Singhal N; Chaturvedi P; Joshi P; Malik A

Case Report

Austin J Clin Case Rep. 2015;2(1): 1065.

Axillary Lymph Node Metastases in Differentiated Thyroid Cancer “An Uncommon Presentation with Clinical Implications”

Singhal N¹*, Chaturvedi P², Joshi P³ and Malik A⁴

¹Surgical Oncology Resident, Tata Memorial Hospital, India

²Department of Head and Neck Surgery, Tata Memorial Hospital, India

*Corresponding author: Singhal N, Mch Surgical Oncology Resident, Tata Memorial Hospital, Mumbai, India

Received: January 05, 2015; Accepted: March 23, 2015; Published: March 30, 2015

Abstract

Differentiated thyroid cancers usually follow an indolent course and in general have a good prognosis. Distant metastases at presentation are not common and if present usually involve the lung, bones and brain. Among the various sites reported axillary lymph node is one of the most uncommon sites. Only 13 cases have been reported in literature so far. Here we report two more cases, including the youngest patient reported till date.

Introduction

Differentiated thyroid cancers constitute more than 90 % of the total thyroid cancers and they usually follow an indolent course with excellent prognosis and long term survival. However a small subset of patients present with advanced stage with distant metastases. Incidence of distant metastases at the time of diagnosis is reported to be less than 2% [1]. The common sites of distant metastases are lung and bones with brain, kidney and skin being the other less common sites. Among all the sites of distant metastases reported axillary lymph node is one of the rare sites. Only 13 cases have been reported in literature so far. Here we report two more cases, including the youngest patient reported till date.

Case 1

19 year old female presented in the outpatient clinic with the history of left neck swelling for 4 years and left axillary swelling since 6 months. She had no other significant complaints or family history. On examination there was a left thyroid lobe swelling 4.5 x 3.5 cm with multiple left level II, III, IV and bilateral supraclavicular lymph nodes, largest of which was 5x5 cm along with a left axillary lymph node mass. She was investigated and underwent a USG guided FNAC of thyroid swelling which was diagnostic of papillary thyroid cancer. Ultrasound of breast revealed only left axillary lymph nodal mass of 4.2x3.8 cm, FNAC of which was consistent with metastases from papillary carcinoma of thyroid. As she presented with bulky cervical nodes, a CT scan was done which showed enlarged mediastinal nodes, multiple sub centimeter nodules in both lungs and multiple enlarged lymph nodes in bilateral supraclavicular and left axillary region all of which showed uptake on the PET scan. She underwent total thyroidectomy with bilateral Selective Neck Dissection (SND II-V) with mediastinal node clearance and left axillary lymph node dissection (level I-II) (Figures 1a,1b &1c).

Figure 1 (a) : Photo of FNAC of thyroid: High power view showing consistent nuclear features &nuclear groove.

    
    
    Figure(a):   Photo of FNAC of thyroid: High power view showing consistent
nuclear features &nuclear groove.

Figure 1(b): CT scan: Showing extensive axillary lymph nodes.

    
    
    Figure 1(b): CT scan: Showing extensive axillary lymph nodes.

Figure 1 (c): PET scan showing uptake in thyroid lobe, mediastinal nodes, paratracheal nodes and axillary nodes.

    
    
    Figure 1 (c):  PET scan showing uptake in thyroid lobe, mediastinal nodes,
paratracheal nodes and axillary nodes.

Intraoperatively disease was involving the tracheoesophageal groove on left side, encasing the left recurrent laryngeal nerve and going on to esophagus. Decision was taken to leave behind a small amount of disease along the tracheoesophageal groove considering the young age of the patient and morbidity involved with the radical surgery required for R0 resection. The patient recovered well and her final histopathology report was a follicular variant of classical type papillary carcinoma and she underwent radioactive iodine treatment and external beam radiotherapy for the residual disease.

