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Breast cancer metastasis to the thyroid gland.

An 82-year-old woman was referred to our clinic for a right-sided thyroid mass discovered after she experienced hoarseness and difficulty speaking. The patient had a history of breast cancer 10 years prior to her current complaint, treated with chemotherapy and radiation. Further analysis revealed right-sided vocal fold immobility, a large right-sided thyroid mass, paratracheal lymphadenopathy, and multiple lytic lesions of the thoracic vertebrae (figure 1).

The patient was scheduled for fine-needle aspiration and core biopsy of the thyroid lesion. Pathology examination revealed cohesive clusters of highly atypical epithelioid cells with abundant cytoplasm, markedly enlarged nuclei with irregular borders, and prominent nucleoli (figure 2, A).

Immunohistochemical staining for thyroid transcription factor-1 was positive in the normal thyroid parenchyma but negative in the tumor (figure 2, B). Strikingly, the tumor stained strongly for estrogen receptor (figure 2, C), consistent with the patient's original breast carcinoma, indicating breast cancer recurrence with metastasis to the thyroid gland. The patient declined further treatment and rapidly succumbed to her disease.

Metastatic disease of the thyroid gland is uncommon, occurring in 1.4 to 3% of patients with suspected thyroid malignancy, (1) and it most frequently results from cancer of the kidney, lung, breast, stomach, esophagus, and uterus. (2,3) Typical presenting symptoms are new or enlarging thyroid mass, neck swelling, dysphagia, dysphonia, and cough. (1) Ultrasound examination often shows ovoid or round hypoechogenic lesions with poorly defined margins and without calcifications. (4)

Diagnosis is confirmed by fine-needle aspiration biopsy or core -biopsy. (4) It is important to distinguish between metastatic disease and a second primary thyroid malignancy, which is more common than thyroid gland metastasis, particularly in patients with a history of breast cancer or renal cell carcinoma. (5) Therefore, immunohistochemistry may be useful if the histopathology is unclear. (1)

Thyroid gland metastasis confers a poor prognosis, with many patients surviving less than 3 years. (3) The recommended treatment for thyroid gland metastasis is thyroidectomy combined with radiation and chemotherapy as dictated by the primary site. (1,3) Although surgery does not universally improve outcomes, early detection and aggressive treatment of thyroid metastasis may improve survival for select patients. (1,3) Therefore, otolaryngologists should consider the possibility of metastatic disease for any patient with a prior history of malignancy presenting with a new thyroid mass.

References

(1.) Chung AY, Tran TB, Brumund KT, et al. Metastases to the thyroid: A review of the literature from the last decade. Thyroid2012;22(3):258-68.

(2.) Lam KY, Lo CY. Metastatic tumors of the thyroid gland: A study of 79 cases in Chinese patients. Arch Pathol Lab Med 1998;122(1):37-41.

(3.) Nakhjavani MK, Gharib H, Goellner JR, van Heerden JA. Metastasis to the thyroid gland. A report of 43 cases. Cancer 1997;79(3):574-8.

(4.) Choi SH, Baek JH, Ha EJ, et al. Diagnosis of metastasis to the thyroid gland: Comparison of core-needle biopsy and fine-needle aspiration. Otolaryngol Head Neck Surg 2016;154(4):618-25.

(5.) Van Fossen VL, Wilhelm SM, Eaton JL, McHenry CR. Association of thyroid, breast and renal cell cancer: A population-based study of the prevalence of second malignancies. Ann Surg Oncol 2013;20(4): 1341-7.

Michael Goldenberg, MA; Joshua Warrick, MD; Mariano Russo, BS; Darrin V. Bann, MD, PhD

From the Division of Otolaryngology-Head and Neck Surgery (Mr. Goldenberg and Dr. Bann), the Department of Pathology (Dr. Warrick), and Department of Biochemistry and Molecular Biology (Mr. Russo), Milton S. Hershey Medical Center, Hershey, Pa.
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Author:Goldenberg, Michael; Warrick, Joshua; Russo, Mariano; Bann, Darrin V.
Publication:Ear, Nose and Throat Journal
Article Type:Report
Date:Oct 1, 2016
Words:572
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