Calcified Thyroid Research Articles

Molecular Aspects of Thyroid Calcification.

In thyroid cancer, calcification is mainly present in classical papillary thyroid carcinoma (PTC) and in medullary thyroid carcinoma (MTC), despite being described in benign lesions and in other subtypes of thyroid carcinomas. Thyroid calcifications are classified according to their diameter and location. At ultrasonography, microcalcifications appear as hyperechoic spots ≤ 1 mm in diameter and can be named as stromal calcification, bone formation, or psammoma bodies (PBs), whereas calcifications > 1 mm are macrocalcifications. The mechanism of their formation is still poorly understood. Microcalcifications are generally accepted as a reliable indicator of malignancy as they mostly represent PBs. In order to progress in terms of the understanding of the mechanisms behind calcification occurring in thyroid tumors in general, and in PTC in particular, we decided to use histopathology as the basis of the possible cellular and molecular mechanisms of calcification formation in thyroid cancer. We explored the involvement of molecules such as runt-related transcription factor-2 (Runx-2), osteonectin/secreted protein acidic and rich in cysteine (SPARC), alkaline phosphatase (ALP), bone sialoprotein (BSP), and osteopontin (OPN) in the formation of calcification. The present review offers a novel insight into the mechanisms underlying the development of calcification in thyroid cancer.

PAPILLARY THYROID CANCER CAUSING AUTONOMIC DYSFUNCTION

SESSION TITLE: Medical Student/Resident Critical Care Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Dysautonomia is the dysfunction of the autonomic nervous system which regulates involuntary bodily functions. Common causes include diabetes mellitus, Parkinson’s, amyloidosis, Lyme disease and paraneoplastic syndromes. We present an unusual case of dysautonomia due to carotid sinus syndrome (CSS) caused by papillary thyroid cancer with extra-thyroid spread producing mass effect on the carotid sinus and carotid sympathetic plexus. CASE PRESENTATION: 26-year-old female with no past medical history who presented with recurrent syncope. She complained of malaise and anisocoria for six days prior to admission. On admission, the patient was noted to have positive orthostatic vital signs, however was clinically euvolemic. Head CT and CTA of head and neck demonstrated a calcified thyroid nodule in the left lobe, measuring 2.2x1.5cm, and a suspected venous varix 2.3x3.1cm in the left lower neck. Ultrasound of the thyroid confirmed the presence of the thyroid nodule with architecture concerning for malignancy. Additionally, the venous varix seen on CTA was noted to be an extra-thyroid mass. MRI of the neck then demonstrated a left carotid space mass exerting mass effect on the left jugular vein. A fine needle aspiration followed signifying papillary thyroid carcinoma. The patient subsequently had a thyroidectomy with neck exploration for removal of the extra-thyroid mass. Following the surgical intervention, the patient’s syncopal episodes and orthostatic hypotension improved. Clinical impression was that the extra-thyroid mass that was causing mass effect on her carotid was compressing the carotid sinus leading to autonomic dysfunction. DISCUSSION: Dysautonomia is a common complication that is commonly caused by a systemic condition affecting the autonomic nervous system. On literature search, dysautonomia has yet to be described as being caused by compression of the carotid artery sympathetic plexus due to papillary thyroid cancer. Carotid sinus syndrome is a cause of syncope following carotid baroreceptor sensitivity. In our case, the patient was experiencing recurrent syncopal episodes from external compression of her carotid artery due to the left carotid space metastatic lesion and mydriasis due to carotid sympathetic plexus invasion. Common causes of CSS include male gender, atherosclerotic disease, prior neck surgeries and radiation. External mass compression is a very rare cause of CSS particularly from papillary thyroid carcinoma which rarely metastasizes. CONCLUSIONS: Syncope is a common presentation to the emergency department. Dysautonomia is a common cause, particularly in people with known systemic processes such as diabetes or Parkinson’s. However, in a young adult, recurrent syncope is an unusual presentation and requires a thorough work up including imaging of the neck. Dysautonomia and CSS should be evaluated for as an uncommon, but possible, cause of syncope in young adults. Reference #1: Shen WK, Sheldon RS, Benditt DG, et al. 2017 ACC/AHA/HRS Guideline for the Evaluation and Management of Patients With Syncope: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines, and the Heart Rhythm Society. J Am Coll Cardiol 2017. Reference #2: Krediet CT, Parry SW, Jardine DL, et al. The history of diagnosing carotid sinus hypersensitivity: why are the current criteria too sensitive? Europace 2011; 13:14. DISCLOSURES: No relevant relationships by Chad Conner, source=Web Response No relevant relationships by Erika Faircloth, source=Web Response No relevant relationships by Nikola Perosevic, source=Web Response

