ABSTRACT Objective: Our aim was to assess the ability of serum magnesium (Mg), measured on the first postoperative day (Mg1PO), to predict the need for calcium (Ca) replacement in patients undergoing total thyroidectomy (TT). Subjects and methods: Eighty patients undergoing TT, with Mg1PO and PTH dosage in the first (PTH1h) and eighth (PTH8h) hours after TT, were evaluated for the need for Ca replacement. Data were evaluated by uni/multivariate logistic regression and Receiver Operating Characteristic (ROC) curve. Results: 32 patients (40%) required Ca replacement. Median PTH1h, PTH8h and Mg1PO were higher in the no replacement group: 17 versus (vs) 3 pg/mL (p < 0.001), 18.2 vs 3.0 pg/mL (p < 0.001) and 2 vs 1.6 mg/dL (p < 0.001), respectively. Mg1PO was the isolated predictor for this replacement (odds ratio = 0.0004, 95% confidence interval: 0.000003-0.04; p = 0.001), with the cut-off value of 1.8 mg/dL showing sensitivity and specificity of 78.1% and 87.5%, respectively. Conclusions: In this group of patients, serum Mg1PO was the isolated predictor for the need for Ca replacement.

ABSTRACT Objective: Cytological analysis and Bethesda classification of thyroid nodules is the standard method of diagnosing differentiated thyroid carcinoma (DTC). However, even for nodules with a non-malignant cytological diagnosis, there is a not insignificant risk of cancer. There are doubts whether this lack of certainty would influence patient prognosis. Our aim was to compare patients with DTC, classified according to the preoperative cytological diagnosis, regarding their evolution. Subjects and methods: A retrospective study was carried out with 108 DTC patients submitted to total thyroidectomy (TT) between 2009 and 2015, divided into three groups according to preoperative cytological diagnosis (Bethesda classification): classes I/II, III/IV, and V/VI. Groups were compared for evolution considering response to treatment at last evaluation as well as time disease free. Statistical analysis used ANOVA, chi squared, and Kaplan-Meier curves with p<0.05 considered significant. Results: Groups differed for time between nodule puncture and TT [in months; V/VI (2.35 ± 2.48) < III/IV (7.32 ± 6.34) < I/II (13.36 ± 8.9); p < 0.0001]. There was no significant difference between groups for evolution at final evaluation (disease free status; classes I/II: 71.4%; classes III/IV: 60%; classes V/VI: 66.6%; p = 0.7433), as well as time disease free (in months; classes I/II: 34.57 ± 25.82; classes III/IV: 38.04 ± 26.66; classes V/VI: 30.84 ± 26.34; p = 0.3841). Conclusions: DTC patients classified according to preoperative cytological diagnosis did not differ for evolution. Although patients with non-malignant cytological diagnoses were submitted to TT later, this did not affect the evolution of the cases.

Resumo O carcinoma anaplásico da tireoide corresponde ao câncer de menor incidência e de pior prognóstico. Neste relato, descrevemos o caso de uma paciente de 64 anos submetida a tireoidectomia total associada a esvaziamento cervical nível VI devido a carcinoma papilífero de tireoide. No seguimento, apresentou sinais de recidiva regional e foi submetida a esvaziamento cervical ampliado e esofagectomia cervical. No intraoperatório, observou-se ausência de plano de clivagem entre o tumor e a artéria carótida comum (ACC) e procedeu-se com implante de shunt carotídeo, resseção em bloco incluindo segmento da ACC e do esôfago acometidos e ponte vascular com interposição da veia safena magna. Foi evidenciado carcinoma anaplásico em revisão de lâmina do exame anatomopatológico. A paciente foi submetida ao tratamento adjuvante e não apresenta sinais de recidiva locorregional. Diante da possibilidade de proceder uma cirurgia curativa com ressecção em bloco, o cirurgião vascular deve estar apto para as opções cirúrgicas.

Abstract Of all thyroid cancers, anaplastic thyroid carcinoma (ATC) has the lowest incidence and worst prognosis. In this report, we describe a 64-year-old female patient who underwent total thyroidectomy and level VI neck dissection for papillary thyroid carcinoma. During follow-up, she showed signs of regional recurrence and underwent extended neck dissection and cervical esophagectomy. Intraoperatively, there was no cleavage plane between the tumor and the common carotid artery (CCA), so a carotid shunt was implanted and en bloc resection, including the affected CCA and esophagus segments was performed followed by vascular bypass with interposition of a great saphenous vein graft. A pathology review found evidence of anaplastic carcinoma. The patient underwent adjuvant treatment and has no signs of locoregional recurrence. Presented with the possibility of carrying out curative surgery with en bloc resection, the vascular surgeon must be prepared for the surgical options.

ABSTRACT Objective: Thyrotropin-stimulated thyroglobulin (STg) after total thyroidectomy is a prognosis marker for differentiated thyroid carcinoma (DTC). As Tg level is influenced by thyrotropin (TSH), perhaps the STg/TSH ratio is also a prognosis marker for these tumours. We aimed to compare STg/TSH ratio and first STg level in differentiated thyroid carcinoma patients for their ability to predict the long-term response to initial treatment. Subjects and methods: This retrospective study evaluated data from 181 DTC patients for first (1st) STg and STg/TSH ratio, at 1-3 months post-total thyroidectomy and before iodine-131 therapy, according to response to initial therapy [Excellent/Indeterminate or Incomplete (Biochemical/Structural)] observed at final evaluation, and with the survival time with excellent/indeterminate response. Results: Cases with incomplete response presented higher STg level [225.13 ± 585.26 ng/mL versus (vs) 20.4 ± 192.9 ng/mL; p < 0.001] and STg/TSH ratio (3.01 ± 7.8 vs 0.27 ± 2.58; p < 0.001). Cutoffs of 5 ng/mL for STg and 0.085 for STg/TSH displayed sensitivities of 76.7% and 76.9%, and specificities of 79.2% and 82.6%, respectively, in predicting response to therapy. Values below these cutoffs were associated with longer survival time in excellent/indeterminate response (140.4 vs 15.9 and 144.6 vs 15.9 months, respectively). Conclusion: STg/TSH ratio has a similar performance to the 1st STg in predicting long-term response to initial therapy.

