Diagnosis of anaplastic thyroid carcinoma on fine needle aspiration cytology - A rare case report

Diagnosis of anaplastic thyroid carcinoma on FNAC ISSN: 2394-0026 (P)Case Report ISSN: 2394-0034 (O)Diagnosis of anaplastic thyroid carcinoma onfine needle aspiration cytology - A rare case report Mobeen Alwani1, Gunvanti B. Rathod2* 1P.G. Student, Pathology Department, SBKS MI & RC, Sumandeep Vidyapeeth, Vadodara, India2Assistant Professor, Pathology Department, SBKS MI & RC, Sumandeep Vidyapeeth, Vadodara, India *Corresponding author email: [email protected] to cite this article: Mobeen Alwani, Gunvanti B. Rathod. Diagnosis of anaplastic thyroidcarcinoma on fine needle aspiration cytology - A rare case report. IAIM, 2015; 2(3): 183-187. Available online at www.iaimjournal.comReceived on: 17-02-2015 Accepted on: 25-02-2015AbstractAnaplastic thyroid carcinoma [ATC] is a rare highly malignant tumor that arises from the follicularcells of the thyroid gland. It accounts for 1% to 2% of all thyroid carcinomas and patients with ATCuniformly have a poor prognosis. Majority of ATCs show spindle cell, giant cell and squamoid cellpatterns; these 3 subtypes frequently coexist and they are not predictive of the patient’s outcome.Patients often present at an advanced stage, making curative surgical resection not feasible.Recognizing the cytological finding of the ATC and making the prompt and proper cytologicaldiagnosis are helpful to determine the treatment plan for the patients who suffer with this entity.Key wordsAnaplastic thyroid carcinoma, Cytological finding, FNAC.Introduction diagnosis of ATC is usually based on clinical examination and cytology, histology, imagingATC is a rare highly malignant tumor that arises study and immunohistochemical study arefrom the follicular cells of the thyroid gland [1, 2, helpful in establishing the correct diagnosis of3]. It accounts for 1% to 2% of all thyroid ATC [5]. Here we are going to discuss a case ofcarcinomas [4]. Most cases of ATC develop in anaplastic carcinoma of the thyroid, presentingelderly patients and ATC is a rapidly growing as midline neck swelling with presence oftumor [1, 2, 3]. Majority of ATCs show spindle thrombus in jugular vein which is quite rare. Thecell, giant cell and squamoid cell patterns; these aim of this paper is to add more facts about the3 subtypes frequently coexist and they are not ATC.predictive of the patient’s outcome [1, 2]. TheInternational Archives of Integrated Medicine, Vol. 2, Issue 3, March, 2015. Page 183Copy right © 2015, IAIM, All Rights Reserved.

Diagnosis of anaplastic thyroid carcinoma on FNAC ISSN: 2394-0026 (P)Case report ISSN: 2394-0034 (O) Photo – 2: Anaplastic carcinomas of thyroid withA 60 years old female patient presented swelling marked pleomorphic malignant cells. (H & Ein the midline of neck since last three months Stain, 20X)which was associated with pain, dysphagia andchange of voice. On examination, diffuse andhard swelling along with sensation of heat wasnoted on the swelling which measures 4.5×4 cm.Ultrasonography (USG) of local part revealed anill defined large hypoechoic mass in the left lobeof thyroid with calcification along with cervicallymphadenopathy raising possibility ofmalignant mass lesion involving left lobe ofthyroid. Fine needle aspiration cytology (FNAC)was performed by standard procedure [6, 7, 8,9] from thyroid swelling and cervical lymph node[10, 11]. The smears from the thyroid swelling Photo – 3: Anaplastic carcinomas of thyroid withshowed neoplastic cells arranged in loose large multinucleated giant cells. (H & E Stain,clusters as well as dispersed singly in the 40X)hemorrhagic background. The individual cellsshowed easily identifiable malignant cytologicfeatures including large, pleomorphic nuclei withirregular nuclear membranes, coarse clumpedchromatin and prominent nucleoli. (Photo - 1,Photo - 2, Photo – 3) The smears from thelymph node also showed the same features.(Photo - 4) Final diagnosis was given asanaplastic thyroid carcinoma. The patient wasmanaged conservatively without surgicalintervention.Photo – 1: Dispersed, single cell pattern with Photo – 4: Malignant cells in lymph node. (H & Enaked nuclei. (H & E Stain, 20X) Stain, 10X)International Archives of Integrated Medicine, Vol. 2, Issue 3, March, 2015. Page 184Copy right © 2015, IAIM, All Rights Reserved.

