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International Journal of Surgery Case... Sep 2023A non-recurrent laryngeal nerve (NRLN) is an unusual variant of the recurrent laryngeal nerve. It is seen in 0.3-0.8 % of individuals. During neck surgery, the NRLN is...
INTRODUCTION AND IMPORTANCE
A non-recurrent laryngeal nerve (NRLN) is an unusual variant of the recurrent laryngeal nerve. It is seen in 0.3-0.8 % of individuals. During neck surgery, the NRLN is predisposed to be injured due to its abnormal anatomic position which results in vocal cord paralysis.
CASE PRESENTATION
We report two patients who underwent thyroid surgery. The indication for surgery was controlled toxic diffuse goiter and multinodular goiter with pressure symptoms in the first and second patients respectively. Intraoperatively we employed the lateral approach using the inferior thyroid artery as a landmark to dissect for the RLN. Once we couldn't find the nerve in its normal position the possibility of NRLN came into picture. Through gentle dissection between the larynx and the carotid sheath the nerve was found entering the larynx directly at right angle in both cases and the diagnosis of NRLN was made and intraoperative pictures were taken.
CLINICAL DISCUSSION
The NRLN is a rare congenital anomaly of the recurrent laryngeal nerve. It is almost always diagnosed on the right side. Three types have been described. In most cases, the NRLN is diagnosed intraoperative. Both of our patients had type 2A right sided NRLN which was diagnosed intraoperative.
CONCLUSION
Through intraoperative careful dissection and search the RLN can be identified and also its rare anomaly, the NRLN, can be diagnosed and injury to the nerve can be avoided.
PubMed: 37651807
DOI: 10.1016/j.ijscr.2023.108751 -
Journal of Clinical & Translational... Sep 2023The incidence of thyroid cancer has increased over the last three decades with studies showing incidence of thyroid cancer is higher among patients with Graves' Disease...
BACKGROUND
The incidence of thyroid cancer has increased over the last three decades with studies showing incidence of thyroid cancer is higher among patients with Graves' Disease (GD) when compared to Toxic multinodular goiter. We conducted a retrospective study to further investigate characteristics and outcomes in patients with thyroid cancer and GD.
METHODS
We retrospectively reviewed 62 patients with a diagnosis of Differentiated Thyroid Cancer (DTC). We compared age at diagnosis, type, size of tumor, radioactive iodine (RAI) use, and DTC recurrence amongst patients with GD, non-GD patients. We used Chi-square to test for independence among categorical variables at a nominal level of 0.05; comparison was based on -test.
RESULTS
Out of 62 patients, 29 patients had GD and DTC (47%). 94% had papillary thyroid cancer. Patients with GD were diagnosed with DTC at a younger age (mean 46 years) in comparison to patients without GD (mean 53 years). There was no difference in the type of DTC. Patients with GD had significantly smaller tumor size (mean size 1.035 cm; p value = 0.002), more Stage 1 and 2 compared to patients without GD (p-value = 0.009). Both groups of patients had similar rates of recurrence on follow up and RAI use.
CONCLUSION
We found patients with GD had smaller tumor size, early-stage DTC when compared to patients without GD and potentially favorable prognosis. More data is needed to understand whether this is due to pathogenesis like Graves antibodies promoting tumor formation or merely earlier detection of DTC in GD.
PubMed: 37547825
DOI: 10.1016/j.jcte.2023.100321 -
Cureus Jul 2023DICER1 syndrome is a rare autosomal dominant syndrome resulting in benign and malignant tumors in various organs with tumors in endocrine organs (pituitary, thyroid,...
