Dynamics of PTH levels in the development of post-operative hypoparathyroidism.

BACKGROUND: Post-operative hypoparathyroidism is the most frequent complication after total thyroidectomy. The identification of preoperative predictors could be helpful to identify patients at risk. This study aimed to evaluate the potential influence of preoperative PTH levels and their perioperative dynamics as a predictor of transient, protracted, and permanent post-operative hypoparathyroidism. METHODS: A prospective, observational study that includes 100 patients who underwent total thyroidectomy between September 2018 and September 2020. RESULTS: Transient hypoparathyroidism was present in 42% (42/100) of patients, 11% (11/100) developed protracted hypoparathyroidism, and 5% (5/100) permanent hypoparathyroidism. Patients who presented protracted hypoparathyroidism had higher preoperative PTH levels. The protracted and permanent hypoparathyroidism rate was higher in groups with greater preoperative PTH [0% group 1 (<40 pg/mL) vs. 5.7% group 2 (40-70 pg/mL) vs. 21.6% group 3 (>70 pg/mL); p = 0.03] and (0 vs. 8.3 vs. 20%; p = 0.442), respectively. The rate of protracted and permanent hypoparathyroidism was higher in patients with PTH at 24 h lower than 6.6 pg/mL and whose percentage of PTH decline was higher than 90%. The rate of transient hypoparathyroidism was higher in patients who showed a PTH decline rate of more than 60%. The percentage of PTH increase one week after surgery in patients with permanent hypoparathyroidism was significantly lower. CONCLUSION: The prevalence of protracted hypoparathyroidism was higher in groups with higher preoperative PTH levels. PTH levels 24 h after surgery lower than 6.6 pg/mL and a decline of more than 90% predict protracted and permanent hypoparathyroidism. The percentage of PTH increase a week after surgery could predict permanent hypoparathyroidism.

Patients who presented protracted and permanent hypoparathyroidism had higher preoperative PTH levels.Patients in groups with higher preoperative PTH levels showed higher rates of protracted and permanent hypoparathyroidism.The percentage of PTH variance one week after surgery in patients with permanent hypoparathyroidism was significantly lower and could predict permanent hypoparathyroidism.

TC-4D como prueba de localización preoperatoria de segunda línea en la evaluación del hiperparatiroidismo primario / 4D-CT as a second line preoperative localization test for the evaluation of primary hyperparathyroidism

Introducción: La tomografía computarizada en cuatro dimensiones (TC-4D) ofrece buena sensibilidad para localizar la glándula patológica responsable del hiperparatiroidismo primario. El objetivo fue evaluar su rendimiento como estudio de segunda línea tras ausencia de localización o resultado no concordante de los estudios habituales. Material y métodos: Estudio observacional retrospectivo que incluyó todos los pacientes intervenidos por hiperparatiroidismo primario con TC-4D como estudio preoperatorio, del 1 de octubre de 2016 al 1 de octubre de 2021, en un centro hospitalario de tercer nivel. Se compararon los resultados de la TC-4D, la ecografía y las exploraciones de medicina nuclear (gammagrafía, SPECT y SPECT-TC) con el gold standard de la exploración quirúrgica y el resultado anatomopatológico, analizando los porcentajes de lateralización correcta y localización aproximada de la glándula patológica. Resultados: El análisis incluyó 64 pacientes, con una curación del 93,8% (60/64). La TC-4D mostró una lateralización correcta del 57,8% (37/64) y reveló la localización aproximada de la glándula en el 48,4% (31/64). La ecografía tuvo unos porcentajes del 31,1% (19/61) y del 18% (11/61) para la lateralización correcta y la localización aproximada, respectivamente, vs. un 34,9% (22/63) y un 28,6% (18/63) de los estudios de medicina nuclear y un 32,7% (16/49) y un 24,5% (12/49) de la SPECT-TC. Estas diferencias fueron estadísticamente significativas. Conclusiones: La TC-4D ofrece un rendimiento aceptable para localizar las lesiones responsables del hiperparatiroidismo primario, por lo que debería considerarse su uso ante la ausencia de localización en los estudios habituales. (AU)

