Palpable Neck Mass Research Articles

6699 Primary Hyperparathyroidism With Severe Hypercalcemia Secondary to Giant Parathyroid Adenoma

Abstract Disclosure: M.P. Lieberman-Ulm: None. M.A. Yanez-Bello: None. V.S. Lagari-Libhaber: None. Background: Parathyroid adenomas are often detected in asymptomatic patients without palpable neck mass and are responsible for 80 to 85% of cases of primary hyperparathyroidism. Oversized or “Giant” parathyroid adenomas (GPAs) are defined as parathyroid adenomas that weigh more than 3.5 g. These are rare, representing less than 1.5% of parathyroid adenomas. The majority of reported cases of GPAs are associated with elevation of PTH and calcium levels, though usually not as high as is seen in patients with parathyroid carcinoma, where PTH levels typically reach greater than three times the upper limit of normal and serum calcium greater than 14 mg/dL. Clinical Case: A 73-year-old man presented with altered mental status and was found to have severe hypercalcemia (serum calcium 20.5 mg/dL, albumin 4.4 g/dL) and AKI stage III (eGFR 16 mL/min/1.73m2). Physical exam showed palpable, mobile, left-sided fullness, and further lab evaluation revealed intact PTH of 2,934 pg/mL, vitamin D, 25-OH of 24.8 ng/mL, and PTHrP of 14 ng/mL. Phosphorous level was not collected prior to treatment. Neck ultrasound was unremarkable. CT revealed a 9 cm hypodense lesion inseparable from the posterior aspect of the left thyroid lobe extending inferiorly to the posterior mediastinum at the level of the carina. Sestamibi scan showed scintigraphic evidence of parathyroid adenoma in the left tracheoesophageal groove. Patient was treated with IV fluids, zoledronic acid, calcitonin, cinacalcet and furosemide in addition to receiving hemodialysis on arrival. He then underwent resection of the mediastinal parathyroid gland. Pathology revealed parathyroid adenoma (16.6 g) without evidence of gross or microscopic invasion into adjacent structures, vascular or perineural invasion. Size greater than 3.5 g classified this mass as a giant parathyroid adenoma. Post-operatively, the patient’s PTH and corrected calcium normalized (17 pg/mL and 9.4 mg/dL, respectively). Conclusion: Giant parathyroid adenomas are a rare cause of primary hyperparathyroidism. Generally, parathyroid adenomas present with less severe clinical and biochemical characteristics than those of parathyroid carcinomas. However, the characteristics of GPA can be similar to parathyroid carcinoma, and differentiating between the two can be challenging. Parathyroid masses are differentiated with histologic diagnosis along with haematoxylin and eosin stain findings. In the case of our patient, his clinical picture was suggestive of parathyroid carcinoma given the severity of his disease, but pathology revealed parathyroid adenoma. Additionally, his calcium and PTH levels normalized after parathyroidectomy. This case may be representative of rare, aggressive giant parathyroid adenoma, however close follow up is imperative to ensure patient does not develop metastatic disease in the future, which would suggest underlying malignancy all along. Presentation: 6/2/2024

8426 Recurrence of Papillary Thyroid Carcinoma Despite Undetectable Levels of Thyroglobulin Measured by Both Immunoassay and LCMS

Abstract Disclosure: M.G. Hamilton: None. G. Patel: None. S. Teja Sathi: None. K. Win: None. P. Lekprasert: None. Serum thyroglobulin (Tg) levels are affected by the presence of anti-thyroglobulin antibodies (anti-Tg Abs) during surveillance of differentiated thyroid cancer (DTC). About 20% of patients have positive anti-Tg Abs post-thyroidectomy and laboratory investigations for DTC surveillance may lead to false negative results. Liquid chromatography-tandem mass spectrometry (LCMS) is superior to immunoassay in measuring Tg levels in patients with the presence of anti-Tg Abs. Mass spectrometry is the only currently available method that could eliminate the interference of anti-Tg Abs in the quantification of Tg but is not readily available. We present the case of a patient who had a recurrence of DTC despite persistently undetectable Tg levels using both immunoassay and LCMS methods. The patient is a 49-year-old female with a history of papillary thyroid cancer who underwent total thyroidectomy followed by adjuvant radio-ablation. She presented to our endocrinology office for routine follow up for her DTC. She reported subjective unknown weight loss over four months. Her physical exam was unremarkable with no palpable neck swelling or mass. Vital signs were within normal limits. She continued to have undetectable levels of Tg as measured by immunoassay, stable levels of anti-Tg Abs ranging from 19 IU/mL to 33 IU/mL, and negative findings on her thyroid ultrasound for the first four years post-op. When she presented to the office five years post-thyroidectomy her anti-Tg Ab level had increased to 114 IU/mL and subsequently to 137 IU/mL a few months later despite undetectable Tg levels on both immunoassay and LCMS. A thyroid ultrasound was completed due to rising anti-Tg Abs levels which showed a suspicious one cm mass at the right thyroid bed and suspicious bilateral cervical lymph nodes. Repeated FNA biopsy of the bilateral cervical lymph nodes confirmed follicular epithelium with nuclear inclusions and grooves, compatible with recurrent papillary thyroid carcinoma. This patient had a recurrence of her DTC despite undetectable Tg levels on both immunoassay and LCMS. Tg is an important aspect of surveillance post-treatment for all patients with DTC because its presence is a surrogate for the presence of thyroid tissue and therefore the recurrence of thyroid malignancy. Clinicians must have a high index of suspicion when monitoring a patient with a history of DTC and the presence of anti-Tg Abs because it interferes with the accurate measurement of Tg levels. A study conducted by Azmat et al. demonstrated that measuring Tg levels via LCMS has been found to eliminate the confounding effect of anti-Tg Abs with a sensitivity and specificity of 44.4% and 94.1% respectively. However, our case illustrates that even LCMS is not always reliable in such situations, and increasing levels of anti-Tg Abs should be an individual risk factor for suspecting recurrence of DTC. Presentation: 6/3/2024

