Riesgo de malignidad de los nódulos tiroideos con atipia de significado incierto / Risk of malignancy in thyroid nodules with atipia of undetermined significance

INTRODUCCIÓN: La atipia de significado incierto o lesión folicular de significado incierto (categoría III del sistema de Bethesda, 2007) tiene una prevalencia de malignidad variable en los distintos estudios (5-37%), y por tal motivo no existe en la actualidad un consenso sobre el manejo adecuado de este resultado: repetir PAAF o cirugía. El objetivo del siguiente trabajo es analizar el riesgo de malignidad en nuestro medio de dichos nódulos para determinar la actitud clínica más adecuada. MATERIAL Y MÉTODOS: Desde la implantación del sistema Bethesda en el Hospital Xeral de Vigo (enero de 2011) hasta septiembre de 2014 se analizaron 431 citologías, de las cuales el 7,1% (32/430) fueron etiquetadas de categoría III. Se revisó el resultado de la segunda citología cuando se repitió la PAAF y el resultado histológico posquirúrgico de los operados. RESULTADOS: En 23 (82,1%) pacientes se indicó la realización de una tiroidectomía y en los 5 restantes (17,9%), la repetición de la PAAF. La citología resultó benigna (categoría ii) en 3 de ellos (60%) e insatisfactoria (categoría i) en 2 (40%). De los 25 pacientes tiroidectomizados, incluidos los 2 operados tras el resultado de la segunda PAAF, las piezas quirúrgicas de 13 (52%) fueron benignas y las de otros 12 (48%) demostraron un carcinoma diferenciado de tiroides: 10 (83,3%) con cáncer papilar de tiroides, uno (8,3%) con cáncer folicular de tiroides y uno (8,3%) con cáncer papilar con áreas de patrón folicular. En nuestros pacientes el riesgo de malignidad de las citologías calificadas como categoría III está entre el 42,9 y el 48% . Conclusión Recomendamos que todos los pacientes con citologías categoría III de Bethesda se sometan a tiroidectomía

INTRODUCTION: Prevalence of malignancy among cytologies with atypia of undetermined significance (Bethesda category iii) is variable, ranging from 5%-37% in the different studies. There is thus no agreement on whether FNA should be repeated or surgery should be performed in these cases. The aim of this paper was to analyze the risk of malignancy in order to establish the most adequate clinical approach. MATERIAL AND METHODS: We analyzed 431 thyroid cytologies performed at our hospital since the introduction of Bethesda System (from January 2011 to September 2014), of which 32 (7.1%) were labeled as category III. The second FNA, when performed, and the histological results after surgery were reviewed. RESULTS: Twenty-three patients (82.1%) underwent thyroidectomy, while repeat FNA was performed in the remaining 5 patients (17.9%). Cytology was reported as benign (category ii) in 3 (60%) and as unsatisfactory (category i) in 2 (40%), who underwent thyroidectomy. Thirteen of the 25 (52%) surgical thyroid specimens showed no malignancy, while differentiated thyroid carcinomas were found in 12 (48%): papillary cancer in 10 (83.3%), follicular cancer in 1 (8.3%), and papillary cancer with follicular areas in 1 (8.3%). The risk of malignancy of Bethesda category III in our patients was 42.9%-48.0%. CONCLUSION: We recommend thyroidectomy for all patients with of cytological Bethesda category iii

Risk of malignancy in thyroid nodules with atipia of undetermined significance.

INTRODUCTION: Prevalence of malignancy among cytologies with atypia of undetermined significance (Bethesda category III) is variable, ranging from 5%-37% in the different studies. There is thus no agreement on whether FNA should be repeated or surgery should be performed in these cases. The aim of this paper was to analyze the risk of malignancy in order to establish the most adequate clinical approach. MATERIAL AND METHODS: We analyzed 431 thyroid cytologies performed at our hospital since the introduction of Bethesda System (from January 2011 to September 2014), of which 32 (7.1%) were labeled as category III. The second FNA, when performed, and the histological results after surgery were reviewed. RESULTS: Twenty-three patients (82.1%) underwent thyroidectomy, while repeat FNA was performed in the remaining 5 patients (17.9%). Cytology was reported as benign (category II) in 3 (60%) and as unsatisfactory (category I) in 2 (40%), who underwent thyroidectomy. Thirteen of the 25 (52%) surgical thyroid specimens showed no malignancy, while differentiated thyroid carcinomas were found in 12 (48%): papillary cancer in 10 (83.3%), follicular cancer in 1 (8.3%), and papillary cancer with follicular areas in 1 (8.3%). The risk of malignancy of Bethesda category III in our patients was 42.9%-48.0%. CONCLUSION: We recommend thyroidectomy for all patients with of cytological Bethesda category III.

