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CORRESPONDENCE
Year : 2018  |  Volume : 14  |  Issue : 9  |  Page : 544-548

Cervical mass as the initial manifestation of occult papillary thyroid carcinoma: Report of three cases


Department of General Surgery, The Second Affiliated Hospital of Dalian Medical University, Shahekou District, Dalian, Liaoning 116023, P.R, China

Date of Web Publication29-Jun-2018

Correspondence Address:
Zhao Yongfu
Department of General Surgery, The Second Affiliated Hospital of Dalian Medical University, Zhongshan Road, Shahekou District, Dalian, Liaoning 116023
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0973-1482.204892

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 > Abstract 

Occult thyroid carcinoma is mostly discovered by autopsy or by other causes of thyroid surgery. To the best of our knowledge, there have been only a few reports concerning the situation that cervical mass was the initial manifestation of occult papillary thyroid carcinoma. The three patients in our report were all admitted to hospital because of the masses on their necks. Although pathology reports showed the nodal presence of thyroid cancer, we did not find the primary tumor on the same side of thyroid. We reported the clinical data of patients, including chief complaint, ultrasonography, computed tomography, and pathology results. We attempt to raise awareness regarding this particular disease and as a reference for clinical diagnosis and treatment. Examinations are needed to confirm the diagnosis for occult cancer of the thyroid. Surgical procedure is the major treatment method at present.

Keywords: Cervical mass, microcarcinoma, occult thyroid cancer, thyroid cancer


How to cite this article:
Yongfu Z, Ziyu L, Chen L, Jingchao X. Cervical mass as the initial manifestation of occult papillary thyroid carcinoma: Report of three cases. J Can Res Ther 2018;14, Suppl S2:544-8

How to cite this URL:
Yongfu Z, Ziyu L, Chen L, Jingchao X. Cervical mass as the initial manifestation of occult papillary thyroid carcinoma: Report of three cases. J Can Res Ther [serial online] 2018 [cited 2019 Jul 20];14:544-8. Available from: http://www.cancerjournal.net/text.asp?2018/14/9/544/204892


 > Introduction Top


In the past four decades, the incidence of thyroid cancer has been on the rise globally.[1] In China, thyroid cancer, in 2012, contributed to 15.6% and 13.8% of the total worldwide incidence and prevalence, respectively.[1] Occult thyroid carcinoma (OTC) refers to any thyroid cancer whose size is <1 cm, accounting for 6%–35% of all thyroid cancer.[2] Due to its small size and nonspecific symptoms,[3] its clinical diagnosis is often missed and mostly found during autopsy studies or thyroidectomies for other reasons. One-third of those cases will have lymph node metastasis.[4] The incidence of thyroid cancer in Dalian City was reported to be 12.94/100,000 in males and 36.31/100,000 in females with a mortality rate as high as 16 times more than other cities in China with male and female mortality rates of 0.3/100,000 and 46/10,000, respectively.[5]

To raise awareness in OTC, we present three cases of this rare disease, admitted to our hospital because of a cervical mass which was the initial manifestation of occult papillary thyroid carcinoma.


 > Case Reports Top


Case 1

A 31-year-old male presented with a chief complaint of the right neck swelling for half a month. He described the mass to be of the size of a “quail egg.” He did not have any other past medical history. He is an occasional smoker and does not drink alcohol. He works as a common worker, and there is no history of thyroid problem or history of cancer in his family. The ultrasound done in the outpatient's department showed nodules of mixed echogenicity on the right side of the chin, and he was admitted to Oral and Maxillofacial Surgery with a preliminary diagnosis of “thyroglossal cyst.”

Physical examination revealed a 2.0 cm × 1.0 cm right oval cervical mass in the submental region, which was soft with regular borders. There were no adhesions with the surrounding tissue and was moving with swallowing movements. There were neither other obvious swellings nor pus discharge.

