Squamous cell carcinoma arising in Hashimoto's thyroiditis

The case of a 76-year-old white woman with squamous cell carcinoma of the thyroid gland arising in a background of Hashimoto's thyroiditis is presented. Squamous cell carcinoma of the thyroid gland is a very rare and aggressive tumor, and only a few cases are reported as arising in Hashimoto's thyroiditis. Although Hashimoto's thyroiditis alone does not necessarily predispose patients to malignancy, the finding of a prominent nodule in such a patient should suggest the possibility of malignancy, and an aggressive search and treatment regimen, including surgical intervention, should be pursued.     

Living Kidney Donor With Small Lymphocytic Lymphoma at the Time of Donation: A Case Report

Living kidney donor guidelines recommend that donors in whom a malignancy is diagnosed should be excluded. Although preoperative screening for malignancies was performed, we experienced a case of living donor with small lymphocytic lymphoma (SLL) at the time of donation. A 53-year-old woman was referred to our hospital for a kidney donation to her son. She had no past medical history of malignancy. We screened the patient using medical examinations, but there was no obvious presence of malignancy. Although preoperative computed tomography showed a small lymph node swelling at the left renal hilum, we diagnosed it as an insignificant lymph node. When a laparoscopic donor nephrectomy was performed, however, we recognized the small lymph node during the surgery and performed a lymphadenectomy. Postoperatively, pathologic examination showed that the small node was lymphocytic lymphoma, known as a low malignant potential disease. Currently, there is no presence of malignancy transmission with the recipient. To the best of our knowledge, this is the first case report of living kidney donor with SLL. Although SLL is considered a low-grade malignancy, it is crucial to follow it carefully in both the donor and the recipient.     

Tireoidite de Hashimoto pode estar associada a um subgrupo de pacientes de esclerose sistêmica com hipertensão pulmonar

IntroductionRecent studies show an association between autoimmune thyroiditis and systemic sclerosis (SSc) and suggest that this condition may interfere with the ES phenotype. However these studies evaluate the autoimmune thyroiditis as a whole and none of them specifically addresses Hashimoto's thyroiditis (HT) in SSc.ObjectiveTo investigate the presence of HT in SSc patients and its possible association with disease manifestations.MethodsClinical manifestations of hypothyroidism, TSH and anti‐thyroid auto antibodies (anti‐TPO. anti TBG and TRAb) were studied in 56 patients with SSc. SSc patients with HT were compared with SSc patients without thyroiditis.ResultsHT was observed in 19.64% of patients with SSc. No association was observed between HT and the different forms of disease or profile of autoantibodies. Likewise, there was no difference between the mean modified Rodnan score and presence of Raynaud's phenomenon, scars, digital necrosis, myositis, arthritis, sicca symptoms, esophageal dysmotility and scleroderma renal crisis when the groups were compared. On the other hand, patients with HT had higher frequency of pulmonary hypertension in relation to patients without HT (66.6% vs 22.5%, p = 0.016).ConclusionsIn the studied sample patients with ES and HT had higher prevalence of pulmonary hypertension. Long‐term follow‐up studies with a larger number of TH and SSc patients are needed to confirm these data.     

甲状腺癌并存淋巴细胞性甲状腺炎的临床病理特点：附129例分析

目的:探讨甲状腺癌(TC)合并淋巴细胞性甲状腺炎(LT)的临床病理特点。方法:回顾性分析87例单纯TC(TC组)及129例TC合并LT患者临床病理资料(TC合并LT组),后者包括40例(31.0%)合并桥本氏甲状腺炎(HT),81例(62.8%)合并慢性淋巴细胞性甲状腺炎(CLT),8例(6.2%)同时合并HT与CLT。结果:所有患者均行手术治疗,根据患者病变情况分别行单侧腺叶切除、次全切除、全切除以及不同范围的淋巴结清扫术。129例TC合并LT患者中,仅1例(0.8%)为甲状腺髓样癌(MTC),其余(99.2%)均为甲状腺乳头状癌(PTC)。与TC组比较,TC合并LT组女性、微小癌、单叶受累、颈淋巴结阴性比率均明显增加,而病灶最大径明显减小(均P0.05);在TC合并LT组中,并CLT患者与合并HT患者各项临床病理指标均无统计学差异(均P0.05)。结论:与LT并存的TC以PTC多见,且多为女性,LT可能对TC原发灶生长及腺内、颈部淋巴结转移有抑制作用;TC合并CLT与合并HT的临床病理特征相似。     

Quality of life after thyroid surgery in women with benign euthyroid goiter: influencing factors including Hashimoto's thyroiditis

Background

Hashimoto's thyroiditis is associated with decreased quality of life (QoL). Thyroid surgery could hypothetically lead to an increase in QoL.

