bluuebunny/crossref_metadata_2025 huggingface dataset:
PSAT287 Metastatic Thyroid Carcinoma from an Old Teratoma
Authors: Shaukat Mishal , Ahmad Mobeen , Ucciferro Peter
Published: November 2022

Introduction

Struma ovarii is rare and makes up 1% of all ovarian tumors out of which only 5-10% are malignant. We present the third reported case of delayed bony metastasis of malignant struma ovarii years after surgical removal.

Clinical Case

A 63 years old female with a medical history of cerebral palsy and teratoma resected in 2013, presented with complaints of right arm pain for 6 months in 2019. Routine lab work and X-rays of the right humerus were normal. An arthrogram showed a destructive process involving the proximal humeral meta-diaphysis, presumably malignant in etiology which was confirmed by a CT scan of the upper arm. A PET scan subsequently showed increased tracer activity associated with the right humeral head and neck along with replacement of marrow cavity by soft tissue density material. A fine needle aspiration of the lesion showed metastatic carcinoma of thyroid follicular origin. Serum TSH was 2.369 miu/ml (normal 0.350-5.500 miu/ml). An ultrasound of the neck demonstrated a normal thyroid without any identifiable nodules. She underwent radical resection of the right proximal humerus with endo-prosthetic reconstruction followed by postoperative radiation to the right shoulder. A repeat bone scan 3 months later showed increased activity in the ribs bilaterally and the distal right humerus. This was followed by a total thyroidectomy that showed no evidence of follicular cancer. A repeat TSH 8 weeks later came back at 88.36miu/ml but surprisingly even after the removal of thyroid gland the serum thyroglobulin remained elevated at 62.2 ng/ml (normal 2.8-40.9 ng/ml). This prompted a nuclear medicine thyroid whole body scan which revealed metastatic disease to the lumbar spine and multiple metastases to the abdomen. Treatment with radioactive iodine was started. The treatment, however was considered suboptimal in her case and she was started on radiation therapy which she is still receiving.

Discussion

Struma ovarii is a specialized ovarian teratoma made up of more than 50% mature thyroid tissue. Of these only 5-10% have malignant potential with less than 200 cases ever being reported. The NRAS, BRAF and JAK3 oncogene mutations have been implicated in the pathogenesis but the exact cause is unknown, resulting in the absence of any guideline directed therapy. The most common sites of metastasis are the peritoneum, mesentery and omentum. Bones are a less common metastatic site. Current treatment strategies include total thyroidectomy with iodine ablation and radioiodine scanning with serum thyroglobulin levels being followed as a tumor marker. It can rarely present as a late metastatic disease years after surgical resection of the tumor and a high index of suspicion is required to make the correct diagnosis.

Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.
PSAT289 Extranodal Marginal Zone B-Cell Lymphoma of the Mucosa-Associated Lymphoid Tissue (MALT) Type of the Thyroid: A Rare Tumor That Requires a Second Look
Authors: Isabel D. Villonco Francesca , Cadeliña Jekrylei I , Arquiza Christine Joy S , Villa Michael L
Published: November 2022

Background

Extranodal marginal zone B-cell lymphoma of the mucosa-associated lymphoid tissue (MALT) type of the thyroid, or MALT lymphoma of the thyroid, is a rare, indolent tumor that accounts for only 1-2% of extranodal lymphomas. It is often associated with lymphocytic thyroiditis - a benign condition that might not be given additional investigation.

Clinical case

A 79-year-old male consulted due to a 3-year history of a gradually enlarging, painless anterior neck mass accompanied by hoarseness. He denied fever, weight loss, dysphagia, dyspnea, palpitations, heat or cold intolerance, or changes in bowel movement. On physical exam, a 4×3×1 cm firm, fixed, non-tender right anterior neck mass and a 2×2 cm right supraclavicular mass were palpated. Thyroid function tests showed: TSH 3.301 uIU/mL (0.55 - 4.78 uIU/ml), FT3 2.560 pg/mL (2.30 - 4.20 pg/mL) and FT4 0.720 ng/dL (0.89 - 1.76 ng/dL). Neck ultrasound revealed multiple cervical lymph nodes measuring 1-2 cm in the right anterior, posterior, submandibular, and left submandibular areas. A lobulated heterogeneous mass measuring 9.7×2.9×4.3 cm occupied almost the entire right thyroid lobe, with intralesional and peripheral vascularity. The left thyroid lobe had an irregular, solid, isoechoic nodule measuring 0.9×0.5×0.9 cm. Fine needle aspiration biopsy of the right thyroid mass showed lymphocytic thyroiditis (Bethesda category II). The patient underwent total thyroidectomy with frozen section and selective neck dissection on the right (levels II, III, IV, and V). Final histopathology and immunohistochemical stains revealed extranodal marginal zone lymphoma of the thyroid gland, with high grade transformation to diffuse large B-cell lymphoma in 10% of the tumor. Level II, III and V lymph nodes were positive for marginal zone lymphoma. Histopathology also showed an adenomatous goiter with lymphocytic thyroiditis. The patient was started on levothyroxine 75 mcg once daily. He completed 1 cycle of chemotherapy (R-CHOP). Two weeks after chemotherapy, he developed febrile neutropenia and expired due to sepsis.

Conclusion

In thyroid nodules and masses where lymphocytic thyroiditis is identified on fine needle aspiration biopsy, particularly in large masses accompanied by cervical lymphadenopathy, the possibility of an existing MALT lymphoma of the thyroid should be considered, and further investigation may be warranted.

Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.
PSAT293 Uncommon Presentation of Hashimoto Thyroiditis
Authors: Alzenaidi Ahlam
Published: November 2022

Hashimoto thyroiditis (HT) is the most common cause of hypothyroidism in developed countries, which presents with diffuse goiter or atrophic gland. Staii et al. reported a 7.4 per cent prevalence of localized HT diagnosed by fine needle aspiration (FNA) cytology in euthyroid patients during thyroid cancer screening. Although, a transient solitary focal presentation of HT in euthyroid patients has not been described so far. Here we describe a case of localized HT presented with a thyroid mass peripartum, which progressed into diffuse thyroiditis after FNA biopsy.

A 27-year-old woman who is 10-day post-partum presents to our endocrine clinic for thyroid mass evaluation noticed by her spouse a few weeks before delivery. The patient has no hypothyroid, hyperthyroid, or mass effect symptoms. On the physical exam: BP 100/64 mmHg, Temp 36.5 C, HR 76 bpm, RR 20 bpm, BMI 24.6 kg/m2. There is a palpated 5-cm non tender right thyroid nodule. Thyroid stimulating hormone (TSH) is 2.04 uiu/ml (N: 0.3-4.2). Thyroid ultrasound (US) shows a 47×25×31 mm right hyperechoic nodule with some septation of hypoechoic areas. It has thin continuous halo, smooth but lobulated margins and Grade 3 doppler. No microcalcification is seen. Left lobe and isthmus are homogenous with no nodules. There is a reactive lymphadenopathy on the right cervical region. An ultrasound guided-FNA cytology shows clusters of follicular cells forming micro- and macro-follicles with background of hemorrhage but no colloid is seen. Cytology is suspicious of a follicular neoplasm, Bethesda IV category. Diagnostic Lobectomy is discussed but the patient opts for repeat biopsy at a different facility. She presents with a similar cytology result after 3 months. She elects follow up as she remains asymptomatic. After 6 months follow up, she has spontaneous reduction of the nodule size and it is not palpated. Neck US shows diffusely heterogeneous gland with hypoechoic areas and significant reduction in size of the right hyperechoic nodule to 22×14×11 mm. Ultrasound findings are suggestive of thyroiditis and further labs are requested. Thyroid peroxidase antibodies >1000 iu/mL (N: <5.61), anti-thyroglobulin antibodies 161.71 iu/mL (N: <4.11), TSH 3.4 uiu/ml (N: 0.35-4.9), free T4 is 10.38 pmol/L (N: 9-19), thyroglobulin 76.76 ng/mL (N: 3.5-77).

These findings suggest that HT may present as a localized form in euthyroid phase and should be considered in the differential diagnosis of thyroid nodule. Serologic evidence of HT and serial US follow-up should be recommended instead of other unnecessary procedures.

Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.
OR04-5 Circulating Cell-Free DNA-Based Biomarkers For Prognostication and Disease Surveillance in Adrenocortical Carcinoma
Authors: Altieri Barbara , Appenzeller Silke , Arlt Wiebke , Asia Miriam , Chortis Vasileios , Elhassan Yasir S , Fassnacht Martin , Kircher Stefan , Landwehr Laura-Sophie , Lippert Juliane , Prete Alessandro , Smith Gabrielle , Steinhauer Sonja , Urlaub Hanna , Ronchi Cristina
Published: November 2022

Adrenocortical carcinoma (ACC) is a rare aggressive cancer with heterogeneous behaviour. Disease surveillance relies on frequent imaging, which comes with significant radiation exposure. Here, we investigated the role of circulating cell-free DNA (ccfDNA)-related biomarkers for prognostication and monitoring of ACC.

We investigated 79 patients with ACC (29M/50F, 52±14yrs; 35 primary tumors [ACC-P] and 44 recurrences [ACC-R]); while 27 patients with adrenocortical adenomas [ACA] (9M/18F, 56±16yrs) and 19 healthy subjects (HS; 9M/10F, 37±9yrs) served as controls.

We extracted ccfDNA from 1-4 ml EDTA-plasma using Nonacus Cell3 Xtract or Qiagen QIAamp MinElute kit and quantified by fluorimeter (ccfDNA concentrations, Biomarker 1). Targeted next-generation sequencing (Illumina NextSeq500) was performed in a first subgroup of 52 baseline ccfDNA samples (23 ACC-P, 20 ACC-R, 8 ACA) using a customised panel of 30 ACC-specific genes (Cell3 Target Nonacus). Leucocyte DNA was sequenced to discriminate germline from somatic variants (Biomarker 2). Sequencing data from matched tumor DNA were available for 28 ACC (20 ACC-P, 8 R-ACC). A combined Biomarker score was calculated for prediction of clinical outcome. ACC-P had the highest ccfDNA concentrations (mean±SD 1.08±1.50 ng/µl) compared to ACC-R (0.29±0.23 ng/µl, P<0.05), ACA (0.17±0.13 ng/µl, P<0.005) and HS (0.11±0.07 ng/µl, P<0.005). Using a cutoff of 0.204 (median HS+2SD), 68% of ACC-P were postitive for Biomarker 1 (vs. ACC-R 55%, ACA 28%, HS 5%; P<0.0001 by Chi square test). At ccfDNA sequencing, 43% of ACC-P showed at least one somatic mutation (=positive Biomarker 2), vs. 15% in ACC-R and 0% in ACA. Mutational status at ccfDNA level matched with tumor DNA in 80% of cases. In 23 ACC-P with available sequencing data, the combined Biomarker score was strongly associated with both progression-free and overall survival (P<0.0001, HR 8.56, 95%CI 2.55-58.7, and P=0.0008, HR 13.3, 95%CI 3.77-47.1, respectively).

10 ACC-P were followed up for at least 6 months: 6 patients tumor-free at last CT scan were negative for Biomarker 1 whereas 3 out of 4 patients with early disease relapse were positive. In two recurrent cases, somatic mutations in ACC driver genes, i.e. MEN1 and ZNRF3, observed at baseline in both tumour and ccfDNA, remained detectable during monitoring.

