Consenso intersocietario* sobre tratamiento y seguimiento de pacientes con cáncer diferenciado de tiroides / Inter Society Consensus for the Management of Patients with Differentiated Thyroid Cancer

La incidencia del cáncer diferenciado de tiroides se incrementó exponencialmente en todo el mundo. Aunque estos tumores presentan un pronóstico excelente, se produjeron múltiples cambios en el enfoque terapéutico y de seguimiento en los últimos años. Esta situación, vinculada principalmente con la estadificación por riesgos de recurrencia de la enfermedad, determinó la necesidad de generar un consenso entre representantes de las 3 sociedades argentinas que habitualmente se encuentran involucradas en el manejo de estos pacientes, (Sociedad Argentina de Endocrinología y Metabolismo, Asociación Argentina de Cirugía de Cabeza y Cuello y Asociación Argentina de Biología y Medicina Nuclear). Las recomendaciones se realizaron de acuerdo a la experiencia de los participantes y a la revisión de la literatura. Rev Argent Endocrinol Metab 52:85-118, 2014 Conflictos de interés: Pitoia F: Consultoría, Advisory Board, Speaker Genzyme-Sanofi; Consultoría, Advi­sory Board, Speaker, Steering Committee Bayer; Consultoría, Advisory Board, Speaker Astra Zeneca. Califano I: Speaker Genzyme-Sanofi; Consultoría, Advisory Board, Speaker AstraZeneca. Faure E: Consultoría, Advisory Board, Speaker Genzyme-Sanofi; Consultoría, Advisory Board, Speaker AstraZeneca. Gauna A: Advisory Board Genzyme-Sanofi.; Advisory Board Bayer. Mollerach A: Advisory Board Genzyme-Sanofi. Orlandi A: Advisory Board, Speaker Genzyme-Sanofi. El resto de los autores no declaran conflictos de intereses.

The incidence of differentiated thyroid cancer increased exponentially worldwide. Although these tumors usually have an excellent prognosis, multiple changes occurred in the therapeutic approach and follow-up in recent years. This situation, mainly related to the stratification by the risk of recurrence of the disease, made it necessary to build a consensus among representative members from the three Argentinean societies that are usually involved in the management of these patients, (Argentinean Society of Endocrinology and Metabo lism, Argentinean Association of Head and Neck Surgery and Argentinean Association of Biology and Nuclear Medicine). The recommendations were done according to personal experiences and review of bibliography. Rev Argent Endocrinol Metab 52:85-118, 2014 Conflicts of interest: Pitoia F: Consultancy, Advisory Board, Speaker Genzyme-Sanofi; Consultancy, Advisory Board, Speaker, Steering Committee Bayer; Consultancy, Advisory Board, Speaker AstraZeneca. Califano I: Speaker Genzyme-Sanofi; Consultancy, Advisory Board, Speaker AstraZeneca. Faure E: Consultancy, Advisory Board, Speaker Genzyme-Sanofi; Consultancy, Advisory Board, Speaker AstraZeneca. Gauna A: Advisory Board Genzyme-Sanofi.; Advisory Board Bayer. Mollerach A: Advisory Board Genzyme-Sanofi.Orlandi A: Advisory Board, Speaker Genzyme-Sanofi. No other financial conflicts of interest exist.

Local ethanol injection for the treatment of deltoid parathyroid cell hyperplasia.

Secondary hyperparathyroidism (SHPT) is a serious complication in dialysis patients and is routinely managed with medical therapy. Refractory disease is usually treated either surgically or by local ethanol injection into the parathyroid glands. Total parathyroidectomy with deltoid implant can be successful; however, recurrent, resistant disease is not uncommon. Local ethanol injection was applied to the deltoid autoimplant of a patient with recurrent, resistant SHPT, which had not been resolved with surgical treatment. Serum intact parathyroid hormone (iPTH) levels subsequently decreased from 1,400 to 219 pg/dl and remained stable for the next 6 months. To our knowledge, this procedure has not been previously described in the literature. Local injection of ethanol may represent an interesting alternative to surgery for the treatment of deltoid parathyroid cell hyperplasia in patients in which surgical treatment is not an option.

