The Role of MRI in Assessing Residual Breast Cancer After Neoadjuvant Chemotherapy

INTRODUCTION

Breast cancer is the most common malignancy among women in the world. The role of neoadjuvant chemotherapy (NAC) in the management of breast cancer is increasing. The decision about the management after NAC depends mainly on the tumor response to NAC.

OBJECTIVES

The role of the current study is to evaluate the role of the MRI scan in assessing the residual disease after NAC, which would help in decision making regarding the best treatment plan for the patient.

PATIENTS AND METHODS

We did this retrospective review for all patients who were diagnosed with breast cancer in our center and had NAC over four years. All patients in our study had a post-NAC magnetic resonance imaging (MRI) scan to assess the residual tumor size. A 2×2 table was used to calculate the diagnostic accuracy, and SPSS software version 25 was used to get the correlation coefficients between the post-NAC MRI measurements and pathological size.

RESULTS

28 female patients were included in our study. The average age was 45.25 ± 10 years. We utilized the tumor size on histology as the standard for comparison. We calculated MRI sensitivity, specificity, PPV, and NPV rates of 90.9%, 100%, 100%, and 94.4%, respectively. The correlation coefficient was strong (r = 0.859, P = 0.01).

CONCLUSION

Magnetic resonance imaging is a good test to assess the residual tumor disease after NAC in breast cancer patients. However, cases of under- and overestimation are still seen, which require more caution when making a decision regarding the management of such cases.

Thyroid Lymphoma: Case Series Review

BACKGROUND

Primary thyroid lymphoma (PTL) is a rare malignancy accounting for about 5% of all thyroid malignancies and less than 2% of extra-nodal lymphomas. Diffuse B-cell lymphoma is the most common pathological subtype of PTL.

PATIENTS AND METHODS

This is a retrospective review of all patients diagnosed with thyroid lymphoma in our hospital during the period from 2011 to 2021. All patients had clinical, radiological, and pathological evaluation. We have followed up these patients since diagnosis till now.

RESULTS

Eight patients were included in our review. Four patients were males and four were females. Mean age at diagnosis was 63 ± 32 years of age. Diagnosis was confirmed only with tissue histology. Six patients had stage IIE disease and two had stage IVE disease. Four patients had disease related mortality. Of the other four patients, two had chemotherapy (RCHOP) and one had local radiotherapy; all achieved complete remission, and the last one had hemithyroidectomy to relieve airway compression and still under treatment.

CONCLUSION

Primary thyroid lymphoma is rare malignancy of the thyroid gland. Advanced stage and age at the time of diagnosis, the presence of compression manifestations, large tumor mass, and presence of distant metastasis, all are poor prognostic criteria. Our knowledge of the disease pathology, diagnosis, and management is still limited and more research studies are required.

Pheochromocytoma associated with a succinate dehydrogenase subunit B mutation: A minireview and a case report

Objective. Pheochromocytomas and paragangliomas are rare neuroendocrine tumors that arise from the chromaffin cells of the adrenal medulla or extra-adrenal tissues. These tumors are characterized by an excessive secretion of catecholamines, which are responsible for the clinical manifestation of the disease. Although most of these tumors are sporadic, underlying genetic abnormalities may be present in up to 24% of the cases. A succinate dehydrogenase subunit B (SDHB) mutation represents one of the rare presentations of the disease. In this study, we represent a rare case of pheochromocytoma associated with SDHB mutation. Methods. We performed a retrospective review of our case in addition to reviewing the available literature on the same topic. Results. A 17-year-old patient presented with sustained hypertension. Clinical, laboratory, and radiological evaluations confirmed the diagnosis of catecholamine-secreting tumor. Laparoscopic adrenalectomy was performed. Histopathological and genetic testing confirmed a pheochromocytoma associated with SDHB mutation. No recurrence was detected on two-years of follow up. Conclusion. Pheochromocytoma associated with SDHB mutation is a rare presentation. Genetic testing for suspecting cases is essential to help to establish the appropriate follow-up plan.

