Papillary thyroid carcinoma without metastases manifesting as an autonomously functioning thyroid nodule

Papillary Thyroid Cancer in a Patient With Graves' Disease and Hyperfunctioning (Hot) Thyroid Nodules: An Unexpected Presentation

Hyperfunctioning (hot) nodules are considered benign while cold nodules are associated with a higher risk of thyroid cancer. In this case report, we present a patient diagnosed with Graves' disease and later found to have papillary thyroid carcinoma (Bethesda VI), confirmed by fine needle aspiration (FNA) biopsy, with regional metastasis to the neck and possible metastasis to the lungs. This paper demonstrates that hot nodules are not always benign, and could be associated with malignancy.

Clinical characteristics associated with the finding of thyroid cancer originating from hot nodules in patients with hyperthyroidism: a case report and systematic review of the literature

Coexistence between thyroid cancer and hyperthyroidism is rare, and most of the nodular lesions from which a malignant tumor is documented in this group of patients correspond to cold nodules. Justified by the increasing number of reports in the literature about malignant tumors diagnosed from hot nodules, a systematic review was carried out to determine possible factors associated with the diagnosis of thyroid cancer from hot nodules in patients with hyperthyroidism. The results suggest that the clinical diagnosis of toxic nodular goiter, nodular lesions of diameter > 10 mm and a histological type compatible with a follicular carcinoma, are factors that on their own increase the risk of making the diagnosis of cancer from a hot nodule.

Malignancy risk of hyperfunctioning thyroid nodules compared with non-toxic nodules: systematic review and a meta-analysis

Background

Hyperfunctioning or hot nodules are thought to be rarely malignant. As such, current guidelines recommend that hot nodules be excluded from further malignancy risk stratification. The objective of this systematic review and meta-analysis is to compare the malignancy risk in hot nodules and non-toxic nodules in observational studies.

Methods

Ovid MEDLINE Daily and Ovid MEDLINE, EMBASE, Scopus, and Web of Science databases were searched. Observational studies which met all of the following were included: (1) use thyroid scintigraphy for nodule assessment, (2) inclusion of both hyperfunctioning and non-functioning nodules based on scintigraphy, (3) available postoperative histopathologic nodule results, (4) published up to November 12, 2020 in either English or French. The following data was extracted: malignancy outcomes include malignancy rate, mapping of the carcinoma within the hot nodule, inclusion of microcarcinomas, and presence of gene mutations.

Results

Among the seven included studies, overall incidence of malignancy in all hot thyroid nodules ranged from 5 to 100% in comparison with non-toxic nodules, 3.8–46%. Odds of malignancy were also compared between hot and non-toxic thyroid nodules, separated into solitary nodules, multiple nodules and combination of the two. Pooled odds ratio (OR) of solitary thyroid nodules revealed a single hot nodule OR of 0.38 (95% confidence interval (CI) 0.25, 0.59), toxic multinodular goiter OR of 0.51 (95% CI 0.34, 0.75), and a combined hot nodule OR of 0.45 (95% CI 0.31, 0.65). The odds of malignancy are reduced by 55% in hot nodules; however, the incidence was not zero.

Conclusions

Odds of malignancy of hot nodules is reduced compared with non-toxic nodules; however, the incidence of malignancy reported in hot nodules was higher than expected. These findings highlight the need for further studies into the malignancy risk of hot nodules.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13044-021-00094-1.

Prevalence of hyperfunctioning thyroid nodules among those in need of fine needle aspiration cytology according to ATA 2015, EU-TIRADS, and ACR-TIRADS

PURPOSE

Given the large number of patients with thyroid nodules, improvement of the specificity of current ultrasound-based thyroid nodule classification systems (ATA, EU-TIRADS, and ACR-TIRADS) is warranted to reduce the number of diagnostic thyroidectomies. Thyroid scintigraphy has been shown to demonstrate hyperfunctional nodules, associated with a low malignancy risk, in euthyroid patients. However, it is not known if thyroid scintigraphy could improve specificity of current classification systems. The aim of this study, therefore, was to determine the frequency of hyperfunctional nodules among those nodules in need of fine needle aspiration cytology (FNA) according to current classification systems and to test if nodule functional status is associated with sonographic features.

