Thyroid Research Articles

Value of multi-parameter 123I-MIBG scintigraphy in the differential diagnosis of Parkinson’s disease

Background123I-MIBG scintigraphy plays a significant role in diagnosing Parkinson's disease (PD), with most studies primarily targeting cardiac uptake and relying on traditional ratio-based parameters for assessment. However, due to variations in scanning conditions and image processing methodologies, the clinical utility of different parameters remains a subject of debate. This study aims to evaluate the diagnostic accuracy of multi-parameter 123I-3-Iodobenzylguanidine (MIBG) scintigraphy and to identify the most reliable metrics for distinguishing PD from Parkinson-plus syndromes.ResultWe recruited 56 PD patients and 44 non-PD controls, who underwent 123I-MIBG scintigraphy and clinical evaluation. MIBG uptake and washout rates (WR) for the heart, salivary glands, and thyroid were assessed, with semi-quantitative methods used to calculate heart-to-mediastinum (H/M) and gland-to-background (P/B, S/B, T/B) ratios. Diagnostic efficacy was evaluated using receiver operating characteristic (ROC) curves. The H/M ratio and cardiac WR parameters scintigraphy exhibited excellent diagnostic efficacy for PD and PPS. The 4 h H/M ratio showed superior diagnostic performance with an area under the ROC curve (AUC) of 0.980. Background and time decay correction improved cardiac WR diagnostic performance (AUC = 0.963). Although P/B, S/B, and T/B ratios showed no significant differences for differential diagnosis, the WR values of the parotid and thyroid glands exhibited moderate diagnostic efficacy with AUCs of 0.648 and 0.638, respectively.ConclusionThe heart H/M ratio and cardiac WR in 123I-MIBG scintigraphy show high diagnostic efficacy for both diagnosing and differentiating PD. Including cardiac WR in routine assessments is recommended. The diagnostic potential of WR in the parotid and thyroid glands also holds promise for PD diagnosis. Incorporating these parameters could enhance the accuracy of PD diagnosis, particularly in clinical scenarios where concurrent cardiac disease may confound the diagnosis.

Biomarkers in Head-and-neck Cancer: A Scoping Review

Abstract Head-and-neck cancers (HNCs) refer to a diverse group of cancers that originate in the soft tissues of the head-and-neck area. This category includes all tumors that start in areas such as the oral cavity, pharynx, larynx, thyroid gland, and cervical esophagus. The application of biomarkers in managing HNCs has grown significantly due to advances in genomics, proteomics, transcriptomics, and related technologies. These biomarkers are valuable for the early diagnosis of head-and-neck squamous cell carcinoma (HNSCC) and play a crucial role in enhancing patient outcomes. HNSCC develops through a series of stages marked by the accumulation of phenotypic and genetic alterations. Identifying particular biomarkers is crucial for specifying the various stages of cancer, making it essential for managing HNSCC. The absence of appropriate biomarkers for monitoring disease progression can result in a poor prognosis due to late-stage diagnosis. The objective of this review is to highlight emerging biomarkers relevant to HNSCC, covering primary locations such as the oral cavity, oropharynx, hypopharynx, larynx, and thyroid.

P-63 PREVENTION OF POSSIBLE ABORTIONS IN PREGNANT WOMEN WITH REFETOFF SYNDROME USING METFORMIN AND THUS ACHIEVING A HEALTHY BIRTH

Abstract Introduction Refetoff syndrome (RS) is an autosomal dominantly inherited rare disease (1/40,000), characterized by thyroid hormone resistance (THR) mostly caused by Thyroid Hormone Receptor Beta (THR-B) gene defect. In the pregnancy period of female RS patients, the probability of live birth may decrease to 15%. It has been reported in the literature that metformin has effects on the thyroid hormone metabolism. Two female patients with RS being followed up in our center had pregnancy period that resulted in healthy deliveries with the use of metformin. This observation led us to question that metformin treatment may have positive effects in pregnancy of these patients by unknown mechanism of THR. We could not find any case reports or studies in the literature about the pregnancy periods in patients with RS, so we wanted to share our follow-up experience. Clinical Case Patient A and B were siblings with genetically proven THR-B mutation (figure 1). Patient A was on metformin treatment for insulin resistance before pregnancy. Her previous two pregnancies resulted in miscarriage following metformin discontinuation in pregnancy. In her third pregnancy under our follow-up, metformin treatment was continued. She completed the pregnancy without any problem and gave birth to healthy twins. Patient B, sister of Patient A, had two pregnancies. She used metformin in both pregnancies because of the favorable outcome in her sister. There were no problems in her pregnancies. The use of metformin has been shown to decrease TSH levels in patients with prediabetes and diabetes. The studies emphasize that metformin leads to a decrease in TSH values in individuals with subclinical or overt hypothyroidism, but this effect is not seen in healthy euthyroid patients. There are also reports that the effect of metformin leads to a decrease in thyroid hormone levels as well as thyroid gland and nodule size. In the literature search, we could only find a case report about metformin use in RS. In the report, metformin was started in a 28-year-old male RS patient due to a diabetic picture that developed over time. THR improved after metformin, but after a while metformin was discontinued due to dyspeptic complaints. Following the cessation of metformin THR became severe again. Although the exact mechanism of the thyroid suppressive effects of metformin is not clearly known, it is hypothesized that metformin, a compound that can cross the blood-brain barrier, increases the number and affinity of thyroid hormone receptors in the pituitary and hypothalamus, causes an increase in central dopaminergic activity, and as a result increases the pituitary feedback effect of peripheral thyroid hormones. Conclusion The incidence of healthy births in patients with RS is low. When we combine the limited literature data with our experience, we suggest that metformin treatment may contribute positively to a healthier pregnancy outcome in patients with RS.Figure 1:The pedigree of the family with Refetoff syndrome Table 1:Summary of pregnancies Table 2:Blood and genetic results of patients and* The records of two patients with Refetoff syndrome who were followed up in our center were obtained from the electronic health records.

