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Com
petin
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tere
sts:
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ts: n
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Asso
ciati
on fo
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ical
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ics (
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ical
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sure
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Case report
For citation purposes: Zhou XC, Hu KQ, Zhou H, Ye YH, Li XY, Jiang Y, et al. Unusual metastases from papillary thyroid carcinoma. Head Neck Oncol. 2012 Nov 23;4(4):75.
Licensee OA Publishing London 2012. Creative Commons Attribution License (CC-BY)
AbstractPapillary thyroid carcinoma is the most common type of well-differenti-ated thyroid carcinoma. Metastases usually occur in regional lymph nodes. Here, we report a patient with un-usual metastases from papillary thy-roid carcinoma. A 55-year-old woman had a history of right papillary thy-roid carcinoma and underwent local excision of the right thyroid lobe in another hospital previously. The pa-tient was found to have metastatic papillary thyroid carcinoma to the left parieto-occipital lobe, bilateral lung, left caput humeri, left triceps brachii muscle, right collum ossis femoris and left thumb. She eventually suf-fered multiple organ failure and died. Therefore, if timely and thorough treatment is not provided, papillary thyroid carcinoma may become met-astatic to brain, lungs, skeletal muscle, bones and other sites through direct haematogenic route.
IntroductionPapillary thyroid carcinoma is the most common type of well-differenti-ated thyroid malignancy and typically has an excellent prognosis and a low
Unusual metastases from papillary thyroid carcinomaXC Zhou1*, KQ Hu2, H Zhou1, YH Ye1, XY Li1, Y Jiang3, JH Chen4
incidence of distant metastasis1. Pap-illary thyroid carcinoma occasionally metastasizes to lungs and bones, but rarely to brain and skeletal muscle. We present an unusual case of metas-tases of papillary thyroid carcinoma to the left parieto-occipital lobe, bi-lateral lung, left caput humeri, left tri-ceps brachii muscle, right collum ossis femoris and left thumb.
Case reportA 55-year-old woman initially pre-sented to our hospital in May 2006 with complaints of headache and tran-sient loss of consciousness for 6 days. She had a history of right papillary thyroid carcinoma and underwent lo-cal excision of the right thyroid lobe in another hospital in 1992. Neck com-puted tomography (CT) (Figure 1a) showed post-operative changes of the right thyroid lobe, calcified nod-ule of the left thyroid lobe (arrow). Thyroid function test, including serum-free thyroxine, slightly fell to a level of 6.53 pmol/L (normal, 7.64–21.1 pmol/L), while serum levels of others were within the normal range. Brain CT (Figure 1b) showed a haem-orrhagic mass with an inhomoge-neous density measuring 5.0 × 3.0 cm in the left parieto-occipital lobe com-pressing posterior horn of the left lateral ventricle and crossing the mid-line to the right hemisphere (arrow). Chest CT (Figure 1c) showed bilateral multiple pulmonary metastases, the largest measuring 3.0 × 3.0 cm in the right lower lobe (arrow). The patient underwent total excision of the left parieto-occipital lobe tumour that showed metastasis from papillary thyroid carcinoma (Figure 2a), fol-lowed by external beam radiation for intracranial lesion and pulmonary metastases.
The patient was not periodically followed up after discharge and she did not visit the hospital until September 2006; she was readmitted with a mass in her left upper arm for 20 days. CT of the left upper arm showed local area of bone destroyed by metastasis measuring 3.0 × 2.0 × 2.0 cm in its dimension with a clear boundary (white arrow) and its in-ternal soft-tissue mass shadow (black arrow) with uniform density in the left caput humeri (Figure 1d), and a low-density mass shadow measuring 2.8 × 3.4 cm in maximum diameter with unclear boundary and non-uni-form density (arrow) in the long head of the triceps brachii muscle (Figure 1e). Ultrasonography of the left up-per arm (Figure 1f) showed two adja-cent hypoechoic nodules measuring 3.0 × 1.8 cm and 3.1 × 1.9 cm in the muscle layer (arrow), in which inter-nal echo was uneven, internal irregu-lar echo-free zone was visible, the border was unclear and the envelope was not obvious. Colour Doppler ul-trasonography showed scarce inter-nal blood flow with peripheral ring of flow. The patient subsequently underwent excision of the mass in the left triceps brachii muscle, which revealed metastases from papillary thyroid carcinoma (Figure 2b). How-ever, the patient refused total thy-roidectomy and further 131I therapy, and she was discharged from the hospital.
