Left Thyroidectomy Research Articles

DICER-1 Mutation Associated Sarcoma of Thyroid in An Adult Male

Abstract Introduction/Objective DICER-1 is an autosomal dominant tumor predisposition syndrome caused by germline DICER1 mutations. In the thyroid, it is associated with an early-onset multinodular goiter (MNG) and low-grade thyroid carcinomas. The aggressive variants thyroblastoma and poorly differentiated carcinoma are however seen in the pediatric age group. We report a case of DICER-1-associated (rhabdomyo) sarcoma without primitive components in an adult male. Methods/Case Report A 44-year-old healthy male with a family history of MNG, presented with a large left neck mass confirmed on imaging with largest 6.4cm, and extension into the mediastinum. FNA showed a malignant spindle cell- rich neoplasm with negative expression for Keratins, TTF-1, PAX-8, Calcitonin, INSM- 1 and SOX-10. The CEA and calcitonin were normal. The lymphoma was excluded by flow cytometry. The patient underwent a left thyroidectomy with central and left selective neck dissection. On gross examination, the left lobe of the thyroid was replaced by a tan- white, partially encapsulated solid mass. Microscopic examination revealed nests and sheets of ovoid to spindle- shaped cells with eosinophilic cytoplasm in fascicles with hypocellular areas with loose stroma. Foci of rhabdomyoblastic differentiation with straps cells, positive for desmin and myogenin were identified. Brisk mitotic activity and tumor necrosis were present. No primitive thyroid epithelium or blastemal component was identified. Tumor cells were negative for S100, SOX10 CD34, CD31, SMA, calponin, CD99, NKX2.2, SS18-SSX which excluded malignant peripheral nerve sheath tumor, angiosarcoma, leiomyosarcoma, Ewing’s sarcoma, and synovial sarcoma. Next-generation sequencing showed a DICER1 c.4517G>A (p.W1506) and c.5437G>C (p.E1813Q) mutation, both variants reported as germ-line variants. A final diagnosis of DICER-1-associated rhabdomyosarcoma was rendered. The patient underwent rehabilitation at another facility and lost to follow-up. Results (if a Case Study enter NA) NA Conclusion The case highlights the expanding spectrum of DICER-1-associated malignant tumors and the importance of keeping it in the differential diagnosis of unusual malignant tumors of the thyroid even in adults.

7205 Anaplastic Thyroid Carcinoma Presenting as New-Onset Thyrotoxicosis and Hypoparathyroidism in a Young Patient: A Diagnostic Dilemma between Hashitoxicosis and Anaplastic Thyroid Cancer

Abstract Disclosure: M. Sulehri: None. E.G. Bustamante: None. A. Elmaaz: None. A. Chaudhuri: None. Introduction: This case report explores the complex diagnostic challenges encountered in a young patient presenting with anaplastic thyroid carcinoma (ATC) manifested by thyrotoxicosis and hypoparathyroidism. Case report: A 29-year-old male who sought multiple emergency room visits for shortness of breath, was initially misdiagnosed with pneumonia. On the third visit, exacerbated respiratory distress led to intubation, CT of the neck and thyroid US unveiling an infiltrative mass centered within the region of the thyroid gland. Initial thyroid function tests showed TSH <0.02 uIU/mL, free thyroxine 6.91 ng/dL, and total T3 204 ng/dL indicating hyperthyroidism, promptly managed with Methimazole and beta blockade. Elevated TPO antibodies (194 unit/mL) were observed, whereas thyroglobulin antibodies and thyroid receptor antibodies were undetected. Concurrently, hypoparathyroidism was noted, marked by low calcium levels (7.9 mg/dL) with albumin of 3.4 g/dL (corrected Calcium 8.4), and low parathyroid hormone (PTH) (<6 pg/mL). Other labs showed ionized calcium 4.30 mg/dL, phosphate 4.6 mg/dL, magnesium 1.8 mg/dL, and vitamin D 54 ng/dl. The patient received calcium carbonate supplement, calcitriol and IV calcium gluconate. Thyrotoxicosis then transitioned to hypothyroidism and levothyroxine replacement therapy was initiated. Definitive diagnosis was delayed due to the patient's overall condition and a low suspicion of malignancy. Left thyroidectomy and tracheostomy were performed, revealing dense subplatysmal necrosis with tumor involvement of both thyroid lobes and isthmus with multiple enlarged nodes. Final surgical pathology confirmed the presence of anaplastic thyroid carcinoma. Due to poor prognosis, the patient was transferred to hospice care where the patient succumbed to his condition within a day. Conclusion: Anaplastic thyroid cancer is considered one the most aggressive and fastest growing tumors. Although it is usually seen in patients after the age of 60, we present a very rare case of ATC in a young patient in the third decade who was presented with infiltrative thyroiditis and hypoparathyroidism. The case underscores the importance of considering rare etiologies in patients with atypical clinical presentation. Presentation: 6/1/2024

