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54 year old found to have a right sided nodule which, on biopsy, was felt to be Hurthle cell. Total thyroidectomy performed 4/04. Tumor was 7 x 3 x 2.5 cm with invasion of tumor through capsule. Although margins of excision were free of tumor. lymphatic invasion was present. An additional microscopic focus of papillary was present on the left. Patient had 150 mCi I-131 in late May. Post treatment scan documented uptake in the right superior mediastinum as well as neck. Thyroglobulin at time of RAI tx was > 4,000. Ultrasound in July noted a single node in right mid lateral neck measuring 2.8 cm. Repeat ultrasound (10/04) now shows 3 enlarged lymph nodes although none are as big as the 2.8 cm previously measured in July. T4 dose has been increased and he is currently taking 175 mcg. However, his most recent TSH is still elevated (18.9 U/ml). His thyroglobulin level is down from 4921 to 1065 ng/ml. Would you recommend a modified neck dissection to try and remove the adenopathy? Will removing the nodes increase the potential for additional RAI uptake (I plan to check him next in 7/05)? Is there any value in waiting to see how low the TG levels go down to when the TSH is more fully suppressed or seeing whether the nodes decrease in size further? Thanks very much for the input.
Response
This patient seems to have Hurthle cell carcinoma with node metastases, probably able to take up radioiodine. From your description it is not clear whether initial surgery included lymph node dissection (probably not). In this case, I would suggest to performed a modified radical neck dissection on the right side of the neck and immediately after I would go on with a second dose of radioiodine. Looking at the levels of serum Tg, I would also check for the presence of distant metastases in the lungs or bones by CT and/or FDG-PET.
Furio Pacini, MD