Thyroid Lobe Research Articles

Selpercatinib for treating recurrent mixed medullary and follicular cell-derived thyroid carcinoma: a case report

BackgroundMixed medullary and follicular cell-derived thyroid carcinoma (MMFCC) is characterized by the coexistence of follicular and C cell–derived tumour cell populations within the same lesion. Due to its rarity, its etiology and clinical course remain unclear, and treatment for advanced or recurrent cases has not been established.Case presentationWe report a case of MMFCC treated with selpercatinib. The patient was a 69-year-old male presenting with tumors in the right thyroid lobe and in the upper mediastinum. Fine-needle aspiration (FNA) cytology of the right thyroid lobe tumor revealed a medullary carcinoma; germline RET mutations were not detected. After resection of the right thyroid lobe with central node dissection, rapid intraoperative diagnosis of the mediastinal mass confirmed malignancy, leading to total thyroidectomy with excision of the upper mediastinal tumor. Histologically, the tumor in the right thyroid lobe and the pretracheal lymph node revealed a mixture of medullary and follicular carcinoma components, diagnosed as MMFCC. The mediastinal lymph node exhibited only medullary carcinoma components. At 11 months postoperatively, computed tomography scans showed enlargement of the right supraclavicular and upper mediastinal lymph nodes. FNA cytology of the right supraclavicular lymph node suggested the recurrence of medullary thyroid carcinoma. The gene panel testing (The Oncomine Dx Target Test Multi-CDx system®, Thermo Fisher SCIENTIFIC) of metastatic lymph node revealed RET somatic mutation (M918T). Treatment with selpercatinib was initiated, and both the cervical and mediastinal lymph nodes showed a reduction in size.ConclusionsWe report a rare case of selpercatinib use for MMFCC. Since RET mutations may occur frequently in MMFCC, selpercatinib could be effective in treating MMFCC.

CA19-9 producing locally advanced papillary thyroid carcinoma: a case report.

CA19-9 is a tumor marker for gastrointestinal and biliary-pancreatic adenocarcinomas; however, its association with thyroid cancer is unknown. Here, we report a case of CA19-9 producing locally advanced papillary thyroid carcinoma (PTC). A 66-year-old woman who was identified with a thyroid tumor after a close examination of an elevated serum CA19-9 level, which was detected at health screening, was referred to our hospital. Ultrasonography revealed a 34 × 31mm hypoechoic lesion in the lower pole of the left thyroid lobe. Computed tomography revealed a solid thyroid tumor with tracheal invasion without any distant metastases. Bronchoscopy revealed tumor exposure into the tracheal lumen on the left side of the trachea. Fine-needle aspiration cytology led to a diagnosis of papillary thyroid carcinoma (PTC). The patient underwent a total thyroidectomy, tracheal sleeve resection with end-to-end anastomosis, and lymph node dissection in the left cervical and superior mediastinal regions (D3c) with a reversed T-shaped upper sternotomy down to the third intercostal level. Histopathological analysis confirmed the diagnosis of PTC with tracheal invasion and no lymph node metastases (pT4a Ex2 N0). Immunohistochemical staining showed the expression of CA19-9 in cancer cells. Postoperatively, the serum CA19-9 level of the patient decreased to within the normal range. Some PTCs produce CA19-9, although less frequently. When elevated serum CA19-9 levels are observed, PTC should be included in the differential diagnosis for further investigation.

Changes of biochemical factors and the effect on recurrence of medullary thyroid carcinoma after surgery

ObjectiveMedullary thyroid carcinoma (MTC) is a rare malignancy secreting calcitonin (Ctn). We aimed to analyze the relationship between Ctn levels at different time points in patients with MTC, and evaluate its predictive effect on recurrence. MethodsA retrospective study of patients diagnosed with MTC in a large medical center were conducted in northern China. The interrelationships between preoperative Ctn, normalization of postoperative serum Ctn at the first month (NPS), and long-term biochemical cure as well as their predicting roles on structural recurrence were assessed. ResultsA total of 212 patients were included in this study. The median follow-up time was 59.5 months. The 5- and 10-year cumulative disease-free survival rates were 81.5 % and 66.8 %, respectively. NPS (OR: 216.33, 95 % CI: 28.69–1631.09, P < 0.001) and absence of structural recurrence (OR: 61.71, 95 % CI: 3.90–975.31; P = 0.003) were associated with biochemical cure. Non-biochemical cure (OR: 28.76; 95 % CI: 2.84–290.86; P = 0.004, HR: 14.63, 95 % CI: 2.27–94.07, P = 0.005), larger tumor size (OR: 8.79, 95 % CI: 2.12–36.40, P = 0.003, HR: 5.41, 95 % CI: 2.04–14.37, P = 0.001), and multifocality (OR: 4.02, 95 % CI: 1.06–15.17, P = 0.040, HR: 3.00, 95 % CI: 1.18–7.60, P = 0.021) were unfavorable independent predictors of structural recurrence and disease-free survival. For sporadic MTC confined to the thyroid lobe, there was no difference in biochemical or structural prognosis between the different surgeries in the subgroup analysis. ConclusionsNPS, rather than preoperative Ctn, predicted long-term biochemical cure for MTC. Non-biochemical cure, larger tumor burden including larger tumor size and multifocality at initial surgery, served as worse prognostic predictors.

