Locally advance thyroid cancer

Dr Sudhi Agarwal

• R; 35/F• c/o left upper cervical

swelling x 5 years• Painless, gradually

progressive • No other complaints• Consulted a local

surgeon due to recent rapid increase in size of swelling

• u/w biopsy 2 months back (records not available)

• Post op developed discharging sinuses at the operated site (A) and drain site (B)

• H/P- Metastatic PTC• Referred by the surgeon

to “higher centre for further management”

A

B

• Patient consulted in SMC• o/e- hard, partially fixed conglomerate mass

of left cervical LNs involving levels 2,3,4 and 5• Upper limit – not reachable completely• Left carotid displaced medially with relatively

slightly feeble pulsations• Thyroid gland – not palpable• Right subcm cervical LNs

Work up

• Blocks review-– Metastatic PTC (follicular variant)

• CECT neck-– Conglomerate mass of lymph nodes (levels 2,3,4,5)

extending from base of skull to clavicle, involving carotid sheath

– 1.5 cm left IJV thrombus– Carotids pushed medially– Right subcm LNs +– Hypodense lesion in left lobe of thyroid

• USG thyroid with doppler– Left IJV thrombus +– Carotids- displaced with normal flow

• IDL-– Bilateral vocal cords mobile

• TFT– WNL

• Other fitness work-up- NAD

• Diagnosis– Papillary thyroid cancer with left cervical lymph nodes

metastasis with left IJV thrombosis

TT + CCLND + left Radical neck dissection on 27-4-2012

8Differentiated Thyroid Cancer

Rt Sup PTG

Rt RLN

Rt Lobe Thy

Right Superior parathyroid gland and EBSLN and recurrent laryngeal nerve identified and saved

9Differentiated Thyroid Cancer

Thyroid

Total thyroidectomy complete; left inferior parathyroid gland (circle) identified and saved

10Differentiated Thyroid Cancer

Left radical neck dissection; conglomerate mass of lymph nodes involving skin and carotid sheath; IJV ligated and divided at base of neck (circle); carotid (C) and vagus (V) identified and saved

CV

T

11Differentiated Thyroid Cancer

CTumor

Tumor is adhered densly with carotid, separated completely by meticulous dissection till base of skull

12Differentiated Thyroid Cancer

Tumor dissected out completely from base of skull

Base of skull

Tumor apex

13Differentiated Thyroid Cancer

Trachea

Neck following complete tumor removal

Clavicle

14Differentiated Thyroid Cancer

Central compartment following complete tumor removal

15Differentiated Thyroid Cancer

• Post-operative period- uneventful• Adjuvant 30 mCi of RAI required for ramnant

ablation and 6 monthly follow up