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LETTER TO THE EDITOR
Year : 2013  |  Volume : 10  |  Issue : 2  |  Page : 86-87

Pleural metastasis resulting from metastatic papillary carcinoma of the thyroid


1 Department of Surgical Oncology, Cancer Institute (WIA), 36, Sardar Patel Road, Adyar, Chennai, India
2 Department of Preventive Oncology, Cancer Institute (WIA), 36, Sardar Patel Road, Adyar, Chennai, India
3 Department of Pathology, Cancer Institute (WIA), 36, Sardar Patel Road, Adyar, Chennai, India

Date of Web Publication16-Apr-2013

Correspondence Address:
Arvind Krishnamurthy
Department of Surgical Oncology, Cancer Institute (WIA), 36, Sardar Patel Road, Adyar, Chennai- 600 020
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0973-0354.110597

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How to cite this article:
Krishnamurthy A, Ramshankar V, Majhi U. Pleural metastasis resulting from metastatic papillary carcinoma of the thyroid. Thyroid Res Pract 2013;10:86-7

How to cite this URL:
Krishnamurthy A, Ramshankar V, Majhi U. Pleural metastasis resulting from metastatic papillary carcinoma of the thyroid. Thyroid Res Pract [serial online] 2013 [cited 2019 Sep 18];10:86-7. Available from: http://www.thetrp.net/text.asp?2013/10/2/86/110597

Sir,

A 40-year-old man underwent total thyroidectomy with bilateral central compartmental dissection and right functional neck dissection for papillary carcinoma thyroid (PTC). The final histopathology confirmed PTC with extrathyroidal spread and metastasis to 2 out of the 14 dissected nodes. He was on regular follow-up on suppressive doses of thyroxine after remnant ablation with 50 mCi of Iodine-131.

Thirteen years later, he presented to us with hoarseness of voice due to a paralyzed left vocal cord. Clinical and ultrasound examination of the neck and thyroid bed was normal. A chest skiagram showed left-sided pleural thickening. A subsequent computed tomography (CT) scan of the chest confirmed the left pleural thickening with minimal pleural effusion and a 1.5 cm aortopulmonary lymph node [Figure 1]. Ultrasound-guided aspiration cytology of the left effusion showed an exudative lymphocyte-rich effusion with some atypical cells, which was suspicious for malignancy. A thoracoscopic examination showed the parietal and diaphragmatic pleura studded with multiple nodular lesions; the underlying pulmonary parenchyma was however normal [Figure 2]. Histopathology of the pleural nodules with immunohistochemistry correlation (Cytokeratin 19(CK19) positive and Thyroid Transcription Factor (TTF) mildly positive) revealed metastatic deposits from PTC [Figure 3]. The pleural based lesions did not show any activity on an Iodine-131 scan; the whole body scan was also negative. His serum thyroglobulin level was mildly elevated at 10 ng/ml. The patient wished to be on follow-up with suppressive doses of thyroxine after undergoing a pleurodesis using tetracycline. The general condition of the patient rapidly deteriorated over the next 4 months and he succumbed to disseminated cancer (subsequently developing liver and brain metastases).
Figure 1: Axial CT scan of the chest showing the left pleural thickening with pleural nodules and minimal pleural effusion

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Figure 2: Thoracoscopic examination of the left pleura showing the parietal and diaphragmatic pleura studded with multiple nodular lesions

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Figure 3: (a) The histopathology of the pleural nodules showing the mesothelial cells infiltrated by follicle-like structures lined by stratified cuboidal and low columnar cells (H and E, × 20), (b) CK19 reveals follicular and papillary structures showing strong cytoplasmic positivity (IHC, × 100)

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Pleural metastasis complicates the clinical course of patients with a wide range of malignancies, which are most often due to lymphoid malignancies and carcinomas of the breast, lung, gastrointestinal tract, or ovaries. Pulmonary metastases from thyroid cancers have been well documented; however, malignant pleural involvement as a manifestation of distant metastasis is rare, mostly described in published literature as isolated case reports. [1],[2],[3] In a retrospective case series, malignant pleural effusion complicated the course of PTC in 0.6% of the patients. [1] They further found that the diagnosis of thyroid cancer preceded the occurrence of malignant pleural effusion by many years and that all patients had radiologically apparent lung metastases at the time pleural effusion. [1] Our patient had pleural metastasis without any radiological evidence of pulmonary metastasis. There are no standard treatment recommendations for such patients. Pleural metastasis is associated with a very poor prognosis; the median overall survival following the appearance of a pleural metastasis is less than a year. [1]

It is important to note that only 50% of patients with cancer, who develop a pleural effusion during their clinical course, have a malignant pleural effusion. [4] A structured evaluation of the effusion is therefore mandatory to establish its etiology and to further plan therapy. In conclusion, metastatic pleural effusion from PTC deserves consideration in the differential diagnosis of an exudative, lymphocyte-rich pleural effusion, especially in the background of a thyroid malignancy.

 
  References Top

1.Vassilopoulou-Sellin R, Sneige N. Pleural effusion in patients with differentiated papillary thyroid cancer. South Med J 1994;87:1111-6.  Back to cited text no. 1
    
2.Siddaraju N, Viswanathan VK, Saka VK, Basu D, Shanmugham C. Fine needle aspiration of follicular variant of papillary thyroid carcinoma presenting with pleural effusion: A case report. Acta Cytol 2007;51:911-5.  Back to cited text no. 2
    
3.Hsu KF, Hsieh CB, Duh QY, Chien CF, Li HS, Shih ML. Hürthle cell carcinoma of the thyroid with contralateral malignant pleural effusion. Onkologie 2009;32:47-9.  Back to cited text no. 3
    
4.Heffner JE. Diagnosis and management of malignant pleural effusions. Respirology 2008;13:5-20.  Back to cited text no. 4
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]


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[Pubmed] | [DOI]



 

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