BackgroundThe role of serum TSH concentrations as a predictor of malignancy of thyroid nodule remains unclear.ObjectiveTo prospectively evaluate the usefulness of serum TSH levels as a predictor of malignancy in thyroid nodules.MethodsPatients with thyroid nodule(s) who underwent fine-needle aspiration biopsy under ultrasonographic guidance in a tertiary, university-based hospital were consecutively evaluated. Patients with known thyroid cancer and/or patients receiving thyroid medication were excluded. Serum TSH levels were measured by two differents methodologies, chemiluminescent (CLIA) and electrochemiluminscent immunoassay (ECLIA). Anatomopathological exam of tissue samples obtained at thyroidectomy was considered the gold standard for the diagnosis of thyroid cancer.ResultsA total of 615 patients participated in the study. The mean age was 55.9±14.7 years, and 544(88.5%) were female. The median TSH values were 1.48 and 1.55 μU/mL, using CLIA and ECLIA, respectively. One-hundred-sixty patients underwent thyroidectomy and the final diagnoses were malignant in 47(29.4%) patients. TSH levels were higher in patients with malignant than in those with benign nodules in both TSH assays: 2.25 vs. 1.50; P = 0.04 (CLIA) and 2.33 vs. 1.27; P = 0.03 (ECLIA). Further analysis using binary logistic regression identified elevated TSH levels, a family history of thyroid cancer, the presence of microcalcifications, and solitary nodule on US as independent risk factors for malignancy in patients with thyroid nodules. Additional analyses using TSH levels as a categorical variable, defined by ROC curve analysis, showed that the risk of malignancy was approximately 3-fold higher in patients with TSH levels ≥2.26 μU/mL than in patients with lower TSH levels (P = 0.00).ConclusionsHigher serum TSH levels are associated with an increased risk of thyroid cancer in patients with thyroid nodules. Using TSH levels as an adjunctive diagnostic test for stratifying the risk of malignancy associated with a thyroid nodule may help on defining the best therapeutic approaches.

Both TI-RADS and the ATA guidelines have high sensitivity and NPV for the diagnosis of thyroid carcinoma. These systems are feasible for clinical application, allowing to better select patients to undergo fine-needle aspiration biopsies.

DRS after initial therapy and sPOTg are strong predictors of disease outcome and might be helpful for defining follow-up strategies in pediatric DTC.

Objective Prospective data on the accuracy of ultrasound (US) classification systems in thyroid nodules are still scarce. The aim of this study is to compare the accuracy of the American College of Radiology Thyroid Imaging Reporting and Data System (ACR‐TIRADS) and European (EU)‐TIRADS classification systems. Design and Patients Consecutive patients with one or more thyroid nodule(s) who underwent fine‐needle aspiration (FNA) under ultrasonographic guidance (FNA‐US) were prospectively evaluated. Measurements Clinical evaluation and US data were collected. The reference standard used for this study was FNA‐US cytology and histopathological diagnosis. Results A total of 186 thyroid nodules in 166 patients were evaluated, resulting in 168 nodules from 149 patients with conclusive benign or malignant results. Sensitivity, specificity, negative predictive value (NPV) and false negative (FN) were 100.0%, 28.7%, 100.0% and 0.0%, respectively, for ACR‐TIRADS; and 90.0%, 19.1%, 96.8% and 9.1% (n = 1), respectively, for EU‐TIRADS. The number of unnecessary FNA‐US indicated by ACR‐TIRADS was lower than EU‐TIRADS (71.3% vs. 80.9%, p = .017), and the number of possibly avoided FNA‐US was higher (26.7% vs. 17.8%). Using the same threshold of ACR‐TIRADS to indicate FNA‐US in EU‐TIRADS 3 nodules (2.5 cm), there was an improvement in specificity (30.6%) and avoided FNA‐US (28.6%). The best performance of both systems was demonstrated when FNA‐US would be indicated only in highly suspicious nodules and/or in the presence of lymphadenopathy, with 85.7% and 89.3% of possibly avoided FNA‐US for ACR‐TIRADS and EU‐TIRADS, respectively, without increasing FN. Conclusion Both systems presented high sensitivity, but low specificity in selecting nodules for FNA‐US. The use of nodular size for FNA‐US selection is questioned.

