Diagnosis and treatment of pancreatic metastases of a papillary thyroid carcinoma

Surgical management of spinal metastases from primary thyroid carcinoma: Demographics, clinical characteristics, and treatment outcomes - A retrospective analysis

Objective

Metastatic spinal tumors represent a rare but concerning complication of primary thyroid carcinoma. We identified demographics, metastatic features, outcomes, and treatment strategies for these tumors in our institutional cohort.

Materials and Methods

We retrospectively reviewed patients surgically treated for spinal metastases of primary thyroid carcinoma. Demographics, tumor characteristics, and treatment modalities were collected. The functional outcomes were quantified using Nurik, Modified Rankin, and Karnofsky Scores.

Results

Twelve patients were identified who underwent 17 surgeries for resection of spinal metastases. The primary thyroid tumor pathologies included papillary (4/12), follicular (6/12), and Hurthle cell (2/12) subtypes. The average number of spinal metastases was 2.5. Of the primary tumor subtypes, follicular tumors averaged 2.8 metastases at the highest and Hurthle cell tumors averaged 2.0 spinal metastases at the lowest. Five patients (41.7%) underwent preoperative embolization for their spinal metastases. Seven patients (58.3%) received postoperative radiation. There was no significant difference in progression-free survival between patients receiving surgery with adjuvant radiation and surgery alone (P = 0.0773). Five patients (41.7%) experienced postoperative complications. Two patients (16.7%) succumbed to disease progression and two patients (16.7%) experienced tumor recurrence following resection. Postsurgical mean Nurik scores decreased 0.54 points, mean Modified Rankin scores decreased 0.48 points, and mean Karnofsky scores increased 4.8 points.

Conclusion

Surgery presents as an important treatment modality in the management of spinal metastases from thyroid cancer. Further work is needed to understand the predictive factors for survival and outcomes following treatment.

Pancreatic metastasis from papillary thyroid cancer: a case report and literature review

Pancreatic metastasis from papillary thyroid cancer (PTC) is extremely rare; only 18 cases have been reported in the literature. However, several reviews have highlighted similar characteristics between metastatic and primary pancreatic tumors. The patient was a 51-year-old male with a history of total thyroidectomy, modified radical neck dissection, and radioactive iodine ablation for PTC in 2014. Nodules suspected of metastasis were found in both lungs on chest computed tomography (CT). However, after 6 months, a follow-up chest CT showed no increase in size; thus, a follow-up observation was planned. Six years after his initial diagnosis, abdominal CT and pancreas magnetic resonance imaging revealed a 4.7 cm cystic mass with a 2.5 cm enhancing mural nodule in the pancreas tail. We diagnosed the pancreatic lesion as either metastatic cancer or primary pancreas cancer. The patient underwent distal pancreato-splenectomy. After surgery, the pathological report revealed that the mass was metastatic PTC. Pancreatic metastasis from PTC indicates an advanced tumor stage and poor prognosis. However, pancreatectomy can increase the survival rate when the lesion is completely resectable. Therefore, surgical resection should be considered as a treatment for pancreatic metastasis from PTC.

ABCA1-Mediated EMT Promotes Papillary Thyroid Cancer Malignancy through the ERK/Fra-1/ZEB1 Pathway

Papillary thyroid cancer (PTC) is the most prevalent histological type of thyroid cancer (TC) worldwide. Although tumor metastasis occurs in regional lymph nodes, distant metastasis (DM) may also occur. Radioactive iodine (RAI) therapy is an effective treatment for TC; however, resistance to RAI occurs in patients with DM. Therefore, in this study, we investigated the efficacy of DM-related biomarkers as therapeutic targets for PTC therapy. ABCA1 expression was higher in aggressive BCPAP cells than in other PTC cells in terms of migration and invasion capacity. The knockdown of ABCA1 substantially decreased the expression of the epithelial-mesenchymal transition (EMT) marker, N-cadherin, and EMT regulator (ZEB1), resulting in suppressed migration and invasion of BCPAP cells. ABCA1 knockdown also reduced ERK activity and Fra-1 expression, which correlated with the effects of an ERK inhibitor or siRNA-mediated inhibition of ERK or Fra-1 expression. Furthermore, ABCA1-knocked-down BCPAP cells suppressed cell migration and invasion by reducing Fra-1 recruitment to Zeb1 promoter; lung metastasis was not observed in mice injected with ABCA1-knocked-down cells. Overall, our findings suggest that ABCA1 regulates lung metastasis in TC cells.

Is lifelong follow-up necessary for low-risk papillary thyroid carcinoma? Case series and a review of the literature

ABSTRACT

Late recurrences of papillary thyroid carcinoma (PTC) are seen rarely, especially for low-risk PTC. However, there are cases of late metastasis described in the literature, even four decades after the first treatment. We presented three low-risk PTC cases with late recurrences. In the first case, recurrence with distant organ metastasis without locoregional disease occurred 36 years after the first treatment. Recurrences in second and third cases were seen with lateral neck metastasis without central (skip metastasis), 17 and 10 years after the primary treatment. Initial treatment was ideal, and all three were followed with a complete response for years, after recurrences were diagnosed and appropriate treatments were administered. Increasing frequency of low-risk PTC increases medical costs of these patients. Thus, some suggest shortening the follow-up period not only because the increasing health burden but also because of the rarity of late recurrences as well. Some authors suggest that dynamically risk-stratified (DRS) low-risk thyroid cancer patients having excellent response to treatment after 5 years of follow-up can be discharged to primary care. Primary care facilities may follow patients with unmeasurable Thyroglobulin (Tg) levels; however, our cases suggest continuing thyroglobulin measurements (annual or at least every few years) for the exceptional but possible late recurrences.

