Thyroid Cancer Presenting Research Articles

Australian males and females have similar rates of presentation for symptomatic and advanced thyroid cancer: Retrospective analysis of the Australian New Zealand Thyroid Cancer Registry.

Thyroid cancer is more commonly diagnosed in females, however recent research has challenged whether this finding is due to a true difference in biology or rates of diagnosis, with concerns that over-diagnosis may be a factor in differences. The rates of symptomatic versus incidental diagnosis by males and females is not well known. This study used the Australian and New Zealand Thyroid Cancer Registry (ANZTCR) to explore whether symptomatic presentation varies between sexes. Retrospective analysis on ANZTCR data between 2017 and 2022 was performed. Symptomatic cases were those with thyroid compressing symptoms, toxic goiter, Graves' disease, or abnormal laryngoscopy. Cases with asymptomatic goiter or surgeries for a thyroid nodule were classified as incidental. Among 1082 patients with differentiated thyroid cancer, 32% of males and 38% of females presented with symptomatic thyroid disease (p=0.06). A similar rate of presentation of advanced thyroid cancer (T3/4) was seen with male and female patients (n=70, 47% vs. n=79, 53%). Females exhibited a higher prevalence of low-risk relapse cancers according to American Thyroid Association stratification (66.3% vs. 50.4%), whereas males exhibited a higher prevalence of high-risk relapse cancers compared to females (27.3% vs. 15.3%, p<0.001). Regression showed symptoms were associated with more advanced T stage (OR=1.62, p=0.02). Symptomatic presentation was similar between males and females, but symptomatic presentation was associated with larger cancers. This study highlights comparable rates of symptomatic detection between males and females with DTCs and symptomatic presentations were responsible for less than 40% of presentations.

7357 Microscopic Papillary Thyroid Cancer Presenting with Cranial Nerve Palsies due to Metastatic Cervical Lymphadenopathy: A Case Report

Abstract Disclosure: N.N. Mukhtar: None. C. Zuo: None. B.R. Haugen: None. Introduction: Tumors metastasizing to head and neck are considered a rare cause of cranial nerve palsy (CNP). In this report, we describe an unusual presentation of metastatic microscopic follicular variant papillary thyroid cancer (FVPTC) presenting with CNP. Case Summary: A 68-year-old previously healthy female presented to her primary care physician with a 6-week history of difficulty speaking and chewing food. She did not notice any dysphagia, change in voice or shortness of breath. Cranial nerve examination was evident for palatal asymmetry, left-sided uvular and right-sided tongue deviations suggesting right glossopharyngeal and hypoglossal nerve palsies. Neck examination revealed a normal thyroid gland without palpable nodules however, the patient had multiple enlarged painless right cervical lymph nodes (CLN). MRI of the brain was normal. CT of the neck and chest showed enlarged, calcified right level II and III CLN (largest 4x3.5 cm) compressing the right internal jugular vein. In addition, bilateral pulmonary nodules (largest 1.7x1.5 cm) suspicious for metastasis were seen. CT-guided biopsy of left upper lobe lung nodule was consistent with metastatic thyroid cancer (positive PAX-8 and TTF-1 immunostaining). Neck ultrasound did not show any thyroid nodules, but did confirm 4 enlarged right CLN (largest 2.9 cm). The patient was referred to our multidisciplinary clinic for further evaluation. Based on the duration of her symptoms (6 weeks), her CNP was most-likely irreversible and agreement to proceed with total thyroidectomy, central and right lateral neck dissection aiming for complete resection in preparation for future treatment with radioactive iodine. Preoperative thyroglobulin level was 30.7 ng/ml (1.6-50), thyroglobulin antibody 24 U/mL (&amp;lt;40) and TSH 0.6 mIU/L (0.4-4.6). Intra-operatively; the patient had extensive, bulky lymphadenopathy extending to surrounding neck muscles and completely encasing right jugular vein. Histopathological examination of the resected tissue showed a unifocal right thyroid lobe microscopic (6x4x3 mm) infiltrative follicular variant papillary thyroid cancer (FVPTC). No extrathyroidal extension, necrosis, angioinvasion or lymphatic invasion were identified. Mitotic index was 3/ 2mm2. 13 out of 36 lymph nodes were positive for metastatic thyroid cancer (3/3 level II, 2/17 level III, 8/16 level IV), largest was 4.6 cm with extra-nodal extension. The patient was discharged on suppressive dose levothyroxine. Molecular studies: Next generation sequencing of the lung biopsy was negative for BRAFV[6]00E mutation and further molecular analyses are ongoing. Conclusion: This case describes two unique presentations of thyroid cancer; a microscopic FVPTC associated with large lateral cervical lymph node metastasis and, CNP as the initial presentation of thyroid cancer which to our knowledge, has not been reported previously. Presentation: 6/2/2024