P-62 A CASE OF PAPILLARY THYROID CARCINOMA WITH ISOLATED BONE METASTASES

Abstract Introduction Thyroid carcinomas constitute less than 3% of all cancers (1). Papillary thyroid carcinoma (PTC) accounts for 80% of thyroid carcinomas and generally has a good prognosis(2). Lymph node metastases are frequently observed in thyroid cancers(30-40%). However, distant metastases are quite rare(1-4%)(2). Clinical Case A 52-year-old female patient presented to the neurosurgery department due to back pain of approximately 2 months. A mass lesion was observed in the T9 vertebral body on a thoracic CT scan, which was destroying the bone structure, causing a compression fracture in the vertebra, and extending into the spinal canal. A total laminectomy of T9 vertebra and partial laminectomies of T8 and T10 vertebrae were performed. Pathology revealed strongly positive for Vimentin, TTF-1, Thyroglobulin, and Pax 8, consistent with carcinoma metastasis. It was recommended to perform a whole-body scan, primarily focusing on the thyroid gland. PET-CT, thoracic and abdominal CT scans revealed a 62x48 mm metastatic lesion in the right iliac bone and metastatic involvement of the T9 vertebra, with no other pathological findings. The patient's history revealed that she had undergone a total thyroidectomy six years ago, and the result was reported as benign. She was on levothyroxine sodium replacement therapy. Blood tests revealed TSH: 0.288 (0.27-4.2 µIU/ml), T4: 18.7 (12-22 pmol/L), T3: 4.78 (3.1-6.8 pmol/L), Anti-Thyroglobulin Antibody: 60.8 (0-115 IU/ml), and Thyroglobulin: >500 (3.5-77 ng/ml). Neck ultrasonography did not reveal any residual thyroid tissue or pathological lymph nodes. Given the suspicion of thyroid carcinoma metastasis and high thyroglobulin levels, the pathology preparations of the total thyroidectomy were re-consulted by our hospital's pathology department. The pathology result was consistent with papillary thyroid carcinoma composed of 55% follicular subtype and 45% solid/trabecular subtype. As surgery for the iliac bone metastasis was not considered appropriate, the patient was referred to the nuclear medicine department for radioactive iodine therapy and to the radiation oncology department for radiotherapy. The nuclear medicine, radiation oncology, and our department continue to follow up and treat the patient. Conclusion PTC is generally a slowly progressing cancer with a good prognosis. The most common site of metastasis in all PTC cases is the cervical lymph node, and only 3.5-3.8% have distant metastases(3). Distant metastases are most commonly seen in the lungs (53.4%), followed by bones (28.1%), liver (8.3%), and brain (4.7%) (1,4). Distant metastases significantly increase mortality from PTC. Therefore, the importance of adjuvant therapy (endocrine therapy, radiotherapy, etc.) and regular follow-up after thyroid cancer surgery should be emphasized. It should be kept in mind that, as in our case, papillary thyroid carcinomas can also present with isolated bone metastases without cervical lymph node metastases.

P-56 THE CASE OF SUBACUTE THYROIDITIS IN AN ELDERLY PATIENT MIMICKING MALIGNANCY

Abstract Introduction Subacute thyroiditis is a self-limiting inflammatory thyroid disease characterized by fever, neck pain, and thyroid dysfunction. It typically appears following an upper respiratory tract viral infection. Most cases of subacute thyroiditis are diagnosed through clinical and laboratory testing. The thyroid gland is large, painful, and tender during thyroid examination. Blood tests typically reveal elevated levels of free T4 and free T3, as well as a significantly increased sedimentation rate and C-reactive protein (CRP). Ultrasonographic findings of subacute thyroiditis are well defined. Clinical Case A 68-year-old male was consulted by the anesthesia department before the endoscopy and colonoscopy procedure planned to screen for malignancy. He was very worried and afraid because of the possibility of cancer and was psychologically negatively affected. He presented with night sweats and 10 kg of weight loss in the last 6 weeks. He had no history of previous disease. When a detailed history was taken, he stated that he had severe pain in his neck before his complaints started and that it went away on its own after a few weeks. On examination, he had no fever, a heart rate of 90 beats per minute, and a blood pressure of 120/80 mmHg. Neck examination showed no thyromegaly or lymphadenopathy. The general and systemic examination was unremarkable. Laboratory investigations showed hemoglobin 12.2 g/dL, WBC 8380 (x109/L), erythrocyte sedimentation rate (ESR) 78 mm/hour, CRP 50.1 mg/L, thyroid stimulating hormone 0.08 mIU/L (N = 0.55 – 4.78 mIU/L), free t4 1.4 ng/dL (N = 0.89 – 1.76 ng/dL), free t3 4.34 ng/L (N = 2.3 - 4.2 ng/L), and negative anti-thyroid peroxidase and thyroid stimulating immunglobulin. Thyroid ultrasonography was suggestive for subacute thyroiditis. He was given NSAIDS. Since his free T4 and T3 levels were normal at follow-up, endocrinological approval was given for the planned procedures. It was recommended to have a beta blocker ready during the procedure if needed. No findings in favor of cancer were detected in the detailed examinations, and the weight loss was attributed to subacute thyroiditis. Conclusion When elderly patients have complaints of weight loss or fatigue, it is important to exclude thyrotoxicosis and make a diagnosis by performing the necessary examinations. Subacute thyroiditis may not be severe; it is easy to diagnose with careful history-taking and simple laboratory examinations, and clinicians should keep it in mind in the differential diagnosis of weight loss.

