Thyroid Nodule 101: Egg Shell Calcification is Not an Indication of a Benign Nodule
Eggshell calcification: Any Calcifications in the thyroid nodule should be carefully evaluated. A rare case example of the principle:
Eggshell calcification of thyroid nodule not always benign.
Egg shell with interrupted calcium rim suspicious for papillary thyroid cancer
Smooth ring in a nodular goiter
Isoechoic mass with smooth ring in a nodular goiter
A 73-year-old man had been diagnosed with colorectal cancer at an academic medical center. An F18-fluorodeoxyglucose PET-CT scan was performed for tumor staging, and a small hypermetabolic nodule was noted in the right thyroid lobe, as shown in
The patient had no prior history of thyroid disease or head and neck radiation. He did not have a family history of thyroid disease or thyroid cancer. He had no symptoms or signs of thyroid dysfunction or local obstructive symptoms. A thyroid ultrasound demonstrated a 1-cm solitary, hypoechoic left thyroid nodule with discontinuous surface macrocalcification . The report indicated that no abnormal nodes or masses in the neck were observed. An ultrasound-guided thyroid biopsy of the nodule showed a papillary thyroid carcinoma. The patient and providers decided to treat the colorectal cancer immediately. After chemoradiation therapy, transanal resection and adjuvant chemotherapy, there was no evidence of persistent colorectal cancer.
After 37 months, the patient was referred to our center for a growing neck mass. The thyroid ultrasound showed the ring of calcification had not changed from the prior exam, but a 4.8-cm very hypoechoic mass with indistinct margins surrounded the calcification was observed. A fine-needle aspiration biopsy was suspicious for anaplastic thyroid carcinoma. A staging F18-fluorodeoxyglucose (FDG) PET-CT scan confirmed the hypermetabolic mass (standardized uptake value [SUV], had grown since the last exam, but without evidence of local or distant metastatic spread of tumor.
A total thyroidectomy and central node dissection was performed and confirmed the diagnosis of a 5.1-cm anaplastic thyroid carcinoma with extrathyroidal extension. The patient refused adjuvant external radiation. Within 4 months, he had vocal cord paralysis with a locally advanced tumor recurrence and lung metastases. He was treated with local neck radiation therapy and chemotherapy — dabrafenib (Tafinlar, Novartis) and trametinib (Mekinist, Novartis) — but died because of airway obstruction 7 months after the diagnosis of anaplastic thyroid carcinoma.
This is an uncommon scenario of an anaplastic transformation of a micropapillary thyroid cancer. Surface calcification of a thyroid nodule has previously been considered evidence of slow growth with a benign pathology. According to Kim and colleagues, among 93 histologically proven thyroid nodules with eggshell calcication, 63.4% were malignant, and 36.6% were benign.
A study of thyroid nodules with eggshell calcifications showed nodules with a disruption or intermittent thickening of the calcified rim or a halo of soft tissue outside the calcification rim were highly significant for thyroid cancer. The molecular events associated with the anaplastic transformation from a well-differentiated papillary thyroid cancer to an anaplastic thyroid cancer are incompletely understood, although the mutational events are thought to involve multiple tumor suppressor genes.
Comments: Great example of why close attention to any calcifications in the thyroid nodule even so called “benign eggshell” ones are still possible thyroid cancer.
Richard Guttler MD,FACE,ECNU
Case thanks to Dr Stephanie Lee