Unfortunately, in October 2006, she was readmitted for 7 days with complaints of right hip pain and dif-ficulty in walking. Hip CT (Figure 1g) showed osteolytic bone destruction and partial fracture of cortical bone in the right caput ossis femoris and collum ossis femoris (arrow) with pe-ripheral soft-tissue swelling. Because
* Corresponding authorEmail: [email protected] Department of Surgery, The Dingli Clinical
Institute of Wenzhou Medical College (Wenzhou Central Hospital), Wenzhou, Zhejiang, PR China
2 Department of Clinical Pharmacy, The Dingli Clinical Institute of Wenzhou Medical College (Wenzhou Central Hospital), Wenzhou, Zhejiang, PR China
3 Department of Pathology, The Dingli Clinical Institute of Wenzhou Medical College (Wenzhou Central Hospital), Wenzhou, Zhejiang, PR China
4 Department of Endocrinology, The Dingli Clinical Institute of Wenzhou Medical College (Wenzhou Central Hospital), Wenzhou, Zhejiang, PR China
For citation purposes: Zhou XC, Hu KQ, Zhou H, Ye YH, Li XY, Jiang Y, et al. Unusual metastases from papillary thyroid carcinoma. Head Neck Oncol. 2012 Nov 23;4(4):75.
Page 2 of 3
Com
petin
g in
tere
sts:
non
e de
clar
ed. C
onfli
ct o
f int
eres
ts: n
one
decl
ared
.Al
l aut
hors
con
trib
uted
to th
e co
ncep
tion,
des
ign,
and
pre
para
tion
of th
e m
anus
crip
t, as
wel
l as r
ead
and
appr
oved
the
final
man
uscr
ipt.
All a
utho
rs a
bide
by
the
Asso
ciati
on fo
r Med
ical
Eth
ics (
AME)
eth
ical
rule
s of d
isclo
sure
.
Case report
Licensee OA Publishing London 2012. Creative Commons Attribution License (CC-BY)
of the restricted left thumb activity soon after hospitalisation, an X-ray of the left thumb (Figure 1h) was taken that showed internal soft-tissue mass shadow with unclear boundary and most destruction and disappearance of phalanx distalis with rough edge (arrow). The patient was arranged for total right hip replacement and left thumb amputation, and histopatho-logic analysis revealed metastatic pap-illary thyroid carcinoma to the right collum ossis femoris (Figure 2c) and left thumb (Figure 2d). The patient once again refused total thyroidec-tomy and further 131I therapy. She eventually suffered multiple organ failure and died in September 2007.
DiscussionPapillary thyroid carcinoma is the most common differentiated thyroid carcinoma and typically has an excel-lent prognosis. Metastases commonly occur in regional lymph nodes2. Distant metastases are generally as-sociated with a follicular carcinoma histology rather than papillary thy-roid carcinoma3,4. The most common sites for distant metastases of papil-lary thyroid carcinoma are the lungs and bones, and rarely the brain, skel-etal muscle and other sites5–10. Distant metastases from papillary thyroid carcinoma are associated with poor prognosis5.
To the best of our knowledge, this is the first case to be reported in the literature showing unusual metastases of papillary thyroid carcinoma to the left parieto-occipital lobe, bilateral lung, left caput humeri, left triceps brachii muscle, right collum ossis femoris and left thumb. There fore, if timely and thorough treatment (which may include radical surgical resection and radioiodine therapy) is not provided, papillary thyroid carcinoma may become metastatic to the brain, lungs, skeletal muscle, bones and other sites through direct haematogenic route. This case also highlights the importance of a peri-odic follow-up of the patient with
(a) (b)
(c) (d)
(e) (f)
(g) (h)
Figure 1: (a) Neck CT shows post-operative changes of the right thyroid lobe, calcified nodule of the left thyroid lobe (arrow). (b) Brain CT shows a haemor-rhagic mass with an inhomogeneous density measuring 5.0 × 3.0 cm in the left parieto-occipital lobe compressing posterior horn of the left lateral ventricle and crossing the midline to the right hemisphere (arrow). (c) Chest CT shows bilateral multiple pulmonary metastases, the largest measuring 3.0 × 3.0 cm in the right lower lobe (arrow). (d) CT of the left upper arm shows local area of bone destroyed by metastasis measuring 3.0 × 2.0 × 2.0 cm in its dimension with clear boundary (white arrow) and its internal soft-tissue mass shadow (black arrow) with uniform density in the left caput humeri. (e) CT of the left upper arm shows a low-density mass shadow measuring 2.8 × 3.4 cm in maximum diameter with unclear boundary and non-uniform density (arrow) in the long head of the triceps brachii muscle. (f) Ultrasonography of the left upper arm shows two adjacent hypoechoic nodules measuring 3.0 × 1.8 cm and 3.1 × 1.9 cm in the muscle layer (arrow), in which internal echo was uneven, internal irregu-lar echo-free zone was visible, the border was unclear and the envelope was not obvious. Colour Doppler ultrasonography shows scarce internal blood flow with peripheral ring of flow. (g) Hip CT shows osteolytic bone destruction and partial fracture of cortical bone in the right caput ossis femoris and collum ossis femo-ris (arrow) with peripheral soft-tissue swelling. (h) An X-ray of left thumb, which shows internal soft-tissue mass shadow with unclear boundary and most destruction and disappearance of phalanx distalis with rough edge (arrow).