Surgery preferences for thyroid diseases in childhood: review of the literature due to a case experience

The authors have yet to decide well about the requirement of thyroid surgery in childhood. There are reasons for this controversy. Some of these controversies are various diseases, differences in evaluations of the diseases, and various follow-ups. So, treatments in different institutions are most diverse. Surgeons must be precise for those who perform surgery in this age group. A 17-year-old girl whom the pediatric endocrinology department followed up for three years with a thyroid nodule diagnosis was operated on. Thyroid function tests were regular. In ultrasonography, a nodule in the left thyroid lobe was detected. The nodule had grown over the years and reached a size of 2x1.5x1.4 cm. Excision was planned when a definitive result could not be reached after three fine-needle aspiration biopsies were repeated in our hospital. Since the fine needle aspiration examinations were inconclusive, only a left lobectomy was performed. After pathology examination resulted in follicular carcinoma, right lobectomy with isthmectomy was added. As a result, a total thyroidectomy in 2-stage was performed. Because of this surgical course of the patient, it was decided to examine the surgical choices of thyroid diseases in children like Graves' disease and benign and malignant nodules. Literature was evaluated to understand if there is an algorithm for decision-making on pediatric thyroid surgery.

Case Report: A pyramidal lobe coexisting with a left-sided thyroid goiter displacing trachea and esophagus: A cadaveric finding with clinical implications

Background The current report describes a unimodular thyroid goiter (TGo), identified unilaterally in a female cadaver, causing displacement or compression effects in the adjacent neck structures (common carotid artery (CCA) and internal jugular vein (IJV),). Methods Routine dissection of the neck of an 86-year-old female donated a Greek cadaver. Results A thyroid gland variant was identified coexisting with a TGo originating from the left thyroid lobe. The variant is a pyramidal lobe located on the left side of the isthmus. Owing to the presence of the TGo, the left CCA, along with the left IJV, deviated 50.6 mm ipsilaterally from the midline of the neck. The right CCA had a minor deviation of 30.8 mm, from the midline to the right side due to the proximity of the shifted trachea and esophagus with the CCA origin. The trachea and esophagus deviated contralaterally to the TGo, 24.4 mm from the midline. Conclusions CCA compression, stenosis, and angulation may cause dizziness, weakness, and hypomnesia. The potential outcomes were worse with IJV compression. Atherosclerosis tends to occur more often in arteries with inclined (angulated) parts.

The potential value of ultrasound in predicting local refractory/relapse events in primary thyroid lymphoma patients.

Primary thyroid lymphoma (PTL) is a rare malignant disorder, and ultrasound plays an important role in PTL diagnosis and follow-up surveillance. Prediction of refractory/relapse events in PTL patients is an essential issue, yet no ultrasonic PTL features have been discovered to be related to refractory/local relapse events. From January 2008 to September 2022, newly diagnosed PTL patients in our center who underwent standard first-line treatment and received an ultrasound examination before treatment were enrolled. Data regarding patients' clinical and sonographic features, as well as their therapeutic responses were collected. Subjects with an ideal prognosis were compared to those with refractory/relapse events. In total, 37 PTL patients were analyzed, including 26 with diffuse large B-cell lymphoma, 2 with follicular lymphoma and 9 with mucosa-associated lymphoid tissue lymphoma. During the median follow-up of 25 months, 30 patients obtained a complete response, 4 were refractory patients, and 3 experienced local relapse. No significant difference was detected in the baseline clinical characteristics between patients with an ideal prognosis and those with refractory/local relapse events. In terms of sonographic features, however, an event-free survival (EFS) curve comparison revealed that patients with bilobar enlargement (defined as an anterior-posterior diameter > 2.5cm on both sides of thyroid lobes) had a poorer EFS than those without (P < 0.0001), and patients with diffuse type had a poorer EFS than those with mixed/nodular types (P = 0.043). No significant difference was observed in EFS between patients with or without signs of suspicious cervical lymph node metastasis, rich blood signal distribution or symptoms of trachea compression. PTL patients with an anterior-posterior diameter > 2.5cm for both thyroid lobes or PTL patients of the diffuse ultrasound type could be prone to refractory/local relapse events.

