Retrospective Analysis of the Development of Human Thyroglobulin during Pregnancy in Patients with Treated Non-Recurrent Differentiated Thyroid Cancer.

Aim: Therapy success in patients with differentiated thyroid cancer (DTC) after thyroidectomy and radioiodine therapy (RIT) is proven by permanent decrease in human thyroglobulin (hTg) to <1 ng/mL. In this retrospective analysis hTg development before, during and after pregnancy were analyzed. Material and methods: A descriptive analysis of hTg courses in 47 women with 57 pregnancies under levothyroxine substitution was performed after treatment of DTC without evidence of residual or recurrent disease. We compared hTg levels before, during and after pregnancies. A median of four measurements were performed during pregnancy. Results: In five out of the 47 patients at least one hTg increase to ≥1.0 ng/mL occurred during pregnancy (P1: 1.1; P2: 1.75; P3: 1.0; P4: 1.1; P5: 1.07 ng/mL). In another three cases an increase to ≥0.5 ng/mL occurred. After delivery, all patients returned to undetectable hTg levels. Human Tg maxima during pregnancy were significantly elevated according to Friedman´s Chi2 and p Holm−Bonferroni. Conclusion: In women with ablative thyroid therapy after DTC, a temporary elevation in hTg levels during pregnancy may occur. The reason therefore remains unclear and requires further investigation.

Interobserver Agreement of Planar and SPECT Tc99m-MIBI Scintigraphy for the Assessment of Hypofunctioning Thyroid Nodules.

INTRODUCTION: Thyroid scintigraphy with 99mTc-methoxyisobutylisonitrile (MIBI) is a helpful tool for the risk stratification of thyroid nodules (TN). Whereas a nodule with low or hypointense MIBI uptake has a low risk for malignancy, a hyperintense uptake may indicate a malignant nodule, which requires surgical resection. The appropriate diagnostic or therapeutic regimen of an isointense nodule with an uptake similar to the paranodular tissue is discussed controversially. Aim of this study was to assess the interobserver agreement (IA) for the assignment of TN to the three categories: hypo-, iso-or hyperintense. METHODS: Retrospective analysis of planar and SPECT images of MIBI scintigraphy was performed in 36 randomly selected patients with hypofunctioning TN and histological diagnosis. Four observers with different levels of experience in MIBI-scintigraphy analyzed MIBI uptake and assigned the nodules to the appropriate category. To assess the IA, Fleiss' Kappa was calculated. RESULTS: The study cohort included 11 patients with papillary thyroid carcinoma (diameter 20.3 mm) and 25 patients with benign nodules (diameter 24.8 mm). The IA for all nodules using planar images was 0.76 compared to 0.80 for SPECT images. The IA was better in the subgroup of malignant nodules for planar images as well as SPECT images (Kappa 0.91 and 0.90, respectively) compared to benign nodules (0.65 and 0.76, respectively). Using SPECT images, only one thyroid carcinoma presented with hypointense uptake, the remainder with hyper- or isointense uptake. In contrast, benign nodules were found in all categories. CONCLUSION: MIBI scintigraphy shows a good IA for the interpretation of thyroid carcinoma. The IA is further improved if MIBI scintigraphy is performed in SPECT technique.

Evaluation of sentinel lymph node biopsy prior to axillary lymph node dissection: the role of isolated tumor cells/micrometastases and multifocality/multicentricity-a retrospective study of 1214 breast cancer patients.

