Search Results (106)

Background/Objectives: Developing high-performance artificial intelligence (AI) models for rare diseases like malignant bone tumors is limited by scarce annotated data. This study evaluates same-modality cross-domain transfer learning by comparing an AI model pretrained on chest radiographs with a model trained from scratch for detecting malignant bone tumors on knee radiographs. Methods: Two YOLOv5-based detectors differed only in initialization (transfer vs. scratch). Both were trained/validated on institutional data and tested on an independent external set of 743 radiographs (268 malignant, 475 normal). The primary outcome was AUC; prespecified operating points were high-sensitivity (≥0.90), high-specificity (≥0.90), and Youden-optimal. Secondary analyses included PR/F1, calibration (Brier, slope), and decision curve analysis (DCA). Results: AUC was similar (YOLO-TL 0.954 [95% CI 0.937–0.970] vs. YOLO-SC 0.961 [0.948–0.973]; DeLong p = 0.53). At the high-sensitivity point (both sensitivity = 0.903), YOLO-TL achieved higher specificity (0.903 vs. 0.867; McNemar p = 0.037) and PPV (0.840 vs. 0.793; bootstrap p = 0.030), reducing ~17 false positives among 475 negatives. At the high-specificity point (~0.902–0.903 for both), YOLO-TL showed higher sensitivity (0.798 vs. 0.764; p = 0.0077). At the Youden-optimal point, sensitivity favored YOLO-TL (0.914 vs. 0.892; p = 0.041) with a non-significant specificity difference. Conclusions: Transfer learning may not improve overall AUC but can enhance practical performance at clinically crucial thresholds. By maintaining high detection rates while reducing false positives, the transfer learning model offers superior clinical utility. Same-modality cross-domain transfer learning is an efficient strategy for developing robust AI systems for rare diseases, supporting tools more readily acceptable in real-world screening workflows. Full article

Background: The disialoganglioside GD2, located at the plasma membrane, is selectively overexpressed in various solid tumors, where it contributes to tumor growth and the development of an aggressive tumor phenotype. Thus, over the last two decades GD2 has been gaining importance both as a tumor marker and a therapy target. In neuroblastoma, anti-GD2 monoclonal antibodies and CAR T-cells have become an integral part of the multimodal treatment for relapsed or refractory high-risk cases, which continue to associate with poor prognosis. GD2 characterization in neuroblastoma is well established for bone marrow aspirates and biopsies, but remains challenging in tumoral tissue samples, mostly due to epitope loss upon fixation. Aims: The aim of our work was to assess a new protocol by staining GD2 in tissue specimens prior to fixation. Methods: Positive controls were tissue specimens from patients with histologically confirmed neuroblastoma and GD2 expression in bone marrow aspirate (n = 5). Nephroblastoma or Hodgkin lymphoma samples were considered as negative controls (n = 5). Tissue staining was performed prior to fixation with either anti-GD2 antibody or isotype control, followed by secondary antibody staining and subsequent paraffinization. To examine GD2 staining before and after paraffinization, fluorescence images were acquired using 3D and 2D immunofluorescence microscopy techniques respectively. Results: GD2 signal was detected in all positive controls, while absent in all negative controls. After fixation, paraffinization and slicing no relevant signal loss was observed. Nevertheless, sufficient staining of 3D specimens required long incubation times, which led to increased cytolysis of the unfixed tissue. Conclusions: We were able to establish and validate a novel protocol to reliably perform immunostaining of the membrane antigen GD2 in unfixed, primary neuroblastoma tissue. Although including few limitations, this staining workflow enables relatively quick assessment of GD2 status and thus, might represent a relevant diagnostic tool within the framework of tumor staging and precision medicine. Full article

