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IN THE NAME OF GOD THYROID CASE PRESENTATION By: Maghsoomi.Z.MD
IN THE NAME OF GOD
THYROID CASE PRESENTATION
By: Maghsoomi.Z.MD
Ø A 38-year-old in 15 th week of gestation was referred to the
Endocrinology Department with suspected thyroid cancer
95.12.14
Lab data
95.12.08DATE
LAB DATA
0.9TSH
7.4T4
<10Anti TPO
95.12.14
Cyst aspiration
98.02.16
Lab data
98.02.26DATE
LAB DATA
0.59TSH
10.2T4
98.02.23
FNA : nondiagnostic and US guided FNA recommended
BHCG + / LMP: 98.03.15
98.04.23
US guided Re FNA was done
98.05.15
Lab data
98.05.2298.02.26DATE
LAB DATA
0.5059TSH
1010.2T4
Anti TPO
Calcitonin
CEA
8.8Ca
Alb
p
98.06.23
98.06.29
GA: 16w
98.07.01
Lab data
98.07.1898.05.2298.02.26DATE
LAB DATA
46.850.5059TSH
6.710.2T4
Anti TPO
<2 pg/mlCalcitonin
0.38CEA
98.8Ca
4Alb
4.5p
98.08.12
• Pregnant woman : 21 w
• Rt Cytology : PTC
• Total thyroidectomy
• Lt Pathology :MTC
• Biochemical remission
• PTC??
• Sonography : no Lymph node
MTC is one of the great mimickers of PTC
In both malignancies:
nuclear elongation, intranuclear pseudoinclusion, groove-like formation, nuclear membrane irregularity
However, predominantly dispersed cell population, neuroendocrine type chromatin, some binucleation,
eccentric nuclei, presence of both plasmacytoid and spindle cells helps to identify MTC.
If in doubt, immunohistochemical studies and/or serum calcitonin analysis will give the final diagnosis
could be misinterpreted as lymphoma and plasmocytoma
Pitfalls in the Cytological Assessment of Thyroid Nodules doi: 10.5146/tjpath.2015.01312
• Synchronous occurrence of these two carcinomas is uncommon and occurs in two forms: first
as discrete MTC and PTC separated by normal thyroid tissue and secondly as a mixed
medullary and follicular-derived thyroid carcinoma, in which single or multiple lesions
demonstrate morphology and immunoreactivity for both MTC and follicular derived
carcinoma, including PTC.
Synchronous papillary thyroid carcinoma and medullary thyroid carcinoma – a pitfall waiting to happen/Malaysian J Pathol 2017;
39(2) : 171 – 174
MTC management
The national comprehensive cancer network (NCCN) guidelines 2018 recommend
ØTotal thyroidectomy and bilateral central neck dissection (level VI) for all patients with medullary thyroid carcinoma (MTC)
whose tumor is ≥1 cm or who have bilateral thyroid disease
ØTherapeutic ipsilateral or bilateral modified neck dissection for clinically or radiologically identifiable disease (levels II–V)
ØProphylactic ipsilateral modified neck dissection for high volume or gross disease in the adjacent central neck may be
considered
ØSuppression of thyroid-stimulating hormone (TSH) is not appropriate
ØPheochromocytoma removal prior to thyroid surgery by laparoscopic adrenalectomy
ATA malignancy in pregnancy
PTC detected in early pregnancy should be monitored sonographically.
If it grows substantially before 24–26 weeks gestation, or if cytologically malignant
cervical lymph nodes are present, surgery should be considered during pregnancy.
However, if the disease remains stable by midgestation, or if it is diagnosed in the
second half of pregnancy, surgery may be deferred until after delivery.
Weak recommendation, low-quality evidence.
American Thyroid Association 2017, DOI: 10.1089/thy.2016.0457
The impact of pregnancy on women with newly diagnosed medullary
carcinoma or anaplastic cancer is unknown.
However, a delay in treatment is likely to adversely affect outcome.
Therefore, surgery should be strongly considered, following assessment
of all clinical factors.
Strong recommendation, low-quality evidence.
American Thyroid Association 2017, DOI: 10.1089/thy.2016.0457
FNA in pregnancy
Pregnancy does not appear to alter a cytological diagnosis of thyroid tissue obtained by FNA.
The timing of FNA, whether during gestation or early postpartum, may be influenced by the clinical
assessment of cancer risk or by patient preference. Strong recommendation, moderate-quality
evidence.
