Occult thyroid cancer discovered by fine-needle aspiration cytology of cervical lymph node: a report of three cases

Diagnostic utility of thyroglobulin detection in fine-needle aspiration of cervical cystic metastatic lymph nodes from papillary thyroid cancer with negative cytology

Cystic changes in metastatic cervical lymph nodes (CLN) from papillary thyroid cancer (PTC) may be a diagnostic pitfall in fine-needle aspiration biopsy (FNAB) cytology. We investigated in a series of CLN metastases from thyroid cancers (TC), including cystic PTC, and from a wide spectrum of extrathyroidal malignancies, the diagnostic role for metastatic TC of the rapid detection of thyroglobulin in eluates from FNAB (FNAB-Tg) of CLN. The study was carried out in a group of 79 subjects (22/57 M/F; median age, 56 years; range, 20-86 years) with enlarged CLN and thyroid nodules (TN), examined for potential metastatic TC, and harboring a large spectrum of incidentally diagnosed extrathyroidal malignancies (n = 24, mostly represented by lymphomas, lung, and breast cancers), CLN metastases from thyroid cancers (n = 28, including 6 cystic metastatic PTC), 6 specific lymphadenitis and 21 reactive lymphadenitis mostly detected (n = 16) during follow-up of patients with previously ablated TC. Markedly high FNAB thyroglobulin (Tg) values were found in all metastatic CLN TC. Two of the six cases with cystic metastatic CLN PTC were diagnosed by FNAB-Tg but not by cytology. In conclusion, FNAB-Tg has been confirmed as an easy modality and fast procedure to diagnose CLN metastasis from TC and high FNAB-Tg values with nondiagnostic cystic cytology strongly suggest cystic metastatic PTC.

Unusual brain metastases from papillary thyroid carcinoma: case report

OBJECTIVE AND IMPORTANCE

Brain metastases from papillary carcinoma of the thyroid gland are unusual. No consensus regarding management has yet been reached. We report a case, review the current literature, and explain our approach on the basis of clinical, pathological, and radiological data.

CLINICAL PRESENTATION

A 33-year-old woman presented with signs of intracranial hypertension. The diagnostic evaluation included chest tomography, head computed tomography, brain magnetic resonance imaging with and without contrast enhancement, total-body scanning, and cerebral scintigraphy. Multiple supratentorial lesions and one right cerebellopontine angle lesion were observed. Histopathological analysis of the surgical specimen confirmed papillary carcinoma of the thyroid gland.

INTERVENTION

A ventriculoperitoneal shunt was placed and a right suboccipital craniotomy was performed, with complete removal of the cerebellopontine angle tumor. Total-brain irradiation with 40 Gy/lesion followed the initial operation. One year after surgery, the patient presented with signs of increased intracranial pressure. A new left frontal lobe lesion with massive peritumoral edema was identified on magnetic resonance imaging scans. The edema was treated clinically and a left frontal craniotomy was performed, with complete resection of the tumor. The patient is currently faring well, with residual expressive aphasia.

CONCLUSION

Surgery followed by radiotherapy seems to be a good alternative for the treatment of this specific type of metastasis. Thorough clinical and radiological evaluation, followed by genetic analysis of the surgical specimen, particularly with respect to the potential for tumor invasion under specific conditions, is recommended. The information obtained contributes to better management and better overall long-term outcomes for these patients.

Internal hemipelvectomy for solitary pelvic thyroid cancer metastases

BACKGROUND AND OBJECTIVES

Radioactive iodine (RAI) therapy remains a primary treatment modality for metastatic thyroid carcinoma, but poor tumor uptake of the agent can limit its usefulness. While offering effective palliation, radiation therapy is not curative, and chemotherapy is even less useful. Surgical resection occasionally remains the only hope of offering a long-term cure in the case of isolated metastases.

METHODS

We describe 3 cases of thyroid cancer metastatic to the pelvic girdle that were unresponsive to RAI and other nonoperative therapies, which presented over a 15-year time period. The pelvic disease was the only site of active disease in all cases, and all 3 patients were suffering considerable pain. All 3 patients underwent internal hemipelvectomy with reconstruction in 2 cases using a pelvic bone allograft.

