Thyroid Biopsy Research Articles

Thyroid nodule core needle biopsy - current approach.

Fine needle aspiration biopsy (FNAB) guided by ultrasonography is routinely used to identify thyroid nodules prior to surgery. Although FNAB has great diagnostic accuracy and safety, it is limited by its relatively low diagnostic accuracy in follicular lesions, such as non-diagnostic or atypia of unclear significance (AUS)/follicular lesion of uncertain significance (FLUS). Additional diagnostic tests are required to overcome these challenges in evaluating thyroid nodules. Thyroid nodules can now be diagnosed with spring-activated single- or double-action needles following the introduction of core needle biopsy (CNB). CNB has the ability to address the limitations of FNAB by obtaining a sizeable tissue sample with more details on the histological structure supporting the capsule and fewer non-diagnostic effects brought on by the absence of follicular cells. Compared to repeated FNAB, CNB has been demonstrated to produce fewer ambiguous results, such as non-diagnostic or AUS/FLUS results. The Korean Endocrine Pathology Thyroid CNB Working Group issued its first set of guidelines for "Pathology Reporting of Thyroid Core Needle Biopsy" in 2015. In 2017, the Korean Society of Thyroid Radiology (KSThR) published "Core Needle Biopsy of Thyroid: 2016 Consensus Statement and Recommendations from the Korean Society of Thyroid Radiology". The main objectives of thyroid CNB are to detect individuals with thyroid illness who require surgery and to obtain a significant number of thyroid lesions with low morbidity.

Next Level of Care Protocols in Radiology: Improving Patient Access to Care

ObjectiveTo introduce a novel next level of care (NLC) protocol used in our breast imaging practice to bypass additional imaging and image-guided biopsy orders and to examine the impact of NLC on breast biopsy wait times compared with thyroid biopsy wait times, which do not use NLC. MethodsOur institutional review board deemed this retrospective analysis to be exempt. NLC was implemented for breast imaging in late 2014. Two 6-month periods before and after the COVID-19 shutdown were sampled and compiled. Data were queried from departmental database and electronic health record for all breast and thyroid biopsies during this time. Time to biopsy (TTB) was defined as the number of days from the diagnostic imaging evaluation recommending the biopsy to the completion of the biopsy. To determine the effect of NLC, TTB was compared between breast and thyroid biopsies. ResultsOf the 1,114 breast biopsies and 154 thyroid biopsies included, the mean TTB was 9 days (95% confidence interval 8.4-9.3) for breast and 23 days (95% confidence interval 20.5-25.0) for thyroid. There was a 61% reduction in the mean TTB for patients in the breast group compared with patients in the thyroid group. The effect of the NLC was comparable among different races and ethnicities in the breast group, but a significantly higher mean TTB (24% higher, P = .025) was observed for thyroid biopsies in Black patients compared with thyroid biopsies in Hispanic patients. ConclusionNLC protocol facilitates imaging evaluations and reduces the time interval to image-guided biopsies.

FRI522 Impact Of TIRADS Score On Thyroid Nodule Biopsy

Abstract Disclosure: U.B. Adeniran: None. A. Olabumuyi: None. O. Adeniran: None. G. Bahtiyar: None. G. Rodriguez: None. Introduction: Thyroid nodules are prevalent, however many thyroid nodules biopsied are benign. In 2017, the Thyroid Imaging Reporting and Data systems Committee of the American college of Radiology (TI-RADS) presented the use of TI-RADS score to risk stratify nodules to TR1 to TR5 with recommendations on biopsy vs follow up. The aim of our study was to ascertain any changes in thyroid biopsy rate before and after the use of ACR TI-RADS in thyroid ultrasound scans in a community hospital in Brooklyn, NY. Methods: We conducted a retrospective single center observational cohort study on patients referred for thyroid nodule assessment between March 2019 - March 2020 & March 2021 - March 2022. Inclusion criteria- all patients with thyroid ultrasound scans without TI-RADS scoring from March 2019- March 2020, all patients with TI-RADS scoring from March 2021-March 2022. Duplicate referrals, patients lost to follow up, incomplete records were excluded. Primary endpoint was to ascertain any differences in thyroid biopsy recommendation rate before and after the use of TI-RADS score in ultrasounds. Chi square test was used to determine the association between TI-RADS use in ultrasound scans and thyroid biopsy recommendation rate. Thyroid nodules were categorized based on the Bethesda System for Reporting Thyroid Cytopathology (BSRTC). Results: A total of 91 patients met the inclusion/exclusion criteria, 13 men and 78 women (M:F- 1:6). Thyroid nodules of 53 patients on ultrasound were reported using TI-RADS score and 38 patients without using the TI-RADS score. TI-RADS group and non TI-RADS group were similar in age, gender, race, and ethnicity. The use of the TI-RADS reporting system was associated with a statistically significant reduction in recommendation for biopsy. Only 26.4% of the patients who had TI-RADS were recommended for biopsy compared to 47.4% of the patients who did not have TI-RADS (P-Value 0.039).A total of 32 patients were recommended for biopsy, however biopsy was done in 26 patients. Majority of the nodules biopsied were benign (BSRTC II), 10 of 14 patients (71.5%) were benign (BSRTC II) in Non TI-RADS group, and 8 of 12 (66.7%) were benign (BSRTC II) in TI-RADS group. Conclusion: TI-RADS score significantly reduced the biopsy recommendations. Its implementation thus results in saving the Healthcare commission a significant cost of unnecessary biopsy in the region of $1,999 per biopsy. With the implementation of TIRADS, the proportion of malignant biopsies was expected to rise. However, there was no significant difference in this group. This may be because the total number of biopsies analyzed was small. It could also be that some of the nodules the TIRADS score did not recommend for biopsy may have been malignant. Further studying of a larger cohort is thus warranted. Presentation: Friday, June 16, 2023

