Bilateral follicular thyroid carcinoma with large sternal metastasis: Case report and review of the literature.

INTRODUCTION AND IMPORTANCE: Follicular thyroid cancer (FTC) typically spreads hematogenously, with bone metastasis being worrisome, often appearing to be resistant to radioactive iodine (RAI) therapy. Metastasis to sternum is exceedingly rare. CASE PRESENTATION: A 43-year-old Egyptian male presented with chest tightness, cough, and shortness of breath. He was initially treated as bronchial asthma. Later, he was referred to our thyroid surgery clinic as a case of goitre and palpable sternal mass. He looked clinically well, with enlarged anterior neck mass and visible sternal mass, no lymphadenopathy. Laboratory tests showed thyroid-stimulating hormone levels within normal (2.13 mIU/L), and mildly decreased FT4 (10.3 pmol/L). Neck/chest CT demonstrated multinodular goitre with retrosternal extension, expansile lytic lesion in the sternum, and bilateral lung metastases. Thyroid fine needle aspiration and cytology showed FLUS, and true cut biopsy from the sternal lesion showed invasive FTC. DISCUSSION: Rare bilateral FTC presenting as slow-growing sternal metastasis. The patient underwent total thyroidectomy, followed by high dose RAI therapy, and concluded with sternectomy and reconstruction surgery repair using polymethyl methacrylate wrapped in proline mesh. On follow-up, he received further RAI ablation therapy and became RAI refractory. He then received systemic therapy (Lenvatinib). Most recent follow up showed that the disease was controlled (low volume cancer) and he was tolerating treatment well with no reported symptoms. CONCLUSION: Bilateral FTC with sternal metastasis is rare, and can be treated with total thyroidectomy, sternectomy and reconstruction, followed by RAI therapy and systemic therapy where required, hence inferring real survival benefit.

Severe hypercalcemia secondary to parathyroid adenoma: Series of four consecutive cases at a tertiary care hospital in Qatar.

INTRODUCTION: In most cases of parathyroid adenoma (PA), it is not palpable and physical examination shows no remarkable findings. Hence diagnosis requires an index of suspicion. The current paper describes four cases of severe hypercalcemia secondary to PA. PRESENTATION OF CASES: Case 1 - 29 years old Sudanese female with history of nausea/vomiting, fatigue, loss of appetite and bone aches. She had large palpable left lower neck swelling, and high calcium and PTH. Ultrasound (US) neck and SPECT/CT scan after sestamibi injection showed left inferior PA. Case 2-73 years old Sudanese male referred with history of abdominal pain and flatulence. He had severely high calcium, elevated parathormone (PTH), and high 24-hour urine calcium. US and SPECT/CT showed a left inferior PA. Case 3-54 years old Bangladeshi male, referred with history of renal colic/urolithiasis. Laboratory results showed severely high calcium and PTH levels. US and SPECT/CT scan showed right inferior PA. Case 4-35 years old Tunisian female, 12 weeks pregnant, referred with recurrent nausea and vomiting of increasing frequency from the second week of pregnancy. Laboratory tests revealed severe hypercalcemia and high PTH. US showed two parathyroid lesions. DISCUSSION: The patients were admitted as emergency cases and investigations diagnosed severe hypercalcemia secondary to PA. All patients underwent neck exploration and PA excision. Histology confirmed PA. The four cases were swiftly assessed and treated before progressing into the more serious hypercalcemic crisis which can lead to grave consequences, particularly in the case of the pregnant female. All patients recovered with no complications and were clinically well with normal calcium level on follow up. CONCLUSION: Severe hypercalcemia must be swiftly and thoroughly assessed to prevent the more serious hypercalcemic crisis. Clinicians need to be suspicious of parathyroid adenoma as a probable cause. Severe hypercalcemia is often accompanied with vomiting, and in pregnant females, this could be mistaken for hyperemesis gravidarum. Excision of the parathyroid adenoma treats the condition and follow up of serum calcium and PTH confirms the favorable outcome of surgery.

Mucosa-associated lymphoid tissue lymphoma (MALT lymphoma) in the thyroid mimicking a painless subacute (De Quervain's) thyroiditis on presentation, fine needle aspiration and cytology, and ultrasound findings: A rare case report.

