You need JavaScript to view this

Association of Papillary Thyroid Carcinoma and Graves' Disease. Unexpected Development and Efficiency of Ablative Dose with Recombinant Human Thyrotropin (rhTSH); Asociación de carcinoma papilar de tiroides y enfermedad de Graves. Inesperada evolución y eficacia de la dosis ablativa con tirotrofina recombinante humana (rhTSH)

Abstract

Differentiated thyroid cancer (DTC) associated with Graves' disease (GD) is a relatively rare disease, occurring in 0.3 % to 9.8 % of GD patients. Some studies suggest an increased aggressiveness of DTC in GD patients, apparently related to thyroid stimulating antibodies. We report the case of a patient with DTC and GD, describing his peculiar evolution. Case report: 22-year-old male who presented with obesity. History of a cousin with DTC and grandmother and mother with goiter. Physical examination: Weight: 116.4 kg, height: 1.73 m, BMI: 38.9. Clinically euthyroid. Thyroid palpation was difficult due to his thick neck. Initial analysis: T3, T4 and TSH within normal range. Thyroid ultrasound (US) showing 11 x 10 mm hypoechoic nodule in right lobe (RL). US-guided fine-needle aspiration (FNA) was requested. Four months later, the patient returned with clinical symptoms of hyperthyroidism (diarrhea, palpitations, insomnia, tremors, cramps and difficulty walking). Laboratory: T3: 557 ng/dl, T4: 18.8 mcg/dl, FT4: 3.73 ng/dl, TSH <0.01 μIU/mL, TPOA: 186 IU/mL, TGA: 965 IU/mL. US-guided FNA: 'Cytological findings are related to papillary thyroid cancer{sup .} Thyroid Scan: {sup D}iffuse enlargement of the gland, 'warm' nodule in RL{sup .} I{sup 131}uptake was: 1st hour: 12 %, 24 hours: 58 %. He  More>>
Authors:
Pacenza, N. A.; Groppo, N.; [1]  Guibourg, H. C. [2] 
  1. Centro Médico “Enrique Tortosa”, Consultorio de Endocrinología, Buenos Aires (Argentina)
  2. Sigma Imágenes Médicas S.A., Servicio de Medicina Nuclear, Buenos Aires (Argentina)
Publication Date:
Jul 01, 2013
Product Type:
Journal Article
Resource Relation:
Journal Name: Revista Argentina de Endocrinologia y Metabolismo; Journal Volume: 50; Journal Issue: 1; Other Information: 25 refs., 3 figs.
Subject:
62 RADIOLOGY AND NUCLEAR MEDICINE; CARCINOMAS; HYPOTHYROIDISM; IODINE 131; NUCLEAR MAGNETIC RESONANCE; PATIENTS; RADIATION DOSES; RADIOTHERAPY; THYROID; THYROID HORMONES; TSH
OSTI ID:
22386214
Country of Origin:
Argentina
Language:
Spanish
Other Identifying Numbers:
Journal ID: ISSN 0326-4610; TRN: AR15A0212091793
Availability:
Also avaible at: http://www.scielo.org.ar/pdf/raem/v50n1/v50n1a05.pdf
Submitting Site:
INIS
Size:
page(s) 35-41
Announcement Date:
Oct 20, 2015

