Thyroid Biopsy Research Articles

Bethesda III and IV Thyroid Nodules Managed Nonoperatively after Molecular Testing with Afirma GSC or Thyroseq v3.

Molecular testing has improved risk stratification and increased non-operative management for patients with indeterminate thyroid nodules, but data on the long-term outcomes of current molecular tests Afirma Gene Sequencing Classifier (GSC) and Thyroseq v3 are limited. To determine the rate of delayed operation and the false-negative rate of the Afirma GSC and Thyroseq v3 in Bethesda III and IV thyroid nodules. Prospective follow-up of a single center randomized clinical trial comparing the performance of Afirma GSC and Thyroseq v3 in the diagnosis of indeterminate thyroid nodules. University of California, Los Angeles. Consecutive participants who underwent thyroid biopsy in the UCLA health system with Bethesda III and IV cytology from August 2017 to November 2019. False negative rate of molecular testing. Of 176 indeterminate nodules with negative or benign molecular test results, 14 (8%) nodules underwent immediate resection, with no malignancies found on surgical pathology. Non-operative management with active surveillance was pursued for 162 (92%) nodules with benign or negative test results. The median surveillance was 34 months (range 12-60 months), and 44 patients were lost to follow-up. Of 15 nodules resected during surveillance, one malignancy was found (overall false negative rate of 0.6%). This was a 2.7 cm minimally invasive Hurthle cell carcinoma that initially tested negative with Thyroseq v3 and underwent delayed resection due to sonographic growth during surveillance. The majority of Bethesda III/IV thyroid nodules with negative or benign molecular test results are stable over 3 years of follow-up. These findings support the high sensitivity of current molecular tests and their role in ruling out malignancy in indeterminate thyroid nodules.

Papillary Carcinoma in a Patient with a Thyroid Nodule: Role of Ultrasonography and its Diagnostic Accuracy

Introduction: While it can be difficult to categorize thyroid lesions, employing ultrasound may enable correct diagnosis, classification, and therapy of thyroid nodules, particularly papillary carcinoma of the thyroid, and assist save unneeded biopsy. Objective: Taking histopathology as the gold standard, assessing the diagnostic precision of ultrasound in the identification of papillary cancer in thyroid nodule patients. Study design: Cross sectional study Study Settings: Department of ENT & Surgery, Jinnah Teaching Hospital, Peshawar Study Duration: This study was conducted from 1st August 2021 till 30th June 2022. Materials and Methods: Patients of both gender who sought assessment for a thyroid nodule were included. On ultrasonography, papillary carcinoma was detected. The gold standard for diagnosing cancers, histology, was used to confirm papillary carcinoma. Using a 2×2 table, diagnostic accuracy was assessed in terms of sensitivity, specificity, PPV, and NPV. Results: Overall 241 participants recruited. The patients were between the ages of 18 and 75. The patients' mean age was 57.80 + 9.245 years. The ratio of men to women was 1.2:1. The ultrasound's sensitivity, specificity, PPV, NPV, and diagnostic accuracy for the diagnosis of papillary thyroid cancer were, respectively, 85.1%, 97.5%, 88.8%, 96.5%, and 95.1%. Conclusion: With clinically significant diagnostic accuracy for the early diagnosis of thyroid papillary carcinoma, ultrasound is a cost-effective, non-invasive diagnostic method that may lessen the need for invasive diagnostic methods like thyroid biopsy. Keywords: Papillary Carcinoma of Thyroid, Ultrasound, Diagnostic Accuracy

IgG4-associated sclerosing thyroiditis: one case, two different clinical courses

Abstract IgG4 related Diseases (IgG4- RD) are characterized swelling of affected organs, elevated levels of serum IgG4, dense lymphocyte infiltration and IgG4- positive plasma cells in tissues pathologically in the involved organs. Involvement of major organs is common and IgG4-RD may lead to organ failure, particularly in the pancreas, liver and biliary tree, kidneys, thyroid gland. We present a case of changing between subtypes of IgG4-related thyroid disease—transition from GD to IgG4-related sclerosing thyroiditis for the first time in the literature. A 48-year-old female patient, who had a diagnosis of psoriasis, and asthma, was admitted to the hospital due to fatigue complaint in 9/2012. Her laboratory assessment was compatible with thyrotoxicosis. It was detected patchy hypoechoic areas within the gland and Vitti 3 blood in the parenchyma in the thyroid doppler ultrasonography (USG). The results were compatible with Graves disease (GD) and methimazole (MMI) and beta blocker treatment were started at diagnosis. Rapid changes in serum thyroid function tests (TFT) in 1–3 months of follow-up were observed under MMI treatment. The patient first described a pressure during swelling in her throat in 8/2016. Grade 3 goiter was detected in her physical examination (PE). The patient had unstable TFT and received short term-intermittent MMI treatment according to TFT results until 9/19. MMI was discontinued upon detection of TSH 29.18(0.38–5.33) µIU/mL. After approximately six months of euthyroid follow-up, she was admitted to the outpatient clinic with complaints of hypothyroidism and compression due to grade 2 goiter. The thyroid is hard on PE. Her laboratory assessments were compatible with hypothyroidism and levothyroxine (LT4) treatment was started. The thyroid volume was 38 ml, the parenchyma was markedly echogenic, no compression sign in adjacent structures on USG. Thyroid tru-cut biopsy was planned with the preliminary diagnosis of Riedel/ IgG4 related disease. Histopathological diagnosis on tru-cut biopsy of thyroid was fibrosclerosing chronic thyroiditis with severe collagen fibrosis and interstitial lymphocyte infiltration. The presence of IgG4 positive plasma cells in the fibrotic stroma was remarkable and compatible with IgG4-associated sclerosing thyroiditis (Figure 1). The serum Ig G4 level was detected as 1.27 g/L(0.04–0.86). No sign of fibrosing disease was detected in neck, thorax and abdomen imaging. The results of laboratory and autoantibody levels are summarized in Table 1 and the Figure 2 and 3. Figure 1. Cytopathological evaluation A. Thyroiditis with diffuse collagen fibrosis and interstitial lymphoplasmacytic cell infiltration (chronic thyroiditis in the sclerosing/fibrotic stage). B. Fibroinflammatory reaction/chronic thyroiditis in core needle biopsy C. Immunohistochemistry: Intense IgG staining in interstitial lymphoplasmacytic cells, D. IgG4 positivity around 30% of IgG positive cells. We present a patient who initially presented with thyrotoxicosis, which was controlled with short-term MMI therapy, then transitioned to hypothyroidism, and the final diagnosis was IgG4-induced thyroiditis. IgG4-related thyroiditis includes IgG4-related Hashimoto's thyroiditis (HT), Riedel's thyroiditis, fibrosing variant of HT, and GD with elevated IgG4 levels. The clinical course of these subtypes is not exactly known due to their rarity.

