GRAVE'S DISEASE AND DIFFUSE THYROID CALCIFICATION: AN UNUSUAL PRESENTATION OF PAPILLARY THYROID CARCINOMA IN AN ADOLESCENT

PAPENDIECK P; VENARA M; MAGLIO S; COZZANI, H.; MATTEOS, FERNANDA; BERGADÁ I; GRUÑEIRO PAPENDIECK, L; CHIESA A

Playa del Carmen

Congreso; XXIV Reuniòn de la Sociedad Latinoamericana de Endocrinología Pediátrica; 2014

Background: Several studies have demonstrated an increased incidence of thyroid cancer in patients with Graves´ disease (1-10%). The main presentation feature of this association is a thyroid nodule, and its management remains an issue of and controversy for those who care for these patients. Case report: A 16 year old girl presented with a diffuse and hard thyroid gland enlargement, tachycardia and weight loss Laboratory evaluation revealed elevated thyroid hormones (T3 > 651 ng/dl, T4 21.5 ug/dl, free T4 5.4 ng/dl), undetectable thyroid-stimulating hormone (TSH 40 UI/L, TPOAb >1000 U/ml andTGAb 1286 U/ml). Cervical ultrasound at initial evaluation showed thyroid gland enlargement with diffuse microcalcifications (snol´l storm appearance) and calcified jugular lymph nodes. She was treated with metilmercaptoimidazol initially to render the patient´ euthyroid. Fine needle aspiration biopsy (FNAB) was performed at random in each thyroid lobe and in one calcified jugular node. Cytology of the thyroid specimens showed thyroid follicular cells arranged in small groups with pseudopapillar structures,the nuclei were enlarged and irregular, some of them had prominent nucleoli and intranuclear pseudoinclusions with central position and abundant calcospherites distributed in a diffuse pattern, scarce HOrthle cells and inflammatory cells, polimorphonuclear cells and lymphoid cells and extended microcalcifications. Lymph node cytology showed normal lymphoid celularity and thyroglobulin (TG) measured in the needle wash out was negative. Lymph node calcifications were strongly suggestive of malignancy; therefore a total thyroidectomy with lymph node resection was performed. Histology revealed a diffuse follicular variant PTCwith several lymph node metastases. Treatment was completed with radioablative therapy with 120mCi 1311 followed by· suppressive dose. Whole body scan revealed no distant metastases. Conclusions: Even when thyroid carcinoma in GD is not frequent, it may be suspected in the presence of thyroid nodules. patient USwas the key tool to suspect the diagnosis although diffuse follicular variant PTC looks like Hashimoto´s thyroiditis sometimes can be easily overlooked. This rare form of PTC typically occurs in young females, with diffuse involvement of oneor both lobes, frequent nodal metastases and usually an aggressive clinical behavior. In this unusual case the presence of asnow storm appearance and lymph node calcifications were highly suspicious of thyroid carcinoma. Although difficult to interpret~nthe presence of patients with GD, in face of the atypical clinical and ultrasound findings FNAB should be always performed.