Assistant Professor, Department of Medical Oncology, ILBS, Vasant Kunj, New Delhi

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1 Open Journal of Clinical & Medical Case Reports Volume 4 (2018) Issue 5 ISSN Calcitonin negative neuroendocrine carcinoma of thyroid: A rare case Saphalta Baghmar, DM*; Archana Rastogi, MD, DNB; Yashwant Patidar, MD; Rajni Yadav, MD *Saphalta Baghmar Assistant Professor, Department of Medical Oncology, ILBS, Vasant Kunj, New Delhi Phone: ; drbsaphalta@gmail.com Abstract Neuroendocrine tumors (NET) of the thyroid gland are derived from parafollicular endocrine cells (C cells) and are referred as medullary thyroid carcinomas (MTC). Calcitonin is always positive in MTC immunohistochemistry and is a prerequisite for pathological diagnosis. Here we report a case of a 42 year old woman who presented with neuroendocrine carcinoma (NEC) of thyroid with liver metastatises. Histopathology of the thyroid lesion was suggestive of Calcitonin negative thyroid NEC, an unusual histology. Existence of this entity should be known to the pathologists and clinicians while diagnosing and treating it. We had discussed the pathological dilemma and treatment with this case. Keywords neuroendocrine carcinoma of thyroid; calcitonin negative; liver metastasis Introduction Neuroendocrine tumors (NETs) usually arise from the foregut (bronchus, lung, stomach, pancreas, liver and irst part of the duodenum), the midgut (second part of the duodenum, jejenum, ileum, appendix and proximal colon) and the hindgut (distal colon, rectum and genitourinary tract) [1]. NET of the thyroid gland is considered to derive from parafollicular endocrine cells (C cells) and is referred as medullary thyroid carcinoma (MTC). Calcitonin secretion is almost always detected in MTC [2,3]. Here, we report a case of primary thyroid NET lacking calcitonin expression which presented to us with liver metastasis. Case History A 42 year female, diabetic, normotensive, chronic bidi smoker (4 pack years), presented to a local hospital with history of lump in upper right side of neck 1 cm x 1 cm for 1 year with occasional mild neck pain. There was no history of dsyphagia or hoarseness of voice, chest pain and breathlessness. On investigation she was found to have hetergenously hypodense thyroid lobe, right sided cervical lymphnodenopathy (LN) with calci ication with asymptomatic enhancing intraconal soft tissue mass in left orbit involving optic nerve on Computed Tomography (CT) scan. Whole body Fluoro Deoxycolic glucose Positron Emiting tomographies (FDG PET) scan was suggestive of hypodense lesion in left lobe (site of primary) with metastatic left cervical LN (level III and IV), upper paratracheal LN and left Baghmar S

