Friday, April 22, 2005

40 Years after a Total Thyroidectomy, a thyroid nodule is found.

A 60 Y/O female, decides to have her thyroid re-evaluated,after her 2 children were found to have thyroid disease. She had her thyroid removed 40 years ago, and remembers they told her they left 1/16 of the thyroid.She also remembers that gland removed, was not harboring cancer. She took thyroid hormone for 40 years until her visit to see me, for replacement therapy, after the surgery.She does not recall any other therapy, such as radioiodine after the surgery. She had a 1-2 cm nodule in the right lobe.It was firm.There was a well healed thyroidectomy scar. He thyroid tests were normal, including TSH on LT4 therapy, and TPO antibody.
The ultrasound showed absent left lobe, but a right lobe with a nodule with coarse calcifications. The nodule had an irregular shape. Because of previous surgery, and the low risk situation, I elected to scan her with I/123. The right lobe was present with a cold nodule in the area of palpated mass. There was faint uptake in the left lobe. I elected to do an ultrasound guided biopsy of this calcified mass, because there was no way to get the medical records, pathology report, or slides from a 40 year old surgery in the southern state of Georgia. I expected the biopsy to be a remnant benign goiter nodule, or Hashimoto's thyroiditis that had recently involved the thyroid tissue left after the original surgery. I was shocked to see papillary thyroid cancer staring up at me from my microscope!
This is a good lesson for us thyroidologists. If you can't get the old records, including the original pathology report and slides, you must treat the case as a new case, and do a complete work up. The coarse calcification 40 years after her surgery was a red herring. She will have a pre-op neck lymph node evaluation, to see if the cancer has spread to her nodes, and will have a node biopsy if I find any suspicious nodes. This will add a node removal to the surgery. If the neck nodes are negative, I will ask the thyroid surgeon to remove the remaining thyroid,nodule, and clean out the central compartment.


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