Fine needle aspiration biopsy of parathyroid; is it meaningful? A cytologic study of 81 cases with histological and clinical correlations

BACKGROUND

Recognizing the parathyroid gland and distinguishing the parathyroid from thyroid lesions in fine needle aspiration (FNA) is challenging. This study aimed to identify cytomorphologic features suggestive of parathyroid origin and to assess the utility of cytopathology in conjunction with ancillary tests in the identification of parathyroid glands.

MATERIALS AND METHODS

Ultrasound (US) guided FNA of parathyroid gland and lesions in 81 patients were reviewed concerning clinical history and correlated to histopathologic findings in available cases. FNA smears were evaluated for cellularity, architectural patterns, cellular and nuclear features, and background of the smears. In 78 cases, FNA was supplemented by a measurement of parathormone (PTH) levels in the needle washout fluid (FNA-PTH assay) and/or GATA3/PTH/chromogranin-A immunostainings.

RESULTS

Sixty-four cases were diagnosed cytologically as parathyroid lesions in conjunction with FNA-PTH assay and/or immunocytochemical examinations. In an additional nine cases, a diagnosis of parathyroid lesions was rendered after repeated FNA with FNA-PTH assay. The histolopathologic diagnosis of surgically excised cases (n = 75) included parathyroid adenoma (60 cases), atypical parathyroid adenoma (4 cases), parathyroid hyperplasia (10 cases), and parathyroid carcinoma (1 case). Major cytological findings of parathyroid tissue included high cellularity, scattered naked nuclei, cribriform and three-dimensional clusters, stippled chromatin, and oxyphilic cytoplasm while papillary pattern or colloid-like material was identified in three cases respectively. No nuclear grooves or inclusions were seen in any case.

CONCLUSIONS

High cellularity scattered naked nuclei, cribriform and three-dimensional patterns, stippled chromatin and oxyphilic cytoplasm are cytomorphologic features that favour parathyroid origin. A combination of these features with FNA-PTH assay and/or GATA3, PTH, and chromogranin-A immunostainings on cytologic specimens aid in the identification of parathyroid glands and the distinguishing of parathyroid from thyroid lesions.

Ultrasound and cytopathological characteristics of thyroid tumours of uncertain malignant potential - from diagnosis to treatment

INTRODUCTION

The latest World Health Organization (WHO) classification from 2022 distinguishes the division of low-risk thyroid neoplasms such as non-invasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTP), follicular tumour of uncertain malignant potential (FT-UMP), and well-differentiated tumour of uncertain malignant potential (WDT-UMP). The final diagnosis is made postoperatively according to histopathologic results. The aim of the study was the assessment of ultrasonographic and cytopathological features of borderline lesions to predict low-risk tumours preoperatively and plan the optimal treatment for that group of patients.

MATERIAL AND METHODS

A total of 35 patients (30 women; 5 men), aged 20-81 years with a mean age of 49 years, were enrolled in the study. The study evaluated 35 focal lesions of the thyroid gland, classified as low-risk neoplasms according to the WHO 2022 classification: FT-UMP (n = 21), NIFTP (n = 7), and WDT-UMP (n = 7). Ultrasonographic features of nodules including contrast-enhanced ultrasound (CEUS) and elastography were assessed by 2 specialists, and the risk of malignancy was evaluated according to EU-TIRADS-PL classification.

RESULTS

Of the 35 focal thyroid lesions, most were categorised as low or intermediate risk of malignancy according to EU-TIRADS-PL, with dominant category 3 [n = 13 (37.2%)] and category 4 [n = 15 (42.8%)]. High-risk category 5 was assessed in 7 lesions (20%). In cytopathology nodules were categorised as follows (Bethesda System TBSRTC 2023): Bethesda II (n = 4), Bethesda III (n = 2), Bethesda IV (n = 25), Bethesda V (n = 3), and Bethesda VI (n = 1). In the CEUS study, contrasting patterns dominated compared to the surrounding parenchyma, such as enhancement equal to the parenchyma (66.6%) or intense (28.5%), heterogeneous (61.9%), centripetal (42.8%), or diffuse (57.1%) with fast (33.3%) or compared to parenchyma contrast wash-in (42.8%) and its fast (33.3%) or comparable to thyroid parenchyma wash-out (52.3%).

CONCLUSIONS

The study indicates that lesions with uncertain malignant potential typically present features suggesting low to intermediate risk of malignancy based on EU-TIRADS-PL classification, with dominant cytopathologic Bethesda IV category. However, 20% of lesions were assessed tas EU-TIRADS-PL category 5. Low-risk tumours, including NIFTP, FT-UMP, and WDT-UMP, require careful observation and monitoring post surgical treatment due to their potential for recurrence and metastasis. The preoperatively prediction of borderline tumour may play an important role in proper treatment and follow-up.

Dosimetry during iodine-131 therapy - a technical point of view from a single centre's own experience

BACKGROUND

Nuclear medicine uses radionuclides in medicine for diagnosis, staging, therapy, and monitoring the response to therapy. The application of radiopharmaceutical therapy for the treatment of certain diseases is well-established, and the field is expanding. Internal dosimetry is multifaceted and includes different workflows, as well as various calculations based on patient- specific dosimetry.

AIM

The objective of this study was to introduce the technical issues which might occur during iodine-131 (¹³¹I) dosimetry performed in nuclear medicine departments.

MATERIAL AND METHODS

Retrospective analysis was performed on a group of 44 patients with papillary thyroid cancer who between May 2021 and October 2021 underwent a 131I treatment: 80-100 mCi (2200-3700 MBq, based on the previous medical history and stage of the disease). Patients underwent a series of ¹³¹I therapy scans using gamma camera Discovery NM 670 CT. Whole body scan (WBS) was performed 2, 4, 24 and 48 hours after ¹³¹I administration. Additionally, after 24 hours of single photon emission computed tomography/ computed tomography, two fields of view (SPECT/CT 2-FOV) were performed from the mid-head to the bladder.

RESULTS

During the dosimetry procedure, several issues arise. Firstly, after receiving therapeutic doses of ¹³¹I, patients should remain in their rooms until the appropriate activity is achieved before being transported to the diagnostic room. Secondly, the walls between examination rooms meet the requirements for accurate diagnosis but not for therapy, leading to the occurrence of artefacts in patients examined behind the wall, potentially influencing the examination results. Thirdly, personnel in the control room also experience additional exposure (10 times greater than in the case of standard diagnostic procedure).

CONCLUSIONS

The dosimetry in patients in whom therapeutic procedures are performed with the use of isotopes is mandatory according to Polish and European law, technical issues which occur during the dosimetry procedures might influence the organization of the work in departments.

Radiosynovectomy of the hip joint - preliminary experience

Introduction

Radiosynovectomy (RSV) is a minimally invasive method of treating and controlling joint inflammation refractory to conventional pharmacotherapy. It consist in intraarticular injection of radioactive colloids which irradiate the inflamed synovial membrane to cause its subsequent involution. Despite the fact that hip joint involvement is quite common in systemic inflammatory arthropathies, hip joint RSVs are rarely performed. The aim of this paper is to assess to safety and efficacy of hip joint radioisotope treatment.

Material and methods

We retrospectively analyzed the effects of 21 hip joint RSVs performed in 14 patients (10 female, 4 male; aged 8 to 79; mean age 48 years). Before the RSV, all the patients underwent clinical and ultrasound examination. The radiosynovectomies were performed using rhenium-186 sulfide under ultrasound guidance. Each patient underwent post-therapeutic scintigraphy to assess intraarticular distribution of the radiopharmaceutical. The effects of the treatment were assessed clinically and ultrasonographically during at least 2 follow-up visits 3 and 6 months after the RSV.

Results

In 9 cases, we observed complete resolution of symptoms 3 and 6 months after the RSV. Four patients had only a partial response and required repeated treatment, and all responded well to the second RSV. In 4 patients the treatment had no significant effect, and no repeated treatment attempt was made. All the responders suffered from inflammatory arthropathies; the non-responders had osteoarthritis, with no history of systemic diseases. In all the patients, no significant adverse effects were observed; in particular there were no radiation burns or infections. All post-therapeutic scintigrams showed proper, intraarticular distribution of the radiopharmaceutical.

