[Results of surgical treatment of papillary thyroid cancer with lymph node metastasis - review of our data in a 5-year period]

A papillaris pajzsmirigyrák prognózisát a gyakori nyaki nyirokcsomóáttét-képzés befolyásolja. Sebészi kezelésük minősége a betegek túlélését és a recidíva előfordulási gyakoriságát is meghatározza. Az Országos Onkológiai Intézet Fej-Nyaki Daganatok Multidiszciplináris Központjában a fej-nyak sebész szerzők által 2013 és 2018 között operált, nyaki áttétet adó papillaris carcinomás betegek adatait vizsgáltuk. 130, nyaki áttétet adó papillaris pajzsmirgy-carcinomás beteg esetében az ATA (American Thyroid Association) 2015. évi irányelvei alapján teljes pajzsmirigy-eltávolítást és nyaki nyirokcsomó-dissectiót végeztünk. Az eltávolított anyagokat szövettani feldolgozásra küldtük, vizsgáltuk a nyirokcsomóáttét(ek) arányát az életkor, a nem, a tumor-multifokalitás, a kétoldaliság, a tokon kívüli terjedés, a nyirok-, érinvázió függvényében. Elemeztük a műtét után fellépő szövődményeket is. 43 betegnél thyreoidectomia, totális és centrális nyaki dissectio (VI. régió), 87 esetben centrális (VI. régió) és laterális (II–V. régió) nyaki dissectio történt. Átmeneti (6 hónapon belül normalizálódó) hypocalcaemia 30 betegnél (23%), permanens hypocalcaemia 4 betegnél (3%) fordult elő. Átmeneti nervus recurrens bénulás 12 esetben (9,2%), permanens bénulás 3 (2,3%) esetben történt. A szövettani értékeléskor érbetörés és tokinvázió 75 betegnél (57,7%), nyirokér-invázió 63 betegnél (48,5%), Hashimoto-thyreoiditis 51 betegnél (39,2%) igazolódott. Microcarcinoma (1 cm-nél kisebb daganat) 43 esetben fordult elő (33%). Az eltávolított nyirokcsomók átlagosan 48%-a volt áttétes. Ez csak a tumormérettel mutatott szignifikáns korrelációt, az életkorral nem találtunk összefüggést. Az oldaliság, a többgócúság, valamint a tok-, nyirokér- és érinvázió, a Hashimoto-status és a beteg neme nem mutatott összefüggést az áttétes nyirokcsomók számával. A túlélést befolyásolta a tok-, ér- és nyirokér-invázió, valamint a tumorméret is. A nyaki áttétet adó, differenciált pajzsmirigyrákos beteganyagunk kezelésében a kivizsgálási protokollt követően a teljes pajzsmirigy-eltávolítás és a megfelelő régiókat tartalmazó nyaki dissectio döntő fontosságú, a radiojód-terápiával kiegészítve az irányelveknek megfelelő kezelési modul. A pajzsmirigydaganat a leggyakoribb endokrin daganatos megbetegedés, melynek sebészi kezelése a multidiszciplináris terápia legfontosabb eleme. 5 év alatt operált, nyaki áttétet is adó, differenciált pajzsmirigyrákos beteganyagunkat feldolgozva ismertetjük eredményeinket az olvasóval. Orv Hetil. 2024; 165(3): 83–88.

[Retrospective analysis of papillary thyroid microcarcinoma cases treated between 2001 and 2010 in the Hungarian National Institute of Oncology]

The standard treatment of papillary microcarcinomas (mPTC; ≤1 cm) regardless of their size, was similar to the advanced ones till the recent past: immediate surgery ± radioactive iodine (RAI) therapy. However, the American Thyroid Association (ATA) 2015 guidelines accept the active surveillance in selected cases. We performed a retrospective analysis on the clinical data of 103 patients with PTmC in a single (62.1%) or multiple nodes (37.9%), treated with immediate surgery followed in most cases by postoperative RAI between 2001 and 2010. N stage of the neck was pN0 in 81, and pN+ in 22 patients. Survival probability was significantly related to age (p<0.001), TSH level (p=0.0347), N stage (p=0.0402) and need for neck dissection (p=0.0045). Overall survival at 5, 10, and 15 years was 95%, 89%, and 86%, while disease-specific mortality at 5 and 10 years was 3% and 5%, respectively. Our data show that immediate radical surgery with or without postoperative RAI yielded long-term survival similar to those published. Nevertheless, progression affecting mostly older men was not prevented by immediate surgery. Our findings do not contradict the acceptability of active surveillance recommended by the 2015 ATA Guidelines.

