Osteonecrosis of the jaw (ONJ) and atypical femoral fracture (AFF) are rare potential adverse effects of bisphosphonates and RANKL antibody therapy. The pathogenic mechanisms of both conditions are known to be independent of each other. Here, we report both conditions sequentially occurring in the same patient.An 81-year-old, obese, diabetic, female was admitted due to hypertensive urgency and persistent jaw pain after tooth extraction. The patient has postmenopausal osteoporosis for fourteen years and was on intermittent, unsupervised treatment with alendronate, denosumab and ibandronate. Upon presentation, the patient was noted with tenderness intraorally of tooth number 35 periapical region. This was associated with elevated erythrocyte sedimentation rate and C-reactive protein. Imaging study showed presence of bony sclerosis which represent a sequestrum in the molar area of the left hemi-mandible. Antibiotic infusion and excision and debridement of left posterior mandible were done. Histopathologic finding was consistent with a diagnosis of osteonecrosis of the jaw. The same patient, upon review, had suffered sequential fracture of both femurs during the eighth and eleventh year of treatment with antiresorptive agents. The fractures were transverse, non-comminuted, at the proximal femoral shaft. Each occurred after a minor trauma and was managed with open reduction and internal fixation. Both fractures were consistent with atypical femoral fractures.ONJ and AFF can occur both in the same patient during prolonged treatment with bisphosphonates and denosumab and may suggest a common pathogenic mechanism.
The cell origin, histopathologic features, and prognosis of medullary thyroid carcinoma and papillary thyroid carcinoma are different and to have them occur simultaneously in a single patient is a rare event. Data about the simultaneous occurrence of these tumors are based mainly on case reports and series.
Granulomatous hypophysitis is an extremely rare condition, with no established definitive treatment. An elderly Asian woman was diagnosed to have recurrent granulomatous hypophysitis 5 years after transsphenoidal surgery. No other intervention was done post-operatively. Since another surgery was not advisable due to the high probability of recurrence, she was started on a trial of oral glucocorticoids. After 3 months of steroid therapy, complete resolution of symptoms and sellar mass were achieved.
Background: Squamous cell carcinoma (SCC) of the thyroid is a rare condition comprising less than 1% of thyroid cancer. SCC of the thyroid may arise from de-differentiation of aggressive thyroid carcinomas secondary to chronic thyroid gland inflammation1. Thyroid SCC is a variant of undifferentiated thyroid carcinoma and is also associated with tall-cell variant of Papillary thyroid carcinoma (PTC). Given its aggressive clinical course, early recognition of the disease is essential to management. Clinical Case: A 67-year-old, Filipino male, presented with anterior neck mass over a period of 11-months. He was clinically euthyroid. Neck ultrasound showed enlarged thyroid gland with hypoechoic left thyroid nodule (1.9cm x 1.2cm) where fine needle aspiration biopsy showed a colloid nodule. Patient then manifested with compressive symptoms, undocumented weight loss and easy fatigability. He had total thyroidectomy with histopathology consistent with Diffuse Sclerosing Variant of PTC with Squamous Differentiation, arising from chronic lymphocytic thyroiditis with extra-thyroidal extension. Immunohistochemical markers showed (+) TTF-1, (+) HBME-1 and (+) PAX – 8. Two months after thyroidectomy, he noticed palpable cervical nodes and hoarseness of voice. PET-CT scan showed hypermetabolism in the thyroid bed and tumor recurrence with 2 FDG-avid lymph nodes, on Level III with SUVS up to 8.5. RAI imaging showed functioning thyroid tissues. Patient had completion thyroidectomy with selective neck dissection within 3 months after initial surgery. Histopathology revealed Keratinizing Squamous Cell Carcinoma metastatic to lymph nodes. Molecular studies were not pursued by patient. Repeat PET/CT Scan showed rapid tumor recurrence in the left thyroid bed with strap muscle and thyroid cartilage infiltration, as well as cervical lymph node invasion. PEG insertion and prophylactic tracheostomy addressed nutritional status and airway protection, respectively. He was treated with course of external beam radiation (60 Gy in 33 fractions). He had concurrent chemotherapy with Carboplatin-Paclitaxel regimen for only 2 cycles. After 13 months of initial presentation, patient eventually succumbed to cardiac arrest. Conclusion: This transformation of the thyroid is a malignancy with high mortality, with average survival length of only less than a year. Combined modality with surgery, radiotherapy and chemotherapy to prevent disease progression and local recurrence is needed. Multidisciplinary approach is significant in the management due to its poor survival rate. References: (1)Hararah KM, Gertz JR, Sippel SR, et. Al. (2015) De-differentiation of Conventional Papillary Thyroid Carcinoma into Squamous Cell Carcinoma. Thyroid Disorders Ther 4: 192. doi:10.4172/2167-7948.1000192
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