SAT473 First Case Of Diffuse Thyroid Lipomatosis With Amyloid Deposits Presenting With Hyperthyroidism

Abstract Disclosure: A.M. Gonzalez Gil: None. M.A. Ruiz Santillan: None. H. Quadri: None. B.K. Force: None. R. Gaba: None. Background: Diffuse thyroid lipomatosis (DTL) is an exceedingly rare entity of unknown etiology which can be associated with amyloidosis. It generally presents with euthyroidism but very few cases with hyperthyroidism have been reported. Clinical Case: A 64-year-old woman from Pakistan with a several-year history of a non-tender goiter presented to the emergency department with an upper respiratory and gastrointestinal viral syndrome in the context of several weeks of progressively worsening fatigue. She also reported unintentional weight loss over several years. She denied other hyperthyroid or compressive symptoms. Her exam was notable for resting sinus tachycardia and an approximately 100 gm painless goiter. Laboratory evaluation was notable for a markedly elevated creatinine with nephrotic range proteinuria. She was declared to have end stage renal disease (ESRD) and hemodialysis was initiated. She was also found to have a suppressed TSH (<0.01 uIU/mL, NR=0.45-5.33) and elevated FT4 (2.17 ng/dl, NR=0.64-1.42). Total T3 was low (42 ng/dl, NR=87-178), which was attributed to hypoalbuminemia and altered peripheral thyroid hormone metabolism with underlying ESRD. Further evaluation revealed elevated ESR, CRP and thyroglobulin levels (625.9 ng/mL, NR=1.5-38.5), while thyroid stimulating immunoglobulin, thyroid receptor antibodies and thyroid peroxidase antibodies were undetectable. A thyroid ultrasound revealed an enlarged fatty thyroid consistent with DTL. A radioactive iodine uptake scan revealed normal 24-hour uptake (14.1%, NR=7-32%) in a slightly heterogeneous thyroid with no aberrant functioning thyroid tissue. She was started on atenolol, with significant improvement in her tachycardia, but her FT4 continued to increase. Methimazole was initiated. Dose uptitration and administration after dialysis resulted in near-normalization of FT4 levels. She subsequently underwent renal and thyroid biopsies, both of which showed apple green birefringence under polarized light with Congo Red stain, indicating amyloidosis. Core thyroid biopsy additionally showed benign adipose tissue with entrapped thyroid follicles, confirming concomitant DTL. Although other authors have found thyroid amyloid deposits in DTL, and yet others have reported hyperthyroidism in DTL without amyloidosis, this is the first reported case of hyperthyroidism in a patient with DTL with amyloid deposits. Interestingly, chronic hypoxia in amyloid goiters has been hypothesized to cause fibroblast-to-adipocyte metaplasia leading to DTL. We speculate that excess thyroid hormone release could also be mediated by follicular cells’ response to hypoxia induced by amyloid and fatty infiltration of the thyroid. Conclusion: To the best of our knowledge, this is the first reported case of diffuse thyroid lipomatosis with amyloid deposits to be associated with concurrent hyperthyroidism. Presentation Date: Saturday, June 17, 2023

SAT480 Diagnosing Dysphagia Due to Thyroid Nodules by Thyroid Ultrasound and the Effectiveness of Radiofrequency Ablation

