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LETTERS TO EDITOR  
Year : 2020  |  Volume : 63  |  Issue : 1  |  Page : 147-149
Synchronous malignancies: A tale of two different tumors


1 Department of Pathology, PGIMER, Dr. Ram Manohar Lohia Hospital, New Delhi, India
2 Department of Surgery, PGIMER, Dr. Ram Manohar Lohia Hospital, New Delhi, India

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Date of Web Publication31-Jan-2020
 

How to cite this article:
Kaushal M, Agarwal P, Srivastava N, Sharma D, Bhardwaj M, Ahuja A. Synchronous malignancies: A tale of two different tumors. Indian J Pathol Microbiol 2020;63:147-9

How to cite this URL:
Kaushal M, Agarwal P, Srivastava N, Sharma D, Bhardwaj M, Ahuja A. Synchronous malignancies: A tale of two different tumors. Indian J Pathol Microbiol [serial online] 2020 [cited 2020 Feb 23];63:147-9. Available from: http://www.ijpmonline.org/text.asp?2020/63/1/147/277387




Editor,

Synchronous tumors refer to occurrence of a second malignancy in a patient with a known primary. While synchronous lesions occur within 6 months of diagnosis of a previous neoplasm, metachronus tumors occur >6 months apart.[1] While nationwide frequency of thyroid cancer in Indian population has been reported to be only 0.1%–0.2% of all cancers,[2] breast cancer is now the most common cancer in Indian females in most cities and is on a rising trend.[3]

A 55-year-old postmenopausal female presented with 3 × 3 cm right breast lump for 10 months. Radiological findings were suggestive of BIRADS IV lesion [Figure 1]a. General patient examination revealed another diffuse midline neck bulge measuring approximately 3 × 3 cm, moving with deglutition. The patient had not suspected a neck swelling otherwise. A contrast enhanced computed tomography of neck, chest, and abdomen was done, which revealed discrete lesions in breast and thyroid [Figure 1]b and [Figure 1]c. Fine needle aspiration cytology (FNAC) of breast [Figure 2]a [Figure 2]b [Figure 2]c and cell block smears revealed similar picture [Figure 2]d [Figure 2]e [Figure 2]f of cellular smears with clusters of large polygonal cells having foamy to eosinophilic cytoplasm. A diagnosis of Invasive carcinoma breast of no special type (Ductal, NOS) was rendered. FNAC and cell block smears from thyroid swelling [Figure 3]a [Figure 3]b [Figure 3]c [Figure 3]d [Figure 3]e [Figure 3]f [Figure 3]g] showed highly cellular smears with follicular epithelial cells arranged in large papillary fragments and sheets. Considerable nuclear overlapping and overcrowding with characteristic intranuclear grooves and inclusions were noted. Background showed thick and thin colloid with scattered hurthle cells. Thus, confirming diagnosis of papillary carcinoma thyroid (Bethesda Category 6). Pre-op molecular testing for BRAF (V600E) was not done as the cytomorphology was diagnostic. Our patient underwent trucut biopsy from the breast lesion and a total thyroidectomy. Features were suggestive of Infiltrating duct carcinoma, no special type [Figure 2]g and [Figure 2]h. Molecular subtype was basal like; triple negative for ER, PR, and Her-2neu [Figure 2]i. The patient also underwent total thyroidectomy which on microscopy was diagnostic of well differentiated, papillary carcinoma thyroid (pT2) with microinvasion in the right lobe, and colloid goiter in the isthmus [Figure 3]h and [Figure 3]i. On follow-up, the patient has currently undergone four cycles of chemotherapy (CAF regimen) and is planned for radical mastectomy after six cycles.
Figure 1: (a) Radio dense lesion with irregular spiculated margins in the upper outer quadrant breast; (b) contrast enhanced computed tomography (CECT) breast shows an enhancing mass in right breast; (c) CECT neck showed a discrete enhancing mass in the left thyroid extending across midline

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Figure 2: Breast and axilla FNA revealed (a) duct epithelial cells showing moderate to abundant cytoplasm in hemorrhagic background (PAP; 200×). (b) Pleomorphic cells clusters with intervening pink stromal material (Giemsa; 400×). (c) Tumor cells show prominent nucleoli owed (Giemsa; 400×). Cell block smears revealed cellular polygonal cell clusters. (d) (H and E; 40×). (e and f) (H and E; 400×). Trucut breast biopsy: (g) pleomorphic nests of epithelial cells showing high-grade nuclear atypia (H and E; 100×). (h) Cell clusters had moderate eosinophilic to foamy cytoplasm (H and E; 400×). (i) IHC for ER, PR, and Her2neu was negative