Radiological, cytological and histopathological correlation in patients undergoing thyroid surgery at a tertiary care hospital in western Gujarat: a cross-sectional study

Introduction: Thyroid gland is affected by various pathologies ranging from diffuse enlargement (goiter) to nodular lesions, thyroiditis, and malignancies. Fine needle aspiration cytology (FNAC) is a simple & most cost-effective method to diagnose neck mass located superficially. Ultrasonography (USG) is the initial imaging modality in the evaluation of the neck swellings. The objective of the study being to correlate cytology, radiology and histopathology of patients undergoing thyroid surgery in our tertiary care center. Methods: All patients who were operated for thyroid gland surgery at our tertiary care hospital of western Gujarat at Ear, Nose, and Throat Department between October 2022 to March 2024 were analysed using statistical software. This study included 54 patients. Results: Out of the fifty-four (54) individuals who showed signs of thyroid enlargement, forty-five (45) were women and 9 were men. The average age of the participants in this research was 43.25±15.50 years. In our research, 79.67% of patients were classified as benign, 12.96% as malignant, and 7.4% were considered suspicious for malignancy. Only 10% were moderately suspicious of cancer (category IV). No patient was identified as highly suspicious of cancer (category V). FNAC specificity for benign was 95.24% and for malignant 93.02%. For TIRADS specificity was 93.33% for benign and 95.45% malignant. Conclusions: Most of the times it is easy to diagnose a thyroid swelling by clinical, radiological, cytological and histo-pathological examinations. Our study analyses FNAC with Bethesda, USG with TIRADS as a most important aspect for early diagnosis carcinoma of thyroid.

O-13 PAPILLARY THYROID CARCINOMA IN STRUMA OVARII: A RARE CASE REPORT

Abstract Introduction Struma ovarii is a subtype of mature teratoma characterized by the presence of predominantly thyroid tissue (>50%) [1]. This condition is usually benign, with malignant transformation occurring in only 0.5-5% of cases, requiring management similar to that of thyroid cancer. The most common malignancy found in struma ovarii, similar to the thyroid gland, is papillary thyroid carcinoma (PTC) [2]. Here, we report a case of a 73-year-old woman with papillary thyroid cancer in struma ovarii. Clinical Case A 73-year-old female patient, who was admitted with abdominal pain, underwent bilateral salpingo-oophorectomy due to 4 and 5 cm lesions thought to be hemorrhagic cysts on her right and left ovaries. Pathology result revealed a 2.2 cm teratoma in the left ovary. In the sections, in addition to struma ovarii (>90%), areas of mature teratoma differentiated in the direction of the ectoderm were observed. Two papillary carcinoma foci of 1 cm and 0.5 cm in diameter were detected within the struma ovarii, but no lymphovascular invasion or capsular involvement was observed (Picture 1). In the right ovary, only areas of mature teratoma (struma ovarii) consisting of benign thyroid tissue were seen. Her comorbidities included Type 2 Diabetes Mellitus, Stage 3 Chronic Kidney Disease and Hepatitis B virus carriage. Thyroid ultrasonography result showed normal thyroid gland size and heterogeneous parenchyma with decreased echogenicity. PET/CT scan showed no pathological FDG uptake in the body in favor of malignancy. Laboratory results were given in Table 1. The patient was evaluated by the thyroid council; the stage was calculated as T1a(m)N0M0, AGES and MACIS scores were considered as low risk and a follow-up decision was made for the patient. Routine thyroid and neck ultrasonography along with abdominal and lung imaging were recommended. TSH level was planned to be maintained between 0.5-1 uU/mL and annual thyroglobulin follow-up was planned. Conclusion The primary treatment for malignant struma ovarii is the surgical removal of the tumor. Additional therapies, such as thyroidectomy and radioiodine, may be required depending on the presence of metastatic disease and the risk of recurrence [2]. In cases with a low risk of recurrence, as in our patient (no extraovarian extension or distant metastases), most authors recommend levothyroxine to suppress TSH to the lower limit or slightly below normal, along with annual serum thyroglobulin monitoring. Severe elevations in thyroglobulin may indicate recurrence or metastatic disease. Long-term monitoring (at least 10 years) of serum thyroglobulin is necessary for patients with malignant struma ovarii. If the biochemical evidence of persistent or recurrent disease is found, appropriate imaging, including the pelvis, should be performed [3]. Financial disclosures: None Funding resources: NoneFigure 1:Histological and radiological findings of the patient Table 1:Laboratory results

