Differentiated thyroid cancer clinical trends in Quito, Ecuador / Tendencias clínicas del cáncer diferenciado de tiroides en Quito, Ecuador

Introduction.Thyroid cancer is currently the first most common cancer in women in Ecuador. This study aimed to assess the changes in clinical presentation and diagnosis of differentiated thyroid cancer at a third level hospital in Quito, Ecuador.Methods and Materials.This is a retrospective case series performed in three consecutive periods from 1990 to 2019 at a tertiary level hospital, in Quito, Ecuador. The clinical records of 875 patients who had been diagnosed and surgically treated for differentiated thyroid cancer were reviewed. Demographic, clinical, imaging, and pathological data were collected and analyzed.Results. Significant trends toward older age, higher educational level, less palpable primary tumors, less palpable neck nodes, less distant metastases, more ultrasound, tomography and cytology exams, smaller primary tumors, more stage I patients, and more histological variant description, were found. Introduction.Thyroid cancer is currently the first most common cancer in women in Ecuador. This study aimed to assess the changes in clinical presentation and diagnosis of differentiated thyroid cancer at a third level hospital in Quito, Ecuador.Methods and Materials.This is a retrospective case series performed in three consecutive periods from 1990 to 2019 at a tertiary level hospital, in Quito, Ecuador. The clinical records of 875 patients who had been diagnosed and surgically treated for differentiated thyroid cancer were reviewed. Demographic, clinical, imaging, and pathological data were collected and analyzed.Results. Significant trends toward older age, higher educational level, less palpable primary tumors, less palpable neck nodes, less distant metastases, more ultrasound, tomography and cytology exams, smaller primary tumors, more stage I patients, and more histological variant description, were found.

Introducción. El cáncer de tiroides es actualmente el cáncer más frecuente en la mujer en Ecuador. El presente estudio ha tenido como objetivo evaluar los cambios en la presentación clínica y el diagnóstico del cáncer diferenciado de tiroides en un hospital de tercer nivel de Quito, Ecuador. Material y Métodos. El presente es un estudio retrospectivo de casos realizado en tres períodos consecutivos desde 1990 a 2019 en un hospital del tercer nivel en Quito, Ecuador. Los expedientes clínicos de 875 pacientes tratados quirúrgicamente por un cáncer diferenciado de tiroides fueron revisados. Los datos demográficos, clínicos, de imagen y patología fueron extraídos y analizados. Resultados. Se encontraron tendencias significativas hacia una edad más avanzada, nivel educativo más alto, menos tumores palpables, menos adenopatías regionales palpables, menos metástasis a distancia, más exámenes de ultrasonido y tomografía, más estudios de citología, más tumores pequeños y pacientes con estadío I y más descripciones de las variantes histológicas. Conclusiones. El cáncer de tiroides no sólo que ha aumentado continuamente en su frecuencia en los años recientes, sino que la presentación clínica, el manejo diagnóstico y terapéutico ha cambiado significativamente en las tres últimas décadas.

Microscopic extrathyroid extension in papillary thyroid carcinoma: impact on response to therapy

ABSTRACT Objectives Evaluate the impact of microscopic extrathyroid extension (MEE) on outcome and therapy response in patients with cT1 and cT2 papillary thyroid carcinoma (PTC). Subjects and methods Retrospective study of 970 consecutive patients, who underwent surgery for PTC between 2000 and 2016. All patients had: tumours ≤ 4 cm, apparent complete tumour resection, without clinically apparent lymph node or distant metastasis at diagnosis and nonaggressive histologic variant. Results Based on the finding of MEE, 175 (18.0%) patients were upstaged to T3. They were older (53.9 versus 50.6 years; P = 0.004) and were more prone to have multifocal tumours (38.2% versus 24.8%; P = 0.001). Radioiodine ablation therapy (RAI) was administered more often to MEE patients (92% versus 40.5%; P < 0.001), as well as prophylactic lymph node resection (35.4% versus 28.6%, P = 0.048). They were more likely to have biochemical incomplete response (4% versus 0.3%; P = 0.03) at the end of the follow-up period. There was no significant association between MEE and recurrence rate, persistence of disease or disease-specific mortality. Conclusion These results support the changes made to the latest edition of the TNM staging system, regarding MEE. Although incomplete biochemical response is more common in these patients, it does not seem to affect their prognosis.

Is thyroid nodule volume predictive for malignancy?

