Case Report
Copyright ©The Author(s) 2021.
World J Clin Cases. Feb 26, 2021; 9(6): 1343-1352
Published online Feb 26, 2021. doi: 10.12998/wjcc.v9.i6.1343
Table 1 Clinical and pathological data of the patient
Biographical data53 years old and female
Family historyNo
Chief complaintThyroid nodule discovered 2 mo prior
Specialized physical examinationThe trachea was in the middle. The thyroid gland moved up and down with swallowing action, and no nodules were felt in the bilateral lobes. There was no hoarseness in the voice and no choking cough when drinking water.
USNodules were found in bilateral lobes of the thyroid gland, and the right lobe had a well-defined hypoechoic nodule with a size of approximately 10 mm × 6 mm. The left lobe had a cystic and solid mixed hypoechoic nodule with a size of approximately 22 mm × 11 mm. The US grade was TI-RADS 4. Multiple solid hypoechoic nodules were detected in bilateral I-IV areas of the neck, and the boundaries of the medulla and cortex were not clear
CEUSLymph nodes were observed on both sides of the neck. T-CEUS suggested that the cortical stage of the lymph nodes was enhanced by uneven medulla, while the medulla was slightly enhanced. Enlarged lymph nodes were considered as reactive hyperplasia
FNACRight thyroid nodule was suspected as a thyroid papillary carcinoma (TBSRTC V). Left thyroid nodule cytology suggested a malignancy (TBSRTC V), but the type was not determined
SurgeryThyroidectomy, bilateral central lymph node dissection, and bilateral recurrent laryngeal nerve exploration
Frozen pathologyBilateral papillary thyroid micropapillary carcinoma and bilateral central lymph nodes showed no cancer metastasis
Paraffin pathologyLeft medullary thyroid carcinoma (Figure 2), with immunohistochemistry results of calcitonin (+), CK (+), TTF1 (+), CK19 (-), thyroglobulin (-), galectin-3 (-), Ki -67 < 1%, and MC (-); right thyroid papillary carcinoma, BRAF V600E mutation
Final diagnosisPapillary thyroid carcinoma of the right lobe (T1N0M0, stage I) and medullary thyroid carcinoma of the left lobe (T1N0M0, stage I)
Postoperative treatmentOral levothyroxine sodium tablets (Euthyrox): 100 µg/time/day
Table 2 Postoperative follow-up monitoring
CT (pg/mL)
TSH (μIU/mL)
TgAb (IU/mL)
Tg (ng/mL)
CEA (µg/L)
Normal< 6.40.5-4.80-1153.5-77< 3.0
Preoperative3454.2< 10.016.820/
1 d after surgery15.742.545< 10.03.3706.440
1 wk after surgery2.690.634< 10.00.497/
1 mo after surgery0.840.09614.40.062/
2 mo after surgery0.550.04814.00.040/
5 mo after surgery< 0.50.473< 10.00.040/
8 mo after surgery< 0.50.343< 10.00.110< 3.0
1 yr after surgery< 0.50.343< 10.00.100< 3.0
1.5 yr after surgery< 0.50.008< 10.00.1001.18
Table 3 Risk classification of medullary thyroid carcinoma patients based on genetic mutations (2015 version of United States thyroid association)
Risk classification
Patient population
ATA-HSTMEN2B; RET codon M918T mutationThyroidectomy ± central lymph node dissection in the neck within 1 year after birth
ATA-HMEN2A; RET codon C634 mutationFive years old or earlier thyroidectomy ± central lymph node dissection
ATA-MODOthersEvery year from the age of 5, physical examination, neck US, and serum calcitonin
Table 4 Cervical lymph node clearance range
Patients without evidence of cervical lymph nodes and distant metastases before surgeryPreventive central lymph node dissection
Preoperative calcitonin 40-150 pg/mL, even if no suspected lymph node metastasis were foundCentral lymph node and ipsilateral II-IV lymph node dissection
Patients with preoperative calcitonin > 200 pg/mLIpsilateral neck II-VI lymph node dissection, and contralateral cervical lymph nodes should also be considered for removal