Neck recurrence in papillary thyroid carcinoma Recidiva cervical no carcinoma papilífero da tireoide

Introduction: papillary thyroid carcinoma is a tumor with good prognosis. However, some patients treated present neck recurrence. Objective: to evaluate the risk factors for neck recurrence. Methods: a retrospective study enrolled 89 patients (68 women and 21 men) diagnosed with papillary carcinoma who underwent total thyroidectomy. In 21 patients, neck dissection was performed and 62 patients underwent radioiodinetherapy. Twelve patients relapsed with metastasis in this period with an average of 3.6 years. Results: out of 89 patients, 76.4% were female. Relapse occurred in nine (13.23%) women and three (14.28%) men. The average age of the patients was 44 years in the control group and in patients with relapsed. Eighteen patients (23.37%) in the control group and eight (64.28%) who relapsed had positive lymph nodes at initial diagnosis. The tumor size was significantly larger in the group of patients with cervical recurrence (3.3cm vs. 1.6cm p=0.008, Student t test), whereas the presence of metastatic lymph nodes at the moment of the first operation was also significant (p=0.004 -Fisher exact test). The tumor size was an independent risk factor for recurrence at the multivariate anaylsis (OR=2.4, IC95%:1.3-4.6 p=0,007, logistic regression). Conclusion: there is an increase in the risk of lymph node recurrence during the follow up of 2.4 folds for each increase of 1cm in the longer nodule diameter.


Dedivitis
Neck recurrence in papillary thyroid carcinoma extension. Male sex and age over 55 years also represent prognostic factors for local recurrence 7,8 . The BRAF mutation was considered a prognostic marker. Present in approximately 45% of cases, this somatic mutation is the most frequently observed genetic alteration in papillary carcinoma patients. Such a mutation is associated with more aggressive tumor behavior, increasing the risk of progression and recurrence 9 .
The aim of this study was to evaluate risk factors for lateral regional recurrence in patients previously treated for papillary carcinoma of thyroid.

The study was approved by the Ethics in
Research Committee of the institution where it was carried out. This is a retrospective study in which we reviewed medical records from the period between 2000 and 2010, with 89 patients (68 women and 21 men) diagnosed with papillary carcinoma and treated at our service. All underwent total thyroidectomy. In addition, 21 patients underwent neck dissection, and 62, radioiodine therapy. Patients were followed up for at least five years, with an average of 8.9 years. There was no locoregional or distant recurrence. Twelve patients had recurrence with cervical metastasis in this period, with an average of 3.6 years of follow-up. Patients were followed for 10 to 20 years.
We recorded age, sex, tumor size, presence of metastasis in the initial diagnosis, neck dissection, radioiodine therapy, and dose performed, and used them to compare the patients who had no recurrence in a period greater than five years (control group) with the group of patients who displayed local relapse, in an attempt to elucidate risk factors for locoregional recurrence.
We organized and described the values obtained by studying each quantitative variable of parametric distribution using the mean and standard deviation. For qualitative ones, we used absolute and relative frequencies. For the comparison between the means of two parametric sample populations, we used the Student's t test. We used the Fisher's exact test to compare categorical variables. We compared the frequency of a phenomenon between groups of qualitative variables using the chi-square test. We used the log-rank test to compare the curves and the Cox regression model in calculating the hazard ratio (HR), with the respective 95% confidence interval (95% CI) in the multivariate analysis. In all analyzes, we used the SPSS® version 17.0 statistical software (SPSS® Inc; Chicago, Ilinois, USA) and in all comparisons we adopted a level of statistical significance of less than 5% (p ≤ 0.05).

RESULTS
Of the 89 patients with papillary carcinoma included in this study, 68 (76.4%) were female, and 21 (23.6%), male. Relapse occurred in nine (13.23%) women and in three (14.28%) men. The age in the relapse-free group varied between 18 and 78 years. In this study, there was a higher frequency of papillary carcinoma in females (76.40%) than in males (23.59%). Nonetheless, the recurrence was greater among men (28%) than among women (9.09%), in accordance with the literature 11-14 . Tumors of greater aggressiveness were found in male patients, this being an independent prognostic factor 13 . However, in our study, this was not a statistically significant prognostic factors for cervical recurrence.
There was no age difference between the groups; both had, on average, the age of 44, not in accordance with the literature, whose average is about 55 years 11 14 . It is known that elderly patients have tumors with unfavorable characteristics, such as advanced stage, larger size, extrathyroidal invasion, palpable lymph node metastases, greater mitotic activity, nuclear polymorphism, and decreased iodine uptake 15 .
Some studies have shown that tumor size larger than 4 cm and male sex are related to a worse prognosis 8 . In addition, even tumors larger than 2 cm are more aggressive than tumors of 2 cm or less, even though they are classified as low-risk tumors 14 . Patients displaying recurrence had tumors greater than 3.5 cm on average, and recurrence free patients had mean tumor size of 1.61 cm, indicating size as a risk factor for lymph node recurrence. Tumors larger than 1.5 cm have a more unfavorable evolution in papillary thyroid carcinoma 16