Piriform sinus fistula. A route of infection in acute suppurative thyroiditis

Fifteen patients had acute suppurative thyroiditis resulting from infection through the left piriform sinus fistula. Characteristic clinical features included (1) onset in infancy or childhood, (2) left lobe involvement, and (3) frequent recurrence unless the fistula was extirpated completely. Fistulectomy in eight patients demonstrated three distinct courses of the fistula: lateral to, medial to, and penetrating the left thyroid lobe. Anatomical and histological findings suggest that the fistula is a remnant of the third pharyngeal pouch. We believe that the fistula is a common route of infection in acute suppurative thyroiditis, allowing bacterial infection to begin either in the perithyroidal space, spreading into the thyroid gland secondarily, or in the thyroid gland, primarily in cases where it penetrates the gland. Complete removal of the fistula is essential to a permanent cure.

Meal-related changes in plasma calcitonin levels in patients with medullary thyroid carcinoma

In 3 patients with medullary thyroid carcinoma, plasma calcitonin levels showed 3 distinct peaks associated with a simultaneous rise in plasma gastrin after each meal. It is suggested that endogenous gastrin secreted following food intake stimulated the calcitonin secretion from the tumor. The peak of the plasma calcitonin secretion after the evening meal was less prominent than that for breakfast or lunch, while no significant differences were observed in peak values in plasma gastrin after each meal. The reason for this discrepancy remains to be clarified.

C cell carcinoma of the thyroid--papillary type

Two cases of papillary type of C cell carcinoma of the thyroid were reported. They showed papillary arrangement with fibrovascular stalk in properly fixed tissues. Histochemically argyrophil reaction was positive in the cytoplasm and amyloid deposited in the stroma. Ultrastructurally secretory granules were found in their cytoplasm. The papillary type is not an artifact but one of the histologic variations of this carcinoma.

Internal fistula as a route of infection in acute suppurative thyroiditis

Seven cases of acute suppurative thyroiditis are described. Six patients had a recurrent painful swelling of the left anterior neck and one was seen at her first episode of the disease. A barium meal revealed a fistula originating from the apex of the left pyriform sinus in all cases. The fistula, a remnant of the fourth pharyngeal pouch, thus seems to be a common route of infection in acute suppurative thyroiditis, allowing bacterial infection to begin in the perithyroidal space and spread to the thyroid gland. Complete extirpation of the fistula is required for a permanent cure.

Medullary carcinoma of the thyroid. Giant cell type

This report presents a rare histological variation of medullary (C-cell) carcinoma of the thyroid, referred to as giant cell type, which is similar to that found in anaplastic carcinoma of the thyroid, or choriocarcinoma. The giant cells in this case possessed specific immunofluorescence for calcitonin and secretory granules in the cytoplasm. The giant cells were tumor cells of medullary carcinoma and could be distinguished from anaplastic carcinoma of the thyroid by various histological characteristics, such as nuclear invagination, an intermingled pattern of giant cells with typical small solid cells, infrequency of mitosis, and the existence of amyloid stroma.

[A case of medullary thyroid carcinoma with ectopic ACTH syndrome (author's transl)]

A 53-year-old male with Cushing's syndrome due to ectopic ACTH production from medullary carcinoma of the thyroid was reported. The clinical course and results of detailed endocrinological studies and immunohistochemical findings about the cancer tissue were described. An abnormally high concentration of calcitonin, ACTH and beta-MSH in both plasma and cancer tissue (thyroid, lymph nodes and liver) were documented by radioimmunoassay. Urinary 17-OHCS was as high as 38.4 mg/day and showed no supression following dexamethasone 8 mg/day administration. ORAL METYRAPONE (3 G/DAY) CAUSED NO RESPONSE IN URINARY 17-OHCS. Parallel increments in plasma calcitonin, ACTH and beta-MSH were observed following calcium and gastrin loading. Total thyroidectomy with modified radical neck dissection caused minimal changes of plasma levels of calcitonin, ACTH and beta-MSH and no improvement in the clinical manifestations of Cushing's syndrome. An aortogram revealed metastatic tumors in the liver. A second operation, total adrenalectomy, resulted in an improvement of the clinical and laboratory findings such as hypokalemia, high blood pressure, muscle atrophy and moon face. Immunofluorescent study showed different distribution patterns in calcitonin- and ACTH-positive cells in the primary focus but similar patterns in the liver metastasis.

Ultrastructural study of thyroid medullary carcinoma

This study deals with 11 cases of thyroid medullary carcinoma of which 7 were familial cases including 3 cases of Sipple's syndrome and 4 cases of sporadic cases. There were also 2 cases of Cushing's syndrome. In addition to the previously described English literatures about human medullary carcinoma of the thyroid, the rod-shaped body with cristae and an abundant glycogen particles in the cytoplasm, nuclear inclusion bodies of cytoplasmic invagination and microvilli at the surface membrane of gland formation were found in our cases. The mean and mode diameters of secretory granules of all familial cases with only calcitonin secretion were larger than those of the sporadic cases with ectopic ACTH and beta-MSH in addition to calcitonin secretion. Ultrastructural study on non-cancerous follicles of grossly normal thyroid of two cases of early familial medullary carcinoma disclosed apparently increased C-cells which were not intrathyroidal metastases. It is supposed that the increased C-cells in the thyroid of the familial cases are multicentric C-cell hyperplasia.