Ultrasound signs of large segmental thyroid regeneration in Hashimoto’s thyroiditis: a case report of two cases

Medullary thyroid cancer, or MTC, is an uncommon type of thyroid malignancy. It originates from a specific group of cells within the thyroid gland called calcitonin-producing C cells. An even rarer complication of MTC is when the cancer extends beyond the thyroid gland and reaches the area behind the breastbone, known as the retrosternal space. This specific scenario is estimated to occur in only 0.2-0.8% of all thyroid cancers associated with MEN syndromes or a positive family history We report the case of an older man who had difficulty breathing and a large swelling on the right side of his neck. A needle aspiration biopsy revealed MTC, and he was treated accordingly. While large thyroid glands have been documented, our case of MTC with extension from the upper right neck to the mid-chest, not associated with MEN syndrome additionally, is one of the infrequent cases to account as the prognosis for retrosternal MTC is generally worse than for MTC that occurs in the neck only. However, early diagnosis and treatment can improve the chances of survival.

Background: Radiofrequency ablation has been reported to be effective and safe in reducing benign thyroid volume nodules. Most studies carried out so far were performed on a limited number of large nodules and often a subset of them required more than one single treatment. Case report: We describe the case of 82-year-old woman with a very large volume thyroid nodule treated with a single session of thyroid radiofrequency ablation. After six months, the patient showed significant improvement of compression symptoms and significant volume reduction of 68% (from 152 mL to 48 mL). Methods: To our knowledge, this is the first case report so far that proves the effectiveness and safety of radiofrequency ablation in such a large thyroid nodule. Conclusions: Radiofrequency ablation is very effective technique for the percutaneous treatment of thyroid nodules. Further data are needed to define the effectiveness and the feasibility in treating large thyroid nodules.

IntroductionPrimary thyroid lymphoma is extremely rare and accounts for <5% of all thyroid malignancies, with an estimated incidence of 2 per 1 million each year. It usually occurs in patients with preexisting Hashimoto thyroiditis and commonly presents between 60 to 70 years. Almost all thyroid lymphomas are non-Hodgkin's lymphoma of B-cell origin, with diffuse large B-cell lymphoma being the most common subtype. Chemotherapy and radiotherapy are the primary treatment of thyroid lymphomas. This case report shows a dramatic response to chemotherapy in a patient with mechanical airway obstruction due to large thyroid lymphoma, which facilitated her extubation.Case PresentationAn 83-year-old woman with a past medical history significant for type 2 diabetes, coronary heart disease, and hypothyroidism controlled on L-thyroxine replacement therapy was presented with 3 months history of gradually progressive dysphagia. It was associated with left-sided neck pain with swallowing, choking on food, and shortness of breath. She denied fever, chills, or excessive sweats. Local examination of her neck revealed a large firm thyroid mass associated with left cervical lymphadenopathy. Her CT neck scan with intravenous contrast showed an enlarged, probably malignant thyroid gland with marked amount of adjacent pathologic lymph nodes and marked transverse narrowing of the trachea to approximately 8.6 mm with no retrosternal extension. Also, Her CT abdominal scan with intravenous contrast showed a 3.6 cm lesion of the medial right hepatic lobe (segment 8) concerning for metastases. The patient underwent an ultrasound-guided thyroid biopsy, and the results confirmed the diagnosis of diffuse large B cell lymphoma of the neck and thyroid. A few days later, the patient experienced respiratory distress and failure secondary to mechanical airway obstruction that required urgent intubation and mechanical ventilation. The discussion among different specialties, including general surgery, concluded that the patient was not a candidate for surgical intervention or tracheostomy, and recommendations were to proceed to palliative chemotherapy. She started R-CHOP chemotherapy (Rituximab, Cyclophosphamide, Doxorubicin, Vincristine, and Prednisone), followed by a marked reduction in the thyroid size and relieving of the tracheal compression on the following CT neck scan. Her condition dramatically improved, and she was extubated after 5 days of receiving the first cycle of R-CHOP chemotherapy.ConclusionOur case report demonstrates dramatic reversal of mechanical airway obstruction caused by a thyroid lymphoma within a few days of initiation of R-CHOP chemotherapy. These cases are usually considered terminal and do not undergo aggressive surgical interventions. R-CHOP chemotherapy needs to be considered in these cases before considering hospice care.Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m., Saturday, June 11, 2022 1:12 p.m. - 1:17 p.m.

