|Year : 2016 | Volume
| Issue : 1 | Page : 27-29
Synchronous medullary carcinoma of thyroid and ductal carcinoma of breast: A report of a rare case with immunohistochemical study
Sanjay D Deshmukh1, Rupali R Bavikar1, Hemant Lekawale2, Lalit Datar2, Bageshri Gogate1, Snehal Purandare2
1 Department of Pathology, Smt. Kashibai Navale Medical College, Pune, Maharashtra, India
2 Department of Surgery, Smt. Kashibai Navale Medical College, Pune, Maharashtra, India
|Date of Web Publication||5-Jan-2016|
Rupali R Bavikar
Department of Pathology, Smt Kashibai Navale Medical College, Pune - 411 001, Maharashtra
Source of Support: None, Conflict of Interest: None
Synchronous malignancies of breast and thyroid have been rarely documented in literature. The reports of secondary malignancies after thyroid cancer and treated breast cancer are relatively not uncommon. We encountered a case of thyroid tumor coexisting with carcinoma of breast. On histopathological and immunohistochemical (IHC) studies, the thyroid was involved by medullary carcinoma and the breast revealed invasive ductal adenocarcinoma. The rarity of this association has prompted us to report this case.
Keywords: Breast, synchronous tumors, thyroid
|How to cite this article:|
Deshmukh SD, Bavikar RR, Lekawale H, Datar L, Gogate B, Purandare S. Synchronous medullary carcinoma of thyroid and ductal carcinoma of breast: A report of a rare case with immunohistochemical study. Thyroid Res Pract 2016;13:27-9
|How to cite this URL:|
Deshmukh SD, Bavikar RR, Lekawale H, Datar L, Gogate B, Purandare S. Synchronous medullary carcinoma of thyroid and ductal carcinoma of breast: A report of a rare case with immunohistochemical study. Thyroid Res Pract [serial online] 2016 [cited 2019 Jun 19];13:27-9. Available from: http://www.thetrp.net/text.asp?2016/13/1/27/168872
| Introduction|| |
When dual malignancies occur, the second malignancy is either synchronous or metachronous. The term synchronous malignancy is defined when histologically different malignancies are noted within 6 months of detection of first malignancy. In this case, the possibilities of metastatic malignancy are carefully ruled out on the basis of histomorphological and immunohistochemical (IHC) studies. Occurrence of second primary malignancy in thyroid cancer patients who have been treated are noted generally after the interval of 0.8–8 years and above. In literature, anaplastic thyroid carcinoma with ductal carcinoma of breast is recently documented. In the present case, we encountered medullary carcinoma of thyroid synchronous with ductal carcinoma of breast in a 45-year-old female.
| Case Report|| |
A 45-year-old female patient presented with lump in right breast since 6 months and lump in anterior neck region since 3 month. The lump in right breast was measuring 3 × 2 cm and it was fixed to underlying structures. Axillary lymph nodes were palpable. Computed tomography (CT) right breast showed heterogeneously enhancing soft tissue lesion measuring 34 × 23 mm, reaching up to retroareolar region [Figure 1]. The lump in anterior neck region was well-defined lesion measuring 4 × 2 cm and it was moving with deglutition. Ultrasonography (USG) of thyroid showed a well-defined, solid, hypoechoic mass lesion of size 40 × 22 mm occupying the right lobe of thyroid. CT thyroid showed well-defined, hypodense lesion with heterogeneous contrast enhancement in right lobe of thyroid with central calcification [Figure 2]. Serum calcitonin level was 11,618 pg/ml (normal value-ND to 11.5 pg/ml).
|Figure 1: (a) CT right breast shows heterogeneously enhancing soft tissue lesion reaching up tosubareolar region. (b) CT thyroid showing well-defined, hypodense lesion in right lobe of thyroid with heterogeneous contrast enhancement and central calcification.CT = Computed tomography|
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|Figure 2: Photomicrograph thyroid tumor composed of cells arranged in sheets, nest, and cord pattern with eosinophilic acellular amyloid deposits. Lower case showing Hashimoto's thyroiditis (H and E, ×:40)|
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The patient was operated. We received aright modified radical mastectomy (MRM) specimen with axillary clearance of lymph nodes and total thyroidectomy specimen. Total thyroid measured 7 × 7 × 2 cm. Right lobe measured 6 × 4 × 1 cm. Cut surface of right lobe showed grayish white encapsulated lesion, while left lobe was unremarkable. Right MRM specimen measured 23 × 17 × 4 cm. It showed a tumor measuring 3 cm in diameter in lower and outer quadrant of right breast.
Section from thyroid nodule showed tumor cells arranged in nests, solid sheets, and cord pattern separated by thick and thin bands of connective tissue. Also seen were patchy deposits of eosinophilic homogeneous, glassy, amyloid deposition [Figure 3]. Congo red of section showed apple green birefringence under polarized microscope confirming amyloid nature of deposit [Figure 4]. IHC marker synaptophysin (clone syn38, Dako) [Figure 4] showed membrane positivity, while chromogranin was negative.
|Figure 3: Polarized microscopy image showing apple green birefringence of amyloid deposits|
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|Figure 4: Photomicrograph showing immunore activity for synaptophysin in tumor cells of thyroid (×:400)|
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Section studied from breast lump showed a tumor composed of cells arranged in nests, gland, and tubule-like structures and small clusters. The cells were round to polygonal with pleomorphic hyperchromatic nuclei and prominent nucleoli. The tumor cells were negative for estrogen receptor (ER) and progesterone receptor (PR), while HER2 neu showed 3 + membrane positivity.
| Discussion|| |
Medullary thyroid carcinoma (MTC) is a rare form of thyroid carcinoma and accounts for 3–5% of all thyroid malignancies. They arise from parafollicular cells or C cells which secrete a hormone calcitonin. Approximately 20% of medullary carcinomas are associated with one of the three familial syndromes MEN2A, MEN2B, and familial MTC. These syndromes are caused by mutation in RET pro-oncogene. Though most of the cases are sporadic, genetic syndromes must be ruled out in all cases of MTC. RET has been identified as estrogen-dependent gene whose expression is induced by estrogen breast carcinoma.
Synchronous malignancies of breast and thyroid are attributed to genetic aberrations and hormonal influences. Thyroid and breast are under the influence of the same hormones. Estrogen plays an important role in development, physiology, and pathology of thyroid gland. thyroid-stimulating hormone (TSH) receptors are found in breast tissue. Increased levels of thyroid peroxidase is associated with better prognosis in breast cancer patients. It is interesting to note that the data from Connecticut Tumor Registry demonstrated a significantly elevated risk of developing thyroid cancer following breast cancer and vice versa. Nontoxic goiter and antiperoxidase antibodies are found twice common in breast carcinoma patients as compared to normal population.
Giani et al., found that overall prevalence of thyroid disease was 47 in 102 (46%) in breast carcinoma patients as compared to 14% in control. The other study group demonstrated 45.5% of breast carcinoma patients showed thyroid enlargement as compared to 10.5% in normal population.
All these studies indicate a significant association between thyroid and breast cancer. Hence in treated patients of breast cancer or thyroid cancer, careful follow-up and screening is mandatory. Surgeons should be aware of synchronous malignancies particularly for patients being diagnosed with malignancies of breast, thyroid, prostate, kidney, and melanoma. This is significant in follow-up and surveillance of treated patients.
To conclude, occurrence of synchronous malignancies of breast and thyroid may be attributed to hormonal influences and genetic changes which may serve as novel targets for cancer prevention and treatment. The cumulative data of such reports will pave the way for better insight in this group of neoplasms.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]