A Tale of Three Cases When Thyroid Cancer Does Not Exist but Metastases Do. A Three-Case Series of Metastatic Follicular Thyroid Carcinoma

Background: Follicular and papillary thyroid carcinomas represent the majority of all malignancies of the thyroid gland. However, follicular thyroid carcinoma (FTC) is much more difficult to diagnose and manage than its papillary counterpart. Among other factors this could be explained by changing diagnostic criteria and by FTC potential for remote distant and often unpredictable metastases sites. Clinical Cases: In our high volume major academic referral center we have encountered three intriguing cases of metastatic FTC with negative surgical thyroid pathology. The first patient is a 61-year-old woman, who at age 50 was diagnosed with 5.4x3.5x4.2 cm left thyroid nodule (TN). FNAB reported hyperplastic nodule versus follicular neoplasm, subsequent surgical pathology report after lobectomy showed hyperplastic nodule. At age 58 she developed a pathological fracture of the 5th thoracic vertebra and pathology report indicated follicular carcinoma of thyroid origin. TG level at this time was 577 ng/ml. Pathology report from completion thyroidectomy again showed nodular hyperplasia, but reexamination of previously resected lobe demonstrated minimally invasive FTC. The second patient is an 83-year-old woman who at age 68 underwent lobectomy for left sided-goiter, pathology report showed benign follicular adenoma. At age 77 she was found to have right-sided skull mass which was determined to be a follicular carcinoma of thyroid origin. Pathology report from completion thyroidectomy was consistent with nodular hyperplasia. At age 82 the patient was noticed to have increased RAI uptake in thyroid bed, sternum, kidneys, and gastroesophageal junction. TG level at this time was 2214 ng/ml. The third patient is a 56-year-old woman initially diagnosed with a 3.5x2.8x2.2cm right TN at age 53. Lobectomy, performed for diagnostic and therapeutic purposes, showed benign follicular adenoma. At age 56 she developed a pathological fracture of the 3rd thoracic vertebra, follicular carcinoma of thyroid origin was shown on pathology report. TG level at this time was 1694 ng/ml. The patient underwent completion thyroidectomy demonstrating multinodular hyperplasia. Conclusion: This case series emphasizes on the pitfalls of follicular neoplasms diagnosis and management. We suggest prolonged clinical and biochemical surveillance of the patients with what appears to be follicular adenoma after lobectomy. Following serum thyroglobulin perhaps represents the most cost-effective surveillance approach of those patients.

A Review and Report of Peripheral Giant Cell Granuloma in a 4-Year-Old Child

Peripheral giant cell granuloma is a common benign and reactive gingival epulis in oral cavity. It is often difficult to make a clinical diagnosis; thereby definitive diagnosis depends on histopathologic features. We report a case of a 4-year-old Caucasian boy presenting with a five-month history a 20 × 15 × 12 mm pedunculated, lobular soft tissue mass of the left anterior maxilla gingiva which was misdiagnosed and maltreated before his referral. An excisional biopsy of the lesion followed by histopathologic examination of the biopsy specimen revealed distinctive features of peripheral giant cell granuloma. Early detection and excision of this hyperplastic nodule especially in children are important to minimize potential dentoalveolar complications.

Thyroglobulin Gene Mutation with Cold Nodule on Thyroid Scintigraphy

Thyroglobulin gene mutation is a rare cause of congenital hypothyroidism, but thyroglobulin gene mutations are thought to be associated with thyroid cancer development. A 21-year-old Japanese man treated with levothyroxine for congenital hypothyroidism had an enlarged thyroid gland with undetectable serum thyroglobulin despite elevated serum TSH level. The patient was diagnosed with thyroglobulin gene mutation, with compound heterozygosity for Gly304Cys missense mutation and Arg432X nonsense mutation. Ultrasonography showed a hypovascular large tumor in the left lobe that appeared as a cold nodule on thyroid scintigraphy. He underwent total thyroidectomy, but pathological study did not reveal findings of thyroid carcinoma, but rather a hyperplastic nodule with hemorrhage. Strong cytoplasmic thyroglobulin immunostaining was observed, but sodium iodide symporter immunostaining was hardly detected in the hyperplastic nodule. The clinical characteristics of patients with thyroglobulin gene mutations are diverse, and some patients are diagnosed by chance on examination of goiter in adults. The presence of thyroid tumors that appear as cold nodules on thyroid scintigraphy should consider the potential for thyroid carcinoma, if the patient has relatively low serum thyroglobulin concentration in relation to the degree of TSH without thyroglobulin autoantibody.