Background and clinical significance: Paget’s disease of bone involves anomalies of the bone metabolism; however, the presence of tumor-derivate abnormal parathyroid hormone (PTH) levels does not represent one of these disturbances. To our best knowledge, the association with normocalcemic variant of primary hyperparathyroidism has been limitedly reported, and here we introduce such an unusual overlap in a male suffering from osteoporosis. Case presentation: A 71-year-old, non-smoker man was hospitalized for mild, nonspecific dysphagia, asthenia, decreased appetite, and mild weight loss during the latest 2 months. His medical history included cardiovascular conditions and an abnormal PTH level with normal serum calcium under daily cholecalciferol supplements (tested twice during latest 12 months). The lab findings pointed out a normocalcemic primary hyperparathyroidism (PTH of maximum 163 pg/mL, and total calcium of 9.3 mg/dL) caused by a right parathyroid tumor of 1.2 cm, as confirmed by computed tomography (CT). Additionally, CT showed a left humerus lesion suggestive of Paget’s disease of bone, a confirmation that also came from the whole-body bone scintigraphy. The subject presented increased P1NP and osteocalcin, CrossLaps as bone formation, and resorption markers, with normal total alkaline phosphatase. CT scan also detected multiple vertebral fractures and small kidney stones. Zoledronate i.v. (3 mg, adjusted for creatinine clearance) was administered, taking into consideration all three bone ailments (Paget’s disease, high PTH/calcium, and osteoporosis) with further follow-up. Conclusions: This case highlights the following technical notes based on a real-life setting: 1. Despite the mentioned bone diseases, no bone pain was present. Loss of appetite, dysphagia, and asthenia may be a consequence of mineral metabolism disturbances. 2. The panel of blood bone turnover markers levels might be related to both hyperparathyroidism and Paget’s disease; notably, rare cases of Paget’s disease with normal alkaline phosphatase were prior reported. 3. A meticulous differentiation between secondary and primary hyperparathyroidism is required. In this instance, lack of hypocalcaemia and vitamin D deficiency was suggestive of the diagnosis of a primary variant. 4. Kidney stones, osteoporosis, and osteoporotic fractures may be correlated with both conditions, as well, while a dual perspective of the therapy, since the patient was not a parathyroid surgery candidate, included a first dose of zoledronate with consecutive long-term follow-up. To our best knowledge, the co-presence of normocalcemic variant of primary hyperparathyroidism represents an exceptional finding in a patient synchronously diagnosed with Pagetic lesions and osteoporosis complicated with vertebral fractures. Full article

Background/Objectives: Resection arthroplasty is well established in treating bone defects following tumor resection, with the distal femur and proximal tibia being its most common localizations. The aim of this study was to analyze the functional outcomes and quality of life following endoprosthetic reconstruction for malignant bone tumors of the knee joint. Methods: We retrospectively included all patients treated with an endoprosthetic reconstruction following resection of a malignant bone tumor of the knee at our institution. Functional outcomes (KOOS, OKS, MSTS, and KSS) and health-related quality of life scores [QoL] (SF-36, Karnofsky Index) were evaluated. Chi-square and Fisher’s exact test was used for categorical variables, T-test and Whitney U-Mann tests for continuous variables. Survival was calculated using the Kaplan–Meier curves. Results: 32 patients were included. A total of 12 patients had died at the time of follow-up. Among the remaining 20 patients (m:w 17:3), mean follow-up was 8.1 years (range, 8.12 ± 6.8). Mean age at the time of tumor diagnosis was 50 ± 23.3 (10–83) years. According to age, patients were divided into two groups (group C1: <29 years, group C2: >29 years). Group C1 showed significantly better results regarding functional outcome (p < 0.05). The anatomic location of the replacement and a revision surgery did not influence the functional outcome (p > 0.05). QoL showed no significant differences in subgroup analysis (p > 0.05). Primary bone tumors had a significantly better survival (primary tumor: 216.90 months [168.42–265.83]; secondary tumor: 37.03 months [11.71–62.35] p = 0.01). Furthermore, pathologic fractures were associated with significantly worse survival (pathologic fracture: 50.24 months [0.00–102.43]; pathologic fracture 190.63 moths [139.28–241.45]; p = 0.007). Conclusions: Knee resection arthroplasty can offer meaningful long-term functional outcomes and acceptable quality of life in selected patients with musculoskeletal tumors. While the rarity and heterogeneity of such cases remain a challenge, our findings contribute to the growing evidence supporting this complex but limb-sparing surgical option. Full article

