bluuebunny/crossref_metadata_2025 huggingface dataset:
SAT465 Spectral Doppler Ultrasound in Thyrotoxicosis, a Valuable Bedside Tool
Authors: Morkos Michael , Raju Karishma , Ibrahim Katherine
Published: October 2023

Disclosure: M. Morkos: None. K. Raju: None. K. Ibrahim: None.

Objective: To assess the utility of spectral Doppler ultrasound as a bedside tool in the differentiation of various etiologies of thyrotoxicosis Research and Design Methods: This is a retrospective cross-sectional study of patients diagnosed with thyrotoxicosis at an academic outpatient endocrinology clinic from August 2019 to November 2022. The peak systolic velocities (PSV) were measured using spectral Doppler ultrasound at the superior and inferior thyroid arteries bilaterally. PSV ≥40 cm/sec in at least a single thyroid artery was considered a specific cut-off for Graves’ disease and PSV of peri-nodular artery ≥ 25 cm/sec was considered a specific cut-off for toxic adenoma. Thyroid antibodies (thyroid stimulating immunoglobulin and thyroid receptor antibody) and occasionally thyroid scan were used to confirm the diagnosis. Descriptive statistics, Chi square, and t-test were utilized to describe and compare data. Results: We identified 73 patients who presented for evaluation and management of thyrotoxicosis, mean age ± standard deviation 45.2 ± 16.4 years, 54 (74.0%) were female, 49 (67.1%) Caucasian, 23 (31.5%) African American, and one (1.4%) was Asian. The confirmed diagnoses were 48 (65.8%) Graves’ disease, 13 (17.8%) thyroiditis, 4 (5.5%) toxic adenoma, 4 (5.5%) amiodarone-induced thyroiditis type 2, 1 (1.4%) toxic multinodular goiter, 1 (1.4%) had a normal repeat thyroid function testing, and 2 (2.7%) were unconfirmed. Diagnosis based on the initial assessment including the spectral Doppler was accurate in 65 (89.0%) of the patients and it was conclusive and confirmatory during the initial encounter in 55 (75.3%) of the patients before additional testing. Thyroid scan was obtained in 9 (12.3%) patients. Incorrectly diagnosed patients included Graves’ disease, thyroiditis, toxic adenoma, and unconfirmed diagnoses, two patients each, a total of eight patients. Conclusion: Spectral Doppler ultrasound can be an effective bedside tool in the clinical assessment of thyrotoxicosis.

Presentation Date: Saturday, June 17, 2023
SAT470 Outcomes Of Radiofrequency Ablation For Autonomously Functioning Thyroid Adenoma- Mayo Clinic Experience
Authors: Dhanasekaran Maheswaran , Rajwani Aadil A , Castro M Regina , Morris John C , Schmitz John , Alan Lee Robert , Callstrom Matthew R , Stan Marius
Published: October 2023

Disclosure: M. Dhanasekaran: None. A.A. Rajwani: None. M.R. Castro: None. J.C. Morris: None. J. Schmitz: None. R.A. Lee: None. M. Callstrom: None. M. Stan: None.

Context: Autonomously functioning thyroid nodules (AFTNs) constitutes 5% of thyroid nodules and is the second most common cause of hyperthyroidism following Graves’ Disease. Untreated hyperthyroidism is associated with adverse cardiovascular and skeletal complications. Currently, radioactive iodine (RAI) and surgery are the standard treatment options for AFTNs, and both incur a risk of post-procedural hypothyroidism. To overcome this and other surgery/radiation-related complications, radiofrequency ablation (RFA) has been utilized in multiple countries (for both toxic and non-toxic thyroid nodules). It has been shown to induce significant nodule volume reduction along with restoration of normal thyroid function in many AFTNs. Methods: We present a single-center experience using RFA as an alternative treatment modality for AFTNs. The study's primary aim was to assess the efficacy of RFA in normalizing thyroid hormone concentration and restoring the euthyroid state. In addition, we analyzed the efficacy of RFA in nodule volume rate reduction (VRR) and its associated adverse events. Results: A total of 22 consecutive patients (17 F and 5 M) underwent RFA for a solitary AFTN (hot nodule in thyroid uptake and scan) under variable degrees of general anesthesia. 72% (n=16) had subclinical hyperthyroidism, 9% (n=2) had overt hyperthyroidism, and 18% (n=4) were biochemically euthyroid on anti-thyroid drugs (ATD). The mean age at the time of ablation was 52.09 years (SD= 14.6), with a mean BMI of 27.36 kg/m2 (SD= 4.67). Average pre-treatment TSH was 0.41 mIU/L (SD= 0.980) and free T4 1.29 ng/dl (SD= 0.33). The thyroid function was assessed after a single RFA session. TSH normalized in all patients within 3-6 months following the ablation. All four patients on ATD pre-treatment discontinued therapy within three months following the procedure. The average VRR (62.54%) was achieved within 3-6 months following the RFA, and importantly, none of the nodules grew back during the follow-up period (up to 24 months). Two patients (9%) developed transient tachycardia requiring short-term beta-blocker therapy, and two (9%) developed mild hypothyroidism requiring levothyroxine therapy. One patient, euthyroid post RFA, developed recurrent hyperthyroidism 45 months later and elected to undergo lobectomy. No serious adverse effects were noted in this cohort. Conclusions - RAI and/or surgery represent the standard of care for toxic adenomas but RFA shows excellent efficacy along with an excellent safety profile. Therefore at centers with RFA expertise it should be considered an alternative treatment strategy, avoiding radiation and surgery-related complications.

