Thyro-Neck Clinic & Research Center

08/12/2025

35 years male presented with Rapidly growing thyroid tumour.
FNAC reveals Anaplastic thyroid carcinoma

Is there any SURGICAL OPTIONS?

When Surgery CAN Be Done
(RESECTABLE ATC)

Surgery is considered only if complete (R0/R1) resection is possible.

Surgery is feasible when:
• Tumor is confined to the thyroid or has minimal invasion.
• No encasement of:
• Carotid artery
• Recurrent laryngeal nerves bilaterally
• Trachea or esophagus (full-thickness invasion makes it unresectable)
• No extensive mediastinal involvement.
• Distant metastasis does not automatically contraindicate surgery if airway compromise can be prevented.

Standard operation:

Total thyroidectomy with en-bloc resection of involved structures
± central/lateral neck dissection (if nodes involved).
• Planned postoperative chemoradiotherapy or targeted therapy.

⸻

When Surgery is NOT an Option
(UNRESECTABLE ATC)

Most patients present late and fall into this group.

Surgery is NOT offered if:
• Carotid artery encasement (>180°)
• Extensive tracheal/esophageal invasion requiring non-survivable reconstruction
• Invasion to prevertebral fascia
• Bulky mediastinal disease
• Poor performance status

In these cases:

→ Chemoradiation or Targeted therapy (BRAF/RET/NTRK)

→ Airway stabilization (stent, tracheostomy, steroids)

→ Palliative care

SUMMARY:

Yes, surgical resection (total thyroidectomy ± en bloc resection) is possible only if the tumor is resectable based on CT imaging. If unresectable, management shifts to chemoradiation or targeted therapy. Airway assessment is the first priority.

03/12/2025

CASE SCENARIO -

27 years old male presented with thyroid swelling
His FNA reveals Medullary thyroid carcinoma
How will you evaluate?

Evaluation of Medullary Thyroid Carcinoma (MTC)

1. Confirm Diagnosis & Biochemical Assessment-

A. Serum Markers:

I. Serum Calcitonin
- Very high levels → larger burden; >500 pg/mL often suggests distant metastasis.

II. Carcinoembryonic Antigen (CEA)
- Marker for disease progression.

B. Additional Biochemical Screening:

MTC can be part of MEN2 syndromes (MEN2A, MEN2B) caused by RET mutations, so evaluate for other endocrine tumors:
• Serum Calcium & PTH
{To screen for hyperparathyroidism (MEN2A).}
• 24-hour urinary metanephrines or plasma free metanephrines
{To rule out pheochromocytoma (MEN2A/MEN2B).}


2. Genetic Evaluation:

RET Proto-oncogene Germline Mutation Testing
• Recommended for all MTC patients regardless of age.
• Determines:
-Whether disease is hereditary or sporadic.
-Need for family screening.
-Surgical extent for patient & relatives.

3. Imaging for Primary Tumor & Nodal Spread:

Neck and Upper Mediastinum
• High-resolution Neck Ultrasound

To Evaluate:
-Thyroid gland (extent of tumor)
-Cervical lymph nodes (levels II–VI)
-Superior mediastinal nodes

If calcitonin >150–200 pg/mL, evaluate for distant metastasis:

Chest
• CT chest (with contrast)
To see Lung or mediastinal metastasis.

Abdomen
• CT/MRI abdomen
-Liver metastasis (common in advanced MTC)
-Check adrenal glands (pheochromocytoma)

Bone
• Bone scan, or
• FDG-PET if widely metastatic disease suspected.

SUMMARY :

Biochemical
• Serum calcitonin
• CEA
• Serum calcium, PTH
• Plasma/urinary metanephrines

Genetic
• RET mutation analysis (patient & family if positive)

Imaging
• Neck ultrasound
• CT chest
• CT/MRI abdomen
• Bone scan / FDG-PET if high calcitonin

26/11/2025

CASE SCENARIO -

45 years old male had total thyroidectomy 2 years back for Papillary thyroid carcinoma
on follow up investigation his Thyroglobulin(Tg ) level raised,
Anti Tg antibody level raised
what will be next plan?

When a patient with a history of papillary thyroid carcinoma after total thyroidectomy has:
• High thyroglobulin (Tg)
• High anti-Tg antibodies (TgAb)

Raised anti-Tg antibodies make Tg an unreliable marker, because antibodies can falsely lower or interfere with Tg measurements.

