Thyroid Carcinomas Found Incidentally in the Cervical Lymph Nodes: Do They Arise From Heterotopic Thyroid Tissues?

Clinicopathological features of incidentally detected metastatic thyroid papillary carcinoma in cervical lymph nodes of non-thyroid cancer patients: a retrospective analysis of 31cases

BACKGROUND

The incidental finding of thyroid inclusions in lymph nodes of neck dissections of non-thyroid cancer patients is an unusual event. It is still controversial for pathologists about whether this represents benign inclusions or metastatic papillary thyroid carcinoma (PTC). This study is to analyze clinicopathological features of such cases in an attempt to explore their clinical implications.

METHODS

Pathological data were searched for incidentally detected PTC of cervical lymph nodes in non-thyroid cancer cases. Clinicopathological characteristics were reevaluated and recorded. BRAF V600E protein expression and sequencing analysis was then performed in cases with sufficient tissues.

RESULTS

31 patients had an incidental finding of PTC in lymph nodes of patients with non-thyroid cancer. BRAF immunohistochemical staining were performed in 17 metastatic lymph nodes with sufficient tumor tissues, and 6 were positive. BRAF V600E point mutation was detected in 5 of 6 BRAF V600E positive cases. Subsequent imaging examinations of the thyroid showed no nodules or calcifications/benign nodules in 20 patients, and suspected malignant nodules in 5 patients. 12 patients underwent total thyroidectomy or ipsilateral lobectomy, and 6 showed PTC in postoperative pathological examinations. The remaining 19 patients without surgery were kept under active surveillance, and no one had recurrence of PTC.

CONCLUSION

Incidentally discovered PTC in lymph nodes has usually interpreted as metastasis from a clinical occult thyroid primary cancer, but primary PTC was not always detected. This suggests it could be double occult lesions. With regards to concurrence with highly malignant tumor, most patients could keep regular surveillance.

The Controversy of Lateral Aberrant Thyroid and the use of BRAF Immunostain

A 29-year-old women presents with primary intrathyroidal papillary thyroid carcinoma (BRAF VE1 positive) with morphologically recognizable metastases to cervical lymph nodes (BRAF VE1 positive) as well as a focus of bland-appearing thyroid follicles within the capsule of a level II lymph node (BRAF VE1 negative). There exist various theories regarding the possible developmental origins of "benign" intranodal thyroid tissue in the lateral neck. While the true nature of the bland follicles may not be definitively resolved in this case, these findings are suggestive that they do not represent metastasis from the main papillary thyroid carcinoma. Additional insight into this unusual phenomenon may be gathered by more specific clonal analysis of these microscopic foci.

Thyroid carcinoma discovered incidentally during surgical resection of head and neck squamous cell carcinoma: A case series

The occurrence of 2 synchronous primary cancers of different origin in the head and neck region is rare. The incidence of thyroid carcinoma found during surgical resection of primary oral squamous cell carcinoma (SCCa) is about 0.3% to 1.9% of patients. Because of the rarity of cases, there is no consensus on management. To clarify significance and management of such lesions, we report 13 cases in which incidental thyroid carcinoma was discovered during surgical resection for primary oral SCCa. A total of 1295 cases of head and neck SCCa from a 4-year period were reviewed, of which we found 13 cases of concurrent thyroid malignancy, providing an incidence rate of approximately 1%. Of these patients, 61.5% received a total or hemithyroidectomy and, of those, 62.5% received radioactive iodine for their thyroid carcinoma; 38.4% did not receive treatment for their thyroid malignancy. The mortality rate for this case series was 23%, of which all deaths were attributed to complications from SCCa. There were no cases where mortality was related to the thyroid carcinoma. Overall, this is consistent with the consensus that incidental thyroid carcinoma found during oral SCCa resection is insignificant compared with the aggressiveness of the primary malignancy.

Incidental cervical lymph node metastasis of papillary thyroid cancer in neck dissection specimens from a tongue squamous cell carcinoma patient: a case report

We report a rare case of lymph node metastasis of papillary thyroid cancer (PTC) incidentally detected in a neck dissection specimen of tongue squamous cell carcinoma (SCC). A 42-year-old Japanese woman was diagnosed with tongue SCC (T1N0M0, Stage I). Partial glossectomy with supraomohyoid neck dissection was performed under general anesthesia, and histopathological examinations revealed primary SCC of the tongue and neck metastasis of PTC in neck dissection specimens. A few months later, total thyroidectomy and left modified radical neck dissection were performed by thyroid surgeons. The histopathological diagnosis was PTC of both the thyroid glands. There was no evidence of tumor recurrence or distant metastasis at the 9-month follow-up.

Incidental thyroid carcinomas. A retrospective study

AIM

The aim of the present study is to report our series of incidental thyroid carcinomas in the last 15 years and their follow-up, discussing therapeutics indications and surgical choices.

