Spindle epithelial tumor with thymus-like differentiation of the thyroid in a 70-year-old man

Spindle epithelial tumor with thymus-like differentiation (SETTLE) is a very rare tumor of the thyroid gland mostly occurring in young patients. The imaging findings of SETTLE tumors are yet to be defined. However, they are usually described as well-defined heterogeneously enhanced masses on CT scan. The current case has the potential growth as compared with a 2009 chest radiography. We took into account the possibility of SETTLE in the case of a bulky mass in patients over 70 years old, particularly in the lower neck. Herein, we report a case of the oldest patient so far. The patient underwent a right lobectomy of the thyroid and mass excision. Follow-up CT scans after 6 months revealed no local recurrence. Surgery is the gold standard treatment for SETTLE. Chemotherapy and radiotherapy could be another possible option for patients with advanced stage SETTLE.

Incidence and Predictive Factors of Central Neck Node Metastasis in Patients with T1, T2 Papillary Thyroid Cancer / 대한내분비외과학회지

PURPOSE: Thyroidectomy without prophylactic central neck dissection may be recommended for small (T1 or T2) papillary thyroid carcinoma (PTC). The aim of this study was to determine the incidence and predictive factors of central cervical lymph node metastasis in T1/2 papillary thyroid carcinoma. METHODS: A retrospective review of 877 patients with T1/2 PTC who underwent thyroidectomy and central lymph node dissection with or without lateral lymph node dissection from March 2007 to February 2014 was performed. The clinicopathologic results were reviewed and the incidence and predictive factors of central cervical lymph node metastasis (LNM) were analyzed. RESULTS: The overall frequency of central LNM was 29.8%. In univariate analysis, male, younger age, bilaterality, multifocality, larger tumor size, lymphovascular invasion, and lateral lymph node metastasis were associated with central LNM. In multivariate analysis, younger age, larger tumor size, lymphovascular invasion, and lateral lymph node metastasis were independent variables of central LNM. CONCLUSION: Central LNM is associated with younger age, larger tumor, lymphovascular invasion, and lateral lymph node metastasis in small (T1/2) PTC patients. Prophylactic central lymph node dissection should be considered in patients with risk factors.

Curcumin Enhances Docetaxel-Induced Apoptosis of 8505C Anaplastic Thyroid Carcinoma Cells

BACKGROUND: Anaplastic thyroid cancer (ATC) is one of the most aggressive malignancies in humans, and its progression is poorly controlled by existing therapeutic methods. Curcumin has been shown to suppress inflammation and angiogenesis. In this study, we evaluated whether curcumin could augment docetaxel-induced apoptosis of ATC cells. We also analyzed changes in nuclear factor kappaB (NF-kappaB) and cyclooxygenase-2 (COX-2) expression levels to delineate possible mechanisms of their combined action. METHODS: ATC cells were cultured and treated with curcumin and docetaxel alone or in combination. The effects on cell viability were determined by MTS assay. Apoptosis was assessed by annexin V staining and confirmed by flow cytometric analysis. Caspase, COX-2, NF-kappaB levels were assayed by Western blotting. RESULTS: Curcumin combined with docetaxel led to lower cell viability than treatment with docetaxel or curcumin alone. Annexin V staining followed by flow cytometric analysis demonstrated that curcumin treatment enhanced the docetaxel-induced apoptosis of ATC cells. Additionally, curcumin inhibited docetaxel-induced p65 activation and COX-2 expression. CONCLUSION: We conclude that curcumin may enhance docetaxel's antitumor activity in ATC cells by interfering with NF-kappaB and COX-2. Our results suggest that curcumin may emerge as an attractive therapeutic candidate to enhance the antitumor activity of taxanes in ATC treatment.