METHODS

Five hundred sixty-six euthyroid patients (TSH 0.55-4.20 μU/ml) presenting for thyroid nodule workup including thyroid sonography and scintigraphy at our department between 09/2013 and 02/2018 were included in this retrospective study. All nodules > 10 mm were classified according to ATA, EU-TIRADS, and ACR-TIRADS and correlated to their functional status as assessed by 99mTc-pertechnetate scintigraphy.

RESULTS

Ultrasound detected 1029 thyroid nodules ≥ 10 mm, including 545 nodules ≥ 15 mm. Prevalence of hyperfunctional nodules among those with recommendation for FNA according to ATA 2015, EU-TIRADS, and ACR-TIRADS was 6.4%, 6.9%, and 6.5% for nodules ≥ 10 mm and 7.2%, 7.6%, and 7.5% only considering nodules ≥ 15 mm. No sonographic feature was correlated to hyperfunctionality of nodules.

CONCLUSION

In euthyroid patients, thyroid scintigraphy demonstrates hyperfunctionality, which cannot be predicted by ultrasound, in up to 6.9% of nodules in need of FNA according to ultrasound-based classifications. Given the known low risk of malignancy in hyperfunctional nodules, thyroid scintigraphy can lower the frequency of fine needle aspirations and-potentially-the frequency of diagnostic hemithyroidectomies in euthyroid patients.

Hyperfunctioning thyroid carcinoma: A systematic review

Hyperthyroidism may be caused by the development of primary or metastatic thyroid carcinoma. The aim of the present study was to collect recently reported cases of hyperfunctioning thyroid carcinoma in order to analyze its pathological characteristics, diagnostic procedures and treatment strategies. A PubMed (https://www.ncbi.nlm.nih.gov/pubmed/) search was performed for studies published between January 1990 and July 2017. Full-text articles were identified using the terms, ‘hyperfunctioning thyroid carcinoma/cancer’, ‘malignant hot/toxic thyroid nodule’, or ‘hyperfunctioning papillary/follicular/Hürthle thyroid carcinoma’. Original research papers, case reports and review articles were included. Among all thyroid carcinoma cases included in the present study, the prevalence of follicular thyroid carcinoma (FTC) was ~10%; however, the prevalence of FTC among hyperfunctioning thyroid carcinomas was markedly higher (46.5% in primary and 71.4% in metastatic disease). The size of hyperfunctioning thyroid tumors was considerably larger compared with that of non-hyperfunctioning thyroid tumors, with a mean size of 4.25±2.12 cm in primary hyperfunctioning thyroid carcinomas. In addition, in cases of metastatic hyperfunctioning thyroid carcinoma, tumor metastases were widespread or large in size. The diagnosis of primary hyperfunctioning thyroid carcinoma is based on the following criteria: i) No improvement in thyrotoxicosis following radioactive iodine (RAI) treatment; ii) development of hypoechoic solid nodules with microcalcifications on ultrasound examination; iii) increase in tumor size over a short time period; iv) fixation of the tumor to adjacent structures; and v) signs/symptoms of tumor invasion. The diagnosis of metastatic hyperfunctioning thyroid carcinoma should be considered in patients suffering from thyrotoxicosis who present with a high number of metastatic lesions (as determined by whole-body scanning), or a history of total thyroidectomy. Surgery is the first-line treatment option for patients with primary hyperfunctioning thyroid carcinoma, as it does not only confirm the diagnosis following pathological examination, but also resolves thyrotoxicosis and is a curative cancer treatment. RAI is a suitable treatment option for patients with hyperfunctioning thyroid carcinoma who present with metastatic lesions.

