A CASE REPORT ONPAPILLARY THYROID CARCINOMA OF LARGE THYROGLOSSAL CYST.pptx

A CASE REPORT ONPAPILLARY THYROID CARCINOMA OF LARGE THYROGLOSSAL CYST

1. PAPILLARY THYROID CARCINOMA OF A LARGE THYROGLOSSAL CYST: A CASE REPORT PRESENTER: DR. AKOIJAM ROMESH SINGH PGT GENERAL SURGERY DEPARTMENT JNIMS, POROMPAT

2. INTRODUCTION

3. Thyroglossal duct cyst: most commonly encountered congenital cervical anomalies During the 5 th week of gestation, the thyroglossal duct lumen starts to obliterate, and disappears by the 8 th week of gestation. Rarely, it may persist in whole or in part. Carcinoma arising from it is rare which composes 1% of total cases. Often diagnosed incidentally after surgical excision

4. The most common primary carcinoma of thyroglossal duct cyst is papillary carcinoma (75−80%). Other tumor types: mixed papillary-follicular carcinomas (7%), squamous cell carcinoma (5%), follicular carcinoma (1.7%), Hurthle cell carcinoma and anaplastic carcinoma (0.9%) The aim of this presentation is to report a case of papillary thyroid carcinoma in a large thyroglossal duct cyst.

5. CASE HISTORY A 45-year-old female presented in JNIMS Out Patient Department, in May 2023, with 1 year history of swelling over midline of the neck, giving a double chin appearance. R apidly increasing in size in the later 5 months. Not associated with pain/ dyspnoea /dysphagia/dysphonia.

6. CLINICAL EXAMINATION A midline infra-hyoid swelling of size 10x10 cm extending upto upper border of the thyroid gland. Moves with deglutition but not with the protrusion of tongue. Smooth surface with well defined margin Non tender, firm in consistency. Limited mobility on both vertical and horizontal direction No palpable cervical lymph nodes.

7. INVESTIGATIONS

8. FNAC of neck swelling : Suggestive of a benign cystic lesion, most likely thyroglossal cyst. CT SCAN OF THE NECK: Midline infrahyoid cystic mass( suggestive of thyroglossal cyst) with right colloid nodule (0.8cm). Fig: CT SCAN OF NECK

9. Fig: CT scan of neck showing thyroglossal cyst

10. Thyroid function tests were within normal limits. Haematological and biochemical investigations normal.

11. Sistrunk’s operation done. Intra-operative findings: Cystic swelling of size 6x6 cm, adherent to platysma and intracystic septations along with a nodule (0.5x0.5 cm). Post operative period was uneventful.

12. EN-BLOCK REMOVAL OF THYROGLOSSAL CYST WITH DUCT REMNANT AND CENTRAL PART OF HYOID BONE

13. The post-op period was uneventful . POST-OPERATIVE PICTURE

14. HPE: PAPILLARY THYROID CARCINOMA OF THYYROGLOSSAL CYST

15. DISCUSSION

16. The first case of thyroid carcinoma arising in thyroglossal duct remnant was reported in 1911 . Thyroid carcinoma arising in thyroglossal duct cyst is a rare entity. Around 250 cases having been published in the world literature [ 2 ]. The cause of thyroglossal duct cyst carcinoma is unclear. The predominating theories are either metastatic disease from an occult primary or spontaneous development from ectopic thyroid tissue found within the thyroglossal duct cyst wall [ 3 ].  

17. Malignancy occurs in about 1% of thyroglossal duct cysts and arises slightly more often in women [ 4 ]. The mean age of patients is 4 th decade of life. The tumor can be located anywhere along the embryological route of descent of the thyroid gland. [1] Majority of thyroid tumors that arise in thyroglossal duct cysts are papillary tumors, with less than 5% being of squamous cell type [ 5 ].

18. The pre-operative evaluation of thyroglossal duct cyst cases should include a complete physical, accurate head and neck examination, thyroid function tests, and a thyroid scan [ 6 ]. In the present case, thorough preoperative evaluation was done along with thyroid function tests which was normal. CT neck showed a right colloid nodule along with thyroglossal duct cyst.

19. The initial symptoms of thyroglossal duct cyst carcinoma are indistinguishable from a benign thyroglossal duct cyst [7]. A rapid increase in size or the presence of a firm, palpable mass may be the signs of malignancy [ 6 ]. Thyroglossal duct cyst carcinoma should be suspected when the lesion is hard, fixed, and irregular [8]. In this present case, the clinical presentation was similar to that of a benign cyst, as the lesion was well demarcated with limited mobility, and no palpable cervical lymph nodes.

20. Widstrom et al. (9) criteria for the diagnosis of primary carcinoma of the thyroglossal duct : Histological identification of thyroglossal duct carcinoma. Demonstration of the normal epithelial lining of the thyroglossal duct. Normal thyroid follicles within walls of the cyst, normal thyroid tissue adjacent to the tumor. No findings of primary thyroid carcinoma on histopathological examination of the thyroid gland . “ 3 among the 4 criteria were demonstrated in this case.”

21. For the definitive management some authors consider Sistrunk’s procedure to be adequate and curative in most cases. Others recommend that total thyroidectomy should be performed in case of thyroglossal duct cyst carcinoma, due to the high incidence of associated papillary or mixed carcinomas in the thyroid gland [ 6 ]. Regional and distant m etastatic spread are rare.

22. In a review by Patel et al., with a median follow-up of 71 months, the 5-year and 10-year Kaplan-Meier overall survival (OS) was 100% and 95.6%, respectively [ 10 ]. Park proposed that follow-up procedures consist of physical examination, ultrasound of the surgical region and thyroid and total body scintigraphy [11]. Neck scan should be re-assessed every six months during the first year and annually after that [12].

23. CONCLUSION

24. Thyroglossal duct cyst carcinoma, is a rare tumor, often diagnosed postoperatively as an incidental finding on histopathological examination. Surgery remains the cornerstone of treatment. Currently, no evidence-based clinical guidelines have been established on the optimal surgical approach and further management.

25. A multidisciplinary approach should be considered to safely identify high-risk patients, who will require a more aggressive treatment approach. For a case of thyroglossal duct cyst with normal thyroid gland, without any clinical or radiological evidence of malignancy, a possibility of underlying malignancy should be kept in mind and can be managed adequately with surgical procedure only, & with regular follow up.

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