Next Steps-

1. Repeat Tg and TgAb using the same laboratory assay

Because inter-assay variability is high.

2. Neck ultrasound

First-line imaging to look for:
• Local recurrence in thyroid bed
• Lymph node metastases

3. TSH-stimulated thyroglobulin (optional)

Using rhTSH (Thyrogen) or temporary levothyroxine withdrawal.

If Tg remains elevated under stimulation → suggests residual/recurrent disease.

4. If US is negative but Tg/TgAb continue to rise → Do whole-body I-131 diagnostic scan

To detect:
• Residual functioning thyroid tissue
• Distant metastasis

5. If Whole body scan is negative but Tg/TgAb still rising → Consider FDG-PET/CT

Specially useful for:
• Iodine-negative recurrence
• Patients with aggressive or recurrent disease

19/11/2025

***IS THERE ANY NEED OF RAI (Radioactive Iodine ) FOR EVERY PATIENT WHO UNDERWENT TOTAL THYROIDECTOMY FOR PAPILLARY / FOLLICULAR THYROID CANCER?
***

No. Radioactive iodine (RAI) ablation is not required for every patient who undergoes total thyroidectomy for papillary or follicular thyroid carcinoma. The decision depends on -
-Risk stratification,
-Tumor features
-Post-operative findings.

***
When RAI is NOT typically needed?

Patients considered low risk generally do not need RAI:

Papillary thyroid carcinoma (PTC) – LOW RISK
• Tumor ≤4 cm, confined to the thyroid.
• No extrathyroidal extension.
• No lymph node metastasis or only tiny micrometastases.
• No aggressive histologic variants (e.g., tall cell, columnar cell).
• Negative margins.
• No evidence of distant metastasis.
• Post-op thyroglobulin levels are low/undetectable.

Follicular thyroid carcinoma – Low Risk
• Minimally invasive follicular carcinoma.
• No vascular invasion or only focal invasion.
• No distant metastasis.

These patients are usually managed with thyroid hormone suppression alone.

***
When RAI is recommended?
- INTERMEDIATE RISK
- HIGH RISK

Intermediate-Risk Features:

RAI usually considered:
• Microscopic extrathyroidal extension.
• Clinically significant lymph node metastasis.
• Aggressive histologic variants.
• Vascular invasion (especially in follicular carcinoma).
• Post-operative thyroglobulin suggesting residual disease.

High-Risk Features:

RAI is generally recommended:
• Gross extrathyroidal extension.
• Distant metastases.
• Large primary tumors (>4 cm).
• Extensive nodal disease.
• Incomplete surgical resection.

***
Special Consideration for Follicular Thyroid Carcinoma (FTC)

Because FTC spreads hematogenously:
• Widely invasive FTC → RAI recommended.
• Minimally invasive FTC without vascular invasion → often no RAI.
• With vascular invasion (≥4 foci) → RAI usually recommended.

Message -

RAI is selective, not routine.
It is guided by patient risk category, pathology, and post-op markers—not just the diagnosis of PTC or FTC alone.

16/11/2025

Case scenario:

60 years old lady presented with huge thyroid swelling for last 20 years.
She has no complaints regarding this.
Her investigation reveals benign nodular goitre.
what will be management plan?

Case summary -

Age-60years
Gender- Female
Presenting - Huge thyroid swelling
Duration - 20years
Cytology -Benign thyroid swelling
No clinical complaints

1. Rassess for Any Subtle Symptoms

Even if she denies complaints, large goitres can cause unnoticed:
• Pressure symptoms (mild dyspnea, dysphagia, hoarseness)
• Signs of retrosternal extension
• Cosmetic concerns
• Subclinical hyperthyroidism

Ask specifically, and consider imaging to rule out hidden compression.

2. Essential Investigations

Since diagnosis is “benign nodular goitre,” ensure the full workup is complete:

a. Thyroid function tests
• Serum TSH, FT3, FT4

b. Ultrasound of neck
• Confirms benign features
• Identifies dominant or suspicious nodules

c. FNAC (fine-needle aspiration)
• Already benign—ensure sampling was done of dominant nodule

d. X-ray neck / CT neck-chest (if large or retrosternal)
• Evaluate tracheal compression, deviation, retrosternal extension

3. Management-

Treatment depends on size, symptoms, cosmetic issues, and progression.

