Case of the month (February 2007): contributed by Gilbert Sigal, MD; Meyer Knobel, MD and Geraldo Medeiros-Neto, MD, MACP
Gravesī Disease followed by differentiated thyroid cancer with controversial histological diagnosis and lung metastasis.
RNS, 61-y-old female, mother of three, born and living in Manaus, Amazon State, Brazil.
The patient developed signs and symptoms of a classical Gravesī disease with ophthalmopathy in, approximately, June 2000. During the next five years she was on and off PTU/MMI therapy with several recurrences (probably due to poor compliance). She was submitted in January 2005 to a sub total Thyroidectomy, and a large nodule was detected in the surgical specimen (about 10cm in diameter). The pathological diagnosis was Medullar Cancer but Immunohistochemistry was negative and serum calcitonin was 2ng/mL (Normal). Neverthless she was submitted to another surgery for lymph nodes dissection. Histology of metastatic lymph nodes indicated follicular carcinoma that stained positive for Thyroglobulin. The patient was referred to the University of Sao Paulo Medical Center.
At physical examination the patient was relatively well, with bilateral exophthalmos (21mm, 23mm) with palpebral edema and conjuntival irritation. She denied diplopia. Her weight was 49kg, height 145cm, normal blood pressure and pulse rate. Cardio pulmonary examination was normal. The cervical area exhibited the scars of the two previous surgeries. A hard, round mass (about 4cm) was felt in the left side, firmly attached to the trachea. An aspirate of this tumor yielded a diagnosis of Follicular Cancer and the aspirate was positive for thyroglobulin (1560ng/mL)
The WBS obtained after 300mCi of Radioiodine indicated extensive pulmonary nodular metastatic disease with a high uptake of radioiodine.
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