[On-site fine-needle aspiration cytology of thyroid nodules. Quality assurance of the Bethesda System for Reporting Thyroid Cytopathology (2008)]

INTRODUCTION

The methods available for the diagnosis of thyroid nodules include physical examination, imaging, laboratory and fine-needle aspiration cytology tests.

AIM

The aim of this study was to determine the quality assurance of fine-needle aspiration cytology of thyroid nodules.

METHOD

Cytology results were rated to 6 categories according to the Bethesda System for Reporting Thyroid Cytopathology (2008) (I. nondiagnostic; II. benign; III. atypia of undetermined significance; IV. follicular neoplasia; V. suspicious for malignancy; VI. malignant). All cytology reports were compared with the final histology diagnosis.

RESULTS

A total of 1384 patient with thyroid nodule underwent fine-needle aspiration biopsy cytology. Smears were classified I. inadequate in 214 (15.9%); II. benign 986; III. atypical 56; IV. follicular neoplasm 41; V. suspicious for malignancy 18; VI. malignant 33 cases. Two hundred and twenty seven (16.8%) of the cases were operated and histologically verified. The positive predictive value in the benign category was 98.25% and in the malignant 88.46%. The sensitivity of the follicular neoplasm was 66.67%.

CONCLUSION

The results suggest that fine-needle aspiration cytology of thyroid nodules using the Bethesda System for Reporting Thyroid Cytopathology has a high diagnostic accuracy. The auditing values of the results meet the proposed threshold values.

[Not Available]

INTRODUCTION

The presence of a substernal goiter which compresses the adjacent structures is per se an indication for resection, mostly total thyreoidectomy should be performed either by a head and neck or general surgeon. In about 1-10% of the cases the goiter is located behind the sternum, and the removal requires different surgical technique.

MATERIALS AND METHODS

Authors operated 182 patients between 2000-2014 with substernal goiter which all reached the level of the jugulum. The 182 cases were examined retrospectively.

RESULTS

All the patients were symptomatic with choking and dyspnea. In 31 cases neck ultrasound were performed, in 7 cases neck MRI and in 138 cases neck-upper mediastinal CT scan were indicated to discover the real situation of the lobes. 15 patients had previous partial thyreoidectomy. Acervical approach was used in 175 cases, 7 patients required median sternotomy to complete the operation. Transient recurrent laryngeal nerve palsy occurred in 1 patient, permanent RLNP in 3. Nine lesions were malignant, 173 were benign.

CONCLUSION

Choking and dyspnea are the most common symptoms of substernal goiter. CT scan is an important preoperative evaluation, while it helps not only to define the position of the thyroid lobes, but also put the right operating team together. Although most of the retrosternal goiters can be removed by a cervical approach, some of them need additional incisions. Hence, it is important to have a thoracic surgeon available. Reviewing the Hungarian literature the authors have not found any other study examining so many patients.

[Pedicled supraclavicular osteocutan island flap for tracheostoma closure]

Authors present a case of a 52-year-old female patient, who underwent an emergency tracheostomy due to life threatening dyspnoea caused by an external compression of a large goiter. Total thyreoidectomy needed to be carried out later, too. Since the atypical tracheostomy did not close spontaneously a reconstruction was planned. A part of the anterior wall of the trachea needed to be replaced, which was done by an osteocutaneous flap on raised on the supraclavicular artery. An island on the artery was harvested with a thin bone chip taken from the coracoid process of the clavicle, which was rotated into the defect then. The bone chip was sutured to the trachea wall and the donor site was closed primarily. Having reviewed the literature the authors propose the application of this flap in a wide range of cases. The advantages of this flap are the satisfactory functional and cosmetic results, as well as the fact that the donor site does not need skin grafting.

