Incidental Solitary Adrenal Metastasis as the Initial Manifestation of a Solid Variant of Papillary Thyroid Carcinoma, With Emphasis on Pathologic Diagnosis and Clinical Management.

Objective: Distant metastases from papillary thyroid carcinoma (PTC) are relatively rare and may be associated with a poor prognosis. The adrenal gland is a highly unusual site of metastasis in the natural course of PTC. Herein, we describe a case of an incidentally detected metastatic solid variant of PTC in the adrenal gland of an asymptomatic patient as the initial presentation. Case Report: A 67-year-old male patient was evaluated for a 4.7-cm adrenal incidentaloma discovered during a workup for nephrolithiasis. Biochemical evaluation revealed a nonfunctioning adrenal mass. The patient underwent adrenalectomy, which revealed metastatic PTC. A subsequent thyroid ultrasound revealed an isthmic nodule. Fine needle aspiration of the nodule was cytologically suspicious for a follicular neoplasm, and gene expression analysis revealed an HRAS c.182A>G sequence variation. The patient subsequently underwent total thyroidectomy, which revealed a 1.2-cm solid variant of PTC in the thyroid isthmus. Postoperatively, the patient underwent radioactive iodine ablation. Discussion: Our case illustrates an exceedingly rare and challenging situation-a metastatic solid variant of PTC in the adrenal gland of a patient with no prior history of PTC. When confronted with a PTC in the adrenal gland in the absence of a previously identified primary tumor, our experience suggests that the next step in management should be total thyroidectomy followed by radioactive iodine ablation. Conclusion: A solid variant of PTC is a rare cause of an incidentally detected adrenal lesion. Multidisciplinary care team coordination is essential for accurate diagnosis and treatment plan formulation.

Pasireotide: A Novel Treatment for Tumor-Induced Hypoglycemia Due to Insulinoma and Non-Islet Cell Tumor Hypoglycemia.

Tumor-induced hypoglycemia is a serious disorder most commonly caused by insulinoma or non-islet cell tumor hypoglycemia (NICTH). The hypoglycemia can be severe and refractory to conventional therapy, leading to significant morbidity and mortality. The objective of this work is to describe a series of challenging cases in which refractory, tumor-induced hypoglycemia was shown to respond to the use of pasireotide, a second-generation somatostatin receptor ligand. We describe the clinical and biochemical features of 3 patients with tumor-induced hypoglycemia due to an occult insulinoma, malignant insulinoma, and non-islet cell tumor hypoglycemia. In these 3 individuals, the hypoglycemia remained refractory to guideline-recommended medical therapy, such as diazoxide, nonpasireotide somatostatin analogues, and glucocorticoids. Pasireotide was substituted to attenuate the refractory hypoglycemia for each patient. The addition of pasireotide led to prompt improvement in the frequency and severity of hypoglycemic episodes for each tumor-induced hypoglycemia patient. We demonstrate the successful treatment of 3 individuals with refractory, tumor-induced hypoglycemia with pasireotide. We offer the first reported use of pasireotide for the successful treatment of nonmalignant insulinoma and non-islet cell tumor hypoglycemia.

Long-Term Outcomes of Thyroid Nodule AFIRMA GEC Testing and Literature Review: An Institutional Experience.

OBJECTIVE: To assess outcomes of thyroid nodules analyzed with the AFIRMA gene expression classifier (GEC) and to perform a comprehensive literature review. STUDY DESIGN: Retrospective analysis of patients with thyroid nodules who underwent AFIRMA GEC testing at our institution. SETTINGS: A tertiary care academic institution. SUBJECTS AND METHODS: We collected clinical outcomes for 416 thyroid nodules that were analyzed with AFIRMA GEC between 2011 and 2015, including long-term follow-up through 2019. We performed a comprehensive literature review. RESULTS: The resection rate for nodules with "suspicious" GEC results was 85% with a positive predictive value of 37%. The resection rate for nodules with "benign" GEC results was 24% with a negative predictive value of 90%. The prevalence of thyroid malignancy in patients with thyroid nodules with indeterminate cytology at our institution during this timeframe was 41%, thus lowering our negative predictive value. Mean follow-up duration for unresected nodules was 27.8 months. Our resection rates for nodules with "benign" GEC were among the highest reported in the literature. CONCLUSIONS: Molecular marker testing of thyroid nodules with indeterminate cytology can aid in the surgical decision making by obviating the need for diagnostic surgery and/or guiding extent of resection. Patients with other indications for surgery may not benefit from such costly testing.

PROLONGED HYPERCALCEMIA FROM ANTIBIOTIC-ELUTING CALCIUM SULFATE BEADS.

