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Sonographic Extranodular and Intranodular Microcalcifications NIDHI AGRAWAL, MD VALERIE PECK, MD DIVISION OF ENDOCRINOLOGY, DIABETES AND METABOLISM NEW YORK UNIVERSITY MEDICAL CENTER
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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
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CASE PMH Turner’s syndrome Endometrial polyps FH Non-contributory No family history of thyroid disease Medications Estradiol Provera
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On Exam Vitals normal Weight 110 pounds, Height 5’ 1”, BMI 20.86 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
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Relevant labs TSH 4.80 mIU/L (0.4-4.0 mIU/L) Free T4 1.1 ng/dL (0.7-2.2 ng/dL) Thyroid Peroxidase Antibody: 0.5 IU/ml (0- 5.5 IU/ml)
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Ultrasound of the neck
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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
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Surgical Pathology
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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
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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
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Psammoma bodies A B THYROID Volume 18, Number 9, 2008
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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
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Thyroid Calcification Psammomatous Microcalcification on USG Dystrophic Coarse calcification on USG Ultrasound Med 2007; 26:1349–1355
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Psammoma Bodies are found in 50% of PTC 258 patients with surgically resected classical PTC All patients underwent preoperative US and FNAB
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Pyo JS et al the prognostic relevance of psammoma bodies and ultrasonographic intratumoral calcifications in papillary thyroid carcinoma. World J Surg. 2013
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Pyo JS et al the prognostic relevance of psammoma bodies and ultrasonographic intratumoral calcifications in papillary thyroid carcinoma. World J Surg. 2013
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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
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