Diagnosing metastatic pheochromocytoma: Trick lies in attention to details!

Functional metastatic pheochromocytoma (PCC) is a very rare tumour and cytoreductive adrenalectomy with oligo metastatectomy is recommended in cases of low tumour burden. We report a rare case of metastatic PCC with an incidentally detected suspicious nodule seen on the anterior surface of the right lobe of the liver. The adrenal and the lesion were excised and sent for histopathology which was reported as a metastasis from PCC. This lesion was not visualised preoperatively on DOTA-PET-CT, highlighting the importance of keeping a low threshold for suspicion of metastasis in abnormal lesions and taking a biopsy during surgery. Inspection of the liver and rest of the abdomen for any abnormality should be done even when operating for any apparently benign lesions.

PTH after Thyroidectomy as a Predictor of Post-Operative Hypocalcemia

Post-thyroidectomy hypocalcemia is a frequent complication with significant morbidity, and has been shown to increase hospital stay and readmission rates. The evaluation of serum parathyroid hormone (PTH) levels after thyroidectomy represents a reliable method to predict post-thyroidectomy hypocalcemia, but it remains infrequently used. This retrospective study investigates serum PTH values 3 h after thyroidectomy as a predictor of hypocalcemia. In this study, we enrolled 141 patients aged between 27 and 71 years eligible for total thyroidectomy who presented with multinodular goiter, suspicious nodule on cytological examination, Graves’ disease, or toxic multinodular goiter. Three hours after total thyroidectomy, 53 patients (37.6%) showed a reduction in serum PTH. Of these patients 75.5% developed hypocalcemia by 24 h after surgery and 100% were hypocalcemic after 48 h (p < 0.001). There was no significant difference attributable to the different thyroid diseases, nor to the age of the patients. PTH at 3 h after total thyroidectomy accurately predicts post-operative hypocalcemia. The early detection of patients at risk of developing post-operative hypocalcemia allows for prompt supplementation of calcium and Vitamin D in order to prevent symptoms and allows for a safe and timely discharge.

Features of Cytologically Indeterminate Molecularly Benign Nodules Treated With Surgery

Background Most cytologically indeterminate thyroid nodules (ITNs) with benign molecular testing are not surgically removed. The data on clinical outcomes of these nodules are limited. Methods We retrospectively analyzed all ITNs where molecular testing was performed either with the Afirma gene expression classifier or Afirma gene sequencing classifier between 2011 and 2018 at a single institution. Results Thirty-eight out of 289 molecularly benign ITNs were ultimately resected. The most common reason for surgery was compressive symptoms (39%). In multivariable modeling, patients aged &lt;40 years, nodules ≥3 cm, presence of an Afirma suspicious nodule other than the index nodule, and compressive symptoms were associated with higher surgery rates with hazard ratios for surgery of 3.5 (P &lt; 0.001), 3.2 (P &lt; 0.001), 16.8 (P &lt; 0.001), and 7.31 (P &lt; 0.001), respectively. Of resected nodules, 5 were malignant. False-negative rate (FNR) was 1.7%, presuming all unresected nodules were truly benign and 13.2% restricting analysis to resected cases. The FNR was significantly higher in nodules with a high-risk sonographic appearance for cancer (American Thyroid Association high-risk classification and American College of Radiology Thyroid Imaging Reporting and Data Systems score of 5) compared with nodules with all other sonographic categories (11.8% vs 1.1%; P = 0.03 and 11.1% vs 1.1%; P = 0.02, respectively). Conclusions Younger age, larger nodule size, presence of an Afirma suspicious nodule other than the index nodule, and compressive symptoms were associated with a higher rate of surgery. The FNR of benign Afirma was significantly higher in nodules with high-risk sonographic features.

