bluuebunny/crossref_metadata_2025_split huggingface dataset:
9365 Now You See Me: The Case Of The Ectopic Thyroid
Authors: Isabelle Suarez Solangel , Majumdar Sachin K 
Published: October 2024

Abstract
Disclosure: S.I. Suarez: None. S.K. Majumdar: None.
Introduction: Lingual thyroid refers to ectopic thyroid tissue located at the base of the tongue or within the thyroglossal tract secondary to failed descent to its usual site (1). Ninety percent of ectopic thyroid glands are found at the base of the tongue and can occur in 1 in every 100,000 patients (2, 3). Clinical presentations commonly relate to obstruction of the oropharynx, and patients may experience dysphagia or throat fullness/discomfort (1). We present a case of lingual thyroid presenting as dysphagia and progressive hypothyroidism. Case: A 38-year-old woman with a history of HLD and hypothyroidism was referred for evaluation of ectopic thyroid tissue. She presented to her provider for concerns of dysphagia, neck swelling, and excessive hair thinning/loss. She had a recent increase in levothyroxine dose from 112 to 125 mcg after a TSH of 20.4 (0.27 to 4.2 uIU/mL). Repeat tests showed a TSH of 29.4 and a free T4 level of 0.79 (0.8 to 1.7 ng/dL). She denied use of thyrotoxic medications, any radiation or surgeries to head or neck, personal or family history of autoimmune disorders. Thyroid was nonpalpable on exam. A thyroid US 5 years prior showed a 15 x 5 x 5 mm right lobe and 12 x 8 x 5 mm left lobe. CT scan of soft tissue of neck with contrast showed a 14 x 13 x 15 mm hyperintense nodular lesion midline along the anterior glossoepiglottic fold at the foramen cecum, with an 8 x 11 x 8 mm hyperintense nodular lesion at midline abutting the anterior body of the hyoid bone, and no thyroid tissue in the expected thyroid bed, findings consistent with ectopic thyroid tissue along the expected thyroglossal duct. Furthermore, an I-123 scan with SPECT confirmed the ectopic thyroid tissue. What was thought to be thyroid lobes on previous thyroid US was likely paratracheal fat. Levothyroxine was increased to 137 mcg per day with improvement at 2 months (TSH 10.4, Free T4 0.91). Adjusting levothyroxine replacement was the primary intervention, given that elevated TSH may result in hypertrophy of lingual thyroid tissue resulting in dysphagia, particularly if there is no mass or suspicion of cancer on imaging. Conclusion Hypothyroidism presenting with dysphagia in the absence of goiter, previous thyroid surgery, or detectable thyroid tissue should warrant consideration of ectopic thyroid tissue and initial therapy should be directed towards normalizing TSH in conjunction with excluding malignant causes. References: 1. Randolph, G. W., & Kamani D. V. (2023). Thyroglossal duct cyst, thyroglossal duct cyst cancer, and ectopic thyroid. UpToDate. Retrieved February 13, 2024, from 2. Patil, Y. S., Rajashekhar R. P. (2015). Lingual Thyroid: A Case Series of Six Lingual Thyroid with Incidence and Different Treatment Modalities. International Journal of Head and Neck Surgery (IJHNS). 10.5005/jp-journals-10001-1234. 3. Kumar, L. K., Kurien, N. M. (2015). Lingual Thyroid. Annals of Maxillofacial Surgery. DOI: 10.4103/2231-0746.161103
Presentation: 6/1/2024
8096 Optimization of Radiation Safety Release Instructions After Iodine-131 Treatment for Differentiated Thyroid Cancers
Authors: Smith A H , Greist T 
Published: October 2024

Abstract
Disclosure: A.H. Smith: None. T. Greist: None.
