Thyroid carcinoma is an uncommon form of human cancer, with an outstanding overall cure rate. This excellent prognosis is based on the fact that well over 99% of thyroid cancers are primary tumors. Metastatic cancer to the thyroid remains very rare. We report a case of clear cell renal carcinoma metastatic to the thyroid gland 23 years after nephrectomy

Hendricks, Frederick

Knoll, Stanley M.

Rezaei, M. Katayoon

Valdez, Carrie

English

George Washington University: Health Sciences Research Commons (HSRC)

Himmelfarb Health Sciences Library, The George Washington UniversityHealth Sciences Research CommonsPathology Faculty Publications Pathology7-2014Metastatic renal cell carconima to the thyroid 23years after nephrectomyCarrie ValdezGeorge Washington UniversityM. Katayoon RezaeiGeorge Washington UniversityFrederick HendricksGeorge Washington UniversityStanley M. KnollGeorge Washington UniversityFollow this and additional works at: http://hsrc.himmelfarb.gwu.edu/smhs_path_facpubsPart of the Pathology CommonsThis Journal Article is brought to you for free and open access by the Pathology at Health Sciences Research Commons. It has been accepted forinclusion in Pathology Faculty Publications by an authorized administrator of Health Sciences Research Commons. For more information, pleasecontact hsrc@gwu.edu.Recommended CitationValdez, C., Rezaei, M.K., Hendricks, F., Knoll, S.M. (2014). Metastatic renal cell carcinoma to the thyroid 23 years after nephrectomy.Urology Case Reports, 2(4), 129-130.OncologyMetastatic Renal Cell Carcinoma to the Thyroid 23 Years AfterNephrectomyqCarrie Valdez a,*, M. Katayoon Rezaei b, Fredrick Hendricks c, Stanley M. Knoll aaDepartment of Surgery, George Washington University, Washington, DC, USAbDepartment of Pathology, George Washington University, Washington, DC, USAcDepartment of Urology, George Washington University, Washington, DC, USAa r t i c l e i n f oArticle history:Received 5 April 2014Accepted 14 April 2014Keywords:ThyroidRenal cell carcinomaMetastaticFine needle aspirationa b s t r a c tThyroid carcinoma is an uncommon form of human cancer, with an outstanding overall cure rate. Thisexcellent prognosis is based on the fact that well over 99% of thyroid cancers are primary tumors.Metastatic cancer to the thyroid remains very rare. We report a case of clear cell renal carcinomametastatic to the thyroid gland 23 years after nephrectomy. 2014 The Authors. Published by Elsevier Inc. All rights reserved.IntroductionWe review a unique case of metastatic renal cell carcinoma tothe thyroid 23 years after nephrectomy. The discussion will includea review metastatic renal cell carcinoma.Case presentationOur patient is a 78-year-old woman with a left thyroid nodule.She is asymptomatic, euthyroid, and has no history of thyroid dis-ease. Her only surgical history was a right nephrectomy 23 yearsago, for a clear cell carcinoma, 4.6 cm in size, low grade (Fuhrman I),and without vascular, lymphatic, or capsular invasion.The patient’s medical and family histories are negative. Onphysical examination, neck examination revealed a 4.5-cm, soft,well-circumscribed nodule replacing the left lobe of the thyroid.There was no lymphadenopathy. Ultrasonographic examinationshowed 4.4-cm and 0.7-cm nodules in the left thyroid lobe and two1.6-cm nodules in the right thyroid lobe.Fine needle aspiration was performed. Although the cellularityand monomorphic cell population were consistent with aneoplastic process, the characteristic features of primary thyroidneoplasm were lacking. The constellation of cytologic features wasin favor of metastatic renal cell carcinoma. The lesional cells werefocally positive for renal cell carcinoma (RCC) and negative forthyroid transcription factor-1 (TTF-1) immunostains.Once the clinical diagnosis of late metastatic RCC wasestablished by cytopathology, the patient underwent total thy-roidectomy. The left lobe was markedly enlarged and replaced bythe nodule, with an intact capsule. The right lobewas normal in sizewith multiple small nodules. The thyroid was not adherent to anysurrounding structures, and there was no lymphadenopathy.Gross pathologic examination of the specimen revealed amarkedly enlarged left lobe. Cut section revealed an extensivelyhemorrhagic mass with golden-orange speckles of friable tissue,akin to the conventional clear cell RCC seen in nephrectomy spec-imens (Fig. 1). Histologic examination showed a well-defineddistinction between the tumor cells and the adjacent thyroidgland. The tumor showed nests of clear cells separated by a richcapillary network, which is the classic architecture and cellularmorphology of clear cell RCC (Fig. 2). A more extensive panel ofimmunostains appropriately highlighted the renal origin of thetumor cells by strong positivity for RCC (Fig. 3) and CD10 as well asnegativity for TTF-1, a pattern in sharp contrast with the neigh-boring thyroid parenchyma.DiscussionThyroid nodules are quite common, occurring in up to 50% of thepopulation, as indicated by ultrasonography. Only about 5% of theseq This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/3.0/).