Hypoechoic Solid Nodule Research Articles

The Value of Preoperative and Intraoperative Ultrasound in the Localization of Intrathyroidal Parathyroid Adenomas

Aim Intrathyroidal parathyroid adenoma (IPA) is rare and may easily be mistaken for thyroid nodule in ultrasonography. The aim of this study was to investigate the characteristic features of IPA and explore the value of preoperative and intraoperative ultrasound in the diagnosis and localization of IPA. Methods 13 of 216 patients who were found to have intrathyroidal parathyroid lesions underwent parathyroidectomy in our hospital because of PHPT. According to the relationship between parathyroid adenoma and thyroid gland, parathyroid adenoma was divided into extra-thyroid type or intra-thyroid type (partial or complete) and the results were compared with surgical and histopathological reports as gold standard. The sonographic features of intrathyroidal parathyroid lesions were analyzed retrospectively. Results A total of 12 intrathyroidal lesions showed profoundly hypoechoic solid nodules with well-defined border, abundant blood flow and polar feeding vessels originating from the superior or inferior thyroid artery (92.3%, 12/13). These nodules were finally confirmed as IPA (or IPAC) after surgery. Polar feeding vessel was not detected in one case of parathyroid hyperplasia confirmed by pathology (7.7%, 1/13). 12 cases were diagnosed and localized on ultrasonography before operation and 10 cases were localized on Tc-99m MIBI SPECT/CT. Conclusions The color Doppler ultrasound findings of IPA were confirmed as profoundly hypoechoic nodules with clear boundary and abundant internal blood flow. The presence of polar feeding vessels which originate from thyroid artery were identified as characteristic features of US for IPA. Preoperative and intraoperative ultrasound could be helpful in the localization and treatment of intrathyroidal parathyroid diseases.

Intrathyroidal Branchial Cleft Cysts Presenting as Bilateral Thyroid Nodules

Introduction: Intrathyroidal brachial cleft cysts are a rare entity and are usually associated with Hashimoto’s thyroiditis. Etiology is not very clear at this point, but they are thought to arise from the ultimobranchial body remnant during embryogenesis of the gland versus originating secondary to chronic inflammation as a form of squamous metaplasia. They are a common finding in the lateral neck but not with the thyroid. We present a case of a suspicious appearing bilateral thyroid nodules which were found to branchial cleft cysts on biopsy. Clinical Case: A 56-year-old woman presented to us for evaluation of thyroid nodules. Her past medical history was pertinent for endometrial cancer status post surgery and radiation, obesity, sleep apnea, hyperlipidemia and hypothyroidism. She was diagnosed with hypothyroidism around 30 years ago and had been on Levothyroxine since then. She was recently noted to have a low TSH level on routine labs done by her primary care provider and therefore her Levothyroxine dose was adjusted. She also underwent a thyroid ultrasound due to exam findings of a palpable thyroid nodule. The ultrasound revealed a suspicious 2.2 cm hypoechoic solid nodule with irregular margins and micro-calcifications in the left mid thyroid lobe. Additionally, she was also noted to have a 0.8 cm hypoechoic nodule with irregular margins in the right mid thyroid lobe. No concerning cervical lymphadenopathy was identified. She was hence referred to us for further evaluation. She denied having compressive symptoms and did not have history of head/neck radiation or family history of thyroid cancer. Both nodules were biopsied but were interpreted as non-diagnostic with insufficient follicular cells and colloid. She underwent repeat biopsy of both nodules which again was interpreted as non-diagnostic. After discussion with patient, given her suspicious ultrasound findings and inconclusive biopsy results she was referred to endocrine surgery for surgical evaluation. Shortly after she underwent total thyroidectomy with pathology consistent with bilateral benign branchial cleft like cysts associated with adjacent thyroid follicles undergoing squamous metaplasia admixed with chronic inflammation. Conclusion: Pathogenesis of these intrathyroidal branchial cleft cysts is still unclear and not many similar cases have been reported in the literature so far. These commonly present as a painless mass but sometimes can also be an incidental finding. There are not a lot of specific details in the literature regarding imaging or pathology characteristics of these lesions therefore resulting in surgical intervention to reach a definitive diagnosis.

Malignancy Risk Stratification of Thyroid Nodules with Macrocalcification and Rim Calcification Based on Ultrasound Patterns

ObjectiveTo determine the association of macrocalcification and rim calcification with malignancy and to stratify the malignancy risk of thyroid nodules with macrocalcification and rim calcification based on ultrasound (US) patterns.Materials and MethodsThe study included a total of 3603 consecutive nodules (≥ 1 cm) with final diagnoses. The associations of macrocalcification and rim calcification with malignancy and malignancy risk of the nodules were assessed overall and in subgroups based on the US patterns of the nodules. The malignancy risk of the thyroid nodules was categorized as high (> 50%), intermediate (upper-intermediate: > 30%, ≤ 50%; lower-intermediate: > 10%, ≤ 30%), and low (≤ 10%).ResultsMacrocalcification was independently associated with malignancy in all nodules and solid hypoechoic (SH) nodules (p < 0.001). Rim calcification was not associated with malignancy in all nodules (p = 0.802); however, it was independently associated with malignancy in partially cystic or isoechoic and hyperechoic (PCIH) nodules (p = 0.010). The malignancy risks of nodules with macrocalcification were classified as upper-intermediate and high in SH nodules, and as low and lower-intermediate in PCIH nodules based on suspicious US features. The malignancy risks of nodules with rim calcification were stratified as low and lower-intermediate based on suspicious US features.ConclusionMacrocalcification increased the malignancy risk in all and SH nodules with or without suspicious US features, with low to high malignancy risks depending on the US patterns. Rim calcification increased the malignancy risk in PCIH nodules, with low and lower-intermediate malignancy risks based on suspicious US features. However, the role of rim calcification in risk stratification of thyroid nodules remains uncertain.

