Asymptomatic Thyroid Nodule Research Articles

6477 Surprise Finding For A Thyroid Nodule: Metastatic Renal Cell Carcinoma

Abstract Disclosure: A. Xu: None. E. Hsu: None. Introduction: A patient with an incidental and asymptomatic thyroid nodule underwent fine needle aspiration biopsy (FNA) after the nodule increased in size. Without a definite pathology after three FNA attempts, thyroidectomy was performed, where pathology found metastatic renal cell carcinoma (RCC). Clinical Case: A 64 year old woman had a past medical history of obesity, type 2 diabetes, RCC (stage I: pT1bN0M0) treated with right radical nephrectomy five years prior and thought to be in remission, remote smoking history smoking, and coronary artery disease with coronary artery bypass graft (CABG) two months prior, on anticoagulation. The patient reported a distant history of right thyroid lobectomy over a decade prior for unclear reasons, but she was adamant that the pathology was benign. Two years prior to presentation, CT chest done for RCC surveillance had detected a left thyroid nodule. Ultrasound at the time revealed a 3.6 x 1.9 x 2.3 cm solid, isoechoic nodule in the upper left lobe, which was not taller than wide, and had smooth margins and no echogenic foci. A repeat ultrasound at the time of presentation showed interval growth of the nodule, now measuring 4.3 x 2.1 x 2.9 cm. FNA was unsatisfactory, yielding predominantly blood. Patient felt well and had no compressive neck symptoms. We opted to wait two months and repeat FNA, which resulted as atypia of undetermined significance - Bethesda category III (AUS). We recommended completion thyroidectomy, but patient preferred to avoid surgery. We decided to wait two months and repeat FNA with molecular testing. This third FNA resulted AUS again; however, due to non-medical reasons, molecular testing was not performed. Another ultrasound showed slight growth of the nodule, 5.1 x 2.9 x 2.0 cm, which appeared hypoechoic now, but was still not taller than wide, with smooth margins and no echogenic foci. Completion thyroidectomy was performed, with pathology showing metastatic clear cell renal cell carcinoma. Immunostains were positive for carbonic anhydrase and renal cell carcinoma marker and negative for TTF-1. Whole-body PET-CT showed no hypermetabolic foci, and a repeat PET-CT one year later still showed no evidence of metastatic disease. Other than a hospitalization for COVID-19, patient is doing well and asymptomatic now over a year after her thyroidectomy. Oncology will continue routine surveillance imaging for her metastatic renal cell carcinoma thought to be in remission. Clinical Lessons: This case of metastatic renal cell carcinoma to the thyroid adds to the small body of literature showing the thyroid as a possible site of RCC metastasis. The long time interval between initial RCC presentation and metastasis to the thyroid makes this diagnosis more difficult; however, clinicians should be aware of the possibility, making thyroidectomy a stronger option in cases where FNA cytology is indeterminate. Presentation: 6/2/2024

6477 Surprise Finding for a Thyroid Nodule: Metastatic Renal Cell Carcinoma

Abstract Disclosure: A. Xu: None. E. Hsu: None. Introduction: A patient with an incidental and asymptomatic thyroid nodule underwent fine needle aspiration biopsy (FNA) after the nodule increased in size. Without a definite pathology after three FNA attempts, thyroidectomy was performed, where pathology found metastatic renal cell carcinoma (RCC). Clinical Case: A 64 year old woman had a past medical history of obesity, type 2 diabetes, RCC (stage I: pT1bN0M0) treated with right radical nephrectomy five years prior and thought to be in remission, remote smoking history smoking, and coronary artery disease with coronary artery bypass graft (CABG) two months prior, on anticoagulation. The patient reported a distant history of right thyroid lobectomy over a decade prior for unclear reasons, but she was adamant that the pathology was benign. Two years prior to presentation, CT chest done for RCC surveillance had detected a left thyroid nodule. Ultrasound at the time revealed a 3.6 x 1.9 x 2.3 cm solid, isoechoic nodule in the upper left lobe, which was not taller than wide, and had smooth margins and no echogenic foci. A repeat ultrasound at the time of presentation showed interval growth of the nodule, now measuring 4.3 x 2.1 x 2.9 cm. FNA was unsatisfactory, yielding predominantly blood. Patient felt well and had no compressive neck symptoms. We opted to wait two months and repeat FNA, which resulted as atypia of undetermined significance - Bethesda category III (AUS). We recommended completion thyroidectomy, but patient preferred to avoid surgery. We decided to wait two months and repeat FNA with molecular testing. This third FNA resulted AUS again; however, due to non-medical reasons, molecular testing was not performed. Another ultrasound showed slight growth of the nodule, 5.1 x 2.9 x 2.0 cm, which appeared hypoechoic now, but was still not taller than wide, with smooth margins and no echogenic foci. Completion thyroidectomy was performed, with pathology showing metastatic clear cell renal cell carcinoma. Immunostains were positive for carbonic anhydrase and renal cell carcinoma marker and negative for TTF-1. Whole-body PET-CT showed no hypermetabolic foci, and a repeat PET-CT one year later still showed no evidence of metastatic disease. Other than a hospitalization for COVID-19, patient is doing well and asymptomatic now over a year after her thyroidectomy. Oncology will continue routine surveillance imaging for her metastatic renal cell carcinoma thought to be in remission. Clinical Lessons: This case of metastatic renal cell carcinoma to the thyroid adds to the small body of literature showing the thyroid as a possible site of RCC metastasis. The long time interval between initial RCC presentation and metastasis to the thyroid makes this diagnosis more difficult; however, clinicians should be aware of the possibility, making thyroidectomy a stronger option in cases where FNA cytology is indeterminate. Presentation: 6/2/2024