In conclusion, ccfDNA-related biomarkers are frequently detected in patients with primary ACC. They may represent a promising, non-invasive tool to predict early disease progression and complement imaging in disease surveillance. Our findings on ccfDNA-based liquid biopsy will be validated in a larger cohort of ACCs with long-term follow up.

Presentation: Saturday, June 11, 2022 12:30 p.m. - 12:45 p.m.
PSAT329 A Delayed Diagnosis of Subclinical Hypothyroidism Due to Interferences with Thyroid Function Immunoassays
Authors: Khine Aye , Yin Ngwe
Published: November 2022

Introduction

Automated immunoassays used to evaluate thyroid function tests (TFTs) are susceptible to various forms of interference that can lead to inaccurate results and misdiagnosis.

Case Description

A 55-year-old male was diagnosed with abnormal TFTs since 2017 [TSH 7.32 mIU/L (range 0.4-4.5), FT3 5.1 pg/mL (range 2.3-4.2), and FT4 1.2 ng/dL (range 0.9-2.2)]. Thyroid peroxidase antibody and thyroglobulin antibody were positive. He was on levothyroxine 50 mcg daily since 2017, and he did not feel significantly different despite treatment. He was referred to endocrine clinic in 2021. He had no symptoms of hypothyroidism or hyperthyroidism except occasional palpitations and headache. He reported blurred vision due to cataracts. He denied thyroid diseases in first degree relatives. He denied taking biotin or desiccated thyroid extract. Physical examination was unremarkable. Differentials included TSH-producing adenoma, assay interference, exogenous T3 use, T3 thyrotoxicosis with interference of TSH assay, and thyroid hormone resistance. Levothyroxine was discontinued in May 2021. Other pituitary hormones including alpha-subunit and MRI pituitary were unremarkable, which ruled out TSH-producing adenoma. Human anti mouse antibody (HAMA) was normal. In June 2021, prior to seeing genetics, FT4, FT3 and Total T3 were checked with equilibrium dialysis method and values were 1.2 ng/dL (range 0.9-2.2), 238 pg/dL (range 210-440) and 105 ng/dL (range 76-181), respectively and TSH 9.13 mIU/L (range 0.40-4.50), thyroglobulin 0.6 ng/ml (range 2.8-40.9), reverse T3 LC/MS/MS 12 ng/dL (range 8-25). Labs were therefore consistent with subclinical hypothyroidism, and he was started back on levothyroxine 75 mcg every morning.

Discussion

TFTs are usually measured by automated immunoassays, and this will have accurate results in most cases. However, immunoassays are vulnerable to interferences that can affect clinical decisions. It is important to consider assay interference such as this and to confirm with equilibrium dialysis method before pursuing further aggressive workup.

Conclusion

Potential interferences in TFTs should always be suspected whenever discrepancies arise. Awareness of these conditions is critical to the institution of appropriate therapy and preventing misdiagnosis.

Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.
PSAT333 Case Of a Large Adenomatoid Hyperplastic Thyroid Goiter
Authors: Lott David , Moll Teresa , Subauste Jose , Garla Vishnu , Lien Lillian
Published: November 2022

An 81-year-old woman presented to the emergency department for evaluation of shortness of breath, dysphagia and chest tightness. In the emergency department, imaging was obtained, with CXR showing complete opacification of R hemithorax. Follow up imaging with CT Chest showed large mediastinal mass contingent with the right lobe of the thyroid, along with large volume (transudative) pleural effusion. Patient underwent thoracentesis with improvement in her shortness of breath, but chest tightness persisted. IR biopsy was obtained, which confirmed the mass was indeed thyroid in origin. At this time, Endocrinology was consulted for concerns of thyrotoxicosis, along with the goiter, as lab work returned with suppressed TSH (<0.01 mcIU/mL), normal Free T4 (1.14 ng/dL). On examination, the Endocrinology team found the patient to be clinically euthyroid, with normal vital signs and only ongoing complaints of chest tightness with deep inspiration. Decision was made to go forward with resection of the mass, with a multidisciplinary approach involving ENT and Cardiothoracic Surgery. The ENT team began the procedure by dissecting the right lobe from the remaining thyroid tissue. The gland was noted to track inferiorly and posteriorly into the chest, and the decision was made to truncate the portion of the gland superior to the clavicle. At the time it was felt that further manipulation of the gland was a high risk from this position. The patient was then handed off to the cardiothoracic surgery team who, using robotic assistance, took a transdiaphragmatic approach. After roughly 3 hours of dissection, the goiter was placed in an endo-catch bag and was able to be removed through a transabdominal/diaphragmatic incision. The remainder of the left lobe was safely left in place. In the end the removed portion of the goiter was found to be 13.7 cm in length and weighed 532 g. Average thyroid weight in iodine replete populations remains roughly 20 g. Pathology returned as adenomatoid hyperplasia in all 4 specimens. Postoperatively the patient did well and follow up with Endocrinology was scheduled.

Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.
PSAT337 Thyroid Storm Triggered by Thyroid Nodule Fine-Needle Aspiration Biopsy
Authors: Rios Paola , Eatz Tiffany Alyssa , PenaHerrera Carlos , Lagari Violet
Published: November 2022

Background

Thyroid storm is a severe and life-threatening thyrotoxicosis precipitated by an acute event such as thyroid gland manipulation, infection, trauma, or an acute iodine load. Patients with known hyperthyroidism or low TSH with the presence of multinodular goiter should undergo radionuclide thyroid scan before deciding on fine-needle aspiration (FNA) biopsy. We present a case of a patient with history of multinodular toxic goiter disease, who had a thyroid storm after she underwent an FNA thyroid biopsy, requiring emergent total thyroidectomy.