12205 Challenging Case Of Anaplastic Thyroid Cancer With Unusual Histological Features: A Diagnostic Dilemma With High Grade Sarcoma

Abstract Disclosure: B. Gautam: None. B. Tiwari: None. M.S. Hossain: None. S. Hossain: None. S.C. Kumar: None. H. liao: None. Introduction: Anaplastic thyroid carcinoma (ATC) is a rare but highly aggressive thyroid cancer accounting for < 2% of cases, characterized by its rapid growth, extensive local invasion, and poor prognosis. Distinguishing ATC from other high-grade sarcomas, such as leiomyosarcoma, is challenging due to shared morphological features and overlapping immunoprofiles. We present a case involving a 73-year-old male presenting with rapidly growing neck mass, leading to diagnostic challenges differentiating between ATC and high-grade sarcomas. Case presentation: A 73-year-old male presented to ED with a rapidly growing painful neck mass for last 3 months, associated with dysphagia, dyspnea & dysphonia. He denied any fever, chills, weight loss and symptoms of hyperthyroidism or hypothyroidism. No personal or family history of thyroid cancer. On physical exam: vitals were normal, Neck exam revealed a left sided neck mass, mobile with deglutition, hard in consistency associated with hoarseness of voice. No stridor or wheeze noted on auscultation. Physical exam was otherwise normal. Laboratory tests showed normal CBC, CMP and TSH 1.45 mIU/L, T4 9.7 ug/dl. CT neck with contrast showed 5.4 x 5.6 x 8.2 cm large lobulated left thyroid mass with rightward airway deviation & substernal extension. Ultrasonogram of thyroid showed 9.6 x 5.3 x 3.3 cm left thyroid lobe with internal calcifications & extrathyroidal extension with several abnormal appearing cervical lymph node, largest measuring 4.9 x 2.4 x 3.3 cm. CT chest/abdomen/pelvis with contrast showed multiple bilateral lung nodules measuring up to 1.5 cm and 1.4 x 1.3 cm left gluteal soft tissue mass. IR-guided left neck mass biopsy was suggestive of primary spindle cell neoplasm with initial immunoprofiles consistent with a high-grade sarcoma, favoring leiomyosarcoma. Given the rapid growth of the neck mass with associated dyspnea, left thyroidectomy was performed and surgical pathology was suggestive of a high-grade sarcoma. However, subsequent pathology review made a final diagnosis of ATC, based on morphologic & immunohistochemical profile showing tumor cells strongly positive for p53 and Desmin with few cells positive for PAX-8, Cam 5.2 and CD68, and negative thyroglobulin, TTF-1, CK7, CK20, CK MNF116, pancytokeratin AE1/AE3 and CK5/6. Thyroseq revealed a distinctive molecular profile specifically positive for TERT and TP53 supporting diagnosis of ATC. Discussion: This case highlights the diagnostic dilemma posed by the resemblance between ATC and high-grade sarcomas due to overlapping clinical, morphological and immunohistology features. While both malignancies may exhibit similar morphological features, specific immunohistochemistry profiles along with molecular testing aid in distinguishing between them and guiding appropriate treatment strategies. Presentation: 6/1/2024

6671 A Recurrent Mass After Thyroid Cancer Treatment

Abstract Disclosure: N. Sekhon: None. K.Z. Win: None. Background: Differentiated thyroid cancers have an excellent prognosis if completely resected and their recurrence rate varies depending on the nature and type of the thyroid tumor. We report a case of symptomatic recurrent mass 1.5 years after hemithyroidectomy for a small locally invasive follicular thyroid cancer. The recurrent mass mimicked malignancy on ultrasound but was pathologically determined to be a suture granuloma. Case: A 62-year-old male with history of follicular thyroid cancer s/p left thyroidectomy presented with a symptomatic neck mass, dysphagia, voice change, and worsening snoring. Thyroid tumor pathology was reported as follicular carcinoma pT1bpNX, 1.4 cm in size, clear margins, no vascular invasion with one focus of transcapsular invasion. He had normal surveillance investigations including thyroglobulin and thyroid ultrasound. He had a normal esophagogastroduodenoscopy which was performed for dysphagia and choking. The thyroid ultrasound showed an indeterminate solid heterogeneous and hypoechoic ovoid soft tissue node measuring 6 mm x 3 mm x 5 mm just right of midline and a 4 mm left neck hypoechoic nodule with no central fatty hilus located lateral to the jugular vein. The lymph node morphology was not typically benign and the patient underwent fine needle aspirate of the mass suggestive of a benign mass. This was followed by surgical removal of the mass and pathologic identification of a suture granuloma. There was resolution of dysphagia after removal of the mass. Discussion: Thyroid tumor recurrence rate is about 15% and is usually seen in aggressive forms or in incomplete resections due to the unrecognized extent of the tumor. Recurrences can be local, regional or distant. Suture granuloma is a rare complication after thyroidectomy and reflects an inflammatory response to retained foreign material. It develops slowly after the thyroidectomy and presents as a painless mass mimicking malignancy or lymph node metastasis. Other lesions that can mimic thyroid cancer on ultrasonography include chronic granulomatous lesions, traumatic neuroma and surgical clip. Conclusion: Our case highlights that suture granuloma should be considered in addition to malignant recurrence in cases of painless mass at the site of thyroidectomy.

