P55 A CHALLENGING RIGHT ATRIAL MASS

A 64–year–old woman presented at the Emergency Department with worsening dyspnoea and fever. Blood tests revealed normal white blood count, elevated C–reactive protein (244 mg/L) and D–dimer (2618 ng/mL). At arterial blood gases test hypoxaemia and hypocapnia was found (pH 7.48, pO2 83 mmHg, pCO2 30 mmHg, base excess –1.2 mmol/L, lactates 1.0 mmol/L). She underwent thoracic computed tomography (CT), which showed right inferior pulmonary embolism with infarction. A transthoracic echocardiography (TTE) revealed the presence of a mobile heterogeneous iso–hyperechoic neoformation completely occupying the right atrial cavity and moving partially across the tricuspid valve (Figure 1). A right atrial thrombotic formation was hypothesized and, due to its dimension, despite a valid hemodynamic, the patient underwent thrombolysis with rtPA 100 mg iv infusion over 2 hours. However, the next day at CT and TTE the mass was still there and unmodified. The screening for thrombophilia and for cancer markers were negative. Cardiac magnetic resonance imaging was waived because the clinical conditions were rapidly deteriorating. Indeed, the patient was transferred for urgent cardiac surgery. The excised mass was 5 cm x 3.5 cm large and adherent to the right atrial roof, 1 cm close to the atrioventricular node. It was completely removed by the cardiac surgeon (Figure 2). The subsequent journey was regular, without complications. The histologic exam revealed that the mass was a giant myxoma (Figure 3). At follow–up the patient persisted asymptomatic. Figure 1. Transthoracic echocardiography. Figure 2. The excised right atrial mass. Figure 3. Histologic examination of the right atrial mass.

P226 LONGITUDINAL EVALUATION OF CONGESTION AND RENAL FUNCTION IN ADVANCED HEART FAILURE PATIENTS TREATED WITH A LEFT VENTRICULAR ASSIST DEVICE

Introduction

In patients affected by advanced heart failure (advHF) long term mechanical support with left ventricular assist devices (LVADs) is a established therapeutic option. Congestion and renal function in pts treated with a LVAD require expert management.

Aim

Describe the longitudinal trend of congestion and renal function during a 12th follow–up in advHF pts treated with a LVAD, examine the correlation between congestion and renal function, study predictors of sustained improvement of congestion and renal function.

Methods

retrospective single–centre analysis of 39 pts treated with a LVAD and followed in ASST–PG23 Hospital for at least 12 months. Biochemical, echocardiographic and clinical parameters were collected at specific time points from baseline to 12 months after hospitalization during which a LVAD was implanted. Congestion was studied with BNP, bilirubin, haematocrit and daily diuretics dosage. Renal function was studied with absolute changes of eGFR (Cockcroft–Gault). Primary endpoint was sustained improvement of congestion and renal function, derived after comparing baseline pre–LVAD and 12th month parameters.

Results

congestion improved early after LVAD implantation, with steep and high reduction of BNP, bilirubin and daily diuretics dosage. The improvement was higher in those pts with a baseline BNP>median. Bilirubin, haematocrit and daily diuretics dosage showed statistically significant correlations with BNP. Sustained improvement of congestion was present in 59% pts, in particular in those with higher baseline BNP (p = 0.04 after χ²–test). Renal function showed an early steep improvement from baseline pre–LVAD to discharge, more significant in those pts with baseline CKD; during the following months renal function did not show significant changes. Sustained improvement of renal function was present in 54% pts, in particular in those with baseline CKD (p = 0.002 after χ²–test). No significant correlations were found after comparing the trend of congestion and renal function. At multivariable logistic regression, no significant predictors were found for sustained improvement of congestion or renal function.

Conclusions

A multiparametric evaluation of congestion in pts with a LVAD is feasible. The benefit derived from LVAD support appears to be higher in those pts with a baseline higher risk, both in term of congestion and renal function. No significant correlation between the trend of congestion and renal function was found.

C15 DOES THE DISTANCE BETWEEN RESIDENCY AND IMPLANTING CENTER AFFECT THE OUTCOME OF PATIENTS SUPPORTED BY LEFT VENTRICULAR ASSIST DEVICE? A MULTICENTER ITALIAN STUDY ON RADIAL MECHANICALLY ASSISTED CIRCULATORY SUPPORT (MIRAMACS) ANALYSIS

Background

Patients with LVAD require continuous monitoring and care, and since Implanting Centers (IC) are more experienced in managing LVAD patients than other health care facilities, the distance between patient residency and IC could negatively affect the outcomes.