Resumo Introdução: A hipocalcemia é uma das complicações mais comuns após a tireoidectomia total. A concentração sérica de vitamina D tem sido apontada como fator de risco para essa complicação. No entanto, o assunto ainda é controverso e o papel da vitamina D na ocorrência de hipocalcemia permanece incerto. Objetivo: Avaliar se os níveis pré-operatórios de vitamina D são capazes de predizer a hipocalcemia pós-tireoidectomia total. Método: Quarenta e sete pacientes com tireoidectomia total foram avaliados prospectivamente quanto aos níveis séricos de 25(OH)vitamina D, cálcio e paratormônio antes da cirurgia, cálcio a cada 6 horas e paratormônio 8 horas após a cirurgia. Os pacientes foram divididos de acordo com o cálcio corrigido no pós-operatório em grupos sem (cálcio corrigido ≥ 8,5 mg/dL) e com hipocalcemia (cálcio corrigido < 8,5 mg/dL), que foram avaliados em relação aos valores pré-operatórios de 25(OH)vitamina D. Resultados: 72,3% dos casos apresentaram concentrações séricas pré-operatórias alteradas de vitamina D- 25 hidroxi e 51% desenvolveram hipocalcemia no pós-operatório. Os grupos com e sem hipocalcemia não diferiram para a 25(OH)vitamina D pré-operatório (p = 0,62). A análise univariada mostrou que a idade (p = 0,03), a concentração de paratormônio no pós-operatório (p = 0,02) e o diagnóstico anatomopatológico de malignidade (p = 0,002) foram preditores de hipocalcemia no pós-operatório. Na análise multivariada, apenas o paratormônio no pós-operatório (p = 0,02) foi associado a hipocalcemia pós-tireoidectomia total. Conclusão: As concentrações séricas pré-operatórias de 25(OH)vitamina D não foram preditores de hipocalcemia pós-tireoidectomia total, enquanto o paratormônio pós-operatório influenciou a ocorrência dessa complicação.

Abstract Introduction: Hypocalcemia is one of the most common complications after total thyroidectomy. Preoperative serum vitamin D concentration has been postulated as a risk factor for this complication. However, the subject is still controversial and the role of vitamin D in the occurrence of hypocalcemia remains uncertain. Objective: To evaluate the capability of preoperative vitamin D concentrations in predicting post-total thyroidectomy hypocalcemia. Methods: Forty-seven total thyroidectomy patients were prospectively evaluated for serum 25(OH) vitamin D, calcium and parathyroid hormone before surgery, Calcium every 6 hours, and parathyroid hormone 8 hours post-operatively. Patients were divided according to postoperative corrected calcium into groups without (corrected calcium ≥8.5 mg/dL) and with hypocalcemia (corrected calcium <8.5 mg/dL), who were then evaluated for preoperative 25(OH) vitamin D values. Results: A total of 72.3% of cases presented altered 25(OH) vitamin D preoperative serum concentrations and 51% evolved with postoperative hypocalcemia. The with and without hypocalcemia groups did not differ for preoperative 25(OH) vitamin D (p = 0.62). Univariate analysis showed that age (p = 0.03), postoperative PTH concentration (p = 0.02), and anatomopathological diagnosis of malignancy (p = 0.002) were predictors of postoperative hypocalcemia. In multivariate analysis only parathyroid hormone in postoperative (p = 0.02) was associated with post-total thyroidectomy hypocalcemia. Conclusion: Preoperative serum concentrations of 25(OH) vitamin D were not predictors for post-total thyroidectomy hypocalcemia, whereas postoperative parathyroid hormone influenced the occurrence of this complication.

Abstract Introduction Laryngeal granulomas are benign, recurrent lesions of many causes (reflux, voice abuse, intubation, and idiopathic), which renders its treatment difficult. Objective To describe our experience in the treatment of laryngeal granulomas. Methods From 16 medical records of the patients with laryngeal granulomas seen between 2010 and 2017 in a university hospital, the following data were analyzed: age, gender, vocal and gastroesophageal symptoms, vocal overuse, intubation, treatments, videolaryngoscopy before and after the treatment. Results Gender: female, 10; male, 6. Age: between 20 and 60 years old (11%). Etiology of the granulomas: intubation (9), reflux (4), idiopathic (3). The initial treatments adopted in all cases were: inhaled beclomethasone dipropionate 100 μg 12/12 hours (1month), proton pump inhibitor, omeprazole 40 mg/day (2months), and dietary and voice education. After this period, 10 patients (7 postintubation, 3 idiopathic) were submitted to surgery, since no improvements in the symptoms or in the lesions were seen. Of these, two recurred, requiring a second surgery, one of which recurred six times and received botulinum toxin A. Only one patient with granulomas due to laryngopharyngeal reflux presented no improvement in the symptoms nor in the lesion after the pharmacological treatment and had been submitted to microsurgery. All of the other patients with reflux granulomas were successfully treated with the drug treatment, and the longest treatment time for complete remission of the symptoms and of the lesions was 9 months. Conclusions In laryngeal granulomas caused by reflux, treatment with inhaled steroids and proton pump inhibitors proved to be effective, although prolonged. In postintubation and idiopathic granulomas, surgery was the best treatment.