PMC5622813_01
Preoperative tomography image of the mass lateral to sternum at the left
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Thorax computed tomography (CT) examination was performed with the initial diagnosis of pulmonary embolism, which revealeda 3x2 cm sized mass located lateral to sternum in the left side of anterior mediastinum (Figure 1).
A) 25x10 magnification H&E and parathyroid pathology section; stained border surrounding connective tissue and partly capsule (arrow); B) 4x10 magnification H&E tumoral area in surrounding connective tissue (asterisk)
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Left inferior parathyroid gland peroperatively appeared bigger than normal and connected to superior parathyroid gland by a band (Figure 2). 90% of the tumors had fibrous bands and trabecular structures seen in microscopic examination. 67% of them had capsular invasion, 12% showed vascular invasion, while mitosis and fusiform tumoral cells were present in 81% (Figure 2 and Figure 4).
Intraoperative macroscopic appearance of left upper and lower parathyroid glands
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Since intact PTH (iPTH) levels decreased by 70% of pre-operative values and the appearance of other parathyroid glands were not pathological, the operation was terminated after left thyroid lobectomy, isthmectomy+unilateral central lymph node dissection were performed (Figure 3).
A) 40x10 magnification H&E, note clear cytoplasm, marked cell membrane, eccentric cell nucleus, patchy nuclear hypertrophy (arrow); cells are arranged as trabeculae and in clusters; B) 4x10 magnification H&E, arrows show peripheral thick capsule which was invaded by tumoral focuses that pass over the capsule to infiltrate surrounding connective tissue. Black capsule marked with asterisk is external surface surgical margin
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90% of the tumors had fibrous bands and trabecular structures seen in microscopic examination. 67% of them had capsular invasion, 12% showed vascular invasion, while mitosis and fusiform tumoral cells were present in 81% (Figure 2 and Figure 4).
A) 10x10 streptavidin peroxidase staining, PTH immunohistochemical staining, diffuse strong cytoplasmic and membranous staining; B) 20x10 streptavidin peroxidase staining, cyclin D1 immunohistochemical staining, diffuse strong nuclear staining; C) 20x10 streptavidin peroxidase staining, Galectin-3 immunohistochemical staining, patchy strong cytoplasmic and nuclear staining; D) 20x10 streptavidin peroxidase staining, ki-67 immunohistochemical staining, note 2% nuclear staining
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We detected a strong staining by Galectin-3 and Cyclin-D1, which were used to differentiate parathyroid adenoma and carcinoma. 2% increase in proliferation was observed by Ki-67 (Figure 5).