RESUMO
Objetivo: Presentar un carcinoma inusual de tiroides y de difícil diagnóstico, su manejo y evolución. Caso clínico: Paciente de raza blanca de 37 años, desde hace 6 meses presentaba formación laterocervical derecha asintomática y ecografía con nódulo tiroideo sobre tiroides heterogénea. Sin antecedentes personales ni familiares de importancia. La punción de una adenopatía regional resultó adenocarcinoma y la del nódulo tiroideo: quiste coloide. Se intervino quirúrgicamente efectuándose un vaciamiento radical derecho y la biopsia por congelación informó carcinoma tiroideo por lo que se completó con vaciamiento cervical izquierdo y tiroidectomía total. La biopsia diferida fue: "carcinoma papilar difuso esclerosante con metástasis ganglionares en 5 de 6 ganglios peritiroideos derechos y en 7 de 9 ganglios cervicales, correspondiendo a 4 derechos y 3 izquierdos. Estadio: I, T3-N1b-M0. Se trató posteriormente con 3 dosis de yodo 131 y radioterapia externa por compromiso ganglionar mediastinal. A 6 meses de seguimiento hasta el presente, continúa libre de enfermedad. Los individuos con insulinorresistencia y síndrome metabólico presentan aumento del tamaño de la glándula tiroides y mayor prevalencia de nódulos. Tanto la insulina como la TSH se constituyen en factores de crecimiento para las células tiroideas, y los niveles de TSH son mayores en individuos con síndrome metabólico, presente en este caso. Conclusión: El carcinoma papilar, variante difusa esclerosante es un tumor inusual, de evolución más agresiva y con rápido compromiso extratiroideo y metástasis a distancia. Los autores declaran no poseer conflictos de interés.
Objective: To report a case of a diffuse sclerosing papillary carcinoma, a rare type of thyroid carcinoma, of difficult diagnosis, its management and further follow-up. Case: 37-year-old white male who presented with a 6-month history of sudden onset of an asymptomatic right-sided lateral cervical lump. No relevant previous medical or family history. On ultrasound, thyroid nodule, heterogeneous thyroid. A fine needle aspiration of a regional node was reported as adenocarcinoma and that of the thyroid nodule as a colloid cyst. Right radical neck dissection was performed. The intra-operatory biopsy revealed thyroid carcinoma; therefore, left neck dissection and total thyroidectomy were undertaken. Histopathology reported "diffuse sclerosing papillary carcinoma with metastasis to 5 of 6 right perithyroid lymph nodes and to 7 of 9 cervical lymph nodes, 4 on the right and 3 on the left. Stage: I, T3-N1b-M0". The patient received 3 doses of iodine 131 as well as external radiotherapy due to mediastinal mass. Follow-up at 6 months (to present) reveals he remains disease free. Thyroid gland enlargement and an increased prevalence of nodules is observed in subjects with insulin resistance and metabolic syndrome. Insulin and TSH are growth factors for thyroid cells, and TSH levels are higher in people with metabolic syndrome, present in this patient. Conclusion: The diffuse sclerosing carcinoma is a rare tumour of uncertain origin, with aggressive behavior, early extrathyroid invasion and distant metastasis. No financial conflicts of interest exist.
