Thyroid anaplastic carcinoma - Forum

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Dottore

Thyroid anaplastic carcinoma - Ärzteforum

Post#1 »

I would be pleased to know the opinion of the Surgeons about this case (i.e. what would you do and why):

White, female, age 60. "Cold" left lobe thyroid nodule 2 cm diameter, FNA (1 month ago) positive for anaplastic carcinoma. She was waiting for operation. Last friday she came to the ER (I was on duty there) complaining sovraclavear "swelling" and a mild hoarseness since a couple of weeks. At physical examen I found a "stone" thyroid tightly adherent to subcutaneous tissues, the skin was locally blushing (like in neoplastic lymphangitis of some breast tumors) and multiple enlarged nodes both laterocervical and sovraclavear were appreciable on the left. An US scan confirmed nodal involvement and found also an almost complete trhombosis of the left internal jugular vein. Chest RX: enlarged upper mediastinum, "free" lungs. ORL: hypomotility of the right (!) vocal cord, respiratory space adequate although reduced.

Everybody knows she has the worst prognosis. What would be your strategy in this case? Thyroidectomy to avoid tracheal compression? Tracheostomy before is too late? Radiotherapy? Radical (!?)extended surgery?


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Surgeon

Re: Thyroid anaplastic carcinoma - Ärzteforum

Post#2 »

I don't know if you saw my post. "Some advice on a case presenting in the ER today 65 yr old male patient rural african background presents with severe stridor arising from a lower neck/superior mediastinal compressing lesion the would appear clinically to be a huge retrosternal thyroid. The trachea is in the centre of the mass and impalpable. The mass has been slowly growing for years, the stridor is recent - worse over a few days. He is otherwise well. We temporise with adrenaline nebulisation and I plan exploratory surgery on the morrow. Working diagnosis is either malignant change or haemorrhage into a preexisting goitre. I discuss the options with him and he emphatically declines any surgery. He then has a respiratory arrest and needed intubation. Now we are a bit stuck. Any suggestions!" We had no histology but it turns out this was an anaplastic Ca. I operated and the patient spent his last 5 days on ICU fortunately well sedated and also ventilated - all I could do was a wedge excision to place a tracheostomy. I think even Rambo wouldn't be able to resect most of these tumours - unless he did it with a anti tank missile!

The moral here seems to be if they get to the stage of needing a tracheostomy the horse has bolted before the surgeon could clsoe the stable door!

In my situation I go with the more pessimistic side.

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Oncologist

Re: Thyroid anaplastic carcinoma - Ärzteforum

Post#3 »

Unfortuately this is a pretty hopeless situation. I suspect your patient may have already expired. There is no place for thyroidectomy or more radical surgery. I would attempt palliation with combine chemo/rt as soon as possible If necesssary (and if possible) the most I would consider would be a trach to buy time. Quite honestly, in this situation a frank discussion with the patient may result in the decision to avoid even a trach using narcotics to treat pain and respiratory urgency.

Chirurgia

Re: Thyroid anaplastic carcinoma - Ärzteforum

Post#4 »

Your patient is really at the end of the way. By your description, whatever you may do won't work. You must accept this eventhough it is not easy, but experience has taught that such a patient with such a tumor with regional and far mtts (mediastinum) has a very poor risk. Even the tracheostomy might be a disaster. An anaplastic tumor is one of the worst tumor of the body, so give him human support and talk to the family about death, which is near.

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