Retropharyngeal Metastasis: A Rare and Frequently Aggressive Presentation of Papillary Thyroid Carcinoma

A case of papillary thyroid carcinoma (PTC) presenting as a solitary metastasis in the right arm muscle is described in an elderly hyperthyroid male patient. A 2-cm nodule in the right bycipites muscle was found to be a papillary carcinoma of thyroid origin and a primary, 3.5-cm tumor was subsequently found in the left lobe of a hyperfunctioning gland due to toxic goiter. Both tumors were well differentiated PTC, follicular variant. No high grade features, nor extrathyroidal spread, nor regional lymph node metastases were found, but histology evidenced intrathyroidal vascular invasion. After radical surgery and radioiodine therapy, the patient is currently disease-free 4 years after diagnosis. This is the third reported case of PTC manifesting as a single soft tissue metastasis and the first associated with hyperthyroidism. Hematogenous spread of differentiated PTC is rare, although less unusual in PTC follicular variant. Histological vascular invasion, hypervascularity and increased blood flow in the hyperfunctioning thyroid gland might have facilitated the dissemination of malignant tumor cells through the bloodstream. Literature data indicate that PTC in elderly patients is increasing and is often clinically aggressive. Radical surgical and radiometabolic treatments are required also in this age group to improve clinical outcome.

CASEAn incidental papillary thyroid carcinoma (PTC) presenting as a mediastinal mass with benign ectopic thyroid cells is a rare occurrence. We present a case of a 33-year-old Filipino female who presented with sudden onset difficulty of breathing and chest heaviness. On workup, she was found to have an anterior mediastinal mass, which showed ectopic thyroid cells on biopsy. Thyroid ultrasound revealed a 1.25x 1 x 1.13 cm nodule on the thyroid gland which showed suspicious for PTC on fine needle aspiration biopsy. The patient underwent total thyroidectomy and excision of the anterior mediastinal mass. The histopathologic report of the thyroid mass revealed a conventional unifocal PTC, while the excised tissues comprising the mediastinal mass were consistent with benign ectopic thyroid tissues with colloid goiter. Since thyroid cancer is considered as lowrisk, suppression therapy and active surveillance is the choice of management for this unusual case.

BackgroundPapillary carcinoma is the most common differentiated malignant thyroid neoplasm. The biological course of this cancer is typically indolent with a protracted clinical course. Metastases commonly occur in regional lymph nodes, and distant metastasis is a late and rare occurrence. We report a patient who presented with cerebellar metastasis prior to the diagnosis of papillary thyroid carcinoma and review the literature of brain metastasis from papillary thyroid carcinoma.ResultsA 75-year old female presented at the emergency room with progressive dizziness, headache and vomiting, where a brain CT and MRI showed a posterior cerebellar tumor. Surgical resection revealed papillary carcinoma consistent with thyroid origin. Subsequent ultrasound and CT-scan revealed a thyroid nodule, after which the patient underwent total thyroidectomy. Pathologic evaluation was consistent with papillary thyroid carcinoma.ConclusionBrain metastasis may rarely be the initial presentation of papillary thyroid carcinoma. Solitary brain metastasis can completely be resected with better prognosis.

Papillary thyroid carcinoma often emerges within the middle-aged group as a painless, irregular thyroid mass, and it can be accompanied by other symptoms such as hoarseness and dysphagia. Cervical node metastasis typically involves the ipsilateral jugular chain and remains confined to cervical nodelevels III and IV in most of the patients. Here, we present a case highlighting the uncommon presentation of papillary thyroid carcinoma. A 63-year-old Malay man with no known medical issues initially exhibited a painless swelling on the right neck level V region. The swelling progressively grew in size and later extended towardthe anterior and contralateral sides of the neck for a duration of a year. He reported a weight loss of 10 kg past a year and experienced consistent fatigue. Physical examination showed multiple firm swellings with regular borders over levels I to V bilaterally. The swellings did not move upon swallowing. Due to the absence of initial thyroid swelling and the presence of multiple cervical lymphadenopathies in his medical history, lymphoma was suspected. A referral to ENT was made for an excision biopsy, but the procedure was abandoned to prevent potential injury to important underlying structures such as blood vessels and nerves. An ultrasound-guided biopsy was subsequently performed over multiple neck regions. It resulted in papillary thyroid carcinoma instead of lymphoma. Despite a suggestive history of lymphoma, papillary thyroid carcinoma should be considered a potential differential for a multilobulated neck mass. Excision biopsy has the potential to upstage the tumor and worsen the patient's prognosis. Fine-needle aspiration for cytology should be prioritized when investigating any neck swelling.

