INTERESTING IMAGE
A Clear Cell Variant of Papillary Thyroid Microcarcinoma With Lung, Bone, and Soft Tissue Metastases Bulent Yazici, MD,* Yesim Ertan, MD,† Aylin Oral, MD,* and Aysegül Akgün, MD* Abstract: A 56-year-old woman presented with a mass lesion on the right occipital bone underwent total resection of the tumor. An adenocarcinoma with immunostaining positive for thyroid transcription factor-1 and thyroglobulin was found. An ultrasound/thyroid scan detected a hot nodule of 9 mm in the right lobe. Fine needle biopsy revealed the similar histological findings with the previous bone resection material. Then, a total thyroidectomy was performed. Histopathologic examination revealed clear cell variant of papillary thyroid microcarcinoma. She received 7.4 GBq of 131I. On posttherapy scan, metastatic focuses were seen in the left lung and soft tissue between the left paravertebral muscles. Key Words: clear cell variant, papillary thyroid microcarcinoma, radioiodine, I-131, distant metastasis (Clin Nucl Med 2015;40: 885–887)
Received for publication January 19, 2015; revision accepted March 24, 2015. From the Departments of *Nuclear Medicine, and †Pathology, Medical Faculty, Ege University, Bornova, Izmir, Turkey. Conflicts of interest and sources of funding: none declared. Correspondence to: Bulent Yazici MD, Department of Nuclear Medicine, Ege University Medical Faculty, Bornova, 35040 Izmir, Turkey. E-mail: [email protected]. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0363-9762/15/4011–0885 DOI: 10.1097/RLU.0000000000000832
REFERENCES 1. Ziessman HA, O'Malley JP, Thrall J, et al. Endocrin System. In Ziessman HA, O'Malley JP, Thrall J, Fahey FH (eds): Nuclear Medicine: The Requisites. Philadelphia, PA: Elsevier Saunders; 2014;79–80. 2. Ardito G, Revelli L, Giustozzi E, et al. Aggressive papillary thyroid microcarcinoma: prognostic factors and therapeutic strategy. Clin Nucl Med. 2013;38:25–28. 3. Kuo EJ, Goffredo P, Sosa JA, et al. Aggressive variants of papillary thyroid microcarcinoma are associated with extrathyroidal spread and lymph-node metastases: a population-level analysis. Thyroid. 2013;23:1305–1311. 4. Ito Y, Hirokawa M, Uruno T, et al. Prevalence and biological behaviour of variants of papillary thyroid carcinoma: experience at a single institute. Pathology. 2008; 40:617–622. 5. Carcangiu ML, Sibley RK, Rosai J. Clear cell change in primary thyroid tumors. A study of 38 cases. Am J Surg Pathol. 1985;9:705–722. 6. Asioli S, Erickson LA, Sebo TJ, et al. Papillary thyroid carcinoma with prominent hobnail features: a new aggressive variant of moderately differentiated papillary carcinoma. A clinicopathologic, immunohistochemical, and molecular study of eight cases. Am J Surg Pathol. 2010;34:44–52. 7. Yang GC, Fried K, Scognamiglio T. Cytological features of clear cell thyroid tumors, including a papillary thyroid carcinoma with prominent hobnail features. Diagn Cytopathol. 2013;41:757–761. 8. Yu XM, Wan Y, Sippel RS, et al. Should all papillary thyroid microcarcinomas be aggressively treated? An analysis of 18,445 cases. Ann Surg. 2011;254:653–660. 9. Mihailovic J, Stefanovic L, Stankovic R. Influence of initial treatment on the survival and recurrence in patients with differentiated thyroidmicrocarcinoma. Clin Nucl Med. 2013;38:332–338. 10. Wartofsky L. Management of papillary microcarcinoma: primum non nocere? J Clin Endocrinol Metab. 2012;97:1169–1172. 11. Ito Y, Uruno T, Nakano K, et al. An observation trial without surgical treatment in patients with papillary microcarcinoma of the thyroid. Thyroid. 2003;13:381–387. 12. Baudin E, Travagli JP, Ropers J, et al. Microcarcinoma of the thyroid gland: the Gustave-Roussy Institute experience. Cancer. 1998;83:553–559. 13. Pellegriti G, Scollo C, Lumera G, et al. Clinical behavior and outcome of papillary thyroid cancers smaller than 1.5 cm in diameter: study of 299 cases. J Clin Endocrinol Metab. 2004;89:3713–3720. 14. Mercante G, Frasoldati A, Pedroni C, et al. Prognostic factors affecting neck lymph node recurrence and distant metastasis in papillary microcarcinoma of the thyroid: results of a study in 445 patients. Thyroid. 2009;19:707–716. 15. Godbert Y, Henriques-Figueiredo B, Cazeau AL, et al. A papillary thyroid microcarcinoma revealed by a single bone lesion with no poor prognostic factors. Case Rep Endocrinol. 2013;2013:719304. 16. Soydal C, Araz M, Ozkan E, et al. Assessment of recurrence rates in papillary thyroid microcarcinoma patients with and without histopathological risk factors after radioiodine ablation treatment. Nucl Med Commun. 2014;36:109–113. 17. Madani A, Jozaghi Y, Tabah R, et al. Rare metastases of well-differentiated thyroid cancers: a systematic review. Ann Surg Oncol. 2015;22:460–466.
