👉Anaplastic thyroid cancer
T4A- OS 15.8months
T4B- OS 6.1months
T4C – OS 2.8 months

Onoda N, Sugitani I, Ito KI, Suzuki A, Higashiyama T, Fukumori T, et al. Evaluation of the 8th edition TNM classification for anaplastic thyroid carcinoma. Cancers. 2020;12:1–11.

https://thyroidresearchjournal.biomedcentral.com/articles/10.1186/s13044-020-00091-w#ref-CR5

Clasificación TIRADS

TIRADS classification 

Rodrigo Arrangoiz MS, MD, FACS cirujano de tumores de cabeza y cuello / cirugia endocrina / cirugía oncológica es experto en el manejo de patología  de la glándula tiroides.

Su entrenamiento fue el siguiente:

• Cirugia general y gastrointestinal:
• Michigan State University:
• 2004 al 2010• Cirugia oncológica / tumores de cabeza y cuello / cirugia endocrina:
• Fox Chase Cancer Center (Filadelfia):
• 2010 al 2012• Maestria en ciencias (Clinical research for healthprofessionals):
• Drexel University (Filadelfia):
• 2010 al 2012• Cirugia de tumores de cabeza y cuello / cirugiaendocrina
• IFHNOS / Memorial Sloan Kettering Cancer Center:
• 2014 al 2016

