Leiomyosarcoma of the thyroid gland. A case report with a comparative study of five cases of anaplastic carcinoma

Neck Surgery for Non-Well Differentiated Thyroid Malignancies: Variations in Strategy According to Histopathology

Lymph node metastases in non-well differentiated thyroid cancer (non-WDTC) are common, both in the central compartment (levels VI and VII) and in the lateral neck (Levels II to V). Nodal metastases negatively affect prognosis and should be treated to maximize locoregional control while minimizing morbidity. In non-WDTC, the rate of nodal involvement is variable and depends on the histology of the tumor. For medullary thyroid carcinomas, poorly differentiated thyroid carcinomas, and anaplastic thyroid carcinomas, the high frequency of lymph node metastases makes central compartment dissection generally necessary. In mucoepidermoid carcinomas, malignant peripheral nerve sheath tumors, sarcomas, and malignant thyroid teratomas or thyroblastomas, central compartment dissection is less often necessary, as clinical lymphnode involvement is less common. We aim to summarize the medical literature and the opinions of several experts from different parts of the world on the current philosophy for managing the neck in less common types of thyroid cancer.

Primary thyroid leiomyosarcoma: a diagnostic and therapeutic challenge

Leiomyosarcoma is a malignant mesenchymal tumour of smooth muscle origin. It is extremely rare as a primary thyroid cancer with only 33 cases previously described in the literature. We present the case of a 69-year-old Caucasian man who presented with a 5-month history of left cervical lymphadenopathy and a suspicious mass in the left thyroid lobe on ultrasound scan. Left hemithyroidectomy confirmed the diagnosis of leiomyosarcoma. A review of current understanding and approaches to management of this rare condition are discussed.

Primary thyroid leiomyosarcoma: a case report and review of the literature

Primary thyroid leiomyosarcoma (LMS) is an extremely rare tumor. We report a case of a 47-year-old male with a rapidly growing neck mass and disfagia. Preoperative investigations were diagnostic of anaplastic carcinoma. Total thyroidectomy with partial esophagectomy and dissection of right infrahyoid muscles was performed. Through histolological and immunohistochemical evaluations a primary thyroid high-grade LMS was diagnosed. At 2 months of follow-up a local recurrence was detected and consequently the patient was submitted to chemotherapy with partial response. He is still alive 9 months after surgery. Diagnosis of primary thyroid LMS is difficult due to its similarity to other more common thyroid tumors. To date, there is no standard therapy and prognosis is poor.

Primary Leiomyosarcoma of the Thyroid Gland - A Rare Malignancy

Primary leiomyosarcoma (LMS) of thyroid is rare malignant neoplasm usually seen in elderly patients. These tumours are characterised by a rapidly growing mass in the neck, difficult to diagnose preoperatively and are highly aggressive with high recurrence rates in spite of radical surgery, chemotherapy and radiotherapy. We herein report a case of 50-year-old female with a rapidly growing painless mass in the neck. Total thyroidectomy with bilateral neck node clearance was done. Histology and Immunohistochemistry revealed primary LMS of thyroid gland. Within 1 month of radical surgery she developed local recurrence. Diagnosis of primary LMS is difficult and immunohistochemistry is necessary to differentiate it from other malignancies of the thyroid. Primary LMS remains a life-threatening tumour and more effective treatment are needed to improve outcome.

Clinicopathological features of primary thyroid leiomyosarcoma without Epstein-Barr virus infection: A case report

Primary thyroid leiomyosarcoma (LMS) is a rare tumor type with an unusual location, the diagnosis is based entirely on histological and immunohistochemical evaluations. In the present study, a rare case of a 74-year-old female patient who exhibited a right anterior neck mass for 12 months, which rapidly enlarged for the last 3 months. Ultrasound of the thyroid revealed a 55×42 mm hypoechoic mass with clear margins in the right lobe. Histological examination of the tumor demonstrated malignant spindle cells in interlacing fascicles and whorls. Additionally, nuclear pleomorphism, tumor giant cells, necrosis and abnormal mitotic figures were observed. The immunohistochemistry indicated that the tumor cells were strongly positive for smooth muscle actin, desmin, p53 and vimentin expression, but negative for cytokeratin, epithelial membrane antigen, thyroid transcription factor-1, paired box-8, 34βE12, cytokeratin 5/6, cluster of differentiation (CD)117, myoglobin, S100, p16. The final histopathological diagnosis was primary thyroid LMS.

