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CASE REPORT
Year : 2016  |  Volume : 13  |  Issue : 1  |  Page : 25-26

Double pyramidal lobe of thyroid gland: A rare presentation


1 Department of the Head and Neck Oncology, Apollo Cancer Hospitals, Hyderabad, Telangana, India
2 Department of Internal Medicine, Poplar Bluff Regional Medical Center, Poplar Bluff, Missouri, USA
3 Department of Gynaecology and Obstetrics, Apollo Hospitals, Hyderabad, Telangana, India

Date of Web Publication5-Jan-2016

Correspondence Address:
Arsheed Hussain Hakeem
Apollo Cancer Hospitals, Jubilee Hills, Hyderabad - 500 096, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0973-0354.168887

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  Abstract 

Knowledge of the variations of the pyramidal lobe of the thyroid assumes importance as it has direct implications on the outcome of the primary surgery and on the postoperative radioiodine ablation. If not recognized and completely removed at the time of initial thyroid surgery, it may be site of residual/recurrent disease and also may interfere with the efficient radioiodine ablation postoperatively. We report a unique case of the double pyramidal lobe of thyroid gland in an operated woman with papillary carcinoma thyroid. Our literature search revealed only one documented case of the double pyramidal lobe. Knowledge and recognition of such a variation is highly useful for clinicians to perform safer and effective thyroid surgery.

Keywords: Pyramidal lobe, radio-iodine ablation, thyroglossal duct, thyroid gland, total thyroidectomy


How to cite this article:
Hakeem AH, Hakeem IH, Wani FJ. Double pyramidal lobe of thyroid gland: A rare presentation. Thyroid Res Pract 2016;13:25-6

How to cite this URL:
Hakeem AH, Hakeem IH, Wani FJ. Double pyramidal lobe of thyroid gland: A rare presentation. Thyroid Res Pract [serial online] 2016 [cited 2019 Jun 15];13:25-6. Available from: http://www.thetrp.net/text.asp?2016/13/1/25/168887


  Introduction Top


Apart from the right and the left lateral lobes of the thyroid gland, there is a projection of thyroid tissue that extends superiorly from the isthmus and is known as the pyramidal lobe. The pyramidal lobe is related to the distal portion of the thyroglossal duct, which develops along the migratory path of the thyroid gland and usually disappears later in the development.[1] Different authors have different views regarding the pyramidal lobe as some consider it as anomaly, while others consider it as morphological variation and most are of the view that it is normal component of the thyroid gland.[1],[2] If pyramidal lobe is not recognized and removed completely at the time of total thyroidectomy for benign and malignant lesions, it may be a source of recurrent disease.[1],[2] Its complete removal is also of significance for the successful postoperative radioactive iodine ablation, as the therapeutic benefit will be reduced as residual pyramidal lobe will absorb most of the radioactive agent.[3],[4] Literature is full of variations as regard to its presence, position and extent of pyramidal lobe. However, by an extensive search of the English language literature on pyramidal lobe, we found only one documented report of double pyramidal lobe.[5] The aim of this case report was to present a unique case of the double pyramidal thyroid lobe in an operated woman with papillary carcinoma thyroid. Knowledge of such a variation that is a double pyramidal is highly useful for clinicians to explore the possibility of its occurrence in order to perform a safer and more effective thyroid surgery.


  Case Report Top


A 56-year-old woman was operated for a papillary carcinoma thyroid. Preoperatively, ultrasonographic (USG) examination had shown a 4 cm × 5 cm solid nodule in the left thyroid lobe. Fine needle aspiration cytology was in favor of papillary thyroid cancer. USG was not useful in detecting pyramidal lobes preoperatively. She was planned for total thyroidectomy and during the procedure double pyramidal lobe was detected. Careful dissection was done starting from isthmus to the hyoid bone. Two pyramidal lobes were identified and carefully dissected and followed to the hyoid bone. Whole of the thyroid gland and both the pyramidal lobes were resected in continuity and too [Figure 1], with preservation of all the parathyroids and bilateral recurrent laryngeal nerves. Postoperative period was uneventful. Histopathology was in favor of classic papillary carcinoma with normal thyroid tissue in the both pyramidal lobes.
Figure 1: Clinical photograph of the total thyroidectomy specimen with double pyramidal lobe

