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Splenectomy for Solitary Splenic Metastasis in Recurrent Papillary Thyroid Cancer. A Case Report and Literature Review

Splenectomy for Solitary Splenic Metastasis in Recurrent Papillary Thyroid Cancer. A Case Report... Hindawi Case Reports in Oncological Medicine Volume 2020, Article ID 2084847, 5 pages https://doi.org/10.1155/2020/2084847 Case Report Splenectomy for Solitary Splenic Metastasis in Recurrent Papillary Thyroid Cancer. A Case Report and Literature Review 1 1 1 2 Antonio Maffuz-Aziz , Gabriel Garnica , Silvia López-Hernández, Janet Pineda-Diaz, 2 1 Javier Baquera-Heredia, and Patricia López-Jiménez Department of Surgical Oncology, American British Cowdray Medical Center, Mexico City, Mexico Department of Surgical and Molecular Pathology, American British Cowdray Medical Center, Mexico City, Mexico Correspondence should be addressed to Antonio Maffuz-Aziz; tonomaffuz@yahoo.com Received 7 October 2019; Revised 18 April 2020; Accepted 22 April 2020; Published 4 May 2020 Academic Editor: Katsuhiro Tanaka Copyright © 2020 Antonio Maffuz-Aziz et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Thyroid cancer is the most common endocrine malignancy, presenting with 23 500 new cases per year in the United States. About 7-23% of the patients will present recurrent metastases disease during follow-up. The classic variant of papillary carcinoma is less aggressive compared to its other variants like diffuse sclerosing, tall cell or columnar cell, and insular variants, and the sites to which this metastasizes is already well identified. Metastasis to the spleen is an extremely rare manifestation of papillary thyroid cancer. To date, only 3 cases have been reported in the literature. Herein, we present a 52-year-old male, who developed spleen metastases, 2.4 years after total thyroidectomy and central neck dissection followed by radioactive iodine ablation and seven months after treatment with sorafenib for lung metastases. The splenic lesion was detected in surveillance studies. This case highlights that splenic metastasis, although rare, may occur even in a patient with a locoregional and systemic controlled thyroid cancer and that it can be treated safely with surgical resection. 1. Introduction reported [6–8]. In this article, we present a case of splenic recurrence of papillary thyroid cancer and a literature review. Thyroid cancer is the leading cause of endocrine cancer and represents 2.1% of all cancer cases worldwide. About 90% 2. Case Presentation are well-differentiated thyroid carcinoma (DTC); papillary cancer is the most common histology [1]. The presence of A 52-year-old male presented with dysphonia of 2 months; distant metastases at the time of diagnosis is 4%, and 7-23% laryngoscopy was performed identifying right vocal cord during follow-up; in nearly 53% of cases, the relapse is paralysis; extension studies identified a tumour dependent reported in locoregional cancer, 28% in local relapse, and on the right thyroid lobe, with oesophageal infiltration and 13% distance metastasis is present; of these, 6% of cases have tracheal displacement, with no evidence of cervical lymph mixed relapses [2]. It has been reported that a global survival nodes. Total thyroidectomy with partial resection of the at 10 years is in a range of 25–70% [3]. oesophagus and lymphadenectomy of the central compart- The most common distant metastasis sites are the lungs ment was performed. The pathology report was classic papil- and bone with 69.0% and 7.1%, respectively [4]. Rare metas- lary thyroid carcinoma 3.6 cm in tumour size, and mixed tasis site locations are extremely low; they have been identi- pattern, with extra thyroid extension, and 1/7 lymph nodes fied in sites such as the liver, adrenal gland, central nervous with metastases. Postoperative iodine-131 dose of 200 mCi system, kidney, and skin and have been reported in 1.85% was delivered, with subsequent iodine-131 tracing that of cases [5]. reported small remnant of functional thyroid tissue in the The presentation of spleen metastases of a primary thy- thyroid bed. He continued hormone replacement therapy roid cancer is even more rare; to date, only 3 cases have been and surveillance. 