Published online: 2020-12-31

Letters to Editor

the ipsilateral thyroid lobe, adjacent musculature, level VI lymphatic tissue. Intraoperative monitoring of intact PTH with a significant drop (>50%) has proved accurate in reflecting an optimal resection.[2] The histological diagnosis of PTC, based on the Schantz and Castleman criteria published in 1973, include trabecular pattern, thick fibrous bands, mitotic figures, necrosis, capsular invasion, and angioinvasion.[4] Recently, immunohistochemistry with negative staining for parafibromin and/or positive for protein gene product 9.5 is being related to malignancy. Recurrent PTC is suspected when serum calcium rises. Although complete cure is unlikely, recurrent disease should also be treated surgically. The role of radiotherapy is not well‑defined. The data from MD Anderson group and mayo clinic suggests that adjuvant radiotherapy appears to increase disease free survival.[5] The prognosis of PTC is extremely variable, depending on early diagnosis and success of initial surgical procedure. Figure 1: Sesta‑methoxyisobutylisonitrile scan showing abnormal focal soft tissue density anterior to the medial end of right clavicle Conclusion clavicle [Figure 1]. This was reminiscent of recurrence in the This case report has shown that it’s preferable to have a high endoscopic tract. She underwent wide local excision of the index of suspicion for PTC in patients with severe forms metastatic deposit and the tract with left hemithyroidectomy of primary hyperthyroidism, than to miss the opportunity and the central compartment clearance. Histopathology for surgical cure in the first go. Furthermore, this limits revealed a metastatic deposit of PTC with infiltration into the applicability of minimally invasive surgery for primary thyroid parenchyma. The initial pathology was reviewed and hyperthyroidism, warranting a proper selection of patients showed features consistent with a benign . undergoing these procedures. 1 Parathyroid carcinoma results in severe and Shreya Bhattacharya, Harit K. Chaturvedi , Andleeb Abrari1, Biswajyoti Hazarika1 complications from recurrence and metastatic spread. Patients Department of Head and Neck Surgery and , Amrita Institute

usually present with a severe form of hyperparathyroidism, of Medical Sciences and Research Centre, Kochi, Kerala, 1Department of such as bone disease, renal disease or hyperkalcemic crisis. Surgical Oncology, Max Cancer Centre, Max Superspeciality Hospital, According to the literature, diagnosis of PTC must be based on Saket, New Delhi, India the concurrence of the following evidence:[1,4] Correspondence to: Dr. Shreya Bhattacharya, • Concomitant renal and bone disease E‑mail: [email protected] • Palpable neck mass References • Elevated serum calcium levels (14-16 mg/dl) 1. Cheah WK, Rauff A, Lee KO, Tan W. Parathyroid carcinoma: A case series. • Elevated PTH (>500 pg/ml and often >1000 pg/ml) Ann Acad Med Singapore 2005;34:443‑6. • Recurrent laryngeal palsy from direct tumor invasion. 2. Digonnet A, Carlier A, Willemse E, Quiriny M, Dekeyser C, de Saint Aubain N, et al. Parathyroid carcinoma: A review with three illustrative With a sensitivity of 91% MIBI scintigraphy may be a valid cases. J Cancer 2011;2:532‑7. tool to assess the presence and localization of PTC.[2] FNAC 3. Dytz MG, Souza RG, Lázaro AP, Gonçalves MD, Vidal AP, dos Santos may not be effective and should be avoided to prevent capsular Teixeira Pde F, et al. Parathyroid carcinoma and oxyphil parathyroid [3] adenoma: An uncommon case of misinterpretation in clinical practice. rupture and seeding of tumor cells. Frozen section may assist Endocr J 2013;60:423‑9. in the diagnosis, but subtle pathological findings may overlap 4. Johnson SJ. Changing clinicopathological practice in . with benign disease.[4] Histopathology 2010;56:835‑51. 5. Munson ND, Foote RL, Northcutt RC, Tiegs RD, Fitzpatrick LA, Grant CS, [2] Surgery is the only effective and curative treatment of PTC. et al. Parathyroid carcinoma: Is there a role for adjuvant radiation therapy? It should be performed as “en bloc” tumor resection with Cancer 2003;98:2378‑84.