Papillary Thyroid Carcinoma With Breast and Bone Metastasis

Papillary thyroid carcinoma is the most common thyroid malignant tumor and usually has a fine prognosis. The most common metastatic site is the cervical lymph node, and distant metastasis is rare. This report describes a female patient with papillary thyroid carcinoma who presented with multiple metastases in the cervical lymph nodes, breast, and spine. The patient's disease course lasted 11 years, and eventually metastatic cancer led to the patient's death. We also analyzed the survival rate and median survival time of papillary thyroid carcinoma with multiple organ metastases using data in the literature.

Rare distant metastases to pancreas, liver, and lung as initial presentation of mixed tall cell and columnar cell variants of papillary thyroid cancer

Summary

The most common sites of distant metastases of papillary thyroid carcinoma (PTC) are lung and bone. Widespread distant metastases of PTC are rare and associated with poor overall prognosis. Metastases to sites such as liver and pancreas are extremely rare, and literature is sparse on overall survival. In this report, we present a 57-year-old man whose initial presentation of PTC was with pancreatic, liver, and lung metastases, and subsequently developed metastases to bone and brain. He underwent a total thyroidectomy, neck dissection, and tracheal resection. Pathology revealed a predominant columnar cell variant PTC with focal areas of tall cell variant, and genomic sequencing showed both PIK3CA and BRAF gene mutations. Radioactive iodine ablation with I-131 did not show any uptake in metastatic sites and he had progression of the metastases within 6 months. Therefore, therapy with lenvatinib was initiated for radioactive iodine refractory disease. Our patient has tolerated the lenvatinib well, and all his sites of metastases decreased in size. His liver and pancreatic lesions took longer to respond but showed response 6 months after initiation of lenvatinib, and he remains on full dose lenvatinib 18 months into treatment.

Learning points

Papillary thyroid carcinoma (PTC) usually metastasizes to lung and bone but can rarely occur in many other sites. Patients with distant metastases have significantly worse long-term prognosis. Lenvatinib can be an effective treatment of radioactive iodine refractory PTC with rare sites of distant metastases. Lenvatinib can be an effective treatment of PTC with BRAF V600E and PIK3CA mutation.

Aggressive Papillary Thyroid Carcinoma Presenting with Metastasis to the Pancreas

Papillary thyroid cancer is the most common type of thyroid cancer. Aggressive forms tend to metastasize to the lungs and bones, but the abdomen is a rare site of metastasis. We present a 46-year-old male patient who presented with a neck mass associated with shortness of breath and hemoptysis. He was found to have a large thyroid mass on imaging. He underwent a total thyroidectomy with bilateral neck dissection, with pathology showing a multifocal tall cell variant of papillary thyroid carcinoma with lymphovascular invasion in both thyroid lobes. Due to recurrent findings of residual thyroid tissue on whole-body scan imaging, the patient underwent radioactive iodine ablation therapy twice, with poor response to therapy, suggested by persistently elevated thyroglobulin levels. However, the residual tissue responded to external beam radiation. After the initial response to radiation, thyroglobulin was noted to have increased again, prompting a PET-CT after administration of recombinant TSH. PET showed a focal area of increased uptake in the head of the pancreas. The patient underwent the Whipple procedure for resection of the metastasis. Pathology showed papillary thyroid carcinoma with strong and diffuse staining for TTF-1 and thyroglobulin. The patient was started on lenvatinib in the postoperative period and is currently tolerating treatment well with evidence of decreasing thyroglobulin levels. Intra-abdominal metastasis from a thyroid malignancy source is quite rare and can be challenging as far as diagnosis and treatment. Surgical resection can be curative and can be followed by radioactive iodine ablation therapy if cancer cells show avidity. Tyrosine kinase inhibitors can be used in refractory disease. New research is being conducted on new agents that can reverse the resistance to radioactive iodine therapy.

Site-Specific Metastasis and Survival in Papillary Thyroid Cancer: The Importance of Brain and Multi-Organ Disease

Introduction-heterogeneity in clinical outcomes and survival was observed in patients with papillary thyroid cancer (PTC) and distant metastases. Here, we investigated the effect of distant metastases sites on survival in PTC patients. Methods-patients with a diagnosis of PTC and known metastases were identified using the Surveillance, Epidemiology, and End Results database (1975-2016). Univariate and multivariate Cox regression analyses were performed to analyze the effect of distant metastases sites on thyroid cancer-specific survival (TCSS) and overall survival (OS). Results-from 89,694 PTC patients, 1819 (2%) developed distant metastasis at the initial diagnosis, of whom 26.3% presented with the multiple-organ disease. The most common metastatic sites were lung (53.4%), followed by bone (28.1%), liver (8.3%), and brain (4.7%). In metastatic patients, thyroid cancer-specific death accounted for 73.2%. Kaplan-Meier curves showed decreased OS in patients with metastases to the brain (median OS = 5 months) and liver (median OS = 6 months) compared to lung (median OS = 10 months) and bone (median OS = 23 months). Moreover, multiple organ metastasis had a higher mortality rate (67.4%) compared to single organ metastasis (51.2%, p < 0.001). Using multivariate analysis, risk factors that significantly influence TCSS and OS were male gender (HR = 1.86, 95% CI = 1.17-2.94, p < 0.001, and HR = 1.90, 95% CI = 1.40-2.57, p = 0.009), higher tumor grade (HR = 7.31, 95% CI = 2.13-25.0, p < 0.001 and HR = 4.76, 95% CI = 3.93-5.76, p < 0.001), multiple organ involvement (HR = 6.52, 95% CI = 1.50-28.39, p = 0.026 and HR = 5.08, 95% CI = 1.21-21.30, p = 0.013), and brain metastasis (HR = 1.82, 95% CI = 1.15-2.89, p < 0.001 and HR = 4.21, 95% CI = 2.20-8.07, p = 0.010). Conclusion-the pattern of distant metastatic organ involvement was associated with variability in OS in PTC. Multi-organ metastasis and brain involvement are associated with lower survival rates in PTC. Knowledge of the patterns of distant metastasis is crucial to personalize the treatment and follow-up strategies.

