CASE
REPORT
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InternationalJournalofSurgeryCaseReports60(2019)46–48
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International
Journal
of
Surgery
Case
Reports
jo u r n al ho me p a g e :w w w . c a s e r e p o r t s . c o m
A
case
of
mixed-pattern
calcifications
in
multinodular
goiter
associated
with
a
benign
diagnosis
D.
Bianchi,
U.
Morandi,
A.
Stefani,
B.
Aramini
∗DivisionofThoracicSurgery,DepartmentofMedicalandSurgicalSciencesforChildrenandAdults,UniversityHospitalofModena,ViaLargodelPozzon.71, 41124Modena,Italy
a
r
t
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c
l
e
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f
o
Articlehistory: Received4April2019
Receivedinrevisedform21May2019 Accepted30May2019
Availableonline8June2019
Keywords: Calcifiednodules Calcifications Malignantnodules Benignlesion Endoscopicultrasound
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BACKGROUND:Calcifiednodulesareoftenfoundinagoiterwhenperforminganultrasoundoftheneck. Ananalysisofdifferentcalcificationpatternscouldcontributetodiscriminatingbetweennoduleswitha lowermalignancyriskandthosewithahighermalignancyrisk.Incertaincases,theresultsofasimple cytologicalanalysisofanodulearenotspecificenoughtobecompletelytrusted.
CASEPRESENTATION:Wepresentthecaseofagoiterwithamixedcalcificationpattern,includingatype ofcalcificationthatisstronglyassociatedwithamalignantdiagnosis,forwhichacompletelybenign diagnosiswasdetermined.
CONCLUSION:Webelievethatfurtherstudiesexaminingacombinationofultrasound(US)andcomputed tomography(CT)scanpresentationsofthyroidnodulesneedtobeperformed.
©2019TheAuthor(s).PublishedbyElsevierLtdonbehalfofIJSPublishingGroupLtd.Thisisanopen accessarticleundertheCCBYlicense(http://creativecommons.org/licenses/by/4.0/).
1. Background
Calcificationsareacommonultrasonographicfindingin thy-roidnodules,andtheassessmentofcalcificationpatternscanbe usefulindifferentiatingbetweenbenignandmalignantnodules. Dependingontheirdiameterandechogeniccharacteristics,thyroid calcificationsaredividedintotwocategories:microcalcifications (<2mmindiameter)andmacrocalcifications(>2mmindiameter withaposterioracousticshadow).
Microcalcificationhasbeenfoundtobestronglyassociatedwith papillarythyroidcarcinoma;itisfoundinupto40%ofcases[1]. Ontheotherhand,variouspatternsofmacrocalcification,suchas annularor“egg-shell”calcification,arelessclearlyassociatedwith malignancy.
Theroleoffine-needleaspiration(FNA)forthyroidnoduleswith macrocalcificationsisunclearduetoarelativelyhighrateoffalse negativesandnondiagnosticcytologies[2].
Ouraimistopresentacaseofmultinodulargoiterinwhichwe foundamixedpatternofcalcifications(bothmicro-and macrocal-cifications),buteventuallyreachedabenigndiagnosis.Thiswork hasbeenreportedinlinewiththeSCAREcriteria[3].
Abbreviations:US,endoscopicultrasound;CT,computedtomography;FNA, fine-needleaspiration.
∗ Correspondingauthor.
E-mailaddresses:Danb9106@gmail.com(D.Bianchi),
uliano.morandi@unimore.it(U.Morandi),alessandro.stefani@unimore.it
(A.Stefani),beatrice.aramini@unimore.it(B.Aramini).
2. Casepresentation
Wepresentacaseinvolvinga76-year-oldfemalepatientwho wasfirstseen by herdoctor for problemsand discomfort with deglutition. Upon an objective examination, the thyroid gland appearedtobemildlyenlarged(moreontherightsideoftheneck) withahardconsistency,butmobilerelativetotheunderlying tis-sues.Theonlycomorbiditywasamentalillness.
Anultrasound(US)oftheneckwasimmediatelyperformedand revealedamultinodularretrosternalgoiter,forwhichthelarger noduleintherightlobepresentedwithadiameterofapproximately 6cmandcompleteringcalcification.Thegoiterextendedintothe uppermediastinumandwaslyingontheaorticarch.
Duetothegoiter’sretrosternalconfiguration,weperformedaCT scanoftheneckandthorax.Thescanshowedtheposterior disloca-tionoftheepiaorticvesselsandlateraldislocationandcompression ofthepharynx.ThelargenoduledescribedpreviouslybasedonUS exhibitedamixedtypeofcalcification;infact,inthecontextofa largeegg-shellcalcification,multiplespotswithmicrocalcifications wereobserved(Fig.1AandB).
Giventhenotabledimensionsofthegoiter,itssymptomatic dis-positionandtheextremecalcificationofthenodule,wechoseto avoidanultrasound-guidedago-biopsyduetothelowprobability ofobtainingagoodtissuesampleandtheconsequentdiagnosis, andinagreementwiththepatient’sendocrinologist,wedecidedto directlyperformastandardthyroidectomythroughacervicotomy. Theprimarydifficultyduringtheoperationwasthecomplete calci-ficationoftheentirerightlobe,whichwasadherenttothetrachea
https://doi.org/10.1016/j.ijscr.2019.05.061
2210-2612/©2019TheAuthor(s).PublishedbyElsevierLtdonbehalfofIJSPublishingGroupLtd.ThisisanopenaccessarticleundertheCCBYlicense(http://creativecommons.
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D.Bianchietal./InternationalJournalofSurgeryCaseReports60(2019)46–48 47
Fig.1.A.Calcifiednodulewith“egg-shell”pattern.B.Microcalcificationspotsinthesamenodule.