ABSTRACT Objective: We aimed to determine the roles of preoperative thyroid nodule diameter and volume in the prediction of malignancy. Subjects and methods: The medical records of patients who underwent thyroidectomy between January 2007 and December 2014 were reviewed. The nodule diameters were grouped as < 1 cm, 1-1.9 cm, 2-3.9 cm and ≥ 4 cm, and volume was grouped as > 5 cm3, 5-9.9 cm3 and > 10 cm3. ROC (Receiver Operating Characteristic) curve analysis was performed to find the optimal cutoff value of diameter and volume that can predict malignancy. Results: There were 5561 thyroid nodules in 2463 patients. Five hundred and forty (9.7%) nodules were < 1 cm, 2,413 (43.4%) were 1-1.9 cm, 1,600 (28.8%) were 2-3.9 cm and 1,008 (18.1%) were ≥ 4 cm. Malignancy rates were 25.6%,10.6%, 9.7% and 8.5% in nodules < 1 cm, 1-1.9 cm, 2-3.9 cm and ≥ 4 cm, respectively. When classified according to volume, 3,664 (65.9%) nodules were < 5 cm3, 594 (10.7%) were 5-9.9 cm3 and 1,303 (23.4%) were ≥ 10 cm3. The malignancy rates were 12.7%, 11.4% and 7.8% for the nodules < 5 cm3, 5-9.9 cm3 and ≥ 10 cm3, respectively (p < 0.001). In ROC curve analysis, an optimal cutoff value for diameter or volume that can predict malignancy in all thyroid nodules or nodules ≥ 4 cm could not be determined. Conclusion: In this surgical series, malignancy risk did not increase with increasing nodule diameter or volume. Although the volume of malignant nodules ≥ 4 cm was higher than that of benign nodules ≥ 4 cm, there was no optimal cutoff value. The diameter or volume of the nodule cannot be used to predict malignancy or decide on surgical resection.

A predictive model to distinguish malignant and benign thyroid nodules based on age, gender and ultrasonographic features / Modelo preditivo para diferenciação entre nódulos malignos e benignos da tireoide com base na idade, sexo e características ultrassonográficas

Abstract Introduction: A discussion in literature about a standardized decision support tool for the management of thyroid nodules remains. Objective: The purpose of this study was to create a statistical prediction model for thyroid nodules management. Methods: Two hundred and four benign and 57 malignant thyroid nodules were selected for a retrospective study. The variables age, gender and ultrasonographic features were examined using univariate and multivariate models. A statistical formula was used to calculate the risk of cancer of each case. Results: In multivariate analysis, irregular shape, absence of halo, lower mean age, homogeneous echotexture, microcalcifications and solid content were associated with cancer. After applying the formula, 20 cases (7.6%) with a calculated risk for malignancy ≤3.0% were found, all of them benign. Setting the calculated risk in ≥80%, 21 (8.0%) cases were selected, and in 85.7% of them cancer was confirmed in histopathology. Internal accuracy of the prediction formula was 92.5%. Conclusions: The prediction formula reached high accuracy and may be an alternative to other decision support tools for thyroid nodule management.

Resumo Introdução: Persiste na literatura uma discussão sobre uma ferramenta padronizada de apoio à decisão para o manejo de nódulos tireoidianos. Objetivo: Criar um modelo de previsão estatística para o manejo de nódulos tireoidianos. Método: Foram selecionados 204 casos de nódulos tireoidianos benignos e 57 malignos para o estudo retrospectivo. As variáveis idade, sexo e características ultrassonográficas foram analisadas com modelos univariados e multivariados. Uma fórmula estatística foi usada para calcular o risco de câncer de cada caso. Resultados: Na análise multivariada, a forma irregular, a ausência de halo, menor idadesubp média, ecotextura homogênea, microcalcificações e conteúdo sólido foram associadas ao câncer. Após a aplicação da fórmula, foram encontrados 20 casos (7,6%) com risco calculado de malignidade ≤ 3,0%, todos benignos. Definiu-se o risco calculado em ≥ 80%, 21 casos (8,0%) foram selecionados e em 85,7% deles o câncer foi confirmado pela histopatologia. A precisão interna da fórmula de previsão foi de 92,5%. Conclusões: A fórmula de previsão alcançou alta precisão e pode ser uma opção para outras ferramentas de apoio à decisão para o manejo de nódulos da tireoide.

Hashimoto's thyroiditis - an independent risk factor for papillary carcinoma / Hashimoto's thyroiditis - an independent risk factor for papillary carcinoma

Abstract Introduction: The link between Hashimoto's thyroiditis and thyroid carcinoma has long been a topic of controversy. Objective: The aim of our study was to determine the prevalence of thyroid carcinoma and Hashimoto's thyroiditis coexistence in histopathologic material of thyroidectomized patients. Methods: In a retrospective study, the clinicohistopathologic data of 2117 patients (1738 females/379 males), who underwent total or partial thyroidectomy for thyroid gland disorder at a single institution from the 1st of January 2005 to the 31st of December 2014 were analyzed. Results: Thyroid carcinoma was detected in 318 cases (15%) and microcarcinoma (thyroid cancer ≤10 mm in diameter) was found in permanent sections in 169 cases (8%). Hashimoto's thyroiditis was detected in 318 (15%) patients. Hashimoto's thyroiditis was significantly more often associated with thyroid carcinoma and microcarcinoma compare to benign condition (p = 0.048, p = 0.00014, respectively). Coexistence of Hashimoto's thyroiditis and thyroid carcinoma/thyroid microcarcinoma did not affect tumor size (p = 0.251, p = 0.098, respectively), or tumor multifocality (p = 0.831, p = 0.957, respectively). Bilateral thyroid microcarcinoma was significantly more often detected when Hashimoto's thyroiditis was also diagnosed (p = 0.041), but presence of Hashimoto's thyroiditis did not affect bilateral occurrence of thyroid carcinoma (p = 0.731). Conclusion: Hashimoto's thyroiditis is associated with significantly increased risk of developing thyroid carcinoma, especially thyroid microcarcinoma.