Isolated external jugular thrombophlebitis secondary to acute pharyngitis: a case report and a review of the literature

BackgroundExternal Jugular Thrombophlebitis (EJT) is a rare clinical phenomenon with few reports in the literature, especially in the pediatric population. This is a report of an unusual case of right-sided EJT in a pediatric patient secondary to acute pharyngitis with sinusitis most prominent on the left side.Case presentationA 13-year-old presented to the emergency department with worsening upper respiratory infectious (URI) symptoms and facial swelling, cough, throat pain, and emesis. The patient had traveled to Switzerland and received amoxicillin for strep throat 6 weeks before this hospitalization. Physical examination revealed nasal purulence, allodynia over the right side of the face without overlying erythema, and oropharyngeal exudate. CT scan revealed left-sided predominate sinusitis and right external jugular vein thrombosis. Blood cultures confirmed the presence of group A streptococcus infection. Treatment included IV antibiotics, non-steroidal anti-inflammatory drugs (NSAIDs), IV steroids, and anticoagulation. Follow-up imaging demonstrated improvement in thrombosis, cellulitis, and sinus disease. The patient was discharged on antibiotics for 6 weeks and anticoagulation for 10 weeks. Follow-up imaging at 6 months revealed no EJT, and medications were discontinued.ConclusionsEJT is a rare condition, and to our knowledge, no reports of EJT with sinusitis most pronounced on the contralateral side have been published. Physicians will benefit from noting clinical signs of EJT such as facial edema, headache, erythema, and palpable neck mass, especially if these symptoms occur with URI symptoms refractory to treatment. The use of anticoagulation is controversial for internal jugular vein thrombosis, and while no guidelines for EJT exist, anticoagulation is likely not necessary save for severe complications.

A prospective study to assess clinicopathological correlation of head and neck masses

Background: One of the most frequent clinical manifestations in the field of otorhinolaryngology is a mass in the head and neck area. A thorough history and good clinical examination including the findings of inspection and palpation are key factors for near accurate provisional diagnosis but histopathological is the gold standard for confirmation. FNAC is an easy, efficient, and affordable way to sample superficial neck masses. Methods: The present research has been performed on 100 patients presenting with clinically palpable head and neck masses in the ENT OPD of Rajindra Hospital, Patiala for duration of 2 years (2021-2023). Clinical diagnosis was correlated with cytology and histopathology findings. The data was compiled and evaluated using adequate statistical tools. Results: In this research, 100 cases of head and neck swellings were examined. Out of 100 swellings, 39 patients had lymph node swellings, 31 presented with thyroid swelling, 20 had salivary gland swelling and 10 were miscellaneous. In this study, most of the swellings found to be inflammatory in nature. Women were far more likely to be involved than men. Clinical and cytological diagnoses were made in all cases. Conclusions: When compared to a biopsy, the procedure of fine needle aspiration cytology for head and neck swellings is not only less invasive but also more cost-effective, and causes far less pain. It is possible to execute the procedure successfully on elderly people and children without the need for anesthesia.