[Our clinical experience with fibula free flap]

Oral cancer incidence in Hungary is strikingly high, even by international standards. In most cases the tumours are to be treated in advanced stage. Hence it follows that we are often forced to remove a part of the mandible, too. We usually use a fibula free flap to reconstruct the bone deficiency. In this paper we report on our clinical experience with fibula free flap.

[Applicable methods of reconstruction for the replacement of soft tissue after the radical resection of oral tumors]

In Hungary the number of oral and pharyngeal cancers is alarmingly high. While the mortality rate in 1955 was 282, by 2005 it rose to 1567. However, in the last 1-2 years stagnation can be observed. Nevertheless, even now significant proportions of men and women are involved. Alcohol consumption and smoking are invariably the leading causes, but one cannot disregard the shortcomings of oral cancer screenings, either. Unfortunately, drastic changes in this field are not likely to occur in the near future. Numerous solutions have been developed for the replacement of soft tissue. In our article, we describe and evaluate four of them. When using these techniques, we were often successful in replacing soft tissue deficiencies.

[Laser surgery of head and neck lesions at the National Institute of Oncology, Budapest]

In spite of the continued expansion of non-surgical therapeutic modalities surgery still plays an important role in the treatment of head and neck cancer. Parallel with the use of conventional approaches, more sophisticated surgical approaches, like the use of laser in oncologic surgery, appeared with a more favorable outcome. Laser is a precise surgical tool, particularly when coupled to an operating microscope (with a variable spot size micromanipulator), allowing microprecision and hemostatic ability. The benefits of the use of laser are: bloodless operation field, high hit probability, "no touch" technique, ablasticity, support of tissue repair, and the lack of edema and scar formation. Between 1981 and 2008, 7934 surgical procedures were performed at the Department of Head and Neck Surgery, National Institute of Oncology, Budapest, Hungary. The aim is to present our results and experience with laser surgery of cutaneous lesions of the head and neck, oral, pharyngeal and laryngeal pathologies including cases of laryngotracheal stenosis.

Angiography-proven liver metastases explain low efficacy of lymph node dissections in medullary thyroid cancer patients

AIM

To report the role of liver angiography in the staging of medullary thyroid cancer (MTC) patients.

MATERIAL AND METHODS

Sixty MTC patients with persistent or recurrent hypercalcitonemia (n=49), a characteristic general symptom (diarrhea, n=4) or a normal basal calcitonin level without general symptoms (n=7) were investigated by dynamic liver CT, MRI and angiography between 06/1998 and 06/2002.

RESULTS

Dual-phase CT and MRI investigations identified hepatic metastases with relatively low frequency (8/58 on MRI, and 7/60 on CT). Angiography indicated liver involvement in 54/60 cases. The hepatic metastases were typically multiple, hypervascular, small foci (only 13 foci measured >/=10 mm). With one exception significant disease progression was not observed over 5 years of follow-up.

CONCLUSIONS

Liver angiography is a powerful tool to reveal hepatic metastases in MTC patients. Frequent, inoperable liver metastases in hypercalcitoninemic MTC patients demonstrate that secondary lymph node dissection is an inefficient technique for restoration of a normal calcitonin level.

[Clinical significance of serum thyroglobulin and antithyroglobulin antibody in differentiated thyroid cancer after thyroid ablation]