INTRODUCTION: We report a rare case of mucosa-associated lymphoid tissue lymphoma (MALT lymphoma) in the thyroid mimicking painless subacute (De Quervain's) thyroiditis. PRESENTATION OF CASE: Patient with history of hypothyroidism presented with huge non-tender goiter, compression symptoms and choking, no lymphadenopathy. Ultrasound (US) showed large thyroid lobes. There was a small hypoechoic nodule, and nonspecific lymphadenopathy. Fine needle aspiration/cytology (FNAC) of right thyroid nodule showed scant follicular cells, abundant polymorphic lympocytes, epithelioid histiocytes, and tingible body macrophages, suggestive of De Quervain's (granulomatous) thyroiditis. Total thyroidectomy was decided due to compression symptoms and huge goiter. DISCUSSION: Intraoperative, thyroid was huge with no adhesions to the strap muscles/trachea. Total thyroidectomy with lymph node biopsy was undertaken. There were no complications. Postoperatively, the patient's condition was stable, breathing normally, and neck wound was clean. PTH was 11 pg/mL and calcium was 2.16 mmol/L, suggesting impending transient hypocalcemia. Histopathology showed lymphoepithelial lesions as clusters of lymphocytes within the thyroid follicles epithelium (MALT Balls). Immunohistochemical staining showed that the neoplastic lymphocytes were B cells and stained positive with B-cell markers CD20 and PAX5, but were negative for Cyclin D1 and for T cell markers CD3, CD5 and CD43. The patient was discussed at the lymphoma MDT meeting and the decision was to start the patient on radiotherapy which the patient received. CONCLUSION: Thyroid MALT lymphoma can mimic painless subacute thyroiditis. The triad of a large swelling of non-tender goiter with compression symptoms during a short period; FNAC findings suggestive of thyroiditis; and US showing enlarged thyroid lobes might cause confusion to the unsuspecting practitioner. Histopathology after excision provides definitive diagnosis.

Right thyroid lobe agenesis and left thyroid colloid benign nodule discovered incidentally in female with breast carcinoma receiving chemotherapy for multiple metastases: Case report and review of the literature.

INTRODUCTION AND IMPORTANCE: Thyroid hemiagenesis (THA) is the failure of embryologic development of a lobe of the thyroid gland and is a rare anomaly of uncertain incidence. The left lobe is more commonly absent than the right lobe. It is discovered incidentally during investigations. CASE PRESENTATION: A 48 year old Egyptian female presented at the thyroid surgery clinic at our institution to follow up after a nodule left thyroid lobe accidently discovered on positron emission tomography (PET) scan undertaken to follow up on bone metastasis of breast cancer which was surgically removed about 14 years ago. CLINICAL DISCUSSION: The patient looked clinically well with no scar in the anterior of the neck, no palpable thyroid nodules, and no lymphadenopathy. Ultrasound imaging of the neck revealed absent right thyroid lobe tissue and a nodule was noted at the upper pole of the left thyroid. Laboratory tests unremarkable, with TSH (2.14 mIU/L), and FT4 (12.4 pmol/L) within normal range. Fine needle aspiration and cytology of the thyroid nodule revealed atypia of undetermined significance. CONCLUSION: THA is rare and right THA is even rarer. It is usually asymptomatic, and diagnosis is mostly incidental while investigating symptoms due to pathology of the other thyroid lobe or any of the parathyroid glands. In much rarer circumstances, right THA might be discovered when investigating conditions not related to the thyroid or parathyroid glands years after the initial pathology as in the current case. Etiology is inconclusive but genetic factors could play a role. No treatment is required if no symptoms are present.

Behaviour and epidemiology of differentiated thyroid cancer among filipinos in and outside the Philippines: Comparison between Qatar, Canada and Philippines.

