Augusto León R

Características de presentación del microcarcinoma papilar del tiroides: Experiencia retrospectiva de los últimos 12 años

BACKGROUND Thyroid microcarcinoma is a tumor of 10 mm or less, that should have a low risk of mortality. However, a subgroup of these carcinomas is as aggressive as bigger tumors. AIM To describe the pathological presentation of these tumors, and compare them with larger tumors. MATERIAL AND METHODS All pathological samples of thyroid carcinoma that were obtained between 1992 and 2003, were studied. In all biopsies, the pathological type, tumor size, the focal or multifocal character, the presence of lymph node involvement and the presence of lymphocytic thyroiditis or thyroid hyperplasia, were recorded. RESULTS One hundred eighteen microcarcinomas and 284 larger tumors were studied. The mean age of patients with microcarcinoma and larger tumors was 42.7+/-14 and 49.3+/-16 years respectively (p <0,001) and 83% were female, without gender differences between tumor types. Mean size of microcarcinomas was 8.6 mm and 116 (98%) were papillary carcinomas. Of these, 109 (94%) were well differentiated and seven (6%) were moderately differentiated. Thirty six (31%) were multifocal and in 10 (8,6%), there was lymph node involvement. The mean size of larger tumors was 23.8 mm and 241 (85%) were papillary carcinomas. Of these, 200 (83%) were well differentiated, and 41 (17%) were moderately differentiated. Eighty five (35%) were multifocal and in 44 (18%) there was lymph node involvement. The prevalence of thyroiditis and hyperplasia was significantly higher among microcarcinomas than in larger tumors (15 and 2.5%, respectively, p <0.001, for the former; 32.4 and 1.7%, respectively, p <0.001, for the latter). CONCLUSIONS In this series, one third of microcarcinomas were multifocal and 10% had lymph node involvement. Therefore, the aggressiveness of these tumors is higher than what is reported in the literature and they should be treated with total thyroidectomy.

Cáncer de mama metastásico: Caracterización de una cohorte según subtipos

Background: The prognosis of breast cancer (BC) is in part determined by the stage at diagnosis and its pathological characteristics. Aim: To evaluate the association between survival of women with metastatic breast cancer and pathological features of the tumor. Patients and Methods: We obtained clinical and pathological data from patients diagnosed with a metastatic BC between 1999 and 2013. The expression of estrogen(ER) and progesterone (PR) receptors and human epidermal growth factor receptor 2 (HER2) was determined by immunohistochemistry. Clinicopathological subtypes were defined as: Luminal A: ER or PR positive, HER2 negative, histological grade (HG) 1 or 2; Luminal B: ER or PR positive, HER2 negative or positive or HG 3; triple negative (TN): ER, PR and HER2 negative, independent of the HG, positive HER2: ER, PR negative and HER2 positive, independent of HG. We analyzed survival based on these subtypes. Results: We identified 54 patients aged 24 to 85 years, with metastatic BC at diagnosis. Seventy five percent had luminal tumors; 19.6% HER2 positive and 7.8% were TN. In 61% of evaluable tumors, HG was classified as 3. The frequency of HER2 positive and high HG tumors was greater in these patients with metastatic BC than in a non-metastatic local BC cohort. Survival was higher among patients with Luminal tumors than in women with non-Luminal cancer (56.4 and 11.4 months, respectively, p = 0.04). Conclusions: Patients with metastatic BC at diagnosis often had HER2 positive tumors and high HG. As in other studies, ER positive tumors had a better survival.BACKGROUND The prognosis of breast cancer (BC) is in part determined by the stage at diagnosis and its pathological characteristics. AIM To evaluate the association between survival of women with metastatic breast cancer and pathological features of the tumor. PATIENTS AND METHODS We obtained clinical and pathological data from patients diagnosed with a metastatic BC between 1999 and 2013. The expression of estrogen (ER) and progesterone (PR) receptors and human epidermal growth factor receptor 2 (HER2) was determined by immunohistochemistry. Clinicopathological subtypes were defined as: Luminal A: ER or PR positive, HER2 negative, histological grade (HG) 1 or 2; Luminal B: ER or PR positive, HER2 negative or positive or HG 3; triple negative (TN): ER, PR and HER2 negative, independent of the HG, positive HER2: ER, PR negative and HER2 positive, independent of HG. We analyzed survival based on these subtypes. RESULTS We identified 54 patients aged 24 to 85 years, with metastatic BC at diagnosis. Seventy five percent had luminal tumors; 19.6% HER2 positive and 7.8% were TN. In 61% of evaluable tumors, HG was classified as 3. The frequency of HER2 positive and high HG tumors was greater in these patients with metastatic BC than in a non-metastatic local BC cohort. Survival was higher among patients with Luminal tumors than in women with non-Luminal cancer (56.4 and 11.4 months, respectively, p = 0.04). CONCLUSIONS Patients with metastatic BC at diagnosis often had HER2 positive tumors and high HG. As in other studies, ER positive tumors had a better survival.

