Douglas Filipenko

Hürthle Cell Neoplasms of the Thyroid : Sonographic Appearance and Histologic Characteristics

Objective. The purpose of this study was to determine the sonographic features of Hürthle cell neoplasms (HCNs) of the thyroid. Methods. We retrospectively analyzed the sonographic appearance of 15 histologically proven HCNs in 15 patients aged 16 to 70 years (mean age, 44 years). Sonographic features that were reviewed included the size and echogenicity of the tumors, the presence of cystic areas or calcifications, and detectable blood flow on color Doppler imaging. Correlation of sonographic findings with pathologic results was performed. Results. The tumors ranged from 0.4 to 7 cm in diameter, but most were less than 3 cm in diameter. Four (27%) of the 15 tumors were homogeneously hypoechoic. Two tumors (13%) were predominantly hypoechoic with isoechoic areas to thyroid parenchyma. Two (13%) neoplasms were isoechoic to thyroid parenchyma. Four (27%) tumors were predominantly isoechoic, containing hypoechoic areas, and 3 (20%) tumors were hyperechoic. Three neoplasms contained cystic components. None of the tumors contained calcifications. One tumor was avascular on Doppler examination. One neoplasm showed only peripheral blood flow. Thirteen tumors showed internal vascularity, 7 of them with peripheral blood flow. Twelve HCNs were benign, and 3 were malignant on pathologic examination. Conclusions. Hürthle cell neoplasms show a spectrum of sonographic appearances from predominantly hypoechoic to hyperechoic lesions and from peripheral blood flow with no internal flow to extensively vascularized lesions. Pathologic criteria differentiating benign and malignant HCNs (absence or presence of a capsular breach, vascular or extrathyroidal tissue invasion, nodal involvement, and distant metastasis) are beyond the resolution of sonography and fine‐needle aspiration biopsy and require removal of the entire lesion. This precludes diagnosis and characterization of HCNs by sonography.

Hemithyroidectomy: The Optimal Initial Surgical Approach for Individuals Undergoing Surgery for a Cytological Diagnosis of Follicular Neoplasm

BackgroundThe primary objective of this study was to determine the true proportion and optimal surgical approach for individuals undergoing thyroid operation for a suspicion of cancer based on a fine-needle aspiration biopsy diagnosis of a follicular neoplasm (FN). A secondary objective of this study was to determine whether patient characteristics could assist the clinician in predicting malignancy in this FN patient cohort.MethodsA retrospective chart, pathology, and cytology review of 370 consecutive primary thyroid operations was performed over a 4-year period at a tertiary care referral center. Clinical patient data were evaluated as an adjunct for predicting malignancy in the FN patient cohort. Univariate and multivariate analyses were used to investigate the association and the predictability.ResultsA total of 80 (22%) of the 370 patients underwent hemithyroidectomy to rule out cancer based on clinical presentation with a fine-needle aspiration biopsy diagnosis of FN. Fifteen (19%) of the FN cases were diagnosed as cancer by histological analysis (4 follicular carcinomas and 11 papillary carcinomas). Hemithyroidectomy was considered adequate treatment for 77 patients (96%). No patient characteristic significantly predicted the presence of cancer by either univariate or multivariate analysis.ConclusionsOverall, in the FN patient population, five hemithyroidectomies were performed to identify each cancer, and no further operation was required in 96% of patients. New diagnostic tools are needed to reduce the number of operations performed for benign pathology in patients with nodular thyroid disease and a needle biopsy diagnosis of FN.The primary objective of this study was to determine the true proportion and optimal surgical approach for individuals undergoing thyroid operation for a suspicion of cancer based on a fine-needle aspiration biopsy diagnosis of a follicular neoplasm (FN). A secondary objective of this study was to determine whether patient characteristics could assist the clinician in predicting malignancy in this FN patient cohort. A retrospective chart, pathology, and cytology review of 370 consecutive primary thyroid operations was performed over a 4-year period at a tertiary care referral center. Clinical patient data were evaluated as an adjunct for predicting malignancy in the FN patient cohort. Univariate and multivariate analyses were used to investigate the association and the predictability. A total of 80 (22%) of the 370 patients underwent hemithyroidectomy to rule out cancer based on clinical presentation with a fine-needle aspiration biopsy diagnosis of FN. Fifteen (19%) of the FN cases were diagnosed as cancer by histological analysis (4 follicular carcinomas and 11 papillary carcinomas). Hemithyroidectomy was considered adequate treatment for 77 patients (96%). No patient characteristic significantly predicted the presence of cancer by either univariate or multivariate analysis. Overall, in the FN patient population, five hemithyroidectomies were performed to identify each cancer, and no further operation was required in 96% of patients. New diagnostic tools are needed to reduce the number of operations performed for benign pathology in patients with nodular thyroid disease and a needle biopsy diagnosis of FN.

Correlation of Virus Load in Plasma and Lymph Node Tissue in Human Immunodeficiency Virus Infection

The impact of long-term changes in plasma viremia, produced by effective combination antiretroviral therapy, on human immunodeficiency virus (HIV) burden within tissue reservoirs is unknown. Fifteen patients who had received at least 1 year of therapy with two or three drug combinations of zidovudine, didanosine, and nevirapine had suitable samples of lymph node tissue obtained by ultrasound-guided core needle biopsy. HIV RNA was extracted from homogenized tissue samples and quantitated using a modified branched DNA assay. Results were correlated with antiretroviral treatment effect on the basis of plasma virus load measurements over the preceding 12-18 months. A statistically significant negative correlation was observed between magnitude of treatment effect on plasma viremia and lymph node virus load. These data suggest that combinations of antiretroviral drugs that produce sustained suppression of plasma HIV RNA may also be able to reduce the virus burden in lymphoid tissues.

