Epidemiology of Simultaneous Medullary and Papillary Thyroid Carcinomas (MTC/PTC): An Italian Multicenter Study

Antineoplastic Effect of ALK Inhibitor Crizotinib in Primary Human Anaplastic Thyroid Cancer Cells with STRN-ALK Fusion In Vitro

Anaplastic thyroid cancer (ATC) is one of the deadliest human cancers and represents <2% of thyroid carcinomas. A therapeutic target for ATC is represented by anaplastic lymphoma kinase (ALK) rearrangements, involved in tumor growth. Crizotinib is an oral small-molecule tyrosine kinase inhibitor of the ALK, MET, and ROS1 kinases, approved in ALK-positive non-small cell lung cancer. Until now, the effect of crizotinib in "primary human ATC cells" (pATCs) with transforming striatin (STRN)-ALK fusion has not been reported in the literature. In this study, we aimed to obtain pATCs with STRN-ALK in vitro and evaluate the in vitro antineoplastic action of crizotinib. Thyroid surgical samples were obtained from 12 ATC patients and 6 controls (who had undergone parathyroidectomy). A total of 10/12 pATC cultures were obtained, 2 of which with transforming STRN-ALK fusion (17%). Crizotinib inhibited proliferation, migration, and invasion and increased apoptosis in 3/10 pATC cultures (2 of which with/1 without STRN-ALK), particularly in those with STRN-ALK. Moreover, crizotinib significantly inhibited the proliferation of AF cells (a continuous cell line obtained from primary ATC cells). In conclusion, the antineoplastic activity of crizotinib has been shown in human pATCs (with STRN-ALK) in preclinical studies in vitro, opening the way to future clinical evaluation in these patients.

Critically evaluated key points on hereditary medullary thyroid carcinoma

Medullary thyroid carcinoma (MTC) accounts for only 3% of all thyroid carcinomas: 75% as sporadic MTC (sMTC) and 25% as hereditary MTC (hMTC) in the context of multiple endocrine neoplasia type 2 (MEN2). Early diagnosis is possible by determining the tumour marker calcitonin (Ctn) when clarifying nodular goitre and by detecting the mutation in the proto-oncogene RET in the MEN2 families. If the Ctn level is only slightly elevated, up to 30 pg/ml in women and up to 60 pg/ml in men, follow-up checks are advisable. At higher levels, surgery should be considered; at a level of > 100 pg/ml, surgery is always advisable. The treatment of choice is total thyroidectomy, possibly with central lymphadenectomy. In the early stage, cure is possible with adequate surgery; in the late stage, treatment with tyrosine kinase inhibitors is an option. RET A mutation analysis should be performed on all patients with MTC. During follow-up, a biochemical distinction is made between: healed (Ctn not measurably low), biochemically incomplete (Ctn increased without tumour detection) and structural tumour detection (metastases on imaging). After MTC surgery, the following results should be available for classification in follow-up care: (i) histology, Ctn immunohistology if necessary, (ii) classification according to the pTNM scheme, (iii) the result of the RET analysis for categorisation into the hereditary or sporadic variant and (iiii) the postoperative Ctn value. Tumour progression is determined by assessing the Ctn doubling time and the RECIST criteria on imaging. In most cases, "active surveillance" is possible. In the case of progression and symptoms, the following applies: local (palliative surgery, radiotherapy) before systemic (tyrosine kinase inhibitors).

TIROSEC: Molecular, Clinical and Histopathological Profile of Papillary Thyroid Carcinoma in a Colombian Cohort

INTRODUCTION

In Colombia, thyroid cancer ranks among the highest incidences, yet our population lacks studies on its molecular profile. This study aims to characterize clinical, histopathologic and molecular data in a Colombian cohort with papillary thyroid carcinoma (PTC).

METHODS

A retrospective review of clinical history, clinicopathologic characteristics, treatment and 5-10-year follow-up for all patients was done. DNA and RNA were extracted from formalin-fixed paraffin-embedded (FFPE) tissue using the Quick-DNA & RNA FFPE Min iPrep kit (Zymo Research). Next-generation sequencing (NGS) analysis was performed with SOPHiA Solid Tumor Solutions kit (SOPHiA GENETICS). Tumor mutation genomic analysis used SOPHiA DDM™ platform, with descriptive analysis reporting frequencies, means and associations via chi-square analysis.

