Skin metastasis on the neck: an unusual presentation of recurrence of papillary thyroid carcinoma

Skin metastasis of papillary thyroid carcinoma: A case report and literature review

The present study reports a rare case of skin metastasis in a 26-year-old female patient with a history of PTC positive for the BRAF V600E mutation. During the 2.5-year follow-up period after the initial surgical treatment of PTC, no evidence of distant metastasis was found via thyroglobulin measurements, neck ultrasound, or neck and chest computed tomography. However, following this period, the patient reported two skin nodules on the left side of the neck. Ultrasound-guided punch biopsy was performed, and the pathology results demonstrated that the patient had skin metastases from the PTC. The patient received surgical resection and complete removal of nodules, and was subsequently discharged from the hospital. A literature review showed that there are numerous potential mechanisms for skin metastasis, and the treatments are diverse and dependent on the patient condition. While surgical treatment may effectively improve patient symptoms and prognosis, long-term surveillance for recurrence is recommended for high-risk cases. Skin metastasis of PTC should be suspected in patients who develop an upper body skin lesion with a history of PTC, even without evidence of disease metastasis. For high-risk patients with skin metastasis of PTC with BRAF and TERT gene mutations, long-term surveillance for recurrence should be recommended in cases with a poor prognosis, and further research of these cases should be conducted in the future to optimize surgical and medical care.

Preliminary Report Examining Efficacy and Safety of Radiofrequency Ablation for the Treatment of Skin-Involving Recurrent Thyroid Cancer

Background: This study assessed the efficacy and safety of ultrasound (US)-guided radiofrequency ablation (RFA) for treatment of skin-involving recurrent thyroid cancer. Methods: In this retrospective case series study, 43 patients (mean age: 67.9 ± 14.4 years; 31 females) with skin-involving recurrent thyroid cancer were treated with RFA for a total of 50 tumors between May 2008 and March 2023. The location of the tumor was classified into epidermis, dermis, or hypodermis on the basis of the involved skin layer. After RFA, the technique efficacy (absence of detectable vasculature and volume reduction at 12 months), clinical success (resolution of symptoms or cosmetic problems), volume reduction ratio (VRR), complete disappearance of tumor, and complications were assessed. Results: Of the 50 recurrent tumors, 9 involved the epidermis, 10 involved the dermis, and 31 involved the hypodermis. A total of 88 RFA sessions (mean, 1.8; range: 1-6) were performed. The technique efficacy at 1 year was 72% (36/50 [confidence interval or CI: 59.6-84.4%]). At the last follow-up (median [interquartile range]: 2.7 [1.1-4.5] years), the clinical success rate was 86% (44/50), the complete disappearance rate 54% (27/50), and the mean VRR 77.3% ± 44.2%. In a subgroup analysis comparing epidermis/dermis vs. hypodermis, there was no statistical difference in technique efficacy (57.9% [11/19] vs. 80.6% [25/31], p = 0.085), clinical success rate (78.9% [15/19] vs. 90.3% [28/31], p = 0.265), complete disappearance rate (42.1% [8/19] vs. 51.6% [16/31], p = 0.541), or mean VRR (65.5% vs. 84.6%, p = 0.141). Skin burns were observed in 4.9% per treatment session (2/41 [CI: 0-11.3%]) of epidermis/dermis-involving tumor procedures and none of the hypodermal tumor procedures. No patients experienced life-threatening or major complications. Conclusions: RFA might serve as a promising approach for managing skin-involving recurrent thyroid cancer, with no major complications reported in this preliminary study. Recurrent tumors involving the epidermis/dermis may pose a higher risk of skin burns than tumors involving the hypodermis. Early intervention with RFA before the tumor extends to the epidermis/dermis may thus be preferable.

BRAFV600E and TERT promoter C228T mutations on ThyroSeq v3 analysis of delayed skin metastasis from papillary thyroid cancer: a case report and literature review

BACKGROUND

Skin metastasis from papillary thyroid cancer (PTC) is a rare entity that can occur up to decades after treatment of the primary tumor. Here, we present a patient who developed skin metastasis 10 years after treatment of her primary tumor and describe the molecular findings of the metastatic lesion.

CASE PRESENTATION

A 44-year-old female with a history of PTC who underwent a total thyroidectomy and radioactive iodine (RAI) treatment 10 years ago presented with a 1.3-cm skin lesion along the prior thyroidectomy scar. A biopsy revealed metastatic PTC, and the patient underwent surgical excision of the lesion. ThyroSeq molecular testing showed the copresence of BRAF^V600E mutation and TERT promoter C228T mutation. The patient subsequently received one round of adjuvant RAI therapy.

CONCLUSIONS

A high index of suspicion is warranted in patients with a history of PTC who develop a skin lesion, even several years after remission of the primary disease. In patients with high-risk mutations, such as BRAF^V600E and TERT promoter C228T mutations, long-term surveillance of disease recurrence is particularly important.

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.

