Remission of primary hyperparathyroidism after fine needle aspiration of a parathyroid nodule mistaken for a thyroid nodule.

Primary hyperparathyroidism (PHPT) is an endocrine disorder characterized by hypercalcaemia and elevated or inappropriately normal concentrations of parathyroid hormone. Remission of PHPT caused by infarction or hemorrhage of a parathyroid adenoma rarely occurs, either spontaneously or induced, not always leading to a definitive cure. We report a case of 72-year-old women with primary hyperparathyroidism who underwent fine-needle aspiration cytology (FNAC) of a parathyroid adenoma mistaken for a thyroid nodule followed by normalization of parathyroid hormone (PTH) and serum calcium levels. Parathyroid origin was confirmed by immunohistochemistry. PTH levels began to rise at 4 months after FNAC demonstrating recurrence of the PHPT. This report shows that FNAC induced hemorrhage may cause remission of PHPT. Nevertheless, patient´s levels of PTH and serum calcium should be monitored, as remission may only be transitory.

Extrapleural solitary fibrous tumor-a revision of three cases.

Extrapleural solitary fibrous tumors are a rare type of spindle cell neoplasm, which can occur in many locations with different histologic and immunohistochemical findings, making the diagnosis challenging. They are usually indolent and their treatment is based on complete surgical resection. There are still some issues to be clarified regarding systemic therapy (specifically when aggressive behavior exists) and long-term follow-up. We present a series of clinical cases in the same Department and review this thematic area.

Remission of primary hyperparathyroidism after fine needle aspiration of a parathyroid nodule mistaken for a thyroid nodule

SUMMARY Primary hyperparathyroidism (PHPT) is an endocrine disorder characterized by hypercalcaemia and elevated or inappropriately normal concentrations of parathyroid hormone. Remission of PHPT caused by infarction or hemorrhage of a parathyroid adenoma rarely occurs, either spontaneously or induced, not always leading to a definitive cure. We report a case of 72-year-old women with primary hyperparathyroidism who underwent fine-needle aspiration cytology (FNAC) of a parathyroid adenoma mistaken for a thyroid nodule followed by normalization of parathyroid hormone (PTH) and serum calcium levels. Parathyroid origin was confirmed by immunohistochemistry. PTH levels began to rise at 4 months after FNAC demonstrating recurrence of the PHPT. This report shows that FNAC induced hemorrhage may cause remission of PHPT. Nevertheless, patient´s levels of PTH and serum calcium should be monitored, as remission may only be transitory.

Leptomeningeal carcinomatosis in gastric cancer: a case report of a rare yet aggressive entity.

Leptomeningeal carcinomatosis (LMC) is exceedingly rare in gastric cancer. It is most commonly seen in breast, lung cancer and melanoma, and is associated with an extremely poor prognosis. If untreated, median overall survival is four to six weeks. No standard treatment for LMC exists and published data are scarce. We present two cases of gastric carcinoma diagnosed with LMC that exemplify how aggressive this condition is and how short the time lapse is to perform any targeted therapy. This report aims to raise awareness of this rare metastatic possibility in gastric cancer and its diagnostic and therapeutic challenges.

Cytohistological Correlation in Pleural Effusions Based on the International System for Reporting Serous Fluid Cytopathology.

The International System for Reporting Serous Fluid Cytology (TIS) was recently developed. Given its novelty, most studies looking into the risk of malignancy (ROM) of serous effusion diagnostic categories were published before the development of TIS. We searched the database of our department for pleural effusions diagnosed in the last five years, excluding those without a corresponding pleural biopsy. Cases were reviewed and reclassified according to the TIS. A cytohistological correlation was performed. In total, 350 pleural effusion specimens with one or more corresponding pleural biopsies were included. After reclassification, 5 (1.43%) were nondiagnostic (ND), 253 (72.29%) were negative for malignancy (NFM), 7 (2.00%) had atypia of unknown significance (AUS), 14 (4.00%) were suspicious for malignancy (SFM), and 71 (20.57%) were malignant (MAL). Calculated ROM was 40% for ND, 20.16% for NFM, 42.86% for AUS, 78.57% for SFM, and 100% for MAL. Effusion cytology sensitivity and specificity were 60.29% and 98.56%, respectively. This is the first publication looking into the cytohistological correlation of a retrospective cohort of pleural effusions based on the TIS. We add to the body of data regarding the ROM for TIS categories, highlighting areas of potential future research.

Low-grade mucinous appendiceal neoplasm mimicking an ovarian lesion: A case report and review of literature.

