Rare dual pathology of the neck: synchronous papillary thyroid carcinoma and angiomatoid fibrous histiocytoma—a case report

Rare dual pathology of the neck: synchronous papillary thyroid carcinoma and angiomatoid fibrous histiocytoma—a case report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Rare dual pathology of the neck: synchronous papillary thyroid carcinoma and angiomatoid fibrous histiocytoma—a case report Aliya Ishaq, Warda Siddiqi, Iyad Hammadi, Arfan AlAwa This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8521659/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Introduction: Fibrohistiocytomas are uncommon mesenchymal tumors that typically originate in the dermis or subcutaneous tissue, and are rarely reported in deeper locations, such as bone, retroperitoneum, or the head and neck. Primary thyroid involvement is exceedingly rare, with only sporadic reports of benign and malignant variants. Papillary thyroid carcinoma (PTC) is the most prevalent thyroid malignancy, characterized by distinct nuclear features and well-established cytological criteria. The coexistence of PTC with fibrohistiocytoma within the thyroid region has not been previously described. We report a case of synchronous PTC and fibrohistocytoma, highlighting the diagnostic challenges posed by overlapping clinical and radiological features and underscoring the role of histopathology in guiding management. Case report ; A 52-year-old Asian male patient presented to our clinic with a history of massive neck swelling with a central open wound present for the past 2 months and now increasing in size. The swelling occupied almost the entire neck, and the neck nodes and thyroid gland were not palpable due to the presence of swelling. Further workup showed a suspicious thyroid nodule and neck swelling, which was attributable to metastatic lymph nodes. The thyroid nodule was biopsied and showed papillary thyroid cancer. The case was discussed in a multidisciplinary team meeting, and it was decided to proceed with total thyroidectomy with modified bilateral neck dissection. Histopathology showed two different pathologies: papillary thyroid cancer PT1b and a lateral neck mass. Histopathology of the lateral neck mass revealed fibrohistiocytoma. Conclusion: The case highlights the diagnostic challenges that arise when such tumors are present concomitantly. Lateral neck mass was attributed to be metastatic papillary thyroid cancer rather than a separate pathology, and no pre op biopsy of the mass was taken. When there is a discrepancy between the size of the primary tumor (in our case, a small thyroid papillary tumor) and the metastatic deposit (a large neck mass attributed to metastatic papillary thyroid cancer), separate biopsies should be taken from both regions to confirm the diagnosis. A multidisciplinary approach should be employed to manage this case. papillary thyroid cancer lateral aberrant thyroid fibrohistiocytoma metastatic papillary thyroid cancer Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Figure 8 Figure 9 Figure 10 Figure 11 Figure 12 Figure 13 Figure 14 Introduction Fibrohistocytoma, also known as fibrous histiocytoma, represents a spectrum of tumors characterized by a mixture of fibroblastic and histiocytic cells, often arranged in a storiform or cartwheel-like pattern (1,2). These tumors are most commonly benign and are frequently encountered as cutaneous lesions, referred to as dermatofibromas, which typically present as small, painless, slow-growing nodules in the dermis (3,4). While the majority of fibrous histiocytomas are benign, malignant variants—historically termed malignant fibrous histiocytoma (MFH)—are recognized and are now more accurately classified as undifferentiated pleomorphic sarcoma (5). Benign fibrous histiocytomas (BFH) usually arise in adults, with a predilection for the extremities and a peak incidence in the third and fourth decades of life (2). The etiology remains idiopathic mainly, though some cases have been associated with prior trauma, insect bites, or chronic inflammation. [ 3 , 10 – 12 ] Malignant forms, on the other hand, are aggressive soft tissue sarcomas that may develop in various anatomical sites, including the extremities, trunk, retroperitoneum, and, less commonly, the head and neck [ 3 , 4 , 8 , 10 ]. MFH is more prevalent in older adults and exhibits a male predominance [ 3 , 4 , 8 , 9 , 10 ]. Histopathological diagnosis of fibrous histiocytoma can be challenging due to its resemblance to other spindle cell tumors, necessitating the use of immunohistochemistry and, occasionally, electron microscopy for definitive diagnosis [ 2 , 3 ]. Subtypes, such as aneurysmal, epithelioid, and cellular variants, further complicate the clinical and pathological landscape [ 2 , 3 , 4 ]. Fibrous histiocytoma—does not appear in standard thyroid nodule classifications because it is not a typical thyroid neoplasm. It is primarily a soft tissue tumor, most often benign. It commonly arises in the skin, subcutaneous tissue, or deep soft tissues such as the extremities, trunk, or head and neck [ 2 , 13 ]. However, sporadic cases of primary malignant fibrous histiocytoma (MFH) of the thyroid have been reported in the literature, with fewer than 20 cases described worldwide [ 3 , 10 – 13 ]. In these rare instances, MFH presents as a primary sarcoma of the thyroid gland, distinct from the common epithelial-derived thyroid cancers (papillary, follicular, medullary, anaplastic). MFH of the thyroid is aggressive and has a poor prognosis, typically requiring surgical resection as the primary treatment [ 3 , 6 – 8 , 10 , 13 ]. Thus, while fibrohistiocytoma is not included in the routine classification of thyroid nodules or cancers, it should be considered in the differential diagnosis of primary thyroid sarcomas, especially in cases with atypical histology or clinical presentation [ 3 , 6 – 10 , 13 ]. Its extreme rarity in the thyroid gland explains its omission from standard thyroid nodule classification systems. Despite being a well-recognized entity in dermatopathology and soft tissue oncology, the epidemiology of fibrous histiocytoma, particularly its malignant forms, remains rarely reported in many regions, including the United Arab Emirates (UAE). Globally, benign fibrous histiocytomas are considered among the most common benign skin tumors. In contrast, malignant fibrous histiocytoma (now undifferentiated pleomorphic sarcoma) is the second most common soft tissue sarcoma in adults, with an annual incidence of approximately 0.88 cases per 