A case report of hyperfunctioning metastatic thyroid cancer and rare I-131 avid liver metastasis

Thyroid cancer is usually, relatively hypofunctional; most patients with thyroid cancer are clinically euthyroid. The combination of thyroid cancer and thyrotoxicosis is not common. We herein, report a case of follicular thyroid cancer with hyperfunctioning metastasis in a 43-year-old woman who presented with thyrotoxicosis, a cold right thyroid nodule, and low I-131 uptake at the thyroid bed. An additional total body scan with I-131 revealed a large radioiodine avid osteolytic bone metastasis with soft tissue masses and liver metastasis. The patient received treatment with total thyroidectomy, methimazole, and I-131 at a cumulative dose of 600 mCi along with recombinant human thyroid-stimulating hormone before the first I-131 treatment and palliative radiation. The patient had normal liver function test and experienced a mild degree of bone marrow suppression after I-131. At the 2-year follow-up, the patient was still alive with the progression of bone metastases but was doing well with less severe thyrotoxicosis, good ambulation, and an Eastern Cooperative Oncology Group performance status of 2. Clinicians should be aware of the unusual concurrent presentation of thyrotoxicosis and thyroid cancer, a differential diagnosis in patients with thyrotoxicosis and low or normal radioiodine uptake over the neck and also potential pitfalls during radionuclide treatment.

Anaplastic carcinoma and toxic multinodular goiter: an unusual presentation

A 70-year-old male was referred with hyperthyroidism and multinodular goiter (MNG). Thyroid ultrasonography showed 2 nodules, one in the isthmus and the other in the left lobe, 51 and 38 mm in diameter, respectively. Neck CT showed a large MNG, thyroid scintigraphy showed increased uptake in the nodule in the left lobe, and fine-needle aspiration biopsy showed a benign cytology of the nodule in the isthmus. The patient declined surgery and was treated with methimazole. After being lost to follow-up for 3 years, the patient returned with complaints of dyspnea, dysphagia, and hoarseness; he was still hyperthyroid. Cervical CT showed a large mass in the isthmus and left lobe with invasion of surrounding tissues, the trachea, the esophagus, and the recurrent laryngeal nerve. Bronchoscopy showed extensive infiltration and compression of the trachea to 20% of its caliber. A tracheal biopsy revealed an anaplastic thyroid carcinoma. The tumor was considered unresectable, and radiotherapy was given. One month later, the patient died. The association between a toxic thyroid nodule and anaplastic thyroid carcinoma has apparently not been reported so far.

Hyperfunction thyroid nodules: their risk for becoming or being associated with thyroid cancers

OBJECTIVE

To retrospectively evaluate the risk of thyroid cancer in patients with hyperfunctioning thyroid nodules through ultrasonographic-pathologic analysis.

MATERIALS AND METHODS

Institutional review board approval was obtained and informed consent was waived. From 2003 to 2007, 107 patients consecutively presented with hot spots on thyroid scans and low serum thyroid-stimulating hormone levels. Among them, 32 patients who had undergone thyroid ultrasonography were analyzed in this study. Thyroid nodules depicted on ultrasonography were classified based on size and categorized as benign, indeterminate, or suspicious malignant nodules according to ultrasonographic findings. The thyroid nodules were determined as either hyperfunctioning or coexisting nodules and were then correlated with pathologic results.

RESULTS

In 32 patients, 42 hyperfunctioning nodules (mean number per patient, 1.31; range, 1-6) were observed on thyroid scans and 68 coexisting nodules (mean, 2.13; range, 0-7) were observed on ultrasonography. Twenty-five patients (78.1%) had at least one hyperfunctioning (n = 17, 53.1%) or coexisting (n = 16, 50.0%) nodule that showed a suspicious malignant feature larger than 5 mm (n = 8, 25.0%), or an indeterminate feature 1 cm or greater (n = 20, 62.5%) in diameter, which could have been indicated by using fine needle aspiration (FNA). Seven patients were proven to have 11 thyroid cancers in 3 hyperfunctioning and 8 coexisting nodules. All of these had at least one thyroid cancer, which could have been indicated by using FNA. The estimated minimal risk of thyroid cancer was 6.5% (7/107).

CONCLUSION

Patients with hyperfunctioning nodules may not be safe from thyroid cancer because hyperfunctioning nodules can coexist with thyroid cancer nodules. To screen out these cancers, ultrasonography should be performed.

