Differentiated Thyroid Carcinoma Long-Term Prognostic Factors.

Introduction: Thyroid cancer is the most common cancer in women in Ecuador. Objective: The aim of this study was to determine the demographics and clinical and treatment variables of patients with papillary or follicular thyroid cancer, referred to as differentiated thyroid cancer (DTC), treated at a third-level hospital in Quito, Ecuador. Methods: We reviewed retrospectively the medical records of patients with DTC, who underwent surgical treatment, from 1990 to 2019. Data included demographics, pathological information, clinical stage, type of surgery, and radioactive iodine (RAI) adjuvant therapy. Patients were monitored for up to 29 years (median follow-up time 6.9 years). Results: The corrected overall 5-, 10-, 20-, and 30-year survival rates (Kaplan-Meier) were 93%, 85%, 70%, and 63%, respectively. On univariate analysis, age, histological type, tumor grade, histological variants, capsular invasion, vascular invasion, tumor size, clinical stage, distant metastases at diagnosis, surgical margins, extrathyroidal invasion, radioactive iodine adjuvant treatment, and locoregional recurrence were found to be significant prognostic factors. In a multivariate analysis, the following independent variables: age over 55 years, extrathyroidal spread, metastasis at diagnosis, and stage II to IV raised the risk of death (hazard risk) (HR). Conclusions: Age over 55 years, extrathyroidal spread, metastasis at diagnosis, and advanced clinical stage were found to have a harmful prognosis and an increased risk of death in a series of Ecuadorian patients surgically treated for a DTC.

Intraoperative indocyanine green angiography in preventing hypoparathyroidism after thyroid cancer surgery.

BACKGROUND: The aim of this study was to determine whether the use of indocyanine green angiography to identify devascularized parathyroids during thyroidectomy for thyroid cancer would decrease the rates of postoperative hypoparathyroidism. METHODS: Retrospective study of patients who had undergone total thyroidectomy for treatment of thyroid cancer between March 2021 and March 2023. The indocyanine group included patients with all four parathyroids identified and evaluated by indocyanine green angiography at the end of the procedure. Those with parathyroid glands classified with no vascularization had the glands autotransplanted. A group without indocyanine angiography was used to compare results. RESULTS: The analysis included 100 patients in each group. Indocyanine angiography identified 14.75% of devascularized parathyroids at surgery. The number of parathyroids with a score of 2 (i.e., good vascularization) was not a safe predictor of normal parathyroid hormone levels after surgery. Indeed, 29.2% of the patients with three parathyroids with a score of 2 developed transient hypoparathyroidism. Permanent hypoparathyroidism occurred in 7% of the patients without indocyanine group and in none of the patients in the indocyanine group (p = 0.014). CONCLUSION: Intraoperative angiography with indocyanine green could contribute to reduce the occurrence of permanent hypoparathyroidism in patients undergoing surgical treatment for thyroid cancer.

Thyroid surgery in children: a single-center experience of 20 years.

OBJECTIVE: Thyroidectomy is a relatively uncommon procedure in pediatric patients. We aimed to review our 20-year experience of thyroid surgery. METHODS: A total of 39 patients who underwent thyroid surgery from 2003 to 2023 were retrospectively evaluated. All patients were followed preoperatively and postoperatively by our institutional multidisciplinary board. Patients were divided into two groups based on their pathologies: benign and malignant. RESULTS: In total, 39 patients (27 girls and 12 boys) underwent 47 thyroid surgeries (total thyroidectomy in 19 patients and subtotal thyroidectomy in 20 patients, with 8 of them having completion thyroidectomy). Notably, 20 (51%) patients had benign and 19 (49%) patients had malignant pathologies. Median age at operation was 157 (9-223) months in the benign group and 182 (1-213) months in the malignant group. In the benign group, 12 (60%) patients had colloidal goiter and 8 (40%) patients had other conditions. In the malignant group, 12 (63%) patients had papillary thyroid carcinoma, 3 (16%) patients had follicular thyroid carcinoma, 2 (11%) had medullary thyroid carcinoma, and 2 patients had other thyroid malignancies. Overall permanent complication rate was 2 out of 39 (5%), which was similar for both groups (1 hypocalcemia in each group). The median follow-up was 38 months (1-179 months) with no local recurrence or distant metastasis. CONCLUSION: Pediatric thyroidectomies are performed on a heterogeneous group of pediatric patients due to a diverse group of pathologies. A multidisciplinary approach is required for proper initial management and surgical strategy with decreased complication rate and event-free survival of these patients in experienced tertiary centers.

Lobectomy in patients with differentiated thyroid cancer: experience of a Chilean tertiary center.

PURPOSE: Thyroid lobectomy (TL) is an appropriate treatment for up to 4 cm intrathyroidal differentiated thyroid cancer (DTC). There is scarce data regarding TL outside first-world centers. Our aim is to report a cohort of patients with DTC treated with TL in Chile. METHODS: We included DTC patients treated with TL, followed for at least 6 months, characterized their clinicopathological features and classified their risk of recurrence and response to treatment. RESULTS: Eighty-two patients followed for a median of 2.3 years (0.5-7.0). Seventy-three (89%) patients had papillary, 8 (9.8%) follicular and 1 (1.2%) high-grade DTC. The risk of recurrence was low in 56 (68.3%) and intermediate in 26 (31.7%). Eight (9.8%) patients required early completion thyroidectomy and radioiodine. At last follow-up, 52 (70.3%) had excellent, 19 (25.7%) had indeterminate, and 1 (1.4%) had structural incomplete response. CONCLUSION: In a developing country, TL is an adequate option for appropriately selected DTC patients.

