: The use of NIRL for PG visualization significantly increased the number of PGs identified during thyroid and parathyroid surgery, and the differences in fluorescent intensity among PGs, thyroid glands, and background were not affected by age, sex, and histopathological diagnosis.

Cutting Edge in Thyroid Surgery: Autofluorescence of Parathyroid Glands.

BACKGROUND: Identification of parathyroid glands may be challenging during thyroid and parathyroid surgery. Accidental resection of the glands may increase the morbidity of the surgery. The aim of this study was to evaluate accuracy in identification of autofluorescent parathyroid glands with the use of near infrared light in real time. STUDY DESIGN: Patients undergoing thyroid and parathyroid surgery between June and August 2015 were included in the study. During the procedure, the surgical field was exposed to near infrared laser light in order to analyze the intensity of the fluorescence of different tissues (parathyroid glands, thyroid glands, and background). Surgical images were recorded and analyzed. RESULTS: Twenty-eight patients were included in the study. Nineteen patients were women and 9 were men. Seven patients had primary hyperparathyroidism, 4 had hyperthyroidism, 3 had goiters, and 11 had thyroid cancer. Three patients had mixed pathologies, including 2 patients with thyroid cancer and primary hyperparathyroidism and 1 patient with goiter and primary hyperparathyroidism. Identification of autofluorescent parathyroid glands was achieved in all patients with near infrared light. The mean fluorescent intensity of parathyroid glands was 40.6 (±26.5), thyroid glands 31.8 (±22.3), and background 16.6 (±15.4). Parathyroid glands demonstrated statistically higher fluorescence intensity compared with the thyroid gland and background (p < 0.0014). No postoperative hypocalcemia or other complications related to the surgery were registered. CONCLUSIONS: Visualization of autofluorescent parathyroid glands with the use of near infrared light allows high rates of parathyroid gland identification and could be a safe, feasible, and noninvasive method for intraoperative identification of parathyroid glands in real time. Further clinical studies must be performed to determine the cost-effectiveness and clinical application of this method.

Microcarcinoma papilar de troides. Frecuencia y factores de riesgo de metástasis ganglionar / Papillary thyroid microcarcinoma. Frequency and risk factors of lymph node metastases

Correspondencia: Manuel R. Montesinos e-mail: mrmontesinos5@ hotmail.com Dirección: Avda. Santa Fe 1877 1 B (1123) Ciudad Autónoma de Buenos Aires Antecedentes: el manejo quirúrgico de los ganglios linfáticos en el microcarcinoma papilar de troi-des es motvo de controversia debido a su excelente pronóstico. Objetvo: cuantficar la frecuencia y patrón de distribución de metástasis ganglionares en los pacientes operados por microcarcinoma papilar de troides e identficar factores predictores de enfermedad regional. Lugar de aplicación: práctica privada. Diseño: retrospectvo observacional. Población: entre junio de 2002 y junio de 2012, a 434 pacientes con microcarcinoma papilar de troides se les realizó troidectomía total y linfadenectomía terapéutica solo cuando se demostró metástasis por biopsia ganglionar. Método: revisión de historias clínicas e informes patológicos. Resultados: 66 pacientes (15,2%) tuvieron ganglios histológicamente positvos. Se encontraron metástasis en ganglios yugulares con ganglios centrales negatvos (metástasis "skip") en 12 casos (2,76%). El análisis multvariado mostró que la edad menor de 45 años (p = 0,02), la invasión extra-capsular (p = 0,003) y adenopatas palpables (p = 0,001) fueron factores de riesgo independientes de metástasis ganglionar. Estos factores, en conjunto, tuvieron alta especificidad (99,7%) y baja sensibilidad (19,7 %). Conclusiones: la estrategia quirúrgica empleada permitó diagnosticar metástasis ganglionares tanto en compartmento central como lateral; esto es de particular importancia ya que a pesar de que algunos de los factores estudiados tuvieron valor predictor de ausencia de metástasis ganglionar se requieren variables adicionales para predecir presencia de enfermedad regional en este subgrupo de pacientes con cáncer de troides.