A. If asymptomatic and no compression

Conservative management (preferred)
• Observation
• Monitor every 6–12 months
• Thyroid function tests
• Neck ultrasound
• Clinical examination
• Iodine supplementation if need.

B. If Goitre is very large, growing, or cosmetically disturbing

Elective Surgery

Near total /total thyroidectomy/Hemithyroidectomy , depending on:
• Size of goitre
. Involved Lobe
• Presence of dominant nodules
• Cosmetic discomfort

Indications for surgery even in benign goitre:
• Large goitre (>4 cm nodules)
• Retrosternal extension
• Mechanical(Tracheal/ esophageal )compression
• Suspicious FNAC or rapid increase in size
• Cosmetic concern
• Patient preference

C. If Mild Compression but Patient Declines Surgery

Radioiodine (I-131) therapy is an option

Useful in:
• Elderly patients
• Poor surgical candidates
• Large multinodular goitre

Reduces goitre size by ~30–60% over 6–18 months.

4. Thyroxine Suppression Therapy?

NOT recommended

• Ineffective in multinodular goitre
• Risk of iatrogenic hyperthyroidism, especially in the elderly

Recommended Plan for THIS Patient-

Based on typical guidelines:

Since she is 60 yrs, with a huge goitre present for 20 years, even if benign:
• Assess for compression clinically + imaging
• If any compression → surgery
• If no compression, no cosmetic issues → observation is acceptable
• If goitre is huge cosmetically or progressively enlarging → elective thyroidectomy.

14/11/2025

FOLLOW UP PROTOCOL FOR BENIGN THYROID NODULE :

Standard follow-up protocol for a benign thyroid nodule :

1. Initial Follow-Up After Benign FNAC

For a nodule confirmed benign on fine-needle aspiration (FNA):

Ultrasound (US) at 12–24 months

• If the nodule is stable (no significant growth and no new suspicious features), extend future follow-ups to every 3–5 years or even stop surveillance depending on clinical context.

2. What Counts as “Significant Growth”?

A nodule is considered to have grown if:
• ≥20% increase in at least two dimensions and ≥2 mm increase, or
• ≥50% increase in volume

If growth meets this threshold, repeat FNAC is typically recommended.

3. When to Repeat FNAC

Repeat FNAC is indicated if:
• The nodule grows significantly
• New suspicious ultrasound features appear
- Microcalcifications,
- Marked hypoechogenicity
- Irregular margins
- Taller-than-wide shape

• The initial FNAC was nondiagnostic and the nodule persists

4. If the Nodule Is Stable Over Time

If the nodule shows:
• No significant growth
• No new suspicious US features

Then:
• Follow-up US can be every 3–5 years
• Some clinicians may stop routine surveillance for consistently stable benign nodules, especially if 4 cm)
• Risk of false-negative FNAC is slightly higher
• Follow up at 12 months, then as indicated
• Surgery considered if compressive symptoms occur

Symptoms or cosmetic concerns
• Management depends on compressive symptoms; surgery or minimally invasive procedures may be discussed

6. When to Stop Surveillance

Stopping follow-up is reasonable when:
• A nodule has had ≥2 benign FNAs, or
• It has been stable for many years, or
• It has low-risk ultrasound features

13/11/2025

Case Scenario -

39 years old male presented with thyroid swelling for 2 years.
FNAC reveals follicular neoplasm.
USG shows left sided large nodule measuring about
3.5cm and right sided 2 small nodule measuring 8mm and 5mm.

what will be management plan?

Case summary
• 39-year-old male
• Multinodular goiter (MNG)
• FNAC: Follicular neoplasm (→ “follicular neoplasm” or “suspicious for follicular neoplasm” means we can’t tell adenoma vs carcinoma on cytology; we need histology for capsular/vascular invasion)
• Ultrasound:
• Left lobe: dominant nodule 3.5 cm
• Right lobe: two small nodules (8 mm, 5 mm)

⸻

Step 1. Interpretation of FNAC
• Follicular neoplasm = Bethesda Category IV
→ Risk of malignancy ≈ 15–30%
→ Surgical excision is indicated for diagnosis (cannot be determined by FNAC alone).

⸻

Step 2. Management options

I. Diagnostic surgical management
• Preferred initial surgery:
Diagnostic Hemithyroidectomy (lobectomy + isthmusectomy) of the affected lobe (here, left side with the 3.5 cm dominant nodule).
• Purpose: Obtain histopathology to differentiate follicular adenoma vs follicular carcinoma.
• Also removes the symptomatic/enlarged side.

