Case presentation
A 67-year-old female patient presented to our hospital with a history of neck swelling for 1 year and hoarseness for 1 month. The swelling was situated in supraclavicular fossa of the right neck. Right vocal cord paralysis was noted in laryngoscopy. Cervical ultrasonography revealed a lymph node which having a major axis 80mm, elastic rigidity and poor movability in the right clavicle fossa, and neoplastic lesion measured 3 x 3 cm in the left lobe of the thyroid gland. Her serum level of thyroid hormones was normal, while white blood cell was >10000 /μL and anti-thyroglobulin antibody was 214 IU/L. Cervical computed tomography (CT) showed lymph nodes swelling with central necrosis, compression of the right common carotid artery, and invasion to the right internal jugular vein with collapse. Multiple nodular lesions with calcification were also found in the left lobe of the thyroid. Right cervical lymph node was detected by F-18 fluorodeoxyglucose positron emission tomography but no distant metastases. The maximum standardized uptake value was calculated to be 40.5 in cervical lymph node. (figure 1) Fine needle aspiration cytology was performed on the right cervical lymph node and diagnosed as PTC.
With a pre-operative diagnosis of clinical T1bN1bM0 PTC, en-bloc total thyroidectomy and right D2b dissection were performed. The right cervical lymph node was firmly adherent to the surrounding tissue, so the following tissues were resected concurrently; right anterior scalene muscle, right phrenic nerve, right vagus nerve, right internal jugular vein. The operation time was 4 hours and 26 minutes, and the blood loss was 373 ml. Postoperative histological result showed multiple white nodules with calcification in both lobes of the thyroid. The atypical epithelium showing nuclear enlargement was follicular and papillary, and the nucleus was frosted glass with a nuclear groove and intranuclear inclusion bodies, which was a finding of papillary thyroid cancer. On the other hand, the cervical lymph nodes measured 80 × 50 × 50 mm, and metastasis of papillary thyroid cancer was observed. In addition, nuclear enlargement and proliferation of spindle-shaped cells with strong irregular karyotype were observed, which was in agreement with ATC. (figure 2) Based on the above, the final pathological diagnosis was anaplastic transformation of metastatic cervical lymph nodes (pT4bN1bMx, Ex2, R0, pStage IVB).
External radiation therapy was started on 20th days after surgery. WBC and CRP were elevated at the time of 32 Gy irradiation on the 45th days after surgery, and same time, fever and cervical skin metastasis were observed. Chest CT showed multiple lung metastases, right pleural dissemination, and right cancerous pleural effusion. External radiation therapy was discontinued due to rapid deterioration of the condition, and BSC policy was decided. In spite of treatment, she expired due to primary illness on 57th days after surgery.