Choroidal metastases as initial manifestation of a papillary thyroid carcinoma: A case report

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Short communication

Choroidal metastases as initial manifestation of a papillary thyroid carcinoma: A case report夽 ˜ Munoz ˜ a , L. Rodríguez Vicente a , I. Ortega Renedo a , M. Chacón González a,∗ , A. Ibánez a M. Rozanova Klecheva , A. Yagüe Hernando b, M.E. Lizuaín Abadia a , B. Jiménez del Rio a a b

˜ La Rioja, Spain Servicio de Oftalmología, Hospital San Pedro, Logrono, ˜ La Rioja, Spain Servicio de Anatomía Patológica, Hospital San Pedro, Logrono,

a r t i c l e

i n f o

a b s t r a c t

Article history:

The case is presented of 78 year-old who consulted due to decreased visual acuity in right eye

Received 20 May 2019

for several months. Indirect ophthalmoscopy revealed an orange-yellow coloured choroidal

Accepted 14 October 2019

mass at the posterior pole, without retinal detachment. Computed tomography showed a

Available online xxx

thyroid mass in the isthmus, as well as multiple pulmonary nodules and metastatic foci.

Palabras clave:

Fine-needle aspiration biopsy of thyroid nodule was diagnostic for a with columnar cell vari-

Cáncer de tiroides

ant of papillary thyroid cancer. Positron emission tomography confirmed papillary thyroid

Carcinoma papilar tiroideo

carcinoma. The patient underwent total thyroidectomy and radioactive iodine therapy.

The findings of transbronchial lung biopsy were compatible with metastatic dissemination.

Metástasis ocular

˜ ˜ S.L.U. All rights © 2019 Sociedad Espanola de Oftalmolog´ıa. Published by Elsevier Espana, reserved.

Metástasis coroidea

Metástasis coroidea como primera manifestación de carcinoma papilar de tiroides: a propósito de un caso r e s u m e n Keywords:

˜ Se presenta caso de varón de 78 anos que consultó por disminución de visión en ojo dere-

Thyroid cancer

cho de meses de evolución. En la exploración funduscópica se detectó existencia de una

Papillary thyroid cancer

masa coroidea de coloración amarillo-anaranjado, sin desprendimiento de retina asociado.

Ocular metastasis

La tomografía computarizada demostró presencia de una masa localizada en istmo tiroideo

Choroidal metastasis

así como múltiples adenopatías y focos de diseminación de aspecto metastásico. La broncoscopia con biopsia pulmonar mostró hallazgos compatibles con diseminación metastásica. La punción-aspiración con aguja fina del nódulo tiroideo fue diagnóstica para un carcinoma

夽 ˜ ˜ Please cite this article as: Chacón González M, Ibánez Munoz A, Rodríguez Vicente L, Ortega Renedo I, Rozanova Klecheva M, Yagüe Hernando A, et al. Metástasis coroidea como primera manifestación de carcinoma papilar de tiroides: a propósito de un caso. Arch Soc Esp Oftalmol. 2019. https://doi.org/10.1016/j.oftal.2019.10.004 ∗ Corresponding author. E-mail address: [email protected] (M. Chacón González). ˜ ˜ S.L.U. All rights reserved. 2173-5794/© 2019 Sociedad Espanola de Oftalmolog´ıa. Published by Elsevier Espana,

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papilar de tiroides subtipo células columnares y la tomografía por emisión de positrones confirmó secundarismo a carcinoma primario de tiroides. Se trató al paciente con tiroidectomía total y tratamiento sustitutivo tiroideo, y posteriormente tratamiento ablativo con radioyodo. ˜ ˜ S.L.U. Todos © 2019 Sociedad Espanola de Oftalmolog´ıa. Publicado por Elsevier Espana, los derechos reservados.