Difficult situation in treatment of medullary thyroid carcinoma in patient with multiple endocrine neoplasia type 2 B(MEN2B)

Abstract Introduction Multiple endocrine neoplasia type 2B (also known as ‘MEN2B’,‘Multiple endocrine neoplasia type 3′ or ‘Wagenmann–Froboese syndrome’) is a genetic disease characterized by the presence of medullary carcinoma of the thyroid, pheochromocytoma, mucosal neuromas, marfanoid features and multiple skeletal abnormalities such as kyphoscoliosis and pes cavus. Clinical Case A 16 years male presented with neck swelling and dysmorphic feature in the form of marfanoid habitus, including multiple tongue and oral mucosal swelling with mucosal neuromas on the anterior third of the tongue, the lips and the inner eyelid. Lips are thickened and bumpy. Visible neck swelling, palpable solid neck mass, high arm span to height ratio at >1.05, elongated fingers, pes cavus and positive wrist sign which is defined as when the distal phalanges of the thumb and fifth finger overlap on encircling the opposite wrist, were present. Ultrasound of the neck revealed a left solid irregular mass (57mmx33mm), that is hypoechoic, has coarse calcification, hypervascularity, that is mostly central, Multiple cervical lymph node(abnormal nodes include shape (round), absent hilum, intranodal necrosis, reticulation, calcification, peripheral vascularity),Investigation at beginning, Normal thyroid function test and biochemical and electrolyte were observed, Chest x ray was normal, FNAC done for thyroid nodule that showed multiple clumps of large hyperchromatic oval cells picture suggesting high suspicion of thyroid malignancy, thyroid biopsy advised, The patient was referred the FDEMC center for further evaluation and investigation prior to the surgery. During investigation at FDEMC center, thyroid function test normal, biochemistry normal, including PTH and electrolytes, Calcitonin was very high 465 pg/mL (0.2–27.7 pg/mL),GH under GTT was normal, IGF 1 182µg/L (150–350),Plasma metanephrine 40 pg/ml(<90pg/ml),and Plasma normetanephrine 27pg/ml(<196pg/ml) were normal. The patient referred to surgery, total thyroidectomy with radical neck dissection with multiple lymph node resection was performed. The biopsy revealed medullary thyroid carcinoma with cervical lymph node secondaries (bilateral multiple foci in both lobes). The patient kept on levothyroxine tab 100mcg.The follow up of the patient after one month by ultrasound and calcitonin level revealed residual thyroid tissue and two large cervical LN in the the ultrasound and a calcitonin level of 322 pg/mL Another surgical neck dissection to the metastatic LN <multiple LN 7×5cm, multiple suprasternal mass dissection 3×2.5cm,remnant of thyroid tissue 0.8cm,Follow up the patient after one month by ultrasound and calcitonin level still showed that there is residual pathological cervical LN, while the calcitonin level still high 412 pg/mL. PET scan done for him showed there is uptake in the head, neck and chest. The calcitonin was repeatedly was high.

Antineoplastic Activity of Pazopanib in Anaplastic Thyroid Cancer in Primary Culture.

Anaplastic thyroid cancer (ATC) is a rare and rapidly fatal human cancer. Its usual treatment includes the combination of surgery, external hyperfractionated radiation therapy, and chemotherapy. These treatments permit achieving about 6-10 months of median survival. For this reason, it is challenging to predict the ATC patient clinical therapy responsiveness. Pazopanib is a multitarget tyrosine kinase inhibitor of VEGF receptors, PDGF, and c-Kit. Until now, the effect of pazopanib in primary human ATC cells (pATC) has not been reported in the literature. The aim of our study was to evaluate in vitro the antineoplastic effect of pazopanib in pATC. Surgical thyroidal tissues were collected from five patients with ATC, from thyroid biopsy at the moment of first surgical operation. An inhibition of proliferation, migration, and invasion, and an increase in apoptosis were demonstrated upon treating pATC cells with pazopanib (p < 0.05). Moreover, pazopanib was able to significantly decrease the VEGF expression in pATC cells (p < 0.05). To conclude, in this study, we demonstrate the antineoplastic activity of the antiangiogenic inhibitor, pazopanib, in human pATC in vitro.