A Case of simultaneous occurrence of Marine - Lenhart syndrome and a papillary thyroid microcarcinoma

BACKGROUND

Marine-Lenhart syndrome is defined as the co-occurrence of Graves' disease and functional nodules. The vast majority of autonomous adenomas are benign, whereas functional thyroid carcinomas are considered to be rare. Here, we describe a case of simultaneous occurrence of Marine-Lenhart syndrome and a papillary microcarcinoma embedded in a functional nodule.

CASE PRESENTATION

A 55 year-old, caucasian man presented with overt hyperthyroidism (thyrotropin (TSH) <0.01 μIU/L; free thyroxine (FT4) 3.03 ng/dL), negative thyroid peroxidase and thyroglobulin autoantibodies, but elevated thyroid stimulating hormone receptor antibodies (TSH-RAb 2.6 IU/L). Ultrasound showed a highly vascularized hypoechoic nodule (1.1 × 0.9 × 2 cm) in the right lobe, which projected onto a hot area detected in the 99mtechnetium thyroid nuclear scan. Overall uptake was increased (4.29%), while the left lobe showed lower tracer uptake with no visible background-activity, supporting the notion that both Graves' disease and a toxic adenoma were present. After normal thyroid function was reinstalled with methimazole, the patient underwent thyroidectomy. Histological work up revealed a unifocal papillary microcarcinoma (9 mm, pT1a, R0), positively tested for the BRAF V600E mutation, embedded into the hyperfunctional nodular goiter.

CONCLUSIONS

Neither the finding of an autonomously functioning thyroid nodule nor the presence of Graves' disease rule out papillary thyroid carcinoma.

A solitary hyperfunctioning thyroid nodule harboring thyroid carcinoma: review of the literature

Hyperfunctioning nodules of the thyroid are thought to only rarely harbor thyroid cancer, and thus are infrequently biopsied. Here, we present the case of a patient with a hyperfunctioning thyroid nodule harboring thyroid carcinoma and, using MEDLINE literature searches, set out to determine the prevalence of and characteristics of malignant “hot” nodules as a group. Historical, biochemical and radiologic characteristics of the case subjects and their nodules were compared to those in cases of benign hyperfunctioning nodules. A literature review of surgical patients with solitary hyperfunctioning thyroid nodules managed by thyroid resection revealed an estimated 3.1% prevalence of malignancy. A separate literature search uncovered 76 cases of reported malignant hot thyroid nodules, besides the present case. Of these, 78% were female and mean age at time of diagnosis was 47 years. Mean nodule size was 4.13 ± 1.68 cm. Laboratory assessment revealed T₃ elevation in 76.5%, T₄ elevation in 51.9%, and subclinical hyperthyroidism in 13% of patients. Histological diagnosis was papillary thyroid carcinoma (PTC) in 57.1%, follicular thyroid carcinoma (FTC) in 36.4%, and Hurthle cell carcinoma in 7.8% of patients. Thus, hot thyroid nodules harbor a low but non-trivial rate of malignancy. Compared to individuals with benign hyperfunctioning thyroid nodules, those with malignant hyperfunctioning nodules are younger and more predominantly female. Also, FTC and Hurthle cell carcinoma are found more frequently in hot nodules than in general. We were unable to find any specific characteristics that could be used to distinguish between malignant and benign hot nodules.

Papillary carcinoma masquerading as clinically toxic adenoma in very young children

BACKGROUND

Autonomously functioning thyroid nodules (AFTN) are extremely rare in children. Malignancy may be rarely found in hyperfunctioning 'hot' nodules in adults. However, there are limited reports of AFTNs in young children presenting as or developing malignancy in future. We report here two young children aged < 6 years old at the time of diagnosis as having an AFTN, which eventually turned out to be papillary carcinoma of thyroid (PTC) on follow-up.

PATIENT FINDINGS

A 2-month-old baby had a right-sided neck swelling since birth. On examination, the baby had clinical and biochemical features of thyrotoxicosis. On sonography, and subsequently on 99mTc-pertechnetate thyroid scan, a hot nodule was found. Patient was treated with carbimazole for 5 years. In spite of euthyroidism achieved, the nodule continuously grew in size. Thyroid cytology was inconclusive, hence hemithyroidectomy was performed and histopathology turned out to be PTC. Another 5-year-old female child had a large right-sided AFTN on thyroid scan. She was treated with radioiodine; however, like the previous case, the nodule started growing in size. She subsequently underwent near total thyroidectomy and histology was reported as PTC.

