bluuebunny/crossref_metadata_2025_split huggingface dataset:
8742 Exploring the Clinical Landscape of Papillary Thyroid Microcarcinoma with Lymph Node Metastasis: A Single-Institution Case Series and Implications for Treatment Decisions
Authors: Manas F N U , Nakdali Rama , Almajali Dina Aljbour , Bhan Arti , Simon Rebecca 
Published: October 2024

Abstract
Disclosure: F. Manas: None. R. Nakdali: None. D. Aljbour Almajali: None. A. Bhan: None. R. Simon: None.
Introduction: Papillary thyroid microcarcinomas (PTMC) refer to papillary thyroid carcinomas with primary tumor size ≤ 1cm. Characterized by their indolent nature, PTMCs boast a mortality rate of less than 1%. Loco-regional spread occurs in approximately 2-6% of cases, while distant metastasis is observed in about 1-2%. Notably, the rate of recurrence after lymph node (LN) metastasis can reach up to 20%. The optimal management of PTMC remains controversial with some studies suggesting no discernible difference in clinical outcomes between patients undergoing active surveillance and those opting for surgical removal. There is limited research on thyroid cancer oncogenes that can predict the progression of PTMC outside of the thyroid gland. We report the clinical outcomes of a series of patients with PTMC who presented with LN metastasis at our institution.Case Series: We describe five patients diagnosed with papillary thyroid microcarcinoma with LN metastasis. All patients presented with a neck mass and evaluation by fine needle aspiration (FNA), showed papillary thyroid cancer. The tumor sizes ranged from 0.15 cm to 1 cm and all cases had extensive LN involvement, with sizes ranging from 0.7 to 4.5 cm. All patients received adjuvant RAI according to ATA guidelines. Molecular testing was not available for any of these patients.Discussion: Our case series offers valuable insight into the clinical outcomes of individuals with PTMC who underwent total thyroidectomy with LN dissection. We postulate that there are two separate groups of patients with PTMC. One group with indolent disease, which lends itself to careful follow-up, even without surgery, and the other group with aggressive disease at presentation. The challenge lies in the correct classification of the patient at baseline so that therapy is tailored to the type of cancer. We need better predictors of disease severity so that patients can be risk-stratified appropriately. The absence of clear guidelines regarding the optimal extent of surgery for PTMC adds complexity to treatment decisions. Nevertheless, our case series sheds light on the infrequent occurrence of PTMC with LN metastasis. It is noteworthy that despite the absence of a mutational profile for these patients, consistent with prior small-scale studies, no genetic alterations have been identified as reliable predictors of LN metastasis in PTMC. Our findings underscore the imperative for further investigative studies to enhance our ability to predict more aggressive cases of PTMC. By addressing the gap in knowledge, future research endeavors may contribute to the refinement of treatment strategies for individuals with PTMC.
Presentation: 6/1/2024
8713 Fluctuating Graves' Disease: A Rare Complication of Alemtuzumab
Authors: Tran Brandon , Woodfield David A , Poudyal Dinesh , Majety Priyanka 
Published: October 2024

Abstract
Disclosure: B. Tran: None. D.A. Woodfield: None. D. Poudyal: None. P. Majety: None.
Background: Alemtuzumab is a monoclonal antibody approved for the treatment of relapsing-remitting multiple sclerosis. Its principal adverse effect is the development of autoimmunity. Thyroid autoimmunity is most common occurring in about 17% to 34%, with Graves’ disease (GD) comprising 60% to 70% of these cases. Alternating hypothyroidism and hyperthyroidism occur rarely in GD. Thyrotropin Receptor Binding Antibodies (TRAb) are functionally heterogeneous and can coexist in the same individual. They can be either stimulating, blocking, or neutral. Spontaneous switch between hypo- and hyperthyroidism, which can be bidirectional, occurs rarely and is thought to be due to a shift in the ratio between blocking and stimulating TRAbs. Clinical Case: A 42-year-old black woman with multiple sclerosis was treated with Alemtuzumab between 2019-2020, before which she was noted to have normal thyroid function tests. In 2022, she presented with hypothyroid symptoms and anterior neck pain with a Thyroid Stimulating Hormone (TSH) of 34.6 (0.35-4.94 uIU/mL) and elevated Thyroid-peroxidase (TPO) antibodies of 76 (0-34 IU/mL). She was started on levothyroxine 175 mcg. Over the next six months, her TSH gradually decreased and eventually became undetectable. Although the levothyroxine dose was gradually tapered, followed by complete cessation, she remained hyperthyroid, both clinically and biochemically. She had symptoms of palpitations, tremors, diaphoresis and a 20 lb weight loss. Additional workup was notable for elevated Thyroid-stimulating Immunoglobulin (TSI) at 19.3 (0-0.55 IU/L) and TRAb at 20 (0-1.75 IU/L). A radioactive iodine uptake scan showed increased and uniform tracer uptake of 72%, confirming GD. She was initially treated with methimazole (MMI) 20mg daily with rapid improvement. MMI was quickly tapered to 2.5mg daily within 2 months and while on this dose, her TSH rose to 58.2 necessitating cessation of MMI. Conclusion: This case illustrates the importance of continued monitoring for autoimmune thyroid complications, in patients receiving Alemtuzumab for multiple sclerosis, even after cessation of treatment. In patients presenting with hypothyroidism, both TPO and TRAb should be checked. Patients with TRAb-positive hypothyroidism should be closely monitored for potential fluctuation in disease course.
