Normal Ectopic Thyroid Masquerading as recurrent thyroid cancer in Lateral neck lymph node.What Went Wrong needing major thyroid and neck dissection surgery, and lifetime thyroid hormone therapy.

Normal Ectopic Thyroid Masquerading as recurrent thyroid cancer in Lateral neck lymph node.What Went Wrong needing major thyroid and neck dissection surgery, and lifetime thyroid hormone therapy.

Benign Ectopic Thyroid BET in the Lateral (Level II) Neck Compartment

 

Dr.Guttler’s Comments:

Image of a Cutting Needle biopsy of the wall of a cystic nodule as seen here could have proved it was benign normal thyroid tissue.

 

1.Lateral neck location of 

EBT is rare and usually associated with abnormal disease in the thyroid gland in the normal position.

2.BET is found in 1 in 100000 cases.

3.This is usually felt to be part of a primary thyroid cancer in the normal located thyroid gland.

4.Tumor board presentation determined that her clinical presentation was most consistent with stage I cT1N1b regionally metastatic papillary thyroid microcarcinoma (PTC) to the right lateral neck without an identified primary lesion on preoperative imaging.

5.They recommended total thyroidectomy and right modified radical neck dissection.

6.At surgery the neck mass was benign thyroid tissue on frozen section.

7. The portions of the scheduled surgeries that were performed were right lateral neck dissection, right hemithyroidectomy, and right-central compartment neck dissection.

8.The

neck dissection specimen contained 45 lymph nodes, all of which were negative for carcinoma.

9. The right thyroid lobe pathology demonstrated benign thyroid parenchyma with multifocal adenomatoid nodules. 

10. The patient has to take thyroid hormone for life.

11.The findings are best classified as a benign ectopic thyroid nodule with cystic alterations.

12.Presentations of ectopic thyroid in the lateral neck often mimic the clinical presentation of cervical metastasis of a thyroid malignancy with unknown primary.

13.There were many chances to save the thyroid gland and avoid the neck dissection.

14. This was published in 2022 when there were other tests to confirm the ectopic thyroid was not cancer. The thyroglobulin TG in the fluid confirmed it was of thyroid origin but did not confirm thyroid cancer as the cause.Thyroid cysts have high washout TG as well. Collecting needle washout during FNA or a cutting needle biopsy CNB for molecular markers could tell it was benign thyroid tissue. needle biopsy CNB for molecular markers could tell it was benign thyroid tissue.

15. The physicians were leaning toward surgery whether subtotal, total with a big neck dissection all for something that a major university should have considered before surgery.

16. 46 lymph nodes removed will leave scars  and local symptoms.

17. Biggest mistake was removing the half thyroid gland. 80% will need thyroid hormone for life even with just one lobe removed.

18. The paper stated “This approach can balance safe and effective oncologic care with reducing the morbidity of potentially avoidable surgery that would predispose the patient to lifelong high-dose thyroid hormone replacement.”

19. This was false as the patient had hypothyroidism treated with LT4 after the surgery.

20. The physicians were leaning toward surgery whether subtotal total with a big neck dissection all for something that a major university should have considered before surgery.

What did we learn? Failure to get the best thyroidologist to do a second opinion BEFORE the surgery could have saved the patient the pain,expense, and lifetime treatment for hypothyroidism.

Even a top university like with expert thyroidologists, cytologists, and molecular marker experts may not have ask for consultative help before the knife was used.

The benign ectopic thyroid nodule could have been ablated with RFA and spared to patient all the anxiety fear and morbidity of major thyroid surgery.

Call me at 310-393-8860 or email to thyroid.manager@thyroid.com before you have surgery.

Ask For Alicia.

Dr.G.

 

 

George S. Liu,



Abstract

Ectopic thyroid most commonly presents in the midline and is typically associated with the absence of an orthotopic thyroid. Less commonly, ectopic thyroid can present in the lateral neck, typically with a coexisting orthotopic thyroid and abnormal pathology in either the ectopic or orthotopic thyroid tissue. This paper describes a rare case of a benign, ectopic thyroid in the lateral neck (level II) associated with a normal, benign orthotopic thyroid. This report illustrates clinical pearls for the management of this unusual entity.

