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18 January 2008 - Case #108

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This case was contributed by Dr. Julia Braza, Beth Israel Deaconess Medical Center, Boston, Massachusetts (USA).



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Case #108

Clinical history:
An 86 year old woman had neck pain and difficulty swallowing. A CT scan 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.

Radiology image:


Microscopic images:




What is your diagnosis?

Click here for diagnosis and discussion:


Diagnosis: Ectopic parathyroid tissue

Immunostains:

Cytokeratin cocktail

Chromagranin

Chromagranin

Synaptophysin

Parathyroid hormone



Discussion:
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 and 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, mediastinum, in or near the thyroid gland or thymus and even in the axilla (Arch Otolaryngol Head Neck Surg 2002;128:71, Ann Thorac Surg 1997;64:238, Nippon Rinsho 1995;53:920, Int Surg 2004;89:6). The parathyroid glands are often symmetrical from side to side, even when ectopic, making localization somewhat easier (eMedicine: Embryology of the Thyroid and Parathyroids [Accessed 8 May 2024]). 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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