bluuebunny/crossref_metadata_2025_split huggingface dataset:
Calcitonin Non-Secreting Mixed Medullary-Papillary Thyroid Carcinoma: Report of a Rare Entity and Therapeutic Implications
Authors: Oleinikov Kira , Grozinsky-Glasberg Simona , Atlan Karine , Maimon Ofra , Popovtzer Aron , Weinberger Jeffrey M , Hirshoren Nir 
Published: May 2021

Abstract
Background: Medullary thyroid carcinoma (MTC) is a relatively rare and aggressive form of thyroid malignancy arising from parafollicular cells. The biochemical hallmark of MTC is elevated serum calcitonin (CTN), which aids initial diagnosis and disease surveillance. An atypical form of calcitonin non-secreting MTC has been previously described, with just over 50 cases published in the literature. This case report of a true mixed medullary-papillary thyroid carcinoma with a non-secretory medullary component is exceptionally rare. Clinical Case: A 67-year-old male presented with new-onset hoarseness and was found to have a 4 cm thyroid nodule replacing the right lobe with associated ipsilateral cord paralysis and ipsilateral cervical lymphadenopathy. The patient had no family history of endocrinopathies. A diagnosis of MTC was rendered at core-needle biopsy, based on the characteristic morphological findings and positive immunohistochemistry (IHC) for calcitonin (CTN) and CEA. Cervico-thoracic CT demonstrated tracheal and esophageal involvement by the tumor. The serum CEA was 8.7 pg/ml [0-5]; however, serum CTN was undetectable &lt; 2 pg/ml [2-8.2]. The patient subsequently underwent a total thyroidectomy with bilateral central neck dissection and right lateral neck dissection. Excision of the tumor necessitated the dissection of involved esophageal muscle from mucosa and removal of four tracheal rings with part of the cricoid. The surgical specimen demonstrated a single 3.6 cm tumor in the right thyroid lobe composed of medullary and papillary intermixed neoplastic cells (mixed MTC-PTC) with predominant medullary component and gross extrathyroidal extension. Positive IHC for calcitonin, CEA, and thyroglobulin confirmed the diagnosis. Out of ninety resected lymph nodes in total, five nodes were involved with medullary carcinoma (with extranodal extension), and three had papillary carcinoma micrometastases. Postoperatively, the patient underwent adjuvant external beam radiation to the surgical bed. At four-month follow-up, CEA levels were 1.4 pg/ml [0-5], TSH 0.04 µIU/ml [0.35-4.9] and thyroglobulin (Tg) with Tg Ab levels were undetectable. The patient continues close surveillance. Conclusion: Calcitonin non-secreting MTC management is challenging due to the lack of a reliable biomarker that aids initial diagnosis, surveillance, and prognostic stratification. Whether a rare form of non-secretory MTC represents a more aggressive variant is yet to be determined. The prognosis of patients with mixed MTC-PTC tumors appears to be driven by the medullary component that prioritizes the optimal surgical approach and further management.
Clavicular Metastasis as an Initial Presentation of Papillary Thyroid Cancer
Authors: Fung Russell K , Fasen Madeline , Warda Firas , Natter Patrick , Nedrud Stacey , Fernandes Rui , Alkhasawneh Ahmad , Gandhi Gunjan Yogendra 
Published: May 2021

Abstract
Background: Papillary thyroid cancer (PTC) metastases to the clavicular bone is rare. While the lung is considered the most common site of metastases from thyroid malignancy, osseous metastases, if seen, are usually observed at sites such as humerus, pelvis, radius, and scapula.
