My Strangest Case: The Man With a Heavy Tongue

Meera Mohan, MD, MS; Paulette Mehta, MD, MPH


August 04, 2020

Physical Examination and Workup

A 63-year-old man was referred to us for recurrence of follicular thyroid carcinoma, with an anaplastic component, after an initial diagnosis of differentiated thyroid cancer 40 years prior. After that initial cancer diagnosis, the patient underwent total thyroidectomy, followed by radioactive iodine ablation and thyroid hormone suppression.

When the patient presented to us 40 years later, he described vague symptoms of exertional dyspnea and wheezing. They had lasted for about 4 months before he sought medical help. Imaging studies confirmed a left hilar mass (5.3 × 3.7 × 5.4 cm), with no evidence of disease spread (Figures 1-3). Bronchoscopy with endobronchial ultrasound of the left hilar mass was consistent with follicular thyroid cancer.

Figure 1.

Figure 2.

Figure 3.

At the time of presentation to the medical oncology department, the patient had undergone left pneumonectomy and had no evidence of disease on imaging studies, except for a bilobed nodule (1 × 0.7 cm) within the superior segment of the right lower lobe and a nodule (0.7 cm) within the posterior basal segment of the right lower lobe. The risk for complication associated with a biopsy of these subcentimeter lung nodules was substantial. The decision was made to pursue active surveillance with frequent imaging studies.

Owing to a lack of consensus or strong evidence-based treatment guidelines, and because of the aggressive nature of this rare cancer, we proceeded with combination chemotherapy with doxorubicin and docetaxel. Molecular study findings, including BRAF V600 and microsatellite instability testing, were unremarkable. The patient also resumed levothyroxine therapy, with the intention of fully suppressing thyroid-stimulating hormone.

After the second cycle of chemotherapy, the patient was found to have an incidental drop in cardiac function, from 60% to 39%. The treatment was thus permanently discontinued. At this point, we pursued active surveillance with CT every 6-8 weeks, given the aggressive nature of the anaplastic thyroid cancer.


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