Comparison of post-mortem radiologic modalities to evaluate suspected neck violence

Abstract Objective Post-mortem computed tomography (PMCT) has become the standard imaging technique prior to forensic autopsy. Dedicated imaging of the excised hyoid-larynx complex (HLC) is often performed to diagnose fractures, which are indicative for violence on the neck. The aim of this study was to define which imaging technique present in our general hospital (in the absence of a micro-CT) is most suited to detect fractures in the HLC. Material and methods 11 post-mortem cases with suspected violence on the neck were subjected to three imaging modalities: 1) hyoid-larynx reconstructions from the initial PMCT, 2) X-ray scan of the explant, and 3) CT scan of the explant. Each of these modalities were studied individually by three expert forensic radiologists for the presence of fractures in the hyoid bone and calcified thyroid cartilage. The results were then compared with the preliminary autopsy findings (i.e. manual palpation and inspection). Results The use of X-ray proofed to be the superior technique to evaluate the number and locations of thyroid cartilage fractures within the excised HLC. To assess fractures in the hyoid bone, the X-ray and CT were considerably more reliable than reconstruction through PMCT. Conclusions In the absence of micro-CT techniques and non-conclusive PMCT, X-ray scanning of the excised HLC is the recommended imaging modality to detect fractures of the HLC because of its high contrast resolution and multiple (8) projection directions. In order to distinguish between peri-mortem and post-mortem injury (vital sign), histological verification remains the golden standard.

Localization and characterization of thyroid microcalcifications: A histopathological study.

Thyroid calcification is frequent in thyroid nodules. The aim of our study was to evaluate the prevalence of calcifications in thyroid tissue samples of patients with various thyroid diseases, and to identify their composition according to their localization. Among 50 thyroid samples included, 56% were malignant (papillary carcinoma) and 44% were benign (adenoma, multinodular goiter, Graves’ disease, sarcoidosis). Calcifications were found in 95% of samples using polarised light microscopy, whereas only 12% were described in initial pathological reports. Three types were individualised and analyzed by infrared spectrometry (μFTIR): colloid calcifications composed of calcium oxalate, capsular calcifications and psammoma bodies, both composed of calcium phosphate. Of notice, psammoma bodies characterized by FE-SEM were composed of concentric structure suggesting a slow process for crystal deposition. Calcium phosphates were found only in malignant samples whereas calcium oxalate was not associated with a define pathology. Proliferation assessed by KI67 staining was high (33% of positive follicles), and RUNX2, OPN, and CD44 positive staining were detected in thyrocytes with a broad variation between samples. However, thyrocyte proliferation and differentiation markers were not associated with the number of crystals. TRPV5 and CaSR expression was also detected in thyrocytes. mRNA transcripts expression was confirmed in a subgroup of 10 patients, altogether with other calcium transporters such as PMCA1 or Cav1.3. Interestingly, TRPV5 mRNA expression was significantly associated with number of colloid calcifications (rho = -0.72; p = 0.02). The high prevalence of calcium oxalate crystals within colloid gel raises intriguing issues upon follicle physiology for calcium and oxalate transport.

SAT-585 Presence of Metastatic Medullary Thyroid Cancer without a Distinct Thyroid Nodule: A Diagnostic Challenge