CONCLUSION

In the light of this report that shows that solitary hyperfunctioning nodules in very young children have high chance of malignancy, we recommend hemithyroidectomy as the treatment of choice.

Preoperative Tc-99m-pertechnetate scan visualization of gross neck metastases from microcarcinoma papillare and another papillary carcinoma of tall cell variant scintigraphically presented like small warm nodule in Graves disease patient

PURPOSE

Preoperative scintigraphic visualization of metastases from well-differentiated thyroid microcarcinoma in patients with Graves disease is extremely rare, as is the scintigraphic visualization of poorly differentiated thyroid carcinoma as a warm nodule. We present a patient with Graves disease and both of these rare entities.

CASE REPORT

A 47-year-old woman complained of a growing left-side neck mass and symptoms of thyrotoxicosis. On clinical examination, the thyroid was palpable without discernible nodularity, while the left side of the neck was occupied by 3 gross, painless nodules. She also had signs of thyrotoxicosis and biochemical parameters of Graves hyperthyroidism. Ultrasound examination showed moderately hypoechogenic thyroid with a small hypoechogenic nodule in the upper pole of the left lobe and 3 gross, almost normoechogenic nodules on the left side of the neck. On Tc-99m-pertechnetate pinhole scintigraphy there was a small, warm nodule in the upper pole of the left lobe and 3 gross metastatic nodules on the left side of the neck. Fine needle aspiration of the neck nodules was consistent with metastases from thyroid papillary carcinoma. After thyrostatic preparation a total thyroidectomy with left modified radical neck dissection was done.

RESULTS AND CONCLUSION

Histopathologic examination disclosed 2 carcinomas in the left thyroid lobe. One of them was a tall cell variant of papillary carcinoma in the upper pole of the left lobe that measured 5 mm and corresponded to the small warm nodule, and the second one was a classic form of papillary microcarcinoma that measured 2 mm. Metastases accrued from the classic form of papillary microcarcinoma. Although the patient had 2 thyroid carcinomas, one with metastases and the other of more aggressive form, which is consistent with advanced stage and aggressiveness, she is now disease-free, 4 years after the operation and radioiodine ablation.

Papillary thyroid carcinoma in an autonomous hyperfunctioning thyroid nodule: case report and review of the literature

BACKGROUND

Whereas thyroid nodules are less common among children than among adults, the anxiety generated by the finding of a thyroid nodule is high because 20% of nodules found in children contain thyroid cancer. Discovery of a nodule in the context of hyperthyroidism is usually comforting due to the presumption that the nodule represents a benign toxic adenoma.

SUMMARY

An 11-year-old girl presented with heavy menses, fatigue, and a right thyroid mass. Laboratory evaluation revealed elevated triiodothyronine and undetectable thyroid-stimulating hormone. Thyroid ultrasonography revealed a 3.5 cm nonhomogenous nodule, and scintigraphy was consistent with an autonomous hyper-functioning nodule. Fine-needle aspiration biopsy could not rule out malignancy, and patient underwent right hemithyroidectomy and isthmusectomy. Pathology was consistent with papillary thyroid carcinoma.

CONCLUSIONS

We report the discovery of papillary thyroid carcinoma in an autonomously hyperfunctioning nodule in an 11-year-old girl. Detection of an autonomously functioning thyroid nodule in children and adolescents does not exclude the possibility of thyroid carcinoma and warrants careful evaluation and appropriate therapy.

Autonomously functioning thyroid nodule treated with radioactive iodine and later diagnosed as papillary thyroid cancer

The malignancy risk is low in hot thyroid nodules verified by scintigraphy. We present a rare case of papillary carcinoma, initially treated as an autonomous hot nodule. Case report. A 36-year old male patient with a hot thyroid nodule and subclinical hyperthyroidism was treated with 10mCi 131 I. On admission, both 99mTc and 131 I thyroid scintigraphic imaging revealed a hot nodule at the right lobe accompanied by lower uptake in the remaining thyroid tissue. After treatment, there was a progressive increase in the nodule size; a fine needle aspiration biopsy was thus performed which showed findings compatible with papillary thyroid cancer. The patient was referred to our department for further management. Total thyroidectomy with right central neck dissection was performed. The pathologic examination showed that the whole nodule (1.5 cm diameter) was a columnary type papillary thyroid cancer.

