SUN-488 A Coexisting of Two Different Thyroid Malignancies: A Collision Phenomenon

A Coexisting of Two Different Thyroid Malignancies: A Collision Phenomenon Introduction: Collision tumors are rare clinical entities wherein two histologically distinct tumor types occur at the same anatomic sites. Simultaneous papillary thyroid carcinoma (PTC) and follicular thyroid carcinoma (FTC) of the same thyroid is a very rare occurrence with limited clinical information. Herein, we report a case of PTC and FTC of the same thyroid lobe. Clinical case: A 79-year-old man presented to the emergency department for evaluation of left hip pain of 2-month duration. Three days before presentation, he sustained a physical trauma to the left side of his body. X-ray imaging of the left femur revealed a lytic bony lesion measuring approximately 5.2 cm x 4.2 cm at the proximal end of left femur as well as a displaced pathologic fracture of its lesser trochanter. Biopsies of the bone lytic lesion suggested metastatic follicular thyroid carcinoma. CT of the neck revealed an enlarged thyroid with a cystic lesion as well as 2 nodules in the left lobe of thyroid gland. Total thyroidectomy was performed. Histopathology revealed 2 separate primary malignancies of PTC and FTC. Following diagnosis, laboratory test results showed TSH 2.6 uIU/mL (reference range, 0.2–4), anti-thyroglobulin antibody (anti Tg) < 1.0 IU/mL (reference range, 0.0–0.9), calcitonin 8.4 pg/mL (reference range, 0–8.4), and CEA 1.1 ng/mL (reference range, 0.0–3.0). The patient was placed on thyroid hormone replacement therapy and was treated with external beam radiation to his bone metastasis. He was scheduled for later further thyroid ablation. In his follow-up visit, three months later, he reported no pain on ambulation. Discussion: For each type of thyroid malignancy, several genes have been identified. However, to date, no common gene mutation responsible for the pathogenesis of the different tumor types has been determined. For instance, point mutations of the RAS oncogene are found in about 40% of thyroid neoplasms (N-RAS, H-RAS, and K-RAS, in order of decreasing frequency) including both PTC and FTC. No single theory can completely explain the pathogenesis of these tumors in all cases, and so, with the present level of understanding of the disease, a combination of theories must be accepted. Management of collision tumors of the thyroid gland is usually complex owing to the presence of dual pathology in the tumor tissues and given the fact that literature on this condition is scarce. Generally, the treatment needs to be individualized. Conclusion: Most likely, a rare phenomenon of simultaneous mutation of different genes can give birth to contemporary different thyroidal neoplasms. References: Zhu Z, Gandhi M, Nikiforova MN, et al. Molecular profile and clinical-pathologic features of the follicular variant of papillary thyroid carcinoma. An unusually high prevalence of ras mutations. Am J Clin Pathol 2003; 120:71.

Coexistence of Two Different Thyroid Malignancies: A Collision Phenomenon

The term “collision tumor” is described as the coexistence of two or more histologically distinct neoplastic morphologies separated by normal tissue in the same organ. Simultaneous papillary thyroid carcinoma (PTC) and follicular thyroid carcinoma (FTC) of the same thyroid lobe is a very rare pathology. Herein, we report a case of PTC and FTC of the same thyroid lobe. A 79-year-old man was evaluated at our hospital for the presence of left hip pain of two-month duration after sustaining a physical trauma to the left side of his body three days prior to admission. X-ray imaging of the left femur revealed a large lytic bony lesion at the proximal end of left femur. Biopsy of the bone lesion was suggestive of FTC. Computed tomography (CT) of the neck revealed an enlarged thyroid with a cystic lesion in the left lobe of the thyroid gland. Total thyroidectomy was performed. Histopathology revealed two separate primary malignancies of PTC and FTC. Genetic studies for RAS gene mutation were negative. He was initiated on suppressive doses of levothyroxine following thyroidectomy. Three months after surgery, thyrotropin alfa stimulated 204.5 mCi I-131 was administered. At seven months of follow-up, the thyroglobulin level was in the lower end of the normal range and anti-thyroglobulin antibody (anti Tg) remained negative (< 1.0 IU/mL). He was doing well and reported no symptoms.

For each type of well-differentiated thyroid cancers, several genes have been identified. However, thus far, no specific gene mutation responsible for the pathogenesis of the different tumor types has been described. Management of thyroid collision tumor is usually complex due to the presence of different pathology in the tumor tissues and given the fact that literature on this condition is limited. Typically, the treatment needs to be individualized. Our report brings up a concept that the occurrence is a rare phenomenon of simultaneous mutation of different genes that could give rise to different thyroidal neoplasms.

