Paratracheal Region Research Articles

Advanced Squamous Cell Carcinoma in the Paratracheal Region: Navigating Diagnosis and Comprehensive Treatment Challenges

Advanced Squamous Cell Carcinoma in the Paratracheal Region: Navigating Diagnosis and Comprehensive Treatment Challenges

7506 Rare Case of Hyperparathyroidism in Third Trimester Pregnancy Requiring Urgent Parathyroidectomy

Abstract Disclosure: A. Rothstein Costris: None. E. Davydov: None. S. Levy: None. Introduction: Primary hyperparathyroidism (PHPT) during pregnancy has risks to both the mother and her fetus. Complications include maternal pre-eclampsia, miscarriage, hyperemesis gravidarum, nephrolithiasis and pancreatitis. Fetal complications encompass hypocalcemia, tetany, intrauterine growth retardation and fetal demise. Though medical treatment is available, parathyroidectomy is the only definitive treatment. Traditionally, surgery is done in the second trimester of pregnancy. We report a case of a third trimester parathyroidectomy in a 29 yo female with PHPT. Case representation: A 29-year-old G1P0 woman at 28 weeks gestation presented with persistent nausea and vomiting, constipation, joint pain, and increased forgetfulness. She has moved to USA from Saudi Arabia and had not received prenatal care in the USA. She was found to have a PTH of 224 (15-65 pg/mL), Calcium of 13.5 (8.2-10.2 mg/dL), Ionized Calcium of 1.63 (1.00-1.35 mmol/L), and a corrected Calcium of 14.2 (8.7-10.1 mg/dL). Electrolyte abnormalities were also noticed, with a Potassium of 2.8 (3.5-5 mmol/L), Phosphorus of 1.7 (2.5-4.5 mg/dL) and Magnesium of 1.2 (1.8-2.3 mg/dL). Vit. D levels were found to be extremely low <7 (20-40 ng/mL). Due to severe dehydration, persistent nausea, vomiting, and hypercalcemia, the patient received fluid resuscitation and Vit. D supplementation. A neck CT scan identified an 11 x 6 x 14 mm arterially hyperenhancing soft tissue structure at T1-T2, suggesting a probable parathyroid adenoma in the right paratracheal region. Management options included surgery or conservative therapy with fluids and Cinacalcet. A joint decision was made between Maternal Fetal Medicine, ENT and Endocrinology to proceed with parathyroidectomy. Surgical excision revealed an enlarged, hypercellular right inferior parathyroid gland (0.51g). Postoperative laboratory studies at 2 weeks showed normal PTH, Ca, Ionized Ca. Conclusion: It is preferable to conduct surgery for PHPT during the second trimester of pregnancy. However, when PHPT leads to severe symptoms, surgery might be considered in the third trimester. The severity of our patient’s symptoms led to inability to tolerate oral intake, deeming surgery necessary. The multidisciplinary team agreed that surgery in the third trimester would be the best course of treatment as it will result in normocalcemia immediately. Second trimester parathyroidectomy is viewed as safer due to the completion of organogenesis and lower teratogenicity risks. Performance of surgery during the third trimester may lead to an increase in the risk of premature birth. However, untreated hypercalcemia may increase fetal loss and thus third trimester parathyroidectomy can be considered as a treatment option for PHPT in pregnancy. It is also imperative to discuss all options with the patient. In our case, the patient had opted for surgery which was successful. Presentation: 6/3/2024

Role of EBUS in lymphoma presenting as superior vena cava syndrome: bronchoscopic and sonographic findings: a case report

BackgroundThe clinical description of superior vena cava syndrome has been widely studied; however, there is limited information on bronchoscopic findings in clinical practice.Case presentationA 57-year-old man presented with facial and neck swelling and pedal edema of 6 months duration. Computed tomography showed mediastinal lesions in the right paratracheal stations with thrombosis of the right internal jugular vein and superior vena cava (SVC). Without establishing a diagnosis, he was started on oral steroids elsewhere and his symptoms progressed. He did not receive anticoagulation therapy. Bronchoscopy showed edematous supraglottic and glottic regions with hyperemia of the airway mucosa. Endobronchial Ultrasonography revealed a mediastinal mass of heterogeneous echotexture in the lower right paratracheal region, with mediastinal collateral blood vessels. He underwent EBUS-guided aspiration cytology and intranodal forceps biopsy, which confirmed the diagnosis of non-Hodgkin’s.ConclusionIn cases with an unconfirmed diagnosis of lymphoma, it is prudent to refrain from administering glucocorticoids, as these medications can exhibit lympholytic properties and may hinder the diagnostic process. Due to extensive collateral formation in superior vena cava syndrome, utilizing Doppler during endobronchial ultrasound transbronchial needle aspiration (EBUS TBNA) can identify numerous mediastinal collateral vessels, thus minimizing the risk of bleeding.

