{"id":49231,"date":"2023-06-30T11:18:01","date_gmt":"2023-06-30T11:18:01","guid":{"rendered":"https:\/\/biomedpharmajournal.org\/?p=49231"},"modified":"2023-07-11T06:01:29","modified_gmt":"2023-07-11T06:01:29","slug":"inaccurate-examination-of-neck-lump-as-regional-metastasis-of-papillary-thyroid-carcinoma-in-children-a-case-report","status":"publish","type":"post","link":"https:\/\/biomedpharmajournal.org\/staging\/vol16no2\/inaccurate-examination-of-neck-lump-as-regional-metastasis-of-papillary-thyroid-carcinoma-in-children-a-case-report\/","title":{"rendered":"Inaccurate Examination of Neck Lump as Regional Metastasis of Papillary Thyroid Carcinoma in Children: A Case Report"},"content":{"rendered":"\n

Introduction<\/strong>\n<\/p>\n\n\n\n

A neck  lump or enlarged neck lymph nodes were common in children because the lymph nodes were an immune system. Involvement of neck lymph nodes can be caused by infection, autoimmune, metabolic disease, and malignancy.1<\/sup> However, enlarged neck lymph nodes can be a mark of metastases from another organ. Thyroid carcinoma is uncommon in children and it can present with or without palpable thyroid enlargement1\u20135<\/sup>. <\/p>\n\n\n\n

Thyroid carcinoma of childhood and adolescence is a rare case finding 1,2<\/sup>, approximately 1.5-3% of all carcinoma in that group in the United States and Europe.2<\/sup> Incidence of thyroid carcinoma is very rare in early childhood and the case can increase with age.2<\/sup> Based on an epidemiological survey in the United States, the new case of thyroid carcinoma is 1.8% in people <20 years old.4<\/sup> Thyroid carcinoma can occur in children who receive external radiation therapy for the treatment of other carcinomas in the neck, autoimmune thyroid disorders, and genetic syndromes.3<\/sup> <\/p>\n\n\n\n

Presentation of differentiated thyroid carcinoma (DTC) was thyroid nodule in children and the incidence of clinically palpable thyroid was 1-1.5%.2,4<\/sup> In the young age population, thyroid nodule was four times the risk of malignancy and DTC was 0.5-3% of all malignancies.2<\/sup> <\/p>\n\n\n\n

The most common thyroid cancer in children was papillary thyroid carcinoma3,5<\/sup> and it usually presents as neck lymph node enlargement, with or without palpable thyroid.4<\/sup> Thyroid in children usually manifests with advanced disease when diagnosed, compared to adults. Approximately 60-80% of children with DTC had regional lymphadenopathy. The prognosis the DTC in children was good with 10-year mortality <10% and overall survival of 98%, but 20-year overall survival was 95%.6<\/sup><\/p>\n\n\n\n

The diagnosis of thyroid in children is the same as in adults. It is based on history taking, physical examination, laboratory analysis, imaging, cytology with fine needle aspiration biopsy, and histopathology from thyroid after surgery. We will report a pitfall of misdiagnosing management of the thyroid carcinoma in children.<\/p>\n\n\n\n

Case Report<\/strong>\n<\/p>\n\n\n\n

An eight-year-old girl came to surgical oncology policlinic Prof. Dr. I.G.N.G. Ngoerah general hospital with a tumor on her right neck below the ear lobe and a scar of biopsy on her right neck (Figure 1). Previously, she went to the regional hospital because there were multiple lumps on right neck below the ear lobe in the last 1.5 years ago. Physical examination on thyroid was on her normal limits. She had neck ultrasonography (Figure 2) and the result was a suspicious malignancy mass of the right thyroid with size 2.71 x 2.19 x 3.1 cm, and right neck lymph nodes enlargement with size 5.31 x 2.87 cm. And then, she underwent a computerized tomography (CT) scan of the neck (Figure 3) to confirm a lesion at the right thyroid and the result was multiple conglomerated lymph node enlargements of the right neck, enhanced with contrast, and suspicious of the malignant lesion. Both thyroid and nasopharynx were within normal limit s. She had done the surgery on the right neck lump without fine needle aspiration biopsy and it was a papillary thyroid carcinoma.<\/p>\n\n\n\n\n\n
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Figure 1: <\/strong>Clinical picture at surgical oncology policlinic Prof. Dr. I.G.N.G. Ngoerah general hospital and scar <\/strong>of biopsy on right neck.<\/strong><\/p>\n

