Large tumor of iliac bone in a young woman imitating malignant disease as a sign of primary hyperparathyroidism

Detection of a bone tumor in a young adult draws suspicion of neoplastic disease. A 22-year-old female was admitted for a bone tumor biopsy. MRI of the pelvis showed an osteolytic lesion at the level of the left sacroiliac joint. Radiologist suggested differential diagnosis between aneurysmal bone cyst and giant cell tumor of bone. Considering the high serum calcium and numerous foci of increased accumulation of the radioisotope on the bone scan, serum iPTH level was evaluated. The diagnosis of hyperparathyroidism was established. Neck ultra­sound revealed focal lesion corresponding to an enlarged parathyroid gland. Parathyroidectomy was performed. The iliac bone tumor showed to be a brown tumor of primary hyperparathyroidism, detected only rarely in adolescents. Non-specific symptoms and lack of routine control of serum calcium in youths make an early diagnosis difficult; moreover, pathological features of brown tumor and giant cell tumor of bone are very similar

Cytometria przepływowa w diagnostyce różnicowej choroby Hashimoto i chłoniaka MALT tarczycy

 Introduction: A combination of traditional cytology methods with fluorescence activated cell sorting (FACS) analysis of fine-needle aspiration biopsy (FNAB) material is considered a powerful diagnostic tool in the differential diagnosis of thyroid lesions suspected of mucosa-associated lymphoid tissue lymphoma (MALT-L). The aim of this study was to demonstrate the FACS-based diagnostic process of thyroid lesions in a clinical situation where ultrasound and cytological examinations did not allow differentiation between Hashimoto’s thyroiditis (HT) and MALT-L. Material and methods: The patients analysed in this study presented significantly different clinical courses of thyroid disease: quickly enlarging painless tumour of the thyroid right lobe in the first case, and chronic HT with palpable tumour in the thyroid isthmus in the second patient. Due to the suspicion of MALT-L resulting from indeterminate ultrasound and FNAB-cytology results, FNAB material was obtained from all the previously examined thyroid lesions and directly subjected to FACS assessment, encompassing κ/λ light chain restriction analysis, as well as measurements of B and T cell surface antigens. Results: The FACS analysis of FNAB material obtained from our patients did not show any definite signs of light chain restriction. Although one of the samples showed a borderline value of κ/λ ratio (κ/λ = 0.31), further immunophenotyping confirmed clonal expansion in none of the examined thyroid regions. Histopathological findings documented the diagnosis of HT in both clinical cases. Conclusion: We believe that FACS represents a useful and reliable complementary diagnostic measure in FNAB-based differential diagnosis of lymphoproliferative thyroid disorders. Wstęp: Skojarzenie oceny cytologicznej oraz cytometrii przepływowej (FACS, fluorescence activated cell sorting) materiału uzyskanego podczas biopsji aspiracyjnej cienkoigłowej (BAC) jest uważane za niezwykle skuteczną metodę w diagnostyce różnicowej zmian tarczycy podejrzanych o obecność pozawęzłowego chłoniaka strefy brzeżnej systemu MALT (MALT-L). Celem pracy było zaprezentowanie opartego na FACS procesu diagnostycznego zmian ogniskowych tarczycy u chorych, u których badanie ultrasonograficzne i cytologiczne nie umożliwiło zróżnicowania przewlekłego zapalenia tarczycy (HT, Hashimoto's thyroiditis) od MALT-L. Materiał i metody: Chorzy opisani w pracy charakteryzowali się całkowicie odmiennym przebiegiem klinicznym choroby tarczycy — ujawniającej się w pierwszym przypadku jako szybko powiększający się guz płata prawego, w drugim jako zmiana ogniskowa w cieśni u chorej z przewlekłym wywiadem HT. Ze względu na podejrzenie MALT-L postawione na podstawie badania cytologicznego oraz podejrzany wzorzec ultrasonograficzny, przeprowadzono ponownie BAC wszystkich wcześniej ocenianych zmian tarczycy, a uzyskany materiał poddano bezpośrednio ocenie za pomocą FACS, obejmującej analizę restrykcji łańcuchów lekkich immunoglobulin κ/λ oraz antygenów powierzchniowych limfocytów T i B. Wyniki: Analiza FACS materiału uzyskanego za pomocą BAC nie ujawniła definitywnych cech restrykcji łańcuchów lekkich. Pomimo granicznych wartości współczynnika κ/λ (κ/λ = 0,31) w jednej z próbek, dalsza analiza fenotypowa nie potwierdziła klonalnej ekspansji w żadnym z badanych obszarów tarczycy. Wyniki histopatologiczne potwierdziły diagnozę przewlekłego zapalenia tarczycy w obu przypadkach klinicznych. Wnioski: Cytometria przepływowa jest badaniem wiarygodnie uzupełniającym ocenę cytologiczną w diagnostyce różnicowej przewlekłego zapalenia tarczycy i limfoproliferacyjnych chorób tarczycy