Locoregional recurrence of parathyroid carcinoma: how to identify this rare but fatal condition using ultrasonography.

Parathyroid carcinoma (PC) is a rare condition with propensity to relapse. The purpose of this study was to evaluate the sonographic findings of locoregional recurrences of parathyroid carcinoma, in order to facilitate diagnosis of this condition using ultrasound (US). This was a retrospective observational study including 21 patients confirmed with pathologically confirmed locoregional recurrence of parathyroid carcinoma. All patients had undergone preoperative US examination at a tertiary center. The imaging, clinical and laboratory data of each case were collected. Sonographic appearance of the largest lesion at each recurrence was evaluated by two experienced radiologists according to a pre-agreed protocol. Overall, 29 relapses occurred in 21 patients. The median age of the patients was 45 years (range 24-71 years). The median size of the largest recurrent lesion at each relapse was 1.8 cm (range 0.8-3.8 cm). Ultrasound images showed hypoechoic solid nodules in 28 relapses (96.6%), inhomogeneous echo-texture in 28 relapses (96.6%), intralesional echogenic septa-like structures in 21 relapses (72.4%), intralesional cystic change in two relapses (6.9%), infiltrative or blurred boundary in 20 relapses (69.0%), irregular shape in 22 relapses (75.9%), marked vascularization on color Doppler imaging in 19 relapses (65.5%), multiple lesions in 26 relapses (89.7%), contralateral recurrence in 3 relapses (10.3%), and subcutaneous recurrence in 10 relapses (34.5%). None of the recurrent lesions exhibited calcification. The total size of all the recurrent lesions at each relapse fairly correlated with the serum intact parathyroid hormone levels (r = 0.450; p = 0.014).

Un intento de reducir intervenciones quirúrgicas innecesarias... ¿Pueden ayudar las características ecográficas a diferenciar el adenoma del carcinoma en las neoplasias tiroideas foliculares?

Introduction and objectivesThyroid nodules frequently require ultrasound and Fine Needle Aspiration Cytology (FNAC) evaluation. However, FNA cytology does not allow differentiation between follicular adenoma and carcinoma on Bethesda type IV lesions. This situation leads to many unnecessary surgical procedures because it is not possible to assure the benignity of the lesions, even when most of the specimens correspond to adenomas or even other benign lesions.The objective is this study is to establish if there are any US characteristics that would help us to predict the risk of malignancy of nodules with a pathological diagnosis of follicular neoplasm in order to achieve a more conservative management for non-suspicious nodules. Material and methodsWe studied 61 nodules in 61 patients (51 women and 10 men) that underwent thyroid surgery and had histopathological results of either follicular adenoma or carcinoma.Different US characteristics of the nodules were analysed (composition, echogenicity, margin, calcification status, the presence of halo and overall observer suspicion of malignancy) and were correlated with the histopathological analysis. ResultsWe have found a statistically significant association between the presence of calcifications, ill-defined borders and overall observer suspicion or impression (defined by well-known suspicious for malignancy ultrasonographic features, such as calcification, poorly defined margin, and a markedly hypoechoic solid nodule; and benign ultrasonographic features, such as predominantly cystic echogenic composition and the presence of a perinodular hypoechogenic halo) with follicular carcinoma. However all those features have shown low sensitivities in the present study (30%, 30% and 50%, respectively). On the other hand, the absence of halo sign has shown a sensitivity of 100% and a negative predictive value (NPV) of 100% in our study. ConclusionsThe presence of calcifications, ill-defined borders and the overall impression or suspicion of malignancy associate with a higher risk for follicular carcinoma in Bethesda type IV thyroid nodules but their absence do not allow to predict benignity in these nodules. Inversely, when a halo sign lesion is observed, benign follicular neoplasm should be considered.

Ultrasound features value in the diagnosis and prognosis of medullary thyroid carcinoma.

