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

 

WHERE’S THE CANCER?

 

Chief Complaint: Thyroid Mass

History and Clinical Course: The patient is a 42-year-old white female referred to the Center by several local physicians. She was found to have a thyroid mass and in June of 2003 she underwent an ultrasound examination that showed a 6.3cm in diameter mass located in the left lobe of the thyroid gland. There was also a “small benign appearing cyst” about 5.2 mm in diameter located within the right lobe. Thyroid function studies were performed and found to be normal with a TSH of 1.5. Two needle biopsies were performed yielding the diagnosis of “thyroid follicular epithelium”. The patient underwent a total thyroidectomy in October 2003 and the actual diagnosis was “Hurthle cell adenoma of the left lobe in a background of chronic thyroiditis”, “5 mm micro papillary carcinoma” in the right lobe. The patient had an uneventful course after her outpatient surgery.

Comment: This case spotlights a number of interesting aspects of thyroid tumor management. The ultrasound report dismissed as a benign cyst, a small thyroid cancer. Needle biopsy failed to diagnose a 6.3cm in diameter Hurthle cell adenoma and its associated chronic thyroiditis. The small malignant tumor was overlooked until the patient underwent thyroidectomy.

If one performs enough thyroid surgery, the incidence of these “occult” or “incidental” cancers is significant. We do not refer to them as “micro” as was done in this case, because of the implication that they are microscopic, and they clearly are not. Some would argue that these little papillary cancers are so small as to be of no significance. That may or may not be true, but we do know with certainty that every large, life threatening cancer was once a small one. Rarely, some patients will present with extensive metastasis to cervical lymph nodes from a primary cancer of the thyroid gland that is not found on either physical examination or other testing. If these truly microscopic tumors can do this, then primary tumors measured in millimeters should also pose the same threat. We have no way to determine or predict which of these small cancers will be of clinical significance, thus their removal seems to be most prudent.

“…Thyroid surgery…it’s all we do…”