Introduction

Ectopic thyroid is uncommon, with an estimated prevalence of 1 in 100,000, and involves the presence of thyroid tissue in an abnormal location, most often in the midline neck near the base of the tongue with an absence of an orthotopic thyroid [1]. Less commonly, ectopic thyroid can occur off midline in the submandibular space (level Ib) or, rarely, in the lateral neck (levels II-IV) [2-6]. We describe a case of benign ectopic thyroid presenting in the right lateral neck (level IIa) with a coexisting benign orthotopic thyroid. Initially, the lesion was suspected to represent cervical metastasis of a thyroid malignancy without a known primary. However, the intraoperative appearance and frozen section analysis of the lateral neck lesion appeared benign, which changed the surgical management and allowed the preservation of the patient’s thyroid gland. This case illustrates clinical pearls for the diagnosis and management of ectopic thyroid in the lateral neck in the rare case that it is encountered. The Stanford Institutional Review Board provided an exemption for this report.

Case Presentation

A 49-year-old female presented to our clinic with a painless mass in the right neck that had been asymptomatic and stable in size for 1.5 years. The mass had been first noted incidentally by her dentist. She had no history of radiation exposure and no personal or family history of head and neck cancer. On examination, the mass was soft, non-tender, mobile, and deep to the sternocleidomastoid muscle. Ultrasound (Figure 1), computed tomography (CT) (Figure 2), and magnetic resonance imaging (MRI) demonstrated a 1.5 x 1.8 x 2.1 cm partially cystic lesion in the right neck compartment (level IIa) and a normal, orthotopic thyroid gland with no suspicious nodules. Fine needle aspiration (FNA) of the right neck lesion demonstrated paucicellular cyst fluid with elevated thyroglobulin (>30,000 ng/mL) and no epithelial cells, consistent with a cystic lesion containing thyroid tissue. Because no epithelial cells were recovered, the cytologist was unable to directly visualize thyroid tissue cells in the sample to assess for features concerning for malignancy. Endocrinologic workup revealed her to be euthyroid.

The patient’s case was discussed at our multi-disciplinary thyroid and parathyroid tumor board, which determined that her clinical presentation was most consistent with stage I cT1N1b regionally metastatic papillary thyroid microcarcinoma (PTC) to the right lateral neck without an identified primary lesion on preoperative imaging. It was determined that the primary malignant lesion would likely be found in the orthotopic thyroid gland on final pathology. Therefore, the tumor board recommended performing a total thyroidectomy, central neck dissection, and right lateral neck dissection. The risks, benefits, and alternatives to surgery were discussed with the patient, including the alternative surgical option of a staged approach with initial right neck dissection followed by total thyroidectomy and central neck dissection if the pathology of the neck nodes was positive for thyroid cancer. The patient elected to proceed with upfront total thyroidectomy and neck dissections. She was scheduled for a total thyroidectomy with central and right lateral neck dissections. Intraoperatively, a 3 cm, gray, right neck mass (level II) was noted. The appearance of the mass was smooth and atypical for cervical metastasis of papillary thyroid cancer. Frozen section analysis of the mass demonstrated bland thyroid tissue epithelium without evidence of malignancy. Based on the frozen section results and the atypical appearance of the level II neck mass, the operation was stopped with a plan to stage a completion thyroidectomy and left central neck dissection if final histopathology demonstrated malignancy. The portions of the scheduled surgeries that were performed were right lateral neck dissection, right hemithyroidectomy, and right-central compartment neck dissection.

Final histopathology demonstrated the right neck mass to be a benign thyroid nodule with cystic alterations and no evidence of malignancy (Figure 3). The neck dissection specimen contained 45 lymph nodes, all of which were negative for carcinoma. The right thyroid lobe pathology demonstrated benign thyroid parenchyma with multifocal adenomatoid nodules. At the 14-month follow-up, the patient was doing well with no evidence of disease, normal vocal-fold mobility on flexible laryngoscopy exam, and stable subclinical hypothyroidism on low-dose levothyroxine.

