Complicaciones post-quirúrgicas en pacientes de 25 a 50 años tiroidectomizados por cáncer de tiroides del Hospital Guayaquil Dr. Abel Gilbert Pontón desde febrero del 2016 a enero 2017
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2017
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Universidad de Guayaquil. Facultad de Ciencias Médicas. Carrera de Medicina
Resumen
La patología maligna tiroidea representa menos de 1% de los cánceres en general, pero el 90% de las patologías malignas endocrinas; ocasiona aproximadamente 0,4% de la mortalidad relacionada al cáncer. Cerca de 20 a 30% de los nódulos tiroideos y 5% de los bocios multinodulares resultan ser malignos. Es más frecuente en mujeres que en varones, relación aproximada de 3 a 1.
La clínica más frecuente es una tumoración palpable, indurada e indolora, de crecimiento rápido. También se pueden presentar disfonía, fijación dérmica del tumor, disnea y disfagia, anorexia, disminución de peso; la función hormonal es variable. Las metástasis son raras e involucran ganglios regionales y luego en pulmones.
Podemos clasificar los procesos malignos de la glándula en primarios y secundarios, siendo los primeros los más frecuentes y de mayor importancia. Las neoplasias primarias se dividen según tengan células parenquimales (epiteliales) o del estroma glandular (fibrosarcomas, linfomas y hemangioendoteliomas malignos).
Entre los tumores epiteliales, tenemos las formas diferenciadas (carcinoma papilar y carcinoma folicular), formas intermedias (carcinoma medular y de células escamosas) y la indiferenciada (carcinoma anaplásico).
Los carcinomas diferenciados corresponden a cerca de 90 a 95% de los carcinomas primarios.
El carcinoma papilar es el más frecuente y de menor agresividad de todos los carcinomas tiroideos, representando 76 a 80% de ellos. En cifras generales, sólo hacen 1,5% de todos los cánceres en adultos y 3% de todos los cánceres en niños. La edad promedio es de 30 a 40 años, aunque 10% se desarrollan en menores de 20 años. Se presenta una relación de 3 a 1 en mujeres frente a varones.
Usualmente es un nódulo solitario indoloro de crecimiento lento, pero puede presentarse también como bocio multinodular; involucra ambos lóbulos tiroideos en un 30%.
Al diagnóstico, 10 a 15% de los pacientes tiene metástasis a los huesos y los pulmones.
Los valores de recurrencia están entre 15 y 25% de los pacientes; sin embargo, la sobrevida es alentadora, 90% a 20 años.
El carcinoma folicular corresponde a 10% de las neoplasias malignas tiroideas, siendo más agresivo que el carcinoma papilar.
La presentación es entre 40 y 50 años y más en mujeres, con una relación de 3 a 1. Se presentan como nódulos solitarios de crecimiento variable, casi siempre indoloros. Raramente producen tirotoxicosis (<1%), debido a que se presentan con mayor frecuencia en lugares con deficiencia de yodo en la dieta.
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Una variante aquí es el carcinoma de células Hürtle, el cual produce tiroglobulina. Son más multifocales o bilaterales y rara vez captan yodo y 25% ya tienen metástasis al diagnóstico.
El carcinoma medular representa entre 4 y 5% de los carcinomas de tiroides. Producen calcitonina con localización en la parte media a superior de los lóbulos tiroideos. No hay diferencia significativa según el sexo, con una relación mujeres-varones de 1,5-1. Cerca de 33% de ellos son familiares, siendo el restante esporádico; en ambas situaciones, se pueden encontrar asociados a la neoplasia endocrina múltiple tipo 2 (NEM-2). La edad típica de presentación en la forma esporádica es entre 50 y 60 años y en la forma asociada a la NEM-2 entre 20 y 30 años.
Son unilaterales en 75% y la mayoría dolorosas, con disfonía, disfagia o disnea. Se asocian también disminución de peso, letargia y dolores óseos, diarrea o síndrome carcinoide. Sólo 1% de los carcinomas tiroideos corresponde al carcinoma anaplásico, siendo la mayoría de ellos originado de un tumor diferenciado.
Tiene igual distribución según el sexo que el carcinoma medular, con mayor incidencia entre 60 y 80 años. Es un tumor de crecimiento indurado y rápido, haciéndolo el más agresivo de todos los carcinomas. Es frecuente el compromiso local, con disfonía, disfagia o disnea; además, presenta metástasis cercanas y a distancia.
Al diagnóstico, 50 a 69% de los pacientes tiene ya adenopatías evidentes.
Dentro de los linfomas, predomina el no Hogdkin de células B, con una presentación cercana al 1% de las neoplasias malignas tiroideas. Confundible con tiroiditis, ya que se presentan luego o durante la tiroiditis de Hashimoto, se muestran como bocio multinodular o difuso, de crecimiento rápido, doloroso.Es más frecuente en mujeres que en varones, principalmente entre los 55 y 75 años.
