ostoperative venous thromboembolism (VTE) is a significant source of morbidity, mortality, and cost. 1,2 Colorectal surgery patients are at particularly high risk for VTE due to positioning during surgery, pelvic dissection, and other conditions often found in these patients, such as cancer and inflammatory bowel disease. 3 A National Surgical Quality Improvement Program (NSQIP) analysis demonstrated an overall rate of VTE in colorectal surgery patients of 2.4%, although other studies have demonstrated rates up to 9%, even in those receiving appropriate chemoprophylaxis. 4-6 Many of these VTEs occur in the postdischarge setting. In a NSQIP study of colorectal surgery patients, the rate of VTE between discharge and 30 days was 0.47%. 7 The cost burden for a postoperative VTE has been estimated to be more than $18,000. 8 Studies from NSQIP have identified multiple factors associated with VTE in colorectal surgery patients, but NSQIP does not record ambulation as a standard variable. 9 Multiple strategies have been implemented to reduce postoperative VTE. Often, these studies focus on increasing compliance with appropriate chemoprophylaxis, risk stratification, or bundling multiple strategies. 10,11 However, despite the fact that postsurgical ambulation is widely encouraged and recommended by the American Society of Colon and Rectal Surgeons clinical practice guidelines, there is little evidence demonstrating the role of ambulation alone in the reduction of VTE. 4,12 The purpose of this study was to create a multidisciplinary
Differentiated thyroid cancer (DTC) is the most common endocrine malignancy and papillary thyroid carcinoma (PTC) accounts for a majority of these. Distant metastases, especially to the lung and bones, occur in about 10% of patients, who can still survive for many years. We report here the case of a 32 year old female who presented with multiple bilateral cervical lymphadenopathy, diagnosed as metastatic PTC on cytology. She underwent total thyroidectomy and bilateral radical neck dissection followed by radioiodine therapy. Subsequently she developed pulmonary and bone metastases, and during the course of successive radioiodine doses, presented with multiple, painless cutaneous and subcutaneous nodules which proved to be metastatic on cytopathology and immunostaining. Radioiodine uptake was not seen in these lesions, suggesting dedifferentiation of follicular cells. This case emphasizes three clinically important issues-firstly, although extremely rare, cutaneous nodules can represent metastatic PTC in patients with pre existing lung and bone lesions and portends a poorer prognosis. Secondly, these lesions may be dedifferentiated and hence not amenable to radioiodine therapy although the bone and lung lesions show radioiodine uptake. SPECT/CT helps us in determining if uptake of 131-I is in the skin lesions or underlying other sites. Redifferentiating agents may play a role in management of such disease. Lastly, immunostaining with CK19 and Thyroglobulin (Tg) can be highly useful to confirm the pathologic diagnosis.
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