Synchronous multifocal medullary and papillary thyroid microcarcinoma detected by elastography

INTRODUCTION

A few cases of concomitant medullary and papillary carcinoma in the same thyroid nodule have been described in the literature. However, the presence of multiple foci of both types of malignancy in the same gland is very rare.

PRESENTATION OF CASE

A 39 year-old female with multiple thyroid nodules, elevated serum calcitonin levels and elastographic findings suggestive of thyroid malignancy, underwent total thyroidectomy and central neck dissection. Histology revealed the presence of one focus of medullary and one focus of papillary carcinoma on each thyroid lobe. Subsequently, the patient underwent treatment with radioactive iodine.

DISCUSSION

This is the third case of synchronous multifocal medullary and papillary thyroid carcinoma reported in the literature. Several theories for the simultaneous development of these malignant entities have been proposed.

CONCLUSION

Ultrasound elastography can be a useful, noninvasive tool in the assessment of thyroid nodules.     

Case report of rare chronic myelogenous leukemia related multibacterial splenic abscess presenting with scrotal swelling

INTRODUCTION

Splenic abscesses associated with leukemia are rare. Most reported cases of splenic abscesses occur after chemotherapy and are related to the immunosuppressive effects of the chemotherapy. Their etiology is most frequently fungal.

PRESENTATION OF CASE

A 58-year-old male presented with splenomegaly and scrotal swelling secondary to a multibacterial splenic abscess which required a splenectomy. Upon investigation he was found to suffer from chronic myeloid leukemia (CML) and epididymitis.

DISCUSSION

Splenic abscesses are rarely found in leukemic patients. Reported cases are fungal and commonly occur after chemotherapy due to immunosuppression. Scrotal swelling with concurrent splenomegaly can be found in other pathologies including brucellosis, Lyme disease and even non-Hodgkin primary testicular lymphoma. Scrotal swelling in our case was likely secondary to epididymitis and exacerbated by the effects of splenomegaly upon the systemic circulation promoting venous congestion.

CONCLUSION

This case illustrated an unusual presentation of CML because the patient presented with splenomegaly, a multibacterial splenic abscess, and scrotal swelling.     

Primary intraosseous ACC of mandible of possible salivary origin: A rare clinical entity

INTRODUCTION

Adenoid cystic carcinoma (ACC) is a malignant tumor mainly of salivary origin which is well known for its deceptively benign histologic appearance characterized by indolent, locally invasive growth with high propensity for local recurrence and distant metastasis.

PRESENTATION OF CASE

An unusual case of a 23-year-old woman was reported in our hospital. After investigations, it showed that it is a second primary intraosseous lesion of mandible that occurred subsequently after ACC of parotid gland. After diagnosis was established, resection of tumor and reconstruction with a free fibula flap was performed. Ten months follow-up showed no signs of recurrence or metastasis.

DISCUSSION

Among the salivary neoplasms, adenoid cystic carcinoma is very rare and intraosseous lesions are even rarer. We found a total of 26 cases of primary ACC of the mandible reported in the literature. Pain and swelling were the most frequent symptoms.

CONCLUSION

This case illustrates two key facts. First, not all cystic lesions are necessarily metastatic or recurrence. Second is, even though the exact origin of this tumor is unknown, central salivary gland tumors should be considered in the differential diagnosis of cystic lytic lesions in the mandible.     

Metastasis from renal cell carcinoma to thyroid presenting as rapidly growing neck mass

INTRODUCTION

Renal cell carcinoma (RCC) is commonly known as the “internist''s tumor” because of its unpredictable behavior. Metastasis to the thyroid gland is rarely found in clinical practice.

PRESENTATION OF CASE

We report a rare case of non-thyroid malignancies NTM from renal cell carcinoma 1.5 years after radical nephrectomy in a 58-year-old man with a rapidly growing neck mass.

DISCUSSION

Malignant melanoma, breast carcinoma, lung, and skin cancer are the most common sources of non-thyroid malignancies (NTM). Although metastases of NTMs to the thyroid gland are uncommon in clinical practice, it should be considered in patients with a history of prior malignancy and a new thyroid mass.

CONCLUSION

Isolated thyroid metastasis should be considered in patients with a previous history of cancer and newly developing thyroid mass.     

Intravascular extension of papillary thyroid carcinoma to the internal jugular vein: A case report

INTRODUCTION

Papillary thyroid cancer (PTC) is the most common thyroid malignancy and usually spreads via lymphatic system. PTC can sometimes show microscopic vascular invasion, but rarely causes tumour thrombus in the internal jugular vein (IJV) or other great veins of the neck.