Diagnosis of anaplastic thyroid carcinoma on FNAC ISSN: 2394-0026 (P)Discussion ISSN: 2394-0034 (O) effective diagnostic modality and cytologicallyMalignant tumors of thyroid follicular cell origin ATC reveals three major patterns such as thehave traditionally been classified as either well- spindle cell, giant cell and squamoid celldifferentiated thyroid carcinoma (WDTC), which patterns, and sometimes these patterns areis composed of papillary and follicular combined in different proportions according tocarcinoma, or undifferentiated/anaplastic the case [1, 2, 3]. Regardless of type, the nucleithyroid carcinoma (ATC). The vast majority of of undifferentiated thyroid carcinoma are highlypatients with WDTC have an excellent prognosis pleomorphic with dark, irregular chromatinregardless of the types of treatment used, clumping, macronucleoli, and occasional intrawhereas patients with ATC uniformly have a nuclear pseudo inclusions. Numerous mitosespoor prognosis [12]. and abnormal mitotic figures may be seen. Squamous differentiation, including keratinThe pathogenesis of ATC is not completely pearl formation, can also be present, and shouldunderstood. Several studies have now shown be distinguished from a metastatic squamousthat some ATCs may be derived from BRAF- cell carcinoma by correlation with clinicalmutated papillary thyroid cancer, and targeted history. In our case there was presence ofexpression of BRAF in thyroid cells of transgenic squamous differentiation along with keratin inmice results in papillary thyroid cancers that necrotic background.undergo dedifferentiation [13, 14]. This According to the TNM system (tumor, nodes,strengthens the theory that WDTC may metastasis) all anaplastic carcinoma are stagededifferentiate to ATC through intermediate 4.The TNM system further distinguishes stage 4forms. Understanding this progression might which includes stage 4A, where tumor is limitedhelp identify valuable prognostic factors that can to the thyroid and considered surgicallyserve as potential therapeutic targets. resectable; stage 4B where tumor extendingClinically the most common presentation of beyond the thyroid, is considered surgicallypatients is a rapidly growing, painful, low unresectable and stage 4C where tumor isanterior neck mass which is often firm and fixed present with distant metastases. In our case theto underlying structures [1, 15, 16, 17]. patient was in stage 4B with involvement ofCompressive symptoms including hoarseness, cervical lymph node.dysphagia, dyspnea and cough are frequent. Patients often present at an advanced stage,Regional nodal metastases and vocal cord making curative surgical resection not feasible.paralysis are seen in up to 40% and 30%, Most studies find that neither the extent ofrespectively, of the patients with ATC [18]. Over surgery nor the completeness of resection has a70% of patients with ATC have direct invasion of significant effect on survival [19]. Because ATCssurrounding tissues, such as fat, trachea, muscle, are rapidly growing, highly aggressive tumors,esophagus, and larynx [5]. Systemic metastases multimodality treatment can be applied [5].occur in up to 75% of patients, with lung beingthe most common site (80%), followed by bone(6% to 15%) and brain (5% to 13%) [15]. ConclusionDiagnosis can be made with help of cytology, Although ATC make up a rare group of tumors, they account for a significant portion of thehistology, imaging study and morbidity and mortality associated with thyroidimmunohistochemical study. FNAC is anInternational Archives of Integrated Medicine, Vol. 2, Issue 3, March, 2015. Page 185Copy right © 2015, IAIM, All Rights Reserved.