12243 The Case of a Metastatic Papillary Thyroid Cancer Presenting as an Unresectable Pelvic Mass

Abstract Disclosure: M. Tucktuck: None. Y. El Soufi: None. O.G. Adeniran: None. A.A. Gliwa: None. Background: Papillary thyroid cancer (PTC) represents around 85% of all thyroid cancers, of which 2-10% of patients will present with metastasis distant to the neck. The frequency of bone metastasis in PTC occurs in only 1-4% of patients. Studies have shown that distant and multi-organ metastasis is associated with higher mortality rates. Clinical case: A 69-year-old woman with diabetes mellitus, cerebrovascular accident, and right lower extremity deep venous thrombosis, presented with right foot and hip pain for 1 week after a mechanical fall. She had a 50 pound weight loss over a year without personal or family history of thyroid cancer or disease or radiation exposure. A soft and nontender mass in the right lower abdomen was noted during a physical exam. Imaging revealed a large heterogeneous lesion (16.3 x 13.3 x 15.5 cm) in the right bony pelvis with internal necrosis, destructing the right iliac bone, and extending into the right sacrum, acetabulum, and musculature, with mass effect on the surrounding vasculature, and enlarged lymph nodes suspicious for metastasis. Thyroid imaging showed a hypervascular hyperechoic 1.3 cm nodule within the right thyroid gland and a large 2 cm left thyroid nodule with scattered microcalcifications. Thyroid function tests were within normal limits. The patient underwent an initial ultrasound guided biopsy of the pelvic mass with indiscriminate results, and later a laparoscopic excisional biopsy of the pelvic mass showed neoplastic papillary proliferation with typical nuclear features, without necrosis or associated ovarian tissue. The immuno-histopathological profile was positive for PAX-8, TTF-1, thyroglobulin, and CK7, and the Ki-67 proliferation index was ∼20-30%. The patient was diagnosed with papillary thyroid cancer with metastasis to the pelvic bone, and was classified as stage IV, cT1bN0M1. As the pelvic mass was inoperable, the patient completed total thyroidectomy and was started on hormone replacement therapy. Subsequent thyroid pathology report was negative for papillary carcinoma. Further review of imaging did not show ectopic thyroid tissue in the neck or an ovarian pathology. Before the patient’s next visit to evaluate for struma ovarii, she passed away. Conclusion: Thyroid cancer is usually treated through thyroidectomy or lobectomy, with radioiodine (RAI) therapy as an effective treatment for differentiated cancers. Our patient, who presented with extremity pain revealing a distant metastasis, completed thyroidectomy with plans to undergo RAI therapy. Our case highlighted the importance of recognizing musculoskeletal presentations as an initial and possibly only finding of a distant metastasis. It also emphasized the utility of multidisciplinary collaboration in detecting and recognizing PTC as a primary thyroid cancer, as early management can reduce mortality and lead to more favorable outcomes. Presentation: 6/2/2024

Impact of the COVID-19 Pandemic on Thyroid Cancer Surgery.