Varied Lineage Thyroid Malignancies in Longstanding Thyroid Swellings: A Series of Three Cases

Long-standing thyroid swellings can present therapeutic and diagnostic challenges. Although benign, these nodules can harbour malignancies of diverse lineages ranging from those of follicular cell origin to rare malignancies such as lymphomas and paragangliomas. Here, the authors are sharing their three clinical experiences with thyroid neoplasms of long duration. The first case is a 42-year-old male patient who presented with an anterior neck swelling of 12 years’ duration. Postoperatively, a diagnosis of Mucosa-associated Lymphoid Tissue (MALT) lymphoma was made based on histopathology and immunohistochemistry. In the second case, a 43-yearold male presented with a neck swelling with eight years of history. Intraoperatively, the lesion was found to be locally aggressive with infiltration into the strap muscles and trachea. A tissue diagnosis of paraganglioma of the thyroid gland was made postoperatively. The third case involves a 72-year-old female who had undergone a left thyroidectomy 10 years back and presented to the Outpatient Department (OPD) with a history of right-sided neck swelling associated with dysphagia and a change in voice. The patient was diagnosed with anaplastic carcinoma, specifically squamous cell carcinoma. Thyroid lesions of abnormally large size create intraoperative problems concerning securing an adequate airway, locating anatomical structures, especially the Recurrent Laryngeal Nerve (RLN), parathyroids, and great vessels of the neck. Postoperatively, the tissue features may be very uncharacteristic, making reaching a proper diagnosis difficult. The use of immunohistochemistry helps in determining the cell lineage and type of malignancy

SAT575 Can We Miss Diagnosis Of Tall Cell Variant Papillary Thyroid Carcinoma?

Abstract Disclosure: J. Huynh: None. A. Makawi: None. G. Elshimy: None. Introduction Large thyroid nodules have a high rate of evolving into malignancy. Fine needle aspiration biopsy (FNAB) is a key diagnostic tool with a caveat of a high false-negative rate for cancer detection ranging from 0.7 to 13%. Key to maximizing the odds of a successful FNAB are the utilization of ultrasound (US) guidance, visualization of the needle tip, preprocedural consideration of the size of the target nodule, and expertise of the cytopathologist. Case presentation 40-year-old African American female who presented to endocrinology clinic given concern for a large left-side thyroid nodule with tracheal deviation seen on a CT scan of the chest. The US revealed a large left hypoechoic, spongiform nodule >5cm with grade 2 vascularity with no calcification measuring 5.1 x 4.3 cm. The thyroid labs were within normal range and she denied any compressive symptoms. FNAB of the nodule showed benign colloid. Given the large size of the nodule, we recommended surgical resection but the patient declined and preferred conservative management. Five months later, she started to experience dysphagia with positional neck pain and shortness of breath. Due to the progression of the compressive signs, the patient opted for left thyroidectomy which revealed multifocal papillary thyroid carcinoma (PTC) tall cell variant (TCV) with the largest foci of 1.7 cm with extrathyroidal extension and vascular invasion. She then underwent completion thyroidectomy followed by postoperative radioactive iodine ablation later on as the second surgery pathology was also consistent with PTC with metastasis to the lymph nodes. She was treated with levothyroxine with the goal to suppress TSH. Postoperatively, the patient is being monitored with biochemical testing and imaging for recurrence given the aggressive nature of her disease. Discussion There is a positive correlation between nodule size and false negative results (FNR). FNR for malignancy is known to be higher in nodules larger than 4cm. Patients with large thyroid nodules causing compressive signs should undergo resection regardless of the FNAB result. This patient had a benign FNAB initially which was misleading as the pathology of thyroidectomy was consistent with TCV PTC, a more aggressive variant. TCV PTC usually presents in larger nodules and with a higher rate of extrathyroidal extension and metastasis compared to classic. The prognosis is poorer with TCV, even without an extranodal extension. This patient received appropriate treatment with total thyroidectomy, THR therapy, sequential imaging, and biochemical testing for recurrence. A key takeaway here is that FNABs may not always reflect accurate histology of the whole lesion with larger nodules having a higher tendency for inadequate sampling. Key to successful biopsy and reducing FNAB false-negative results is an experienced radiologist, a cytopathologist familiar with these tumors, and US guidance. Presentation: Saturday, June 17, 2023

