509
Carcinomatous Infiltration of the Thyroid Presenting as Thyroiditis and Stridor Annie W. C. Kung, T. Lorentz, Elaine Tsui and Christina Wang Departments of Medicine and Surgery, University of Hong Kong, Queen Mary Hospital, Hong Kong
Carcinomatous involvement of the thyroid gland is a very unusual cause of hyperthyroidism. We report a patient with adenocarcinoma of the lung presenting with severe hyperthyroidism and stridor. Aspiration cytology and subsequent emergency isthmusectomy showed tumor infiltration of the thyroid and trachea. Thyroid function declined rapidly into hypothyroid range within 2 weeks, mimicking that of thyroiditis. Despite local irradiation to the neck and thyroxine replacement, she died from complication of progressive disease. This case illustrates the usefulness of needle aspiration cytology when the possibility of the presence of metastatic lesion is being considered.
Case Report An 81-year-old lady was admitted with a one day history of shortness of breath. She presented 18 months before with chest pain and chest X-ray showed a 2 cm-diameter lesion over the right lower lobe. The lesion was inaccessible to transbronchial biopsy, and cytological examination of sputum and bronchial lavage revealed no malignant cells. There was no other evidence of malignancy. In particular, no goitre was present. As the patient refused further invasive investigation, she was observed at the out-patient clinic. Serial chest Xrays showed progressive enlargement of the lesion but otherwise the patient remained asymptomatic. The presumptive diagnosis was carcinoma of the lung. On the present admission, she noticed shortness of breath for 1 day. Neck pain and symptoms of hyperthyroidism were absent. On examination she had a fever of 39 °C, inspiratory stridor, a non-tender, firm goitre of 1 / 2 times normal and sinus tachycardia of 140/min. There was no thrill or bruit over the goitre. Direct laryngoscopy revealed extrinsic compression of the trachea at 1.5 cm below the vocal cords. Otherwise the trachea and the bronchial tree appeared normal. An endotracheal tube was immediately inserted and the patient was nursed in the intensive care unit with oxygen support. While awaiting emergency operation, an aspiration needle biopsy was performed which yielded mostly necrotic tissue and a few bizzare malignant cells. Thyroid function showed markedly elevated total T4 of 880 mmol/1 (normal 62—154), free thyroxine index of 1011 after serial dilution of the serum (normal 76-150), total T3 of 2.8 mmol/1 (normal 0.8—3), thyroglobulin of 335.3 mg/1 (normal 0-41), thyroidstimulating hormone (TSH) < 0.05 mU/1 (normal 0.29-3.7). Antimicrosomal and antithyroglobulin antibodies were not detected. Erythrocyte sedimentation rate (ESR) was 13 mm/hr.
Fig. 1 Clinical course of the patient representing change in serum free thyroxine index( ),TotalT3( )TSH( )andThyroglobulin (Tg, ) in relation to time (day of presentation).
At operation, the isthmus of the thyroid was found adherent to the trachea causing construction. There was dense malignant tissue on both sides of the neck adjacent to the thyroid. Isthmusectomy and tracheostomy was performed. Histology of the resected thyroid, trachea and malignant tissue lateral to the thyroid all showed bizarre malignant cells with tendency to form glands. Stain for mucin was positive while stain for thyroglobulin was negative. Features were consistent with poor differentiated adenocarcinoma, most likely to be metastatic from the lung. In view of the histological findings, all drugs were stopped. Circulating thyroid stimulating antibody (Hinds, Takai, Rapoport, Filetti and Clerk 1981) was negative. Thyroid function declined rapidly and the patient became hypothyroid by day 20 of presentation (Fig. 1) and thyroxine supplement was started. Local irradiation was given to the neck region but the patient eventually died of superimposed pneumonia. We believe that the metastatic lesions led to disruption of thyroid follicles and release of preformed thyroid hormones and thyroglobulin. The clinical picture mimicked that of painless thyroiditis. Unfortunately, the patient's urgent condition precluded thyroid scan, which would have helped to differentiate thyroiditis from Graves' disease. Discussion
The clinical diagnosis was tumor destruction of the thyroid gland leading to severe hyperthyroxinaemia with impending thyroid storm. In view of the urgency for surgical decompression, she was given propylthiouracil, Lugol's iodine, dexamethasone and also ice packs to lower the temperature, p-blocker was not given in view of her old age and previous history of chronic obstructive airway disease.
