Plasma Cell Granuloma of The Thyroid: Report of Case and Review of Literature

ObjectiveTo report the 12th case of a patient with a plasma cell granuloma of the thyroid, a rare cause of goiter and hypothyroidism.MethodsWe present a case report of a woman with a plasma cell granuloma of the thyroid. The clinical and pathologic features of the lesion are described, the differential diagnosis is discussed, and the relevant literature is reviewed.ResultsPlasma cell granulomas are uncommon benign lesions most typically located in the lung and only rarely identified in other organs. Only 11 cases of plasma cell granuloma of the thyroid gland have been reported previously. We describe the case of a 55-year-old woman with a long history of hypothyroidism and compressive symptoms from an enlarging neck mass. A thyroidectomy was performed. On gross examination, the thyroid had been replaced by firm, white, fibrotic tissue with a multinodular appearance. On microscopy, the infiltrate consisted predominantly of plasma cells that were polyclonal with the expression of both kappa and lambda light chains. A minor component of CD5- and CD20-positive (T and B) lymphocytes was observed. These features were important for establishing the diagnosis of a plasma cell granuloma and distinguishing the lesion from a plasmacytoma.ConclusionThis is the 12th reported case of plasma cell granuloma of the thyroid gland, a very rare cause of either a diffuse or a nodular goiter and hypothyroidism. The presence of a polyclonal plasma cell population with the expression of both kappa and lambda light chains helps to distinguish a plasma cell granuloma from a malignant plasmacytoma of the thyroid gland. (Endocr Pract. 2008; 14:611-617)     

Thyroid: an Unusual Hideout for Sarcoidosis

ObjectiveTo present a case of dysphagia secondary to a progressively increasing nontoxic multinodular goiter caused by sarcoidosis.MethodsWe summarize the clinical presentation and pertinent pathology in a patient with sarcoidosis involving the thyroid gland. A review of literature regarding this topic is also presented.ResultsA 54-year-old man was noted to have asymptomatic nontoxic thyromegaly. Biopsy of right thyroid nodule was benign while the biopsy from the isthmus nodule was nondiagnostic. He presented with acute onset of dysphagia two months later and the work-up for gastrointestinal causes was negative. Chest imaging showed left-sided lymphadenopathy, and biopsy of a lymph node showed sarcoidosis. Two years after the initial presentation a repeat biopsy of the isthmus nodule was again reported as nondiagnostic. Because he had persistent dysphagia, he underwent total thyroidectomy with resolution of dysphagia. Histopathological examination of the thyroid revealed non necrotizing granulomas consistent with sarcoidosis.ConclusionThis case brings to light this uncommon etiology of a nontoxic multinodular goiter. Involvement of the thyroid gland by sarcoidosis is very rare. It has been reported in 4.2 to 4.6% of patients with sarcoidosis. In patients with pulmonary or extrapulmonary sarcoidosis and associated thyromegaly, possible involvement of the thyroid by this process should be considered. (Endocr Pract. 2013;19:e40-e43)     

Unusual Clinical Course of Graves’ Thyrotoxicosis and Concomitant Sarcoidosis: Case Report and Review of Literature

ObjectiveTo report a case of Graves’ disease with concomitant sarcoidosis involving the thyroid gland.MethodsWe present the clinical, laboratory, imaging, and pathologic findings and describe the clinical course of a patient with Graves’ disease and sarcoidosis, who was unresponsive to propylthiouracil and radioiodine treatment.ResultsA 23-year-old woman presented with thyrotoxicosis and a large goiter. Laboratory studies and findings on thyroid uptake and scan were consistent with Graves’ disease. She was also found to have hilar lymph-adenopathy and hepatosplenomegaly. Despite treatment with antithyroid drugs and radioiodine therapy, her hyperthyroidism persisted. Surgical resection of the thyroid gland and 2 lymph nodes disclosed noncaseating granulomas, consistent with sarcoid.ConclusionAutoimmune endocrinopathies and, less commonly, thyroid autoimmune disease have been reported in patients with sarcoidosis. Similarities exist in the pathogenesis of these two conditions. Concomitant sarcoidosis in the thyroid gland in patients with Graves’ disease may contribute to the resistance to antithyroid drugs and radioiodine therapy. (Endocr Pract. 2007;13:159-163)     