Laboratory investigations showed no renal or hepatic impairment, normal glucose and lipid level and normal thyroid function tests. On ultrasound, a 0.20 mm × 0.20 mm mass of heterogeneous echogenicity and clear borders was found in the left lobe of thyroid. The right lobe of the thyroid was normal [Figure 1]a-c]. Computed tomography (CT) scan [Figure 1]d had similar results as the ultrasound with other systemic abnormalities seen.
Figure 1: Imaging Studies of Case 1. (a) Left thyroid ultrasonography showing a 0.2*0.2cm with clear borders and of heterogeneous echogenicity at the lower pole of thyroid. (b) Right thyroid ultrasonography: A 1.9*0.6cm with clear borders and abnormal echogenicity near the right thyroid. (c) Cervical lymph node ultrasonography another mass near the right thyroid at area 3, 2.0*0.5 cm of size with clear borders. (d) CT Scan: Mass of regular border and abnormal echogenicity seen near the right thyroid

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Surgical exploration through a 4 cm incision in the right submental region for neck exploration showed an oval mass of size 0.20 mm × 0.15 mm, with regular borders, and no adhesions with the surrounding tissue. The mass was removed, sent for histopathological examination and the wound was closed as per standard technique. Postoperative recovery was without incident, and he was given anti-inflammatory drugs, fluid replacement therapy, and standard wound healing dressing. When the pathological finding came out being a cystic mass, lined with a single layer of cubic epithelium with the part of the epithelium having a papillary nature [Figure 2]a, he was referred to the Department of General Surgery. Immunohistochemistry staining results suggested papillary thyroid carcinoma metastasis with thyroid transcription factor (TTF)-1 (+), triglyceride (TG) (+), CK19 (+), Galect3 (+), CyclinD1 (+), P53 nearly 10%. After standard preoperative preparation, a 6 cm horizontal sub-thyroid incision was made, and the thyroid was exposed as per standard surgical technique with proper hemostasis. 0.3 mL of nano-carbon was injected in the thyroid for staining. The thyroid had one right lesion of size 0.3 cm × 0.2 cm × 0.2 cm being hard in consistency with clear boundaries. The mass was resected and sent for histopathology. Intraoperative pathology report of the mass [Figure 2]b and [Figure 2]c in the thyroid did not confirm neoplastic changes. Because the Doppler ultrasound on the right neck showed swollen lymph nodes, the safest option considered was an en bloc resection down to the level of the clavicle, medial to the right common carotid artery, lateral to the trachea, larynx, and tracheoesophageal groove. The incision was extended to 20 cm from the lower margin of the mandible to the upper border of the clavicle on the right side. In the 2, 3, and 4 areas, there were numerous enlarged lymph nodes, the biggest being of size 2.0 cm × 1.5 cm × 1.5 cm.
Figure 2: Histopathology of Case 1. (a) Submental mass histopathology showing papillary carcinoma metastasis from thyroid. (b) 1 Left thyroid histopathology: benign lesions. (c) Right thyroid histopathology: benign lesions, but a lymph node near the right thyroid showed papillary carcinoma metastasis

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The left lobe of the thyroid was also removed without lymph node resection. Both accessory nerves and vascular structures did not suffer any damage bilaterally. Two drainage tubes were inserted, and the incision was closed by standard procedure lavage. The final histopathologic diagnosis was OTC (papillary). After an uneventful postoperative recovery and timely removal of the drainage tubes, the patient was advised to do regular follow-up with regular thyroid blood tests and ultrasound and was discharged on euthyrox. Until now, the patient is without complaints and no recurrence has been noted.

Case 2

A 50-year-old male presented with a chief complaint of the right neck swelling for 2 years. When he initially noticed the right neck swelling 2 years ago, he described the mass to be of the size of a “broad bean” and he sought consult at another institution. The ultrasound report stated that there were multiple cystic nodules with calcification in the region of the neck with cervical lymph nodes enlargement. They did a fine-needle biopsy, but the medical records could not be traced back, and the patient did not know the results also. However, he recalled that the fluid drained was black. He was given some Chinese medication, which he did not recall the name but to no avail. Over the past 6 months before admission to our institution, the right neck mass swelling grew to the size of an “egg,” as he described it.