Papillary thyroid carcinoma with thyroiditis: lymph node metastasis, complications / 대한외과학회지

PURPOSE: The aim of this study was to evaluate the clinicopathologic characteristics of papillary thyroid cancer with thyroiditis, and to determine the rate of its complications for it. METHODS: A retrospective review of 1,247 patients with papillary thyroid cancer who underwent primary thyroidectomy was performed. Among them, 316 patients had thyroiditis (group I) while 931 patients had no thyroiditis (group II), as reflected in the final pathologic reports. The two groups' clinicopathologic results and rate of complications were compared. RESULTS: Female gender, preoperative hypothyroidism, total thyroidectomy, no extrathyroid extension, no lymphovascular invasion, and no perineural invasion were associated with group I. More central lymph nodes were removed in group I than in group II, but there were fewer central lymph nodes with metastasis in group I than in group II. For the lateral lymph nodes, the two groups had the same numbers of removed nodes and nodes with metastatic tumor. Multivariate analysis revealed female predominance, more cases of preoperative hypothyroidism, more dissected lymph nodes, and fewer lymph nodes with metastasis in group I. Among the patients who underwent lobectomy, postoperative hypothyroidism occurred more in group I than in group II (P < 0.001). There was no difference in postoperative complications between the two groups. CONCLUSION: Papillary thyroid cancer with thyroiditis showed less aggressive features. Postoperative hypothyroidism occurred more in the patients with thyroiditis.

Parathyroid carcinoma with lung metastasis in a thirteen-year-old girl / 대한외과학회지

Parathyroid carcinoma is a rare disease in pediatric patients. We present a case of a 13-year-old girl who presented to the Thyroid Department for an asymptomatic palpable neck mass for 1 year. The high levels of calcium, ionized calcium, and parathyroid hormone level along with parathyroid scintigraphy studies suggested primary hyperparathyroidism. Parathyroid carcinoma was confirmed by biopsy and pathologic examination after resection. Six months postoperatively, persistent hypercalcemia and multiple lung metastases were found on computed tomography. Bilateral lung wedge resection was performed. En bloc resection for primary parathyroid carcinoma and aggressive resection of metastatic disease is the most effective treatment to control hypercalcemia.

Impact of preserving the parathyroid glands on hypocalcemia after total thyroidectomy with neck dissection / 대한외과학회지

PURPOSE: The aims of this study were to determine the incidence and evaluate the risk factors for hypocalcemia after total thyroidectomy and to investigate how many parathyroid glands should be preserved to prevent postoperative hypocalcemia. METHODS: From March 2007 to February 2011, a retrospective review of 866 patients who underwent total thyroidectomy and node dissection for thyroid cancer was performed. The incidence and predisposing factors for hypocalcemia were analyzed. Among them, a total of 191 cases had four of their parathyroid glands identified intraoperatively. These patients were then divided into one preserved parathyroid gland group (group I, n = 22) and two or more preserved parathyroid glands group (group II, n = 169). The incidence of hypocalcemia with regards to the number of preserved parathyroid glands was determined and the results between the two groups were compared. The total calcium, ionized calcium and parathyroid hormone levels were compared between the two groups. RESULTS: The overall incidence of transient and permanent hypocalcemia was 9.2% and 0.5%, respectively. The decreased number of preserved parathyroid gland and increased number of removed central lymph node were the significant risk factors for developing postoperative hypocalcemia. In 191 cases identified with four parathyroid glands, the incidence of hypocalcemia was related to the number of preserved glands (group I, 22.7%; group II, 3.0%; P < 0.001). CONCLUSION: The insufficient number of preserved parathyroid glands is the only cause of hypocalcemia after total thyroidectomy and node dissection. At least one preserved parathyroid gland may prevent postoperative permanent hypocalcemia.

