Sonographic findings in autonomous adenoma of the thyroid gland in a goiter-endemic region

Ultrasound scanning was carried out in 84 patients with autonomous nodules and 67 patients with inactive nodules. The echo pattern was correlated to the macro- and microscopic findings as well as to the function of the nodules. The autonomous nodules showed a low echogenicity in 57%, a normal parenchyma-identical echogenicity in 10% and a high echogenicity in 33%. In comparison the echo pattern of the inactive nodules showed low level echoes in 31%, normal in 36% and a high level echoes in 31%. Only one third of the nodules showed a homogeneous echo pattern, one third showed liquid degeneration and one third a mixed echo pattern. There is no correlation between the echo pattern of the autonomous nodules and the metabolic function of the nodules. 65 patients have been operated (37 autonomous and 28 inactive nodules). The macroscopic findings showed bleeding and cysts in most of the echo-poor nodules, also those with homogeneous structures. In the histological findings microfollicular structures were found in both high- and low-echogenicity nodules (18/16%). Macrofollicular changes and mixed forms were found mainly in nodules with parenchyma-identical and high echogenicity (58/48%). Ultrasound is very helpful in the morphological diagnosis of thyroid nodules, but there is no significant correlation to metabolic activity or to microscopic structures of the nodules in the thyroid gland.     

Lipid-rich cell thyroid adenoma: histopathology with comparative lipid analysis

Summary A second case of the unique lipid-rich cell thyroid adenoma is described complemented by detailed lipid analysis. New observations were made. The cytoplasm of the tumour cells contained scattered, aggregated sudanophil crystals; under polarized light the frozen, unstained sections exhibited numerous birefringent lipid crystals; electron microscopy provided further evidence that the clear cell appearance was due to intracellular lipid droplets with scanty glycogen particles. Comparative lipid analysis by thin layer chromatography and high-pressure liquid chromatography (HPLC) revealed quantitative and qualitative differences in lipid composition of tumour cells when compared with goitre cells from normal thyroid gland and subcutane fat. Qualitative differences in triglyceride composition (by HPLC) between tumour cells and subcutaneous fat indicated that the fat accumulation in the follicle cells was not a result of simple storage, but an expression of altered intracellular lipid metabolism.Preliminary results presented at the XII European Congress of Pathology, Porto, Portugal, 1989     

Trisomy 18 in a canine thyroid adenoma

A canine thyroid adenoma showing trisomy 18 as the sole clonal cytogenetic abnormality (9 of 30 analyzed metaphases) is reported. Because trisomies are a recurrent cytogenetic finding in human benign thyroid tumors as well, it is suggested that the molecular relationship between these trisomies and the development of thyroid tumors can be determined by comparative gene mapping.     

Sources and nature of variation in DNA analysis of follicular thyroid adenoma

We investigated the sources and nature of variation that may occur in the DNA analysis of thyroid adenomas from cytological and histological samples. Imprints and smears gave identical results. However, the nuclear area was higher in smears where the optical density of the nuclei was lower. In measuring imprints, the interactive selection of nuclei was preferred to the automatic, because the risk of measuring nuclear fragments or undesired objects was thus avoided. The reproducibility and the variation of the DNA measurements depended on the degree of observer training in quantitative pathology, the method of field selection, and the type of instrumentation. Biological variation in the spatial distribution of nuclei with different ploidy values in some adenomas seemed to hide the influence of section thickness on measurements. Our data seem to suggest that it is best to apply a constant section thickness and 5 micron sections seem acceptable.     

Immunohistochemical analysis of survivin expression in thyroid follicular adenoma and carcinoma.