Methods

Data of patients discharged after receiving a LVAD implantation between 2010 and 2021 collected into the MIRAMACS database were retrospectively analyzed. The population was divided into two groups: A (n = 175) and B (n = 141), according to a distance between patient residency and IC ≤ or >of 90 miles. The primary end–point was freedom form Adverse Events (AEs), a composite outcome composed by death, cerebrovascular accident, hospital admission because of GI bleeding, infection, pump thrombosis or right ventricular failure. Secondary end–points were incidences of mortality and complications. All patients were followed–up regularly, according to participating centers protocols, by means of clinical visits, telemonitoring and local care–sharing.

Results

Baseline clinical characteristics and indications for LVAD did not differ between the two groups (Figure 1). Mean duration of support was 25.5±21 months for Group A and 25.7±20 months for Group B (p = 0.79). At 3 years, freedom from AEs was similar between Group A and B (p = 0.32, Figure 2), and there were no differences in rates of mortality and LVAD–related complications (Figure 2).

Conclusions

Distance from the IC does not represent a barrier to successful outcome, as long as regular and continuous follow–up is provided. Telemonitoring could offer several benefits, including early detection of complications and continuous evaluation of patient conditions and data of the pump. Moreover, it seemed to reduce the patient anxiety related to the device, increasing direct communication with the VAD–team. On the other hand, shared health programs with local facilities remains an attractive way to follow–up patient, provided that LVAD specific resources and trained staff are available. The dissemination of LVAD–specific care knowledge is also important to face urgent or emergent needs in the rapidly enlarging population of LVAD patients, by empowering local healthcare facilities.

X-ray scanning microscopies of microcalcifications in abdominal aortic and popliteal artery aneurysms

Abdominal aortic and popliteal artery aneurysms are vascular diseases which show massive degeneration, weakening of the vascular wall and loss of the vascular tissue functionality. They are driven by inflammatory, hemodynamical factors and biological alterations that may lead, in the case of an abdominal aortic aneurysm, to sudden and dangerous ruptures of the arteries. Here, human aortic and popliteal aneurysm tissues were obtained during surgical repair, and studied by synchrotron radiation X-ray scanning microdiffraction and small-angle scattering, to investigate the microcalcifications present in the tissues. Data collected during the experiments were transformed into quantitative microscopy images through the combination of statistical approaches and crystallographic methods. As a result of this multi-step analysis, microcalcifications, which are markers of the pathology, were classified in terms of chemical and structural content. This analysis helped to identify the presence of nanocrystalline hy-droxy-apatite and microcrystalline cholesterol, embedded in myofilament, and elastin-containing tissue with low collagen content in predominantly nanocrystalline areas. The generality of the approach allows it to be transferred to other types of tissue and other pathologies affected by microcalcifications, such as thyroid carcinoma, breast cancer, testicular microli-thia-sis or glioblastoma.

Comparison of growth factor and interleukin content of adult peripheral blood and cord blood serum eye drops for cornea and ocular surface diseases

INTRODUCTION

Various blood-derived products have been proposed for the topical treatment of ocular surface diseases. The aim of the study was to compare the different content of Growth Factors (GFs) and Interleukins (ILs) in peripheral blood (PB-S) and Cord Blood (CB-S) sera.

MATERIALS AND METHODS

Sera were obtained from 105 healthy adult donors (PB-S) and 107 umbilical/placental veins at the time of delivery (CB-S). The levels of epithelial-GF (EGF), fibroblast-GF (FGF), platelet-derived-GF (PDGF), insulin-GF (IGF), transforming-GF alpha (TGF-α,) and beta 1-2-3 (TGF-β1-β2-β3), vascular endothelial-GF (VEGF), nerve-GF (NGF), Interleukin (IL)-1β,IL-4,IL-6,IL-10, and IL-13 were assessed by Bio-Plex Protein Array System (Bio-Rad Laboratories, CA, USA). The Mann-Whitney test for unpaired data was applied to compare GFs and ILs levels in the two sources. The associations among each GF/IL level and the obstetric data for CB-S and hematological characteristics for PB-S were also investigated.