BACKGROUND: Appendiceal tumors are rare lesions that may not be easily differentiated from primary ovarian lesions preoperatively, despite the use of advanced diagnostic methods by experienced clinicians. CASE SUMMARY: A 59-year-old G2P2 woman, with chronic pelvic pain, underwent a pelvic ultrasound that revealed an adnexal mass measuring 58 mm × 34 mm × 36 mm, with irregular borders, heterogeneous echogenicity, no color Doppler vascularization and without acoustic shadowing. Normal ovarian tissue was visualized in contact with the lesion, and it was impossible to separate the lesion from the ovary by applying pressure with the ultrasound probe. Ascites, peritoneal metastases or other alterations were not observed. With the international ovarian tumor analysis ADNEX model, the lesion was classified as a malignant tumor (the risk of malignancy was 27.1%, corresponding to Ovarian-Adnexal Reporting Data System category 4). Magnetic resonance imaging confirmed the presence of a right adnexal mass, apparently an ovarian tumor measuring 65 mm × 35 mm, without signs of invasive or metastatic disease. During explorative laparotomy, normal morphology of the internal reproductive organs was noted. A solid mobile lesion involved the entire appendix. Appendectomy was performed. Inspection of the abdominal cavity revealed no signs of malignant dissemination. Histopathologically, the appendiceal lesion corresponded to a completely resected low-grade mucinous appendiceal neoplasm (LAMN). CONCLUSION: The appropriate treatment and team of specialists who should provide health care to patients with seemingly adnexal lesions depend on the nature (benign vs malignant) and origin (gynecological vs nongynecological) of the lesion. Radiologists, gynecologists and other pelvic surgeons should be familiar with the imaging signs of LAMN whose clinical presentation is silent or nonspecific. The assistance of a consultant specializing in intestinal tumors is important support that gynecological surgeons can receive during the operation to offer the patient with intestinal pathology an optimal intervention.

Non-adenomatous sellar lesions: single-centre 10-year experience.

OBJECTIVE: A minority of lesions found in the sellar region are non-adenomatous neoplastic, inflammatory, or cystic masses. Our study aims to describe the prevalence and characteristics of these lesions in a multidisciplinary pituitary outpatient clinic. DESIGN: We conducted an observational study which included 36 patients (15.9% of those followed up in this outpatient clinic between 2006 and 2016 who had pituitary surgery) submitted to pituitary surgery with histological results showing a non-adenomatous sellar lesion. We evaluated clinical, radiological, and biochemical (pituitary function) characteristics during the pre-operative and post-operative period. RESULTS: Thirty-six patients (50% female) with a mean age of 41.3 ± 21.9 years and a mean follow-up duration of 8.0 ± 9.0 years were included. Histologic diagnoses were divided into benign neoplasms (80.6%), malignant neoplasms (11.1%), inflammatory lesions (5.6%), and cystic masses (2.8%). The most common clinical presentation was headache (66.7%) and visual defects (61.1%). Forty-seven percent of patients had at least one pituitary axis insufficiency at the time of diagnosis. In the majority of cases (58.3%), a transsphenoidal approach was used for the initial pituitary surgery. Thirteen patients had more than one pituitary surgery and eight also had radiotherapy. At the time of data retrieval, five patients had no pituitary hormonal insufficiency and 13 patients had some visual defect improvement. CONCLUSIONS: Although rare, non-adenomatous sellar lesions may be associated with significant causes of morbidity, such as hypopituitarism and visual defects, per se or due to the various treatment modalities employed. Moreover, since the lesions are difficult to distinguish from adenomas, these patients require a careful multidisciplinary approach.

Treatment Sequencing in a Chronic Lymphocytic Leukemia Patient with Central Nervous System Involvement.

Early-stage chronic lymphocytic leukemia (CLL) with neurologic involvement is a rare condition and should require a careful follow-up. Although no standard protocol exists for this condition, intrathecal chemotherapy, combined with systemic chemoimmunotherapy, has been used previously. This case describes the treatment of a patient with CLL and symptomatic compromise of the central nervous system. Our results suggest that a combination of chemotherapy, radiotherapy, and ibrutinib, administered sequentially over a 2-year period, led to a near-complete resolution of the cerebral spinal fluid neoplastic infiltration. Importantly, this response has been maintained with ibrutinib monotherapy for more than 12 months.

Transsphenoidal meningoencephalocele protruding into the nasal cavity.

Spontaneous transsphenoidal meningoencephalcele is a rare entity, even rarer through the Sternberg's canal, a congenital defect on the lateral wall of the sphenoid sinus. We report such a case in an obese 52-year-old female with spontaneous cerebrospinal fluid (CSF) rhinorrhoea and recurrent meningitis. Brain CT, MRI and CT cisternography were performed. Surgical correction and short-term follow-up were recorded. CT scan showed a defect on the lateral wall of the right sphenoid sinus filled with a soft tissue mass extending to the nasal cavity. MRI scan revealed brain parenchyma from the right temporal lobe herniated through the sphenoid bone defect. CT cisternography showed 270 mmH2O opening pressure and confirmed the CSF leakage. Surgical correction was performed with resolution of the symptoms. MRI and CT are complementary modalities for evaluating this entity, the first being the method of choice for meningoencephalcele diagnosis although bone defects are best depicted on CT scan. CT cisternography identifies the specific site of leak and confirms benign intracranial hypertension, consistently reported in meningoencephaloceles. Obesity and benign intracranial hypertension have been reported as a combined mechanism allegedly contributing to meningoencephaloceles through congenital skull base defects, by increasing intraabdominal pressure thus decreasing venous return, with augmented intracranial pressure and subsequent reduced absorption of the CSF.

