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Seminoma of testicle metastatic to thyroid
SEMINOMA
OF TESTICLE
ALAN D. STEINFELD,
METASTATIC
TO THYROID
M.D.
ROBERT KNISLEY, M.D. JOHN MARCACCIO, M.D. ALFRED0
ESPARZA, M.D.
From the Departments of Radiation Oncology, Medical Oncology, Urology, and Pathology, Rhode Island Hospital, and Sections on Radiation Medicine, Medicine and Pathology, Brown University, Providence, Rhode Island
ABSTRACT-A twenty-four-year-old white man is described who presented with seminoma and initially was treated with standard inguinal orchiectomy and radiation therapy for retroperitoneal disease. The case is reported because of the unusual nature of his later recurrence of disease, which was in the right lobe of the thyroid gland. This is a rare site for isolated recurrence, and there is a paucity of reports of metastatic tumor of any type to the thyroid gland. The patient had a complete remission after combined chemotherapy with cyclophosphamide, vinblastine, bleomycin, and cisplatin.
The usual locations for metastases from seminoma of the testicle are the para-aortic and mediastinal lymph nodes and the lungs. Less common metastatic sites include the liver, bones, and brain.’ Recently, we have seen a patient in whom a metastatic focus of seminoma developed in the thyroid gland as his first site of recurrent disease. Case Report A twenty-four-year-old white man presented with a three-month history of a gradually enlarging, painless, right testicular mass. A right inguinal orchiectomy, with high ligation of the spermatic cord, was performed for suspected testicular tumor. Pathologic examination of the specimen revealed a large neoplasm with extensive replacement of the testicular parenchyma. Microscopically the neoplasm was classified as an anaplastic seminoma in view of the cellular pleomorphism and numerous mitoses (Fig. 1A). The tumor involved the testicular capsule and the epididymis, and a separate nodule of metastatic tumor was noted
UROLOGY
/ FEBRUARY
1984
/ VOLUME
XXIII,
NUMBER
along the spermatic cord. Extensive involvement of lymphatic channels and blood vessels was observed, not only in the testicle but also in the soft tissue around the spermatic cord (Fig. 1B). Serum obtained prior to orchiectomy was negative for PHCG (@subunit of human chorionic gonadotropin) and AFP (alphafetoprotein), A chest x-ray film and chest tomogram, as well as bone and liver scans were normal. Computerized tomography of the abdomen revealed an abnormal lymph node at the level of the third lumbar vertebra. This was confirmed by bipedal lymphangiography. A chest roentgenogram taken as part of the lymphangiogram showed contrast material in the thoracic duct at the left supraclavicular fossa. No filling of left or right supraclavicular nodes was demonstrated. Primary treatment consisted of radiation therapy with photons from a 4 MeV linear accelerator. Anterior and posterior opposed portals were used to deliver 3,000 rad in 20 fractions (5 fractions/week) to the ipsilateral iliac
2
163
Frcum 1. Microphotographs (A) of the testicular tumor showing loosely arranged cells with pale cytoplasm and large vesicular nuclei, nucleoli, and several mitotic figures. (B) Tumor nodule in spermatic cord demonstrates invasion of blood vessels. (Hematoxylin and eosin, original magnijications x 1,000 and x 63, respectively.)
and inguinal nodes, and bilateral para-aortic nodes. An additional 500 rad were given in 2 fractions through a small field covering the abnormal node in the mid lumbar area. After a one-week rest period, radiation was given to the mediastinum and supraclavicular region. Three thousand rad were delivered in 19 treatments over four elapsed weeks. Anterior and posterior opposed fields were again used with each field treated each day. The patient tolerated his treatment well, except for mild nausea. Physical examination and laboratory studies during and on completion of radiation indicated no evidence of metastatic tumor. The patient was seen regularly in follow-up. An x-ray film of the abdomen was taken two and one-half months after radiation to the para-aortic region was completed. Residual contrast material was seen in the paraaortic nodes, with complete clearing of the previously noted abnormality. At a routine follow-up visit ten months after diagnosis, and seven months after completing radiation, an indistinct mass, 2 to 3 cm in diameter, was noted in the right lobe of the thyroid. Additionally, he was found to have a soft, movable 1 by 2-cm lymph node in the right mid cervical region. No other abnormalities were found on physical examination. A thyroid scan showed a filling defect in the right lobe of the gland (Fig. 2). Metastatic seminoma was found on excisional biopsy of the lymph node. The patient was hospitalized for restaging and treatment of recurrent seminoma. Perti-
164
Thyroid scan showing filling defect in mid portion of right lobe.