PATIENTS AND METHODS

We have considered 1793 patients operated on Surgical Sciences Department of "Sapienza" University of Rome from January 1, 2001 to December 31, 2015. The study was conducted on 83 totally thyroidectomized patients with a real incidental thyroid carcinoma, by clinical, laboratory and instrumental controls. Whole-body scan was the most important test in postoperative evaluation.

RESULTS

In our series, the incidence of incidental carcinomas was 4.62%. Compared to the total number of cancer patients, the percentage is 21,9%. In 15.66% of cases there was multifocality and in 7.23% also bilaterality. Regarding the histological type, in all cases they were papillary carcinoma. The size of the neoplastic lesions ranged from a minimum of 3 to a maximum of 10 mm. Whole-body scan revealed lymph node metastasis in 57.69% of patients.

DISCUSSION

Comparing these data with our previous studies we have seen a significant increase in incidence of incidental thyroid carcinomas over the years. Our therapeutical choice is total thyroidectomy and complection thyroidectomy after lobectomy, because of a relevant percentage of multifocality and/or bilaterality of these tumors. Many Authors on the contrary prefer a more conservative approach invoking the good prognosis of these tumors. The 57.69% of lymph node metastasis at postoperative whole-body scan comfort us in our setting.

CONCLUSION

Incidental thyroid carcinomas are not uncommon. We consider only tumors until 1 cm in diameter. Multifocality and bilaterality are often present such as occult lymph node metastasis. Our therapeutical choice is total thyroidectomy in order to conduct a proper follow-up.

Incidental nodal metastasis of differentiated thyroid carcinoma in neck dissection specimens from head and neck cancer patients

BACKGROUND

Occult differentiated thyroid carcinomas are not uncommon. The initial presentation of a thyroid carcinoma is often detection of a metastatic cervical lymph node.

METHODS

A retrospective review was performed of the medical records of 304 patients who underwent neck dissection between 1996 and 2008 for squamous cell carcinoma of the head and neck.

RESULTS

Ten patients (3.3 per cent) had nodal metastasis originating from papillary thyroid cancer. All of these patients underwent thyroidectomy and post-operative 131iodine radiometabolic therapy. No patient developed a thyroid tumour after surgery.

CONCLUSION

Despite its metastatic spread, thyroid cancer does not affect the overall prognosis of patients who are already being treated for a more aggressive malignancy. However, in otherwise healthy patients, it is worth treating this second malignancy to avoid potential complications related to local disease or metastatic thyroid cancer.

Incidental findings of thyroid tissue in cervical lymph nodes: old controversy not yet resolved?

The clinical significance of papillary or follicular thyroid tissue incidentally discovered in cervical lymph nodes during pathological assessment of neck dissections for non-thyroid cancers of the upper aero-digestive tract is critically reviewed. Special emphasis is given to controversies over normal-looking, nodal, thyroid follicles. Arguments for and against the benign nature of these follicles are considered together with processes that could be involved in their formation. The admittedly limited evidence suggests that benign, thyroid follicular inclusions rarely occur in cervical lymph nodes. Histological criteria that could be helpful in recognizing the inclusions, which include assessing their extent in conjunction with the size of the node, are discussed. Finally, an algorithm based on collaboration between specialists, correlating histological findings with imaging and loco-regional control of the upper aero-digestive tract cancer, is suggested for the management of patients with incidentally discovered, nodal thyroid tissue.

An unexpected finding in the resection specimen of a carcinoma of the oral cavity: A case report

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The occurrence of two synchronous, primary cancers is rare.

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Thyroid carcinoma is incidentally found in the resection specimen after surgery for head and neck cancer in 0.3–1.9% of the patients.

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A papillary thyroid carcinoma was found coincidentally in lymph nodes recovered after a ‘commando’ procedure for carcinoma of the oral cavity.

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A tailor made therapeutic approach of incidental thyroid gland carcinoma in head and neck cancer depends on prognosis and life expectancy.

Introduction

The occurrence of two synchronous, primary cancers is rare. Thyroid carcinoma is incidentally found in the resection specimen after surgery for head and neck cancer in 0.3–1.9% of the patients.

Presentation of case

In this report, we describe the case of a 72-year-old patient in whom a primary (synchronous) papillary thyroid carcinoma was found coincidentally upon pathologic examination of lymph nodes recovered from the cervical neck lymph node dissection specimen after a ‘commando’ procedure for carcinoma of the oral cavity.

Discussion and conclusion

There is no gold standard concerning treatment of the incidentally discovered thyroid gland carcinoma. The decision to perform surgery depends on the life expectancy of the patient, whether the thyroid gland demonstrates clinical or radiologic lesions, the already completed treatment for the head and neck cancer and should always be adjusted to the specific patient.

Anaplastic carcinoma in submandibular region: A diagnostic dilemma

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Anaplastic carcinoma arising in ectopic thyroid tissue is extremely rare.

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Another possibility that should be taken into account in appearance of thyroid tissue in the lateral cervical region is the presence of a thyroid carcinoma metastasis.

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FNA can contribute significantly to the accurate preoperative assessment of ectopic thyroid tissue, particularly if malignancy is suspected.