Citation Formats

Pacenza, N. A., Groppo, N., and Guibourg, H. C. Association of Papillary Thyroid Carcinoma and Graves' Disease. Unexpected Development and Efficiency of Ablative Dose with Recombinant Human Thyrotropin (rhTSH); Asociación de carcinoma papilar de tiroides y enfermedad de Graves. Inesperada evolución y eficacia de la dosis ablativa con tirotrofina recombinante humana (rhTSH). Argentina: N. p., 2013. Web.
Pacenza, N. A., Groppo, N., & Guibourg, H. C. Association of Papillary Thyroid Carcinoma and Graves' Disease. Unexpected Development and Efficiency of Ablative Dose with Recombinant Human Thyrotropin (rhTSH); Asociación de carcinoma papilar de tiroides y enfermedad de Graves. Inesperada evolución y eficacia de la dosis ablativa con tirotrofina recombinante humana (rhTSH). Argentina.
Pacenza, N. A., Groppo, N., and Guibourg, H. C. 2013. "Association of Papillary Thyroid Carcinoma and Graves' Disease. Unexpected Development and Efficiency of Ablative Dose with Recombinant Human Thyrotropin (rhTSH); Asociación de carcinoma papilar de tiroides y enfermedad de Graves. Inesperada evolución y eficacia de la dosis ablativa con tirotrofina recombinante humana (rhTSH)." Argentina.
@misc{etde_22386214,
title = {Association of Papillary Thyroid Carcinoma and Graves' Disease. Unexpected Development and Efficiency of Ablative Dose with Recombinant Human Thyrotropin (rhTSH); Asociación de carcinoma papilar de tiroides y enfermedad de Graves. Inesperada evolución y eficacia de la dosis ablativa con tirotrofina recombinante humana (rhTSH)}
author = {Pacenza, N. A., Groppo, N., and Guibourg, H. C.}
abstractNote = {Differentiated thyroid cancer (DTC) associated with Graves' disease (GD) is a relatively rare disease, occurring in 0.3 % to 9.8 % of GD patients. Some studies suggest an increased aggressiveness of DTC in GD patients, apparently related to thyroid stimulating antibodies. We report the case of a patient with DTC and GD, describing his peculiar evolution. Case report: 22-year-old male who presented with obesity. History of a cousin with DTC and grandmother and mother with goiter. Physical examination: Weight: 116.4 kg, height: 1.73 m, BMI: 38.9. Clinically euthyroid. Thyroid palpation was difficult due to his thick neck. Initial analysis: T3, T4 and TSH within normal range. Thyroid ultrasound (US) showing 11 x 10 mm hypoechoic nodule in right lobe (RL). US-guided fine-needle aspiration (FNA) was requested. Four months later, the patient returned with clinical symptoms of hyperthyroidism (diarrhea, palpitations, insomnia, tremors, cramps and difficulty walking). Laboratory: T3: 557 ng/dl, T4: 18.8 mcg/dl, FT4: 3.73 ng/dl, TSH <0.01 μIU/mL, TPOA: 186 IU/mL, TGA: 965 IU/mL. US-guided FNA: 'Cytological findings are related to papillary thyroid cancer{sup .} Thyroid Scan: {sup D}iffuse enlargement of the gland, 'warm' nodule in RL{sup .} I{sup 131}uptake was: 1st hour: 12 %, 24 hours: 58 %. He received methimazole 20 mg daily. He was operated on 2 months later ({sup t}otal thyroidectomy{sup )}. Pathology: {sup F}ollicular variant of papillary thyroid carcinoma in right lobe and classical variant of papillary carcinoma in area of the left lobe{sup .} Thirty-five days after surgery (S) (without levothyroxine): TSH <0.01 μIU/mL, Thyroglobulin (Tg) 32.1 ng/mL. Sixty days after S: TSH <0.1 μIU/mL, FT4 1.2 ng/dL, T3 1.3 ng/dL. Clinically euthyroid with normal neck palpation. Chest Computed axial tomography (CT): {sup N}ormal{sup .} US of the neck: {sup B}ilateral thyroid lodge is free{sup .} Ninety days later: TSH 0.32 μIU/mL, TRAb 29 % (normal: until 15 %). Thyroid Scan with {sup 99m}Tc pertechnetate: {sup P}athological uptake in middle and lower cervical region right and left lower neck. He was reoperated on 4 months after his initial S: {sup R}esection of epithelial proliferation with thyroid aspect in superior mediastinum region{sup .} Pathology: {sup N}ode with extensive infiltration of neoplastic proliferation of follicular variant of papillary carcinoma with areas of connective tissue infiltrated periganglionar of papillary thyroid cancer{sup .} Lab 40 days after the second surgery: TSH 2.3 μIU/mL, FT4 0.82 ng/dL, Tg 4.7 ng/mL. Neck and chest CT showed neither pathological lesions nor lymphadenopathy. I{sup 131} uptake with 7.4 MBq was: 1st hour: 8 % and 24 hours: 12 %. Neck Scan: {sup M}ultiple areas of tracer fixation in the neck{sup .} No pathological signs on neck palpation. Ablative dose of 7.4 GBq of I{sup 131} was performed to the patient, previously using rhTSH (two doses of 0.9 mg), reaching TSH >100 μIU/mL. Scan post ablative dose: {sup I}mportant focus on right paratracheal region. Neck MRI showed: Absence of thyroid gland. Rounded image of about 10 mm at right paratracheal level. The patient initiates suppressive therapy with levothyroxine (LT4). Six months after ablation therapy (without LT4): TSH >100 μIU/mL, Tg: 13.8 ng/mL, TGA: 431 IU/mL. Body Scan with 2 mCi: {sup P}athological focus of radioiodine behind the right sternoclavicular joint. New neck MRI: Image in right pretracheal region smaller than the previous study{sup .