Neck US Research Articles

Focused Neck Ultrasound and Lymph Node Sampling by Respiratory Physicians in Suspected Lung Cancer

Background: Malignant cervical lymphadenopathy in the setting of lung cancer represents N3 disease, and neck ultrasound (NUS) with sampling is described in the Royal College of Radiologists ultrasound training curriculum for the non-radiologists. This study reviews the incorporation of NUS +/− biopsy in the routine practice of a lung cancer fast-track clinic in the UK. Methods: We retrospectively assessed 29 months of activity of a lung cancer fast-track clinic. Systematic focused NUS was conducted in suspected thoracic malignancy, sampling nodes with a ≥5-mm short axis, under real-time US using a linear probe (5–12 Mhz). Fine-needle aspirations (FNAs) with or without 18 Ga core biopsies were taken. Results: Between August 2017 and December 2019, of 152 peripheral lymph nodes (LNs)/deposits sampled, 98 (64.5%) were supraclavicular fossa LNs with median [IQR] size 12 [8–18] mm. Core biopsies were performed in 54/98 (55%) patients, while all patients had FNAs. No complications occurred. The representative yield was 90/95 (94.7%) in cases with suspected cancer. No difference was seen between FNA versus core biopsy (p = 0.44). Of the 5 non-diagnostic samples, one was FNA only. The commonest diagnosis was lung cancer in 66/98 (67.3%). PDL-1 was sufficient in 35/36 tested (97.2%). ALK-FISH was successful in 24/25 (96%) cases. EGFR mutation analysis was successful in 28/31 (90.3%) cases. Median time from clinic to initial diagnosis was 7 [5–10] days. Computed tomography (CT) scans reported no significant lymphadenopathy in 18/96 (18.7%) cases, yet 10/18 (55.5%) cases were positive for malignancy. Conclusion: Neck nodal sampling by respiratory physicians was safe, timely, with a high diagnostic yield and suitability for molecular testing. Neck US can provide a timely diagnosis in cases that may be missed by CT alone.

Biopsy Confirmed Subacute Thyroiditis Associated With COVID-19

Subacute thyroiditis is a transient inflammatory disease of the thyroid associated with anterior neck pain, and systemic symptoms. The diagnosis is generally reserved for a specific type of thyroiditis characterized by granulomatous inflammation and the presence of giant cells. We hereby present a case of a woman with a COVID-19 diagnosis, and a compatible biopsy result for subacute thyroiditis.On 06/03/2020, a 28 year old woman with previous history of ankylosing spondylitis managed with certolizumab pegmol, presented with fatigue, headache, odynophagia, and fever (38.1°C). 2 days later an oropharyngeal swab (PCR) for SARS-CoV-2 turned out positive. On the 4th day the fever spiked to 39°C with added malaise. Acetaminophen 1 gr PO TID was prescribed. The patient denied dyspnea, and thorax CT-Scan was normal. Complete remission was achieved in 3 weeks. On 08/01/20 she returned to work after a negative swab test. On 08/04/20, she presented with fever (38.7°C), malaise, distal tremors, anorexia, tachycardia, myalgias, arthralgias, and fatigue. 2 days later anterior neck pain that radiated to the jaw, and diffuse goiter was noticed. A thyroid function panel reported Total T4: 24 µg/dL (4.5-12.5), fT4 5.2 ng/dl (0.8-1.8), TSH: 0.001 mUI/L (0.37-4.7), thyroglobulin 135 ng/ml (3-42). TPO-Ab <35 IU/mL and TgAb <20 IU/mL.A neck US showed increased volume in the right lobe with multiple hypoechoic regions on both lobes, and diminished vascularization at color Doppler. I-131 scan showed no uptake. A biopsy of the right lobe reported fibrosis with inflammatory infiltrate composed of lymphocytes, plasma cells, histiocytes, and scarce neutrophils. Some cells with epithelioid appearance and a multinucleated giant cell were also found. Residual thyroid follicles showed colloid depletion and degenerative changes to the epithelium, which was consistent with a diagnosis of subacute thyroiditis.Treatment was initiated with prednisone 10 mg PO QD, propranolol 20 mg PO BID for 2 weeks, and acetaminophen 1 gr PO TID PRN. Fever and pain were intermittent for 6 weeks, but the rest of the symptoms subsided within 2 weeks. On 11/15/20, the patient attended a check-up with lab results that were consistent with hypothyroidism, negative IgM, and positive IgG SARS-CoV-2. Replacement therapy with levothyroxine 88 mcg per day was initiated.This case, which confirms the diagnosis of subacute thyroiditis via biopsy, among the others reported worldwide suggests that there’s an increased risk for women for subacute thyroiditis associated with COVID-19. Further research is needed to confirm risk factors for the development of the disease.

