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LOCALLY INVASIVE PAPILLARY THYROID CANCER
Endorama April, 2015 DG 3434001, SM 3458383
• Category: Thyroid • Attendings: Angelos & Grogan
CASE #1
74yo male with a history of PTC s/p total thyroidectomy, L neck dissection & RAI in 2007
PMH: DM2, CHF, prostate ca s/p XRT, htn, OSA, abnormal stress test, obesity
Medications: coreg, lasix, aldactone, tekturna, synthroid, januvia
Family History: noncontributory
Physical Exam: palpable firm immobile left neck mass
OSH ADMISSION
8/2014: admitted to OSH with back pain – Spine CT demonstrated a lung nodule – CT chest revealed multiple pulmonary nodule and a large
right mediastinal paratracheal lymph node – CT neck: 3.6cm L level 3 LN compressing the IJ – Endobronchial bx mediastinal LN: metastatic PTC – Thyroglobulin: 13.6
Referred to UCMC endocrine surgery
IMAGING
Chest CT: R paratracheal 3.3x3.2cm lymph node in the mediastinum, multiple pulmonary nodules
Neck CT: enlarged left level 3 node measuring 3.6cm compressing the IJ.
Neck Ultrasound: multiple enlarged abnormal left neck lymph nodes, largest 3.2cm corresponding to the palpable mass on exam. Additional level 5 LN measuring 1.3cm
PET: extensive hypermetabolic metastases including LN of the left neck and chest as well as bilateral pulmonary nodules and osseus mets at C3.
OR
Chest: median sternotomy & rsxn of mediastinal tumor
OR
Neck: left modified radical neck dissection, ligation and resection of left internal jugular vein
– Invasion of IJ, encased vagus nerve, phrenic nerve, and brachial plexus
Common Carotid
Internal Jugular
(Head) (Feet)
Common Carotid
Vagus
Vagus
Phrenic nerve
C5/Brachial Plexus
PATHOLOGY
Mediastinal Mass Metastatic papillary thyroid carcinoma 6.0cm. Likely an effaced LN with minimal extranodal extension. Lymphovascular invasion is present.
Left Neck Contents Metastatic PTC in all levels Soft tissue deposit 4.7cm in level III with involvement of IJ and surrounding but not invading nerves. Peripheral soft tissue margin focally involved. Level II 5/8 LN positive, largest 2cm with extranodal extension Level III 1/1 LN positive with no extranodal extension Level IV 3/5 LN positive, largest 0.7cm with no extranodal extension Level V 2/3 LN positive with minimal extranodal extension Vagus nerve margin: negative for carcinoma
POSTOPERATIVE MANAGEMENT
Known residual disease -positive soft tissue margin in neck -multiple pulmonary nodules -C3 lesion
Adjuvant therapy RAI External Beam Radiation (?)
CASE #2
61yo interventional cardiologist with a one month history of increasing right neck mass
PMH: Parkinson’s disease, hypercholesterolemia
Medications: sinemet, amantadine, crestor
Family History: no history of endocrinopathy
Physical Exam: firm immobile mass in the right neck, no palp lymphadenopathy
Labs: TFT WNL
IMAGING
CT neck with contrast R thyroid: ill defined thyroid nodule with an exophytic component extending anteriorly, measuring 4.8x3.2cm. There are heterotopic calcifications and mediastinal extension and an exophytic nodule extending into the R TE groove measuring 2.1cm. L Thyroid: well delineated 2.9cm nodule
Ultrasound neck 4.2cm complex heterogeneous vascular nodule replacing R love and isthmus. 3.5cm nodule in the left thyroid lobe with benign characteristics
OR
Collar incision: • Tumor was firmly adherent to the trachea • Mass completely encasing the recurrent laryngeal nerve • Adherent to the R carotid and innominate artery Mini-sternotomy in order to get proximal and distal control of the great vessels
Head
Feet
Tumor
Innominate
Subclavian
Common Carotid
POSTOP
Awaiting final pathology…