Thyro-Neck Clinic & Research Center

02/08/2026

♦️♦️38 years old male presented with thyroid swelling .
Sonographic findings reveals 1.3cm / 0.7cm lesion in the isthmus.
FNAC reveals Nodular Goitre.
After Isthmussectomy histopathology reveals Classical type of papillary thyroid carcinoma.
What will be next plan of management? ♦️♦️

🚩🚩This patient has an incidentally diagnosed classical papillary thyroid carcinoma (PTC) after isthmusectomy, which requires risk stratification before deciding whether completion thyroidectomy is necessary.

Summary

* Age: 38 years
* S*x: Male
* Tumor location: Isthmus
* Tumor size: 1.3 × 0.7 cm
* Preoperative FNAC: Nodular goitre
* Operation: Isthmusectomy
* Histopathology: Classical papillary thyroid carcinoma

🟥Step 1: Review the Final Histopathology Carefully

Before deciding on further surgery, obtain the full pathology report and determine:

* Exact tumor size
* Unifocal vs multifocal
* Surgical margin status
* Microscopic or gross extrathyroidal extension (ETE)
* Lymphovascular invasion
* Perineural invasion
* Tall-cell or other aggressive variants
* Presence of lymph nodes in the specimen
* BRAF mutation (optional, not routinely required)

🟥Step 2: Postoperative Evaluation

* High-resolution neck ultrasonography
* Serum TSH
* Clinical examination of the neck

🟥Management

If All of the following are present:

* Tumor ≤2 cm
* Classical PTC
* Unifocal
* Negative margins
* No lymphovascular invasion
* No microscopic or gross ETE
* No suspicious cervical lymph nodes
* No contralateral thyroid nodule requiring surgery

Observation is a reasonable option.

Close follow-up includes:

* Neck ultrasound every 6–12 months initially
* TSH suppression to approximately 0.5–2 mIU/L

Recent studies suggest that isthmusectomy alone can be adequate treatment for carefully selected low-risk PTC confined to the isthmus.

🟥Completion Thyroidectomy is Recommended If Any High-Risk Feature Exists

Completion thyroidectomy should be performed if there is:

* Tumor >2 cm
* Positive surgical margin
* Gross or microscopic ETE
* Multifocal disease
* Bilateral thyroid nodules suspicious for malignancy
* Aggressive histological subtype
* Clinically involved lymph nodes
* Lymphovascular invasion (relative indication depending on overall risk)

🟥If completion thyroidectomy is done:

* Central neck dissection only if there are clinically or radiologically involved lymph nodes. Prophylactic central neck dissection is not routinely recommended for a T1N0 tumor.
* RAI is generally not indicated for low-risk T1 disease after complete surgery.

🟥Particular Consideration for Isthmic Tumors

Papillary carcinoma arising in the isthmus has been associated in some series with:

* Higher rates of multifocality
* Bilateral disease
* Central compartment lymph node metastasis
* Extrathyroidal extension

Because of this, some endocrine surgeons favor completion thyroidectomy even for small isthmic cancers. However, current ATA- and NCCN-consistent management supports individualized decision-making rather than routine completion thyroidectomy for all isthmic PTCs.

🟥🟥📚 Next Step for This Patient

1. Review the detailed pathology report.
2. Perform a meticulous postoperative neck ultrasound.
3. If the tumor is 1.3 cm, classical PTC, unifocal, confined to the isthmus, margins negative, no ETE, no lymphovascular invasion, and no suspicious lymph nodes, active surveillance after isthmusectomy is an acceptable option.
4. If any adverse pathological feature is identified, proceed with completion thyroidectomy.

Follow-up

* TSH suppression:
* 0.5–2 mIU/L for low-risk disease.
* Neck ultrasound:
* At 6–12 months, then periodically based on findings.

27/07/2026

24/07/2026

♦️♦️♦️18 years old female underwent Total thyroidectomy with central clearance with bilateral neck dissection (Level II to V(rt) Level II to IV(lt)) on 22/12/25
Preoperative Serum calcitonin was 10174pg/ml
Preoperative imaging shows no distant metastasis.

