Ömercan TOPALOĞLU, Güldeniz Gizem AÇIKGÖZ, Sakin TEKİN, Barkın MALKOÇ, Esin KAYMAZ, Güldeniz KARADENİZ ÇAKMAK, Taner BAYRAKTAROĞLU

Hipopitüitarizm ile Birlikte Olan Papiller Tiroid Kanserinin Takibinde Zorluk: Olgu Sunumu ve Literatürün Gözden Geçirilmesi

Amaç: Papiller tiroid kanserinin hipopitüitarizm ile birlikte görüldüğü ilginç bir olgu sunuyoruz. Olgu: Kırkaltı yaşında kadın hasta boyun sağ kısmında ele gelen ağrılı sertlik, yutkunma güçlüğü, öksürük ve boğaz ağrısı şikâyeti ile başvurdu. Hastanın 8 yıldır tip 2 diyabet tanısı mevcuttu, 15 yıl önce nonfonksiyone hipofiz adenomu sebebiyle kraniyotomi, 10 yıl önce gamma knife alma öyküsü mevcuttu. Hasta insülin glarjin ve lispro, prednizolon, levotirosin (LT4) kullanmaktaydı. Fizik bakısında önemli bir özellik bulunmadı. Hipofiz MR görüntülemede parsiyel “empty sella” izlendi. Tiroid sonografisinde sağ lob orta kesimde 33x27x30 mm, düzensiz sınırlı, mikrokalsifikasyon içeren solid nodül izlendi. İnce iğne aspirasyon sitolojisinde “malignite yönünden kuvvetli şüpheli yaymalar” saptandı. Öncelikle sağ lobektomi, sonrasında tamamlayıcı tiroidektomi uygulanan hastanın patolojik analizinde papiller tiroid kanseri (PTK) saptandı. Postoperatif radyoaktif iyot (RAİ) tedavisinden 14 ay sonra kontrol sonografisinde sağ tiroid lojunda 30x14x15mm vaskülaritesi kodlanmayan solid alan izlendi. Serbest T4 (sT4), tiroglobulin ve anti-tiroglobulin düzeylerini takip etmeye karar verdik. Komplikasyon veya nüks izlenmedi. Sonuç: Hipofiz yetmezliğinde PTK takibi ile ilgili çalışmalar kısıtlıdır. Biz total tiroidektomi sonrasında RAİ uyguladık ve sT4 düzeyine göre LT4 tedavisi verdik.

Anahtar Kelimeler:

Tiroid kanseri, hipofiz yetmezliği, hipofiz, tiroid, hipopituitarizm.

Difficulty in Follow-Up of Papillary Thyroid Cancer Co-Existent with Hypopituitarism: Case Report and Review of the Literature

Aim: We present an interesting case of papillary thyroid cancer co-existent with hypopituitarism. Case: Fortysix-year-old female was applied with a complaint of painful palpabl lump in the right side of the neck, difficulty swallowing, cough and dyspnea. The patient was diagnosed with type 2 diabetes mellitus 8 years ago, underwent craniotomy for nonfunctioning pituitary adenoma 15 years ago, and received gamma knife 10 years ago. She had been taking insulin glargine and lispro, prednisolone, and levothyroxine (LT4). Physical examination was unremarkable. Pituitary MRI revealed partial empty sella. A solid nodule of 33x27x30 mm with irregular borders and containing microcalcifications in the right thyroid lobe was detected on sonography. Fine needle aspiration cytology revealed “strongly suspicious features for malignancy”. Papillary thyroid carcinoma (PTC) was detected after right lobectomy and then complementary thyroidectomy. Follow-up sonography performed 14 months later than radioactive iodine (RAI) showed an avascular solid area of 30x14x15 mm in the right. We decided to monitor free thyroxine (fT4), thyroglobulin and anti-thyroglobulin levels. LT4 dose was adjusted to keep fT4 level closer to the upper limit of normal. No complications or recurrences were detected. Conclusion: Studies on the follow-up of PTC cases with hypopituitarism are limited. We performed RAI after total thyroidectomy, and treated the patient with LT4 by adjusting fT4 level.

Keywords:

Thyroid cancer, pituitary insufficiency, pituitary, thyroid, hypopituitarism.,

PDF

___

1- Jameson J, Weetman AP. Thyroid Cancer. In: Longo DL. editors. Harrison's Hematology and Oncology. 2nd ed. McGraw Hill; 2013.
2- Perez-Montiel MD, Suster S. The spectrum of histologic changes in thyroid hyperplasia: a clinicopathologic study of 300 cases. Hum Pathol 2008; 39(7): 1080-7. doi: 10.1016/j.humpath.2007.12.001.
3- LiVolsi VA. Papillary thyroid carcinoma: an update. Mod Pathol 2011; 24 Suppl 2: S1-9. doi: 10.1038/modpathol.2010.129.
4- Haugen BR, et al. 2015 American Thyroid Association Management Guidelines for Adult Patients with Thyroid Nodules and Differentiated Thyroid Cancer: The American Thyroid Association Guidelines Task Force on Thyroid Nodules and Differentiated Thyroid Cancer. Thyroid 2016; 26(1): 1-133. doi: 10.1089/thy.2015.0020.
5- Casey MB, et al. Distinction between papillary thyroid hyperplasia and papillary thyroid carcinoma by immunohistochemical staining for cytokeratin 19, galectin-3, and HBME-1. Endocr Pathol 2003;14: 55-60. doi: 10.1385/ep:14:1:55.
6- Vianello F, et al. Follicular thyroid carcinoma with metastases to the pituitary causing pituitary insufficiency. Thyroid 2011; 21(8): 921-5. doi: 10.1089/thy.2010.0335.
7- Gut P, et al. Lack of TSH stimulation in patients with differentiated thyroid cancer - possible causes. Contemp Oncol (Pozn) 2012; 16(3): 273-5. doi: 10.5114/wo.2012.29299.
8- Kuo SF, et al. Concurrent papillary thyroid cancer with pituitary ACTH-secreting tumor. J Formos Med Assoc 2007; 106(4): 330-5. doi: 10.1016/S0929-6646(09)60262-X.
9- Risse JH, et al. Recombinant human thyrotropin in thyroid cancer and hypopituitarism due to sella metastasis. Thyroid 1999; 9(12): 1253-6. doi: 10.1089/thy.1999.9.1253.
10- Cancer Genome Atlas Research Network. Integrated genomic characterization of papillary thyroid carcinoma. Cell 2014; 159(3): 676-90. doi: 10.1016/j.cell.2014.09.050.
11- Kimura ET, et al. High prevalence of BRAF mutations in thyroid cancer: genetic evidence for constitutive activation of the RET/PTC-RAS-BRAF signaling pathway in papillary thyroid carcinoma. Cancer Res 2003; 63(7): 1454-7.
12- Shen X, et al. A six-genotype genetic prognostic model for papillary thyroid cancer. Endocr Relat Cancer 2017; 24(1): 41-52. doi: 10.1530/ERC-16-0402.