PRESENTATION OF CASE

We report a case of a 62-year-old female presented with symptomatic central neck mass. Clinical examination revealed a hard solitary right-sided thyroid nodule with ipsilateral cervical lymphadenopathy. Ultrasonography (US) confirmed the clinical diagnosis and visualised a dilated ipsilateral IJV. Fine-needle aspiration cytology revealed PTC cells so total thyroidectomy with right neck dissection was done. A tumour thrombus was discovered in the distended right IJV and was cleared successfully. The patient recovered well after the operation with no local or distant metastasis detected.

DISCUSSION

Tumour vascular spread is observed in tumours with angio-invasive features including follicular carcinoma of the thyroid gland where great cervical veins can be affected. PTC commonly spreads to the lymph nodes and vascular spread via direct intravascular extension is extremely rare. Neck US has an important role in the diagnosis, and operators should attempt to detect signs of tumour thrombi in all patients with thyroid masses. Aggressive surgical treatment with vascular repair is recommended whenever possible to minimise the risk of potentially fatal complications of the intraluminal masses.

CONCLUSION

Intravascular tumour extension of PTC is rare but with serious consequences. Diagnosis with neck US is possible but some cases are only discovered intraoperatively. Thrombectomy with vascular repair or reconstruction is usually possible.     

Amyloid goiter related with Crohn's disease: A rare association: Amyloid goiter secondary to Crohn's disease

INTRODUCTION

Amyloid goiter (AG) is characterized by enlargement of the thyroid gland as a result of extensive amyloid deposition in a bilateral and diffuse manner.

PRESENTATION OF CASE

A 58-year-old male patient was diagnosed of Crohn''s Disease (CD). He was admitted to our clinic with complaint of respiratory distress and rapid growth swelling in the neck. Ultrasound examination revealed huge multinodular goiter on both sides of thyroid gland. We performed bilateral total thyroidectomy. Pathological evaluation revealed AG.

DISCUSSION

Amyloid leads to degeneration in tissues, thereby disrupts the function of the relevant organs. It is important to distinguish AG from other reasons of goiter, particularly thyroid medullary cancer that can cause amyloid deposition in thyroid gland. Secondary amyloidosis frequently involves thyroid gland at microscopic level, but rarely causes goiter. An analysis of current literature revealed that only few cases of AG occurred secondary to CD. Herein we presented a case of AG who has rapidly growing goiter that associated with CD.

CONCLUSION

AG must be kept in mind in case of rapidly growing goiter, especially in patients with chronic inflammatory bowel diseases.     

Poorly differentiated thyroid carcinoma with sternal invasion. A case report and review of the literature

INTRODUCTION

Surgical resection of poorly differentiated thyroid carcinoma with direct invasion of the sternum has not been previously reported. Only 4 cases of concomitant thyroidectomy and sternal resection and reconstruction for sternal metastases have been published.

PRESENTATION OF CASE

A 66-year-old female with a poorly differentiated thyroid carcinoma and direct sternal invasion underwent total thyroidectomy and resection of the manubrium and both clavicular heads, and chest wall reconstruction with polypropylene mesh and bilateral myocutaneous pectoralis major muscle flaps. Postoperatively, the patient received radioactive iodine ablation. She developed a local recurrence, requiring additional ablation with radioactive iodine and external beam radiation therapy. Although there was no clinical or radiographic evidence of recurrent disease 5-years postoperatively, a possible local recurrence was discovered 4 months later.

DISCUSSION

In previous case reports the sternal metastases were not in continuity with the thyroid tumor. In our patient, however, there was evidence of direct extension between the thyroid tumor and the sternal mass that were connected together with cords of tumor.

CONCLUSION

In our patient with poorly differentiated thyroid carcinoma invading the sternum, total thyroidectomy and resection of the manubrium with sternal reconstruction, combined with adjuvant radioactive iodine ablation and external beam radiation therapy was associated with prolonged survival after 5 years despite a small local recurrence.     

Lingual thyroid: A case report

Introduction

Lingual thyroid (LT) gland is a rare clinical entity which was found to occur due to the failure of the thyroid gland to descend to its normal cervical location during embryogenesis. The presence of an ectopic thyroid gland located at the base of the tongue may present with symptoms like dysphagia, dysphonia, upper airway obstruction or even hemorrhage at any time from infancy through adulthood.

