RESUMO
Antecedentes: el papel del estudio patológico intraoperatorio (EPI) en cirugía tiroidea ha sido discutido largamente y es todavía motivo de controversia. Objetivo: estimar los resultados del EPI en el diagnóstico de malignidad, su relación con la biopsia por punción-aspiración preoperatoria con aguja fina (PAAF) y el estudio patológico diferido (EPD), así como su contribución al cambio en la estrategia quirúrgica en cirugía tiroidea. Material y métodos: revisión retrospectiva de las historias clínicas de 773 pacientes operados por patología tiroidea entre enero de 2014 y diciembre de 2015. En todos se efectuó EPI y EPD; a 686 (89%) pacientes también se les efectuó la biopsia por PAAF preoperatoria. Resultados: los resultados del EPI fueron benigno en 215 pacientes (27,8%), maligno en 419 (54,2%) y no definitivo en 139 (18,0%). Cuando estos resultados fueron comparados con la EPD se encontraron 19 casos (8,8%) de falsos negativos y 4 (0,95%) de falsos positivos. Considerando solo los resultados definitivos, el EPI tuvo sensibilidad 95%, especificidad 98%, valor predictivo positivo 99%, valor predictivo negativo 91% y exactitud 91%. Cuando se comparó el EPI con la PAAF preoperatoria, los valores de sensibilidad más bajos (44%) correspondieron a las categorías de Bethesda III y IV. El EPI influyó en la estrategia quirúrgica en 95 pacientes (12,28%): en 53 (6,8%), la hemitiroidectomía cambió a tiroidectomía total; en 37 (4,8%), el diagnóstico de metástasis ganglionares permitió realizar un vaciamiento modificado de cuello, y en 5 (0,6%) ocurrieron ambas situaciones. Conclusión: el EPI tuvo altos valores de utilidad diagnóstica cuando se compararon con el EPD. También se correlacionó con la PAAF preoperatoria, pero tuvo menos utilidad en las categorías Bethesda III y IV. El EPI contribuyó a cambiar la decisión de técnica quirúrgica en un grupo de pacientes y evitar una segunda operación.
Background: the role of intraoperative pathologic evaluation (IPE) in thyroid surgery has largely been discussed and it is still controversial. Objective: to estimate the results of IPE in diagnosis of malignancy, its correlation with preoperative fine needle aspiration (FNA) biopsy and permanent pathologic evaluation (PPE), and its contribution to change surgical strategy in thyroid surgery. Materials and methods: retrospective chart review of 773 patients operated on for thyroid disease between January 2014 and December 2015. All patients underwent IPE and PPE; 686 (89%) patients had also preoperative FNA biopsy. Results: IPE resulted benign in 215 patients (27.8%), malignant in 419 (54.2%) and non definitive in 139 (18.0%). When these results were compared with PPE, 19 cases were false negative (8.8%) and 4 false positive (0.95). Considering only definitive results, IPE had sensitivity 95%, specificity 98%, positive predictive value 99%, negative predictive value 91% and accuracy 91%. When IPE was compared with preoperative FNA biopsy, lowest values of sensitivity (44%) corresponded with Bethesda categories III and IV. IPE influenced surgical strategy in 95 patients (12.28%): in 53 (6.8%) hemithyroidectomy changed to total thyroidectomy, in 37 (4.8%) lymph node metastases diagnosis allowed to perform modified neck dissection, and in 5 (0.6%) both situations occurred. Conclusion: IPE had high values of diagnostic utility when compared with PPE. It also correlated with preoperative FNA biopsy, but had less utility in Bethesda categories III and IV. IPE contributed to change surgical technical decision in a subset of patients and avoid a second operation.
