Thyroid malignancies – Our experience Dr. Satish chandra T Associate professor Dr P S I M S & RF

Introduction 157 thyroid surgeries over 7 yrs 34 malignancies – 20% Age range from 14 yrs to 74 yrs 32 operable, 2 inoperable (anaplastic, bony metastasis papillary)

Types of surgeries Hemithyroidectomy follwed by completion thyroidectomy 6 Total thyroidectomy 16 Total thyroidectomy with neck dissection. 10

Clinical presentation Most common presentation swelling in thyroid - 20 Vocal cord paralysis without thyroid swelling - 1 Isolated lymphnode swelling - 1 Thyroid swelling with lymphnodes – 9 Thyroid swelling with distant metastasis - 1 Family h/o – 2

FNAC Follicular neoplasm 7 Papillary carcinoma 21 Medullary carcinoma 3 Anaplastic 1 Multinodular goiter 2

HPE diagnosis Papillary carcinoma 23 Medullary carcinoma 3 Follicular carcinoma 6 Anaplastic 1

FNAC / HPE Useful screening test for planning False negatives - low Sensitivity – high except for follicular carcinoma 6 cases – second surgery ( completion thyroidectomy)

Preop Thyroid profile FNAC Other routine investigations U/S to rule out non palpable nodules CT scan in suspicious malignancy

surgery Usually under GA Special conditions (not fit for GA) – regional block (2 cases) Pedicles Identify the nerve, parathyroid Drain

Post op Usual hospital stay for 6 days I V antibiotics for 2 days Calcium supplementation in total thyroidectomy cases for 1 week Thyroxin supplementation from post op day 1

Contd- All cases – i131 scan after 45 days One case showed minimal remnants in thyroid bed – were ablated simultaneously Post op I131 irradiation

Complications Immediate post op stridor – laryngeal oedema + arytenoid dislocation (recovered in 36 hours) Managed with reintubabtion RLN transient palsy in 3 cases (recovered)

Outcome Of all the 32 operated malignancy patients 31 were doing well One patient with medullary carcinoma of age 74 yrs, operated twice for the neck secondaries – died during follow up

Interesting cases Micro papillary carcinoma Medullary carcinoma Papillary carcinoma with jugular invasion ( tumor emboli) Papillary with bone metastasis Presentation as isolated vocal cord paralysis

Papillary carcinoma (occult) of thyroid with neck secondaries

Medullary carcinoma Female patient of age 23with neck swelling Husband who happens to be her first cousin died 4 months back with similar swelling some other hospital She was operated and doing well Father in law, who is her maternal uncle developed thyroid swelling after 2 yrs at the age of 72 Did total thyroidectomy with neck clearance Neck recurrence after 18months Neck clearance done After 12 months he developed axillary nodes with symptoms of hyper calcitonin levels, lost the patient after a month She is having a daughter of 9 yrs age – what to do?

Tumor emboli in internal jugular vein 31 years female patient with thyroid swelling Neck nodal swelling in level 2 Fnac – papillary carcinoma Ultrasound with Doppler – right internal jugular vein shows emboli at the level of carotid bifurcation Ct scan with contrast - thyroid selling with neck nodes and non enhancing internal jugular vein on right side Total thyroidectomy with Mrnd type 1 Hpe of tumor emboli – papillary carcinoma in IJV

Vocal cord paralysis - evaluation Female patient 52 yrs - hoarseness of voice O/e left vocal cord paralysis Examination of neck and chest wnl Ultrasound neck - mild enlargement of left thyroid lobe Ct scan of neck with contrast - a nodule in the left lobe of thyroid, in tracheo esophageal groove area Fnac – inconclusive after repeated efforts Hemithyroidectomy – lesion directly involving the nerve Hpe – papillarycarcinoma

Thank you