https://file.scirp.org/pdf/IJOHNS_2017072615211601.pdf

https://file.scirp.org/pdf/IJOHNS_2018071317420392.pdf

• Clin Thyroidol 2021;33:484–486.
• The evaluation of patients with thyroid nodules requires adequate stratification to estimate the risk of thyroid cancer:
  • Evaluation also requires an understanding of the patient’s situation
• To assist clinicians in this task, multiple thyroid nodule sonographic risk-stratification systems (RSSs) have been developed, including:
  • The American Thyroid Association (ATA) system
  • The American College of Radiology Thyroid Imaging Reporting and Data System (ACR TI-RADS)
  • The Korean Thyroid Imaging Reporting and Data System (K-TIRADS)
  • The European Thyroid Imaging Reporting and Data System (EU-TIRADS)
  • The Artificial Intelligence Thyroid Imaging Reporting and Data System (AI TI-RADS)
• In general, studies assessing the performance of these RSSs have been retrospective and have included patients who have undergone a diagnostic intervention (i.e., thyroid nodule biopsy or surgery):
  • This type of study design can introduce bias into the assessment of diagnostic properties by increasing the proportion of high risk cases
• Although RSSs for thyroid nodules aim to standardize thyroid cancer risk assessment and recommendations:
  • The ACR TI-RADS is associated with a lower number of recommendations for thyroid biopsy:
    • This is due, in part, to the system’s relatively more conservative thresholds for recommending thyroid biopsy
• In the current study, a comparison of thyroid nodule RSSs is evaluated:
  • In thyroid nodule risk distribution in an unselected group of patients undergoing thyroid ultrasound
  • By assessing the impact of risk distribution, in addition to the size thresholds, on biopsy recommendations
• Methods:
  • This was a multi-institutional study of seven radiology practices that participate in the ACR registry
  • Each practice prospectively submitted thyroid ultrasound reports on adult patients between October 2018 and March 2020
  • Sites provided the maximum size of the thyroid nodules and followed structured reporting according to the five ACR TI-RADS ultrasound features
  • Patients with thyroid cancer, nodule size less than 5 mm or greater than 5 cm, and incomplete / unrealistic data were excluded
  • The submitted reports were then retrospectively categorized following the criteria of ACR TI-RADS, the ATA system, K-TIRADS, EU-TIRADS, and AI TI-RADS
  • The distribution of risk categories and thyroid biopsy recommendation rates were compared
  • Because of the large sample size, even small differences in the proportions observed were expected to be statistically significant
• Results:
  • The study population consisted of:
    • 12,208 patients, mostly women (84%), encompassing a total of 27,933 thyroid nodules
  • The mean patient age was 60.7 years, and the mean (±SD) nodule size was 1.5 ± 0.92 cm
  • There were 1896 nodules that could not be classified according to the ATA system
  • According to ACR TI-RADS:
    • The distribution of thyroid nodules was:
      • TIRADS 1 (TR1) (3.1%), TR2 (8.2%), TR3 (31.0%), TR4 (48.3%), and TR5 (9.4%)
  • The ACR TI-RADS and AI TI-RADS:
    • Placed more nodules in the TR2 category (8.2% and 10%, respectively) than the other systems (range, 1.2%–2.5%)
  • EU-TIRADS:
    • Placed more nodules in the high suspicion / TR5-equivalent category (18.9%) than did the other systems (range, 9.1–12.5%)
  • AI TI-RADS had the lowest level of TR3 nodules (26.1%) as compared with the other systems (range, 31–44.4%)
  • In all, the most common category for all nodules was TR4 and its equivalents (42.1–48.3%)
  • ACR TI-RADS recommended biopsies in 29.1% of the thyroid nodules:
    • One of the lowest rates as compared with other systems (ATA, 58.7%; EU-TIRADS, 38.9%; K-TIRADS, 57%)
    • AI TI-RADS recommended biopsy for 26.3% of the nodules
  • Finally, when evaluating thyroid biopsy recommendations according to risk category:
    • The rate of recommended biopsy was similar in the TR5 categories and equivalents (68.7–75.5%)
  • There was variability for TR2:
    • With ACR TI-RADS recommending biopsy in 0% of the nodules (range for others, 2.8–17.7%)
  • The largest differences were for TR3 and TR4 nodules:
    • For which ACR TI-RADS and AI TI-RADS recommended biopsy in 19.0% to 22.3% and 32.7% to 33.7 %, respectively; the range for the other systems was 33.3 to 53.7% for TR3 and 29.0 to 64.0% for TR4
  • Conclusions:
    • Differences in the distribution of sonographic thyroid nodule risk categories and biopsy size thresholds among the various RSSs contribute to variability in clinical recommendations for thyroid biopsies
    • ACR TI-RADS generally recommends a lower number of biopsies:
      • Because of a combination of its risk assignment criteria and more conservative biopsy thresholds
  • This large multi-center study validates the clinical utility of thyroid nodule risk stratification:
    • By evaluating patients who underwent thyroid ultrasound regardless of their diagnostic workup
  • Using ACR TI-RADS, 11.3% of the thyroid nodules were considered either benign or very low risk for thyroid cancer, while 9.4% were considered high risk
  • Most patients had nodules considered either T3 or T4 (31.0% and 48.3%, respectively)
  • This distribution highlights the importance of high-quality ultrasound risk stratification in the evaluation of patients with thyroid nodules, as it can facilitate reassurance in patients with low-risk nodules
  • Similarly, a robust RSS may appropriately justify the consideration of biopsy in those at higher ris
  • In addition, the study evaluated the impact of size thresholds across the different risk categories to guide the need for thyroid biopsies
  • Application of ACR TI-RADS was associated with a biopsy rate of 29.1%:
    • Lower than that for all the other systems except for AI TI-RADS
  • This was driven, in part:
    • By fewer biopsy recommendations for nodules in categories TR3 and TR4
    • As well as a greater proportion of nodules in the TR2 category:
      • For which biopsy is not recommended
  • Taken together, these findings suggest that, in addition to different size thresholds for biopsy, the distribution of risk categories affects biopsy recommendation rates
  • In fact, the overall proportion of nodules recommended for biopsy varied between the systems, from 26.3% in AI TI-RADS to 58.7% in the ATA system
  • These findings highlight the urgent need for and value of current efforts to harmonize thyroid nodule RSSs, particularly in terms of risk-category definitions and management recommendations by malignancy estimates and size thresholds for biopsy
  • This endeavor might be challenging, given that clinical evidence that can guide the selection of biopsy size thresholds is limited
  • More importantly, in this large study, most nodules were categorized as TR3 or TR4, and overall the mean nodule size was 1.5 cm, representing a group of patients in whom management recommendations by the major RSSs are highly variable
  • These findings underscore the value of a care model that uses the best available evidence to understand thyroid cancer risk and supports the collaboration of patients and clinicians when deciding how to respond to this risk

#Arrangoiz #ThyroidSurgeon #CancerSurgeon #ThryoidExpert #ThyroidNodules #ThyroidCancer #Miami

-Mirizzi syndrome is subclassified in to 5 types :

🔴𝗜: Is obstruction of the extrahepatic bile duct stone/s in the Hartmann’s pouch or cystic duct.