P-66 A INSTANCE OF PAPILLARY THYROID CANCER MANIFESTED WITH SCAPULAR METASTASIS

Abstract Introduction Bone metastasis of well differentiated thyroid tumors observed in 2% and 13% of the patients. Bone metastasis usually occurs mostly in spine, but also in extremities, rib cage and pelvic bones. Here we present a case differentiated thyroid cancer diagnosed with scapular bone metastasis. Clinical Case A 58-year-old male patient had pain on his left scapula that began a year ago. The intensity of the pain worsened over the months. It did not wake him up, but it worsened when he slept on his back. There was no history of trauma, shortness of breath, or pain while swallowing. Physical examination revealed soreness and abnormality at the lateral edge of the scapula. The thyroid gland was not palpable. He was diagnosed with benign prostatic hyperplasia. His family did not have a history of malignancy. He was a lifelong nonsmoker who consumed alcohol infrequently. A magnetic resonance imaging (MRI) of the left shoulder was scheduled due to a suspicious tumor seen on shoulder x-ray imaging. An MRI revealed a 44x40 millimeter mass lesion, T1A hypointense and T2A hyperintense, superimposed on the body of the scapula, causing bone structural enlargement (Figure 1). A tru-cut biopsy was performed, and the pathology results were consistent with thyroid cancer metastases. Positron emission tomography/computed tomography was planned for further metastatic investigation; no new metastases were identified. Hemoglobin: 14.3 g/dL, platelets: 192x109/L creatinine: 0.85 mg/dL calcium: 9.13 mg/dL, AST/ALT: 14/13 U/L, TSH: 1.67 mIU/L, free T4: 0.94 ng/dL. Ultrasonography showed 16x8x8 mm hypoechoic solid nodule with microcalcifications was seen in the posterior of the left lobe and 7x6 mm hypoechoic solid nodule was seen in the posterior right lobe, and reactive lymph nodes smaller than 1 cm were discovered in the bilateral cervical chain. A fine needle aspiration biopsy of a thyroid left lobe inferior nodule revealed follicular neoplasm bethesda V. Total thyroidectomy was performed. Pathology report revealed papillary carcinoma with a classic+follicular pattern, localized in the right lobe, invasion of the tumor capsule, and multifocal intrathyroidal and lymphatic invasion were present. The mitotic index was 0–1/2 mm². The patient’s cancer stage was T1bNxM1, STAGE 4B according to thyroid cancer staging calculator. Risk score was evaluated as high according to American Thyroid Association. Bone metastases received 30 GY of radiation over a 10-day period. 150 mci radioactive iodine therapy (RAI) was scheduled for two months after radiation treatment. Anti-thyroglobulin antibody 12.8 U/mL (0-115), thyroglobulin 0.0693 µg/L, TSH 0.013 mIU/L, and freeT4 1.28 ng/dL at fourth month following surgery under levothyroxin suppression medication. Conclusion Papillary thyroid cancer with bone metastasis shortens life expectancy. Total thyroidectomy, anti-resorptive bone agents, corticosteroids, RAI, metastasectomy, radiotherapy, tyrosine-kinase inhibitors are the treatment options.Figure1:44*40 milimeter mass lesion on scapula

Intoxication of sheep by Astragalus arequipensis in northwestern Argentina.

Spontaneous intoxication by Astragalus arequipensis was diagnosed in a flock of 300 sheep in Jujuy province, northwestern Argentina, that grazed an area heavily invaded by this plant. The main clinical signs were intention tremors, ataxia, and progressive loss of condition. Autopsy of 2 affected animals revealed loss of body condition. The main microscopic changes were fine cytoplasmic vacuolation of cells in the cerebrum, cerebellum, thyroid and adrenal glands, kidney, liver, pancreas, urinary bladder, and lymph nodes, and swollen axons in the cerebellum. Ultrastructurally, the cytoplasmic vacuoles consisted of dilated secondary lysosomes. Composite leaf and stem samples of A. arequipensis analyzed by high-performance liquid chromatography contained 0.05% swainsonine. The diagnosis of intoxication by A. arequipensis was made based on the clinical history and signs; gross, microscopic, and ultrastructural changes; and detection of swainsonine in the plant.