Clinical Case: A 44-year-old man presented with an enlarging right neck mass for six months after light trauma to that area. Other than mild pain in the described area, the patient reported 20 lbs of weight loss. Initial x-ray revealed a large soft tissue density mass that extended to the midline of the right proximal clavicle. Soft-tissue neck ultrasound noted a 5.4 x 3.6 cm mass extending from the thyroid with findings of increased vascularity and calcification. CT scan of the neck depicted the extension of the mass into the adjacent sternoclavicular junction with osteolysis of the middle third of the clavicle as well as the superior aspect of the sternal body. A fine needle aspiration of the mass revealed thyroid neoplasm with follicular features and positive immunostaining consistent with thyroid carcinoma. Chest CT showed invasion into the right proximal clavicle, tracheal deviation and extension into the mediastinum. The patient underwent a composite resection of the tumor, including a segmental osteotomy of approximately two-thirds of the medial clavicle. Post surgically the patient’s serum calcium was low at 7.9 mg/dL with a concurrently low PTH of 9 pg/mL and a low 25-hydroxyvitamin D of 16.8 ng/mL. Thyroglobulin was markedly high at 15655.0 ng/mL (confirmed on dilution), and thyroglobulin antibody &lt; 1.0 IU/mL. Pathology report confirmed PTC with extra-thyroidal extension and involvement of clavicle (staged pT4a pN0), however margins and lymph nodes were negative for carcinoma with further genomic findings showing positive KRAS mutation. The patient’s post-operative course was complicated by a large expanding left neck hematoma after a fall; he was immediately readmitted with the hematoma subsequently safely evacuated. Levothyroxine has been held at this time with plans for radioactive iodine treatment eight weeks after surgery.
Conclusion: Bone metastases from differentiated thyroid cancer is rare, especially clavicular metastasis arising from PTC. Bone scintigraphy, x-ray and fine needle biopsy are some of the widely utilized methods employed in the evaluation of bone metastasis in the setting of thyroid malignancy. The prospect of recovery is generally favorable in cases of bone metastases, however various factors can affect prognosis and long-term outcomes.
Reference: Krishnamurthy A. Clavicle metastasis from carcinoma thyroid- an atypical skeletal event and a management dilemma. Indian J Surg Oncol. 2015;6(3):267-270. doi:10.1007/s13193-015-0387-y
Diagnosis of Medullary Thyroid Cancer During COVID-19 Pandemic, the Benefit of Using a Standardized Protocol
Authors: Mortensen Michael , Dong JiaXi , Vinales Karyne Lima , Correa Ricardo Rafael 
Published: May 2021

Abstract
Introduction: The reported prevalence of malignancy in thyroid nodules ranges from 4% to approximately 10%, with a small percentage (~2-8%) being medullary thyroid cancer (MTC). During the COVID-19 pandemic, elective thyroid FNA was temporarily halted at our institution. In response to this, our institution has devised a new protocol to aid in the detection of MTC, which includes serum calcitonin measurement as a surrogate marker for potential MTC. A severely elevated calcitonin (&gt;100 pg/mL) is considered for surgery even without FNA diagnosis. We present a case of MTC that was detected due to the adopting of this protocol during COVID-19 pandemic at the Phoenix VAMC. Case Presentation: 71 year old male with an incidentally noted 3.0 cm solid, hypoechoic nodule with internal calcification, TI-RADS category 5. TSH level was normal at 3.309 mIU/mL. The patient denied any personal or family history of thyroid cancer, MEN syndrome, radiation exposure, or compressive symptoms. Following established protocol published by our institution in clinical thyroidology we performed a serum calcitonin that came back elevated at 1515 pg/mL (normal &lt; 10 pg/mL). Given the marked elevation in serum calcitonin levels and highly suspicious radiographic appearance of the thyroid nodule, we strongly suspected medullary thyroid cancer and elected to send him directly for total thyroidectomy without performing FNA. The patient underwent total thyroidectomy with central neck dissection. Pathology showed a 3.2 cm medullary thyroid carcinoma without extrathyroidal extension or perineural invasion. Lymphovascular invasion was present. 6/10 central comparement lymph nodes were positive for metastatic disease. Postoperative calcitonin level was 2 pg/mL. Discussion: Our patient had markedly elevated serum calcitonin levels in addition to a high-risk ultrasonographic features, which was highly suspicious for MTC. Per our COVID-19 protocol, we measured the serum calcitonin level to screen for MTC and then referred him directly to surgery without FNA given the high suspicion for MTC. By using this protocol, we were able to diagnose and treat MTC expeditiously. The measurement of serum calcitonin is still controversial in the U.S, with the ATA remaining equivocal on this method. We believe that our case can serve as a practical example that validates our institution’s use of calcitonin screening of thyroid nodules in diagnosing MTC during the COVID-19 pandemic.
