Case: A 61 year old female, presented to ENT in July 17 with 6 month history of left sided neck swelling, gradually increasing in size over the last 1 month prior to presentation. She complained of tenderness over the swelling and pain and discomfort around her left shoulder. She denied any problems with her voice, breathing or swallowing. Her past medical history consisted of recurrent UTIs, renal stones and medullary sponge kidney. She smokes 15 cigarettes per day and no family history of thyroid cancer. Examination-Left sided level V lymph nodes were hard and tender. An ultrasound guided fine needle aspiration was suggestive of medullary thyroid cancer (MTC). Despite a recent chest radiograph showing clear lung fields a CT neck and chest showed multiple lung nodules and adrenal deposits suggestive of metastatic disease. She was referred to Endocrinology in August 17 for further investigations; Two urinary metadrenalines, U&Es, TFTs and calcium were all within normal range. CEA 417 (03 mg/l) and calcitonin - 9,000 (015 ng/l) were both grossly elevated. Her case was discussed at the regional thyroid cancer MDT and she underwent bilateral neck dissection and total thyroidectomy in October 17. Histology confirmed metastatic medullary thyroid cancer and an incidental 1.2 mm papillary microcarcinoma. She has made an excellent post operative recovery and her calcitonin 2 months post operatively has improved to 4,970 (015 ng/l). She is on Levothyroxine, alfacalcidol and calcichew post operatively. In view of her normal PTH we would aim to wean her off calcichew and alfacalcidol. Her MEN2 genetic testing was negative. She is awaiting a follow-up CT neck and thorax.
i) What is the most common presentation of MTC?
ii) What is the most important pre-operative investigation in patients with MTC?
iii) What percentage of MTC is thought to be genetic?
iv) What is the role of TSH suppression or high dose radioactive iodine in MTC?
16 - 18 Apr 2018
Society for Endocrinology