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Female, 58 years old Otolaryngology examination report Endoscopic findings: Hyperemia of the pharyngeal mucosa, smooth epiglottic mucosa, smooth mucosa in bilateral pyriform sinuses and arytenoid regions. The left vocal cord was fixed in the paramedian position with a smooth surface. The right vocal cord showed compensatory movement, and there was a gap on glottic closure. Endoscopic diagnosis: Left vocal cord paralysis Examination date: September 18 of the previous year
Color Doppler ultrasound report Examination date: 16:03:56 on October 8 of the previous year Ultrasound findings: Right thyroid lobe 46 × 17 × 18 mm, left thyroid lobe 49 × 16 × 18 mm, isthmus 6 mm. A 20 × 13 mm hypoechoic mass was seen in the upper right lobe with ill-defined borders and irregular shape, containing several punctate and short linear hyperechoic foci (largest 3.3 mm); no obvious color flow on CDFI. Another 9 × 6 mm similar mass was noted in the middle-lower right lobe. A 12 × 7 mm similar mass was seen in the isthmus. A 22 × 13 mm similar mass was present in the middle-upper left lobe. Several additional hypoechoic and mixed-echo masses were found in both lobes with relatively clear borders (largest 7 × 4 mm on the right and 19 × 14 mm on the left); no obvious color flow on CDFI. Thyroid parenchyma showed heterogeneous echogenicity with normal internal vascular distribution. Blood flow in the superior thyroid arteries was patent bilaterally (right: PSV 0.23 m/s, RI 0.59; left: PSV 0.21 m/s, RI 0.66). Multiple hypoechoic masses were detected adjacent to the cervical vessels bilaterally with relatively clear borders and no visible hilar structure (largest 17 × 8 mm on the right and 12 × 6 mm on the left), containing punctate and short linear hyperechoic foci; no obvious color flow on CDFI. Bilateral submandibular and parotid glands showed homogeneous echogenicity with no obvious masses. No obvious mass in the submental region. No abnormal color flow on CDFI. No obvious masses in the bilateral parathyroid regions and no abnormal blood flow on CDFI. Ultrasound impression: Multiple solid masses with calcification in both thyroid lobes and isthmus — malignancy suspected; multiple solid masses with calcification in bilateral neck — possible metastatic lymph nodes; remaining nodules in both thyroid lobes — likely benign.
Surgical ward (partial) record …. Normal pulsation, no jugular venous distension, trachea midline, negative hepatojugular reflux, no visible chest wall veins, normal symmetrical chest, steady regular breathing, normal intercostal spaces, symmetrical bilateral chest expansion, no pleural friction rub, no subcutaneous crepitus. Both lungs resonant. No dry or moist rales, normal breath sounds bilaterally, no pleural friction rub. No precordial bulge, normal apical impulse located 0.5 cm inside the left midclavicular line at the 5th intercostal space, impulse diameter about 1.5 cm, no thrill. Cardiac dullness border not enlarged. Abdomen flat, no visible abdominal wall veins, no gastrointestinal pattern or peristalsis. Soft abdomen, no tenderness or rebound, no liver or kidney percussion tenderness, negative shifting dullness, normal bowel sounds (4-5 times per minute). Genitalia normal. Anus and rectum normal. Spine normal, no deformity, normal mobility, no tenderness or percussion pain. No lower limb edema, normal extremities, no clubbing, no joint redness, swelling or tenderness, normal joint mobility. Normal knee and ankle reflexes, negative Babinski sign, negative Kernig sign, no flapping tremor. Specialist findings Trachea midline. A mass approximately 1.0 cm in diameter was palpable in the thyroid, firm, with clear borders, non-tender, moving with swallowing. No obvious masses in the right thyroid lobe or isthmus. No vascular bruit on thyroid auscultation. No enlarged lymph nodes in bilateral neck or supraclavicular regions. Auxiliary examinations B-ultrasound from outside hospital on October 8: Suggested multiple solid masses with calcification in both lobes and isthmus — malignancy suspected; multiple solid masses with calcification in bilateral neck — possible lymph node metastasis. Preliminary diagnosis: Bilateral thyroid malignancy Date: October 17 of the previous year Attending physician’s initial diagnosis: Bilateral thyroid malignancy
