1/25. The incidental diagnosis.incidental findings transcend medical practice. Two cases are discussed in which significant conditions were discovered during clinical examination for an unrelated disorder. The first case presents a disease reported for the first time in a male. Recent literature has alluded to missed diagnoses found only at autopsies. With cost constraint as a national theme, the appropriate use of technology presents a challenge to the physician. The cases discussed raise questions about the process of diagnosis. Both situations bring to light the limitations of clinical investigation early in the pathologic process.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
2/25. The diagnostic dilemma of incidentalomas. Working through uncertainty.The clinical evaluation of incidentally found nodules in the adrenal, thyroid, and pituitary glands is a challenge for physicians, regardless of their level of expertise. Choosing the most direct and cost-effective diagnostic approach and deciding when to treat or not to treat are common dilemmas in clinical practice. This article outlines one diagnostic approach using medical decision-making techniques such as heuristic thinking, critical appraisal of the literature, treatment threshold probability assessment, Bayes' theorem, and discriminant properties of diagnostic tests. These skills are usually discussed in postgraduate training curricula. Nevertheless, they often seem foreign to many clinicians. Evidence suggests that training in these techniques can improve clinical decision making. Use of the skills outlined herein provides a framework to work through the diagnostic uncertainty common in the evaluation of incidentalomas. This approach does not provide perfect answers, as noted in examplar 3 in which two experts argued about the actual pretest probability and treatment thresholds for pituitary incidentalomas. Even if there were no such disagreement, each patient presents unique issues, and there will always be some uncertainty. Nevertheless, this approach provides a starting point from which critical decisions can be made for individual patients.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
3/25. Cribriform variant papillary thyroid cancer: a characteristic of familial adenomatous polyposis.Inherited cancer syndromes may predispose to more than one type of cancer, and these characteristically develop at an earlier age than their sporadic counterparts. The occurrence in a single individual of multiple, early onset primary cancers may indicate an inherited cancer susceptibility. Familial adenomatous polyposis (FAP), an autosomal, dominantly inherited susceptibility to colorectal adenomas and cancer also predisposes to childhood medulloblastomas and to a specific rare histologic type (cribriform variant) of papillary thyroid cancer. We describe a patient who developed a childhood medulloblastoma of the cerebellum, and subsequently a cribriform papillary thyroid cancer. These cancers predated the diagnosis of FAP in this patient, who was later found to have several relatives with FAP. The adenomatous polyposis coli (APC) mutation delineated in this family was in the region associated with those causing an increased risk of thyroid cancer. We submit that the diagnosis of the cribriform variant of papillary thyroid cancer in a young individual, especially after a previous cancer diagnosis, should alert the physician to the possibility of a diagnosis of FAP.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
4/25. Thyroid carcinoma and Graves' disease.OBJECTIVE: To describe an unusual patient with thyroid carcinoma who had metastatic pulmonary nodules that regressed transiently during the active phase of Graves' disease. methods: The clinical, pathologic, and laboratory findings in a female patient with thyroid carcinoma, pulmonary lesions, and Graves' ophthalmopathy are presented. In addition, the patient's clinical course and results of serial studies are reviewed. RESULTS: A 62-year-old woman underwent excision of a follicular carcinoma of the thyroid and then total thyroidectomy in 1984. Two years later, chest radiography disclosed multiple pulmonary lesions; open-lung biopsy revealed follicular carcinoma. thyroglobulin determinations continued to increase, and computed tomography of the chest showed an increase in the size and number of pulmonary nodules. Clinically, the patient remained unchanged until 4 years postoperatively, when she noted rapid onset of diplopia, proptosis, and diminished visual acuity. During this time, a thyroid-stimulating immunoglobulin assay was strongly positive, thyroglobulin levels were decreased, and computed tomography and radiography of the chest showed evidence of tumor regression. Orbital decompression partially restored vision, and the inflammatory signs decreased gradually. Concurrently, the thyroid-stimulating immunoglobulin level declined, the thyroglobulin level increased, and the pulmonary lesions increased in size and number. The patient ultimately died of metastatic disease. CONCLUSION: The reduction in size of the pulmonary nodules and decrease in thyroglobulin levels when the thyroid-stimulating immunoglobulin level was high and the regrowth of lesions when it declined suggest a causal relationship. The hypothesis of an operative autoimmune factor cannot be substantiated without serologic evidence in this case but should prompt physicians to search for other such occurrences.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
5/25. Cowden disease.Cowden disease represents an unusual, but unique syndrome which can be recognized most consistently by the development of characteristic verrucous, keratotic, papular, and nodular lesions about facial orifices, on the oral mucosa, and over the dorsal surfaces of the forearms and hands. The cause of these diverse hyperplastic changes is not known. Recognition of these lesions as signs of more extensive disease should alert the physician to examine the thyroid gland, breasts, female reproductive tract, GI tract, and skeleton for evidence of the associated changes we have enumerated. Because of the tendency for lesions of the thyroid, breast, and intestines to undergo malignant change, these patients require close observation and evaluation.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