IgG4-related disease presenting with an epidural inflammatory pseudotumor: a case report.

BACKGROUND: Inflammatory pseudotumor is a rare clinical condition that can be related to immunoglobulin G4 disease. Only a few cases of spinal inflammatory pseudotumors have been reported in the literature and an association with immunoglobulin G4 disease was not conclusive in any of them. We describe what we believe to be the first biopsy-proven case of an epidural inflammatory pseudotumor related to immunoglobulin G4 disease. CASE PRESENTATION: A 57-year-old Caucasian woman presented to our hospital with severe paraparesis, gait disturbance, and sensory loss secondary to a relapsing epidural mass. Examination of a biopsy specimen revealed a lymphoplasmacytic infiltration with fibrosis and an immunoglobulin G4-positive plasma cell ratio of over 50 %, which are compatible with a diagnosis of immunoglobulin G4-related inflammatory pseudotumor. Our patient was successfully treated with systemic and epidural administration of glucocorticoids. CONCLUSION: Immunoglobulin G4-related disease is an emerging clinical condition in which central nervous system involvement is still uncommon. We describe the case of a patient with an epidural mass with medullar compression, which was proved to be an immunoglobulin G4-related epidural inflammatory pseudotumor. Our findings suggest a new manifestation of immunoglobulin G4-related disease. This disorder should be considered in the differential diagnosis of spinal tumors as a potentially treatable condition with glucocorticoids.

Otosclerosis of the incus.

OBJECTIVE: To report a case of a patient with otosclerosis of the incus. PATIENTS: A 61-year-old woman with a progressive hearing loss on her left ear and a computed tomographic scan of the temporal bone revealing an expansible lesion of the incus. INTERVENTIONS: The ossicle was removed by using a transtympanomastoid approach; the ossicular chain was reconstructed using a titanium partial ossicular replacement prosthesis. MAIN OUTCOME MEASURE: The diagnosis of the disease was obtained by means of histopathologic examination of the specimen. RESULTS: The patient obtained a good postoperative hearing result. The histopathologic examination of the specimen documented an otosclerosis of the incus. CONCLUSION: Otosclerotic involvement of the middle ear ossicles, apart from footplate, was very rarely mentioned. Most subjects were incidentally diagnosed postmortem by means of examination of specimens from temporal bone collections. The diagnosis and treatment of a patient with otosclerosis of the incus is exceptional; however, otosclerosis should be considered in the differential diagnosis of expansible lesions of the ossicles.

Miliary brain metastases from primary gastric small cell carcinoma: illustrating the seed and soil hypothesis.

Miliary metastases are a very rare condition usually found in the context of primary lung tumor (small cell and adenocarcinoma), and refer to the existence of numerous tumor nodules in widespread areas of the brain. Besides pulmonary neoplasia, pancreatic adenocarcinoma and malignant melanoma have also been implicated in some cases of miliary metastases. We present the first case of miliary metastases originating in a primary small cell gastric carcinoma (PSCGC), a rare type of neuroendocrine gastric tumor. This location should therefore be investigated whenever other more frequent tumors have been excluded as a cause for this particular type of metastases. The pathological resemblance of PSCGC with small cell lung carcinoma may correspond to an underlying similarity in biological behavior, which accounts for this particular pattern of metastatic spreading, as proposed in the seed and soil hypothesis.

Primary amyloidosis as a cause of microvascular angina and intermittent claudication.

Primary systemic amyloidosis or AL amyloidosis is a rare condition characterized by extracellular deposits of fibrils composed of fragments of immunoglobulin light chains. Widespread deposition of this amyloid in tissues interferes with their normal function and leads to multiple organ failure. Clinical manifestations are highly variable due to the wide range of organs involved. The heart is affected in 90% of cases; in 30% of these, cardiac dysfunction is the form of presentation and in 50% it is the cause of death. The commonest form of cardiovascular manifestation is congestive heart failure due to restrictive cardiomyopathy caused by extensive interstitial infiltration of amyloid into the myocardium. Occasionally, it can present as angina, due to infiltration of amyloid into the walls of small vessels. The authors describe the case of a patient in whom the disease presented simultaneously with heart failure and effort angina, as well as intermittent claudication.