Asymptomatic Thyroid Nodule Detection in a Referred Patient, A Case Report

Asymptomatic Thyroid Nodule Detection in a Referred Patient, A Case Report

Auto-machine learning for opportunistic thyroid nodule detection in lung cancer screening chest CT.

e13639 Background: Automated Machine Learning (Auto-ML) in medical imaging is a process that allows non-experts to utilize machine learning techniques, opening the door for non-coder physician-driven exploitation of the technology. Auto-ML was applied for opportunistic detection of thyroid nodules in the context of low-dose lung cancer screening chest CT, facilitated by an innovative platform integration. By leveraging scans originally intended for lung cancer screening, suspicious appearing asymptomatic thyroid nodules can also be screened for where technically feasible. Methods: CT scans from the National Lung Screening Trial (NLST) dataset were utilized. This dataset contains low-dose chest CT examinations initially used for lung cancer screening. Annotation was carried out within a no-code web-based platform, Gesund.ai. A board-certified diagnostic radiologist annotated 100 CT examinations. A case was labeled "suspicious" if it presented a thyroid nodule of 1 cm or greater in diameter, while cases with no such nodules were deemed "not suspicious." The Auto-ML feature was then engaged within the software platform for parameter adjustments to refine the model without the need for manual coding. This phase was characterized by an iterative exploration of model performance, facilitated by the platform’s robust validation tools. Results: Upon training and validation, the Auto-ML model, cultivated from 100 annotated cases and assessed against a separate set of 130 cases, demonstrated a discernment accuracy of 0.51 in identifying "suspicious" thyroid nodules with a sensitivity and precision of 0.51 and 0.62 respectively. The AUC for this class stands at 0.69, indicating a moderate ability to distinguish between the presence and absence of thyroid nodules. This metric, while foundational, offers insight into the model's potential efficacy in real-world diagnostic scenarios, reflecting the initial capabilities of the platform's Auto-ML integration in enhancing diagnostic processes. Conclusions: The findings from this study highlight the potential of Auto-ML in revolutionizing opportunistic screening for thyroid nodules via lung cancer CT. The initial accuracy rate underscores the necessity for further refinement and validation of the model, but also demonstrates the promising potential of Auto-ML. Institutional Auto-ML would include extraction of appropriate studies through the no-code software platform integrated directly within the PACS framework. This process would ensure data immobility and foster a secure environment for dataset creation. Annotation would be carried out by multiple physician imagers within the same facility, enhancing the data’s accuracy and comprehensiveness specific for the institution’s patient population. This exploration highlights the strategic role of Auto-ML in advancing cancer patient care through innovative technological integration.