Ultrasound (US) is the most important imaging in the preoperative diagnosis of medullary thyroid carcinoma (MTC). MTC are easy to be misdiagnosed due to lacking typical malignant US features. This study investigated US features, clinical characteristics, prognosis, and detection methods, aimed to explore the association between US features and biological behavior, and improve early diagnosis of MTC. A total of 189 MTC patients were enrolled in the study. Based on US features, 29 MTC were categorized as "indeterminate" (i-MTC) and 160 MTC were categorized as "malignant" (m-MTC) according to Thyroid Imaging, Reporting and Data System published by America College of Radiology (ACR TI-RADS). We compared US features, clinical characteristics and prognosis between both groups. We analyzed cytological categories of fine needle aspiration (FNA) within each i-MTC and m-MTC group according to the 2017 Bethesda System for Reporting Thyroid Cytopathology (TBSRTC). We assessed the positive rate of FNA, frozen pathological examination, and preoperative serum calcitonin (Ctn) level in i-MTC and m-MTC groups. Preoperative US features were significantly different in shape, margin, composition, echogenicity, and calcifications between i-MTC and m-MTC (p < 0.05). I-MTC showed a hypoechoic solid or solid-cystic nodule lacking malignant US features. While m-MTC was presented as a solid nodule with obviously malignant US features. There were significant differences in lymph node dissection, extent of tumor, lymph node metastasis, and TNM stage and prognosis between i-MTC and m-MTC (p < 0.05). Compared to m-MTC, i-MTC underwent central neck dissection more frequently rather than lateral neck dissection at the time of the initial operation; i-MTC had less extrathyroidal invasion and lymph node metastasis, earlier stage, higher rate of biochemical cure, and lower rate of structural persistence/recurrence (p < 0.05). The 2017 TBSRTC of i-MTC and m-MTC was significantly different (p < 0.05). Preoperative serum Ctn level had a higher diagnostic sensitivity for both i-MTC and m-MTC when comparing to FNA and frozen pathological examination (p < 0.05). US features were associated with biological characteristics and prognosis of MTC. I-MTC lack malignant US features, preformed less aggressiveness, and better prognosis. TBSRTC according to FNA combined with serum Ctn were helpful for the detection of i-MTC.

Ultrasonography and Atypical Sites of Endometriosis.

In the present pictorial we show the ultrasonographic appearances of endometriosis in atypical sites. Scar endometriosis may present as a hypoechoic solid nodule with hyperechoic spots while umbilical endometriosis may appear as solid or partially cystic areas with ill-defined margins. In the case of endometriosis of the rectus muscle, ultrasonography usually demonstrates a heterogeneous hypoechogenic formation with indistinct edges. Inguinal endometriosis is quite variable in its ultrasonographic presentation showing a completely solid mass or a mixed solid and cystic mass. The typical ultrasonographic finding associated with perineal endometriosis is the presence of a solid lesion near to the episiotomy scar. Under ultrasonography, appendiceal endometriosis is characterized by a solid lesion in the wall of the small bowel, usually well defined. Superficial hepatic endometriosis is characterized by a small hypoechoic lesion interrupting the hepatic capsula, usually hyperechoic. Ultrasound endometriosis of the pancreas is characterized by a small hypoechoic lesion while endometriosis of the kidney is characterized by a hyperechoic small nodule. Diaphragmatic endometriosis showed typically small hypoechoic lesions. Only peripheral nerves can be investigated using ultrasound, with a typical solid appearance. In conclusion, ultrasonography seems to have a fundamental role in the majority of endometriosis cases in “atypical” sites, in all the cases where “typical” clinical findings are present.

MON-450 Prophylactic Thyroidectomy in a Patient with Codon 891 Mutation of the RET Proto-Oncogene

Background: Medullary thyroid cancer (MTC) is a neuroendocrine tumor of the parafollicular or C cells of the thyroid gland, accounting for 1-2% of thyroid cancers in the United States. About 25% MTCs are familial as a part of the MEN2 syndrome or familial MTC (FMTC). Germline mutations in codon 891 are predominantly associated with FMTC. Case: 65-year-old Caucasian male was referred to the Endocrinology clinic after bilateral thyroid nodules were found on thyroid US. The patient had requested an ultrasound of his thyroid after his brother was diagnosed with MTC following fine-needle aspiration for an incidental thyroid nodule prompting total thyroidectomy and genetic testing. The patient’s brother was found to be heterozygous for RET mutation (c.2617T>G;pSer891Ala). This resulted in screening of the other siblings including this patient, also found to be heterozygous for this mutation. Both parents were deceased, and their clinical history is not known. Only one of the remaining two siblings had genetic testing; one brother refused testing for the mutation and one sister was positive for the mutation but had no thyroid nodules on ultrasound. She underwent prophylactic thyroidectomy. Neither the patient, nor his siblings, have any progeny. The patient screened negative for primary hyperparathyroidism and pheochromocytoma. Calcitonin (739, normal </=14.3 pg/mL)and CEA levels (31.7, 0-3.0 ng/mL) were elevated. Thyroid ultrasound (US) showed two solid hypoechoic nodules with lobulated margins and internal coarse calcifications in the right and two in the left thyroid lobe; 1.5 cm and 1.2 cm in maximum diameter, and 1.2 cm and 3 mm in maximum diameter, respectively. Based on elevated calcitonin and CEA levels, known RET mutation and evidence for thyroid nodules, we recommended a total thyroidectomy and central neck dissection. Pathology revealed multifocal, bilateral medullary carcinoma (largest focus of 1.5 cm), with 4/4 lymph nodes positive for metastasis. This was classified as mpT1bN1aM0 (Stage III). Patient was started on levothyroxine with plans to repeat calcitonin and CEA levels and neck ultrasound, 3 months following surgery. CT chest, abdomen and pelvis did not reveal any distant metastasis. Conclusion: Inherited MTCs are rare. Early diagnoses by screening of at-risk family members in MEN2 kindreds is important because MTC can be life-threatening and can be cured and prevented by early thyroidectomy. While our suspicion for FMTC in this patient and his siblings is high, FMTC is now considered a variant of MEN2A and ongoing screening for pheochromocytoma and primary hyperparathyroidism is recommended.

