Thyroid cancer - 6yr old boy - Forum

[Noro]

Dear all, but especially endocrine experts,
6yr old African boy, healthy, presents with firm multiple neck nodes ant and
post triangles neck non tender. CXR and bloods NAD. Biopsy Follicular
variant papillary Ca thyroid. On review small hard thyroid felt.
I'd first like to ask how you would play this next, and then I've a few more
questions to ask later

[Oncologist]

For such a patient my usual approach would be Total thyroidectomy with
modifed neck dissection followed by I131 scan post op and radio ablation of
any residual uptake.

[Surgeon]

The unfortunate child has disseminated (bilateral nodes AND
posterior triangles) disease, and the mainstay of treatment will be
ablative doses of I131, with T4 and TSH suppression.
But first you must remove all tissue that will take up I131, as
safely as you can, incurring as little morbidity. This implies a
total thyroidectomy, and node "picking".

[I wonder whether a Surgeon is going to stick their neck out by
suggesting bilateral radical block dissections, and clearance of the
posterior triangles? Rather like Vesalius would have imagined.]

[Noro]

This young patient would be best served by a total thyroidectomy and
modified Neck dissection, Nothing heroic , but try and pick out all the
apparent LN's.this should be followed byI 131 scan. If any activity is
picked up in the neck than he will require an additional ablative dose of
I131.

[Noro]

I decided to do a bilateral functional neck dissection (post triangles
included) rather than node picking because there seemed a lot of fibrosis
and the nodes were difficult to define clearly, also it seems to me to
remove all nodes and associated tissue gives the best chances of a full
clearance.
I did a total thyroidectomy , taking one recurrent laryngeal nerve which was
involved with the tumour, and managed to identify two parathyroids,
preserving one and a half of them. The tumour was densely adherent to the
trachea and had to be removed by sharp dissection. All this took about 7
hours (including a lunch break). Phew - I'm glad I don't have these ops
often!
We hoped to get away without a trache, but on extubation a week later he
struggled to breath and so we left him with a trache for 2 further weeks. We
removed it today and I'm pleased to say that though he is hoarse he can
phonate, and maintains a good airway whilst running round the ward at 90
miles an hour.
No signs at any stage of hypocalcaemia.
We have left him off T4 since the op and intend to send him for a profile
scan soon, prior to radioiodine and then commencing him on his T4.
Histology failed to comment on features of vascular invasion but commented
that in many nodes tumour had invaded into surrounding fat. It does
therefore seem to be quite an aggressive tumour.
Would anyone add local neck irradiation?