RESULTS

The levels of EGF, TGF-α, TGF-β2, FGF, PDGF, VEGF, NGF, IL-1B, IL-4, IL-6, IL-10, and IL-13 were significantly higher in CB-S compared to PB-S. Conversely, the levels of IGF-1, IGF-2, and TGF-β1 were significantly higher in PB-S. The female sex and the weight of the child showed a significant association in predicting EGF and PDGF levels.

CONCLUSION

A significantly different content in those GFs and ILs was demonstrated in the two blood sources. Since each GF/IL selectively regulates different cellular processes involved in corneal healing, the use of PB-S or CB-S should be chosen on the basis of the cellular mechanism to be promoted in each clinical case.

Therapeutic Possibilities of 131I-Mibg in Metastatic Carcinoid Tumors - Preliminary Report

The poor results of traditional therapy in advanced carcinoid tumors and the well-proven uptake of 131I-MIBG shown by some of these tumors induced us to attempt a radiometabolic approach. We selected for the treatment 5 patients (3 men and 2 women) who showed progression of disease, a fairly good uptake of 131l-MIBG with severe related symptoms, and a poor response to traditional therapy. A cumulative radioactivity of 5.5-29.6 GBq was given. Acute side effects after 131l-MIBG ad ministration or late radiation-induced damages were not observed. Symptoms increased during the first 2-4 weeks in 2 patients: in one of these relief was achieved with drugs. Results concerning objective remission of the disease were unsatisfactory. In contrast, definite improvement of symptoms was shown in 2 of 5 patients, resulting in a better quality of life.

Body Fluid Spaces in Patients on CAPD

Total body water (TBW) and extracellular water (ECW) were determined in 9 CAPD patients on treatment from 5 to 14 months (mean 8.6 months).

The mean value of TBW was normal and directly correlated to body weight, but TBW was abnormally distributed between extracellular and intracellular space. ECW volume was significantly lower than the predicted value (12.1 ± 1.4 I versus 16.8 ± 1.9 I) and out of proportion to TBW (34.8 ± 3.9% versus 47.8 ± 1.5%). The calculated ICW, therefore, appeared clearly hyperexpanded.

The data suggest that cell overhydration was the distinctive feature in our CAPD patients.

Sentinel Node Biopsy in Breast Cancer: The Experience of Brescia Civic Hospital

The accuracy of the sentinel node technique in the evaluation of axillary node involvement in breast cancer was evaluated in 83 consecutive patients with monofocal T1–2 carcinoma, who were clinically N0 and who underwent lymphoscintigraphy with 99mTc-colloid integrated with intraoperative sentinel node detection by a portable probe. Lymphoscintigraphy revealed at least one sentinel node in 75 patients (90.4%), always identified by the probe. In eight patients (9.6%) the sentinel node was detected neither by lymphoscintigraphy nor by the probe. All removed lymph nodes were analyzed by hematoxylin-eosin histology and the sentinel node by immunostaining. In 28/75 patients (37.3%) at least one metastatic axillary lymph node was detected; in 16 of the 28 N+ subjects (57%) only the sentinel node was positive. The false negative rate (sentinel node negative/other axillary lymph nodes positive) was 17.85% (5/28 patients). In 9/23 patients (39%) micrometastases were found in the sentinel node only. In conclusion, specific sentinel node positivity in 57% of cases supports the validity of the sentinel node concept. Moreover, nine patients would have been considered No by standard hematoxylin-eosin histology without sentinel node-aided immunostaining. A 17.8% false negative rate calls for caution in patients with negative sentinel nodes.

Effects of processing on structural, mechanical and biological properties of collagen-based substrates for regenerative medicine

The aim of this work was to investigate the structural features of type I collagen isoforms and collagen-based films at atomic and molecular scales, in order to evaluate whether and to what extent different protocols of slurry synthesis may change the protein structure and the final properties of the developed scaffolds. Wide Angle X-ray Scattering data on raw materials demonstrated the preferential orientation of collagen molecules in equine tendon-derived collagens, while randomly oriented molecules were found in bovine skin collagens, together with a lower crystalline degree, analyzed by the assessment of FWHM (Full Width at Half Maximum), and a certain degree of salt contamination. WAXS and FT-IR (Fourier Transform Infrared) analyses on bovine collagen-based films, showed that mechanical homogenization of slurry in acidic solution was the treatment ensuring a high content of super-organization of collagen into triple helices and a high crystalline domain into the material. In vitro tests on rat Schwannoma cells showed that Schwann cell differentiation into myelinating cells was dependent on the specific collagen film being used, and was found to be stimulated in case of homogenization-treated samples. Finally DHT/EDC crosslinking treatment was shown to affect mechanical stiffness of films depending on collagen source and processing conditions.