Malignant giant cell tumor of bone (GCTB) is a rare malignant bone tumor. This analysis was conducted on patients with malignant GCTB at our center. The clinical, demographic, and prognostic characteristics were evaluated and compared. During 1 January 2015 to 31 December 2022, fifty patients were included in the study, which made up 3.3% of the contemporary GCTB patients. The clinical characteristics were comparable between the 24 patients with primary malignant GCTB (PMGCTB) and 26 patients with secondary malignant GCTB (SMGTCB). The tumor location was mainly at the axial and pelvic region (70%) and differed between the two types (p = 0.040). H3F3A pathogenic variant presented frequently in SMGCTB (p = 0.020). Cox regression analysis showed the prognostic outcomes were poor in those with a tumor located in the axial bone and sacrum with invasion of other places. H3F3A mutation status is also a risk factor, while chemotherapy and denosumab failed to demonstrate prognostic benefits. Malignant GCTB is a rare condition with a poor prognosis, especially in SMGTCB. The location and H3F3A mutation status had an influence on prognosis, and systemic therapy should be taken into consideration for patients with unfavorable prognostic features. Full article

The jaw bones can manifest various cysts and tumors of different origins and etiologies. Any bone lesions lacking any potential odontogenic origin might require more accurate diagnostics, adequate investigation, and careful patient anamnesis. In cases of sharply demarcated radiolucency or mixed radiolucent–radiopaque radiological appearance lesions, they can sometimes extend between the displaced tooth roots or cause their resorption. The scope of cortical bone in radiographic studies might have a different status, and lesions can spread outside of the bone. If no odontogenic feature is present, an additional blood examination for bone markers and calcium–phosphate markers is useful to establish any endocrine-related pathologies. In the primary hyperparathyroidism (PHP), bone blood markers and bone scintigraphy are very useful to establish the possible occurrence of brown tumor. On the other hand, in central giant cell granuloma (CGCG), only a direct tumor lesion biopsy might confirm the diagnosis, where in microscopic evaluation, mostly fibroblasts and secondary cells have multinucleated giant cells along with some accessory cells like macrophages, dendrocytes, and other endothelial cells. Because both lesions can have similar clinical and radiological appearances and unclear borders, with different shapes, sizes, and symptoms, it is quite important to compare both clinical and radiological patient characteristics. The authors aim to present how radiological studies alone can easily lead to lesion misdiagnosis. They also aim to emphasize how local treatment methods without advanced microsurgical reconstruction can, in some cases, improve patient outcomes. Full article

Osteosarcoma (OSA) is the most common primary bone malignancy in dogs, characterized by aggressive growth and high metastatic potential. Despite advances in treatment, the prognosis for affected animals remains poor, mainly due to metastatic disease. Metastasis is a complex process that involves forming new blood vessels in the primary tumor (angiogenesis), intravasation, the transport of cancer cells to other locations, extravasation, and the growth of cancer cells in the secondary site. Gold nanoparticles (AuNPs), due to their unique physicochemical properties, are considered promising tools in cancer therapy, both as drug delivery systems and potential anti-metastatic agents. Previously, it has been demonstrated that 500 µg/mL glutathione-stabilized gold nanoparticles (Au-GSH NPs) inhibit cancer cell extravasation—one of the steps of the metastatic cascade. This study aimed to evaluate the anti-metastatic properties of Au-GSH NPs through their influence on OSA cell migration, proliferation, and colony formation in vitro, as well as their antiangiogenic properties on the chick embryo chorioallantoic (CAM) model. Additionally, we investigated whether these effects are associated with changes in alpha-2-macroglobulin (A2M) expression, as it was previously demonstrated to play an essential role in the metastatic cascade. Au-GSH NPs significantly inhibited migration and colony formation in canine osteosarcoma cells (from OSCA-8, OSCA-32, and D-17 cell lines) at 200 µg/mL concentrations. Interestingly, at 500 µg/mL, Au-GSH NPs inhibited angiogenesis on the CAM model and cancer cell migration, but fewer colonies were formed. These results may be directly related to the higher efficiency of Au-GSH NPs uptake by OSA cells at the dose of 200 μg/mL than at the dose of 500 μg/mL, as demonstrated using Microwave Plasma Atomic Emission Spectroscopy (MP-AES). Moreover, this is the first study that demonstrates a significant increase in A2M expression in cancer cells after Au-GSH NPs treatment. This study provides new insight into the potential use of Au-GSH NPs as anti-metastatic agents in canine osteosarcoma, indicating that their anti-metastatic properties may be related to A2M. However, further in vitro and in vivo studies are needed to explore the molecular mechanism underlying these effects and to evaluate the clinical relevance of AuNPs in veterinary oncology. Full article

