Locally Advanced Papillary Thyroid Carcinoma with Cutaneous Fungation and Major Vascular Invasion: A Case Report of Aggressive Multidisciplinary Surgical Management

Abstract

Background: Differentiated thyroid carcinoma (DTC) generally carries an excellent prognosis following complete surgical resection. However, giant DTCs with extensive locoregional invasion involving major cervical vessels, the aerodigestive tract, and overlying skin are rare and pose significant diagnostic and surgical challenges. Careful preoperative imaging and multidisciplinary planning are essential to achieve complete tumor resection while preserving critical structures whenever feasible Case presentation: A 65-year-old woman presented with a progressively enlarging right-sided neck swelling with fungation through the overlying skin. Ultrasound-guided fine-needle aspiration cytology confirmed a papillary thyroid neoplasm. Contrast-enhanced computed tomography (CECT) of the neck revealed a large multilobulated heterogeneous mass measuring 8.6 × 6.5 × 9.2 cm arising from the right thyroid lobe, extending into the superior mediastinum, right submandibular space, lower cervical region, and prevertebral space, with involvement of the overlying skin. The trachea was displaced to the left without definite invasion, and fat planes with the strap muscles and upper thoracic esophagus were lost without clear esophageal infiltration. The mass completely encased the right internal jugular vein and partially encased the right common carotid artery (>180° contact), which remained patent. Multiple metastatic cervical lymph nodes were identified bilaterally at levels IA, IB, II, V, and the supraclavicular regions. The patient underwent total thyroidectomy with bilateral modified neck dissection, ligation of the right internal jugular vein, partial resection of the muscular layer of the cervical esophagus, tracheal shaving, and reconstruction with a right pectoralis major myocutaneous flap. The surgical specimen was submitted for histopathological examination Conclusions: Locally advanced differentiated thyroid carcinoma with extensive soft tissue and vascular involvement can be successfully managed with meticulous preoperative evaluation and aggressive multidisciplinary surgical intervention. Comprehensive imaging, careful operative planning, and appropriate reconstructive techniques are critical for achieving complete resection and optimizing functional outcomes in selected patients Keywords: Differentiated thyroid carcinoma; Papillary thyroid carcinoma; Locally advanced thyroid cancer; Total thyroidectomy; Neck dissection; Pectoralis major myocutaneous flap