18 January 2008 – Case of the Week #108
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We thank Dr. Julia Braza, Beth Israel Deaconess Medical Center, Boston, Massachusetts (USA), for contributing this case. To contribute a Case of the Week, email NatPernick@Hotmail.com with the clinical history, your diagnosis and microscopic images in JPG, GIF or TIFF format (send as attachments, we will shrink if necessary). Please include any other images (gross, immunostains, etc.) that may be helpful or interesting. We will write the discussion (unless you want to), list you as the contributor, and send you $35 (US dollars) for your time after we send out the case. Please only send cases with a definitive diagnosis, and preferably cases that are out of the ordinary.
Case of the Week #108
An 86 year old woman had neck pain and difficulty swallowing. A CT scan (figure 1-arrow) showed a nodular enhancing mass in the left hypopharynx at the level of the glottis / subglottis, obscuring the left pyriform sinus. The interpretation was possible pharyngeal neoplasm such as squamous cell carcinoma, with infection less likely.
The mass was biopsied.
What is your diagnosis?
Ectopic parathyroid tissue
The biopsied material consists primarily of parathyroid chief cells and adipose tissue, with a thin fibrous capsule dividing the cells into lobules. There is also a focus of adjacent mucinous glands, and a separate fragment of squamous epithelium overlying skeletal muscle.
Immunostains were: cytokeratin cocktail; chromogranin; synaptophysin; parathyroid hormone (the parathyroid glands are on the upper left hand side, the mucinous glands are on the lower right hand side). These findings are consistent with parathyroid tissue. No definite evidence of parathyroid hyperplasia or adenoma was identified.
The serum PTH level was within normal limits, and the surgeon indicated that the entire mass had been excised. Thus, the precise cause of the patient’s new onset pain and difficulty swallowing is unclear.
Ectopic parathyroid glands are relatively common, with an estimated incidence of 35%. They often become symptomatic due to hyperplasia associated with secondary hyperparathyroidism, and have been described in the pyriform sinus (Arch Otolaryngol Head Neck Surg 2002;128:71), mediastinum (Ann Thorac Surg 1997;64:238), in or near the thyroid gland or thymus (Nippon Rinsho 1995;53:920) and even in the axilla (Int Surg 2004;89:6). The parathyroid glands are often symmetrical from side to side, even when ectopic, making localization somewhat easier (eMedicine). Ectopic parathyroid tissue can undergo adenomatous change, and cause primary hyperparathyroidism, hypercalcemia and acute pancreatitis (World J Surg Oncol 2004;2:41).
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