2 Case Reports in Oncological Medicine Figure 1: Abdominal CT showing cystic lesion in the spleen of 40 mm diameter. Figure 3: Pathology macroscopic picture shows the spleen with a cystic lesion of 5.5 cm. 0.2 cm, with simple papillary formations (Figure 3). In sections with haematoxylin and eosin staining, the neoplastic prolifer- ation cyst is with a papillary growth pattern, and cuboidal cells, nuclear pleomorphism, empty nuclei and abundant nuclear bars are without mitosis (Figure 4). In immunohistochemistry, diffuse cytoplasmic positive thyroglobulin, CK19 diffuse cyto- plasmic positive, TTF-1 diffuse nuclear positive, PAX8 diffuse nuclear positive, and CK5/6 negative were observed (Figure 5). The diagnosis was papillary thyroid carcinoma with a cystic pattern, of conventional type, well differentiated, with focal microcalcification and intraluminal xanthomatous response, without extracapsular extension. No areas of tall, columnar, or oncocytic cells were identified. There were no poorly differ- entiated or anaplastic areas. Figure 2: PET/CT images show a 40 mm lesion without increased 3. Discussion metabolic activity. The presence of spleen metastases from solid tumours is At 16 months of surveillance, right basal pulmonary nodule extremely rare and generally exists in the context of a multi- was identified in X-ray; then, whole-body iodine-131 scan and organ disease. The presence of isolated spleen metastases has thyroglobulin levels were negative, so 18F-fluorodeoxyglucose- been reported <1% in autopsy studies; however, it is associ- positron emission tomography (18F-FDG PET/CT) was per- ated in 17 to 61% with metastases in other distant organs formed which was positive for bilateral pulmonary tumour [9]. In the present case, spleen metastases present after treat- activity; this being the only place where distant metastasis ing lung metastases. Although the frequency of metastatic was found at the time of the study, the spleen was normal. lesions of solid organs to the spleen is rare (2.3-7.1%), it is Thoracoscopy was performed, where pulmonary metastases the most common sites of origin in breast (22.9%), lung were confirmed secondary to well-differentiated papillary (20.2%), colorectal (9.4%), ovary (9%), and stomach (6.9%) thyroid cancer. Treatment with sorafenib was started, cancer [10]. The reason why this type of dissemination is rare assessing complete pulmonary control after 12 months of is still poorly understood; lack of afferent lymphatic vessel, treatment. the splenic capsule, the immunological capacity of the spleen Seven months after finished sorafenib treatment, and 29 parenchyma cells (macrophages and lymphocytes), and the months from initial treatment, 18F-FDG PET/CT was per- angled and spiral shape of the splenic artery constitute bar- formed, in which there was no evidence of metabolic activity rier methods for the presence of metastases in this organ [11]. in the lung or in any other organ; however a cystic lesion was To date, only 3 cases of thyroid metastases to the spleen found in the spleen 10 mm in diameter without metabolic have been reported. The first case was reported by Paolini activity. A control 18F-FDG PET/CT at 6 months showed et al. [7]; a patient with history of follicular thyroid cancer, the lung without evidence of disease, and the splenic lesion which developed lung and spleen metastases; the patient grew to a diameter greater than 40 mm; it was observed with- was diagnosed with splenomegaly and infiltration to the dia- out metabolic activity (Figure 1). Due to the increment of size phragm, colon, pancreas, and stomach. The second case and risk of spontaneous rupture, it was decided to perform reported was by Mayayo et al. [6]; with poorly differentiated splenectomy (Figure 2). thyroid carcinoma, the patient