6/25. Three cases of papillary carcinoma and three of adenoma in thyroglossal duct cysts: clinical-diagnostic comparison with benign thyroglossal duct cysts.The clinical and diagnostic findings of 3 cases of papillary thyroid carcinoma in thyroglossal duct cyst (TDC) were compared to those of 3 cases of adenoma in TDC and 2 cases of benign TDC. The neck masses of the subjects with benign TDC grew slowly, whereas those of 2 patients with papillary carcinoma and 1 of the patients with adenoma grew rapidly (especially those with carcinoma). On the other hand, one case of carcinoma, and two cases of adenoma in TDC were diagnosed incidentally. Benign TDC had an anechoic pattern at US, whereas the cysts containing carcinoma and adenoma showed the presence of a mural nodule at US. Microcalcifications in the mural mass were present in one patient with carcinoma. The 3 patients with carcinoma in TDC underwent total thyroidectomy. The histology was negative in all 3 patients for thyroid cancer and thyroid nodules. However, in 2 of them it revealed the carcinoma invading the cyst wall and adjacent tissues, 1 of which also exhibited 2 metastatic lymph nodes in the central neck area. The cases reported illustrate the utility of enhancing one's clinical suspicion of carcinoma in patients bearing TDC, even when incidentally discovered. In particular, rapid growth of the cystic mass, and the presence of a mural nodule on US, especially with calcifications, must raise the physician's suspicion for a cancer arising in TDC.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
7/25. The interpretation of 131I scans in the evaluation of thyroid cancer, with an emphasis on false positive findings.Radioiodine has aided the management of differentiated thyroid cancer for several decades. Most thyroid cancers retain the ability to trap iodine, and radionuclides of iodine can be used both diagnostically and therapeutically. The availability of sensitive diagnostic tests, coupled with the ability to deliver targeted therapy, gives physicians the ability to manage thyroid cancer better than with any other type of cancer. The correct interpretation of radioiodine scans is critical in the appropriate management of patients with thyroid cancer. False positive findings do occur. A radioiodine scan showing abnormal uptake outside the thyroid bed must be studied carefully and alternative reasons for the finding must be considered. The scan should be analysed systematically. Is there residual thyroid? If so, what is the 48 or 72 h neck uptake? Radioiodine uptake in the salivary glands, stomach, gastrointestinal and urinary tracts should be acknowledged as physiological. Diffuse uptake is seen in the liver in most patients with functioning thyroid at the time of their post-therapy scan. When there is uptake of the radioiodine outside these regions, contamination must be considered. A variety of cases illustrating true positive, true negative, and false positive findings is presented in this review, and the causes and consequences of misinterpretation of radioiodine scans are discussed.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
8/25. Chemotherapy-induced radiation recall myositis.Myofasciitis syndrome encompasses a group of disorders characterized by chronic inflammation and/or fibrosis of the subcutaneous septa and muscular fascia. We report on a patient in whom myositis was diagnosed in the areas previously irradiated for papillary thyroid carcinoma and anal canal carcinoma respectively 21 and 3 years after radiotherapy. We are not able to explain why myopathy developed at the same time in two different sites at a different interval from the two radiotherapic schemes. We can suppose that the patient developed a subclinical regional myopathy after the first radiotherapic scheme. radiation induced heritable mutations within surviving cells that were unable to tolerate the second damage by systemic chemotherapy. It is unclear how radiosensitization correlates with an ability to reactivate latent effects in normal tissue. physicians using chemotherapic radiosensitizers should be aware of their potential to induce a delayed form of radiosensitization. We report this case to encourage physicians to be alert to the knowledge of the clinical, histologic and morphologic characteristics of radiation myositis in order to distinguish it from an infectious or immune fasciitis or myositis.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
9/25. Intratracheal ectopic thyroid tissue: a case report and literature review.We discuss a case of intratracheal ectopic thyroid tissue (ETT) that was retrieved from the files of the Otorhinolaryngic--head and neck pathology Registry at the Armed Forces Institute of pathology. The patient was a 54-year-old man who had a history of papillary thyroid carcinoma, which had been treated with a subtotal thyroidectomy. During routine follow-up 4 years later, the patient's primary care physician detected an elevated thyroglobulin level. Further referrals and evaluations revealed that the patient had intratracheal ETT. The patient refused to undergo surgical excision and remains without evidence of recurrent carcinoma. In a medline literature review, we found only 13 other well-documented cases of intratracheal ETT since 1966; in all but two cases, patients had benign disease. Once the possibility of thyroid carcinoma has been eliminated by histologic examination, intratracheal ETT can be managed by complete surgical excision with the prospect of an excellent long-term clinical outcome.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
10/25. Insular carcinoma of the thyroid in an adolescent: a case report and review of the literature.A 15-year-old girl was referred for a thyroid gland mass, which rapidly enlarged in the brief interval between initial evaluation and surgery. Fine needle aspiration of the mass suggested a diagnosis of papillary thyroid carcinoma. Upon pathological examination of this aggressive tumor, an "insular" pattern of tumor was identified. Insular carcinoma of the thyroid gland is unusual in the pediatric age group, however its aggressive nature and prognosis have important management implications for those physicians involved in the care of affected patients. Aggressive surgical debulking, very close observation of the course of disease, and adjunctive radioiodine therapy may all be indicated as were performed in this case. A description of the pathology of this condition, and a review of the clinical experience with insular carcinoma in childhood and adolescence are presented.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
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