100,000 population (3). In Saudi Arabia, a neighboring country with similar demographics, malignant fibrous histiocytoma accounts for about 13.2% of all soft tissue sarcomas, with an overall sarcoma incidence of 2.4 cases per million population per year—significantly lower than the rates reported in Western countries (6.3 cases per 100,000 in the US and 4.0 per 100,000 in Europe) (4). These regional differences may reflect variations in genetic, environmental, and healthcare factors, as well as possible underreporting or differences in cancer registry practices (4). By elucidating the epidemiology of fibrohistiocytoma in the UAE, this study aims to inform clinicians, pathologists, and public health authorities, ultimately contributing to the development of improved diagnostic, therapeutic, and preventive strategies for this diverse group of tumors. Case Report Patient information: A 52-year-old man presented with a slowly enlarging anterior neck mass of 12 months’ duration. The mass has gradually increased in size and is now causing pain and discharge. He denied dysphagia, dyspnea, voice changes, weight loss, or previous head and neck irradiation—no signs and symptoms of hypo or hyperthyroidism. There was no family history of thyroid malignancy. Clinical findings: On Physical examination, he was hemodynamically stable, and local neck examination revealed a firm, non-tender, mobile, 8 x 10 cm mass in the left lateral cervical region with overlying central skin necrosis and minimal discharge. The mass was not moving with deglutition or tongue protrusion. No cervical lymphadenopathy, cutaneous lesions, or systemic abnormalities were noted. Mass was occupying almost the entire neck, and examination of the thyroid or lymph nodes was practically not possible. An image of a clinical neck examination is shown in Fig. 1 , with the patient’s permission. Given the clinical findings, the differential diagnosis included lateral aberrant thyroid, lymphoma, or metastatic lymphadenopathy. The patient was reassured and scheduled for Diagnostic assessment; Further workup, including a contrast-enhanced CT scan of the neck, chest, abdomen, and pelvis, as well as a neck ultrasound, is recommended. Laboratory evaluation revealed normal thyroid function tests, excluding hyperthyroidism or hypothyroidism. Inflammatory markers were within normal limits, making thyroiditis unlikely. Neck ultrasound demonstrated a solid, hypoechoic left thyroid nodule 14.5 × 9.8 × 12 mm, slightly ill-defined with numerous echogenic and calcific foci, which was identified in the upper posterior zone of the left lobe, raising suspicion for papillary thyroid carcinoma, classified as TI-RADS 4, alongside a well-defined, hypoechoic lateral neck lesion distinct from the jugular chain. Fine-needle aspiration cytology (FNAC) of the thyroid nodule was reported as Bethesda IV (follicular neoplasm/suspicious for follicular neoplasm). A CT scan of the neck, chest, abdomen, and pelvis was done to assess the local extent of the lateral neck mass and its relationship with surrounding vital structures and distal metastases. Contrast-enhanced CT confirmed a discrete thyroid nodule and an adjacent soft-tissue lesion, with no evidence of extracapsular invasion or metastatic disease. A CT scan of the neck is shown in Fig. 2 . The CT scan of the chest revealed a suspicious peripheral pulmonary nodule, as shown in Fig. 3 . A laryngoscopy performed preoperatively demonstrated bilateral free vocal fold mobility, with no evidence of laryngeal deviation, compression, or lesions. Findings of indirect laryngoscopy are shown in Fig. 4 . Therapeutic intervention: Therapeutic intervention: A multidisciplinary team meeting was conducted between surgery, ENT, endocrine, radiology, and oncology, and consensus achieved was that of papillary thyroid cancer with lateral aberrant thyroid, and the decision was made to go for total thyroidectomy along with left lateral neck dissection. The concern of having a different pathology in a lateral neck mass was raised and discussed in MDT. Still, the consensus was in favour of papillary thyroid cancer with neck Mets, and the need for biopsy of the neck mass was not deemed necessary. There was a suspicious peripheral right-sided lung nodule, and MDT decided to have a follow-up CT scan after one year. Patient underwent a total thyroidectomy with excision of the lateral mass. Intraoperatively, the thyroid lesion was confined to the left lobe without extrathyroidal extension. The lateral lesion was firm, encapsulated, and clearly separate from lymphatic chains, raising suspicion of a mesenchymal tumor rather than nodal metastasis. Recurrent laryngeal nerves and parathyroid glands were preserved. Operative findings are shown in Figs. 5, 6 , and 7 . Figure 5 shows the operative findings of a lateral neck mass. Figure 7 shows the removed thyroid gland. Pathology Papillary thyroid carcinoma, classic subtype (pT1b, pN0 per AJCC 8th edition) Tumor focality: Unifocal (left lobe) Tumor size: 1.4 cm (greatest dimension) Negative for lymphovascular invasion, perineural invasion, and extrathyroidal extension Surgical margins: Free of carcinoma Lymph node status: 12 regional lymph nodes examined, all negative for metastasis Pathologic Staging pT1b : Tumor > 1 cm but ≤ 2 cm, confined to the thyroid pN0 : No regional lymph node metastasis Left neck mass : Well-defined, encapsulated fibrohistiocytic tumor (10 cm), subcutaneous-based with expansile dermal and deep soft-tissue components. There were extensive secondary degenerative and hemorrhage-related changes, foreign body giant cell reaction, xanthogranulomatous/fibroinflammatory changes, chronic peripheral inflammation, extensive hemosiderosis, fibrosis, and cholesterol cleft-filled central cystic changes. Skin, fat, and skeletal muscle were not involved. Resection margins were free of tumor. Lymph nodes : All lymph nodes (six from the left neck, one from the left supraclavicular area, one from the right level IV, and four from the right level II) showed benign reactive lymphoid hyperplasia and were negative for metastasis. Immunohistochemistry (IHC) panel performed: Histopathology slides are shown in Figs. 8 – 14 Cytokeratin (CK [AE1/AE3]) S-100 protein Melan-A Factor XIIIa (FXIIIa) CD34 INI1 ALK HHV8 CD68 Smooth muscle actin (SMA) CD31 Desmin ERG The tumor cells were positive for desmin (strong and diffuse), FXIIIa, CD68, and CD31. CD68 and CD31 stained histiocytic and foamy cells, and CD34 highlighted prominent vascularity. The tumor cells were negative for the remaining