Breaking the 2015 ATA Recommendation for Medullary Thyroid Cancer (MTC) Guidelines. Case Report

Abstract Male patient, 49 years old. Thyroid US with a suspicious nodule. Fine Needle Aspiration Biopsy (FNAB) suggest MTC, with a pre-operative serum calcitonin (CTN) of 591 pg/mL. Total thyroidectomy with central and bilateral dissection was performed. Biopsy. Results: MTC in left thyroid nodule of 2,6 cm without metastasis in 29 lymph nodes. In the follow up, undetectable serum CTN for 6 years. In 2015 serum CTN of 4.7 pg/mL and Carcinoembryonic antigen (CEA) 1.2 ng/mL. Evolution of serum markers in table 1. Along with the rise of markers, the neck US showed bilateral subcentimetric LN in the group IV. In the follow-up, the size is stable; FNAB of the LN in different centers don′t show any sign of malignancy, along with undetectable CTN levels in the sample. The doubling time of CTN and CEA (March 2020): 16 and 51.3 months respectively. Given the lack of cervical compromise and going against MTC ATA 2015 recommendations, a neck and thorax CT, hepatic MRI and bone scintigraphy were ordered, despite not presenting CTN levels &amp;gt;150 pg/mL. The hepatic MRI shows 3 hypervascular hepatic lesions, which are recommended to be contrasted with a liver-specific agent (gadoxetic acid) to improve characterization of the lesions. Thanks to this procedure, 4 focal lesions are discovered, one larger than 10 mm, without contrast agent retention, suggests metastasis. PET 68Ga-DOTATATE: 2 focal lesions with overexposure of somatostatin receptors in the hepatic parenchyma, which correlate to known lesions, with SUVmáx of 6,8 y 7,3. After an evaluation by a surgeon, surgery is done in July 2020 removing 5 lesions; the biopsy confirmed MTC metastasis. Conclusions: the clinical guidelines may give general direction and allow to manage cases based on evidence; however, they must always be used considering the context of each particular case. In this one, if the guidelines had been strictly followed, it would not have been possible to detect the hepatic metastases within the window of opportunity to achieve a surgical resection with curative intent. Table1. Mar15 CTN 7,3 Pro- CTN 0,12 CEA 1,2. Oct15 CTN 16,1 Pro- CTN 0,15 CEA 0,7. Jan16 CTN 17 Pro- CTN 0,18 CEA 0,5. Jul16 CTN 17,9 Pro- CTN 0,18 CEA 1,6. Nov16 CTN 20,7 Pro- CTN 0,33 CEA 1,8. Aug17 CTN 35,2 Pro- CTN 0,4 CEA 1,8. Jun18 CTN 42,5 Pro- CTN 0,34 CEA 1,8. Nov18 CTN 50,7 Pro- CTN 0,57 CEA 1,8. Mar19 CTN 59,5 Pro- CTN 0,52 CEA 2,4. Nov19 CTN 80,7 Pro- CTN 0,66 CEA 2,4. Mar20 CTN 111 Pro- CTN 0,8 CEA 2,9. Normal Values: CTN &amp;lt; 2 pg/mL, Pro- CTN &amp;lt; 0,12 ng/mL, CEA &amp;lt; 0,1 ng/mL

Papillary Thyroid Carcinoma Within Thyroglossal Duct Cyst

A 55-year-old female with medical history of hypothyroidism and fibrocystic disease of the breast presented with complains of a painful anterior neck mass, difficulty swallowing and hoarseness of the voice. Symptoms had progressed over a period of 5 months. CT neck with contrast indicated the presence of an ectopic thyroid tissue anterior to the thyroid cartilage measuring approximately 1.7 x 1.2 x 3.1 cm, with indistinct inferior margins and internal calcifications. The hyoid bone or thyroid cartilage had no irregularities. The thyroid gland itself was unremarkable except for small complex thyroid nodules in both lobes. No masses within the pharynx or larynx were noted.Family history was significant for lymphoma in her father.On physical exam, a hard, mobile right anterior neck mass was appreciated. Labs showed normal TSH of 1.05 uIU/mL and normal free T4 of 1.2 ng/dL.Further evaluation with a dedicated neck US showed a right submandibular mass, superior to the thyroid, lobulated and heterogeneous measuring 2.0 x 1.0 x 2.3 cm with multiple areas of calcifications and internal Doppler flow. The thyroid gland had normal size and texture with bilateral sub centimeter non-concerning nodules.After ENT evaluation and an unremarkable flexible fiberoptic nasolaryngoscope, patient underwent surgical excisional biopsy of the neck mass. Pathology was consistent with thyroglossal duct cyst with the presence of thyroid follicles. An incidental finding of a 0.9 cm papillary microcarcinoma was noted, which was encapsulated with focal extracapsular follicular structures showing papillary nuclear features with no perineural or lymphovascular invasion. The tumor cells were immunoreactive for TTF-1 and PAX8.Development of papillary thyroid cancer within the thyroglossal duct cyst is a rare event, reportedly occurring in 1% of thyroglossal duct cysts. There are no well-established management guidelines.Current management strategies consist of monitoring with serial neck ultrasound versus total thyroidectomy with consideration of postsurgical I-131 treatment, based on pathology results. Our patient opted for undergoing total thyroidectomy.