} The patient received 5.55 GBq of I{sup 131}. The same radioiodine treatment was repeated 8 months later. At present, 4 years after the patient's initial surgery, he is in good general health, performing his normal activities, with TGA in sharp decline, negative I{sup 131}body scan and without signs of persistent or recurrent disease. Conclusions: We report a case of follicular variant papillary TC associated with GD with concomitant development of hyperthyroidism, with positive TGA, in a 22-year-old obese man. Highlights: 1) The importance of initial US exploration in a patient with GD, 2) Residual neoplastic lymph node tissue after 2 S, performed by an experienced surgeon, with enough functioning tissue to prevent a significant elevation of TSH and allow I{sup 131} ablative therapy, 3) Tumor local aggressiveness shown by adjacent tissues and lymph node infiltration, 4) Failure to identify residues in the neck by CT and US; instead, effectiveness of the neck MRI without contrast and {sup 99m}Tc thyroid scan, 5) Effective use of ablative radioiodine therapy with rhTSH. (authors) [Spanish] El carcinoma diferenciado de tiroides (CDT) asociado a enfermedad de Graves (EG) es una asociación relativamente rara, ocurriendo en el 0,3 % al 9,8 % de los pacientes operados por EG. Se presenta el caso de un paciente con EG y CDT de tiroides con características evolutivas y terapéuticas peculiares. Varón de 22 años que consultó por obesidad. Peso: 116,4 kg, Talla: 1,73 m, BMI: 38,9, clínicamente eutiroideo, con palpación tiroidea dificultosa por grosor de cuello. Análisis iniciales: T3, T4 y TSH dentro de rango normal y ecografía tiroidea con nódulo hipoecoico en lóbulo derecho (LD) de 11 x 10 mm. Se le solicitó punción aspirativa con aguja fina (PAAF) bajo guía ecográfica. Vuelve a los 4 meses con cuadro clínico de hipertiroidismo. Análisis: T3: 557 ng/dL, T4: 18,8 mcg/dL, T4 L: 3,73 ng/dL, TSH: < 0,01 μIU/mL, ATPO: 186 UI/mL, ATG: 965 UI/mL. La citología mostró: {sup H}allazgos citológicos vinculables con carcinoma papilar (CP) tiroideo{sup .} Centellograma tiroideo: {sup N}ódulo integrado en LD{sup .} Es tratado con metimazol y se opera a los 2 meses: {sup T}iroidectomía total{sup ;} cuya anatomía patológica (AP) reveló un {sup C}P variante folicular en lóbulo derecho y zona de CP variante clásica en lóbulo izquierdo{sup .} A los 35 y 60 días de operado (sin instaurar levotiroxina): presenta TSH <0,1 μIU/mL con T3 y T4 normales. Clínicamente eutiroideo, con palpación de cuello normal. Tomografía axial computada (TAC) de tórax: {sup N}ormal{sup .} Ecografía de cuello: {sup L}odge tiroidea bilateral libre{sup .} TRab 29 % (V.N. hasta 15 %). Centellograma tiroideo con Tc{sup 99m}: {sup C}aptación patológica en región cervical media e inferior derecha y cervical inferior izquierda{sup .} Se reopera a los 4 meses de la primera cirugía (Cx). Se resecó proliferación epitelial en región de mediastino superior{sup .} AP: {sup G}anglio con infiltración de CP variante folicular{sup .} Análisis a los 40 días de la 2° Cx: TSH: 2,3 μIU/mL, , T4 L: 0,82 ng/dL, tiroglobulina (Tg): 4,7 ng/mL. TAC de cuello y de tórax normales. Captación de I{sup 131}: : 1 h: 8 %, 24 h: 12 % y centellograma con 7,4 MBq de I{sup 131M}últiples áreas de fijación del trazador en cuello{sup .} Resonancia magnética nuclear (RMN) de cuello sin contraste: {sup I}magen redondeada de 10 mm a nivel paratraqueal derecha{sup .} Se logra hacer dosis ablativa con 0,9 mg de rhTSH con 200 mCi de I{sup 131,} alcanzando una TSH >100 μIU/mL. A los 6 meses de la DT (sin levotiroxina): TSH >100 μIU/mL, Tg: 13,81 ng/mL, ATG: 431 UI/mL. Rastreo con 2 mCi: {sup A}umento patológico del radioyodo solo a nivel de la articulación esternoclavicular derecha{sup .} RMN de cuello: {sup I}magen en región pretraqueal derecha de menor tamaño que la anterior{sup .} Se le indicó DT de 150 mCi de I{sup 131}. Posteriormente requirió 2 DT de I{sup 131} más. En la actualidad, a 4 años de la primera operación, el paciente se halla en buen estado general, con Tg negativa, con ATG en disminución franca y rastreo corporal de I{sup 131} negativo y sin signos de persistencia o recidiva de la enfermedad. Conclusiones: Varón obeso de 22 años portador de un CP de tiroides concomitante con la instalación de un hipertiroidismo por EG, con ATG positiva. Se resalta: 1) La importancia de la evaluación ecográfica inicial de un paciente con EG, 2) Tejido neoplásico residual ganglionar después de 2 Cx, efectuada por cirujano experimentado, suficientemente funcionante como para impedir elevación significativa de TSH y permitir dosis ablativa de I{sup 131}; 3) Agresividad local del tumor demostrado por infiltración ganglionar y tejidos adyacentes; 4) TAC y ecografía de cuello que no pudieron identificar restos en cuello y efectividad, en cambio, de la RMN de cuello sin contraste y del centellograma tiroideo con Tc{sup 99m}; 5) Eficaz utilización de la dosis ablativa con rhTSH. (authors)}
journal = {Revista Argentina de Endocrinologia y Metabolismo}
issue = {1}
volume = {50}
journal type = {AC}
place = {Argentina}
year = {2013}
month = {Jul}
}