The COVID-19 pandemic caused major disruptions to healthcare services in 2020, delaying cancer diagnosis and treatment. While early-stage thyroid cancer often progresses slowly, it is crucial to determine whether treatment delays associated with the pandemic have impacted the clinical presentation and management of advanced-stage thyroid cancer. The purpose of our study was to determine the impact of the early COVID-19 pandemic on thyroid cancer presentation and treatment times. Utilizing the National Cancer Database, chi-squared tests and regression analyses were performed to compare patient demographic and clinical characteristics over time for 56,011 patients diagnosed with primary thyroid cancer who were treated at the Commission on Cancer-accredited sites in 2019 and 2020. We found that thyroid cancer diagnoses decreased between 2019 and 2020, with the biggest drop among patients with cT1 disease relative to other T stages. We also found that patients diagnosed with thyroid cancer in 2020 had similar treatment times to patients diagnosed in 2019, as measured by both the time between diagnosis and start of treatment and the time between surgery and start of radioactive iodine therapy. Overall, our study suggests that resources during the pandemic were allocated to patients with advanced thyroid disease, despite a decrease in diagnoses.

Geographic disparities in thyroid cancer staging at presentation: Insights from an Australian context.

Thyroid cancer diagnoses have increased over recent decades at a rate much higher than that of any other cancer in Australia. Rural patients are known to have reduced access to healthcare and may have different thyroid cancer presentation rates. This study examined the relationship between thyroid cancer diagnosis and patient rurality. Data from the Australia and New Zealand Thyroid Cancer Registry from 2017 to 2022 were analyzed, stratifying patient postcodes into rurality groups using the Australian Statistical Geography Standard. The American Thyroid Association (ATA) guidelines were used to stratify risk categories and management to compare treatment adequacy between the groups. Statistical analysis assessed demographic, clinical, and management differences. Among 1766 patients, 70.6% were metropolitan (metro) and 29.4% were non-metropolitan (non-metro). Non-metro patients were older at diagnosis (median 56 vs. 50years, p<0.001), presented more frequently with T stage greater than 1 (stage 2-4, 41.9% vs. 34.8%, and p=0.005), AJCC stage greater than 1 (stage 2-4, 18.5% vs. 14.6%, and p=0.019), and cancers larger than 4cm (14.3% vs. 9.9%, p=0.005). No significant differences in treatment adequacy were observed between the groups for ATA low-risk cancers. Non-metropolitan patients in the registry present with more advanced thyroid cancer, possibly due to differences in healthcare access. Further research should assess long-term survival outcomes and influencing factors. Understanding the impact on patient outcomes and addressing healthcare access barriers can optimize thyroid cancer care across geographic regions in Australia.

Sex differences and racial/ethnic disparities in the presentation and treatment of medullary thyroid cancer

BackgroundThis study assessed for disparities in the presentation and management of medullary thyroid cancer (MTC). MethodsPatients with MTC (2010–2020) were identified from the National Cancer Database. Differences in disease presentation and likelihood of guideline-concordant surgical management (total thyroidectomy and resection of ≥1 lymph node) were assessed by sex and race/ethnicity. ResultsOf 6154 patients, 68.2% underwent guideline-concordant surgery. Tumors >4 ​cm were more likely in men (vs. women: OR 2.47, p ​< ​0.001) and Hispanic patients (vs. White patients: OR 1.52, p ​= ​0.001). Non-White patients were more likely to have distant metastases (Black: OR 1.63, p ​= ​0.002; Hispanic: OR 1.44, p ​= ​0.038) and experienced longer time to surgery (Black: HR 0.66, p ​< ​0.001; Hispanic: HR 0.71, p ​< ​0.001). Black patients were less likely to undergo guideline-concordant surgery (OR 0.70, p ​= ​0.022). ConclusionsMale and non-White patients with MTC more frequently present with advanced disease, and Black patients are less likely to undergo guideline-concordant surgery.

