Thyroid

Severe symptomatic hypocalcemia following total thyroidectomy in a patient with a history of Roux-en-Y gastric bypass surgery

January 21, 2014     Justin A. Gross, MD; Steven M. Olsen, MD; Cody A. Koch, MD, PhD; Eric J. Moore, MD
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Abstract

Patients who undergo a Roux-en-Y gastric bypass (RYGB) procedure are at moderate risk for calcium and vitamin D deficiency. Those who subsequently undergo thyroid or parathyroid surgery are at high risk for developing severe symptomatic hypocalcemia if they are not monitored and adequately treated prophylactically. We describe the case of a morbidly obese 40-year-old man who had undergone RYGB surgery 6 months prior to the discovery of metastatic papillary thyroid carcinoma. He subsequently underwent total thyroidectomy with central and bilateral neck dissection. Following surgery, he developed severe symptomatic hypocalcemia, as his calcium level fell to a nadir of 6.0 mg/dl. He required aggressive oral and intravenous repletion therapy with calcium, vitamin D, and magnesium for 10 days before hospital discharge. Providers should institute careful preoperative screening, patient counseling, and prophylactic calcium and vitamin D therapy for all thyroid surgery patients who have previously undergone RYGB surgery to prevent the development of severe and life-threatening hypocalcemia. Only a few reports of patients have been published on the dangers of thyroid and parathyroid surgery in patients who have undergone bariatric surgery. We report a new case to add to the body of literature on this patient population. We also review calcium homeostasis and supplementation as they relate to this situation.

Primary Burkitt lymphoma of the thyroid

December 20, 2013     Samuel Albert, MD
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Abstract

Primary Burkitt lymphoma of the thyroid is extremely rare. The author describes a new case in a 15-year-old boy who presented with a rapidly enlarging thyroid mass and dyspnea.

Undifferentiated thyroid carcinoma

October 23, 2013     Lester D.R. Thompson, MD
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Histologically, undifferentiated thyroid carcinomas show a variety of patterns, from sheet-like, storiform, fascicular, angiomatoid, and meningothelial to solid, exhibiting extensive lymph-vascular invasion.

Thyroglossal duct cyst carcinoma: Case report and review of the literature

September 18, 2013     David W. Jang, MD; Andrew G. Sikora, MD, PhD; Anatoly Leytin, MD
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Abstract

Well-differentiated thyroid carcinoma of a thyroglossal duct cyst (TGDC) is a rare entity, found in about 1% of all TGDCs. Diagnosis is usually made incidentally after a Sistrunk procedure. Options for further therapy include total thyroidectomy, T4 suppression therapy, and radioactive iodine ablation. In a patient with a normal-appearing thyroid gland and no evidence of metastatic disease, the treatment course is controversial. The recent literature emphasizes the identification of risk factors that may prompt the clinician to pursue more aggressive treatment. We present the case of a 35-year-old woman who was found to have a 1-cm midline neck mass that showed atypical cells on fine-needle aspiration. Histologic analysis after a Sistrunk procedure revealed a small focus of papillary carcinoma within the TGDC. The patient subsequently underwent total thyroidectomy with no evidence of carcinoma on histologic examination.

Post-thyroidectomy early serum ionic calcium level: Predictor of prolonged hypocalcemia

August 21, 2013     Sanjana V. Nemade, MS, FCPS(ENT) and Atul P. Chirmade, MS
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Abstract

One of the more common complications of thyroid surgery is postoperative hypocalcemia, which is potentially serious. Its clinical manifestations range from minimal twitching to life-threatening tetany. Affected patients might require a prolonged hospital stay and supplementation with calcium and vitamin D. In cases of post-thyroidectomy hypocalcemia, it is not always easy to predict which patients will require close monitoring of serum calcium levels. We conducted a study to determine whether early (<24 hr) measurement of serum ionic calcium (SiCa) levels can predict the development of post-thyroidectomy hypocalcemia. We retrospectively analyzed the charts of 150 adults (144 women and 6 men) who had undergone total or partial thyroidectomy, and we identified 42 patients (all women) who had either transient (<1 mo; n = 27) or prolonged (1 to 6 mo; n = 15) temporary hypocalcemia. We found that the patients who turned out to have prolonged hypocalcemia had significantly lower early levels of SiCa than did the patients who later developed only transient hypocalcemia (p = 0.000002). Also, patients with prolonged hypocalcemia had a significantly higher incidence of serious sequelae, including carpopedal spasms and signs of tetany. We conclude that early measurement of SiCa is a reliable predictor of prolonged temporary hypocalcemia following total or partial thyroidectomy.