Background: No study assessed the behaviour/epidemiology of differentiated thyroid cancer (DTC) among Filipinos in the Middle East/north Africa; or compared such behaviour with Filipino DTC patients in and outside the Philippines. Materials and methods: Retrospective review of all adult Filipinos with DTC diagnosed between 2015 and 2020 at our institution [papillary TC (PTC, n = 110); follicular TC (FTC, n = 4)]. Chi-square or t-test compared the frequency, demography, history, ultrasound, laboratory and histopathology of PTC vs FTC; and compared the epidemiology of DTC among Filipinos in Qatar vs Canada (1 study) vs the Philippines (3 studies). Results: DTC frequency was ≈43.84 cases/100,000 Filipinos in Qatar. Males had more aggressive disease in terms of lymphovascular invasion, number of nodules, stage IV disease and metastases. PTC and FTC were similar, but more PTC patients presented with solid tumors and higher number of involved lymph nodes. DTC behaviour among Filipinos in Qatar vs Canada was fairly homogenous. Conversely, DTC among Filipinos in Qatar vs Philippines exhibited many dissimilarities: Qatar had significantly younger patients, less hyperthyroid/thyrotoxicity symptoms and neck swelling at presentation, fewer solid nodules, micro-calcifications, and multi-nodular disease; smaller tumors; more stage I and less stage IV disease; and no distant metastasis (P 0.01 to < 0.0001). Conclusions: DTC epidemiology among Filipinos in Qatar and Canada was fairly homogenous. Conversely, DTC in Qatar vs the Philippines was dissimilar. DTC among Filipinos in Qatar has presentations that could be misinterpreted as non-suspicious. This warrants additional practices for earlier detection among Filipinos.

Subacute (De Quervain's) thyroiditis presenting as painful thyroid nodule suspicious of papillary thyroid carcinoma: Case report.

INTRODUCTION: We report a case of subacute thyroiditis (SAT) in a 29 -year-old female who presented with painful thyroid swelling. PRESENTATION OF CASE: Patient presented with neck pain, tender neck swelling and generalized fatigue. She had no history of neck or chest radiation or compressive symptoms. Ultrasound (US) imaging reveled bilateral nodules of the thyroid gland. Lymph nodes were unremarkable. FNAC was suspicious for papillary thyroid carcinoma. The patient was discussed at the thyroid multidisciplinary meeting, and after deliberation the decision was to offer the patient the choice of repeating FNAC of the bilateral nodules in one month or to proceed with total thyroidectomy. DISCUSSION: Despite being aware of the possibility that the final pathology could be benign, the patient insisted on total thyroidectomy, given that her FNAC results were suspicious of papillary thyroid carcinoma, and in order to avoid recurrence of the condition and the pain. Following the patient's preference, total thyroidectomy was performed, and surgery was not straightforward as intraoperatively, there was a diffusely inflamed gland. Histopathology findings revealed benign pathology. Follow up until 1.5 years showed that the patient was satisfied, and with normal voice. CONCLUSION: SAT is a painful but potentially self-limiting. In some cases, FNAC findings might be suspicious for papillary thyroid carcinoma. Treatment is mostly conservative, but if the pain is severe and the patient insists on surgery as in our case despite the possibility of the condition being of benign pathology, then surgery should be undertaken.

Atypical parathyroid adenoma: Series of two consecutive cases from a tertiary care hospital in Qatar.

INTRODUCTION: Atypical parathyroid adenomas (APA) are an uncommon cause of hypercalcemia and comprise a minority of parathyroid adenomas. PRESENTATION OF CASES: Case 1 - Egyptian male, 48 years old with history of type 2 diabetes mellitus, incidentally discovered increased serum of calcium level on routine investigation, was diagnosed as PHPT, US and MIBI scan showed large left inferior parathyroid adenoma, focused exploration and excision of the APA was undertaken, histopathology confirmed APA. Case 2 - Egyptian male, 60 years old, cardiac patient with history of diabetes, hypertension and multiple cardiac interventions, had nausea, vomiting, constipation abdominal pain, polyuria, polydipsia, and history of passing renal stones, hypercalcemia workup showed primary hyperparathyroidism (PHPT), MIBI was negative and SPECT scan suggested right inferior parathyroid adenoma, focused exploration and excision of the APA was undertaken, histopathology confirmed APA. DISCUSSION: APA are an uncommon cause of hypercalcemia and are responsible for a minority of parathyroid adenomas. Combined US and MIBI and SPECT scans can detect APA. Focused exploration and excision of the APA under general anaesthesia can completely remove the APA. CONCLUSION: Awareness of the physician and a high index of suspicion to symptoms or signs that could reflect an underlying PHPT is essential. Yearly biochemical and neck US follow up are required to detect any risk of recurrence or malignancy in the long term.

