Papillary thyroid microcarcinoma with minimal extrathyroidal extension. Is its course so indolent that it requires a less aggressive treatment?

BACKGROUND

Although the incidence of papillary thyroid microcarcinoma (PTMC) has increased in recent decades, the role played by minimal extrathyroidal extension (mETE) in the prognosis of PTMC is still unclear. The aim of this study is to analyze the factors associated with PTMC with mETE and its long-term prognosis.

MATERIAL AND METHODS

We conducted a retrospective study on patients with a histological diagnosis of PTMC. We excluded patients who had previously undergone thyroid surgery, those who had other synchronous malignancies, those with an ectopic location of the PTMC, and those lost to follow-up within 2years. We compared group 1 (PTMC without extrathyroidal extension) to group 2 (PTMC with mETE) and performed a multivariate analysis.

RESULTS

We observed PTMC with mETE in 11.2% (n=18) of patients. On the multivariate analysis, mETE was associated with age ≥45 years (OR: 4.383; 95% CI: 1.051-18.283, p = .043), tumor size ≥8mm (OR: 5.913; 95% CL: 1.795-19.481; p = .003), bilaterality (OR: 4.430; 95% CI: 1.294-15.173; p = .018) and metastatic lymph nodes (OR: 12.588; 95% CI: 2.919-54.280; p = .001). During a mean follow-up of 119.8±65 months, one recurrence was detected in group 2 (0% vs. 5.6%; p = .112). No patients died of the disease. Disease-free survival was lower in group 2 (124.9±5.6 vs. 97.4±10.3 months; p = .034).

CONCLUSIONS

The mETE of PTMC is a factor of worse prognosis associated with the presence of metastatic lymph nodes and a lower rate of disease-free survival.

Improving the waiting list by using 75-year-old donors for recipients with hepatocellular carcinoma

The best treatment for hepatocellular carcinoma (HCC) associated with liver cirrhosis is liver transplantation and the best results are obtained when the tumors fulfill the Milan criteria. However, although the number of transplants is increasing, the organ deficit is growing, which lengthens time on the waiting list, increasing the risk of tumor progression of and exclusion from the list. The use of elderly donors is a valid option for patients on the transplant waiting list with HCC, reducing time on the waiting list. We report our experience with patients transplanted for HCC associated with hepatic cirrhosis using livers from donors >75 years of age. Our preliminary results supported the use of elderly suboptimal donors making it possible to give priority to these patients. All patients in the series achieved good graft function after a follow-up of 2 years with a 100% disease-free survival rate. More extensive long-term studies are needed to confirm these findings.

What Is the Attitude of Hospital Transplant-related Personnel Toward Donation?

The attitude of health-care workers, especially in transplant-related services, is fundamental in the process of organ procurement. In this study we examine the attitude of workers in transplant-related services toward cadaveric organ donation and transplantation (ODT) in a third-level hospital in Spain. A random sample was stratified according to type of service and job category (n = 309) among personnel in transplant-related services (organ procurement units, transplant units and follow-up units). Attitude toward cadaveric organ donation was evaluated using a validated psychosocial questionnaire. Seventy percent (n = 215) of respondents were found to be in favor of donation, as opposed to 30% against or undecided (n = 94). Regarding job category, attitude was most favorable among physicians (86%, n = 99; p = 0.000). With respect to type of service, attitude tended to be more negative in organ procurement units and more positive in the follow-up units of transplanted patients (41% vs 81%, p = 0.013). Upon analysis of the psychosocial variables, significant results were found with respect to the following factors: (1) age (39 vs 42 years, p = 0.007); (2) having discussed ODT with family members or with a partner (p = 0.007); (3) understanding of the concept of brain death (p = 0.001); (4) attitude toward carrying out an autopsy (p = 0.001); and (5) concern about the possibility of mutilation after organ extraction. Attitude toward cadaveric donation was lower than expected among personnel in transplant-related services, especially among ancillary personnel and workers in organ procurement units.