Conclusions

Radiosynovectomy of the hip joint in systemic joint diseases, especially performed using ultrasound-guidance, is a safe and effective treatment modality.

Current picture of anaplastic thyroid cancer patients' care and meetable needs: A survey of 94 Institutions from the EORTC Endocrine and Head and Neck Cancer Groups

Anaplastic thyroid carcinoma (ATC) is a rare cancer accounting for 40% of thyroid cancer-specific deaths. In the last 5 years, improved insights into molecular pathways led the Food and Drug Administration to license BRAF/MEK inhibitors (B/Mi) in BRAF^V600E-mutant ATC, and pembrolizumab in solid cancer with high tumour mutational burden (TMB-H) (≥10 mutations/megabase) (mut/Mb). In Europe, clinicians face challenges in prescribing novel treatments, as the European Medical Association (EMA) has not licensed B/Mi nor immunotherapy (IO) for ATC so far. Some patients manage to receive these drugs through alternative ways. We investigated the extent of this phenomenon launching an online survey from March 12th to 19th 2021 open to 239 Institutions in the EORTC Endocrine and Head & Neck Cancer Groups. Questions enquired about the number of ATC patients evaluated/year, feasibility of BRAF assessment, accessibility to B/Mi-IO, availability of clinical trials and interest in new studies. Colleagues from 94 Institutions (20 Countries) joined: 30 centres evaluated ≥5 ATC patients/year, with an overall incidence >200 patients/year. 80.8% tested BRAF status, 43.6% by next-generation sequencing. 62.7% and 70% of responders reported limitations in prescribing B/Mi and IO, respectively: either the impossibility of offering them, or drugs accessibility exclusively under certain conditions (e.g. health insurance, clinical trials, compassionate use, off-label). Only 13.8% had clinical trials ongoing while 91.5% of sites claimed ATC-dedicated trials. Disparities in access to novel treatments are diffuse. Access to cutting-edge therapies is an urgent issue in this setting, and clinical trials seem feasible within an appropriate network.

Management of hypoparathyroidism: a Position Statement of the Expert Group of the Polish Society of Endocrinology

Over the past few years, there have been significant advances in our understanding of hypoparathyroidism (HypoPT) in terms of its epidemiology, clinical presentation, etiology, and skeletal and renal complications. Moreover, the available treatment options for HypoPT have changed. This position statement of the Expert Group of the Polish Society of Endocrinology summarizes the current state of knowledge and provides recommendations for optimal management to assist clinicians in the diagnosis, treatment, and monitoring of HypoPT in Poland. The specific aspects of HypoPT management in children, pregnant and lactating women, and patients with chronic kidney disease are also discussed. HypoPT is a rare disorder characterized by hypocalcemia and the lack or deficiency of parathyroid hormone (PTH). Hypoparathyroidism can be associated with complications, including nephrocalcinosis, nephrolithiasis, renal insufficiency, cataract, seizures, cardiac arrhythmia, depression, and an increased risk of infection. Minimizing complications of HypoPT requires careful evaluation and close monitoring of laboratory parameters. Conventional management of HypoPT has focused on maintaining serum calcium levels using oral calcium and active vitamin D. However, this approach is limited because it does not restore normal PTH function, is often associated with inadequate biochemical control, and raises concerns as to long-term side effects. HypoPT is the only classic endocrine insufficiency that is not commonly treated with the substitution of the missing hormone. Recently, recombinant human PTH(1-84) has become available, offering hope that the use of the missing hormone in the treatment of HypoPT will help achieve better control and reduce the risk of complications. However, this treatment is currently unavailable in Poland.

Position paper from the Endocrine Task Force of the European Organisation for Research and Treatment of Cancer (EORTC) on the management and shared decision making in patients with low-risk micro papillary thyroid carcinoma

The incidence of differentiated thyroid cancer (DTC) has been increasing worldwide, mostly, as an increase in the incidental detection of micro papillary thyroid carcinomas (microPTCs), many of which are potentially overtreated, as suggested by the unchanged mortality. Several international guidelines have suggested a less aggressive approach. More recently, it has been shown that active surveillance or minimally invasive treatments (MIT) are good alternatives for the management of these patients. In this context, patient participation in the decision-making process is paramount. The Endocrine Task Force of the European Organisation for Research and Treatment of Cancer (EORTC) has undertaken the task to establish consensus and define its position based on the scientific evidence concerning, 1) the current state of diagnostic and management options in microPTCs, including the current opinion of physicians about shared decision making (SDM), 2) the available evidence concerning patients' needs and the available decision instruments, and 3) to provide practical suggestions for implementation of SDM in this context. To improve SDM and patients' participation, knowledge gaps and research directions were highlighted.

Basics of prevention and management of iodine-based contrast media-induced thyroid dysfunction - position paper by the Polish Society of Endocrinology

Medical practice involves a high number of radiological examinations using iodinated contrast media (ICM). Therefore, it is crucial for doctors of different specialties to be aware of possible adverse effects associated with ICM use. The most common and well characterized adverse effect is contrast-induced nephropathy, whereas thyroidal adverse reactions remain a diagnostic and therapeutic dilemma. ICM-induced thyroid dysfunction represents a highly heterogenous group of thyroid disorders. Due to supraphysiological iodine concentration, ICM can induce both hyper- and hypothyroidism. In most cases, the ICM-induced thyroid dysfunction is oligo- or asymptomatic, mild, and transient. In rare cases, however, the ICM-induced thyroid dysfunction may be severe and life threatening. Recently, the European Thyroid Association (ETA) Guidelines for the Management of Iodine-Based Contrast Media-Induced Thyroid Dysfunction were published. The authors advise an individualized approach to prevention and treatment of ICM-induced thyroid dysfunction, based on patient's age, clinical symptoms, pre-existing thyroid diseases, coexisting morbidities, and iodine intake. There is a geographic variation of ICM-induced thyroid dysfunction prevalence, which is linked to iodine intake. The prevalence of ICM-induced hyperthyroidism, which may pose a serious therapeutic challenge, is greater in countries with iodine deficiency. Poland is a region with a history of iodine deficiency, contributing to an increased prevalence of nodular thyroid disease, especially in the elderly. Therefore, the Polish Society of Endocrinology has proposed national, simplified principles of ICM-induced thyroid dysfunction prevention and treatment.

Diagnosis and treatment of thyroid cancer in adult patients — Recommendations of Polish Scientific Societies and the National Oncological Strategy. Update of the 2022 Update [Diagnostyka i leczenie raka tarczycy u chorych dorosłych — Rekomendacje Polskich Towarzystw Naukowych oraz Narodowej Strategii Onkologicznej. Aktualizacja na rok 2022 — uzupełnienie]

N/A.

Factors Associated With Injury to Recurrent Laryngeal Nerve in Patients Undergoing Surgery for Thyroid Cancer: A Single-centre Study Using Translaryngeal Ultrasound

AIMS

Intraoperative injury to the recurrent laryngeal nerve (RLN) is a serious complication occurring more frequently in patients with thyroid cancer than in those with benign thyroid diseases. However, data on the risk factors for RLN injury among patients with thyroid cancer are scarce. Currently, RLN injury is diagnosed by laryngoscopy, but translaryngealultrasonography (TLUS), which is less invasive, appears to have a similar accuracy. Herein, we analysed risk factors ofintraoperative RLN injury in patients with thyroid cancer and assessed the diagnostic performance of TLUS.

PATIENTS AND METHODS

In this prospective study, we enrolled patients undergoing surgery for thyroid cancer from October 2020 to October 2021. Medical and surgical variables were analysed as risk factors of RLN injury. TLUS was compared with laryngoscopy in diagnosing RLN injury.

RESULTS

There were 185 patients who underwent 196 surgeries. Of all surgeries, 23 (11.7%) caused RLN injury ascertained on laryngoscopy. Compared with laryngoscopy, TLUS displayed high sensitivity (97.7%; 95%CI: 94.3%-99.4%) and specificity (100%; 95% CI: 82.4%-100%). Before surgery, medical and surgical characteristics did not differ significantly between patients with or without RLN injury, but RLN entrapment by tumour was more frequent in those with the injury (P < 0.001). The risk of RLN injury was increased in patients undergoing thyroidectomy with lateral neck dissection (OR = 4.53; 95% CI: 1.29-14.32) and in those with lymph node metastases (OR = 2.76; 95% CI: 1.03-7.01).

