Papillary thyroid microcarcinoma with minimal extrathyroidal extension. Is its course so indolent that it requires a less aggressive treatment?

BACKGROUND: Although the incidence of papillary thyroid microcarcinoma (PTMC) has increased in recent decades, the role played by minimal extrathyroidal extension (mETE) in the prognosis of PTMC is still unclear. The aim of this study is to analyze the factors associated with PTMC with mETE and its long-term prognosis. MATERIAL AND METHODS: We conducted a retrospective study on patients with a histological diagnosis of PTMC. We excluded patients who had previously undergone thyroid surgery, those who had other synchronous malignancies, those with an ectopic location of the PTMC, and those lost to follow-up within two years. We compared group 1 (PTMC without extrathyroidal extension) to group 2 (PTMC with mETE) and performed a multivariate analysis. RESULTS: We observed PTMC with mETE in 11.2% (n = 18) of patients. On the multivariate analysis, mETE was associated with an age ≥45 years (OR: 4.383; 95% CI: 1.051-18.283, p = .043), tumor size ≥8 mm (OR: 5.913; 95% CI: 1.795-19.481; p = .003), bilaterality (OR: 4.430; 95% CI: 1.294-15.173; p = .018) and metastatic lymph nodes (OR: 12.588; 95% CI: 2.919-54.280; p = .001). Over the mean follow-up period of 119.8 ±â€¯65 months, one case of recurrence was detected in group 2 (0% vs. 5.6%; p = .112). No patients died of the disease. Disease-free survival was lower in group 2 (124.9 ±â€¯5.6 vs. 97.4 ±â€¯10.3 months; p = .034). CONCLUSIONS: The mETE of PTMC is a factor of worse prognosis associated with the presence of metastatic lymph nodes and a lower rate of disease-free survival.

Microcarcinoma papilar de tiroides con extensión extratiroidea mínima. ¿Tiene un curso tan indolente para precisar un tratamiento menos intensivo? / Papillary thyroid microcarcinoma with minimal extrathyroidal extension. Is its course so indolent that it requires a less aggressive treatment?

Introducción Aunque el microcarcinoma papilar de tiroides (MCPT) ha sufrido un incremento en la incidencia en las últimas décadas, todavía no está claro qué papel desempeña la extensión extratiroidea mínima (EETm) en su pronóstico. El objetivo de este estudio es analizar los factores asociados al MCPT con EETm y su pronóstico a largo plazo. Material y métodos Estudio retrospectivo cuya población a estudio la constituyen los pacientes con diagnóstico histológico de MCPT. Se excluye a los pacientes con: cirugía tiroidea previa, otras enfermedades malignas sincrónicas, localización ectópica del MCPT o pérdida durante el seguimiento antes de los 2 años. Se comparan 2grupos: grupo 1 (MCPT sin extensión extratiroidea) y grupo 2 (MCPT con EETm). Se realiza un análisis multivariante. Resultados El 11,2% (n = 18) de los pacientes presentaron MCPT con EETm. En el análisis multivariante, la EETm se asoció con la edad ≥ 45 años (OR: 4,383; IC del 95%: 1,051-18,283; p = 0,043), el tamaño tumoral ≥ 8mm (OR: 5,913; IC del 95%; 1,795-19,481; p = 0,003), la bilateralidad (OR: 4,430, IC del 95%; 1,294-15,173; p = 0,018) y las adenopatías metastásicas (OR: 12,588; IC del 95%; 2,919-54,280; p = 0,001). Durante un seguimiento medio de 119,8 ± 65 meses, una recurrencia fue detectada en el grupo 2 (0% vs. 5,6%; p = 0,112). Ningún paciente falleció debido a la enfermedad. La supervivencia libre de enfermedad fue menor en el grupo 2 (124,9 ± 5,6 vs. 97,4 ± 10,3 meses; p = 0,034). Conclusión La EETm del MCPT es un factor de peor pronóstico, asociada a la presencia de adenopatías metastásicas y a una menor supervivencia libre de enfermedad (AU)