Ectopic Intrathyroidal Nonfunctioning Parathyroid Cyst

ObjectiveTo describe a rare case of ectopic intrathyroidal parathyroid cyst (PC) in a 29-year-old woman who had been referred to us because of a multinodular goiter.MethodsWe review the clinical, laboratory, and radiographic findings as well as the treatment in our patient and provide a brief discussion of the associated literature.ResultsUltrasonography of the neck showed the presence of 2 thyroid nodules in the left lobe, the larger of which was solid and the smaller of which had a cystic appearance. A small nodular area was also found in the right thyroid lobe (diameter, less than 8 mm). A thyroid scan performed with technetium showed the absence of uptake by both left lobe nodules. Fine-needle aspiration biopsy (FNAB) of the 2 major nodular lesions revealed that the larger thyroid nodule was benign and the smaller was a cyst with clear fluid. Measurement of parathyroid hormone in the FNAB fluid showed a high concentration, suggestive of the diagnosis of PC. Normal serum levels of parathyroid hormone and calcium indicated that it was a nonfunctioning intrathyroidal PC. The PC disappeared after FNAB, but the lesion recurred 3 months later. Therefore, the patient underwent near-total thyroidectomy. Histologic examination confirmed the diagnosis of intrathyroidal PC, and a papillary microcarcinoma (6 mm in diameter) was found in the right lobe of the thyroid.ConclusionAlthough an ectopic intrathyroidal PC is rare, the frequency of occult papillary microcarcinoma of the thyroid is high. The association we describe, however, should be considered incidental. To our knowledge, this is the first report of an association of an intrathyroidal PC with papillary microcarcinoma of the thyroid. (Endocr Pract. 2007;13:56-58)     

Does Unilateral Lobectomy Suffice to Manage Unilateral Nontoxic Goiter?

ObjectiveTo evaluate the effectiveness of ipsilateral lobectomy to treat unilateral, nontoxic, benign nodular goiter and to define predictive factors for recurrence.MethodsPatients undergoing thyroid lobectomy for unilateral, nontoxic, benign nodular goiter between 2002 and 2007 were included. Patients were excluded if coincidental thyroid cancer was detected at histopathologic examination and completion thyroidectomy was performed. Potential predictors of recurrence including age; sex; family history; preoperative volume of the thyroid gland; preoperative number, size, and ultrasonography characteristics of the nodules; duration of postoperative follow-up; postoperative use of thyroxine; and histopathologic diagnoses were recorded at baseline. Follow-up visits were scheduled every 3 months during the first year and every 6 months thereafter. Recurrent disease was defined as a hypoechogenic or hyperechogenic nodule larger than or equal to 3 mm detected in the remaining contralateral lobe during ultrasonography. Patients with a thyrotropin value greater than 5 mIU/L received thyroxine. Fineneedle aspiration biopsy was performed for nodules greater than 10 mm or for nodules with characteristics suggestive of malignancy. Reoperation was indicated if a nodule was greater than 3 cm in diameter, posed a risk of malignancy, or caused compression signs or symptoms.ResultsA total of 104 patients were included. Histopathologic diagnoses at initial operation were adenoma in 45 patients, colloidal nodular goiter in 45 patients, and chronic lymphocytic thyroiditis in 14 patients. Average duration of follow-up was 39.75 ± 21.75 months (range, 5-87 months). Recurrence was seen in 63 patients (60.6%). Histopathologic characteristics of the lobectomy material (P <.001), preoperative volume of the thyroid gland (P <.006), and multinodularity (P <.011) were significant predictors of recurrence.ConclusionsHigher preoperative thyroid volume, histopathologic characteristics of nodules, and multinodular disease are associated with an increased risk of recurrence in patients with unilateral nodular goiter. Unilateral lobectomy is an effective therapeutic option with low reoperation rates in unilateral benign thyroid disease. (Endocr Pract. 2010;16:36-41)     

Hyalinizing trabecular tumor in a background of lymphocytic thyroiditis: a challenging neoplasm of the thyroid