Complication after Total Thyroidectomy and Node Dissection for Thyroid Cancer / 대한내분비외과학회지

PURPOSE: The typical complications after thyroidectomy are bleeding, hematoma, hoarseness, hypocalcemia, chylous fistula, etc. The aim of this study was to determine the incidence and to evaluate risk factors of complication after total thyroidectomy and lymph node dissection (ND) for thyroid cancer. METHODS: We performed a retrospective review of 623 patients with thyroid cancer and who underwent total thyroidectomy and ND and the patients were treated at our hospital from March 2007 to February 2010. The clinical features of complications were reviewed and the incidence and predisposing factors of the complication were analyzed. RESULTS: Postoperative bleeding occurred in 0.2% of the patients. The overall incidence of transient and permanent hypocalcemia was 8.5% and 0.6%, respectively. Graves disease, a decreased number of preserved parathyroid glands and an increased number of removed central lymph nodes constituted the risk factors for postoperative hypocalcemia. On multivariate logistic regression analysis, the presence of Graves disease and a decreased number of preserved parathyroid glands were the independent risk factors for postoperative hypocalcemia. Hoarseness occurred in 1.6% of the patients. The incidence of chylous fistula after lymph node dissection in the central neck and lateral neck was 0.5% and 0.3%, respectively. CONCLUSION: Total thyroidectomy with ND is a safe procedure because the overall incidence of postoperative complications is low. Careful surgery is required for thyroid cancer patients with Graves disease. Parathyroid gland insufficiency is the important cause of hypocalcemia after total thyroidectomy and ND. To reduce voice change, careful dissection is required around the recurrent laryngeal nerve and excessive tracheal traction should be avoided.

Surgical Treatment of Graves' Disease: Comparison between Total Thyroidectomy and Subtotal Thyroidectomy

PURPOSE: Subtotal thyroidectomy has been the standard operation for Graves' disease in achieving a favorable outcome in recovery of euthyroid state. However, the postoperative outcomes following subtotal thyroidectomy differ by surgeon and postoperative thyroid dysfunctions develop as time passes. Here, we have studied the validity of total thyroidectomy for Graves' disease patients, with a comparison to subtotal thyroidectomy. METHODS: A total of 299 patients with Graves' disease underwent thyroid operation consecutively in Asan Medical Center, Seoul, Korea from December 1995 to December 2005. Among them, 241 cases had subtotal thyroidectomy and 43 had total thyroidectomy. The subtotal thyroidectomy cases were divided into 3 groups according to estimated remnant thyroid; or =6 g. Also, according to postoperative thyroid function, the patients were divided into euthyroid, hypothyroidism and hyperthyroidism groups. The postoperative changes of thyroid function, postoperative complications and hospital days were analyzed. RESULTS: In subtotal thyroidectomy, postoperative thyroid function showed euthyroid in 25 (10.4%), hypothyroidism 206 (85.5%) and hyperthyroidism 10 (4.1%). However, total thyroidectomy showed no persistent hyperthyroidism or recurrence. The postoperative thyroid function state changed in 24 patients out of 148 who had more than 2 years postoperative follow-up. Hyper-functional changes developed with higher rates (Hypo-6 vs. hyper-18). The postoperative complication rate was higher in subtotal thyroidectomy including bleeding, hoarseness and hypocalcemia. CONCLUSION: In our study, the patients showing normal thyroid function after subtotal thyroidectomy were very limited and thyroid dysfunction developed continuously with time lapse, especially towards hyperthyroid state. Therefore, we suggest that total thyroidectomy should be considered as a treatment option in Graves' disease.

Comparison of Operative Methods for Tertiary Hyperparathyroidism

PURPOSE: Tertiary hyperparathyroidism (THPT) occurs in less than 8% of the patients with secondary hyperparathyroidism after successful kidney transplantation. Tertiary hyperparathyroidism is commonly due to parathyroid hyperplasia, but about 2.6% of the THPT cases may be due to single or double adenomas. We investigate the usefulness of limited resection of single or two-gland parathyroid by comparing the blood calcium and PTH levels with respect to operative strategy. METHODS: We analyzed a total of 13 cases of tertiary hyperparathyroidism that were diagnosed and operated on at Asan Medical Center from May 1996 to April 2005. The patients were grouped according to the operative strategy: 3 and 1/2-parathyroidectomy (n=5), 3-parathyroidectomy (n=6), and 2-parathyroidectomy (n=2), and then we compared the mean blood PTH, calcium and creatinine levels. One patient in the 3-parathyroidectomy group underwent hemodialysis due to kidney transplant rejection, and this data was excluded from the analysis. RESULTS: The mean blood calcium and PTH levels of the 2-parathyroidectomy group were higher than that of the other two groups. There were no cases of transient hypocalcemia in the 3 groups (<7.5 mg/dl), and there were no cases of hypercalcemia at one year postoperative in the 3 & 1/2-parathyroidectomy and 2-parathyroidectomy groups. The blood calcium and blood PTH levels were less than 9.1 mg/dl and more than 100 pg/ml, respectively, in the one 3-parathyroidectomy patient who underwent hemodialysis due to kidney transplant rejection. CONCLUSION: Our preliminary conclusions, based on our small groups and the short follow-up period, are that the blood calcium and PTH levels will be higher in the limited resection group if kidney transplant rejection occurs, and tumor recurrence will be also more often found in the limited resection group. Therefore, our recommendation is that 3 and 1/2-parathyroidectomy and 2-parathyroidectomy are preferable operative strategies for tertiary hyperparathyroidism.

