Deng-Huang Su

Follicular variant of papillary thyroid carcinoma : Diagnostic limitations of fine needle aspiration cytology

OBJECTIVE To study the diagnostic sensitivity and specificity of fine needle aspiration cytology (FNAC) offollicular variant of papillary thyroid carcinoma (FVPTC). STUDY DESIGN The study group consisted of 390 papillary thyroid carcinoma (PTC) cases diagnosed histologically with thyroidectomy specimens. The FNAC and histopathologic classification were compared in terms of the appearance of FVPTC and non-FVPTC statistically with the chi squared test. Also, several features of the cytologic smears of FVPTC were reviewed. RESULTS Twelve of the 390 PTC cases were classified as FVPTC histologically. Five of the 12 cases were also reported as FVPTC in the diagnosis by FNAC and the other 7 as the usual type of PTC (UTPTC). There was 1 case classified as UVPTC histologically but FVPTC cytologically. If we use histologic diagnosis as the gold standard, the sensitivity and specificity of FNAC diagnosis of FVPTC were 42% and 83%, respectively. CONCLUSION FNAC may be a good tool for diagnosing PTC, but it is unreliable to differentiate between FVPTC and UTPTC.

Secondary infection and ischemic necrosis after fine needle aspiration for a painful papillary thyroid carcinoma: a case report.

BACKGROUND Papillary thyroid carcinoma (PTC) is often asymptomatic and rarely presents as a painful goiter. Further, the thyroid gland is not easily infected. Therefore, acute suppurative thyroiditis (AST) is unusual. PTC is also seldom combined with AST. We report a case of painful PTC with secondary infection after fine needle aspiration (FNA). CASE A 19-year-old girl complained of a painful goiter without skin change after an episode of upper airway infection. PTC was diagnosed according to the FNA cytology (FNAC) at another hospital. The goiter became more painful after FNA. The patients second FNAC at our hospital revealed only many polymorphonuclear leukocytes (PMNs). Antibiotic treatment ameliorated the pain, but the goiter persisted. The third FNAC revealed some PMNs and papillary carcinomatous cells. After total thyroidectomy, pathology revealed ischemic necrosis with a focal PMN aggregation around the needle track and papillary carcinomatous cells nearby. According to the time sequence, secondary infection after FNA was suspected. CONCLUSION A painful goiter is an unusual presentation of PTC. Although FNAC is feasible for studying a thyroid lesion, malignant cells might be missed when secoandary injection and ischemic necrosis occur after FNA. Therefore, aseptic procedures are necessary to prevent bacteria from seeding into the thyroid.

Acute Suppurative Thyroiditis Caused by Salmonella typhimurium: A Case Report and Review of the Literature

A 79-year-old woman with acute suppurative Salmonella thyroiditis is reported. She presented with fever and an enlarged, painful thyroid mass. Diagnosis was suspected by clinical symptoms and signs and confirmed by ultrasound, neck magnetic resonance imaging, aspiration cytology, and culture. The culture of fine-needle aspirate yielded Salmonella typhimurium. She was treated by parental antibiotics and surgical drainage. The source and route of infection remained unclear under a series of examinations. No piriform sinus fistula was evident on the imaging study. A hematogenous spread seems to be the most possible route.

Determining when to operate on patients with Hashimoto's thyroiditis with nodular lesions: The role of ultrasound-guided fine needle aspiration cytology

OBJECTIVE To elucidate the role of ultrasound-guided fine needle aspiration cytology (FNAC) in determining whether to request an operation. STUDY DESIGN Twenty-four consecutive patients (23 women and 1 man) with Hashimotos thyroiditis combined with nodular lesions revealed by ultrasonography were included in the study. Ultrasound-guided FNAC was performed on their thyroid tissue compatible with Hashimotos thyroiditis and nodular lesions. RESULTS Two of 24 patients (8.3%) had papillary thyroid cancer, which was diagnosed from aspirates of 31 nodular lesions and confirmed by operative pathologic findings. CONCLUSION If a patient with Hashimotos thyroiditis has nodular lesions shown by ultrasonography, ultrasound-guided FNAC is helpful in elucidating the nature of the lesion and determining whether to request an operation.

Hypopituitarism: A Sequela of Severe Hypoxic Encephalopathy

BACKGROUND/PURPOSE Central diabetes insipidus (DI) is an established phenomenon after hypoxic encephalopathy or brain death, but hypopituitarism is seldom described. This study investigated the characteristics of 11 patients with DI and hypopituitarism which developed after severe hypoxic encephalopathy. METHODS The medical records of patients with DI and hypopituitarism after severe hypoxic encephalopathy from 1997 to 2002 were retrospectively reviewed. Eleven patients with DI and hypopituitarism after severe hypoxic episodes were included. Demographic data, primary diagnosis, the time of onset of DI, the time of diagnosis of hypopituitarism, the presence of symptoms of hypopituitarism, and outcome of these patients were analyzed. RESULTS Eleven patients comprising nine females and two males aged 47.4 +/- 19.3 years (range, 24-74 years) were included. The mean interval from the precipitating event to the onset of DI was 60 +/- 46 hours (range, 11-131 hours). The mean interval from the precipitating event to the diagnosis of hypopituitarism was 423 +/- 182 hours (range, 132-672 hours). The average duration of hospitalization was 63 +/- 35 days (range, 9-113 days). The overall mortality rate during hospitalization was 45%. Four patients died of sepsis and one died of heart failure due to acute myocardial infarction. CONCLUSION The development of DI after severe hypoxic encephalopathy is a sign of severe brain damage. It usually ensues immediately or days after loss of brain stem reflexes. Hypopituitarism developed several weeks later than DI in these patients. Recognition and treatment of these deficiencies may prevent organ dysfunction.