FICUHE2.
nent laboratory studies included a normal triiodothyronine and thyroid-stimulating hormone. The @HCG was negative, but serum AFP was elevated at 228 (normal O-20). Results of chest x-ray film and tomograms, bone scan, liver scan, IVP, and abdominal CT scan were all normal. The patient was started on chemotherapy with cyclophosphamide, 1,000 mg, and vinblastine, 10 mg IV push. He received a five-day course of bleomycin, 30 mg daily, given as a twenty-four-hour drip. On the day prior to discharge, cis-platinum, 200 mg, was administered intravenously After the second course of
UROLOGY
/ FEBRUARY
1984
i
VOLUME
XXIII,
NUMBER
2
chemotherapy, the thyroid mass was no longer palpable. The chemotherapeutic program was continued for one year. Bleomycin was discontinued after 2 courses (total 300 mg) because of mild pulmonary toxicity. The AFP returned to normal. A repeat thyroid scan was normal. At last follow-up, twenty-eight months after initial diagnosis and eighteen months after relapse, he remains alive and well, without evidence of tumor. Seminoma is the commonest of testicular tumors, accounting for almost one half of all testicular germinal neoplasms.2 The combination of a high proportion of patients presenting with disease confined to the testicle, and the exquisite radiosensitivity of the tumor, have resulted in a ten-year survival of 90 per cent of all patients. Anaplastic seminoma may have a slightly more aggressive course. Few patients present with disease beyond the testicle. Of 2,346 cases reported in the literature, 25 per cent had metastases to regional nodes or distant sites at presentation2 Maier, Mittemeyer, and Sulak’ found 17 per cent of 277 patients to have nodal or distant metastases at presentation. These sites include the paraaortic nodes, lung, left supraclavicular node, mediastinal nodes, liver, bone, and brain, in order of frequency. l Inguinal nodes may be involved, particularly if the scrotum has undergone surgery. When treatment fails, the sites of spread are similar to the areas of initial presentation of metastatic tumor. In his review of autopsy material at the Armed Forces Institute of Pathology, Mostofi4 found the para-aortic and iliac nodes, liver, and lungs to be most commonly involved with metastatic seminoma. Less commonly, the kidneys, adrenals, pleura, peritoneum, and mediastinum were involved. The locations of first recurrence of disease follow the same pattern found in the autopsy series. Martin et al.’ had 2 patients in whom metastases developed after initial treatment. One patient had a lung metastases successfully resected, while the other received a second course of radiation for para-aortic and supraclavicular spread. Friedman and Purkayastha5 described 24 patients with recurrent seminoma seen at Walter Reed Army Hospital. Left supraclavicular lesions were the commonest metastasis, found in 9 patients (37 % ). Retroperitoneal
UROLOGY
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FEBRUARY
1984
I
VOLUME
XXIII,
NUMBER
nodes were almost as common, 8 cases (33 % ) . The mediastinal lymph nodes, bones, lung, and liver were among other distant foci. A similar distribution was found in the 8 patients with recurrent seminoma reported by Quivey et al6 Our patient demonstrated a most unusual pattern of failure. The thyroid gland is an uncommon site for metastatic spread of any form of tumor. Of 467 cancer patients undergoing autopsy at the Mayo Clinic, Mortensen, Woolner, and Bennets found 18 (3.9%) with thyroid metastases. In all cases, the thyroid was involved as part of general systemic metastases. Their study confirmed the earlier report by Willis9 who found 5.2 per cent of patients dying of cancer to have thyroid involvement. Ricei was able to locate embolic tumor cells in the thyroids of 9 per cent of patients dying of cancer. This underscores the idea that frequency with which such metastases are found depends on the degree with which the pathologist looks for them. Shimaoka, Sokal, and Pickren13 added their results of 1,980 autopsies on patients dying of cancer, to series found in the literature. A total of 302 thyroid metastases were found in 5,668 patients (5.3%). Only 3 patients had testicular primary disease. While secondary carcinoma of the thyroid is infrequently seen at autopsy, the diagnosis is made even less commonly antemortem. In more than 65,000 thyroidectomies done at the Mayo Clinic, only 12 cases of metastatic tumor were found.11J2 Shimaoka et ~1.‘~ collected 1,646 cases of thyroid malignancies, found at thyroidectomy, from the world of literature. Metastatic tumors accounted for 77 (4.7%) of the total. The types of tumor which spread to the thyroid were studied by Haquenauer et al. I4 in a literature review. He found 130 cases of metastatic thyroid tumors to which he added 5 additional cases. Eighty-four patients (62 %) had renal primary tumors, with cancers of the breast and digestive system accounting for 14 per cent and 10 per cent of the cases, respectively. Lung tumors were responsible for only 5 per cent of at the total. In contrast, Shimaoka et aZ.,13 Roswell Park Memorial Institute, noted malignant melanoma to be the most frequent tumor to metastasize to the thyroid. It accounted for 39 per cent (16 of 188 cases) and was followed in frequency by cancers of the breast (21% ), kidney (12 % ), and lung (11% ). Cancers arising in virtually every organ have been reported to spread to the thyroid.
