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Resumen: Introducción: La incidencia de cáncer papilar de tiroides (PTC) ha aumentado de 1975 a 2015. Basados en criterios publicados, el ultrasonido (US) es muy efectivo para predecir el riesgo de malignidad. Todos estos criterios se enfocan en los nódulos tiroideos; sin embargo, 2% de los casos se pueden presentar como focos ecogénicos difusos sin un nódulo identificable. Caso: Mujer de 17 años con historia de 3 meses con una masa palpable en la región anterior derecha del cuello, sin otros síntomas. El US de cuello revela múltiples focos ecogénicos de distribución difusa en el parénquima tiroideo con un nódulo de 6 mm TI-RADS 5 en el lóbulo izquierdo y ganglio linfáticos con componentes sólidos y quísticos, pérdida del hilio graso y con puntos ecogénicos. Se le realizó tiroidectomía total con linfadenectomía bilateral. Discusión: Las microcalcificaciones son muy sugestivas de CPT. Los ecos puntiformes se correlacionan en patología con una forma de calcificación distrófica llamada cuerpos de Psammoma, los cuales se depositan en tejido no viable. La tiroiditis crónica también puede presentar calcificaciones distróficas. Por lo tanto, un parénquima tiroideo normal con presencia de microcalcificaciones, obliga a realizar una biopsia con aguja fina para descartar CPT. Estudios recientes sugieren que la lobectomía es una opción viable y debe ser la primera elección en CPT localizado (< 2 cm). Sin embargo, esto no se debe realizar en estos pacientes, ya que la presencia de microcalcificaciones difusas nos indica un tamaño del tumor mucho mayor y resultaría en un pronóstico desfavorable. Conclusión: Las microcalcificaciones difusas deben obligar al radiólogo a sospechar la variedad difusa del CPT como primera sospecha diagnóstica.
Abstract: Introduction: The incidence of thyroid papillary cancer (PTC) has increased from 1975 to 2015. Ultrasound is effective for predicting thyroid malignancy based on published criteria. All of these criteria focus on thyroid nodules but also 2% of the cases may appear as diffuse punctuate echogenic foci without an identifiable nodule. Case: A 17-year-old female with a 3-month history of a palpable mass on the right anterior side of the neck without any further symptoms. Neck ultrasound revealed multiple punctuate echogenic foci scattered along the thyroid parenchyma with a 6 mm nodule TI-RADS 5 on the left lobe, lymph nodes with cystic and solid components, loss of echogenic hilum and punctuate echogenic foci. The patient underwent a total thyroidectomy with bilateral lymphadenectomy. The pathology report revealed diffuse distribution of papillary cancer with a nodule on the left lobe and metastatic disease on the lymph nodes. Discussion: Microcalcifications are highly suggestive of PTC. Punctuate echogenic foci correlate in pathology with a form of dystrophic calcifications, called Psammoma bodies, which are deposited in nonviable tissue. Chronic thyroiditis may also present dystrophic calcifications. Thus, a normal thyroid parenchyma with microcalcifications should encourage the radiologist to perform a fine-needle aspiration biopsy (FNAB). Recent studies suggest that lobectomy is a viable option and should be pursued in the setting of localized PTC (<2 cm). A lobectomy should not be performed in patients with diffuse microcalcifications since it would result in an unfavorable outcome. Conclusions: Diffuse microcalcifications should immediately make the radiologist suspect diffuse PTC as a first diagnostic option.
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INTRODUCCIÓN: Los quistes tiroglosos son las lesiones más comunes de la línea media cervical y se ha descrito el carcinoma papilar de tiroides en el 1%. Debido a su baja incidencia no existe un consenso acerca del tratamiento óptimo. Caso clínico: Paciente mujer de 34 años de edad consulta por aumento de volumen cervical doloroso y se evidencia nódulo doloroso en región cervical media. Ecografía de tiroides visualiza una lesión quística compleja. Se completa el estudio con tomografía computada del cuello con contraste que evidencia quiste del conducto tirogloso con compromiso inflamatorio-infeccioso, por lo que se decide cirugía. Biopsia evidencia cáncer papilar de 0.25 cm en quiste del conducto tirogloso, con bordes quirúrgicos negativos. Por bajo riesgo se decide control imagenológico estricto. DISCUSIÓN: Los quistes del conducto tirogloso comprenden las lesiones cervicales congénitas más frecuentes. Se presentan como masas indolentes y asintomáticas. El diagnóstico es confirmado mediante ecografía y la tomografía es utilizada para ampliar el estudio. La aparición de cáncer tiroideo en estos quistes es poco común, y generalmente son indistinguibles de las lesiones benignas en el preoperatorio. En relación al manejo del cáncer papilar en quiste del conducto tirogloso no existe un consenso de su tratamiento óptimo. Para los casos de bajo riesgo se sugiere control anual con TSH y ecografía tiroidea. Para aquellos pacientes de alto riesgo se sugiere tiroidectomía total y ablación de los restos tiroides con yodo radioactivo, con control anual con niveles de tiroglobulina. El pronóstico es excelente, con tasas de remisión que superan el 95%. CONCLUSIONES: Los carcinomas en quistes de conducto tirogloso son poco comunes y en la mayoría de los casos son lesiones diagnosticadas de manera incidental después de la resección quirúrgica. Para definir necesidad de tiroidectomía, debe realizarse estudio individualizado por un equipo multidisciplinario con amplia experiencia.