Introduction: Four-dimensional computerized tomography (4D-CT) offers a good sensitivity for the localization of the pathological gland responsible of primary hyperparathyroidism. The aim was to evaluate its results as a second line preoperative localization test after inconclusive or discordant results of usual preoperative studies. Material and methods: Observational retrospective study that included all patients intervened for primary hyperparathyroidism with 4D-CT scan as preoperative study, from 1st October 2016 to 1st October 2021, in a tertiary referral centre. The results of 4D-CT, cervical ultrasound, and nuclear medicine explorations (scintigraphy, SPECT and SPECT-CT) were compared with the gold standard of the surgical exploration and the pathological result. The correct lateralization and the approximate localization rates of the pathological gland were evaluated. Results: A total of 64 patients were analysed, with a 93,8% (60/64) remission rate. 4D-CT showed a correct lateralization in 57,8% (37/64) of the cases and revealed the approximate localization of the gland in 48,4% (31/64) of the cases. The cervical ultrasound had a rate of 31,1% (19/61) and 18% (11/61) for the correct lateralization and approximate localization, respectively, compared to 34,9% (22/63) and 28,6% (18/63) in nuclear medicine explorations, and 32,7% (16/49) and 24,5% (12/49) in SPECT-CT. These differences were statistically significant. Conclusion: 4D-CT demonstrated acceptable results for the localization of the lesions responsible of primary hyperparathyroidism, thus its use should be considered with the absence of localization in routinely studies. (AU)

Large goiters and postoperative complications: does it really matter?

INTRODUCTION: Thyroidectomy is one of the most commonly performed surgical procedures worldwide. Although the mortality rate is currently approaching 0%, the incidence of complications in such a frequent surgery is not insignificant. The most frequent are postoperative hypoparathyroidism, recurrent injury, and asphyxial hematoma. The size of the thyroid gland has traditionally been considered one of the most important risk factors, but there is currently no study that analyzes it independently. The objective of this study is to analyze whether the size of the thyroid gland is an isolated risk factor for the development of postoperative complications. PATIENTS AND METHOD: A prospective review of all patients who underwent total thyroidectomy at a third-level hospital between January 2019 and December 2021 was conducted. The thyroid volume was calculated preoperatively using ultrasound and, together with the weight of the definitive piece, was correlated with the development of postoperative complications. RESULTS: One hundred twenty-one patients were included. When analyzing the incidence of complications based on the quartiles of weight and glandular volume, there were no significant differences in the incidence of transient or permanent hypoparathyroidism in any of the groups. No differences were found in terms of recurrent paralysis. No fewer parathyroid glands were visualized intraoperatively in patients with larger thyroid glands, nor did the number of them accidentally removed during surgery increase. In fact, a certain protective trend was observed with regard to the number of glands visualized and glandular size or in the relationship between thyroid volume and accidental gland removal, with no significant differences. CONCLUSION: The size of the thyroid gland has not been shown to be a risk factor for the development of postoperative complications, contrary to what has traditionally been considered.

4D-CT as a second line preoperative localization test for the evaluation of primary hyperparathyroidism.

INTRODUCTION: Four-dimensional computerized tomography (4D-CT) offers a good sensitivity for the localization of the pathological gland responsible of primary hyperparathyroidism. The aim was to evaluate its results as a second line preoperative localization test after inconclusive or discordant results of usual preoperative studies. MATERIAL AND METHODS: Observational retrospective study that included all patients intervened for primary hyperparathyroidism with 4D-CT scan as preoperative study, from 1st October 2016 to 1st October 2021, in a tertiary referral centre. The results of 4D-CT, cervical ultrasound, and Nuclear Medicine explorations (scintigraphy, SPECT and SPECT-CT) were compared with the gold standard of the surgical exploration and the pathological result. The correct lateralization and the approximate localization rates of the pathological gland were evaluated. RESULTS: A total of 64 patients were analysed, with a 93,8% (60/64) remission rate. 4DCT showed a correct lateralization in 57,8% (37/64) of the cases and revealed the approximate localization of the gland in 48,4% (31/64) of the cases. The cervical ultrasound had a rate of 31,1% (19/61) and 18% (11/61) for the correct lateralization and approximate localization, respectively, compared to 34,9% (22/63) and 28,6% (18/63) in Nuclear Medicine explorations, and 32,7% (16/49) and 24,5% (12/49) in SPECT-CT. These differences were statistically significant. CONCLUSION: 4D-CT demonstrated acceptable results for the localization of the lesions responsible of primary hyperparathyroidism, thus its use should be considered with the absence of localization in routinely studies.