Histopathological Spectrum of Thyroid Neoplasm - A Retrospective Study Done at Tertiary Cancer Care Hospital

Thyroid lesions are fairly common &amp; have a wide spectrum of diseases ranging from functional, immune mediated to neoplastic lesions. All thyroidectomy specimens were included in the study period of 1.5 years from September 2019 to February 2021 at our institute, a total of 10,200 biopsies were sent to our department for histopathological examination, out of which 7200 were diagnosed as malignant cases, of which 408 (5.6%) cases were thyroid cancer (TC) cases. One hundred forty-five (35.53%) out of 408 TC cases underwent thyroid surgeries, fifty consecutive cases who fulfilled the inclusion criteria were registered in our study. All grossed, processed, stained sections of haematoxylin and eosin were reviewed and observed under microscope. Average age of the patients suffering from TC was found 44.80 years. Female preponderance seen with F:M-1.38:1. Most common location of tumor was Right lobe of thyroid (32%) followed by Left Lobe (26%). Malignant lesions (96%) predominated over Benign lesions (4%). Papillary carcinoma thyroid was the most common malignancy (72%) followed by Follicular carcinoma (14%). Both benign cases were of Trabaecular Adenoma (4%). Majority of tumors were Unifocal (62%) followed by Mutlifocal (38%). Keywords: Thyroid Neoplasm, Benign and Malignant lesions

Two lymphoma histotypes and papillary thyroid carcinoma coexisting on Hashimoto ground: a case report and review of the literature

BackgroundPapillary carcinoma is the most frequent type of thyroid carcinoma, while primary thyroid lymphoma is uncommon disease. The coexistence of these entities has already been described, and the common risk factor is considered Hashimoto thyroiditis. The two most frequent histotypes of primary thyroid lymphoma are diffuse large B-cell and mucosa-associated lymphoid tissue lymphoma, but the coexistence of both with papillary carcinoma is rarely reported.MethodsWe present a case of a previously healthy 57-years old male with rapidly growing lump on the right side of the neck. Ultrasonography revealed nodules in both thyroid lobes. Fine needle aspiration cytology and pertechnetate scintigraphy were performed. Due to the Bethesda T-5 in the “cold” nodule of the right lobe, surgery with histopathological and immunohistochemistry analysis was indicated.ResultsHistopathological and immunohistochemistry methods confirmed concomitant malignancies in the thyroid gland: diffuse large B-cell lymphoma and papillary carcinoma in the right, and mucosa-associated lymphoid tissue lymphoma in the left lobe with Hashimoto thyroiditis in the remaining tissue. Patient underwent therapy procedures and was without signs of local recurrence or metastatic spread on subsequent follow-up.ConclusionsSudden appearance of the neck mass in patients with Hashimoto thyroiditis should raise suspicion on primary thyroid lymphoma and be promptly taken in the diagnostic workup, including fine needle aspiration cytology. Pathology with immunohistochemistry is crucial for further clinical decision making. Since the standardized protocol in management of these complex patients is missing, personal approach and close collaboration between cytologist, pathologist, surgeon, haematologist and nuclear medicine specialist is essential.

Parathyroid Adenoma with Multiple Bone Fractures: A Case Report

Background: Parathyroid adenoma is a benign neoplasm of the parathyroid glands and can result in hypercalcemia due to excessive secretion of parathyroid hormone (PTH). This elevated PTH can have various manifestations, including bone fractures.&#x0D; Case presentation: We report the case of Tn. AB is a 41-year-old man with a series of recurrent bone fractures following minor traumas. Within a span of three years, he suffered from fractures in the right femur, left femur, and left humerus, which led to multiple surgeries, including total hip replacements. Further assessments showed an increased level of PTH and a suspicious lesion in the neck region. A CT scan revealed a potential parathyroid adenoma in the peritracheal region of the right side. Moreover, a Sestamibi scan confirmed an adenoma in the postero-inferior lobe of the right thyroid, consistent with Perrier type C, alongside osteoblastic processes and brown tumours. A subsequent parathyroidectomy confirmed a 2 cm diameter adenoma in the right lower parathyroid lobe. Histopathology from the excised tissue confirmed the diagnosis of parathyroid adenoma.&#x0D; Conclusion: Parathyroid adenomas can have significant clinical manifestations, including recurrent bone fractures, due to their metabolic effects on bone integrity. Early detection and surgical intervention can prevent complications and improve the quality of life for these patients.

A Rare Presentation of Metastatic Breast Carcinoma to the Thyroid Three Years after Mastectomy: A Case Report

Abstract Introduction: Breast cancer is the most common cancer in women. Yet, metastasis to the thyroid is a rare occurrence. Here we present the case of a patient with breast cancer metastasis to the thyroid gland to discuss the management of such presentations compared to the current literature. We also present this case to add to the existing literature and aid in the expansion and better understanding of rare incidences as such. Presentation of Case: A 38-year-old female with no chronic medical illnesses was diagnosed with invasive ductal carcinoma of the right breast T3N0M0 in 2017. Chemotherapy eight cycles of neoadjuvant chemotherapy followed by right simple mastectomy, sentinel lymph node biopsy, and adjuvant radiation to the chest wall. The patient has been on hormonal therapy since diagnosis. In 2020, the patient presented with a left neck mass and underwent a total thyroidectomy. Pathological analysis of the specimen confi rmed the presence of poorly differentiated cells consistent with mammary ductal cells while the right thyroid lobe demonstrated features of papillary thyroid carcinoma. Conclusion: Intrathyroidal metastasis of extrathyroidal cancers is rare but should be considered when patients are present with a history of cancer. Thyroidectomies in isolated secondary thyroid cancers have been shown to prolong the disease-free period but are not a defi nitive cure

