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Thyroid Carcinoma
| HOSP # | WARD | Nuclear Medicine | |
| CONSULTANT | DOB/AGE | 62 y Female |
Abnormal Result
Thyroglobulin value of <0.1 ug/L upon signing results out.
Presenting Complaint
Patient presented with a neck “swelling” in October 2016. Systemic complaints were not inquired, but none was reported.
History
TFT: euthyroid since presentation when the thyroid functions were first tested in 2016.
Examination
A solitary thyroid nodule was found in the neck, moving with swallowing.
Laboratory Investigations
TFT: euthyroid upon presentation, which is clear from the table below.
| 07/11/2019 | 08/08/2019 | 21/06/2019 | 20/02/2019 | 20/11/2018 | 26/09/2018 | 21/09/2018 | 05/07/2018 | 13/06/2018 | 29/05/2018 | 07/05/2018 | 08/01/2018 | 05/04/2017 | 26/10/2016 | |
| TSH | δ- 1,49 | δ- 7,07 H | δ+62,97 H | 0.01 L | δ- 0.01 L | δ+88,52 H | 3,84 | 6,35 H | δ+ 9,88 H | 2,86 | 4,05 | δ+ 3,26 | 1,62 | |
| Free T4 | 21,4 | δ+ 22,3 H | δ- 3.0 L | δ- 29,8 H | δ+ 42,7 H | δ- 3,1 L | 17,3 | CEGK | 15,1 | δ+ 14,9 | 12 | |||
| Free T3 | 4,8 | |||||||||||||
| Thyroglobulin (3.5-77.0 ug/L) | <0.1 L | <0.1 L | 0.1 L | <0.1 L | δ- <0.1 L | 7,9 | 8,8 | 7,6 | ||||||
| Anti-thyroglobulin Ab (<115 U/ml) | <10 | <10 | <10 | <10 | <10 | 11 | 14 | 11 |
From results above it can be seen that the patient was euthyroid upon presentation (in 2016 and later until excision – highlighted in bold)
Hemithyroidectomy was done in May 2018, and another hemithyroidectomy in September 2018, thus the thyroglobulin after the first and second surgery was still detectable, but absent after September 2018.
Other Investigations
Ultrasound upon first presentation was indicative of a “suspicious nodule” in the thyroid gland.
Final Diagnosis
PATHOLOGICAL DIAGNOSIS – excision biopsy of nodule (17/01/2018)
Specimen A:
Right lobe of thyroid, hemithryoidectomy:
Encapsulated follicular variant of papillary thyroid carcinoma
Specimen B:
Right cervical lymph node (Level VI), biopsy:
Negative for malignancy (0/1)
PATHOLOGICAL DIAGNOSIS – left thyroid lobectomy (11/05/2018):
Left lobe of thyroid, excision: Negative for malignancy
PATHOLOGICAL DIAGNOSIS:
Right thyroid, lobectomy: Negative for malignancy (05/09/2018):
Take Home Messages
- Thyroglobulin level is directly proportional to thyroid tissue present in vivo, hence is a useful tumour marker for thyroid cancer.
- Anti-thyroglobulin antibody level is tested with Thyroglobulin to exclude false low values of thyroglobulin. If Anti-thyroglobulin Ab levels are increased with a decreased thyroglobulin level, the decrease in tumour marker is likely due to immunological clearance of the thyroglobulin and the result is hence likely false. This is the reason for the following canned text in TrakCare when the thyroglobulin level measures low:
The presence of thyroglobulin antibodies may interfere with the
thyroglobulin assay. The result of this test must be treated with reserve
if the patient has a positive thyroglobulin antibody test.TrakCare canned text for low thyroglobulin
- Upon total removal of the thyroid, thyroid replacement therapy is necessary, preferably slightly hyperthyroid levels to suppress TSH, and hence prevent tumour growth, as is also evidenced by this patient’s TSH and free T4 results.
- As with most other tumour markers, thyroglobulin should be used for follow-up as a proxy of tumour size or regression.
