Rare Presentation of Papillary Thyroid Cancer
Mahfujul Z. Haque, BS1
Michael Burcescu, MD2
Zirak Sajjad, BS1
1Michigan State University College of Human Medicine,
Grand Rapids, MI, USA
2Detroit Medical Center, Detroit, MI, USA
Word Count: 444
Table/Figure Count: 4
Reference Count: 4
Acknowledgements: N/A
Funding Sources: None
Conflicts of Interest: None
Consent Statement: N/A
Corresponding author:
Mahfujul Haque
15 Michigan St NE,
Grand Rapids, MI 49503
Email: haquema4@msu.edu
Written informed consent was obtained from the patient to publish this
report in accordance with the journal’s patient consent policy.
Key Words: papillary thyroid cancer, thyroid nodule, neoplasm, endocrine
cancer
Article Type: Case Image
The patient is a 51-year-old African American female with incidental
thyroid nodules identified on MRI of the cervical spine. Patient
describes a tender palpable right thyroid nodule but is otherwise
asymptomatic. There is no history of tobacco use or toxic occupational
exposure. There is no palpable neck mass. Thyroid panel was within
normal limits. The majority of parathyroid adenomas are located adjacent
and posterior or just inferior to the thyroid gland. Rarely, an
intrathyroidal ectopic parathyroid gland may become adenomatous and
mimic thyroid nodule. When it does, it is usually homogenously
hypoechoic to thyroid tissue and may demonstrate a peripheral rim of
hyper-vascularity. Here we describe the case of an incidental nodule
with irregular margins and punctate echogenic foci consistent with a
TI-RADS 5 nodule and suggestive of malignancy.
Fine needle aspiration biopsy of right upper thyroid nodule showed
moderately cellular with cohesive groups as sheets and singly scattered
cells exhibiting nuclear grooves, powdery chromatin, irregular nuclear
outlines. A few intranuclear pseudo-inclusions are seen with some
colloids in the background. True papillae, psammoma bodies, and necrosis
were not detectable despite sampling with 3 adequate passes.
Figure 1A is an axial T1 that demonstrates an unexpected nodule
of the right thyroid lobe after gadolinium administration.Figure 1B demonstrates the same nodule with a traditional T1
view. Figure 1C demonstrates a T2 hyper intensive nodularity of
the right thyroid lobe. Figure 2A demonstrates a long-axis
ultrasound image of the right thyroid lobe revealed a 1.5 x 1.0 x 1.3 cm
hypoechoic solid nodule with irregular margins, punctate echogenic foci,
and mildly increased vascularity on color Doppler investigation.Figure 2B demonstrates a transverse ultrasound image of the
right thyroid lobe showed a 1.5 x 1.0 x 1.3 cm hypoechoic solid nodule
with irregular margins and punctate echogenic foci. Figure 3Ademonstrates a longitudinal-axis ultrasound image of the right thyroid
lobe with a slight enlargement of the nodule, measuring 1.5 x 1.2 x 1.3
cm, with hypoechoic wider than tall features, irregular margins, and
punctate echogenic foci, which are consistent with the previous
sonographic evaluation. Figure 3B demonstrates a
longitudinal-axis color Doppler image of the right thyroid lobe reveals
increased vascularity within the thyroid nodule, indicating heightened
blood flow to the nodule. Figure 4A demonstrates a
Longitudinal-axis ultrasound image of the right thyroid lobe with
further nodule enlargement to 1.9 x 1.3 x 0.9 cm.
Studies report that 5-15% of all detected thyroid nodules and up to
11% of incidental thyroid nodules, represent malignancy [2]. The
SEER database reports the USA incidence of thyroid carcinoma to be 14.9
per 100,000 with a 1:2.8 male to female predilection [3]. Papillary
thyroid cancer (PTC), a common endocrine tumor originating from thyroid
follicular cells, represents 85% of thyroid malignancy [1]. PTC is
invasive and known to metastasize to adjacent structures including:
lungs, mediastinal lymph nodes, and bone. Well-established risk factors
for thyroid cancer include radiation exposure, family history of thyroid
cancer, occupational exposure, and obesity [1].
PTC is associated with favorable mortality of 11-17% and a low
recurrence rate of 5-15% [1][4]. Extra-thyroidal growth, larger
tumor size, and older age at diagnosis detrimentally impact outcome
[1]. The primary treatment for PTC is surgical. Preprocedural
considerations include tumor size, metastases, extra-thyroidal
extension, and airway compromise. Patients with unifocal PTC, measuring
> 4 cm, are candidates for thyroid lobectomy
[1][5]. For larger lesions, total or near-total thyroidectomy is
often required [1][5]. Ablation with radioactive iodine (RAI) is
recommended for patients with residual tumor or metastasis. Additional
considerations include patient age, microvascular invasion, and
histologic subtyping [1]. RAI is performed 4 - 6 weeks following
excision and repeated until residual radiotracer uptake is eliminated
[1]. Successful intervention results in decreased serum
thyroglobulin within 4 - 6 weeks. Thyroid hormone supplementation
reduces tumor stimulation by suppressing TSH production [1].
Sonographic and biochemical recurrence monitoring are typically
performed at 6-12 month intervals for at least 5 years.