Large Nodules Research Articles

Pathological and Immunohistochemical Characterization of Follicular Gastritis (Gastric Lymphofollicular Hyperplasia) in 41 Dogs.

Gastric lymphofollicular hyperplasia (GLFH) is characterized by large lymphoid nodules in the lamina propria. Its etiology and immunohistochemical characteristics are poorly understood. This study analyzed 41 canine GLFH cases, including clinical, endoscopic, histopathological, and immunohistochemical evaluations. Young French Bulldogs (75.06%) were the most affected. Endoscopically, lymphoid nodules were identified in both the antrum and gastric body. Lymphoid follicle diameters were similar in the gastric body (mean 295.587 μm) and antrum (mean 294.641 μm). Associated lesions included glandular atrophy, lymphoplasmacytic inflammation, and fibrosis. Minimal, moderate, and severe colonization with Helicobacter-like organisms (HLOs) were observed in 20, 6, and 3 cases, respectively. B-cell lymphocytes positive for Bcl6 and Pax5 were localized centrally in large follicles, surrounded by CD3+ T lymphocytes. Small follicles lacked germinal centers and showed mixed T and B lymphocytes. A positive correlation was found between the follicle diameter and both HLOs colonization (p = 0.049) and follicular hyperplasia (p < 0.001). A regression analysis indicated that HLOs colonization and hyperplasia accounted for 42.3% of follicle diameter variance (R2 = 0.423, p < 0.001). Additional studies are required to investigate potential correlations between GLFH and HLOs, as well as to assess the role of this lesion in the progression to neoplasia.

Comparison of diagnostic performance of the current score-based ultrasound risk stratification systems according to thyroid nodule size.

The lack of standardization in risk stratification systems (RSSs) has led to uncertainty in selecting the most effective RSS for diagnosing malignancy risk in thyroid nodules. Therefore, the aim of this study was to compare the diagnostic performance of four current score-based RSSs according to thyroid nodule size, with the goal of determining the most effective RSS and aiding in clinical decision-making. Between July 2013 and January 2019, a total of 2,667 consecutive patients presenting with 3,944 thyroid nodules were pathologically diagnosed after thyroidectomy and/or ultrasound (US)-guided fine-needle aspiration (FNA). These nodules were retrospectively dichotomized into two groups: small nodules (<1 cm) and large nodules (≥1 cm). The four RSSs were used to assign US categories, and the diagnostic performances were computed and compared based on the size of thyroid nodules, both before and after the application of size thresholds for biopsy. After thyroidectomy or biopsy, 1,781 (45.2%) thyroid nodules were found to be malignant. (I) After applying size thresholds for biopsy in ≥1 cm nodules, the highest specificity, accuracy, area under the curve (AUC) and the lowest FNA rate and unnecessary FNA rate were observed in the Artificial Intelligence-Thyroid Imaging Reporting And Data System (AI-TIRADS) (66.1%, 75.3%, 0.785, 55.1%, and 38.6%, respectively, P<0.05 for all). (II) Before applying size thresholds for biopsy in ≥1 cm nodules, the FNA rate and unnecessary FNA rate of the four RSSs were lower they were after the application of the size threshold: American College of Radiology Thyroid Imaging Reporting and Data System (ACR-TIRADS), 59.1% versus 61.4%, 39.8% versus 45.4%; AI-TIRADS, 52.3% versus 55.1%, 34.0% versus 38.6%; TIRADS issued by Kwak et al. (Kwak-TIRADS), 52.5% versus 76.1%, 34.4% versus 52.1%; Chinese Thyroid Imaging Reporting and Data System (C-TIRADS), 51.5% versus 66.2%, 34.4% versus 50.1% (P<0.05 for all). (III) The small nodules showed higher sensitivity and lower specificity than the large nodules (ACR-TIRADS, 97.7% versus 95.5%, 46.2% versus 62.5%; AI-TIRADS, 97.2% versus 92.7%, 49.9% versus 71.6%; Kwak-TIRADS, 97.2% versus 92.5%, 49.7% versus 71.3%; C-TIRADS, 94.2% versus 90.7%, 55.0% versus 71.8%, respectively, all P<0.05). A potential effective strategy for managing large nodules in the current score-based RSSs could be to rely solely on US categories rather than size thresholds for biopsy. Additionally, the diagnostic performance of small nodules showed higher sensitivity and lower specificity compared to large nodules before applying size thresholds for biopsy. These findings suggest a possible new management strategy for large nodules and provide a basis for the managing small nodules.

Deep Learning-Based Slice Thickness Reduction for Computer-Aided Detection of Lung Nodules in Thick-Slice CT.

Computer-aided detection (CAD) systems for lung nodule detection often face challenges with 5 mm computed tomography (CT) scans, leading to missed nodules. This study assessed the efficacy of a deep learning-based slice thickness reduction technique from 5 mm to 1 mm to enhance CAD performance. In this retrospective study, 687 chest CT scans were analyzed, including 355 with nodules and 332 without nodules. CAD performance was evaluated on nodules, to which all three radiologists agreed. The slice thickness reduction technique significantly improved the area under the receiver operating characteristic curve (AUC) for scan-level analysis from 0.867 to 0.902, with a p-value < 0.001, and nodule-level sensitivity from 0.826 to 0.916 at two false positives per scan. Notably, the performance showed greater improvements on smaller nodules than larger nodules. Qualitative analysis confirmed that nodules mistaken for ground glass on 5 mm scans could be correctly identified as part-solid on the refined 1 mm CT, thereby improving the diagnostic capability. Applying a deep learning-based slice thickness reduction technique significantly enhances CAD performance in lung nodule detection on chest CT scans, supporting the clinical adoption of refined 1 mm CT scans for more accurate diagnoses.

