Diagnosing amyloid goitre with thyroid aspiration biopsy

[Amyloid goitre, a benign entity with fast growth]

Amyloid goitre is an infrequent benign entity characterized by a rapid increase in the size of the thyroid gland due to amyloid deposit in the parenchyma. Such an increase in size, which takes place over only a few months, can cause symptoms such as dyspnea, dysphagia and dysphonia. We present three cases diagnosed in the same centre and estimated its incidence. All cases showed similar morphology, with varying proportions of thyroid follicles, mature adipose tissue and amyloid. AA Amyloid accumulation was verified and associated to previous pathologies (Crohn's disease, juvenile rheumatoid arthritis and chronic renal disease). One case showed a papillary microcarcinoma. Amyloid goitre is an infrequent entity which should be considered in the differential diagnosis of all patients with goitre, especially those with chronic underlying diseases.

Amyloid Goiter in Familial Mediterranean Fever: Description of 42 Cases from a French Cohort and from Literature Review

Our aim was to describe the main features of amyloid goiter in adults with amyloidosis secondary to familial Mediterranean fever. Therefore, we analyzed cases from a French cohort of familial Mediterranean fever patients with amyloidosis and from literature review. Forty-two cases were identified: 9 from the French cohort and 33 from literature review. Ninety percent of patients were on hemodialysis for renal amyloidosis before the development of goiter. The goiter grew up rapidly in 88% of cases; 75.6% of patients were euthyroid, 58% displayed dyspnea, and 44.8% dysphagia. Various features were seen on ultrasound, from diffuse to multinodular goiter. When it was performed, fine-needle aspiration biopsy almost always revealed amyloidosis. Thirty-one patients underwent thyroidectomy: to manage compressive symptoms (72%) or rule out malignancy (27%). Histology showed mature adipose tissue in 64% of cases and lymphocytic infiltration in 21.4%. In conclusion, amyloid goiter in familial Mediterranean fever preferentially occurs in patients with end stage renal failure. Fine-needle aspiration biopsy seems to be a sensitive exam for diagnosis, but thyroidectomy remains sometimes necessary to rule out malignancy or release compressive symptoms.

Amyloid goiter diagnosis by ultrasound-guided fine needle aspiration performed by interventional pathologist

Amyloid goiter (AG) (primary or secondary) is extremely rare. An abdominal fat pad core needle biopsy (CNB) is the diagnostic gold standard for secondary amyloidosis. Although CNB is useful to detect amyloid infiltration of a specific organ, fine-needle aspiration (FNA) is proven to be the best diagnostic method for thyroid disorders. Guidelines recommend an ultrasound-guided FNA (US-FNA) whenever possible. This procedure is usually performed by various interventional specialists, including pathologists, who perform the procedure in addition to validating the adequacy of the sample. We report a rare case of AG diagnosed using US-FNA performed by a pathologist in a 39-year-old patient with systemic amyloidosis. US-FNA performed by pathologists is a proven, less-invasive, and cost-effective tool that ensures acquisition of adequate specimens and reduces nondiagnostic rates of this procedure to ensure timely cytological diagnosis.

Amyloid goiter - A rare case report and literature review

INTRODUCTION

Amyloid goiter is a rare presentation of thyroid swelling, which occurs with either primary or secondary amyloidosis. This condition must be differentiated from other types of goiters or malignancies. Even though the thyroid is extensively involved by amyloid, patients are usually euthyroid, but many different presentations and overlaps have been reported. Currently the treatment is surgical resection of the thyroid gland.

CASE PRESENTATION

We report a case of a 53-year-old previously healthy male who presented with a 2 year history of a progressively enlarging painless neck swelling. The patient was euthyroid and denied any associated symptoms. The patient subsequently underwent an uneventful total thyroidectomy along with an unremarkable follow up and was diagnosed with primary amyloidosis involving only the thyroid gland confirmed by histopathology.