Horm.metab.Res.23(1991)509-510 © Georg Thieme Verlag Stuttgart • New York
Occult secondary metastasis to the thyroid is not uncommon (Shimaoka, Sokal and Pickren 1962) but clinical metastasis to the thyroid presenting with thyroid dysfunction or thyroiditis is a rare entity.
Received: 31 May 1990
Accepted: 13 May 1991 after revision
Downloaded by: York University libraries. Copyrighted material.
Introduction
Horm. metab. Res. 23 (1991) There are only few reported cases of either hyper(Edmonds and Thompson 1978; Eriksson, Ajmani and Mallette 1977) or hypothyroidism (Sirota, Goldfield, Eng and Unger 1968) associated with carcinomatous involvement of the thyroid. These patients usually have a nodular goitre and may or may not have other features of subacute thyroiditis (Watts and Sewell 1988; Tibaldi, Shapiro and Mahadevia 1986), including fever, tender goitre, raised ESR, elevated thyroid hormones followed by a variable period of hypothyroidism, and low thyroidal radioiodine uptake. The high T4 together with a relatively normal T3 level in this patient helps to distinguish between hyperthyroidism due to excessive release of performed hormone, which occurs in thyroiditis, versus that due to hormone overproduction from thyrotoxicosis. Aspiration cytology is usually helpful in making the correct diagnosis but may be difficult if there is a lot of tissue destruction as in our case, and multiple sampling may be necessary. Treatment of the hyperthyroidism is usually symptomatic with e. g. flblockers, salicylates, nonsteroidal antiinflammatory drugs, or glucocorticoids. Local irradiation to the neck (Eriksson, Ajmani and Mallette 1977) or surgical thyroidectomy (Edmonds and Thompson 1978) may be useful if the thyroid is the only metastatic lesion. Replacement of thyroid hormones in patients with hypothyroidism may help to improve the general well-being of the patient. In our patient, the profound hypothyroidism could also be partly accounted by the anti-thyroid therapy given pre-operatively. The most common primary sources of malignancy are the kidney, breast, lung and lymphoid tissue (Ivy 1984). Most of these patients are elderly and have extensive progressive diseases and poor prognosis and interpretation of thyroid function tests may be difficult because of concommittent euthyroid sick syndrome where TSH levels may be suppressed. However, patients with malignant lymphoma or renal cell carcinoma may benefit from systemic chemotherapy (Skarin 1986) or interferon (Quesada,
Annie W. C. Kung, T. Lorentz, Elaine Tsui and Christina Wang Rios, Swanson, Trown and Gutterman 1985) respectively with some prolongation of survival.
References Edmonds, C. J., B. D. Thompson: Clin. Endocrinol. (Ocf.) 8: 411-45 (1978) Eriksson, M., S. K. Ajmani, L. E. Mallette: JAMA 238: 1276-1278 (1977) Hinds, W., N. Takai, B. Rapoport, S. Filetti, O. H. Clark: J. Clin. Endocrinol. Metab. 52:1204-1210(1981) Ivy, H. K.:Ma.yoClin. Proc. 59: 856-859 (1984) Quesada, J. R., A. Rios, D. Swanson, P. Trown, J. U. Gutterman: J. Clin. Oncol. 3:1522-1529(1985) Shimaoka, K., J. E. Sokal, J. W. Pickren:Cancer 15:557-562 (1962) Sirota, D. K., E. B. Goldfleld, Y. F. Eng, A. H. Unger: J. Mt. Sinai Hosp. 35: 242-245 (1968) Skarin, A. T: Seminars in Oncol. 13 (Suppl. 5): 10-25 (1986) Tibaldi, J. M., L. E. Shapiro, P. S. Mahadevia: Mayo Clin. Proc. 61: 399-400(1986) Watts, N. B., C. W. Sewell: Am. J. Med. Sci. 296 (2): 126-128 (1988)
Requests for reprints should be addressed to: Dr. Annie Kung Department of Medicine University of Hong Kong Queen Mary Hospital Hong Kong
Downloaded by: York University libraries. Copyrighted material.