Conservative Management of Bowel Endometriosis: Cross-Sectional Analysis for Assessing Clinical Outcomes and Quality-of-Life.

Background/Objectives: Bowel endometriosis (BE) is characterized by the presence of endometrial-like tissue within the muscular layer of the bowel wall. When BE does not result in the severe obstruction to fecal transit and in the absence of (sub)occlusive symptoms, the decision to perform surgery can be challenging, as intestinal procedures are associated with higher complication rates and long-term bowel dysfunction. This cross-sectional study aims to evaluate the quality of life (QoL) in patients with BE who avoided surgery, as well as to investigate the impact of the characteristics of BE nodules on the QoL and intestinal function. Methods: A retrospective cross-sectional analysis was conducted involving 580 patients with BE who did not undergo surgery but were treated conservatively with medical therapy or expectant management between January 2017 and August 2022. The diagnosis of BE was established through transvaginal ultrasound and confirmed via double contrast barium enema. After at least one year of follow-up, the QoL and intestinal function were assessed using the Endometriosis Health Profile-5 (EHP-5) questionnaire and the Bowel Endometriosis Symptom (BENS) score, while pain symptoms were quantified with the Visual Analog Scale (VAS 0-10). Statistical analyses were performed to explore potential associations between the QoL and the characteristics of BE nodules (size, location, and evidence of stenosis), as well as the type and duration of medical therapy. Results: Patients with BE reported a satisfactory overall QoL, with a mean EHP-5 score of 105.42 ± 99.98 points and a VAS score below three across all pain domains. They did not demonstrate significant impairment in bowel function, as indicated by a mean BENS score of 4.89 ± 5.28 points. Notably, patients receiving medical therapy exhibited a better QoL compared to those not receiving treatment (p < 0.05), with the exception of postmenopausal patients, who reported the highest QoL overall (p < 0.05). Among the characteristics of BE, nodule location significantly impacted the QoL and symptom intensity, with low (rectal or rectosigmoid) nodules less tolerated compared to sigmoid nodules, particularly regarding non-menstrual pelvic pain (NMPP), dyschezia, and psychological impact on daily life (p < 0.05). Conclusions: Women can effectively manage BE conservatively in the absence of (sub)occlusive symptoms, even when large nodules are present, causing significant radiological stenosis. The characteristics of BE nodules do not significantly affect the QoL or symptom intensity; however, the location of BE nodules is a crucial factor negatively influencing these outcomes. Medical therapy may confer a beneficial impact on patients of reproductive age with BE, but its use should be carefully considered for those approaching menopause, weighing the risks and benefits.

8012 A Severe Thrombotic Event Following Blood Thinner Interruption for Thyroid Fine Needle Aspiration Biopsy: A Case Report

Abstract Disclosure: V.A. Mendpara: None. P.P. Rao: None. M.V. Kellis: None. M.D. Lundholm: None. Background: This case highlights the potential severe thrombotic consequences of blood thinner medication interruption for thyroid fine needle aspiration (FNA). Case Presentation: A 77-year-old woman came to the endocrinology clinic for follow-up on thyroid nodules. She was a former smoker with controlled type 2 diabetes, hypertension, hyperlipidemia, and atrial fibrillation with patent foramen ovale on apixaban. She had no family history of thyroid cancer and no radiation exposure. Thyroid nodules were found incidentally, and she denied compressive symptoms. She had annual surveillance for the past 4 years, and her latest thyroid US redemonstrated 4 solid, hypoechoic nodules. The largest nodule, previously biopsied and benign in 2020, remained stable on the right. The next largest nodule in the left mid-thyroid was now 1.1 x 0.8 x 0.9 cm—a 30% growth from the previous year—with new punctate echogenic foci consistent with the TIRADS 5 classification. This finding was shared with the patient, who favored investigating with an FNA. At the recommendation of her PCP and the performing provider, she held her apixaban for approximately 48 hours before the FNA procedure.The US-guided thyroid FNA biopsy was uneventful, and the results indicated a benign nodule. However, 4 hours post-procedure, the patient suddenly became unresponsive while in the middle of cooking dinner. She was taken to the ED and found to have an ischemic stroke by basilar embolism, attributed to her interruption in apixaban therapy. Tenectaplase led to initial improvement but had subsequent hemorrhagic transformations affecting the midbrain, thalamus, and pons. This marked the beginning of a complex 2-month hospitalization requiring tracheostomy and percutaneous endoscopic gastrostomy (PEG) placement, followed by nearly a year of physical, occupational, and speech rehabilitation. Despite these efforts, she has not been able to return to her pre-stroke level of function and independence. Discussion: There is no consensus on the safety of performing a thyroid fine needle aspiration (FNA) biopsy for patients on blood thinner medications. Providers who favor holding blood thinners before FNA cite concerns for post-procedural hematoma formation or increased risk of non-diagnostic results. However, there is less discussion about the risks of interrupting these medications. This case emphasizes the potential for severe consequences from interrupting medically-indicated blood thinner therapy. The temporary discontinuation of apixaban for a routine thyroid FNA led to a life-threatening thrombotic event in our patient’s case. This outcome highlights the importance of carefully weighing the risks and benefits of medication interruptions for vulnerable populations. Further study is needed to investigate the safety of thyroid FNA on uninterrupted blood thinner therapy. Presentation: 6/2/2024

