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\begin{document}


\def\RunningAuthor{Vedha pal jeyamani et al.}
\firstPage{3178}
\articleType{Case Report}
\receivedDate{18.05.2019}
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\title{Papillary thyroid cancer patient with hyperthyroidism\- - a case study}
\author{Punitha~S,  
            Vedha~pal~jeyamani\textsuperscript{*},  
            Sindhu~S,  
            Bhuvaneshwari~P, 
            Arshath~A~\\[5pt]{Department of pharmacy practice\unskip, Jaya college of paramedical sciences, Chennai , Tamil Nadu, India}}

\begin{abstract}
Thyroid carcinoma is the majority widespread endocraine malignancy in that papillary thyroid cancer is a well-differentiated type. Since hyperthyroidism protects from thyroid cancer due to lack of reproduction of thyroid tissue by the thyroid-stimulating hormone. The papillary carcinoma is the fast-growing and metastases to local region rapidly. A 60 years old post menopausal women with a known case of hypertension of past 6 years on treatment and with hyperthyroidism of past 2 months was presented in the outpatient department in the hospital with chief complaints of mass in the neck with dyphagia, cough, breathlessness, sense of fullness and odynophagia of past 2 weeks. On physical and general examination patient found with diffuse thyroid swelling with enlarged right sided lymph node. The patient was diagnosed with papillary thyroid caricinoma with various investigation reports includes CT Scan, Immouno history chemistry reports, Histopathology and Two fine-needle aspiration biopsies. The patient has undergone 6 cycles of chemotherapy with the corticosteroids, anti-cancer drugs which includes Vincristine, Cyclophosphamide, Doxorubicin, anti- emetic drugs and also with H2 receptor blockers. The papillary thyroid cancer is common and occurs predominantly in females than in males and with good prognosis and decreased death rates. The higher level of thyroid function is very rare in case of PTC.
\end{abstract}\def\keywordstitle{Keywords}

\begin{keywords}Papillary Thyroid carcinoma,\newline Hyperthyroidism,\newline chemotherapy
\end{keywords}
\twocolumn[ \maketitle {\printKwdAbsBox}]
\makeatletter{\raggedright\textsuperscript{*}Corresponding Author\par Name:\ Vedha~pal~jeyamani~\\ Phone:\ ~\\  Email:\ swetha21112000@gmail.com
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\section{Introduction}
Thyroid carcinoma is the most widespread endocraine malignancy\unskip~\citep{594529:13813171}. In the female, the thyroid cancer is in 2\ensuremath{^{nd}} place following breast cancer, and it is thrice most common in women when compared to men \unskip~\citep{594529:13813172}. The most common types of thyroid carcinoma are papillary, follicular, medullary and anaplastic \unskip~\citep{594529:13813173}. Papillary carcinoma of the thyroid is the well-differentiated type of thyroid cancer which are with associated symptoms like swelling mass in the neck thyroid region with dysphagia\unskip~\citep{594529:13813174,594529:13813175}. 

Thyroid cancer and hyperthyroidism has proposed that hyperthyroidism prevents thyroid cancer by which the thyroid-stimulating hormone decreases the stimulation to thyroid tissue by thyroid-stimulating hormone \unskip~\citep{594529:13813175}. The papillary carcinoma tend to grow faster and develop in the one lobe of the thyroid gland then often leads to the metastases to the locoregional lymph nodes \unskip~\citep{594529:13813176}. In this case study, we report aimed to overview a rare case of papillary thyroid associated with hyperthyroidism \unskip~\citep{594529:13813177}.
    
\section{\textbf{Case Report}}

\bgroup
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\centering \makeatletter\IfFileExists{images/4e799053-566e-41b7-94dd-260916ebc663-upicture1.png}{\includegraphics{images/4e799053-566e-41b7-94dd-260916ebc663-upicture1.png}}{}
\makeatother 
\caption{\boldmath {CT Scan Neck}}
\label{f-0482e3e7de23}
\end{figure*}
\egroup