P-13 EXTRANODAL LYMPHOMA WITH ENDOCRINE ORGAN INVOLVEMENT: CASE REPORTS

Abstract Introduction The incidence of extranodal lymphomas has increased in the last decade, most commonly occurring in the gastrointestinal tract, head and neck, skin/soft tissue and central nervous system. We report two cases of extranodal lymphoma in the thyroid and adrenal gland. Clinical Cases A 61-year-old male patient diagnosed with Small Lymphocytic Lymphoma (CLL) was referred to us after his follow-up at the Hematology Clinic. Thyroid ultrasonography (USG) revealed a nodular ovoid lesion, that has a semisolid structure of 36x12 mm in size, with a cystic component in the center, located at the right lobe - isthmus junction, and with increased vascularity. Laboratory tests were as in Table 1. It was learned that the patient had received chemotherapy for CLL in 2009 and was in remission, and there was no family history of thyroid cancer. Since the fine needle aspiration biopsy (FNAB) was suspicious for lymphoid neoplasia, a tru-cut biopsy was performed. The flow cytometry result was found to be compatible with B-cell clonality, and the pathology result revealed mature B-cell neoplasia infiltration. Immunohistochemically, dense plasma cells were observed with CD138. Thyroidectomy was recommended to the patient, but he refused and was followed up. A 73-year-old female patient was referred to our clinic with the suspicion of adrenal insufficiency due to ongoing nausea, vomiting, and hypotension symptoms. Laboratory tests at presentation were as shown in Table 2. The patient was started on 80 mg/day methylprednisolone, which was thought to be acute adrenal insufficiency biochemically and clinically, and since hyperkalemia persisted, 0.05 mg/day fludrocortisone was added to the treatment. It was learned that the patient had been examined for abdominal pain for 6 months, and 15 mm nodular lesions were observed in both adrenal glands in the abdominal CT, but no further examination was performed. In adrenal CT, lesions measuring 41x30 mm on the right and 30x22 mm on the left at the body-medial crus level were observed in both adrenal glands, with a density higher than expected for adenoma (Figure 1). The findings were evaluated as significant in favor of nonadenomatous lesions, and due to progression in lesion sizes and high suspicion of malignancy, pheochromocytoma was excluded by checking urine catecholamines from the lesion in the right adrenal gland, and a tru-cut biopsy was performed. As a result of the pathology, the patient was diagnosed with high-grade B-cell neoplasia and hematological treatment was started. Conclusion Extranodal lymphoma involvement has been described with multiple different presentations in every tissue of the body, even within an organ system. Therefore, it should be included in the differential diagnosis of mass lesions. Tissue biopsy and immunohistochemistry are the most important methods for determining the specific subtype and cell origin.Figure 1:CT images of patientLesions in bilateral adrenal glands Table 1:Laboratory workup*Thyroid Stimulating Hormone. Table 2:Laboratory workup*Blood Urea Nitrogen,C-reactive Protein, Adrenocorticotropic hormone, Thyroid Stimulating Hormone

P-52 ASYMPTOMATIC MIXED PITUITARY MACROADENOMA IN A YOUNG MALE PATIENT

Abstract Introduction Central hyperthyroidism due to a thyrotropin (TSH)-secreting pituitary adenoma is a rare cause of hyperthyroidism, representing 0.5-1.0% of all pituitary adenomas. The etiopathogenesis of TSH-secreting-adenomas is unknown and no definite role for various oncogenes has been proven. Plurihormonal pituitary adenomas reveal greater tumor recurrence and local invasion than do mono-secreting pituitary adenomas and therefore they need to be followed more closely. Clinical Case We present the case of a 19-year-old male who was admitted to the endocrinology clinic, was asymptomatic, and had abnormal thyroid tests during routine examinations. Laboratory tests revealed TSH 1.33 (normal RI), freeT4 2.5 (high), freeT3 6.78 (high), and the patient had tachycardia (pulse 120/min) on physical examination, but had no complaints. Thyroid antibody tests were negative, and ultrasonography revealed normal thyroid gland size and homogeneous parenchyma. Alpha subunit test was requested with suspicion of TSHoma and genetic test was requested considering thyroid hormone receptor resistance. In the pituitary panel tests, the patient's GH and IGF1 tests were found to be high for his age and gender, The lowest GH value in the GH-OGTT test was 3.95 ng/mL. LH was high but testosterone was within the normal reference range. The patient was found to have mandibular prognathism and his secondary sex characteristics were normal. Pituitary MRI revealed a nodular appearance on the left side of the pituitary gland, measuring 13x9 mm, hypointense on T1A, hyperintense on T2A, and showing contrast medium uptake. The infundibulum deviates to the right, and there is no pressure on the optic chiasm. Visual field test was normal. AlphaSubunit pituitary tumor marker value was found to be high at 1.9ng/mL (RIs ≤0.5). The genetic test for resistance to thyroid hormone, also came back normal. The patient underwent endoscopic transsphenoidal pituitary adenomectomy due to pituitary macroadenoma by an experienced neurosurgeon. No postoperative complications developed. In cytopathological evaluation, histochemical studies performed with silver stain showed that the reticulin roof was lost. In immunohistochemical studies, SF-1, PIT-1, LH (diffuse), GH (densely granular), TSH (rare) and LMWK (perinuclear cytoplasmic weighted) were positive. T-PIT and Prolactin were negative. Ki-67 proliferation index was 5%. Postoperative pituitary tests were normal and no deficiency was observed and no treatment was required. At the postoperative 3rd month follow-up, the lowest GH value in the GH-OGTT test was 0.16 ng/mL, and no residual mass was observed in the pituitary MRI. The patient, who had no postoperative complaints, is being followed up by the endocrinology clinic. Conclusion Mixed pituitary tumors are rare and can sometimes appear as silent tumors, but may be aggressive during follow-up, so better follow-up is necessary.Table 1:Pituitary panel biochemical results

Multimorbid patients in endocrine surgery

Endocrine surgery in multimorbid, frail and geriatric patients is increasing, is often urgent and characterized by special risk constellations. Successful parathyroid gland surgery nearly always results in amarked improvement, irrespective of the specific risk profile of the patient. Except for critical intubation and mediastinal interventions in the risk profile, surgery of the thyroid glands is predominantly beneficial and justifiable even in frail patients. For surgery of the adrenal glands and for gastroenteropancreatic neuroendocrine tumors (GEP-NET), the expected extension of resection, the underlying disease or the grading are decisive for whether alternative treatment measures or surveillance appear to be more beneficial for patients at risk.

