A CASE OF HÜRTHLE CELL CARCINOMA PRESENTING WITH MALIGNANT PLEURAL EFFUSION

Abstract

TOPIC: Disorders of the Pleura TYPE: Medical Student/Resident Case Reports INTRODUCTION: Hürthle cell carcinoma (HCC) is uncommon, accounting for 3% of thyroid neoplasms. It is more clinically aggressive compared to other differentiated thyroid cancers. Though thoracic involvement has been reported, it has rarely caused malignant pleural effusion. Here, we describe a case of metastatic HCC presenting with dyspnea and recurrent unilateral pleural effusion. CASE PRESENTATION: A 73-year-old male presented with dyspnea. His past medical history was significant for thyroid HCC diagnosed in 2005. He had undergone thyroidectomy, which was consistent with widely invasive HCC with clear cell change, and radioactive iodine ablation in 2006. He followed with his endocrinologist and oncologist, and was disease free on regular scans. However, his serum thyroglobulin levels continuously rose, prompting a PET scan in 2013 which demonstrated 2 new nodules in the left lower lobe of the lung. Patient had thoracotomy with left lower wedge resection in 2014; pathology was consistent with atypical carcinoid of uncertain source. He remained asymptomatic until he developed dyspnea in 2015; CT chest showed an increase in size of his pulmonary nodules. Biopsy revealed metastatic poorly differentiated thyroid cancer. He underwent right upper lobe radiation and left chest wall mass resection. He continued to have pleuritic chest pain and imaging in 2018 showed a recurrent large left pleural effusion, requiring thoracentesis with symptomatic relief. Cytology was negative at the time. He was then treated with several chemotherapy agents, complicated by side effects. He was diagnosed with left loculated pleural effusion in late 2020, and again pleural fluid was negative for malignancy. He continued to have episodes of desaturation and cardiothoracic surgery was consulted for video-assisted thoracoscopic surgery-guided left indwelling pleural catheter placement. However, he suddenly became hemodynamically unstable and was diagnosed with ST-elevation myocardial infarction. He refused left heart catheterization and continued to deteriorate, ultimately pursuing inpatient hospice. DISCUSSION: Hürthle cell carcinoma is a rare, aggressive form of cancer with high rates of recurrence. Local occurrence and metastatic disease could be found in 30% patients over 20 years after total or subtotal thyroidectomy. Pulmonary metastasis has been reported to be the most common site, though its incidence is significantly less in patients who were treated by total thyroidectomy. Nevertheless, it is imperative to consider HCC recurrence in patients presenting with dyspnea and pleural effusion despite interventions and being disease-free. CONCLUSIONS: Though this patient had negative cytopathologic studies, the recurrence of his unilateral pleural effusion accompanied by progression of his cancer without any other obvious cause cause makes malignant pleural effusion due to HCC the most likely diagnosis. REFERENCE #1: Ahmadi, S., Stang, M., Jiang, X. S., & Sosa, J. A. (2016). Hürthle cell carcinoma: current perspectives. OncoTargets and therapy, 9, 6873–6884. https://doi.org/10.2147/OTT.S119980 REFERENCE #2: Bagherzadegan, N., Feller-Kopman, D., Ernst, A., Haerle, S., & Lunn, W. (2009). An unusual case of hürthle cell carcinoma presenting as metastatic pleural disease 16 years after thyroidectomy. Journal of bronchology & interventional pulmonology, 16(3), 204–206. https://doi.org/10.1097/LBR.0b013e3181b01521 REFERENCE #3: Besic, N., Schwarzbartl-Pevec, A., Vidergar-Kralj, B., Crnic, T., Gazic, B., & Marolt Music, M. (2016). Treatment and outcome of 32 patients with distant metastases of Hürthle cell thyroid carcinoma: a single-institution experience. BMC cancer, 16, 162. https://doi.org/10.1186/s12885-016-2179-3 DISCLOSURES: No relevant relationships by Saloni Goyal, source=Web Response No relevant relationships by Dimitry Petrenko, source=Web Response No relevant relationships by Cleo Zarina Reyes, source=Web Response No relevant relationships by Joseph Schellenberg, source=Web Response