THE ROLE OF CALCITONIN IN THE PREOPERATIVE STAGE AS THE PREDICTOR OF MEDULLARY THYROID CANCER METASTASES

the aim of the stydy was to analyze the detectability of medullary thyroid metastases in patients at treatment and diagnostic stages, to investigate the applicability of serum calcitonin level as predictor of possible presence of medullary thyroid metastases. The study included data from 148 patients who underwent surgical treatment for the initial diagnosis of medullary thyroid cancer. The age of patients ranged from 12 to 83 years, the mean age was 48,2±1,9 years; the distribution by gender was as follows: men – 34 (23%), women – 114 (77%). Patients were divided into two groups depending on the pathomorphological report: 1 group (100 (67,6%) – patients without metastases), 2 group (48 (32,4%) – patients with locoregional metastases). Among 148 studied patients with medullary thyroid cancer, as a result of the histopathological conclusion, in 48 (32,4%) metastases were detected in regional lymph nodes, among which 10 (6,7%) patients had metastases only in the central collector and 38 (25, 7%) –both in the central and lateral collectors. At the preoperative stage, the level of undiagnosed metastases by ultrasound was 64,58% (31 patients). Subsequently, at the intraoperative stage, during the rapid histological biopsy, the number of undiagnosed metastases decreased to 37,5% (18 patients), and in the postoperative period, according to the results of histopathological examination, the remaining patients were diagnosed with the medullary thyroid cancer metastases. Ultrasound helped to detect metastases in 17 patients, which was 35,42% of all detected metastases. At the stage of intraoperative study, the detection of metastases increased and amounted to 30 (62,5%), and in the postoperative period as a result of histopathological examination metastases were confirmed in 48 patients (100%). Quantitative indicators of both detected and undiagnosed metastases at all stages of treatment and diagnostic search are statistically significant (p<0,01). The detection of metastases in the central lymphatic collector (N1a) at the preoperative stage was 2,08%, this index has doubled (to 4,16%) after intraoperative rapid histological conclusion, and after histopathological conclusion the index has increased more than 10 times (20,84 %). This tendency to grow of metastaseses detection was followed also on lateral collectors: N1b and psilateral were observed at 15 (31,2%) patients at the preoperative stage, their number increased to 23 (47,9%) intraoperatively and to 31 (64,6%) postoperatively; N1b contralateral was observed in 1 (2,1%), 5 (10,4%) and 7 (14,6%), respectively. Such a low percentage of metastases detection at the preoperative stage by ultrasound prompted to CT level study as the predictor of possible metastases. We investigated the preoperative basal blood CT value as a marker of the medullary thyroid cancer metastases presence probability. Due to the small number of the group (n=10) with N1a, the association of CT (cut-off level 137 pg/ml) with the possible presence of metastases was not significant (AUC = 0.594), while in the group with N1b there was a more significant difference. Thus, CT cut-off levels of 358 pg/ml for N1b ipsilateral, and 498 pg/ml for N1b contralateral detection of possible metastases in collectors, with AUC: 0.877 and 0.832, respectively, which justifies the importance of the lateral neck dissection in addition to the mandatory central dissection in order to remov possible medullary thyroid cancer metastases. Thus, ultrasound is insufficiently reliable method of metastases verifying in medullary thyroid cancer (DE = 35.4% at d mts <0.6 cm). In the absence of ultrasound data (or fine needle aspiration (FNA) biopsy results) on the presence of metastases to raise awareness of the disease prevalence, to clarify the prognosis of its development it’s important to use the additional criterion – the calcitonin level. Basal calcitonin level is the reliable predictor of the medullary thyroid cancer metastases. Its cut-off level of 137 pg/ml indicates the possible presence of metastases in the central group (N1a) (AUC=0,594). The CT cut-off level – 358 pg/ml (AUC=0,793) suggests the presence of the medullary thyroid cancer metastases (N1a+N1b). CT cut-off levels – 358 pg/ml for N1b ipsilateral, and 498 pg / ml for N1b contralateral (AUC: 0,877 and 0,832), respectively. The calculated values of the countersensitivity test to detect metastases for different levels of basal CT in the preoperative stage in the clinical setting will help the practitioner in deciding on treatment tactics to determine the extent of surgery in patients diagnosed (or suspected) with the medullary thyroid cancer metastases.

