HHS Public Access Author manuscript Author Manuscript
Ear Nose Throat J. Author manuscript; available in PMC 2015 July 01. Published in final edited form as: Ear Nose Throat J. 2014 July ; 93(7): 252–254.
Papillary thyroid cancer in a gravid woman Darrin V. Bann, PhD, Neerav Goyal, MD, MPH, and David Goldenberg, MD, FACS The MD/PhD Program (Dr. Bann) and the Division of Otolaryngology–Head and Neck Surgery, Department of Surgery (Dr. Goyal and Dr. Goldenberg), Penn State College of Medicine, Hershey, Pa.
Author Manuscript
A 34-year-old woman presented at 19 weeks’ gestation with a large right-sided neck mass. Her medical history was significant only for two previous pregnancies, one of which resulted in a spontaneous abortion and the other in a live birth. The patient denied any signs or symptoms other than the mass. Ultrasonography demonstrated a 1.8 × 2.2 × 2.2-cm mass in the right side of the thyroid gland (figure 1), which had metastasized to the ipsilateral level IV lymph nodes. Fine-needle aspiration biopsy was highly suggestive of papillary thyroid cancer. The patient was offered surgery, but she chose to postpone the procedure until after she had delivered her child. Following the birth of her child, the patient was scheduled for a total thyroidectomy with central and right lateral neck dissection of the level II to IV lymph node compartments. Videostroboscopic studies conducted prior to the procedure confirmed that both vocal folds were functional.
Author Manuscript
During surgery, the thyroid tumor was found to be adherent to the right recurrent laryngeal nerve (RLN) (figure 2, A). To preserve the patient’s vocal fold function, sharp dissection was used to free the visible tumor from the nerve (figure 2, B) before the thyroid gland and abnormal central compartment lymph nodes were removed. Postoperatively, the patient was treated with radioactive iodine ablation of the remnant thyroid tissue. She retained function of both RLNs. Differentiated thyroid cancer (DTC) is more common among women than men; 35% of women diagnosed with thyroid cancer are between the ages of 20 and 44 years.1 Furthermore, DTC is the second most commonly diagnosed malignancy during pregnancy, with only breast cancer being diagnosed more frequently. The incidence of DTC during pregnancy ranges from 3.6 to 14 per 100,000 live births.1
Author Manuscript
Multiparity and fertility agents such as clomiphene may increase the risk of developing DTC.2 However, DTC in pregnant women is no more aggressive than it is in nonpregnant women. Moreover, a retrospective study has indicated that there is no difference in recurrence or survival between women who undergo surgery for DTC during their pregnancy and those who do so afterward.3 Accordingly, the American Thyroid Association recommends that biopsy-confirmed DTC discovered in early pregnancy be monitored sonographically.
Bann et al.
Page 2
Author Manuscript
Patients with a tumor that increases in volume by 50% or increases in diameter by 20% by 24 weeks’ gestation may be referred for surgery during the second trimester, while surgery for patients with less aggressive disease can be deferred until the postpartum period.4 Invasive disease is relatively uncommon in DTC, occurring in only ~16% of cases; however, the RLN is involved in 33 to 61% of all cases of invasive disease.5 Involvement of the RLN is not associated with decreased survival, although damage to the nerve by the tumor or during surgery may cause significant morbidity. In cases of RLN invasion by DTC, several factors should influence the extent of surgical resection including (1) preoperative vocal fold paralysis, (2) function of the contralateral RLN, (3) tumor histology, and (4) the likelihood of tumor response to radioactive iodine ablation.5
Author Manuscript