Presentation Date: Saturday, June 17, 2023
SAT474 A Case Report Of Moyamoya Disease Associated With Uncontrolled Graves' Disease
Authors: Tan Zi , Briggie Erin , Correia Marcelo
Published: October 2023

Disclosure: Z. Tan: None. E. Briggie: None. M. Correia: None.

Background: Moyamoya disease is an uncommon cerebrovascular disease that is featured by narrowing of large intracranial arteries and the development of prominent small-vessel collaterals. The etiology of Moyamoya disease is unknown, but it can be associated with multiple conditions including atherosclerosis, sickle cell disease, and Protein S deficiency. It is rarely associated with uncontrolled Graves’ disease. Clinical Case: A 37-year-old female with a history of Graves’ disease and type 1 diabetes presented with sudden onset of slurred speech and right-sided weakness. A CTA of the head and neck showed a small hypodensity in the left basal ganglia without corresponding perfusion deficit and narrowed left internal carotid arteries without focal stenosis. In addition, a brain MRI showed patchy infarcts in the left middle cerebral artery territory. A cervical and cerebral angiogram showed multiple areas of stenosis which was concerning for Moyamoya disease. She ultimately underwent balloon angioplasty of the left internal carotid artery with improvement in perfusion. During the workup for secondary causes of Moyamoya disease, her TSH was < 0.01 µIU/mL (0.270-4.20 µIU/mL), with elevated T4 at 3.84 ng/dl (0.80-1.80 ng/dl) and elevated TSI at 15.5 IU/L (< 0.54 IU/L). Importantly, she was diagnosed with Graves’ disease 2 years before admission, and this condition has never been well controlled due to poor compliance with methimazole. A TSH measured 5 months before admission was also undetectable with elevated T4 at 2.8 ng/dl. Her other workups for Moyamoya disease were negative including HIV antigen/antibody, syphilis IgG antibody, Lyme disease IgG & IgM antibodies, hepatitis panel antibodies, ANA, ANCA, free protein S, dsDNA antibody, factor 5 Leiden mutation, vascular endothelial growth factor-D and urine drug screening test. She started methimazole 20 mg daily and was discharged to acute rehabilitation. After rehabilitation, her Graves’ disease is slowly improving with most recent TSH < 0.008 µIU/mL and free T4 at 2.39 ng/dl. She is almost back to her baseline with significant improvement in speech and strength. Conclusion: Uncontrolled Graves’ disease should be considered in the differential diagnosis of Moyamoya disease in young subjects who present with stroke-like symptoms.

Reference: Ischemic Stroke and Intraventricular Hemorrhage in Moyamoya Syndrome Associated With Graves' Disease: A Case Report. Neurologist 2022

Presentation Date: Saturday, June 17, 2023
FRI201 A Rare Case Of Severe Ectopic ACTH Syndrome Presenting With Thrombocytopenia And Hemolytic Anemia
Authors: Mohammad Nazar , Scott Alyssa , Raja-Khan Nazia
Published: October 2023

Disclosure: N. Mohammad: None. A. Scott: None. N. Raja-Khan: None.

Background: Ectopic ACTH syndrome (EAS) is a rare but serious endocrine emergency requiring urgent diagnostic and therapeutic intervention due to the severity of hypercortisolism induced by ACTH-secreting tumors. Here we present an unusual case of EAS associated with hemolytic anemia and thrombocytopenia. Case Presentation: A 64-year-old female with a history of COPD presented with ongoing fatigue, weakness, and bruising of the extremities. The patient was lethargic, then became hypotensive and encephalopathic. Physical exam revealed diffuse ecchymoses. Patient otherwise had no symptoms or physical stigmata of Cushing’s. Labs were significant for hypokalemia, hemolytic anemia, thrombocytopenia, and lactic acidosis. CT demonstrated consolidation in the right hilum, right posterior lung pleural thickening, hypodense lesion in the right hepatic lobe, and bilateral adrenal hyperplasia. Treatment with antibiotics and plasmapheresis was initiated due to suspicion for thrombotic thrombocytopenic purpura and sepsis. Further workup revealed elevated ACTH 1819pg/mL and AM cortisol 102.4ug/dL. Pituitary MRI was normal. Treatment with etomidate infusion was recommended given the severity of hypercortisolism which was refractory to ketoconazole. However, due to clinical deterioration comfort care was initiated. Autopsy revealed metastatic small cell lung cancer. Conclusion: To our knowledge, this is the first report of EAS presenting with thrombocytopenia and hemolytic anemia. Urgent diagnosis and treatment of hypercortisolism is needed to reduce morbidity and mortality in EAS. While surgical excision of the ACTH-secreting tumor is the mainstay of treatment, cortisol levels should be decreased with medication prior to surgery. In severe cases that are refractory to ketoconazole, etomidate infusion can be considered.

Presentation: Friday, June 16, 2023
SAT511 High Intensity Focused Ultrasound (HIFU) Ablation for Benign Thyroid Nodules: A Single-Center Cohort
Authors: Mavromati Maria , Meyer Patrick , Vermeulen François , Demarchi Marco , Saiji Essia , De Vito Claudio , Jornayvaz Francois , Leboulleux Sophie , Wolff Adriana , Triponez Frédéric
Published: October 2023

Disclosure: M. Mavromati: None. P. Meyer: None. F. Vermeulen: None. M. Demarchi: None. E. Saiji: None. C. De Vito: None. F. Jornayvaz: None. S. Leboulleux: None. A. Wolff: None. F. Triponez: None.

