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Implantation along the Access Tract after Bilateral Axillo-Breast Approach Thyroidectomy: A Rare Complication in Minimally Invasive Surgery
*Corresponding author: Dr. Manish Ora, Department of Nuclear Medicine, Sanjay Gandhi Post Graduate Institute Of Medical Sciences, SGPGIMS, Lucknow, Uttar Pradesh, India. drmanishora@yahoo.com
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Received: ,
Accepted: ,
How to cite this article: Sharma S, Ora M, Nazar AH, Pradhan PK, Arya A. Implantation Along the Access Tract After Bilateral Axillo-Breast Approach Thyroidectomy: A Rare Complication in Minimally Invasive Surgery. Indian J Nucl Med. 2026;41:580-1. doi: 10.25259/IJNM_132_25.
Abstract
Bilateral axillo-breast approach (BABA) is a minimally invasive, remote access technique that utilises small incisions in the axillae and periareolar regions. Its outcomes are comparable to open thyroidectomy with similar complication rates. However, there is a theoretical risk of “tract seeding” or “subcutaneous thyroid tissue implantation” after these techniques, predominantly the transoral approach. A 17-year-old male presented with a progressive anterior neck swelling for 9 months. Ultrasonography (USG) of the neck revealed a TIRADS 3 nodule (4.8 cm × 4.0 cm) in the left thyroid lobe, and fine-needle aspiration cytology was classified as Bethesda Category V. The patient underwent total thyroidectomy with BABA. Histopathological examination revealed a unifocal invasive follicular thyroid carcinoma in the left thyroid lobe, pathological Stage pT3a (AJCC eighth edition). Whole-body radioiodine scan (WBRI) scan after thyroxin withdrawal showed residual tissue in the thyroid bed and thyroglossal duct. Multiple focal areas of increased uptake were noted in the anterior chest wall along the pectoral muscle along the surgical access path. The patient received 100 mCi of high-dose radioiodine (I-131) therapy.
Keywords
Bilateral axillo-breast approach
Radioiodine therapy
Thyroid cancer
Total thyroidectomy
Tract seeding
Fig 1a and b shows pretherapy and posttherapy whole-body radioiodine scan (WBRI) scans. These show increased tracer uptake in the thyroid bed, suggesting a postsurgical thyroid bed remnant. Multiple focal areas of abnormal tracer uptake are noted in the right anterior chest wall. Fig 1c and d shows single-photon emission computed tomography/computed tomography (SPECT/CT) images at the level of the thyroid bed with a remnant on the left side of the thyroid bed. Fig 2a-d shows axial (a and b) and coronal (c and d) CT and fused SPECT/CT images showing focal areas of increased uptake in the anterior chest wall along the surgical access path, suggestive of subcutaneous thyroid tissue implantation or tract seeding.
Thyroid cancer, the most common endocrine-related cancer, is particularly prevalent in young women.[1] Conventional open thyroidectomy is the standard surgical treatment for thyroid cancer.[2] However, it leaves central neck scarring challenges for young female patients. Endoscopic thyroidectomy has emerged as a cosmetic alternative in selected cases. Several approaches have been introduced, including unilateral transaxillary approach, bilateral axillo-breast approach (BABA), axillo-bilateral breast approach, chest-breast approach, and transoral approach. The BABA is a minimally invasive, remote access technique that uses small incisions in the axillae and periareolar regions. It provides a direct view of thyroid lobes and the central neck compartment, allowing for precise dissection and identification of recurrent laryngeal nerves and parathyroids.[3]
Compared to the open thyroidectomy, BABA offers equivalent surgical completeness, radioactive iodine uptake, postoperative thyroglobulin levels, and lymph node retrieval with an incidence of side effects including hypoparathyroidism and recurrent laryngeal nerve injury.[4] There is a theoretical risk of “tract seeding” or “subcutaneous thyroid tissue implantation” after these techniques, predominantly the transoral approach. However, these cases are sporadic and observed implantation to the sternocleidomastoid and chest wall after endoscopic thyroid carcinoma surgery. We found no similar case in the review of English literature demonstrating implantation after BABA for thyroid cancer.[5,6]
Author contributions:
SS: Data collection, image analysis, and initial manuscript drafting; MO: Conceptualisation, study supervision, case interpretation, critical revision of the manuscript, initial manuscript drafting and final approval; AHN: Clinical management of the patient, data acquisition, and manuscript review; PKP: Technical inputs, and manuscript editing; AA: Clinical management of the patient, case interpretation, and final manuscript approval. All authors contributed to the article and approved the submitted version.
Ethical approval:
Institutional Review Board approval is not required.
Declaration of patient consent:
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Conflicts of interest:
There are no conflicts of interest.
Use of artificial intelligence (AI)-assisted technology for manuscript preparation:
The authors confirm that there was no use of artificial intelligence (AI)-assisted technology for assisting in the writing or editing of the manuscript and no images were manipulated using AI.
Financial support and sponsorship: Nil.
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