Abstract #1405611: A Case Regarding Severe Hypothyroidism Which Complicated to De Novo Nephrotic Syndrome (Minimal Change Disease)

Hypothyroidism is a condition of an under-reactive thyroid. More prevalent in women, 10% exhibit some degree of thyroid insufficiency. It has numerous metabolic effects and may have an impact on renal physiology and worsening kidney function. Hypothyroidism was cited in certain case studies as a contributing factor to minimal change disease, which we will be highlighting here. We report a case of an 82-year-old female with PMH of graves’ disease status post left thyroidectomy in 2009 and was started on Levothyroxine, reported non-compliance, presented to the emergency department with a complaint of generalized edema mostly lower extremities that is progressively worsening over 2 weeks along with foamy urine. Unremarkable physical exam except for 2+ lower extremity pitting edema. On lab, high thyroid stimulating hormone (TSH) was 65.2 ulU/ml, normal Free Thyroxin (FT4) and low Free Triiodothyronine (FT3) 0.4 pg/ml, Serum Creatinine is 4.35 mg/dl, Urinalysis shows >500 protein, urine protein/Cr was 3, hypoalbuminemia and hyperlipidemia were present. A Glomerulopathy workup was initiated. She was admitted for further testing. Autoimmune kidney diseases were ruled out and a renal biopsy was performed, the specimen revealed Minimal change disease. She was started on Prednisone 60 mg daily and Levothyroxine 125 mcg. Three weeks later, patient showed a good response to therapy with an improvement of symptoms and repeated creatinine was 3.8. Hypothyroidism can be caused by partial or total thyroidectomy. As a highly lipophilic substance, Thyroxine binds to receptors that are expressed in cells all over the body to exhibit its physiological action. In patients with thyroidectomy, exogenous levothyroxine is the thyroid hormone supply to the body. Not having enough supply, can alter kidney function by affecting vascular resistance, re-absorptive process, and renal blood flow. It can also affect the RAAS system, beta-adrenergic receptors, and dopaminergic activation of the renal tubular cells. Gradual worsening of kidney function leads to an increase in the loss of free and bound thyroid hormones and eventually increases thyroxine requirement. GFR is reversibly reduced (by about 40%) in more than 55% of adults with hypothyroidism. Thyroxine treatment is effective by reducing edema, capillary permeability of albumin, and plasma colloid osmotic pressure. Proteinuria can sometimes be reversible by prompt initiation of thyroxine treatment. Also, the severity of symptoms plays a role in recovery. More research is needed to determine the relationship between hypothyroidism and nephrotic syndrome as only a few isolated occurrences were reported in the literature.

Delayed Tracheal Perforation After Thyroidectomy: A Case Report and Literature Review.

Thyroidectomy is a safe procedure that is frequently performed for benign or malignant thyroid disease. Complications after thyroidectomy occur in approximately 3%-5% of patients. Tracheal perforation is a very rare post-thyroidectomy complication, and delayed tracheal perforation without intraoperative tracheal injury is even rarer; only 25 case reports have been published globally, with varied management. We present the case of a 36-year-old man presenting with dyspnea and cough 2weeks after left thyroidectomy. A defect measuring approximately 2cm was confirmed on the anterior wall of the trachea by computed tomography and flexible laryngoscopy. The patient's symptoms improved with conservative treatment including systemic steroids, and surgical treatment was not required. Even in the absence of unusual intraoperative events, delayed tracheal necrosis and perforation should be considered as possible postoperative complications following thyroidectomy.

Concurrent Parathyroid Adenoma and Thyroid Carcinoma in a Domestic Shorthaired Feline.

A 10 yr old female spayed domestic shorthair was referred for an 11mo history of persistent total hypercalcemia and elevated ionized calcium with intermittent episodes of lethargy, vomiting, and diarrhea with a history of recurrent urinary tract infections and intermittently elevated kidney values. An abdominal ultrasound, thoracic radiographs, cervical ultrasound, and ionized calcium level, parathyroid hormone (PTH), and PTH-related peptide (PTHrp) levels were assessed. Results were consistent with chronic kidney disease, splenomegaly, diffuse thickening of small intestines, nodular lesions noted in the left thyroid and right parathyroid, and elevated ionized calcium, PTH, and elevated PTHrp levels. A left thyroidectomy and right cranial parathyroidectomy were performed. Hypocalcemia and anemia developed postoperatively, which were managed with calcium carbonate, calcitriol, and calcium gluconate and benign neglect of anemia. Histopathology was consistent with a left thyroid carcinoma and right cranial parathyroid adenoma. Thyroid carcinoma and parathyroid adenomas have not previously been reported to occur concurrently in domestic felines and should be considered when ionized calcium is elevated with both PTH and PTHrp levels increased in addition to ultrasonographic lesions.