Abstract Disclosure: Z. Idrees: None. M. Morkos: None. Objective: Thyroid nodules can cause dysphagia by direct esophageal compression. Diagnosis of esophageal compression during thyroid ultrasound has not been described. Radiofrequency ablation of thyroid nodules may be able to treat the compressive symptoms. Methods: We present a case series of four patients who presented with dysphagia due to compressive nodular goiter. Thyroid ultrasound was performed by a certified endocrinologist (Endocrine Certification in Neck Ultrasound) who assessed esophageal compression. Nodules were treated with thyroid radiofrequency ablation (RFA). Symptom score, ranging from zero (no symptoms) to ten (severe symptoms), was used to assess the severity of dysphagia before and one month after the procedure. Results: We report four patients who presented with symptomatic thyroid nodules, complaining of dysphagia at the level of the lower neck. Initial symptom scores were 10, 7, 8, and 2 respectively. Thyroid ultrasound demonstrated esophageal compression in all patients due to the culprit responsible nodules and two thyroid biopsies were done to rule out malignancy. Three patients declined surgery and preferred RFA, while the fourth was a poor surgical candidate. RFA was conducted in each by one endocrinologist. The culprit nodules were targeted for RFA, except in case two which was retrosternal. Therefore, a more superficial same-sided nodule was ablated in case two with the goal of reducing mass effect on that side. All the patients reported improvement in their dysphagia and decline in symptom score a month after the procedure to 0, 4, 2, and 0 respectively. Thyroid US demonstrated improvement of esophageal compression one-month after the procedure. No complications were noted. Conclusion: Thyroid ultrasound is a valuable tool in diagnosing dysphagia due to esophageal compression caused by thyroid nodules and in monitoring the response to therapy. Thyroid RFA is a minimally invasive and effective tool for treating symptomatic thyroid nodules. Presentation Date: Saturday, June 17, 2023

SAT566 A Rare Case Of Aggressive Anaplastic Thyroid Presenting As Thyrotoxicosis

Abstract Disclosure: A. Al-Juboori: None. Y. Al-Yousif: None. S. Fomin: None. M. Sundaram: None. Background:Anaplastic Thyroid cancer is a rare neoplasm with a poor prognosis and high mortality rate. Usually, it presents with symptoms like dysphagia and hoarseness. However, it is rarely presented with thyrotoxicosis from the rapid destruction of thyroid follicle cells, causing excessive leakage of preformed thyroid hormones into the circulation. Clinical presentation can vary from a subclinical state to a life-threatening thyroid storm. Management requires an inter-professional team approach. Clinical Case:77-year-old female patient, who visited the urgent care on August 12 complaining of sore throat, Amoxicillin was prescribed. Presented to ER 10 days later complaining of a headache, gum discomfort, shortness of breath, worsening sore throat, neck pain, and gradual worsening dysphagia to liquids and solids. Physical exam revealed anterior painful and firm neck mass upon palpation. Stridor was noted upon auscultation and was found to be in arterial fibrillation with a rapid ventricular rate for which Amiodarone drip and heparin drip were initiated. IV hydrocortisone 50 mg TID was added to the treatment right away for symptomatic relief. The results of the thyroid function test revealed an increased serum FT4 and FT3, and low serum TSH. Antibodies were normal. Clinical presentation increases the suspicion of undifferentiated thyroid cancer versus lymphoma. CT revealed leftward tracheal deviation along with a big undetermined right thyroid mass with accompanying cervical and supraclavicular adenopathy. IR was consulted urgently for a thyroid biopsy. High-grade anaplastic cancer was discovered after a biopsy with metastasis to the surrounding lymph. The decision was made to transfer the patient to a tertiary care facility for invasive interventions. Anaplastic thyroid cancer accounts for 2-3% of all thyroid gland neoplasm, it often affects persons over the age of 60, and the mean age at the time of diagnosis is 65 years, most common in female population compared to males with a ratio of 2:1. There have been only around 9 other cases reported in the literature in which thyrotoxicosis is the initial presentation of anaplastic thyroid cancer. Diagnosis is usually made via core needle biopsy. 70% of individuals with anaplastic thyroid carcinoma will have contiguous spread and distant metastasis at the time of diagnosis. It most commonly compresses the trachea and esophagus. Given the rapid progression of illness, patients can die from local airway obstruction. Average survival is just 6 months with only 1 in 5 people surviving after 12 months. Conclusion:Anaplastic thyroid cancer-induced thyrotoxicosis is an uncommon and rare presentation of thyroid neoplasm. Debulking surgery is the cornerstone for removing tumors and securing the patient’s airway along with controlling thyrotoxicosis. A low survival rate was reported in these patients. Presentation: Saturday, June 17, 2023