SAT208 Hypercalcemic Crisis In Metastatic Parathyroid Carcinoma: An Unusual Presentation Of A Rare Endocrine Disease

Abstract Disclosure: A. Barnett: None. T. Sliker: None. R.J. Harper: None. G. Elshimy: None. Introduction: Hypercalcemia can be life-threatening with a wide differential, including parathyroid carcinoma (PC), which accounts for only 0.005% of all malignancies in the U.S. Maintaining an index of suspicion for PC in PTH-mediated hypercalcemia is vital for improving long-term survival and outcomes. Frozen section can be misleading when PC is suspected. We describe a case of hypercalcemia due to recurrent metastatic PC 9 years after initial diagnosis. Case: A 57-year-old male presented for endophthalmitis and altered mentation. Records revealed primary hyperparathyroidism with calcium 11.7 mg/dL, PTH 337 (11.1-79.5pg/mL), and 24-hour urine calcium 810 mg/day. Sestamibi showed right lower parathyroid adenoma and a possible right upper parathyroid adenoma. Right superior parathyroidectomy revealed PC invasive into adipose tissue, increased vascularity and positive margins. A hemithyroidectomy and central neck dissection was performed with intraoperative report noting normal-appearing right inferior parathyroid affixed to thyroid, confirmed by frozen section biopsy. The right inferior parathyroid was minced and re-implanted into the right strap muscle. Patient did not return for follow-up. Recent admission labs showed calcium 15.2 mg/dL, ionized calcium 6.8 (4.5-5.3mg/dL), PTH 546 pg/mL, creatinine 1.54 mg/dL, 25-OH vitamin D 21.64 ng/mL, and phosphorus 1.9 mg/dL. He was treated with intravenous fluids, zoledronic acid, and calcitonin. Due to a high suspicion of locally recurrent or metastatic PC, further imaging obtained. A Neck CT and US showed no abnormalities of right surgical bed or cervical lymphadenopathy. Sestamibi revealed a right lower lung lobe nodule, measuring 2.3cm, with intense immediate and delayed uptake concerning for metastatic or primary lung neoplasm and mild focal retention in the right paratracheal region, suspicious for tumor recurrence. PTHrP was negative. He underwent video-assisted thoracoscopic right lower lobectomy that showed an ovoid, well-circumscribed 2.5 x 2.3 x 2.3cm tumor, which stained positive for PAX-8 and synaptophysin, consistent with PC. Discussion: Clinicians should suspect PC in cases with severe hypercalcemia or absolute PTH above 500mg/dL to allow for better surgical planning. Complete en bloc resection is the standard treatment to improve long-term outcomes and reduce disease recurrence. Diagnosis of PC following incomplete surgical resection has increased recurrence rates of greater than 50%. Our patient’s recurrence was 9 years after diagnosis, but most recurrences occur within 2-3 years and occasionally more than 20 years later. The ipsilateral parathyroid was re-implanted based on frozen section results in this patient, which may have been misleading. Frozen sections of parathyroid tissue are notoriously difficult to distinguish normal parathyroid versus PC and only diagnostic in 15% of cases as described in one case series. To reduce the risk of recurrent disease, physicians shouldn’t entirely depend on these results when there is high suspicion for PC. Presentation: Saturday, June 17, 2023