Double ipsilateral parathyroid adenomas, with one supernumerary and ectopic at the same time: a case report

BackgroundDouble adenomas (DA) represents a distinct clinical entity of primary hyperparathyroidism (PHPT). DA may follow various embryologic distribution patterns and could be supernumerary and/or ectopic.Case presentationWe describe the first case of PHPT which comes as a result of double ipsilateral adenoma, of which one was both ectopic and supernumerary. A 45 year-old Greek male patient with diagnosed PHPT due to a single lower right parathyroid adenoma was admitted to our department for surgical treatment. The preoperative tests (neck US, Sestamibi scan) were conclusive for single gland disease. The patient underwent focused parathyroidectomy. The frozen section revealed a parathyroid adenoma with a slight possibility for parathyroid carcinoma. Ten minutes after the excision, intact PTH (iPTH) dropped >50% related to preoperative values and was within normal range. Right hemithyroidectomy with additional ipsilateral central neck dissection was performed, because of the possibility for parathyroid carcinoma. The final pathology report showed that the first excised tissue proved to be a parathyroid adenoma, while a second subcapsular one and a normal right upper parathyroid gland were also found.ConclusionsPreoperative localization of DA using routine imaging tests and the utility of intraoperative parathyroid hormone assay are still unreliable in detecting multiple adenomas. Furthermore, a slight possibility of a second and simultaneously supernumerary and ectopic adenoma maybe present. Therefore, it would be advisable to establish the use of more advanced imaging tests (such as 4D-CT, 4D-MRI) or other diagnostic tools when DA are suspected.

Extracardiac imaging findings in COVID-19-associated multisystem inflammatory syndrome in children.

BackgroundCoronavirus disease 2019 (COVID-19)-associated multisystem inflammatory syndrome in children (MIS-C) is an emerging syndrome that presents with a Kawasaki-like disease and multiorgan damage in children previously exposed to COVID-19.ObjectiveTo review the extracardiac radiologic findings of MIS-C in a group of children and young adults with a confirmed diagnosis of MIS-C.Materials and methodsIn a retrospective study from April 1, 2020, to July 31, 2020, we reviewed the imaging studies of 47 children and adolescents diagnosed with MIS-C, 25 females (53%) and 22 males (47%), with an average age of 8.4 years (range 1.3–20 years). Forty-five had chest radiographs, 8 had abdominal radiographs, 13 had abdominal US or MRI, 2 had neck US, and 4 had brain MRI.ResultsThirty-seven of 45 (82%) patients with chest radiographs had findings, with pulmonary opacities being the most common finding (n=27, 60%), most often bilateral and diffuse, followed by peribronchial thickening (n=26, 58%). Eight patients had normal chest radiographs. On abdominal imaging, small-volume ascites was the most common finding (n=7, 54%). Other findings included right lower quadrant bowel wall thickening (n=3, 23%), gallbladder wall thickening (n=3, 23%), and cervical (n=2) or abdominal (n=2) lymphadenopathy. Of the four patients with brain MRI, one had bilateral parieto-occipital abnormalities and another papilledema.ConclusionThe diagnosis of MIS-C and its distinction from other pathologies should be primarily based on clinical presentation and laboratory evidence of inflammation because imaging findings are nonspecific. However, it should be considered in the setting of bilateral diffuse pulmonary opacities, peribronchial thickening, right lower quadrant bowel inflammation or unexplained ascites in a child presenting with Kawasaki-like symptoms and a history of COVID-19 infection or recent COVID-19 exposure.

Artificial intelligence to predict the BRAFV600E mutation in patients with thyroid cancer.

PurposeTo investigate whether a computer-aided diagnosis (CAD) program developed using the deep learning convolutional neural network (CNN) on neck US images can predict the BRAFV600E mutation in thyroid cancer.Methods469 thyroid cancers in 469 patients were included in this retrospective study. A CAD program recently developed using the deep CNN provided risks of malignancy (0–100%) as well as binary results (cancer or not). Using the CAD program, we calculated the risk of malignancy based on a US image of each thyroid nodule (CAD value). Univariate and multivariate logistic regression analyses were performed including patient demographics, the American College of Radiology (ACR) Thyroid Imaging, Reporting and Data System (TIRADS) categories and risks of malignancy calculated through CAD to identify independent predictive factors for the BRAFV600E mutation in thyroid cancer. The predictive power of the CAD value and final multivariable model for the BRAFV600E mutation in thyroid cancer were measured using the area under the receiver operating characteristic (ROC) curves.ResultsIn this study, 380 (81%) patients were positive and 89 (19%) patients were negative for the BRAFV600E mutation. On multivariate analysis, older age (OR = 1.025, p = 0.018), smaller size (OR = 0.963, p = 0.006), and higher CAD value (OR = 1.016, p = 0.004) were significantly associated with the BRAFV600E mutation. The CAD value yielded an AUC of 0.646 (95% CI: 0.576, 0.716) for predicting the BRAFV600E mutation, while the multivariable model yielded an AUC of 0.706 (95% CI: 0.576, 0.716). The multivariable model showed significantly better performance than the CAD value alone (p = 0.004).ConclusionDeep learning-based CAD for thyroid US can help us predict the BRAFV600E mutation in thyroid cancer. More multi-center studies with more cases are needed to further validate our study results.

