Residency Program - Case of the Month

Clinical history:

The patient is a 68 year-old man who initially presented with pancreatitis and was incidentally found to have hypercalcemia due to hyperparathyroidism. His past medical and surgical history were non-contributory. He had a remote history of smoking, having quit 27 years ago, and a history of exposure to radiation while working at a nuclear power plant.  Family history included a brother with pancreatic cancer. On review of systems, he complained of occasional night sweats, upper abdominal pain, nausea, diarrhea, urinary frequency and kidney stones. Physical examination revealed no adenopathy, no thyromegaly and no palpable thyroid nodules. 

A parathyroid sestamibi scan was performed and demonstrated a left inferior parathyroid adenoma. An ultrasound was later performed but did not reveal any parathyroid candidates, possibly due to an overlying clavicle limiting the study. The ultrasound did identify a right thyroid nodule with calcifications, measuring greater than 1 cm in diameter. A needle biopsy was performed at an outside facility and demonstrated nodular stromal fibrosis within a probable thyroid follicular neoplasm. Subsequently, a right hemithyroidectomy and left inferior parathyroidectomy were performed.

Gross description:

A 9.5 gram right hemithyroidectomy specimen was received measuring 4.9 cm (superior to inferior), 3.3 cm  (medial to lateral), and 1.6 cm (anterior to posterior). Within the middle of the lobe was a 1.4 x 1.2 x 0.9 cm firm, white-tan, well-circumscribed, non-encapsulated nodule extending to within 0.1 cm of the inked surface along the anterior and posterior margins. No additional masses were identified.

Microscopic Photographs:

Immunohistochemical stains:

Figure 1: Congo Red

Figure 2: Synaptophysin

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