Category: Reproductive Endocrinology
The simultaneous, discreet, existence of differentiated thyroid carcinoma and medullary thryoid carcinoma, separated by normal tissue, is rare. This is different from mixed medullary-follicular carcinomas.
Methods : case
Results : A 61/F with Hashimoto’s thyroiditis with superimposed multinodular goiter underwent biopsy and was positive for medullary thyroid carcinoma. Calcitonin was found to be elevated at 201pg/mL and CEA 4.3ng/mL (normal 0-4). She underwent total thyroidectomy with a right sided lymph node exploration. Pathology revealed a right sided 1cm medullary cancer with chronic lymphocytic thyroiditis. In the left side, a minimally invasive follicular cancer of 8 mm with focal capsular invasion was found. 6 of 31 nodes in the central neck, 6 of 30 nodes in the lateral neck and 0 of 23 in the right neck were positive for medullary thyroid carcinoma.
Discussion : Post operatively, her calcitonin went down to 17 pg/mL; however surveillance ultrasound showed residual lymph nodes leading to repeat neck exploration then thyrogen-stimulated radioactive iodine treatment with 100 mci of I-131. Calcitonin levels did not normalize and rose to 151pg/mL. Surveillance ultrasound showed a right pretracheal node that was negative for malignancy. A PET-CT showed no evidence of FDG avid disease in the head/neck, chest or abdomen/pelvis. She underwent venous sampling study, with values of 330 in the right high internal jugular, 208 in the right mid internal jugular, and 256 in the base of the right internal jugular. A targeted ultrasound-guided fine needle aspiration of a prominent lymph node on the right level II was positive for calcitonin and this led to a repeat extensive neck surgery. Final pathology showed upper right metastatic medullary cancer and 4 of the 16 lymph nodes with extrathyroidal extension. Calcitonin dropped to 3 post surgery and thyroglobulin became negative with negative serial ultrasounds. More recently, her TG is elevated upto 8 pg/mL and we are proceeding with follow up imaging studies for surveillance.
Simultaneous medullary and follicular thyroid carcinoma is rarely described. It is an important clinical entity that must be identified early to avoid delays in definitive treatment. Surveillance after surgery through monitoring for recurrence with serial calcitonin, thyroglobulin, CEA, TSH, in addition to imaging modalities and thyrogen stimulated scans is of paramount importance. Although localization of distant metastasis with calcitonin lower than 150-300 is not easily achieved even with the most sensitive imaging techniques, selective venous sampling techniques can also be employed to localize recurrent medullary thyroid carcinomas.
Roselyn Mateo– Clinical Fellow, BIDMC, Boston, Massachusetts
Barry Sacks– Associate Clinical Professor of Radiology, Harvard Medical School, Beth Israel Deaconess Medical Center
Johanna Pallotta– Associate Professor Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, Massachusetts
Roselyn Mateo is a second year Clinical Fellow in Beth Israel Deaconess Medical Center in Boston, MA. She finished her Internal Medicine Residency in Rush University Medical Center and later on served as Chief Resident. Her clinical and research interests include Diabetes, Obesity, Lipids and Metabolism and Health Disparities.
Associate Clinical Professor of Radiology
Harvard Medical School, Beth Israel Deaconess Medical Center
Barry Sacks is Associate Professor of Radiology at Harvard Medical School and is the Section Chief of Interventional Radiology at Beth Israel Deaconess Medical Center. He is a an expert at complex thyroid and parathyroid studies .
Associate Professor Harvard Medical School
Beth Israel Deaconess Medical Center
Johanna Pallotta has practiced Endocrinology for over 50 years and her expertise in thyroid and parathyroid cancer is unparalleled. She is a master clinician and has been involved in the forefront of groundbreaking clinical practices in Endocrinology and advancement of the fellowship program.