Coincidence? - Graves’ Disease & Thyroid Cancer

Abstract

Abstract Background: DG coincidently with thyroid carcinoma has been reported as a rare phenomenon. It was thought that DG would be a protective condition in the development of cancer. However, published studies indicate the opposite, reporting an increased prevalence of differentiated thyroid cancer in DG compared to the general population. Some authors even report greater aggressiveness of this type of cancer in the presence of DG, with higher rates of, multifocality, metastatic disease and with a higher risk of recurrence. Clinical Case: Female, 46 years old, smoker 10 U.M.A., sent to the Endocrinology consultation due to symptomatic hyperthyroidism. No history of exposure to cervical radiotherapy, contact with iodinated products or cervical pain. Analytically, TSH <0.008 uUI / mL (0.27-4.2), free T4 4.09 ng/dL(0.93-1.70), free T3>20 pg/mL(2.57-4, 43), high levels of anti-thyroid and anti-TSH receptors 11.4IU/L (N <1.75), diagnosing with Graves’ disease. The thyroid ultrasound revealed a globose and hypervascularized thyroid. In the right hemithyroid, an echogenic nodular area of ​​ill-defined limits of about 12mm was identified, associated with some hyperechogenic elements. Bilateral cervical and submandibular lymph nodes were visualized with a short 8 mm axis, highlighting a ganglion in the right jugular chain, questioning the presence of millimeter echogenic foci. She started metibasol, with improved thyroid function and opted for ultrasound surveillance. Four months later, she repeated the ultrasound of the thyroid, maintaining a hypercogenic area, with ill-defined limits in the right lobe, with a 13mm longest axis. She also maintained adenopathies in the right jugulo-carotid chain, rounded, without hilum, the largest one with 13x9x17mm, and it was performed a fine needle aspiration of the ganglion. There was no measurement of thyroglobulin in the wash. The morphological changes were compatible with ganglion metastasis due to papillary thyroid carcinoma with a predominantly follicular pattern. She started 5% lugol solute, 7 drops every 8 hours for 8 days before surgery and underwent total thyroidectomy and central and lateral lymphadenectomy, with the identification of a mixed, multifocal papillary carcinoma. in the right lobe and isthmus, the microscopic size of the largest focus was 40mm, without invasion of the capsule or vascular invasion, with ganglion metastases in the lateral (9/46) and central district (6/6) (pT2N1b). She underwent treatment with I131 at a dose of 120mCi. Conclusion: This clinical case stands out for its uniqueness, given the simultaneity of Graves’ disease and thyroid cancer. The presence of cervical adenomegaly, which is rare in DG, increased clinical suspicion. Due to the increase of the adenopathy in a short period of time, we decided to perform a biopsy, which in this case was essential for the diagnosis and subsequent treatment.