The impact of coexisting Hashimoto's thyroiditis on the feasibility of endoscopic thyroidectomy in papillary thyroid carcinoma

Objective：The safety of endoscopic thyroidectomy in patients with Hashimoto's thyroiditis (HT) is a matter of concern. This study aimed to assess the effect of concomitant HT on the feasibility of endoscopic thyroidectomy in patients with papillary thyroid carcinoma (PTC). MethodsThis study is an observational, retrospective study. All patients were histopathologically diagnosed with HT. The study group consisted of 44 patients (40 %) with PTC who also had HT, whereas the remaining 66 patients (60%) without HT were assigned to the control group. The number of dissected lymph nodes, mean operation time, thyroid volume, blood loss, TSH level, and postoperative complications were recorded and statistically analysed. ResultsOne patient underwent conversion to open thyroidectomy because of recurrent laryngeal nerve (RLN) transection. Another patient required reoperation owing to postoperative haemorrhage. Statistically significant differences were observed in mean operation time (105.4 ± 10.7 vs 98.2 ± 7.4 min, P = 0.0001),mean thyroid lobe volume (12.2 ± 5.8 vs 9.6 ± 3.5 mL [mL], P = 0.0041), TSH level(4.1 ± 1.5 mIU/L vs 3.4 ± 0.9 mIU/L, P ＝ 0.0028), and the number of dissected lymph nodes between groups (4.1 ± 1.5 vs 3.4 ± 0.9,P = 0.0028). The estimated mean blood loss (31.5 ± 6.8 vs 29.5 ± 3.9 mL, P = 0.0529) and rate of complications (15.9% vs 10.6%, P = 0.4136) did not show statistically significant differences between groups. ConclusionThe coexistence of PTC and HT increases the operation time and difficulties in endoscopic thyroidectomy but does not affect postoperative outcomes. Endoscopic thyroidectomy can be safely performed with acceptable complication rates.

Thyroid Hemiagenesis: An Incidental Discovery during Treatment for Papillary Thyroid Carcinoma

Abstract Thyroid hemiagenesis (THA) is a rare congenital abnormality in which one of the thyroid lobes fails to develop normally. The prevalence rates range from 0.02% to 0.25%, with no gender preponderance and most commonly involve the left lobe. We report a case of left THA in a 37-year-old female that was found incidentally during total thyroidectomy for right papillary thyroid carcinoma. Most patients with THA are asymptomatic, however, may have subclinically raised thyroid-stimulating hormone levels or be predisposed to developing thyroid disorders such as nodular goiter, hyperthyroidism, Grave’s disease, Hashimoto’s thyroiditis, hyperparathyroidism, or malignancy. Usual imaging techniques such as ultrasonography, computed tomography, and magnetic resonance imaging allow the confirmation of diagnosis and provide clearer glandular and regional visualization. Additional modalities such as thyroid scintigraphy enable the functional assessment and identification of any suspicious nodules and aid in decision-making. THA is a very uncommon condition and the diagnosis is primarily made through imaging. Clinicians should be aware that this condition exists along with documented associations of concomitant thyroid disorders and malignancy.

P-82 Riedel's thyroiditis: three-year follow-up under steroid, rituximab and mycophenolate mofetil treatment