Introduction:Benign thyroid nodules may increase in size over time and cause local compressive symptoms. Current guidelines suggest surgery for benign symptomatic nodules, however, complications such as hypothyroidism, bleeding, infection and recurrent laryngeal nerve injury are of concern for a growing number of patients. Minimally invasive techniques may therefore be an alternative to surgical resection. The objective of our study was to evaluate the efficacy and safety of high intensity focused ultrasound (HIFU) ablation in a single-center cohort of benign symptomatic thyroid nodules.Materials and methods:Between February 2021 and May 2022, 13 patients were treated by HIFU for a single benign solid symptomatic thyroid nodule. Benign nature of thyroid nodules was confirmed by a Bethesda II result in fine-needle aspiration, before HIFU. Treatment was performed under hypnosis, carried out by an experienced anesthesiologist. Patients were evaluated by clinical examination and ultrasound at 6 and 12 months after treatment. Results: A total of 13 patients (12 female and 1 male) were treated with HIFU for a single solid symptomatic benign thyroid nodule. Mean age was 57 years (range: 48-67 years). Thyroid nodules had an mean maximum diameter of 48 mm (range: 31-66 mm) and a meanvolume of 28.4 mL (range: 8.5-53 mL). At 12 months after HIFU, 4 patients underwent surgical ablation (31%) because of nodule growth (n=2, 15.4%) or persistent local compression (n=2, 15.4%). Those nodules were benign on final histology. Among non-operated nodules, mean decrease of volume at 6 months was 35% (range: 20-46%) and smaller nodules showed a better response to treatment. Altogether, 8 patients (61.5%) reported a clinical improvement 6 months after treatment, while 4 patients (31%) underwent surgery. Treatment was well tolerated in the majority of patients and had to be stopped because of pain in only one case (7.7%). There were no treatment-related local complications. Conclusion:High-intensity focused ultrasound (HIFU) ablation for benign symptomatic thyroid nodules is a safe minimally invasive technique but volume reduction was only 20-46% at 6 months, while 31% of patients required surgery after all. This could be attributed to the large initial volume of nodules included in our cohort. Clinical hypnosis is a useful alterative for pain management.

Presentation Date: Saturday, June 17, 2023
SAT515 Searching For Markers To Identify Angioinvasion In Papillary Thyroid Cancer
Authors: Buczyńska Angelika , Kościuszko Maria , Sidorkiewicz Iwona , Wiatr Aleksandra Anna , Siewko Katarzyna , Adamska Agnieszka , Jacek Krętowski Adam , Popławska-Kita Anna
Published: October 2023

Disclosure: A. Buczyńska: None. M. Kościuszko: None. I. Sidorkiewicz: None. A. Wiatr: None. K. Siewko: None. A. Adamska: None. A. Krętowski: None. A. Popławska-Kita: None.

The incidence of Papillary Thyroid Cancer (PTC) has increased significantly over last decades. Despite the great progress in PTC clinical management, the association of angioinvasion with tumor aggressiveness in PTC remains as significant clinical problem, suggesting worse patients prognosis. Therefore cancer metastasis occurs through cell detachment and angioinvasion, epithelial–mesenchymal transition (EMT) and cell migration, changes in cell morphology are initiated through Rho-GTPase-dependent actin cytoskeleton polymerization. 8-hydroxydeoxyguanosine (8-OHdG) is generated accordingly to increased oxidative stress, however has been characterized by paradoxical anti-oxidative, anti-inflammatory and anti-mutagenic effects following Rho-GTPase inhibition, which were noted in various cancer models. Since oxidative stress has been recognized as one of the main risk factors for thyroid cancer development and progression, the total oxidative and antioxidant capacities may also be potentially involved in the process of angioinvasion. Regardless, the identification of angioinvasion in PTC remains controversial mainly due to loose criteria in judging vascular invasion. Thus, searching for laboratory biomarkers of angioinvasion is of paramount importance.In this study, the potential screening utility of oxidative stress-related markers, such as total oxidative capacity (TOC), total antioxidant capacity (TAC) and 8-OHdG was assessed to identify angioinvasion in PTC patients.For the purpose od this study, 50 patients diagnosed with angioinvasive PTC (study group) and 50 patients with very low risk PTC (control group) were enrolled. The TOC, TAC and 8-OHdG concentrations were evaluated using enzyme-linked immunosorbent assay (ELISA). Following the received results, the TAC and 8-OHdG concentrations were decresed among study group comparing to control group (p<0.001; p<0.02, respectively). However, there were no differences in TOC among studied groups (p>0.05). The AUC values for TAC=0.76 and AUC for 8-OHdG= 0.70 (all, p<0.05) suggest their screening utility. The results indicate that angioinvasion process is associated with decreased antioxidant defense in PTC patients which may insight new medical targets in the future.

Presentation Date: Saturday, June 17, 2023
SAT516 Impact Of The Braf V600E Gene Mutation In Patients With Papillary Thyroid Cancer From Northern Ecuadorian Andes
Authors: Solis Pazmiño Andrea Paola , Cardenas Tamara , Cucalon Jessica , Jaramillo-Koupermann Gabriela , Galvez Gabriela , Reyes Carlos , Vega Jorge Salazar-
Published: October 2023

Disclosure: A.P. Solis Pazmiño: None. T. Cardenas: None. J. Cucalon: None. G. Jaramillo-Koupermann: None. G. Galvez: None. C. Reyes: None. J. Salazar- Vega: None.