Prevalencia y coste de glucemias venosas posiblemente innecesarias en atención primaria / Prevalence and cost of possibly unnecessary venous blood glucose measurements in primary care

La Asociación Americana de Diabetes publica anualmente sus recomendaciones para el cribado de diabetes mellitus. Aunque en la población general hay un porcentaje notable de diabéticos no diagnosticados, en nuestro medio la realización de análisis de cribado de diabetes es frecuente, y sospechamos que muchos de esos análisis podrían ser prescindibles. En una muestra de 105 personas atendidas en atención primaria hemos analizado el número de glucemias venosas realizadas sin ninguna de las indicaciones establecidas por la Asociación Americana de Diabetes. Por término medio se pide una glucemia venosa que se puede calificar como prescindible cada 15 meses. Su número es significativamente superior en personas mayores de 45 años y también superior (aunque con una probabilidad de error ligeramente mayor de 0,05) en las mujeres que en los varones (AU)

The American Diabetes Association issues annually its recommendations for diabetes mellitus screening. Although there is a high proportion of people with undiagnosed diabetes in the general population, it is suspected that many of these screening tests could be needless. An analysis was made of the number of venous blood glucose measurements that did not meet the American Diabetes Association requirements performed in 150 people seen in primary care. On average, an unnecessary venous blood glucose measurement is performed every 15 months. The number is significantly higher in people over 45 years of age, and also in women as compared to men (although with a p value slighty higher than 0.05) (AU)

[Impact of the application of the American Thyroid Association criteria on the diagnosis of hypothyroidism in pregnant women in Vigo, Spain]. / Impacto de la aplicación de los criterios de la asociación americana de tiroides en el diagnóstico de hipotiroidismo en gestantes de Vigo, España.

In order to determine the impact of the application of the American Thyrold Associations (ATA) criteria for the diagnosis of hypothyroidism in pregnant women in the health district of Vigo, Spain, concentrations of serum thyrotropin (TSH), free thyroxine (T4L) and anti-thyroid antibodies were analyzed, comparing the frequency of pregnant women diagnosed with hypothyroidism and applying the criteria used in the hormone laboratory at Xeral Hospital and referential criteria established by ATA. The application of ATA referential criteria increased by 29.6% the number of female patients diagnosed with hypothyroidism. The application of ATA guidelines had an impact on the measurement of TSH concentrations in pregnant women, which calls for an evaluation of referential values of TSH based on the population and the local diagnostic methods.

Impacto de la aplicación de los criterios de la Asociación Americana de Tiroides en el diagnóstico de hipotiroidismo en gestantes de Vigo, España / Impact of the application of the American Thyroid Association criteria on the diagnosis of hypothyroidism in pregnant women in Vigo, Spain

Con el objetivo de determinar el impacto de la aplicación de los criterios de la Asociación Americana de Tiroides (ATA) en el diagnóstico de hipotiroidismo en gestantes del área sanitaria de Vigo en España, se analizó la concentración sérica de tirotropina (TSH), tiroxina libre (T4L) y anticuerpos antitiroideos, comparando la frecuencia de gestantes diagnosticadas de hipotiroidismo aplicando los criterios utilizados en el laboratorio de hormonas del Hospital Xeral y los criterios de referencia propuestos por la ATA. La asunción de dichos criterios implicaría un aumento de un 29,6% de pacientes diagnosticadas de hipotiroidismo. La aplicación de los criterios ATA tuvo una repercusión en la medición de la concentración de TSH en gestantes lo que sugiere una evaluación de los valores de referencia de TSH en función de la población y los métodos de diagnóstico locales.

In order to determine the impact of the application of the American Thyrold Associations (ATA) criteria for the diagnosis of hypothyroidism in pregnant women in the health district of Vigo, Spain, concentrations of serum thyrotropin (TSH), free thyroxine (T4L) and anti-thyroid antibodies were analyzed, comparing the frequency of pregnant women diagnosed with hypothyroidism and applying the criteria used in the hormone laboratory at Xeral Hospital and referential criteria established by ATA. The application of ATA referential criteria increased by 29.6% the number of female patients diagnosed with hypothyroidism. The application of ATA guidelines had an impact on the measurement of TSH concentrations in pregnant women, which calls for an evaluation of referential values of TSH based on the population and the local diagnostic methods.