What you see might not be what you get: Analysis of 15 prospective cases of non-invasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTP).

INTRODUCTION: Noninvasive follicular thyroid neoplasm with papillary-like nuclear (NIFTP) is a new entity. No previous study reported prospective cases, outlining using many quantitative and qualitative variables. METHODS: Retrospective analysis of all (15) prospective NIFTP cases diagnosed between 2017 and 2021 at our institution. Statistical quantitative analysis outlined demographic, history, ultrasound, histopathology and treatment characteristics. Qualitative analysis examined the cases, with details provided on three cases to highlight the different possible presentations and configurations. RESULTS: Mean age was 41.5 ± 9.91 years, 73.3% were females, and mean BMI was 29.49 ± 5.74 kg/m2. About 87% patients were symptomatic; 86.6% had neck swelling. Ultrasound (US) showed multiple nodules in 71.4% of cases. Fine-needle aspiration cytology (FNAC) showed that follicular lesion of undetermined significance (42.8%) was most common, followed by benign nodule (21.3%). Using the Bethesda System for Reporting Thyroid Cytopathology, 7 cases were category III, 3 category IV, 3 category II, and 1 category I. 60% of patients underwent total thyroidectomy. All cases were diagnosed postoperatively, 2 patients had additional papillary microcarcinoma. In 3 cases, the NIFTP site in the histopathology of resected specimen was different than the US-recommended site of the FNAC. CONCLUSION: We found discrepancies in the site and diagnosis of the preoperative US recommendation for the FNAC vs the postoperative histopathology of the specimen. These suggest that NIFTP might be incidentally and postoperatively diagnosed, irrespective of US or FNAC findings, hence its 'true' incidence might remain underestimated. As NIFTP cases higher BMI, Future research could predict preoperative diagnosis of NIFTP and explore associations with BMI.

Choroidal metastasis as initial presentation of aggressive medullary thyroid carcinoma with widespread mediastinal, brain, pituitary, bone, lung, and liver metastasis: Case report and literature review.

INTRODUCTION: Medullary thyroid carcinoma (MTC) is a neuroendocrine tumor that originates from the parafollicular C cells of the thyroid gland. MTC can be due to sporadic or hereditary causes due to gain of function germ line mutations in the RET proto-oncogene. MTC presenting as ocular symptoms due to choroidal mass is rare with bad prognosis. PRESENTATION OF CASE: A 38-year-old Sudanese male presented to Hamad General Hospital, complaining of sudden painless decrease of vision of the right eye of 3 weeks duration. After investigations using imaging methods, the patient was discovered to have metastatic MTC that presented as choroidal mass and metastasized to his lung, bone, brain, pituitary, liver and mediastinum. DISCUSSION: In terms of investigations, serum levels of calcitonin have superior diagnostic accuracy. Our patient undertook diagnostic imaging including ultrasonography, fine needle aspiration and computerized tomography (CT) scan and/or MRI imaging. He undertook total thyroidectomy and left neck dissection followed by stereotactic radiosurgery for the right orbit and pituitary. He then received systemic anti-RET therapy (Selpercatinib). At 5 months follow up there was dramatic drop in CEA from 888 µg/L to 164 µg/L, and calcitonin from >585.2 pmol/L to 354 pmol/L. CONCLUSION: Choroidal metastasis as initial presentation of MTC is extremely rare and challenging to diagnose. Surgeons need a high index of suspicion when ocular symptoms accompany a neck mass or thyroid-related symptoms. MTC has a progressive course with involvement of blood vessels and neck lymph nodes. Choroidal metastasis of MTC is challenging to manage.

Water clear cell ectopic non-iatrogenic giant parathyroid adenoma in sternohyoid muscle with thyroid nodule and asymptomatic hypercalcemia due to primary hyperparathyroidism: Case report and literature review.