ObjectiveTo describe a case of hyalinizing trabecular tumor (HTT) in a background of lymphocytic thyroiditis that was misdiagnosed as papillary thyroid carcinoma (PTC) based on fine-needle aspiration (FNA) cytologic findings and overtreated with total thyroidectomy.MethodsWe present a case report, including the imaging and pathologic findings, of a 68-year-old woman who presented with a multinodular goiter that was suspicious for PTC.ResultsOn the basis of FNA cytologic findings, she underwent a total thyroidectomy, and histologic examination of the thyroid gland revealed HTT in a background of lymphocytic thyroiditis. Radioiodine treatment was not administered because of the tumor’s low risk profile. No metastatic foci were established under nonsuppressive levothyroxine therapy after 3 years of follow-up.ConclusionsHTT is a challenging entity because of the uncertainty of its nature, the diagnostic challenges,and the mimicry of other types of thyroid tumors. In order to avoid overtreatment, endocrinologists and thyroid surgeons should be aware of the features of HTT, and suspicious cases should be evaluated by experienced cytopathologists. (Endocr Pract. 2011;17:e140-e143)     

A Case of Riedel’s Thyroiditis Treated with Tamoxifen: Another Successful Outcome

ObjectiveTo report a case of Riedel’s thyroiditis, which was successfully treated with tamoxifen.MethodsWe present the clinical, laboratory, and imaging findings and describe the clinical course of a patient with Riedel’s thyroiditis.ResultsA 40-year-old woman presented with hypothyroidism and a large goiter, which was unresponsive to hormone replacement therapy. Magnetic resonance imaging confirmed the presence of an enlarged thyroid gland, more pronounced on the right than on the left. The patient had progressive discomfort attributable to compressive symptoms in the neck. Surgical exploration of the neck disclosed a hard, immobile thyroid mass, which could not be resected because of adherence to surrounding structures. Biopsy of the thyroid and of the muscles of the neck revealed Riedel’s thyroiditis. Treatment with tamoxifen, in a dosage of 20 mg twice a day for more than 1½ years, completely resolved the neck mass (substantiated by follow-up magnetic resonance imaging) and relieved the signs and symptoms of compression of the neck.ConclusionTamoxifen treatment is effective in resolving the mass and compression in Riedel’s thyroiditis. (Endocr Pract. 2004;10:483-486)     

Unusual Initial Manifestation of Metastatic Follicular Carcinoma of the Thyroid with Thyrotoxicosis Diagnosed by Technetium Tc 99m Pertechnetate Scan: Case Report and Review of Literature

ObjectiveTo report a case of metastatic thyroid cancer diagnosed on a technetium Tc 99m pertechnetate (TcO₄^–) thyroid scan.MethodsWe present the clinical findings, laboratory results, imaging studies, and surgical pathology report in a man with thyrotoxicosis in whom metastatic well-differentiated thyroid cancer was diagnosed incidentally on a routine TcO₄ ^– thyroid scan in the setting of a presumed diagnosis of benign toxic thyroid disease. In addition, we review the literature regarding coexistence of metastatic thyroid cancer and thyrotoxicosis.ResultsA 68-year-old man with thyrotoxicosis was referred for radioiodine therapy. A routine TcO₄^- thyroid scan revealed high-grade extrathyroidal uptake in the right upper hemithorax as well as in the left side of the thorax. In view of this finding, radioiodine treatment was deferred; further imaging with computed tomography revealed a 6.5-cm mass in a rib on the right side. A biopsy of the rib confirmed the presence of metastatic follicular carcinoma of the thyroid. Scintigraphy revealed sites of metastatic involvement predominantly in the bones along with a cold nodule in the left thyroid lobe, consistent with the primary tumor.ConclusionThis case emphasizes the impact of scintigraphic findings on determining the correct management of a patient who would have otherwise undergone inappropriate treatment. Through an extensive literature review, the incidence of malignant involvement in hyperfunctioning thyroid glands and the possible role of sodium iodide symporter expression by thyroid cancer metastatic lesions in preoperative detection of metastatic sites are addressed. (Endocr Pract. 2009;15:458-462)     

Ganglioneuroma Manifesting as an Incidental Adrenal Mass in an Adult With Turner’s Syndrome

ObjectiveTo report a case of ganglioneuroma masquerading as an incidental adrenal mass in an adult patient with Turner’s syndrome.MethodsWe present the clinical, laboratory, radiologic, and pathologic findings in this patient.ResultsA 31-year-old woman with Turner’s syndrome who had previously been treated with growth hormone replacement had an incidentally discovered mass, apparently arising from the left adrenal gland. The mass was “silent” clinically and biochemically, but imaging characteristics were not reassuring for a benign cortical adenoma. Because of uncertainty regarding the nature of the mass, it was removed laparoscopically; during this procedure, it was noted to be intimately associated with, but anatomically distinct from, the left adrenal gland. The pathology report confirmed the presence of a benign ganglioneuroma.Conclusion: Although ganglioneuroma has previously been noted to be associated with Turner’s syndrome (especially in pediatric patients), to the best of our knowledge this is the first report of a ganglioneuroma manifesting as an incidental adrenal mass in an adult patient with Turner’s syndrome. (Endocr Pract. 2005;11:382-384)     