SAT476 A Case of Thyroid Hemiagenesis

Abstract Disclosure: P. Kachhadia: None. S. Khan: None. S. Aldasouqi: None. A. Abu Limon: None. Introduction: Thyroid hemiagenesis is congenitally rare, in which one side of the thyroid does not develop. Hemiagenesis is more common with an absent left thyroid lobe, at a 4:1 ratio. Though prevalence is sited at 0.05%, actual incidence of hemiagenesis amongst the population is unknown as most patients are euthyroid and asymptomatic. We present a case of a patient who was referred to our clinic for unilateral thyroid enlargement on physical exam. Thyroid Ultrasound (US) was done which showed an absent left thyroid lobe along with enlarged right thyroid lobe and hypervascularity. There was also an incidental thyroid nodule noted on US. Case Presentation: Patient is a 38 year old female who presented to the clinic 4 years prior for enlarged thyroid nodule noted on ultrasound. With symptoms of dysphagia and a visibly enlarged gland, an US with labs was prompted by her primary physician. US showed absent left thyroid lobe and right lobe enlargement with hypervascularity and incidental subcentimeter nodule. Clinically and biochemically, the patient was euthyroid. Singular right lobe was verified on clinic real time ultrasound and on NM uptake scan. The 24 hour uptake was at 30.5%, with the upper limit of normal being 30%. With increased uptake and hypervascularity, thyroid stimulating immunoglobulin and thyrotropin receptor antibodies were checked and were not detected. It was thought that the right thyroid gland enlargement and hypervascularity were compensatory due to the left hemiagenesis. The thyroid nodule was monitored, and within 3 years of original imaging, it enlarged to 0.98 x 0.59 x 0.39 cm, with TI-RADS 5 assessment per ACR criteria. Patient chose to undergo thyroid biopsy which showed Bethesda III, Follicular Lesion of Undetermined Significance (FLUS). Microscopy showed follicular cells arranged in microfollicles and crowded groups with round, enlarged, irregular nuclei and overlapping nucleoli. Intranuclear chromatin clearing and intranuclear grooves are present. Background is hemorrhagic with minimal colloid. Molecular Thyroseq testing was at 5-10% chance of malignancy or noninvasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTP). Genetic markers were only positive for copy number alterations. Discussion: Thyroid Hemiagenesis, though rare, has been associated with other thyroid pathologies such as hypothyroidism, hyperthyroidism and thyroid malignancies. Genetic studies have not found a common background within cases reported. As these patients are more likely to incur additional thyroid pathologies, questions still remain as to the clinical management and outcome of such patients. Due to concerning cytological features for PTC, the patient was offered right thyroidectomy and will be looking to make a decision in the near future. Presentation Date: Saturday, June 17, 2023

Drivers of Thyroid Ultrasound Use: A Retrospective Observational Study

ObjectiveExcessive use of thyroid ultrasound (TUS) contributes to the overdiagnosis of thyroid nodules and thyroid cancer. In this study, we evaluated drivers of and clinical trajectories following TUS orders. MethodsWe conducted a retrospective review of 500 adult patients who underwent an initial TUS between 2015 and 2017 at Mayo Clinic in Rochester, MN. A framework was employed to classify the indication for TUS, and it was characterized as inappropriate when ordered without a guideline-based indication. Medical records were reviewed for up to 12 months following the TUS, and clinical outcomes were evaluated. ResultsThe mean age mean age (SD) was 53.6 years (16.6), 63.8% female, and 86.6% white. TUS orders were triggered by incidental findings on unrelated imaging (31.6%), thyroid symptoms (20.4%), thyroid abnormalities on routine physical examination (17.2%), and thyroid dysfunction workup (11.8%). In females and males, the most common reason were incidental findings on imaging (female, 91/319, 28.5% and male, 67/181, 37.0%). In primary care practice, TUS orders were mostly triggered by symptoms (71/218, 32.5%), while thyroid dysfunction workup was the primary reason in endocrinology (28/100, 28.0%). We classified 11.2% (56/500) TUS orders as likely to have been ordered inappropriately based on current guidelines. Finally, 119 patients (119/500, 23.8%) had a thyroid biopsy with 11.8% had thyroid cancer (14/119. 11.8%). ConclusionsIncidental findings on imaging, symptoms, and routine physical exam findings in asymptomatic patients were the most prevalent drivers of TUS. Furthermore, 1 in 10 TUS were likely inappropriately ordered based on current practice guidelines.