markers tested. Final integrated diagnosis: Angiomatoid fibrous histiocytoma Comments: The tumor is a well-circumscribed, encapsulated fibrohistiocytic neoplasm, favoring angiomatoid fibrous histiocytoma over other entities such as atypical fibroxanthoma or undifferentiated pleomorphic sarcoma. AFH may recur locally, so close clinical follow-up is recommended. Follow-Up and outcome: The patient’s recovery was uneventful, with no vocal cord palsy or hypocalcemia. He commenced on levothyroxine suppression therapy and was discharged on postoperative day three. At the six-month follow-up, he remained asymptomatic. Neck ultrasound showed no evidence of recurrence or residual disease in the thyroid bed or cervical compartments. Serum thyroglobulin was undetectable. The patient continues on annual surveillance with endocrinology and head and neck surgery. Follow-up at one year was unremarkable, and the pulmonary nodule seen on repeat chest CT imaging at one year remained unchanged and was deemed insignificant by the MDT. Discussion Rarity and Significance Fibrohistiocytomas are rarely encountered in deep locations and are exceptionally uncommon in the thyroid region [ 3 , 6 , 7 , 8 , 10 , 13 ]. Reports of synchronous occurrence with papillary thyroid carcinoma (PTC) are virtually nonexistent, making this case unique. The presence of two distinct tumors in the same anatomical field emphasizes the importance of considering rare differential diagnoses when evaluating neck masses. Diagnostic Challenges Radiologically, fibrohistocytomas may mimic metastatic lymph nodes, particularly in patients with suspected thyroid malignancy. In this case, the lateral lesion was initially presumed to be nodal metastasis. FNAC was inconclusive, underscoring the limitations of cytology in diagnosing mesenchymal lesions. Definitive classification relied on histopathology and immunohistochemistry, which demonstrated fibrohistocytic differentiation and excluded thyroid or neural origin [3,6,7,8,10,13} Clinical Implications Recognition of this dual pathology is crucial in guiding management. Misinterpreting the fibrohistocytoma as metastatic disease could have led to an unnecessarily extensive neck dissection. Instead, surgical excision of both lesions with histological confirmation enabled accurate staging and avoided overtreatment. Postoperative levothyroxine therapy and routine surveillance remain appropriate for PTC, while fibrohistocytoma requires no additional intervention. Conclusion This case highlights an exceptionally rare coexistence of papillary thyroid carcinoma and fibrohistocytoma in the same anatomical region. The lateral mass mimicked nodal disease, but histology confirmed a distinct benign mesenchymal tumor. Such overlap highlights the importance of correlating radiology with thorough histopathological and immunohistochemical evaluations to prevent misclassification. Accurate recognition of dual pathology is essential for tailoring follow-up and preventing overtreatment. [ 3,6,7,8,10,13] Patient perspective: Patient was pleased and satisfied with the management he received and with the outcome. Declarations Ethics approval and consent to participate. Ethical approval was obtained from the hospital’s ethics committee, which exempted IRB approval, as this is a case report. Consent to publish: Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal. Availability of data and materials: All materials are available and can be provided on request Competing interests: None Funding: None. Authors' information: Aliya Ishaq (Corresponding author ) — Department of General Surgery, Dubai Hospital, Dubai Health, Dubai, United Arab Emirates. ORCID iD: 0009-0002-9926-9888 Email: [email protected] Warda Siddiqi — College of Medicine, Mohamed Bin Rashid University (MBRU) of Medicine and Health Sciences, Dubai Health, Building 14, Dubai Healthcare City, Dubai, United Arab Emirates. ORCID iD: 0009-0003-2435-3134 Email: [email protected] Iyad Hammadi: Department of Head and Neck and ENT Surgery, Dubai Hospital, Dubai, United Arab Emirates. E-mail: [email protected] Arfan AlAwa: Department of General Surgery, Dubai Hospital, Dubai Health, Dubai, United Arab Emirates. Email: [email protected] References Ringel MD, Sosa JA et al (2025) 2025 American Thyroid Association guidelines for differentiated thyroid cancer. Thyroid 35(9):1–150. 10.1089/thy.2025.0012 NCCN (2025) Thyroid Carcinoma. Version 1.2025. J Natl Compr Canc Netw 23(7):1–85. 10.6004/jnccn.2025.0345 Kalode S, Bawankule S, Dahake R et al (2025) Papillary thyroid carcinoma: interesting case report. Int J Surg Case Rep 115:109016. 10.1016/j.ijscr.2024.109016 Zhang L, Li X, Wang Y et al (2025) Papillary thyroid microcarcinoma as lateral neck mass. Oncol Lett 29(3):e14895. 10.3892/ol.2025.14895 Kim H, Kim J, Kim D et al (2023) Molecular landscape of advanced thyroid cancer. Endocr Relat Cancer 30(2):T29–T48. 10.1530/ERC-22-0293 Sbaran N, Agaimy A (2021) WHO classification of soft tissue tumours: fibroblastic updates. Virchows Arch 479(1):1–19. 10.1007/s00428-021-03110-2 Thway K, Fisher C (2021) Angiomatoid fibrous histiocytoma: a review with recent molecular updates. Histopathology 79(5):689–701. 10.1111/his.14412 Wang J, Zhao C, Li H et al (2017) Angiomatoid fibrous histiocytoma: clinicopathologic series. World J Surg Oncol 15:23. 10.1186/s12957-017-1094-0 Wong JY et al (2017) Cranial angiomatoid fibrous histiocytoma: case report and review. Surg Neurol Int 8:29. 10.4103/2152-7806.201206 Weiss SW, Goldblum JR, Folpe AL (2008) Benign fibrous histiocytoma: update on classification. Semin Diagn Pathol 25(1):10–20. 10.1053/j.semdp.2007.10.003 Tessler FN, Middleton WD, Grant EG et al (2017) J Am Coll Radiol 14(5):587–595. 10.1016/j.jacr.2017.01.046 . ACR Thyroid Imaging Reporting and Data System (TI-RADS) Patil A, Garbyal RS, Gupta R (2017) Primary sarcomas of thyroid gland: series and review. J Clin Diagn Res 11(2):ER01–ER04. 10.7860/JCDR/2017/23652.9395 Hsu KF, Hsieh CB, Yu JC et al (2008) Primary malignant fibrous histiocytoma of the thyroid. World J Surg Oncol 6:89. 10.1186/1477-7819-6-89 Renshaw AA (2016) Benign fibrous histiocytoma of the thyroid: case and review. J Ultrasound Med 35(3):663–665. 10.7863/ultra.16.03003 Additional Declarations No competing interests reported. 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8","display":"","copyAsset":false,"role":"figure","size":14645,"visible":true,"origin":"","legend":"\u003cp\u003eThyroid gland papillary thyroid carcinoma (left side) in thyroid gland parenchyma (right Side), H and E stain, original magnification x 100\u003c/p\u003e","description":"","filename":"8.