DICER1 syndrome is a rare autosomal dominant syndrome resulting in benign and malignant tumors in various organs with tumors in endocrine organs (pituitary, thyroid, adrenal, ovaries, and pancreas). Here we present a rare case of 18-year-old twin sisters with DICER1 syndrome who presented at the age of 15 years with hirsutism, deepening of the voice, and amenorrhea. They were diagnosed with a Sertoli-Leydig cell tumor of the ovary and underwent unilateral oophorectomy, with no evidence of recurrence or metastasis during follow-up. Genetic analysis showed the same germline DICER1 mutation in both cases. They also had large multinodular goiters (nodule size ranging from 1.0 to 2.3 cm) nodules were increasing in size. Fine needle aspiration cytology (FNAC) of thyroid nodules for both the sisters showed atypia of undetermined significance/follicular lesion of undetermined significance (AUS/FLUS), and they both underwent total thyroidectomy revealing papillary thyroid carcinoma. No pituitary lesion was observed in the brain magnetic resonance imaging (MRI) of either of them. A chest CT scan showed bilateral sub-pleural benign-looking nodules in both patients. The twin sisters developed some features, such as Sertoli-Leydig cell tumor, multinodular goiter, and papillary thyroid carcinoma, and had positive genetic tests for DICER1 germline mutation. The father and paternal grandfather had a family history of papillary thyroid carcinoma. Both patients require active surveillance due to the increased risk of developing tumors in multiple organs associated with this disease.
PubMed: 37546126
DOI: 10.7759/cureus.41344 -
Medicine Aug 2023Inflammation plays an important role in the pathogenesis of many cancer types and is associated with thyroid malignancy. The systemic immune-inflammation index (SII) is...
Inflammation plays an important role in the pathogenesis of many cancer types and is associated with thyroid malignancy. The systemic immune-inflammation index (SII) is a new inflammation marker that can be calculated from routine complete blood count (CBC). This study investigated the association between SII, a marker derived from routine CBC, and different thyroid diseases. The objective was to determine if this simple inflammation marker can distinguish between benign and malignant thyroid diseases. The medical records of all patients who underwent surgical treatment for thyroid disease between January 2018 and January 2022 were systematically evaluated. The routine preoperative CBC parameters' demographic, clinical, and laboratory data were recorded. A total of 241 patients were included in the study, and the patients were grouped as having multinodular goiter (n = 125), lymphocytic thyroiditis (n = 44), and papillary thyroid carcinoma (PTC) (n = 73) according to pathological results. The SII was defined as the ratio of the total count of neutrophils × platelets divided by the lymphocyte count. Subgroup analysis of patients was performed according to the presence of follicular variant or thyroiditis, micro or macro carcinoma, or bilaterality of the tumor. The SII level was significantly higher in the PTC group than in the lymphocytic thyroiditis and multinodular goiter groups (P < .001). When we grouped the patients according to the presence of PTC as benign or malignant, the optimum cutoff point for SII level was found 654.13, with 73.8% sensitivity and 72.3% specificity from ROC analysis. In the subgroup analysis of patients with PTC, the SII level was similar according to the clinicopathological characteristics of the tumor. The differential diagnosis of thyroid diseases is important for patient management. We found that preoperative SII levels were significantly elevated in patients with PTC compared to those with benign thyroid disorders, and this simple marker can be used for the differentiation of benign and malignant thyroid disease.
Topics: Humans; Thyroiditis, Autoimmune; Carcinoma, Papillary; Thyroid Neoplasms; Thyroid Cancer, Papillary; Hashimoto Disease; Inflammation; Goiter; Retrospective Studies; Lymphocytes
PubMed: 37543770
DOI: 10.1097/MD.0000000000034596 -
International Journal of Surgery Case... Aug 2023In areas with iodine deficiency, multinodular goiter is a prevalent cause of hyperthyroidism. If left untreated, it can grow until it is noticeably huge in size....
INTRODUCTION
In areas with iodine deficiency, multinodular goiter is a prevalent cause of hyperthyroidism. If left untreated, it can grow until it is noticeably huge in size. Although it is a rare clinical phenomenon, thyroid swelling extending into the retro-pharyngeal space presents a substantial difficulty for the surgeon. In this article, we report a giant thyroid mass that had extended to the retro-pharyngeal space and how it posed a challenge during surgery.
CASE PRESENTATION
Female, 30-year-old, presented with a huge goiter of 15 years duration which extended to retro-visceral space and completely encircled them without extension to retro-sternal space. After the patient was rendered euthyroid with propylthiouracil (PTU), the thyroid mass was removed surgically. Postoperatively, the patient developed only a transient, asymptomatic hypocalcemia, as a complication.
