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F-18 FDG-PET-CT in the Diagnostic of a Late Medullary Thyroid Carcinoma Recurrence in a Patient with Follicular-Papillary Thyroid Cancer  [PDF]
Doina Piciu,Andra Piciu
Case Reports in Endocrinology , 2014, DOI: 10.1155/2014/741262
Abstract: Mixed medullary and follicular or papillary carcinoma of thyroid is an extremely rare tumor, characterized by coexistence of morphological and immunohistochemical features of both medullary carcinoma and follicular (or papillary) carcinoma. This case report describes for the first time in the indexed database a late recurrence of a medullary thyroid carcinoma initially diagnosed as follicular-papillary form, treated and monitored accordingly. After 14 years, a superior mediastinum tumor was discovered incidentally at a thorax computer tomography. The whole-body I-131 scan was negative and F-18 FDG-PET-CT showed glucose avidity of the tumor. The patient was operated on and the histology revealed medullary thyroid carcinoma. If there are no possibilities to have routinely extensive immunohistologic profiles, it is recommended to check the serum calcitonin, at least in any patient with confirmed thyroid carcinoma. 1. Introduction Thyroid carcinoma is the most frequent endocrine cancer, accounting for about 5% of thyroid nodules [1] with a general incidence reported to be between 1.2 and 3.8 100.000 inhabitants [2, 3]. The differentiated thyroid cancers represent about 80% of all thyroid cancers [2], with a good prognosis [4, 5], while medullary, respectively, anaplastic forms, with considerable lower incidences [1, 6–9], have an aggressive evolution, frequently very severe and fast. The mixed forms are very rare and considered to be of different cell origins, with specific clinical behaviours [10–15]. Considered rare among human malignancies, the thyroid carcinoma has a very important increasing incidence in the last 10 years [3, 16], reported by studies from all over the world, with the fact that requires a new approach regarding the management of this pathology and special attention to the unusual or more aggressive forms. 2. Case Presentation A 67-year-old male was admitted to our institute with the diagnostic of multiple cervical lymph nodes and right thyroid nodule. He was submitted to total thyroidectomy, with selective right lymphadenectomy for a follicular-papillary thyroid carcinoma with right cervical lymph nodes metastasis, T3N1?M0, stage III, according to the TNM of the moment [17]. At 4 weeks after the surgery, without thyroid hormone replacement the patient was evaluated prior to the metabolic irradiation with I-131. Therefore, the serum level of the thyroid-stimulating hormone (TSH) was >100?mIU/L, increased; the thyroglobulin (Tg) specific tumor marker was 13.2?ng/mL (N.V. < 0.1?ng/mL, undetectable in case of cured patients); the
Collision tumor of the thyroid: follicular variant of papillary carcinoma and squamous carcinoma
Rohan R Walvekar, Subhadra V Kane, Anil K D'Cruz
World Journal of Surgical Oncology , 2006, DOI: 10.1186/1477-7819-4-65
Abstract: A 65 year old woman presented with a large thyroid swelling of 10 years duration and with swellings on the back and scalp which were diagnosed to be a follicular variant of papillary thyroid carcinoma with metastasis. Clinical examination, radiology and endoscopy ruled out any other abnormality of the upper aerodigestive tract. The patient was treated surgically with a total thyroidectomy with central compartment clearance and bilateral selective neck dissections. The histopathology revealed a collision tumor with components of both a follicular variant of papillary carcinoma and a squamous carcinoma. Immunohistochemical analysis confirmed the independent origin of these two primary tumors. Adjuvant radio iodine therapy directed toward the follicular derived component of the thyroid tumor and external beam radiotherapy for the squamous component was planned.Collision tumors of the thyroid gland pose a diagnostic as well as therapeutic challenge. Metastasis from distant organs and contiguous primary tumors should be excluded. The origins of squamous cancer in the thyroid gland must be established to support the true evolution of a collision tumor and to plan treatment. Treatment for collision tumors depends upon the combination of primary tumors involved and each component of the combination should be treated like an independent primary. The reporting of similar cases with longer follow-up will help define the epidemiology, biology and establish standardized protocols for treatment of these extremely rare tumors.Collision tumors within the thyroid gland are extremely rare and reported cases have mixed histologies of follicular or papillary and medullary carcinomas [1]. The co-existence of a follicular variant of a papillary carcinoma and squamous carcinoma in the thyroid gland is unique. Detailed histopathological and immunohistochemical studies solve the questions that pertain to the origins of these tumors. Collision tumors such as the one presented, especially wit