Active surveillance is a feasible and safe strategy in selected patients with papillary thyroid cancer and suspicious cervical lymph nodes detected after thyroidectomy.

Objective: After initial treatment, up to 30% of patients with papillary thyroid cancer (PTC) have incomplete response, mainly cervical lymph node (LN) disease. Previous studies have suggested that active surveillance (AS) is a possible option for these patients. Our aim was to report the results of AS in patients with PTC and cervical LN disease. Materials and methods: In this retrospective observational study, we included adult patients treated and followed for PTC, who presented with cervical LN disease and were managed with AS. Growth was defined as an increase ≥ 3mm in either diameter. Results: We included 32 patients: 27 (84.4%) women, age of 39 ± 14 years, all initially treated with total thyroidectomy, and 22 (69%) with therapeutic neck dissection. Cervical LN disease was diagnosed 1 year (0.3-12.6) after initial management, with a diameter of 9.0 mm (6.0-19.0). After a median AS of 4.3 years (0.6-14.1), 4 (12.5%) patients had LNgrowth: 2 (50%) of whom were surgically removed, 1 (25%) was effectively treated with radiotherapy, and 1 (25%) had a scheduled surgery. Tg increase was the only predictive factor of LN growth evaluated as both the delta Tg (p < 0.0366) and percentage of Tg change (p < 0.0140). None of the included patients died, had local complications due to LN growth or salvage therapy, or developed distant metastases during follow-up. Conclusion: In selected patients with PTC and suspicious cervical LNs diagnosed after initial treatment, AS is a feasible and safe strategy as it allows effective identification and treatment of the minority of patients who progress.

Neoadjuvant Treatment of Locally Advanced Thyroid Cancer: A Preliminary Latin American Experience.

Background: Surgical resection is not always achievable in thyroid cancer patients. Neoadjuvant therapy is rarely used, but recent trends favor multikinase inhibitors or selective tyrosine kinase inhibitors. These aim to reduce tumor volume, enabling previously unfeasible surgeries. Patients and Methods: Consecutive patients with locally advanced malignant thyroid tumors who received systemic therapies with a neoadjuvant intention were included in this retrospective multicenter case series conducted in five Latin American referral centers. Primary outcomes were pre- versus postneoadjuvant response evaluations using the Response Evaluation Criteria in Solid Tumors, feasibility of surgery, and completeness of resection. Secondary outcomes were mortality and status at the last visit. Results: Twenty-seven patients were included in this analysis. Patients with unresectable differentiated thyroid cancer (DTC) or poorly differentiated thyroid cancer (PDTC) received sorafenib (n = 6) or lenvatinib (n = 12), those with medullary thyroid cancer (MTC) were treated with vandetanib (n = 5) or selpercatinib (n = 1), and those with anaplastic thyroid cancer (ATC) harboring a BRAFV600E mutation (n = 3) received dabrafenib and trametinib. The median patient age was 66 years (range 12-82), and 52% of the patients were female. In patients with PTC and PDTC, the median reduction in the diameter of the primary tumor was 25% (range 0-100%) after a median of 6 months of treatment. Surgical intervention was performed in 10 (55%) of the patients. Among these, six patients (60%) achieved R0/R1 resection status. Six patients with MTC had a median reduction in tumor diameter of 24.5% (range 1-49) after a median treatment time of 9.5 months. Only one patient receiving selpercatinib, with a tumoral reduction of 25% could undergo surgery, resulting in an R2 resection due to extensive mediastinal extension. Three patients with ATC showed a median tumor diameter reduction of 42% (range 6.7-50) after a median treatment time of 2 months. Two patients underwent surgical intervention and achieved R1 and R2 resection, respectively. Conclusions: While neoadjuvant therapy achieved tumoral responses, surgical resection was feasible in 55% of DTC, 33% of ATC, and 16% of MTC patients, with R0/R1 resection in 26% of the cohort, underscoring the need for patient selection and further research in this area.

Active surveillance of nodal metastasis in differentiated thyroid carcinoma: a systematic review and meta-analysis.

PURPOSE: Cervical lymph nodes (LN) represent the most common site of recurrence in differentiated thyroid cancer (DTC), frequently requiring repeated interventions that contribute to increase morbidity to a usually indolent disease. Data on active surveillance (AS) of nodal metastasis are limited. Therefore, we performed a systematic review and meta-analysis to evaluate AS in nodal metastasis of DTC patients. METHODS: MEDLINE, EMBASE, and Cochrane databases were searched up to July 2023 for studies including DTC patients with metastatic LN who were followed up with AS. The primary outcome was disease progression, according to the study's definition. Additional outcomes were LN enlargement ≥3 mm, occurrence of new cervical metastasis, and conversion from AS to surgical treatment. RESULTS: The search identified 375 studies and seven were included, comprising 486 patients with metastatic nodal DTC. Most were female (69.5%) and had papillary thyroid cancer (99.8%). The mean AS follow-up ranged from 28-86 months. Following each study's definition of progression, the pooled incidence was 28% [95% confidence interval (CI), 20-37%]. The pooled incidence of LN growth ≥ 3 mm was 21% [95% CI, 17-25%] and the emergence of new LN sites was 19% [95% CI, 14-25%]. Combining growth of 3 mm and the emergence of new LN criteria, we found an incidence of 26% [95% CI, 20-33%]. The incidence of neck dissection during AS was 18% [95% CI, 12-26%]. CONCLUSIONS: AS seems to be a suitable strategy for selected DTC patients with small nodal disease, avoiding or postponing surgical reintervention. PROSPERO REGISTRATION: CRD42023438293.

