Category: Thyroid

Monitor: 10

10 - ANAPLASTIC TRANSFORMATION OF TALL CELL VARIANT PAPILLARY THYROID CANCER IN A RECURRENT LYMPH NODE 28 YEARS AFTER TOTAL THYROIDECTOMY

Friday, Apr 26
11:30 AM – 12:00 PM

Objective :

Papillary Thyroid Cancer (PTC) is the most common type of thyroid cancer and the one with most favorable prognosis. Locoregional recurrence is frequently seen in patients with PTC and depending on clinical characteristics can be treated with surgery, radioactive iodine (RAI), external beam radiation therapy, and ethanol injections or observed over time. Tall cell variant (TCV) PTC is associated with aggressive behavior and worse clinical outcomes. Anaplastic transformation of TCV PTC in metastatic lymph nodes is exceptionally rare. This case describes anaplastic transformation of TCV PTC in a recurrent lymph node in the neck 28 years after initial surgery. 


Methods : n/a


Results : n/a


Discussion :

76 year-old male with metastatic RAI-refractory PTC diagnosed in 1990, status post total thyroidectomy and RAI therapy, presented with hoarseness of the voice and rapidly progressive neck mass.  Previously he had three surgeries for recurrences in the neck in 2006-2009. He has known subcentimeter pulmonary metastasis since 2012 that remained stable over time. He also had stereotactic radiation therapy to a 3.3 cm left hilar mass in 2013.  In 2017 he was found to have a left 1.2 cm parathacheal mass that was metabolically active on PET scan. Neck exploration at that time failed to identify that lesion. In 2018 he presented with progressive hoarseness. Physical exam revealed palpable left neck mass.  His thyroglobulin was 4.81 ng/ml (stable over the last couple years), with negative TG antibodies, TSH of 0.12 uIU/ml and FT4 of 1.61 ng/dL. CT neck with contrast showed extrinsic complex mass to the left of the upper thoracic esophagus measuring 3.6x5.1x4.5 cm containing cystic and solid components.  Patient underwent left modified neck dissection and pathology revealed 4.2 cm anaplastic thyroid carcinoma arising from TCV PTC invading soft tissue, prevertebral fascia, and carotid artery (BRAFpositive). He had R2 resection and consequently, chemo radiation followed by Dabrafenib and Trametinib was recommended. Shortly after surgery he went to hospice due to significant morbidity and poor prognosis.


Conclusion :

Anaplastic thyroid cancer is frequently arising from differentiated thyroid cancer, including TCV PTC. This case demonstrates a unique finding of anaplastic transformation of TCV PTC in a recurrent lymph node 28 years after initial surgery. We hypothesize that external beam radiation exposure to that area 5 years prior could have attributed to the anaplastic transformation. Here we illustrate the importance of individualized risk stratification and close follow up of high risk patients with aggressive histology and exposure to radiation therapy. 

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Gustavo Meyreles-Chaljub

Endocrinology, Diabetes and Metabolism Fellow
University of South Florida, Florida

USF-Endocrinology and Metabolism Fellow

Cameron Bell

Internal Medicine Resident
University of South Florida

USF PGY3-Internal Medicine

Juan Hernandez-Prera

Assistant Member in Anatomic Pathology
Moffitt Cancer Center

Assistant Member in Anatomic Pathology

Gary Clayman

Director
Clayman Thyroid Center

Head and neck surgeon at Clayman Thyroid Center

Mark Lupo

Medical Director Thyroid & Endocrine Center of Florida
Thyroid & Endocrine Center of Florida

Medical Director Thyroid & Endocrine Center of Florida

Valentina Tarasova

Endocrinologist
Moffitt Cancer Center

Endocrinologist at Moffitt Cancer Center