Clinical Case

62-year-old female patient with history of multinodular goiter (MNG) disease diagnosed in another country one year prior to admission. She was on methimazole for a few months but was off the medication upon presentation. She was admitted for evaluation due to worsening compressive symptoms. On presentation, she was hypertensive, tachycardic, with dysphonic voice and had a large goiter palpated bilaterally with extension over the sternocleidomastoid muscle. Laboratory results confirmed that she had thyrotoxicosis. TSH was 0.05 mclU/mL, n: 0.27-4.2mclU/mL; FreeT4 > 7.77 ng/dL, n: 0.93-1.70ng/dL; T3 was 552 ng/dL, n: 80-200 ng/dL; TSI and TRAB were elevated: 476 and 23 respectively. In view of this, methimazole 40 mg daily, prednisone 20 mg daily, cholestyramine 4 mg four times a day, potassium iodine 50 mg three times per day, and propranolol were started. Chest CT demonstrated a thyroid gland that was heterogeneous in appearance and markedly enlarged with a right thyroid lobe measuring approximately 6.2×5.8 cm and the left lobe measuring approximately 5.5×5.0 cm. Patient underwent ultrasound guided FNA biopsy of the right thyroid lobule ordered by another team two days after the medication regimen was initiated. One day after procedure, patient had altered mental status, stridor, acute respiratory failure, worsening of hypertension and tachycardia, requiring intubation. It was not possible to place an oral gastric tube, so propylthiouracil 400 mg was given via rectal route every 8 hours and her steroid dose was increased. Her FreeT4 decreased to 3.99 ng/dL and T3 to 165 ng/dL the following day. However, patient condition continued to deteriorate, and she underwent emergent total thyroidectomy, despite not being euthyroid. Patient tolerated the procedure and was able to be extubated the following day without postoperative complications. At the time of discharge, patient was on Levothyroxine 150 mcg oral daily.

Conclusion

FNA biopsy of toxic thyroid nodules are rarely indicated due to the risk of thyroid storm in patients with underlying hyperthyroidism. Control of the hyperthyroid state should be the priority prior to FNA of any thyroid nodule. Total thyroidectomy may be performed in the hyperthyroidism state as a life-saving procedure when there is failure control hyperthyroidism, as is the case here.

Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.
PSAT355 A Case Report Identifying Graves’ Ophthalmopathy in a Myasthenia Gravis Crisis and Response to Teprotumumab
Authors: Zia Abdul , Paul Kristy , Noor Abdullah , Hanson Jeremy , Romo Karina , Uwaifo Gabriel
Published: November 2022

Background

Thyroid disease is relatively common in patients with Myasthenia Gravis (MG), affecting 5%–10% of patients, conversely, the prevalence of MG in patients with Graves’ disease is 0.14%. Of thyroid diseases seen in MG, Graves’ Disease (GD) is the most common. Graves ophthalmopathy (GO) is a known complication associated with GD, however, in patients with MG, its identification may be difficult, as both GD and MG may present with similar ocular signs and subtle differences. This case identifies GO in a MG crisis and its response to teprotumumab.

Clinical Case

A 53-year-old-woman with MG presented with one year of worsening bilateral eye and arm weakness, fatigue, eye pain, headaches and palpitations. Examination revealed bilateral ptosis, eyelid edema, and ⅘ bilateral upper extremity strength. Workup revealed suppressed TSH (<0.010, n 0.5-5.0 ml U/L) and elevated antibodies: Thyroid Stimulating Immunoglobulin (4.86, n <0.54 IU/L) and Thyrotropin Receptor Antibodies (TRAb) (8.08, n ≤1.75 IU/L). Thyroid ultrasound showed several bilateral cystic nodules and increased thyroid parenchyma vascularity without thyromegaly, suggestive of GD. Thyroid Uptake and Scan showed diffusely elevated 24-hour uptake (71%, n 10-30%) consistent with GD. Treatment was initiated with methimazole 5 mg daily. At follow up, she had symptoms of eyelid weakness, diplopia, headaches, and muscle weakness. Graves’ Ophthalmopathy Clinical Activity Score (CAS) was 5/10. Examination showed bilateral ptosis with eyelid edema, proptosis, conjunctival redness, and chemosis. Extraocular muscle movements intact without pain, normal pupils and visual fields. Ophthalmology review and orbital CT showed bilateral exophthalmos with extraocular muscle thickening consistent with thyroid eye disease (TED). The classic coke-bottle-sign of the anterior tendon of the inferior rectus muscles was noted. Given her presentation, clinical course and progression of TED, she commenced a teprotumumab treatment trial. Clinical improvement of GO was noted upon follow-up assessment after 5 doses of teprotumumab: CAS 2/10, decreasing proptosis on exam, and TRAb (3.86, n ≤1.75 IU/L).

Conclusion

This case highlights the potentially misleading clinical findings and difficult diagnoses of coexisting GO and MG. Although muscular weakness is common in GD, concomitant MG is rare and may cause profound additional morbidity. Ocular signs in both diseases may cause diagnostic confusion, although ptosis is more consistent with MG and lid retraction with GD alone. GO can mimic some of the neuromuscular and ophthalmologic signs of MG and can be easily missed or mistakenly attributed to either MG or GD. This may result in a delayed diagnosis/inappropriate treatment of GO, thus, clinicians should maintain suspicion for coexisting diagnoses.

Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.
PSAT361 Severe Hyponatremia in a Patient with Myxedema Coma
Authors: Nemati Maryam , Rubinow Katya
Published: November 2022

Introduction

Patients with myxedema coma present with hypothermia, bradycardia, hypotension, altered mental status, and hyponatremia. We present an interesting case of myxedema coma with severe hyponatremia and discuss hyponatremia management.

