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LETTER TO THE EDITOR
Year : 2016  |  Volume : 12  |  Issue : 1  |  Page : 423-424

Bilateral axillary and infrahilar nodal metastases in follicular variant of papillary thyroid carcinoma (transformed into poorly differentiated subtype) in the setting of elevated thyroglobulin and negative radioiodine scintigraphy


Radiation Medicine Centre, Bhabha Atomic Research Centre, Tata Memorial Hospital Annexe, Parel, Mumbai, Maharashtra, India

Date of Web Publication13-Apr-2016

Correspondence Address:
Sandip Basu
Radiation Medicine Centre, Bhabha Atomic Research Centre, Tata Memorial Hospital Annexe, Jerbai Wadia Road, Parel, Mumbai - 400 012, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0973-1482.172136

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How to cite this article:
Basu S. Bilateral axillary and infrahilar nodal metastases in follicular variant of papillary thyroid carcinoma (transformed into poorly differentiated subtype) in the setting of elevated thyroglobulin and negative radioiodine scintigraphy. J Can Res Ther 2016;12:423-4

How to cite this URL:
Basu S. Bilateral axillary and infrahilar nodal metastases in follicular variant of papillary thyroid carcinoma (transformed into poorly differentiated subtype) in the setting of elevated thyroglobulin and negative radioiodine scintigraphy. J Can Res Ther [serial online] 2016 [cited 2021 Jan 19];12:423-4. Available from: https://www.cancerjournal.net/text.asp?2016/12/1/423/172136



Sir,

Axillary lymph node metastases are rare in the history of thyroid carcinoma.[1],[2],[3],[4],[5] We herein report a case of differentiated thyroid carcinoma who presented with this uncommon site of metastasis from a follicular variant of papillary carcinoma of the thyroid (FVPCT) with gradual dedifferentiation during recurrences.

The patient, a 46-year-old female initially presented with anterior neck swelling and had undergone subtotal thyroidectomy followed by completion thyroidectomy in 2006. The histopathology report was suggestive of FVPCT with areas showing poorly differentiated features. The patient was treated with 1554 MBq due to high radioiodine uptake despite two times surgery (28%). The follow-up diagnostic scan with 159.1 MBq showed no iodine avid focus in the scan with low uptake (0.05%) and undetectable serum thyroglobulin (Tg). The patient was put on thyroxine suppression and followed up with Tg. Over the period of years, the Tg showed an increasing trend (UD in 2007 and 2008, 66.3 ng/ml in 2009); she was detected to have neck recurrence and histopathology following surgical excision demonstrated poorly differentiated carcinoma, and she was treated with external radiotherapy. Following this the serum Tg level on suppression was 0.23 ng/ml in 2010, 12.6 ng/ml in 2011, 11.7 ng/ml in 2012; the whole body radioiodine scan, however, was negative. Fludeoxyglucose-positron emission tomography-computed tomography (FDG-PET/CT) at that time showed a left infrahilar lymph node focus (SUVmax 10.23). The patient was, however, kept on thyroxine suppression; subsequently the serum Tg increased further to 58.5 ng/ml in 2013 and 135.7 ng/ml in 2014. The patient was labeled as a case belonging to the group “elevated Tg and negative radioiodine scintigraphy” (TENIS). In 2014, an LDS was repeated with adequate preparation regarding iodine restriction, which still showed no iodine avid focus in the scan with low neck uptake (0.11%). In view of rising Tg, she was decided to be treated empirically with 7992 MBq I-131 at the same time. However, the posttreatment scan showed no radioiodine avid focus anywhere in the body. In the present visit, the serum Tg was still raised (> ng/dl) and the repeat FDG-PET/CT [Figure 1] at this time showed persistence of the left infrahilar lymphadenopathy (SUVmax 8.65) with FDG avid bilateral axillary lymph nodes (right axillary SUVmax 4.4 and left axillary SUVmax 5.58). A biopsy from the left axillary nodes was considered in view of this being rare site of disease; the hydroxypyruvate reductase showed poorly differentiated carcinoma consistent with metastasis from the primary malignancy in the thyroid.
Figure 1: Whole body fludeoxyglucose-positron emission tomographycomputed tomography illustrating abnormal foci of fludeoxyglucose uptake in the left infrahilar lymphadenopathy (SUVmax 8.65) and bilateral axillary lymph nodes (right axillary SUVmax 4.4 and left axillary SUVmax 5.58)

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In the literature, axillary node metastasis from thyroid carcinoma has been reported to be associated with aggressive biology. It is an uncommon site of disease involvement from thyroid carcinoma, with the last systematic review published in 2014 reports a total of 16 reports including all histopathological subtypes.[5] By far the majority has been in the setting of papillary thyroid carcinoma. However, its detection by FDG-PET/CT in the setting of TENIS has been unreported; the present case in the setting of poor differentiation thus is commensurate with the previous impression of axillary node metastases signifying aggressive biology. In our case, in the disease recurrence, papillary thyroid carcinomas was transformed into poorly differentiated carcinoma (associated with guarded prognosis), that had later metastasized to two atypical and unusual sites, infrahilar and bilateral axillary nodes.

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Conflicts of interest

There are no conflicts of interest.

 
 > References Top

1.
Koike K, Fujii T, Yanaga H, Nakagawa S, Yokoyama G, Yahara T, et al. Axillary lymph node recurrence of papillary thyroid microcarcinoma: Report of a case. Surg Today 2004;34:440-3.  Back to cited text no. 1
    
2.
Ers V, Galant C, Malaise J, Rahier J, Daumerie C. Axillary lymph node metastasis in recurrence of papillary thyroid carcinoma: A case report. Wien Klin Wochenschr 2006;118:124-7.  Back to cited text no. 2
    
3.
Nakayama H, Wada N, Masudo Y, Rino Y. Axillary lymph node metastasis from papillary thyroid carcinoma: Report of a case. Surg Today 2007;37:311-5.  Back to cited text no. 3
    
4.
Krishnamurthy A, Vaidhyanathan A. Axillary lymph node metastasis in papillary thyroid carcinoma: Report of a case and review of the literature. J Cancer Res Ther 2011;7:220-2.  Back to cited text no. 4
    
5.
Cummings AL, Goldfarb M. Thyroid carcinoma metastases to axillary lymph nodes: Report of two rare cases of papillary and medullary thyroid carcinoma and literature review. Endocr Pract 2014;20:e34-7.  Back to cited text no. 5
    


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