Presentation: 6/1/2024
9188 Hashitoxicosis To Graves': A Case Of Fluctuating Thyroid Autoimmunity Induced By The Covid Vaccine
Authors: Lamar K , Meda N , Straughan J , John D , Suryanarayanan S K 
Published: October 2024

Abstract
Disclosure: K. Lamar: None. N. Meda: None. J. Straughan: None. D. John: None. S.K. Suryanarayanan: None.
Introduction: Thyroid antibodies are essential for identifying autoimmune thyroid disease. In Graves' disease thyroid stimulating immunoglobulin (TSI) is crucial to diagnosing, guiding treatment, and determining prognosis for ophthalmopathy; thyroid peroxidase (TPO) antibody is likewise crucial in the diagnosis of Hashimoto’s Thyroiditis. Conversion between these two diseases is extremely rare. Case: The patient is a 60-year-old female with a medical history of hypertension, asthma, T2NxM0 low grade gastrointestinal stromal tumor (GIST), and hyperaldosteronism who was referred to the endocrine clinic for “thyroid disorders'' with symptoms including weight gain and palpitations. Her labs showed thyroid stimulating hormone (TSH) &lt;0.01mIU/L, free Triiodothyronine (fT3) 6.5ng/mL, free Thyroxine (fT4) 1.6ng/dL, TPO antibodies 46IU/mL, negative TSI antibodies 102%, and a negative Thyroglobulin antibody (Tg Ab) &lt;1IU/mL. A slightly enlarged thyroid was noted on ultrasound. Radioactive iodine uptake (RAI) was normal with 15% uptake at 6 hours and 25% at 24 hours. These findings led to the diagnosis of Hashimoto thyrotoxicosis. She started methimazole 10mg and atenolol 50mg. One year later, she received the Pfizer mRNA COVID-19 vaccine and had her GIST tumor resected. She then began switching between hyper-, hypo-, and euthyroid states with multiple titrations of her Methimazole dose. Repeat testing demonstrated a positive TPO 41 IU/mL, negative Tg Ab &lt;1, positive TSI 294%, and positive RAI with 47% uptake at 6 hours and 61% at 24 hours, consistent with Graves’ disease. It was found that even minor titration by 2.5mg in her Methimazole led to profound changes in her thyroid laboratory values and symptoms. She underwent total thyroidectomy and was started on levothyroxine with significant improvement. Discussion: This patient initially presented with antibodies as well as low uptake on the radio-iodine scan indicating her state of hyperthyroidism was due to Hashitoxicosis, but then later these tests were repeated and were more indicative of Grave’s disease. This was possibly due to immune challenges in the patient, assay inter-variability of thyroid autoantibodies, or an effect of the patient receiving the COVID vaccine. The phenomenon of TSI antibodies converting from negative to positive has not been well documented previously. The goal of this case was to report an interesting conversion of Grave’s disease identifying antibodies and the importance of evaluating underlying immune challenges which could play a role in altering clinical disease.
Presentation: 6/1/2024
8112 Hyalinizing Trabecular Tumor of the Thyroid in a Patient with Familial Adenomatous Polyposis
Authors: Kelly C , O’Donnell B M 
Published: October 2024

Abstract
Disclosure: C. Kelly: None. B.M. O'Donnell: None.