P-85 Inflammatory myofibroblastic tumor: An extremely rare tumor of the thyroid gland poses challenges in diagnosis and management

Abstract Introduction Inflammatory myofibroblastic tumor (IMT) is an exceedingly rare mesenchymal tumor characterized by myofibroblastic spindle cells and an inflammatory cell infiltrate. The clinical presentation of IMT in the thyroid gland varies widely, ranging from an asymptomatic thyroid nodule to a diffuse, rigid, fixed, and painful mass. While IMT of the thyroid gland is generally considered a benign borderline tumor with very low metastatic potential, its diagnosis and management can be intricate. Surgery remains the preferred treatment, with recurrence being rare following successful removal. Nonetheless, the optimal management of residual tumors is contentious and may involve a second surgery or the use of immunosuppressants and chemotherapeutic agents. Clinical Case A 47-year-old female patient presented with painless discomfort and stiffness around the thyroid gland. A neck ultrasound revealed a hypoechoic nodule measuring 21×12 mm on the left lobe and a hypoisoechoic heterogeneous nodule 35×28 mm in size on the right lobe of the thyroid gland. These nodules displayed low vascularity, and no pathologic lymph nodes were detected. Fine needle aspiration biopsies (FNABs) were performed on the nodules in both lobes at different times, indicating thyroiditis in the right lobe and spindle-shaped cells with atypia of uncertain significance in the left lobe. Subsequent evaluation of FNAB materials at a referral center suggested a high suspicion of lymphoid malignancy. The patient underwent thyroidectomy; however, the surgeon chose to preserve the left thyroid lobe due to its extreme fibrotic and stone-like consistency, thereby preserving recurrent laryngeal nerve function. Histological analysis confirmed the presence of an inflammatory myofibroblastic tumor characterized by spindle cells accompanied by abundant histocytes, plasma cells, and lymphocytes. The tumor cells exhibited positivity for SMA. Postoperative ultrasound revealed a residual tumor approximately 2 cm in size located in the left isthmus and adjacent left lobe, which remained stable over a 6-month follow-up period. Conclusion Our case highlights the potential for misdiagnosing IMT of the thyroid gland as malignant thyroid tumors. Furthermore, the management of a residual tumor presents a complex clinical challenge. The surgical team is reluctant to pursue a second surgery due to potential risks to recurrent laryngeal nerve function. In this session, we aim to solicit expert opinions and engage in interactive discussions regarding the management of the residual tumor in this specific case.

Potential implications of thyroid autoantibodies in children, adolescents, and young adults with thyroid nodules in Japan: The Fukushima Health Management Survey.

There have been no systematic epidemiological evaluations of the relationship between thyroid autoimmunity and the clinical background of young patients with thyroid nodules. We aimed to clarify the clinical features associated with thyroglobulin or thyroperoxidase antibodies (thyroid autoantibodies [Tabs]) in children and young adults with nodules. We performed a cross-sectional study using data from 3,018 participants of 3-29 years of age with nodules, including thyroid cancer, from the Fukushima Health Management Survey. After stratification of the data for body mass index (BMI) and the bilateral width and thickness of the area (BWTAR) as indicators of thyroid volume for age, sex, body surface area (BSA), and sex-adjusted standard deviation score (SDS), trend analyses were performed. A logistic regression analysis was performed using tab-positivity as an objective variable. The overall prevalence of tab-positivity is 13.9%. It was high in females (17%), participants with diffuse goiter (DG) (19.2%), and those with papillary thyroid carcinoma (PTC) (12.8%). The age- and sex-adjusted odds ratios (95% confidence intervals) for BMI-SDS, BWTAR-SDS, presence of DG, diagnosis of PTC, and TSH concentrations were 0.962 (0.863-1.073), 1.263 (1.171-1.361), 7.357 (4.816-11.239), 2.787 (1.965-4.014), and 1.403 (1.257-1.564), respectively. Tab positivity was independently associated with a large thyroid, the presence of DG, the presence of PTC, and a high TSH concentration in patients with nodules. Based on the systematic epidemiologic evidence shown in young patients, Tab positivity might complement ultrasonography for the assessment of the thyroid function and identification of malignancy in younger patients with asymptomatic thyroid nodules.