Introduction: Iodine-131 (I-131) is a common therapy for treatment of differentiated thyroid cancers (DTC); however its radioactivity poses a risk to public health. There is wide inter-facility variation in release instructions to minimize incident exposure to other individuals. Isolation measures to reduce gamma exposure may pose harm to an individual's mental or physical health, especially in new parents or patients who require caregivers. Most studies estimating incident exposure utilize cumulative dosimetry to estimate duration of safety release instructions, but this relies on expert assumptions of the clearance of I-131, which is altered in patients who have had their thyroid removed. Measuring real-time longitudinal gamma exposure would optimize recommendations to balance the radiation safety risks with the risks associated with isolation. Objective: Quantify real-time longitudinal incident gamma radiation exposure to others from patients with DTC status post thyroidectomy treated with I-131. Methods: Patients were asked to measure exposure rates at a distance of one meter three times a day for fourteen days, using a portable ion chamber at their homes. Exposure rates over time were used to form an exponential decay model and to estimate the time after which cumulative exposure is below a reasonably low threshold. Results: 32 patients were included in the study. The average effective half-life was 15.8 hours. Exposure readings over time were best fit with an exponential decay model using one decay rate, rather than a model that uses separate extrathyroidal and thyroidal decay rates. Among patients administered less than 114 mCi, cumulative gamma exposure is less than 100 mR after 24 hours of isolation. Between 114 and 163 mCi, cumulative gamma exposure is less than 100 mR after 48 hours of isolation. Conclusion: Cumulative gamma radiation exposure at one meter was found to be low enough to consider re-evaluating isolation protocols and safety release instructions for long-term distancing in patients status post thyroidectomy treated with I-131.
Presentation: 6/1/2024
7824 Orbital Lymphoma masquerading as Thyroid Eye Disease
Authors: Ganawa S , Joseph S , Anshuman C , Luciane L D , Sajid A , Anne C , Dhage S 
Published: October 2024

Abstract
Disclosure: S. Ganawa: None. S. Joseph: None. C. Anshuman: None. D. Luciane L: None. A. Sajid: None. C. Anne: None. S. Dhage: None.
Thyroid eye disease (TED) is the most common extrathyroidal manifestation in Graves’ disease (GD). In this case report, we present a case of a 64 years old lady, who was initially diagnosed with thyroid eye disease about 9 years ago. However, she was clinically and biochemically euthyroid. She was offered an orbital decompression surgery by local ophthalmology team. Patient wasn’t keen on the surgery at this stage.Recently she experienced increased swelling of her eyes, with conjunctival redness, oedema, and diplopia bilaterally, more evident on the left side. She was initiated on intravenous methylprednisolone (IVMP) weekly, by local ophthalmology team and was referred to our specialist thyroid eye clinic for further management.On presentation to us, her clinical activity score (CAS) was 5/7, but she was euthyroid clinically and biochemically. She was continued on weekly IVMP and oral mycophenolate mofetil (MMF) was added on as per the latest EUGOGO guidelines published in 2021. Her treatment was reviewed after the anti thyroperoxidase (TPO) and anti-Thyroid Stimulating Hormone receptor (TSH) antibodies were reported as negative and her eyes worsened despite the treatment with IVMP and MMF.Her repeat MR orbit at this stage showed possible orbital lymphoma. Her immunosuppressive medications were discontinued at this stage. After further discussions at regional thyroid eye MDT and radiology MDT, an orbital biopsy was arranged for, which confirmed Extra nodal Marginal Zone lymphoma, with no high-grade component. She has been referred to the oncology unit for further assessment and management.This case highlights the importance of considering alternative differential diagnosis in certain patients with atypical features or those who are non-responders to the first line immunosuppressive therapies for thyroid eye disease. Details of this case and relevant literature will be reviewed in this report.
Presentation: 6/3/2024
12570 Papillary Thyroid Carcinoma Found In A Malignant Struma Ovarii
Authors: Arunachalam Amar , Iyer Priyanka 
Published: October 2024

Abstract
Disclosure: A. Arunachalam: None. P. Iyer: None.