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Figure 2:<\/strong> Neck ultrasonography.<\/strong><\/p>\n

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Figure 3: <\/strong>Computerized <\/strong>tomography scan of neck.<\/strong><\/p>\n

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She was referred to Prof. Dr. I.G.N.G. Ngoerah general hospital and we found a scar from  surgery on her right neck (Figure 1). We examined the neck region and thyroid function. The neck examination found painless with multiple lymph nodes and solid consistency in the right neck with the greatest diameter of 5 cm, a scar of biopsy, small enlargement of right thyroid of 1 cm. The thyroid function was within  normal limits with free thyroxine (FT4) 1.21 ng\/dl and thyroid stimulating hormone (TSH) 2.63 \u00b5IU\/ml. She had done total thyroidectomy and right radical neck dissection (Figure 4). <\/p>\n\n\n\n\n\n
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Figure 4: <\/strong>Total thyroidectomy and right Radical Neck Dissection. Surgical incision plan (A), right radical neck dissection with sternocleidomastoid muscle removal (B and C), wound closure after surgery (D).<\/strong><\/p>\n

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The surgical pathology examination was papillary thyroid carcinoma with four metastasis lymph nodes from nine lymph nodes at levels II, III, and IV. She did not consume levothyroxine after surgery because she will undergo radioactive iodine (RAI). The laboratory results before RAI were TSH 192.40 \u00b5IU\/ml, thyroglobulin 200 ng\/ml, and antithyroglobulin antibody 12 IU\/ml.  One month after the surgery, she underwent RAI using NaI-131 33 mCi. The results were no signs of residual malignancy in the area of surgery, residual functional left thyroid tissue at the level of the thyroid cartilage, and multiple subcentimeter nodules of bilateral lung that are currently not capturing radioactivity should be considered as metastases due to competitive residual functional thyroid tissue. She consumed levothyroxine for hormonal suppression starting from 50 \u00b5g per day with target of TSH <0.1 \u00b5IU\/ml. After thyroid ablation, she was no any local recurrent in surgical field and had no complains. Her schedule of second RAI was next 9 months.<\/p>\n\n\n\n

Discussion<\/strong><\/p>\n\n\n\n

Neck lymph nodes are an important part of immune system and it can enlarge because of infection, autoimmune, metabolic disease, and malignancy. Lymph nodes involvement in a variety of conditions is accompanied by a large number of available diagnostic procedures. This can be a challenge for clinicians to establish a proper diagnosis and therapy in pediatric patients through history taking, physical examination, and adjunct examination.1<\/sup><\/p>\n\n\n\n

Adjunct\nexamination can help clinician to confirm the enlargement of neck lymph nodes.\nIt includes laboratory or microbiology test, radiological examination\n(sonography, CT scan, or magnetic resonance imaging), cytology test, and\nhistopathology test.<\/p>\n\n\n\n

Thyroid carcinoma\nin children has a unique characteristic, in which 36% the size of the tumor at\nfirst diagnosis is more than 4 cm and only 9% less than 1 cm. Papillary thyroid\ncarcinoma in children with less than 1 cm size of tumor at diagnosis is only 1.5-3%\nand it is usually multicentric.2<\/sup> In\naddition, it is necessary to evaluate for risk factors that can cause thyroid carcinoma\nin children, such as a family history of thyroid carcinoma or radiation\nexposure.<\/p>\n\n\n\n

