Utilizing Dynamic Risk Stratification in Patients With Tall Cell Variant Papillary Thyroid Cancer

OBJECTIVES

Tall cell variant (TCV) papillary thyroid cancer (PTC) is a subtype of PTC associated with aggressive tumor behavior, advanced stage, and higher rates of recurrence and mortality. The present study aimed to test an established dynamic risk stratification tool in the TCV population, with the goal of better predicting the postoperative course of these patients.

STUDY DESIGN

Retrospective chart review.

METHODS

A total of 94 patients with TCV who underwent total thyroidectomy with radioactive iodine ablation were retrospectively reviewed from 1998 through 2020. Biochemical, structural, and overall response to treatment was determined for each patient, based on postoperative thyroglobulin levels and imaging findings. Primary outcomes were locoregional and distant recurrence, presence of disease at final follow-up, need for additional intervention, and disease-specific mortality.

RESULTS

Patients with TCV who were stratified as having an excellent overall response to treatment had lower rates of locoregional recurrence than indeterminate, biochemical incomplete, and structural incomplete responses (2.0%, 33.3%, 55.0%, and 85.7% at 5 years respectively, p < 0.001). The same was true for distant recurrence as well (2.0%, 9.0%, 35.1%, and 42.9%, p < 0.001). An excellent response was also associated with lower rates of presence of disease at final follow-up, need for additional intervention, and disease-specific mortality.

CONCLUSIONS

Although TCV is an aggressive subtype associated with worse clinical outcomes than classical PTC, patients with an excellent overall response to treatment have significantly improved outcomes when compared to indeterminate, biochemical incomplete, and structural incomplete responses.

LEVEL OF EVIDENCE

3 Laryngoscope, 133:2430-2438, 2023.

Elevated hCG can be a benign finding in perimenopausal and postmenopausal women

In a perimenopausal or postmenopausal woman, an elevation in human chorionic gonadotropin (hCG) can raise the concern of malignancy or even pregnancy, but it can also be a benign physiologic finding due to production in the pituitary gland in this patient population. Diagnosing the underlying cause of hCG elevation can be challenging, especially if a pituitary source is not considered. Pituitary hCG production remains largely underrecognized and can lead to unnecessary testing, harmful therapy such as chemotherapy, or delay in receiving appropriate care for other unrelated diseases. It is therefore important to establish guidelines to aid medical evaluation.

Use of SGLT-2 Inhibitors in Patients With Type 1 Diabetes Mellitus

Introduction: Sodium-glucose cotransporter 2 (SGLT-2) inhibitors are the newest class of oral antihyperglycemic medications approved for the treatment of type 2 diabetes mellitus (DM2). Although they are not approved for use in type 1 diabetes mellitus (DM1), SGLT2 inhibitors may help DM1 patients achieve their HbA1c goals by decreasing their insulin requirements, without inducing hypoglycemic episodes and weight gain. Methods: We conducted a retrospective chart review of 26 patients with DM1 treated with off-label SGLT-2 inhibitors. The primary objective was change in HbA1c and weight. The secondary objective was assessing the effect on insulin requirements, blood pressure, and lipid profile. Results: Improvement in HbA1c level was seen in 20 of the 26 patients (77%) after initiation of SGLT-2 inhibitors. The average decrease in HbA1c was 0.32% (P = .032), with changes seen as early as 1 month posttherapy and maintained with continued SGLT-2 inhibitor use. There was a trend toward weight loss that was not significant. No significant changes in blood pressure or lipid profiles were seen except for a slight increase in low-density lipoprotein (P = .049). No patient developed euglycemic diabetic ketoacidosis. Three patients discontinued therapy due to uncontrolled genital yeast infections. Conclusion: SGLT-2 inhibitors can be a useful adjunctive therapy in patients with DM1 to improve glycemic control and weight. Although our study did not show any significant changes in the metabolic profile and insulin requirements in these patients, a larger sample size may yield different results.

PSEUDOHYPONATREMIA IN THE SETTING OF HYPERCHOLESTEROLEMIA

Objective

To describe a case of pseudohyponatremia in the setting of hypercholesterolemia.

Methods

A 69-year-old man was admitted to the hospital after asymptomatic hyponatremia was detected on follow-up blood work for acute, drug-induced cholestatic hepatitis.

Results

Plasma sodium (P_Na) was 119 mmol/L and total protein was 4.7 g/dL. Plasma osmolality was 283 mOsm/kg, urine osmolality was 332 mOsm/kg, and random urine sodium was 45 mmol/L. Pseudohyponatremia was suspected and lipid profiling showed triglycerides were 281 mg/dL, cholesterol was 1,340 mg/dL, high-density lipoprotein was 21 mg/dL, and low-density lipoprotein was 1,419 mg/dL. Direct ion-selective electrode (ISE) using a blood gas analyzer revealed a P_Na level of 132 mmol/L. P_Na concentration can be measured using direct or indirect ISE. With indirect ISE, the sample is diluted before analysis and the P_Na is measured with the assumption that plasma is composed of 93% water. When hyperlipidemia is present, the actual plasma water fraction is decreased, and therefore using indirect ISE will result in falsely low P_Na levels. Direct ISE analyzes the sample without dilution. Thus, the P_Na is measured directly irrespective of plasma water fraction and so is not affected by changes in plasma percentage concentration.

Conclusion

Around two thirds of laboratories in the United States use indirect ISE. Awareness of pseudohyponatremia is important to prevent inappropriate management.

Iron Overload Leading to Torsades de Pointes in β-Thalassemia and Long QT Syndrome

The authors present a unique case of torsades de pointes in a β-thalassemia patient with early iron overload in the absence of any structural abnormalities as seen in hemochromatosis. Genetic testing showed a novel KCNQ1 gene mutation 1591C>T [Gln531Ter(X)]. Testing of the gene mutation in Xenopus laevis oocytes showed loss of function of the IKs current. The authors hypothesize that iron overload combined with the KCNQ1 gene mutation leads to prolongation of QTc and torsades de pointes.