Isolated Metastasis of the Ascending Ramus of the Mandible of Thyroid Follicular Carcinoma: A Case Report and Literature Review

Objectives: The mandibular metastatic spread of carcinoma from the thyroid gland is exceedingly rare. In August 2020, we treated a 69-year-old woman exhibiting thyroid follicular carcinoma metastasis to the ascending ramus region of the mandible showing evidence of detailed radiological and pathological features. Methods: We present a case report of thyroid carcinoma that metastasized to the ascending ramus region of the mandible at 21 years after partial thyroidectomy. We also present relevant information in a literature review of 35 articles, consisting of 43 cases (including our case) of thyroid carcinomas with jaw bone metastasis. We statistically analyzed the demographical and clinical results in terms of age, sex, type of primary cancer, site and time of metastasis, treatment, and outcome.Results: Unlike most of the other cases, in our case, the thyroid cancer had metastasized to the ascending ramus region of the mandible, which made the diagnosis relatively difficult. The patient underwent partial mandibular resection, thyroidectomy, and iodine-131 treatment. The patient was followed up regularly, and no new symptoms were observed at seven months after post-treatment.Conclusions: Surgery is the most common treatment for thyroid metastases of the mandible. Clinicians should ask thyroid cancer patients for follow-up to monitor whether any new complications have occurred. Patients must undergo complete examination of the maxillofacial bone for up to 40 years or more. Otolaryngologists and stomatologists should pay extra attention to patients with thyroid cancer or nodules to avoid misdiagnosis or missing the recognition of thyroid metastatic cancer.

Thyroid Gland Metastasis From Endometrial Carcinoma Causing Acute Severe Dyspnea

Thyroid metastasis from cervical carcinomas is an extremely rare disease; therefore, only a few cases have so far been reported in the literature. Due to the lack of data and the heterogeneity of clinical cases, the percentage of patients affected by thyroid metastases eligible to undergo surgery is not easily predictable. This report describes a rare case of endometrioid adenocarcinoma metastasized to the thyroid gland. A 72-year-old woman was referred to the ENT department of our hospital (Ospedale Degli Infermi di Biella, Italy) presenting with dyspnea and rapidly worsening condition, in need of emergency surgery. The peculiarity of this case lies in the metastasis isotype rarity, in its voluminous dimension, and in its mediastinal localization, which required the intervention of a multidisciplinary team to establish successful treatment planning.

Case Report and Review of Literature: Thyroid Metastases From Breast Carcinoma

RationaleThe thyroid is a rare site for distant metastases from breast carcinoma. The incidence of thyroid metastases in fine needle aspiration biopsy (FNAB) was less than 0.2%.Patient concernsWe report a case of 54-year-old woman with a history of breast carcinoma presented with diffuse scattered microcalcifications in thyroid and enlarged bilateral cervical lymph nodes detected on ultrasound (US). Physical examination of the patient revealed firm and enlarged thyroid lobes.DiagnosesFNAB and immunohistochemistry (IHC) of the thyroid lesion confirmed the thyroid metastases from breast cancer.Interventions and OutcomesDue to the comorbidities of breast carcinoma metastases to the right axillary, cervical lymph nodes and left chest wall, the patient received chemotherapy. After a follow-up of 19 months, the patient was alive without any new distant metastases.LessonsOur case highlights that thyroid metastases should be considered in a patient combined with thyroid lesions and a history of breast carcinoma. IHC played an important role in differentiating thyroid metastases from primary thyroid cancer.

Thyroid metastases from breast carcinoma: case report and review of literature

Rationale: The thyroid is a rare site for distant metastases from breast carcinoma. The incidence of thyroid metastases in fine needle aspiration biopsy (FNAB) was less than 0.2%.Patient concerns: We report a case of 54-year-old woman with a history of breast carcinoma presented with diffuse scattered microcalcifications in thyroid and enlarged bilateral cervical lymph nodes detected on ultrasound (US). Physical examination of the patient revealed stiff and enlarged thyroid lobes.Diagnoses: FNAB and immunohistochemistry （IHC）of the thyroid lesion confirmed the thyroid metastases from breast cancer.Interventions and outcomes: Due to the comorbidities of breast carcinoma metastases to the right axillary, cervical lymph nodes and left chest wall, the patient received chemotherapy. After a follow-up of 10 months, the patient was alive without any new distant metastases.Lessons: Our case highlights that thyroid metastases should be considered in a patient combined with thyroid lesions and a history of breast carcinoma. IHC played an important role in differentiating thyroid metastases from primary thyroid cancer.

