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Clinical Challenge
December 2016

An Expansile Mass Following Central Lymph Node Dissection

Author Affiliations
  • 1Tulane University Medical Center, New Orleans, Louisiana
  • 2Department of Neurosurgery, University of California, San Francisco, San Francisco
  • 3Department of Otolaryngology, Tulane University Medical Center, New Orleans, Louisiana
JAMA Otolaryngol Head Neck Surg. 2016;142(12):1237-1238. doi:10.1001/jamaoto.2016.3459

A woman in her 60s returned for a 6-month follow-up after undergoing a substernal total thyroidectomy for a T3N0M0 right-sided undifferentiated insular carcinoma that caused dysphagia, dysphonia, and tracheal deviation (Figure, A and B). The procedure was uneventful and well tolerated. Her history of end-stage renal disease precluded postoperative radioactive iodine treatment. Ultrasonography performed at her 3-month follow-up showed no evidence of disease recurrence or local metastasis. Her compressive symptoms had also resolved. Ultrasonography revealed a 1.3 × 1.1 × 1.0-cm hypoechoic mass in the right central compartment and a suspicious lymph node in the right carotid sheath. Fine-needle aspiration confirmed recurrence of a malignant neoplasm in the central compartment; however, the lymph node was not amenable to sampling based on its anatomic location. The patient decided to undergo a right central (level VI) lymph node dissection. Intraoperatively, insular carcinoma was dissected away from the cricothyroid membrane and recurrent laryngeal nerve. In the right central compartment several prelaryngeal and pretracheal nodes were identified and excised. After removal of the most distal of these nodes, a separate pale tan mass 2 cm in diameter was visualized at the level of the thoracic inlet. The mass demonstrated respiratory expansion and retraction. The expansile mass was excised. Histopathologic analysis revealed a cystic mass composed primarily of mucosal cells and sparse fibroconnective tissue (Figure, C and D).

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