Pituitary Metastasis Masquerading as Pituitary Macroadenoma-from a Primary Follicular Thyroid Malignancy

Background: Metastasis to the pituitary is very rare. Thyroid carcinoma as a primary source of pituitary metastasis is uncommon. Pituitary metastasis is common in posterior pituitary. Metastasis can also occur to anterior pituitary with varied presentations. Case Description: A 47-year-old lady presented with galactorrhoea, ptosis, diminished vision of the right eye, and headache from 6 months. She had a pituitary macroadenoma with suprasellar, para-sellar and infrasellar extension on evaluation. She underwent initial transnasal transsphenoidal decompression followed by pteronial craniotomy with decompression of the residual tumour. The histopathology was metastatic tumor of sella. Further evaluation showed a thyroid nodule and bilateral lung nodules. With suspicion of a primary thyroid malignancy, total thyroidectomy was performed and biopsy report of the thyroid showed follicular carcinoma. Conclusion: Metastasis to the pituitary can be a rare presentation of thyroid cancer. It may masquerade a pituitary adenoma. Key-words: Sella, Pituitary metastases, Parasellar, Suprasellar, Diabetes Insipidus, Thyroid.

The clinical and histopathological characteristics of thyroid gland diseases in adolescents requiring surgical treatment: a ten-year follow-up study.

The present research aimed to determine the clinical and pathohistological characteristics of thyroid gland diseases in adolescents who were previously surgically treated at the Endocrine Surgery Center of the University Medical Center of Serbia from 01/01/2001 to 01/01/2011. The study covered 170 patients of both sexes from the population of adolescents (aged 16 to 20 years) with various malignant and benign thyroid gland diseases. The data for this study were extracted from the medical histories of patients and the electronic database of the Center for Endocrine Surgery. Detailed data analysis included diagnosis, symptomatology, surgical intervention type, and disease stage. The following thyroid status parameters were analyzed from preoperative data: thyroxine (T4), thyroxine free fraction (FT4), triiodothyronine (T3), triiodothyronine free fraction (FT3), and thyroid stimulating hormone (TSH). In addition, the pathohistological features of diagnosed thyroid diseases were also determined, with a special focus on the presence of well-differentiated cancers. Papillary carcinomas were the most common of well-differentiated cancers in adolescents over the ten-year follow-up period. Based on the assessed data, total thyroidectomy was the most commonly used type of surgical intervention in these patients. The conducted research provides essential information related to both the biological characteristics and diagnostics of these cancers and their surgical treatment in such a sensitive population. Moreover, research showed that the clinical presentation of thyroid cancer in adolescents is almost identical to that in adults.

An unusual presentation of medullary thyroid cancer with proximal myopathy

An unusual presentation of medullary thyroid cancer with proximal myopathy

SAT541 Pleural Effusion As First Manifestation Of Recurrent Follicular Thyroid Cancer

Abstract Disclosure: N.S. Kadakia: None. C.A. Poku: None. Pleural effusions are a rare presentation of Follicular Thyroid Cancer (FTC). We portray a case of a patient with a remote history of FTC who presented with pleural effusion 57 years later as the first sign of recurrence. A 80 year old male presented to the hospital 8/2021 with shortness of breath and was found to have a pleural effusion. He had a history of FTC diagnosed at age 23 status post total thyroidectomy, external beam radiation and radioactive iodine. He was started on thyroid hormone replacement and was subsequently lost to follow up. Chart review showed unremarkable neck ultrasounds completed in 2004 and 2006. During admission 8/2021, a malignant pleural effusion was diagnosed after the effusion tested positive for TTF-1 and thyroglobulin (Tg). He was diagnosed with recurrent metastatic thyroid cancer. A CT scan of the neck showed a small paratracheal nodule while a PET scan revealed hypermetabolic activity in the left pleura. A neck ultrasound reported a 2 cm cervical lymph node on the right with preserved fatty hilum and an ovoid 1 cm isoechoic solid nodule in the left surgical bed. There was evidence of bulky calcified lymph nodes on CT. The pleural lesion was not accessible however biopsy of a supraclavicular lymph node was consistent with metastatic follicular carcinoma. After a delay due to iodine contrast exposure, a whole body scan with radioactive iodine was completed in 1/2022 and showed multiple foci of uptake in the right neck, right thyroid, left clavicular region, and lung bases. He was treated with 250 mCi I-131 sodium iodide in 1/2022 and levothyroxine dose was increased with a target TSH of less than 0.1. His Tg level was mildly increased. Thyroglobulin antibodies (Tg ab) were positive but have continued to trend down after treatment. A follow up CT chest done 7/2022 had persistent pleural thickening but significant improvement in pleural effusion and thus thyroxine kinase inhibitors (TKI) chemotherapy has not been initiated. Malignant pleural effusion is a rare presentation of FTC metastasis with a reported median survival of 11 months (Kazushige). Pleural effusion is a poor prognostic sign in patients with FTC and distant metastases (Broome). This affirms that prompt recognition is of essence however it also raises the question of how effective current therapies are. A retrospective study evaluated 20 patients who received RAI for pulmonary metastasis from FTC, and found the efficacy rate was relatively low (40%). There is insufficient data to determine the effectiveness of RAI as treatment for metastatic FTC to the pleura. This case adds to the limited literature on recurrence of FTC with pleural effusion and highlights limitations of current management. If the response to RAI is deemed inadequate then consideration should be given to the use of TKI. 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