Los otros tumores malignos son extraordinariamente infrecuentes. Las metástasis tiroideas son infrecuentes y son manifestación tardía de un cáncer no primario de la glándula.
En cuanto al tratamiento, la tiroidectomía es el componente inicial y más importante en el manejo del carcinoma tiroideo, salvo el anaplásico. La tiroidectomía subtotal, con o sin istmectomía según el caso, es adecuada para pacientes con carcinomas no indiferenciados o microcarcinomas; mientras que la tiroidectomía total está indicada para el resto de carcinomas y recidivas locales.
Se debe considerar la terapia posterior con I131, según el grado histológico del tumor y para metástasis sensibles o tejido tiroideo residual, seguida de terapia hormonal. De poseer metástasis ganglionares, se añade la disección radical modificada de cuello.
Thyroid malignancy accounts for less than 1% of cancers in general, but 90% of endocrine malignancies; Causes approximately 0.4% of cancer-related mortality. About 20 to 30% of thyroid nodules and 5% of multinodular goiters turn out to be malignant. It is more frequent in women than in men, approximate ratio of 3 to 1. The most frequent clinic is a palpable, indurated and painless, fast-growing tumor. Dysphonia, dermal tumor fixation, dyspnea and dysphagia, anorexia, weight loss may also occur; The hormonal function is variable. Metastases are rare and involve regional lymph nodes and then in the lungs. We can classify the malignant processes of the gland in primary and secondary, being the first more frequent and of greater importance. Primary neoplasms are divided according to parenchymal cells (epithelial) or glandular stroma (fibrosarcomas, lymphomas and malignant hemangioendotheliomas). Among the epithelial tumors, we have differentiated forms (papillary carcinoma and follicular carcinoma), intermediate forms (squamous cell carcinoma and squamous cell carcinoma) and undifferentiated carcinoma (anaplastic carcinoma). Differentiated carcinomas correspond to about 90 to 95% of primary carcinomas. Papillary carcinoma is the most frequent and least aggressive of all thyroid carcinomas, representing 76 to 80% of them. In general, only 1.5% of all cancers in adults and 3% of all cancers in children make up. The average age is 30 to 40 years, although 10% develop in children under 20 years. There is a 3 to 1 ratio in women compared to men. It is usually a slowly growing painless solitary nodule, but may also present as a multinodular goiter; Involves both thyroid lobes in 30%. At diagnosis, 10 to 15% of patients have metastases to the bones and lungs. Recurrence values are between 15 and 25% of patients; However, survival is encouraging, 90% to 20 years. Aggressive than papillary carcinoma. The presentation is between 40 and 50 years and more in women, with a ratio of 3 to 1. They present as solitary nodules of variable growth, almost always painless. They rarely produce thyrotoxicosis (<1%), because they occur more frequently in places with iodine deficiency in the diet. One variant here is the Hürtle cell carcinoma, which produces thyroglobulin. They are more multifocal or bilateral and rarely capture iodine and 25% have metastases at diagnosis. Medullary carcinoma accounts for 4% to 5% of thyroid carcinomas. They produce calcitonin with a location in the middle to upper part of the thyroid lobes. There is no significant difference according to sex, with a male-to-male ratio of 1.5-1. 11 About 33% of them are relatives, the rest being sporadic; In both situations, may be associated with multiple endocrine neoplasia type 2 (NEM-2). The typical age of sporadic presentation is between 50 and 60 years and in the form associated with NEM2 between 20 and 30 years. They are unilateral in 75% and most painful, with dysphonia, dysphagia or dyspnea. Weight loss, lethargy and bone pain, diarrhea or carcinoid syndrome are also associated. Only 1% of thyroid carcinomas correspond to anaplastic carcinoma, the majority of which originate from a differentiated tumor. It has the same distribution according to sex as the medullary carcinoma, with a higher incidence between 60 and 80 years. It is an inducible and rapid growth tumor, making it the most aggressive of all carcinomas. Local involvement is common, with dysphonia, dysphagia, or dyspnea; In addition, it presents near and distant metastases. At diagnosis, 50-69% of patients already have evident lymphadenopathy. Within the lymphomas, non-Hogdkin B cell predominates, with a presentation close to 1% of thyroid malignancies. Confoundable with thyroiditis, as they occur after or during Hashimoto's thyroiditis, they are shown as multinodular or diffuse goitre, rapidly growing, painful. It is more common in females than in males, mainly between 55 and 75 years. The other malignant tumors are extraordinarily infrequent. Thyroid metastases are infrequent and are late manifestation of non-primary cancer of the gland. As for treatment, thyroidectomy is the initial and most important component in the management of thyroid carcinoma, except for anaplastic carcinoma. Subtotal thyroidectomy, with or without isthmectomy as appropriate, is adequate for patients with undifferentiated carcinomas or microcarcinomas; While total thyroidectomy is indicated for the remaining carcinomas and local recurrences. Further therapy should be considered with I131, depending on the histological grade of the tumor and for sensitive metastases or residual thyroid tissue, followed by hormonal therapy. If you have ganglion metastases, modified radical neck dissection is added.