Background Although the incidence of papillary thyroid microcarcinoma (PTMC) has increased in recent decades, the role played by minimal extrathyroidal extension (mETE) in the prognosis of PTMC is still unclear. The aim of this study is to analyze the factors associated with PTMC with mETE and its long-term prognosis. Material and methods We conducted a retrospective study on patients with a histological diagnosis of PTMC. We excluded patients who had previously undergone thyroid surgery, those who had other synchronous malignancies, those with an ectopic location of the PTMC, and those lost to follow-up within 2years. We compared group 1 (PTMC without extrathyroidal extension) to group 2 (PTMC with mETE) and performed a multivariate analysis. Results We observed PTMC with mETE in 11.2% (n=18) of patients. On the multivariate analysis, mETE was associated with age ≥45 years (OR: 4.383; 95% CI: 1.051-18.283, p = .043), tumor size ≥8mm (OR: 5.913; 95% CL: 1.795-19.481; p = .003), bilaterality (OR: 4.430; 95% CI: 1.294-15.173; p = .018) and metastatic lymph nodes (OR: 12.588; 95% CI: 2.919-54.280; p = .001). During a mean follow-up of 119.8±65 months, one recurrence was detected in group 2 (0% vs. 5.6%; p = .112). No patients died of the disease. Disease-free survival was lower in group 2 (124.9±5.6 vs. 97.4±10.3 months; p = .034). Conclusions The mETE of PTMC is a factor of worse prognosis associated with the presence of metastatic lymph nodes and a lower rate of disease-free survival (AU)

Surgical oncology in patients aged 80 years and older is associated with increased postoperative morbidity and mortality: A systematic review and meta-analysis of literature over 25 years.

BACKGROUND: The study aim is to analyze the evolution over the last 25 years of the results reported after abdominal oncological surgery in patients aged 80 years of age and older. The primary endpoint was morbidity and mortality in this group of patients; the secondary endpoint was overall survival. METHODS: A systematic search strategy was used to browse through Medline/PubMed, EMBASE, Scopus, ClinicalTrials.gov, Cochrane Database of Systematic Reviews, and Cochrane Central Register of Controlled Trials using a combination of standardized index terms. Studies published between 1997 and 2017 were selected. Only those studies that showed morbidity and mortality after digestive and hepatobiliary tract oncological surgery in individuals aged 80 years and older were included. The PROSPERO registration number is CRD42018087921. PRISMA and MOOSE guidelines were applied. RESULTS: A total of 79 studies were included, categorized by origin of malignancy: esophageal (7), stomach (26), liver (4), pancreas (19), and colorectal (23). Compared with the non-elderly group, the elderly group had similar esophageal morbidity with higher mortality (RR 2.51, 1.50 to 4.21; P = 0.0005); higher gastric morbidity (RR 1.25, 1.09 to 1.43; P = 0.001), and mortality (RR 2.51, 1.81 to 3.49; P = 0.0001); similar liver morbidity and mortality; higher pancreatic morbidity (RR 1.17, 1.03 to 1.33; P = 0.02) and mortality (RR 2.37, 1.86 to 3.03; P < 0.00001); and similar colorectal morbidity with higher mortality (RR 4.44, 1.91 to 10.32; P = 0.005). CONCLUSION: Oncological surgery of most abdominal visceral tumors is associated with increased morbidity and mortality in patients older than 80 years.

Papillary thyroid microcarcinoma with minimal extrathyroidal extension. Has it so indolent course to require a less aggressive treatment? / Microcarcinoma papilar de tiroides con extensión extratiroidea mínima. ¿Tiene un curso tan indolente para precisar un tratamiento menos intensivo?