DISCUSSION AND CONCLUSION

Amyloid goiter is a rare entity; a high index of suspicion is required in patients with an enlarging thyroid gland and a concomitant history of chronic inflammatory processes or plasma cell dyscrasia. FNA biopsy should be performed to exclude the top differential of primary thyroid malignancy. Thyroidectomy is necessary for definitive diagnosis and symptom relief. Every effort should be made to delineate the extent of the disease, and in those previously healthy plasma cell dyscrasia should be excluded.

Evaluation of the structure, autoimmunity, and functions of the thyroid gland in familial Mediterranean fever patients

Objective Familial Mediterranean fever (FMF) is an autosomal recessive autoinflammatory disorder that is frequently seen in the eastern Mediterranean region. The thyroid gland can be affected in FMF patients through autoimmunity or amyloidosis. Here, we aimed to evaluate the structure and functions of the thyroid gland in addition to possible autoimmunity in FMF patients. Subjects and methods The study was conducted by the Endocrinology and Metabolism and Internal Medicine Departments. Thirty FMF patients and 30 age and gender-matched healthy controls were enrolled in the study. Free thyroxin (fT4), free triiodothyronine (fT3), thyroid-stimulating hormone (TSH), and anti-thyroid peroxidase (anti-TPO) autoantibodies were investigated. Detailed thyroid grayscale and Doppler Ultrasonography examinations and shear-wave elastosonography (SWE) were performed in the patient and control groups. Results Anti-TPO was detected in 24% (n = 7) of the patients. On the grayscale US, mean thyroid volumes were similar between the FMF and the control groups (p > 0.05). By Doppler US, thyroid vascularity observed was detected in 10.3% (n = 3) of the patients. SWE revealed that the mean velocity value of right vs. left lobe in the patient group was 1.77 ± 0.45 m/s and 1.95 ± 0.51 m/s, respectively. Compared to the control group, the mean velocity values were significantly higher in the right (p = 0.004) and left (p = 0.01) lobes of the patient group. The mean stiffness value in the patient group was also significantly higher in the right and left lobes [10.13 ± 5.65 kPa (p = 0.005) and 12.24 ± 6.17 kPa (p = 0.02), respectively]. Conclusion Recognizing the complications of FMF early in the course of the disease is as important as the early diagnosis of the disorder. Based on this, thyroid functions and changes in its structure should be evaluated carefully for early diagnosis of a possible coexisting thyroid disorder. Arch Endocrinol Metab. 2020;64(1):66-70.

AMYLOID GOITER AS THE FIRST RECOGNIZABLE MANIFESTATION OF IMMUNOGLOBULIN LIGHT CHAIN AMYLOIDOSIS

Objective

Clinically apparent thyroid enlargement due to massive amounts of amyloid deposition, known as amyloid goiter, is rare. Endocrinologists should become familiar with this manifestation of systemic amyloidosis, which may be diagnosed by Congo red staining of the specimen obtained by fine-needle aspiration.

Methods

We describe a 70-year-old man who presented with a slowly enlarging goiter. It was asymptomatic, predominantly left-sided, nontoxic, and multinodular with atypia of undetermined significance (Bethesda System category III) by cytology. The goiter tested negative using the ThyraMIR miRNA Gene Expression Classifier kit (eviCore Healthcare, Bluffton, SC).

Results

Left thyroid lobectomy produced a 220-g specimen with nodular hyperplasia and prominent amyloid deposition confirmed by Congo red staining. Liquid chromatography tandem mass spectrometry detected a peptide profile consistent with light chain amyloid deposition of the lambda type, formerly called primary amyloidosis. In retrospect, he had been diagnosed with restrictive cardiomyopathy, cardiac conduction system disease, coronary artery disease, non-nephrotic range proteinuria, and chronic kidney disease, which had been attributed to his longstanding type 2 diabetes mellitus. Extensive workup subsequently demonstrated cardiac amyloidosis and monoclonal gammopathy of unknown significance, consistent with light chain amyloidosis.

