Papillary Ca of Thyroid is known for metastasis in cervical lymph node. In a lady of 34 years, with Papillary CA in a single cervical lymph node, which was diagnosed after excision biopsy, with no focal lesion in Thyroid gland on Ultrasonography, what should be the plan of management?
Total or near total thyroidectomy WITH nodal dissection (extension to be discussed according to the localisation of the nodal metas)!
Total thyroidectomy, central neck dissection, ipsilateral selective neck dissection +- radio iodine based on histology
Please read the paper:Occult papillary thyroid carcinoma: diagnostic and clinical implications in the era of routine ultrasonography World J Surg. 2008 Sep;32(9):1955-6
Papillary carcinoma with clinically apparent node metastasis but lacking a primary carcinoma lesion in the thyroid is designated as occult papillary carcinoma. In the era of routine ultrasonographic examination, occult papillary carcinoma is defined as papillary carcinoma with clinically apparent node metastasis but showing a primary lesion that is microscopic or overlooked by ultrasonography. Patients with occult papillary thyroid carcinoma were found to have a favorable overall prognosis. However, occult papillary carcinoma is automatically classified as N1b in the UICC classification, and in our series it is also likely to show other aggressive clinicopathologic features. In particular, extranodal tumor extension portends a worse prognosis for patients with occult papillary carcinoma. Therefore, careful total thyroidectomy with lymph node dissection is recommended except for elderly or high-risk patients.
Thank you for Pierre Bourgeois, Jiannis Hajiioannou, Sindeval Silva, Li-Jen Liao your responses..
This means there is an occult primary .For sure she needs total thyroidectomy for thyroid gland management. As far as node is concerned , further treatment will depend on the location of the node. If it is in the central compartment she will need through central compartment clearance. If the node is in lateral compartment , she will need Bocca's type neck dissection clearing lateral compartment with preservation of SCM muscle , IJV and SAN.
She will also need posoperative RAI scan and if needed ablation for residual thyroid if any for efficient follow up.And ofcourse thyroxine therapy
Thank you Arsheed Hakeem.. The node was in right level II region.. I feel Bocca's dissection is more appropriate for her..
This is metastatic thyroid disease from an occult primary. Treatment should be total thyroidectomy, central neck dissection, levels IIa, III, IV. If the metastatic lesion is high, IIb should also be included. If the metastatic lesion is large or is encroaching on the posterior limit of Level II, consideration may given to clearing Level V as well. Post-operative radioactive iodine would also be required.
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