Serum thyroglobulin is used as part of the early postoperative assessment of differentiated thyroid cancer (DTC) since there is a clear relationship between an increased risk of recurrence and persistent disease after initial treatment and high postoperative stimulated thyroglobulin (ps-Tg) values. Thus, although ps-Tg above 10-30 ng/mL is considered an independent predictor of worse prognosis, the value that is associated with distant metastases is not defined. Thus, this was our objective. We selected 655 DTC patients from a nuclear medicine department database (Irmandade Santa Casa de Misericórdia de São Paulo, Brazil). All patients had received total thyroidectomy and radioactive iodine (RAI) therapy and had ps-Tg values higher than 10 ng/mL with negative anti-thyroglobulin antibodies. Then, we selected patients who presented post-therapy whole-body scan with pulmonary and/or bone uptake but with no mediastinum or cervical uptake. Patients with negative findings on functional imaging or any doubt on lung/bone uptake were submitted to additional exams to exclude another non-thyroid tumor. Of the 655 patients, 14.3% had pulmonary and 4.4% bone metastases. There was a significant difference in ps-Tg levels between patients with and without metastases (Po0.001). The cutoff value of ps-Tg was 117.5 ng/mL (sensitivity: 70.2%; specificity: 71.7%) for those with lung metastasis, and 150.5 ng/mL (sensitivity: 79.3%; specificity: 85%) for those with bone metastasis. The cutoff value for patients with eitherpulmonary or bone metastasis was 117.5 ng/mL (sensitivity: 70.2%; specificity: 83.7%). Our findings demonstrated that ps-Tg could predict distant metastasis in DTC patients. We identified a cutoff of 117.5 ng/mL with a high negative predictive value of 93.7%.

Objective: We aimed to evaluate the impact of minimal extrathyroidal extension (mETE) alone on the risk of recurrence of papillary thyroid carcinoma (PTC). The impact of other factors, including multifocality, age, tumor size, and stimulated thyroglobulin (sTg) values was also assessed. Subjects and methods: We retrospectively analyzed 1,108 PTC patients from a medical institution, who presented tumors ≤ 4 cm without any adverse characteristics other than mETE. Patients were classified according to their response to initial treatment 12 to 24 months after surgery as proposed by the 2015 American Thyroid Association (ATA) guideline. Statistical analysis was performed using multivariate logistic regression and receiver operating characteristic (ROC) curve. Results: In the multivariate logistic regression analysis, mETE did not have an impact on the response to initial treatment (p = 0.44), similar to multifocality, age, and tumor size. Initial Tg value was the only variable associated with a poor response (p < 0.01, odds ratio = 1.303, 95% confidence interval 1.25-1.36). The ROC analysis revealed that Tg was significant (area under curve = 0.8750); the cutoff value of sTg as a predictor of poor response was 10 ng/mL (sensitivity = 72.2%, specificity = 98.5%). Conclusion: For low-risk PTC presenting mETE as the only aggressive feature, the initial sTg value is essential to identify patients who may have a poor response after initial treatment and benefit from further treatment.

Background: Intrathoracic meningocele is a relatively rare condition, with 60 to 85% of cases being associated with neurofibromatosis type 1. In most cases, meningoceles are small and asymptomatic, and regular follow-up with periodic imaging is recommended without a surgical approach. Most patients become symptomatic between 30 and 50 years of age. Surgical treatment is indicated only when there is an accelerated growth of the meningocele or when the patient presents intense symptoms due to the compression of adjacent structures. Clinical Case: CRSG, 39 years old, female, with non-consanguineous parents. Patient referred to Endocrinology at age 20 by dermatology with the diagnosis of neurofibromatosis made because of the presence of cutaneous neurofibromas and cafe au lait spots. Her father had neurofibromatosis and C-cell hyperplasia diagnosed after total thyroidectomy, and the genetic analysis of RET oncogene was negative. During follow-up, patient evolved with complaints of paresthesia in bilateral upper limbs and mechanical type cervicalgia. In cervical spine MRI, dural ectasia was observed from C4 to T2 levels, with enlargement of the vertebral canal and remodeling of the posterior wall of the vertebral bodies. In parallel, the patient had a diagnosis of primary hyperparathyroidism with serum calcium of 10.7mg/dL(8.6-10.2), vitamin D 29.8ng/dL(>20), PTH 115pg/ml(15-65) and serum phosphorus of 2.2mg/dL(2.8-4.1), and normal renal function. 99mTc-sestamibi scan showed an increased parathyroid gland posterior to the superior pole of the right lobe of the thyroid. After discussion of the case with Neurosurgery and Neuroradiology, it was then hypothesized as a cervical-thoracic meningocele and opted for conservative treatment followed by serial imaging, due to the high surgical risk and little clinical compromise of the patient at the time. Subsequently, she evolved with nausea, intermittent vomiting that made her need daily antiemetic medication. We considered the hypotheses of emesis secondary to hypercalcemia and/or secondary to cerebrospinal fluid hypotension caused by meningocele. Treatment with pamidronate was initiated and the patient and is still under evaluation for probable intracranial cerebrospinal fluid hypotension. Conclusion: Neurological complaints are common during the follow-up of patients with neurofibromatosis and their differential diagnosis is of great importance for adequate therapeutic management. Regarding the main tumor lesion, in addition to the mentioned meningocele in the case, it should be differentiated from neurofibroma, neuroblastoma, ganglioneuroma and cystic hygromas of the posterior mediastinum. Reference: Huang TW, Huang HP, Ye QY, et al. A neurofibromatosis type 1 patient with thoracic encapsulated fluid and intracranial hypotension syndrome: a case report. Neurologist 2011;17:167-171.