Clinical Nuclear Medicine • Volume 40, Number 11, November 2015 Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
www.nuclearmed.com
885
Yazici et al
Clinical Nuclear Medicine • Volume 40, Number 11, November 2015
FIGURE 1. A 56-year-old woman presented with a bulging mass on the right occipital area. Computed tomography (CT) revealed a tumoral lesion with a diameter of 4 cm on the right occipital bone. Preoperative thorax CT and mammography were performed. Only a nonspecific nodule of 7 mm in the left lung's inferior lobe was detected. The thyroid gland was not investigated. The patient underwent total resection of the lesion. Histological examination of the bone resection material showed a clear cell adenocarcinoma (A, hematoxylin/eosin, original magnification 10; B, hematoxylin/eosin, original magnification 20) with immunostaining positive for nuclear thyroid transcription factor-1 (TTF-1) (C, original magnification 20). By reason of TTF-1 positivity, immunohistochemistry of thyroglobulin was also performed, and the specimen was positive for cytoplasmic thyroglobulin (D, original magnification 20).
FIGURE 2. Ultrasonography found only a nodule of 9 mm in the right lobe. It was hot on thyroid scan with 99mTc pertechnetate (black-arrow). Some thyroid cancers maintained trapping but not organification appear hot on 99mTc but cold on 123I scan (discordant nodules).1 Although 123I scan was not performed, probably, the nodule was discordant. 886
www.nuclearmed.com
© 2015 Wolters Kluwer Health, Inc. All rights reserved. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Clinical Nuclear Medicine • Volume 40, Number 11, November 2015
Clear Cell Papillary Thyroid Microcarcinoma
FIGURE 3. Fine needle biopsy was performed to this nodule, and similar histological findings with the previous bone material were demonstrated. The serum thyroglobulin level was more than 300 μg/L with thyroid-stimulating hormone of 1.3 μIU/L. Then, a total thyroidectomy was performed, and histopathologic examination revealed a clear cell variant of papillary thyroid microcarcinoma (PTMC) (A, hematoxylin/eosin, original magnification 10) that was 8 mm in the right lobe. The carcinoma cells had oval nuclei with irregular contours and clear cytoplasm in microfollicular and trabecular patterns (B; hematoxylin/eosin, original magnification 40). There was no lymphovascular or thyroid capsule invasion. Although most PTMCs have an indolent course, some had aggressive behavior strongly correlated with some histopathological features.2 Additionally, some aggressive histologic variants (diffuse sclerosing, tall cell) of PTMC associated with extrathyroidal spread were defined.3 However, clear cell change even in papillary thyroid carcinomas (PTCs) is very rare. Ito et al4 defined only one case with clear cell variant in a study of 1521 patients with PTC. Only a few case series of clear cell variant PTCs have been reported in the literature.5–7
FIGURE 4. She received 7.4 GBq (200 mCi) of 131I after thyroid hormone withdrawal for 6 weeks. At the radioiodine treatment, the serum thyroglobulin was more than 300 μg/L with thyroid-stimulating hormone of 82 μIU/L. On posttherapy whole-body scan and SPECT/CT images, besides the residual thyroid tissue (A, B, white arrowheads), metastatic focuses were seen (A, B, black arrows) in the hilum of the left lung (C, white arrows), posterior-basal segment of the left lung's inferior lobe (D, black arrows) and soft tissue between the left paravertebral muscles at the level of fifth lumbar vertebra (E, white arrowheads). The risk of distant metastases in PTMC is very low.2,8–16 The incidence of soft tissue metastasis even in all types of well-differentiated thyroid cancers is extremely rare.17 We considered that clear cell change is poor prognostic factor in PTMC even if does not have extrathyroidal extension. Further studies are necessary to confirm these findings. © 2015 Wolters Kluwer Health, Inc. All rights reserved. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
www.nuclearmed.com
887
