Sonographic Evaluation of Intrathyroid Metastases

Case report: Thyroid metastasis from hepatocellular carcinoma: a rare case with diffuse solid occupancy and unusual imaging findings

Background

Thyroid metastasis represents a rare occurrence, with commonly observed primary tumors originating from renal cell carcinoma, malignant neoplasms of the gastrointestinal tract, lungs, and breast. However, the metastasis of hepatocellular carcinoma to the thyroid gland remains infrequent. Previous investigations have consistently demonstrated an unfavorable prognosis for patients with malignancies that have metastasized to the thyroid. In this context, we present a noteworthy case of thyroid metastasis from hepatocellular carcinoma (HCC), characterized by a distinct ultrasonographic manifestation of diffuse thyroid lesion, deviating from the previously documented imaging presentations of thyroid metastases in HCC.

Case presentation

A 62-year-old Chinese female patient was diagnosed with hepatocellular liver cancer in 2019, following which she underwent a radical hepatic resection. Pathological examination revealed HCC located in the right lobe (stage T3bN0M0 IIIB). No additional interventions were administered subsequent to the surgery. After a span of 15 months, the patient presented with dyspnea. Ultrasonographic findings showed diffuse solid infiltration within the thyroid gland, along with tumor thrombi in both internal jugular veins. Computed tomography (CT) scans demonstrated malignant thyroid lesions infiltrating the retropharyngeal space, prevertebral space, and esophageal wall. The subsequent pathology report from the puncture biopsy confirmed the malignant nature of the tumor, and immunohistochemical analysis definitively established its hepatic origin.

Conclusions

Patients with a history of HCC should be subjected to long-term monitoring and habitual thyroid ultrasonography. Newly detected thyroid nodules in such patients should be immediately regarded suspect for potential metastatic disease. Even when a nodule doesn't exhibit malignant characteristics on ultrasound, FNAB should be administered promptly to elucidate the pathological condition. Larger, swiftly multiplying thyroid masses should warrant an immediate CNB. The identification of thyroid metastases, particularly when coupled with peripheral tissue invasion, typically signifies a bleak prognosis.

To diagnose primary and secondary squamous cell carcinoma of the thyroid with ultrasound malignancy risk stratification

Objectives

This study aimed to investigate the clinico-ultrasound features of primary squamous cell carcinoma of the thyroid (PSCCT) and secondary SCCT (SSCCT) and evaluate the accuracy of fine needle aspiration (FNA) recommendation for SCCT with American College of Radiology-Thyroid Imaging and Reporting Data System (ACR-TIRADS) and Chinese-TIRADS (C-TIRADS).

Materials and methods

We retrieved 26 SCCT patients (11 PSCCT, 15 SSCCT) from our hospital's pathology database (5,718 patients with thyroid malignancy) over 23 years. Medical records and ultrasound data of the 26 patients with 27 SCCTs were analyzed retrospectively, and each SCCT focus was categorized based on the two TIRADSs.

Results

For 26 patients (21 males, 5 females) with an age range of 42-81 years, rapidly enlarging thyroid/neck nodules (18/26, 69.2%), dysphagia (7/26, 26.9%), hoarseness (6/26, 23.1%), dyspnea (5/26, 19.6%), cough (4/26, 15.4%), neck pain (2/26, 7.7%), B symptoms (2/26, 7.7%), and blood in sputum (1/26, 3.8%) were presented at diagnosis. Five asymptomatic patients (5/26, 19.2%) were detected by ultrasound. Hoarseness was more common in PSCCT (5/11, 45.5%) than in SSCCT (1/15, 6.7%) (P=0.032). For 27 SCCTs with a mean size of 3.7 ± 1.3 cm, the ultrasound features consisted of solid (25/27, 92.6%) or almost completely solid composition (2/27, 7.4%), hypoechoic (17/27, 63%) and very hypoechoic echogenicity (10/27, 37%), irregular/lobulated margin with extra-thyroidal extension (27/27, 100%), taller-than-wide shape (13/27, 48.1%), punctate echogenic foci (6/27, 22.2%), hypervascularity (23/27, 85.2%) and involved neck lymph (13/26, 50.0%). A total of 27 SCCTs were evaluated as high malignancy risk stratification (≥TR4 and 4B) by the two TIRADSs and recommended FNA in 96.3-100% (26/27, 27/27). Pathologically, more than half of PSCCTs (7/12, 58.3%) and a quarter of SSCCTs (4/15, 26.7%) were poorly differentiated, while moderately and well-differentiated grades were observed in 5 PSCCTs and 11 SSCCTs (P=0.007). Thirteen patients (50.0%) underwent surgery with radical operation in 5 cases (5/13, 38.5%).

Conclusion

SCCT is an extremely rare and aggressive malignancy with a male predominance. PSCCT and SSCCT had similar clinical and ultrasound features except for tumor differentiation and the symptom of hoarseness. SCCT showed a high malignancy risk stratification in ACR-TIRADS and C-TIRADS, with a high rate of FNA recommendation.

