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Radiology Quiz Case 1—Diagnosis

Radiology Quiz Case 1—Diagnosis Diagnosis: Papillary thyroid carcinoma with miliary lung metastases Thyroid cancer mainly consists of papillary, follicular, medullary, and anaplastic variants, with proportions estimated at 78%, 13%, 4%, and 2%, respectively.1 The remaining 3% of thyroid carcinomas include lymphoma, sarcoma, metastatic lesions, and Hürthle cell tumor (a variant of follicular carcinoma that is not radioiodine avid). Cancer of the thyroid gland can occur at any age, but the majority of patients are elderly, particularly those with the follicular, medullary, or anaplastic type.2 Papillary thyroid carcinoma usually affects young adults, with a female-male ratio of 4:1. A small percentage of patients (4%) develop distance metastases to bone, lungs, and liver.3 Rarely, the presence of distant metastases may be the only manifestation of thyroid cancer.3 A search of the world literature revealed that miliary spread of thyroid cancer to the lungs is extremely rare, with only 2 reported cases of the papillary variety4,5 and a single case of the medullary type.6 An awareness of miliary dissemination of thyroid cancer is important, especially during the diagnostic investigation of stable or slowly developing miliary lesions or when a thyroid carcinoma is detected incidentally in a thyroidectomy specimen. Miliary lung opacities are relatively common findings in diseases such as tuberculosis, pulmonary sarcoidosis, eosinophilic granuloma, or bronchial carcinoid tumor.7 Occasionally, extrathoracic malignancies, eg, melanoma and renal cell cancer, may give rise to multifocal lung disseminations.8 The diagnosis of any unknown diffuse interstitial processes in the lungs is usually made on bronchoscopy with transbronchial biopsy and bronchoaveolar lavage.5,9 In our patient, the diagnosis of the primary tumor was made on fine-needle aspiration cytology, and the avid uptake of radioactive iodine in the pulmonary lesions confirmed their metastatic nature. The majority of cases of papillary thyroid tumors present as a solitary nodule, but there is a high incidence (approximately 50%) of metastases to cervical lymph nodes.3 The incidence of nodal spread is higher in younger individuals, and it is not unusual for 1 or more enlarged neck nodes to be detected before the primary lesion is found.3 The unique characteristics of nodal spread of papillary thyroid carcinoma are as follows: (1) the nodal disease can be extensive even with small intrathyroidal primary lesions (as in this case); (2) the nodal metastases may be upstream and remote from the primary site (as in this case); (3) the nodal appearance on computed tomographic scans can be variable, and the nodes can be solid, cystic, calcified, hemorrhagic, or hyperdense (as in this case); and (4) the presence of nodal disease has no long-term bearing on survival. Our patient underwent a total thyroidectomy with bilateral selective neck dissections (levels II, III, IV, and VI). This procedure was followed by radioactive iodine treatment and regular follow-up monitoring of serum thyroglobulin levels. Histologic examination of the thyroid specimen revealed that within the gland there were 2 separate well-differentiated papillary carcinomas with small blood vessel invasions in addition to hyalinized stroma. These features were consistent with the occult sclerosing variant of papillary carcinoma—defined as an uncapsulated lesion measuring no more than 1.5 cm in diameter and showing extensive hyalinization of the tumor stroma.5 This subtype, in distinct contrast to the tall-cell variant, generally follows an indolent clinical course. In systematic autopsy studies, occult papillary cancers have been detected in up to 35.6% of examined thyroid glands,10 which suggests that most of these tumors remain small and never become overt carcinomas. The tumor may remain quiescent, without further dissemination, even if cervical lymph node metastases are present.11 However, higher rates of cervical recurrence and distant spread occur when there is intrathyroidal spread with involvement of small blood vessels.12 The 10-year survival rate in cases of intrathyroid papillary cancer is more than 90%, but this figure decreases to 60% when there is distant metastasis.2 References 1. Hundahl SAFleming IDFremgen AMMenck HR A National Cancer Data Base report on 53,856 cases of thyroid carcinoma treated in the US, 1985-1995. Cancer 1998;832638- 2648PubMedGoogle ScholarCrossref 2. Watkinson JCGaze MNWilson JA Stell & Maran’s Head and Neck Surgery. 4th ed. Woburn, Mass: Butterworth-Heinmann; 2000 3. Shaha ARFerlito ARinaldo A Distant metastases from thyroid and parathyroid cancer. ORL J Otorhinolaryngol Relat Spec 2001;63243- 249PubMedGoogle ScholarCrossref 4. Harach HRFranssila KO Occult papillary carcinoma of the thyroid appearing as lung metastasis. Arch Pathol Lab Med 1984;108529- 530PubMedGoogle Scholar 5. Fend FGruber UFritzsche HRothmund JBreitfellner GMikuz G Occult papillary carcinoma of the thyroid with pulmonary lymphangitic spread diagnosed by lung biopsy. Klin Wochenschr 1989;67687- 690PubMedGoogle ScholarCrossref 6. Clague JEPearson MGSharma ATaylor W Medullary carcinoma of the thyroid presenting as multifocal bronchial carcinoid tumour. Thorax 1991;4667- 68PubMedGoogle ScholarCrossref 7. Case records of the Massachusetts General Hospital: weekly clinicopathological exercises. N Engl J Med1986314564574. Case 8-1986 PubMedGoogle Scholar 8. Filderman AECoppage LShaw CMarthay RA Pulmonary and pleural manifestations of extrathoracic malignancies. Clin Chest Med 1989;10747- 807PubMedGoogle Scholar 9. Fedullo AJEttehsohn DB Bronchoalveolar lavage in lymphangitic spread of adenocarcinoma to the lung. Chest 1985;87129- 131PubMedGoogle ScholarCrossref 10. Harach HRFranssila KOWasenius VM Occult papillary carcinoma of the thyroid: a “normal” finding in Finland: a systematic autopsy study. Cancer 1985;56531- 538PubMedGoogle ScholarCrossref 11. Schwartz TB Benign metastases from thyroid malignancies. Lancet 1986;2733- 735PubMedGoogle ScholarCrossref 12. Carcangiu MLZampi GPupi ACastagnoli ARosai J Papillary carcinoma of the thyroid: a clinicopathologic study of 241 cases treated at the University of Florence, Italy. Cancer 1985;55805- 828PubMedGoogle ScholarCrossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Otolaryngology - Head & Neck Surgery American Medical Association

