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How will you manage a case of papillary carcinoma of 27 year old male presented with solitary thyroid nodule of 2cm in his left lower pole along with multiple ipsilateral mobile lymphonode in level III, IV and V but without distant metastasis?

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The given scenario suggest that patient belongs to the below mentioned group:

  • High risk patient with High risk tumour & N1b nodal status and M0
  • T1 N1 Mo with high risk (stage IV A)

 

Total thyroidectomy c parathyroid preservation and Selective neck dissection IIb-Vb +Post operative radiotherapy and RIA should be the choice of treatment.

 

History

Detailed history should include:

Age , Sex, Hoarseness, Obstructive symptoms, Progression, Pain, dysphagia, H/o childhood irradiation, Family history, Symptoms of toxicity.

Physical examination

  • General
  • L/E THYROID IS DONE ONE SIDE AT A TIME : Look for overlying skin consistency + Examination of neck nodes, Pharynx, Larynx and trachea
  • Indirect Laryngoscopy: Fibre-optic endoscopy of vocal cord to rule out palsy/ invasion

Chest radio graph

  • Tracheal shift
  • Mediastinal external
  • Pulmonary metastasis
  • Other co-morbid

Ultrasonography

  • Difference cystic/nodular
  • Solitary or multinodule (cystic up to 1 mm/solid up to 3mm)
  • Tumour size
  • Calcification(MTC)
  • Extracapsular extension
  • Vascular invasion
  • Neck nodes(level i-vii)
  • Assist FNAC
  • Involvement of contralateral lobe

Radiology

  • Extent and relationship
  • Indication: Large retrosternal extension
  • Multiple LN deposits
  • Pulmonary metastasis
  • Abdominal CT lymphoma staging
  • MRI may detect vessel involvement

Laboratory investigation

  • T3 and T4
  • Serum calcium
  • Thyroid antibodies
  • Thyroglobulin
  • Calcitonin

Cytology: FNAC is cheap, safe and reliable

  • FNAC do not distinguish between benign and malignant follicular neoplasm
  • FNAC can miss multifocal cancer.

 

Scintigraphy:
  • Gold standard
  • visualizes nodules greater than 5 mm
  • uses- 123I – Thyroid pathology
    • 123I-MIBG -(monoiodobenzyl guanidine) MTC, suspect of MEN
    • Ga citrate- lymphoma (use in long standing Hashimoto thyroiditis)
    • 99m Tchnetium now used for various reasons like  half life of 6 hrs, cheap readily available, low radiation dose. It is trapped but not organified.

 

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