Mixed medullary and follicular or papillary carcinoma of thyroid is an extremely rare tumor, characterized by coexistence of morphological and immunohistochemical features of both medullary carcinoma and follicular (or papillary) carcinoma. This case report describes for the first time in the indexed database a late recurrence of a medullary thyroid carcinoma initially diagnosed as follicular-papillary form, treated and monitored accordingly. After 14 years, a superior mediastinum tumor was discovered incidentally at a thorax computer tomography. The whole-body I-131 scan was negative and F-18 FDG-PET-CT showed glucose avidity of the tumor. The patient was operated on and the histology revealed medullary thyroid carcinoma. If there are no possibilities to have routinely extensive immunohistologic profiles, it is recommended to check the serum calcitonin, at least in any patient with confirmed thyroid carcinoma. 1. Introduction Thyroid carcinoma is the most frequent endocrine cancer, accounting for about 5% of thyroid nodules [1] with a general incidence reported to be between 1.2 and 3.8 100.000 inhabitants [2, 3]. The differentiated thyroid cancers represent about 80% of all thyroid cancers [2], with a good prognosis [4, 5], while medullary, respectively, anaplastic forms, with considerable lower incidences [1, 6–9], have an aggressive evolution, frequently very severe and fast. The mixed forms are very rare and considered to be of different cell origins, with specific clinical behaviours [10–15]. Considered rare among human malignancies, the thyroid carcinoma has a very important increasing incidence in the last 10 years [3, 16], reported by studies from all over the world, with the fact that requires a new approach regarding the management of this pathology and special attention to the unusual or more aggressive forms. 2. Case Presentation A 67-year-old male was admitted to our institute with the diagnostic of multiple cervical lymph nodes and right thyroid nodule. He was submitted to total thyroidectomy, with selective right lymphadenectomy for a follicular-papillary thyroid carcinoma with right cervical lymph nodes metastasis, T3N1？M0, stage III, according to the TNM of the moment [17]. At 4 weeks after the surgery, without thyroid hormone replacement the patient was evaluated prior to the metabolic irradiation with I-131. Therefore, the serum level of the thyroid-stimulating hormone (TSH) was >100？mIU/L, increased; the thyroglobulin (Tg) specific tumor marker was 13.2？ng/mL (N.V. < 0.1？ng/mL, undetectable in case of cured patients); the
References
[1]
F. Pacini, M. Schlumberger, H. Dralle, R. Elisei, J. W. Smit, and W. Wiersinga, “European consensus for the management of patients with differentiated thyroid carcinoma of the follicular epithelium,” European Journal of Endocrinology, vol. 154, no. 6, pp. 787–803, 2006.
[2]
R. Elisei, E. Molinaro, L. Agate et al., “Are the clinical and pathological features of differentiated thyroid carcinoma really changed over the last 35 years? Study on 4187 patients from a single Italian institution to answer this question,” The Journal of Clinical Endocrinology and Metabolism, vol. 95, no. 4, pp. 1516–1527, 2010.
[3]
J. Ferlay, E. Steliarova-Foucher, J. Lortet-Tieulent, et al., “Cancer incidence and mortality patterns in Europe: estimates for 40 countries in 2012,” European Journal of Cancer, vol. 49, no. 6, pp. 1374–1403, 2013.
[4]
R. I. Haddad, “New developments in thyroid cancer,” Journal of the National Comprehensive Cancer Network, vol. 11, no. 5, supplement, pp. 705–707, 2013.
[5]
R. M. Tuttle, H. Tala, J. Shah et al., “Estimating risk of recurrence in differentiated thyroid cancer after total thyroidectomy and radioactive iodine remnant ablation: using response to therapy variables to modify the initial risk estimates predicted by the new American Thyroid Association staging system,” Thyroid, vol. 20, no. 12, pp. 1341–1349, 2010.
[6]
D. S. McLeod, A. M. Sawka, and D. S. Cooper, “Controversies in primary treatment of low-risk papillary thyroid cancer,” The Lancet, vol. 381, no. 9871, pp. 1046–1057, 2013.
[7]
V. Muntean, I. Domsa, A. Zolog, et al., “Incidental papillary thyroid microcarcinoma: is completion surgery required?” Chirurgia, vol. 108, no. 4, pp. 490–497, 2013.
[8]
L. Pedrazzini, A. Baroli, L. Marzoli, R. Guglielmi, and E. Papini, “Cancer recurrence in papillary thyroid microcarcinoma: a multivariate analysis on 231 patients with a 12-year follow-up,” Minerva Endocrinologica, vol. 38, no. 3, pp. 269–279, 2013.
[9]
D. Piciu, A. Piciu, and A. Irimie, “Papillary thyroid microcarcinoma and ectopic papillary thyroid carcinoma in mediastinum: a case report,” Clinical Nuclear Medicine, vol. 37, no. 2, pp. 214–215, 2012.
[10]
M. Volante, M. Papotti, J. Roth et al., “Mixed medullary-follicular thyroid carcinoma: molecular evidence for a dual origin of tumor components,” American Journal of Pathology, vol. 155, no. 5, pp. 1499–1509, 1999.
[11]
R. Ben Salah, A. Mekni, R. Doghri, et al., “A mixed medullary-follicular thyroid carcinoma discovered by fine needle aspiration,” La Tunisie Medicale, vol. 90, no. 6, pp. 488–490, 2012.
[12]
M. ？akir, H. Altunba？, M. K. Balci, ü. Karayal？in, and G. Karpuzo？lu, “Medullary thyroid carcinoma, follicular variant,” Endocrine Pathology, vol. 13, no. 1, pp. 75–79, 2002.
[13]
P. Zoroquiain, J. Torres, I. Goni, L. Fernandez, and A. Solar, “True mixed medullary papillary carcinoma of the thyroid: a case report with low blood calcitonin levels,” Endocrine Pathology, vol. 23, no. 3, pp. 168–171, 2012.
[14]
A. N. Hanna, C. W. Michael, and X. Jing, “Mixed medullary-follicular carcinoma of the thyroid: diagnostic dilemmas in fine-needle aspiration cytology,” Diagnostic Cytopathology, vol. 39, no. 11, pp. 862–865, 2011.
[15]
R. Luboshitzky and M. Dharan, “Mixed follicular-medullary thyroid carcinoma: a case report,” Diagnostic Cytopathology, vol. 30, no. 2, pp. 122–124, 2004.
[16]
D. S. Cooper, G. M. Doherty, B. R. Haugen et al., “Revised American thyroid association management guidelines for patients with thyroid nodules and differentiated thyroid cancer,” Thyroid, vol. 19, no. 11, pp. 1167–1214, 2009.
[17]
A. R. Shaha, “TNM classification of thyroid carcinoma,” World Journal of Surgery, vol. 31, no. 5, pp. 879–887, 2007.
[18]
P. Maruna, J. Duskova, Z. Limanova, S. Dvoraková, E. Vaclavikova, and B. Bendlova, “Mixed medullary and follicular cell carcinoma of the thyroid in a 71-year-old man with history of malignant melanoma,” Medical Science Monitor, vol. 14, no. 4, pp. CS31–CS36, 2008.
[19]
M. Kos, V. Separovi？, and B. Sarcevi？, “Medullary carcinoma of the thyroid: histomorphological, histochemical and immunohistochemical analysis of twenty cases,” Acta Medica Croatica, vol. 49, no. 4-5, pp. 195–199, 1995.
