Radiofrequency ablation as a novel modality in Ecuador for treating toxic thyroid nodules: a case series.

Background: Treating hyperthyroidism induced by autonomously functioning thyroid nodules (AFTNs) through radioactive iodine and surgery often results in undesirable hypothyroidism. Radiofrequency ablation (RFA) has arisen as a favorable option. European guidelines recommend RFA for small AFTN in young patients, aiming to restore normal thyroid function and avoid irradiation. The procedure, costing between 500 and 1,000 euros, is conducted in outpatient clinics and takes 15 to 40 minutes. We aimed to describe the clinical outcomes of AFTN patients treated with RFA in Ecuador. Case Description: We included eight patients with toxic thyroid nodules suppressed thyroid-stimulating hormone (TSH), with symptomatic hyperthyroidism. The mean age was 41.63 years [standard deviation (SD): 14.97 years]. The median follow-up time was 8 months. Nodules were solid (37.5%) or predominantly solid (62.5%). The mean volume pre-RFA was 5.27 mL [interquartile range (IQR), 0.70-9.66 mL]. After ablation, the median volumes at 1, 3, and 6 months were [2.25 (SD: 1.67; P<0.12), 1.28 (SD: 1.1; P=0.013), and 1.37 (SD: 1; P=0.23) mL], respectively. The volume reduction (VR) was 45.8%, 75.1%, and 69.7% at 1-, 3-, and 6-month follow-up, respectively. Conclusions: RFA holds promise as a potential therapeutic approach for managing AFTNs. The success and the feasibility of RFA in this series are consistent with other studies as a treatment option in young patients with small AFTN. However, more research is needed to establish comprehensive guidelines and protocols to maximize the benefits of RFA in AFTNs.

Radiofrequency ablation for thyroid nodules in Ecuador: a cross-sectional study.

OBJECTIVES: To describe the demographic characteristics and clinical outcomes following the first cohort of patients with Bening Thyroid Nodule (BTN) and (Papillary Thyroid Microcarcinoma) (PTMC) treated with Radiofrequency Ablation (RFA)in Ecuador. METHODS: Single-center, cross-sectional study. We included adults undergoing RFA for BTN and PTMC between July 2019 and May 2022. Descriptive statistics and the Wilcoxon signed-rank test were used to compare some pre- and post-intervention outcomes. RESULTS: We included 44 patients with 36 BTNs and eight PTMCs. The median age was 45.80 years (IQR 16-79 years), and most patients had normal thyroid function (72.72%). The median follow-up time was 7.80 months (IQR1.0-34.0). Nodules were primarily solid (43.21%) or predominantly solid (56.81%). The pre-RFA median volume in the benign lesions group was 10.30 ml (IQR 1.86-18.97). After ablation, the 1-month, 3-month, 6-month, and 12-month median volumes were 6.90 (IQR 0.48-10.15; p < 0.01) mL, 5.72 (IQR 0.77-7.25; p = 0.045); 0.98 (IQR 0.25-3.64; p < 0.01), and 0.11 (IQR 0.07-11.26; p = 0.026), respectively. The volume rate reduction was 47.20%, 72.20%, 74.00%, and 96.20% at 1, 3, 6, and 12-month follow-ups, respectively. The pre-RFA median volume in the PTMC group was 0.25 ml (IQR 0.19-0.48). After ablation, the 1-month, 3-month, and 6-month mean volumes were 0.19 (range 0.12-0.31; p = 0.120) mL, 0.10 (IQR 0.05-0.15; p = 0.13), and 0.01 (IQR 0.005-0.04; p = 0.364), respectively. CONCLUSIONS: In this first report from Ecuador, we found that RFA may be a feasible alternative for treating benign and malignant thyroid nodules in the short term. Long-term data are needed to evaluate oncologic outcomes in PTMC patients.

Ablation techniques or active surveillance compared to surgical resection in patients with low-risk papillary thyroid cancer: a systematic review and meta-analysis.

