Giant papillary thyroid carcinoma with massive cystic degeneration and extensive neck involvement: a case report
Mkdad Khadoor, Ahmad Al-Bitar, Modar Doyya, Masa Daba, Souheb Al-MahasnaIntroduction:
Papillary thyroid carcinoma (PTC) is the most common thyroid malignancy and generally carries an excellent prognosis. However, a subset of patients presents with giant, locally aggressive tumors that pose significant management challenges, particularly when complicated by airway compromise, vocal cord palsy, and lymph node involvement.
Case presentation:
A 73-year-old man with no prior medical history presented with a 4-year history of slowly enlarging neck masses. Clinical examination revealed a massive goiter without palpable lymphadenopathy. Imaging demonstrated a large thyroid mass with cystic and solid components and severe tracheal deviation. Multiple suspicious cervical lymph nodes were present. Laboratory studies showed suppressed TSH (0.005 mIU/L) with normal free thyroid hormone levels. The patient underwent surgical debulking because the tumor was infiltrating the trachea. Gross pathology revealed a 760-gram thyroid gland measuring 26.5 × 13.5 × 6.5 cm with cystic degeneration and papillary excrescences. Histopathology confirmed PTC with lymphovascular invasion, extrathyroidal extension, and positive surgical margins. Cervical lymph nodes showed metastatic deposits. Postoperatively, the patient developed progressive respiratory failure and died approximately 45 days after surgery.
Clinical discussion:
This case illustrates several adverse prognostic features in PTC: advanced age (≥70 years), a giant tumor (>10 cm), gross extrathyroidal extension, lymphovascular invasion, bulky nodal metastases, and positive surgical margins. Such patients are at high risk for recurrence and disease-specific mortality. The patient’s clinical course, culminating in death within 45 days of surgery, underscores the aggressive nature of this presentation despite surgical intervention. Management requires multidisciplinary input, with surgical debulking followed by high-dose radioactive iodine and vigorous TSH suppression. Long-term surveillance is mandatory.
Conclusion:
Although PTC is typically indolent, it can occasionally reach a massive size with life-threatening local invasion. This case highlights the importance of recognizing aggressive clinicopathological features and tailoring adjuvant therapy accordingly. The rapid postoperative decline in this patient emphasizes that, even with surgical intervention, giant PTC with extensive local invasion carries a grave prognosis, particularly in elderly patients with multiple high-risk features.