Post operative serum calcitonin
16/02/26 Serum calcitonin 59pg/ml (After 2 months )
25/03/26 Serum calcitonin 40.7pg/ml (3 months)
19/05/26 Serum calcitonin 114.8pg/ml (5 months)
19/07/26 Serum calcitonin 149pg/dl (7 months)
CEA- 2.54 ng/ml

CT Scan of Neck , Chest, Abdomen on 19/07/26 reveals nothing abnormality.
No localized disease or distant metastasis.

What will be next plan of management? ♦️♦️♦️

💢💢💢💢💢💢💢💢💢💢💢💢💢💢💢💢💢

🚩This pattern is most consistent with biochemically progressive medullary thyroid carcinoma (MTC) without currently identifiable structural disease. The rising calcitonin is important, but another neck operation or systemic therapy should not be started solely because the calcitonin is rising when imaging shows no abnormality.

🚩The postoperative s. calcitonin was 40.7 pg/mL, followed by 114.8 and 149 pg/mL. That upward trend warrants closer evaluation. Calcitonin and CEA doubling times are major prognostic markers in persistent MTC. a calcitonin doubling time 2 years is substantially more favorable.

Current values suggest a potentially short doubling time.

High resoulation cervical ultrasound with expert hand is preferable for meticulous central and lateral compartment mapping, even though the CT neck is negative. Any suspicious node should undergo US-guided FNAC ± calcitonin measurement in the needle washout before reoperation.

In a specialized center, reasonable next functional imaging options include ^18F-DOPA PET/CT or ^68Ga-DOTATATE PET/CT or FDG-PET/CT becomes particularly useful when the biology appears aggressive, such as a short calcitonin/CEA doubling time.

🚩Next steps -

Do not perform blind/re-exploratory neck dissection with a negative CT/US and no anatomically localized disease.
Vandetanib, cabozantinib, selpercatinib/pralsetinib or other systemic treatment is not indicated merely for biochemical disease in an asymptomatic patient without measurable progressive structural disease.

Radioactive iodine also has no role in MTC.

📍One particularly important issue in this 18-year-old

She should have germline RET testing together with genetic counselling. RET genotype has implications for hereditary MEN2, prognosis, family screening, and future targeted treatment.

If RET-positive, ensure appropriate MEN2 evaluation, particularly plasma free metanephrines or 24-hour urinary fractionated metanephrines for pheochromocytoma and serum calcium ± PTH for hyperparathyroidism, according to the mutation/MEN2 phenotype.

🚩🎈🚩Summary -

1. Expert neck US , confirm germline RET, and document CEA alongside calcitonin.

2. In ~2–3 months: repeat calcitonin + CEA using the same assay and calculate doubling times.

3. If calcitonin continues rising above 150 pg/mL or doubling time is short: pursue more sensitive localization—particularly ^18F-DOPA PET/CT or ^68Ga-DOTATATE PET/CT, depending on local availability/expertise—and targeted imaging based on the findings.

4. If imaging remains completely negative: continue active biochemical and imaging surveillance rather than empirical surgery or systemic therapy.

5. The key concern here is not the absolute value of 149 pg/mL itself, but the trajectory. The rise from 40.7 → 114.8 → 149 over four months could represent biologically active microscopic residual disease, so establishing the true calcitonin doubling time is the next major prognostic step. Short doubling times are associated with substantially higher recurrence/progression risk.

18/07/2026

♦️♦️47 years old man presented with rapidly growing thyroid swelling for last 3 months.
FNAC reveals Non Hodgkin's Lymphoma.
What will be next plan of management? ♦️♦️

🟥A 47-year-old man with a rapidly enlarging thyroid swelling over 3 months and FNAC showing Non-Hodgkin lymphoma (NHL) should be managed as primary thyroid lymphoma (PTL) until proven otherwise. The next step is confirming the diagnosis, staging the disease, and initiating systemic therapy, rather than proceeding directly to thyroidectomy.

🚩1: Confirm the diagnosis

FNAC alone is often insufficient to fully classify lymphoma.

