Thyro-Neck Clinic & Research Center

29/04/2026

♦️♦️CASE SCENARIO♦️♦️ -
55 years old male presented with rapidly growing thyroid swelling for last 4 momths with right sided neck swelling for same duration.
FNAC from thyroid- Papillary thyroid carcinoma
FNAC from right sided neck node from 2 different lab. One is Metastatic Papillary carcinoma and another poorly differetiated carcinoma.
what will be next plan of management?

🚩MANAGEMENT -

This is not a straightforward papillary thyroid carcinoma case anymore—the different FNAC report (one showing metastatic papillary carcinoma and another suggesting poorly differentiated carcinoma) plus rapid growth raises concern for tumor differentiation or mixed pathology, which significantly changes management.

📍Key points

* Rapid progression (4 months) → aggressive behavior
* Conflicting FNAC from lymph node → possibility of:
* Poorly differentiated thyroid carcinoma (PDTC)
* Anaplastic transformation (early)
* Sampling error / tumor heterogeneity
* Possible locally advanced disease (especially if trachea involved clinically or radiologically)

🚩Next Plan-

1. Histological Confirmation (Mandatory)

FNAC is no longer sufficient here.

* Core needle biopsy or excisional biopsy from suspicious cervical lymph node

* Aim:
To Confirm if this is:
* Classical papillary carcinoma
* Poorly differentiated carcinoma
* Anaplastic carcinoma

This step is critical because treatment differs drastically.

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2. Comprehensive Imaging for Staging

* Contrast-enhanced CT scan of neck and chest
* Assess:
* Tracheal/esophageal invasion
* Vascular involvement (carotid, IJV)
* Extent of nodal disease
* Mediastinal extension
* Consider:
* MRI if airway/esophageal invasion unclear
* PET-CT

3. Multidisciplinary Tumor Board Discussion

Involve:

* Head & neck surgeon
* Endocrine surgeon
* Medical oncologist
* Radiation oncologist

Management Based on Final Diagnosis

📍If confirmed Papillary Thyroid Carcinoma (PTC) with nodal metastasis

* Total thyroidectomy + therapeutic neck dissection
* Central compartment (level VI)
* Right lateral neck dissection (levels II–V)
* Followed by:
* Radioactive iodine (RAI) therapy
* TSH suppression

📍If Poorly Differentiated Thyroid Carcinoma (PDTC)

* Surgery if resectable:
* Total thyroidectomy + comprehensive neck dissection
* Followed by:
* External beam radiotherapy (EBRT)
* Consider systemic therapy

📍If Anaplastic carcinoma / Unresectable disease

* Surgery usually not beneficial (unless for airway protection)
* Management:
* EBRT + chemotherapy
* Consider:
* Tracheostomy if airway compromise
* Molecular testing (BRAF, etc.) for targeted therapy

4. Airway Assessment (Very Important)

Given rapid growth:

* Evaluate for:
* Stridor
* Tracheal compression
* Preparation for urgent airway management if needed

🎈🎈🎈
📚Do NOT proceed directly to thyroidectomy yet.
📚First resolve the histological discrepancy with core/excision biopsy, then stage with imaging, and decide treatment accordingly.

25/04/2026

03/04/2026

📍CASE SCENARIO-

📍27 years old male noticed a swelling infront of his neck for last 8 months.
On investigation his thyroid function is normal.
USG reveals multiple nodules in both lobes(largest 2.3cm in rt lobe)
FNA reveals nodular goitre with thyroiditis.
What will be next plan of management?📍

🚩27-year-old euthyroid male with bilateral multinodular goitre (largest 2.3 cm),
FNAC benign nodular goitre with thyroiditis,

🎈In this case the next step is usually conservative follow-up, not immediate surgery, provided there are no red-flag features. ATA guidance recommends that in multinodular glands, each nodule ≥1 cm is assessed by US risk pattern, and after a benign FNAC, follow-up is based mainly on ultrasound features, not just size. 