presented abdominal pain at 6 Pathology reported a 5:5×5:5×4cm semi ovoid months of surveillance. Spleen, liver, and pancreas metasta- tumour, cystic-looking lesion, with serous content, wall cut ses were identified. The diagnosis was made by fine-needle Case Reports in Oncological Medicine 3 (a) (b) Advice on equations (c) (d) Figure 4: (a) Ovoid splenic lesion of cystic appearance, 5.5 cm major axis on the wall. (b) Papillary projections are observed. (c) Photomicrograph in which simple papillae protruding from the cyst wall (haematoxylin and eosin, 4x) are observed. (d). At a higher magnification, cuboidal cells with clear nuclei and bars, characteristic of papillary thyroid carcinoma (haematoxylin and eosin, 20x) are observed. (a) (b) (c) (d) Figure 5: Photomicrographs of the immunohistochemical study performed on the splenic lesion. (a) PAX8 diffuse nuclear positive. (b) Diffuse cytoplasmic positive thyroglobulin. (c) TTF-1 diffuse nuclear positive. (d) CK19 diffuse cytoplasmic positive. 4 Case Reports in Oncological Medicine noma where the 1-year survival rate was 86.6%, and median aspiration cytology (FNA). And the last case reported by Kand et al. [8] was in a 50-year-old patient with a follicular survival time is 66.6 months [18], In metastases secondary to variant of a papillary carcinoma, who was diagnosed with melanoma, median overall survival after splenectomy is 11 months, with a survival of 23 months for the subgroup of an iodine-131 uptake study, which was captured at a diffuse level throughout the spleen, in addition to associating bone patients treated for a solitary lesion [19]. lesions. The definitive diagnosis was made using FNA as well. Distant metastasis is considered an important prognostic Our patient was diagnosed incidentally in surveillance factor in papillary thyroid cancer, which affects survival. The studies; he had no symptoms of abdominal pain and it 5-year survival rate is almost 100% for localized papillary, 99% for locoregional cancer and 78% for metastatic papillary seemed only a cystic lesion. Before 1990, when imaging techniques were not used thyroid cancer [20]. effectively, splenic metastasis rates were between 2.3% and For patients with only lung metastases, the survival rate 7.1% and most of them were found during autopsies or were at 10 years is 73.6%, which are significantly higher than just encountered coincidentally [10], because they are mostly patients with multiple organ metastases for whom the 10-year survival rate is 34.3% [21]. asymptomatic. Therefore, studies such as 18F-FDG PET/CT currently have an important tool for detection. In a study performed on 68 oncology patients with FDG avid malig- 4. Conclusions nancy and solid splenic masses on anatomical imaging, Papillary thyroid cancer is a very common neoplasm; there a 18F-FDG PET/CT had 100% accuracy in characterizing lot of information in articles and guides regarding its behav- lesions as benign or malignant. The sensitivity, specificity, iour and management options. However, on rare behaviour, positive predictive value, and negative predictive value of uncommon site metastases can occur, and its management 18F-FDG PET/CT in differentiating benign from malignant is not well defined. solid splenic lesions in patients with and without malignant disease are 100%, 100%, 100%, and 100% versus 100%, Data Availability 83%, 80%, and 100%, respectively. It should however be kept in mind that non-FDG-avid tumours, such as some renal or The [DATA TYPE] data used to support the findings of this thyroid cancers, may metastasize to the spleen [12, 13]. study are included within the article. Although the information in the literature regarding the relationship between 18F-FDG PET/CT and the diagnosis Conflicts of Interest of metastatic spleen lesions is only for solid tumours, the probable explanation is that most well-differentiated thy- The authors declare that there is no conflict of interest roid carcinomas are relatively slow growing and can be regarding the publication of this paper. 