I was asked to consult on a patient who felt well but went to his doc with hemoptsis. A lesion was biopsied through the bronchoscope-the diagnosis came back papillary cancer either metastatic or ectopic. The patient has been treated for several years for hypothyroidism-no local symptoms ever reported until this one episode of coughing up blood. The US of the thyroid shows two nodules left neck -neither palpable-1.5 cm posterior and 1.0 cm -isthmus no clear nodule.-Can you advise next steps? Is this likely to be locally invasive disease ? If so how is the trachea managed in such cases? What is the role for local radiation or I 131? I favor an US guided biopsy of the nodule(s) in the thyroid but the surgeon says it wont change our management. How often have you seen this?
Jeffrey Sanfield MD
You didn’t tell me the patient’s age or general condition, so I will assume the person is older (50-70) and generally well. I have seen this infrequently, fortunately, primarily with Hurthle or follicular cancers, and it always spelled big trouble. I think you must assume direct invasion as the most likely situation. Thus, while 131-I might provide a cure, prior surgical resection would be the usual program. This is a very specialized sort of surgery, with resection and re-anastomosis of the trachea as the possible approach. A surgeon at MGH has written several papers about this. Unfortunately even with this rather heroic approach, often the tumor has spread so that final outcome is not as desired. I suggest a neck MRI and chest CAT to try to understand the situation better and see if there is bulky disease or lung mets. Assuming no obvious contraindication, then the approach might be thyroidectomy and tumor resection including probably a tracheal resection, followed by RAI scan and ablation. Let us hope that the tumor takes up RAI well. Finally one should consider radiation, but I think this needs to be decided after operation and RAI treatment. The decision would be based on extent of disease and the resection, RAI uptake, age, histology, post-ablation TG, and possibly other factors. I would tend in this situation to favor radiation but we need the next set of data in order to think it thru. There is a discussion of this problem in Thyroid Manager.
Leslie J De Groot,MD