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<p>Papillary thyroid carcinoma (PTC) is the most common differentiated thyroid malignancy. Occult PTC, characterized by cervical lymph node metastasis without an identifiable primary thyroid lesion, is uncommon and presents notable diagnostic and therapeutic challenges. A 54-year-old woman presented with a painless, gradually enlarging swelling on the left side of her neck for six months. Examination revealed a hard, non-mobile mass in level III of the cervical region. Contrast-enhanced computed tomography (CECT) showed a well-defined, enhancing lymph node overlying posterior and lateral to the carotid artery, with no abnormalities in the thyroid gland. PET-CT demonstrated FDG uptake in the suspicious node, but no metabolic activity in the thyroid. Fine-needle aspiration cytology (FNAC) was consistent with metastatic PTC. The patient underwent total thyroidectomy with modified radical neck dissection. Histopathology confirmed metastatic papillary carcinoma in the lymph node; serial sectioning of the thyroid revealed no evidence of a primary tumor. Immunohistochemistry showed strong cytoplasmic staining for thyroglobulin and nuclear positivity for thyroid transcription factor-1 (TTF-1), confirming the thyroidal origin. Postoperative radioactive iodine (RAI) whole-body scan showed no uptake. She received adjuvant RAI ablation and TSH suppression therapy and remains disease-free at one-year follow-up. Possible mechanisms for occult PTC include spontaneous regression of the primary lesion, carcinoma arising in ectopic thyroid tissue, or undetected microcarcinoma. Diagnosis requires a multidisciplinary approach combining high-resolution imaging, cytology, histopathology, and immunohistochemistry. Treatment follows standard PTC protocols involving surgery, RAI therapy, and long-term surveillance. This case highlights the importance of considering occult PTC in patients with isolated cervical lymphadenopathy and no apparent thyroid lesion. A systematic diagnostic workup, including PET-CT and comprehensive histopathology, is essential. Despite the absence of a visible primary tumor, prompt surgical and adjuvant therapy can ensure excellent outcomes and long-term disease control.</p>

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Isolated Nodal Papillary Thyroid Carcinoma: Diagnostic Implications of a Missing Primary

  • 期刊论文

  • 发表日期：

    2025年11月13日

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  • K. Vivekraajan,
  • M. K. Rajasekar

摘要

Papillary thyroid carcinoma (PTC) is the most common differentiated thyroid malignancy. Occult PTC, characterized by cervical lymph node metastasis without an identifiable primary thyroid lesion, is uncommon and presents notable diagnostic and therapeutic challenges. A 54-year-old woman presented with a painless, gradually enlarging swelling on the left side of her neck for six months. Examination revealed a hard, non-mobile mass in level III of the cervical region. Contrast-enhanced computed tomography (CECT) showed a well-defined, enhancing lymph node overlying posterior and lateral to the carotid artery, with no abnormalities in the thyroid gland. PET-CT demonstrated FDG uptake in the suspicious node, but no metabolic activity in the thyroid. Fine-needle aspiration cytology (FNAC) was consistent with metastatic PTC. The patient underwent total thyroidectomy with modified radical neck dissection. Histopathology confirmed metastatic papillary carcinoma in the lymph node; serial sectioning of the thyroid revealed no evidence of a primary tumor. Immunohistochemistry showed strong cytoplasmic staining for thyroglobulin and nuclear positivity for thyroid transcription factor-1 (TTF-1), confirming the thyroidal origin. Postoperative radioactive iodine (RAI) whole-body scan showed no uptake. She received adjuvant RAI ablation and TSH suppression therapy and remains disease-free at one-year follow-up. Possible mechanisms for occult PTC include spontaneous regression of the primary lesion, carcinoma arising in ectopic thyroid tissue, or undetected microcarcinoma. Diagnosis requires a multidisciplinary approach combining high-resolution imaging, cytology, histopathology, and immunohistochemistry. Treatment follows standard PTC protocols involving surgery, RAI therapy, and long-term surveillance. This case highlights the importance of considering occult PTC in patients with isolated cervical lymphadenopathy and no apparent thyroid lesion. A systematic diagnostic workup, including PET-CT and comprehensive histopathology, is essential. Despite the absence of a visible primary tumor, prompt surgical and adjuvant therapy can ensure excellent outcomes and long-term disease control.