THYROID CANCER

CASE REPORT

GG, 51 years, female

First admission july 2010

No chief complaints

Familial history son with pituitary failure; no history of thyroid cancer

Personal history thyroid disease since 1995 (no medical documents available)

No chronic medication use; without history of cervical irradiation

Clinical exam

H 169cm

W 91kg

BMI 31.9kg/m2

BP 110/80mmHg

HR 80/min

Clinical exam 2

Thyroid gr. Ib goiter,

ferm consistency,

mobile with swallowing,

painless, irregular surface,

with a nodule of 2cm palpable in the right lobe, mobile,

increased consistency;

no enlarged cervical lymph nodes.

Thyroid nodule management

History Physical examination

Thyroid US with focus on risk stratification for malignancy

TSH + free thyroxine Calcitonin ?

TSH, FT4 normal Calcitonin not measured

Thyroid ultrasound Right lobe volume 11.27ml,

2 coalescent nodules in the center, hypoechoic, regular margins, 24.3x13mm in size;

anterior and inferior, hypoechoic elipsoidal nodule of 4.3x1.7mm,

laterally hypoechoic nodule of 1.8mm;

at the junction with the isthmus - hypoechoic inomogenous nodule of 5.7x2.6mm.

Left lobe volume 10.37ml, in the center, posterior a hypoechoic

nodule of 11x7.9mm with CFD signal in the periphery;

superior a hypoechoic nodule of 7x3.5mm, with CFD signal in the periphery;

inferior an inomogenous hypoechoic nodule of 8.9x6.4mm with CFD signal both intranodular and in the periphery and a transonic area in the center;

posterior another hypoechoic nodule of 5.4x3mm, without CFD signal.

Isthmus 3.6x19.2mm. Latero-cervical lymph nodes of 7-8mm inflamatory in aspect.

Presumtive diagnosis

1. MULTINODULAR GOITER (SUSPICIOUS US

FINDINGS)

2. NORMAL THYROID FUNCTION

3. GRADE 1 OBESITY

Differential diagnosis thyroid nodule

Thyroid nodule management

FNAB Right lobe Abundant cellularity with cells grouped in nests, with rich, granular cytoplasm, with enlarged and irregular nuclei, with incisions and rare pseudo-inclusions.

Left lobe benign aspect

Conclusion papillary carcinoma of the right lobe. Benign left lobe nodule

Evolution

28.07.2010 surgery total thyroidectomy with lymph node excision

Pathological result

Intrathyroid papillary carcinoma,

classical variant,

bilateral, multifocal

lymph node metastases (2/11 lymph nodes)

pT2N1M0

Bilateral nodular goiter

TNM classification

Evolution

15.10.2010 RADIOIODINE THERAPY (100 mCi)

WBS important remnant tissue in the right thyroid lodge and retrosternal in the left thyroid lodge; without distant metastases

18.10.2010 L-thyroxine 125g/day

RIT indication No indication (low risk of relapse or cancer-specific mortality)

Definite indication (use high activity (3.7 GBq (100 mCi)) after thyroid hormone withdrawal)

Probable indication (use high or low activity (3.7 or 1.1 GBq (100 or 30 mCi))

Complete surgery Distant metastases Less than total thyroidectomy

Favorable histology Incomplete tumor resection No lymph node dissection

Unifocal T

Follow-up

Date TSH FT4 Stimulated Tg Anti Tg Ab Treatment

December 2010 0.292 1.83 - - LT4 175g

January 2011 44.85 - 0.366ng/ml 19UI/ml LT4 175g

April 2011 0.1 1.31 - - LT4 175g

November 2011 0.1 1.23 - - LT4 175g

January 2012 49 - < 0.1 ng/ml 16UI/ml LT4 150g

January 2012 total cholesterol 269mg/dl

US follow-up

January 2011 left thyroid lodge nodule of 4x9mm

April 2011 left thyroid lodge nodule of 3.3x8mm + right latero cervical lymph node 5.5x16.5mm

November 2011 right latero cervical lymph node 5.5x13.8mm November 2012 the same image of the right cervical lymph node

Follow-up protocol

Final diagnosis

1. Surgically removed and radioiodoablated

multifocal bilateral papillary thyroid

carcinoma pT2N1M0 under supressive LT4

therapy.

2. Grade 1 obesity

3. Hypercholesterolemia