11/148. Cold thyroid nodule as the sole manifestation of Rosai-Dorfman disease with mild lymphadenopathy, coexisting with chronic autoimmune thyroiditis. A case of thyroid Rosai-Dorfman disease (RDD) without apparent lymphadenopathy in a 49-year-old woman with underlying euthyroid chronic autoimmune thyroiditis, as indicated by high thyroid autoantibodies titers, is presented. The initial presentation was that of a cold, hypoechogenic nodule of left thyroid lobe which increased in size during the two years of follow up, together with new ultrasonographic findings of the right lobe. No biochemical abnormalities were found apart from mild hypercalcemia. A near total thyroidectomy was performed. Histologically, the left lobe nodule as well as the right lobe lesions consisted of typical RDD cellular population, with the pathognomonic phenomenon of emperipolesis. Infiltration to the periphery of the gland was observed and three adjacent lymph nodes were also involved. The uninvolved thyroid parenchyma showed changes compatible with chronic autoimmune thyroiditis. No other localizations or systemic manifestations of RDD were revealed. Normocalcemia was restored promptly and the patient remains free of clinically overt disease one year post-operatively. ( info) |
12/148. Follicular thyroid cancer presenting initially with soft tissue metastasis. Follicular thyroid cancer rarely manifests itself as a distant metastatic lesion. We report a case of an otherwise asymptomatic 58-year-old woman with follicular thyroid cancer who initially presented with a soft tissue mass on the right scapular region. An incisional biopsy specimen of soft tissue metastasis showed thyroid follicular neoplasm. Upon this diagnosis, the thyroid gland was re-evaluated by ultrasound, which demonstrated a solitary, hypoechoic nodule in the right lobe. ultrasonography guided fine-needle aspiration biopsy of the thyroid nodule confirmed follicular neoplasm and the diagnosis of metastatic follicular thyroid cancer was established. The patient refused any type of treatment and left hospital against medical advice. 2.5 years later the patient was admitted to the hospital with giant, sarcoma-like multiple soft tissue masses. On this admission, the serum thyroglobulin level was extremely elevated (3500 ng/ml) and she only accepted to receive chemotherapy. epirubicin and cyclophosphamide were administered. She received three courses of chemotherapy and is alive with a stable disease after 3 months of follow-up. This case of follicular thyroid cancer is reported because of its uncommon initial presentation with soft tissue metastasis which spread to multiple areas as giant soft tissue masses during follow-up. ( info) |
13/148. A clear cell variant of follicular carcinoma presenting as an autonomously functioning thyroid nodule. We report a case of an autonomously functioning thyroid nodule (AFTN) that proved to be almost exclusively a clear cell variant of follicular carcinoma. AFTNs are generally felt to be benign lesions with exceptions forming the basis of case reports. Likewise, clear cell tumors of the thyroid are rare. To our knowledge, this combination of two unusual thyroid conditions has not been previously reported. The initial scans of this patient were so characteristic for a degenerating AFTN that attention was first directed toward a very large contralateral lobe. While it is debatable whether all AFTNs should be biopsied, on the basis of this and other cases, it is recommended that AFTNs that contain a central photopenic area on scan be biopsied to be sure that cystic degeneration, a commonly seen phenomenon in larger AFTNs, is indeed present rather than a malignancy. ( info) |
14/148. ultrasonography of Zenker's diverticulum: special reference to differential diagnosis from thyroid nodules. There have been only two case reports so far in literature on ultrasonographic features of Zenker's diverticulum. We report a case of Zenker's diverticulum and discuss the ultrasonographic images in comparison with those of thyroid nodules. awareness of changeable internal echoes and not mistaking strong echogenic foci caused by air for calcification were most important for making the differential diagnosis of Zenker's diverticulum from thyroid nodules. ( info) |
15/148. Use of immunohistochemistry in fine needle aspiration of thyroid nodules in patients with a history of malignancy. A report of two cases. BACKGROUND: A history of a nonthyroid malignancy may present a diagnostic dilemma in the assessment of fine needle aspiration (FNA) of thyroid nodules. One reported series, on patients with prior malignancies and a thyroid nodule, indicated that in 17% of patients, the thyroid nodule represented metastatic malignancy, 6% were classified as primary thyroid cancers, and the remainder were benign or inconclusive lesions. The resolution of this problem is essential to patient management. CASES: We report two cases in which patients with a history of renal cell carcinoma presented with a thyroid nodule. The first patient was an 80-year-old female whose Papanicolaou-stained FNA demonstrated clusters of round to polygonal cells with round to ovoid, hyperchromatic nuclei and abundant, wispy cytoplasm. The second patient was a 55-year-old female with clusters and single cells with round to oval, eccentric nuclei and copious, granular, gray cytoplasm noted on Papanicolaou-stained material. In each case, the diagnosis was inconclusive on initial review of Papanicolaou-stained slides, and immunohistochemical staining was ordered to better characterize the lesions. Tumor cells from case 1 were positive for cytokeratin cocktail and vimentin and negative for thyroglobulin, epithelial membrane antigen and calcitonin, suggestive of metastatic renal cell carcinoma. In contrast, the tumor cells from case 2 expressed cytokeratin, thyroglobulin and vimentin, consistent with a primary thyroid neoplasm. In each case, the cytologic diagnoses were confirmed in the resected specimens. CONCLUSION: immunohistochemistry is a helpful adjunct in the evaluation of thyroid nodules in patients with a past history of malignancy. ( info) |