SAT539 Thyroid Cancer Presenting as Aspiration Pneumonia

Abstract Disclosure: S. Aslam: None. M. Asif: None. I. Nadeem: None. W.J. Khan: None. Background Goiter, most often, is first noticed as a visible neck mass; however, some patients may present with signs and symptoms of hypothyroidism, or hyperthyroidism. Retrosternal extension can cause compression of the trachea, esophagus, and jugular veins resulting in dysfunction of these viscera. CaseA 68-year-old male presented with SOB, and weakness for 5 days. He had SaO2 79% on room air requiring oxygen, RR 28/min, HR 78/min and Temp.101.6 F, BP 94/48 mmHg. The lung exam revealed bilateral rhonchi and coarse crypts. Minimal non-tender nodularity was noted on the thyroid palpation not previously noticed by the patient or his family. Chest x-ray showed bilateral airspace opacities. CT chest revealed a large upper mediastinal mass displacing the trachea and esophagus to the right, a nodule in the left lobe of thyroid, subcarinal and right hilar lymphadenopathy and bilateral dependent consolidative opacities suggesting aspiration pneumonia but no PE. A barium esophagogram showed a 7.5 cm mediastinal mass causing 50% narrowing and displacement of esophagus and compression with left sided deviation of trachea. A barium swallow study was done, and the patient was found to have aspiration with all administered food types due to an abnormal swallowing mechanism. The patient was advised NPO and placed on NG tube feeding to prevent further aspiration. The patient underwent bronchoscopy and EBUS from station 4 lymph node, the pathology of which did not show any malignant cells. However, due to high clinical suspicion of a malignant process, the patient underwent a CT-guided biopsy of the mediastinal mass that showed bland thyroid tissue. Ultrasound of thyroid revealed multiple right and left lobe nodules. TSH and free T4, and calcitonin were WNL. The patient's hypoxia and fever resolved after completion of the antibiotics including ceftriaxone and doxycycline and being nothing per oral within 7 days. Due to persistent dysphagia, he was placed on PEG tube feeding and discharged from the hospital to a nursing home. The patient underwent ultrasound-guided fine needle biopsy of 1 right-sided and 2 left-sided thyroid nodules that resulted as papillary thyroid cancer. He underwent a successful right-sided thoracotomy and removal of large sized thyroid mass. The patient is seeing endocrinology as an outpatient for radioactive iodine and hormone replacement therapy. Conclusion We treated a patient of follicular carcinoma who presented with extrathyroidal symptoms. Retrosternal or ectopic thyroid tumors can present as euthyroid state without obvious enlargement of the normal thyroid gland. A meticulous clinical evaluation should include the differential diagnosis of retrosternal goiter or ectopic thyroid with cancer when treating patients who preset with sign and symptoms concerning for mediastinal disease. Presentation Date: Saturday, June 17, 2023

Inequities in Thyroid Cancer Care: Populations Most at Risk for Delays in Diagnosis and Treatment.