Resumo: Introdução: A relação entre a tireoidite de Hashimoto e o carcinoma de tireoide tem sido um tema de controvérsia por um longo tempo. Objetivo: Determinar a prevalência da coexistência de carcinoma de tireoide e tireoidite de Hashimoto no exame histopatológico de amostras de pacientes tireoidectomizados. Método: Em um estudo retrospectivo, foram analisados os dados clinico-histopatológicos de 2.117 pacientes (1.738 mulheres/379 homens), submetidos à tireoidectomia total ou parcial por distúrbio da glândula tireoide em uma única instituição, de 1º de janeiro de 2005 a 31 de dezembro de 2014. Resultados: O carcinoma de tireoide foi detectado em 318 casos (15%) e o microcarcinoma (câncer de tireoide ≤ 10 mm de diâmetro) foi encontrado em secções permanentes em 169 casos (8%). A tireoidite de Hashimoto foi detectada em 318 (15%) pacientes e foi associada ao carcinoma da tireoide e ao microcarcinoma com maior frequência em comparação com condições benignas (p = 0,048, p = 0,00014, respectivamente). A coexistência de tireoidite de Hashimoto e carcinoma/microcarcinoma não influenciou o tamanho do tumor (p = 0,251, p = 0,098, respectivamente) ou a multifocalidade tumoral (p = 0,831, p = 0,957, respectivamente). O microcarcinoma de tireoide bilateral foi detectado com maior frequência quando a tireoidite de Hashimoto também foi diagnosticada (p = 0,041), mas a presença de tireoidite não influenciou na ocorrência bilateral de carcinoma (p = 0,731). Conclusão: A tireoidite de Hashimoto está associada a um aumento significativo do risco do desenvolvimento de carcinoma de tireoide, especialmente microcarcinoma da tireoide.

A pioneering RET genetic screening study in the State of Ceará, Brazil, evaluating patients with medullary thyroid cancer and at-risk relatives: experience with 247 individuals

ABSTRACT Objective: Initial diagnosis of medullary thyroid carcinoma (MTC) is frequently associated with advanced stages and a poor prognosis. Thus, the need for earlier diagnoses and detection in relatives at risk for the disease has led to increased use of RET genetic screening. Subjects and methods: We performed RET screening in 247 subjects who were referred to the Brazilian Research Consortium for Multiple Endocrine Neoplasia (BRASMEN) Center in the State of Ceará. Direct genetic sequencing was used to analyze exons 8, 10, 11, and 13-16 in MTC index cases and specific exons in at risk relatives. Afterward, clinical follow-up was offered to all the patients with MTC and their affected relatives. Results: RET screening was performed in 60 MTC index patients and 187 at-risk family members. At the initial clinical assessment of the index patients, 54 (90%) were diagnosed with apparently sporadic disease and 6 (10%) diagnosed with hereditary disease. After RET screening, we found that 31 (52%) index patients had sporadic disease, and 29 (48%) had hereditary disease. Regarding at-risk relatives, 73/187 were mutation carriers. Mutations in RET codon 804 and the rare p.M918V mutation were the most prevalent. Conclusions: Performing RET screening in Ceará allowed us to identify a different mutation profile in this region compared with other areas. RET screening also enabled the diagnosis of a significant number of hereditary MTC patients who were initially classified as sporadic disease patients and benefited their relatives, who were unaware of the risks and the consequences of bearing a RET mutation.

Guided intraoperative scintigraphic tumor targeting of metastatic cervical lymph nodes in patients with differentiated thyroid cancer: a single-center report

ABSTRACT Objective: Our aim was to present our experiences related to performing neck surgery using the guided intraoperative scintigraphic tumor targeting (GOSTT) procedure for patients who had locally recurrent or persistent differentiated thyroid cancer (DTC) and who had undergone previous thyroid surgery. Subjects and methods: We retrospectively evaluated 11 patients who had locally recurrent or persistent DTC, who had undergone previous surgery, and for whom reoperation was planned for metastatic cervical lymph nodes (LNs). We performed the neck surgery using the GOSTT procedure on all patients and at a single academic institution. Results: The 11 patients had a total of 26 LNs, as marked with a radiotracer, and those LNs' mean size was 14.7 ± 8.2 mm (range: 5-34 mm). Histopathological examinations revealed DTC metastasis in all 26 of the preoperatively marked LNs. Of the 11 patients, only one needed a reoperation in the neck; she had another successful surgery (also using the GOSTT procedure). In the evaluation of the patients' final status, all were disease-free in their necks. There also were no GOSTT-associated postoperative complications. Conclusion: The GOSTT procedure is a useful, successful, inexpensive, and comfortable procedure for marking and mapping metastatic LNs, especially in DTC patients who have undergone previous surgery.