Ultrasound imaging in thyroid nodule diagnosis, therapy, and follow-up: Current status and future trends.

Ultrasound, the primary imaging modality in thyroid nodule management, suffers from drawbacks including: high inter- and intra-observer variability, limited field-of-view and limited functional imaging. Developments in ultrasound technologies are taking place to overcome these limitations, including three-dimensional-Doppler, -elastography, -nodule characteristics-extraction, and novel machine-learning algorithms. For thyroid ablative treatments and biopsies, perioperative use of three-dimensional ultrasound opens a new field of research. This review provides an overview of the current and future applications of ultrasound, and discusses the potential of new developments and trends that may improve the diagnosis, therapy, and follow-up of thyroid nodules.

The Effect of Relaxation and Respiratory Exercise on Anxiety in Thyroid Biopsy Patients

Objectives: It is known that high stress levels increase the risk of complications in invasive procedures. The aim of this study is to investigate the effect of the relaxation and respiratory exercise on the anxiety state specific to the thyroid biopsy procedure in patients. Methods: 100 randomly selected thyroid biopsy patients from 200 patients watched the Relaxation and Respiratory Exercise video (group 1) and did the instructions, and the rest 100 patients were control group (group 2) who did not watch it. The State-Trait Anxiety Inventory state scale (STAI-I) and trait anxiety scale (STAI-II) were administered to all patients before the procedure. Group 1 watched the video just before the biopsy procedure. After the biopsy procedure, all the 200 patients rested for 15 minutes, and the STAI- I scale was filled again. Results: When the STAI-II and pre-biopsy STAI-I questionnaire results of the patients were compared between two groups; study group (Group 1): Patients who were selected to watch the video, control group (Group 2): Patients who were not watching the video), no statistically significant difference was found (p&gt;0,005). When the anxiety levels in the first STAI-I performed before the biopsy and the STAI-I tests performed after the procedure were compared, a statistically significant decrease was found in the anxiety levels of the SG (p&lt;0,001). Anxiety levels of female patients were statistically significantly higher than male patients. Conclusions: Although thyroid biopsy is a minimally invasive procedure, it may cause anxiety in patients. Watching the video before the procedure resulted in a decrease in the anxiety levels of the patients.

Histopathologic Patterns and Cytohistologic Correlation of Thyroid Lesions among Patients with Thyroid Biopsies in Jimma Medical Centre, South West Ethiopia: A Retrospective Study

Introduction Thyroid diseases are major health problems that are manifested by alteration in hormone secretion, enlargement of the thyroid gland (goitre), or both. Identifying and characterizing lesions of the thyroid gland has a pivotal role since most of the lesions require medical or surgical management. Fine needle aspiration cytology (FNAC) is an important initial screening tool and histopathologic examination is the gold standard in the definitive diagnosis of thyroid disease. Objectives To assess histopathologic patterns and cytohistologic correlation of thyroid lesions among patients with thyroid biopsy. Methods A five-year retrospective study was conducted with a review of 581 biopsies submitted from thyroidectomy specimens at Jimma University Medical Centre (JUMC), Pathology Department from September 2015 to September 2020. This also includes a review of 286 cases in which fine needle aspiration was done prior to surgery. Data was analysed using Statistical Package for the Social Sciences (SPSS) version 26. Descriptive and analytic studies were done. Cross tabulation, chi square (χ2 ) test and logistic regression with multivariate analysis were done to look for associations between the study variables. Results Majority of thyroid lesions were found to be non-neoplastic and 149 (25.6%) were neoplastic. Colloid goitre was found in 417 (71.8%) cases. Adenoma, carcinoma, and thyroiditis accounted for 54 (9.3%), 95 (16.3%) and 12 (2.1%) cases respectively. Among 286 FNAC results, cyto-histologic correlation was achieved in 233 (86.6%) cases. Sensitivity and specificity of FNAC were 71% and 92.7% respectively, with diagnostic accuracy of 86.6%. Conclusion Nodular colloid goitre is by far the most common thyroid lesion and papillary thyroid carcinoma (PTC) is the most frequent histologic type of malignancy. FNAC remains a sensitive, specific and accurate tool in the evaluation and management of thyroid lesions.

A Case of Granulomatosis with Polyangiitis Concurrent Papillary Thyroid Cancer

Purpose: To report a biopsy-proven case of granulomatosis with polyangiitis (GPA) who visited for red eye and discomfort. We detected papillary thyroid cancer by a whole-body scan.Case summary: A 56-year-old female presented to our clinic with hyperemia and discomfort in the right eye for the past 1 month. The visual acuity was 0.9 in the right eye. Congestion and chemosis of the right conjunctiva were observed by slit-lamp microscopy. There was a firm, erythematous, tender mass near the right nasolacrimal duct. Impairment of adduction and infraduction and proptosis were observed. Radiologically, a 3.6 × 2.6 × 1.2 cm right orbital mass was seen in the intraorbital extraconal space, invading the right nasolacrimal duct and nasal cavity. Pathologic and supplementary investigations showed granulomatous, c-anti-neutrophil cytoplasmic antibodies (ANCA)-positive inflammation in the mass. The patient was diagnosed with GPA. Whole-body computed tomography and positron emission tomography-computed tomography revealed multiple lesions in the right orbit, nasal cavity, mediastinum, retropubic area, and left thyroid gland. Thyroid ultrasonography and biopsy led to a diagnosis of papillary carcinoma with lymph node metastasis. Topical and systemic steroids and rituximab injection were administered, and total thyroidectomy with bilateral central lymph node dissection was performed. This led to improvements in proptosis and limitation of extraocular movement.Conclusions: GPA is a rare disease that may initially present with ocular symptoms. It can be associated with malignancies even in the absence of immunosuppression. Patients with ocular problems suspected of having GPA should undergo autoimmune antibody testing, including ANCA and tissue biopsy.

