|Year : 2013 | Volume
| Issue : 3 | Page : 111-113
Metastatic lesions to thyroid associated with dual primaries: A report of two cases
Binit Kumar Khandelia1, Shrijeet Chakraborti1, Santosh Rai2, Hema Kini1
1 Department of Pathology, Kasturba Medical College, Mangalore, Karnataka, India
2 Department of Radiodiagnosis, Kasturba Medical College, Mangalore, Karnataka, India
|Date of Web Publication||6-Aug-2013|
Department of Pathology, Kasturba Medical College, Mangalore Lighthouse Hill Road, Mangalore - 575 001, Karnataka
Source of Support: None, Conflict of Interest: None
The presence of metastatic malignancy entails a search for the primary tumor. In this study, two unusual cases of metastatic tumors, one a diffuse B-cell Non-Hodgkin lymphoma (NHL) and the other squamous cell carcinoma (SqCC), to the thyroid gland, revealed two primary sites on further work-up. In view of diffuse B-cell NHL involving the nasopharynx, parapharyngeal and cervical lymph nodes, it was presumed that the involvement of thyroid was secondary. Similarly, because of uncommon occurrence of SqCC of thyroid and proven synchronous SqCC in lung and larynx, the tumor in the thyroid was diagnosed as a metastatic SqCC.
Keywords: B-cell non-hodgkin lymphoma, metastasis, squamous cell carcinoma, thyroid gland
|How to cite this article:|
Khandelia BK, Chakraborti S, Rai S, Kini H. Metastatic lesions to thyroid associated with dual primaries: A report of two cases. Thyroid Res Pract 2013;10:111-3
|How to cite this URL:|
Khandelia BK, Chakraborti S, Rai S, Kini H. Metastatic lesions to thyroid associated with dual primaries: A report of two cases. Thyroid Res Pract [serial online] 2013 [cited 2020 Jan 24];10:111-3. Available from: http://www.thetrp.net/text.asp?2013/10/3/111/116133
| Introduction|| |
Metastasis to the thyroid gland is uncommon, with reported incidences ranging from 0.5%  in unselected autopsy studies, to as high as 24% , in those with widespread metastatic disease. Malignant melanoma and carcinomas of lung, breast, kidney, gastrointestinal tract, head and neck etc., have been noted to secondarily involve the thyroid gland. We present two very unusual cases with metastases to the thyroid.
| Case Reports|| |
A 52-year-old female presented with a swelling in the front of neck of 3 months duration. She gave a history of left hemithyroidectomy 20 years ago, further details of which were not available. Examination revealed a firm, diffuse swelling, moving with deglutition, involving the right lobe of thyroid as well as multiple cervical lymph nodes. Computed tomogram (CT) of the head and neck showed a 5.8 cm × 5.6 cm × 5.1 cm heterogeneous mass lesion involving the right lobe of the thyroid gland [Figure 1]a, with multiple, bilateral, enlarged, level III cervical lymph nodes and a separate homogenous mass lesion in the right parapharynx [Figure 1]b. Fine needle aspiration cytology (FNAC) of the thyroid showed benign follicular cells in cohesive sheets [Figure 1]c, admixed with small- to medium-sized lymphoid cells [Figure 1]d-g. These lymphoid cells were arranged in dyscohesive sheets, and had high N:C ratio, coarse chromatin, prominent nucleoli and irregular nuclear membrane. FNAC of cervical lymph node showed a similar monomorphous population of small- to medium-sized lymphoid cells [Figure 1]h and i. A cytological diagnosis of Non-Hodgkin lymphoma (NHL) involving the thyroid and cervical lymph nodes was made.
|Figure 1: Computed tomogram scan of head & neck, shows mass in right lobe of thyroid (a: arrow), multiple, bilateral cervical lymph nodes and right parapharyngeal mass (b: arrow). Thyroid fine needle aspiration cytology (FNAC) shows benign follicular cells (e: LG ×100) admixed with abnormal lymphoid cells (c: PAP ×100; d: PAP ×400; f: LG ×100; g: LG ×400). Cervical lymph node FNAC shows similar abnormal lymphoid cells (h: PAP ×400; i: LG ×400). Nasopharyngeal mass biopsy shows ulcerated (l: H and E, ×100) respiratory epithelium (j: H and E, ×100) and submucosal sheets of abnormal lymphoid cells (k and m: H and E, ×400), positive for Leucocyte common antigen (n: ×400), CD20 (o: ×400), CD3 and Pan-CK negative (q: ×100). CD3 positive in reactive lymphocytes (p: ×100). [LG: Leishman stain, PAP: Papanicolaou stain, H and E: Hematoxylin and Eosin stain]|
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Panendoscopy revealed a growth in the fossa of Rosenmuller, extending into the posterior pharyngeal wall, suggestive of nasopharyngeal carcinoma. Nasopharyngeal biopsy was done, which showed focally ulcerated respiratory mucosa [Figure 1]j with an underlying tumor [Figure 1]k and l composed of round small- to medium-sized tumor cells, having coarse chromatin, and scanty eosinophilic cytoplasm [Figure 1]m. These tumor cells were immunopositive for Leucocyte common antigen [Figure 1]n and CD20 [Figure 1]o, negative for Pan-Cytokeratin [Figure 1]p and CD3 positive in reactive infiltrating lymphocytes [Figure 1]q. The final diagnosis was diffuse B-cell NHL involving the nasopharynx, parapharyngeal and cervical lymph nodes with dissemination to the thyroid gland.