Background: surgical management of lymph nodes in papillary thyroid microcarcinoma is controver-sial due to its excellent overall prognosis. Objetve: to quantfy the frequency and patern of lymph node metastasis in patents operated on for papillary thyroid microcarcinoma and to identfy predictve factors of regional disease. Seg: private practice. Design: retrospectve, observatonal. Populaton: between June 2002 and June 2012, 434 patents with papillary thyroid microcarcinoma underwent total thyroidectomy and therapeutic neck dissecton only when there was biopsy proved lymph node metastasis. Method: review of clinical records and pathological reports. Results: 66 patents (15.2 %) had histologically positve lymph nodes. Metastasis in jugular lymph no-des with normal central nodes (skip metastasis) was found in 12 (2.76 %) cases. Multvariate analysis showed that less than 45 years (p = 0.02), extracapsular invasion (p = 0.003) and palpable adenopathy (p = 0.001), were independent risk factors of lymph node metastasis. These factors, together, had high specificity (99.7 %) but low sensibility (19.7 %). Conclusions: surgical strategy employed allowed to diagnostic lymph node metastases in both central and lateral compartments; this is of particular importance because even though some of the factors studied proved to be predictve of lack of lymph node metastases, additonal variables are needed to predict presence of regional disease in this subset of thyroid cancer patents.

Factores predictores de metástasis ganglionar en el carcinoma diferenciado de tiroides / Predictors of lymph node metastases in differentiated thyroid carcionma

ANTECEDENTES: son necesarios factores pronósticos confiables de metástasis ganglionar para adaptar el tratamiento quirúrgico inicial de pacientes con carcinoma diferenciado de tiroides. OBJETIVO: determinar la frecuencia y factores pronósticos asociados con metástasis ganglionar en pacientes operados por carcinoma diferenciado de tiroides. Lugar de apicación: práctica privada. DISEÑO: retrospectivo observacional. POBACIÓN: entre enero de 2000 y agosto de 2010, a 600 pacientes con 639 tumores (39 bilaterales) se les realizó tiroidectomía total y linfadenectomía terapéutica sólo cuando se demostró metástasis por biopsia ganglionar. MÉTODO: revisión de historias clínicas e informes patológicos. RESUTADOS: 145 enfermos (22.7 %) tuvieron ganglios histológicamente positivos. El análisis multivariado mostró que la edad menor de 45 años (p = 0.001), adenopatías palpables (p = 0.0001), multicentricidad (p = 0.005) e invasión extracapsular (p = 0.0001) fueron factores de riesgo independientes de metástasis ganglionar. Estos factores, en conjunto, tuvieron una alta especificidad (97 %)y una baja sensibilidad (40 %). Se encontraron metástasis en ganglios yugulares con ganglios centrales negativos ("skip" metástasis) en 29 casos (5.54 %). CONCUSIONES: a pesar de que algunos de los factores estudiados tuvieron valor pronóstico, se requieren variables adicionales para definir mejor el manejo quirúrgico.

BACKGROUND: reliable prognostic factors of lymph node metástasis are needed to adapt initial surgical treatment of patients with differentiated thyroid carcinoma. OBJETIVE: to determine the frequency and predictive factors associated with lymph node metástasis in patients operated on for differentiated thyroid carcinoma. SETTING: prívate practice. DESIGN: retrospective observational. POPUATION: between January 2000 and August 2010, 600 patients with 639 tumours (39 bilateral) underwent total thyroidectomy and therapeutic neck dissection only when there was biopsy proved lymph node metástasis. Method: review of clinical records and pathological reports. RESUTS: 145 patients (22.7 %) had histologically positive lymph nodes. Multivariate analysis showed that lessthan 45 years (p = 0.001), palpable adenopathy (p = 0.0001), multicentricity (p = 0.005) and extracapsular invasión (p = 0.0001) were independent risk factors of lymph node metástasis. These factors, together, had high specificity (97 %) but low sensibility (40 %). Metástasis in jugular lymph nodes with normal central nodes (skip metástasis) was found in 29 (5.54 %) cases. CONCUSIONS: even though some of the factors studied proved to be of prognostic valué, additional variables are needed to better define surgical management.