CONCLUSION

Intraoperative RLN injury in patients with thyroid cancer is more common after operations requiringgreater resections and with lymph node involvement. TLUS could be used to diagnose RLN injury.

Selumetinib Plus Adjuvant Radioactive Iodine in Patients With High-Risk Differentiated Thyroid Cancer: A Phase III, Randomized, Placebo-Controlled Trial (ASTRA)

PURPOSE

Selumetinib can increase radioactive iodine (RAI) avidity in RAI-refractory tumors. We investigated whether selumetinib plus adjuvant RAI improves complete remission (CR) rates in patients with differentiated thyroid cancer (DTC) at high risk of primary treatment failure versus RAI alone.

METHODS

ASTRA (ClinicalTrials.gov identifier: NCT01843062) is an international, phase III, randomized, placebo-controlled, double-blind trial. Patients with DTC at high risk of primary treatment failure (primary tumor > 4 cm; gross extrathyroidal extension outside the thyroid gland [T4 disease]; or N1a/N1b disease with ≥ 1 metastatic lymph node(s) ≥ 1 cm or ≥ 5 lymph nodes [any size]) were randomly assigned 2:1 to selumetinib 75 mg orally twice daily or placebo for approximately 5 weeks (no stratification). On treatment days 29-31, recombinant human thyroid-stimulating hormone (0.9 mg)-stimulated RAI (131I; 100 mCi/3.7 GBq) was administered, followed by 5 days of selumetinib/placebo. The primary end point (CR rate 18 months after RAI) was assessed in the intention-to-treat population.

RESULTS

Four hundred patients were enrolled (August 27, 2013-March 23, 2016) and 233 randomly assigned (selumetinib, n = 155 [67%]; placebo, n = 78 [33%]). No statistically significant difference in CR rate 18 months after RAI was observed (selumetinib n = 62 [40%]; placebo n = 30 [38%]; odds ratio 1.07 [95% CI, 0.61 to 1.87]; P = .8205). Treatment-related grade ≥ 3 adverse events were reported in 25/154 patients (16%) with selumetinib and none with placebo. The most common adverse event with selumetinib was dermatitis acneiform (n = 11 [7%]). No treatment-related deaths were reported.

CONCLUSION

Postoperative pathologic risk stratification identified patients with DTC at high risk of primary treatment failure, although the addition of selumetinib to adjuvant RAI failed to improve the CR rate for these patients. Future strategies should focus on tumor genotype-tailored drug selection and maintaining drug dosing to optimize RAI efficacy.

Diagnosis and treatment of thyroid cancer in adult patients - Recommendations of Polish Scientific Societies and the National Oncological Strategy. 2022 Update [Diagnostyka i leczenie raka tarczycy u chorych dorosłych - Rekomendacje Polskich Towarzystw Naukowych oraz Narodowej Strategii Onkologicznej. Aktualizacja na rok 2022]

The guidelines Thyroid Cancer 2022 are prepared based on previous Polish recommendations updated in 2018. They consider international guidelines - American Thyroid Association (ATA) 2015 and National Comprehensive Cancer Network (NCCN); however, they are adapted according to the ADAPTE process. The strength of the recommendations and the quality of the scientific evidence are assessed according to the GRADE system and the ATA 2015 and NCCN recommendations. The core of the changes made in the Polish recommendations is the inclusion of international guidelines and the results of those scientific studies that have already proven themselves prospectively. These extensions allow de-escalation of the therapeutic management in low-risk thyroid carcinoma, i.e., enabling active surveillance in papillary microcarcinoma to be chosen alternatively to minimally invasive techniques after agreeing on such management with the patient. Further extensions allow the use of thyroid lobectomy with the isthmus (hemithyroidectomy) in low-risk cancer up to 2 cm in diameter, modification of the indications for postoperative radioiodine treatment toward personalized approach, and clarification of the criteria used during postoperative L-thyroxine treatment. At the same time, the criteria for the preoperative differential diagnosis of nodular goiter in terms of ultrasonography and fine-needle aspiration biopsy have been clarified, and the rules for the histopathological examination of postoperative thyroid material have been updated. New, updated rules for monitoring patients after treatment are also presented. The updated recommendations focus on ensuring the best possible quality of life after thyroid cancer treatment while maintaining the good efficacy of this treatment.

Summary of meta-analyses of studies involving TIRADS classifications (EU-TIRADS, ACR-TIRADS, and K-TIRADS) in evaluating the malignant potential of focal lesions of the thyroid gland

Numerous scientific societies around the world have published their TIRADS (Thyroid Imaging Reporting and Data System) classifications that evaluate the risk of malignancy of focal thyroid lesions, presenting different ultrasound features for each category and lesion size thresholds to determine eligibility for biopsy. The use of such risk estimation systems in focal thyroid lesions facilitates the reporting of thyroid ultrasound findings and improves the qualification of focal lesions for fine-needle aspiration biopsy (FNAB). In this publication, the three most popular TIRADS classifications, European – EU-TIRADS, Korean – K-TIRADS, and developed by the American Society of Radiology – ACR-TIRADS, are presented and discussed based on a literature review. The results of available head-to-head statistical analyses comparing the classifications are also presented. The advantage of the EU-TIRADS and K-TIRADS systems is that they include only the most important ultrasound features, so their application is not time-consuming, and the scores are easy to incorporate into clinical practice. ACR-TIRADS, unlike other scales, is based on a unique classification system and represents the most comprehensive classification. Each of the five categories of ultrasound features – morphology, echogenicity, shape, margins, microcalcifications – are evaluated and assigned a score from 0 to 3, with a higher score being associated with a higher risk of cancer. Based on the available data, the greatest benefit has been demonstrated for the ACR-TIRADS classification, which also has implications for minimising the number of unnecessary FNABs. However, limitations related to the heterogeneity of the groups analysed in the study, including differences in the populations studied, inclusion criteria, proportions of patients of either sexes, and the number of malignant lesions analysed, should also be taken into account.

Summary of meta-analyses of studies considering lesion size cut-off thresholds for the assessment of eligibility for FNAB and sonoelastography and inter- and intra-observer agreement in estimating the malignant potential of focal lesions of the thyroid gland

Thyroid cancer is a tumour with a steadily increasing incidence. It accounts for 7% to 15% of focal lesions detected by ultrasound, depending on age, gender and other factors affecting its occurrence. Fine-needle aspiration biopsy is an essential method to establish the diagnosis but, in view of its limitations, sonoelastography is seen as a non-invasive technique useful in differentiating the nature of lesions and monitoring them after fine-needle aspiration biopsy. This paper presents a literature review on the role of both sonoelastographic techniques (relative strain sonoelastography, shear wave sonoelastography) to assess the deformability of focal thyroid lesions. Ultrasound examination is a relatively subjective method of thyroid imaging, depending on the skills of the examiner, the experience of the centre, and the quality of equipment used. As a consequence, there are inconsistencies between the results obtained by different examiners (inter-observer variability) and by the same examiner (intra-observer variability). In this paper, the authors present a review of the literature on inter-observer and intra-observer variability in the assessment of individual features of ultrasound imaging of focal lesions in the thyroid. In addition, the authors report on an analysis of cut-off thresholds for the size of lesions constituting the basis for fine-needle aspiration biopsy eligibility assessment. The need to diagnose carcinomas up to 10 mm in diameter is highlighted, however a more liberal approach is recommended in terms of indications for biopsy in lesions associated with a low risk of malignancy, where, based on consultations with patients, active ultrasound surveillance might even be considered.