Correlation between the size of pheochromocytoma and the level of metanephrines

Objective. Pheochromocytomas (PHEO) and paraganglioma (PGLs) are rare neuroendocrine catecholamine-producing tumors that arise from the chromaffin cells of either the adrenal medulla or extra-adrenal paraganglionic tissues. Despite the recent advances in imaging technologies, biochemical evidence of excessive catecholamine production by the tumor is considered the most important test for the diagnosis of these tumors. The aim of the present study is to investigate the role of the catecholamine metabolites (normetanephrine and metanephrine) levels in the diagnosis of PHEO/PGLs and to evaluate if their levels correlate with the size of these tumors. Patients and Methods. Twenty-five patients were included in the study during the time period of 10 years. Their data were compared with another set of 25 patients to obtain the sensitivity and specificity of metanephrine and normetanephrine in the diagnosis of PHEO/PGLs. The tumor size was reviewed in every patient to obtain the correlation coefficient between the tumor sizes and the plasma/24-hour urinary metanephrine levels. Results. The sensitivity and specificity rates for plasma metanephrine were 80-92% and 92-96%, respectively; while for 24-hour urinary metanephrine were 80-90% and 95-100%, respectively. We found a strong positive relationship between the tumor size and the plasma levels of normetanephrine (r=0.518, p<0.01), and metanephrine (r=0.577, p<0.01). While the relation with the 24-hour urinary concentrations of normetanephrine (r=0.384, p=0.01) and 24-h urinary meta-nephrine (r=0.138, p<0.01) was low. Conclusion. The determination of plasma and 24-hour urinary levels of metanephrines is a reliable test for the diagnosis of PHEO, as they are continuously produced by the tumor cells in contrast to catecholamines.

Correlation between preoperative calcium and parathormone levels with parathyroid gland volume

Objective. Hyperparathyroidism is a prevalent disease with parathyroid adenomas being the most common cause. Surgical excision remains the standard treatment for parathyroid adenoma. Successful preoperative localization of the parathyroid adenoma could facilitate the decision regarding the extent of surgical exploration. The aim of the current study was to assess the correlation between the preoperative values of parathyroid hormone and ionized calcium with the adenoma weight and volume in patient with primary hyperparathyroidism caused by single-gland adenoma. Patients and Methods. We did this retrospective review for all patients who were diagnosed with primary hyperparathyroidism due to a solitary parathyroid adenoma in our general surgery department over 4 years. SPSS software was used to get the correlation coefficient between the peak preoperative levels of calcium and parathyroid hormone with the parathyroid adenoma weight and volume. Results. Ninety-nine patients were included into the study. The average age at surgery was 62.65±12.00 years. The correlation coefficient between the adenoma volume and weight with the preoperative ionized calcium level was weakly positive (r=0.329, p<0.01) and (r=0.281, p=0.019), respectively, while the correlation with the preoperative parathyroid hormone level was stronger (r=0.708, p<0.01) and (r=0.650, p<0.01), respectively. Conclusions. The strong positive relationship between the preoperative parathyroid hormone and calcium levels with the parathyroid adenoma size and weight can help the surgeon to predict the volume of the involved gland and avoid an unnecessary dissection.

SP11.5 Effect of COVID-19 Pandemic on Thyroid Surgery

Introduction

The rapidly expanding COVID-19 pandemic has affected all aspects of daily life, including health care systems. The impact on COVID 19 on thyroid surgery is clear due to the delay in most thyroid related activities, including the delay in the thyroid investigations, screening and surgery.

The aim of the current study is to illustrate the impact of COVID 19 on thyroid surgery.

Methods

Retrospective review of our activities during 7 months (January – July) in 2021 during COVID-19 pandemic and comparing it with a similar period in 2019.

Results

During the period of seven months in 2019, we performed 69 thyroid surgeries, while during the same period in 2021 we performed 16 thyroid operations. In 2019, 35 patients had diagnostic thyroidectomy (malignancy was found in 9 of them), while only one case in 2021 had diagnostic thyroidectomy. Six patients in 2019 had completion thyroidectomy; one of them had thyroid cancer, while four patients in 2021 had completion thyroidectomy; all were benign. Malignancy was diagnosed in 26 patients in 2019 and in 10 patients in 2021. Most patients in 2019 had early stage disease (T1: 14 patients, T2: 4 patients, and T3: 6 patients), while most patients in 2021 had high stage disease (T1: 3, T2: 1, T3: 5, and T4: 1). Lymph node involvement was found in 9 patients from 24 in 2019, and in 9 patients of 10 in 2021.

Conclusion

Because of the COVID pandemic, most thyroid cancer patients presented with advanced disease with high incidence of lymphatic metastasis.

TH1.13 The Role of Metanephrines in the Diagnosis of Pheochromocytoma

Introduction

Pheochromocytomas are rare neuroendocrine catecholamine-producing tumors that arise from either the adrenal medulla (PHEO) or extra-adrenal paraganglionic tissues (paraganglioma/PGLs). PHEO is responsible for about 0.01–0.1% of the cases of hypertension. Assessment of the plasma/urinary levels of metanephrines (catecholamines metabolites) is now considered the gold standard for the diagnosis of PHEOs.