Factores predictores de metástasis ganglionar en el carcinoma diferenciado de tiroides

Antecedentes: son necesarios factores pronósticos confiables de metástasis ganglionar para adaptar el tratamiento quirúrgico inicial de pacientes con carcinoma diferenciado de tiroides. Objetivo: determinar la frecuencia y factores pronósticos asociados con metástasis ganglionar en pacientes operados por carcinoma diferenciado de tiroides. Lugar de apicación: práctica privada. Diseño: retrospectivo observacional. Pobación: entre enero de 2000 y agosto de 2010, a 600 pacientes con 639 tumores (39 bilaterales) se les realizó tiroidectomía total y linfadenectomía terapéutica sólo cuando se demostró metástasis por biopsia ganglionar. Método: revisión de historias clínicas e informes patológicos. Resutados: 145 enfermos (22.7 %) tuvieron ganglios histológicamente positivos. El análisis multivariado mostró que la edad menor de 45 años (p = 0.001), adenopatías palpables (p = 0.0001), multicentricidad (p = 0.005) e invasión extracapsular (p = 0.0001) fueron factores de riesgo independientes de metástasis ganglionar. Estos factores, en conjunto, tuvieron una alta especificidad (97 %)y una baja sensibilidad (40 %). Se encontraron metástasis en ganglios yugulares con ganglios centrales negativos ("skip" metástasis) en 29 casos (5.54 %). Concusiones: a pesar de que algunos de los factores estudiados tuvieron valor pronóstico, se requieren variables adicionales para definir mejor el manejo quirúrgico.(AU)

Background: reliable prognostic factors of lymph node metástasis are needed to adapt initial surgical treatment of patients with differentiated thyroid carcinoma. Objetive: to determine the frequency and predictive factors associated with lymph node metástasis in patients operated on for differentiated thyroid carcinoma. Setting: prívate practice. Design: retrospective observational. Popuation: between January 2000 and August 2010, 600 patients with 639 tumours (39 bilateral) underwent total thyroidectomy and therapeutic neck dissection only when there was biopsy proved lymph node metástasis. Method: review of clinical records and pathological reports. Resuts: 145 patients (22.7 %) had histologically positive lymph nodes. Multivariate analysis showed that lessthan 45 years (p = 0.001), palpable adenopathy (p = 0.0001), multicentricity (p = 0.005) and extracapsular invasión (p = 0.0001) were independent risk factors of lymph node metástasis. These factors, together, had high specificity (97 %) but low sensibility (40 %). Metástasis in jugular lymph nodes with normal central nodes (skip metástasis) was found in 29 (5.54 %) cases. Concusions: even though some of the factors studied proved to be of prognostic valué, additional variables are needed to better define surgical management.(AU)

Acceleration of the Increase of Endogenous Thyrotropin Hormone for Follow up Studies or Radioiodine Treatment in Patients with Differentiated Thyroid Carcinoma / Incremento rápido de tirotrofina endógena en pacientes con carcinoma diferenciado de tiroides para seguimiento o tratamiento con radioyodo

In follow up (F-U), ablation (A), or treatment (T) with radioiodine of patients with differentiated thyroid carcinoma (DTC), it is necessary to obtain elevated figures of serum TSH to assess hTg serum values or carry out 131I scanning. During the past few decades, the method employed was the withdrawal of hormonal treatment (WTH) for several weeks and its variants with the inconvenient symptoms of hypothyroidism, often restraining the use of this method. We aimed to obtain a rapid rice of serum TSH after a very short withdrawal of thyroid hormonal treatment (eight to nine days ) with the use of three or four intravenous application of TRH (200 mcg) during the first 6 days of withdrawal (TRH-St). One hundred determinations were carried out in 66 patients with DTC (ages19-80 y.o ), 20 males and 46 females. Sixty seven TRH-St were carried out for F-U, 20 for FU/T and 13 for A. In all cases the TSH values after the 3rd or 4th TRH application (samples 1 and 2) were over the value of 25 mIU/L and in the case of the second sample 99/100 determination were over the value of 30 mU/L. The values obtained were for the first sample 70.9 mIU/L ± 54.5 (range 25-310) and for the second sample 85.2 ± 61.3 (range 26-360), p<0.001. Patients considered that the symptoms and discomfort observed were mild when compared to those observed in patients submitted previously to the WTH method for 4/5 weeks. The results observed with TRH-St, allow us to consider the method as an alternative to the classic withdrawal method or the use of rhTSH with an adequate relation cost benefit.