ODP469 Coexistence of two thyroid malignancies with Hurthle cell and Papillary thyroid carcinoma

Abstract Background The simultaneous presentation of mul tiple thyroid malignancies is a rare occurrence with each type of thyroid cancer having different cellular origins, histopathological appearance, and clinical course. Collision tumors representtwo histologically different tumor types occurring at the same anatomic region. When diagnosed within 6 months of the original they are also referred to as synchronous tumors. Papillary thyroid carcinoma (PTC) is the most common (80-85%) differentiated thyroid carcinomas (DTC), followed by follicular thyroid carcinoma (FTC) (10-15%), and Hurthle cell carcinoma (3–5%). We report a rare case of a patient with dual thyroid malignancy containing both PTC and Hurthle cell carcinoma in different thyroid lobes. Case presentation Patient is a 50 year old female with past medical history of hypertension and family history of thyroid disease in her sister and cousins, who presented with thyroid gland enlargement. Patient denied any hyper/hypothyroidism or compressive symptoms. Labs showed normal TSH and free T4. Thyroid ultrasound revealed a heterogeneous nodule with microcalcification in the right thyroid lobe and three well circumscribed left mid pole nodules. FNA thyroid biopsy of the right thyroid nodule demonstrated many Hurthle cells with uniform nuclei. The genomic classification identified multiple chromosomal copy number alterations consistent with a clonal neoplasm with intermediate-high risk for cancer, although no point mutations or gene fusions were found. Patient initially underwent right hemi-thyroidectomy and isthmectomy. Pathology confirmed two well circumscribed angioinvasive Hurthle cell carcinoma measuring 3.4×2.1×2. 0 cm and 1.6×1.5×1.4 cm with multiple foci of capsular invasion oncocytic features along with a 0.2 cm papillary thyroid microcarcinoma without extrathyroidal extension. After three weeks, patient proceeded with completion left thyroidectomy and showed a 1.2×1.1×1. 0 cm well circumscribed, partially encapsulated nodule, consistent with Papillary thyroid carcinoma (PTC). Lymph nodes were negative for metastasis. Patient received whole body I-131 scan and radioiodine ablation therapy. She was subsequently placed on Levothyroxine for thyroid hormone replacement and remained euthyroid without cancer recurrence. Conclusion Collision tumors account for 1% of thyroid malignancies with the most commonly reported combination being PTC and medullary thyroid carcinoma. Interestingly, this case presented with a rare finding of collision and synchronous tumors in the form of PTC and Hurthle cell carcinoma which was known to associate with increased chromosomal copy number instead of point genetic mutation. Previous literature have described collision effect, stem cell, hostage, and single progenitor theories in an attempt to explain the origin of these phenomena with possible molecular mechanisms. Clinicians should be aware that the dual thyroid malignancy with different histogenetic origin may co-exist in the same patient. The therapeutic strategy should be tailored based on each thyroid cancer variant with correlated biological behavior, clinical and genetic features. Presentation: No date and time listed

Metastatic Clear Cell Renal Carcinoma with Benign Ultrasonographic Findings in the Thyroid Gland

Metastasis to the thyroid gland is rare, and the incidence of thyroid metastasis is from 1.4% to 3% for all thyroid malignancies. The most common metastatic malignancy to the thyroid gland is renal cell carcinoma. Ultrasonography is useful to assess the malignancy risk of thyroid nodules, and the ultrasonographic features of metastatic renal cell carcinoma in the thyroid gland are hypoechoic solid nodules with increased vascularity. Here, we report a case of metastatic clear cell renal carcinoma with benign ultrasonographic features and fine-needle aspiration cytology in the thyroid gland. A 76-year-old woman visited our hospital for surgical management of a growing left thyroid mass. Her history comprised previous left nephrectomy for an unknown reason. Thyroid ultrasonography revealed a well-defined, isoechoic, solid mass. Left thyroidectomy was performed, and the final diagnosis was metastatic clear cell renal carcinoma of the thyroid gland.

