Management dilemma in metastatic papillary thyroid carcinoma

Papillary thyroid cancer is the most common type of well-differentiated thyroid cancer. It is associated with a survival rate greater than 95% with appropriate treatment, particularly in younger patients. We present the unique case of a 25-year-old male with severe Autistic spectrum disorder (ASD) with a right level V neck mass of several months. Due to his severe ASD, his first assessment was conducted in the hospital foyer, and every subsequent clinical assessment and blood test required a general anaesthetic (GA). He was subsequently diagnosed with T2 N1b M0 (Stage I) papillary thyroid cancer. He required extensive multidisciplinary team (MDT) input to determine the goal for his treatment whilst taking into consideration perioperative care, wound management, compliance with exam and blood tests, radioactive iodine administration and lifelong medication requirements if total thyroidectomy was considered. Following multiple MDT and family meetings, the decision was made to proceed with right hemi-thyroidectomy, right level I-V and central neck dissection. He required one-week stay in the intensive care unit under sedation post-operatively, and was discharged from hospital a further six days later with no complications. He is currently being followed-up every six months which presents its own challenges. This case highlights the extraordinary challenges and considerations that need to be made when dealing with surgical pathology in a patient with severe intellectual disability, even in the setting of a relatively common surgical pathology.