Challenging case: Diagnosing thyroid cancer

thyroid-cancer

The Thyroid Program at Boston Children’s Hospital is one of the first and largest centers in the United States exclusively devoted to the care and treatment of children with thyroid diseases. The expertise of a comprehensive, integrated team — including endocrinology, radiology, surgery, nuclear medicine, oncology and pathology, as well as oncologists from the Rare Tumors Program at Dana-Farber/Boston Children’s Cancer and Blood Disorders Center — attracts patients from across the country and around the world.

Challenging case: Diagnosing thyroid cancer

thyroid-cancer-scan
FIG. 1 Radioactive iodine scan showing abnormal areas of uptake
in the thyroid bed and left neck (arrows), representing residual
thyroid cancer.

A female patient presented at age 11 to an endocrinologist in Puerto Rico for poor growth. Her doctor noted left neck swelling with enlarged lymph nodes in the neck. Ultrasound showed a left thyroid nodule, and biopsy was consistent with papillary thyroid cancer.

Her endocrinologist referred her to Boston Children’s Hospital for further care, managed by Ari J. Wassner, MD, director of the Thyroid Program. Her evaluation revealed multiple abnormal lymph nodes in the left neck that contained metastatic thyroid cancer.

A total thyroidectomy and removal of the metastatic lymph nodes was performed by Robert Shamberger, MD, chairman of the Department of Surgery.

She was treated with thyroid hormone and frequent laboratory monitoring by her endocrinologist in Puerto Rico, who communicated frequently with Wassner to collaboratively manage her thyroid hormone treatment. She then had radioactive iodine therapy administered in collaboration with nuclear medicine.

thyroid-cancer-image
FIG. 2 Ultrasound showing the abnormal lymph node in the
left neck (arrow). Biopsy proved that this contained metastatic
thyroid cancer, and it was removed surgically with intraoperative
ultrasound guidance.

The patient returned one year later to Boston Children’s for follow-up, where ultrasound specialists discovered residual thyroid cancer growing right up against her trachea.

This was removed by Shamberger, and she received an additional dose of radioactive iodine. This treatment (which includes another scan) allowed the nuclear medicine specialist to discover a previously unsuspected lymph node with metastatic thyroid cancer in the left neck (Fig. 1). When this lymph node did not respond to radioiodine therapy, a third surgery was recommended. Utilizing intraoperative ultrasound guidance by an ultrasound expert — a highly specialized technique available in our program — Shamberger was able to find and remove the lymph node (Fig. 2), which was positive for thyroid cancer.

thyroid-cancer-scan 2
FIG. 3 Postoperative radioactive iodine scan showing resolution
of prior foci of thyroid cancer.

At age 16, the patient returned for her most recent visit to Boston, and this time her ultrasound and radioactive iodine scan showed no more evidence of thyroid cancer (Fig. 3). While she continues to require ongoing monitoring, at this point her long-term prognosis is excellent.

Conclusion

Collaborative, multidisciplinary care has produced an excellent outcome for this patient with metastatic thyroid cancer. Throughout her course, the patient’s care has been managed effectively through close collaboration between her endocrinologist in Puerto Rico and her Thyroid Program endocrinologist.

Learn more about the Thyroid Program at Boston Children’s Hospital.

thyroid-cancer-wassner

About our expert: Ari J. Wassner, MD is an endocrinologist at Boston Children’s Hospital, director of the Thyroid Program and assistant professor of Pediatrics at Harvard Medical School. He is a graduate of Harvard Medical School and completed pediatric residency and endocrinology fellowship training at Boston Children’s.