Optimization of diagnosis, surgical treatment and prediction of the course of thyroid tumors and adrenal incidentalomas

Abstract

The article summarizes and analyzes the material devoted to studying the results of diagnosis and treatment of nodular pathology of the thyroid and adrenal glands. The aim is to study molecular and biochemical factors in benign formations and well differentiated malignant tumors, as well as in normal thyroid tissue; analysis of the results of molecular genetic researches; a role of iodine and selenium deficiency in the pathogenesis of goiter transformation of the thyroid gland; determination of optimal protocols for management of adrenal incidentalomas. The object of the study is patients with benign formations and
malignant well differentiated thyroid carcinomas, and adrenal tumors. Material and methods: clinical-epidemiological, biochemical, morphological, ultrasound, and statistical. Results. In patients with benign thyroid pathology, iodine deficiency was detected in 43.6% of patients, optimal iodine supply — in 38.5% of patients, and a high level of iodine excretion — in 17.9% of patients. A significantly reduced level of blood selenium was found in 76.5% of patients, suboptimal content — in 13.6% of patients, and an optimal concentration — only in 9.9% of patients. Selenium deficiency was noted in patients with nodular thyroid pathology, autoimmune thyropathies and their combination, in comparison with echographically unchanged thyroid gland. According to the received data, BRAF mutations were found significantly more often (p<0.001) in patients with classical and oxyphil cell variants of papillary carcinoma (PC) (60% and 100%, respectively), compared to the follicular variant of papillary thyroid carcinoma (6.7%). Among locally invasive papillary thyroid carcinomas, BRAF-negative cases significantly more often prevailed (p<0.05) over non-invasive PC. All cases of the follicular variant of PC had signs of invasion and were noted significantly more often compared to the classical and oxyphil cell variants (p<0.01). BRAFV600E mutation was found both in tumors with metastases to the regional lymph nodes of the neck (55%) and in tumors without metastases (37.5%). A comparative evaluation of adrenalectomies (and adrenal resections) by laparoscopic and lumbotomic accesses was carried out according to a number of criteria. Thus, in particular, the average time from the beginning of the operation to the clipping of the central vein of the adrenal gland is less during laparoscopic operations in the in the whole group (including less experienced surgeons). Intraoperative blood loss during endoscopic surgery averaged (100.0±26.4) ml, and during thoracophrenolumbotomy — (250.0±74.3) ml. Conclusions. 1. The BRAFV600E gene mutation is a diagnostic marker of papillary thyroid carcinoma, its detection confirms the malignancy and can be used as an additional method for preoperative diagnosis of papillary thyroid cancer. BRAF-negative, cytologically indeterminate thyroid nodules do not exclude malignancy, and such patients may be recommended surgical treatment or careful observation. 2. Expansion of the number of molecular genetic markers in the preoperative diagnosis of thyroid cancer and the development of a specific genetic panel can significantly improve the quality of diagnosis and, accordingly, surgical treatment. 3. Endoscopic surgery is the gold standard in the treatment of patients with adrenal tumors due to less intraoperative blood loss, fewer intra- and postoperative complications, and early recovery compared to open surgery. 4. Open surgical interventions (lumbotomy, thoracophrenotomy) may be indicated for adrenal formations with a diameter of >8 cm and locally advanced forms of adrenocortical cancer and malignant pheochromocytomas with signs of invasion into neighboring organs.