Prevalence and cost of possibly unnecessary venous blood glucose measurements in primary care.

The American Diabetes Association issues annually its recommendations for diabetes mellitus screening. Although there is a high proportion of people with undiagnosed diabetes in the general population, it is suspected that many of these screening tests could be needless. An analysis was made of the number of venous blood glucose measurements that did not meet the American Diabetes Association requirements performed in 150 people seen in primary care. On average, an unnecessary venous blood glucose measurement is performed every 15 months. The number is significantly higher in people over 45 years of age, and also in women as compared to men (although with a p value slighty higher than 0.05).

El lavado de la aguja aumenta la rentabilidad diagnóstica de la punción-aspiración con aguja fina de tiroides / Needle washing increases the diagnostic yield of fine needle aspiration biopsy of the thyroid gland

Introducción y objetivo La enfermedad nodular tiroidea es un proceso frecuente en nuestra práctica clínica y la punción-aspiración con aguja fina (PAAF) es la técnica diagnóstica de elección. Su mayor limitación es la prevalencia de muestras no diagnósticas. Desde la implantación en 2007 de los criterios de Bethesda (documento de consenso sobre los criterios morfológicos y la terminología diagnóstica en la interpretación de las extensiones citológicas de tiroides) se demostró en nuestro servicio una mayor prevalencia de PAAF no diagnósticas. Decidimos añadir a la técnica habitual la recogida y el centrifugado del material remanente en las agujas de punción mediante lavado en una solución ThinPrep® y evaluar el aumento de la rentabilidad diagnóstica de la PAAF tras este cambio. Pacientes y métodos Muestreo sistemático de 168 pacientes a los que se realizó una PAAF en el Servicio de Endocrinología y Nutrición del Hospital Xeral-Cíes de Vigo desde enero de 2010 hasta noviembre (..) (AU)

Background and objective Nodular thyroid disease is a common condition in our clinical practice, and fine needle aspiration biopsy (FNAB) is the diagnostic procedure of choice. Its main limitation is the number of non-diagnostic samples. Since the Bethesda criteria were implemented in 2007 (a consensus document on the morphologic criteria and diagnostic terminology for interpretation of thyroid cytological samples), a higher prevalence of non-diagnostic FNAB was shown. In addition to the standard technique, we decided to collect and centrifuge the material remaining in puncture needles by washing them in a ThinPrep® solution, and to assess the increase in the diagnostic yield of FNAB after this change. Patients and methods Systematic sampling of 168 patients who underwent FNAB at the Nutrition and Endocrinology Department of the Xeral-Cies Hospital (Vigo, Spain) from January 2010 to November 2011. Patients were classified into 2 groups: 75 patients in whom the residual material in the needle was not collected (non-washing group) and 93 patients in whom the material was collected (washing-group). All FNABs were performed by the same endocrinologist. Data are shown as percentage (± standard error) for ordinal variables or as mean (± standard deviation) for quantitative variables. A Chi-square test was used for statistical analysis (..) (AU)

Needle washing increases the diagnostic yield of fine needle aspiration biopsy of the thyroid gland.

BACKGROUND AND OBJECTIVE: Nodular thyroid disease is a common condition in our clinical practice, and fine needle aspiration biopsy (FNAB) is the diagnostic procedure of choice. Its main limitation is the number of non-diagnostic samples. Since the Bethesda criteria were implemented in 2007 (a consensus document on the morphologic criteria and diagnostic terminology for interpretation of thyroid cytological samples), a higher prevalence of non-diagnostic FNAB was shown. In addition to the standard technique, we decided to collect and centrifuge the material remaining in puncture needles by washing them in a ThinPrep(®) solution, and to assess the increase in the diagnostic yield of FNAB after this change. PATIENTS AND METHODS: Systematic sampling of 168 patients who underwent FNAB at the Nutrition and Endocrinology Department of the Xeral-Cies Hospital (Vigo, Spain) from January 2010 to November 2011. Patients were classified into 2 groups: 75 patients in whom the residual material in the needle was not collected (non-washing group) and 93 patients in whom the material was collected (washing-group). All FNABs were performed by the same endocrinologist. Data are shown as percentage (± standard error) for ordinal variables or as mean (± standard deviation) for quantitative variables. A Chi-square test was used for statistical analysis of comparisons between percentages, and a Student's t test for comparisons between quantitative variables. A value of p<0.05 was considered statistically significant. RESULTS: No significant differences were found between the groups in age, sex, plasma TSH levels or nodule size. The rate of non-diagnostic FNABs was 44% (± 0.06) in the non-washing group and 17.2% (± 0.04%) in the washing group, with a significant difference (p < 0.01). DISCUSSION: Collection and subsequent processing of the residual material in the needle after FNAB significantly decreased the prevalence of non-diagnostic punctures in our patients. Collection of the residual material in the needle in this way is strongly recommended.

