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Thyroid metastasis from esophageal adenocarcinoma: a case report and literature review
Surgical Case Reportsvolume 5, Article number: 137 (2019)
The incidence of metastatic spread of gastrointestinal malignancies to the thyroid gland is relatively low and most of these malignancies originate from the colorectum. Thyroid metastasis originating from the esophagus is poorly documented.
A 79-year-old man presented with hoarseness of voice and swallowing difficulty. Eighteen months earlier, he had undergone preoperative chemotherapy (S-1 and oxaliplatin [SOX] therapy) and subtotal esophagectomy with regional lymph nodes dissection and retrosternal narrow gastric tube reconstruction for advanced Barrett’s esophageal adenocarcinoma. In the ultrasonographic examination, there was a hypoechoic, indistinct border and heterogeneous nodule in the left lobe of the thyroid gland. Pathological examination of an ultrasound-guided fine-needle aspiration showed adenocarcinoma, supporting a diagnosis of esophageal adenocarcinoma metastases in the thyroid.
This is a first case of a patient with thyroid metastasis from Barrett’s esophageal adenocarcinoma after subtotal esophagectomy.
The incidence of metastatic spread of gastrointestinal malignancies to the thyroid gland is relatively low, and most of these malignancies originate from the colorectum . Thyroid metastasis originating from the esophagus is poorly documented. Herein, we report a first case of a patient with thyroid metastasis from Barrett’s esophageal adenocarcinoma after subtotal esophagectomy.
A 79-year-old man presented with hoarseness of voice and swallowing difficulty. Eighteen months earlier, he had undergone preoperative chemotherapy (S-1 and oxaliplatin [SOX] therapy) and subtotal esophagectomy with regional lymph node dissection and retrosternal narrow gastric tube reconstruction for advanced esophageal cancer. The histological examination of the resected specimen revealed Barrett’s esophageal adenocarcinoma pStage III (8th UICC TNM classification) (Fig. 1).
Upper gastrointestinal endoscopy showed no abnormal finding including anastomosis site (cervical esophagus and gastric tube). Contrast-enhanced computed tomography (CT) revealed a low-density mass in his left thyroid gland (Fig. 2a). In the ultrasonographic examination, there was a hypoechoic, indistinct border and heterogeneous nodule measuring 16.9 mm × 19.7 mm × 23.9 mm in the left lobe of the thyroid gland (Fig. 2b, c). Pathological examination of an ultrasound-guided fine-needle aspiration showed adenocarcinoma, supporting a diagnosis of esophageal adenocarcinoma metastases in the thyroid (Fig. 2d). The patient commenced chemotherapy with pembrolizumab, combined chemotherapy of docetaxel with cisplatin (CDDP), and 5-fluorouracil (5-FU) in a clinical trial. This treatment effectively shrank the tumor after seven courses.
The incidence of intrathyroidal metastases in autopsy series varies from 1.25 to 24.0% in cancer patients [2, 3]. The metastatic spread of gastrointestinal malignancies to the thyroid gland is relatively rare; the majority originate from the colorectum . Thyroid metastasis from the esophagus has only been reported in eight cases in the English-language literature [1, 4,5,6,7,8,9,10,11]. Importantly, this is the first case of thyroid metastasis from Barrett’s esophageal carcinoma.
Table 1 summarizes the clinical features of the eight previously published cases plus our report of thyroid metastasis from esophageal cancer. The age of the patients at presentation was variable, ranging from 32 to 79 years with an average age of 62.1 years. Four out of the eight previously reported cases were treated with thyroidectomy, and the management in the other two cases was not reported . In the postoperative histopathological specimen, six patients showed squamous cell carcinomas and two were adenocarcinomas. Thyroid metastasis of Barrett’s adenocarcinoma has never been reported previously in any literature.
Generally, despite being second to the adrenal glands as the most vascular perfused organ in the body , the thyroid is rarely considered to be the sole site of metastases in the clinical practice and is usually asymptomatic [14, 15]. Cichon et al. reported that metastasis to the thyroid only accounts for 2 to 3% of all thyroid carcinomas identified in the clinical practice . The most common primary sites are the kidney, breast, and lung [17,18,19,20]. Direct extension of adjacent primaries, a hematogenous pathway, and lymphatic route for metastatic spread to the thyroid have been estimated [6, 21]. Czech et al. suggested that the vertebral vein plexus may play an important role in the process of metastases from other organs to the thyroid . Unfortunately, according to a review of the related literature, no case of careful imaging and pathologic evaluation of the most likely route of metastasis in the thyroid has been reported. In our case, the tumor may be considered as a lymphogenous metastasis because there were cervical lymph node metastases in the postoperative histopathological specimen and this lymph node was anatomically close to the thyroid. Of course, we acknowledge that further examination such as autopsy may be useful to clarify the mechanism.
There is no clear consensus on therapeutic strategy for metastatic thyroid cancers from esophageal cancer. Thus, the management is determined on a case-by-case basis [1, 9, 22]. Overall, most patients with metastasis to the thyroid had poor outcomes, with reported 9-month survival after the original diagnosis  (Table 1). However, one case was reported where the patient was without evidence of recurrence 4 years after thyroidectomy . In the present case, the patient commenced chemotherapy with pembrolizumab, CDDP, and 5-FU in a clinical trial and experienced a favorable therapeutic effect. If the tumor is still reduced with no new metastatic lesion for some time, we might consider performing surgical resection (i.e., thyroidectomy).
