A Rare Case of Negative Serum Calcitonin in Metastatic Medullary Thyroid Carcinoma: Diagnosis, Treatment, and Follow-Up Strategy.

BACKGROUND Medullary thyroid carcinoma is a rare tumor and represents less than 5% of all thyroid cancers. Tumor size and the presence of possible metastases are strictly related to serum calcitonin level, which also suggests prognosis. A serum calcitonin level above the normal range is highly suspicious for medullary cancer. This tumor has no characteristic patterns on ultrasound and fine-needle aspiration, so serum calcitonin level is the only significant element for diagnosis. The literature contains 47 cases of serum calcitonin-negative medullary thyroid cancer with heterogeneous behavior, ranging from non-aggressive to aggressive form. CASE REPORT We report a rare case of a young man with negative serum calcitonin but with lateral cervical node metastases from medullary thyroid carcinoma. At the beginning, diagnosis was not achieved due to normal range of serum calcitonin and a negative thyroid ultrasonography for large nodules. Nevertheless, in another medical center he underwent a neck biopsy of the lateral cervical mass. The histologic findings showed metastases of medullary thyroid cancer. Therefore, a total thyroidectomy plus cervical lymphadenectomy was performed. During the follow-up, due to unusefulness of serum markers, and as CEA levels were negative pre- and post-operatively, an ¹8F-DOPA PET scan was performed. In 3 years of follow-up, there is still no evidence of disease relapse. CONCLUSIONS Our case shows how a normal serum level of calcitonin cannot exclude medullary thyroid cancer. Early diagnosis is crucial because it influences appropriate surgical therapy and patient outcome. The current lack of an optimal strategy for the diagnosis and postoperative follow-up for patients with negative serum calcitonin tumor presents a diagnostic challenge for physicians.

Subhepatic perforated acute appendicitis in a patient with midgut malrotation: A case report and review of the literature.

INTRODUCTION AND IMPORTANCE: Subhepatic acute appendicitis (SHAA) is a very rare cause of acute abdomen, developing in association with two types of congenital anomalies like as midgut malrotation (MM) and maldescent of the caecum. Preoperative diagnosis of SHAA is a challenge because of its rarity and atypical presentation. Imaging may be helpful for determining the correct diagnosis. Surgery represents the standard treatment of SHAA. CASE PRESENTATION: A 25-year-old Caucasian male presented to the Emergency Department with a one-day history of right lower quadrant (RLQ) abdominal pain, nausea and vomiting. Physical examination revealed RLQ abdominal rebound tenderness with guarding. Laboratory tests reported high levels of C-reactive protein and neutrophilic leukocytosis. Abdominal contrast-enhanced computed tomography showed a SHAA with intraluminal appendicolith, fat infiltration and pelvic fluid collection in a patient with MM. The patient underwent laparoscopic appendectomy: a retrocaecal subhepatic phlegmonous and perforated appendicitis was sectioned and removed with drainage of pelvic abscess. The postoperative course of the patient was uneventful. CLINICAL DISCUSSION: SHAA is characterized by anatomical variation of appendix and atypical presentation. Preoperative clinical diagnosis of SHAA is very difficult and imaging may be helpful for determining the correct diagnosis, as well as confirming MM or maldescent of the caecum. Laparoscopic appendectomy represents the correct treatment of SHAA. CONCLUSION: SHAA is a rare surgical emergency that should be considered in the differential diagnosis of patients with RLQ abdominal pain. Preoperative diagnosis needs a high index of suspicion and is facilitated by imaging. Surgery represents the appropriate treatment of SHAA.

An unusual cause of abdominal pain: Case report of a Superior Mesenteric Artery syndrome.

INTRODUCTION AND IMPORTANCE: Superior Mesenteric Artery (SMA) syndrome is an occlusive vascular disease, mainly caused by a severe weight loss that leads to a reduction of the fatty cushion around the SMA. Postprandial abdominal pain, early satiety, vomits, weight loss and malnutrition are the main symptoms of SMA syndrome. Therapy consists of nutritional support, while mini-invasive surgery is indicated when conservative measures are unsuccessful. CASE PRESENTATION: A 39-years old caucasian woman reported the following symptoms: epigastric pain irradiated up to the right hypochondrium, late post-prandial vomiting and severe weight loss. During previous hospitalizations a gastroscopy, a colonoscopy, and radiographic study of food transit were performed, these exams showed a slow gastric emptying. We performed an abdomen CT scan discovering SMA syndrome typical features. A duodenojejunostomy was performed in videolaparoscopy; the procedure was completed easily without complications. CLINICAL DISCUSSION: Debilitating conditions with severe weight loss or anatomic abnormalities are the main causes of SMA syndrome. Symptoms are usually unclear and non-specific. The commonest SMA syndrome features are highlighted with contrast CT. This syndrome is often misunderstood and not considered in differential diagnosis of abdominal pain, determining a delay in diagnosis and further weight loss. An early diagnosis is useful to choose the best treatment of the case. For severe cases, surgery represents the best treatment, especially duodenojejunostomy that is usually linked to rapid symptoms' resumptions without post-operative consequences. CONCLUSION: SMA syndrome should be included in differential diagnosis of abdominal pain. Severe cases can be treated with mini-invasive surgery.