I have a woman who is 51 with a 1.9 cm left lobe thyroid nodule. The radiologist noted multiple sub centimeter hypoechoic nodules on the right lobe and “multiple probable Reactive lymph nodes.” On FNA the one left lobe nodule is a spindle cell carcinoma –favor medullary carcinoma–the other nodules were not biopsied. She was then referred to me and her baseline calcitonin of 1353 (ref<5) and CEA 13.6 (ref<3). On careful history there is no evidence of MEN 2 in the family and we are getting her RET status. Only family history is colon cancer and she has just had a negative colonoscopy. She has two children we will test if needed. What is the most up-to-date pre-op staging? US with more attention to lymph nodes? CT or MRI or PET? Who is doing the best work on medullary cancer? I have a Johns Hopkins trained and experienced ENT surgeon or the patient can consider Mayo at less coverage with her insurance. Otherwise she is covered at Indiana Univ in Indianapolis. Anything actually hopeful on what is going on with non-surgical therapy?
Kathryn A. Wilson, MD
FACE, Urbana, IL
With this presentation, the best pre-operative staging includes careful neck ultrasound and CT scan of the neck, mediastinum and chest. Also liver ultrasound may be indicated, but it is unlikely that she has liver disease, particularly if the patient is without symptoms. The next step is total thyroidectomy with prophylactic central neck dissection if no lymph nodes are seen in the other chains of the neck.
F. Pacini MD