18F-fluorodeoxyglucose negative [14]. Several studies have reported that it has a high sensitivity (up to 85%) and References specificity (up to 95%) for distant metastases in patients with well-differentiated thyroid cancer [15]. [1] C. M. Kitahara and J. A. Sosa, “The changing incidence of Use of FNA is a useful diagnosis tool, since a sensitivity of thyroid cancer,” Nature Reviews. Endocrinology, vol. 12, 98.4%, a positive predictive value of 99.2%, and 98.1% accu- no. 11, pp. 646–653, 2016. racy for diagnosis and < 1% of complications have been [2] R. Cirocchi, S. Trastulli, A. Sanguinetti et al., “Recurrent differ- reported [16], although it is generally avoided because of entiated thyroid cancer: to cut or burn,” World Journal of Surgical Oncology, vol. 9, no. 1, pp. 2–5, 2011. the risk of intra-abdominal bleeding or dissemination in some cases. [3] L. Y. Wang, F. L. Palmer, I. J. Nixon et al., “Multi-organ distant metastases confer worse disease-specific survival in differenti- For this reason and based on the clinical evolution that ated thyroid cancer,” Thyroid, vol. 24, no. 11, pp. 1594–1599, the patient had, which was presented as a growth of the lesion, we decided to perform splenectomy because it was a [4] I. Sugitani, Y. Fujimoto, and N. Yamamoto, “Papillary thyroid unique and viable cystic lesion for resection. carcinoma with distant metastases: survival predictors and the Pathologic findings, the presence of isolated epithelial importance of local control,” Surgery, vol. 143, no. 1, pp. 35– cells or forming three-dimensional groups with round nuclei, 42, 2008. with inclusions or bars, are characteristics that should be sus- [5] N. S. Fedala, S. Kabour, F. Yaker, L. A. Ali, A. E. M. Haddam, pected in a thyroid origin, especially in patients with a history and F. Chentli, “Métastases inhabituelles des carcinomes of papillary thyroid carcinoma [6]. thyroïdiens différenciés,” Annales d'endocrinologie, vol. 75, The long-term survival after splenectomy in patients with no. 5–6, pp. 360-361, 2014. metachronous splenic metastasis from thyroid papillary can- [6] E. Mayayo, S. Blázquez, V. Gómez-Aracil, A. Saurí, and cer is unknown because of the limited number of reported S. Martinez, “Spleen metastasis from thyroid carcinoma. cases in the literature; however, based on the data obtained Report of a case with diagnosis by fine needle aspiration from the study by Madani et al. [17] where they analysed a cytology,” Acta Cytologica, vol. 47, no. 6, pp. 1116–1118, study of 492 patients with thyroid cancer and rare sites of metastasis, they mention patients with generally aggressive [7] R. Paolini, S. Toffoli, A. Poletti et al., “Splenomegaly as the first tumours, with a global survival of 60 months and disease- manifestation of thyroid cancer metastases,” Tumori, vol. 83, free period of 84 months. Other sites like colorectal carci- no. 4, pp. 779–782, 2018. Case Reports in Oncological Medicine 5 [8] P. Kand and R. Asopa, “Metastatic involvement of the spleen in differentiated carcinoma of thyroid,” Indian Journal of Nuclear Medicine, vol. 25, no. 4, pp. 171-172, 2010. [9] C. A. Schön, C. Görg, A. Ramaswamy, and P. J. Barth, “Splenic metastases in a large unselected autopsy series,” Pathology, Research and Practice, vol. 202, no. 5, pp. 351–356, 2006. [10] K. Y. Lam and V. Tang, “Metastatic tumors to the spleen: a 25-year clinicopathologic study,” Archives of Pathology & Laboratory Medicine, vol. 124, no. 4, pp. 526–530, 2000. [11] S. S. Lee, L. Morgenstern, E. H. Phillips, J. R. Hiatt, and D. R. Margulies, “Splenectomy for splenic metastases: a changing clinical spectrum,” The American Surgeon, vol. 66, no. 9, pp. 837–840, 2000. [12] U. Metser and E. Even-Sapir, “The role of 18F-FDG PET/CT in the evaluation of solid splenic masses,” in Seminars in Ultra- sound, CT and MRI, vol. 27, no. 5pp. 420–425, WB Saun- ders, 2006. [13] U. Metser, E. Miller, A. Kessler et al., “Solid splenic masses: evaluation with 18F-FDG PET/CT,” Journal of Nuclear Medi- cine, vol. 46, no. 