Thyroid

Kikuchi disease and thyroid follicular adenoma

August 31, 2010     Mohamed Abdel Khalek, MD, Xin Zhong, BS, Krzysztof Moroz, MD, and Emad Kandil, MD
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Medullary thyroid carcinoma

June 30, 2010     Lester D.R. Thompson, MD
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Type I thyroplasty revision 1 year after a window was mistakenly created on the cricoid cartilage

April 30, 2010     Hilmi Alper Şenkal, MD and Taner Yilmaz, MD
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Abstract

Unilateral vocal fold paralysis causes glottic incompetence and can result in significant morbidity. To prevent such morbidity, surgeons treat affected patients with vocal fold medialization techniques; type I thyroplasty medialization surgery is widely used for this purpose. In this procedure, a window is opened on the thyroid cartilage to allow for placement of a silicon prosthesis to medialize the vocal fold. A 38-year-old woman presented to our clinic for evaluation of hoarseness and a low-pitched voice, which we diagnosed as being caused by left vocal fold paralysis. Two years earlier, she had undergone a thyroidectomy for the treatment of benign thyroid disease. One year after that, she underwent type I thyroplasty medialization surgery at another center. During that operation, the surgeon had mistakenly created the window on the cricoid cartilage rather than the thyroid cartilage. When he inserted the silicon prosthesis into the cricoid window, the patient developed acute respiratory obstruction. At that point, the prosthesis was removed and the operation was terminated. One year later, she presented to us, and we performed a revision type I thyroplasty. Intraoperatively, we discovered that the original window had been opened on the cricoid cartilage instead of the thyroid cartilage, which was intact. We left the cricoid window untouched, opened a new window on the thyroid cartilage, and completed the type I thyroplasty in the usual fashion. The patient's postoperative recovery was uneventful, and she was doing well at 5 years of follow-up. To the best of our knowledge, no case of a thyroplasty window being opened on a cricoid cartilage has been reported in the literature.

Papillary carcinoma arising in median ectopic thyroid tissue: Management of the thyroid gland

April 30, 2010     Susan Cordes, MD and Jeffrey J. Nelson, MD
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Abstract

Thyroid tissue in an ectopic location is rare, 1 in 100,000 to 300,000 persons, and usually in the lateral neck. Median ectopic thyroid tissue is even more unusual, with the vast majority of cases being lingual thyroid tissue. We present a case of carcinoma arising in median, nonlingual ectopic thyroid tissue along with an analysis of the literature to determine the most appropriate management of the orthotopic thyroid gland.

Disseminated plasmacytoma of the thyroid

March 1, 2010     Brian J. Park, MD, MPH, Randy J. Kalish, MD, and Arthur P. Vercillo, MD
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Abstract

Extramedullary plasmacytomas most commonly occur in the nasal cavity, nasopharynx, paranasal sinuses, and larynx. Thyroid involvement is rare, as fewer than 75 cases have been previously reported in the literature. We report a new case of disseminated plasmacytoma of the thyroid, which occurred in a 68-year-old woman. The diagnosis was made with an incisional biopsy. The patient initially experienced a complete response to radiotherapy (46.8 Gy in 26 fractions), but she developed multiple metastases at distant sites, including the breast, abdominal wall, and buttock despite various chemotherapy regimens. Ultimately, she was placed on palliative radiotherapy. We also briefly review the diagnostic and treatment options for patients with extramedullary plasmacytoma.

Parathyroid carcinoma: A rare cause of primary hyperparathyroidism

August 31, 2009     Brian Kung, MD, Ronald Winokur, MD, David Cognetti, MD, Brian O'Hara, MD, and David Rosen, MD
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Abstract

Most cases of primary hyperparathyroidism (80 to 90%) are caused by a parathyroid adenoma; most of the rest are caused by either parathyroid gland hyperplasia or multiple adenomas. Parathyroid carcinoma can be the cause of primary hyperparathyroidism in 1 to 5% of patients. When the appropriate clinical scenario is presented, it must be considered in the differential diagnosis. We describe the case of a 72-year-old woman with a long history of hypercalcemia and arthritic shoulder and neck pain who was admitted with an elevated calcium level and acute renal failure secondary to bilateral obstructing ureteral calculi. A sestamibi scan and magnetic resonance imaging detected the presence of what appeared to be a right inferior parathyroid adenoma. Her intact parathyroid hormone (PTH) level was 2,257 pg/ml. Following placement of bilateral ureteral stents and adequate hydration, the patient was taken to the operating room for a neck exploration and removal of a parathyroid adenoma with rapid intraoperative PTH monitoring. A 4 x 2.5-cm, 10-g mass was removed from the right inferior pole of the thyroid gland. Following excision, her intraoperative PTH level dropped from 1,103 to 110 pg/ml. Her ionized calcium levels fell from a high of 8.4 mg/dl preoperatively to 4.7 mg/dl. On final pathologic examination, the mass was confirmed to be a parathyroid carcinoma.