What happens to the bone structure after normocalcemic primary hyperparathyroidism surgery?

BACKGROUND: Bone disease in primary hyperparathyroidism is a clear indication for surgical treatment. However, it is not known whether surgery benefits hypercalcemic primary hyperparathyroidism and normocalcemic primary hyperparathyroidism equally. The aim of our study was to evaluate the bone changes in patients undergoing parathyroidectomy based on the biochemical profile 1 and 2 years after surgery. METHODS: This prospective study included 87 consecutive patients diagnosed with primary hyperparathyroidism who underwent surgery between 2016 and 2018. Bone densitometry (1/3 distal radius, lumbar, and femur) and bone remodeling markers (osteocalcin, type 1 procollagen [P1NP], ß-cross-linked telopeptide of type I collagen [BCTX]) were performed preoperatively and postoperatively. Postoperative changes in bone mineral density and bone markers were compared and evaluated according to the clinical characteristics and the individual biochemical profile. RESULTS: One year after surgery, all patients showed an increase in bone mineral density at the lumbar site (mean, 0.029 g/cm2; range, 0.017-0.04; P < .001) and femur neck (mean, 0.025 g/cm2; range, 0.002-0.05; P < .001); however, there were no changes in the distal third of the radius (mean, -0.003 g/cm2; range, -0.008 to 0.002; P = NS). There were no significant differences when comparing normocalcemic primary hyperparathyroidism and hypercalcemic primary hyperparathyroidism. Serum osteocalcin (37 ± 17.41), P1NP (67.53 ± 31.81) and BCTX (0.64 ± 0.37) levels were elevated before surgery. One year after the surgery, we observed a significant decrease in P1NP (33.05 ± 13.16, P = .001), osteocalcin (15.80 ± 6.19, P = .001), and BCTX (0.26 ± 0.32, P < .001) levels. CONCLUSION: Our findings indicate that parathyroidectomy has similar benefits for normocalcemic primary hyperparathyroidism and hypercalcemic primary hyperparathyroidism in terms of bone improvement. Although the most substantial improvement occurred during the first postoperative year in both groups, we consider that studies with longer follow-up are warranted.

Effect of preoperative potassium iodide administration on Graves' disease surgery: a propensity score analysis.

BACKGROUND: Preoperative administration of a saturated solution of potassium iodide (SSKI) is recommended in the guidelines for the management of hyperthyroidism due to Graves' disease. Studies addressing its effect on complications after thyroidectomy are inconclusive. METHODS: Retrospective multicenter Propensity Score study of patients undergoing total thyroidectomy for Graves' disease, from January 2013 to September 2019 in two tertiary centers in Madrid, Spain. Patients were given SSKI prior to surgery or not according to surgeons' preferences. Electronic clinical records were reviewed searching: baseline characteristics surgical variables, pathological findings, and postoperative complications. RESULTS: Ninety patients were analyzed: 44 received SSKI and 46 were not given SSKI. No significant differences were found in the main postoperative complications with or without SSKI: transient hypoparathyroidism (40.9% vs. 50%), permanent hypoparathyroidism (6.8% vs. 13%), transient recurrent laryngeal nerve (RLN) palsy (2.3% vs. 8.7%), definitive RLN palsy (2.3% vs. 2.2%), or cervical hematoma (2.3% vs. 4.3%). CONCLUSION: Preoperative administration of SSKI had no impact on postoperative complications after thyroidectomy for Graves' disease.

Comparative prospective study on the presentation of normocalcemic primary hyperparathyroidism. Is it more aggressive than the hypercalcemic form?