OBJECTIVE: Calcium sulfate beads (CSBs) are biocompatible hydrophilic crystals that are used to deliver local antibiotics in periprosthetic joint infections. Hypercalcemia after placement of CSBs is uncommon and poorly understood. METHODS: We present the case of a woman who presented with symptomatic hypercalcemia after placement of antibiotic-eluting CSBs. RESULTS: A 58-year-old, Caucasian woman presented with altered mental status, respiratory failure, and septic shock 2 days after placement of antibiotic-eluting CSBs for a left prosthetic hip infection. Laboratory analysis revealed severe hypercalcemia at presentation. She had no known history of fractures, kidney stones, parathyroid, or calcium disorders. She was not on any medications that could induce hypercalcemia. She was treated with aggressive intravenous hydration and 8 doses of calcitonin. Due to impaired renal function, bisphosphonate was contraindicated. She subsequently became anuric with worsening renal failure and volume overload and the decision was made to initiate dialysis. She received 8 days of continuous renal replacement therapy followed by 2 sessions of hemodialysis which improved her serum calcium levels, mental status, and renal failure with no long-term complications. CONCLUSION: Hypercalcemia secondary to the placement of antibiotic-eluting CSBs is rare. Larger volumes of CSBs may contribute to hypercalcemia. In some cases, hypercalcemia can be severe and symptomatic as in the case of our patient. Serum calcium levels should be monitored frequently after placement of CSBs and managed as appropriate.

Association of Galectin-3 With Diabetes Mellitus in the Dallas Heart Study.

CONTEXT: Galectin-3 is a biomarker associated with inflammation and fibrosis in cardiac, liver, and renal disease. Galectin-3 is higher in overweight and obese individuals; whether an association with diabetes exists independent of weight is unknown. OBJECTIVE: To evaluate if galectin-3 is associated with diabetes mellitus. DESIGN: We performed measurements of galectin-3 among participants in the Dallas Heart Study (DHS) Phases 1 and 2 (DHS-1 and DHS-2; n = 3392, and n = 3194, respectively). Of these, 1989 participants were evaluated longitudinally in both studies. Associations of galectin-3 with prevalent and incident type 2 diabetes were determined using logistic regression models. Associations of galectin-3 with relevant biomarkers and fat compartments were evaluated using Spearman correlation coefficients and multivariable linear regression models, respectively. SETTING AND PARTICIPANTS: DHS is a population-based, single-site, multiethnic study conducted in Dallas County, Texas, with oversampling to comprise 50% blacks. RESULTS: Galectin-3 levels were associated with diabetes prevalence in DHS-1 [OR 1.56 per SD change in log-galectin (95% CI 1.41 to 1.73)] and DHS-2 [OR 1.86 (95% CI 1.67 to 2.06)]. Galectin-3 levels in DHS-1 also associated with incident diabetes mellitus over the 7.1 (interquartile range 6.6 to 7.6)-year follow-up period [OR 1.34 (95% CI 1.14 to 1.58)]. These associations maintained significance in models adjusted for traditional metabolic risk factors (age, sex, race, body mass index, and hypertension) and renal function. Galectin-3 levels correlated with levels of biomarkers implicated in inflammation (high-sensitivity C-reactive peptide, IL-18, monocyte chemoattractant protein 1, soluble TNF receptor 1A, myeloperoxidase), insulin secretion (C-peptide and C-peptide/homeostatic model assessment for insulin resistance), and subcutaneous adiposity. CONCLUSIONS: Galectin-3 is associated with diabetes prevalence and incidence, possibly through the inflammatory pathway contributing to ß-cell fibrosis and impaired insulin secretion.

Very Severe Hypertriglyceridemia in a Large US County Health Care System: Associated Conditions and Management.

CONTEXT: Patients with very severe hypertriglyceridemia (triglyceride levels ≥2000 mg/dL; 22.6 mmol/L) require aggressive treatment. However, little research exists on the underlying etiologies and management of very severe hypertriglyceridemia. OBJECTIVE: We hypothesized (i) very severe hypertriglyceridemia in adults is mostly associated with secondary causes and (ii) most patients with very severe hypertriglyceridemia lack appropriate follow-up and treatment. DESIGN: We queried electronic medical records at Parkland Health and Hospital Systems for lipid measurements in the year 2016 and identified patients with serum triglyceride levels ≥2000 mg/dL (22.6 mmol/L). We extracted data on demographics, underlying causes, lipid-lowering therapy, and follow-up. RESULTS: One hundred sixty-four serum triglyceride measurements were ≥2000 mg/dL (22.6 mmol/L) in 103 unique patients. Of these, 60 patients were admitted to the hospital (39 for acute pancreatitis). Most were Hispanic (79%). The major conditions associated with very severe hypertriglyceridemia included uncontrolled diabetes mellitus (74%), heavy alcohol use (10%), medication use (7%), and hypothyroidism (2%). Two patients were known to have monogenic causes of hypertriglyceridemia. After the index measurement of triglycerides ≥2000 mg/dL (22.6 mmol/L), the use of triglyceride-lowering drugs increased, most prominently the use of fish oil supplements, which increased by 80%. However, in follow-up visits, hypertriglyceridemia was addressed in only 50% of encounters, and serum triglycerides were remeasured in only 18%. CONCLUSION: In summary, very severe hypertriglyceridemia was quite prevalent (∼0.1% of all lipid measurements) in our large county health care system, especially in Hispanic men. Most cases were related to uncontrolled diabetes mellitus, and follow-up monitoring was inadequate.