Be Aware of the Patient With Benign Follicular Thyroid Lesion Histology and Rising Thyroglobulin Level

Objective: The accurate diagnosis of thyroid follicular/Hürthle cell tumors is challenging and a matter of controversy. We present a series of patients in whom a misclassification of follicular/Hürthle cell thyroid lesions as benign has led to devastating clinical outcomes.Methods: The Thyroid Cancer Registry of Rabin Medical Center was screened for patients with metastatic differentiated thyroid carcinoma (DTC) who had been initially diagnosed with benign follicular lesion between 1974 and 2015 and treated with hemithyroidectomy. Clinical, pathologic, and outcome data were collected from the medical files. Adequate pathology specimens, when available, were re-evaluated.Results: Seven patients met the inclusion criteria. The original pathologic diagnosis was follicular adenoma in 4 patients and Hürthle cell adenoma in 3 patients. Five patients had bone metastases, of whom one also had lung metastases and one, liver metastases. One patient had both cervical and lung metastases, and 1 patient had only meta-static neck lymph nodes. Six patients had a final diagnosis of encapsulated follicular variant of papillary thyroid carcinoma (EFVPTC), and 1 patient was diagnosed as having follicular thyroid cancer metastasis by bone biopsy. In 3 of the patients, capsular invasion was detected retrospectively; only 1 patient had evidence of vascular invasion. All 7 patients had high levels of thyroglobulin at diagnosis of metastatic DTC.Conclusion: Misclassification of follicular thyroid lesions as benign may lead to progressive disseminated DTC. To minimize the clinical risk of misdiagnosis, especially if a thorough evaluation of the specimens by an experienced pathologist is unfeasible, we suggest long-term follow-up of serum thyroglobulin levels.Abbreviations: DTC = differentiated thyroid carcinoma; EFVPTC = encapsulated follicular variant of papillary thyroid carcinoma; FVPTC = follicular variant of papillary thyroid carcinoma; NIFTP = noninvasive follicular thyroid neoplasm with papillary-like nuclear features; PTC = papillary thyroid carcinoma     

Secondary Parathyromatosis in a Patient with Normal Kidney Function: Review of Diagnostic Modalities and Approaches to Management

ObjectiveTo present a patient with secondary parathyromatosis, a rare complication of parathyroidectomy, and to discuss issues currently pertinent to its diagnosis and management.MethodsData were derived from clinical and pathologic observations obtained during patient care.ResultsThe index patient developed intractable hyperparathyroidism and hypercalcemia that has persisted after 4 surgical procedures and has remained largely resistant to medication, albeit with partial amelioration with combined bisphosphonate and cinacalcet.ConclusionDespite the rarity of this difficult complication of parathyroidectomy, its iatrogenic basis emphasizes a need for heightened awareness and caution among surgeons and endocrinologists. Herein we report an instance of intractable secondary parathyromatosis in a patient with normal kidney function, and we review current approaches to diagnosis and management. (Endocr Pract. 2014;20:e4-e7)     

Rhabdomyolysis and Peroneal Nerve Compression Associated With Thyroid Hormone Withdrawal in the Setting of Remnant Ablation: Review of the Literature

ObjectiveTo review the putative mechanisms whereby hypothyroidism is associated with severe myopathy, neural injury, and acute compartment syndrome and report a case of nontraumatic common peroneal nerve compression associated with hypothyroidism-induced rhabdomyolysis in a patient with diabetes prepared for remnant ablation after thyroidectomy for differentiated thyroid carcinoma.MethodsWe performed a review of the Englishlanguage literature on the PubMed database using the terms hypothyroidism, muscle disease, hypothyroid myopathy, rhabdomyolysis, compression neuropathy, and acute compartment syndrome.ResultsMyopathy occurs frequently among patients with overt hypothyroidism; however, severe myoneural injury seems to be precipitated or accompanied by comorbid conditions. Focal peroneal neuropathy may be related to hypothyroidism-induced extrinsic compression from severe myopathy and soft tissue swelling in a narrowed fascial compartment.ConclusionSevere short-term iatrogenic hypothyroidism may lead to severe myopathy and compression nerve injury in patients with underlying diabetic neuropathy. We recommend avoidance of withdrawal of thyroid hormone for purposes of remnant ablation among patients with preexisting diabetic neuropathy. (Endocr Pract. 2011;17:629-635)     