Hypercalcitoninemia is not pathognomonic of medullary thyroid carcinoma
Toledo, Sergio PA;Louren?o Jr, Delmar M;Santos, Marcelo Augusto;Tavares, Marcos R;Toledo, Rodrigo A;Correia-Deur, Joya Emilie de Menezes;
Clinics , 2009, DOI: 10.1590/S1807-59322009000700015
Abstract: hypercalcitoninemia has frequently been reported as a marker for medullary thyroid carcinoma. currently, calcitonin measurements are mostly useful in the evaluation of tumor size and progression, and as an index of biochemical improvement of medullary thyroid carcinomas. although measurement of calcitonin is a highly sensitive method for the detection of medullary thyroid carcinoma, it presents a low specificity for this tumor. several physiologic and pathologic conditions other than medullary thyroid carcinoma have been associated with increased levels of calcitonin. several cases of thyroid nodules associated with increased values of calcitonin are not medullary thyroid carcinomas, but rather are related to other conditions, such as hypercalcemias, hypergastrinemias, neuroendocrine tumors, renal insufficiency, papillary and follicular thyroid carcinomas, and goiter. furthermore, prolonged treatment with omeprazole (> 2-4 months), beta-blockers, glucocorticoids and potential secretagogues, have been associated with hypercalcitoninemia. an association between calcitonin levels and chronic auto-immune thyroiditis remains controversial. patients with calcitonin levels >100 pg/ml have a high risk for medullary thyroid carcinoma (~90%-100%), whereas patients with values from 10 to 100 pg/ml (normal values: <8.5 pg/ml for men, < 5.0 pg/ml for women; immunochemiluminometric assay) have a <25% risk for medullary thyroid carcinoma. in multiple endocrine neoplasia type 2 (men2), ret mutation analysis is the gold-standard for the recommendation of total preventive thyroidectomy to relatives at risk of harboring a germline ret mutation (50%). false-positive calcitonin results within men2 families have led to incorrect indications of preventive total thyroidectomy to ret mutation negative relatives. in this review, we focus on the differential diagnosis of hypercalcitoninemia, underlining its importance for the avoidance of misdiagnosis of medullary thyroid carcinoma and conseq
Simultaneous medullary and papillary thyroid cancer: two case reports
Gianlorenzo Dionigi, Patrizia Castano, Valentina Bertolini, Luigi Boni, Francesca Rovera, Maria Tanda, Carlo Capella, Luigi Bartalena, Renzo Dionigi
Journal of Medical Case Reports , 2007, DOI: 10.1186/1752-1947-1-133
Abstract: This paper describes two rare cases of the simultaneous occurrence of MTC and PTC in the thyroid gland. Case 1 is unique for different reasons: (a) the patient was affected by both multicentric MTC and PTC; (b) a "composite thyroid carcinoma" with mixed feautures of MTC and PTC carcinomas was found in the istmus of the gland; and (c) these tumors were associated with diffuse lymphocytic-type thyroiditis (LT). Case 2 is notable for the long follow up: 16 years disease free.There are only 16 reports in the English medical literature describing a total of 20 cases of concurrent occurrence of both PTC and MTC in the same thyroid gland. We discuss whether the finding of another cancer in these patients was coincidental or from possible activation of a common tumorigenic pathway for both follicular and parafollicular thyroid cells.Papillary thyroid carcinoma (PTC) is the most common histological type of thyroid cancer (75–80%) [1]. It derives from the follicular cells of the endoderm. [1]. PTC produce thyroglobulins and thyroid hormones [1]. Medullary thyroid cancer (MTC) represents only 5–8% of cases [2]. MTC has a different embryological origin: it derives from parafollicular cells of the ultimobranchial body of the neural crest. MTC secrets calcitonin and other hormonal peptides and is considered part of the amine precursor uptake and decarboxilation system of the thyroid [2]. MTC may occur either as a hereditary or a nonhereditary entity. Hereditary MTC can occur either alone as familial MTC (FMTC) or as the thyroid manifestation of multiple endocrine neoplasia type 2 syndromes [2].Thyroid carcinoma is frequently associated with genetic alterations. Activating point mutations of RET proto-oncogene have been demonstrated to be causative of the familial form of medullary thyroid cancer, both as isolated FMTC and associated to MEN 2A and 2B [2]. Somatic rearrangements of RET designated as RET/PTC (from papillary thyroid carcinoma) were identified in papillary thyroid car