Para efectuar ablación (A) , tratamiento con radioyodo (T) o seguimiento (S) en pacientes portadores de carcinoma diferenciado de tiroides (CDT) se hace necesario incrementar los valores de tirotrofina sérica (TSH) para elevar la sensibilidad del centellograma y la especificidad de la determinación de tiroglobulina sérica (hTg). Por años el método clásico fue la suspensión del tratamiento opoterápico (WTH) o sus variantes y ocasionalmente el uso de TSH de origen animal o , raramente, humana. Hace una década, la introducción de la TRH recombinante (rhTSH) significó evitar la desagradable sintomatología del hipotiroidismo que conllevaba el uso del método (WTH) y que en ocasiones impedía su utilización. Nuestro objetivo: el rápido ascenso de la TSH sérica después de muy breve WTH (ocho a nueve días) utilizando tres o cuatro aplicaciones intravenosas de la hormona liberadora de tirotrofina (TRH) durante los primeros seis días de WTH, método que denominamos TRH-St. Se efectuaron cien TRH-St en 66 pacientes: 20 masculinos, 46 femeninos, edades 19-80 años; 61 carcinomas papilares de diversas variantes anatomopatológicas, 4 foliculares y una variantes Hürthle. En todos los estudios después de la 3ra y cuarta aplicación de TRH (muestras 1 y 2 respectivamente) los valores de TSH fueron superiores a 25 mUI/L y con respecto a la cuarta TRH, 99/100 estudios ofrecieron valores de TSH superiores a 30 mUI/L. Los promedios obtenidos fueron: muestra 1 : 70.9 ± 54,5 mUI/L de TSH (rango 25-310); muestra 2: 85.2 ± 61.3 (rango 26-360): p < 0,001. Los pacientes consideraron que la sintomatología adversa del hipotiroidismo y el "disconformismo" fueron leves y sin comparación con los observados por aquellos pacientes sometidos anteriormente al método de supresión hormonal por 4/5 semanas.. Estas observaciones nos llevan a considerar que el método TRH-St , es una alternativa válida del método clásico de suspensión hormonal o del uso de rhTSH con una relación adecuada costo / beneficio.

[Laparoscopic approach in the treatment of malignant adrenal tumours]. / Abordaje laparoscópico en el tratamiento de las tumoraciones adrenales malignas.

BACKGROUND: Malignant primary or secondary adrenal tumours are uncommon. For most of them early surgery with adrenalectomy is the only means of cure. Although controversy exists on this issue, the increasing experience in laparoscopic surgery extends the indication for laparoscopic adrenalectomy to potentially malignant and to metastatic adrenal tumours. Our aim was to evaluate the technical feasibility of laparoscopic adrenalectomy for malignant neoplasias, describing the results of our consecutive series of patients. MATERIAL AND METHODS: We retrospectively analysed 13 patients who underwent laparoscopic adrenalectomy for malignant neoplasia between March 1999 and June 2009, at the Hospital de Clínicas of the Universidad of Buenos Aires and at the Hospital Alemán of Buenos Aires. A transperitoneal laparoscopic approach was used in all patients. The mean follow up was 37.9 months (2-84). RESULTS: Thirteen laparoscopic adrenalectomies were performed due to malignant neoplasia. Mean age was 55.2+12 years. The relationship between male and female was 10/3. Five patients had an adrenal carcinoma, 1 patient a malignant phaeochromocytoma, and 7 patients had metastatic tumours. Three patients required conversion to laparotomy. Average operation time was 146.4 min. There were two perioperative complications and no mortality. Average length of hospital stay was 4.6 days (1-35). The survival at 3 years was 46%. The cause of death was the underlying disease in all cases. CONCLUSION: Laparoscopic adrenalectomy is a reasonable technique for malignant adrenal tumours, when the open oncological resection can be reproduced by the laparoscopic approach.