BACKGROUND: Although the incidence of papillary thyroid microcarcinoma (PTMC) has increased in recent decades, the role played by minimal extrathyroidal extension (mETE) in the prognosis of PTMC is still unclear. The aim of this study is to analyse the factors associated with PTMC and mETE and the long-term prognosis of PTMC. MATERIAL AND METHODS: We conducted a retrospective study with a population consisting of patients with a histological diagnosis of PTMC. We excluded patients who had previously undergone thyroid surgery, those who had other synchronous malignancies, those with an ectopic location of the PTMC and those lost to follow-up within 2years. We compared group 1 (PTMC without extrathyroidal extension) versus group 2 (PTMC with mETE) and performed a multivariate analysis. RESULTS: We observed PTMC with mETE in 11.2% (n=18) of the patients. In the multivariate analysis, mETE was associated with an age ≥45 years (OR, 4.383; 95% CI 1.051-18.283, p=.043), a tumour size ≥8mm (OR, 5.913; 95% CI 1.795-19.481; p=.003), bilaterality (OR, 4.430; 95% CI 1.294-15.173; p=.018) and metastatic lymph nodes (OR, 12.588; 95% CI 2.919-54.280; p=.001). During a mean follow-up of 119.8±65 months, one recurrence was detected in group 2 (0% vs. 5.6%; p=.112), but none of the patients died due to the disease. Disease-free survival was lower in group 2 (124.9±5.6 vs. 97.4±10.3 months; p=.034). CONCLUSIONS: The mETE of MCPT is a factor of worse prognosis, associated with the presence of metastatic lymph nodes and lower disease-free survival.

Usefulness of lymphocyte-to-monocyte, neutrophil-to-monocyte and neutrophil-to-lymphocyte ratios as prognostic markers in breast cancer patients treated with neoadjuvant chemotherapy

Background. Nowadays, neoadjuvant chemotherapy (nCT) in breast cancer is more and more standardized, not only in advanced tumours but also in those for which there is an attempt to achieve breast-conserving surgery. In literature, we can find evidences of the relationship between several types of tumours and systemic inflammatory response. Our objective is to analyse the prognostic value of blood parameters (lymphocytes, neutrophils, monocytes, lymphocyte-to-monocyte ratio (LMR), neutrophil-to-monocyte ratio (NMR) and neutrophil-to-lymphocyte ratio (NLR) in breast cancer (BC) patients treated with nCT. Methods. A retrospective cohort of 150 breast cancer patients treated with nCT and subsequently with surgery was analysed. Data about the patients, histology, response to chemotherapy and peripheral blood values of lymphocytes, monocytes and neutrophils was collected, and used to calculate the LMR, NMR and NLR. Univariate and multivariate analyses were performed for the variables to see the relationship of the ratios to disease-free survival (DFS) and overall survival (OS). Results. Patients with high LMR (≥5.46) and low NLR (<3.33) were associated with a lower percentage of relapse (P = 0.048 and P = 0.015, respectively) and, above all, NLR was associated with a better survival (P = 0.024), being those factors that predict a good progress. Conclusion. High LMR and low NLR can be considered as favourable prognostic factors in BC patients treated with nCT (AU)

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Molecular Adsorbent Recirculating System Treatment Can Reduce Blood Levels of N-Acetylcysteine in Patients With Acetaminophen Overdose: Case Reports.

BACKGROUND: Acetaminophen poisoning continues to be a major cause of liver failure that can lead to liver transplantation. N-acetylcysteine (NAC) is the cornerstone of treatment. Some authors use a Molecular Adsorbent Recirculating System (MARS) system in acetaminophen poisoning. It is reported that the MARS system eliminates acetaminophen more efficiently than conventional dialysis. It is theoretically possible that treatment with MARS administered after NAC will increase the effectiveness of treatment. CASE REPORTS: The first patient, a woman of 14 years old, presented blood levels of 112 mg/dL 12 hours after ingestion of 15 g of acetaminophen. Treatment with NAC was initiated. At 17 and 23 hours after ingestion, blood levels were 23.5 µg/mL and 5.9 µg/mL, respectively. The second patient, a woman of 28 years old, presented blood levels of 115 mg/dL 4 hours after ingestion of 40 g of acetaminophen. Treatment with NAC was initiated. At 14 and 23 hours after ingestion, blood levels were 15.8 µg/mL and <2 µg/mL, respectively. In both patients, we performed MARS after completing treatment with NAC, and after the first session, blood levels were below the lower limit of detection (≤2 µg/mL). DISCUSSION: The correct timing of MARS to avoid interactions with the administered dose of NAC in acetaminophen overdose is essential so as to not impair the effectiveness of this treatment. These considerations in the management of this entity help in the resolution of liver failure, thus avoiding the need for a liver transplant.