INTRODUCTION: Thyroglossal cysts are the most common affection of the cervical midline. Papillary carcinoma has been described in 1% of this cysts. Due to its low incidence a consensus on the optimal treatment does not exist. Clinical case: A 34 year old female with no relevant past medical history, presented with a painful cervical mass of many weeks of appearance. The thyroid ecography showed a complex cystic lesion and the cervical computed tomography with contrast evidenced a cyst of the thyroglossal duct with inflammatory and infectious findings. Surgery with no incidents was performed. Biopsy reported a 0.25 cm papillary cancer in the thyroglossal duct cyst, with negativa surgical margins. Strict follow up with imaging studies was decided. DISCUSSION: the thyroglossal duct cyst are the most common congenital cervical affections. Classically, they present as indolente, asyntomatic masses on the cervical midline. The diagnosis is confirmed with ecography and computed tomography is used to extent evaluation. Thyroid cancer in thyroglossal duct cyst is uncommon and generally indistinguishable from benign lesions in the preoperative phase. A consensus regarding the optimal management of this patients does not exist. For low risk cases, an anual control with THS and thyroid ecography is suggested. For patients with high risk a Sistrunk with total thyroidectomy and radioactive ablation of thyroids remnants is recommend. Follow up with anual thyroglubin levels should be performed. The prognostic is excellent, with more than 95% remission rates. CONCLUSSIONS: Thyroglossal duct cyst carcinomas are rare. In most cases, diagnosis is made incidentally after surgical resection. To decide wheter thyroidectomy is necessary each case should be analyzed individually by a multidisciplinary team with vast experience.
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Humanos , Feminino , Adulto , Cisto Tireoglosso/diagnóstico , Neoplasias da Glândula Tireoide/diagnóstico , Carcinoma Papilar/diagnóstico , Cisto Tireoglosso/cirurgia , Cisto Tireoglosso/patologia , Tireoidectomia , Neoplasias da Glândula Tireoide/cirurgia , Neoplasias da Glândula Tireoide/patologia , Carcinoma Papilar/cirurgia , Carcinoma Papilar/patologiaRESUMO
ABSTRACT Objectives: The objectives of this study were to evaluate the following: 1) the accuracy of sentinel lymph node mapping (SLNM) in detecting metastasis in papillary thyroid carcinoma (PTC), and 2) if SLNM could modify the American Joint Committee on Cancer (AJCC) staging of previous cN0 PTC patients. Subjects and methods: Forty SLNM were performed prospectively in 38 consecutive cN0 PTC patients, with total thyroidectomy and elective compartment neck dissection (CND). The results of SLNM were compared with CND pathological findings to verify the accuracy of sentinel SLNM. Results: The mean patients' follow-up was 36 months. A total of 133 SLN were found at levels VI, II, III and IV. The SLN was identified in 95% of the patients with one false negative, 95% sensitivity, a 94% negative predictive value and 97% accuracy. The SLNM upstaging from cN0 to pN+ was 49%, and to stages III and IVa, it was 21%. Conclusions: For this series of cN0 PTC patients: 1) SLNM accuracy was 97%, and 2) SLNM upstaging from cN0 to pN+ was 49%, whereas to stages III and IVa, it was 21%.
