Amelia Oleaga

Guía clínica para el manejo de pacientes con carcinoma diferenciado de tiroides de bajo riesgo

Incidence of thyroid cancer is increasing in Spain and worldwide. Overall thyroid cancer survival is very high, and stratification systems to reliably identify patients with worse prognosis have been developed. However, marked differences exist between the different specialists in clinical management of low-risk patients with thyroid carcinoma. Almost half of all papillary thyroid carcinomas are microcarcinomas, and 90% are tumors < 2 cm that have a particularly good prognosis. However, they are usually treated more aggressively than needed, despite the lack of adequate scientific support. Surgery remains the gold standard treatment for these tumors. However, lobectomy may be adequate in most patients, without the need for total thyroidectomy. Similarly, prophylactic lymph node dissection of the central compartment is not required in most cases. This more conservative approach prevents postoperative complications such as hypoparathyroidism or recurrent laryngeal nerve injury. Postoperative radioiodine remnant ablation and strict suppression of serum thyrotropin, although effective for the more aggressive forms of thyroid cancer, have not been shown to be beneficial for the treatment of low risk patients, and may impair their quality of life. This guideline provides recommendations from the task force on thyroid cancer of the Spanish Society of Endocrinology and Nutrition for adequate management of patients with low-risk thyroid cancer.

Declaración de consenso para la acreditación de unidades multidisciplinares en cáncer de tiroides

Thyroid cancer is the leading endocrine system tumor. Great advances have recently been made in understanding of the origin of these tumors and the molecular biology that makes them grow and proliferate, which have been associated to improvements in diagnostic procedures and increased availability of effective local and systemic treatments. All of the above makes thyroid cancer a paradigm of how different specialties should work together to achieve the greatest benefit for the patients. Coordination of all the procedures and patient flows should continue throughout diagnosis, treatment, and follow-up, and is essential for further optimization of resources and time. This manuscript was prepared at the request of the Working Group on Thyroid Cancer of the Spanish Society of Endocrinology and Nutrition, and is aimed to provide a consensus document on the definition, composition, requirements, structure, and operation of a multidisciplinary team for the comprehensive care of patients with thyroid cancer. For this purpose, we have included contributions by several professionals from different specialties with experience in thyroid cancer treatment at centers where multidisciplinary teams have been working for years, with the aim of developing a practical consensus applicable in clinical practice.

Preoperative TSH value, does it predict the surgical findings in papillary thyroid cancer?

Material and methods – We collected retrospectively preoperative serum [TSH] from patients diagnosed of papillary thyroid cancer (PTC) who had undergone total thyroidectomy during the period 2001-2013 in a single tertiary center. We recorded demographic data, nodule number, tumor size and neoplasm features in surgical pathology. Patients with Graves’s disease or primary hypothyroidism under treatment prior to surgery were excluded.

Incidental thyroid carcinomas in patients operated on for benign thyroid pathology, are there preoperative factors suggesting a higher risk?

We evaluate retrospectively 568 patients with total thyroidectomy operated on for reasons other than malignancy between 2005 and 2011. We compare demographic and clinical characteristics between two groups: patients without ITC and patients with discovery of ITC in final pathological study of thyroid. Analysis included age, sex distribution, preoperative hyperfunction, pathology of benign tissue (adenoma vs hyperplasia/inflammation), and thyroid size measured by weight.

Early measure of postoperative iPTH and corrected calcium as predictors of future hypoparathyroidism: which, when and why?

Material and methods – We include 748 patients who underwent total thyroidectomy from 2005 to 2011. They were evaluated more than one year after surgery. Permanent hypoPT (PhypoPT) is defined by [iPTH]<15 pg/ml without treatment one year passed after surgery. [iPTH] between 5-15 pg/ml were defined as partial deficiency, whereas less than 5 pg/ml were considered total deficiency. Cases with spontaneous recovering of parathyroid function after a period of [iPTH]<15 were named as transient hypoPT (ThypoPT). We analyze the correlation between [iPTH] measured 24 hours after surgery, [iPTH24h], and future parathyroid function. We also analyze the correlation between [iPTH] measured immediately, 1 to 3 hours after surgery, [iPTH1-3h], corrected calcium monitored 6 hours postoperatively , [Ca6h], and subsequent parathyroid status.