Background: Delays in treatment for thyroid cancer (TC) have been associated with higher overall mortality rates. However, few studies have explored the impact of health disparities on delayed presentation and treatment for TC. This study aims to investigate what patient sociodemographic factors contribute to delays in presentation and treatment of TC. Methods: Using the National Cancer Database, we identified patients diagnosed with well-differentiated TC between 2004 and 2016 who underwent thyroidectomy. Multivariable regression analyses were conducted to examine the impact of race, insurance status, income, and distance from treatment facility on time to surgical treatment, stage, the presence of distant metastases, and tumor size. Results: We identified 89,105 patients diagnosed with well-differentiated TC who underwent thyroidectomy. Nonwhite patients who were uninsured or had Medicare or Medicaid insurance were more likely to experience delays in care, present with higher stages at diagnosis, and have distant metastases and larger tumors at presentation. Distance from treatment facility was associated with delays in surgical treatment and higher stage at presentation. Conclusion: Delays in TC presentation and surgical treatment vary by race, insurance status, and patient location. Health care policies should focus on targeting at-risk individuals to reduce health care disparities in this disease.

Abstract #1399269: Never Too Old for Genetics: An Unusually Late Presentation of Medullary Thyroid Cancer in MEN2A

Virtually all germline RET pathogenic variant carriers develop medullary thyroid carcinoma (MTC). If possible, thyroidectomy should be performed prophylactically, before developing MTC. We describe a patient with pheochromocytoma found to have a germline RET p.Cys634Ser pathogenic variant at age sixty years who would be categorized as high risk based on genotype classification described by the American Thyroid Association and would have warranted prophylactic thyroidectomy at a young age. A 60-year-old man with history of hypothyroidism and osteopenia was found to have an adrenal mass during evaluation for kidney stones. It measured 4.1 x 3.2 x 3.8 cm on CT scan of abdomen and pelvis. MRI with and without gadolinium revealed a 4 cm left adrenal mass with T2 enhancement. Diagnosis of pheochromocytoma was confirmed with elevated levels of plasma free metanephrine and normetanephrine. The adrenal nodule showed avid uptake on PET CT Gallium-68 DOTATATE scan. No uptake was noted on the contralateral adrenal gland or in the neck. Patient underwent left adrenalectomy. Surgical pathology confirmed pheochromocytoma. Patient also had evidence of primary hyperparathyroidism (pHPT). Germline genetic analysis revealed a RET c.1900T >A(p.Cys634Ser) pathogenic variant confirming the diagnosis of multiple endocrine neoplasia type 2A (MEN2A). Calcitonin level was noted to be mildly elevated at 27.8 pg/ml. Subsequently, patient underwent total thyroidectomy, subtotal parathyroidectomy and bilateral central neck dissection. Surgical pathology revealed multifocal MTC, diffuse C-cell hyperplasia, and a foci of papillary thyroid microcarcinoma. Immunohistochemistry for calcitonin revealed diffuse C-cell hyperplasia. Patient was doing well on postoperative follow up and calcitonin level downtrended to < 2 pg/ml. Nearly all patients with MEN2A have either C-cell hyperplasia (CCH) or MTC, approximately 50% have a pheochromocytoma and 20-30% have pHPT. Age-related penetrance of CCH and hMTC is mutation dependent. Peak incidence in index patients is in the third decade of life in MEN2A. Our patient presented in the sixth decade of life. We decided to pursue genetic testing. The DOTATE scan did not show uptake in the neck and the calcitonin was only mildly elevated. However, as there is known complete penetrance of MTC in patients with MEN2A syndrome, patient underwent total thyroidectomy with central neck dissection with results of surgical pathology confirming presence of MTC. This case highlights the importance of considering genetic syndromes even in patients who present at older ages and challenges the classic genotype-phenotype correlation of the RET p.Cys634Ser pathogenic variant and MTC.

