Subcentimetric Papillary Thyroid Carcinoma: Does the Diagnosis Kind Impact Prognosis?

INTRODUCTION: Subcentimetric papillary thyroid carcinoma (SPTC) (papillary thyroid carcinoma with less than 10 mm in size) usually presents an excellent prognosis, with few aggressive reported cases. Given the globally increased incidence of SPTC, physicians are struggling with the need to identify prognostic factors to stratify SPTC. The aim was to compare clinicopathological variables and prognosis between clinically and incidentally diagnosed SPTC. Materials and methodsː This is a retrospective observational study on patients with SPTC who underwent thyroidectomy between 2002 and 2015. Two groups were considered: G1 (n=60 (61.9%)), clinical diagnosis (Bethesda III-VI cytology in the thyroid tumor/in cervical lymphadenopathies) and G2 (n=37 (38.1%)), incidental diagnosis (thyroidectomy for benign thyroid pathology). The histological material was reviewed, and molecular analysis of the BRAF, RAS, and TERT promoter (TERTp) genes was performed. Resultsː Ninety-seven individuals were included, 60 (61.9%) of which were from G1, with a predominance of female sex (n=83 (85.6%)). Individuals of G1 were younger (53.0±14.2 versus 59.3±13.9 years; p=0.035), were more frequently treated with 131-iodine (39.2% versus 13.4%; p=0.007), had the largest diameter (8 (p25-p75: 7-9) versus 5 (p25-p75: 4-6.5) mm; p<0.001), and higher frequency of minimal extracapsular invasion (45% versus 24.3%; p=0.041). Increased tumor size was the only independent predictor of a clinical diagnosis (p<0.001). Conclusionsː Clinically and incidentally diagnosed SPTC showed excellent medium- to long-term prognosis. A larger SPTC was more likely a driver of clinical detection than a marker of tumor aggressiveness, but caution should be taken as contradictory data persists.

Hyperthyroidism in McCune-Albright Syndrome - a case report.

OBJECTIVES: We intend to describe a case of McCune-Albright Syndrome (MAS), a rare disease characterized by fibrous dysplasia (FD), cutaneous hyperpigmentation and hyperfunctioning endocrinopathies (HFE). CASE PRESENTATION: We report the case of a 13-year-old male child who presented with a café-au-lait macule in the lumbosacral region and disabling polyostotic FD, requiring several surgical interventions and bisphosphonates from the age of 3 years (Y) + 9 months (M) due to persistent and severe pain. Hyperthyroidism (HT) became apparent at 5 Y + 1 M with a T3/T4 ratio greater than 20. Treatment with anti-thyroid drugs (ATD) was carried out for 7 Y and there was a progressive improvement in pain complaints 8 M after starting ATD, allowing treatment with pamidronate to be discontinued. Total thyroidectomy was performed at 12 Y + 5 M. CONCLUSIONS: This is a case of MAS-associated HT that reflects the deleterious effect of thyroid hormone excess on FD, reinforcing the need of having a low threshold for suspicion of HFE that may arise.

Multiple Bone Fractures in a Patient With Difficult-to-Treat Cushing's Disease.

Osteoporosis at a young age should prompt clinicians to search for secondary causes, namely endogenous Cushing's syndrome.We report a case of a 33-year-old male with a history of spontaneous fracture of the 12th thoracic vertebra and florid features of Cushing's syndrome. The physical exam evidenced moon face, facial plethora, muscle atrophy of the upper and lower limbs, and accumulation of abdominal fat. Bone mineral density revealed osteoporosis in the lumbar spine and in the femoral neck. Scintigraphy showed bone fractures in several costal arches, dorsal columns, and sternum. Hypercortisolism was confirmed by blood work. Serum cortisol, adrenocorticotropic hormone and corticotropin (ACTH), and 24-hour urine cortisol values were elevated. Imaging with MRI sellar region was normal and bilateral catheterization of inferior petrosal sinuses was positive. The patient underwent transsphenoidal pituitary surgery (TPS) and a lesion in the right side of the pituitary was identified and resected. Postoperatively, the patient did not meet the remission criteria and we decided to initiate treatment with ketoconazole alongside pituitary radiotherapy. After two years of surgery, the patient presented with recurrent bone fractures, height loss (25 cm), intense fatigue, and difficulty walking without assistance. Due to severe disease, we performed bilateral adrenalectomy, which was essential to control hypercortisolism and improve the patient's quality of life.