Features of Ultrasound Imaging of Different Types of Thyroid Calcifications and their Association with Cancer Risk

The features of multiparametric ultrasound imaging different types of thyroid calcifications and its significance in cancer risk stratification were studied on the material of 932 patients referred for thyroid biopsy. It has been established that calcification in the thyroid gland is represented by macrocalcifications, microcalcifications, calcified capsules and fully calcified nodules with characteristic ultrasonic features. MicroPure technology was determined to improve visualization of microcalcifications, differentiate them from other hyperechogenic point structures, but was ineffective for other types of calcifications. The frequency of microcalcification in thyroid nodules is significantly associated with the risk of their malignancy, but can be detected in benign nodules and in intact parenchyma; for other types of calcifications, the dependence on the risk of malignancy is either absent or not linear. The frequency of microcalcification in thyroid nodules is significantly associated with the risk of their malignancy, but can be detected in benign nodules and in intact parenchyma; for other types of calcifications, the dependence on the risk of malignancy is either absent or not linear. Thus, ultrasound assessment of thyroid nodule calcification using MicroPure technology allows us to stratify their oncologic risk, which can be used in the choice of further patient management tactics.

Gastroesophageal reflux disease and risk of cancer: Findings from the Korean National Health Screening Cohort.

Little is known about the association of cancers other than esophageal adenocarcinoma with gastroesophageal reflux disease (GERD). This study aimed to examine the association between GERD and the risk of different types of cancer. A cohort study was conducted using data from the National Health Screening Cohort. We included 10,261 GERD patients and 30,783 non-GERD individuals who were matched in a 1:3 ratio by age and sex. All participants were followed-up until cancer diagnosis, death, or end of the study (December 31, 2015). Hazard ratios were calculated using the Cox proportional hazards model, adjusting for smoking and alcohol consumption, physical activity, body mass index, income, area, and Charlson Comorbidity Index. The median follow-up time was 9.9 years. GERD was associated with an increased risk of esophageal (adjusted hazard ratios [aHR] = 3.20 [1.89-5.41]), laryngeal (aHR = 5.42 [2.68-10.96]), and thyroid cancers (aHR = 1.91 [1.55-2.34]) after controlling for all covariates. The results were consistent when examining GERD with esophagitis (K210) and without esophagitis (K219) separately. For thyroid cancer, the results were insignificant after controlling for having ever-received thyroid biopsy procedures. A dose-response relationship was found between GERD and esophageal cancer as well as laryngeal cancer, with patients with a longer duration of GERD treatment showing a stronger effect. In contrast, GERD was associated with a reduced risk of colorectal (aHR = 0.73 [0.59-0.90]), liver (aHR = 0.67 [0.51-0.89]), and pancreatic cancers (aHR = 0.43 [0.24-0.76]), which might have resulted from differences in healthcare utilization between GERD and non-GERD groups. GERD was associated with an increased risk of esophageal and laryngeal cancers. Additionally, early detection and treatment of precancerous lesions among the GERD group could lead to a lower risk of colorectal, liver, and pancreatic cancers.

Parenchymal microcalcifications in the thyroid gland: Clinical significance and management strategy.

This study is firstly, to investigate the presence of microcalcification among the patients who underwent thyroid ultrasound and biopsy and to evaluate the incidence of intrathyroid lymphatic spread and cervical lymph node metastasis of thyroid cancer with thyroid microcalcifications. Also, we compared the diagnostic performance between fine needle aspiration (FNA) and core needle biopsy (CNB) for assessing parenchymal microcalcifications in the thyroid gland. We retrospectively assessed total 66 patients with thyroid microcalcifications on ultrasound. The histopathologic characteristics of the surgical specimens considered as the gold standard for diagnosing malignancy. Patients with surgically proven malignancy were evaluated for multifocality, intrathyroid lymphatic spread in the opposite lobe, or cervical lymph node metastasis. Among the 66 confirmed patients, 53 patients had malignant lesions (80.3%) and 13 patients had benign lesions (19.7%). The pathologic results of the 44 patients who underwent total thyroidectomy. Among them, 33 patients (75%) showed multifocality, 30 patients (68.2%) showed intrathyroid lymphatic tumor spread. CNB was performed on 41 patients, and FNA was performed on 54 patients. Both CNB and FNA were performed on 29 patients. There were no statistical differences in terms of diagnostic performance between CNB and FNA. Thyroid microcalcifications demonstrate a high prevalence of malignancy. Both CNB and FNA demonstrate similar diagnostic accuracies.

Coexistence of Slipped Capital Femoral Epiphysis and multiple endocrine neoplasia type 2B (MEN2B) - a case report

Introduction: MEN 2B syndrome is distinguished by the occurrence of medullary thyroid cancer, pheochromocytoma, mucosal neuromas, marfanoid features, and skeletal anomalies, including kyphoscoliosis, joint laxity, pes cavus, and, in a smaller number of cases, slipped capital femoral epiphysis (SCFE).
 Case report: We describe a case report of a 15-years-old patient with the diagnosis of the MEN2B syndrome with a rare manifestation of Slipped Capital Femoral Epiphysis (SCFE). A 15-year-old female presented to the orthopedics out-patient department (OPD) with complaints of pain around the right hip and knee and walking with a limp for approximately four months. Additionally, the feeling of enlarged thyroid gland was reported. X-ray confirmed the presence of the SCFE, while thyroid biopsy revealed the presence of medullary thyroid cancer (MTC). Thus, the diagnosis of MEN2B was made.
 Conclusion: Slipped capital femoral epiphysis (SCFE) can occasionally be a manifestation of MEN 2B syndrome. It is important for physicians to be aware of this association, as it can contribute to the early detection of a potentially life-threatening condition.

