CAN WE IDENTIFY HIGH DIFFERENTIATED CANCER IN THYROID ULTRASOUND IMAGING?

Primary diagnostics of thyroid neoplasms remains actual issue of modern endocrinology. Comprehensive clinical examination, ultrasound, and fine needle biopsy enable to make a conclusion about thyroid nodule properties but with a lot of mistakes, and take much time. Aims: assessment of diagnostic value of ultrasound criteria those may direct at papillary thyroid cancer. Materials and methods: one carried out observation multicenter retrospective continuous research among patients undergone for thyroid nodules surgery. It included adult patients (18-78) of both sexes. Patients’ case reports within 2013-2019 were sampled. Patients were shared into 2 groups according to final histological results. Results: the objects of research were 124 in-patients’ case reports. 32 of them were diagnosed thyroid cancer (24 - papillary, 8 – follicular), and 92 – benign nodules. Among searched criteria all (except hypoechogenicity) evidently differed between benign nodules and papillary cancer. In comparison criterion «absence of thin halo» reached the upper border of evidence of suspicion for papillary cancer. Multiple comparison indicated statistical difference between benign nodules (p<0,001) and follicular cancer (p<0,05). 2 of 24 papillary cancer patients (9%) in ultrasound did not demonstrate any criterion; all after this were arranged to benign nodules. 21 of 24 patients (88%) with 2 and more positive criteria were assessed correctly, but 51 of 92 benign nodules (56%) in ultrasound were assessed as papillary cancer. Conclusions: ultrasound imaging accuracy in thyroid papillary cancer is approximately equal in presence of 2 to 4 criteria; maximum accuracy (74%) is reached in presence of 3 criteria. In presence of 1 or 5 criteria is significantly lower: in 1 criterion due to low specificity, in 5 criteria – due to rarity of simultaneous combination. Follicular cancer can’t be identified in ultrasound imaging.

DIAGNOSTICS AND TREATMENT OF PATIENTS WITH SUBCLINICAL FORMS OF HORMONAL-ACTIVE ADRENAL TUMORS

The increased incidence of accidental revealing adrenal tumors in radiation studies requires further improvement of laboratory diagnostic methods for the timely detection of their latent hormonal activity and malignancy potential, as well as the determination of strategic therapeutic approaches. The aim of the work was to evaluate the capabilities of modern laboratory diagnostics in verification of latent forms of hormone-active adrenal tumors to determine further treatment tactics. The study included 207 (14.9%) of 1390 patients in whom the hormones precursors of steroidogenesis and catecholamine metabolites were studied in blood plasma by liquid chromatography, as well as tumor markers. These patients were divided into a group of subclinical forms of hormone-active NP tumors (n = 173) and a group of truly hormone-inactive formations (n=34). It has been established that pre-aldosteroma is characterized with an increase of corticosterone (8.1±3.4 ng/ml), 11-deoxycorticosterone (12.3±3.0 ng/ml), 18-hydroxycorticosterone (5.4±1,4 ng/ml) in blood. For pre-corticosteroma: increased cortisol (119.2±16.1 ng/ml), 11-deoxycortisol (11.5±1.9 ng/ml), 11-deoxycorticosterone (12.8±2.1 ng/ml), the ratio of cortisol/cortisone (9.1±1.6 ng/ml) in blood. The presence of «silent» pheochromocytoma was confirmed by an increase of blood free methanephrine (105.0±27.1 ng/ml) and normetanephrine (196.0±43.6 ng/ml), as well as chromogranin A (223.3±15.3 pg/ml). The latent forms of adrenocortical cancer were characterized by an increase in blood dehydroepiandrosterone sulfate (45.2±3.9 μmol/L), cancer embryo antigen (9.8±1.2 ng/ml), vascular endothelial growth factor (1122.0±24.5 ng/ml), IL-6 (95.4±1.8 pg/ml), 11-deoxycortisol (21.8±4.5 ng/ml), 11-deoxycorticosterone (4.2±3.2 ng/ml). All 173 patients with hormone-active NP tumors, as well as 30 (88.2%) with large (6.5±2.0 cm) hormone-inactive formations with the presence of compression syndrome, underwent adrenalectomy. Determination of the precursors of steroidogenesis and catecholamine metabolites in blood plasma by liquid chromatography can reliably identify the functional activity of adrenal tumors and determine their malignant potential, as well as substantiate indications for timely surgical treatment.