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Figure 3: Thyroid FNA revealed cellular aspirate comprising tubules and balls of follicular epithelial cells: (a) (PAP; 100×), (b) (PAP; 200×), (c) anatomical borders in follicular sheets (PAP; 100×); (d) follicular cell sheets in a hemorrhagic background (Giemsa; 200×); (e) nuclear crowding, grooves, and pleomorphism evident (Giemsa; 400×); (f) intranuclear inclusions were noted in many of the nuclei (Giemsa; 400×); (g) cell block smears (H and E; 100×); (h) thyroid resection section: papillae lined by nuclei showing clearing and evident grooving (H and E; 400×); (i) intranuclear inclusions (H and E; 400×)

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The association between thyroid disorders and breast neoplasms has been a matter of debates for decades. Recent papers have highlighted the complex interplay by demonstrating that on one hand, L-thyroxine, T4, has a proliferative effect in vitro on breast cancer cells, and even in the absence of estrogen, thyroid hormone can promote nuclear estrogen receptor-α (ERα)-dependent proliferation of breast cancer cells bearing this receptor. On the other hand, clinical evidence exists establishing beneficial effects of hypothyroidism on the course of breast cancer.[4] Nio et al. in their large-scale observational study found that patients with thyroid disorders (thyroid cancer, adenoma, or adenomatous goiter) had an increase incidence of developing breast cancer; however, vice versa was not true.[5]

Several key factors have been attributed to this mosaic entanglement between thyroid and breast. A beneficial role of thyroid peroxidase antibodies (TPOAbs) in patients with breast cancer has been demonstrated in few studies with a potential for targeted therapy.[6] Interestingly, Nielsen et al. attributed shared genetic susceptibility as observed by germline mutation in the tumor suppressor gene, PTEN, succinate dehydrogenase (SDHx), and KLLN to be the link between these two organs.[7] An underrecognized role of multiorgan cancer susceptibility gene, CHEK2, is also suspected in multiorgan carcinogenesis and responsible for defective DNA damage repair.[8]

There exists a causal relationship between thyroid malignancy and carcinoma breast. Several pathogenic mechanisms and theories have been suggested; however, none is conclusive. Through the present case, we highlight the coexistence of these two lesions along with importance of multisystem examination in a patient diagnosed with either thyroid or breast malignancy.

Acknowledgements

The authors acknowledge support of Lab and OT technicians who work tirelessly with the doctors.

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.

Ethics statement by all authors

As this is a case report without identifiers, approval from Institutional Review Board is not required.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Sapalidis K, Schizas N, Lazopoulos A, Kamparoudi P, Paliouras D, Sardeli C, et al. Multiple metachronous and synchronous malignancies with lung and thorax involvement. Report of two cases. Respir Med Case Rep 2018;24:5-7.  Back to cited text no. 1
    
2.
Unnikrishnan AG, Menon UV. Thyroid disorders in India: An epidemiological perspective. Indian J Endocrinol Metab 2011;15(Suppl 2):S78-81.  Back to cited text no. 2
    
3.
Breast Cancer India. Trends of Breast Cancer in India [Internet]. India: The Pink Initiative; 2015. Available from: http://www.breastcancerindia.net/index.html. [Last cited on 2017 Oct 15].  Back to cited text no. 3
    
4.
Hercbergs A, Mousa SA, Leinung M, Lin HY, Davis PJ. Thyroid hormone in the clinic and breast cancer. Horm Cancer 2018;9:139-43.  Back to cited text no. 4
    
5.
Nio Y, Iguchi C, Itakura M, Toga T, Hashimoto K, Koike M, et al. High incidence of synchronous or metachronous breast cancer in patients with malignant and benign thyroid tumor or tumor-like disorders. Anti Cancer Res 2009;29:1607-10.  Back to cited text no. 5
    
6.
Godlewska M, Arczewska KD, Rudzińska M, Łyczkowska A, Krasuska W, Hanusek K, et al. Thyroid peroxidase (TPO) expressed in thyroid and breast tissues shows similar antigenic properties. PLoS One 2017;12:e0179066.  Back to cited text no. 6
    
7.
Nielsen SM, White MG, Hong S, Aschebrook-Kilfoy B, Kaplan EL, Angelos P, et al. The breast-thyroid cancer link: A systematic review and meta-analysis. Cancer Epidemiol Biomarkers Prev 2016;25:231-8.  Back to cited text no. 7
    
8.
Verkooijen RBT, Smit JWA, Romijn JA, Stokkel MPM. The incidence of second primary tumors in thyroid cancer patients is increased, but not related to treatment of thyroid cancer. Eur J Endocrinol 2006;155:801-6.  Back to cited text no. 8
    

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Correspondence Address:
Poojan Agarwal
Department of Pathology, PGIMER, Dr. RML Hospital, New Delhi - 110 001
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJPM.IJPM_468_18

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