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  Discussion Top


Most of the variations in the thyroid gland are due to persistence of the thyroglossal duct or tract. The most common example of this persistence is the pyramidal lobe. The pyramidal lobe of the thyroid gland varies in shape, size, position, as well as appearance. The prevalence of pyramidal lobe has been reported in 12–65% of cases in various studies on either cadaveric or operative surgical specimens.[1],[2] Pyramidal lobe can be a potential site of primary localization of a solitary or multifocal malignant thyroid cancer.[3] It can also be a site of recurrent thyroid disease after total thyroidectomy.[3] Remnant pyramidal is a frequent site for recurrence of benign diseases after total and subtotal resection of the thyroid gland.[6],[7],[8] It may result in inefficient postoperative radioiodine ablation as it may take up the most of isotope administered to the patient.[9] Knowledge about its anatomic and morphologic variations is necessary for safe and effective thyroid surgery.

Our literature search revealed only one such case of double pyramidal lobe.[5] The purpose of case report was to add a rare variation of the pyramidal lobe and to emphasize the necessity and importance of exploration of the visceral compartment of the neck and resection of this structure during primary operations on the thyroid. Therefore, the possibility of identifying the pyramidal lobe should not be ignored during surgery as it often remains unvisualized during preoperative imaging studies. This means it needs to be actively sought and identified during surgery, more so if the patient is undergoing total thyroidectomy for differentiated thyroid carcinoma. Apart from decreasing the chance of local recurrence in benign disease, it ensures complete thyroid tissue removal in the well differentiated carcinoma that often can be multifocal.[10] Complete removal of the pyramidal lobe also makes postoperative radio iodoine ablation effective and increases the sensitivity of serum thyroglobulin as tool for follow-up.[10]

The possibility of identifying a pyramidal lobe should be always kept in mind and knowledge of various positions, size, and number are of significance. It should always be examined during thyroid surgery and removed completely in total and subtotal thyroidectomy.

 
  References Top

1.
Braun EM, Windisch G, Wolf G, Hausleitner L, Anderhuber F. The pyramidal lobe: Clinical anatomy and its importance in thyroid surgery. Surg Radiol Anat 2007;29:21-7.  Back to cited text no. 1
    
2.
Zivic R, Radovanovic D, Vekic B, Markovic I, Dzodic R, Zivaljevic V. Surgical anatomy of the pyramidal lobe and its significance in thyroid surgery. S Afr J Surg 2011;49:110, 112, 114.  Back to cited text no. 2
    
3.
Geraci G, Pisello F, Li Volsi F, Modica G, Sciumè C. The importance of pyramidal lobe in thyroid surgery. G Chir 2008;29:479-82.  Back to cited text no. 3
    
4.
Rosário PW, Maia FF, Cardoso LD, Barroso A, Rezende L, Padrão EL, et al. Correlation between cervical uptake and results of postsurgical radioiodine ablation in patients with thyroid carcinoma. Clin Nucl Med 2004;29:358-61.  Back to cited text no. 4
    
5.
Ignjatovic M. Double pyramidal thyroid lobe. J Postgrad Med 2009;55:41-2.  Back to cited text no. 5
[PUBMED]  Medknow Journal  
6.
Sternberg JL. Sublingual pyramidal lobe. Complications of subtotal thyroidectomy for Graves' disease. Clin Nucl Med 1986;11:766-8.  Back to cited text no. 6
[PUBMED]    
7.
Snook KL, Stalberg PL, Sidhu SB, Sywak MS, Edhouse P, Delbridge L. Recurrence after total thyroidectomy for benign multinodular goiter. World J Surg 2007;31:593-8.  Back to cited text no. 7
    
8.
Cigrovski-Berkovic M, Solter D, Solter M. Why does the patient with Graves' disease remain euthyroid/mildly hyperthyroid following total thyroidectomy – The role of thyrotropin receptor antibodies (TRAb) and vestigial remnants of the thyroglossal tract. Acta Clin Croat 2008;47:171-4.  Back to cited text no. 8
    
9.
Stachlewska-Nasfeter E, Bisz D, Tomaszewicz-Kubasik H. Significance of intraoperative isotope detection in primary and secondary radical surgical treatment of thyroid cancer. Wiad Lek 2001;54 Suppl 1:241-5.  Back to cited text no. 9
    
10.
Mazzaferri EL. Long-term outcome of patients with differentiated thyroid carcinoma: Effect of therapy. Endocr Pract 2000;6:469-76.  Back to cited text no. 10
    


    Figures

  [Figure 1]


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