SAT-478 A Case of Congenital Thyroid Hemi-Agenesis- Caution for Complications!

Introduction: Congenital Thyroid hemi-agenesis is an uncommon clinical entity. We present a case highlighting the importance of awareness of this condition and the need to evaluate and manage co-existing hypothyroidism and risk of malignancy. Case: A 20 year old female known to have Hashimoto’s thyroiditis (non-adherent to levothyroxine), and hemi-agenesis of left lobe of thyroid gland, presented with right-sided thyroid enlargement. She was clinically euthyroid. Physical exam: enlarged right sided thyroid gland with palpable anterior cervical lymphadenopathy. Left lobe could not be palpated. TFTs were notable for TSH 4.98 uIU/ml (0.358-3.74) and Free T4 0.79 ng/dl (0.76-1.46) consistent with sub-clinical hypothyroidism while Anti TPO antibody was positive at 8332.8 U/mL (0 - 60). CBC negative for leukocytosis. US thyroid: left-sided thyroid agenesis with intact isthmus and enlargement of right lobe of the thyroid 7.7 cm x 1.6 cm x 2.6 cm with 2 sub-centimeter hypoechoic solid nodules and 2 enlarged lymph nodes 1.5 cm and 2.3 cm (not found in US thyroid 2 years ago) Levothyroxine was re-started. ENT evaluation determined that her lymphadenopathy was benign and consistent with Hashimoto’s thyroiditis. Subsequent TFTs improved. Discussion: Thyroid Gland embryogenesis occurs in the 4th week of fetal life. Subsequent abnormal bilobal differentiation of the thyroid gland is presumed to be the etiology of congenital hemi-agenesis. Its prevalence in several studies is estimated to be between 0.05-0.25%. It is symptomatic pre-dominantly in females and may have familial origin with vast majority of cases having left hemi-agenesis with intact isthmus. It is helpful to know that most symptomatic patients have compensatory hypertrophy of the remnant lobe. It is important to remember that compensatory enlargement of the remnant lobe in the setting of hypothyroidism may be a sign of insufficient endogenous thyroxine production and/or replacement. Although rarely symptomatic, hemi-thyroid remnant may need to be evaluated for co-existing hyperthyroidism, hypothyroidism, carcinoma and multinodular goiter among others, with hypothyroidism thought to be the most common. US thyroid is a useful modality to help guide the evaluation of patients with hemi-agenesis. Awareness of this congenital condition is key in preventing unnecessary evaluations and interventions. Non-resolving lymphadenopathy in Hashimoto’s thyroiditis must be evaluated for lymphoma, however, based on studies, no additional risk of malignancy was identified in patients with underlying thyroid hemi-agenesis.

MON-441 Primary Thyroid Maltoma: A Rare Non-hodgkin Malignancy

Introduction: Thyroid lymphoma is a rare malignancy; only 2% of extranodal lymphomas arise within the thyroid gland. Furthermore, lymphomas represent no more than 2% of all malignant thyroid tumors and almost always non-Hodgkin type. Case: A 58-year-old female with a medical history of rheumatoid arthritis treated with Golimumab for years. Exam revealed a right thyroid lobe enlargement with bilateral palpable nodules. Labs include TSH of 1.4 mU/L, Free T4 of 1.76 ng/dL, normal anti-thyroid peroxidase antibodies, but elevated anti-thyroglobulin. US of the thyroid showed right-sided, hyperechoic nodule measuring 1.3cm, and left-sided solid hypoechoic nodule measuring 2.2cm. US-guided FNA of the right nodule yielded atypical cells of undetermined significance (2017 Bethesda category III). FNA of the left nodule showed severe, chronic thyroiditis, with small clonal population of cells and suspicion for lymphoma. She underwent total thyroidectomy with left central lymph node dissection. Microscopic evaluation showed a predominant lymphocytic population with plasmacytoid/plasma cells. The histological finding was consistent with extranodal marginal zone lymphoma (EMZL) of mucosa-associated lymphoid tissue (MALT lymphoma or MALToma). However, thyroid tissues were negative for clonal immunoglobulin gene rearrangements (both immunoglobulin heavy and light chains). Immunohistochemistry demonstrated that the tumor cells were CD19, CD 20, CD 22, PAX5, CD78A positive, highlighting predominantly small to medium-sized B- cell lymphocytes, along with plasmacytoid/plasma cells (MUM1 and CD 75A positive). Furthermore, occasional reactive germinal centers (CD10, BCL6 positive, BCL2 negative) were noted. In conclusion, these features were consistent with a low grade, non-Hodgkin’s lymphoma of MALT type. Discussion: EMZL is a clinically indolent non-Hodgkin lymphoma, and growing evidence suggests that numerous cases originate in the background of chronic immune stimulation. MALToma is associated with Hashimoto’s thyroiditis or other immune diseases. Whereas half of EMZL can still arise without a Hashimoto thyroiditis background. Characteristics of the MALToma include reactive follicles, with the neoplastic cells invading the marginal zone (small lymphocytes, marginal zone B-cells, and plasma cells). The key findings are the presence of clonality (light chain restriction), and confirmation of B-cell origin (presence of B-cell markers). The immunophenotype is confirmed by immunohistochemistry and flow cytometry. Localized EMZL of the thyroid can be effectively treated with radiation alone. Surgery is usually used for diagnostic biopsy only. Chemotherapy is usually reserved for those with advanced stages