2 intraconal retroorbital region (Figure 1). Fine needle cytology of thyroid lesion was suggestive of poorly differentiated thyroid cancer. Histopathological diagnosis of orbital lesion was not done. Total thyroidectomy with left modi ied neck dissection was done and histopathology was suggestive of poorly differentiated neoplasm involving thyroid and LN. She was given External beam radiotherapy (EBRT) to face & neck 50GY/25# by Three dimensional conformal radiotherapy with concurrent cisplatin post operatively in view of poorly differentiated carcinoma at her parent hospital. She then lost to follow up. She was a symptomatic for 2 years and then presented to us with intermittent fever and abdominal pain for 1 month. She recently had decreased appetite and signi icant weight loss. There was no history of nausea, vomiting, altered bowel habits, blood loss from any site. Repeat PET Scan revealed FDG avid con luent lymph node in left cervical level III region in iltrating adjacent sternocleidomastoid muscle suggestive of recurrent diseases. Hypermetabolic multiple hypodense lesion of varying sizes with central necrosis in both lobes of liver likely metastatic. There was mild thickening with no signi icant FDG uptake in left intraconal retro orbital region. Biopsy of liver lesion revealed neuro endocrine carcinoma ( igure 2A). Immunohistochemistry was positive for cytokeratin, carcinoenbryonic antigen (CEA), synaptophysin and chromogranin (Figure 2B); Ki 67 index 40 percent but negative for thyrogloglobulin, S100 and calcitonin, suggestive of calcitonin negative neuroendocrine carcinoma. Her serum Calcitonin and carcinoembryonic antigen (CEA) were normal. Serum Chromogranin A level was 650 ng/ml (normal values are <94 ng/ml). Thyroid slides were reviewed and similar histology was con irmed. Patient was started on cisplatin and etoposide regime but expired after 2 cycles of it due to dysfunctional cardiac pacemaker implanted 2 years back. Discussion NETs usually arise in gastrointestinal tract and bronchus but can rarely originate in the ovary, thymus, parotid gland, breast, and testis [4]. Medullary thyroid carcinomas (MTC) are the calcitonin expressing NET. When tumor cells do not express calcitonin, but stain positive for neuroendocrine markers like Chromogranin A and synaptophysin, differential diagnosis are paragangliomas, metastatic NETs. Paragangliomas are NETs derived from neural crest paraganglia of autonomic system. Rarely, they can be seen in thyroid gland [5]. Immunohistochemically they are chromogranin A and synaptophysin positive and calcitonin negative, like our case. Our patient did not express S100 protein; diagnosis of a paraganglioma was excluded. Metastatic NETs from other organs to thyroid can also show neuroendocrine properties. They are mostly calcitonin negative like in our case but at the baseline thyroid was the only organ involved; so it is regarded as primary site. CNNSTT was irst described in 2011 by Chernyavsky et al [6]. He described a case with calcitonin negativity and NSE, synaptophysin and thyroglobulin positivity. As thyroglobulin was positive, tumor was arising from true follicular cells rather than parafollicular cells. In our case, since thyroglobulin was negative, tumor can be considered as arising from parafollicular cells rather than true follicular cells as in the case described by Ismi et al [7]. There are few case reports describing CNNETT [2,6 10]. Based on positive staining with chromogranin, synaptophysin and CEA but negative calcitonin immunostaining, Page 2

3 the index case is of calcitonin negative neuroendocrine carcinoma of thyroid. CNNETs are rare, so little is known about their prognosis. There are immunohistochemically differences even among these tumors. Chernyavsky et al. reported thyroglobulin positivity while others did not [6]. CEA expression was positive in the case reported by Wang et al. [9] while it was negative in Ismi's case [7]. Nakazawa et al. diagnosed their case as calcitonin free NET of thyroid with Calcitonin gene related peptide (CGRP) immunoreactivity which was negative in 2 cases of Schmid et al. [2,10]. CGRP was not available at our institute, so we were not able to get it done. As there is no uniqueness in pathology, there prognostic feature is also not unique. They even don't have serum markers like calcitonin, so early diagnosis of recurrences is also dif icult. CNNET, most of the published cases were also treated surgically for a local disease as in cases of MTC except one [7], which was treated with chemotherapy as it was metastatic at the time of diagnosis. Our case was also treated with total thyroidectomy. Radiotherapy was given to suspected orbital metastasis (histopathological con irmation not done in local hospital). She presented to us in metastatic stage, so we treated her with chemotherapy. Clinically she was responding but succumbed to an episode of malfunction of cardiac pacemaker which was implanted 2 years back. Conclusions To conclude, Calcitonin negative neuroendocrine carcinoma of thyroid is rare entity, thus precluding prediction of their biological behaviour and prognosis. They are a group of thyroid malignancies with immunohistochemically calcitonin negative and neuroendocrine marker positive. They are mostly localized in thyroid gland treated surgically, but occasionally they can have distant metastases like in our case which requires systemic chemotherapy. Figures Figure 1A: Axial image of contrast enhanced CT scan of the neck reveal an enhancing soft tissue lesion in left lobe of thyroid (white arrow) and enlarged enhancing level III cervical lymph node (dashed white arrow). Figure 1B: Corresponding coronal 18 FDG enhanced PETCT scan image shows FDG uptake in thyroid lesion (white arrow) and cervical lymphnode (dashed white arrow). Figure 1C and D: Axial contrast enhanced MRI (Figure C) and CT scan (Figure D) shows associated enhancing lobulated mass lesion in left orbit superio laterally in intraconal location abutting the left optic nerve (Black arrow in ig C and D). Page 3

Vol 4: Issue 5: 1388 Figure 2A: Liver in iltration by sheets and islands of F i g u r e 2 B : N e u r o e n d o c r i n e t u m o u r w i t h Chromogranin immuno staining (LSAB, 200x) neuroendocrine

1(7275): 238 9. 2. Nakazawa T, Cameselle Teijeiro J, Vinagre J, Soares P, Rousseau E, Eloy C, et al.