Severe upper airway obstruction due to thyroid cancer is often related severe hypoxia and hypercarbia during anesthesia induction. Attempts to insert an endotracheal tube or a bronchoscope may cause complete immediate airway obstruction. We anesthetized two patients. One had a large mediastinal thyroid mass which compressed trachea and caused near complete obstruction, and the other patient had a large papillary thyroid cancer, which had invaded larynx and compressed the upper trachea. Patients were sedated with fentanyl 150 i.v. and a target controlled infusion (TCI, 1.8/ml) of propofol. A femorofemoral cardiopulmonary bypass was performed under local anesthesia. After bypass, the propofol TCI concentration was increased to 3.5/ml, and fentanyl 500 and vecuronium 6 mg were injected. Ventilation was performed using a laryngeal mask in one patient, and a laryngeal tube in the other. After removing the tumor mass, the airway was secured, and the cardiopulmonary bypass discontinued. All patients recovered uneventfully and were discharged. We discuss the management of severe upper airway obstruction and the usefulness of cardiopulmonary bypass.

We present a case of large, symptomatic lingual thyroid which was successfully and safely removed via a transoral approach, using the da Vinci robotic system, in an academic medical centre in Singapore. A 17-year-old female adolescent presented with a large lingual thyroid causing upper airway obstruction. She underwent robotic, minimally invasive, transoral resection using the da Vinci system. Post-operative recovery was uneventful; she was able to commence oral feeding almost immediately, and was discharged from hospital on the fourth post-operative day. It is surgically feasible and safe to undertake transoral robotic resection of a large lingual thyroid. This approach may allow faster recovery and shorter hospitalisation for patients. Surgical safety requires a full understanding of the intralingual neurovascular anatomy.

Thyroid storm (TS) is a life-threatening exacerbation of the hyperthyroid state. Acute airway obstruction is a life-threatening disease that requires emergency intervention. The present report describes a case of concomitant TS (Burch-Wartofsky Point Scale score, 70 points; thyroid-stimulating hormone, <0.01 µIU/ml; free triiodothyronine, 30.8 pmol/l; and free thyroxine, 106.7 pmol/l) and acute airway obstruction in a 63-year-old female patient. Although treating the TS was viewed as the primary medical concern, the airway obstruction induced by the large thyroid also needed to be solved urgently. In the present case, thyroidectomy was immediately performed, following which the TS was controlled by medical treatment (propylthiouracil, sodium iodide, hydrocortisone and esmolol). After the surgery, the airway obstruction and TS were alleviated, before the patient was eventually discharged from the hospital 14 days after surgery. At 1 month after discharge from the hospital, the patient had normal thyroid function with oral intake of levothyroxine tablet and did not complain of dyspnoea. The present case report aims to emphasize the need for the heightened awareness of patients with TS and trachea stenosis, and underscore the importance of solving the airway obstruction accompanying the TS.

Introduction Awake fiberoptic bronchoscopy has long been considered the criterion standard for the management of difficult airways because of large thyroid malignancies. After an unsuccessful attempt to intubate with a fiberoptic bronchoscope in the supine position, the decision to switch to the left lateral position was made. We present this case to propose the utilization of the lateral position for awake intubation. Case presentation We report a rare case of a patient with a large papillary carcinoma of the thyroid planned for surgical excision. The patient presented to our hospital with complaints of difficulty breathing while lying down in the supine position and oozing blood from the necrotic tissue. The breathing difficulties subsided in the lateral position. Conclusion We demonstrated how the left lateral position with an adjunct maneuver facilitates intubation in large thyroid malignancies.

A 75-year-old woman with a longstanding history of a substernal thyroid goiter presented with acute shortness of breath, and she was intubated due to respiratory distress. Computed tomography (CT) scan revealed a compressive substernal goiter with associated vascular compression, axillosubclavian thrombosis, and saddle pulmonary embolism. Weight-based heparin was immediately administered, and the patient subsequently underwent successful thyroidectomy via a cervical incision. This case report of a rare saddle pulmonary embolism associated with a substernal thyroid goiter underscores the importance of early elective thyroidectomy. Successful management of these potentially devastating pulmonary emboli (PE) associated with large substernal goiters is possible. How to cite this article Nelson DW, LoPinto M, Sidani C, Lew JI. Large Substernal Thyroid Goiter Associated with Saddle Pulmonary Embolism. World J Endoc Surg 2016;8(3):214-216.

A case report of a 36-year-old patient who presented with seizures, a large thyroid and decreased consciousness level requiring admission to the intensive care unit, where the final diagnosis had a prevalence of 2.1/100,000 and a female to male ratio of 4:1. The final diagnosis was suggested early by a focussed internet search. This is unusual because as clinicians we often tell the general public to ignore an internet search. The early suggestion demonstrated that in the right hands the use of internet searches can help us make more informed decisions and aid patient management when combined with traditional investigative medical practice. However, the lesson with this case is that there are many unusual and rare causes of presentations to critical care units and as clinicians we should keep an open mind and wide differential diagnosis so as not to miss the rarer reasons for these presentations.

