Stage Eleven: Third Reoccurrence

When the Thyroid Bed Isn’t Empty: A granddaughter’s clinical notes on leiomyosarcoma, recurrence, and the questions medicine struggles to answer. 

On June 9th, 2026, my grandmother lay quietly in a PET-CT scanner at Sampige Onco Diagnostics in Bengaluru as a radioactive sugar called fluorodeoxyglucose, or FDG, travelled through her blood. The idea behind the scan is simple but harsh: cancer cells use glucose more quickly than healthy cells. Wherever the sugar gathers and lights up on the scan, it means something is hungry. Something is growing. 

She is seventy-four. This was the third time her leiomyosarcoma had come back, a recurrence.

What did the scan find? 

The radiologist’s report was clear and direct. In the right thyroid bed, where there should be nothing since her thyroid was removed years ago, a new mass had formed. It measured 2.7 by 3.5 by 5.0 centimetres. The mass showed uneven enhancement, was lobulated, and was FDG-avid, with an SUVmax of 3.1. It pressed against the trachea and the right carotid artery. It partially compressed the right internal jugular vein, which ran along its posterior aspect. It also touched the sternocleidomastoid muscle and, in one spot, reached the skin. When I first read the report, I approached it not as a granddaughter, but as someone who has spent the past year studying head and neck cancer, focused on early detection and the limits of what medicine can do.

Why the Thyroid Bed? 

This is the question I keep coming back to. The thyroid is gone. The bed, the space it once filled and lined with fascia, blood vessels, lymphatics, and connective tissue, is still there. Leiomyosarcoma, which starts in smooth muscle cells, finds this environment familiar. The carotid artery and the internal jugular vein both have smooth muscle walls. The neck’s fascial planes are packed with supportive tissue. The tumour is not coming back to where the thyroid was. It is coming back to where the blood vessels are. It is coming home. 

Oncologists call this organotropism, which means a tumour tends to seek out the microenvironments that support it, even after surgery. You can remove the organ, but you cannot always remove the soil.

The lymph nodes. 

In this report, I was more concerned about two other findings than the primary lesion measurements. 

First, there were a few mildly FDG-avid right supraclavicular lymph nodes, all smaller than a centimeter. The largest was 7 millimetres with an SUVmax of 2.8. The radiologist noted concern for metastases. 

Second, there was mild FDG uptake in mediastinal lymph nodes in the paratracheal, subcarinal, and right hilar regions. The reference right hilar node measured 1.2 by 0.8 centimetres, with an SUVmax of 3.7, higher than that of the primary lesion. 

These findings were described as interval appearance, meaning they were not seen on the January 12th, 2026 comparison scan. In five months, the tumour had not only come back locally, but had also started to affect lymph nodes farther away. 

A follow-up PET scan was recommended for the mediastinal nodes. However, the surgeon decided to act without delay.

Fourteen days later.

On June 23rd, 2026, my grandmother had her third surgery. The doctors performed a wide local excision with lymph node dissection and a pectoralis major myocutaneous flap. This means they took a piece of muscle and skin from her chest to rebuild what they removed from her neck. The operation took two and a half hours. During surgery, the team found a firm mass, about 6 by 4 centimetres, in the thyroid bed. They took it out and then repaired the area.

The adrenal finding. 

The report also found a stable, non-FDG-avid hypodense lesion next to the left adrenal gland, measuring 1.3 by 1.1 centimetres. This is slightly larger than its January size, 1.2 by 1.1 centimetres, but it remains metabolically inactive. The radiologist identified this as a myelolipoma, which is a benign, non-cancerous lesion made up of fat and bone marrow elements that sometimes develops near the adrenal gland. It is not cancer. It does not require treatment, but it should be monitored, as careful observation is important in oncology.

What she keeps asking? 

My grandmother is seventy-four years old, and in the past three years she has faced this same rare cancer three times. She still wonders quietly, in the moments between medication schedules, wound care, and physiotherapy, what she did wrong. 

I want to say this clearly, for her and for every patient who has ever sat in a waiting room blaming themselves: leiomyosarcoma has no known lifestyle or environmental cause. It starts in smooth muscle cells on its own, without warning and without a reason that medicine can yet explain. No dietary choice caused it. No habit explains it. There is no answer to her question, because medicine cannot answer it yet. This is the same question that has led me to dedicate my career to finding out why. 

Why does it happen? Not what it looks like. Not how we treat it. Just why.

What comes next? 

She is in the ICU. Her wound looks good, and her vital signs are stable. We are still waiting for the histopathology report. When it comes back, it will tell us the mitotic rate, the surgical margins, and the Ki-67 proliferation index. These results will show how aggressive the cells were and whether the surgeon was able to remove all of them. I will update this post when we get those results. 

For now, she is alive and resting. Somewhere in the data from this PET scan, in the SUV values, the nodal involvement patterns, and the changes between January and June, there is a question about timing that I cannot stop thinking about. 

If we had found this in January, when the comparison scan was done, what would we have seen? Would the supraclavicular nodes have been clear? Would the mediastinal nodes have shown nothing? 

The window I want to study, the space between nothing and something, between the seed and the soil, is not just a theory for me. It is recorded in four pages of a PET-CT report from a diagnostics centre in Malleshwaram. 

It is my grandmother.