[Clinical recurrence of multinodular goiter after surgery. A multivariate study on the risk factors]

INTRODUCTION

In multinodular goiter there is no consensus on which is the most adequate surgical technique, since although the techniques with partial resection show lower risk of complications they are associated with a higher risk of recurrences. The objective of this study is to define the risk factors for recurrence of multinodular goiters after surgery in a series with a mean postoperative follow-up higher than 12 years.

PATIENTS AND METHOD

231 multinodular goiters with partial thyroid surgery are analyzed. The recurrence is assessed through clinical exploration, and is confirmed with echography. The variables analyzed are age, sex, family history of thyroid pathology, residence in goitrogenic areas, asymptomatic hyperthyroidism, compression syndromes, intrathoracic extension of goiter, surgeon experience with endocrine surgery, weight of the thyroid, and surgical technique, chi2 test, Student's t test and a logistic regression test are applied.

RESULTS

After a mean postoperative follow-up of 152 +/- 71 months 67 goiters (29%) showed recurrence with a mean time for recurrence of 85 +/- 67 months. Risk factors detected in the multivariate study were youngest age, surgeon's lack of experience in endocrine surgery, and the surgical technique. Forty-six patients (69%) were operated because of recurrence, most of them by surgeons experienced in endocrine surgery. Thyroidectomy was completed in all cases, and two definitive postoperative complications occurred.

CONCLUSIONS

The index of clinical recurrences is high and increases with the progression; primary risk factors are age, surgeon's experience, and surgical technique. The implication is that partial resection techniques should be carried out by surgeons with experience and there should be avoided in young patients.

[Importance of primary health-care professionals in the sanitary education about organ donation]

AIM

To determine the influence of the information on donation generated from primary health-care on the attitude towards organ donation.

DESIGN

Descriptive transversal study.

SETTING

45 municipalities of Murcia Region, Spain.

PARTICIPANTS

The population in this study was randomly selected and stratified according to age, sex, and geographic localization among people over > or =15 years of age (n=1887). INTERVENTIONS AND MEASURES: The attitude was evaluated according to a questionnaire psychosocial aspects of donation. There is valued the information transmitted on donation to the population from primary care (group A) or other informative sources (group B), and if this information was to favour or in opposition to the same one.

STATISTICS

chi2 test, t Student, and logistic regression analysis.

RESULTS

Of 1887 surveys, 129 cases (group A) (7%) had received information from primary care. In this group, the 89% is in favour of the donation. In 120 cases the received information was favourable, presenting an attitude in favour of the donation of 93%, whereas in all 9 remaining cases the information was in against, decreasing the attitude to favour up to 44% (P<.05). In the group B (n=1758) the attitude in favour of the donation was of 65% (P<.05, with regard to the group A). The 62% (n=1083) received favourable information, improving in them the favourable attitude towards the donation up to 74%. The rest (38%; n=675) had received also unfavourable information, decreasing his attitude to favour up to 51% (P<.05).

CONCLUSIONS

Little information about organ donation is transmitted from primary care, but when it is realized a very positive impact has if it is favourable and very negative if it is unfavourable.

[Importance of primary health-care professionals in the sanitary education about organ donation]

AIM

To determine the influence of the information on donation generated from primary health-care on the attitude towards organ donation.

DESIGN

Descriptive transversal study.

SETTING

45 municipalities of Murcia Region, Spain.

PARTICIPANTS

The population in this study was randomly selected and stratified according to age, sex, and geographic localization among people over > or =15 years of age (n=1887). INTERVENTIONS AND MEASURES: The attitude was evaluated according to a questionnaire psychosocial aspects of donation. There is valued the information transmitted on donation to the population from primary care (group A) or other informative sources (group B), and if this information was to favour or in opposition to the same one.

STATISTICS

chi2 test, t Student, and logistic regression analysis.

