Tuesday, August 08, 2006

40 Heathy Years after So Called Papillary Thyroid Cancer Surgery: Serious Recurrence due to Undiagnosed Medullary Thyroid Cancer

60 Y/O female had a total thyroidectomy, lymph node removal from the neck, and superior mediastinum, and a mutilating radical removal of all neck structures on the right. Why?
The pathologic report, I tracked down from 1960's called it a very, very agressive papillary thyroid cancer. She had mytosis in some areas, and spindle cell formation, but no signs of papillary structures, but many spindle cell groups. Her parents elected at age 18, not to tell her about the cancer, until age 24. They told her she was cured, but had to take thyroid hormone for life. She never saw an endocrinologist, and was fine until 37 years later, when she developed diarrhea. Specialist Gastroenterologist did not find a reason for the diarrhea, but had drawn a calcitonin, which was markedly elevated, at 4000, normal< 20. This was ignored, and never sent to the her primary physician. 38 years after the surgery, she developed dysphagia. An MR revealed a mass in the thyroid bed and in the mediastinum. It circled the carotid, esophagus, and some great vessels in the mediastinum. The calcitonin was still in the 4000 range and the CEA was 2 fold elevated. She saw experts on the east coast, and they were reluctant to intervene surgically. When I saw her, I was able to obtain the pathology report from 1960's. She had exactly the same disease as in the 1960's. The diagnosis of Medullary Cancer of the thyroid was not widely known, and usually called atypical aggressive papillary cancer then. Ultrasound guided FNA diagnosed Medullary adenocarcinoma in the masses in the thyroid bed.

Wow, I am impressed that something looking so aggressive in 1960, had not killed her in 40 years!

Armed with the knowledge that it was an extremely indolent cancer, I began to lobby for a debulking surgery to decrease tumor burden, and decrease diarrhea due to tumor bulk. I sent her to MD Anderson in Texas to see a extreme surgeon to operate.

I will update as this story unfolds.


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