A PERPLEXING THYROID NODULE:
A Case Study from ESAP™
QUESTION
The Endocrine Self-Assessment Program (ESAP) is a self-study program aimed at physicians seeking certification or recertification in endocrinology; program directors interested in a testing and training instrument; and individuals simply wanting a self-assessment and a broad review of endocrinology. ESAP is available in both print and online formats. It consists of 160 multiple-choice questions in all areas of endocrinology, diabetes, and metabolism. There is extensive discussion of each correct answer, a comprehensive syllabus, and references. ESAP is updated annually with new questions and new syllabus materials. Learn more at www.endoselfassessment.org.
A 45-year-old woman is referred for evaluation of a left thyroid nodule. She has been treated for five years by her primary care physician for documented Hashimoto disease and hypothyroidism, treated with levothyroxine, 112 mcg daily. Her thyroid gland has been normal in size but firm. During the last year, her physician noted an increase in size of the left thyroid lobe, now estimated to be 3 cm in diameter, and recently palpated a 2-cm nodule. The patient has not noted this change in size and has no symptoms of compression of neck structures (e.g., dysphagia, dysphonia). The patient smokes cigarettes, but otherwise has no notable medical history.
On physical examination, she appears healthy with normal vital signs. BMI is 26.2 kg/m2. She appears to be clinically euthyroid. Her right thyroid lobe is palpable and firm. The left lobe contains a 2- to 3-cm firm nodule with a smooth surface that moves well with swallowing. There are no abnormal lymph nodes palpable in the neck. The serum TSH concentration is 1.4 mIU/L.
You perform a fine-needle aspiration biopsy of the nodule with ultrasound guidance to verify needle placement. You then review the slides with the cytologist (see image below).
Which one of the following best describes the cytologic findings in this patient?
A. Hashimoto disease
B. Benign nodular goiter
C. Suggestive of thyroid lymphoma
D. Suggestive of papillary carcinoma
E. Medullary thyroid carcinoma
FLARE
Congratulations to the FLARE Award Winners!
Congratulations to the winners of the Society’s Future Leaders Advancing Research in Endocrinology (FLARE) Internship and Mentoring Network Travel Awards! FLARE Mentoring Network Travel Award winners receive free airfare and lodging to gain individualized, in-person mentoring from Society members. FLARE interns expand their leadership skills through a year of service on a Society governance committee. To view a list of the accomplished FLARE winners and learn more about the program, please visit http://www.endocrine.org/FLARE.
GLOBAL EXPERTS LEAD
ICE/ENDO 2014
Plenary Sessions
The world’s largest gathering of endocrinologists promises to deliver a plenary slate for the ages. At ICE/ENDO 2014, you’ll hear from internationally renowned experts in the most rapidly evolving areas of endocrinology — including signaling, metabolism, cancer, diabetes, pediatric endocrinology, genomics, and the application of big data.
Stars Shine During Presidential Plenary Sessions
Saturday’s sessions begin with 2012 Nobel Laureate Robert J. Lefkowitz, MD, presenting his groundbreaking work on the historical understanding of G-protein coupled receptors — the largest, most versatile, and most ubiquitous family of cellular receptors. He will discuss how recent paradigm shifts in our understanding of their function may lead to novel classes of therapeutic agents.
C. Ronald Kahn, MD, of the Joslin Diabetes Center, will assess the incredible progress made over the past decade in defining molecular mechanisms of insulin action from the classical tyrosine kinase cascade to new aspects such as unique unoccupied insulin
receptor signaling, receptor and membrane molecule modifying interactions, and signaling feedback pathways in insulin resistance.
A Winning Array of Award Lectures
Five award lectures highlight the depth and variety of plenary sessions at ICE/ENDO 2014:
• The Edwin B. Astwood Award Lecture will feature Domenico Accili, MD’s examination of the mechanisms of β cell failure and potential treatments for type 2 diabetes.
• David M. Altshuler, MD, PhD, will probe human genetic variation and type 2 diabetes inheritance during the Roy O. Greep Award Lecture.
• James A. Fagin, MD, will provide a comprehensive analysis of the most promising targets for thyroid cancer treatment in his Clinical Investigator Award Lecture.
• Maria I. New, MD, will illuminate recent advances in the prenatal diagnosis of congenital adrenal hyperplasia during the Endocrine Regulation Prize Lecture.