* Corresponding author. Tel.: þ1-2483905864.E-mail address: carrievaldezmd@gmail.com (C. Valdez).Contents lists available at ScienceDirectUrology Case Reportsjournal homepage: www.elsevier .com/locate/eucr2214-4420/$ e see front matter  2014 The Authors. Published by Elsevier Inc. All rights reserved.http://dx.doi.org/10.1016/j.eucr.2014.04.002Urology Case Reports 2 (2014) 129e130nodules are thyroid cancer. Primary thyroid carcinoma increasedfrom 1% to almost 3% over the past 20 years with the advent ofextensive imaging of the head and neck, with incidental discoveryof thyroid nodules.1 Although metastatic disease to the thyroidgland is rare, when it does occur kidney is the most common pri-mary tumor site.2 Other primary sites include melanoma, lung,breast, esophagus, and uterus; our senior author reported a rarecase finding of colon cancer metastasis to the thyroid.3This report describes a tumor arising from the renal paren-chyma; a clear cell carcinoma, which accounts for 70%-80% of allrenal carcinomas. One of the common characteristics of clear cellcarcinoma is its tendency tometastasizewidely before giving rise toany local symptoms. In addition to the common sites, metastasesfrom renal cancer can occur virtually anywhere in the body,including the thyroid.When renal cell cancers recur, about 60% recur within 2 years,70% within 3 years, 80% within 4 years, and most of the rest within5 years. Recurrences can, however, occur many years later. It hasbeen reported that 4%-11% of patients develop a recurrence 10 yearsafter initial nephrectomy.4The prognosis after surgical excision of clear cell tumors varieswith the size of the tumor, the Fuhrman grade, and the pathologicstage. Overall, approximately 20%-50% of patients will developmetastatic disease after nephrectomy.5 However, clear cell cancers<5 cm in size, low grade (Fuhrman 1), and completely resected,carry an excellent prognosis with a recurrence rate of<5%. This wasthe prognosis for our patient based on her original pathology23 years ago.In a 10-year review of 43 patients with metastatic disease to thethyroid gland at the Mayo clinic, Nakhjavani2 identified the kidneyas the most common primary tumor site (33%), with an averagetime from diagnosis of the primary tumor to metastasis to thethyroid gland of 106 months. After a thorough review of the Englishscientific literature, we were not able to find a longer interval thanour patient (23 years) from initial diagnosis of renal carcinoma tometastasis to the thyroid gland. There is no useful guidance in theliterature on the extent of thyroidectomy for metastatic disease. Inour case, we chose total thyroidectomy because our patient also hadnodules within the contralateral lobe.ConclusionHigh-quality cytopathology services have become extremelyimportant in themanagement of thyroid nodules. Needle aspirationis an accurate, quick, and low-risk technique that may yield inter-esting results such as in this case. This technique served our patientwell in identifying the rare finding of metastatic RCC to the thyroid23 years after initial diagnosis.References1. SEER Cancer Statistics Review, 1975-2009. 2012; Available from: http://seer.cancer.gov/csr/1975_2009_pop09/.2. Nakhjavani MK, Gharib H, Goellner JR. Metastasis to the thyroid gland. A reportof 43 cases. Cancer. 1997;79:574e578.3. Hanna WC, Trachiotis GD, Knoll SM. Colon cancer metastatic to the lung and thethyroid gland. Arch Surg. 2006;141:93e96.4. McNichols DW, Segura JW, DeWeerd JH. Renal cell carcinoma: long-term survivaland late recurrence. J Urol. 1981;126:17e23.5. Flanigan RC, Campbell SC, Clark JL. Metastatic renal cell carcinoma. Curr TreatOptions Oncol. 2003;4:385e390.Figure 1. Large hemorrhagic mass with focal golden yellow discoloration, similar toconventional renal cell carcinoma.Figure 2. Nests of clear cells traversed by a rich capillary network, hematoxylin andeosin, medium power.Figure 3. Strong diffuse labeling of tumor with renal cell carcinoma marker, highpower.C. Valdez et al. / Urology Case Reports 2 (2014) 129e130130

Metastatic renal cell carconima to the thyroid 23 years after nephrectomy

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Metastatic renal cell carconima to the thyroid 23 years after nephrectomy

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