Saturday, March 14, 2009

A German Story of a Failed Treatment Plan for a Radiation Exposured Patient With a Toxic Nodule, and the Negative Long Term Effect on HER.

A 45 Y/O female presented to my center with a thyroid nodule. The history was positive for radiation therapy for a skin problem as a child in Germany. At age 30 she had symptoms of hyperthyroidism, and was diagnosed with a single toxic nodule by thyroid uptake and scan. The endocrinologist in Berlin referred her to a surgeon, who did a lobectomy removing only the lobe with the toxic nodule. 15 years later is when she arrived at my doorstep after a CT scan, done for another unrelated problem revealed a mass in the thyroid. A large scar over the left side of her neck was secondary to the childhood irradiation. A palpable mass was noted in the right lobe. The scar from the surgery was located over the other lobe area that was removed in Berlin. Her thyroid blood tests were normal, but the high frequency ultrasound was abnormal. There was a large nodule in the right lobe, but there were 10 nodules in all ranging in size from 3-10 mm. The left lobe was also enlarged and had nodules as well. Did the surgeon do a nodule removal only or was this regrowth? The ultrasound guided FNA of all nodules > 5 mm were benign. The patients problems began when the Berlin endocrinologist and the surgeon failed to factor in the radiation history in the surgery plan for the toxic nodule. The radiation history should have been the reason to do a total thyroidectomy to remove at risk thyroid tissue along with the toxic nodule. This would have removed the risk of cancer in the future, and would have prevented the progression of her goiter to the point that now she will need careful ultrasound and blood monitoring for the rest of her life. Any one of the nodules that were not biopsied could be a cancer, and if they grow another round of biopsies will be needed. The endocrinologists should have known that patients in their area have a high incidence of iodine deficient goiters. That toxic nodules arise out of those glands. Also that needed to remember that radiation therapy for benign conditions of the head and neck causes goiters, nodules, benign and malignant tumors. Her life would have been simple if they did a total as recommended, and simple thyroid blood T4, and TSH, would have been the only followup needed. Instead she will need yearly ultrasounds to follow the massive number of nodules that are present,or go in for another surgery now.
I wish her luck in the future,


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