Serum thyroglobulin (Tg) is a suitable marker for differentiated thyroid carcinoma following total thyroid ablation. Between 1998 and 2003, serum samples from 715 papillary and 179 follicular tumor patients treated with total/nearly total thyroidectomy and radioiodine ablation therapy were collected. According to the "Guidelines for Oncotherapy in Hungary", serum Tg, antithyroglobulin antibody (TgAb), TSH and FT4 levels were measured in periods of 3 months following the first treatment and of 6 months after 2 years. In the present work the prognostic value of Tg and TgAb data of cancer patients with hormone substitution therapy were evaluated individually and retrospectively. Serum Tg and TgAb concentrations were measured with a highly sensitive immunoradiometric (IRMA) method, and with a second generation, broad epitope specificity competitive radioimmunoassay, respectively. TSH levels determined by fourth generation LIAISON kit were in a range of 0.05-0.10 mIU/L. Accuracy of measuring of Tg <1 ng/ml made it possible to select the low cut-off level (Tg <2 ng/ml) following total thyroidectomy. In the predominant part of TSH-suppressed patients (746/774, 96%) the serum Tg concentration was below the cut-off level of 2 ng/ml. The sensitivity of Tg determination in 59 TSH-suppressed thyroid cancer patients with lung and bone metastases was as high as 86 to 100%. On the contrary, the number of false negative data was high in cases with lymph node metastases of papillary cancer, and sensitivity did not exceed 62%. Specificity and sensitivity of Tg in TgAb negative patients were 91 to 100%. Based on our results it could be concluded that measuring of Tg and TgAb, using a current IRMA method and a second generation RIA kit, proved to be effective tools for the postoperative monitoring of differentiated thyroid tumours. It has to be noted that determination of TgAb is highly recommended for the adequate interpretation of serum Tg levels. Persistently high and/or increasing serum TgAb concentration with low Tg result had a diagnostic value during the follow-up and can be connected with the recurrence or persistence of the differentiated thyroid cancer.

FDG PET imaging in hereditary thyroid cancer

AIM

To report the role of different imaging methods in staging individuals with multiple endocrine neoplasia 2A (MEN2A) or familial medullary thyroid carcinoma (FMTC).

MATERIAL AND METHODS

Fourteen newly diagnosed gene carriers underwent cervical ultrasound scanning (US), cervical and mediastinal CT, MRI and whole-body meta-[131I]iodobenzylguanidine (MIBG) scintigraphy and [18F]fluorodeoxyglucose (FDG) PET scanning.

RESULTS

US identified seven true primary cancer. CT and MRI located only tumors > or =5 mm in diameter. MIBG scintigraphy and FDG PET could not identify MTC foci within the thyroid. Whole-body FDG PET identified two true-positive and one false-positive lymph node metastases. MIBG scintigraphy did not identify lymph node metastases. Total thyroidectomy was performed in 12 cases, and subtotal thyroidectomy in two subjects.

CONCLUSIONS

Whole-body FDG PET and cervical US help stage individuals carrying mutant genes verifying MEN2A or FMTC.

PET identifies transitional metabolic change in the spinal cord following a subthreshold dose of irradiation

Positron emission tomographic (PET) investigations were performed to obtain in vivo information on symptomless radiation-induced pathological changes in the human spinal cord. PET investigations were carried out prior to radiotherapy and during the regular follow-up in an early hypopharyngeal cancer patient (the spinal cord was irradiated with a biologically effective dose of 80 Gy2), with [18F]fluorodeoxyglucose (FDG), [11C]methionine and [15O]butanol as tracers; radiosensitivity and electroneuronographic (ENG) studies were also performed. A very low background FDG accumulation (mean standardized uptake values, i.e. SUV: 0.84) was observed in the spinal cord before the initiation of radiotherapy. An increased FDG uptake was measured 2 months after the completion of radiotherapy (mean SUV: 1.69), followed by a fall-off, as measured 7 months later (mean SUV: 1.21). By 44 months after completion of irradiation, the FDG accumulation in the irradiated segments of the spinal cord had decreased to a level very close to the initial value (mean SUV: 1.11). The simultaneous [15O]butanol uptake results demonstrated a set of perfusion changes similar to those observed in connection with the FDG accumulation. The patient exhibited an extremely low [11C]methionine uptake within the irradiated and the nonirradiated spinal cord during the clinical course. She has not had any neurological symptoms, and the results of central ENG measurements before radiotherapy and 2 months following its completion proved normal. Radiobiological investigations did not reveal unequivocal signs of an increased radiosensitivity. A transitory increased spinal cord FDG uptake following radiotherapy may be related to the posttherapeutic mild inflammatory and regenerative processes. The normal [11C]methionine accumulation observed is strong evidence against intensive cell proliferation. The high degree of normalization of the temporarily increased FDG uptake of the irradiated spinal cord segments by 44 months is in good agreement with the results of monkey studies, which demonstrated a nearly complete recovery from radiation-induced spinal cord injury.