1, pp. 52–59, 2005. [14] M. W. Saif, I. Tzannou, N. Makrilia, and K. Syrigos, “Role and cost effectiveness of PET/CT in management of patients with cancer,” The Yale Journal of Biology and Medicine, vol. 83, no. 2, pp. 53–65, 2010. [15] J. K. Chung, Y. So, J. S. Lee et al., “Value of FDG PET in pap- illary thyroid carcinoma with negative 131I whole-body scan,” Journal of Nuclear Medicine, vol. 40, no. 6, pp. 986–992, 1999. [16] L. Cavanna, A. Lazzaro, D. Vallisa, G. Civardi, and F. Artioli, “Role of image-guided fine-needle aspiration biopsy in the management of patients with splenic metastasis,” World Jour- nal of Surgical Oncology, vol. 5, no. 1, 2007. [17] A. Madani, Y. Jozaghi, R. Tabah, J. How, and E. Mitmaker, “Rare metastases of well-differentiated thyroid cancers: a sys- tematic review,” Annals of Surgical Oncology, vol. 22, no. 2, pp. 460–466, 2015. [18] T. Okuyama, M. Oya, and H. Ishikawa, “Isolated splenic metastasis of sigmoid colon cancer: a case report,” Japanese Journal of Clinical Oncology, vol. 31, no. 7, pp. 341–345, 2001. [19] J. H. W. De Wilt, W. H. McCarthy, and J. F. Thompson, “Sur- gical treatment of splenic metastases in patients with mela- noma,” Journal of the American College of Surgeons, vol. 197, no. 1, pp. 38–43, 2003. [20] Cancer.Net, Thyroid cancer : statistics, Statistics adapted from the American Cancer Society's (ACS) publications, 2020. [21] H. J. Song, Z. L. Qiu, C. T. Shen, W. J. Wei, and Q. Y. Luo, “Pulmonary metastases in differentiated thyroid cancer: effi- cacy of radioiodine therapy and prognostic factors,” European Journal of Endocrinology, vol. 173, no. 3, pp. 399–408, 2015. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Case Reports in Oncological Medicine Hindawi Publishing Corporation

Splenectomy for Solitary Splenic Metastasis in Recurrent Papillary Thyroid Cancer. A Case Report and Literature Review

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Hindawi Case Reports in Oncological Medicine Volume 2020, Article ID 2084847, 5 pages https://doi.org/10.1155/2020/2084847 Case Report Splenectomy for Solitary Splenic Metastasis in Recurrent Papillary Thyroid Cancer. A Case Report and Literature Review 1 1 1 2 Antonio Maffuz-Aziz , Gabriel Garnica , Silvia López-Hernández, Janet Pineda-Diaz, 2 1 Javier Baquera-Heredia, and Patricia López-Jiménez Department of Surgical Oncology, American British Cowdray Medical Center, Mexico City, Mexico Department of Surgical and Molecular Pathology, American British Cowdray Medical Center, Mexico City, Mexico Correspondence should be addressed to Antonio Maffuz-Aziz; tonomaffuz@yahoo.com Received 7 October 2019; Revised 18 April 2020; Accepted 22 April 2020; Published 4 May 2020 Academic Editor: Katsuhiro Tanaka Copyright © 2020 Antonio Maffuz-Aziz et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Thyroid cancer is the most common endocrine malignancy, presenting with 23 500 new cases per year in the United States. About 7-23% of the patients will present recurrent metastases disease during follow-up. The classic variant of papillary carcinoma is less aggressive compared to its other variants like diffuse sclerosing, tall cell or columnar cell, and insular variants, and the sites to which this metastasizes is already well identified. Metastasis to the spleen is an extremely rare manifestation of papillary thyroid cancer. To date, only 3 cases have been reported in the literature. Herein, we present a 52-year-old male, who developed spleen metastases, 2.4 years after total thyroidectomy and central neck dissection followed by radioactive iodine ablation and seven months after treatment with sorafenib for lung metastases. The splenic lesion was detected in surveillance studies. This case highlights that splenic metastasis, although rare, may occur even in a patient with a locoregional and systemic controlled thyroid cancer and that it can be treated safely with surgical resection. 