Child with DTC

Abstract

A 11-year-old boy presented with an anterior neck swelling for 4 years which was progressively increasing in size but without pressure symptoms and no symptoms of hypothyroidism or hyperthyroidism. He gave a history of occasional cough with breathlessness on exertion. Examination of neck showed right thyroid lobe solitary thyroid nodule 3 × 3.5 cm, hard in consistency, left thyroid lobe was enlarged, but no nodule was palpable. He also had bilateral multiple level 2, 3, 4 and 5 nodes, rounded and firm in consistency, largest 1 × 1.5 cm in right level 3, nontender. Investigations revealed TSH (Thyrotropin) 3.26 miu/l Thyroglobulin TG > 300 ng/ml (ATG <20.0 IU/ML), USG Neck: ill-defined infiltrative lesion replacing right lobe and isthmus with multiple punctate calcifications, extra-thyroidal extension with abutment to right ICA; ill-defined lesions in left lobe. Bilateral multiple enlarged level IIA, IIB, III, IV, V, and VI nodes. FNAC thyroid and lymph nodes showed papillary thyroid carcinoma. Chest X-ray showed bilateral miliary mottling in both lung fields. CECT neck showed 42 × 26 × 18mm heterogenous mass lesion involving right thyroid lobe with multiple enhancing lymph nodes at bilateral level I, II, III, IV, V and VI and numerous tiny nodular lesions in both lung fields suggestive of lung metastases. The child was taken up for total thyroidectomy + CCLND + B/L SLND. At operation right lobe was found to be enlarged and adherent to trachea but could be separated. Multiple enlarged LNs in central compartment (largest 2 × 2 cm). CCLND done till brachiocephalic artery. Right and left RLN preserved, Rt RLN densely adherent to central compartment lymph nodes but could be shaved off. Both left-sided parathyroids identified but de-vascularized, hence auto transplanted in the right SCM. Multiple enlarged LNs on both sides from level II to V. B/L SLND done (level II–V). Right lateral LN mass was densely adherent to IJV, dissected with difficulty. Grossing: weight- 20 g (TT specimen), Right lobe—3.5 × 3 × 1.5, Left lobe—3 × 2 × 1; c/s: fleshy, greyish white right lobe, isthmus and left lobe normal. Post op period developed symptomatic hypocalcemia managed by intravenous calcium followed by oral calcium and vitamin D supplements. Histopathology revealed: Papillary thyroid carcinoma (solid variant); right CCLND: metastatic carcinoma (2/3) left CCLND: metastatic carcinoma (6/7); right SLND: metastatic carcinoma (11/26); left SLND: metastatic carcinoma (10/51). He was referred for WBRAI scan. Serum thyroglobulin levels were >300 ng/ml with ATG of 252 IU/ML. Pretherapy WBRAI scan showed uptake in thyroid bed, right level II lymph node and bilateral lung metastases. He was given 100 mCI of I-131 orally under medical supervision. Post therapy scan was the same as pre-therapy. Second WBRAI was done after 1 year and showed increased uptake in right level II, bilateral lungs. Scanning was again repeated after 9 months and pre-therapy scan showed increased uptake in right level II, bilateral lung nodules (macronodular) and the child was treated with 100 mCi again. His serum TG remained >300 ng/ml even after 200 mCi (Figs. 1, 2, 3, 4, and 5).