Hashimoto thyroiditis onset after laparoscopic removal of struma ovarii: an overview to unravel a rare and intriguing finding

Follicular Thyroid Carcinoma Arising from the Struma Ovarii Coexisting with Papillary Thyroid Carcinoma, Hashimoto's Thyroiditis and Polycystic Ovarian Syndrome-a Case Report and Literature Review

Purpose

Struma ovarii is a highly specialized teratoma consisting primarily of mature thyroid tissue. However, malignant struma ovarii coexisting with thyroid carcinoma, not to mention autoimmune disease, is uncommon. Malignant struma ovarii complicated with papillary thyroid carcinoma, Hashimoto's thyroiditis and polycystic ovarian syndrome has never been reported in literature.

Patients and Methods

A 32-year-old female was admitted to our hospital due to a history of abdominal distension and menolipsis over the past half a year. Physical examination touched a 6 × 6 cm mass with a clear boundary, normal movement, and no pressing pain in the right adnexal area, Imaging revealed a cystic solid mass of 6 × 7 cm in the right ovary and the level of tumor markers including CA125, CA199, CA153, CEA, AFP were normal, but with low TSH and increased TPOAb, TGAb, TRAb. Laparoscopic right ovary tumor resection was performed, followed by comprehensive staging surgery, as well as thyroidectomy after pathologic diagnosis. The patient was diagnosed with a combination of follicular thyroid cancer from struma ovarii, papillary thyroid carcinoma and Hashimoto's thyroiditis, along with polycystic ovarian syndrome. Immunohistochemical staining showed positivity for Ag, CK-pan, CK7, PAX8 and TTF-1 in the right ovarian mass, and the left thyroid was positive for the BRAF V600E mutation.

Results

The patient underwent thyroxine suppression therapy and radioactive iodine 131I therapy after operation. Serum thyroglobulin was undetectable, and no signs of recurrence or metastasis were detected in the imaging examination at the 2-year follow-up.

Conclusion

Malignant struma ovarii coexisting with thyroid carcinoma is rare. No report has been identified in literature review on the rare malignant struma ovarii coexisting with thyroid carcinoma, Hashimoto's thyroiditis and polycystic ovarian syndrome. Our case can offer experience of diagnosis and treatment to some extent for such rare case. Therefore, it is essential to consider the association between ovarian tumors and the endocrine system. This case is valuable in understanding the diagnosis and management of such an unusual complicated disease.

Tumor markers of uterine cervical cancer: a new scenario to guide surgical practice?

Since the introduction of Pap smear screening, the incidence and mortality of cervical cancer (CC) have been reduced drastically in USA and in other western states. Nevertheless, CC still remains the main cause of death from gynecological cancer in developing countries where screening programs are scant or inexistent. This evidence highlights the efficacy of screening, and the wide use of Human Papilloma Viruses (HPV) vaccines in developed countries. More and more people are, consequentially, undergoing a screening procedure, usually combined with HPV DNA test, increasing the early diagnosis of intraepithelial HPV-related lesions. The long transit time from early cervical lesion to invasive cancer provides an opportunity to identify pre-cancerous lesions where treatment result is maximum. In fact, when an invasive CC occurs, the overall survival rate strictly depends on stage of disease with an average survival of 70% at 5 years. Under the pressure of this reality, researches have made efforts to individuate cancer markers as indicator of specific cancer events. Some markers were showed to be able to detect those intraepithelial lesions have more chance to evolve to invasive forms (p16^ink4a, p16, E-cadherin, Ki67, pRb, p53). Markers such as CEA, SCC-Ag, CD44, have been developed to detect invasive forms. Although cancer markers actually are not used only for early diagnosis, they may be useful in others fields of application such as evaluation and monitoring of treatments to improve diagnosis and treatment of CC.

Fertility sparing surgery for stage IA type I and G2 endometrial cancer in reproductive-aged patients: evidence-based approach and future perspectives

Fertility-sparing surgery (FSS) in reproductive-age patients affected by endometrial cancer (EC) gained growing attention in the last decade, although the first reports were already published in 1990-2000s. Nevertheless, only few patients undergoing FSS for stage I, type I EC had been reported in each case series, without a robust multicenter study. In the available literature there are even fewer reported cases of conservative treatment of Stage IA and G2 EC. Considering these important gaps in our current knowledge, the purpose of this review was to summarize the available evidence about conservative treatments for stage IA type I and G2 EC, to improve the pretreatment counseling for reproductive-age patients. According to our overview, women who have low-risk disease (G1 or G2, endometrioid histotype confined to the endometrium) are candidates for progestin therapy. In addition, FSS could be considered a valid option for reproductive-aged patients with stage IA type I and G2 EC. Nevertheless, we solicit new trials to clarify the medium- and long-term outcomes in this kind of patients.

Preoperative work-up for definition of lymph node risk involvement in early stage endometrial cancer: 5-year follow-up

This prospective cohort study aimed to analyze the accuracy of magnetic resonance imaging (MRI) and hysteroscopic excisional biopsy (HEB) for predicting the low- and high-risk patients with endometrial carcinoma for nodal involvement at preoperative evaluation. From January 2005 to December 2006, all patients with a diagnosis of endometrial carcinoma were prospectively included in the study and underwent pelvic MRI and HEB. The pelvic MRI (without contrast) was aimed to evaluate the extent of myometrial invasion (MI < 50%, MI ≥ 50%), the possible involvement of cervical stroma, the ovarian, and lymph nodes status. HEB was performed under general anesthesia, retrieving multiple biopsies through a 5-mm, monopolar, loop electrode. According to our data analysis, the integration of MRI and HEB showed an elevated accuracy and high rates of sensitivity (85.0%), specificity (88.5%), negative predictive value (91.9%) and positive predictive value (79.0%) in identifying low-risk patients who do not need comprehensive surgical staging.

Hyperthyroidism due to struma ovarii: Diagnostic pitfalls and preventing thyroid storm

We report struma ovarii in a case that had hyperthyroidism and was treated with laparoscopic tumor resection. A 40-year-old Japanese woman presented with tachycardia, finger tremor, and weight loss. Although blood examination showed hyperthyroidism, test results for thyroid stimulating hormone receptor antibody and thyroid stimulating antibody were negative, and thyroid scintigraphy showed no abnormal findings. Because she was diagnosed with an ovarian tumor, and whole-body scintigraphy showed that iodine uptake was detected in the pelvic space, we diagnosed her with an ovarian tumor, which caused excessive thyroid hormone secretion. After controlling the thyroid hormone level, we resected the ovarian tumor laparoscopically. The thyroid hormone level was within the normal range postoperatively without any medications. Based on our experience, physicians need to remember that ovarian tumors can cause hyperthyroidism. Controlling the thyroid hormone level preoperatively by using antithyroid drugs and performing minimally invasive laparoscopic surgery is considered useful for preventing thyroid storm.