Unusual metastasis of papillary thyroid cancer to the pancreas, liver, and diaphragm: a case report with review of literature

Background

Papillary thyroid cancer (PTC) is the most common form of well-differentiated endocrine malignancy. Distant metastases of PTC are rare and usually occur in the bones, lungs, and thoracic lymph nodes despite the common locoregional metastases to the lymph nodes of the neck. The metastasis of PTC to the pancreas is extremely rare. Here, we present a patient with PTC that had simultaneously metastasized to the pancreas, liver, and diaphragm.

Case presentation

A 47-year-old male patient suffering from mild abdominal pain for 2 months was admitted to our hospital. The ultrasound (US) and computed tomography (CT) scan of the abdomen revealed a pancreatic space-occupying lesion and pancreatic duct dilatation, and the patient underwent exploratory laparotomy. Intraoperative examination identified a hard mass (approximately 4.0 cm × 3.0 cm) in the body and tail of the pancreas and a mass (1.5 cm in diameter) in the diaphragm. Three light masses were also noted on the surface of his liver. The patient underwent radical distal pancreatectomy, splenectomy, diaphragm, and liver mass resection. After surgery, the pathological report revealed that the masses resected from the pancreas, liver, and diaphragm were PTC metastases. Then, the patient had a thyroid US and an endoscopic US-guided fine needle aspiration biopsy of the thyroid mass. Pathology showed papillary cancer. Subsequently, the patient received a complete thyroidectomy, a cervical lymphadenectomy, bilateral parotidectomy, and bilateral submandibular gland resection.

Conclusions

Aggressive surgeries, such as pancreaticoduodenectomy (PD), should be considered for selected patients with metastatic diseases from PTC to alleviate the symptoms and prolong their survival.

Cholestatic syndrome as initial manifestation of pancreatic metastasis of papillary thyroid carcinoma: case report and review

Most papillary thyroid carcinomas (PTC) harbor excellent prognosis. Although rare, distant metastases normally occur in lungs and/or bones. Here we describe a rare case of pancreatic metastasis presenting with rapid onset cholestatic syndrome. A literature review was also performed. A 73-year-old man with a high risk PTC was submitted to total thyroidectomy (TT) followed by radioiodine therapy. After initial therapy, he persisted with progressive rising serum thyroglobulin levels but with no evidence of structural disease. Recently, the patient presented with a rapid onset and progressive cholestatic syndrome. A 4 cm lesion in pancreas was identified, with echoendoscopy fine-needle aspiration biopsy (FNAB) confirming a pancreatic metastasis from PTC. The patient was submitted to a successful pancreaticoduodenectomy. Pancreatic metastases of PTC are rare and few long-term follow-up data are available to guide management. Fourteen cases were former reported, mean age was 65.7 years-old with mean time between PTC and pancreatic metastasis diagnosis of 7.9 years. Nine of them had another distant metastasis, nine were diagnosed by FNAB and just two received sorafenib.

Promoter Methylation of Four Tumor Suppressor Genes in Human Papillary Thyroid Carcinoma

BACKGROUND & OBJECTIVE

Papillary thyroid cancer (PTC) is considered to be the most common type of thyroid malignancies. Epigenetic alteration, in which the chromatin conformation and gene expression change without changing the sequence of DNA, can occur in some tumor suppressor genes and oncogenes. Methylation is the most common type of epigenetic alterations that can be an excellent indicator of PTC invasive behavior.

METHODS

In this research, we determined the promoter methylation status of four tumor suppressor genes (SLC5A8, RASSF1, MGMT, and DNMT1) and compared the results of 55 PTC cases with 40 goiter patients. For methylation, we used the methylation-sensitive high resolution melting (MS-HRM) assay technique. The resulting graphs of each run were compared with those of 0%, 50%, and 100% methylated controls.

RESULTS

Our data showed that the promoter methylation of SLC5A8, Ras association domain family member 1(RASSF1), and MGMT were significantly different between PTC tissue and goiter with P-value less than 0.05. The most significant differences were observed in RASSF1; 77.2% of hyper-methylated PTC patients versus 15.6% hyper-methylated goiter samples (P<0.001).

CONCLUSION

RASSF1 promoter methylation can be a PTC genetic marker. RASSF1 promoter methylation is under the impact of the methyltransferase genes (DNMT1 and MGMT), protein expression, and promoter methylation.

Long-Term Outcomes After Hepatic and Pancreatic Resections for Metastases from Thyroid Cancer: a Systematic Review of the Literature

PURPOSE

The objective of our systematic review was to evaluate the long-term outcomes of surgical resection as a treatment strategy for liver and pancreatic metastases from thyroid cancer (TC).

