Hurthle Cell Neoplasm Case Study

[zoralsurgeon]

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Hey guys, here's a case study I read in a study guide..NOT homework. Any feedback is greatly appreciated.

Patient presented with a large mass (4.5cm X 3.7cm x 3.5cm) on left lower lobe of thyroid gland. Patient is a male, 21 years of age in good health with no other complications.

Ultrasound was conducted and a fine needle biospy was suggested.

Upon pathological analysis, the specimen consisted almost entirely of hurthle cells, some of which were in microfollicular groups. Features of papillary carcinoma were NOT present.

Differential diagnosis included:
adenoma, carcinoma, less likely hurthle cell rich region of a non-neoplastic process.

1.) What would be recommended for this patient?

I was thinking a complete excision of the lesion, possible total thyroidectomy.

2.) Should this patient be treated by an ENT or some other type of endocrine surgeon?

3.) Would you have any other recommendations for this patient?

 

[Jolie South]

Yea, you can't really tell if it's follicular carcinoma without a core-biopsy or excision of the mass itself because that's determined by architecture, which you don't get on FNA.

For a board question, You'd have to go to excision to determine whether this is adenoma or carcinoma. I don't know if you'd go directly for total vs. lobectomy then proceed to total if you get a diagnosis of carcinoma.

These days, I think ENTs are typically the folks doing thyroids, though I know the old school general surgeons do them too.

Other recommendations: For post-op, all the stuff that you'd expect post thyroidectomy: possible hypocalcemia, hoarseness from damage to recurrent laryngeals, and necessary thyroid replacement with levothyroxine +/- radioablation.

 

[Smurfette]

1. you don't core needle biopsy the thyroid...FNA it. Core needles bleed too much in the very vascular thyroid, and the neck is really not a location where you want to be doing larger bore biopsies as there are way too many other structures around.

2. for suspected hurthle cell, do a lobectomy first. Can do completion thyroidectomy if path dictates it (i.e. malignant). Final path may not have hurthle cells, but be follicular or papillary tissue (benign or malignant).

3. Thyroids are a turf war between general surgery and ENT which are determined more by referral patterns than anything else. Both are trained to do them. Where I trained, the gen surg guys did the majority of the thyroids and parathyroids. You can refer to either, but in the real world, they are normally sent to the guy who does the higher volume of these cases (assuming all other things equal...outcomes are better with higher volumes). You can send the patient to an endocrine surgeon as well (these are general surgeons). You will not be asked on a test to pick between one surgeon or another...the point is more to recognize that you need a tissue diagnosis, and refer to a surgeon (ENT/endocrine/general).

4. Usually these patients also get thyroid function tests and a family history to r/o MEN syndromes and other endocrine pathologies (most people do this before FNA results!). Patient needs typical counseling about thyroid nodules (i.e. if benign on surgery, no more needed, if malignant, will need add'l surgery to remove remaining gland and need synthroid for life).