Radiology Quiz Case 1—Diagnosis

Archives of Otolaryngology - Head & Neck Surgery , Volume 130 (12) – Dec 1, 2004

Radiology Quiz Case 1—Diagnosis

Abstract

Diagnosis: Papillary thyroid carcinoma with miliary lung metastases Thyroid cancer mainly consists of papillary, follicular, medullary, and anaplastic variants, with proportions estimated at 78%, 13%, 4%, and 2%, respectively.1 The remaining 3% of thyroid carcinomas include lymphoma, sarcoma, metastatic lesions, and Hürthle cell tumor (a variant of follicular carcinoma that is not radioiodine avid). Cancer of the thyroid gland can occur at any age, but the majority of patients are...
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Publisher
American Medical Association
Copyright
Copyright © 2004 American Medical Association. All Rights Reserved.
ISSN
0886-4470
eISSN
1538-361X
DOI
10.1001/archotol.130.12.1446
Publisher site
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Abstract

Diagnosis: Papillary thyroid carcinoma with miliary lung metastases Thyroid cancer mainly consists of papillary, follicular, medullary, and anaplastic variants, with proportions estimated at 78%, 13%, 4%, and 2%, respectively.1 The remaining 3% of thyroid carcinomas include lymphoma, sarcoma, metastatic lesions, and Hürthle cell tumor (a variant of follicular carcinoma that is not radioiodine avid). Cancer of the thyroid gland can occur at any age, but the majority of patients are elderly, particularly those with the follicular, medullary, or anaplastic type.2 Papillary thyroid carcinoma usually affects young adults, with a female-male ratio of 4:1. A small percentage of patients (4%) develop distance metastases to bone, lungs, and liver.3 Rarely, the presence of distant metastases may be the only manifestation of thyroid cancer.3 A search of the world literature revealed that miliary spread of thyroid cancer to the lungs is extremely rare, with only 2 reported cases of the papillary variety4,5 and a single case of the medullary type.6 An awareness of miliary dissemination of thyroid cancer is important, especially during the diagnostic investigation of stable or slowly developing miliary lesions or when a thyroid carcinoma is detected incidentally in a thyroidectomy specimen. Miliary lung opacities are relatively common findings in diseases such as tuberculosis, pulmonary sarcoidosis, eosinophilic granuloma, or bronchial carcinoid tumor.7 Occasionally, extrathoracic malignancies, eg, melanoma and renal cell cancer, may give rise to multifocal lung disseminations.8 The diagnosis of any unknown diffuse interstitial processes in the lungs is usually made on bronchoscopy with transbronchial biopsy and bronchoaveolar lavage.5,9 In our patient, the diagnosis of the primary tumor was made on fine-needle aspiration cytology, and the avid uptake of radioactive iodine in the pulmonary lesions confirmed their metastatic nature. The majority of cases of papillary thyroid tumors present as a solitary nodule, but there is a high incidence (approximately 50%) of metastases to cervical lymph nodes.3 The incidence of nodal spread is higher in younger individuals, and it is not unusual for 1 or more enlarged neck nodes to be detected before the primary lesion is found.3 The unique characteristics of nodal spread of papillary thyroid carcinoma are as follows: (1) the nodal disease can be extensive even with small intrathyroidal primary lesions (as in this case); (2) the nodal metastases may be upstream and remote from the primary site (as in this case); (3) the nodal appearance on computed tomographic scans can be variable, and the nodes can be solid, cystic, calcified, hemorrhagic, or hyperdense (as in this case); and (4) the presence of nodal disease has no long-term bearing on survival. Our patient underwent a total thyroidectomy with bilateral selective neck dissections (levels II, III, IV, and VI). This procedure was followed by radioactive iodine treatment and regular follow-up monitoring of serum thyroglobulin levels. Histologic examination of the thyroid specimen revealed that within the gland there were 2 separate well-differentiated papillary carcinomas with small blood vessel invasions in addition to hyalinized stroma. These features were consistent with the occult sclerosing variant of papillary carcinoma—defined as an uncapsulated lesion measuring no more than 1.5 cm in diameter and showing extensive hyalinization of the tumor stroma.5 This subtype, in distinct contrast to the tall-cell variant, generally follows an indolent clinical course. In systematic autopsy studies, occult papillary cancers have been detected in up to 35.6% of examined thyroid glands,10 which suggests that most of these tumors remain small and never become overt carcinomas. The tumor may remain quiescent, without further dissemination, even if cervical lymph node metastases are present.11 However, higher rates of cervical recurrence and distant spread occur when there is intrathyroidal spread with involvement of small blood vessels.12 The 10-year survival rate in cases of intrathyroid papillary cancer is more than 90%, but this figure decreases to 60% when there is distant metastasis.2 References 1. Hundahl SAFleming IDFremgen AMMenck HR A National Cancer Data Base report on 53,856 cases of thyroid carcinoma treated in the US, 1985-1995. Cancer 1998;832638- 2648PubMedGoogle ScholarCrossref 2. Watkinson JCGaze MNWilson JA Stell & Maran’s Head and Neck Surgery. 4th ed. Woburn, Mass: Butterworth-Heinmann; 2000 3. Shaha ARFerlito ARinaldo A Distant metastases from thyroid and parathyroid cancer. ORL J Otorhinolaryngol Relat Spec 2001;63243- 249PubMedGoogle ScholarCrossref 4. Harach HRFranssila KO Occult papillary carcinoma of the thyroid appearing as lung metastasis. Arch Pathol Lab Med 1984;108529- 530PubMedGoogle Scholar 5. Fend FGruber UFritzsche HRothmund JBreitfellner GMikuz G Occult papillary carcinoma of the thyroid with pulmonary lymphangitic spread diagnosed by lung biopsy. Klin Wochenschr 1989;67687- 690PubMedGoogle ScholarCrossref 6. Clague JEPearson MGSharma ATaylor W Medullary carcinoma of the thyroid presenting as multifocal bronchial carcinoid tumour. Thorax 1991;4667- 68PubMedGoogle ScholarCrossref 7. Case records of the Massachusetts General Hospital: weekly clinicopathological exercises. N Engl J Med1986314564574. Case 8-1986 PubMedGoogle Scholar 8. Filderman AECoppage LShaw CMarthay RA Pulmonary and pleural manifestations of extrathoracic malignancies. Clin Chest Med 1989;10747- 807PubMedGoogle Scholar 9. Fedullo AJEttehsohn DB Bronchoalveolar lavage in lymphangitic spread of adenocarcinoma to the lung. Chest 1985;87129- 131PubMedGoogle ScholarCrossref 10. Harach HRFranssila KOWasenius VM Occult papillary carcinoma of the thyroid: a “normal” finding in Finland: a systematic autopsy study. Cancer 1985;56531- 538PubMedGoogle ScholarCrossref 11. Schwartz TB Benign metastases from thyroid malignancies. Lancet 1986;2733- 735PubMedGoogle ScholarCrossref 12. Carcangiu MLZampi GPupi ACastagnoli ARosai J Papillary carcinoma of the thyroid: a clinicopathologic study of 241 cases treated at the University of Florence, Italy. Cancer 1985;55805- 828PubMedGoogle ScholarCrossref

Journal

Archives of Otolaryngology - Head & Neck SurgeryAmerican Medical Association

Published: Dec 1, 2004

Keywords: diagnostic radiologic examination,radiology specialty

References