Fluorine-18 Fluorocholine Positron Emission Tomography/Computed Tomography in Primary Hyperparathyroidism: A Case Report and Review of Literature.

Positron emission tomography (PET) tracers (Fluorine-18 Fluorocholine [18F-Fluorocholine] and Carbon-11 Choline [11C-Choline]) have been widely used with promising accuracy in detecting abnormal parathyroids, being crucial for an effective and safe minimally invasive parathyroidectomy. We report a case of a 72-year-old woman with a long-term personal history of osteoporosis and recurrent nephrolithiasis with the need for invasive interventions. Primary hyperparathyroidism was biochemically assumed, although localization of the hyperfunctioning parathyroid had been challenging since cervical ultrasound and technetium-99m sestamibi scintigraphy were negative/equivocal. An 18F-Fluorocholine positron emission tomography/computed tomography (PET/CT) was performed, having identified a small cervical nodule with increased tracer uptake, compatible with a right parathyroid adenoma. After its removal, the patient went into clinical and biochemical remission. 18F-Fluorocholine PET/CT allowed an effective and safe parathyroidectomy as conventional imaging modalities were inaccurate in detecting the abnormal parathyroid, in this patient with serious hyperparathyroidism-related complications.

Secukinumab, Pituitary Enlargement and Panhypopituitarism: Are They Related?

Pituitary adenomas are the most common cause of hypopituitarism associated with pituitary enlargement, but other aetiologies have been emerging, namely immune checkpoint inhibitor-induced hypophysitis (ipilimumab, nivolumab and pembrolizumab). Secukinumab is a recently approved human monoclonal antibody used for the treatment of psoriasis, with no know reported cases of hypophysitis. We describe a challenging case of panhypopituitarism in a patient with a pituitary incidentaloma and a temporal relationship between secukinumab initiation and the manifestation of clinical features suggestive of hypopituitarism. In such intricate work-up, the differential diagnoses should be carefully considered, taking into account the therapeutic and prognostic implications. LEARNING POINTS: Pituitary adenomas are the leading cause of hypopituitarism associated with pituitary enlargement, but clinicians should be aware of non-tumoural causes such as hypophysitis.Drug-induced hypophysitis has been described with immune checkpoint inhibitors used for diverse types of malignancies, but there is no evidence of an association between hypophysitis and the novel antipsoriatic agent, secukinumab.The differential diagnosis of hypopituitarism requires careful investigation so that management is appropriate and prognosis is improved.

Management of Pipkin Fractures Using a Safe Surgical Hip Dislocation.

INTRODUCTION: Pipkin fractures are rare events and usually occur as a consequence for high-energy trauma. Surgery to obtain anatomical reduction and fixation is the mainstay treatment for the majority of these injuries; nonetheless, controversy exists regarding the best surgical approach. DESCRIPTION OF THE CASE: We present the case of a 41-year-old male, which sustained a type II Pipkin fracture following a motorcycle accident. In the emergency department, an emergent closed reduction was performed, followed by surgery five days later. Using a surgical hip dislocation, a successful anatomical reduction and fixation was performed. After three years of follow-up, the patient presented with a normal range of motion, absent signs for avascular necrosis or posttraumatic arthritis, but with a grade II heterotopic ossification. DISCUSSION: Safe surgical hip dislocation allows full access to the femoral head and acetabulum, without increasing the risk for a femoral head avascular necrosis or posttraumatic arthritis. Simultaneously, this surgical approach gives the opportunity to repair associated acetabular or labral lesions, which explains the growing popularity with this technique. CONCLUSION: Although technically demanding, safe surgical hip dislocation represents an excellent option in the reduction and fixation for Pipkin fractures.