Assessment of the value of the different variants of abnormal digital rectal examination finding in predicting carcinoma of the prostate: a preliminary report of a two-center study

Background Digital rectal examination is a veritable tool for the clinical diagnosis and screening for carcinoma of the prostate. This study aims to assess the value of the different variables which constitute abnormal digital rectal examination (DRE) findings. Results Following ethical approval, one hundred and thirty-one men met the inclusion criteria and were enrolled in the study. The peak incidence of abnormal DRE finding was in the 8th decade of life, while the PPV was 66.5%. Of the total, 44 (33.5%) were nodular hyperplasia, 12 (9.2%) were prostate intra-epithelia neoplasia, while 75 (57.3%) were adenocarcinoma. With a positive predictive value (PPV) of 73.3%, a hard nodular feel was the only abnormal DRE finding that independently and significantly predicted the risk of prostatic adenocarcinoma. A suspicious nodule and obliterated median groove had PPV of 23.1% and lobar asymmetry, 0%. There was a statistically significant correlation (P = 0.005) between DRE findings and histology, between PSA and histology (P = 0.000) and between the size of the prostate and PSA value (P = 0.021). The mean size of the prostate was 101.2 g, standard deviation 92.11783, maximum 648 g and minimum 13.6 g. Conclusion Most of the variants of abnormal DRE findings do not sufficiently predict the risk of adenocarcinoma on their own. They need to be in combination with other DRE findings or a raised PSA to significantly predict adenocarcinoma.

Scrotal skin nodule: sebaceous cyst or tuberculosis? A lesson learnt!

Tuberculosis (TB) is a great mimic of many diseases and may present a dilemma in diagnosis. Sebaceous cyst is the commonest swelling that occurs in the scrotal skin. We present a 23-year-old patient who presented with a painful hard scrotal skin nodule, clinically diagnosed to be an infected calcified sebaceous cyst, excised and reported to be due to TB. Nodular scrotal skin TB is extremely rare but should nonetheless be considered as a differential diagnosis in regions where it is prevalent. Thus, excision of any suspicious nodule is indicated.

THYROID MALIGNANCY IN MULTI NODULAR GOITER;

Objectives: To assess the incidence of malignancy in patients with Multinodular goiter in southern Punjab. Study design:A retrospective study. Place & Duration of study: Department of General Surgery, Sheikh Zayed Medical College & Hospital Rahim YarKhan, from April 2010 to May 2012. Patients and Methods: All patients were presented in OPD with history of Multinodular goiter onclinical examination or USG neck. FNAC of any dominant nodule or suspicious nodule on USG neck was performed. All patients wereoperated & total thyroidectomies were done in all patients irrespective of the age. We sent all specimens for histopathological examinationand reports were collected from department. The whole information collected was entered in a pre designed proforma. Results: During 2years period, total 141 patients of thyroid disease were seen in OPD out of which 98 patients have Multinodular goiter. Histopathology ofthese patients showed 10 malignancies & 88 benign. Most of the patients that turned out to be malignant belong to 41-50 years agegroup. 7 patients were female and 3 were male. Among the malignancies 50% were papillary, 30% were follicular, and 10% wereanaplastic carcinoma & lymphomas each. Conclusions: Multinodular goiter (MNG) is the commonest indication of thyroidectomy iniodine deficient areas of Pakistan. This study concludes that don’t consider MNG as a benign disease anymore until proved otherwise.

Incidentally Detected Squamous Cell Carcinoma of Renal Pelvis in Patients with Staghorn Calculi: Case Series with Review of the Literature

Squamous cell carcinoma of the renal pelvis is a rare neoplasm, often unsuspected clinically due to its rarity and ambiguous clinical and radiological features, and hence patients present at advanced stages resulting in poor prognosis. We report here four cases of incidentally diagnosed primary renal squamous cell carcinoma, treated at our hospital over a short span of one year, and review the relevant literature. Mean age of the patients (3 males, 1 female) was 60 years. All suffered from staghorn stones. Interestingly, renal carcinoma was unsuspected clinically in all patients. In one case, a computerised tomography scan showed a suspicious nodule. All underwent nephrectomy for nonfunctioning kidney. In just two cases, tumor was identified on gross examination, while the other two only showed thickened pelvis. Our series emphasises the need for pelvicalyceal biopsy during treatment for long-standing nephrolithiasis, and thorough sampling of the renal pelvis in nephrectomy specimen of such patients.