Impact of historic histopathologic sample review on the risk of recurrence in patients with differentiated thyroid cancer

ABSTRACT Objective To compare the historic risk of recurrence (RR) and response to therapy to risk stratification estimated with historical pathology reports (HPRs) and contemporary re-review of the pathological slides in patients with differentiated thyroid cancer (DTC). Subjects and methods Out of 210 DTC patients with low and intermediate RR who underwent total thyroidectomy and remnant ablation in our hospital, 63 available historic pathologic samples (HPS) were reviewed. The RR and the response to therapy were evaluated considering historical histological features (histological type, tumor size, capsular invasion, number of lymph node metastases) and then, reassessed after observing additional histological features (vascular invasion, extrathyroidal extension, size of lymph node metastases, presence of extranodal extension, and/or status of the resection margins). Results A change in the RR category was observed in 16 of 63 cases (25.4%). Out of 46 patients initially classified as low RR, 2 patients were reclassified as intermediate RR, 4 as high RR, and 1 as noninvasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTP). Out of 17 patients initially classified as intermediate RR, 3 were reassigned to the low RR group, 5 as high RR, and 1 as NIFTP. The percentages of structural incomplete response at final follow-up changed from 2.2 to 0% (p = 1) in patients with low RR and from 6.3 to 20% (p = 0.53) in patients with intermediate RR. Conclusion A detailed report of specific features in the HPR of patients with DTC might give a more accurate RR classification and a better estimation of the response to treatment.

Malignancy rates for Bethesda III subcategories in thyroid fine needle aspiration biopsy (FNAB)

OBJECTIVES: Most thyroid diseases are nodular and have been investigated using ultrasound-guided fine needle aspiration biopsy (FNAB), the reports of which are standardized by the Bethesda System. Bethesda category III represents a heterogeneous group in terms of lesion characteristics and the malignancy rates reported in the literature. The objective of the present study was to evaluate the differences in the malignancy rates among Bethesda III subcategories. METHODS: Data from 1,479 patients who had thyroid surgery were reviewed. In total, 1,093 patients (89.6% female, mean age 52.7 (13-89) years) were included, and 386 patients were excluded. FNAB results (based on Bethesda Class) and histopathological results (benign or malignant) for coincident areas were collected. Bethesda III patients were subcategorized according to cytopathological characteristics (FLUS: follicular lesion of undetermined significance, Bethesda IIIA; AUS: atypia of undetermined significance, Bethesda IIIB). Data were correlated to obtain the malignancy rates for each Bethesda category and the newly defined subcategory. RESULTS: FNAB results for these patients were as follows: Bethesda I: 3.1%; Bethesda II: 18.6%; Bethesda III: 35.0%; Bethesda IV: 22.1%; Bethesda V: 4.1%; and Bethesda VI: 17.1%. The malignancy rates for Bethesda Class IIIB were significantly higher than those for Bethesda Class IIIA (p<0.001) and Bethesda Class IV (p<0.001). Bethesda Class IIIA showed significantly lower malignancy rates than Bethesda Class III overall (p<0.001) CONCLUSIONS: Improvements of the Bethesda System should consider this subcategorization to better reflect different malignancy rates, which may have a significant impact on the decision-making process.

Metastatic lymph node characteristics as predictors of recurrence/persistence in the neck and distant metastases in differentiated thyroid cancer

ABSTRACT Objective: The aim of this study was to evaluate the association between this characteristic and outcomes in patients with lymph node metastasis in a Brazilian cohort. Subjects and methods: This study examined a retrospective cohort of adult patients diagnosed with differentiated thyroid cancer and lymph node metastases from 1998 to 2015 in two referral centers. Number, location, size and extranodal extension (ENE) of metastatic lymph nodes were assessed and correlated with response to initial therapy. Results: A greater number of metastatic nodes, larger size, presence of lateral neck disease and ENE were all associated with a lower probability of achieving an excellent response to initial therapy (p ≤ 0.05 for all these parameters). Local recurrent disease had a significant association with lymph node number (6 in the recurrence/persistence group versus 4 in the non-recurrent group; p = 0.02) and ENE (19.2 versus 75%, p = 0.03). Lateral neck disease was the only characteristic associated with distant metastasis and was present in 52.1% of the group without metastasis and 70.4% of the group with metastasis (p = 0.001). Conclusion: The lymph node characteristics were associated with response to initial therapy and neck recurrence/persistence, confirming the importance of the analysis of these factors in risk stratification in a Brazilian population and its possible use to tailor initial staging and long term follow-up.