Rendimiento de la biopsia intraoperatoria por congelación en el estudio del linfonodo centinela en cáncer de mama

Introduccion: La biopsia del linfonodo centinela (LC) se ha convertido en la tecnica estandar para estadificar el compromiso axilar en el cancer de mama. El diagnostico intraoperatorio del compromiso metas-tasico del linfonodo permite decidir en forma inmediata la necesidad de diseccion axilar. El objetivo general de este estudio fue determinar el rendimiento de la biopsia intraoperatoria por congelacion en la pesquisa de metastasis en el LC, en pacientes con cancer de mama, entre 1999 y 2011. Material y Metodos: Estudio retrospectivo de las pacientes operadas por cancer de mama invasor, en que se realizo biopsia del LC, con estudio intraoperatorio por congelacion. Resultados: 503 pacientes con biopsia del LC con estudio intrao-peratorio. Ciento cincuenta y cuatro (30,6%) pacientes tuvieron metastasis en el LC, de estos 103 (66,9%) fueron detectadas en la biopsia rapida. No hubo diferencias significativas en la capacidad de deteccion para los tumores de hasta 2 cm y los tumores mayores de 2 cm (p = 0,86). La sensibilidad, especificidad, valor predictivo positivo (VPP) y valor predictivo negativo (VPN) de la biopsia intraoperatoria para la deteccion de metastasis en el LC fue de 66,9%, 99,7%, 99% y 87%, respectivamente. Conclusiones: El rendimiento obtenido es comparable al descrito en la literatura, siendo efectiva solo para la pesquisa de macrometastasis (MA). Dada la baja frecuencia de metastasis en el LC en tumores de hasta 2 cm, asociado a un numero relativamente alto de micro (MI) y submicrometastasis (SM) y de falsos negativos, nos parece que, en estos casos, la utilizacion de la biopsia intraoperatoria del LC es innecesaria.

IMPACTO DE LAS METÁSTASIS DEL LINFONODO CENTINELA Y SU TAMAÑO, EN EL TRATAMIENTO DEL CÁNCER DE MAMA

Impact of sentinel lymph node metastases in the treatment of breast cancer Introduction: The importance of sentinel lymph nodes (SL) metastasis at breast cancer patients has been questioned and observation without axillary dissection (AD) associated with adjuvant therapies has been the recommendation in recent years. Objective: To evaluate the macro (MA), micro (MI) and submicrome- tastasis (SM) of breast cancer in SL, and their impact on the posterior AD. Methods: We reviewed results of biopsies from patients with invasive breast cancer with MA, MI and SM found in the SL operated at our institution between May 1999 and December 2011. Results: We found 134 patients with MA, 33 patients with MI and 30 patients with SM, in a total of 632 patients with invasive breast cancer in those who underwent SL. These were operated 130, 24 and 17 patients respectively. The frequency of no sentinels lymph nodes (NSL) with metastases found on AD was 46.9% (61/130) for MA, 33.3% (8/24) for MI and 23.5% (4/17) for SM. The NSL metastasis from MA modified the TNM in 26.9% (35/130), those from MI in 20.8% (5/24) patients, while the SM only modified in one patient (5.9%). Conclusions: The frequency of lymph nodal involvement in AD is significantly higher in patients with MA. The number of AD without clear therapeutic input is high and increases with decreasing size of SL metastases. The results support to not perform AD in patients with MI and SM in the SL, who received conservative surgery and adjuvant therapy.

