CASE OF THE MONTH

 

PRESENTED BY

THE THYROID SURGERY CENTER OF TEXAS, P.A.

1927 Lohmans Crossing Road, Suite 201, Austin, TX 78734

www.thyroidcancer.com

512-608-9595; Fax-512-608-9833

 

A Big One

 

This patient is a 35-year-old white male who came to us from Fort Worth with a very large left-sided thyroid mass and a history of it having been present for only about 8 months. In June, the patient was stung about the head and neck by black ground wasps and he thought perhaps this was related to the mass. We didn’t think so. 

On physical examination, he had a left-sided thyroid mass roughly 12cm in widest diameter. It appeared to involve a portion of the isthmus. The mass had an irregular surface to it and was quite “spongy” to palpation. There were no clinically positive lymph nodes in the neck. His thyroid function studies were normal, his TSH was 0.797. No other testing was indicated as it would not change the proposed treatment plan, namely thyroidectomy. He did have a CT scan before he came to us, but it was not helpful and provided no new information. 

The patient underwent an outpatient total thyroidectomy and paratracheal lymph node dissection for what proved to be a papillary carcinoma. Interestingly, his larynx was deviated from the mid-line all the way over to just below the angle of the jaw on the right side, and he had what appeared to be a persistent thyroglossal duct extending all the way up to the base of tongue. The resected lymph nodes within the specimen were all negative for tumor, and there was no evidence of angio invasion or any other aggressive microscopic characteristics. His postoperative course was uneventful with the exception of some mild hypocalcemia, which should prove to be temporary. He has been referred locally for an ablative dose of radioactive iodine and whole body scanning. His prognosis is probably quite good.

Comments: At first, I thought this would prove to be a lymphoma based on its size, physical characteristics, and especially its rapid growth. I learned after his operation that the patient then thought he might have actually had this mass for several years. This would have changed my preoperative impression, but it would not have changed the treatment plan.

It is ironic that the really big thyroid tumors are generally benign. With this in mind, I would like to make a point about “observation” of thyroid tumors. Since there is no direct correlation between size and malignancy, when a patient tells me she is “watching a tumor”, I am compelled to ask “What are you watching it for?”, since enlargement of a thyroid mass, by itself, is no indication of malignancy. It would make more sense to say, “We’re waiting to see if any metastasis occurs”. This, of course, does not sound like a prudent course of action. My point is you must be pretty certain a tumor is benign to “watch it”, and one must accept the responsibility of that decision.

Addendum: We knew preoperatively that the patient’s grandfather was a pioneer in the early use and experimentation with radioactive materials. After his operation, the patient added that he recalls his grandfather saying that the small rock in a glass jar on his desk was a piece of uranium. Radiation induced papillary carcinoma? Interesting question.

 

 

 

“…Thyroid surgery…it’s all we do…”