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

 

It quacks like a duck, but it isn´t

 

The patient is a 48 y/o lady referred by a local endocrinologist with a right thyroid mass, an elevated calcitonin level at 61, and a needle biopsy report that was non-diagnostic but called “worrisome” for medullary carcinoma of the thyroid. Ultrasound revealed several nodules in the right lobe of the thyroid, the largest being 1.2 cm in diameter and very firm on examination. The left lobe was normal on ultrasound. The thyroglobulin and thyroglobulin antibodies were both elevated. Negative family history. A 24-hour urine specimen for catecholamines and their metabolites was negative. Given the negative urine test and the unilaterality of the tumors, it was felt that this most likely represented a sporadic case of medullary CA of the thyroid (most medullary cancers of the MEN Syndromes are bilateral).

Medullary cancer of the thyroid isn’t really a thyroid cancer, but rather a cancer of the calcitonin producing C-Cells found within the gland. It can be indolent in behavior or very aggressive, and regional lymph node metastasis is the rule. Because it is not truly a thyroid cancer, radioactive Iodine therapy is virtually of no value. Therefore, an aggressive surgical approach is mandatory, performing a total thyroidectomy and paratracheal lymph node dissection, even performing modified or radical neck dissection when indicated.

Total thyroidectomy with paratracheal node dissection was performed and the frozen section diagnosis was “multifocal C-Cell clusters and background of lymphocytic thyroiditis (suspect medullary carcinoma)”. However, on the final report no cancer was found, only florid Hashimoto’s thyroiditis. (It was not a duck). The patient underwent an uneventful out patient procedure with no complications.

It is known that some patients with Hashimoto’s disease will sometimes have an elevated calcitonin level, but a calcitonin of 61 was well beyond the expected range and the biopsy was “worrisome”. Given the pre-op physical and laboratory findings, any such patient would receive exactly the same treatment plan again today. This case underscores the need to remind ourselves and our patients that “we always wait for the final report”, and that needle biopsy diagnoses of thyroid tumors can be misleading.

“…Thyroid surgery…it’s all we do…”