scholarly journals SUN-490 Mass Cord Compression: Metastasis of Insular Thyroid Cancer

2020 ◽  
Vol 4 (Supplement_1) ◽  
Author(s):  
Dina Jaber ◽  
Bianca Vazques ◽  
Gary Nagamoto ◽  
Mohamad Hosam Horani
Keyword(s):  
Thyroid Cancer ◽  
Thyroid Carcinoma ◽  
Chest Wall ◽  
Distant Metastasis ◽  
Tumor Resection ◽  
Complex Form ◽  
Lower Extremity Weakness ◽  
Poorly Differentiated Carcinoma ◽  
Patient Reported ◽  
Poorly Differentiated

Abstract Intro: Insular thyroid cancer is a rare and complex form of thyroid cancer, often referred to as poorly differentiated carcinoma. The exact incidence of insular thyroid cancers is difficult to assess due to controversial classification of this thyroid cancer over the years. It is termed poorly differentiated as it falls between the well-differentiated and undifferentiated carcinomas both morphologically and biologically[1]. Case: A 41 year old Hispanic female, with a history of prolactinoma and hyperparathyroidism, presented to the hospital with 10 days of progressive lower extremity weakness and paresthesias from T4 downwards, inability to bear weight, and no bowel movement for 12 days. MRI revealed a large thoracic soft tissue mass (7x4x4cm) centered in the posterior and medial aspect of the chest wall at T4-T5 with involvement of the spinal cord and vertebral bodies. She was also found to have a right sided thyroid mass (4.5x5x4 cm) with tracheal deviation- HerThyoid function test, were normal Intact PTH was 261, Thyroglobulin over 300, and Thyroid Antibodies were negative. Patient underwent T3-T6 laminectomy, T2-T7 fusion, and T4-T5 tumor resection, which was subtotal due to vascularity. Second procedure included a right thoracotomy, chest wall resection of ribs 4 and 5 with full resection of paraspinal mass, total thyroidectomy, parathyroidectomy with central cervical lymphadenectomy. Pathology results of paraspinal mass showed insular thyroid carcinoma. Post operatively, the patient reported improvement of sensation and strength in lower extremities. Genetic testing for MEN syndrome was negative. Discussion: Insular thyroid carcinoma, also referred to as poorly differentiated carcinoma is a rare form of thyroid cancer. Insular carcinoma was characterized by to include the following complex histologic features, “formation of solid clusters (insulae) of tumor cells containing a variable number of small follicles; variable but consistently present mitotic activity, capsular and blood vessel invasion; and frequent necrotic foci, sometimes leading to formation of peritheliomatous patterns”[1]. The cells originate from follicular epithelium and possess the potential to concentrate radioiodine[2]. Unlike anaplastic carcinoma of the thyroid, p53 and p21 staining was negative in insular carcinomas[3]. Thyroglobulin staining is generally positive[4]. Distant metastasis occurs in about 31% of patients with insular thyroid carcinoma[5]. In cases of distant metastasis, treatment with thyroidectomy and radioiodine therapy were shown to independently improve survival[5]. The Constellation of Insular thyroid cancer, hyperparathyroidism and Prolactinoma, has not been reported before. References: [1]. Am J Surg Pathol. 1984;8:655- [2] J of Nuc Med 32(7), 1358 [3] Ann of Surg vol. 231,3 (2000): 329 [4] JCEM 99. 1167–9. 10.1210/jc.2014 [5] Cancer. 2012 Jul;118(13) 3260

Genetic profile of advanced thyroid cancers in relation to distant metastasis

2020 ◽  
Vol 27 (5) ◽  
pp. 285-293 ◽  
Author(s):  
Eyun Song ◽  
Dong Eun Song ◽  
Jonghwa Ahn ◽  
Tae Yong Kim ◽  
Won Bae Kim ◽  
...  
Keyword(s):  
Thyroid Cancer ◽  
Thyroid Carcinoma ◽  
Distant Metastasis ◽  
Distant Metastases ◽  
Thyroid Tumors ◽  
Primary Tumors ◽  
Thyroid Cancers ◽  
Histone Methyltransferases ◽  
Thyroid Carcinomas ◽  
Poorly Differentiated