Objective: To describe a rare case of acute presentation of papillary thyroid carcinoma (PTC). Clinical Presentation and Intervention: A 19-year-old male presented with an expanding cervical mass following blunt trauma. A computed tomography scan revealed a mass suspected to be hematoma that was compressing the vessels and thereby deviating the trachea. Immediate surgery was performed. Neither vascular injury nor active bleeding was seen; instead, a solid, hematoma-like tumefaction in the right thyroid lobe was revealed. A total thyroid lobectomy was performed. A histologic paraffin section confirmed a PTC that was permeated by hematoma. Conclusion: This was a unique case of an acute, life-threatening presentation of previously asymptomatic PTC in an adolescent.

Brain metastases as the first clinical presentation of a papillary thyroid carcinoma (PTC) are exceptional, while cavernous angiomas are common cerebral malformations. We report the case of a 36-year-old male with an incidental brain lesion mimicking a cavernous angioma on MRI. Gamma knife radiosurgery was performed, but after 6 months, the patient developed neurological symptoms, and a repeat brain MRI revealed a significant increase in the mass. The patient underwent neurosurgery, and the histological examination of the lesion revealed metastatic carcinoma of thyroid origin. PET-CT and neck ultrasound, subsequently performed, were concordant for the presence of a right lobe nodule and ipsilateral lymph nodes, both with ultrasound features suspicious of malignancy. Total thyroidectomy with central and right lateral neck dissection was performed, and histology confirmed an intrathyroidal multifocal PTC with lymph node metastases. Postoperative radioiodine was administered, and focal uptake within the thyroid bed, without distant metastases or brain remnants, was found on the post-therapeutic whole-body scan. At 2 years from diagnosis, the patient is in good health and undergoes clinical and imaging follow-up. Brain cavernous angiomas are common cerebral vascular malformations that are usually diagnosed by MRI. Despite the high accuracy of MRI, the exam is not pathognomonic, and misdiagnosis cannot be excluded. Brain metastases from PTC are very rare; however, they can mimic a cavernous angioma. Therefore, the differential diagnosis should always be considered.

Papillary thyroid carcinoma (PTC) has the highest incidence of cervical lymph node metastasis among thyroid malignancies. Lateral neck swelling as the only manifestation of PTC in the absence of palpable thyroid lesion is not common. Here, we report a case of an adult female who presented with right cervical mass and excision biopsy revealed metastatic papillary carcinoma of thyroid. Total thyroidectomy with central compartment neck dissection was performed, and histopathology showed multifocal PTC. How to cite this article Saldanha M, Biniyam K, Permi HS, Bhat VS. Unusual Presentation of Papillary Thyroid Carcinoma. Int J Head Neck Surg 2015;6(1):32-34.