Securing a definite airway for anaesthetic management in patients with tracheal compression is a real challenge to an anaesthetist. Many case reports illustrates acute airway compromise in the course of anaesthesia due to tumor related compression. We describe the anaesthetic management of a massive retrosternal goiter with severe intrathoracic tracheal narrowing scheduled for thyroidectomy.

Primary thyroid lymphoma is an extremely rare thyroid malignancy that usually occurs in patients with preexisting Hashimoto thyroiditis and commonly presents in older women. The most common type is non-Hodgkin's lymphoma of B-cell origin, particularly diffuse large B-cell lymphoma (DLBCL), which is primarily treated with chemotherapy and radiotherapy. We reported an 83-year-old woman with a past medical history of hypothyroidism who suffered dysphagia and dyspnea secondary to a large thyroid mass. Her CT neck scan showed an enlarged thyroid mass with pathological cervical lymphadenopathy and marked tracheal narrowing. The ultrasound-guided biopsy confirmed the diagnosis of DLBCL of the thyroid. A few days later, she experienced respiratory distress and failure that required endotracheal intubation and mechanical ventilation. She was not considered for tracheostomy or surgical interventions, and after discussion with her family, the decision was made to start R-CHOP therapy (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone) which resulted in a marked reduction of the thyroid size and reversal of the mechanical airway obstruction, enabling her extubation. This case report demonstrated the dramatic response of a large thyroid lymphoma to R-CHOP therapy, reducing the thyroid size and its fatal obstructive complications, including mechanical airway obstruction, within a few days of the initiation of R-CHOP therapy.

The diagnosis and treatment of hypothyroidism during the fetal period may decrease perinatal morbidity and are believed to be important to optimize growth and intellectual development. Herewith a case report of fetal goitrous hypothyroidism is presented in a euthyroid mother, detected at 34 weeks' gestation by ultrasonography, and treated with intra-amniotic levothyroxine injections. The mother had two previous consecutive pregnancies (13 and 8 years ago), also complicated by the occurrence of fetal goiter, resulting in tracheal compression, asphyxia, and early neonatal death in the first and in an emergency cesarean section delivery, because of fetal malpresentation, in the second neonate affected by congenital hypothyroidism (CH). The present male newborn, although born without observable goiter, had a large thyroid on ultrasonography and an early rise of his peripheral venous blood thyrotropin confirmed the diagnosis of CH. Low serum thyroglobulin in the proband and his older brother and parental consanguinity was mostly compatible with a thyroglobulin defective synthesis and secretion as the cause of CH and fetal goiter. Despite apparently sufficient dose of intraamniotic levothyroxine injections repeated weekly from 34-37 weeks' gestation (i.e., four injections of 500 microg levothyroxine), neonatal bone age on the second day of life showed delayed skeletal maturation.

