Papillary thyroid carcinoma is the most common well-differentiated thyroid malignancy accounting for more than 80 to 90% of all thyroid tumors. It has an overall excellent prognosis owing to advances in screening via imaging and ultrasound-guided fine-needle aspiration biopsy, which have facilitated early detection, diagnosis, and surgical treatment followed by adjuvant radioactive iodine therapy. Exceptionally rare cases of papillary thyroid tumors may present with enormous growth due to delayed consultation and, thus, late diagnosis, posing a challenge to definitive management, quality of life, overall survival, and prognosis. We report a case of a 35-year-old woman who presented with a 4-year history of a bleeding exophytic and fungating anterior neck mass. Computed tomography showed a fungating mass arising from the left thyroid lobe that measured 14.1 x 14.0 x 11.1 cm with areas of necrosis and hemorrhage, left internal jugular vein thrombus formation, and compression of the left internal carotid artery. The mass causes a displacement of the trachea to the right side and multiple bilateral cervical lymphadenopathies. The patient was fully aware, and she consented to undergo wide excision, total thyroidectomy, neck dissection, and pectoralis major muscle flap reconstruction. However, she went into arrest intraoperatively attributed to massive pulmonary embolism. Papillary thyroid cancer is well known for its excellent prognosis. However, outcomes may not be favorable and can even be fatal in advanced and extensive cases. Although fungating papillary cancers are rare, they remain more common in the developing countries, where early detection and access to healthcare remains limited. They also represent a big challenge to surgeons. Even if the outcome was not good, we opted to report this case as there were many learning points. If only patients with good and excellent outcomes are reported in the literature, it will overestimate the treatment success of these complex cases.
papillary thyroid cancer

Introduction: Thyroid carcinoma remains the most common endocrine malignancy and incidence has increased due to improved diagnosis. Most Differentiated Thyroid Cancers (DTC) are indolent and easily cured with surgery, radioactive iodine (RAI) therapy and TSH suppression. However, persistent and recurrent disease is not uncommon among Filipinos. RAI therapy is being used more frequently even for low risk patients due to this observed aggressiveness of DTC in our population. This study sought to identify factors that are associated with failure of initial RAI for DTC, leading to repeat doses. Methods: This is a single-center, retrospective cohort study conducted in the Nuclear Medicine Department of a tertiary care center in the Philippines, involving 325 patients who underwent RAI from 2006-2016 Results: Out of 570 patients who underwent RAI therapy for DTC, only 325 were included. Majority (n=280, 86%) had PTC and the rest had FTC (n=45, 14%). Twenty four percent (n=67) of the PTC group and 31% (n=14) of the FTC had subsequent RAI therapy after initial therapy due to either persistent or recurrent disease, with a mean interval of 21-22 months. Distant metastasis at presentation (M1), uptake in distant tissues on the initial post-therapy whole body scan (WBS) and TNM stage 4 were predictive for repeat RAI for FTC. A negative post-therapy WBS was found to be associated with no need for repeat RAI. On the other hand, the initial RAI dose of 150 mCi or higher was noted to be associated with repetition of RAI for PTC. Other risk factors noted were the presence of lymph nodes and distant metastasis at presentation and loco-regional uptake on the posttherapy WBS. Conversely, a negative post-treatment scan appeared to be protective against repeat RAI, as in FTC. However, multivariate analysis of risk factors showed that only metastasis at presentation (LN or distant) was associated with repeat RAI therapy. Conclusion The only risk factor associated with failure of initial RAI for patients with PTC and FTC in this study was distant metastasis at presentation. Nodal involvement at presentation was noted to be a significant factor for among those with PTC.
Thyroid Cancer, Papillary ; Recurrence

Cystic nodule is an unusual presentation of Papillary Thyroid Carcinoma (PTC), seen in less than 10% of cases. Even by ultrasound, finding a thyroid cyst carries a less than 5% chance of malignancy. We present a case of a 45-year-old male, who came in for incidental finding of a palpable thyroid mass with no significant predisposing history. Thyroidectomy was done and immunohistochemical staining confirmed it to be papillary thyroid cancer. He underwent high dose radiation therapy with post therapy whole body scan showing no evidence of radioavid foci aside from the thyroid bed.The malignant potential of cystic nodule(s) should never be overlooked in certain select patients even if it carries a low chance of malignancy. The diagnosis of PTC relies primarily on the typical nuclear features, however in cases of histologic uncertainty, immunohistochemical stains such as HBME-1 may be used to help classify unusual presentations of PTC. Treatment and monitoring of Cystic Papillary Thyroid Carcinoma follows the conventional guideline on solid PTC.
Thyroid Cancer, Papillary

