A case of lung cancer with hyperthyroidism]

We here report a case of metastasis from lung cancer to the thyroid. On presentation, this patient showed painful anterior cervical swelling and right supraclavicular lymph node swelling. Laboratory data showed primary hyperthyroidism. Although subacute thyroiditis was suspected, echo-guided needle aspiration biopsy and lymph node biopsy revealed poorly differentiated squamous cell carcinoma. As a result, primary lung cancer with thyroid metastasis was diagnosed based on mediastinal enlargement on chest X ray films and normal findings in organs other than the lung and thyroid. Chemotherapy for lung cancer induced a decrease in the size of tumor and the normalization of thyroid function. However, 2 months after the normalization, cervical swelling enlarged and a lung mass in right upper lobe and skin tumor appeared. Despite treatment with chemotherapy, she died. Postmortem revealed that the right upper lung carcinoma was the primary lesion and immunohistochemical staining for surfactant protein was positive in the thyroid, skin tumor and lymph node, which revealed these carcinomas had metastasized from lung cancer. To the best of our knowledge, thyrotoxicosis induced by thyroid metastasis of lung cancer is an uncommon case.     

A Case of Subacute Ataxia in the Summertime: Tick Paralysis

Tick paralysis is caused by a neurotoxin secreted in the saliva of a gravid female tick, and manifests with ataxia, areflexia, ascending paralysis, bulbar palsy, and ophthalmoparesis. An 84-year-old man presented in June in coastal Mississippi with several days of subacute ataxia, bulbar palsy, unilateral weakness, and absent deep tendon reflexes. MRI/MRA and extensive serum and cerebrospinal fluid investigations were unrevealing. His symptoms progressed over several days, until his nurse discovered and removed an engorged tick from his gluteal fold. Within hours of tick removal, his subacute symptoms completely resolved. While tick paralysis is rare in adults, it is a condition that internists should be familiar with, particularly in seasons and areas with high prevalence of disease. This case also highlights the importance of performing a thorough skin exam on patients with the aforementioned neurologic abnormalities.KEY WORDS: Infectious disease, Neurology, Neuromuscular disorder, Clinical vignette     

Risk of vocal palsy after thyroidecitomy with identification of the recurrent laryngeal nerve

The purpose of this study was to assess the risk of vocal palsy after thyroidectomy with identification of recurrent laryngeal nerve (RLN) during surgery. In all, 521 patients treated by the same surgeon were enrolled in this study. Temporary and permanent vocal palsy rates were analyzed for patient groups classified according to surgery for primary benign thyroid disease, thyroid cancer, Graves' disease, and reoperation. Measurement of the vocal palsy rate was based on the number of nerves at risk. Twenty-six intentionally sacrificed RLNs were excluded from analysis. Forty patients developed postoperative unilateral vocal palsy. Complete recovery of vocal palsy was documented for 35 of the 37 patients (94.6%) whose RLN integrity had been ensured intraoperatively. Recovery from temporary vocal palsy ranged from 3 days to 4 months (mean, 30.7 days). The overall incidences of temporary and permanent vocal palsy were 5.1% and 0.9%, respectively. The rates of temporary/permanent vocal palsy in groups classified according to underlying disease were 4.0%/0.2% for benign thyroid disease, 2.0%/0.7% for thyroid cancer, 12.0%/1.1% for Graves' disease, and 10.8%/8.1% for reoperation. Surgery for thyroid cancer, Graves' disease, and recurrent goiter were associated with significantly higher vocal palsy rates. Most patients without documented nerve damage during the operation recovered from postoperative vocal palsy. Total lobectomy with routine RLN identification is recommended as a basic procedure in thyroid surgery.     

Clinical features of bone metastases resulting from thyroid cancer: a review of 28 patients over a 20-year period

