General Surgery · Year 3 · from General Surgery

Case 1: Papillary Thyroid Carcinoma

Patient Demographics

  • Age: 35 years
  • Sex: Female
  • Occupation: Marketing executive

Chief Complaint

"My doctor felt a lump in my neck during a routine physical."

History of Present Illness

The patient presents for evaluation of a thyroid nodule discovered incidentally during an annual physical examination 2 weeks ago. She is asymptomatic and had not noticed the nodule herself. She denies dysphagia, voice changes, neck pain, or compressive symptoms. She has no history of radiation exposure to the head or neck. She reports feeling generally well with stable weight and normal energy levels.

Past Medical History

  • No significant medical history
  • No prior neck surgery or radiation
  • Regular menstrual cycles

Family History

  • No family history of thyroid cancer or thyroid disease
  • No history of MEN syndrome

Medications

  • None

Physical Examination

  • Vitals: BP 118/74 mmHg, HR 70 bpm
  • General: Well-appearing young woman in no distress
  • Neck examination:
  • 1.5 cm firm, non-tender nodule in the right thyroid lobe
  • Nodule moves with swallowing
  • No cervical lymphadenopathy
  • Trachea midline
  • No thyromegaly
  • Voice: Normal

Laboratory Results

  • TSH: 1.8 mIU/L (normal)
  • Free T4: 1.2 ng/dL (normal)
  • Calcium: 9.4 mg/dL (normal)

Imaging and Cytology

Thyroid Ultrasound:

  • Right lobe: 1.6 x 1.2 x 1.1 cm solid, hypoechoic nodule
  • Irregular margins
  • Microcalcifications present
  • Taller than wide configuration
  • No extrathyroidal extension
  • TI-RADS Category 5 (high suspicion)
  • Left lobe: Normal
  • No suspicious cervical lymphadenopathy

Fine Needle Aspiration (FNA):

  • Bethesda Category VI: Malignant
  • Papillary thyroid carcinoma

Preoperative Workup

  • Laryngoscopy: Bilateral vocal cord mobility normal
  • CT neck without contrast: Confirms nodule location, no lymphadenopathy, trachea not compromised

Surgical Planning Discussion

Options presented to patient:

  1. Thyroid lobectomy: For low-risk, unifocal PTC <4 cm
  2. Total thyroidectomy: Allows RAI therapy, bilateral examination, lower recurrence

After discussion of risks, benefits, and her preferences, the patient opted for total thyroidectomy given desire for comprehensive treatment and avoiding potential second surgery.

Operative Procedure

  • Total thyroidectomy via collar incision
  • Recurrent laryngeal nerves identified bilaterally and preserved
  • Parathyroid glands identified and preserved with intact blood supply
  • Central neck dissection not performed (no suspicious nodes)
  • Intraoperative nerve monitoring used

Pathology Results

  • Right lobe: 1.5 cm papillary thyroid carcinoma, classical variant
  • Negative margins
  • No extrathyroidal extension
  • No lymphovascular invasion
  • Left lobe: Benign
  • AJCC Stage: pT1bN0M0 (Stage I, given age <55)

Postoperative Course

  • Day 1: Serum calcium 8.2 mg/dL, PTH 18 pg/mL (normal)
  • No hypocalcemia symptoms
  • Voice normal
  • Started on levothyroxine 125 mcg daily
  • Discharged POD 1

Adjuvant Therapy Decision

  • Tumor board discussion
  • ATA risk stratification: Low risk
  • Radioactive iodine (RAI): Not recommended for low-risk T1bN0 disease
  • TSH suppression: Maintain TSH 0.5-2.0 mIU/L

Follow-up Plan

  • Thyroglobulin levels every 6-12 months
  • Neck ultrasound at 6-12 months, then periodically
  • TSH monitoring for levothyroxine dose adjustment

Teaching Points

  1. Thyroid nodules are common; most are benign
  2. TI-RADS guides FNA decision based on ultrasound features
  3. Bethesda system classifies FNA cytology and guides management
  4. Surgery is primary treatment for differentiated thyroid cancer
  5. Extent of surgery (lobectomy vs. total) based on risk factors
  6. Low-risk PTC has excellent prognosis (>98% survival)

Clinical Image

Image Description: Thyroid ultrasound demonstrating a hypoechoic nodule with irregular margins and microcalcifications, features highly suspicious for malignancy (TI-RADS 5). The taller-than-wide configuration and punctate echogenic foci are characteristic of papillary thyroid carcinoma.

Attribution: Image from Wikimedia Commons, Category:Thyroid nodules. Source: https://commons.wikimedia.org/wiki/Category:Thyroid_nodules

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