8126 PTH-Independent, Calcitriol-Mediated Hypercalcemia In Renal Cell Carcinoma

Abstract Disclosure: G.K. Rai: None. A. De Rosairo: None. K. Madani: None. D. Sacoto: None. A.A. Franco-Akel, MD: None. R. Belokovskaya: None. Hypercalcemia of malignancy is a known complication of advanced cancer. It occurs through various mechanisms, one of which is via 1,25-dihydroxyvitamin D (calcitriol). Calcitriol-mediated hypercalcemia accounts for approximately 1% of cases of hypercalcemia in the setting of malignancy and is usually seen in lymphomatous solid tumors. We present a gentleman with clear cell renal cell carcinoma associated with hypercalcemia with normal levels of intact parathyroid hormone (PTH), PTH-related protein (PTHrP), and 25-hydroxyvitamin D but elevated calcitriol levels. A 48 year-old-male with no significant past medical history with complaints of fatigue, hematuria, and weight loss of 38 pounds in 3 months was following urology for an elective right-sided nephrectomy. MRI of the abdomen and pelvis found a 16.1 cm renal mass with necrotic areas, causing mass effects on the liver, pancreas, and IVC. Preoperative laboratory showed hypercalcemia of 13.7 mg/dL (corrected 13.9 mg/dL) with microcytic anemia (hemoglobin 8.8 g/dL, MCV 72 fl). Workup showed low iPTH (3 pg/dL), 25-hydroxyvitamin D (16.9 ng/dL), and phosphorus level (1.7mg/dL) with elevated calcitriol (94.3 pg/dL) and a normal PTHrP. CT chest showed multiple pulmonary nodules on bilateral lobes, with the largest nodule ∼ 4.5 mm. Hypercalcemia was managed with IV fluids, calcitonin 300 units Q12 for two days, Denosumab IV infusion, prednisone 60 mg for three days, and oral ergocalciferol 50,000 units weekly. Calcium levels normalized, after which the patient underwent nephrectomy. Pathology revealed renal cell carcinoma grade G4 with mixed features of clear cell carcinoma with sarcomatoid and rhabdoid features. We report an incidental finding of hypercalcemia in a patient with renal mass. The elevated calcitriol levels can be attributed to ectopic calcitriol production through the renal mass. Post nephrectomy calcium levels remained within normal range for consecutive weeks. With this, we concur that hypercalcemia most likely originated from the renal mass that had ectopic production of calcitriol. Dysregulated calcitriol production is a well-known complication of lymphomas and granulomatous disease but is seldom reported with solid tumors. Usually, the etiology for hypercalcemia in patients with renal cell carcinoma is the overproduction of PTHrP, which was not the case with our patient. The ultimate resolution of hypercalcemia of malignancy was attained by treating the underlying malignancy. Presentation: 6/1/2024

8126 PTH-independent, Calcitriol-mediated Hypercalcemia in Renal Cell Carcinoma

Abstract Disclosure: G.K. Rai: None. A. De Rosairo: None. K. Madani: None. D. Sacoto: None. A.A. Franco-Akel, MD: None. R. Belokovskaya: None. Hypercalcemia of malignancy is a known complication of advanced cancer. It occurs through various mechanisms, one of which is via 1,25-dihydroxyvitamin D (calcitriol). Calcitriol-mediated hypercalcemia accounts for approximately 1% of cases of hypercalcemia in the setting of malignancy and is usually seen in lymphomatous solid tumors. We present a gentleman with clear cell renal cell carcinoma associated with hypercalcemia with normal levels of intact parathyroid hormone (PTH), PTH-related protein (PTHrP), and 25-hydroxyvitamin D but elevated calcitriol levels. A 48 year-old-male with no significant past medical history with complaints of fatigue, hematuria, and weight loss of 38 pounds in 3 months was following urology for an elective right-sided nephrectomy. MRI of the abdomen and pelvis found a 16.1 cm renal mass with necrotic areas, causing mass effects on the liver, pancreas, and IVC. Preoperative laboratory showed hypercalcemia of 13.7 mg/dL (corrected 13.9 mg/dL) with microcytic anemia (hemoglobin 8.8 g/dL, MCV 72 fl). Workup showed low iPTH (3 pg/dL), 25-hydroxyvitamin D (16.9 ng/dL), and phosphorus level (1.7mg/dL) with elevated calcitriol (94.3 pg/dL) and a normal PTHrP. CT chest showed multiple pulmonary nodules on bilateral lobes, with the largest nodule ∼ 4.5 mm. Hypercalcemia was managed with IV fluids, calcitonin 300 units Q12 for two days, Denosumab IV infusion, prednisone 60 mg for three days, and oral ergocalciferol 50,000 units weekly. Calcium levels normalized, after which the patient underwent nephrectomy. Pathology revealed renal cell carcinoma grade G4 with mixed features of clear cell carcinoma with sarcomatoid and rhabdoid features. We report an incidental finding of hypercalcemia in a patient with renal mass. The elevated calcitriol levels can be attributed to ectopic calcitriol production through the renal mass. Post nephrectomy calcium levels remained within normal range for consecutive weeks. With this, we concur that hypercalcemia most likely originated from the renal mass that had ectopic production of calcitriol. Dysregulated calcitriol production is a well-known complication of lymphomas and granulomatous disease but is seldom reported with solid tumors. Usually, the etiology for hypercalcemia in patients with renal cell carcinoma is the overproduction of PTHrP, which was not the case with our patient. The ultimate resolution of hypercalcemia of malignancy was attained by treating the underlying malignancy. Presentation: 6/1/2024