BACKGROUND: The global prevalence of thyroid cancer is on the rise. About one-third of newly diagnosed thyroid cancer cases comprise low-risk papillary thyroid cancer (1.5 cm or more minor). While surgical removal remains the prevailing approach for managing low-risk papillary thyroid cancer (LPTC) in patients, other options such as active surveillance (AS), radiofrequency ablation (RFA), microwave ablation (MWA), and laser ablation (LA) are also being considered as viable alternatives. This study evaluated and compared surgical thyroid resection (TSR) versus non-surgical (NS) methods for treating patients with LPTC. METHODS: The study encompassed an analysis of comparisons between surgical thyroid resection (TSR) and alternative approaches, including active surveillance (AS), radiofrequency ablation (RFA), microwave ablation (MWA), or laser ablation (LA). The focus was on patients with biopsy-confirmed low-risk papillary thyroid cancer (LPTC) of less than 1.5 cm without preoperative indications of local or distant metastasis. The primary outcomes assessed were recurrence rates, disease-specific mortality, and quality of life (QoL). Data were collected from prominent databases, including Cochrane Database, Embase, MEDLINE, and Scopus, from inception to June 3rd, 2020. The CLARITY tool was utilized to evaluate bias risk. The analysis involved odds ratios (OR) with 95% confidence intervals (CI) for dichotomous outcomes, as well as mean differences (MD) and standardized mean differences (SMD) for continuous outcomes. The study is registered on PROSPERO under the identifier CRD42021235657. RESULTS: The study incorporated 13 retrospective cohort studies involving 4034 patients. Surgical thyroid resection (TSR), active surveillance (AS), and minimally invasive techniques like radiofrequency ablation (RFA), microwave ablation (MWA), and laser ablation (LA) were performed in varying proportions of cases. The analysis indicated that specific disease mortality rates were comparable among AS, MWA, and TSR groups. The risk of recurrence, evaluated over different follow-up periods, showed no significant differences when comparing AS, RFA, MWA, or LA against TSR. Patients undergoing AS demonstrated better physical health-related quality of life (QoL) than those undergoing TSR. However, no substantial differences were observed in the overall mental health domain of QoL when comparing AS or RFA with TSR. The risk of bias was moderate in nine studies and high in four. CONCLUSION: Low-quality evidence indicates comparable recurrence and disease-specific mortality risks among patients with LPTC who underwent ablation techniques or active surveillance (AS) compared to surgery. Nevertheless, individuals who opted for AS exhibited enhanced physical quality of life (QoL). Subsequent investigations are warranted to validate these findings.

Surgical approach for thyroglossal duct cyst cancer: a case report of challenging conventional thinking.

This article reports an older woman with a 2-year history of enlarging submental neck mass. Head and neck imaging displayed a group with a solid central component. Additionally, a fine-needle aspiration suggested neoplasia. Thyroglossal duct cyst cancer is sporadic, accounting for ˂1% of all thyroid malignancies. A Sistrunk procedure was followed by a total thyroidectomy and unilateral neck dissections. From histological and immunohistochemical examinations, the incidental finding of carcinoma indicates the diagnosis of thyroid tissue thyroglossal duct cyst carcinoma, as it is the most common site for malignancy in ectopic thyroid tissue. The patient had an excellent recovery without additional treatments after surgery.

Managing thyroid cancer in Steinert's disease: the role of radiofrequency ablation.

Radiofrequency ablation (RFA) is a minimally invasive, non-surgical technique used to treat benign or microcarcinoma thyroid nodules (TN) that provides an alternative for patients considered high-risk candidates for surgery. Myotonic dystrophy type 1 (DM1), also known as Steinert's Disease, is a multisystem disorder that affects various organs and tissues, including the thyroid. In this case, we presented a male patient diagnosed with DM1 who incidentally discovered a left TN with features indicative of thyroid cancer. Due to the patient's increased surgical risk associated with DM1, we opted for RFA as the treatment approach. In the follow-up, the TN decreased by 76.92% in size. The patient's thyroid function remained standard, with no reported complications or adverse effects post-treatment.

Hidden lymphoma in the appendix: a case of primary appendiceal diffuse large B-cell lymphoma presenting as acute appendicitis.

The occurrence of diffuse large B-cell lymphoma (DLBCL) of the appendix presenting as acute appendicitis is rare, constituting only a minuscule portion (0.015%) of gastrointestinal lymphoma cases. We present a case of a 55-year-old woman that was admitted to the emergency department with symptoms of acute appendicitis and underwent an interval laparoscopic appendectomy with a right hemicolectomy and lymph node resection. Pathological examination revealed the presence of DLBCL in the appendix. The patient is undergoing chemotherapy.

Bowel volvulus in the chest after an esophagectomy: an uncommon type IV hiatal hernia.

