2. Case Description
The patient was a middle-aged male with a body mass index (BMI) of 38.4 who was hospitalized with thyroid nodules for 40 days. Physical examination showed that the thyroid gland was firm and no obvious mass was palpable; ultrasonography showed normal thyroid gland size, heterogeneous glandular echoes, patchy hypoechoic areas, the larger one was located in the right lobe, with a range of about 2.7 × 1.09 cm, a hypoechoic nodule was observed in the lower deep layer of the right lobe, with a size of about 0.61 × 0.60 cm, aspect ratio > 1, regular borders, and punctate hyperechogenicity was observed; an anechoic nodule was observed in the middle superficial layer, with a size of about 0.28 × 0.34, aspect ratio < 1, regular borders, and no significant focal hyperechogenicity was observed; a solid hypoechoic nodule was observed in the lower grade of the left lobe, with a size of about 0.54 × 1.01 cm, aspect ratio < 1, regular borders, and no significant focal hyperechogenicity was observed. No significant abnormal enlarged lymph nodes were found in bilateral neck. Cytological examination of the right thyroid lobe nodule showed atypical cells suggestive of papillary thyroid carcinoma. Thyroid function tests: thyroid stimulating hormone TSH 0.862 mIU/L (normal reference value 0.372 – 4.94 mIU/L); parathyroid hormone PTH 64.62 pg/ml (normal reference value 15 – 56 pg/ml); serum calcium Ca 2.42 mmol/L (normal reference value 2.2 – 2.65 mmol/L).
Resection of the right lobe and isthmus of the thyroid gland and central lymph node dissection were planned, during which the right lobe and isthmus of the thyroid gland were first removed, and grayish white nodules were observed in the right lobe of the thyroid gland by dissection, about 0.4 cm in diameter, and the remaining sections were grayish red and soft.During the resection, two masses measuring 1.5 × 0.8 × 0.7 cm and 2.5 × 1.5 × 0.5 cm were found in the dorsal and lateral aspect of the middle and upper parts of the right lobe, respectively.The texture was firm, the surface was smooth and the boundary was clear. The possibility of parathyroid gland mass was considered, so it was decided to remove the tissue for rapid pathological examination.The results showed that round cells were scattered in the fibroadipose tissue of the middle and upper dorsum of the right lobe, not excluding the mass of parathyroid gland origin; most of the tissues submitted to the lateral aspect of the middle and lower parts of the right lobe were fat, in which a few round cells were scattered.At the same time, the left thyroid gland was dissected to explore the tracheoesophageal groove of the lower pole of the thyroid gland in its dorsal pole, and no abnormal hyperplastic parathyroid tissue was observed.PTH values were 29.68 pg/ml and 35.71 pg/ml at 15 and 30 minutes after tumor resection, respectively, and serum calcium was 2.30 mmol/L on the first day after surgery.Postoperative paraffin pathology (Fig. 1. ) revealed that the superior dorsal mass and the middle and lower lateral mass in the right lobe were consistent with parathyroid lipoadenoma, and immunohistochemistry (Fig. 2. ) revealed PTH (+); CgA (+); SyN (-); CD56 (-); TTF-1 (-); Tg (-); Ki-67 (< 1% +), and the right lobe of the thyroid gland was papillary thyroid carcinoma 0.4 cm in diameter; there was one lymph node metastasis in the central group, and the diameter of the metastasis was 0.05 cm; the isthmus was nodular goiter.Euthyrox 50 μg was orally administered daily after surgery.