Long-standing lateral neck mass as the initial manifestation of well-differentiated thyroid carcinoma

Ultrasonography, Cytology, and Thyroglobulin Measurement Results of Cervical Nodal Metastasis in Patients With Unclear Papillary Thyroid Carcinoma

Objective: This study aimed to evaluate the ultrasonography (US), cytology, and thyroglobulin (Tg) measurement results of nodal metastasis in patients showing unclear US or cytology results of primary papillary thyroid carcinoma (PTC). Methods: From January 2016 to December 2018, 179 patients underwent US-guided fine-needle aspiration (FNA) to diagnose lymphadenopathy in the neck. Among them, 36 patients underwent subsequent total thyroidectomy and nodal dissection, and cervical lymph node (LN) metastasis from PTC was confirmed. However, two patients were excluded because of mismatch between the US and pathological findings of LNs. US images and cytological slides for metastatic LNs were retrospectively analyzed, and serum and FNA Tg levels for metastatic LNs were investigated using data from the electric medical records. Primary PTC patients with suspicious results on both US and cytology were classified as the clear group, and the remaining patients were classified as the unclear group. Results: Of the 34 patients, 24 had clear results of primary PTC on both US and cytology (clear group), whereas 10 had unclear results of primary PTC on US or cytology (unclear group). Of the 10 patients in the unclear group, seven had suspicious nodal metastasis from PTC on cytology after US-guided FNA of the cervical LN, and the remaining three had negative cytology but a positive Tg measurement. Metastatic LNs with cystic change tended to show a positive Tg measurement but negative cytology. Conclusions: The combination of US, cytology, and Tg measurement is necessary for diagnosing nodal metastasis from PTC. In cases with unclear primary PTC on US or cytology, the detection of nodal metastasis may be helpful for assessing primary PTC.

Papillary Thyroid Microcarcinoma with a Large Cystic Dilated Lymph Node Metastasis to the Neck Mimicking a Branchial Cleft Cyst: A Potential Pitfall

Lateral cervical cystic mass in a young adult very rarely could be a first sign of an occult thyroid papillary microcarcinoma metastasis. In this paper, we presented a 37-year-old male patient whose preoperative 6 cm left lateral cervical cystic mass was initially diagnosed as branchial cleft cyst, but then the postoperative histopathological examination of the mass was revealed as papillary thyroid carcinoma metastasis. Preoperative fine needle aspiration biopsy was relevant with a branchial cleft cyst. In the left thyroid lobe there were 3 solid nodules with 4, 6, and 12 mm dimensions, respectively. One of the nodules had malignant well-differentiated cells diagnosed after fine needle aspiration biopsy. After total thyroidectomy, histopathologic evaluation of biopsy material's showed papillary thyroid microcarcinomas. This case indicates that especially in a young adult lateral cervical cystic mass should be carefully considered preoperatively for the possibility of metastatic occult thyroid carcinoma, especially for papillary carcinoma in differential diagnosis, and evaluation of the thyroid gland should be taken into account.

Cervical lymphadenopathies signaling thyroid microcarcinoma. Case study and review of the literature

BACKGROUND

Some lateral cervical lymphadenopathies may lead to the discovery of papillary microcarcinomas (PMC) of the thyroid that are not radiologically apparent. This relatively rare clinical situation raises questions about the diagnostic approach to chronic cervical lymphadenopathy and the impact of lymph node metastasis on PMC prognosis. PURPOSE OF THE ARTICLE: To study the epidemiologic, clinical, and prognostic criteria of cases of lymphadenopathy that signaled PMC.

PATIENTS AND METHODS

A retrospective study of 167 consecutive cases of PMC compared with 13 cases where a cervical mass signaled other forms of PMC.

RESULTS

The mean age was 48.5 years, the ratio of men to women was 5:8, and the mean PMC size was 5.5mm. These data did not differently significantly from those of the other PMC cases. The preoperative imaging found fluid content in six cases, with microcalcifications in three cases. All cases were treated by modified radical neck dissection on the side with the lymphadenopathy and total thyroidectomy with central neck dissection. The lymphadenopathy included a ruptured capsule in five cases and was accompanied by central lymph node metastases in three cases. Thyroid capsule involvement was significantly more common in cases of PMC discovered due to lymphadenopathy than in other cases of PMC (69% versus 9.7%, respectively; p<0.001). The mean follow-up was 7.3 years. There were no deaths due to PMC signaled by lymphadenopathy. Two cases of lymph node recurrence after 8 and 10 years were controlled by another surgery and radioactive iodine treatment.

CONCLUSION

Any chronic cervical mass should suggest the possibility of thyroid origin, especially in cases with cystic content or microcalcifications in subjects with no particular risk factors. An ultrasound of the thyroid should be done, as well as a fine needle aspiration biopsy of the lymphadenopathy with a thyroglobulin assay. Treatment is the same as for any thyroid carcinoma, and results in a good oncological outcome, despite the possibility of lymph node recurrences.

The Missing Thyroid

BACKGROUND

Several patients have been referred to our practice after having undergone attempted thyroidectomy, during which the thyroid gland was not found. These patients were reviewed to identify factors associated with failure to identify or adequately resect the thyroid.

STUDY DESIGN

Patients referred for a "missed thyroid" between October 1, 1990 and December 31, 2002, were reviewed retrospectively. Seven patients who underwent neck exploration for thyroid cancer (n=6) or Graves' disease (n=1) were identified. Surgical indications, history of neck operations, means of recognizing the complication, incision location, and intraoperative and pathologic findings were analyzed.