O-14 A RARE CASE OF PULMONARY SARCOIDOSIS IN PATIENT WITH FOLLICULAR THYROID CANCER

Abstract Introduction As a rule, follicular thyroid cancer is a mildly aggressive type of cancer. However, follow-up after radical treatment consists of assessing the achievement of structural and biochemical remission. If a metastatic process is suspected, additional examination is carried out. Rarely, it is possible to detect a second malignant tumor in the same patient or granulomatous diseases, which complicates differential diagnostics. Clinical Case A 53-year-old patient was diagnosed with multinodular goiter a long time ago. She contacted the clinic to determine follow-up based on the results of a biopsy of the left lobe nodule of the thyroid gland which corresponded to BSRTC IV (follicular neoplasm). Left hemi-thyroidectomy was indicated. Intraoperative pathology corresponded to follicular cancer so total thyroidectomy was performed. Postoperative histological examination confirmed follicular cancer 2.2x2.0 cm pT2N0. Radioactive iodine therapy (80 mCi) was performed. After therapy, a whole body scan revealed a focus of retention in the neck, centrally and paramedianly on the left. She received LT4 suppressive therapy. At the first control after combined therapy: TG - 14.7 ng/mL, Anti-TG - normal. After 4 months suppressive therapy: TG - 5.52 ng/mL, Anti-TG - normal. Thyroid ultrasound revealed the lymph nodes with suspicion ultrasound characteristic in the left III and IV zones. Cytological examination showed a picture of hyperplastic lymphadenitis, malignant cells were not detected. CT scan of the chest detected sharply enlarged mediastinal lymph nodes. Thoracoscopy with excision of the paraaortic lymph nodes was performed. Histological examination showed granulomatous lymphadenitis (sarcoidosis). Methylprednisolone therapy was initiated, LT4 suppressive therapy is ongoing. Conclusion Our case demonstrates the complexity of differential diagnosis in suspected metastases of follicular thyroid cancer.

P-59 A CASE REPORT: A RARE CASE OF PAPILLARY THYROID CARCINOMA WITH BRAIN METASTASIS WITHOUT LOCAL RECURRENCE

Abstract Introduction Papillary thyroid carcinoma (PTC) is the most common type of thyroid malignancy and generally has an excellent prognosis. However, distant metastases, particularly to the brain, are rare and associated with poor outcomes. This case report presents a 67-year-old female patient with a history of PTC, who developed brain metastasis in the follow-up. Clinical Case A 67-year-old female patient presented four years ago with a rapidly growing 4 cm mass, extending from the right thyroid gland to the right jugular vein. Fine-needle aspiration biopsy (FNAB) of the lesion was reported as suspicious for follicular neoplasm. Ultrasound imaging revealed pathological lymphadenopathy in the bilateral cervical chains. The patient underwent total thyroidectomy and bilateral neck dissection. Pathology confirmed the diagnosis of the follicular variant of papillary thyroid carcinoma (PTC), with extrathyroidal extension into muscle and adipose tissue, as well as lymph node metastases. After surgery, while the patient's TSH level was 68.6 µIU/ml, her thyroglobulin (Tg) level was 1.02 ng/ml, with negative anti-Tg antibodies. The patient received 150 mCi of radioactive iodine (RAI) approximately 3 months after surgery. One year after RAI therapy, a whole-body iodine scan showed no evidence of residual disease or metastasis. Follow-up Tg levels of the patient remained around 0.04 ng/ml. 3.5 years after surgery, there was a slight increase in thyroglobulin levels (0.26 ng/ml), although no recurrent disease was detected on ultrasound of the thyroid bed. The patient was planned to be under close surveillance but she did not come to visits regularly. The patient subsequently presented with complaints of imbalance and brain MRI revealed a mass lesion measuring 46x43x55 mm in the frontal region. The mass was surgically resected, and the pathology confirmed metastatic papillary thyroid carcinoma (PTC). A postoperative whole-body iodine scan was negative for metastatic disease. At that time, the TSH level was 0.5 µIU/ml, and thyroglobulin (Tg) was 0.04 ng/ml. Cranial radiotherapy was planned for the patient. Conclusion Approximately 10% of patients with PTC develop distant metastases, most commonly to the lungs and bones. Brain metastasis from PTC is extremely rare, occurring in less than 1% of cases. Due to its rarity, brain metastasis from PTC is not typically considered in the differential diagnosis for patients presenting with new neurological symptoms, potentially delaying diagnosis. Despite aggressive treatment, the prognosis for patients with PTC and brain metastasis remains poor, with a median survival of approximately 17 months. This case highlights the importance of considering the possibility of brain metastasis in high-risk PTC patients who present with neurological symptoms despite the lack of significant elevation in thyroglobulin (Tg) levels or evidence of recurrence on neck ultrasound.