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Humanos , Masculino , Feminino , Adulto , Pessoa de Meia-Idade , Idoso , Adulto Jovem , Neoplasias da Glândula Tireoide/patologia , Carcinoma Papilar/secundário , Biópsia de Linfonodo Sentinela/métodos , Linfonodo Sentinela/patologia , Metástase Linfática/diagnóstico , Valor Preditivo dos Testes , Estudos Prospectivos , Reprodutibilidade dos Testes , Sensibilidade e Especificidade , Estadiamento de NeoplasiasRESUMO
Resumen Se comunica el caso de una paciente de 71 años de edad con antecedente tabáquico, ingresada por padecer infecciones recurrentes. Tenía aumento de volumen del hemicuello izquierdo con nódulo de 4 cm de diámetro de 15 años de evolución hasta llegar a dimensiones de 20 x 15 cm. Se resecó de manera completa, excepto por su infiltración a la tráquea que quedó como remanente. El diagnóstico histopatológico fue: carcinoma papilar de tiroides infiltrante a la tráquea. En relación con este caso, se recomienda no dejar a libre evolución porque la incidencia del carcinoma papilar de tiroides asociado con bocio multinodular es similar a la encontrada en nódulos fríos solitarios, por lo que se recomienda actuar de manera temprana con cirugía.
Abstract This paper reports the case of a 71-year-old female with a history of tobacco addiction who presented with recurrent infections. She had an increase of volume of left neck with nodule of 4 cm of diameter of 15 years of evolution until arriving at dimensions of 20 x 15 cm. It was completely dry except for its infiltration into the trachea that remained as a remnant. The histopathological diagnosis was: papillary carcinoma of the thyroid infiltrating to trachea. Regarding this case, it is recommended not to leave free evolution, since the incidence of papillary thyroid carcinoma associated with multinodular goiter is similar to that found in solitary cold nodules, which is why it is recommended to act early with surgery.
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O mapeamento do linfonodo sentinela (MLNS) é largamente utilizado em pacientes com melanoma cutâneo, câncer de mama e outras neoplasias malignas sólidas com a finalidade de estadiá-las e indicar esvaziamento linfático apenas na presença de metástase. Nos últimos anos aumentou o interesse pelo uso do MLNS em pacientes com carcinoma papilífero de tireoide (CPT) sem metástases linfáticas detectáveis clinicamente (estádio cN0), devido à alta frequência de metástases ocultas nesses pacientes. O MLNS pode evitar o esvaziamento linfático do compartimento central (ECC) em portadores de CPT sem metástase. Mesmo que não se planeje o ECC eletivo, o MLNS pode também ser usado para estadiar adequadamente o pescoço e indicar tratamento posterior com radioiodoterapia em casos com metástase. Esse estudo tem como objetivo verificar: 1) a efetividade da técnica do MLNS nos pacientes com CPT; 2) a acurácia do MLNS em diagnosticar as metástases linfáticas; 3) se o MLNS pode modificar o estadiamento dos pacientes com CPT cN0. MÉTODOS: Trata-se de estudo de acurácia, prospectivo longitudinal de 38 casos consecutivos de CPT clinicamente N0, atendidos em um único centro, no período de 2010 a 2015. Todos foram submetidos à tireoidectomia total, MLNS com radiofármaco e ECC eletivo. Os resultados relativos ao MLNS foram comparados com o exame anatomopatológico do conteúdo do ECC. RESULTADOS: O tempo médio de seguimento dos doentes foi de 36 ± 13 meses. Os LNS foram localizados com maior frequência nos níveis VI e III. O LNS foi detectado em 95% da casuística e os valores de avaliação de testes diagnósticos foram: 1 falso negativo, 95% de sensibilidade, 100% de especificidade, 94% de valor preditivo negativo e 97% de acurácia. O MLNS foi capaz de reestadiar 49% dos pacientes inicialmente N0 para pN positivo. Quanto ao grupo de estadiamento AJCC (que leva em conta a idade), 3% dos pacientes foram reestadiados para estádio III e 18% para estádio IV. CONCLUSÕES: 1) a técnica de...
Sentinel lymph node mapping (SLNM) is widely perfomed in melanoma, breast cancer and other solid tumors, to adequately stage these diseases. More recently, the interest in SLNM for clinically N0 Papillary Thyroid Cancer (PTC) has increased due to the high rate of occult metastases in these patients, to avoid unnecessary central neck dissection (CND), and its complications. Even if routine elective CND is not planned, SLNM can be used to adequately stage the neck, and to indicate further treatment with radioiodine in cases with neck metastases, for instance. This study aims to evaluate 1) SLNM effectiveness in PTC patients, 2) SLNM accuracy to diagnosis lymph node metastases and 3) if SLNM can upstage cN0 PTC patients. METHODS: This is a prospective longitudinal, diagnostic test accuracy study with 38 consecutive cN0 PTC patients, treated in a single center between 2010 and 2015. Surgical treatment in all cases included total thyroidectomy and elective CND after SLNM. Results of SLNM were compared to CND pathological findings, in order to verify if sentinel lymph node (SLN) predicted the occurrence of PTC occult lymph node metastasis. RESULTS: The mean patients' follow-up was 36 ± 13 months. 133 SLN were found in the neck, on levels VI and III. The SLN was identified in 95% of the patients with 1 false negative, 95% sensitivity, 94% negative predictive value and 97% accuracy. The SLNM upstaging from cN0 to pN+ was 49%, with 3% stage III and 18% stage IVa. CONCLUSION: 1) SLNM was effective in 95% of procedures, 2) SLNM accuracy was 97%, 3) SLNM upstaging from cN0 to pN+ was 49%, and to stage III and IVa was 21%...