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The presence of anaplastic carcinoma in the submandibular region without any evidence of primary tumor at the orthotopic thyroid gland may pose diagnostic difficulties.

Introduction

Thyroid carcinoma arising in an extrathyroid area is a rare entity.

Presentation of case

We report a case of anaplastic carcinoma in the submandibular region occurring in a 70-year-old woman.

Discussion

The location of the mass along with no evidence of primary tumor at the orthotopic thyroid gland posed a diagnostic dilemma: was this an ectopic thyroid carcinoma or rather a case of occult differentiated thyroid carcinoma metastasis that transformed to anaplastic carcinoma? Based on the histopathological findings we concluded that the tumor arised in ectopic thyroid tissue. Although the mass was completely resected, the patient died 10 months after diagnosis due to pulmonary metastases.

Conclusion

Conclusively, the possibility of ectopic thyroid tissue, with or without disease, should be considered in cases of a mass in the submandibular region.

Incidental thyroid cancer found during surgery for head and neck squamous cell carcinoma

OBJECTIVE

To quantify the incidence of occult thyroid cancer encountered during neck dissection in patients with head and neck squamous cell carcinoma (HNSCC), to discuss the management of these patients, and to assess the need for further treatment of the incidentally discovered thyroid cancer.

STUDY DESIGN

Case series with chart review.

SETTING

University-based tertiary care hospital.

METHODS

The authors retrospectively reviewed 2538 neck dissections performed at their institution over a 15-year period. Twenty-nine patients had an incidental pathologic finding of thyroid cancer at surgery. The authors reviewed demographics, diagnoses, histopathology, initial and subsequent management, and outcome.

RESULTS

Well-differentiated thyroid cancer (WDC) was found in every case in this cohort. Fifteen patients died during the period of the study (2.4-year follow-up), with 14 patients still alive (4.3-year follow-up). Seven patients, all of whom are still alive, received further treatment for their thyroid cancer: 2 with completion thyroidectomy, 2 with I-131 ablation, and 3 with both. There was no clinical evidence of recurrence of thyroid cancer in any of the patients who died, and none died as a result of thyroid cancer. In addition, none of the patients still alive have biopsy-proven evidence of thyroid cancer recurrence.

CONCLUSION

None of the patients in this cohort died as a result of their thyroid disease, and none of the patients had evidence of recurrence of their WDC during the follow-up period. The results suggest that further management of occult WDC discovered in patients receiving neck dissections for HNSCC is not necessary.

Significance of incidentally detected thyroid tissue in lymph nodes of neck dissections in patients with head and neck carcinoma

BACKGROUND

The incidental discovery of thyroid tissue in lymph nodes of neck dissections performed for a separate primary head and neck cancer is an unusual clinical entity. Careful screening of large number of lymph nodes in the neck dissection specimens by the pathologist is critical in picking up such cases. There is controversy regarding clinical significance of such incidentally detected thyroid tissue in cervical nodes as to whether these represent benign inclusions or whether they represent metastatic focus of an underlying thyroid cancer. The appropriate clinical approach in such cases is less clear because it occurs in the context of another malignancy, usually squamous cell carcinomas with a more aggressive potential.

MATERIALS AND METHODS

On reviewing the records of 1602 neck dissections done in patients with head and neck cancers over the years 2007-2011, this study identified 5 patients with incidentally detected thyroid tissue with features of malignancy in cervical lymph nodes. Subsequent thyroidectomies done in 4 cases showed primary thyroid cancer.

CONCLUSION

The study's results emphasize the need for the clinician to do an accurate reevaluation and follow-up of patients with incidental occult metastasis for detection of primary thyroid tumor. A thorough sampling and screening of lymph nodes in neck dissection specimens by the pathologist is also essential. Incidentally discovered thyroid tissue in cervical lymph nodes need not always be benign inclusions. Aggressive therapy, however, may not be needed in all cases.

Heterotopic breast tissue versus occult metastatic carcinoma in lymph node, a diagnostic dilemma

Breast cancer is the leading cause of cancer in women and the third leading cause of cancer mortality in the United States. We report a case of a patient who underwent bilateral simple mastectomies and right sentinel node biopsy for invasive lobular carcinoma in the right breast. An ipsilateral sentinel lymph node showed a microscopic focus of ductal elements. Although residual lobular carcinoma was identified in the right breast, no ductal carcinoma was identified in either breast. The ducts were discrete distributed in a 3-mm focus in the lymph node parenchyma as well as the subcapsular sinus. By immunohistochemistry, the ducts were positive for cytokeratin, estrogen receptor/progesterone receptor and did not show a myoepithelial layer by P63 or smooth-muscle myosin heavy-chain staining. The differential diagnosis includes heterotopic epithelial inclusions and benign mechanical transport. Mechanical transport of the breast tissue was ruled out because primary tumor type in the breast and the ductal structures in the lymph nodes were of different types. The diagnosis of occult metastatic tumor was based on the lack of the myoepithelial layers associated with the ductal structures. The diagnostic dilemma of the differential diagnoses is discussed, and pertinent literature is reviewed.