Unsupervised neural networks as a support tool for pathology diagnosis in MALDI-MSI experiments: A case study on thyroid biopsies

Artificial intelligence is getting a foothold in medicine for disease screening and diagnosis. While typical machine learning methods require large labeled datasets for training and validation, their application is limited in clinical fields since ground truth information can hardly be obtained on a sizeable cohort of patients. Unsupervised neural networks – such as Self-Organizing Maps (SOMs) – represent an alternative approach to identifying hidden patterns in biomedical data. Here we investigate the feasibility of SOMs for the identification of malignant and non-malignant regions in liquid biopsies of thyroid nodules, on a patient-specific basis. MALDI-ToF (Matrix Assisted Laser Desorption Ionization - Time of Flight) mass spectrometry-imaging (MSI) was used to measure the spectral profile of bioptic samples. SOMs were then applied for the analysis of MALDI-MSI data of individual patients’ samples, also testing various pre-processing and agglomerative clustering methods to investigate their impact on SOMs’ discrimination efficacy. The final clustering was compared against the sample’s probability to be malignant, hyperplastic or related to Hashimoto thyroiditis as quantified by multinomial regression with LASSO. Our results show that SOMs are effective in separating the areas of a sample containing benign cells from those containing malignant cells. Moreover, they allow to overlap the different areas of cytological glass slides with the corresponding proteomic profile image, and inspect the specific weight of every cellular component in bioptic samples. We envision that this approach could represent an effective means to assist pathologists in diagnostic tasks, avoiding the need to manually annotate cytological images and the effort in creating labeled datasets.

ODP593 Thyroid sarcoidosis: case study and literature review

Abstract Introduction Sarcoidosis is a disorder characterized by noncaseating granulomas, most commonly in the lungs, lymph nodes, and skin. Patients often present with cough, skin or eye changes, enlarged lymph nodes, fatigue, or are found to have incidental findings on chest imaging. While any organ can be involved, thyroid involvement is rare, reportedly seen postmortem in 4.2 to 4.6% of sarcoidosis cases. We describe the case of a young adult male with thyroid sarcoidosis in addition to neurosarcoidosis. Case Presentation A 37-year old African American male was found to have a goiter on routine examination. Work up revealed an elevated TSH level of 11.1 uIU/mL (0.4-4. 0) with a free T4 of 0.91 ng/dL (0.7-1.9). Thyroid ultrasound demonstrated a dominant right-sided thyroid mass measuring 5.5×3.1×4.1 cm. Fine needle aspiration cytology reported polymorphic lymphocytes, few lymphohistiocytic aggregates, scant hurthle cells, and multinucleated giant cells. Thyroidectomy was recommended; intra-operatively the right thyroid lobe contained a 5-cm firm, hard, whitish mass in the mid inferior portion which could not be excised due to extensive fibrosis. Incisional biopsy was performed demonstrating fibrotic lymphocytic thyroiditis and non-caseating granulomas with no evidence of malignancy. He presented to the ER six weeks later with confusion, headaches, retro-orbital pain, and periodic involuntary movements in all extremities. MRI of the brain showed dural-based lesion in the right lateral and inferior temporal fossa. He underwent craniotomy and excisional biopsy of the lesion, which showed granulomatous inflammation, favoring a diagnosis of neurosarcoidosis. In a future admission, he was found to have dural venous sinus occlusion and new granulomas on brain MRI. It was then noted that previous thyroid biopsy revealed granulomatous disease, which was then linked to his sarcoidosis. He was discharged on prednisone and methotrexate with eventual further neurological complications. Discussion Thyroid sarcoidosis is very rare and because of this, it is frequently misdiagnosed initially and fine needle aspiration of the thyroid is frequently nondiagnostic. Histopathology is usually necessary to rule out malignancy and identify non-caseating granulomas. In some reported cases, thyroid sarcoidosis shared clinical, ultrasonographic, and even cytologic features with papillary thyroid cancer. Our case was unique for several reasons. Firstly, although not immediately noted, incisional thyroid biopsy was the first diagnostic clue of sarcoidosis. More commonly, patients are already diagnosed with systemic sarcoidosis. Additionally, typical findings such as mediastinal hilar adenopathy, hypercalcemia, and elevated angiotensin converting enzyme levels were absent. Although sarcoidosis of the thyroid is rare and often benign, it is important to consider this differential diagnosis while ruling out more likely causes as early detection can lead to early treatment and prevent adverse outcomes. The ideal treatment remains unclear, regarding whether to treat pharmacologically or concurrently with surgical intervention. Presentation: No date and time listed