Usefulness of lymphocyte-to-monocyte, neutrophil-to-monocyte and neutrophil-to-lymphocyte ratios as prognostic markers in breast cancer patients treated with neoadjuvant chemotherapy.

BACKGROUND: Nowadays, neoadjuvant chemotherapy (nCT) in breast cancer is more and more standardized, not only in advanced tumours but also in those for which there is an attempt to achieve breast-conserving surgery. In literature, we can find evidences of the relationship between several types of tumours and systemic inflammatory response. Our objective is to analyse the prognostic value of blood parameters (lymphocytes, neutrophils, monocytes, lymphocyte-to-monocyte ratio (LMR), neutrophil-to-monocyte ratio (NMR) and neutrophil-to-lymphocyte ratio (NLR) in breast cancer (BC) patients treated with nCT. METHODS: A retrospective cohort of 150 breast cancer patients treated with nCT and subsequently with surgery was analysed. Data about the patients, histology, response to chemotherapy and peripheral blood values of lymphocytes, monocytes and neutrophils was collected, and used to calculate the LMR, NMR and NLR. Univariate and multivariate analyses were performed for the variables to see the relationship of the ratios to disease-free survival (DFS) and overall survival (OS). RESULTS: Patients with high LMR (≥5.46) and low NLR (<3.33) were associated with a lower percentage of relapse (P = 0.048 and P = 0.015, respectively) and, above all, NLR was associated with a better survival (P = 0.024), being those factors that predict a good progress. CONCLUSION: High LMR and low NLR can be considered as favourable prognostic factors in BC patients treated with nCT.

Clinical Significance of Contamination of the Preservation Solution in Liver Transplantation.

INTRODUCTION: The aim of the present study was to describe the incidence and microbiological profiles of positive cultures obtained from preservation solution (PS) and correlate these findings with infectious complications detected in the liver transplant (LT) recipient. PATIENTS: We conducted a single-center, retrospective study between December 2010 and August 2014 among 178 LT. In all grafts, a PS culture was carried out. All the infections in the receipt until hospital discharge were collected. In patients with >1, infection was considered the most severe according to Clavien-Dindo classification. RESULTS: PS culture was positive for bacterial or fungal agents in 79 of 178 LT recipients (44%). The most commonly cultured organisms were coagulase-negative staphylococci (64%), Enterobacteriaceae (17%), and Staphylococcus aureus (4.7%). In the 79 patients with positive PS, 49 blood cultures were requested in the period after LT. Twenty-five postoperative infections (31.7%) were diagnosed. Only 4 of 79 patients (5%) with PS contamination had a postoperative infections related with isolated microorganism. CONCLUSIONS: Contamination of PS appears in a high percentage of liver grafts before LT, although there is a poor correlation with postoperative infections in LT recipient. In these patients, a standardized process including fungal and bacterial cultures could be useful.

Perioperative fast track program in intraoperative hyperthermic intraperitoneal chemotherapy (HIPEC) after cytoreductive surgery in advanced ovarian cancer.