DISCUSSION
If a goiter is large enough, it can grow inferiorly into the mediastinum and outside the typical boundaries of the thyroid bed. However, they rarely grow into the retro-pharyngeal space and present a management issue. The management of this patient was also more complicated as the goiter grew enormous and giant, particularly when it came to controlling the airway and surgically removing the tumor.
CONCLUSION
A preoperative CT scan is an important part of diagnostic studies for a giant goiter to diagnose extrathyroidal bed extension. Total or near-total thyroidectomy through a large cervical incision is the mainstay of treatment for such patients to relieve compression symptoms and treat associated hyperthyroidism.
PubMed: 37487349
DOI: 10.1016/j.ijscr.2023.108543 -
European Journal of Nuclear Medicine... Oct 2023Treatment of hyperthyroidism caused by autonomously functioning thyroid nodules (AFTN) with I often leads to undesirable hypothyroidism. Radiofrequency ablation (RFA)...
Radiofrequency ablation for autonomously functioning nodules as treatment for hyperthyroidism: subgroup analysis of toxic adenoma and multinodular goitre and predictors for treatment success.
PURPOSE
Treatment of hyperthyroidism caused by autonomously functioning thyroid nodules (AFTN) with I often leads to undesirable hypothyroidism. Radiofrequency ablation (RFA) has emerged as a promising alternative. This retrospective analysis aimed to examine the efficacy of, and postprocedural hypothyroidism after, RFA for AFTN.
METHODS
Patients with hyperthyroidism caused by AFTN and treated with RFA were included if follow-up of at least 1 year was available. Cure was defined as thyroid medication-free biochemical euthyroidism. To predict cure, patient and treatment factors were analysed. A distinction was made between solitary toxic adenoma (STA) and toxic multinodular goitre (TMG).
RESULTS
Forty-eight patients (36 STA, 12 TMG) were included. One year post-RFA cure rate was 72% in STA versus 25% in TMG (p = 0.004). One patient developed hypothyroidism. In 11 patients that remained hyperthyroid, a second RFA was successful in 83% of STA and 40% of TMG patients. At last available follow-up, this amounted to a total cure rate of 81% in STA and 33% in TMG (p = 0.002). In STA, cured patients had a higher baseline TSH and a lower FT3 than non-cured patients (p = 0.026 and 0.031). Cure was observed in 91% of patients when > 2.1 kJ/mL was delivered during RFA, compared to 44% when less energy was administered.
CONCLUSION
The efficacy of RFA was nearly 3 times higher in STA patients compared to TMG. Severity of hyperthyroidism and kJ/mL delivered during RFA predicts cure. Direct comparison to the current standard of care is needed to implement RFA in treatment of hyperthyroidism caused by AFTN.
PubMed: 37466647
DOI: 10.1007/s00259-023-06319-9 -
International Journal of Surgery Case... Jul 2023The prediction and early identification of non-recurrent laryngeal nerve (RLN) may minimize risk of injury. It could be associated with other coincident variants that...
INTRODUCTION AND IMPORTANCE
The prediction and early identification of non-recurrent laryngeal nerve (RLN) may minimize risk of injury. It could be associated with other coincident variants that predict non-RLN, leading to its proper identification.
CASE PRESENTATION
A patient with multinodular goiter underwent total thyroidectomy under intraoperative neuromonitoring (IONM) guidance. Preoperative thoracic computerized tomography (CT) scan/angiography revealed aberrant right subclavian artery (ARSA). During thyroid surgery, the vagus nerve (VN) was identified in the neurovascular bundle. An anatomic variation of the VN was observed, as it was medially placed in relation to the common carotid artery (CCA). Pre-dissection electrophysiological stimulus of the VN (V1) was negative. Thus, a right non-RLN was identified with careful surgical dissection. The branching point of the non-RLN on the VN was identified, and non-RLN was fully exposed until the laryngeal entry. IONM revealed that V1 signal was negative if derived distal to the non-RLN separation, and positive if derived proximal to the non-RLN separation.
CLINICAL DISCUSSION
ARSA detected by preoperative CT scan is associated with non-RLN. The medial course of the VN in relation to the CCA was found as a coincident anatomic variant with the non-RLN. Absence of pre-dissection V1 signal by IONM was an electrophysiological variant associated with the non-RLN.