7639 A Rare Cause of Lung Adenocarcinoma with Metastasis to the Thyroid

Abstract Disclosure: E. Echevarria-Torres: None. C.G. Yap: None. K.E. Izuora: None. A rare cause of lung adenocarcinoma with metastasis to the thyroid. Metastasis to the thyroid gland from non-thyroid malignancies is rare. When metastasis occurs, presenting symptoms are typically nonspecific, representing a diagnostic challenge. With the goal of raising awareness, we present a case of lung adenocarcinoma with metastasis to the thyroid. An 85-year-old man with a history of hypertension, hyperlipidemia and 60 years smoking history presented to the endocrine clinic for evaluation of subclinical hyperthyroidism. On the physical exam, there was fullness in the right thyroid area which on ultrasound showing a large right thyroid nodule occupying the entire lobe. There was also a solid 4.5 cm x 3.4 cm x 4.6 cm nodule in the mid-anterior left thyroid lobe. Fine needle aspiration cytology of right nodule revealed malignant cells and cell block material positive for TTF-1 (Thyroid Transcription Factor 1) concerning for malignancy. The left thyroid nodule cytology was consistent with benign follicular nodule. Chest CT ordered for surgical planning showed right upper lobe pleural-based lung opacity measuring 3.7 cm x 2.9 cm with supra clavicular lymphadenopathy. Biopsy of lung mass and supra clavicular lymph nodes revealed primary lung adenocarcinoma involving the lymph nodes consistent with stage Iva (cT3NxM1b). The patient was referred to oncology for further management. Discussion: Metastatic lesions to the thyroid gland account for less than 1 % of all malignant thyroid tumors with most cases found on autopsy. This is hypothesized to be due to the rich blood supply and high iodine content of the thyroid gland. Thyroid metastasis usually presents several years after initial diagnosis and treatment of non- thyroid malignancy. Patients can present with enlarging thyroid nodules, neck swelling, dysphagia and, in rare instances, upper airway obstruction. We present a rare case of lung cancer with metastasis into the thyroid. The thyroid nodule initially palpated upon physical exam led to eventual thyroid ultrasound and subsequently to his diagnosis of lung adenocarcinoma after findings of lung nodule which was biopsied and showed primary lung adenocarcinoma. TTF-1 was also positive which is typically expressed by lung adenocarcinomas. Treatment for thyroid metastasis is surgery, along with treatment of primary malignancy. The earlier the diagnosis and treatment the more favorable the prognosis. Radiotherapy and chemotherapy are other means to reduce the recurrence. Thyroid hormone replacement will be warranted post operatively for hypothyroidism. We present this uncommon case to raise awareness about the presentation of thyroid metastasis to enhance timely diagnosis and intervention. Presentation: 6/1/2024

7081 A Spotlight on Marine Lenhart Syndrome

Abstract Disclosure: R. Alshantti: None. A.M. San Hernandez: None. J. Wu: None. C.P. Barsano: None. M.F. Siddiqui: None. Introduction: Marine-Lenhart Syndrome is a rare condition with a prevalence of 0.8-4.1% of cases with Graves’ disease. It is defined by the coexistence of Graves’ disease and autonomously functioning thyroid nodule(s). It is an under-recognized cause of hyperthyroidism. A limited number of cases have been reported in the literature. We report an interesting case of Marine-Lenhart Syndrome characterized by the presence of elevated thyroid stimulating immunoglobulins (TSI) and an autonomous right thyroid nodule. Case Description: A 37-year-old man with a history of hyperthyroidism from Graves’ disease and a right thyroid nodule was referred to endocrinology clinic. He was diagnosed with hyperthyroidism in 2015 at an outside facility. He had elevated thyroid stimulating immunoglobulins (TSI) and a 2.9 cm right thyroid nodule which was biopsied and had benign cytopathology. Hyperthyroidism was treated with methimazole (MMI) but without subsequent remission of Graves’ disease. He ran out of MMI and re-presented with symptomatic hyperthyroidism with fatigue, tremors, and hyperdefecation. There was no ocular involvement or thyroid compressive symptoms. Biochemical work up was consistent with uncontrolled hyperthyroidism (suppressed TSH 0.01 uIU/mL [Ref range: 0.45-5.33], and elevated FT4 2.58 ng/dl [Ref range: 0.70-2.20], elevated free T3 8.7 pg/ml [Ref range: 2.5-3.9], and mildly elevated TSI 0.72 IU/L [Ref range: 0.54 or less]. MMI was therefore reinitiated. Thyroid Uptake scan demonstrated an increased focal 24-hour Iodine-131 uptake of 57% in the right lobe with suppression of the left lobe. Thyroid ultrasound support the finding of large right thyroid nodule (2.3 x 2.4 x 3.9 cm) with diffuse heterogeneous thyroid. The presence of TSI, lack of control of hyperthyroidism for more than 2 years of treatment, and presence of a functioning thyroid nodule raise the suspicion of Marine-Lenhart Syndrome. Indeed, the findings of an autonomously functioning right thyroid nodule with concomitant Graves’ disease establish the diagnosis of Marine-Lenhart Syndrome. The option of RAI ablation vs total thyroidectomy was discussed with the patient. The patient opted for thyroidectomy. Conclusion: Based on studies, approximately 35% of patients with Graves’ disease have thyroid nodule(s) and only 2.7% are functioning adenomas. The combination of positive TSI or TrAb and functioning thyroid nodules has been termed Marine-Lenhart syndrome. The syndrome was named after David Marine and Carl Lenhart who initially described it in 1911. Unlike Graves’ disease, patients with Marine-Lenhart Syndrome have a lower remission rate with thioamides, require definitive treatment with RAI ablation at a high dose or total thyroidectomy, and may easily be misdiagnosed by many endocrinologists. Presentation: 6/2/2024