Conclusion

Amyloid goiter should be included in the differential diagnosis of enlarging goiters with Bethesda System category III cytology in patients with monoclonal gammopathy of uncertain significance, clinical manifestations of systemic amyloidosis, or known diagnosis of monoclonal cell dyscrasia.

A rare case of primary thyroid amyloidosis

INTRODUCTION

Amyloid goiter is due to the deposition of amyloid in the thyroid, resulting with enlargement of the gland and compressive symptoms.

CASE

We herein present a case of a 45-year-old male patient who complained of a big swelling in the neck. Ultrasound showed an enlarged thyroid gland with mediastinal involvement. The multinodular appearance was consistent with the diagnosis of multinodular goiter. He had a history of multiple myeloma but no sign of systemic amyloidosis.

DISCUSSION

Thyroid gland was removed and the histopathological examination revealed a diffuse deposition of amyloid associated with metaplastic lipomatosis of the stroma.

CONCLUSIONS

The treatment of choice in patients with amyloid goiter is total thyroidectomy to solve compression symptoms.

An Enlarged Goiter Presenting with a Rare Diffuse Lipomatosis of the Thyroid Gland

BACKGROUND Diffuse lipomatosis of the thyroid gland is a particularly rare histopathological condition characterized by diffuse fatty infiltration within the thyroid stroma. CASE REPORT We report a case of a 53-year-old woman who presented with a 2-year history of massive neck goiter and mild dysphagia. A computed tomography (CT) scan revealed heterogeneous enhancing of an enlarged thyroid gland with left lobe cranial extension and compression of the pharynx, and caudal bilateral retrosternal growth. The patient underwent total thyroidectomy and histopathological examination revealed mature fatty tissue diffusely distributed throughout the thyroid gland. Excision of the gland was somewhat challenging due to the very thin thyroid capsule and recurrent protrusion of fat from the capsule. CONCLUSIONS Diffuse thyroid lipomatosis is an extremely rare histopathological condition characterized by diffuse fatty infiltration in thyroid stroma. Despite its rarity, it should be considered in the differential diagnoses of a patient presenting with a goiter.

Thyroid FNAC: Causes of false-positive results

In this paper, we aim to focus on false positive results in the evaluation of thyroid aspirations, covering cystic, inflammatory, follicular and oncocytic lesions, papillary carcinoma, and medullary carcinoma of thyroid. The recently described entity noninvasive follicular thyroid neoplasm with papillary-like nuclear features is also discussed detailing the impact of its introduction on the sensitivity and specificity of thyroid FNA, as well as the use of molecular tests for diagnostics. Medicolegal issues in relation to current practice in English law are also described.

Prevalence and predictors of thyroid functional abnormalities in newly diagnosed AL amyloidosis

BACKGROUND

Data on the effect of systemic immunoglobulin light chain amyloidosis (AL amyloidosis) on thyroid function are limited.

OBJECTIVE

To assess the prevalence of hypothyroidism in AL amyloidosis patients and determine its predictors.

METHODS

1142 newly diagnosed AL amyloidosis patients were grouped based on the thyroid-stimulating hormone (TSH) measurement at diagnosis: hypothyroid group (TSH above upper normal reference; >5 mIU L^-1 ; n = 217, 19% of study participants) and euthyroid group (n = 925, 81%). Predictors for hypothyroidism were assessed in a binary multivariate model. Survival between groups was compared using the log-rank test and a multivariate analysis.

RESULTS

Patients with hypothyroidism were older, more likely to present with renal and hepatic involvement and had a higher light chain burden compared to patients in the euthyroid group. Higher proteinuria in patients with renal involvement and lower albumin in patients with hepatic involvement were associated with hypothyroidism. In a binary logistic regression model, age ≥65 years, female sex, renal involvement, hepatic involvement, kappa light chain restriction and amiodarone use were independently associated with hypothyroidism. Ninety-three per cent of patients in the hypothyroid group with free thyroxine measurement had normal values, consistent with subclinical hypothyroidism. Patients in the hypothyroid group had a shorter survival compared to patients in the euthyroid group (4-year survival 36% vs 43%; P = 0.008), a difference that was maintained in a multivariate analysis.