A 33 year old female presented to the Endocrinology clinic for evaluation of a 1.4 cm thyroid nodule. She has a relevant past medical history of Familial Adenomatous Polyposis (FAP). She was diagnosed with FAP in her early 20s after she had developed hematochezia. When she underwent her first endoscopy she reports there “were hundreds of polyps” as well as multiple stomach ulcers/polyps. In 2012 she underwent a total proctocolectomy with ileal pouch-anal anastomosis (IPAA). Then in August 2023 the patient underwent a Whipple procedure due to the discovery of duodenal polyps on endoscopy that demonstrated low grade dysplasia. On pathology the duodenal adenoma was significant for adenocarcinoma invading the lamina propria, no lymphovascular invasion, negative margins, and 0/20 involved lymph nodes. No chemotherapy indicated per Medical Oncology. Thyroid ultrasound was performed as a screening assessment, and given the presence of a nodule she was referred to Endocrinology. On repeat ultrasound approximately 1 year after her initial ultrasound, the nodules measured 15.5. mm x 15.9 mm x 16.9 mm; increased in size from 14 mm x 14 mm x 12 mm. Due to the increase in size and the nodule characteristics of hypoechogenecity and taller-than-wide shape we recommended the patient undergo fine needle aspiration (FNA) biopsy of the nodule. Cytology from the FNA was notable for Papillary Thyroid Carcinoma. In December 2023 the patient underwent a total thyroidectomy, and pathology showed bilateral foci of hyalinizing trabecular tumor. Hyalinizing trabecular tumors (HTT) of the thyroid are follicular neoplasms with benign behavior. On sonographic imaging they tend to present as round to oval hypoechoic, well-defined lesions. On cytology these lesions can be mistaken for papillary thyroid carcinoma (PTC), medullary thyroid carcinoma, non-invasive follicular thyroid neoplasm with papillary like features, paraganglioma, and follicular neoplasm. The incidence of HTT varies but is approximately 1.5% of benign thyroid tumors. While FAP has been linked to thyroid tumors, in 70-90% of cases the pathology is consistent with cribriform-morular variant of PTC (CMV-PTC). CMV-PTC is in and of itself a rare variant accounting for less than 1% of all PTCs in the general population. Historically, the lifetime risk of thyroid cancer development in FAP patients is 2%, but this number has been climbing recently with a prevalence as high as 12% in patients screened with ultrasonography. It is important that this patient’s case be added to the body of medical literature as HTT is not currently known to be associated with FAP, but as more lesions are found with increased ultrasound surveillance, it may be an emerging extraintestinal manifestation of the disease.
Presentation: 6/1/2024
8259 Hypercalcemia as an Unusual Presentation of Hyperthyroidism
Authors: Mohammadrezaei F , Mubashir A , Chen K 
Published: October 2024

Abstract
Disclosure: F. Mohammadrezaei: None. A. Mubashir: None. K. Chen: None.
Background: Asymptomatic Non-Parathyroid dependent hypercalcemia can occur in 20% of patients with hyperthyroidism [1]. It is uncommon for hyperthyroidism to present with hypercalcemia, and it is rare for calcium levels to exceed 12 mg/dl [2]. Case Presentation: A 65-year-old man was referred to Endocrinology for hypercalcemia with complaint of poor appetite and gradual 10–15-pound weight loss over the past year. Patient was under the care of a rheumatologist for joint pain who noted his calcium levels to be elevated at 12.1 mg/dl (8.2-10.1). Further investigation into hypercalcemia revealed an alkaline phosphatase level of 129 IU/L (36-112), 25OH Vitamin D level of 60.6 NG/ML (30-100), ACE level of 79.8 U/L (9-67), PTH of 18 PG/ML (15-65) and PTHrP levels &lt; 2.0 pmol/L (&lt; 2.0). A CT scan of the chest, abdomen, and pelvis was performed due to hypercalcemia and mildly elevated ACE level and did not reveal any evidence of sarcoidosis; however, it showed enlargement of the thymus. On our initial examination, his vital signs were within normal range and physical examination revealed fine tremors in his upper extremities. On further evaluation, his thyroid function tests (TFTs) showed suppressed TSH &lt; 0.005 MICU/ML (0.39-4.08) and elevated FT4 7.34 NG/DL (0.58-1.64) and patient was initiated on methimazole and propranolol. Thyroid Stimulating Immunoglobulin (TSI) was positive 1.96 IU/L (0.00-0.55) consistent with Graves' disease. Thyroid ultrasound revealed a heterogeneous thyroid with multiple nodules and radioactive iodine uptake and scan displayed multiple "hot and cold" areas consistent with a multinodular goiter (MNG) and elevated uptake of 78% at 24 hours (10-30%). Subsequent fine-needle aspiration (FNA) findings were benign. Following initiation of treatment for hyperthyroidism and normalization of FT4, the patient's unintentional weight loss improved with weight regain and more notably, hypercalcemia resolved, as indicated by calcium levels of 10 and 9.5 at 3 months and 1 year respectively, supporting the diagnosis of hyperthyroidism-related hypercalcemia. Conclusion: The key takeaway from this case is the identification of hypercalcemia as a potential complication of hyperthyroidism, though the precise mechanism remains unclear. It may be related to the stimulation of bone turnover by thyroid hormones. Further studies are needed to uncover the exact underlying pathophysiological mechanism. References: (1) Baxter JD, Bondy PK: Hypercalcemia of thyrotoxicosis. Ann Intern Med. 1966, 65:429-42. 10.7326/0003- 4819-65-3-429. (2) Khan H, Nawaz M, Schofield J, Soran H. Severe hypercalcaemia secondary to relapsed Graves' disease. BMJ Case Rep. 2021 Jan 18;14(1): e238898.
