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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?
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