Journal of the Royal Society of Medicine Volume 85 August 1992
493
Case reports
Hurthle cell carcinoma presenting with retroorbital metastasis
Case presented to Section of Endocrinology, 23 October 1991
M P J Vanderpump MB ChB MRCP W M G Tunbridge MD FRCP Department of Medicine, Newcastle General Hospital Westgate Road Newcastle Upon Tyne NE4 6BE Keywords: Hurthle cell carcinoma; unilateral proptosis; Graves' ophthalmopathy
The differential diagnosis of unilateral proptosis includes Graves' disease and retroorbital tumour. We describe a patient who presented with unilateral proptosis and in whom the initial clinical impression as well as computed tomography (CT) scan of the orbits suggested a diagnosis compatible with Graves' ophthalmopathy. Subsequent investigations, however, revealed Huirthle cell carcinoma of the thyroid which had metastasized to the orbit. The tumour was insensitive to radioiodine and external radiation, and palliation of symptoms from widead bone metastases was achieved by embolization.
Case report A 61-year-old man presented with a 3-month history of double vision and painful swelling in the right eye. Six months earlier he had received steroid injections into- a painful left knee. Examinationrevealedbilateralperiorbital oedema, reduced visual acuity in the right eye, 6/9, blurring of the right optic disc and a diffuse goitre. He was clinically
Figure R. Angiogram of left knee pre (left) and post (right) embolition. There is a highly vascular metastasis in the upper tibia with the blush of tumour circulation. Successful embolization with steel coils resulted in dramatic relief of pain
euthyroid, confirmed by Free T4 16 pmol/l, Total T3 2.0 ng/l and sensitive TSH 0.67 mU/l. Thyroid microsomal antibodies were positive at a titre 1: 100. CT scan of the orbits showed swelling of the right medial rectus muscle (Figure 1) but following a trial of methylprednisolone 500 mg intravenously his vision continued to deteriorate, so transantral orbital decompression was performed. Metastatic tumour deposit was found adjacent to the right medial rectus, compressing and displacing the optic nerve. Both radioiodie and ultrasound scan suggested tumour replacing the left lobe of the thyroid which was confirmed by fine nedle sipiration cytology. Histology, following total thyroidtomy, confirmed Huirthle cell carcinoma of the thyroid which had metastasized to the orbit. Total thyroid ablation wvith radioiodine was given as well as external radiation to the orbit. Following recurrence of pain in the left knee, metastasis in the left tibia was confirmed which failed to take up radioiodine and did not respond to external radiation. Dramatic pain relief was achieved by embolization to this and subsequent metastases (Figure 2). Pathological fracture through the left tibial plateau required skilful orthopaedic reconstruction with plate augmented by cement to maintain mobility. One year following presentation painful metastases in the right humerus were successfully embolized but shortly afterwards he deteriorated quickly and died. No postmortem was obtained.
Figure 1. Coronal CT scan throztgh skull at level of orbits revealing large well defined mass involving right medial rectus muscle causing proptosis and displacement ofglobe laterally. Suggestion of minimal involvement of left medial rectus
Discussion The importance of the disincion between Graves' ophthahno pathy and retroorbital tumour in the differential diagnosis of unilateral proptosis is illustrated by this case, in which ironically the retroorbital tumour was a metastatic deposit from a Hiirthle cell carcinoma of the thyroid. The CT scan appearances were reported as compatible with Graves' ophthalmopathy, despite the unusually focal enlargement of the right medial rectus muscle, in view of the absence of bone erosion and the minimal enlargement of the left medial
0141-0768/92
080493-02/$02.00/0
©3 1992 The Royal Society of Medicine
494
Journal of the Royal Society of Medicine Volume 85 August 1992
rectus muscle. In Graves' ophthalmopathy the extraocular muscles can be infiltrated either individually or as a group. Usually the infiltration is bilateral but asymmetrical enlargement occurs in as many as 30% of cases'. On CT scanning thyroid extraocular myopathy predominantly involves the non tendinous portion of the muscles, as in this case, in contrast to myositis associated with orbital pseudotumour which usually involves all portions of the muscle and adjacent orbital fat2. Hiirthle cell carcin,.Jis a rare ceed hitftlogically as a subtype fiollicular related to the well di 6frentiat.d tuir o a* gland it does however &aiiifest dH by being of intermediate malignant pQt ie, andaa higher tendency to absorption of radioiode ythe primary u o6 *-4 metastases4. -Hurthle cells are clid p by a abundant amount of *i tt notco granular appearance. any disease entity and t1C q an* a nonencapsulated hyp 1 g . Hashimoto's thyroiditis, ;jes In this form they are cle ll neoplasms are solitarym, _ - lplir d partial encapsulation. T' EIen
malignant tumours is made by pathological criteria alone such as vascular invasion, capsular invasion, and the presence of metastases5. Thyroid tumours are considered to be relatively benign but only if they present early and are well differentiated. When presenting late with metastases, they have a poor prognosis, but symptoms from metastases can be relieved by occlusion of their blood supply.