Unusual etiology of secondary thyrotoxicosis delay in diagnosis.[2] We report a rare case of thyrotoxicosis and its presentation due to metastatic nonseminomatous germ cell tumor (NSGCT) of testis that highlights the importance of a systematic clinical DOI: 10.4103/2278-330X.149954 and biochemical assessment. Dear Editor, A 48‑year‑old man presented with persistent gradual The incidence of clinical hyperthyroidism has been reported back pain for 2 months with inconclusive magnetic as 0.8/1,000 women per year, and it is less common in resonance imaging (MRI) findings, so lumbar spondylitis men.[1] Causes of thyrotoxicosis include Grave’s disease, toxic was assumed and started on symptomatic treatment. On multinodular goiter, toxic adenoma, and thyroiditis. Rarely, laboratory results, patient showing primary hyperthyroidism thyrotoxicosis can arise as a paraneoplastic syndrome. In this (triiodothyronine (T3) 14.2 ng/dL, thyroxin (T4) 138 µg/dL, setting, systemic symptoms of underlying malignancy may be and thyroid stimulating hormone (TSH) 0.14 μIU/mL) was wrongly attributed to primary hyperthyroidism leading to a treated with radioiodine thyroid ablation in absence of 46 South Asian Journal of Cancer ♦ January-March 2015 ♦ Volume 4♦ Issue 1 Letters to Editor hyperthyroidism signs and symptoms based upon enhanced high concentration of HCG in occasional germ cell tumors diffuse thyroid tracer uptake on thyroid scan mimicking Grave’s can overcome its low‑binding affinity of the alpha subunit for disease. TSH receptor for inducing secondary hyperthyroidism. There is On appearance of palpable supraclavicular lymph node, palpable lag time between elevated thyroid hormone levels and clinical mass in the left upper abdominal quadrant and enlarged right evidence of hyperthyroidism.[4] Despite lack of standard guidelines side testis with secondary hydrocele were detected on systemic for management of paraneoplastic hyperthyroidism, symptomatic examination, which were probably missed on initial evaluation. hyperthyroidism should be treated immediately with β‑adrenergic Fine needle aspiration cytology of supraclavicular lymph node receptor antagonist and antithyroid drugs for better tolerability showed a germ cell tumor. Human chorionic gonadotropin (HCG; of chemotherapy.[3,5,6] The treatment of the underlying cancer 57,220 mIU/L), alfa fetoprotein (193 U/L), and lactate is definitive treatment of paraneoplastic hyperthyroidism. In dehydrogenase (777 U/L) were markedly elevated. Final diagnosis conclusion, this case highlights the importance of a comprehensive of carcinoma testis, NSGCT, stage III C, poor prognosis risk clinical history and systematic physical examination including group with paraneoplastic hyperthyroidism was arrived upon genitals for all patients presenting with hyperthyroidism. and started upon two cycles of PEB (cisplatin, etoposide, Acknowledgments bleomycin) chemotherapy. Patient underwent high inguinal right Nalini Kilara has revised the manuscript critically and gave final side orchiectomy after two cycles of PEB chemotherapy, and on approval of the version to be published. histopathological examination, presence of mixed germ cell tumor with predominantly (90%) and choriocarcinoma (5%) Consent elements was diagnosed. His tumor marker values were decreased Written informed consent was obtained from the subject on chemotherapy with recovery of thyroid function with thyroxin for publishing this case report and accompanying images. supplementation [Table 1]. Two more cycles of PEB chemotherapy Vinayak V. Maka, S. Murali, Nalini Kilara with surgical excision of residual disease was planned. Department of Medical Oncology, M S Ramaiah Medical College, MSRIT Paraneoplastic hyperthyroidism is a rare but recognized Post, Bangalore, Karnataka, India phenomenon associated with NSGCT and high‑serum HCG Correspondence to: Dr. Vinayak V. Maka, E‑mail: [email protected] levels, although the exact prevalence is unknown. In one large References prospective cohort analysis study of 144 patients, Oosting 1. Vanderpump MP, Tunbridge WM, French JM, Appleton D, Bates D, Clark F, et al., reported hyperthyroidism to be present in 3.5% of the et al. The incidence of thyroid disorder in the community: A twenty‑year patients with disseminated NSGCT and almost 50% in patients follow‑up of the Whickham Survey. Clin Endocrinol (Oxf) 1995;43:55‑68. with high‑serum HCG levels (>50,000 IU/L).[3] Exceedingly 2. McCracken EJ, Johnston PC, Lindsay JR, Mulholland C, McAleer JJ, Black RN. Testicular choriocarcinoma: An unusual case of paraneoplastic thyrotoxicosis. QJM 2012;105:675‑7. Table 1: Serial tumor markers showing progressive 3. Oosting SF, de Haas EC, Links TP, de Bruin D, Sluiter WJ, de Jong IJ, et al. decline in their levels in response to chemotherapy and Prevalence of paraneoplastic hyperthyroidism in patients with metastatic orchiectomy non‑seminomatous germ‑cell tumours. Ann Oncol 2010;21:104‑8. Baseline 1st PEB 2nd PEB Post orchiectomy 4. Oppenheimer JH. Thyroid hormone action at the nuclear level. Ann Intern Med 1985;102:374‑84. AFP 4,000 193 63 5. Kellner O, Voigt W, Schneyer U, Dempke W, Schmoll HJ. HCG induced Beta HCG 57,220 10,000 1,000 hyperthyreosis in germ cell cancer. Anticancer Res 2000;20:5135‑8. LDH 700 Normal Normal 6. Meister LH, Hauck PR, Graf H, Carvalho GA. Hyperthyroidism due to PEB=Cisplatin, etoposide, bleomycin, AFP=alpha fetoprotein, HCG=human chorionic secretion of human chorionic gonadotropin in a patient with metastatic gonadotropin, LDH=lactate dehydrogenase choriocarcinoma. Arq Bras Endocrinol Metabol 2005;49:319‑22.

