Concurrent Papillary and Follicular Thyroid Cancer Presenting as Shoulder Pain

Abstract

Differentiated thyroid cancer arises from thyroid follicular epithelial cells. It accounts for more than 90% of thyroid cancers. In areas of sufficient iodine nutrition, about 85% of differentiated thyroid cancers are papillary, 10% are follicular and 3% are Hurthle cell carcinomas. The coexistence of different types of thyroid cancer in a single patient is a rare condition. This is the case of a 56 year-old man with medical history of arterial hypertension who presented to clinics with right shoulder pain. Imaging of the right shoulder showed a osteolytic lesion involving the right humerus with associated cortical disruption consistent with pathological fracture secondary to metastatic disease. Bone biopsy showed papillary thyroid carcinoma. Subsequently, ultrasound-guided fine needle aspiration biopsy to a right lobe nodule was performed, which confirmed the presence of papillary thyroid carcinoma. There was also evidence of cervical lymph node involvement. Patient proceeded to total thyroidectomy with neck dissection, and surgical pathology revealed the presence of 2.5 cm right lobe papillary carcinoma and 1.5 cm left lobe follicular carcinoma. Postoperatively, he was found with persistent elevated thyroid-stimulating hormone (TSH) and elevated quantitative thyroglobulin with elevated thyroglobulin antibodies. Patient received therapeutic radioiodine (I-131) for ablation of thyroid cancer. Whole body iodine scan demonstrated residual functioning thyroid tissue within post-thyroidectomy bed, with or without residual carcinoma, and large expansile uptake lesion involving the right humeral head and neck. Therefore, patient will receive a second dose of radioactive iodine. He has been started on thyroid hormone replacement with a goal of TSH <0.1 uIU/mL for high risk American Thyroid Association (ATA) stratification, and has remained clinically euthyroid. Thyroid carcinoma is the most common endocrine malignancy and one of the most rapidly increasing cancers in the United States. This increase in incidence is largely due to incidental detection on diagnostic imaging. Here we present an uncommon case of two distinct thyroid malignancies occurring simultaneously in a patient presenting with a pathological fracture. Synchronous occurrence of two types of differentiated thyroid cancer is a rare event, and has only been reported in case series. Bone metastasis from differentiated thyroid cancer can occur in 2-13% of patients. Despite the therapy for papillary thyroid carcinoma and follicular thyroid carcinoma remain the same, proper identification will lead to prompt therapy and increased survival. Physicians should be aware of this variety.

A patient with a rare co‐occurrence of papillary and follicular thyroid carcinomas

“…Additionally, lymph node metastasis was reported in four patients, 5,6,13,15 and distant metastasis to the rib/femur/shoulder bone, and adrenal gland have also been reported in four patients. 5,6,9,11 TCTs seemed to be located mainly either in the right lobe (n = 8), 3,10,[13][14][15] or both lobes (n = 10), [5][6][7][8][9]11,12,17,18 as opposed to only in the left lobe (n = 3). 3,16 Lastly, only 6 of 20 patients had TCTs with 2+ foci.…”

“…The most reported TCT is PTC and MTC as highlighted in a recent case series by Ryan et al 2 Though the co-occurrence of PTC and other carcinomas in the thyroid have been reported, 19 the coexistence of PTC and FTC are extremely rare, with only 20 cases reported in the English literature. [3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18] Among the cases of co-existent PTC and FTC, the median age is 56 years old (range: 12-79 years old), with a female preponderance (66%) as per our review of current published English literature. Additionally, lymph node metastasis was reported in four patients, 5,6,13,15 and distant metastasis to the rib/femur/shoulder bone, and adrenal gland have also been reported in four patients.…”

“…[3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18] Among the cases of co-existent PTC and FTC, the median age is 56 years old (range: 12-79 years old), with a female preponderance (66%) as per our review of current published English literature. Additionally, lymph node metastasis was reported in four patients, 5,6,13,15 and distant metastasis to the rib/femur/shoulder bone, and adrenal gland have also been reported in four patients. 5,6,9,11 TCTs seemed to be located mainly either in the right lobe (n = 8), 3,10,[13][14][15] or both lobes (n = 10), [5][6][7][8][9]11,12,17,18 as opposed to only in the left lobe (n = 3).…”

“…Ultrasonography of the thyroid using the TI‐RADs grading scale is both sensitive and specific to further guide the investigation of asymptomatic thyroid nodules 20 . TI‐RADs risk stratifies patients using a standardized scoring 1–5 system determined from five categories of ultrasound findings (composition, echogenicity, shape, margin, and echogenic foci). Higher cumulative scores indicate a greater likelihood of malignancy 21 .…”

“…2 However, there are only 20 cases to date that describe the concurrent presentation of both PTC and follicular thyroid carcinoma (FTC). [3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18]…”