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+A 50-year-old male patient was admitted to our Department for a thyroid nodule on the right side of the neck, which was incidentally detected on carotid Doppler ultrasound scan.
+Fine-needle aspiration cytology (FNAC) showed a follicular lesion.
+At the time of our evaluation, the patient was in good health.
+The medical history revealed hypertension, vitiligo, and celiac disease.
+On physical examination, a small nodule (1 cm) was palpable in the right thyroid lobe.
+No enlarged neck lymph nodes were palpable.
+Neck ultrasound showed a 1.3 cm hypoechoic nodule with irregular margins in the right thyroid lobe together with bilateral small thyroid nodules (4–5 mm) and the absence of enlarged cervical bilateral lymph nodes.
+Thyroid function tests were normal with the absence of thyroid autoantibodies.
+Serum calcium was normal (9.7 mg/dl; normal range, 8.4–10.4 mg/dL) and PTH, routinely measured together with serum calcium in our Center in patients undergoing thyroid surgery, slightly elevated (68 pg/mL (intact PTH, 2nd generation assay; normal range, 10–65 pg/mL)).
+The re-review of the original slides of FNAC confirmed a follicular lesion.
+In particular, the cytology of the nodule showed epithelial cells with hyperchromatic nuclei organized in small cohesive clusters resembling microfollicles typically observed in thyroid follicular lesions were evident (Fig.1a).
+The patients underwent right lobectomy.
+During neck exploration, there were no macroscopic signs of local invasion.
+The intraoperative frozen-section pathological examination raised the suspicion of a PC.
+Definitive histology showed a markedly irregular infiltrative growth of the tumor with invasion of the thyroid tissue and cervical soft tissues (Fig.1b, c).
+Immunostaining for thyroglobulin was negative, whereas staining for chromogranin A and PTH showed a strong reactivity (Fig.1d–f).
+Based on the light microscopic findings and the immunohistochemical profile, the tumor was diagnosed as a PC.
+Postoperative serum calcium (8.7 mg/dl) and phosphate (3 mg/dl) levels were in the normal range.
+One month after surgery, serum calcium and plasma PTH were 9.6 mg/dL and 47 pg/mL, respectively.
+Neck ultrasound and total body computed tomography scan were negative for local and metastatic disease.
+Eight months later, serum calcium and plasma PTH levels were 9.1–9.2 mg/dl and 38–44 pg/ml (1–84 PTH 3rd generation assay, normal range, 8–40 pg/mL), respectively.
+Neck ultrasound did not show any pathological lesions.
+In order to exclude a familiar form of PHPT, in which PC may rarely occur as a nonfunctioning tumor [11], the screening of serum calcium and neck ultrasound in the first-degree relatives was normal.