Jose R.

Reyes Memorial Medical Center

Department of Surgery

Protocol
August 10, 2023, 2:00 PM

General Information:
EM 56/F

Chief Complaint:
Difficulty of breathing

History of Present Illness:

The patient had a 5 year history of enlarging anterior neck mass, initially noted around
4cm in diameter, described as well circumscribed and movable, during this time no other
symptoms was noted other than the mass. No consult was done and no medications were
taken.

Interval history showed gradual enlargement of the lesion, patient sought consult at our
institution. 2 months prior, there was noted a rapid enlargement of the neck mass. This is
was accompanied by voice changes, cough and occasional episodes of dyspnea.

1 week prior to consult, patient had productive cough, consult done at local clinic, given
antibiotics for 7 days but with temporary relief which prompted consult at our institution.

Past Medical History:

 (-) DM
 (-) HTN
 (+) Asthma- diagnosed last 2018, last attack 3 weeks prior
 (-) PTB
 (-) Cardiac disease
 (-) Pulmonary disease
 (-) kidney disease
 (-) Allergies
 (-) previous surgery

Family History:
 (-) HTN
 (-) DM
 (-) Asthma
 (-) PTB
 (-) Cardiac disease
 (-) Pulmonary disease
  (-) Renal disease
 (-) CVA
 (-) Cancer

Personal/Social History:
 Non smoker
 Non alcoholic beverage drinker
 No illicit drug use

Review of Systems:
(+) unquantified weight loss
(+) bone pains

Physical Examination:
 ECOG : 1
 Weight: 45.5 kg
 Height: 1.54 m
 BMI: 19.1

 GCS 15
 Awake, not in distress
 120/80 102 18 36.5 99%
 Pink palpebral conjunctivae, anicteric sclera
 (+) multinodular mass on the anterior neck, does not move with deglutition and
tongue protrusion, fixed
 Symmetric chest expansion, (+) bilateral wheezes, (+) stridor
 Adynamic precordium, no murmurs
 Abdomen non distended, normoactive bowel sounds, soft and nontender
 Full and equal pulses

Ancillaries:
Neck CT Scan with IV Contrast (07/27/23, JRRMMC)

A large, fairly-defined, lobulated, heterogeneously-enhancing mass with necrotic

areas as well as ring-like central calcification is seen in the right side of the neck,
measuring approximately 14.6 x 12.3x7.8 (CCxTx AP) extending from the right
parotid space at the level of C1 down to the level of T4 at the right lower
paratracheal region. Mass effect is seen as contralateral deviation of the
pharyngeal and laryngeal airway and causing marked narrowing of its lumen, most
pronounced between the level of T1 , measuring 0.4 x 1.2 cm

It likewise causes contralateral displacement of the hyoid bone, thyroid cartilage,

cricoid as well as arytenoid cartilages. It is seen to encase and obliterate the right
internal jugular vein with abrupt cut-off of contrast material at the level of C4
vertebra. It also encases the ipsilateral common and external carotid arteries, left
common carotid artery and left internal jugular vein. The right thyroid lobe is not
visualized. The left thyroid lobe is occupied by multiple, hypodense lesions, the
largest measuring approximately 1.2 cm in its widest dimension.

The following extensions are seen

-Superiorly, involving the right submandibular space.

-Anteriorly, to involve the bilateral submandibular and anterior cervical spaces
-Inferiorly, into the right lower paratracheal region and prevascular space,
encasing the right brachiocephalic artery.

Several, enhancing, prominent to enlarged lymph nodes, some with necrotic

centers, are visualized in the submental, right submandibular, right upper to lower
internal jugular, left lower internal jugular, right paratracheal and prevascular
regions, the largest measuring 1.9 cm in short axis dimension.

The parotid glands are within normal size with normal density and configuration.

The visualized bones are intact

Partially visualized chest shows multiple varisized nodules and masses in the
bilateral upper lobes, the largest of which measures 3.7 x 24 cm (TxAP), likely
representing pulmonary metastases.

IMPRESSION:
Right neck mass with vascular encasement and multispatial extension exerting
mass effect consistent with the known case of malignancy, which may be thyroid
in origin
Cervical and mediastinal lymph node metastases
 Incidental finding of pulmonary metastases

Chest and Upper abdomen CT Scan with contrast (07/30/23, JRRMMC)

CHEST:

Multiple varisized hypoenhancing nodules and masses, some with pleural tagging, are
seen scattered in both lungs, the largest of which is located in the posterior segment of the
right upper lobe, measuring 4.0 x 3.4 x 2.9 cm.

Enlarged lymph nodes with necrotic centers are seen in the prevascular, paratracheal,
precarinal, and subcarinal regions, the largest measuring 1.7 cm in its short axis.

There is no demonstrable mediastinal mass noted.

Minimal pleural effusion is seen in both hemithoraces

There is no mass seen within the lumen of the trachea and pulmonary bronchi

The heart is enlarged. The aorta and pulmonary arteries are normal in caliber.

Osteophytes are noted along the anterior margins of the thoracolumbar spine.

The visualized chest wall soft tissues and osseous structures are intact.

Endotracheal tube and nasogastric tubes are seen in place.

UPPER ABDOMEN:

The right liver lobe is small in size while the left is enlarged, both with irregular contours
and homogenous tissue attenuation. There is calcification of the septa with fibrotic
changes. The biliary tree is not dilated.

The gallbladder is normal in size with thickened wall. No intraluminal densities seen are
seen. The pancreas, adrenal glands and spleen are normal in size with no focal lesions
seen. The pancreatic duct and common bile duct are not dilated.

The kidneys are normal in size, configuration with good excretion of the injected
contrast.

Renal arterial and parenchymal opacifications at both sides symmetrical and

simultaneous

The collecting systems are not dilated.

IMPRESSION:

CHEST:

-Pulmonary masses and nodules, as detailed above, worrisome for metastases.

-Enlarged lymph nodes, likely nodal metastases Minimal pleural effusion, bilateral.
-Degenerative osseous changes of the thoracolumbar spine

UPPER ABDOMEN:

-Hepatic cirrhosis with calcifications in keeping with fibrotic changes. Possibility of

schistosomiasis is not totally NOT excluded.
-Thickened gallbladder wall which may be reactive in nature.

FNAB (5/30/23, JRRMMC)

ROUND TO SPINDLE CELL NEOPLASM WITH ATYPICAL CYTOLOGIC FEATURES,
SPECIMENS LABELED "RIGHT THYROID LOBE" & “RIGHT CERVICAL LYMPH
NODE".

DIAGNOSIS:
Upper airway obstruction secondary to anaplastic thyroid carcinoma stage IVC
(cT4bN2cM1) with pulmonary metastasis
s/p fine needle aspiration biopsy (05/30/23, JRRMMC)
S/p core needle biopsy (08/01/23, JRRMMC)

PLAN
 For tracheostomy and tube gastrostomy
 Refer to radonco
 Refer to medonco
 Refer to palliative medicine
 Refer to dietary

Challenges/Dilemma:

1. What treatments can we offer for this patient considering the advance stage of the
tumor?