Background: The thyroid storm is a rare disorder characterized by multisystem involvement and high mortality rates. A high index of suspicion should be maintained in patients with thyrotoxicosis associated with evidence of systemic decompensation. Case Presentation: A 25 year old male was referred to an endocrine clinic with the diagnose of Graves disease, complained about 34kg weight loss, goiter, diarrhea, palpitation and exophthalmia, his hormonal profile showed TSH <0.05 uUI/mL (0.4-5.8), T4l >7.77 ng/dl (0.7-1.8), TRAb 25.2 UI/L, T3>651,0 ng/dl; Methimazole 20mg/day, and Propanolol 120mg/day were introduced at that appointment. After a month the patient was admitted at Santa Casa de São Paulo hospital as a result of orquiepididymitis and jaundice. He evolved 48hs after the admission with respiratory insufficiency, fever and tachycardia. Propylthiouracil 200mg 4/4hs, Lugol 8/8hs, dexamethasone, Tazocin, Meropenem, Vancomicine were introduced by the internal medicine team. The laboratory profile showed: total bilirubin 11.4, direct 10.4, RNI 2.06, AST 40, ALT 46, hemoglobin 10.7, hematocrit 33.4, leucocytes 7800 (86,7% neutrophils), plaques 128.000. Transthoracic echocardiogram revealed diffuse hypokinemia, mainly antero-septal, FE=38%, moderated left ventricle eccentric hypertrophy. After 48hs the endocrine team discontinued thionamide drugs, lithium and plasmapheresis was indicated. The patient did 3 session of plasmapheresis, the day after the first section he was extubated, and his hormonal scan revealed TSH 0.01 (0.4-5.8), T4l 1.04 (0.7-1.8), at that day. After recovering from the infection a total thyroidectomy was performed, and levothyroxine 1.0mcg/kg/day was introduced. The patient had post-operative hypoparathyroidism and is takin calcitriol, calcium carbonate and cholecalciferol. Conclusion: A multimodality treatment approach should be used. Therapeutic plasma exchange (TPE) is a potential therapeutic option for thyroid storm, but its indication is not well established. The literature contains few reported cases and no clear guidelines about indication criteria and best time to start. When there are threatening symptoms, TPE should be done early, without waiting for the efficiency of conventional treatment. It’s effect can be explained by the rapid decline of plasma hormones and antibodies responsible for Graves’ disease. It is a relatively safe therapy, although it has a high cost. Monitoring the thyroid hormones is interesting, but clinical improvements are often dissociated from the hormonal levels and must be mainly judged on the patient’s condition.

Background: Intracranial teratomas are rare and comprise about 0.5% of all intracranial tumors. Actually, a total of 15 cases of sellar-suprasellar teratoma have been described in the last 26 years. Teratomas occur more frequently in children and young adults than in the older population and in males as compared to females. Symptoms at diagnosis are usually neurological defects, diabetes insipidus, and hypopituitarism. Teratoma diagnosis can be suggested through neuroimaging findings. Magnetic Resonance Imaging (MRI) remains the preferred modality. Neuro-radiological findings of mixed-density mass, usually with mixed cystic and solid components inclusions of teeth, fat, and calcification can be suggestive. Tumor markers as beta-HCG and alpha-FP can be useful. Optimal treatment for mature teratoma is neurosurgical excision and in cases of immature teratomas or mixed germ cells tumors teratomas, a multi-step treatment is required with neurosurgical excision, adjuvant or neo-adjuvant radiotherapy and chemotherapy. Clinical Case : A 15-year-old woman, with a headache, secondary amenorrhea, syncope, progressive visual loss, polydipsia, and polyuria due to diabetes insipidus. A craniopharyngioma or another parasellar mass was suspected, an MRI showed an expansive suprasellar process with a cystic component with chiasm compression. A hormone panel showed corticotrophic and thyrotrophic deficiencies. Hormone replacement was started and the patient was referred for surgery. The immediate postoperative progressed well, although one month later she presented recurrence of the compressive symptoms (a headache and visual loss). She was submitted to second surgery. According to the pathology, the mass was identified as a suprasellar immature teratoma, with germ component, as well as cystic areas (ki67: 80%). In addition, tumor markers tests were requested: beta-HCG 5.47mIU/mL (<5.0), alpha-FP 3.1ng/mL (<7.0), DHL 635U/L (240-480). The patient was staged and referred to oncology unit that indicated radiotherapy, as a postoperative adjuvant therapy. At the most recent follow-up, approximately 9 months later, MRI shows a residual, stable tumor and patient presents with bitemporal hemianopsia. Conclusion: Intracranial germ cell tumors are uncommon, with only 15 cases of sellar-suprasellar teratoma described in the literature. It is important to recognize this entity in the differential diagnosis once they mimic many other lesions. Future reports on this rare location for a teratoma may help ascertain long-term outcomes. Reference: Chiloiro, S., Giampietro, A., Bianchi, A., & De Marinis, L. (2015). Clinical management of teratoma, a rare hypothalamic-pituitary neoplasia. Endocrine, 53(3), 636-642. doi:10.1007/s12020-015-0814-4