🔴𝗜𝗜: Is with a cholecystocholedochal fistula (diameter < 1/3 or the common hepatic duct wall).

🔴𝗜𝗜𝗜: Is with a cholecystocholedochal fistula (diameter < 2/3 of the common hepatic duct wall).

🔴𝗜𝗩: Is with a cholecystocholedochal fistula (involving the whole common hepatic duct wall).

🔴𝗩: Any type associated with a cholecystoenteral fistula (i.e,fistula to stomach, duodenum or hepatic flexure or transverse colon). This is sometimes sub-classiied depending on whether gallstone ileus is present or not.

𝙍𝙚𝙛:Difficult Acute Cholecystitis Treatment and Technical Issues,1st ed. 2021© Springer.

#Arrangoiz #Surgeon #CASO #Miami #CenterforAdvancedSurgicalOncology

• Kinase inhibitors:
  • May be appropriate for select patients with recurrent or persistent MTC that is not resectable
  • Although kinase inhibitors may be recommended for patients with MTC:
    • It is important to note that kinase inhibitors:
      • May not be appropriate for patients with stable or slowly progressing indolent disease
  • Vandetanib and cabozantinib:
    • Are oral receptor kinase inhibitors:
      • That increase progression free survival (PFS):
        • In patients with metastatic MTC
• RET inhibitors that are FDA-approved for RET-mutated MTC include:
  • Selpercatinib and pralsetinib
• Vandetanib:
  • Is a multi-targeted kinase inhibitor
  • It inhibits:
    • RET
    • Vascular endothelial growth factor receptor (VEGFR)
    • Endothelial growth factor receptor (EGFR)
  • In a phase III randomized trial in patients with unresectable, locally advanced, or metastatic MTC (n = 331):
    • Vandetanib increased PFS when compared with placebo (HR, 0.46; 95% CI, 0.31– 0.69; P < .001)
    • OS data are not yet available
    • A post-hoc subgroup analysis including 184 patients with symptomatic and progressive disease at baseline:
      • Also showed increased PFS (HR, 0.43; 95% CI, 0.28–0.64; P < .001) in patients who received vandetanib, compared to the placebo:
        • Although time to worsening pain was not significantly different between the two groups (HR, 0.67; 95% CI, 0.43–1.04; P = .07)
        • In this subgroup, the overall response rate (ORR) was:
          • 37% in the patients who received vandetanib and 2% in patients who received the placebo (P < .001)
  • The FDA approved the use of vandetanib for patients with locally advanced or metastatic MTC:
    • Who are not eligible for surgery and whose disease is causing symptoms or growing:
      • However, access is restricted through a vandetanib Risk Evaluation and Mitigation Strategy (REMS) program:
        • Because of potential cardiac toxicity
  • The NCCN Panel recommends vandetanib (category 1):
    • As a preferred option for patients with recurrent or persistent MTC
• Cabozantinib:
  • Is a multi-targeted kinase inhibitor:
    • That inhibits:
      • RET
      • VEGFR2
      • MET
  • In a phase 3 randomized trial (EXAM) in patients with locally advanced or metastatic MTC (n = 330):
    • Cabozantinib increased median PFS when compared with placebo:
      • 11.2 vs. 4.0 months:
        • HR, 0.28; 95% CI, 0.19–0.40; P < .001
    • Following long-term follow-up:
      • The median OS for patients treated with cabozantinib was:
        • 26.6 months compared to 21.1 months for placebo:
          • Although this difference was not statistically significant (stratified HR, 0.85; 95% CI, .64–1.12, P = .24)
  • Exploratory analyses have suggested that cabozantinib:
    • May have a greater clinical benefit:
      • For medullary thyroid cancers harboring:
        • RET M918T or RAS mutations:
          • Although prospective trials are needed to confirm
  • In 2012:
    • The FDA approved the use of cabozantinib for patients with progressive, metastatic MTC
  • The NCCN Panel recommends cabozantinib (category 1):
    • As a preferred option based on the phase III randomized trial and FDA approval
  • Rare adverse events with cabozantinib include:
    • Severe bleeding and gastrointestinal perforations or fistulas:
      • Severe hemorrhage is a contraindication for cabozantinib
• RET mutations account for a significant percentage of MTC cases:
  • Supporting investigation into the impact of recently developed RET inhibitors on RET-mutated MTC
  • The phase I–II LIBRETTO-001 study:
    • Evaluated the efficacy of the RET inhibitor selpercatinib in 143 patients with RET-mutant MTC in patients previously treated with vandetanib or cabozantinib (n = 55):
      • The ORR and 1-year PFS rates were:
        • 69% (95% CI, 55%–81%) and 82% (95% CI, 69%–90%), respectively
    • In patients with no previous vandetanib or cabozantinib treatment (n = 88):
      • The ORR and 1year PFS rates were:
        • 73% (95% CI, 62%–82%) and 92% (95% CI, 82%– 97%), respectively
    • The most commonly reported toxicities (grade 3 and 4) were:
      • Hypertension (21%)
      • Increased alanine aminotransferase (11%)