Struma ovarii is a monodermal teratoma primarily composed of mature thyroid tissue.[1] Depending on histologic findings, struma ovarii can be classified as benign or malignant. Among malignant struma ovarii, papillary type is the most common.2Women with struma ovarii can present with pelvic pain and less frequently ascites. Clinical features of hyperthyroidism can occur.[3] We present a 66 year old female of Chinese descent status post hysterectomy and left oophorectomy in 9/2021, prior right oophorectomy in 1985 with pathology consistent with a teratoma as per patient, who presented after being lost to follow-up. Her pathology of her left ovary showed diffuse thyroid tissue with focal areas consistent with papillary thyroid carcinoma. Her initial diagnosis was found in the setting of abdominal pain. She had a transvaginal ultrasound with a 16.9 x 13.1 x 8.9 cm cystic mass. Patient was lost to follow-up .She denied any symptoms of hyper or hypothyroidism. On biochemical evaluation, TSH 1.45 mcunit/ml, FT4 0.91 ng/dl, Thyroblobulin 4.21 ng/ml, Thyroglobulin Antibody undetectable. Thyroid ultrasound was significant for a 0.5 left thyroid isthmus nodule which was benign after FNA biopsy. CT chest, abdomen, pelvis without any evidence of distant metastasis. Decision was made to monitor with repeat thyroid ultrasound and biochemical evaluation in one year because no evidence of concerning lesions in the thyroid for PTC or evidence of distant metastasis. The frequency of struma ovarii among ovarian teratomas is less than 3% which makes this case rare. The most common sites of metastasis of a malignant struma ovarii include abdominal cavity, liver, lungs, brain and bone.[4] In certain cases, thyroid tissue found in struma ovarii can secrete T3 and T4.[5] Our patient had no abnormalities on imaging of the thyroid with normal thyroid function tests. We recommended monitoring of the thyroid gland to assess for malignant transformation. Mainstay of treatment is hysterectomy and bilateral salpingo-oophorectomy for postmenopausal women and unilateral salpingo-oophorectomy or cystectomy for women in the reproductive age. For metastatic struma ovarii, thyroidectomy and adjuvant treatment with radioactive iodine can be considered.[6]The risk of recurrence is lower based on size, location and histopathological features of the tumor. One study proprosed following unilateral salipingo-oophorectomy in patients with low risk of recurrence, TSH suppression at 0.1 to 0.5 mIU/L..[7] Considering the findings for our patient who presents years after hysterectomy and left oophorectomy in 2021 with normal thyroid gland on ultrasound and appropriate thyroid function tests, we recommended no additional complementary treatment with monitoring of labs and imaging in one year. This patient currently shows no evidence of metastatic disease or high risk of recurrence but long term monitoring remains a mainstay of the management.
Presentation: 6/2/2024
12231 PAPP-A As A Potential Target In Thyroid Eye Disease
Authors: Conover Cheryl A , Bale Laurie K , Hamadi Dana , Stan Marius 
Published: October 2024

Abstract
Disclosure: C.A. Conover: None. L.K. Bale: None. D. Hamadi: None. M. Stan: ; Tourmaline, Genentech, Third Rock Ventures, ArgenX, Septerna, OrthoDi. ; Horizon, Immunovant, Lassen, Sling.
Background: Proptosis in Thyroid Eye Disease (TED) can result in facial disfigurement and visual dysfunction. Studies revealed an interaction between thyroid-stimulating hormone receptor (TSHR) and insulin-like growth factor-I receptor (IGF-IR) that is essential in promoting TED pathogenesis. Treatment with Insulin-like growth factor I receptor (IGF-IR) inhibitors has been shown to be effective in reducing proptosis but with side effects. PAPP-A is metalloprotease that can increase pericellular IGF bioavailability through specific cleavage of inhibitory IGF binding proteins, in particular IGFBP-4. We propose that inhibition of IGF-IR indirectly and more selectively with PAPP-A inhibitory antibodies attenuates IGF-IR signaling in TED with fewer side effects. Methods: Informed consent was obtained from TED patients undergoing surgery in Mayo Clinic operating suites in Rochester, MN. Retro-orbital tissue was collected from 19 TED patients and 2 control subjects for fibroblast isolation and culture and was performed in a sterile tissue culture facility. TED and control fibroblasts were treated with pro-inflammatory cytokines, and flow separation of CD34- and CD34+ orbital fibroblasts was done, the latter representing infiltrating fibrocytes into the orbit in TED. Main outcome measured were PAPP-A expression and proteolytic activity, IGF-I stimulation of phosphatidylinositol 3 kinase/Akt pathway and inhibition by immuno-neutralizing antibodies against PAPP-A, CD34+ status and associated PAPP-A and IGF-IR expression. Results: Primary cultured cells showed that PAPP-A is expressed in orbital fibroblasts from TED patients but not in control subject fibroblasts and were markedly increased by pro-inflammatory cytokines stimulation. IGF-IR expression was not affected by cytokine treatment. Inhibition of PAPP-A’s proteolytic activity suppressed IGF-IR activation in orbital fibroblasts from TED patients. CD34+ orbital fibroblasts represent 80% of cells in culture from TED patients, and approximately 70% of these cells were accountable for PAPP-A and IGF-IR expression. Conclusion: These results support a role for PAPP-A in TED pathogenesis and indicate the potential for novel therapeutic targeting of the IGF axis.
