Renal Cell Carcinoma Metastasis to Thyroid, Presenting Like Non-toxic Multi Nodular Goiter

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ABSTRACT

Theoretically, metastatic renal cell cancer (RCC) is able to metastasize well to organs with a rich blood supply, but thyroid with a good vascularity is known to be a site with rare metastasis of RCC. Distant metastasis of RCC may also occur several years after its first diagnosis. Therefore, there is a high possibility of overlooking metastatic RCC to thyroid. To avoid this, we have to take the patient's past history in detail, and to keep in mind that the distant metastasis of RCC could be occurred in the thyroid years later.

Keywords: Thyroid cancer; Renal cell cancer; Metastasis

INTRODUCTION

Renal cell cancer (RCC) is the most common renal malignancy in adults. And its metastasis is relatively common at diagnosis and frequently involves the lung, bone, brain, liver and adrenal glands with rich blood supply (1). Thyroid represents a very uncommon site of metastatic disease of RCC. Herein, we report the patient presenting with neck discomfort &

engorgement who had diagnosed distant metastatic RCC to thyroid.

CASE REPORT

A 61-year-old female visited our clinic with neck discomfort and engorgement (Fig. 1). She had a past surgical history of left partial nephrectomy and right radical nephrectomy for clear cell RCC 12 years ago. She has had a routine follow-up after adjuvant therapy since nephrectomy. Metastatic nodules in the lung was found on chest computed tomography taken one year ago, but they stopped growing no more and turned into stable nodules in a few months.

In a physical examination, there was no abnormalities except diffusely engorged neck. Her thyroid function test including a thyroid-stimulating hormone was all normal. Thyroid ultrasonography showed increased size of 4 mass in both thyroid glands compared to the result from 5-years ago (Fig. 2). The sizes of mass varied from 1.7 cm to 5.2 cm. Fine needle aspiration J Endocr Surg. 2021 Sep;21(3):75-78

https://doi.org/10.16956/jes.2021.21.3.75 pISSN 2508-8149·eISSN 2508-8459

Short Communication

Received: Jul 15, 2021 Revised: Sep 24, 2021 Accepted: Sep 25, 2021 Correspondence to Yeo Goo Chang

Department of Surgery, Inje University Seoul Paik Hospital, College of Medicine, Inje University, 9 Mareunnae-ro, Jung-gu, Seoul 04551, Korea.

E-mail: [email protected] Copyright © 2021. Korean Association of Thyroid and Endocrine Surgeons; KATES This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (https://

creativecommons.org/licenses/by-nc/4.0/).

ORCID iDs HaengJin Ohe

https://orcid.org/0000-0003-1489-823X Kyeong Woon Choi

https://orcid.org/0000-0003-2528-0689 Yeo Goo Chang

https://orcid.org/0000-0003-4104-0351 Conflict of Interest

No potential conflict of interest relevant to this article was reported.

Author Contributions

Conceptualization: Yeo Goo Chang; Data curation: HaengJin Ohe; Investigation:

HaengJin Ohe; Project administration: Kyeong Woon Choi; Supervision: Yeo Goo Chang;

Validation: Kyeong Woon Choi; Writing - original draft: HaengJin Ohe; Writing - review &

editing: HaengJin Ohe.

HaengJin Ohe , Kyeong Woon Choi , Yeo Goo Chang

Department of Surgery, Inje University Seoul Paik Hospital, College of Medicine, Inje University, Seoul, Korea

Renal Cell Carcinoma Metastasis to

Thyroid, Presenting Like Non-toxic

Multi Nodular Goiter

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(FNA) cytology did not reveal any malignancy. Omitting further evaluations with suspicious malignancy, surgical biopsy was taken from her thyroid following total thyroidectomy (Fig. 3) upon patient request, which revealed the similar morphologic features (Fuhrman's nuclear grade 2–3) and the specific immuno-histochemical characteristics (Table 1) supporting the metastasis of the previous clear cell RCC. With these findings, we can conclude it was a final diagnosis of delayed metastasis of RCC in thyroid.