1. Introduction reported [6–8]. In this article, we present a case of splenic recurrence of papillary thyroid cancer and a literature review. Thyroid cancer is the leading cause of endocrine cancer and represents 2.1% of all cancer cases worldwide. About 90% 2. Case Presentation are well-differentiated thyroid carcinoma (DTC); papillary cancer is the most common histology [1]. The presence of A 52-year-old male presented with dysphonia of 2 months; distant metastases at the time of diagnosis is 4%, and 7-23% laryngoscopy was performed identifying right vocal cord during follow-up; in nearly 53% of cases, the relapse is paralysis; extension studies identified a tumour dependent reported in locoregional cancer, 28% in local relapse, and on the right thyroid lobe, with oesophageal infiltration and 13% distance metastasis is present; of these, 6% of cases have tracheal displacement, with no evidence of cervical lymph mixed relapses [2]. It has been reported that a global survival nodes. Total thyroidectomy with partial resection of the at 10 years is in a range of 25–70% [3]. oesophagus and lymphadenectomy of the central compart- The most common distant metastasis sites are the lungs ment was performed. The pathology report was classic papil- and bone with 69.0% and 7.1%, respectively [4]. Rare metas- lary thyroid carcinoma 3.6 cm in tumour size, and mixed tasis site locations are extremely low; they have been identi- pattern, with extra thyroid extension, and 1/7 lymph nodes fied in sites such as the liver, adrenal gland, central nervous with metastases. Postoperative iodine-131 dose of 200 mCi system, kidney, and skin and have been reported in 1.85% was delivered, with subsequent iodine-131 tracing that of cases [5]. reported small remnant of functional thyroid tissue in the The presentation of spleen metastases of a primary thy- thyroid bed. He continued hormone replacement therapy roid cancer is even more rare; to date, only 3 cases have been and surveillance. 2 Case Reports in Oncological Medicine Figure 1: Abdominal CT showing cystic lesion in the spleen of 40 mm diameter. Figure 3: Pathology macroscopic picture shows the spleen with a cystic lesion of 5.5 cm. 0.2 cm, with simple papillary formations (Figure 3). In sections with haematoxylin and eosin staining, the neoplastic prolifer- ation cyst is with a papillary growth pattern, and cuboidal cells, nuclear pleomorphism, empty nuclei and abundant nuclear bars are without mitosis (Figure 4). In immunohistochemistry, diffuse cytoplasmic positive thyroglobulin, CK19 diffuse cyto- plasmic positive, TTF-1 diffuse nuclear positive, PAX8 diffuse nuclear positive, and CK5/6 negative were observed (Figure 5). The diagnosis was papillary thyroid carcinoma with a cystic pattern, of conventional type, well differentiated, with focal microcalcification and intraluminal xanthomatous response, without extracapsular extension. No areas of tall, columnar, or oncocytic cells were identified. There were no poorly differ- entiated or anaplastic areas. Figure 2: PET/CT images show a 40 mm lesion without increased 3. Discussion metabolic activity. The presence of spleen metastases from solid tumours is At 16 months of surveillance, right basal pulmonary nodule extremely rare and generally exists in the context of a multi- was identified in X-ray; then, whole-body iodine-131 scan and organ disease. The presence of isolated spleen metastases has thyroglobulin levels were negative, so 18F-fluorodeoxyglucose- been reported <1% in autopsy studies; however, it is associ- positron emission tomography (18F-FDG PET/CT) was per- ated in 17 to 61% with metastases in other distant organs formed which was positive for bilateral pulmonary tumour [9]. In the present case, spleen metastases present after treat- activity; this being the only place where distant metastasis ing lung metastases. Although the frequency of metastatic was found at the time of the study, the spleen was normal. lesions of solid organs to the spleen is rare (2.3-7.1%), it is Thoracoscopy was performed, where pulmonary metastases the most common sites of origin in breast (22.9%), lung were