Clinical Outcome of Carotid Body Paraganglioma Management: A Review of 10-Year Experience.

Background Carotid body paragangliomas are rare neoplasms usually benign, however sometimes presenting as highly aggressive tumors. Surgery is the main line of treatment. Purpose To study and describe clinical presentations, surgical approaches, postoperative complications, and treatment outcomes. Materials and Methods A single-institution retrospective analysis of 19 cases with carotid body paragangliomas who were candidates for surgery from January 2009 through January 2019 with a mean follow-up period of 58.8 months. Results The mean age was 46 years with the female predominance of 63%. The mean size of the tumor was 4.3 cm. All cases were presented with a painless pulsating neck lump located anteriorly at the level of the hyoid bone. Neck US was done in all cases as a primary screening investigation. CT scanning was the second main investigation performed in 17 cases (89.5%) revealing tumors attached to the carotid artery at its bifurcation. Urinary catecholamine metabolites were measured in all cases to rule out familial functioning types. 5 cases (26.3%) were malignant. All cases were surgically approached through transcervical transverse incision. 11, 5, and 3 cases were classified as Shamblin's type II, III, and I, respectively. All tumors were R0 resected with nodal neck dissection conducted in the malignant group. Major complications occurred in 4 cases (21%) during tumor dissection from the adventitia of carotid bifurcation. ECA ligation was performed in one case (5.3%). 2 patients (10.5%) suffered XII nerve paralysis. Carotid artery blowout occurred in one patient (5.3%) and was immediately controlled. No operative mortality occurred. All patients were free of disease during the follow-up period. 4 malignant cases (21%) suffered a systemic relapse to bone and lung metastasis justifying adjuvant chemotherapy, radiotherapy, or both. Conclusions Surgery is the treatment of choice for carotid body paragangliomas. Complete R0 resection should be justified especially in case of malignancy. Adjuvant chemotherapy or radiotherapy is an option for patients with primary malignancy or relapse.

Ultrasonography surveillance in papillary thyroid carcinoma patients after total thyroidectomy according to dynamic risk stratification.

To investigate the role of neck US surveillance in patients with papillary thyroid carcinoma (PTC) after total thyroidectomy according to dynamic risk stratification (DRS) based on response to initial therapy. This retrospective study included 812 patients with PTC who underwent total thyroidectomy with prophylactic central neck dissection from January 2003 through February 2007. The relative risk of recurrence/persistence according to DRS was evaluated with the multivariable Cox regression proportional hazard model. There were 132 men and 680 women. The mean age at surgery was 45.2 years. Postoperative US was used for DRS. According to DRS, 676 patients had excellent response, 78 indeterminate response, 40 biochemical incomplete response, and 18 structural incomplete response to initial therapy. Neck US was performed during follow-up and detected locoregional recurrences in 21 patients (2.6%): 12 with excellent response, 2 with biochemical incomplete response, and 7 with structural incomplete response according to DRS. Only 1 patient (0.1%) with excellent response had a locoregional recurrence that exceeded 8 mm in its shortest diameter, which is the size cut-off for diagnostic US fine-needle aspiration in suspicious lymph nodes. This patient did not develop biochemical abnormalities during follow-up. Postoperative neck US surveillance after total thyroidectomy with prophylactic central neck dissection is not essential in PTC patients who show excellent response to initial therapy. Future studies are needed to verify the role of US surveillance in patients who receive variable degrees of treatments.

MON-250 Late Diagnosis of ACTH-secreting Pulmonary Neuroendocrine Tumor by Repeated 68Ga Dotatate Pet/ct: Influence of Tumor Size in Abnormal Uptake?