METHODS

A systematic search of three electronic databases for articles published up to October 2018 was conducted. All appropriate observational studies and case reports which reported outcomes from patients with TC metastatic to the liver or pancreas were considered eligible for inclusion in the present systematic review.

RESULTS

A total of 15 studies, which comprised of 16 patients that underwent hepatic or pancreatic resection for TC metastasis, were included in the present systematic review; among them, 5 presented with metastasis to the liver, whereas 11 had pancreatic metastatic disease. The median time interval between the initial thyroidectomy and the diagnosis of metastases (either hepatic or pancreatic) was 60 months (SE 23.8, 95% CI 13.3-106.7) for the entire cohort and the mean overall survival was 37.6 months (SE 8, 95% CI 22-53.3). Five patients with pancreatic metastases presented with recurrence whereas no recurrences were noted in patients with liver metastases.

CONCLUSIONS

Surgical resection of liver and pancreatic metastases from TC seems to be a safe and efficient treatment option for selected patients. In that setting, long-term outcomes in patients with resected TCLM are encouraging given the absence of recurrence as reported from the included studies, whereas in the case of TCPM, survival is limited due to advanced disease at diagnosis and recurrence rates.

Circulating ctDNA methylation quantification of two DNA methyl transferases in papillary thyroid carcinoma

Papillary thyroid cancer (PTC) is the most common type of cancer among thyroid malignancies. Tumor-related methylation of circulating tumor DNA (ctDNA) in plasma could represent tumor specific alterations can be considered as good biomarkers in circulating tumor cells. In this study, we studied the methylation status of seven promoter regions of two DNA methyl Transferases (MGMT and DNMT1) genes as the methylated ctDNA in plasma and tissue samples of patients with PTC and goiter patients as noncancerous controls.

METHODS

Both ctDNA and tissue genomic DNA of 57 PTC and 45 Goiter samples were isolated. After bisulfite modification, the methylation status was studied by Methylation-Sensitive High Resolution Melting (MS-HRM) assay technique. Four promoter regions of O6-methylguanine-DNA methyltransferase (MGMT) and three promoter regions of DNA methyltransferase 1 (DNMT1) were assessed.

RESULTS

From seven candidate promoter regions of two methyltrasferase coding genes, the methylation status of ctDNA within MGMT (a), MGMT (c), MGMT (d), and DNMT1 (b) were meaningfully different between PTC cases and controls. However, the most significant differences were seen in circulating ctDNA MGMT (c) which was hypermethylated in 25 (43.9 %) of patients with PTC vs 2 (4. 4 %) of goiter samples. Between two selected DNA methyl transferase, the methylation of MGMT as the maintenance methyltransferase was significantly higher in PTC cases than goiter controls (P-value < .001). The resulting areas under the receiver operating characteristic (ROC) curve were 0.78 for MGMT (d) for PTC versus goiter samples that can represent the overall ability of MGMT (d) methylation status to discriminate between PTC and goiter patients.

CONCLUSION

Among seven candidate regions of ctDNA the MGMT (c) and MGMT (d) showed higher sensitivity and specificity for PTC as a suitable candidates as biomarkers of PTC.

Multiple Simultaneous Rare Distant Metastases as the Initial Presentation of Papillary Thyroid Carcinoma: A Case Report

Papillary thyroid carcinoma (PTC) commonly metastasizes to regional lymph nodes. However, they infrequently cause rare distant metastases (RDMs), with the exclusion of lungs and bone metastases. RDMs are seldom identified prior to a primary thyroid cancer diagnosis. Therefore, cases initially presenting with synchronously multiple RDMs from PTC are extremely infrequent. This is a rare case of a 48-year-old man with initial diaphragm, pancreatic, and liver tumors from PTC. Following resection of the tumors, an ultrasound-guided fine-needle aspiration (US-FNA) cytology of a mass in the thyroid's left lobe revealed PTC. After postoperative recovery for more than 4 months, physical examination identified an irregular large nodule in the thyroid's isthmus and left lobe, a swollen lymph node in the left neck, and a mass in the right parotid gland. Ultrasound reexamination revealed numerous hypoechoic masses as follows: one in the thyroid's isthmus and entire left lobe (7.3 × 5.9 × 5.1 cm) and multiple in the thyroid's right lobe (0.2-0.3 cm). Ultrasound examination also showed several swollen lymph nodes in the left neck, a mass in the left gluteus maximus, and several masses in both the bilateral parotid and salivary region. The US-FNA's pathological examination confirmed metastatic PTCs in the left gluteus maximus and bilaterally located in the parotid and salivary gland. 18-fluorodeoxyglucose positron-emission tomography and computed tomography scan revealed abnormal uptakes in numerous locations (e.g., the thyroid's isthmus and left lobe, bilateral parotid gland, subcutaneous tissues, etc.). The patient underwent palliative therapy, including total thyroidectomy, bilateral central neck dissection, left lateral neck dissection, and excision of the bilateral parotid and salivary gland. A whole-body scan post-therapeutic radioactive iodine ablation showed exclusive thyroid bed uptake. Subsequently, the patient underwent continuous thyroid stimulating hormone repression therapy and was treated with lenvatinib chemotherapy for ~8 months. The primary thyroid tumor, pancreatic metastasis, and cervical lymph node metastasis were both positive for BRAF ^V600E and TERT promoter (C288T) mutations. After 13 months of follow-up, the patient is currently in stable clinical conditions. In conclusion, the present case is an extremely rare occurrence of simultaneous multiple RDMs from PTC as the initial presentation.