The Risk Factors of Hypocalcemia after Total Thyroidectomy: What is the Main Cause of Transient Hypocalcemia? / 대한내분비외과학회지

PURPOSE: Parathyroid injury and metabolic events are known causes of post thyroidectomy hypocalcemia and many other clinical risk factors are also noted. This retrospective study was undertaken to determine the main causative factor of transient hypocalcemia after total thyroidectomy. METHODS: 237 patients underwent total thyroidectomy and 10 patients underwent lobectomy were enrolled in this study. The incidence of transient and permanent hypocalcemia was investigated and we evaluate the risk factors. In 36 patients who underwent total thyroidectomy and 10 patients who underwent lobectomy, serum total calcium and, ionized calcium, i-PTH were measured at post operative day 1, 3, 7 and compared according to the number of preserved parathyroid glands. RESULTS: The incidence of transient and permanent hypocalcemia after total thyroidectomy was 3.4% (8/237) and 0.4% (1/237) respectively. Among the investigated risk factors, the number of preserved parathyroid gland was the only significant factor for hypocalcemia and, tumor extent, extent of central lymph node dissection and, lateral lymph node dissection were not the significant risk factors. The incidence of hypocalcemia was closely related to the number of preserved parathyroid gland (0 (66.7%), 1 (5.2%), 2 (0.7%), 3 (0%), 4 (0%))(P<0.001). The levels of serum total calcium, ionized calcium and, i-PTH were significantly different between the patients in whom only 1 parathyroid gland was preserved and more than 1 gland preserved at post operative day 1, 3. However there was no difference between two groups at post operative day 7. CONCLUSION: The technical aspect of parathyroid preservation is the most important factor for post thyroidectomy hypocalcemia.

Extent of Prophylactic Neck Dissection in Sporadic Medullary Thyroid Cancer / 대한내분비외과학회지

PURPOSE: The extent of prophylactic lateral neck lymph node dissection is very controversial in medullary thyroid cancer. This retrospective study was undertaken to evaluate the efficacy of prophylactic lateral neck lymph node dissection. METHODS: A total of 29 patients underwent curative operation for medullary thyroid carcinoma at our institution. Of these 29 patients, 13 patients had prophylactic lateral neck dissection and 16 patients had non-prophylactic lateral neck dissection. Among 13 patients, one-compartment prophylactic lymph node dissection was performed in 10 patients and two-compartment prophylactic lymph node dissection was performed in 3 patients. Postoperative calcitonin level was evaluated between these groups. RESULTS: A normalized calcitonin level was detected after surgery in 74% of patients without lateral neck lymph node metastases, and in 10% of patients with lateral neck lymph node metastases. In comparison of prophylactic node dissection group and non-prophylactic node dissection group, the rate of normalized calcitonin level after surgery is 100%, 66.7% in stage 1, 100%, 50% in stage 2, 0%, 80% in stage 3, 14.3%, 0% in stage 4. In the patients who one-compartment prophylactic lymph node dissection was performed, 40% of patients had positive lymph node metastasis, and 70% had persistent hypercalcitoninemia. However, there was no postoperative hypercalcitoninemia in the patients with twocompartment prophylactic lymph node dissection although lymph node metastasis was not identified with pathologic examination. CONCLUSION: Prophylactic lymph node dissection was more effective in the early stage of medullary thyroid carcinoma than late stage. The two or more compartment lymph node dissection is more effective than just one-compartment dissection for the normalization of serum calcitonin level.

