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CASE REPORT
Year : 2015  |  Volume : 3  |  Issue : 2  |  Page : 43-45

Breast metastases in medullary carcinoma thyroid may be an indicator of disseminated disease


1 Department of Surgical Oncology, Government Medical College, Amritsar, Punjab, India
2 Department of Otolaryngology, Sri Guru Ram Das Institute of Medical Sciences and Research, Amritsar, Punjab, India
3 Department of Head and Neck Surgical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
4 Department of Pathology, Tata Memorial Hospital, Mumbai, Maharashtra, India

Date of Web Publication1-Feb-2016

Correspondence Address:
Bikramjit Singh
Department of Surgical Oncology, Government Medical College, Amritsar - 143 001, Punjab
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2320-3846.175210

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  Abstract 


Metastases in medullary carcinoma thyroid are not an uncommon phenomenon; however, metastases to the breast are extremely rare. Authors are reporting a rare case of medullary carcinoma thyroid metastases to breast in a 42-year-old female. Biopsy was performed to distinguish between primary duct carcinoma and metastatic medullary carcinoma thyroid. Further investigations revealed multiple involvements of cervical as well as axillary lymph nodes, bones, lungs, and dermis. Though survival of isolated metastases of medullary carcinoma thyroid to the breast may be better compared to other solid tumors of the breast, with wide spread dissemination survival is poor. Breast metastases on presentation seem to be a manifestation of wide spread disease.

Keywords: Breast, medullary, metastases, thyroid


How to cite this article:
Singh B, Pal P, Chaturvedi P, Shet T. Breast metastases in medullary carcinoma thyroid may be an indicator of disseminated disease. Saudi Surg J 2015;3:43-5

How to cite this URL:
Singh B, Pal P, Chaturvedi P, Shet T. Breast metastases in medullary carcinoma thyroid may be an indicator of disseminated disease. Saudi Surg J [serial online] 2015 [cited 2022 May 27];3:43-5. Available from: https://www.saudisurgj.org/text.asp?2015/3/2/43/175210




  Introduction Top


Metastases in medullary carcinoma thyroid (MCT) are not an uncommon phenomenon. MCT initially metastasizes to regional lymph nodes in 60% of patients. Eventually, hematogenous dissemination occurs to the lungs, liver, bone, and rare sites such as the brain and skin.[1]

Metastatic lesions of the breast from extramammary sites are very uncommon, accounting for only 0.2–1.3% of all breast tumors.[2] Malignancies most often implicated include those of hematolymphoid origins such as lymphoma and malignant melanoma.[3] Metastasis of MCT to the breast is an extremely rare occurrence with only a few cases reported in literature.

The authors are reporting a rare case of MCT metastasizing to the breast, highlighting its clinical significance and importance of differentiating it from a primary breast malignancy.


  Case Report Top


A 42-year-old female presented to our Head and Neck Surgery Department with the right level II and III cervical lymphadenopathy, right axillary swelling, and a hard nodule in the upper outer quadrant of the left breast. An ultrasonography of the neck revealed a lesion in the right thyroid lobe measuring 2.7 cm × 1.7 cm × 1.5 cm, with ipsilateral upper and mid-jugular lymph nodes. A computed tomography scan done of the neck and chest confirmed the presence of the thyroid nodule. Further, additional information was also obtained regarding perinodal extension exhibited by the right cervical metastatic mass measuring 7.5 cm × 5 cm, along with the presence of bilateral lung nodules, right axillary lymphadenopathy, and solitary nodule in upper outer quadrant of the left breast. A fine needle aspiration cytology (FNAC) of the thyroid nodule suggested a diagnosis of MCT. However, FNAC performed on the right axillary swelling preferred a diagnosis of an adenocarcinoma over a neuroendocrine carcinoma. To establish the diagnosis and to distinguish a primary duct carcinoma from a metastatic MCT, an incisional biopsy was performed of the axillary as well as the breast lesion and submitted for histopathology.

Histopathology of the incisional biopsy specimen revealed a tumor with pushing borders within the breast parenchyma [Figure 1]. The tumor cells showed a tubular and acinar pattern mimicking an infiltrating duct carcinoma [Figure 2]. The tumor cells showed sudden anisonucleosis and the sclerotic stroma showed myxohyaline material, which subsequently was confirmed as amyloid by Congo red stain.
Figure 1: Normal breast adjacent to metastatic tumor (H and E, ×200)

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Figure 2: Higher power reveals medullary carcinoma with tubules and acini mimicking usual breast carcinoma; however, the interstitial stroma focally revealed the hyaline waxy amyloid (H and E, ×400)

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On immunohistochemistry, tumor showed strong expression of calcitonin and cacinoembryonic antigen, but were negative for estrogen receptors/progesterone receptors, S-100, and smooth muscle actin (SMA) [Figure 3].
Figure 3: Strong calcitonin expression within tumor cells (H and E, ×400)

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The excision biopsy of the axillary swelling too showed MCT within lymph node with perinodal extension going to deep dermis. A positron emission tomography scan done to quantify the disease and for accurate staging showed uptake in the right neck nodes, the biopsy area of the breast and axilla along with several asymptomatic skeletal metastases involving the right iliac crest, the right humerus, and C2, C3, C4, and L5 vertebrae.

Hence, a diagnosis was made of medullary carcinoma of the thyroid with metastasis to the breast, axillary lymph node, and multiple skeletal metastasis. The patient was operated for a total thyroidectomy, which confirmed the diagnosis of MCT and was followed by adjuvant radiotherapy. The asymptomatic disseminated metastases were kept under observation. Unfortunately, the patient succumbed to the disease within a year.