Angiomyomatous hamartoma: Unusual presentation of a rare entity

Angiomyomatous hamartoma (AMH) is a rare benign vascular growth primarily affecting inguinal and femoral lymph nodes (LNs). Here, we present a unique case of AMH manifesting as a submental neck mass, a location seldom reported in literature. A 20-year-old male presented with a palpable midline neck mass adjacent to the hyoid bone. Ultrasonography suggested a partially cystic lesion, prompting consideration of thyroglossal duct cyst or necrotic lymph node. Fine-needle aspiration (FNA) hinted at a benign cystic lesion, potentially a thyroglossal duct cyst. Surgical excision via the Sistrunk approach revealed no cyst but characteristic features of AMH upon histopathological examination. This case underscores the importance of considering AMH in the differential diagnosis of subcutaneous nodules in unusual locations and highlights the role of surgical excision for both diagnosis and treatment. Our findings expand the understanding of AMH's clinical presentation and emphasize the necessity of a comprehensive differential diagnosis approach for nodal lesions.

Intraluminal extension of papillary thyroid carcinoma into the Internal Jugular Vein; a case report

BackgroundPapillary thyroid carcinoma (PTC), being the most common thyroid malignancy, is a slow-growing tumor and is usually limited to the thyroid. Extra thyroid extension is uncommon; besides, invasion to the vasculature seems to be extremely rare and usually indicates aggressive nature of the disease.Case presentationWe present a case of a 40-year-old lady who referred with a palpable neck mass a month after total thyroidectomy which its histopathologic examination revealed follicular variant of PTC; the same variant as prior thyroidectomy. Preoperative ultrasonography failed to comment on the intravascular component of the mass. Surgical procedure confirmed a mass attaching and infiltrating to the internal jugular vein, which turned out to be persistent disease.ConclusionsAwareness of this entity is important for surgeons, oncologists and radiologist as it can influence patient management.

Clinical Characteristics of Primary Thyroid Lymphoma

Background and Objectives Primary thyroid lymphoma is rare in thyroid cancer and also in extranodal lymphoma. As such, there has been only a few studies done on this rare disease, and this study evaluated its clinical characteristics and prognosis.Subjects and Method A retrospective review was conducted on 18 patients who were treated for primary thyroid lymphoma between January 2006 and December 2021. We investigated clinical, radiologic, pathologic findings, treatment modalities and prognosis.Results The study involved 18 patients, all of whom were confirmed through histopathological assessments via thyroidectomy (5/18), core needle biopsy (12/18), and incisional biopsy (1/18). Among these, three patients were male, while 15 were female, with a mean age of 66.4±8.78 (49-82). The most common symptom was a palpable neck mass (8/18). The most common pathologic type was diffuse large B cell lymphoma (9 patients), followed by mucosaassociated lymphoid tissue lymphoma (6 patients). At the time of diagnosis, 3 (20.0%) 8 (53.3%), 0, and 4 (26.7%) number of patients were found in Stage I, II, III and IV, respectively. Twelve patients received chemotherapy and three patients received radiation therapy. Three patients were lost to follow-up without treatment.Conclusion Primary thyroid lymphoma should be included in differential diagnosis when making a diagnosis for rapid growing thyroid nodule. Core needle biopsy is considered as first line pathologic diagnostic tool due to limitation of fine needle cytology.

P-83 Primary thyroid lymphoma presented with hypercalcemia and rapidly growing neck mass

Abstract Introduction Primary thyroid lymphoma is an uncommon malignancy, accounting for 1% to 2% of extranodal lymphomas and 1% to 5% of thyroid malignancies. Large B-cell lymphoma is the most prevalent form of primary thyroid lymphoma. Here, we present a patient with hypercalcemia and a rapidly growing neck lesion who was diagnosed with diffuse large B-cell lymphoma of the thyroid gland. Clinical Case A 75-year-old patient presented to the emergency room with loss of appetite and decreased oral intake over the previous five days, as well as abdominal pain and inability to pass gas and feces. The nausea and vomiting symptoms began simultaneously with the abdominal discomfort. Inspection revealed a distinct, palpable, and erythematous mass in the patient's neck, which the patient reported developing within the previous three months. After noticing the growing mass and consulting her primary care physician, she was referred to an ENT specialist; a biopsy was conducted and the results were pending. Her preliminary laboratory results revealed hypercalcemia and renal failure with depressed parathyroid hormone levels. The following were the initial laboratory results: creatinine 2,14 mg/dL, Ca 13,5 mg/dL, Albumin: 4,2 g/dL, P 2,9 mg/dL, Mg:1 mg/dl, parathormone 11.6 ng/dL procalcitonin 0.04% ng/mL and hemoglobin 10.2% g/dl. Abdominal CT revealed a contracted gallbladder with stone formations in the lumen, but no other abnormalities. The patient was admitted to the internal medicine ward with an initial diagnosis of hypercalcemia and prerenal acute kidney failure as a result of decreased oral intake. The patient's hypercalcemia was determined to be PTH-independent, and malignancy was suspected due to a 4-month history of progressive neck lesion. The thyroid gland was 49×40×87mm in the right and 38×40×62mm in the left, and the isthmus was 50mm thick with lobulated outlines on contrast enhanced cervical MR. The signal intensity of parenchyma was heterogeneous. 18F-FDG PET/CT uncovered a bilateral, distinct increase in the size of the thyroid gland with protrusions to the hyoid bone in superior sequences. The solid mass was found to have diffusely increased FDG uptake and a hypermetabolic pattern, both of which are indicative of malignant characteristics. The lesions encompass the trachea and there are reports of invasion of the cricoid cartilage and thyroid cartilage. A second main malignant disease concern was raised when small intestine FDG uptake and wall thickening suggested malignancy. The patient was re-evaluated by the endocrinology clinic, and additional workup tests were ordered due to the suspicion of Riedel Struma, which was based on the control sedimentation rate of 93 mm/h and the firmness of the gland upon palpation. An open surgical biopsy was performed. The pathology report concluded that it is consistent with diffuse large B-cell lymphoma that is CD20-positive. The hematology department has scheduled chemotherapy treatment for the patient.