FRI367 An Unusual Presentation Of A Thyroid Nodule: A Thyroid Paraganglioma

Abstract Disclosure: M. Owrangi: None. F. Hasan: None. Introduction: Thyroid paraganglioma (PGL) is a rare thyroid tumor that originates from inferior laryngeal paraganglia. We present a case of a patient initially believed to have a thyroid nodule which turned out to be a PGL. Case Presentation: A 49 year-old white female with history of GERD and mild dysphagia who was found to have a left parathyroid adenoma vs. a left exophytic thyroid nodule. Previous ultrasounds had all showed slow but progressive enlargement of the lesion. Her labs had showed iPTH, Ca, TSH, and free T4 all within reference range and she was clinically euthyroid. She had 2 fine needle aspirations (FNA) which were both non diagnostic. She ultimately underwent surgical excision of the mass. The pathological examination showed cells that were positive for synaptophysin, chromogranin, GATA-3, S100, and neuron-specific enolase. They were negative for Ki-67, PTH, thyroglobulin, TTF-1, CK AE1/AE3, and CD 138. The overall findings were consistent with thyroid PGL. Discussion: In this case Thyroid PGL was diagnosed after pathological examination, including immunohistochemistry, was performed on a surgically excised sample, after 2 FNAs were non-diagnostic. Thyroid PGLs are elusive tumors. One study suggested that since they were first described in 1964, until 2015, there have only been 54 reported cases of thyroid PGLs, with a strong female predominance (88.9%). They often present as asymptomatic thyroid nodules and their diagnosis can be difficult by FNA alone as they can morphologically mimic medullary thyroid carcinoma, intrathyroidal parathyroid proliferation, metastatic neuroendocrine tumor, or calcitonin-negative neuroendocrine tumor of the thyroid gland (CNNETT). Thyroid PGLs are often benign, slow growing tumors and account for only 0.012% of all head and neck tumors with a malignancy rate of 4-16%. They usually present as single nodules averaging 3.5 cm and are often diagnosed with routine ultrasound assessment of the neck. Since they are associated with the parasympathetic nervous system, signs and symptoms including tachycardia, palpitations, and weight loss due to hormonal activity are classically absent from thyroid PGLs. In about 30% of cases, thyroid PGLs have a genetic predisposition and are more than one and associate with other tumors such as pheochromocytoma. Major hereditary disorders associated with paraganglioma include von Hippel-Lindau disease, multiple endocrine neoplasia, familial paraganglioma syndromes 1 to 4, and neurofibromatosis. Therefore, it is highly recommended that patients with a diagnosis of thyroid PGL undergo additional investigations with imaging, hormonal activity assessment, and genetic testing. Given the difference in management of thyroid PGLs compared to its cytology mimics, and their association with some familial cancer syndromes, use of immunohistochemical staining is crucial in making the correct diagnosis. Presentation: Friday, June 16, 2023

Prevalence and characterization of asymptomatic thyroid nodules in Assin North District, Ghana.

Ultrasound is now the initial imaging modality of choice for detection and characterization of lesions of the thyroid gland. Ultrasound imaging studies of the thyroid gland report varied prevalence of asymptomatic thyroid nodules (ATN), ranging from 20 to 67%. This study estimated the prevalence, characterized and determined factors associated with ATN in selected communities in the Assin North Municipality, Central Region, Ghana. The study was a cross-sectional design, involving 320 participants from six (6) communities in the Assin North District of the Central Region of Ghana. Socio-demographic data and data from ultrasound examination of the thyroid gland were analyzed using descriptive and inferential statistical techniques. The prevalence of ATN was 11.3% among 320 participants with the mean age of 56.53(±16.5) years. ATNs were common in the left lobe (69%) and predominantly solitary (64%). ATNs increased with age and body mass index (BMI). Those aged 60 years and above had significantly higher odds (OR = 24.40, 95% CI = 2.59-229.86) of having ATNs, likewise overweigh (OR = 5.32, 95% CI = 1.12-25.20) and obese (OR = 12.51, 95% CI = 1.47-106.58) individuals. The prevalence of ATN in our study population was relatively low, and more predictable among those 60 years or older, those in unhealthy BMI categories. There is the need for the reinforcement and intensification of educational campaigns on the consumption of iodized dietary salt as well as the consumption of foods rich in iodine content, particularly among older individuals.

Bibliometric analysis of research on thyroid ultrasonography.