\begin{table*}[!htbp]
\caption{\boldmath {Chemotherapy cycles} }
\label{tw-33b7e53f205c}
\def\arraystretch{1.1}
\ignorespaces 
\centering 
\begin{tabulary}{\linewidth}{p{\dimexpr.2586\linewidth-2\tabcolsep}p{\dimexpr.34519999999999996\linewidth-2\tabcolsep}p{\dimexpr.24309999999999995\linewidth-2\tabcolsep}p{\dimexpr.1531\linewidth-2\tabcolsep}}
\tbltoprule \rowcolor{kwdboxcolor}\multicolumn{4}{p{\dimexpr(1\linewidth-2\tabcolsep)}}{\cAlignHack Chemotherapy Drugs Cycles}\\
\tblmidrule 
\multicolumn{4}{p{\dimexpr(1\linewidth-2\tabcolsep)}}{\cAlignHack \textbf{1\ensuremath{^{st}} Cycle}}\\
Brand Name of Drugs  &
  Generic Name of Drugs &
  DOSE &
  ROA\\
Inj. Cytocristine &
  Inj. Vincristine  &
  1 mg/ ml &
  IV\\
Inj. Cycloxan &
  Inj. Cyclophosphamide &
  200 mg/ 5ml &
  IV\\
Inj. Medidox &
  Inj. Doxorubicin &
  50 mg/ 25ml &
  IV\\
Inj. Decadran &
  Inj. Dextromethasone  &
  4 mg / ml &
  IV\\
Inj. Rantac  &
  Inj. Ranitidine  &
  2 ml &
  IV\\
Inj. Emeset  &
  Inj. Ondansatron  &
  2 ml &
  IV\\
\multicolumn{4}{p{\dimexpr(1\linewidth-2\tabcolsep)}}{\cAlignHack \textbf{2\ensuremath{^{nd }}Cycle}}\\
Inj. Cytocristine  &
  Inj. Vincristine &
  1 mg/ ml &
  IV\\
Inj. Phosmid &
  Inj. Cyclophosphamide &
  500 mg/5ml &
  IV\\
Inj. Medidox  &
  Inj. Doxorubicin &
  50 mg/ 25ml &
  IV\\
Inj. Decadran  &
  Inj. Dextromethasone &
  4 mg / ml &
  IV\\
Inj. Rantac  &
  Inj. Ranitidine  &
  2 ml &
  IV\\
Inj. Emeset  &
  Inj. Ondansatron  &
  2 ml &
  IV\\
\multicolumn{4}{p{\dimexpr(1\linewidth-2\tabcolsep)}}{\cAlignHack \textbf{3\ensuremath{^{rd}} Cycle }}\\
Inj. Cytocristine &
  Inj. Vincristine  &
  1 mg /ml &
  IV\\
Inj. Cycloxan &
  Inj. Cyclophosphamide  &
  500 mg / 5ml &
  IV\\
Inj. Medidox &
  Inj. Inj. Doxorubicin &
  50 mg / 25 ml &
  IV\\
Inj. Decadran &
  Inj. Dextromethasone  &
  4 mg / ml &
  IV\\
Inj. Rantac  &
  Inj. Ranitidine  &
  2 ml &
  IV\\
Inj. Emeset  &
  Inj. Ondansatron  &
  2 ml &
  IV\\
\multicolumn{4}{p{\dimexpr(1\linewidth-2\tabcolsep)}}{\cAlignHack \textbf{4\ensuremath{^{th}}  Cycle}}\\
Inj. Cytocristine &
  Inj. Vincristine  &
  1 mg / ml &
  IV\\
Inj. Cycloxan &
  Inj. Cyclophosphamide  &
  500 mg / 5 ml &
  IV\\
Inj. Amdoxo &
  Inj. Doxorubicin  &
  50 mg / 25 ml &
  IV\\
Inj. Decadran &
  Inj. Dextromethasone  &
  4 mg / ml &
  IV\\
Inj. Rantac  &
  Inj. Ranitidine  &
  25 mg / 2 ml &
  IV\\
Inj. Emeset  &
  Inj. Ondansatron  &
  4 mg / 2 ml &
  IV\\
\multicolumn{4}{p{\dimexpr(1\linewidth-2\tabcolsep)}}{\cAlignHack \textbf{5\ensuremath{^{th}} Cycle}}\\
Inj. Cytocristine &
  Inj. Vincristine  &
  1 mg / ml &
  IV\\
Inj. Cycloxan &
  Inj. Cyclophosphamide  &
  500 mg / 5ml &
  IV\\
Inj. Amdoxo &
  Inj. Doxorubicin  &
  50 mg / 25ml &
  IV\\
Inj. Decadran &
  Inj. Dextromethasone  &
  4 mg / ml &
  IV\\
Inj. Rantac  &
  Inj. Ranitidine  &
  25mg / 2 ml &
  IV\\
Inj. Emeset  &
  Inj. Ondansatron  &
  4 mg / 2 ml &
  IV\\
Inj. Avil  &
  Inj. Pheniramine &
  25mg / 2ml &
  IV\\
\multicolumn{4}{p{\dimexpr(1\linewidth-2\tabcolsep)}}{\cAlignHack \textbf{6\ensuremath{^{th}} Cycle}}\\
Inj. Cytocristine &
  Inj. Vincristine  &
  1 mg / ml &
  IV\\
Inj. Cycloxan &
  Inj. Cyclophosphamide &
  500 mg / 5 ml &
  IV\\
Inj. Amdoxo &
  Inj. Doxorubicin  &
  50 mg / 25 ml &
  IV\\
Inj. Decadran &
  Inj. Dextromethasone &
  4 mg / 2ml &
  IV\\
Inj. Rantac  &
  Inj. Ranitidine  &
  25 mg /2 ml &
  IV\\
Inj. Emeset  &
  Inj. Ondansatron  &
  4mg / 2 ml &
  IV\\
Inj. Avil  &
  Inj. Pheniramine  &
  25 mg / 2ml &
  IV\\
\tblbottomrule 
\end{tabulary}\par 
\end{table*}
A 60 years old post menopausal women with a known case of hypertension of past 6 years on treatment and with hyperthyroidism of past 2 months was presented in Outpatient department of a hospital with the clinical presentation of mass in the neck with dyphagia, cough, breathlessness, sense of fullness and odynophagia since 2 weeks.