Objective: To identify factors independently associated with incomplete response to therapy based on the 2015 ATA guidelines in surgically treated Filipino patients with papillary thyroid carcinoma (PTC). Methodology: This is a retrospective cohort study of adults aged 21-74 years with papillary thyroid carcinoma (PTC) treated with surgery with or without radioactive iodine therapy (RAI) in Makati Medical Center from 2013 to 2017. We collected the following factors through a review of charts: age at diagnosis, gender, family history of thyroid cancer, date of surgery, tumor size, capsular/lymphovascular invasion, lymph node/distant metastases, stage, risk of recurrence, dose of post-surgical RAI therapy, initial post-treatment serum Thyroglobulin (Tg) and anti-Tg antibody levels (Negative Tg level: suppressed non-stimulated Tg <0.2 ng/mL or TSH-stimulated Tg <1 ng/mL; Positive Tg level: suppressed Tg ≥1 ng/mL or a TSH-stimulated Tg ≥10 ng/mL or rising anti-Tg antibody levels), thyroid stimulating hormone suppression, post-operative imaging studies and levothyroxine dose. Response to therapy was checked 6-24 months post-therapy. Results: We analyzed a total of 115 patients with PTC who underwent thyroidectomy. Patients who had family history of thyroid cancer were less likely to have an incomplete or indeterminate response (p=0.045). None of the patients with excellent response had lymphovascular invasion. Having a positive Tg (p=0.001) and positive anti-Tg postoperatively (p<0.001) were strongly associated with incomplete or indeterminate response. Conclusion Patients who were positive for thyroglobulin and anti-thyroglobulin post-operatively were strongly associated with incomplete or indeterminate response to therapy in PTC.
Thyroid Cancer, Papillary

Background/Objective: Papillary thyroid carcinoma is the most common type of thyroid cancer. Treatment includes surgery and remnant ablation with radioactive iodine theraphy while follow-up monitoring includes I- 131 whole body scans land thyroglobulin monitoring. Lymphovascular invasion (LVI) has been used as a predictor of metastasis in different cancers. Therefore, it might be useful in predicting metastasis in patients with papillary thyroid carcinoma since metastasis in this type of carcinoma travels via the lymphatic route. The purpose of this study was to determine the association of LVI with metastasis among patients with papillary thyroid carcinoma Methodology: Records of patients with papillary thyroid carcinoma (histopathologic reports, thyroglobulin levevls and I-131 whole body scans) were reviewed. Univariate and multivariate anlyses were performed. Results: A total of 108 subjects were recruited for this study, 47 (43.5%) of which had LVI. There was no association found between LVI and metastasis on baseline (p=0.72) and follow-up scans (p=0.07). However, there was an association between metastasis resolution on follow-up scans and high-dose radioactive treatment (p=0.02) regarless of presence or absence of LVI. Conclusion There was a significant association of the presence of LVI with elevated thyroglobulin levels (p-value<0.0001). A significant association was also seen with LVI and dose of activity with resolution of thyroid remnant, locoregional lymph node and distant metastasis (p=0.02). Even though no association jwas seen between LVI and metastasis, a robust percentage of patients with LVI were positive for metastasis on whole body scans.
Thyroid Cancer, Papillary

Anal melanoma is a rare melanocytic malignancy, which roughly comprises 2% of all anorectal malignancies.1 2 The anal area is the most common site for primary gastrointestinal melanomas.2 Patients with anal melanomas commonly complain of bleeding, anal pain and mass, tenesmus, and changes in bowel habits. In cases with metastases, symptoms such as weight loss, anemia, fatigue and bowel obstruction could be present.2 Risk factors of anal melanoma include old age, multiple sexual partners, anal sex, smoking, history of other malignancies (i.e., cervical, vulvar, or vaginal cancer), activation of the receptor tyrosine kinase c-Kit, and family history of malignancies.3 4 The diagnosis of anal melanoma is established through biopsy—usually done with colonoscopy—and immunological staining.5 HMB-45 is the immunological stain commonly used for the detection of both primary and metastatic melanomas.6 Endoscopic ultrasonography also helps to characterize lesions and assess the depth of infiltration.7
Melanoma ; Thyroid Cancer, Papillary