Complexity of diagnosis and management of a giant thyroid nodule: A case report and a concise literature.

It is crucial for doctors to decide whether a thyroid nodule is benign or malignant when a patient presents with one, as it will significantly impact how the patient is managed in the future. However, it is not as straightforward to determine between the two; even a physical examination, thyroid function test, ultrasonography, and biopsy have been well performed. It can be more stressful if a patient has an increased risk of malignancy, such as age (below 20- and above 60-year-old), solid nodule, rapid growth, hoarseness, lymphadenopathy, and microcalcifications on the ultrasonography. The aim of this case was to present the management of a giant thyroid nodule with malignancy presentation and a benign biopsy finding. A 41-year-old male complained of a palpable neck mass, hoarseness, and dysphagia. The thyroid function test was normal. Ultrasonography revealed suspicion of malignancy with category 4 of American College of Radiology-Thyroid Imaging Reporting and Data System (ACR-TIRADS). The biopsy revealed follicular neoplasm, and was classified as Bethesda IV. The patient underwent a total thyroidectomy due to the large tumor size and symptoms. Histopathological findings post-surgery revealed a follicular thyroid adenoma. This case highlights a complex diagnosis and management of follicular thyroid neoplasm due to their potential for both benign and malignant. Comprehensive pre- and post-operative care is essential to determine the nature of nodules. Post-operative follow-up care might improve the patient's outcome and prevent complications.

Role of fine needle aspiration cytology (FNAC) in head and neck lesions in coastal population at a tertiary care hospital – A study of 500 cases

Head and neck swellings are a very common presentation encountered by clinicians and patients across all age groups. Various lesions give rise to head and neck lumps. Swellings can arise from soft tissues, lymph nodes, thyroid gland, salivary glands etc. FNAC being minimally invasive, quick and inexpensive helps in differential diagnosis of head and neck masses.A retrospective study was conducted at Karwar institute of medical sciences Karwar from January 2018 to December 2021 in coastal population, to evaluate the role of FNAC in palpable head and neck masses and also to study their distribution and To evaluate the diagnostic accuracy, sensitivity and specificity of FNAC in diagnosing Head and neck lesions and cyto-histopathological correlation (wherever possible). 500 patients with head and neck swelling underwent FNAC. FNAC diagnosis was correlated with detailed clinical history and investigations. Out of 500 fine needle aspiration procedures 35.6% (178) were of lymph node, 33.8% (169) were of thyroid, 9.6% from salivary gland (48), 17.8% (89) from skin and soft tissue swellings and 3.2% (16) inconclusive. The present study concluded that most of the swellings in head and neck region are benign and affect females more than males. Overall accuracy rate more than 90% and diagnostic accuracy in differentiating non-neoplastic lesions from neoplastic lesions is well established. Our study found that fine needle aspiration cytology to be an easy, safe, rapid, convenient, least invasive, accurate and relatively complication-free outpatient method for diagnosis of lesions of the head and neck

CLINICAL AND IMAGING CHARACTERISTICS, TNM STAGING OF PATIENTS WITH CERVICAL LYMPH NODE METASTASES IN PAPILLARY THYROID CANCER AT CAN THO ONCOLOGY HOSPITAL