SAT570 Thyroid Lymphoma In A Patient With Hashimoto’s Thyroiditis

Abstract Disclosure: T. Aggarwal: None. S. Reyes: None. I.C. Glitza Oliva: None. E. Korytnaya: None. Background:Primary thyroid lymphoma (PTL) accounts for < 5% of thyroid malignancies. Patients with Hashimoto’s thyroiditis (HT) are at greater risk for developing PTL, with a relative risk of 67 compared to those without thyroiditis. The most common and more aggressive subtype of PTL is diffuse large B cell lymphoma (DLBCL) which is found in more than 50% of the cases, followed by MALT lymphoma and follicular lymphoma (FL), which represents only about 10% of cases. PTL can be classified as a nodular, diffuse, or mixed type based upon ultrasound (US) findings. Diffuse type PTL presents the biggest diagnostic challenge due to resemblance to thyroiditis on US imaging. Certain US features such as enhanced posterior echoes, markedly hypoechoic appearance of thyroid tissue and linear echogenic strands are suggestive of diffuse type PTL but can also be seen in HT. Positive predictive value for US was only 33.7% for diffuse type of PTL. Diagnosis of PTL is ultimately established by biopsy with immunophenotypic assessment. Management of PTL includes chemotherapy, radiation therapy or combined modality treatment. Given sensitivity of PTL to radiation and chemotherapy, surgery is rarely performed and is reserved only for alleviation of severe compressive symptoms in aggressive disease or protection of airway. Case Presentation: A 58-year-old female with 10-year history of HT, hypothyroidism and goiter underwent total thyroidectomy due to worsening compressive symptoms in her neck. She denied weight loss, fevers, or night sweats. Preoperative US showed enlarged heterogenous hypoechoic thyroid gland with echogenic strands and normal vascularity, consistent with the appearance in HT. Surgical pathology unexpectedly showed extensive follicular hyperplasia, focal grade 3b FL (80%), and large foci of DLBCL arising within FL (20%). Background changes of oncocyte metaplasia and lymphocytic infiltrates consistent with Hashimoto Thyroiditis were described. Both cytogenic FISH studies as well as immunohistochemistry failed to reveal MYC and BCL2 and/or BCL6 rearrangements. Positron emission tomography (PET) scan showed mild to moderately fluorodeoxyglucose- avid lymph nodes in the right superior mediastinal, right superior paratracheal and left neck region. The patient has completed 6 cycles of R-CHOP chemotherapy with complete response as evidenced by normal follow up PET imaging. Conclusion:PTL is a rare malignancy and less than 1% patients with Hashimoto’s thyroiditis develop thyroid lymphoma. Diffuse- type PTL should be included in the differential diagnosis while managing patients with HT who present with worsening compressive symptoms involving aerodigestive tract and rapid enlargement of goiter and have markedly hypoechoic thyroid gland with heterogenous internal echoes and posterior acoustic enhancement on US images. Presentation: Saturday, June 17, 2023

Effect of left paratracheal pressure on left carotid blood flow.

Gautier et al. demonstrated that a compression in the left paratracheal region (left paratracheal pressure, LPP) can be used to seal the oesophagus. However, at this level, the left common carotid artery is very close to the carotid that could be affected during the manipulation. This study aimed to assess the hemodynamic effects of LPP on the carotid blood flow. We prospectively included 47 healthy adult volunteers. We excluded pregnant women and people with anomalies of the carotid arteries. The common and internal carotid arteries were preliminarily studied with ultrasounds to exclude atheromatous plaques or vascular malformation. A planimetry of the common and internal carotid arteries was performed. Doppler echography served to measure the peak systolic (PSV) and end-diastolic velocities (EDV) in the common and internal carotid arteries. All measurements were repeated while applying LPP. Forty-seven participants were enrolled (32 women; mean [SD] age: 42 [13] years). The mean PSV difference [95% CI] in the left common carotid artery before and after LPP at the group level was -15.30 [-31.09 to 0.48] cm s-1 (p = .14). The mean surface difference [95% CI] in the left common carotid artery before and after LPP was 24.52 [6.11-42.92] mm2 (p = .11). Similarly, the same surface at the level of the left internal carotid artery changed by -18.89 [-51.59 to 13.80] mm2 after LPP (p = .58). Our results suggest that LPP does not have a significant effect on carotid blood flow in individuals without a carotid pathology. However, the safety of the manoeuvre should be evaluated in patients at risk of carotid anomalies.

Optimal Place for Precordial Stethoscope Attachment in Nonintubated Children under Two Years of Age: An Observational Trial

Background: The precordial stethoscope is a non-invasive monitoring method in pediatric anesthesia. We previously investigated optimal place for its attachment among intubated children under two years old. Now we also did in nonintubated children under two years old.
 Methods: Twenty-five patients who underwent general anesthesia in our institution were involved in this study. Lung and heart sounds via precordial stethoscope were recorded (MP3 format) at the six places: Site A (paratracheal region), B (suprasternal notch), C (between place of the nipple and clavicle on the left midclavicular line), D (between place of the costal arch and nipple on the left midclavicular line), E (horizontal level of Site D on the left midaxillary line), and F (epigastric fossa). Two blinded evaluators scored random sorted lung and heart sounds on a 10-point scale (0: cannot hear at all and 10: can hear clearly) individually.
 Results: Statistically significant differences were observed between Sites A: 10.0 (8.5–10.0), B: 9.0 (2.5–9.5), C: 8.0 (6.5-9.0) and D: 1.5 (1.0–6.5), E: 4.5 (1.5–7.0), F: 1.0 (0.0–4.5) for lung sounds and between Sites B: 9.0 (5.0–10.0), C: 9.5 (8.0–10.0), D: 9.0 (4.5–9.5) and A: 0.0 (0.0–0.0), E: 0.5 (0.0–2.5), F: 0.5 (0.0–0.5) for heart sounds.
 Conclusion: Site C is the optimal place for precordial stethoscope attachment for children under two years of age during general anesthesia

ODP585 Occult metastatic medullary thyroid carcinoma without detectable primary tumor.