Sentinel node in melanoma patients: triple negativity with routine techniques and PCR as positive prognostic factor for survival.

Lymph node mapping and sentinel lymph node biopsy are currently used to stage patients with cutaneous malignant melanoma. Immunohistochemical stains contribute to the detection of micrometastases; however, molecular biology techniques are associated with better diagnostic sensitivity. Sixty sentinel lymph nodes were included in this study. The primary lesions were malignant melanoma stage I or II, with a follow-up of longer than 2 years. Sentinel lymph nodes were studied with hematoxylin-eosin, immunohistochemistry for S-100 and HMB-45, and molecular biology techniques (reverse transcription (RT)-PCR) for the detection of tyrosinase messenger RNA. In 15 of 60 cases (25%), tyrosinase was detected by RT-PCR; three of these cases were also positive by immunohistochemistry. The population was divided into three groups: (i) hematoxylin-eosin-/immunohistochemistry+/molecular biology techniques+ (3 cases); (ii) hematoxylin-eosin-/immunohistochemistry-/molecular biology techniques+ (12 cases); (iii) hematoxylin-eosin-/immunohistochemistry-/molecular biology techniques- (45 cases). Correlation of the groups with overall survival showed the following: (i) 2 of 3 patients died (67%); (ii) 5 of 12 died (42%), and (iii) all 45 patients are alive, with no lymphadenectomy and a median follow-up of 84 months. The inclusion of molecular biology techniques appears to be of great value for the detection of sentinel lymph node micrometastases in patients with cutaneous malignant melanoma. In our series, those patients who showed negativity with all the three methods had a null recurrence rate. Therefore, this triple negativity could be a positive prognostic factor for overall survival. Our findings suggest the possibility of molecular oncological staging, which would allow the selection of patients with submicroscopic metastases for a complete treatment.

Restauración de la voz: reconstrucción laringofaríngea con colgajo libre de yeyuno post-laringofaringectomía total / Laringeal function restored: reconstruct laryngopharyngoesophageal tract with a free jejunal graft

Antecedentes: la laringofaringectomía ocasiona una considerable morbilidad, y desafía al cirujano a reconstruir no sólo la continuidad faringoesofágica si no también la laringe. El objetivo es presentar los resultados de la reconstrucción del TADS realizando una neolaringe con injerto libre de yeyuno. Lugar de aplicación: Hospital Público universitario, Hospital Privado de Comunidad. Diseño: Observacional retrospectivo. Material y Métodos: se trataron 15 pacientes con tumores avanzados del TADS, en quienes se reconstruyó el tránsito faringo-esofágico y la laringe con una asa de yeyuno. Se diseca una asa proximal de yeyuno de unos 20 cm de longitud se trasplanta al cuello, revasculariza y anastomosa al esófago, faringe y tráquea. A través de un traqueostoma lateral ocluido el aire se expulsa hacia la boca donde se modula la voz. Resultados: el porcentaje global de éxito del procedimiento fue del 93,4 por ciento. Hubo una necrosis (6,6 por ciento), una fístula (6,6 por ciento) y dos muertes 30 y 60 días de postoperatorio (necrosis de colgajo, falla cardiorespiratoria). Once pacientes deglutieron bien, 1 regular y 1 mal. Seis pacientes lograron una buena calidad de voz, 6 regular y uno malo. La supervivencia media fue de 22,6 meses (rango 4-89). Un paciente vive sin evidencia de enfermedad (89 meses), 10 fallecieron por recurrencia (supervivencia media: 19 meses), 1 falleció por disrrupción del tronco arterial braquiocefálico por decúbito de la cánula de traqueostomía (4 m). Conclusiones: Los resultados demuestran la viabilidad del procedimiento y sus ventajas cuando se lo compara con otras alternativas de la literatura de rehabilitación de la voz