A 46-year-old Malay woman presented with a neck swelling that had gradually increased in size over 12 years. Examinations and investigations confirmed advanced papillary thyroid carcinoma with metastases. She underwent a total thyroidectomy with complications of hoarseness of voice and hypocalcemia managed conservatively. Further radioactive iodine therapy was planned after thyroxine treatment.

1. DAHVINIA B.DEVAN

2. Name Siti Sanah
Age 46 years old
Race Malay
Address Tawau, Sabah
Date of
admission
18/7/2007
Date of clerking 19/7/2007

3. Presented with anterior neck swelling for the past 12
years

4. She noticed the swelling 12 years ago while looking at
herself in the mirror during her last pregnancy
At that time the swelling was as big as a 20 cents coin
located at the anterior of her neck on the right side,
after delivery the swelling persisted and over 12 years
it gradually increased in size, currently as big as a

5.  It was :
 not painful
 there was no skin changes on the overlying skin
 no other swellings
 Does not complain of obstructive symptoms such as:
 shortness of breath
 difficulty in swallowing
 However she had unintentional weight loss where she had lost 12
kilograms in the past 2 months

6. Her menstruation has been irregular for the last 2
years missing up till 3 months at times. And her
menstruation bleeding lasts only for 2 days where she
uses 2 pads per day, not fully soaked
Otherwise, she denied any hypo or hyperthyroid
symptoms such as heat/cold intolerance, tremors,
palpitation, anxiety, sleeping difficulties, irritability,
frequent perspiration, muscle weakness, depression,
lethargy, constipation or diarrhea.

7. No history of exposure to radiation previously or history
of living in highlands
She does not have cough, bone aches/ history of
fractures
She initially presented to Hospital Tawau early this year
where an FNAC was done with results suggesting
Papillary thyroid carcinoma, she was than referred to
Putrajaya hosp for total thyroidectomy and further
management

8. She has no known medical illness
Never been hospitalized for other reasons besides
child birth

9. She is not on any medication
Does not use over the counter drugs or traditional
medicines
There are no known drug allergies
She is not allergic to any food

10. She is a divorcee living with 3 out of her 5 children
ranging from 25 years old – 12 years old
She used to work as a laborer in a provisional store
but has stopped working for the last 3 years as 2 of
her children had started working
The 2 eldest children support her financially
Currently she stays at home and does chores around
the house
She lives in a rented wooden house in tawau
She does not smoke and does not consume alcohol.

11. None of her family members suffers from a similar
condition.
Her mother is well
her father passed away because of old age
No family history of thyroid disorders or malignancies

12. Normally consumes rice, and vegetables, occasionally
fish
Uses normal salt that is being sold

13. Swelling
Loss of weight
Hoarseness of voice

14. General examination
My patient is sitting in bed. She is of average built,
She is conscious and orientated to time and place.
She has no clubbing, no pallor, no jaundice no
koilonychia, no onicholysis, her palms are moist and
sweaty, there is no fine tremor, her skin is not dry

15. Vital signs :
 No signs of pretibial edema
 Eyes
no peripheral loss of eyebrows, conjungtiva not
injected, not pale, no exopthalmus,no lid retraction or
lid lag
Temperature 37 ⁰C
Pulse 88 bpm
Blood pressure 140/90 mmhg
Respiratory 15 breaths per minute

16. Neck examination
Inspection:
diffuse swelling at the anterior neck extending from
the posterior margin of the right
sternocleidomastoideus muscle to the anterior border
of the left sternoccleidomastoideus muscle , vertically
and from the hyoid bone down to the sternal notch
It moves with deglutination and does not move with
the protrusion of the tongue
The jugular vein is not distended and no dilated veins
over the swelling
no surgical scars
no other skin changes
No other swelling seen