4 Vol 4: Issue 5: 1388 Figure 2A: Liver in iltration by sheets and islands of F i g u r e 2 B : N e u r o e n d o c r i n e t u m o u r w i t h Chromogranin immuno staining (LSAB, 200x) neuroendocrine tumour cells (He, 100x) References 1. Williams ED, Sandler M. The classi ication of carcinoid tum ours. Lancet Lond Engl Feb 2; 1(7275): Nakazawa T, Cameselle Teijeiro J, Vinagre J, Soares P, Rousseau E, Eloy C, et al. C cell derived calcitonin free neuroendocrine carcinoma of the thyroid: the diagnostic importance of CGRP immunoreactivity. Int J Surg Pathol Sep; 22(6): Baloch ZW, LiVolsi VA. Neuroendocrine tumors of the thyroid gland. Am J Clin Pathol Jun;115 Suppl: S Turaka K, Mashayekhi A, Shields C, Lally S, Kligman B, Shields J. A case series of neuroendocrine (carcinoid) tumor metastasis to the orbit. Oman J Ophthalmol. 2011; 4(3): Yu B H, Sheng W Q, Wang J. Primary paraganglioma of thyroid gland: a clinicopathologic and immunohistochemical analysis of three cases with a review of the literature. Head Neck Pathol Dec; 7(4): Chernyavsky VS, Farghani S, Davidov T, Ma L, Barnard N, Amorosa LF, et al. Calcitonin negative neuroendocrine tumor of the thyroid: a distinct clinical entity. Thyroid Oﬀ J Am Thyroid Assoc Feb; 21(2): Ismi O, Arpaci RB, Berkesoglu M, Dag A, Sezer E, Bal KK, et al. Calcitonin negative neuroendocrine tumor of thyroid gland mimicking anaplastic carcinoma: an unusual entity. Gland Surg Aug; 4(4): Kasajima A, Cameselle Teijeiro J, Loidi L, Takahashi Y, Nakashima N, Sato S, et al. A Calcitonin Non producing Neuroendocrine Tumor of the Thyroid Gland. Endocr Pathol Feb 9; 9. Wang TS, Ocal IT, Sosa JA, Cox H, Roman S. Medullary thyroid carcinoma without marked elevation of.calcitonin: a diagnostic and surveillance dilemma. Thyroid Oﬀ J Am Thyroid Assoc Aug; 18(8): Schmid KW, Ensinger C. Atypical medullary thyroid carcinoma with little or no calcitonin expression. Virchows Arch Int J Pathol Sep; 433(3): Page 4

5 Manuscript Information: Received: October 17, 2017; Accepted: March 12, 2018; Published: March 15, 2018 Authors Information: Saphalta Baghmar*¹; Archana Rastogi²; Yashwant Patidar³; Rajni Yadav⁴ ¹Assistant Professor Department of Medical Oncology, Institute of liver and biliary sciences (ILBS), D1, Vasant Kunj, New Delhi , India ²Additional Professor Department of Pathology, ILBS, Vasant Kunj, New Delhi , India ³Associate Professor Department of Radiology ILBS, Vasant Kunj, New Delhi , India ⁴Assistant Professor Department of Pathology All India Institute of Medical Sciences, Ansari Nagar, New Delhi Citation: Baghmar S, Rastogi A, Patidar Y, Yadav R. Calcitonin negative Neuroendocrine Carcinoma of Thyroid: A rare case. Open J Clin Med Case Rep. 2018; Copy right statement: Content published in the journal follows Creative Commons Attribution License ( Baghmar S 2018 Journal: Open Journal of Clinical and Medical Case Reports is an international, open access, peer reviewed Journal focusing exclusively on case reports covering all areas of clinical & medical sciences. Visit the journal website at For reprints and other information, contact editorial of ice at info@jclinmedcasereports.com Page 5

Calcitonin-negative neuroendocrine tumor of thyroid gland mimicking anaplastic carcinoma: an unusual entity

Case Report Calcitonin-negative neuroendocrine tumor of thyroid gland mimicking anaplastic carcinoma: an unusual entity Onur Ismi 1, Rabia Bozdogan Arpaci 2, Mustafa Berkesoglu 3, Ahmet Dag 3, Emel Sezer