Introduction Neuroendocrine tumors originate from the GI tract, lungs or endocrine glands. Diagnosis can be done by different imaging modalities including Octreoscan, MIBG scan, FDG PET/CT and Ga-Dotatate PET/CT. Case 52 year old female with past history of hypertension, presented to an outside facility with complaint of a right lower neck mass, hoarseness and cough. Thyroid ultrasound identified a 0.3 cm right lobe calcific density with no discrete nodules. Neck CT showed right thyroid calcification and a 2.5 cm right supraclavicular mass. A core needle biopsy of the mass was consistent with metastatic low grade neuroendocrine carcinoma. Immunostains were positive for EP-CAM, TTF-1, synaptophysin, CD56 and CK7. Metastatic pulmonary carcinoma was suspected. She was seen at our institution for a multidisciplinary team evaluation. Pathology slides for additional stains were unavailable. Whole body CT showed low suspicion mediastinal lymph nodes. FDG PET/CT showed a 2.6 cm right neck hypermetabolic mass and a tiny calcified density in the right thyroid lobe, but no metastatic disease elsewhere. Endoscopic ultrasound-guided transbronchial biopsy of the mediastinal nodes was negative for cancer. An Octreotide scan showed only right neck mass hypermetabolism. Gallium-68 Dotatate scan had just become available and was able to identify increased uptake in the right supraclavicular region and an additional focus of uptake within the superior aspect of the right thyroid lobe. Fine-needle aspiration of the right thyroid focus was consistent with medullary thyroid carcinoma. Calcitonin was 1268 pg/ml, CEA 1.7 ng/ml and RET proto-oncogene was positive (p.C609Y). She had normal parathyroid hormone, calcium and plasma metanephrines. Total thyroidectomy was performed. Pathology was consistent with right neck metastatic medullary thyroid carcinoma with 18/27 lymph nodes involved. Multifocal medullary thyroid carcinoma from 0.2-0.6 cm was found in the right lobe. The left lobe had a 0.2 cm focus of medullary thyroid carcinoma with 1/2 lymph nodes involved. Her most recent neck ultrasound showed a persistent, stable hypoechoic 0.5 cm right lateral neck lesion. Most recent neck CT was unremarkable. PET/CT done 2 months ago showed only mildly prominent mediastinal lymph nodes that are stable compared with 2 years ago. Calcitonin decreased initially from 1268 pg/ml to 321 pg/ml and has now plateaued in the low 500s. CEA and other biomarkers are normal. Patient's daughter and son tested positive for the RET proto-oncogene mutation. Conclusion Metastatic medullary thyroid carcinoma without a discrete thyroid nodule is an uncommon presentation. Our patient presented with a metastatic neuroendocrine neck mass and conventional imaging modalities failed to identify the primary site, leading to delay in proper treatment. Ga-Dotatate PET/CT may improve management of patients with neuroendocrine tumors.

Comparison of Ultrasonography and Computed Tomography Features of Calcified Thyroid Nodules

Comparison of Ultrasonography and Computed Tomography Features of Calcified Thyroid Nodules

Advantages of Routine Ultrasound Combined With Contrast-Enhanced Ultrasound in Diagnosing Papillary Thyroid Carcinoma.

This study aimed to evaluate the advantages of routine ultrasound (US), contrast-enhanced US (CEUS), and the combination of these 2 methods in diagnosing papillary thyroid carcinoma (PTC). We subjected 89 patients with calcified thyroid nodules to conventional US and CEUS and then retrospectively analyzed the US and CEUS features of 89 patients with single, solid PTC. On this basis, we then evaluated the ability of US, CEUS, and their combination to diagnose PTC. In the 89 patients with thyroid nodules, US findings differed significantly from CEUS findings (P < 0.05). In the US group, the diagnostic sensitivity, specificity, and accuracy were 87.5%, 78.8%, and 88.0%, respectively; in the CEUS group, these values were 92.9% (P < 0.05), 87.9% (P < 0.05), and 92.9% (P < 0.05), respectively; and when the methods were combined, the diagnostic sensitivity, specificity, and accuracy were 96.7%, 92.7%, and 94.9%, respectively. A typical PTC nodule can be definitively diagnosed using US and CEUS; more specifically, the features of slow progression, late enhancement, and low enhancement were highly associated with a diagnosis of PTC. When these features were combined, they exhibited higher diagnostic performance than any individual method.

Application of Straight Line Tunnel With Less Subcutaneous Separation in Transthoracic Endoscopic Thyroidectomy