Papillary thyroid carcinoma metastatic to the pancreas: Case report

Papillary thyroid carcinoma (PTC) is generally associated with an excellent long-term outcome. Distant metastasis is rare with only 5-7% of patients developing distant disease. Metastasis of PTC to the pancreas is an exceedingly rare occurrence. To date, few cases have been reported. We present the case of an 81-year-old man with past medical history of PTC status post total thyroidectomy with local recurrence treated with radioactive iodine and selective neck dissection. Ten years after his initial diagnosis, PET-CT scan revealed a new hypermetabolic 1.1 cm × 0.9 cm left lower lobe lung nodule and hypermetabolism in the proximal body of the pancreas. Follow-up MRI cholangiogram showed a 1.0 × 0.8 cm T1 hypointense lesion in the proximal body of the pancreas. Endoscopic ultrasound-guided fine-needle aspiration biopsy of the pancreatic mass showed neoplastic epithelial cells arranged in papillary clusters with fibrovascular cores and syncytial sheets with high nuclear to cytoplasmic ratio, visible nucleoli, nuclear pallor, focal nuclear grooves, and rare intranuclear pseudoinclusions. Immunohistochemical stains performed on the smears showed positive nuclear expression of TTF-1 and PAX-8. The findings were consistent with metastatic PTC. Surgical resection of the lung nodule confirmed metastatic PTC. Pancreatic metastases usually occur after long time intervals with reports of up to 8 years in PTC. This makes the diagnosis more challenging, and metastatic disease should always be in the differential diagnosis in cases presenting with a pancreatic mass, especially in patients with a prior malignancy.

Primary squamous cell carcinoma of the pancreas with effective comprehensive treatment: A case report and literature review

RATIONALE

Primary squamous cell carcinoma (SCC) of the pancreas is a rare entity since the pancreas lacks squamous cells. This condition is associated with a poor prognosis, and there is currently no optimal treatment strategy for it.

PATIENT CONCERNS

A 64-year-old female patient with a complaint of epigastric pain for 3 months was referred to our hospital.

DIAGNOSES

She was finally diagnosed with primary SCC of the pancreas with lymph node metastasis on the basis of radiological and pathological findings.

INTERVENTIONS

She received chemoradiation along with targeted therapy and was provided with treatment response evaluation through PET/CT.

OUTCOMES

She eventually died of tumor progression after 8 months.

LESSONS

Primary SCC of the pancreas is associated with a poor prognosis. Comprehensive therapy and proper radiologic evaluation may facilitate prolonged survival of these patients.

Langerhans' Cell Histiocytosis Masquerading as Metastatic Papillary Thyroid Cancer on F-18 FDG PET/CT: Diagnostic Dilemma Solved by PET/CT-Guided Biopsy

We present a case of papillary thyroid cancer (post-thyroidectomy status) on regular treatment with suppressive Levothyroxine therapy. On follow-up at 6 months after radioactive iodine ablation for remnant thyroid tissue, her thyroglobulin, and anti-thyroglobulin levels were 0.06 ng/ml and 670 IU/ml, respectively. Low-dose whole-body I-131 scan was negative. To look for the cause of isolated increased anti-thyroglobulin level, a whole-body ¹⁸F-FDG PET/CT was done which revealed multiple FDG-avid lytic skeletal lesions suggestive of metastases. For confirmation of diagnosis, ¹⁸F-FDG PET/CT-guided metabolic biopsy was done, which revealed Langerhans' cell histiocytosis on histopathological examination.

Pancreatic metastasis of papillary thyroid carcinoma preoperatively diagnosed by endoscopic ultrasound-guided fine-needle aspiration biopsy: a case report with review of literatures

Pancreatic metastatic tumors from thyroid carcinoma are extremely rare. We report a case of an 80-year-old female with a pancreatic metastatic tumor derived from papillary thyroid carcinoma which was initially resected 158 months prior to detection of the metastatic pancreatic tumor. The patient has encountered cervical lymph-node metastasis on three occasions following the initial operation. Metastatic pancreatic lesions and cervical lymph nodes were first detected using 18-fluorodeoxyglucose positron-emission tomography/computed tomography, and she was preoperatively diagnosed using endoscopic ultrasound-guided fine-needle aspiration biopsy. A coin lesion, 10 mm in size, was detected in the left lung by chest computed tomography with no abnormal uptake in 18-fluorodeoxyglucose positron-emission tomography/computed tomography. Distal pancreatectomy and cervical lymph-node dissection were performed. Adjuvant chemotherapy with weekly paclitaxel was administered because anaplastic transformation had been detected in one of the cervical lymph nodes. The patient eventually died from multiple lung metastases 11 months after removing the metastatic pancreatic lesion. We reported a rare case of a pancreatic metastatic tumor from thyroid carcinoma, and found that 18-fluorodeoxyglucose positron-emission tomography/computed tomography and endoscopic ultrasound-guided fine-needle aspiration biopsy are useful for preoperatively diagnosing tumors.

PANCREAS METASTASES FROM PAPILLARY THYROID CARCINOMA: A REVIEW OF THE LITERATURE

OBJECTIVE

Although locoregional metastases occur in 5 to 10% of patients with papillary thyroid cancer (PTC), distant metastases are rare, especially to the pancreas. Here we review the literature regarding metastases to the pancreas from PTC and present an illustrative patient.

METHODS

The literature search was performed through using the PubMed database. The information regarding our illustrative case was obtained from the medical records of our institution.