Introduction Papillary thyroid cancer (PTC) is the most frequent differentiated thyroid carcinoma, accounting for 85% of cases,1 the majority of which usually express as a thyroid mass that could disseminate to locoregional lymphatic nodes. Remote blood dissemination is unusual and occurs in only 10% of cases.1–3 The presence of choroidal metastasis is an infrequent occurrence, mostly described in patients with advanced primary carcinoma frequently originated in pulmonary or mammary neoplasias. The appearance of choroidal metastasis secondary to primary thyroid neoplasia is extremely rare but must be taken into account in the differential diagnostic of choroidal masses. The case is presented of a 78 year-old male with a choroidal mass on the right side leading to the casual diagnostic of columnar cells PTC variant.

Clinic case report Male, smoker, 78 years of age, without known oncological history who visited the Ophthalmology Dept. due to diminished visual acuity in the right eye with several months evolution. Maximum corrected visual acuity in the right eye was finger counting at 1 m and 1 in the left eye. Extrinsic and intrinsic ocular motility was normal. Slit lamp examination identified incipient cataract and intraocular pressure of 12 mmHg in both eyes. Funduscopic examination revealed a single elevated pale orange-yellow mass located in the posterior pole of the right eye (Fig. 1A). Ocular echography in mode A and B showed a mass localized on the choroids without inner reflectiveness reduction, kappa angle, choroidal cup or retinal detachment (Fig. 1B). Fluorescein angiography was not allowed by the patient, for which reason autofluorescence was performed showing tumor hypoautofluorescence with hyperautofluorescent areas inside (Fig. 1C). Optical coherence tomography

Fig. 2 – (A) T2 axial orbit MR showing the presence of a hypointense mass in the right side posterior pole. (B) FSAT sequence sagittal orbit MR showing a hypointense mass in the right eye posterior pole. (C) Thoracic CT, coronal reconstruction showing mediastinic metastatic adenopathies. (D) Thoracic axial CT showing a thyroid mass which is hypointense compared to the rest of healthy, hyper-intense thyroid parenchyma, in addition to bilateral hiliar adenopathies.

(OCT) showed the presence of a choroidal mass in the posterior pole associated to subretinal fluid with neurosensory retina detachment (Fig. 1D). Nuclear magnetic resonance found a choroidal mass in posterior pole without cerebral compromise (Fig. 2A–B). Suspecting a metastatic tumor possibly of pulmonary origin, the Oncology and Pneumology Depts. Were requested to perform oncological screening tests. Analyses revealed significantly raised thyroglobulin (6926 ng/ml [2–78]) with the rest of thyroid function analytic parameters within nor-

Fig. 1 – (A) RE fundus showing the presence of a yellow-orange rounded mass in posterior pole. (B) Mode B echography shows a mass located in the choroids with defined edges and without choroidal cup. (C) Autofluorescence showing tumor hypoautofluorescence with hyperautofluorescent areas inside. (D) SD-OCT showing the choroidal mass with subretinal fluid (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article).

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Fig. 3 – (A) Cytology corresponding to PAAF of the mediastinic adenopathy. Cytological extension with Papanicolaou staining showing papillary groups of cells with poorly defined cytoplasm, rounded or oval-shaped nuclei with slight nucleus size variability. (B) Histological section with 20X increase stained with hematoxylin-eosin of the total thyroidectomy. The upper part of the image shows the columnar cell variant of the thyroid papillary carcinoma and the lower part shows normal thyroid tissue. (C) This image shows the vascular invasion by the papillary carcinoma.

mal ranges. Chest and abdomen computerized tomography (CT) showed the existence of a hypovascular mass located in the thyroid isthmus as well as multiple supraclavicular, hilar, paratracheal and paraesophageal adenopathies (Fig. 2C–D). It also showed numerous sub-pleural millimetric nodules and a left paravertebral extrapleural mass possibly related to secondary implants. Positron emission tomography (PET)/CT study showed a possible high histological thyroid primary tumor in the left thyroid lobe/isthmus with cervical and mediastinic adenopathies as well as pulmonary metastases. Bronchoscopy with pulmonary biopsy was compatible with carcinomatous metastases probably of thyroid origin (Fig. 3A). ECO-punction-aspiration with fine needle (PAAF) of the thyroid revealed PTC histopathological data. With the diagnostic of thyroid carcinoma, the patient underwent full thyroidectomy with partial resection of level IV adenopathy 2 months after the baseline diagnostic. Histopathology confirmed columnar variant PTC (Bethesda VI) in stage T3aN1bM1 (Fig. 3B–C). Subsequently, the patient underwent treatment with radioiodine for ablation and treatment of metastases. Despite successful response to radioiodine treatment, and result was amaurosis as a consequence of massive choroidal hemorrhage.