Thyroid Metastasis from Primary Breast Cancer

Breast cancer (BC), the most commonly diagnosed malignancy, frequently metastasizes to the bone, lungs, brain and liver at advanced stages, whereas the thyroid gland represents a rare target site for secondary disease. We examined the most recent literature about thyroid metastasis (TM) from BC after we encountered a peculiar case of a 71-year-old woman who developed sudden dysphagia, severe hypothyroidism and hypoparathyroidism due to TM 18 years after the diagnosis of her primary cancer. Based on published data, the prevalence of TM in BC ranges from 3% to 34%, with a median onset time of 48.2 months, although longer time intervals are not infrequent. TM negatively impacts the prognosis of these patients, however thyroid surgery can limit the local disease burden. Therefore, we suggest that clinicians involved in the follow-up care of BC patients should consider a differential diagnosis of secondary thyroid malignancy when incidental lesions are diagnosed during radiological evaluations or local symptoms affect the cervical region, even many years after the diagnosis of the primary cancer.

Ultrasonic Characterization of Primary Squamous Cell Carcinoma of the Thyroid

OBJECTIVES

To identify the ultrasonographic characteristics of primary squamous cell carcinoma of the thyroid (PSCCT), and to assess the value of the 2015 American Thyroid Association (ATA) guideline and 2017 American College of Radiology (ACR) Thyroid Imaging, Reporting and Data System (TI-RADS) in the evaluation of this disease.

METHODS

Eight patients with 9 PSCCTs over a 20-year study period were enrolled. Ultrasonic characteristics including nodule echogenicity, composition, shape, margin, calcification, size, vascularity, and cervical lymphadenopathy were reviewed. All nodules were then evaluated by 2017 ACR TI-RADS and 2015 ATA guidelines.

RESULTS

The average size of PSCCTs was 3.87 ± 1.41 cm. All PSCCTs were hypoechoic or very hypoechoic, solid nodules with intranodular vascularity. The average resistive index (RI) was 0.84 ± 0.18. Near half of PSCCTs (44.4%) demonstrated extrathyroidal extension. Taller-than-wide signs and cervical lymphadenopathy were observed in 33.3% of PSCCTs, and microcalcification was observed in 11.1% of them. All PSCCTs were classified as high suspicion patterns by 2015 ATA and recommended for fine-needle aspiration (FNA). Six PSCCTs (66.7%) were classified as grade 5 by 2017 ACR TI-RADS, while the remaining were grade 4. 88.9% of PSCCTs were recommended for FNA based on 2017 ACR TI-RADS.

CONCLUSION

PSCCT has certain ultrasonic features, including relatively large, hypoechoic, or very hypoechoic solid nodules with intranodular vascularity and extrathyroidal extension. Both 2015 ATA and 2017 ACR TI-RADS could identify PSCCT as suspicious for malignancy.

Metastases to the Thyroid Gland: What Can We Do?

Metastases to the thyroid gland arise from other malignant tumors such as renal cell carcinoma, colorectal cancer, lung cancer, and breast cancer. In clinical practice, the incidence is low, and the symptoms are not specific, so it is often missed and misdiagnosed. It is finally diagnosed via the comprehensive application of many diagnostic methods, such as ultrasound, fine-needle aspiration biopsy, and immunohistochemistry analysis. Surgery-based comprehensive treatment is often adopted, but because it is usually in the late stage of the primary tumor, the prognosis is poor. In order to better understand the related characteristics of thyroid metastatic cancer and then improve the clinical diagnosis and treatment and the prognosis of patients, in this paper, we systematically summarize the research status of thyroid metastatic cancer.

Occult breast cancer metastasis to the thyroid gland: Case report

Thyroid metastases of occult breast cancer are very rare. A 48‐year‐old female patient presented with chronic bone pain, bone, liver and thyroid nodules, and pleural effusion. Histopathological result of the thyroid showed poorly differentiated papillary thyroid carcinoma. However, clinical laboratory and immunohistochemistry studies showed breast origin of the thyroid lesion.

Any thyroid mass may be a secondary neoplasm and occult breast cancer should also be considered among the primary sources in spite of its rarity. Immunohistochemistry can play an important role in detecting the origin of malignancy.

Imaging of the Thyroid: Practical Approach

Imaging evaluation of the thyroid gland spans a plethora of modalities, including ultrasound imaging, cross-sectional studies, and nuclear medicine techniques. The overlapping of clinical and imaging findings of benign and malignant thyroid disease can make interpretation a complex undertaking. We aim to review and simplify the vast current literature and provide a practical approach to the imaging of thyroid disease for application in daily practice. Our approach highlights the keys to differentiating and diagnosing common benign and malignant disease affecting the thyroid gland.

Intrathyroid metastasis of breast cancer: Sonographic findings

Metastasis of ductal carcinoma of the breast to the thyroid gland is uncommon and usually detected at autopsy. The incidences of metastases to the thyroid have been reported at 3%, and the most common primary malignancy is renal cell carcinoma. We report a rare case of intrathyroid metastatsis of breast ductal carcinoma in a patient who was treated for breast cancer 15 years earlier.

Ultrasonography of Extrathyroidal Diseases Mimicking Intrinsic Thyroid Lesions

Some localized or multisystem diseases as well as congenital anomalies occasionally involve thyroid and unusual findings will be identified during thyroid ultrasonography. Recognition of these entities will minimize unnecessary complementary examination and lead to appropriate management for patients. Therefore, we aim to review sonographic features of these extrathyroidal diseases that affect thyroid in adults. Our review derives from cases diagnosed in our hospital and published literature, with pictures accessible using as illustration. These disorders included intrathyroidal parathyroid adenoma, intrathyroidal cystic findings of nonthyroid origin, metastases to the thyroid, esophageal diverticulum, paratracheal air cysts, and ossification of anterior longitudinal ligament.