Incidental Diffuse Sclerosing Variant Papillary Thyroid Cancer in Grave’s Disease
Authors: Canales Nicolle , Nieves Yadiel Rivera , Ortega Nydia Ivette Burgos , Castellano Janet Marie Colon , Cordero Nicole Hernández , Santini Alberto Javier Grana , Feliciano-Emmanuelli Melba , Gonzalez-Rodriguez Loida Alejandra , Alvarado Milliette , Ramirez Margarita , Carlo Victor J , Mojica Wilma Rodriguez , Pabón Marcel Mesa 
Published: May 2021

Abstract
The diffuse sclerosing variant papillary thyroid carcinoma (DSPTC) is an uncommon form of this neoplasm. Some studies describe its high propensity for tumor invasion, metastasis, and mortality compared with classic papillary thyroid carcinoma. Histologic features of DSPTC may resemble diffuse inflammation as seen with Grave’s or Hashimoto’s thyroiditis, which makes initial diagnosis challenging.
A 27-year-old female with Noonan’s Syndrome was evaluated on an outpatient basis after developing atrial fibrillation de novo. Thyroid function tests were consistent with hyperthyroidism with TSH: &lt;0.005 (n: 0.300-3.000 uIU/mL), FT4: 3.59 (0.71-1.85 ng/mL) and FT3: 16.77 (n: 2.0-7.0 pmol/L). Diffuse goiter was noted on physical exam, but no ophthalmopathy or dermopathy was present. TRAB and TSI were elevated at 38.4 (n: &lt;16%) and 423% (n: &lt;140%) respectively. A twenty-four-hour radioiodine uptake was 48% (n:10-35%) and described as essentially homogenous with two foci of decreased radiotracer concentration suggestive of cold nodules. Thyroid ultrasound showed diffuse nodularity bilaterally with associated clusters of calcifications and no discrete nodules. No abnormal appearing lymph nodes were identified. Fine-needle aspiration of both nodular areas was positive for DSPTC. Total thyroidectomy with central neck dissection was performed. Gross and microscopic post-surgical pathology confirmed the presence of diffuse sclerosing papillary thyroid cancer, along with local metastasis to one central lymph node. Patient was scheduled for radioactive iodine therapy.
Diffuse sclerosing variant is considered an aggressive histotype of papillary thyroid cancer. Ultrasound features include diffuse scattered microcalcifications with or without discrete nodules that may be confused with chronic inflammatory changes. Despite the limited number of cases, DSPTC is recognized to have specific characteristics, a high female to male ratio, and a young patient age. DSPTC has a high potential for aggressive biologic behavior if not treated promptly at the time of diagnosis. When suspected, total thyroidectomy with lymph node excision followed by radioiodine therapy has been proposed as the correct management to decrease the risk of persistent or recurrent disease.
Papillary Thyroid Carcinoma Within Thyroglossal Duct Cyst
Authors: Anbari Raghda Al , Xhikola Majlinda , Kadiyala Sushma 
Published: May 2021

Abstract
A 55-year-old female with medical history of hypothyroidism and fibrocystic disease of the breast presented with complains of a painful anterior neck mass, difficulty swallowing and hoarseness of the voice. Symptoms had progressed over a period of 5 months. CT neck with contrast indicated the presence of an ectopic thyroid tissue anterior to the thyroid cartilage measuring approximately 1.7 x 1.2 x 3.1 cm, with indistinct inferior margins and internal calcifications. The hyoid bone or thyroid cartilage had no irregularities. The thyroid gland itself was unremarkable except for small complex thyroid nodules in both lobes. No masses within the pharynx or larynx were noted.
Family history was significant for lymphoma in her father.
On physical exam, a hard, mobile right anterior neck mass was appreciated. Labs showed normal TSH of 1.05 uIU/mL and normal free T4 of 1.2 ng/dL.
Further evaluation with a dedicated neck US showed a right submandibular mass, superior to the thyroid, lobulated and heterogeneous measuring 2.0 x 1.0 x 2.3 cm with multiple areas of calcifications and internal Doppler flow. The thyroid gland had normal size and texture with bilateral sub centimeter non-concerning nodules.
After ENT evaluation and an unremarkable flexible fiberoptic nasolaryngoscope, patient underwent surgical excisional biopsy of the neck mass. Pathology was consistent with thyroglossal duct cyst with the presence of thyroid follicles. An incidental finding of a 0.9 cm papillary microcarcinoma was noted, which was encapsulated with focal extracapsular follicular structures showing papillary nuclear features with no perineural or lymphovascular invasion. The tumor cells were immunoreactive for TTF-1 and PAX8.
