May 16, 2012

A case of papillary carcinoma of the thyroid gland in a woman from Fukushima

(From Dr. Shunichi Ono’s blog.  Dr. Ono is an internal medicine doctor who used to work as a TEPCO engineer.)

Note:  The woman’s statement is shown in blue.

A woman in her early 30's who evacuated from Kooriyama-city, Fukushima, to western Japan reports that she has been diagnosed with papillary carcinoma of the thyroid gland and scheduled for surgery soon.  With her permission, I would like to present her case on my blog.  Of course I understand that we cannot conclude this case is related to the Fukushima nuclear accident.  However, it is certain that we would have to carefully watch the situation from now on.

Personal history

March 11, 2011 to March 15, 2011, in Kooriyama-city.
I wore a mask when going outside.  I couldn’t get an N95 mask, so I used a regular mask.  Water supply had been stopped, and I had to line up outside to get water.  I didn’t open windows but I didn’t put weather stripping to seal around the windows, either.  I live in the first floor apartment.  On March 14, I took 10 mL of Isodine, iodine-containing gargling medicine.  The radioactive plume came over the Kanto region on March 15.  I left Kooriyama-city in the afternoon of March 15, driving towards Numazu, Shizuoka, in the rain, as if chasing after the plume.  The Tohoku Expressway was blocked, so it took me 15 hours.

March 16, 2011 to April 4, 2011, in Numazu, Shizuoka.
I led a normal life.  The second wave of the radioactive plume on March 21 came with the rain, so I didn’t go outside to avoid it.

April 5, 2011 to April 23, 2011, in Inawashiro, Fukushima, and Nasu, Tochigi.
My house was partially destroyed.  Also the ambient radiation level in Kooriyama-city at the time was 2 μSv/hr, so I didn’t think I would be able to return home even while I was staying in Shizuoka.

April 24, 2011 to September 2011, I moved to XX-cho, Aizu.
I couldn’t and didn’t want to quit work, so I moved to Aizu which had a lower radiation level.  It was 0.14 μSv/hr at the time.  However, I was commuting to Sendai and Tochigi on the Expressway for work everyday.  I didn’t work within the 80-km zone, but I was passing through Kooriyama, Fukushima, after all, going from Aizu to Sendai and Tochigi.

September 2011 to January 2012, moved to Numazu, Shizuoka.

January 2012 to present, moved to a place more west than Osaka.

I have been and still am extremely careful with choosing clean food and water.
The urine test by Riken, done on urine collected on February 21 to 22, 2012, showed no iodine and cesium, with the MDA of 0.073.

Medical history

July 2011, Hospital “A” in Aizuwakamatsu-city, Fukushima.
I had sore throat, sputum, unstoppable diarrhea, weight loss, fatigue and excessive sleepiness.  I wondered about a thyroid condition, so I went to see an endocrinologist.  Thyroid ultrasound revealed a 5-mm tumor.  I hadn’t noticed any nodule previously.  I had a biopsy, but it was undeterminable due to an insufficient sample size.  The doctor assured me that it was okay, however.  I told the doctor I was worried about the effect of radiation, but the doctor laughed at me saying radiation should not be affecting me.

Lab test items in Japanese as shown above (normal range in the second column):
Thyroglobulin 20.3
anti-thyroglobulin antibody 18.6
nonspecific Ig-E 24

Lab test items in Japanese as shown above (normal range in the second column) :
WBC 5500
RBC 514
Hemoglobin 14.9
Hematocrit 45.4
Platelets 22.6

December 2011,  Clinic “B” in Shizuoka.
I brought a referral letter to get thyroid ultrasound and blood test.  The tumor was 6 mm in size.  They told me they would only do a biopsy if it was over 7 mm.  Blood test was normal.  I was told to return in 6 months to a year.

Lab test items in Japanese as shown above (normal range in the third column):
Thyrogloblin 20.2
Anti-thyroglobulin antibody 13
Anti-TPO antibody <5

Lab test items in Japanese as shown above (normal range in the third column):
Glucose 74
Sodium 141
Chloride 104
Total protein 6.8
Albumin 4.3
Urea nitrogen 13
Creatinine 0.59
Triglyceride 174
Potassium 4.1
Calcium 9.1
Phosphorus 3.3
WBC 6700
RBC 489

April 2012,  a free thyroid ultrasound event for the evacuees at Hospital “D.”
I was told the nodule was irregular in shape with a higher chance of being malignant.  I was told to get regular examinations.  This was the first time the shape of the nodule was mentioned to me.