BACKGROUND: Ectopic parathyroid gland is not uncommon, and is associated with primary hyperparathyroidism. Giant parathyroid adenoma (PA) and concurrent presence of enlarged thyroid nodule increases the probability of ectopic location. The combination of a giant PA that is ectopic (within the strap muscle) in the neck is very rare, especially in cases with no previous surgery. The rare histopathological findings of the current case, water clear cell parathyroid adenoma (WCCPA), could explain the patient's presentation, since it has low endocrine function. CASE PRESENTATION: A 56-year-old Qatari female on routine visit to primary health care physician for hypertension, was incidentally discovered to be hypercalcemic and was referred to the emergency department of our institution. Neck ultrasound showed a thyroid nodule on the left side, but 99mTc-sestamibi scintigraphy identified a left PA. FNAC of the thyroid nodule showed that it was a colloid nodule. She underwent left hemithyroidectomy and excision of left PA. Intraoperatively, the PA was giant and in the sternohyoid muscle. Intraoperative monitoring of intact PTH (IOiPTH) confirmed successful excision. DISCUSSION: Ectopic giant parathyroid adenoma is rare especially with the intramuscular location in sternohyoid muscle in the neck without previous neck surgeries. The presence of thyroid nodule could be a precipitating factor for migration of the PA. Preoperative assessment with the radiological image is crucial for diagnosis but sometimes fail to localized the PA. CONCLUSION: Giant asymptomatic PA with long standing low function before hyperfunctioning should raise the suspicion of WCCPA. If diagnosis is confirmed, metastasis from a clear cell renal cell carcinoma should be ruled out.

First case of huge classic papillary thyroid cancer rupturing spontaneously leading to ischemic necrosis, perforation and inflammation of overlying skin: Case report and review of the literature.

INTRODUCTION: Papillary thyroid cancer (PTC) is the commonest form of well-differentiated endocrine carcinoma. It is categorized into indolent and aggressive, where the indolent subtypes (classic, follicular) rarely demonstrate aggressive behavior. We present a classic PTC presenting with a rapidly growing huge anterior neck mass that subsequently spontaneously ruptured subcutaneously resulting in ischemia, necrosis, and perforation of overlying skin leading to inflammation. PRESENTATION OF CASE: A 37-year-old female with no comorbidities presented to our emergency department with a neck swelling of 2 years duration that rapidly enlarged one week prior to presentation. Though the mass initially appeared of inflammatory nature, the tumor was a PTC, and she underwent total thyroidectomy with selective right side neck dissection and debridement of necrotic skin. The gross specimen revealed a fragmented non-intact right thyroid lobe mass causing pressure ischemia, necrosis and perforation of the skin. Histopathology showed a 9 × 9 × 5 cm classic PTC staged as pT3b N1b. Postoperative course was uneventful, she was discharged by the eighth postoperative day, and then she received a high dose of radioactive iodine ablation (RAI). DISCUSSION: Classic PTC is usually of a smaller size and a relatively benign course compared to other PTC subtypes and thyroid cancers. It is indolent with favorable prognosis. Although it is associated with increased risk of lymph node metastases at the time of diagnosis, it is slow growing with high survival rates approaching 95%. CONCLUSION: Despite that classic PTC progresses slowly, it should still be suspected in neck swellings presenting with rapid and aggressive behavior. Prompt and systematic assessment is required with surgical intervention and radioactive iodine ablation therapy.

First bilateral non-invasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTP) co-occurring with bilateral papillary thyroid microcarcinoma. Case report and literature review.

INTRODUCTION: Non-invasive follicular thyroid neoplasm with papillary-like features (NIFTP) is a recently characterized lesion with very low malignant potential. This has allowed for less aggressive management of this tumor subtype. Papillary thyroid carcinoma (PTC) has malignant potential and requires different considerations in management. PRESENTATION OF CASE: A 33-year-old woman presented to our Thyroid Surgery Clinic with a left neck swelling slowly enlarging over 4 years, and recent right-sided neck pain. Neck ultrasound and fine needle aspiration for cytology found bilateral thyroid nodules, labelled as 'follicular lesion of undetermined significance' (FLUS). Final pathology report after total thyroidectomy identified four distinct tumors: bilateral NIFTP lesions and bilateral papillary microcarcinomas. DISCUSSION: Management of NIFTP comprises partial or total thyroidectomy without further intervention. Management of PTC is the same but with the possible addition of radioactive ablation due to the increased malignant potential. This is the first report of bilateral NIFTP lesions and bilateral papillary microcarcinomas co-occurring together in the same patient, so management was challenging. The decision was made to give the patient low dose radioactive iodine ablation and continue monitoring. Ultrasound of the neck follow up 6 months later showed no residual thyroid tissue or local recurrence. CONCLUSION: Although rare, NIFTP can co-occur with PTC. Bilateral NIFTP with bilateral PTC is extremely rare. Surgeons and pathologists need to be aware of this rare entity that can co-occur in both thyroid lobes. Total thyroidectomy is the definitive treatment. Post-surgery surveillance is important and follow up needs to be watchful for any recurrence or metastasis.