IntroductionThe incidence of thyroid cancer (TC) is increasing worldwide. Most new TC cases are papillary thyroid cancer (PTC). Ideally, the individualization of treatment decisions should not only be based on the context and values of the patient but also on the biology of the tumor. Among them, BRAF V600E + TERT has been associated with aggressive clinic-pathologic outcomes, including tumor recurrence and mortality. The aim of this study was to determine the prevalence of the BRAFV600E mutation in PTC patients from the northern Ecuadorian Andes.MethodsA retrospective cohort study of 193 tumors, was classified according to the TNM system (AJCC 7th edition) and the patients were managed based on the 2015 ATA guidelines from June 2016 to December 2019 in Hospital Eugenio Espejo, Quito-Ecuador. PTC genomic DNA from formalin-fixed, paraffin-embedded tissue was analyzed for exon 15 of the BRAF oncogene by Sanger Sequencing.ResultsFrom 193 patients included, 146 were positive for the mutation (75.6%), and 47 were wild type (24.4%). In the bivariate analysis, the mutation was significantly associated with the presence of distant metastasis (p = 0.02), and it was also a predictor of distant metastasis (odds ratio [OR], 4.1; 95% CI 1.5 - 10.8). There was no significant association between BRAF positivity with demographic variables (age, gender, BMI, altitude), or with tumor characteristics (tumor size, focality, aggressive/nonaggressive variant, lymph node metastases, ACJJ stage, thyroglobulin or iodotherapy values).ConclusionIt has been proposed that patients harboring the mutation be managed more aggressively in the early stages, however, we conclude that the impact of BRAF V600E on PTC is still controversial. To the best of our knowledge, this is the first report of its kind carried out in the Ecuadorian population. Studies involving massive sequencing and prospective clinical correlation are needed in the future.

KEYWORDS: Papillary thyroid carcinoma, BRAF V600E mutation, distant metastasis.

Presentation Date: Saturday, June 17, 2023
FRI204 A Rare Case Of Cushing Syndrome In Pregnancy: Diagnosis And Therapeutic Challenges
Authors: Cardona Zulma , Szmuilowicz Emily Deborah
Published: October 2023

Disclosure: Z. Cardona: None. E.D. Szmuilowicz: None.

Introduction: Cushing’s syndrome (CS) rarely occurs during pregnancy, and diagnosis of Cushing’s syndrome in pregnancy is challenging due to physiologic changes during gestation. CS is associated with severe maternal and fetal complications. Clinical Case: A 36-year-old woman presented at 21 weeks gestational age with a known adrenal nodule admitted for evaluation of HTN, bilateral lower extremity edema, transaminitis, hyperglycemia, and acute hypoxemic respiratory failure. Reported proximal muscle weakness, facial swelling, anxiety, depression, perspiration, and headaches associated with HTN. Physical exam notable for mild supraclavicular fat deposition, chest and neck plethora, hypertrichosis, and bruising. CT abdomen pelvis revealed a 2.3-cm left adrenal nodule measuring 30 Hounsfield units. Biochemical evaluation included a plasma renin activity of 0.719 ng/mL/h [ref range: 0.167-5.380 ng/mL/h], aldosterone <1.0 ng/dL [ref range: 0.167-5.380 ng/dL], potassium 2.6 mEq/dL, free plasma metanephrines (MN) < 25 pg/mL [ref range: < or = 57 pg/mL], free normetanephrines (NMN) < 25 pg/mL [ref range: < or = 148 pg/mL, total free MN and NMN < 25 [ref range: < or = 205 pg/mL]. 24-hour urine free cortisol (UFC) was markedly elevated at 1854.1 mcg/24h [ref range: 3.1-50.0 mcg/24h], repeat 2186.2 mcg/24h, ACTH: 1.5 pg/mL [ref range: 7.2-63.6 pg/mL], confirming a diagnosis of ACTH-independent CS. Her case was complicated due to the adrenal nodule location. Patients with left adrenal nodules are at risk of developing inferior vena cava (IVC) syndrome during left adrenalectomies, especially in the third trimester, due to compression exerted by the uterus while lying on the right side during the procedure. She underwent an uncomplicated laparoscopic left adrenalectomy. Was started on hydrocortisone (HC) following surgery. There was concern for transient neonatal adrenal insufficiency at delivery. Measuring adrenal insufficiency in utero is challenging; however, estriol could serve as a surrogate marker of fetal adrenal function. Her estriol was normal, possibly indicating intact fetal adrenal activity. She had an uncomplicated vaginal delivery with no signs of adrenal insufficiency in her baby. Interestingly, she had a severely low alkaline phosphatase (ALP) which completely normalized soon after adrenalectomy. Clinical Lesson: This case depicts the challenges in managing CS in pregnancy and its repercussions regarding maternal, fetal, and delivery outcomes. Additionally, it highlights the importance of implementing a multidisciplinary approach, including obstetricians, endocrinologists, endocrine surgeons, and pediatricians, to ensure the optimization of therapeutic strategies.

Presentation: Friday, June 16, 2023
SAT523 Molecular Profile of Local vs. Regional Aggressive Thyroid Cancer: A Multicenter Study
Authors: Tessler Idit , Gecel Nir , Payne Rick , Avior Galit , Eran Alon
Published: October 2023

Disclosure: I. Tessler: None. N. Gecel: None. R. Payne: None. G. Avior: None. A. Eran: None.