RESULTS

Of 1887 surveys, 129 cases (group A) (7%) had received information from primary care. In this group, the 89% is in favour of the donation. In 120 cases the received information was favourable, presenting an attitude in favour of the donation of 93%, whereas in all 9 remaining cases the information was in against, decreasing the attitude to favour up to 44% (P<.05). In the group B (n=1758) the attitude in favour of the donation was of 65% (P<.05, with regard to the group A). The 62% (n=1083) received favourable information, improving in them the favourable attitude towards the donation up to 74%. The rest (38%; n=675) had received also unfavourable information, decreasing his attitude to favour up to 51% (P<.05).

CONCLUSIONS

Little information about organ donation is transmitted from primary care, but when it is realized a very positive impact has if it is favourable and very negative if it is unfavourable.

Research training during medical residency (MIR). Satisfaction questionnaire

INTRODUCTION

It is during Medical Residency Training (MIR) that knowledge, abilities and habits are acquired, which will shape professional activity in the future. It is therefore very likely that residents who do not acquire the necessary habits and knowledge for research activities will eventually not carry out these activities in the future. The aim of this study was to analyze the level of satisfaction of residents with his or her scientific and research training, and to determine any deficiencies with respect to this training.

MATERIALS AND METHODS

The aim of the questionnaire used was to determine the level of satisfaction of residents regarding their scientific and research training during their residency period. Questionnaires were usually distributed via internal mail to all residents (MIR physicians) registered at a third level teaching hospital, with a completion rate of 78% (n = 178).

RESULTS

As far as the evaluation of scientific training is concerned, 68% of residents were dissatisfied or very dissatisfied. With respect to scientific studies carried out, 49% of residents had not taken part in any, but the number of studies carried out increases as the residency progresses. On the other hand, 22% of residents reported not having started their doctoral thesis, 50% having attended doctorate courses, 24% having a title for their thesis, and only 4% having written a thesis. Doctorate courses, thesis topics, and written theses increase with the year of residency, and a greater activity may be seen in this respect in surgical departments. If we analyze help available to residents for their carrying out scientific activities, 55% reported that only selected assistant doctors would offer help, and 21% reported that no doctors would offer help. Dissatisfaction with research training increases with the year of residency. With regard to main specialist fields, it can be seen that residents in surgical fields carry out more theses, whereas central fields report less facilities. Finally, if we evaluate the influence that these variables may have on the general satisfaction of residents with his or her residency, these variables are seen to be significant factors of dissatisfaction.

CONCLUSIONS

Most residents are dissatisfied with their scientific training and have relatively few facilities for developing such skills, which in turn results in a scarce number of scientific studies and doctoral theses.

Influence of different sources of information on attitude toward organ donation: a factor analysis

OBJECTIVES

To determine media through which the population receives information on donation; to analyze the association between the sources of information and the psychosocial variables with respect to the opinion on donation; and to determine how each source of information influences this opinion.

MATERIALS AND METHODS

A questionnaire on donation was administered to a random sample of 2000 persons stratified by age, gender, and geographical location, of whom 1143 respondents claimed to have no experience with donation and/or transplantation. A statistical analysis was done between the sources of information or the psychosocial variables or their co-variation to determine their specific impact on the population.

RESULTS

The medium with the greatest impact on the population is television; the second factor is the press and radio; the third is magazines and talks with friends/family; the fourth is hoardings and posters, and campaigns about organ donation; and the last factor is information given by health professionals. In the factor analysis between sources of information and psychosocial variables, an association was observed between press, radio, and information given by health professionals and a higher education level; and between information provided by discussions in schools, by age, and a higher level of education. Sources of Information sources as that have a favorable effect on donation include discussions, (P = .0079), and information by health professionals (P < .0005) and by friends (P = .0132) and by family (P = .0044).

CONCLUSIONS

Opinion on donation is more favorable among subjects who have received information on an individual basis and at specialized meetings. The only psychosocial variable associated with some sources of information is the level of education.