Bone is the second most frequent site of metastasis resulting from thyroid cancer. Many studies have investigated clinical features and prognostic factors of distant metastases stemming from thyroid cancer in Western countries. The purpose of this study was to review clinical characteristics of Korean patients with bone metastasis originating from thyroid cancer. Between January 1985 and August 2004, 28 patients with thyroid cancer were diagnosed with bone metastases at the Yonsei Severance Hospital in Seoul, Korea. Their clinical characteristics were analyzed retrospectively. Incidence of bone metastasis from follicular thyroid cancer was 6.8% (9 of 132 patients), and 0.4% (13 of 3,154 patients) from papillary thyroid cancer, with an odds ratio of 17.67 (95% confidence interval; 7.41-42). Twelve patients had no symptoms of bone metastasis. Overall mean number of metastasis sites was 2.6 +/- 1.9, and 12 patients had a solitary bone metastasis. Survival rates between the synchronous and metachronous metastasis groups were not significantly different, and the number of metastasis sites did not affect survival. However, the survival of patients that underwent curative treatment was longer than those with palliation (P = 0.0317). In Korea, the overall incidence of bone metastasis resulting from thyroid cancer was less than our expectation. Many patients were asymptomatic, and had a tendency of undergoing less aggressive or palliative treatment, even though the long-term survival of distant metastasis resulting from thyroid cancer with active treatment is relatively good. Further studies of the prognostic factors and effectiveness of various treatments of these patients are needed to enhance survival.     

桥本甲状腺炎与乳头状甲状腺癌颈淋巴结转移的相关性分析

目的探讨桥本甲状腺炎与乳头状甲状腺癌淋巴结转移的相关性。方法对我院2010年6月-2013年6月收治的经筛选符合要求的乳头状甲状腺癌患者250例临床资料进行回顾性分析,按照患者是否合并桥本甲状腺炎分为对照组（单纯乳头状甲状腺癌）、观察组（合并桥本甲状腺炎组）,比较两组患者临床病理特征和患者颈部淋巴结转移情况。结果观察组女性患者显著高于对照组（P〈0．05）,中央淋巴结清扫数量也显著高于对照组（P〈0．05）,两组患者中央以及颈侧淋巴结转移无显著性差异（P〉0．05）,多元回顾性分析结果显示,合并桥本甲状腺炎与否与患者是否存在乳头状甲状腺癌颈淋巴结转移无显著相关性（P〉0．05）。结论桥本甲状腺炎与乳头状甲状腺癌颈淋巴结转移无显著相关性,但需要综合考虑各种相关危险因素以给患者提供最合适的治疗方案。     

Expression of vascular endothelial growth factor-C in benign and malignant thyroid tumors

In contrast to vascular endothelial growth factor (VEGF), which stimulates angiogenesis, VEGF-C is thought to stimulate lymphangiogenesis. The role of VEGF-C in thyroid cancer pathogenesis has not been clarified. One might expect a different pattern of VEGF-C expression in the various types of thyroid cancer because of their different means of metastases. In this investigation, we determined whether the differential expression of VEGF-C might explain the different propensity to lymph node metastasis in thyroid cancers. One hundred eleven normal and neoplastic thyroid tissues were analyzed by real-time quantitative PCR. Papillary thyroid cancers had a higher VEGF-C expression than other thyroid malignancies (P < 0.0005 ANOVA). Among the normal thyroid tissues from patients with malignant or benign thyroid diseases, there was no significant difference in VEGF-C expression. Paired comparison of VEGF-C expression between thyroid cancers and normal thyroid tissues from the same patients showed a significant increase of VEGF-C expression in papillary thyroid cancer (1.10 +/- 0.41 vs. 0.70 +/- 0.13; P = 0.001) and a significant decrease of VEGF-C expression in medullary thyroid cancer (0.11 +/- 0.13 vs. 0.78 +/- 0.29; P = 0.001). In contrast, there was no significant difference of VEGF-C expression between cancer and normal tissues in other types of thyroid cancer. In summary, VEGF-C expression is increased in papillary thyroid cancer, compared with paired normal thyroid tissues, but not in other thyroid cancers that are also prone to lymph node metastasis. The lymphangiogenic role of VEGF-C in thyroid cancers therefore appears to be complex and other factors are likely to be also involved.     

Lung cancer, thyroid cancer or both: An unusual case presentation

Cancer metastasis to the thyroid is rare. Primary sites that have been reported to metastasize to the thyroid gland include breast and kidney. There are very few case reports describing metastasis of a lung primary cancer to the thyroid gland. We describe a case of a never-smoker patient with metastatic adenocarcinoma of the lung and a malignant thyroid mass presenting simultaneously. The thyroid biopsy could not distinguish whether it was a metastasis or incidentally found thyroid primary carcinoma. Based on EGFR mutational status it was determined that he has a primary lung cancer and thyroid metastasis. He was started on erlotinib and has had a marked response in both the lung and the thyroid masses. The presence of mutations within the EGFR gene can help distinguish lung adenocarcinoma from other carcinomas like thyroid cancer. This is the first published case of primary lung adenocarcinoma with metastasis to thyroid and with EGFR mutation.     