🚫Management steps-

🚩1) Clinical observation + repeat neck ultrasound
• Repeat thyroid USG in 12–24 months if the dominant nodule has low/intermediate suspicion features.
• If the nodule has high-suspicion US features (irregular margins, microcalcification, taller-than-wide, marked hypoechogenicity, etc.), then repeat US ± repeat US-guided FNAC within 12 months.
• If the nodules are very low suspicion / spongiform, repeat US can be delayed to ≥24 months. 

🚩2) No routine thyroxine suppression
• Do not start levothyroxine only to shrink the goitre if TSH is normal.
• TSH suppression therapy is not routinely recommended for benign euthyroid nodular goitre because benefit is limited and there are risks (subclinical hyperthyroidism, arrhythmia, bone loss). 

🚩3) Treat/monitor thyroiditis

FNAC mentions thyroiditis:
• Check anti-TPO antibody (if not already done)
• Repeat TSH ± FT4 after 6–12 months, because autoimmune thyroiditis can later become hypothyroid
• If hypothyroidism develops later → then start levothyroxine replacement (not suppressive therapy)

🚩4) Repeat FNAC only if indicated

Repeat FNAC is not routinely needed now if the cytology is benign, unless:
• Nodule grows by >20% in at least 2 dimensions (minimum increase 2 mm), or
• >50% increase in volume, or
• New suspicious ultrasound features appear, or
• New cervical lymph nodes appear. 

🏥🏥When would surgery be indicated?🏥🏥

Consider thyroidectomy (usually total/near-total in bilateral MNG) if any of these are present:
• Compressive symptoms: dysphagia, dyspnea, choking, voice change
• Retrosternal extension
• Cosmetic concern
• Suspicion of malignancy on repeat US/FNA
• Rapid enlargement
• Recurrent cystic/large symptomatic nodules
• Patient preference / inability to ensure follow-up

Large asymptomatic benign euthyroid multinodular goitre alone is not an indication for surgery.

🟥SUMMARY-

1. Reassure patient, observation and follow up.
2. Repeat USG neck in 12 months (or 12–24 months depending on US risk pattern)
3. Repeat FNAC only if increase in size or suspicious sonographic changes
4. Check thyroid autoantibodies and periodic TFT because of thyroiditis
5. No thyroxine suppression in euthyroid state
6. Surgery only if compressive symptoms / cosmetic issue / suspicion of malignancy / progressive enlargement

30/03/2026

Anatomy of Larynx

29/03/2026

Thyroid & Head-Neck Oncosurgeon

A specialized center for Thyroid, Parathyroid, Parotid and Head-neck cancer surgery by multidisciplinary team to achieve comprehensive cure.

22/03/2026

CASE SCENARIO -
♦️45 years old male patient diagnosed as a case of Medullary thyroid carcinoma. He was operated 1 year back.
Preoperative serum calcitonin was 120pg/mL
Postoperatively after 6 weeks Serum calcitonin level 10pg/mL
After 6 months Serum calcitonin - 35pg/mL
After 1 year Serum calcitonin -40pg/mL

What will be next steps of management? ♦️

🚩This patient most likely has biochemical persistent/recurrent medullary thyroid carcinoma (MTC) rather than “cure,” because post-op calcitonin never became undetectable and is rising (10 → 35 → 40 pg/mL). In MTC, a detectable/rising calcitonin after total thyroidectomy suggests residual or recurrent disease, and follow-up is guided by calcitonin + CEA , neck imaging, and resectability. Radioiodine is not useful in MTC. 

👉Interpretation of this case
• Pre-op calcitonin 120 pg/mL = relatively low tumor burden.
• 6 weeks post-op calcitonin 10 pg/mL = biochemical response, but not complete biochemical cure.
• 6 months 35 pg/mL, 1 year 40 pg/mL = persistent disease with mild rise.
• Because current calcitonin is 150 pg/mL or rising significantly. 