Background: 68Ga DOTATATE PET/CT (68Ga-PET) has been proposed as a superior method in identifying ectopic ACTH syndrome (EAS). However, recent systematic review suggests its sensitivity is not as high as believed (1). We report a challenging case of EAS whose source was uncovered only after repeated 68Ga-PET. Clinical Case: A 15‐year-old male presented with rapid onset of typical features of Cushing’s syndrome (CS) and metabolic impairment. Hormone evaluation confirmed severe ACTH-dependent CS. Pituitary transsphenoidal surgery was performed due to positive responses in desmopressin stimulation and high dose dexamethasone suppression test, in addition to a 4 mm nodule in pituitary MRI. No tumor was found in surgical specimen and no hormonal improvement was observed after surgery. Inferior petrosal sinus sampling demonstrated no central to peripheral ACTH gradient. Neck US, thorax/abdomen/pelvis CT were negative and PET-CT/FDG was inconclusive. OctreoScan® identified anomalous uptake on left mediastinum and led the patient to a thoracic surgery (TS) with nodule resection at left hilum. Pathology confirmed ACTH positive 10 mm neuroendocrine tumor (NET) infiltrating a lymph node. The patient had transient clinical and hormonal improvement, with recurrence 7 months later. Thoracic CT (T-CT) showed a 7 mm nodule on inferior segment of superior left lobe, PET-CT/FDG and OctreoScan® were negative but abnormal uptake was verified by 68Ga-PET in subcarinal area. A sub centimetric lymph node was resected and pathology confirmed ACTH positive NET, although the patient did not achieve remission. Octreotide LAR, cabergoline and ketoconazole did not control hypercortisolism and bilateral adrenalectomy was performed. Then, T-CT showed stable lung nodule and 2nd 68Ga-PET was negative. One year later, T-CT evidenced growth of lung nodule to 15 mm and 3rd 68Ga-PET demonstrated for the first time, abnormal uptake in this area. The patient underwent resection of left superior lung lobe along with ipsilateral hilar lymph nodes, and histopathology study revealed an ACTH-secreting atypical pulmonary carcinoid tumor with Ki67 of 10% and 5 out of 11 lymph nodes affected. ACTH fell from 288 to 64 pg/mL after surgery. Conclusion: Despite the high sensitivity attributed to 68Ga-PET, false negatives have been reported. In the present case, primary tumor was evidenced by 68Ga-PET seven years after the first resection of a metastatic lymph node, in the 3rd 68Ga-PET assessment and after tumor growth. This adds to the evidence that further studies are needed to better assess the accuracy of 68Ga-PET for EAS. Reference: [1] Varlamov et al. Diagnostic utility of Gallium‐68‐somatostatin receptor PET/CT in ectopic ACTH‐secreting tumors: a systematic literature review and single‐center clinical experience. Pituitary 2019; 22:445–455

MON-524 Prospective Evaluation of Patients with Encapsulated Classical Variant of Papillary Thyroid Cancer and Noninvasive Follicular Thyroid Neoplasm with Papillary-Like Nuclear Features (NIFTP): Have They A Similar Prognosis?

Background: Our previous retrospective study demonstrated that the absence of tumor capsule or, if present, its invasion were independent risk factors for the persistence of the disease (OR 6.75, CI 1.97-23.08 and OR 7.89, CI 1.78-34.94, respectively) in papillary thyroid cancer (PTC). This data was confirmed also analyzing separately the most frequent PTC variants [follicular variant (FVPTC) and classical variant (CVPTC)]. Moreover, we demonstrated that the absence of tumor capsule was significantly more frequent in FVPTC BRAF V600E mutated than FVPTC wild-type for BRAF gene or with rare-BRAF mutations (e.g., BRAF K601E, BRAF V600_K601delinsE). These data confirmed the importance of the integrity of the tumor capsule in FVPTC which led in 2016 to the definition of a new thyroid neoplasm entity named NIFTP. According to these retrospective data, we have assumed that the integrity of the tumor capsule in CVPTC could have a prognostic role similar to that confirmed in the NIFTP group. Methods: we have prospectively collected data of patients (pts) underwent total thyroidectomy or lobectomy for encapsulated-CVPTC (E-CVPTC) or NIFTP. In both cases the tumor was accurately analyzed by the pathologists according to the criteria used for the NIFTP (in particular with one capsule sample every 1 mm). All pts performed at least one clinical control and neck US within 6 months from surgery. Results: From January 2018 to June 2019, 144 E-CVPTC and 177 NIFTP were prospectively collected. 83/144 (57.6%) E-CVPTC and 106/177 (59.8%) NIFTP cases were included. The others were excluded due to the presence of other thyroid tumors associated in the same gland. No differences in epidemiological and pathological features were found between E-CVPTC and NIFTP except for the tumor size, significantly bigger in NIFTP than E-CVPTC [22±16mm (2-68) vs 8±11mm (1-80), p<0.00]. A significantly higher rate of NIFTP’ pts underwent lobectomy respect to E-CVPTC pts (34%vs14.5%, p=0.02). After a mean of 9 months of follow-up all pts had an excellent response according to ATA guidelines. Conclusions: These prospective data demonstrated that NIFTP and E-CVPTC have a similar clinical behavior in a short-term follow-up, thus suggesting that the presence of an intact tumor capsule is predictive of a good outcome. A longer follow up is needed to confirm these initial interesting findings.