Isolated pelvic metastasis of thyroid cancer

Thyroid cancer rarely metastasizes to the pelvis. We report a case where the metastasis was found two years before the thyroid cancer. Treatment included initial surgery with resection of the metastatic tumor and reconstruction of the acetabulum with bone cement, and secondly total thyroidectomy, node dissection and I131. Surgical treatment of locoregional recurrence had no influence on the clinical course leading to the patient's death. Early diagnosis of unique metastasis of a thyroid cancer is important in terms of prognosis and quality of life. This case is exceptional due to the unique bone metastasis and treatment options for acetabular metastases. Therapeutic options should be adapted according to algorithms reported in the literature.     

人钠碘转运体mRNA在良恶性甲状腺疾病中表达的研究

目的探讨人钠碘转运体（hNIS）mRNA在良恶性甲状腺疾病中的表达及其在疾病诊断中的价值.方法24例Graves病,27例桥本氏甲状腺炎,21例亚急性甲状腺炎,24例无功能性甲状腺结节性增生,22例无功能性腺瘤,21例乳头状甲状腺癌及17例滤泡状甲状腺癌（其中4例颈部淋巴转移）,经细针抽吸甲状腺组织,用实时荧光定量PCR法测定hNIS mRNA的表达.结果良性与恶性甲状腺疾病间hNIS mRNA表达量无显著差异（P＞0.05）,各组间亦无显著差异（P＞0.05）.4例颈部淋巴转移病灶其原发癌表达阳性,但只有2例转移灶表达阳性.结论hMSmRNA定量检测不能用于良恶性甲状腺疾病的鉴别.颈部转移淋巴中有部分未表达hNIS mRNA而原发灶有表达,其机理值得探讨.     

Jaw Opening and Swallow Triggering Method for Bilateral-Brain-Damaged Patients: K-Point Stimulation

The aim of this study was to confirm the response in patients stimulated at the trigger point (K-point). Since we have already clinically encountered patients with hyperactive bite reflexes who were able to open their mouth and swallow after stimulation of the trigger point, we investigated this response in other brain-damaged patients. The trigger point lies on the mucosa lateral to the palatoglossal arch and medial to the pterygomandibular fold at the height of the postretromolar pad. A total of 57 brain-damaged patients, including patients with pseudobulbar palsy due to bilateral upper motor neuron disease and bulbar palsy due to medulla oblongate. Other supratentorial brain-damaged patients and 20 non-brain-damaged subjects were also examined. The subjects were gently stimulated at the trigger point by a finger or a tongue depressor. We found that the pseudobulbar palsy patients with a hyperactive bite reflex responded by mouth opening and swallowing after a jaw movement similar to mastication elicited by the stimulation. The other pseudobulbar palsy patients, who did not have hyperactive bite reflexes and could open their mouth spontaneously, responded by swallowing with jaw movements similar to mastication after the stimulation. The bulbar palsy patients and the supratentorial brain-damaged patients showed no response to the stimulation. The non-brain-damaged subjects also did not respond, but all of the subjects reported a strange sensation after the stimulation. We concluded that stimulating the trigger point was useful for opening the mouth and facilitating swallowing in pseudobulbar palsy patients and that this technique may be of help in these patients in terms of oral health care and feeding.     

A case of occult thyroid cancer detected as a solitary nodular lung metastasis

An 82-year-old woman was admitted to our hospital with cough and back pain. A chest radiograph showed a solitary nodular lesion in the right lower lung field. It was diagnosed by a transbronchial biopsy as lung metastasis of a papillary adenocarcinoma of the thyroid. However, her cervical CT and ultrasonography showed only a cyst in a right lobe of the thyroid, and its biopsy did not show evidence of malignancy. In addition, multiple bone metastasis and pituitary metastasis were revealed. We therefore diagnosed this case as systemic metastasis of papillary adenocarcinoma of the thyroid. She was given best supportive care and she died seven months later. Autopsy revealed two tiny lesions (3mm and 6mm) in the thyroid right lobe to be papillary adenocarcinoma. We report this case because occult thyroid cancer caused systemic metastasis and the chest X-ray showed lung metastasis from the thyroid cancer as a solitary nodular lesion.     

Incidental metastatic microcarcinoma of the thyroid identified after total parathyroidectomy.