The incidence of thyroid diseases has increased, which may be partly related to the widespread use of thyroid ultrasound resulting in a large number of asymptomatic thyroid nodules to be found. Research has found that many thyroid ultrasound examinations are completely avoidable. However, the purpose of the present study was to use bibliometrics to analyze the relevant research literature of thyroid ultrasound and understand the overall status of the current research in this field. We searched the Science Citation Index Expanded (SCI-E) database in the Web of Science Core Collection. Search terms were "ultrasonography" and "thyroid gland". The date range for the document search was from 1900 to May 10, 2021. Export the full record of the search results and the references in txt. format, and use the CiteSpace software to analyze the annual publication of literatures, the distribution of countries and institutions where the literatures came from, the distribution of journals and authors. The keywords used in the literature were also analyzed. A total of 1,241 publications were included in the results, and the frequency of citations was 27,149. The top 5 countries for the number of publications published were the USA, Turkey, Italy, South Korea, and China; the top 5 countries by centrality were the USA, Germany, Italy, Canada, and China. The number of institution-published papers was generally low, and the centrality score was low. Research in this field was relatively scattered among institutions and cooperation between institutions was few. There was little collaboration between authors from different institutions. The most cited authors were mainly from European and North American countries. Journals, such as Thyroid, Journal of Clinical Ultrasound, and Journal of Endocrinological Investigation, had great influence in this field. Keyword analysis results showed that research is mainly focused on the differentiation of benign and malignant thyroid nodules. There was an increase in thyroid ultrasound research, but there was few cooperation exist between institutions. The main research direction was the differentiation of benign and malignant thyroid nodules.

Update on the Evaluation of Thyroid Nodules.

Thyroid nodules (TN) are prevalent in the general population and represent a common complaint in clinical practice. Most are asymptomatic and are associated with a 7%-15% risk of malignancy (1). Methods: PubMed and Medline were searched for articles with a focus on the epidemiology, diagnosis, and management of TN over the past 5 y. Results: The increase in frequency of imaging has led to a rise in the incidence of incidentally diagnosed TN. The initial evaluation of a TN includes assessing thyroid function, clinical risk factors, and neck imaging. Ultrasound remains the gold standard for assessing TN morphology, and biopsy is the standard method for determining whether a TN is benign. Recently published risk stratification systems using morphologic characteristics on ultrasonography have been effective in reducing the number of unnecessary biopsies. Advances in molecular testing have reduced the number of surgical procedures performed for diagnostic purposes on asymptomatic TN with indeterminate cytology. Scintigraphy is the first-line study for assessing a hyperfunctioning nodule. Many TN can be followed clinically or with serial ultrasound after the initial diagnosis. Surgical intervention is warranted when local symptoms are present, in patients with clinical risk factors, as well as in most situations with malignant cytology. Active surveillance is an option in cases of micropapillary thyroid cancer. Emerging nonsurgical approaches for treating TN include ethanol ablation for TN; sclerotherapy for thyroid cysts; and thermal techniques, such as radiofrequency ablation, laser ablation, microwaves, and high-intensity focused ultrasound. Conclusion: Most TN are benign and can be safely monitored. The indications for biopsy and frequency of imaging should be tailored on the basis of risk stratification. Treatment options should be individualized for each patient's particular situation. Active surveillance should be considered in certain cases of papillary microcarcinoma.

Agreement Between Ti-RADS Classification and Bethesda Cytopathological Findings from Thyroid Nodules in Young Adults.

Thyroid nodules are common in young adults. We sought to compare the sonographic characteristics (thyroid imaging reporting and data system [Ti-RADS] classification) with the reported cytological results (Bethesda categories) from thyroid nodules in young recruits and examine the efficiency of our unique multidisciplinary clinic. In this retrospective cohort, we identified young recruits (18-25years) who underwent needle biopsies for asymptomatic thyroid nodule(s), with cytology reports of Bethesda categories II-V, performed in our "Rapid Diagnostic Service" at a large Israeli Defense Forces Medical Corps healthcare facility, between 2013 and 2018. We studied the concordance rates between their Ti-RADS and Bethesda grades, and the preoperative Bethesda grades accuracy versus final pathology results, and the time period needed for their thyroid nodules workup. A total of 81 patients were included who contributed 91 nodules. A fair agreement was found between the Ti-RADS classifications and the Bethesda grades (Cohen's κ=0.238) that was more noticeable in males than in females. The agreement rate was 87.5% in males (21 of 24), but only 77.6% in females (59 of 67) [P=.029]. Of the 5 operated benign cases, all had low Ti-RADS, and 2 had low Bethesda. Of the 8 operated malignant cases, 6 had high Ti-RADS, and 5 had high Bethesda. On average, 37.64days elapsed between the first visit to the ultrasound study, and 24.2days elapsed until biopsy was performed. Despite an overall fair agreement between the sonographic features and cytological findings in young adults, we recommend a more aggressive approach and repeated biopsies despite reported benign pathology, because of a high false-negative rate.