[Lingual thyroid: a rare disease resembling base of tongue neoplasm]

The ectopic thyroid gland occurring in the midline of the base of tongue is a rare developmental anomaly. It may cause differential diagnostic problems with real malignant tumor. Symptoms, if where are any: foreign-body-feeling, swallowing difficulties, dyspnea, articulation disorders, bleeding and hypothyroidism, but in many cases the diagnosis is accidental. We describe two cases of lingual thyroid gland operated in our department, and discuss the present trends of the treatment of this disease. We agree with most of the authors that only cases presenting with symptoms should be operated, and if possible the normal thyroid tissue should be replaced into the body. However, all discovered cases have to be followed to avoid late hormonal disturbances.

Markov model-based estimation of individual survival probability for medullary thyroid cancer patients

The relatively benign, but occasionally rapidly fatal clinical course of medullary thyroid cancer (MTC) has raised the need for individual survival probability estimation. A retrospective study on 91 MTC clinical case histories with a mean follow-up of 6 years indicated prevalences of local, regional and distant residual tumor on primary care completion of 23%, 54% and 54%, respectively. Local, regional and distant relapses during follow-up occurred in 8%, 23% and 26% of the patients, with a cause-specific death in 26% of the cases. Prognostic factors statistically significantly influencing the cause-specific survival were selected by uni- and multivariate analysis. A Markov method-based model was developed for the estimation of individual time-dependent local, regional and distant relapse-free and cause-specific survival probability functions, with parameters numerically determined via a maximum likelihood procedure. These parameters include relative risk factors related to prognosticators, a residual or recurrent local/regional/distant tumor, and combinations of these entities. In multivariate studies, the patient s age and gender, the genetic basis of the dis-ease, lymph node involvement, the existence of a general symptom (diarrhoea) at presentation, and the dosage of external irradiation proved to be prognosticators. The cause-specific survival function of the study population indicated mean 5, 10 and 15-year survival probabilities of 69%, 62% and 58%.

CONCLUSION

Survival probabilities can be predicted for extrastudy cases provided that the same laws and principles govern the clinical course of these cases and those comprising the study. For individual survival probability estimation, a Pascal program (MEDUPRED) was written and is available on the home page of the National Institute of Oncology, Budapest (www.oncol.hu).

[Neoadjuvant chemotherapy in head and neck cancer]

BACKGROUND: Neoadjuvant chemotherapy has an increasing role in multimodality treatment of advanced head and neck cancer. In this paper we summarize our first results with this treatment. METHOD: Thirty-five, previously untreated, mostly inoperable head and neck cancer patients were given two cycles of Cisplatin and 5FU chemotherapy. We continued the therapy only in case of regression until four cycles, then the patients received surgical and/or radiotherapy according to their status. After the treatment patients' status was regularly evaluated. RESULTS: We detected 4 complete and 20 partial responses after the chemotherapy. Three patients became eligible for a radical operation. At this moment 10 patients are free of tumor, 8 patients died in consequence of the tumor, we have no data in 3 cases, 3 patients are given palliative therapy because of progression, 4 patients are receiving radiotherapy and 7 patients with partial response are candidates for further active oncotherapy. CONCLUSIONS: Although the number of the patients we treated is too small for a statistical analysis, our results are similar to the conclusion of the large randomized studies: after neoadjuvant chemotherapy of advanced head and neck cancer partial response can improve the result of surgical or radiological treatment. Neoadjuvant chemotherapy does not improve survival in advanced head and neck cancer, but it is of great importance because of better quality of life of patients, especially those who had organ preserving therapy.

[Radial forearm and fibula free flap reconstruction after radical resection of head and neck malignancies]

The incidence of head and neck cancer has been rapidly increasing in Hungary during the last decade. Most of these tumors are discovered in advanced stage, consequently, surgical removal of the tumor results in large complex defects in the soft tisses and bone elements of the face and neck. For optimal anatomical and functional reconstruction we perform free flap transfer in increasing number of cases. Between December 1993 and March 2001 in the Head and Neck Surgery Department of the National Institute of Oncology the defects after resection of head and neck tumors were reconstructed with free flaps in 85 cases. Radial forearm flap in 64 cases, fibula osteoseptocutaneous flap in 14 cases were used. In 87% of the patients the postoperative period was uneventful, the surgical complications were not more numerous than following traditional reconstructions. The average duration of operations became shorter by 2.5 hours during the last two years than before. In most of the cases we achieved good functional and esthetic results. The quality of life of the patients was excellent in 14%, almost normal in 73% and bad with serious problems of social life in 13%. It is surprising that there was no significant difference between the survival of neck node positive and negative patients. In our practice the replacement of large defects in the head and neck region with free flaps is a reliable and useful method for reconstruction.