Wrong egg in the usual nest: Thyroid papillary carcinoma within a branchial cleft cyst

July 21, 2013     Mustafa Sagit, MD; Ayhan Gokler, MD; Istemihan Akin, MD; Unsal Han, MD
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Abstract

Branchial cleft cysts are the most common lesions to arise laterally in the neck. Ectopic thyroid tissue within a branchial cleft cyst is rare, and a papillary carcinoma arising from this tissue is extremely rare. We present a case of a lateral neck cyst representing a primary papillary carcinoma that arose in ectopic thyroid tissue within a branchial cleft cyst in a 41-year-old woman. After the mass was surgically excised, thyroid ultrasonography, thyroid scintigraphy, and whole-body F18-fluorodeoxyglucose-positron emission tomography/computed tomography detected no abnormality. The negative findings notwithstanding, surgery on the thyroid gland was planned, but the patient refused it. Therefore, she was followed up with ultrasonography and scintigraphy for 5 years, during which time she exhibited no evidence of recurrence. Total thyroidectomy is still the primary option in such cases, but when it cannot be performed for any reason, vigilant follow-up is essential.

Giant cell tumor of the larynx: A case of malignant sarcomatous transformation

June 11, 2013     Richard J. Vivero, MD; Sandeep P. Dave, MD; Carmen R. Gomez, MD; and Donald T. Weed, MD
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Abstract

We report what is to the best of our knowledge the first case of malignant transformation of a giant cell tumor of the larynx. The patient, a 34-year-old man, presented to our tertiary care university teaching hospital where he underwent hemilaryngopharyngectomy with radial forearm free flap reconstruction and 11 of 15 cycles of chemotherapy. He remained disease-free at approximately 6 years and 4 months of follow-up. The patient is decannulated and continues to have a good voice with excellent quality of life to this day. We discuss the patient's clinical course and subsequent treatment within the context of a review of the current literature regarding this disease entity. Our experience demonstrates that giant cell tumor of the larynx may present as a malignant neoplasm without adversely affecting the patient's prognosis when treated aggressively with surgical resection and adjunct chemotherapy.

Previous presentation: The information in this article has been updated from its original presentation as a poster at The Triologic Society's Combined Southern and Middle Sections Meeting; January 8-11, 2009; Bonita Springs, Fla.

Extraosseous Ewing sarcoma and peripheral primitive neuroectodermal tumor of the thyroid gland: Case report and review

April 17, 2013     Magdalena Chirila, MD, PhD; Mihaela Muresan, MD; Elisabeta Ciuleanu, MD, PhD; and Marcel Cosgarea, MD, PhD
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Abstract

The Ewing family of tumors and peripheral primitive neuroectodermal tumor (pPNET) represent different manifestations of the same entity. Immunohistochemical and cytogenetic studies suggest that these tumors have a common origin. Ewing sarcoma is more common in bone, while pPNET is more common in soft tissues. Extraosseous Ewing sarcoma (EoES) is rare. We present the case of a 48-year-old man who presented with acute obstructive respiratory failure secondary to a large thyroid swelling. The patient was initially diagnosed with giant B-cell non-Hodgkin lymphoma and treated with chemotherapy. However, subsequent immunohistochemical staining of biopsy specimens revealed that the patient actually had EoES/pPNET of the thyroid gland. We performed a nearly complete surgical resection of the tumor plus a total laryngectomy and resection of five tracheal rings. However, the patient died of a cerebral metastasis 1 month later after he had completed one cycle of postoperative chemotherapy.