State of the art of thyroid pathology: FNA diagnostic accuracy in an intermediate center in Ibagué

Background: In Colombia, thyroid cancer is the 7th cancer in incidence and mortality for both sexes. Currently the fine needle aspiration (FNA) is the most used method for studying nodular lesions of the thyroid.
 Objective: Describe the characteristics of a sample of surgical specimens in a histopathological diagnostic centre located in an intermediate city, correlate characteristics of PTC variants and calculate diagnostic accuracy for FNA
 Materials and methods: In this retrospective study pathology report data was gathered from a diagnosis centre, information was included from patients who underwent thyroid biopsy or resection between years 2015 to 2022, with a total of 495 cases, information was gathered, and a statistical analysis was performed.
 Results: a higher frequency for all thyroid pathologies in patients younger than 55 years of age. In men papillary carcinoma (PTC) was the most frequent diagnosis (42.7%) while in women it was hyperplasia (39.1%). From all diagnoses of PTC (n=233)77.6% had an additional diagnosis. Cases with previous FNA, 65.3% of which had a Bethesda score of II to IV and 30.5% of those had a definitive diagnosis of carcinoma.
 Conclusions: There is coexistence of benign thyroid diseases and PTC. FNA is essential for the initial histopathological study of thyroid lesions, however it has multiple factors that may affect its diagnostic accuracy.

Should encountering atypia of undetermined significance / follicular lesion of undetermined significance after thyroid biopsy lead to the operation?

Objectives: Nodular goiter is the most common disease of the thyroid gland. Thyroid nodules are malignant in 3-5% cases. To determine the incidence of malignancy in patients defined as atypia of undetermined significance (AUS) or follicular lesion of undetermined significance (FLUS) as a result of fine needle aspiration biopsy (FNAB) and evaluate the clinical, biochemical and sonographic features as possible predictors of malignancy. Methods: Patients who had undergone at least one FNAB and diagnosed as AUS/FLUS from January 2011 to December 2015 were included in the study. Age, gender, benign disease, thyroid stimulating hormone (TSH) level, size, localization, number, time of FNAB, ultrasonography (USG) characteristics, follow-up data on repeated FNAB results and, if surgical excision was performed, final pathological results were analyzed. Results: A total of 5181 thyroid nodules were biopsied in 4089 patients, and the biopsy specimen taken from 611 nodules was diagnosed histopathologically as AUS/FLUS (11.79%). After FNAB, 167 of 611 patients diagnosed with AUS/FLUS were operated. While 65.9% (n = 110) of 167 patients who underwent surgery were made a benign diagnosis; malign diagnosis was made to 34.1% (n = 57). Conclusions: The rate of malignancy in surgically confirmed nodules was 34.1% in this study, which is higher than the Bethesda classification. Due to the high malignancy rate which determined in cytologically diagnosed AUS/FLUS, we think that the repeat decision of the FNAB should be reconsidered and the surgical plan after the first FNAB should be considered more seriously.

Comparison of thyroid fine needle aspiration biopsy and ultrasonography results.

Thyroid nodules are one of the most common health problems in the community. Although most of the nodules are benign, Fine needle aspiration biopsy (FNAB) is requested due to malignancy concerns. In this research, the aim was to make a comparison of the results of thyroid ultrasonography (USG) and FNAB for thyroid nodules. This study was conducted retrospectively on the data of 532 patients. Detail Edu ultrasonographic assessment was conducted before the FNAB procedure and FNAB was performed by an endocrinology specialist. FNAB results and Thyroid USG features were compared, and thyroid FNAB results were graded using the classification of World Health Organization Bethesda-2017. The average age of the individuals included in the research was 49.99 ± 13.65 (min = 18-max = 97). According to the 2017 Bethesda classification, 74.6% of FNAB results were benign, 16% follicular lesion of undated mined significance or A type of undated mined significance, 0.9% were malignant, and 1.1% were suspicious for malignancy. When USG findings were compared according to FNAB results, it was found that malignant lesions were significantly higher in single nodules (non- cystic and non- mixed lesions). Lesions with a single nodule on USG were found to be 3.6 times more likely to be malignant (OR 95% CI: 1.172-11.352). The gold standard method for the diagnosis the presence of thyroid nodules is thyroid fine needle aspiration biopsy with ultrasound guidance. Taking samples from the correct nodule and component increases its value. The presence of a single nodule from the thyroid USG features was found to be an important predictor of malignancy according to the biopsy results.