Thyroid malignancy accounts for less than 1% of cancers in general, but 90% of endocrine malignancies; Causes approximately 0.4% of cancer-related mortality. About 20 to 30% of thyroid nodules and 5% of multinodular goiters turn out to be malignant. It is more frequent in women than in men, approximate ratio of 3 to 1. The most frequent clinic is a palpable, indurated and painless, fast-growing tumor. Dysphonia, dermal tumor fixation, dyspnea and dysphagia, anorexia, weight loss may also occur; The hormonal function is variable. Metastases are rare and involve regional lymph nodes and then in the lungs. We can classify the malignant processes of the gland in primary and secondary, being the first more frequent and of greater importance. Primary neoplasms are divided according to parenchymal cells (epithelial) or glandular stroma (fibrosarcomas, lymphomas and malignant hemangioendotheliomas). Among the epithelial tumors, we have differentiated forms (papillary carcinoma and follicular carcinoma), intermediate forms (squamous cell carcinoma and squamous cell carcinoma) and undifferentiated carcinoma (anaplastic carcinoma). Differentiated carcinomas correspond to about 90 to 95% of primary carcinomas. Papillary carcinoma is the most frequent and least aggressive of all thyroid carcinomas, representing 76 to 80% of them. In general, only 1.5% of all cancers in adults and 3% of all cancers in children make up. The average age is 30 to 40 years, although 10% develop in children under 20 years. There is a 3 to 1 ratio in women compared to men. It is usually a slowly growing painless solitary nodule, but may also present as a multinodular goiter; Involves both thyroid lobes in 30%. At diagnosis, 10 to 15% of patients have metastases to the bones and lungs. Recurrence values are between 15 and 25% of patients; However, survival is encouraging, 90% to 20 years. Aggressive than papillary carcinoma. The presentation is between 40 and 50 years and more in women, with a ratio of 3 to 1. They present as solitary nodules of variable growth, almost always painless. They rarely produce thyrotoxicosis (<1%), because they occur more frequently in places with iodine deficiency in the diet. One variant here is the Hürtle cell carcinoma, which produces thyroglobulin. They are more multifocal or bilateral and rarely capture iodine and 25% have metastases at diagnosis. Medullary carcinoma accounts for 4% to 5% of thyroid carcinomas. They produce calcitonin with a location in the middle to upper part of the thyroid lobes. There is no significant difference according to sex, with a male-to-male ratio of 1.5-1. 11 About 33% of them are relatives, the rest being sporadic; In both situations, may be associated with multiple endocrine neoplasia type 2 (NEM-2). The typical age of sporadic presentation is between 50 and 60 years and in the form associated with NEM2 between 20 and 30 years. They are unilateral in 75% and most painful, with dysphonia, dysphagia or dyspnea. Weight loss, lethargy and bone pain, diarrhea or carcinoid syndrome are also associated. Only 1% of thyroid carcinomas correspond to anaplastic carcinoma, the majority of which originate from a differentiated tumor. It has the same distribution according to sex as the medullary carcinoma, with a higher incidence between 60 and 80 years. It is an inducible and rapid growth tumor, making it the most aggressive of all carcinomas. Local involvement is common, with dysphonia, dysphagia, or dyspnea; In addition, it presents near and distant metastases. At diagnosis, 50-69% of patients already have evident lymphadenopathy. Within the lymphomas, non-Hogdkin B cell predominates, with a presentation close to 1% of thyroid malignancies. Confoundable with thyroiditis, as they occur after or during Hashimoto's thyroiditis, they are shown as multinodular or diffuse goitre, rapidly growing, painful. It is more common in females than in males, mainly between 55 and 75 years. The other malignant tumors are extraordinarily infrequent. Thyroid metastases are infrequent and are late manifestation of non-primary cancer of the gland. As for treatment, thyroidectomy is the initial and most important component in the management of thyroid carcinoma, except for anaplastic carcinoma. Subtotal thyroidectomy, with or without isthmectomy as appropriate, is adequate for patients with undifferentiated carcinomas or microcarcinomas; While total thyroidectomy is indicated for the remaining carcinomas and local recurrences. Further therapy should be considered with I131, depending on the histological grade of the tumor and for sensitive metastases or residual thyroid tissue, followed by hormonal therapy. If you have ganglion metastases, modified radical neck dissection is added.
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Neoplasias de la tiroides, Nódulos, Tiroidectomía, Complicaciones posoperatorias, Hospital de Especialidades Guayaquil Dr. Abel Gilbert Pontón, Cantón Guayaquil, Ecuador