A 70-year-old female with known schizophrenia presented in hyperthyroid crisis. Examination revealed muscle wasting, tremor, sweating, low-grade fever, and sinus tachycardia. Biochemistry confirmed the diagnosis (TSH <0.1 mlU/l, thyroxine 41 pmol/l (925), tri-iodothyronine 25 pmol/l (3.56.5)). The patient was commenced on i.v. esmolol and carbimazole (40 mg) crushed into warm milk.
However, lacking mental capacity, and refusing to take all medication, she underwent emergency thyroidectomy. The thyroid was recognised to be malignant intra-operatively, so total thyroidectomy and extensive lymph node dissection was undertaken. A histological diagnosis of follicular thyroid carcinoma was made (FTC pT4c N0 (0/8) Mx STAGE IV).
Postoperative thyroid hormone levels proved difficult to control with high dose thionamides. CT and NM imaging revealed a large (8×10×12 cm), highly vascular, hepatic metastasis, as well as persistent neck disease. Radioiodine therapy was determined to be inappropriate, due to her overactive status, the likelihood of all 131I being retained in the hepatic lesion, and as the patient required one-to-one nursing due to her psychiatric condition.
The patient was unfit for hepatic surgery, so underwent percutaneous arterial embolisation, with the aim of tumour debulking and amelioration of symptoms. This has allowed palliative control of the thyrotoxic state with carbimazole and thyroxine, and concomitantly improved the patients psychiatric condition. Her psychiatric team, and family (predominantly living abroad), were included in all stages of treatment.
This case presents an unusual history of thyroid follicular malignancy, coupled with significant psychiatric disease. Management decisions highlight the benefit of discussion though Network Multidisciplinary teams, and access to/ consideration of all available treatment options. Hepatic metastases are a relatively unusual feature of follicular thyroid cancer, but like other neuroendocrine hepatic disease may be hyperfunctioning. Cases have previously reported radiofrequency ablation or hepatic surgery as alternative approaches to their treatment.