CONCLUSION

A significant proportion of patients with AL amyloidosis present with hypothyroidism, predominantly subclinical, which carries a survival disadvantage. Routine assessment of TSH in these patients is warranted.

Amyloid goiter related with Crohn's disease: A rare association: Amyloid goiter secondary to Crohn's disease

INTRODUCTION

Amyloid goiter (AG) is characterized by enlargement of the thyroid gland as a result of extensive amyloid deposition in a bilateral and diffuse manner.

PRESENTATION OF CASE

A 58-year-old male patient was diagnosed of Crohn's Disease (CD). He was admitted to our clinic with complaint of respiratory distress and rapid growth swelling in the neck. Ultrasound examination revealed huge multinodular goiter on both sides of thyroid gland. We performed bilateral total thyroidectomy. Pathological evaluation revealed AG.

DISCUSSION

Amyloid leads to degeneration in tissues, thereby disrupts the function of the relevant organs. It is important to distinguish AG from other reasons of goiter, particularly thyroid medullary cancer that can cause amyloid deposition in thyroid gland. Secondary amyloidosis frequently involves thyroid gland at microscopic level, but rarely causes goiter. An analysis of current literature revealed that only few cases of AG occurred secondary to CD. Herein we presented a case of AG who has rapidly growing goiter that associated with CD.

CONCLUSION

AG must be kept in mind in case of rapidly growing goiter, especially in patients with chronic inflammatory bowel diseases.

Symptomatic amyloid goiters: report of five cases

BACKGROUND

Massive amyloid deposition in the thyroid to the point of goiter formation is rare. Here we describe the clinical presentation and outcomes of five patients with amyloid goiter (radiographically confirmed goiter in the context of tissue-proven thyroid amyloidosis) encountered in the past 23 years at our institution.

METHODS

Mayo Clinic archives were searched between 1987 and 2010 for a diagnosis of "thyroid amyloidosis," "amyloid deposits," "amyloid deposition," or "liquid chromatography consistent with amyloid." Inclusion criteria were symptomatic thyromegaly; tissue confirmation of thyroid enlarged by amyloid deposits; and radiologic confirmation of thyroid enlargement.

RESULTS

Five patients were identified who met all inclusion criteria. Amyloid goiter etiology included both primary and secondary amyloidosis, and the goiters ranged in weight from 50 to 130 g each. Diagnosis was made by fine-needle aspiration biopsy with Congo red staining and, if needed, spectrophotometry. All five patients had histories of persistent hoarseness for several years before presentation with compressive symptoms referable to their enlarging thyroids, and all had some degree of thyroid dysfunction (both hypothyroidism and hyperthyroidism) by the end of our follow-up period, which ranged from 5 months to 13 years. Two patients underwent surgical interventions, two were managed conservatively, and in one, the goiter shrank after systemic therapy for amyloidosis.

CONCLUSIONS

Our clinical observations suggest slower goiter progression and a higher prevalence of thyroid dysfunction than previously thought.

Primary amyloid goiter mimicking rapid growing thyroid malignancy

Amyloid accumulation in the thyroid gland leading to a clinically detectable mass, known as amyloid goiter, is a rare condition associated with primary amyloidosis. Moreover, a localized primary amyloid goiter involving only the thyroid gland is rarer still. Here, we report a patient with a localized primary amyloid goiter that had grown rapidly, causing dysphagia and dyspnea on exercise, and confused us with malignancy such as anaplastic carcinoma. After surgery, no further symptoms occurred. A diagnosis of amyloid goiter was established on microscopic examination. In patients with a rapidly enlarging thyroid gland presenting with dysphagia, dyspnea, or hoarseness, amyloid goiter and malignancy should both be suspected, even when systemic amyloidosis is not suspected.