RESULTS

The thyroid was missed on initial exploration in four patients and in the second or third operation in three patients. In three patients, the surgeon misidentified the thymus (two patients) or nodal tissue (one patient) as the thyroid gland. In one patient, the thyroid could not be identified. In one patient, the thyroid was deemed unresectable because of scar tissue. In two patients, an inadequate "near-total" thyroidectomy was performed. In five patients with long necks, the neck incision was too far below the cricoid cartilage.

CONCLUSIONS

Failure to identify the thyroid gland at the normal anatomic position was associated with low cervical incisions and a history of earlier neck operations. These findings emphasize the need for improved understanding of thyroid anatomy, embryology, localization procedures, and surgical technique.

Unexpected findings in neck dissection for squamous cell carcinoma: Incidence and implications

BACKGROUND

During the pathologic examination of neck dissections, unexpected pathologic findings may occasionally be encountered. These pathologic findings may simulate malignant disease and/or have implications on the already complicated management of patients with head and neck cancer.

METHODS

We retrospectively reviewed 202 consecutive patients with a preoperative diagnosis of squamous cell carcinoma (SCC), who underwent 307 neck dissections performed by a single surgeon and examined by a single pathologist.

RESULTS

Ten patients had an unexpected finding. These included metastatic papillary thyroid carcinoma, leukemia, lymphoma, Warthin's tumor, and tuberculosis. Two of three patients with benign-appearing thyroid tissue within lymph nodes received no further treatment, and both remained well beyond 6 years. Four patients succumbed to SCC; none died from the incidentally discovered pathologic findings.

CONCLUSIONS

Unexpected pathologic findings may be present in more than 3% of neck dissections. Although this is usually indolent, with the underlying SCC remaining the main prognostic determinate, it may significantly complicate postoperative management.

Incidence of occult thyroid carcinoma metastases in lateral cervical cysts

PURPOSE

To establish the incidence of thyroid carcinoma metastasis in adult patients presenting with apparently benign cervical cysts. The authors report their experience with four cases of papillary thyroid carcinoma who present with a lateral cervical cystic mass and no palpable disease in the thyroid gland.

MATERIALS AND METHODS

A retrospective review of patients undergoing surgery for solitary cervical cysts in our clinic from 1994 to 2002 was performed. Patients with a clinically obvious primary malignancy, age less than 16 years were excluded from the study.

RESULTS

Thirty-seven patients were identified. A diagnosis of benign cervical cyst was shown by histological examination of the resected specimen in 32 patients (86.4%), with a mean age of 34 years (range, 16-59 years). A diagnosis of squamous cell carcinoma metastasis arising from an occult tonsillary primary was confirmed histologically in one patient (2.7%). Papillary thyroid carcinoma metastasis was confirmed by histological examination of the resected specimen in 4 patients (10.8 %), with a mean age of 29 years (range, 18-37 years). Diagnostic studies performed included ultrasound, computed tomography scan, fine-needle aspiration (FNA), and excisional biopsy. FNA was found to be helpful in only one of the 3 cases with papillary thyroid carcinoma metastasis. Final histopathological examination exhibited primary focus in the thyroid gland in all 4 patients, with a mean size of 0.5 cm (range, 0.3-0.8 cm).

CONCLUSION

Our data indicate that nearly 1 out of every 10 lateral cervical cysts in young adult patients represents lymphatic metastases from occult thyroid carcinoma. An excisional biopsy for definitive diagnosis should be undertaken without prolonged delay, even if FNA does not reveal malignancy.

Multinodular goiter

MNG is a common clinical problem. Though most goiters are benign and asymptomatic, they may cause concern when they create compressive symptoms, develop autonomous functioning nodules, or form suspicious nodules. Diagnostic evaluation should include clinical evaluation, laboratory tests including TSH, and consideration of additional evaluation and imaging when there exists suspicion of complicating factors or risk of malignancy. In nontoxic MNG, suppression therapy or serial clinical exams and TSH values are appropriate in an asymptomatic, nonsuspicious goiter. In toxic MNG, treatment of the resulting thyrotoxicosis followed by RAI or surgery is indicated. When compressive symptoms, risk of malignancy, or cosmetic deformity develops, surgery also may be indicated.

Incidental metastatic papillary thyroid carcinoma in microvascular reconstruction

OBJECTIVES/HYPOTHESIS

Occult papillary thyroid carcinoma has a reported prevalence of 1% to 35% based on autopsy studies. Cervical lymphatic metastases from papillary thyroid carcinoma have been associated with a higher likelihood of recurrence with a questionable impact on survival. Without clinically evident disease in the thyroid or cervical nodes, management of these patients presents a treatment dilemma. We propose an individualized treatment plan for patients in whom metastatic papillary thyroid carcinoma is incidentally detected during neck exploration for other purposes.

STUDY DESIGN

Retrospective review and discussion of the literature.

METHODS

The clinical course of two patients with incidentally discovered metastatic papillary thyroid carcinoma to the cervical lymph nodes is described. Both patients had previously received head and neck irradiation in childhood and required free flap reconstruction of extensive skull base defects following extirpation of meningiomas.

RESULTS

Neck dissection specimens from levels I and II obtained during exposure of recipient vessels for microvascular tissue transfer revealed papillary thyroid carcinoma in both cases. The patients subsequently underwent total thyroidectomy, neck dissection, and postoperative radioactive iodine ablation of residual thyroid tissue. After 1 year of follow-up, both patients were without evidence of recurrent disease.

CONCLUSIONS

An individualized approach is justified to treat metastatic papillary thyroid carcinoma incidentally discovered during other procedures. The case reports underscore the importance of pathological analysis of surgical specimens obtained during head and neck reconstruction.