Assessing The Risk of False-Negative Fine-Needle Aspiration Cytology and of Incidental Cancer in Nodular Goiter

ObjectiveIn cases of multinodular goiter with negative cytologic result, reasonable management options include surgical treatment, simple follow-up, or more recently introduced conservative therapies such as laser or radiofrequency ablation, and recombinant human thyroid-stimulating hormone-augmented radioiodine. For patients who are eligible for follow-up or nonsurgical treatments, the possibility that they may have an undiagnosed malignancy (false-negative [FN]-fine-needle aspiration cytology [FNAC] result or incidental thyroid cancer [ITC]) should be considered. The aim of our study was to assess the risk of malignancy in patients known to have presumably benign thyroid disease.MethodsSurgical series of patients who underwent total thyroidectomy for benign disease between 2000 and 2010 at two Italian centers were reviewed. Patients with any preoperative suspicion of malignancy were excluded.ResultsHistologic examination revealed that 84 of 970 (8.6%) thyroidectomized patients had malignancy (5% ITC and 3.6% FN-FNAC), with 89.8% of ITCs having a diameter <10 mm, and 65.7% of FN-FNAC cancers having a diameter >30 mm. Sixty-seven thyroid malignancy patients (79.8%) had stage I disease (American Joint Committee on Cancer criteria). The risk of FN-FNAC increases with increasing size of the nodule, while the risk of ITC increases as nodule size decreases.ResultsThe risk of malignancy in presumably benign thyroid disease cannot be overlooked, but can be minimized through skillfully performed ultrasonography (US) examination and FNAC. Once a patient with multinodular goiter is referred for follow-up or nonsurgical therapy, careful US surveillance is mandatory. (Endocr Pract. 2013;19:444-450)     

Incidental Thyroid Cancer in Toxic and Nontoxic Goiter: is TSH Associated with Malignany Rate? Results of A Meta-Analysis

ObjectiveIn the last 6 years, several studies reported a positive association between thyrotropin (TSH) and papillary cancer risk. The rationale is based on stimulatory action exerted by TSH on thyroid cell proliferation and/ or progression of a pre-existing papillary carcinoma. To validate this hypothesis, we performed a meta-analysis comparing the incidence of thyroid cancer in 2 groups of patients who underwent surgery for toxic or nontoxic nodular goiter.MethodsUsing data from 2,150 patients with toxic multinodular goiter (TMNG) and 873 patients with toxic adenoma (TA), the overall incidence of thyroid cancer (and 95% confidence interval [CIs]) was estimated to be 5.9% (3.9 to 8.3) for patients with TMNG and 4.8% (2.5 to 7.9) for patients with TA. Four studies were included in the meta-analysis with a total of 1,964 subjects undergoing thyroidectomy for allegedly benign thyroid disease (520 patients with TMNG or TA and 1,444 for multinodular goiter [MNG] or uninodular goiter [UNG]).ResultsWe did not find any significant differences in the risk of incidental thyroid cancer (ITC) in patients with TMNG versus MNG (odds ratio [OR]: 0.91, 95% CI: 0.47 to 1.77, I⁴: 62.6%), TA versus uninodular goiter (UNG) (OR: 0.46, 95% CI: 0.12 to 1.79, I⁵: 12%), and TMNG or TA versus MNG or UNG (pooled analysis) (OR: 0.86, 95% CI: 0.46 to 1.60, I⁶: 51.5%).ConclusionsThe results of this meta-analysis did not confirm an association between low TSH values and lower thyroid cancer rate, at least in patients with nodular disease. (Endocr Pract. 2013;19:212-218)     

Development of Thyroid Storm After Surgical Resection of A Thyrotropin-Secreting Pituitary Adenoma