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8521659/v1/c5c6215f25f826f386cb0ed0.jpg"},{"id":101297614,"identity":"c031d0ff-8a54-49bd-aee3-5448a8f3dd60","added_by":"auto","created_at":"2026-01-28 09:28:17","extension":"jpg","order_by":9,"title":"Figure 9","display":"","copyAsset":false,"role":"figure","size":12931,"visible":true,"origin":"","legend":"\u003cp\u003eNeck mass - spindle angiomatous storiform hypercellular lesion, well-defined, encapsulated, pushing skeletal muscle above – H and E stain x100\u003c/p\u003e","description":"","filename":"9.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8521659/v1/6599059a250c906e670aff9e.jpg"},{"id":101297683,"identity":"8f921579-1b02-4625-84a8-4f3f53ebdd1d","added_by":"auto","created_at":"2026-01-28 09:28:33","extension":"jpg","order_by":10,"title":"Figure 10","display":"","copyAsset":false,"role":"figure","size":14746,"visible":true,"origin":"","legend":"\u003cp\u003eNeck mass – Prussian blue iron special stain shows hemosiderin pigment deposits in tumor cells and foamy histiocytes x200\u003c/p\u003e","description":"","filename":"10.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8521659/v1/249a0f9d74d2835d389d03be.jpg"},{"id":101274845,"identity":"9b8f29c2-0876-4e04-a06e-cef5eaf3981a","added_by":"auto","created_at":"2026-01-28 03:13:17","extension":"jpg","order_by":11,"title":"Figure 11","display":"","copyAsset":false,"role":"figure","size":32665,"visible":true,"origin":"","legend":"\u003cp\u003eNeck mass – fibrohistiocytic cellular lesion, storiform spindle cells and foamy macrophages, H and E stain x 200\u003c/p\u003e","description":"","filename":"11.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8521659/v1/68ecec92d759a2d6527d962b.jpg"},{"id":101297875,"identity":"ee710020-c05f-4d6a-9384-bb95e00d74bf","added_by":"auto","created_at":"2026-01-28 09:29:10","extension":"jpg","order_by":12,"title":"Figure 12","display":"","copyAsset":false,"role":"figure","size":54291,"visible":true,"origin":"","legend":"\u003cp\u003eNeck mass Factor XIlla immunomarker highlights fibrohistiocytic tumor cells x200\u003c/p\u003e","description":"","filename":"12.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8521659/v1/a641a2506bae2765e3ecd3f9.jpg"},{"id":101297941,"identity":"bb3970e8-a810-430a-b33a-21c3bb5f163f","added_by":"auto","created_at":"2026-01-28 09:29:24","extension":"jpg","order_by":13,"title":"Figure 13","display":"","copyAsset":false,"role":"figure","size":48332,"visible":true,"origin":"","legend":"\u003cp\u003eNeck mass CD68 immunomarker highlights fibrohistiocytic and histiocytic tumor cells x400\u003c/p\u003e","description":"","filename":"13.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8521659/v1/c46d8b19c06dd354867a0a45.jpg"},{"id":101297578,"identity":"9df6abde-e6bc-40a6-b3fd-194aa563b375","added_by":"auto","created_at":"2026-01-28 09:28:03","extension":"jpg","order_by":14,"title":"Figure 14","display":"","copyAsset":false,"role":"figure","size":38814,"visible":true,"origin":"","legend":"\u003cp\u003eNeck mass CD34 immunomarker negative in tumor cells but highlights vascular channels ×100\u003c/p\u003e","description":"","filename":"14.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8521659/v1/ca558c492e3ee56b7c398c93.jpg"},{"id":107487342,"identity":"84ca3785-8459-48e6-afd7-f6f8aa324109","added_by":"auto","created_at":"2026-04-22 02:40:58","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":5409427,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8521659/v1/66ee6077-44d9-47d4-96ac-a13cb0a49acf.pdf"},{"id":101297942,"identity":"345d9894-6441-4163-ab63-e4f56597372b","added_by":"auto","created_at":"2026-01-28 09:29:25","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":755192,"visible":true,"origin":"","legend":"","description":"","filename":"CAREchecklistEnglish2013.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8521659/v1/2978d202e73b38fb4b4344f4.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Rare dual pathology of the neck: synchronous papillary thyroid carcinoma and angiomatoid fibrous histiocytoma—a case report","fulltext":[{"header":"Introduction","content":"\u003cp\u003eFibrohistocytoma, also known as fibrous histiocytoma, represents a spectrum of tumors characterized by a mixture of fibroblastic and histiocytic cells, often arranged in a storiform or cartwheel-like pattern (1,2). These tumors are most commonly benign and are frequently encountered as cutaneous lesions, referred to as dermatofibromas, which typically present as small, painless, slow-growing nodules in the dermis (3,4). While the majority of fibrous histiocytomas are benign, malignant variants\u0026mdash;historically termed malignant fibrous histiocytoma (MFH)\u0026mdash;are recognized and are now more accurately classified as undifferentiated pleomorphic sarcoma (5). Benign fibrous histiocytomas (BFH) usually arise in adults, with a predilection for the extremities and a peak incidence in the third and fourth decades of life (2). The etiology remains idiopathic mainly, though some cases have been associated with prior trauma, insect bites, or chronic inflammation. [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan additionalcitationids=\"CR11\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] Malignant forms, on the other hand, are aggressive soft tissue sarcomas that may develop in various anatomical sites, including the extremities, trunk, retroperitoneum, and, less commonly, the head and neck [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. MFH is more prevalent in older adults and exhibits a male predominance [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Histopathological diagnosis of fibrous histiocytoma can be challenging due to its resemblance to other spindle cell tumors, necessitating the use of immunohistochemistry and, occasionally, electron microscopy for definitive diagnosis [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Subtypes, such as aneurysmal, epithelioid, and cellular variants, further complicate the clinical and pathological landscape [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Fibrous histiocytoma\u0026mdash;does not appear in standard thyroid nodule classifications because it is not a typical thyroid neoplasm. It is primarily a soft tissue tumor, most often benign. It commonly arises in the skin, subcutaneous tissue, or deep soft tissues such as the extremities, trunk, or head and neck [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. However, sporadic