Langerhans cell histiocytosis (LCH) (cells identified in 1868, disease named in 1985), has a wide range of clinical presentations, including the rare event of infiltration of the thyroid gland. However, an association seems to exist between LCH and papillary thyroid carcinoma (PTC), as eight cases of LCH co-existing with PTC have been described in the english literature [1]. We extend this association with a metachronous case of PTC, occurring 4 years from the diagnosis of LCH, while the LCH was in remission (Table ​(TableII). TABLE I Time of Presentation of Papillary Thyroid Carcinoma (PTC) in Relation to the Diagnosis of LCH In our case PTC was metachronous and not therapy related. This is verified by the fact that the patient did not receive etoposide or high doses of methotrexate, or local radiotherapy [2,3]. The radiation exposure was minimal; only two X-rays were performed at diagnosis, while imaging of the head was performed with MRI and no CT-scans. Therefore, a causative relationship is highly unlikely. More specifically, a 9-year-old boy, with low risk [RO-]LCH, V600E BRAF mutation positive, received vinblastine/prednisolone according to the LCH III protocol, and achieved remission. Four years following diagnosis of LCH, in the routine follow-up, an 8 mm lesion was revealed in the thyroid gland by ultrasound. Total resection of the thyroid gland revealed a V600E BRAF mutation-negative papillary carcinoma, while it was negative for LCH [SD100−, CD1a−, Langerin−]. No information exists on the V600E BRAF mutation status from the LCH cases co-existing with PTC [1]. In our case, the LCH sample was positive for the V600EBRAF mutation, while the PTC was negative for the mutation. It is possible that LCH and PTC share a common determinant, despite the different BRAF mutation status, as approximately half of the reported cases of LCH are negative for the mutation and only around half of the reported PTCs are positive for the mutation [4]. The role of the V600E BRAF mutation is currently unknown. One could speculate that, since the LCH has been shown to increase the expression of T-helper type 2 cytokines [5], the presence of the V600E BRAF mutation could exacerbate this defect in LCH cytokine regulation. Thus, the particular oncogene might be eliciting an inflammatory pro-tumorigenic microenvironment, possibly linking the LCH-induced deregulated immunologic cascade to neoplastic transformation. It would be of great interest to have more information on the BRAF mutation status from cases of LCH co-existing with PTC, as it would help to elucidate the role of V600E BRAF mutation in PTC development. In summary, the thyroid gland is a potential target organ for LCH, both through direct involvement of the disease and through its association with the development of thyroid carcinoma. Thus, routine evaluation of the thyroid gland at diagnosis and during follow-up should be considered. Further research is needed to understand the association of LCH with PTC, as well as the molecular and immunological basis for this tropism to the thyroid gland.

Introduction Papillary thyroid carcinomas are one of the most common endocrine neoplasms. It is well known for its low malignant potential. Papillary carcinomas mostly metastases to lymph nodes of level six. Recent advances in the pathology that is with proper ultra sound guided FNAC, early diagnosis can be made. Here we are presenting a patient with a huge neck mass that presented to our medical college hospital and how we managed the same. Case Blog 53 years old male patient, presented to a tertiary hospital with complaints of swelling in front of neck for the past 7 years. The patient was having a progressive swelling, it started as a small pea shaped swelling and it slowly progressed and has reached the present size (Figure 1). The patient was having no difficulty in respiration. CT scan of the neck region with chest was taken as the lower extent was not palpable and the FNAC of the swelling was taken. FNAC revealed papillary thyroid carcinoma. CT scan showed a huge soft tissue mass over left supra clavicular region with solid and cystic attenuation extending to the superior aspect of the thoracic inlet. The mass was shifting trachea to the right side (Figure 2). There were no palpable neck nodes. The patient was planned for surgical exploration of the tumour with sternotomy as the tumour was extending in to the thoracic inlet. A total thyroidectomy with central compartment neck dissection was done. The mass was proved to be papillary thyroid carcinoma of intra cystic variant. Discussion Papillary thyroid carcinoma is the most common thyroid cancer. Papillary thyroid cancer also has an excellent prognosis. Total thyroidectomy is done once histo pathological diagnosis is established [1]. This patient to begin with presented with a small pea shaped swelling on front of left side of neck and it started slowly progressing in size. Once the size of the tumour is more than 10 mm, total thyroidectomy is indicated. These papillary carcinomas mostly metastases to central neck nodes [2]. Hence for a better outcome it is always mandatory to go for central neck node dissection for proven cases of lymphatic spread. Biochemical analysis of free T4 and TSH is necessary before surgery. This patient was euthyroid before surgery was planned. Surgery of total thyroidectomy and neck dissection of central compartment was done [3]. Recurrent laryngeal nerve was identified during the procedure. Parathyroid glads were identified and preserved on the right side. The patient was kept on regular followup. Histopathological diagnosis confirmed it to be a papillary thyroid carcinoma. Conclusion Total thyroidectomy with central compartment dissection appears to be adequate treatment even for masses that are extending upto supra clavicle also with extension to thoracic inlet. CT scan plays a very important role in pre-operative planning for huge neck mass. Preservation of recurrent laryngeal nerve and parathyroid glands are very important in this surgery. Though it is controversial in the absence of neck node one should go for central node dissection, from our institutional experience, it is always safer to go for central node dissection, so that recurrence of the tumour can be avoided.