In children without Down syndrome who have acute megakaryoblastic leukemia (AMKL), inv(16)(p13q24)/CBFA2T3::GLIS2 is the most frequent genetic aberration. Pediatric CBFA2T3::GLIS2-positive AMKL is strongly associated with a poor prognosis and a high cumulative incidence of relapse. One of the key laboratory signs of CBFA2T3::GLIS2-positive AMKL is the RAM immunophenotype, which looks very similar to that of solid-tumor bone marrow (BM) infiltration. For this reason, in cases of isolated extramedullary involvement of CBFA2T3::GLIS2-positive AMKL, excluding solid tumors may be challenging. We report a case of a girl with isolated extramedullary CBFA2T3::GLIS2-positive AMKL relapse, which was misdiagnosed as secondary Ewing sarcoma. The morphological differential diagnosis between Ewing sarcoma and AMKL presented significant challenges owing to their overlapping histological features (small, round blue-cell morphology and similar growth patterns). The tumor cells’ immunophenotype completely mirrored that at the initial diagnosis of AMKL. Additional cytogenetic and molecular studies confirmed the presence of the CBFA2T3::GLIS2 fusion, but no Ewing sarcoma-specific EWSR1, FUS and CIC fusion transcripts were found. Thus, extramedullary CBFA2T3::GLIS2-positive AMKL relapse was confirmed. The presented case demonstrates the difficulties in differential diagnosis between AMKL relapse and the development of a secondary tumor. Full article

Background/Objectives: Aneurysmal bone cysts (ABCs) are rare bone tumors that can occur in the skull, leading to extensive bone destruction and compression of surrounding tissues. Due to the rarity of these lesions, there are limited data available in the literature, which primarily consists of case reports. We aimed to collect and analyze the available data to summarize the current state of knowledge on this rare pathology, while also conducting a statistical analysis to identify potential risk factors and management strategies. Methods: A review was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, covering studies published from January 1950 to December 2023. A total of 60 articles and 74 case reports were included. Results: The mean age at diagnosis was 14.8 ± 12.5 years, with slightly higher male gender predominance. Regarding the different skull bones, a statistically significant higher growth trend of ABCs was found at the parietal bone in the male population (p = 0.025). At the occipital bone, a significant correlation was observed with the age of incidence for symptomatic lesions (p = 0.007) and development from fibrous dysplasia (p = 0.019). Secondary lesions showed a higher frequency of complications within the first months post-surgery (p = 0.041). Conclusions: No significant correlation was found between ABCs and fibrous dysplasia (FD) or head trauma. Male patients with FD showed a higher tendency to develop an aneurysmal cyst at the occipital bone at an older age and a higher tendency for growth in ABCs at the parietal bone. However, to date, no molecular or genetic correlation with male hormones has been reported in the literature. Surgery remains the only effective treatment, but complications should be carefully considered, particularly in patients with pre-existing pathological conditions. Full article

Background: Turmeric (Curcuma longa L.) rhizomes, whose secondary metabolites include polyphenols and terpenoids, have been used medicinally for millennia. However, modern scientific inquiry has primarily focused on medicinal effects of turmeric’s polyphenolic curcuminoids, including when evaluating turmeric use to maintain bone health. Methods: Disease-specific biological effects of turmeric’s major secondary metabolites (polyphenols and/or terpenoids), with or without associated turmeric rhizome-derived polysaccharides, were determined in vivo using pre-clinical models of clinically relevant resorptive bone diseases induced by different mechanisms. These included inflammatory arthritis, cancer-driven osteolytic bone metastases, and hormone deficiency-driven post-menopausal osteoporosis. Results: In the arthritis model, the safety profile of curcuminoids alone was superior. However, curcuminoids and terpenoids each had anti-inflammatory effects and prevented bone resorption, with polysaccharide-containing curcuminoid extracts having greater effect than curcuminoids alone. In the human osteolytic breast cancer bone metastases model, curcuminoid extracts containing polysaccharides tended to yield greater effects in reducing bone osteolysis and tumor progression than curcuminoids alone or more complex extracts. In contrast, only purified curcuminoids prevented bone loss in a post-menopausal osteoporosis model, while polysaccharide-containing curcuminoid extracts were without effect. In vitro metabolite effects on disease-specific mechanistic pathways in synoviocytes, osteoclasts, or breast cancer cells were consistent with documented in vivo outcomes and included differential metabolite-specific effects. Conclusions: In summary, these findings suggest that turmeric’s potential medicinal musculoskeletal effects are complex, pathway- and target-specific, and not limited to curcuminoids, with safety concerns potentially limiting certain uses. Full article

