澱粉樣甲狀腺腫： 案例報告及文獻回顧 Amyloid goiter: a case report and literature review 李浩銘1 諶鴻遠2 詹德全1 陳登偉1 俞志誠1 施銘朗1 Hao-Ming Li1, Hueng-Yuan Shen2,3, De-Chuan Chan 1, Teng-Wei Chen 1 Jyh-Cherng Yu 1, Ming-Lang Shih1,3 三軍總醫院 外科部 一般外科1, 核子醫學部2,甲狀腺腫 瘤治療團隊3 Division of General Surgery 1, Department of nuclear medicine2, Tumor Board of Thyroid Cancer3 Tri-Service General Hospital  

CASE PRESENTATION A 67-year-old male had bilateral neck mass for two years, mild compression symptoms. Neck sonography: bilateral heterogeneous thyroid nodules (L’t: 5.7cm, R’t: 3cm) FNAC: L’t: atypia of undetermined significance R’t: non-diagnostic LAB: positive for Anti-TPO and Anti-Tg

2016-08-21 LEFT LOBECTOMY OF THYROID Diffused nodularities, including two 5x3x3 cm nodules in the upper pole and lower pole, and one 3x3x3cm nodule in the isthmus lobe of thyroid. Operative findings: 1. Diffused nodularities in the L'tlobe,  two ＞5x3x3 cm nodules in the upper pole and lower pole, 3x3x3cm nodule in the isthmus 2. Frozen section was deferred, thyroid lymphoma or medullary carcinoma cannot be ruled out 3. L't recurrent larygeal nerve was visualized and identified, neuromonitor showed intack signals of the L't R2, no other signal because of muscle relaxant effect. Frozen section report: suspicious of thyroid lymphoma or medullary carcinoma.

PATHOLOGY Diagnosis: Amyloid goiter and Hashimoto’s thyroiditis Prominent amyloid deposition intermixed with lymphoplasmacytic inflammation. Congo-red: positive (apple green birefringence) Diagnosis: Amyloid goiter and Hashimoto’s thyroiditis

DISCUSSION Amyloid is rarely diffusely deposited in the thyroid, sometimes causing goiter and occasionally hypothyroidism. 80% of patients with secondary amyloidosis, 50% with primary amyloidosis. Associated with inflammatory disorders: rheumatoid arthritis, ankylosing spondylitis, Crohn’s disease and familial Mediterranean fever (FMF). Endocr Pract. 2010;16(6):1056. F. Villa et al. / International Journal of Surgery 6 (2008) S16–S18

DISCUSSION Amyloid is most often detected in the stroma in medullary thyroid cancers. Hypothyroidism should be corrected, if present, and thyroidectomy may be indicated in patients with obstructive symptoms. Treatment of primary amyloid with dexamethasone and a peripheral blood autologous stem cell transplant. N Engl J Med. 1997;337(13):898 Thyroid. 2013 Nov;23(11):1490-5. Epub 2013 Sep 19  Thyroid. 2007;17(1):77 

TAKE HOME MESSAGE Progressive, rapidly growing, bilateral thyroid enlargement and a concomitant history of chronic inflammatory processes DDx with medullary thyroid carcinoma, frozen section or core biopsy? Medical treatment or surgical ? ( obstruction)

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