Deaths related to differentiated thyroid cancer: a rare but real event

ABSTRACT Objective The present study describes the clinical and tumor characteristics of patients that died from differentiated thyroid cancer and reports on the cause and circumstances of death in these cases. Subjects and methods Retrospective analysis of all the differentiated thyroid cancer (DTC) related deaths at a single institution over a 5-year period, with a total of 33 patients. Results Most of the patients were female (63.6%), with a mean age at diagnosis of 58.2 years. The most common histologic type was papillary (66.7%) and 30.3% were follicular. The distribution according to the TNM classification was: 15.4% of T1; 7.7% T2; 38.4% T3; 19.2% of T4a and 19.2% of T4b. Forty-four percent of cases were N0; 20% N1a and 36.6% of N1b. Twelve patients were considered non-responsive to radioiodine. Only one of the patients did not have distant metastases. The most common metastatic site was the lung in 69.7%. The majority of deaths were due to pulmonary complications related to lung metastases (17 patients, 51.5%), followed by post-operative complications in 5 cases, neurological disease progression in 3 cases, local invasion and airway obstruction in one patient. Median survival between diagnosis and death was reached in 49 months while between disease progression and death it was at 22 months. Conclusion Mortality from DTC is extremely rare but persists, and the main causes of death derive from distant metastasis, especially respiratory failure due to lung metastasis. Once disease progression is established, median survival was only 22 months.

Recombinant human TSH versus thyroid hormone withdrawal in adjuvant therapy with radioactive iodine of patients with papillary thyroid carcinoma and clinically apparent lymph node metastases not limited to the central compartment (cN1b)

ABSTRACT Objective To compare the short- and long-term outcomes of adjuvant therapy with radioactive iodine (RAI) preceded by the administration of recombinant human TSH (rhTSH) versus thyroid hormone withdrawal (THW) in patients with papillary thyroid carcinoma and clinically apparent lymph node metastases not limited to the central neck compartment (cN1b). Subjects and methods The sample consisted of 178 cN1b patients at intermediate risk who underwent total thyroidectomy with apparently complete tumor resection [including postoperative ultrasonography (US) without anomalies] and who received adjuvant therapy with RAI (30-100 mCi) preceded by the administration of rhTSH (n = 91) or THW (n = 87). Results One year after RAI, the rates of excellent response to therapy, i.e., nonstimulated thyroglobulin (Tg) ≤ 0.2 ng/mL with negative antithyroglobulin antibodies and negative neck US, and of structural disease were similar for the two preparations (84% and 4.5%, respectively, in both groups). During follow-up (median 66 months), the rate of structural or biochemical (nonstimulated Tg > 1 ng/mL, with increment) recurrence was also similar in the two groups (4.5%). In the last assessment, the percentage of patients without evidence of disease, i.e., nonstimulated Tg < 1 ng/mL and no evidence of structural disease, was similar for the two preparations [92.3% in the rhTSH group and 97.7% in the THW group (p = 0.17)]. Conclusion Preparation with rhTSH was equally effective (short- and long-term) as THW for adjuvant RAI therapy of cN1b patients at intermediate risk and with apparently complete tumor resection.

Dynamic prediction of the risk of recurrence in patients over 60 years of age with differentiated thyroid carcinoma

ABSTRACT Objective The reclassification of the risk according to the response to the initial treatment makes the treatment of differentiated thyroid cancer (DTC) vary in each individual. As the influence of age on this diagnostic strategy is unknown, we have decided to assess it in adults who are over 60 years of age. Subjects and methods Ninety patients with DTC above 60 years old were enrolled, with total thyroidectomy plus radioiodine ablation, negative anti-thyroglobulin antibodies, follow-up ≥ 2 years and with clinical and pathological information to classify the risk of recurrence according to ATA (American Thyroid Association) and reclassify based on the response to initial therapy according to MSKCC (Memorial Sloan Kettering Cancer Center). The structural persistence at the end of the follow-up was the gold standard of our analysis. Results The structural persistence in ATA low, intermediate and high risk categories was 0, 38, and 100%, respectively. In the intermediate group, none of those with an excellent response to the initial treatment showed structural persistence, whereas 39% of those with an incomplete/indeterminate response showed structural persistence (p < 0.01). Conclusions The re-stratification according to the response to the initial treatment in patients over 60 years of age with an ATA intermediate risk of recurrence allowed for the distinction of disease-free patients at the end of the follow-up from those with structural persistence and a worse clinical progression.

Is radioactive iodine- 131 treatment related to the occurrence of non-synchronous second primary malignancy in patients with differentiated thyroid cancer?