SAT-058 A Rare Case of Primary Hyperparathyroidism in a Pediatric Patient

Introduction: Primary hyperparathyroidism (PHPT) is the third most common endocrine disorder in adult patients, but it is rare in pediatric patients. It is usually diagnosed when patients present with symptomatic hypercalcemia or known complications. In children, atypical presentation often results in delayed diagnosis and increased morbidity. We report a 10-year-old boy presenting with abdominal pain and emesis, found to have hypercalcemia and, ultimately, PHPT. His genetic evaluation was notable for a mutation in the RET gene (3.2C>A) of unknown clinical significance. Case presentation: A 10-year-old male with a history of constipation presented to the emergency department with five days of abdominal pain and emesis. Initial workup revealed high serum calcium (Ca) of 17.3 mg/dL (8.7-10.7) and ionized Ca (ICal) of 2.01 mmol/L (0.95-1.32). Further evaluations revealed low phosphorus level 3.5 mg/dL (4.5-6.5) and high parathyroid hormone level (iPTH) of 329.2 pg/mL (8.0-85.0). These findings were consistent with PHPT. Neck US demonstrated a cervical mass in the mid-right thyroid measuring 0.5 x0.3 x0.5cm, questionable for parathyroid adenoma, which was confirmed with 99mTc-MIBI scintigraphy and neck CT. His Ca level initially responded to fluid resuscitation and Lasix, with Ca level decreasing to 13.6. However, on hospital day two, his Ca level became refractory to all interventions, rising to 16 and prompting the use of bisphosphonates. The patient underwent neck exploration with partial parathyroidectomy and lymph node excision. Pathology revealed hypercellular parathyroid tissue consistent with parathyroid hyperplasia. Intraoperatively iPTH was reduced from 3,134.7 to 79.8 and remained within normal limits since. Postoperatively course was uncomplicated, and the patient was discharged home on oral Ca carbonate and vitamin D. A genetic evaluation was remarkable for a change in the RET gene (3.2C>A), a finding of unknown clinical significance. This change has not been seen in association with an individual who fulfills the clinical diagnosis of MEN2A. To further determine if the variant identified in the RET gene is a benign variant, the mother was tested for MEN2A and was negative. Father could not be tested, but family history was significant for thyroid malignancies. The patient is currently doing well four months postoperatively. His Ca level remains normal. Due to the genetic finding and the concern of MEN2A syndrome, the patient is followed closely by pediatric endocrinology and genetics. Conclusion: PHPT is a common endocrine disorder in adults but rare in children. The diagnosis of pediatric PHPT is almost always delayed due to atypical presentation and rarity of the disease. As secondary organ damage is common, a multi-organ assessment is mandatory. Due to the association with other syndromes, a genetic evaluation should be performed.

Ultrasound-guided-fine-needle Aspiration Drainage and Percutaneous Ethanol Injection for Benign Neck Cysts.

Background:Ultrasound-guided-fine-needle aspiration drainage (US-FNAD) and US-percutaneous ethanol injection (US-PEI) have been widely used in the management of benign neck cysts. However, the long-term results of US-FNAD and US-PEI are not well elucidated.Methods:We retrospectively collated patients under neck US examinations from March 2007 to December 2017 and investigated the recurrence after US-FNAD and US-PEI. Univariate and multivariate Cox regression analyses were used to assess significant risk factors for recurrence after US-FNAD.Results:A total of 1075 patients were recruited, and their age was 50 ± 15 (mean ± standard deviation) years. A total of 862 patients had thyroid cysts, 118 patients had thyroglossal duct cysts (TGDC), twenty patients had branchial cleft cysts, 64 patients had parotid sialocysts, and 11 patients had plunging ranulas. Majority of the patients (97%, 1037/1075) reported significant symptom improvement immediately. However, 38% of the patients had recurrence with a median 3-year follow-up period. In a multivariate Cox regression analysis with adjustment for age and gender, plunging ranula (hazard ratio [HR]: 2.44, 95% confidence interval [CI]: 1.19–4.99) and lateral dimension size ≥ 0.8 cm (HR: 1.32, 95% CI: 1.04–1.67) after US-FNAD were independent risk factors for recurrence. There were 15 male and 19 female patients who received US-PEI therapy after repeated US-FNAD, of whom 23 patients had thyroid cysts, 6 had plunging ranulas, 4 had TGDC, and one had a branchial cleft cyst. The overall success rate was 94% (32/34), with a median follow-up period of 1.6 years. Two recurrent symptomatic patients had plunging ranulas. Some patients stated mild pain (21%, 7/34) and swelling sensation (26%, 9/34) after the injection. No major complications, such as vocal fold paresis or airway compression, were found.Conclusion:US-FNAD is an effective tool in the management of benign neck cysts with a 38% recurrence rate. Plunging ranulas have the highest rate of recurrence after FNAD. US-PEI is effective for most recurrent neck cysts after repeated US-FNAD.

Thyroid Imaging Reporting and Data System (TIRADS) Versus Thyroid Scan for Solitary Thyroid Nodules