Abstract #1405977: Follicular Thyroid Cancer Presenting as Atypical Femur Fracture

Follicular thyroid cancer (FTC) is the second most common thyroid cancer and is known to metastasize hematogenously. The incidence of distance metastasis in FTC is approximately 6%-20% with bones and the lungs being the most common sites. Outcomes for patients with metastatic follicular thyroid cancer are poor, with a 10-year survival of 41%. 54-year-old female presented to endocrine clinic following an atypical fracture to her lesser trochanter. This occurred while applying minor force to the brake pedal in her car. Further evaluation with imaging revealed a 3.5cm boney lesion and a bone biopsy was consistent with metastatic follicular thyroid cancer. Her history included a left hemithyroidectomy in 2014 for a 5.2cm nodule that pathology initially reported as follicular adenoma. She was not followed by endocrinology after surgery. Ultrasound in 2013 showed two subcm right thyroid nodules. In 2022, she underwent FNA of two thyroid nodules and lymph nodes. She had a 0.9cm isthmus nodule that was suspicious for malignancy, 0.7cm right lower pole thyroid nodule that was benign. Two lymph nodes were also benign, but had Tg levels of 8 and 2ng/mL. Her imaging also showed pulmonary nodules and a right parietal bone lesion. She underwent completion thyroidectomy with bilateral central neck dissection and right lateral neck dissection. Pathology confirmed PTC follicular variant 0.6cm unifocal lesion in the right lobe with no angioinvasion, lymphatic invasion and no ETE. 53 lymph nodes were all negative. Due to her known distant disease, she is stage IVc. Pathology believes her bone lesion is consistent with the 0.6cm lesion and not the prior 5.2cm left nodule. She underwent treatment with I-131 with 198mCi. Post scan showed uptake in the left thyroid bed, right parietal bone and left lesser trochanter. Lung nodules did not demonstrate iodine avidity. Tg Levels prior to surgery was 2421. At time of RAI Tg was 2927 and was down to 234.6 three months after RAI. This patient was found to have boney metastasis of follicular thyroid cancer after presenting with an atypical femur fracture. This diagnosis was confirmed with her bone biopsy followed by pathology of the thyroid. RAI therapy is the most effective treatment for metastatic disease but its effect depends on the extent of uptake. Other treatments include surgery pending the location, or external beam radiation. This case highlights how a small follicular cancer can present with metastatic disease, causing morbidity for patients such as atypical fractures and pain.

Abstract #1406373: A Rare Case of Hyperthyroidism in a Patient with Metastatic Thyroid Cancer Presenting as Flaccid Paralysis

Hyperthyroidism in patients with thyroid cancer is rare although increasingly reported. We describe an unusual case of hyperthyroidism associated with metastatic thyroid cancer presenting as flaccid paralysis. A 53-year-old man with a history of a goiter presented to our hospital with severe low back pain for 1 month and inability to walk. He experienced loss of sensation and motor strength in his legs a few days prior to admission. Of note, he was informed about a neck mass years ago, but elected not to follow-up with any medical providers. MRI and CT imaging revealed a large mediastinal mass with cervical lymphadenopathy and multiple lytic lesions in the spine (T11, L1, L5), right ilium, lung, and liver. Initial labs showed mild hyperthyroidism. Biopsy of a right cervical lymph node revealed metastatic thyroid carcinoma, favoring follicular variant of papillary thyroid carcinoma. His hospital course was further complicated by bowel perforation and atrial fibrillation, requiring amiodarone to control his tachyarrhythmia. Subsequent labs revealed worsening thyrotoxicosis with free T4 of 7.62 ng/dL, free T3 of 14.55 pmol/L, and negative thyroid antibodies. He was a poor surgical candidate and unable to receive radioiodine for diagnosis or treatment due to his recent iodine exposure. Methimazole and PTU were not administered as he was strict NPO due to concerns of worsening his bowel perforation. Instead, he received high-dose dexamethasone for both his spinal cord compression and hyperthyroidism. After extensive goals of care discussion, he was eventually transitioned to hospice care. Hyperthyroidism associated with thyroid cancer is rare, as these cancers are typically hypo-functioning and suppression of thyrotropin helps decrease cancer progression. However, these cases are increasingly described in the literature, with a recent systematic review reporting 28 cases of hyperthyroidism in metastatic thyroid cancer patients. Among patients with thyroid cancers, hyperthyroidism can arise from the primary lesion, metastatic lesions, underlying Graves’ disease, toxic nodules, or even precipitated by a large iodine load. The etiology of hyperthyroidism in our patient is unconfirmed, but given the degree of his thyrotoxicosis, we suspect it was primarily from his metastatic disease and worsened by iodinated contrast and/or amiodarone. Our case highlights the importance of monitoring thyroid hormone levels in patients with thyroid cancers and the consequence of using iodine-containing medications, which can precipitate thyroid hormone dysfunction and delay appropriate treatments such as radioiodine ablation.