The objective of this paper was to evaluate the value of straight-line tunnel application in transthoracic endoscopic thyroidectomy. Forty patients were given 3-port transthoracic endoscopic thyroidectomy from March 2011 to June 2014. Preoperative diagnoses found 20 cases of nodular goiter, 16 cases of adenoma, and 4 cases of thyroid calcification. We used a metal rod to free skin flap in a straight way toward the neck, and a straight-line tunnel was created to obtain a good view. All 40 cases involving endoscopic thyroidectomy were performed successfully, 28 were performed with unilateral subtotal thyroidectomy, 5 were performed with unilateral thyroidectomy, 5 were performed with bilateral partial thyroidectomy, and 2 were performed with radical thyroidectomy for carcinoma. One is anaplastic thyroid carcinoma (ATC) and the other is follicular thyroid carcinoma. Operation time was 78.5 ± 18.6 minutes, intraoperative blood loss was 40.2 ± 15.6 mL, intraoperative flap-freeing time was 14.3 ± 3.8 minutes, and the diameter of the thyroid tumor was 3.8 ± 2.5 cm. Postoperative hospital stay was 3.5 ± 2.0 days. One patient got voice hoarseness and recovered in 3 months. Two patients suffered from transient hypocalcemia and recovered without treatment. No subcutaneous effusion or seroma was observed. No recurrence was found during the 12- to 36-month (mean: 28 months) follow-up. One patient felt chest numbness 3 months after the surgery. Thirty-two patients were very satisfied with the cosmetic appearance and 8 patients were satisfied. The application of straight-line tunnel in transthoracic endoscopic thyroidectomy is a simple, safe, feasible procedure with less trauma, seroma, and skin contraction.

CT-detected solitary thyroid calcification: an important imaging feature for papillary carcinoma.

PurposeTo evaluate computed tomography (CT) detection of solitary thyroid calcification for identifying thyroid papillary carcinoma and to determine whether the predictive ability changes when the size increases after enhancement.Materials and methodsCT scans on all 96 patients with thyroid nodules who underwent both enhanced CT examination of neck and thyroidectomy from 2014 to 2016 in the Shandong Cancer Hospital affiliated to Shandong University were reviewed. The cases without calcification and the cases with peripheral calcification, multiple coarse calcifications, or punctate calcification were excluded. Imaging features, including location and size of the lesions, were reviewed on plain and contrast-enhanced CT. The patients were grouped by histological results. The comparisons were evaluated by using Fisher’s exact test and binary logistic regression.ResultsThe study population consisted of 96 patients (74 females, 22 males; mean age 49.8±11.3 years). Papillary thyroid carcinoma was observed in both solitary calcified thyroid nodules (85.4%) and solely coarse calcifications surrounded by low-density focus (58.2%). The difference was significant (P=0.006). Of 64 patients with an amplification of lesions after contrast enhancement, 58 (90.6%) were diagnosed with a malignant lesion. At the same time, of the 32 patients with no increase in size, 10 (31.2%) were diagnosed with carcinoma and 22 (68.8%) with nodular goiter. This difference was significant (P<0.001), and after binary logistic regression, increasing size was an independent risk factor for cancer.ConclusionSolitary calcified thyroid nodules detected on CT represent a high risk for papillary thyroid carcinoma, especially when the size of the lesions increases after contrast- enhanced CT.

Killian-Jamieson diverticulum mimicking a calcified thyroid nodule on ultrasonography: A case report and literature review.

As a rare hypopharyngeal diverticulum, Killian-Jamieson diverticulum (KJD) is usually incidentally detected, small, asymptomatic and likely to be misdiagnosed as a thyroid nodule. In order to avoid unnecessary treatments resulting from misdiagnosis, principles to distinguish between esophageal diverticula and thyroid nodules should be noted clearly. The current study presents a case of an asymptomatic unilateral KJD that mimicked a calcified thyroid nodule. In the current case, a 40-year-old man presented with a 'suspected malignant thyroid nodule' in the left thyroid gland, and underwent left thyroid lobectomy and a neck exploration. However, no visible 'suspected tumor', but a sac protruding from the left anterolateral wall of the cervical esophagus, was observed during the surgery. A swallow test on ultrasonography (US) in combination with pharyngoesophagography was then performed, which confirmed the diagnosis. The patient recovered well during the 3-month follow-up after the operation. The present study indicates that real-time US and pharyngoesophagography are important techniques to distinguish a KJD from a thyroid nodule so that unnecessary surgical intervention can be avoided.