A rare case of cardiac metastasis from primary anaplastic thyroid carcinoma

A 56-year-old man, followed for anaplastic thyroid carcinoma, revealed by a large cervical mass and confirmed on anatomopathological examination of a thyroid biopsy, since April 2022

Patterns of thyroid tumors in Northern Saudi Arabia with a specific focus on CK19, CD56, and Galectin-3 tumor markers.

The goal of this study was to look at the patterns of thyroid tumors and how thyroid cancer markers showed up in immunohistochemistry in Northern Saudi Arabia. This study investigated retrospectively 190 patients who attended with thyroid complaints. About 140 thyroid biopsies were diagnosed in the Department of Pathology at King Salman Hospital, Ha'il, from November 2019 to November 2020. Out of the 190 patients who attended with thyroid complaints, 140/190 (73.7%) were detected with thyroid lesions (58 malignant and 82 benign). Benign lesions included goiter 49/82 (60%), follicular adenoma 17/82 (21%), Hashimoto's thyroiditis 13/82 (16%), and toxic goiter 3/82 (3%). 5/6 (83.3%) of males with benign lesions had goiters. CK19 was positive in 68.5% of the cases; 71.8% were papillary, 66.7% were follicular, and 100% were undifferentiated carcinomas. Out of the 26/54 (48%) CD56-positive cases, 18/39 (46%) were papillary, 7/12 (58.3%) were follicular, and 3/3 (100%) were undifferentiated carcinomas. Out of the 35/54 (64.8%) Galectin-3-positive cases, 69.2% were papillary, 7/12 (58.3%) were follicular, and 3/3 (100%) were undifferentiated carcinomas. Thyroid cancer is prevalent in northern Saudi Arabia, with the predominant type being papillary thyroid carcinoma. Most patients are female and younger. The combined use of CK19, CD56, and Galectin-3 tumor markers assists in the accurate differential diagnosis of thyroid neoplasms.

Abstract #1412895: Comparison of Radiological Features of ATA and TIRAD System of Evaluating Thyroid Nodules - A Prospective Study in a Tertiary Care Hospital of Pakistan

The occurrence of thyroid carcinoma had ascended through recent years. Excessive detection of thyroid nodules due to intensified use of thyroid ultrasonography and also increased FNAB (fine- needle aspiration biopsy) procedures are believed to cause the surge in the diagnosis of incidental papillary thyroid carcinomas. There have been two guidelines most commonly used in both clinical practice and scientific area; American Thyroid Association (ATA-2015) guideline and ACR-TIRADS (American College of Radiology - Thyroid Imaging Reporting and Data System) guideline. These guidelines have been established based on sonographic topographies and aim to distinguish nodules according to their doubt of malignancy to give recommendations for FNAB or follow-up. This study aims to compare the radiological features of ATA and TIRADS system of evaluating thyroid nodules. This was a prospective study, enrolling 105 patients. The patients presenting to Radiology Department of the study hospital with neck swelling/nodules for Ultrasound Neck and Thyroid were requested to participate in study after providing the informed consent. The participants must be of 18 years of age or above, however the patients with a known diagnosis of thyroid cancer or having recurrence of prior thyroid cancer were excluded. Proforma was filled as per ATA & ACR TI-RADS classification system. A few patients were followed with FNAB and Histopathology reports. Of all the nodules, 30 (28.5%) were benign, whereas 75 (71.5%) were malignant. ATA guidelines showed improved diagnostic efficiency than ACR TI-RADS (P<0.01). ACR TI-RADS confirmed a higher specificity (P<0.05), whereas the ATA outline had a higher sensitivity (P<0.01). The ACR-TIRADS and ATA guidelines performed better in differentiating nodules >1 cm. Both systems revealed good diagnostic presentation, however, ATA guidelines resulted in a superior number of thyroid biopsies or FNABs. Therefore, we believed that ACR-TIRADS is a better system in this regard, it can help us ruling out unnecessary biopsies.

