A 17-year-old male patient presented at our facility with a rapidly growing anterior neck mass of about 4 weeks duration. There was no history of fever, weight loss, night sweat, or thyroid hormone related symptoms. The family history was unremarkable for malignancy or tuberculosis.
Physical examination revealed circa 4 cm x 5 cm slightly right sided, nontender, soft to firm consistency, movable, roughly demarcated anterior neck swelling. The swelling moved slightly upon swallowing but not with protrusion of the tongue. There were no associated regional lymphadenopathy and the overlying skin was unremarkable.
The laboratory findings were as follows: Haemoglobin 16.5 g/dl, Leucocytes 8275/ul, Thrombocytes 27,300/ul, Calcium 4.98 mval/l, TSH 2.89 uU/ml, FT3 3.39 pg/ml, FT4 1.24 ng/dl, INR-1.030, Creatinine 1.02 mg/dl. Tumor markers: Alpha-fetoprotein (AFP) 1.74 ng/ml, Human chorionic gonadotropin (hCG) < 1.20 U/l, Calcitonin 2.36 pg/ml, Lactate dehydrogenase (LDH)309U/l (normal range < 248), Thyroglobulin (Tg) 29.8 ng/ml, Anti-thyroid peroxidase (anti-TPO)21.9 IU/ml (normal range 1-16).
A thyroid ultrasound revealed an enlarged thyroid gland with right lobe volume of 62 ml and left lobe volume of about 14 ml. A big lesion of about 40 ml was located around the caudal part of the right lobe. It also showed multiple thyroid nodes. Thyroid scintigraphy confirmed a multinodular goiter with "cold" nodes.
Magnetic resonance imaging (MRI) of the neck revealed diffused contrast enhanced right sided neck mass of about 8.2 cm x 3.4 cm x 3.6 cm with extension to the base of the tongue. Around the sinus sphenoidalis and sinus mastoidis was found little fluid without any evidence of tumor, infiltration or lymphadenopathy. (Figure 1).
Exploration, thyroidectomy and surgical resection of the tumor was carried out on the 21.01.2019. We found an enlarged multinodular thyroid gland with diffuse tumor of the right lobe infiltrating the nearby tissues and pressing on the trachea.
Frozen section histological examination revealed a tumor most likely to be germ cell tumor and sensitive to Chemotherapy. Based on these intraoperative and the histological findings, we carried out near-total thyroidectomy aiming at tumor debulking and tracheal decompression without causing damage to the nearby organs.
The postoperative was uneventful, and the patient was discharged on the fifth postoperative day. The final histological examination revealed a teratocarcinosarcoma of the thyroid gland, an analog to the sinonasal teratocarcinosarcoma (Figures 2-4).
Immunnohistochemical staining with desmin and myogenin revealed rhabdomyoblastic differentiation of the stromal component (Figure 5). Subsequently, SALL4 staining was done to exclude immature teratoma with rhabdomyosarcomatous foci.
Staging Computed tomography (CT) of the thorax, Magnetic Resonance Imaging (MRI) of the abdomen, Head and Neck as well as Full Body Scintigraphy did not show any evidence of metastasis or primary tumor focus. The patient was given chemotherapy with Cisplatin, Etoposid, and Ifosfamid. The tumor was found to be regressive after the chemotherapy. A second staged surgical resection was carried out on the third of April 2019. This was followed with Radiochemotherapy. The Patient is currently doing well and is on surveillance.