Surgical record Department: Surgery Surgery start time: 19:00 on October 22 of the previous year Preoperative diagnosis: Bilateral thyroid malignancy Intraoperative diagnosis: Bilateral thyroid malignancy; bilateral thyroid malignancy (tumor invading trachea and esophagus) Procedure name: Open biopsy of right thyroid and isthmus Surgical course Position and incision: Supine with neck extended. After anesthesia, the surgical field was disinfected. A transverse neck incision was made, skin flaps were raised, and the midline was opened to expose the thyroid. Exploration: The left lobe, right lobe, and isthmus of the thyroid were firm and fixed, forming a mass adherent to the trachea and esophagus. Enlarged lymph nodes were palpable in both sides of the neck. Surgical steps: A 1 × 0.5 cm piece of tissue was taken from the right thyroid and a 0.5 × 0.3 cm piece from the isthmus and sent for frozen section. Report: (Right thyroid and isthmus) papillary carcinoma. Hemostasis was achieved and the wound closed. The family was informed in detail of the condition intraoperatively. The thyroid could not be resected (see conversation record for details). One drainage tube was placed in the surgical field. Instruments and dressings were counted correctly. Subcutaneous tissue and skin were closed. The wound was dressed with sterile gauze. The operation went smoothly with minimal blood loss and no transfusion. The patient was returned to the ward in stable condition after anesthesia recovery. Intraoperative events and management The left lobe, right lobe, and isthmus of the thyroid were firm and fixed, forming a mass adherent to the trachea and esophagus. The family was informed in detail of the condition intraoperatively. The thyroid could not be resected (see conversation record for details). Surgery end time: 20:54 on October 22 of the previous year Record time: 21:00 on October 22 of the previous year
PET/CT report Department: Medical Oncology Examination: PET/CT whole-body tumor tomography Clinical diagnosis: Fever, thyroid malignancy Scan time: 13:42 on April 2 Report time: 14:10 on April 2 Verification time: 12:57 on April 3 Brief history: Diagnosed with thyroid malignancy more than 5 months ago, fever for over 20 days. Open biopsy (right thyroid and isthmus) performed at outside hospital in October last year, pathology: papillary carcinoma of right thyroid and isthmus. Targeted therapy continued until March 25. Recurrent fever for over 20 days with Tmax 39.2°C, treated intermittently with antibiotics until April 1; temperature now normal. Hospital CT on March 23: small nodule in right lung; mild chronic inflammation in both lungs; upper mediastinal and bilateral supraclavicular lymph nodes; likely heterogeneous fatty liver; pancreatic fatty infiltration; small amount of pelvic fluid. Blood tests on March 26: FT₄ 17.7 pmol/L, FT₃ 3.4 pmol/L, TSH 3.190 μIU/mL, Tg 480.0 ng/mL, Tg-Ab <10.0 IU/mL, TPO-Ab <9.0 U/mL. Blood tests on April 2: AFP, CEA, CA199, CA125, CA153, CA724 all negative. Past history: ovarian cyst surgery more than 10 years ago. PET/CT performed for restaging. Imaging findings: Brain: No obvious abnormal glucose metabolism in cerebral cortex, bilateral basal ganglia, thalamus, or cerebellum. No abnormal density in brain parenchyma. Ventricles and cisterns normal. No widening of sulci or fissures. Midline structures centered. Orbits: No abnormal hypermetabolic foci in eyeballs or orbits. Intact eyeball walls, no intraocular masses. Optic nerves normal. Clear orbital fat planes. Nasopharynx: No abnormal hypermetabolic foci in nasopharynx or parapharyngeal spaces. Smooth posterior nasopharyngeal wall, symmetrical lateral walls, patent fossae of Rosenmüller and Eustachian tube openings, clear parapharyngeal spaces. Mucosal thickening in right maxillary sinus, likely chronic inflammation. Other paranasal sinuses unremarkable. Neck: Multiple low-density nodules with calcification in both thyroid lobes and isthmus, poorly demarcated from adjacent tracheal wall. Two prominent nodules (left ~13.0 × 10.8 mm, right ~11.5 × 8.0 mm) with SUVmax ~5.4 and 6.0 respectively. Multiple calcified lymph nodes around trachea, bilateral cervical vessels, and supraclavicular regions, some with abnormal glucose metabolism. Three prominent nodes (right cervical vessels ~10.8 × 7.6 mm SUVmax ~4.0; left supraclavicular ~11.7 × 10.1 mm SUVmax ~3.8; right supraclavicular ~17.4 × 14.4 mm SUVmax ~4.7). No abnormal hypermetabolism or masses in oropharynx or hypopharynx. Chest: Ground-glass nodules in posterior and anterior segments of right upper lobe (~5.7 mm and 4.9 mm, SUVmax ~0.7 and 0.6). Several small solid nodules in both lungs, some irregular, largest ~5.0 × 3.0 mm, SUVmax ~0.5. Patent bronchi. No abnormal hypermetabolic foci or enlarged lymph nodes in mediastinum or bilateral hila. No pleural effusion. Heart not enlarged. No abnormal hypermetabolism or enlarged nodes in bilateral axillae. No abnormal hypermetabolism or masses in bilateral breasts. Abdomen: Diffuse increased glucose metabolism in parts of transverse, descending, sigmoid colon and rectum (SUVmax ~12.9), likely physiologic. Physiologic uptake in gastric wall. Liver surface smooth with patchy low-density areas (average CT ~39.4 HU). No biliary dilatation. Spleen normal. Pancreatic fatty infiltration. No abnormal hypermetabolism or masses in kidneys or adrenals. No abnormal retroperitoneal nodes. No ascites. Pelvis: Increased metabolism in sigmoid colon and rectum as above. Physiologic tracer in bladder. No abnormal hypermetabolism or masses in uterus or adnexa. No abnormal inguinal nodes. No pelvic fluid. Skeleton: No abnormal hypermetabolic foci. Bones intact, no destructive lesions. Conclusions: Post-targeted therapy for thyroid malignancy: 1. Multiple thyroid malignancies with metastases to bilateral cervical and supraclavicular lymph nodes; metabolically active tumor. 2. Ground-glass nodules in right upper lobe — follow-up recommended. Small solid nodules in both lungs — metastasis not excluded; correlate clinically. 3. Heterogeneous fatty liver.
Medical record August 27, 14:20 Chief complaint: Follow-up after thyroid cancer surgery at outside hospital History: Thyroid cancer surgery at outside hospital; intraoperative finding of severe local invasion, incomplete resection performed; postoperative sorafenib therapy. Physical examination: Postoperative changes Preliminary diagnosis: Status post thyroid cancer surgery Management: Complete examinations Prescriptions: Ultrasound of thyroid, neck, and supraclavicular region; CT of thyroid (plain + contrast)
Ultrasound Doppler report Department: Head and Neck Tumor Examination: Supraclavicular, thyroid, neck Thyroid: Irregular morphology of both lobes with heterogeneous, disordered echogenicity. Multiple clustered hyperechoic areas (left: 15 × 9 mm and 9 × 6 mm; right: 11 × 7 mm), ill-defined, irregular, containing coarse granular hyperechoic foci with posterior shadowing in some areas; minimal blood flow. No obvious masses in parathyroid regions. Neck: High-echo masses on surface of left mid-neck internal jugular vein and posterior to lower-neck internal jugular vein (14 × 6 mm and 17 × 9 mm), ill-defined and irregular; latter contains granular hyperechoic foci; minimal blood flow. Right mid-upper neck around internal jugular vein: Several hypoechoic and intermediate-echo masses (18 × 10 mm, 12 × 6 mm, 10 × 7 mm etc.), clear borders, regular shape, some with nodular or granular hyperechoic foci; minimal blood flow. Midline neck from thyroid cartilage to suprasternal notch: Tubular anechoic structure ~6 mm in diameter with smooth wall in subcutaneous tissue. Supraclavicular regions: No obvious masses bilaterally; no abnormal color flow signals. Ultrasound impression: 1. Heterogeneous changes in both thyroid lobes with multiple solid nodules and calcification (TI-RADS 4B) 2. Multiple solid nodules in left neck levels III–IV and right neck levels II–III, some with calcification (possible lymph node metastasis) 3. Tubular structure in midline neck subcutaneous tissue — correlate clinically Examination date: 14:38 on August 30
Medical record September 20, 09:59 Chief complaint: Follow-up after thyroid cancer surgery at outside hospital History: Thyroid cancer surgery at outside hospital; intraoperative finding of severe local invasion, incomplete resection performed; postoperative sorafenib therapy Ultrasound (August 30): Heterogeneous changes in both thyroid lobes with multiple solid nodules and calcification (TI-RADS 4B); multiple solid nodules in left neck levels III–IV and right neck levels II–III, some with calcification (possible lymph node metastasis); tubular structure in midline neck subcutaneous tissue — correlate clinically CT (September 2): Multiple thyroid nodules with calcification; multiple lymph nodes in bilateral neck, around trachea, and supraclavicular regions, some with calcification — correlate with ultrasound. High-density tubular shadow in midline neck subcutaneous tissue Physical examination: Postoperative changes Preliminary diagnosis: Status post thyroid cancer surgery Management: Explained condition to patient and recommended consultation at the original surgical hospital