Graves’ disease has been associated with papillary and follicular thyroid carcinoma, but rarely both carcinomas concurrently. We present a case of papillary and follicular thyroid carcinoma complicated by the additional issue of severe Graves’ orbitopathy requiring steroid treatment and surgical management.
A 51-year-old Caucasian man was diagnosed with Graves’ hyperthyroidism with associated severe orbitopathy. He had no prior medical history and was not taking any other medication. He had a 15 pack year smoking history, with recent cessation. Thyroid receptor antibody titre was elevated at 35.5 IU/L (< 1.8) and nuclear medicine thyroid scan showed diffusely increased uptake (4.3%). He was treated with propylthiouracil followed by carbimazole, as well as methylprednisolone and selenium for orbitopathy.
In the context of worsening liver function derangement and orbitopathy, thyroidectomy was arranged. Anatomical pathology revealed a multifocal papillary thyroid carcinoma with widespread lymphovascular invasion, with metastatic papillary carcinoma in two of five perithyroidal lymph nodes. The largest focus was 20 mm and tumour was seen less than 0.1 mm from margins. There was also minimally invasive and angioinvasive follicular carcinoma. American Joint Committee on Cancer (AJCC) Staging was pT1b, pN1a.
Subsequently the patient was diagnosed with hepatitis C and treated with glecaprevir and pibrentasvir.
Three months after thyroidectomy, and following right orbital decompression, high ablative dose (4.95GBq) radioactive iodine (I-131) was administered, with enhanced steroid cover in light of his orbitopathy.
This case demonstrates the rare co-occurrence of Graves’ disease and papillary and follicular thyroid carcinoma, and highlights successful use of glucocorticoids to reduce the risk of exacerbating Graves’ orbitopathy with high dose I-131.