Case presentation

Patient is a 67-year-old female with history of hypothyroidism following thyroidectomy for papillary thyroid carcinoma, hypertension, and medication nonadherence who was found down and brought to the hospital for altered mental status. On presentation she had a temperature of 35 °C, heart rate of 49, BP of 130/105, and intermittent O2 desaturations due to hypoventilation. On exam she was somnolent with nystagmus and lateral gaze deviation. She was moving all extremities. Lung and heart exam were normal. Labs showed sodium of 102 mEq/L (135-145 mEq/L) and serum osmolality of 243 mOsm/kg (280-300 mOsm/kg). TSH was 35U/mL (0.4-5 U/mL), and free T4 was <0.2 ng/dL (4.8-10.8 ug/dL). CBC and creatinine were normal. Head CT and chest XR were unremarkable. In the ER, she received hypertonic saline 3% as a 150mL bolus along with 1L of isotonic saline. Her sodium rapidly corrected to 117 mEq/L over 2.5 hours. She was given 3 doses of desmopressin 2mcg to control the overcorrection. She received hydrocortisone 100mg IV followed by 50mg IV q8hr. After the first dose of hydrocortisone, she was given levothyroxine 100mcg IV once followed by 75mcg IV daily. Hydrocortisone was discontinued after her cortisol level returned at 49 ug/dL (5.0-22.6 mcg/dL). Plasma sodium stabilized at 114meq/L in 48hrs. With continued IV levothyroxine alone, plasma sodium increased to 122 mEq/L by day 3 and then rose to 134 mEq/L on day 4. Free T4 improved to 0.4 ng/dL on day 3. Her mentation improved slowly and returned to baseline by day 6.

Discussion

In patients with chronic, severe hyponatremia, treatment usually entails hypertonic saline delivered either by bolus or continuous infusion with a targeted sodium correction rate of ≤8 mEq/L in any 24-hour period. However, when hyponatremia is due specifically to hypothyroidism, hypertonic saline confers high risk of overcorrection, as was evident in this patient. The pathogenesis of hyponatremia in myxedema coma is multifactorial, involving reduced free water clearance due to lower renal perfusion, inappropriately elevated ADH levels due to decreased cardiac output, and tubular dysfunction. Therefore, isotonic IV fluids and levothyroxine therapy directly address the mechanisms underlying hyponatremia and avoid the undue risk of hypertonic saline. Myxedema coma constitutes a unique context for the etiology and treatment of severe hyponatremia.

Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.
PSAT376 Utility of lncRNAs in thyroid cancer diagnosis
Authors: Kim Daham , Yu Juyeon , Kim Jiwon , Hwang Yoon-a , Kim Jin Kyong , Ku Cheol Ryong , Yoon Jung Hyun , Kwak Jin Young , Nam Kee-Hyun , Lee Eun Jig
Published: November 2022

Objectives

Improved molecular testing for common somatic mutations and identification of mRNA and microRNA expression classifiers have emerged as the most promising approaches for diagnosis of thyroid nodules. However, it is necessary to effectively increase diagnostic accuracy further. Currently, lncRNA research has moved to the forefront of human cancer research, as recent findings have revealed a crucial role of lncRNAs in gene modulation. We evaluated the diagnostic value of the selected lncRNAs from The Atlas of Noncoding RNAs in Cancer (TANRIC) thyroid cancer dataset.

Methods

Using TANRIC thyroid cancer dataset, we compared 12,727 lncRNAs from the thyroid cancer tissues of 59 thyroid cancer patients with paired normal thyroid tissues. lncRNAs with significantly increased or decreased expression in thyroid cancer tissues were selected as candidates for thyroid cancer diagnosis. The expression levels of candidate lncRNAs were confirmed in patients with thyroid nodules who underwent surgery at the Severance Hospital. Subsequently, the candidate lncRNAs were applied to actual fine needle aspiration to verify their diagnostic value.

Results

LRRC52-AS1, LINC02471, LINC02082, UNC5B-AS1, LINC02408, MPPED2-AS1, LNCNEF, LOC642484, ATP6V0E2-AS1, and LOC100129129 were selected as candidates for thyroid cancer diagnosis. The expression levels of LRRC52-AS1, LINC02082, UNC5B-AS1, MPPED2-AS1, LNCNEF, and LOC100129129 were significantly increased or decreased in malignant nodules compared to their expression levels in benign nodules or paired normal thyroid tissues in our surgical tissue samples. The combination of LRRC52-AS1, LINC02082, and UNC5B-AS1 showed favorable results, with 89% sensitivity and 100% specificity, for thyroid cancer diagnosis using fine needle aspiration.

Conclusions

lncRNA expression analysis could be a promising approach for advancing molecular diagnosis of thyroid cancer. Further studies are needed to discover lncRNAs of additional diagnostic value.

Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.
PSAT380 Characteristics and prognosis of Differentiated Thyroid Cancer in patients with Graves Disease
Authors: Panthi Sujata , Crow Hanna M , Bantis Leonidas , Choudhary Chitra
Published: November 2022

Background

The incidence of thyroid cancer in the United States and worldwide has increased 300% over the last three decades.1 Graves’ disease (GD) is the most common cause of hyperthyroidism. GD occurs due to activating antibodies to the TSH receptor. Thyroid-stimulating antibodies can result in intrinsic and genetic factors to favor the tumor growth process.2 Recent studies show that the incidence of thyroid cancer is higher among patients with GD when compared to toxic multinodular goiter.3 The current study compares the outcomes of Differentiated Thyroid Cancer (DTC) in patients with GD with non-GD patients.

Objective

The aim of the study was to compare demographics, pathology, stage, and prognosis of DTC in patients with GD with non-GD patients.

Methods

This was a retrospective chart review of 42 patients with a diagnosis of DTC with or without GD. Patients were selected using HERON (Healthcare Enterprise Repository Ontological Narration) software. We compared age at diagnosis, type and size of the tumor, radioactive iodine (RAI) use, and DTC recurrence amongst patients with GD with non-GD patients. We used the Chi-square to test for independence among the categorical variables at a nominal level of 0.05. The comparison of continuous variables was based on the t-test.