Tratamiento con dosis fija de tiroxina en gestantes con hipotiroidismo subclínico / Treatment with fixed thyroxine doses in pregnant women with subclinical hypothyroidism

Introducción El tratamiento del hipotiroidismo se hace habitualmente calculando la dosis de tiroxina en función del peso del paciente. En algunas situaciones se ha comprobado la utilidad de administrar dosis fijas de la hormona para normalizar la concentración de TSH, cuyo control es especialmente importante en el caso de pacientes gestantes. Pacientes y métodos Se administró una dosis fija de 50 mcg/día de tiroxina a 68 mujeres con hipotiroidismo subclínico diagnosticado durante la gestación, autoinmune o no, y se evaluó trimestralmente a través de la concentración de TSH la necesidad de modificarla. Se programaron incrementos o decrementos de 25 mcg/día en los casos en los que el cambio de dosis fuese necesario. Resultados El 42% de las pacientes alcanzaron una concentración plasmática de TSH inferior a 3μU/mL con la dosis de 50 mcg/día de tiroxina. Si se toman como referencia los valores de la población general no gestante, dicha dosis fue óptima durante el embarazo en el 79,4% de las pacientes; y no lo fue en el 20,6% restante. Discusión Nuestros datos sugieren que una dosis fija de 50 mcg/día de tiroxina es insuficiente en un porcentaje elevado de pacientes con hipotiroidismo diagnosticado en la gestación, tanto si se toman como valores de referencia de concentración de TSH los de la población general como (especialmente) si se usan las recomendaciones más recientes. Dosis de 75 mcg/día serán probablemente más adecuadas, aunque se necesitan estudios que evalúen la posibilidad de sobretratamiento con dichas dosis (AU)

Background Hypothyroidism is usually treated with thyroxine doses on patient weight. In some cases, however, fixed doses have proved to useful to normalize TSH levels, which is especially important during pregnancy. Patients and methods Sixty-eight women diagnosed with subclinical hypothyroidism, autoimmune or not, during pregnancy were given a fixed dose of thyroxine 50mcg/day. TSH measurements were performed to assess the need to change the dose, which was increased or decreased by 25mcg/day when necessary. Results With a dose of 50mcg/day of thyroxine, 42% of patients reached a TSH level less than 3μU/mL, 79.4% reached a TSH level less than 4.5μU/mL, and 20.6% had TSH levels higher than 4.5μU/mL.Discussion Our data suggest that a fixed dose of thyroxine 50mcg/day is inadequate in a significant proportion of pregnancy-diagnosed hypothyroidism regardless of whether the reference of TSH level used is 4.5 or 3μU/mL. Starting dose of 75mcg/day is probably more adequate, but studies are needed to evaluate the possibility of overtreatment with such dose (AU)

Treatment with fixed thyroxine doses in pregnant women with subclinical hypothyroidism.

BACKGROUND: Hypothyroidism is usually treated with thyroxine doses on patient weight. In some cases, however, fixed doses have proved to useful to normalize TSH levels, which is especially important during pregnancy. PATIENTS AND METHODS: Sixty-eight women diagnosed with subclinical hypothyroidism, autoimmune or not, during pregnancy were given a fixed dose of thyroxine 50 mcg/day. TSH measurements were performed to assess the need to change the dose, which was increased or decreased by 25 mcg/day when necessary. RESULTS: With a dose of 50 mcg/day of thyroxine, 42% of patients reached a TSH level less than 3 µU/mL, 79.4% reached a TSH level less than 4.5 µU/mL, and 20.6% had TSH levels higher than 4.5 µU/mL. DISCUSSION: Our data suggest that a fixed dose of thyroxine 50 mcg/day is inadequate in a significant proportion of pregnancy-diagnosed hypothyroidism regardless of whether the reference of TSH level used is 4.5 or 3 µU/mL. S starting dose of 75 mcg/day is probably more adequate, but studies are needed to evaluate the possibility of overtreatment with such dose.