Nodule In Left Thyroid Lobe Research Articles

ODP510 Pseudolymphoma of the Thyroid Gland in Association with Hashimoto's Thyroiditis: A Benign Lesion in Whitish Thyroid Gland

Abstract Background Pseudolymphoma or reactive lymphoid hyperplasia is a benign localized tumor-forming lymphoid hyperplasia found in various organs. Its occurrence in the thyroid gland is rare and could mimic malignant lesion. Here, we present a case of pseudolymphoma of the thyroid in a patient with Hashimoto's Thyroiditis. Case description A 24-year-old woman without underlying disease presented with incidentally found thyroid nodule. Ultrasound revealed mild thyroid enlargement with diffuse heterogeneous parenchymal echotexture. A 5×7×8.5-mm hypoechoic solid nodule with irregular margin was found in the left upper pole. No microcalcification was detected. Multiple subcentimeter lymph nodes at bilateral cervical group VI and left cervical group IV were also detected, measuring up to 5 mm in short axis. Fine-needle aspiration was performed and suggested malignancy (Bethesda class V). Laboratory testing showed euthyroid state with positive anti-thyroglobulin antibodies and anti-thyroid peroxidase antibodies. The blood test and ultrasound findings suggested the underlying of Hashimoto's thyroiditis. The patient underwent total thyroidectomy and lymph node dissection without postoperative complication. Gross examination of the thyroid showed multiple well-demarcated whitish nodular lesions, ranging from 2-10 mm, in the upper pole of both thyroid lobe and a well-circumscribed area of a 7-mm greyish nodule in left thyroid lobe. Microscopically, the whitish lesion in both lobe composed of hyperplastic lymphoid tissues with many follicular centers on the background of lymphocytic thyroiditis. The immunohistochemistry study revealed a polyclonal nature of the plasma cell infiltrates. No abnormal staining with AE1/AE3 or cyclin D1 was found. Pseudolymphoma was diagnosed based on these findings. Papillary thyroid microcarcinoma (6 mm) without capsular invasion was also diagnosed in the lesion of left mid lobe. The cervical lymph nodes showed metastatic papillary thyroid carcinoma (1.5 mm) in level III cervical lymph nodes. No perinodal extension was found. Postoperative course was unremarkable and the patient was in stable condition at 18 months after the operation. Conclusion Although primary thyroid lymphoma is often considered in patients with Hashimoto's thyroiditis. The possibility of pseudolymphoma characterized by the presence of well-demarcated pearly white nodules and polyclonal cell populations should also be considered. Presentation: No date and time listed

MON-405 Cushing's Disease: An Oligosymptomatic Patient with ACTH-Secreting Pituitary Macroadenoma

BACKGROUND Cushing's disease (CD) is mainly due to pituitary microadenomas producing ACTH. Only 10% of CD presents with macroadenomas. CD is suspected by the presence of classic signs and symptoms and is often associated with metabolic diseases. We present a case of non-classical presentation of CD due to a pituitary macroadenoma CLINICAL CASE 73-years woman with hypertension, diabetes and dyslipidemia in treatment with metformin 850mg bid, insulin NPH 50U/d, Enalapril 10mg bid and Atorvastatin 20mg was referred to endocrinology clinic for noticed in the last year cervical tumor that increases in volume. She noticed occasional headache and decreased visual acuity, denied difficulty in breastfeeding, menopause at 45 years old. Physical evaluation reveals TA 110/60 Weight 82 Kg BMI 39 Central obesity. Thin skin. Abdomen white and thin striae. Nodule in left thyroid lobe 2cm. Muscular atrophy in lower limbs. Absence of reddish striae, hump, skin or mucosa hyperpigmentation, hirsutism and facial plethora. Campimetry by confrontation: bitemporal heteronymous hemianopsia. Blood analysis: Glucose 103mg/dL HbA1C 11.3% Creatinine 1.25mg/dL Total cholesterol 94mg/dl LDLc 40mg/dl Triglyceride 112mg/dl ALT 18 AST 23 TSH 1.83uU/ml (0.27-4.2) Free T4 0.86ng/ml (0.93-1.7). Thyroid US: left nodule 26x20mm with macrocalcifications, irregular edges and central vascularization. FNA Bethesda III. To rule out secondary hypothyroidism, was requested TSH 2.77 Free T4 0.72 FSH 35.6 (48.6-143) LH 14.35 (13-45) Prolactin 9.98 (18-24) Cortisol AM 10.5 (3.7-19.4). A 75ug qd levothyroxine was started 3 months later, she reported headache more frequently, asthenia and difficulty climbing stairs, lower limbs paresthesias, higher dose of insulin was needed (NPH 58U, insulin Lispro 5U before lunch) Glucose 225 HbA1C 14.9% Triglycerides 300 Cortisol AM 9.3ug/dl Cortisol PM 9.7 ACTH1 118.1pg/ml (5-63) ACTH2 135.8. Free urinary cortisol 76.4ug/24h. Dexamethasone suppression test 2mg/6h by 48h: Cortisol before test was 11ug/dL and after 1.4 Pituitary MRI described a macroadenoma involving the left cavernous sinus and the left carotid artery. After Transsphenoidal surgery, pathology was informed as Pituitary Adenoma, Positive immunohistochemistry ACTH, proliferation index Ki67 1% 1-year post surgery, she had stopped insulin and enalapril. Her only medication is levothyroxine 100ug. Her last blood analysis: Glucose 92 HbA1C 7.2% Creatinine 1.48 Free T4 1.3 FSH 30 LH 16 Prolactin 10.4 Cortisol AM 9.2. CONCLUSION Sometimes, CD can be oligosymptomatic despite being a pituitary macroadenoma, so it can be considered a differential diagnosis in patients with metabolic syndrome REFERENCES Buliman A, et al. Cushing´s disease: a multidisciplinary overview of the clinical features, diagnosis and treatment. J Med Life 2016