Primary leiomyosarcoma of thyroid gland: the youngest case

Primary leiomyosarcomas of the thyroid gland are extremely rare. We report a case of a 32 year-old women with a multinodular goiter. She underwent total thyroidectomy. The tumor histology showed spindle-shaped cells that expressed desmine, caldesmone and smooth muscle actine but were negative cytokeratins.

Hemangiopericytoma of the Thyroid

A 52-year-old woman presented with a painless right thyroid mass of 4 months dura tion, with a recent increase in size in the last few weeks. The neoplasm was character ized by bland spindle cells with a low mitotic rate arranged around vascular elements of variable shape and caliber. Multiple immunohistochemical stains failed to show evi dence of epithelial, neuroendocrine, or specific mesenchymal differentiation. Electron microscopic studies revealed spindle cells with micropinocytotic vesicles, surrounded by variable but sometimes abundant basement lamina-like material. To the authors' knowledge, this is the first report of a typical hemangiopericytoma of the thyroid gland. This lesion must be distinguished from epithelial and neuroendocrine tumors with spindle cells and from other mesenchymal neoplasms that may occur in the thyroid. Int J Surg Pathol 2(4):311-318, 1995

Primary thyroid leiomyosarcoma: A case report and literature review

Primary thyroid leiomyosarcoma (LMS) is an extremely rare soft tissue cancer; only 22 cases have been reported in the literature to date. In the current study, the case of an 83-year-old male patient who presented with a neck mass that had grown rapidly over the previous 3 months is reported. The patient underwent thyroid lobectomy twice and two cycles of immunotherapy for the treatment of primary thyroid LMS; however, he succumbed to the disease 5 months after the second surgery. An accurate diagnosis of primary thyroid LMS is difficult, as the disease is often misdiagnosed as anaplastic carcinoma, and requires the combined assessment of clinical, imaging and pathological data. Diagnosis of the current patient with primary thyroid LMS and a comprehensive review of the relevant literature are presented herein.

Thyroid leiomyosarcoma: presentation of two cases and review of the literature

Introduction

Leiomyosarcoma is a tumor which is rarely seen in the thyroid gland. The diagnosis may be difficult and the treatment is controversial.

Objective

The objective of the study is to review the literature about a rare malignant disease of the thyroid gland which has high mortality.

Methods

Two cases of thyroid leiomyosarcoma are presented and the previous 23 cases in the current literature are reviewed.

Results

A total of 25 cases of thyroid leiomyosarcoma are reviewed; the most common complaint was rapidly growing anterior neck mass, and ten of the 25 patients had distant metastasis at the initial admission. Fifteen of the 25 patients died with the disease in the first 12 months after the diagnosis.

Conclusion

The differential diagnosis of thyroid leiomyosarcoma is important and should be performed with other malignancies of the gland, especially with anaplastic carcinoma. The prognosis is poor and there is no consensus regarding the treatment.

Leiomyosarcoma: a rare tumor of the thyroid

Primary leiomyosarcoma of the thyroid gland is uncommon. To date, 20 cases have been reported in English in the literature. The tumors usually present in elderly patients with female predilection and are associated with poor clinical outcome. Herein, we report an additional case of primary thyroid leiomyosarcoma in a 64-year-old woman. She underwent total thyroidectomy and later was discovered to have multiple lung and liver metastases. The patient died 3 months after surgery. The major differential diagnoses including undifferentiated (anaplastic) carcinoma of the thyroid, spindle cell variant of medullary thyroid carcinoma, spindle cell tumor with thymus-like differentiation, uncommon primary tumor of the thyroid and metastatic tumors with predominant spindle cells are discussed.

Primary leiomyosarcoma of the thyroid gland

Primary leiomyosarcomas of the thyroid gland are rare. We present the case of a 65-year-old woman with a rapidly enlarging neck mass for 2 months. The preoperative differential diagnosis included medullary thyroid cancer, anaplastic thyroid cancer, and primary versus metastatic sarcoma. The patient underwent total thyroidectomy, bilateral central neck dissections, and cervical thymectomy; she is currently being treated with ifosfamide and adriamycin. We review the literature on leiomyosarcoma of the thyroid, including the differential diagnoses, pathology, and alternative treatment strategies, including surgery and adjuvant therapy.

Leiomyosarcoma of the thyroid gland

The existence of primary thyroid sarcomas represents a contentious issue. Some authors believe that thyroid sarcomas are, in fact, anaplastic carcinomas with sarcomatous (spindle cell) features. From the standpoint of treatment and prognosis, the histogenesis of thyroid 'sarcomas' is academic, because these tumors, irrespective of the therapeutic intervention, are lethal 1. Primary thyroid leiomyosarcomas are extremely rare. Only nine isolated cases have been reported in the literature and such tumors carry a very poor prognosis [1-7] .