  Discussion Top


MCT originates from the parafollicular cells of the thyroid and represents 3–10% of thyroid malignancies.[4] Initial metastasis is to the regional lymph nodes in 40% of patients, with subsequent metastasis to distant organs via hematogenous dissemination. It metastasizes mainly to the lungs, followed by the liver and bone. Rare instances of metastasis to the brain and skin have also been documented.[1]

Metastatic lesions to the breast from extramammary sites are very uncommon, accounting for only 0.2–1.3% of all breast tumors.[2] This is thought to be due to the abundance of fibrofatty tissue within the breast with a relative paucity of blood vessels, precluding hematogenous dissemination. Other authors suggest retrograde lymphatic dissemination as a possible, though less likely, mechanism of metastasis to the breast. They hypothesize that following neck dissection or radiation therapy to the neck, there is blockage of lymphatics facilitating lymphatic dissemination from supraclavicular lymph nodes to subclavicular axillary nodes and then onto the breast.[5] The most common malignancies known to metastasize to the breast include hematological malignancies viz. lymphomas in up to 17% of patients, followed by malignant melanoma in 15% and RMS in 12%, although any tumor may metastasize to the breast.[3] Metastasis of MCT to the breast is extremely rare, with only a few cases reported in literature.

Metastatic lesions of the breast often mimic a primary breast malignancy. However, it is crucial to differentiate between the two due to the vast difference in treatment ideology as well as prognosis. Due to the indolent nature of MCT characterized by extremely slow progression of disease, several studies have documented a 5-year survival rate of over 90% in patients with persistent MCT.[6] However, unlike differentiated thyroid cancers, radioactive iodine therapy has no role in the management of these patients, and surgery forms the mainstay of treatment. Revision surgery of the neck to eliminate residual locoregional disease, as well as metastasectomy not only improve local control but also help in the palliation of symptoms of raised calcitonin such as diarrhea.

Any patient with suspected breast malignancy should undergo a thorough clinical examination to rule out the possibility of metastatic MCT disease to the breast, especially in patients with thyroid nodules or family history of thyroid disease. The mammography picture of metastatic MCT is that of a well-circumscribed mass with increased density, without spiculations and microcalcifications characteristic of most primary breast malignancies.[7]

FNAC is often considered to be the best initial investigation providing vital information regarding the possible diagnosis without any significant morbidity. However, if inconclusive as in the present case, histopathological examination of the incisional biopsy specimen is the most valuable diagnostic test. Metastatic MCT can be differentiated from similar looking breast malignancies by the presence of amyloid-like material on H and E staining. In addition, staining of the tissue with calcitonin on immunohistochemistry is confirmatory of metastatic MCT, as was seen in our patient.[3]


  Conclusion Top


To summarize, (1) breast metastases is a sign of disseminated disease, (2) patients will have bilateral or multiple metastasis at the time of presentation, (3) spread is by hematogenous route rather than by retrograde lymphatic dissemination due to neck dissection or previous neck irradiation, and (4) mostly occurs without lymph node involvement. Although FNAC often points toward a possible diagnosis, histopathology complemented by immunohistochemistry on the biopsy specimen is confirmatory distinguishing it from other metastatic tumors or primary breast carcinomas. Despite the fact that MCT with isolated metastasis to the breast may have a better survival compared to other solid tumors, survival with widespread dissemination is poor. Breast metastases on presentation seem to be a manifestation of disseminated disease.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Kiely N, Williams N, Wilson G, Williams RJ. Medullary carcinoma of the thyroid metastatic to breast. Postgrad Med J 1995;71:744-5.  Back to cited text no. 1
    
2.
Kim JH, Lee S, Kim WS, Han HS, Lim SD, Hwang TS. Metastatic medullary thyroid carcinoma to the breast. Basic Appl Pathol 2008;1:149-51.  Back to cited text no. 2
    
3.
Kang M, Hazarika D, Ghosal S, Kaur J, Kwatra N, Khandelwal N. Metastatic medullary thyroid carcinoma to the breast: Radiological features. Eur J Radiol Extra 2008;65:47-9.  Back to cited text no. 3
    
4.
Choi WJ, Lee YY, Kim S, Kim YK, Kim ES, Seo SO, et al. A case of medullary thyroid carcinoma in which the skin metastasis was concurrently present and response occurred to chemotherapy. Cancer Res Treat 2008;40:202-6.  Back to cited text no. 4
    
5.
Ricciato MP, Lombardi CP, Raffaelli M, De Rosa A, Corsello SM. Metastatic breast involvement from medullary thyroid carcinoma: A clue to consider the need of early diagnosis and adequate surgical strategy. Thyroid 2010;20:831-2.  Back to cited text no. 5
    
6.
Chen H, Roberts JR, Ball DW, Eisele DW, Baylin SB, Udelsman R, et al. Effective long-term palliation of symptomatic, incurable metastatic medullary thyroid cancer by operative resection. Ann Surg 1998;227:887-95.  Back to cited text no. 6
    
7.
Bartella L, Kaye J, Perry NM, Malhotra A, Evans D, Ryan D, et al. Metastases to the breast revisited: Radiological-histopathological correlation. Clin Radiol 2003;58:524-31.  Back to cited text no. 7
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]


This article has been cited by
1 Medullary carcinoma of thyroid metastasis to breast: A cytological experience
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Diagnostic Cytopathology. 2019;
[Pubmed] | [DOI]



 

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