Methods

In a follow-up analysis of a prospective cohort study that included euthyroid women undergoing thyroid surgery for benign thyroid disease, 248 patients were willing to answer the SF-36 QoL questionnaire.

Results

At follow-up after a median of 26 months, only the SF-36 module of “bodily pain” had increased (P = .046). Preoperative anti–thyroid peroxidase antibody levels were positively correlated with increasing QoL in the SF-36 modules “bodily pain” (P < .001) and “role emotional” (P < .001). For the presence of histologically confirmed Hashimoto's thyroiditis, a significant positive correlation (P < .001) was found for all modules apart from “physical functioning.”

Conclusions

In women with benign euthyroid goiter, thyroid surgery does not lead to an overall improvement in health-related QoL. It should not be recommended for patients with elevated anti–thyroid peroxidase antibody levels. Patients with histologically confirmed Hashimoto's thyroiditis might benefit in terms of QoL.     

手术误治甲状腺炎性疾病的经验教训分析

目的总结分析容易误诊为甲状腺肿瘤的甲状腺炎病例的临床特点。方法回顾性分析我科2009-2012年期间19例误诊为甲状腺肿瘤病例的临床资料。结果19例患者全部经历手术,术后8例确诊为慢性淋巴细胞性甲状腺炎,10例确诊为亚急性甲状腺炎,1例为化脓性甲状腺炎。手术术式根据术中病理及病情而有不同,亚急性甲状腺炎患者多予以活检术,慢性淋巴细胞性甲状腺炎多予以峡部切开或楔形切除术。结论非典型甲状腺炎与甲状腺肿瘤的鉴别有时相当困难,但只要其具有非肿瘤特点时临床医师应高度重视,综合判断,可降低误诊率。     

Prognostic factors and treatment outcomes for patients with Fournier's gangrene: a retrospective study

Fournier's gangrene is a gas‐forming, necrotising soft tissue infection affecting the perineum. It spreads rapidly along the deep fascial planes and is associated with a high mortality rate. With a growing elderly population with comorbidities, the frequency of severe cases of Fournier's gangrene is expected to increase. We retrospectively reviewed 20 patients diagnosed with Fournier's gangrene at our institution from 2003 to 2014 and analysed data. Thirteen patients had diabetes mellitus, two had been diagnosed with liver cirrhosis, and four were chronic alcoholics. Of 15 patients admitted to an intensive care unit, 11 underwent colostomy, and 4 required skin grafts for wound healing. The wide wounds of two patients were healed using vacuum‐assisted closure (VAC^®) dressing without additional surgery. The mortality rate was 25%, and the patients whose Fournier's gangrene severity index (FGSI) score was higher than 9 points or whose blood urea nitrogen (BUN) level was higher than 50 mg/dl had a poor prognosis. In order to treat Fournier's gangrene, aggressive surgical treatment, including wide debridement and stoma creation, should be considered as soon as possible to improve survival rates. Additionally, VAC dressing is helpful in healing the wide debridement wound without additional reconstructive surgery.     

The Reliability of Fine-Needle Aspiration Biopsy in Terms of Malignancy in Patients With Hashimoto Thyroiditis