All attempts should be made to preserve the RLN with resection of all gross tumor, particularly in cases of known contralateral RLN dysfunction. However, if the RLN is completely encased by the tumor, it may be necessary to sacrifice the nerve to completely resect the tumor. In such cases, the RLN may be reanastamosed if a sufficient amount of distal stump remains. Alternately, the ansa cervicalis (ansa hypoglossi) may be anastamosed to the RLN in an attempt to provide some postoperative function.6
References
Author Manuscript
1. Uruno T, Shibuya H, Kitagawa W, et al. Optimal timing of surgery for differentiated thyroid cancer in pregnant women. World J Surg. 2014; 38(3):704–708. [PubMed: 24248429] 2. Imran SA, Rajaraman M. Management of differentiated thyroid cancer in pregnancy. J Thyroid Res. 2011; 2011:549609. [PubMed: 21687597] 3. Cooper DS, Doherty GM, Haugen BR, et al. American Thyroid Association (ATA) Guidelines Taskforce on Thyroid Nodules and Differentiated Thyroid Cancer. Revised American Thyroid Association management guidelines for patients with thyroid nodules and differentiated thyroid cancer. Thyroid. 2009; 19(11):1167–1214. [PubMed: 19860577] 4. Stagnaro-Green A, Abalovich M, Alexander E, et al. Guidelines of the American Thyroid Association for the diagnosis and management of thyroid disease during pregnancy and postpartum. Thyroid. 2011; 21(10):1081–1125. [PubMed: 21787128] 5. Liao S, Shindo M. Management of well-differentiated thyroid cancer. Otolaryngol Clin North Am. 2012; 45(5):1163–1179. [PubMed: 22980691] 6. Nishida T, Nakao K, Hamaji M, et al. Preservation of recurrent laryngeal nerve invaded by differentiated thyroid cancer. Ann Surg. 1997; 226(1):85–91. [PubMed: 9242342]
Author Manuscript Ear Nose Throat J. Author manuscript; available in PMC 2015 July 01.
Bann et al.
Page 3
Author Manuscript Author Manuscript Figure 1.
Author Manuscript
Ultrasonographic image shows the large right-sided papillary thyroid cancer (arrow).
Author Manuscript Ear Nose Throat J. Author manuscript; available in PMC 2015 July 01.
Bann et al.
Page 4
Author Manuscript Author Manuscript
Figure 2.
Intraoperative photographs show the recurrent laryngeal nerve (arrows) before (A) and after (B) dissection of the tumor off the nerve.
Author Manuscript Author Manuscript Ear Nose Throat J. Author manuscript; available in PMC 2015 July 01.
Ear Nose Throat J. Author manuscript; available in PMC 2015 July 01. Published in final edited form as: Ear Nose Throat J. 2014 July ; 93(7): 252–254.
Papillary thyroid cancer in a gravid woman Darrin V. Bann, PhD, Neerav Goyal, MD, MPH, and David Goldenberg, MD, FACS The MD/PhD Program (Dr. Bann) and the Division of Otolaryngology–Head and Neck Surgery, Department of Surgery (Dr. Goyal and Dr. Goldenberg), Penn State College of Medicine, Hershey, Pa.
Author Manuscript
A 34-year-old woman presented at 19 weeks’ gestation with a large right-sided neck mass. Her medical history was significant only for two previous pregnancies, one of which resulted in a spontaneous abortion and the other in a live birth. The patient denied any signs or symptoms other than the mass. Ultrasonography demonstrated a 1.8 × 2.2 × 2.2-cm mass in the right side of the thyroid gland (figure 1), which had metastasized to the ipsilateral level IV lymph nodes. Fine-needle aspiration biopsy was highly suggestive of papillary thyroid cancer. The patient was offered surgery, but she chose to postpone the procedure until after she had delivered her child. Following the birth of her child, the patient was scheduled for a total thyroidectomy with central and right lateral neck dissection of the level II to IV lymph node compartments. Videostroboscopic studies conducted prior to the procedure confirmed that both vocal folds were functional.