Right ectopic paraesophageal parathyroid adenoma with refractory hypercalcemia in pregnancy: A case report and review of the literature.

INTRODUCTION: Ectopic parathyroid adenoma is rare during pregnancy but poses multiple challenges in treatment. It presents as primary hyperparathyroidism which leads to symptoms and complications of hypercalcemia in both the mother and fetus. PRESENTATION OF CASE: A 38-year-old Sudanese female presented with diffuse bone pain and polyuria. Laboratory investigations revealed elevated serum calcium and parathyroid hormone. Ultrasound of the neck did not show any abnormal lesion, however 99mTc-sestamibi scan showed a right sided parathyroid adenoma, and an earlier CT scan showed the adenoma to be in an ectopic paraesophageal position. Focused surgical neck exploration was done, and the ectopic parathyroid adenoma was excised. DISCUSSION: Preoperative localization of the ectopic parathyroid adenoma allows for a focused surgical procedure. Ultrasound is the safest during pregnancy, but 99mTc-sestamibi and CT scan may be necessary if ultrasound or initial bilateral neck exploration do not detect any adenoma. Mild elevations in maternal serum calcium can have detrimental effects on the fetus which suggests that a surgical approach may be necessary in the majority of cases. CONCLUSIONS: Ectopic parathyroid adenoma is rare during pregnancy and is detrimental to both the mother and fetus. Preoperative localization allows for a focused surgery which is a definitive treatment and can safely be performed during the 2nd trimester of pregnancy.

Two separate tumours-Concomitant papillary carcinoma in thyroglossal duct cyst and right thyroid lobe: Case report and review of the literature.

INTRODUCTION: Malignancy of thyroglossal duct cyst (TGDC) is rare, usually as papillary carcinoma, and less frequently as squamous cell or follicular carcinoma. TGDC carcinoma can present as a mass arising from the neck, with or without compression symptoms. Papillary carcinoma in TGDC concomitant with another papillary carcinoma in the thyroid gland is extremely rare. PRESENTATION OF CASE: 31 years old female with a neck lump since 2 years, slowly increasing in size, with mild pain while drinking fluids, and no change of voice. No past history of neck irradiation or family history of thyroid cancers. Ultrasonography of the neck showed TGDC and right thyroid nodule. Ultrasound guided fine needle aspiration and cytology of the TGDC showed TGDC papillary carcinoma. The patient underwent Sistrunk's procedure and total thyroidectomy. DISCUSSION: Rare case of classic papillary carcinoma arising in TGDC, concomitant with another papillary carcinoma in the right thyroid nodule. Preoperative work up included US and fine needle aspiration and cytology (FNAC). Post-operative histopathology showed papillary carcinoma in the TGDC; and another in the right thyroid lobe that was a papillary carcinoma with follicular patterns. CONCLUSIONS: TGDC carcinoma concurrent with another carcinoma in the right thyroid lobe as two separate tumours are extremely rare. All patients should undergo Sistrunk's procedure, and total thyroidectomy for the thyroid tumour. Follow-up requires thyroxine replacement therapy to treat hypothyroidism and to suppress TSH in order to prevent recurrence; and neck ultrasound and thyroglobulin tumour marker to detect recurrence if present.

First ever case report of co-occurrence of hobnail variant of papillary thyroid carcinoma and intrathyroid parathyroid adenoma in the same thyroid lobe.