A unique RET EXON 11 (G691S) polymorphism in an Indian patient with a collision tumor of the thyroid
Bharat Rekhi, Rakesh R Badhe, Maria Desouza, Devendra Chaukar, Anil K D'Cruz, Suprita Arya, S V Kane
Diagnostic Pathology , 2007, DOI: 10.1186/1746-1596-2-39
Abstract: A 59 year old lady presented with a neck mass, associated with hoarseness of voice of 5 years duration. Radiological examination revealed nodular masses in the left lobe of her thyroid, along with one in the isthmus, extending into the right lobe and associated with enlarged neck nodes. FNAC from the left thyroid showed features of medullary carcinoma. On total thyroidectomy, 2 distinct tumor nodules were identified in the left lobe with another in the isthmus, showing features of medullary carcinoma (MTC), papillary carcinoma and follicular variant of papillary carcinoma, respectively, accompanied with nodal metastasis. Subsequently, she underwent radioablation. RET gene analysis of the patient, her 2 daughters and a grandson revealed a unique G691S polymorphism on Exon 11.This unique case of a collision tumor of thyroid, including component of an MTC deals with the value of RET gene analysis and therapeutic implications in the index case and in family members.The two discrete functional cellular components of a thyroid gland i.e. follicular epithelium and parafollicular C cells give rise to distinct neoplasms i.e. differentiated follicular or papillary thyroid carcinoma (PTC), from the former type and a medullary thyroid carcinoma (MTC) from the latter type of cells [1]. A MTC manifests either in sporadic or in hereditary form; the latter occurs as an isolated familial MTC or as a part of a multiple endocrine neoplasia (MEN I and II) syndrome [2]. Varying admixture of the two cell types, designated as a mixed tumor, is uncommon, but reported in a substantial number of cases [3-6]. This entity has also been recognized in the WHO classification of thyroid tumors1. However, occurrence of distinct tumor nodules, without an intermingling of the cell types, known as a 'collision' or a 'concurrent' thyroid tumor that represents < 1% of all thyroid malignancies, has been reported as few case reports [7-10]. Further, only occasional case reports have dealt with the genetic
Carcinoma misto medular-papilar de tireóide: relato de caso
Sousa, Maísa S.;Soares, Edson G.;Halah, Fernanda P.B.;Maciel, Léa M.Z.;
Arquivos Brasileiros de Endocrinologia & Metabologia , 2001, DOI: 10.1590/S0004-27302001000600016
Abstract: cases of mixed medullary-papillary carcinoma are rare and have not been classified by who. we report a 32yo patient who had a diagnosis on cytological analysis by fine needle biopsy as hürthle cell neoplasm with probable metastases to cervical nodules, due to the presence of numerous isolated cells of an oxyphilic pattern. after total thyroidectomy, on histology, a mixed medullary-papillary carcinoma with oxyphilic differentiation was diagnosed based on the papillary arrangement with fibrovascular septa containing cells showing a predominant oxyphilic pattern, both in the thyroid nodule and in regional cervical lymph nodes. amorphous material of amyloidal aspect, which stained positively for congo red, accompanied by focal calcification, was observed, both in the primary tumors and in the metastases. thyroglobulin was not immunostained in the cells obtained by fine needle aspiration biopsy, but was immunostained in histology fields, both in the thyroid nodules and in the metastases. the immunoreaction for calcitonin was predominant on cytologic analysis and in the hystologic exam of the primary tumor and metastases. dual differentiation in thyroid neoplasms has been interpreted as indicative of a common stem cell origin. it has been reported that the ultimobranchial body in man contributes both with c-cells and follicular cells to the thyroid. thus, a common stem cell could give rise to such a mixed medullary-papillary neoplasm.
Ocurrencia simultánea de Carcinoma Tiroideo Papilar, folicular y medular en paciente con bocio recidivante.