Presentation: 6/1/2024
7276 Hypothyroid Patients With Gastric Diseases In Treatment With Liquid L-T4: An Observational Study
Authors: Fallahi Poupak , Ragusa Francesca , Patrizio Armando , Mazzi Valeria , Botrini Chiara , Elia Giusy , Balestri Eugenia , Barozzi Emilio , Rugani Licia , Palmisano Elena , Cosenza Maria Carla , Varricchi Gilda , Ulisse Salvatore , Benvenga Salvatore , Ferrari Silvia Martina , Antonelli Alessandro 
Published: October 2024

Abstract
Disclosure: P. Fallahi: None. F. Ragusa: None. A. Patrizio: None. V. Mazzi: None. C. Botrini: None. G. Elia: None. E. Balestri: None. E. Barozzi: None. L. Rugani: None. E. Palmisano: None. M. Cosenza: None. G. Varricchi: None. S. Ulisse: None. S. Benvenga: None. S. Ferrari: None. A. Antonelli: None.
We have conducted an observational and retrospective study, by enrolling patients with hypothyroidism and gastric diseases in treatment with liquid L-T4 (L-LT4) or tablet L-T4 (T-LT4). The aim of the study was to compare the stability of TSH in these patients. Eighty-four patients were in treatment with L-LT4, and 120 patients with T-LT4; all of them assumed L-T4 30 minutes before breakfast. The patients were affected by different types of gastric disease: a) in T-LT4 group: 74 chronic gastritis (CG); 4 gastrectomy for gastric cancer (GTx); 42 gastro-plastics (GP); b) in L-LT4 group: 60 CG; 3 GTx; 21 GP (p&gt;0.05). In the T-LT4 group 66% of the patients were chronically treated with PPI, against 51% in the L-LT4 group (p&gt;0.05). The frequency of Helicobacter Pylori infection was 17% in both T-LT4 and L-LT4 groups. The gender distribution, mean age and body weight were similar in the two groups (p&gt;0.05). The mean L-T4 dosage in the T-LT4 group at the basal evaluation was 1.22+/-0.27 μg/kg/die, in the L-LT4 group was 1.36+/-0.22 μg/kg/die (p&gt;0.05). At the basal evaluation the prevalence of patients with a TSH &gt; 3.5 μIU/mL in the T-LT4 group was 36%, whereas in the L-LT4 group was of 46% (p&lt;0.05). After adjustment of the dosage of the LT-4 therapy, the patients were re-evaluated with an interval range of 5-9 months, for 4 times, during an overall period ranging from 23 to 31 months. At the first re-evaluation, the prevalence of patients with a TSH&gt;3.5 μIU/mL was 13% in both groups. At the second re-evaluation, the prevalence of patients with a TSH &gt; 3.5 μIU/mL in the T-LT4 group was 26%, and of 13% in the L-LT4 group (p&lt;0.05). At the third re-evaluation, the prevalence of patients with TSH&gt;3.5 μIU/mL in the T-LT4 group was 19%, and of 9% in the L-LT4 group (p=0.05). At the fourth and last re-evaluation, the prevalence of patients with a TSH &gt; 3.5 μIU/mL in the T-LT4 group was 18%, and of 5% in the L-LT4 group (p&lt;0.05). Mean FT4 and FT3 circulating levels were not significantly different in the two group at each visit. These data highlight a more stable control of TSH levels in hypothyroid patients with gastric disorders in the long-term follow-up, by using a liquid L-T4 formulation therapy with respect to a tablet L-T4.
