Occult Retrosternal Anaplastic Thyroid
NL Berridge, F Pakzad, R Stanbridge (1), FF Palazzo – Department of
Endocrine Surgery & Department of Cardiothoracic Surgery (1)
Hammersmith Hospital, London, UK.
Anaplastic thyroid carcinoma (ATC) is the most aggressive variant of thyroid malignancy; it represents less than 2% of thyroid cancers. ATC usually manifests as rapid enlargement of a pre-existing goitre in a patient in their 6th decade onwards. Almost invariably patients with ATC have a poor prognosis.
We report a case of 70-year-old gentleman who presented with a several month history of productive cough and orthopnoea whilst undergoing chemotherapy for Chronic Lymphoid Leukaemia. Examination of the neck was reported as unremarkable. A CT chest demonstrated a large retrosternal goitre with tracheal deviation. Fine needle aspiration cytology was suggestive of a papillary thyroid cancer for which he was referred to the Department of Endocrine Surgery at Hammersmith Hospital. He was seen within 2 weeks by which time his respiratory symptoms had rapidly deteriorated into overt stridor. Following urgent admission a repeat CT demonstrated marked tracheal compression. An emergency tracheal stent was successfully placed and an ultrasound guided core biopsy was performed. This demonstrated an undifferentiated histological architecture compatible with an ATC. Plans were made for the patient to undergo urgent chemotherapy however he passed away 2 weeks after diagnosis due to airway obstruction from stent migration.
Incidentally asymptomatic retrosternal goitres are not an uncommon finding during cross-sectional imaging studies. Most retrosternal goitres are benign however this cannot be guaranteed without tissue sampling. Hence, the early diagnosis of differentiated thyroid cancer prior to aggressive transformation in the elderly will improve outcomes.
Compared to other reported cases, this unusual presentation of ATC should be recognized. It highlights the rapid progression of ATC and that instituting early combined multimodality management would impact favourably on the local control rate and may avoid death from suffocation.