ODP475 Developing suppurative thyroiditis

Abstract Suppurative thyroiditis is rare and associated with significant mortality. A high level of suspicion and aggressive management is needed to reduce the risk of serious outcomes. A 67-year-old male with a medical history including diabetes type 2, cognitive impairment, and ESRD presented with decreased appetite and lethargy for a few days. He presented with fever, tachycardia, and hypertension. There was a non-tender fullness around the anterior neck region. Initial laboratory tests revealed leukocytosis to 24K/uL, lactic acid of 5. 0 mmol/L, ESR 100 mm/hr, CRP 419 ng/dl, and blood culture was positive for gram-positive cocci in clusters for which he was started on iv vancomycin and piperacillin/tazobactam. CT scan on admission showed a probable inflammatory process in the neck originating from the thyroid bed, concerning acute thyroiditis and developing abscess/abscesses vs. very atypical presentation of thyroid cancer. Thyroid ultrasound showed diffuse thyroid enlargement with heterogeneous echogenicity. Repeat CT obtained due to apparent thyroid enlargement with erythema and tenderness on examination and fever on day 7 showed extensive heterogeneous thyroid enlargement with ill-defined margins to the adjacent soft tissue structures. A modified barium swallow revealed severe oropharyngeal dysphagia leading to thyroid fine-needle aspiration of both thyroid lobes by interventional radiology and subsequent urgent incision and drainage (I&amp;D) of the right neck and thyroid biopsy under general anesthesia by ENT. I&amp;D showed purulent drainage from the thyroid. Cultures were positive for MRSA. Surgical pathology reported a necrotic muscle and abscess and fragment of thyroid tissue. Thyroid function tests (TFTs) on admission revealed a TSH 0.31 mcIU/ml (reference: 0.30 - 5. 0 mcIU/ml) and a free T4 of 2.21 ng/dl (reference: 0.76- 1.46 ng/dl) and repeat TFTs with a TSH of 0.30 mcIU/mL, free T4 of 1.87 ng/dL, free T3 of 2.15 pg/ml (reference: 2.18- 3.98 pg/ml), consistent with sick euthyroid syndrome. TPO and TSI were negative. Subsequently, the patient's fever resolved, and the neck swelling improved. He continued IV vancomycin for a month. TFTs six weeks later showed an elevated TSH of 13.10 mcIU/ml and normal free T4 of 1. 03 ng/dl. Conclusion MRSA suppurative thyroiditis is rare, and its diagnosis may be delayed due to its indolent course, especially in immunocompromised patients. Therefore, a high index of clinical suspicion is needed for this endocrine emergency in a patient presenting with fever and neck swelling. While an early FNA of the thyroid is likely to aid in diagnosing thyroid infection, TFTs may be variable and not helpful. Presentation: No date and time listed

LBSAT290 Papillary Thyroid Cancer Discovered After Benign Afirma Gene Testing, A Case Report

Abstract Introduction Grave's disease is an autoimmune form of hyperthyroidism characterized by antibody stimulation of the thyrotropin receptor. Although there are conflicting study results, patients suffering from Grave's disease appear to have an increased incidence of thyroid cancer. Fine needle aspiration helps detect potential carcinoma, however, it is indeterminate in 15-30% of cases. In cases where fine needle aspiration of a thyroid nodule returns Atypia of Undetermined Significance (AUS) or Follicular Lesion of Undetermined Significance (FLUS), next-generation sequencing, including Afirma gene testing (created by Veracyte inc) provides guidance for therapy. However, like any screening test, the chance for false negatives still exists. We describe the case of a 41-year-old man suffering from Grave's disease with a solitary thyroid nodule which was found to be papillary thyroid carcinoma despite benign Afirma gene testing. Case description A 41-year-old male with no past medical history presented to his primary care provider with no active complaints but was found to have a blood pressure of 142/92 mmHg. He notably had a diffusely enlarged thyroid gland on examination. The patient was sent for thyroid function testing which demonstrated TSH: &amp;lt; 0. 01 uIU/ml and a free T4: 1.1 ng/dL. The patient was sent for a thyroid ultrasound which demonstrated a right-sided nodule measuring: 3.5 cm×2.4 cm×3.2 cm (TI-RADS 4). Radioactive idodine uptake scan revealed this was a cold nodule and the patient underwent fine-needle aspiration biopsy and Afirma gene testing. The patient's biopsy demonstrated AUS while Afirma gene testing was benign. After discussing treatment options for Grave's disease with his endocrinologist, the patient underwent total thyroidectomy. Post-surgical biopsy of the patient's thyroid demonstrated follicular variant papillary thyroid carcinoma with capsular invasion. The patient is currently being followed closely by endocrinology with regular TFT and thyroglobulin testing. Discussion Grave's disease is postulated to increase patients’ risk of developing papillary thyroid cancer. Many of the proposed hypotheses explaining this higher risk center around thyroid-stimulating antibodies promoting tumor invasion and angiogenesis. When these patients demonstrate suspicious thyroid nodules on imaging, they undergo fine-needle aspiration, however, these biopsies are indeterminate in 15-30% of cases. Afirma gene testing has been proposed as a sensitive test to rule out carcinoma in these indeterminate cases. We describe a case where, despite benign Afirma gene testing, the patient was found to have papillary thyroid cancer after thyroidectomy. We propose that Grave's disease patients with suspicious nodules with indeterminate biopsy and benign Afirma testing still be considered for total thyroidectomy given their increased risk of thyroid cancer. Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.