Acromegaly is a rare disease with an annual incidence of 3 to 4 cases in a million.[1] Diagnosis is often delayed due to the slow progression of the disease. Persistent elevation of growth hormone (GH) in acromegaly causes a reduction in life expectancy by 10 years. Aside from multiple cardiovascular, respiratory and metabolic co-morbidities, it has also been proven to cause an increased incidence of cancer. The main treatment of acromegaly is surgical excision of the functioning pituitary adenoma. Multiple comorbidities, including obstructive sleep apnea (OSA), left ventricular hypertrophy (LVH) and soft tissue swelling, make surgery complicated, if not impossible. Medical therapy to reduce co-morbidities may be indicated in certain situations. Somatostatin receptor ligands (SRL) are able to reduce, and possibly normalize, IGF-1 levels.[2] Reduction of insulin-like growth factor-1 (IGF-1), the main mediator of GH, is able to resolve headache, sweating, fatigue and soft tissue swelling, and also reduce ventricular hypertrophy. This case report illustrates the successful use of the SRL octreotide LAR in treating acromegaly. It also confirms the observation from several case series that thyroid cancer is the most common malignancy in acromegaly.
Acromegaly ; Thyroid Cancer, Papillary

The cell origin, histopathologic features, and prognosis of medullary and papillary thyroid carcinoma are different and to have them occur simultaneously in a single patient is a rare occurrence. This is a case of a 38-year-old female who presented with an enlarging anterior neck mass whose fine needle aspiration biopsy could not rule out a papillary lesion. Thus, she was advised to undergo total thyroidectomy, and her final histopath showed a simultaneous medullary and papillary thyroid carcinoma. Her initial serum calcitonin was elevated at 252 pg/ ml, and it remained persistently elevated over the course of 7 months. A repeat ultrasound revealed solid nodules with coarse calcifications and enlarged lymph nodes at both submandibular regions. This warranted a repeat surgery with neck dissection with the finding of eight lymph nodes positive for metastatic carcinoma. On follow up after her second surgery, the calcitonin decreased to 42.70 pg/ml. Knowledge of this simultaneous occurrence of medullary thyroid carcinoma and papillary cancer is important for its prognostic implications and therapeutic plan
Thyroid Neoplasms ; Thyroid Cancer, Papillary

OBJECTIVE: The objective of the study is to describe the pattern of nodal metastasis in papillary thyroid carcinoma (PTC) among Filipinos and to determine the possible clinicopathologic factors associated with level V involvement.
METHODS: This study included patients >18 years old with PTC with clinically positive neck node (cN1b) who underwent total thyroidectomy with lateral neck dissection (levels II-IV) or posterolateral neck dissection (II-V) from 2011-2016 at the Department of Otorhinolaryngology-Head and Neck Surgery, Philippine General Hospital. Histopathology reports were reviewed for the presence of nodal metastasis per level, tumor size, tumor location, gross extrathyroidal involvement and subtype. Univariate analysis utilized Pearson Chi-square test or the Fischer exact test. Multivariate analysis utilized logistic regression.
RESULTS: Lymph node involvement in the lateral neck was highest in level III (87.04%), followed by level IV (81.48%), IIa (66.67%), V (60.00%) and IIb (42.59%). No clinicopathologic factor was found to be associated with level V involvement.
CONCLUSION: The pattern of lymph node metastasis among Filipinos is similar but higher than that reported in the literature. Level V involvement is high and thus, this study suggests including level II-V in the neck dissection among Filipinos with cN1b papillary thyroid carcinoma.

Objective: To report a case of thyroglossal duct carcinoma with concurrent papillary thyroid carcinoma Methods: Design: Case Report. Setting: Tertiary National University Hospital. Patient: One. Results: A 46-year-old woman was diagnosed with thyroglossal duct carcinoma after undergoing a Sistrunk procedure. Due to presence of thyroid nodules, the patient underwent second stage thyroidectomy with central neck dissection which revealed papillary thyroid carcinoma. Conclusion Thyroglossal duct carcinomas are rare entities and there is no current consensus regarding their management. Difficulties arise in the diagnosis of these tumors as they present similarly to benign thyroglossal duct cysts. Most cases are diagnosed postoperatively. Proper preoperative assessment including head and neck examination, biopsy, and radiologic imaging is necessary to recognize patients who could benefit from more aggressive management.
Thyroglossal Cyst ; Thyroid Cancer, Papillary