Abstract Introduction Riedel's thyroiditis (RT) is an uncommon thyroiditis characterized by fibrosis, macrophage, and eosinophil infiltration and is assumed to be the primary cause of autoimmunity in the pathogenesis. Invasion of the surrounding tissues, particularly the trachea, occurs. RT is also regarded as thyroid involvement in IgG4-related systemic illness. Because there is no conventional medical treatment protocol for RT, this paper aims to highlight the problems we had in diagnosing and our approach throughout therapy. Clinical Case In the last 1.5 years, a 44-year-old female patient on levothyroxine replacement diagnosed with hypothyroidism developed bilateral swelling in the eyes, double vision, drooping eyelids, shortness of breath, and feeling something lodged in the throat. A diffusely enlarged and stiff thyroid gland was palpated in her physical examination. Neck CT revealed a diffusely enlarged thyroid gland 7cm in diameter and constricted trachea. She did not have any constitutional symptoms. According to physical and radiologic exams, preliminary differential diagnoses were anaplastic thyroid carcinoma and IgG4-related thyroiditis. In laboratory tests, TSH: 4.5 mIU/L, st3-4: normal, Anti TPO: +++ TRAB: 0.15 U/L, ANA: Negative, IgG4: 0.52 g/L (0.03-2.01), ACE:21.39. Since the thyroid fine needle aspiration biopsy reported a hypocellular smear, a lacrimal gland biopsy was performed for systemic involvement of IgG4 related disorder's. Her dyspnea was becoming critical; therefore, she was administered 0.5 mg/kg steroid for two weeks before the scheduled bilateral total thyroidectomy, and a considerable decrease in dyspnea, swallowing sensations, and regression in compression findings were seen. Lacrimal biopsies demonstrated persistent inflammation with plasma cells and severe fibrosis, consistent with late-stage IgG4-related illness. Both thyroid lobes were enlarged in neck T1 and T2-weighted MRI images (right lobe was 34×25×68 mm, the left lobe was 35×26×69 mm), diffuse hypointensity was noted, contrast uptake decreased in the thyroid parenchyma following IVCM, and the data was determined to be compatible with RT. The thyroid gland grew markedly on PET-CT, narrowing the air column, with increased FDG absorption in a heterogeneous character (SUVmax: 4.9), and mild-moderate involvement in bilateral lacrimal and parotid glands.The decision was made to continue steroid treatment at 1 mg/kg for one month. Rituximab was given twice every six months while the steroid was lowered. Mycophenolate mofetil (MMF) (2×500 mg) was introduced as a maintenance immunosuppressive medication. The initial radiologic findings regressed in the control neck MRI and PET-CT in the first year. The MRI findings were also steady in the second and third years of MMF. Conclusion Immunosupression therapy with steroid, rituximab and MMF was effective in our RT patient for the long term without significant complications. Clinical and radiological responses similar to surgery can be obtained with immunosuppressive agents.Figure 1.PET-CT and MRI images at diagnosis and third year

O-13 Parathyroid carcinoma - a rare and challenging entity

Abstract Background Parathyroid carcinoma is a rare malignancy, accounting for less than 1% of all cases of primary hyperparathyroidism (HPT). This entity affects both men and women equally and is usually diagnosed in the fourth or fifth decade of life. It can occur sporadically or be associated with genetic syndromes such as hyperparathyroidism-jaw tumor syndrome. Its clinical presentation can overlap with that of primary HPT, with hypercalcemia that can lead to a range of symptoms, such as fatigue, weakness, bone pain, kidney stones, and gastrointestinal disorders. Distinguished by its rarity and clinical challenges, this condition requires a high level of suspicion and its initial surgical approach correlates with long-term prognosis. Clinical Case This is the case of a male patient, 39 years old, Caucasian, with a previous history of hypertension diagnosed 5 months earlier, deep vein thrombosis (DVT) diagnosed 2 months earlier, and active tobacco use. Additional study performed after the DVT episode found severe hypercalcemia (14.3 mg/dL, N 8.6-10.0), hypophosphatemia (2.2 mg/dL, N 2.5-4.5), and renal dysfunction (Creatinine 1.43 mg/dL). The patient was asymptomatic and was admitted to the Internal Medicine department, to correct the hypercalcemia and further investigation. Increased PTH levels (1555 pg/mL, N 15-65) were found, and a cervical ultrasound revealed, on the left thyroid lobe, a bilobed nodule, mainly solid, hypoechogenic, with irregular margins and macrocalcifications, with 34×22 mm. Full body CT showed osteolytic lesions on several ribs and both iliacs and kidney stones. A bone scintigraphy was also done, showing a diffuse fixation on the axial and appendicular skeleton, compatible with diffuse osteomedullary infiltration. Due to these findings, the collaboration of the Endocrinology department was requested. Based on the PTH levels and the characteristics of the cervical mass, suspicion arose regarding a potential case of parathyroid carcinoma. Subsequently, a parathyroid scintigraphy using Sestamibi was conducted, whose report revealed an intense hyperfixation at a nodular formation projecting on the lower two-thirds of the thyroid left lobe, without unequivocal identification of its origin - thyroid nodule vs. parathyroid tissue. Based on intraoperative findings and clinical suspicion, en bloc resection of the tumor along with the thyroid lobe and unilateral neck exploration was performed by the Surgery department, with the pathological assessment confirming the malignancy diagnosis. The patient was referred to an oncologic tertiary center, for follow-up and genetic testing. Conclusion We want to shed light on this rare entity and the importance of multidisciplinary critical thinking, alongside imaging. Markedly elevated PTH and/or calcium levels on a patient with a cervical mass should arouse suspicion of a parathyroid carcinoma, which must not be biopsied and warrants a more extensive surgery to ensure the best possible prognosis.