PSAT371 Thyroid Ultrasound, Biopsy and Cancer in a US Veteran Population

Abstract Background Thyroid cancer is a common malignancy and has an increasing incidence. The most common demographic is young adult women with papillary thyroid cancer, which constitutes about 75% of the disease. The decision to perform a fine needle aspiration biopsy of a thyroid nodule is based on the ultrasound appearance of the nodule. Both the American Thyroid Association and the American College of Radiology have systems by which to grade these nodules such that the risk of malignancy is predicted and biopsy is recommended. Methods We reviewed the medical records of all patient undergoing evaluation of a thyroid nodule at the Oklahoma City US Department of Veterans Affairs Medical Center. We recorded results of the biopsy as well as ultrasound findings and surgical pathology. Results Among 162 subjects undergoing evaluation of a thyroid nodule, 81% were men and average ago was &amp;gt;60 years. Only 7 of the 162 had a malignancy diagnosed. Neither age, sex, nor nodule size was associated with malignancy. All with malignancy had a TiRADS score or either 4 or 5 on ultrasonic study of the thyroid, but only a minority of TiRADS 4 (3.6%) or TiRADS 5 (5.5%) had thyroid cancer. Punctate calcium was found in 6 of the 7 with thyroid cancer and was the only finding statistically associated with malignancy. No patient with a Bethesda Classification of III or IV had malignancy Conclusion The presently available estimates of cancer using thyroid ultrasound are based on a general population are not applicable to this older, predominantly male population. Determination of the need for biopsy and surgery for thyroid nodules should take age and sex into account. Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.

ODP469 Coexistence of two thyroid malignancies with Hurthle cell and Papillary thyroid carcinoma

Abstract Background The simultaneous presentation of mul tiple thyroid malignancies is a rare occurrence with each type of thyroid cancer having different cellular origins, histopathological appearance, and clinical course. Collision tumors representtwo histologically different tumor types occurring at the same anatomic region. When diagnosed within 6 months of the original they are also referred to as synchronous tumors. Papillary thyroid carcinoma (PTC) is the most common (80-85%) differentiated thyroid carcinomas (DTC), followed by follicular thyroid carcinoma (FTC) (10-15%), and Hurthle cell carcinoma (3–5%). We report a rare case of a patient with dual thyroid malignancy containing both PTC and Hurthle cell carcinoma in different thyroid lobes. Case presentation Patient is a 50 year old female with past medical history of hypertension and family history of thyroid disease in her sister and cousins, who presented with thyroid gland enlargement. Patient denied any hyper/hypothyroidism or compressive symptoms. Labs showed normal TSH and free T4. Thyroid ultrasound revealed a heterogeneous nodule with microcalcification in the right thyroid lobe and three well circumscribed left mid pole nodules. FNA thyroid biopsy of the right thyroid nodule demonstrated many Hurthle cells with uniform nuclei. The genomic classification identified multiple chromosomal copy number alterations consistent with a clonal neoplasm with intermediate-high risk for cancer, although no point mutations or gene fusions were found. Patient initially underwent right hemi-thyroidectomy and isthmectomy. Pathology confirmed two well circumscribed angioinvasive Hurthle cell carcinoma measuring 3.4×2.1×2. 0 cm and 1.6×1.5×1.4 cm with multiple foci of capsular invasion oncocytic features along with a 0.2 cm papillary thyroid microcarcinoma without extrathyroidal extension. After three weeks, patient proceeded with completion left thyroidectomy and showed a 1.2×1.1×1. 0 cm well circumscribed, partially encapsulated nodule, consistent with Papillary thyroid carcinoma (PTC). Lymph nodes were negative for metastasis. Patient received whole body I-131 scan and radioiodine ablation therapy. She was subsequently placed on Levothyroxine for thyroid hormone replacement and remained euthyroid without cancer recurrence. Conclusion Collision tumors account for 1% of thyroid malignancies with the most commonly reported combination being PTC and medullary thyroid carcinoma. Interestingly, this case presented with a rare finding of collision and synchronous tumors in the form of PTC and Hurthle cell carcinoma which was known to associate with increased chromosomal copy number instead of point genetic mutation. Previous literature have described collision effect, stem cell, hostage, and single progenitor theories in an attempt to explain the origin of these phenomena with possible molecular mechanisms. Clinicians should be aware that the dual thyroid malignancy with different histogenetic origin may co-exist in the same patient. The therapeutic strategy should be tailored based on each thyroid cancer variant with correlated biological behavior, clinical and genetic features. Presentation: No date and time listed

RF11 | PSAT274 A Dramatic Response of a Thyroid Lymphoma to R-CHOP Chemotherapy Reversing Mechanical Airway Obstruction and Respiratory failure, A Case Report