Major clinical challenges exist with differentiated thyroid cancers with distant metastases or rare but aggressive types, such as poorly differentiated thyroid carcinomas and anaplastic thyroid carcinomas. The precise characterization of the mutational profile in these advanced thyroid cancers is crucial. Samples were collected from primary tumors and distant metastases of 64 patients with distant metastases from differentiated thyroid cancer, poorly differentiated thyroid carcinoma, or anaplastic thyroid carcinoma. Targeted next-generation sequencing was performed with 50 known thyroid-cancer-related genes. Of the 82 tissues, 63 were from primary tumors and 19 from distant metastases. The most prevalent mutation observed from the primary tumors was TERT promoter mutation (56%), followed by BRAF (41%) and RAS (24%) mutations. TP3 was altered by 11%. Mutations in histone methyltransferases, SWI/SNF subunit–related genes, and PI3K/AKT/mTOR pathway-related genes were present in 42%, 12%, and 22%, respectively. When the mutational status was analyzed in 15 matched pairs of thyroid tumors and their matched distant metastases and one pair of distant metastases with two distinct sites, the concordance was high. A similar frequency of mutations in TERT promoter (58%) and BRAF (42%) as well as histone methyltransferases (37%), SWI/SNF subunits (10%), and PI3K/AKT/mTOR pathway (26%) were noted. The same main, early and late mutations were practically always present in individual primary tumor–metastasis pairs. Enrichment of TERT promoter, BRAF, and RAS mutations were detected in highly advanced thyroid cancers with distant metastasis. The genetic profiles of primary thyroid tumors and their corresponding distant metastases showed a high concordance.

scholarly journals MON-452 Poorly Differentiated Thyroid Carcinoma Metastatic to the Adrenal Gland

2020 ◽  
Vol 4 (Supplement_1) ◽  
Author(s):  
Priyanka Mathias ◽  
Anjali Manavalan ◽  
Sandra Aleksic ◽  
Noah Bloomgarden ◽  
Ulrich Schubart
Keyword(s):  
Thyroid Cancer ◽  
Adrenal Gland ◽  
Thyroid Carcinoma ◽  
Distant Metastasis ◽  
Differentiated Thyroid Carcinoma ◽  
Whole Body ◽  
Poorly Differentiated Thyroid Carcinoma ◽  
Poorly Differentiated ◽  
The Right ◽  
Post Therapy