cases of primary malignant fibrous histiocytoma (MFH) of the thyroid have been reported in the literature, with fewer than 20 cases described worldwide [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan additionalcitationids=\"CR11 CR12\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. In these rare instances, MFH presents as a primary sarcoma of the thyroid gland, distinct from the common epithelial-derived thyroid cancers (papillary, follicular, medullary, anaplastic). MFH of the thyroid is aggressive and has a poor prognosis, typically requiring surgical resection as the primary treatment [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan additionalcitationids=\"CR7\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Thus, while fibrohistiocytoma is not included in the routine classification of thyroid nodules or cancers, it should be considered in the differential diagnosis of primary thyroid sarcomas, especially in cases with atypical histology or clinical presentation [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan additionalcitationids=\"CR7 CR8 CR9\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Its extreme rarity in the thyroid gland explains its omission from standard thyroid nodule classification systems.\u003c/p\u003e \u003cp\u003eDespite being a well-recognized entity in dermatopathology and soft tissue oncology, the epidemiology of fibrous histiocytoma, particularly its malignant forms, remains rarely reported in many regions, including the United Arab Emirates (UAE). Globally, benign fibrous histiocytomas are considered among the most common benign skin tumors. In contrast, malignant fibrous histiocytoma (now undifferentiated pleomorphic sarcoma) is the second most common soft tissue sarcoma in adults, with an annual incidence of approximately 0.88 cases per 100,000 population (3). In Saudi Arabia, a neighboring country with similar demographics, malignant fibrous histiocytoma accounts for about 13.2% of all soft tissue sarcomas, with an overall sarcoma incidence of 2.4 cases per million population per year\u0026mdash;significantly lower than the rates reported in Western countries (6.3 cases per 100,000 in the US and 4.0 per 100,000 in Europe) (4). These regional differences may reflect variations in genetic, environmental, and healthcare factors, as well as possible underreporting or differences in cancer registry practices (4).\u003c/p\u003e \u003cp\u003eBy elucidating the epidemiology of fibrohistiocytoma in the UAE, this study aims to inform clinicians, pathologists, and public health authorities, ultimately contributing to the development of improved diagnostic, therapeutic, and preventive strategies for this diverse group of tumors.\u003c/p\u003e"},{"header":"Case Report","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\n\u003ch2\u003ePatient information:\u003c/h2\u003e\n\u003cp\u003eA 52-year-old man presented with a slowly enlarging anterior neck mass of 12 months\u0026rsquo; duration. The mass has gradually increased in size and is now causing pain and discharge. He denied dysphagia, dyspnea, voice changes, weight loss, or previous head and neck irradiation\u0026mdash;no signs and symptoms of hypo or hyperthyroidism. There was no family history of thyroid malignancy.\u003c/p\u003e\n\u003c/div\u003e\n\u003ch3\u003eClinical findings:\u003c/h3\u003e\n\u003cp\u003eOn Physical examination, he was hemodynamically stable, and local neck examination revealed a firm, non-tender, mobile, 8 x 10 cm mass in the left lateral cervical region with overlying central skin necrosis and minimal discharge. The mass was not moving with deglutition or tongue protrusion. No cervical lymphadenopathy, cutaneous lesions, or systemic abnormalities were noted. Mass was occupying almost the entire neck, and examination of the thyroid or lymph nodes was practically not possible.\u003c/p\u003e\n\u003cp\u003eAn image of a clinical neck examination is shown in Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e, with the patient\u0026rsquo;s permission.\u003c/p\u003e\n\u003cp\u003eGiven the clinical findings, the differential diagnosis included lateral aberrant thyroid,\u003c/p\u003e\n\u003cp\u003elymphoma, or metastatic lymphadenopathy. The patient was reassured and scheduled for\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDiagnostic assessment;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFurther workup, including a contrast-enhanced CT scan of the neck, chest, abdomen, and pelvis, as well as a neck ultrasound, is recommended.\u003c/p\u003e\n\u003cp\u003eLaboratory evaluation revealed normal thyroid function tests, excluding hyperthyroidism or hypothyroidism. Inflammatory markers were within normal limits, making thyroiditis unlikely. Neck ultrasound demonstrated a solid, hypoechoic left thyroid nodule 14.5 \u0026times; 9.8 \u0026times; 12 mm, slightly ill-defined with numerous echogenic and calcific foci, which was identified in the upper posterior zone of the left lobe, raising suspicion for papillary thyroid carcinoma, classified as TI-RADS 4, alongside a well-defined, hypoechoic lateral neck lesion distinct from the jugular chain. Fine-needle aspiration cytology (FNAC) of the thyroid nodule was reported as Bethesda IV (follicular neoplasm/suspicious for follicular neoplasm).\u003c/p\u003e\n\u003cp\u003eA CT scan of the neck, chest, abdomen, and pelvis was done to assess the local extent of the lateral neck mass and its relationship with surrounding vital structures and distal metastases. Contrast-enhanced CT confirmed a discrete thyroid nodule and an adjacent soft-tissue lesion, with no evidence of extracapsular invasion or metastatic disease.\u003c/p\u003e\n\u003cp\u003eA CT scan of the neck is shown in Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e\n\u003cp\u003eThe CT scan of the chest revealed a suspicious peripheral pulmonary nodule, as shown in Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e\n\u003cp\u003eA laryngoscopy performed preoperatively demonstrated bilateral free vocal fold mobility, with no evidence of laryngeal deviation, compression, or lesions. Findings of indirect laryngoscopy are shown in Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e.