Management of benign thyroid nodules based on the findings of fine-needle aspiration.

Fine-needle aspiration (FNA) biopsy is a safe, simple, and inexpensive procedure that is particularly applicable for lesions of the head and neck. In our department, it is widely used for the evaluation of thyroid nodules. A total of 189 patients participated in a prospective study of benign thyroid nodules. Our aim was to verify the modality of treatment used in our department and the reliability of benign cytologic results of colloid goiter. All patients had cold nodules on thyroid scanning. The patients were divided into two groups, the first comprising 93 patients who did not undergo thyroid surgery and were followed up for 5 to 11 years. One case of malignancy was found in this group during the follow-up. The second group was comprised of 96 patients who were operated on despite FNA results of colloid goiter. Among them, five cases of malignancy were found. Four of these five cases could not be regarded as FNA failure. Our study confirms that the combination of clinical findings with those of the FNA is a reliable approach to the management of benign thyroid nodules. Nevertheless, long-term follow-up is mandatory and repetitive aspirations should be considered.

Transient cold nodule of the thyroid due to localized postpartum thyroiditis.

A 27-year-old woman with no previous personal or family history of thyroid disease was referred to us for the evaluation of thyroid nodule, five months postpartum. Thyroid scintigraphy demonstrated a left cold nodule. Fine needle aspiration cytology of the nodule showed a mixture of colloid, follicular cells and lymphocytes, suggesting lymphocytic thyroiditis. Thyroid function tests were normal and thyroid autoantibodies were negative. After two months the thyroid nodule was not palpated and thyroid scintigraphy returned to normal. Thyroid function tests remained normal twelve months after delivery. These findings suggest that postpartum thyroiditis may present as a localized transient form and should be considered in the differential diagnosis of painless solitary nodule that appears postpartum.

Basement membrane material (hyaline globules) in synovial sarcoma. A case report with description of a potential diagnostic pitfall.

BACKGROUND: Synovial sarcoma (SS), a malignant mesenchymal tumor, has a biphasic growth pattern characteristically. Histologically and cytologically the tumor can pose diagnostic difficulty when the epithelial component is predominant. CASE REPORT: A 22-year-old female presented with a rapidly enlarging mass on the lower left side of the neck. Fine needle aspiration of the tumor yielded abundant, discohesive round-oval cells mingled with amorphous hyaline material, raising a suspicion of medullary carcinoma of the thyroid. In addition, air-dried, Giemsa-stained smears demonstrated rosettelike structures with central magenta globular material, mimicking adenoid cystic carcinoma. However, histologic examination of the excised tumor, including immunohistochemical and ultrastructural studies, proved it to be a typical SS with copious basement membrane accumulations. CONCLUSION: The cytologic appearance of SS can be confusing. However, a false diagnosis may be avoided if adequate needle sampling is ensured and clinical correlation considered.

Immunohistochemical localization of gonadotropin and gonadal steroid receptors in human pineal glands.

Recently, we demonstrated that melatonin secretion was increased in male patients with GnRH deficiency and decreased to normal levels during testosterone treatment. These data suggested that gonadal steroids modulate melatonin secretion, probably by activating specific receptors in the pineal gland. We used immunohistochemistry to localize gonadotropin (LH and FSH) and gonadal steroid (androgens and estrogens) receptors in human pineal glands. Tissues were obtained at autopsy from 25 males, aged 19-87 yr, and five prepubertal children, aged 0.2-10 yr. Positive staining for all four types of receptors (LH, FSH, androgen, and estrogen) in the pineal parenchymal cells, pinealocytes, was evident in all 30 glands examined. Double staining revealed that nuclear receptors (androgen or estrogen) co-existed with cytoplasmatic receptors (LH or FSH) in the same cells. The results demonstrate the presence of gonadotropin and gonadal steroid receptors in human pinealocytes from infancy to old age.

Seasonal variation of gonadotropins and gonadal steroids receptors in the human pineal gland.

Recently abnormal melatonin secretion was demonstrated in hypogonadal male patients which was normalized during testosterone administration. These results suggested that both gonadal steroids and gonadotropins may modulate melatonin secretion, probably by activating specific receptors in the pineal gland. We used immunohistochemistry to localize luteinizing hormone, follicle stimulating hormone, estrogen and androgen receptors in human pineal glands. Tissues were obtained at autopsy from 53 adult males (aged 19-94 years) over a period of 1 year. Positive staining for the four types of receptors was evident in all 53 specimens examined. The percent of positively stained cells revealed a significant seasonal variation of gonadotropin receptors with higher values in the winter than in the summer. Day-night difference was evident only for follicle stimulating hormone-receptors during the summer and winter, with higher values at night. Androgen receptors and estrogen receptors were present in all specimens but did not reveal day-night or seasonal variations. These data demonstrate the presence of gonadotropin and gonadal steroid receptors in the human pineal gland. Gonadotropin receptors exhibited seasonal variation with higher values in the winter.