Abstract Background Occult thyroid cancer is a particularly rare type of thyroid carcinomas. The absolute majority is presented by papillary thyroid carcinoma. We report a case of a medullary thyroid carcinoma (MTC) that was detected as a primary tumor neither on preoperative ultrasound examination nor on postoperative morphological examination. Case A 57-year-old patient with no personal or family history of thyroid disease presented to the surgeon with the complaint of swelling in the cervical lymph nodes. Ultrasonography of the thyroid showed a hypoechoic 4 mm zone with peripheral calcification in the right lobe and two suspicious malignant lymph nodes 14×12 mm and 10×7 mm in the right paratracheal region. A blood test revealed no abnormalities in thyroid function (TSH 0.9 mUI/L, fT3 4.25 pmol/l, fT4 10.2 pmol/l). However, the calcitonin (CT) and the carcinoembryonic antigen (CEA) levels were significantly elevated – 144 pg/ml (N for male <12) and 28 pg/ml (N <5). We performed an ultrasound-guided fine-needle aspiration (FNA) cytology from the thyroid nodule with subsequent FNA-CT measurement which showed no signs of MTC (cells, adequate CT level). On the other hand, FNA of the lymph node revealed cytomorphology characteristics of MTC and according to FNA-CT measurement, the CT concentration exceeded the upper reporting range of 2000 pg/ml. We carried out the measurement of stimulated CT. Taking into account the significant CT level increase (0 min – 168 pg/ml, 2 min – 1050 pg/ml, 5 min – 857 pg/ml), we excluded the extrathyroidal CT production. Genetic analysis demonstrated the absence of usual RET mutation. Computed tomography was carried out showing multiple calcifications up to 6 mm in diameter in the lung. On the cervical scan: the right upper paratracheal lymph node (11 mm) and a 6 mm mass with calcification in the structure along the front line of the right main bronchus (at the level of the bifurcation), the rest of the lymph nodes were not enlarged. The patient underwent total thyroidectomy with central lymph node dissection. On the section in the middle third of the lobe, there was a dense, yellowish-grey knot of 5 mm in size and 8 lymph nodes 5-15 mm. Surprisingly the right lobe node was represented by colloid goiter with foci of fibrosis and calcifications. In two of the eight cervical nodes, we identified nodal metastases that contained a component of MTC. The primary tumor was not detected even after thorough and complete pathologic examination and immunohistochemical study of the thyroid. Postoperative CT level (third day after surgery) has fallen to 5.45 pg/ml. Conclusion Metastatic medullary thyroid carcinoma without detectable primary tumor is a rare but real occurrence that might be encountered in practice. The lack of malignant findings in the thyroid gland during preoperative examination complicates the diagnostic. Presentation: No date and time listed

Extended lower paratracheal lymph node resection during esophagectomy for cancer – safety and necessity

BackgroundThe ideal extent of lymphadenectomy (LAD) in esophageal oncological surgery is debated. There is no evidence for improved survival after standardized paratracheal lymph node resection performing oncological esophagectomy. Lymph nodes from the lower paratracheal station are not standardly resected during 2-field Ivor-Lewis esophagectomy for esophageal cancer. The objective of this study was to evaluate the impact of lower paratracheal lymph node (LPL) resection on perioperative outcome during esophagectomy for cancer and analyze its relevance.MethodsRetrospectively, we identified 200 consecutive patients operated in our center for esophageal cancer from January 2017 – December 2019. Patients with and without lower paratracheal LAD were compared regarding demographic data, tumor characteristics, operative details, postoperative complications, tumor recurrence and overall survival.Results103 out of 200 patients received lower paratracheal lymph node resection. On average, five lymph nodes were resected in the paratracheal region and cancer infiltration was found in two patients. Those two patients suffered from neuroendocrine carcinoma and melanoma respectively. Cases with lower paratracheal lymph node yield had significantly less overall complicated procedures (p = 0.026). Regarding overall survival and recurrence rate no significant difference could be detected between both groups (p = 0.168 and 0.371 respectively).ConclusionThe resection of lower paratracheal lymph nodes during esophagectomy remains debatable for distal squamous cell carcinoma or adenocarcinoma of the esophagus. Tumor infiltration was only found in rare cancer entities. Since resection can be performed safely, we recommend LPL resection on demand.