Background: Primary malignant bone tumors are exceedingly rare, with an incidence of 0.5 to 1 per million, and sacral localization is even more uncommon, representing only 1–3.5% of these tumors. These malignancies are often diagnosed late due to their asymptomatic nature until they present as large, advanced intrapelvic tumors. Management is complicated by the need for precise surgical intervention and the consideration of adjuvant therapies based on tumor histology and patient factors. Methods: We conducted a single-center, retrospective analysis of patients who underwent complete, partial, or hemisacrectomy for primary malignant bone tumors or recurrent sacral metastases. Excluded were patients with metastatic disease not necessitating sacrectomy. Data collected included demographics, clinical characteristics, tumor types, resection status, adjuvant therapies, recurrence, metastasis, and complications. Surgical approaches were categorized as posterior, anterior, or combined anterior–posterior. The primary outcomes were overall survival and disease-free survival, while the secondary outcomes focused on complication rates and functional outcomes. Results: The study included 19 patients (7 females, 12 males) with a mean age of 48.9 years at the time of surgery. Primary malignancies were present in 90% of patients. Surgical approaches varied: 20% underwent double access and 5% anterior access only, and the remainder had posterior approaches. High partial sacrectomy (above S3) was performed in 20%, while low sacrectomy (at or below S3) was performed in 80%. Complete resection with clean margins (R0) was achieved in 65% of cases, while 35% had R1 resections with microscopic tumor remnants. Root resection was necessary in 25% of patients. Local recurrence occurred in 25% of patients, with two requiring reoperation and neurological sacrifice. Distant metastases were observed in 20% of cases. Postoperative complications affected 60% of patients. The most common issues were surgical wound dehiscence with delayed healing (35%) and visceral changes affecting the bowel and urination (25%). No mechanical complications were reported. Conclusions: Sacrectomy remains a challenging procedure with substantial morbidity and variability in outcomes. The choice of surgical approach—posterior, anterior, or combined—depends on tumor location and extent. While posterior-only approaches are often preferred for lower sacral lesions, combined approaches may be necessary for more extensive tumors. Survival and disease-free survival rates are influenced by resection margins and the biological behavior of the tumor. Wide-margin resections (R0) are associated with lower local recurrence rates but do not eliminate the risk of distant metastases. Full article

Ectopic adrenocorticotropic hormone syndrome (EAS) occurs when a tumor develops neuroendocrine differentiation with the secretion of ACTH resulting in hypercortisolism and possibly Cushing’s syndrome (CS). Only 5–10% of CS cases are attributed to EAS; of these, breast tumors comprise less than 1%. Two known variants of breast neuroendocrine tumors include neuroendocrine-differentiated carcinoma and ductal carcinoma with neuroendocrine features. Currently, guidelines for treatment are limited and EAS is associated with significant morbidity and mortality. A 39-year-old female presented with a rapidly enlarging breast mass. Biopsy demonstrated invasive poorly differentiated breast carcinoma with high-grade neuroendocrine features and necrosis. Staging at diagnosis confirmed metastatic disease of the liver and bone. First-line chemotherapy (Cisplatin/Etoposide/Durvalumab) was initiated with evidence of disease progression after four cycles. Given a poor response to therapy, a simple mastectomy was performed for local control and complete pathologic analysis, demonstrating high-grade neuroendocrine carcinoma with large-cell features. Second-line therapy (Adriamycin/Cyclophosphamide) was initiated for three cycles after which the patient required admission for severe and refractory hypokalemia. Workup confirmed elevated ACTH consistent with paraneoplastic EAS and further evidence of disease progression. Third-line therapy (Nab-Paclitaxel) was initiated, and genetic testing was completed, confirming the PIK3 mutation, for which access to Alpelisib therapy was requested. Given symptoms of progressive severe CS with significant liver disease limiting medical therapies, the patient underwent urgent bilateral laparoscopic adrenalectomy after which she was able to be discharged home while awaiting additional systemic therapy. EAS resulting in CS secondary to breast neuroendocrine carcinoma is a rare and challenging diagnosis. Further research is needed to inform treatment guidelines to improve outcomes. While patient survival is dependent upon the underlying disease process, laparoscopic bilateral adrenalectomy is an accepted, definitive treatment option. Full article