The presence of a pelvic mass with suspicious clinical and sonographic features associated with elevated levels of CA 125 may be suggestive of gynecological malignancy even in fertile women. However, there are benign conditions of the ovaries and uterus that are associated with increased concentrations of serum CA 125. Some of these conditions show an altered sonographic pattern and can mimic pelvic cancer. One such condition is struma ovarii which may lead to suspicion of an ovarian malignancy since all the signs are present. A 31-year-old woman was admitted to the Institute of Gynecology of Messina University in September 1998. Four weeks prior to referral, she had undergone a voluntary termination of pregnancy. An ultrasound scan performed on that occasion revealed a pelvic mass with a diameter of a few centimeters. At admission, she complained of a slight lower abdominal pain and pelvic examination revealed a tender mass in the left adnexal region with a quite normal sized uterus. No symptoms or clinical signs that might suggest thyroid hormone imbalance were present. An ultrasound scan revealed that the uterus and the right ovary were normal in size and morphology; in the left adnexal region there was an 11 cm solid/cystic mass. MRI confirmed ‘the presence of a 10×11×9 cm pelvic mass in L5-S1scan showing a nodular component with necrotic features and some small calcifications.’ Free fluid was present. The detection of serum CA 125 levels showed a value of 689 U/ml. The other hematological and biochemical tests were normal and a chest X-ray was negative. Some days later the patient underwent laparotomy. At operation about 300 ml of ascitic fluid was drained off and then submitted for cytological analysis. An irregular cystic mass in the left ovary measuring 10×9 cm was found. The tumor was removed through a salpingo-oophorectomy and sent for frozen section assessment. All abdominal and pelvic organs were examined and the results were normal. The frozen section reported a benign multicystic lesion with thyroid tissue (struma ovarii) (Fig. 1). The ascitic fluid was negative for malignant cells, and pathology confirmed a benign struma of the left ovary. Present ovarian lesion. Architectural pattern of a ‘struma ovarii’ inside which are patent by both large and small thyroid follicles. These contain colloid-like material while an inflammatory infiltrate occurs everywhere in the interstitium (H.E. original magnification ×125). Post-operative recovery was uneventful. Serum CA 125 levels decreased to 52 U/ml three days after surgery and returned to normal after a week. Thyroid function tests performed only after surgery were within normal limits. The patient was discharged after 7 days. Struma ovarii is a rare benign tumor of the ovary. Although thyroid elements have been described in almost 20% of the cases of dermoid cysts, the term ‘struma’ is used when the thyroid tissue constitutes more than 50% of the tumor (1). Struma ovarii usually presents itself with abdominal and pelvic symptoms of a mass. In some cases it can develop ascites and hydrothorax (pseudo-Meigs syndrome), and in a small percentage an endocrinological activity may be present (2, 3). Recently, some authors have reported cases of struma ovarii associated with ascites, pleural effusions and elevated serum CA 125 levels (1, 4). Our case shows analogies with the few cases reported in the literature (1-3). It differs in some important respects. Firstly the patient’s age, which is much lower than that when the majority of these tumors occur i.e. in the fifties. Our patient’s desire to preserve fertility raised an additional problem, as the few cases reported in the literature concern postmenopausal women who had no need of a planned conservative surgery. Secondly, the growth of the pelvic mass was rather swift, probably due to the concomitant initial pregnancy. Thirdly, the absence of pleural effusion, in our opinion, was due to the early diagnosis and timely treatment. Finally, this clinical report emphasizes that there are benign gynecological conditions which may manifest themselves in different ways and may show clinical, ultrasonographic and biochemical signs suggestive of malignancy (5, 6). For these reasons it is wise to behave with caution in the assessment of pelvic masses, particularly in patients of fertile age who wish to preserve their fertility.

Medullary carcinoma of the thyroid is a rare neuroendocrine carcinoma that originates from the malignant proliferation of parafollicular C cells. In almost 100% of the cases, medullary carcinoma of the thyroid is associated with high levels of calcitonin and carcinoembryonic acid (CEA). Both carcinoembryonic antigen and calcitonin are used for the diagnosis and surveillance of medullary carcinoma of the thyroid. Calcitonin-negative medullary carcinoma of the thyroid is an extremely rare entity that is characterized by classic medullary carcinoma of the thyroid morphology without raised serum calcitonin levels. We describe the case of a middle-aged lady who presented with a few-month history of neck swelling associated with compressive symptoms. CT of the neck showed a large right thyroid nodule with central necrosis and retrosternal extension to the superior mediastinum. There was also a 360-degree encasement of the right common carotid artery. She underwent fine needle aspiration (FNAC) of the right thyroid nodule, and histopathology showed typical features of medullary carcinoma of the thyroid. Immunohistochemical staining for calcitonin and carcinoembryonic antigen was negative but positive for other neuroendocrine markers, i.e., synaptophysin and chromogranin A. Serum calcitonin and carcinoembryonic antigen levels were also in the normal range. So, a rare diagnosis of calcitonin-negative medullary carcinoma of the thyroid was made. As the disease was inoperable because of vascular encasement, a plan for external beam radiation therapy (ERBT) to the neck was made. Medullary carcinoma of the thyroid with normal serum levels of calcitonin is a very rare entity, with only a few cases reported in the literature. In this case report, we have presented a rare case of medullary thyroid carcinoma (MTC) with normal-range serum calcitonin levels, how it was diagnosed, and how to follow up postoperatively.

Medullary thyroid carcinoma (MTC) is a rare cause of chronic diarrhea. When systemic symptoms such as diarrhea occur, distal metastasis often exists. The most common clinical presentation of MTC is solitary thyroid nodule. It was uncommon that chronic diarrhea as initial presentation of MTC without visible thyroid nodule. A 66-year-old woman suffered from watery diarrhea for 4 months. Irritable bowel syndrome was impressed initially. Water diarrhea persisted for another one year under medical treatment. Abdominal echography showed a 6.9cm non-cirrhotic hepatic tumor unexpectedly. Finally, core-needle biopsy for the hepatic tumor revealed metastatic medullary thyroid carcinoma. Physical examination revealed a palpable nodule in left thyroid lobe. Further thyroid ultrasonography disclosed multiple nodular goiter and the largest left thyroid nodule had punctate microcalcification. Fine needle aspiration cytology confirmed the diagnosis of MTC. Palliative surgery with total thyroidectomy, and liver bi-segmentectomy were done. After palliative surgery, watery diarrhea was partially improved. (J Intern Med Taiwan 2014; 25: 25-29)