Intrathyroid Parathyroid Carcinoma with Intrathyroidal Metastasis to the Contralateral Lobe: Source of Diagnostic and Treatment Pitfalls

Intrathyroidal parathyroid carcinoma is extremely rare clinical entity with potentially multiple diagnostic pitfalls. We report a case of 40-year-old man presented with classical manifestations of primary hyperparathyroidism, severe hypercalcemia and profoundly increased serum parathyroid hormone level. Neck ultrasonography demonstrated multinodular goiter with predominant 34 mm nodule in left thyroid lobe. Additional 16 mm nodule was found beneath the left lobe. Routine percutaneous fine-needle aspiration of predominant nodule indicated follicular thyroid carcinoma, while left inferior nodule was confirmed to be of parathyroid origin. The patient underwent surgery, during which frozen sections identified medullary thyroid carcinoma with metastasis to upper mediastinal lymph node. Permanent sections of the predominant left lobe nodule revealed intrathyroidal parathyroid carcinoma surrounded with multiple microscopic metastases. Left inferior nodule was metastatic lymph node. Additional 10 mm intrathyroidal metastasis of primary parathyroid carcinoma was found within right thyroid lobe. This case indicates that fine-needle-aspiration and intraoperative biopsy are of limited value in diagnosing parathyroid carcinoma, especially if localized intrathyroidally. Oncological en-block resection is treatment of choice, implying ipsilateral lobectomy in case of thyroid invasion. This firstly described case of intrathyroidal parathyroid carcinoma causing intrathyroidal dissemination may influence future treatment strategies.

潜在性甲状腺機能亢進症の経過の後に後期高齢期に診断されたＰｌｕｍｍｅｒ病の１例

A 81-year-old woman with a thyroid tumor and subclinical hyperthyroidism since ten years ago was admitted to our hospital for palpitations and hyperthyroidism (FT(4) 1.75 ng/dl, FT(3) 5.37 pg/ml, TSH<0.03 microIU/ml). Although thyroid stimulating antibody (TSAb) was transiently and mildly positive, anti-TSH receptor antibody (TRAb), microsome test, and thyroid test were negative. Thyroid echogram showed an isoechoic nodule in the left lobe (33 x 42 x 22 mm) and a small nodule (10 x 15 x 9 mm) in right lobe. Thyroid scintiscan showed a hyperfunctional (hot) nodule in left thyroid lobe with suppressed uptake in the remainder of the gland. The uptake rate of thyroidal radioiodine ((123)I) in 24 hours was within the normal range (7.3%). Based on the above findings, a diagnosis of Plummer disease was made. Since she refused invasive surgical or radioiodine treatment, she was treated with 10 mg thiamazole daily. After treatment with propranolol and thiamazole, the thyrotoxic symptoms disappeared and thyroid function returned to normal level. She had osteoporosis but she had neither atrial fibrillation nor cardiac symptoms. This was a rare case of Plummer disease that appeared in extremely old age after a long course of subclinical hyperthyroidism.