RESULTS

All 3 experienced symptomatic relief and early mobilization. While the infection rate was 100%, these all responded completely to operative debridement, irrigation, and antibiotics. One patient, found postoperatively to have a positive surgical margin, developed a local recurrence at 4 months and died. A second patient developed a local recurrence at 11 months and died. The third patient underwent a revision of her hip arthroplasty because of acetabular loosening after a fall 21 months postoperatively. She is alive, disease-free, and ambulatory with the aid of a cane 32 months after the original procedure.

CONCLUSIONS

We propose this surgical procedure in selected patients with metastatic pelvic thyroid cancer. It provides symptomatic relief with a chance for prolonged disease-free survival some patients.

Papillary microcarcinoma of the thyroid gland in renal transplant patients

Among organ transplant recipients there is a world wide increase in the number of de novo tumors as well as a decrease in the time of the first appearance after the transplantation. Between 1973 and the 31st of August 1999 1709 cadaver renal allograft transplantations were performed in our Department. Four thyroid cancers were detected among the renal transplanted patients. Two of them proved to be papillary microcarcinomas. Although the elevated risk of thyroid cancers is well established in the literature papillary microcarcinomas have never been reported before in an immunosuppressed patient. Authors highlight that the thyroid gland should always be carefully checked in organ transplant recipients, since better survival might be achieved even in the immunosuppressed population. Metastatic tumor is relatively benign which is in correlation with the literature, but there has been little experience in organ transplanted patients so far.

Cervical cystic lymph node metastasis as first manifestation of occult papillary thyroid carcinoma: report of seven cases

BACKGROUND

Cervical cystic lymph node metastases as first and sole manifestation of occult papillary thyroid carcinoma are observed exceptionally rarely. In the seven patients here reported, a cystic, ovoid mass in the lateral aspect of the neck was the initial symptom of the papillary microcarcinoma.

METHODS

There were six men and one woman, aged between 17 and 54 years (mean 31.7 years), who complained of round, movable, painless masses in the lateral aspect of the neck. Two patients were first seen with two cervical tumors. Tumors had been present from a few days to 12 months (mean 5.1 months). The cystic nature of tumors was demonstrated by echographic studies. In all cases, thyroid tumors were not palpable on physical examination and no abnormalities of the thyroid gland were shown by other diagnostic procedures.

RESULTS

The diagnosis was made preoperatively by fineneedle aspiration cytology of the nodes in five of the seven cases. All patients underwent thyroidectomy with conservative neck dissection followed by radioactive iodine therapy. After a follow-up period from 1 to 7 years, all patients are alive with no apparent signs of recurrence or metastasis.

CONCLUSIONS

In a young patient with solitary lateral cervical cyst, the diagnosis of lymph node metastasis from occult papillary thyroid carcinoma should be considered. Any lateral mass requires tissue diagnosis, and fine-needle aspiration is usually adequate for clarification of the histology. Ipsilateral modified neck dissection and total thyroidectomy followed by radioactive iodine therapy offers a favorable prognosis.

Selective expression of CD44 cell-adhesion molecule in thyroid papillary carcinoma fine-needle aspirates

Recent descriptions of numerous pitfalls in the cytologic diagnosis of thyroid papillary carcinoma on fine-needle aspiration biopsy specimens have prompted studies of new ancillary diagnostic methods. We evaluated the potential use of immunocytochemical staining of thyroid fine-needle aspiration biopsy specimens for CD44, a glycosylated cartilage link protein associated with extracellular matrix adhesion and lymphocyte homing. Fourteen of 16 (88%) classic, surgically confirmed, thyroid aspiration biopsies stained intensely positive for this marker, whereas 0 of 30 (0%) similarly-processed benign aspirates from colloid nodules showed immunoreactivity for CD44 antigen. From this study, we conclude that most papillary carcinomas of the thyroid express the celladhesion molecule CD44, which may be of clinical value in confirming the diagnosis on borderline fine-needle aspiration specimens. Further study of CD44 expression may prove of significant interest in explaining the unusual mode of spread and clinical course of this disease.

Highly aggressive behaviour of occult papillary thyroid carcinoma

Occult papillary thyroid carcinoma is generally associated with an excellent prognosis. Distant metastasis of this tumour is extremely rare. A case of occult papillary thyroid carcinoma with metastases to the lungs, cervical lymph nodes, skeleton, and the brain is reported. The tumour expressed itself in extremely aggressive clinical behaviour and responded only partially to aggressive therapy. The controversial methods of treatment for occult papillary thyroid carcinoma are also discussed.