Case Report SPONTANEOUS REGRESSION OF ...

Case Report SPONTANEOUS REGRESSION OF PRIMARY MICROCARCINOMA THYROID AFTER METASTASIZING SUPRACLAVICULAR AND CERVICAL LYMPH NODES

PAPILLARY TO RIGHT

Muhammad Mumtaz Khan1, Ghulam Saqulain2, Sabeen Nasir1, Naveed Sharif1 1

Peshawar Medical College, Peshawar (Ripah International University, Islamabad), Pakistan Capital Hospital, Islamabad, Pakistan

2

ABSTRACT Objective: Papillary microcarcinoma thyroid is a rare focus of malignancy within normal thyroid or in adenomatous colloid goiter. Our aim is to bring to focus the possibility of papillary microcarcinoma thyroid presenting as lymph node metastasis without thyroid enlargement. Case report: We present a case who initially reported with a small cystic to nodular swelling in the right supraclavicular lymph node. The biopsy revealed it to be lymph node showing metastatic papillary carcinoma thyroid. Clinically there was no enlargement of the thyroid gland. Thyroid function tests, neck ultrasound and thyroid scan were normal. Therefore, a diagnosis of metastatic papillary microcarcinoma thyroid was made. Another lesion appeared in the right cervical region after six months having identical morphology as earlier case. Again, a battery of tests were performed including neck ultrasound and thyroid scan which were normal. TTF-1 immunohistochemical stain was strongly positive in both the cases which confirmed thyroid their origin. The patient did not opt for surgery; however, there was no recurrence after more than 10 years follow up. Conclusion: The possibility of papillary microcarcinoma thyroid as a metastatic lesion in a lymph node biopsy must be kept in mind even in the absence of thyroid enlargement. Keywords: Papillary microcarcinoma thyroid, Lymph node metastasis, Spontaneous regression. This case report can be sited as: Khan MM, Saqulain G, Nasir S, Sharif N. Spontaneous regression of primary papillary microcarcinoma thyroid after metastasizing to right supraclavicular and cervical lymph nodes. Pak J Pathol. 2016: 27(4): 178-182. INTRODUCTION According to the World Health Organization (WHO) microcarcinoma thyroid are defined as a focus malignancy of 10 mm diameter or less present within normal thyroid or adenomatous colloid goiter [1]. They are not detectable clinically. Usually they are discovered incidentally (thyroid incidentalomas) on ultrasound or MRI and the majority of them are papillary microcarcinoma

thyroid

(PMCT).

Most

PMCT have an excellent prognosis. They may present as palpable lymphadenopathy in the head and neck region. Even in very small PMCT with a diameter less than 1 mm, nodal metastases have been described [2]. A PMCT measuring 4 mm manifesting as a single bone lesion in left 4 th rib has been described [3]. The detection of papillary microcarcinoma of the

thyroid is increasing due to frequent use of ultrasound and fine-needle aspiration cytology. The average prevalence of PTMC is around 10% with a wide range 2.0–35.6%; moreover PMCT patients represent up to 30% of all thyroid carcinomas [4]. Anastasilakis AD et al., after an extensive review of the literature on the subject, determined that PMCT as lymph node metastasis typically presents at a relatively younger age compared to the rest of metastatic malignancies in the head and neck region. The mean age of the reviewed cases was less than 40 years, while PMCT without a clinically evident lymph node metastasis (LNM) presents at a mean age of 45-52 years. These differences probably reflect the more aggressive behavior of PMCT presenting as LNM, which may arise at a similar age but become apparent earlier than the remaining

Correspondence: Dr Muhammad Mumtaz Khan, Professor, Department of Pathology, Peshawar Medical College, Warsak Road, Peshawar, Pakistan

PMCT [5].

Email: [email protected]

carcinoma thyroid (PCT) in particular are more

Thyroid cancer in general and papillary

Received: 06 Nov 2016; Revised: 04 Dec 2016; Accepted: 27 Dec 2016

Pakistan Journal of Pathology 2016; Vol. 27 (4): 178-182.