Objective: Reconstructing the anterior mandible in patients with irradiated and contracted soft tissues remains challenging despite advances in computer-assisted design and three-dimensional printing. Unpredictable soft-tissue changes reduce the effectiveness of these technologies. This paper explores an alternative using a single-adjustable-osteotomy fibula flap technique. Methods: A retrospective study was performed on patients with anterior segmental mandibular defects due to recurrent tumors, secondary reconstruction, or osteoradionecrosis and previously received radiotherapy who represented the highest risk of soft tissue complexity while limiting the utility of computer technology. All patients underwent mandible reconstruction using the adjustable, single-osteotomy fibula method, which eliminated the need for computer-assisted design. We evaluated the effectiveness and outcome. Results: From 2016 to 2023, 11 patients were included in this study. The median patient age was 58 (ranging 49–65) years. Included patients had either recurrent tumors (n = 6), secondary reconstruction needs (n = 3), or mandibular osteoradionecrosis (n = 2). No complete flap failures occurred. Five of six patients with recurrent cancer required two skin island fibular flaps for intraoral and external defect repair. One patient experienced partial skin paddle loss requiring an additional free flap, and another had plate exposure requiring removal after bone union was achieved. Conclusions: The adjustable single-osteotomy fibula flap technique offers a reliable alternative for anterior mandibular reconstruction in complex cases. This approach demonstrates advantages in surgical simplicity and flexibility while maintaining acceptable outcomes. However, careful patient selection and consideration of defect extent remain crucial for success. Full article

The reconstruction of long bone defects after the primary traumatic, secondary infectious, or tumor-related loss of substance continues to represent a surgical challenge. Distraction osteogenesis using segmental transport, vascularized bone transfer, and the induced membrane technique (IMT) are established methods of reconstruction. IMT has become increasingly popular in recent decades due to its practicability, reproducibility, and reliability. At the same time, the original technique has undergone numerous modifications. The results are correspondingly heterogeneous. This article is intended to provide an overview of the current principles and modifications of IMT, outline the causes of failure of the IMT, and introduce the pearl-string technique (PST). The PST developed in our hospital is based on the pearl-string-like arrangement of thermodisinfected, decorticated femoral heads (TDFHs) in combination with a mechanically stable osteosynthetic construct. The TDFHs are biologically activated with either an RIA or autologous iliac crest bone graft. To gain a better understanding of these variations, the surgical technique of both procedures is illustrated step-by-step in this article. Full article

Background/Objectives: Brown tumors are rare bone lesions associated with hyperparathyroidism, particularly secondary hyperparathyroidism (SHPT), in chronic renal failure. While brown tumors commonly affect bones rich in marrow, the involvement of the sphenoid sinus is extremely rare and can present with neurological symptoms. This study reports a case of a sphenoid sinus brown tumor in a patient on hemodialysis, highlighting its clinical presentation and diagnostic challenges. Methods: A 31-year-old woman undergoing chronic hemodialysis presented with a severe headache, diplopia, and progressive vision loss in her left eye. Laboratory tests revealed hypercalcemia, hypophosphatemia, and elevated parathyroid hormone (PTH) levels, consistent with SHPT. The diagnosis was confirmed through a clinical examination and magnetic resonance imaging (MRI). Results: The clinical examination confirmed decreased visual acuity in the left eye. The laboratory results revealed serum calcium of 15.5 mg/dL, phosphate of 1.0 mg/dL, and PTH of 2000 pg/mL, consistent with SHPT. The imaging studies identified a brown tumor in the sphenoid sinus exerting a mass effect on adjacent structures. This case underscores the rarity of brown tumors in this location, with very few similar reports in the literature. Conclusions: Although rare, brown tumors should be considered in patients with SHPT who present with neurological symptoms or cranial lesions. An early diagnosis through biochemical and imaging studies is crucial to prevent severe complications. The management involves treating the underlying hyperparathyroidism, with surgical intervention indicated in cases of neural compression. Full article