A 54-year-old woman underwent total thyroidectomy for a one-year history of anterior neck mass. The specimen was a 29.88–gram thyroid gland that on sectioning showed a single 2.0 x 1.5 x 1.5 cm encapsulated nodule with tan-brown solid cut surfaces noted on the right thyroid lobe. No gross lesions were noted on sectioning of the isthmus and left thyroid lobe. Microscopic examination showed a thinly encapsulated nodule composed of tightly-packed follicles. (Figure 1) Examination of the entire capsule did not show capsular or vascular invasion. The follicles were lined by follicular cells that had crowded and enlarged nuclei with pale chromatin and some nuclear membrane irregularities such as grooving. (Figure 2) There were no papillae, psammoma bodies, necrosis, mitotic figures and solid or trabecular architecture seen. Based on these features, the diagnosis rendered was non-invasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTP). NIFTP is a term adopted in 2016 to replace the nomenclature of a thyroid tumor previously termed “non-invasive encapsulated follicular variant of papillary thyroid carcinoma (FVPTC)”.1 In the most recent edition of the World Health Organization (WHO) Classification of Tumors, NITFP is considered a low-risk follicular cell-derived neoplasm whose definition also reflects the diagnostic criteria of this tumor.2

A 57-year-old woman with a 2-year history of a left infra-auricular mass with no associated symptoms presented with a 6.0 cm ´ 4.0 cm ´ 3.0 cm firm, non-tender, movable mass. No imaging was done. Fine needle aspiration biopsy (FNAB) revealed sheets of epithelial cells that had abundant dense grayish-blue cytoplasm in a mucinous background with abundant lymphocytes (Figure 1), suggestive of salivary gland neoplasm with oncocytic or oncocytoid features (Category IVB, Salivary Gland Neoplasm of Uncertain Malignant Potential).1 Total parotidectomy revealed a 4.3 X 3.2 X 3.0 cm deep lobe lesion with a tan-grey to dark brown, smooth and dull external surface. Cut sections showed a cream-white to pink, lobulated, heterogenous cut surfaces. Microscopically, the lesion was unencapsulated with poorly demarcated borders. The neoplastic cells were arranged in haphazard sheets and surrounded by abundant lymphocytes. The tumor cells had abundant eosinophilic and granular cytoplasm compatible with oncocytes with mild to moderate nuclear atypia. There were occasional cystic spaces that contained mucin though mucocytes were not readily apparent. (Figure 2) Necrosis, perineural and lymphovascular space invasion or anaplasia were not evident.

Abstract Introduction: Simultaneous hypersecretion of both catecholamines and cortisol in one adrenal tumor is rarely seen because cortical cells, which produce cortisol, and medullary cells, which secrete catecholamines, are derived from different germ layers1. Formidable challenges ensue from a tumor with a complex behavior. We demonstrate here the clinical course and multi-modal management of the case of an adrenocortical adenoma which had neuroendocrine differentiation accounting for the excess of both catecholamine and cortisol hormones in a patient with multiple neoplasms. Clinical Case: An adrenal mass was incidentally discovered in a 61-year old female undergoing imaging as part of the metastatic work-up for an esophageal mass. The patient has insulin-requiring diabetes mellitus, hypertension and a history of breast cancer. A right adrenal gland mass, avidly enhancing, measuring 3.8 x 2.7 x 2.7 cm was found on abdominal imaging. The 24-hour urine metanephrine collections were done, and these were more than twice elevated in two instances at 2.516 mg/24 hours and 2.101 mg/24 hours (NV: 0–1 mg/24 hours). An unsuppressed cortisol level at 6.57 μg/dL (NV: ≤ 1.8 μg/dL) was obtained after the 1 mg dexamethasone suppression test. Hypercortisolism was confirmed with an elevated 24-hour urine free cortisol at 312.07 μg/24 hours (NV: 20–90 μg/24 hours). Adrenocorticotrophic hormone (ACTH) was low at 0.90 pg/ml, indicative of the presence of an adrenal form of Cushing’s. Primary aldosteronism was ruled out based on a ratio between plasma aldosterone concentration and plasma renin activity of less than 20. Pre-operative alpha blockade with terazosin was initiated. Right adrenalectomy was done. Histopathology revealed an adrenal mass of cortical origin, atypically staining positively for synaptophysin, which is indicative of neuroendocrine differentiation of the tumor. The patient had better blood pressure and glycemic control after the adrenalectomy. Clinical Lessons: An adrenocortical adenoma very seldom undergoes neuroendocrine differentiation. Pathophysiologic mechanisms include a genetic aberration in cortical cells leading to production of catecholamines2. This case underscores the importance of a comprehensive biochemical evaluation of a patient with an adrenal mass because control of hormonal hypersecretion is essential in reducing cardiovascular risks, morbidity and mortality. References: 1Duan L, Fang F, Fu W, et al. Corticomedullary mixed tumor resembling a small adrenal gland-involvement of cancer stem cells: case report. BMC Endocr Disord. 2017;17(1):9. Published 2017 Feb 13. doi:10.1186/s12902-017-0157-7.2Donatini G, Van Slycke S, Aubert S, Carnaille B. Corticomedullary mixed tumor of the adrenal gland-a clinical and pathological chameleon: case report and review of literature. Updates Surg. 2013 Jun;65(2):161–4. Epub 2012 Jan 7. PMID: 22228558.