Abstract #1385480: Goiter and Abdominal Mass: A Rare Presentation of Riedel’s Thyroiditis

Riedel’s thyroiditis (RT), also known as fibrous thyroiditis, is a rare inflammatory autoimmune disease that is often associated with various forms of systemic fibrosis such as sclerosing mesenteritis (SM). A 38-year-old female with a past medical history of hypertension presented with a painful growing goiter and a mesenteric mass, which was complicated by biliary obstruction and hydronephrosis. Physical exam showed tenderness on the abdomen and a diffusely enlarged firm thyroid gland, with no palpable nodules. Initial labs revealed C-reactive protein of 115 mg/L, TSH 180 mIU/L; Free T4: 0.79 ng/dL, positive Thyroid Peroxidase (>1051 IU/mL); normal IgG1 and IgG4. CT abdomen/pelvis demonstrated a mesenteric mass that encased multiple mesenteric vessels and the right ureter without bowel obstruction. Thyroid ultrasound showed an enlarged heterogeneous thyroid without a discrete nodule consistent with autoimmune thyroiditis. Thyroid fine needle aspiration (FNA) was non-diagnostic. Thyroid biopsy showed mostly fibrosis with scattered lymphoplasmacytic aggregates, with no evidence of carcinoma, lymphoma, IgG4-related disease, and no Hürthle cell presence. Interestingly, the mesenteric mass biopsy revealed the same pattern. Peripheral flow cytometry and infectious workup were negative. Diagnosis of RT and SM were made. The patient was treated with steroids and improved clinically. The hallmark of RT is the extension of fibrosis beyond the thyroid. This patient exhibited common features of RT such as neck pressure, and pain; female gender, elevated inflammatory markers, nondiagnostic FNA (scant cellularity due to fibrosis), and a positive steroid response. Moreover, intense infiltrative fibrosis mixed with lymphocytes and plasma cells instead of an extensive lymphocytic infiltrate with the germinal center formation on histology supports Riedel’s thyroiditis rather than Hashimoto's. Similarly, SM is a rare, non-neoplastic inflammatory and fibrotic disease that affects the integrity of mesenteric vessels causing common bile duct and ureter obstruction. Negative flow cytometry, the presence of sclerosis, and the absence of bowel/liver lesions involvement make other common causes of a mesenteric mass (lymphoma, desmoid tumor, carcinoid) less likely, supporting the diagnosis of SM. The concurrent timing of her thyroid enlargement and the mesenteric mass as well as the similarity in histology (dense fibrosis with patchy lymphoplasmacytic aggregates) suggests an association between RT and SM. Overall, the case highlights the challenges in diagnosing RT given its extreme rarity and emphasizes the importance of early treatment to prevent systemic involvement.

T-lymphoblastic lymphoma of mediastinal lymph nodes with secondary thyroid involvement in an adolescent

Introduction Among tumors of lymphatic tissue, T-lymphoblastic lymphoma is a rare disease, with children and adolescents being affected more often. The thymus, lymph nodes and various extranodal localizations are involved in the tumor process, but no descriptions of secondary thyroid involvement in the tumor process in children with primary lymphoma of other localizations were found in the available literature.The aim of the study was to describe a rare observation of secondary thyroid involvement in mediastinal lymphoma with deciphering of tumor immunophenotype in an adolescent immunomorphological analysis of surgical material.Materials and methods. We analyzed the archived medical records, data of clinical, laboratory, instrumental and morphological studies of non-Hodgkin’s lymphoma of mediastinal lymph nodes with thyroid involvement. Histological examination of the material stained with hematoxylin and eosin followed by immunohistochemical examination with a set of 16 mono- and polyclonal antibodies was carried out 22 years later on the archive paraffin blocks.Results Morphological examination of the thyroid biopsy specimen and resectate of its isthmus made pathological and anatomical conclusion: non-Hodgkin’s lymphoma of the thyroid gland, prolymphocytic variant. Thanks to an adequately planned program of polychemotherapy, it was possible to achieve long-term remission with a 22-year recurrence-free survival rate. The retrospective data of clinical, instrumental, laboratory investigations and the results of immunohistochemical analysis of the archived tissue material with the help of a panel of 16 mono- and polyclonal antibodies were compared and the following conclusion was made: C83.5 (ICD-O code 9837/3) upper mediastinal lymphocytic T-lymphoma with secondary damage of the thyroid gland. Complete remission after polychemotherapy with a 22-year recurrence-free survival.Discussion It was shown that correctly planned treatment on the basis of competent identification of the histo- and cytogenesis of the tumor in the course of well-coordinated teamwork of specialists of different profile (hematologists, pathologists, chemotherapists, etc.) resulted in a favorable outcome. We managed to achieve a long-term remission with no recurrence of the disease for 22 years. By means of immunomorphological analysis, based on the recommendations of new classification of the haemopoietic and lymphoid tissue tumors, at the present stage of medical science development we managed to decode the tumor immunophenotype, which made more concrete, but not refuted the pathological anatomists’ conclusion, made 22 years ago.Conclusion Analysis of the presented case showed that the tumor immunophenotype corresponded to T-lymphoblastic lymphoma with secondary thyroid involvement. In spite of the fact that in this tumor any extranodal localization is possible, in the available literature we could not find any information about secondary involvement of thyroid in tumor process.