Presentation of case

We are presenting a case of 5-year-old girl who presented with lingual thyroid, treated with Suppression treatment followed by elective surgical resection.

Discussion

Incidence of ectopic lingual thyroid gland is reported as 1:100,000. It is more common in females. Most of presentations due to oropharyngeal obstruction, including dysphagia, dyspnea and dysphonia. Investigations include thyroid function tests, neck US, Technetium scanning and C.T.

Conclusion

Lingual thyroid is a rare anomaly. Dysphagia and dysphonia are common presenting symptoms. Pathogenesis of this ectopic is unknown. Different types of surgical approaches have been described in the management.     

Investigation prior to thyroglossal duct cyst excision

INTRODUCTION

Investigation of the anterior midiine neck lump has been debated over the years with little agreement on best practice. Thyrogiossai duct cysts (TDCs) are the most common aetiology. A TDC may contain ectopic thyroid tissue, which may affect the decision to excise.

METHODS

A computerised survey was sent to a representative sample of UK-based ENT surgeons to determine current practice in investigation of presumed TDCs and the incidence of ectopic thyroid tissue.

RESULTS

Overall, 95% of those surveyed use ultrasonography, with 32% also arranging thyroid function tests. Fifteen per cent had encountered absent normal thyroid tissue in the presence of a midiine neck swelling. In 64% of cases this represented the only functioning thyroid tissue. Thyroid function tests were normal in all but two cases.

CONCLUSIONS

The results show a significant change in practice over the last decade. All surgeons would arrange some form of investigation of a presumed TDC, with the vast majority using ultrasonography. Radioisotope scanning should only be used if the ultrasonography or thyroid function tests are abnormal. The incidence of ectopic thyroid tissue in this survey was higher than previously calculated, with a 0.17% prevalence of midiine neck lumps representing the only functioning thyroid tissue.     

Follicular unit transplantation for the treatment of secondary cicatricial alopecia

BACKGROUND:

Cicatricial alopecia encompasses a diverse group of disorders characterized by the permanent destruction of hair follicles and irreversible hair loss. Follicular unit transplantation was developed in 1994. However, large-scale clinical trials are necessary to study follicular unit transplantation for treating Chinese cicatricial alopecia patients.

OBJECTIVE:

To investigate the efficacy of follicular unit transplantation in the treatment of cicatricial alopecia in Chinese patients.

METHODS:

Patients with cicatricial alopecia were enrolled. The designated recipient area, follicular unit density of the donor site, transplanted density and operative time were recorded. Postoperative follow-up was conducted within six to 24 months; the density of hair in the recipient area was calculated using a Folliscope (Hansderma Co, USA). Patients’ self-reported satisfaction and long-term complications were recorded.

RESULTS:

Thirty-seven patients were enrolled. Cicatricial alopecia was caused by burns (n=8), trauma (n=21) and plastic surgery (cleft lip and palate repair [n=8]). Burn patients had a significantly larger bald area than the other patients (P<0.01). The operative time was significantly correlated with recipient area. The longest operation was 14.5 h; the largest transplanted area was 96 cm². At follow-up, the surviving follicular unit density/transplanted follicular unit density rate was 64.29% to 95.00% (mean 78.96%); the surviving/transplanted (S/T) area was 100% for 30 patients, 90% to 100% for five patients and <90% for two patients. The lowest S/T area was 82.81%. The S/T index was significantly and inversely correlated with operative time. Regarding long-term complications, two patients had postoperative epidermoid cysts that healed with local treatment.

CONCLUSION:

Follicular unit transplantation is an effective method for treating cicatricial alopecia. It is relatively safe and yields satisfactory postoperative results. Extending the results of the present study to Chinese clinical practice is warranted.     

De Garengeot Hernia

Background and Objectives:

We report a case of appendicitis presenting in an incarcerated femoral hernia, otherwise known as de Garengeot hernia. This rare hernia usually presents with both diagnostic and therapeutic dilemmas. We wish to underline the usefulness of laparoscopy in both the diagnosis and treatment of de Garengeot hernias.

Methods:

A diagnostic laparoscopy was performed initially. The appendix was seen to disappear into the hernia sac. A laparoscopic appendectomy was then performed prior to open exploration of the groin.

Results:

We were able to obtain a correct diagnosis and perform an appendectomy prior to making a groin incision. Operative findings included an incarcerated, inflamed appendix within a femoral hernia.

Conclusions:

Diagnostic laparoscopy could be a valuable tool in the correct diagnosis and management of unusual presentations of incarcerated groin hernias.     