      • Increased aspartate aminotransferase (9%)
      • Hyponatremia (8%)
      • Diarrhea (6%)
    • Dose reductions due to treatment-related adverse events were reported in 30% of patients
  • Pralsetinib, another RET inhibitor, was evaluated in the phase I–II ARROW study:
    • Which included 92 patients with RET-mutant MTC
    • The ORR was:
      • 60% (95% CI, 46%–74%) in patients previously treated with vandetanib or cabozantinib (n = 61)
      • 74% (95% CI, 49%–91%) in patients with no previous vandetanib or cabozantinib treatment (n = 22)
    • Pralsetinib was generally well-tolerated, with the most commonly reported grade 3–4 treatment-related adverse events being:
      • Hypertension (11%)
      • Neutropenia (10%)
    • These results are currently reported in abstract form, and the ARROW study is ongoing and continuing to enroll patients
• In 2020:
  • The FDA approved both of these RET inhibitors for RET-mutated MTC requiring systemic therapy
  • Based on the data and the FDA approvals:
    • The NCCN Panel recommends selpercatinib and pralsetinib:
      • As preferred options for patients with RETmutant disease
    • RET somatic genotyping may be done:
      • In patients who are germline wild-type or if germline status is unknown
• When locoregional disease is identified in the absence of distant metastases:
  • Surgical resection is recommended with (or without) postoperative EBRT or IMRT
• For unresectable locoregional disease that is symptomatic or progressing by Response Evaluation Criteria in Solid Tumors (RECIST) criteria:
  • The following options can be considered:
    • RT (EBRT or IMRT)
    • Systemic therapy
• Treatment can be considered for symptomatic distant metastases (eg, those in bone):
  • Recommended options include:
    • Palliative resection, ablation (eg, radiofrequency, embolization), or other regional treatment
    • Vandetanib (category 1)
    • Cabozantinib (category 1)
  • These interventions may be considered for asymptomatic distant metastases (especially for progressive disease):
    • But disease monitoring is acceptable given the lack of data regarding alteration in outcome
    • If systemic therapy is indicated, then vandetanib and cabozantinib are category 1 preferred options
    • Selpercatinib or pralsetinib are preferred options for patients with RETmutation positive disease
• Pembrolizumab is also an option for patients with:
  • TMB-H (metastatic tumor mutational burden-high [≥ 10 mutations/megabase (mut/Mb)]) disease:
    • Based on results of the phase II KEYNOTE-158 trial:
      • Which included two patients with thyroid cancer
• The NCCN Panel does not recommend treatment with systemic therapy:
  • For increasing calcitonin or CEA alone
• In the setting of symptomatic disease or progression:
  • The NCCN Panel recommends systemic therapy or enrollment in a clinical trial:
    • As stated above for locoregional disease:
      • Preferred systemic therapy options include:
        • Vandetanib (category 1)
        • Cabozantinib (category 1)
        • Selpercatinib:
          • For patients with RET-mutation positive disease
        • Pralsetinib:
          • For patients with RET-mutation positive disease
        • Other small-molecule kinase inhibitors (ie, sorafenib, sunitinib, lenvatinib, pazopanib):
          • May be considered if clinical trials or the NCCN-preferred systemic therapy options are not available or are not appropriate
• If the patient progresses on a preferred option:
  • Then systemic chemotherapy can be administered:
    • Using dacarbazine or combinations including dacarbazine
  • Pembrolizumab is also an option for patients with TMB-H (≥10 mut/Mb) disease (useful in certain circumstances)
  • EBRT or IMRT can be used for local symptoms
  • Intravenous bisphosphonate therapy or denosumab can be considered for bone metastases
  • Best supportive care is also recommended
• Results from clinical trials have shown:
  • The effectiveness of novel multi-targeted therapies have shown promise in the management of MTC, these include:
    • Sunitinib
    • Sorafenib
    • Lenvatinib
    • Pazopanib
• Severe or fatal side effects from kinase inhibitors include:
  • Bleeding, hypertension, and liver toxicity:
    • However, many side effects can be managed
• Because some patients may have indolent and asymptomatic disease:
  • Potentially toxic therapy may not be appropriate
• Calcitonin levels decreased dramatically after vandetanib therapy:
  • Which did not directly correlate with changes in tumor volume:
    • Thus, calcitonin may not be a reliable marker of tumor response in patients receiving RET inhibitor therapy
• A phase 2 trial in patients with progressive metastatic MTC:
  • Assessed treatment using pretargeted anti–CEA radioimmunotherapy with iodine-131:
    • OS was improved in the subset of patients with increased calcitonin doubling times

