RESUMEN
INTRODUCTION: Medullary thyroid carcinoma (MTC) originates in the thyroid parafollicular cells and represents 3-4% of the malignant neoplasms that affect this gland. Approximately 25% of these cases are hereditary due to activating mutations in the REarranged during Transfection (RET) proto-oncogene. The course of MTC is indolent, and survival rates depend on the tumor stage at diagnosis. The present article describes clinical evidence-based guidelines for the diagnosis, treatment, and follow-up of MTC. OBJECTIVE: The aim of the consensus described herein, which was elaborated by Brazilian experts and sponsored by the Thyroid Department of the Brazilian Society of Endocrinology and Metabolism, was to discuss the diagnosis, treatment, and follow-up of individuals with MTC in accordance with the latest evidence reported in the literature. MATERIALS AND METHODS: After clinical questions were elaborated, the available literature was initially surveyed for evidence in the MedLine-PubMed database, followed by the Embase and Scientific Electronic Library Online/Latin American and Caribbean Health Science Literature (SciELO/Lilacs) databases. The strength of evidence was assessed according to the Oxford classification of evidence levels, which is based on study design, and the best evidence available for each question was selected. RESULTS: Eleven questions corresponded to MTC diagnosis, 8 corresponded to its surgical treatment, and 13 corresponded to follow-up, for a total of 32 recommendations. The present article discusses the clinical and molecular diagnosis, initial surgical treatment, and postoperative management of MTC, as well as the therapeutic options for metastatic disease. CONCLUSIONS: MTC should be suspected in individuals who present with thyroid nodules and family histories of MTC, associations with pheochromocytoma and hyperparathyroidism, and/or typical phenotypic characteristics such as ganglioneuromatosis and Marfanoid habitus. Fine-needle nodule aspiration, serum calcitonin measurements, and anatomical-pathological examinations are useful for diagnostic confirmation. Surgery represents the only curative therapeutic strategy. The therapeutic options for metastatic disease remain limited and are restricted to disease control. Judicious postoperative assessments that focus on the identification of residual or recurrent disease are of paramount importance when defining the follow-up and later therapeutic management strategies.
Asunto(s)
Biomarcadores de Tumor/sangre , Calcitonina/sangre , Carcinoma Medular/diagnóstico , Carcinoma Medular/terapia , Neoplasias de la Tiroides/diagnóstico , Neoplasias de la Tiroides/terapia , Neoplasias de las Glándulas Suprarrenales/diagnóstico , Neoplasias de las Glándulas Suprarrenales/metabolismo , Neoplasias de las Glándulas Suprarrenales/terapia , Biomarcadores/análisis , Biopsia con Aguja Fina , Brasil , Calcitonina/metabolismo , Carcinoma Medular/secundario , Carcinoma Neuroendocrino , Diagnóstico Diferencial , Medicina Basada en la Evidencia/métodos , Salud de la Familia , Estudios de Seguimiento , Humanos , Mutación , Feocromocitoma/diagnóstico , Feocromocitoma/metabolismo , Feocromocitoma/terapia , Pronóstico , Proto-Oncogenes Mas , Proteínas Proto-Oncogénicas c-ret/genética , Neoplasias de la Tiroides/secundario , Nódulo Tiroideo/diagnóstico , Nódulo Tiroideo/cirugía , Tiroidectomía/métodosRESUMEN
Introdução O carcinoma medular de tireoide (CMT) origina-se das células parafoliculares da tireoide e corresponde a 3-4% das neoplasias malignas da glândula. Aproximadamente 25% dos casos de CMT são hereditários e decorrentes de mutações ativadoras no proto-oncogene RET (REarranged during Transfection). O CMT é uma neoplasia de curso indolente, com taxas de sobrevida dependentes do estádio tumoral ao diagnóstico. Este artigo descreve diretrizes baseadas em evidências clínicas para o diagnóstico, tratamento e seguimento do CMT. Objetivo O presente consenso, elaborado por especialistas brasileiros e patrocinado pelo Departamento de Tireoide da Sociedade Brasileira de Endocrinologia e Metabologia, visa abordar o diagnóstico, tratamento e seguimento dos pacientes com CMT, de acordo com as evidências mais recentes da literatura. Materiais e métodos: Após estruturação das questões clínicas, foi realizada busca das evidências disponíveis na literatura, inicialmente na base de dados do MedLine-PubMed e posteriormente nas bases Embase e SciELO – Lilacs. A força das evidências, avaliada pelo sistema de classificação de Oxford, foi estabelecida a partir do desenho de estudo utilizado, considerando-se a melhor evidência disponível para cada questão. Resultados Foram definidas 11 questões sobre o diagnóstico, 8 sobre o tratamento cirúrgico e 13 questões abordando o seguimento do CMT, totalizando 32 recomendações. Como um todo, o artigo aborda o diagnóstico clínico e molecular, o tratamento cirúrgico inicial, o manejo pós-operatório e as opções terapêuticas para a doença metastática. Conclusões O diagnóstico de CMT deve ser suspeitado na presença de nódulo tireoidiano e história ...
