Hurthle cell carcinoma (HCC) of the thyroid gland is rare accounting only for 3-10% of differentiated thyroid cancer. Widely invasive HCC (WI-HCC) has the highest incidence of metastasis among the differentiated thyroid cancers. Distant metastases, late recurrence, and a decreased affinity for radioactive iodine (RAI) are unfortunate features of WI-HCC. The low iodine avidity complicates detection of residual and/or metastatic disease. We present a case of WI-HCC without regional nodal disease or distant metastasis at diagnosis with subsequent development of retroperitoneal metastasis.
A 64-year-old female initially presented with hoarseness and dysphagia. Her past medical history was significant for a thyroid nodule diagnosed 20 years prior. There was no personal or family history of thyroid cancer. Otolaryngology evaluation showed a right vocal fold paralysis. A neck ultrasound (US) showed a right thyroid lobe measuring 6.8 x 3.3 x 3.7cm that was completely replaced by a lobulated heterogenous nodule with coarse calcifications and cystic/solid components. Fine-needle aspiration was reported as follicular neoplasm, Hurthle cell type. Total thyroidectomy and central neck dissection was performed. Final pathology revealed a 4.6cm Hurthle cell carcinoma in the right lobe with vascular invasion (> 4 vessels) and extrathyroidal extension. No lymph nodes were positive (0/3). Given the aggressive pathology, ablation with 150 mCi of I-131was completed. Whole body scan post-ablation showed thyroid bed activity. Post- operative thyroglobulin (TG) was 230 and down trended post-ablation. Surveillance US and neck MRI showed no recurrence of disease. Five months post-ablation, the TG levels rose from 80 to 190. CT of the chest, abdomen/pelvis showed a 3.8cm retroperitoneal mass. PET scan, at the time, showed a hypermetabolic left pelvic mass with SUV of 28. Due to location, biopsy was prohibitive and complete resection of the pelvic mass was achieved. Pathology was consistent with metastatic hurthle cell carcinoma. Post-resection TG levels fell to undetectable (TG <2, antibody negative) within 4 months.
Results : NA
HCC, particularly widely invasive, follows a more aggressive course requiring alternative imaging modalities for detection of residual and/or metastatic disease. While post-operative RAI may have benefit, surveillance with CT and/or PET scan along with thyroglobulin monitoring is criticalfor identification of residual and/or metastatic disease.
Conclusion : NA
Deepika Nandiraju– Fellow in training, Thomas Jefferson University hospital, Philadelphia, Pennsylvania
Mona Gossmann– Internal medicine resident, Thomas Jefferson University Hospital
Tasha Kouvatsos– Clinical Assistant professor, Thomas Jefferson University hospital, Wynnewood, Pennsylvania
Fellow in training
Thomas Jefferson University hospital
second year Fellow in training
Internal medicine resident
Thomas Jefferson University Hospital
Internal medicine resident - PGY3