BACKGROUND: Some patients with primary hyperparathyroidism (PHPT) have an elevated PTH that does not always correlate with high blood calcium levels. We aimed to compare the clinical presentation between normocalcaemic and hypercalcaemic forms using ionized calcium levels as an inclusion criterion. METHODS: We included all patients referred for surgery for PHPT between January 2015 and December 2017. Patients were divided into 2 groups (hypercalcaemic (hPHTP)/normocalcaemic (nPHPT)). RESULTS: 104 patients were included.64% of the patients who were initially classified as normocalcaemic had high ionized calcium levels. There were no differences between groups except in terms of bone resorption parameters:patients with hypercalcaemia had higher osteocalcin (37.4vs23.5 ng/mL,P = .02), collagen amino-terminal propeptide (73.5vs49.2 ng/mL,P = .005), and beta-CTX levels (0.68vs0.38 ng/mL,P = .001). Bone involvement as measured by densitometry was similar. CONCLUSSIONS: When these patients' diagnosis and classification is accurate, their clinical presentation and symptoms are similar to those of the classical form. Since the only difference is in terms of bone resorption parameters, in most cases it seems to be an attenuated form or even similar to the classical presentation. The improvement in diagnostic sensitivity supports the use of ionized calcium levels in patients suspected to have nPHPT.

Development of Thyroid Carcinoma During Treatment With Pembrolizumab in a Lung Cancer Patient.

Pembrolizumab, a programmed death 1 inhibitor, has been shown to have clinically significant efficacy in different types of cancer, providing long-term survival benefit for patients with lung cancer. Herein, we report the development of a primary thyroid cancer in a lung cancer patient that was being treated with pembrolizumab. Primary thyroid malignancy (and not only metastatic disease or immunotherapy-induced thyroiditis) should be considered in patients with lung cancer being treated with immune checkpoint inhibitors who develop new incidental thyroid lesions on imaging studies.

Ascitis quilosa tras colecistectomía: presentación de un caso / Chylous ascites after cholecystectomy: case report and literatura review

INTRODUCCIÓN: La ascitis quilosa es la presencia de líquido linfático en la cavidad peritoneal. Como consecuencia de una cirugía abdominal es muy infrecuente, encontrando 5 casos previos en la literatura revisada tras colecistectomía. OBJETIVO: Presentar un caso clínico de ascitis quilosa poscolecistectomía, su manejo y una revisión de la literatura. MATERIALES Y MÉTODOS: Varón de 77 años, quiloperitoneo 21 días después de realización de colecistectomía programada por colecistitis aguda. Resultados: Se realiza drenaje percutáneo con débito de 5 L en 24 horas, se inicia octreótido subcutáneo y nutrición parenteral total. Al tercer día disminuye el débito por el drenaje, por lo que se inicia dieta rica en triglicéridos de cadena media con buena evolución posterior. De los 5 casos previos tras colecistectomía, el 60% se resolvió con tratamiento conservador, un paciente precisó reintervención y otro colocación de un shunt portosistémico intrahepático trasnyugular (TIPSS). CONCLUSIÓN: La ascitis quilosa es una complicación postquirúrgica infrecuente, encontrando solo 5 casos previos tras colecistectomía. Inicialmente el manejo debe ser conservador, en caso de persistencia se deben valorar otras medidas.

INTRODUCTION: Chylous ascites is defined as the presence of lymph fluid in the peritoneal cavity. It is a rare complication after abdominal surgery; only 5 previously reported cases were found after cholecystectomy. Aim: Present a case report and a literature review. MATERIALS AND METHOD: Case report of a 77 year old male who underwent an elective cholecystectomy due to acute cholecystitis. Chyloperitoneum showed up 21 days after surgery. RESULTS: We performed a percutaneous drainage and 5 L of fluid were removed in 24 hours. We started treatment with subcutaneous Octreotide and total parenteral nutrition. After 3 days drain output decreased and we started a medium-chain triglycerides diet with good progress. The outcome of 60% of the 5 previous case reports of chyloperitoneum after cholecystitis, were successful with conservative management, surgical intervention was needed in one patient and a transjugular intrahepatic portosystemic shunt (TIPSS) was placed in another patient. CONCLUSION: Chylous ascites is a rare complication after surgery, there are only 5 previously case reports after cholecystectomy. Conservative management has to be the first option and in case of persistence another therapy has to be considered.