2
165
While histologic confirmation of the presence of seminoma of the thyroid of our patient was not obtained, the accuracy of the diagnosis is reasonably certain. The 3 patients reported by lesions on Bacourt et al. I5 all had low-density isotope thyroid scan. Case 2 of Shimaoka et al. l3 also had a “cold spot” on her scan. The palpable node in our patient cleared completely after chemotherapy, and his thyroid scan reverted to normal. As in most instances of metastatic thyroid disease, our patient was euthyroid. We have not been able to locate any other report of seminoma of the testicle metastatic to the thyroid where the diagnosis was made other than at autopsy. We suspect that the thyroid nodule in our patient represents a hematogenous metastasis, and that tumor spread to the right cervical lymph node from the thyroid. The thyroid mass was larger than the node, suggesting that it had been there longer. Furthermore, the right cervical region is not a usual location for nodal spread of seminoma. While some patients will have thoracic ducts which drain on the right, our patient’s lymphangiogram did show a duct on the left side. The mid cervical node is on the drainage route of the thyroid, reinforcing the idea that its involvement followed that of the thyroid. This patient’s initial therapy followed that advocated by Maier and Sulak.3 That tumor recurred in a location near a site of prophylactic radiation should not be interpreted as a need to routinely extend this area to include the thy-
166
roid. The effective use of salvage chemotherapy in such patients clearly eliminates this need. Department
of Radiation Oncology Rhode Island Hospital Providence, Rhode Island 02902 (DR. STEINFELD) References
1. Martin LS, Woodruff MW, Webster JH, and Pickren JW: Testicular seminoma, Arch Surg SO: 306 (1965). 2. Smith RB, DeKernion JB,-and Skinner DG: Management of advanced testicular seminoma. I Urol 121: 429 (1979). 3. Maier JG, and Sulak MH:*Radiation thera‘py in malignant testis tumors, Cancer 32: 1212 (1973). 4. Mostofi FK: Testicular tumor, ibid 32: 1186 (1973). 5. Friedman M, and Purkayastha M: Recurrent seminoma: the management of late metastasis, recurrence, or a second primary tumor, Radiology 83: 25 (1960). 6. Quivey JM, et al: Malignant tumors of the testis: analysis of treatment results and sites and causes of failure, Cancer 39: 1247 (1977). 7. Maier JC, Mittemeyer BT, and Sulak MH: Treatment and prognosis in seminoma of the testis, J Ural 99: 72 (1968). 8. Mortensen JD, Woolner LB, and Bennet WA: Secondary malignant tumors of the thyroid gland, Cancer 9: 306 (1956). 9. Willis RA: Metastatic tumor of the thyroid gland, Am J Path01 7: 187 (1931). 10. Rice CO: Microscopic metastases in the thyroid gland, ibid 10: 407 (1934). 11. Pemberton J, and Bennet RJ: Hypernephroma of the thyroid gland: a review of the literature and a report of two cases, Surg Clin North Am 14: 593 (1934). 12. Wychulis AR, Beahts OH, and Woolner LB: ,Metastasis of carcinoma to the thyroid gland, Ann Surg 160: 169 (1964). 13. Shimaoka K, Sokal JE, and Pickren JW: Metastatic neoplasms in the thyroid gland, Cancer 15: 557 (1962). des can14. Haquenauer JE et al: Les metastases thyroidiennes cers epitheliaux, Ann Otolaryngol Chir Cervicofac 97: 353 (1980). 15. Bacourt F, et al: Metastases thyroidiennes des tumeurs du rein, Nouv Press Med 9: 1431 (1980).