PURPOSE: Sentinel lymph node biopsy (SLNB) alone has thus become an accepted surgical approach for patients with limited axillary metastatic disease. We investigated to what extent isolated tumor cells (ITC) or micrometastasis in SLNBs is associated with proven tumor cells or metastasis in non-sentinel lymph nodes. Furthermore, we investigated the feasibility of SLNB in multifocal and multicentric tumors as both entities have been considered a contraindication for this technique. METHODS: 1214 women suffering from T1 and T2 invasive breast cancer, with clinically and sonographically insuspect axillary status and undergoing primary breast cancer surgery including SLNB and axillary staging in case of SLN (sentinel lymph node) metastases, were recruited into this multicentered study. RESULTS: ITC and micrometastases were found in 2.01 and 21.4% of patients with SLN metastases (n = 299). Among patients with sentinel micrometastases, 4.7% showed further axillary micrometastases, while only two patients (3.1%) had two axillary macrometastases. Multifocal and multicentric tumors were diagnosed in 9.3 and 2.6% of our patients who at least had one SLN resected, respectively. Detection rates of SLNs did not differ between the cohorts suffering from unicentric and multifocal or multicentric disease. Moreover, the portion of tumor-free SLNs, the number of SLNs with metastasis as well as the mean number of resected SLNs did not differ. CONCLUSIONS: No patient with sentinel node micrometastases showed more than two axillary macrometastases. Multifocal and multicentric disease is no contraindication for SLNB.

Evaluation of Sentinel Lymph Node Biopsy and Axillary Lymph Node Dissection for Breast Cancer Treatment Concepts - a Retrospective Study of 1,214 Breast Cancer Patients.

BACKGROUND: Most breast cancer patients require lumpectomy with axillary sentinel lymph node biopsy (SLNB) or axillary lymph node dissection (ALND). The ACOSOG Z0011-trial failed to detect significant effects of ALND on disease-free and overall survival among patients with limited sentinel lymph node (SLN) metastases. Intense dose-dense chemotherapy and supraclavicular fossa radiation (SFR) are indicated for patients with extensive axillary metastases. In this multicentered study, we investigated the relevance of ALND after positive SLNB to determine adequate adjuvant therapy. METHODS: We retrospectively analyzed data from 1,214 patients with clinically nodal negative T1-T2 invasive breast cancer undergoing surgery at Hanau City Hospital Breast cancer center. RESULTS: 681 patients underwent ALND after SLNB. 20 patients (8.5%) from the group with 1 or 2 SLN metastases (n = 236) showed more than 3 lymph node metastases after ALND. 13 patients (31.7%) from the group with more than 2 SLN metastases (n = 41) were diagnosed with a minimum of 4 axillary lymph node metastases after ALND. CONCLUSIONS: In 8.5% of the patients with 1 or 2 SLN metastases, ALND detected more than 3 macrometastases, setting the indication for intense dose-dense chemotherapy and SFR. More than 2 SLN metastases, T stage and grading predict lymph node metastases.

Calculation and validation of a plasma calcitonin limit for early detection of medullary thyroid carcinoma in nodular thyroid disease.

BACKGROUND: The early diagnosis of medullary thyroid carcinoma (MTC) is crucial for effective therapy. Elevated plasma calcitonin concentrations (pCT-Cs) are generally a specific and sensitive indicator for C-cell hyperplasia or MTC. The presence of thyroid nodules raises the possibility of MTC. Hence, in endemic goiter regions, there is a need for information regarding the pCT-C values that are indicative of C-cell hyperplasia or MTC. The aim of this study, therefore, was to determine an upper pCT-C to distinguish patients with and without MTC in a collective with nodular thyroid disease, and to give an estimation of the prevalence of MTC in an endemic goiter area. METHODS: Basal pCT-C was measured in 21,928 patients with thyroid nodules living in central Germany, an area with endemic goiter due to previous iodine deficiency. In 218 subjects with pCT-Cs exceeding 10 ng/L, stimulated pCT-C was additionally determined, as suggested by the German consensus recommendation. A nominal normal range for basal pCT-C was calculated with data from 21,900 subjects without known MTC. The predicted upper limit was then validated using the known diagnoses of 376 patients with pCT-Cs exceeding 10 ng/L, 28 of whom presented with MTC. RESULTS: For basal pCT-C, calculation of the three-sigma borders after logarithmic transformation revealed upper limits of the nominal normal range of 14.6 ng/L in females and 32.8 ng/L in males, respectively. However, three male patients with small MTCs had basal pCT-Cs between 15 and 33 ng/L. None of the patients with MTC had a basal pCT-C below 15 ng/L or an increase in pCT-C after pentagastrin stimulation that was less than 80 ng/L. In the basal pCT-C range between 15 and 50 ng/L (n = 192; eight with MTC), the positive predictive value for the detection of MTC was 4% in our group. Applying an upper limit for basal pCT-C of 15 ng/L in both sexes, 329 of the total of 21,928 patients exceeded this range. Among these, the final outcome is known in 231 subjects, including all 28 MTCs. CONCLUSIONS: An upper limit of 15 ng/L instead of 10 ng/L for basal pCT-C is able to detect all MTC and reduce false-positive cases. The prevalence of MTC in nodular thyroid disease in our group was approximately 1.8 per thousand.

