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 Table of Contents  
CASE REPORT
Year : 2019  |  Volume : 7  |  Issue : 2  |  Page : 59-62

Long-Standing Asymptomatic Neck Swelling Presenting With Cannonball Metastasis: An Unusual Case Report


1 Department of Respiratory Medicine, ESIC Medical College & Hospital, Faridabad, Haryana, India
2 Department of Pathology, ESIC Medical College & Hospital, Faridabad, Haryana, India

Date of Web Publication20-Jun-2019

Correspondence Address:
Dr. Ruchi Arora Sachdeva
Department of Respiratory Medicine, ESIC Medical College and Hospital, NIT-3, Faridabad, 121001
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jacp.jacp_2_19

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  Abstract 

The purpose of this article is to report a case of a 38-year-old man with complaint of dry cough. The physician noticed a neck swelling that was never investigated because it did not cause any serious trouble to the patient. Diagnostic workup revealed primary follicular thyroid carcinoma with cannonball secondaries in lungs, contrary to female and elderly age group preponderance.

Keywords: Cannonball metastasis, thyroid carcinoma, young male


How to cite this article:
Sachdeva RA, Dawar S, Nagar S, Parashar D, Chandoke RK, Pujani M. Long-Standing Asymptomatic Neck Swelling Presenting With Cannonball Metastasis: An Unusual Case Report. J Assoc Chest Physicians 2019;7:59-62

How to cite this URL:
Sachdeva RA, Dawar S, Nagar S, Parashar D, Chandoke RK, Pujani M. Long-Standing Asymptomatic Neck Swelling Presenting With Cannonball Metastasis: An Unusual Case Report. J Assoc Chest Physicians [serial online] 2019 [cited 2019 Sep 15];7:59-62. Available from: http://www.jacpjournal.org/text.asp?2019/7/2/59/260627


  Introduction Top


Thyroid carcinoma is rare among human malignancies (1%); it is the most frequent endocrine cancer accounting for about 5% of thyroid nodules.[1] Follicular thyroid carcinoma (FTC) accounts for 10% to 15% of thyroid cancers and occurs more commonly in women over 50 years of age. It tends to invade blood vessels and metastasize by hematogenous spread to distant sites, most commonly to the bones and lungs. The incidence of distant metastasis in FTC has been reported as 6% to 20%.[2],[3] Distant metastasis may be the initial presentation of the disease or may occur after initial treatment for cancer.[4]


  Case report Top


A 38-year-old man, laborer by occupation in a fan manufacturing factory, presented with symptoms of dry cough on and off and dyspnea (modified Medical Research Council Grade 2) over a span of 3 months. He was having a slow-growing anterior neck swelling for over a period of 12 years, which did not cause any troublesome symptoms. There was no history of any intoxicant addiction. He denied having any previous neck surgery or irradiation. There was no history of cancer in his family.

On examination, he was conscious, cooperative, and a well-oriented person. His vitals were in normal range. General physical examination revealed a 4 × 3 cm, hard immobile swelling in midclavicular line just below the left nipple that was nontender and firm. Local examination of the neck revealed a firm, diffuse swelling in front of the neck measuring 11 × 8 cm. This neck lump was nontender; it moved with deglutition and getting below the swelling was not possible [Figure 1] and [Figure 2]. There was no cervical lymphadenopathy. Diffuse crepts were heard over both his lung fields.
Figure 1 Prominent neck swelling.

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Figure 2 Left chest wall swelling.

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Blood investigations that included complete blood counts and electrolytes and thyroid function tests were in normal range. Ultrasound of the neck and thorax suggested the neck lump and chest swelling had characteristics that raised suspicion for malignancy. Multiple, well-defined, round nodular lesions were observed in the chest radiograph, suggestive of cannonball secondaries.

Contrast-enhanced computed tomography (CECT) of the neck showed mixed attenuation (calcification and necrosis) mass in right lobe of thyroid, measuring 95 × 51 × 67 mm, extending up to sternal notch and upper neck. CECT of the thorax revealed multiple, well-defined, spherical enhancing lesions suggesting metastatic secondaries in both the lung fields. Also, there was a superficial anterior chest wall mass extending up to subcutaneous space and vertebral metastases at the level of D7–D9. These findings were later confirmed in positron emission tomography scan as primary thyroid lesion with secondaries in lungs, vertebrae, and chest wall [Figure 3] and [Figure 4].
Figure 3 Computed tomography of the neck showing thyroid mass.

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Figure 4 Computed tomography of the thorax showing bilateral cannonball secondaries.

