lingual thyroid carcinoma with nodal metastasis

Lingual Thyroid Lingual Thyroid Carcinoma with Carcinoma with

Nodal MetastasisNodal Metastasis

Waldemar Riefkohl, MD and Thomas Waldemar Riefkohl, MD and Thomas Kennedy, MDKennedy, MD

Dept. of Otolaryngology – HNSDept. of Otolaryngology – HNSGeisinger Medical CenterGeisinger Medical Center

Case ReportCase Report 25 year old school teacher and aspiring 25 year old school teacher and aspiring

singer was referred by an outside singer was referred by an outside otolaryngologist in September ’04otolaryngologist in September ’04

June ’03 - evaluation for abnormal menstrual June ’03 - evaluation for abnormal menstrual cycle led to the diagnosis of hypothyroidism.cycle led to the diagnosis of hypothyroidism.

April ’04 - she noted a left upper neck mass April ’04 - she noted a left upper neck mass that was not painful.that was not painful.

Denied dysphagia, odynophagia, otalgia, Denied dysphagia, odynophagia, otalgia, dyspnea, hoarseness, hemoptysis and dyspnea, hoarseness, hemoptysis and unplanned weight lossunplanned weight loss

Case ReportCase Report

Antibiotics had no effect and CT was Antibiotics had no effect and CT was ordered by the PCP.ordered by the PCP.

Radiologic Testing (outside facility):Radiologic Testing (outside facility):• CT with contrast was reported as normalCT with contrast was reported as normal

• Ultrasound of the neck - left upper Ultrasound of the neck - left upper cervical lymph node and small normally cervical lymph node and small normally located thyroid glandlocated thyroid gland

• MRI of the neck - left level II lymph node MRI of the neck - left level II lymph node but otherwise normal.but otherwise normal.


Referred to a local Otolaryngologist Referred to a local Otolaryngologist who proceeded with an excisional who proceeded with an excisional biopsy of the left neck mass.biopsy of the left neck mass.

Diagnosis – metastatic papillary thyroid Diagnosis – metastatic papillary thyroid carcinomacarcinoma


PMH: PMH: Petite mal seizures, Petite mal seizures, hypothyroidismhypothyroidism

Medications: Depakote and LevoxylMedications: Depakote and Levoxyl

Surgical History: Surgical History: NoneNone

Allergies: Allergies: NoneNone


Family History:Family History:

Father has diabetesFather has diabetes

Mother in good healthMother in good health

Brother and a sister with seizures Brother and a sister with seizures Grandfather with “thyroid Grandfather with “thyroid problems” problems” Grandmother Grandmother with parathyroid disease. with parathyroid disease. Great aunt Great aunt died from thyroid cancer died from thyroid cancer


Social HistorySocial History: :

Spanish school teacher for the 6Spanish school teacher for the 6thth- - 88thth grades. Loves to sing and is grades. Loves to sing and is in the church choir Regularly in the church choir Regularly requested to sing at weddings and requested to sing at weddings and other social events.other social events.

Occasional alcohol Occasional alcohol

Denies tobacco useDenies tobacco use

Case ReportCase ReportExamination:Examination: OralOral– clear, tongue mobile.– clear, tongue mobile.

Indirect examIndirect exam– cherry red spot at the tongue – cherry red spot at the tongue basebase

left of midline, vocal cords left of midline, vocal cords mobilemobile

and without lesions.and without lesions.

PalpationPalpation– firm mass at tongue base (tender),– firm mass at tongue base (tender), bilateral cervical level IIA node L>R,bilateral cervical level IIA node L>R, no obvious palpable thyroid glandno obvious palpable thyroid gland no supraclavicular or paratracheal no supraclavicular or paratracheal

massmass


Thyroid scanThyroid scan::


Treatment OptionsTreatment Options::

• Radioactive iodine ablation of Radioactive iodine ablation of primary tumor and cervical primary tumor and cervical metastasis.metastasis.

• Bilateral cervical node dissections Bilateral cervical node dissections followed by radioactive iodine.followed by radioactive iodine.

• Surgical resection of all thyroid Surgical resection of all thyroid tissue followed by radioactive iodine.tissue followed by radioactive iodine.

Lingual Thyroid with Papillary Carcinoma

Lingual Thyroid with Papillary Carcinoma (Follicular variant)

Psammoma Bodies

Cervical Lymph Node with Papillary Carcinoma

Postop TreatmentPostop Treatment

Post-op thyroglobulin – 53.8 ng/ml (range Post-op thyroglobulin – 53.8 ng/ml (range 4-40 ng/ml)4-40 ng/ml)

Radioactive iodine - 101.5 mCi of I131 Radioactive iodine - 101.5 mCi of I131 two months after surgerytwo months after surgery

Follow up thyroglobulin <0.2 ng/ml and Follow up thyroglobulin <0.2 ng/ml and II131131 whole body scan negative whole body scan negative

Lingual Thyroid Lingual Thyroid CarcinomaCarcinoma

Rare – occurs in 1% of lingual thyroidRare – occurs in 1% of lingual thyroid (Jarvis (Jarvis 1969)1969)

First 2 cases reported independently by Gunn First 2 cases reported independently by Gunn and Rutgers in 1910and Rutgers in 1910

40 cases in the world literature to date40 cases in the world literature to date (Perez (Perez 2003)2003)

Histopathologic subtypeHistopathologic subtype• Follicular carcinoma (predominating)Follicular carcinoma (predominating)• PapillaryPapillary

Medullary and anaplastic not reportedMedullary and anaplastic not reported

Lingual Thyroid Lingual Thyroid CarcinomaCarcinoma

First case report of lingual thyroid First case report of lingual thyroid carcinoma with nodal metastasis in a carcinoma with nodal metastasis in a female with no orthotopic thyroid glandfemale with no orthotopic thyroid gland

First case report to shift the First case report to shift the predominating histopathology from predominating histopathology from follicular to papillary carcinomafollicular to papillary carcinoma

Lingual Thyroid CarcinomaLingual Thyroid Carcinoma

Surgical excision of all thyroid followed by Surgical excision of all thyroid followed by radioactive iodine ablation.radioactive iodine ablation.

Surgical approaches include lateral Surgical approaches include lateral pharyngotomy, transoral, and trans-pharyngotomy, transoral, and trans-cervical supra or transhyoid approaches.cervical supra or transhyoid approaches.

Large lesions and poor medical risk Large lesions and poor medical risk patients may select single modality patients may select single modality radioactive iodine.radioactive iodine.

ConclusionConclusion

Patient with lingual thyroid carcinoma with nodal metastasis

Treated with surgical resection and radioactive iodine successfully

The patient is currently two years since her surgery and free from disease.

She continues to teach foreign languages and remains hopeful in becoming a professional singer.

lingual thyroid carcinoma with nodal metastasis

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