[Ventriculopleural shunt to treat hydrocephalus]

INTRODUCTION

Ventriculoatrial and ventriculopleural shunts (VPS) are alternatives to ventriculoperitoneal shunts for draining cerebrospinal fluid from patients with hydrocephalus. VPS has seldom been used because of the risk of respiratory insufficiency due to pneumothorax or pleural effusion. However, valves are currently available with anti-siphon devices for use with standard shunting systems to prevent the development of pleural effusion. The aim of this study was to analyze outcome after VPS in eight patients in whom we used the new valves for avoiding overdrainage of cerebrospinal fluid.

MATERIAL AND METHOD

Nine VPS procedures were performed in eight hydrocephalic patients between 1988 and 2000. We used differential pressure valves in eight procedures and a flow regulator valve in one. The externally adjustable Sophy valve was used in six cases. The indication for VPS was peritoneal adhesions in four cases, persistent ascites in two, ventriculoatrial valve obstruction in one, and infection of the peritoneal shunt (peritonitis) in one. The ninth case involved replacement of a previously obstructed valve.

RESULTS

After a follow-up period of 22 months all shunts were functioning well and the only patient with symptoms of hydrocephalus was the one who required valve replacement at six months. No surgical morbidity or mortality was observed, and only one patient developed transitory signs of excessive cerebrospinal fluid drainage, which was corrected by regulating the magnetic valve gradient. The death of one patient 36 months after surgery was unrelated to pleural drainage.

CONCLUSIONS

Valves newly designed to prevent overdrainage of cerebrospinal fluid give satisfactory results, such that VPS should be considered as an alternative to peritoneal drainage.

[Prognostic factors in gallbladder cancer]

BACKGROUND AND AIM

Carcinoma of the gallbladder is the most frequent biliary tract lesion but the 5-year survival is less than 5%. The aim of this study was to analyze the influence of several clinico-pathological variables on survival in a series of 226 carcinomas of the gallbladder.

PATIENTS AND METHODS

The results were retrospectively analyzed and prognostic factors were identified by univariate statistical analysis and Cox regression model. All patients underwent surgery and in 67 of these (29.6%), surgery was potentially curative. In 63 patients (27.9%) diagnosis was made when the resected gallbladder was studied for benign disease. Tumor node metastasis (TNM) stage was 0 in 7 patients (3.1%), stage I in 19 patients (8.4%), stage II in 21 patients (9.3%), stage III in 61 patients (27%) and stage IV in 118 patients (52%).

RESULTS

Overall 5-year survival was 17.3%. In the univariate analysis, significant variables were the presence of jaundice, weight loss, palpation of abdominal tumors at diagnosis, surgical technique, TNM stage and the three variables of this system (T: size, N: adenopathies; M: distant metastasis). In the multivariate analysis, the three variables of the TNM system and surgical technique were significantly associated with survival.

CONCLUSIONS

The most important prognostic factor was TNM stage. Currently, radical cholecystectomy in stages II and III has become another important prognostic factor.

[Esophageal perforations. Presentation of 23 cases]

AIM

Esophageal perforations are the most serious perforations of the digestive tract and their treatment remains controversial. The aim of this study was to analyse the outcome of patients with esophageal perforations given surgical and conservative treatment.

PATIENTS AND METHODS

Retrospective study of 23 patients with esophageal perforations, 8 cervical (35%) and 15 thoracic (65%). Medical treatment was indicated in patients who fulfilled Cameron's criteria (minimal signs of clinical sepsis; disruption contained in the mediastinum; drainage of the cavity back into the esophagus; minimal symptoms). The remaining patients underwent surgery.

