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

 

Taking The Easy Way Out

 

This patient is a 59y/o lady who came to us from Yakima, Washington with a history of subclinical hyperthyroidism and difficulty in swallowing.  Her thyroid hormone levels were normal with the exception of one T3 level that was minimally elevated, and a suppressed TSH.  A thyroid scan showed diffuse uptake with no dominant hot or cold nodules and high normal uptake.  A barium swallow/cervical esophogram was performed and reported as normal.  A CT scan of the neck and chest revealed a nodular thyroid with an 8 cm. mass in the right side of the superior mediastinum.

She was started on Tapazole but developed bronchitis and this medication was stopped due to concerns about immunosuppresion, though her WBC’s never fell out of normal range.  One consultation recommended radioactive Iodine as treatment; another suggested opening the chest with a sternal split to resect the tumor.  She opted to come to Texas.

After office consultation and review of her records, the patient underwent a total thyroidectomy and resection of a large mediastinal mass through a cervical approach as an outpatient at Seton SW Hospital.  Her post op course was uneventful and she is now euthyroid.  No malignant change was found.

Notice the compression of the trachea and the esophagus on CT scan.  Indeed, the esophagus (you can see some air in it on the scan) is seen pushed far to the left and the posterolateral wall of the trachea is distorted.  This explains her difficulty in swallowing.

These tumors are taking the easy way out of the neck.  They can’t go posterior because of the spine.  They can’t go anterior because of the sternum.  To grow upwards would be in conflict with gravity.  So down they go, following the path of least resistance.

Only surgical removal could resolve both the subclinical hyperthyroidism and the compression caused by the tumor.  Splitting the sternum is almost never necessary, even with extremely large substernal thyroids.  Surgical removal was also the only way to establish a tissue diagnosis with certainty.  Fortunately, as in this case, these enlargements are most often benign.

 

 

“…Thyroid surgery…it’s all we do…”