Atypical cervical mass

Abstract

Hemoptysis as first sign of a thyroid differentiated cancer represents an atypical behavior of a cervical mass, usually associating lung metastasis or direct tracheal invasion. Late presentation (for instance, due to COVID-19 pandemic circumstances) associates a poor prognosis. This is a case report. We aim to introduce a 70-year old female case who was admitted for an atypical cervical mass associating hemoptysis as onset; the diagnostic of metastatic papillary thyroid cancer was established; the delay of hospital admission did not allow a radical intervention with curative purpose. The lady was admitted as an emergency for an endocrine checkup of a progressively growing cervical mass in addition to hemoptysis that developed a few weeks before. Specific blood endocrine panel confirmed the normal thyroid function with negative thyroid autoimmunity. Anterior cervical ultrasound showed intensely hypoechoic, inhomogeneous, large structure, with macro-calcifications (TIRADS 5). Fine needle aspiration cytology exam revealed a papillary carcinoma of thyroid, consistent with Bethesda 6 score. Computed tomography detected a voluminous thyroid tumor process of 92 by 58 by 89 mm. The superior, middle and inferior left later-cervical lymph nodes which are located posterior to the later-cervical vascular package, have maximum diameters of approximately 30/34 mm (axial) and 54 mm (vertical). Multiple micro-nodules of oval form in both lungs have diameters up to 29 mm (probably secondary lesions). Osteolytic tumor lesion at the level of the lateral arch of the vertebral body thoracic T 1 and the head of the left first rib extends to the level of the left foramen from the spaces cervical C7 to thoracic T1, respective between thoracic T1 and T2, with maximum diameters of 23/32 mm. CT also showed brain metastasis, as a iodophil, inhomogeneous, well-contoured tumor that is located on the right frontal precentral gyrus, with maximum diameters of 10/13 mm (axially) and 13 mm (vertically) and small areas of perilesional edema. Further adjuvant therapy was refused by the patient; palliative tracheostomy is needed. Atypically aggressive presentation of well differentiated thyroid cancer of papillary type might be associated with delayed presentation; whether this comes as direct consequence of pandemic era is still a matter of debate.