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Humanos , Masculino , Feminino , Adulto Jovem , Adulto , Pessoa de Meia-Idade , Idoso , Carcinoma Papilar , Metástase Linfática , Esvaziamento Cervical , Biópsia de Linfonodo Sentinela , Glândula TireoideRESUMO
OBJECTIVE: To compare the distribution of histological subtypes of thyroid cancer in Kingston and St Andrew (KSA), Jamaica, within two consecutive 15-year periods. METHODS: We extracted all cases of thyroid carcinoma archived in the Jamaica Cancer Registry files over the 30-year period from 1978 to 2007. The cases were separated into two groups: 1978-1992 (Group I) and 1993-2007 (Group II). We analysed age, gender and histological subtype distribution within each group, and then made comparative analyses between the two periods. RESULTS: There were 311 cases in which the histological subtype was documented. The patients ranged in age from 12 to 94 years, with male to female ratios of 1:4.2 (group I) and 1:5.6 (group II). The highest frequencies of cases occurred in patients between the ages of 20 and 59 years. The commonest histological subtype in group I was follicular (52.7%); in group II, it was papillary (60%), followed by follicular (26.7%) and medullary (6.7%). There was an overall 263% increase in the papillary to follicular cancer ratio from group I (0.62) to group II (2.25). The increase in papillary carcinomas was statistically significant (p < 0.001) overall, and in patients less than 50 years of age (p < 0.001). CONCLUSION: The recent KSA thyroid cancer data show a histological profile similar to that described globally, with papillary carcinomas being commonest, followed by follicular and then medullary. The significant increase in papillary cancer frequency in KSA is most likely the result of gradual recognition of the entity follicular variant of papillary cancer.
OBJETIVO: Comparar la distribución de subtipos histológicos del cáncer tiroideo en Kingston y Saint Andrew (KSA), Jamaica, dentro de dos períodos consecutivos de 15 años. MÉTODOS: Se extrajeron todos los casos de carcinoma de la tiroides registrados en los archivos del Registro de Cáncer de Jamaica por un periodo de 30 años, de 1078 a 2007. Los casos estaban separados en dos grupos: 1978-1992 (Grupo I) y 1993-2007 (Grupo II). Se analizó la edad, el género y la distribución de subtipos histológicos dentro de cada grupo, y se llevó a cabo entonces un análisis comparativo entre los dos períodos. RESULTADOS: Hubo 311 casos en los que se documentó el subtipo histológico. La edad de los pacientes fluctuó de 12 a 94 años, con una proporción varón/hembra de 1:4.2 (grupo I) y 1:5.6 (grupo II). Las frecuencias más altas de casos ocurrieron en pacientes entre 20 y 59 años de edad. El subtipo histológico más común en el grupo I fue el folicular (52.7%), en tanto que en el grupo II fue el papilar (60%), seguido del folicular el (26.7%) y medular (6.7%). Se produjo un incremento general de 263% en la proporción de cáncer papilar frente al folicular del grupo I (0.62) al grupo II (2.25). El aumento en los carcinomas papilares fue estadísticamente significativo (p < 0.001) de manera general y en los pacientes con menos de 50 años de edad (p < 0.001). CONCLUSIÓN: Los datos recientes del cáncer de tiroides en KSA muestran un perfil histológico similar al que se describe globalmente, siendo los carcinomas papilares los más comunes, seguidos por el folicular y luego el medular. El aumento significativo en la frecuencia de cáncer papilar en KSA es muy probablemente el resultado del reconocimiento gradual de la variante de la entidad folicular del cáncer papilar.