Being a known patient of chronic gastritis, he was 1 year ago also diagnosed with nodular lesions in the right upper lung lobe and bilateral upper lobe emphysema by CT scan.

Otherwise, he did not have any other past medical history. He does not smoke and drink. He was previously working as a farmer but now has retired. There was no previous personal or family history of thyroid or any other neoplasm.

He was initially seen by the Department of Oral Maxillofacial Surgery. Physical examination revealed a 2.5 cm × 2.5 cm right neck mass at the inframandibular region, which was soft, cystic in nature with regular borders, with no overlying hyperemic skin or discoloration. There was no discharge, mobile from the underlying fascia and was not causing any obvious symptoms of discomfort. Laboratory investigations showed no renal or hepatic impairment and normal glucose and lipid level and normal thyroid function tests. CT scan [Figure 3]a revealed multiple cervical masses. Surgical exploration through a 4.0 cm incision in the right inframandibular region for neck exploration showed a cystic mass of size 0.25 cm × 0.25 cm) containing a reddish-brown liquid. Postoperative recovery was without incident, and he was given anti-inflammatory, fluid replacement therapy and standard wound healing procedures as per hospital protocol. A CT scan of the abdomen was also performed when he complained of abdominal discomfort, but it was inconclusive. However, the possibility of hepatic and renal cysts as well as of gall bladder cysts was not excluded. When the pathological finding [Figure 4]a came back being a cystic mass, lined with a single layer of cubic epithelium with papillary hyperplasia seen bordered by a cystic wall made of lymphoid tissue, he was referred to the Department of General Surgery. Immunohistochemistry staining results suggested papillary thyroid carcinoma metastasis with CK19 (+), TG (+), CT (−), TTF-1 (+), Nap-A (−), P53 partly (+), Cyclin D1 (+), and Ki-67 (+). After adequate preoperative preparation [Figure 3]b and [Figure 3]c, thyroid exploration was performed. A 6 cm horizontal sub-thyroid incision was made, and the thyroid was exposed as per standard surgical technique with proper hemostasis. 0.3 mL of nano-carbon was injected in the thyroid for staining. The thyroid right lobe had an obvious mass of size 0.5 cm × 0.5 cm × 0.3 cm, which was of hard consistency with clear boundaries while the left lobe had multiple nodules. Intraoperative pathology report [Figure 4]b and [Figure 4]c of the mass in the right thyroid did not confirm neoplastic changes. Because the Doppler ultrasound on the right neck showed swollen lymph nodes, en bloc resection was performed by extending the incision by 20 cm from the lower margin of the mandible to the upper border of the clavicle on the right side. In the 2, 3, and 4 areas, there were numerous enlarged lymph nodes, the biggest being of size 1.5 cm × 0.8 cm × 0.6 cm. The left lobe of the thyroid was also removed without lymph node resection. Both accessory nerves and vascular structures did not suffer any damage bilaterally. Two drainage tubes were inserted, and the incision was closed by standard procedure lavage. The final histopathologic diagnosis was OTC of papillary type. After an uneventful postoperative recovery and timely removal of the drainage tubes, the patient was discharged on euthyrox and advised to come regular follow-up with regular thyroid function tests, ultrasound. Until now, the patient is without complaints and no recurrence has been noted.
Figure 3: Imaging studies of Case 2. (a) CT: No abnormalities seen. (b) Cervical lymph node ultrasonography: normal. (c) Thyroid ultrasonography: normal

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Figure 4: Histopathology reports of Case 2. (a) Primary lesion in the right neck being papillary carcinoma metastasis. (b) Right thyroid: nodular goiter (d = 0.5). (c) Left thyroid: benign lesions