ObjectiveTo describe a patient with a thyrotropinsecreting pituitary adenoma in whom postoperative thyroid storm developed.MethodsWe present a case report with details of the initial presentation, laboratory evaluation, surgical and pathologic findings, and subsequent course in a patient with a thyrotropin (thyroid-stimulating hormone or TSH)- secreting adenoma and postoperative thyroid storm.ResultsAn 18-year-old male patient presented with severe headaches and was found to have a large suprasellar tumor and a mildly elevated level of TSH. Thyroid storm developed immediately after surgical resection of the pituitary mass. Results of laboratory evaluation undertaken preoperatively became available after the patient had undergone the surgical procedure and revealed thyroid hormone levels 2 to 3 times the upper limit of normal. Propylthiouracil and β-adrenergic blocking agents controlled the postoperative thyrotoxicosis and were subsequently discontinued as his TSH and thyroid hormone levels normalized.ConclusionThis case demonstrates the rare case of a TSH-secreting adenoma in a young patient, which was complicated by the development of postoperative thyroid storm. In addition, this case emphasizes the importance of preoperative pituitary hormonal evaluation and treatment of hormonal abnormalities in all patients presenting with sellar or suprasellar tumors. (Endocr Pract. 2008;14:732- 737)     

Hürthle cell carcinoma of the thyroid presenting as thyrotoxicosis

ObjectiveTo report a case of hyperthyroidism associated with Hülllnnvl-ürthle cellcarcinoma and to review the literature regarding this relationship.MethodsWe describe the clinical, biochemical, radiologic, and pathologic data of a patient with Hürthle cellcarcinoma associated with thyrotoxicosis and reversible heart failure. We discuss the mechanistic aspects and review previously reported cases of functionalHürthle cellcarcinomas.ResultsA 43-year-old womanpresented with thyrotoxicosis and nonischemic cardiomyopathy. She had a “hot” nodule inthe left lobe of the thyroid onsodium pertechnetate scan. She underwent a left hemithyroidec-tomy and isthmusectomy. Pathologic findings revealed a minimally invasive Hürthle cellcarcinoma. Onfollow-up, the dilated cardiomyopathy had resolved. The associationof thyroid carcinoma with thyrotoxicosis is rare.ConclusionsSome Hürthle cellcarcinomas canbe functionaland lead to thyrotoxicosis. To our knowledge, we present the first case of reversible dilated cardiomyopathy due to thyrotoxicosis originating from Hülll-ürthle cellcarcinoma. (Endocr Pract. 2012;18:e5-e9)     

IS MEASUREMENT OF CIRCULATING TUMOR DNA OF DIAGNOSTIC USE IN PATIENTS WITH THYROID NODULES?

Objective: Circulating tumor DNA (ctDNA), a subset of cell-free DNA (cfDNA), is a potential biomarker for thyroid cancer. We determined the performance of a ctDNA panel for detecting thyroid malignancy in patients with thyroid nodules.Methods: Sixty-six patients with thyroid nodules without a prior history of cancer enrolled in a prospective, 1-year study in which blood was drawn for ctDNA analysis prior to undergoing fine-needle aspiration biopsy (FNAB) of thyroid nodules. The ctDNA panel consisted of 96-mutations in 9 cancer driver genes. The primary outcome measures were the sensitivity, specificity, and positive and negative predictive values (PPV, NPV) of our ctDNA panel for the diagnosis of thyroid malignancy as determined by pathologic and/or molecular tissue examination.Results: Results from 10 subjects could not be determined due to inadequate volume or technical issues. The final classifications of the thyroid nodules were 13 malignant and 43 benign lesions. A KRAS G12V mutation was detected in the plasma of 1 patient with stage IVA papillary carcinoma whose tissue contained the same mutation. Two of the 43 patients with benign lesions also had ctDNA detected, giving a sensitivity of 7.7%, specificity of 95.35%, PPV of 33.33%, and NPV of 77.35%. There were no significant differences between benign or malignant lesions in cfDNA levels.Conclusion: Neither cfDNA measurements nor our panel of ctDNA mutations are sensitive or specific enough to provide valuable information over FNAB. An expanded panel and the inclusion of proteomics may improve sensitivity and specificity for thyroid cancer detection.Abbreviations: cfDNA = cell-free DNA; ctDNA = circulating tumor DNA; FNAB = fine-needle aspiration biopsy; NIFTP = noninvasive follicular thyroid neoplasm with papillary-like nuclear features     

