|LETTER TO EDITOR
|Year : 2019 | Volume
| Issue : 4 | Page : 432-433
Occult papillary thyroid carcinoma with pleural effusion – A rare presentation
Ajay Verma1, Arpita Singh2, Ved Prakash1, Surya Kant3, Ambarish Joshi3
1 Department of Pulmonary and Critical Care Medicine, King George's Medical University, Lucknow, Uttar Pradesh, India
2 Department of Pulmonary and Critical Care Medicine, Dr Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
3 Department of Respiratory Medicine, King George's Medical University, Lucknow, Uttar Pradesh, India
|Date of Submission||29-Mar-2018|
|Date of Decision||10-Jun-2019|
|Date of Acceptance||20-Nov-2019|
|Date of Web Publication||16-Jul-2020|
Dr. Ved Prakash
Department of Pulmonary and Critical Care Medicine, King George's Medical University, Lucknow, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Verma A, Singh A, Prakash V, Kant S, Joshi A. Occult papillary thyroid carcinoma with pleural effusion – A rare presentation. J Datta Meghe Inst Med Sci Univ 2019;14:432-3
|How to cite this URL:|
Verma A, Singh A, Prakash V, Kant S, Joshi A. Occult papillary thyroid carcinoma with pleural effusion – A rare presentation. J Datta Meghe Inst Med Sci Univ [serial online] 2019 [cited 2020 Aug 14];14:432-3. Available from: http://www.journaldmims.com/text.asp?2019/14/4/432/289855
A middle-aged female, aged 45 years, presented to us with the chief complaints of cough for 3 months; initially, it was dry and finally turned out to be productive with no diurnal and postural variation. There was a history of breathlessness for 1 month, which was insidious in onset and gradually progressive. A history of weight loss and loss of appetite was present, along with a history of fever for 1 month, mild-to-moderate grade, not associated with chills and rigors. There was no history of hemoptysis, jaundice, and urinary complaints; no swelling over joints and feet; and pain in the abdomen. The patient also complained of generalized body ache. The patient was diagnosed with right-sided tubercular pleural effusion about 3 months back by a private practitioner and registered under antitubercular treatment Directly observed treatment, short-course (DOTS) category I; in spite of that, cough and dyspnea kept on increasing, and radiology also revealed increasing pleural effusion.
On general examination, the patient was conscious; was well oriented to time, place, and person; was afebrile; had a pulse of 90/min, a blood pressure of 110/80 mmHg, a respiratory rate of 18/min; had bilaterally equal carotids; his jugular venous pulse did not raised and right cervical lymphadenopathy was present, 3 cm × 2 cm in size. Auscultation of the chest revealed absent breath sounds in the right mammary, inframammary, infraaxillary, and infrascapular regions. No pleural rub or adventitious breath sound was heard. Abdominal examination revealed no organomegaly. Central nervous system (CNS) examination revealed normal higher CNS functions, and there was no neurological focal deficit.
On investigations, the patient was found to have metastatic papillary carcinoma – primary likely thyroid. Hematological tests revealed hemoglobin – 9.7 mg%, red blood cell (RBC) – 3.29 cells/mm3, white blood cell – 10,500 cells/mm3, and mean corpuscular volume – 84.6 mg/dL; peripheral blood smear revealed normocytic, normochromic RBCs and increased platelet count. Pleural fluid examination showed pleural fluid glucose level of 98 mg/dL and pleural fluid protein level of 4.6 mg/dL. Blood urea was 15 mg/dL, serum creatinine was 1.0 mg/dL, serum sodium was 134 mEq/L, and serum potassium was 3.6 mEq/L. Sputum smear examination for acid-fast bacilli (AFB), using Ziehl–Neelsen staining, came out to be negative. The culture of pleural fluid showed no growth after 48 h of incubation.
On histopathology, the pleural fluid cell block revealed metastatic papillary carcinoma and fluid cytology revealed lymphocytes in hemorrhagic background, with no malignant cells. Fine-needle aspiration cytology (FNAC) of the right cervical supraclavicular lymph node revealed metastasis of papillary carcinoma, with the most likely primary site as thyroid.