On examination, the patient was conscious, oriented, febrile, loss of body weight, moderately built, fatigue. On physical examination the vitals were increased in Temperature - 100\ensuremath{^\circ}F, Pulse rate - 78/min, Respiratory rate - 20/min, Blood pressure - 130/90 mmHg and with a diffuse thyroid swelling with enlarged right-sided lymph node. The nodes were not tender and sized about 3 cm in diameter. Her abdominal examination reveled soft, no organomegaly, her other systems and biochemical investigations were within limits. 

The patient is poorly educated and lives a sedentary lifestyle with low economic status, had no revelant family history and takes a mixed diet. Her social habits include increased coffee intake and has regular sleep sequence. Patients Glasscow coma scale was normal during admission.

The USG abdomen and X-rays showed no abnormalities. Computer tomography (CT) Neck p/c had confirmed that the presence of enlarged thyroid mass in the neck of the patient, that extended in the right thyroid lobe., Figure~\ref{f-0482e3e7de23} X-ray is done to rule out the lung metastases.

Immunohistory chemistry on the cell block was positive Thyroid transcription factor (TTF-1) consistant with cells of thyroid origin.

Two fine-needle aspiration biopsies (FNA)\textbf{\space }were performed in the right thyroid lobe. The smears shows group of epitherial cell in flat sheets and some cells with nuclear grooves and few cells with promintent intranuclear pseudoinclusions, no colloid, no lymphogranularbodies. This are the cytological diagnosis of PTC.

Histophatology were performed to rule out the diagnosis of the papillary carcinoma with locoreginal lymph nodes confirmed extracapsular and vascular invastion in patient.
    
\section{Results and Discussion}
Papillary thyroid carcinoma is most widespread type of thyroid cancer and it is more commonly increased among women than in men \unskip~\citep{594529:13813178,594529:13813179}. Hyperthyroidism is the probable etiological diagnosis in the patient with a toxic thyroid nodule, which is the common etiological factor \unskip~\citep{594529:13813180}.

Patient with hyperfunctioning of the thyroid gland is considered to be less risk for thyroid cancer exposure \unskip~\citep{594529:13813181}. A literature review has reported that recently increasing in the number of cases with high-level thyroid function test associated with thyroid malignancy \unskip~\citep{594529:13813182,594529:13813183}.

PTC is one of the rapid growing type in the carcinoma, and it has a clear and good prognosis and have a good long term survival rates \unskip~\citep{594529:13813184,594529:13813185}. The patient was undergone 6 cycles of chemotherapy,Table~\ref{tw-33b7e53f205c}.

The variation of the PTC during the last decade has reported that most recently diagnosed PTC are smaller mass, and older patients were diagnosed \unskip~\citep{594529:13813186}.
    
\section{Conclusion}
The papillary thyroid cancer is common and occurs predominantly in females than in males. Although it is a rapid growing carcinoma, it has satisfactory prognosis and has long survival rates. The higher level of thyroid function is very rare in case of PTC.
\section*{Acknowledgement}The authors would like to thank the patient for her contribution in giving a willing informed consent and involvement in this case study. We appreciate Dr. Bhaskaran M.D (Oncology), Chennai for his valued support and guidance.

\textbf{Compliance with Ethical Standards}

Additional informed consent was obtained from the participants from whom identifying information and images included in this article.\textbf{\space }
    

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