INTRODUCTION: Diffuse peritoneal dissemination in advanced ovarian cancer can be treated using optimal effort surgery involving peritonectomy procedures and the administration of hyperthermic intraoperative intraperitoneal chemotherapy (HIPEC). OBJECTIVE: To report on our experience in the treatment of advanced ovarian cancer using peritonectomy procedures and HIPEC through the fast track program. PATIENTS AND METHOD: From September 2008 until May 2010, forty-six patients with primary advanced (stage III-C) or recurrent ovarian cancer have been included in the fast track protocol if they had optimal cytoreduction CC-0 or CC-1 accompanied by HIPEC and there had no more than one digestive anastomosis. RESULTS: The mean peritoneal cancer index (PCI) was 12.35 (3-21). The median operation time was 380 min (200-540). Optimal surgery CC-0 was achieved in 38 of the 46 patients and CC-1 in the remaining 8. Mean postoperative hospital stay was 6.94 ± 1.56 days (3-11). Major morbidity rates were 15.3%. Paralytic ileus was the most frequent of these. There was no mortality related to the procedure. CONCLUSION: Surgery with peritonectomy procedures and HIPEC in advanced ovarian carcinoma is possible under fast track surgery programs in patients with low volume peritoneal carcinomatosis. Prospective and randomized studies are needed.

Improving the waiting list by using 75-year-old donors for recipients with hepatocellular carcinoma.

The best treatment for hepatocellular carcinoma (HCC) associated with liver cirrhosis is liver transplantation and the best results are obtained when the tumors fulfill the Milan criteria. However, although the number of transplants is increasing, the organ deficit is growing, which lengthens time on the waiting list, increasing the risk of tumor progression of and exclusion from the list. The use of elderly donors is a valid option for patients on the transplant waiting list with HCC, reducing time on the waiting list. We report our experience with patients transplanted for HCC associated with hepatic cirrhosis using livers from donors >75 years of age. Our preliminary results supported the use of elderly suboptimal donors making it possible to give priority to these patients. All patients in the series achieved good graft function after a follow-up of 2 years with a 100% disease-free survival rate. More extensive long-term studies are needed to confirm these findings.

Tolerancia y quimerismo en el trasplante hepático / Tolerance and chimerism in liver transplantation

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Embolización por radiología intervencionista de un angioma yeyunal recidivado / Embolization by interventional radiology of relapsed jejunal haemangioma

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Fallo hepático agudo por el virus de la hepatitis C en el puerperio / Acute liver failure caused by hepatitis C virus in the puerperium

La infección por el virus de la hepatitis C (VHC) es un problema de salud global en nuestros sistemas sanitarios. La prevalencia de pacientes infectados en la población general es de alrededor del 2%. En el subgrupo de pacientes embarazadas el porcentaje de pacientes infectadas oscila entre el 1 y el 3% de los casos. Varios estudios han descrito la relación entre el embarazo y la hepatitis crónica C y la mayoría de las veces se ha observado que los valores séricos de transaminasas se normalizan mientras que los valores de ARN del VHC aumentan durante el segundo y el tercer trimestres de gestación. La influencia de las hormonas maternas después del alumbramiento en la evolución natural de la infección por el VHC no ha sido suficientemente estudiada y permanece por ello en controversia. En esta nota clínica se describe la peculiar evolución de una paciente con hepatitis crónica por el VHC en el puerperio

Hepatitis C virus (HCV) infection is a global problem in our health systems. The prevalence of infected patients in general population is about 2%. In the subgroup of pregnant woman the percentage of infected patients ranges from 1-3%. Several studies have described the relationship between pregnancy and chronic HCV infection, and in most cases serum transaminases levels return to normal values while HCV-RNA levels increase during the second and third trimester. The influence of maternal hormones after delivery in the natural history of HCV infection has not been sufficiently studied and consequently remains controversial. This case report shows the peculiar clinical course of a patient with chronic HCV infection in the puerperium

[Acute liver failure caused by hepatitis C virus in the puerperium]. / Fallo hepático agudo por el virus de la hepatitis C en el puerperio.

Hepatitis C virus (HCV) infection is a global problem in our health systems. The prevalence of infected patients in general population is about 2%. In the subgroup of pregnant woman the percentage of infected patients ranges from 1-3%. Several studies have described the relationship between pregnancy and chronic HCV infection, and in most cases serum transaminases levels return to normal values while HCV-RNA levels increase during the second and third trimester. The influence of maternal hormones after delivery in the natural history of HCV infection has not been sufficiently studied and consequently remains controversial. This case report shows the peculiar clinical course of a patient with chronic HCV infection in the puerperium.