Predictors of recurrence after total thyroidectomy in 1,611 patients with papillary thyroid carcinoma: postoperative stimulated serum thyroglobulin and ATA initial and dynamic risk assessment.

Objective: Despite a favorable prognosis, some patients with papillary thyroid carcinoma (PTC) develop recurrence. The objective of this study was to examine the impact of the combination of initial American Thyroid Association (ATA) risk stratification with serum level of postoperative stimulated thyroglobulin (s-Tg) in predicting recurrence in patients with PTC and compare the results with an assessment of response to initial therapy (dynamic risk stratification). Subjects and methods: We retrospectively analyzed 1,611 patients who had undergone total thyroidectomy for PTC, followed in most cases (87.3%) by radioactive iodine (RAI) administration. Clinicopathological features and s-Tg levels obtained 3 months postoperatively were evaluated. The patients were stratified according to ATA risk categories. Nonstimulated thyroglobulin levels and imaging studies obtained during the first year of follow-up were used to restage the patients based on response to initial therapy. Results: After a mean follow-up of 61.5 months (range 12-246 months), tumor recurrence was diagnosed in 99 (6.1%) patients. According to ATA risk, recurrence was identified in 2.3% of the low-risk, 9% of the intermediate-risk, and 25% of the high-risk patients (p < 0.001). Using a receiver operating characteristic curve approach, a postoperative s-Tg level of 10 ng/mL emerged as the ideal cutoff value, with positive and negative predictive values of 24% and 97.8%, respectively (p < 0.001). Patients with low to intermediate ATA risk with postoperative s-Tg levels < 10 ng/mL and excellent response to treatment had a very low recurrence rate (<0.8%). In contrast, higher recurrence rates were observed in intermediate-riskto high-risk patients with postoperative s-Tg > 10 ng/mL and indeterminate response (25%) and in those with incomplete response regardless of ATA category or postoperative s-Tg value (38.5-87.5%). Using proportion of variance explained (PVE), the predicted recurrence using the ATA initial risk assessment alone was 12.7% and increased to 29.9% when postoperative s-Tg was added to the logistic regression model and 49.1% with dynamic risk stratification. Conclusion: The combination of ATA staging system and postoperative s-Tg can better predict the risk of PTC recurrence. Initial risk estimates can be refined based ondynamic risk assessment following response to therapy, thus providing a useful guide for follow-up recommendations.

Quality of life of patients with thyroid cancer in Colombia.

INTRODUCTION: Quality of life (QoL) in thyroid cancer patients is comparable to patients with other tumours with worse prognosis. The aim was to evaluate QoL in Colombian patients with thyroid carcinoma and to explore the association of QoL scores with patient features. METHODS: This is a cross-sectional study. The present research was carried out from data obtained for the validation study of the Spanish version of the THYCA-QoL. Adult patients with thyroid carcinoma who underwent total or partial thyroidectomy were included and asked to complete the Spanish-validated versions of the THYCA-QoL and EORTC QLQ-C30 questionnaires. The scores of each domain and single items underwent linear transformation to values of 0-100. Comparisons of scale scores with clinical variables were performed. RESULTS: We included 293 patients. The global EORTC QLQ-C30 score was 73.2±22.1 and the domains with poorer values were emotional and cognitive and the symptoms with poorer values were insomnia and fatigue. The global THYCA-QOL score was 28.4±17.8. The domains with poorer values were neuromuscular and psychological and the single items with poorer values were headaches and tingling hands/feet. CONCLUSION: Colombian patients with thyroid cancer have a good prognosis, but they experience important problems related to QoL. QoL was influenced by demographic and clinical factors such as age, sex functional status and clinical stage.

Tiroidectomía total en enfermedad de graves basedow y tiroiditis. Complicaciones postoperatorias y relación con neoplasia tiroidea / Total thyroidectomy in graves basedow disease and thyroiditis. Postoperative complications and relationship with thyroid neoplasia