Abstract Background: Poorly differentiated thyroid carcinoma (PDTC) constitutes 1-15% of all thyroid cancers.1 Invasive adrenal metastases secondary to PTDC are exceedingly rare. Clinical Case: A 64-year-old woman with a non-toxic multinodular goiter presented with right upper quadrant abdominal pain and distension for three months. CT imaging revealed a 13.5 cm right suprarenal retroperitoneal mass invading the liver and inferior vena cava (IVC), concerning for adrenocortical carcinoma. She underwent resection of the mass with en block right adrenalectomy, partial hepatectomy, and IVC resection. Pathology demonstrated metastatic thyroid cancer with necrosis of the adrenal gland and IVC. Immunohistochemical staining was positive for PAX8, TTF1, and thyroglobulin (Tg). Completion thyroidectomy revealed an encapsulated 2 cm focus of PDTC with Hurthle cell phenotype in the right thyroid lobe. The mitotic activity was 5/10 per HPF. There were focal areas of tumor necrosis, 3 foci of capsular invasion, and extensive angioinvasion. Surgical margins were free of tumor invasion. Eight resected lymph nodes were negative for malignancy (Stage T1bN0M1; AJCC 8, Stage IVb). Genetic testing was positive for somatic mutations of NRAS, TERT, PTEN, and GNAS with broad copy number loss on chromosome 22q conferring aggressive tumor behavior.3 MRI of the brain and spine ruled out additional metastases. A radioactive iodine (RAI) whole-body scan (WBS) showed residual uptake of 7.6% in the right thyroid bed and a focus of increased uptake at the right sternoclavicular joint. A therapeutic dose of 206 mCi of I-131 was administered. A post-therapy WBS demonstrated focal activity in the right thyroid bed, distal right clavicle, and lower lung lobes. Chest CT and MRI of the right shoulder revealed no structural evidence of metastases corresponding to radiotracer uptake. The stimulated Tg level prior to RAI was 323 ng/mL with a TSH of 66 uU/mL (0.4-4.6 uU/mL). Tg antibodies were undetectable. She was maintained on 150 mcg of levothyroxine with the goal of TSH suppression. Tg levels declined to 4.8 ng/mL at three months, and to 0.3 ng/mL eight months post-RAI. Discussion: PDTC is an aggressive thyroid cancer subtype with distant metastasis reported in 36-85% of cases.2 Distant metastasis is predictive of poorer outcomes, with patients three times more likely to die from the disease than those without metastatic disease.1 Adrenal metastasis of thyroid cancer is rare, and unlike in our patient, usually asymptomatic and frequently detected on a post-therapy scan. Despite a dramatic response to therapy, given the poorly differentiated features of the primary tumor, a whole-body PET-CT is warranted to evaluate for RAI refractory disease. References: 1. Ibrahimpasic T et al. J Clin Endocrinol Metab. 2014;99(4):1245-52. 2. Sanders EM Jr et al. World J Surg. 2007;31(5):934-45. 3. Cheng DT et al. J Mol Diagn. 2015;17(3):251-64.

scholarly journals Mouse Model of Thyroid Cancer Progression and Dedifferentiation Driven by STRN-ALK Expression and Loss of p53: Evidence for the Existence of Two Types of Poorly Differentiated Carcinoma

Thyroid ◽  
2019 ◽  
Vol 29 (10) ◽  
pp. 1425-1437
Author(s):  
Alyaksandr V. Nikitski ◽  
Susan L. Rominski ◽  
Vincenzo Condello ◽  
Cihan Kaya ◽  
Mamta Wankhede ◽  
...  
Keyword(s):  
Thyroid Cancer ◽  
Mouse Model ◽  
Cancer Progression ◽  
Poorly Differentiated Carcinoma ◽  
Poorly Differentiated

scholarly journals Lenvatinib Administered via Nasogastric Tube in Poorly Differentiated Thyroid Cancer

2019 ◽  
Vol 2019 ◽  
pp. 1-4 ◽  
Author(s):  
Eleonora Molinaro ◽  
David Viola ◽  
Nicola Viola ◽  
Pierpaolo Falcetta ◽  
Francesca Orsolini ◽  
...  
Keyword(s):  
Thyroid Cancer ◽  
Thyroid Carcinoma ◽  
Gastric Tube ◽  
Kinase Inhibitors ◽  
Locally Advanced ◽  
Differentiated Thyroid Carcinoma ◽  
Cervical Esophagus ◽  
Extrinsic Compression ◽  
Poorly Differentiated ◽  
Iodine 131