Objective Much controversy relates to the risk of non-synchronous second primary malignancies (NSSPM) after radioactive iodine treatment (RAI-131) in differentiated thyroid cancer (DTC) patients. This study evaluated the relationship between RAI-131 and NSSPM in DTC survivors with long-term follow-up. Materials and methods Retrospective analysis of 413 DTC cases was performed; 252 received RAI-131 and 161 were treated with thyroidectomy alone. Exclusion criteria were: prior or synchronous non-thyroidal malignancies (within the first year), familial syndromes associated to multiple neoplasms, ionizing radiation exposure or second tumors with unknown histopathology. Results During a mean follow-up of 11.0 ± 7.5 years, 17 (4.1%) patients developed solid NSSPM. Patients with NSSPM were older than those without (p = 0.02). RAI-131 and I-131 cumulative activity were similar in patients with and without NSSPM (p = 0.18 and p = 0.78, respectively). Incidence of NSSPM was 5.2% in patients with RAI-131 treatment and 2.5% in those without RAI-131 (p = 0.18). Using multivariate analysis, RAI-131 was not significantly associated with NSSPM occurrence (p = 0.35); age was the only independent predictor (p = 0.04). Under log rank statistical analysis, after 10 years of follow-up, it was observed a tendency of lower NSSPM-free survival among patients that received RAI-131 treatment (0.96 vs . 0.87; p = 0.06), what was not affected by age at DTC diagnosis. Conclusion In our cohort of DTC survivors, with a long-term follow-up period, RAI-131 treatment and I-131 cumulative dose were not significantly associated with NSSPM occurrence. A tendency of premature NSSPM occurrence among patients treated with RAI-131 was observed, suggesting an anticipating oncogenic effect by interaction with other risk factors.

Survival score scales of patients operated with spinal metastases: retrospective application in a Brazilian population / Escalas de prognóstico em pacientes operados com metástases vertebrais: aplicação retrospectiva em população brasileira

ABSTRACT Spinal cord epidural metastasis (SEM) is a common complication of systemic cancer. Predicting these patient’s survival is a key factor to select the proper treatment modality, but the three most used score scales to predict their survival (Tokuhashi revised score, Tomita score and Bauer modified score) were designed in single institutions and their reliability to predict correctly the patient’s survival were first tested only in those specific populations. This prognostication issue is addressed in this article, evaluating retrospectively the survival of 17 patients with SEM from a Brazilian general hospital with these score scales. Our results show that the actual survival of those patients were worse than the predicted of all three score scales, suggesting that differences between the different populations might have affected their reliability and alert that their usage as a major factor to select the most appropriate treatment have to be done with caution.

RESUMO Metástases vertebrais são uma complicação comum em pacientes com câncer sistêmico. Avaliar o prognóstico e a sobrevida desses pacientes é um fator de grande importância para escolher o tratamento mais adequado, porém as três escalas mais usadas atualmente para prever a sobrevida deles (Tokuhashi revisada, Tomita e Bauer modificada) foram desenhadas em instituições isoladas, e sua habilidade em estimar corretamente a sobrevida desses pacientes foram testadas primeiramente apenas nessas populações específicas. Essa questão de estimar o prognóstico é abordada nesse artigo, analisando retrospectivamente a sobrevida de 17 pacientes com metástase vertebral provenientes de um hospital geral no Brasil com essas escalas. Nossos resultados apontam que a sobrevida real desses pacientes foi menor que a prevista pelas três escalas, sugerindo que as diferenças entres as diferentes populações podem ter afetado a aplicabilidade delas. Assim, alertamos que o uso dessas escalas em populações diferentes das estudadas originalmente deve ser feito com cuidado.

Histological variants and prognostic factors of papillary thyroid carcinoma at the Colombian Instituto Nacional de Cancerología, 2006-2012 / Variantes histológicas y factores pronósticos del carcinoma papilar de tiroides en el Instituto Nacional de Cancerología de Colombia, 2006-2012

Introduction: Thyroid cancer is the most common endocrine neoplasia and the papillary subtype is the most frequent; there are histological and clinical factors associated with a higher risk of recurrence and metastasis. Objective: The aim of this study was to examine the histological, prognostic and clinical characteristics of papillary thyroid carcinomas diagnosed at the National Cancer Institute of Colombia. Materials and methods: A retrospective cohort study was carried out on 619 patients with papillary thyroid carcinoma between 2006 and 2012; we analyzed the sociodemographic, histological, prognostic and clinical characteristics. Results: 87.7% of cases were women. The presence of two or more variants in the same case was considered a particular variant, which we called combined pattern. Combined pattern was then the most frequent (50.9%), followed by the follicular variant (23.4%) including subtypes encapsulated and unencapsulated, and the classic variant (22.1%). Mean tumor size was 20.8 mm. More than half of the cases had capsular invasion, extrathyroidal invasion and lymph node involvement. When compared with the other variants, the combined pattern carcinomas had a higher risk of invasion of the thyroid capsule, extraganglionar invasion and metastasis. Conclusions: Our results are in many aspects similar to those already reported. However, the presence of the combined pattern implied a higher risk for capsular invasion, nodal involvement, extranodal involvement and metastasis in comparison with those which had just one variant. Further studies are necessary to confirm these results.