178

Spontaneous regression of primary papillary microcarcinoma thyroid after metastasizing to right supraclavicular and cervical lymph nodes

common in women, with a reported ratio of 3:1; in

side lower neck for the last 03 years. Examination

PMCT series, females represented 70-89% of the

revealed a nodular swelling firm in consistency and

cases. However, in cases of PMCT presenting as an

measuring 4x3 cm in size above the sternal end of

enlarged lymph node, female predominance is

right clavicle between the sternal and clavicular

considerably lower. This may also be related to the

heads of sternocleidomastoid muscle. The swelling

abovementioned

PMCT

was non-fluctuant and lacked signs of inflammation.

presenting as LNM, as PCT is more aggressive in

There was no pulsation or bruit. Clinically there was

men [5].

no other lymph node enlargement and thyroid was

In a retrospective study to determine the predictive

normal in appearance.

aggressiveness

of

factors for lymph node metastasis in papillary

Routine

investigations

were

all

normal.

microcarcinomas it was found that a tumor size of 5

Keeping in view a high incidence of tuberculous

mm or more, extrathyroidal extension, multifocality,

lymphadenopathy, Mantoux test and fine needle

sclerosis and the expression of S100A4 and cyclin

aspiration cytology (FNAC) were advised. Mantoux

D1 predicted lymph node metastasis. It was also

test was not significant. The FNAC revealed clumps

pointed out that S100A4 expression may discriminate

of monomorphic epithelial cells arranged mostly in

between ‘more aggressive forms’ and clinically silent

papillary

papillary microcarcinomas [6].

lymphocytes. A diagnosis of metastatic papillary

Microscopically it has all the characteristics

configurations

along

with

scattered

lesion was made and biopsy was advised.

of papillary carcinoma thyroid, i.e., branching papillae

The mass was excised under general anesthesia.

having a fibrovascular stalk covered by a single to

Using a horizontal supraclavicular incision, the mass

multiple layers of cuboidal epithelial cells and nuclei

was

having optically clear or empty appearance and

subcutaneous tissue and deep fascia under general

invaginations of the cytoplasm that may be seen as

anesthesia. Gentle blunt dissection from surrounding

intranuclear

tissue

inclusions

(“pseudo-inclusions”)

or

intranuclear grooves [7].

exposed

revealed

after

grayish

cutting

white

through

cystic

skin,

swelling

measuring 3x2 cm with origin from the lymphatics

The aim of the article is to change our

around the internal jugular vein. The cyst leaked

diagnostic approach in dealing with patients who

draining chocolate colored fluid on attempting to

report for chronic lymphadenopathy in the head and

remove it. The sample was sent for histopathological

neck region and to keep the possibility of PMCT in

examination. Recovery was uneventful and the

mind even though the thyroid gland itself may be

patient was discharged on second post op day.

normal in appearance and on imaging. We here present

lymph

microcarcinoma

node thyroid

metastasis first

in

by

papillary

the

Grossly it was a nodular soft tissue mass measuring 3x1.5x0.5 cm. The consistency was soft

right

and the cut surface was grayish white, friable

supraclavicular lymph node followed by right cervical

containing small cystic spaces filled with papillary

lymph node followed by spontaneous regression of

projections. Microscopically the normal architecture

the primary.

of lymph node was totally obliterated due to formation of small cystic spaces filled with papillary projections

CASE REPORT A 29 years old adult male was admitted on 07-04-2004, to the ENT Department of Capital

and lined by neoplastic cells with empty nuclei (Figure-1).

Hospital, Islamabad, Pakistan, with a swelling right Pakistan Journal of Pathology 2016; Vol. 27 (4): 178-182.

179


The patient was examined systematically. No abnormality

could

be

detected

on

systemic

examination. Clinically there was no enlargement of thyroid gland. Thyroid function tests (TFTs) were within normal range. Thyroid ultrasound and thyroid scan

were

normal.