PET-TC en Endocrinología / PET-CT in Endocrinology

El examen PET-TC ha ganado un lugar en el estudio de los tumores de origen endocrino. El marcador metabólico 18F-FDG es el más empleado internacionalmente y el único por el momento en nuestro medio. Las principales limitaciones del método en Endocrinología incluyen la alta diferenciación y baja agresividad de la mayoría de los tumores endocrinos, dificultad en la identificación de lesiones de escasa celularidad y el pequeño tamaño. Las indicaciones para su empleo deben ser precisas debido a que no todos los tumores presentan sustancial avidez por este compuesto por una parte y poder extraer la máxima eficacia diagnóstica del método con adecuadas indicaciones por la otra. La indicación más importante es en pacientes con cáncer diferenciado de tiroides (CDT) con valores de Tg elevados y barridos con 131I negativos. Es aconsejable su indicación con valores de Tg mayores a los 10 ng/ml y con TSH estimulada (endógena o exógena). El objetivo es la localización de las recidivas y metástasis para su exéresis o el empleo de otras terapias alternativas al 131I. Tiene alto valor pronóstico ya que es mayor la fijación de FDG en las lesiones más agresivas. Un paciente con Tg elevada, barrido con 131I negativo y FDG positivo obliga al clínico a actuar más agresivamente para eliminar los focos patológicos, mientras que con FDG negativo puede tener una conducta expectante con controles posteriores. La introducción de otros marcadores emisores de positrones específicos como el 124I, isótopo del Iodo, seguramente aportarán mejores imágenes y diagnósticos. En los tumores neuroendocrinos la FDG tiene limitada aplicación, salvo cuando hay un grado significativo de desdiferenciación. En el cáncer medular de tiroides (CMT) es conveniente indicarlo cuando los niveles de calcitonina superan los 1000 pg/ml con el objeto de localizar el/los sitios de su producción. Con la introducción de radiofármacos más específicos de las diferentes líneas celulares que componen el espectro de los tumores neuroendocrinos con emisores de positrones, tales como 18F-DOPA, 68Ga DOTA, 11C metomidato, 11C-5-hidroxitriptofano, etc., se podrá estudiar con mayor precisión el comportamiento metabólico-molecular de estos tumores.

PET/CT scans have reached an important place in the evaluation of endocrine tumors. The metabolic marker 18F-FDG is the most widespread over the world, and, for the time being, it is the only one available in our country. The limitations of this technique in Endocrinology include high differentiation and low aggressiveness of most endocrine tumors, and low detection rate for low cellularity and/or small lesions. Indications for PET/CT scan in these tumors should be precise, due to the fact that not all of these lesions are significantly glucose-avid and to extract the maximum diagnostic efficacy of this modality to achieve the optimum diagnostic accuracy. The most important indication is DTC with high Tg levels and negative 131I scans. It is advisable to indicate a PET/CT scan in patients with Tg > 10 ng/ml and stimulated TSH (endogenous or exogenous). The aim is to locate recurrencies and metastases in order to remove them, either surgically or by any other therapy alternative to 131I. Due to higher uptake in more aggressive lesions, this study has a high prognostic value. In patients with high Tg levels, negative I-131 scan, and abnormal FDG uptake, the practitioner must act more aggressively in order to remove the pathologic foci, while with a negative FDG -PET scan, the conduct can be expectant, with periodic follow-up. The introduction of other positron-emitting tracers like 124-Iodine, is likely to yield superior quality images and provide better diagnoses. FDG has a limited efficiency in neuroendocrine tumors, unless they show a significant level of desdiffer-entiation. The scan is indicated in MTC, when calcytonin levels are above 1000 pg/ml, in order to locate the tumor sites. With the introduction of more specific positron-emitting radiopharmaceuticals, such as 18F-DOPA, 68Ga DOTA, 11C metomidate, 11C-hidroxytriptophan and others, it will be possible to study the metabolic-molecular behavior of these tumors with a more accurate approach.

[Resistance surveillance of Neisseria gonorrhoeae in a hospital in Santa Fe province, Argentina: 1997-2004]. / Vigilancia de la resistencia de Neisseria gonorrhoeae en un hospital de la provincia de Santa Fe, Argentina: 1997-2004.

Resistance phenotypes characterized by minimum inhibitory concentration, disk diffusion and beta-lactamase production were determined in 434 isolates from patients attending the Sexually Transmitted Disease Service at Dr. José Maria Cullen Hospital in Santa Fe, Argentina. Susceptibility tests to penicillin, tetracycline, ciprofloxacin, espectinomycin, azithromycin and ceftriaxone were performed. Pulsed-field gel electrophoresis was conducted made to on three ciprofloxacin-resistant isolates. Epidemiologically speaking, three interesting events should be highlighted: during 1997, plasmid-mediated high level tetracycline-resistant strains were observed (33.3%); from 2002 to 2004 a significant increase of plasmid-mediated penicillin-resistant strains was registered (9.7% to 34.8%); and in the year 2000 the first two quinolone-resistant strains emerged in the province. In our hospital, the first azithromycin-resistant isolate emerged in 2004. We therefore emphasize the importance of the Clinical Microbiology Laboratory in order to provide information for the empiric treatment of this infection.