Nodular goiter with amyloid deposition in an elderly patient: fine-needle cytology diagnosis and review of the literature

Background

Amyloidosis is a systemic disease characterized by the extracellular deposition of amyloid fibrils in different organs and tissues. The thyroid gland may be affected by diffuse or nodular amyloid deposits, along with multiple myeloma (MM) (Amyloid Light-Chain Amyloidosis, AL amyloidosis) or chronic inflammatory diseases (Amyloid A Amyloidosis, AA amyloidosis), but thyroid gland involvement rarely appears as the first clinical manifestation in both conditions. The present study reports a case of primary thyroidal nodular amyloid goiter diagnosed by fine-needle cytology (FNC) in an elderly patient.

Case report

A 66-year-old female patient presented with dysphagia and hoarseness; the patient suffered from rheumatoid arthritis but did not have kidney failure or altered thyroid function. Ultrasound examination (US) showed a 30 mm irregular, hypoechoic area in the left thyroid lobe. FNC showed abundant, dense and amorphous material similar to the one stained in purple at Diff-Quik stain and pinkish at the Papanicolaou. Spindle cells with thin, bland and bent nuclei were scattered in this material; few thyroid follicular cells were also present. An alcohol-fixed smear was stained with Congo red: the amyloid material appeared cherry red and it also showed apple-green birefringence when observed with a polarizing microscope. A differential diagnosis between different thyroid pathologies was considered and the cytological diagnosis of nodular amyloid goiter was pointed out. The patient underwent thyroid lobectomy and the subsequent histological examination confirmed the cytological diagnosis.

Conclusions

FNC is a safe and effective procedure for the diagnosis of thyroid amyloidosis. Congo red-stained smears can be used to demonstrate the presence of amyloid material, showing the typical green birefringence under polarized light. An early and accurate cytological diagnosis may suggest an hematological screening and the appropriate treatment for the thyroid nodule.

Giant amyloid goiter in Crohn's disease

Crohn's disease is one of the causes of secondary amyloidosis, which can lead to amyloid infiltration of the thyroid gland. It is essential to follow strict controls to prevent the appearance of a large amyloid goiter. Two patients with amyloid goiter secondary to Crohn's disease, with a large adipose tissue component and who required surgical treatment, were studied. Both surgical interventions were difficult because of the fragility of the thyroid tissue. A patient with Crohn's disease and secondary amyloidosis could begin to develop amyloid goiter. This is usually fast growing and commonly causes compressive symptoms, although in some cases it only grows in the neck with no evidence of these symptoms. When surgery is indicated, patients should be remitted to hospitals with experienced endocrine surgeons, given that there is a high risk of developing complications.

Amyloid accumulation in the toxic nodule of the thyroid gland in a patient with end stage renal failure

Amyloidosis is characterized by accumulation of amorphous, proteinaceous material in various organs and tissues of the body. Amyloid may accumulate in the thyroid gland in cases of medullary thyroid carcinoma and systemic amyloidosis. Amyloid accumulates extracellularly in the thyroid parenchyma and disrupts the normal follicular patterns. Most of the cases reported up to now were clinically euthyroid, but many presentation forms and overlaps have been reported. Herein we present a patient with toxic nodular goiter with amyloid deposition in the toxic nodule as well as the remaining thyroid tissue.

Diffuse amyloid deposition in thyroid gland: a cause for concern in familial Mediterranean fever

Thyroid gland is among the many organs that could be infiltrated in systemic amyloidosis. However, diffuse infiltration of the thyroid gland secondary to systemic amyloidosis associated with Familial Mediterranean fever (FMF) is rare. Here, we present a 49-year-old woman diagnosed with FMF and systemic amyloidosis, who had a large goiter and multiple nodules that developed slowly through the years and was complicated by tracheal compression symptoms and a mild thyroid dysfunction. Multiple fine needle aspiration biopsies of the nodules and the thyroid parenchyma revealed amyloid deposits. We would like to point out that amyloidosis may have a significant impact on the thyroid gland and fine needle aspiration biopsy is a valuable tool for diagnosis.