An unusual clinical presentation of a rare tumor of the thyroid gland: report on one case of leiomyosarcoma and review of literature

Primary muscle tumors of the thyroid gland are exceedingly rare. We report on the case of a patient with primary leiomyosarcoma of the thyroid gland and review the literature. An 83-year-old woman complaining of neuropathic pain in her left arm and enlargement of her anterior neck underwent multiple surgical biopsies of the thyroid gland. The tumor was composed of interlacing fascicles of spindle-shaped cells that expressed smooth muscle actin and vimentin but were negative for cytokeratins and thyroglobulin. Ultrastructurally, bundles of myofilaments were present. Magnetic resonance imaging showed a thyroid tumor that directly extended to the adjacent vertebra with an associated pachymeningitis. The patient died 2 months after surgery. The diagnosis of primary leiomyosarcoma of the thyroid gland is difficult and requires numerous clinical, radiologic, and pathologic data. To our knowledge, this case is the first one with such a locoregional extension.

Over-expression of c-kit in a primary leiomyosarcoma of the thyroid gland

Primary leiomyosarcoma of the thyroid gland is rare. In this paper, we report a case of high-grade leiomyosarcoma of the thyroid gland in a 43-year-old man. Lung metastasis was also noted in this patient. Despite of aggressive surgical treatment, the patient died of uncontrolled local recurrent disease 6 months after the initial operation. Immunohistochemical studies showed the tumor cells were positive for c-kit proto-oncogene product. Imatinib mesylate was used as a post-operative adjuvant treatment but the response was poor. The role of tyrosine kinase inhibitors on the treatment of thyroid leiomyosarcomas is still unclear because this is the first report of c-kit over-expression in such tumors. Nevertheless, our results show that c-kit over-expression might not be an indicator of good response to imatinib mesylate treatment in thyroid leiomyosarcomas.

Anaplastic carcinoma of the thyroid with rhabdomyosarcomatous differentiation: a report of two cases

Anaplastic carcinoma of the thyroid gland (ACT) is a highly malignant tumor that is almost invariably associated with a fatal outcome. It demonstrates a variety of peculiar histological features, with squamoid, giant cell and spindle cell growth patterns. The spindle cell variant of ACT is usually indistinguishable from a true sarcoma and it can simulate fibrosarcoma, malignant fibrous histiocytoma (MFH), hemangiopericytoma and angiosarcoma or rhabdomyosarcoma. Although a rhabdomyosarcomatous appearance has sometimes been mentioned in the literature, true skeletal muscle differentiation has never been consistently proved. We report two cases of ACT with rhabdomyosarcomatous differentiation, as demonstrated by means of immunohistochemistry and electron microscopy. Both cases disclosed a very similar histological appearance, with a main population of small, pleomorphic, round-to-oval cells arranged in a storiform pattern, admixed with scattered pleomorphic giant cells, an image similar to that of the usual type of MFH. Stains for epithelial markers showed only few, scattered, weakly positive cells. Thyroglobulin and calcitonin were negative in tumor cells in both cases. On the contrary, positivity to vimentin was strong and generalized. Immunomarkers of muscular differentiation showed a consistent positivity. At the ultrastructural level, the cells disclosed the same spindle and pleomorphic morphology, with large, bizarre nuclei and cytoplasm with abundant mitochondria, rough endoplasmic reticulum, secretory granules and lipid droplets. There were also cells with wide cytoplasm filled with filamentous material, either of actin or myosin, as well as Z-band material. In conclusion, the cases reported here show a clear-cut rhabdomyosarcomatous differentiation of ACT, confirmed both immunohistochemically and ultrastructurally, a feature not previously reported in the literature. These findings may contribute to the broadening of the differentiation spectrum of this unusual neoplasm.

Spindle epithelial tumor with thymus-like differentiation (SETTLE) of the thyroid

BACKGROUND

Tumors of the so-called intrathyroidal epithelial thymoma type are a rare group of thyroid neoplasm tumors. Of this type of tumor, spindle epithelial tumor with thymus like differentiation (SETTLE) has been reported only 17 times in English literature.

METHODS

An 18-year-old woman was initially seen with a 6-cm left thyroid mass that was resected with a left thyroidectomy. Histopathologic features of the excised left thyroid tumor together with an immunohistochemistry and electron microscopy led us to a diagnosis of SETTLE.