Introduction Medullary thyroid carcinoma (MTC) originates in the thyroid parafollicular cells and represents 3-4% of the malignant neoplasms that affect this gland. Approximately 25% of these cases are hereditary due to activating mutations in the REarranged during Transfection (RET) proto-oncogene. The course of MTC is indolent, and survival rates depend on the tumor stage at diagnosis. The present article describes clinical evidence-based guidelines for the diagnosis, treatment, and follow-up of MTC. Objective The aim of the consensus described herein, which was elaborated by Brazilian experts and sponsored by the Thyroid Department of the Brazilian Society of Endocrinology and Metabolism, was to discuss the diagnosis, treatment, and follow-up of individuals with MTC in accordance with the latest evidence reported in the literature. Materials and methods: After clinical questions were elaborated, the available literature was initially surveyed for evidence in the MedLine-PubMed database, followed by the Embase and Scientific Electronic Library Online/Latin American and Caribbean Health Science Literature (SciELO/Lilacs) databases. The strength of evidence was assessed according to the Oxford classification of evidence levels, which is based on study design, and the best evidence available for each question was selected. Results Eleven questions corresponded to MTC diagnosis, 8 corresponded to its surgical treatment, and 13 corresponded to follow-up, for a total of 32 recommendations. The present article discusses the clinical and molecular diagnosis, initial surgical treatment, and postoperative management of MTC, as well as the therapeutic options for metastatic disease. Conclusions 7 .
Asunto(s)
Humanos , Calcitonina/sangre , Carcinoma Medular/diagnóstico , Carcinoma Medular/terapia , Neoplasias de la Tiroides/diagnóstico , Neoplasias de la Tiroides/terapia , Biomarcadores de Tumor/sangre , Neoplasias de las Glándulas Suprarrenales/diagnóstico , Neoplasias de las Glándulas Suprarrenales/metabolismo , Neoplasias de las Glándulas Suprarrenales/terapia , Biopsia con Aguja Fina , Brasil , Biomarcadores/análisis , Calcitonina/metabolismo , Carcinoma Medular/secundario , Diagnóstico Diferencial , Medicina Basada en la Evidencia/métodos , Salud de la Familia , Estudios de Seguimiento , Mutación , Pronóstico , Feocromocitoma/diagnóstico , Feocromocitoma/metabolismo , Feocromocitoma/terapia , Proteínas Proto-Oncogénicas c-ret/genética , Neoplasias de la Tiroides/secundario , Nódulo Tiroideo/diagnóstico , Nódulo Tiroideo/cirugía , Tiroidectomía/métodosRESUMEN
BACKGROUND: Liposuction in plastic surgery consists of the removal of excess fatty tissue in healthy individuals. In recent decades, this procedure has become more common worldwide. Associated with liposuction, lipografting has also been used for improving body contours, and has become known as liposculpture. Liposuction sometimes causes complications, including fat embolism, as described in the medical literature. The present study aims at ascertaining whether there is intravascular mobilization of fat after mechanical liposuction surgery and/or fat graft when carried out using one of the most common specific procedures used for liposuction, the superwet technique. METHODS: A total of 30 Wistar rats were included in this study. Before the surgery, the animals were placed in the supine position and anesthetized with thiopental for 50 to 60 minutes, as it is generally performed in clinical practice. The animals were divided in the following 3 groups. Group A, consisting of 10 rats, served as controls, and were only anesthetized. Group B consisted of 10 rats, which underwent only liposuction. Group C also comprised 10 rats, which were liposuctioned and then lipografted in the dorsal region. Blood was collected just before and again, 48 hours after the procedure. After 48 hours, the animals were killed, and the lungs, kidneys, liver, and brain were histologically examined. RESULTS: All the collected samples were analyzed microscopically with 2 different stains, namely, hematoxylin and eosin, and Sudan black. Fat particles were found in the lungs of 3 animals in group B (those that underwent only liposuction) and in 6 animals of group C (liposuction and lipografting). No fat particles were found in any organ of the control group. CONCLUSIONS: With this experiment, the authors showed that there is a risk of systemic mobilization of fat after liposuction surgery and that this risk is even higher when fat grafts are also carried out.
