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…