1008 Incidental Solitary Cystic Mediastinal Lymphangioma with Mass Effect Complications: A Case Report

Abstract Introduction Cystic mediastinal lymphangiomas (CML) are exceedingly rare, representing <1% of cystic lymphangiomas (CL), and typically present before 2 years of age. Few cases describe adult presentations of solitary CML and none describe symptomatic cases with ‘mass-effect’ complications. We describe an incidental finding of a symptomatic solitary CML causing mass effect complications and our definitive surgical management. Case Report A 44-year-old Caucasian male presented with reduced responsiveness due to mixed drug overdose of fluoxetine and ibuprofen. Plain chest radiograph (CXR) revealed incidental new mediastinal widening. Thoracic computed tomography (CT) showed a well-defined lesion (75x63mm) in the right paratracheal region, with associated compression of the superior vena cava, left brachiocephalic vein and displacement of the azygos vein. Further questioning revealed 6-months history of non-productive cough, worsening dyspnoea on exertion and chest pain radiating to the right of the chest. Complete surgical resection was performed via posterolateral thoracotomy. It was seen compressing the 2nd and 3rd intercostal nerves. Enlarged lymph nodes at station 4 and 10 were excised and sent for analysis with aspirate from the excised lesion. Pathological gross examination showed a multiloculated cystic lesion containing thin straw-coloured fluid. Microscopically, it was thin walled with smooth muscle and scattered clusters of lymphocytes; its lining was markedly attenuated comprising bland flat endothelial cells, positive for CD-31. Lymph node samples showed reactive changes. Conclusions Although CMLs are benign, their location and growth in the mediastinum can result in compression of surrounding structures. Early detection and complete surgical resection are paramount to prevent such complications and lesion recurrence.

545 INCIDENCE OF INVOLVEMENT OF PARATRACHEAL LYMPHNODES IN SIEWERT AEG-I TUMORS

Abstract Transthoracic esophagectomy with 2-field-lymphadenectomy (LAD) is the state of the art treatment of resectable adenocarcinoma of the distal esophagus (Siewert-Stein AEG type I) and may be performed in AEG II cardia cancers. However, it remains unclear whether paratracheal LAD contributes to a survival benefit. In this study we collected data regarding lymph node involvement of paratracheal nodes. Methods From 2014 to 2019 consecutive patients were included in the prospective analysis. Patients underwent hybrid or open Ivor Lewis esophagectomy and 2-field LAD. Paratracheal tissue was removed from the right side of the trachea along the superior vena cava above the azygos vein up to the the upper thoracic aperture. Paratracheal lymph nodes were histologically evaluated separately from the nodes of other stations. Results Ninety-five consecutive patients (12 were female, mean age 67, sd 10, AEG I 84, AEG II 11) were included in the prospective observation study. Seventy-two and 5 patients preoperatively received chemotherapy or radiochemotherapy, respectively. All of them underwent transthoracic esophagectomy (Ivor Lewis 93, McKeown 2—because of coexisting ultralong segment Barrett esophagus). Overall the mean (sd) lymph node count was 37 (12). In the right paratracheal region we found a median of 6 lymph nodes (range;1–22). In 42 (44%) patients positive lymph nodes were recorded, but there was no case with right paratracheal node involvement. Conclusion In the present study paratracheal lymph node involvement was evaluated after transthoracic esophagecotmy with 2-field lymphadenectomy. Remarkably, despite a high proportion of overall lymphatic involvement we did not observe any paratracheal nodal metastasis. Larger studies may show whether paratracheal lyphmadenectomy is necessary during radical esophagectomy for AEG I and AEG II cancers.

676 NECESSITY OF EXTENDED LOWER PARATRACHEAL LYMPH NODE RESECTION DURING ESOPHAGECTOMY FOR CANCER

Abstract Objective To evaluate the impact of lower paratracheal lymph node resection on oncological radicality and complication rate during esophagectomy for cancer. Backround The ideal extend of lymphadenectomy (LAD) in esophageal surgery is debated. Until today, there has been no proof for improved survival after standardized paratracheal lymph node resection performing oncological esophagectomy. Methods Lymph nodes from the lower paratracheal station are not standardly resected during 2-field Ivor-Lewis esophagectomy for esophageal cancer. Retrospectively, we identified 200 patients operated in our center for esophageal cancer from January 2017—December 2019. Histopathologically, 143 patients suffered from adenocarcinoma, 53 patients from squamous cell carcinoma, two patients from neuroendocrine carcinoma, and one from melanoma of the esophagus. Patients with and without lower paratracheal LAD were compared to patients regarding demographic data, tumor characteristics, operative details, postoperative complications, tumor recurrence and overall survival. Results 103 of 200 patients received lower paratracheal lymph node resection. On average, six lymph nodes were resected in the paratracheal region with histopathological cancer positivity in two patients. Those two patients suffered from neuroendocrine carcinoma and melanoma, none of the AC or SCC patients were positive. There was no significant difference between both groups regarding age, gender, BMI, or comorbidity. Harvesting of lower paratracheal lymph nodes was associated with less postoperative overall complications (p-value 0,029). Regarding overall survival and recurrence rate no difference could be detected between both groups (p-value 0,168, respectively 0,371). Conclusion The resection of lower paratracheal lymph nodes during esophagectomy seems not mandatory for distal squamous cell carcinoma or adenocarcinoma of the esophagus. It may be necessary in NEC, Melanoma of the esophagus or on demand if suspicious LN are detected in the CT scan. No increase of morbidity was caused by paratracheal dissection.