[Current diagnostic method, prognosis estimation and therapy of papillary thyroid cancer: recommendations of the medical universities and the National Oncologic Institute of Budapest]

Physical examination, cervical ultrasonography (US) and aspiration cytology are the mainstays of the preoperative diagnostics of papillary thyroid carcinoma. For the staging of suspected malignant cases, cervical and mediastinal CT (MRI for inconclusive results) is indicated before any surgery. The end-result of primary treatment is assessed by total-body iodine scintigraphy and the serum human thyroglobulin (hTG) level. For long-term follow-up, physical examination and the serum hTG level are the most reliable tools (6-monthly), supplemented by cervical US and chest X-ray (yearly), and total-body iodine scintigraphy (2-yearly). If these furnish positive results, further examinations may be indicated. In suspected relapses of hTG non-producing and iodine non-accumulating papillary carcinomas, 201thallium chloride or 99mTc-sesta-MIBI (methoxy-isobutyl-isonitrile) scintigraphy, and positron emission tomography with 18fluoro-deoxyglucose or 11C-methionine may be of help. For estimation of the prognosis (cause-specific survival) of the patients, the MACIS score system of the Mayo Clinic is widely accepted, the patients being divided into low-risk and intermediate/high-risk categories. The recommended standard surgical intervention is near-total thyroidectomy (2-4 g residual glandular tissue left at the upper pole of the less-involved lobe), with a central cervical lymph node dissection for diagnostic purposes. In cases of lymph node dissemination, dissection (radical, modified radical, selective or microdissection) of any of the involved compartments (central, right or left cervical, or upper mediastinal) is indicated for therapeutic reasons, the method of which is depending on the extent of the metastatic involvement. Following adequate surgical intervention, no adjuvant radioiodine therapy is indicated for low-risk cases with a tumour of less than 1 cm diameter. For other low-risk or intermediate/high-risk patients, radioiodine ablation (R0N0M0) or a therapeutic radioiodine dosage (R2N1M1) is indicated. In cases at high-risk of local/regional relapse and in radioiodine non-accumulating tumorous cases, external radiotherapy may be applied. Thyroid hormone medication in a TSH suppressive dose is indicated during the first 5 postsurgical years: the goal is to achieve a TSH level below 0.1 (determined by a 3rd generation assay). If no relapse occurs or the case is a low-risk one, following the 5 years, it is enough to maintain the TSH level in a subnormal range (0.1-0.3).

[Treatment of keloids (review of the literature, therapeutic suggestions)]

The authors treated 25 patients with 31 keloids. They used cryotherapy after intralesional steroid infiltration. One area was treated 3-4 times. All patients showed more or less improvement. 18 keloids were completely cured, 9 improved, 2 showed only minimum change, the treatment had to be given up in two patients. The method has been found effective but is recommended primarily in case of small and not too old lesions.

[Results following total laryngectomy at the Budapest Clinic of Head-Neck surgery]

The data on 356 laryngectomies during a 12-year period were analysed retrospectively. The operations were divided into three groups: group I, laryngectomy alone; group II, laryngectomy and secondary neck dissection; group III, one-stage laryngectomy and radical neck dissection. Most patients had advanced disease (stage III and IV: 54.5% and 23.9%, respectively). Supraglottic and glotto-supraglottic tumours were commonest (39.6% and 36.8%, respectively). The results of palpation, fine-needle biopsy and histology of the lymph nodes are compared. The mean survival time for the three groups was 53.4, 42.7 and 29.8 months, respectively, and the 5-year survival rates were 61.9%, 32.0% and 30.8%, respectively.