Asunto(s)
Tejido Adiposo/trasplante , Embolia Grasa/etiología , Lipectomía/efectos adversos , Animales , Encéfalo/patología , Embolia Grasa/sangre , Embolia Grasa/patología , Riñón/patología , Lipectomía/métodos , Hígado/patología , Pulmón/patología , Masculino , Ratas , Ratas WistarRESUMEN
PURPOSE: Genetic polymorphisms in genes encoding for enzymes involved in the biotransformation of carcinogens have been shown to be relevant as risk for cancer and may be of considerable importance from a public health point of view. Considering that N-acetyltransferase 2 (NAT2) polymorphisms modulate the response to ionizing radiation, the strongest risk factor recognized to cause differentiated thyroid cancer (DTC) thus far, we sought to determine the influence of NAT2 detoxification system on thyroid cancer susceptibility. EXPERIMENTAL DESIGN: We conducted a prospective case-control study, comparing 195 patients presenting with DTC that were previously genotyped for GSTT1, GSTM1, GSTP1, and CYP1A1, comprising 164 papillary carcinomas and 31 follicular carcinomas, with 196 control individuals paired for gender, age, ethnicity, diet routine, lifetime occupational history, smoking history, general health conditions, and previous diseases. We used PCR-RFLP assays and the combination of 6 variant alleles to define 18 NAT2 haplotypes that characterized slow, intermediate, or rapid phenotypes. RESULTS: A multivariate logistic regression analysis identified the presence of *12A and the absence of *12B, *13, *14B, *14D, *6A, and *7A NAT2 haplotypes as risk factors for DTC. The inheritance of a rapid acetylation phenotype doubled the risk for a papillary carcinoma (odds ratio, 2.024; 95% confidence interval, 1.252-3.272). We found no relationship between genotypes and clinical, pathologic, or laboratory features of patients or between genotypes and outcome. CONCLUSIONS: We showed that NAT2 genotypes and the NAT2 rapid acetylation phenotype are important susceptibility factors for DTC, suggesting that NAT2 detoxification system is involved in this tumor pathogenesis.
Asunto(s)
Arilamina N-Acetiltransferasa/genética , Neoplasias de la Tiroides/genética , Brasil , Estudios de Casos y Controles , Femenino , Predisposición Genética a la Enfermedad , Haplotipos , Humanos , Inactivación Metabólica , Masculino , Persona de Mediana Edad , Fenotipo , Polimialgia Reumática , Estudios Prospectivos , Factores de RiesgoRESUMEN
The large use of simple and effective diagnostic tools has significantly contributed to the increase in diagnosis of thyroid cancer over the past years. However, there is compelling evidence that most micropapillary carcinomas have an indolent behavior and may never evolve into clinical cancers. Therefore, there is an urgent need for new tools able to predict which thyroid cancers will remain silent, and which thyroid cancers will present an aggressive behavior. There are a number of well-established clinical predictors of malignancy and recent studies have suggested that some of the patients laboratory data and image methods may be useful. Molecular markers have also been increasingly tested and some of them appear to be very promising, such as BRAF, a few GST genes and p53 polymorphisms. In addition, modern tools, such as immunocytochemical markers, and the measure of the fractal nature of chromatin organization may increase the specificity of the pathological diagnosis of malignancy and help ascertain the prognosis. Guidelines designed to select nodules for further evaluation, as well as new methods aimed at distinguishing carcinomas of higher aggressiveness among the usually indolent thyroid tumors are an utmost necessity.
