4.1  Case 1: Suspected malignancy in retropharyngeal nodes
An asymptomatic 37‐year‐old woman with a history of papillary cancer of the thyroid, presented in December 2019, referred for suspected malignancy involving high retropharyngeal lymph nodes bilaterally, detected on a contrasted CT in October 2019 (Figure 2).
FIGURE 2  Contrast computed tomography axial and coronal reveal retropharyngeal adenopathy The patient had four previous surgeries for well‐differentiated papillary thyroid cancer at other institutions. In 2006, she underwent total thyroidectomy, removal of one central compartment node, and nine lateral neck lymph nodes of which six contained malignancy. Based on abnormal ultrasounds and thyroglobulin levels over the years, the patient was taken back to surgery on three subsequent occasions, including a comprehensive procedure in 2018, with revision neck dissection bilaterally including level 6 and left level 5. Seven of 31 lymph nodes were positive.
Her only medication was oral levothyroxine. Head and neck physical examination was notable only for surgical scars.
Due to the unusual location of these lymph nodes, there was concern that these might represent a more aggressive lesion. The CT was indistinct in evaluating the borders of the lesions. There were additional involved lymph nodes more inferiorly in the right neck and some questionable lymph nodes by CT criteria on the left. Review of her surgical pathology from 2018 confirmed classical papillary thyroid cancer. Her thyroglobulin was 6.0, unstimulated. Stimulated thyroglobulin elevated to 29.3.
We advised contrasted MRI, and positron emission tomography/CT (PET‐CT) to further evaluate, along with presentation at our multidisciplinary head and neck tumor conference. The MRI showed the well‐encapsulated cystic retropharyngeal lymph nodes more distinctly (Figure 3), with 2 cm as the largest dimension. The PET‐CT was negative for fluorodeoxyglucose uptake, suggesting low‐grade lesions. The retropharyngeal lesions were felt to be inaccessible for FNA.
FIGURE 3  Magnetic resonance imaging with gadolinium, T2 images reveal cystic abnormal retropharyngeal lymph nodes more distinct We recommended bilateral revision neck dissection followed by bilateral exploration of the parapharyngeal space, carefully following the carotid upward to excise the retropharyngeal lymph nodes. Laryngeal nerve integrity monitoring would be used. Mobilization of the tail of parotid, ligation of the external carotid artery, and possible identification of the facial nerve in the parotid were felt to be potentially necessary to achieve the exposure of the retropharyngeal nodes. The patient was consented appropriately regarding risks, including cranial neuropathies and first bite syndrome.
The patient obtained second opinion and presented again in early March, and surgery was scheduled 2 weeks later. By March 15, the COVID‐19 pandemic was in ascendance and elective surgery was suspended. The working rule in our Case Review Committee had been to delay surgery for well‐differentiated thyroid cancer. This case was prereviewed by committee members because of the unusual anatomic location of the lesions. The recommendation was to repeat the MRI to confirm stability on two similar studies. Repeat MRI confirmed no changes in the lesions between January and April. Based on this, we recommended not to hospitalize during the pandemic and planned surgery in 3 months.