SAT-380 A Case of Primary Hyperparathyroidism on the Third Trimester of Pregnancy

Introduction: This is the case of a pregnant woman on her 3rd trimester who was diagnosed with primary hyperparathyroidism. Since there are two patients involved, the potential complications that can be brought about by the diagnostic tests and the treatment had to be weighed against the benefits.Case: The patient is SA, a 34-year old female on her 29th week of pregnancy, admitted due to a month history of abdominal pain described as intermittent, crampy, generalized, non-radiating, and mild-to-moderately severe in intensity. She was advised to do tests but did not comply. In the interim, there was recurrence of symptoms but with resolution. However, the crampy abdominal pain recurred, now localized at the right upper quadrant and epigastric areas, radiating to the right upper back, moderate in intensity, and with associated nausea and vomiting, leading to admission.She was first managed under OB-Gynecology, given hydration, pain management and Betamethasone. She was also referred to Cardiology for blood pressure control, and Surgery for evaluation of the abdominal pain. Due to an increasing trend of her blood glucose, she was referred to Endocrinology and started on insulin. Mild bilateral nephrocalcinoses seen in an abdominal ultrasound prompted work-up showing an elevated serum ionized calcium at 1.88 meq/L (n 1.12-1.32 meq/L), elevated intact PTH at 451.13 pg/ml (n <67.9 pg/ml), and low Vitamin D at 10.96 ng/ml (n >30ng/ml). Parathyroid ultrasound showed nonthyroidal tissue measuring 0.4 x 0.6 cm at the right inferior area. Saline hydration and diuresis with Furosemide were started to manage the hypercalcemia. A multi-disciplinary meeting was held to discuss the options for management and risks involved. The goal was to deliver the baby in stable condition possibly to term, while keeping maternal calcium levels and blood pressure normal.However on her 30th week of gestation, she had persistent elevated blood pressure and underwent emergency caesarian section. After delivery, the patient was advised against breastfeeding for adequate management of her hypercalcemia. She was started on Cinacalcet, Calcitonin, and Ibandronic Acid. A Parathyroid Sestamibi Scan done showed a parathyroid adenoma on the right inferior lobe, and she underwent right inferior parathyroidectomy, with left thyroidectomy and isthmusectomy. Findings showed a right inferior parathyroid adenoma and a benign follicular nodule on the left thyroid. She was started on Calcium Carbonate and Calcitriol, and discharged stable.Conclusions: This case shows that when two lives are at stake every step of the management, whether diagnostic or therapeutic, must be communicated well to the patient and to the other members of the team. It is ultimately a choice made by the expectant mother but through the proper guidance and updated knowledge of the team, combined with a good clinical eye especially in the treatment of pregnant women.

First report of in-situ preservation of a subcapsular parathyroid gland through super-meticulous capsular dissection during robotic radical thyroidectomy

PurposeMeticulous capsular dissection can preserve the function of the parathyroid gland in most patients, but it is difficult to identify and preserve the subcapsular parathyroid gland. We performed in-situ preservation of the subcapsular parathyroid gland during robotic radical thyroidectomy using super-meticulous capsular dissection, and evaluated its effect on postoperative parathyroid function. MethodsA 45-year-old woman was admitted with bilateral thyroid nodules. Color Doppler ultrasound demonstrated a 7 × 7 × 6 mm hypoechoic area in the middle and inferior part of the right lobe and 3 × 3 × 3 mm hypoechoic nodule in the middle part of the left lobe. She was diagnosed with right thyroid papillary cancer by fine-needle aspiration. Robotic bilateral thyroidectomy plus right central lymph node dissection was performed. During the left thyroidectomy, we found that the left inferior parathyroid gland was just under the true capsule. Subsequently, the super-meticulous capsular dissection was performed for in-situ preservation of the parathyroid gland. ResultsThe patient's serum parathyroid hormone concentration was 43.77 pg/ml before and 37.98 pg/ml after surgery (normal: 15–65 pg/ml). Her blood calcium level was 2.21 mmol/l before and 2.18 mol/l after surgery (normal: 2.10–2.65 mmol/l). ConclusionsThe super-meticulous capsular dissection, which could cut through the true capsule to identify subcapsular parathyroid and protect its anatomic structure as well as blood supply, is recommend for in-situ preservation of subcapsular parathyroid gland during robotic radical thyroidectomy.

