Ectopic Thyroid Nodule in the Esophagus R. W. Postlethwait, M.D., and Don E. Detiner, M.D. ABSTRACT An incidental finding in a 51-year-old man was a small nodule in the cervical portion of the esophagus. The bluish appearance on endoscopy suggested a hemangioma, but subsequent excision showed the submucosal nodule to be thyroid tissue. T w o patients with this lesion have been reported previously.
T
wo patients have previously been reported with a nodule of thyroid in the esophagus. Lawson Whale [4]in 1921 described a woman of unstated age who was seen after swallowing a fish bone. Esophagoscopy showed no bone, but at the level of the second dorsal vertebra posteriorly there was a nodule a little smaller than a cherry attached by a broad pedicle. It was removed by forceps and was found to consist of thyroid tissue. She had no goiter or other abnormalities. Porto [3] in 1960 reported a 56-year-old man with slightly painful swallowing. Examinations, including barium swallow, were normal. Esophagoscopy showed a pea-sized papillomatous lesion in the cervical esophagus (site not further specified). T h e entire lesion was removed by forceps. Histological examination showed it to be thyroid tissue.
A 51-year-old man was admitted because of recurrent right upper quadrant pain subsequently demonstrated to be due to cholelithiasis. He had no symptoms or signs indicating thyroid or esophageal disease. A gastrointestinal series showed a polypoid lesion in the cervical esophagus (Figure). Esophagoscopy showed a 1 cm polypoid, bluish lesion on the left anterolateral wall about 3 cm below the cricopharyngeus. T h e mucosa was intact, and biopsy was not done. T h e esophagus was exposed through a left oblique neck incision. T h e nodule could be felt in the wall of the esophagus. T h e muscle layers were divided and the nodule excised without opening the mucosa. Histological examination showed normal thyroid tissue. Recovery was uneventful, and subsequently he was found to be euthyroid. F,rom the Department of Surgery, Duke IJniversity Medical Center, and the Veterans Administration Hospital, Durham, N.C. Accepted for publication April 29, 1974. Address reprint requests to Dr. Postlethwait, Veterans Administration Hospital, 508 Fultoii St., Durham, N.C. 27705.
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THE ANNALS OF THORACIC SURGERY
CASE REPORT:
Ectopic Esophageal Thyroid Nodule
Roentgenographic series showing polypoid lesion in the ceruical esophagus.
Comment According to Gray and Skandalakis [Z], the thyroid originates from the ventral aspect of the fourth branchial arch. It may be recognized by the end of the third week after conception in an area known as the tuberculum impar. At this stage it is in contact with the developing heart. As the embryo elongates, the thyroid descends as a tube which, in the fifth week, loses its lumen and breaks into fragments. The distal remnant develops into thyroid tissue, first as an irregular, platelike mass ventral to the trachea, and then by lateral growth extending to the parathyroid primordia. During the same period (21 days after conception onward) the esophagus and respiratory tract are forming. The first primordium of the respiratory system appears in the midline of the ventral wall of the foregut between the thyroid primordium cranially and the anterior intestinal portal caudally. Separation of the respiratory and digestive tract begins between the twenty-fifth and twenty-seventh days, and the separation is complete between 30 and 36 days. The close relationships of these structures during development indicates the probable sites of ectopic thyroid. Fish and Moore [I] have reviewed the subject of ectopic thyroid tissue. Many instances of lingual thyroid and almost as many cases of intralaryngeal or intratracheal thyroid have been reported. Both suprahyoid and infrahyoid masses of thyroid have also been described. Rarely, ectopic
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POSTLETHWAIT AND DETM ER thyroid occurs in juxtaposition to the aorta, pericardium, or heart. Only the 3 patients noted above have been reported to have thyroid tissue in the esophagus, so discussion of the clinical implications hardly seems warranted. Removal during endoscopy was successful in the first 2 patients. In our patient, biopsy was not performed since the endoscopic appearance of the lesion suggested a hemangioma. Presumably, as when found in other aberrant sites, the thyroid nodule in the esophageal wall could be the only thyroid tissue present.
References 1. Fish, J., and Moore, R. M. Ectopic thyroid tissue and ectopic thyroid carcinoma: A review of the literature and report of a case. Ann Surg 157:212, 1963. 2. Gray, S. W., and Skandalakis, J. E. Embryology for Surgeons. Philadelphia:
Saunders, 1972. 3. Porto, G. Esophageal nodule of thyroid tissue. Layngoscope 70:1336, 1960. 4. Whale, H. L. Oesophageal tumour of thyroid tissue. Br Med J 2:987, 1921.