RESULTS

Most of the specimen was composed of highly cellular spindle cells that formed intersecting and streaming fascicles. The spindle cells showed both vimentin immunoreactivity and cytokeratin immunoreactivity but no immunoreactivity for thyroglobulin or calcitonin. Electron microscopic examination of the spindle cells demonstrated prominent cytoplasmic tonofilaments, desmosomes, and basal lamina consistent with epithelial cell origin. DNA content analysis by flow cytometry revealed DNA diploidy.

CONCLUSIONS

SETTLE of thyroid gland is an extremely rare entity. A review of the literature reveals that SETTLE has distinctive morphologic features and an immunohistochemical profile.

MR imaging of primary leiomyosarcoma of the thyroid gland

Primary leiomyosarcoma of the thyroid gland is extremely rare and radiological information on this tumor is scant. We presented radiological findings on primary thyroid leiomyosarcoma in a 66-year-old woman in which anaplastic carcinoma was suspected based on clinical and cytological features and discussed the radiological clues to distinguish between the two diseases. Ultrasonography showed an ill-defined hypoechoic mass without halo in the left lobe and the isthmus of the thyroid gland. Computed tomography depicted a low-density mass with calcification and necrosis, which invaded the thyroid cartilage. No lymphadenopathy was seen. The tumor was demonstrated as an isointense mass on T1-weighted MR images and a mass of intermediate signal on T2-weighted images. The tumor showed a fair enhancement on gadolinium-enhanced T1-weighted images. Although the radiological picture was nonspecific, primary thyroid leiomyosarcoma appeared less invasive and far less frequent in developing nodal metastasis than anaplastic carcinoma in light of the literature.

Thyroid carcinosarcoma, a rare and aggressive histotype: a case report

Thyroid carcinosarcoma is a rare and aggressive thyroid tumor. Histological examination of a tumor showed the characteristic of epithelial carcinoma and mesenchymal differentiation. We retrospectively analyzed the course of the patient and reviewed the literature in which only 19 other cases are described. Carcinosarcoma of the thyroid is a very aggressive tumor with a clinical course similar to anaplastic thyroid carcinoma. Survival is very short despite aggressive multimodal treatment.

Anaplastic thyroid carcinoma: behavior, biology, and therapeutic approaches

Anaplastic thyroid carcinoma (ATC), although exceedingly rare, is the most aggressive solid tumor known. Early studies on the effects of different therapies may be biased by the inclusion of responsive "small cell" ATC patients, which are now known to be mostly lymphoma patients. Local control of disease with surgery and/or external beam radiotherapy (XRT) is of fundamental importance to enhance survival. Ultimately, nearly all ATC patients die from their disease, which is widely metastatic. Development of effective systemic chemotherapy agents would provide the best chance for long-term survival of patients. Early preliminary data suggest that paclitaxel may be helpful, although no agent has yet been identified to result in dramatic improvements in survival. Select patients may benefit from aggressive multimodal therapy, although it is important to provide appropriate palliative care when desired.

Primary smooth muscle tumors of the thyroid gland

BACKGROUND

Primary smooth muscle tumors of the thyroid gland are rare. To date, there are few cases reported of primary thyroid leiomyomas and leiomyosarcomas.

METHODS

One leiomyoma and four leiomyosarcomas arising within the thyroid gland were identified in the files of the Endocrine Tumor Registry of the Armed Forces Institute of Pathology. Histologic and immunohistochemical features were reviewed and follow-up obtained.

RESULTS

The patients included 2 females, ages 56 and 64 years, and 3 males, ages 45, 68, and 83 years. The patients presented with a mass in the thyroid gland that had increased in size over a number of months. All the tumors originated within a single lobe of the thyroid gland and measured from 1.1 to 9 cm in greatest dimension. Histologically, there was a fascicular pattern of growth comprised of spindle-shaped cells with blunt-ended nuclei. The leiomyoma was encapsulated, cytologically bland, and amitotic; the leiomyosarcomas were invasive with increased cellularity, pleomorphism, a high mitotic rate, necrosis, and hemorrhage. Immunohistochemical staining showed reactivity with vimentin, smooth muscle actin, muscle specific actin, and desmin. The patient with the leiomyoma was alive without evidence of disease 11 years after the initial presentation, with surgical resection as the only treatment. Three of the patients with leiomyosarcomas were dead within 2 years of diagnosis, in spite of aggressive therapeutic intervention. The remaining patient was still alive 10 months after initial presentation with multiple lung metastases.

CONCLUSIONS

Smooth muscle tumors of the thyroid gland are distinctive tumors. Leiomyosarcomas can be distinguished from anaplastic carcinoma, although patient outcome is uniformly unfavorable.