Background. The tyrosine kinase inhibitors (TKIs) are indicated for the treatment of locally advanced or metastatic progressive thyroid carcinoma (CDT), refractory to radioactive iodine. The following report describes the efficacy of lenvatinib administered through a nose-gastric tube (SNG) in a patient affected with a poorly differentiated thyroid carcinoma (PDTC) which determined a stenosis of the esophagus. Material and Methods. A patient was followed up for papillary thyroid carcinoma follicular variant (T3NxMx), subjected to total thyroidectomy and treated with iodine-131 radio metabolic therapy. Two years after surgery, following the onset of dysphonia and dysphagia, patient was submitted to a computed tomography (CT) scan of the neck that showed the presence of a lesion of 6 × 2.5 × 3.5 cm, which determined trachea deviation and cervical esophagus compression. The biopsy indicated the presence of PDTC, triggering tracheal lumen reduction and sub-stenosis of the cervical esophagus for an ab-extrinsic compression. A nose-gastric tube (SNG) was placed and lenvatinib was started at a dose of 20 mg/day, administered via this probe after opening the capsules and diluting the drug in 10 ml of saline solution. Results. One month later, CT showed a significant cervical lesion reduction. Bronchoscopy confirmed tracheal infiltration, but the residual caliber was improved from 50% to 75%. At the esophagogastroduodenoscopy (EGDS), the sub stenosis of the cervical esophagus was no longer appreciated; however, a double perforation of the esophagus was found, without fistula. Conclusion. Lenvatinib therapy is effective also when administered via SNG. Our result is of particular relevance in the management of thyroid cancer patients, especially in the presence of subjects unable to swallow. Further studies are needed to validate the administration of lenvatinib by SNG, in order to extend the indications to this alternative administration way, beside the oral one.

scholarly journals SUN-474 An Unusual Case of Poorly Differentiated Thyroid Carcinoma with an Excellent Prognosis

2020 ◽  
Vol 4 (Supplement_1) ◽  
Author(s):  
Vishnu Priya Pulipati ◽  
Ambika Pinakini Amblee
Keyword(s):  
Early Detection ◽  
Thyroid Carcinoma ◽  
Lymph Nodes ◽  
Distant Metastasis ◽  
Differentiated Thyroid Carcinoma ◽  
Response To Therapy ◽  
Positive Margins ◽  
Poorly Differentiated Thyroid Carcinoma ◽  
Post Surgery ◽  
Poorly Differentiated

Abstract Background: Poorly differentiated thyroid carcinoma (PDTC) is a rare and aggressive subtype with morphological/behavioral features between differentiated thyroid carcinoma (DTC) and anaplastic thyroid carcinoma (ATC). Clinical case: A 43-year-old female presented with 3 cm right thyroid mass noted on US neck. FNA biopsy showed undifferentiated carcinoma, large cell type. Additional immune-stains were suggestive of ATC. Pre-surgery non-stimulated thyroglobulin (NSTG) was 311 (RR 0–55 ng/dl). Pathology post-total thyroidectomy with bilateral level VI lymph node dissection showed a 3.2 x 2.5 x 2.5 cm carcinoma with vascular and capsular invasion. Most of the mass consisted of very atypical pleomorphic cells, mitosis was difficult to find. The tumor did not show the widely invasive-destructive pattern commonly seen in ATC. An adjacent differentiated component showed predominantly follicular pattern and was described as dedifferentiated follicular carcinoma. All lymph nodes were negative for metastatic disease. Post-surgery NSTG was <0.2 (RR <0.1ng/ml as athyreotic), stimulated TG was 2.22 with negative TG antibodies. Four months later, she received 193.5 mCi radioactive iodine (RAI) therapy. The post-therapy scan showed no Iodine-131 avid uptake in neck or distant metastasis. Neck imaging and TG levels done periodically showed no structural or biochemical evidence of recurrence. Currently the patient is cancer-free for 14 years since diagnosis with no need for additional therapies. Discussion: PDTC accounts for 1–15% of all thyroid cancers. Although PDTC is rare, it is a clinically significant histological diagnosis as it represents the main cause of death from non-anaplastic follicular cell-derived thyroid carcinoma. The Turin proposal published in 2007 suggested three criteria for the diagnosis of PDTC which included the pattern of growth and high-grade features. PDTC presents more frequently with locally invasive extra-thyroidal disease, metastasis to regional lymph nodes and distant organs compared to DTC. Despite the capacity to have RAI uptake, there has been no evidence of significant improvement in survival due to tumor heterogeneity in differentiation. Recent data suggest that age more than 45 years, tumor size more than 4cm, extra-thyroidal extension, higher pathological T stage, positive margins, and distant metastasis predict worse prognosis. Conclusion: Our patient showed an excellent response to therapy in spite of having PDTC with positive margins. We hypothesize that this could be likely due to young age at the time of diagnosis, early detection of tumor while it was localized in the thyroid without distant metastasis as well as heterogeneity in the tumor with differentiated cells that are responsive to RAI. We conclude that with early detection, timely surgery, and adjuvant therapy, excellent prognosis can be achieved in patients with PDTC.