The aim of this study was to analyze the presence of malignancy in patients with Hashimoto''s thyroiditis and to investigate the reliability of preoperative fine-needle aspiration biopsy (FNAB). The retrospective study included 44 patients who were operated on for nodular goiter between December 2010 and October 2011. The patients underwent thyroidectomy following a cytologic analysis plus FNAB. Hashimoto''s thyroiditis was confirmed on histopathology in all patients. FNAB results were defined as benign in 14 (31.8%), suspicion for malignancy in 17 (38.6%), malignant in 9 (20.5%), and inadequate in 4 (9.1%). Following the thyroidectomy, presence of papillary thyroid carcinoma and follicular variant of papillary thyroid carcinoma were detected in 10 patients (22.7%) and 1 (2.3%) patient, respectively. The FNAB results were interpreted in terms of malignancy, which revealed the sensitivity as 80%; specificity, 40%; false positives, 69.2%; false negatives, 14.3%; positive predictive value, 31.8%; negative predictive value, 85.7%; and diagnostic accuracy, 50%. The coexistence of Hashimoto''s thyroiditis with papillary thyroid carcinoma is quite common. The FNAB results for such cases are hard to evaluate, and they are likely to increase the number of false positives.Key words: Hashimoto''s thyroiditis, Papillary thyroid carcinoma, Fine needle aspiration biopsyHashimoto''s thyroiditis (HT) is also known as chronic lymphocytic thyroiditis, with an incidence rate of 1% to 4% and incidence of 3 to 6 per 10,000 individuals per year.¹ It is the second most common thyroid lesion next to endemic goiter, and it is more frequent in women.² It generally presents as diffuse goiter, while its presentation as 1 or 2 predominant nodules is quite rare. In the preoperative stage, it is quite difficult to determine whether these nodules are caused by HT or by an HT-related malignancy. There are numerous studies suggesting that there is a strong relation between HT and thyroid neoplasms and that HT leads to a higher incidence rate for thyroid malignancy.³ However, Pradeep et al⁴ have reported that they did not observe any associated malignancy in HT in their series.Fine-needle aspiration biopsy (FNAB) is a safe procedure, which is well defined for the primary diagnosis of thyroid patients.⁵ The initial aim in performing FNAB is to identify the thyroid nodules that require surgery and decrease the overall incidences of thyroidectomy in patients with benign diseases.^6,7 FNAB is reported as a superior and cost-effective procedure for the diagnosis of HT, as compared with antibody testing.⁸ Nevertheless, the false positives and false negatives in FNAB lead to a diagnostic pitfall.⁶The aim of this study was to analyze the presence of malignancy in HT patients and to investigate the reliability of FNAB through a comparison between pre- and postoperative histopathologic results.     

局灶性甲状腺炎与甲状腺乳头状癌常规超声及实时剪切波弹性成像表现

目的 对比观察局灶性甲状腺炎与甲状腺乳头状癌（PTC）常规超声及实时剪切波弹性成像（SWE）表现。方法 回顾性分析经病理证实的36例局灶性甲状腺炎及100例PTC患者[其中50例合并桥本甲状腺炎（HT）],对比其常规超声声像图表现及杨氏模量值。结果 136例甲状腺结节均为实性。局灶性甲状腺炎与PTC患者之间,结节位置、数量、直径、形态及内部钙化差异均无统计学意义（P均>0.05）,边界模糊、内部回声及纵横比>1差异均有统计学意义（P均<0.05）。局灶性甲状腺炎与PTC之间杨氏模量值最大值（E_max）、最小值（E_min）及平均值（E_mean）差异均无统计学意义（P均>0.05）;PTC患者中,合并HT者与无HT者之间SWE杨氏模量值E_max、E_min及E_mean差异均无统计学意义（P均>0.05）。结论 局灶性甲状腺炎与PTC常规超声表现存在一定差异,有助于鉴别诊断;SWE对二者无明显鉴别诊断价值,是否合并HT不影响SWE诊断PTC。     

Paraimmunoblastic variant of small lymphocytic lymphoma/leukemia

We report 16 cases of a distinctive, biologically aggressive variant of small lymphocytic lymphoma/leukemia (SLL/L) that is characterized by the diffuse proliferation of cells normally comprising the pseudoproliferation centers (so-called paraimmunoblasts). Demographically, the patients differed in no significant regard from patients with SLL/L of usual type. Rapidly progressive, generalized lymphadenopathy was the dominant clinical finding in 15 of the 16 patients; one patient presented with symptoms related to lymphomatous involvement of the stomach and regional lymph nodes. Splenomegaly was observed in five patients. Seven patients, two of whom had a history of indolent-phase chronic lymphocytic leukemia, had an absolute lymphocytosis at diagnosis. In most patients, bone marrow involvement was noted at diagnosis. It consisted predominantly of small lymphocytic infiltrates indistinguishable from those observed in SLL/L of usual type; significant paraimmunoblastic infiltration was infrequent and generally occurred late in the disease course. Immunohistochemical and cytogenetic study further substantiated the hypothesized relationship of these cases to SLL/L. Findings included (a) coexpression of sIg and Leu-1 antigen in the majority of cases and (b) the presence of a t(11;14) (q13;q32) chromosome translocation in two of three cases with analyzable metaphases. Although treatment protocols were not uniform, follow-up data indicated an accelerated clinical course. Eleven patients have died of their disease between 3 and 39 months after diagnosis; the median survival was 28 months.     

