ONCOCYTIC INTRATHYROID PARATHYROID ADENOMA MASQUERADING AS HURTHLE CELL NEOPLASM: FINE NEEDLE ASPIRATION CYTOLOGY OF TWO CASES

Ectopic parathyroid adenomas in thyroid tissue are uncommon (0.7 - 6%), and their oncocytic variants are exceedingly rare. We report two cases of intrathyroid parathyroid adenoma which were diagnosed as Hurthle cell adenoma on cytology. Case 1 is a 49-year-old female with a 2.4 cm hypoechoic nodule in the left lateral neck. Electrochemiluminescent immunoassay of the aspirate revealed PTH level of 422 pg/ml, conrming the presence of hyperfunctional parathyroid tissue. Subsequent resection of the left thyroid lobe revealed an enlarged intrathyroidal parathyroid. Case 2 is a 58-year-old female with a 2.1 cm hypoechoic nodule in the posterior-mid left thyroid lobe. Strong overexpression of parathyroid hormone and Chromogranin A genes and low expression of thyrocyte-related genes suggested parathyroid origin of the cells sampled. MEN1 mutation and multiple copy number alterations indicated the neoplastic nature of the nodule. Parathyroid oxyphil cells and oncocytic thyrocytes share cytomorphological ndings and distinguishing them by cytology alone is challenging, especially when the targeted lesion is intrathyroidal. Distinguishing intrathyroid oncocytic parathyroid adenoma from oncocytic thyroid follicular lesions has signicant clinical implications as Bethesda-IV category lesions have 20%–30% risk of malignancy. While stippled chromatin or intracytoplasmic fat vacuoles may be suggestive of parathyroid origin, these are not specic. Classifying the origin of a nodule as parathyroid vs thyroid rests upon the detection of PTH in aspirate material by ECL, immunocytochemistry or next-generation sequencing. In parathyroid aspirates, PTH level 100 pg/mL is suggestive of the presence of PTH-secre ≥ ting tissue at the site biopsied or along the needle track.

Thyroid Gland Abscess: Uncommon complication

The thyroid gland is naturally resistant to infectious processes, which explains the rarity of thyroid abscess. It represent about 0.1% of the surgical thyroid pathology. We report in this article a case of thyroid gland abscess in a 61 year-old man who was followed for diabetes and hypothyroidism with poor adherence, who consulted in emergency department for acute neck swelling. CT scan showed a fluid collection of the left thyroid lobe. The patient was operated, and histopathological examination concluded of laryngeal carcinoma associated to thyroid papillary carcinoma.

Solitary Intrathyroid Metastasis Occurring 23 Years after Resection of Renal Cell Carcinoma

A case of solitary intrathyroid metastasis is described in a 60-year-old male patient. He had a history of renal cell carcinoma classified as T1b resected 23 years earlier. A mass was palpable in the right thyroid lobe. Ultrasound showed a hypoechoic polylobular nodule with intense vascularisation in the right lobe. Fine needle aspiration cytology was normal, but thyroidectomy was performed due to mass enlargement, the ultrasound pattern, and the oncological history. Histological examination revealed the presence of an intrathyroid metastasis of renal cell carcinoma. The bone scan and thoracoabdominal CT scan were normal. Postoperative care was uneventful.

Unnecessity of Routine Dissection of Right Central Lymph Nodes in cN0 Papillary Thyroid Carcinoma Located at the Left Thyroid Lobe

ObjectiveThe lymph node posterior to the right recurrent laryngeal nerve (LN-prRLN) is an important part of the central lymph nodes (LNs). We aimed to explore the rate and predictors of LN-prRLN metastasis in cN0 papillary thyroid carcinoma (PTC) located at the left thyroid lobe.MethodsPatients with surgically treated primary left lobe PTC were retrospectively enrolled. The metastatic distribution of LN-prRLN and postoperative complications were assessed. The association between LN-prRLN metastasis and clinicopathological variables was evaluated by univariate and multivariate analyses.ResultsA total of 857 patients were included for the analysis. Central LN metastasis was noted in 310 (35.3%) cases. The most (27.6%) and least (1.7%) commonly involved LNs were the left paratracheal LN and the LN-prRLN. In the univariate analysis, the tumor size, multifocality, the extent of extrathyroidal extension (none vs. macroscopic vs. macroscopic maximal), and perineural invasion were associated with positive LN-prRLN. In the multivariate analysis, tumor size of >40.0 mm and macroscopic maximal invasion were found as the only two independent predictors. Transient and permanent hypoparathyroidism were noted in 90 (10.2%) and 13 (1.5%) patients, respectively. Voice change was noted in 40 (4.6%) patients, and 20 patients recovered.ConclusionsIn cN0 PTC located at the left lobe, LN-prRLN metastasis was very uncommon. We found that LN-prRLN dissection is not required routinely, but should be performed if the tumor size is >40.0 mm and macroscopic maximal extrathyroidal extension is present.

