A 48 y.o. male comes in with shortness of breath

what do you notice on his xray?

hint: where is the trachea ; how should the patient be managed.

Our patient is awaiting surgery and genetic analysis  for a NUT carcinoma of the thyroid. This is a rare aggressive tumor that  arises from midline structures in the  head, neck or thorax. The disease results from a rearrangement of the nuclear protein in the testis (NUTM1) gene on chromosome 15q14, most commonly leading to fusion to the BRD-3 or BRD-4 gene. It results in a rapidly growing poorly differentiated tumor with a poor prognosis.

While NUT carcinoma is extremely rare, anaplastic carcinoma of the thyroid, an alternative diagnosis, is also extremely rare. It is also a poorly differentiate tumor but often presents with mets to the lungs. In the 1930’s- 1970’s radiation was a standard treatment for tonsillitis, ear infection and acne.  But abnormal rate of thyroid cancers were noted in later life in children who had been irradiated. Follicular thyroid cancer can occur 30 or 40 years after radiation. While the practice of radiation is no longer practiced, radiation from nuclear accidents like Chernobyl have resulted in an increase in thyroid carcinoma even today.

While these are very aggressive tumors there is a spectrum of thyroid masses which include benign disease. Goiters were very common prior to the addition of iodine to salt.  30-70% of children had goiters in the Great Lakes, Appalacian Pacific Northwest..   In WWI goiters  disqualified  many individuals for military service.  Iodized salt was first available in 1924.  In addition to salt, iodine is found dairy foods(mild cans are cleaned with iodophor), seafood, seaweed, and grains( if they are grown in iodine rich soils).

Our patient’s airway was of concern.  He was admitted to the ICU and placed on steroids.  It was determined he did not have lymphoma and surgery was scheduled for Dec 15.  He elected to go home rather than wait in the ICU.  While he had mild wheezing with exertion, he had no significant airway compromise.

Kuo LKuo L, Barletta J, Schoenfeld J,et al NUT carcinoma of the thyorid: an unusual case with a complete response to treatment. Clinical Thyroidology 2021;33:38-47.

French C, Bishop JA, Lewis JS, Muller S, Westra WH. “NUT carcinoma.” In WHO Classification of Head and Neck Mumours. A. El-Naggar, J.K.C. Chan, J Grandis, T. Takata, P. Slootweg, Eds. IARC Press 2017. 21.

Leung A,Braverman L, Pearce E.  History of the U.S. Iodine fortification and supplementation.  Nutrients 2012 Nov;4(11) 1740-46.

Pearce E. Iodine Policy in the United States https://slideplayer.com/slide/7049508/