Effect of L-thyroxine treatment on peripheral blood dendritic cell subpopulations in patients with Hashimoto’s thyroiditis

Recent reports suggested dendritic cells (DCs) to be important players in the pathogenesis of autoimmune thyroid processes in humans. However, there are virtually no data addressing the influence of thyroid autoaggression-associated disturbances of thyrometabolic conditions on DCs biology. The aim of the study was to evaluate the influence of L-thyroxine supplementation on conventional and plasmacytoid peripheral blood DCs subtypes in patients with hypothyroidism due to Hashimoto’s thyroiditis (HT). Eighteen patients with newly diagnosed hypothyroidism due to HT were included into the study. All patients received L-thyroxine treatment with doses adjusted to reach euthyroidism. Peripheral blood DC subtypes structure and immunoregulatory phenotype were analyzed by flow cytometry in the same patient prospectively at two time points: (i) beforeand (ii) 3 months after beginning of L-thyroxine treatment (hypothyroidism vs. euthyroidism, respectively). Percentage of plasmacytoid DCs in peripheral blood mononuclear cells fraction was significantly decreased in the course of L-thyroxine treatment (0.27 ± 0.19 vs. 0.11 ± 0.08; p < 0.05), whereas we did not observe any changes in the number of conventional DCs. However, the phenotypic analysis showed a significant increase of conventional DCs expressing CD86 and CD91 (64.25 ± 21.6% vs. 86.3 ± 11%; p < 0.05 and 30.75 ± 11.66% vs. 44.5 ± 13.3%; p < 0.05; respectively) in euthyroid patients. Standard L-thyroxine supplementation in HT patients exerted significant immunoregulatory effects, associated with quantitative and phenotypic changes of peripheral blood DC subpopulations