MON-460 An Extremely Rare Case of Urothelial Carcinoma Metastasizing to the Thyroid Gland

BACKGROUND Metastasis of primary malignancies to the thyroid gland is uncommon, with an overall incidence of 2%. The most common malignancy to metastasize to the thyroid is lung neoplasm (22%) as reported in an autopsy series and renal cell carcinoma (25%) in a clinical series. CLINICAL CASE A 78 year-old-white male was found to have a thyroid nodule on CT neck performed for surveillance of urothelial carcinoma diagnosed 3 years prior. On retrospective review of CT chest from the previous year, the thyroid nodule had increased in size but didn’t meet criteria for FNAC. Neck/Thyroid US demonstrated a right lobe solid hypoechoic nodule measuring 1.1 x 0.7 x 1.1 cm (longitudinal x anterior-posterior, lateral respectively). Nodule margin was well defined, with no internal vascularity, microcalcifications or abnormal cervical lymph nodes. Seven months later, US reported the nodule to have increased in size to 2.1 x 2.1 x 4.7 cm at which point FNAC was performed. Cytology revealed malignant cells compatible with metastasis from the urothelial carcinoma. Three years prior, his high-grade papillary urothelial carcinoma with extensive infiltration into the muscularis propria had been treated with a partial cystectomy and radiation therapy. Surgical margins and all tested lymph nodes had been negative for neoplasm. The patient underwent right thyroid lobectomy and pathology confirmed high-grade malignant neoplasm consistent with metastatic tumor from the patient’s known urothelial carcinoma. CONCLUSION We present a rare case of urothelial carcinoma with metastasis to the thyroid gland. While evaluating thyroid nodules in patients with other known malignancies, clinicians should have a lower threshold for FNAC. This will assist with earlier diagnosis of potential metastatic disease and improve clinical outcomes.

Malignancy risk of thyroid nodules with nonshadowing echogenic foci.

PurposeThis study was conducted to determine the malignancy risk and diagnostic value of various types of nonshadowing echogenic foci (NEF) in the risk stratification of thyroid nodules.MethodsA total of 1,018 consecutive thyroid nodules (≥1 cm) with final diagnoses were included. The presence of NEF was determined and types of NEF were classified according to the presence of a comet tail artifact (CTA), location, and size through a prospective evaluation. The associations with malignancy, malignancy risk, and diagnostic value of various types of NEF were assessed.ResultsIntrasolid punctate NEF without CTA was the only type of NEF that was an independent predictor of malignancy (P<0.001). The malignancy risk of intrasolid punctate NEF without CTA was substantially higher in solid hypoechoic nodules than in isoechoic or nonsolid nodules (71.3% vs. 9.2%, P<0.001). In solid hypoechoic nodules, slightly increased sensitivity (70.8% vs. 67.9%) for malignancy and a similar malignancy risk (71.4% vs. 71.3%) were observed for intrasolid punctate NEF (with or without CTA) and intrasolid punctate NEF without CTA, respectively. NEF with CTA at the margin of the cystic component was not associated with malignancy or benignity in nonsolid nodules (P>0.05).ConclusionIntrasolid punctate NEF without CTA was the only independent predictor of malignancy. However, solid hypoechoic nodules with intrasolid punctate NEF should be classified as high-suspicion nodules regardless of coexisting CTA. Other types of NEF had no added value for detecting malignancy compared to intrasolid punctate NEF without CTA.

Association of Ultrasonographic Findings and Thyroid Malignancy: A Cross-Sectional Study