RESULTS

Two patients with cervical perforations (25%) met Cameron's criteria. Evolution after conservative treatment was favourable. The remaining patients (75%) were surgically treated: simple closure of the perforation was performed in four and drainage of the cervical abscess in two. Two of the patients who underwent surgery presented pleural hemorrhage, one of which was associated with pneumonia. Four patients with thoracic perforation (27%) met the criteria for conservative treatment. One presented respiratory distress syndrome during treatment and required intensive care. Evolution was favorable in all. The remaining 11 patients (73%) received surgical treatment: in five (46%) simple closure of the perforation was performed, in three (27%) bipolar exclusion was performed and in the remaining patients, other techniques were used. Morbidity was 82% (nine patients) mainly due to pneumonia and mortality was 46% (five patients).

CONCLUSIONS

Treatment of esophageal perforation should be individualized. Conservative treatment should be considered in patients meeting Cameron's criteria as their evolution is favorable, with low morbidity and mortality and surgery is not necessary.

[Treatment of retroperitoneal sarcoma]

AIM

To evaluate the results of treatment of retroperitoneal sarcomas.

PATIENTS AND METHODS

We evaluated clinical, diagnostic, surgical and histological parameters as well as adjuvant therapy and evolution in 15 patients with retroperitoneal sarcoma.

RESULTS

All patients presented abdominal tumors at diagnosis. Imaging revealed retroperitoneal origin. Complete surgical resection was carried out in seven patients (47%), reduction in size of tumor mass in five (33%) and exploratory laparotomy in three (20%). Histological analysis revealed 12 liposarcoma (80%), two leiomyosarcoma (13%) and one fibrosarcoma. Adjuvant therapy was given to two patients. Of the patients who underwent complete surgical resection, four survived without relapse (1, 2, 5 and 5 years respectively). With the other treatments, there were no survivals at 2 years. Adjuvant therapy did not influence survival.

CONCLUSIONS

Retroperitoneal sarcoma is diagnosed late. Prognosis is poor due to tumor relapse and only complete surgical removal produces a "cure".

[Superior vena cava syndrome caused by multinodular goiter]

Currently, the vena cava superior syndrome (VCSS) is mainly of oncologic origin. We report here four cases of this syndrome caused by intrathoracic multinodular goiter. All patients had compressive symptoms, particularly of the oesophagus and trachea. Axial CT was the imaging technique that delineated the intrathoracic multinodular goiter compressing brachiocephalic vessels. Surgery (total thyroidectomy) was used and all compressive symptoms resolved.

[Intestinal invagination in the adult]

Idiopathic intestinal invagination is a relatively frequent process in children in comparison with cases of intestinal obstruction/subocclusion by invagination secondary to a tumor in adults which is unusual and more often observed in patients over the age of 60 years. Two clinical cases of intestinal obstruction in young adult males due to intestinal invagination by a tumor of the small intestine are presented. One case was due to a submucosal lipoma which lead to ileo-ileal intussusception and an ileo-cecal invagination by a terminal ileum lymphoma. The clinical and diagnostic aspects of this infrequent disease are discussed.

[Information campaign on organ donation and transplant in school children]

OBJECTIVES

To increase schoolchildren's understanding and clarify their wrong ideas on organ donation and transplant (ODT).

DESIGN

Quasi-experimental study.

SETTING

12 schools in the Autonomous Community of Murcia.

PARTICIPANTS

428 schoolchildren from the fourth and fifth years of Basic General Education during the academic year 1996 to 1997.

INTERVENTIONS

An informative campaign carried out by health-service staff, which consists of four activities connected with ODT. Their knowledge was evaluated through a questionnaire on ODT from the ALCER (Murcia) Organisation for children in the first EGB cycle.

MEASUREMENTS AND MAIN RESULTS

Average score was 5.15 points pre-campaign, 8.01 soon after and 7.39 long after, the differences between the pre-campaign and the two after, and between both the afters, were statistically significant.

CONCLUSIONS

Knowledge of ODT was increased and wrong ideas were clarified. After three months there is a significant drop from the immediate post-campaign situation, which shows that subsequent activities to maintain children's level of knowledge must be carried out.