LGCmain
Indian Journal of Pathology and Microbiology
Home About us Instructions Submission Subscribe Advertise Contact e-Alerts Ahead Of Print Login 
Users Online: 861
Print this page  Email this page Bookmark this page Small font sizeDefault font sizeIncrease font size


 
  Table of Contents    
LETTER TO EDITOR  
Year : 2021  |  Volume : 64  |  Issue : 2  |  Page : 432-434
Pleura-based mass clinicoradiologically construed as lung carcinoma, revealing an occult primary papillary thyroid carcinoma (BRAF positive)


1 Department of Pathology, Rajiv Gandhi Cancer Institute and Research Centre, New Delhi, India
2 Department of Radiodiagnosis, Rajiv Gandhi Cancer Institute and Research Centre, New Delhi, India

Click here for correspondence address and email

Date of Submission05-Feb-2020
Date of Decision19-May-2020
Date of Acceptance03-Aug-2020
Date of Web Publication9-Apr-2021
 

How to cite this article:
Kumar A, Pasricha S, Kamboj M, Jajodia A. Pleura-based mass clinicoradiologically construed as lung carcinoma, revealing an occult primary papillary thyroid carcinoma (BRAF positive). Indian J Pathol Microbiol 2021;64:432-4

How to cite this URL:
Kumar A, Pasricha S, Kamboj M, Jajodia A. Pleura-based mass clinicoradiologically construed as lung carcinoma, revealing an occult primary papillary thyroid carcinoma (BRAF positive). Indian J Pathol Microbiol [serial online] 2021 [cited 2021 May 8];64:432-4. Available from: https://www.ijpmonline.org/text.asp?2021/64/2/432/313307




Dear Editor,

Papillary thyroid carcinoma (PTC) is the most common thyroid cancer which commonly presents with regional lymphadenopathy and rarely shows systemic distant metastasis at presentation.[1] Metastatic involvement of pleura has been described in the literature in an already diagnosed case of PTC,[2] with the largest series till date from MD Anderson Cancer Center, reporting an incidence of about 0.6%.[3],[4] However, breathlessness and pleural effusion as presenting symptoms revealing an occult primary in the thyroid is an extremely rare event.[5] This can prompt an erroneous diagnosis of primary lung adenocarcinoma with unwarranted toxic chemotherapy and radiation exposure. Here, we report a case of pleura-based mass with papillary adenocarcinoma morphology initially construed as primary lung adenocarcinoma, which on histopathological work-up revealed a metastatic tumor deposit from an occult PTC.

A 48-year-old male with complaints of hemoptysis and breathing difficulty for 5 months was evaluated elsewhere. A PET-CT was performed which revealed right-sided pleural effusion with metabolically active right pleural deposits (largest: 2.5 cm), mediastinal and cervical lymph nodes [Figure 1]. Right lobe of thyroid showed ill-defined hypodense lesion with heterogeneous tracer uptake. A working clinicoradiological diagnosis was Lung carcinoma (Stage IV). A pleural biopsy performed was reported as primary lung papillary adenocarcinoma in view of strong immunopositivity for TTF1 and p40 being negative. On further investigations, no driver mutations (EGFR/ROS1/ALK: Negative) were identified.
Figure 1: Axial CT image showing heterogeneously enhancing nodular deposit in right pleural space with pleural effusion

Click here to view


The patient subsequently presented to our center in respiratory distress and was started with 1st cycle of pemetrexed and carboplatin based chemotherapy. Concomitantly, paraffin-embedded blocks were sent for histopathological review. Examination of the sections revealed a non-small cell carcinoma: adenocarcinoma in predominantly papillary pattern along with strong and diffuse TTF-1 positivity [Figure 2]a and [Figure 2]b. However, on diligent morphological assessment, presence of nuclear stratification, regimentation, and psammoma bodies [Figure 3]a and [Figure 3]b was evocative of metastatic deposit of PTC and provoked us to rule out this remote possibility. Subsequently, IHC panel was expanded to include thyroglobulin, PAX-8 and BRAF, which were all strongly positive [Figure 4]a,[Figure 4]b,[Figure 4]c and provided tangible evidence of metastatic PTC. Based on these findings, a tumor deposit from papillary thyroid carcinoma was suggested. The case was discussed in the multispecialty tumor board and PET scan was reviewed. The radiological findings were in resonance with the histopathological diagnosis of metastatic PTC. Subsequently, the patient underwent total thyroidectomy with bilateral selective neck dissection, which on histopathological examination revealed a multifocal papillary thyroid carcinoma (mpT2N1b) involving both lobes of thyroid and isthmus.
Figure 2: (a) Papillary pattern of the tumor on histopathological examination. (b) TTF1 positivity in tumor cells

Click here to view
Figure 3: (a) Nuclear crowding and regimentation noted on high magnification. (b) Occasional foci of psammomatous calcifications observed

Click here to view
Figure 4: (a) PAX-8 expression in tumor cells. (b) Thyroglobulin positivity in tumor cells. (c) Strong BRAF (V600E) expression in tumor cells

Click here to view


Although most cases with pleural metastasis also have concomitant lung involvement, the latter was not observed in the presented case. Metastasis of PTC to pleura is rare and has been described in literature, as a part of disease progression in a known case. However, primary presentation of PTC as pleural effusion and pleural mass is extremely rare and can be deceptive which can lead to needless toxic or radical treatment. Hence, the present case highlights the significance of diligent histomorphological assessment along with the use of judicious IHC panel and discussion in multispecialty tumor board to arrive at a definitive strategy for diagnosis and management.

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

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Sakomoto RI, Sumida LC, Lum CA, Tauchi-Nishi PS. Recurrent papillary thyroid carcinoma with pleural metastasis diagnosed by effusion cytology: A report of cases with clinicopathological correlation. Hawaii J Med Public Health 2015;74:51-6.  Back to cited text no. 1
    
2.
Cho SW, Choi HS, Yeom GJ, Lim JA, Moon JH, Park DJ, et al. Longterm prognosis of differentiated thyroid cancer with lung metastasis in Korea and its prognostic factors. Thyroid 2014;24:277-86.  Back to cited text no. 2
    
3.
Vassilopoulou-Sellin R, Sneige N. Pleural effusion in patients with differentiated papillary thyroid cancer. South Med J 1994;87:1111-6.  Back to cited text no. 3
    
4.
Olson MT, Nuransoy A, Ali SZ. Malignant pleural effusion resulting from metastasis of thyroid primaries: A cytomorphological analysis. Acta Cytol 2013;57:177-83.  Back to cited text no. 4
    
5.
Tamura T, Shiozawa T, Satoh H, Kurishima K, Kagohashi K, Takayashiki N, et al. Pleural fluid due to papillary thyroid cancer. Oncol Lett 2019;18:962-6.  Back to cited text no. 5
    

Top
Correspondence Address:
Sunil Pasricha
Department of Pathology, Rajiv Gandhi Cancer Institute and Research Centre, New Delhi
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJPM.IJPM_93_20

Rights and Permissions


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

Top
 
 
  Search
 
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
    Email Alert *
    Add to My List *
* Registration required (free)  


    References
    Article Figures

 Article Access Statistics
    Viewed130    
    Printed0    
    Emailed0    
    PDF Downloaded3    
    Comments [Add]    

Recommend this journal