Objective: To determine the association of thyroid malignancy and the following ultrasonographic findings: presence of solid hypoechoic nodule, irregular margins (infiltrative, microlobulated, or speculated), microcalcifications or disrupted rim calcifications with small extrusive hypoechoic soft tissue component, taller than wide shape of the thyroid nodule, and evidence of extrathyroidal extension.&#x0D; Methods:&#x0D; Design: Cross-Sectional Study&#x0D; Setting: Tertiary Government Training Hospital&#x0D; Participants: Records of patients admitted to the Otorhinolaryngology- Head and Neck Surgery ward with a diagnosis of nodular non-toxic goiter, multinodular non-toxic goiter, and thyroid malignancy who underwent thyroid surgery between January 2017 and June 2018 were considered for inclusion.&#x0D; Results: A total of 33 patients, 7 males and 26 females, were included in this study. Patients’ age ranged from 26 to 69 years with an average of 46 years. Thirteen (39.4%) had malignant while 20 (60.6%) had benign histopathologic results. There was a significant association between presence of solid hypoechoic nodule (Fisher exact, n = 33, p = .0047), irregular margins and microcalcifications with malignant histopathology results (X2 (df = 1, N = 33) = 8.57, p = .003). No significant difference was noted in the proportion of subjects with malignancy according to taller than wide nodules (Fisher exact, n = 33, p = 1.000) or presence of extrathyroidal extension nodules or presence of extrathyroidal extension (Fisher exact, n = 33, p = .276). On multivariate analysis using logistic regression, only microcalcification was found to be a significant predictor of malignancy (OR = 8.96, 95% CI: 1.02 – 87.19, p = .05).&#x0D; Conclusion: There was a significant association between presence of solid hypoechoic nodule, margins and microcalcifications with thyroid carcinoma. Only microcalcification was found to be a significant predictor of thyroid malignancy on ultrasound, although our confidence interval was broad.&#x0D; Keywords: calcifications; thyroid; thyroid carcinoma; thyroid nodule; ultrasonography

Hyperfunctioning thyroid carcinoma: A systematic review.

Hyperthyroidism may be caused by the development of primary or metastatic thyroid carcinoma. The aim of the present study was to collect recently reported cases of hyperfunctioning thyroid carcinoma in order to analyze its pathological characteristics, diagnostic procedures and treatment strategies. A PubMed (https://www.ncbi.nlm.nih.gov/pubmed/) search was performed for studies published between January 1990 and July 2017. Full-text articles were identified using the terms, ‘hyperfunctioning thyroid carcinoma/cancer’, ‘malignant hot/toxic thyroid nodule’, or ‘hyperfunctioning papillary/follicular/Hürthle thyroid carcinoma’. Original research papers, case reports and review articles were included. Among all thyroid carcinoma cases included in the present study, the prevalence of follicular thyroid carcinoma (FTC) was ~10%; however, the prevalence of FTC among hyperfunctioning thyroid carcinomas was markedly higher (46.5% in primary and 71.4% in metastatic disease). The size of hyperfunctioning thyroid tumors was considerably larger compared with that of non-hyperfunctioning thyroid tumors, with a mean size of 4.25±2.12 cm in primary hyperfunctioning thyroid carcinomas. In addition, in cases of metastatic hyperfunctioning thyroid carcinoma, tumor metastases were widespread or large in size. The diagnosis of primary hyperfunctioning thyroid carcinoma is based on the following criteria: i) No improvement in thyrotoxicosis following radioactive iodine (RAI) treatment; ii) development of hypoechoic solid nodules with microcalcifications on ultrasound examination; iii) increase in tumor size over a short time period; iv) fixation of the tumor to adjacent structures; and v) signs/symptoms of tumor invasion. The diagnosis of metastatic hyperfunctioning thyroid carcinoma should be considered in patients suffering from thyrotoxicosis who present with a high number of metastatic lesions (as determined by whole-body scanning), or a history of total thyroidectomy. Surgery is the first-line treatment option for patients with primary hyperfunctioning thyroid carcinoma, as it does not only confirm the diagnosis following pathological examination, but also resolves thyrotoxicosis and is a curative cancer treatment. RAI is a suitable treatment option for patients with hyperfunctioning thyroid carcinoma who present with metastatic lesions.

SAT-618 Ectopic Thyroid-Stimulating Hormone-Secreting Pituitary Adenoma of the Nasopharynx Diagnosed by 68Ga-DOTA-TATE PET/CT