Adjuvant external-beam radiotherapy in patients with high-risk well-differentiated thyroid cancer

June 30, 2009     Peter V. Chen, MD, MS, Ryan Osborne, MD, Eugene Ahn, MD, Sofia Avitia, MD, Elliot Abemayor, MD, PhD, and Guy Juillard, MD
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Abstract

The role of adjuvant external-beam radiation therapy (EBRT) in well-differentiated thyroid cancer is not well delineated. Many clinicians rely solely on iodine 131 (131I) to destroy thyroid remnants following thyroidectomy. However, the lesser uptake of isotope in tumor cells suggests that 131I alone may not be sufficient to eradicate microscopic residual disease when no gross thyroid tissue remains. We conducted a retrospective study to examine the potential benefit of adjuvant EBRT in patients at high risk for microscopic residual disease following thyroidectomy. Between 1973 and 2001, 44 patients with well-differentiated papillary or follicular thyroid cancer were found to have extracapsular extension following thyroidectomy. These patients were divided into 2 groups based on the type of treatment; 11 patients had received adjuvant EBRT (with or without 131I) and 33 patients had not received EBRT (i.e., they received adjuvant 131I only). We reviewed their medical records and compiled data on local recurrence and overall survival (Kaplan-Meier analysis). Despite having a less favorable prognosis, the EBRT group experienced no local recurrences during a mean follow-up of 7.8 years; in contrast, 9 local recurrences were seen in the no-EBRT group. Also, the median survival for patients without a local recurrence was longer than that for those who had failed locally (425 vs. 317 mo). Although our population was not large enough for these differences to achieve statistical significance, our study did show that adjuvant EBRT provided excellent results. We hypothesize that a reciprocal irradiation effect between cancer cells and normal cells may be necessary in order for 131I to be tumoricidal. If so, a patient with microscopic residual disease would not have enough cancer cells to sufficiently concentrate 131I. Because EBRT does not depend on such a mechanism, it may be more effective than 131I in controlling disease in the setting of microscopic disease. Larger studies are needed to validate our results. In the meantime, we believe that adjuvant EBRT should play an important role in the treatment of patients with high-risk well-differentiated thyroid cancer.

Lingual thyroid

May 31, 2009     Manish Gupta, MS and Gul Motwani, MS
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Abstract

Lingual thyroid gland is a rare clinical entity caused by failure of the gland's anlage to descend early in the course of embryogenesis. It may present with symptoms of dysphagia, upper airway obstruction, or even hemorrhage anytime from infancy through adulthood. Treatment of this disorder includes the use of exogenous thyroid hormone to correct the hypothyroidism and to induce shrinkage of the gland. When symptoms of obstruction or bleeding appear, ablative therapy by means of surgery or radioiodine is warranted. We report our experience with lingual thyroid gland and discuss elements of the diagnostic and therapeutic evaluation, with emphasis on the clinical findings, laboratory tests, and radiographic imaging studies.

Follicular variant of papillary carcinoma arising from lingual thyroid

May 31, 2009     Churunal K. Hari, FRCS, Manoj Kumar, FRCS, Mohamed M. Abo-Khatwa, FRCS, Julia Adams-Williams, MRCS, and Hisham Zeitoun, MPhil, FRCS
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Abstract

Malignant transformation of ectopic lingual thyroid tissue is an uncommon event; only 43 cases have been reported in the literature. Only 10 of these cases were papillary carcinomas, in contrast to normal thyroid gland neoplasms, of which papillary tumors form the predominant group. We present a case of a follicular variant of papillary carcinoma originating from the lingual thyroid, along with a review of the literature. Our patient was treated with surgical excision followed by 131I therapy. To date, only 2 other cases of a follicular variant of lingual thyroid tumor have been reported.

