A rare form of hyperthyroidism leading to the diagnosis of acromegaly: A case report.

Acromegaly is a rare disease, usually caused by a pituitary tumor. It typically exhibits slow evolution and can result in numerous complications. In the present case report, the patient presented with hyperthyroidism associated with ophthalmopathy and right nodular goiter. The laboratory tests revealed persistent high levels of phosphorus without an apparent cause. After ruling out common pathologies associated with this finding, a focus was placed on the clinical aspects associated with acromegaly, a rare cause of hyperphosphatemia. Laboratory tests and MRI confirmed the diagnosis. The patient underwent transsphenoidal surgery, but the disease remained active, thus medical treatment was initiated, to a poor initial response. Associated with acromegaly, two distinct thyroid pathologies were diagnosed: Toxic adenoma and Graves' disease. This case highlights the challenges in diagnosing and managing a rare endocrine pathology.

Shear Wave Elastography versus Strain Elastography in Diagnosing Parathyroid Adenomas.

OBJECTIVES: The aim of the study was to compare elastographic means in parathyroid adenomas, using shear wave elastography and strain elastography. METHODS: This prospective study examined 20 consecutive patients diagnosed with primary hyperparathyroidism and parathyroid adenoma, confirmed by biochemical assay, technetium-99 sestamibi scintigraphy, and pathology report, after parathyroid surgery. All patients were examined on conventional 2B ultrasound, 2D shear wave elastography, and strain elastography. We determined using 2D shear wave elastography (SWE) the elasticity index (EI) in parathyroid adenoma, thyroid parenchyma, and surrounding muscle and examined using strain elastography the parathyroid adenoma, and determined the strain ratio with the thyroid tissue and muscle tissue. RESULTS: All patients had positive sestamibi scintigraphy and underwent surgery, with confirmation of parathyroid adenoma in all cases. The mean parathormone (PTH) value before surgery was 153.29 pg/ml (36.5, 464.8) and serum calcium concentration was 10.5 mg/dl (9, 11.5). We compared using 2D-SWE and strain elastography parathyroid adenoma with thyroid tissue and with surrounding muscle. The mean EI measured by SWE in parathyroid adenoma was 4.74 ± 2.74 kPa and in thyroid parenchyma was 11.718 ± 4.206 kPa (mean difference = 6.978 kPa, p < 0.001), and the mean EI value in muscle tissue was 16.362 ± 3.829 kPa (mean difference = 11.622, p < 0.001). Using ROC analysis, we found that an EI below 7 kPa correctly identifies parathyroid tissue. We evaluated parathyroid adenomas using strain elastography by color mapping and strain ratio as a semiquantitative measurement; however, we could not find any statistical correlation comparing the strain ratio obtained from the parathyroid adenoma with the thyroid tissue (p=0.485). CONCLUSION: Ultrasound elastography is a helpful tool in identifying parathyroid adenomas. A cutoff value below 7 kPa can be used in 2D-SWE. Color maps in strain elastography without adding strain ratio can be used, parathyroid adenoma being identified as score 1 in the Rago criteria.

Strain Elastography as a Valuable Diagnosis Tool in Intermediate Cytology (Bethesda III) Thyroid Nodules.

Fine needle aspiration (FNA) is considered the gold standard in the diagnostic of thyroid nodules. Using the recommended BETHESDA reporting system, up to 20% of results are classified as intermediate cytology. As there is no consensus whether ultrasound evaluation, lobectomy or surgery is the best treatment option, intermediate cytology results are considered a grey zone of the FNA. The main aim of our study was to evaluate the performance of combined advanced ultrasound techniques in the process of diagnosis and evaluation of the intermediate cytology cases after FNA. We evaluated 54 consecutive cases with intermediate cytology on FNA, using conventional B-mode ultrasound (2B), and strain elastography, using a linear multifrequency 6-13 MHz linear probe (Hitachi Prerius Machine, Hitachi Inc, Japan). All nodules were classified with our Thyroid Imaging Report and Data System (TI-RADS) proposed model, considering: vertical appearance, with antero-posterior diameter bigger than the transvers diameter, the so called taller than wide shape, irregular borders, intranodular inhomogeneity, marked hypoecogenicity, micro calcifications, the presence of suspect lymph nodes, and increased stiffness as suspicious for malignancy. The classification outcomes were compared with the pathology results, considered the gold standard diagnosis. The prevalence of cancer was 28.8%, with 13/45 cases having a clear diagnostic of cancer. Six cases were diagnosed with borderline follicular neoplasia, a category with unclear evolution, also considered as malignant in the analysis of the imaging results. In total, 16/19 cancer cases had increased stiffness on elastography. The cancer prevalence increased with TI-RADS category, being 25% in TI-RADS 4b category and 92.8% in TI-RADS 5 category. The AUROC (Area Under Receiver Operating Curve) of elastography alone, in differentiation of malignant thyroid nodules was 74.9%; the combination of elastographic and conventional ultrasound characteristics generated an even better AUROC, of 84.5%. The combined conventional ultrasound and elastography identified thyroid cancer in cases with intermediate cytology with a sensitivity of 89.5% with a specificity of 50%. High risk thyroid nodules, identified by combined high risk conventional ultrasound characteristics and increased stiffness, on strain elastography, are highly predictive for malignancy, in the intermediate cytology cases.