Thyroid Gland Abscess: Uncommon complication

The thyroid gland is naturally resistant to infectious processes, which explains the rarity of thyroid abscess. It represent about 0.1% of the surgical thyroid pathology. We report in this article a case of thyroid gland abscess in a 61 year-old man who was followed for diabetes and hypothyroidism with poor adherence, who consulted in emergency department for acute neck swelling. CT scan showed a fluid collection of the left thyroid lobe. The patient was operated, and histopathological examination concluded of laryngeal carcinoma associated to thyroid papillary carcinoma.

Case Report: Modified Thoracoscopic-Assisted Cervical Resection for Retrosternal Goiter

Introduction: The treatment of choice for retrosternal goiters (RSG) is surgical resection to relieve symptoms and rule out malignancy. Although the majority of RSG can be removed by a cervical approach only, an extracervical approach (e.g., sternotomy, thoracotomy or thoracoscopy) may be required. Herein, we describe a refined thoracoscopic-assisted cervical two-team RSG resection without thoracoscopic mediastinal dissection.Technique: A 57-year-old man presented with a large RSG with posterior mediastinal extension (PME) and extensive peritumoral vascularization. Due to its extension below the aortic arch and its small connection with the right thyroid lobe, a combined cervical and thoracoscopic approach was intended. The endocrine surgery unit performed the cervical mobilization of the right thyroid lobe, while the thoracic surgery unit gently pushed the mediastinal tumor through the thoracic inlet without performing mediastinal dissection. This allowed a safe visualization of the inserting vessels by the endocrine surgery team at the neck, followed by a stepwise division of the vessels and resection of the retrosternal nodule through the cervical access.Comment: The described approach is indicated for RSG with posterior mediastinal extension, anteroposterior dimension smaller than the thoracic inlet and inaccessibility from a cervical approach only. This minimally invasive approach is associated with a faster recovery, decreased morbidity and postoperative pain, shorter hospital stay and better cosmetic results.

Escisión transcervical de un adenoma paratiroideo mediastínico gigante

Primary hyperparathyroidism (HPTP) is the third most common neuroendocrine disorder, its main cause is parathyroid adenoma. Within the classification, those adenomas that weigh more than 3.5 g are classified as giant parathyroid adenomas (APG), and are associated with a worse evolution and malignancy. The purpose of this article is to present our diagnostic and therapeutic approach of a patient with HPTP ssociated with a mediastinal APG. A search in the international literature of the last 10 years revealed that only 8 other centers ha ve reported the extraction of an APG of similardimensions to ours and in a similar location. Case presentation: A 66-year-old woman with a history of multinodular goiter, thyroid profile and parathormone (PTH) measurement were requested, with a report of 350.60 pg/mL. A thyroid/parathyroid scintigraphy was performed with 99mTc sestaMIBI which reported persistence of a focal area of the concentration located in the topography of the lower pole of the right thyroid lobe. This study was complemented with SPECT-CT, which reported an image of hyperfunctioning right inferior parathyroid compatible with adenoma and the patient was diagnosed with PTH. Finally, resection was performed, obtaining a tumor measuring 7.0 × 4.5 × 2.0 cm, with a weight of 24.5 g. Conclusions: Our case highlights the use of imaging studies to facilitate localization and achieve diagnosis together with clinical presentation and biochemical profile. Selective treatment was achieved safely through a minimally invasive transcervical technique, combined with the measurement of PTH. Keywords: Parathyroid adenoma; neoplasia; hypercalcemia; primary hyperparathyroidism; case report.

