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來源：Affacare 發(fā)布時(shí)間：2022-11-02 瀏覽數(shù)：774
01Case information
Admission information
The patient, male, 45 years old, was admitted with the chief complaint that bilateral thyroid tumors were found in physical examination for 2 months.
Current medical history
Current medical history: the patient found multiple thyroid nodules on both sides during the unit physical examination 2 months ago. One week ago, I came to our hospital for further diagnosis and treatment, and the color ultrasound of the outpatient reexamination showed that:
Therefore, ultrasound-guided puncture biopsy of thyroid tumor was performed in the outpatient department. The biopsy showed that the cytological pathology of the right hypoechoic thyroid nodule showed nuclear groove and intranuclear pseudoinclusion bodies, tending to papillary thyroid carcinoma.
The outpatient department was admitted to the hospital with the diagnosis of "papillary carcinoma of the right thyroid". There was no obvious surgical contraindication after completing preoperative examination, and no abnormal enlarged lymph nodes were found in the neck by enhanced CT scanning.2
Past history: nothing special.
Supplementary Examination
Neck enhanced CT showed that the right lobe of the thyroid occupied the middle pole, with a diameter of 1.1cm. Please consider the clinic. Multiple small lymph nodes can be seen on both sides of the neck without abnormal enhancement.
02Surgical analysis
Treatment plan
Comprehensive patient's condition: the diagnosis of papillary thyroid carcinoma in the right lobe of the patient can be established, and there is a clear indication for surgery. At the same time, the patient had scar constitution and was more concerned about neck scar, so after full communication with the patient, he decided to perform complete endoscopic bilateral thyroidectomy and right central lymph node dissection through oral vestibular approach.
Postoperative pathological results
Pathological diagnosis: (right side) papillary thyroid carcinoma, the maximum diameter of the tumor is 1.2cm, and another (left side) thyroid small focal epithelial dysplasia, another lymph node without metastasis (0/2).
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