RESUMO
Objetivo: Presentar un carcinoma inusual de tiroides y de difícil diagnóstico, su manejo y evolución. Caso clínico: Paciente de raza blanca de 37 años, desde hace 6 meses presentaba formación laterocervical derecha asintomática y ecografía con nódulo tiroideo sobre tiroides heterogénea. Sin antecedentes personales ni familiares de importancia. La punción de una adenopatía regional resultó adenocarcinoma y la del nódulo tiroideo: quiste coloide. Se intervino quirúrgicamente efectuándose un vaciamiento radical derecho y la biopsia por congelación informó carcinoma tiroideo por lo que se completó con vaciamiento cervical izquierdo y tiroidectomía total. La biopsia diferida fue: "carcinoma papilar difuso esclerosante con metástasis ganglionares en 5 de 6 ganglios peritiroideos derechos y en 7 de 9 ganglios cervicales, correspondiendo a 4 derechos y 3 izquierdos. Estadio: I, T3-N1b-M0. Se trató posteriormente con 3 dosis de yodo 131 y radioterapia externa por compromiso ganglionar mediastinal. A 6 meses de seguimiento hasta el presente, continúa libre de enfermedad. Los individuos con insulinorresistencia y síndrome metabólico presentan aumento del tamaño de la glándula tiroides y mayor prevalencia de nódulos. Tanto la insulina como la TSH se constituyen en factores de crecimiento para las células tiroideas, y los niveles de TSH son mayores en individuos con síndrome metabólico, presente en este caso. Conclusión: El carcinoma papilar, variante difusa esclerosante es un tumor inusual, de evolución más agresiva y con rápido compromiso extratiroideo y metástasis a distancia. Los autores declaran no poseer conflictos de interés.(AU)
Objective: To report a case of a diffuse sclerosing papillary carcinoma, a rare type of thyroid carcinoma, of difficult diagnosis, its management and further follow-up. Case: 37-year-old white male who presented with a 6-month history of sudden onset of an asymptomatic right-sided lateral cervical lump. No relevant previous medical or family history. On ultrasound, thyroid nodule, heterogeneous thyroid. A fine needle aspiration of a regional node was reported as adenocarcinoma and that of the thyroid nodule as a colloid cyst. Right radical neck dissection was performed. The intra-operatory biopsy revealed thyroid carcinoma; therefore, left neck dissection and total thyroidectomy were undertaken. Histopathology reported "diffuse sclerosing papillary carcinoma with metastasis to 5 of 6 right perithyroid lymph nodes and to 7 of 9 cervical lymph nodes, 4 on the right and 3 on the left. Stage: I, T3-N1b-M0". The patient received 3 doses of iodine 131 as well as external radiotherapy due to mediastinal mass. Follow-up at 6 months (to present) reveals he remains disease free. Thyroid gland enlargement and an increased prevalence of nodules is observed in subjects with insulin resistance and metabolic syndrome. Insulin and TSH are growth factors for thyroid cells, and TSH levels are higher in people with metabolic syndrome, present in this patient. Conclusion: The diffuse sclerosing carcinoma is a rare tumour of uncertain origin, with aggressive behavior, early extrathyroid invasion and distant metastasis. No financial conflicts of interest exist.(AU)
RESUMO
OBJECTIVE: To investigate Ki-67 and p21Waf1/Cip1 expression and apoptosis, before and after treatment, in tumour biopsies obtained from patients with superficial bladder cancer who underwent vinorelbine intravesical therapy. PATIENTS AND METHODS: Twenty patients with high-risk superficial bladder cancer (including one or more of the following parameters: tumour diameter > 3 cm, histological grade 3, or multicentric tumours) were treated 1-6 times (weekly) with intravesical vinorelbine (50 mg/mL) instillations. Transurethral tumour marker biopsies were obtained one week before the first instillation of the drug and one week after the last. The biopsies were immunostained for Ki-67 and p21Waf1/Cip1 with monoclonal antibodies, on tissue sections derived from paraffin-embedded samples obtained before and after vinorelbine treatments. In addition, apoptosis was determined using a terminal deoxynucleotidyl transferase-mediated dUTP biotin nick-end labelling (TUNEL) technique. RESULTS: There were no significant differences in the cell proliferation marker Ki-67 in biopsies taken before or after treatment. However, p21Waf1/Cip1 showed significantly higher expression in biopsies obtained after vinorelbine treatment, with median (range) values of 40 (20-90)% before and 70 (50-80)% after (P < 0.001, paired nonparametric Wilcoxon test). The apoptotic index was significantly higher after vinorelbine therapy, with median (range) values of 0.89 (0.06-3.8)% before and 2.25 (0.17-18.7)% after treatment (P < 0.001, paired nonparametric Wilcoxon test). Despite the brief treatment and few patients there was a clinical response in nine patients, together with low toxicity in all. CONCLUSION: The intravesical treatment of tumours with vinorelbine affects p21Waf1/Cip1 expression without blocking cell proliferation, although increasing apoptosis. The preliminary results suggest that vinorelbine may be useful for treating superficial bladder tumours, and thus a phase II study is warranted.
