CASE OF THE MONTH

 

PRESENTED BY

THE THYROID SURGERY CENTER OF TEXAS, P.A.

1927 Lohmans Crossing Road, Suite 201, Austin, TX 78734

www.thyroidcancer.com

512-608-9595; Fax-512-608-9833

 

History/Findings: The patient is a 25 year old concert violinist from South Carolina who presented with a 5 cm x 4 cm x 3 cm mass in the left mid jugular area. Other small nodes were palpated in the remainder of the left neck, as well. There was a hard 2 cm in diameter mass located in the left lobe of the thyroid gland and the remainder of the gland was palpable and slightly firm. He underwent 5 fine needle aspirations, a CT scan, and a MRI while home in South Carolina. He was told he needed a thyroidectomy and radical neck dissection. (Please note a radical neck dissection would sacrifice the spinal accessory nerve which would paralyze the left trapezius muscle, a catastrophic deficit to a concert violinist.) The patient elected to come to Austin for additional consultation and treatment. 

Lab/Imaging: FNA #1 on 12-23-02 Left Neck – Apparent cyst with fragments of epithelium. FNA #2 on 01-16-03 Left thyroid – Atypical cellular fragments, suspicious for papillary carcinoma. FNA #3 on 01-24-03 Left thyroid – Consistent with colloid nodule. FNA #4 Left neck cyst – Histiocytes with epithelial cells. FNA #5 Solid neck mass – Consistent with papillary carcinoma.

MRI – Described the palpable masses and some calcification of the left thyroid lobe.

CAT scan – Describes the palpable left neck mass but “no significant lymphadenopathy”; incidental note was made of a polyp in the left maxillary sinus.

TFT’s within normal limits.

Clinical Course: The patient was taken to the operating room where a total thyroidectomy in continuity with a left paratracheal and pretracheal lymph node dissection was performed along with a modified radical neck dissection. The jugular vein was sacrificed due to the surrounding lymphadenopathy, but the spinal accessory nerve was preserved. His post operative course was uneventful and he left the hospital after a brief outpatient stay. He and his family drove back to South Carolina 2 days later. His TSH was 90 at 3 weeks post-op. He was given an ablative dose of 150 mc of radioactive iodine. A total body scan done at that time was negative. He will continue in followup, and his prognosis remains good.

Final Pathology: The final pathology report revealed the primary tumor to be papillary carcinoma, 2.5 cm to 3 cm in greatest dimension. The tumor was well differentiated. Additional foci of tumor were encountered in the isthmus of the gland. The right lobe was negative for tumor. Six out of seven paratracheal lymph nodes were found to be positive for metastatic papillary cancer and an additional 15 positive lymph nodes were encountered in the left neck dissection specimen. All in all, 32 lymph nodes were resected.

Comments: A 25 year old male with a very hard left thyroid mass and massive left sided cervical lymphadenopathy has thyroid cancer until proven otherwise. We need to be prudent and selective in our employment of pre-operative testing. This will save a lot of money, avoid significant patient discomfort, and expedite the patient’s diagnosis and treatment. 

“…Thyroid surgery…it’s all we do…”