Abstract
Neck metastasis from a differentiated thyroid cancer with no detectable primary in the thyroid gland is rare, with few cases reported in the literature. Due to this there is no clear consensus about its etiology, treatment or prognosis. A new case in 41-year-old women with a 3cm neck metastasis is presented, she had a cystic metastasis from a papillary thyroid carcinoma with no detectable primary despite a meticulous clinical and imaging inspection. Even after surgery the primary tumor couldn’t be found on the thyroid gland. She had surgery and Iodine therapy. During active surveillance a central neck compartment recurrence was detected requiring surgery. A complete revision of literature shows only 9 cases reported; the theories about its origin are not clear. It seems to have as good prognosis as its counterpart with primary found in the gland.
Keywords: Unknown primary; Thyroid cancer; Neck metastasis cancer; Papillary thyroid cancer
Introduction
Thyroid cancer is the most frequent endocrine tumor of the head and neck. Most of them are papillary thyroid cancer with an incidence of neck metastasis between 20 to 60%, most of them located in the central compartment. At least 30% will have a concurrent lateral neck metastasis (level II to V) or a recurrence in the lateral neck during the follow up. It is frequent to come upon an asymptomatic cystic lateral neck metastasis from a papillary thyroid cancer usually with no clinical tumor in the thyroid gland. With the increasing and improving in resolution of thyroid ultrasound, even microscopic thyroid nodules can be found, so the identification of the primary in the thyroid usually is a not a big challenge. Small nodules up to 3-5 mm can be responsible of a lateral neck metastasis. Fine needle aspiration biopsy (FNAB) is being used as the main method to obtain enough cytological sample in the metastatic node and in the thyroid nodule to do the diagnosis. Some other studies as CT scan or MRI are usually unnecessary and only done if the preoperative plan changes. A PET CT in these cases are not required since the primary is identified in the thyroid. Some cases when the FNAB is insufficient may require a trucut or even an open biopsy to obtain tissue. The initial treatment is a total thyroidectomy with a comprehensive neck dissection. There are few cases reported in literature presented with a neck metastasis from a thyroid cancer with no primary identified in the thyroid neither by ultrasound nor by a pathological exam of all the thyroid excised gland, so this clinical case is another contribution to this strange tumor behavior.
Case Presentation
A 41-year-old female attended at the head a neck service with a right lateral neck node level II. She noticed it for the last year, but only recently was aware due to the progressive growing. She did not refer weight loss, dysphagia, or dysphonia. Physical evaluation revealed neck nodes between 1-3cm in level II with no fixation and with no thyroid palpable nodule. Fiberoptic Larynx evaluation was completely normal. She has no risk factors nor radiation history. Blood thyroid test was normal. (TSH: 1,5 ui/ml). Neck ultrasound showed a round cystic and solid lymph node in level II size 2.7cm (Figure 1) and three additional suspicious round neck lymph nodes with microcalcifications levels II and III between 1-3cm. A complete and accurate ultrasound of the thyroid gland was performed finding a normal gland with no nodes (Figure 2). A FNAB was perform on the level II node identifying irregular cells with clear nuclei, nuclear clefts and fine chromatin suggestive of papillary carcinoma metastatic to the lymph node (Figure 3). A Ct scan showed similar findings to the ultrasound and the chest Rx was normal.
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