P-55 A RARE CAUSE OF TACHYCARDIA IN A POSTPARTUM FEMALE PATIENT WITH HYPOTHYROIDISM: LEFT ATRIAL MYXOMA

Abstract Introduction Primary heart tumors are uncommon with cardiac myxoma being the most frequently observed type. This tumor occurs in about 0.03% of the general population, typically appearing sporadically in adults. It can also be inherited as part of the Carney complex. While cardiac myxoma is biologically benign, it behaves functionally as a malignant tumor due to its potential to cause obstruction within the heart, embolization, and various systemic symptoms. Hashimoto's thyroiditis (HT) is a chronic autoimmune condition characterized by lymphocytic inflammation of the thyroid gland. Clinical Case A 39-year-old female patient with a diagnosis of primary hypothyroidism visited our outpatient clinic 18 months postpartum. She had palpitations for the past 4 years, which had worsened over the last 2 years and were now severe enough to disturb her sleep. Additionally, she complained of hand tremors when hungry, severe headaches, extreme weakness, and drowsiness after meals. Her medical history included a diagnosis of HT 16 years ago and she was receiving levothyroxine 100 mcg daily. She has lost her mother due to a cerebrovascular event at age 45. On physical examination, her blood pressure was 120/80 mmHg, her heart rate was 88 beats per minute, she had rosacea on her face, and the rest of the examination was normal. Laboratory analysis was as follows: TSH: 1.2mU/L (0.55-4-78), fT3: 3.24ng/L(2.3-4.2), fT4: 1.26ng/dl(0.89-1.76), Hb: 12g/dL(12-15.6), ferritin: 6 microgram/L(10-291), anti thyroglobulin: 269.9IU/mL (<1.3), anti thyroid peroxidase: 389U/mL (<60), glucose: 86mg/dl(70-99). During follow-up, her levothyroxine dose was reduced due to tachycardia, and she was also treated for iron deficiency anemia. Although an echocardiogram was planned to investigate her tachycardia, she did not undergo the procedure. An echocardiogram of the patient revealed an ejection fraction of 60% and a 4.3x3.3cm, well-circumscribed, round shaped mass in the left atrium. This mass, which was attached to the interatrial septum with a stalk and deviated the septum to the right, was consistent with a myxoma and contained areas of calcification. The patient underwent surgery for the left atrial mass, and the pathology results confirmed cardiac myxoma. In evaluations for Carney complex, cortisol was suppresse with the 1 mg dexamethasone suppression test, the glucose-growth hormone (GH) suppression test showed GH levels <0.05 μg/L, and a genetic test could not be performed. Conclusion Tachycardia in hypothyroid patients can occur as a side effect of levothyroxine treatment. Additionally, iron deficiency anemia can also lead to sinus tachycardia in these patients. However, if a patient presents with unusual symptoms, such as nocturnal tachycardia, it is crucial to consider the possibility of an underlying cardiac condition. When cardiac myxoma is identified, it is important to evaluate the patient for Carney Complex.

Prediction of difficult mask ventilation in Thai adult patients undergoing elective surgery using ultrasound of distance from skin to hyoid bone, and from skin to thyroid isthmus: a prospective cohort observational study

BackgroundA previous study showed that airway ultrasound, specifically the distance from the skin to the hyoid bone (DSHB), may be correlated with a higher risk of difficult mask ventilation (DMV). However, the study was conducted in Italy and lacks data for the Asian and Thai populations. This study aimed to predict DMV using pre-operative ultrasonography to measure the DSHB and from the skin to the thyroid isthmus (DSTI) in Thai patients undergoing elective surgery under general anesthesia.MethodsIn total, 189 patients who underwent general anesthesia during elective surgery were enrolled in this prospective cohort observational study. Pre-operative physical examinations and airway evaluations were performed as usual. Airway ultrasound was performed to measure DSHB and DSTI before the anesthetic procedure. Anesthesiologists and nurse anesthetists performed bag-and-mask ventilation. DMV was assessed and recorded according to Han’s mask ventilation classification in which DMV-0 indicates no attempt at mask ventilation; DMV-I indicates successful ventilation by mask; DMV-II indicates ventilation by mask with oral airway/adjuvant ventilation; DMV-III indicates that ventilation required two providers; and DMV-IV indicates the patient’s inability to undergo mask ventilation.ResultsThirty (17%) patients were classified as having DMV-0, and DMV-I, II, and III classifications were observed in 126(67%), 18(10%), and 12(6%) patients, respectively. None of the patients were classified as DMV-IV. The DSHB medians were 0.4(0.3–0.6), 0.7(0.5–1), 0.7(0.6–0.8), and 0.6(0.3–0.9) cm in DMV-0, I, II, and III, respectively (p < 0.001). The DSTI medians were 0.9(0.8–1.1), 0.8(0.7–1.1), 0.7(0.6–0.9), and 0.8(0.8–1.4) cm for DMV-0, I, II, and III, respectively (p = 0.041). Multivariate logistic regression indicated that the following factors were associated with difficult mask ventilation (DMV-III): male sex, modified Mallampati classification III, edentulousness, DSHB, and DSTI, with an area under the curve of 0.89.ConclusionsThis study showed that airway ultrasonography to determine DSHB and DSTI during patients’ routine physical examinations significantly improved the prediction of DMV. Patients classified as having DMV-III require prompt management for airway difficulties. However, the individual factors DSHB and DSTI alone are insufficient to predict DMV.Trial registrationRegistration number: TCTR2020093002.