Transverse colon volvulus is an uncommon cause of bowel obstruction. Moreover, a thoracic herniation into the thorax is still rare. An early diagnosis and treatment are critical to the patient since they can lead to bowel infarction, peritonitis and death. We reported a 55-year-old woman admitted to the emergency department at a hospital. She presented with severe abdominal pain, mainly in the epigastrium, associated with dyspnea, nausea and vomiting. An abdominal CT scan showed a large hiatal hernia in the thorax with signs of volvulus in the involved segment.

The diagnostic dilemma: Giant Mucocele of the appendix-challenging conventional thinking.

This article reports on a 76-year-old male patient diagnosed with a mucocele of the appendix. A mucocele of the appendix is a benign fluid-filled swelling caused by the accumulation of mucus in the appendix due to a blockage in its discharge route. The patient presented with symptoms of chronic constipation and rectal tenesmus and was diagnosed through physical examination, imaging studies and laboratory tests. The patient underwent an open ileocolectomy procedure to remove the affected appendix. The results of the histopathological analysis showed a confined low-grade appendiceal mucinous neoplasm. The overall survival rate after surgery for mucocele of the appendix is excellent, with a low recurrence rate.

Successful outcome of combined surgical and negative pressure therapy in complex enterocutaneous fistulas: a case report.

An enterocutaneous fistula (ECF) is a complex medical issue that occurs when abnormal communication between the small intestine and the skin occurs. This can lead to the leakage of digestive contents, such as feces and food, onto the skin's surface. The case of an 86-year-old woman is presented, who developed high-output ECF after undergoing Hartmann surgery, intestinal transit reconstruction for perforated diverticulitis and incisional hernia treatment involving hernioplasty and polypropylene mesh. The patient had suffered from a serous-purulent discharge from a low-volume surgical wound for several years. Despite optimizing the patient's nutritional status, a laparotomy and small bowel resection were performed successfully. However, using vacuum dressing as a cover for the fistula in the lower gastrointestinal tract remains a subject of debate and limited research. No officially recognized international guidelines recommend its use for small bowel ECF.

Large congenital facial teratoma.

This case report discusses a presentation of a giant facial teratoma, a rare congenital neoplasm. Head and neck locations of the tumour uncommonly distort the face and may be associated with functional problems. We present a case of teratoma arising from the right parotid extending to the extracranial regions, successfully managed by surgical resection. Reviewing this case with the supporting body of literature anticipates further investigation to address patients' needs more thoroughly.

Perforated mediastinal gastric volvulus: an uncommon complication of hiatal hernia.

A woman in her 50s was admitted to the emergency department with a 3-day history of abdominal pain, mainly in the right hypochondrium, radiating to the back, associated with postprandial vomiting and dysphagia. The abdominal ultrasound study found no abnormalities. Laboratory tests showed increased C-reactive protein levels, creatinine and high white blood cell count without a left shift. Abdominal computed tomography scan exhibited mediastinal herniation, twist and perforation of the gastric fundus associated with air-fluid levels in the lower mediastinum. The patient underwent diagnostic laparoscopy requiring laparotomy conversion due to hemodynamic instability related to the pneumoperitoneum. During the intensive care unit (ICU) stay, thoracoscopy with pulmonary decortication was performed to treat complicated pleural effusion. After ICU and standard infirmary bed recovery, the patient was discharged from the hospital. This report illustrates a case of perforated gastric volvulus as the cause of nonspecific abdominal pain.

Combination of Mustardé cheek advancement flap and paramedian forehead flap as a functional and aesthetic alternative.

Depending on the size and location, defects resulting from the surgical procedure due to basal cell carcinoma (BCC) may be challenging to reconstruct. A combination of more than one flap type might be necessary for moderate to large-sized defects, especially in face lesions. We present a patient with a large BCC in the nasal region, successfully closed using a combination of rotation and advancement flaps. The patient showed excellent functional and cosmetic outcomes.

Identification of KIT and BRAF mutations in thyroid tissue using next-generation sequencing in an Ecuadorian patient: A case report.