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Case 3

A 53-year-old male presented with a chief complaint of left neck swelling for a ½ year. When he initially noticed the left neck swelling ½ year ago, he described the mass to be of the size of a “soybean” and he did not care because he thought it was just a swollen lymph node that would have resolved with time. Otherwise, he did not have any other past medical history. He had been smoking one pack of cigarettes per week for 10 years and drank around two bottles of beer per week. Having no family history of thyroid of any other cancer, he was a common office worker and no risk factors in his occupation had been identified to be linked to this neoplasm.

However, as the mass kept increasing in size, he went to hospital and underwent a fine-needle biopsy which showed undifferentiated carcinoma and thyroid carcinoma was not excluded. Thus, thyroid surgery for thyroid cancer resection was recommended.

Physical examination revealed a 2.5 cm × 1.5 cm left neck mass, which was rubbery in nature, with regular borders. There was also no overlying skin hyperemia or discoloration, and the mass was mobile from the underlying fascia. Laboratory investigations showed no renal or hepatic impairment, normal glucose and lipid level and normal thyroid function tests. On thyroid ultrasound, multiple nodules of mixed echogenicity were seen in both sides of the thyroid, with the largest being of size 2.6 cm × 1.4 cm. On the contrary, there was no unusual swelling in the right neck. CT scan revealed multiple enlarged lymph nodes on the left side of the neck and left thyroid nodules. The first surgical exploration was done through a 4.0 cm incision anterior to the left sternocleidomastoid muscle border. Findings included a mass of size 2.3 cm × 2.0 cm × 1.8 cm. It was tough with irregular borders and adhering to surrounding structures. Postoperative recovery was without incident, and standard wound healing procedure was as per hospital protocol. When the pathological finding [Figure 5]a came back being thyroid papillary carcinoma metastasis, the patient was referred to the Department of General Surgery. After proper preoperative preparation, a 6 cm horizontal sub-thyroid incision was made, and the thyroid was exposed as per standard surgical technique with proper hemostasis. 0.3 mL of nano-carbon was injected in the thyroid for staining. Both lobes of the thyroid and its isthmus had obvious masses of largest size 0.5 cm × 0.5 cm, all of which were of hard consistency with clear boundaries. Intraoperative pathology report of the mass in the right thyroid showed papillary thyroid cancer, but the left lobe did not show neoplastic changes [Figure 5]b and [Figure 5]c, due to the previous results of lymph node biopsy being malignant, a total thyroidectomy was performed. An en bloc resection was done. Both accessory nerves and vascular structures did not suffer any damage bilaterally. Two drainage tubes were inserted, and the incision was closed by standard procedure lavage. The postoperative pathology showed nodular goiter with focal fibrosis in the left thyroid and papillary carcinoma in the right thyroid. After an uneventful postoperative recovery and timely removal of the drainage tubes, the patient was discharged on euthyrox and advised for regular follow-up with regular thyroid blood tests and ultrasound. Until now, the patient is without complaints and no recurrence has been noted.
Figure 5: Histopathology of Case 3. (a) Right thyroid: papillary carcinoma metastasis (d = 0.3). (b) Left thyroid: nodular goiter. (c) Cervical lymph node at left neck: no metastasis

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 > Discussion Top


It is difficult to diagnose OTC unless it has reached a later nodal or metastatic stage. All our cases were first referred to the Department of Oral Maxillofacial Surgery because of the neck lesions. OTC with cervical lymph node metastasis at the time of presentation has been stated to occur in nearly one-fifth of all cases with thyroid carcinoma.[6]

The initial evaluation of an adult patient presenting with a neck mass should include identification of the risk factors for malignancy, a detailed head and neck examination including the upper digestive tract and thyroid gland. When radiographic assessments such as ultrasound or CT are used to evaluate such a mass, they may give important structural information about the mass as well as its adjacent structures, but they cannot replace a tissue diagnosis, which will be required before definitive treatment.

