Correspondence: Lt Col Irfan Shukr, Department of Surgery, CMH Rawalpindi

A 33 years old, male patient, resident of Attock reported with swelling left side of neck of 4 years duration. This young man noticed a soft, painless swelling in the left side of his neck, just above the left clavicle. The swelling was small, and gave the patient no discomfort at all initially, so he avoided going to the hospital. The patient was clinically euthyroid. The swelling increased very slowly in size over the following three and a half years, until by December 2003 it had become large enough to cause significant disfigurement. However, it remained painless and there were no pressure symptoms. At this time, the patient also noticed two smaller swellings adjacent to the original larger one. Worried, he now reported to the hospital for treatment. The patient’s younger brother, aged 19 years, had a similar swelling on the anterior aspect of the neck. His first cousin, aged 30 years, also had a similar swelling in her neck. Both had not consulted a doctor so far. There was no family history of hypertension or diabetes mellitus. On examination his vital signs, including his blood pressure were within normal limits. There were no café- au- lait patches or neurofibromas on the skin. A large 7 by 9 cm swelling was present on the left side of the neck, extending from just left side of the midline to anterior border of left trapezius, and from mandible to clavicle. It did not move on swallowing. Its temperature was not raised, and was nontender. It had lobulated surface, firm consistency, with regular, well-defined edges except inferiorly where lower limit was not palpable. It had little mobility in transverse direction and was deep to left sternocleidomastoid muscle (fig. 1). Two smaller swellings of a similar character were palpable just lateral to the large swelling. No other swellings or lymph nodes were palpable in the neck. Thyroid gland was not enlarged. FNAC of the swelling was suggestive of metastatic follicular carcinoma of the thyroid gland. Serum TSH was not raised. Blood hemoglobin, and creatinine and electrolytes were with in normal limits. Radical lymph node dissection was done on the left side of the neck (fig. 2), with total thyroidectomy. Thyroid was normal on naked eye examination. Histopathological examination showed it to be metastatic medullary carcinoma of the thyroid gland with microscopic primary in the left lobe of thyroid gland and not metastatic follicular carcinoma. Patient had smooth recovery from the operation. After diagnosis serum calcitonin and CEA levels were done. They were not raised. Serum parathyroid and corrected serum calcium were also normal. Ultrasound abdomen was normal. Vanillyl mandelic acid was within normal limits in 24 hour collected urine. Following healing of neck wound, external beam radiation was given to the neck and superior mediastinum. His brother and cousin have been advised to consult us for counseling, which they had not consented so far. 

Fig. 1:     Enlarged lymph nodes causing swelling on the left side of neck     Fig. 2:     Radical Lymph node of neck-dissected specimen.

DISCUSSION