%lJ
1 TrokWIll SK. Recognition and differential diagnosis of enl -*Ocular muscles in computed tomography. Am J 9;87:50 3-12 n~kn D. The use of computed tomography and ~C-2 a in the evaluation of orbital mass. Surv Ophthalmol
.t-
C*bin LH. Histological typing Qf thyroid tumours. Histologcal Classification of Tumours, vol 11. ("ui*j~j~$I Health COrganization, 1974:22 4 *.}sr~~ er T, Segal K, Levy R, Sidi J. Hiirthle cell -; ethyroid. Cancer 1986;57:1613-17 D 3*n A, Calandra DB, Lawrence AM, Paloyan E. 6 HUr1iz'~% btumours of the thyroid gland. Surgery 1985; &11624' (
(A:opfd 11- DWeember 1991)
Dysthyroid eye disease with radiological features of orbital tumour
F Lewis RccP G M Kyle FRcS G Murray FRCR D F Child FRCP Maelor Hospitcd Croesnewydd Road, Wrexham Ciwyd LL13 7TD Keywords dysthyroid eye disease; orbital tumour
We report an unusual presentation of dysthyroid eye diseae. A patient presented with diplopia and left-sided unilateral exophthalmos. CT scan revealed a m at the, a of the orbit, suggestive of a metatatic deposit. Bilateral signsOf dysthyroid eye disease later developed and a-week after the start of treatment with prednisolone, an MRI scan failed to show any evidence of the mass but did reveal classil changes of dysthyroid eye disease. The interpretation of CT scans in. dysthyroid eye disease can be difficult, and a discete orbital mas can be an unusual manifestation.
Case report A 73-year-old woman presented to.the Eye Clinic with a one week history of double vision on upward gaze. On examination, there wasi failure-of elevation of the globe on the left, more marked on abduction, compatible with a superior rectus muscle weakness. Visual acuity was 6/6 in the right eye and 6/18 in the left eye. Intra-ocular pressures were normal. Early lid-rebaction was noed -and thyroid function tests were requested. These revealed thyrotoxicodsi with FT3 18.7 (normal range 2.2-6.8) and TSH 0.12-(normal range 0.25-8.0). Over,the following 2 weeks, the problems with the left eye. worsened. Visual acuity fell to 6/60 with unilateral, painless, Correspondence to: Dr D F Child
F~gu e 1
Fu
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1.