Aspects regarding nomenclature, classification and pathology of neuroendocrine neoplasms of the digestive system - a review.

Neuroendocrine neoplasms (NENs) of the digestive system are composed of cells with a neuroendocrine phenotype. These tumors produce and secrete peptide hormones and biogenic amines and they are called neuroendocrine neoplasms because of the marker proteins that they share with the neural cell system. The classification and nomenclature used to designate NENs have undergone changes over the past decades due to the accumulation of evidence related to the biological characteristics and their evolution. The European Neuroendocrine Tumor Society (ENETS) proposed a classification system based on the tumor grading and staging according to their localization. The latest internationally recognized NEN classification was published by the World Health Organization (WHO) in 2010. In accordance with the 2010 WHO criteria, the determination of the NEN malignancy potential is based on grading, depending on the mitotic activity and the Ki67 proliferation index, as well as on the tumor TNM stage. It is worth emphasizing that the terms neuroendocrine tumor (NET) and neuroendocrine carcinoma (NEC), without reference to grading or differentiation, are inadequate for prognostic assessment or the therapy determination, being inappropriate in pathology reports. The functional status of the tumor is based on the clinical findings but not on the pathological data or immunohistochemically profile. Despite the inability to establish a single system of sites, these are common features to establish the basis of most systems, documentation of these features allowing for greater reliability in the pathology reporting of these neoplasms.

Laparoscopic repair of perforated peptic ulcer.

INTRODUCTION: Perforations of the peptic ulcers (PPUs) are the most common cause of emergency surgery among the complications of the gastroduodenal ulcers and the leading cause for morbidity and mortality due to secondary peritonitis and sepsis. PPU is a condition in which laparoscopic perforation repair (LPR) is an optimal solution. It makes possible the identification of the perforation's site and allows closure of the perforation and the subsequent peritoneal lavage, as in an open repair (OR) but without the large upper mid-abdominal incision. The main objective of this review was to evaluate the latest reported results in the laparoscopic treatment of the PPU. EVIDENCE ACQUISITION: Using PubMed and EMBASE databases between 1989 and June 2017 we did an extensive electronic literature search. The search terms used were "laparoscopic perforated peptic ulcer." Inclusion criteria were all the published studies that reported the outcomes of LPR and LPR compared with OR for PPU were included in the analysis. The exclusion criteria included animal or laboratory studies, pediatric surgery trials, papers reporting less than 30 cases of LPR, clinical trials without major outcomes, and other language then English. EVIDENCE SYNTHESIS: There were 32 studies included, counting 3488 patients with LPR and 5208 with OR. OR patients had more frequent shock at admission and had a higher ASA risk class. LPR patients had shorter hospital stays with two days, morbidity (11.12% vs. 14.71% OR) and mortality (1.95% vs. 8.35% OR) were lower. Leakage was three times higher in LPR arm (2.18% vs. 0.79% OR). Conversion occurred in 4.18% overall. The three primary reasons for conversions were the size of the perforation, the inability to locate the perforation and technical difficulties. CONCLUSIONS: LPR showed similar or better results than OR in terms of morbidity, mortality, operation time and hospital stay, caution is needed as the OR patients tend to be more shocked or with higher ASA at presentation. The higher leakage rate after LPR should be addressed in the training of the laparoscopic surgeons or other safety measures should be developed and employed.

Intraoperative assessment of sentinel lymph nodes in early-stage breast cancer.

The assessment of axillary lymph node (ALN) status provides heavily weighing prognostic indicators in deciding on breast carcinoma treatment. In the 6th and 7th editions of the American Joint Committee on Cancer (AJCC) Cancer Staging Manual are evaluated the nodal metastases based on size and taking into account the number of metastatic cells. According to these Manuals, a positive node is equated to metastasis whose size reaches at least 0.2 mm or amounting to more than 200 tumor cells. The clinical significance and the therapeutic optimum of the presence of a minimal nodal involvement after axillary sentinel lymph nodes (SLNs) biopsy remain controversial. The need for further axillary treatment (ALN dissection or axillary radiation) in clinical N0 patients with early-stage breast carcinoma and SLNs metastases remains unclear. In all likelihood, the delivery of the regular adjuvant treatment in association with systemic treatment and radiation therapy results in survival rates similar to axillary treatment completion. This review also presents several assessment methods related to the SLNs at the surgical stage, such as cytological, histological, immunohistochemical and molecular diagnostic techniques, evaluating the advantages and disadvantages of each of them. More studies including larger groups of breast patients are needed to confirm which of them is the most reliable method for the evaluation of the SLNs.