Papillary microcarcinoma of the thyroid comprises 10-20% of all thyroid malignancies. Most microcarcinomas are slow growing and have a favorable prognosis. Lymph node metastasis caused by thyroid microcarcinoma is uncommon, and distant metastasis to lung or bone is even rarer. Thyroid microcarcinoma with metastasis to a thymic lymph node was not previously reported. We describe a case of incidental 1 mm micropapillary thyroid cancer identified within a thymic lymph node following total parathyroidectomy for secondary hyperparathyroidism.     

Recombinant human thyrotropin in thyroid cancer and hypopituitarism due to sella metastasis.

We present a patient with thyroid cancer and hypopituitarism who required recombinant human thyrotropin (rhTSH) for 131I scanning with respect to subsequent therapy. The thyroid cancer had been unknown until central neurological symptoms developed, leading to the diagnosis of a huge metastasis to the sella that was the only manifestation of metastatic spread. The failure to generate endogenous thyrotropin (TSH) was overcome by the use of rhTSH for performing a 131I test. Unfortunately, the 131I uptake was not sufficient for therapy. This subject is the first reported case who required the application of rhTSH due to a single thyroid cancer metastasis in the sella region with secondary failure to generate endogenous TSH.     

Recent outcome of Graves' disease patients with papillary thyroid cancer

OBJECTIVE: The objective was to evaluate the clinical behavior and outcome of 202 papillary thyroid cancers in Graves' disease patients during the period 1994-2004. DESIGN: This was a retrospective, non-randomized case-control study. METHODS: Since 1994, we have included an ultrasonogram of the neck in the initial examination of thyroid disease patients who consult our outpatient clinic. We evaluated the tumor status and long-term outcome of Graves' disease patients with thyroid cancer and of age- and tumor size-matched euthyroid papillary thyroid cancer patients as controls. Serum TSH receptor antibody (TRAb) was measured in the Graves' disease group. RESULTS: A total of 154 papillary thyroid cancers were diagnosed in the Graves' disease patients and were treated surgically. At surgery, no significant differences in multifocality, lymph node metastasis, or distant metastasis were found between the Graves' disease group and the euthyroid group. On the whole, the clinical course of the cancers in both the Graves' disease group and euthyroid group was relatively good. No significant correlations were found between the TRAb levels in the Graves' disease group and multifocality or the presence of lymph node metastasis. Papillary thyroid cancer was discovered as an incidental finding in 2% of the 2356 surgically treated Graves' disease patients, but none of them developed metastasis during the follow-up period. CONCLUSION: The results in this series of patients do not support the claim that thyroid cancer is more aggressive in Graves' disease patients than in euthyroid patients.     

Identifying differentially expressed genes associated with metastasis of follicular thyroid cancer by cDNA expression array.

Patients with follicular thyroid carcinoma have a higher incidence of metastasis than papillary thyroid carcinoma when thyroid cancer is diagnosed. The cDNA expression array technology is utilized herein to profile differentially expressed genes from metastatic human follicular thyroid carcinoma and reveal new tumor markers as well as target genes for therapeutic intervention. Tissue samples were obtained during surgical resection of the thyroid follicular carcinoma and metastatic tissue in the brain of the same patient. Two identical Atlas human cDNA expression arrays were hybridized with 32P-labeled cDNA probes derived from RNA of either primary thyroid cancer or metastatic tissue. Parallel analysis of the hybridized signals allowed us to identify the alteration of gene expression in the metastasis process. Eighteen genes significantly overexpressed and 40 genes significantly underexpressed were identified in the metastatic thyroid cancer. Genes that displayed an altered expression were associated with the processes of cell cycle regulation, apoptosis, DNA damage response, angiogenesis, cell adhesion and mobility, invasion, and immune response. An expression profile of genes that are associated with metastasis process of follicular thyroid cancer was also discussed. Further investigation is required to understand the precise relationship between the altered expression of these genes and the metastasis process of follicular thyroid cancer.     

Insidious hearing loss and facial palsy as the presenting symptoms of meningeal carcinomatosis resulting from adenocarcinoma of the lung]

An 80-year-old man was admitted to our hospital with a complaint of insidious hearing loss and facial palsy. Chest X-ray film showed an abnormal shadow in the right lower lobe. Adenocarcinoma of the lung was diagnosed by transbronchial brushing cytology. During admission, headache and dysphagia appeared, although no abnormality was detected in the brain CT and MRI. Lumbar puncture yielded adenocarcinoma cells in the cerebrospinal fluid. A diagnosis of leptomeningeal metastasis from the adenocarcinoma of the lung was considered and intrathecal administration of methotrexate was performed. The patient's condition deteriorated gradually and he died of respiratory failure. Autopsy revealed massive invasion of tumor cells in the leptomeninges of the brain and spinal cord. This case illustrates that facial nerve palsy with insidious hearing impairment may appear as the initial symptoms in meningeal carcinomatosis resulting from lung cancer metastasis.     