RESUMOO câncer de tireóide é responsável por cerca de 1% dos novos casos de doença maligna diagnosticados. A maioria destes tumores são carcinomas papilares e foliculares, também denominados de carcinomas diferenciados de tireóide (CDT). Estes carcinomas têm uma taxa de cura de aproximadamente 80%, enquanto 20% apresentarão recorrência local e 5 a 10% desenvolverão metástases à distância. Porém, alguns pacientes apresentam uma doença mais agressiva. A identificação de tais pacientes tem grande impacto no manejo clínico do CDT. Várias classificações de estádio clínico e fatores prognósticos são apresentados, bem como os principais exames para seguimento dos pacientes com CDT. Thyroid carcinoma accounts for roughly 1% of all new malignant diseases. Of these, at least 94% are differentiated thyroid carcinoma (DTC), either papillary thyroid carcinoma or follicular thyroid carcinoma. Patients with DTC are usually considered as having a good prognosis, 80% of patients are cured, 20% will develop loco-regional recurrence and 5-10% distant metastasis. However, the disease may have an aggressive course in some patients. The identification of these patients has a major impact in the clinical management of DTC. Several prognostic factors and classification will be addressed, as well the most useful tests for patient's follow-up. CARCINOMAS DIFERENCIADOS DE TIREÓIDEO CÂNCER DE TIREÓIDE é a neoplasia maligna mais freqüente do sistema endocrinológico, apesar de ser uma patologia relativamente rara, sendo responsável por aproximadamente 1% dos novos casos de doença maligna (1). A cada ano, nos EUA, surgem 14.000 novos casos, e ocorrem 1.100 mortes decorrentes do carcinoma diferenciado da tireóide (2). No Brasil, estes números são proporcionais, ocorrendo 66 novos casos em cada 100.000 habitantes por ano (3).As neoplasias da tireóide são classificadas de acordo com o tipo histológico em adenoma folicular, carcinoma papilar, carcinoma folicular e carcinoma anaplásico ou indiferenciado. A maioria dos tumores tireoi-

RESUMO -Sintomas psicológicos, especialmente ansiedade e depressão, têm sido associados à hiperprolactinemia. Para avaliar a presença desses sintomas, foram submetidos à entrevista através do Composed International Diagnostic Interview, seguido pela escala de Hamilton para depressão, 32 pacientes (5 homens e 27 mulheres) com hiperprolactinemia de várias etiologias e 16 normoprolactinêmicos. A prolactina sérica na época da avaliação variou de 28 a 180 ng/mL, sendo que 11 dos pacientes usavam bromocriptina. Detectou-se presença atual de distúrbios de ansiedade em 18 pacientes (56,2%) e 5 controles (31,2%), depressão em 10 pacientes (31,2%) e 2 controles (12,5%), distmia em duas pacientes e outros diagnósticos psiquiátricos em 6 pacientes (18,7%). Os escores da depressão variaram entre 16 e 31 nos pacientes e foram 12 e 16 nos controles. A frequência de sintomas psiquiátricos como um todo, foi significativamente maior nos hiperprolactinêmicos (teste do quiquadrado), mas a diferença não foi significativa na análise isolada de ansiedade ou depressão. A hiperprolactinemia representa um fator de risco de 3,57 para depressão, 3,32 para ansiedade e 3,84 para outros sintomas psiquiátricos. Não houve diferença significativa na frequência de sintomas psiquiátricos entre portadores ou não de adenomas hipofisários e usuários ou não de bromocriptina. Não houve correlação (r= 0,07) entre a prolactina e a frequência de sintomas psiquiátricos. Conclui-se pela necessidade de atentar para a concomitância de hiperprolactinemia e distúrbios psiquiátricos, cujo reconhecimento permitirá abordagem terapêutica específica. PALAVRAS-CHAVE: hiperprolactinemia, prolactinoma, ansiedade, depressão, bromocriptina. Hyperprolactinemia and psychological disturbanceABSTRACT -Psychological symptoms, specially anxiety and depression, have been associated to hyperprolactinemia. To evaluate the presence of these symptoms, 32 patients (5 men and 27 women) with hyperprolactinemia of several etiologies and 15 individuals with normal prolactin levels were submitted to the Composed International Diagnostic Interview, followed by the Hamilton rating scale for depression. The serum prolactin, at the time of evaluation, ranged between 28 and 180 ng/mL. Eleven patients were receiving bromocriptine. The presence of anxiety was detected in 18 patients (56.2%) and 5 controls (32.2%), depression was detected in 10 patients (31.2%) and 2 controls (12.5%), dysthymia in 2 patients and other psychiatric diagnosis in 6 patients (18.7%). The scores of depression ranged between 16 and 31 for the patients, and were 12 and 16 for the controls. The frequency of psychiatric symptoms, as a whole, was significantly higher in the hyperprolactinemic patients (chi-square test), but the difference was not significant in isolated analysis of anxiety and depression. The hyperprolactinemia represents a risk of 3.52 for depression, 3.32 for anxiety and 3.84 for other psychiatric symptoms. There was no significant difference in the frequency of psychiatric symptoms among patients with o...