HIPERPARATIROIDISMO PRIMARIO: MANEJO QUIRÚRGICO

Abstract Primary hyperparathyroidism. Surgical treatment Background : Primary hyperparathyroidism (HPTP) is the most common cause of hypercalcaemia in the ambulatory setting. This condition affects between 0.1-2% of the population. Surgery is the only curative treatment. Objective: The aim of the study is to present our 10-year surgical experience. Methods : Analytical-descriptive study. We included all patients diagnosed with HPTP treated with surgery in our hospital between June 2003 and June 2013. Results: 173 patients underwent surgery for HPTP. The mean age was 57.5 ± 13.5 years. Asymptomatic in 98 cases (56.6%). Resection the abnormal parathyroid glands was performed in all cases with intraoperative PTH monitoring. In 167 patients (96.5%) intraoperative PTH declined ≥ 50%. The median follow-up was 61 months (1-117 months). Cure was achieved in 169 patients (97.7%). Four cases (2.3%) had recurrence. Conclusions: Surgery is effective and safe for the treatment of HPTP. A decline in intraoperative PTH ≥ 50% predicts cure in 97.7% of cases.

Cáncer medular de tiroides: Experiencia quirúrgica en 10 años

Background: Medullary thyroid cancer (MTC) represents approximately 5% of all thyroid cancers. Surgery is the only curative treatment, which includes total thyroidectomy and in most cases, neck dissection. Aim: To report our 10-year experience with surgical treatment of MTC. Material and methods: Review of medical records and pathology reports of a university hospital. We retrieved data from 28 patients aged 47.2 ± 16 years (21 women) operated for a MTC treated between June 2002 and June 2012. Results: In 20 patients, MTC was diagnosed in the preoperative period. Total thyroidectomy was performed in all cases and included a neck dissection in 24 patients. Median follow-up was 48 (2-120) months. Twenty-five patients (89.2%) achieved complete remission of the disease and three had disease recurrence. There were no deaths during the follow up. Conclusions: The diagnosis of MTC is mainly based on cytology. Total thyroidectomy with neck dissection is the treatment of choice. An early-stage diagnosis is associated with low rates of recurrence and absence of mortality.

Hallazgos anatomopatológicos definitivos en pacientes tiroidectomizados con diagnóstico preoperatorio de neoplasia folicular

Defi nitive anatomopathological fi ndings in thyroidectomized patients with preoperative diagnosis of follicular neoplasm Background: The fi nding of follicular neoplasm, using a FNAP, is an indication for partial or total thyroidectomy, to obtain the defi nitive malignant or benign histology. Frequently, it is possible to identify signifi cant additional histological diagnosis. Aim: To obtain the defi nitive histological fi ndings in patients with follicular neoplasm by FNAP. Patients and Method: Transversal analysis of 133 patients that underwent to total thyroidectomy between 2003 and 2009, that fi lled de requirements for adequate histological assessment. Results: In 33.1% of the treated patients the fi nal diagnosis was indeed a follicular neoplasm (adenoma in 26.3% and cancer in 6.8%). In the 51.9% the fi nding was follicular colloidal hyperplasia and other thyroid cancer in 8.3%. The total malignant prevalence in the whole gland was 29.3%. Conclusions: The thyroidec- tomy is the treatment of choice and the fi nal diagnostic procedure for these patients. The histological fi ndings of cancer different from follicular not only in the punctioned nodule are a secondary and an additional argu-

Tiroglobulina y sus limitaciones en el seguimiento del carcinoma diferenciado del tiroides: Report of two cases