n. Los centros de alto volumen tienden a realizar tiroidectomías totales, tanto en patologías malignas y benignas. En este trabajo se analizan las complicaciones y la relación de las enfermedades estudiadas con la patología oncológica. Materiales y métodos. Se realizó una revisión de los pacientes intervenidos quirúrgicamente de Tiroidectomía Total (TT) por enfermedad de graves y tiroiditis. Se excluyeron las resecciones tiroideas parciales, subtotales, aquellas que requirieron linfadenectomía cervical y las realizadas por otras afecciones de la glándula entre enero 2010 y enero 2020 en el Servicio de Cirugía General N° 1, Hospital Nacional de Clínicas. Resultados. La histología fue del 64% para enfermedad de Graves, 28% Tiroiditis de Hashimoto y 8% Tiroiditis Linfocitaria (TL). El 100% de las TL presentaron Carcinoma Papilar de Tiroides (CPT) como resultado final de la anatomía patológica. El 25% del examen diferido de la pieza quirúrgica informó (CPT) en EG. Discusión. La complicación posoperatoria que rigió nuestra serie fue el Hipoparatiroidismo, manifestación que se presentó de manera transitoria en el 50% de la población estudiada, perdurando por más de seis meses en solo un caso (6%). Autores como Delbridge y cols. realizan el trasplante sistemático de al menos una paratiroides. La asociación de la neoplasia tiroidea fue elevada en nuestra serie, con una incidencia del 37%. Por lo que la Tiroidectomía debe ser total. Conclusión. La mayoría de los centros de cirugía endocrina del mundo, han difundido ampliamente el uso de la TT, por ser un procedimiento seguro en manos de cirujanos experimentados

n. High volume centers tend to perform total thyroidectomies, both in malignant and benign pathologies. This work analyzes complications and the relationship of diseases studied with oncological pathology. Materials and methods. A review of the patients surgically intervened with total thyroidectomy (TT) due to serious disease and thyroiditis was performed. Partial thyroid resections were excluded, subtotals, those that required cervical lymphadenectomy and those performed by other conditions of the gland between January 2010 and January 2020 in the General Surgery Service No. 1, National Hospital of Clinics. Results. Histology was 64% for serious disease, 28% hashimoto and 8% lymphocyte thyroiditis (TL). 100% of the FTAs presented papillary thyroid carcinoma (CPT) as a final result of the pathological anatomy. 25% of the deferred examination of the surgical piece reported (CPT) in EG. Discussion. The postoperative complication that governed our series was hypoparathyroidism, a demonstration that was presented temporarily in 50% of the population studied, enduring for more than six months in just one case (6%). Authors such as Delbridge et al. They perform the systematic transplant of at least one parathyroid. The Association of Thyroid Neoplasia was high in our series, with an incidence of 37%. So, the thyroidectomy must be total. Conclusion. Most of the world's endocrine surgery centers have widely disseminated the use of TT, for being a safe procedure in the hands of experienced surgeons

Benign cervical schwannoma with tracheal invasion.

Schwannomas commonly develop in the cervical region, 25% - 45% of cases are diagnosed in this anatomical region. Tracheal neurogenic tumors are exceedingly rare and can be misdiagnosed as invasive thyroid carcinomas or other infiltrating malignancies when present at the level of the thyroid gland. Here, we present a case of synchronous benign cervical schwannoma with tracheal invasion and papillary thyroid carcinoma in a patient who was initially hospitalized for COVID-19. The patient presented with dyspnea that was later found to be caused by tracheal extension of a cervical tumor. Surgical excision was performed, and the surgical team proceeded with segmental tracheal resection, removal of the cervical mass, and total thyroidectomy. The specimen was sent for pathological analysis, which revealed synchronous findings of a benign cervical schwannoma with tracheal invasion and papillary thyroid carcinoma. The literature on this subject, together with the present case report, suggests that neurogenic tumors should be included in the differential diagnosis of obstructing tracheal cervical masses. Surgical excision is the first-line of treatment for benign cervical schwannomas.

Surgical safety and effectiveness of bilateral axillo-breast approach robotic thyroidectomy: a systematic review and meta-analysis.

OBJECTIVES: To assess the safety and effectiveness of bilateral axillo-breast approach robotic thyroidectomy in thyroid tumor. METHODS: Bilateral axillo-breast approach robotic thyroidectomy and other approaches (open thyroidectomy, transoral robotic thyroidectomy, and bilateral axillo-breast approach endoscopic thyroidectomy) were compared in studies from 6 databases. RESULTS: Twenty-two studies (8830 individuals) were included. Bilateral axillo-breast approach robotic thyroidectomy had longer operation time, greater cosmetic satisfaction, and reduced transient hypoparathyroidism than conventional open thyroidectomy. Compared to bilateral axillo-breast approach endoscopic thyroidectomy, bilateral axillo-breast approach robotic thyroidectomy had greater amount of drainage, lower chances of transient vocal cord palsy and permanent hypothyroidism, and better surgical completeness (postopertive thyroblobulin level and lymph node removal). Bilateral axillo-breast approach robotic thyroidectomy induced greater postoperative drainage and greater patient dissatisfaction than transoral robotic thyroidectomy. CONCLUSION: Bilateral axillo-breast approach robotic thyroidectomy is inferior to transoral robotic thyroidectomy in drainage and cosmetic satisfaction but superior to bilateral axillo-breast approach endoscopic thyroidectomy in surgical performance. Its operation time is longer, but its cosmetic satisfaction is higher than open thyroidectomy.

Reliability of radioguided occult lesion localization in reoperation of loco-regional persistent/recurrent differentiated thyroid cancer: Retrospective cohort study.