HYPOCALCEMIA AFTER PARATHYROIDECTOMY

The aim of the study was to estimate the frequency and timing of hypocalcemia after surgical treatment for primary, secondary and tertiary hyperparathyroidism. Materials and methods. 21 patients were operated for hyperparathyroidism, 15 - for primary (group 1), 6 - for secondary and tertiary (group 2). In I group the median baseline level of total serum calcium was 3.06 mmol/l, phosphorus0.9 mmol/l, and parathyroid hormone360 pmol/l. In II group all patients were on program dialysis for end-stage chronic kidney failure for at least five years. The median baseline serum total calcium level was 2.29 mmol/l, phosphorus2.64 mmol/l, and parathyroid hormone-1822 pmol/l. Results. A day after removal of the parathyroid adenoma (1 group) the level of calcium and phosphorus was normalized, the content of parathyroid hormone (median 21.4 pmol/l) significantly decreased. In one case (6.7%) on the fifth day there were clinical signs of hypocalcemia and the level of calcium decreased to 1.86 mmol/l. All patients of the second group underwent subtotal parathyroidectomy. After a day the level of parathyroid hormone significantly decreased (median227 pmol/l). The phosphorus content has returned to normal. The calcium level in all cases exceeded 2 mmol/l. On day 4-5 the total calcium content decreased and ranged from 1.14 mmol/l to 2.04 mmol/l. Four patients (66,7%) showed clinical signs of hypocalcemia. It was found that the development of hypocalcemia has a positive correlation of average value with the level of parathyroid hormone, phosphorus and negative with the content of calcium before surgery. Conclusion. The decrease in the level of total calcium with the development of clinical symptoms occurs on 4-5 days after surgery for primary hyperparathyroidism in 6.7% and for secondary or tertiary - in 66.7%. Risk factors for hypocalcemia are the baseline low level of calcium and high of parathyroid hormone, phosphorus.

PARATHYROID CARCINOMA WITH INTRATHYROID LOCATION: CASE FROM PRACTICE

Carcinoma of the parathyroid gland is a rare malignant tumor of the person, which manifests itself clinical syndrome of hyperparathyroidism. The tumor is characterized by structural signs of invasive growth and is characterized by an unfavorable clinical prognosis, often accompanied by metastasis and the formation of relapses. The article provides background information about the incidence of parathyroid carcinoma, the gender and age characteristics of patients with this disease, options for localization of the tumor in the gland itself (typical topic of the neoplasm), in other areas of the neck, thyroid, thymus, and so on. We discuss the features of clinical manifestations of parathyroid carcinoma, among which the most typical are manifestations of hyperparathyroidism and hypercalcemia, and also provide figures for five - and ten-year survival. The article presents the author’s observation of parathyroid carcinoma with an intrathyroid location in a 64-year-old man. After the examination, the patient underwent a cervicotomy with revision of the areas of the typical location of the parathyroid gland in the neck, hemithiroidectomy on the left with a parathyroid tumor incorporated in the thyroid tissue, which was later proved using immunohistochemical research methods. The article details the macroscopic, microscopic, and immunohistochemical characteristics of the operating material. A special feature of the case is a rare atypical intrathyroid localization of parathyroid carcinoma.

HYPERLACTATEMIA IN TREATMENT OF DIABETES TYPE 2 BY METFORMIN

It was previously found that when it is treated type 2 diabetes mellitus (DM2) by metformin, hyperlactemia does not develop or occurs extremely rarely, and due to concomitant pathology. Clinicians usually do not monitor blood lactate levels. Goal: to analyze the frequency of hyperlactatemia in patients with DM2, its possible causes and role in this of metformin, clinical manifestations, ways of elimination and prevention. We observed in the dynamics of 38 patients with DM2 receiving metformin in doses of 1500–3000 mg / day. All patients were tested the level of lactate in the blood. Hyperlactatemia was detected in 6 cases (12.8% of patients), of which two patients (5.3%) showed lactic acidosis: the blood lactate level of them was 4.0 μmol/L and 4.6 μmol/L. A correlation between the level of lactic acid and the dose of metformin has not been established. All observed patients had polymorbidity and compelled polypharmacy. Hypothyroidism was observed in 42.1% of patients; in patients with lactic acidosis hypothyroidism was decompensated, i.e. it was chronic oxygen starvation of tissues. Conclusion: Observations confirmed that treatment of DM2 with metformin is rarely complicated by lactic acidosis and even moderate hyperlactatemia. Complications of diabetes, concomitant pathology and compelled polypharmacy, including metformin, disrupt the metabolism of lactic acid, its elimination, utilization in gluconeogenesis processes; in ≈12.8% of cases, the level of lactate in the blood rises. The risk of lactic acidosis, i.e. death threat occurs in ≈5.3% of patients. Along with the etiological factors of lactic acidosis widely presented in publications in patients with type 2 diabetes mellitus, in ≈42.1% of cases, lactate accumulation is promoted by hypothyroidism, the decompensation of which creates chronic oxygen starvation of tissues. To check periodically the level of lactic acid and monitor the function of the thyroid gland it is necessary in all patients with DM2, even if they are not treated with metformin.