O-10 Lymph node ACTH washout determined the source of ACTH secretion in a patient with Cushing's Syndrome due to medullary thyroid cancer

Abstract Introduction Ectopic ACTH syndrome constitutes 18% of Cushing's syndrome cases, and in rare cases, ACTH secretion from medullary thyroid cancer cells is the source of ectopic ACTH production. Here we report a catastrophic Cushing's syndrome case owing to medullary thyroid cancer in which the source of ACTH production was demonstrated by lymph node ACTH washout. Clinical Case A 23 year-old male was admitted to other clinics with complaints of inability to lose weight despite diet and exercise, and weight gain of approximately 40 kg, which had been going on for the last two years. At his application, his weight was 160 kg and his body mass index was 42.51 kg/m2. On physical examination, clinical stigmata suggesting Cushing's syndrome such as moon face, buffalo hump, supraclavicular fat deposition, acanthosis nigricans, centripedal obesity, purple striae on the abdomen were noted. The biochemical and hormonal evaluation confirmed ACTH-dependent Cushing's syndrome (Table 1). To establish the source of excess ACTH, first, a pituitary MRI was performed which revealed a 4×2 mm adenoma on the left side of the gland. In PET-CT, a 24×20 mm hypoechoic nodule in the inferior of the right thyroid lobe, and several pathological lymph nodes at the right side of the neck were detected. Serum calcitonin levels were high (6528 ng/L) and fine-needle aspiration biopsy from the thyroid nodule documented medullary thyroid cancer. The patient underwent bilateral total thyroidectomy and right cervical lymph node dissection. The pathology report was compatible with metastatic medullary thyroid cancer. After surgery, the remission of hypercortisolemia was not achieved and the patient was started on metyrapone treatment before the permanent treatment plan. Postoperative Gallium-68 DOTA PET-CT indicated residual disease and increased uptake in retropharyngeal, bilateral cervical level 2-4, right level 3, bilateral central, and bilateral lower cervical lymph nodes. The persistence of hypercortisolemia after surgery was most likely attributed to residual disease, however, it was considered that pituitary adenoma may also be the cause of ACTH secretion. Therefore, to confirm the source of ACTH secretion, ACTH washout samples were taken from the cervical lymph nodes and were found to be high as 958 ng/L. Reoperation was performed for recurrent mass and lymph node metastases. Conclusion Medullary thyroid cancer should definitely be considered in cases of ectopic ACTH syndrome. ACTH washing from the suspected lymph node may be an option for diagnostic purposes. In addition to the patient's primary tumor, hypercortisolism should also be treated.Table 1.Cushing's assessment tests

P-66 Primary Thyroid Lymphoma mimicking Riedel Thyroiditis

Abstract Introduction Although Riedel's thyroiditis and primary thyroid lymphoma are rare diseases of the thyroid, they should be considered in the differential diagnosis of patients presenting with a neck mass. We report here the case who was followed up with the diagnosis of Riedel's thyroiditis and later diagnosed with lymphoma. Clinical Case A 67-year-old female presented with swelling in the neck, pain and shortness of breath. Thyroid ultrasound demonstrated enlarged thyroid gland, heterogeneous parenchyma, irregular contours, thin septations and pseudonodule formations. Laboratory tests revealed, TSH 4.17 mIU/L, fT4 1.37 ng/dl, anti TPO 147 IU/mL, sedimentation 13mm/h, and CRP of 5.5 mg/dl. In neck CT, an 8*4 cm hypodense mass infiltrating both thyroid lobes, extending anteriorly and superiorly, surrounding the trachea by 270 degrees, was detected. Follicle cells were seen in the fine needle aspiration biopsy, but no neoplasm was found. In PET-CT, increased FDG uptake was detected in the thyroid parenchyma (SUVmax: 22.89) and in one subcentimetric lymph node (SUVmax: 3.5) in the right cervical region. No neoplasm was found in the tru-cut biopsy and the biopsy was reported as granulomatous thyroiditis. When her current complaints and physical examination findings were evaluated together, methylprednisolone was started, considering Riedel's thyroiditis. In the follow-up examination, the thyroid size of the patient decreased significantly and the steroid dose was reduced. The patient, who could not be followed up for a while, developed swelling and pain in the neck again, and was followed up in the ICU with acute respiratory failure, a tracheal stent was applied to the patient. The patient was then followed in the ward, with dyspnea, dysphagia and hoarseness continued, was admitted to our polyclinic again and was hospitalized. The patient stated that her oral intake decreased due to dysphagia and there was a loss of 40 kg. She had no fever or night sweats. She was not smoking. Physical examination revealed a hard, fixed mass that completely filled the right neck and reached the midline. In the endoscopic examination, the vocal cords were paralytic, the air passage was inadequate, and the mass was invading the trachea. Tracheostomy was applied to the patient. Trucut biopsy was taken from the thyroid tissue. In addition, PET-CT was taken. On PET-CT, right thyroid dimensions showed significant morphological progression compared to the previous study, very dense at similar levels (previous SUVmax: 22.89,current SUVmax: 22.76);intense FDG uptake was detected in 8 mm lymph nodes in the left cervical and 19×20 mm lymph nodes in the right supraclavicular (SUVmax 22.17) region.Diffuse Large B-Cell Lymphoma was detected as a result of thyroid biopsy and R-CHOP treatment was started on the patient. She was discharged after 2 cycles of chemotherapy (Figure). The diagnosis of both Riedel's thyroiditis and primary thyroid lymphoma are histopathological. The importance of open surgical biopsy and cooperation with an endocrine-specific pathologist was emphasized through our case.Figure.Photos of the patient at her initial and last state