Presentation: 6/3/2024
6910 Hypothyroidism Induced by a TSH Receptor Peptide -Implications for Thyroid Autoimmunity
Authors: Xiang Pingping , Latif Rauf , Morshed Syed A , Davies Terry F 
Published: October 2024

Abstract
Disclosure: P. xiang: None. R. Latif: None. S.A. Morshed: None. T.F. Davies: None.
The “Neutral” thyrotropin receptor autoantibodies (N-TSHR-Ab) directed at the TSHR ectodomain's hinge region have been shown to induce thyroid cell damage in vitro and also when administered in vivo. For example, during these earlier studies we developed a mouse monoclonal antibody (MC1) specific for a peptide (aa 322-340) in the hinge region (MC1 - Mab) which was able to induce thyroid cell stress and apoptosis. In order to examine the effect of in vivo generated N-TSHR-Abs we immunized Balb/c mice with the same hinge region peptide and examined their thyroid function over the subsequent 18 weeks. We found that TSHR-peptide immunized mice developed N-TSHR-Abs against the peptide which resulted in thyroid damage shown by thyroid follicular cell apoptosis, thyroglobulin release, induction of thyroglobulin antibodies and hypothyroidism with increased TSH levels. These data add further evidence to the complexity of the immune response to the TSHR and indicate that the simple presence of stimulating type TSHR antibodies is not the entire story of Graves’ disease.
Presentation: 6/3/2024
5052 Hypothyroidism Management with Roux en Y Gastric Bypass
Authors: Vallabh Sean Nikunj , Swavely Jessica , Kattamanchi Adithya 
Published: October 2024

Abstract
Disclosure: S.N. Vallabh: None. J. Swavely: None. A. Kattamanchi: None.
Background: Roux en Y Gastric Bypass surgery has been shown to cause effective weight loss in individuals who qualify for the procedure. However, drug absorption is reduced in certain medications post-bariatric surgery. There is consistent evidence for diminished absorption in cyclosporine, thyroxine, phenytoin, and rifampin. No current literature found an association between levothyroxine liquid form and increased absorption status-post bariatric surgery. However, there are studies showing increased liquid absorption of levothyroxine in patients with suboptimal thyroid-stimulating hormone. Case presentation: The patient is a 60-year-old female with a past medical history significant for hypothyroidism and gastric bypass at the age of 21 years old who came in with the chief complaints of cold intolerance, fatigue, and hair loss. She was taking max dose of levothyroxine 300 mcg five days a week and 450 mcg two days out of the week and had an abnormal thyroid-stimulating hormone level of 340.47 the normal range is (0.45-5.33). The free thyroxine level was 0.44 the normal range is (0.61-1.24). The patient had been on oral Levothyroxine for decades, remaining symptomatic with elevated thyroid-stimulating hormone. The patient was trialed on liquid levothyroxine same dose. After the patient started a liquid regimen of her levothyroxine, her fatigue diminished, her cold intolerance lessened, her hair loss decreased, her thyroid stimulating hormone normalized to 0.91 the normal range is ( 0.4-4.50), and the free thyroxine increased to 2.1 the normal range is ( 0.8-1.8). Her levothyroxine dose was reduced to 300 mcg six days a week and 450 mcg 1 day a week. Conclusion: In conclusion, levothyroxine liquid form has been able to help normalize thyroid function in a patient with a remote history of bariatric surgery with severely uncontrolled hypothyroidism in spite of very high doses of levothyroxine. Bariatric surgery has been associated with weight loss and more stable thyroid levels. However, it also can lead to decreased absorption of oral levothyroxine. There are limited studies showing increased liquid absorption of levothyroxine in patients with bariatric surgery compared to oral form. More research needs to be conducted to see if liquid thyroxine leads to symptom abatement and its role in gastric bypass surgery for patients with hypothyroidism. Reference:•Virili, Camilla, et al. “Levothyroxine therapy: Changes of TSH levels by switching patients from tablet to liquid formulation. A systematic review and meta-analysis.” Frontiers in Endocrinology, vol. 9, 2018, https://doi.org/10.3389/fendo.2018.00010. •Zendel, Alex, et al. “The impact of bariatric surgery on thyroid function and medication use in patients with hypothyroidism.” Obesity Surgery, vol. 27, no. 8, 2017, pp. 2000–2004, https://doi.org/10.1007/s11695-017-2616-7.
Presentation: 6/3/2024