CONCLUSION
ARSA is a reliable variant for predicting the non-RLN. VN medial to the CCA and absence of electrophysiological V1 signal could precisely predict the non-RLN. Therefore, the coincidence of three anatomical and electrophysiological variants with non-RLN could lead to the prediction of non-RLN.
PubMed: 37429206
DOI: 10.1016/j.ijscr.2023.108457 -
Journal of the Endocrine Society Jul 2023In patients with neurofibromatosis type 1 (NF1), guidelines suggest screening for pheochromocytoma by metanephrine measurement and abdominal imaging, which may lead to...
CONTEXT
In patients with neurofibromatosis type 1 (NF1), guidelines suggest screening for pheochromocytoma by metanephrine measurement and abdominal imaging, which may lead to the discovery of gastroenteropancreatic neuroendocrine tumors (GEP-NETs) and their differential diagnosis, gastrointestinal stromal tumors (GISTs). Other endocrine manifestations such as follicular thyroid carcinoma and primary hyperparathyroidism have also been reported in a few cases.
OBJECTIVE
This study aimed to describe prevalence and clinical presentation of these manifestations through systematic screening in a large cohort of patients.
METHODS
In this monocentric retrospective study, 108 patients with NF1 were included and screened for endocrine manifestations and GISTs. Clinical, laboratory, molecular profile, pathology, and morphologic (abdominal computed tomography scan and/or magnetic resonance imaging) and functional imaging were collected.
RESULTS
Twenty-four patients (22.2% of the cohort, 16 female, mean age 42.6 years) presented with pheochromocytomas that were unilateral in 65.5%, benign in 89.7%, and with a ganglioneural component in 20.7%. Three female patients (2.8% of the cohort, aged 42-63 years) presented with well-differentiated GEP-NETs, and 4 (3.7%) with GISTs. One patient had primary hyperparathyroidism, 1 patient had medullary microcarcinoma, and 16 patients had goiter, multinodular in 10 cases. There was no correlation between pheochromocytoma and other NF1 tumoral manifestations, nor correlations between pheochromocytoma and genotype, despite a familial clustering in one-third of patients.
CONCLUSION
The pheochromocytoma prevalence in this NF1 cohort was higher (>20%) than previously described, confirming the interest of systematic screening, especially in young women. The prevalence of GEP-NETs and GISTs was about 3%, respectively. No phenotype-genotype correlation was observed.
PubMed: 37409183
DOI: 10.1210/jendso/bvad083 -
Medicina (Kaunas, Lithuania) Jun 2023Acromegaly is a rare disease associated with increased levels of growth hormones (GHs) that stimulates the hepatic production of insulin growth factor-1 (IGF-1)....
Acromegaly is a rare disease associated with increased levels of growth hormones (GHs) that stimulates the hepatic production of insulin growth factor-1 (IGF-1). Increased secretion of both GH and IGF-1 activates pathways, such as Janus kinase 2/signal transducer and activator of transcription 5 (JAK2/STAT5), and mitogen-activated protein kinase (MAPK), involved in the development of tumors. Given the disputed nature of the topic, we decided to study the prevalence of benign and malignant tumors in our cohort of acromegalic patients. In addition, we aimed to identify risk factors or laboratory parameters associated with the occurrence of tumors in these patients. The study group included 34 patients (9 men (25.7%) and 25 women (74.3%)). No clear relationship between the levels of IGF-1 or GH and tumor development could be demonstrated, but certain risk factors, such as diabetes mellitus (DM) and obesity, were more frequent in patients with tumors. In total, 34 benign tumoral proliferations were identified, the most common being multinodular goiter. Malignant tumors were present only in women (14.70%) and the most frequent type was thyroid carcinoma. DM and obesity might be associated with tumoral proliferation in patients with acromegaly, and findings also present in the general population. In our study we did not find a direct link between acromegaly and tumoral proliferations.
Topics: Male; Humans; Female; Acromegaly; Insulin-Like Growth Factor I; Thyroid Neoplasms; Growth Hormone; Diabetes Mellitus; Insulin; Obesity
PubMed: 37374352
DOI: 10.3390/medicina59061148