6850 A Case of Anaplastic Thyroid Carcinoma With a Complete Metabolic Response to Pembrolizumab

Abstract Disclosure: E. Tirthani: None. J.T. Kung: None. Background: Anaplastic thyroid carcinoma (ATC) is an aggressive disease with limited therapeutic options and generally poor prognosis. Post-surgery, most patients are treated with a combination of chemotherapy, radiation, and tyrosine kinase inhibitors +/- immune checkpoint inhibitors. We describe a unique case of ATC with a complete metabolic response to pembrolizumab, a selective PD-1 inhibitor, as evidenced by imaging. Clinical Case: A 69-year-old female presented to the clinic for evaluation of a rapidly enlarging neck mass. The initial ultrasound showed a large mixed cystic-solid right thyroid nodule with irregular margins with micro- and macrocalcifications, which was biopsied. Cytology showed discohesive high-grade malignant tumor cells with enlarged nuclei, nuclear hyperchromasia in the background of necrosis, and dense neutrophilic infiltration concerning for ATC. A CT scan of the neck and chest showed a complex cystic thyroid mass with central necrosis and calcification with paratracheal, supraclavicular, and mediastinal lymphadenopathy. MRI of the brain was negative for metastatic disease. The patient underwent a total thyroidectomy with right and left level 6 and 7 neck dissection. Intra-operatively, gross extrathyroidal extension of the tumor was noted to the right carotid, larynx, right recurrent laryngeal nerve, and esophagus, with residual tumor left behind near the larynx. Pathology confirmed stage IVC ATC, positive for PIK3CA, NF1, p53 mutations, and BRAF negative. 90% of tumor cells showed PD-L1 expression on immunohistochemical staining. The post-surgical PET scan showed two discrete, well-defined foci of very intense FDG uptake, corresponding to the right lower cervical and para-esophageal lymph nodes with no evidence of distant metastasis. Systemic chemotherapy with carboplatin and paclitaxel (5 cycles) was initiated with concurrent intensity modulated radiation therapy (total 60 Gy/40 fractions to thyroid bed and bilateral neck). Repeat imaging showed minimal change in the size of the PET-positive lymph nodes. Immunotherapy was initiated and with just 2 cycles of 400 mg IV pembrolizumab, a repeat PET scan was obtained, which showed a complete metabolic response to therapy. Minimal residual FDG activity in the right supraclavicular region was thought to be secondary to posttreatment changes. The patient was able to resume her activities of daily living and had an improvement in appetite. The plan is to continue 400 mg IV pembrolizumab every 6 weeks while cautiously assessing for adverse effects from immunotherapy. Conclusion: It is rare to see a complete metabolic response to therapy with pembrolizumab without concurrent use of tyrosine kinase inhibitors in patients with ATC. A high tumoral PD-L1 expression may be the key to having this kind of dramatic response. Presentation: 6/3/2024