Results

The mean age of patients was 50 years (range 23–86). Out of 42 patients, 29 patients had GD and 13 patients did not have GD. 92% had papillary thyroid cancer and the mean tumor size was 1.3 cm (range 0.09–7.5). 86% of the patients had Stage 1 and 2 DTC. Patients with GD were diagnosed with DTC at a younger age (mean age 46 years) when compared to the patients without GD (mean age 59 years) with a p-value of 0.013. There was no difference in patients with GD in regard to the type of DTC (P = 0.54) and the stage of DTC (p-value 0.139). Both groups of patients had a similar rate of recurrence and RAI use (Table).

Conclusion

The current study concludes that patients with GD were diagnosed with DTC at an earlier age when compared to patients without GD. The stage of DTC and recurrence rate were similar in the two groups. The study was limited to a small number of patients.

Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.
PSAT383 Tension-free Thyroidectomy in the Treatment of Thyroid Cancer and Follicular Neoplasia: Experience of the First 100 Cases
Authors: Sleptsov Ilya , Sablin Ilya , Chernikov Roman , Pushkaruk Alexander , Fedotov Yuri
Published: November 2022

Background

and aims. The safety of thyroid surgery in terms of recurrent laryngeal nerve palsy and hypoparathyroidism was increasing in the last decade. In this study, we present a new method of tension-free thyroidectomy (TFT), which could be used to further decrease the complication rate after thyroidectomy.

Patients and Methods

The procedure is based on the medial approach to the recurrent laryngeal nerve and the parathyroid glands after the division of isthmus and successive total dissection of Barry ligament. One hundred consecutive patients (128 nerves at risk) underwent "tension-free thyroidectomy" (TFT) from August to November 2021 performed by one surgeon. There were 80 females and 20 male patients (ratio 4: 1) with a mean age of ninety-two 46,4 (range from 17 to 75). Lobectomy was carried out in 74 (74%) patients, total thyroidectomy in 26 (26%). In 42 cases patients additionally underwent central or/and lateral neck dissection. Indications for surgery were papillary carcinoma (N=52), medullary cancer (N=2), follicular neoplasia - Bethesda IV group after fine-needle biopsy (N=46). Mean thyroid nodule size was 25,3 mm (ranged 7 - 120 mm). Intraoperative transient neuromonitoring was used in all the cases (5 mA), in 20 cases permanent neuromonitoring was also used. Translaryngeal untrasound or direct laryngoscopy were routinely used prior and after surgery to evaluate vocal cords mobility. Calcium and parathormone level were measured in patients after thyroidectomy on the first, 14th and 30th postoperative days.

Results

The mean operating time of lobectomy was 80±39 (range: 25-120), for total thyroidectomy 80 ±36 (range: 55-130). There was no conversion to the conventional lateral-to-medial approach. No fluctuation of electric activity of laryngeal nerves during surgery was revealed. Intraoperative loss of signal (LOS) due to thermal effect of electrocautery and subsequent transient unilateral laryngeal nerve palsy occurred in 3 cases (2,3% from the total number of nerves at risk). In all these patients normal vocal fold function was confirmed on the 30th day after surgery. No permanent nerve palsy cases revealed. Three patients (out of 26 in the total thyroidectomy group – 11,5%) exhibited a decrease of parathyroid hormone level on the postoperative day 1 which was resolved in two weeks under the substitution therapy with calcium and alfacalcidol. No cases of permanent hypoparathyroidism occurred.

Conclusion

TFT (tension-free thyroidectomy) can be considered a safe and feasible operation in patients with thyroid cancer and follicular neoplasia. Larger and comparative (randomized) studies with conventional dissection technique should be performed to investigate the hypothesis that this approach can provide a lower complication rate.

Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.
PSUN38 Incidence and prognosis of amiodarone induced thyroid dysfunction: a nationwide cohort study in Korea
Authors: Sohn Seo Young , Cho Sung Woo , Lee Jae Hyuk
Published: November 2022

Background

Amiodarone is commonly associated with thyroid dysfunction. Incidence of amiodarone induced thyroid dysfunction is variable in the literature and prognosis of patients who developed amiodarone induced thyroid dysfunction compared to euthyroid patients is still unclear.

Results

During a mean follow up of 7.4 years, 777 (3.9%) developed thyrotoxicosis (incidence rate 3.96 per 1000 person years) and 2,225 (11.3%) developed hypothyroidism (incidence rate 11.93 per 1000 person years). Patients with thyrotoxicosis or hypothyroidism had a lower MACE rate compared to euthyroid patients (45.2% vs. 50.2% and 48.5% vs. 50.2%). Multivariate analysis revealed that older age (>65 years), chronic kidney, ischemic heart disease and chronic obstructive lung disease were independent risk factors of MACE. Patients who developed thyrotoxicosis or hypothyroidism had a lower risk of MACE than euthyroid patients (HR=0.75 [95% CI: 0.68-0.83] and HR=0.73 [95% CI: 0.69-0.77]).

Conclusion

The incidence of amiodarone-induced thyrotoxicosis was higher compared to hypothyroidism. The patients with thyrotoxicosis or hypothyroidism had lower cardiovascular events in patients treated with amiodarone.