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THE ANNALS OF THORACIC SURGERY
T
wo patients have previously been reported with a nodule of thyroid in the esophagus. Lawson Whale [4]in 1921 described a woman of unstated age who was seen after swallowing a fish bone. Esophagoscopy showed no bone, but at the level of the second dorsal vertebra posteriorly there was a nodule a little smaller than a cherry attached by a broad pedicle. It was removed by forceps and was found to consist of thyroid tissue. She had no goiter or other abnormalities. Porto [3] in 1960 reported a 56-year-old man with slightly painful swallowing. Examinations, including barium swallow, were normal. Esophagoscopy showed a pea-sized papillomatous lesion in the cervical esophagus (site not further specified). T h e entire lesion was removed by forceps. Histological examination showed it to be thyroid tissue.
A 51-year-old man was admitted because of recurrent right upper quadrant pain subsequently demonstrated to be due to cholelithiasis. He had no symptoms or signs indicating thyroid or esophageal disease. A gastrointestinal series showed a polypoid lesion in the cervical esophagus (Figure). Esophagoscopy showed a 1 cm polypoid, bluish lesion on the left anterolateral wall about 3 cm below the cricopharyngeus. T h e mucosa was intact, and biopsy was not done. T h e esophagus was exposed through a left oblique neck incision. T h e nodule could be felt in the wall of the esophagus. T h e muscle layers were divided and the nodule excised without opening the mucosa. Histological examination showed normal thyroid tissue. Recovery was uneventful, and subsequently he was found to be euthyroid. F,rom the Department of Surgery, Duke IJniversity Medical Center, and the Veterans Administration Hospital, Durham, N.C. Accepted for publication April 29, 1974. Address reprint requests to Dr. Postlethwait, Veterans Administration Hospital, 508 Fultoii St., Durham, N.C. 27705.
98
THE ANNALS OF THORACIC SURGERY
CASE REPORT:
Ectopic Esophageal Thyroid Nodule
Roentgenographic series showing polypoid lesion in the ceruical esophagus.
Comment According to Gray and Skandalakis [Z], the thyroid originates from the ventral aspect of the fourth branchial arch. It may be recognized by the end of the third week after conception in an area known as the tuberculum impar. At this stage it is in contact with the developing heart. As the embryo elongates, the thyroid descends as a tube which, in the fifth week, loses its lumen and breaks into fragments. The distal remnant develops into thyroid tissue, first as an irregular, platelike mass ventral to the trachea, and then by lateral growth extending to the parathyroid primordia. During the same period (21 days after conception onward) the esophagus and respiratory tract are forming. The first primordium of the respiratory system appears in the midline of the ventral wall of the foregut between the thyroid primordium cranially and the anterior intestinal portal caudally. Separation of the respiratory and digestive tract begins between the twenty-fifth and twenty-seventh days, and the separation is complete between 30 and 36 days. The close relationships of these structures during development indicates the probable sites of ectopic thyroid. Fish and Moore [I] have reviewed the subject of ectopic thyroid tissue. Many instances of lingual thyroid and almost as many cases of intralaryngeal or intratracheal thyroid have been reported. Both suprahyoid and infrahyoid masses of thyroid have also been described. Rarely, ectopic
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POSTLETHWAIT AND DETM ER thyroid occurs in juxtaposition to the aorta, pericardium, or heart. Only the 3 patients noted above have been reported to have thyroid tissue in the esophagus, so discussion of the clinical implications hardly seems warranted. Removal during endoscopy was successful in the first 2 patients. In our patient, biopsy was not performed since the endoscopic appearance of the lesion suggested a hemangioma. Presumably, as when found in other aberrant sites, the thyroid nodule in the esophageal wall could be the only thyroid tissue present.
References 1. Fish, J., and Moore, R. M. Ectopic thyroid tissue and ectopic thyroid carcinoma: A review of the literature and report of a case. Ann Surg 157:212, 1963. 2. Gray, S. W., and Skandalakis, J. E. Embryology for Surgeons. Philadelphia:
Saunders, 1972. 3. Porto, G. Esophageal nodule of thyroid tissue. Layngoscope 70:1336, 1960. 4. Whale, H. L. Oesophageal tumour of thyroid tissue. Br Med J 2:987, 1921.
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