Thyroid carcinoma is the most prevalent endocrine tumor, and the papillary carcinoma (PC) is the most common histological type. In the follow-up, after thyroidectomy serum thyroglobulin (s-Tg) is used as a marker to evaluate recurrence of thyroid carcinoma. In most cases, this parameter allows an adequate diagnosis, but occasionally s-Tg may miss the detection of a recurrence. We report a 57 year-old female and a 36 year-old male subjected to a total thyroidectomy for a papillary thyroid carcinoma with intermediate and high-risk of recurrence. Both had a cervical recurrence without a concomitant increase in s-Tg levels. In both, Tg staining was positive in the tumor cells. These cases confirm that in these patients, the follow-up must be done with measurement of s-Tg and complementary diagnostic tests.Thyroid carcinoma is the most prevalent endocrine tumor, and the papillary carcinoma (PC) is the most common histological type. In the follow-up, after thyroidectomy serum thyroglobulin (s-Tg) is used as a marker to evaluate recurrence of thyroid carcinoma. In most cases, this parameter allows an adequate diagnosis, but occasionally s-Tg may miss the detection of a recurrence. We report a 57 year-old female and a 36 year-old male sujected to a total thyroidectomy for a papillary thyroid carcinoma with intermediate and high-risk of recurrence. Both had a cervical recurrence without a concomitant increase in s-Tg levels. In both, Tg staining was positive in the tumor cells. These cases confirm that in these patients, the follow-up must be done with measurement of s-Tg and complementary diagnostic tests

¿Es curable el cáncer de mama en etapa precoz?: Resultados del tratamiento combinado con cirugía, radioterapia y quimioterapia

Background: Breast cancer will develop in one out of ten women during their lifetime. Early diagnosis has increased in recent years. Aim: To describe a population of women with breast cancer stage T1N0M0. To analyze radiation therapy toxicity and to evaluate treatment results. Material and methods: Retrospective review of the medical records of 125 women (aged 35 to 80 years) with breast cancer T1N0M0, that were treated between January 1997 and May 2004, with breast conserving surgery and postoperative radiation therapy at an oncology center. Patients lost from follow up were contacted by telephone. Results: An abnormal screening mammography was the reason for consult in 62% of cases. The average tumor size was 11.6 mm. Tumors detected with screening mammogram were smaller than those detected on physical exam. The most common radiotherapy toxicity was erithema, which was severe in 2.5% of cases. No patient had to stop the radiation treatment due to toxicity. One patient developed arm edema. Tamoxifen was prescribed for 5 years to 80% of patients and 17 patients received chemotherapy. After an average follow up of 40 months, no patient has developed local breast relapse, three patients developed contralateral breast cancer and three developed distant metastasis. Two patients died from breast cancer. Disease free survival was 95%. Conclusions: Radiotherapy was well tolerated and had excellent local control. Screening mammography detects small tumors. Survival is excellent for early stage breast cancer (Rev Med Chile 2007; 135: 427-35). (Key-words: Breast neoplasms; Mammography; Radiotherapy; Tamoxifen)

NUEVAS TERAPIAS SISTÉMICAS PARA EL TRATAMIENTO DEL MELANOMA

Resumen El melanoma es un tumor maligno que tiene una alta tendencia a metastizar localmente, regionalmente al sistema linfatico, y en forma sistemica, preferentemente a pulmones, higado, cerebro y hueso. La cirugia es el principal tratamiento para el melanoma, con excelentes resultados en estadios precoces, pero escasa utilidad en etapas avanzadas con enfermedad sistemica. Tradicionalmente los tratamientos en base a quimioterapias citotoxicas han aportado poco beneficio a los pacientes en etapa IV, lo que ha motivado una amplia investigacion e innovacion en esta area. Actualmente la Food and Drug Administration (FDA) ha aprobado nuevas terapias para el tratamiento del melanoma metastasico, irresecable o recurrente, en base a drogas inmuno moduladoras y drogas que bloquean la transduccion de senales, con resultados muy promisorios. Los cirujanos que tratamos pacientes con melanoma, debemos estar al dia sobre el uso de estas nuevas terapias que representan una nueva oportunidad de tratamiento para nuestros pacientes.