Pheochromocytoma due to unilateral adrenal medullary hyperplasia.

We describe two male patients, aged 17 and 47 years, with clinical and biochemical features of pheochromocytoma. Both patients had normal-sized adrenal glands on abdominal CT scan and abnormal unilateral uptake of I-123 metaiodobenzylguanidine (MIBG) on scintigraphy. The surgical adrenalectomy revealed normal macroscopic glands in both patients. Histological examination showed adrenal medullary hyperplasia with adrenal cortico-medullary ratios of 2:1 and 4:1. Unilateral adrenalectomy resulted in amelioration of symptoms and normalization of catecholamines excretion. DNA examination for RET protooncogene revealed no mutations in exons 10, 11, 13, 14 and 16. Our results suggest that diffuse adrenal medullary hyperplasia may be the initial pathological change in the adrenal gland leading, subsequently, to the development of nodular hyperplasia and adrenal medullary tumor. These results indicate that the syndrome of pheochromocytoma may occur as an unilateral adrenal medullary hyperplasia in patients without evidence for multiple endocrine neoplasia.

Hemifacial spasm associated with external carotid artery compression of the facial nerve.

We report a unique case of hemifacial spasm due to compression of the facial nerve by the main trunk of the external carotid artery within the parotid space. Decompression of the facial nerve as well as partial section of the proximal trunk of the nerve, caused the hemifacial spasm to disappear. Our case gives support to the theory that hemifacial spasm can be caused by pressure on the facial nerve along all its course and not only in its intra-cranial portion.

Syncytial variant of nodular sclerosing Hodgkin's disease presenting as a thyroid nodule. A case report.

The fine needle aspiration cytology of a thyroid nodule in a 19-year-old female showed Reed-Sternberg (RS) cell variants in clusters, thereby suggesting the possibility of syncytial variant of nodular sclerosing Hodgkin's disease (NSHD). A similar picture was observed on imprint smears of an excised cervical lymph node, the histology of which confirmed the original diagnosis. Following chemotherapy, the nodule disappeared. The patient was spared major thyroid surgery. It is important to recognize the rare morphologic variants and unusual clinical presentations of common diseases in order to perform appropriate studies that will ensure that the patient receives the best clinical management. Morphologic clues that should arouse the cytopathologist's awareness of this rare variant of NSHD are presented.

Hodgkin's disease presenting as a solitary thyroid nodule.

Two patients with unusual Hodgkin's disease who initially had a painless, solitary, thyroid cold nodule are described. Fine-needle aspiration revealed lymphocytic thyroiditis in one patient and a diagnosis of Hodgkin's disease was made 1 year later. In the second patient, aspiration of the nodule demonstrated a syncytial variant of nodular sclerosis Hodgkin's disease. Both patients underwent radiologic work-up, and surgery of the thyroid was avoided. After chemotherapy, both thyroid nodules disappeared. Thyroid involvement by Hodgkin's disease may be more common than anticipated, and may present atypically as a solitary thyroid nodule. Lymphocytic thyroiditis may accompany the disease and may cause a delay in the diagnosis. Recognition of this entity and the use of fine-needle aspiration may prevent unnecessary thyroid surgery, thus maintaining intact thyroid function after therapy.

Hirschsprung's disease associated with isolated familial medullary carcinoma of the thyroid.

We present two siblings with neonatal Hirschsprung's disease in whom isolated familial medullary carcinoma of the thyroid was diagnosed at the age of 16 and 19 years. Rectal biopsy in each patient revealed total absence of ganglion cells in the myenteric plexus and hypertrophied nerve fibers characteristic of Hirschsprung's disease. Both underwent total thyroidectomy and histological examination revealed bilateral and multifocal medullary carcinoma of the thyroid. These two patients belong to a large family in whom another 12 affected members with medullary carcinoma of the thyroid were found. Our description is the first report of an association between Hirschsprung's disease and isolated familial medullary carcinoma of the thyroid. We suggest that familial occurrence of Hirschsprung's disease could be an early presentation of familial medullary carcinoma of the thyroid either as the isolated form or as part of multiple endocrine neoplasia type IIa or IIb.

The impact of intraoperative autotransfusion on cardiac surgery. A prospective randomized double-blind study.

The effect of intraoperative autotransfusion during coronary artery bypass grafting was studied in a randomized double-blind trial involving 38 patients. Nineteen patients had the collected RBCs washed and autotransfused (autotransfusion group), while the remaining patients had their washed cells discarded (control group). Postoperative hemoglobin and hematocrit values were similar. Exposure to banked blood was markedly decreased in the autotransfusion group compared with the control group. In addition, the mean volume of banked packed RBCs transfused per patient was significantly less in the autotransfusion group compared with the control group. Platelet utilization also was markedly decreased in the autotransfusion group. Cryoprecipitate and fresh frozen plasma utilization also was less in the autotransfusion group than in the control group, but this did not reach statistical significance. We conclude that the intraoperative use of autotransfusion decreases the volume of homologous blood products transfused, which results in reduced exposure of the patients to banked blood products.