Metastases of breast cancer to the thyroid gland in two patients - a case report

Introduction: Metastatic cancer is rarely found in the thyroid (only 2-3% of malignant tumours found in that gland); primary sources usually including breast, kidney, and lung tumours. Cases reports: Two cases of advanced breast cancer with thyroid metastases in female patients are presented. The similarities between these two cases included: 1) postmenopausal age; 2) diagnosis based on result of FNAB (numerous groups of cells with epithelial phenotype strongly implying metastatic breast cancer); 3) thyroid function - overt hyperthyroidism in the first woman and subclinical hyperthyroidism in the second one; 4) the presence of nodular goitre in clinical examination, the occurrence of many nodular solid normoechogenic lesions with calcifications in both thyroid lobes in US; and 5) negative antithyroid antibodies. The main difference was the time of establishing diagnosis; in the first woman - before mammectomy, parallel to diagnostics of breast tumour, and in the second woman four years after mammectomy, during cancer dissemination (with right pleural effusion and lung metastasis). In the first case, mammectomy was followed two weeks later by thyroidectomy. The second patient was disqualified from thyroid surgery due to systemic metastatic disease. Conclusions: 1. Fine needle aspiration biopsy of the thyroid gland should obligatorily be performed in patients with breast cancer and nodular goitre, even without any clinical data of metastatic disease. 2. The clinical context of cytological findings is of critical value. 3. In patients with breast cancer accompanied by multinodular goitre, we recommend that more punctures be performed during FNAB than is routinely done. (Pol J Endocrinol 2010; 61 (5): 512-515)Wstęp: Przerzuty do tarczycy są stosunkowo rzadko diagnozowane (2-3% złośliwych nowotworów tarczycy). Najczęściej narządem wyjściowym dla nowotworu przerzutowego są: sutek, nerka i płuco. Opis przypadków: Zaprezentowano przypadki 2 chorych z rozpoznanym rakiem sutka i przerzutami do tarczycy. Podobieństwa pomiędzy pacjentkami obejmują: 1) wiek pomenopauzalny; 2) ustalenie rozpoznania za pomocą BAC (liczne grupy komórek o fenotypie nabłonkowym, prawdopodobnie przerzut z raka sutka); 3) nadczynność tarczycy (jawna klinicznie u jednej pacjentki, subkliniczna u drugiej); 4) obecność wola guzkowego, w badaniu USG liczne lite zmiany ogniskowe normoechogeniczne, lite ze zwapnieniami w obu płatach tarczycy; 5) prawidłowe stężenia przeciwciał przeciwtarczycowych. Główną różnicą był moment postawienia rozpoznania; u pierwszej pacjentki przed mammektomią, równolegle do diagnostyki guza piersi, u drugiej 4 lata po mammektomii, w fazie rozsiewu choroby, z płynem w opłucnej i przerzutami do płuc. U pierwszej pacjentki przeprowadzono mammektomię, a dwa tygodnie później całkowitą tyreoidektomię, wdrożono substytucję L-tyroksyną i przekazano do dalszej terapii onkologicznej. Drugą pacjentkę zdyskwalifikowano z zabiegu z uwagi na stwierdzenie ogólnoustrojowego rozsiewu choroby. Wnioski: 1. Diagnostyka cytologiczna zmian ogniskowych w tarczycy u pacjentek z wywiadem raka sutka powinna być obligatoryjnie wykonywana, mimo braku jednoznacznych cech potwierdzających obecność zmian przerzutowych. 2. Kontekst kliniczny badania cytologicznego ma kluczowy charakter. 3. W przypadku podejrzenia przerzutu do tarczycy należy rozważyć możliwość poszerzenia zakresu badania cytologicznego w wolu wieloguzkowym poprzez selekcję większej liczby bioptowanych zmian ogniskowych. (Endokrynol Pol 2010; 61 (5): 512-515

Risk factors of permanent hypoparathyroidism after total thyroidectomy and central neck dissection for papillary thyroid cancer: a prospective study

Introduction: Inadvertent removal of, or damage to the parathyroid glands in the course of operations on the anterior neck compartment are responsible for over 80% of cases of chronic hypoparathyroidism (HypoPT). This study searched for factors related to the development of permanent HypoPT after total thyroidectomy and central neck lymphadenectomy in patients with thyroid carcinoma. Material and methods: In total, 89 of 103 screened patients met the study’s criteria and were put under prospective one-year observation. Demographic and surgical factors as well as the biochemical parameters of mineral homeostasis, controlled both preoperatively and postoperatively, were subject to statistical analysis. In line with contemporary guidelines, postoperative hypocalcaemia, rather than an abnormally low serum parathormone (PTH) concentration, was considered a diagnostic criterion of HypoPT. Results: On postoperative day one (POD1), serum concentration of PTH decreased below the normal range (< 12 pg/mL) in 29 patients and was undetectable in 19 patients (< 6 pg/mL). At one year postoperatively, 12 patients with undetectable POD1 PTH required treatment for hypocalcaemia and were diagnosed with permanent hypoPT. All the other patients regained normocalcaemia. Relative risk of permanent HypoPT associated with undetectable POD1 PTH was 88.75. A significant difference in median POD1 serum calcium concentration between the patients with undetectable POD1 PTH and those with detectable POD1 PTH was found (p < 0.001). The difference between the POD1 serum calcium in patients with permanent or transient HypoPT in the subgroup with undetectable POD1 PTH did not reach the level of statistical significance (median, 1.82 mmol/L vs. 1.96 mmol/L). At one month postoperatively, in patients who later developed permanent HypoPT, serum calcium was lower than it was in all other patients (p = 0.167). At one year postoperatively, serum concentration of PTH was in the normal range in 10 of 12 patients with permanent HypoPT; however, it was significantly lower than it had been before the operation and distinctly lower than it was in patients who regained normocalcaemia. The number of parathyroid glands either dissected or autotransplanted did not affect the development of permanent HypoPT. Conclusions: Undetectable POD1 PTH is an important risk factor of permanent HypoPT. The main cause of permanent HypoPT was irreversible damage to the left in situ parathyroid glands