Tall Cell Variant PTC

Abstract

A 35-year-old gentleman came with a history of swelling in the front of his neck for one and a half years which was gradually increasing in size. He also gave a history of breathlessness and stridor for one and a half months and hemoptysis, 2–3 episodes per month. He was a chronic tobacco smoker, chronic alcoholic but has been abstaining for the last 8 years. On examination, he had a 4 × 4 cm hard solitary thyroid nodule without any deep cervical lymphadenopathy. The FNAC from the thyroid nodule was reported as papillary thyroid cancer. Indirect laryngoscopy showed B/L VC were mobile. CECT showed a 44 × 42 mm necrotic soft tissue mass lesion in the left side of the neck involving the left thyroid gland extending to infra-glottic larynx, infiltration noted over the left thyroid gland and cricoid cartilage and trachea with airway narrowing. He underwent total Thyroidectomy + Tracheostomy + tracheal resection and crico-tracheal anastomosis. Operative findings included adherent strap muscles to the surface of the left lobe of thyroid and growth arising from the left lobe of thyroid and isthmus extending to the intraluminal part of the trachea by invading the cricoid and upper 2 tracheal rings. Total thyroidectomy was performed with en-bloc resection of cricoid and tracheal rings (preserving normal posterior wall of trachea); crico-tracheal anastomosis performed with intermittent 3–0 vicryl sutures. On histology: “the sections from left lobe and isthmus show a tumour disposed in papillary pattern with central fibrovascular core. These cells show nuclear stratification, clearing, grooving, psuedoinclusions in few and granular eosinophilic cytoplasm. Most of these cells are tall, have abundant eosinophilic cytoplasm. The tumour is seen infiltrating the skeletal muscles and trachea. The inferior margin of trachea is also involved. Foci of lymphovascular invasion are seen. The right lobe appears free of tumour.” The patient subsequently received 125 mci RAI since his TG was elevated (166 ng/ml) and RAI scan showed uptake in thyroid remnant and left cervical LN (level II). On follow-up his TG started rising and he became RAI refractory. PET scan revealed hypermetabolic cervical, mediastinal lymphadenopathy with multiple pulmonary nodules suggestive of metastatic disease. He is currently on TKI and his TG values are 53.3 ng/ml (Figs. 1, 2, 3, 4, and 5).