Background: Genetic testing for the diagnosis of thyroid cancer has rapidly evolved in recent years. While commonly applied for diagnosis, its role in predicting genotype-phenotype correlation and guiding management is emerging. Here we evaluate differences in the molecular profile of local vs. regional aggressive disease. Methods: We performed a retrospective multicenter study of patients who underwent molecular profiling for DTC between 2018-2021, dividing them into three groups: low-risk, locally aggressive, and regional aggressive. We analyzed the patients' basic characteristics, disease aggressive features (extranodal extension, perineural invasion), lymphovascular invasion, and extrathyroidal extension), and the mutation distribution according to disease aggressiveness. Genetic variants were stratified by risk levels according to the 2015 ATA guidelines. Results: The study included a total of 652 patients, 414 in the low-risk group, 73 in the locally aggressive group, and 165 in the regional aggressive group. The regional aggressive group had the lowest age at diagnosis (mean age of 44.64±13.78 years vs. 52.52±14.53 and 53.58±14.93 for the low-risk and locally-aggressive, respectively, p>0.001), the highest rate of mutation-positive nodules (86.1% vs. 6.6% and 67.1%), and the highest rate of aggressive mutation (76.4% vs. 17.6 and 39.7). On the contrary, RAS mutations were more common in the low-risk (31.4% vs. 19.2% and 6.1% in the local- and regional aggressiveness groups). Conclusion: This study showed that local and regional aggressive thyroid cancer has a distinct molecular profile, with a higher prevalence of high-risk mutations in the regional group. These findings may enhance the use of genetic testing in predicting disease aggressiveness and guiding management in thyroid cancer.

Presentation Date: Saturday, June 17, 2023
SAT533 The Case of an Ectopic Thyroid Twin
Authors: Limon Ahmad Abu , Aldasouqi Saleh A , Kachhadia Palak , Khan Shaza
Published: October 2023

Disclosure: A. Abu Limon: None. S.A. Aldasouqi: Consulting Fee; Self; Abbott Laboratories. P. Kachhadia: None. S. Khan: None.

Introduction: Ectopic thyroid tissue is a rare but known developmental abnormality during the descent of the thyroid tissue from the floor of the foregut to its final location Infront of the trachea. The most frequent ectopic locations are the base of the tongue and anywhere along the course of the thyroglossal duct. It is very rare to have an ectopic thyroid tissue located in the mediastinum. It’s even more rare when the patient still has an almost normal thyroid gland in its usual location in the neck, and both are sizable and functional. Case Presentation: We are reporting the case of a 38-Year-old African American Female, who was involved in a car accident with non-critical injuries to her neck and chest area. She underwent a contrasted CT scan of her neck and chest that showed an anterior mediastinal mass towards the right at the level of the great vessels and arch, right paratracheal location overall measuring 6.0 x 4.6 x 4.5 cm. She was seen by Cardiothoracic surgery group and underwent Mediastinoscopy that confirmed a large firm to hard mass just inferior to the innominate artery was firmly adherent to the trachea as well as surrounding structures. Multiple biopsies showed thyroid tissue with focal mild chronic inflammation, benign. No atypia or malignancy is noted. Then, she was referred to our clinic for further evaluation. When interviewed, the patient denies any compressive symptoms (Shortness of breath, palpitations, chest pain or dysphagia). The patient has no personal or family history of thyroid disorders, including no thyroid cancer history. She has no Goiter on exam and no Pemberton sign is elicited. Laboratory work up was unremarkable including normal thyroid functions. Neck Ultrasound confirmed presence of a thyroid gland in its expected location, with Right Lobe Measurement: 5.04 x 1.70 x 1.47 cm Vol: 6.02 ml and Left Lobe Measurement: 3.94 x 1.25 x 1.21 cm Vol: 2.87 ml. We were keen to explore this matter further and ordered a thyroid uptake scan with 0.97 uCi iodine-123, that showed a 24-hour normal uptake of 27.4% at the thyroid bed and a separate substernal and RT paratracheal location uptake. Discussion: This patient has supplementary ectopic thyroid tissue in her mediastinum along with a normal thyroid gland in her neck. From the literature review and search, This is a very rare occurrence. The discussion with the patient is about the specific concern of the malignant potential of this ectopic thyroid and if surgical intervention is needed. The probability of cancer on ectopic thyroid tissue is less than 1% and when it occurs papillary carcinoma is the most common histology. Our patient has benign biopsy results and no signs nor symptoms related to this ectopic thyroid gland. The final decision is to not undergo surgery, but rather, a follow up with CT scan in 6 months.

Presentation Date: Saturday, June 17, 2023
SAT539 Thyroid Cancer Presenting as Aspiration Pneumonia
Authors: Aslam Sadia , Asif Muhammad , Nadeem Ifrah , Khan Wahab J
Published: October 2023

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
OR32-01 Clinical Performance Of Multiplatform Molecular Diagnostic Testing Of Cytology Indeterminate Thyroid Nodules: A Blinded, Single Institution Observational Study With Surgical Pathology And Surveillance Follow Up
Authors: Cipriani Nicole A , Antic Tatjana , Banizs Anna , Finkelstein Sydney David
Published: October 2023

Disclosure: N.A. Cipriani: None. T. Antic: None. A. Banizs: Employee; Self; Interpace Diagnostics. S.D. Finkelstein: Employee; Self; Employee of Interpace Diagnostics.

