A 65-year-old man with anaplastic thyroid carcinoma presents with a 6 cm mass replacing the left lobe, fixed to strap muscles, with level III lymphadenopathy. CT chest shows no distant metastases. Performance status is ECOG 2. What is the most appropriate initial management strategy?

• A Total thyroidectomy with modified radical neck dissection followed by adjuvant chemoradiation
• B Palliative external beam radiotherapy alone to the neck
• C Tracheotomy for airway protection, biopsy for tissue diagnosis, followed by concurrent chemoradiation ✓
• D Empirical radioiodine therapy after confirming iodine avidity on PET scan

Explanation

Anaplastic thyroid carcinoma is aggressive and often unresectable at presentation. The priority is airway protection (tracheotomy may be needed), tissue diagnosis via biopsy, followed by concurrent chemoradiation if disease is confined to the neck. Surgery is reserved for rare cases where gross complete resection is achievable. Radioiodine is ineffective as anaplastic carcinoma is not iodine-avid. Palliative radiotherapy alone is suboptimal compared to concurrent chemoradiation for locoregionally confined disease in patients with acceptable performance status.

Reference: Robbins and Cotran Pathologic Basis of Disease, 10th ed.

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Written and medically reviewed by the StethoPrep medical team.