METHOD FOR DESIGNING SURGICAL ACCESS FOR ADRENALECTOMY USING 3D-MODELING

In the literature, insufficient attention is paid to the preoperative planning of the approach to adrenal glands using the modern capabilities of computed tomography (CT) navigation. The aim of the work was to demonstrate the possibilities of designing safe access for adrenalectomy using three-dimensional printed models based on preoperative CT data. The possibilities of preoperative access design for edrenalectomy were studied in 362 adrenal tumor patients who underwent CT imaging on Aquillion 64 (Toshiba, Japan), followed by post-processor image processing, construction of multi-plane and 3D reconstructions. All patients were divided into retrospective (n=157) and prospective (n=205) groups. In 3 clinical cases, preoperative access design was supplemented by the creation of a three-dimensional printed model of the adrenal gland with a tumor using the Slicer 4.10.1 software. Reliable anthropometric (body mass index, body shape) and CT-criteria for designing surgical access to the left and right adrenals were determined: diameter of formation; tumor syntopy in relation to the walls of the inferior vena cava; the length of the central adrenal vein and the place where it flows into the inferior vena cava; the location of the tumor relative to the inferior vein of the right lobe of the liver, as well as relative to the gate of the right kidney; location near the aortic-renal vascular triangle, gate of the left kidney and spleen vessels. Three patients with a borderline number of risk criteria for the development of vascular complications associated with the technical difficulties of adrenalectomy (for right adrenals≥4, for left adrenals≥3) underwent CT-segmentation of images with the subsequent creation of three-dimensional plates - a model of an NP tumor with neighboring organs and vessels. Preoperative CT design of the approach, taking into account the risk criteria for complications and the use of 3-D printed models, can reasonably apply endoscopic and open options for adrenalectomy, significantly improving the immediate results of treatment of patients.

THE PREVALENCE OF MODIFIABLE RISK FACTORS IN THE POPULATION AND IN PATIENTS WITH DIABETES MELLITES, INCLUDING DIABETIC FOOT SYNDROME

Goal of work - identify modifiable risk factors for chronic non-infectious diseases in patients with type 2 diabetes mellitus and in the formation of diabetic foot syndrome. Material and methods. A comparative medical and social study was conducted - a survey of patients in clinics of the city of Perm, suffering and not suffering from diabetes. The study involved 230 people who were assigned according to the presence/absence of diabetes mellitus. The first group included 178 patients with an average age of 45.8 (30.0; 59.0). The second group included 27 patients with diabetes mellitus, with an average age of 61.7 years (50.0; 62.0). The third group included 25 patients with diabetic foot syndrome, whose average age was 64.72 years (61.0; 69.0). Women predominated in all groups. Original and generally accepted questionnaires were used to study the presence of common risk factors for chronic diseases among respondents. Results. The analysis of the studied materials showed a clear qualitative and quantitative pattern of accumulation of risk factors in the age exponent. Most risk factors tend to grow up to 54-65 years. Risk factors such as smoking, alcohol abuse, poor nutrition and overweight, depression and hypertension predominate (р<0,05) in older age groups of respondents. In patients with diabetes mellitus, low physical activity, poor nutrition, and obesity predominate (р<0,05). In patients with diabetic foot syndrome, the same risk factors were identified as in patients without this pathology. At the same time, in respondents with diabetic foot syndrome, physical activity was minimal, and body mass index values were much higher (р<0,05); in addition, patients with diabetic foot syndrome are more likely (р<0,05) to be depressed and perceive their health as «very poor.»