In this study, we aimed to investigate the role of the plasma and 24-hour urinary metanephrines levels in the diagnosis of PHEO/PGLs.

Patients and Methods

Retrospective review of 26 patients diagnosed with PHEO/PGLs. We measured the plasma/ 24-h urinary metanephrines. The data were compared with another set of 26 patients with other adrenal pathologies. The correlation coefficient between the tumor sizes and the plasma/24-hour urinary metanephrines levels was calculated.

Results

The mean tumor size was 4.88 ± 1.99 cm. The sensitivity and specificity of the plasma metanephrines were about 95.8% and 98%, respectively, while for 24-hour urinary metanephrines were about 83.3% and 98%, respectively. We found a strong positive relationship (r = 0.472, P = 0.05) between the tumor size and the summed plasma concentrations of metanephrines. The relation between the tumor diameter and summed 24-hour urinary metanephrine was potentially strong (r = 0.354, P = 0. 083).

Conclusion

Plasma/24-hour urinary metanephrines are of great value in the diagnosis PHEOs/ PGLs as they are continuously produced by the tumor. There are strong relations between the size of these tumors and the plasma and urinary concentration of these metabolites, which can help to predict the size of the tumor even before imaging.

EP-631 Left Ovarian Teratoma Containing Follicular Thyroid Carcinoma: A case Report

Introduction

A mature cystic teratoma of the ovary is composed of well-differentiated derivatives of the three germ layers, the ectoderm, the mesoderm and the endoderm. About 20% of ovarian teratomas contain thyroid tissues. When thyroid tissue comprises more than 50% of the ovarian teratoma, it is termed; struma ovarii. Patients are usually asymptomatic or predominantly presented with a pelvic mass in 45% of cases or abdominal pain.

We represent a rare case of stuma ovarii containing follicular thyroid carcinoma.

Case presentation

A 56 years old patient presented with a left ovarian mass. The patient had no history of any thyroid abnormalities and no family history of thyroid malignancy. The patient underwent total hysterectomy (TH) and bilateral salpingo-oophrectomy (BSO). Mature cystic teratoma of the left ovary containing highly differentiated follicular carcinoma with omental deposits was discovered.

The case was referred for thyroid MDT for discussion of further management. Thyroid US and CT scans showed slightly small thyroid containing multiple hypoechoic nodules with no evidence of distant metastasis.

Management

The patient had total thyroidectomy and the final histopathology reported incidental multifocal papillary microcarcinomas of follicular variant; stage pT1a. Post-operatively the patient had Radio-iodine ablation. TSH suppression with thyroxin was initiated. The patient had regular radiological and thyroglobulin checks and no recurrence was detected on 5 years of follow-up.

Conclusion

The treatment for malignant struma ovarii depends on the tumor stage. The initial surgery includes TH and BSO with omentectomy. The adjuvant treatment includes thyroxine, total thyroidectomy with RAI ablation. Long-term follow-up is recommended.

TH6.6 Characteristics of Cervical Lymph Node Involvement in Papillary Thyroid Carcinoma

Background

Papillary thyroid carcinoma (PTC) accounts for 80–85% of all thyroid carcinoma. The SR reaches over 90% over a 10-year of follow-up. The frequency of cervical lymph node metastasis ranges from 40–90%.

We analyzed the data of 37 PTC patients who underwent thyroidectomy and neck dissection to illustrate the pattern of cervical lymph node metastasis in PTC.

Methods

Retrospective review of 37 patients who underwent thyroidectomy with neck dissection for PTC. Preoperative assessment included FNAC, US +/- CT/MRI scans.

Results

The patients’ average age was 44± 19.5 years. Female to male ratio was 1.5:1. The incidences of lymph node metastasis according to the neck level were; 40.5% (15) at level II, 67.6% (25) at level III, 45.9% () at level IV, 16.2% (6) at level V, 54% (20) at level VI, while no metastasis was found at level I. 29 cases (78.4%) had multiple levels involvement, while 6 patients had single level metastasis; 5 at level VI and one at level II. Two patients had no metastatic lymph nodes.

Conclusion

Selective neck dissection has proven to reduce the potential morbidity associated with more extensive neck dissection without affecting the oncological outcomes. Levels III and IV are commonly involved, and usually dissected in continuity. Level II dissection is recommended whenever there is extensive involvement of levels III/IV. Level VI is usually dissected, even as a prophylactic procedure due to the high frequency of microscopic metastases. Level V dissection is usually not recommended unless involved. Involvement of Level I is rare.