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Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Criança , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Carcinoma/epidemiologia , Neoplasias da Glândula Tireoide/epidemiologia , Fatores Etários , Carcinoma/patologia , Distribuição de Qui-Quadrado , Jamaica/epidemiologia , Sistema de Registros , Fatores Sexuais , Neoplasias da Glândula Tireoide/patologiaRESUMO
Aproximadamente 10 por cento das neoplasias de tireóide aparecem abaixo dos 21 anos e representam 3 por cento das neoplasias da infância, com predomínio em meninas (2F:1M). São papilíferos em 90 por cento casos e mais freqüentemente bilaterais, multifocais e de maior dimensão. Invasão de cápsula e metástases ganglionar ou pulmonar são mais freqüentes que no adulto. O efeito carcinogênico da radiação é especialmente importante na criança pré-púbere. Em 5 por cento dos casos de PTC existe história familial. Genes como o RET/PTC, RAS e BRAF estão habitualmente envolvidos na gênese do processo. A apresentação clínica pode ser nódulo cervical (90 por cento casos) sem que represente um fator de pior prognóstico. O US e a PAAF são procedimentos diagnósticos valiosos. O tratamento deve ser cirúrgico (tireoidectomia total com esvaziamento ganglionar) seguido de PCI e radioterapia ablativa. A substituição com L-tiroxina deve objetivar a supressão crônica do TSH. O prognóstico ao longo prazo é melhor que no adulto. A quantificação da Tg plasmática também é útil na detecção da doença residual.
Approximately 10 percent of thyroid cancers are present in patients less than 21 years of age, representing 3 percent of all cancers of children and adolescents, with predominance in females 2:1 in relation to males. Thyroid cancers in this age group are usually papillary (90 percent), bilateral, multifocal and bigger in size compared to adults. Capsule invasion and lymphatic and pulmonary metastases are more frequent in children. Radiation sensitivity seems to represent an important factor in prepubertal patients. Familial history is reported in 5 percent of the cases. Genes such as RET/PTC, RAS and BRAF are usually involved in thyroid carcinogenesis in this age group. Cervical adenomegaly is a common clinical presentation, but does not represent a poor prognostic factor in children. Ultrasound and fine needle aspiration biopsy are valuable diagnostic procedures. Surgery is the preferred treatment including thyroidectomy and ganglionary excision, followed by ablative radioiodine therapy. L-thyroxine replacement with suppressive dosage should be employed targeting chronic TSH suppression. Long-term prognosis is usually better in children when compared with adults. Plasma thyroglobulin measurement is also useful to detect residual thyroid cancer disease.
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Adolescente , Criança , Feminino , Humanos , Masculino , Carcinoma Papilar , Neoplasias da Glândula Tireoide , Carcinoma Papilar/sangue , Carcinoma Papilar/genética , Carcinoma Papilar/patologia , Carcinoma Papilar/terapia , Predisposição Genética para Doença , Radioisótopos do Iodo/uso terapêutico , Neoplasias Pulmonares/secundário , Tireoidectomia , Tireoglobulina/sangue , Neoplasias da Glândula Tireoide/sangue , Neoplasias da Glândula Tireoide/genética , Neoplasias da Glândula Tireoide/patologia , Neoplasias da Glândula Tireoide/terapia , Tiroxina/uso terapêuticoRESUMO
OBJETIVO: Verificar a incidência de carcinoma papilífero associado à doença de Graves e sua evolução. MÉTODO: Estudamos retrospectivamente os prontuários de 90 pacientes com doença de Graves submetidos a tratamento cirúrgico nos últimos 13 anos. RESULTADOS: Encontramos carcinoma papilífero de tireóide em sete pacientes (7,8 por cento), sendo cinco mulheres e dois homens, com idade média de 43 anos. Em apenas dois casos havia diagnóstico prévio. O tratamento foi tireoidectomia total em cinco casos. Na evolução, apenas um paciente apresentou metástase mediastinal detectada à pesquisa de corpo inteiro. O tempo de seguimento médio foi de 39 meses, estando todos os pacientes vivos e sem sinais de doença. CONCLUSÃO: Nossos dados confirmam a baixa incidência de carcinoma papilífero em doença de Graves, e sugerimos o tratamento cirúrgico precoce em pacientes com nódulos no bócio difuso tóxico.
BACKGROUND: The aim of the present study is to evaluate the incidence of papillary carcinoma in Graves' disease and it's clinical course. METHOD: We retrospectively studied 90 patients with Graves' disease operated on the last 13 years. RESULTS: Seven had papillary cancer (7,8 percent) and five were females. Only two of them had previous diagnosis. Total thyroidectomy was performed in five patients. Only one developed mediastinal metastasis. Average follow-up was 39 months, and all patients are alive and disease-free. CONCLUSIONS: Our data are in agreement with literature reports and we recommend early surgical treatment for patients with nodular diffuse toxic goiter.