Asymptomatic Bilateral Giant Adrenal Myelolipomas: Case Report and Review of Literature

ObjectiveTo describe an unusual case of bilateral giant adrenal masses caused by a primary adrenal myelolipoma.MethodsWe present the clinical, laboratory, and pathologic findings in a 32-year-old man with bilateral adrenal masses. The previous reports of bilateral myelolipomas also were reviewed.ResultsDuring a routine examination, a 32-year-old Thai man was found to have an asymptomatic abdominal mass. A computed tomographic scan of the abdomen disclosed bilateral adrenal masses; the one on the left was approximately 27 by 24 by 12 cm, and the one on the right side was 9 by 5 by 5 cm. The computed tomographic scan characteristics showed that both masses consisted mainly of low-density tissues (-30 to -90 Hounsfield units), suggestive of fatty component. An endocrinologic evaluation revealed no evidence of adrenal cortical or medullary functional abnormalities. Bilateral adrenalectomy was performed because of the large size of the lesions and the inability to rule out malignant involvement.ConclusionMyelolipoma is a relatively rare benign tumor of the adrenal glands composed of adipose cells and mature hematopoietic elements. Most such lesions are small, asymptomatic, and unilateral; giant or bilateral myelolipomas are quite rare. To our knowledge, our current case may represent the largest bilateral lesions in the literature. (Endocr Pract. 2007;13:667-671)     

Calcitonin-Secreting Pancreatic Neuroendocrine Tumors: A Case Report and Review of the Literature

ObjectiveWe report the presentation and novel therapy of a calcitonin-secreting pancreatic neuroendocrine tumor (PNET) and review the literature on this unusual neoplasm.Methods:We cite the history of a 38-year-old male who presented with fatigue, weight loss, and diarrhea and was found to have a pancreatic head mass on cross-sectional imaging, as well as liver metastases.Results:The patient’s laboratory evaluation was notable for a >100-fold elevation of the peptide hormone calcitonin in serum. As calcitonin is typically secreted by thyroid C-cells, hypercalcitoninemia is considered a marker for medullary thyroid cancer (MTC) or C-cell hyperplasia, but it may be present in several physiologic or pathologic conditions or may be ectopically secreted in rare PNETs. An octreotide scan confirmed the presence of somatostatin (SST) receptors on the pancreatic mass and liver metastases, leading to the diagnosis of a calcitonin-secreting PNET. We initiated treatment with long-acting SST analogs and peptide receptor radionuclide therapy (⁹⁰Yttrium-DOTATOC) and achieved disease regression while maintaining a high quality of life.Conclusion:Functional PNETs that secrete calcitonin are exceedingly rare, but they are important to consider in the differential diagnosis of nonthyroid-mediated hypercalcitonemia or pancreatic tumors that present with diarrhea, as the management differs markedly from both MTC and other pancreatic malignancies. (Endocr Pract. 2014;20:e140-e144)     

A Longitudinal Study of Thyroidectomized Patients in a Region of Northern Italy: Benign Versus Malignant Disease

ObjectiveThyroid disease is very common, particularly nodular goiter. Total thyroidectomy is a therapeutic option for both malignant and benign disease. The aim of the study was to evaluate the number of total thyroidectomy surgeries and the rate of benign and malignant histologic exams over the last decade.MethodsHospital discharge records in the Emilia Romagna region (Italy) that reported total thyroidectomy as the principal surgical procedure and included the relative histologic diagnosis were reviewed for the period 2000 to 2010. Mean increment and geometric mean of increments per year were calculated to evaluate differences over the years.ResultsMore than 25,000 patients underwent total thyroidectomy between 2000 and 2010. The total number of thyroidectomies increased over this period, with a mean increment of 7.16% per year. The percentage of malignancies among the total number of thyroidectomies increased from 26.1% (2000) to 39.9% (2010) (mean increment, 1.38% per year). Nontoxic multinodular goiter was the most frequent diagnosis, accounting for 36% of all thyroidectomies.ConclusionBetween 2000 and 2010, the proportion of patients thyroidectomized for benign disease progressively decreased, as documented by a lower thyroidectomy/malignancy ratio. Currently, about 60% of thyroid interventions are performed for benign pathology. Improved preoperative diagnostic accuracy and the availability of nonsurgical procedures will presumably further reduce the number of thyroidectomies with benign histologic diagnoses. (Endocr Pract. 2013;19:259-262)