Cho, W

Conboy, P

Das, S

Yang, W

Journal of Surgical Case Reports

English

Differentiated carcinomas of the thyroid gland usually have a good prognosis with prognosis often discussed in terms of 20 year survival. Nevertheless its 10-year-survival rate decreases when accompanied by distant metastasis. Follicular thyroid cancer (FTC) is the second most common thyroid cancer and usually presents with a solitary thyroid nodule with or without cervical lymphadenopathy. Distance metastasis at initial diagnosis is seldom observed with incidence range from 1 to 9%. In cases of bone metastasis, the incidence is only 2-3% and weight-bearing skeleton is preferentially affected. In our case, we present a patient with FTC that metastasized to the upper limb causing severe pain and pathological fracture at the initial presentation

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Journal of Surgical Case Reports, 2017;1, 1–3doi: 10.1093/jscr/rjx002Case ReportC A S E R E PORTFollicular thyroid carcinoma presentingwith pathological fracture of the humerusat initial diagnosisWanding Yang*, WaiSum Cho, Sudip Das, and Peter ConboyDepartment of Otorhinolaryngology, Head and Neck Surgery, Leicester Royal Infirmary, Infirmary Square,LE1 5WW, UK*Correspondence address. Department of Otorhinolaryngology, Head and Neck Surgery, Leicester Royal Infirmary, Infirmary Square, LE1 5WW, UK.Tel: +07894431802; Fax: +44 1162586082; E-mail: dingyang@doctors.org.ukAbstractDifferentiated carcinomas of the thyroid gland usually have a good prognosis with prognosis often discussed in terms of20 year survival. Nevertheless its 10-year-survival rate decreases when accompanied by distant metastasis. Follicular thy-roid cancer (FTC) is the second most common thyroid cancer and usually presents with a solitary thyroid nodule with orwithout cervical lymphadenopathy. Distance metastasis at initial diagnosis is seldom observed with incidence range from1 to 9%. In cases of bone metastasis, the incidence is only 2–3% and weight-bearing skeleton is preferentially affected. Inour case, we present a patient with FTC that metastasized to the upper limb causing severe pain and pathological fractureat the initial presentation.INTRODUCTIONFollicular carcinoma of thyroid gland is the secondmost commonthyroid cancer after papillary thyroid carcinoma. Clinically,differentiated thyroid cancer (DTC) commonly presents with asolitary thyroid nodule and/or cervical lymphadenopathy.Distant metastasis at initial presentation, especially those involv-ing bone, is seldom seen and associated with poor clinical out-comes. In those cases, the axial skeleton and in particular thespine and the ribs are preferentially involved resulting symptomssuch as severe pain and compression fracture [1, 2]. A patho-logical fracture of the upper limb as an initial symptom of a latediagnosis of DTC is therefore extremely rare and has almost neverbeen reported in literature. In this paper, we present a case of apatient with follicular thyroid cancer who presented with patho-logical fracture of the humeruswithout preceding illness.CASE REPORTA previously fit and well 38-year-old man was presented to theemergency department with immediate extreme pain in theleft arm after twisting it at home that day. Plain radiographs ofthe left upper limb showed a fracture of the left proximalhumerus associated with a lytic lesion (Fig. 1).An urgent staging magnetic resonance imaging (MRI) of theleft humerus demonstrated a fairly well-defined destructivelesion of proximal left humerus, which measured ~6 cm cranio-caudally (Fig. 2). Both the cortex and the marrow were diffuselyinfiltrated and there was a small extra-osseous tumour massanteriorly. Computed tomography (CT) scan of thorax/abdo-men/pelvis with contrast could not identify a clear primarysource of malignancy but it showed an enlarged right lobe thy-roid gland with retrosternal extension (Fig. 3).Received: October 28, 2016. Accepted: January 3, 2017Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved. © The Author 2017.This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited.For commercial re-use, please contact journals.permissions@oup.com1The thyroid lobe was investigated 6 years before where amulti-nodular goitre (MNG) with a dominant solitary nodule onthe right thyroid lobe was discovered. Ultrasound did not showany suspicious characteristics. A fine needle aspiration cytology(FNAC) specimen of the solitary nodule was reported as a Thy2with features consistent with a simple nodule. The investigationswere arranged by the patient’s general medical practitioner whoreassured the patient without the input of secondary services.Following the finding of the CT scan, the patient wasreferred to the local ENT department, where ultrasound of theneck and core biopsy of the thyroid nodule was conducted. Theimage confirmed a MNG with largest nodule in the right lobe.And the core biopsy showed a follicular pattern with thyroidfollicles of varying sizes set in a mixture of fibrous tissue.A CT guided biopsy of the left humerus after the initial pres-entation confirmed a metastatic