17. Palpation
Warm, non tender, position of the trachea cannot be
appreciated
 irregular shape swelling measuring 22 x 15 cm with
smooth surface and firm consistency, well defined
edge on the left side but not on the right side
(irregular), moves with swallowing, mobile vertically
and laterally, not attached to the overlying skin and
or underlying structures, no fluctuance, not pulsatile,
no thrill
the carotid pulse absent on left sign
no cervical or supraclavicle lymph nodes palpable

18. Percussion
There is no retrosternal extension of the lump
Auscultation
There is no bruit heard
Hoarseness of voice present

19. Condition Supporting
Thyroid Malignancy Increase in size, LOW, age, sex,
hoarseness of voice, possible
history of long standing goitre
Goitre Age, sex, diet, noticed during
pregnancy

20. Inv results
Full blood count Hb: 11.5
Hematocrite 34.3
Platlet : 225
TWC: 6.1
TFT T4 3.23 pmol/L (9-24) (L)
TSH 29.20 (o.49-4.67) (H)
Random blood sugar 5.06 (n)
Liver function test NORMAL
Renal profile Urea 3.7 ; Na:139 ; k:1.9 ; creatinin:37
Coagulation profile INR: 1.145
Ptt :27 (23-40) n
Pt : 12.7 (11-16)n

21. Inv results
Serum Calsium’ 2.23
Serum phosphate 1.31 (0.8-1.6) N
Neck Ct scan highly suggestive of cancer of thyroid
with invasion to larynx including vocal
cords and hypopharynx
Metastasis to cervical lymph nodes
and bilateral lungs
Histopathology
(biopsy)
Trucut biopsy suggestive of papillary
thyroid cancer

22. ECG
Chest x-ray
Vocal cord assestment Right vocal cord – with 70 degrees
scope
-Rt vocal cord immobile on resp and
phonation
-Lf vocal cord mobile , gap present on
phonation
TRO rt vocal cord palsy

23. Advanced papillary thyroid carcinoma
History
PE
INV.
-TFT
-CTSCAN
-biopsy

24. 1. Monitor TFT
2. Blood pressure monitoring
3. To start patient on L.Thyroxine 100mcg OD
4. Start patient on amlodipine 50mg
5. Lung function test
6. Echocardiography
7. Incentive spirometry for patient
8. Total thyroidectomy planned for 28th
July 2011
9. To repeat all blood investigations pre-op

25. Lung function test Normal ventilatory function
Echocardiography Ejection fraction 73%, with no LVH and
mild MR
18/7/2011  27/7/2011 :
TFT showed fluctuating results ranging from T4 and TSH from
L-thyroxin was started initially as patient was subclinically hypothyroid
however withhold at certain periods where TFT showed normal or
hyperthyroid.
Repeated blood examinations no significant difference

26. 27th
July 2011
T3: 7.06 ( raised) TSH: 3.23 (N)
Plan
1. Continue with the surgery
2. NBM 6 hours prior to surgery
3. Give anti-hypertensives + sips of clear fluid on day of
operation
4. GXM 6 pints of blood, 2 point in OT and 4 standby in
lab

27. Rt lobe of thyroid replaced by tumour measuring 10 x
10
Adherent to strap muscle
Rt IJV thrombosed with tumour
weight of gland 668 gram
Right carotid artery free from tumour, vagus nerve
preserved
Right recurrent laryngeal nerve not seen
Right parathyroid glands not seen
Tumour infiltrated trachea and shaved off

28.  Left thyroid lobe normal
 Left superior parathyroid gland seen however inferior could not be seen
 Strap muscle which has infiltrated by tumour was excised
 2 drains was placed, left and right
Intra-op diagnosis : Advanced Follicular Thyroid Carcinoma
Intra –op v/s: 110-90/60-57 mmhg, 60-70 bpm, SpO2 97-98
Intra-op ABG: 7.33/44/122/-2.1/22.9/99.4%/lac 0.9
CVP: 11-15
Hb: 10.9 g/dl
Plan
 Pt sent to ICU intubated, on ventilator and sedated cont IV midazolam,
IV morphine 2mg/hourly