Discussion The most frequent endocrine neoplasia is thyroid carcinoma, of which PTC is the most frequent (approximately 85% of all thyroid neoplasias).1 Hematic dissemination occurs in only 10 % of cases, preferably in the lungs followed by bones and brain.1–3 Distance hematogenous metastatic dissemination is extremely infrequent. The existence of uveal metastases secondary to primary thyroid neoplasia is an unusual event. In a series of 420 uveal metastases cases, Shields et al. found 2 cases due to thyroid carcinoma4 while Ferry and Font only found 1 out of 227 cases.5 Of all thyroid carcinoma with choroidal metastases described in the literature, 10 are derived from PTC, 7 from follicular carcinoma and 6 from medullary carcinoma.1–3 All patients had a previous record of thyroid carcinoma and exhibited advanced stages of the disease. The importance of the case is due to the unusual presentation that expressed as choroidal metastasis as the first clinical sign of the disease, and also because it is a columnar cell variant of papillary carcinoma first described by Dr. H.L. Evans in 1986.6 Histologically,

it is characterized by papillas or pseudo-glandular spaces covered by stratified epithelium. Mitosis figures are frequent and the ki67 proliferation index is high.7,8 From the immunohistochemical viewpoint, thyroglobulin immunoreactivity is high while TTF-1 is always positive.8 The most frequent presentation in these patients is diminished visual acuity when the lesion is located in the macula of the optic nerve, as in the case described herein. In addition, the literature comprises cases with myodesopsia, photopsia or scotoma clinic. In a smaller number of patients asymptomatic choroidal masses could be found, usually diagnosed in a routine checkup.4 The diagnostic is based on the ocular fundus examination and radiological imaging tests such as ocular echography and MR. It is recommended to take a choroidal biopsy in the presence of an uveal mass as first expression of a tumor. In the present case, PTC diagnostic is based on funduscopic examination and lungs and thyroid samples without the necessity of performing trans-retinal biopsy due to the risk of complications this procedure entails (retina detachment, tumor dissemination and choroidal hemorrhage among others). In addition, a thorough systemic study should be made due to suspected metastatic tumor and to discard the most frequent tumors for each sex such as prostate in males and breast in females. Treatment must be individualized taking into account prognostic factors. The literature describes several treatment options for managing choroidal metastases. The most widely utilized is radiotherapy with 131 I3,9 with total thyroidectomy that produces positive results as in the present case. Other therapies are external radiotherapy for cases refractory to radioiodine,3,4,9,10 episcleral brachytherapy with 125 I, immunotherapy and chemotherapy.3 Enucleation is only for untreatable pain, neovascular glaucoma or excessive tumor growth, although it has been utilized exceptionally as a diagnostic method when the primary source of the tumor could not be determined.3 Prognosis is determined by the stage of the tumor and the number of compromised nodes. Advanced stages with a high number of compromised nodes as in the case reported herein have poor prognosis. The incidence of choroidal metastases derived from PTC is low. To date, the authors were unable to find any case described in the literature. By way of conclusion, the appearance of choroidal metastases is infrequent and mostly described in patients with

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advanced primary carcinoma most frequently originated in pulmonary or mammary gland neoplasia.3,4 The appearance of choroidal metastases secondary to thyroid carcinoma is a rare event. Therefore, in the presence of uveal metastases of unknown origin an extensive systemic assessment of the patient must be carried out, also discarding thyroid carcinoma as possible etiology. The presence of hematogenous metastases derived from thyroid carcinoma is a factor that indicates poor evolution of the disease. It is essential to carry out an early diagnostic in order to preserve at least the ocular anatomy of the patient and visual acuity in the best of cases. The example discussed herein is an infrequent case of choroidal PTC metastasis where multidisciplinary approach is essential for adequate diagnostic and therapeutic management.

Conflict of interests No conflict of interests was declared by the authors.

references

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