RESULTS

Among 231 sequenced patients, mean age at diagnosis was 46 (± 12.35) years, with higher frequency in women (81.82%). Two cases were reclassified as non-invasive follicular thyroid neoplasm (NIFT-P); an NRAS mutation was found in one of them. Predominant histologic subtype was classic PTC (57.64%) followed by tall cell (28.82%). Of the 229 sequenced carcinomas, mutations were identified in 186 cases, including BRAF, IDH1, RAS and PIK3CA. Notable copy number variations (CNVs) were PDGFRA, CDK4 and KIT, with RET being the most frequent gene fusion, including CCDC6-RET in two classic subtype cases.

CONCLUSION

This is the first study in Colombia (TIROSEC) to our knowledge that integrates molecular and histopathologic profiles enriching our local comprehension and knowledge of PTC. The identification of target mutations such as BRAF, RET and NTRK fusions holds the potential to guide targeted therapies for tumor recurrence and predict aggressive behavior.

Measuring discrepancies between simple medullary and synchronous medullary/papillary thyroid carcinomas: a comparative cross-sectional study

Objective

To study the clinicopathological characteristics of patients with synchronous medullary and papillary thyroid carcinomas.

Methods

The clinical data of patients with medullary thyroid carcinoma (MTC) operated in our hospital (Department of Thyroid Surgery, China-Japan Union Hospital, Jilin University) from February 2009 to February 2023 were evaluated using an analytical review approach. They were divided into an observation group (patients with synchronous MTC and papillary thyroid carcinoma PTC) and a control group (simple MTC) according to whether the clinical data were associated with MTC, in order to compare the clinical features, pathological types, stage characteristics and molecular biology characteristics of the two groups and to investigate the follow-up of the two groups.

Results

The study included 122 MTC, 30 with synchronous MTC/PTC and 92 simple MTC. When the data were compared, the sex ratio, preoperative calcitonin level, preoperative CEA level, presence of calcifications in the MTC lesions, surgical methods, number of MTC lesions, presence of nodular goitre and presence of thyroiditis were higher in the observation group than in the control group. There was a significant difference between the groups when the MTC lesion diameter was ≤1cm in terms of preoperative CEA value (P<0.05); when the MTC lesion diameter was >1cm, there was a statistical difference between the two groups in terms of preoperative Ctn value (P<0.05). Type III was significantly different from the simple group, while type IV was more similar to the simple group. The preoperative serum Ctn value was positively correlated with maximum tumour diameter in both groups, although the correlation was stronger in the easy group. Preoperative CEA was positively correlated with maximum tumour diameter in both groups, with a stronger correlation in the combination group. Preoperative Ctn and CEA were positively correlated with lymph node metastasis in the simple group, whereas there was no apparent correlation with lymph node metastasis in the combination group. The cut-off value of preoperative serum Ctn for cervical lymph node metastases in the simple group was 39.2pg/ml and for lateral cervical lymph node metastases 195.5pg/ml. The cut-off value of preoperative serum Ctn for cervical lymph node metastases in the combination group was 60.79pg/ml and for lateral cervical lymph node metastases 152.6pg/ml. In the simple group, prognosis was significantly worse in the progression group (P<0.001), with no statistical difference between the remission and stable groups. In the combination group, the prognosis of the progression and stable groups was significantly worse than that of the remission group (P<0.001), with no statistical difference between the progression and stable groups.

Conclusion

In patients with synchronous medullary and papillary thyroid carcinomas, preoperative Ctn and CEA levels, calcifications, solitary lesions, combined goitre or thyroiditis differ significantly from simple MTC. Therefore, clinical management should pay attention to the above factors and early risk screening should be performed to improve prognosis as much as possible.

Simultaneous Occurrence of Medullary Thyroid Carcinoma and Papillary Thyroid Carcinoma: A Case Series with Literature Review

BACKGROUND

Papillary thyroid carcinoma (PTC) is the most common type of differentiated TC, while medullary TC (MTC) accounts for 4%. The concomitant presence of PTC and MTC is rare.

METHODS

This is a retrospective, single-center observational study conducted over 16 years (2001-2017). The data were collected from the clinical records of patients who underwent total thyroidectomy at the Endocrine Unit-Department of Medicine of the University Hospital of Pisa, Italy.

