J Endocr Surg.  2020 Mar;20(1):3-11. 10.16956/jes.2020.20.1.3.

Anaplastic Transformation of Metastatic Papillary Thyroid Carcinoma in a Cervical Lymph Node: a Timeline and Short Review

• Cinamon U
• Horev Y
• Vaknine H

• KMID: 2471988
• DOI: http://doi.org/10.16956/jes.2020.20.1.3

Abstract

Anaplastic thyroid cancer (ATC) is accepted as the transformation of a pre-existing glandular papillary thyroid carcinoma (PTC). Anaplastic transformation of a neck PTC metastasis in a lymph node is extraordinary. We present a patient with an exceptional timeline of an untreated neck PTC recurrence in a lymph node and its rare anaplastic transformation. A 68-year-old patient with PTC and neck metastasis, (stage III/II 7th/8th American Joint Committee on Cancer [AJCC], respectively) underwent thyroidectomy and neck dissection in July 2010, followed with radioiodine treatment (150 mCi) (August 2010). He received an additional 150 mCi in June 2012, because an iodine scan suggested right neck recurrence. In October 2013, an ultrasound revealed a 2.3 cm, suspicious right neck lymph node (level II-III). Yet only in 2017, after growing to 2.7 cm, the patient consented for a fine needle aspiration. PTC was verified, yet intervention was declined. In June 2018, he presented with a rapid growing neck mass occupying right levels II, III, carotid artery encasement and jugular vein involvement. A large bore needle biopsy revealed a highly malignant tumor, surrounded by necrosis, positive for cytokeratin (CK MNF 116), thyroid lineage marker (PAX8), negative for TTF-1 and thyroglobulin, i.e., ATC. The patient deceased in November 2018. This unique "natural history" of an untreated patient with PTC neck recurrence in a lymph node demonstrated a rare, yet a possible long-term consequence of anaplastic transformation. This case study, in addition to the sparsity of reported information, may advocate treating PTC neck recurrence.

Keyword

Thyroid carcinoma, papillary; Thyroid carcinoma, anaplastic; Neoplastic cell transformation

MeSH Terms

Aged
Biopsy, Fine-Needle
Biopsy, Needle
Carotid Arteries
Cell Transformation, Neoplastic
Humans
Iodine
Joints
Jugular Veins
Keratins
Lymph Nodes*
Neck
Neck Dissection
Necrosis
Neoplasm Metastasis
Recurrence
Thyroglobulin
Thyroid Carcinoma, Anaplastic
Thyroid Gland*
Thyroid Neoplasms*
Thyroidectomy
Ultrasonography
Iodine
Keratins
Thyroglobulin

Figure

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  Fig. 1. Axial ultrasound study of the right neck (October 2014). A 2.3×2.3 cm suspicious lymph node (level III) adjacent to the Jugular vein is demonstrated. The right thyroid bed is empty (*).

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  Fig. 2. An axial neck computed tomography scan frame (June 2018). An 11 cm mass occupies the right neck, level III (*). The mass has central necrosis, encases the carotid artery and involves the Jugular vein.

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  Fig. 3. Coronal computed tomography scan of the neck (June 2018). There is a large mass in the right neck, level III with central necrosis.

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  Fig. 4. Positron emission tomography/computed tomography imaging (July 2018). The study demonstrates the right massive neck involvement including levels VI, VII. There is no obvious chest involvement.

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  Fig. 5. Pathological timeline. Histological characteristics: (A) Metastatic PTC in a cervical lymph node (July 2010). The pinkish papillary fronds (thick arrows) can readily be appreciated, embedded within bluish lymphoid tissue containing several reactive germinal centers (thin arrows; H&E stain ×40). (B) On higher magnification, the cytological features of PTC, such as overlapping of nuclei, nuclear inclusions (thick arrows) and clearance (thin arrows), are evident (H&E stain ×100). (C) Anaplastic transformation. The core biopsy from the cervical mass demonstrates a high-grade epithelial tumor surrounded by necrosis (2018). Note the different appearance from the “original” lymph node metastasis (B) (H&E stain ×200). (D) The anaplastic tumor is positive for cytokeratin (CK MNF 116-IHC ×100). (E) PAX 8 demonstrates positive nuclear staining in about 50%–60% of the cells (PAX 8-IHC ×100). PTC = papillary carcinoma; H&E = haematoxylin and eosin.

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