From Russia with love....
From Russia with love....
The patient of this “interesting Case” study is a 37 y/o American who was living in Russia at the time her diagnosis of Metastatic Papillary Thyroid Cancer was made. In spite of the fact the patient had physical findings of multiple tumors and enlarged lymph nodes consistent with Papillary Cancer she underwent a needle biopsy anyway, which confirmed the diagnosis. Had we seen her first, a needle biopsy would not have been performed.
Once the patient realized she needed surgery, she visited the local medical facilities. When she found cats roaming the halls of the hospital, she asked someone on staff why they were there. The answer was “for the rats , of course.” That was all it took for her to hit the internet, find us, and board a plane for Texas. We shared a number of emails before she arrived for her thyroid cancer treatment.
On her physical examination she had a very hard and irregularly shaped mass in the left lobe of this thyroid and the entire gland was firm and felt to be shrunken, making it quite likely that there was also an underlying Hashimoto’s thyroiditis. She had been hypothyroid for years and Hashimoto’s would most likely explain that problem, as well. The right lobe was hard and irregularities were palpated there , as well. Finally, there was a large and very firm 3.5 cm. mass in the lateral neck just above the collar bone. This was presumed to be a metastatic lymph node. See photos.
The correct operation for a patient with these findings is a total thyroidectomy with removal of the lymph nodes next to the windpipe on the side of the cancer, called a paratracheal lymph node dissection. Also, because of the presence of enlarged and suspicious lymph nodes in the lateral neck, a modified neck dissection or selective neck dissection would be performed to remove all the lymph nodes that have cancer in them or are likely to have cancer in them. Many years ago a radical neck dissection might have been performed but we have learned through time that we can spare the patient significant risk and post operative difficulties by tailoring the operation to what the individual patient actually needs. This is a judgment call that can only be made after significant experience in dealing with thyroid cancer, and there is still the unlikely risk of missing a lymph node if the operation is not extensive enough.
So, this patient had a total thyroidectomy with bilateral paratracheal and pre tracheal lymph node dissections and a left modified neck dissection. This patient had multiple microscopic areas of cancer in both lobes, something very commonly seen in Papillary Cancer cases. Ironically there was actually more cancer in the right side of the thyroid gland than the left, though the patient had a LEFT sided lymph node metastasis above the left collar bone. There were 4 lymph nodes in the left paratracheal lymph node dissection and one had cancer in it. There were 6 lymph nodes in the right paratracheal lymph node dissection and none of them contained metastatic cancer. In the left modified neck dissection specimen there were a total of 17 lymph nodes, and three of them contained metastatic cancer from the thyroid, one of these was the big one felt on physical examination. It is interesting that the left sided thyroid cancer was smaller than the cancer identified in the right lobe, but it was the left sided cancer that wanted to do all the spreading to adjacent and lateral lymph nodes. I guess it just didn’t read the “cancer rule book.” In the course of her operation I had to move (transplant) two of her parathyroid glands in order to preserve their function and maintain normal calcium levels in the blood. She took some calcium supplement for awhile post op but never appeared to have any signs or symptoms of low calcium.
Another interesting thing occurred post op. She called me about ten days after her operation to tell me she didn’t fell well. Now we expect our patients to get a little tired a few weeks after such surgery because they become hypothyroid. We want their TSH levels to rise to at least the 30 or 40 range before giving them the radioactive Iodine. Well this lady’s TSH (normal TSH is around 3) came back at 98.76 just a little more than a week after her surgery. This is a good thing in that it documents that her surgery was quite complete and virtually zero functioning thyroid tissue of any kind was left behind.
She received her ablative dose of radioactive Iodine very quickly.
Papillary cancer patients with this much disease in the neck are at some risk to develop another lymph node metastasis at some future point in their life and I have seen this as late as 11 years later. The risk of this is quite low but it should always be discussed with the patient so there are never any surprises. Patients don’t like surprises, and neither do I.
Below are some interesting photos that tell the story step by step. Her scars are quite good though I’m certain some patients might not agree. You have to keep these things in perspective, this wasn’t the normal thyroidectomy with little or no visible scarring, this was an extensive and sophisticated life saving operation. She was very grateful for her outcome and the scar looked terrific to her! I assure you the alternative would not have been acceptable.