Background: Genetic analysis of final needle aspiration biopsies (FNAB) can improve the diagnostic accuracy of cytology indeterminate thyroid nodules (ITN). A combination multiplatform molecular algorithmic testing (MPTXv1) approach with mutational analysis (ThyGeNEXT®) complemented by quantitative microRNA (miRNA) expression (ThyraMIR®) can assign nodules to three diagnostic categories: Negative (low malignancy risk), Moderate (intermediate risk), or Positive (high risk). Test performance was assessed in a blinded observational study to evaluate the potential incremental benefit of adding miRNA pairwise expression profiling (MPTXv2) to reduce the Moderate category and improve diagnostic accuracy [RR1] of ITN. Methods: An 11 miRNA marker Profiler was trained to quantify the equilibrium between miRNA pairs supporting growth promotion versus growth suppression using surgical pathology confirmed nodular disease (n=50). Performance without (MPTXv1) and with miRNA pairwise expression profiling (MPTXv2) was assessed using a test cohort of 101 FNAB of ITN (Bethesda Diagnostic Category III/IV) from a single institution. Molecular analysis was performed in blinded fashion with outcome determined based on surgical pathology and surveillance tracking of patients managed for benign disease. Results: MPTXv1 performance (3 categories) without profiler showed 91% sensitivity, 97% specificity, 97% NPV and 85% PPV of 101 patient cohort with 23% cancer prevalence. MPTXv2 performance showed significant [RR2] incremental improvement with 91% sensitivity, 99% specificity, 97% NPV and 95% PPV. Of note, Nodules classified as Moderate malignancy risk decreased from 25 to 6 patients (a 76% reduction). Conclusion: Diagnostic test performance limitations inherent in isolated mutational or isolated RNA classifier analysis to both rule-in and rule-out of thyroid cancer can be improved by a combination platform [RR5] approach (MPTX) which can delivers high sensitivity and specificity. Furthermore, blinded observational analysis of deeper analysis by incorporating miRNA pairwise expression profiling (MPTXv2) further improves performance by increasing the proportion of patients that will receive a highly accurate prediction of ITN status, reducing false positives and negatives

Presentation: Sunday, June 18, 2023
FRI211 Recurrent Hypertensive Crises In A Patient With A Large Pheochromocytoma; A Complicated Intensive Care Unit Course
Authors: Sokoloff Samantha , Iwamaye Amy
Published: October 2023

Disclosure: S. Sokoloff: None. A. Iwamaye: None.

Introduction: Hypertensive crisis is a well-known complication of surgery in patients with pheochromocytomas. However, as demonstrated in this case, these crises can be triggered by even routine intensive care unit procedures if sufficient alpha blockade has not been achieved. Thus, prevention of these episodes in the critical care setting presents a therapeutic challenge. Case: A 47-year-old female with a medical history of hypertension and intraductal papilloma presented for right lumpectomy for recent increase in papilloma size. General anesthesia and a laryngeal mask airway (LMA) were used. Intraoperatively, hypertensive crisis developed with systolic blood pressure of three hundred and oxygen saturation of forty percent. Hypoxia persisted after LMA was exchanged for endotracheal intubation and ECMO initiation was necessary to restore oxygenation. The patient was admitted to the Intensive Care Unit and blood pressure normalized postoperatively. Echo showed normal ejection fraction with an incidental finding of a peri-hepatic mass. This prompted evaluation for pheochromocytoma, which was biochemically confirmed with plasma free metanephrine and normetanephrine of 13,900 (<= 57 pg/mL) and 2,560 (<= 148 pg/mL), respectively. Abdominal CT-scan showed an 8.0 x 7.0 x 8.0 cm right adrenal mass. MIBG showed increased activity in the mass without evidence of metastatic disease. Doxazosin was initiated for alpha blockade. One week postoperatively, ECMO was weaned off and the patient was extubated. Shortly after extubation, a second hypertensive crisis occurred with an increase in systolic blood pressure to over two hundred and a decrease in oxygen saturation to forty percent. Re-intubation was unsuccessful and cricothyrotomy was required. Both nitroprusside and clevidipine failed to reduce blood pressure and a labetalol infusion was necessary to end the episode. The patient underwent surgery for cricothyrotomy to tracheostomy conversion two days later. By that point, labetalol had been weaned off and doxazosin had been titrated to three mg every twelve hours. A titratable IV phentolamine infusion was used for further alpha blockade intra-operatively and normotension was maintained. Over the next two weeks, adequate alpha blockade was achieved with titration of doxazosin dosage to thirteen mg two times daily. Uncomplicated adrenalectomy was then completed. Pathology showed a pheochromocytoma with retained SDHB, focal positivity for ACTH, and without capsular or vascular invasion. Conclusion: Routine critical care procedures such as extubation can trigger hypertensive crises in patients with pheochromocytomas. These episodes may be resistant to multiple intravenous anti-hypertensive agents. Titratable intravenous phentolamine can be used as a precautionary measure during necessary procedures if adequate alpha blockade with oral agents has not yet been achieved.

Presentation: Friday, June 16, 2023
SAT394 Over-representation Of Adoptees Among Transgender Subjects Seeking Gender-Affirming-Hormonal-Therapy (GAHT) In A Large Tertiary Medical Center
Authors: Yaish Iris , Keltch Gali , Greenman Yona , Kolitz Tamara , Tordjman Karen Michele
Published: October 2023

Disclosure: I. Yaish: None. G. Keltch: None. Y. Greenman: None. T. Kolitz: None. K.M. Tordjman: None.