Application of Translaryngeal Ultrasound (TLUS) in Patients with Neck Surgery—A Single-Centre, Prospective Cohort Study on Technique Evaluation

Purpose: The primary objective of this study was to assess the value of translaryngeal ultrasound (TLUS) in assessing vocal fold (VF) function in patients after thyroid, parathyroid and neck lymph node surgery. Methods: A total of 219 patients that underwent 230 surgical procedures were enrolled in this prospective study. The study was conducted from October 2020 to October 2021. Patients’ VFs were analysed independently with TLUS and laryngoscopy before and after the surgery. Various TLUS variables, such as vocal folds displacement velocity (VFDV), arytenoids symmetry and angle between VFs, were measured. The questionnaire evaluating discomfort caused to patients by both methods was conducted. Results: Of the 230 surgeries in this study, 85% were from oncological indications. The incidence of RLN injury was 10.4%. The accuracy of TLUS compared to laryngoscopy was 98.3%, with sensitivity 98.1%, specificity 100%, PPV 100% and NPV 83.3%. Laryngoscopy was found to cause significantly more discomfort than TLUS. VF visibility was lower in men; smokers; and patients with higher BMI (32 vs. 28 kg/m²), multifocal cancer, higher left lobe volume and higher fT3 levels. Arytenoid symmetry VFDV was lower for “e” and “i” right side and “i” left side in injured/disabled VFs/RLN. Conclusions: TLUS can be an excellent and non-invasive method of VF evaluation in most patients. There are some technical aspects that can improve its accuracy. Sometimes, RLN injury after the surgery, especially among oncological patients, is unavoidable. Therefore, it is vital to diagnose dysphonia early with convenient methods, such as TLUS.

Identification of the Optimal Cut-Off Value of PSA for Assessing Severity of Disease in [68Ga]Ga-PSMA-11 PET/CT Study in Prostate Cancer Patients after Radical Prostatectomy

Objective: The objective of this study was to identify the optimal cut-off value of prostate specific antigen (PSA) to assess the extent of the disease in [68Ga]Ga-PSMA-11 PET/CT study in patients after radical prostatectomy. Materials and Methods: Retrospective analysis was performed on a group of 215 patients who underwent a [68Ga]Ga-PSMA-11 PET/CT examination because of suspected recurrence after radical prostatectomy. Patients were divided into four groups: 1, no active lesions suggesting recurrence (n = 92); 2, suspected isolated local recurrence (n = 19); 3, oligometastatic disease (n = 82); and 4, polymetastatic disease (n = 22). Results: In group 1, the mean PSA level was 0.962 ng/mL (median: 0.376; min: 0.004; max: 25 ng/mL); in group 2, it was 4.970 ng/mL (median 1.320; min: 0.003; max: 40.350 ng/mL); in group 3, it was 2.802 ng/mL (median: 1.270; min: 0.020; max: 59.670 ng/mL); and in group 4, it was 4.997 ng/mL (median: 3.795; min: 0.007; max 21.110 ng/mL). Statistically significant differences were shown in PSA levels when comparing groups 1 and 2 (p = 0.0025) and groups 3 and 4 (p = 0.0474). The PSA cut-off point for discriminating groups 1 and 2 was 0.831 (sensitivity: 0.684; specificity: 0.772; area under the curve (AUC): 0.775), and for groups 3 and 4, it was 2.51 (sensitivity: 0.682; specificity: 0.780; AUC: 0.720). Conclusions: Our preliminary data suggested that the PSA level has an essential influence on determining the extent of disease in a [68Ga]Ga-PSMA-11 PET/CT study in patients after radical prostatectomy. Identification of the optimal cut-off values for the oligo- and polymetastatic diseases might be helpful in stratifying these patients.

Thyroglobulin measurements in washouts of fine-needle aspiration biopsy in monitoring the patients with differentiated thyroid carcinoma - analysis of non-compliance results

INTRODUCTION

Approximately 35% patients with papillary thyroid carcinoma (PTC) and 13% with follicular thyroid carcinoma (FTC), present with cervical lymph nodes (LNs) metastases at the time of diagnosis. In addition, 15-20% of patients treated with total thyroidectomy develop, after an interval of five years, metastases to the neck LNs on ultrasound examination. Fine-needle aspiration biopsy (FNAB) represents the gold standard technique for the detection of cervical LNs metastases. However, the aspiration of small and cystic LNs metastases occasionally yields a sparse and suboptimal specimen. The aim of the study was to evaluate the diagnostic performance of the technique of thyroglobulin (Tg) measurement of the washout FNAB (FNAB-Tg) and the clinical outcome of discrepant results between FNAB-Tg and final histopathologic diagnosis.

MATERIAL AND METHODS

Two hundred FNAB-Tg samples from 200 patients (158 women; 42 men; age 51.37 ± 16.77 [53]) diagnosed with DTC were examined for the assessment of the diagnostic utility of FNAB-Tg from suspicious LNs. FNAB-Tg ranged from 1.96 to 5000 ng/mL in metastatic LNs (mean; 1510 ± 1486 ng/mL [958.5]) and from 0.04 to 635.9 ng/mL in nonmetastatic LNs (mean; 57.86 ± 319.19 ng/mL [1.96], p < 0.001.

RESULTS

The most accurate diagnostic performance was displayed for concentration of 33.28 ng/mL in FNAB-Tg with AUC of 0.91 and high sensitivity and specifity (0.92 and 0.93). FNAB-Tg in conjunction to the cythopatologic examination of suspicious LNs in differentiated thyroid carcinoma (DTC) patients increases the diagnostic accuracy of FNAB (sensitivity 0.99; specificity 0.99; AUC 1.00).

CONCLUSIONS

FNAB-Tg may be particularly useful in detecting of cystic metastases earlier characterized as indeterminate upon cythopatologic examination, and in differential diagnosis of various LNs metastasizing malignancies. FNAB-Tg measurement has high specificity and sensitivity in the detection of LNs metastases of DTC.

Therapeutic plasma exchange with albumin as a valuable method of preparing thyrotoxic patients for a life-saving thyroidectomy

Hyperthyroidism affects approximately 1.2% of the population and its routine treatment includes antithyroid drugs (ATDs), radioiodine and surgery. Management of patients with resistance or contraindications to ATDs who require thyroidectomy may be challenging. We present the experience of our department in preparing thyrotoxic patients for life-saving thyroidectomy by using therapeutic plasma exchange (TPE) with albumin: one patient with Graves' disease and previous history of agranulocytosis and cholestatic jaundice after ATDs and two patients with amiodarone-induced thyrotoxicosis. Five to six TPEs were applied to each patient resulting in a decrease of fT3 by 57% to 83%, fT4 by 21% to 60% and decrease/normalization of total thyroid hormones. All patients underwent surgery successfully. In case of drug-resistant thyrotoxicosis or contraindications to ATDs, TPE can be a valuable tool in preparing patients for surgery. Albumin used as a replacement fluid appears to be effective in ameliorating clinical and laboratory symptoms of thyrotoxicosis.

Novel Germline c.105_107dupGCT MEN1 Mutation in a Family with Newly Diagnosed Multiple Endocrine Neoplasia Type 1

In multiple endocrine neoplasia type 1 (MEN1), the causative MEN1 gene mutations lead to the reduced expression of menin, which is a tumor suppressor protein. In this study, we present a case of a 16-year-old woman with severe primary hyperparathyroidism and a non-functioning pituitary microadenoma. Genetic testing demonstrated a novel germline heterozygote variant c.105_107dupGCT of MEN1, leading to Leu duplication in position 37 of the menin polypeptide chain. As such a mutation was not reported before as a causative one, confirmation of its pathogenicity required showing the same mutation in a symptomatic first-degree relative. An identical mutation was found in the patient’s father, who was further diagnosed with hyperparathyroidism and a pituitary microadenoma. We observed the presence of the same MEN1-related tumors but an entirely different symptom severity. To the best of our knowledge, this is the first report of MEN1 syndrome caused by the c.105_107dupGCT MEN1 mutation. This case report demonstrates the importance of genetic evaluation towards MEN1. Genetic testing for MEN1 mutations should be performed in all patients with MEN1-related tumors, and in the young patients even with only one such tumor, despite the supposedly negative family history.