Considerations for Thyroid Fine Needle Aspiration (FNA) Biopsies During the COVID-19 Pandemic

Considerations for Thyroid Fine Needle Aspiration (FNA) Biopsies During the COVID-19 Pandemic

Four Cases of Esophageal Diverticulum Presented as Incidentally Discovered Asymptomatic Posterior Thyroid Nodules

Abstract Esophageal content in the thyroid by fine-needle aspiration is a rare occurrence. Here are four cases of esophageal diverticulum that presented as incidentally discovered asymptomatic posterior thyroid nodules in four patients (one 85-year-old female, one 85-year-old male, one 57-year-old male, and one 26-year-old female) who underwent ultrasound-guided fine-needle aspiration (FNA). The FNA cytopathological findings include bland mature nonkeratinizing superficial squamous cells, abundant filamentous bacteria, scattered degenerated chronic inflammatory cells, and amorphous debris, consistent with oral pharyngeal contents. These findings in the thyroid FNA biopsy may raise differential diagnoses, including Zenker diverticulum and Killian-Jamieson diverticulum of the esophagus, thyroglossal duct fistula and a third or fourth branchial fistula, and benign epidermal inclusion cyst. Thyroglossal duct fistula appears as a midline tract, which may connect the thyroid gland and the foramen cecum, as well as the branchial fistula usually present in the pediatric population, and it may connect the thyroid gland and the hypopharyngeal piriform sinus, although with an unusual presentation seen in adults. However, all four cases were reviewed with radiologists and confirmed as deep posterior thyroid nodules. The squamous epidermal inclusion cyst is usually in the superficial dermis and has predominantly anucleated squamous cells and very few if any well-preserved nucleated squamous cells. The abundant filamentous bacteria/yeast may represent colonization and no infection, which is confirmed by almost absence of neutrophils. So, the final diagnosis of these four cases is suggestive of esophageal diverticulum and no surgical treatment is necessary with the recommendation of esophagogastroduodenoscopy. As noted above, there is no evidence of malignancy; however, the false-negative rate of FNA diagnosis in a squamous-related entity is reported to be about 2% to 5%, so these patients are deemed appropriate for follow-up. In summary, we presented four cases of incidentally discovered asymptomatic posterior thyroid nodules suggestive of esophageal diverticulum by FNA biopsy.

SUN-617 Metastatic Papillary Thyroid Cancer Presenting with Vertebral Fracture

: Of the major differentiated Thyroid malignancies, Papillary carcinoma has the highest incidence, representing 80% of cases and is most commonly diagnosed between the 3rd and 6th decade of life. Most commonly discovered as an asymptomatic thyroid nodule, Papillary carcinoma, due to its unencapsulated nature, preferentially invades local lymph nodes over hematogenous spread. Distant metastases are rare of Papillary carcinoma and even more unusual as the presenting symptom.Here we present the case of a 73 year old Caucasian Female who presented to the ED with 3 months of constant progressively worsening lower back pain. She reports associated pain into her right lateral thigh and tingling sensations over the left lateral thigh. Patient denied bladder/bowel dysfunction or saddle anesthesia. To manage the pain, our patient had been taking a full dose aspirin and was seeing a chiropractor who had given her the diagnosis of herniated disks from xray radiography. Increased severity of her pain had brought her into the ED. On physical exam, our patient had point tenderness over her lumbar spine, without any motor sensory defects. ED CT scan demonstrated a comminuted compression fracture of her L3 spine with bilateral neural forminal compromise. MRI the following day confirmed the findings. Intraoperatively during correction of the compression fracture, biopsy of the bone was sent to for analysis. The sample stained positive for TTF, thyroglobulin and PAX-8 all consistent with metastatic thyroid cancer. In the following days, our patient had an Ultrasound that confirmed a 1.6cm nodule in the right thyroid lobe. Fine needle Aspiration confirmed the findings on biopsy. Definite treatment involved thyroidectomy and samples under microscopy showed papillary cell carcinoma of the thyroid gland. Discussion: Due to its slow course and minimal invasiveness, Papillary thyroid carcinoma has great outcomes after medical and surgical management. In 90% of cases, this cancer presents as a thyroid nodule and rarely metastasizes. Ultrasound and FNA can lead to a timely diagnosis and elective surgical management can be scheduled. The standard of care is complete thyroidectomy and follow up radioactive Iodine therapy are used as definitive treatment for this malignancy, resulting in a 80% ten year survival rate. Success of management drops significantly if there is metastasis of Papillary thyroid carcinoma with some studies suggesting a 10 year survival rate at 40% and only 21% if there is bone metastasis. After the lungs and liver, bone is the 3rd most common site papillary thyroid carcinoma metastasis to. Conclusion: This presentation of spinal metastasis and the resulting compression fracture as presenting symptoms of papillary Thyroid cancer is a rare presentation of this malignancy.