Case 2

45 year old lady underwent right hemithyroidectomy for a right thyroid nodule in 2001 at a local hospital. Histopathology was suggestive of classical variant of papillary thyroid cancer, in view of this she underwent completion thyroidectomy and Left selective neck dissection (II-IV) along with central compartment clearance in 2001 at Tata Memorial hospital. There was no residual tumor identified in the completion thyroidectomy specimen. She was advised a RAI scan post surgery but she defaulted and then presented with the recurrent disease 11 years later. At presentation she had a 10x8x5 cm right supraclavicular mass with palpable right level III and IV lymph nodes and bilateral axillary lymphadenopathy. Serum thyroglobulin was not elevated (0.02) and core biopsy showed no evidence of dedifferentiation. CT scan showed 9x6x5 cm mass from thyroid cartilage to clavicle reaching skin and abutting trachea and common carotid artery. PET-CT revealed two discrete nodules in right lung of 4mm size in upper and lower lobe, along with metabolically active bilateral axillary nodes (Figures 2a, 2b & 2c).

Figure 2 (a): Clinical image showing recurrence at neck following first surgery.

    
    
    Figure 2 (a):  Clinical image showing recurrence at neck following first
surgery.

Figure 2(b): Microphotograph of resected axillary lymph node mass: tall cell variant, no area of dedifferentiation.

    
    
    Figure 2(b):  Microphotograph of resected axillary lymph node mass: tall cell
variant, no area of dedifferentiation.

Figure 3(c): PET scan showing uptake in axillary nodes.

    
    
    Figure 3(c):  PET scan showing uptake in axillary nodes.

She underwent thyroid bed exploration with right neck node clearance with bilateral axillary sampling and DP flap. Histopathology was Tall cell variant with no area of dedifferentiation. Patient was planned for adjuvant Radioiodine treatment but defaulted and had recurrent disease within 7 months. She presented with multiple chest wall nodules largest of which was 6x4 cm along with multiple neck nodes and underwent palliative radiotherapy following which she was again lost to follow up.

Discussion

Axillary lymph node is one of the rarest sites of metastases for thyroid cancers; only 18 cases have been reported in literature so far (Table 1) [2-15]. Of these differentiated thyroid cancers have accounted for 13 cases, with papillary thyroid cancer being the predominant variety accounting for 12 cases and follicular variant contributing a solitary case [13]. Among patients with papillary thyroid ca, 75% (9/12) had poorly differentiated tumor or had an aggressive subtype like tall cell variant. In our series also both the patients were papillary ca with one of them being a tall cell variant.

Table 1: Table showing the outcomes at different papillary stages.




  
    Year 
    Author 
    Age (yrs) 
    Sex 
    Histology 
    Differentiation 
    Axillary node appearance 
    Metastatic Sites 
    Outcome 
  
  
    2014 
    Present study
    19
    F
    Papillary
    Well diff.
    concurrent
    Lung
    Dis Fr 2 mos
  
  
    2014 
    Present study
    58
    F
    Papillary
    Tall cell.
    Recurrent 11 yrs
    Lung
    NA
  
  
    2013 
    Cumings [15]
    56
    F
    Papillary
    Well diff.
    Recurrent 8 yrs
    Lung, bone
    ALD
  
  
    2013 
    Cumings 15
    59
    M
    Medullary
    NA
    Recurrent 3 mo
    None
    Dis Fr 9 mos
  
  
    2012 
    Machado14
    71
    M
    Papillary
    Well Diff.
    Recurrent 7 yrs
    lung
    ALD 8 months
  
  
    2012 
    Chiofalo et al. [13]
    65
    M
    Follicular
    Hurthle cell Signet cell
    concurrent
    Multiple bone
    ALD 1year
  
  
    2011 
    Krishnamurthy et al. [12]
    64
    F
    Papillary
    Tall cell
    Recurrent 6 yrs
    None
    Dis Fr 6 months
  