Measuring calcitonin in pregnancy
The utility of measuring calcitonin in pregnant women with thyroid nodules is unknown. The task
force cannot recommend for or against routine measurement of serum calcitonin in pregnant
women with thyroid nodules. No recommendation, insufficient evidence.
CASE 2
v A 35 years old female with neck mass since 5 years ago
1st Sonography:93.11.7
93.11.18
After about 3 months ,total thyroidectomy was done Pathology related to completion surgery: 94.1.25
Whole body scan : 94.2.30
.
Anti Tg(iu/ml)Tg (ng/ml)TSH (Miu/L)Date
Ablation with 50mc RAI >5094.4.21
Levothyroxine13900.06194.5.31
1300<0.040.194.12.24
Pregnant
>4000<0.040.195.6.8
5.196.1.7
0.196.5.16
197.1.19
o.41.497.11.2
514.20.369.0398.04.25
she presented with weakness
Sonography report:98.6
Lymph node dissection was done:98.6.11
ovalدر سونوگرافی انجام شده از گردن تصویر چند کانون هیپواکو
shape درZone V گردن سمت چپ مشاهده می شود که بزرگترین
م افتراق هماتو.واسکوالریتی خاصی ندارد.می باشد6mm*11آنها
از آنها انجام FNAآبسه و لنف نود نکروتیک مشکل است لذا
وک به یک لنف نود مشک.تیرویید ضایعه ایی دیده نمی شودBedدر.شد
.انجام شدFNAراست مشهود است که zone VIدر mm 6*10ابعاد
After about 3 weeks from lymph node dissection
sonography of neck was repeated 98/7/3
• A 35 years old female
• PTC 5 years ago
• Total thyroidectomy
• 50 mci RAI 4 years ago
currently
• Lymph nod involvement Rt zone 2 (6/19)
• After surgery Rt zone 6 FNA positive
Oncol Res Treat 2019;42:143-147. doi: 10.1159/000488905
Lymph node mapping
High-resolution ultrasonography in the preoperative assessment
(lymphatic mapping; sensitivity 97%, specificity 93%)
The accuracy higher for the lateral nodal compartments
Ultrasound-guided fine-needle aspiration cytology
high specificity and accuracy (95-98% and 95-97%, respectively)
Neck computed tomography and/or magnetic resonance imaging have a very limited role in preoperative
mapping, except in very special indications
(such as extensive cervical lymphadenopathy with extension of the diseased thyroid behind the sternum or the
clavicle, evaluation for possible involvement by extensive disease of other vital structures of the neck such as
the trachea or esophagus, etc.).
Oncol Res Treat 2019;42:143-147. doi: 10.1159/000488905
Thyroid. 2018 May;28(5):593-600. doi: 10.1089/thy.2017.0434.
352 patients with intermediate and high-risk DTCresidual nodal metastases detected on 131-I scanswith SPECT/CT following initial surgery, but prior to 131-I therapy.at the University of Michigan
Thyroid. 2018 May;28(5):593-600. doi: 10.1089/thy.2017.0434. Epub 2018 Apr 23
Assessment during long-term follow-up after initial surgery
(median follow-up time: 1048.5 days, range: 62–2878 days).
Thyroid. 2018 May;28(5):593-600. doi: 10.1089/thy.2017.0434.
The sensitivity, specificity, and accuracy were
69.2%, 89.7%, and 80.0% for ultrasound; 63.5%, 94.8%, and 80.0% for CT; and 53.8%, 79.3%, and 67.3% for PET-CT,
The sensitivity and specificity of ultrasound and CT were higher than for PET-CT.
PET-CT is a valid imaging modality for the diagnosis of iodine-negative lesions on iodine scan
2016 Jan 28. doi: 10.5041/RMMJ.10233
THYROID, 2014. DOI: 10.1089/thy.2014.0098
a Most authors agree that nodes < 1 cm can usually be observed.depending on the unique situation of each patient, it may be reasonable to avoid surgery on nodes as large as 1.5–2 cm in carefully selected patients. Initial intervention was a formal attempt at central or lateral neck dissection and not just a node plucking or limited retrieval
of nodes.Active surveillance or RAI therapy are both reasonable options if the lymph node metastasis is RAI avid.
THYROID, 2014. DOI: 10.1089/thy.2014.0098