Skin Metastasis Occurring 30 Years After Thyroidectomy for Papillary Thyroid Carcinoma

The skin is an extremely rare site of metastasis from papillary thyroid carcinoma (PTC) and is linked to underlying disseminated malignancy, which reflects a dismal prognosis. We present the case of a 70-years-old Saudi female who presented at our clinic with an eight-month history of two painful and itchy skin nodules over the scalp and the medial aspect of the right arm. She had a history of total thyroidectomy for PTC 30 years prior. Computed tomography-positron emission tomography showed multiple fluorodeoxyglucose avid lung and skeletal metastases. This case highlights the fact that skin nodules in a patient with a history of PTC should be assessed carefully with a high suspicion of skin metastasis to avoid any delay in treatment.

Radiofrequency ablation of recurrent thyroid cancers: anatomy-based management

Although differentiated thyroid cancer has an excellent prognosis and low mortality, its recurrence rate has been reported to be very high. While surgery is recommended as the standard treatment for recurrent thyroid cancer, reoperation may increase the incidence of complications due to fibrosis and anatomical distortion. In patients with high surgical risk or those who refuse repeated surgery, ultrasonography-guided ablation techniques including radiofrequency ablation, ethanol ablation, and laser ablation are suggested as alternative treatments. In this manuscript, we introduce an anatomy-based management concept for radiofrequency ablation for recurrent thyroid cancer, and present a review of the relevant literature, including indications, basic techniques, clinical outcomes, and complications.

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.

Follicular Thyroid Carcinoma Metastases on Round Ligament of Liver

ABSTRACT

We describe a case of a 69-year-old woman with follicular thyroid cancer of long evolution, with thyroidectomy 20 years before, who had remained clinically stable until now, when she started to present abnormal levels of serum thyroglobulin. An 123I whole-body scan showed a high uptake in the upper right half of her abdomen, and an 18F-FDG PET/CT located this focus at the liver's round ligament. Pathology findings after surgery showed the focus to be a differentiated thyroid cancer metastasis. This is an unusual presentation of differentiated thyroid cancer metastasis.

Cutaneous thyroid carcinoma sixteen years after benign total thyroidectomy: a unique case

BACKGROUND

Cutaneous metastasis of papillary thyroid carcinoma is rare and is a hallmark of a locally aggressive tumor.

CASE REPORT

We present a unique case of cutaneous thyroid carcinoma sixteen years after total thyroidectomy for multi-nodular goiter. The tumor originated from the upper anterior thoracic wall's skin and was found to invade the rostral half of the sternum's external periosteum and the caudal part of the right sternocleidomastoid muscle. Wide local excision of the neoplasm was performed with macroscopically free margins and right selective neck dissection (lymph node levels IV and V). The skin deficit was reconstructed with a right pectoralis major island flap. The histopathologic findings displayed a papillary thyroid carcinoma with Hürthle cell predominance and microscopically positive margins at the excised portion of the sternocleidomastoid muscle. The patient was placed on close follow-up, and nine months postop, there are no clinical signs of recurrence.

CONCLUSION

To our knowledge, this is the first case of cutaneous thyroid carcinoma following benign thyroidectomy. A possible mechanism for this incidence is the malignant transformation of benign thyroid cells inoculated into the skin. Dissecting along the fascial planes during thyroidectomy and preserving the thyroid capsule establishes a clean surgical field and minimizes the chance of inoculation of thyroid cells into the adjacent structures. Close follow-up and a high level of suspicion for skin lesions in patients with thyroid disease are warranted in all cases. HIPPOKRATIA 2020, 24(2): 88-90.

Bioinformatics analysis suggests that COL4A1 may play an important role in gastric carcinoma recurrence

OBJECTIVE

Cancer recurrence is a complicated problem for clinicians that contributes to poor prognosis. This study aimed to use advanced gastric carcinoma genes profiles to predict increased risk of cancer recurrence in order to identify patients in need of adjuvant therapy for prognosis improvement.

METHODS

Differentially expressed genes were identified for advanced gastric carcinoma by analyzing the GSE2685 from the Gene Expression Omnibus database (GEO) using R package. The candidate genes were then obtained by gene ontology (GO), Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway, protein-protein interaction analysis and survival analysis. Logistic regression analysis was performed to determine the relationship between candidate genes and the recurrence of gastric carcinoma.

RESULTS

Collagen type IV alpha 1 (COL4A1) was overexpressed in gastric carcinoma tissue by analyzing the GSE2685 gene expression profiles from the Gene Expression Omnibus database. COL4A1 was also overexpressed in gastric carcinoma tissue from the Cancer Genome Atlas dataset and further determined that higher COL4A1 expression led to poorer overall survival. A univariate analysis suggested that COL4A1 was strongly correlated with T stage and gastric carcinoma recurrence (P = 0.014 and 0.041, respectively). Moreover, a multiple logistic regression analysis indicated that COL4A1 was significantly associated with gastric carcinoma recurrence (hazard ratio 1.605, 95% confidence interval 1.063-2.677, P = 0.008).

CONCLUSIONS

COL4A1 may promote gastric carcinoma recurrence and could be used as a therapeutic target for gastric carcinoma recurrence.

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.