Histopathological Verification of the Diagnostic Performance of the EU-TIRADS Classification of Thyroid Nodules-Results of a Multicenter Study Performed in a Previously Iodine-Deficient Region

Background: To validate the European Thyroid Imaging and Reporting Data System EU-TIRADS classification in a multi-institutional database of thyroid nodules by analyzing the obtained scores and histopathology results. Methods: A total of 842 thyroid lesions (613 benign, 229 malignant) were identified in 428 patients (mean age 62.7 years) and scored according to EU-TIRADS, using ultrasound examination. In all tumors, histopathological verification was performed. Results: In EU-TIRADS 2 (154 nodules) all nodules were benign; in EU-TIRADS 3, only 3/93 malignancies were identified. In EU-TIRADS 4, 12/103 were malignant, and in EU-TIRADS 5 (278 benign vs. 214 malignant). The malignant nodules that would not have qualified for biopsy were: EU-TIRADS 3, 2/3 (67%) malignancies were <20 mm, in EU-TIRADS 4, 7/12 (58%) were <15 mm. In EU-TIRADS 5, 72/214 (34%) were <10 mm; in total, 81/229 (36%) malignant lesions would have been missed. The cutoff between EU-TIRADS 3/4 had sensitivity of 100%, specificity of 25.1%. Using cutoff for EU-TIRADS 5, 93.4%, 54.6%, respectively. Conclusion: The application of EU-TIRADS guidelines allowed us to achieve moderate specificity. The vast majority of malignancies in EU-TIRADS 3, 4, and 5 would not have been recommended for biopsy because having a smaller size than that proposed classification.

Prospective analysis of inter-observer and intra-observer variability in multi ultrasound descriptor assessment of thyroid nodules

Aim: The aim of this study was to evaluate the inter- and intra-observer variability and accuracy of ultrasound assessment of thyroid nodules using a descriptive lexicon. Materials and methods: A prospective study was performed on complete ultrasound examinations, including sonoelastography and color Doppler ultrasound of 18 patients with 20 thyroid nodules. A total of 20 records of thyroid nodules from these techniques were duplicated, numbered, and randomly arranged. Five radiologists assessed the recordings independently. Cohen Kappa and Fleiss Kappa statistics were used to determine the degree of intra- and inter-observer agreement. Results: Mean accuracy rates for all radiologists, for all ultrasound features, ranged from 82.7 to 87.8%. For B-mode and strain elastography, accuracies ranged from 65.0 to 100% and 47.4 to 86.8%, respectively. Concerning intra-observer variability, three radiologists demonstrated almost perfect agreement (the κ-value ranged from 0.81 to 0.86), and a substantial agreement was noted for the two remaining radiologists. The κ-values for inter-observer agreement ranged from 0.61 for macrocalcifications (substantial agreement) to 0.33 for Asteria four-point elastography scale criteria (fair agreement). Conclusions: The results suggest relatively good inter-observer and excellent intra-observer agreement in the assessment of thyroid nodules using ultrasound, and fair agreement in the case of strain elastography.

Integration of Sonoelastography Into the TIRADS Lexicon Could Influence the Classification

Aim: Numerous TIRADS (Thyroid Image Reporting and Data System) classifications have been developed, and various ultrasound (US) parameters are employed in different countries. The aim of our study was to introduce risk classification and management in a native population based on the Guidelines of Polish National Societies Diagnostics and Treatment of Thyroid Carcinoma but with the addition of sonoelastography. Materials and Methods: We examined prospectively 208 patients with 305 thyroid lesions employing B-mode ultrasound and sonoelastography (SE). Nodule composition, echogenicity, margins, shape, presence or absence of calcifications, thyroid capsule, nodule size were assessed using B-mode ultrasound. Moreover, sonoelastography results were presented using the Asteria scale. Results: In univariate analysis, the following US features were significantly associated with malignancy: >50% solid /solid component, marked hypoechogenicity, ill-defined margins, micro and macrocalcification, taller-than wide shape, no/partial halo pattern, infiltration of the capsule and an Asteria score of 4. Multivariate logistic regression analysis of B-mode features revealed that ill-defined margins (OR 10.77), markedly hypoechogenicity (OR 5.12), microcalcifications (OR 4.85), thyroid capsule infiltrations (OR 3.2), macrocalcifications (OR 3.01), and hard lesion in SE (OR 6.85) were associated with a higher Odds Ratio (OR) for malignancy. Multivariate logistic regression analysis revealed that combining two features increases the OR and the best combination was irregular margins and Asteria scale 4 (OR 20.21). Adding a third feature did not increase the OR. Conclusions: Sonoelastography increases the value risk of predicted malignancy, with consequent different approach to further clinical investigation and management. A solitary feature (Asteria 4) in a solid tumor can result in its categorization as TIRADS 4, but coexistence with high risk features allows it to be upgraded to TIRADS 5. The irregular margin was the strongest single feature which allowed for the assignment of a solid tumor into TIRADS 5 category. The highest accuracy was found by combining the features of age, margin, echogenicity (markedly hypoechoic), capsule infiltration, microcalcifications and sonoelastography (Asteria 3,4) of the tumors.

Safety and efficacy of two starting doses of vandetanib in advanced medullary thyroid cancer

Vandetanib is an oral tyrosine kinase inhibitor approved for treatment of advanced symptomatic or progressive medullary thyroid cancer (MTC). The current study (Nbib1496313) evaluated the benefit-risk of two starting doses of vandetanib in patients with symptomatic or progressive MTC. Patients were randomized 1:1 to receive vandetanib 150 or 300 mg daily and followed for a maximum of 14 months (Part A), with the option to then enter an open-label phase (Part B) investigating vandetanib 100, 150, 200 and 300 mg daily doses. Efficacy was assessed in Part A, and safety and tolerability during Parts A and B up to 2 years post randomization. Eighty-one patients were randomized in Part A and 61 patients entered Part B, of whom 37 (60.7%) received 2 years of treatment. Overall, 25% of patients experienced an objective response (OR) at 14 months (OR rate, 0.29 (95% CI, 0.176-0.445) for 300 mg, and 0.20 (95% CI, 0.105-0.348) for 150 mg; one-sided P value approximately 0.43). The most common adverse events (AEs) included diarrhea, hypocalcemia, asthenia, QTc prolongation, hypokalemia and keratopathy, all at generally higher incidence with 300 vs 150 mg (Part A). Part B safety and tolerability was consistent with Part A. OR was observed with both vandetanib doses; the 300 mg dose showed a more favorable trend vs 150 mg as initial dose. Thus, for most patients, 300 mg vandetanib is the most appropriate starting dose; dose reductions to manage AEs and lower initial doses for patients with particular comorbidities can be considered.

Guidelines of Polish National Societies Diagnostics and Treatment of Thyroid Carcinoma. 2018 Update

Significant advances have been made in thyroid can-cer research in recent years, therefore relevant clinical guidelines need to be updated. The current Polish guidelines "Diagnostics and Treatment of Thyroid Carcinoma" have been formulated at the "Thyroid Cancer and Other Malignancies of Endocrine Glands" conference held in Wisła in November 2015 [1].

Postoperative hypoparathyroidism in patients after total thyroidectomy - retrospective analysis

OBJECTIVES

Hypoparathyroidism is the most frequent complication of thyroidectomy. The incidence rates of temporary and permanent postoperative hypoparathyroidism vary from 7 to more than 60% and from 0 to 9%, respectively.

DESIGN

The aim of the study has been to evaluate the incidence of hypoparathyroidism and clinical manifestations of hypocalcaemia after total thyroidectomy, as well as assess factors that affect the frequency of the symptomatic hypocalcaemia, and benefits resulting from the measurement of parathyroid hormone (PTH) concentration on the first day after thyroidectomy.

SETTING

The studied group consisted of 330 patients after total thyroidectomy, while the control group consisted of 86 patients who underwent total resection of one lobe only or subtotal thyroidectomy.

RESULTS

Based on the measurements of serum PTH concentration on the first day after total thyroidectomy, postoperative hypoparathyroidism was diagnosed in 48% of patients. After total thyroidectomy, the frequency of clinical symptoms of hypocalcaemia was twice less than the incidence of hypoparathyroidism confirmed by biochemical testing. Total thyroidectomy occurred to be an independent factor of the increased risk of postoperative hypoparathyroidism. This risk was even higher in the cases widened by lymphadenectomy, and among patients with Graves' disease. In the group of patients with decreased serum PTH concentration the occurrence of clinical symptoms of hypocalcaemia significantly depended on serum PTH concentration - patients with lower PTH levels reported paresthesias more frequently.