Protective Effect of Micronized Purified Flavonoid Fraction on Ischemia/Reperfusion Injury of Rat Liver

BACKGROUND

Flavonoids have been subjected to considerable investigation because of its antioxidant and anti-inflammatory properties. However, there is no previously reported study about its effect on hepatic ischemia/reperfusion (I/R). We investigated the effects of micronized purified flavonoid fraction (MPFF) on hepatic I/R injury in rats.

METHODS

Thirty rats were recruited in the study as follows: group A, sham operation (n = 10); group B, I/R (n = 10); and group C, I/R+MPFF (n = 10). In group C, rats received (80 mg/kg/day) MPFF by gavage for 3 days before surgery, 30 minutes before ischemia and just before the reperfusion. Blood samples were taken, and serum aspartate aminotransferase (AST), alanine aminotransferase (ALT), and lactate dehydrogenase (LDH) levels were measured to assess liver functions. Liver tissues were taken for histological evaluation and to determine the total antioxidant capacity (TAC), catalase (CAT), total oxidant status (TOS), oxidative stress index (OSI), and myeloperoxidase (MPO).

RESULTS

The present data showed a decrease in AST, ALT, and LDH levels in the MPFF-treated rats when compared with I/R group rats (P < .001 for all). In the MPFF-treated rats, tissue levels of TOS, OSI, and MPO were significantly lower than those in the I/R group (P < .01, P < .001, and P < .05, respectively). Increases in TAC and CAT levels were statistically significant in the MPFF-treated rats compared with the I/R group (P = .01 for both). On the other hand, MPFF attenuated histological alterations that were induced by I/R.

CONCLUSIONS

The present study demonstrates that MPFF ameliorates I/R-induced liver damage, probably through antioxidant and anti-inflammatory properties.

Sequential left pneumonectomy and right upper lobectomy for hemoptysis in post-tuberculosis destroyed lung and aspergilloma

The case of a 30-years-old man from Angola who was referred with a history of previous tuberculosis at the age of 14, recurrent hemoptysis and a radiological picture of destroyed left lung and shrunken right upper lobe containing a fungus ball is presented. After careful functional evaluation the patient underwent sequential left pneumonectomy and right upper lobectomy due to the fear of massive and possibly fatal hemoptysis. Both operation were well tolerated and had an uneventful postoperative course. There was no significant difference between his postoperative and his preoperative functional status. The patient is now living an active life with only seven lung segments.

Survival Following Complete Resection of Multifocal T4 Node-Negative NSCLC: A Retrospective Study

BACKGROUND

Multifocal NSCLC in the same lobe are staged as T4. This study was designed to assess the impact of multifocal NSCLC in the same lobe on survival in completely resected node-negative patients to determine whether the T4 (stage III B) designation is valid.

METHOD

We reviewed our database from October 1987 through 2004 to identify completely resected patients with N0 multifocal (T4) NSCLC. Patients with multifocal pure bronchiolo-alveolar carcinoma were excluded. Thirty-two patients had multifocal NSCLC in the same lobe and were node-negative.

RESULTS

Five-year survival rate was 42.4 % for the whole group with a median survival of 48 months. When tumors were staged independently of the satellite nodule/s, patients in stage I A had a 5-year survival rate of 55 % while those in stage I B had a rate of 22 %.

CONCLUSION

Patients with N0 multifocal intralobar NSCLC should be upstaged but not to stage IIIB. They should undergo complete surgical resection whenever multiple nodules are detected preoperatively.

Surgical treatment of complicated pilonidal disease: limited separate elliptical excision with primary closure

OBJECTIVE

We aimed at treating complicated pilonidal sinus (PS) patients by a simple and effective surgical procedure.

