A. Testa

Thyroid cancer in suppressed contralateral lobe of patients with hot thyroid nodule

We studied 60 patients with thyrotoxicosis due to single toxic nodule. At surgery in 3 patients (5%) a papillary carcinoma has been detected in the contralateral suppressed lobe. Thyroid function tests and thyroid scan confirmed thyrotoxicosis. Thyroid stimulating hormone (TSH) was undetectable in all patients. It is common opinion that differentiated thyroid tumour growth is TSH dependent. On the basis of our study two hypotheses are possible: (1) the development of thyroid carcinoma precedes the adenoma and suppressed TSH levels inhibit tumour growth; (2) suppressed TSH levels do not protect patients from the occurrence of cancer. In the evaluation of hot thyroid nodule we suggest careful ultrasonographic control in order to look for nodules outside the adenoma. A complete surgical examination of the whole thyroid gland is required and intraoperative biopsies are advocated in abnormal areas.

Ultrasound detection of foreign body and gas contamination of a penetrating wound

We report a case in which ultrasonography (US) examination was used in the Emergency Department to reveal and diagnose gas contamination of a penetrating wound. Air microbubbles are extremely small and their typical distribution and movement are like those of sparkling-wine microbubbles. US assessment of spontaneous disappearance of the air bubbles can distinguish a harmless traumatic nature of the wound from a life-threatening gas-producing bacterial infection.

Primary papillary carcinoma arising from median ectopic thyroid in multinodular goitre

CARCINOMA ARISING from thyroglossal duct remnants is a rare entity [ 11. An interesting case of papillary thyroid carcinoma of the thyroglossal duct remnants, observed among 700 patients with thyroid carcinoma, is here reported and its particular features described. A 66-year-old woman, with a lo-year history of multinodular goitre, noticed a progressively growing mass in the midline of her neck 12 months ago. She had been in suppressive thyroid therapy for the last 7 years (L-thyroxine 2 pg/kg body weight resulting in suppressed thyroid stimulating hormone (TSH) response to thyrotropin releasing hormone (TRH). Free and total T4 and T3 were within normal range and TSH levels were undetectable. No uptake was detected over the midline neck mass in the 13tI thyroid scan, in which the thyroid gland appeared enlarged with a dishomogeneous distribution of the tracer. Ultrasonography revealed a diffuse enlargement of the thyroid gland, with mixed lesions and, above the gland, a solid lesion 2.0 cm in diameter with calcification. Cytopathological examination of the neck mass suggested a papillary proliferation. At surgery, a mass of diameter 2.2 cm just below the hyoid bone, was removed and a total thyroidectomy was performed. The mass was 3 cm above the upper margin of the thyroid gland and so was unconnected to it. Histological examination confirmed the presence of papillary carcinoma in the mass, whereas no evidence of neoplasm resulted in the thyroid gland. The interesting aspect of this case is the inability of the continuous, prolonged administration of thyroid hormone in protecting the patient from the occurrence of cancer. The case reported seems to contradict the belief that the growth of papillary carcinoma depends solely on TSH stimulation. This view stems from at least two kinds of observations: (i) that thyroid hyperplasia associated with elevated TSH levels in congenital goitrous patients untreated for many years can lead to malignant degeneration [2] and (ii) that differentiated tumours can show normal TSH receptors. This fact can explain their TSH dependent growth, whereas anaplastic cancer lacks high-affinity receptors and shows TSH-independent growth [3]. In conclusion the case described is consistent with a rare neoplastic localisation in the thyroglossal duct remnants and supports the possible+ven though unusual-development of cancer during suppressive therapy.

Goal-directed Ultrasonography for Detecting Traumatic X-ray Missed Fibula Fracture in the Emergency Department

We present the case of a 45-year-old man who presented to the emergency department (ED) for ankle trauma sustained during a football match. Physical examination and X-ray of his ankle were negative for bone fractures. He was discharged from the ED, but returned 3 weeks later with a painful and swelling leg. Compressive ultrasonography of his right lower limb was negative for venous thrombosis, but ultrasound evaluation of the leg clearly showed a fibula fracture. Although the diagnosis of fractures usually relies on X-ray, the literature contains many reports of goal-directed ultrasound diagnosis of long bone fracture in military settings and remote locations. The usefulness of a noninva-sive examination like bedside ultrasonography and goal-directed evaluation of patients in the ED are discussed, with reference to the literature.