Hyperaldosteronism
| HOSP # | WARD | Murraysburg Hospital, Female Ward | |
| CONSULTANT | DOB/AGE | 51 y female |
Abnormal Result
Aldosterone: 1380 pmol/L
Renin: 2.1 ng/L
Aldosterone: Renin ratio: 657.14 pmol/ng
Presenting Complaint
Uncontrolled Hypertension, unresolved on maximum dose of 3 antihypertensives.
History
Examination
Laboratory Investigations
Other Investigations
Urine electrolytes
Serum Results
| Date | Sodium mmol/L | Potassium mmol/L | eGFR ml/min | GGT U/L | Chol mmol/L | TSH mIU/L | T4 pmol/L | FreeT3 pmol/L | Cort nmol/L |
| 21/04/2015 | 2,8 | >60 | 5,07 | ||||||
| 30/11/2015 | 3,8 | >60 | 4,53 | ||||||
| 15/11/2016 | >60 | 4,04 | |||||||
| 20/03/2017 | >60 | 4,36 | |||||||
| 05/06/2018 | 144 | 3,4 | 56 | 4,39 | 1,79 | 11,9 | 5 | 394 | |
| 20/08/2018 | 131 | 4,6 | 42 | ||||||
| 21/08/2018 | |||||||||
| 24/08/2018 | |||||||||
| 26/08/2018 | |||||||||
| 26/08/2018 | |||||||||
| 26/09/2019 | 139 | 2,4 | 45 | 0.81 | |||||
| 27/09/2019 | 142 | 2,6 | 43 | ||||||
| 01/10/2019 | |||||||||
| 02/10/2019 | 139 | 2,9 | 40 | CEGK | |||||
| 03/10/2019 | |||||||||
| 07/10/2019 | 138 | 3,9 | 38 | ||||||
| 31/10/2019 | 139 | 1,9 | 30 | 28 |
Urine metanephrines
| Urine collection period | 24 h | Reference value |
| Urine volume | 3080 ml | |
| Ucreat | 2,2 mmol/L | |
| Umetadren | 160 nmol/L | |
| Unormetadren | 870 nmol/L | |
| dUmetadren | 493 nmol/24h | 152-913 |
| dUnormetadren | 2680 nmol/24h | 699-2643 |
| Umetadren:cr | 73 nmol/mmol creat | 17-91 |
| Unormetad:cr | 395 nmol/mmol creat | 75-309 |
Final Diagnosis
Primary hyperaldosteronism causing secondary hypertension with accompanying renal injury.
Take Home Messages
Reference Ranges for Aldosterone:
- Upright 70 – 1066 pmol/L
- Supine 49 – 643 pmol/L
Screening for primary hyperaldosteronism: most sensitive when >350 pmol/L
Reference Ranges for Renin:
- Upright: 2.7 – 27.7 ng/L
- Supine: 1.7 – 23.9 ng/L
Beta-blockers suppress renin levels and should be stopped 2 weeks before testing.
Aldosterone: Renin Ratio:
Most sensitive when the ratio is >118 pmol/ng.
Effects of hyperaldosteronism
- One’s expectation is a high serum sodium, but since it normalizes with an increase in fluid volume, hence hypertension as in this case, there is normal sodium.
- Low serum potassium due to loss in urine, although this can also be normal.
- Increased urine potassium concentration (>30 mmol/L) in a random urine specimen suggests increased mineralocorticoid effect.
- The renin:aldosterone ratio is used to compensate for the increase in aldosterone which is caused by an increase in renin (for instance which is caused by hypovolemia or low blood pressure).
- Some studies recently published are suggesting that the prevalence of hyperaldosteronism are significantly more than was (and is) thought, and hence urinary (24 hour) aldosterone measurement may be more accurate to screen for hyperaldosteronism. The authors of recent estimates of the prevalence of hyperaldosteronism are of opinion that hyperaldosteronism may be the cause of around 10% of unexplained “essential” hypertensives (see attached articles).