RESULTS

Over 690 analyzed cases, 650 (94.2%) were exclusive DTC, 19 exclusive MTC (2.75%) and 5 PTC/MTC (0.7%). No case of mixed medullary/follicular TC or hereditary MTC (familial MTC/multiple endocrine neoplasia type 2) was found. Among the five PTC/MTC cases, there was a male prevalence (M:F = 3:2), and all PTC components were at stage I, whereas 40% of MTC were at stage I and III and 20% of MTC were at stage II; microPTC (mPTC) was prevalent (80%) and also microMTCs were frequent (40%); 60% of MTC patients recovered, while 40% of patients developed metastatic disease. The search for germline mutations of the RET gene resulted in being negative in all cases.

CONCLUSIONS

The incidence of PTC/MTC has been increasing over the past 30 years. The etiology of PTC/MTC forms is still unknown, and although this simultaneous occurrence could be only a coincidence, we cannot exclude the hypothesis of a shared genetic origin.

Synchronous occurrence of medullary and papillary thyroid cancer and survival rates

PURPOSE

Concurrence of medullary and papillary thyroid carcinoma (MTC and PTC) represents less than 1% of all thyroid malignancies. We aimed to reveal the demographic and clinical characteristics of this rare pathology and to evaluate the effect of the same or contralateral lobular localization of these two malignancies in clinical and laboratory features. Evaluation of progression-free survival (PFS) in current pathology is one of the important features of our study.

METHODS

All patients diagnosed with simultaneous MTC and PTC after thyroidectomy were evaluated retrospectively. Data on the following variables were recorded: age, gender, tumor localization (ipsilateral lobe located MTC and PTC-Group I, contralateral lobe located MTC and PTC-Group II), tumor size, cervical lymph node metastasis, distant metastasis, tumor stage, postoperative basal calcitonin, carcinoembryonic antigen, thyroglobulin (Tg), and anti-Tg values. In all our cases, since MTC progressed before PTC, progression was accepted as serum calcitonin values exceeded 150 pg/mL.

RESULTS

Groups were formed as follows: Group I, four cases where MTC and PTC were localized in different foci in the same lobe; Group II, nine cases where they were localized in different lobes. There was only one case in which two tumors were located in the same focus. The case with dual differentiation was included in Group I (35. 7%). When the PFS of the two groups were compared, no statistically significant difference was found ( P = 0.87).

CONCLUSIONS

As a result of this analysis, the location of the simultaneously detected PTC in the same or different lobes with the MTC does not make a significant difference in clinical and laboratory features.

Mixed medullary‑follicular thyroid carcinoma: A case report and literature review

Papillary thyroid cancer (PTC) and medullary thyroid cancer (MTC) originate from follicular and neuroendocrine parafollicular C cells, respectively. PTC and MTC simultaneously exist in tumors containing both MTC and PTC features in a rare condition known as mixed medullary-follicular thyroid carcinoma (MMFTC). In the present study, a 60-year-old female presented with a small mass on the left side of the neck. Ultrasonography indicated a hyperechoic nodule measuring ~11.9×9.7 mm2 in the left lobe of the thyroid gland. The preoperative calcitonin serum value was elevated and total thyroidectomy and bilateral central compartment lymph node dissection was performed. Histological and immunohistochemical analysis of the tumor demonstrated MMFTC. No metastasis was observed in lymph nodes isolated from the bilateral central compartment. Given the rarity of MMFTC, enhancing understanding and management of such tumors is crucial.

Case reports of collision and composite carcinomas of the thyroid: an insight into their origin and clinical significance

BACKGROUND

Collision and composite carcinomas of the thyroid are extremely rare, and their clinical and biological characteristics are poorly understood.

CASE PRESENTATION

The first case was a 41-year-old female patient with a right thyroid nodule. Pathological diagnosis was papillary thyroid carcinoma (PTC) and medullary thyroid carcinoma composite carcinoma. Surgical treatment was right thyroid lobectomy + left partial thyroidectomy + right central neck lymph node dissection. The second case was a 60-year-old female with bilateral thyroid nodules. Total thyroidectomy was performed, and the pathological diagnosis was thyroid collision carcinoma involving follicular thyroid carcinoma on the left side and PTC on the right side. The clinical, histological and gene changes of collision and composite carcinomas of the thyroid are poorly described. With different biological invasion characteristics, the ideal treatment and the prognosis is currently unknown and individualized treatment is necessary.

CONCLUSIONS

It is recommended that in composite carcinoma, each cancer is evaluated and treated according to the most severe tumor. Collision carcinoma should be treated as two separate synchronous primary tumors. For both collision and composite carcinomas of the thyroid, the follow-up after treatment should be extensive.