RESULTS

Since 1991, 11 cases of pancreas metastases of PTC have been reported. The average age at diagnosis was 55.3 years. There were 8 males and 3 females. Three had classic PTC histology, 2 had tall cell variant, and 2 had follicular variant. Four had T4 tumors, and 2 had T3 tumors. Seven had thyroid cancer spread to regional lymph nodes. One had distant metastasis. Pancreas metastases were diagnosed from 1 month to 13 years after primary PTC was detected; the average was 7 years. Our patient was an 84-year-old female diagnosed with PTC with a BRAFV600E mutation following total thyroidectomy. A whole-body scan after radioactive iodine (RAI) remnant ablation was negative for metastases. A pancreatic tumor was identified 2 years later on a fluorodeoxyglucose (FDG)-positron emission tomography (PET) scan. A biopsy of the tumor was histologically similar to PTC and positive for thyroglobulin, thyroid transcription factor-1, and the BRAFV600E mutation.

CONCLUSION

The biological reasons why PTCs metastasize to the pancreas remain to be elucidated. Older patients with non-RAI avid, FDG-PET-positive metastases, and symptoms of pancreatitis are at increased risk of this rare entity.

ABBREVIATIONS

FDG = fluorodeoxyglucose FNA = fine-need aspiration PTC = papillary thyroid cancer RAI = radioactive iodine Tg = thyroglobulin TgAb = antithyroglobulin antibodies TNM = tumor-node-metastasis.

Unusual Thyroid Carcinoma Metastases: a Case Series and Literature Review

The most common sites of metastatic differentiated thyroid cancer are the neck lymph nodes, while distant metastases typically involve the lungs, the bones, and less frequently the brain. Uncommon metastatic sites include the liver, adrenal gland, kidney, pancreas, and skin. The epidemiological aspects of thyroid metastases in rare sites are largely unknown and their identification could have a significant impact on patients management. A mini-series of unusual metastatic sites of thyroid carcinoma is proposed as a contribution to current knowledge on anatomopathological characteristics and clinical outcome. Of the six cases that were assessed, the metastases were the following: skin metastases (2), skin and pancreas metastases (1), renal metastasis (1), adrenal metastasis (1), and liver metastasis (1). In our experience, metastases in rare sites do not always represent a negative prognostic factor for disease outcome. In fact they can occur as single distant lesion and if surgically resectable, their treatment can also lead to local disease remission.

(18)F-FDG-PET/CT findings in pancreatic metastasis

PURPOSE

This study aimed to evaluate the fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT) findings and pattern of FDG uptake in pancreatic metastases.

MATERIALS AND METHODS

A total of 19 consecutive patients (26 lesions) with histologically or clinically confirmed pancreatic metastases who had undergone (18)F-FDG-PET/CT were enrolled in this retrospective study. Among the 19 patients, 14 patients underwent abdominal contrast-enhanced CT (ceCT). The location, size and FDG uptake patterns of the pancreatic lesions were recorded. Metabolic activity by means of maximum standardised uptake value (SUVmax) was measured by drawing regions of interest at the site of pancreatic lesions. Twenty pancreatic cancer patients were included in this study as comparative data analysis. The difference of SUVmax between pancreatic metastases and primary pancreatic cancer were compared using the Mann-Whitney U test. P < 0.05 was considered significant.

RESULTS

Three different patterns of FDG uptake could be distinguished in the pancreatic metastatic lesions, including focal nodule or mass, multiple foci and segmental lesion with high FDG uptake. The average SUVmax in pancreatic metastases was 7.8 ± 6.9 versus 7.4 ± 3.9 in primary pancreatic cancer (P = 0.987 > 0.05). Four intrapancreatic isodense nodules in three patients were undetected on ceCT.

CONCLUSION

The described patterns of FDG uptake findings may be helpful for a better characterisation of pancreatic metastases although semiquantitative analysis using SUVmax could not be used as a criterion for differentiating pancreatic metastases from primary pancreatic cancer. FDG-PET/CT has also an advantage in detecting unsuspected pancreatic metastases which cannot be detected by ceCT imaging. Thus, it is a useful adjunct to the described features on CT.

Spinal metastases due to thyroid carcinoma: an analysis of 202 patients

BACKGROUND

Spinal metastases (SMs) due to thyroid cancer (TC) are associated with significantly reduced quality of life. The goal of this study is to analyze the clinical manifestations, presentation, and treatments of TC SMs, and to describe specific features of SMs associated with different TC types.

PATIENTS AND METHODS

A retrospective analysis of 202 TC SM patients treated at Medstar Washington Hospital Center (37) and collected from the literature (165) was performed.

