Diagnosis and surgical treatment of small papillary carcinomas of the thyroid gland

[Molecular markers as risk factors for thyroid cancer]

Thyroid cancer is the most common malignant tumor of the endocrine system. An increase in the incidence of thyroid cancer has been noted over the past decade, mainly due to papillary cancer. The influence of environmental factors, increased availability of medical care, including sensitive diagnostic tests, such as ultrasound and fine - needle aspiration (FNA), can affect the fact of the growth of this incidence. Palpation of thyroid gland has very low diagnostic value for detecting thyroid cancer, while thyroid ultrasound and FNA can detect malignant tumors in 20% of cases. Today, the FNA is the fastest, most accurate, economically accessible, and quite safe method for cytological diagnosis of the thyroid nodules. And molecular genetic testing of FNA samples could serve as an additional reliable diagnostic tool in the case of atypia of undetermined significance.

Clinicopathologic features and treatment outcomes in differentiated thyroid carcinoma patients with concurrent Graves' disease

The clinical behaviors and treatment outcomes of thyroid carcinomas in patients with Graves' disease is a matter of controversy. This study aimed to identify the clinicopathologic features, treatment outcome, and the indicators for predicting recurrence, and to suggest the optimal extent of surgery in these patients. We retrospectively analyzed data of 58 patients who underwent surgical treatment for differentiated thyroid cancer and concurrent Graves' disease. The follow-up period ranged from 23 to 260 months (mean+/-standard deviation, 116.8+/-54.0). In our series, the mean age was 40.8+/-12.7 yr (range, 15-70), with a male-to-female ratio of 1: 6.25. The mean tumor size was 13+/-9 mm (range, 3-62). The surgical methods included 19 cases of total thyroidectomy, 38 cases of subtotal thyroidectomy, and 1 case of completion total thyroidectomy. Locoregional recurrence occurred in four patients (6.9%). The 10-yr overall survival and disease-free survival of patients were 95.8% and 91.1%, respectively. Age over 45 yr (p=0.031), tumor size over 10 mm (p=0.049), multiplicity (p=0.007), extracapsular invasion (p=0.021), and clinical cancer (p=0.035) were significantly more prevalent in patients with locoregional recurrence than in those without recurrence. We recommend that Graves' disease patients should undergo regular ultrasonography screening for early detection of thyroid carcinoma. We also suggest that the choice of extent of surgery should depend on the diagnostic timing (clinical or incidental) and factors for predicting recurrence.

Microcarcinoma da tireóide: experiência e conduta em clínica privada

OBJETIVO: Estudar o microcarcinoma papilífero observado nas tireoidectomias realizadas em nossa clínica privada. MATERIAL E MÉTODOS: Revisamos clínica e histologicamente 1.930 pacientes submetidos a tireoidectomias no período de 2002 a 2006, tendo 606 carcinomas e, desses, 332 como microcarcinomas papilíferos. Avaliamos sexo, idade, tipo histológico, tamanho da neoplasia, multifocalidade, freqüência do esvaziamento cervical, resultados da PCI e tireoglobulina sérica. RESULTADOS: Dos 332 pacientes, 48 eram do sexo masculino e 146 tinham idade superior a 45 anos. Todos foram submetidos a tireoidectomia total, 19 concomitantemente a esvaziamento cervical de necessidade (5,72%), e 313 a iodoterapia (94,27%). Tivemos metástase a distância em 5 pacientes (1,5%). Após 1 ano, de 170 pacientes submetidos à PCI, temos 141 considerados livres de doença, 21 com anti-tireoglobulina positivo, 6 com tireoglobulina superior a 2 ng/ml, sendo 1 com metástase pulmonar e outro com recidiva linfonodal (0,3%). CONCLUSÃO: Recomendamos que seja realizada a tireoidectomia total, esvaziamento cervical de necessidade e iodoterapia ablativa na presença de fatores clínicos e anátomo-patológicos de risco.

Papillary thyroid microcarcinoma: A surgical perspective

Papillary thyroid microcarcinoma (PTMC) is defined as a papillary thyroid cancer measuring less than 10mm in its greatest diameter. It is the most common form of thyroid cancer, detected in up to 36% in autopsy studies. The wide availability and use of neck ultrasonography in the evaluation of carotid arteries and of the thyroid resulted in an increased detection of PTMC. PTMC is often multifocal. The diagnosis is usually based on a combination of clinical examination, laboratory investigations, and specialized radiological techniques (mainly neck ultrasonography combined with fine-needle aspiration cytology). A common scenario is the diagnosis of PTMC as an incidental finding following thyroidectomy for a presumably benign thyroid disease. Despite some controversy, most authors agree that PTMC should be treated by total or near-total thyroidectomy, provided it can be performed safely. Because of its many and major advantages, in our clinical practice, total or near-total thyroidectomy is the procedure of choice for the management of PTMC. Given the high incidence of PTMC as an incidental finding and the frequent multi-focality, we also favor total or near-total thyroidectomy for the surgical management of nodular thyroid disease (multinodular goiter or dominant presumably benign thyroid nodule/s). Despite some controversy, we perform central neck lymph node dissection electively, in the presence of cervical lymphadenopathy. Radioiodine ablation therapy may be used as an adjuvant therapy. Prognostic factors (such as tumor multicentricity, positive lymph nodes, capsular or vascular invasion) or scoring systems (such as the AMES) can be used to select patients for radioiodine adjuvant therapy. Suppression therapy is needed after surgical management. Despite the potential for neck lymph node and even distant metastases, the biological behavior of PTMC is in general benign and the prognosis is very good.

