Presentation
Left neck swelling for the two months. No hearing or swallowing complaints. No fever or weight loss.
Patient Data
There is a heterogenous lobulated lesion with internal vascularity measuring about 2.6 x 2.8 x 4.2 cm noted at the bifurcation of the left common carotid artery (at the site of the patient's complaint) appears close to the surrounding vessels without obvious invasion, another similar lesion but smaller in size 1.0 x 2.3 cm on the right side.
The right thyroid lobe shows a heterogenous mainly hypoechoic nodule with internal cystic structure about 1.0 x 0.7 x 1.2 cm.
The left thyroid lobe shows an isoechoic nodule, the largest measures about 3.0 x 2.4 x 4.1 cm showing internal vascularity, and the other nodule appears exophytic originating from its inferior region.
There is well defined lobulated relatively hype vascular enhancing soft tissue lesion measuring 3.6 x 2.8 cm seen in the left submandibular space, at the level of the left carotid bifurcation without obvious displaying carotid arteries however, it deviates them medially, this mass also deviates the submandibular gland anteriorly with a clear separating fatty planes, it appears to be mainly supplied from the ascending pharyngeal artery.
The thyroid gland appears enlarged with a heterogenous nodule seen in the left lobe.
Pathology report:
left submandibular mass excisional biopsy: features most consistent with lymph node metastatic medullary carcinoma
left lateral neck, dissection: metastatic medullary carcinoma in four out of sixteen lymph nodes was identified; the size of the largest nodal deposit is 1.2 x 0.3 cm; and no evidence of extranodal extension was seen
thyroid gland, total thyroidectomy, and central lymph node: medullary carcinoma, classical type (tumor location is seen in the left lobe, tumor largest diameter is 3.5 cm, no encapsulation, however lymphovascular invasion present, no multi-centricity
other pathology: the right lobe shows hyperplastic nodules with Hurthle cell changes; no parathyroid tissue was identified in this material
lymph nodes: the separate piece submitted in this container is a central lymph node "as oriented by the surgeon" and shows total replacement by tumor, the other smaller pieces show fatty tissue only
There is a solitary calcified nodule seen in the anterior segment of the right upper lobe, which measures about 2.5 mm.
A linear atelectatic band is seen in the lingula.
There are abnormally enhancing cervical and mediastinal lymph nodes seen as the following:
The left anterior jugular measures about 1.6 x 0.9 cm, the left lower cervical measures about 1.0 x 1.3 cm, and the left upper paratracheal, the largest, measures about 1.8 x 1.0 cm.
Case Discussion
The patient presented with a suspicious mass on the left side of the neck and subsequently underwent a total thyroidectomy and neck dissection. Histopathology was done and showed medullary thyroid carcinoma with metastatic lymph nodes.
After one year, the patient came for follow-up, and new enhancing lymph nodes were noted.
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