RESULTS

The mean age of patients with SMs was 56.9±14.7 years, and the female-to-male ratio was 2.1:1. Of all patients, 29% (28% of follicular thyroid cancer [FTC] and 37% of papillary thyroid cancer [PTC]) had SMs only. Twenty-nine percent of all patients and 54% of patients with single-site SMs had neither bone non-SMs nor solid organ metastases at the time of presentation. Thirty-five percent of patients had SMs as an initial presentation of TC. TC patients presenting with SMs had a lower rate of other bone and visceral involvement compared with patients whose SMs were diagnosed at the time of thyroid surgery or during follow-up (p<0.05). SMs were more often the initial manifestation of FTC (41% vs. 24%), while PTC SMs were more commonly diagnosed after TC diagnosis (76% vs. 59%; p<0.05). PTC SMs were more frequently diagnosed as synchronous (63% vs. 36% in FTC) versus FTC SMs that developed as metachronous metastases (64% vs. 37% in PTC; p<0.01). All FTC SMs developed within 82 (0-372) months and all PTC SMs within 35 (0-144) months (p<0.01). In FTC SMs as TC manifestation, solid organ metastases involvement was less common than in FTC SMs that were found after TC diagnosis (34% vs. 67%; p<0.01); multisite FTC SMs compared to solitary FTC SMs were associated with the development of other bone nonspinal metastases (82% vs. 30%; p<0.01) and solitary organ metastases (65% vs. 41%; p<0.01). These correlations were not observed in PTC SMs. FTC patients often had neural structure compression (myelopathy/radiculopathy; 72% vs. 36% in PTC), while PTC patients frequently were asymptomatic (38% vs. 5% in FTC; p<0.01). FTC SMs more commonly were (131)I-avid (p<0.01). FTC patients required surgery more frequently (72% vs. 55% in PTC; p<0.05).

CONCLUSIONS

Our study reveals that a significant part of TC SMs patients have solitary spinal involvement at the time of presentation and may be considered for aggressive treatment with the intention to improve quality of life and survival. FTC SMs and PTC SMs appear to have distinct presentations, behavior, and treatment modalities, and should be categorized separately for treatment and follow-up planning.

Pancreatic metastasis of papillary thyroid carcinoma: a case report with review of the literature

In this article we give a case report on a PTC patient with pancreatic metastasis. In this case, the patient was admitted to our hospital for recurrence of PTC and occupying pancreatic lesions. We considered that the pancreatic neoplasm may be pancreatic metastasis of PTC but there is no previous experience about therapeutic approaches to this type of metastases. After some discussion the distant metastasis within the pancreas was successfully removed by a laparotomy and postoperative histology confirmed the diagnosis. After that surgery, the patient recovered well and then received total thyroidectomy and cervical lymph node dissection for recurrent thyroid cancer. After recovery he was discharged from hospital without further treatment. Eventually, he died of acute myocardial infarction in January 2010. To conclude, it is widely believed that the surgical operation should be chosen more positively in the management of those patients without multiple organ metastases. Thus on one hand it can serve to make a definite diagnosis, and on the other hand it can help the body get rid of the bulk of the tumor burden to prolong survival time of the patients.

FDG PET/CT in the detection of pancreatic metastasis in a patient with follicular thyroid carcinoma and negative I-131 whole body scan findings

We identified a rare follicular thyroid carcinoma (FTC) metastasis to the pancreas in a patient of FTC. A 65-year-old woman presented at our hospital for evaluation of a pancreatic mass. She had a history of FTC. After total thyroidectomy, I-131 whole body scan showed increased I-131 uptake in the thyroid bed, but there was no evidence of distant metastasis. However, F-18 FDG PET/CT showed a mass with FDG uptake in the pancreatic head. Follow-up PET/CT showed FDG uptake in the pancreatic head and thyroid bed. Pylorus preserving pancreaticoduodenectomy was performed. Histopathological examination supported the diagnosis of metastatic FTC to pancreas.

Papillary thyroid carcinoma with lung metastasis arising from dyshormonogenetic goiter: a case report

Prior radiation exposure is the best known risk factor for thyroid cancers, and papillary thyroid carcinoma (PTC) may arise from dyshormonogenetic goiter. A 17-year-old female patient was admitted to the department of chest diseases with respiratory symptoms. The patient had undergone a thyroid surgery for goiter at the age of 9. A bilateral nodular opacity was detected by radiological examination. The histopathologic examination of the specimen obtained from computed tomography guided trucut biopsy was diagnosed as PTC. We present a very rare case of PTC with lung metastasis that had undergone subtotal thyroidectomy due to dyshormonogenetic goiter eight years ago.

Coexisting iodine avid and iodine nonconcentrating lesions with multiple distant soft tissue metastasis in papillary thyroid cancer

Distant soft tissue metastasis and the simultaneous presence of iodine concentrating and nonconcentrating lesions in papillary thyroid cancer are extremely rare. The concerned patient, a histopathologically proven case of papillary thyroid cancer with nodal metastases treated with total thyroidectomy, bilateral cervical nodal dissection, and radioablation, subsequently developed lung, muscle, and liver metastasis. Triggered by increased thyroglobulin, the iodine-131 whole body scan and 200 mci iodine-131 post-therapy scan showed a left gluteus maximus lesion and a liver lesion. Fludeoxyglucose (FDG) positron emission tomography-computed tomography (PET-CT) scan intended to find additional lesions revealed iodine and FDG nonconcentrating bilateral pulmonary nodules and a single FDG avid hepatic and two muscle metastases. Although FDG concentration in metastatic pulmonary nodules is generally low, the CT characteristics were classical for metastatic lesion. A follow-up FDG PET-CT study six months after 200 mci iodine-131 radioablation showed treatment response in muscle and liver lesions but not lungs.