Introducción. El cáncer de tiroides es la neoplasia más común y el subtipo papilar es el más frecuente; hay factores histológicos y clínicos asociados con un mayor riesgo de recidiva y metástasis. Objetivo. Examinar las características histológicas, clínicas y de pronóstico de los carcinomas papilares de tiroides diagnosticados en el Instituto Nacional de Cancerología de Colombia. Materiales y métodos. Se llevó a cabo un estudio de cohorte retrospectiva que incluyó a 619 pacientes con carcinoma papilar de tiroides entre 2006 y 2012; se analizaron las características sociodemográficas, histológicas, de pronóstico y clínicas. Resultados. El 87,7% de casos correspondió a mujeres. La presencia de dos o más variantes histológicas en un mismo caso se consideró como una variante a la cual se denominó patrón combinado; esta fue la más frecuente (50,9 %), seguida de la variante folicular (23,4 %), incluidos los subtipos encapsulados o no encapsulado y la variante clásica (22,1 %). El promedio del tamaño tumoral fue de 20,8 mm. En más de la mitad de los casos se evidenció invasión capsular, invasión extratiroidea y metástasis en ganglios linfáticos. Comparados con otras variantes histológicas, los carcinomas con patrón combinado presentaron mayor riesgo de invasión de la cápsula tiroidea, de invasión extraganglionar y de metástasis. Conclusión. En muchos aspectos los resultados fueron similares a los reportados previamente; sin embargo, se encontró que la presencia del patrón combinado aumentaba el riesgo de invasión capsular, metástasis en nódulos linfoides y extensión extratiroidea en comparación con los que tenían una sola variante. Sería necesario hacer estudios acerca del mecanismo biológico de la diferenciación en células cancerosas con el fin de ahondar sobre este fenómeno.

Persistent and recurrent disease in patients with papillary thyroid carcinoma with clinically apparent (cN1), but not extensive, lymph node involvement and without other factors for poor prognosis

Objective Lymph node metastases (LNM) are frequent in patients with papillary thyroid cancer (PTC). The risk of persistent disease (PD) and tumor recurrence (TR) is increased when factors for poor prognosis other than LNM exist, when LNM are numerous, large, detected by preoperative ultrasonography (US), or exhibit extranodal extension. This study evaluated the risk of PD and TR in patients with LNM not exhibiting these characteristics.Subjects and methods Eighty-six patients with 5 or fewer LNM detected during intraoperative inspection, but not by preoperative US, who had no other factors for poor prognosis [tumors > 4 cm, extensive extrathyroid invasion, vascular invasion, aggressive histological subtype, distant metastases, incomplete tumor resection], were studied. All patients underwent total thyroidectomy followed by radioiodine ablation. PD was defined as metastases on initial post-therapy whole-body scans (RxWBS) or detected by imaging methods up to 12 months after ablation. TR was defined as structural disease diagnosed more than one year after ablation in patients without PD.Results PD was diagnosed in 3/86 patients (3.5%). TR was observed in 2/83 patients (2.5%) after 62 months of follow-up. There was no case of death due to the disease. A correlation was observed between pre-ablation Tg and PD or TR [1/48 (2%) with Tg ≤ 2 ng/mL versus 2/22 (9%) with Tg > 2 ≤ 10 ng/mL versus 2/7 (28.5%) with Tg ≥ 10 ng/ml)]. It is noteworthy that 38 patients had up to 3 positive LN and pre-ablation Tg ≤ 2 ng/ml, and none of them had PD or TR.Conclusions The frequency of PD and TR was low in patients with PTC with 5 or fewer LNM and without other factors for poor prognosis. Low postoperative stimulated Tg was predictive of the absence of PD and TR in these patients.

Should a family history of papillary thyroid carcinoma indicate more aggressive therapy in patients with this tumor? / História familiar de carcinoma papilífero de tireoide deve indicar terapia mais agressiva em pacientes com este tumor?

Objective To determine whether the currently recommended therapy for papillary thyroid carcinoma (PTC) that show no classical factors indicating a poor prognosis is also effective in cases with a family history of this tumor. Subjects and methods: Forty-two patients were studied; 10 were submitted to lobectomy and 32 to total thyroidectomy, including 23 without lymph node dissection and 9 with lymph node dissection. None of the patients received radioiodine or was maintained under TSH suppression. Results No case of recurrence was detected by imaging methods and there was no increase in thyroglobulin or antithyroglobulin antibodies during follow-up (24 to 72 months). Conclusion The treatment usually recommended for patients with PTC does not need to be modified in the presence of a family history of this tumor if no factors indicating a poor prognosis are present (tumor ≤2 cm, non-aggressive histology, no extensive extrathyroid invasion or important lymph node involvement, complete tumor resection, no evidence of persistent disease after surgery). .

Objetivo Avaliar se a terapia atualmente recomendada para o carcinoma papilífero de tireoide (CPT) sem fatores clássicos de pior prognóstico é efetiva também nos casos em que existe história familiar deste tumor. Sujeitos e métodos: Foram avaliados 42 pacientes; dez foram tratados com lobectomia e 32 com tireoidectomia total, sendo 23 sem dissecção de linfonodos e 9 com dissecção linfonodal. Nenhum paciente recebeu radioiodo ou foi mantido com TSH suprimido. Resultados Nenhuma recidiva nos métodos de imagem foi observada, nem incremento da tireoglobulina ou anticorpos antitireoglobulina durante o seguimento (24 a 72 meses). Conclusão Em pacientes com CPT, sem fatores de pior prognóstico (tumor ≤2 cm, histologia não agressiva, sem invasão extratireoidiana extensa ou acometimento linfonodal importante, ressecção tumoral completa, sem indícios de doença persistente após a cirurgia), o tratamento usualmente recomendado não precisa ser modificado quando há história familiar desse tumor. .