CONCLUSIONS

Serum PTH levels below 5 pg/ml seems to be a good prognostic factor of the occurrence of hypocalcaemia symptoms. The information about low PTH concentration allows to start the pharmacotherapy faster and avoid clinical manifestation of hypocalcaemia.

Diagnostics and Treatment of Thyroid Carcinoma

Revised Guidelines of Polish National Societies Prepared on the initiative of the Polish Group for Endocrine Tumours approved in their final version between November 16th and 28th, 2015 by the Scientific Committee of the V Conference "Thyroid Cancer and other malignancies of endocrine glands" organised between November 14th and 17th, 2015 in Wisla, Poland; called by the following Societies: Polish Endocrine Society, Polish Society of Oncology, Polish Thyroid Association, Polish Society of Pathologists, Society of Polish Surgeons, Polish Society of Surgical Oncology, Polish Society of Clinical Oncology, Polish Society of Radiation Oncology, Polish Society of Nuclear Medicine, Polish Society of Paediatric Endocrinology, Polish Society of Paediatric Surgeons, Polish Society of Ultrasonography Gliwice-Wisła, 2015 DECLARATION: These recommendations are created by the group of delegates of the National Societies, which declare their willingness to participate in the preparation of the revised version of the Polish Guidelines. The members of the Working Group have been chosen from the specialists involved in medical care of patients with thyroid carcinoma. Directly before the preparation of the Polish national recommendations the American Thyroid Association (ATA) published its own guidelines together with a wide comment fulfilling evidence-based medicine (EBM) criteria. ATA Guidelines are consistent with National Comprehensive Cancer Network (NCCN) Recommendation. According to the members of the Working Group, it is necessary to adapt them to both the specific Polish epidemiological situation as well as to the rules referring to the Polish health system. Therefore, the Polish recommendations constitute a consensus of the experts' group, based on ATA information. The experts analysed previous Polish Guidelines, published in 2010, and other available data, and after discussion summed up the results in the form of these guidelines. It should be added that Part II, which constitutes a pathological part, has been available at the website of the Polish Society of Pathologists for acceptance of the members of the Society, and no essential comments have been proposed. The Members of the Group decided that a subgroup elected from among them would update the Guidelines, according to EBM rules, every year. The Revised Guidelines should help physicians to make reasonable choices in their daily practice; however, the final decision concerning an individual patient should be made by the caring physician responsible for treatment, or optimally by a therapeutic tumour board together with the patient, and should take into consideration the patient's health condition. It should be emphasised that the recommendations may not constitute a strict standard of clinical management imposed on medical staff. The data from clinical trials concerning numerous clinical situations are scarce. In such moments the opinion of the management may differ from the recommendations after considering possible benefits and disadvantages for the patient.

Diagnostic Performance of Shear Wave Elastography Parameters Alone and in Combination with Conventional B-Mode Ultrasound Parameters for the Characterization of Thyroid Nodules: A Prospective, Dual-Center Study

The aims of our study were to determine whether shear wave elastography (SWE) can improve the conventional B-mode differentiation of thyroid lesions, determine the most accurate SWE parameter for differentiation and assess the influence of microcalcifications and chronic autoimmune thyroiditis on SWE values. We examined 119 patients with 169 thyroid nodules who prospectively underwent B-mode ultrasound and SWE using the same ultrasound machine. The parameters assessed using SWE were: mean elasticity within the entire lesion (SWE-whole) and mean (SWE-mean) and maximum (SWE-max) elasticity for a 2-mm-diameter region of interest in the stiffest portion of the lesion, excluding microcalcifications. The discriminant powers of a generalized estimating equation model including B-mode parameters only and a generalized estimation equation model including both B-mode and SWE parameters were assessed and compared using the area under the receiver operating characteristic curve, in association with pathologic verification. In total, 50 and 119 malignant and benign lesions were detected. In generalized estimated equation regression, the B-mode parameters associated with higher odds ratios (ORs) for malignant lesions were microcalcifications (OR = 4.3), hypo-echogenicity (OR = 3.13) and irregular margins (OR = 10.82). SWE-max was the only SWE independent parameter in differentiating between malignant and benign tumors (OR = 2.95). The area under the curve for the B-mode model was 0.85, whereas that for the model combining B-mode and SWE parameters was 0.87. There was no significant difference in mean SWE values between patients with and without chronic autoimmune thyroiditis. The results of the present study suggest that SWE is a valuable tool for the characterization of thyroid nodules, with SWE-max being a significant parameter in differentiating benign and malignant lesions, independent of conventional B-mode parameters. The combination of SWE parameters and conventional B-mode parameters does not significantly improve the diagnosis of malignant thyroid nodules. The presence of microcalcifications can influence the SWE-whole value, whereas the presence of chronic autoimmune thyroiditis may not.

Analysis of clinical significance of equivocal thyroid cytology with a special consideration for FLUS category - five years of new classification of FNA results

INTRODUCTION

The diagnostic category of follicular lesion of undetermined significance (FLUS) was intended to allow selection of cases with low risk of malignancy from all smears with indeterminate, suspicious cytology (ISC), which can potentially take advantage from repeat fine-needle aspiration (rFNA). Aim of the study was a comparison of the risk of malignancy related to FLUS nodules and other nodules with ISC: suspected follicular neoplasm (SFN) and suspected malignancy (SM), as well as analysis of the usefulness of assessing ultrasonographic malignancy risk features (UMRF) in nodules with ISC.

MATERIAL AND METHODS

We analysed UMRF, rFNA, and results of histopathological examination (H) in 441 FLUS, 135 SFN, and 72 SM nodules.

RESULTS

The frequency of exposing cancer in H in FLUS nodules was 5.9%, and when cytological follow up was also included it was 2.9%. rFNAs made the diagnosis more precise in 72.7% of FLUS, and in 5.2% it was diagnosis/suspicion of cancer. The incidence of cancer in SFN nodules was 8.2%, in SM nodules with suspicion of papillary cancer - 61.1%, and in nodules with suspicion of other or unspecified malignancy - 53.8% (p < 0.0001 FLUS vs. both groups). The presence of calcifications is the only independent UMRF for nodules with ISC (OR 4.7). Features of importance are also microcalcifications (OR 3.8), especially in the SM group, and taller-than-wide-shape (OR 2.2). FLUS and SFN nodules are characterised by particularly low value of assessing suspicious margins; analysis of hypoechogenicity is of low value in SFN nodules, like suspected vascularisation in SFN and SM nodules.

CONCLUSIONS

The risk of cancer in FLUS and SFN nodules is lower than in SM nodules. rFNAs of FLUS nodules make the diagnosis more precise in more than 70% of cases and are effective in revealing cancers. UMRFs present variable diagnostic value depending on the subcategory of ISC.

Shear wave elastography in medullary thyroid carcinoma diagnostics

Shear wave elastography (SWE) is a modern method for the assessment of tissue stiffness. There has been a growing interest in the use of this technique for characterizing thyroid focal lesions, including preoperative diagnostics.

AIM

The aim of the study was to assess the clinical usefulness of SWE in medullary thyroid carcinoma (MTC) diagnostics.

MATERIALS AND METHODS

A total of 169 focal lesions were identified in the study group (139 patients), including 6 MTCs in 4 patients (mean age: 45 years). B-mode ultrasound and SWE were performed using Aixplorer (SuperSonic, Aix-en-Provence), with a 4-15 MHz linear probe. The ultrasound was performed to assess the echogenicity and echostructure of the lesions, their margin, the halo sign, the height/width ratio (H/W ratio), the presence of calcifications and the vascularization pattern. This was followed by an analysis of maximum and mean Young's (E) modulus values for MTC (EmaxLR, EmeanLR) and the surrounding thyroid tissues (EmaxSR, EmeanSR), as well as mean E-values (EmeanLRz) for 2 mm region of interest in the stiffest zone of the lesion. The lesions were subject to pathological and/or cytological evaluation.