Clinical Manifestation of Multiple Endocrine Neoplasia Type I / 대한내분비외과학회지

PURPOSE: Multiple endocrine neoplasia type I is rarely reported in Korea. The purpose of this study is to analyze the clinical features and the treatment of MEN1 which had been carried out in our institution. METHODS: Eight patients underwent surgery for MEN1-related hyperparathyroidism, duodenopancreatic tumors and pituitary tumors at our institution and were reviewed retrospectively. RESULTS: Of the eight patients, all patients had hyperparathyroidism. There were 5 total parathyroidectomy patients and 3 subtotal parathyroidectomy patients, none of them had persistent and recurrent hyperparathyroidism after operation. However, one of total parathyroidectomy patients had persistent hypoparathyroidism. Of the 8 patients, seven had duodenopancreatic tumors; four of them had pancreatic islet-cell tumors, two had malignant gastrinoma and one had Zollinger-Ellision syndrome. Pituitary tumors were observed in 6 patients among the 8; four of them had prolactinoma, and 2 had adenoma which was confirmed by magnetic resonance imaging. Of the eight patient, only one patient was confirmed to have another MEN1 family member and the mutation of MEN1 gene on chromosome 11q13 was proved on gene study. CONCLUSION: The clinical features of these patients were similar to those in other reports and the results of surgical treatment were relatively satisfactory. However, the detection of other MEN1 patients among the family members was relatively poor. Close follow up of family members and gene study will be required.

Long-term Follow-up of Patients with Elevated PTH Levels after Operation for Primary Hyperparathyroidism / 대한내분비외과학회지

PURPOSE: Elevation of serum parathyroid hormone (PTH) with normocalcemia after parathyroidectomy for primary hyperparathyroidism (pHPT) has been documented. This study was performed to investigate the factors correlated with elevated PTH level after surgery. METHODS: Twenty-one patients who underwent successful parathyroidectomy for pHPT had elevated postoperative serum PTH level despite normocalcemia. Patients were categorized into 2 groups based on their serum PTH level: patients who had fluctuation between normal and elevated PTH (group 1, n=12) and patients with early elevated PTH levels, and then normalized during follow up (group 2, n=6). Serum level of PTH, total calcium, ionized calcium, alkaline phosphatase, creatinine, vitamin D, osteocalcin and bone densitometry were compared before and after surgery. Three patients with persistently elevated PTH showed impaired renal function and they were excluded from this analysis. RESULTS: There were no difference in total calcium and ionized calcium (8.84±0.44 mg/dl vs. 8.74±0.32 mg/dl, 4.66±0.20 mg/dl vs. 4.56±0.31 mg/dl) between two groups. In comparison of variable group and normalized group, tumor size, 2.36 ±1.29 cm vs. 1.80±0.34 cm; preoperative PTH level, 418.18 ±488.90 pg/ml vs. 281.33±44.39 pg/ml; alkaline phosphatase levels, 369.36±570.80 IU/L vs. 202.17±115.63 IU/L; increment of bone densities of lumbar spine and femur, 18.32± 18.55% vs. 12.08±12.26%, 12.54±19.05% vs. 4.17± 5.03%; vitamin D level, 24.68±12.98 ng/ml vs. 31.22± 13.88 ng/ml; osteocalcin level is 15.71±5.33 ng/ml vs. 37.03±15.00 ng/ml. In 3 patients with creatinine level 4.00 ±3.64 mg/dl showed impaired renal function and their PTH level was persistently elevated. CONCLUSION: Patients with more advanced pHPT showed more variable postoperative PTH level than patients with normalized PTH level, although statistically insignificant due to small numbers. Patients with persistently elevated PTH level would be considered possibility of impaired renal function.