The histological subtypes of thyroid carcinoma in children is similar to adult, there are 90-95% papillary and 5% follicular. Poorly differentiated thyroid carcinoma in children is very rare case, t<\/a>he incidence is about 2-5%. 2,7<\/sup> Papillary thyroid carcinoma had good prognostic, but with proper treatment, it had risk of recurrence with estimation 14-25% in five years and 34-40% in 10 years.8<\/sup> Sporadic papillary thyroid carcinoma occurred 1.4% of pediatric carcinoma in United States of America.9<\/sup> <\/p>\n\n\n\n

Based on gender,\nthe incidence of carcinoma changes according to age group. The incidence in the\n5-14 age group, boys have a 6:1 risk of developing thyroid carcinoma, whereas\nin the age group more than 14 years, girls are more at risk with 5:2.9<\/sup> Other\ncharacteristic is higher probability of neck lymph nodes metastasis and distant\nmetastasis. In the previous report, 90% of children with papillary thyroid\ncarcinoma had involvement of neck lymph nodes enlargement and 7% of children\nhad distant metastasis (most common site is the lung).2<\/sup> <\/p>\n\n\n\n

The most patient of\nDTC needs total thyroidectomy for the initial surgical approach.2,4,8<\/sup>\nAmerican Thyroid Association recommend central neck dissection for patients had\ncentral neck lymph nodes metastasis and lateral neck dissection for patients\nhad metastasis lymph nodes on lateral neck.4<\/sup><\/p>\n\n\n\n

Suspicious lymph nodes on lateral neck can be investigated prior surgery by neck ultrasonography and confirmation of metastasis by fine needle aspiration biopsy.4<\/sup> Preoperative diagnosis of a lump in the neck is necessary to differentiate the presence of lymph node metastases or not. The accurate prediction can help surgeon to select the surgical technique and reduce reoperation.10<\/sup><\/p>\n\n\n\n

The incidence of central cervical metastasis in children was 60-90% macro or microscopic metastasis, so the prophylactic central neck dissection should be performed during total thyroidectomy.8<\/sup> Other report showed metastatic papillary thyroid carcinoma of lymph nodes without primary carcinoma in thyroid gland. It can be categorized as an occult thyroid carcinoma.11<\/sup><\/p>\n\n\n\n

Other\ninvestigation used lymph node ratio (LNR), that is an index by dividing the\nnumber of positive lymph nodes by the total of lymph nodes resected. The cut-off\nvalue point of 0.45 was useful to predict recurrence in pediatric patients.8<\/sup> In\nthat research, there were a significant result of recurrence with p = 0.02 on\npediatric patient who performed total thyroidectomy and modified radical neck\ndissection. There were 3 recurrences in 12 patients (25%) with LNR \u22640.45 and 4\nrecurrences in 4 patients (100%) with LNR >0.45.8<\/sup><\/p>\n\n\n\n

Most cases are\nrecommended RAI after total thyroidectomy, but RAI can not replace the surgery.\nRAI can be repeated 6-12 months after first treatment. Other modality to\ntreatment is hormonal replacement. The suppressive therapy of thyroid hormone\ncan reduce risk of tumor growth proliferation by TSH. In children, there is\nstill a growth process, so there are side effects of suppression treatment. The\nside effect of Iodine 131 is temporary loss of salivary flow, change of taste, sialadenitis,\nand infertility. The accumulative doses of iodine up to 300 mCi does not cause\ninfertility in girl but can cause infertility in < 10% boy. The accumulative\ndoses of more than 800 mCi can cause infertility in 60% girl and > 90% boy.2<\/sup><\/p>\n\n\n\n

Based on this\ncase, we need to sharpen the diagnostic of neck lymph nodes enlargement,\nespecially in children. The history taking, physical examination, and\nradiological examination are triple instruments to achieve diagnostic. The\npathological examination was the gold standard to distinguish the lesion as benign\nor malignant. We can do fine needle aspiration biopsy as a less invasive method\nto evaluate neck lymph nodes enlargement.<\/p>\n\n\n\n