SUN-489 MetastaticThyroidCancer

Background In many cases, thyroid cancer leads to metastasis; however, isolated metastasis to the liver from thyroid cancer is a rare event. When this occurs, patients have a very poor prognosis. Case Study A clinical case of a 33-year-old woman, born in Piura and coming from Lima, with no major history, diagnosed with a 4-month-old cervical tumor is presented. An ultrasound scan and a further biopsy were performed before an eventual diagnosis of papillary thyroid carcinoma. Operation was performed, and a classical papillary carcinoma of 0.90 inches was detected, along with macro-metastasis in a parathyroid ganglion. Post-surgical thyroglobulin was 1071 ng/ml (n&lt; 50 ng/ml). The tomography in her lung showed three nodules in the middle lobe. A further dose of 150 millicuries of radioactive iodine (I-131) was given, with whole-body scanning, post positive in both lung fields and right lank pain. The tomography in the abdomen revealed a hepatic pedicle injury, compatible with teratoma. A liver resection surgery was scheduled, and metastatic papillary carcinoma was identified. A V600 mutation in BRAF gene was present in thyroid gland and not detectable in the liver. Conclusions This case shows an example of thyroid cancer with uncommon metastasis in the liver, which occurs in 0.5% of all thyroid metastases. It is even rarer that positive iodine was found. Liver metastasis represents a poor prognosis, however it has been reported that resective surgery offers patients a better chance of survival. Multiple factors influence its pathogenesis, including BRAF mutations. In this case, mutation was detected in thyroid gland, but not in liver metastasis, which could represent diverse BRAF mutations.

SUN-479 Metastatic Renal Cell Carcinoma (RCC) to the Thyroid: Case Report and Clinical Lesson

Background: Metastatic neoplasms to the thyroid gland are rare and have been observed more in autopsy series than in clinical series. Case: A 71-year old woman presented for thyroid nodule evaluation which was incidentally noted on CT/PET scan. She was diagnosed with renal cell carcinoma (RCC) stage IV (6.4 cm, left nephrectomy) 4 months prior. She had right hemi-thyroidectomy 30 years prior for a benign nodule. She was clinically and biochemically euthyroid with dysphagia and hoarseness in her voice. Thyroid u/s revealed multiple nodules in the left lobe with a dominant 3.6 x 2.9 x 3.6 cm solid, heterogeneous nodule with grade 3 hypervascularity. History positive for 1 cm right renal mass and multiple pulmonary nodules increasing in size thought to be consistent with metastases. The FNA of the dominant nodule was indeterminate, Bethesda III (AUS), GSC suspicious (Affirma, 50% ROM) with negative malignancy classifiers. Patient underwent completion thyroidectomy, and surgical path was consistent multifocal clear cell renal cell carcinoma (CRCC) with the largest focus of 3 cm based on clear cell features and strong positivity for stains: CK OSCAR, RCC, PAX-8 & CD-10. Patient is currently on Pazopanib post thyroid surgery for 18 months, and is stable with no further increase in the size of lung nodules or right renal mass and negative serial PET scans. Clinical lesson: CRCC represents 3-4% of all adult malignancies and 85% of all primary renal tumors. In clinical series, CRCC is the most frequent source of thyroid metastases and represents 12-34% of all secondary thyroid tumors. About 17% of patients with CRCC have metastatic disease at diagnosis. Metastases can be synchronous or metachronous to the primary tumor. Latency from nephrectomy to diagnosis of thyroid mets varies from 2 months-21.9 years. Metastases can be solitary (more common), multiple or diffuse. Radiological findings typically reveal hypoechoic and vascularized mass on ultrasound and cold on thyroid scan. Metastases to thyroid can pose diagnostic problem and be a source of confusion in cytology interpretation. Metastatic CRCC can simulate morphologically primary thyroid neoplasm such as Hurthle cell neoplasm or thyroid carcinomas with clear cell changes. Metastatic carcinoma within the thyroid gland is negative for thyroglobulin, TTF-1, calcitonin unlike primary thyroid cancer. CRCC is usually positive for periodic acid-Schiff and Oil red O, vimentin, and CD10. The mean survival in patients with CRCC who had thyroidectomy alone or with adjuvant treatment was 3 years. Conclusion: Thyroid metastases should be considered in patients with thyroid nodules and positive history of RCC. The preoperative distinction between primary and secondary tumors is difficult. Immunohistochemistry is a useful method for the evaluation of patients with suspected thyroid nodules.