Chest X-ray revealed right-sided pleural effusion. Ultrasonography (USG) neck showed that both the parotid glands and submandibular glands were normal in morphology and echotexture. The right lobe of the thyroid gland was normal in morphology and echotexture measuring 1.5 cm × 1.0 cm × 0.8 cm, whereas the size of the left lobe was 1.0 cm × 0.9 cm × 0.6 cm. There was evidence of a hypoechoic mass lesion of size 8.7 cm × 6.8 cm × 5.6 cm with few calcific foci within the isthmus size 2 mm normal in morphology and echotexture. USG neck revealed a hypoechoic mass lesion in the left lobe of the thyroid gland with few calcific foci within the neoplastic mass.
Pleural effusion is a commonly encountered medical problem and a manifestation of a wide range of diseases. A structured approach to the investigation of the patient with a pleural effusion could allow an accurate diagnosis. Pleural fluid analysis is the most useful test in differentiating possible causes and directing further investigations. Tubercular pleurisy was initially suspected in this patient as the cause of the unilateral pleural effusion showing the nature of lymphocyte-dominant exudates, considering the high incidence of tubercular pleurisy in India. However, the likelihood of tubercular pleurisy as the cause of the pleural effusion decreased because of the negative AFB smear.
The possibility of thyroid cancer as a cause of malignant effusion was not initially suspected. After histopathology of the cell block of the pleural fluid, the diagnosis of metastatic papillary carcinoma was confirmed.
Thyroid malignancies presenting with pleural effusion are rare. Only approximately 4% of patients presented initially with distant metastasis in well-differentiated thyroid cancer. In this case, although pleural fluid cytology had not suggested the involvement of pleura, a definitive diagnosis could be rendered only on cell block examination of pleural fluid. An ancillary aid such as immunohistochemistry could have helped to establish pleural involvement on routine pleural fluid cytology alone. This case emphasizes the possibility of rare cases of papillary thyroid carcinoma (PTC) that may be associated with a dismal prognosis. In our case, the initial diagnosis of PTC could be made on correlating FNAC features of thyroid aspirate with those of lymph node aspirate.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.,,,,,,,,
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Hausheer FH, Yarbro JW. Diagnosis and treatment of malignant pleural effusion. Cancer Metastasis Rev 1987;6:23-40.
Hoie J, Stenwig AE, Kullmann G, Lindegaard M. Distant metastases in papillary thyroid cancer. A review of 91 patients. Cancer 1988;61:1-6.
Kim JY, Park DW, Na JO, Hwang BY, Kim DL, Shin DH, et al
. A case of malignant pleural effusion with pleural metastasis in a patient with papillary thyroid carcinoma. J Korean Soc Endocrinol 2002;17:269-74.
Lee KY, Myong NH, Kim KY. Occult papillary thyroid carcinoma presenting as a metastatic pleural effusion. Tuberc Respir Dis 1995;42:594-9.
Massin JP, Savoie JC, Garnier H, Guiraudon G, Leger FA, Bacourt F. Pulmonary metastases in differentiated thyroid carcinoma. Study of 58 cases with implications for the primary tumor treatment. Cancer 1984;53:982-92.
Nĕmec J, Zamrazil V, Pohunková D, Zeman V, Röhling S. Mode of spread of thyroid cancer. Oncology 1979;36:232-5.
Shaha AR, Shah JP, Loree TR. Differentiated thyroid cancer presenting initially with distant metastasis. Am J Surg 1997;174:474-6.
Vernon AN, Sheeler LR, Biscotti CV, Stoller JK. Pleural effusion resulting from metastatic papillary carcinoma of the thyroid. Chest 1992;101:1448-50.
Vassilopoulou-Sellin R, Sneige N. Pleural effusion in patients with differentiated papillary thyroid cancer. South Med J 1994;87:1111-6.