The objectives of the study were to evaluate the performance of sentinel lymph node biopsy (SLNB) in detecting occult metastases in papillary thyroid carcinoma (PTC) and to correlate their presence to tumor and patient characteristics. Twenty-three clinically node-negative PTC patients (21 females, mean age 48.4 years) were prospectively enrolled. Patients were submitted to sentinel lymph node (SLN) lymphoscintigraphy prior to total thyroidectomy. Ultrasound-guided peritumoral injections of (99m)Tc-phytate (7.4 MBq) were performed. Cervical single-photon emission computed tomography and computed tomography (SPECT/CT) images were acquired 15 min after radiotracer injection and 2 h prior to surgery. Intra-operatively, SLNs were located with a gamma probe and removed along with non-SLNs located in the same neck compartment. Papillary thyroid carcinoma, SLNs and non-SLNs were submitted to histopathology analysis. Sentinel lymph nodes were located in levels: II in 34.7 % of patients; III in 26 %; IV in 30.4 %; V in 4.3 %; VI in 82.6 % and VII in 4.3 %. Metastases in the SLN were noted in seven patients (30.4 %), in non-SLN in three patients (13.1 %), and in the lateral compartments in 20 % of patients. There were significant associations between lymph node (LN) metastases and the presence of angio-lymphatic invasion (p = 0.04), extra-thyroid extension (p = 0.03) and tumor size (p = 0.003). No correlations were noted among LN metastases and patient age, gender, stimulated thyroglobulin levels, positive surgical margins, aggressive histology and multifocal lesions. Sentinel lymph node biopsy can detect occult metastases in PTC. The risk of a metastatic SLN was associated with extra-thyroid extension, larger tumors and angio-lymphatic invasion. This may help guide future neck dissection, patient surveillance and radioiodine therapy doses.

IMPORTANCE Single-photon emission computed tomography/computed tomography (SPECT/CT) and radioguided sentinel lymph node biopsy (rSLNB) are techniques that could potentially benefit surgeons and pathologists in the identification of sentinel lymph node (SLN) metastases in patients with papillary thyroid carcinoma (PTC). Evidence suggests that these novel techniques lead to substantial changes in PTC management by reducing understaging and of occult lymph node (LN) metastases and optimizing neck surgery by increasing the necessity of lateral lymphadenectomy and decreasing central lymphadenectomy.OBJECTIVES To correlate the presence of LN metastases in PTC with clinical and pathological features using SPECT/CT and rSLNB. DESIGN, SETTING, AND PARTICIPANTS For this prospective cohort study from June 2010 to November 2013, 42 patients with thyroid nodules suspicious for papillary carcinoma or classified as malignant on cytology examination without suspicion of lymph node metastases by clinical and ultrasound examinations were recruited from a single public medical institution.INTERVENTIONS All 42 patients underwent preoperative lymphoscintigraphy after an ultrasound-guided peritumoral injection of Technetium Tc 99m nanocolloid. Cervical images were acquired with a SPECT/CT scanner 15 minutes after radiotracer injection. Approximately 2 hours after lymphoscintigraphy, the patients were submitted to intraoperative rSLNB using a handheld gamma probe. All SLNs identified were removed alongside with non-SLNs from the same compartment. Papillary thyroid carcinoma, SLNs and non-SLNs were submitted for histopathology and immunohistochemical analyses. RESULTSOf the 42 patients initially enrolled, 37 were included in analysis, including 6 men and 31 women with a mean (range) age of 47 (22-83) years. Overall, T stage was as follows: T1, 23 patients (62.2%); T2, 8 patients (21.6%); and T3, 6 patients (16.2%). Sentinel lymph nodes were identified in 92% of the patients, and among these metastases were present in 17 patients (46%). The SLNs were false-negative in 3 patients. Metastases in the lateral compartment ocurred in 7 patients (18%). There was a significant association between LN metastases and tumor size (odds ratio, 1.06; 95% CI, 1.00-1.13; P = .02), with a Cohen d effect of 0.683 (medium to large effect). Overall, 17 patients (46%) with LN metastases had management changed because they were submitted to higher radioiodine ablation doses and closer clinical surveillance.CONCLUSIONS AND RELEVANCE Radioguided SLNB is able to detect occult cervical lymph node metastases in patients with papillary thyroid carcinoma, and in 7 patients (18%) rSLNB detected lymph node metastases in the lateral compartments. The rSLNB technique lead to management change in 14 patients (37.8%).