29. IV ranitidine 50 mg tds
IVD 2NS 2 DSIV
IV ca gluconat 1 g tds 1/7
Repeat blood examinations in ICU (FBC,
coagulation screeen, RP, ABG, serum calsium post
op 6 hours than bd)
ECG stat in ICU
i/o charting
DVT foot pump
Extubation cm

30. Completed 4 pints of packed cells
Completed 2 unit of FFP
Phy examination:
Vital signs
Lungs clear, CVS DRNM
Bp 120/64 mmhg
Pulse rate 55 bpm
temperature afebrile

31. Drain
Significant inv results:
Hb: 11.2 (N)
platlet 151 (N)
Rp creat 42
ca: 1.912.01 (L)
inr/pt/aptt : 1.1/26/13.1 (N)
Drain amount
Right (functioning) 50 cc hemoserous
Left (functioning) 50 cc hemoserous

32. Plan
2 units of FFP
Once tolerating orally start Ca. lactate 2 tabs tds
Cont VM post extubation
FBC and Coagulation screen daily
Endocrine: plan to get RAI therapy date prior to start of
thyroxine therapy

33. ICU day 2
Hb 11.5 g/dl, pt/aptt: 27/12.7 N
Off cbd, ryles tube, of ivi morphine
Start tab tramadol 50mg td + ca lactate 2tab tds
Chest physio
Trace TFT/alb(33)
ICU day 2 (evening)
Extubated, change to CPAP ,pt comfortable
Hoarseness of voice>>>promient
Changed to VM 50% cmabg 7.45/33/178/231/-0.2/99%, lac 0.6
Ca: 2.06 (L) add ca lactate 4 tab qid + alfacalcidol 1 mcg od
repeat ca cm (2.08)
Start l.thyroxine 200 mcg odRAI date only in September
Cont other medications
Allowed to ward +incentive spirometry and chest physio

34. POD3-POD5
Pt v/s normal,ambulating
Hoarseness of voice not worsening
Bp: 146/81 pr: 88
No hypocalcemia symptoms
Lungs clear, cvs DRNM
Wound clean, no hematoma drains
Chovstek sign (-)
POD 3 Ca 2.08- on calsium gluconate IV tds and ca. lactate
4 tab qid +alfacalcidol
IV ca stopped and serum ca on POD4 : 2.10
drains amount
right 50 cc
left 30 cc

35. Pod 6
-patient allowed for discharge,
-remove drain
-referral to Tawau hosp for follow up and medication
-tab L-thyroxine 200mcg od 2/12
-tab calsium lactate 300mg x 3 od 2/12
-cap alfacalcidol 1 mcg od
-amlodipine 5mg od 1/12
-PCM 500mg x 2 qid 1/12

36. Management of differentiated thyroid cancer

39. Type findings
Pappillary Orphan annie, psamoma bodies
Follicular Follicles,Capsular/vascular invasion

40. Medullary Amyloid deposition
IHC: calcitonin
Anaplastic pleomorphic giant tumor
cell nuclei
Lymphoma Reed-sternberg cells,

41. Post thyroidectomy complications
1. Hypocalcemia
2. Hypoparathyroidism
3. Vocal cord dysfunction
4. Recurrent laryngeal nerve injury
5. Hematoma
6. Haemorrhage
7. Wound infection
8. tracheostomy

42. AACE Clinical Practice Guidelines for the Diagnosis and
management of Thyroid Nodules. Endocr Pract 1996;2:78-
84.
Solomon BL, Wartofsky L, Burman KD. Current trends in
the management of well-differentiated papillary thyroid
carcinoma. J Clin Endocrinol Metab 1996;81:333-339.
Pyke CM, Hay ID, Goellner Jr, et al. Prognostic
significance of calcitonin immunoreactivity, amyloid
staining and flow cytometric DNA measurements in
medullary thyroid carcinoma. Surgery 1991;110:964-970.
Bailey and love Surgery textbook