Anterior Cervical Mass

Prof. Suhail Al-Salam, MBChB, FRCPath

Department of Pathology, CMHS, UAEU

Consultant Pathologist, Tawam Hospital

A 67-year-old patient with type 2 diabetes

Lower anterior neck mass of 10 cm diameter

4 months duration,

Past Medical History 2014: diagnosed with well differentiated papillary

thyroid carcinoma which was treated with subtotal

thyroidectomy followed by Radioactive I 131 100 Mci,

post treatment follow up thyroid scan was negative

for residual or metastatic disease.

2016: patient had recurrent thyroid tumor and he

underwent for re-surgery and therapeutic dose 30

Mci of radioactive I 131.

March 2017 patient underwent 3rd surgery due to

recurrent disease, and was considered as radioactive

Iodine refractory thyroid carcinoma and started on

Sorafenib for 3 months completed on May 2017 but

clinically he was not responding as the tumor

increasing in size progressively.

CT Head &Neck

The mass was unresectable and biopsy

was taken,

CYTOKERATIN EMA

VIMENTIN THYROGLOBULIN

PAX8 TTF1

P63 KI67

Differential Diagnosis

Recurrent Papillary carcinoma

Anaplastic Thyroid Carcinoma

Metastatic carcinoma

Anaplastic Thyroid Carcinoma Undifferentiated carcinoma of thyroid gland

2% of thyroid cancers but 40% of thyroid cancer deaths

Rapidly enlarging, bulky neck mass invades adjacent

structures causing hoarseness, dysphagia, dyspnea

Three histologic patterns:

Large, pleomorphic giant cells resembling osteoclasts with

cellular connective tissue septa,

Spindle cells resembling sarcoma

Squamoid cells that are relatively undifferentiated but also

appear epithelial with occasional focal keratinization

(Am J Surg Pathol 1991;15:160)

(Int.J.Endocrinoloy 2014;790834:1-13)

Pathogenesis

Anaplastic transformation of papillary,

follicular or Hürthle cell carcinoma,

Most cases have a core of conserved

mutations in well differentiated and

anaplastic areas, plus increases in

mutation rates in anaplastic areas

(Am J Surg Pathol 2003;27:1559)

Sugitani et al. has reported that almost

1% of PTC may progress to ATC

(World J Surg. 2012; 36(6):1247-54.)

Signaling Pathways

Molecular Changes Associated with aggressive

behavior and Anaplastic thyroid carcinoma

BRAF (V600E) mutation

TERT mutation

TP53 mutation

NRAS

KRAS

(J Oncol Pract. 2016 Jun;12(6):511-8)

Conclusions

Papillary thyroid carcinoma can

progress to Anaplastic carcinoma

Cytokeratin, vimentin, PAX8, TTF1,

thyroglobulin and p63 are good primary

panel for solving the differential

diagnosis

A combined BRAF&TERT mutations in

a papillary carcinoma caries a high risk

of recurrence and anaplastic

transformation

Thank you

Do you have

any question?