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W is a 44 yo woman referred 3/02 for a thyroid nodule 1.2 cm bx “c/w Hash thyroiditis with Hurthle cell proliferation” cannot r/o Hurthle cell neoplasm h/o ? partial Lt thyroidectomy in 1991 on Synthroid since. Saw PMD to have BW checked, fullness noted Rt. Lobe. Had u/s and BX of rt. Nodule. No compressive sx. Despite TSH 0.01 no sx of over relacement. 1991 ?Partail lt thyroidectomy for a nodule smoker : strong for throid dz in mo, aunt, cousins P: 90 Mild bilat thyr enlarg : TSH: 0.01, fT4: 1.57 Thyroid U/S: (1/02) inhomog, mild bilat enlarg. 1.2 X 1.0 cm echogenic nod Rt. Lobe prob within thyroid, poss parathyr adenoma. Path: as above. Most c/w chronic thyroiditis but more Hurhtle cellls than usual. Less likely and definitely not favored could be Hurthle cell neoplasm. Path recommended following without surg if sero positive for Hash. Synthroid decreased and d/ced based on bw and mild sx of hyperthyr. Anti-TPOAbs 3345(0-34) T3:376 fT4: 1.77 TSH: 0.01 (off Synthroid). PTHi profile WNLRAUI/scan: 6 hr: 70%, 24 hr 57%, scan: cold defect Lt. Lobe., nonhomog in Lt. Lobe, homog in Rt. Lobe. Repeat u/s: 7 mm nod Lt lobe felt to be too small to rep cold area on scan. Rest of gland “c/w MNG” Treated with 29mci I-131 8/27/02. Became hypo 10/02 ,started Syhtroid 88 mcg. F/u with PMD for adjustments in dose. Repeat thyroid u/s 3/26/03: 6 mm nodule in lt.lobe not seen. Rt. Nodule 1.3 X 0.8 cm (uchanged from 8/02 1.4 X 1.1 cm). Rt lobe 3 X 1.4 X .07, LT lobe 3.6 X1.2X1.0 cm. Somewhat smaller gland.
Questions:
- Would recommend follow up (serial u/s), repeat bx , or surgery? If repeat u/s, when and how often?
- Is it worrisome that nodule and gland are still present after I-131 rx with subsequent hypothyroidism.
- Does patient have Grave’s disease. If so, wouldn’t expect gland to have been destroyed by I –131 RX?
Thanks again,
Lisa Wisniewski, MD
Response
May I offer several comments? Firstly, it would have been a good case for surgical therapy of the hyperthyroidism. Secondly, Graves’ Disease and Hashimoto’s Disease overlap in most ways except for the metabolic status. With an elevated RAIU and autonomous hyperthyroidism, she must have thyroid stimulating antibodies, so I would tend to call this a variety of Graves Disease. The gland remains palpable in part because it must contain a lot of lymphs and fibrous reaction. Lastly, for sure you are going to keep a close watch on the “nodule” in the right lobe, which has too many Hurthle cells and now has received about 1000 rads of gamma rays from the 131-I. Hurthle cell rich nodules in Hashimoto’s glands, and variable “pseudo-nodules “ seen on US, are a frequent problem. If on serial US the R nodule enlarges, or if a repeat biopsy in a year shows a more worrisome histology, it will need resection. Otherwise it is probably safe to watch it, but I think you can never offer complete complete reassurance to the patient in this setting.
Leslie J De Groot,MD