Case report:
A 65-year-old patient presented to our service with a left-sided
basi-cervical swelling that had been evolving for 4 months. The swelling
had progressively increased in size over the last 2 months, causing
dysphagia. The swelling was 8 cm in diameter, with indistinct margins,
immobile during swallowing, and had both indurated and soft areas. It
was fistulized to the skin.
The blood count showed hyperleukocytosis of 13,600 cells/mm3 (85%
neutrophils, with lymphopenia: 8.5% lymphocytes, i.e., 1,200/mm3),
normocytic normochromic anemia with a hemoglobin level of 9.3 gr/dl, and
platelets of 307,000/mm3. CRP was high at 69 mg/L.
Cervical computed tomography showed a necrotic mass in the left lobe of
the thyroid compressing the airway, communicating with a second necrotic
mass in the subcutaneous tissue of the anterolateral cervical region,
extending to the left sternocleidomastoid muscle. This mass was
fistulized to the skin and initially suggested cervical tuberculosis
(Fig 1 ).
When the subcutaneous mass was punctured and incised, pus and whitish
material resembling caseous tuberculosis were discovered. The biopsies
of the fistula margins and the abscess wall concluded a non-specific
granulomatous lesion. Acid-fast
bacilli (AFB) PCR was negative.
For 15 days, the patient received antibiotics intravenously. A
regression of local inflammatory signs and biological inflammatory
syndrome were noted. However, the mass increased in size, softened, and
friable tumor tissue showed up at the permeation orifice.
A second biopsy of this tissue revealed an anaplastic thyroid carcinoma.
Immunohistochemical analysis showed tumor cells expressing keratin, EMA,
and PAX8 diffusely and intensely. Tumor cells were focally positive for
TTF1 (Fig 2 ).
A second computed tomography showed tumor growth in the left thyroid
mass invading the esophageal wall, prevertebral plane, and covering more
than half of the circumference of the left internal carotid artery.
Suspect bilateral jugulo-carotid lymph nodes had also appeared
(Fig 3 ).
Both a PET scan and a thoraco-abdomino-pelvic computed tomography did
not reveal any distant hypermetabolic foci. Following a
multidisciplinary consultation meeting,
the patient was referred for
radio-chemotherapy due to the inoperability of the tumor.