Assuntos
Humanos , Feminino , Adolescente , Adulto , Pessoa de Meia-Idade , Idoso , Idoso de 80 Anos ou mais , Adulto Jovem , Glândula Tireoide/patologia , Tireoidectomia , Biópsia por Agulha/métodos , Neoplasias da Glândula Tireoide , Carcinoma Papilar/diagnóstico , Estudos Retrospectivos , Carcinoma Medular/diagnósticoRESUMO
BACKGROUND: Parathyroid gland (PG) identification during thyroid and parathyroid surgery is challenging. Accidental parathyroidectomy increases the rate of postoperative hypocalcaemia. Recently, autofluorescence with near infrared light (NIRL) has been described for PG visualization. The aim of this study is to analyze the increased rate of visualization of PGs with the use of NIRL compared to white light (WL). MATERIALS AND METHODS: All patients undergoing thyroid and parathyroid surgery were included in this study. PGs were identified with both NIRL and WL by experienced head and neck surgeons. The number of PGs identified with NIRL and WL were compared. The identification of PGs was correlated to age, sex, and histopathological diagnosis. RESULTS: Seventy-four patients were included in the study. The mean age was 48.4 (SD ±13.5) years old. Mean PG fluorescence intensity (47.60) was significantly higher compared to the thyroid gland (22.32) and background (9.27) (p < 0.0001). The mean number of PGs identified with NIRL and WL were 3.7 and 2.5 PG, respectively (p < 0.001). The difference in the number of PGs identified with NIRL and WL and fluorescence intensity was not related to age, sex, or histopathological diagnosis, with the exception of the diagnosis of thyroiditis, in which there was a significant increase in the number of PGs visualized with NIRL (p = 0.026). CONCLUSION: The use of NIRL for PG visualization significantly increased the number of PGs identified during thyroid and parathyroid surgery, and the differences in fluorescent intensity among PGs, thyroid glands, and background were not affected by age, sex, and histopathological diagnosis.
Assuntos
Pescoço/diagnóstico por imagem , Glândulas Paratireoides/diagnóstico por imagem , Paratireoidectomia , Espectroscopia de Luz Próxima ao Infravermelho , Glândula Tireoide/diagnóstico por imagem , Tireoidectomia , Adulto , Feminino , Humanos , Período Intraoperatório , Masculino , Pessoa de Meia-Idade , Pescoço/cirurgia , Glândulas Paratireoides/cirurgia , Estudos Retrospectivos , Espectroscopia de Luz Próxima ao Infravermelho/métodos , Glândula Tireoide/cirurgia , Resultado do TratamentoRESUMO
BACKGROUND: Identification of parathyroid glands may be challenging during thyroid and parathyroid surgery. Accidental resection of the glands may increase the morbidity of the surgery. The aim of this study was to evaluate accuracy in identification of autofluorescent parathyroid glands with the use of near infrared light in real time. STUDY DESIGN: Patients undergoing thyroid and parathyroid surgery between June and August 2015 were included in the study. During the procedure, the surgical field was exposed to near infrared laser light in order to analyze the intensity of the fluorescence of different tissues (parathyroid glands, thyroid glands, and background). Surgical images were recorded and analyzed. RESULTS: Twenty-eight patients were included in the study. Nineteen patients were women and 9 were men. Seven patients had primary hyperparathyroidism, 4 had hyperthyroidism, 3 had goiters, and 11 had thyroid cancer. Three patients had mixed pathologies, including 2 patients with thyroid cancer and primary hyperparathyroidism and 1 patient with goiter and primary hyperparathyroidism. Identification of autofluorescent parathyroid glands was achieved in all patients with near infrared light. The mean fluorescent intensity of parathyroid glands was 40.6 (±26.5), thyroid glands 31.8 (±22.3), and background 16.6 (±15.4). Parathyroid glands demonstrated statistically higher fluorescence intensity compared with the thyroid gland and background (p < 0.0014). No postoperative hypocalcemia or other complications related to the surgery were registered. CONCLUSIONS: Visualization of autofluorescent parathyroid glands with the use of near infrared light allows high rates of parathyroid gland identification and could be a safe, feasible, and noninvasive method for intraoperative identification of parathyroid glands in real time. Further clinical studies must be performed to determine the cost-effectiveness and clinical application of this method.