Anaplastic Carcinoma and Toxic Multinodular Goiter: An Unusual Presentation

Abstract

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.

Remarkable Presentation: Anaplastic Thyroid Carcinoma Arising from Chronic Hyperthyroidism

“…To our knowledge, a 2014 report by Marcelino et al is the only published case that associates chronic hyperthyroidism with subsequent development of ATC [ 8 ]. Their study reports a similar presentation in a 70-year-old male who had been diagnosed with a toxic nodule three years prior to diagnosis of ATC.…”

“…A subsequent neck CT scan showed a suspicious mass involving the left thyroid lobe and isthmus (7 × 6 × 5 cm), with invasion of the surrounding soft tissue, trachea, and recurrent nerve. Their patient was not a surgical candidate and underwent radiotherapy without much improvement in thyroid size before passing away several weeks later of airway compression [ 8 ]. Similar to Marcelino et al, previous work-up of our patient's thyroid nodules, including biopsies of bilateral nodules, was negative for malignancy.…”

“…Although thyrotoxicosis can develop in a gland with ATC, it is rare to find ATC develop from underlying longstanding hyperthyroidism. We found only one other case in the literature of ATC arising from a patient with chronic hyperthyroidism [ 8 ]. In this report, we present our experience with a patient who developed ATC after many years of hyperthyroidism and toxic multinodular goiter.…”

Malignancy risk of hyperfunctioning thyroid nodules compared with non-toxic nodules: systematic review and a meta-analysis

“…Papillary thyroid carcinomas (PTCs) and follicular thyroid carcinomas (FTCs) were the most commonly reported malignancies. However, follicular variant of papillary thyroid carcinomas (fvPTC), Hurthle cell, anaplastic (with a concomitant hot nodule) and medullary thyroid carcinomas (described as a cold area of the HN) were also identified [ 28 , 29 ].…”

“… Qjm 1 60 AFTN FVPTC Lado-Abeal J. et al [ 68 ] 2010 Identification of a paired box gene 8-peroxisome proliferator-activated receptor gamma (PAX8-PPAR gamma) rearrangement mosaicism in a patient with an autonomous functioning follicular thyroid carcinoma bearing an activating mutation in the TSH receptor Endocrine-Related Cancer 1 55 TMNG FTC Lima, M. J., et al 2018 Autonomously hyperfunctioning cystic nodule harbouring thyroid carcinoma - Case report and literature review.” International Journal of Surgery Case Reports 1 49 AFTN FVPTC Majima, T., et al [ 56 ] 2005 Papillary thyroid carcinoma without metastases manifesting as an autonomously functioning thyroid nodule. Endocrine Journal 1 59 AFTN PTC Marcelino, M., et al [ 28 ] 2014 Anaplastic carcinoma and toxic multinodular goiter: an unusual presentation European Thyroid Journal 1 70 TMNG Anaplastic thyroid carcinoma Mircescu, H., et al [ 35 ] 2000 Hyperfunctioning malignant thyroid nodule in an 11-year-old girl: pathologic and molecular studies. Journal of Pediatrics 1 11 AFTN PTC Mirfakhraee, S., et al [ 8 ] 2013 A solitary hyperfunctioning thyroid nodule harboring thyroid carcinoma: review of the literature Thyroid research 1 29 AFTN FTC Nagai, G. R., et al 1987 Scintigraphic hot nodules and thyroid carcinoma Clinical Nuclear Medicine 3 2 FTC and 1 PTC Nemec, J., et al [ 57 ] 1980 Metastatic thyroid cancer with severe hyperthyroidism mimicking independen...…”