\u003c/p\u003e\n\u003ch3\u003eTherapeutic intervention:\u003c/h3\u003e\n\u003cdiv class=\"Heading\"\u003eTherapeutic intervention:\u003c/div\u003e\n\u003cp\u003eA multidisciplinary team meeting was conducted between surgery, ENT, endocrine, radiology, and oncology, and consensus achieved was that of papillary thyroid cancer with lateral aberrant thyroid, and the decision was made to go for total thyroidectomy along with left lateral neck dissection. The concern of having a different pathology in a lateral neck mass was raised and discussed in MDT. Still, the consensus was in favour of papillary thyroid cancer with neck Mets, and the need for biopsy of the neck mass was not deemed necessary. There was a suspicious peripheral right-sided lung nodule, and MDT decided to have a follow-up CT scan after one year.\u003c/p\u003e\n\u003cp\u003ePatient underwent a total thyroidectomy with excision of the lateral mass. Intraoperatively, the thyroid lesion was confined to the left lobe without extrathyroidal extension. The lateral lesion was firm, encapsulated, and clearly separate from lymphatic chains, raising suspicion of a mesenchymal tumor rather than nodal metastasis. Recurrent laryngeal nerves and parathyroid glands were preserved.\u003c/p\u003e\n\u003cp\u003eOperative findings are shown in Figs.\u0026nbsp;5, \u003cspan class=\"InternalRef\"\u003e6\u003c/span\u003e, and \u003cspan class=\"InternalRef\"\u003e7\u003c/span\u003e.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFigure 5 shows the operative findings of a lateral neck mass.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFigure \u003cspan class=\"InternalRef\"\u003e7\u003c/span\u003e shows the removed thyroid gland.\u003c/p\u003e\n\u003ch3\u003ePathology\u003c/h3\u003e\n\u003cul\u003e\n\u003cli\u003e\n\u003cp\u003e\u003cstrong\u003ePapillary thyroid carcinoma, classic subtype\u003c/strong\u003e (pT1b, pN0 per AJCC 8th edition)\u003c/p\u003e\n\u003cul\u003e\n\u003cli\u003e\n\u003cp\u003eTumor focality: Unifocal (left lobe)\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003eTumor size: 1.4 cm (greatest dimension)\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003eNegative for lymphovascular invasion, perineural invasion, and extrathyroidal extension\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003eSurgical margins: Free of carcinoma\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003eLymph node status: 12 regional lymph nodes examined, all negative for metastasis\u003c/p\u003e\n\u003c/li\u003e\n\u003c/ul\u003e\n\u003c/li\u003e\n\u003c/ul\u003e\n\u003ch3\u003ePathologic Staging\u003c/h3\u003e\n\u003cul\u003e\n\u003cli\u003e\n\u003cp\u003e\u003cstrong\u003epT1b\u003c/strong\u003e: Tumor\u0026thinsp;\u0026gt;\u0026thinsp;1 cm but \u0026le;\u0026thinsp;2 cm, confined to the thyroid\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003e\u003cstrong\u003epN0\u003c/strong\u003e: No regional lymph node metastasis\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003e\u003cstrong\u003eLeft neck mass\u003c/strong\u003e: Well-defined, encapsulated fibrohistiocytic tumor (10 cm), subcutaneous-based with expansile dermal and deep soft-tissue components. There were extensive secondary degenerative and hemorrhage-related changes, foreign body giant cell reaction, xanthogranulomatous/fibroinflammatory changes, chronic peripheral inflammation, extensive hemosiderosis, fibrosis, and cholesterol cleft-filled central cystic changes. Skin, fat, and skeletal muscle were not involved. Resection margins were free of tumor.\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003e\u003cstrong\u003eLymph nodes\u003c/strong\u003e: All lymph nodes (six from the left neck, one from the left supraclavicular area, one from the right level IV, and four from the right level II) showed benign reactive lymphoid hyperplasia and were negative for metastasis.\u003c/p\u003e\n\u003c/li\u003e\n\u003c/ul\u003e\n\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\n\u003ch2\u003eImmunohistochemistry (IHC) panel performed:\u003c/h2\u003e\n\u003cdiv id=\"Sec9\" class=\"Section3\"\u003e\n\u003ch2\u003eHistopathology slides are shown in Figs.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan class=\"InternalRef\"\u003e14\u003c/span\u003e\u003c/h2\u003e\n\u003cul\u003e\n\u003cli\u003e\n\u003cp\u003eCytokeratin (CK [AE1/AE3])\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003eS-100 protein\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003eMelan-A\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003eFactor XIIIa (FXIIIa)\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003eCD34\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003eINI1\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003eALK\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003eHHV8\u003c/p\u003e\n\u003c/li\u003e\n\u003c/ul\u003e\n\u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\n\u003cdiv id=\"Sec12\" class=\"Section3\"\u003e\n\u003cdiv id=\"Sec13\" class=\"Section4\"\u003e\n\u003cul\u003e\n\u003cli\u003e\n\u003cp\u003eCD68\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003eSmooth muscle actin (SMA)\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003eCD31\u003c/p\u003e\n\u003c/li\u003e\n\u003c/ul\u003e\n\u003c/div\u003e\n\u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\n\u003cul\u003e\n\u003cli\u003e\n\u003cp\u003eDesmin\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003eERG\u003c/p\u003e\n\u003c/li\u003e\n\u003c/ul\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\n\u003cp\u003eThe tumor cells were positive for desmin (strong and diffuse), FXIIIa, CD68, and CD31. CD68 and CD31 stained histiocytic and foamy cells, and CD34 highlighted prominent vascularity. The tumor cells were negative for the remaining markers tested.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\n\u003ch2\u003eFinal integrated diagnosis:\u003c/h2\u003e\n\u003cdiv id=\"Sec17\" class=\"Section3\"\u003e\n\u003cul\u003e\n\u003cli\u003eAngiomatoid fibrous histiocytoma\u003c/li\u003e\n\u003c/ul\u003e\n\u003cdiv id=\"Sec18\" class=\"Section4\"\u003e\n\u003ch2\u003eComments:\u003c/h2\u003e\n\u003cul\u003e\n\u003cli\u003e\n\u003cp\u003eThe tumor is a well-circumscribed, encapsulated fibrohistiocytic neoplasm, favoring angiomatoid fibrous histiocytoma over other entities such as atypical fibroxanthoma or undifferentiated pleomorphic sarcoma.\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003eAFH may recur locally, so close clinical follow-up is recommended.