Thyroidectomy in a community hospital: Findings of 100 consecutive cases

April 30, 2009     Duncan S. Postma, MD, FACS, Marie O. Becker, MD, FACS, Adrian Roberts, MD, Spencer Gilleon, MD, and Joseph Soto, MD
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Abstract

The objective of this study was to determine the characteristics and surgical outcomes of 100 consecutive cases of thyroidectomy (in 98 patients) at a community hospital from October 2005 to mid-November 2006. Preoperative laryngoscopy was performed in 94% of patients and postoperative laryngoscopy in 100%. Patients' thyroid nodules had been found incidentally in 28% of cases. The two most common indications for surgery were results of fine-needle aspiration biopsy (FNA) in 55% and size of the thyroid in 22% of cases. Of the 98 patients, 79 (81%) had benign diagnoses, 7 (7%) had microcarcinomas, and 12 (12%) had well-differentiated thyroid cancer. Overall, 5 patients (5%) had temporary recurrent laryngeal nerve paralysis, but this occurred in only 1 (1%) patient in the group with smaller lesions, a statistically significant difference (p< 0.02); none had permanent paralysis. Of 36 patients at risk for hypocalcemia, 3 (8%) and 1 (3%) had temporary and long-term hypocalcemia, respectively. There was no incidence of significant hemorrhage. FNA results were very accurate. We show that thyroidectomy can be performed with minimal laryngeal nerve paralysis or other complications. Larger lesions had significantly higher rates of temporary laryngeal nerve paralysis.

Possible risk factors for respiratory complications AFTER thyroidectomy: An observational study

March 31, 2009     Ganiyu A. Rahman, MBBS, FWACS, FICS
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Abstract

It is widely accepted that thyroid surgery is not without morbidity. One well known postoperative complication is respiratory distress. The aim of this prospective observational study was to determine the incidence of post-thyroidectomy respiratory complications and to identify possible predictive factors. The study population was made up of 262 patients who had undergone thyroidectomy for goiter at the University of Ilorin Teaching Hospital in Nigeria from January 1989 through December 2003. Information was collected on 8 possible predictive factors for respiratory complications: (1) the duration of the goiter, (2) the preoperative status of the recurrent laryngeal nerve, (3) the presence or absence of tracheal narrowing or deviation, (4) the presence or absence of retrosternal extension, (5) the ease or difficulty of endotracheal intubation, (6) the presence or absence of thyroid cancer, (7) the presence or absence of giant goiter, and (8) whether or not the goiter represented a recurrence. Respiratory complications occurred in 20 of the 262 patients (7.6%). Of these 20 patients, 16 (80%) had a goiter of at least 5 years' duration, 12 (60%) had a giant goiter, 5 (25%) had tracheal narrowing, 4 (20%) had a malignant goiter, 3 (15%) had palsy of the recurrent laryngeal nerve preoperatively, and 2 patients each (10%) had retrosternal extension, a difficult intubation, or a recurrent goiter. Twelve patients (60%) had at least 4 of the 8 possible risk factors, and 6 others (30%) had 3 factors. Postoperative tracheotomy was necessary for 4 patients. No deaths occurred. While the findings of this observational study can only suggest the possibility of causation, preoperative factors such as long-standing goiter and giant goiter should be taken into consideration in postoperative management and the prevention of respiratory complications. In addition, the presence of at least 4 of the 8 factors studied should likewise alert the management team.

Giant intrathyroid parathyroid adenoma: A preoperative and intraoperative diagnostic challenge

March 1, 2009     Wanli Cheng, MD, Greg T. MacLennan, MD, Pierre Lavertu, MD, and Jay K. Wasman, MD
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Abstract

We describe the case of an unusually large (giant) cystic intrathyroid parathyroid adenoma in a 73-year-old woman who had a 1-year history of hypercalcemia and a 5-year history of an asymptomatic enlargement of the left lobe of the thyroid. This unique case highlights the potential difficulties that can arise in the evaluation of thyroid nodules in patients with hyperparathyroidism. These difficulties were accentuated in this case by the large size of the mass, its intrathyroid location, and cytologic features that were compatible with a lesion of thyroid origin. In some cases, including this one, even a thorough preoperative evaluation that includes fine-needle aspiration biopsy and radiographic and nuclear medicine studies may not allow for a definitive preoperative diagnosis. The histologic overlap between thyroid and parathyroid lesions can also be problematic at the time of intraoperative frozen-section evaluation. Intraoperative parathyroid hormone monitoring may be helpful in these difficult cases.

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