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Fine-needle aspiration cytology (FNAC) of the thyroid nodule showed a follicular lesion (category IV TBSRTC 2014) [Figure 5]. FNAC from of the left side chest wall yielded clusters of atypical cell, having moderate to marked pleomorphic nuclei with raised nucleocytoplasmic ratio and rosettes with pseudoacini cells at places, suggestive of metastatic deposits from carcinoma [Figure 6].
Figure 5 Fine-needle aspiration cytology of thyroid nodule.

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Figure 6 Fine-needle aspiration cytology of chest wall lesion.

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Oncologist’s consultation for further management was sought; the patient was declared inoperable citing extensive metastases and was put on palliative chemotherapy along with respiratory supportive care as required.


  Discussion Top


Our patient presented with dry cough and had a progressive neck swelling. Dry cough raised the suspicion of distant metastasis, which was later confirmed by radioimaging and cytopathology. Hence, the patient presented at an advanced stage of the disease. In a study conducted by Parameswaran et al.,[5] when metastatic disease was diagnosed at initial presentation, the predominant sites were the bones (spine, pelvis, hip, and scapula) (42%), followed by lungs (33%), brain (17%), and lymph nodes (8%).

Distant metastasis occurs in less than 10% of patients with papillary and FTC, but represents the most frequent cause of thyroid cancer-related deaths.[6],[7] Thyroid cancer may spread to the lymph nodes, lungs, bone, and, occasionally, brain. Sometimes, thyroid tumor is very large and starts growing into the adjacent structures in the neck, such as the trachea, esophagus, blood vessels, muscles, or nerves. This is considered to be "locally advanced" thyroid cancer.

Also, the age at which patient presented to us was an unusual finding contrary to many studies, one of which is by Donnel et al.[8] in which 17 patients of age 52 to 80 years (mean, 60 years) have had a carcinosarcoma of the thyroid. As discussed earlier, it has a female predominance and the prognosis is not good in females, whereas males have a better prognosis. Parameswaran et al.[5] stated that among 20 patients, 13 (65%) were women. The median patient age at diagnosis was 65 years. The above findings make this case a rare presentation with respect to the age and gender of the patient.

Ultrasonographic features suggestive of malignant thyroid nodules are hypoechogenicity, microcalcifications, absence of peripheral halo, irregular borders, intranodular hypervascularity, and regional lymphadenopathy. A combination of these ultrasonographic findings might have a high predictive value for malignancy.[8]

FNAC is the gold standard for differential diagnosis, although there are limitations: inadequate samples and follicular neoplasia.[9],[10],[11] Any solitary thyroid nodule (≥1 cm) should be subjected to cytology unless proven to be hyperfunctioning with low-suppressed serum thyroid-stimulating hormone. In all cases, the sensitivity of the method depends largely on the experience of the cytologist reading the slides and the methodology of sample collection and smear staining. In the event of inadequate samples, FNAC is repeated. In the case of follicular neoplasia, after excluding the hyperfunctioning nature of the nodule by thyroid-stimulating hormone measurement and confirmatory thyroid scan (hot nodule), no other test can distinguish the benign or malignant nature of the nodule. Luo et al.[12] reported that FNACs usually miss 25% of malignancies in solitary nodular goiter and this rate goes up in case of multinodular goiter. They also found male gender of young age with multinodular goiter as high risk factors for malignancy and a higher chance of false-negative report.

In case of FNAC-proven benign lesions, there is always a rare chance (<1%) of turning malignant later on in life. About 70% of these conversions usually occur in 2 to 3 years. Some authors advice regular follow-up (ultrasound and FNAC) of the nodule for 3 years, after which long break can be given.[13],[14] Our patient had a 12-year history of neck swelling, and thus it was difficult to say when it would have turned malignant, as it has never been investigated previously; this also leaves us with a question as for how long we should follow up.The definitive treatment is thyroidectomy, although small tumors that have not spread outside the thyroid gland may be treated by just removing the side of the thyroid containing the tumor (lobectomy). If lymph nodes are enlarged or show signs of cancer spread, they will be removed as well. Even if the lymph nodes are not enlarged, it is still recommended for surgical removal of lymph nodes next to the thyroid along with the removal of the thyroid. Treatment after surgery depends on the stage of the cancer[15],[16]:
  1. Radioactive iodine (RAI) treatment is sometimes used after thyroidectomy for early-stage cancers (T1 or T2), but the cure rate with surgery alone is excellent. If the cancer does come back, radioiodine treatment can still be given.
  2. RAI therapy is often given for more advanced cancers such as T3 or T4 tumors, or cancers that have spread to lymph nodes or distant areas. The goal is to destroy any remaining thyroid tissue and try to treat any cancer remaining in the body. Areas of distant spread that do not respond to RAI might need to be treated with external beam radiation therapy, targeted therapy, or chemotherapy.
  3. People who have had a thyroidectomy will need to take daily thyroid hormone (levothyroxine) pills. If RAI treatment is planned, the start of thyroid hormone therapy may be delayed until the treatment is finished (usually about 6–12 weeks after surgery).