METHOD

Between 2000 and 2004, 24 selected complicated PS patients were treated with 'limited separate elliptical excision and primary closure'. Patients with extensive or bilateral gluteal involvement, having more lateral, caudal or cephalic sinuses, multiple recurrences and unhealed chronic wounds after pilonidal surgery were included. Asymmetric excision and primary closure was performed to main diseased tissue in the midline. Additionally, small separate elliptical excisions with primary closure were performed in other involved tissues. The fistula tract or granulation tissue were excised subcutaneously if present. All patients were operated under local anaesthesia. The fascial attachments between the skin and coccyx were released at the deep point in the midline and at one side of wound. Suction drains and prophylactic antibiotics were used; subcutaneous tissues were closed with running polyglactin sutures and skin with polypropylene subcutaneously.

RESULTS

The mean age of patients was 28.4 years (range 18-38). The mean follow-up time was 2.8 years. One recurrence, one seroma, one wound infection and one wound breakdown were recorded. Healing was always by first intention except in patients with wound infection and breakdown.

CONCLUSION

Most of the complicated PS patients can be operated with acceptable rates of recurrences and complications by using 'limited separate elliptical excisions with primary closure'.

Preliminary results of G versus GViElC: A phase III trial of gemcitabine associated to vindesine or gemcitabine alone in elderly or poor performance patients with advanced non-small cell lung cancer (NSCLC)

17083

Background: Monochemotherapy with gemcitabine (GEM) or vinorelbine is considered the standard treatment in elderly or poor performance (PS) patients (pts) with advanced NSCLC. Many topics report a synergic enhancement of antitumor effect of GEM if associated to Vindesine (VDS). The aim of this study is to evaluate if GEM combined to VDS produces an advantage in terms of overall survival (OS) compared to GEM alone without enhancement of toxicity. Methods: Chemonaive pts with stage IIIB/IV NSCLC, aged ≥ 70 years with PS < 2 or aged < 70 years with PS > 2 were enrolled. Pts were randomized to receive either GEM 1200 mg/m2 day 1 and 8 every 21 days for three cycles (arm 1) or GEM 1000 mg/m2 and VDS 3 mg/m2 (max dose 5 mg) both drugs infused on day 1 and 8 every 21 days for three cycles (arm 2). Pts of both arms received other three cycles in case of responsive or stable disease. Overall survival (OS) was the primary end-point, secondary end-points were time-to-progression and toxicity. First interim analysis was planned at 120 pts enrolled. Results: From May 2002 to December 2005, 107 pts from 13 Italian institutions were enrolled. Their characteristics are: 24 stage IIIB and 83 stage IV, 79 pts with ≥ 70 years (ECOG PS 0–1) and 28 pts with < 70 years (ECOG PS > 2). In arm 1 there were enrolled 55 pts while 52 pts in arm 2: both arms were well balanced with pts characteristics. Conclusions: The enrollment of this phase III trial is ongoing: we are achieving first step for an interim analysis to assess if GEM associated to VDS produces an advantage in terms of OS compared to standard treatment as GEM in monochemotherapy without toxicity enhancement. (Supported by GIVOP: Gruppo Interdisciplinare Veronese di Oncologia Polmonare).

No significant financial relationships to disclose.

Vascular Tissue Banking: State of the Art

INTRODUCTION

The cardiovascular homograft banks in Italy were set up in 1994 in Milan (Lombardia) and Treviso (Veneto) and in 2001 in Bologna, Emilia Romagna. In this study we briefly summarize the data from Emilia Romagna Cardiovascular Tissue Bank.

MATERIAL AND METHODS

In Emilia Romagna, vascular homografts were harvested from brain-dead multiorgan donors (aged 15-55 years) by a dedicated vascular surgery team. All donors were virologically screened for human immunodeficiency virus (HIV), hepatitis B and C, Treponema pallidum, cytomegalovirus (CMV), and Toxoplasma. After transferring the vascular homografts to Emilia Romagna Cardiovascular Tissue Bank facilities, the arteries were prepared, classified (class III to I), and transferred to an antibiotic-containing solution under a laminar flow cabinet. After the decontamination, all homografts were cryopreserved and stored in the vapour phase of liquid nitrogen. Microbiological tests were performed in all phases of preparation. Samples were routinely taken from 1 vessel and formalin fixed for the histology. Bags with cryopreserved homografts were sent in dry ice to the hospitals when required and thawing protocol of the Bank was included.

