Birsen Unsal Koyuncu, Hasan Altunbas

Akdeniz University School of Medicine, Division of Endocrinology and Metabolism, Antalya, TURKEY

Anahtar Kelimeler: Erkek, anaplastik tiroid karsinom, tiroidit, boyun ağrısı

Özet

Giriş: Anaplastik tiroid karsinomu tüm tiroid kanserlerinin %2-5’ini oluşturur. Kadınlarda daha sık görülür. Burada boyun ağrısı ile başvuran, hızlı büyüyen anaplastik tiroid kanserli erkek hasta olgusunu sunuyoruz.
Olgu: 62 yaşında erkek hasta, subakut tiroidit tanısını taklit eden boyunda ağrı ve hassasiyeti ile başvurdu. 1 ay glukokortikoid tedavisini takiben ağrı ve hassasiyeti devam etti. Yapılan tiroid ince iğne aspirasyon biyopsisi tiroidin andiferansiye anaplastik karsinomu ile uyumlu geldi.
Sonuç: Glukokortikoid tedaviye yanıt alınamayan ağrılı tiroid durumunda, anaplastik tiroid karsinom tanısını da akılda tutmak gerekir.

Giriş

Anaplastic thyroid carcinoma constitutes 2-5% of all thyroid cancers(1). Mean diagnosis age is 65 and is more commonly seen in women(1). Rarely, the rapid growth of the thyroid tumor causes thyroiditis, hyperthyroid symptoms, and neck pain and sensitivity(2). In this article, we present a case of a male patient with rapidly growing anaplastic thyroid carcinoma.

Olgu Sunumu

A 62-year-old male patient presented with a two-month history of sudden neck swelling, pain, tenderness and difficulty with swallowing. The patient had a history of euthyroid nodular goiter. He has been taking prednisolone for one month due to a diagnosis of subacute thyroiditis. His symptoms persisted despite the treatment and he was admitted to our clinic for further evaluation.

On physical examination, he was found to have firm, fixed, bilateral, asymmetrically enlarged, tender thyroid with nodules as well as left cervical lymphadenopathy. On thyroid ultrasonography, there were a large hypoechoic areas with nodules which the largest one being 35 mm, in both thyroid lobes and isthmus. There were multiple hypoechoic lymph nodes with the largest one measuring 9x24 mm in size in the left jugular chain. TSH: <0.005 uIU/ml (normal range; 0.27 to 4.2), FT4: 2.4 ng/dl (normal range; 0.93-1.70), FT3: 3.2 pg/ml (normal range; 1.8-4.6) were found. Thyroid autoantibodies were positive. On thyroid scintigraphy, hetergenuously distributed low level activity in both lobes with hypoactive nodules in the left lobe and active nodular appearance in the right superior lobe were detected. Fine needle aspiration biopsy of the thyroid was compatible with undifferentiated anaplastic thyroid carcinoma (Figure 1). Invasion of the trachea and bilateral metastatic paratracheal lymphadenopathies in the neck and in the mediastinum were detected on FDG-PET. The patient was regarded as inoperable case and was treated with radiotherapy. Then he was referred to Oncology Department for chemotherapy.

Tartışma

Almost all patients with anaplastic thyroid carcinoma are admitted to the hospital with rapidly growing thyroid mass (85%). In 90% of patients, regional or distant metastases are detected at the time of diagnosis.(5) Neck pain and tenderness, dyspnea as a result of invasion (35%), dysphagia (30%), hoarseness (25%) and hemoptysis (25%) are found in patients.(2) Rarely, rapid growth of tumor causes thyroiditis, hyperthyroid symptoms, severe neck pain and sensitivity. There are normal serum thyroid hormone levels and TSH concentrations in most patients except in thyroiditis and thyrotoxicosis accompanied by rapid tumor growth and tissue desctruction.(3) In our case, a male patient was admitted with rapidly progressive symptoms seen rarely in the literature.

There is no effective treatment for metastatic anaplastic thyroid cancer and the disease is often fatal.(4) Median survival is 3 to 7 months after diagnosis. Due to the advanced level of cancer at the time of diagnosis, there is no role for surgery in the treatment.(5) Patients presenting with locally advanced inoperable cancer are recommended to undergo combined radiotherapy and chemotherapy for local control of cancer.(5)

Subacute thyroiditis and cyst/nodule bleeding are thought in occur in fast growing thyroid masses. Our patient was thought to have a thyroid malignancy due to no significant change in tumor size and persistent pain even after one month of steroid therapy. Failure to respond to early steroid therapy also indicated that was likely not subacute thyroiditis. Fine-needle aspiration was not used in the differential diagnosis of a painful thyroid lesion. It is not clear if the hyperactive nodule in superior right lobe was related to thyrotoxicosis in this patient. It was likely due to the thyroiditis caused by widespread anaplastic cancer cells. There are similar reports on this issue in the literature.(6) In general; suppression of the thyroid supports this idea. Our patient’s becoming euthyroid while taking antithyroid therapy can be explained by the effect of high dose steroid therapy taken during radiation. High level of thyroid antibodies may indicate autoimmune thyroid disease. However, antibodies can also be explained by thyroiditis associated with malignancy.

As a conclusion, In patients with painful, firm thyroid lesions, a diagnosis of subacute thyroiditis shouldn’t solely be considered, and patients who undergo glucocorticoid treatment should be followed closely. Fine needle aspiration should be performed to avoid missing anaplastic carcinoma.

Kaynaklar

  1. Akslen LA, Haldorsen T, Thoresen SO, Glattre E. Incidence of thyroid cancer in Norway 1970-1985. Population review on time trend, sex, age, histological type and tumour stage in 2625 cases. APMIS 1990; 98(6):549-558
  2. McIver B, Hay ID, Giuffrida DF, et al. Anaplastic thyroid carcinoma: a 50-year experience at a single institution. Surgery 2001;130(6):1028-1034
  3. Murakami T, Noguchi S, Murakami N, et al. Destructive thyrotoxicosis in a patient with anaplastic thyroid cancer. Endocrinol Jpn 1989;36(6):905-907
  4. Tennvall J, Lundell G, Wahlberg P, et al. Anaplastic thyroid carcinoma: Three protocols combining doxorubicin, hyperfractionated radiotherapy and surgery. Br J Cancer 2002;86(12):1848-1853
  5. Kebebew E, Greenspan FS, Clark OH, et al. Anaplastic thyroid carcinoma. Treatment outcome and prognostic factors. Cancer 2005;103(7):1330-1335
  6. Phillips JS, Pledger DR, Hilger AW. Rapid thyrotoxicosis in anaplastic thyroid carcinoma. J Laryngol Otol 2007; 121 (7): 695-697