Use of continuous ambulatory infusions of concentrated subcutaneous (s.q.) hydromorphone versus intravenous (i.v.) morphine: cost implications for palliative care

Health care practitioners are increasingly under pressure to curtail spending while trying to deliver excellent patient care. These issues are also affecting palliative care, particularly now that palliative care programs are expanding. A comparison of cost-effectiveness and feasibility of using continuous subcutaneous (s.q.) ambulatory infusion of hydromorphone versus intravenous (i.v.) ambulatory morphine is illustrated in this study. With the high doses of morphine required in chronic cancer pain, the use of subcutaneous morphine is not feasible due to the volume of solution required to be delivered. Hydromorphone can be prepared in concentrated solutions enabling it to be delivered by the subcutaneous route. Morphine stability data are available. However, hydromorphone stability has only been verified for seven days; thus, stability data were needed post-seven days. Concentrations of 10 mg/ml, 20 mg/ml, 50 mg/ml, and 100 mg/ml, in 0.9 percent normal saline or dextrose 5 percent water, were analyzed via high-performance liquid chromatography (HPLC) at seven and 28 days. Cost comparisons of supplies and associated costs with subcutaneous versus intravenous solutions were obtained. Hydromorphone was found to be stable for 28 days in both dilutants. Cost analysis of a hydromorphone 28-day supply resulted in substantial savings over the equivalent costs of morphine infusions.

Superior labral anteroposterior lesions: MR arthrography with arm traction

OBJECTIVE

The purpose of this study was to investigate the efficacy of arm traction combined with MR arthrography in the evaluation of superior labral anteroposterior (SLAP) lesions.

MATERIALS AND METHODS

Cadaveric shoulders were studied with a 1.5-T MR imaging unit with the arm externally rotated. Fifteen milliliters of a gadolinium-containing contrast agent were injected into the glenohumeral joint. Twenty-four sets of images of cadaveric joints were evaluated independently by two observers. These sets consisted of MR arthrographic images obtained with traction (applied to the wrist using 1- to 3-kg weights) and without traction in five shoulders in which SLAP lesions had been excluded arthroscopically or by cadaveric sectioning; and MR arthrographic images obtained with and without traction in seven shoulders in which various types of SLAP lesions had been created arthroscopically and later confirmed by cadaveric sectioning.

RESULTS

Analysis of the data indicated that MR arthrography in combination with arm traction and external rotation improved diagnostic accuracy with regard to identification and categorization of SLAP lesions when compared with studies made without traction.

CONCLUSION

The combination of MR arthrography and arm traction with the shoulder in external rotation provides a more effective approach for detection of SLAP lesions than does similar MR arthrography performed without arm traction.

Changes in ABA and gene expression in cold-acclimated sugar maple

To determine if cold acclimation of sugar maple (Acer saccharum Marsh.) is associated with specific changes in gene expression under natural hardening conditions, we compared bud and root translatable mRNAs of potted maple seedlings after cold acclimation under natural conditions and following spring dehardening. Cold-hardened roots and buds were sampled in January when tissues reached their maximum hardiness. Freezing tolerance, expressed as the lethal temperature for 50% of the tissues (LT(50)), was estimated at -17 degrees C for roots, and at lower than -36 degrees C for buds. Approximately ten transcripts were specifically synthesized in cold-acclimated buds, or were more abundant in cold-acclimated buds than in unhardened buds. Cold hardening was also associated with changes in translation. At least five translation products were more abundant in cold-acclimated buds and roots compared with unhardened tissues. Abscisic acid (ABA) concentration increased approximately tenfold in the xylem sap following winter acclimation, and the maximum concentration was reached just before maximal acclimation. We discuss the potential involvement of ABA in the observed modification of gene expression during cold hardening.

Effects of soil freezing and drought stress on abscisic acid content of sugar maple sap and leaves

In 1991 and 1992, mature maple trees (Acer saccharum Marsh.) were freeze-stressed or drought-stressed by preventing precipitation (snow or rain) from reaching the forest floor under selected trees. Lack of snow cover caused a decrease in soil temperature to well below 0 degrees C from December to April and a lowering of the soil water content to 10%. The abscisic acid (ABA) concentration in the spring sap of deep-soil frost-stressed trees was significantly higher than in control or drought-stressed trees. The increase in ABA concentration in the xylem sap in the spring of 1991 and 1992 preceded symptoms of canopy decline and a decrease in leaf area that were observed during the summers of 1991 and 1992. These results suggest a role for ABA in root-to-shoot communication in response to environmental stress. The largest differences in ABA concentration induced by the treatments was found in sap collected at the end of sap flow. The increase in ABA concentration in spring sap at the end of the sap flow could be used as an early indicator of stress suffered by trees during the winter. Not only did the increase in ABA concentration occur before any visible symptoms of tree decline appeared, but the trees that showed the most evident decline had the highest ABA concentrations in the spring sap. Leaf ABA concentration was not a good indicator of induced stress.