confirmed secondary to well-differentiated papillary (20.2%), colorectal (9.4%), ovary (9%), and stomach (6.9%) thyroid cancer. Treatment with sorafenib was started, cancer [10]. The reason why this type of dissemination is rare assessing complete pulmonary control after 12 months of is still poorly understood; lack of afferent lymphatic vessel, treatment. the splenic capsule, the immunological capacity of the spleen Seven months after finished sorafenib treatment, and 29 parenchyma cells (macrophages and lymphocytes), and the months from initial treatment, 18F-FDG PET/CT was per- angled and spiral shape of the splenic artery constitute bar- formed, in which there was no evidence of metabolic activity rier methods for the presence of metastases in this organ [11]. in the lung or in any other organ; however a cystic lesion was To date, only 3 cases of thyroid metastases to the spleen found in the spleen 10 mm in diameter without metabolic have been reported. The first case was reported by Paolini activity. A control 18F-FDG PET/CT at 6 months showed et al. [7]; a patient with history of follicular thyroid cancer, the lung without evidence of disease, and the splenic lesion which developed lung and spleen metastases; the patient grew to a diameter greater than 40 mm; it was observed with- was diagnosed with splenomegaly and infiltration to the dia- out metabolic activity (Figure 1). Due to the increment of size phragm, colon, pancreas, and stomach. The second case and risk of spontaneous rupture, it was decided to perform reported was by Mayayo et al. [6]; with poorly differentiated splenectomy (Figure 2). thyroid carcinoma, the patient presented abdominal pain at 6 Pathology reported a 5:5×5:5×4cm semi ovoid months of surveillance. Spleen, liver, and pancreas metasta- tumour, cystic-looking lesion, with serous content, wall cut ses were identified. The diagnosis was made by fine-needle Case Reports in Oncological Medicine 3 (a) (b) Advice on equations (c) (d) Figure 4: (a) Ovoid splenic lesion of cystic appearance, 5.5 cm major axis on the wall. (b) Papillary projections are observed. (c) Photomicrograph in which simple papillae protruding from the cyst wall (haematoxylin and eosin, 4x) are observed. (d). At a higher magnification, cuboidal cells with clear nuclei and bars, characteristic of papillary thyroid carcinoma (haematoxylin and eosin, 20x) are observed. (a) (b) (c) (d) Figure 5: Photomicrographs of the immunohistochemical study performed on the splenic lesion. (a) PAX8 diffuse nuclear positive. (b) Diffuse cytoplasmic positive thyroglobulin. (c) TTF-1 diffuse nuclear positive. (d) CK19 diffuse cytoplasmic positive. 4 Case Reports in Oncological Medicine noma where the 1-year survival rate was 86.6%, and median aspiration cytology (FNA). And the last case reported by Kand et al. [8] was in a 50-year-old patient with a follicular survival time is 66.6 months [18], In metastases secondary to variant of a papillary carcinoma, who was diagnosed with melanoma, median overall survival after splenectomy is 11 months, with a survival of 23 months for the subgroup of an iodine-131 uptake study, which was captured at a diffuse level throughout the spleen, in addition to associating bone patients treated for a solitary lesion [19]. lesions. The definitive diagnosis was made using FNA as well. Distant metastasis is considered an important prognostic Our patient was diagnosed incidentally in surveillance factor in papillary thyroid cancer, which affects survival. The studies; he had no symptoms of abdominal pain and it 5-year survival rate is almost 100% for localized papillary, 99% for locoregional cancer and 78% for metastatic papillary seemed only a cystic lesion. Before 1990, when imaging techniques were not used thyroid cancer [20]. effectively, splenic metastasis rates were between 2.3% and For patients with only lung metastases, the survival rate 7.1% and most of them were found during autopsies or were at 10 years is 73.6%, which are significantly higher than just