Background: The incidence of thyroid cancer has increased worldwide. Ecuador presents the highest incidence among Latin American countries and the second around the world. Genetic alteration is the driving force for thyroid tumorigenesis and progression. The change from valine (V) to glutamic acid (E) at codon 600 of the BRAF gene (BRAFVal600Glu) is the most commonly reported mutation in thyroid cancer. Moreover, the BRAF mutation is not the only mutation that has been correlated with TC. For instance, mutations and overexpression of the KIT gene has been associated with different types of cancer, including lung and colon cancer, and neuroblastoma. Case presentation: A woman in her early fifties, self-identified as mestizo, from Otavalo, Imbabura-Ecuador had no systemic diseases and denied allergies, but she had a family history of a benign thyroid nodule. Physical examination revealed a thyroid gland enlargement. The fine-needle aspiration biopsy indicated papillary thyroid cancer. The patient underwent a successful total thyroidectomy with an excellent recovery and no additional treatments after surgery. Using Next-Generation sequencing a heterozygous mutation in the BRAF gene, causing an amino acid change Val600Glu was identified. Similarly, in the KIT gene, a heterozygous mutation resulting in an amino acid change Leu678Phe was detected. Moreover, an ancestry analysis was performed, and the results showed 3.1% African, 20.9% European, and 76% Native American ancestry. Conclusions: This report represents the genetic characteristics of papillary thyroid cancer in an Ecuadorian woman with a mainly Native American ethnic component. Further studies of pathological variants are needed to determine if the combined demographic and molecular profiles are useful to develop targeted treatments focused on the Ecuadorian population.

Paradigms about the COVID-19 pandemic: knowledge, attitudes and practices from medical students.

BACKGROUND: As the disease caused by the novel coronavirus has spread globally, there has been significant economic instability in the healthcare systems. This reality was especially accentuated in Ecuador where, the shortage of healthcare workers combined with cultural and macroeconomic factors has led Ecuador to face the most aggressive outbreak in Latin America. In this context, the participation of final-year medical students on the front line is indispensable. Appropriate training on COVID-19 is an urgent requirement that universities and health systems must guarantee. We aimed to describe the knowledge, attitudes, and practices of Ecuadorian final-year medical students that could potentially guide the design of better medical education curricula regarding COVID-19. METHODS: This was a cross-sectional 33-item online survey conducted between April 6 to April 2020 assessing the knowledge, attitudes, and practices toward the diagnosis, treatment, prevention, and prognosis toward COVID-19 in Ecuadorian final-year medical students. It was sent by email, Facebook, and WhatsApp. RESULTS: A total of 309 students responded to the survey. Out of which 88% of students scored high (≥ 70% correct) for knowledge of the disease. The majority of students were pessimistic about possible government actions, which is reflected in the negative attitude towards the control of COVID-19 and volunteering during the outbreak in Ecuador (77%, and 58% of the students, respectively). Moreover, 91% of students said they did not have adequate protective equipment. The latter finding was significantly associated with negative attitudes. CONCLUSIONS: Although a large number of students displayed negative attitudes, the non-depreciable percentage of students who were willing to volunteer and the coexisting high level of knowledge displayed by students, suggests that Ecuador has a capable upcoming workforce that could benefit from an opportunity to strengthen, improve and advance their training in preparation for COVID-19. Not having personal protective equipment was significantly associated to negative attitudes. Providing the necessary tools and creating a national curriculum may be one of the most effective ways to ensure all students are trained, whilst simultaneously focusing on the students' most pressing concerns. With this additional training, negative attitudes will improve and students will be better qualified.

Thyroid cancer overdiagnosis and overtreatment: a cross- sectional study at a thyroid cancer referral center in Ecuador.

BACKGROUND: In contrast to the rapid increase in thyroid cancer incidence, the mortality has remained low and stable over the last decades. In Ecuador, however, thyroid cancer mortality has increased. The objective of this study is to determine possible drivers of high rates of thyroid cancer mortality, through a cross-sectional analysis of all patients attending a thyroid cancer referral center in Ecuador. METHODS: From June 2014 to December 2017, a cross-sectional study was conducted at the Hospital de Especialidades Eugenio Espejo, a regional reference public hospital for endocrine neoplasia in adults in Quito, Ecuador. We identified the mechanism of detection, histopathology and treatment modalities from a patient interview and review of clinical records. RESULTS: Among 452 patients, 74.8% were young adults and 94.2% (426) were female. 13.7% had a family history of thyroid cancer, and patients' median tumor size was 2 cm. The incidental finding was 54.2% whereas 45.8% was non-incidental. Thyroid cancer histology reported that 93.3% had papillary thyroid cancer (PTC), 2.7% follicular, 1.5% Hurtle cells, 1.6% medullary, 0.7% poor differentiated, and 0.2% anaplastic carcinoma. The mean MACIS (metastasis, age, completeness, invasion, and size) score was 4.95 (CI 4.15-5.95) with 76.2% of the thyroid cancer patients having MACIS score less than or equal to 6. The very low and low risk of recurrence was 18.1% (79) and 62% (271) respectively. An analysis of 319 patients with non-metastatic thyroid cancer showed that 10.7% (34) of patients had surgical complications. Moreover, around 62.5% (80 from 128 patients with thyroglobulin laboratory results) of TC patients had a stimulated-thyroglobulin value equal or higher than 2 ng/ml. Overall, a poor surgical outcome was present in 35.1% (112) patients. Out of 436 patients with differentiated thyroid carcinoma, 86% (375) received radioactive iodine. CONCLUSION: Thyroid cancer histological characteristics and method of diagnosis are like those described in other reports without any evidence of the high frequency of aggressive thyroid cancer histology. However, we observed evidence of overtreatment and poor surgical outcomes that demand additional studies to understand their association with thyroid cancer mortality in Ecuador.