The clinical outcome of papillary thyroid carcinoma (PTC) patients with an indeterminate response after initial therapy is reported to be intermediate, between incomplete and excellent responses. This study evaluated the outcomes of PTC patients with indeterminate response after initial therapy. It was further determined whether the indeterminate findings predicted outcomes more precisely. Patients were further classified into 3 groups based on risk of structural persistence/recurrence: Tg group: detectable thyroglobulin, negative antithyroglobulin antibody, regardless nonspecific imaging findings; TgAb group: positive antithyroglobulin antibody, regardless thyroglobulin levels and nonspecific imaging findings, and Image group: nonspecific findings on neck ultrasonography or faint uptake in the thyroid bed on whole-body scan, undetectable thyroglobulin and negative antithyroglobulin antibody. Sixty-six patients aged 44.1±12.7 years were studied, of whom 58 (87.9%) were females. All patients underwent total thyroidectomy, and 52 patients (78.8%) received radioiodine. After 5.7 years (P25–75 2.6–9.75 years) of follow-up, most patients (89.4%) were reclassified as having an excellent response or remained in the indeterminate response to therapy. Structural recurrence/persistence disease was detected in 7 (10.6%) patients. The persistence/recurrence rate in groups were as follow: Tg, 2.63%; TgAb, 31.25%; Image, 8.3% (p=0.007). The 10-years disease-free survival rate in the TgAb group was significantly reduced (p=0.022). Our results suggest that patients with PTC and indeterminate response due to positive serum antithyroglobulin antibody have more risk of development of structural disease. These findings suggest a more individualized follow-up strategy for patients with an indeterminate response.

RESUMOA transformação neoplásica resulta de uma série de alterações genéti-cas, envolvendo ativação de proto-oncogenes e inativação de genes supressores tumorais. Ativação do proto-oncogene ras por mutações em ponto é a alteração genética mais freqüente em tumores espontâ-neos da tireóide. Avaliamos a expressão do gene ras no bócio nodular. Fragmentos de tecido tireoidiano normal e neoplásico foram coletados durante o ato cirúrgico, sendo que 79 pacientes tiveram diagnóstico histopatológico de bócio colóide e foram incluídos no estudo. O RNA total foi extraído pelo método de Trizol e o cDNA sintetizado através do Reverse Trancriptidase. Os genes H-ras e K-ras foram amplificados através de PCR com primers específicos. Do total da amostra, 62% apresentaram aumento da expressão de um dos genes ras estudados. Evidenciou-se aumento da expressão do H-ras em 9 dos 29 (31%) casos e do K-ras em 12 dos 32 (37,5%) tumores estudados. Os resultados demonstraram aumento da expressão do ras na doença nodular da tireóide e sugerem um papel importante desses genes na transformação neoplásica da tireóide. Neoplastic transformation results from a series of genetic alterations involving activation of protooncogenes and inactivation of tumor suppressor genes. Activation of ras protooncogenes by point mutation is the most frequent genetic alteration in spontaneous thyroid neoplasias. The goal of this study was to evaluate ras gene expression in the nodular goiter. Seventy-nine patients submitted to thyroidectomy and with a histological diagnosis of nodular goiter were included in the study. Tissues were obtained from both tumor and normal thyroid during surgery and frozen in liquid N 2 . Total RNA was isolated using TRIzol reagent and the cDNA was synthesized by reverse transcription. Twenty-one of the 34 (62%) nodules showed elevated expression of at least one of the ras genes studied. H-ras exhibited overexpression in 9 of 29 (31%) and K-ras in 12 of 32 (37.5%) tumor samples examined. Our results showed ras over expression in nodular disease, with different pattern of expression between H and K-ras genes, suggesting that control of these proto-oncogenes expression might play an important role on neoplastic transformation in thyroid cells. OBÓCIO MULTINODULAR (BMN) é definido como aumento da glându-la tireóide devido à proliferação multifocal de tireócitos, resultando em estruturas foliculares heterogêneas. É uma patologia comum, clinicamente detectada em 2-6% dos indivíduos em regiões com dieta suficiente de iodo (1).