Related Disciplines > Surgery
You are looking at 51 - 60 of 92 items
Search for other papers by Alex González Bóssolo in
Google Scholar
PubMed
Search for other papers by Michelle Mangual Garcia in
Google Scholar
PubMed
Search for other papers by Paula Jeffs González in
Google Scholar
PubMed
Search for other papers by Miosotis Garcia in
Google Scholar
PubMed
Search for other papers by Guillermo Villarmarzo in
Google Scholar
PubMed
Search for other papers by Jose Hernán Martinez in
Google Scholar
PubMed
Summary
Classical papillary thyroid microcarcinoma (PTMC) is a variant of papillary thyroid carcinoma (PTC) known to have excellent prognosis. It has a mortality of 0.3%, even in the presence of distance metastasis. The latest American Thyroid Association guidelines state that although lobectomy is acceptable, active surveillance can be considered in the appropriate setting. We present the case of a 37-year-old female with a history of PTMC who underwent surgical management consisting of a total thyroidectomy. Although she has remained disease-free, her quality of life has been greatly affected by the sequelae of this procedure. This case serves as an excellent example of how first-line surgical treatment may result more harmful than the disease itself.
Learning points:
-
Papillary thyroid microcarcinoma (PTMC) has an excellent prognosis with a mortality of less than 1% even with the presence of distant metastases.
-
Active surveillance is a reasonable management approach for appropriately selected patients.
-
Patients should be thoroughly oriented about the risks and benefits of active surveillance vs immediate surgical treatment. This discussion should include the sequelae of surgery and potential impact on quality of life, especially in the younger population.
-
More studies are needed for stratification of PTMC behavior to determine if conservative management is adequate for all patients with this specific disease variant.
Search for other papers by Colin L Knight in
Google Scholar
PubMed
Search for other papers by Shamil D Cooray in
Google Scholar
PubMed
Search for other papers by Jaideep Kulkarni in
Google Scholar
PubMed
Director of Otolaryngology, University Hospital Geelong, Geelong, Victoria, Australia
Search for other papers by Michael Borschmann in
Google Scholar
PubMed
Deakin University School of Medicine, Geelong, Victoria, Australia
Melbourne Clinical School-Western Campus, Department of Medicine, The University of Melbourne, St. Albans, Victoria, Australia
Search for other papers by Mark Kotowicz in
Google Scholar
PubMed
A 51 year old man presented with sepsis in the setting of thioamide-induced agranulocytosis. Empiric broad-spectrum antibiotics was followed by directed narrow-spectrum antibiotics, and his neutrophil count recovered with support from granulocyte-colony stimulating factor (G-CSF) analogue transfusions. After a brief period of multi-modal therapy for nine days including potassium iodide (Lugol’s iodine), cholestyramine, propanolol and lithium to temper his persisting hyperthyroidism, a total thyroidectomy was performed while thyroid hormone levels remained at thyrotoxic levels. Postoperative recovery was uncomplicated and he was discharged home on thyroxine. There is limited available evidence to guide treatment in this unique cohort of patients who require prompt management to avert impending clinical deterioration. This case report summarises the successful emergent control of thyrotoxicosis in the setting of thioamide-induced agranulocytosis complicated by sepsis, and demonstrates the safe use of multi-modal pharmacological therapies in preparation for total thyroidectomy.
Learning points:
-
Thioamide-induced agranulocytosis is an uncommon but potentially life-threatening complication of which all prescribers and patients need to be aware.
-
A multi-modal preoperative pharmacological approach can be successful, even when thioamides are contraindicated, when needing to prepare a thyrotoxic patient for semi-urgent total thyroidectomy.
-
There is not enough evidence to confidently predict the safe timing when considering total thyroidectomy in this patient cohort, and therefore it should be undertaken when attempts have first been made to safely reduce thyroid hormone levels.
-
Thyroid storm is frequently cited as a potentially severe complication of thyroid surgery undertaken in thyrotoxic patients, although the evidence does not demonstrate this as a common occurrence.