UROLOGY
/ FEBRUARY
1984
i
VOLUME
XXIII,
NUMBER
2
OF TESTICLE
ALAN D. STEINFELD,
METASTATIC
TO THYROID
M.D.
ROBERT KNISLEY, M.D. JOHN MARCACCIO, M.D. ALFRED0
ESPARZA, M.D.
From the Departments of Radiation Oncology, Medical Oncology, Urology, and Pathology, Rhode Island Hospital, and Sections on Radiation Medicine, Medicine and Pathology, Brown University, Providence, Rhode Island
ABSTRACT-A twenty-four-year-old white man is described who presented with seminoma and initially was treated with standard inguinal orchiectomy and radiation therapy for retroperitoneal disease. The case is reported because of the unusual nature of his later recurrence of disease, which was in the right lobe of the thyroid gland. This is a rare site for isolated recurrence, and there is a paucity of reports of metastatic tumor of any type to the thyroid gland. The patient had a complete remission after combined chemotherapy with cyclophosphamide, vinblastine, bleomycin, and cisplatin.
The usual locations for metastases from seminoma of the testicle are the para-aortic and mediastinal lymph nodes and the lungs. Less common metastatic sites include the liver, bones, and brain.’ Recently, we have seen a patient in whom a metastatic focus of seminoma developed in the thyroid gland as his first site of recurrent disease. Case Report A twenty-four-year-old white man presented with a three-month history of a gradually enlarging, painless, right testicular mass. A right inguinal orchiectomy, with high ligation of the spermatic cord, was performed for suspected testicular tumor. Pathologic examination of the specimen revealed a large neoplasm with extensive replacement of the testicular parenchyma. Microscopically the neoplasm was classified as an anaplastic seminoma in view of the cellular pleomorphism and numerous mitoses (Fig. 1A). The tumor involved the testicular capsule and the epididymis, and a separate nodule of metastatic tumor was noted
UROLOGY
/ FEBRUARY
1984
/ VOLUME
XXIII,
NUMBER
along the spermatic cord. Extensive involvement of lymphatic channels and blood vessels was observed, not only in the testicle but also in the soft tissue around the spermatic cord (Fig. 1B). Serum obtained prior to orchiectomy was negative for PHCG (@subunit of human chorionic gonadotropin) and AFP (alphafetoprotein), A chest x-ray film and chest tomogram, as well as bone and liver scans were normal. Computerized tomography of the abdomen revealed an abnormal lymph node at the level of the third lumbar vertebra. This was confirmed by bipedal lymphangiography. A chest roentgenogram taken as part of the lymphangiogram showed contrast material in the thoracic duct at the left supraclavicular fossa. No filling of left or right supraclavicular nodes was demonstrated. Primary treatment consisted of radiation therapy with photons from a 4 MeV linear accelerator. Anterior and posterior opposed portals were used to deliver 3,000 rad in 20 fractions (5 fractions/week) to the ipsilateral iliac
2
163
Frcum 1. Microphotographs (A) of the testicular tumor showing loosely arranged cells with pale cytoplasm and large vesicular nuclei, nucleoli, and several mitotic figures. (B) Tumor nodule in spermatic cord demonstrates invasion of blood vessels. (Hematoxylin and eosin, original magnijications x 1,000 and x 63, respectively.)
and inguinal nodes, and bilateral para-aortic nodes. An additional 500 rad were given in 2 fractions through a small field covering the abnormal node in the mid lumbar area. After a one-week rest period, radiation was given to the mediastinum and supraclavicular region. Three thousand rad were delivered in 19 treatments over four elapsed weeks. Anterior and posterior opposed fields were again used with each field treated each day. The patient tolerated his treatment well, except for mild nausea. Physical examination and laboratory studies during and on completion of radiation indicated no evidence of metastatic tumor. The patient was seen regularly in follow-up. An x-ray film of the abdomen was taken two and one-half months after radiation to the para-aortic region was completed. Residual contrast material was seen in the paraaortic nodes, with complete clearing of the previously noted abnormality. At a routine follow-up visit ten months after diagnosis, and seven months after completing radiation, an indistinct mass, 2 to 3 cm in diameter, was noted in the right lobe of the thyroid. Additionally, he was found to have a soft, movable 1 by 2-cm lymph node in the right mid cervical region. No other abnormalities were found on physical examination. A thyroid scan showed a filling defect in the right lobe of the gland (Fig. 2). Metastatic seminoma was found on excisional biopsy of the lymph node. The patient was hospitalized for restaging and treatment of recurrent seminoma. Perti-
164
Thyroid scan showing filling defect in mid portion of right lobe.
