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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 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 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 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) Ultrasound of the neck Ultrasound of the neck 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 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 Poor PPV sensitivity (36%) (94.2%) High (93%) 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