OBJECTIVES: We aimed to determine the radioguided occult lesion localization (ROLL) reliability in the reoperation of patients with differentiated thyroid cancer (DTC) and persistent or recurrent non-palpable loco-regional disease who underwent surgery at the Instituto Nacional de Cancerología between 2012 and 2021. DESIGN: Observational retrospective cohort study. PARTICIPANTS: We included data from patients with DTC that underwent resection with ROLL. MAIN OUTCOME MEASURES: Reliability analysed as percentage of patients with complete resection of tumour lesion using ROLL, disease-free survival, second loco-regional relapse, adequate resectability and complications. RESULTS: Two hundred and four cases were obtained. Pathological examination revealed papillary thyroid carcinoma in 202 patients, and follicular thyroid carcinoma in 2. Reliability was 96.57% in patients who underwent ROLL. When wide resection was performed-at surgeon's discretion-the reliability increased to 97.5%. CONCLUSIONS: The high reliability obtained suggests that ROLL was effective to localize non-palpable relapsing lesions. To our knowledge, this is the largest sample size published on this topic to date.

Efectividad, eficiencia y seguridad de la cirugía radioguiada usando semillas radioactivas I125 / Effectiveness, efficiency and safety of radio-guided surgery using radioactive seeds I125

INTRODUCCIÓN: La localización de tumores no palpables puede suponer un reto en su resección para poder localizarlos y extirparlos con precisión y exactitud. Existen numerosas técnicas para facilitar esta localización en el momento de la intervención: guiado por arpón (WGL, del inglés wire guided localization), cirugía radioguiada usando semillas radioactivas Iodo125 (RSL, del inglés radioactive seed localization), localización radioguiada (ROLL, del inglés radioguided occult lesion localization) o ecografía intraoperatoria. La RSL podría suponer una mejora para la resección del tumor y una menor necesidad de planificación para el paciente y el centro hospitalario, todo ello con una menor dosis de radiactividad respecto a otras técnicas. OBJETIVO: Evaluar la efectividad, la eficiencia y la seguridad, así como los retos organizativos, de la cirugía radioguiada con RSL I125 (Iodo125) en pacientes con tumores resecables no palpables de mama, pulmón o tiroides frente a otras opciones actualmente disponibles. MÉTODO: Revisión sistemática de la literatura con dos fases. En la primera se limitó la búsqueda a informes de evaluación de tecnologías, revisiones sistemáticas (RS) y metaanálisis (MA). Si la evidencia para alguna de las indicaciones fuera insuficiente, se contempla una segunda fase incluyendo ECAs (ensayos clínicos aleatorizados) para dichas indicaciones. Para su elaboración se consultaron las siguientes bases de datos referenciales hasta febrero de 2023 (con lenguaje libre y controlado): Medline, Embase, Cochrane Library, WOS (SCI), PubMed (ahead of print/first online), InaHTA y CINAHL. Se incluyó una búsqueda en la base de datos clinicaltrials.gov de ensayos clínicos en marcha para la tecnología en evaluación. La selección de los estudios y el análisis de su calidad se realizaron por dos investigadores independientes. La síntesis de los resultados se llevó a cabo de forma cuantitativa. Las herramientas seleccionadas para evaluar la calidad de los estudios incluidos fueron AMSTAR-2 para revisiones sistemáticas y ROB 2 para ECAs. RESULTADOS: Se incluyeron 5 estudios, todos ellos RS con MA y para la misma indicación (tumores de mama resecables no palpables), no se encontró evidencia en RS ni en ECAs para las otras dos indicaciones (tumores de pulmón o tiroides resecables no palpables). Para tumores de mama resecables no palpables, en términos de seguridad, 3 de los estudios incluidos no encontraron diferencias estadísticamente significativas en la ratio de complicaciones durante y tras la intervención al comparar RSL frente a WGL. En términos de efectividad, se encontraron diferencias significativas a favor del uso de la RSL frente a WGL en la presencia de márgenes de resección positivos (4 estudios) y en la necesidad de reintervención (3 estudios). Se encontraron diferencias estadísticamente significativas a favor de la WGL frente a RSL en el número de localizaciones exitosas (1 estudio). No se encontraron diferencias estadísticamente significativas entre las técnicas RSL y ROLL en la necesidad de reintervención ni en la presencia de márgenes de resección positivos (1 estudio). En términos de resultados organizativos, 3 de los estudios incluidos analizaron el tiempo de intervención de RSL frente a WGL. Uno de los estudios recogió una diferencia significativa a favor del uso de la RSL, mientras que los otros dos estudios no recogieron diferencias significativas. Debe de ser tenida en cuenta la naturaleza radiactiva de las semillas para la correcta implementación de planes organizativos para el uso, almacenamiento y desecho de estas. En términos de eficiencia, solamente 1 de los estudios incluidos recogió información sobre aspectos económicos comparando RSL frente a WGL. Este estudio de costes destacaba la heterogeneidad de los datos que imposibilita un MA sobre aspectos económicos. A pesar de ello, todos los estudios que incluye la revisión incluida concluyen que la RSL supone para los centros hospitalarios un menor coste que la WGL. La perspectiva de los pacientes se incluye en una de las RS incluidas, se analiza únicamente comparando la técnica RSL frente a WGL en pacientes con tumores de mama resecables no palpables. En dos de los estudios que incluye la RS los pacientes sometidos a RSL mostraron una mayor satisfacción y comodidad frente a aquellos en los que se usó WGL. Uno de los estudios incluidos en la RS evaluó la ansiedad que producía la resección del tumor tras la intervención en aquellos pacientes sometidos a la técnica RSL frente a los sometidos a WGL, obteniendo resultados similares para ambos grupos. El dolor tras la intervención fue analizado en 6 de los estudios incluidos en la RS, en uno de ellos se obtuvo un valor del dolor menor estadísticamente significativo en aquellos pacientes sometidos a RSL frente a aquellos sometidos a WGL. En los 5 estudios restantes, no se obtuvieron diferencias estadísticamente significativas entre los dos grupos de pacientes en términos de dolor. Los estudios en marcha localizados para la tecnología RSL fueron solamente 5, todos ellos completados, aunque sin resultados publicados, es destacable el mayor número de estudios en marcha para otras tecnologías alternativas, como semillas magnéticas, que no incluyen a RSL como comparador. CONCLUSIONES: La tecnología RSL es una alternativa a la tecnología de referencia WGL para la localización de tumores resecables no palpables de mama. Debido a la ausencia de evidencia, no ha sido posible la evaluación de esta tecnología para las indicaciones de tumores resecables no palpables en tiroides o pulmón. En la indicación tumores resecables no palpables en mama, la tecnología RSL frente a WGL no mostró diferencias estadísticamente significativas en términos de seguridad, pero sí mostró diferencias estadísticamente significativas a favor de su uso frente a WGL en términos de efectividad y resultados organizativos. RSL no mostró diferencias estadísticamente significativas en términos de efectividad frente a ROLL. Respecto a los aspectos económicos de la RSL para tumores de mama, dada la heterogeneidad de los datos, los autores de la RS incluida no realizaron un análisis estadístico. Si bien, todos los estudios concluyen que la RSL supone para los centros hospitalarios un menor coste que la WGL. Las variables de perspectiva de los pacientes muestran una igualdad de esta entre las técnicas WGL y RSL para la indicación de tumores resecables no palpables en mama. Se necesitan ECAs tanto para las indicaciones de tumores resecables no palpables de tiroides y pulmón, como para establecer comparaciones directas de RSL con otras tecnologías de localización (ROLL, semillas magnéticas, ecografía intraoperatoria o localización por radar). Sería conveniente la realización de estudios que incluyan aspectos económicos y la perspectiva del paciente. Futuras RS e informes de evaluación deben tener en cuenta tecnologías de localización alternativas (semillas magnéticas o localización por radar) para las que no se ha encontrado evidencia para este informe, pero que dado su reciente desarrollo y los estudios en marcha se espera que se genere evidencia en los próximos años.