Development of papillary thyroid cancer within the thyroglossal duct cyst is a rare event, reportedly occurring in 1% of thyroglossal duct cysts. There are no well-established management guidelines.
Current management strategies consist of monitoring with serial neck ultrasound versus total thyroidectomy with consideration of postsurgical I-131 treatment, based on pathology results. Our patient opted for undergoing total thyroidectomy.
Percutaneous Polidocanol Injection as an Alternative Treatment in Differentiated Thyroid Cancer Oligometastasis
Authors: Alvarez Castillo Marlen Alejandra , Palomo Antonio Segovia 
Published: May 2021

Abstract
Introduction: Differentiated thyroid cancer (DTC) presents central lymph node metastasis in 20-50% and lateral in 12-86% of patients, the treatment of choice is surgical reintervention but it carries a higher risk of complications secondary to fibrosis formation in the surgical bed. Alternative nonsurgical therapies such as percutaneous ethanol injection (PEI), radiofrequency or laser ablation have been described. Objective: To report a case of oligometastasis in CDT which underwent percutaneous polidocanol injection (PPI). Clinical Case: A 35-year-old female who underwent a total thyroidectomy in 06-2019 for papillary thyroid cancer (AJCC: stage I/ ATA: intermediate risk), and ablative dose of 150 mCi I131, under treatment with levothyroxine 150 mcg/d. Hospitalized 02-2020 for progressive dysphonia of 2 months of evolution, with studies of TSH 0.04 mIU/ml, TgAb 13 IU/ml, Tg 0.5 ng/ml and neck USG: right lymph node level III of 0.97 cm in short axis, suspected of malignancy. Tg washout 4743.72 ng/ml (positive), 1cc of 1% polidocanol is administered, guided by USG. 7 days later with 0.90 cm in short axis, a second dose of 1% polidocanol was administered and a new Tg washout was taken, 2.4 ng/ml (indeterminate). She was reevaluated in the first and fourth months of the procedure, with 0.10 cm in the short axis and complete disappearance of the lesion, respectively. Control studies at the fourth month of TgAb 13 IU/ml, Tg 0.4 ng/ml. Discussion: PEI is described for thyroid cysts and adenomas and for cervical lymph node metastases, this is a minimally invasive procedure in the treatment of lesions smaller than 10 mm but requires multiple sessions and it can cause pain due to extravasation, skin necrosis and damage to the recurrent laryngeal nerve. It requires a follow-up time of up to 65 months, producing a reduction in serum Tg less than 2.4 ng/ml, a decrease in the size of the lesion and disappearance in 46% of the cases. In our center we have experience with PPI in thyroid cysts and adenomas since 2017, this requires fewer sessions and a lower dose, obtaining results of volume reduction in thyroid cysts of 80%. In this case we observed a reduction of 90% in the first month and disappearance in the fourth month, with a significant decrease in Tg washout from the first administration. Conclusion: Polidocanol is safe and effective so it should be considered in the treatment of oligometastasis in DTC.
Solitary Fibrous Thyroid Tumor: A Case Report
Authors: Mohamed Abubakr H B , Qureshi Faisal , Eldin Randa Sharag 
Published: May 2021

Abstract
Introduction: Solitary fibrous thyroid nodules are rare tumors and can mimic benign thyroid goiter and neoplasms. Case Description45 years old Caucasian female, with no significant past medical history, who presented to endocrinologyclinic for left neck mass evaluation. She denied previous history of thyroid disease, weight loss, cold/heatintolerance, menstrual irregularity, toxic or obstructive thyroid related symptoms. Her family history issignificant for maternal pancreatic cancer. Clinical exam was unremarkable except for left thyroid mass. An initial thyroid ultrasound showed left thyroid nodule 20 x16 x 25 mm in size five years prior topresentation. Repeated Fine Needle aspiration yielded benign follicular cells, histiocytes and fewlymphocytes. The nodule continued to increase in size reaching 46 mm in the long axis per thyroidultrasound at presentation to clinic. Her TSH, FT4 and total T3 remained within normal ranges. She wasreferred for surgical evaluation and underwent left thyroid lobectomy. Pathology reported 50 mm wellcircumscribed intrathyroidal neoplasm composed of spindle cells with pauci to moderate cellularity with noincreased mitotic activity, nuclear atypia, or necrosis. Immunohistochemistry