Abstract
Background
de Quervain’s thyroiditis is an inflammatory condition of the thyroid mostly treated medically, rarely requiring surgical treatment. We intend to review the surgical experience with de Quervain’s thyroiditis at a tertiary cancer center over a period of 22 years.
Methods
A retrospective review of medical records from 1992 to 2014 at a tertiary cancer center was performed and all patients with a histopathological diagnosis of de Quervain’s thyroiditis were included.
Results
Ten patients with a histopathological diagnosis of de Quervain’s thyroiditis were included in the study. One patient in the study presented with dysphagia due to the goiter. The remaining patients presented with thyroid nodules. None presented with typical symptoms of the disease. Seven of the ten patients that had been evaluated for a goiter at an outside facility underwent fine needle aspiration cytology. Of the seven patients, one patient was suspected to have medullary carcinoma of the thyroid, two had follicular neoplasia, and the others had indeterminate nodules. Eight of the ten patients underwent surgery for suspected malignancy, with eight receiving a total thyroidectomy and two patients getting a thyroid lobectomy with isthmusectomy. Two patients had an abnormally hard gland to palpate during surgery with the others not having any suspicious findings. Seven of the ten of the patients had lymph node sampling from level 6 and all were benign on final pathology. The mean duration of post-operative follow-up was 15 months. There was no morbidity associated with surgery in any of these patients with eight of the ten patients requiring thyroid hormone replacement. None of the patients needed further neck surgery for thyroid disease.
Conclusion
de Quervain’s thyroiditis is an inflammatory condition of the thyroid that is rarely treated surgically. However when presentation is atypical and the FNAC is inconclusive or is suspicious for a malignancy, patients receive surgery putting them at a risk for morbidity. Good clinical assessment with combined use of ultrasound with FNAC especially read by an experienced cytopathologist has the potential to reduce unnecessary operative intervention.
1
Introduction
Subacute granulomatous thyroiditis/de Quervain’s thyroiditis is a painful inflammatory condition of the thyroid thought to be of viral origin. It is characterized by pain and tenderness in the neck, low grade fever, elevated erythrocyte sedimentation rate and mild thyrotoxic manifestations with suppressed thyroid stimulating hormone progressing to a hypothyroid state as the condition resolves on its own. Diagnosis is based on clinical examination with laboratory tests indicating a transient hyperthyroid state with a raised erythrocyte sedimentation rate and reduced I 131 uptake. The condition rarely requires histopathological confirmation. Clinical presentation may not be typical, with patients often presenting in a euthyroid state with a thyroid nodule resulting in difficulty in diagnosis. Prior to the widespread use of fine needle aspiration cytology (FNAC), many patients were subjected to surgery. FNAC and improvements in imaging have largely reduced unnecessary thyroidectomies. However when the cytology is inconclusive or shows features suggestive of a follicular lesion, patients are offered diagnostic surgery. Experience in the surgical management of de Quervain’s thyroiditis has been limited with few studies from high volume centers. Even though ours is a referral tertiary cancer care center, we do see a large number of patients with an atypical diagnosis on FNAC. We intend to review our experience with de Quervain’s thyroiditis and will start with a case report.
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Case report
A 58-year-old lady presented to the office after being referred by her primary care physician to our head and surgery clinic with bilateral thyroid nodules. She did not report neck pain or fever but felt that the nodules were increasing in size. She had undergone FNAC at an outside hospital, which was reported as a follicular neoplasm (Bethesda category IV) on the right and Hurthle cell lesion (Bethesda category III) on the left. The FNAC was reviewed at our institute, and the diagnosis was revised as benign (Bethesda category II), consistent with bilateral lymphocytic thyroiditis by the cytopathologist. On ultrasound, both nodules were irregular with the one on the right measuring 2.4 cm and the one on the left measuring 1.5 cm. The background parenchyma appeared heterogenous bilaterally, suggestive of thyroiditis. There was no cervical lymphadenopathy. In spite of the revised benign FNAC diagnosis, the patient elected to undergo a total thyroidectomy with lymph node sampling. The patient was counseled that surgery was probably not necessary. However she elected to undergo surgery as the initial FNAC report had suggested a follicular neoplasm. The final pathology after total thyroidectomy was subacute granulomatous thyroiditis (i.e. de Quervain’s thyroiditis).