=
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iis left-sided exphthalmo *. I It was not thought tI*tbo ( dysthyroid eye diseae -
apex of th left orbit
separatfom the o the inferiw tobe eilrgd Iwas tobea surgical opinion to co before furi interven
righteye/F.here was -tissueswelling and e to -simple measures
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f
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AuMRI commenc e-A wns lii4 Pfteroid tlie performed one week a th failed,o show any evidence Qf the mnoss, but did reveal sign , L9924 of dysthyroid eye disease with bilateral muscle-enlargement. After treatment with steroids, her visionimproved rapidly Society of and the keratitis completely resolved. Her left gaze is still Medidine
493
Case reports
Hurthle cell carcinoma presenting with retroorbital metastasis
Case presented to Section of Endocrinology, 23 October 1991
M P J Vanderpump MB ChB MRCP W M G Tunbridge MD FRCP Department of Medicine, Newcastle General Hospital Westgate Road Newcastle Upon Tyne NE4 6BE Keywords: Hurthle cell carcinoma; unilateral proptosis; Graves' ophthalmopathy
The differential diagnosis of unilateral proptosis includes Graves' disease and retroorbital tumour. We describe a patient who presented with unilateral proptosis and in whom the initial clinical impression as well as computed tomography (CT) scan of the orbits suggested a diagnosis compatible with Graves' ophthalmopathy. Subsequent investigations, however, revealed Huirthle cell carcinoma of the thyroid which had metastasized to the orbit. The tumour was insensitive to radioiodine and external radiation, and palliation of symptoms from widead bone metastases was achieved by embolization.
Case report A 61-year-old man presented with a 3-month history of double vision and painful swelling in the right eye. Six months earlier he had received steroid injections into- a painful left knee. Examinationrevealedbilateralperiorbital oedema, reduced visual acuity in the right eye, 6/9, blurring of the right optic disc and a diffuse goitre. He was clinically
Figure R. Angiogram of left knee pre (left) and post (right) embolition. There is a highly vascular metastasis in the upper tibia with the blush of tumour circulation. Successful embolization with steel coils resulted in dramatic relief of pain
euthyroid, confirmed by Free T4 16 pmol/l, Total T3 2.0 ng/l and sensitive TSH 0.67 mU/l. Thyroid microsomal antibodies were positive at a titre 1: 100. CT scan of the orbits showed swelling of the right medial rectus muscle (Figure 1) but following a trial of methylprednisolone 500 mg intravenously his vision continued to deteriorate, so transantral orbital decompression was performed. Metastatic tumour deposit was found adjacent to the right medial rectus, compressing and displacing the optic nerve. Both radioiodie and ultrasound scan suggested tumour replacing the left lobe of the thyroid which was confirmed by fine nedle sipiration cytology. Histology, following total thyroidtomy, confirmed Huirthle cell carcinoma of the thyroid which had metastasized to the orbit. Total thyroid ablation wvith radioiodine was given as well as external radiation to the orbit. Following recurrence of pain in the left knee, metastasis in the left tibia was confirmed which failed to take up radioiodine and did not respond to external radiation. Dramatic pain relief was achieved by embolization to this and subsequent metastases (Figure 2). Pathological fracture through the left tibial plateau required skilful orthopaedic reconstruction with plate augmented by cement to maintain mobility. One year following presentation painful metastases in the right humerus were successfully embolized but shortly afterwards he deteriorated quickly and died. No postmortem was obtained.
Figure 1. Coronal CT scan throztgh skull at level of orbits revealing large well defined mass involving right medial rectus muscle causing proptosis and displacement ofglobe laterally. Suggestion of minimal involvement of left medial rectus
Discussion The importance of the disincion between Graves' ophthahno pathy and retroorbital tumour in the differential diagnosis of unilateral proptosis is illustrated by this case, in which ironically the retroorbital tumour was a metastatic deposit from a Hiirthle cell carcinoma of the thyroid. The CT scan appearances were reported as compatible with Graves' ophthalmopathy, despite the unusually focal enlargement of the right medial rectus muscle, in view of the absence of bone erosion and the minimal enlargement of the left medial
0141-0768/92
080493-02/$02.00/0
©3 1992 The Royal Society of Medicine
494
Journal of the Royal Society of Medicine Volume 85 August 1992
rectus muscle. In Graves' ophthalmopathy the extraocular muscles can be infiltrated either individually or as a group. Usually the infiltration is bilateral but asymmetrical enlargement occurs in as many as 30% of cases'. On CT scanning thyroid extraocular myopathy predominantly involves the non tendinous portion of the muscles, as in this case, in contrast to myositis associated with orbital pseudotumour which usually involves all portions of the muscle and adjacent orbital fat2. Hiirthle cell carcin,.Jis a rare ceed hitftlogically as a subtype fiollicular related to the well di 6frentiat.d tuir o a* gland it does however &aiiifest dH by being of intermediate malignant pQt ie, andaa higher tendency to absorption of radioiode ythe primary u o6 *-4 metastases4. -Hurthle cells are clid p by a abundant amount of *i tt notco granular appearance. any disease entity and t1C q an* a nonencapsulated hyp 1 g . Hashimoto's thyroiditis, ;jes In this form they are cle ll neoplasms are solitarym, _ - lplir d partial encapsulation. T' EIen
malignant tumours is made by pathological criteria alone such as vascular invasion, capsular invasion, and the presence of metastases5. Thyroid tumours are considered to be relatively benign but only if they present early and are well differentiated. When presenting late with metastases, they have a poor prognosis, but symptoms from metastases can be relieved by occlusion of their blood supply.