Amyloid goiter and hypopituitarism in a patient with systemic amyloidosis

Systemic amyloidosis may infiltrate the thyroid or other endocrine glands but rarely causes endocrine dysfunction. We describe a 45 years old female patient with diffusely enlarged goiter and hypopituitarism secondary to amyloid infiltration of the thyroid gland and possibly pituitary gland, respectively. She was on chronic haemodialysis for 3 years due to systemic amyloidosis. While she was being prepared for thyroidectomy, adrenal failure developed. Her anterior pituitary hormone levels were low and magnetic resonance imaging of the hypophysis showed low signal intensity in right part of the adenohypophysis. She improved with corticosteroid replacement therapy and underwent subtotal thyroidectomy without any complication. Histopathologically, amyloid deposition was demonstrated in the thyroid gland. To our knowledge, this is the first case with amyloid goiter and hypopituitarism secondary to systemic amyloidosis. Amyloid infiltration should be considered in a systemic amyloidosis patient presenting with rapidly enlarged thyroid gland and signs of hypopituitarism.

[Amyloid goiter secondary to Crohn's disease]

Secondary amyloidosis is generally caused by malignant tumors or chronic inflammatory diseases. Most cases of secondary amyloidosis are discovered due to proteinuria or nephrotic syndrome caused by renal amyloidosis. Clinically significant thyroid involvement is found in only a small percentage of cases, although a finding of amyloid deposit in autopsies is not infrequent. We present a case of amyloid goiter. The patient was diagnosed with Crohn's disease 7 years previously and had kidney failure of unknown cause. She was referred to our department for a goiter discovered incidentally. The patient finally underwent thyroidectomy due to progressive growth of the thyroid gland with compressive symptoms. The histologic analysis showed thyroid amyloidosis.

A case of amyloid goiter associated with intrathyroid parathyroid and lymphoepithelial cyst

Diffuse enlargement of the thyroid gland accompanied by an interstitial tissue deposition of amyloid is a special entity termed an amyloid goiter. An amyloid goiter is a rare thyroid lesion, which has been described a long time ago. In this report, we add a new classic case of amyloid goiter that differs from other reported cases in its association with intrathyroid parathyroid and lymphoepthelial cyst involved with amyloidosis. The presence of parathyroid tissue inside the thyroid parenchyma and surrounded by amyloid material elicited a diagnostic problem due to suspected medullary carcinoma. Careful histological examination and immunohistochemical staining for parathormone and calcitonin have largely helped in the differential diagnosis. Bilaterality, diffuse, and homogeneous involvement of the thyroid gland, with absence of definite masses, all direct the diagnosis toward amyloid goiter.

Transthyretin amyloid goiter in a renal allograft recipient

Amyloid deposition in the follicular, perifollicular blood vessels, and thyroid stroma can occur in systemic forms of amyloidosis, although diffuse enlargement of the thyroid is generally not present. Marked, widespread enlargement of the thyroid gland with amyloid deposits or amyloid goiter is a rare condition reported in association with primary and secondary amyloidosis but has not been described in association with transthyretin amyloid deposition. Senile transthyretin amyloidosis is primarily associated with amyloid deposits in the heart, while the familial forms of amyloidosis due to transthyretin gene mutations are associated with deposits of amyloid in multiple tissues, classically giving rise to polyneuropathy. In this report, we describe the findings of parathyroid and lymph node amyloid deposits and amyloid goiter with transthyretin reactivity in a recipient of a kidney allograft, reportedly for renal amyloidosis, initially assumed clinically to be due to inflammatory bowel disease-related secondary amyloid deposition. This case underscores the importance of routine immunohistochemical classification of amyloid deposits for accurate diagnosis and to guide clinical management decisions.