Thyrotoxic Goiter and Asymptomatic Thyroid Nodule as an Initial Presentation of Clear Cell Renal Cell Carcinoma

Thyroid nodule as a metastasis to renal cell carcinoma (RCC) is rarely found. We present two cases – presented with thyroid nodules and diagnosed as metastatic RCC; one patient had thyrotoxic goiter, whereas the second patient presented with asymptomatic thyroid nodule. Subsequently, hemithyroidectomy and total thyroidectomy were performed, respectively. Then, both patients underwent radical nephrectomy for the primary tumor. At present, patients are under regular oncology follow-up, with no evidence of disease recurrence.

Evaluation and management of thyroid incidentalomas detected prior to the parathyroid surgery

BackgroundWe investigated the management of thyroid incidentalomas associated with cases of parathyroid lesions in order to suggest a practical approach to their management from a surgical point of view. Methods639 patients underwent radiological and ultrasound investigation of the thyroid area because of parathyroid disorders and parathyroidectomy and had at least three years of follow-up. All follow-up data for these cases were investigated from the moment the lesion was detected and up to the last report. ResultsOut of 639 cases, incidental or asymptomatic thyroid nodules were found in 179 patients (28%), of which, 22 patients were operated (parathyroidectomy + thyroidectomy) and 157 remained with the nodules. For these patients, the average period of follow-up was 7 years 5 mo. Following the results of the follow-up, 52 patients (33%) were suggested to have surgery of the thyroid gland and 49 were operated (16 total thyroidectomies and 33 hemithyroidectomies). The complications after the second surgery included recurrent laryngeal nerve palsy (n = 3), superior laryngeal nerve palsy (n = 1), permanent hypocalcaemia (n = 8), and surgical damage to the internal jugular vein (n = 1). All complications occurred at the previously operated side of the neck. ConclusionWhile surgery remains the management of choice for malignant thyroid incidentalomas, for benign cases, if an asymptomatic thyroid nodule was detected inside the thyroid lobe on the side of planned parathyroidectomy and if the size of the nodule is ˃1.5 cm we suggest combined parathyroidectomy + hemithyroidectomy.

Ultrasonographic prevalence and characteristics of non-palpable thyroid incidentalomas in a hospital-based population in a sub-Saharan country

BackgroundThyroid incidentalomas (TI) are highly prevalent asymptomatic thyroid nodules with ultrasound as the best imaging modality for their detection and characterization. Although they are mostly benign, potential for malignancy is up to 10–15%.In sub-Saharan Africa little data exists on the prevalence and risk categorization of TI. The aim of this study was to determine the prevalence and ultrasound characteristics of non-palpable thyroid incidentalomas among adults in sub-Saharan setting.MethodsA cross sectional study was carried out between March and August 2015, at two university teaching hospitals. Sampling was consecutive and included all adults aged ≥ 16 years, presenting for any ultrasound other than for the thyroid, with no history or clinical signs of thyroid disease, and no palpable thyroid lesion. Ultrasound was done using 4 to 11 MHz linear probes. Subjects with diffuse thyroid abnormalities were excluded. Variables studied were age, gender, thyroid volume, ultrasound characteristics of thyroid nodules, TIRADS scores. Differences were considered statistically significant for p-value < 0.05.ResultsThe prevalence of TI was 28.3% (126 persons with TI /446 examined). This prevalence was 46.2% in population ≥ 61-year-old; 6.3% in population ≤ 20-year-old; 33.3% for females and 18.4% for males (p < 0.001). Of the 241 TI found, 49.4% were cysts, 33.6% solid, 17.0% mixed; 37.8% <5 mm and 22% >10 mm. Solid TI were mainly hyperechoic (42.0%), 3/81 were markedly hypoechoic. Sixty-nine out of 126 persons with TI (54.8%) had at least two nodules. Solitary nodules were predominant in the age group ≤20 years. Of 241 TI, 129 (53.5%) were classified TIRADS 2, 81 (33.6%) TIRADS 3, 25 (10.4%) TIRADS 4A, 6 (2.5%) TIRADS 4B, and none TIRADS 5. Characteristics associated with increased risk of malignancy where mostly founded on solid nodules (p < 0.000) and nodules larger than 15 mm (p < 0.001).ConclusionThyroid incidentalomas were very frequent with a prevalence of 28.3% and potential risk of malignancy in 12.9%. Prevalence had a tendency to increase with age and in female. Cystic nodules were the most prevalent. Potential for malignancy would be increased for larger and solid nodules.