Background: Thyroid carcinomas are the most common endocrine malignancies. The cervical lymph node metastasis rate in patients with PTC ranges from 30-80% and there is a significant difference in survival at 14 years for those with and without lymph node metastases. Therefore, the early detection of metastatic cervical lymph nodes plays an essential role in deciding upon the optimal surgical treatment plan for the majority of patients, which will allow careful postoperative screening, adjuvant therapies, and minimizes the chance of disease recurrence, so we conducted this study. Objectives: To evaluate clinical and imaging characteristics, TNM staging of papillary thyroid carcinoma patients with cervical lymph node metastases at Can Tho Oncology Hospital between 2021 and 2023. Materials and methods: This was a descriptive cross-sectional study, including 52 patients who underwent total thyroidectomy and therapeutic neck dissection. Evaluating general characteristics such as age, gender, reasons for encounter, thyroid nodule and cervical lymph node characteristics on clinical examination and imaging, cancer staging. Results: The average age was 40.0 ± 14.1 years (range 13 - 71). The female/male ratio was 2.5:1. The most common age group was <55 years (86.5%). Half of the patients (50%) were admitted to our institute due to palpable neck mass. The proportion of palpable nodules on clinical examination was three quarters. Nodule locating in a single lobe was the dominant characteristic (about 90%). The TIRADS classifications were TIRADS 5 (55.8%), TIRADS 4 (40.4%) and TIRADS 3 (3.8%). The common location of metastatic cervical lymph node was lateral compartment (86.6%). The absence of central hilar structure shown on ultrasound was 94.2%. Stage I thyroid cancer had the highest rate (84.6%). Conclusions: The presence of nodules in a single lobe was the most notable characteristic of thyroid cancer. TIRADS 4 and 5 were shown on ultrasonography in the majority of patients. The lateral compartment was the most common location for metastatic cervical lymph nodes, while the central hilar structure of those nodes mostly absent.

SAT206 A Case Of Parathyroid Carcinoma Presenting As A Parathyroid Adenoma

Abstract Disclosure: P. Subarajan: None. A. Boutsicaris: None. C.A. Poku: None. N. Lopez: None. Distinguishing between parathyroid adenoma (PA) and parathyroid cancer (PC) in patients with primary hyperparathyroidism (PHPT) can be difficult to determine before pathology results. Estimates vary between studies, but roughly 85% of cases of PHPT are PAs. We present a case of a PC that presented clinically as a PA. A 59 year old female presented to Endocrinology for hypercalcemia that was incidentally noted to be 13.8 and 12.8 on initial recheck. Endocrinology completed a secondary workup of the hypercalcemia which noted a PTH of 147 in the setting of a calcium (Ca) of 12.6. Lab review showed that her corrected Ca had been elevated over the preceding 2 years. She had a replete 25-OH vitamin D of 43 and a GFR of 29. A neck ultrasound revealed a 2.1 cm mass suspicious for a parathyroid mass. A sestamibi scan was consistent with increased focal uptake at the inferior pole of the right thyroid lobe. She had renal dysfunction, hypercalcemia and newly diagnosed osteoporosis which prompted referral to endocrine surgery. Intraoperatively, an enlarged right inferior parathyroid gland and a large mass encompassing the inferior thyroid pole extending into the anterior mediastinum with lymphadenopathy were noted. En Bloc resection was completed and final pathology was consistent with high grade parathyroid carcinoma infiltrating the adjacent thyroid gland. Genetic testing for HPT-JT was negative and ultrasound monitoring has remained negative. PC is rare and typically has a clinical presentation and course that sets it apart from PA. The PTH is typically 3-10 times above the upper limit of normal in PC and only 1-2 times above the upper limit of normal in PA. As a result of the variation in PTH, serum Ca is more elevated in PC than PA. PC patients typically present with a parathyrotoxicosis that is profound. A palpable neck mass can be present in 40-70% of individuals with PC. Our patient had an equivocal presentation that appeared more consistent with PA, which can be problematic when deciding on the optimal surgical approach. Amino-PTH is hypersecreted in PC and reacts with 3rd generation PTH assays, but not second generation assays. Clinically, using a third/second generation PTH assay ratio >1 can support a possible clinical suspicion of PC over PA. En Bloc resection is the surgical approach of choice for suspected PC. En Bloc resection may not always be done for a patient with a presentation and evaluation consistent with PA: data shows that only 12.5% of PC patients underwent En Bloc resection, as opposed to 78.6% who underwent parathyroidectomy alone. This puts patients at risk of requiring repeat surgical intervention and poses a higher risk for recurrence. It brings to question whether every PA should be addressed with an En Bloc resection to avoid this inherent risk. This case adds to the literature of PC presenting as PA and supports the argument for standard En Bloc resection in all cases. Presentation: Saturday, June 17, 2023

SAT209 Metastatic Parathyroid Carcinoma And The Challenge Of Maintaining Calcium Balance