De novo familial adenomatous polyposis associated thyroid cancer with a c.2929delG frameshift deletion mutation in APC: a case report and literature review

BackgroundGermline mutations in the APC gene located on chromosome 5q 21–22 can lead to familial adenomatous polyposis (FAP) and the development of colorectal cancer (CRC) if left untreated. As a rare extracolonic manifestation, thyroid cancer is diagnosed in about 2.6% of FAP patients. The genotype–phenotype correlation in FAP patients with thyroid cancer remains unclear.Case presentationWe present a 20-year-old female of FAP with thyroid cancer as the initial manifestation. The patient was asymptomatic and developed colon cancer liver metastases 2 years after the diagnosis of thyroid cancer. The patient underwent multiple surgical treatments in several organs, and regular colonoscopy with endoscopic polypectomy was performed. Genetic testing demonstrated the c.2929delG (p.Gly977Valfs*3) variant in exon 15 of the APC gene. This represents a previously undescribed APC mutation. This mutation causes loss of multiple structures on the APC gene including the 20-amino acid repeats, the EB1 binding domain, and the HDLG binding site, which may be pathogenic through β-catenin accumulation, cell cycle microtubule dysregulation, and tumor suppressor inactivation.ConclusionsWe report a de novo FAP case with thyroid cancer presenting atypically aggressive features harboring a novel APC mutation and review APC germline mutations in patients with FAP-associated thyroid cancer.

Papillary thyroid carcinoma arising from ectopic thyroid tissue in a neck branchial cyst

A 35-year-old man presented with a right lateral neck mass for 6 years. Thyroid function test was within normal limits. Computed tomography scan of the neck was suggestive of branchial cyst, tuberculous lymphadenopathy and normal thyroid gland. Fine needle aspiration cytology of cervical lymph node was suggestive of metastatic carcinoma. Branchial cystectomy spearing the thyroid gland was undertaken. Histopathology analysis of the resected specimen confirmed it to be papillary thyroid carcinoma originating from ectopic thyroid tissue in a branchial cyst. The patient was scheduled for total thyroidectomy and neck dissection. Unfortunately, he was lost to follow-up. A brief review of the literature regarding this unusual presentation of thyroid cancer has been provided.

Racial, ethnic, and socioeconomic disparities in the presentation and management of pediatric thyroid cancer.

Disparities across race and socioeconomic status (SES) in cancer treatment exist for many malignancies. Disadvantaged groups have repeatedly been shown to receive sub-optimal treatment. This study intends to analyze racial and SES disparities in the presentation and management of pediatric thyroid cancer. A retrospective national database study of children who underwent thyroidectomy for thyroid papillary, medullary, and follicular carcinoma between 2007 and 2016 was conducted using the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) database. Multivariable logistic regression was conducted to identify predictors of 1) tumor stage/size at diagnosis and 2) treatment modalities. 1942 children were analyzed. The average tumor size at presentation was 20mm for White patients, 26mm for Non-White patients, and 27mm for Hispanic patients (p<0.001). Stage of disease differed significantly by race/ethnicity (p<0.001) with Non-White and Hispanic patients having more distant disease than White patients at presentation. On multivariable regression, Hispanic patients (OR 1.41, 95%CI 1.06-1.87, p=0.017) were more likely to be diagnosed at later stages. Non-White (OR 2.03, 1.50-2.73, p<0.001) and Hispanic patients (OR 1.57, 1.19-2.07, p=0.002) had larger tumors at diagnosis than White patients after controlling for other SES factors. SES disparities exist in pediatric thyroid cancer. Non-White and Hispanic patients are more likely to present with larger tumors and distant disease as compared to White patients. Understanding and intervening on these SES disparities is essential to improve outcomes.

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