Type A Thymoma with Spinal and Cranial Metastases: A Case Report.

Introduction: While metastases of malignant thymomas have been shown, type A thymomas are often treated as benign. Type A thymomas often have excellent response to treatment, low recurrence rate, and a small malignant potential. To date, there have been no reports of type A thymomas with spinal metastases. Case Report: A 66-year-old female with a type A thymoma metastatic to the T7 and T8 vertebral bodies and brain, with associated pathologic burst fracture, collapse of T7, and significant focal kyphosis . The patient underwent successful T7-T8 posterior corpectomy and T4-T11 posterior spinal fusion. At 2 years of follow-up, she was ambulating without assistive devices and completed spinal radiation and initial chemotherapy. Conclusion: Metastatic type A thymoma is a rare phenomenon. While traditionally thought to have low recurrence rates and overall excellent survival rates, our case suggests that the biologic malignant potential of a type A thymoma may not be fully understood.

Subcutaneous metastasis from recurrent basaloid squamous cell carcinoma of the esophagus.

BACKGROUND: Esophageal cancer is the 11th most common cause of cancer mortality in the United States. It is aggressive in nature and has an ability to spread rapidly through direct extension, lymphatic spread, or hematogenously. With an estimated incidence of 1%, cutaneous metastases from esophageal cancer are extremely rare. CASE PRESENTATION: In this case study and review, we describe a case of recurrent esophageal basaloid squamous cell carcinoma presenting as multiple, rapidly progressing and tender subcutaneous nodules. A 69-year-old male with history of basaloid squamous cell carcinoma of the esophagus treated with concurrent chemoradiation, presented to his oncologist with complaints of a large, painful nodule at the nape of his neck approximately two years after completing treatment. On further examination, he was noted to have multiple, well circumscribed, solid, tender nodules on his abdominal wall along with a painful nodule on the pulp of his index finger. Histopathology from all sites revealed skin infiltration by high-grade invasive basaloid subtype of squamous cell carcinoma, similar to patient's prior known and treated primary esophageal cancer. Further imaging work up showed extensive metastatic disease involving lung, liver, and brain. CONCLUSION: Esophageal squamous cell carcinoma rarely metastasize to the skin. Subcutaneous nodules can be the first presentation of recurrent disease. The lesions are commonly confused with skin infections and treated inappropriately with antibiotics, leading to delay in diagnosis of recurrent disease. Early biopsy of suspicious lesions should be performed, especially in patients with history of cancer, such that prompt diagnosis and treatment can occur to maximize patient outcomes.

Lipoid Pneumonia and Sarcoidosis.

INTRODUCTION: Lipoid pneumonia is a rare, underdiagnosed disorder, and its combined presentation with sarcoidosis is even more unusual. METHODS: This paper presents a case in which both lipoid pneumonia and sarcoidosis were present, and includes the relevant literature review on lipoid pneumonia. RESULTS: Lipoid pneumonia may be acute or chronic in its presentation, resulting from exogenous or endogenous factors, or classified as idiopathic, with its precise incidence unknown. Radiographic changes maybe variable, but typically include lower lobe consolidation. Pathologic changes consist of an inflammatory giant cell reaction around lipid-related empty vacuoles and giant cell granulomas. Treatment in the case of exogenous lipoid pneumonia consists of removal of the offending oil ingestion. However, in endogenous lipoid pneumonia, treatment is aimed at the underlying cause, as there is no standard treatment. Repeated bronchoalveolar lavage, corticosteroids, and surgical resection have been used as therapies. The course of the disease is usually not progressive.

A review of methotrexate-associated hepatotoxicity.

Methotrexate is effective not only in treating psoriasis and rheumatoid arthritis but also various other disorders. The use of methotrexate has been somewhat limited by concerns regarding its adverse effects, including its potential for hepatotoxicity. The purpose of this article is to provide an overview of methotrexate-associated hepatotoxicity, including risk factors, pathogenesis and recommendations for monitoring it by US, UK and European guidelines, as well as providing a brief overview of its mechanism of action and of high-dose methotrexate.

Rheumatoid nodules in the thyroid bed following total thyroidectomy: a case report.

INTRODUCTION: Rheumatoid nodules occur in 30 percent of patients with active rheumatoid arthritis. Common sites include the buttocks or the extensor surface of the forearm, with one group documenting their presence in the thyrohyoid membrane. To the best of our knowledge, rheumatoid nodules have not been described in the thyroid bed. CASE PRESENTATION: We present the case of a 46-year-old Caucasian woman with active rheumatoid arthritis and Hashimoto's thyroiditis who presented with compressive neck symptoms. An ultrasound scan revealed that both lobes of her thyroid were enlarged. The right lobe measured 7.9×3.4×3.3cm and the left 8.3×3.3×3.1cm. A solitary 1.0×0.6×0.8cm nodule was seen in the right lower lobe. Her thyroid-stimulating hormone level was 4.22uU/mL (0.34 to 5.60). A total thyroidectomy was performed due to her symptoms and the possible growth of a nodule when on levothyroxine. A postoperative ultrasound scan showed no remaining thyroid tissue. The pathology revealed several small neoplasms ranging from a well-encapsulated adenoma to highly atypical follicular and papillary Hurthle cell lesions in the setting of Hashimoto's thyroiditis. Low-dose radioactive iodine (33.4mCi) was given. Four months later, our patient complained of a feeling of fullness in her neck. A solid nodule of mixed echogenicity (5.6×3.3×2.3cm) was seen in the right level VI of the neck, and solid tissue of mixed echogenicity (2.9×2.3×1.7cm) on the left. Following repeat surgery, the pathology from the right specimen showed Hashimoto's thyroiditis. The left specimen had areas of granuloma formation with fibrinoid necrosis and palisading histiocytes, consistent with the histology of rheumatoid nodules. No evidence of malignancy was seen. The patient continues to do well and remains disease-free. CONCLUSIONS: Rheumatoid nodules have not been reported in the thyroid bed. Their pathogenesis is not clear. Postoperative release of tumor necrosis factor alpha and local vascular damage may have triggered the nodule formation in this case. Rheumatoid nodules must be kept in the differential diagnosis of an enlarging thyroid in the setting of active rheumatoid arthritis. A fine-needle aspiration biopsy may show granuloma formation and be the most cost-effective initial diagnostic step, especially if there is a concern for malignancy. Early identification of these nodules will help decrease morbidity from unnecessary interventions and result in treatment that is both timely and appropriate.

Etanercept-induced lupus erythematosus presenting as a unilateral pleural effusion.

A 72-year-old man receiving etanercept for the treatment of psoriatic arthritis had an exudative pleural effusion with nonspecific fluid analysis and pleural biopsy findings. He was ultimately found to have drug-induced lupus erythematosus due to the etanercept. The spectrum of autoimmune disease due to the use of tumor necrosis factor inhibitors is reviewed.