A RARE CASE OF PAPILLARY CARCINOMA OF THYROID IN A YOUNG FEMALE: A CASE REPORT

symptoms


Case Presentation
A 13-years old girl presented in surgical Out-Patient department of Jinnah Hospital, Lahore in July 2021 with complaint of multiple swellings in neck for three months.The swelling on front right side of neck was painless and gradually enlarging.She also complained of dysphagia for 1 month.There was no history of dyspnea, stridor, and lethargy or weight loss.No history of neck irradiation in past or history of goiter in family.There was no history of contact with tuberculosis patient.
On examination, she was a young enthusiastic girl who was afebrile, had a heart rate of 75 per minute and rest vitals were stable.There was a large swelling measuring 10×7cm in front of neck, more obvious on right side, which was moving with deglutition.Swelling was firm to hard in consistency.There were multiple other ipsilateral swellings in neck.Temperature of skin was normal.There was no retrosternal extension of this swelling.Multiple enlarged hard lymph nodes at level II, III and IV of neck on right side were palpable; the largest of size 5×4 cm at level II.They seemed to be matted together.Her body mass index was 16.1 2 Kg/m and ECOG status was 1.
On investigations, patient was euthyroid preoperatively.Complete blood count and all other baseline investigations were also normal.Pre-operative thyroglobulin level was 100 ng/ml.Fine needle aspiration cytology of thyroid showed multinodular goitre.Fine needle aspiration of lymph node showed reactive hyperplasia.Being a young female and since tuberculosis is endemic in our population, there was a strong suspicion of tuberculosis, therefore excision biopsy of lymph node was planned.Surprisingly, excision biopsy of lymph node showed a papillary carcinoma.
The computed tomography scan was done to plan for the surgery.It showed multiple discrete, matted lymph nodes on both sides of neck, largest on right side measuring 3×3.8 mm.There were some nodes visible even in anterior mediastinum.There was asymmetrical, heterogeneously enhancing enlarged thyroid and isthmus.The enlarged thyroid was also present retrosternally but no compression existed.
Total thyroidectomy with selective (central and anterolateral) neck dissection was done.Right lobe of thyroid was about 5×6 cm and was hard in consistency.Right-sided inferior thyroid artery was displaced infe-riorly.On right side, there was severe desmoplastic reaction of tumor due to which trachea and esophagus were adherent to it.Left lobe was normal looking.Multiple enlarged lymph nodes were present in level II, III, IV and VI.The largest lymph node was at level III that was about 3×4 cm.Patient had an uneventful recovery.Drains were removed on second post-opera-tive day and discharged from ward on third post-opera-tive day.The patient was not given any thyroxine to render her euthyroid.Later her thyroid scan showed small residual tissue for which she was referred to nuclear medicine for radio-iodine ablation.

DISCUSSION
The incidence of thyroid cancers has increased over time not only affecting adults but also children and adolescents.It is overall a rare tumor but among the endocrine tumors, it is the most common one.Thyroid cancers account for almost 0.5 to 1.5% of all cancers in adolescent age group.The differentiated thyroid cancers are most common type of all thyroid cancers.

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Their incidence is 0.02 to 0.3 per 100,000 children.The children and adolescents who have locally advanced tumours tend to have a good prognosis as compared to adults with same extent of disease.The survival longterm is for decades particularly if there is no distant metastasis.The literature suggests to completely excise the tumour by a high-volume thyroid surgeon to increase the survival, especially disease-free.Such patients may not even require radioactive iodine (RAI), if distant metastasis do not exist.The patient should be counselled to follow up regularly with serum thyroglobulin levels 10 and neck ultrasound.
Most of the thyroid cancers in pediatric population are differentiated thyroid cancers which arise from thyroid follicular cells in 95% cases.Out of these, most common are papillary carcinomas accounting for 90% cases and the rest are follicular (9%).Medullary We reported here a rare case of papillary thyroid carcinoma in a 13-year old girl.Her presentation was with multiple neck swellings, but due to younger age group, most of our suspicion was directed towards tuberculosis.The lymph node biopsy actually done to confirm our diagnosis of granulomatous inflammation came out to be metastatic thyroid carcinoma.A key point that leads to diagnosis of PTC in children is lymphadenopathy.The lymphadenopathy, like in our case, can be very difficult to differentiate whether caused by metastasis of PTC or reactive to tuberculosis.The added toll comes when the radiology does not help in 9 diagnosing infective or metastatic pathology.A thorough examination and histopathology is crucial to such cases.Total thyroidectomy followed by radio-iodine therapy is the treatment of choice in such patients.
The patient should be investigated starting from baseline complete blood count, thyroid function tests.The initial investigations include ultrasonography and fine-needle aspiration cytology.The ultrasound focuses on suspicious nodules.But as in our case, if suspicion of malignancy is high, we can perform excisional biopsy.Staging workup include whole body CT 13 scan.No staging system for post-operative staging has been standardized yet.The most frequently used system is TNM classification to determine the mortality.There is a limitation that all adolescents having no

Figure 1 :
Figure 1: Preoperative photograph of swelling of patient

Figure 5 :
Figure 5: Intraoperative picture with thyroid exposed

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thyroid arises from thyroid C-cells.There occur wide changes in genes and lesser point mutations in proto-oncogenes in PTC.Some rearranged oncogenes include RAS, RET, TRK and p53.The radiation to neck and head are other risk factors.The ATA has sub-15,16 divided PTC into pre and post-pubertal PTC.