Background: The etiology of transgenderism is still unclear. Possible mechanisms range from inborn brain-specific anatomical characteristics, to endocrine-related genetic polymorphisms. In addition, psychosocial developmental factors, particularly trauma from early childhood, are believed to contribute. In line with a handful of previous reports, we were struck by what seemed to be an over-representation of adoptees among adult subjects seeking GAHT at our Transgender Health Center. Aims of Study: To confirm that adopted individuals are more likely to seek a gender transition process than nonadopted subjects, and to determine whether there are major differences between the 2 subgroups. Design and Methods: A retrospective study of treatment-naïve adult subjects seeking GAHT at our center between 01.05.2014 and 31.12.2022. The prevalence of adopted subjects in the cohort was compared with the national rate by one sample binomial test. Adoptees were compared to nonadopted subjects in the cohort by nonparametric tests. Results: During the study period, 671 new adult transgender subjects initiated GAHT at our clinic. Among them, 14 adoptees or 2.09%, which is an order of magnitude greater than the corresponding national rate of 0.22% (P<0.0001). This rate is lower than that reported from clinics for transgender youth in Canada (7.6%), in the US (8.2%), and in Britain (3.8%). Age of adoption was at, or below, one year in 13 cases, and at age 2.7 yr in one. The distribution of assigned-at-birth sexes was different between the 2 groups. Among the 657 nonadopted subjects, the breakdown was quite balanced, 323 had been assigned male sex (49.2%), and 334 female (50.8%). Among adoptees, only 3/14 (21.4%) were born males, and 11 (78.6%) females, P=0.056, by Fisher’s exact test. There was also a trend for adopted subjects to be somewhat older than non-adopted subjects. Their median age was 25.5 yr [IQR 23-30.75], as opposed to 23 yr [IQR 19-30] in non-adopted subjects, P=0.08. Characterization, and comparisons of parameters such as socioeconomic status, co-morbidities, and others, are still ongoing. Conclusions: There is an over-representation of adopted adults requesting GAHT at our center. However, the rate is lower than what has been reported from pediatric clinics, suggesting some of these subjects may seek help at a younger age. The findings support a contributory role of adoption in early infancy and the trauma around it in the development of transgenderism. Further research should attempt to decipher the mechanisms through which this early life event interacts with inborn properties.

Presentation: Saturday, June 17, 2023
SAT396 Transgender Care From The VA Perspective
Authors: Nayak Pratima R
Published: October 2023

Disclosure: P.R. Nayak: None.

Background: Medically necessary care for transgender and gender non-conforming veterans was officially mandated in 2011 by the Veterans Health Administration. However, access to care can be difficult and tortuous to navigate. Additionally, the healthcare disparities experienced by transgender veterans extend beyond medical therapy; mental health services, appropriate sexual health education, and population specific needs and screenings are often inadequate.

In 2019, providers and staff at our VA medical center formed a multi-disciplinary team to provide coordinated and whole health focused gender-affirming care for this unique population. The team consists of an endocrinologist, mental health providers, social workers, clinical pharmacist, speech therapist, primary care provider, and a prosthetic representative.Case: A 32 year old transmale veteran with depression and bipolar disorder met with our social worker after expressing his desire to continue his transition. He had come out to his community and presented as male for over a year. He was referred to the endocrinologist who recommended egg harvesting prior to starting hormone replacement therapy per veteran's desire for biologic children. A social worker coordinated his consultation with a reproductive endocrinologist for the procedure. Simultaneously, a prosthetics representative helped veteran obtain a chest binder and a stand-to-pee device. Upon completion of egg harvesting, he started testosterone therapy, titrated to therapeutic levels.A year after starting hormones, he pursued top surgery and completed this locally. Due to ongoing menstrual bleeding on intramuscular testosterone, he was referred to ob-gyn and subsequently underwent hysterectomy and left oophorectomy. Post hysterectomy, he and his partner began experiencing relationship problems. They were referred to the sex therapist to work on their physical intimacy and sexuality. Three years on hormone therapy, veteran reported difficulty with the voice variations, though his voice had deepened to his liking far earlier in his medical transition. He started working with a speech therapist for voice masculinization with improvement noted at follow up. Conclusion: A multi-disciplinary approach to gender-affirming care is beneficial in providing patients with the care they deserve in a timely, respectful and coordinated manner. Our patient experienced a smoother and supportive transition due to the team of providers who were able to provide gender appropriate care across several disciplines during each phase of his transition. Without a team approach, this population often face several hurdles and delays to their transition. Since 2019, we have served over 50 transgender and gender non-confirming veterans in their transition. While not all have met their transition goals, most have benefited from the support and guidance of our team.

Presentation: Saturday, June 17, 2023
SAT403 Long-term Metabolic Effects Of Gonadotropin Releasing Hormone Agonist (GnRH) Therapy In Transgender Women Veterans
Authors: Le Guillaume , Pinkson Sheila , Trejo Jonathan , Hernandez Lyan Gondin , Mok Mary , Mendoza Amiel , Tripathy Devjit
Published: October 2023

Disclosure: G. Le: None. S. Pinkson: None. J. Trejo: None. L. Gondin Hernandez: None. M. Mok: None. A. endoza: None. D. Tripathy: None.