Predictive factors of postoperative hypoparathyroidism after total thyroidectomy

Material and methods We analyze retrospectively 649 patients with total thyroidectomy from 2005 to 2011, followed up more than one year after surgery. Permanent hypoPT (PhypoPT) is defined by [iPTH]< 15 pg/ml without treatment more than one year after surgery. [iPTH] between 5 and15 pg/ml were defined as partial deficiency, whereas less than 5 pg/ml was considered total deficiency. Cases with spontaneous recovering of parathyroid function after a period of [PTHi]< 15 were named as transient hypoPT (ThypoPT). We consider age, thyroid size (by weight), sex, preoperative [iPTH], existence of hyperthyroidism, central dissection and cause of surgery as variables in our study.

BRAF V600E mutation in papillary thyroid cancer: clinical and pathological features. Is there any role in tailoring initial treatment?

Introduction: BRAF (V600E) mutation is the most frequent detected genetic alteration in papillary thyroid carcinomas (PTC) and its presence has been related to aggressive features. Lymph node metastases are common in PTC and are associated with an increase of loco regional recurrence. Nevertheless prophylactic lymph node dissection (PCLND) is not routinely performed because of high rate of surgical complications.

RevisionesFeocromocitoma: actualización diagnóstica y terapéuticaPheochromocytoma: Diagnostic and Therapeutic Update

Pheochromocytomas are catecholamine-secreting tumors that arise from chromaffin cells of the sympathetic nervous system. In 80-85% of cases, these tumors are located in the adrenal medulla while the remainder is located in extra-adrenal chromaffin tissues (paragangliomas). Pheochromocytomas account for 6.5% of incidentally discovered adrenal tumors. These tumors may be sporadic or the result of several genetic diseases: multiple endocrine neoplasia type 2, von Hippel-Lindau syndrome, neurofibromatosis type 1, and familial paraganglioma associated with mutations in succinate dehydrogenase subunits. Diagnosis of pheochromocytoma should first be established biochemically by measuring plasma free metanephrines and urinary fractionated metanephrines. The radiological imaging tests of choice are computed tomography (CT) or magnetic resonance imaging (MRI). The first-line specific functional imaging test is scintigraphy with (123)I-metaiodobenzylguanidine (MIBG); if this test is unavailable, scintigraphy with (131)I-MIBG is the second choice. Positron emission tomography (PET) with (18)F-F-fluorodopamine (F-DA) is useful in metastatic disease. The treatment of choice is laparoscopic surgery after adequate alpha adrenergic blockade. Approximately 10% of tumors are malignant. Chemotherapy is used for inoperable disease. Prognosis is good except in malignant disease, in which 5-year survival is less than 50%. The identification of the genes causing hereditary pheochromocytoma has led to changes in the recommendation for genetic testing.El feocromocitoma es un tumor productor de catecolaminas que procede de las celulas cromafines del sistema nervioso simpatico. El 80-85% se localiza en la medula adrenal y el resto, en el tejido cromafin extraadrenal (paraganglioma). Los feocromocitomas suponen el 6,5% de los incidentalomas suprarrenales. Pueden ser esporadicos o encontrarse asociados a varias enfermedades geneticas: neoplasia endocrina multiple 2, enfermedad de von Hippel-Lindau, neurofibromatosis de tipo 1 y paraganglioma familiar con mutaciones en la succinato deshidrogenasa. El diagnostico de feocromocitoma debe establecerse bioquimicamente mediante la determinacion de metanefrinas plasmaticas y/o urinarias. El diagnostico de localizacion inicialmente debe basarse en la realizacion de tomografia computarizada o resonancia magnetica. La gammagrafia con 123I-metayodobencilguanidina (MIBG) es la prueba funcional de imagen de eleccion; en su defecto puede realizarse con 131I-MIBG. La tomografia por emision de positrones con 18F-F-fluorodopamina ha resultado de utilidad en enfermedad metastasica. El tratamiento de eleccion es la cirugia por via laparoscopica, despues de la realizacion del bloqueo alfaadrenergico. Aproximadamente el 10% de los tumores son malignos. Para la enfermedad inoperable puede utilizarse la quimioterapia. El pronostico es bueno, excepto en los casos de enfermedad maligna donde la tasa de supervivencia a los 5 anos es menor del 50%. El conocimiento de nuevos genes causantes de enfermedad hereditaria ha supuesto un cambio en las recomendaciones sobre la necesidad de realizar estudio genetico.