Presentation: 6/2/2024
7502 Patient Suffering from Laryngeal Edema in the Setting of Hypothyroidism
Authors: Seidenberg J , Prabhu P , Ansari M 
Published: October 2024

Abstract
Disclosure: J. Seidenberg: None. P. Prabhu: None. M. Ansari: None.
Hypothyroidism can present with many different symptoms including dry skin, weight gain, and lethargy, with severe presentations being altered mental status, bradycardia, hypotension, and myxedema coma. Rarely, hypothyroidism can present with isolated laryngeal myxedema with few cases being noted. Myxedema is defined as swelling and thickening of the skin, and airway compromise secondary to myxedema is a potentially life-threatening presentation. In this case report, the patient is a 41-year-old female with PMH of hypothyroidism, homelessness, alcohol use, and morbid obesity who presented to the ED for nausea, vomiting, abdominal pain, and throat swelling. The swelling had been present for several months and acutely worsened with voice changes on the day prior to presentation. She noted poor compliance with Levothyroxine for several months. On exam, she was found to have hoarseness, difficulty swallowing, drooling, and tenderness in anterior neck. She was admitted to ICU for airway protection observation. On her blood work, she was found to have an undetectable T4, TSH &gt; 100 (0.45-4.5 UI/mL), and CT neck and abdomen negative for alternative causes of swelling. Laryngoscopy showing normal larynx. The patient had a Popoveniuc myxedema score of 35 with no electrolyte abnormalities. She was given racemic epinephrine with minimal effect and IV Levothyroxine 200 mcg. After 3 days of IV Levothyroxine 84 mcg and high dose Decadron, she had improvement in throat swelling and breathing. She was later discharged with Synthroid and a 5-day Decadron course. Myxedema is a potentially life-threatening presentation of hypothyroidism. Patients who have untreated hypothyroidism can have chronic myxedema with acute worsening of symptoms that put them at risk of airway compromise, even with an initially low diagnostic score. Patients should be screened on admission when they present with unknown cause of airway compromise for hypothyroidism and treated with empiric high dose levothyroxine IV followed by daily IV levothyroxine until symptom improvement and daily TSH and T3/T4 improvement. Treatment with both high dose steroids and racemic epinephrine should be initiated before diagnosis due to feasible alternative or additional causes of airway obstruction.
Presentation: 6/3/2024
6417 Phase 1 Healthy Volunteer Data Supports Phase 2 Study of LASN01 in Thyroid Eye Disease (TED) - Actively Enrolling
Authors: Takamura T , Dimaano C , Jun T , Swaney J , King D , Fardis M 
Published: October 2024

Abstract
Disclosure: T. Takamura: Employee; Self; Lassen Therapeutics. C. Dimaano: Employee; Self; Lassen Therapeutics. T. Jun: Employee; Self; Lassen Therapeutics. J. Swaney: Employee; Self; Lassen Therapeutics. D. King: Employee; Self; Lassen Therapeutics. M. Fardis: Employee; Self; Lassen Therapeutics.
Interleukin-11 (IL-11) is a key effector of fibro-inflammatory disease processes in multiple organs. IL-11 is elevated in both orbital fibroblasts and serum of thyroid eye disease (TED) patients and stimulates hyaluronic acid (HA) production from TED patient-derived orbital fibroblasts (OF). LASN01 inhibits a number of signals which are known to be associated with TED including hyaluronic acid elevation and procollagen. In patient-derived orbital fibroblasts IGF-1 and IL-11 induced HA release, as well as TGFβ stimulated procollagen production were inhibited by LASN01. LASN01 is a highly specific, fully human monoclonal antibody that binds to IL-11R with high affinity and inhibits IL-11 signaling. A randomized, placebo controlled (3:1) Phase 1 trial was conducted in healthy volunteers to assess safety, pharmacokinetics (PK) and target engagement with single and multiple ascending doses (SAD and MAD) of intravenous LASN01 in healthy volunteers. Fifty-eight volunteers were dosed in 5 single dose cohorts (25-1200 mg) and 2 multiple dose cohorts (600-1200 mg). Sixty-one treatment emergent adverse events (TEAEs) were reported by 35 subjects, which included no serious or severe adverse events. The most common AEs were headaches (13) and light headedness/dizziness (5). Data from healthy volunteers in the Phase 1 SAD/MAD Phase 1 trial show favorable safety and predictable and linear PK and dose-dependent target engagement. The half-life in the 1200 mg cohort was approximately 11 days. This data supports monthly dosing in the Phase 2 study. A proof-of-concept, global, randomized, double-masked Phase 2 trial is actively enrolling. Patients with diagnosed Graves’ disease and active, moderate to severe thyroid eye disease (TED), within 12 months of start of symptoms and with a Clinical Activity Score (CAS) ≥ 3, will be randomized to 3 treatment arms (high and low dose LASN01 and placebo) and will be treated Q4 weeks for 12 weeks with a follow-up period of 12 weeks. The primary endpoint is the percentage of patients with response in proptosis (≥2mm) on active treatments vs. placebo. Secondary endpoints include degree of proptosis reduction, assessment of diplopia, lid retraction, and extraocular movements. Orbital MRIs will be collected to assess proptosis and extraocular muscles. LASN01 is the only agent being developed for TED which offers the possibility of addressing the fibro-inflammatory pathology of TED.
