Isthmusectomy for well-differentiated thyroid carcinoma located to the isthmus: A report of two cases and review of the literature

Papillary thyroid cancer is the most common endocrine malignancy, and due to its favorable prognosis, the extent of surgery has been a matter of debate. About 10% of these tumors are located in the thyroid isthmus, with no specific management in current guidelines. In the last decades, isthmusectomy has been proposed as a therapeutic option for isthmic papillary thyroid carcinoma, although there is no consensus on its management. We present two cases of patients from our institution with solitary isthmic papillary thyroid carcinoma without clinical macroscopic extrathyroidal extension or clinical-radiological lymph node involvement who were treated with isthmusectomy without prophylactic lymph node dissection. Neither of them had any postoperative complications. Both had an intermediate risk of recurrence due to aggressive variants. None of them had signs of recurrence during follow-up. We intend to show that isthmusectomy seems to be an effective and safe surgical alternative in selected patients through these cases.

“RARE TUMOUR OF THE HAND: MALIGNANT ACROSPIROMA OF THE HAND“

Background: Malignant acrospiroma is among one of the rare tumors of the eccrine sweat glands. It accounts for around 6% of all malignant eccrine tumors. It typically presents as large ulcerated nodules, and diagnosis can be challenging as it has great overlap with its benign counterpart. There are limited cases reported for hand acrospiroma’s. Case presentation: We report a case of malignant acrospiroma presenting as swelling which was treated with surgical excision. The patient was referred to oncosurgery for chemoradiaton. Conclusion: Wide surgical excision, with or without prophylactic lymph node dissection, is the treatment of choice. Evidence is lacking on the efficacy and/or advised regimen of chemoradiotherapy. Prognosis is poor with systemic disease. More studies are needed for the management of this disease.

Prophylactic lymph node dissection in clinically N0 differentiated thyroid carcinoma: example of personalized treatment

Considering the ‘differentiated thyroid carcinoma (DTC) epidemic’, the indolent nature of DTC imposes a treatment paradigm shift toward elimination of recurrence. Lymph node metastases in cervical compartments, encountered in 20–90% of DTC, are the main culprit of recurrent disease, affecting 5–30% of patients. Personalized risk-stratified cervical prophylactic lymph node dissection (PLND) at initial thyroidectomy in DTC with no clinical, sonographic or intraoperative evidence of lymph node metastases (clinically N0) has been advocated, though not unanimously. The present review dissects the controversy over PLND. Weighing the benefit yielded from PLND up against the PLND-related morbidity is so far hampered by the inconsistent profit yielded by PLND and the challenging patient selection. Advances in tailoring PLND are anticipated to empower optimal patient care.

An update on the management of low-risk differentiated thyroid cancer

Low-risk papillary cancers, which represent the vast majority of thyroid cancers diagnosed today, do not require aggressive treatment or follow-up. Initial treatment consists of a total thyroidectomy without prophylactic lymph node dissection. A hemithyroidectomy is an alternative in some patients with an intrathyroidal tumor and with a normal contralateral lobe at pre-operative neck ultrasonography. The use of post-operative radioiodine should be restricted to selected patients. Follow-up at 6–18 months is based on serum thyroglobulin (Tg), Tg-antibody determination and neck ultrasonography. In the absence of any abnormality (excellent response to treatment), the risk of recurrence is extremely low and follow-up may consist of serum TSH monitoring that is maintained in the normal range, and a Tg and Tg-antibody titer determination every year. There is no need for referral to a specialized center. In patients with detectable serum Tg or detectable Tg antibodies, the trend over time of these markers on levothyroxine treatment will dictate subsequent follow-up: a decreasing trend is reassuring, but an increasing trend should lead to imaging, starting with neck ultrasonography.

POSSIBILITIES OF PREOPERATIVE DIAGNOSIS OF IODINE RESISTANCE REGIONAL LYMPH NODES METASTASES OF DIFFERENTIATED THYROID CANCER

Recently, there has been an increase in the incidence and detectability of patients with differentiated thyroid cancer. At the same time in a number of patients in the combined treatment, initially low susceptibility of regional metastases to radioiodine therapy is revealed, or iodine resistance develops during treatment, which significantly worsens the prognosis. The need to identify patients with radioiodine resistance at the preoperative stage to justify the scope of surgical treatment is an extremely important task. Objective of research. The research was developed to examine the possibility of preoperation diagnostics of iodine-refractory regional metastases for in patients with differentiated thyroid cancer. A number of patients with differentiated thyroid cancer develop iodine-refractory regional metastases, which significantly worsens the prognosis. Given contradictory attitude towards prophylactic lymph node dissection in the central neck area and an increase in the number of organ-preserving operations, we have searched for a method of preoperative diagnosis of radioiodine-resistance. Materials and methods. The results of treatment of 67 patients with differentiated thyroid cancer were analyzed, which after radioiodine therapy metastases in cervical lymph nodes were revealed. Depending on the results of post-therapy scintigraphy, patients were divided into two groups: with iodine-positive (n = 32) (first group) and iodine-negative (n = 35) metastases (second group). All patients were operated on again, the presence of metastases was confirmed morphologically, and the expression of the TERT, TG, SLC5, KRT19, KRT5, ERBB2, 2 reference genes GUSB and B2M was analyzed and the status of the BRAF gene (mutation search V600E). Results. When comparing the results of molecular genetic studies in both groups, differences in the average expression of the SLC5 gene (NIS), the frequency of the wild-type BRAF gene, and, in addition, the ratios of the mutant (V600E) and non-mutated alleles of the BRAF gene (p = 0,05; p = 0,013 and p = 0,034). The combination of 5 indicators: the expression level of SLC5, KRT5, ERBB2, the non-mutated status of the BRAF gene, the proportion of the mutant (V600E) / non-mutant alleles of the BRAF gene, predict the probability of resistance of regional metastases to radioiodine - in 90,9% of cases, and in 75,0% of cases - preservation of their ability to fix the radionuclide. The conclusion. The level of SLC5, KRT5, ERBB2 gene expression, the non-mutated status of the BRAF gene, the ratio of the number of mutant (V600E) / non-mutant alleles of the BRAF gene in the biopsy material allow before the operation to predict the effectiveness of the forthcoming radioiodine therapy and, and at supposed resistance radioiodine therapy to form indications to prophylactic lymph node dissection in the central neck area. The possibility of such a prognosis based on the results of a primary tumor study requires further clarification.