Analysis of Clinical Outcome of Patients with Poorly Differentiated Thyroid Carcinoma

Background. We retrospectively analyzed whether poor differentiation is the independent prognostic factor for thyroid carcinoma or not. Methods. The subjects were 29 patients with PDTC who were treated between April 1996 and March 2006 to compare with those of well-differentiated papillary carcinoma patients (n = 227). Results. The relapse free (RFS), distant relapse-free survival and cause-specific survival, rates were significantly lower in patients with PDTC (P < .0001, P < .001, and P < .05). After classification into focal (<10%) and diffuse type (over 10%) of PDTC, there were no significant differences in RFS and cause-specific survival due to component type or proportion of poorly differentiated component. On multivariate analysis, poor differentiation (P < .0005, RR = 4.456, 95% CI; 1.953–10.167) and extrathyroidal infiltration (P < .05, RR = 2.898, 95% CI; 1.278–6.572) showed a significant impact on DFS, and poor differentiation (P < .05, RR = 9.343, 1.314–66.453) and age (P < .005, RR = 1.306, 1.103–1.547) significantly impacted cause-specific survival. Conclusion. Poor differentiation was an independent factor for survival. Distant relapse was significantly more common among PDTC patients, and systemic therapy might be warranted

A giant axillary mass treated as breast cancer metastasis

　A 69-year-old woman with a giant fist-sized left axillary mass was admitted to the Dermatology Department of Kawasaki Medical School. No primary tumor was identified, and she was referred to the Department of Breast and Thyroid Surgery of Kawasaki Medical School Hospital. A 90-mm tumor was found in the left axilla, which exhibited ulceration and infection. Imaging analysis revealed no abnormalities in the breast or other organs such as the lungs. Needle biopsy revealed a poorly differentiated carcinoma exhibiting a mixture of glandular structures and keratinization, and it was difficult to determine the original tumor. The differential diagnoses were primary skin cancer, including adnexal organs, occult breast cancer, accessory breast cancer and metastatic tumor from unknown malignancy. Immunohistochemical analysis revealed that this tumor had no estrogen receptor, progesterone receptor or human epidermal growth factor receptor 2 expression. Primary chemotherapy was initiated because the National Cancer Comprehensive Network guidelines recommend that unclassified axillary epithelial malignancies in women be treated as occult breast cancer. After 4 cycles of epirubicin plus cyclophosphamide followed by 4 cycles of docetaxel plus doxifluridine, the axillary tumor shrunk to 15 mm in size. Axillary lymph node dissection, including skin resection of the axilla, was performed, and radiotherapy to the left breast and left axilla/supraclavicular lymph node area was administered. There has been no recurrence for over 4 years

A Case of Takotsubo syndrome after Surgery for Papillary Thyroid Cancer

　The patient was an 82-year-old woman undergoing treatment for bronchial asthma. In December 200X, she visited her former doctor because of a left cervical mass and pain, and was referred to our hospital for detailed examination. A 19-mm mass was found in the left lobe of the thyroid gland and there were many swollen lymph nodes on both sides of her neck. Fine-needle aspiration cytology revealed malignant and papillary cancer in both the left lobe and left cervical lymph node, but no lung metastasis was found in chest CT, and it was judged to be T1bN1bM0 Stage IVa. Total thyroidectomy + bilateral cervival lymphnode dissection was performed. The left lobe mass of the thyroid gland invaded the sterno-thyroid muscle, but no infiltration to other organs, including the lymph nodes on both sides, was observed. On the night of the operation, wheezing, dyspnea, lower mandibular breathing, and impaired consciousness suddenly developed, and the oxygen saturation of peripheral artery (SpO2) decreased to 60%. No postoperative bleeding was observed. Chest CT demonstrated no signs of heart failure, but based on thickening of the bronchial wall, the cause of hypoxemia was considered to be bronchial asthma. Steroids and oxygen (high-dose, 15 L/ min) were administered, but respiratory acidosis developed and non-invasive positive pressure ventilation (NIPPV) was started. The respiratory condition gradually improved thereafter. Acute coronary syndrome (ACS) was suspected based on symptoms, increased troponin T, and ST elevation on ECG. Echocardiography revealed akinesis and left ventricular apical and basal hypercontractility. No coronary arterial stenosis was noted on coronary angiography and left ventriculography demonstrated Takotsubo-like wall movement (hypercontraction of the base and contraction failure of the apex), leading to a diagnosis of Takotsubo syndrome (TS). The subsequent course was good and she was discharged on the 10th postoperative day