Papillary follicular variant thyroid cancer in a malignant struma ovarii: a report of a rare case.

Summary: A 33-year-old female presented in 2013 with left flank pain. Ultrasound and MRI pelvis showed a complex mass 9 × 7 cm arising from the left ovary suggestive of ovarian torsion. She underwent a laparoscopic cystectomy, but the patient was lost to follow-up. Three years later, she presented with abdominal distension. Ultrasound and CT scan revealed a solid left ovarian mass with ascites and multiple peritoneal metastasis. Investigations showed elevated CA 125, CA 19-9. Ovarian malignancy was suspected. She underwent total abdominal hysterectomy and bilateral salpingo-oophorectomy on November 2016. The histopathology confirmed a well-differentiated thyroid cancer of ovarian origin with features of a papillary follicular variant without evidence of ovarian cancer and the thyroglobulin (Tg) level was elevated, more than 400 consistent with the diagnosis of malignant struma ovarii. The follow-up post-surgery showed normalization of CA 125, CA 19-9 and Tg. The patient underwent total thyroidectomy on January 2017. The histology was benign excluding thyroid cancer metastases to the ovary. She was started on thyroxine suppression, following which she received two ablation doses 131iodine (131I) each 5.3 GBq. The Tg remains slightly elevated at less than 10. 131I WBS showed no residual neck uptake and no distant avid metastasis. She was planned for molecular analysis which may indicate disease severity. We describe a case of malignant struma ovarii with widespread metastatic dissemination and a good response to surgery and 131I treatment without recurrence after 5 years of follow-up. The Tg remains slightly elevated indicating minimal stable residual disease. Learning points: Malignant struma ovarii is a rare disease; diagnosis is difficult and management is not well defined. Presentation may mimic advanced carcinoma of the ovary. Predominant sites of metastasis are adjacent pelvic structures. Thyroidectomy and 131iodine therapy should be considered. The management should be similar to that of metastatic thyroid cancer.

Dendritic myxofibrolipoma: often misdiagnosed as sarcoma.

The author describes a benign soft tissue tumor that could be easily mistaken for sarcoma. It represents a combined feature of solitary fibrous tumor and spindle cell lipoma. The clinical presentation, diagnosis, and management of this lesion are discussed. It highlights the importance of proper diagnosis to prevent unnecessary and ineffective treatment by clinicians as the complete excision of this lesion is the treatment of choice and recurrence is very unlikely. It is believed that this case is the first reported case of dendritic myxofibrolipoma occurring in the lower lip mucosa in an Omani patient.

A case of disseminated tuberculosis with adrenal insufficiency.

We present the case of a 37 year-old female who had disseminated tuberculosis (TB) with bilateral adrenal involvement resulting in primary adrenal failure (Addison's disease) with refractory hyponatraemia and possible extrapontine 'myelinolysis'. Laboratory results were remarkable for adrenal insufficiency. A Mantoux reaction was positive with evidence of pulmonary miliary TB. The magnetic resonance imaging scan showed all the characteristic changes of adrenal TB.

Insulinoma: a rare cause of a common metabolic disorder - hypoglycaemia.

We describe the first patient diagnosed with an insulinoma in Oman and successfully managed with a distal laparoscopic pancreatectomy. The importance of obtaining a good history from the patient and/or his family is stressed. All patients with loss of consciousness must have a Reflow check carried out and, if hypoglycaemic, this should be documented in the laboratory and a simultaneous serum sample stored for measurement of insulin, C-peptide proinsulin and sulphonylurea levels, if subsequently indicated. If magnetic resonance imaging fails to locate the tumour, endoscopic ultrasound of the pancreas, or indium 111 labelled octreotide scanning is indicated if the patient's hypoglycaemia has previously responded to treatment with octreotide.