Asunto(s)
Biomarcadores de Tumor/metabolismo , Carcinoma Papilar/patología , Neoplasias de la Tiroides/patología , Factores de Edad , Carcinoma Papilar/etiología , Carcinoma Papilar/metabolismo , Exposición a Riesgos Ambientales/efectos adversos , Femenino , Humanos , Metástasis Linfática/diagnóstico por imagen , Masculino , Mucina-1 , Mucinas/genética , Mucinas/metabolismo , Fragmentos de Péptidos/genética , Proteínas Proto-Oncogénicas B-raf/genética , Traumatismos por Radiación/mortalidad , Factores de Riesgo , Neoplasias de la Tiroides/etiología , Neoplasias de la Tiroides/metabolismo , Tirotropina/sangre , Factores de Tiempo , UltrasonografíaRESUMEN
The large use of simple and effective diagnostic tools has significantly contributed to the increase in diagnosis of thyroid cancer over the past years. However, there is compelling evidence that most micropapillary carcinomas have an indolent behavior and may never evolve into clinical cancers. Therefore, there is an urgent need for new tools able to predict which thyroid cancers will remain silent, and which thyroid cancers will present an aggressive behavior. There are a number of well-established clinical predictors of malignancy and recent studies have suggested that some of the patientÆs laboratory data and image methods may be useful. Molecular markers have also been increasingly tested and some of them appear to be very promising, such as BRAF, a few GST genes and p53 polymorphisms. In addition, modern tools, such as immunocytochemical markers, and the measure of the fractal nature of chromatin organization may increase the specificity of the pathological diagnosis of malignancy and help ascertain the prognosis. Guidelines designed to select nodules for further evaluation, as well as new methods aimed at distinguishing carcinomas of higher aggressiveness among the usually indolent thyroid tumors are an utmost necessity.
O uso cada vez mais freqüente de métodos diagnósticos simples e efetivos tem contribuído significativamente para um aumento no diagnóstico de câncer da tiróide nos últimos anos. Entretanto, existem importantes evidências de que muitos dos microcarcinomas papilíferos têm um comportamento indolente e podem nunca evoluir para cânceres clínicos. Existe, portanto, uma necessidade urgente de desenvolver novas ferramentas capazes de predizer quais os tumores tiroidianos que permanecerão silenciosos e quais desenvolverão comportamento agressivo. Há uma série de marcadores clínicos de evolução bem estabelecidos e alguns estudos recentes sugerem que dados laboratoriais e métodos de imagem podem ser úteis. Marcadores moleculares também vêm sendo ativamente investigados e alguns, como BRAF, os genes GST e polimorfismos de p53, parecem promissores. Além disso, marcadores imunocitoquímicos e a medida da natureza fractal da cromatina podem aumentar a especificidade do diagnóstico anatomopatológico e ajudar a predizer o prognóstico. Existe uma necessidade imperiosa de elaborarmos diretrizes destinadas a selecionar os nódulos que merecem prosseguimento em sua avaliação, assim como novos métodos capazes de identificar lesões mais agressivas entre os geralmente indolentes tumores tiroidianos.
Asunto(s)
Femenino , Humanos , Masculino , Carcinoma Papilar/patología , Neoplasias de la Tiroides/patología , Biomarcadores de Tumor/metabolismo , Factores de Edad , Carcinoma Papilar/etiología , Carcinoma Papilar/metabolismo , Exposición a Riesgos Ambientales/efectos adversos , Metástasis Linfática , Mucinas/genética , Mucinas/metabolismo , Fragmentos de Péptidos/genética , Proteínas Proto-Oncogénicas B-raf/genética , Factores de Riesgo , Traumatismos por Radiación/mortalidad , Factores de Tiempo , Neoplasias de la Tiroides/etiología , Neoplasias de la Tiroides/metabolismo , Tirotropina/sangreRESUMEN
The trend of increasing thyroid cancer has been recognized in Brazil as well as all over the world for several decades. The large use of simple and effective diagnostic tools has significantly contributed to this trend. It is estimated that small carcinomas found at surgery for benign thyroid disorders and by ultrasonography will be identified at greater frequency in the further years. Part of these tumors occurs in low-risk patients that may benefit of less aggressive management strategies. However, the characterization of low-risk patient is still confusing and we lack adequate markers to tell apart patients that may present a troublesome progression of the disease. Furthermore, the use of new follow-up methods has recently changed some guidelines. A multidisciplinary team, including basic scientists, endocrinologists, nuclear medicine physicians, thyroid surgeons and endocrine pathologists reviewed the pertinent literature and, based on their experience, propose some management guidelines for Brazilian patients with low-risk thyroid carcinomas.