[Portal-splenic-mesenteric venous thrombosis secondary to a mutation of the prothrombin gene]. / Trombosis venosa portoesplenomesaraica secundaria a mutación del gen de la protrombina.

Thrombosis of the portal-mesenteric axis is an infrequent cause of intestinal ischemia or infarction. In addition to the multiple acquired factors that contribute to the development of this entity, hereditary risk factors, especially the factor V Leiden mutation and the G20210A mutation of the prothrombin gene, have been implicated. The G20210A mutation of the prothrombin gene is found in up to 40% of patients with splenic-portal-mesenteric thrombosis. The present case illustrates the unusual and nonspecific presentation of this mutation in the form of diarrhea and images of thrombosis of the superior mesenteric-portal vein and cavernous transformation of the portal vein. Delayed diagnosis is highly frequent since the clinical signs, laboratory investigations and radiological tests do not suggest the diagnosis. The patient received anticoagulant treatment and showed clinical improvement with complete portal-mesenteric recanalization. Currently the diagnostic technique of choice is magnetic resonance angiography or computerized tomography angiography and treatment consists of indefinite anticoagulation. This case illustrates that an unusual or atypical localization of venous thrombosis may be a manifestation of thrombophilia, emphasizing the importance of genetic screening in these cases.

Trombosis venosa portoesplenomesaraica secundaria a mutación del gen de la protrombina / Portal-Splenic-Mesenteric venous thrombosis secondary to a mutation of the prothrombin gene

La trombosis del eje portomesaraico es una causa infrecuente de isquemia o infarto intestinal. Además de múltiples factores adquiridos que contribuyen al desarrollo de este cuadro, recientemente se han implicado factores de riesgo hereditario, especialmente la mutación del factor V de Leiden y la mutación G20210A del gen de la protrombina. La mutación G20210A del gen de la protrombina se encuentra hasta en el 40% de los pacientes con trombosis portoesplenomesaraica. El presente caso ilustra la presentación inusual e inespecífica de dicha mutación, en forma de diarreas e imágenes de trombosis de la vena mesentérica superior y porta y cavernomatosis portal. Es muy frecuente el retraso en el diagnóstico ya que los signos clínicos, analíticos y la radiología no apuntan el diagnóstico. El paciente recibió tratamiento anticoagulante y mejoró clínicamente, con una repermeabilización completa portomesaraica. En la actualidad la técnica diagnóstica de elección es la angiorresonancia magnética o la angiotomografía computarizada, y el tratamiento, la anticoagulación de manera indefinida. Nuestro caso ilustra que una localización inusual o atípica de trombosis venosa puede ser la manifestación de una trombofilia, lo que recalca la importancia del cribado genético en estos casos

Thrombosis of the portal-mesenteric axis is an infrequent cause of intestinal ischemia or infarction. In addition to the multiple acquired factors that contribute to the development of this entity, hereditary risk factors, especially the factor V Leiden mutation and the G20210A mutation of the prothrombin gene, have been implicated. The G20210A mutation of the prothrombin gene is found in up to 40% of patients with splenic-portal-mesenteric thrombosis. The present case illustrates the unusual and nonspecific presentation of this mutation in the form of diarrhea and images of thrombosis of the superior mesenteric-portal vein and cavernous transformation of the portal vein. Delayed diagnosis is highly frequent since the clinical signs, laboratory investigations and radiological tests do not suggest the diagnosis. The patient received anticoagulant treatment and showed clinical improvement with complete portal-mesenteric recanalization. Currently the diagnostic technique of choice is magnetic resonance angiography or computerized tomography angiography and treatment consists of indefinite anticoagulation. This case illustrates that an unusual or atypical localization of venous thrombosis may be a manifestation of thrombophilia, emphasizing the importance of genetic screening in these cases