encountered coincidentally [10], because they are mostly patients with multiple organ metastases for whom the 10-year survival rate is 34.3% [21]. asymptomatic. Therefore, studies such as 18F-FDG PET/CT currently have an important tool for detection. In a study performed on 68 oncology patients with FDG avid malig- 4. Conclusions nancy and solid splenic masses on anatomical imaging, Papillary thyroid cancer is a very common neoplasm; there a 18F-FDG PET/CT had 100% accuracy in characterizing lot of information in articles and guides regarding its behav- lesions as benign or malignant. The sensitivity, specificity, iour and management options. However, on rare behaviour, positive predictive value, and negative predictive value of uncommon site metastases can occur, and its management 18F-FDG PET/CT in differentiating benign from malignant is not well defined. solid splenic lesions in patients with and without malignant disease are 100%, 100%, 100%, and 100% versus 100%, Data Availability 83%, 80%, and 100%, respectively. It should however be kept in mind that non-FDG-avid tumours, such as some renal or The [DATA TYPE] data used to support the findings of this thyroid cancers, may metastasize to the spleen [12, 13]. study are included within the article. Although the information in the literature regarding the relationship between 18F-FDG PET/CT and the diagnosis Conflicts of Interest of metastatic spleen lesions is only for solid tumours, the probable explanation is that most well-differentiated thy- The authors declare that there is no conflict of interest roid carcinomas are relatively slow growing and can be regarding the publication of this paper. 18F-fluorodeoxyglucose negative [14]. Several studies have reported that it has a high sensitivity (up to 85%) and References specificity (up to 95%) for distant metastases in patients with well-differentiated thyroid cancer [15]. [1] C. M. Kitahara and J. A. Sosa, “The changing incidence of Use of FNA is a useful diagnosis tool, since a sensitivity of thyroid cancer,” Nature Reviews. Endocrinology, vol. 12, 98.4%, a positive predictive value of 99.2%, and 98.1% accu- no. 11, pp. 646–653, 2016. racy for diagnosis and < 1% of complications have been [2] R. Cirocchi, S. Trastulli, A. Sanguinetti et al., “Recurrent differ- reported [16], although it is generally avoided because of entiated thyroid cancer: to cut or burn,” World Journal of Surgical Oncology, vol. 9, no. 1, pp. 2–5, 2011. the risk of intra-abdominal bleeding or dissemination in some cases. [3] L. Y. Wang, F. L. Palmer, I. J. Nixon et al., “Multi-organ distant metastases confer worse disease-specific survival in differenti- For this reason and based on the clinical evolution that ated thyroid cancer,” Thyroid, vol. 24, no. 11, pp. 1594–1599, the patient had, which was presented as a growth of the lesion, we decided to perform splenectomy because it was a [4] I. Sugitani, Y. Fujimoto, and N. Yamamoto, “Papillary thyroid unique and viable cystic lesion for resection. carcinoma with distant metastases: survival predictors and the Pathologic findings, the presence of isolated epithelial importance of local control,” Surgery, vol. 143, no. 1, pp. 35– cells or forming three-dimensional groups with round nuclei, 42, 2008. with inclusions or bars, are characteristics that should be sus- [5] N. S. Fedala, S. Kabour, F. Yaker, L. A. Ali, A. E. M. Haddam, pected in a thyroid origin, especially in patients with a history and F. Chentli, “Métastases inhabituelles des carcinomes of papillary thyroid carcinoma [6]. thyroïdiens différenciés,” Annales d'endocrinologie, vol. 75, The long-term survival after splenectomy in patients with no. 5–6, pp. 360-361, 2014. metachronous splenic metastasis from thyroid papillary can- [6] E. Mayayo, S. Blázquez, V. Gómez-Aracil, A. Saurí, and cer is unknown because of the limited number of reported S. 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Case Reports in Oncological MedicineHindawi Publishing Corporation

Published: May 4, 2020

References