Thyroid Cancer 101:
ALWAYS GET OUTSIDE OPINION BEFORE HAVING THYROID SURGERY FOR NODULES OR CANCER.
The wrong diagnosis or treatment can result in your death.
In a Time of Too many biopsies on small thyroid nodules comes a patient with a very big nodule that was watched because the physicians thought the ultrasound image did not warrant a biopsy for years while it continued to grow. HMO’s love to save money by not doing “unnecessary testing. This physician was following orders or get bounced from the HMO. However, the HMO will not like the fact he should have biopsied the patient’s nodule when it was 1.5-2 cm 7 years ago.Now he and the HMO are in serious trouble because failure to make a timely diagnosis of a dangerous cancer with potential deadly outcome is a cause for a malpractice suit.
Patient#3 56 Y/O female comes for an evaluation for non-invasive treatment for her large nodule. She has Hashimoto’s thyroiditis on pig thyroid. Over the years the nodule kept growing and even when it was above 2 cm they did not do a biopsy. Only when it was almost 4 cm did her physician recommend a biopsy. She did not want surgery and came to me for evaluation for radiofrequency ablation thinking it could not be cancer because they told her it was benign for years and did not need a biopsy.
Except for a FHX of a mother with prior thyroid surgery that was benign years ago and her over use of iodine supplements she was healthy on no other medications.
PE: large visible right nodule.
Firm on examination, and no palpable lymph nodes but tracheal deviation to left from the nodule. TSH normal with elevated TPO antibodies 597 N < 9 and normal thyroglobulin 22.4. Calcitonin >3000, and CEA was 200. The molecular markers by Interpace DX was positive for KRAS and suspicious classifier. The result was highly positive for cancer favoring MCT.
Ultrasound images of a hyperechoic nodule with indistinct capsule and 4+ Doppler blood flow.Lymph node evaluation found a suspicious 8 mm lymph node in the left neck with abnormal blood flow.
USGFNA of the lymph node was positive for spindle cells with salt and pepper nuclei and eccentric nuclei consistent with medullary thyroid cancer.
The nodule also showed the same spindle cell lesion consistent with medullary thyroid cancer.
Hypercellular cytology on low power.
Classic tilted fry pan with yolk at the edge for medullary thyroid cancer, and a spindle cell with extreme eccentric nuclei.
Medullary thyroid cancer is less than 5% of all the thyroid cancers. However it carries a worse prognosis. Calcitonin blood test can find it early, but it is not recommended on all thyroid nodules. It has a tendency to travel to lymph nodes early. Finding one when it is small requires that a biopsy be done and the pathology does not miss the diagnosis calling it a Hurthle cell or follicular carcinoma.
In my practice I have seen 3 patients miss-diagnosed as follicular cancers.
- Patient #1 was treated for the wrong cancer for years before the correct diagnosis was made. She was treated with radioiodine and only after recurrent disease in the neck was the diagnosis made.It was years later and the cancer had spread to her liver. She died and Kaiser and the physicians lost a suit to the tone of over one million.I reviewed the case as an expert witness and the very first needle biopsy of the nodule was obvious it was not follicular but medullary cancer.
- Patient #2 also was told she had follicular cancer and was on the way for surgery and radioiodine when she asked for a second opinion. Again the very first needle biopsy slides made the diagnosis of medullary not follicular cancer. Because she asked for outside opinion she had the proper surgery for medullary not follicular cancer, and her post op thyroidectomy and neck dissection cancer marker was negative for calcitonin.
- Patient#3 is very unusual in that Kaiser physicians used a crystal ball to decide the nodule was not cancer and did not biopsy the nodule as it grew of the last few years. Finally they decided to get a biopsy but by then she was on to having an ablation procedure instead knowing it was benign. The patient was so sure it was benign she wanted to not have surgery but radiofrequency ablation instead. I saw her and was surprised she never had a biopsy with a 5 cm nodule. The first slide on the Dif Quik eRose adequacy assessment was positive for spindle cells with salt and pepper eccentric nuclei and pink granules for meduillary cancer. Delaying the diagnosis because no biopsy was done when the nodule was 1-2 cm in size may result in advanced medullary cancer that may kill her. Shame on the physicians that did not biopsy the nodule sooner before it spread to the lymph nodes. Most physicians are needle happy to biopsy every nodule causing too many surgeries. This is the rare case of no biopsy causing grave harm to the patient with a rare cancer without to many treatment options.
- Second opinions available by calling or email to 310-393-8860 or firstname.lastname@example.org
- Richard Guttler MD,FACE,ECNU