Endocrine Abstracts

Background

The risk of cancer is relatively higher in Graves’ patients presenting simultaneously with thyroid nodules. Radioiodine (RAI) therapy recommended in intermediate-high risk differentiated thyroid carcinoma may be associated with worsening of a pre-existing Graves’ orbitopathy (GO) or developing a new onset. The impact of RAI therapy in patients with differentiated thyroid cancer on the course of a pre-exisiting GO has not been specifically investigated. we report a sever GO patient treated by recombinant Tsh (RhTSH) for intermediate-risk of papillary thyroid cancers (PTC).

Case

A 47-year-old man, presented to our center with exophthalmos and ptosis of eyes. His thyroid function tests and thyroid autoantibodies were as follows: TSH; 0.01 (0.4–4 uIU/ml), FT3; 5.41 (1.6–4.9 pg/ml), FT4; 1.74 (0.78–1.76 ng/dl); anti TPO was positive TSH-R Ab; 1.249. On the ultrasonographic examination of the thyroid gland the paranchyme was heterogeneous and in the right lobe 11.2 × 8.9 mm heterogeneous, iso-hyporechogenic nodule and pathologic lymphadenopathy were detected in levels 4 of neck. US-guided fine-needle aspiration biopsy was performed and the cytological examination were suspicious for papillary thyroid cance of the nodule and malign sitology of the lymph node. Computed tomography scan of orbita demostrated bilateral anterior bulging of bulbus oculi clearly and bilateral enlargement of medial, inferior and superior rectus muscles and also swelling of the optic nerve. In addition to antithyroid and beta blocker, for severe ophthalmopathy intravenous pulse therapy with high doses of methylprednisolone as 500 mg tapered in 24 weeks duration, followed by 250 mg for 24 weeks. He underwent thyroidectomy and a dissection of the santral and right lateral lymph nodules was conducted. The diagnosis were PTC with < 5% of hobnail variant and mestatic lymph nodules was confirmed. Once stabilized of GO under oral methylprednisolone and became euthyroid he reseved 150 mCi RAI with rhTSH with no changes in GO after One month observation.

Discussion

The risk of cancer is relatively higher in Graves’ patients in the presence of an accompanying nodular disease. Moreover, some authors reported that thyroid cancer associated with GD seemed to be more aggressive. RAI therapy is recommended in high-risk differentiated thyroid carcinoma, but it might worsen or induce a new onset of GO. Glucocorticoid treatment should be given especially in patients who will receive high doses of RAI. RAI with rhTSH had no difference in GO outcome at first month.