Background Thyroid-stimulating hormone (TSH)-secreting pituitary adenomas are rare, accounting for up to 3% of all pituitary tumors. Ectopic TSH-secreting tumors are even rarer and can be difficult to detect. We report the first use of 68Gallium (Ga)-DOTA-TATE PET/CT to diagnose an ectopic TSH-secreting tumor located in the nasopharynx. Clinical case A 48-year-old woman presented to clinic for evaluation of hyperthyroidism. Three years prior to presentation, the patient complained of typical hyperthyroid symptoms. Thyroid function tests showed TSH 3.57 uIU/ml (ref 0.34-4.82); fT4 2.37 ng/dL (0.76-1.8); TT4 24 ug/dL (4.7-13.3); fT3 5.18 pg/mL (2.3-4.2); TT3 260 ng/dL (87-167). Over the next three years, she had persistently elevated T4 and T3 with normal TSH, despite treatment with thionamides. A RAIU scan showed diffuse thyroid gland uptake without any evidence of a focal hyper- or hypofunctioning nodule and a thyroid ultrasound revealed heterogeneous echogenicity and a 1.9 x 0.8 x 1.3 cm hypoechoic solid nodule within the isthmus. On her initial evaluation, physical examination was notable for an enlarged thyroid gland and resting tremor in bilateral hands. Thyroid function tests remained similar to prior; Tg antibodies <2 IU/mL (ref <2); TPO antibody <63 (<101); TSI <89% (<140); TBII <1% (<16). Dilution and heterophile antibody blocking studies were negative and TSH measured on different laboratory assays yielded similar results. Alpha subunit was 0.3 with alpha subunit to TSH ratio 1.16. On review of her prior images, she was noted to have a mildly enhancing 9 x 10 mm nodule in the nasopharynx extending from the posterior aspect of the nasal septum and a normal pituitary. 68Ga-DOTA-TATE PET/CT revealed a 6 x 8 x 11 mm nasopharyngeal soft tissue nodule attached to the right posterior nasal septum, compatible with a neuroendocrine tumor. The patient underwent successful endoscopic resection of the mass. Intraoperatively, a pedunculated tumor arising from posterior nasal septum and anterior sphenoid wall on the right was noted. Pathology confirmed ectopic pituitary neoplasm with immunohistochemical staining positive for PRL and TSH, and negative for ACTH. Immediately postoperatively, she had a high fT4 and low TSH. Even after her fT4 normalized, her TSH remained partially suppressed at 2 months, but fully recovered at 5 months. Conclusion Ectopic TSH-secreting pituitary adenomas are rare. We describe the tenth case of an ectopic TSH-secreting pituitary adenoma located in the nasopharynx in a patient who presented with signs and symptoms of hyperthyroidism. Our case was the first, to our knowledge, to utilize the somatostatin receptor agent 68Ga-DOTA-TATE to aid in identifying the lesion, emphasizing the importance of recognizing 68Ga-DOTA-TATE PET/CT as an imaging modality in the diagnosis of ectopic pituitary adenomas, as these tumors can be challenging to diagnose radiographically.

SAT-607 "Eye" Spy with My Big Eye: Thyroid Ophthalmopathy Secondary to Hashitoxicosis

Introduction: Hashitoxicosis is the transient hyperthyroid phase of chronic autoimmune thyroiditis, common in children. It is characterised by mild-moderate symptoms of hyperthyroidism, small painless goiter and normal or slightly increased uptake on thyroid scintigraphy. It is differentiated from Graves’ Disease (GD) by its shorter course and absence of thyroid ophthalmopathy (TAO). We present a rare case of TAO associated with Hashitoxicosis in an adult. Case Presentation: A 55 year-old gentleman, with current tobacco use and family history of thyroid disease, presented with complaints of a bulging left eye and double vision for 3-6 months. He endorsed pain and fatigue of eye muscles, and dry eyes. Additionally, he endorsed weight gain, increased appetite, and flat affect. Examination revealed a 5 mm proptosis and restrictive strabismus of the left eye with a normal fundus bilaterally. The thyroid gland was normal to palpation. Laboratory tests revealed a TSH of 0.016 mcIU/ml (normal 0.358-3.800 mcIU/ml), total T3 of 90 ng/dl (normal 60-181 ng/dl) and total T4 8.2 mcg/dl (normal 4.7-13.3 mcg/dl). A TSH receptor antibody (TRAb) was normal (1.35 IU/l, normal <1.75 IU/l), while a thyroid peroxidase (TPO) antibody titre was elevated (5780.7 U/ml, normal <60.1 U/ml), confirming Hashitoxicosis. Thyroid scintigraphy showed normal uptake (4.25% at 4 hours, 24.1% at 24 hours) with a focal photopenic area in the left lower lobe suggesting a non-functioning nodule. A thyroid ultrasound showed mild generalised enlargement of the thyroid gland with hypervascularity and multiple 1 cm hypoechoic solid nodules bilaterally. Magnetic Resonance Imaging (MRI) of the orbit confirmed left sided TAO due to markedly enlarged inferior rectus and mildly enlarged medial and lateral recti. The patient was diagnosed with TAO due to Hashitoxicosis. He is currently awaiting an orbital decompression and strabismus surgery. Discussion: Initial release of preformed thyroid hormones from the inflamed thyroid gland leads to Hashitoxicosis. Traditionally, bilateral TAO with hyperthyroidism is considered pathognomonic for GD. In patients with unilateral TAO, Hashitoxicosis should also be considered. The pathophysiology of TAO due to Hashitoxicosis is not well-understood. Presence of low level TRAb may be implicated, however, more research is required to clarify the natural history of this condition. Current practice suggests that steroids and other immunosuppressive agents such as Rituximab may alleviate symptoms of TAO. Decompression surgery is considered for cases not responding to medical management.