Primary Thyroid Lymphoma: A Case Report

Background. Primary thyroid lymphoma (PTL) is a rare thyroid gland malignancy. In addition to airway compression symptoms and signs, which are the most common clinical findings, PTL may present with hypothyroidism or B symptoms of lymphoma, including night sweats, weight loss, and fever. Hashimoto thyroiditis is considered a significant risk factor and the most important underlying cause of PTL. Treatment options for PTL include chemotherapy, radiotherapy, and surgery. In this study, we present a patient who exhibited airway compression symptoms and was treated via total thyroidectomy. Case Report. A 62-year-old woman presented with complaints of weakness and fatigue lasting for approximately four years. The thyroid gland appeared enlarged on inspection and firm on palpation. The patient was diagnosed with hypothyroidism, characterized by elevated autoimmune antibody levels. Ultrasound imaging revealed thyroid enlargement with parenchymal heterogeneity. Despite achieving euthyroidism through thyroid hormone replacement therapy, thyroid enlargement and ultrasound features persisted during follow-up, accompanied by ongoing complaints of neck pain and redness. On magnetic resonance imaging, the thyroid gland appeared markedly enlarged with abnormal superior and inferior extensions. Due to the rapid, diffuse growth of the goitre, the patient underwent bilateral total thyroidectomy. She was discharged on the first postoperative day after an uneventful recovery. In her postoperative first-week follow-up, she reported no complaints and was doing well. Following the histopathological diagnosis of B-cell marginal zone lymphoma, the patient was referred to the Department of Hematology, and a close follow-up was arranged. At her postoperative ninth-month follow-up, she remains asymptomatic and recurrence-free. Conclusions. Thyroid lymphoma can present with rapid growth in the thyroid gland. In addition to chemotherapy and radiotherapy, surgery may be indicated in cases with symptoms and signs of airway compression.

Historical Control Data of Spontaneous Lesions of Laboratory New Zealand White and Dutch Belted Rabbits (Oryctolagus Cuniculus) Used in Toxicity Studies.

A retrospective study was performed to determine the incidences of spontaneous findings in control laboratory New Zealand White (NZW) and Dutch Belted (DB) rabbits. Terminal body and organ weights data were also collected. A total of 2170 NZW (526 males/1644 females), 100 DB rabbits (50 animals per sex), aged 4- to 7-month-old were obtained from 158 non-clinical studies evaluated between 2013 and 2022. The NZW rabbits had greater mean terminal body weights than DB strain. Mixed cell infiltration in the lung was the most recorded finding in both strains, followed by pulmonary inflammation/mononuclear cell infiltration. Differentiation between pulmonary "infiltration"/"inflammation" remained challenging as interpretation of guidelines for diagnostic terminology may vary amongst pathologists. Other common findings included mineralization and basophilia of the renal tubules; hepatic/renal mononuclear cell infiltration, all more common in females. Cysts were commonly recorded, with high prevalence in the oviduct, thyroid gland, ovary in NZW strain, while uterine, pituitary gland, and thyroid gland cysts were the most identified in DB rabbits. Neoplasms and infectious etiologies were absent. Most of the animals were sexually mature. To our knowledge, this is the most recent comprehensive study of spontaneous lesions and organ weights in both rabbit strains and should facilitate the differentiation of spontaneous and induced lesions in safety studies.

Nitrate induced hepatic fibrosis in tadpoles of Bufo gargarizans by mediating alterations in toll-like receptor signaling pathways.

The nitrate pollution has become an increasingly serious environmental problem worldwide, and the toxic effects of elevated nitrate levels in the environment on aquatic animals remain to be elucidated. The purpose of the present study was to investigate the mechanisms of liver injury to tadpoles after exposure to nitrate from embryonic to metamorphic climax and to assess the recovery process of liver function after cessation of exposure. In the group with continuous nitrate exposure, the livers and thyroid of tadpoles showed remarkably histological lesions, of this with structural disorganization of the hepatocytes, cellular atrophy, and fibrosis, as well as significant reduction in the follicular and colloidal area of the thyroid. Meanwhile, the expression levels of genes related to inflammatory signaling pathways, such as TLR2, TLR6 and NF-κB, were significant elevated. After termination of exposure at Gs23, liver damage (histologic, ultrastructural, and molecular levels) was almost completely recovered, whereas thyroid gland damage was irreversible. Overall, this study shed light on the harmful effects of nitrate pollution on amphibian health and emphasizes the importance of controlling nitrate emissions in the environment.

A Rare Case of an Intracardial Ectopic Thyroid in the Right Ventricle

The ectopic thyroid gland is an abnormal development of the embryo. Most of the ectopic thyroid occurs in the path around the thyroglossal duct or on the lateral side of the neck. However, ectopic thyroid occurs in the heart, which is rare. We report a case of right ventricular ectopic thyroid. This case highlights the imaging characteristics of computed tomography (CT) and cardiac magnetic resonance (CMR) and discusses the underlying mechanisms for a timely diagnosis.