Identification of calcifications in thyroid nodules: comparison between ultrasonography and CT

Objective To investigate the agreement and difference between ultrasonography (US) and CT in identifying calcification inside thyroid nodules. Methods Twenty thousand two hundred and forty-eight medical records with thyroid nodules and calcification diagnosed by either US, CT or pathology were reviewed. Therein, 3 827 thyroid nodules with calcifications reported were compared and statistically evaluated. The pathological report was also reviewed regarding the demographics, the final pathological diagnosis, and the status of lymph node metastasis. Results Out of 3 827 records, 90.6% were found to have calcifications in US report; while 2 040 (53.3%) showed calcifications in CT report. This difference between US and CT was statistically significant (P<0.001). Among 404 cases with calcification reported in pathology, the agreement between US and pathology was higher than that between CT and pathology (87.9% vs 81.9%, P=0.018). Conclusions US is more sensitive than CT in detecting calcification occurred in thyroid nodules. Key words: Ultrasonography; Tomography, X-ray computed; Thyroid nodule; Calcification

Correlation analysis of different calcified thyroid nodules with age and gender by contrast-enhanced ultrasound

Objective To investigate the value of contrast-enhanced ultrasound(CEUS) to diagnose thyroid nodules with different calcifications, and analyze its correlation with age and gender. Methods The image characteristics of high frequency ultrasound and pathological results of 522 patients with calcified thyroid nodules were analyzed retrospectively. CEUS enhancement patterns of different age and gender were observed and compared. Results There were no malignant nodules in patients under the age of 10. In the group of male and female, malignant nodules patients constituted the highest proportion between 40-49 years old and a minimal proportion between 10-19 years old. The CEUS for weak enhancement with micro calcifications were mostly malignant nodules; the high or equal enhancement with macrocalcifications were mostly benign nodules. But a part of micro calcifications in young women patients (20 to 29 years old) with high or equal enhancement were mostly malignant nodules. Conclusions The CEUS for weak enhancement with microcalcifications are mostly malignant nodules, but a part of microcalcifications in young women patients (20 to 29 years old) with high or equal enhancement are mostly malignant nodules. Key words: Contrast-enhanced ultrasound; Thyroid nodules; Calcification; Age; Gender

Thyroid calcifications: a pictorial essay.

Incidental diagnosis of thyroid nodules is very common on adult neck ultrasonography examination. Thyroid calcifications are encountered in benign thyroid nodules and goiters as well as in thyroid malignancy. Depiction and characterization of such calcifications within a thyroid nodule may be a key element in the thyroid nodule diagnosis algorithm. The goal of this paper is to display typical radio-pathological correlations of various thyroid pathologies of benign and malignant conditions in which the calcification type diagnosis can play a key role in the final diagnosis of the thyroid nodule.

Chemical diversity of calcifications in thyroid and hypothetical link to disease

Even though calcifications in thyroid nodules constitute a common finding in imaging and histopathology, and also may occur in both benign and malignant thyroid disease, their clinical importance remains unclear. A way to establish a possible relationship between their presence and the associated pathology may be given through a precise description of their chemical composition. In order to attain this goal, last generation Field Effect Scanning Electron Microscopy (FE-SEM) and classical Fourier Transform Infra Red (FT-IR) experiments have been performed on thyroid calcifications. Calcifications corresponding to different pathologies have been considered, including Graves' disease, papillary carcinoma or multinodular goiter. The complete set of experiments shows for the first time a chemical diversity of pathological calcifications but no correlation between the chemical composition of the pathological calcifications and the disease.

Progressive Tracheal Erosion Consecutive to a Calcified Left Thyroid Lobe

A 66-year-old man came for treatment of neck pain associated with halitosis and lithoptysis. The patient had undergone right thyroid lobe resection 40 years earlier and had been treated with I 131 for a left thyroid adenoma. Computed tomography (CT) of the neck and chest evidenced a coarse dense calcification of the left thyroid lobe (Fig 1A). An air crescent was visible on axial CT (Fig 1B), suggesting a sinus toward the tracheal lumen. Bronchoscopy obviated an erosion of the left tracheal wall, disclosing the calcified thyroid (Fig 2A,B). The calcified left thyroid lobe was resected. The damaged tracheal wall was repaired by segmental resection. Follow-up bronchoscopy showed a satisfactory outcome.Fig 2View Large Image Figure ViewerDownload (PPT) Calcifications within the thyroid gland are common and may be a sign of benign or of malignant thyroid disease [1Komolafe F. Radiological patterns and significance of thyroid calcification.Clin Radiol. 1981; 32: 571-575Abstract Full Text PDF PubMed Scopus (32) Google Scholar]. Coarse calcification is caused by abnormal calcium deposition in the thyroid tissue, usually following inflammation or necrosis [1Komolafe F. Radiological patterns and significance of thyroid calcification.Clin Radiol. 1981; 32: 571-575Abstract Full Text PDF PubMed Scopus (32) Google Scholar]. In our patient, I 131 therapy seemed to be the first cause of the inflammation and necrosis, leading to calcification. Skin sinus formation from a calcified thyroid cyst has been described in prior reports [2Pal I. Sengupta S. Ramaswamy B. Saha S. Benign calcified thyroid cyst with skin sinus formation.Laryngoscope. 2008; 118: 75-77Crossref PubMed Scopus (4) Google Scholar]. This is a rare description of tracheal erosion and tracheal sinus formation.