🚫Next steps of management-

📚1) Confirm biochemical test properly

• Repeat serum calcitonin in the same lab / same assay
• CEA (very important)
• Review the exact operative details:
Total thyroidectomy done?
Central neck dissection?
Lateral neck dissection?
• Final histopathology: tumor size, multifocality, LN status, margin status, extranodal extension
• RET mutation status if not already done

🎈WHY?

• Calcitonin assay variability exists.
• Management depends heavily on calcitonin and CEA doubling time (DT).
• ATA recommends using serial values to estimate doubling time; DT >2 years is more favorable, while 150 pg/mL (many use this threshold)
• Rapid calcitonin/CEA doubling time
• Suspicious symptoms (bone pain, cough, diarrhea, weight loss, neck mass)
• Abnormal neck imaging with concern for bulky disease

Possible later imaging if indicated:
• Contrast-enhanced CT neck/chest
• Liver CT or MRI
• Bone imaging (MRI / bone scan depending symptoms)
• Functional imaging (e.g., FDG PET or DOTATATE in selected advanced cases), but not routine first step at calcitonin 40

ATA follow-up algorithms particularly emphasize systemic localization when postoperative calcitonin is >150 pg/mL. 

⸻

📚4) If neck disease is localized and resectable → Re-operative compartment-oriented surgery

If ultrasound/FNA identifies:
• Persistent/recurrent central or lateral neck nodal disease
• Or thyroid bed recurrence

Then:
• Reoperation by experienced thyroid surgeon
• Prefer compartment-oriented dissection, not “berry picking”

Important caution:

Reoperation is indicated only if structurally identifiable disease is present and resectable.
Do not reoperate for biochemical disease alone (i.e., rising calcitonin without localized structural target).

⸻

📚5) If imaging is negative (most likely in this case) → Active surveillance

If neck US is negative and patient asymptomatic:

Management:
• Observation / surveillance
• Repeat:
• Calcitonin + CEA every 6 months
• Neck US every 6–12 months initially (or sooner if marker rise accelerates)

This is the likely best management for this patient, given:
• Low absolute calcitonin
• Slow rise
• No structural disease yet documented

⸻

📚6) No role for radioactive iodine
• RAI is NOT indicated in medullary thyroid carcinoma.
• MTC does not take up iodine. 

⸻

📚7) TSH management
• Continue levothyroxine replacement
• Do NOT suppress TSH like papillary thyroid cancer
• Keep TSH in normal range in MTC patients 

⸻

👉👉Consider hereditary workup (if not already done)

All MTC patients should have:
• RET proto-oncogene testing
• Screen for MEN2
• If RET positive, evaluate:
• Pheochromocytoma (plasma free metanephrines / urinary metanephrines)
• Hyperparathyroidism (calcium, PTH)

⸻
Summary of this case-

🟥🟥What I would do now in this exact patient??

This is biochemical persistent/recurrent MTC.
Because postoperative calcitonin remained detectable and rose from 10 to 40 pg/mL over 1 year, the next step is:
1. Repeat calcitonin and measure CEA (prefer same assay)
2. Calculate calcitonin/CEA doubling time
3. Perform high-resolution neck US as first imaging (calcitonin

19/03/2026

Anatomy of Pharynx

01/03/2026

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23/02/2026

🎈🎈48 years old lady underwent left Hemithyroidectomy opertaion due to left sided nodular goitre (Bathesda-III).
Postoperative histopathology reveals
-Diffuse sclerosing type papillary thyroid carcinoma
-capsular invasion present
- multifocal
-psammoma bodies present
- surgical margin clear
- no perineural and perivascular invasion
- extensive fibrosis

what will be next plan of management? 🎈🎈

🚩🚩🚩Based on the histopathology, this is Diffuse Sclerosing Variant of Papillary Thyroid Carcinoma (PTC) — an aggressive subtype.