SAT-472 Increased Thyroid Cancer Risk in Acromegaly: A Report of 3 Cases

Introduction: There is a high incidence of thyroid cancer in patients with acromegaly. We present three patients who were diagnosed with acromegaly and thyroid cancer within a short time interval. Case 1: A 34-year-old female who had uvulopalatopharngoplasty for sleep apnea presented for evaluation of elevated IGF-1 1226 ng/mL (88-246). She reported increased shoe size, growth of facial hair, and increased hand size causing her to resize her wedding band multiple times. GH did not suppress on oral glucose tolerance testing (OGTT) and MRI revealed a 2.2 cm pituitary macroadenoma. On initial exam, she was noted to have to have thyromegaly and ultrasound showed a 1.3 cm solid nodule with microcalcifications. She underwent transsphenoidal hypophysectomy (TSSH) and a month later was sent for FNA biopsy of the nodule which was consistent with papillary carcinoma (PTC). She underwent total thyroidectomy two months later with 1 cm PTC on final pathology. Case 2: A 60-year-old female presented for evaluation of thyroid nodules. An ultrasound revealed a right solid 2.2 cm isoechoic nodule and a left 1.2cm solid nodule with calcifications. At the initial encounter, physical exam was notable for prominence of the forehead and jawline and sausage digits. History was significant for carpal tunnel syndrome, osteoarthritis, DM2, excessive perspiration and snoring. Screening IGF-1 was elevated 771 ng/mL (81-225) and GH failed to suppress on OGTT. FNA biopsy of the left nodule showed PTC. Pituitary MRI revealed an 8mm microadenoma. She underwent TSSH and then a total thyroidectomy three months later with a 1cm PTC, follicular variant on final pathology. Case 3: A 30-year-old female presented with amenorrhea, increased hand/foot size and changes in the jaw. IGF-1 was 729 ng/mL(63-373) and GH failed to suppress on OGTT. MRI showed a 2.5cm pituitary adenoma with cavernous sinus invasion. She underwent TSSH and was on medical treatment for acromegaly for about two years when she was noted to have a thyroid nodule on palpation. Ultrasound showed a 10 mm isthmus solid isoechoic nodule and a 15 mm left midpole solid hypoechoic nodule. FNA of the isthmus nodule was consistent with PTC. Total thyroidectomy pathology showed a 0.7cm PTC. Conclusion: Carcinomas are the third most frequent cause of mortality in acromegalic patients, after vascular and respiratory diseases. Sustained secretion of GH and IGF-1 is known to induce proliferation and inhibit apoptosis. Thyroid nodular disease is more frequent in acromegalic patients, and thyroid cancer is one of the most commonly detected cancers in acromegaly. It remains controversial whether acromegaly increases the risk of malignant transformation of thyroid nodules. In all of our patients with acromegaly, stage I PTC was likely present at the time of diagnosis. Periodic thyroid ultrasound exam should be considered an important part of monitoring patients with acromegaly.

Usefulness of core needle biopsy for the diagnosis of thyroid Burkitt\u2019s lymphoma: a case report and review of the literature

BackgroundThyroid lymphomas are an exceptional finding in patients with thyroid nodules. Burkitt’s lymphoma is one of the rarest and most aggressive forms of thyroid lymphomas, and its prognosis depends on the earliness of medical treatment. Given the rarity of this disease, making a prompt diagnosis can be challenging. For instance, fine-needle aspiration (FNA) cytology, which is the first-line diagnostic test that is performed in patients with thyroid nodules, is often not diagnostic in cases of thyroid lymphomas, with subsequent delay of the start of therapy.Case presentationHere we report the case of a 52-year-old woman presenting with a rapidly enlarging thyroid mass. Thyroid ultrasonography demonstrated a solid hypoechoic nodule. FNA cytology was only suggestive of a lymphoproliferative disorder and did not provide a definitive diagnosis. It is core needle biopsy (CNB) that helped us to overcome the limitations of routine FNA cytology, showing the presence of thyroid Burkitt’s lymphoma. Subsequent staging demonstrated bone marrow involvement. The early start of an intensive multi-agent chemotherapy resulted in complete disease remission. At 60 months after the diagnosis, the patient is alive and has not had any recurrence.ConclusionsClinicians should be aware that thyroid Burkitt’s lymphoma is an aggressive disease that needs to be treated with multi-agent chemotherapy as soon as possible. To diagnose it promptly, they should consider to order/perform a CNB in any patient with a rapidly enlarging thyroid mass that is suspicious for lymphoma.

Revised Value of Contrast-Enhanced Ultrasound for Solid Hypo-Echoic Thyroid Nodules Graded with the Thyroid Imaging Reporting and Data System

The use of ultrasound in differentiation of benign and malignant solid hypo-echoic thyroid nodules is a dilemma in clinical practice. The aim of this study was to investigate the revised value of contrast-enhanced ultrasound (CEUS) for differentiating solid hypo-echoic thyroid nodules using the Thyroid Imaging Reporting and Data System (TI-RADS).The study included 135 patients with 135 nodules confirmed by fine-needle aspiration and/or surgery. Every nodule underwent both conventional US and CEUS. Binary logistic regression analysis for conventional US features revealed that irregular shape, microcalcification and height greater than width were significant malignant predictive features. Binary logistic analysis for CEUS features indicated that hetero-enhancement, slow wash-in, an ill-defined enhancement border and fast wash-out were significantly associated with malignancy. The areas under the curve of the TI-RADS, CEUS and the combination were 0.806, 0.934 and 0.950, respectively. CEUS is a potentially useful tool in the differentiation of solid hypo-echoic thyroid nodules.

Quantification of solid hypo-echoic thyroid nodule enhancement with contrast-enhanced ultrasound

Background: The purpose of this study was to investigate the value of the quantitative assessment of enhancement on contrast-enhanced ultrasound (CEUS) for diagnosing solid hypo-echoic thyroid nodules (SHTNs).