Medullary Thyroid Cancer MCT 101: Why is the Diagnosis Difficult by Community Based Pathologists?
The answer is that it is rare, the evidence based system says it is too costly to screen all thyroid nodules for calcitonin ( MCT cancer markers), it looks like Hurthle cell or follicular carcinoma to the average pathologist.
Whats the big deal it will be found at surgery anyway? Wrong as the first surgery for thyroid cancer is inadequate for MCT. Total thyroid or partial thyroidectomy is fine for regular thyroid cancers but grossly inadequate for MCT. MCT needs total and modified radical neck surgery as the initial treatment due to high chance of neck lymph node involvement. Also after the thyroid is out you can never get a proper pre-op calcitonin and CEA, unless for blood was frozen ahead.
Being rare is no excuse for missing MCT on the first needle biopsy or even on the on-site adequacy sample.
Examples of missed MCT are shown below.
- Pathologist at a community hospital called it a Hurthle carcinoma. The endocrinologist treated her for 17 years with radioiodine and multiple neck dissections until it was finally diagnosed just before she died. The very first needle biopsy slide I put on the microscope was obvious MCT!
- “Salt and pepper” nuclei of MCT and no nucleoli usually seen in Hurthle cell neoplasm.
- The “tilted fry pan” effect of MCT is shown here. As the yolk moves to the edge of the egg white so does the nuclei in MCT. Also the spindle cells with nuclei in an eccentric location.
- Rapid adequacy on another case was diagnosed with the first eROSE air dried slide.
- Note the spindle cells and pink granules of calcitonin in the cytoplasm and the eccentric nuclei of MCT.
- The second was called a follicular thyroid carcinoma and told to have a her thyroid out and Radioiodine. She was smart and asked for an outside opinion. The ultrasound found abnormal lymph nodes that was also MCT on biopsy.
- She had the proper total TX and bilateral neck dissection and is alive today. The first case died and her estate collected 1.4 million malpractice judgement.
- The third case was just pure malpractice as failure to diagnose this serious cancer in a timely manner to protect her life. 2012 to 2018 she was called a simple benign nodular goiter as her nodule grew from 1.5 she never was sent for a biopsy until it was very large (5 CM ). She came for an opinion about alternative to surgery for her she thought benign nodule. The biopsy was not benign but another MCT. The delay in initial diagnosis could have a negative effect on her survival as it is found in her neck lymph nodes and thyroid. She was referred to a thyroid cancer surgeon, and to a malpractice lawyer.
- ALWAYS GET AN OUTSIDE OPINION BEFORE SURGERY OR RADIOIODINE FOR THYROID CANCER AS THEY BE MISSING MCT OR GIVING YOU THE WRONG TREATMENT FOR REGULAR THYROID CANCER.
- 310-393-8860 or [email protected] for details.
- Richard Guttler MD,FACE,ECNU
- Clinical Thyroiologist