Incidental paratracheal air cyst in papillary thyroid cancer patient: a case report

Paratracheal air cyst (PTAC) is a collection of air in the right posterior side of the trachea with an uncertain etiology. We report a papillary thyroid cancer patient with a PTAC that was removed during thyroid cancer surgery. A 68-year-old woman was diagnosed with right papillary thyroid cancer with suspicion of central lymph node metastasis. She had a history of hypertension and a rear-end collision car accident 20 years prior. On computed tomography, an ovoid cyst was incidentally found in the paratracheal region at the thoracic inlet level. Emphysematous lung with an obstructive lung defect was noted without any symptoms. Bilateral total thyroidectomy with ipsilateral central compartment neck dissection was indicated for the patient. During surgery, removal of the cyst was inevitable for complete central neck dissection. Histopathologic analysis revealed an etiology of tracheal mucus sprouting through weak trachea points. No postoperative complications occurred. The patient continued on levothyroxine medication without further radioactive iodine therapy. After 6 months, follow-up ultrasound showed no evidence of recurrence. We hypothesized that obstructive lung disease with impaired lung function or trauma history might have contributed to the development of PTAC. Future studies are needed to determine if PTACs have any association with obstructive lung disease or trauma.

A Case of Unilateral Choroidal Granuloma as a Sole Presentation of Sarcoidosis

<strong>Introduction:</strong> Sarcoidosis is an inflammatory disease that affects multiple organs in the body, but mostly the lungs and lymph glands. It is one of the leading causes of inflammatory eye disease. The most common ocular manifestations are uveitis and conjunctival involvement. However, it can involve any part of the eye and its adnexal tissues and cause episcleritis/scleritis, eyelid abnormalities, conjunctival granuloma, optic neuropathy, lacrimal gland enlargement and orbital inflammation. Rarely, it can present as bilateral choroidal granuloma. However, choroidal granuloma without other signs of intraocular inflammation and/or systemic involvement is an extremely rare manifestation. <strong>Case Description:</strong> A 38-year-old African American woman came to the ophthalmology service with the primary complaint of decreased visual acuity in her right eye and right eye pain. Upon examination, a serous macular detachment secondary to central serous retinopathy and a solitary choroidal granuloma were observed. On physical examination, she had eyelid enlargement and facial papules. Laboratory findings showed elevated ACE, while ANA, ANCA, Lyme, Syphilis, anti-dsDNA, QuantiFERON, RF, IL-2 R and lysozyme were all negative. A CT of the chest showed only mildly increased mediastinal lymph nodes in the right paratracheal region. Ophthalmology, rheumatology, and pulmonary teams were involved in further management. Treatment was started with daily oral prednisone and consequent addition of methotrexate which eventually resulted in reduced size of granuloma, resolution of the eye pain and improvement in vision. <strong>Discussion:</strong> There is no single way to diagnose sarcoidosis. Primary occurrence is, most often, between 20 and 40 years of age, with women being diagnosed more frequently than men. The disease is 10 to 17 times more common in African Americans than in Caucasians. The main diagnostic tools include Chest X-rays and high-resolution CT scan to look for pulmonary infiltrates or lymphadenopathy. Some patients with sarcoidosis may have elevated serum calcium levels, angiotensin converting enzyme (ACE) and/or lysozyme. The gold standard for the diagnosis is a tissue biopsy. However, suspected lesions may not be easily accessible, as in this case where only the eye was affected. Ocular sarcoidosis can involve any part of the eye and its adnexal tissues. A solitary choroidal granuloma is one of the manifestations recognized in sarcoidosis, though the much more common manifestation is bilateral uveitis (reported in 30–70% of cases) and conjunctival nodules (found in 40% of cases). Ophthalmic manifestations can be isolated but most patients have evidence of systemic involvement at the time of the initial examination and have bilateral ocular presentation, unlike this patient who had solitary, unilateral choroidal granuloma without other signs of intraocular inflammation and systemic involvement. <strong>Conclusion:</strong> There are several cases of sarcoidosis reporting choroidal granuloma with either other ocular involvements and/or associated hilar lymphadenopathy and other systemic manifestations. This patient is a rare case where the sole presentation of sarcoidosis is a unilateral solitary granuloma. Biopsy was not feasible due to location of the lesion. This case shows the importance of a multi-disciplinary approach in rare cases where the gold standard for diagnosis is not possible.