Long-term Primary Medical Therapy with Somatostatin Analogs in Acromegaly

To cure acromegalic patients, transsphenoidal surgery is considered first, especially for microadenoma. However, less than 50% of patients with macroadenoma achieve satisfactory biochemical control. Moreover, surgery may cause hypopituitarism. Medical therapy may offer the prospect of near normalization of growth hormone (GH)/insulin-like growth factor-1 levels with substantial tumor shrinkage in a significant number of patients. Here, we report two cases of acromegaly under treatment with somatostatin analogs alone for more than 10 years. Case 1 was a 54-year-old man with a pituitary macroadenoma. He received 4 years of octreotide treatment followed by 6 years of prolonged-release (PR) lanreotide resulting in normal GH level. Case 2 was a 60-year-old woman with a 1.3 cm pituitary tumor. She received 8 years of octreotide treatment followed by 6 years of PR lanreotide resulting in subnormal GH level and gallbladder sludge. She had received bilateral total hip replacement for hip osteoarthritis at the age of 59 years. These cases illustrate that long-term treatment with somatostatin analogs offers an alternative choice in selected acromegalic patients, such as those with pituitary tumor who cannot be cured by surgery, those who have unacceptable anesthetic risk and those who refuse surgery.

Secondary hyperparathyroidism as a palpable intrathyroid parathyroid gland in a patient with hypophosphatemic osteomalacia

Secondary hyperparathyroidism is sometimes seen in patients with hypophosphatemic osteomalacia after long-term oral phosphate therapy. Parathyroidectomy is sometimes needed for the correction of hypercalcemia in these patients, and is rarely performed in patients without hypercalcemia. A 46-year-old female patient had hypophosphatemic osteomalacia with unknown cause and secondary hyperparathyroidism. A palpable neck mass developed after long-term oral phosphate therapy. An intrathyroid parathyroid gland was confirmed through partial thyroidectomy and parathyroidectomy. Renal phosphate wasting decreased strongly, and serum parathyroid hormone was in the normal range after the operation. A correction of secondary hyperparathyroidism may partially overcome hyperphosphaturia in some patients with hypophosphatemic rickets.

Lanreotide treatment in a patient with interferon-associated Graves’ ophthalmopathy

BackgroundWe report a case of Graves’ ophthalmopathy (GO) developed after the administration of interferon-α for chronic hepatitis C.MethodsThe GO was treated with lanreotide.ResultsA 47-year-old female patient presented with euthyroid GO with spontaneous retrobulbar pain, eyelid edema, conjunctival injection and eyelid retraction of the right eye and conjunctival injection of the left eye 6 months after administration of interferon-α for chronic hepatitis C. Orbital computed tomography revealed no involvement of extraorbital muscles and no increase in retrobulbar adipose tissue. Only soft tissue was involved. These symptoms subsided after 12 weeks of lanreotide treatment, except right eyelid retraction, which, however, disappeared later during follow-up.ConclusionThe use of interferon-α may be complicated by GO and lanreotide might be considered for GO if patients cannot accept steroid therapy.

Serial association analyses of recurrent gap time data via Kendall's tau

Recurrent event data are frequently encountered in long-term follow-up studies. In many applications, the gap times between two successive recurrent events are natural outcomes of interest. Investigation on patterns of associations among recurrent gap times within subjects is an important inferential issue. In this paper, we introduce flexible functions of previous gap times to create a class of summary measures of serial associations for a sequence of recurrent gap times through Kendalls tau. Such a general class of serial association measures provides a useful tool to quantify the predictive abilities of event history with different aspects. Non-parametric estimators of the proposed measures of serial associations are developed by generalizing the existing estimator of Kendalls tau for two serial gap times, in which inverse probability of censoring weights is used to overcome the induced dependent censoring. Various tests are further constructed for testing the constancy of serial associations over different events. Our method is applied to Denmark schizophrenia data and the results show that association structures are different for distinct ages of onset of schizophrenia.

Refractory Acromegaly with Tongue Cancer-A Case Report

Acromegaly is a disorder due to long-term exposure to elevated growth hormone and subsequent insulin-like growth factor-1 levels in an adult, resulting in acral and facial disfigurement, musculoskeletal disability, cardiovascular disease, respiratory dysfunction, and diabetes mellitus. Neoplastic disorders are possible complications of hypersomatotropism. Here we present a 74-year-old male patient with acromegaly secondary to pituitary adenoma. Multiple treatments including surgery, medical therapy, and radiotherapy were attempted. Growth hormone decreased to normal level only after repeated surgery, radiotherapy, and medical treatment. He was found to have squamous cell carcinoma of the tongue 19 years after initial diagnosis of acromegaly. Subtotal glossectomy was performed. The treatment options for acromegaly and the relationships between acromegaly and malignancy are reviewed.