Wednesday, November 08, 2006

Distant Metastatic Disease 30 years after Partial Thyroidectomy for Thyroid Cancer

I was not expecting this when a nurse called me to see her 85 Y/O father. He had a mass under the skin of his abdomen which was removed, and was found to be metastatic papillary thyroid cancer.The story gets worse. Since his surgery in his home country 30 years ago, he never knew that he had had thyroid cancer. The family did not tell him. They thought he had been cured by the partial thyroid surgery. There was no cancer follow up. With the distant cancer spread 30 years later, the family asked me to see him. He was wearing a pacemaker, had heart disease, and was not a good surgical risk. He was taking a heart drug, amioaderone, which was very high in iodine content. He had nodular masses in the lung by CT, and had significant thyroid tissue
still in the neck by ultrasound. 24 Hr uptake was 18%, the scan showed bilateral thyroid gland with cold masses in the left lobe. The thyroid tests confirmed severe hypothyroidism with TSH of 70. He had never been treated with thyroid hormone for the cancer or hypothyroidism. The TSH stimulated cancer marker TG was > 2000.
He was ready for ablation therapy, but was incontinent! No hospital would take him.
What do you do with this case?
After much thought, because he was most effected by the hypothyroidism, I elected to treat his hypothyroidism first. He had wide spread cancer with very high cancer marker, and had no local symptoms due to the cancer. I will wait for local symptoms and then treat for symptom relief with external radiation. This is a very sad case, because if he knew he had cancer, the patient might have sought medical care when there was a chance it would have help.

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