Surgery with Adrenal Mass; “Incidental” Medullary Carcinoma

Question

Thank you so much for responding to my e mails. I wish to get your views on these cases.

1. 43 year old male diagnosed with NHLymphoma 1991,post surgery,post RT.Incidental finding of 1.3 cm adrenal adenoma right, serial ct/mri of the adrenals showed increase in size 2003 1.8 cm,2004 1.6 cm. He is clinically ok, non hypertensive, the nodule looks silent and benign, HU <10. My questions are:
   1. He is to undergo a nasal surgery under general anesthesia, is it safe to proceed with surgery or do we have to r/o functioning adrenal nodule first?
   2. He also has subclinical hypothyroidism,ft4 11,tsh 12,anti tg>2000,anti tpo 130,thyroid scan, hyperfunctioning and warm nodules. Can his subhypo be attributed to the radiation he received while during treatment for HL ymphoma of the axillary node or is this definitely thyroiditis alone? can we also consider the thyroid nodules to be radiation exposure related
2. female late 20s, 2002 presented with subclinical hypothyroidism and a discreet solid nodule on the right lobe.FNAC was colloid nodule. She received t4 suppression for about a year before finally deciding to have thyroidectomy. NO FROZEN section, surgery done at the suburb. Histopath showed medullary ca. Problem: surgery done was subtotal. Parathyroids were normal looking says the surgeon, patient non hypertensive. Should we subject patient to completion thyroidectomy, can we be guided by calcitonin level and cea alone at this time.
3. What exactly is the clinical significance of (histopath reading) HYPERPLASTIC nodules.We see a lot of these lately. Thanks so much sir for your time and wisdom.

Lynn F.W.Bilar,MD

Response

1. The adrenal mass seems to be a non functioning incidentaloma. The only test that I would recommend in view of a general anasthesia is measurement of plasma/urinary epinephrins just to exclude the rare possibility of pheocromocytoma. Regarding the thyroid, definitely the patient has autoimmune thyroiditis with subclinical hypothyroidism. This can develop spontaneously on a genetic background but that are also convincing evidence that autoimmune thyroiditis may be triggered by exposure to external radiation. Clinically it makes no difference, except that true cold nodules in the setting of radiation exposure have higher chance to be malignant and thus must be submitted to FNAC.
2. Medullary thyroid cancer is a potentially lethal disease and frequently presents with lymph node metastases, either clinically evident or unsuspected. In my opinion the patient should undergo a careful ultrasound of the neck for lymph nodes and calcitonin measurements before and after pentagastrin stimulation. If the results are fine, I would procede with completion thyroidectomy and dissection of the central node compartment. If there is suspicion of lateral lymph node involvement surgery should be more aggressive. In addition, being the patient young one should screen blood DNA for germline mutations of the ret proto-oncogene. This is because about 5-7% of apparently sporadic MTCs are indeed hereditary cases or "de novo" disease misdiagnosed as sporadic.
3. In my view hyperplastic nodule should refer to nodules as those found in the context of goiter where the disease is expression of minor TSH hyperstimulation, These leions are usually policlonal in origin as opposed to true adenomas which are usually monoclonal proliferations. I hope that this information answers your questions.

Sincerely,

Furio. Pacini MD