Lupus nephritis in juvenile myelomonocytic leukemia.

A 13-year-old girl developed lupus nephritis and Hashimoto thyroiditis in the chronic phase of juvenile myelomonocytic leukemia (JMML). At age 7 months, she was diagnosed as having JMML based on the hepatosplenomegaly, leukocytosis, thrombocytopenia, increased levels of fetal hemoglobin, and spontaneous in vitro growth of granulocyte-macrophage progenitors. At the onset of JMML, she had hypergammaglobulinemia, antinuclear antibodies, rheumatoid factors and anti-smooth muscle antibody. She had been placed on oral 6-mercaptopurine for about 12 years, with clinical improvement. At age 13 years, she was found to have hematuria and proteinuria. She also developed arthritis and Raynaud's phenomenon as well. She had antinuclear antibodies, rheumatoid factors, LE phenomenon, beta-1C (C3) nephritic factor (C3NeF), antithyroid antibodies, and hypocomplementemia. The renal biopsy specimens revealed a diffuse increase in the mesangial cells and matrix by light microscopy, and intense staining of IgG, Clq and C3 by immunofluorescence microscopy. The hormonal study ultimately showed decreased thyroid functions. So she was diagnosed as lupus nephritis and Hashimoto thyroiditis. The patient is the first example to show close relationship between stem cell abnormalities in JMML and development of overt autoimmune disorders.     

Lymphocytic adenohypophysitis accompanying occlusion of bilateral internal carotid arteries--case report.

A 45-year-old female presented with blurred vision, headache, and abnormal thirstiness. She was not pregnant nor postpartum. She had diabetes insipidus and bitemporal hemianopsia. Radiological evidence suggested a mass arising in the sella turcica with extension into the parasellar and suprasellar regions. Carotid angiography showed occlusions of bilateral internal carotid arteries at the cavernous portions. The mass was subtotally removed by the trans-sphenoidal approach and was histologically diagnosed as an adenohypophysitis. Laboratory data showed the patient to be in an active state of autoimmune disorder and hypopituitarism. When a patient presents with pituitary insufficiency and an enhanced intrasellar mass lesion on computed tomographic scan, lymphocytic adenohypophysitis must be included in the differential diagnosis.     

Anti-neutrophil cytoplasmic antibody associated glomerulonephritis in a patient with Down's syndrome

A 9-year-old boy with Down's syndrome developed a glomerulonephritis associated with crescents and anti-neutrophil cytoplasmic antibodies (ANCA). The patient also had type 1 diabetes mellitus, chronic lymphocytic thyroiditis, and bronchial asthma. Prednisone therapy resulted in an improvement in renal function and a reduction in ANCA titers.     

Masson's tumor of the breast: Rare differential for new or recurrent breast cancer—Case report,pathology, and review of the literature

A 66‐year‐old woman had a new left breast mass with a prior history of a stage IIIC left breast cancer. She had excision of the mass. The pathology noted intravascular papillary endothelial hyperplasia (IPEH) also known as Masson's tumor. Although a benign lesion, this remains in the differential of breast lesions with vascular morphology. IPEH has been described at multiple sites throughout the body. It must be distinguished from angiosarcoma. Although Masson's tumor has been previously documented in the breast, prior treatment for breast cancer presents a diagnostic dilemma. Treatment for the breast cancer may be a contributing event for Masson's tumor.     

Pituitary apoplexy precipitating diabetes insipidus after living donor liver transplantation

Pituitary apoplexy occurring after surgery is a rare but life-threatening acute clinical condition that follows extensive hemorrhagenous necrosis within a pituitary adenoma. Pituitary apoplexy has been reported to occur spontaneously in the majority of cases or in association with various inducing factors. Reported is a case of pituitary apoplexy complicated by diabetes insipidus following living donor liver transplantation (LDLT). To the best of our knowledge, this has not been previously reported. A 56-year-old woman with nonalcoholic steatohepatitis underwent LDLT from her daughter. The patient also required dopamine support and transfusions because of massive intraoperative bleeding. Postoperatively, her coagulopathy continued, and she underwent a second laparotomy because of unknown bleeding on postoperative day 7, when she needed transfusions and dopamine support to maintain her vital signs. She complained of severe headache, excessive thirst, frequent urination, and diplopia from postoperative day 10. She also had polyuria greater than 300 ml/h and was diagnosed with pituitary apoplexy precipitating diabetes insipidus on postoperative day 13. She was treated conservatively without surgery because of the hormonally inactive status and slight mass effect of her tumor. It is important for anesthesiologists and critical care personnel in LDLT settings to take into consideration this complication as a differential diagnosis.     