AKT activation promotes metastasis in a mouse model of follicular thyroid carcinoma

The phosphatidylinositol 3-kinase/AKT pathway is crucial to many cell functions, and its dysregulation in tumors is a common finding. The molecular basis of follicular thyroid cancer metastasis is not well understood but may also be influenced by AKT activation. We previously created a knockin mutant mouse that expresses a mutant thyroid hormone receptor-beta gene (TRbetaPV mouse) that spontaneously develops thyroid cancer and distant metastasis similar to human follicular thyroid cancer. In this study, we investigated whether our mouse model exhibits similar AKT activation as human follicular thyroid cancer. Western blot analysis on thyroids from both wild-type and TRbeta(PV/PV) mice revealed elevation of activated AKT in TRbeta(PV/PV) mice. Immunohistochemistry and confocal microscopy reveal activated AKT in both the thyroid and metastatic lesions of TRbeta(PV/PV) mice. Whereas all three AKT isoforms were overexpressed in primary tumors from TRbeta(PV/PV) mice in the cytoplasm of thyroid cancer cells, only AKT1 was also found in the nucleus, matching the localization of activated AKT in a pattern similar to human follicular thyroid cancer. In the metastases, all AKT isoforms correlated with phosphorylated AKT nuclear localization. We created primary thyroid cell lines derived from TRbeta(PV/PV) mice and found reduction of phosphorylated AKT levels or AKT downstream targets diminishes cell motility. Activated AKT is common to both human and mouse follicular thyroid cancer and is correlated with increased cell motility in vitro and metastasis in vivo. Thus, TRbeta(PV/PV) mice could be used to further dissect the detailed pathways underlying the progression and metastasis of follicular thyroid carcinoma.     

Fine-needle aspiration. Usefulness for diagnosis and management of metastatic carcinoma to the thyroid

The usefulness of fine-needle aspiration (FNA) for the diagnosis and management of metastatic carcinoma to the thyroid was determined by reviewing the records of 19 patients identified during a six-year period. Fine-needle aspiration was able to document metastatic cancer to the thyroid in 14 patients with, and five patients without a history of prior nonthyroidal cancer. Breast, kidney, and lung were the most frequent carcinomas metastatic to the thyroid. Age range and time from diagnosis of the primary carcinoma to documentation of metastasis were similar to those in prior surgical series from this institution. The finding of metastatic disease on FNA was totally unexpected in four patients. The possibility of metastasis was not mentioned before FNA in six patients with a known history of nonthyroidal cancer. Only six patients underwent a thyroid operation after FNA. Fine-needle aspiration was able to direct appropriate surgical or conservative management without adversely affecting survival among patients.     

利用131 I治疗分化型甲状腺癌肺转移患者的疗效评价及相关因素分析

目的研究分析131 I治疗分化型甲状腺癌肺转移患者的疗效评价及相关因素。方法选取2005年1月至2015年1月在榆林市第一医院、北京协和医院及四川大学华西医院治疗的分化型甲状腺癌肺转移患者82例作为研究对象,在接受甲状腺癌手术后,采用131 I 对其进行治疗,观察治疗3个月后的短期疗效,并分析影响疗效的相关因素。结果随着治疗次数的增加,患者的缓解率呈逐渐下降的趋势。分析131 I 治疗效果的影响因素,与男性相比,女性患者的治疗缓解率较高(χ2=5.707,P<0.05),且治疗前血清甲状腺球蛋白水平较低的患者治疗缓解率明显高于水平较高的患者(χ2=3.934,P<0.05)。进一步分析可见,治疗前甲状腺球蛋白水平是影响患者治疗效果的主要因素之一,缓解组与未缓解组比较差异有统计学意义(t=8.462,P <0.05)。经多元 logistic 回归分析,131 I的治疗效果与患者治疗前甲状腺球蛋白呈明显负相关。结论131 I对分化型甲状腺癌肺转移患者有十分显著的疗效,且患者性别、治疗前血清甲状腺球蛋白水平是影响其疗效的相关因素。