76 https://jes-online.org https://doi.org/10.16956/jes.2021.21.3.75

Metastatic RCC to Thyroid

Fig. 1. Photograph of a patient presenting with neck discomfort and features of neck engorgement who is subsequently diagnosed with metastatic clear cell renal cell cancer.

Fig. 2. On ultrasound, hypoechoic mass with internal heterogeneous echogenicity are shown in both thyroid lobes. and those mass are enlarged compared with sizes from previous study.

Fig. 3. These resection specimens from both thyroid lobes show multi-lobulated, mostly solid and partially cystic mass with thin fibrous capsule which focally invade thyroidal capsule.

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DISCUSSION

RCC is the ninth most common cancer worldwide, and it represents 2% to 3% of all

malignant tumors in adult. The most common sites of metastases were lung (45%), following by bone (30%) and lymph node (22%) (2). And it is known that 1% to 3% of patient with RCC is bilateral, late recurrence is one of the specific biologic behaviors of RCC (3).

Although metastasis to the thyroid remains uncommon, an increasing number of cases are being reported of non-thyroid cancer found in the thyroid gland (4). RCC remains the most common cancer to metastasize to the thyroid, with nearly 25% of the cases of metastatic disease in the thyroid attributed to RCC (7). Although FNA is the most accurate and cost- effective method of thyroid nodule evaluation, FNA cytology may be non-diagnostic in up to 25 per cent of patients with nodular thyroid disease (5). Therefore, it is sometimes very difficult to suspect secondary thyroid cancer without surgery.

In ultrasound, hypoechoic, non-homogenous, and vascularized mass are very common findings for both of primary and secondary thyroid cancer. FNA cytology is thought to be helpful in the discrimination of primary and secondary thyroid cancer, but both can be misinterpreted easily due to the common cytological findings for both of them (4).

Furthermore, a more recent study (6) reported that FNA was able to detect only 46% of the total thyroid cancers discovered at pathological evaluation of the surgical specimen, even though nearly half of the cancers missed by FNA were more than 1 cm in size. Next, core needle biopsy can be considered, but it is not routinely recommended if the result of FNA cytology is unclear. Therefore, secondary thyroid cancer is not suspected in preoperative evaluation and is mostly diagnosed by histopathological examination after surgery (8).

Pathologically, the presence of a predominantly interstitial pattern of infiltration is more compatible with the diagnosis of metastatic RCC rather than primary thyroid cancer.

Additional immunohistochemistry is essential for differentiating primary thyroid cancer and metastatic RCC and elucidating the histological origin of RCC. The existence of large amounts of lipid material and glycogen (periodic acid-Schiff positive), as well as the absence of mucin, a negative stain for thyroid transcription factor-1 and thyroglobulin which are sensitive markers for primary thyroid cancer, and a positivity for CD10, vimentin, cytokeratin, all favor a diagnosis of clear cell RCC and metastasis (Table 1) (9,10). It is completely revealed the similar morphologic features and the specific immuno-histochemical characteristics supporting the metastasis of the previous clear cell RCC.

Most RCC metastases to the thyroid are usually asymptomatic and do not affect thyroid function, even if the literature reports cases of emergency treatments for acute respiratory compromises (11). Some reports for isolated metastatic cancer to the thyroid, surgical

Table 1. Clinically useful immunohistochemical panel for helping to differentiate between primary versus metastatic thyroid cancer and to classify common subtype of RCC

Cancer Subtype Positive Negative

This patient Vimentin, CD10, cytokeratin, PAS Thyroglobulin, TTF1, CD34

Thyroid cancer Primary Thyroglobulin, TTF1, TTF2, PAX8 -

RCC Clear cell Vimentin, CD10 -

Papillary Vimentin, PAX8 CD10

Chromophobe - CD10

RCC = renal cell cancer; PAS = periodic acid-Schiff; TTF = thyroid transcription factor.

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treatment should be considered in order to avoid potential morbidity of tumor recurrence in the neck, even if the prognosis remain poor. Although therapy of metastatic malignancies is often considered to be palliative, aggressive surgical treatment in isolated cases may be curative and of clear survival benefit (12).

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