Presentation: 6/3/2024
6847 Poorly Differentiated Thyroid Cancer: A Rare Entity
Authors: Fatima Sanna , Ward Samuel , Champion Amber 
Published: October 2024

Abstract
Disclosure: S. Fatima: None. S. Ward: None. A. Champion: None.
Introduction: Poorly differentiated thyroid carcinoma (PDTC) is a rare thyroid carcinoma originating from follicular epithelial cells. Regarding the degree of differentiation, PDTC ranks between differentiated thyroid cancer and anaplastic thyroid cancer. We hereby present a rare case of PDTC. Case: 29-year-old female with a history of metastatic papillary thyroid cancer (PTC) presented to the emergency department with shortness of breath. She initially noticed a left thyroid mass in 2021. CT neck in 1/2022 showed a 7 cm left thyroid mass with substernal extension, small right thyroid mass with tracheal compression, left bulky cystic nodal masses extending anterior and posterior to carotid and internal jugular vein. PET scan in 3/2022 showed left 7.6 cm thyroid mass SUV 12.1 with tracheal compression, left level II-IV adenopathy with level IV nodal masses 5.1 cm SUV 4.5. Ultrasound-guided FNA in 4/2022 showed PTC in left 8.7cm thyroid nodule; right 2.8 cm nodule showed Atypia of Undetermined Significance; Left 5.5 cm neck level III lymph node (LN) showed PTC metastasis; right 5.1 cm neck level III LN showed PTC metastasis (+ thyroglobulin and TTF-1). CT chest in 11/2022 showed additional involvement of manubrium. Repeat core needle biopsy of left thyroid mass showed left invasive thyroid carcinoma. She was started on neoadjuvant Lenvatinib in 1/2023. Follow-up CT neck in 5/2023 showed a reduction in the size of the left thyroid mass to 5.5cm x 5.8cm x 6.5cm. At this time, she had symptoms of dysphagia, orthopnea, weight loss of about 60 lbs and neck pain. In 11/2023 at time of current presentation she underwent total thyroidectomy, bilateral modified radical neck dissection and manubriectomy. Surgical pathology showed PDTC in left thyroid mass, PTC in right thyroid mass with metastatic PDTC in left proximal sternocleidomastoid, manubrium and LN involvement in neck and mediastinum. OmniSeq Insight testing showed APC and BRCA1 gene mutations, negative BRAF V600E, RET fusion, RET mutation, NTRK1/2/3 fusion and PD L1 immunohistochemistry score is &lt;1%. The patient is planned to receive [1]3[1]I ablation therapy. Conclusion: PDTC accounts for 3–5% of all thyroid carcinomas. The 5, 10-, and 15-year survival rates of patients are 50–85%, 34–50%, and 0%, respectively. RAS gene alterations are found in 25–35%, BRAF mutation in 15–27%, TERT promoter mutation in 40% and mutant TP53 in 16–28% of PDTCs. TERT promoter gene and TP53 mutation usually indicate an aggressive phenotype and a dismal prognosis. Surgery, [1]3[1]I therapy, and external beam radiotherapy constitute the mainstay of traditional treatment for patients with advanced disease; however, treatment is challenging. Tyrosine kinase inhibitors i.e, sorafenib and lenvatinib, have been used in cases of progressive, recurrent, or metastatic disease not responsive to [1]3[1]I therapy. Immunotherapy may be an option in PD-L1-positive tumors.
Presentation: 6/1/2024