INDICATIONS FOR SURGERY AND TECHNICAL PECULIARITIES OF THYROIDECTOMY IN PATIENTS WITH RETROSTERNAL GOITER

The paper is devoted to determining the frequency, features of the clinical course and technique of safe thyroidectomy in patients with retrosternal goiter. Materials and methods. We analyzed the treatment of 26 patients with retrosternal goiter. All patients underwent the neck-approach thyroidectomy with the identification of the recurrent laryngeal nerve during surgery. Results. It was found that patients with Graves’ disease did not have retrosternal goiter, with mixed toxic goiter the frequency was 13.7%, with nodular euthyroid goiter – 26.1%. In 11.5% of patients with retrosternal goiter, the diagnosis was made by chest x-ray, in 76.9% - by ultrasound imaging, in 19.2% - by CT imaging. Of the 26 patients, 1 (3.8%) was hospitalized urgently due to respiratory failure and compression syndrome, and 25 (96.2%) were admitted as planned. Operations in 25 (96.2%) were performed under endotracheal, in 1(3.8%) – under mask anesthesia. Intraoperatively, it was found that the location of the recurrent laryngeal nerve changed in the case of chest goiter that required special care when mobilizing the posterior surface of the thyroid gland from the trachea in the zone of the lower thyroid artery and in Berry ligament. Technical manipulations aimed at preventing damage to the recurrent laryngeal nerve at different stages of thyroidectomy are proposed. Conclusion. The results of operations in patients with substernal goiter show that if it is carefully performed and the recurrent laryngeal nerve is preserved, the postoperative period does not differ from that in the usual location of the thyroid gland and even relieves, since the compression syndrome is eliminated.

RARE COMPLICATION OF SURGICAL TREATMENT OF THYROID CANCER

Thyroid cancer is the leading cancer in the endocrine system. Over the past few decades, the incidence of this pathology worldwide has increased at a higher rate than other cancers. The main method of treatment for thyroid cancer is surgical. Some of the complications that can result from surgical treatment are tracheomalacia and trachea damage. Tracheomalacia is a pathological softening of tracheal rings resulting from prolonged compression of the trachea resulting in degenerative changes in cartilages. As a result of the removal of the thyroid tumor, a defect of its wall may form. Damage of the trachea can occur when the thyroid isthmus is separated from it. In addition, when separating the thyroid gland from the trachea, performing central lymphodissection, the blood supply of the trachea may be disturbed, which is carried out according to the segmental type, characterized by a lack of the number of collaterals. There is presented a clinical case of successful treatment of a rare complication after thyroid surgery for papillary cancer in the form of trachea in a patient of 49 years. By analyzing the clinical example, taking into account the macroscopic picture of trachea defects, their location and dimensions, it is possible to assume segmental disorder of blood supply of the upper third of the trachea in the postoperative period with the development of ischemic changes and regions of necrosis of ring ligaments. In order to prevent such complications in thyroid operations, it is necessary to preserve the paratracheal vascular anastomotic network by carefully preparing the tracheal branches of the lower thyroid artery.

CHOICE OF THE METHOD OF SURGERY IN PATIENTS WITH A SINGLE THYROID FOLICULAR TUMOR

Due to modern methods, revealing follicular neoplasia became possible at the stage when it is small. This fact contributes to the search for surgical organ-saving interventions. Goal: to substantiate the choice of the optimal treatment tactics for patients with a single follicular thyroid tumor to improve the results of treatment and the quality of life of patients undergoing surgery. Material and methods. The basis of the study was an analysis of the results of the examination and treatment of 376 patients who were given a conclusion “follicular neoplasia” during cytological examination of thyroid biopsy sample. Based on the ultrasound data, volumetric nodular mass and thyroid parameters were calculated. All patients were divided into 2 groups. The first group of patients underwent hemithyroidectomy, the second group of patients underwent resection of the thyroid lobe with a nodulus. Results. In patients of group I, up to 56.0±9.6% of unaffected thyroid tissue is removed, while in group II, 2.7±1.8% of intact parenchyma is removed. Thus, we can conclude that hemithyroidectomy foresees removal of more than 50% of sound thyroid parenchyma is removed. In patients where the volume of the node occupies less than 40% of the thyroid lobe, it is advisable to perform resection of the lobe without replacement therapy after surgery. Conclusion. A comparative analysis between the study groups showed the advantages of resection of the lobe with the tumor over hemithyroidectomy. This primarily leads to higher quality of life after surgery.