[Pathohistologic and immunohistochemical characteristics of thyroid carcinoma]

Numerous pathohistologic criteria, difficulties and pitfalls in the process of diagnosing of thyroid carcinoma are discussed. Benign hyperplastic papillae may be present in colloidal cystic goiter and hyperplastic goiter. These structures are lined by cells with normochromatic nuclei and do not disturb the thyroid tissue architecture. Papillae in papillary thyroid carcinoma have cells with ground-glass, hypochromatic nuclei. Follicles inspissated in capsula of follicular or even colloidal adenoma may be evaluated as capsular invasion--diagnostic feature of follicular carcinoma. Undifferentiated thyroid carcinoma is sometimes similar to fibrosarcoma and reveal cellular pleomorphism, anaplasia and numerous foci of necrosis. Medullary thyroid carcinoma with scanty stromal amyloid, its papillary variant and carcinoid-like histologic type consist of oval cells with eosinophilic cytoplasm and dark nuclei.

Surgical Treatment of Thyroid Cancers With Concurrent Graves Disease

BACKGROUND

Thyroid cancers with concurrent Graves disease are relatively rare. Accordingly, the natural history and optimal surgical treatment of thyroid cancers with Graves disease are controversial.

METHODS

Sixty-one thyroid cancers with concurrent Graves disease were retrospectively reviewed. Histopathologic diagnoses included 58 papillary thyroid carcinomas (95.1%), 1 follicular carcinoma (1.6%), 1 medullary carcinoma (1.6%), and 1 Hürthle cell carcinoma (1.6%).

RESULTS

The sample included 54 females and seven males. Subjects' ages ranged from 20 to 73 years (mean +/- SD, 35.9 +/- 10.6 years; median, 37 years). Average tumor size was 10.7 +/- 15.9 mm (range, 1-70 mm). Forty-nine tumors (80.3%) were 10 mm or smaller. Surgical procedures included subtotal thyroidectomy (40 patients), total thyroidectomy (16 patients), total thyroidectomy plus neck dissection (2 patients), near-total thyroidectomy (1 patient), and lobectomy with contralateral subtotal lobectomy (1 patient). Thirty-seven patients (60.7%) underwent postoperative 131I ablation for thyroid remnant. Neck lymph node metastases occurred in three patients and lung metastases in two patients. Patients who developed metastases were younger and had significantly larger tumors and higher pretreatment serum T3 level than those who did not develop metastases. No deaths occurred during the 6.2 +/- 4.1 year follow-up period (range, 1 year and 2 months to 18 years and 11 months).

CONCLUSIONS

Most thyroid cancers with concurrent Graves disease were 10 mm or smaller. Subtotal thyroidectomy is adequate for patients with Graves disease with concurrent carcinoma 10 mm or smaller.

Sentinel lymph node biopsy in patients with papillary thyroid carcinoma

BACKGROUND

It remains controversial whether modified radical neck dissection (MRND) for patients with papillary thyroid carcinoma improves prognosis. However, it is highly probable that the incidence of local recurrence is reduced by lymph node dissection. Sentinel lymph node (SLN) biopsy (SLNB) for patients with melanoma and breast carcinoma has been validated as an accurate method for assessing lymph node status. The objective of this study was to determine the feasibility of SLNB for the evaluation of cervical lymph node status in patients with papillary thyroid carcinoma.

METHODS

After injection of methylene blue around the tumor in 22 patients with papillary thyroid carcinoma, blue-stained lymph nodes were dissected as SLNs. After the SLNB, all patients also underwent subtotal thyroidectomy and MRND. SLNs and other lymph nodes were investigated with regard to their number, distribution, size, lymph node status, and ratio of metastatic area.

RESULTS

There was concordance between the SLN findings and the regional lymph node status in 19 of 21 patients (90.5%; 7 patients had both positive SLN and regional lymph node results, and 12 patients had both negative SLN and regional lymph node results). Two patients had negative SLN results but, in the end, had positive nonsentinel lymph nodes (NSLNs). The overall reliability rate of SLNB was 86.3% (19 of 22 patients). The authors experienced no complications with the use of methylene blue for the detection of SLNs.

CONCLUSIONS

SLNB using methylene blue is feasible technically and is safe, and the findings correlate with cervical lymph node status. Therefore, SLNB is a good technique for estimating the status of cervical lymph nodes in patients with papillary thyroid carcinoma.