II. Completion thyroidectomy -

• If histopathology shows:
• Follicular carcinoma (especially with vascular/capsular invasion)
→ Completion thyroidectomy is indicated.

• If benign (follicular adenoma) → no further surgery; follow-up with USG and thyroid function tests.

III. Small nodules in contralateral lobe
•

10/11/2025

Comprehensive follow-up protocol after total thyroidectomy for papillary thyroid carcinoma (PTC), based on major guidelines (e.g., American Thyroid Association [ATA] 2015 and NCCN updates):

1. Immediate Postoperative Period (Hospital / Early Post-Op)

To monitor for complications and plan long-term follow-up.

• Calcium / PTH levels: monitor for hypocalcemia(start calcium ± calcitriol if needed)
• Thyroid hormone replacement: start levothyroxine to suppress TSH.
• Initial target:
High risk: TSH 4 cm, gross extrathyroidal extension, nodal/distant metastases, or intermediate-risk features.
Low-risk patients may omit RAI.

⸻

3. 6–12 Months After Surgery (After ± RAI)

To assess treatment response.
• Serum Tg and TgAb:
• Measured on thyroid hormone therapy or after TSH stimulation (either by withdrawal or rhTSH).
• Neck ultrasound.
• RAI whole-body scan (if RAI given) may be performed at 6–12 months to confirm ablation success.

Response categories (ATA 2015):

I. Respone- Excellent
Undetectable Tg, no TgAb
Imaging Negative
Risk- Very low

II. Response - Biochemical incomplete
Tg detectable,
Imaging negative
Risk- Moderate

III. Response - Structural incomplete
Structural disease
Risk- Higher

IV. Response -Indeterminate
Nonspecific findings
Risk- Needs follow-up

4. Long-Term Follow-Up (Annually or as indicated)

To lifelong surveillance for recurrence.

• Tg and TgAb every 6–12 months (more frequent if incomplete/indeterminate response).
• Neck ultrasound every 12–24 months, or more often if abnormal Tg trend.
• TSH suppression adjustment:
• Excellent response → relax TSH to low-normal range (0.5–2.0).
• Persistent disease → maintain stronger suppression (

08/11/2025

Case Scenario -

9 years old girl presenting with left thyroid nodule. Her cytology reveals papillary thyroid carcinoma.
What will be next plan?

Papillary thyroid carcinoma (PTC) in a 9-year-old girl. Pediatric thyroid cancers are rare but generally have an excellent prognosis when properly managed.

1. Confirm and Stage the Diagnosis

• High-resolution neck ultrasound:

To assess both lobes, isthmus, and cervical lymph nodes (central and lateral compartments).

• Thyroid function tests (TFTs) —

though PTC often occurs in euthyroid patients.

• Fine-needle aspiration (FNA)-

Should have confirmed papillary carcinoma.

If lymphadenopathy is detected → neck node mapping with ultrasound ± contrast-enhanced CT (if extensive disease is suspected).

2. Surgical Management:

In children, papillary thyroid carcinoma tends to be multifocal and bilateral, so:

Recommended:
• Total thyroidectomy (preferred)
• Because of high rates of multifocality (up to 30–40%) and bilateral disease.

3. Neck Dissection
• Central compartment neck dissection (Level VI):

Therapeutic:
If nodes are clinically or radiologically positive.

Prophylactic:
Often recommended in pediatric patients even if nodes are not clinically involved, because of high risk of microscopic metastasis.

• Lateral neck dissection: only if nodes in lateral compartments are positive.

4. Postoperative Management
• Thyroid hormone replacement (levothyroxine):

To maintain euthyroidism and suppress TSH (which can stimulate tumor recurrence).

• Radioactive iodine (RAI) ablation:
Considered if:

There is residual disease,
Lymph node or distant metastasis,
Or if the primary tumor is large (>1–2 cm).
Usually given a few weeks after surgery once TSH rises (either via withdrawal or recombinant TSH).

• Serum thyroglobulin (Tg) and anti-Tg antibody levels: used as tumor markers for follow-up.

5. Long-term Follow-up

Children require lifelong surveillance:
• Neck ultrasound every 6–12 months initially.
• Thyroglobulin levels (on TSH suppression or after stimulation).
• Monitor for hypocalcemia, hypothyroidism, and other surgical complications.