Abstract Introduction Primary thyroid lymphoma is extremely rare and accounts for &amp;lt;5% of all thyroid malignancies, with an estimated incidence of 2 per 1 million each year. It usually occurs in patients with preexisting Hashimoto thyroiditis and commonly presents between 60 to 70 years. Almost all thyroid lymphomas are non-Hodgkin's lymphoma of B-cell origin, with diffuse large B-cell lymphoma being the most common subtype. Chemotherapy and radiotherapy are the primary treatment of thyroid lymphomas. This case report shows a dramatic response to chemotherapy in a patient with mechanical airway obstruction due to large thyroid lymphoma, which facilitated her extubation. Case Presentation An 83-year-old woman with a past medical history significant for type 2 diabetes, coronary heart disease, and hypothyroidism controlled on L-thyroxine replacement therapy was presented with 3 months history of gradually progressive dysphagia. It was associated with left-sided neck pain with swallowing, choking on food, and shortness of breath. She denied fever, chills, or excessive sweats. Local examination of her neck revealed a large firm thyroid mass associated with left cervical lymphadenopathy. Her CT neck scan with intravenous contrast showed an enlarged, probably malignant thyroid gland with marked amount of adjacent pathologic lymph nodes and marked transverse narrowing of the trachea to approximately 8.6 mm with no retrosternal extension. Also, Her CT abdominal scan with intravenous contrast showed a 3.6 cm lesion of the medial right hepatic lobe (segment 8) concerning for metastases. The patient underwent an ultrasound-guided thyroid biopsy, and the results confirmed the diagnosis of diffuse large B cell lymphoma of the neck and thyroid. A few days later, the patient experienced respiratory distress and failure secondary to mechanical airway obstruction that required urgent intubation and mechanical ventilation. The discussion among different specialties, including general surgery, concluded that the patient was not a candidate for surgical intervention or tracheostomy, and recommendations were to proceed to palliative chemotherapy. She started R-CHOP chemotherapy (Rituximab, Cyclophosphamide, Doxorubicin, Vincristine, and Prednisone), followed by a marked reduction in the thyroid size and relieving of the tracheal compression on the following CT neck scan. Her condition dramatically improved, and she was extubated after 5 days of receiving the first cycle of R-CHOP chemotherapy. Conclusion Our case report demonstrates dramatic reversal of mechanical airway obstruction caused by a thyroid lymphoma within a few days of initiation of R-CHOP chemotherapy. These cases are usually considered terminal and do not undergo aggressive surgical interventions. R-CHOP chemotherapy needs to be considered in these cases before considering hospice care. Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m., Saturday, June 11, 2022 1:12 p.m. - 1:17 p.m.

PSAT337 Thyroid Storm Triggered by Thyroid Nodule Fine-Needle Aspiration Biopsy

Abstract Background Thyroid storm is a severe and life-threatening thyrotoxicosis precipitated by an acute event such as thyroid gland manipulation, infection, trauma, or an acute iodine load. Patients with known hyperthyroidism or low TSH with the presence of multinodular goiter should undergo radionuclide thyroid scan before deciding on fine-needle aspiration (FNA) biopsy. We present a case of a patient with history of multinodular toxic goiter disease, who had a thyroid storm after she underwent an FNA thyroid biopsy, requiring emergent total thyroidectomy. Clinical Case 62-year-old female patient with history of multinodular goiter (MNG) disease diagnosed in another country one year prior to admission. She was on methimazole for a few months but was off the medication upon presentation. She was admitted for evaluation due to worsening compressive symptoms. On presentation, she was hypertensive, tachycardic, with dysphonic voice and had a large goiter palpated bilaterally with extension over the sternocleidomastoid muscle. Laboratory results confirmed that she had thyrotoxicosis. TSH was 0.05 mclU/mL, n: 0.27-4.2mclU/mL; FreeT4 &amp;gt; 7.77 ng/dL, n: 0.93-1.70ng/dL; T3 was 552 ng/dL, n: 80-200 ng/dL; TSI and TRAB were elevated: 476 and 23 respectively. In view of this, methimazole 40 mg daily, prednisone 20 mg daily, cholestyramine 4 mg four times a day, potassium iodine 50 mg three times per day, and propranolol were started. Chest CT demonstrated a thyroid gland that was heterogeneous in appearance and markedly enlarged with a right thyroid lobe measuring approximately 6.2×5.8 cm and the left lobe measuring approximately 5.5×5.0 cm. Patient underwent ultrasound guided FNA biopsy of the right thyroid lobule ordered by another team two days after the medication regimen was initiated. One day after procedure, patient had altered mental status, stridor, acute respiratory failure, worsening of hypertension and tachycardia, requiring intubation. It was not possible to place an oral gastric tube, so propylthiouracil 400 mg was given via rectal route every 8 hours and her steroid dose was increased. Her FreeT4 decreased to 3.99 ng/dL and T3 to 165 ng/dL the following day. However, patient condition continued to deteriorate, and she underwent emergent total thyroidectomy, despite not being euthyroid. Patient tolerated the procedure and was able to be extubated the following day without postoperative complications. At the time of discharge, patient was on Levothyroxine 150 mcg oral daily. Conclusion FNA biopsy of toxic thyroid nodules are rarely indicated due to the risk of thyroid storm in patients with underlying hyperthyroidism. Control of the hyperthyroid state should be the priority prior to FNA of any thyroid nodule. Total thyroidectomy may be performed in the hyperthyroidism state as a life-saving procedure when there is failure control hyperthyroidism, as is the case here. Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.

The Significance of RAS-Like Mutations and MicroRNA Profiling in Predicting Malignancy in Thyroid Biopsy Specimens.

