Seeking optimization of LT4 treatment in patients with differentiated thyroid cancer

: Levothyroxine sodium (LT4) is the mainstay treatment to replace thyroid hormonal production in thyroidectomized patients, but, depending on the aggressiveness of the cancer and on the risk of recurrence, patients with differentiated thyroid cancer may also be treated in a TSH-suppressive or semi-suppressive mode. The pathophysiological rationale for this LT4 treatment stems from the role of TSH, considered to be a growth factor for follicular cells, potentially inducing initiation or progression of follicular cell-derived thyroid cancer. Therefore, accurate tailoring of treatment, taking into account both patient characteristics (age and comorbidities) and risk of persistent/recurrent disease, is highly recommended. Furthermore, adjustments to traditional LT4 treatment should be made in thyroidectomized patients due to the lack of thyroidal contribution to whole body triiodothyronine (T3) concentration. Since LT4 exhibits a narrow therapeutic index and the side effects of over- and under-treatment could be deleterious, particularly in this category of patients, caution is required in dose individualization, in the mode of ingestion, and in potential pharmacological and other types of interference as well. Our aim was to analyze the current knowledge concerning LT4 dose requirements in patients with thyroid cancer according to different therapeutic approaches, taking into account a number of factors causing interference with LT4 efficacy. Specific mention is also made about the use of the novel LT4 formulations

Hemorrhagic uterine necrosis after surgical vessel ligation and B-Lynch suture in persistent post-cesarean uterine atony: case report and review of literature

Uterine necrosis is a rare life-threatening condition reported in few case reports and series, associated with uterine artery embolization for uterine fibroids or postpartum hemorrhage. We report a hemorrhagic uterine necrosis in a nulliparous 35 years-old woman underwent cesarean section at 40+1 weeks of gestation for obstructed labor, presenting post-partum persisting bleeding and uterine atony and congestion. Bleeding stopped only after placement of two set of compressive sutures, curettage of uterine cavity and placement of Bakri Balloon but the uterine body never contracted and become congested. Notwithstanding an effective antibiotic therapy, the patient developed an intermittent fever and signs of severe anemia. Clinical and radiological diagnosis with CT and MRI scan were compatible with uterine necrosis characterized by hemorrhagic infarction of the uterine wall and decomposition of its muscular tissue. Hysterectomy was discussed with patient and performed on day 32 after C-section. Uterine apoplexy, a rare life-threatening disease, was detected with CT by lack of uterine contrast enhancement and a gas-filled uterine cavity and necrosis was confirmed with MRI by showing fluid degeneration of the myometrium. Failure to recognize a necrotic uterus on imaging can cause delayed hysterectomy, which is mandatory and potentially life-saving