Intraoperative demonstration of Mikulicz cells in nasal scleroma. A case report.

The frozen section diagnosis of scleroma (rhinoscleroma) may pose some difficulty to the unsuspecting pathologist. Intraoperative cytology is a helpful technique that, when combined with frozen section, enhances the diagnostic accuracy. Imprint smears obtained from a tissue sample of an obstructive nasal mucosal mass demonstrated the characteristic Mikulicz cells, thus confirming the frozen section diagnosis of scleroma. The importance of intraoperative cytology in the evaluation of surgical specimens is emphasized.

Intraoperative cytology of lipoblastoma. A case report.

Soft tissue tumors in infants and children often cause considerable concern to the surgeon and pathologist, especially when a rare tumor, such as lipoblastoma, is in question. Frozen section may not yield a definitive diagnosis, and the histologic picture could be deceptive, tempting one to make a false diagnosis of malignancy. Except for a single case report, no detailed cytologic study of this rare benign neoplasm appears to have been reported previously. The varied cytologic findings, as observed on imprint smears of a tumor removed from a 12-month-old boy, are presented. The differential diagnosis of childhood myxoid neoplasms is discussed briefly.

Endemic goiter in Ethiopian Jews--possible pathogenetic factors.

Goiter size, thyroid function tests and thyroid cytology were studied in 100 immigrant Ethiopian Jews, 1-12 months after arrival in Israel on Operation Solomon (1991), who were referred for evaluation of goiter. Female-to-male ratio was 2.2:1. Hypothyroidism was rare (1%) whereas hyperthyroidism was frequently diagnosed (11%). Elevated thyroglobulin (TG) serum levels were found in 36% of the patients. Antithyroid antibodies were not detected. Thyroid cytology revealed rich colloid goiters in all patients. Thyroid carcinomata and chronic lymphocytic thyroiditis were not diagnosed. Both hyperthyroidism and elevated TG levels were found only in female patients and were equally distributed in patients maintained on either Israeli or Ethiopian diets. It is suggested that the major factors in the pathogenesis of endemic goiter in Ethiopian Jews are genetic and/or food goiterogens, with only a minor role for iodine deficiency.

Intraoperative cytology of small cell carcinoma of the ovary with hypercalcemia. A case report.

Small cell carcinoma of the ovary is a rare but lethal neoplasm occurring in the young. In two-thirds of the cases the tumor produces paraendocrine hypercalcemia. The tumor, despite the name, is composed of a dimorphic population of small and large cells, the histogenesis of which is still a controversial matter. Except for a single illustration, no detailed study of this rare entity appears to have been performed previously. The composite cytologic features as seen on touch imprints are presented in this case report, with ultrastructural and immunohistochemical correlations.

Small cell carcinoma of the ovary: an immunohistochemical and ultrastructural study with a review of the literature.

This is an immunohistochemical and ultrastructural study of two small cell carcinomas of the ovary with a review of the literature. These cases showed a dimorphic population of small and large cells sharply demarcated from each other. Cytokeratin 18 and vimentin were mainly expressed in the large tumour cells, some of which also stained for alpha-smooth muscle actin. Periodic-acid-Schiff-positive, alpha-1-antitrypsin-positive hyaline globules were present in one case. Ultrastructural findings included filamentous nucleolonema as well as evidence of smooth muscle differentiation. Some of these observations have not been previously reported. Certain of the above features seem to support a germ cell origin of small cell carcinoma, but they cannot be considered specific for germ cell neoplasms. Thus, small cell carcinoma of the ovary cannot be classified into one of the known categories of ovarian tumours at the present time.

Adenoma of the gallbladder in childhood.

Adenoma of the gallbladder is a rare benign tumor presenting as a sessile or pedunculated lesion with a papillary or nonpapillary structure. Of late, attention has been drawn to its malignant potential; its occurrence has never been reported in children. An 8-year-old girl who was successfully treated by cholecystectomy for a symptomatic adenoma of the gallbladder is reported.

Radionuclide blood pool scintigraphy in a child with intestinal arteriovenous malformation (juvenile angiodysplasia). A case report and review of the literature.

Arteriovenous (AV) malformation or angiodysplasia of the gastrointestinal tract is a very rare cause of bleeding in children. These lesions are congenital anomalies and thought to be of hamartomatous origin. We report on a 4-year-old child with an AV malformation of the distal ileum treated by local resection. A brief review of the relevant literature is included. The importance of radionuclide blood pool scanning in the evaluation of these patients is emphasized.