Utilidad del estudio molecular de nódulos tiroideos con citología indeterminada / Current use of molecular profiling for indeterminate thyroid nodules

El análisis citológico tiene un papel fundamental en el estudio de los nódulos tiroideos. Sin embargo, hasta un 30% de estos muestran citologías indeterminadas (Bethesda III o IV). En estos casos, se realizan cirugías diagnósticas que únicamente demuestran malignidad en un 15-35% de los pacientes. Se precisa una herramienta de mayor precisión para determinar la benignidad o malignidad del nódulo tiroideo con citología indeterminada sin precisar cirugías diagnósticas, evitando así posibles complicaciones y/o costes innecesarios. El uso complementario de paneles moleculares junto con la citología ha sido, de momento, la única herramienta que parece ayudar en este difícil escenario. Se realiza una revisión de la bibliografía sobre el estudio molecular complementario de los nódulos tiroideos para tratar de resumir las características intrínsecas de cada uno de los test disponibles, su coste-efectividad, y determinar sus indicaciones y su aplicabilidad en la práctica clínica habitual

Even though cytology remains the gold standard to assess the nature of thyroid nodules, up to 30% of the results are indeterminate (Bethesda III and IV). In these cases, current guidelines recommend performing diagnostic surgery, which proves malignancy in only 15-30% of cases. A more precise method is needed to avoid unnecessary surgeries, surgical complications and costs in the process of diagnosing indeterminate nodules. Complementary use of molecular profiling tests seems to help in this complex scenario. We present a review of the current literature on the usefulness of molecular profiling of thyroid nodules so as to define its indications, costs and usability for clinical practice

Necrosis mamaria en paciente con linfoma no Hodgkin primario de células T / Breast necrosis in a patient with primary T-cell non-Hodgkin lymphoma

No disponible

Current use of molecular profiling for indeterminate thyroid nodules. / Utilidad del estudio molecular de nódulos tiroideos con citología indeterminada.

Even though cytology remains the gold standard to assess the nature of thyroid nodules, up to 30% of the results are indeterminate (BethesdaIII and IV). In these cases, current guidelines recommend performing diagnostic surgery, which proves malignancy in only 15-30% of cases. A more precise method is needed to avoid unnecessary surgeries, surgical complications and costs in the process of diagnosing indeterminate nodules. Complementary use of molecular profiling tests seems to help in this complex scenario. We present a review of the current literature on the usefulness of molecular profiling of thyroid nodules so as to define its indications, costs and usability for clinical practice.

Hidroadenocarcinoma de células claras de localización mamaria / Hydroadenocarcinoma of clear cells located in the breast

No disponible

Normocalcaemic primary hyperparathyroidism: a diagnostic and therapeutic algorithm.

In recent years, there has been increasing interest in understanding the implications of diagnosing normocalcaemic primary hyperparathyroidism (nPHPT). Many patients hope that nPHPT might explain some of their symptoms, but surgeons hesitate to offer treatment to patients whose calcium levels are normal but whose parathyroid hormone (PTH) levels are elevated in the absence of secondary causes of hyperparathyroidism. This potential new diagnosis is not well understood and may lead to inappropriate investigation and possible unnecessary operations. However, because a significant number of patients with nPHPT progress to hypercalcaemic primary hyperparathyroidism (PHPT), some consider nPHPT to be an early or mild form of hypercalcaemia. Rather than being an indolent disease, nPHPT was reported to be associated with systemic complications similar to 'classical' PHPT, and hence there is growing interest to understand who should be offered surgical treatment and who should be monitored. Further standardisation of diagnostic definition, associated complications, patient selection, surgical management and long-term outcomes are necessary. The recommendations outlined in this review are based on limited evidence from non-randomised cohort studies and expert opinion.