As the clinical manifestation of OTC remains insidious, the value of ultrasonic imaging in diagnosing OTC remains indispensable as the first measure. In recent years, the technological evolution of ultrasound has enabled the detection of thyroid nodules as small as 0.2 cm in size.[7]

CT and ultrasounds in the diagnosis of thyroid carcinoma cervical lymph node metastasis are 81% and 60%, respectively.[4] In the three patients, ultrasound was able to find the lesions, but we were still uncertain about their nature. The latter can be done by cervical lymph node biopsy and immunohistochemistry. Fine-needle aspiration (FNA) cytology of the thyroid gland is an accurate diagnostic test used routinely in the initial evaluation of nodular thyroid disease.[8] A survey of clinical members of the American Thyroid Association revealed that most endocrinologists (96%) performed FNA biopsy for diagnosis of thyroid nodules. The importance of FNA biopsy in thyroid practice cannot be overemphasized.[8]

Patients with occult papillary thyroid carcinoma are found to have a favorable overall prognosis.[7] Even if OTC is automatically classified as N1b in the International Union Against Cancer classification, it can present with aggressive clinicopathologic features with extranodal tumor extension having a worse prognosis.[7]

From our experience, we recommend total thyroidectomy with lymph node dissection except for the elderly or high-risk patients when there is no definitive preoperative tissue diagnosis.


 > Conclusion Top


Most OTC of papillary nature show excellent prognosis, but its insidious course can make the patient present late in the course of the disease. Ultrasound and CT scan are the best preliminary investigations with the definitive diagnosis being FNA cytology or biopsy preoperatively. Treatment in patients with low or acceptable surgical risk should undergo total thyroidectomy with lymph node dissection.

Acknowledgments

We would like to thank all members who directly and indirectly contributed to the completion of this article, in particular, Dr. Guangzhi Wang for his guidance and patience.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
 > References Top

1.
Dong F, Zhang B, Shan G. Distribution and risk factors of thyroid cancer in China. China Oncol 2016;26:47-52.  Back to cited text no. 1
    
2.
Tüber L. Die epithelialen Formen der malignen Struma. Virchows Arch 1907;189:69-152.  Back to cited text no. 2
    
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Ferretti S, Patriarca S, Carbone A, Zanetti R. TNM classification of malignant tumours, VII edition 2009. Changes and practical effects on cancer epidemiology. Epidemiol Prev 2010;34:125-8.  Back to cited text no. 3
    
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Çoban G, Yildirim E, Gemici K, Erinanç H. MRI findings of lumbosacral metastasis from occult follicular thyroid cancer: Report of a case. Surg Today 2014;44:553-7.  Back to cited text no. 4
    
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Mu H, Li Y, Zhang R. Analysis of incidence, mortality and prevalence of thyroid cancer in five cities of Liaoning Province during 2000~2011. China Cancer 2015;24:889-95.  Back to cited text no. 5
    
6.
Coleman SC, Smith JC, Burkey BB, Day TA, Page RN, Netterville JL. Long-standing lateral neck mass as the initial manifestation of well-differentiated thyroid carcinoma. Laryngoscope 2000;110(2 Pt 1):204-9.  Back to cited text no. 6
    
7.
Ito Y, Hirokawa M, Fukushima M, Inoue H, Yabuta T, Uruno T, et al. Occult papillary thyroid carcinoma: Diagnostic and clinical implications in the era of routine ultrasonography. World J Surg 2008;32:1955-60.  Back to cited text no. 7
    
8.
Burch HB, Burman KD, Cooper DS, Hennessey JV, Vietor NO. A 2015 survey of clinical practice patterns in the management of thyroid nodules. J Clin Endocrinol Metab 2016;101:2853-62.  Back to cited text no. 8
    


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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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