  
    2009 
    Kepenecki [11]
    63
    F
    Papillary
    Well diff.
    concurrent
    None
    NA
  
  
    2009 
    Angeles- Angeles [10]
    58
    F
    Papillary
    Insular
    Recurrent 17 yrs
    Breast
    NA
  
  
    2007 
    Nakayama [9]
    21
    M
    Papillary
    Partially poorly
    Concurrent
    Lung
    ALD
  
  
    2006 
    Ers et al. [8]
    62
    F
    Papillary
    NA
    Recurrent 5 yrs
    None
    Dis fr 10 yrs
  
  
    2004 
    Koike et al. [7]
    51
    M
    Papillary
    Partially poorly
    Recurrent 5 yrs
    Multiple
    Dead
  
  
    2003
    Lal [6]
    65
    M
    Papillary
    Poor
    Recurrent 41 yrs
    Multiple
    Dead
  
  
    2003
    Lal [6]
    59
    M
    Medullary
    Poor
    concurrent
    Multiple
    ALD
  
  
    2003
    Lal [6]
    45
    M
    Papillary
    Poor
    concurrent
    Multiple
    Dead
  
  
    2002
    Minagawa et al. [5]
    52
    M
    Mucoepidermoid
    NA
    concurrent
    Lung, vertebra
    Dead
  
  
    1998
    Chen et al. [4]
    66
    F
    Papillary
    Well different
    concurrent
    None
    NA
  
  
    1996
    Ueda et al. [3]
    45
    F
    Papillary
    NA
    Recurrent 7 yrs
    None
    NA
  
  
    1993
    Mizukami et al. [2]
    58
    M
    Adeno Ca (Mucin producing)
    poorly
    Recurrent 7 mos
    None
    Dis Free



Table 1:  Table showing the outcomes at different papillary stages.

Mean age of presentation is 55.6 yrs (Range 21-71 yrs). Thus it is mainly seen in late middle or elderly age, however in our series a 19 year old girl presented with axillary metastases which to best of our knowledge is the youngest case ever which has clinical implications since majority of these patients would be subjected to RAI therapy which can cause significant acute and delayed effects including secondary malignancies.

Although thyroid cancers are more common in females, with regards to axillary metastases no sex predilection has been seen with male and female almost equally represented (F- 10 M-8). Among differentiated cancers also this relationship is maintained (F-7 M-6). In our series both the patients were females. About half of these patients presented with concurrent axillary lymph node metastases along with primary. In our series also one patient presented with concurrent axillary metastases while the other one presented in the recurrent disease setting.

All patients reported in literature [2-15] had in common extensive cervical lymph node metastases which can be substantiated by the fact that bulky lymph nodal mass especially in lower cervical region can lead to obstruction of cervical lymphatic vessels and thereby potentiate retrograde lymphatic flow to axillary nodes. Also almost all of them (90%) had at least one of the poor prognostic features (viz. age > 45 yrs, T > 4 cm, presence of multiple sites of distant metastases). This similarities are replicated in our series too as both of our patients had extensive cervical lymph node and lung metastases. Thus, presence of extensive cervical lymph nodes and distant metastases should alert a clinician to look out for axillary nodes as a potential site harboring metastatic disease.

With regards to management of this rare subset of patients there are no formal guidelines as most of the literature concerning advanced differentiated thyroid cancer pertains to laryngotracheal and esophageal invasion. The consensus is to resect and achieve an R0 resection at these sites. Results have been mostly extrapolated from these and till now there are only 7 cases in literature, reported to have undergone axillary dissection [12-15]. Of these 7 patients 2 are disease free, 2 patients are alive with disease while outcomes have not been reported for the remaining 3 patients. In our series one of the patients has just finished treatment for her disease while the other lady had a recurrence within 7 months of surgery; this result should be interpreted with caution taking in to perspective the very advanced nature of her disease along with non adherence to the planned adjuvant treatment.

Conclusion

Thyroid cancer metastasis to axillary lymph nodes is rare; however it has got clinical implications. It should be considered in the differential diagnoses of axillary masses in the presence of thyroid malignancy. Also during follow up, in the setting of persistently raised serum thyroglobulin level and a negative RAI scan clinicians should keep this possibility in mind. Surgical resection with axillary dissection is associated with improved outcomes, but the prognosis is usually ominous.

References

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Citation: Singhal N, Chaturvedi P, Joshi P and Malik A. Axillary Lymph Node Metastases in Differentiated Thyroid Cancer “An Uncommon Presentation with Clinical Implications”. Austin J Clin Case Rep. 2015;2(1): 1065. ISSN : 2381-912X

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