Cancer Surgery Pre-Operative Lymph Node Evaluation is Important

With the new high frequency ultrasound machines, it is now possible to evaluate the lymph nodes in patients with proven papillary, follicular, or medullary cancer on FNA, prior to the surgery. This will allow the surgeon to add a lymph node removal to the total thyroidectomy and central compartment surgery.Here is a case.

61 Y/O female with FNA proven papillary thyroid cancer on USG FNA, returns for a pre-op neck US lymph node evaluation. There are 3 nodes located lateral to the primary thyroid cancer thyroid nodule. They are suspicious as they do not have hilar lines. These are found in benign nodes, and disappear in cancer nodes.There is chaiotic blood flow in the nodes, on power doppler. They are tall compared to width with a ratio >0.5. Biopsy was positive for papillary cancer, and the Thyroglobulin washings were positive for high levels of TG in the node. The surgeon was notified about positive nodes in zone 4 on the right lateral to the thyroid mass. He was advised to consider node removal along the whole right jugular chain at the time of the standard total thyroidectomy, and central compartment node removal.

What this means to patients with biopsy proven cancer, is that they need a diagnostic Neck lymph node ultrasound with new high frequency untrasound machines, and if a suspicious node is found, then an USguided FNA, and Cancer Tg washing should be done.
This will result in a change in the surgery if positive.


Dr.G.

The Absent Thyroid Lobe or Thyroid Hemiagenisis

The last blog about a patient born with only half of a thyroid, was followed by questions of why, from emailers ?
Well, there are some 100 cases of failure to produce a thyroid lobe.Usually it is in a female, and 75% on the left lobe.There is a high degree of disease in the opposite lobe. The most common disease is Hyperthyroid Graves'. Absent thyroid lobe was found in less than 0.01% of 24,000 screened children. There is an even rarer type, that includes the isthmus. My patient had absent isthmus and left lobe. She also had a nodular cystic goiter in the remaining lobe. The past work up included thyroid scans before and after Bovine TSH Stimulation. Now the ultrasound allows early definitive diagnosis. Failure to know about this can cause patients to become hypothyroid after unilateral lobectomy. If the lobe is absent, the patient needs thyroid hormone therapy. Usually, if the lobe is normal, and present, the patient may not need thyroid hormone after lobectomy.


Dr.G.

What Happened to the Left Lobe of my Thyroid?

40 Y/O female presented with a right side 2.5 cm nodule felt by her internist.She was euthyroid, with normal TSH, negative TPO antibodies. A large mass was visible from across the room. The left lobe was not palpible. The ultrasound confirmed the presence of a complex cystic mass. However, when we looked at the left lobe it was absent!
She asked me what happened to her left lobe, if she did not have surgery? This is a rare congenital defect. total absence of the lobe, plus isthmus. This will not impact the overall thyroid problem, but if she needs surgery, to remove the right nodule and lobe, she will be rendered hypothyroid, and will need to take thyroid hormone.Her work up for the nodule was negative, and she was treated with thyroid hormone.

Dr.G.

Pregnancy Problems without Support from her Thyroidologist

32 Y/O female calls about her thyroid condition after 2 misscarriages. She is my patient, and was treated with radioiodine for Graves' Disease 3 years ago.She was last seen 2 years ago, and stated she was seeing her internist for her thyroid hormone RX's, and did not feel she needed to see me. During the last two years, she had two miscarriages. She a prior a prenancy which resulted in a healthy baby. The last one prompted her return for my opinion. She had elevated TSH when she last conceived ( TSH 7.0 ). She took prenatal vitamins which contained iron, at the same time as her thyroid hormone.She stated none of the other doctors, including her OB told her iron caused decreased absorbtion of the thyroid hormone,. and hypothyroidism. She also was never told that she needed prenatal vitamins with iodine during the pregnancy. However she was lucky, that the vitamins, called
Citracal had 150 mcg of iodine. She was never told of the potential danger of the Graves' thyroid stimulation antibody, TSI, which can not hurt her, because she had her thyroid gland destroyed by Radioactive iodine, but could stimulate her baby's thyroid, causing Neonatal Graves Disease. This is a rare, but serious disease she could pass to her baby. A blood test, which was never done in the two pregnancies, could have diagnosed this and allowed early therapy. I told her she was high risk, due to her Graves' thyroid diease and therapy, and needed to be sure her TSH was normal 0.5-2.0, before conception. IQ and neuologic problems occur if you are hypothyroid at conception. Also 6 weeks after conception, there is a 20-50% increase in thyroid hormone needed during the pregnancy. Finally, The thyroid blood hormones need to be kept in the upper normal range, during the pregnancy, and 6 week post delivery, there is a lowering of the dose back to pre-pregnancy levels. She felt she did not need me during the prior pregnancies, but clearly realized she was wrong. I am monitoring her thyroid status this time.


Dr.G.