Primary leiomyosarcoma of the thyroid gland

Primary leiomyosarcoma of the thyroid gland is extremely rare, and to the best of our knowledge only five well-documented cases have been reported in the world literature. We herein report a 58-year-old female patient with primary leiomyosarcoma of the thyroid who was successfully treated by total thyroidectomy with a modified neck dissection. Immunohistochemically, the tumor cells showed positive reactivity to alpha-smooth muscle actin and vimentin. Radical surgery was thus considered to be essential in the treatment of this rare but rather aggressive malignancy.

Peripheral Nerve Sheath Tumors of the Thyroid Gland: A Series of Four Cases and a Review of the Literature

Primary peripheral nerve sheath tumors (PNSTs) of the thyroid gland are exceptionally rare. Two schwannomas and two malignant PNSTs (MPNSTs), arising primarily within the thyroid gland, were identified in the files of the Endocrine Tumor Registry at the Armed Forces Institute of Pathology. The patients included two females, age 69 and 80 yr, and two males, age 18 and 33 yr. The patients presented with a mass in the thyroid gland confined to a single lobe of the thyroid without involvement of the cervical neck region. None of the patients had a history of neurofibromatosis. The benign tumors were encapsulated, one of them cystic, with the characteristic cellular and nuclear features of schwannomas. The MPNSTs were invasive tumors, effacing the thyroid parenchyma, with a fascicular pattern of growth composed of neural appearing cells with increased cellularity, increased mitotic activity, and with focal necrosis. Immunoreactivity for 5100 protein and vimentin was seen in all tumors. The patients with schwannomas, treated only by surgical resection, were alive without evidence of disease, over a period of 5-33 yr. Both patients with MPNSTs died of the disease 8 mo and 42 mo, respectively, with widely disseminated disease. Primary thyroid PNSTs are exceptionally rare tumors. MPNSTs, in this limited experience, have a fatal outcome irrespective of aggressive adjuvant therapy.

Leiomyosarcoma of the thyroid: immunohistochemical and ultrastructural study

A primary leiomyosarcoma of the thyroid was seen in a 54 yr old female. The patient had a solitary, cold nodule with no abnormalities of thyroid function tests. Histologically it was composed of characteristic interlacing fascicles of spindle cells which, electron microscopically, showed thin myofilaments with focal dense bodies. Immunohistochemistry showed a strong reaction with vimentin, smooth muscle actin and desmin. No epithelial differentiation was noted immunohistochemically or ultrastructurally. No tumor recurrence was detected 15 mths after surgery. It is postulated that the smooth muscle differentiation had arisen by metaplastic change or de-differentiation with re-differentiation of anaplastic thyroid carcinoma.

Primary leiomyosarcoma of the thyroid gland

A primary leiomyosarcoma of the thyroid gland in a 72 year old Japanese woman is described. This is the second case reported in the English literature. The patient presented with a 7 month history of a gradually expanding tumor in the right neck. The surgical specimen taken by thyroid lobectomy revealed a relatively well demarcated tumor, 2 x 2 x 3 cm in size, confined to the right lobe. Histologically, the tumor showed a classical leiomyosarcomatous appearance of interlacing fascicles of spindle-shaped cells with occasional blunt-ended nuclei and a high frequency of mitotic figures. Immunohistochemistry of the tumor cells clearly showed smooth muscle differentiation; the cells were positive for desmin, muscle-specific actin and vimentin and negative for cytokeratin, epithelial membrane antigen, carcinoembryonic antigen, thyroglobulin and calcitonin. The patient was free of disease for 3 years and 11 months without further treatment when evidence of multiple bone metastases appeared on bone scintigraphy. She died of pneumonia 4 years and 3 months after the lobectomy.

Thyroid thymoma in childhood

A nontoxic thyroid nodule was detected in a female infant soon after birth. At 4 years of age, the nodule was removed. Histological examination disclosed a Iobulated spindle-cell neoplasm with focal epithelioid differentiation. The tumor demonstrated diffuse immunopositivity for low-molecular-weight keratins with scattered cells staining for S- 100 protein or leukocyte common antigen; the tumor was negative for calcitonin and thyroglobulin. By electron microscopy, the spindle-shaped cells contained bundles of intracytoplasmic tonofilaments and desmosomes. The light- and electron-microscopical features and immunohistochemical profile of this tumor were those of the recently described primary thyroid thymoma. Thymoma should be considered as a possible, albeit rare, cause of a thyroid mass in infancy or childhood.