Fig.2. A.Macroscopicallycompletecalcifiednodule.B.Calcifiedrimwhencut.
andvascularstructures(Fig.1AandB).However,nomajorbleeding orcomplicationsoccurredduringsurgery.
Macroscopically, the pathologist described a nodule with a weightof130gthatwaspartiallycavitatedand extremelyhard whencut(Fig.2AandB).
Amicroscopichistologicalexaminationexcludedthepresence ofatypicalcellsandrevealednodularhyperplasiainfibroticareas. Thepatient’spostoperativecoursedidnotinvolveany compli-cationsrelatedtothesurgicalprocedure,andshewasdischarged twodaysafterthesurgery.
3. Discussionandconclusion
Itiscommonlyknownthatmicrocalcificationpatternsare asso-ciatedwith an elevatedrisk of papillary carcinoma findings in thyroidnodules,butthatUSfindingsofmacrocalcificationsin thy-roidnodulesareassociatedwithasignificantlylowermalignancy risk(upto27.6%ofcases);inparticular,Kimetal.reportedthat annularcalcificationwasassociatedwiththelowestriskof malig-nancy[1].
Nonetheless, for nodules with macrocalcifications, FNA has proventobeinaccurateandisthereforenothelpfulfor discriminat-ingbetweenbenignandmalignantnodules,asobservedbyDong GyuNa,whodescribedanondiagnosticresultin65.1%ofcasesand inconclusiveresultsin67.1%ofcases;afindingwhichleadsustothe conclusionthatUScalcificationpatternsshouldbestudiedmoreto
assesstheappropriatepredictorsforclinicaluse[2].Somerecent studieshaveanalyzedthepossiblediagnosticvalueofCTfor dis-criminatingbetweenbenignandmalignantthyroidnodules[4–7]. Althoughwehavefoundalargeamountofdatausedtoanalyze singularpatternsofcalcificationaspredictorsofmalignancy,even usingradiologicalassessments,wehavefoundnodatathatrefer toapossiblyhighermalignancyriskrelatedtothecoexistenceof multiplepatternsofcalcification[8–11].
Incasessuchasoursthatinvolvedifferentpatternsof calcifi-cation,whichpatternsshouldberegardedasmoreimportantfor choosingthecorrecttherapeuticprocedure?
Fornodulesassociatedwithdifferenttypesofcalcification,the patternthatisassociatedwithahigherriskofamalignant prog-nosis, rather than simplythemostrepresented pattern, should probablyberegardedasthedominanttype.
In our experience, although we encountered the extensive macrocalcificationof a largenodule(6cm) withacontroversial patternofcalcifications,thisnodulewaseventuallydeterminedto bebenign.Weoptedforthesurgicalremovalofthethyroidgland merelyduetoitsdimensionsandthediscomfortthatthepatient wassuffering.However,nopublicationsinthecurrentliterature provideacleardescriptionofhowacombinedmicro-and macro-calcificationpatternisrelatedtotheriskofamalignantorbenign lesion. Willit bepossible inthefuture tobetter comparehow radiologicalfindingsrelatetonodulehistology?IsanFNAbiopsy indicated in casesinvolvingcombinedcalcification inthesame
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48 D.Bianchietal./InternationalJournalofSurgeryCaseReports60(2019)46–48
nodule,evenifahighriskofafalsenegativehasbeendescribed? In a retrospectivestudy, Zhou et al. [12] studiedthe quantita-tivecontrast-enhancedUSindicatorsfordiscriminatingbetween benignandmalignantthyroidnodules.Theauthorsconcludedthat quantitativecontrast-enhancedUSmaybeusefulandthatthe nod-uletoperi-nodulepeakintensityratioshowedthebestdiagnostic efficacy;however,thesituationremainsunclearandcontroverted. In summary, our case report highlighted some interesting points,whichshouldbetakenintoconsiderationforfurther clini-calstudy:1.theimpossibilityofperforminganFNAbiopsyinsome situations,asinourcase,wherethelobeswerecompletelycalcified notonlyinsidebutalsoexternally;2.thenecessityofperforming athyroidectomyevenwithoutabiopsy,basedonthesymptoms ofthepatientandduetothelowprobabilityofobtainingagood qualitysample,whichisusefulforthediagnosis;3.despitethe sci-entificliteratureregardingmicrocalcifications,whicharemainly consideredasasignofpapillarycarcinoma,weshowedacaseofa completelycalcifiedthyroidgoiter(withmicro-and macrocalcifi-cations)withabenigndiagnosis.Thiscouldsuggestthenecessity inthefuturetobetterdefineorreconsiderthecalcificationsina thyroidgoiter,whichofcourseisnotpossibletobedetermined byasinglecase,butinfurthermultiple-casestudies.Webelieve thatattentionshouldbefocusedonabetterclassificationand def-initionof the calcifications, not only regarding the radiological findings,asrecentlydescribed,butalsoinregardtodiscovering newapproachestoanalyzingtheircharacteristics.
Conflictsofinterest
TheAuthorshavenofinancialandpersonalrelationshipsto dis-close.
Sourcesoffunding
Nofunding.
Ethicalapproval
ForsinglecasereportNOethicalapprovalneeds.Patientsigned aconsentforpublishingthecasereport.
Consent
Patientsignedaconsentforthepublicationofthiscasereport.
Author’scontribution
DBandBAwrotethecasereport.ASandUMrevisedthecase report.
Registrationofresearchstudies
EthicalBoardapprovalisnotrequiredforcasereportsinour Center.
Guarantor
Prof.UlianoMorandiistheGuarantorofthiscasereport.
Provenanceandpeerreview
Notcommissioned,externallypeer-reviewed.
Acknowledgement
Notapplicable.
References
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