Vigilancia de la resistencia de Neisseria gonorrhoeae en un hospital de la provincia de Santa Fe, Argentina: 1997-2004 / Resistance surveillance of Neisseria gonorrhoeae in a hospital in Santa Fe province, Argentina: 1997-2004

Se determinaron los fenotipos de resistencia caracterizados por la concentración inhibitoria mínima, la difusión con discos y la producción de β-lactamasa de 434 aislamientos de Neisseria gonorrhoeae obtenidos de pacientes atendidos en el Servicio de Enfermedades de Transmisión Sexual del Hospital Dr. José María Cullen, Santa Fe, Argentina. Se realizaron pruebas de sensibilidad a los siguientes antimicrobianos: penicilina, tetraciclina, ciprofloxacina, espectinomicina, azitromicina y ceftriaxona. A tres aislamientos resistentes a ciprofloxacina se les realizó electroforesis de campo pulsado. Se destacaron tres situaciones epidemiológicas de interés: en el año 1997, alta incidencia de aislamientos con resistencia plasmídica a tetraciclina (33,3%); en el período 2002-2004, un aumento significativo de la resistencia plasmídica a penicilina (9,7% a 34,8%); y en el año 2000, la emergencia de dos de los tres primeros aislamientos con resistencia a quinolonas del país. El primer aislamiento resistente a azitromicina en nuestro hospital emerge en el 2004. Este trabajo jerarquiza el rol del Laboratorio de Microbiología Clínica en la orientación del tratamiento empírico de la gonorrea.

Resistance phenotypes characterized by minimum inhibitory concentration, disk diffusion and β-lactamase production were determined in 434 isolates from patients attending the Sexually Transmitted Disease Service at Dr. José María Cullen Hospital in Santa Fe, Argentina. Susceptibility tests to penicillin, tetracycline, ciprofloxacin, espectinomycin, azithromycin and ceftriaxone were performed. Pulsed-field gel electrophoresis was conducted made to on three ciprofloxacin-resistant isolates. Epidemiologically speaking, three interesting events should be highlighted: during 1997, plasmid-mediated high level tetracycline-resistant strains were observed (33.3%); from 2002 to 2004 a significant increase of plasmid-mediated penicillin-resistant strains was registered (9.7% to 34.8%); and in the year 2000 the first two quinolone-resistant strains emerged in the province. In our hospital, the first azithromycin-resistant isolate emerged in 2004. We therefore emphasize the importance of the Clinical Microbiology Laboratory in order to provide information for the empiric treatment of this infection.

[Evaluation of cefoxitin and cefotaxime screening plates for the detection of methicillin-resistance in Staphylococcus aureus]. / Evaluación de placas de screening de cefoxitina y cefotaxima para la detección de resistencia a meticilina en Staphylococcus aureus.

Detection of methicillin-resistant Staphylococcus aureus (MRSA) isolates represents a serious problem to low and media level microbiology labs. In this work cefoxitin (FOX) and cefotaxime (CTX) screen plates (AS) (8-16 microg/ml) with and without 4% of NaCl were evaluated to detect MRSA. Sensitivity, specificity, positive and negative predictive values were determined. The AS oxacillin and the agglutination test MRSA-Screen Latex for the detection of PLP2a were used as reference methods for the evaluation of the different studied screening plates. The 100% (94 strains) PLP2a positive were detected as MRSA with FOX (8 microg/ml), and CTX (8 microg/ml with 4% NaCl) AS. The advantage of FOX AS (8 microg/ml) is that it does not need the addition of NaCl, and CTX AS (8 microg/ml with 4% NaCl) is that cefotaxime is an antimicrobial easily accessible in our country.

Centellograma esofagogastrics en el diagnostico del reflujo gastroesofagico. / Gatroesophageal scintigraphy in the diagnosis of gastroesophageal reflux

En 7 casos con hernia hiatal comprobada radiologicamente se realizo centellograma esofagogastrico. Se describe la tecnica utilizada. En 6 se obtuvo evidencia centellografica de reflujo, mientras que la radiografia simple habia detectado 4. Resulta un metodo confortable para los pacientes ya que elimina el uso de la sonda nasogastrica

Centellograma esofagogastrics en el diagnostico del reflujo gastroesofagico. / Gatroesophageal scintigraphy in the diagnosis of gastroesophageal reflux

En 7 casos con hernia hiatal comprobada radiologicamente se realizo centellograma esofagogastrico. Se describe la tecnica utilizada. En 6 se obtuvo evidencia centellografica de reflujo, mientras que la radiografia simple habia detectado 4. Resulta un metodo confortable para los pacientes ya que elimina el uso de la sonda nasogastrica