High-Risk Features in This Case
• Diffuse sclerosing variant (more aggressive than classical PTC)
• Multifocal disease
• Capsular invasion
• Psammoma bodies (common in this variant)
• Hemithyroidectomy already done
• Margins clear
• No vascular/perineural invasion reported

This patient is in high risk group as per American Thyroid Association (ATA) risk stratification.

⸻

✅ Recommended Next Management Plan

📍📍Completion Thyroidectomy (Strongly Recommended)

Because:
• Aggressive histologic variant (Diffuse sclerosing type)
• Multifocal disease
• Capsular invasion
• High risk of bilateral and nodal involvement

👉 Remove the remaining right thyroid lobe

Allows:
• Better staging
• Facilitation of radioactive iodine therapy
• Thyroglobulin monitoring for recurrence

⸻

♦️♦️Neck Evaluation Before Completion Surgery
• High-resolution neck ultrasound
• Assess central & lateral cervical lymph nodes
• If suspicious → FNAC

Diffuse sclerosing variant has a high incidence of nodal metastasis.

If nodes positive → Therapeutic neck dissection

⸻

🎴🎴Post-Total Thyroidectomy Radioactive Iodine (RAI) Ablation

After completion thyroidectomy:

👉 RAI ablation is recommended

Indications in this case:
• Aggressive variant
• Multifocality
• Capsular invasion
• Age > 45
• Likely intermediate/high ATA risk

⸻

💹💹TSH Suppression Therapy

Start Levothyroxine with:
• TSH target:
•

18/02/2026

🎈🎈FOLLOW UP PROTOCOL AFTER HEMITHYROIDECTOMY FOLLOWING PAPILLARY THYROID CARCINOMA 🎈🎈

After a hemithyroidectomy (lobectomy) for papillary thyroid carcinoma (PTC), follow-up focuses on detecting recurrence, monitoring thyroid function, and deciding whether further treatment is needed.

⸻

🚩Initial Post-Operative Assessment (6–12 weeks after surgery)

📚Clinical Evaluation
• Wound healing
• Voice changes (recurrent laryngeal nerve)
• Palpation of the remaining lobe and neck nodes

📚Thyroid Function Tests
• TSH
• Free T4

Most patients will need levothyroxine to:
• Replace hormone (if hypothyroid)
• Mildly suppress TSH (goal depends on risk)

⸻

🚩TSH Target After Lobectomy

TSH suppression depends on recurrence risk:

Low risk (most lobectomy cases)
TSH Target- 0.5 – 2.0 mIU/L
Intermediate risk
TSH Target - 0.1 – 0.5 mIU/L
High risk
TSH Target-4 cm
• Gross extrathyroidal extension
• Positive margins
• Clinically significant lymph node metastases
• Aggressive histology
• Vascular invasion
• Multifocal disease in remaining lobe

⸻

🚩Radioactive Iodine (RAI)

After hemithyroidectomy alone:
• RAI is not routinely used
• Only considered if upgraded to high-risk disease and completion thyroidectomy performed

⸻

🚩Long-Term Follow-Up Schedule (Typical Low-Risk Patient)

👉Year 1
• TSH every 3–6 months
• Tg ± TgAb every 6–12 months
• Neck US at 6–12 months

👉Years 2–5
• Annual TSH
• Annual Tg
• Neck US every 1–2 years

👉After 5 years
• Individualized follow-up

⸻

🚩Recurrence Risk After Lobectomy

For properly selected low-risk patients:
• Structural recurrence: ~2–6%
• Disease-specific survival: >99%

Papillary thyroid carcinoma has an excellent prognosis.

⸻

🚨 Red Flags During Follow-Up
• Rising thyroglobulin
• New neck mass
• Abnormal lymph node on ultrasound
• Persistent TSH elevation despite therapy