8578 Papillary Thyroid Carcinoma in Autonomous Nodule with Low Risk Characteristics in Adolescent

Abstract Disclosure: A. Aponte Velez: None. M.M. Mangual Garcia: None. Thyroid nodules in children are uncommon but are known to carry a greater risk of malignancy than adult thyroid nodules. Additionally, differentiated thyroid cancer (DTC) in children is more commonly found with extrathyroidal extension and metastases which makes the approach and treatment similar but with important differences. The incidence of DTC in children is increasing, making a personalized evaluation of thyroid nodules in pediatric patients even more valuable. Guidelines recommend evaluation of nodules based on sonographic characteristics rather than size of nodule. However, not having worrisome sonographic characteristics may not be as reassuring as in adult patients. A 13 year old female patient presented with a palpable non tender right sided solid thyroid mass. She had no family history of thyroid cancer or history of irradiation. Thyroid function tests were remarkable for TSH:0.017 and positive thyroid stimulating immunoglobulin. Thyroid Ultrasound findings described heterogenous parenchyma with multiple discrete lesions on right thyroid lobe with a dominant solid isoechoic nodule at upper lobe measuring 2.1 x 3.5 x 1.9cm and a smaller nodule in lower lobe. Thyroid scan demonstrated a large functional hot nodule occupying most of right thyroid lobe with suppression of rest of thyroid parenchyma. Ultrasound guided FNA was performed of this lesion and results were negative for malignancy. Patient underwent total thyroidectomy with pathology report revealing right thyroid nodule encapsulated classical variant of papillary thyroid carcinoma. No lymph node metastases were identified. Non neoplastic thyroid parenchyma revealed chronic lymphocytic thyroiditis. Patient underwent radioiodine therapy with Whole Body Scan post radioiodine therapy demonstrating focal increased radionuclide localization at in region of neck consistent with functional thyroid tissue. There was no evidence of metastatic disease. In children, risk of malignancy is underestimated in ultrasonography and cytology. In this patient, papillary thyroid carcinoma was identified despite being stratified as having low risk of malignancy based on ultrasonography characteristics, hyperfunctioning nodule in scintigraphy study along with negative FNA results. Hyperfunctional nodules are usually reassuring for low risk of malignancy but rarely DTC can be found as in our patient. Guidelines agree that FNA is not recommended in functional nodules as surgical resection is the main therapy in children. However, surgery may be deferred if subclinical hyperthyroidism and low risk sonographic characteristics are present such as in our patient. If surgery had been deferred, based on low risk of malignancy, the risk of progression of disease would have been higher. Prognosis of DTC in children is good but the recurrence rate along with morbidity at such a young age may improve with more studies of DTC in children. Presentation: 6/2/2024

7254 An Unusual Case Of Hypercalcemia

Abstract Disclosure: S. Shushtarian: None. M. Balogun: None. T. Kaur: None. Hypercalcemia varies depending on severity. Higher serum calcium levels and more severe symptoms may indicate primary hyperparathyroidism or a malignant cancer. This is a case of a 32 year old female who presented with recurrent history of nephrolithiasis, found to have hypercalcemia of 13.4 mg/dL and parathyroid hormone of 1928.9 pg/mL, with phosphorus of 1.5 mg/dL. Ultrasound of her thyroid revealed a complex nodule arising from the right parathyroid gland measuring 2.2 X 2.0 cm. CT chest revealed diffuse osseous sclerosis secondary to metabolic disorder. Sestamibi scan did not localize any parathyroid adenoma. MRI of the thoracic and lumbar spine showed multiple small enhancing lesions throughout the pelvis and in the left rib, likely brown tumors related to hyperparathyroidism. X-ray of bony prominence on the patient’s left knee revealed a large lytic lesion of the proximal tibial diaphysis measuring 5.1 X 1.9 cm, concerning for aggressive neoplasm. Subsequent left tibial bone biopsy revealed giant cell rich lesions consistent with brown tumor of hyperparathyroidism. Due to our patient’s high calcium levels and large nodule size, she was referred to a tertiary center as the concern for parathyroid carcinoma and post-op hungry bone syndrome was high. Pre-op PTH level was 1408 pg/mL and post-op PTH was 96 pg/mL. The tumor removed was 2.1 cm. Post surgical pathology was consistent with atypical parathyroid adenoma. Patient was referred for genetic testing. An atypical parathyroid adenoma (APA) only accounts for 1.2 to 1.3% of cases of primary hyperparathyroidism. 80-85% of primary hyperparathyroidism is due to typical adenoma, and 10 to 15% of cases are due to hyperplasia or multiple gland disease. APA can often be confused with parathyroid carcinoma (PC), as they both have a 1:1 male to female ratio, high serum calcium levels, symptomatic hypercalcemia, high PTH levels, and fragility fractures. There are studies showing that both APA and PC have loss of nuclear parafibromin immunoreactivity. In addition, neither APA nor PC have any correlation with menopause, hormones, or gene deletions, unlike typical adenomas. Biopsy is necessary for diagnosis as the histological and immunohistochemical differences can differentiate APA vs PC. Histological features include pseudo-capsular invasion, bands of fibrosis, pronounced trabecular growth, nuclear atypia, and prominent nucleoli. Also, APA has a strong membranous staining pattern of E-cadherin, whereas PC has a loss of membranous staining. These differences are essential as although APA and PC clinically present similarly, APA lacks the invasive growth and possibility for metastatic disease that PC has. The likelihood for relapse of APA is low. Presence of malignancy criteria are indicative that a mass is actually PC and not APA. Despite this, APA is still considered a tumor of uncertain malignant potential and requires follow up. Presentation: 6/3/2024

Clinical Implication of the New AI-TIRADS Classification of Thyroid Nodules; Our Real Clinical Experience

Background: Ultrasound and fine needle aspiration biopsy (FNAB) play a primary role in determining the nature of nodules. Objectives: The aim of our study is to determine the diagnostic accuracy, sensitivity, and specificity of artificial intelligence-thyroid imaging reporting and data system (AI-TIRADS) in differentiating malignant from benign nodules to establish the treatment plan for patients and avoid unnecessary FNAB. Methods: This cross-sectional study was conducted between September 2020 and September 2021 (one year). Patients (n = 133) who had an indication for surgery due to nodular thyroid disease and were referred to the therapeutic training center of 5 Azar and Falsafi private section hospitals, Gorgan, Iran, were included. The diagnostic accuracy of FNAB and AI-TIRADS was calculated. Results: The mean age of patients with malignant pathology (39.65 ± 11.69) was lower than that of patients with benign pathology (44.14 ± 13.54), which was statistically significant (P = 0.042). Fifty-two out of 72 nodules less than 25 mm were malignant, demonstrating a higher prevalence of benign pathology in larger nodules. A pooled analysis of thyroid reporting (TR) = 2 and TR points ≥ 7 for their power in predicting the final pathology outcome showed figures of 0.97, 0.93, 0.97, and 0.97 for sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV), respectively, with an overall pooled accuracy of 0.97 for these two groups of sonographic results. Conclusions: We concluded that AI-TIRADS has a high sensitivity and diagnostic accuracy in differentiating benign from suspicious nodules.