Presentation: Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m.
RF11 | PMON26 A Lump By Any Other Name: A Case of Diffuse Large B Cell Lymphoma of the Thyroid
Authors: Farghani Saima , Minhas Simran
Published: November 2022

Patient is a 49-year-old female with a past medical history of hypothyroidism who presented to the endocrinology office for evaluation of a neck mass. A thyroid ultrasound in 2020 had shown significantly enlarged and diffusely heterogenous thyroid gland compatible with diffuse thyroid goiter without nodules. Her neck swelling worsened and therefore a thyroid ultrasound was repeated and showed a large hypoechoic nodule in the left thyroid gland. She had no symptoms such as night sweats, fevers, or weight loss. A computed tomography (CT) scan of the neck with contrast was obtained on 7/20/2020 showing a markedly enlarged thyroid gland with multiple >1 centimeter (cm) thyroid nodules, with a suspected exophytic extension nodule medial to the left lobe. Multiple adenopathy was present with an enlarged left lower cervical lymph node and a right-sided level 4 lymph node concerning for thyroid malignancy with local metastatic disease. She underwent a fine needle aspiration (FNA) with flow cytometry of the lymph node on 9/2/2020 which was benign. Her goiter continued to increase in size and she was referred to endocrine surgery for fine needle core biopsy of the left thyroid nodule which was favorable for diffuse large B cell lymphoma (DLBCL) with a germinal center phenotype on 4/5/2021. Flow cytometry was positive for CD-10 mature B cells. FNA biopsy of the left lower cervical lymph node showed polymorphic lymphocytes and rare macrophages. She was staged IIE. She underwent 4 cycles of rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP) and received 18 rounds of consolidation radiation after completion of chemotherapy. She had near-complete response to treatment and is now monitored through routine follow-ups. Primary thyroid lymphoma is a rare condition characterized as a lymphomatous process involving the thyroid gland without any contiguous spread or distant metastasis at the time of diagnosis. It comprises nearly 1% to 5% of all thyroid malignancies and is more common in women. DLBCL is the most common histiotype and accounts for 50% to 70% of all cases. Patients may notice a unilateral or bilateral rapidly enlarging neck mass with compressive symptoms, but B symptoms are less common. Nearly 30% to 40% of patients carry a diagnosis of hypothyroidism at the time of diagnosis as the lymphomatous process replaces the normal thyroid parenchyma. Diagnosis is made usually via core needle biopsy and flow cytometry since FNA biopsy is frequently inconclusive. Treatment is with chemotherapy, usually R-CHOP, and radiation therapy with an overall 5-year prognosis of 34.5%. Surgical decompression may be necessary if compressive symptoms are present. While this is a rare disease, providers should be cognizant of DBLCL especially when faced with a presentation such as the one summarized in this report.

Presentation: No date and time listed
RF11 | PSAT249 Radiofrequency Ablation for Thyroid Nodules: The First Ecuadorian Prospective Cohort
Authors: Naranjo Eddy P Lincango , Garcia Cristhian , Tana Andrea S Cho , Cordero-Garate Juana , Solis-Pazmino Paola , Godoy Richard
Published: November 2022

Introduction

Radiofrequency ablation (RFA) is a promising, non-surgical method, used for the treatment of benign and malignant thyroid nodules (TN). While this minimally invasive technique has been studied extensively in Europe and Asia, it has been recently adopted in Latin America. The aim of our study is to describe the clinical outcomes following the first cohort of TN subjected to ablative radiofrequency in Ecuador.

Methods

This single-center, prospective study, carried out at ITECC (Instituto de la Tiroides y Enfermedades de Cabeza y Cuello) in Ecuador, included adults who underwent RFA for benign and malignant thyroid nodules (TN), between September 2020 and January 2022. The trans-isthmic approach and moving shot technique using the RF Medical equipment with an 18G needle and 5 or 7 mm tip were applied. Nodule size and volume, thyroid function, and complications were evaluated before and after RFA. Initial volume and change in TN volume were calculated with the ATA calculator and the independent-samples T-test.

Results

A total of 26 patients with 28 TNs were included. 25 TNs were benign (Bethesda II) and 3 were micropapillary thyroid cancer (MPTC) (Bethesda VI). In the benign lesions group, most were female (82.6%), <55 years of age (73.9%), euthyroid (62.5%), and symptomatic (95.6%); had a mean maximum diameter of 3.3 ± 1.3 (range: 0.8–5.5) cm and a mean initial volume of 13.1 ± 11.6 ml; and had predominantly solid component (36.4%). A substantial volume reduction was observed since the first month after RFA (1 month: mean volume 8.6 ± 4.2 ml, p=0.01; 6 months: mean volume 4.5 ± 3.9 ml, p=0.04; and 12 months: mean volume 4.9 ± 6.9 ml, p=0.25; vs. baseline). All patients were asymptomatic at the last follow-up. In the MPTC group, two patients were males (66.7%); all were <55 years of age (100.0%) and euthyroid (100.0%); most were asymptomatic diagnosed by routine US (66.7%); had a mean maximum diameter of 0.6 ± 0.1 (range: 0.5–0.8) cm and a mean initial volume of 0.056 ± 0.001 ml. At 1-month follow-up after RFA all TN were fibrosed and no lymph node or distant metastases were found. Finally, in both groups, no major complications were found and only one patient reported ecchymosis at the puncture site. Thyroid function was not affected.

Conclusions

To the best of our knowledge, we are the pioneers in Ecuador and the third country, after Brazil and Colombia, in Latin America that implemented RFA in the management of TN. In our first experience, RFA was a safe and effective technique. RFA induced a substantial volume reduction, improved symptoms, avoided cosmetic concerns, and did not affect normal thyroid function. Our results are consistent with other series. Data on a longer follow-up are needed to confirm long-term efficacy.

Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m., Saturday, June 11, 2022 1:30 p.m. - 1:35 p.m.
RF23 | PSAT258 Comparable Bioavailability of a Novel Levothyroxine Solution taken 10 or 30 minutes prior to a High-Fat, High-Calorie Breakfast
Authors: Washington Kris , Baron Michelle , Vandse Sunil
Published: November 2022

Levothyroxine (LT4) is the recommended treatment for hypothyroidism and the second most prescribed medication in the US. Several formulations are available, however most patients take LT4 tablets. Evidence suggests that absorption of levothyroxine tablets is decreased when taken with food, especially those rich in soy, iodine, and fiber. In order to avoid erratic absorption of LT4, it is recommended that oral formulations are taken on an empty stomach, 30-60 minutes before breakfast. However, compliance with this recommendation is often difficult for patients with busy schedules or on multiple medications, yet important in patients with conditions that are sensitive to changes in TSH levels such as pregnancy and thyroid cancer.There is evidence that oral liquid LT4 formulations that bypass the gastric dissolution phase of absorption may mitigate this food effect. ThyquidityTM (levothyroxine sodium) oral solution has demonstrated bioequivalence to Synthroid® under fasting conditions and allows individualized dosing flexibility. A bioavailability study was conducted to assess the rate and extent of absorption of the oral LT4 solution (100 mcg /5 mL) administered either 10 or 30 minutes before a standardized high-calorie, high-fat breakfast in an open-label, randomized, single-dose, 2-period, 2-sequence, crossover study. A single 600 μg oral dose of LT4 solution (ThyquidityTM, 30 mL) was administered to healthy adults either 10 or 30 minutes before consuming a 950 kcal, high fat (56%) breakfast in each study period and blood was collected for total (bound and free) T4 for 48 hours after drug administration. Treatment periods were separated by a 40-day wash-out period.The ratios of geometric LS means with corresponding 90% confidence intervals were calculated from the exponential of the difference between the LT4 solution administration 10 and 30 minutes prior to the meal for AUC0-48 and Cmax. An absence of food effect (bioequivalence) would be concluded if the baseline corrected 90% confidence intervals of this ratio fell within 80.00% to 125.00% for Ln-transformed AUC0-48 and Cmax.Forty healthy volunteers participated in the trial, 38 were included in the data analysis. There were no serious adverse events or discontinuations due to AEs. The geometric LS mean ratios of AUC0-48 and Cmax for baseline-adjusted LT4 were 88.74% (84.71-92.95%) and 85.07% (81.1-89.33%) respectively. The corresponding 90% CIs were included within the acceptable range for bioequivalence, indicating the absence of a meaningful difference in LT4 absorption when administering at 10 or 30 minutes before a meal.Based on these results, it may be possible to decrease the interval between the administration of Thyquidity (levothyroxine sodium) oral solution to 10 minutes before breakfast, thus offering patients further dosing flexibility.

Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m., Sunday, June 12, 2022 12:36 p.m. - 12:41 p.m.
RF23 | PSAT306 Thyrotoxic Periodic Paralysis: An Uncommon Complication Presenting From an Unsuspected Demographic
Authors: Deb Avijit K , Smith Allison , Aiya Utsav , Rashid Rakin , Harxhi Rea , Ruby Edward
Published: November 2022

Background

Thyrotoxic Periodic Paralysis (TPP) is a rare complication of thyrotoxicosis mostly reported in Eastern Asian countries with relatively few known cases among non-Asian diaspora in the West.

Case

A 28-year-old African American male with no documented medical history reported to the ED with concern for mechanical fall secondary to progressively worsening muscle weakness. Symptoms began the prior evening with proximal lower extremity and bilateral shoulder weakness which then became severe generalized weakness in all four extremities by morning prompting a fall due to unstable gait and inability to maintain stable seated position. A 60 lb weight loss over the prior year was also noted. Vital signs were notable for blood pressure 154/67 mmHg, tachycardia 109 beats per minute, and tachypnea 20 breaths per minute. Initial labs were significant for hypokalemia 2.2 mEq/L (3.5–5.5 mEq/L), hs-troponin 59 ng/L (n < 20 ng/L), CK 444 U/L (38–174 U/L), ALP 186 U/L (35–110 U/L), TSH < 0.01 uIU/mL (0.35–5.5 uIu/mL), free T4 4.13 ng/dL (0.61–1.12 ng/dL), free T3 15.10 pg/mL (2.5–3.9 pg/mL) and total T3 404 ng/dL (87–178 ng/dL). EKG revealed sinus tachycardia with prolonged PR-interval to 236 ms and prominent precordial U-waves. The patient was given potassium chloride 40 meq IV and PO supplementation, started on propranolol 10mg PO QID and methimazole 30mg PO daily, and admitted to telemetry. Endocrinology recommended increasing the methimazole dose to 20mg PO TID. Thyroid ultrasound revealed a heterogeneous hyper-vascular gland. Follow up labs included: thyroid stimulating immunoglobulin 4.97 IU/L (n < 0.10 IU/L), thyroid peroxidase antibody 19 IU/L (n < 9 IU/mL), gamma glutamyl transpeptidase 22 (9–65 U/L). Findings were consistent with Graves’ disease. Repeat metabolic panel showed appropriate potassium response to supplementation trending between 3.9 meq/L to 4.2 meq/L at six-hour intervals. Hs-troponin peaked at 108 ng/L likely due to demand ischemia in the setting of persistent tachycardia. Follow-up 2D echocardiogram was remarkable for borderline LVH with 60% EF. Patient displayed rapid improvement in muscle strength as potassium normalized; creatine kinase trended down to 49 U/L with resolving myopathy. Patient was discharged on methimazole 20mg PO TID and propranolol 10mg PO QID and told to increase PO intake of potassium rich foods. He was advised to avoid strenuous activity for at least 2 weeks.His potassium was 4.5 meq/L on follow-up endocrinology appointment one week after discharge. He did not endorse residual symptoms and remained compliant with medications.

Conclusion

This is a case of TPP amidst undiagnosed Graves’ disease that resolved with timely potassium repletion. Documented TPP cases in non-Asians, especially African Americans, are rare and should be investigated further.

Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m., Sunday, June 12, 2022 1:12 p.m. - 1:17 p.m.