Struma ovarii is a rare monodermal ovarian teratoma composed predominantly of thyroid tissue, accounting for approximately 1% of ovarian neoplasms and 2%-3% of mature teratomas. Its coexistence with differentiated thyroid carcinoma - and particularly in the setting of normocalcemic primary hyperparathyroidism - has not been previously described. A 26-year-old woman presented with a painless 2×2 cm midline neck swelling. Ultrasound and fine-needle aspiration confirmed papillary thyroid carcinoma. Biochemistry revealed an elevated parathyroid hormone (81.1pg/mL) despite normal serum calcium (9.4 mg/dL) and vitamin D insufficiency. Tc-99m sestamibi single-photon emission tomography with computed tomography (SPECT-CT) localized a left inferior parathyroid adenoma. She underwent total thyroidectomy, central lymph node dissection, and parathyroidectomy. Forty-five days later, whole-body I-131 scintigraphy for remnant ablation revealed unexpected pelvic uptake. SPECT-CT and transvaginal ultrasound identified a 2.6×2.5 cm left ovarian cystic mass. Tumor markers were normal. Laparoscopic cystectomy was performed. Histopathology confirmed benign struma ovarii arising within a mature cystic teratoma. The patient's postoperative course was uneventful, she resumed thyroid hormone replacement, and follow-up showed normalization of parathyroid hormone levels without recurrence. Concurrent presentation of papillary thyroid carcinoma, normocalcemic primary hyperparathyroidism, and struma ovarii constitutes a novel endocrine triad not previously described. Normocalcemic primary hyperparathyroidism requires a high index of suspicion and rigorous biochemical and imaging evaluation, since normal serum calcium may mask a significant parathyroid adenoma. Pelvic radioiodine uptake outside the thyroid bed can also be seen in benign struma ovarii, not only metastasis, underscoring the need to correlate functional and anatomical imaging. Accurate diagnosis and tailored management of such complex endocrine neoplasms depend on a multidisciplinary approach and strict long‑term surveillance. This report provides important educational insights for endocrinologists and surgeons managing concurrent endocrine pathologies. Normocalcemic primary hyperparathyroidism may mask a significant parathyroid adenoma and requires high clinical suspicion despite normal serum calcium. Critically, in thyroid cancer surveillance, unexpected extra-thyroidal radioiodine uptake - particularly in the pelvis - must include struma ovarii in the differential diagnosis to prevent inappropriate treatment escalation. Multimodal imaging and thorough histopathological evaluation are essential to distinguish benign struma ovarii from metastatic disease and guide appropriate management.

Cervical cord compression secondary to extension of a long standing papillary thyroid carcinoma as well as multiple cases of distal cord compression from occult follicular thyroid carcinoma have been reported. But cervical cord compression from Papillary Thyroid Carcinoma has not been reported so far. Forty eight year old lady presented with progressive quadriparesis of 2months duration. MRI of the cervical spine showed destructive lesion with soft tissue component in vertebral bodies and posterior elements of C4-C6 vertebrae with cord compression along with a large thyroid mass extending to retrosternal region likely malignant. USG guided FNAC & Biopsy of thyroid lesion was inconclusive. She underwent Preoperative Selective angioembolisation for vertebral metastasis followed by total thyroidectomy with cervical cord decompression, bone grafting and plating. HPE reported follicular variant of Papillary Thyroid carcinoma. Four weeks postoperatively she underwent radioiodine ablation by 263mci of I 131. She then received palliative EBRT to cervical and dorsal spine 30Gy/10 fractions. She is alive and neurologically stable at 6months follow up. Papillary thyroid carcinoma has an excellent prognosis. Hence a prompt management of primary disease and aggressive approach to metastatic lesion may prolong survival and allow favorable prognosis.

A lateral neck mass can be the initial presentation of a papillary thyroid carcinoma. A 24-year-old female presented with a 2.0 x 2.0 cm, non-erythematous, non-tender, right lateral neck mass. A neck ultrasound showed an enlarged right jugulodigastric (Level II) lymph node and a normal-sized thyroid gland exhibiting mild parenchymal disease with no nodules. Positron emission tomography-computed tomography scan (PET-CT) showed an enlarged intensely fluorodeoxyglucose (FDG)-avid right level III lymph node, which may be primary versus metastatic. Fine-needle aspiration biopsy (FNAB) of the lymph node showed the presence of atypical cells that are highly suspicious for metastatic carcinoma. A cervical lymph node excision biopsy was performed and histopathology showed metastatic papillary thyroid carcinoma. The patient underwent total thyroidectomy with neck dissection. The final histopathologic examination of the thyroid gland revealed chronic lymphocytic thyroiditis with the lymph nodes negative for metastasis. She eventually underwent radioactive iodine ablation (RAI) with a dose of 30mCi. Post-RAI whole-body scan showed functioning thyroid tissue remnants with no distant metastasis. This case adds to the limited data that ectopic thyroid carcinoma can be present in patients who initially present with neck masses.

