One year ago I saw a a 60 Y/O M with a thyroid nodule. He was in remission from Leukemia, and wanted to explore the reason for the nodule. He had only Chemotherapy.
No External beam radiotherapy.The USGFNA was consistent with MCT. The pre-op calcitonin was about 1000 N <2. There was nodes in the central compartment, and down into the upper chest. USGFNA of lateral neck nodes was negative for cytology and calcitonin washings. The DNA studies confirmed sporadic, not family MCT. He had extensive surgery. The total thyroid was removed, as well as a node removal down into the upper chest by opening the chest. Both lateral neck node compartments were negative. Post op calcitonin was 40. He had worse problems with a recurrence of the leukemia. One year later after another remission and 4 weeks after the last round of chemotherapy, he presented himself in my office with a calcitonin of 81. The lymph node mapping of his neck was positive for abnormal shaped nodes on both sides. USGFNA of nodes in 4 lateral neck compartment was negative! Hunting for the Calcitonin rise, I did a thin slice PET/CT. The liver was PET/CT negative. He had nodes everywhere, but only one was PET positive. It was in a difficult position for FNA, and only 11 mm in size. I was able to due the biopsy, and show it was the probable source of the calcitonin rise. The surgeon was worried about finding the node group at the time of surgery. One hour before surgery, I injected 1% methylene blue dye on the anterior surface of the node to help in localization. There were smaller nodes near the PET positive one. The surgeon removed 3/12 nodes that were positive.The recovery was uneventful, and the calcitonin post op was 35.
What did we learn?
1. The prior leukemia caused generalized inflammation of nodes throughout his body, confusing me as to the initial place for USGFNA of nodes. The PET/CT was able to find the active MCT cancer node, and the CT slice number allowed us to find the right node to biopsy.
2. Calcitonin washings of the needle after smearing for cytology was the best way to diagnose lymph node mets from MCT.
3. Though MCT is more likely to cause death,than Papillary thyroid cancer, finding early recurrences before they spread to the liver can prolong life.
4.All areas of node surgery in the initial surgery were clear except the very posterior positive node found in Level IIb.
5. The best chance for survival and even cure is a radical surgery with removal of the thyroid, the central nodes and right and left lateral node compartments.
6. The surgeon must be expert in this type of surgery. I sent the patient to a world expert in Houston Texas at MD Anderson Cancer Center.
Until next time on thyroid rounds, at the Santa Monica Thyroid Center,
Good Day,
Dr.G.
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