Abstract
Introduction
Case Presentation
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Figure 1: Preoperative chest x-ray showing a giant mass at right hemithorax. |
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Figure 2: Chest computed tomography showing the mass invading the chest wall. |
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Figure 3: PET-CT showing the malign FGD uptake (SUV max 7.2). |
The mass (12.5x10x6.5 cm) was totally excised with partial resection of the invaded right 2nd, 3rd, 4th, and 5th ribs. A lobectomy due to parenchymal destruction and lymph node dissection (4th, 7th, 9th, 10th, and 11th lymph nodes) was also performed. The large chest wall defect was closed using 3 titanium bars and a proline mesh (Figure 4). There were no complications from the procedure and the patient was discharged at day 5 uneventfully.
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Figure 4: Titanium bars with proline mesh for the chest wall stability |
The final histopathological examination confirmed the diagnosis of PTC metastasis. The surgical margins was clear and, lung parenchyma and lymph nodes did not show any evidence of tumor cells. The diagnosis was supported by immunostaining (Thyroglobulin (CM022C) and HB -1 was positive) (Figure 5). Radioactive iodine (I131) was provided as an additional treatment to the patient. At the 8th month control no recurrences was seen (Figure 6).
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Figure 5: Pathological examination: immunostaining (Thyroglobulin (CM022C) positive, the HB -1 positive) |
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Figure 6: Postoperative chest X-ray at 8th month control. |
Discussion
Bone metastases with the follicular type and PTC occur 7-20% and 1-7% of the cases respectively. Medical drugs (analgesics, bisphosphonates), radiotherapy, surgery and radioisotopes are used in a multidisciplinary approach for the treatment of thyroid metastasis. I131 is an effective treatment modality for treatment of thyroid cancer with bone metastasis however resistance is frequently observed. Surgical treatment is indicated when patients present with intractable pain, lesions are unresponsive to medical therapy, there is low radioactive involvement, or present with spinal instability [6]. While the first option in the treatment of metastases is usually I131 therapy, we suggested surgery as a more viable option because of complaints of dyspnea, the presence of a mediastinal shift, and compression of the mass in our case. However, we did use I131 in the post-operative treatment of our patient.
A literature search was carried out in "PubMed" and "ResearchGate" using the following keywords: papillary thyroid carcinoma, chest wall and metastasis. Four studies were found that resemble to our current case. Kaya and Çermik [7] reported a case with diagnosis of papillary carcinoma metastasis who underwent surgery but died due to multiple new metastases. In the present case, a metastatic lesion was also detected first, but it was quite large and single so we anticipated that it would have a relatively good prognosis. In the second case in the literature, presented by Li et al. [8] a chest wall surgery was performed using endoscopic thyroid surgery with metastasis to the sternocleidomastoid muscle. Our patient had distant metastases independent of the remote operation. Nakada et al. [9] presented the third case. After PTCs, the sternal metastases became resistance to radioactive iodine therapy; therefore, percutaneous ethanol injection (PEI) therapy was successfully performed. In our case, many of the unknown effects of PEI on dyspnea and due to the emergency situation caused by the mediastinal shift, "surgery" was considered as the first choice of treatment. Karamustafaoğlu et al. [10] presented the fourth case report having similarities to our case. In this series of 4 patients, 3 patients presented PTC and one diagnosed as medullary thyroid carcinoma. Three patients who underwent chest wall resection died due to distant metastasis between 5 to 36 months, but one PTC case was still alive at 5th year follow-up. We closely monitored our patient up to the 8th month because of recurrence rate.
As a conclusion and take home message papillary thyroid carcinoma should be closely monitored after surgery, even if the malignant potential of thyroid carcinoma is low. For the treatment of metastases radioactive iodine treatment, as the first choice, should be kept in mind however when a resistance is faced surgical treatment could be performed. In the cases with a mediastinal shift and dyspnea caused by a resectable tumor, surgery should be considered as the first choice.
Declaration of conflicting interests
The author declared no conflicts of interest with respect to the authorship and/or publication of this article.
Funding
The author received no financial support for the research and/or authorship of this article.