INTRODUCTION: The localisation of non-palpable or non-visible tumours can be a challenge in resection to locate and remove them with precision and accuracy. Numerous techniques exist to facilitate this localisation at the time of surgery: wire guided localisation (WGL), radioguided surgery using radioactive seeds I125 (RSL), radioguided occult lesion localisation (ROLL) or intraoperative ultrasound. RSL could mean an improvement for tumor resection and less need for planning for the patient and the hospital, all of that with a lower dose of radioactivity compared to other techniques. OBJECTIVE: To evaluate the effectiveness, efficiency and safety, as well as organisational challenges, of radioguided surgery with RSL I125 (Iodine125) in patients with resectable non-palpable tumours of the breast, lung or thyroid versus other currently available options. METHODS: systematic review of the literature with two phases, including in the first phase technology assessment reports and systematic reviews, and if the evidence for any of the indications was insufficient, a second phase including RCTs (randomised clinical trials). The following reference databases were consulted until February 2023 (with free and controlled language): Medline, Embase, Cochrane Library, WOS (SCI), PubMed (ahead of print/first online), InaHTA and CINAHL. A search of the clinicaltrials.gov database of ongoing clinical trials for the technology under evaluation was included. Study selection and quality analysis were performed by two independent investigators. Synthesis of the results was carried out qualitatively. Study quality was assessed using the AMSTAR-2 tools for systematic reviews and ROB 2 for RCTs. RESULTS: 5 studies were included, all of them systematic reviews with metaanalyses and for the same indication (non-palpable resectable breast tumours), no evidence was found in SR or RCTs for the other two indications (non-palpable resectable lung or thyroid tumours). For non-palpable resectable breast tumours, in terms of safety, 3 of the included studies found no statistically significant difference in the complication rate during and after surgery when comparing RSL versus WGL. In terms of effectiveness, significant differences were found in favour of RSL versus WGL in the presence of positive margins (4 studies) and in the need for reoperation (3 studies). Statistically significant differences in favour of WGL over RSL were found in the number of successful sites (1 study). No statistically significant differences were found between RSL and ROLL techniques in the need for reoperation and the presence of positive margins (1 study). In terms of organisational outcomes, 3 of the included studies analysed the operating time of RSL versus WGL, one of the studies showed a significant difference in favour of RSL, and the other two showed no significant difference. The radioactive nature of the seeds must be considered for the proper implementation of organisational plans for their use, storage and disposal. In terms of efficiency, only 1 of the included studies reports information on economic aspects comparing RSL versus WGL. This cost study highlights the heterogeneity of the data which makes it impossible to provide an MA on economic aspects. Despite this, all the studies included in the included review conclude that RSL is less costly for hospitals than WGL. CONCLUSIONS: RSL technology is an alternative to the reference WGL technology for the localisation of resectable non-palpable breast tumours. Due to a lack of evidence, it has not been possible to evaluate this technology for the indications of resectable non-palpable non-palpable tumours in the thyroid or lung. In the indication of non-palpable resectable tumours in the breast, RSL versus WGL showed no statistically significant differences in terms of safety but did show statistically significant differences in favour of its use over WGL in terms of effectiveness and organisational outcomes. RSL did not show statistically significant differences in terms of effectiveness versus ROLL. Regarding economic aspects, given the heterogeneity of the data, the authors of the included SR did not perform a statistical analysis. However, all data conclude that RSL is less costly for hospitals than WGL. Patient perspective variables show an equality between WGL and RSL techniques. RCTs are needed both for indications of non-palpable resectable tumours of the thyroid and lung, and to establish direct comparisons of SLR with other localisation technologies (ROLL, magnetic seeds, intraoperative ultrasound or radar localisation). Studies that include economic aspects and the patient's perspective would be desirable. Future SRs and evaluation reports should take into account alternative localisation technologies (magnetic seeds or radar localisation) for which no evidence has been found for this report but given their recent development and ongoing studies it is expected that evidence will be generated in the coming years.