• Peter J. Tontonoz, MD, PhD, will enlighten attendees on the integration of metabolic and inflammatory signaling through liver X receptors during the Gerald D. Aurbach Award Lecture.
Other Noteworthy Sessions
Make plans to attend any of the following plenary sessions at
ICE/ ENDO 2014
:
• Teresa L. Wood, PhD: Insulin and IGF Receptor Signaling in Stem Cell Homeostasis
• Stuart H. Ralston, MD, FRCP: Genetic Determinants of Bone Disease
• Rosemary O’Connor, PhD: IGF and Cancer Signaling
• Susan E. Ozanne, PhD: Early Environmental Influences on Type 2 Diabetes Risk
• Michael A. Cowley, PhD: Leptin: The Link between Obesity and Heart Disease?
• Andrea C. Gore, PhD: Endocrine Disruptors and the Neuroendocrine Control of Reproduction and Behavior
• Dolores M. Shoback, MD: Metabolic Bone Disease, the Calcium Sensing Receptor, and Parathyroid Hormone
• Hertzel C. Gerstein, MD, MSc. FRCPC: Outcomes Trials in Diabetes
Plan Now to Join Us
Register now at ice-endo2014.org to learn all the latest advancements in endocrinology from the field’s leading minds.
A PERPLEXING THYROID NODULE:
A Case Study from ESAP™
ANSWER
The Endocrine Self-Assessment Program (ESAP) Enjoy this case? Access more by visiting endoselfassessment.org today. Self-assess your knowledge with casevignettes like this or learn more about your performance with practice improvement modules (PIMs). Self-assessment products from The Endocrine Society offer CME credits and MOC points. Visit endoselfassessment.org and use the personalized “My Modules” dashboard to manage your CME and MOC needs.
The answer is: D
Hashimoto disease and hypothyroidism in this patient had been stable for some years until her physician palpated an enlarging left thyroid nodule. This development is worrisome because patients with Hashimoto disease have an increased incidence of differentiated thyroid cancer and thyroid lymphoma; the latter almost never occurs in the absence of Hashimoto disease.
The most efficient evaluation of thyroid nodules uses fine-needle aspiration biopsy, which is a rapid, safe, and relatively inexpensive diagnostic procedure. Currently, fineneedle aspiration biopsy is the most accurate diagnostic tool for thyroid nodules and has excellent correlation with surgical pathologic findings in many studies. For diagnosis of thyroid cancer, fine-needle aspiration biopsy has a sensitivity of 85%, a specificity of 80%, and a very low percentage of false-positive and false-negative results (i.e., about 2% to 5%, depending on the performing institution and whether ultrasound guidance is used). The apparent discordance between the sensitivity and specificity for cancer and the very low false-positive and false-negative
rates is because of classification of follicular neoplasm. Most patients are referred for surgery treatment because cytologic examination alone cannot distinguish between adenoma and differentiated follicular carcinoma, but only 20% actually have carcinoma.
Because thyroid nodules are so common, and because the cytologic distinction between benign and malignant nodules may not always be clear-cut, endocrinologists caring for patients must be familiar with the basics of interpreting thyroid cytology, so that they can interact intelligently with the cytologist.
Obtaining sufficient thyroid material is required for successful and accurate interpretation of thyroid specimens. Fifteen to 20% of aspirates are inadequate for interpretation. Fine-needle aspiration biopsy should be repeated in those cases and is adequate on the second aspirate about half the time. In samples that can be interpreted, cytologists look for the relationship between cellular material and colloid. The more colloid present in relation to cells, the more likely it is that the lesion is benign. The absence of colloid in cellular samples suggests a thyroid neoplasm. For most thyroid disorders, interpretation of cellular architecture is focused on the thyroid follicular cell. In benign disorders, follicular cells are a little larger than red blood cells, uniform in shape, have dark chromatin, and are not crowded or overlapping on the smears. Follicular tumors may have normal-appearing follicular cells, but contain little colloid.
Although no classic papillary fronds with vascular cores are present, the aspirate in this patient is suggestive of papillary carcinoma (Answer D). Follicular cells on the slides are more than five times larger than adjacent red blood cells. Their nuclei have delicate, vesiculated chromatin. Some of the follicular cells have nuclear grooves and others have nuclear inclusions. Almost no colloid is present. All of these findings are seen in pathologic material from papillary carcinoma.