AbstractBackground: Solitary Thyroid nodules are a common finding which is defined as localized thyroid enlargement within an otherwise apparently normal gland. It is more common in females. Most of them are asymptomatic usually accidently discovered in neck US or carotid Doppler. Solitary thyroid nodule has a higher risk for malignancy than multiple nodules as reported in literature. Previously Radioactive Isotope scanning was first line for characterization before FNAC which is the gold standard to exclude malignancy. The availability and safety of US in addition to marvelous technological advances that yields high diagnostic power made it a prefect tool for the initial characterization of thyroid nodules. Recently TI-RADS (Thyroid Imaging Reporting and Data System) were proposed on the basis of ultrasound features for initial Solitary thyroid nodule characterization.Aim of Study: To compare between Thyroid Imaging Reporting and Data System and thyroid scan to evaluate the malignant potentiality of the solitary thyroid nodule with taking reference the results of fine needle aspiration cytology (FNAC) and histopathology as gold standard.Material and Methods: Thirty patients were enrolled in our cross section study with solitary thyroid nodule referred from the Otolaryngology Department to Radiology Department at Ain Shams University Hospitals. All patients underwent full thyroid ultasound examination with full comment on the nodules as regarde shape, echogenicity, margins, internal components and echogenic foci and classified according to the Americal college of radiology (ACR) Thyroid Imaging Reporting and Data System (TIRADS) Classification guideline, then thyroid scan was done to all cases. Results of both ultrasound and thyroid scan are compared with histopatholog-ical results of Fine needle aspiration cytology (FNAC).Results: The sensitivity and specificity of TIRADS on considering TR4 and TR5 lesions positive ( suspiciuos) when compared with histopathological findings were 100% and 79.2% respectively with PPV of 54.5%, NPV of 100% and accuracy of 83.3%. While isotope sensitivity when considering a cold nodule to be positive (suspiciuos) was 66.7% with specificity of 16.7%, PPV of 20%, NPV of 66.7% and accuracy of 26.7%.Conclusion: Our results suggest that ACR TIRADS clas-sification is superior to thyroid scan as regarde charchterization of solitary thyroid noude and considered reliable in predicting thyroid malignancy.

Thyroid Cancer Patients With No Evidence of Disease: The Need for Repeat Neck Ultrasound.

Ultrasonography (US) is considered the most sensitive tool for imaging persistent or recurrent papillary thyroid cancer (PTC) in the neck. To clarify the usefulness of routine neck US in low- and intermediate-risk patients with PTC with no evidence of disease 1 year after thyroidectomy. Retrospective analysis of prospectively recorded data. Academic center. Two hundred twenty-six patients with PTC with sonographically normal neck lymph nodes and unstimulated serum thyroglobulin (Tg) levels that were either undetectable (<0.20 ng/mL) or low (0.21 to 0.99 ng/mL) at the 1-year evaluation. Yearly assessment: unstimulated serum Tg level, anti-Tg-antibody (TgAb) titer, TSH levels, and ultrasound examination of neck lymph nodes. Rates of ultrasonographic lymph node abnormalities at the 3-year and last follow-up visits. In patients with an undetectable Tg level at the 1-year evaluation, sonographically suspicious neck lymph nodes were found in 1.2% of patients at 3 years and in 1.8% at the last visit [negative predictive values (NPVs) of 1-year Tg < 0.2 ng/mL: 98.8% (95% CI 95.8% to 99.9%) and 98.2% (95% to 99.6%), respectively]. Similar NPVs emerged for low detectable 1-year Tg levels [98.2% (90.3% to 99.9%) and 94.5% (84.9% to 98.9%) at the 3-year and last visits, respectively]. Seventy-five percent of the nodal lesions were likely false positive; none required treatment. Low- and intermediate-risk patients with PTC with negative ultrasound findings and unstimulated Tg levels <1 ng/mL at the 1-year evaluation can be safely followed with clinical assessments and unstimulated serum Tg determinations. Neck US might be repeated if TgAb titers rise, or unstimulated Tg levels exceed 1 ng/mL.

Parathyroid Glands Hyperplasias Mimicking Medullary Thyroid Carcinoma Metastatic Lymph Nodes on 18F-DOPA PET/CT

A pre operatory assessment by neck US, F-DOPA and F-choline PET/CT was performed in a 43-year-old MEN 2A woman affected by hyperparathyroidism and medullary thyroid carcinoma (MTC). On F-DOPA, two thyroid uptakes were analyzed as multifocal MTC and two others in the central neck compartment as MTC metastatic lymph nodes. After surgery, multifocal intra thyroidal MTC and two parathyroid glands hyperplasias were proved without MTC adenopathies. We report a case of rare false positive uptake on F-DOPA. In case of several endocrine diseases coexistence as in MEN 2A, F-DOPA should be carefully analyzed.

MON-559 Inappropriate Dosing of I-131 in Non-Metastatic Differentiated Thyroid Cancer