RESULTS

The B-mode assessment showed that all MTCs were hypoechogenic, with no halo sign, and they contained micro- and/ or macrocalcifications. Ill-defined lesion margin were found in 4 out of 6 cancers; 4 out of 6 cancers had a H/W ratio > 1. Heterogeneous echostructure and type III vascularity were found in 5 out of 6 lesions. In the SWE, the mean value of EmaxLR for all of the MTCs was 89.5 kPa and (the mean value of EmaxSR for all surrounding tissues was) 39.7 kPa Mean values of EmeanLR and EmeanSR were 34.7 kPa and 24.4 kPa, respectively. The mean value of EmeanLRz was 49.2 kPa.

CONCLUSIONS

SWE showed MTCs as stiffer lesions compared to the surrounding tissues. The lesions were qualified for fine needle aspiration biopsy based on B-mode assessment. However, the diagnostic algorithm for MTC is based on the measurement of serum calcitonin levels, B-mode ultrasound and FNAB.

Effect of L-thyroxine treatment on peripheral blood dendritic cell subpopulations in patients with Hashimoto's thyroiditis

Recent reports suggested dendritic cells (DCs) to be important players in the pathogenesis of autoimmune thyroid processes in humans. However, there are virtually no data addressing the influence of thyroid autoaggression-associated disturbances of thyrometabolic conditions on DCs biology. The aim of the study was to evaluate the influence of L-thyroxine supplementation on conventional and plasmacytoid peripheral blood DCs subtypes in patients with hypothyroidism due to Hashimoto's thyroiditis (HT). Eighteen patients with newly diagnosed hypothyroidism due to HT were included into the study. All patients received L-thyroxine treatment with doses adjusted to reach euthyroidism. Peripheral blood DC subtypes structure and immunoregulatory phenotype were analyzed by flow cytometry in the same patient prospectively at two time points: (i) before and (ii) 3 months after beginning of L-thyroxine treatment (hypothyroidism vs. euthyroidism, respectively). Percentage of plasmacytoid DCs in peripheral blood mononuclear cells fraction was significantly decreased in the course of L-thyroxine treatment (0.27 ± 0.19 vs. 0.11 ± 0.08; p < 0.05), whereas we did not observe any changes in the number of conventional DCs. However, the phenotypic analysis showed a significant increase of conventional DCs expressing CD86 and CD91 (64.25 ± 21.6% vs. 86.3 ± 11%; p < 0.05 and 30.75 ± 11.66% vs. 44.5 ± 13.3%; p < 0.05; respectively) in euthyroid patients. Standard L-thyroxine supplementation in HT patients exerted significant immunoregulatory effects, associated with quantitative and phenotypic changes of peripheral blood DC subpopulations.

Patterns of cyclin A and B1 immunostaining in papillary thyroid carcinoma

INTRODUCTION AND OBJECTIVES

Cyclin A, encoded by CCNA (cyclin A) gene with locus in chromosome 4q27, and cyclin B1, encoded by CCNB1 (cyclin B1) gene with locus in chromosome 5q12, are proteins that play a key role in the passage through the restriction point in G2 phase of the cell cycle. The aim of the study was to analyse immunohistochemically the expression of cyclins A and B1 in different variants of papillary thyroid carcinoma (PTC).

MATERIAL AND METHODS

The immunostaining patterns of the proteins in question in the tissue of 40 resected PTC (20 cases of classic variant of PTC, 9 cases of PTC follicular variant and 11 cases of other non-classic variants of PTC) were investigated.

RESULTS

On analyzing cyclin A and B1 expression, positive staining in 90% cases of PTC were observed. The study revealed a significant difference in expression of cyclins A and B1 between classic and non-classic variants of PTC. The expression of both examined cyclins was weaker in the classic variant of PTC. In the group of follicular variant of PTC, the expression of cyclins was of medium intensity and in the group of other non-classic variants of PTC, the expression was clearly higher.

CONCLUSIONS

The results of the presented study suggest that cyclins A and B1 expression may have a characteristic pattern of immunostaining for particular variants of PTC. If the obtained results are confirmed in a larger group of patients, the diagnostic panel constructed of the antibodies against these proteins may increase the diagnostic accuracy in PTC cases.

Lateral spread of heat during thyroidectomy using different haemostatic devices

INTRODUCTION

The presented study is an attempt to comprehensively analyze the lateral spread of heat during thyroidectomy. Obtained results may be valuable in other surgical disciplines in which thermal analysis is difficult or impossible.

OBJECTIVE

The aim of the study was to evaluate the temperature distribution in the operating field during thyroidectomy performed with the use of modern haemostatic instruments, and to define the safety margin for the investigated devices.

MATERIALS AND METHODS

Ninety-three patients were thyroidectomised due to thyroid neoplasm. During all the operations the thermovisual measurements were carried out along with continuous intraoperative neuromonitoring of the recurrent laryngeal nerve (CIONM). Investigated patients were divided into 5 groups, named according to the applied haemostatic technique: LigaSure (N=17); ThermoStapler (N=20); Focus (N=19); SonoSurg (N=17) and Monopolar (N=20).

RESULTS

At maximal performance settings, the highest working temperature was observed for the ThermoStapler, while the lowest temperature was recorded for the Monopolar. Safety margin and working time were increased in Focus and SonoSurg, compared to LigaSure and ThermoStapler. The differences in the necrosis thickness were negligible. The largest distance of the midline of the active blade from isotherm of 42ºC observed in the study was 5.51 mm; none of investigated devices used at a bigger distance had influence on the morphology of the electric signal of CIONM.

CONCLUSION

The thermo-visual camera allows non-invasive, safe, and real-time monitoring and analysis of temperature distribution in the operation area during thyroidectomy. Proposed minimal safety margin for the analysed devices is 5.51 mm.

Continuous intraoperative neuromonitoring (CIONM) of the recurrent laryngeal nerve is sufficient as the only neuromonitoring technique in thyroidectomy performed because of benign goitre

INTRODUCTION

Recently, intraoperative neurophysiological neuromonitoring (IONM) of recurrent laryngeal nerves (RLN) has been evolving quickly. This evolution touched many aspects of the technique, leading to continuous stimulation of the RLN with real time analysis of the electrical signal.

OBJECTIVE

The aim of the study was to estimate the value of continuous intraoperative neuromonitoring (CIONM) as the only technique for intraoperative neuromonitoring in thyroidectomy performed because of benign goitre.

MATERIAL AND METHODS

The study comprised 80 women qualified for thyroidectomy due to nodular goitre. The patients were divided into 4 groups depending on the technique used for RLN integrity verification: group 1 - thyroidectomy with CIONM; group 2 - thyroidectomy with direct, intermittent stimulation of RLN and vagus nerve (NX); group 3 - both CIONM and intermittent stimulation of RLN and NX; group 4 - thyroidectomy without any IONM.

RESULTS

Mean operation time did not differ significantly among the groups with IONM, but was significantly longer in comparison to group 4, as well as the operation's cost. In the analysed groups there was no significant difference in complication ratio.

CONCLUSION

CIONM with RLN visualization in thyroidectomy performed because of benign goitre is as safe as other methods of IONM and gives a continuous confirmation of the electrical integrity of the loop NX-RLN-vocal folds during almost the entire procedure. There is a clinical need for the development of external stimulation of NX (transdermal or trancranial), particularly for minimally invasive techniques in which access to NX is limited (i.e. transoral thyroidectomy).