510
Carcinomatous Infiltration of the Thyroid Presenting as Thyroiditis and Stridor Annie W. C. Kung, T. Lorentz, Elaine Tsui and Christina Wang Departments of Medicine and Surgery, University of Hong Kong, Queen Mary Hospital, Hong Kong
Carcinomatous involvement of the thyroid gland is a very unusual cause of hyperthyroidism. We report a patient with adenocarcinoma of the lung presenting with severe hyperthyroidism and stridor. Aspiration cytology and subsequent emergency isthmusectomy showed tumor infiltration of the thyroid and trachea. Thyroid function declined rapidly into hypothyroid range within 2 weeks, mimicking that of thyroiditis. Despite local irradiation to the neck and thyroxine replacement, she died from complication of progressive disease. This case illustrates the usefulness of needle aspiration cytology when the possibility of the presence of metastatic lesion is being considered.
Case Report An 81-year-old lady was admitted with a one day history of shortness of breath. She presented 18 months before with chest pain and chest X-ray showed a 2 cm-diameter lesion over the right lower lobe. The lesion was inaccessible to transbronchial biopsy, and cytological examination of sputum and bronchial lavage revealed no malignant cells. There was no other evidence of malignancy. In particular, no goitre was present. As the patient refused further invasive investigation, she was observed at the out-patient clinic. Serial chest Xrays showed progressive enlargement of the lesion but otherwise the patient remained asymptomatic. The presumptive diagnosis was carcinoma of the lung. On the present admission, she noticed shortness of breath for 1 day. Neck pain and symptoms of hyperthyroidism were absent. On examination she had a fever of 39 °C, inspiratory stridor, a non-tender, firm goitre of 1 / 2 times normal and sinus tachycardia of 140/min. There was no thrill or bruit over the goitre. Direct laryngoscopy revealed extrinsic compression of the trachea at 1.5 cm below the vocal cords. Otherwise the trachea and the bronchial tree appeared normal. An endotracheal tube was immediately inserted and the patient was nursed in the intensive care unit with oxygen support. While awaiting emergency operation, an aspiration needle biopsy was performed which yielded mostly necrotic tissue and a few bizzare malignant cells. Thyroid function showed markedly elevated total T4 of 880 mmol/1 (normal 62—154), free thyroxine index of 1011 after serial dilution of the serum (normal 76-150), total T3 of 2.8 mmol/1 (normal 0.8—3), thyroglobulin of 335.3 mg/1 (normal 0-41), thyroidstimulating hormone (TSH) < 0.05 mU/1 (normal 0.29-3.7). Antimicrosomal and antithyroglobulin antibodies were not detected. Erythrocyte sedimentation rate (ESR) was 13 mm/hr.
Fig. 1 Clinical course of the patient representing change in serum free thyroxine index( ),TotalT3( )TSH( )andThyroglobulin (Tg, ) in relation to time (day of presentation).
At operation, the isthmus of the thyroid was found adherent to the trachea causing construction. There was dense malignant tissue on both sides of the neck adjacent to the thyroid. Isthmusectomy and tracheostomy was performed. Histology of the resected thyroid, trachea and malignant tissue lateral to the thyroid all showed bizarre malignant cells with tendency to form glands. Stain for mucin was positive while stain for thyroglobulin was negative. Features were consistent with poor differentiated adenocarcinoma, most likely to be metastatic from the lung. In view of the histological findings, all drugs were stopped. Circulating thyroid stimulating antibody (Hinds, Takai, Rapoport, Filetti and Clerk 1981) was negative. Thyroid function declined rapidly and the patient became hypothyroid by day 20 of presentation (Fig. 1) and thyroxine supplement was started. Local irradiation was given to the neck region but the patient eventually died of superimposed pneumonia. We believe that the metastatic lesions led to disruption of thyroid follicles and release of preformed thyroid hormones and thyroglobulin. The clinical picture mimicked that of painless thyroiditis. Unfortunately, the patient's urgent condition precluded thyroid scan, which would have helped to differentiate thyroiditis from Graves' disease. Discussion
The clinical diagnosis was tumor destruction of the thyroid gland leading to severe hyperthyroxinaemia with impending thyroid storm. In view of the urgency for surgical decompression, she was given propylthiouracil, Lugol's iodine, dexamethasone and also ice packs to lower the temperature, p-blocker was not given in view of her old age and previous history of chronic obstructive airway disease.