#Arrangoiz #HeadandNeckSurgeon #CancerSurgeon #ThyroidSurgeon #ThyroidExpert #CASO #Miami #CenterforAdvancedSurgicalOncology

Busoga hernias, also known as Gill-Ogilvie hernias

🔴They are a variant of the direct inguinal hernia involving the conjoint tendon.

🔴Busoga herniae have been noted to occur most commonly in young, athletic men with a well-developed abdominal musculature. There is an increased incidence of Busoga hernia in Uganda.

🔴The conjoint tendon medially reinforces the posterior wall of the inguinal canal. It is protrusion here, at the medial aspect of the posterior aspect of the inguinal canal were weakening can result in herniation. Weakening in the conjoint tendon is thought to be secondary to rigorous training, with kicking, running, and sharp turns

#Arrangoiz #Miami #Surgeon #CASO #CenterforAdvancedSurgicalOncology

📙📜Holy plane of Heald📜📙

🔴Dissection is along the avascular alveolar plane between the presacral and mesorectal fascia, described as holy plane (Heald’s “holy plane”).

🔴The mesorectum refers to a fatty connective tissue layer, measuring 2–3 cm in thickness, with associated vessels, lymphatics and lymph nodes, which surrounds the rectum and is enveloped by fascia.

🔴mesorectal dissection occurs in a total avascular plane that, once identified, can be easily dissected, exposing ‘the white side of the yellow’ as Heald first described in 1979. As the posterior dissection continues downward, the mesorectum looks more and more bilobate (indicating a good quality of the dissection) until it thins out and disappears.
Once again traction and counter traction are essential in lateral and anterior resection to identify the dissection plane.

🔴The relationship of the rectum and pelvic autonomic nerves during open surgery when standing on the patient’s left. The ligation of the inferior mesenteric artery should be performed 1.5–2 cm from its origin from the aorta to avoid damaging the superior hypogastric plexus. At the pelvis, for posterior and lateral tumours, dissection should be directed below the Denonvillliers fascia to avoid damaging the neurovascular bundles that run along the tip of the seminal vesicle (2 and 10 o’clock directions).

#Arrangoiz #Surgeon #Teacher #CancerSurgeon #CASO #Miami #CenterforAdvancedSurgicalOncology