Abstract Disclosure: K.M. Tuna: None. S. Badour: None. E.P. Monsour: None. G. Acosta Garcia: None. D. Barb: None. Background: Parathyroid carcinoma is a rare malignancy representing less than 1% of all parathyroid disorders. Presentation is significant for highly elevated calcium (Ca) and parathyroid hormone (PTH) levels, and usually a palpable neck mass (>3cm). Diagnosis is often made after surgery based on histopathology findings. The primary treatment modality remains surgical, but there is no effective approach for metastatic disease. Case presentation: A 51-year-old woman initially presented with multinodular goiter and compressive symptoms in 2008. Workup showed an elevated Ca of 14.4 mg/dl (normal 8.4-10.2 mg/dl) and PTH of 502 pg/ml (normal 12-88 pg/ml) while albumin 4.3 g/dl (normal 3.5-5.2 g/dl) and normal thyroid function tests. Radioactive Iodine uptake scan showed a 4.4 cm cold nodule on the right inferior pole. Sestamibi scan showed increased left upper pole activity. The patient underwent total thyroidectomy with surgical exploration for parathyroid adenoma. Pathology showed right intrathyroidal parathyroid carcinoma with lymphovascular invasion. The patient was lost to follow-up until 2022 when she was admitted with severe hypercalcemic crisis (Ca 15.8 mg/dl, Albumin 3.9 g/dl, and PTH 805 pg/ml). The patient was treated with IV fluids, calcitonin, and multiple rounds of bisphosphonates, and was then maintained on high-dose cinacalcet due to refractory and recurrent hypercalcemia. Repeat Sestamibi and neck US were unremarkable, although CT chest showed a 1.3 cm nodule in the right lower lung lobe. This was not FDG- nor DOTATATE-avid on PET-CT. The patient underwent laparoscopic wedge resection of the right lung nodule, and the pathology was consistent with metastatic parathyroid carcinoma. Her Ca and PTH levels normalized immediately after surgery (PTH decreased from 883 to 27 pg/ml) suggesting possible remission. Prior to discharge, she was started on oral calcium and vitamin D due to dropping Ca levels and clinical signs of hungry bone syndrome. She was readmitted one month later for preexistent heart failure exacerbation and declining renal function. Her PTH was noted to be elevated again, although Ca remained normal, raising concern for recurrent or persistent disease. However, the patient’s renal impairment and lung effusion limited further imaging. Ca and PTH were monitored frequently during hospitalization and weekly after discharge. PTH levels peaked at 634 pg/ml and then dropped to 127 pg/ml without intervention. Ca remained in the normal range while on calcium citrate and calcitriol. Conclusion: Treatment of metastatic parathyroid carcinoma remains a challenge. Mortality is secondary to complications of hypercalcemia; therefore, controlling calcium levels should be the main therapeutic goal. Hungry bone syndrome should be considered after surgery. Metastatic disease may occur even after 20 years; thus, lifelong close monitoring is indicated. Presentation: Saturday, June 17, 2023

FRI368 Thyroid Paraganglioma: A Rare Manifestation Of Paraganglioma Syndrome Associated With SDHD Mutation

Abstract Disclosure: K. Samuel: None. C. McMullen: None. C. Veloski: None. S. Kushchayev: None. J.E. Hallanger-Johnson: None. J. Hernandez Prera: None. J. Muzaffar: None. G.Q. Yang: None. V. Tarasova: None. Background: Thyroid paragangliomas (TP) are exceptionally rare, representing 0.5% of all paragangliomas (PGL) with total of less than 70 cases reported to date. We report a case of a TP presenting with an indeterminate thyroid nodule, as a first manifestation of multifocal head and neck PGL, associated with succinate dehydrogenase complex subunit D (SDHD) mutation. Clinical case: A 59-year female was initially seen at the tertiary referral center for an indeterminate thyroid nodule discovered incidentally on neck ultrasound (US) ordered for evaluation of a palpable posterior left neck mass. Neck/thyroid US showed multiple nonspecific bilateral lymph nodes measuring up to 1.2 cm and a 1.7 cm right interpolar markedly hypoechoic and hypervascular solid thyroid nodule (TR5). Clinically, the patient did not have symptoms related to the thyroid nodules or lymph nodes in the neck. Thyroid function tests were within normal range. An US-guided FNA biopsy was nondiagnostic. Core biopsy was suspicious for papillary thyroid carcinoma (hypercellular thyroid parenchyma with some follicular cells with nuclear irregularity, grooves, and hyperchromasia). Pathology slides review at the tertiary center showed nondiagnostic sample (Bethesda I) on cytopathology and neuroendocrine neoplasm consistent with PGL on core biopsy (immunohistochemical stains showed tumor cells positive for synaptophysin, chromogranin and GATA3. TTF1, TG, calcitonin, CEA and AE1/3 negative). US of the neck/thyroid 4 months later showed stable disease. Calcitonin and 24-h urinary catecholamines, metanephrines were within normal limits. There was no family history of pheochromocytoma or PGL. Genetic testing showed germline SDHD mutation (p.P81L(c.242c>5). 68Ga-DOTATATE PET/CT revealed multifocal areas of increased somatostatin receptor expression from the skull base to the left thoracic inlet, which included right and left skull base lesions, left neck level IIA lymph node, right and left level III lymph nodes, right thyroid lobe lesion, and left prevascular superior mediastinal lesion. An MRI of the brain and neck with and without contrast showed 1.7 cm right jugular, 0.6 cm right carotid, and 0.6 cm left vagal PGL, 1.3 cm right thyroid nodule, left level II 1.1x.6 cm lymphadenopathy, and 0.4 cm left superior mediastinal nodule. A CT of the neck w/contrast showed multiple areas likely representing bilateral carotid body tumors, left vagal PGL, right glomus jugular, and thyroid PGL stable over 6 months. MIBG nuclear medicine scan revealed no radiotracer accumulation in the lesions. EBRT therapy is planned to the skull base lesion. Conclusions: TP should be considered in the differential diagnosis of hypervascular thyroid nodules in patients with SDH-related pheochromocytoma-PGL syndromes. This case illustrates the importance of experienced multidisciplinary team evaluation and management of complex and rare PRG cases. Presentation: Friday, June 16, 2023