[Necrotizing gastritis in a patient in severe neutropenia]

One extremely rare complication of chemotherapy for hematologic malignancies that is burdened with a high mortality rate (50%-80%) is necrotizing gastritis and gastric gangrene as result of poor clinical outcome of neutropenic gastritis (NG). We present a unique case of a neutropenic patient with necrotizing full thickness gastritis due to bacterial and fungal infection. Up to date only few such cases have been reported in world literature. A 28-year-old patient was subjected to dose-escalated BEACOPP (bleomycin, etoposide, doxorubicin, cyclophosphamide, vincristine, procarbazine, prednisone), (chemotherapy regimen) for Hodgkin lymphoma. In neutropenic patient abdominal pain, bleeding from the alimentary tract was observed. Hemorrhagic gastritis was recognized at endoscopy and CT demonstrated marked gastric wall thickness. Following NG diagnosis intensive treatment was initiated. On day 2 the patient's condition deteriorated (septic shock, multiple organ failure). Repeat endoscopy revealed gastric necrosis and laparotomy was performed. As consequence of cardiac arrest and cardiopulmonary resuscitation the surgical procedure was limited to total gastrectomy, feeding jejustomy and esophageal drainage through nasoesophageal catherization. Roux-loop esophagojejunostomy was performed on day 22 and supplemented 4 days later by endoscopic placement of covered self-expandable stent due to anastomosis leak. The procedure proved successful and oral feeding was well-tolerated. The patient was discharged in 32 days following recognition of gastric necrosis. Chemotherapy complications in neutropenic patients are life-threatening conditions. Immediate pharmacological treatment usually leads to improvement. Surgical management usually the resection of necrotic zones is restricted to cases of poor prognosis or deterioration of patient's condition and complications.

Thyroid hormones influence human dendritic cells' phenotype, function, and subsets distribution

BACKGROUND

Dendritic cells (DCs) are the most effective antigen-presenting cells and key regulators of immune response. The immunoregulatory properties of DCs strongly depend on the microenvironment in which DCs have been matured and activated. Thyroid hormones are an important part of this environment and regulate many vital processes including growth and cellular metabolism. The aim of the study was an analysis of the influence of thyroid hormones on blood DC subtypes ex vivo, including the surface expression of molecules involved in antigen presentation, costimulation, and maturation, as well as on functional properties of DCs in vitro.

METHODS

Blood samples for the quantitative and phenotypic analysis of peripheral blood plasmacytoid and myeloid DC subtypes were collected from thyroidectomized patients at two time points: (i) at the time of the so-called stimulation with endogenous thyrotropin-a group of hypothyroid patients after l-thyroxine (L-T(4)) withdrawal (pretreatment group)-and (ii) after 2 months of L-T(4) administration for thyrotropin suppression-a posttreatment group. The phenotype of DCs including HLA-DR, costimulatory molecules (CD40, CD80, and CD86), and maturation marker CD83 was assessed by flow cytometry. The influence of isolated peripheral blood DCs on autologous peripheral blood mononuclear cell proliferation and cytokine secretion (interferon alpha, interleukin-12) under triiodothyronine (T(3)) deficiency or T(3) excess was investigated in culture experiments.

RESULTS

The percentage of peripheral blood plasmacytoid and myeloid DCs was higher after L-T(4) administration when compared with the pretreatment group. Moreover, the expression of CD86 on both DC subtypes was higher in the L-T(4) treated than in the hypothyroid patients. In the in vitro experiments, T(3) stimulation increased CD86 expression on cultured DCs. The phenotypic difference was paralleled by enhanced ability of T(3)-stimulated DCs to activate interleukin-12 secretion and proliferation of autologous peripheral blood mononuclear cells (PBMLs) in coculture experiments.

CONCLUSIONS

In the present study, we provide for the first time an evidence that the thyrometabolic status has an influence on the phenotype and function of human peripheral blood DCs. This observation may be of potential importance for the understanding of the pathogenesis of immune and endocrine disorders.

Aberrant methylation as a main mechanism of TSGs silencing in PTC

In the present study the role of tumour suppressor genes (TSGs) hypermethylation and genetic instability of LOH/MSI type in thyroid tumorigenesis was assessed. Expression, methylation status and presence of LOH/MSI were analyzed for 8 TSGs selected from imprinted (IR) and non-imprinted (NIR) chromosomal regions in papillary thyroid carcinomas (PTCs) and nodular goitres (NGs). The results show that methylation-induced gene silencing occurs at an early step of thyroid carcinogenesis and involves multiple genes. Genetic changes of LOH/MSI type are less frequent. In PTC samples, the lack of significant differences in the frequency of LOH in IR and NIR suggests that it is not a key mechanism changing the pattern of gene expression. Co-methylation observed both in NG and PTC raises a possibility that, in thyroid tissue, methylation-induced silencing may occur not only in malignant transformation but also in functional context. We did not recognize any of the studied TSGs - in regard to aberrant methylation status or LOH/MSI frequency - as a selective molecular marker in thyroid tumorigenesis.

Is the PIK3CA gene expression level in FNAB washouts equivalent to that in postoperative tissue specimens of papillary thyroid carcinoma?

INTRODUCTION

Papillary thyroid carcinoma (PTC) is the most common malignant tumor of the thyroid gland. The pathogenesis of PTC remains still mostly enigmatic, although PI3K/PTEN/AKT pathway has been proposed to play a role in development of PTC. Moreover, the significance of genetic analysis in the material from fine-needle aspiration biopsy (FNAB) in PTC patients has recently been demonstrated. Hereby, we present a study analyzing expression of PIK3CA in FNAB washouts of PTC and a comparison of the level of that expression with respective expression in postoperative PTC tissue. Furthermore, we have assessed correlation between tumor size, evaluated according to pTNM scale, and level of PIK3CA gene expression in postoperative PTC tissue.

METHODS

Total RNA was extracted by use of an RNeasy Micro Kit (Qiagen, Hilden, Germany) in FNAB material, and RNeasy Midi Kit (Qiagen, Hilden, Germany) in tissue material. The purity of total RNA was assessed by NanoDrop® ND-100 spectrophotometr. One hundred nanograms of total RNA were used in the first strand cDNA synthesis with TaqMan® Reverse Transcripton Reagents (Applied Biosystems, Branchburg, New Jersey, USA). The gene expression level of PIK3CA was analyzed by real-time PCR in the ABI PRISM ®7500 Sequence Detection System in the 21 (17 women, 4 men) FNAB and 20 (16 women, 4 men) postsurgical specimens of PTC. pTNM staging of PTC was assessed based on UICC classification.

RESULTS

Overexpression of PIK3CA was confirmed in FNAB washout specimens and in postoperative tissues of PTC, in comparison to macroscopically unchanged thyroid tissue. Furthermore, statistically significant differences in PIK3CA gene expression levels between both examined groups were not confirmed. Moreover, correlation between pTNM staging and level of PIK3CA gene expression in PTC samples was not found.

CONCLUSION

The genetic analysis of overexpression of PIK3CA in FNAB washout specimens may be equivalent of postsurgical PTC tissue. A possibility of its future clinical application in FNAB specimens - adequate or undetermined for cytological analysis - awaits for evaluation. The level of expression of PIK3CA is independent of primary thyroid tumour size, evaluated according pTNM scale.

Metastases of breast cancer to the thyroid gland in two patients - a case report

INTRODUCTION

Metastatic cancer is rarely found in the thyroid (only 2-3% of malignant tumours found in that gland); primary sources usually including breast, kidney, and lung tumours.

CASES REPORTS

Two cases of advanced breast cancer with thyroid metastases in female patients are presented. The similarities between these two cases included: 1) postmenopausal age; 2) diagnosis based on result of FNAB (numerous groups of cells with epithelial phenotype strongly implying metastatic breast cancer); 3) thyroid function - overt hyperthyroidism in the first woman and subclinical hyperthyroidism in the second one; 4) the presence of nodular goitre in clinical examination, the occurrence of many nodular solid normoechogenic lesions with calcifications in both thyroid lobes in US; and 5) negative antithyroid antibodies. The main difference was the time of establishing diagnosis; in the first woman - before mammectomy, parallel to diagnostics of breast tumour, and in the second woman four years after mammectomy, during cancer dissemination (with right pleural effusion and lung metastasis). In the first case, mammectomy was followed two weeks later by thyroidectomy. The second patient was disqualified from thyroid surgery due to systemic metastatic disease.

CONCLUSIONS

1. Fine needle aspiration biopsy of the thyroid gland should obligatorily be performed in patients with breast cancer and nodular goitre, even without any clinical data of metastatic disease. 2. The clinical context of cytological findings is of critical value. 3. In patients with breast cancer accompanied by multinodular goitre, we recommend that more punctures be performed during FNAB than is routinely done. (