P-19 A case of Birt Hogg Dube syndrome presented with parathyroid carcinoma

Abstract Introduction The Birt Hogg Dube syndrome is an autosomal dominant genodermatosis caused by a mutation in the folliculin gene. It is characterized by benign lung cysts with spontaneous pneumothorax, kidney tumors, and hair follicle tumors. Other solid tumors may accompany. Our case is a man with Birt Hogg Dube Syndrome who has parathyroid cancer. Clinical Case A 50-year-old male was referred to our clinic for treatment of hypercalcemia and elevated parathormone; he complained of weakness, muscle, and joint discomfort. His previous medical history included Renal Cell Carcinoma, Coronary artery by-pass graft, pulmonary thromboembolism, hypertension, nephrolithiasis, and stage 4 chronic kidney disease. There was a familial history of colon cancer, with both his aunt and uncle having been diagnosed. The systemic evaluation revealed the presence of constipation, polyuria, pollakiuria. A palpable 3 cm nodular lesion was discovered in the inferior lobe of the patient's left thyroid, and the patient's vital signs were stable. There were lesions on the inner surface of the right thigh and the skull. The biopsies obtained from the lesions on the skin revealed a lipoma on the cranium and a fibrofolliculoma on the thigh upon pathological examination. Regarding laboratory exams, both the hemogram and transaminase levels were within normal limits. Serum albumin was measured at 4.9 g/L creatinine at 2.5 mg/dl, calcium at 12 mg/dl, ionized calcium at 5.9 mg/dl, phosphorus at 2.4 mg/dl, parathormone at 373 ng/dL, and 25-OH Vitamin D at 32 ng/ml. Alkaline phosphatase was determined to be 66 U/L, and 24-hour calcium output was 60 mg/day. The thyroid function test results were euthyroid, while the anterior pituitary panel was normal. The patient underwent a left inferior parathyroidectomy after thyroid ultrasonography and parathyroid scintigraphy revealed a parathyroid adenoma. The parathyroid carcinoma is identified in the pathology report. The ultrasound-observed nodule on the isthmus of the thyroid has been identified as thyroid papillary carcinoma. Bone mineral density was normal. A previously performed CT scan of the thorax for dyspnea revealed the presence of multiple cystic structures in the lungs. Taking into account the patient's history of multiple malignancies, an 18-FDG-PET CT scan was performed, revealing a significant FDG uptake (SUV Max: 22) in the patient's sigmoid colon. Pathology analysis of the removed lesion confirmed that it was a tubulovillous adenoma with high-grade dysplasia. The patient, who showed heterozygosity for the Folliculin gene, was identified as having Birt-Hogg-Dube syndrome after further genetic panel testing. Conclusion According to the most recent literature evaluation, our patient is the first Birt Hogg Dube individual to present with parathyroid carcinoma. There is some evidence in the published literature linking somatic mutation of the Folliculin gene to the development of parathyroid cancer.

P-85 Inflammatory myofibroblastic tumor: An extremely rare tumor of the thyroid gland poses challenges in diagnosis and management

Abstract Introduction Inflammatory myofibroblastic tumor (IMT) is an exceedingly rare mesenchymal tumor characterized by myofibroblastic spindle cells and an inflammatory cell infiltrate. The clinical presentation of IMT in the thyroid gland varies widely, ranging from an asymptomatic thyroid nodule to a diffuse, rigid, fixed, and painful mass. While IMT of the thyroid gland is generally considered a benign borderline tumor with very low metastatic potential, its diagnosis and management can be intricate. Surgery remains the preferred treatment, with recurrence being rare following successful removal. Nonetheless, the optimal management of residual tumors is contentious and may involve a second surgery or the use of immunosuppressants and chemotherapeutic agents. Clinical Case A 47-year-old female patient presented with painless discomfort and stiffness around the thyroid gland. A neck ultrasound revealed a hypoechoic nodule measuring 21×12 mm on the left lobe and a hypoisoechoic heterogeneous nodule 35×28 mm in size on the right lobe of the thyroid gland. These nodules displayed low vascularity, and no pathologic lymph nodes were detected. Fine needle aspiration biopsies (FNABs) were performed on the nodules in both lobes at different times, indicating thyroiditis in the right lobe and spindle-shaped cells with atypia of uncertain significance in the left lobe. Subsequent evaluation of FNAB materials at a referral center suggested a high suspicion of lymphoid malignancy. The patient underwent thyroidectomy; however, the surgeon chose to preserve the left thyroid lobe due to its extreme fibrotic and stone-like consistency, thereby preserving recurrent laryngeal nerve function. Histological analysis confirmed the presence of an inflammatory myofibroblastic tumor characterized by spindle cells accompanied by abundant histocytes, plasma cells, and lymphocytes. The tumor cells exhibited positivity for SMA. Postoperative ultrasound revealed a residual tumor approximately 2 cm in size located in the left isthmus and adjacent left lobe, which remained stable over a 6-month follow-up period. Conclusion Our case highlights the potential for misdiagnosing IMT of the thyroid gland as malignant thyroid tumors. Furthermore, the management of a residual tumor presents a complex clinical challenge. The surgical team is reluctant to pursue a second surgery due to potential risks to recurrent laryngeal nerve function. In this session, we aim to solicit expert opinions and engage in interactive discussions regarding the management of the residual tumor in this specific case.