There is controversy regarding the effects of long-term GnRH agonist therapy on cardiovascular risk factors in older men with prostate cancer. GnRH agonists are used for gender affirming hormone therapy in adolescents and in adults who fail to suppress testosterone adequately. We examined the cardiometabolic effects of long-term GnRH agonist therapy in transwomen veterans. A retrospective chart review was performed on 74 transwomen veterans who were followed at the ALM VA Endocrinology clinic for at least 12 months and had detailed clinical, hormonal and biochemical profile (testosterone, estradiol, HbA1c, lipid profile) measured. Thirtytwo transwomen on GnRH agonist therapy (age 48 ± 2 yrs, BMI 28 ± 1 kg.m2) followed for 45 ± 5 months were compared with 22 transwomen (age 44 ± 3 yrs, BMI 28 ± 2 kg.m2) followed for 41 ± 7 months not on GnRH therapy. In the GnRH group, 14 were on oral E2, 12 on E2 patch and 6 were on E2 Injection. Similarly, in the non-GnRH group, the number of subjects on oral E2, E2 patch or E2 Injection were 17, 1, and 4 respectively. The average oral estrogen dose in both groups was 4 ± 0.4 mg. In the GnRH group, serum testosterone declined from 420 ± 36 ng/dl to 40 ± 5 ng/dL and serum estradiol before and after therapy was 39 ± 9 vs 89 ± 12 pg/mL. GnRH therapy led to increase in BMI (28 ± 1 vs 31 ± 2 kg.m2, p=0.006), though no difference was observed in SBP (126 ± 2 vs 120 ± 2 mmHg, p=ns), total Cholesterol (170 ± 7 vs 171 ± 8 mg/dL), HDL Cholesterol (45 ± 2 vs. 46 ± 2 mg/dL), LDL Cholesterol (98 ± 7 vs 99 ± 5 mg/dL) before and after treatment. There was no change in BMI (28 ± 2 vs 29 ± 1 kg.m2), SBP (121 ± 3 vs 125 ± 3, p=ns), total cholesterol (173 ± 5 vs. 170 ± 9 mg/dL), HDL chol (46 ± 2 vs. 49 ± 2 mg/dL), or LDL chol (97 ± 6 vs. 95 ± 7 mg/dL) in the control group. Plasma triglycerides increased in both the GnRH (134 ± 10 vs 168 ± 16 mg/dL, p<0.05) as well as in the control group (154 ± 30 vs 167 ± 20 mg/dL, p<0.05) after treatment. In conclusion, long-term estrogen therapy in transwomen increased plasma triglyceride. Concomitant GnRH agonist therapy was associated with greater weight gain, but did not affect other cardiovascular risk factors.

Presentation: Saturday, June 17, 2023
SAT405 Bone Analysis Of Transgender Women Amateur Athletes Undergoing Gender-affirming Hormone Therapy
Authors: dos Santos Lívia Marcela , Nakamoto Fernanda Patti , Simões Ferreira Raphael Einsfeld , Claudino Barbosa Renata Cleia , Costa Falcão Luiza Helena Degani , DIas Cruz Caroline Pinheiro , Achkar Gabriel Barasnevicius , Cardoso Sá Beatriz Meconi , Lima Fábio Mitsuo , dos Santos Quaresma Marcus Vinicius Lucio , Mobilia Alvares Leonardo Azevedo
Published: October 2023

Disclosure: L.D. Santos: None. F.P. Nakamoto: None. R.E. Ferreira: None. R.C. Barbosa: None. L.H. Falcão: None. C.P. Cruz: None. G.B. Achkar: None. B.M. Sá: None. F.M. Lima: None. L.A. Alvares: None.

Introduction: At the end of puberty, cisgender men (CM) have stronger bones and muscle mass than cisgender women (CW). Studies have shown a high prevalence of low bone mass in the general population of (transgender womenan) (TW). However, few articles are concerned with lean mass and bone mass in TW athletes. Objective: To assess the bone density of amateur volleyball TW athletes and compare them with CM and CW. Methods: A cross-sectional study was carried out with 8 TW (29 yo, range 27-36); BMI 24.1, range 19.3-31.7), 11 cisgender women (CW) and 8 cisgender men (CM) matched by age and BMI. The height (cm) of TW was 172 (range 164-181), that of CW was 176±0.1 and that of CM was 185±5.6. The TW had received hormone therapy for 3 (range 1-16) years. Measurements of BMD and body composition were taken with dual-energy X-ray absorptiometry. Results: The LS-BMD (lumbar spine) (g/cm2) of TW was 1.283 (range 0.9770-1.498), that of CW was 1.529±0.1614, and that of CM was 1.5115±0.1883 (TW vs. CW, p>0.05; TW vs. CM, p>0.05; CW vs. CM p>0.05). The FN-BMD (femur neck) (g/cm2) of TW was 1.203 (range 0.9660-1.332), that of CW was 1.337±0.1629, and that of CM was 1.4448±0.1334 (TW vs. CW, p>0.05; TW vs. CM, p<0.05; CW vs. CM p>0.05). Android/gynecoid (AG) ratio: TW: 0.85 (range 0.47-1.4); CW 0.73±0.13, CM 1.10±0.24. The lean corporal mass (kg) was 54.4 (range 44.3-66.9) in TW, 51.9±8.1 in CW, and 67.5±6.3 in CM (TW vs. CW, p>0.05; TW vs. CM, p<0.05; CW vs. CM p<0.05). Discussion: We observed lower bone density in TW amateur athletes undergoing gender-affirming hormone therapy, as well as in the general TW population. Despite the lack of statistical significance, probably as a consequence of the number of volunteers, the AG ratio was intermediate in TW. Lean mass was equal between TW and CW, unlike in the general TW population in other cohorts thay analyzed non-athelets. Conclusion: Despite their high volume of physical activity, there was a lower BMD in the TW group than in the other groups.

Presentation: Saturday, June 17, 2023