# Case Report: Diagnosis and treatment strategy for a case of multiple chest wall implantations and neck lymph node metastasis following total areola endoscopic surgery for papillary thyroid carcinoma

## TL;DR

An elderly patient with papillary thyroid cancer developed chest wall and neck metastases after endoscopic surgery and was treated with anlotinib, showing tumor shrinkage and symptom improvement.

## Contribution

Presents a rare case of metastasis after endoscopic thyroid surgery and suggests anlotinib as a treatment option in complex scenarios.

## Key findings

- Multiple chest wall implantations and neck lymph node metastases occurred after total areola endoscopic surgery for PTC.
- Anlotinib therapy led to reduced lesion size and significant pain relief in the patient.
- The tumor transitioned from classic PTC to the more aggressive tall-cell variant.

## Abstract

Endoscopic thyroid surgery has gained increasing prominence in the field of thyroid surgery. However, special attention should be paid to its limitations in total thyroidectomy, surgical tract implantation metastasis, and suboptimal cervical lymph node dissection. This case report describes the occurrence of chest wall implantations and neck lymph node metastases in an elderly patient following total areola endoscopic surgery for papillary thyroid carcinoma (PTC), emphasizing the need for appropriate diagnostic and therapeutic interventions in such cases.

The patient underwent comprehensive preoperative evaluation, including neck ultrasound and chest computed tomography (CT), followed by neck lymph node dissection and resection of the chest wall implantation lesions. The patient was then initiated on oral anlotinib therapy and scheduled for regular clinical follow-up, without undergoing genetic testing.

We present a case involving a 65-year-old female who underwent total areola endoscopic surgery for PTC. Due to postoperative laryngeal stridor and intermittent respiratory distress, radioactive iodine-131 therapy was not pursued, respecting the preferences of the patient and her family. During this period, multiple chest wall implantations were identified and excised under local anesthesia. Pathological examination revealed a transition from classic PTC to the tall-cell variant. Despite further neck lymph node metastasis and recurrent chest wall implantation, the family declined general anesthesia surgery. Anlotinib was administered. Follow-up showed a reduction in the size of neck and chest wall lesions, with significant pain relief.

Careful preoperative assessment is essential to appropriately select patients for Total areola endoscopic thyroid surgery. In elderly patients with postoperative local lymph node recurrence, surgical tract metastasis, vocal cord paralysis, mild dyspnea, patient and family refusal of further treatment, or progression to the more aggressive tall cell variant of PTC without prior radioiodine therapy, oral administration of anlotinib may be considered after thorough discussion. This targeted therapy may result in tumor regression, symptom amelioration, and potentially extended overall survival in such challenging cases.