Hurthle thyroid cancer requires tissue sample for diagnosis

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DEAR DR. ROACH: Recently, I underwent a needle biopsy of a thyroid nodule. The cytology report reads “suspicious for Hurthle cell neoplasm (Bethesda Category IV).” I have an appointment with a surgeon for a more definitive diagnosis. Is this already cancer? If so, how can my thyroid bloodwork be within normal limits? -- M.P.

ANSWER: I am sorry to hear about this.

Hurthle cell carcinoma is a specific type of thyroid cancer; however, a cytology report from a needle biopsy is not a definitive diagnosis. A needle biopsy provides cells, not their architecture, and the pathologist reading the cytology is making a best guess based on the material. Definitive diagnosis comes from looking at a tissue biopsy. However, the cytology report is concerning. In a large series, about 15 to 30 percent of Bethesda category IV cytology findings turn out to be cancer, and surgery is usually recommended.

Your surgeon will evaluate all the information, including an ultrasound (and possibly a PET or CT) scan, and may want to remove a lobe or the thyroid entirely. Hurthle cell tumors tend to be more aggressive and can be harder to identify with a thyroid scan, as they do not take up iodine the way most other thyroid cancers do.

The usual thyroid blood tests, such as TSH, T4 and free thyroxine index, do not diagnose cancer; they measure the amount of thyroid hormone in the blood. Most thyroid cancers do not make thyroid hormone, but the rest of the thyroid is able to make normal hormone. Thyroid cancer is usually diagnosed when someone notices a mass in the neck.

DEAR DR. ROACH: I am a 52-year-old female in good health; however, for about the past seven to eight months, I have been bothered by swelling and stiffness in my hands, especially while sleeping. The swelling is not in the joint itself but rather in the fleshy tissues between the second joint and my palms. I wake up during the night with discomfort. My fingers feel like sausages, but there is no numbness in my wrists or fingers. Both hands are affected. After I am up and moving around for about 10 minutes, the swelling and stiffness decrease, but my fingers remain slightly swollen. (I haven’t been able to wear my wedding ring during this time.)

To date, I have had bloodwork (complete blood count with differential, basic metabolic panel, rheumatoid factor, sed rate) and a connective tissue cascade. All of these tests came back normal or negative. My doctor has recommended an EMG test of both forearms, but I’m not convinced that this will be helpful. In addition, I tried five cryotherapy sessions in 10 days, and had only slight improvement in the elbow discomfort and no noticeable relief with the swelling/stiffness in my hands.

Any thoughts on what the issue might be? My mother has had rheumatoid arthritis since age 19. -- D.A.

ANSWER: The location of the swelling you are describing is suspicious for synovitis. The synovium is the tissue around a joint that makes the joint fluid. It is not normally able to be felt. Inflammation in the synovium makes me concerned for inflammatory arthritis, such as rheumatoid arthritis, psoriatic arthritis and the arthritis associated with inflammatory bowel disease.

The tests your doctor did for rheumatoid arthritis are the right ones, and the fact that they are negative makes RA less likely. However, some people (25 to 30 percent) have RA without any positive blood tests. Your family history puts you at additional risk.

Seven months is too long to go through this without a diagnosis. I would strongly recommend you see a rheumatologist.

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