Surgical approach selection and prognosis analysis of papillary thyroid microcarcinoma in the isthmus

Objective:To compare the prognosis of papillary thyroid microcarcinoma of the isthmus（PTMCI） after different surgical methods, and to investigate the most appropriate surgical plan for it, so as to provide reference for the selection of clinical surgical plan. Methods:The clinical data of 106 PTMCI patients diagnosed with postoperative pathology after surgical treatment in Department of Otolaryngology Head and Neck Surgery, Ningbo Medical Center Lihuili Hospital from January 2016 to June 2023 were retrospectively analyzed. The patients were divided into 3 groups according to whether there were nodules in the lateral lobe of the thyroid gland, namely, isolated PTMCI group, PTMCI group with unilateral lobe nodules, and PTMCI group with bilateral lobe nodules. Combined with follow-up information, the differences of recurrence rate, survival rate and postoperative complications after different surgical methods were compared among all groups. The surgical procedures included isthmic thyroidectomy, isthmic + unilateral lobectomy, and total thyroidectomy. All patients underwent central lymph node dissection at the same time. Results:There were no significant difference in recurrence rate, survival rate and postoperative complications among all groups and between groups. Postoperative recurrence occurred in 2 patients, among which 1 patient was PTMCI with multiple focal tumors in unilateral lobe undergoing isthmus + unilateral lobectomy + ipsilateral central lymph node dissection. The recurrence was manifested as contralateral cervical lymph node metastasis. Another case of PTMCI with bilateral benign nodules underwent isthmus + unilateral lobe（larger nodule） resection + ipsilateral central lymph node dissection, and the recurrence was manifested as residual glandular recurrence. One patient developed permanent hoarseness after surgery. The postoperative pathology of 31 patients（29.2%） indicated multiple focal thyroid carcinoma. Postoperative pathology of 41 patients（38.7%） suggested lymph node metastasis in the central region of neck. The disease-specific survival rate was 100%. Conclusion:Isthmic thyroidectomy is recommended for isolated PTMCI. Isthmus of thyroid+ unilateral lobectomy is feasible for PTMCI with unilateral lobectomy. If multiple suspicious malignant nodules（≥3） occur in unilateral lobectomy, total thyroidectomy is recommended. Total thyroidectomy is feasible for PTMCI with bilateral nodules. All PTMCI patients should undergo prophylactic central cervical lymph node dissection at the same time.

Robot-Assisted Resection of Exposed Colon With TaTME After Heavy Ion Radiotherapy for Locally Recurrent Rectal Cancer: A Case Report

Introduction Heavy ion radiotherapy has shown promising results in treating pelvic recurrence of rectal cancer. We report a case in which a patient underwent robot-assisted low anterior resection with transanal mesorectal excision (TaTME) following heavy ion radiotherapy, owing to challenges associated with spacer placement. Case presentation A 54-year-old man was diagnosed with upper rectal cancer. He underwent robot-assisted low anterior resection. Eight courses of CapeOX were administered as postoperative adjuvant chemotherapy. Immediately after completion of adjuvant chemotherapy (8 months postoperatively), computed tomography (CT) scan revealed a 30-mm large nodule on the dorsal surface of the oral anastomotic intestine, which was detected by positron emission tomography–CT. Given that the tumor had an indistinct border with the sacrum and its superior margin extended to the second sacrum, it was concluded that a combined sacral resection was not advisable, and heavy ion radiotherapy was indicated. Robot-assisted low anterior resection combined with TaTME was performed approximately 2 months after heavy particle radiotherapy [73.6 Gy (relative biological effectiveness)/16 sessions]. CT scan conducted 3 months after irradiation revealed substantial shrinkage of the recurrent tumor. Conclusion Robot-assisted resection of exposed colon with TaTME after heavy ion radiotherapy is regarded as an effective strategy for treating locally recurrent rectal cancer.

Risk Stratification of Thyroid Nodules Diagnosed as Bethesda Category III by Ultrasound, Size, and Cytology.