Cost comparison of initial lobectomy versus fine-needle aspiration for diagnostic workup of thyroid nodules in children

BackgroundThough uncommon in children, pediatric thyroid nodules carry a higher risk of malignancy than adult nodules. While fine-needle aspiration (FNA) has been well established as the initial diagnostic test in adults, it has been more slowly adopted in children. The purpose of this study was to examine the comparative cost of FNA versus initial diagnostic lobectomy (DL) in the pediatric patient with an ultrasound-confirmed thyroid nodule. MethodsA decision tree model was created using an adolescent with an asymptomatic thyroid nodule as the reference case. Probabilities were defined based on review of the pediatric and adult literature. Costs were determined from previous literature and the publicly available Medicare physician fee schedule. Tornado plot and sensitivity analyses were performed to assess sources of cost variation. ResultsUsing decision analysis, FNA was less costly than DL with an estimated cost of $2529 vs. $5680. Tornado analysis demonstrated that the probability of an initial indeterminate FNA result contributed most to cost variation. On sensitivity analysis, when probability of an indeterminate FNA result was increased to 35%, the maximum value found in the literature, FNA remained less costly. In Monte Carlo simulation set to 10,000 iterations, FNA was superior to DL in 74% of cases. ConclusionsIn this theoretical model based on available literature and costs, FNA is less costly than DL for initial diagnostic workup of thyroid nodules in children. Securing resources to offer FNA in the work-up of thyroid nodules may be financially beneficial to hospitals and patients. Level of evidenceLevel 1 cost effectiveness study - using reasonable costs and alternatives used in study with values obtained from many studies, study used multi-way sensitivity analysis.

Thyroid nodules – how to proceed?

Asymptomatic thyroid nodules are very common and detected with increasing frequency by radiological investigations of the neck as so-called “incidentalomas”. If a thyroid nodule is found, the question arises how to proceed with this case. The goal is to recognize the very rare malignant nodules and to perform an adequate therapy. Every work-up of a thyroid nodule includes functional evaluation by determination of thyroid stimulating hormone (TSH). Is the level of the hormone suppressed, a scintigraphy is indicated to rule out a hot thyroid nodule implying a benign finding. Ultrasound is the imaging of choice for the thyroid gland and provides information with respect to size, number and configuration of the nodes. Depending on sonographic evaluation and other possible risk factors, a fine-needle aspiration biopsy of the node is performed. Based on the cytologic findings further therapeutic procedures are determined.

Thyroid Paraganglioma.

Thyroid paragangliomas are rare tumors that arise from the inferior laryngeal paraganglia. Most patients are female and present with an asymptomatic thyroid nodule. Histologically, the tumor is composed of cells arranged in a well-defined nest (zellballen) pattern surrounded by a thin fibrovascular stroma. It is a diagnostic pitfall and is occasionally misdiagnosed as follicular neoplasm, medullary thyroid carcinoma, intrathyroid parathyroid proliferation, and especially secondary neuroendocrine tumors. Immunohistochemical stains (cytokeratin, parathyroid hormone, thyroid transcription factor 1, tyrosine hydroxylase, chromogranin A, synaptophysin, S100, calcitonin, carcinoembryonic antigen) are essential in establishing the diagnosis. Loss of succinate dehydrogenase complex, subunit B (SDHB), immunoexpression can be used to triage genetic testing because some mutations are associated with a higher risk for developing metastasis. Total thyroidectomy or lobectomy for solitary lesion is the preferred treatment. Elective lymph node dissection is usually not indicated. Postoperatively, patients should receive hormonal evaluation for functional disease and imaging for evaluation of multifocal or metastatic disease.