Differentiated thyroid cancer: feasibility of loboisthmectomy in an endemic region

Aim

The aim of the present retrospective study was to assess the feasibility of loboisthmectomy for the treatment of differentiated thyroid cancer in a endemic area, evaluating the histopathological features and the results of a case series of 1154 patients.

Patients and Methods

The clinical records of 1154 patients submitted to total thyroidectomy in our Department were retrospectively reviewed to analyze the histopathological characters and the results.

Results

In 1044 cases (90.5%) a papillary cancer was observed, in 110 (9.5%) a follicular carcinoma; microcarcinomas were 399 (34.5%). Multifocality was present in 323 cases (28%), in 142 unilateral (12.3%) and in 181 bilateral (15.7%). Thyroiditis coexisted in 472 patients (40.9%), multinodular goiter in 404 (35%), Graves’ disease in 48 (4.1%), and multinodular toxic goiter in 38 (3.3%). Complications were: postoperative bleeding in 20 patients (1.7%), transient unilateral vocal cord paralysis in 20 (1.7%) definitive in 10 (0.86%), a transient bilateral paralysis in 1 (0.08%), a transient hypoparathyroidism in 351 (30.4%), and a definitive in 24 (2.07%). Nodal recurrence occurred in 25 patients (2.16%).

Conclusions

Total thyroidectomy remains the safest treatment in differentiated thyroid cancer, especially if performed in high volume centers in which complications can be minimized. Loboisthmectomy can be a viable and safe alternative in small (< 1 cm) unifocal tumors in patients at low risk. Loboisthmectomy is limited in endemic areas by the association with other thyroid diseases. A correct and detailed information of the patient is essential before planning surgery.     

Co-occurrence of papillary thyroid cancer and MALT lymphoma of the thyroid with severe airway obstruction: A case report and review of the literature

INTRODUCTION

Co-occurrence of papillary thyroid carcinoma (PTC) and mucosa-associated lymphoid tissue (MALT) lymphoma resulting in severe airway obstruction is very rare.

PRESENTATION OF CASE

A 58-year-old woman visited our department because of enlargement of a neck mass. Computed tomography (CT) and ultrasonography showed 2 discrete hypoechoic nodules. Fine-needle aspiration biopsy revealed thyroid lymphoma in the left lobe and PTC in the right lobe. After 1 week, she returned to the emergency room at our hospital with shortness of breath and difficultly in swallowing. CT revealed enlargement of the left lobe, which was severely compressing the trachea. We performed emergency total thyroidectomy with lymphadenectomy. The postoperative course was uneventful, and the patient was discharged without any symptoms.

DISCUSSION

The most common treatment for PTC is surgery; however, the treatment for thyroid lymphoma remains controversial. We propose that surgery be performed in the cases of symptoms such as shortness of breath and difficulty in swallowing.

CONCLUSION

We performed emergency total thyroidectomy to relieve obstruction of the trachea and to remove the two malignant tumors. We suggest total thyroidectomy for a case of co-occurrence of two malignant tumors, causing severe airway obstruction.     

Neuroendocrine breast carcinoma metastatic to the liver: Report of a case and review of the literature

INTRODUCTION

Primary neuroendocrine breast carcinoma (NEBC) is a rare entity of breast cancer.

PRESENTATION OF CASE

We herein report a case of right hepatectomy for a NEBC liver metastasis.

DISCUSSION

Little is known about its evolution, bilologic behavior and optimal treatment. Its malignant potential has been addressed in few reports, with cases of metachronous metastases in diverse sites, even years following treatment of the breast primarily.

CONCLUSION

Treating this kind of cancer implies both breast and hepatic surgery.Primary neuroendocrine breast carcinoma (NEBC) is a rare entity of breast cancer. Little is known about its evolution, biologic behavior and optimal treatment. Its malignant potential has been addressed in few reports, with cases of metachronous metastases in diverse sites, even years following treatment of the breast primarily. We herein report a case of right hepatectomy for a NEBC liver metastasis.     

An uncommon folliculosebaceous cystic hamartoma on the lower extremity

BACKGROUND:

Folliculosebaceous cystic hamartomas (FSCH) are a recently recognized cutaneous hamartoma comprised of follicular, sebaceous and mesenchymal elements. Only nine cases have been previously reported. The authors present a case of FSCH on the lower extremity in addition to a literature review.

OBJECTIVE:

To further characterize the clinical, histological and immunohistological features of FSCH.