* Core needle biopsy (preferred) or incisional biopsy if necessary
* Histopathology with
* Immunohistochemistry (IHC)


Essential IHC panel:

* CD20
* CD3
* CD5
* CD10
* BCL2
* BCL6
* MUM1
* Ki-67
* Cyclin D1
* CD23

The most common subtype is:

* Diffuse Large B-cell Lymphoma (60–70%)
* MALT lymphoma

🚩2: Evaluate airway

Rapid thyroid enlargement can produce:

* Stridor
* Dyspnea
* Dysphagia
* Hoarseness

Assess:

* Flexible laryngoscopy
* Oxygen saturation
* CT neck

If severe airway compromise:

* High-dose corticosteroid
* Awake fiberoptic intubation if necessary
* Tracheostomy only if absolutely unavoidable (often technically difficult in lymphoma)

Many thyroid lymphomas shrink dramatically within days after steroids or chemotherapy.

🚩3: Complete staging

Imaging

Preferred:

* PET-CT

If unavailable:

* Contrast CT neck
* CT chest
* CT abdomen
* CT pelvis

Assess:

* Cervical nodes
* Mediastinum
* Extranodal disease
* Splenic involvement

🚩4. MDT discussion

Should involve:

* ENT/Head-Neck surgeon
* Hematologist
* Radiation oncologist
* Pathologist
* Radiologist

🚩5. Definitive treatment

Treatment depends on histology.

A. Diffuse Large B-cell Lymphoma (most common)

Standard treatment:

R-CHOP × 6 cycles

* Rituximab
* Cyclophosphamide
* Doxorubicin
* Vincristine
* Prednisolone

Followed by:

* Involved-site radiotherapy (30–36 Gy) for localized disease in many patients.

B. MALT lymphoma

Localized disease:

* Radiotherapy alone (24–30 Gy)

Advanced disease:

* Rituximab ± chemotherapy

🚩Role of Surgery

Routine thyroidectomy is not indicated.

Surgery is reserved for:

* Diagnostic biopsy when core biopsy is inconclusive
* Uncontrolled airway compromise
* Rare uncertainty in diagnosis

Total thyroidectomy is generally avoided because lymphoma is highly chemosensitive and radiosensitive.

🚩6. Response assessment

After 2–4 cycles:

* Clinical examination
* PET-CT (preferred)

At completion:

* PET-CT to assess complete metabolic response

🚩7. Follow-up

Every 3 months for 2 years

Then every 6 months until 5 years

Then annually

Monitor:

* Clinical examination
* Neck examination
* LDH
* Thyroid function (particularly if radiotherapy was given)
* Imaging only if clinically indicated

🚩8. Prognosis

Depends on:

* Histologic subtype
* Stage
* Age
* Performance status
* LDH level

outcomes:

* Localized MALT lymphoma: >90% 5-year survival
* Localized DLBCL: 70–90% with modern immunochemotherapy
* Advanced DLBCL: prognosis depends on International prognostic imdex(IPI) but remains potentially curable

📚📚In short-

1. Admit if there is any concern for airway compromise.
2. Arrange a core needle biopsy with IHC to confirm the lymphoma subtype.
3. Perform complete staging with PET-CT (or CT neck/chest/abdomen/pelvis if PET-CT is unavailable).
4. Discuss the case in a multidisciplinary tumor board.
5. If DLBCL is confirmed, initiate R-CHOP chemotherapy, with consideration of involved-site radiotherapy for localized disease.
6. Do not perform thyroidectomy unless required for diagnosis or exceptional airway indications.
7. Assess treatment response with interim and end-of-treatment PET-CT.

05/07/2026

♦️♦️32 years young lady presented with right sided thyroid swelling measuring about 3cm.
USG shows multiple nodules in both lobes.
TIRADS-3 in right and TIRADS-4 in left.
USG guided FNAC reveals Bathesda -IV.
What will be next plan of management? ♦️♦️

🚩🚩For a 32-year-old woman with:

* Right thyroid swelling: ~3 cm
* Ultrasound: Bilateral multiple thyroid nodules
* Right lobe: TI-RADS 3
* Left lobe: TI-RADS 4
* USG-guided FNAC: Bethesda IV (Follicular Neoplasm/Suspicious for Follicular Neoplasm)

the management should be individualized according to current guidelines from the American Thyroid Association and National Comprehensive Cancer Network.

📚Step 1. Clarify which nodule was biopsied

The first priority is to determine:

* Which nodule (right or left) yielded the Bethesda IV result?
* Does the cytology correspond to the TI-RADS 4 nodule?