Asunto(s)
Carcinoma Papilar/terapia , Neoplasias de la Tiroides/terapia , Carcinoma Papilar Folicular/terapia , Estudios de Seguimiento , Humanos , Pronóstico , Factores de RiesgoRESUMEN
A incidência do câncer diferenciado da tiróide vem aumentando há várias décadas no Brasil, assim como em todo o mundo. A popularização de métodos diagnósticos sensíveis e de uso relativamente simples tem contribuído para o diagnóstico cada vez mais freqüente de carcinomas de pequeno tamanho. Uma parte destes tumores ocorre em pacientes denominados de baixo risco, que poderiam se beneficiar de estratégias de conduta menos agressivas. Entretanto, a definição de baixo risco ainda é confusa e não existem meios seguros para distinguir os pacientes que evoluirão de forma pior dos demais. Por outro lado, o uso de novos métodos de acompanhamento vem mudando a maneira de conduzir estes casos. Um grupo multidisciplinar que inclui pesquisadores básicos, endocrinologistas, médicos nucleares, cirurgiões e patologistas endócrinos reviu a literatura pertinente e, com base em sua experiência, propõe algumas normas de conduta no carcinoma diferenciado da tiróide chamado de baixo risco em nosso meio.
Asunto(s)
Humanos , Carcinoma Papilar/terapia , Neoplasias de la Tiroides/terapia , Carcinoma Papilar Folicular/terapia , Estudios de Seguimiento , Pronóstico , Factores de RiesgoRESUMEN
BACKGROUND: Total pharyngolaryngoesophagectomy and gastric transposition (TPLEGT) for pharyngoesophageal (PE) tumors may require thyroidectomy (with or without removal of the parathyroid glands) to obtain adequate margins around the tumor. As a result, a considerable number of patients may have hypoparathyroidism (HP) develop. The objective of this article is to report our experience with different types of thyroidectomy and to describe the relationship of thyroidectomy to HP in TPLETG. These results are compared with data in the literature. METHODS: From 1985 to 2001, 40 patients underwent TPLEGT, with main index tumors in the esophagus (n = 17), hypopharynx (n = 17), and larynx (n = 6). All patients had advanced cTNM or pTNM stages (III or IV). Postoperative HP was diagnosed based primarily on the symptoms and calcium and phosphorus analysis but not on parathyroid hormone (PTH) levels. RESULTS: Total thyroidectomy (TT) was done in 12 (30%) patients and 11 (91.6%) had permanent HP develop. In none of these patients was the parathyroid separated and implanted (fear of a tumor implant). Partial thyroidectomy (PT) (lobectomy and isthmus) was done in 25 (62.5%) patients, and permanent HP occurred in 11 (44%) patients. The thyroid was preserved in three patients, and none had HP develop. Of the 40 patients, 13 (32.5%) had no HP, five (12.5%) had temporary HP, and 22 (55%) had permanent HP. There was a correlation between the type of thyroidectomy, location of primary tumors, and development of HP. Only seven reports in the past 30 years have dealt with TPLEGT, thyroidectomy, and HP. HP occurred in 32.5% of the cases of TT and in 19.5% of the cases of PT. CONCLUSIONS: Permanent HP was very frequent (55%) in our series. In patients who underwent TPLEGT, HP was almost certain when TT was done (91.6%). PT was no guarantee that HP would not occur (44% permanent HP). The frequency of permanent HP based on primary index tumors was 47%, 59%, and 66.6% for esophageal, hypopharyngeal, and laryngeal cancer, respectively.
Asunto(s)
Neoplasias Esofágicas/cirugía , Hipoparatiroidismo/prevención & control , Neoplasias Faríngeas/cirugía , Tiroidectomía , Adulto , Anciano , Femenino , Estudios de Seguimiento , Humanos , Hipoparatiroidismo/epidemiología , Masculino , Persona de Mediana Edad , Metástasis de la Neoplasia , Recurrencia Local de Neoplasia , Análisis de Supervivencia , Tiroidectomía/métodosRESUMEN
Polymorphous low-grade adenocarcinoma (PLGA) is a malignant neoplasm of low aggressiveness that occurs almost exclusively in the minor salivary glands, primarily those in the palate. We report a case of PLGA that arose in the base of the tongue and subsequently metastasized to the neck. The tumor was resected through the oral cavity with wide margins and dissection. The neck metastasis was treated with radical neck dissection and radiotherapy. The patient recovered and remained disease-free at follow-up 30 months later. This case shows that PLGA, which has a variable morphologic appearance, can occur at sites other than the salivary glands.