Endocrine Abstracts

Introduction: Recent studies have revealed that thyroid autoimmunity and thyroid cancer may coexist, although a pathogenic relationship has not been clearly established. Graves’ disease (GD) is an autoimmune thyroid disease and is considered the most common cause of hyperthyroidism. Thyroid cancer is the most common malignancy of the endocrine system and represents the eighth most diagnosed cancer worldwide. Although in patients with GD, the presence of thyroid nodules is not uncommon, thyroid cancer is a very rare occurrence.

Case report: We report the case of a 46-year-old male patient, diagnosed with Graves disease, Graves orbitopathy, and a micronodular goiter in 2018, with two hypoechoic nodules in the right lobe, with a maximum of 0.92/0.67/0.90 cm, and another in the left lobe, measuring 0.45/0.50/56 cm. Thyroid function was effectively controlled with thiamazole, and the morphology was evaluated through periodical cervical ultrasound (US). At the last follow-up in November 2023, the US showed the rapid enlargement of the nodules, with more than 1 cm since the last follow-up in 2022, with hypoechogenicity, microcalcifications, poorly defined margins, and irregular appearance, associated with bilateral lymphadenopathy. Elastography displayed an Asteria score of 3 in strain elastography, indicating a high level of suspicion. A decision was made for the patient to undergo a total thyroidectomy with lymph node dissection. The pathological evaluation following the procedure described multifocal classical papillary carcinoma in both thyroid lobes with lymph node metastasis (pT1b(m)N1aL/V0Pn0Ro). Following surgery, the patient is due to receive radioactive iodine therapy and thyroid-stimulating hormone suppression therapy with levothyroxine.

Conclusion: The case reported highlights the fact that, although rare, the risk of thyroid cancer in patients with both GD and thyroid nodules exists. Further studies are needed to assess if there could be a causal relationship between these entities and the prevalence of thyroid cancer among patients with GD. Clinicians should consider careful evaluation, including ultrasound, nuclear imaging, and fine needle aspiration, when appropriate, in patients with GD and thyroid nodules, as there is no consensus or recommended protocol for the detection of thyroid cancer in these patients.