Page 3 of 3
Com
petin
g in
tere
sts:
non
e de
clar
ed. C
onfli
ct o
f int
eres
ts: n
one
decl
ared
.Al
l aut
hors
con
trib
uted
to th
e co
ncep
tion,
des
ign,
and
pre
para
tion
of th
e m
anus
crip
t, as
wel
l as r
ead
and
appr
oved
the
final
man
uscr
ipt.
All a
utho
rs a
bide
by
the
Asso
ciati
on fo
r Med
ical
Eth
ics (
AME)
eth
ical
rule
s of d
isclo
sure
.
For citation purposes: Zhou XC, Hu KQ, Zhou H, Ye YH, Li XY, Jiang Y, et al. Unusual metastases from papillary thyroid carcinoma. Head Neck Oncol. 2012 Nov 23;4(4):75.
Case report
Licensee OA Publishing London 2012. Creative Commons Attribution License (CC-BY)
3. Machens A, Holzhausen HJ, Lautenschlager C, Thanh PN, Dralle H. Enhancement of lymph node metastasis and distant metastasis of thyroid carci-noma. Cancer. 2003 Aug;98(4):712–9.4. Shoup M, Stojadinovic A, Nissan A, Ghossein RA, Freedman S, Brennan MF, et al. Prognostic indicators of outcomes in patients with distant metastases from differentiated thyroid carcinoma. J Am Coll Surg. 2003 Aug;197(2):191–7.5. Koutkia P, Safer JD. Adrenal metastasis secondary to papillary thyroid carcinoma. Thyroid. 2001 Nov;11(11):1077–9.6. Lecumberri B, Álvarez-Escolá C, Martín-Vaquero P, Nistal M, Martín V, Riesco-Eizaguirre G, et al. Solitary hemorrhagic cerebellar metastasis from occult papil-lary thyroid microcarcinoma. Thyroid. 2010 May;20(5):563–7.7. Aguiar PH, Agner C, Tavares FR, Yamaguchi N. Unusual brain metastases from papillary thyroid carcinoma: case report. Neurosurgery. 2001 Oct;49(4): 1008–13.8. Pazaitou-Panayiotou K, Kaprara A, Chrisoulidou A, Boudina M, Georgiou E, Patakiouta F, et al. Cerebellar metastasis as first metastasis from papillary thyroid carcinoma. Endocr J. 2005 Dec;52(6): 653–7.9. Bae SY, Lee SK, Koo MY, Hur SM, Choi MY, Cho DH, et al. Distant, solitary skeletal muscle metastasis in recurrent papillary thyroid carcinoma. Thyroid. 2011 Sep; 21(9):1027–31.10. Morita N, Morimoto K, Yonezawa K, Otsuki N, Nibu KI. Infratemporal fossa metastasis of papillary thyroid cancer. Head Neck. 2012 Apr;12.
of the thyroid: case report and literature review. Surg Neurol. 2000 Oct;54(4): 320–6.2. Al-Dhahri SF, Al-Amro AS, Al-Shakwer W, Terkawi AS. Cerebellar mass as a primary presentation of papillary thyroid carci-noma: case report and literature review. Head Neck Oncol. 2009 Jun;1:23.
papillary thyroid carcinoma after the initial treatment.
References1. Cha ST, Jarrahy R, Mathiesen RA, Suh R, Shahinian HK. Cerebellopontine angle metastasis from papillary carcinoma
(a) (b)
(c) (d)
Figure 2: (a) Metastatic papillary thyroid carcinoma to the left parieto-occipital lobe (haematoxylin–eosin stain; original magnification 400×). (b) Metastatic papillary thyroid carcinoma to the left triceps brachii muscle (haematoxylin–eosin stain; original magnification 400×). (c) Metastatic papillary thyroid carci-noma to the right collum ossis femoris (haematoxylin–eosin stain; original magnification 400×). (d) Metastatic papillary thyroid carcinoma to left thumb (haematoxylin–eosin stain; original magnification 400×).