Clinical Usefulness of Ultrasonography-Guided Laryngeal Electromyography

To investigate the proper approach and technical method of ultrasonography-guided laryngeal electromyography (US-guided LEMG). This is a prospective study. Twenty patients who underwent US-guided LEMG were enrolled. US-guided LEMG was cooperatively performed by one otolaryngologist, one neurologist, and one radiologist. The location of the needle electrode was confirmed with US after electrode insertion into the laryngeal intrinsic muscle. The US transducer was applied on the neck by a transverse/midline and transverse/oblique approach to identify the cricothyroid (CT), thyroarytenoid (TA) muscles, and the location of the needle electrode. CT muscles were easily identified on US in all 20 patients. TA muscles were identified in 17 patients (85%). The transverse/oblique approach was helpful to detect TA muscle in case of calcified thyroid cartilage or anatomic variation. US-guided LEMG, which enables the exact insertion of the needle electrode, improves the reliability of examination and is helpful in early detection and to prevent complications.

Computerized analysis of calcification of thyroid nodules as visualized by ultrasonography

ObjectiveThe purpose of this study is to quantify computerized calcification features from ultrasonography (US) images of thyroid nodules in order to determine the ability to differentiate between malignant and benign thyroid nodules. MethodsWe designed and implemented a computerized analysis scheme to quantitatively analyze the US features of the calcified thyroid nodules from 99 pathologically determined calcified thyroid nodules. Univariate analysis was used to identify features that were significantly associated with tumor malignancy, and neural-network analysis was performed to classify tumors as benign or malignant. The diagnostic performance of the neural network was evaluated using receiver operating characteristic (ROC) analysis, where in the area under the ROC curve (Az) summarized the diagnostic performance of specific calcification features. ResultsThe performance values for each calcification feature were as follows: ratio of calcification distance=0.80, number of calcifications=0.68, skewness=0.82, and maximum intensity=0.75. The combined value of the four features was 0.84.With a threshold of 0.64, the Az value of calcification features was 0.83 with a sensitivity of 83.0%, specificity of 82.4%, and accuracy of 82.8%. ConclusionsThese results support the clinical feasibility of using computerized analysis of calcification features from thyroid US for differentiating between malignant and benign nodules.

2090864 Thyroid Calcifications: What Is Suspicious or Not on Ultrasound?

2090864 Thyroid Calcifications: What Is Suspicious or Not on Ultrasound?

Metallic Wires-like Thyroid Calcifications

55 years-old male with a history of tuberculosis with pleuropericarditis was referred by the pneumologist for the evaluation of a large goiter with massive enlargement of the left thyroid lobe, with potential metallic wires inside (as described at a barium radioscopy). The clinical examination revealed a very large, firm left thyroid lobe, without compressive signs; the rest of the thyroid was normal on examination. The patient was euthyroid, the serum calcitonin was normal, antithyroid antibodies (antithyroperoxidase, anti-thyroglobulin) were negative. The ultrasonography of the thyroid revealed a huge left thyroid lobe (long arrow) with a 52/43/31 millimeters hypoechogenic nodule with mixed structure (predominantly solid), with very coarse, dense calcifications inside (short arrows) corresponding to the so-called metallic wires previously described. Total thyroidectomy was performed; the histopathological examination diagnosed a benign thyroid nodule and confirmed the calcifications (Figure 1).

Chain of rings: a radiographic sign of papillary thyroid cancer

Papillary thyroid cancer is the most common form of thyroid malignancy in children and adult with frequent metastases to the cervical lymph nodes. We present a case of metastatic papillary thyroid cancer with remarkable imaging findings of consecutive metastatic calcified lymph nodes resembling a chain of rings. While accompanying by a coarsely calcified thyroid mass, possible thyroid cancer should be considered and serve as a guide to warrant further thyroid cancer evaluation.