Anaplastic thyroid carcinoma with destructive thyrotoxicosis in a patient with preexisting multinodular goiter

Anaplastic Thyroid Carcinoma Mimicking Cervical Tuberculosis: A Case Report

Anaplastic thyroid carcinoma is a rare and aggressive form of thyroid cancer that has a poor prognosis and a high mortality rate. It is characterized by rapid growth and invasion of nearby tissues. It typically presents as a rapidly growing goiter or nodule that is firm to the touch and firmly attached to the underlying structures. Case reports of unusual presentations of anaplastic thyroid carcinoma have been reported. The presentation of anaplastic thyroid carcinoma mimicking cervical tuberculosis is very unusual. We reported a case of a 65-year-old patient who had a left cervical swelling that had been evolving for 4 months, causing dysphagia. Initial imaging showed a necrotic mass in the left lobe of the thyroid, communicating with a second necrotic mass in the subcutaneous tissue that was fistulized to the skin and suggesting cervical tuberculosis. The mass was incised with pus and whitish material resembling caseous tuberculosis was discharged. Acid-fast bacilli (AFB) Polymerase chain reaction (PCR) was negative and biopsy revealed a nonspecific granulomatous lesion. Due to the growth of the mass and the presence of a permeation nodule, a second biopsy was performed, revealing anaplastic thyroid carcinoma. The patient was referred for radiochemotherapy due to tumor inoperability.

Dietary iodine intake, therapy with radioiodine, and anaplastic thyroid carcinoma

Background Anaplastic thyroid cancer (ATC) is one of the most aggressive tumors. The aim of the study was to determine the correlation between a higher dietary intake of iodine, frequency of ATC and the characteristics of ATC, and to find out how often patients with ATC had a history of radioiodine (RAI) therapy. Patients and methods This retrospective study included 220 patients (152 females, 68 males; mean age 68 years) with ATC who were treated in our country from 1972 to 2017. The salt was iodinated with 10 mg of potassium iodide/ kg before 1999, and with 25 mg of potassium iodide/kg thereafter. The patients were assorted into 15-year periods: 1972-1986, 1987-2001, and 2002-2017. Results The incidence of ATC decreased after a higher iodination of salt (p = 0.04). Patients are nowadays older (p = 0.013) and have less frequent lymph node metastases (p = 0.012). The frequency of distant metastases did not change over time. The median survival of patients in the first, second, and third periods was 3, 4, and 3 months, respectively (p < 0.05). The history of RAI therapy was present in 7.7% of patients. Conclusions The number of patients with a history of RAI therapy did not change statistically over time. The incidence of ATC in Slovenia decreased probably because of higher salt iodination.

Anaplastic thyroid carcinoma mimicking thyroid abscess

Anaplastic thyroid carcinoma (ATC) is a particularly fearsome form of thyroid cancer due to its extreme aggressiveness and dismal prognosis. Patients with ATC typically present with a rapidly enlarging neck mass with compressive symptoms. We report a case of ATC, mimicking a thyroid abscess; in a 52-year-old Chinese male with one month history of enlarging neck mass. Ultrasound of the neck was suggestive of a thyroid cyst and fine needle aspiration cytology was negative for malignancy. He presented again 2 weeks later with increased swelling and pain suggestive of right neck abscess. An incision and drainage was performed and histopathology result of a proximal isolated enlarged lymph node biopsied revealed metastatic carcinoma. Subsequent right thyroid wedge biopsy finding 1 month later were confirmatory of ATC.

Anaplastic carcinoma and toxic multinodular goiter: an unusual presentation

A 70-year-old male was referred with hyperthyroidism and multinodular goiter (MNG). Thyroid ultrasonography showed 2 nodules, one in the isthmus and the other in the left lobe, 51 and 38 mm in diameter, respectively. Neck CT showed a large MNG, thyroid scintigraphy showed increased uptake in the nodule in the left lobe, and fine-needle aspiration biopsy showed a benign cytology of the nodule in the isthmus. The patient declined surgery and was treated with methimazole. After being lost to follow-up for 3 years, the patient returned with complaints of dyspnea, dysphagia, and hoarseness; he was still hyperthyroid. Cervical CT showed a large mass in the isthmus and left lobe with invasion of surrounding tissues, the trachea, the esophagus, and the recurrent laryngeal nerve. Bronchoscopy showed extensive infiltration and compression of the trachea to 20% of its caliber. A tracheal biopsy revealed an anaplastic thyroid carcinoma. The tumor was considered unresectable, and radiotherapy was given. One month later, the patient died. The association between a toxic thyroid nodule and anaplastic thyroid carcinoma has apparently not been reported so far.

Thyroid cancer in Plummer's disease

Thyroid cancer with concomitant hyperthyroidism is rare. Most foci of malignancy are small and seen postoperatively as incidental findings after surgery for hyperthyroidism. Thyroid masses with clinical features of malignancy and concomitant hyperthyroidism are less-commonly reported. We report two cases of multinodular toxic goitre or Plummer's disease with clinical features of malignancy. Both patients had large multinodular goitres with evidence of metastasis to the manubrium for the first patient and to the lymph node and lungs for the second patient. Both were clinically euthyroid but with free hormone excess and suppressed thyroid stimulating hormone (TSH) on laboratory testing. Both patients received methimazole prior to thyroidectomy. Histopathology revealed follicular variant of papillary cancer with metastasis to the manubrium for the first patient and follicular thyroid cancer with lymph node metastasis for the second. While rare, thyrotoxicosis can occur with malignancy, Plummer's disease may harbour cancer and behave aggressively.