Primary neuroendocrine tumors - an extremely rare cause of obstruction of extrahepatic bile ducts: a case report.

Primary neuroendocrine tumors of the extrahepatic bile ducts are extremely rare - up to date, only 77 cases have been reported in the literature, which represents between 0.2-2% of all gastrointestinal carcinoid tumors. The paper focuses on the case of a woman patient, aged 37 years, admitted to the Clinic with the diagnosis of obstructive jaundice, unaccompanied by pain and where imaging indicates a tumor in the third average of the common bile duct (CBD). The surgery involved the excision of CBD, lymphadenectomy and restoring the biliodigestive continuity of Roux-en-Y hepaticojejunostomy. The histopathological and immunohistochemical examinations revealed the presence of a well-differentiated neuroendocrine tumor of CBD. Based on the case report and literature, we attempted to accurately identify and relate this type of tumor to other varieties encountered in the extrahepatic bile ducts, pointing out elements of a positive diagnosis, differential diagnosis, histopathology and immunohistochemistry, and referring to the therapeutic attitude, evolutionary methods and prognosis.

Laparoscopic Repair for Perforated Peptic Ulcer: A Retrospective Study.

BACKGROUNDS: The incidence of patients presenting with perforated peptic ulcers (PPU) has decreased during the last decades. At the same time, a laparoscopic approach to this condition has been adopted by increased number of surgeons. The aim of this study was to evaluate the early postoperative results of the laparoscopic treatment of perforated peptic ulcer performed in eight Romanian surgical centers with extensive experience in laparoscopic surgery. METHODS: Between 2009 and 2013, 297 patients with perforated peptic ulcer were operated in the eight centers participating in this retrospective study. The patients' charts were reviewed for demographics, surgical procedure, complications and short-term outcomes. RESULTS: Boey score of 0 was found in 122 patients (41.1%), Boey 1 in 169 (56.9%), Boey 3 in 6 (2.0%). For 145 (48.8%) patients, primary suture repair was performed, in 146 (49.2%) primary suture repair with omentopexy. There were 6 (2.0%) conversions to open surgery. The operative time was between 25 and 120 min, with a mean of 68 min. Two (0.7%) deaths were noted. Mean hospital stay was 5.5 days, ranges 3-25 days. Postoperative complications included: 7 (2.4%) superficial surgical site infections, 5 (1.6%) cardiovascular, 3 (1.0%) pulmonary, 2 (0.7%) duodenal leakages, 3 (1.0%) deep space infections and 1 (0.3%) upper digestive hemorrhage. CONCLUSIONS: This study shows that the laparoscopic approach for PPU is feasible; the procedure is safe, with no increased risk of duodenal fistulae or residual intraperitoneal abscesses. We now consider the laparoscopic approach for PPU as the "gold standard" in patients with Boey score 0 or 1.

Laparoscopic Repair of Inguinal Hernia TEP versus TAPP.

AIM: The purpose of the study was to compare the results of laparoscopic inguinal hernia repair using two different methods: transabdominal preperitoneal (TAPP) repair and the technique of totally extraperitoneal repair (TEP). METHODS: In this retrospective study were included 90 cases of inguinal hernia that underwent for laparoscopic approach of inguinal hernia repair at the Emergency County Hospital Timisoara at the 2nd Surgical Clinic between 2012 and 2013. The primary outcome was recurrence of the hernia at two years follow-up. Secondary outcomes were short and long-term complications: hematoma and seroma formation, inflammation of the testis, chronic inguinal pain, reoperation, 30 days mortality. RESULTS: Of the 90 patients who underwent unilateral hernia repair, 70 were completely followed-up for 24 months, 36 (81.81%) patients with TEP and 34 (73.91%) with TAPP. Regarding the main outcome there was no recurrence of the hernia at two years follow-up.There were two cases of bleeding in the TAPP group;both were managed by laparoscopic sealing of the damaged vessels, 8 cases of post-operative edema of testis in TAPP and 3 cases in TEP. Regarding thesubcutaneous emphysema there were 16 cases in TAPP and 3 cases in TEP. CONCLUSIONS: Differences between TEP and TAPP in our study were related to minor complications, no major complications occurred. After the two years follow-up of 70 of a total of 90 patients, there was no recurrence of the hernia.