Coexisting Metastatic Papillary Carcinoma Thyroid and Clear Cell Neuroendocrine Tumour in Thyroid- A Rare Case Report

Coexisting Metastatic Papillary Carcinoma Thyroid and Clear Cell Neuroendocrine Tumour in Thyroid- A Rare Case Report

Xeroderma Pigmentosum: An Uncommon Risk Factor for Aggressive Follicular Thyroid Carcinoma

Abstract Introduction: Follicular thyroid carcinoma (FTC) is the second most common thyroid cancer, which typically presents in an older populations, and carries a near 100% 5-year relative survival rate if diagnosed prior to cancer spreading outside of the thyroid. Clinical Case: A 26-year old female presented to emergency room with persistent jaw pain, despite course of antibiotics prescribed by dentist. She has a past medical history of xeroderma pigmentosum (XP) with over 130 surgeries for malignant skin lesions, as well as benign multinodular goiter for which she underwent total thyroidectomy at the age of 18, with pathology reporting benign tissue and follicular adenoma. Emergency room imaging of maxillofacial/sinus incompletely captured a mass in the left paratracheal region, extending into the lumen of the trachea. Patient was then transferred to University Hospital for further evaluation. Dedicated neck imaging confirmed 4.6cm mass in expected area of thyroid gland, invading into left tracheal wall, cervical esophagus, and hypopharynx. Additional imaging revealed numerous pulmonary nodules, and a 4mm enhancing focus of left superior temporal gyrus. Nuclear positron emission tomography imaging revealed regions of hypermetabolic activity in the left maxillary sinus, the facial nodules, cervical lymph nodes, and mass like region of hypermetabolic activity in the thyroid bed. Biopsy confirmed follicular thyroid parenchyma, concerning for follicular carcinoma. Patient then underwent mass resection and tracheostomy. Some thyroid tissue was left on contralateral side to malignancy due to adjacency to only functional recurrent laryngeal nerve. Pathology following surgery confirmed follicular thyroid carcinoma, with evidence of angioinvasion. Thyroglobulin mass spectrometry prior to surgery was 302 ng/mL. Conclusion: While it is well known that patients with XP suffer from early development of mucocutaneous and ocular cancers in sun-exposed areas, these patients also have increased risk for multinodular goiter as well as internal malignancies. Furthermore, treatment of any internal malignancy is limited due to inability for patients with XP to be treated with radiation. Providers for patients with XP should have very low thresholds to investigate all new symptoms aggressively, maximizing chances of diagnosing malignancies in early stages.

An unusual cause of "reverse batwing" sign.

An unusual cause of "reverse batwing" sign.

The Extent of Therapeutic Central Compartment Neck Dissection in Unilateral cT1N1a or cT2N1a Papillary Thyroid Carcinoma.

PurposePapillary thyroid carcinomas (PTCs) frequently metastasize to the central neck compartment. Therapeutic central compartment neck dissection (CCND) is a well-established treatment for PTC nodal metastases; however, the extent to which therapeutic CCND should be performed remains controversial. In this study, we investigated the predictive risk factors for contralateral paratracheal lymph node metastasis (LNM) in unilateral cT1N1a or cT2N1a PTC.Patients and MethodsIn this case–control study, which was conducted at a single center, demographic and pathological data from unilateral cT1N1a or cT2N1a PTC patients were collected from January 2017 to March 2019. All patients were treated with total thyroidectomy and bilateral CCND.ResultsTwo hundred thirty-seven patients met the inclusion criteria. Forty-nine patients (20.7%) were diagnosed with positive lymph nodes in the contralateral paratracheal region. Male sex (p=0.003), T2 disease (21–40 mm) (p<0.001), inferior pole tumor (p=0.011), near isthmus tumor (p<0.001), aggressive pathology (p<0.001), intraglandular dissemination (p=0.009), pretracheal LNM (p<0.001), >5 metastatic lymph nodes (p<0.001) and extranodal invasion (p=0.003) were significantly associated with contralateral paratracheal LNM in univariate analysis. Multivariate analysis showed that male sex (p=0.005, OR=17.545), T2 disease (p=0.003, OR=34.317), inferior pole tumor (p=0.022, OR=8.289), near isthmus tumor (p=0.001, OR=40.229), aggressive pathology (p=0.027, OR=48.063), pretracheal LNM (p=0.002, OR=14.235) and >5 metastatic lymph nodes (p=0.025, OR=23.426) were independent risk factors for contralateral paratracheal LNM.ConclusionMale sex, T2 disease, a tumor located near the isthmus or inferior pole, aggressive pathology, pretracheal LNM and >5 metastatic lymph nodes were predictive factors for contralateral paratracheal LNM in unilateral cT1N1a or cT2N1a PTC. These data may be useful to identify targets for surveillance or develop therapeutic interventions for patients with CCND.