Survivin is one of the 8 members of human inhibitor of apoptosis , which is differentially expressed in cancerous/transformed cells versus normal differentiated tissues. This retrospective study of thyroid histologic samples aimed to assess the clinical usefulness of survivin immunostaining for discrimination between follicular adenoma and carcinoma of thyroid. Immunohistochemical staining for survivin was performed on 41 lesions from patients who had undergone surgery for either follicular adenoma or carcinoma of thyroid. Survivin expression was significantly (P < 0.005) higher in the cases that received a diagnosis of carcinoma in comparison with follicular adenomas cases. Odds ratio of follicular carcinoma for survivin expression was 21.375 (95% CI: 3.283 to 139.177). Our results showed potential value of survivin in discrimination between follicular thyroid adenoma and follicular thyroid carcinoma. We conclude that survivin is a potential candidate for further investigation in the proper histologic diagnosis of thyroid cancers.     

Functioning oxyphil cell adenoma in a patient with secondary hyperparathyroidism

A 45-year-old Japanese woman who has been receiving haemodialysis for 13 years suffered from an ectopic calcifying nodule and deformity of the thorax. She was diagnosed as hyperparathyroidism secondary to chronic renal failure. Total parathyroidectomy was performed, and the excised parathyroid glands showed hyperplasia in four and an adenoma in the left upper gland. On the electron microscopic study, the adenoma was composed of oxyphil cells and transitional oxyphil cells, the latter predominating in number. It was revealed from immunohistochemical study that the oxyphil cells in adenoma were strongly stained for parathyroid hormone (PTH). Continuous stimuli to secrete PTH seemed to generate the functioning oxyphil cell adenoma with an ability of PTH production, as well as hyperplasia of parathyroid chief cells. It seems to be the first case of tertiary hyperparathyroidism caused by an oxyphil cell adenoma. Functions of oxyphil cells and transitional oxyphil cells are briefly discussed.     

Takotsubo cardiomyopathy in a patient with pituitary adenoma and secondary adrenal insufficiency

We describe a case of Takotsubo cardiomyopathy in a case of pituitary macroadenoma in acute adrenal crisis. A 48-year-old man presented with acute onset altered sensorium, vomiting, and gasping. On admission, he was unresponsive and hemodynamically unstable. He was intubated and ventilated and resuscitated with fluids and inotropes. The biochemical evaluation revealed hyponatremia, hyperkalemia, and hypocortisolism. Hyponatremia was corrected with 3% hypertonic saline. Contrast enhanced computed tomography (CT) scan of the brain revealed a sellar-suprasellar mass with hypothalamic extension with no evidence of pituitary apoplexy. A diagnosis of invasive pituitary adenoma with the Addisonian crisis was made and steroid replacement was initiated. Despite volume resuscitation, he had persistent refractory hypotension, recurrent ventricular tachycardia, and metabolic acidosis. Electrocardiogram (ECG) showed ST elevation and T-wave inversion in lateral leads; cardiac-enzymes were increased suggestive of acute coronary syndrome. Transthoracic echocardiography showed severe regional wall motion abnormalities (RWMAs) involving left anterior descending territory and low ejection fraction (EF). Coronary angiogram revealed normal coronaries, apical ballooning, and severe left ventricular dysfunction, consistent with a diagnosis of Takotsubo''s cardiomyopathy. Patient was managed with angiotensin-converting enzyme inhibitors and B-blockers. He improved over few days and recovered completely. At discharge, ECG changes and RWMA resolved and EF normalized to 56%. In patients with Addisonian Crisis with persistent hypotension refractory to optimal resuscitation, possibility of Takotsubo''s cardiomyopathy should be considered. Early recognition of association of Takotsubos cardiomyopathy in neurological conditions, prompt resuscitation, and supportive care are essential to ensure favorable outcomes in this potentially lethal condition.     

Pregnancy in a patient with hypopituitarism following surgery and radiation for a pituitary adenoma

This is a case of partial hypopituitarism resulting from surgery and radiation for a non- functioning pituitary macroadenoma. The patient had amenorrhea which was secondary to hypogonadotrophic hypogonadism and had been on L-thyroxine for central hypothyroidism. For pregnancy, ovulation was induced by gonadotrophins and this was followed by an intrauterine insemination. The antenatal period was uneventful and a Caesarean section was done at 33 weeks when the patient presented with preterm labour. Both infant and mother are well, eight months after delivery.     