Author Manuscript
During surgery, the thyroid tumor was found to be adherent to the right recurrent laryngeal nerve (RLN) (figure 2, A). To preserve the patient’s vocal fold function, sharp dissection was used to free the visible tumor from the nerve (figure 2, B) before the thyroid gland and abnormal central compartment lymph nodes were removed. Postoperatively, the patient was treated with radioactive iodine ablation of the remnant thyroid tissue. She retained function of both RLNs. Differentiated thyroid cancer (DTC) is more common among women than men; 35% of women diagnosed with thyroid cancer are between the ages of 20 and 44 years.1 Furthermore, DTC is the second most commonly diagnosed malignancy during pregnancy, with only breast cancer being diagnosed more frequently. The incidence of DTC during pregnancy ranges from 3.6 to 14 per 100,000 live births.1
Author Manuscript
Multiparity and fertility agents such as clomiphene may increase the risk of developing DTC.2 However, DTC in pregnant women is no more aggressive than it is in nonpregnant women. Moreover, a retrospective study has indicated that there is no difference in recurrence or survival between women who undergo surgery for DTC during their pregnancy and those who do so afterward.3 Accordingly, the American Thyroid Association recommends that biopsy-confirmed DTC discovered in early pregnancy be monitored sonographically.
Bann et al.
Page 2
Author Manuscript
Patients with a tumor that increases in volume by 50% or increases in diameter by 20% by 24 weeks’ gestation may be referred for surgery during the second trimester, while surgery for patients with less aggressive disease can be deferred until the postpartum period.4 Invasive disease is relatively uncommon in DTC, occurring in only ~16% of cases; however, the RLN is involved in 33 to 61% of all cases of invasive disease.5 Involvement of the RLN is not associated with decreased survival, although damage to the nerve by the tumor or during surgery may cause significant morbidity. In cases of RLN invasion by DTC, several factors should influence the extent of surgical resection including (1) preoperative vocal fold paralysis, (2) function of the contralateral RLN, (3) tumor histology, and (4) the likelihood of tumor response to radioactive iodine ablation.5
Author Manuscript
All attempts should be made to preserve the RLN with resection of all gross tumor, particularly in cases of known contralateral RLN dysfunction. However, if the RLN is completely encased by the tumor, it may be necessary to sacrifice the nerve to completely resect the tumor. In such cases, the RLN may be reanastamosed if a sufficient amount of distal stump remains. Alternately, the ansa cervicalis (ansa hypoglossi) may be anastamosed to the RLN in an attempt to provide some postoperative function.6
References
Author Manuscript
1. Uruno T, Shibuya H, Kitagawa W, et al. Optimal timing of surgery for differentiated thyroid cancer in pregnant women. World J Surg. 2014; 38(3):704–708. [PubMed: 24248429] 2. Imran SA, Rajaraman M. Management of differentiated thyroid cancer in pregnancy. J Thyroid Res. 2011; 2011:549609. [PubMed: 21687597] 3. Cooper DS, Doherty GM, Haugen BR, et al. American Thyroid Association (ATA) Guidelines Taskforce on Thyroid Nodules and Differentiated Thyroid Cancer. Revised American Thyroid Association management guidelines for patients with thyroid nodules and differentiated thyroid cancer. Thyroid. 2009; 19(11):1167–1214. [PubMed: 19860577] 4. Stagnaro-Green A, Abalovich M, Alexander E, et al. Guidelines of the American Thyroid Association for the diagnosis and management of thyroid disease during pregnancy and postpartum. Thyroid. 2011; 21(10):1081–1125. [PubMed: 21787128] 5. Liao S, Shindo M. Management of well-differentiated thyroid cancer. Otolaryngol Clin North Am. 2012; 45(5):1163–1179. [PubMed: 22980691] 6. Nishida T, Nakao K, Hamaji M, et al. Preservation of recurrent laryngeal nerve invaded by differentiated thyroid cancer. Ann Surg. 1997; 226(1):85–91. [PubMed: 9242342]
Author Manuscript Ear Nose Throat J. Author manuscript; available in PMC 2015 July 01.
Bann et al.
Page 3
Author Manuscript Author Manuscript Figure 1.
Author Manuscript
Ultrasonographic image shows the large right-sided papillary thyroid cancer (arrow).
Author Manuscript Ear Nose Throat J. Author manuscript; available in PMC 2015 July 01.
Bann et al.
Page 4
Author Manuscript Author Manuscript
Figure 2.
Intraoperative photographs show the recurrent laryngeal nerve (arrows) before (A) and after (B) dissection of the tumor off the nerve.
Author Manuscript Author Manuscript Ear Nose Throat J. Author manuscript; available in PMC 2015 July 01.