scholarly journals SUN-486 Unusual Presentation of Metastatic Follicular Thyroid Cancer

2020 ◽  
Vol 4 (Supplement_1) ◽  
Author(s):  
Nikoletta Proudan ◽  
Kersthine Andre
Keyword(s):  
Thyroid Cancer ◽  
Thyroid Carcinoma ◽  
Follicular Carcinoma ◽  
Cord Compression ◽  
Whole Body ◽  
Follicular Thyroid Cancer ◽  
Lower Extremity Weakness ◽  
History Of ◽  
The Right ◽  
Work Up

Abstract Distant metastasis of follicular thyroid cancer to the bone has been well documented. However, spinal cord compression as the initial presentation of metastatic follicular thyroid cancer without any thyroid symptoms is relatively rare. Here we discuss such a case. A 78-year-old female with history of HTN and melanoma presented to the ED with a 1-month history of middle back pain that progressed to lower extremity weakness, numbness, and inability to ambulate. MRI showed a T7 vertebral mass with cord compression and edema. Metastatic work up was unremarkable except for incidental bilateral thyroid nodules, the largest on the right lobe, at 1.6 cm, with peripheral calcifications. The patient underwent T6-T7 laminectomy with vertebral decompression, partial colpectomy, and T4-T10 fusion. Pathology of the thoracic vertebral mass was positive for CAM 5.2, cytokeran 7, TTF-1, and PAX8 consistent with either metastatic pulmonary adenocarcinoma or thyroid carcinoma. The patient denied shortness of breath, dysphagia, hoarseness, or neck tenderness. She had no personal history of hyperthyroidism or hypothyroidism, or radiation exposure. She also did not have any family history of thyroid cancer. Laboratory work up was significant for TSH of 3.71 mcU/mL (0.4-4.0 mcU/mL), Free T4 1.56 ng/dL (0.7-1.9 ng/dL), thyroglobulin (Tg) 6940 ng/mL (1.6-55.0 ng/mL), and thyroglobulin antibody (Tg Ab) 20 IU/mL (0-115 IU/mL). FNA of the right thyroid nodule showed follicular neoplasm with very similar morphological features to the epidural pathology, favoring a follicular carcinoma. She underwent total thyroidectomy. Pathology showed a 1.6 x 1.1 cm follicular carcinoma with capsular and angiolymphatic invasion, but with uninvolved margins of resection. TNM staging was pT1b, pNx, pM1. She was ablated with 109 mCi of I-131 after withdrawal therapy. Whole body scan after treatment revealed radioiodine avid metastatic disease at T7 and activity in the thyroid bed compatible with residual thyroid tissue. Patient completed 10 fractions of external beam radiotherapy to the spine for a total of 30 Gy. Three months follow up lab work showed Tg 580 ng/mL and negative Tg Ab with a suppressed TSH. Thyroid bed ultrasound did not show any residual tissue or abnormal lymph nodes. Ten-year survival rates in patients with bony metastatic differentiated thyroid cancer range from 13-21% (1). Metastatic thyroid carcinoma should be considered in the differential diagnosis of every patient with new onset bony metastasis and thyroglobulin should be considered as a tumor marker in the initial work up. Research shows increased survival with I-131 avidity and complete bone metastasis resection (1). 1. Ramadan, Sami et al. “Spinal metastasis in thyroid cancer.” Head & neck oncology vol. 4 39. 25 Jun. 2012, doi:10.1186/1758-3284-4-39

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