UNUSUAL PRESENTATION OF AMIODARONE PULMONARY TOXICITY (APT) WITH MULTIPLE LUNG NODULES

SESSION TITLE: Diffuse Lung Disease 2 SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/09/2018 01:15 pm - 02:15 pm INTRODUCTION: The incidence of amiodarone-induced pulmonary toxicity (APT) is 5%-15%. Diffuse interstitial infiltrate is the most common radiographic finding associated with APT. Fewer than 10 cases of multiple pulmonary nodules due to APT have been reported in the literature. We report a case of APT presenting as bilateral multiple pulmonary nodules. CASE PRESENTATION: A 59-year-old female presented to the pulmonary clinic for evaluation of multiple pulmonary nodules found incidentally on cardiac MRI. Patient’s complaints consisted of progressive DOE, persistent dry cough without any constitutional symptoms. A dedicated chest CT revealed multiple, various sized, bilateral pulmonary nodules. The nodules were predominantly in the lower lung zones. Her PMHx was significant for HFpEF, PAF on chronic amiodarone, and papillary thyroid cancer s/p left thyroidectomy one year ago. Given the history of malignancy and a high suspicion for metastatic disease, the patient was sent for VATS. Diagnostic lung wedge biopsies revealed an intense lymphoplasmacytic interstitial infiltrate and alveoli filled with macrophages with fine vacuolization on histopathologic examination. In some nodules, there were minor foci of organizing pneumonia. There was no evidence of granulomas or metastatic thyroid tumor. The finding was suggestive of inflammatory process most consistent with amiodarone toxicity. DISCUSSION: The clinical presentation of APT varies from non-productive cough, dyspnea on exertion to acute respiratory failure. Typically, pulmonary toxicity of amiodarone consists of diffuse alveolar damage, organizing pneumonia, hypersensitivity pneumonitis, and irreversible pulmonary fibrosis. Multiple lung nodules due to APT has been reported but rare in the literature. Nodular pulmonary disease is thought to be an inflammatory response to drug-induced phospholipid accumulation in the alveolar cells. Therefore, the lung nodules due to APT may be reversible and has a favorable outcome by discontinuing the drug. The use of corticosteroid also has been shown to be helpful. The diagnosis of APT is challenging due to the complex nature of clinical and radiographic findings. CONCLUSIONS: In summary, APT presenting with diffuse nodular pulmonary disease is rare; however, clinicians must be aware of the variability of clinical and radiographic finding of APT. APT should be considered in patients taking amiodarone present with new pulmonary nodules radiographically. Reference #1: 1. Morell, EB et al., 2005. Multiple pulmonary noduels and amiodarone. KL-6 as a new diagnostic tool. Rev Esp Cardiol 58(4):447-449 Reference #2: 2. Rodriguez-Garcia, JL et al., 2001. Pulmonary mass and multiple lung nodules mimicking a lung neoplasm as amiodarone-induced toxicity. Eur J Intern Med 12(4):372-376 Reference #3: 3. Wolkove, N et al., 2009. Amiodarone pulmonary toxicity. Can Respir J 16(2):43-48 DISCLOSURES: No relevant relationships by Michael Ayers, source=Web Response No relevant relationships by Debabrata Bandyopadhyay, source=Web Response No relevant relationships by Anna Kyu Chen, source=Web Response No relevant relationships by Md Islam, source=Web Response No relevant relationships by Matthew Stanton, source=Web Response

PRIMARY SQUAMOUS CELL CARCINOMA OF THE THYROID GLAND - CASE REPORT AND REVIEW OF THE LITERATURE

Background Primary squamous cell carcinoma of the thyroid gland (PSCTC) is a rare malignancy, but demonstrates a very aggressive behaviour and has a poor prognosis. The best treatment is radical surgery and postoperative chemo- and radiotherapy, although there are some reports that this tumour is resistant to conservative therapy. Patients often present with a large tumour mass on the neck with a solid consistency. Diagnosis is usually set during the operation - on a frozen section. Case report We present a case of a 71-year old man with weight loss and rapidly growing neck mass for the last two months. MRI showed a tumour of the left lobe of the thyroid gland, compressing the trachea and the adjacent structures. A left thyroidectomy with isthmectomy has been performed. Frozen section showed primary squamous cell carcinoma. Tumour recurrence two months later led to the second operation with the same effect. The patient died in a couple of months. Conclusion Because of its rarity and poor biology, treatment of PSCTC remains unsatisfactory. There are still many challenges on its origin, behaviour and prognostic factors. The results of postoperative chemo- or radiotherapy are controversial.

Clinico-cytoradiological correlation of thyroid surgery in patients with thyroid nodule

