Surgery for metastatic neuroendocrine tumors with occult primaries.

INTRODUCTION: Neuroendocrine tumors (NETs) frequently metastasize prior to diagnosis. Although metastases are often identifiable on conventional imaging studies, primary tumors, particularly those in the midgut, are frequently difficult to localize preoperatively. MATERIALS AND METHODS: Patients with metastatic NETs with intact primaries were identified. Clinical and pathologic data were extracted from medical records. Primary tumors were classified as localized or occult based on preoperative imaging. The sensitivities and specificities of preoperative imaging modalities for identifying the primary tumors were calculated. Patient characteristics, tumor features, and survival in localized and occult cases were compared. RESULTS: Sixty-one patients with an intact primary tumor and metastatic disease were identified. In 28 of these patients (46%), the primary tumor could not be localized preoperatively. A median of three different preoperative imaging studies were utilized. Patients with occult primaries were more likely to have a delay (>6 mo) in surgical referral from time of onset of symptoms (57% versus 27%, P = 0.02). Among the 28 patients with occult primary tumors, 18 (64%) were found to have radiographic evidence of mesenteric lymphadenopathy corresponding, in all but one case, to a small bowel primary. In all but three patients (89%), the primary tumor could be identified intraoperatively. CONCLUSION: The primary tumor can be identified intraoperatively in a majority of patients with metastatic NETs, irrespective of preoperative localization status. Referral for surgical management should not, therefore, be influenced by the inability to localize the primary tumor.

Regional recurrence after lymphadenectomy for clinically evident lymph node metastases from papillary thyroid cancer: a cohort study.

BACKGROUND: The presence of lymph node (LN) metastases in papillary thyroid cancer (PTC) has limited prognostic utility for predicting disease-specific survival. Pathologic features of the LNs beyond their presence and location do not factor into the AJCC staging system. Most LN metastases are microscopic. The natural history of patients with PTC and clinically evident LN metastases (CELNM) has not been well characterized. METHODS: Patients with CELNM from PTC undergoing lymph node dissection (LND) by a single surgeon were identified (1999-2009). Patients with and without recurrence were compared by clinical and pathological factors using Student's t test, Fisher's exact test, and Chi-squared test. Logistic regression was used to determine the association between recurrence and CELNM after adjustment for confounders. RESULTS: Ninety-two patients were identified who underwent surgery for CELNM. With a median follow-up of 27.5 months, 27 patients (29%) developed regional nodal recurrence with no disease-related deaths. Patients with and without recurrence were similar with respect to all clinical and pathologic variables analyzed except for the number of metastatic LNs. With a similar number of LNs sampled in both groups, the mean number of metastatic LNs was significantly higher in the group of patients with recurrence versus those without recurrence (12 vs. 6, p = 0.03) and remained significantly associated with the likelihood of recurrence (p = 0.009) in the logistic regression model. CONCLUSIONS: Patients with CELNM have an appreciable incidence of early regional cervical recurrence but not distant metastases. Among clinical and pathological factors evaluated, the number of metastatic LNs is associated with recurrence.

Painful acute radiation thyroiditis induced by 131I treatment of Graves' disease.

A 44-year-old woman, chronic smoker with Graves' disease was treated with radioactive iodine ablation (RAI). One week after the treatment, she presented with severe pain in the anterior neck with radiation to the angle of the jaw associated with fatigue, tremor and odynophagia. Physical examination demonstrated an asymmetric and exquisitely tender thyroid gland. There was no laboratory evidence of thyrotoxicosis. Acute radiation thyroiditis was diagnosed. Non-steroidal anti-inflammatory drugs and hydrocodone-acetaminophen started initially were ineffective for pain control. Prednisone provided relief and was continued for 1 month with a tapering dose. Symptoms completely resolved after 1 month at which time the thyroid remained diffusely enlarged and non-tender. Three months following RAI ablation she developed hypothyroid symptoms. Levothyroxine was initiated. The patient has remained asymptomatic on continued follow-up care.

Acute secondary adrenal insufficiency as the presenting manifestation of small-cell lung carcinoma.

A 66-year-old man, chronic smoker, presented with episodes of syncope, hypotension and constitutional symptoms. Initial evaluation revealed pre-renal azotaemia and acute secondary adrenal insufficiency.MRI performed was interpreted as a pituitary macroadenoma with enlargement of the infundibulum (stalk). Further endocrinological tests performed suggested central hypothyroidism and hypogonadism. Subsequent development of haemoptysis, headache and diplopia warranted further investigations, which revealed stage IV small-cell lung carcinoma with adrenal metastases. Subsequent brain imaging showed lesions in the brain parenchyma, pituitary and stalk, characteristic of metastases. Thus, we present a very atypical case of pituitary metastases presenting with acute secondary adrenal insufficiency.