thyroid cancer.The patient underwent urgent excision of tumour andreplacement of left proximal humerus. Histologically, the massfrom the left proximal humerus demonstrated features consist-ent with metastatic thyroid carcinoma. Six weeks later, heunderwent total thyroidectomy and neck dissection. A largethyroid lobe was found with no local invasion and four largeLevel VI lymph nodes were excised. The pathologic findingsconfirmed complete excision of a 70mm widely invasive follicu-lar carcinoma with evidence of vascular invasion and metasta-sis of three out of the four central neck nodes.After thyroidectomy, the patient was seen by clinical oncol-ogy and radioiodine therapy was administered. He continues tobe followed up by the local orthopaedic and ENT teams.Figure 1: X-ray showed lytic lesion and pathological fracture of left proximalhumerus. Plain radiographs of the left.Figure 2: MRI left humerus showed pathological fracture of the neck and prox-imal shaft humerus, measure 6 × 2.5 × 2.8 cm in maximal dimension. An urgentstaging magnetic resonance.Figure 3: CT Chest with contrast showed an enlarged right lobe thyroid glandwith retrosternal extension causing compression and deviation of trachea(arrow). (A) axial view. (B) coronal view. CT scan.2 | W. Yang et al.DISCUSSIONPatients with bone metastases of unknown origin are notuncommon in clinical practice. The primary tumour is mostlikely found in breast and prostate followed by the thyroidgland [3]. The bone metastases in DTC is osteolytic in natureand its distribution preferentially involves the weight-bearingskeletons such as vertebrae (52.5%), femur (20.4%), pelvis(16.0%) and clavicle (13.6%) [4]. Common manifestations of theosseous metastases include pain, fracture and spinal cord com-pression associated with lesion in the axial skeleton. In thiscase, we described an extremely rare scenario where patho-logical fracture of the upper limb was the initial presentation ofmetastatic DTC.Of interest in our case is that the patient presented with athyroid lump 6 years before which was diagnosed as a domin-ant nodule with a background of benign MNG. In the absence ofsuspicious sonographic ultrasound features and benign patho-cytological finding of Thy2 on FNAC, the patient was reassuredby the general practitioner. Although ultrasound-guided FNACis an excellent tool for evaluating patients with solitary thyroidnodules, its utility in patients with MNG has been questionedin the past [5]. The British Thyroid Association (BTA) recom-mends FNAC should be carried out if ultrasound features areequivocal, indeterminate or suspicious of malignancy [6]. In ourcase, FNAC was performed although the nodule appearedbenign and subsequent FNAC result supported the findingsthat the nodule was benign in nature. Despite this, our patientpresented with a malignancy 6 years later. In cases whereFNAC were conducted and proven to be benign in patients withnon-functional, cervical MNG the incidental thyroid cancer dis-covered at the time of thyroidectomy can be as high as 23% [5].Male gender tends to be associated with an increased likelihoodof cancer on final pathology [5, 7].In conclusion, despite the relative rarity of causing patho-logical fracture in the humerus, thyroid cancer should beconsidered during assessment of the patient with pathologicalfractures of unknown primary origin. Although the gold stand-ard for investigation thyroid nodule remains ultrasound-guidedFNAC, a benign FNAC especially in male patients with a MNGmay need a more aggressive management due to the increasedrisk of an undetected thyroid cancer.CONFLICT OF INTEREST STATEMENTNone declared.REFERENCES1. Pittas AG, Adleer M, Fazzari M, Tickoo S, Rosai J, Larson SM,et al. Bone metastases from thyroid carcinoma: clinical char-acteristics and prognostic variables in one hundred forty-sixpatients. Thyroid 2000;10:261–8.2. Kallel F, Hamza F, Chargeddine S, Amouri W, Jardak I,Ghorbel A, et al. Clinical features of bone metastasis for dif-ferentiated thyroid carcinoma: a study of 21 patients from aTunisian center. Indian J Endocrinol Metab 2014;18:185–90.3. Rougraff BT. Evaluation of the patient with carcinoma ofunknown origin metastatic to bone. Clin Orthop 2003;415:S105–9.4. Wu K, Hou SM, Huang TS, Yang RS. Thyroid carcinoma withbone metastases: a prognostic factor study. Clin Med Oncol2008;2:129–34.5. Campbell MJ, Seib CD, Candell L, Gosnell JE, Duh QY, ClarkOH, et al. The underestimated risk of cancer in patients withmultinodular goiters after a benign fine needle aspiration.World J Surg 2015;39:695–700.6. British Thyroid Association. Guidelines for the managementof thyroid cancer. Clin Endocrinol 2014;81:14–5.7. Nixon IJ, Simo R. The neoplastic goitre. Curr Opin OtolaryngolHead Neck Surg 2013;21:143–9.Follicular thyroid carcinoma | 3

Follicular thyroid carcinoma presenting with pathological fracture of the humerus at initial diagnosis.

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Follicular thyroid carcinoma presenting with pathological fracture of the humerus at initial diagnosis

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