21-year-old female with papillary thyroid carcinoma. Celeste Thomas MD January 26, 2012
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1 21-year-old female with papillary thyroid carcinoma Celeste Thomas MD January 26, 2012
2 History of Present Illness 21-year-old woman Saw her PCP to request a referral to dermatology Found to have a fullness in her neck on the left side ultrasound FNA papillary thyroid cancer CT imaging concerning for left lymph node involvement No dysphagia, cough, shortness of breath, dysphonia
3 History of Present Illness No family history of thyroid cancer Employed as a radiation technologist in a veterinarian s office Past three years (since age 19) Each animal gets approximately three images while she is holding them She hold four animals a day, three to four days a week Wears a lead garment to cover her trunk but no thyroid collar
4 History Past Medical History Gluten Sensitivity Anemia Past Surgical History Tonsillectomy, age 13 Allergies: NKDA Medications: None Family History Mother with history of nontoxic goiter, being evaluated for hyperparathyroidism No thyroid cancer Social History Employment Tobacco, 5 cigarettes in lifetime Rare alcohol use, No illicit drugs
5 Physical Exam Vital signs: BP 102/61, Pulse 58, Temp 96.3, RR 18 Ht 5 6, Wt 155 lb Gen: well-nourished, no distress HEENT: EOMI, no Chvostek sign Neck: incision c/d/i, JP drain in left neck CV: regular rate, no extra heart sounds Pulm: good respiratory effort, lungs CTAB Abd: bowel sounds present, soft, nontender Neuro: sensation intact to light touch
6 Ultrasound
7 Final Pathologic Diagnosis Complete thyroidectomy: Papillary thyroid carcinoma, multifocal (largest nodule 2.5 cm) Chronic lymphocytic thyroiditis Parathyroid tissue without diagnostic abnormality Left neck contents, excision Five level II lymph nodes, no tumor Metastatic papillary thyroid carcinoma in 5 of 12 level III lymph nodes Metastatic papillary thyroid carcinoma in 2 of 4 level IV lymph nodes
8 Radiation Units Activity: The number of times each second a radioactive material decays and releases radiation Disintegration/sec=1 Becquerel (Bq) 37 billion Bq = 1 curie Dose (absorbed): The amount of radiation energy absorbed into a given mass of tissue 1 joule/kg = 1 Gray 1 Gray = 100 rad (1 cgy = 1 rad) Dose (equivalent): energy per unit mass times adjustments for the type of radiation involved (quality factor) and the biological response in the tissue (a weighting factor) Gray x quality factors= Sievert (Sv) 1 Sievert =100 rem
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13 United States Radiologic Technologists Cohort All registered radiologic technologists certified for a minimum of 2 years (N = 146,022) as of 1982 Baseline questionnaire to 133,519 in (90,305 responded) Second questionnaire mailed to 125,707 in 1994 (91,173 responded) Both questionnaires completed and returned by 70,859 technologists
14 Radiation Technologists cohort Follow-up of the cohort Date of first questionnaire completion until diagnosis of thyroid cancer, death, or completion of second questionnaire Participants reporting a diagnosis of thyroid cancer were contacted to obtain consent and acquire medical records Era employed was considered given improvement in radiation safety over time
15 Characteristics of Participants with Thyroid Cancer diagnosed during the first follow-up Gender Thyroid Cancer after baseline Thyroid Cancer Free N % N % Female Male Age at Baseline < >= Age First Worked < >= Unknown Ever smoked 100 cigarettes Prior Thyroid Condition
16 Results Early employment before 1950 was found to be associated with increased incident thyroid cancer before completion of the baseline survey The only determinant of occupational exposure that was related to prospective thyroid incidence was Holding the patients for procedures at least 50 times, HR = % CI
17 References DeGroot, L, Paloyan, E Thyroid carcinoma and radiation. A Chicago endemic. JAMA 225:487 Zabel E et al. Thyroid cancer and employment as a radiologic technologist. International Journal of Cancer: , ( ). Dal Maso L et al. Risk factors for thyroid cancer: an epidemiological review focused on nutritional factors. Cancer Causes Control :75-86 Tuttle R et. al. Empiric Radioactive Iodine Dosing Regimens Frequently Exceed Maximum Tolerated Activity Levels in Elderly Patients with Thyroid Cancer. The Journal of Nuclear Medicine : U.S. Department of Energy, Office of Science, Low Dose Radiation Research Program
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