Other

otolaryngologic

and

endoscopic examinations were normal. A TTF-1 Figure-1: Lymph node with complete effacement of the normal architecture due to metastatic papillary carcinoma forming cystic spaces with papillary fronds in the lumen H&Ex10.

positivity on immunohistochemistry (IHC) confirmed the primary to be thyroid (Figure-4).

The cores of the papillae were filled by a polymorphous population of lymphoid cells. Most of the papillae contained psammoma bodies in their tips (Figure-2).

Figure-4:

Papillae

showing

strong

nuclear

positivity for immunohistochemical stain TTF-1 x10. Figure 2: Lymph node showing a cystic space with papillae fronds in the lumen. Some of papillae contain psammoma bodies in their tips H&Ex10. Nuclear grooves and nuclear inclusions were seen along with Orphan Ani nuclei (figure-3).

Keeping in view these findings, the diagnosis was revised as “papillary microcarcinoma thyroid with metastasis to right supraclavicular lymph node”. After about 6 months on 03-09-2004 the patient reported with another swelling in the right cervical region close to parotid. The biopsy revealed identical morphology as before with TTF-1 positivity on IHC and a diagnosis of “papillary microcarcinoma thyroid metastatic to right cervical lymph node” was made. Again, a battery of tests were performed including neck ultrasound and thyroid scan which were normal. The patient did not opt for surgery. The patient was

Figure 3: Papillae lined by optically clear nuclei. H&Ex20 This was a typical picture of papillary carcinoma

thyroid.

Therefore,

a

diagnosis

examined on 15-07-2015 and did not reveal any recurrence of the tumor or metastasis.

of

“papillary carcinoma thyroid metastatic to right supraclavicular lymph node” was made.

followed up for more than 10 years. He was last

DISCUSSION The above case highlighted the possibility of numerous differential diagnoses of enlarged lymph


180


nodes in the head and neck region. The majority of

recurrence of the lesion highlights spontaneous

lymph node presentations in the head and neck in

regression of the primary focus. Many tumors

our region turn out to be tuberculous, reactive or out

especially renal cell carcinoma [10] lung cancer

rightly metastatic with the primary either known or

[11,12], thyroid carcinomas and malignancies in other

easily discovered on investigations.

The problems

organs [13,14] are known for spontaneous regression

arise when the primary is not traceable as in our case

after metastases which also appears to be the case

which limits our approach to make decisions on

in our patient.

clinical findings and microscopic appearance of the CONCLUSION

tumor in the metastatic lymph node. The metastatic papillary carcinoma was

The possibility of papillary microcarcinoma

diagnosed on first lymph node biopsy in the parotid

thyroid must be kept in mind in a cervical lymph node

region when the thyroid gland itself was normal in

biopsy even in the absence of thyroid enlargement.

appearance. There have been reports of occult papillary carcinoma thyroid presenting as cervical

RECOMMENDATIONS

lymphadenopathy. In one of the cases the primary

Spontaneous regression of tumors is an area

focus was discovered after initial diagnosis on lymph

which has not been given due consideration.

node biopsy [2] and in the other two cases it was

Demystifying the process of spontaneous regression

found on ultrasonography before biopsy [8]. In our

by research aimed at factors responsible for it will

case

enlighten us about treating and preventing cancer in

the

metastatic

papillary

carcinoma

was

discovered incidentally without finding any primary

a better way.

focus in the thyroid even after investigations. Garrel R et al., studied 13 cases of PMCT

AUTHORS CONTRIBUTION

diagnosed on lymph node biopsy out of which 12

Muhammad Mumtaz Khan: Concept and manuscript

cases revealed a primary focus in thyroid, but in one

writing

case, no primary could be found even after detailed

Ghulam Saqulain: Data collection

investigations [9]. Anastasilakis AD et al., reported a

Sabeen Nasir & Naveed Sharif: Review

case of PMCT who presented as a solitary lymph node metastasis without evidence of primary tumor in thyroid imaging but multiple foci measuring 2-5 mm

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