Sonographic Extranodular and Intranodular Microcalcifications NIDHI AGRAWAL, MD VALERIE PECK, MD DIVISION OF ENDOCRINOLOGY, DIABETES AND METABOLISM NEW YORK UNIVERSITY MEDICAL CENTER

CASE  31 y/o F  Referred to our clinic with abnormal bone density  Found to have a small multi-nodular goiter  No history of head/neck radiation  Asymptomatic  No compressive symptoms  No symptoms suggestive of hypothyroidism or hyperthyroidism

CASE  PMH Turner’s syndrome Endometrial polyps  FH Non-contributory No family history of thyroid disease  Medications Estradiol Provera

On Exam  Vitals normal  Weight 110 pounds, Height 5’ 1”, BMI  Neck:  Small goiter with several bilateral nodules  Non tender, no bruits  No palpable lymph nodes  Respiratory/ Cardiovascular/Gastrointestinal exam: Normal  Neuro: Grossly Normal  No pedal edema

Relevant labs  TSH 4.80 mIU/L ( mIU/L)  Free T4 1.1 ng/dL ( ng/dL)  Thyroid Peroxidase Antibody: 0.5 IU/ml ( IU/ml)

Ultrasound of the neck

Case  FNA consistent with Bethesda VI Papillary Thyroid Carcinoma  Patient underwent a total thyroidectomy and modified neck dissection  Uneventful post-operative course  Received 125 mCi of RAI

Surgical Pathology

Surgical pathology  Papillary Thyroid Carcinoma foci in both lobes  Marked fibrosis, infiltrative pattern of growth  Focal tall cell features  Lymph nodes positive for metastatic PTC  Presence of diffuse Psammoma bodies

Microcalcifications  Microcalcifications help in identifying papillary cancers as a single ultrasonographic sign:  Specificity (93%)  Poor sensitivity (36%)  PPV (94.2%)  High Accuracy  Probably correspond to clusters of Psammoma bodies on HPE THYROID Volume 18, Number 9, 2008

Psammoma bodies A B THYROID Volume 18, Number 9, 2008

Psammoma bodies  Most commonly seen in PTC, meningioma, and ovarian malignancy  Represent “ghosts” of dead papillae which attract calcium deposits  May be formed by necrosis and calcification of tumor thrombi

Thyroid Calcification Psammomatous Microcalcification on USG Dystrophic Coarse calcification on USG Ultrasound Med 2007; 26:1349–1355

Psammoma Bodies are found in 50% of PTC 258 patients with surgically resected classical PTC All patients underwent preoperative US and FNAB

Pyo JS et al the prognostic relevance of psammoma bodies and ultrasonographic intratumoral calcifications in papillary thyroid carcinoma. World J Surg. 2013

Pyo JS et al the prognostic relevance of psammoma bodies and ultrasonographic intratumoral calcifications in papillary thyroid carcinoma. World J Surg. 2013

Conclusion  Sonographic microcalcifications in a thyroid nodule are suggestive of malignancy and correlate with Psammoma body clusters  Extratumoral Psammoma bodies have been shown to be associated with:  Spread of tumor cells via vascular or lymphatic channels  More aggressive PTC  Our case suggests that the detection of extranodular microcalcifications, which correlate with extranodular psammoma bodies, may be a useful prognostic indicator of aggressive PTC