RESULTS AND CONCLUSIONS

From January 2002 to October 2004, 543 homografts from 125 heart-beating donors were harvested and transferred to Emilia Romagna Cardiovascular Tissue Bank. After preparation, 459 of 543 (85%) were cryopreserved and stored. Vascular homografts classified class I were discarded. Other criteria of rejection were: (1) positive serology, and (2) persistent positive microbiology after decontamination. From March 2002, 333 cryopreserved homografts were assigned to several vascular surgery departments in Italy. The assessment of 3-year activity of Emilia Romagna Cardiovascular Tissue Bank might be used as an indicator of the efficiency of selecting, cryopreserving, and allocating quality-controlled vascular homografts.

Combined 99mTc-ECD SPECT and neuropsychological studies in MCI for the assessment of conversion to AD

Identifying pre-clinical Alzheimer's disease (AD) in subjects with mild cognitive impairment (MCI) is a major issue in clinical diagnosis. Establishing a combination of predictive markers from different fields of research might help in increasing the diagnostic accuracy. Aim of this study was to evaluate the potential role of 99mTc-ECD single photon emission computed tomography (SPECT) and memory scores in predicting conversion to AD in MCI subjects. Thirty-one MCI subjects underwent a clinical and neuropsychological examination, and a regional cerebral blood flow (rCBF) SPECT scan at baseline. Subjects had been followed periodically through 2 years in order to monitor the progression of cognitive symptoms. Canonical variate analysis of principal components was able to separate all subjects who converted to AD from those who remained stable, the former being characterized by a specific hypometabolic pattern, involving the parietal and temporal lobes, precuneus, and posterior cingulate cortex. Canonical correlation analysis of combined baseline memory deficits and rCBF SPECT images identified pre-clinical AD with a sensitivity and specificity of 77.8%. The pattern of hypoperfusion 99mTc-ECD SPECT and the severity of memory deficits predict the risk of progression to probable AD dementia in MCI subjects.

The use of flexible spiral drains after non-cardiac thoracic surgery. A clinical study

OBJECTIVE

After an observational study on 50 patients determined the efficacy and safety of a small calibre (19F), flexible, fluted spiral drains with round cross-section after non-cardiac thoracic surgery we undertook a prospective study to compare these drains to standard chest drains also in terms of pain using a Visual Analog Score.

METHODS

One hundred consecutive patients who had to undergo non-cardiac chest surgery either by thoracotomy or by VATS were randomly assigned to receive small calibre drains with round cross-section (group A) or the standard chest drains (group B) to drain the pleural space. Drains were connected to a unitized chest drainage system. Pain was assessed using a Visual Analog Scale (VAS) 0-100.

RESULTS

The amount of fluid evacuated daily in patients who received the spiral drains was as much as 1150 ml, that of patients who received standard drains was as much as 950 ml. In no case did spiral drains have to be replaced with standard tubes. In group A first drain was removed after a mean of 3.4 days and the second after a mean of 5.9 days; in group B after a mean of 4.1 and 6.1 days, respectively. Patients were discharged after a mean of 8.5 days in group A (SD 4.04) and 8.1 days in group B (SD 4.76). There were no drains-related complications in both groups. The drains-related pain for the patient was significantly less for patients with spiral drains compared to standard drains at rest, during cough induced by respiratory therapists and at the time of removal.

CONCLUSIONS

Spiral drains proved to be at least as safe and effective as conventional tubes after lung surgery; they allowed for evacuation of large amounts of blood/fluid as well as air, and were associated with minimal discomfort.

Isolated metastasis of malignant melanoma into follicular carcinoma of the thyroid gland

A 38-yr-old woman with a history of malignant melanoma (MM) presented with a thyroidal nodule. Fine needle aspiration biopsy of the thyroid was consistent with metastatic MM. The patient underwent thyroidectomy: microscopic examination revealed a follicular carcinoma nodule harboring a focus of metastatic melanoma. On review of the fine needle aspiration biopsy specimen, the population of cells with more uniform nuclei with focal follicle formation, which initially was interpreted as cells originating from normal thyroid tissue, was seen to actually represent the follicular carcinoma component. Tumor-to-tumor metastasis is an interesting phenomenon and there are only few cases of MM metastasis to other tumors. MM metastasis into a neoplastic thyroid nodule is a very rare combination and may be explained because the nodule in question represents the most highly vascularized component of the thyroid.