FICUHE2.
nent laboratory studies included a normal triiodothyronine and thyroid-stimulating hormone. The @HCG was negative, but serum AFP was elevated at 228 (normal O-20). Results of chest x-ray film and tomograms, bone scan, liver scan, IVP, and abdominal CT scan were all normal. The patient was started on chemotherapy with cyclophosphamide, 1,000 mg, and vinblastine, 10 mg IV push. He received a five-day course of bleomycin, 30 mg daily, given as a twenty-four-hour drip. On the day prior to discharge, cis-platinum, 200 mg, was administered intravenously After the second course of
UROLOGY
/ FEBRUARY
1984
i
VOLUME
XXIII,
NUMBER
2
chemotherapy, the thyroid mass was no longer palpable. The chemotherapeutic program was continued for one year. Bleomycin was discontinued after 2 courses (total 300 mg) because of mild pulmonary toxicity. The AFP returned to normal. A repeat thyroid scan was normal. At last follow-up, twenty-eight months after initial diagnosis and eighteen months after relapse, he remains alive and well, without evidence of tumor. Seminoma is the commonest of testicular tumors, accounting for almost one half of all testicular germinal neoplasms.2 The combination of a high proportion of patients presenting with disease confined to the testicle, and the exquisite radiosensitivity of the tumor, have resulted in a ten-year survival of 90 per cent of all patients. Anaplastic seminoma may have a slightly more aggressive course. Few patients present with disease beyond the testicle. Of 2,346 cases reported in the literature, 25 per cent had metastases to regional nodes or distant sites at presentation2 Maier, Mittemeyer, and Sulak’ found 17 per cent of 277 patients to have nodal or distant metastases at presentation. These sites include the paraaortic nodes, lung, left supraclavicular node, mediastinal nodes, liver, bone, and brain, in order of frequency. l Inguinal nodes may be involved, particularly if the scrotum has undergone surgery. When treatment fails, the sites of spread are similar to the areas of initial presentation of metastatic tumor. In his review of autopsy material at the Armed Forces Institute of Pathology, Mostofi4 found the para-aortic and iliac nodes, liver, and lungs to be most commonly involved with metastatic seminoma. Less commonly, the kidneys, adrenals, pleura, peritoneum, and mediastinum were involved. The locations of first recurrence of disease follow the same pattern found in the autopsy series. Martin et al.’ had 2 patients in whom metastases developed after initial treatment. One patient had a lung metastases successfully resected, while the other received a second course of radiation for para-aortic and supraclavicular spread. Friedman and Purkayastha5 described 24 patients with recurrent seminoma seen at Walter Reed Army Hospital. Left supraclavicular lesions were the commonest metastasis, found in 9 patients (37 % ). Retroperitoneal
UROLOGY
/
FEBRUARY
1984
I
VOLUME
XXIII,
NUMBER
nodes were almost as common, 8 cases (33 % ) . The mediastinal lymph nodes, bones, lung, and liver were among other distant foci. A similar distribution was found in the 8 patients with recurrent seminoma reported by Quivey et al6 Our patient demonstrated a most unusual pattern of failure. The thyroid gland is an uncommon site for metastatic spread of any form of tumor. Of 467 cancer patients undergoing autopsy at the Mayo Clinic, Mortensen, Woolner, and Bennets found 18 (3.9%) with thyroid metastases. In all cases, the thyroid was involved as part of general systemic metastases. Their study confirmed the earlier report by Willis9 who found 5.2 per cent of patients dying of cancer to have thyroid involvement. Ricei was able to locate embolic tumor cells in the thyroids of 9 per cent of patients dying of cancer. This underscores the idea that frequency with which such metastases are found depends on the degree with which the pathologist looks for them. Shimaoka, Sokal, and Pickren13 added their results of 1,980 autopsies on patients dying of cancer, to series found in the literature. A total of 302 thyroid metastases were found in 5,668 patients (5.3%). Only 3 patients had testicular primary disease. While secondary carcinoma of the thyroid is infrequently seen at autopsy, the diagnosis is made even less commonly antemortem. In more than 65,000 thyroidectomies done at the Mayo Clinic, only 12 cases of metastatic tumor were found.11J2 Shimaoka et ~1.‘~ collected 1,646 cases of thyroid malignancies, found at thyroidectomy, from the world of literature. Metastatic tumors accounted for 77 (4.7%) of the total. The types of tumor which spread to the thyroid were studied by Haquenauer et al. I4 in a literature review. He found 130 cases of metastatic thyroid tumors to which he added 5 additional cases. Eighty-four patients (62 %) had renal primary tumors, with cancers of the breast and digestive system accounting for 14 per cent and 10 per cent of the cases, respectively. Lung tumors were responsible for only 5 per cent of at the total. In contrast, Shimaoka et aZ.,13 Roswell Park Memorial Institute, noted malignant melanoma to be the most frequent tumor to metastasize to the thyroid. It accounted for 39 per cent (16 of 188 cases) and was followed in frequency by cancers of the breast (21% ), kidney (12 % ), and lung (11% ). Cancers arising in virtually every organ have been reported to spread to the thyroid.