Thyroid Cancer in Ecuador, a 16 years population-based analysis (2001-2016).

BACKGROUND: Thyroid cancer is the most frequent endocrine neoplasia worldwide. Information from Andean countries is scarce. In Ecuador there is no reports available of the epidemiology of this type of cancer. The aim of this study is to present the epidemiology and the burden of disease of thyroid cancer. METHODS: This is a cross-sectional population-based analysis of thyroid cancer epidemiology in Ecuador from 2001 to 2016. The variables studied were the overall mortality rate, socio-demographics characteristics of the hospitalized patients, geographical trends and the burden of thyroid cancer in Ecuador. All the data was obtained from the official records reported by the Ministry of Public Health's and retrieved from the public databases of the Vital Statistics Deaths and Births Databases and the National Institute of Census and Statistics (INEC). RESULTS: In Ecuador, over a period of 16 years from 2001 to 2016 a total of 23,632 hospital admissions were reported, which caused 1539 deaths due thyroid cancer. Data demonstrated an annual mean of 1477 cases, which caused 96 deaths per year in average. The annual incidence fluctuated from 3 in 2001 to 22 in 2016 per 100,000 inhabitants. Women were 5 times more likely than men to have thyroid cancer. The average length of stay for both sexes were 4 days. The mortality attributable to thyroid cancer represent less than 0.3% of all cancer deaths. CONCLUSION: Ecuador has one of the highest rates of thyroid cancer in Latin America, ranking first among women in Latin America. Although this cancer is frequent, mortality rate is relatively low. As this is the first national report of thyroid cancer in the country, a further analysis of the pathological variants and the grading of this neoplasia is needed.

Multiple Endocrine Neoplasia Type 2B (MEN2B) delayed diagnosis: importance of opportune recognition of MEN2 Syndromes in pediatric thyroid cancer

ABSTRACT Background: RET proto-oncogene mutations are responsible for familial thyroid medullary carcinoma and multiple endocrine neoplasia (MEN) type 2A and 2B. These syndromes develop specific biomarkers and, in the case of MEN2B, clinically observable stigmas. However, the diagnosis of patients with MEN2B is usually delayed. Because of the close genotype-phenotype correlation, molecular testing is the final approach for the diagnosis to establish preventive care and therapeutic behaviors. Discussion: pM918T is classified as ''highest risk'' for medullary carcinoma with a 50% of lifetime risk for developing pheochromocytoma. Most cases of MEN2B are due to a de novo mutation. Even with the increased risk of developing pheochromocytoma, our 24-year-old patient does not yet present one. Other factors may be involved in the modulation of the phenotype in different populations. Case report: We present the case of a woman diagnosed with a thyroid nodule at the age of nine. She underwent a total thyroidectomy plus radical cervical lymph node dissection, with a diagnosis and initial management of papillary thyroid carcinoma. During the evolution of the disease, she developed pulmonary metastases. At the age of 24, after her first endocrinological evaluation, typical physical manifestations of MEN2B were observed. A re-evaluation of the original thyroidectomy revealed a medullary carcinoma, with positive manifestation CEA and calcitonin. The analysis of RET proto-oncogene identified a de novo mutation in exon 16 (pM918T). Conclusion: The timely diagnosis of MEN2B offers opportunities to make appropriate preventive and therapeutic decisions that may change the natural evolution of the disease and its complications.