BACKGROUNDSpinal tuberculosis may present in atypical form to involve only the posterior spinal element with relative sparing of the anterior vertebral body and intervertebral disc. Recognition of this unusual pattern is important to avoid delay in diagnosis and treatment.OBSERVATIONSThe authors report a case of a 59-year-old woman with right-sided radiculopathy and motor weakness. Her lumbosacral magnetic resonance imaging showed a large heterogeneous cyst arising from the right L4–5 facet joint. Laminectomy with excision of the cyst was performed. During surgery, the cyst contained cheese-like material that, on histopathological examination, revealed focal aggregates of tuberculous granuloma. Postoperatively, the patient recovered remarkably with no interval development of instability or any deformity.LESSONSFacet cyst tuberculosis is rare but should be considered in the differential diagnosis in patients coming from endemic regions. Laminectomy with excision of the cyst along with concurrent antitubercular chemotherapy is a safe and durable treatment option in this case.

Background and Significance of the StudyBrain tumors is a large group of benign and malignant neoplasms arising from the brain parenchyma and its adjacent structures [1].Though considered to be uncommon, with less incidence compared to neoplastic processes of the prostate, lungs, breast and colon, it is among the significant causes of cancer-related deaths [2,3].It is associated with a high level of physical, neurological, cognitive and psychosocial changes [4].The worldwide incidence of brain tumors is 3.4 to 18.6 per 100,000 and is reported to have an increasing trend in the last decades Background: Brain tumors, although affecting only a small percentage of the population, poses a large impact worldwide with its high incidence of morbidity and mortality.In the turn of the century, we have witnessed major breakthroughs in the diagnosis and management of patients with brain tumors that is largely becoming molecular-based and personalized.In developing countries like the Philippines, major efforts are yet to be made in order to deliver the ideal treatment modalities to patients with brain tumor, yet certain socio-cultural factors and the lack of standardized protocol limit and even hinder this goal.Hence, it is important to be able to describe our patient population and to determine if they were able to receive adequate treatment in order to pave the way to further identification of ways to clinical improvement in the future.Objectives: This study aims to describe the clinical characteristics of patients diagnosed with brain tumors and to identify the different treatment modalities utilized to treat them in the Philippine General Hospital from January 2010 to December 2015.Methodology: Between 2010 and 2015, a total of 262 medical records of adult patients with brain tumors were successfully retrieved.The demographic data, clinical presentation, performance status, histopathologic diagnosis and treatment of all patients were recorded.The descriptive statistics using the STATA 13.0 software was used to summarize the data obtained.Results: Majority of the patients were females (59.2%) with a mean age of 41.7 years and a mean duration of symptoms of 13.2 months.The majority of the patients (66.8%) had a KPS of 80-100.Headache, focal deficits, seizures and visual disturbances were the most common symptoms reported.Meningioma, Astrocytoma and glioblastoma were the most common histopathologic diagnosis.More than half of the patients received surgery alone (56.5%) but this is still lower than the expected number of patients who were advised to have surgery (60.7%).The use of combination therapy was found to be increasingly utilized within the duration of the study but a lower proportion of patients completed the planned treatment (13.1%).Around 10.5% of the patients only had regular follow-up to see if any progression in the tumor takes place.No intervention was done in 17.6% of patients who were noted to be either with poor prognosis, those who were lost to follow-up or those who had no consent to any intervention.Conclusion: In summary, there are multiple treatment modalities available to improve the outcome of patients with brain tumors.Although surgery alone remains to be the treatment of choice in majority of the patients, combination therapy was shown to have an increasing popularity.A lower proportion of patients received these treatment modalities than what was expected.Giving minimal or no intervention to the patient was already of decreasing trend in the institution.Further studies to determine the outcome after these treatment modalities on the patients diagnosed with brain tumors are deemed necessary in the future.