Organochlorine pesticides and epigenetic alterations in thyroid tumors

Purpose

Cancer incidence depends on various factors e.g., pesticide exposures which cause epigenetic alterations. The present research aimed to investigate the organochlorine pesticides (OCPs) impacts on promoter methylation of three tumor-suppressor genes and four histone modifications in thyroid nodules in 61 Papillary thyroid carcinoma (PTC) and 70 benign thyroid nodules (BTN) patients.

Methods

OCPs were measured by Gas chromatography. To identify promoter methylation of TSHR, ATM, and P16 genes, the nested-methylation-specific PCR (MSP) was utilized, and histone lysine acetylation (H3K9, H4K16, and H3K18) and lysine methylation (H4K20) were detected by performing western blot analysis.

Results

Further TSHR methylation and less P16 methylation were observed in PTC than in BTN. No substantial difference was detected for ATM methylation between PTC and BTN groups. Also, OCP dramatically increased the odds ratio of TSHR (OR=3.98, P=0.001) and P16 (OR=5.65, P<0.001) methylation while confounding variables reduced the chances of ATM methylation arising from 2,4-DDE and 4,4-DDT influence. Hypomethylation of H4K20 and hypo-acetylation of H3K9, H4K16, and H3K18 (P<0.001) were observed in PTC samples than BTN. Furthermore, OCPs substantially decreased the odds ratio of H3K9 (OR=3.68, P<0.001) and H4K16 (OR=6.03, P<0.001) acetylation.

Conclusion

The current research indicated that OCPs could contribute to PTC progression by TSHR promoter hypermethylation and decreased acetylation of H3K9 and H4K16. In addition, in PTC patients, assessing TSHR promoter methylation and acetylation of H3K9 and H4K16 could have predictive values.

The protean role of Val804Met RET mutation in thyroid neoplasms: An example of a "MEN2C" syndrome?

BACKGROUND

Val804Met RET is one of the most common genetic alterations in Multiple Endocrine Neoplasia 2 and is considered to confer only a moderate risk for familial medullary thyroid carcinoma (MTC). The associated phenotype can however be much more complex in some cases.

METHODS

A clinical, genetic, and pathological analysis was conducted on a family cluster of thyroid neoplasms associated with Val804Met RET mutation.

RESULTS

All the kindreds who are carriers of the mutated RET received total thyroidectomy + /- VI level dissection. The proband presented with a pT1bN0 MTC, her 29-yo brother showed a concomitant papillary thyroid carcinoma (PTC) and MTC, their father had a pT1a PTC plus a follicular adenoma, while the uncle of the proband showed C-cell hyperplasia. None had clinical or biochemical evidence of parathyroid disorders or pheochromocytoma.

CONCLUSIONS

In the presence of Val804Met RET several types of thyroid premalignant and malignant should be screened for, and without limiting to MTC.

Thyroid Collision Tumors: The Presence of the Medullary Thyroid Carcinoma Component Negatively Influences the Prognosis

Thyroid collision tumors (TCTs) are rare pathological findings, representing <1% of thyroid cancers. This study aimed to compare the main pathological features of TCTs containing medullary thyroid carcinoma (MTC) and papillary thyroid carcinoma (PTC) components with MTC-only tumors and PTC-only tumors. Methods: The retrospective study included 69 cases diagnosed with TCTs (with simultaneous MTC and PTC components), MTC and PTC. All tumors were comparatively assessed for the classical histopathological prognostic features, including a new grading system for MTC. Results: The main component of TCTs had more frequent microscopic extrathyroidal extension (mETE) (p = 0.000), lymphovascular invasion (LVI) (p = 0.000), perineural invasion (PNI) (p = 0.044), and lymph node metastasis (p = 0.042). Additionally, the TCTs’ MTC component presented with more frequent LVI (p = 0.010). Comparing TCTs’ MTC and PTC components with MTC-only tumors and PTC-only tumors revealed that only the TCTs’ MTC components had statistically significant more frequent mETE (p = 0.010) than MTC-only tumors. When applied to the MTC component of TCTs, the pathological parameters of the new grading system of MTC showed no correlations with other microscopic or clinical aspects. Conclusion: Using classical pathological prognostic features, the comparative analysis revealed that the main TCTs’ component was more aggressive than the minor one. Contrary to PTCs, in TCTs, the medullary component was more aggressive than the papillary one, but also more aggressive than MTC-only tumors.