A Clear Cell Variant of Papillary Thyroid Microcarcinoma With Lung, Bone, and Soft Tissue Metastases Bulent Yazici, MD,* Yesim Ertan, MD,† Aylin Oral, MD,* and Aysegül Akgün, MD* Abstract: A 56-year-old woman presented with a mass lesion on the right occipital bone underwent total resection of the tumor. An adenocarcinoma with immunostaining positive for thyroid transcription factor-1 and thyroglobulin was found. An ultrasound/thyroid scan detected a hot nodule of 9 mm in the right lobe. Fine needle biopsy revealed the similar histological findings with the previous bone resection material. Then, a total thyroidectomy was performed. Histopathologic examination revealed clear cell variant of papillary thyroid microcarcinoma. She received 7.4 GBq of 131I. On posttherapy scan, metastatic focuses were seen in the left lung and soft tissue between the left paravertebral muscles. Key Words: clear cell variant, papillary thyroid microcarcinoma, radioiodine, I-131, distant metastasis (Clin Nucl Med 2015;40: 885–887)
Received for publication January 19, 2015; revision accepted March 24, 2015. From the Departments of *Nuclear Medicine, and †Pathology, Medical Faculty, Ege University, Bornova, Izmir, Turkey. Conflicts of interest and sources of funding: none declared. Correspondence to: Bulent Yazici MD, Department of Nuclear Medicine, Ege University Medical Faculty, Bornova, 35040 Izmir, Turkey. E-mail: [email protected]. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0363-9762/15/4011–0885 DOI: 10.1097/RLU.0000000000000832
REFERENCES 1. Ziessman HA, O'Malley JP, Thrall J, et al. Endocrin System. In Ziessman HA, O'Malley JP, Thrall J, Fahey FH (eds): Nuclear Medicine: The Requisites. Philadelphia, PA: Elsevier Saunders; 2014;79–80. 2. Ardito G, Revelli L, Giustozzi E, et al. Aggressive papillary thyroid microcarcinoma: prognostic factors and therapeutic strategy. Clin Nucl Med. 2013;38:25–28. 3. Kuo EJ, Goffredo P, Sosa JA, et al. Aggressive variants of papillary thyroid microcarcinoma are associated with extrathyroidal spread and lymph-node metastases: a population-level analysis. Thyroid. 2013;23:1305–1311. 4. Ito Y, Hirokawa M, Uruno T, et al. Prevalence and biological behaviour of variants of papillary thyroid carcinoma: experience at a single institute. Pathology. 2008; 40:617–622. 5. Carcangiu ML, Sibley RK, Rosai J. Clear cell change in primary thyroid tumors. A study of 38 cases. Am J Surg Pathol. 1985;9:705–722. 6. Asioli S, Erickson LA, Sebo TJ, et al. Papillary thyroid carcinoma with prominent hobnail features: a new aggressive variant of moderately differentiated papillary carcinoma. A clinicopathologic, immunohistochemical, and molecular study of eight cases. Am J Surg Pathol. 2010;34:44–52. 7. Yang GC, Fried K, Scognamiglio T. Cytological features of clear cell thyroid tumors, including a papillary thyroid carcinoma with prominent hobnail features. Diagn Cytopathol. 2013;41:757–761. 8. Yu XM, Wan Y, Sippel RS, et al. Should all papillary thyroid microcarcinomas be aggressively treated? An analysis of 18,445 cases. Ann Surg. 2011;254:653–660. 9. Mihailovic J, Stefanovic L, Stankovic R. Influence of initial treatment on the survival and recurrence in patients with differentiated thyroidmicrocarcinoma. Clin Nucl Med. 2013;38:332–338. 10. Wartofsky L. Management of papillary microcarcinoma: primum non nocere? J Clin Endocrinol Metab. 2012;97:1169–1172. 11. Ito Y, Uruno T, Nakano K, et al. An observation trial without surgical treatment in patients with papillary microcarcinoma of the thyroid. Thyroid. 2003;13:381–387. 12. Baudin E, Travagli JP, Ropers J, et al. Microcarcinoma of the thyroid gland: the Gustave-Roussy Institute experience. Cancer. 1998;83:553–559. 13. Pellegriti G, Scollo C, Lumera G, et al. Clinical behavior and outcome of papillary thyroid cancers smaller than 1.5 cm in diameter: study of 299 cases. J Clin Endocrinol Metab. 2004;89:3713–3720. 14. Mercante G, Frasoldati A, Pedroni C, et al. Prognostic factors affecting neck lymph node recurrence and distant metastasis in papillary microcarcinoma of the thyroid: results of a study in 445 patients. Thyroid. 2009;19:707–716. 15. Godbert Y, Henriques-Figueiredo B, Cazeau AL, et al. A papillary thyroid microcarcinoma revealed by a single bone lesion with no poor prognostic factors. Case Rep Endocrinol. 2013;2013:719304. 16. Soydal C, Araz M, Ozkan E, et al. Assessment of recurrence rates in papillary thyroid microcarcinoma patients with and without histopathological risk factors after radioiodine ablation treatment. Nucl Med Commun. 2014;36:109–113. 17. Madani A, Jozaghi Y, Tabah R, et al. Rare metastases of well-differentiated thyroid cancers: a systematic review. Ann Surg Oncol. 2015;22:460–466.
