Category: Thyroid

Monitor: 21

21 - POORLY DIFFERENTIATED THYROID CANCER: A DIAGNOSTIC DILEMMA

Friday, Apr 26
12:30 PM – 1:00 PM

Objective : Poorly differentiated thyroid cancer is a rare, follicular cell derived cancer that has a controversial diagnostic history.


Methods : n/a


Results : A 50 year old woman with a four-year history of multinodular goiter presented with symptoms of worsening dysphagia.Initial thyroid ultrasound at an outside hospital showed a left-side 1.7 cm nodule, which was negative for malignancy on fine needle aspiration (FNA) evaluation. Repeat FNA due to mild enlargement of the nodule was unsatisfactory for evaluation due to scant cellularity. After one year of loss to follow-up, she presented with worsening dysphagia.Thyroid ultrasound showed significant increase in the left isthmus nodule to 3.0 x 2.8 x 1.7 cm. Her TSH was noted to be 1.72 uIU/mL. Due to significant increase in size, symptoms of dysphagia and history of unsatisfactory FNA, she underwent thyroidectomy.  Surgical pathological evaluation revealed poorly differentiated thyroid carcinoma, 2.5 cm in greatest dimension with a focus of papillary microcarcinoma. The surgical margins were clear and there was no extrathyroidal extension or lymphovascular invasion. Postoperative neck ultrasound showed no residual soft tissue in the thyroidectomy bed. A second pathological review was requested at a premier academic institution and the lesion was described as follicular variant of papillary carcinoma, with no lymphovascular invasion or extrathyroidal extension.  A small focus of nuclear atypia, without excess mitotic activity or tumor necrosis, was noted in one of the recut slides. After thyroid hormone withdrawal, an I-131 radioiodine (RAI) whole body scan demonstrated no abnormal uptake in the neck or distant metastasis.Stimulated thyroglobulin and thyroglobulin antibody were both <0.1 ng/mL. Genetic evaluation of the tumor was negative for BRAFV600E, RAS, RETPTC1, RETPTC3, KRAS and NRAS. RAI adjuvant treatment was not given. Close monitoring with serial neck mapping ultrasounds and tumor markers is planned.


Discussion : Poorly differentiated thyroid cancer is a rare, heterogeneous entity with a controversial history.Currently, the Turin criteria is used for diagnosis; however there have been concerns raised regarding the strict nature of the histopathological criteria. Thus, Memorial Sloan Kettering Cancer Center has broadened the spectrum by use of a less restrictive criteria.  Given its aggressive nature, even in patients with disease limited to the neck, close surveillance is warranted.


Conclusion : Poorly differentiated thyroid cancer remains a diagnostic dilemma for both endocrinologists and pathologists. We present an interesting case which demonstrates that discordance among academic pathologists persists about this clinical entity.

Tanzila S. Razzaki

Endocrinology Fellow
Rutgers NJMS
Cedar Grove, New Jersey

Endocrinology Fellow PGY4

Lissette M. Cespedes

Assistant Professor of Medicine
Rutgers New Jersey Medical School
Newark, New Jersey

M.D. Degree: Rutgers-New Jersey Medical School; Residency: Internal Medicine, Rutgers-Robert Wood Johnson Medical School; Fellowship: Endocrinology, Diabetes and Metabolism, Rutgers-Robert Wood Johnson Medical School

Tanzila S. Razzaki

Endocrinology Fellow
Rutgers NJMS
Cedar Grove, New Jersey

Endocrinology Fellow PGY4