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Journal of Cancer Research and Therapeutics, Vol. 7, No. 2, April-June, 2011, pp. 220-222 Case Report Axillary lymph node metastasis in papillary thyroid carcinoma: Report of a case and review of the literature Arvind Krishnamurthy, Anitha Vaidhyanathan Department of Surgical Oncology, Cancer Institute (WIA), 36, Sardar Patel Road, Adyar, Chennai - 600 020, Tamil Nadu, India Code Number: cr11055 PMID: 21768721 Abstract We report a case of axillary lymph node metastasis as a consequence of recurrent papillary thyroid carcinoma (PTC) in a 64-year-old lady. The patient initially presented in 2004 with a 10 × 10 cm size thyroid swelling of approximately 3-year duration and bilateral cervical lymphadenopathy. She underwent total thyroidectomy with bilateral neck dissection then. Pathological examination confirmed that the resected lesions were PTC and nodal metastases from thyroid. On follow-up over the next 6 years, she underwent excisions twice for cervical nodal recurrences. She presented to us in January 2010 with multiple right axillary adenopathy. Therapeutic right axillary dissection was done. Histopathologic examination revealed metastatic PTC with tall cell differentiation in 7 out of the 17 nodes. The patient is currently on thyroxine suppression therapy and remains disease free for the past 6 months. We review our experience and present a brief review of literature. Keywords: Axillary lymph node metastasis, papillary thyroid carcinoma, prognosis Introduction Papillary thyroid carcinoma (PTC) is an indolent neoplasm associated with a low mortality rate. Mazzaferri analyzed data of 576 patients treated for PTC and documented cervical lymph node metastasis (LNM) in 46% of patients at presentation. [1] Axillary LNM as part of the disease spectrum of thyroid carcinoma is rare, with only isolated case reports. [2],[3],[4],[5],[6],[7] We found no studies to document patterns of lymph flow from the thyroid bed to axillary lymph nodes when the cervical lymphatics are blocked. However, we endeavor to present previously suggested hypotheses and correlate them with our patients' history. Case Report A 64-year-old clinically euthyroid lady reported to our unit in 2004 with a 10 × 10 cm size thyroid swelling of 3-year duration and bilateral cervical lymphadenopathy of 6-month duration. The right-sided neck nodal involvement was from levels II to V and the left-sided in levels IV and V. Preoperative examination of tissue obtained by fine-needle aspiration cytology (FNAC) revealed PTC with LNM. Laryngoscopy revealed both vocal cords to be mobile. Her chest skiagram revealed normal lung fields. Past medical and family histories were unremarkable. She underwent a total thyroidectomy with right-sided radical neck dissection and left-sided Type III modified radical neck dissection. Postoperative histopathology revealed PTC in both the lobes of the thyroid with extra-thyroidal extension and bilateral neck metastases with 18/21 and 4/26 nodes positive for tumor on the right and left side, respectively. A radioactive iodine (I 131 ) scan revealed 1.9% uptake in the neck, and a whole body scan was negative. She underwent residual thyroid ablation with 100 mCi of I 131 and was kept on thyroxine suppressive therapy. She was offered external beam radiotherapy, only to decline. Over the next 6 years, she developed two recurrences, both regional, involving the right level V cervical nodes which were managed by appropriate surgical excisions. Histology on both occasions showed metastatic PTC in the cervical lymph nodes. The regular I 131 scan showed no uptake in her neck, and serum thyroglobulin levels were normal. In January 2010, she presented with isolated but multiple right axillary nodal enlargement. Her thyroid bed and neck were normal clinically, and by ultrasound. Serum thyroglobulin was elevated at 176 units. FNAC from the nodal mass was suggestive of metastatic PTC. Therapeutic right axillary node dissection was done [Figure - 1]. Postoperative histopathology of axillary nodes revealed metastatic PTC with tall cell differentiation in 7 out of the 17 nodes [Figure - 2]. Her postoperative whole body I 131 scan was negative. She is currently on thyroxine suppression therapy and remains disease free at 6-months follow-up [Figure - 3]. Discussion Rouviere, as early as 1932, believed that there is communication between the cervical and axillary lymphatics, and that physiologic flow is centripetal to the jugulosubclavian junction. But altered lymphatic flow at the jugulosubclavian junction or even at the superior mediastinum has been known to occur primarily because of the blockage of lymph nodes, secondary to metastases, fibrosis as a result of surgical manipulation or even as a consequence of radiotherapy. In such instances, disease has been known to spread in a retrograde direction along the transverse cervical lymph nodes in the supraclavicular region to the axilla. [5],[8] Thus, inherently suggesting that while extensive surgery, radiotherapy, and multiple recurrences could be responsible for metachronous axillary LNM, locoregional anomalous metastatic patterns of lymphatic dissemination probably play a role in patients identified with synchronous lesions. Axillary LNM is rare even in other malignancies of the head and neck. A review conducted over a time span of 10 years identified only four cases of axillary LNM from head and neck squamous cell carcinoma (SCC). Three common characteristics were noted among these patients with axillary metastasis: (a) the initial neck mass or primary tumor had been successfully treated years prior to the development of the axillary metastases, (b) the neck had been treated with both surgery and radiotherapy, and (c) in all cases there was a new primary tumor or late recurrent SCC. [9] In our patient, the malignancy, bilateral neck dissection with an initial right-sided yield of 18/21 positive nodes, and subsequent cervical nodal recurrences over a period of 6 years could have caused the axillary LNM. Nakayama reviewed isolated reports of thyroid carcinomas presenting with axillary LNM. Carcinomas such as medullary thyroid carcinoma, mucoepidermoid carcinoma, and mucin-producing poorly differentiated adenocarcinoma were documented; however, there has been no report of such an event arising in a follicular thyroid carcinoma. [5] In our search, we found only seven reports [2],[3],[4],[5],[6],[7] in the English language literature documenting axillary LNM in PTC. These details are summarized in [Table - 1]. Including our case, there are six women and two men. The mean age was 55, with a patient aged as young as 21 [5] presenting with PTC and a concurrent axillary nodal mass. Three patients presented with concurrent axillary LNM [2],[5],[6] and five presented with axillary LNM as part of recurrent [2],[3],[4],[7] disease. In the cases with recurrent disease, the period from initial diagnosis to the development of axillary nodal recurrence ranged from 5 to 41 years. [2],[3],[4] The patients with axillary metastatic lesions had predominantly poorly differentiated tumors other than the case described by Kepenecki [6] where the histology was indicative of a well-differentiated neoplasm, thereby suggesting that axillary LNM may be associated with a poorly differentiated carcinoma. [2],[3],[5] Moreover, in repeated recurrences, PTCs can be transformed into poorly differentiated carcinomas, or into histological variants associated with worse prognosis as seen in our patient. Many authors have found no prognostic significance for cervical nodal metastases in differentiated thyroid cancer; [1],[10] however, in the isolated reports of metastatic axillary disease, four of the seven patients had distant metastatic lesions, with the lung being the commonest site, with only one patient alive with disease. Thus, axillary LNM can be an indicator of systemic disease and poor prognosis. [2],[3],[4],[5],[6],[7] Prophylactically, in view of this experience, we recommend monitoring axillary lymph nodes to be part of surveillance in patients who develop multiple recurrent or second primary malignancies after aggressive treatment of the neck. References
Copyright 2011 - Journal of Cancer Research and Therapeutics The following images related to this document are available:Photo images[cr11055t1.jpg] [cr11055f2.jpg] [cr11055f1.jpg] [cr11055f3.jpg] |
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