Clinical Nuclear Medicine • Volume 40, Number 11, November 2015 Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
www.nuclearmed.com
885
Yazici et al
Clinical Nuclear Medicine • Volume 40, Number 11, November 2015
FIGURE 1. A 56-year-old woman presented with a bulging mass on the right occipital area. Computed tomography (CT) revealed a tumoral lesion with a diameter of 4 cm on the right occipital bone. Preoperative thorax CT and mammography were performed. Only a nonspecific nodule of 7 mm in the left lung's inferior lobe was detected. The thyroid gland was not investigated. The patient underwent total resection of the lesion. Histological examination of the bone resection material showed a clear cell adenocarcinoma (A, hematoxylin/eosin, original magnification 10; B, hematoxylin/eosin, original magnification 20) with immunostaining positive for nuclear thyroid transcription factor-1 (TTF-1) (C, original magnification 20). By reason of TTF-1 positivity, immunohistochemistry of thyroglobulin was also performed, and the specimen was positive for cytoplasmic thyroglobulin (D, original magnification 20).
FIGURE 2. Ultrasonography found only a nodule of 9 mm in the right lobe. It was hot on thyroid scan with 99mTc pertechnetate (black-arrow). Some thyroid cancers maintained trapping but not organification appear hot on 99mTc but cold on 123I scan (discordant nodules).1 Although 123I scan was not performed, probably, the nodule was discordant. 886
www.nuclearmed.com
© 2015 Wolters Kluwer Health, Inc. All rights reserved. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Clinical Nuclear Medicine • Volume 40, Number 11, November 2015
Clear Cell Papillary Thyroid Microcarcinoma
FIGURE 3. Fine needle biopsy was performed to this nodule, and similar histological findings with the previous bone material were demonstrated. The serum thyroglobulin level was more than 300 μg/L with thyroid-stimulating hormone of 1.3 μIU/L. Then, a total thyroidectomy was performed, and histopathologic examination revealed a clear cell variant of papillary thyroid microcarcinoma (PTMC) (A, hematoxylin/eosin, original magnification 10) that was 8 mm in the right lobe. The carcinoma cells had oval nuclei with irregular contours and clear cytoplasm in microfollicular and trabecular patterns (B; hematoxylin/eosin, original magnification 40). There was no lymphovascular or thyroid capsule invasion. Although most PTMCs have an indolent course, some had aggressive behavior strongly correlated with some histopathological features.2 Additionally, some aggressive histologic variants (diffuse sclerosing, tall cell) of PTMC associated with extrathyroidal spread were defined.3 However, clear cell change even in papillary thyroid carcinomas (PTCs) is very rare. Ito et al4 defined only one case with clear cell variant in a study of 1521 patients with PTC. Only a few case series of clear cell variant PTCs have been reported in the literature.5–7
FIGURE 4. She received 7.4 GBq (200 mCi) of 131I after thyroid hormone withdrawal for 6 weeks. At the radioiodine treatment, the serum thyroglobulin was more than 300 μg/L with thyroid-stimulating hormone of 82 μIU/L. On posttherapy whole-body scan and SPECT/CT images, besides the residual thyroid tissue (A, B, white arrowheads), metastatic focuses were seen (A, B, black arrows) in the hilum of the left lung (C, white arrows), posterior-basal segment of the left lung's inferior lobe (D, black arrows) and soft tissue between the left paravertebral muscles at the level of fifth lumbar vertebra (E, white arrowheads). The risk of distant metastases in PTMC is very low.2,8–16 The incidence of soft tissue metastasis even in all types of well-differentiated thyroid cancers is extremely rare.17 We considered that clear cell change is poor prognostic factor in PTMC even if does not have extrathyroidal extension. Further studies are necessary to confirm these findings. © 2015 Wolters Kluwer Health, Inc. All rights reserved. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
www.nuclearmed.com
887