Clinical diagnostic value of American College of Radiology thyroid imaging report and data system in different kinds of thyroid nodules

BACKGROUND

To evaluate the diagnostic value of American College of Radiology (ACR) score and ACR Thyroid Imaging Report and Data System (TI-RADS) for benign nodules, medullary thyroid carcinoma (MTC) and papillary thyroid carcinoma (PTC) through comparing with Kwak TI-RADS.

METHODS

Five hundred nine patients diagnosed with PTC, MTC or benign thyroid nodules were included and classified into the benign thyroid nodules group (n = 264), the PTC group (n = 189) and the MTC group (n = 56). The area under the curve (AUC) values were analyzed and the receiver operator characteristic (ROC) curves were drawn to compare the diagnostic efficiencies of ACR score, ACR TI-RADS and KWAK TI-RADS on benign thyroid nodules, MTC and PTC.

RESULTS

The AUC values of ACR score, ACR TI-RADS and Kwak TI-RADS for distinguishing malignant nodules from benign nodules were 0.914 (95%CI: 0.886-0.937), 0.871 (95%CI: 0.839-0.899) and 0.885 (95%CI: 0.854-0.911), respectively. In distinguishing of patients with MTC from PTC, the AUC values of ACR score, ACR TI-RADS and Kwak TI-RADS were 0.650 (95%CI: 0.565-0.734), 0.596 (95%CI: 0.527-0.664), and 0.613 (95%CI: 0.545-0.681), respectively. The AUC values of ACR score, ACR TI-RADS and Kwak TI-RADS for the discrimination of patients with MTC, PTC or benign nodules from patients without MTC, PTC or benign nodules were 0.899 (95%CI: 0.882-0.915), 0.865 (95%CI: 0.846-0.885), and 0.873 (95%CI: 0.854-0.893), respectively.

CONCLUSION

The ACR score performed the best, followed ex aequo by the ACR and Kwak TI-RADS in discriminating patients with malignant nodules from benign nodules and patients with MTC from PTC.

Thyroglobulin Measurement Through Fine-Needle Aspiration for Optimizing Neck Node Dissection in Papillary Thyroid Cancer

BACKGROUND

Thyroglobulin measurement in fine-needle aspiration (FNA-Tg) is an additional diagnostic tool of lymph node metastasis (LNM) in papillary thyroid carcinoma (PTC). However, its performance as a preoperative indicator of lateral neck LNM in PTC is unclear. We evaluated the use of FNA cytology and FNA-Tg to detect neck LNM presurgery using a simple methodology, and established a cut-off value for diagnosing LNM in PTC.

METHODS

We performed a retrospective cohort study based on hospital records, including 299 FNA-Tg measurements from 228 patients with PTC. The cut-off value for FNA-Tg was obtained through a receiver operating characteristic (ROC) curve analysis. The relationships between various parameters and FNA-Tg were analyzed using Spearman's correlation.

RESULTS

Of 299 lymph nodes (LNs) from 228 patients following surgery, 151 were malignant and 148 were benign. The median FNA-Tg levels were 414.40 ng/mL and 6.36 ng/mL in the metastatic and benign LNs, respectively. An FNA-Tg cut-off value of 28.3 ng/mL had the best diagnostic performance (93.38% sensitivity, 70.27% specificity, area under the ROC curve [AUC] 0.868) in the whole cohort. The diagnostic value performed better in the lateral neck group (level II-V, n = 163) than in the central neck group (level VI, n = 136); in the lateral neck group, the sensitivity and specificity of the FNA-Tg cut-off (16.8 ng/mL) were 96.25% and 96.36%, respectively.

CONCLUSIONS

FNA-Tg is a useful technique for the diagnosis of LNM before surgery, especially in lateral neck dissection.

CLINICAL TRIAL REGISTRATION NUMBER

ChiCTR1900028547.

A new proposed tumor-node-metastasis-age staging system for stage IV medullary thyroid carcinoma based on the SEER database