SAT314 Bilateral Sporadic Carotid Paraganglioma As A Rare Cause Of Syncope

Abstract Disclosure: A.G. Olafimihan: None. U.A. Ogar: None. I. Asemota: None. E. Krishnaraju: None. A. Okafor: None. Introduction: Carotid body tumors (CBT) are rare, mostly non-secretory skull-based neuroendocrine tumors originating from the parasympathetic ganglia. They are the most common (60%) paragangliomas of the head and neck. Bilaterality is seen in 5% of patients with sporadic CBT. CBT mainly presents as an asymptomatic neck mass. Seldomly, it compresses the carotid sinus, inducing bradycardia and hypotension, and presenting with recurrent syncope. Case presentation: A 70-year-old Eritrean woman visiting the US with a history of myasthenia gravis status post thymectomy on pyridostigmine presented following an episode of presyncope with five similar episodes in the past year. She described it as sudden onset lightheadedness that resolves with sitting and sometimes results in syncope. She had no palpitations, headaches, or sweating.Her admitting vital signs were significant for bradycardia (48bpm) with hypotension (112/54mmhg). A physical exam revealed mobile, mildly tender, palpable neck masses bilaterally, with reproducible worsening bradycardia on palpation of the masses. ECG was unremarkable except for sinus bradycardia. A CT angiogram head and neck with contrast showed multiple hyper-enhancing lesions (two on the right, one on the left; largest = 1.6 x 1.0 cm) at the junction of bilateral carotid bulbs suggestive of multiple paragangliomas. An MRI of the neck re-demonstrated these lesions with the classical ‘salt and pepper’ appearance. CT of the brain, chest, abdomen and pelvis were negative for metastatic lesions. Biochemical testing including plasma metanephrines, catecholamines and dopamine levels was normal, suggesting nonfunctional tumors. Genetic testing was negative for mutations associated with paragangliomas. She did not have more episodes during her three-day admission but remained bradycardic with uneventful telemetry. She was counseled to avoid sudden neck movement and neck pressure. She was discharged with multidisciplinary (endocrinology, neurology, vascular surgery, and ENT surgery) outpatient follow-up. Over the five months post-discharge, she had only two mild symptomatic episodes. Following multi-specialist deliberations at the tumor board, including a risk-benefit assessment of a surgical excision, and extensive discussions with our patient and her family, the decision to hold off surgery was made. Surgical intervention was associated with possible vagal nerve injury, and high aspiration risk given her comorbid myasthenia gravis. Her conservative management plan included a cardiology work-up for symptom-directed therapy with a pacemaker placement. Conclusion: Recurrent syncope is an uncommon presentation of carotid body tumors requiring workup to rule out functionality, genetic mutations, and metastases. Management involves a multi-disciplinary approach and individual risk-benefit assessment of treatment options. Presentation: Saturday, June 17, 2023

AIUM Practice Parameter for the Performance and Interpretation of Diagnostic Ultrasound of the Thyroid and Extracranial Head and Neck.

AIUM Practice Parameter for the Performance and Interpretation of Diagnostic Ultrasound of the Thyroid and Extracranial Head and Neck.

Infected Ruptured Parathyroid Cyst Presenting with Hypercalcemia and Airway Obstruction: A Case Report.

Parathyroid cysts (PC) are infrequently encountered and characterize less than 1% of all head and neck masses. When present, PCs may present as a palpable neck mass and lead to hypercalcemia and rarely respiratory depression. Furthermore, the diagnostics of PCs is difficult as they can masquerade as a thyroid or mediastinal mass given their proximity. PCs are theorized to be a progression of parathyroid adenomas and often routine surgical excision is sufficient for cure. To our knowledge, there is no documented report of a patient with an infected parathyroid cyst that led to severe dyspnea. This case describes our experience of a patient with an infected parathyroid cyst presenting as hypercalcemia and airway obstruction.