Response to sorafenib treatment in advanced metastatic thyroid cancer / Resposta ao tratamento com sorafenibe em pacientes com carcinoma metastático de tireoide

Objective: To investigate the efficacy of sorafenib in progressive radioiodine resistant metastatic thyroid carcinoma.Subjects and methods: Off-label observational study. Sorafenib 400 mg twice daily was evaluated. Therapy duration was 12 ± 3 months (range 6-16 months).Results: Eight patients were included (seven papillary, one insular variant). The eight patients meeting study criteria received sorafenib 400 mg orally twice a day until disease progression or unacceptable toxicity developed. One patient showed a partial response with tumor regression of -35%, six months after the beginning of the treatment; five patients exhibited stable disease and two patients had progressive disease and died. Thyroglobulin decreased within 4 weeks in all patients by 50% ± 23%.Adverse events: one patient had heart failure, and recovered after sorafenib withdrawal. However, she died five months later of sudden death.Conclusion: These data suggest a possible role for sorafenib in the treatment of progressive metastatic DTC. Adverse event are usually manageable, but severe ones may appear and these patients should be strictly controlled.

Objetivo: Investigar a eficácia do sorafenibe no carcinoma de tireoide metastático progressivo e refratário à iodoterapia.Sujeitos e métodos: Estudo observacional do efeito do sorafenibe off-label administrado 400 mg duas vezes ao dia. A duração da terapia foi de 12 ± 3 meses (variação de 6-16 meses).Resultados: Oito pacientes foram incluídos (sete com variante papilífera e um com variante insular). Os oito pacientes que preencheram os critérios do estudo receberam o sorafenibe 400 mg por via oral duas vezes por dia até progressão da doença ou toxicidade inaceitável. Um paciente apresentou uma resposta parcial com regressão tumoral da lesão alvo de 35% seis meses após o início do tratamento; cinco pacientes apresentaram doença estável e dois pacientes progrediram e morreram. A tireoglobulina diminuiu 50% ± 23% em 4 semanas em todos os pacientes.Eventos adversos: um paciente teve insuficiência cardíaca e morreu por morte súbita cinco meses após a retirada do sorafenibe.Conclusão: Esses dados sugerem um possível papel para sorafenibe para o tratamento do CDT metastático progressivo.

Análisis de factores de agresividad de microcarcinoma papilar de tiroides / Features influencing aggressiveness of papillary thyroid microcarcinoma

Background: the risk factors determining the aggressiveness of papillary thyroid microcarcinoma (PTMC) are not well known. Aim: to determine if tumor size, along with other features of the tumor, influences its prognosis. Patients and Methods: we analyzed the medical records of 147 patients (age range 16-92 years, 93 percent women) at the Clinical Hospital of University of Chile who underwent thyroid surgery and in whom at least one focus of PTMC was found. We determined the association between different clinical characteristics and the presence of capsular invasion, lymph nodal extension or recurrence. Results: a tumor size over 5 mm, a follicular subtype and being aged more than 45 years, were significantly associated with the presence of capsular invasion. The latter two variables were protective. In the multivariate analysis, only a tumor size over 5 mm was significantly associated with thyroid capsule involvement. Conclusions: a tumor size over 5 mm is associated with capsular invasion in PTMC.

Introducción: los factores de riesgo que determinan una conducta agresiva de microcarcinoma papilar de tiroides (MCPT) no se conocen. Nuestra hipótesis es que el tamaño del tumor, posiblemente junto con otras características del cáncer puede influir en el pronóstico de esta patología. Material y Método: se analizaron las historias clínicas de 147 pacientes que se sometieron en nuestro hospital a cirugía de tiroides y en los cuales se encontró al menos un foco de MCPT. Resultados: se determinó la existencia de una correlación entre las diferentes características clínicas y la presencia de invasión capsular, la extensión ganglionar linfático o la recidiva. En el análisis univariado, el tamaño del tumor mayor de 5 mm, se correlacionó significativamente con la presencia de invasión capsular (p < 0,05). Entre las variables estudiadas, sólo un tamaño superior a 5 mm se asoció significativamente con el compromiso de la cápsula tiroidea en el análisis multivariado. Conclusiones: aunque en general el MCPT se comportan con baja agresividad, se encontró que aquellos que son mayores de 5 mm a menudo tienen invasión capsular, que se ha relacionado con aumento de la agresividad y recidiva. Se recomienda un tratamiento orientado según la presencia de factores de riesgo como las que se describen aquí.