Medical Anecdotal Report
Date of Medical Observation: July 2017
A 40-plus-year-old female with history of subtotal thyroidectomy (total lobectomy on the right side) 15 years ago for papillary thyroid carcinoma consulted me for a neck mass on the right side. On physical examination, there was a 1-cm neck node on the right side just below the ear, not significantly tender. Concomitantly, I was able to palpate a 3-cm nodule on the left thyroid lobe, again not tender. I saw this patient 6 months ago and there was no palpable mass at the last check-up.
With these findings, I was primarily considering a thyroid papillary carcinoma recurrence, one, on the neck node at right side, and two, on the left lobe of the thyroid gland. My secondary clinical diagnosis consisted of an inflammatory lymph node hyperplasia on the right side of the neck and a colloid nodule / cyst (benign) on the left lobe of the thyroid gland.
I requested for an ultrasound of the neck. Result showed a complex mass on the left lobe of the thyroid gland and absent right lobe and lymph nodes on the right upper neck.
When she came back to me after one week for follow-up, with the neck node slightly decreasing in size, with the patient having sore throat, and with the ultrasound result, I now placed as my primary clinical diagnosis as an inflammatory lymph node hyperplasia on the right side of the neck and a colloid nodule / cyst (benign) on the left lobe of the thyroid gland. The thyroid papillary carcinoma became the secondary clinical diagnosis.
I did a needle evaluation and aspiration-biopsy of the left thyroid mass and it yielded 6 cc of brown colloid fluid with marked decrease in size of the mass. After the needle evaluation, my diagnosis was colloid nodule. I started her on levothyroxine.
As far as I can recall, in my 35 years of practice, this is the third or fourth case of a colloid nodule appearing on the remaining thyroid lobe after a subtotal thyroidectomy (total lobectomy only) for papillary carcinoma.
My specific insights:
Not all masses occurring on the remaining thyroid lobe after a subtotal thyroidectomy for thyroid papillary carcinoma are cancers as illustrated in this case and in my two and three other cases before.
Subtotal thyroidectomy (total lobectomy only) is an option in the surgical treatment for thyroid papillary carcinoma confined to one lobe of the thyroid gland. As shown in this patient, she is already 15 years in remission without recurrence after a subtotal thyroidectomy (total lobectomy only).
Clues that one can use in suspecting a colloid nodule or colloid cyst developing on the remaining thyroid lobe after a subtotal thyroidectomy for thyroid papillary carcinoma consist of sudden and recent appearance of a relatively large mass (I saw her just 6 months ago with no thyroid mass – the present mass must be very recent and the size was already 3 cm when I saw her this time – usually colloid fluid accumulation and build-up is the cause of sudden enlargement – thyroid papillary cancer usually does not grow that fast in terms of size) and with no signs of malignancy such as stony hard mass, fixation, hoarseness of voice, and ipsilateral neck nodes.
Note 1: On the first consult, I have to consider recurrence because of the physical examination findings and a background history of thyroid papillary cancer. Thyroid cancer can recur on the neck nodes even after 15 years and also on the remaining thyroid lobe. At that time also, patient did not complain of sore throat and there was insignificant tenderness on the neck node and thyroid nodule.
Note 2: At that time also, with this consideration of possible cancer recurrence, I was already feeling anxious and empathizing with the patient (since she has been with me for the last 15 years) and I was praying and hoping that my secondary diagnosis will turn out to be the correct diagnosis. My prayer was answered.