An unusual presentation of coexisting parathyroid carcinoma and papillary carcinoma thyroid: a case report and literature review

Parathyroid carcinoma is the rarest endocrine cancer with aggressive behaviour. It may be presented as a feature of severe hypercalcemia, musculoskeletal involvement and a neck mass. There should be a high clinical suspicion if there is marked hypercalcemia, very high parathyroid hormone levels, palpable neck mass, recurrent laryngeal nerve palsy due to invasion and severe bone and renal symptoms. Thyroid pathology has been seen in 15-70% of patients with primary hyperparathyroidism (PHPT) especially with parathyroid adenoma. Medullary thyroid carcinoma is common with PHPT as in MEN 2 syndrome and rarely co-existed with non-medullary thyroid carcinoma. Parathyroid carcinoma and papillary thyroid carcinoma is extremely rare. Only 16 cases are reported in the literature.

Difficult situation in treatment of medullary thyroid carcinoma in patient with multiple endocrine neoplasia type 2 B(MEN2B)

Abstract Introduction Multiple endocrine neoplasia type 2B (also known as ‘MEN2B’,‘Multiple endocrine neoplasia type 3′ or ‘Wagenmann–Froboese syndrome’) is a genetic disease characterized by the presence of medullary carcinoma of the thyroid, pheochromocytoma, mucosal neuromas, marfanoid features and multiple skeletal abnormalities such as kyphoscoliosis and pes cavus. Clinical Case A 16 years male presented with neck swelling and dysmorphic feature in the form of marfanoid habitus, including multiple tongue and oral mucosal swelling with mucosal neuromas on the anterior third of the tongue, the lips and the inner eyelid. Lips are thickened and bumpy. Visible neck swelling, palpable solid neck mass, high arm span to height ratio at >1.05, elongated fingers, pes cavus and positive wrist sign which is defined as when the distal phalanges of the thumb and fifth finger overlap on encircling the opposite wrist, were present. Ultrasound of the neck revealed a left solid irregular mass (57mmx33mm), that is hypoechoic, has coarse calcification, hypervascularity, that is mostly central, Multiple cervical lymph node(abnormal nodes include shape (round), absent hilum, intranodal necrosis, reticulation, calcification, peripheral vascularity),Investigation at beginning, Normal thyroid function test and biochemical and electrolyte were observed, Chest x ray was normal, FNAC done for thyroid nodule that showed multiple clumps of large hyperchromatic oval cells picture suggesting high suspicion of thyroid malignancy, thyroid biopsy advised, The patient was referred the FDEMC center for further evaluation and investigation prior to the surgery. During investigation at FDEMC center, thyroid function test normal, biochemistry normal, including PTH and electrolytes, Calcitonin was very high 465 pg/mL (0.2–27.7 pg/mL),GH under GTT was normal, IGF 1 182µg/L (150–350),Plasma metanephrine 40 pg/ml(<90pg/ml),and Plasma normetanephrine 27pg/ml(<196pg/ml) were normal. The patient referred to surgery, total thyroidectomy with radical neck dissection with multiple lymph node resection was performed. The biopsy revealed medullary thyroid carcinoma with cervical lymph node secondaries (bilateral multiple foci in both lobes). The patient kept on levothyroxine tab 100mcg.The follow up of the patient after one month by ultrasound and calcitonin level revealed residual thyroid tissue and two large cervical LN in the the ultrasound and a calcitonin level of 322 pg/mL Another surgical neck dissection to the metastatic LN <multiple LN 7×5cm, multiple suprasternal mass dissection 3×2.5cm,remnant of thyroid tissue 0.8cm,Follow up the patient after one month by ultrasound and calcitonin level still showed that there is residual pathological cervical LN, while the calcitonin level still high 412 pg/mL. PET scan done for him showed there is uptake in the head, neck and chest. The calcitonin was repeatedly was high.

Papillary thyroid carcinoma metastasis to a branchial cleft cyst

Branchial cleft cysts (BCCs) are the most common benign masses of the lateral neck. However, rarely, it can develop into a malignant cyst, either as a primary or a metastatic lesion. We report an extremely rare case of papillary thyroid carcinoma (PTC) metastasis to the BCC. The patient clinically presented with a palpable neck mass, and computed tomography revealed a well-defined, thin-walled cystic mass with a small contrast-enhanced mural nodule. Surgical excision of the cystic mass was performed, and the histopathologic results revealed a BCC with a microscopic papillary carcinoma. Thyroid evaluation and thyroidectomy were subsequently performed, and a PTC was confirmed. The imaging findings and differential diagnosis are discussed in this report.