Background: Whilst some imaging signs of endometriosis are common and widely accepted as ‘typical’, a range of ‘subtle’ signs could be present in imaging studies, presenting an opportunity to the radiologist and the surgeon to aid the diagnosis and facilitate preoperative surgical planning. Objective: To summarise and analyse the current information related to indirect and atypical signs of endometriosis by ultrasound (US) and magnetic resonance imaging (MRI). Methods: Through the use of PubMed and Google scholar, we conducted a comprehensive review of available articles related to the diagnosis of indirect signs in transvaginal US and MRI. All abstracts were assessed and the studies were finally selected by two authors. Results: Transvaginal US is a real time dynamic exploration, that can reach a sensitivity of 79-94% and specificity of 94%. It allows evaluation of normal sliding between structures in different compartments, searching for adhesions or fibrosis. MRI is an excellent tool that can reach a sensitivity of 94% and specificity of 77% and allows visualisation of the uterus, bowel loop deviation and peritoneal inclusion cysts. It also allows the categorisation and classification of ovarian cysts, rectovaginal and vesicovaginal septum obliteration, and small bowel endometriotic implants. Conclusion: The use of an adequate mapping protocol with systematic evaluation and the reporting of direct and indirect signs of endometriosis is crucial for detailed and safe surgical planning.

A ata de defesa com as respectivas assinaturas dos membros da banca examinadora encontra-se no processo de vida acadêmica do aluno. Data: 26/02/2016 DEDICATÓRIA Dedico esta pesquisa a José Cabrera e Neusa, um casal simples, trabalhador e de valores inestimáveis. Nunca mediram esforços para que seus filhos pudessem estudar, mesmo que isso parecesse inalcançável. MEUS PAIS vocês são meus maiores exemplos de respeito, amor e compaixão ao ser humano. Tudo o que sou, devo a vocês. Ricardo e Rafael, meus irmãos e melhores amigos. Vocês fazem parte de todos os ciclos da minha vida e são a certeza de que não estarei sozinha. AGRADECIMENTOS À Prof a. Dra. Elba Cristina Sá de Camargo Etchebehere, minha orientadora, e ao Prof. Dr. Carlos Takahiro Chone, meu co-orientador, pelos quais tenho grande respeito e admiração, pois, mesmo extremamente atarefados, sempre estiveram disponíveis para solucionar todas as minhas dúvidas e foram os maiores incentivadores para que esse trabalho fosse realizado. À Prof a. Dra. Denise Engelbrecth Wittmann, por ter selecionado todos os pacientes que participaram deste trabalho e por estar sempre disponível para me ajudar.A todos os funcionários do Serviço de Medicina Nuclear da UNICAMP, pelo profissionalismo, organização e, particularmente, por permitirem que um novo protocolo fosse implantado numa rotina já tão sobrecarregada.Ao Clesnan Rodrigues-Oliveira, responsável por toda análise estatística deste estudo, por ter sido tão acolhedor e paciente nos momentos de maiores dúvidas.As secretárias Cristina Maria Alves dos Santos e Erika Oliveira Silva por todo auxílio, disponibilidade e cuidado.À secretária de Pós Graduação Marcinha, pela paciência, ajuda e atenção.Ao meu noivo, Diego José Leão de Oliveira, por todo carinho e torcida durante cada etapa, mas principalmente pela paciência e compreensão pela distância e tempo em que eu estava ausente. RESUMOObjetivo: Avaliar a capacidade da biópsia radioguiada do linfonodo sentinela (BLS R ) de detectar metástases ocultas do carcinoma papilífero de tireoide (CPT) e correlacionar a presença dessas metástases com as características clínicas e patológicas.Método: Quarenta e dois pacientes com diagnóstico de CPT e sem evidências clínicas e ultrassonográficas de comprometimento linfonodal cervical (34 mulheres, idade média de 47 anos) foram prospectivamente estudados. Os pacientes foram submetidos à linfocintilografia pré-operatória, após injeção peritumoral de fitato-99m Tc (7,4 MBq) guiada por ultrassonografia. Foram adquiridas imagens da região cervical através de uma tomografia computadorizada por emissão de fóton único acoplada à tomografia computadorizada (SPECT/CT), 15 minutos após a injeção do radiotraçador. Em seguida, o paciente foi conduzido ao centro cirúrgico para realização da BLS R (após cerca de 2 horas da linfocintilografia com SPECT/CT).Todos os linfonodos sentinelas identificados foram removidos, juntamente com pelo menos um linfonodo não sentinela do mesmo nível cervical. O carcinoma papilífero de tireoide, linfonodos sentinelas e lin...

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