Search for other papers by Maryam Heidarpour in
Google Scholar
PubMed
Search for other papers by Mehdi Karami in
Google Scholar
PubMed
Search for other papers by Pegah Hedayat in
Google Scholar
PubMed
Search for other papers by Ashraf Aminorroaya in
Google Scholar
PubMed
Summary
Primary hyperparathyroidism revealed by thoracic spine brown tumor and peptic ulcer bleeding is rare. We presented a case of 33-year-old male patient who was admitted with paraplegia. Thoracic spine magnetic resonance imaging (MRI) showed extradural lesion at T4 level. He underwent surgical decompression in T4. According to histopathologic finding and elevated serum parathormone (PTH) and hypercalcemia (total serum calcium 12.1 mg/dL), the diagnosis of brown tumor was down. Ultrasonography of his neck showed a well-defined lesion of 26 × 14 × 6 mm. The day after surgery, he experienced 2 episodes of melena. Bedside upper gastrointestinal endoscopy showed gastric peptic ulcer with visible vessel. Treatment with intragastric local instillation of epinephrine and argon plasma coagulation was done to stop bleeding. After stabilization of the patient, parathyroidectomy was performed. Histologic study showed the parathyroid adenoma without any manifestation of malignancy. At discharge, serum calcium was normal (8.6 mg/dL). On 40th day of discharge, standing and walking status was normal.
Learning points:
-
Thoracic spine involvement is a very rare presentation of primary hyperparathyroidism.
-
The issue of whether primary hyperparathyroidism increases the risk of peptic ulcer disease remains controversial. However, gastrointestinal involvement has been reported in association with classic severe primary hyperparathyroidism.
-
The treatment of brown tumor varies from case to case.
Search for other papers by Georgios Velimezis in
Google Scholar
PubMed
Search for other papers by Argyrios Ioannidis in
Google Scholar
PubMed
Search for other papers by Sotirios Apostolakis in
Google Scholar
PubMed
Search for other papers by Maria Chorti in
Google Scholar
PubMed
Search for other papers by Charalampos Avramidis in
Google Scholar
PubMed
Search for other papers by Evripidis Papachristou in
Google Scholar
PubMed
Summary
During embryogenesis, the thymus and inferior parathyroid glands develop from the third pharyngeal pouch and migrate to their definite position. During this process, several anatomic variations may arise, with the thyroid being one of the most common sites of ectopic implantation for both organs. Here, we report the case of a young female patient, who underwent total thyroidectomy for papillary carcinoma of the thyroid. The patient’s history was remarkable for disorders of the genitourinary system. Histologic examination revealed the presence of well-differentiated intrathyroidal thymic tissue, containing an inferior parathyroid gland. While each individual entity has been well documented, this is one of the few reports in which concurrent presentation is reported. Given the fact that both the thymus and the inferior parathyroid are derivatives of the same embryonic structure (i.e. the third pharyngeal pouch), it is speculated that the present condition resulted from a failure in separation and migration during organogenesis.
Learning points:
-
Intrathyroidal thymus and parathyroid are commonly found individually, but rarely concurrently.
-
It is a benign and asymptomatic condition.
-
Differential diagnosis during routine workup with imaging modalities can be challenging.
Search for other papers by Gulay Simsek Bagir in
Google Scholar
PubMed
Search for other papers by Soner Civi in
Google Scholar
PubMed
Search for other papers by Ozgur Kardes in
Google Scholar
PubMed
Search for other papers by Fazilet Kayaselcuk in
Google Scholar
PubMed
Search for other papers by Melek Eda Ertorer in
Google Scholar
PubMed
Summary
Pituitary apoplexy (PA) may very rarely present with hiccups. A 32-year-old man with classical acromegaloid features was admitted with headache, nausea, vomiting and stubborn hiccups. Pituitary magnetic resonance imaging (MRI) demonstrated apoplexy of a macroadenoma with suprasellar extension abutting the optic chiasm. Plasma growth hormone (GH) levels exhibited suppression (below <1 ng/mL) at all time points during GH suppression test with 75 g oral glucose. After treatment with corticosteroid agents, he underwent transsphenoidal pituitary surgery and hiccups disappeared postoperatively. The GH secretion potential of the tumor was clearly demonstrated immunohistochemically. We conclude that stubborn hiccups in a patient with a pituitary macroadenoma may be a sign of massive apoplexy that may result in hormonal remission.
Learning points:
-
Patients with pituitary apoplexy may rarely present with hiccups.
-
Stubborn hiccupping may be a sign of generalized infarction of a large tumor irritating the midbrain.
-
Infarction can be so massive that it may cause cessation of hormonal overproduction and result in remission.