Thyroid ultrasound report:
Thank you for participating in the thyroid ultrasound experience on April XX, 2012.  
You have a history of a tumor in the right lobe of thyroid gland and fine needle aspiration biopsy.
Our examination revealed a 5.1x3.8mm mass.  It is irregular and elongated, and the image suggests a possibility of thyroid cancer.
Thyroid cancer grows slowly in general, and it might not lead to subjective symptoms for many years in a lot of cases.
The most definitive diagnostic method is fine needle aspiration biopsy, just as you had before, but it might be difficult to collect cells when the size of the mass is small.  
We recommend that you repeat thyroid ultrasound every 6 months to watch the course of the mass, and repeat the fine needle aspiration biopsy if the mass shows a tendency to grow in size.

Thyroid ultrasound result:
3. There is a mass.  It is recommended that you go to a thyroid clinic for further testing.

April 2012, color doppler ultrasound, blood test, biopsy, EKG and urinalysis at Clinic “C.”
Biopsy result would be available in two weeks.  During the examination the first thing the doctor said to me was “Thyroid cancer is not fatal!!”  I think the doctor already had suspicion from the ultrasound result.  I had been ready to deal with the result since then.  My heart rate was only 50 and thyroid function was low.  There were many things that I could think might have been related to this, but I thought they were from the stress of moving and working.

Lab test items in Japanese as shown above (normal range in the third column):
Total cholesterol 174
Triglyceride 32
Arteriosclerotic index 0.9
Anti-thyroid peroxidase antibody <5.0
Anti-thyroglobulin antibody 10.8

May 2012, second visit to  Clinic “C.”
The biopsy result was questionable due to possible contamination.  It was decided to repeat biopsy with staining for definite determination.  The result was to be back in two weeks.

May 2012, third visit to Clinic “C.”
Even though they told me the second biopsy result would not be back for  two weeks, they called me four days later, asking me to come in since the result was in, which was ominous.  The diagnosis was a papillary adenocarcinoma.  It was 6 mm in size and in the right lobe of thyroid gland.  The doctor explained it to me, looking at the images of biopsy result.  I was told an inexperienced doctor might call it benign.  Dr. C. is dedicated to treat radiation-related illnesses and has experiences in Chernobyl.  He understands I was in Fukushima at the time of the accident and how that might have affected my condition

This was a very detailed record, and I reported it almost in whole.  This is all the information I have, and I won’t be able to answer any questions beyond what’s written.

However, considering the following points, we should be guarded about the development of any other cases in the future:
  • She took 10 mL of Isodine.
  • She evacuated from Kooriyama-city at a relatively early time.
  • Thyroglobulin is essentially normal.

In regards to thyroid cancers, Dr. Shunichi Yamashita is said to be the top specialist in Japan.  

He has lectured on the topic as below. 

Based on this graph, thyroid cancer incidence is not supposed to increase for three years after a nuclear accident.
Also, Japan Thyroid Association has sent the following letter to the thyroid specialists.

Dear Japan Thyroid Association members,

Fukushima prefecture is carrying out “Prefectural Resident Health Management Survey” for all residents for the purpose of long-term health management as part of the “health watch” project, in the face of radioactive contamination due to Tokyo Electric Company Fukushima Dai-ichi Nuclear Power Plant accident, which happened along with the Great East Japan Earthquake.
As part of this survey, we have begun the ultrasound examination of thyroid gland in all prefectural residents ages 0 to 18 at the time of the accident.  (Please refer to the explanation for the residents.)

So far, because we have carried out the examination on weekends and holidays at Fukushima Medical University Hospital since October 2011 and on weekdays at the outside areas since mid-November,  the first-stage examination has already been done on over 15,000 residents.

At this time, the examination results are to be mailed to the residents after consultation with special committees in and outside the Medical University.  We are contacting the supporting association members to ask for understanding of how to deal with these results.

In the first-stage ultrasound examination, we have defined what needs the second-stage examination as nodules over 5.1 mm and cysts (non-solid but colloidal or liquid collection only) over 20.1 mm.  Thus, in addition to those with no abnormal findings, those with nodules smaller than 5 mm or cysts smaller than 20 mm have been decided not to be the subjects of further testing such as biopsies, or treatments.  We would imagine that you might receive a few inquiries or consultations from parents regarding these results.  Please explain to them well to make sure they understand that any further testing is not necessary before the next examination
unless symptoms appear.

Also, this examination will be carried out every two years until age 20 and every five years from then on, leading to a long-term thyroid examination project.  Coordination with base hospitals all over the nation will be essential, and the examination will be widely publicized to the residents from now on.

Your continued understanding and cooperation towards this examination will be appreciated.

January 16, 2012

Shunichi Yamashita, M.D.
Fukushima Medical University Radiological Resident Health Management Center Chief

Shinichi Suzuki、M.D,
Fukushima Medical University Radiological Resident Health Management Center
Clinical Department Vice Chair (in charge of thyroid examination)

Should we not reconsider how the thyroid ultrasound results are to be managed?

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