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
Spontaneous regression of primary papillary microcarcinoma thyroid after metastasizing to right supraclavicular and cervical lymph nodes
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
Pakistan Journal of Pathology 2016; Vol. 27 (4): 178-182.
180
Spontaneous regression of primary papillary microcarcinoma thyroid after metastasizing to right supraclavicular and cervical lymph nodes
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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