06/11/2025

Case Summary -

27 years old lady diagnosed as papillary thyroid carcinoma. She is 4 months pregnant.
what will be next steps of management

Age: 27 years old
Diagnosis: Papillary thyroid carcinoma (PTC)
Gestation: 4 months pregnant (~16 weeks)

Management Plan:

Papillary thyroid carcinoma (PTC) during pregnancy depends on several factors including gestational age, tumor size, aggressiveness, and maternal/fetal safety.

1. Confirm Diagnosis and Staging
• Confirm diagnosis with ultrasound-guided FNAC (which can be safely done in pregnancy).

Evaluate:
Tumor size
Extrathyroidal extension
Lymph node involvement (neck ultrasound)

Avoid radioactive iodine scans — contraindicated in pregnancy.

⸻

2. Assess Tumor Aggressiveness
• Low-risk PTC
-small
-intrathyroidal,
-slow-growing
usually indolent during pregnancy.

• High-risk features
-large tumor >4 cm,
-rapidly growing,
-local invasion,
-bulky nodal disease
more urgent treatment may be needed.

⸻

3. Timing of Surgery

A. If tumor is small, stable, and asymptomatic
• Defer thyroid surgery until after delivery.
• Pregnancy does not worsen prognosis.
• Perform serial neck ultrasound each trimester.
• Thyroidectomy can be done postpartum, typically after 6 weeks.

B. If tumor shows rapid growth or compressive symptoms
• Surgery (thyroidectomy) can be safely performed in the second trimester (13–24 weeks).
• Second trimester is safest (less risk of miscarriage and preterm labor).
• Avoid surgery in 1st trimester (organogenesis) and 3rd trimester (preterm labor risk).

⸻

4. Thyroid Hormone (TSH) Suppression
• Continue or start levothyroxine to keep TSH suppressed but within safe maternal-fetal range:
• Goal: TSH 0.1–0.4 mIU/L (mild suppression).
• Regular monitoring every 6–8 weeks.

⸻

5. Radioactive Iodine (RAI) Therapy
• Contraindicated in pregnancy (and while breastfeeding).
• If indicated, perform after delivery and cessation of breastfeeding (usually ≥6 weeks postpartum).

⸻

6. Postpartum Plan
• Definitive total thyroidectomy (if not done during pregnancy).
• RAI ablation after surgery and when safe postpartum.
• Continue TSH suppression therapy and follow-up with thyroglobulin levels and neck ultrasound.

30/10/2025

Case Summary

• Age: 26 years young male presented with left thyroid nodular goiter
• Surgery: Hemithyroidectomy for presumed nodular goiter
• Histopathology reveals Follicular Variant Papillary Thyroid Carcinoma (FVPTC)
⸻

What will be next steps of management???

⚕️ Next Steps in Management

1. Review the Final Pathology Report Carefully

Key features to determine further management:
• Tumor size
• Capsular or vascular invasion
• Extrathyroidal extension
• Surgical margin status
• Lymph node involvement (if any)
• Multifocality

→ These factors determine whether completion thyroidectomy or observation is appropriate.

2. Risk Stratification (ATA Criteria)

• # Risk group- Low Risk

Features- Intrathyroidal, unifocal, 4 cm
• Positive margins
• Extrathyroidal extension
• Lymph node metastases
• Vascular invasion
• Bilateral or multifocal disease
• Need for radioactive iodine (RAI) therapy anticipated

If none of the above:
→ Hemithyroidectomy alone may be adequate.

⸻

4. Postoperative Evaluation (if completion not done)
• Neck ultrasound (6–12 weeks post-op)
• TSH level
• Thyroglobulin (Tg) and anti-Tg antibodies (baseline)
• Consider genetic testing (rarely indicated for FVPTC)

⸻

5. If Completion Thyroidectomy Performed
• Wait at least 4–6 weeks after first surgery.
• Then RAI ablation considered if intermediate/high risk.
• Levothyroxine started to suppress TSH.

6. Long-term Follow-up

Parameter- Serum Tg & anti-Tg Ab
Frequency - Every 6–12 months

Parameter- Neck Ultrasound
Frequency - 6–12 months post-op, then as indicated

Parameter- TSH Suppression Goal
Low-risk: 0.5–2.0 mIU/L; High-risk:

28/10/2025

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