The bone marrow aspiration and trephine biopsy showed diffuse lymphomatous infiltration. The patient received four cycles of chemotherapy with R-CHOP (rituximab - cyclophosphamide, hydroxydoxorubicin, vincristine/oncovin, prednisolone) regimen followed by four cycles of radiotherapy and presently tumor-free 2 year and three months after treatment.
A 72-year-old male presented with hoarseness of voice, loss of weight and appetite, swelling in the front of neck of 3 months duration, and another swelling in the left supraclavicular region. CT scan of the neck and chest showed a 3 cm × 3 cm cystic nodule in the left lobe of thyroid [[Figure 2]a, arrow], 5 cm × 4 cm cystic swelling in the left supraclavicular region and a 5.4 cm × 4.6 cm mass in the perihilar region of the right upper lobe of lung [[Figure 2]g, arrow], engulfing the right main stem bronchus. FNAC of both the thyroid [Figure 2]b-d and supraclavicular cystic swellings, showed pleomorphic, polygonal to spindle-shaped tumor cells, strap and tadpole cells with hyperchromatic nuclei and intracytoplasmic keratinization, and was diagnosed as keratinizing squamous cell carcinoma (SqCC).
|Figure 2: Computed tomogram (CT) scan of head & neck shows a cystic nodule in left lobe of thyroid (a: arrow). Thyroid FNA shows follicular cells in cohesive sheets (b: LG ×100) along with cluster of malignant squamous cells (c: LG ×400), tadpole cells (d inset: PAP ×400) and intracellular keratinization (d: PAP ×400). Bronchoscopy revealed right vocal cord growth (e: arrow) which on histology was moderately differentiated squamous cell carcinoma (f: H and E, ×400). CT scan of chest shows nodular homogenous mass in the right lung (g: arrow). Bronchial brush cytology showed scattered malignant squamous cells and benign endobronchial cells (h: PAP ×400). [LG: Leishman stain, PAP: Papanicolaou stain, H and E: Hematoxylin and Eosin stain]|
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Bronchoscopy revealed a growth in the right vocal cord [Figure 2]e which on biopsy showed SqCC [Figure 2]f. Re-evaluation of the CT scan of neck and chest did not show any direct extension of the laryngeal mass into the thyroid gland. Bronchoscopic brushing of the right lung mass exhibited cytological features of SqCC [Figure 2]h. The final diagnosis was primary right lung and laryngeal moderately differentiated SqCC with cystic metastases to the left lobe of thyroid and left supraclavicular lymph nodes. The patient shifted to the regional cancer institute for further treatment and was lost to follow-up.
| Discussion|| |
Metastases to the thyroid gland are very uncommon, known to arise from various primary sites, but most commonly from the kidney,  lung,  breast, oesophagus and uterus. ,
Lymphomas of the thyroid are rare, accounting for 1-5% of thyroid neoplasms and less than 2% of extranodal lymphomas, the most common type being diffuse large B-cell lymphoma (50-80%), followed by extranodal marginal zone B-cell lymphoma (20-30%).  Primary thyroid lymphomas show a female preponderance (4-5:1), present commonly in the seventh decade and arise usually in a setting lymphocytic thyroiditis/Hashimoto's thyroiditis.  Immunohistochemistry helps distinguish anaplastic carcinoma and lymphomas,  but not primary versus secondary lymphoma of the thyroid.  The prognosis of patients with thyroid lymphomas is excellent with current treatment regimes. 
In the first case, the patient did not give any history of Hashimotos's thyroiditis. In view of diffuse B-cell NHL involving the nasopharynx, parapharyngeal and cervical lymph nodes, it was presumed that the involvement of thyroid was secondary. The patient responded well to chemotherapy.
Among the malignant pulmonary neoplasms metastasising to the thyroid, adenocarcinomas are the commonest, followed by squamous cell, small cell, large cell and bronchioloalveolar carcinomas.  Primary SqCC of the thyroid accounts for less than 1% of all thyroid malignancies.  In the second case, in view of the uncommon occurrence of SqCC in thyroid and proven synchronous SqCC in lung and larynx, demonstrated by bronchial brush cytology and laryngeal biopsy, respectively, the tumor in the thyroid was diagnosed as a metastatic SqCC. Immunohistochemistry is not helpful to distinguish between primary versus secondary SqCC of thyroid. Laryngeal cancer can present as a thyroid mass due to direct extension of tumor into the thyroid gland.  However, a synchronous SqCC involving all the above mentioned sites, is a possibility as reported by Iqbal et al.  Occasionally secondary in thyroid is the primary presenting manifestation of pulmonary carcinoma,  similar to the second case.
Thyroid NHL and SqCC mandates a complete diagnostic work-up for staging, search for primary disease, and hence ensures proper treatment in such cases.
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[Figure 1], [Figure 2]