Correlation between thyroid fine needle aspiration and pathological examination: a 10 year retrospective study.

OBJECTIVE: To establish the diagnostic performance of fine-needle aspiration in detecting benign and malignant neoplasm in comparison with post-thyroidectomy histopathological findings among patients who received a thyroidectomy. METHODS: Retrospective observational data collected between 2011-2021 were included from patients who received partial or total thyroidectomy. The Bethesda system was used to classify neoplasms from fine-needle aspiration procedures as benign or malignant. Sample characteristics, diagnostic accuracy, sensitivity, specificity, and predictive values were evaluated. RESULTS: Patients (n=360) who underwent thyroidectomy were analyzed, of whom 142 (39.4%) and 218 (60.6%) had benign and malignant neoplasms, respectively. Using the Bethesda system, 23 (6.4%) were classified as unsatisfactory result (BI), 83 (23.1%) as benign (BII), 50 (13.9%) as atypia of undetermined significance (BIII), 23 (6.4%) as suspected follicular or Hürthle cell neoplasia (BIV), 102 (28.3%) as suspected malignancy (BV) and 79 (21.9%) as malignant (BVI). The fine-needle aspiration diagnostic accuracy for carcinomas was 92%, while the sensitivity and specificity were 94.4% and 86.9%, respectively. The negative and positive predictive values were 87.9% and 93.9%, respectively. CONCLUSION: Fine-needle aspiration has high diagnostic accuracy, sensitivity and specificity, and is a reliable test for distinguishing between benign and malignant thyroid pathologies.

Papillary thyroid carcinoma with desmoid fibromatosis: a case report and review of literature.

Desmoid-type fibromatosis (DF) is a rare monoclonal, fibroblastic proliferation characterized by an unpredictable and variable clinical course. We present the case of a 56-year-old woman who underwent total thyroidectomy for papillary thyroid carcinoma in 2012 and who developed a cervical mass at the left laterocervical level during follow-up, raising the diagnosis of tumor recurrence. Computed tomography of the neck showed solid formations with heterogeneous contrast uptake in the right lateral region of the neck. At the level of the thoracic operculum, a second 26-mm formation was observed that medially contacted the left lateral wall of the trachea. Lateral lymphadenectomy was performed, which was incomplete. Histology showed findings consistent with desmoid-type fibromatosis. DF are slowly proliferating, non-metastatic tumors with a highly invasive capacity that are usually present in familial adenomatous polyposis (FAP)-Gardner syndrome. Our case had a history of massive colonic polyposis and first-degree relatives of colorectal cancer.

La fibromatosis de tipo desmoide (FD) es una rara proliferación fibroblástica monoclonal caracterizada por un curso clínico impredecible y variable. Presentamos el caso de una mujer de 56 años intervenida de tiroidectomía total por carcinoma papilar de tiroides en 2012 y que durante el seguimiento desarrolla una masa cervical a nivel laterocervical izquierdo, planteando el diagnóstico de recidiva tumoral. La tomografía computarizada de cuello demostró formaciones sólidas con captación heterogénea de contraste en la región lateral derecha del cuello. A nivel del opérculo torácico se observó una segunda formación de 26 mm que contactaba medialmente con la pared lateral izquierda de la tráquea. Se realizó una linfadenectomía lateral, que resultó incompleta. La histología mostró hallazgos compatibles con FD. La FD son tumores de proliferación lenta, no metastásicos y con una capacidad altamente invasiva que suelen estar presentes en la poliposis adenomatosa familiar (PAF)-síndrome de Gardner. Nuestro caso tenía antecedentes de poliposis colónica masiva y familiares de primer grado de cáncer colorrectal.

Comprehensive analysis of clinicopathologic and sonographic features in thyroid cancer with skip lymph node metastasis: establish and assessment of a prediction nomogram.