Anaplastic thyroid carcinoma initially presented with abdominal cutaneous mass and hyperthyroidism

A 63-year-old female was admitted to our hospital with a tender abdominal wall mass about 15 cm in diameter, which she had for 1 month. About 1 week earlier, the patient had also perceived a mass in the neck area. Computed tomography revealed huge thyroid and periumbilical masses. The thyroid hormone levels were consistent with a hyperthyroid state. Pathological examination of the thyroid mass was compatible with anaplastic thyroid carcinoma (ATC) and the abdominal cutaneous mass was shown to be metastatic ATC. Despite palliative radiotherapy and chemotherapy, the patient died of respiratory failure on her 63rd day of hospitalization. This case demonstrates that abdominal cutaneous metastasis and hyperthyroidism can occur as initial manifestations of ATC. To our knowledge, this is the first reported case.

Thyroid metastasis of endometrial carcinosarcoma associated with Graves' disease

A 54-year-old woman who had undergone total abdominal hysterectomy and bilateral adnexial resection because of endometrial carcinosarcoma presented with thyrotoxicosis, rapidly enlarging neck mass, right cervical tenderness to the ears, palpitation, swelling and heat intolerance, 3 years after the operation. Her serum thyroid hormone levels confirmed hyperthyroidism. Triiodothyronine/thyroxine ratio was 18. The thyroid antibodies were markedly elevated. A thyroid scan showed a cold area corresponding to the thyroid nodule, with high radioiodine uptake in the remaining thyroid tissue. Antithyroid drugs were started to control the hyperthyroidism. In our patient, who had a history of malignancy, the rapidly enlarging neck mass was considered as metastasis to the thyroid gland. The patient underwent bilateral total thyroidectomy. Histopathological examination demonstrated findings compatible with Graves' disease on the left and a carcinosarcoma metastasis on the right thyroid lobe. We suggest that both destructive thyroiditis and Graves' disease contributed to our patient's thyrotoxicosis. Metastatic thyroid carcinoma and destructive thyroiditis should be considered in patients with rapidly enlarging neck mass and a prior history of visceral malignancy.

Anaplastic Thyroid Carcinoma With Thyrotoxicosis and Hypoparathyroidism

OBJECTIVE

To describe a patient who presented with anaplastic thyroid carcinoma and thyrotoxicosis in whom hypoparathyroidism developed.

METHODS

We present the clinical and laboratory findings in a patient with anaplastic thyroid carcinoma and thyrotoxicosis. We also review the literature for previous cases of anaplastic thyroid carcinoma with thyrotoxicosis.

RESULTS

A 74-year-old man presented with left-sided neck pain and a rapidly enlarging neck mass. Initial thyroid function tests revealed the following: thyrotropin (thyroid-stimulating hormone or TSH) 0.03 microIU/mL, free thyroxine 1.28 ng/dL, and total triiodothyronine 119 ng/dL. A thyroid radioiodine uptake scan was 2.2% at 25 hours. Pathology examination of the neck mass disclosed anaplastic thyroid carcinoma. His thyrotoxicosis was managed with beta-adrenergic blockade. The thyroid carcinoma was treated palliatively with external beam irradiation. During week 9 after the patient's initial presentation, symptomatic hypocalcemia developed, with an ionized serum calcium level of 0.75 mmol/L (normal range, 1.15 to 1.29) and a parathyroid hormone level of 21.2 pg/mL (normal range, 10 to 65). He was given calcium gluconate intravenously for initial management, followed by orally administered calcium carbonate and calcitriol. At week 15, he died of complications attributable to anaplastic thyroid carcinoma.

CONCLUSION

Thyrotoxicosis due to thyroiditis is a rare initial manifestation of anaplastic thyroid carcinoma. Hypoparathyroidism due to anaplastic thyroid carcinoma has not been reported previously.

Anaplastic thyroid cancer and hyperthyroidism

We report a rare case of thyrotoxicosis in a patient with anaplastic thyroid cancer. A 65-yr-old male presented with a 2-d history of rapidly enlarging neck mass and back pain. Physical examination revealed a large, hard thyroid mass and resting tachycardia. He did not have any symptoms suggestive of airway compression at presentation. Thyroid hormone levels were consistent with a hyperthyroid state. CT scan of the neck and thorax showed a heterogeneous mass replacing the thyroid, bilateral pulmonary nodules, and a metastasis with pathological fracture at the level of T-8. Technetium-pertechnetate scan failed to show any uptake in the region of the thyroid. Fine needle aspiration of the thyroid revealed anaplastic thyroid cancer. The patient was started on steroids and radiation therapy of his spine lesion. Brief surgical exploration of the thyroid revealed extensive local infiltration of adjacent neck tissues and marked tumor necrosis. Immunohistochemical stains of the tumor were positive for p53, thyroglobulin, and thyroid transcription factor-1. The tumor had an extremely aggressive course and the patient died of asphyxiation from severe airway compromise 11 d after his initial presentation.