Management of Thyroid Carcinoma with Significant Mediastinal Involvement without Sternotomy

ABSTRACT

Papillary thyroid carcinoma usually presents as a palpable thyroid swelling, and presenting as cervical lymphadenopathy is uncommon. Metastasis to the cervical lymph nodes could have several primary sources. A 70 year old male presented with painless left cervical mass which was insidious in onset, gradually increasing in size since past one year. Physical examination revealed an oval left cervical mass, extending from anterior border of sternocledomastoid (SCM) muscle to the posterior triangle of neck at level III, IV and V. Plain and contrast enhanced Computed tomography (CT) of neck and thorax demonstrated an ill defined irregular intensely enhancing multi-lobulated lesion in the left supraclavicular region. Fine needle aspiration cytology (FNAC) was suggestive of either a metastatic lesion or a primary lesion. Level V lymph node biopsy suggested papillary carcinoma thyroid. The patient underwent total thyroidectomy with bilateral lymph node dissection with excision of mediastinal lymph nodes via cervical approach without sternotomy. Histopathological examination of the specimen confirmed Papillary Thyroid Carcinoma (conventional type) with secondaries to the neck. On discharge, the patient was given radioactive iodine therapy for two weeks, followed by lifelong oral thyroxine. No signs of recurrence were noted in the follow up visits. A combination of radiological and histopathological investigations can help to assess a cervical mass of thyroid origin. The transcervical approach is simpler and safer than the transsternal approach and avoids the morbidity of a sternal split.