QUESTION--AO, Female, 57 years old

In 2006, she was referred to the doctor with a complaint of sudden swelling in the right side of the neck. In the physical examination, a fixed tumoral mass to the surrounding tissues was detected in the isthmus and right thyroid lobe.

14/02/2006 The thyroid ultrasound reported that 35x65x45 mm nodular mass in the right thyroid lobe.

10/03/2006 Thyroid Tc-99m scan showed a hypoactive nodule in the right thyroid lobe.

15/03/2006 The FDG/PET CT scan showed a diffuse pathologic FDG uptake was observed in PET images, which was large enough to fill the upper and middle parts of the right lobe of the thyroid gland, invading the subcutaneous tissues, and compressing the trachea.

2006 TSH: 0.837 (0.27-4.20), FT4:1.33 (0.93-1.7), FT3:2.88 (2.57-4.43), Anti-TPO:560 (˂12), Anti-Tg:508 (˂40)

16/03/2006: Incisional biopsy was done and pathology report was “Diffuse Large B-cell Non-Hodgkin's lymphoma”

Hematologic chemotherapy was performed.

The FDG/PET CT scan (15/09/2006) showed no pathologic FDG uptake was observed in PET images.

The FDG/PET CT scan (18/12/2006) showed no pathologic FDG uptake was observed in PET images.

22/10/2010 Thyroid USG: Thyroid paranchyme is heterogenous. No nodule was observed.

There were no complaints until 1/2016

07/01/2016 The thyroid ultrasound reported 40x36x30 mm nodular mass in the right thyroid lobe. There is no pathologic LAP.

08/1/2016   A thyroid true cut biopsy was performed.

13/01/2016 pathology report was “B-cell Non-Hodgkin's lymphoma”

15/01/2016 The FDG/PET CT scan showed a diffuse pathologic FDG uptake was observed in thyroid right lobe PET images.

Hematologic chemotherapy was performed.

02/05/2016 The FDG/PET CT scan showed no pathologic FDG uptake was observed in PET images.

11/02/2017  TSH: 0.88 (0.35-4.94), FT4:1.07 (0.7-1.48), FT3:3.34 (1.71-3.71), Anti-TPO:25.58 (˂5.6), Anti-Tg:1.94 (˂4.11)

11/02/2017  thyroid USG: Thyroid paranchyme is heterogenous. There are two hypoechoic nodules 4.8 mm in the right and 2.5 mm in the left lobe.

What would you recommend to this patient ?

1) Follow 6 months periods

2) Thyroidectomy and Radiotherapy (RT) to prevent future relapses?

3) Do recommend I-131 ablation after thyroidectomy before RT

Ali Saklamaz,  Turkey

 RESPONSE-In this case both total thyroidectomy and/or radiotherapy are good option. However, I woud go for adjuvant external radiotherapy, once other localization outside the thyroid gland has been ruled out by total body CT scan (PET CT is not enough). Sincerely, F. Pacini MD




I thank you in advance for your work in providing endo text.  It is a very valuable resource.

I am writing with an inquiry regarding a challenging patient I am presently caring for with non-islet cell hypoglycemia.  He is a 70 year old male with a ~ 15 year history of metastatic adrenal cortical carcinoma. He has very bulky disease with complete infiltration of the liver.   He recently developed intractable, severe hypoglycemia resulting in loss of consciousness.  His insulin levels are low and his cortisol levels are normal.    He is presently euglycemic on oral hydrocortisone therapy.

I suspected IGF-II as the likely culprit of his problem, but his ratio of IGF-II (167 ng/ml) to IGF-I (53 ng/ml) is ~ 3.  His Growth Hormone level is elevated at 3.78 ng/ml.  My differential diagnosis for this gentleman is “big IGF-II”or tumor consumption.  A less likely diagnosis that I will consider is ectopic production of somatostatin.    I have contacted multiple laboratories and can not find a commercially available “big IGF-II” assay.

Can  you comment on the questions of

1)      Are you aware of a laboratory that runs the “big IGF-II” assay?

2)      Is the “big IGF-II” worth pursuing in this case

3)      Is there a test to confirm the diagnosis of tumor consumption as a cause for NICH?

I thank you in advance for your assistance with this case.Mark Wilson, MD  Santa Barbara, CA

RESPONSE--Dear Dr. Wilson-Thank you for sharing your challenging case, and your current successful management.  I agree that your patient with non-islet cell hypoglycemia could have elevated levels of "big" or immature forms of IFG-II +/- increased glucose utilization by the tumor.  Additional contributing factors could be his extensive liver disease and presumed poor nutritional status.  I am not aware of any commercial laboratories that specifically measure "big" IGF-II, only IGF-II as you have already obtained.

In addition to diet, treatment of this condition with glucocorticoids has been successful as apparently is the case for your patient.  If this later fails, in addition to the other available general medical treatments described, growth hormone could be tried (there are some case reports indicating success with this combination).

When the available biochemical/hormonal tests do not document a specific etiology for hypoglycemia increased glucose utilization is assumed to be a contributing factor. Treating the tumor medically or surgical debulking can be helpful.  Actual measurements of glucose utilization are usually made in research settings.

We have just revised/updated our section in Endotext, including this information.  Thank you for sharing this case with us. Ruth Weinstock,  MD