An 80-year-old white woman was referred to the Department of Surgery for a symptomatic thyroid nodule (Fig. 1). The nodule had been diagnosed four years earlier by US, which revealed a solid and well defined heterogeneous formation in the right hemithyroid, measuring 33 x 21 mm, containing an area of cystic degeneration. The patient was asymptomatic at that time, with a euthyroid status. FNAB guided by US of the thyroid nodule was performed and the cytological examination was inconclusive. Given the age of the patient, comorbidities and her asymptomatic status, surveillance was decided.
Her medical history included hypertension, dyslipidemia, obesity, paroxysmal atrial fibrillation, pulmonary tuberculosis, chronic thrombocytopenia and RCC nine years ago, treated by a radical nephrectomy. The tumor removed was 5 cm in size; it was located in the upper pole of the right kidney and a clear cell carcinoma was reported, of Fuhrman nuclear grade 2. The patient's postoperative course and subsequent recovery were uneventful. Neither postoperative chemotherapy nor interferon was proposed.
During follow-up, a computed tomography (CT) scan revealed a 20 mm vascularized nodule in the middle portion of the pancreas body (Fig. 2).
A subsequent magnetic resonance imaging (MRI) identified a solid nodule in the transition between the pancreatic body and tail, measuring 20 x 13 mm, with an enhancement pattern suggestive of a neuroendocrine origin (Fig. 3). An octreotide scintigraphy was performed identifying a focus of anomalous hyper-expression of somatostatin receptors, with increased uptake in the pancreas and the right lobe of the thyroid. In order to rule out von Hippel-Lindau syndrome a cerebral MRI was done, as well as ophthalmologic evaluation, which were normal.
In 2012 the patient remained euthyroid but the appearance of symptoms, such as cervical pain and hoarseness, led to a new FNAB guided by US that once again was inconclusive. Cervical examination revealed a nodule in the right lobe of the thyroid, measuring about 3 x 3 cm. Due to the symptoms, a hemithyroidectomy and isthmectomy was performed. The resection was carried out without difficulty after identifying superior and inferior right parathyroid glands and the right laryngeal recurrent nerve (Fig. 4). The postoperative course was uneventful. After 11 months, the patient was doing well and had not developed any additional metastasis. The follow-up CT-scan showed an increase in the size of the nodule in the body of the pancreas previously identified, and a new one in the head of the pancreas with similar characteristics. After the multidisciplinary team discussion no further investigation or treatment was proposed due to patient's age and comorbidities.