P-80 A rare case of papillary thyroid carcinoma within a mature cystic ovarian teratoma

Abstract Introduction Mature teratoma is the most common ovarian germ cell neoplasm. Teratomas can contain various tissue groups, such as skin, hair, and thyroid tissue. Teratomas in which more than 50% of the tumor tissue is composed of thyroid tissue are defined as Struma Ovarii. Malignant transformation of Struma Ovarii has been reported at a rate of 0.5-5%, most commonly presenting as thyroid papillary and follicular carcinomas. Metastasis is observed in 5% of malignant cases. Clinical Case A 45-year-old female with a history of Hashimoto's thyroiditis presented in July 2022 with complaints of abdominal pain. Abdominal contrast-enhanced tomography revealed a hypo dense lesion 5 cm in diameter the right adnexal region, and in the magnetic resonance images 5 cm mass was observed in the right adnexal area. Serum Ca-125 level was 212 U/mL (0-35) at admission. Due to high suspicion of malignancy ovarian cystectomy has been performed. Pathology of specimen revealed a 0.5 cm thyroid papillary carcinoma with follicular variant in infiltrative features but no lymphovascular invasion. Subsequently, the patient underwent a total abdominal hysterectomy and bilateral salpingo-oophorectomy due to the unverifiable risk of malignancy. Pathological examination showed no malignancy. The patient presented to our clinic in June 2023, neck ultrasound revealed a 13×12 mm heterogeneous hypoechoic thyroid nodule with thick and thin septations and occasional internal vascularity in the left thyroid lobe. Fine-needle aspiration biopsy of the thyroid was performed, and cytology results were reported as benign. The serum thyroglobulin level was found to be 83.7 ng/mL. In terms of the treatment plan, BRAF and K-RAS gene analysis was planned based on the pathology preparations. The patient will be evaluated for total thyroidectomy/radioactive iodine ablation/no treatment based on the results. Follow-up is ongoing, and test results are awaited. Conclusion Malignant transformation of mature teratoma is rare and thyroid papillary carcinoma being the most frequently seen malignancy. There is no consensus on treatment and follow-up, but it is recommended to classify patients based on their risks and consider options such as total thyroidectomy/radioactive iodine ablation/no treatment for follow-up. Literature suggests the need for guidelines and treatment algorithms for the management of malignant struma ovarii. Some authors recommend whole-body iodine scanning in determining risk and follow-up, asserting that iodine-based treatment and follow-up methods would be meaningless without thyroidectomy. There is also an approach advocating for only salpingo-oophorectomy in low-risk patients and subsequent follow-up. Thus, a consensus on guidelines and treatment algorithms for malignant struma ovarii is needed.

An Ectopic Parathyroid Adenoma of the Retropharynx in a Patient with Primary Hyperparathyroidism and Papillary Thyroid Cancer-A Rare Case.

The frequency of concurrent thyroid cancer in patients with primary hyperparathyroidism (pHPT) varies. While the pathological association between thyroid and parathyroid disorders is frequently noted, the co-occurrence of parathyroid adenoma and papillary thyroid cancer is exceptionally rare. Furthermore, an ectopic parathyroid adenoma in the retropharyngeal space is exceedingly rare. Therefore, anatomical variations through the utilization of relevant diagnostic tools play a crucial role in guiding decisions pertaining to clinical manifestations, diagnostic methods, surgical interventions, and operative strategies for parathyroid tumors. We present a case of a 51-year-old female patient with papillary thyroid carcinoma in the right thyroid lobe and an ectopic parathyroid adenoma in the retropharyngeal space confirmed through surgical intervention. The elevated preoperative levels of serum calcium and parathyroid hormone, along with low serum phosphate, returned to normal ranges after surgery. This case sheds light on the unusual occurrence of an ectopic parathyroid adenoma in the retropharyngeal region within a thyroid cancer patient, providing valuable insights into the realm of thyroid malignancies.