A case of pyogenic osteomyelitis of the cervical spine following stellate ganglion block

A 56-year-old woman had been treated with stellate ganglion block (SGB) for pigmentation degeneration retinopathy over 6 years. She had no history of diabetes mellitus or immunodeficiency. She complained of high back pain but was afebrile. She was diagnosed as pyogenic osteomyelitis by the MRI findings and hematological examination. Antibiotics was administerd for 3 weeks and inflammatory signs disappeared. We should bear in mind that pyogenic osteomyelitis is very rare but one of the most serious complications with SGB.     

Chronic Lymphocytic Leukemia,Small Lymphocytic Lymphoma,and Monoclonal B-Cell Lymphocytosis

Chronic lymphocytic leukemia (CLL), small lymphocytic lymphoma (SLL), and monoclonal B-cell lymphocytosis (MBL) are clonal proliferations of small, mature B cells. CLL and SLL are considered neoplastic, although they are indolent and many patients with these lymphomas never require treatment. Most MBL cases share immunophenotypic and genetic features with CLL and SLL but have a small burden of clonal cells. This review focuses on the pathologic features of CLL, SLL, and MBL and their differential diagnoses. Guidelines are provided to separate the entities from one another and to avoid pitfalls in distinguishing these entities from other lymphomas and from reactive lymphoid proliferations.     

Urinary manifestations in Isaacs's syndrome. Our experience in 8 cases

Introduction

Isaacs's syndrome (IS), is a rare neurological disorder, characterized by sustained muscular activity, fasciculations, cramps, myokymia, excessive sweating, and occasional elevation of creatine phosphokinase (CPK) enzyme.

Aim

To report our experience in patients with IS and urinary manifestations, describing clinical findings, test's results, and response to treatment. Methods An observational, retrospective analysis of patients with IS and urinary manifestations treated at German Hospital of Buenos Aires between 2001 and 2011 was done. Diagnosis was performed with clinical examination and electromyography (EMG) of external sphincter of the anus and/or urethra. Demographic, clinical, and treatment variables were analyzed. International Prognostic Scoring System (IPSS) at diagnosis and follow up was made.

Results

Eleven IS patients were recruited, of whom 8 (72.72%) were females with a mean age 47.87 years (DS ± 13.95) and presented associated lower tract urinary symptoms (LUTS). Six of them (75%) had voiding and 2 (25%) filling symptoms. Urodynamic and electromyographic findings reproduced symptomatology in all patients. Patients with voiding symptomatology were treated with combination of alpha‐blockers with benzodiazepines; membrane stabilizings agents; antiepileptics; neurotropic; corticoids; posterior tibial nerve stimulation and botulinum toxin, achieving improvement in 4/6. The two patients with storage symptoms were treated in first instance with anticholinergic drugs, one of which did not respond completely was added oral pentosansulfate and electrical stimulation, reversing the symptomatology. Four patients had associated pathologies: Hashimoto's thyroiditis; Sjögren's syndrome; dysautonomia, and myasthenia gravis.

Conclusions

In our experience, IS urinary manifestations are common and usually has a good evolution with adequate treatment for each patient.     

Extremely high level of serum thyroglobulin after surgery in a patient with follicular thyroid carcinoma. Recurrence, distant metastasis, or other etiology?

A 67-year-old female patient with a tumor of the thyroid underwent right lobectomy of the thyroid. The tumor was histologically diagnosed as a follicular carcinoma of the thyroid. Serum studies revealed very high (> 8,000 ng/ml) levels of thyroglobulin after surgery. We suspected distant metastases from follicular carcinoma or recurrence in the left lobe of the thyroid. She therefore underwent left lobectomy of the thyroid. No recurrence of follicular carcinoma was recognized in the resected thyroid tissue, but severe autoimmune thyroiditis was diagnosed histologically. Total-body 131I scintigraphy did not show abnormal distant uptake. Serum studies revealed very low levels of thyroglobulin (< 2.0 ng/ml) after the second surgery. We speculate that silent thyroiditis might have occurred after the first surgery, resulting in the high levels of serum thyroglobulin. Silent thyroiditis should be considered as a possible cause of high serum thyroglobulin levels.