DrMahak ,DrC Jayakumar,DrMohan p Abraham DrVinitha PrasadDrPraveena Bhaskaran and drNavya George
Eleven year old previously asymptomatic girl child presented with a a painless swelling, the size of a grape, over the left side of the neck since 4 weeks noticed accidentally. She has received a cod course antibiotics but with poor response.
Fever, cough, weight-loss night sweats fatiguability breathlessness were absent
No history suggestive dysphagia,dysphasia restriction of neck movements, hypo/hyperthyroidism. No history of radiation exposures to the child either I uteri or after birth
Family history of thyroid nodule in mother at 26 years of age for which she underwent total thyroidectomy. HPE showed MNG goitre with no evidence of malignancy. Maternal grandfather had colonic cancer
Clinically vitals were stable. Non tender enlarged lymoh nodes present bilaterally (left>right), largest measuring 3*2 cm. Non tender 1*1 cm firm swelling moving with deglutition present over the left side of the neck. Systemic examination was normal.
Differentials considered‐—-
Thyroid adenoma
Tuberculosis
Infectious Mononucleosis
Grave’s disease
Kikuchi Fujimoto
Kimura
Castleman’s disease
Laeukaemia
Lymphomas
Other malignancies
Blood counts were normal with negative CRP and ESR. TFT was normal.
Chest Xray done to rule out TB showed multiple pulmonary nodules in bilateral lungfields. Quantiferon Gold was negative. USG neck was performed which showed multiple enlarged lymph nodes, increased vascularity of lymph nodes, heterogenous echotexture of left thyroid with one iso-hypoechoic nodule.
On the basis of this report, USG Guided FNAC performed which was reported as Category V according to Bethesda Classification ie. Suspicous of Malignancy.
Therefore, total thyroidectomy with unilateral neck dissection was performed. Histopathological examination of the biopsy samples showed papillary thyroid cancer with metastasis to 21/26 samples.
Whole Body 131 scan and thyroid scintigraphy was performed after 1 month and minimal residue thyroid tissue detected with left upper, lower cervical and mediastinal metastases and bilateral pulomonary metastases.
Stimulated Tg levelswere found to very high 2695ng/mL suggestive of recurrence. Parents were thus counselled for multiple sittings of high dose I-131 therapy and family counselled for evaluation of elder child to rule out any thyroid abnormality.
About 2% children present with thyroid nodules out of which 19% are found to be malignant whereas only 12% nodules in adults are found to be malignant.
Among Pediatric thyroid cancers, Papillary thyroid cancers account for 86% of the cases. The most common presentation is an asymptomatic swelling either incidentally detected the patient or the Pediatrician. Children usually present with an advanced disease with distant metastases or recurrent disease. However, compared to adults, their prognosis is still good with upto 98% patients with papillary thyroid cancer. It is important to rule out syndromes associated with thyroid cancers like Familial Adenomatous Polyposis, Werner’s, Cowden’s, MEN2.
Carry Home Message:
Benign looking asymptomatic neck swellings in an otherwise normal and healthy child can be treachorous in presentation and must be investigated.