Lateral Lymph Node Metastasis (LLNM) is common in Papillary Thyroid Carcinoma (PTC) and is associated with a poor prognosis. LLNM without central lymph node metastasis as skip metastasis is not common. We aimed to investigate clinicopathologic and sonographic risk factors for skip metastasis in PTC patients, and to establish a nomogram for predicting the possibility of skip metastasis in order to determine the therapeutic strategy. We retrospectively reviewed the data of 1037 PTC patients who underwent surgery from 2016 to 2020 at a single institution. Univariate and multivariate analyses were used to identify the clinicopathologic and preoperative sonographic risk factors of skip metastasis. A nomogram including the risk factors for predicting skip metastasis was further developed and validated. The incidence of skip metastasis was 10.7%. The univariate and multivariate analyses suggested that gender (p= 0.001), tumor location (p= 0.000), extrathyroidal extension (p= 0.000), and calcification (p= 0.000) were independent risk factors. For papillary thyroid microcarcinoma, tumor location (p= 0.000) and calcification (p= 0.001) were independent risk factors. A nomogram according to the clinicopathologic and sonographic predictors was developed. The receiver operating characteristic curve indicated that AUC was 0.824 and had an excellent consistency. The calibration plot analysis showed a good performance and clinical utility of the model. Decision curve analysis revealed it was clinically useful. A nomogram for predicting the probability of skip metastasis was developed, which exhibited a favorable predictive value and consistency. For the female PTC patient, tumor located at the upper pole is more likely to have skip metastasis. Surgeons and sonographers should pay close attention to the patients who have the risk factors. Evidence level: This article's evidence level is 3. Level 3 evidence is derived from non-randomized, controlled clinical trials. In this study, patients who receive an intervention are compared to a control group. Authors may detect a statistically significant and clinically relevant outcome.

Beyond the Recommendations of the Clinical Guidelines for Medullary Thyroid Cancer - A Case Report / Más allá de las recomendaciones de las guías clínicas de cáncer medular de tiroides - a propósito de un caso

Medullary thyroid cancer (MTC) is a rare disease from parafollicular C cells. Calcitonin has been suggested as a screening; its levels are proportional to the tumor size and predictive of metastatic disease. We present a case where an early action was taken with lower cut-off points. Male patient, 49 years old. Thyroid ultrasound (US) with a suspicious nodule. Fine Needle Aspiration Biopsy (FNAB) suggests MTC, with pre-operative serum calcitonin (CTN) of 591 pg/mL. Total thyroidectomy with central and bilateral dissection was performed. Biopsy: MTC in left nodule of 26 mm without lymph nodes (LN) metastases. Follow-up with undetectable CTN for six years. After that, CT was 4.7 pg/mL, and carcinoembryonic antigen (CEA) was 1.2 ng/mL. Neck US showed bilateral LN. FNAB of LN does not show recurrence. A progressive rise of markers with doubling time of CTN and CEA was 16 and 51.3 months, respectively. CTN raised until 112 pg/mL. Given the lack of cervical compromise, a neck and lung CT, liver MRI, and bone scintigraphy were ordered despite CTN levels < 150 pg/mL. MRI showed hypervascular hepatic lesions, contrasted with gadoxetic acid. PET Ga68-DOTATATE showed lesions with overexpression of somatostatin receptors in the liver. Surgery was done, and a biopsy confirmed metastases. Conclusions: The clinical guidelines may allow the management of cases; however, they should be used considering each case context. In our patient, if the guidelines had been strictly followed, it would not have been possible to detect liver metastases to achieve a surgical resection with curative intent.

Paciente masculino, 49 años. Ecografía tiroidea con nódulo sospechoso. Biopsia por aspiración con aguja fina (PAAF) sugiere cáncer medular de tiroides (CMT), calcitonina sérica preoperatoria (CTN) de 591 pg/mL. Se realizó tiroidectomía total con disección central y bilateral. Biopsia: CMT en nódulo tiroideo izquierdo de 2,6 cm sin metástasis en 29 ganglios linfáticos (GL). En el seguimiento, CTN sérica indetectable durante 6 años. Posteriormente CTN sérica de 4,7 pg/mL y antígeno carcinoembrionario (CEA) de 1,2 ng/mL. Ecografía cervical de control mostró GL subcentimétricos bilaterales en grupo IV. PAAF de GL sin evidencia de malignidad, con niveles de CTN indetectables en la muestra. El doblaje de CTN y CEA fue 16 y 51,3 meses respectivamente. Dado ausencia de compromiso cervical, se solicitó TC de cuello y tórax, RM hepática y gammagrafía ósea, a pesar de no presentar niveles de CTN > 150 pg/mL. La RM mostró 3 lesiones hepáticas hipervasculares; se complementa con un PET Ga-DOTATATE que mostró 2 lesiones focales con sobreexposición de receptores de somatostatina en el parénquima hepático, con SUVmáx de 6,8 y 7,3. Se realiza cirugía extirpando 5 lesiones; la biopsia confirmó metástasis de CMT. Conclusiones: Las guías clínicas pueden dar orientaciones generales y permitir el manejo de casos basados en la evidencia; sin embargo, siempre deben usarse considerando el contexto de cada caso en particular. Si se hubieran seguido estrictamente las pautas, no habría sido posible detectar las metástasis hepáticas dentro de la ventana de oportunidad para lograr una resección quirúrgica con intención curativa.