Background: Thyroid swellings are commonly encountered in the surgical practice and accurate preoperative evaluation of thyroid disorder becomes mandatory for proper management of the patient. Aims and Objectives: To evaluate the clinical and radiological features of thyroid nodule with thyroid surgery. Materials and Methods: A total of 60 patients were included with more than 15 years of age presented with thyroid nodule. Results: Fifty three patients were females and seven were males with goitre duration of 6-60 months and presented with progressive increase in the size of the goitre. After clinical evaluation majority of patients were diagnosed as STN. According to ultrasonography, 58 patients were diagnosed as benign lesions while 2 patients were diagnosed with malignant lesions. According to FNAC, maximum number of patients i.e., 37 were diagnosed with colloid goitre while 2 patients had malignant lesions. On histopathological examination, 58 patients were diagnosed with benign lesions while 2 were diagnosed with malignant lesions. USG findings were correlated with thyroid surgery, Among 60 patients of thyroid nodule. 56 patients underwent hemi thyroidectomy.in which 34 were right thyroidectomy and 22 were left thyroidectomy and 4 patients underwent total thyroidectomy. One patient of total thyroidectomy was develop recurrent laryngeal nerve palsy. Conclusion: USG and FNAC has been shown to be more sensitive, specific and accurate than either technique alone but high resolution USG has important and cost effective investigation to decide the extent and type of surgery of thyroid nodules.

再発にて判明した遺伝性甲状腺髄様癌 (MEN2A/FMTC) の1例

We report a 42-year-old man with hereditary medullary thyroid cancer (multiple endocrine neoplasia, MEN2A/familial medullary thyroid carcinoma, FMTC), which was diagnosed at the time of tumor recurrence. He had a past history of a left thyroidectomy with neck dissection 7 years previously. A RET gene analysis revealed a point mutation (codon 618), and we diagnosed him as having hereditary medullary thyroid cancer. We resected the recurrent tumor in the right thyroid lobe together with performing a right lateral and central neck dissection. A RET gene analysis should be performed for patients with medullary thyroid cancer. When a RET gene mutation is present, a total thyroidectomy must be performed for the medullary thyroid cancer.

Multi-nodular Goiter with Intra-tracheal Thyroid Tissue: Ectopic or Implanted? And Ectopic Nasopharyngeal Thyroid Tissue: A Case Report

We present a case of intra-tracheal thyroid tissue in a 44 year old woman who had been treated for multi-nodular goiter with left thyroidectomy 26 years earlier, the thyroid tissue was found in the trachea lumen which may appears to have been implanted at the time of this operation or it is a case of ectopic thyroid tissue. The patient presented with progressive right thyroid lobe swelling. Clinical examination and investigations were carried out. Right thyroidectomy was performed first, then after discovering in laryngostroboscopy, CT scan and MRI, the presence of intra-tracheal lesion narrowing the airways, patient had another procedure to remove the residual left thyroid lobe and the intra-tracheal tissue which was thyroid tissue as confirmed by histology examination. Post-operative I131 whole body-scan showed ectopic thyroid tissue in nasopharynx and residual tissue in thyroid bed. Currently the patient is free of complaint, but further investigation: SPECT-CT Scan was requested for better localization.

肾上腺髓质增生症病例报告一例

患者，男，51岁，曾行2次甲状腺手术。1992年术后病理不详。2007年(第2次手术)术后病理证实为甲状腺髓样癌。术后口服甲状腺素片至今。2013年6月因左腰部间歇性隐痛就诊我科。PET/CT见双侧肾上腺占位，FDG代谢轻度增高。2013年6月行左侧肾上腺切除术，术中见左侧肾上腺多发结节占位，直径约3 cm。术后病理：左侧肾上腺髓质结节状增生。右侧肾上腺占位暂未给予特殊处理，以随访为主。随访至2013年10月底，患者一般情况良好，血压稳定，右侧肾上腺占位较前相仿。 A 51-year-old man underwent two thyroid surgeries. The first operation called left thyroidectomy was in 1992 with unclear pathological results. He underwent right thyroidectomy in 2007 and medullary thyroid carcinoma was pathologically confirmed. He has been in oral administration of thyroxine after the first surgery. The patient consulted the doctor in our department because of suffering from the pain in his left hip on June 2013. PET/CT examination revealed bilateral adrenal masses with slightly increased FDG metabolic. And then he underwent a left adrenalectomy. During the operation, the surgeon found multiple nodules occupying the left adrenal gland with a diameter of about 3 cm. Histopathological report: nodular hyperplasia of the left medulla. We follow up the right adrenal mass which was given no special treatment until October 2013. The patient was in good condition whose right adrenal masses were similar as the previous ones.

Aspergillosis of thyroid gland managed by thyroidectomy

We experienced a very rare case of thyroidal Aspergillus in a 65‐year‐old man who came to our hospital complaining of fever and persistent pain in the articulations. The patient had a history of chronic renal failure. After physical examination and imaging tests, fine‐needle biopsy of the thyroid showed fungus hyphae angling at a45‐degree compatibility with Aspergillus and thyrocites, with Hurthle cell differentiation. We performed left thyroidectomy without any complications. Because most of thyroidal Aspergillus diagnoses are made after autopsy and insufficient data about its management, we present, to the best of our knowledge, the first case of thyroidal Aspergillus in the literature that was treated by left thyroidectomy successfully.