2
Case report
A 58-year-old lady presented to the office after being referred by her primary care physician to our head and surgery clinic with bilateral thyroid nodules. She did not report neck pain or fever but felt that the nodules were increasing in size. She had undergone FNAC at an outside hospital, which was reported as a follicular neoplasm (Bethesda category IV) on the right and Hurthle cell lesion (Bethesda category III) on the left. The FNAC was reviewed at our institute, and the diagnosis was revised as benign (Bethesda category II), consistent with bilateral lymphocytic thyroiditis by the cytopathologist. On ultrasound, both nodules were irregular with the one on the right measuring 2.4 cm and the one on the left measuring 1.5 cm. The background parenchyma appeared heterogenous bilaterally, suggestive of thyroiditis. There was no cervical lymphadenopathy. In spite of the revised benign FNAC diagnosis, the patient elected to undergo a total thyroidectomy with lymph node sampling. The patient was counseled that surgery was probably not necessary. However she elected to undergo surgery as the initial FNAC report had suggested a follicular neoplasm. The final pathology after total thyroidectomy was subacute granulomatous thyroiditis (i.e. de Quervain’s thyroiditis).
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Methods
Following the institutional review board approval, a retrospective review of our institutional thyroid database was performed to identify patients with a confirmed pathologic diagnosis of de Quervain’s thyroiditis managed by the Head and Neck surgery service at Memorial Sloan Kettering Cancer center between 1992 and 2014. Ten patients with sufficient data and follow-up were identified. The details collected from the medical records included symptomatology, preoperative ultrasound, FNAC results, the indication for surgery, extent of surgery, lymph node sampling, difficulty encountered during dissection and complications.
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Results
After searching our pathology database, ten patients with a histopathological diagnosis of granulomatous thyroiditis or de Quervain’s thyroiditis ( Fig. 1 ) were included in the study. In terms of symptomatology, one patient in the study presented with dysphagia due to the goiter. The remaining patients presented with thyroid nodules. The cytologic diagnoses rendered by the outside institute and/or by MKSCC were listed in Table 1 . Eight of the ten patients had been evaluated for a goiter at an outside facility and had undergone FNAC, which were reviewed by the cytopathologists at MSKCC. Of the eight patients who were referred, one patient was diagnosed as “suspicious for malignancy” (medullary carcinoma, Bethesda category V), in part due to the presence of spindle cells in the cytologic sample. It is not uncommon to find spindle cells in de Quervain’s thyroiditis which may mimic medullary thyroid cancer. However, the serum calcitonin was normal in this particular patient, and a diagnosis of medullary carcinoma of the thyroid can be excluded clinically if serum calcitonin is normal. Among the remaining seven patients, the initial cytologic diagnoses from an outside institute were: follicular neoplasia (Bethesda category IV, n = 2), atypical (Bethesda category III, n = 3), and benign (Bethesda category II, n = 1). A significant number of the cases were downgraded after expert cytological review at MSKCC. The reviewed diagnoses were: atypical (n = 3), benign (n = 3) and unsatisfactory for evaluation (Bethesda category I, n = 2). Of the two patients who were seen only at MSKCC, none had a FNAC suggesting follicular neoplasm. Eight of the ten patients underwent surgery for suspected malignancy, with eight receiving a total thyroidectomy and two patients getting a thyroid lobectomy with isthmusectomy. Two patients had an abnormally hard gland to palpate during surgery, while the remaining patients did not have any suspicious findings. Difficulty in mobilizing the gland was appreciated in one patient, which was probably due to previous surgery for Zenker’s diverticulum. Seven of ten of the patients had lymph node sampling from level 6 and all were benign on final pathology. The mean duration of post-operative follow-up was 15 months. There was no morbidity associated with surgery in any of these patients. Eight of the ten patients required thyroid hormone replacement. None of the patients needed further neck surgery for thyroid disease.