Incidencia y seguimiento a 5 años de la recidiva locorregional durante 4 años consecutivos en una unidad multidisciplinar de patología mamaria / Incidence and 5-year follow-up of locoregional recurrence during 4 consecutive years in a multidisciplinary breast unit

Objetivos. Analizar la incidencia de recidiva locorregional y la evolución de las pacientes diagnosticadas de carcinoma infiltrante de mama con seguimiento de larga evolución. Métodos. Estudio retrospectivo de pacientes intervenidas por carcinoma infiltrante de mama entre enero de 2006 y diciembre de 2009. Criterios de inclusión: seguimiento mínimo de 24 meses, diagnóstico de recidiva locorregional de mama confirmado mediante biopsia. Se recogieron características diagnósticas y terapéuticas del tumor primario y la recidiva, la biología molecular, el tiempo libre de enfermedad y la supervivencia global a 5 años. Resultados. Cuatrocientas setenta y dos pacientes cumplieron los criterios de inclusión, con una mediana de seguimiento de 66 meses (47-85). Quince (3,2%) pacientes presentaron recaída locorregional. El diagnóstico fue carcinoma ductal infiltrante, la mediana del tamaño tumoral fue de 18 mm (12-30) y 16 mm en la recidiva (8-28). De las piezas analizadas, en 5 casos (2 luminal A, 2 luminal B y un HER2) la biopsia de la recidiva mostró un cambio histopatológico a triple negativo. Se observó un mayor índice de proliferación celular en la recidiva frente al tumor primario (45 vs. 30%; p = 0,068). La supervivencia libre de enfermedad en meses fue mayor en las pacientes con tumores que no eran triple negativo (33 vs. 28 meses; p = 0,199). Solo una paciente (6%) falleció a lo largo del periodo de seguimiento. Conclusiones. La incidencia de recidiva locorregional a 5 años permanece baja y dentro de los estándares actuales. La selección a triple negativo mostró peores tasas de supervivencia libre de enfermedad (AU)

Aims. To evaluate our results in locoregional recurrences in a cohort of patients with infiltrating breast cancer. Methods. A retrospective study was performed over patients with breast cancer who underwent surgery for breast cancer form January 2006 to December 2009 in Breast Surgery Unit of Fundación Jiménez Díaz University Hospital. Those with a minimum follow-up of 2 years and a locoregional recurrence confirmed by biopsy were selected. We analyzed patient and tumor's characteristics, time to recurrence confirmed by biopsy and long-term oncological outcomes. Results. 472 completed the inclusion criteria with a median follow-up of 66 months (47-85). Of them, 15 patients (3.2%) had a locoregional recurrence. A triple-negative breast cancer was found in 5 patients at the time of relapse (2 luminal A, 2 luminal B and one HER2), compared to one patient at the initial surgery. A higher cellular proliferation index was observed in recurrence tumors (45 vs. 30%; P = .068). Disease-free survival was higher in triple-negative non-selected patients (33 vs. 28 months; P = .199). During the follow-up period, one patient died (6%). Conclusions. In our experience, locoregional recurrence of breast cancer is low and similar to the existing standard guidelines. Patients with triple-negative selected tumors showed worst disease-free survival rates (AU)

Mortality after thyroid surgery, insignificant or still an issue?

BACKGROUND: Thyroidectomy is considered to be a safe procedure. Although very uncommon, death may occur after thyroid resection. The aim of this study was to investigate the prevalence and causes of death after thyroidectomy and the associated risk factors in the modern era of thyroid surgery. PATIENTS AND METHODS: A structured questionnaire was sent to all endocrine surgery units in Spain to report all deaths that occurred after thyroidectomy in recent years. RESULTS: Twenty-six surgical units, encompassing 30.495 thyroidectomies, returned the questionnaire. A total of 20 deaths (0.065%) were recorded: 12 women (60%) and 8 men (40%) with a median age of 65 years (range 32-86). Half of the patients had a retrosternal goiter with a median weight of 210 g. The median operative time was 185 min. Histological diagnoses were benign goiter (35%) or thyroid carcinoma (65%): differentiated (30%), medullary (20%), poorly differentiated/anaplastic (10%), and colorectal cancer metastasis (5%). Causes of death were cervical hematoma (30%), respiratory distress/pneumonia due to prolonged endotracheal intubation (25%), tracheal injury (15%), heart failure (15%), sepsis (wound infection/esophageal perforation) (10%) and mycotic aneurysm (5%). The median time from surgery to death was 14 days (range 1-85). CONCLUSIONS: Death after thyroidectomy is very uncommon, and most often results from a combination of advanced age, giant goiters, and upper airway complications.