A significant response to sunitinib in a patient with anaplastic thyroid carcinoma
A 79-year-old man with a medical history of hypertension and diabetes was diagnosed with a localized papillary thyroid carcinoma was admitted at the Ramón y Cajal University Hospital Madrid (Spain). There was no evidence of distant metastasis at diagnosis. The patient underwent a total thyroidectomy and a suspicious right-cervical lymph node was also resected. The pathological stage after surgery was pT2 pN1b M0. Following surgery, thyroid ablation therapy with 150 mCi of radioactive iodine (131I) was given. One year later, although no evidence of distant spread of the disease was observed in a whole body scan, serum thyroglobulin levels were 24 ng/ml (normal range <3 ng/mL), despite suppressive thyroxin therapy. Therefore, a second course of 131I was administered, achieving a total dose of 350 mCi of 131I. Two years after surgery, during a follow-up visit, it was noted that the patient had recurrence of his disease, due to a rapid appearance of a midline hard, rigid, painful, and violet neck mass, just below the scar of previous thyroidectomy, and bilateral cervical lymph nodes [] together with moderate dyspnoea. Macroscopic neck mass size was initially measured as 6.5 × 3.5 cm. Multiple and bilateral lung metastasis were detected in a computer tomography (CT) scan. Fine needle aspiration cytology of the thyroid mass revealed anaplastic thyroid carcinoma cells. Based on recent reported data with multi-target tyrosine kinase inhibitors in iodine-refractory thyroid cancer patients added to the age, performance status, and comorbidities of the patient, we decided to start treatment with sunitinib (SUTENT®, Pfizer Inc, NY) as a single agent under “off-label” use request from a clinical trial. The patient signed the appropriate informed consent and local legal procedures were followed. Sunitinib was administered orally at 50 mg per day for 4 weeks followed by 2 weeks of rest. A weekly follow up was undertaken and at the first week of treatment a reduction in neck tumor bulk was noted (6.0 × 3.0 cm) with clinical improvement of pain and less violet neck mass []. After the start of the treatment for 4 weeks the tumor mass clearly showed a reduction in size (3.0 × 1.5 cm) and skin color was almost normal []. The patient reported neither pain nor dyspnoea at this time and Eastern Cooperative Oncology Group (ECOG) performance status was 0. After the end of second cycle, 12 weeks from the beginning of treatment, a complete macroscopic response of the ATC in the neck was achieved [] and it was maintained for 8 more weeks. Tolerability of sunitinib was acceptable with grade 2 asthenia and grade 2 neutropenia with only one week of rest needed to recover after third cycle. However, response in tumor size over neck mass did not correlate with lung metastasis shrinkage that were stable after 12-20 weeks of treatment. Unfortunately, the patient died as a result of a massive upper gastrointestinal bleeding 5 months after the start of sunitinib treatment and while the patient was still on treatment.