This correlation is essential before deciding the extent of surgery.

📚Step 2. Preoperative evaluation

Perform:

* Complete history and physical examination
* Flexible laryngoscopy to document vocal cord mobility
* Thyroid function tests (TSH ± FT4)
* High-resolution neck ultrasound with central and lateral lymph node mapping
* Review cytology by an experienced cytopathologist if needed
* Consider molecular testing (Afirma, ThyroSeq, etc.) if available and if the result would change management

📚Step 3. Surgical management

Preferred option in this patient: Total thyroidectomy

Because:

* Bilateral multinodular disease
* Bethesda IV cytology
* Contralateral TI-RADS IV suspicious nodule
* Young patient who is likely to require future surgery if only one lobe is removed

Total thyroidectomy is a reasonable and often preferred option.

Advantages:

* Removes bilateral disease
* Eliminates need for completion thyroidectomy if malignancy is confirmed
* Easier postoperative surveillance with thyroglobulin
* Facilitates radioactive iodine treatment if indicated

When hemithyroidectomy is appropriate

Diagnostic hemithyroidectomy (lobectomy) would be appropriate if:

* Bethesda IV is confined to a solitary unilateral nodule
* Contralateral lobe is normal or has only benign nodules
* No suspicious lymph nodes
* No history of radiation exposure
* No strong family history of thyroid carcinoma

In this patient, bilateral disease makes lobectomy less attractive.

📚Step 4. Intraoperative considerations

* Routine recurrent laryngeal nerve identification
* Preservation of parathyroid glands
* Therapeutic central neck dissection only if metastatic lymph nodes are clinically or radiologically proven
* Do not perform prophylactic central neck dissection for indeterminate (Bethesda IV) nodules

📚Step 5. Postoperative management

Depends on final histopathology.

Possible outcomes include:

* Follicular adenoma
* Non-invasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTP)
* Follicular thyroid carcinoma
* Follicular variant of papillary thyroid carcinoma
* Hurthle cell neoplasm

Management will then include risk stratification, consideration of radioactive iodine (if indicated), levothyroxine replacement, and long-term surveillance.

🚩🚩Recommendations-

Given:

* Young patient
* Bilateral multinodular goiter
* One suspicious (TI-RADS IV) contralateral nodule
* Bethesda IV cytology

Recommended plan:

1. Confirm which nodule produced the Bethesda IV result.
2. Perform preoperative laryngoscopy and comprehensive neck ultrasound with lymph node mapping.
3. Discuss the case in a multidisciplinary thyroid team if available.
4. Proceed with total thyroidectomy, particularly if the Bethesda IV cytology corresponds to the TI-RADS IV nodule or if significant bilateral nodular disease is present.
5. Await final histopathology to determine the need for radioactive iodine and further treatment.

Bethesda IV alone does not mandate total thyroidectomy. However, bilateral clinically significant nodular disease, especially with a contralateral TI-RADS IV lesion, is a strong indication to favor total thyroidectomy over diagnostic lobectomy to avoid staged surgery and facilitate long-term management.

02/07/2026

♦️♦️26 years old male presented with thyroid swelling for 8 months.
He is euthyroid and single nodule 2.5 cm in size.
FNA reveals Bathesda -III.
What will be next plan of management? ♦️♦️

🟥A 26-year-old male with a 2.5 cm solitary thyroid nodule, euthyroid, and Bethesda Category III (Atypia of Undetermined Significance/Follicular Lesion of Undetermined Significance) requires a structured, risk-based approach according to current American Thyroid Association and National Comprehensive Cancer Network recommendations.

🚩Step 1. Reassess the Risk

Review the following carefully:

* Complete history
* Family history of thyroid cancer
* Previous neck irradiation
* Rapid increase in size
* Voice change
* Dysphagia
* Compressive symptoms
* Physical examination
* Consistency and mobility
* Cervical lymph nodes
* Vocal cord examination if indicated

⸻

🚩Step 2. Review Ultrasound Carefully

The ultrasound risk category largely determines the next step.