Pancreas as delayed site of metastasis from papillary thyroid carcinoma

Introduction. Follicular variant (FV) papillary thyroid carcinoma (PTC) has aggressive biologic behavior as compared to classic variant (CV) of PTC and frequently metastasizes to the lungs and bones. However, metastasis to the pancreas is extremely rare manifestation of FV-PTC. To date, only 9 cases of PTC have been reported in the literature. Pancreatic metastases from PTC usually remain asymptomatic or manifest as repeated abdominal aches. Associated obstructive jaundice is rare. Prognosis is variable with reported median survival from 16 to 46 months. Case Presentation. Herein we present a 67-year-old Saudi woman, who developed pancreatic metastases seven years after total thyroidectomy and neck dissection followed by radioactive iodine ablation (RAI) for FV-PTC. Metastasectomy was performed by pancreaticoduodenectomy followed by sorafenib as genetic testing revealed a BRAF V600E mutation. She survived 32 months after the pancreatic metastasis diagnosis. Conclusion. Pancreatic metastases are rare manifestation of FV-PTC and are usually sign of extensive disease and conventional diagnostic tools may remain to reach the diagnosis.

Pancreatic metastasis arising from a BRAF(V600E)-positive papillary thyroid cancer: the role of endoscopic ultrasound-guided biopsy and response to sorafenib therapy

BACKGROUND

Lungs and bones are the most common sites for distant metastases from papillary thyroid cancer (PTC). Metastases to the pancreas are extremely rare. Here we present a man with pancreatic metastases from PTC, report our experience with sorafenib therapy, and discuss the role of endoscopic ultrasound (EUS)-guided biopsy in its diagnosis.

PATIENT FINDINGS

A 56-year-old man underwent total thyroidectomy, right-modified neck dissection, and radioactive iodine (RAI) remnant ablation for PTC at age 47 years (in 2002). Between 2002 and 2007, he had three more neck surgeries, two RAI therapies, and external beam radiotherapy for persistent and subsequently metastatic PTC. In 2008, a computed tomography/positron emission tomography (CT/PET) scan showed an 18F-fluorodeoxyglucose (FDG)-avid pancreatic focus. Magnetic resonance imaging (MRI) revealed a pancreatic nodule at the same location. An EUS-guided biopsy confirmed the diagnosis of pancreatic metastasis from PTC, and molecular studies showed positive BRAF(V600E) mutation. He was treated with sorafenib for 6 months. Although a lung CT scan done 2 months after initiation of sorafenib suggested stability of the disease, MRI studies done at 3 and 6 months showed clear progression with an increase in the size of the lung and pancreatic metastases. Subsequently, he developed liver, bone, and omental metastases. He died in July 2011, 9 years and 8 months after the initial diagnosis of PTC and 20 months after discovery of the pancreatic metastasis.

SUMMARY

A middle-aged man with PTC developed lung metastases despite multiple surgeries and RAI therapies. Seven years after the initial diagnosis, a pancreatic metastasis was accidentally discovered. Both the metastasis and the primary thyroid tumor are positive for BRAF(V600E) mutation. The lung and pancreatic metastases progressed while the patient was receiving sorafenib for 6 months, and the patient died 20 months after diagnosis of pancreatic metastasis.

CONCLUSION

PTC rarely metastasizes to the pancreas. In this patient, an FDG PET scan and EUS-guided biopsy played important roles in the diagnosis. PTC metastases to the pancreas usually occur in otherwise advanced disease. In the patient presented here, sorafenib may have slowed disease progression but the overall utility of tyrosine kinase inhibitors in pancreatic metastases from PTC is not clear.

Histological subtype is the most important determinant of survival in metastatic papillary thyroid cancer

BACKGROUND

Papillary thyroid cancer (PTC) comprises the commonest type of thyroid cancer and carries the highest rate of survival. However, when metastatic disease occurs, survival is significantly affected.

METHODS

We aimed to identify prognostic histopathological and clinical factors that modify survival in metastatic PTC. All cases of metastatic PTC treated at our department in the last 20 years were reviewed and analyzed.

RESULTS

Histological subtype was the most important determinant of survival, as classic PTC demonstrated clearly improved survival compared to follicular subtype of PTC and other less frequently seen histological subtypes. The instant risk of death for the other histological subtypes was 4.56 times higher than the risk for the classic papillary type. Overall, a 10-year survival of 76.6% in our patients was seen.

CONCLUSIONS

Patients with aggressive variants of PTC are more at risk for the development of metastatic disease. In these patients, established treatment modalities (surgery, radioiodine therapy) should be offered promptly, as well as close follow-up.

Metastases of well-differentiated thyroid cancer to the gastrointestinal system

BACKGROUND

The incidence of distant metastases at the time of initial presentation of well-differentiated thyroid cancer is approximately 4%. During the course of treatment and follow-up, the prevalence of distant metastases ranges from 2% in low-risk patients up to 33% in high-risk patients. When present, distant metastases occur primarily in the lungs and, to a lesser extent, in bones. Of all sites for distant metastasis, gastrointestinal metastases of thyroid cancer are very uncommon and account for 0.5-1% of all distant metastases.

SUMMARY

Indications of metastases to the gastrointestinal system can be overlooked with traditional total body radioisotope scans that image the abdomen, including both diagnostic and posttherapy scans, because of the confounding presence of physiologic enteric radioactivity. When suspected in high-risk patients, other imaging procedures such as computed tomography, magnetic resonance imaging, and PET-computed tomography should be considered. This communication will review thyroid cancer metastases to the gastrointestinal system in regard to occurrence rate, diagnosis, and treatment.

CONCLUSIONS

Because of the extreme rarity of patients with metastases of thyroid cancer to the gastrointestinal tract, long-term follow-up data as well as information on prognosis are very limited. Aggressive management may provide symptomatic relief or palliation, but cure is unlikely once widespread metastases supervene. Attempts at complete or near-complete surgical resection of the metastases invading the digestive tract, followed by 131-I treatment, offer the best opportunity for improvement but will only rarely result in cure in selected patients.