How accurate are health care workers' perceptions of patient suffering? A pilot study.

Health care workers' perceptions of patient suffering have not been well studied. Patients and health care workers were invited to answer a single, open-ended question. To develop a survey tool that could be validated and used for future research, what health care workers thought causes or caused the most suffering for patients was compared with what patients actually identified as the cause of their worst suffering. Health care workers underestimated loss and significantly underestimated physical nonpainful symptoms as causes of maximal suffering. Communication, emotional, and systems issues were often overestimated by health care workers. Health care workers may not accurately perceive what causes the worst suffering for patients. More studies are needed.

Limited sensitivity of parathyroid imaging with (99m)Tc-sestamibi/(123)I subtraction in an endemic goiter area.

UNLABELLED: Double-phase single-tracer scintigraphy with (99m)Tc-sestamibi is now generally used for parathyroid imaging but, at least in endemic goiter areas, complementary thyroid scintigraphy is recommended. Although (123)I-sodium iodide is considered to be the optimal thyroid agent, it is hardly ever used because of high costs and logistic difficulties. Our study presents the results of using the (99m)Tc-sestamibi/(123)I subtraction technique in a region with a high goiter prevalence. Special attention was paid to the changes in sensitivity and specificity and their relationship to thyroid volume as well as to autonomous and nodular thyroid disease. METHODS: One hundred three scintigraphic parathyroid examinations on 96 patients were included in this study. Fifty-eight of all patients had concomitant morphologic or functional alterations of the thyroid. Initially, 10 MBq (123)I-sodium iodide were injected. Then, 150 MBq (99m)Tc-sestamibi were administered after 3-5 h, followed by planar scintigraphic imaging of the neck and upper chest region using a double-isotope technique. RESULTS: An area with increased tracer uptake on the subtraction image was found in 44 cases. Forty-three of them proved to be true-positive. No suspicious lesions were detected scintigraphically on the remaining 59 examinations. However, histologic examination revealed a parathyroid adenoma or hyperplasia in 11 of these cases. The mean parathyroid volume of these false-negative patients was 0.9 mL. Secondary hyperparathyroidism with multiple enlarged parathyroid glands was found in 4 of these cases. The sensitivity of the parathyroid scintigraphy was 80% (43/54) and the specificity was 98% (48/49). There was a distinct difference in the sensitivity between the subgroups with thyroid volumes of >15 mL and <15 mL (76% vs. 88%), although the resected parathyroid glands had a similar size in both subgroups. The specificity was 97% and 100%, respectively. No significant difference in the sensitivity and specificity was observed between the subgroups with and without morphologic or functional alterations of the thyroid (80% vs. 79% and 96% vs. 100%, respectively). CONCLUSION: The sensitivity of parathyroid imaging with (99m)Tc-sestamibi/ (123)I subtraction depends mainly on the thyroid and parathyroid volumes rather than on the presence of nodular or autonomous thyroid disease.