Non-functioning oxyphilic parathyroid carcinoma: a case report

Background Non-functioning parathyroid carcinoma is an extremely rare malignancy among endocrine tumors. We report a case in which non-functional oxyphilic parathyroid carcinoma was diagnosed from clinical symptoms and pathological diagnosis. Case presentation The patient was a 42-year-old man with no medical or family history of note. He had presented to a local hospital with a neck mass 2 months earlier. Medullary thyroid carcinoma was diagnosed and he was referred to our department. A 3.5-cm mass was observed in the left thyroid lobe. Laboratory data for thyroid functions, thyroglobulin, anti-thyroglobulin antibodies, anti-thyroid peroxidase antibodies, serum calcium, and parathyroid hormone (PTH) were all within normal ranges. Ultrasonography revealed a 40-mm irregular, hypoechoic mass throughout the left thyroid lobe. Follicular thyroid tumor was suspected from fine-needle aspiration cytology. Left lobectomy was performed. Pathological features revealed a thick fibrous capsule around the tumor, and a thick fibrous band was observed inside the tumor. Both capsular invasions and vascular invasions were observed. Tumor cells were eosinophilic and displayed solid growth. Immunohistochemically, tumor cells were negative for thyroid transcription factor-1, negative for thyroglobulin, negative for chromogranin A (positive for normal parathyroid tissue within the nodule), positive for PTH, and positive for parafibromin. Ki-67 labeling index was 10%. Based on these findings, non-functional oxyphilic parathyroid carcinoma was diagnosed. One and a half years postoperatively, calcium and PTH were within normal ranges, and he has shown no evidence of recurrence or metastasis. Conclusions Non-functioning oxyphilic parathyroid carcinoma is an extremely rare malignancy, and definitive diagnosis is difficult to obtain preoperatively. Few reports have been made worldwide, and information on the long-term prognosis is scarce. Long-term surveillance by imaging is mandatory, since no indices that can be used as a marker for postoperative recurrence and metastasis have been identified.

Percutaneous Ethanol Injection as Treatment for Thyroid Cystic Nodules

Background: Thyroid cystic nodules are common and frequently benign. Aspiration of thyroid cyst decreases compression symptoms and volume. However, they commonly recur, and usually, surgery is required for definitive treatment. A less invasive approach, done less frequent, is percutaneous ethanol injection (PEI), which has shown fewer recurrences than simple aspiration and is well-tolerated with few side effects. We present 2 patients that where treated in our clinic with PEI. Clinical Case: 41-year-old female with a history of primary hypothyroidism on Levothyroxine, with neck discomfort, and no risk factors for thyroid cancer had a cystic thyroid nodule 1.5 x 1.8 x 2.8 cm over the right thyroid lobule. Cytology results reported as Bethesda II. One year later, her thyroid nodule was 1.9 x 2.6 x 3.3 cm. Underwent FNA and 6 cc of dark brown liquid was drained from the cyst which was reported again as Bethesda II. The patient was monitored with thyroid ultrasound after a year, and the cystic nodule was 2.2 x 2.9 x 3.1 cm. PEI was decided as the next approach. After six cc was aspired, 0.5 cc of desiccated ethanol was injected into the remained cystic. Eight months after PEI, cystic size was 0.7 x 0.9 x 0.8 cm. The second case is a 40-year-old female who presented complaining of neck discomfort without changes in her voice. The patient did not have any risk factors for thyroid cancer. Thyroid ultrasound was done, which showed a 2.3 x 2.7 x 3.3 cm cyst on her right thyroid lobe. PEI was arranged and 9 cc of dark fluid was aspirated with a posterior injection of 0.5 cc of desiccated ethanol. Symptoms resolved, and the patient was lost to follow up. Five years later, she was seen again. Neck ultrasound showed a cyst of 0.4 x 0.6 x 0.8 cm on her right thyroid lobe. Neither of the two patients had a side effect associated, and the procedure was well tolerated. Conclusions: Percutaneous ethanol injection is a good alternative in the treatment for cystic thyroid nodules due to decrease in cystic size, which we observed that continued for five years of follow up in one of our patients. These will avoid frequent cystic aspiration secondary to recurrence or invasive surgical management.