This case highlights the need for awareness of the possibility of potential metastatic deposits in unexpected sites. A new thyroid mass with a history of cancer, however remote the previous primary cancer was, should be evaluated for the possibility of metastasis. Metastasis should also be strongly considered whenever the histology is unusual for a primary thyroid lesion. Although the prognosis of metastasis in the thyroid is commonly poor, patients may have improved quality of life and longer survival time after early accurate diagnosis and proper treatment.
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All data generated or analyzed during this study are included in this published article.
S-1 and oxaliplatin
Union for International Cancer Control
Squamous cell carcinoma
Yoshida A, Imamura A, Tanaka H, Hirano M, Kamma H, Ueno E, Ushio H, Aiyoshi Y, Soeda S. A case of metastasis from gastric cancer to the thyroid gland. Jpn J Surg. 1989;19:480–4.
Berge T, Lundberg S. Cancer in Malmo 1958–1969. An autopsy study. Acta Pathol Microbiol Scand Suppl. 1977;1:235.
Nakhjavani MK, Gharib H, Goellner JR, Van Heerden JA. Metastasis to the thyroid gland. A report of 43 cases. Cancer. 1997;79:574–8.
Shuangshoti S. Primary carcinomas of esophagus and bronchus with presentation simulating primary carcinoma of thyroid gland. J Med Assoc Thai. 1982;65:38–44.
Yamada T, Tatsuzawa Y, Yagi S, Fujioka S, Kitagawa S, Nakagawa M, Minato H, Kurumaya H, Matsunou H. Lymphoepithelioma-like esophageal carcinoma: report of a case. Surg Today. 1999;29:542–4.
Basu S, Nair N, Borges AM. Squamous cell carcinoma of esophagus masquerading as solitary thyroid nodule. Indian J Cancer. 2005;42:205–7.
Cumbo-Nacheli G, De Sanctis JT, Chung MH. Proximal esophageal adenocarcinoma presenting as a thyroid mass: case report and review of the literature. Thyroid. 2007;17:267–9.
Moulick A, Guha P, Das A, Das AK. Squamous cell carcinoma of proximal esophagus with simultaneous metastases to thyroid and sternum: a case report and review of the literature. Tanaffos. 2012;11:67–70.
Chen ED, Cheng P, Yan XQ, Ye YL, Chen CZ, Ji XH, Zhang XH. Metastasis of distal esophageal carcinoma to the thyroid with presentation simulating primary thyroid carcinoma: a case report and review of the literature. World J Surg Oncol. 2014;12:106.
Cheng P, Xiang Y, Chen E, Zou Z, Zhang X. Papillary thyroid microcarcinoma with synchronous asymptomatic advanced esophageal squamous cell carcinoma: a case report and review of the literature. Oncol Lett. 2015;9:731–4.
Reese J, Chebolu A, Shen Y, Mihlon F. Case report: Diffuse metastatic infiltration of the thyroid by esophageal adenocarcinoma mimicking non-neoplastic thyroid disease. Radiol Case Rep. 2017;13:108–11.
Chen JY, Chen IW, Hsueh C, Chao TC, Gao BR, Lin JD. Synchronous diagnosis of metastatic cancer to the thyroid is associated with poor prognosis. Endocr Pathol. 2015;26:80–6.
Wychulis AR, Beahrs OH, Woolner LB. Metastasis of carcinoma to the thyroid gland. Ann Surg. 1964;160:169–77.
Chen H, Nicol TL, Udelsman R. Clinically significant, isolated metastatic disease to the thyroid gland. World J Surg. 1999;23:177–80 Discussion 181.
Kihara M, Yokomise H, Yamauchi A. Metastasis of renal cell carcinoma to the thyroid gland 19 years after nephrectomy: a case report. Auris Nasus Larynx. 2004;31:95–100.
Cichon S, Anielski R, Konturek A, Barczynski M, Cichon W. Metastases to the thyroid gland: seventeen cases operated on in a single clinical center. Langenbecks Arch Surg. 2006;391:581–7.
Pillay SP, Angorn IB, Baker LW. Tumour metastasis to the thyroid gland. S Afr Med J. 1977;51:509–12.
Ericsson M, Biorklund A, Cederquist E, Ingemansson S, Akerman M. Surgical treatment of metastatic disease in the thyroid gland. J Surg Oncol. 1981;17:15–23.
Czech JM, Lichtor TR, Carney JA, Van Heerden JA. Neoplasms metastatic to the thyroid gland. Surg Gynecol Obstet. 1982;155:503–5.
McCabe DP, Farrar WB, Petkov TM, Finkelmeier W, O’Dwyer P, James A. Clinical and pathologic correlations in disease metastatic to the thyroid gland. Am J Surg. 1985;150:519–23.
Fujita T, Ogasawara Y, Doihara H, Shimizu N. Rectal adenocarcinoma metastatic to the thyroid gland. Int J Clin Oncol. 2004;9:515–9.
Murakami S, Yashuda S, Nakamura T, Mishima Y, Iida H, Okano H, Nakano M. A case of renal cell carcinoma with metastasis to the thyroid gland and concomitant early gastric cancer. Surg Today. 1993;23:153–8.
Lin JD, Weng HF, Ho YS. Clinical and pathological characteristics of secondary thyroid cancer. Thyroid. 1998;8:149–53.
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