METHODS:

The clinical, histological and immunohistological features of FSCH were evaluated and the literature reviewed.

RESULTS:

This lesion uncommonly presents as exophytic papules or nodules on the leg, and most commonly presents on the central part of the face. Clinical differential diagnoses included nevus, neurofibroma and adnexal tumour. The diagnostic microscopic features of infundibular cystic structures with attached sebaceous glands and characteristic stroma were present in all lesions. Many of the stromal spindle cells were CD34-positive.

CONCLUSION:

The FSCH is a recently recognized hamartoma comprised of follicular, sebaceous and mesenchymal elements. Although reported only rarely, its incidence is likely much higher. In the present patient, the FSCH was located in femoral region, which is very rare.     

The female athlete triad: a case series and narrative overview

Objective:

To illustrate the varying presentations of the female athlete triad and to inform the practitioner of the potential sequelae of this common condition.

Clinical Features:

Four patients presented with a variety of signs and symptoms of the female athlete triad including low caloric intake, osteoporosis, amenorrhea and/or endothelial dysfunction.

Intervention and Outcome:

A conservative treatment approach was utilized in each case including education on the female athlete triad, education on increased caloric intake and a referral to the family physician.

Conclusion:

Health care practitioners should be aware of the different clinical presentations of the female athlete triad. A narrative review of the literature is provided to educate practitioners on the components of the female athlete triad, proper diagnosis and appropriate management.     

Primary squamous cell carcinoma of breast with ipsilateral axillary lymph node metastasis: An unusual case

Introduction

Pure squamous cell carcinoma of the breast [SCCB] is rare.

Presentation of Case

We report a case of primary squamous cell carcinoma of breast with ipsilateral axillary lymph node metastasis in a 58year old woman.

Discussion

It is a breast carcinoma entirely composed of metaplastic squamous cells that may be keratinized, non-keratinized or spindled. The pure squamous cell carcinoma usually present with central cystic cavity, which we found in our case, also supported by immunohistochemical evidence.

Conclusion

Although a rare breast cancer subtype, SCCB is of considerable interest due to its pathological heterogeneity and differences in clinical behavior and less reported occurrence of nodal metastasis.     

Invasive Lobular Carcinoma of the Male Breast: A Rare Histology in an Uncommon Disease

Summary

Background

Breast cancer in men is an uncommon disease. Nearly all cases of male breast cancer originate in the terminal ductulolobular unit, with exceedingly rare reports of lobular carcinoma in men. Invasive lobular cancer is found in no more than 1-2% of male breast cancer cases. Most of what is known about this disease is in the form of approximately 30 case reports in the literature.

Case Report

We report the case of a 52-year-old man who presented at our institution with a lump in his left breast. Ultrasound-guided biopsy revealed an invasive lobular cancer. The rare histological type was confirmed by the result of the histological examination of the mastectomy specimen. The treatment was completed by dose dense chemotherapy, radiation, and endocrine therapy.

Conclusion

Even though lobular structures are quite infrequent in the normal male, sporadic cases of invasive lobular breast cancer have been described. A short overview will be given in this case report.Key Words: Male breast cancer, Lobular carcinoma, Rare histology     

Gastric schwannoma: a benign tumour often mistaken clinically, radiologically and histopathologically for a gastrointestinal stromal tumour--a case series

INTRODUCTION

Gastric schwannomas are rare mesenchymal tumours that arise from the nerve plexus of the gut wall. They present with non-specific symptoms and are often detected incidentally. Pre-operative investigation is not pathognomonic and many are therefore diagnosed as gastrointestinal stromal tumours (GISTs). Operative resection is usually curative as they are almost always benign, underpinning the importance of differentiating them from GISTs.

METHODS

Three cases of gastric schwannomas were identified over a seven-year period. The clinical details and management were reviewed retrospectively.

RESULTS

There were two women and one man with a mean age of 62 years (range: 51–69 years). Two patients presented with bleeding and one with abdominal pain. The mean tumour size was 5.2cm (range: 2–10cm) and the tumours were resected completely following total or wedge gastrectomies. Histology in all cases showed spindle cells with a cuff of lymphoid tissue. Immunohistochemistry confirmed positive S100 staining and negative CD117 and DOG-1 staining in all cases.

CONCLUSIONS

We report our experience with these unusual primary stromal tumours of the gut and their presentations, preoperative investigations, operative findings and pathological findings are discussed. Operative resection in all cases has been considered curative, which is supported by previous series confirming the excellent prognosis of gastric schwannomas.