Determinants of circulating calcitonin value: analysis of thyroid features, demographic data, anthropometric characteristics, comorbidities, medications, and smoking habits in a population with histological full exclusion of medullary thyroid carcinoma

Objective

Calcitonin (Ctn) measurement is crucial for the early diagnosis of medullary thyroid carcinoma (MTC). However, Ctn levels can be skewed/elevated due to other reasons, and the Ctn upper reference value remains controversial. In this field, studies have heterogeneous settings, published data are controversial, and no evidence has been achieved. The study's aim was to evaluate all previously investigated Ctn determinants in a population with histological exclusion of MTC.

Methods

The institutional records from 2010 to 2022 were reviewed to select patients with thyroid nodules who had undergone total thyroidectomy with histological exclusion of MTC and who had tested for Ctn just before surgery. Thyroid features, demographic and anthropometric data, comorbidities, medications, and lifestyle information were collected. Univariate and multivariate analyses were performed.

Results

A total of 127 cases were included. The median age for thyroidectomy was 51 years. Median Ctn was 1.04 pg/mL (interquartile range (IQR) 1.04-2.77), with two cases having values above 10 pg/mL. In univariate analysis, Ctn was correlated with gender (p < 0.001), body weight (p = 0.016), height (p = 0.031), body surface area (p = 0.016), thyroid size (p = 0.03), thyroglobulin (p < 0.001), and chronic kidney disease (p < 0.001). After multivariate analysis, the model with the highest accuracy included gender, chronic kidney disease, and thyroid-stimulating hormone (TSH) with an adjusted R-squared of 0.4.

Conclusions

This study demonstrates, in a population histologically proven as MTC-free, that the Ctn value is mainly influenced by gender, anthropometric/thyroid features, and chronic kidney disease, with the further impact of TSH.

Modification of the Surgical Strategy for the Dissection of the Recurrent Laryngeal Nerve Using Continuous Intraoperative Nerve Monitoring

BACKGROUND

The aim of this study was to describe first experiences and changes in management using continuous intraoperative neuromonitoring (C-IONM) in thyroid and parathyroid surgery.

METHOD

Retrospective analysis of patients who underwent surgery with C-IONM since 2012. Surgical maneuvers were modified when electrophysiologic events occurred. Patients with persistent loss of signal (LOS) underwent postoperative laryngoscopy.

RESULTS

One hundred and one patients (of 1586 neck surgeries) were included and 19 had events: In 13 these were temporary (resolved before end of surgery) and led to intraoperative modifications in surgical approach; in all cases traction was released, and in 8, recurrent laryngeal nerve (RLN) approach was changed [superior approach (2), inferior approach (2), both (4)]. Six patients had persistent LOS (5.9%, present at end of procedure), with RLN palsy (RLNP) on postoperative day 1: In three, LOS occurred at electrode placement on the vagus nerve, leading to distal placement of the electrode allowing ipsilateral dissection under continuous monitoring; all three had complete recovery at 6 months. In the three other patients, LOS occurred on the RLN: one probable thermal, one traction lesion and one accidental section of the anterior RLN branch. The RLN recovered within 6 months in two patients, and in the third, RLNP persisted after 6 months (1/101 = 1%).

CONCLUSION

C-IONM provides real-time evaluation of the RLN function, allowing for adaptation of surgical maneuvers to prevent RLNP. It seems particularly useful in difficult cases like redo neck surgery, invasive thyroid cancer and intrathoracic or large goiter. Care should be given at electrode placement on the vagus nerve.

Small bowel intussusception due to malignant melanoma: primary lesion or metastases? A case report

Intussusception is a rare condition in the adult population: it is responsible for 1% of all bowel obstructions. In most of intussusceptions a malignant tumor is involved; a lot of studies show that approximately 50% of malignant metastases causing small bowel intussusception are metastatic melanomas. In present paper a case of a small bowel intussusception probably due to metastases of an occult melanoma, in a 69-year-old patient, is presented. Surgery resection, careful research of possible primitive neoplasms and an accurate follow-up program has been the treatment of choice. All the investigations carried out did not allow to identify a possible primitive neoplasm. The last whole body PET carried out 44 months after surgery resulted disease-free.

(99m)Tc-MIBI Uptake in a Thyroid Adenoma with Diffuse Adipose Metaplasia

A 71-year-old female underwent a (99m)Tc-MIBI scan to characterize a cold nodule (30 mm) of the left thyroid lobe. The nodule showed diffuse uptake and retention of the radiotracer. After resection, histological examination demonstrated a microfollicular adenoma with diffuse white adipose metaplasia. Although mitochondria in brown adipose tissue have been widely studied, we have only a limited understanding of the relevance of mitochondria in white adipose tissue. Active mitochondria are present in white adipocytes, and this may account for the MIBI uptake, mimicking a hyperproliferation pattern, in our patient^.

Aberrant origin of the inferior thyroid artery from the common carotid artery: a rare anatomical variation

We describe the case of a rare anatomical variant of the inferior thyroid artery (ITA) taking its origin directly from the common carotid artery (CCA) instead of the thyrocervical trunk (TCT). This anatomical feature exposes to risks of perioperative bleeding and nerve injuries when it is unrecognized by the surgeons. Knowledge of its existence may be helpful to reduce risks for the patient.

A giant adrenal pseudocyst mimicking an adrenal cancer: case report and review of the literature

Adrenal pseudocysts are rare lesions that develop within the adrenal glands, generally from vessel ectasia or from degenerative adenomas or hematomas. They are usually non-functional and asymptomatic. The reported potential malignant transformation of an adrenal cyst is ca. 7% and indicates radical excision of these masses. We report the case of a 69-year-old man with hypertension, chronic obstructive pulmonary disease, and obesity in whom microscopic hematuria was detected during a routine examination performed by his family doctor. To investigate the cause of this microscopic hematuria, the patient underwent computed tomography of the abdomen, which showed a well-defined 12-cm lesion of the left adrenal gland with calcification and necrotic components that was compressing the left kidney, pancreas, and spleen. Suspecting adrenal carcinoma, after preoperative staging, a left subcostal laparotomy was performed, with resection of the left adrenal gland, a splenectomy, and resection of the pancreatic tail. The histology showed an adrenal pseudocyst with a fibrous capsule containing amorphous eosinophilic material with calcification and cholesterol crystals. The patient's postoperative course was uneventful, and he was discharged 12 days after surgery.