In cytologically indeterminate thyroid nodules undergoing molecular testing, estimated risk of malignancy is variable. Identification of a non-cancer-specific mutation (RAS-like) confirms a neoplastic process but does not differentiate between benign, malignant, and low-risk neoplasms. This study aims to retrospectively evaluate institutional experience of Interpace (ThyGeNEXT® and ThyraMIR®; Pittsburgh, PA) testing and to determine the rate of malignancy in resected nodules, stratified by mutational analysis and microRNA profile. Of 1917 fine need aspirations, 140 (7.3%) underwent Interpace testing: 47 (33.6%) were molecular-not-benign (harbored mutation, fusion, and/or positive miRNA) and 93 (66.4%) were molecular-benign (no mutations or fusions and negative microRNA). Surgery was spared in 79.6% of molecular-benign and 61.4% of all tested patients. Fifty-four (38.6%) underwent resection. Seventeen (89.5%) of the resected molecular-benign were benign and 2 were malignant. Thirteen (37.1%) of the resected molecular-not-benign were benign, 7 (20%) were noninvasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTP), and 15 (42.9%) were malignant (p < 0.05, negative predictive value (NPV) 89.4-95.6%, positive predictive value (PPV) 22.3-42.8%). Most molecular-not-benign (72.3%) had RAS-like mutation. Twenty-three were resected: 3 were malignant and 7 were NIFTP. Nodules with non-RAS-like mutations (BRAF V600E-like, others) were more likely to be malignant than RAS-like (H/N/KRAS, BRAF K601E) (p < 0.05, NPV 86.9-96.5%, PPV 100%). Most nodules had RAS-like mutations and most were benign or low-risk neoplasms (NIFTP). This study supports the role of histologic examination in the distinction of malignancy in RAS-like thyroid neoplasms and underscores the role of molecular testing in risk stratification, patient counseling, and operative management.

Thyroid functional state in children with duodenal ulcer

Background. Most experts agree that duodenal ulcers are much more common in children. In recent years, the research interest in the relationship between the thyroid system and duodenal ulcer processes has become evident. The purpose of the study is to investigate the thyroid functional state in children with duodenal ulcer. Materials and methods. The observation group consisted of 56 children aged 7 to 18 years with a verified duodenal ulcer and 15 healthy children. All pediatric patients underwent fibroesophagogastroduodenoscopy with a targeted thyroid biopsy and examination for the presence of the Helicobacter pylori bacterium, intragastric pH-metry, ultrasound examination of the abdominal cavity and thyroid gland; the concentration of thyroid hormones (thyroid-stimulating hormone, T3, T4) was also studied. Reliability was assessed using Student’s t-test. The difference was considered significant at p&lt;0.05. Results. The average age of children with duodenal ulcer was 13.1±3.1 years. In all age categories, duodenal ulcer occurred more often in boys— 58.9%. During an in-depth ultrasound examination, the structure of the thyroid gland in 52 (92.8%) children was homogeneous, in 4 (7.1%) individuals it was heterogeneous, but without nodular formations. Serum concentrations of thyroid-stimulating hormone and T3 in children with duodenal ulcer also did not differ from the average levels in children of the comparison group. At the same time, a decrease in the concentration of T4 was noted, which can be considered as a variant of euthyroid sick syndrome— the syndrome of reduced T4. The average serum level of T4 (32.67±3.84 nmol/l) was significantly lower (p=0.001) in children infected with Helicobacter pylori than in those without infection (39.45±4.23 nmol/l) and healthy individuals (89.12±5.91 nmol/l). Conclusions. Children with a duodenal ulcer have a violation of the thyroid status due to a decrease in the thyroxine concentration. A functional shift in the thyroid status in these patients can be considered as a prognostically unfavorable sign of possible deterioration of the ulcer course.

Malign ve benign tiroid nodüllerinin ayrımında ARFI elastografi

Aim: To examine the diagnostic performance of virtual touch tissue quantification (VTQ) mode of Acoustic Radiation Force Impulse (ARFI) elastography imaging in differentiating benign and malignant thyroid nodules. Materials and Methods: Two hundred four solid and mostly solid nodules &amp;gt;5mm were prospectively evaluated with ultrasonography, VTQ mode of ARFI elastography, fine needle aspiration biopsy, and when indicated with tissue pathology. Three shear-wave velocities (SWV) measurements were done in 196 nodules. The SWV ratio for each nodule was calculated as the mean value of the SWV of the nodule divided by the mean value of the adjacent parenchyma. The diagnostic performance of SWV value and SWV-ratio were assessed by a receiver-operating characteristic (ROC) curve analysis. Results: The mean SWV value in the normal parenchyma, in benign and malign thyroid nodules, were 2.13±0.44 m/s, 2.06±0.80 m/s, and 2.06±0.88 m/s respectively. The SWV-ratios were 0.97±0.37 for benign thyroid nodules and 1.02±0.40 for malignant thyroid nodules. There was no significant difference between benign and malign nodules in terms of mean SWV values (t=0.008) (P=0.994) or SWV-ratios (t =0.596; P=0.527). No cut-off point was found to predict malignancy. In subgroup analysis, AUCs for the SWV and SWV-ratio were significantly different between nodules ˂10 mm and those ≥10 mm, but not with any other two groups (all P&amp;gt;0.05) (Table-2). The cutoff points for the differential diagnosis were 2.59 m/s for SWV and 1.0 for SWV- ratio respectively for nodules &amp;lt;10 mm. Conclusion: VTQ mode of ARFI imaging does not have a good diagnostic performance for detecting malignancy and cannot contribute to reducing unnecessary thyroid biopsies.