An 87-year-old woman was referred to our department for a 15 cm right-sided cervical tumor with bleeding and skin ulceration, developed on a 6 cm papillary thyroid carcinoma diagnosed two years earlier. Surprisingly, there were no other compressive symptoms. Unexpectedly, but successfully, total thyroidectomy and neck dissection were performed. There were no poorly differentiated or anaplastic components in the final histological analysis. Impressive dehiscence occurred shortly after surgery and was also successfully managed. Our case highlights the benefit of considering surgery in the context of a tertiary care center even for an apparent massive aggressive cervical mass and despite old age.
An 87-year-old woman was referred to our department for a 15 cm right-sided cervical tumor with bleeding skin ulceration, signs of local infection (Fig. 1, panel A and B), and limited cervical mobility. Surprisingly, there were no other compressive symptoms. The patient had refused surgery on a 6 cm-papillary thyroid carcinoma (PTC) diagnosed 3 years earlier. Initially, considering the size of the tumor, anaplastic or at least poorly differentiated carcinoma was suspected. Unexpectedly, but successfully, total thyroidectomy and central and right lymph node dissection were performed. During surgery, the subhyoid muscles and right internal jugular vein had to be excised due to cancer invasion, but the tumor was easily removed from the pharyngeal, esophageal, or tracheal structures. The patient suffered from initial dysphonia and moderate dysphagia, resulting from right recurrent paralysis. The right parathyroids could not be preserved, but hypocalcemia was easily controlled. The right facial nerve was damaged resulting in permanent right facial paralysis. As the skin suture was under great tension, a 6 cm dehiscence occurred 8 days after surgery (Fig. 1, panel C) and was treated with a skin flap (Fig. 1, panel E). The patient’s neck mobility was rapidly recovered. The skin flap was not planned at the time of definitive excision as the tumor was infected and complete resection seemed an unlikely possibility. The histological analysis revealed a 16 cm PTC (Fig. 1, panel D) with polymorphic, well-differentiated subtypes (classic variants, tall cells, Warthin-like variant, columnar cells) extending to the skin, with cervical lymphadenopathies of up to 2.9 cm in diameter, in the right lateral areas, pT4a(m)N1b (20/28). Despite the impressive clinical presentation, there were neither poorly nor undifferentiated components observed. B-Raf c.1799T>A (p.Val600Glu) (BRAFV600E) and telomerase reverse transcriptase C228T (TERTC228T) promoter mutations, identified on fine-needle aspiration (washed-out solution), are known for being predictive of radioiodine resistance (1). Considering both mutations and the patient’s advanced age and low autonomy, the multidisciplinary panel agreed to avoid iodine treatment. Post-operative 3-month evaluation showed an empty thyroid bed (Fig. 1, panel F) with unthreatening lymphadenopathies and stable subcentimetric pulmonary nodes with thyroglobulin concentration at 0.4 µg/L and positive anti-thyroglobulin antibodies at 3451 UI/mL (n < 40 UI/mL) under levothyroxin treatment.
Our case highlights the benefit of considering surgery in the context of a tertiary care center even for an apparent massive aggressive cervical mass and despite old age. At 7 months from the initial surgery, the patient was free of any symptoms related to the remaining metastatic disease, and her vital functions were preserved.
Declaration of interest
The authors declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of this case report.
This study did not receive any specific grant from any funding agency in the public, commercial, or not-for-profit sector.
Consent was obtained from each patient or subject after a full explanation of the purpose and nature of all procedures used.
Author contribution statement
Lucie Allard and Camille Buffet designed the work, interpreted the data, and drafted the work. All authors made substantial contributions to the conception of the work, revised it critically, gave the final approval for the version to be published, and agreed to be accountable for all aspects of the work.
The authors thank Liz Atzel and Fabiana Pani for editing the English version of the manuscript.
Liu J, Liu R, Shen X, Zhu G, Li B, Xing M. The genetic duet of BRAF V600E and tert promoter mutations robustly predicts loss of radioiodine avidity in recurrent papillary thyroid cancer. Journal of Nuclear Medicine 2020 61 177–182. (https://doi.org/10.2967/jnumed.119.227652)
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