Thyroid cancer in Plummer's disease

Abstract

Thyroid cancer with concomitant hyperthyroidism is rare. Most foci of malignancy are small and seen postoperatively as incidental findings after surgery for hyperthyroidism. Thyroid masses with clinical features of malignancy and concomitant hyperthyroidism are less-commonly reported. We report two cases of multinodular toxic goitre or Plummer's disease with clinical features of malignancy. Both patients had large multinodular goitres with evidence of metastasis to the manubrium for the first patient and to the lymph node and lungs for the second patient. Both were clinically euthyroid but with free hormone excess and suppressed thyroid stimulating hormone (TSH) on laboratory testing. Both patients received methimazole prior to thyroidectomy. Histopathology revealed follicular variant of papillary cancer with metastasis to the manubrium for the first patient and follicular thyroid cancer with lymph node metastasis for the second. While rare, thyrotoxicosis can occur with malignancy, Plummer's disease may harbour cancer and behave aggressively.

Thyrotoxicosis with concomitant thyroid cancer

“…The incidence of DTC is higher than expected in Plummer's disease (18.3 vs 3.0%) (Smith et al 2013). The predominant pathological pattern is PTC, follicular variant of papillary thyroid cancer (FVPTC) and FTC are also involved (Ngalob & Isip-Tan 2013, Smith et al 2013.…”

“…Although 'hot' nodule is generally considered as benign, a higher incidental cancer rate than expected can be found in patients with Plummer's disease compared to historical reports (Smith et al 2013). Hence, if ultrasonography suggests malignant signs such as calcifications and vascularity or metastases, FNAB of primary nodule or metastases should be recommended (Ngalob & Isip-Tan 2013).…”

“…Magnetic resonance imaging (MRI) is thought to be more precise than CT in the anatomo-topographic evaluation of the substernal goiter (Porterfield et al 2008). Thyroid scan with 99m Tc-pertechnetate presents functioning thyroid nodule with minimal uptake of the rest gland (Ngalob & Isip-Tan 2013). Although 'hot' nodule is generally considered as benign, a higher incidental cancer rate than expected can be found in patients with Plummer's disease compared to historical reports (Smith et al 2013).…”

“…If patient has a perspicuous diagnosis of Plummer's disease associated with DTC, surgery is the first choice because it can not only resect the primary tumor and metastases, but resolve compression and thyrotoxicosis symptoms rapidly as well. Biochemical euthyroidism achievement with ATDs before surgery and subsequent 131 I therapy for the unresectable metastases are also necessary (Ngalob & Isip-Tan 2013).…”

A 68-Year-Old Man with Apathetic Hyperthyroidism and Lung Cancer

“…nodular goiter or toxic adenoma [7]. Herein is reported a non-small cell pulmonary carcinoma diagnosed by complete necropsy performed in an old male with apathetic hyperthyroidism, atrial fibrillation and heart failure.…”