This study aimed to evaluate the performance of an integrated risk stratification system (RSS) based on ultrasound (US) RSSs, nodule size, and cytology subcategory for diagnosing malignancy in thyroid nodules initially identified as Bethesda category III on fine-needle aspiration. This retrospective study was conducted at two institutions and included consecutive patients with Bethesda category III nodules, and final diagnoses confirmed by repeat biopsy or surgery. A total of 320 Bethesda category III nodules (≥1 cm) from 309 patients (223 female and 86 male; mean age, 50.9 ± 12.0 years) were included. The malignancy risk of Bethesda category III nodules and predictors of malignancy were assessed according to US RSSs, nodule size, and cytology subcategory. The diagnostic performances of US-size cytology (USC) RSS and US RSS alone for malignancy were compared. The intermediate or high suspicion US category independently increased the malignancy risk in all US RSSs (P ≤ 0.001). Large nodule size (≥3 cm) independently increased the malignancy risk of low- or intermediate suspicion US category nodules. Additionally, the atypia of undetermined significance cytology subcategory independently increased the malignancy risk of low suspicion US category nodules in most US RSSs. The area under the receiver operating characteristic curve of the USC RSSs was greater than that of the US RSSs alone (P < 0.048). Malignancy was not found in the very low risk category of USC RSS. The diagnostic performance of USC RSS for malignancy was superior to that of US RSS alone in Bethesda category III nodules. Malignancy can be ruled out in the very low-risk category of USC RSS.

The Effect of Thyroid Nodule Size and Characteristics on the Accuracy of Fine-Needle Aspiration Biopsy and the Risk of Malignancy

Objective: Ultrasound evaluation of nodule characteristics and FNAB is a simple, cost-effective method. However, its reliability in large nodules is controversial. This study aims to examine the impact of thyroid nodule size and characteristics on malignancy risk and FNAB accuracy as evaluated by ultrasound. Material and Method: This retrospective study included 522 patients who underwent thyroidectomy between January 1, 2020, and January 1, 2024. The data included the patients’ age, gender, preoperative thyroid ultrasound findings, preoperative FNAB pathology findings, operation notes, and postoperative pathology results colleected from hospital archives. Kruskal-Wallis Variance Analysis, ROC (Receiver Operating Characteristics) curve analysis, Bonferroni Corrected Mann-Whitney U Test, Chi-Square Tests, were used at statistical analysis. Results: The median age was 49.45 years. The threshold value for nodule size in the X plane was 27 mm (p27 mm.

Exploring the diagnostic landscape: A narrative review of the evolving role and advancement of MRI in the detection and characterization of lung câncer

This review aims to evaluate the diagnostic performance of magnetic resonance imaging (MRI) with respect to the detection of lung cancer. Many studies have shown that computed tomography (CT) has increased sensitivity and specificity for the treatment of cancer. The major drawback of CT is the radiation dose imparted by it. x. In most advanced scenarios, Positron emission tomography (PET/MRI) is used. Our goal was also to evaluate the reasons for MRI being the choice of modality. The publications considered in the review were obtained from PubMed/MEDLINE, the Cochrane Library and EMBASE. Only studies published in the English language with the subject modality being MRI or PET/MRI were included. Review articles, case reports and conference reports were excluded from the study. A total of 3140 articles were identified, of which 120 publications were considered. All these studies had an overall surface aim to evaluate the diagnostic performance of MRI in detecting lung cancer. By comparing these publications, we can conclude that MRI can be a potential alternative to CT in detecting cancer lesions 3 mm in diameter or greater. Smaller lesions undetected by MRI were found to be benign and stable during follow-up, indicating the use of this technique for acceptable clinical management. Compared with CT, MRI does not provide any added benefits for lung cancer detection. It offered high sensitivity to large nodules of 3 mm or greater. However, CT has emerged to be beneficial in evaluating small nodules. A multisequence MRI protocol may be helpful in diagnosing lung metastasis with a sensitivity comparable to that of CT.

Exploring the impact of microstructure refinement on high temperature steam oxidation behavior of FeCrAl alloy

Microstructure refinement is an effective way to improve the mechanical properties and radiation resistance of FeCrAl alloy, which may also increase the susceptibility to high temperature steam oxidation (HTSO) due to the increased surface chemical activity. To investigate the microstructural effects on the HTSO behavior, a FeCrAl alloy was subjected to controlled annealing strategies to produce three types of microstructures: “fine sub-grains + fine precipitates”, “coarse grains + fine precipitates” and “coarse grains + coarse precipitates”. The three alloys were exposed to high temperature steam during a heating and holding procedure. Large oxide nodules and rough multilayer-structured oxide films were formed during heating, which subsequently evolved into a single α-Al2O3 layer during the isothermal oxidation. Microstructure refinement can promote the oxidation and slightly increase the weight gain. However, the variation of isothermal oxidation parabolic rate constants brought by the microstructure refinement is 1-2 orders of magnitude lower than that brought by alloying. Microstructure refinement can improve other service performance of FeCrAl alloy without significantly deteriorating the HTSO resistance, indicating its advantages for engineering applications.

Malignant blue melanoma

Malignant blue melanomas arise from blue nevi and all related intradermal melanocytic proliferations. They harbor specific, mutually exclusive mutations in the G-coupled protein pathway, mainly involving GNAQ or GNA11. Other rare genetic drivers include CYSLTR2 or PCLB4 mutations. PKC and GRM1-gene fusions have been recently added to this list. Malignant blue melanomas have a predilection for the scalp area, presenting as rapidly growing nodules within a pre-existing lesion. Histopathologically, these tumors are located in the dermis and subcutaneous fat and consist of large nodules or expanding dense sheets. Tumor necrosis is commonly seen. Large spindle-shaped and epithelioid melanocytes with high-grade cytologic atypia and frequent mitotic figures are at higher magnification. A benign blue nevus or intermediate-grade blue melanocytoma is frequently found on the side of the central mass. Loss of nuclear BAP1 immunoreactivity is a poor prognostic factor.