Conclusion<\/strong>\n<\/p>\n\n\n\n

Inchildren, enlarged neck lymph nodes must be considered as a metastasis lesion of thyroid. Although thyroid carcinoma is rare in children, we can do fine needle aspiration biopsy to evaluate the origin of enlargement. It can reduce the increase in cancer staging and the risk of metastasis. The most common thyroid cancer in children was papillary thyroid carcinoma.<\/p>\n\n\n\n

References<\/strong><\/p>\n\n\n\n

  1. Lang S, Kansy B. Cervical lymph node diseases in children. GMS Curr Top Otorhinolaryngol Head Neck Surg<\/em>. 2014;13:1\u201327. doi:10.3205\/cto000111<\/li>
  2. Vaisman F, Corbo R, Vaisman M. Thyroid carcinoma in children and adolescents-systematic review of the literature. J Thyroid Res<\/em>. 2011;2011:Article ID 845362. doi:10.4061\/2011\/845362
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  3. Chan CM, Young J, Prager J, Travers S. Pediatric Thyroid Cancer. Adv Pediatr<\/em>. 2017;64(1):171\u2013190. doi:10.1016\/j.yapd.2017.03.007
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  4. Francis GL, Waguespack SG, Bauer AJ, et al. Management Guidelines for Children with Thyroid Nodules. Thyroid<\/em>. 2015;25(7):716\u2013759. doi:10.1089\/thy.2014.0460
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  5. Verburg FA, Van Santen HM, Luster M. Pediatric papillary thyroid cancer: Current management challenges. Onco Targets Ther<\/em>. 2017;10:165\u2013175. doi:10.2147\/OTT.S100512
    CrossRef <\/a><\/li>
  6. Parisi MT, Eslamy H, Mankoff D. Management of differentiated thyroid cancer in children: Focus on the American Thyroid Association pediatric guidelines. Semin Nucl Med<\/em>. 2016;46(2):147\u2013164. doi:10.1053\/j.semnuclmed.2015.10.006
    CrossRef <\/a><\/li>
  7. Piromchai P, Ratanaanekchai T, Kasemsiri P. Diagnosis and Treatment of Anaplastic Thyroid Carcinoma. Int J Clin Med<\/em>. 2012;3(1):69\u201373. doi:10.4236\/ijcm.2012.31016
    CrossRef <\/a><\/li>
  8. Rubinstein JC, Dinauer C, Herrick-Reynolds K, Morotti R, Callender GG, Christison-Lagay ER. Lymph node ratio predicts recurrence in pediatric papillary thyroid cancer. J Pediatr Surg<\/em>. 2019;54(1):129\u2013132. doi:10.1016\/j.jpedsurg.2018.10.010
     CrossRef <\/a><\/li>
  9. Gayathri BN, Sagayaraj A, Prabhakara S, Suresh TN, Shuaib M, Mohiyuddin SMA. Papillary Thyroid Carcinoma in a 5-Year-Old Child\u2014Case Report. Indian J Surg Oncol<\/em>. 2014;5(4):321\u2013324. doi:10.1007\/s13193-013-0282-3
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  10. Agyekum EA, Ren YZ, Wang X, et al. Evaluation of Cervical Lymph Node Metastasis in Papillary Thyroid Carcinoma Using Clinical-Ultrasound Radiomic Machine Learning-Based Model. Cancers (Basel)<\/em>. 2022;14(21):5266. doi:10.3390\/cancers14215266
    CrossRef<\/a> <\/li>
  11. Li D, Li J, Zhou J, Xiao Q, Gao H. Metastatic papillary thyroid carcinoma with no primary tumor in the thyroid gland: a case report and review of literature. Transl Cancer Res<\/em>. 2022;11(1):299\u2013305. doi:10.21037\/tcr-21-1780
    CrossRef<\/a><\/li><\/ol>\n","protected":false},"excerpt":{"rendered":"

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