CONCLUSION

In the case of a small-sized toxic thyroid nodule, the possibility of malignancy cannot be totally ruled out. Suspicious hot nodules should be cytologically evaluated before radioactive iodine treatment to determine the existing malignancy risk. Fine needle aspiration biopsy should be performed in all hot thyroid nodules that increase in size after radioactive iodine treatment.

Multifocal hyperfunctioning thyroid carcinoma without metastases

Hyperthyroidism due to thyroid carcinoma is rare, and most cases are caused by hyperfunctioning metastatic thyroid carcinoma rather than primary carcinoma. Among primary hyperfunctioning thyroid carcinoma, multifocal thyroid carcinoma is exceedingly rare, with the only one case being reported in the literature. Here, we describe the case of a 62-year-old woman with multifocal functioning thyroid carcinoma. Technetium-99m (99m Tc) scintigraphic imaging showed four hot areas in the thyroid gland. Histopathological examination of all four nodules revealed papillary carcinoma, corresponding to hot areas in the 99m Tc scintigram. DNA sequencing of the thyrotropin receptor (TSH-R) gene from all nodules revealed no mutation, indicating that activation of TSH-R was unlikely in the pathophysiogenesis of hyperfunctioning thyroid carcinoma in the present case.

US Features of Thyroid Malignancy: Pearls and Pitfalls

Thyroid nodules are common and occur in up to 50% of the adult population; however, less than 7% of thyroid nodules are malignant. High-resolution ultrasonography (US) is commonly used to evaluate the thyroid gland, but US is frequently misperceived as unhelpful for identifying features that distinguish benign from malignant nodules. Microcalcifications are one of the most specific US findings of a thyroid malignancy. Other useful US features include a marked hypoechogenicity, irregular margins, and the absence of a hypoechoic halo around the nodule. Lymphadenopathy and local invasion of adjacent structures are highly specific features of thyroid malignancy but are less commonly seen. The number, size, and interval growth of nodules are nonspecific characteristics. Suspicious US features may be useful for selecting patients for fine-needle aspiration biopsy when incidental nodules are discovered and when multiple nodules are present. Common interpretative pitfalls that may lead to failure to recognize a malignancy include mistaking cystic or calcified nodal metastases for nodules in a multinodular thyroid, mistaking diffusely infiltrative thyroid carcinomas and multifocal carcinomas for benign disease, and failing to recognize microcalcifications in papillary thyroid cancer.

Anaplastic thyroid carcinoma associated with Graves' disease

This report concerns a 79-year-old woman with coexisting anaplastic thyroid carcinoma (ATC) and Graves' disease (GD). The patient was referred to our clinic because of palpitation and a palpable mass on the left side of her neck. Thyroid function tests showed hyperthyroidism with elevated thyroid-stimulating antibodies. Ultrasonography of the thyroid demonstrated an adenomatous nodule-like marcated nodule (27.6 x 26.5 x 36.4 mm) with cystic degeneration inside the left lobe. (123)I thyroid scintigraphic imaging showed a cold area corresponding to the nodule with continuous uptake in the remaining thyroid tissue despite suppressed TSH levels. These findings led to a diagnosis of GD. On the other hand, the thyroid nodule could not be definitely diagnosed even after fine needle aspiration biopsy (FNAB) which produced findings suggestive of both papillary thyroid carcinoma and ATC. Open biopsy of the nodule showed an ATC. Regional lymph node metastases as well as multiple lung metastases, which could not be found at the initial visit, had been already developed by that time. Our case is pathophysiologically interesting because it suggests that GD or thyroid-stimulating antibodies (TSAb) may stimulate malignant transformation of differentiated carcinoma. It is also clinically important because it indicates that all thyroid nodules, particularly palpable cold nodules, associated with GD require careful management to detect malignancy because they are at higher risk of harboring malignancy.