Medullary thyroid carcinoma (MTC) is a rare and lethal cancer. There are currently controversies regarding its staging. This study aimed to verify the significance of the patient's age in the prognosis of MTC and propose its addition to the current staging system. Data on cancer-specific survival (CSS) from the Surveillance, Epidemiology, and End Results database between 2010 and 2015 were used. X-Tile, nomograms, Cox proportional hazards regression analysis, Kaplan-Meier curves, and log-rank tests were used to evaluate mortality rates to create a new staging system. A total of 849 patients were included. Patients were divided into three categories based on their ages at diagnosis: ≤41 years, n = 224 (26.4%); 42-71 years, n = 516 (60.8%); and ≥72 years, n = 109 (12.8%). Independent factors for survival in the multivariate analysis included age (42-71 years, hazard ratio [HR], 2.81, 95% confidence interval [CI], 1.07-7.42; ≥72 years, HR, 8.71, 95% CI, 2.88-26.34), T stage (T2, HR, 3.60, 95% CI, 1.31-9.88), and M stage (M1, HR, 8.43, 95% CI, 4.40-16.16), with P<0.05. The Harrell's concordance index for tumor node metastasis (TNM) nomogram and TNM-age nomogram was 0.904 and 0.908, respectively. The areas under the curve (AUCs) for a 3-year CSS were 0.88 and 0.873, respectively. The corresponding AUCs for a 5-year CSS were 0.892 and 0.888, respectively. A new TNM-age staging system based on cancer-specific mortality rate analysis is proposed. This system provides a more accurate risk stratification and ensures more rational treatment measures for patients with stage IV MTC.

Mixed medullary-papillary thyroid carcinoma with mixed lymph node metastases: A case report

Mixed medullary-follicular-derived carcinoma is a very rare event. It is extremely important to make the correct diagnosis, due to prognostic and treatment implications. A genetic study of these patients is advisable to exclude the presence of MEN 2.

What Is New in Thyroid Cancer: The Special Issue of the Journal Cancers

The incidence of thyroid cancer has increased over the past 3 to 4 decades. Nonetheless, the mortality from thyroid cancer has remained stable. The thyroid gland may develop nodules encompassing several types of cell proliferation, from frankly benign to very aggressive forms with many intermediate challenging variants. For this reason, there is growing interest in evaluating thyroid nodules from many points of view, from the clinical to the molecular aspects, in the search for innovative diagnostic and prognostic parameters. The aim of this Special Issue was to provide an overview of recent developments in understanding the biology and molecular oncology of thyroid tumors of follicular cell derivation and their repercussions on the diagnosis, prognosis, and therapy. The contributions of many experts in the field made up a Special Issue of Cancers journal, that focusing on different aspects, including mechanistic and functional facets, gives the status of art of clinical and biological perspectives of thyroid cancer.

Intermixed medullary and papillary thyroid cancer in a patient with renal cell carcinoma

SUMMARY

We report a rare case of concurrent medullary thyroid cancer (MTC) and papillary thyroid cancer (PTC) with intermixed disease in several of the lymph node (LN) metastases in a patient who was subsequently diagnosed with clear cell renal cell carcinoma (RCC). A 56 year old female presented with dysphagia and was found to have a left thyroid nodule and left superior cervical LN with suspicious sonographic features. Fine needle aspiration biopsy (FNAB) demonstrated PTC in the left thyroid nodule and MTC in the left cervical LN. Histopathology demonstrated multifocal PTC with 3/21 LNs positive for metastatic PTC. One LN in the left lateral neck dissection exhibited features of both MTC and PTC within the same node. In the right lobe, a 0.3 cm focus of MTC with extra-thyroidal extension was noted. Given persistent calcitonin elevation, a follow-up ultrasound displayed an abnormal left level 4 LN. FNAB showed features of both PTC and MTC on the cytopathology itself. The patient underwent repeat central and left radical neck dissection with 3/6 LNs positive for PTC in the central neck and 2/6 LNs positive for intermixed PTC and MTC in the left neck. There was no evidence of distant metastases on computed tomography and whole body scintigraphy, however a 1.9 x 2.5 cm enhancing mass within the right inter-polar kidney was discovered. This lesion was highly suspicious for RCC. Surgical pathology revealed a 2.5 cm clear cell RCC, Fuhrman grade 2/4, with negative surgical margins. She continues to be observed with stable imaging of her triple malignancies.

LEARNING POINTS

Mixed medullary-papillary thyroid neoplasm is characterized by the presence of morphological and immunohistochemical features of both medullary and papillary thyroid cancers within the same lesion. Simultaneous occurrence of these carcinomas has been previously reported, but a mixed disease within the same lymph node is an infrequent phenomenon. Prognosis of mixed medullary-papillary thyroid carcinomas is determined by the medullary component. Therefore, when PTC and MTC occur concurrently, the priority should be given to the management of MTC, which involves total thyroidectomy and central lymph node dissection. Patients with thyroid cancer, predominantly PTC, have shown higher than expected rates of RCC. To our knowledge, this is the first report describing the combination of MTC, PTC, and RCC in a single patient.