INTRODUCTION: The hobnail variant of papillary thyroid cancer (PTC) is rare. Intrathyroid parathyroid adenoma (ITPA) is also rare. Co-ocurrence of PTC and ITPA in the same thyroid lobe is extremely rare. Likewise, primary hyperparathyroidism with such non-medullary thyroid carcinoma is rare. The specific molecular profile of hobnail PTC (HPTC) is different from the classic, poorly differentiated and anaplastic variants and may contribute to its aggressive behavior. HPTC's genetic profile remains unclear. PRESENTATION OF CASE: A 61-year-old woman presented to our endocrine clinic with generalized aches, bone pain, polyuria, and right neck swelling of a few months' duration. Laboratory findings revealed hypercalcemia and hyperparathyroidism. Ultrasound of the neck showed 4.6 cm complex nodule within the right thyroid lobe. Sestamibi scan suggested parathyroid adenoma in the right thyroid lobe. Fine-needle aspiration (FNA) revealed atypical follicular lesion of undetermined significance. She underwent right lobectomy, which normalized the intraoperative intact parathyroid hormone levels. Final pathology with immunohistochemical stains demonstrated HPTC and IPTA (2 cm each). Next-generation sequencing investigated the mutation spectrum of HPTC and detected BRAFV600E mutation. CONCLUSIONS: A parathyroid adenoma should not exclude the diagnosis of thyroid carcinoma. Thyroid evaluation is needed for patients with primary hyperparathyroidism to prevent missing concurrent thyroid cancers. Cytomorphologic features to distinguish thyroid from parathyroid cells on FNA cytology must be considered. Immunohistochemical stains are important. BRAFV600E is the most common mutation in HPTC. This is possibly the first reported case of HPTC and ITPA co-occurring within the same thyroid lobe. Studies that define other molecular abnormalities may be useful as therapeutic targets.

Giant parathyroid adenoma: a case report and review of the literature.

BACKGROUND: Giant parathyroid adenoma is a rare type of parathyroid adenoma defined as weighing > 3.5 g. They present as primary hyperparathyroidism but with more elevated laboratory findings and more severe clinical presentations due to the larger tissue mass. This is the first reported case of giant parathyroid adenoma from the Middle East. CASE PRESENTATION: A 52-year-old Indian woman presented with a palpable right-sided neck mass and generalized fatigue. Investigations revealed hypercalcemia with elevated parathyroid hormone and an asymptomatic kidney stone. Ultrasound showed a complex nodule with solid and cystic components, and Sestamibi nuclear scan confirmed a giant parathyroid adenoma. Focused surgical neck exploration was done and a giant parathyroid adenoma weighing 7.7 gm was excised. CONCLUSIONS: Giant parathyroid adenoma is a rare cause of primary hyperparathyroidism and usually presents symptomatically with high calcium and parathyroid hormone levels. Giant parathyroid adenoma is diagnosed by imaging and laboratory studies. Management is typically surgical, aiming at complete resection. Patients usually recover with no long-term complications or recurrence.

The largest reported papillary thyroid carcinoma arising in struma ovarii and metastasis to opposite ovary: case report and review of literature.

BACKGROUND: Malignant struma ovarii (MSO) is a very rare, germ cell tumor of the ovary, histologically identical to differentiated thyroid cancers. Struma ovarii (SO) is difficult to diagnose on clinical basis or imaging and is mostly discovered incidentally, with few published cases in the literature. CASE PRESENTATION: A 42-year old primiparous woman presented with abdominal pain and midline pelvic palpable firm mass arising from the pelvis. Imaging showed pelvic solid cystic mass. Total abdominal hysterectomy, bilateral salpingo-oopherectomy (TAH BSO) and infracolic omentectomy were performed. Histopathology revealed left ovary papillary thyroid carcinoma (PTC) arising in SO (11 cm) and metastatic papillary thyroid carcinoma in the right ovary. Thyroid functions tests were all normal, ultrasound thyroid showed two complex nodules in the left thyroid lobe. Total thyroidectomy was decided, but the patient refused further surgical management and was lost to follow up as she left the country. We undertook a comprehensive literature search, and MSO and thyroid management data from 23 additional publications were analyzed and tabulated. This PTC MSO is probably the largest reported in the literature. CONCLUSIONS: Among the different surgeries for MSO, TAH + BSO appears to have the best clinical outcome. However, unilateral salpingo-oopherectomy/ unilateral oophorectomy and bilateral salpingo-oopherectomy also seem effective. Ovarian cystectomy alone seems associated with higher recurrence. There remains no consensus on the associations between MSO tumor size and potential extent of metastasis, and about the management of thyroid gland. However, surveillance and thyroid gland work up to detect concurrent thyroid cancer are recommended.