ACTA ENDOCRINOLOGICA (BUC)

We report a case of anaplastic thyroid carcinoma mimicking acute thyroiditis with skin necrosis. A 82 years woman, with no significant previous medical disorders, was admitted with a few weeks history of a painful rapidly enlarging neck mass associated with hoarseness, dysphagia to solids, dyspnea and a general state deterioration. Physical exam was significant for a left-anterior lateral neck tumor of about 7 cm. The mass was tender, firm, nonpulsatile and nonfluctuant; it was fixed to the underlying cervical tissues. Antero-cervical skin tissues were swollen, hyperemic, presenting necrosis with penetrating tendency, severe neck pain and tenderness, associated with fever, suggesting an acute thyroiditis. The thyroid function was normal (TSH = 0.81 mUI/L, TT3 = 62 ng/dL, TT4= 8.77 ug/dL) as well as antithyroid peroxidase antibody (0.5 UI/mL), while thyreoglobulin was high (384 ng/mL). Thyroid scintigram revealed a cold nodule. Thyroid ultrasound revealed a giant left thyroid mass with necrosis, lymph nodes involvement and displacement of trachea. Fine needle aspiration confirmed the clinical suspicion features of anaplastic thyroid cancer: mitoses, anisocytosis and marked anisokaryosis with enlarged nuclei. Computed tomography confirmed a voluminous mass involving the thyroid, with calcifications, necrosis with multiple latero-cervical lymph nodes, compressing right carotid artery and internal jugular vein; it was detected also a pulmonary metastasis (right medium pulmonary lobe). The patient was diagnosed on having a thyroid carcinoma of the anaplastic type, TNM stage IVc. Surgery was performed through cervical approach without sternotomy, by total thyroidectomy and resection of proximal cervical structures involved by the tumor mass. After surgery, the patient was started on levothyroxine 100 μg/ day and scheduled for cervical radiotherapy, but the tumor relapsed in several weeks. Local disease can be controlled with radiotherapy either alone or in combination with chemotherapy.

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Laparoscopic adrenalectomy is currently considered the gold standard for adrenal tumors up to 6 cm, and although with far less morbidity than the open alternative, when it comes to its complications we should not look away. The case concerns a 51-year old obese male that underwent left laparoscopic adrenalectomy for incidentaloma and developed pancreatic tail fistula. Without an evident pancreatic lesion during surgery and an uneventful early postoperative course the patient was discharged only to return 4 days later with respiratory symptoms and mild abdominal discomfort in the left upper quadrant. The CT scan diagnosed a left subphrenic fluid collection and left basal pneumonia, thus the patient underwent laparoscopic reintervention for drainage of the pancreatic fluid collection and received conventional antibiotherapy for pneumonia. The patient was discharged in good condition with the drainage tube in situ. The drainage tube was extracted 14 days later.

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Thyroid cancer, the most frequent endocrine malignancy, is in most patients a treatable disease, with excellent outcome and cure rate. However, a few patients present with rapidly progressive metastatic differentiated thyroid cancer which loses the radioiodine uptake capacity. These rare cases are prone to a rapid evolution and poor prognosis. Medullary thyroid cancer is a neuroendocrine tumor occurring sporadically or as part of endocrine tumor syndromes, genetic tests being part of standard clinical evaluation. Current knowledge of tumor biology in thyroid cancer allowed development of a new class of drugs, thyrosine kinase inhibitors (TKI). Their use in clinical trials allowed the development of more specific drugs, increasingly effective and with less adverse reactions, interfering with multiple thyrosine kinase enzymes. Improvement of the progression free survival, decrease of tumor volume and tumor markers, as well as patients with stable disease on TKI are strong arguments for including patients in clinical trials. Currently, only four TKI are approved by FDA: sorafenib and lenvatinib for DTC; vandetanib and cabozantinib for MTC. In this paper we present this new class of drugs used in the treatment of aggressive thyroid cancer.

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