Pathophysiologic Correlations in Asbestos-induced Airway Disease in the Guinea Pig

To determine whether asbestos-induced changes in the structure of the walls of small airways might be associated with abnormalities of pulmonary function, guinea pigs were given 10 mg of amosite asbestos (test group) or saline (control group) by intratracheal instillation. Pulmonary function tests performed 6 months later revealed significant increases in FRC, RV, and TLC in the test group. Measurement of airway wall thickness showed that both membranous and respiratory bronchioles were significantly thickened in the test group; this group also had airways of smaller internal diameter than the controls. Analysis for lung collagen content as hydroxyproline showed a 50% increase in the asbestos exposed animals. There was, however, only minimal and very focal interstitial fibrosis (asbestosis) in the lung parenchyma. Analysis of fiber size indicated that the fibers obtained by digestion of the tissue or from the lavage fluid were significantly longer and wider than those in the original asbestos sample; however, the tissue contained considerably larger fibers than the lavage fluid. We conclude that: Asbestos can produce airway fibrosis and narrowing causing air trapping on pulmonary function examination; this process occurs in the absence of significant interstitial fibrosis of the parenchyma (asbestosis), implying that abnormalities of pulmonary function which are consistent with airflow obstruction in asbestos exposed animals can be caused by pathologic changes in the small airways alone; long asbestos fibers are preferentially retained in the lung, and the longest fibers appear to be in a compartment inaccessible to lavage, presumably, in this model, in airway walls. Enhanced penetration of long fibers into tissue may be one reason why long fibers are more pathogenic than short ones.

AIDS-related extrapulmonary Pneumocystis carinii infection presenting as a solitary rectal ulcer.

Extrapulmonary infection with Pneumocystis carinii, although uncommon, is increasingly recognized. Use of aerosolized pentamidine versus a systemic medication is thought to be a contributing factor due to the low concentrations of drug that are incapable of suppressing systemic infection. Infection with P carinii has been reported in every organ system including the gastrointestinal system. A 28-year-old acquired immunodeficiency syndrome patient receiving prophylaxis with aerosolized pentamidine who presented with a solitary rectal ulcer is reported. Initial biopsy was characteristic of extrapulmonary P carinii infection, with numerous organisms present. Occasional cytomegalovirus inclusion bodies were noted which may have been a copathogen but which were not treated. Treatment with intravenous pentamidine resulted in documented eradication of P carinii and complete resolution of the ulcer. Although lower gastrointestinal pneumocystosis has been described without ulceration, this is the first description of rectal ulceration presenting as the initial manifestation of extrapulmonary pneumocystosis.

In situ detection of rubella RNA and antigens in cultured cells.

We developed in situ hybridization and immunofluorescent procedures to detect rubella RNA and antigens in tissue-cultured cells infected with rubella virus. cDNA fragments of the rubella virus E1 structural gene were used as probes for in situ hybridization to detect rubella RNA sequences in Vero cells infected with rubella virus. Using antibodies against rubella proteins, indirect immunofluorescence detected rubella virus structural proteins in Vero cells infected with rubella virus. The immunofluorescence method has also been applied to study the expression of rubella polypeptide E1 in transfected COS cells and may be applied to the detection and study of persistent rubella virus infection in human tissues.

Thyroid Invasion by Locally Advanced Esophageal Cancer Masquerading as Anaplastic Carcinoma

A64-year-old woman with no previous history of thyroid disease was evaluated for enlargement of the thyroid gland. Over a 2-month period, she developed progressive dysphagia and recently noticed a hoarsening of her voice. She did not have any respiratory complaints. She also had no history of head and neck radiation exposure or family history of thyroid cancer. Her past medical history included a hysterectomy for cervical cancer and a remote appendectomy. A neck examination revealed that her thyroid gland was firm and diffusely enlarged, and she otherwise had no evidence of cervical adenopathy. An ultrasound showed diffuse enlargement of the thyroid gland, especially its right inferior pole that measured 3.8 2.6 cm and displaced the trachea (Fig. 1). The gland had a heterogeneous appearance, and there was no evidence of neck adenopathy. A fine-needle aspiration biopsy revealed a poorly differentiated carcinoma. She was subsequently sent for a computed tomography (CT) scan of the neck, which demonstrated a locally advanced esophageal cancer with direct invasion of the posterior aspect of the thyroid gland as well as extension into other surrounding structures (Fig. 2). The patient subsequently underwent placement of feeding gastrostomy and palliative chemoradiation treatment. Invasion of the thyroid gland by local extension of malignancies arising from adjacent structures is uncommon. The incidence of thyroid gland invasion in laryngopharyngeal cancer has been reported in 0% to 23% of cases (1–3). The current literature suggests that en-bloc resection of the thyroid gland and other involved structures, if feasible, is recommended treatment (4). Recent studies have reported subglottic tumor extension (1–3) and vocal cord fixation (2) as correlating with local invasion of the thyroid gland. As our case illustrated, a locally advanced upper aerodigestive tract malignancy can present in a manner virtually identical to an anaplastic thyroid cancer. This case highlights the importance of CT imaging and fine needle aspiration cytology in evaluating individuals who present with what is suspected to be either a locally advanced or anaplastic thyroid cancer.