Differentiated thyroid cancer (DTC) accounts for the majority of thyroid cancers. While radioactive iodine (RAI) treatment after thyroidectomy plays an adjunctive role in some patients, the majority of patients with DTC at our institution receive RAI. The dosing of RAI is mostly empiric. A low dose of 30 mCi of I-131 is generally favored over higher doses in low or intermediate risk disease with lower risk features while higher doses may need to be considered for high risk patients (Haugen et al.). Higher rates of nausea, neck pain, lacrimal and salivary gland dysfunction and altered taste have been described for 100 mCi of I-131 compared with 30 mCi (Schlumberger et al. and Mallick et al.). The aim of this study was to determine the average dose of RAI for DTC and to identify the risk factors in low risk patients who received high dose of 131-I (≥100 mCi) at our tertiary care institution. Methods: This was a retrospective study of 33 patients with DTC who underwent RAI treatment from January 2015-May 2018 at a single academic medical center. Data were collected from the Nuclear Medicine department. Patients over the age of 18 with a documented non-metastatic DTC diagnosis were included. Patients who received RAI at an outside facility or with no pathology report were excluded. Results: Post-operative ultrasound was not routinely performed, and only 30% of patients had a neck US before RAI dose administration. The average dose of I-131 was 75.7 mCi regardless of the American Thyroid Association (ATA) risk. Sub-analysis per ATA risk group for the average dose showed 64.7 mCi in the low risk group, 98.9 mCi in the intermediate risk group, and 95.9 mCi in the high-risk group. The tertile ranges for the RAI dose were: T1: 29-33, T2:79-115 and T3:150 mCi. 63% of patients in the low risk group received a low dose of I-131(29-33m Ci), 22 % received 79-115 mCi and 13 % received 150 mCi. In the intermediate risk group 28% received 29-33 mCi and 28% received high dose 150 mCi while 42% received 79-115 mCi. In the high-risk ATA group 25% received a low dose of I-131with 29-33 mCi. Patients in the low risk group who received more than 30 mCi but less than 150 mCi showed no high-risk features with undetectable Tg level and no high risk histopathologic features or significant lymphadenopathy. However, of the patients in the low risk group who received ≥150 mCi, 75% had an elevated stimulated Tg level > 10 ng/ml and only one patient had a post-operative neck ultrasound that showed residual tissue. Conclusion: In this small cohort, patients with non-metastatic DTC received intermediate to high doses of RAI regardless of the ATA risk. More than 1/3 of patients in the low risk group received more than the recommended RAI dose per ATA guidelines. Despite the obvious multiple benefits of RAI post-operatively, selective criteria should be used to avoid unnecessary exposure of high dose RAI that may carry additional risk both in the short and long term.

Abstract #185 Efficacy of 18F-Fluorocholine PET/ CT, 99MTC-MIBI Spect/CT and Highresolution Neck US in the Detection of Parathyroid Adenomas

Abstract #185 Efficacy of 18F-Fluorocholine PET/ CT, 99MTC-MIBI Spect/CT and Highresolution Neck US in the Detection of Parathyroid Adenomas

Adherence to ATA 2015 guidelines in the management of unifocal non-invasive papillary thyroid cancer: a clinical survey among endocrinologists and surgeons.

Despite updated guidelines, management of thyroid nodules remains controversial. We aim to check implementation of new guidelines by ear-nose-throat (ENT) surgeons and endocrinologists. A questionnaire was e-mailed including demographic data and an index case: a healthy 26-year-old women with a 3-cm Bethesda III (B3) atypia of undetermined significance solitary nodule and eventually papillary thyroid cancer (PTC). Respondent rate was 50.5%, 93 endocrinologists, 55 surgeons. For this case, 77.4% would repeat fine-needle aspiration (FNA), 25.3% order molecular analysis and 22.6% do surgery. If repeated FNA remained B3, 51% would choose surgery, 17.3% molecular analysis and 31.6% follow-up only. If repeated FNA was B6, 58.5% would recommend total (TTx) and 41.5% hemithyroidectomy (HTx). In pathologically confirmed PTC after HTx, 42.4% would recommend completion, 26.8% radioactive iodine (RAI) treatment. For a > = 4-cm tumor, 49.2% would recommend TTx. For a tumor 2-4cm, 41% would recommend TTx. Variables favoring TTx were family history and radiation exposure. Only 17.4% would prefer TTx when small benign contralateral tumor is present. Reassessment at 1year with undetectable thyroglobulin (Tg) included stimulated Tg (stTg) (72.5%), neck US only (27.5%) and combined US-stTg (59.4%); only 10.3% would order a diagnostic scan. For recurrence in two (13-9mm) lymph nodes, 59.3% recommend reoperation, 16.3% RAI and 24.4% active surveillance. There were no major differences between endocrinologists and ENT surgeons. We report a considerable lack of adherence to new guidelines, with only 50% recommending HTx for a 4-cm unifocal low-risk PTC tumor.

Accuracy of Neck Ultrasonography in Predicting the Size and Location of Parathyroid Adenomas.

Ultrasonography (US) is a reliable tool for the preoperative localization of parathyroid adenomas (PTAs). The aim of this study was to evaluate the accuracy of US for estimating both the size and the location of PTAs and the effect of operator expertise. Retrospective cohort study. A single tertiary medical center. All patients who underwent parathyroidectomy for primary hyperparathyroidism between 1996 and 2012 were included. The estimated PTA localization and size by preoperative ultrasound were compared with the intraoperative findings and pathology report. The cohort included 410 patients. US correctly localized the adenoma in 76% of cases with a sensitivity of 76.2% and a positive predictive value of 86.8%. Measurements were least accurate for adenomas measuring <1 cm in diameter (24%). Scans made by a single senior operator specializing in the neck had a higher accuracy rate than scans made by multiple operators, with a significant difference for small adenomas ( P < .001). US is an accurate and sensitive tool for evaluating PTA size and location. Neck US is less accurate for small adenomas (<1 cm). In these cases particularly, the experience and expertise of the US operator may play an important role.