Medullary carcinoma of the thyroid with parathyroid adenoma and hypercalcaemia

A patient with hyperparathyroidism due to a parathyroid adenoma was found to have metastatic medullary carcinoma in lymph nodes close to the thyroid gland. The finding of normal calcitonin and parathormone concentrations after removal of the adenoma suggested that the parathyroid lesion was not the result of the hypocalcaemic action of calcitonin produced by the tumour in the thyroid.Seventeen other examples of the association between medullary carcinoma and parathyroid enlargement are briefly reviewed.The pathogenesis of the parathyroid lesions is discussed, and it is suggested that some may be caused by the hypocalcaemic action of calcitonin, while others may be part of a syndrome of multiple endocrine adenomatosis.     

Ciliated metaplasia in a gastric adenoma in a Swedish patient

The second European case of ciliated gastric metaplasia is presented, this time in a Swedish patient. Cilia were found in cystically dilated glands underneath a gastric adenoma. The possibility that cilia represent adaptative metaplasia aimed at expelling the retained mucus within the cysts is discussed.     

Spontaneously acquired haemophilia: report of a patient with prostatic adenoma

We report the case of a 86-year-old man admitted in a local hospital with spontaneous haematoma, an isolated prolonged activated partial prothrombin time (114/32 seconds; ratio = 3.6), an anemia and a normal platelet count. Two diagnosis were suspected: a coagulation factor defect, or the presence of a lupus anticoagulant or of anti-factor antibodies. An acquired haemophilia A was confirmed with a factor VIII activity level < 1 U/dL associated with the presence of an anti-factor VIII inhibitor. The factor VIII inhibitor titer reached 195 Bethesda U/mL. A prostatic adenocarcinoma was suspected: a 5 cm prostatic tumour was found and the PSA level was 113 ng/mL. The patient was treated with recombinant factor VIIa: Novoseven (90 microg/kg). None immunosuppressive agents were prescribed in this elderly patient. The patient's disease was identified as a spontaneously acquired haemophilia A associated with prostatic adenocarcinoma.     

Follicular adenoma with papillary architecture: a lesion mimicking papillary thyroid carcinoma

AIMS: The purpose of this study was to investigate the significance of 'benign' encapsulated follicular thyroid nodules with papillary structures. METHODS AND RESULTS: Twenty-one cases of encapsulated neoplastic thyroid nodules with papillary structures and nuclear features not diagnostic of papillary thyroid carcinoma (PTC) were obtained. All cases were reviewed with particular attention to nuclear features (fine chromatin pattern, optical clearing, grooves and inclusions). Representative sections were submitted for measurement of the maximum diameter of 200 round or nearly round nuclei and for immunostaining for MIB1, CK19, HBME and Ret oncogene protein. Nine cases displayed scattered optically clear nuclei or nuclear grooves in less than 30% of total neoplastic cells. They were grouped in the category of thyroid nodules with limited nuclear features of papillary thyroid carcinoma (PTC), but not diagnostic of PTC. The other 12 cases had fine or coarse chromatin, but lacked other features of nuclei in PTC. The diameter of the nuclei ranged from 5.6 to 7.2 microm and were smaller than those of PTC (6.3-10.0 microm). Immunostaining revealed positive reactivity for MIB1 in the papillary structures. Immunostaining for CK19 and HBME varied from negative or focally weak to diffusely moderate reactivity. Ret oncogene protein immunostaining showed focal and weak reactivity in one case and was negative in other cases of the study. Clinical follow-up from 6 months to 15 years revealed no evidence of metastasis. CONCLUSIONS: The papillary structures in the study cases are unlikely to represent degenerative changes due to their proliferative activity. In view of (i) the encapsulation and the uniformity of the constituent cells, (ii) the varying degrees of immunoreactivity for CK19 and HBME and negative immunoreactivity for Ret oncogene protein, and (iii) the absence or insufficiency of nuclear criteria for the diagnosis of PTC and the absence of lymph node metastasis in all study cases, we believe that these lesions represent the papillary variant of follicular adenoma. Recognition of this pathological entity is important to avoid an over-diagnosis of PTC.