de Miliani,Yhajaira Zerpa; Uzcategui,Lilia Rosa; Miliani,Nelson; Gomez-Perez,Roald;
Revista Venezolana de Endocrinología y Metabolismo , 2007,
Abstract: abstract objectives: to report an unusual case of a 49 year old patient with recurrent goiter and the simultaneous presence of three types of histological thyroid cancer. clinical case: a 49 year old female patient, with the presence of recurrent goiter. there was no history of head or neck irradiation, nor a family or personal history of endocrine neoplasia or others. a subtotal thyroidectomy was preformed in 1986 for benign tumor, without medication of substitutive therapy with l-tiroxine. there was a recurrence of the goiter which was deformant with compressive symptoms and biochemical hypothyroidism (tsh:50uui/ml and t4l:0.03 ng/dl), the fine needle aspiration biopsy reported possible papillary carcinoma. the thyroid ultrasound revealed a right thyroid lobe with volume greater than 16.8 cc, with multiple cervical lymph nodes to the left side with extensions to the lateral anterior mediastinum. the x-ray of the thorax was normal. a total thyroidectomy was performed with modified radical dissection to the left side of the neck of the levels ii to vi. the histological results showed: a) hashimoto thyroiditis, b) mixed carcinoma: follicular, papillary and solid areas with affinity for congo red dye which is characteristic of amyloid compatible with medullary carcinoma, c) left cervical lymph nodes with metastases of thyroid carcinoma predominantly medullary and follicular carcinoma and d) mediastinal lymph node metastases of follicular carcinoma of thyroid . radioiodine therapy was performed with 200 mci of i131. the serum calcitonin was 1282 pg/ml and post-surgical ultrasound of the thyroid showed vascularity and retroesternal loe, since there was persistence of the tumor, a new cervicothomy was performed to complete the dissection of the lymph nodes from level vii, with histological findings of medullary carcinoma. levothyroxine therapy was indicated and thirty sessions of radioactive therapy were completed, with levels of post-radioactive calcitonin of 30 pg/ml,
Unusual histologic type of medullary carcinoma of thyroid: A case report
Haery H,Asady Amoli F
Tehran University Medical Journal , 1999,
Abstract: In this paper we have reported and discussed an unusual histopathologic feature of medullary carcinoma which is one of the pitfalls in the diagnosis of this tumor. The patient was a 14 years old girl who complained of painless, gradually growing cervical mass from one year ago. She had no history of head and neck radiotherapy of familial history of thyroidal or other endocrine disease. In laboratory investigations a cold thyroid nodule was confirmed and FNA of it was reported as follicular lesion. The patient underwent lobectomy isthmectomy with frozen section wich was reported as Hurthle neoplasm and then the other lobe of patient's thyroid resected. In it's pathologic exam another nodule was observed which mostly composed of spindle cells; at last histochemically medullary carcinoma confirmed
Medullary and papillary carcinoma of the thyroid gland occurring as a collision tumor with lymph node metastasis: A case report
Mehr Sadat Alavi, Negar Azarpira
Journal of Medical Case Reports , 2011, DOI: 10.1186/1752-1947-5-590
Abstract: A 32-year-old Iranian man presented with a fixed anterior neck mass. Ultrasonography revealed two separate thyroid nodules as well as a suspicious neck mass that appeared to be a metastatic lesion. The results of thyroid function tests were normal, but the preoperative calcitonin serum value was elevated. Our patient underwent a total thyroidectomy with neck exploration. Two separate and ill-defined solid lesions grossly in the right lobe were noticed. Histological and immunohistochemical studies of these lesions suggested the presence of medullary thyroid carcinoma and papillary thyroid carcinoma. The lymph nodes isolated from a neck dissection specimen showed metastases from both lesions.The concomitant occurrence of papillary thyroid carcinoma and medullary thyroid carcinoma and the exact diagnosis of this uncommon event are important. The treatment strategy should be reconsidered in such cases, and genetic screening to exclude multiple endocrine neoplasia 2 syndromes should be performed. For papillary thyroid carcinoma, radioiodine therapy and thyroid-stimulating hormone suppressive therapy are performed. However, the treatment of medullary thyroid carcinoma is mostly radical surgery with no effective adjuvant therapy.Papillary thyroid carcinoma (PTC) and medullary thyroid carcinoma (MTC) are two different thyroid neoplasia. The former originates from thyroglobulin-producing follicular cells, whereas the latter arises from calcitonin-producing cells. MTC is a rare tumor that arises from neural crest-derived parafollicular C cells. Tumors showing both features are rare and represent less than 1% of all thyroid malignancies [1] and have different patterns of clinical presentation and biological behavior. A review of the literature revealed similar lesions [1-11]. Mutations in the RET gene, rearrangements of the tyrosine kinase receptors RET (ret/PTC) and NTRK1, and point mutation of the BRAF gene have been documented in PTC tumors [12-15]. However, the exact patho
Follicular thyroid carcinoma  [PDF]
Krgovi? Ksenija Lj.,Paunovi? Ivan R.,Dikli? Aleksandar ?.,?ivaljevi? Vladan R.
Acta Chirurgica Iugoslavica , 2003, DOI: 10.2298/aci0303107k
Abstract: Follicular thyroid cancer is the second most common thyroid malignancy. This tumor has a predisposition for hematogenous dissemination an extrathyroid spread. Accurate cytological diagnosis of follicular thyroid cancer is not possible and this fact highlights the necessity for surgical treatment of any suspicious thyroid nodule. Aggressiveness of this tumor is greater than in the case of papillary thyroid cancer and it is the reason for radical surgical treatment of follicular thyroid cancer. Total thyroidectomy facilitates later adjuvant therapy with thyroid hormones and radioiodine. This procedure improves the outcome and the risk of relapse. Results of our study clearly demonstrate that diagnosis of follicular thyroid cancer in us is established in the early phase of the disease (78.57%), but the significant number of the patients (21.43%) is still in the advanced phase of the disease.
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