2
165
While histologic confirmation of the presence of seminoma of the thyroid of our patient was not obtained, the accuracy of the diagnosis is reasonably certain. The 3 patients reported by lesions on Bacourt et al. I5 all had low-density isotope thyroid scan. Case 2 of Shimaoka et al. l3 also had a “cold spot” on her scan. The palpable node in our patient cleared completely after chemotherapy, and his thyroid scan reverted to normal. As in most instances of metastatic thyroid disease, our patient was euthyroid. We have not been able to locate any other report of seminoma of the testicle metastatic to the thyroid where the diagnosis was made other than at autopsy. We suspect that the thyroid nodule in our patient represents a hematogenous metastasis, and that tumor spread to the right cervical lymph node from the thyroid. The thyroid mass was larger than the node, suggesting that it had been there longer. Furthermore, the right cervical region is not a usual location for nodal spread of seminoma. While some patients will have thoracic ducts which drain on the right, our patient’s lymphangiogram did show a duct on the left side. The mid cervical node is on the drainage route of the thyroid, reinforcing the idea that its involvement followed that of the thyroid. This patient’s initial therapy followed that advocated by Maier and Sulak.3 That tumor recurred in a location near a site of prophylactic radiation should not be interpreted as a need to routinely extend this area to include the thy-
166
roid. The effective use of salvage chemotherapy in such patients clearly eliminates this need. Department
of Radiation Oncology Rhode Island Hospital Providence, Rhode Island 02902 (DR. STEINFELD) References
1. Martin LS, Woodruff MW, Webster JH, and Pickren JW: Testicular seminoma, Arch Surg SO: 306 (1965). 2. Smith RB, DeKernion JB,-and Skinner DG: Management of advanced testicular seminoma. I Urol 121: 429 (1979). 3. Maier JG, and Sulak MH:*Radiation thera‘py in malignant testis tumors, Cancer 32: 1212 (1973). 4. Mostofi FK: Testicular tumor, ibid 32: 1186 (1973). 5. Friedman M, and Purkayastha M: Recurrent seminoma: the management of late metastasis, recurrence, or a second primary tumor, Radiology 83: 25 (1960). 6. Quivey JM, et al: Malignant tumors of the testis: analysis of treatment results and sites and causes of failure, Cancer 39: 1247 (1977). 7. Maier JC, Mittemeyer BT, and Sulak MH: Treatment and prognosis in seminoma of the testis, J Ural 99: 72 (1968). 8. Mortensen JD, Woolner LB, and Bennet WA: Secondary malignant tumors of the thyroid gland, Cancer 9: 306 (1956). 9. Willis RA: Metastatic tumor of the thyroid gland, Am J Path01 7: 187 (1931). 10. Rice CO: Microscopic metastases in the thyroid gland, ibid 10: 407 (1934). 11. Pemberton J, and Bennet RJ: Hypernephroma of the thyroid gland: a review of the literature and a report of two cases, Surg Clin North Am 14: 593 (1934). 12. Wychulis AR, Beahts OH, and Woolner LB: ,Metastasis of carcinoma to the thyroid gland, Ann Surg 160: 169 (1964). 13. Shimaoka K, Sokal JE, and Pickren JW: Metastatic neoplasms in the thyroid gland, Cancer 15: 557 (1962). des can14. Haquenauer JE et al: Les metastases thyroidiennes cers epitheliaux, Ann Otolaryngol Chir Cervicofac 97: 353 (1980). 15. Bacourt F, et al: Metastases thyroidiennes des tumeurs du rein, Nouv Press Med 9: 1431 (1980).
UROLOGY
/ FEBRUARY
1984
i
VOLUME
XXIII,
NUMBER
2