THE HIDDEN PARATHYROID: A RARE CASE OF ECTOPIC TRACHEOBRONCHIAL PARA-AORTIC PARATHYROID ADENOMA

SESSION TITLE: Medical Student/Resident Disorders of the Mediastinum Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Ectopic parathyroid glands arise due to abnormal embryological migration and are found in 1-3% of the population. They are mostly located in the anterior mediastinum near the thymus. It is difficult to identify the ectopic site even with advanced imaging modalities. We present a diagnostically challenging case of parathyroid adenoma in an unusual site. CASE PRESENTATION: A 77-year-old male with no significant medical history presented with abdominal discomfort and was noted to have hypercalcemia of 16mg/dl. The patient reported that he was in his usual state of health until a few months ago, when he developed abdominal pain, nausea, with occasional episodes of forgetfulness. On presentation, his vital signs were stable. Labs revealed hypercalcemia, ionized calcium 2.05 mmol/L, parathyroid hormone(PTH) 664pg/ml, normal thyroid-stimulating hormone, phosphorus 2mg/dl, and 25 hydroxyvitamin D 26ng/dl. After initial stabilization, he underwent neck ultrasonography(US) that was negative. Sestamibi scan revealed a soft tissue density abutting the posterior aspect of the thyroid. Subsequent computerized tomography(CT) scan of the neck revealed a 3mm lesion in the right intrathyroidal area suspicious for adenoma and the patient underwent right thyroidectomy with neck exploration. However, the exploration did not reveal an adenoma and the patient continued to have hypercalcemia. He had a repeat sestamibi scan and CT scan that demonstrated an arterial enhancing 1 cm nodule in the left paratracheal region close to the tracheobronchial angle, near the aortic arch. The patient underwent an endobronchial ultrasound with biopsy confirming the parathyroid adenoma and subsequently underwent a video-assisted thoracoscopic surgery(VATS) resection of ectopic parathyroid, with the resolution of hypercalcemia. DISCUSSION: Ectopic parathyroid glands are commonly found in the visceral compartment of the mediastinum, aortopulmonary window, or close to the right pulmonary artery near the tracheal bifurcation which makes the diagnosis challenging (1). Symptomatic mediastinal adenomas are rare accounting for 1% of operations for hyperparathyroidism. As the ectopic adenomas can be in varied locations, radiological assistance is pivotal for diagnosis, but sometimes imaging modalities also fail to identify the lesion. Accurate preoperative localization is the key to managing the disease. Sestamibi scan and neck US are first-line imaging modalities. Anterior mediastinal tumors are managed through a transcervical approach, and tumors at unusual sites might need VATS, sternotomy, or thoracotomy (2). CONCLUSIONS: It is vital to recognize ectopic parathyroid adenoma as a cause of hyperparathyroidism to prevent unnecessary interventions that increases the health care costs, and morbidity. In cases of persistent hypercalcemia due to hyperparathyroidism, ectopic hyperparathyroidism should be considered. Reference #1: Cupisti K, Dotzenrath C, Simon D, Roher HD, Goretzki PE. Therapy of suspected intrathoracic parathyroid adenomas. Experiences using open transthoracic approach and video-assisted thoracoscopic surgery. Langenbecks Arch Surg. 2002;386(7):488-93. Reference #2: Medrano C, Hazelrigg SR, Landreneau RJ, Boley TM, Shawgo T, Grasch A. Thoracoscopic resection of ectopic parathyroid glands. Ann Thorac Surg. 2000;69(1):221-3. DISCLOSURES: No relevant relationships by Dimitrios Drekolias, source=Web Response No relevant relationships by Naga Vaishnavi Gadela, source=Web Response No relevant relationships by Karthik Gonuguntla, source=Web Response No relevant relationships by Kamran Manzoor, source=Web Response No relevant relationships by Nikola Perosevic, source=Web Response No relevant relationships by MIlica Perosevic, source=Web Response

Para-tracheal neck dissection - is dissection of the upper part of level Ⅵ necessary?

Papillary thyroid carcinoma (PTC) has a high propensity for regional metastases, however, the impact of such metastases on the outcome of the patients is minimal. The central compartment of the neck is considered the first and the most common echelon of metastases from thyroid carcinoma. Physical examination along with ultrasonography are the gold standard pre-operative evaluation of patients with PTC. Ultrasonography is highly sensitive in evaluating lateral neck nodes, however, its value in evaluating the central compartment is limited, resulting in a relatively high rate of occult metastases in this compartment. The main potential complications of para-tracheal neck dissection (PTND) are recurrent laryngeal nerve paralysis and hypocalcemia and these may be higher in patients undergoing PTND compared to thyroidectomy alone. New histological data is available showing no evidence of lymph nodes in the central compartment above a level parallel to the inferior border of the cricoid cartilage. These findings support withholding dissection of the upper para-tracheal region routinely as a part of PTND in patients with well-differentiated thyroid cancer. By doing that, the complications may be lower and identical to thyroidectomy alone, thus may abolish arguments against more common use of elective PTND in patients with thyroid carcinoma.