Look for suspicious features:

* Hypoechoic solid nodule
* Irregular margins
* Microcalcifications
* Taller-than-wide shape
* Extrathyroidal extension
* Suspicious cervical lymph nodes
* Increased vascularity (less specific)

Classify using:

* ACR TI-RADS
* ATA Ultrasound Risk Stratification

⸻

🚩Step 3. Repeat FNAC

For most Bethesda III nodules, the next investigation is:

Repeat ultrasound-guided FNAC after approximately 3 months.

Approximately:

* 50–60% become benign (Bethesda II)
* 10–30% remain Bethesda III
* Some are upgraded to Bethesda V or VI
* Overall malignancy risk is approximately 10–30% (higher in surgically selected series)

⸻

🚩Step 4. Consider Molecular Testing (if available)

If repeat cytology remains Bethesda III:

Useful tests include:

* ThyroSeq
* Afirma Genomic Sequencing Classifier

These help avoid unnecessary surgery, although they are not widely available in many countries.

⸻

🚩Step 5. Decide Between Surveillance and Surgery

Observation is appropriate if:

* Repeat FNAC is benign
* Low-risk ultrasound pattern
* No suspicious lymph nodes
* No significant growth
* Patient is comfortable with follow-up

Follow-up with ultrasound every 6–12 months.

⸻

🚩♦️Diagnostic hemithyroidectomy (thyroid lobectomy) is appropriate if:

* Repeat FNAC remains Bethesda III
* Suspicious ultrasound features
* Nodule ≥4 cm (stronger indication)
* Progressive enlargement
* Positive molecular test
* Patient preference
* Compressive symptoms

For this 2.5 cm nodule, surgery is not mandatory solely because of size.

⸻

🚩Step 6. If Suspicious Lymph Nodes Are Present

Perform:

* Ultrasound-guided FNA of the lymph node
* Thyroglobulin washout from needle aspirate if metastatic papillary thyroid carcinoma is suspected

This may change management directly to definitive thyroid cancer surgery.

⸻

📚💢Suggested Management for This Patient

Current information:

* Age: 26 years
* Solitary nodule: 2.5 cm
* Euthyroid
* Bethesda III
* No other high-risk features mentioned

Recommended next step:

1. Review ultrasound risk category (preferably assign an ACR TI-RADS score).
2. Repeat ultrasound-guided FNAC in about 3 months.
3. If repeat FNAC is benign → observe with periodic ultrasound.
4. If repeat FNAC remains Bethesda III or is upgraded (Bethesda IV–VI), discuss molecular testing (if available) or proceed to diagnostic hemithyroidectomy based on the overall clinical and ultrasound risk profile.

♨️💢🚩Practical approach in Bangladesh♦️💢🚩

Because molecular testing is often unavailable or inaccessible, many endocrine surgeons would:

* Repeat ultrasound-guided FNAC performed by an experienced cytopathologist.
* If cytology remains Bethesda III and the ultrasound is suspicious or the patient prefers definitive diagnosis, perform diagnostic hemithyroidectomy with isthmusectomy.
* If the repeat FNAC is benign and the ultrasound is low risk, continue surveillance with serial ultrasound.

21/06/2026

♦️♦️Importance of TIRADS in Ultrasound Evaluation of Thyroid Swelling♦️♦️

TIRADS (Thyroid Imaging Reporting and Data System) is a standardized ultrasound-based risk stratification system used to assess thyroid nodules and estimate their likelihood of malignancy. It helps clinicians make evidence-based decisions regarding FNAC, follow-up, and surgery.

🚩Why TIRADS is Important

1. Risk Stratification
* Categorizes thyroid nodules from benign to highly suspicious based on ultrasound features.
* Provides an estimated risk of malignancy.

2. Guides FNAC Decision
* Prevents unnecessary biopsy of low-risk nodules.
* Identifies nodules that require FNAC despite small size due to suspicious features.

3. Improves Communication
* Creates a uniform reporting system between radiologists, endocrinologists, and surgeons.
* Reduces variability in ultrasound interpretation.

4. Reduces Overtreatment
* Many thyroid nodules are benign.
* TIRADS helps avoid unnecessary investigations and surgery.

5. Follow-up Planning
* Determines which nodules require surveillance and the appropriate interval for repeat ultrasound.

🚩ACR TIRADS Scoring System

TR1- Benign-