Discussion

To the best of our knowledge, this is the first report in the English-language literature of a benign, ectopic thyroid in the lateral neck (levels II-IV) associated with a normal, benign orthotopic thyroid. Two prior reports describe benign ectopic thyroid in the lateral neck associated with an orthotopic, multinodular thyroid goiter [2,3]. Three prior reports describe ectopic thyroid in the lateral neck associated with PTC involving either the ectopic or orthotopic thyroid gland [4-6]. Table 1 summarizes the findings of these case reports. Based on these case reports and the one presented here, ectopic thyroid tissue in the lateral neck typically presents with the appearance of a cystic nodule and, interestingly, typically coexists with an orthotopic thyroid, in contrast with midline ectopic thyroid, which most commonly lacks an orthotopic thyroid in 70-90% of patients [1,2].

Location of ectopic thyroid # Cases / # Nodules Characteristic of ectopic nodule Ectopic thyroid pathology Orthotopic thyroid pathology Reference
Right level IV 1 / 1 2 cm cystic Papillary thyroid carcinoma Total benign Sánchez Fuentes et al. 2015 [4]
Left levels II and III 1 / 2 Two 4 cm nodules, calcified and cystic Benign ectopic thyroid tissue Left lobe papillary thyroid carcinoma nodule Choi et al. 2008 [5]
Lateral neck (unspecified) 6 / 6 2/6 palpable, 4/6 on ultrasound (US) Nodular goiter Multinodular goiter Santangelo et al. 2016 [2]
Right levels II and III 1 / 1 2.5 cm cystic mass Papillary thyroid carcinoma Benign thyroid Agosto-Vargas et al. 2017 [6]
Left lateral neck (unspecified) 1 / 3 2.5 cm to 9 cm in size, smooth Adenomatous goiter Adenomatous goiter Nasiru Akanmu et al. 2009 [3]

The embryologic development of ectopic thyroid in the lateral neck remains unclear. One theory is that ectopic thyroid tissue in the lateral neck originates from the ultimobranchial bodies, the neural crest progenitors of parafollicular C cells, in the lateral anlage of the thyroid gland. By contrast, midline ectopic thyroid is thought to arise from endodermal remnants left along the thyroglossal duct tract during the descent of the primordial thyroid gland [1].

Presentations of ectopic thyroid in the lateral neck often mimic the clinical presentation of cervical metastasis of a thyroid malignancy with unknown primary. Detection of thyroid tissue outside of the central neck compartment (level VI) rightly warrants strong suspicion for cervical metastasis of a primary thyroid malignancy until proven otherwise. The rare presentation of an off-midline ectopic thyroid is important to be aware of in cases in which preoperative imaging does not reveal a primary thyroid malignant lesion, and there is strong clinical suspicion for a benign lesion based on intraoperative findings. In such cases, a staged approach can be considered with upfront excisional biopsy and frozen section analysis prior to staged completion of thyroidectomy and central neck dissection. This approach can balance safe and effective oncologic care with reducing the morbidity of potentially avoidable surgery that would predispose the patient to lifelong high-dose thyroid hormone replacement.

Conclusions

Most cases of ectopic thyroid present in the midline with an absence of an orthotopic thyroid; rarely, ectopic thyroid can present in the lateral neck. This is the first report of a benign, ectopic thyroid in the lateral neck (level II) associated with a normal orthotopic thyroid. The presentation of thyroid tissue in the lateral neck rightly warrants suspicion for cervical metastasis of a primary orthotopic thyroid malignancy. However, the absence of a primary lesion on preoperative imaging and benign intraoperative characteristics, including frozen section analysis, suggests that a staged surgical approach can be considered. In our case, a staged surgical approach confirmed the diagnosis of off-midline ectopic thyroid and spared the patient completion thyroidectomy and the associated morbidity of lifelong dependence on high-dose thyroid hormone supplementation. This report contributes to the limited literature on lateral neck ectopic thyroids and refines their characterization to note their typical coexistence with an orthotopic thyroid, in contrast with midline ectopic thyroids.


 

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