The targeted therapy drugs sorafenib (Nexavar) and lenvatinib (Lenvima) may be tried if the cancer has spread to several places and RAI and other treatments are not helpful.


  Conclusion Top


FTC is a rare form of disease with a poor prognosis. Any patient attending outpatient department with a neck swelling and cough should always be evaluated with suspicion of advanced malignancy. A swelling more than 1 cm should undergo FNAC and detailed evaluation along with necessary radiological workup. Patients with proven benign nodule must follow-up for 3 years as there is a possibility of any benign lesion turning malignant.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Coleman PM, Babb P, Damiecky P, Groslaude P, Honjo S, Jones J et al. Cancer Survival Trends in England and Wales 1971-1995: Deprivation and NHS Region Series SMPS no. 61 London: Stationery Office 1999. pp. 471-8.  Back to cited text no. 1
    
2.
Dinneen SF, Valimaki MJ, Bergstralh EJ, Goellner JR, Gorman CA, Hay ID. Distant metastases in papillary thyroid carcinoma: 100 cases observed at one institution during 5 decades. J Clin Endocrinol Metab 1995;80:20415.  Back to cited text no. 2
    
3.
Mihailovic J, Stefanovic L, Malesevic M. Differentiated thyroid carcinoma with distant metastases: probability of survival and its predicting factors. Cancer Biother Radiopharm 2007;22:250-5.  Back to cited text no. 3
    
4.
Shaha AR, Shah JP, Loree TR. Differentiated thyroid cancer presenting initially with distant metastasis. Am J Surg 1997;174:474-6.  Back to cited text no. 4
    
5.
Parameswaran R, Shulin Hu J, Min En N, Tan WB, Yuan NK. Patterns of metastasis in follicular thyroid carcinoma and the difference between early and delayed presentation. Ann R Coll Surg Engl 2017;99:151-4.  Back to cited text no. 5
    
6.
Mazzaferri EL, Kloos RT. Current approaches to primary therapy for papillary and follicular thyroid cancer. J Clin Endocrinol Metab 2001;86:1447-63.  Back to cited text no. 6
    
7.
Schlumberger MJ, Filetti S, Hay ID. Non toxic goiter and thyroid neoplasia. In: Larsen RP, Kronenberg HM, Melmed S, Polonsky KS, editors. Williams’ Textbook of Endocrinology. 10th ed. Philadelphia: WB Saunders Company; 2003. pp. 457-90.  Back to cited text no. 7
    
8.
Donnel CA, Pollock WJ, Sybers WA. Thyroid carcinoma. Arch Pathol Lab Med 1987;111:1169-72.  Back to cited text no. 8
    
9.
Hegedus L. Thyroid ultrasound. Endocrinol Metab Clin North Am 2001;30:339-60.  Back to cited text no. 9
    
10.
Marqusee E, Benson CB, Frates MC, Doubilet PM, Larsen PR, Cibas ES et al. Usefulness of ultrasonography in the management of nodular thyroid disease. Ann Internal Med 2000;133:696-700.  Back to cited text no. 10
    
11.
Cap J, Riska A, Rehorkova P, Hovorkova E, Kerekes Z, Pohnetalova D. Sensitivity and specificity of the fine needle aspiration biopsy of the thyroid: clinical point of view. Clin Endocrinol 1999;51:509-15.  Back to cited text no. 11
    
12.
Luo J, McManus C, Chen H, Sippel RS. Are there predictors of malignancy in patients with multinodular goiter? J Surg Res 2012;174:207-10.  Back to cited text no. 12
    
13.
Negro R. What happens in a 5-year follow-up of benign thyroid nodules. J Thyroid Res 2014;2014:459791.  Back to cited text no. 13
    
14.
Lee S, Skelton TS, Zheng F, Schwartz KA, Perrier ND, Lee JE et al. The biopsy-proven benign thyroid nodule: is long-term follow-up necessary? J Am Coll Surg 2013;217:81-8.  Back to cited text no. 14
    
15.
Mitchell AL, Gandhi A, Scott-Coombes D, Perros P. Management of thyroid cancer: United Kingdom National Multidisciplinary Guidelines. J Laryngol Otol 2016; 130(S2):S150-60.  Back to cited text no. 15
    
16.
Treatment of Thyroid Cancer, by Type and Stage: guidelines by American Cancer Society. Available at https://www.cancer.org/cancer/thyroid-cancer/treating/by-stage.html. [Accessed April 1, 2019].  Back to cited text no. 16
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]



 

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