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Limited information is available on the presentation, treatment outcomes, and prognostic factors of papillary thyroid carcinoma with lung metastases.This study retrospectively analyzed the data of 2003 patients with thyroid cancer who were treated and followed up at Chang Gung Memorial Hospital from January 1979 to December 2002. In total, 1516 papillary thyroid carcinomas were enrolled. One hundred two (6.7%) papillary thyroid carcinomas with lung metastases were followed including 57 women with mean age of 41.7 +/- 17.3 years and 45 men with mean age of 49.6 +/- 17.2 years. These patients included 52 patients with papillary thyroid carcinoma who presented with lung metastases at the time of diagnosis. The 102 cases of papillary thyroid carcinomas with lung metastases included 72 cases with lung metastases only, and 30 cases with other organ involvement.After mean follow-up periods of 8.8 +/- 0.6 years, 28 (27.5%) of the patients with lung metastasis died, while 6 improved to clinical stage I. The 5-, 10-, 15-, and 20-year survival rates in patients with papillary thyroid carcinoma without distant metastasis and in the lung metastases groups were 99.0%, 98.5%, 98.0%, 98.0%, and 91.3%, 75.0%, 64.0%, 51.2%, respectively. Comparing the Kaplan-Meier survival curves between the patients with papillary thyroid carcinomas with lung metastases only and those with multiorgan metastases demonstrates no statistically significant difference in mortality rates. However, age, gender, postoperative thyroglobulin (Tg) level and tumor size displayed statistically significant differences between the lung metastases and no distant metastasis groups. Fifty of the 102 patients with papillary thyroid carcinomas with lung metastases developed lung metastases during follow-up. Larger amounts of remnant thyroid tissues with higher Tg levels were noted in these patients compared to those without distant metastasis.The prognosis of patients with papillary thyroid carcinoma with lung metastases at time of diagnosis is the same as for those whose lung metastases are discovered later. Survival analysis demonstrates no difference between lung metastases and multiorgan metastases.

Ketoconazole is an imidazole derivative used to treat systemic and superficial mycoses by inhibiting sterol synthesis in fungi. The drug impairs steroid hormone synthesis by blocking mitochondrial P450-dependent enzyme systems. Because of its potent inhibitory effects on adrenal steroidogenesis, ketoconazole is valuable in controlling hypercortisolism. We investigated the effects of long-term treatment of this drug on three patients who had residual or recurrent Cushing's disease after surgical treatment. Ketoconazole was administered orally and adjusted according to individual response and 24-hour urinary free cortisol excretion levels. All three patients had good clinical and biochemical responses to ketoconazole therapy without adverse effects. The 24-hour urinary free cortisol levels were kept around 114.8+/-52.4 microg/24 h, 143.0+/-59.9 microg/24 h, and 122.9+/-79.9 microg/24 h, respectively (reference range, 35 to 120 microg/24 h). All three patients had follow-up magnetic resonance imaging or computed tomography of the pituitary gland, which revealed no significant changes in the sellar region. Daily ketoconazole doses ranged from 200 to 1200 mg per day. Follow-up periods were 65, 86, and 83 months, respectively. In conclusion, ketoconazole is valuable in the long-term treatment of residual or recurrent Cushing's disease when surgical treatment is contraindicated or unsuccessful.

Background: The follicular variant of papillary thyroid carcinoma (FVPTC) presents with biological and morphological features similar to papillary thyroid carcinoma. Pre-operative diagnosis of FVPTC and its clinical course is important in identifying appropriate surgical procedures. Methods: This study enrolled 85 patients, 68 females (mean age 41.4 + 13.7 years) and 17 males (mean age 50.1 + 12.3 years) with papillary thyroid carcinomas diagnosed as FVPTC. From the patient database at Chang Gung Medical Center (CGMC), 170 pure papillary thyroid carcinoma cases and 85 with minimally invasive follicular thyroid carcinomas of gender- and age-matched patients were randomly selected as control groups. All patients were categorized into high- and low-risk groups according to AMES criteria. Results: Of the three groups, 7.1% (follicular), 11.8% (FVPTC) and 34.1% (pure papillary thyroid carcinoma) of patients presented with lymph node or soft tissue invasion (P ¼ 0.0001). Additionally, 29.4, 11.8 and 2.4% of patients with follicular carcinoma, FVPTC and pure papillary thyroid carcinoma, respectively, presented with distant metastases at the time of diagnosis. Of the 85 FVPTC cases, 75 underwent pre-operative fine needle aspiration cytology (FNAC) examination at CGMC. Only 11 cases were diagnosed pre-operatively with papillary thyroid carcinomas. Kaplan‐Meier survival curves for these three groups demonstrated that follicular thyroid carcinoma had a prognosis worse than both papillary thyroid carcinomas. Conclusions: Most FVPTC cases were diagnosed as follicular neoplasm via pre-operative FNAC. In this study, FVPTC patients had a high ratio of distant metastases, few lymph node metastases and soft tissue invasion. Aggressive treatment was indicated for the high-risk FVPTC patients.

A 47-year-old woman had undergone cholecystectomy for gallstones in December 1994 at a local hospital. In December 1995 she presented at the surgical outpatient department with intermittent right upper quadrant pain. Laboratory studies revealed serum albumin 4.3 g/dl (normal 3.5–5.3 g/dl), total cholesterol 307 mg/dl (normal The patient underwent choledocholithotomy with choledochojejunostomy, Roux-en-Y jejunojejunostomy, and a T-tube drainage in the common bile duct in February 1998. The liver biopsy displayed cholestasis and no cirrhotic change. Following surgery the woman was regularly followed up in the outpatient department and intrahepatic stones were removed intermittently via a T-tube. Cholangitis was noted during follow-up, and the patient received five 7-day courses of amoxicillin 1000 mg/day in divided doses from September 1998 to February 1999. The jaundice was persistent during follow up, and painful xanthomas developed on both hands and elbows in February 1999, particularly on the palmar side (Figure 1). Laboratory tests revealed significantly raised serum total cholesterol, total bilirubin, and alkaline phosphatase levels (Figure 2). Lipoprotein electrophoresis displayed that total cholesterol was 1046 mg/dl, β-lipoprotein (low-density lipoprotein) was 72.6% (normal 36–61%), pre-β-lipoprotein (very low-density lipoprotein) was 15.7% (normal 2–30%), and α-lipoprotein (high-density lipoprotein) was 11.7% (normal 22–48%). Subsequently, the patient received no more amoxicillin, and the xanthomas gradually regressed. Total regression of hypercholesterolaemia and xanthomas was achieved in November 2000, at which point total serum cholesterol was 200 mg/dl, total bilirubin was 12 mg/dl, and alkaline phosphatase was 676 U/litre.