was positive for STAT 6 andCD34and negative for PAX-8, TTF-1, S100 and SMA. The patient remains euthyroid with no lymph nodeor organ involvement after 5 years from initial presentation. Discussion: Solitary fibrous tumors (SFT) of the thyroid are rare although they have been described in differentanatomic sites (1). It presents as slow growing, painless, non toxic nodule in middle age of both sexes (1,2). The diagnosis of these tumors via FNA is difficult due to cellular paucity. Histologic findings may bechallenging due to shared features with other thyroid undifferentiated, papillary and follicular cancervariants. Immunohistochemistry are warranted to assist in confirmation-STAT6 and CD34 (3). SFT tumorsare mostly benign tumors and carries favorable prognosis. References: (1) Thompson, L.D.R., Wei, C., Rooper, L.M. et al. Thyroid Gland Solitary Fibrous Tumor: Report of 3 Cases and aComprehensive Review of the Literature. Head and Neck Pathol13, 597–605 (2019)(2) Ghasemi-Rad M, Wang KY, Jain S, Lincoln CM. Solitary fibrous tumor of thyroid: a case report with review ofliterature. Clin Imaging. 2019;53:105–107. doi: 10.1016/j.clinimag.2018.09.011.(3) Matoso A, Easley SE, Mangray S, Jacob R, DeLellis RA. Spindle cell foci in the thyroid gland: an immunohistochemicalanalysis. Appl Immunohistochem Mol Morphol. 2011;19(5):400–7.
A Case of Rare Autoimmune Pancytopenia Due to Graves’ Disease
Authors: Wang Ally Wen , Mahajan Geeti , Etra Aaron , Saul Shira R 
Published: May 2021

Abstract
Introduction: Graves’ disease has been associated with cytopenias, most commonly anemia. Pancytopenia is a rare complication and is not often encountered.
Case Presentation: A 54-year-old woman with history of multiple sclerosis on alemtuzumab was referred for abnormal thyroid function tests. At the initial visit, the patient reported a 20-pound unintentional weight loss, tremors, sweating and heat intolerance. She was 3 years post-menopausal and had no history of recent viral illness, contrast exposure or family history of thyroid disease. Physical exam revealed an anxious appearing woman with fine tremors in both hands, hyperreflexia but no lid lag or exophthalmos. Labs included TSH &lt;0.005 uIU/mL (0.400-4.2), free T4 2.89 ng/dL (0.80-1.50), TSH receptor binding antibody 8.24 IU/L (&lt; 2.00), TSI 7.27 IU/L (&lt;0.56), WBC 2900/uL (4500-11000), ANC 1746/uL (1900 - 8000), hemoglobin 11.4 g/dL (11.7-15.0) and platelet 207,000/uL (150,000-450,000). Thyroid ultrasound noted sub-centimeter hypoechoic/cystic nodules and 24-hour thyroid uptake showed 56.4% symmetric uptake (upper limit of normal 30%). Due to leukopenia, the patient was started on propranolol and underwent radioiodine ablation with 14.8 mCI. Two weeks later, she reported easily bruising and gum bleeding and her blood work was significant for pancytopenia. The patient was referred to hematology and two bone marrow samples were obtained. Though MDS/MPN was initially suspected based on atypia in both specimens, there were no immunophenotypic, cytogenetic or molecular abnormalities suggesting a neoplastic process. Instead the patient was thought to have autoimmune pancytopenia secondary to Graves’ and the atypia was believed to be secondary to peripheral consumption. She was started on prednisone 1 mg/kg/day with resolution of her cytopenias.
Discussion: Graves’ disease has been associated with hematological abnormalities including isolated anemia (the most common), thrombocytopenia or leukopenia. Pancytopenia is an uncommon complication and is rarely described in the literature. The exact mechanism remains unclear, but may be related to either reduced production of hematopoietic cells from the bone marrow or increased destruction of mature hematopoietic cells due to autoantibodies. Since thyroid hormones are known to increase erythropoietin, this leads to an exaggerated consumption of iron, folic acid and vitamin B12 and can cause various forms of anemias. Leukopenia may be secondary to immunologic destruction whereas thrombocytopenia may be due to antiplatelet antibodies or increased splenic sequestration. Pancytopenia is rare. Our patient was treated with high dose prednisone with resolution of her pancytopenia, which suggests an autoimmune process as the mechanism. Our case showcases a rare complication of Graves’ disease and highlights that high dose steroid therapy may improve cytopenias associated with this condition.