16/148. Incidental detection of a malignant hurthle cell carcinoma by Tc-99m sestamibi cardiac imaging. A 60-year-old man reported chest pain and shortness of breath. His medical history was negative for myocardial infarction but positive for "mini strokes" and type 2 diabetes mellitus. Tc-99m sestamibi cardiac imaging revealed an abnormal focus of increased activity in the left lobe of the thyroid. Although no cardiac abnormalities were found, a I-123 thyroid scan subsequently showed a solitary hypofunctioning nodule involving the middle and inferior aspects of the left lobe of the thyroid, which fine-needle aspiration proved was a Hurthle cell carcinoma. ( info) |
17/148. Sonography and scintigraphy are necessary in diagnostics of cystic thyroid lesions. Thyroid sonography in an otherwise asymptomatic 50-year-old woman revealed a mainly cystic lesion within the right thyroid lobe. Thyroid (99)Tc scan showed an enhanced uptake over the right thyroid lobe with suppressed activity over the remaining thyroid tissue. Following aspiration of 6 ml of cyst fluid, a solid lesion became apparent in the location of the original cyst corresponding to the scintigraphically detected autonomous adenoma. This case report emphasizes that ultrasonography and scintigraphy are complementary methods and should be used as such in the primary evaluation of thyroid nodules. ( info) |
| A patient who underwent I-131 therapy for a solitary toxic thyroid nodule subsequently experienced vocal cord paralysis, a rare complication. The patient was examined because of hoarseness 1 week after treatment. Indirect laryngoscopy at the time confirmed right vocal cord paralysis. When the examination was repeated in 6 months, no improvement was noted; vocal cord paralysis was then declared permanent. Surprisingly, 11 months after the onset of symptoms, the patient observed improvement in her voice. At 14 months, she experienced complete vocal recovery. However, a computed tomography performed after this showed that her right vocal cord paralysis was unresolved. The apparent complete recovery of her voice is believed to be a result of adaptive compensatory mechanisms. patients who recover from hoarseness after injury to the recurrent laryngeal nerve should have cord function documented by indirect laryngoscopy or other means before the physician performs a procedure that could harm the contralateral nerve, because damage to this nerve could result in devastating consequences. ( info) |
19/148. Management of the solitary thyroid nodule: results of a North American survey. The present survey evaluated current trends in the management of the nontoxic solitary thyroid nodule by expert endocrinologists in north america and compared their results with a similar European Thyroid association survey. A questionnaire was circulated to all clinical members of the American Thyroid association. An index case (a 42-yr-old woman with a solitary 2 x 3-cm thyroid nodule and no clinical suspicion of malignancy) and 11 variations were provided to evaluate how each alteration would affect management. One hundred and seventy-eight members replied and 142 responses were retained for analysis, corresponding to a response rate of 43% of clinically active members. Based on the index case, basal serum TSH was the routine choice of 99%, and serum T4 and/or free T4 were included by 61% of the respondents. Thyroid peroxidase antibodies and serum calcitonin were included by 30% and 5%, respectively. Thyroid scintigraphy was used by 23% ((123)I, 63%; (99m)Tc, 31%; (131)I, 6%), and ultrasonography was used by 34%. Fine needle aspiration biopsy was routinely used by all and was guided by palpation in 87%. Based on the individually chosen diagnostic tests indicating a benign solitary thyroid nodule in a euthyroid subject, L-T4 treatment was advocated by 47%, no specific treatment and follow-up was advocated by 52%, and surgery was advocated by 1%. Clinical factors suggesting thyroid malignancy (e.g. rapid nodule growth and a large nodule of 5 cm) lead a significant number of clinicians (40 - 50%; P < 0.00001) to disregard biopsy results and to choose a surgical strategy. Nevertheless, North American endocrinologists heavily rely on fine needle aspiration biopsy results. Compared to the European Thyroid association survey, North American endocrinologists use imaging [scintigraphy, 23% vs. 66% (P < 0.0001); ultrasonography, 34% vs. 80% (P < 0.0001)] and serum calcitonin (5% vs. 43%; P < 0.0001) less frequently. A nonsurgical strategy prevails in north america, and despite controversies on the effect of L-T4, this treatment is supported by more than 40% in both europe and north america. ( info) |
20/148. Intrathyroid thyroglossal duct cyst simulating a thyroid nodule. A case of intrathyroid thyroglossal duct cyst is reported. A 50-year-old woman presented with a right lateral neck mass that was clinically indistinguishable from a thyroid nodule. Ultrasound-guided fine-needle aspiration biopsy (US-FNAB) revealed normal-looking squamous cells. Right thyroid lobectomy was performed and microscopic examination revealed a cyst lined by squamous epithelium that was consistent with a thyroglossal duct cyst. The lesion was completely surrounded by normal thyroid tissue. Our experience suggests that intrathyroid thyroglossal duct cyst should be remembered in the differential diagnosis of a thyroid nodule. Detection of benign squamous cells by US-FNAB may be useful for ruling out the possibility of a cystic thyroid tumor. ( info) |