Search for other papers by Marta Araujo Castro in
Google Scholar
PubMed
Search for other papers by Ainhoa Abad López in
Google Scholar
PubMed
Search for other papers by Luz Martín Fragueiro in
Google Scholar
PubMed
Search for other papers by Nuria Palacios García in
Google Scholar
PubMed
Summary
The 85% of cases of primary hyperparathyroidism (PHPT) are due to parathyroid adenomas (PA) and less than 1% to parathyroid carcinomas (PC). The PA usually measure <2 cm, weigh <1 g and generate a mild PHPT, whereas the PC usually exceeds these dimensions and are associated with a severe PHPT. However, giant PA (GPA), which is defined as those larger than 3 g, has been documented. Those may be associated with very high levels of PTH and calcium. In these cases, their differentiation before and after surgery with PC is very difficult. We present a case of severe PHPT associated with a large parathyroid lesion, and we discuss the differential aspects between the GPA and PC.
Learning points:
-
In parathyroid lesions larger than 2 cm, the differential diagnosis between GPA and PC should be considered.
-
Pre and postsurgical differentiation between GPA and PC is difficult; however, there are clinical, analytical and radiographic characteristics that may be useful.
-
The depth/width ratio larger or smaller than 1 seems to be the most discriminatory ultrasound parameter for the differential diagnosis.
-
Loss of staining for parafibromin has a specificity of 99% for the diagnosis of PC.
-
The simultaneous presence of several histological characteristics, according to the classification of Schantz and Castleman, is frequent in PC and rare in GPA.
Search for other papers by Melissa H Lee in
Google Scholar
PubMed
Search for other papers by Penelope McKelvie in
Google Scholar
PubMed
Search for other papers by Balasubramanian Krishnamurthy in
Google Scholar
PubMed
Search for other papers by Yi Yuen Wang in
Google Scholar
PubMed
Search for other papers by Carmela Caputo in
Google Scholar
PubMed
Summary
Most cases of acromegaly are due to growth hormone (GH)-secreting pituitary adenomas arising from somatotroph cells. Mixed pituitary adenoma and gangliocytoma tumours are rare and typically associated with hormonal hypersecretion, most commonly GH excess. Differentiating these mixed tumours from conventional pituitary adenomas can be difficult pre-operatively, and careful histological analysis after surgical resection is key to differentiating the two entities. There is little literature addressing the possible mechanisms for the development of mixed pituitary adenoma–gangliocytomas; however, several hypotheses have been proposed. It still remains unclear if these mixed tumours differ from a clinical perspective to pituitary adenomas; however, the additional neural component of the gangliocytoma does not appear to modify the aggressiveness or risk of recurrence after surgical resection. We report a unique case of acromegaly secondary to a mixed GH-secreting pituitary adenoma, co-existing with an intrasellar gangliocytoma.
Learning points:
-
Acromegaly due to a mixed GH-secreting pituitary adenoma and intrasellar gangliocytoma is rare.
-
These mixed tumours cannot be distinguished easily from ordinary pituitary adenomas on the basis of clinical, endocrine or neuroradiologic findings, and histological analysis is required for a definitive diagnosis.
-
Surgical resection is usually sufficient to provide cure, without the need for adjuvant therapy.
-
These mixed tumours appear to have a good prognosis although the natural history is not well defined.
-
The pathogenesis of these mixed tumours remains debatable, and ongoing research is required.
Search for other papers by Shamil D Cooray in
Google Scholar
PubMed
Department of Medicine, Monash University, Melbourne, Australia
Search for other papers by Duncan J Topliss in
Google Scholar
PubMed
Summary
A 58-year-old man with metastatic radioiodine-refractory differentiated thyroid cancer (DTC) presented with left thigh and right flank numbness. He had known progressive and widespread bony metastases, for which he received palliative radiotherapy, and multiple bilateral asymptomatic pulmonary metastases. CT scan and MRI of the spine revealed metastases at right T10–L1 vertebrae with extension into the central canal and epidural disease at T10 and T11 causing cord displacement and canal stenosis but retention of spinal cord signal. Spinal surgery was followed by palliative radiotherapy resulting in symptom resolution. Two months later, sorafenib received approval for use in Australia and was commenced and up-titrated with symptomatic management of mild adverse effects. Follow-up CT scan three months after commencement of sorafenib revealed regression of pulmonary metastases but no evident change in most bone metastases except for an advancing lesion eroding into the right acetabulum. The patient underwent a right total hip replacement, intra-lesional curettage and cementing. After six months of sorafenib therapy, CT scanning showed enlarging liver lesions with marked elevation of serum thyroglobulin. Lenvatinib was commenced and sorafenib was ceased. He now has stable disease with a falling thyroglobulin more than 5 years after metastatic radioiodine-refractory DTC was diagnosed.