\u003c/p\u003e\n\u003c/li\u003e\n\u003c/ul\u003e\n\u003c/div\u003e\n\u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec19\" class=\"Section2\"\u003e\n\u003ch2\u003eFollow-Up and outcome:\u003c/h2\u003e\n\u003cp\u003eThe patient\u0026rsquo;s recovery was uneventful, with no vocal cord palsy or hypocalcemia. He commenced on levothyroxine suppression therapy and was discharged on postoperative day three. At the six-month follow-up, he remained asymptomatic. Neck ultrasound showed no evidence of recurrence or residual disease in the thyroid bed or cervical compartments. Serum thyroglobulin was undetectable. The patient continues on annual surveillance with endocrinology and head and neck surgery. Follow-up at one year was unremarkable, and the pulmonary nodule seen on repeat chest CT imaging at one year remained unchanged and was deemed insignificant by the MDT.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003eRarity and Significance\u003c/h2\u003e \u003cp\u003eFibrohistiocytomas are rarely encountered in deep locations and are exceptionally uncommon in the thyroid region [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Reports of synchronous occurrence with papillary thyroid carcinoma (PTC) are virtually nonexistent, making this case unique. The presence of two distinct tumors in the same anatomical field emphasizes the importance of considering rare differential diagnoses when evaluating neck masses.\u003c/p\u003e \u003cdiv id=\"Sec22\" class=\"Section3\"\u003e \u003ch2\u003eDiagnostic Challenges\u003c/h2\u003e \u003cp\u003eRadiologically, fibrohistocytomas may mimic metastatic lymph nodes, particularly in patients with suspected thyroid malignancy. In this case, the lateral lesion was initially presumed to be nodal metastasis. FNAC was inconclusive, underscoring the limitations of cytology in diagnosing mesenchymal lesions. Definitive classification relied on histopathology and immunohistochemistry, which demonstrated fibrohistocytic differentiation and excluded thyroid or neural origin [3,6,7,8,10,13}\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec23\" class=\"Section2\"\u003e \u003ch2\u003eClinical Implications\u003c/h2\u003e \u003cp\u003eRecognition of this dual pathology is crucial in guiding management. Misinterpreting the fibrohistocytoma as metastatic disease could have led to an unnecessarily extensive neck dissection. Instead, surgical excision of both lesions with histological confirmation enabled accurate staging and avoided overtreatment. Postoperative levothyroxine therapy and routine surveillance remain appropriate for PTC, while fibrohistocytoma requires no additional intervention.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis case highlights an exceptionally rare coexistence of papillary thyroid carcinoma and fibrohistocytoma in the same anatomical region. The lateral mass mimicked nodal disease, but histology confirmed a distinct benign mesenchymal tumor. Such overlap highlights the importance of correlating radiology with thorough histopathological and immunohistochemical evaluations to prevent misclassification. Accurate recognition of dual pathology is essential for tailoring follow-up and preventing overtreatment. [ 3,6,7,8,10,13]\u003c/p\u003e \u003cdiv id=\"Sec25\" class=\"Section2\"\u003e \u003ch2\u003ePatient perspective:\u003c/h2\u003e \u003cp\u003ePatient was pleased and satisfied with the management he received and with the outcome.\u003c/p\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval was obtained from the hospital’s ethics committee, which exempted IRB approval, as this is a case report.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to publish:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u0026nbsp;\u003c/strong\u003eAll materials are available and can be provided on request\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u0026nbsp;\u003c/strong\u003eNone\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003eNone. \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' information:\u003c/strong\u003e\u003c/p\u003e\n\u003col start=\"1\" type=\"1\"\u003e\n \u003cli\u003e\u003cstrong\u003eAliya Ishaq \u0026nbsp;(Corresponding author ) — Department of General Surgery, Dubai Hospital, Dubai Health, Dubai, United Arab Emirates.\u003c/strong\u003e\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003e\u003cstrong\u003eORCID iD: 0009-0002-9926-9888\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEmail: [email protected] \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003col start=\"2\" type=\"1\"\u003e\n \u003cli\u003e\u003cstrong\u003eWarda Siddiqi — College of Medicine, Mohamed Bin Rashid University (MBRU) of Medicine and Health Sciences, Dubai Health, Building 14, Dubai Healthcare City, Dubai, United Arab Emirates.\u003c/strong\u003e\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003e\u003cstrong\u003eORCID iD: 0009-0003-2435-3134\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEmail: [email protected]\u003c/strong\u003e\u003c/p\u003e\n\u003col start=\"3\"\u003e\n \u003cli\u003e\u003cstrong\u003eIyad Hammadi: Department of Head and Neck and ENT Surgery, Dubai Hospital, Dubai, United Arab Emirates.\u003c/strong\u003e\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003e\u003cstrong\u003eE-mail: [email protected]\u003c/strong\u003e\u003c/p\u003e\n\u003col start=\"4\"\u003e\n \u003cli\u003e\u003cstrong\u003eArfan AlAwa: Department of General Surgery, Dubai Hospital, Dubai Health, Dubai, United Arab Emirates.\u003c/strong\u003e\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003e\u003cstrong\u003eEmail: [email protected]\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eRingel MD, Sosa JA et al (2025) 2025 American Thyroid Association guidelines for differentiated thyroid cancer. Thyroid 35(9):1\u0026ndash;150. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1089/thy.2025.0012\u003c/span\u003e\u003cspan address=\"10.1089/thy.2025.0012\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNCCN (2025) Thyroid Carcinoma. Version 1.2025. J Natl Compr Canc Netw 23(7):1\u0026ndash;85. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.6004/jnccn.2025.0345\u003c/span\u003e\u003cspan address=\"10.6004/jnccn.2025.0345\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKalode S, Bawankule S, Dahake R et al (2025) Papillary thyroid carcinoma: interesting case report. Int J Surg Case Rep 115:109016. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.ijscr.2024.109016\u003c/span\u003e\u003cspan address=\"10.1016/j.ijscr.2024.109016\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhang L, Li X, Wang Y et al (2025) Papillary thyroid microcarcinoma as lateral neck mass. Oncol Lett 29(3):e14895. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3892/ol.2025.14895\u003c/span\u003e\u003cspan address=\"10.3892/ol.2025.14895\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKim H, Kim J, Kim D et al (2023) Molecular landscape of advanced thyroid cancer. Endocr Relat Cancer 30(2):T29\u0026ndash;T48. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1530/ERC-22-0293\u003c/span\u003e\u003cspan address=\"10.1530/ERC-22-0293\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSbaran N, Agaimy A (2021) WHO classification of soft tissue tumours: fibroblastic updates. Virchows Arch 479(1):1\u0026ndash;19. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s00428-021-03110-2\u003c/span\u003e\u003cspan address=\"10.1007/s00428-021-03110-2\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eThway K, Fisher C (2021) Angiomatoid fibrous histiocytoma: a review with recent molecular updates. Histopathology 79(5):689\u0026ndash;701. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/his.14412\u003c/span\u003e\u003cspan address=\"10.1111/his.14412\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWang J, Zhao C, Li H et al (2017) Angiomatoid fibrous histiocytoma: clinicopathologic series. World J Surg Oncol 15:23. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12957-017-1094-0\u003c/span\u003e\u003cspan address=\"10.1186/s12957-017-1094-0\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWong JY et al (2017) Cranial angiomatoid fibrous histiocytoma: case report and review. Surg Neurol Int 8:29. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.4103/2152-7806.201206\u003c/span\u003e\u003cspan address=\"10.4103/2152-7806.201206\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWeiss SW, Goldblum JR, Folpe AL (2008) Benign fibrous histiocytoma: update on classification. Semin Diagn Pathol 25(1):10\u0026ndash;20. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1053/j.semdp.2007.10.003\u003c/span\u003e\u003cspan address=\"10.1053/j.semdp.2007.10.003\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTessler FN, Middleton WD, Grant EG et al (2017) J Am Coll Radiol 14(5):587\u0026ndash;595. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.jacr.2017.01.046\u003c/span\u003e\u003cspan address=\"10.1016/j.jacr.2017.01.046\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. ACR Thyroid Imaging Reporting and Data System (TI-RADS)\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePatil A, Garbyal RS, Gupta R (2017) Primary sarcomas of thyroid gland: series and review. J Clin Diagn Res 11(2):ER01\u0026ndash;ER04. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.7860/JCDR/2017/23652.9395\u003c/span\u003e\u003cspan address=\"10.7860/JCDR/2017/23652.9395\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHsu KF, Hsieh CB, Yu JC et al (2008) Primary malignant fibrous histiocytoma of the thyroid. World J Surg Oncol 6:89. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/1477-7819-6-89\u003c/span\u003e\u003cspan address=\"10.1186/1477-7819-6-89\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRenshaw AA (2016) Benign fibrous histiocytoma of the thyroid: case and review. J Ultrasound Med 35(3):663\u0026ndash;665. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.7863/ultra.16.03003\u003c/span\u003e\u003cspan address=\"10.7863/ultra.16.03003\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"papillary thyroid cancer, lateral aberrant thyroid, fibrohistiocytoma, metastatic papillary thyroid cancer","lastPublishedDoi":"10.21203/rs.3.rs-8521659/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8521659/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eIntroduction:\u003c/h2\u003e \u003cp\u003eFibrohistiocytomas are uncommon mesenchymal tumors that typically originate in the dermis or subcutaneous tissue, and are rarely reported in deeper locations, such as bone, retroperitoneum, or the head and neck. Primary thyroid involvement is exceedingly rare, with only sporadic reports of benign and malignant variants. Papillary thyroid carcinoma (PTC) is the most prevalent thyroid malignancy, characterized by distinct nuclear features and well-established cytological criteria. The coexistence of PTC with fibrohistiocytoma within the thyroid region has not been previously described. We report a case of synchronous PTC and fibrohistocytoma, highlighting the diagnostic challenges posed by overlapping clinical and radiological features and underscoring the role of histopathology in guiding management.\u003c/p\u003e\u003ch2\u003eCase report ;\u003c/h2\u003e \u003cp\u003eA 52-year-old Asian male patient presented to our clinic with a history of massive neck swelling with a central open wound present for the past 2 months and now increasing in size. The swelling occupied almost the entire neck, and the neck nodes and thyroid gland were not palpable due to the presence of swelling. Further workup showed a suspicious thyroid nodule and neck swelling, which was attributable to metastatic lymph nodes. The thyroid nodule was biopsied and showed papillary thyroid cancer. The case was discussed in a multidisciplinary team meeting, and it was decided to proceed with total thyroidectomy with modified bilateral neck dissection. Histopathology showed two different pathologies: papillary thyroid cancer PT1b and a lateral neck mass. Histopathology of the lateral neck mass revealed fibrohistiocytoma.\u003c/p\u003e\u003ch2\u003eConclusion:\u003c/h2\u003e \u003cp\u003eThe case highlights the diagnostic challenges that arise when such tumors are present concomitantly. Lateral neck mass was attributed to be metastatic papillary thyroid cancer rather than a separate pathology, and no pre op biopsy of the mass was taken. When there is a discrepancy between the size of the primary tumor (in our case, a small thyroid papillary tumor) and the metastatic deposit (a large neck mass attributed to metastatic papillary thyroid cancer), separate biopsies should be taken from both regions to confirm the diagnosis. A multidisciplinary approach should be employed to manage this case.\u003c/p\u003e","manuscriptTitle":"Rare dual pathology of the neck: synchronous papillary thyroid carcinoma and angiomatoid fibrous histiocytoma—a case report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-28 03:13:12","doi":"10.21203/rs.3.rs-8521659/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"8508fefa-cf0a-4cdb-9a87-751ba92f19f6","owner":[],"postedDate":"January 28th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-04-20T17:40:00+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-28 03:13:12","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8521659","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8521659","identity":"rs-8521659","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}