Horm.metab.Res.23(1991)509-510 © Georg Thieme Verlag Stuttgart • New York
Occult secondary metastasis to the thyroid is not uncommon (Shimaoka, Sokal and Pickren 1962) but clinical metastasis to the thyroid presenting with thyroid dysfunction or thyroiditis is a rare entity.
Received: 31 May 1990
Accepted: 13 May 1991 after revision
Downloaded by: York University libraries. Copyrighted material.
Introduction
Horm. metab. Res. 23 (1991) There are only few reported cases of either hyper(Edmonds and Thompson 1978; Eriksson, Ajmani and Mallette 1977) or hypothyroidism (Sirota, Goldfield, Eng and Unger 1968) associated with carcinomatous involvement of the thyroid. These patients usually have a nodular goitre and may or may not have other features of subacute thyroiditis (Watts and Sewell 1988; Tibaldi, Shapiro and Mahadevia 1986), including fever, tender goitre, raised ESR, elevated thyroid hormones followed by a variable period of hypothyroidism, and low thyroidal radioiodine uptake. The high T4 together with a relatively normal T3 level in this patient helps to distinguish between hyperthyroidism due to excessive release of performed hormone, which occurs in thyroiditis, versus that due to hormone overproduction from thyrotoxicosis. Aspiration cytology is usually helpful in making the correct diagnosis but may be difficult if there is a lot of tissue destruction as in our case, and multiple sampling may be necessary. Treatment of the hyperthyroidism is usually symptomatic with e. g. flblockers, salicylates, nonsteroidal antiinflammatory drugs, or glucocorticoids. Local irradiation to the neck (Eriksson, Ajmani and Mallette 1977) or surgical thyroidectomy (Edmonds and Thompson 1978) may be useful if the thyroid is the only metastatic lesion. Replacement of thyroid hormones in patients with hypothyroidism may help to improve the general well-being of the patient. In our patient, the profound hypothyroidism could also be partly accounted by the anti-thyroid therapy given pre-operatively. The most common primary sources of malignancy are the kidney, breast, lung and lymphoid tissue (Ivy 1984). Most of these patients are elderly and have extensive progressive diseases and poor prognosis and interpretation of thyroid function tests may be difficult because of concommittent euthyroid sick syndrome where TSH levels may be suppressed. However, patients with malignant lymphoma or renal cell carcinoma may benefit from systemic chemotherapy (Skarin 1986) or interferon (Quesada,
Annie W. C. Kung, T. Lorentz, Elaine Tsui and Christina Wang Rios, Swanson, Trown and Gutterman 1985) respectively with some prolongation of survival.
References Edmonds, C. J., B. D. Thompson: Clin. Endocrinol. (Ocf.) 8: 411-45 (1978) Eriksson, M., S. K. Ajmani, L. E. Mallette: JAMA 238: 1276-1278 (1977) Hinds, W., N. Takai, B. Rapoport, S. Filetti, O. H. Clark: J. Clin. Endocrinol. Metab. 52:1204-1210(1981) Ivy, H. K.:Ma.yoClin. Proc. 59: 856-859 (1984) Quesada, J. R., A. Rios, D. Swanson, P. Trown, J. U. Gutterman: J. Clin. Oncol. 3:1522-1529(1985) Shimaoka, K., J. E. Sokal, J. W. Pickren:Cancer 15:557-562 (1962) Sirota, D. K., E. B. Goldfleld, Y. F. Eng, A. H. Unger: J. Mt. Sinai Hosp. 35: 242-245 (1968) Skarin, A. T: Seminars in Oncol. 13 (Suppl. 5): 10-25 (1986) Tibaldi, J. M., L. E. Shapiro, P. S. Mahadevia: Mayo Clin. Proc. 61: 399-400(1986) Watts, N. B., C. W. Sewell: Am. J. Med. Sci. 296 (2): 126-128 (1988)
Requests for reprints should be addressed to: Dr. Annie Kung Department of Medicine University of Hong Kong Queen Mary Hospital Hong Kong
Downloaded by: York University libraries. Copyrighted material.
510