In DTC, 5% of distant metastases become radioiodine-refractory, resulting in a median overall survival of 2.5–3.5 years. Tyrosine kinase inhibitor (TKI) therapy has recently been demonstrated to increase progression-free survival in these patients but poses some unique management issues and is best used as part of an integrated approach with directed therapy.
Learning points:
-
Directed therapies may have greater potential to control localised disease and related symptoms when compared to systemic therapies.
-
Consider TKI therapy in progressive disease where benefits outweigh risks.
-
Active surveillance and timely intervention are required for TKI-related adverse effects.
-
There is a need for further research on the clinical application of TKI therapy in advanced DTC, including comparative efficacy, sequencing and identifying responders.
Search for other papers by Rowena Speak in
Google Scholar
PubMed
Search for other papers by Jackie Cook in
Google Scholar
PubMed
Search for other papers by Barney Harrison in
Google Scholar
PubMed
Endocrinology
Search for other papers by John Newell-Price in
Google Scholar
PubMed
Mutations of the rearranged during transfection (RET) proto-oncogene, located on chromosome 10q11.2, cause multiple endocrine neoplasia type 2A (MEN2A). Patients with mutations at the codon 609 usually exhibit a high penetrance of medullary thyroid cancer (MTC), but a sufficiently low penetrance of phaeochromocytoma that screening for this latter complication has been called to question. Patients with other RET mutations are at higher risk of younger age onset phaeochromocytoma if they also possess other RET polymorphisms (L769L, S836S, G691S and S904S), but there are no similar data for patients with 609 mutations. We investigated the unusual phenotypic presentation in a family with MEN2A due to a C609Y mutation in RET. Sanger sequencing of the entire RET-coding region and exon–intron boundaries was performed. Five family members were C609Y mutation positive: 3/5 initially presented with phaeochromocytoma, but only 1/5 had MTC. The index case aged 73 years had no evidence of MTC, but presented with phaeochromocytoma. Family members also possessed the G691S and S904S RET polymorphisms. We illustrate a high penetrance of phaeochromocytoma and low penetrance of MTC in patients with a RET C609Y mutation and polymorphisms G691S and S904S. These data highlight the need for life-long screening for the complications of MEN2A in these patients and support the role for the screening of RET polymorphisms for the purposes of risk stratification.
Learning points:
-
C609Y RET mutations may be associated with a life-long risk of phaeochromocytoma indicating the importance of life-long screening for this condition in patients with MEN2A.
-
C609Y RET mutations may be associated with a lower risk of MTC than often quoted, questioning the need for early prophylactic thyroid surgery discussion at the age of 5 years.
-
There may be a role for the routine screening of RET polymorphisms, and this is greatly facilitated by the increasing ease of access to next-generation sequencing.
Search for other papers by Chun-Han Lo in
Google Scholar
PubMed
Search for other papers by Ding-Ping Sun in
Google Scholar
PubMed
Summary
Insulinomas are the most common cause of hypoglycemia resulting from endogenous hyperinsulinism. Traditionally, inappropriately elevated levels of insulin in the face of hypoglycemia are the key to diagnosis. However, contradictory levels of insulin and C-peptide do not necessarily exclude the diagnosis. A 50-year-old female was brought to our emergency department because of conscious disturbance on the previous night. She had no history of diabetes mellitus, and was not using any medications or alcohol. Laboratory data showed low sugar, a significantly low insulin level, and elevated C-peptide. After admission, she had multiple episodes of spontaneous hypoglycemia after overnight fasts without discomfort. It was considered that a neuroendocrine tumor was the source of her hypoglycemia. CT scan of the abdomen revealed a 1.1cm hypervascular nodule in the pancreatic tail. Elective laparoscopic distal pancreatectomy was incorporated into her treatment course. A 1.2×1.0cm homogenous well-encapsulated tumor was resected. We monitored her glucose levels in the outpatient clinic every month for a period of six months. She did not have another episode of spontaneous hypoglycemia.
Learning points
Insulinoma causes endogenous hypoglycemia – it cannot be ruled out in patients presenting with hypoglycemia and low insulin levels; history and imaging studies should be done for further assessment
A 24-h fast test has the same clinical significance as that of 72-h fast test
C-peptide is a useful biochemical marker in addition to serum insulin, which can be used to diagnose insulinomas
CT scan is used to measure the tumor size and localize the tumor. However, definitive diagnosis is only achieved through histopathologic evaluation of diseased tissue
