Papillary Carcinoma of Thyroglossal Duct Cyst

Dr. Pawanjit Rohila Prof. R.K.Karwasra Deptt. Of Surgery and Surgical Oncology Pt. BD Sharma PGIMS Rohtak

Carcinomas of thyroglossal duct cysts are extremely rare (1.5%)

Papillary.80% Mixed papillary/follicular9.5% Squamous cell.7.6% Others.2.9%

Most of the times the diagnosis is postoperative There is no clear consensus regarding further management after adequate excision of the cyst

Case One
40 years old female presented with asymptomatic , submental,midline swelling for last 5 years, increasing in size for last 6 months and increased suddenly after FNAC 6x6x4 cm non-tender, firm mass at the level of hyoid bone Not moving with deglutition and protrusion of tongue Bilaterally palpable cervical lymph nodes X-ray STN revealed soft tissue mass anterior to hyoid without calcifications Patient was euthyroid and thyroid gland was normally located on ultrasonography FNAC of the mass reported to be Adenomatous goiter

Pre-op Diagnosis : PLAN :

Thyroglossal Duct cyst with hematoma following FNAC Sistrunks procedure with frozen section examination

Operative Findings 6x6x5cm mass having blood clots within, adherent to hyoid and bilateral multiple nodes Thyroid was normal upon palpation Sistrunks procedure performed Tissue sent for Frozen Section Examination Papillary carcinoma in TGDC with invasion of cyst wall, LN + for metastasis

Total thyroidecectomy with bilateral MRND (type III) performed

Final Histopathology Report Revealed

Papillary Carcinoma in a thyroglossal duct cyst with extra cystic extension Normal thyroid tissue in cyst wall, both lobes of Thyroid showing normal structure without any focus of malignancy Level II, III, and VI nodes positive for metastasis I131 SCAN..1.6% UPTAKE PATIENT REFERRED FOR RADIOABLATION

2nd Case
24 years old female presented with progressively increasing asymptomatic midline swelling in sub-mental region for last 1 years and pain in the swelling for last 25 days after FNAC. 44 cms. Firm, non-tender mass above the level of hyoid bone . Moving with deglutition and protrusion of tongue without palpable cervical LAP. Patient was euthyroid and thyroid gland was normally located on USG. FNAC of the mass reported to be metastasis from papillary carcinoma of thyroid. CECT neck revealed a hypo dense lesion of 4.54 cm with calcification showing heterogeneous enhancement seen in the floor of mouth. Few subcentimetric lymph nodes were seen in bilateral cervical region.

Pre-op diagnosis : Plan :

TGDC with Papillary carcinoma Sistrunks opn. With Total Thyroidectomy and LN Sampling

Operative findings 4.54 cm Fibrocystic mass above the hyoid bone adherent to the underlying muscles Thyroid gland was normal on palpation A single enlarged level II lymph node on the right side. Few enlarged lymph nodes were excised

Frozen section examination of LNs revealed reactive hyperplasia

Formal neck dissection not done.

Total thyroidectomy with Sistrunks operation performed

Final Histopathology Report revealed

Thyroid as unremarkable Lymph nodes as reactive. Papillary carcinoma in ectopic thyroid tissue

No Clear Consensus In Literature Regarding Management

Sistrunks Procedure With Thyroid Suppression V/S Total Thyroidectomy With MND

Justifications For Total Thyroidectomy

Any papillary carcinoma in neck originates in thyroid gland Papillary carcinomas are multifocal in origin Enables post operative thyroid scan and thyroid ablation Thyroglobulin estimation is more relevant if there is no thyroid Patient needs thyroid suppression therefore why to leave the possible culprit behind ? Procedure is safe and has low morbidity

Justifications for Sistrunks Procedure

Disease is less aggressive Papillary carcinoma in thyroglossal duct cyst originates de novo Retrospective analysis at various centers has demonstrated that thyroidectomy with nodal dissection dose not improve out come Patients should not be subjected to morbidity of thyroidectomy especially the low risk group

Our view
Total thyroidectomy is safe with low morbidity Patient follow-up and management is better controlled after thyroidectomy Radio ablation is possible only after thyroidectomy Patient takes Eltroxin lifelong in either case so why to leave the possible culprit behind?

Thanks