Diagnosis of anaplastic thyroid carcinoma on FNAC ISSN: 2394-0026 (P)cancer. Recognizing the cytological finding of the ISSN: 2394-0034 (O)ATC and making the prompt and proper 8. Rathod GB, Goyal R, Bhimani RK,cytological diagnosis are helpful to determinethe treatment plan for the patients who suffer Goswami SS. Metaplastic carcinoma ofwith this entity. breast in 65 years old female - A case report. Medical Science, 2014; 10(39): 77-81. 9. Disha Singla, Gunvanti Rathod.References Cytodiagnosis of renal cell carcinoma – A case report. IAIM, 2015; 2(2): 133-137.1. Venkatesh YS, Ordonez NG, Schultz PN, 10. Gunvanti Rathod, Pragnesh Parmar. FineHickey RC, Goepfert H, Samaan NA. needle aspiration cytology of swellingsAnaplastic carcinoma of the thyroid: A of head and neck region. Indian Journalclinicopathologic study of 121 cases. of Medical Sciences, 2012; 66: 49-54.Cancer, 1990; 66: 321-30. 11. Gunvanti Rathod, Sangita Rathod,2. Chiacchio S, Lorenzoni A, Boni G, Rubello Pragnesh Parmar, Ashish Parikh.D, Elisei R, Mariani G. Anaplastic thyroid Diagnostic efficacy of fine needlecancer: Prevalence, diagnosis and aspiration cytology in cervicaltreatment. Minerva Endocrinol, 2008; lymphadenopathy – A one year study.33: 341-57. International Journal of Medical and3. Aldinger KA, Samaan NA, Ibanez M, Hill Pharmaceutical Sciences, 2014; 4(5): 1-CS Jr. Anaplastic carcinoma of the 8.thyroid: A review of 84 cases of spindle 12. Shaha AR. Implications of prognosticand giant cell carcinoma of the thyroid. factors and risk groups in theCancer, 1978; 41: 2267-75. management of differentiated thyroid4. Gilliland FD, Hunt WC, Morris DM, et al. cancer. Laryngoscope, 2004; 114: 393-Prognostic factors for thyroid 402.carcinoma. A population - based study 13. Quiros RM, Ding HG, Gattuso P, et al.of 15,698 cases from the Surveillance, Evidence that one subset of anaplasticEpidemiology and End Results (SEER) thyroid carcinomas are derived fromprogram 1973-1991. Cancer, 1997; 79: papillary carcinomas due to BRAF and564-573. p53 mutations. Cancer, 2005; 103: 2261-5. Guiffrida D., Gharib H. Anaplastic thyroid 2268.carcinoma. Current diagnosis and 14. Knauf JA, Ma X, Smith EP, et al. Targetedtreatment. Ann. Oncol., 2000; 11(9): expression of BRAFV600E in thyroid cells1083-1089. of transgenic mice results in papillary6. Rathod GB, Ghadiya V, Shinde P, Tandan thyroid cancers that undergo RK. Pleomorphic sarcoma in 60 years old dedifferentiation. Cancer Res., 2005; 65: male – A case report. International 4238-4245. Journal of Current Microbiology and 15. Tennvall J, Lundell G, Hallquist A, et al. Applied Sciences, 2014; 3(8): 510-517. Combined doxorubicin, hyper7. Gunvanti Rathod, Pragnesh Parmar, fractionated radiotherapy, and surgery in anaplastic thyroid carcinoma: report Sangita Rathod, Ashish Parikh. on two protocols. The Swedish Anaplastic Thyroid Cancer Group. Suprascapular malignant fibrous Cancer, 1994; 74: 1348-1354. histiocytoma – A case report. Discovery, 2014, 12(31): 50-53.International Archives of Integrated Medicine, Vol. 2, Issue 3, March, 2015. Page 186Copy right © 2015, IAIM, All Rights Reserved.

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