Malignant paraganglioma of the thyroid gland with synchronous bilateral carotid body tumors

February 25, 2013     Nadia Mohyuddin, MD; Karen Ferrer, MD; Urjeet Patel, MD, FACS
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Abstract

We describe a case of primary malignant paraganglioma of the thyroid gland that was found in a 55-year-old woman who had undergone surgery for bilateral carotid body tumors. The paraganglioma was treated with a total thyroidectomy followed by radiation therapy, and the patient was disease-free after more than 2 years of follow-up. Malignant paragangliomas of the thyroid gland are extremely rare. The diagnosis of malignancy is based on histopathologic findings, tumor behavior, and metastasis. These tumors can be misdiagnosed as other types of thyroid malignancies, thus resulting in less than optimal treatment. A genetic etiology was suspected in our patient.

Primary papillary carcinoma of the thyroid arising in a branchial cyst: Case report and review of the literature

February 25, 2013     Parvathidevi K. Gollahalli, SSAHE; Panduranga Chikkannaiah, MD, SSAHE; Vamseedhar Annam, MD, SSAHE
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Abstract

We report a case of papillary carcinoma of the thyroid that arose in a branchial cyst. The patient, a 45-year-old woman, presented with a left lateral neck mass of 3 months' duration. The cyst was removed intact. Because we could not rule out the possibility that a small primary malignancy was present within the gland, we performed a total thyroidectomy; however, no occult primary tumor of the thyroid was found. The patient was placed on thyroid hormone replacement therapy, and she was well at 2 years of follow-up. We briefly review the literature regarding the possible embryologic origin of such a phenomenon and the role of fine-needle aspiration cytology in differentiating a branchial cyst from a metastatic lymph node. To the best of our knowledge, this is only the 11th reported case of a thyroid papillary carcinoma arising in ectopic thyroid tissue within a branchial cyst, and the second such report from India.

Nasopharyngeal metastasis of follicular carcinoma of the thyroid with extensive clear cell change: A case report

December 31, 2012     Trupti Shreyans Patel, MD; Swapan L. Desai, MD; Priti P. Trivedi, MD; Manoj J. Shah, MD
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Abstract

Thyroid carcinoma metastatic to the maxillofacial area is extremely rare. Other carcinomas can metastasize to this area, but very few cases of follicular thyroid carcinoma metastasizing to the nasopharynx have been reported. Carcinoma from the kidney, liver, large bowel, prostate, and thyroid are known to have the potential for clear cell differentiation, and all of them can metastasize to the sinonasal area. Histochemical and immunohistochemical evaluations, along with clinical details, are useful in distinguishing metastases of these clear cell tumors from primary sinonasal tumors. In this article we describe a rare case of metastatic thyroid carcinoma with clear cell change mimicking metastatic renal cell carcinoma in the nasopharynx.

Traumatic thyroid hematoma associated with thyroid carcinoma

September 7, 2012     Carlos M. Rivera-Serrano, MD; Brian J. Park, MD, MPH; Robert L. Ferris, MD
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Abstract

Thyroid hematoma secondary to blunt trauma is uncommon, and no consensus exists for its management. We describe the case of a 46-year-old man who presented with neck swelling after he had sustained a blunt-trauma injury to his neck while playing soccer. Imaging revealed a large mass consistent with a thyroid hematoma. The patient was admitted for observation and followed up with serial imaging. He was eventually discharged without surgical intervention. However, he later underwent a thyroid lobectomy to treat compressive symptoms and for cosmetic reasons. Pathology revealed that the patient had a papillary thyroid carcinoma, which might have predisposed him to the hemorrhage. Thyroid hematoma secondary to blunt trauma has been documented in normal thyroid glands and in glands with preexisting benign pathology, but to the best of our knowledge, no report associating this condition with a thyroid carcinoma has previously been reported in the literature. A neoplasm should be suspected in a case of thyroid hematoma that fails to resolve with conservative treatment. The management of this condition is surgeon- and case-specific, and the overall prognosis is good.

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