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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