%lJ
1 TrokWIll SK. Recognition and differential diagnosis of enl -*Ocular muscles in computed tomography. Am J 9;87:50 3-12 n~kn D. The use of computed tomography and ~C-2 a in the evaluation of orbital mass. Surv Ophthalmol
.t-
C*bin LH. Histological typing Qf thyroid tumours. Histologcal Classification of Tumours, vol 11. ("ui*j~j~$I Health COrganization, 1974:22 4 *.}sr~~ er T, Segal K, Levy R, Sidi J. Hiirthle cell -; ethyroid. Cancer 1986;57:1613-17 D 3*n A, Calandra DB, Lawrence AM, Paloyan E. 6 HUr1iz'~% btumours of the thyroid gland. Surgery 1985; &11624' (
(A:opfd 11- DWeember 1991)
Dysthyroid eye disease with radiological features of orbital tumour
F Lewis RccP G M Kyle FRcS G Murray FRCR D F Child FRCP Maelor Hospitcd Croesnewydd Road, Wrexham Ciwyd LL13 7TD Keywords dysthyroid eye disease; orbital tumour
We report an unusual presentation of dysthyroid eye diseae. A patient presented with diplopia and left-sided unilateral exophthalmos. CT scan revealed a m at the, a of the orbit, suggestive of a metatatic deposit. Bilateral signsOf dysthyroid eye disease later developed and a-week after the start of treatment with prednisolone, an MRI scan failed to show any evidence of the mass but did reveal classil changes of dysthyroid eye disease. The interpretation of CT scans in. dysthyroid eye disease can be difficult, and a discete orbital mas can be an unusual manifestation.
Case report A 73-year-old woman presented to.the Eye Clinic with a one week history of double vision on upward gaze. On examination, there wasi failure-of elevation of the globe on the left, more marked on abduction, compatible with a superior rectus muscle weakness. Visual acuity was 6/6 in the right eye and 6/18 in the left eye. Intra-ocular pressures were normal. Early lid-rebaction was noed -and thyroid function tests were requested. These revealed thyrotoxicodsi with FT3 18.7 (normal range 2.2-6.8) and TSH 0.12-(normal range 0.25-8.0). Over,the following 2 weeks, the problems with the left eye. worsened. Visual acuity fell to 6/60 with unilateral, painless, Correspondence to: Dr D F Child
F~gu e 1
Fu
. ... ..
1.
=
tosh
iis left-sided exphthalmo *. I It was not thought tI*tbo ( dysthyroid eye diseae -
apex of th left orbit
separatfom the o the inferiw tobe eilrgd Iwas tobea surgical opinion to co before furi interven
righteye/F.here was -tissueswelling and e to -simple measures
a
1
Vol
f
20 sg-jw,.
e
AuMRI commenc e-A wns lii4 Pfteroid tlie performed one week a th failed,o show any evidence Qf the mnoss, but did reveal sign , L9924 of dysthyroid eye disease with bilateral muscle-enlargement. After treatment with steroids, her visionimproved rapidly Society of and the keratitis completely resolved. Her left gaze is still Medidine
