A pregnant woman with metastatic papillary thyroid carcinoma and paraplegia: Multiple considerations involved in the management.

A 35 years old primigravida hailing from a humble, rural background with no previous history related to thyroid carcinoma, presented with acute paraparesis at the last trimester of pregnancy and was diagnosed to harbor metastatic papillary thyroid carcinoma (PTC) following magnetic resonance imaging (MRI) of the spine with guided biopsy, which demonstrated near complete collapse of D5 and D10 vertebral bodies with altered signal on the D4 to D6 and D9 to D11 vertebral bodies, in addition to a gravid uterus and a large goiter. There was also evidence of bilateral nodular lesions in the lung parenchyma and a fairly large hepatic lesion in segment 8 of the liver . Histopathology revealed metastatic follicular variant of thyroid papillary carcinoma. This case with challenging presentation had multiple issues to be resolved during its management: a) acute paraparesis and the requirement of radioiodine ((131)I) treatment soon after total thyroidectomy, b) her first valuable pregnancy that required to be managed successfully, c) the poor general condition, d) the abstinence from iodine containing medications, in relation to the Cesarean section planned, e) the timing of total thyroidectomy, f) postnatal care of the newborn and g) radioprotective measures. All were important considerations in the management of this patient. Iodine restricted diet and medications were recommended and were communicated to the obstetricians involved in the patient. The patient underwent Cesarean section and total thyroidectomy at the same sitting. The newborn baby was healthy and was started on artificial feeding. Recombinant TSH primed protocol was not considered immediately in view of a major surgery being undertaken and the poor general condition, so that the patient would not require frequent support during the isolation period. In the first 3 weeks of the postoperative period, she was put on T3 substitution and after a 2 weeks gap was given (131)I and whole body diagnostic scan was undertaken 48h after the administration of (131)I scan dose. Both the diagnostic and post (131)I treatment scan demonstrated multiple foci of (131)I uptake in the skeleton, lungs and liver. Following discharge from the isolation ward, adequate separation from the infant was ensured and the childcare was undertaken by relatives. The patient had a remarkable improvement clinically. During the next 3-½ years she was treated 2 more times with (131)I with cumulative doses of about 25.9GBq. The last post-treatment scan is depicted in. She has been presently ambulatory with complete resolution of paraplegia and a significantly better quality of life without any requirement of support, despite the presence of extensive skeletal disease. A recent review entitled "Approach to the pregnant patient with thyroid cancer", addresses this topic as a separate category. Similar emphasis has also been given by other authors while dealing with these patients. In our experience, patients with PTC metastatic lesions in the vertebrae show better response compared to those with large flat bone metastases likely related to the small size of the former. In conclusion, a teamwork of surgeons, obstetricians, nuclear medicine physicians as well as the strong support by the relatives, was necessary to favorably treat this patient with metastatic PTC, paraplegia and pregnancy.