A retrospective analysis of occupational radiation, chronic inflammation like lupus erythematosus, exposure to pesticides as a possible risk factor lichen planus, genetic condition like xeroderma pigmentosum, for non-melanoma skin cancers and thermal burns. Recently photosensitizing agents have been shown to increase the risk of NMSC in population at DOI: 10.4103/2278-330X.149955 risk.[4] Patients with history of exposure to pesticides are at the Dear Editor, increased risk of developing cancers. In rural India, the practice Occupational exposure to ultraviolet (UV) radiation is a of using pesticides with bare hands and feet results in direct known risk factor in the causation of non‑melanoma skin contact with pesticides, which might be a risk factor for the cancer (NMSC). Squamous cell carcinoma and basal cell development of NMSC. Skin is the most exposed organ while carcinoma are commonly described as NMSCs. The incidence handling pesticides by cultivators. In this series, a retrospective of NMSC is high in western countries with an incidence of study of the epidemiology of NMSCs was done to identify around 100 per 100 000 individuals in Europe and 99 per possible high risk group of patients who develops NMSC. 100 000 individuals in Australia.[1,2] The exact incidence of skin The data of patients with NMSC have been obtained from the cancer in India is not known. Exposure to UV radiation is a hospital cancer registry of a regional cancer center in eastern known risk factor in the development of malignant melanoma of India for the period of January 2010 to December 2011. A total of the skin and NMSC. The association of occupational exposure 124 (n) histologically confirmed patients with NMSC were found in to UV radiation and NMSC has been demonstrated.[3] Other the database and have been included for this retrospective analysis. factors responsible for NMSC include exposure to arsenic, Parameters like gender, occupational history, and site distribution of tar (occupational exposure and therapeutic coal tar), ionizing NMSC were retrospectively analyzed. The occupational history was South Asian Journal of Cancer ♦ January-March 2015 ♦ Volume 4♦ Issue 1 47