The aspirates do not have lymphocytes, which excludes a cytologic diagnosis of Hashimoto disease (Answer A) or thyroid lymphoma (Answer C). The absence of colloid excludes a benign nodular goiter (Answer B). Medullary thyroid carcinoma (Answer E) may be suspected on fine-needle aspiration. However, distinctive nuclear features of medullary carcinoma cells (inconspicuous nucleoli, dusty neuroendocrine chromatin, multinucleation) and cytoplasmic borders that are poorly defined are missing from the present cellular material. In fact, the nucleoli and chromatin are prominent in this cytologic smear. More importantly, one would want calcitonin immunostaining, with or without amyloid stain, before entertaining this diagnosis.
NANCY RODNAN to Lead the Society’s Publications Department
Nancy Rodnan has joined the Society as the senior director of publications. She will oversee all aspects of the Society’s publishing enterprise, which includes five scholarly journals (Journal of Clinical Endocrinology & Metabolism, Endocrinology, Molecular Endocrinology, Endocrine Reviews and Hormones and Cancer), Endocrine News, and Endocrine Press, the Society’s publishing imprint that issues print and electronic books as well as journals for a broad audience of healthcare professionals and patients.
“The Endocrine Society’s journals rank among the most authoritative peer-reviewed biomedical research journals in the world,” says executive director and CEO, Barbara Byrd Keenan. “Nancy’s innovation, valuable experience, and proven record of accomplishment will help ensure the Society’s publishing program continues to excel well into the future.”
Prior to her employment at the Society, Rodnan led the publications department at the American Society for Biochemistry and Molecular Biology (ASBMB), managing the Journal of Biological Chemistry, Molecular and Cellular Proteomics, the Journal of Lipid Research, and other ASBMB publications for more than 10 years. Previously, Nancy had leadership positions in publications with the Federation of American Societies for Experimental Biology and the American Chemical Society.
“I feel fortunate to become part of an organization that is so well run and has such an excellent reputation in scientific publishing,” Rodnan says. “I am looking forward to working with the talented staff in the Publications Department and exploring new opportunities in publishing that align with the overall strategic goals of the Society.”
New from the Hormone Health Network: Diabetes and Pregnancy and PCOS Patient Guides
Visit www.hormone.org and download the Network’s latest patient guides on diabetes and pregnancy and polycystic ovary syndrome (PCOS) and help your patients learn more about these conditions.
Diabetes and Pregnancy: A Patient’s Guide, offers assurance to women with diabetes that, with proper care and planning, they can have both a healthy pregnancy and a healthy baby. The guide was cr5eated in collaboration with DiabetesSisters, a peer support group that offers education and support services to help women with diabetes live healthier, fuller lives.
The development of this patient gude was supported by an educational grant from Novo Nordisk Inc.
Polycystic Ovary Syndrome: A Patient’s Guide, describes the risk factors for and symptoms of this common hormonal disorder among girls and womaen of reproductive age. The guide describes considerations when making a diagnosis, as well as tests needed to screen for health problems that occur more often in PCOS. While there is no cure for PCOS, the guide reassures women that treatment for symptoms and related disorders, along with a healthy lifestyle, can improve a woman’s quality of life.
New from the Hormone Health Network: Diabetes and Pregnancy and PCOS Patient Guides
Visit www.hormone.org and download the Network’s latest patient guides on diabetes and pregnancy and polycystic ovary syndrome (PCOS) and help your patients learn more about these conditions.
Diabetes and Pregnancy: A Patient’s Guide, offers assurance to women with diabetes that, with proper care and planning, they can have both a healthy pregnancy and a healthy baby. The guide was cr5eated in collaboration with DiabetesSisters, a peer support group that offers education and support services to help women with diabetes live healthier, fuller lives.
The development of this patient gude was supported by an educational grant from Novo Nordisk Inc.
Polycystic Ovary Syndrome: A Patient’s Guide, describes the risk factors for and symptoms of this common hormonal disorder among girls and womaen of reproductive age. The guide describes considerations when making a diagnosis, as well as tests needed to screen for health problems that occur more often in PCOS. While there is no cure for PCOS, the guide reassures women that treatment for symptoms and related disorders, along with a healthy lifestyle, can improve a woman’s quality of life.
– See more at: http://endonews.matrixdev.net/april-2014-society-news/#sthash.1uCf0dJi.dpuf
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