The presence of cervical lymph node (LN) metastasis at the initial presentation of papillary thyroid carcinoma (PTC) constitutes an independent risk factor for disease recurrence, increases the risk for mortality, and impacts overall outcome. The 2016 American Joint Committee on Cancer raised the age cutoff for PTC staging from 45 to 55years for better prediction of overall survival. Age > 55years is considered a significant risk factor for a more aggressive and advanced disease with worse outcomes. We identified histopathological factors for disease recurrence in PTC patients younger and older than 55years of age. Data on all patients who underwent thyroid surgery due to PTC between 2006 and 2018 in the Tel Aviv Sourasky Medical Center were retrieved for this retrospective cohort study. Patients with lymph node (LN) metastases were further investigated for preoperative presentation, pathological characteristics, and recurrence. A multivariate analysis was used to detect predictors for recurrence and patient outcome for each age-group. Twenty-two of the 183 patients (12%) with PTC who met the inclusion criteria and had sufficient follow-up period sustained recurrence. The predictors of recurrence varied between the two age-groups. The size of thyroid lesions (p = 0.003) was identified as a risk factor in the older group, while the number of metastatic cervical LNs (p = 0.001) and the ratio of metastatic-to-total dissected cervical LNs (p = 0.027) were the main predictors of recurrence for the younger group. The histopathological factors predictive for disease recurrence differed among PTC patients younger and older than 55years of age.

Distant metastasis of thyroid carcinoma is rare, and it occurs particularly rarely in renal regions, which represent ~3% of all thyroid distant metastases, with fewer than 30 single case study reports existing in the literature. The present study (and subsequent literature review) of papillary thyroid carcinoma (PTC) reports the case of a 53-year-old male patient who presented with a left renal mass and who had no previous history of thyroid disease. Following renal and thyroid surgery, postoperative pathology confirmed the case to be a follicular variant of PTC, accompanied by renal metastasis. The patient exhibited brain metastasis during a later follow-up. In conclusion, thyroid metastases to the renal site are extremely rare events, particularly for men who present initially with renal neoplasms, which may easily be misdiagnosed as renal cell carcinoma. PTC tends to have a good prognosis; however, when it is accompanied by distant metastasis, the prognosis becomes less favorable.

Introduction and importanceNeck masses are common in clinical practice, with branchial cysts presenting as painless, slow-growing lateral neck masses. Metastatic involvement of branchial cysts by thyroid carcinoma is rare. Papillary thyroid carcinoma (PTC) represents 75 %–85 % of thyroid cancers and often presents with a neck mass. This case report describes a rare presentation of metastatic PTC mimicking a branchial cyst in a 35-year-old female, emphasizing the importance of thorough evaluation. Case presentationA 35-year-old female presented with a three-year history of a slowly enlarging right submandibular neck mass. She was otherwise healthy, with no significant family or medical history. Physical examination revealed a well-defined, non-tender mass in the right anterior neck, measuring 3.4 cm. No lymphadenopathy or thyroid nodules were detected. MRI revealed an enlarged cystic lymph node. Fine-needle aspiration initially suggested a branchial cyst, but histopathology after excision confirmed metastatic PTC. Subsequent thyroid ultrasound showed a 3 mm hypoechoic nodule in the right lobe, classified as TI-RADS IV. Total thyroidectomy was planned. Clinical discussionBranchial cysts are typically benign, but this case highlights the possibility of malignancy. Excision and postoperative biopsy are essential for diagnosis, as seen in this case, leading to a total thyroidectomy plan. ConclusionNeck masses can conceal malignancies, including metastatic PTC. This case underscores the importance of thorough pathological evaluation to ensure appropriate management.