Category: Thyroid

Monitor: 28


Saturday, Apr 27
10:30 AM – 11:00 AM

Objective : We describe the case of a patient with brachial plexopathy caused by compression from an enlarged lymph node due to metastatic Papillary Thyroid Cancer [PTC]

Methods : A case presentation

Results : A 38-year-old female presented with a 6-month history of worsening enlargement of a right-side neck mass associated with weakness of her ipsilateral grip strength. Exam was notable for bilateral neck masses, greater on the right, supraclavicular fullness and right upper extremity sensory loss with decreased strength in the intrinsic interossei muscles of 4th and 5th digits, biceps and triceps. CT Neck revealed a right thyroid mass measuring 2.4 x 2.2 cm with multiple right-sided neck lymph nodes, the largest measuring 2.8 x1.5 cm in the supraclavicular region.

Labs were notable for TSH: 3.25 uIU/ml, Free T4: 1.2 ng/dl, and Thyroglobulin Ab: <1.0 IU/ml. CT-guided FNA of the thyroid mass and lymph node revealed Intracystic Papillary Thyroid Carcinoma. An MRI showed a solid mass in the right lobe of the thyroid gland and right cervical chain adenopathy with right level IV cervical lymph nodes exerting mass effect on the anterior superior aspect of the brachial plexus.

A total thyroidectomy with radical lymph node dissection, radical anterior cervical dissection, exploration of brachial plexus and resection of tumor was performed. Final pathology confirmed PTC, Classic Variant, 2 cm in greatest dimension, with lympho-vascular and capsular invasion. The surgical margins were uninvolved; however, 11/24 lymph nodes showed metastatic involvement with extra-nodal extension. A I-131 radioactive iodine whole body scan was completed after thyroid hormone withdrawal protocol and showed 1.1% uptake in the neck only, without distant metastasis. A stimulated TG was 53.9 ng/ml, TSH of 47.9 uIU/ml and Anti-Thyroglobulin Ab <1 IU/ml and she was treated with 125mCi of I131. The post-treatment scan was unchanged. Following surgery, neurological deficits completely resolved.

Discussion : PTC is the most common thyroid malignancy, accounting for nearly 80-85% of all the thyroid neoplasms. Around 15% of patients present with extra-thyroidal involvement of adjacent soft tissues and nearly 35 to 50% of the excised neck lymph nodes reveal histological involvement.

Conclusion : Neoplastic brachial plexopathy is usually associated with breast and lung cancer and typically presents with pain and motor weakness due to local compression. Metastatic PTC causing brachial plexopathy is unusual with only 2 reported cases in the literature to date. MRI remains the gold standard for detecting the source and extent of neurological involvement. Following surgical decompression, full neurological recovery occurred in all 3 patients.


Malik Faheem

Internal Medicine Resident
Rutgers New Jersey Medical School
Newark, New Jersey

Undergraduate: Government College University(GC), Lahore, Medical School: Allama Iqbal Medical College, Residency: Rutgers NJMS

Lissette M. Cespedes

Assistant Professor of Medicine
Rutgers New Jersey Medical School
Newark, New Jersey

M.D. Degree: Rutgers-New Jersey Medical School; Residency: Internal Medicine, Rutgers-Robert Wood Johnson Medical School; Fellowship: Endocrinology, Diabetes and Metabolism, Rutgers-Robert Wood Johnson Medical School

Malik Faheem

Malik Faheem, MD