Year : 2003 | Volume
: 51 | Issue : 1 | Page : 81--83
Papillary carcinoma thyroid presenting as a choroidal metastasis. Report of a case and brief review of literature.
U Singh, S Kaushik, Surinder S Pandav, Mangat Ram Dogra, M Powari, A Das, M Hemachandra
Department of Ophthalmology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
Department of Ophthalmology, Postgraduate Institute of Medical Education and Research, Chandigarh
A patient of papillary thyroid carcinoma, who initially presented with a choroidal metastasis and secondary intractable glaucoma is reported. The orange-coloured tumour posed a diagnostic difficulty, until histopathology of the enucleated eye confirmed the metastasis from the thyroid. The initial presentation of distant metastasis in patients with thyroid cancer is rare.
|How to cite this article:|
Singh U, Kaushik S, Pandav SS, Dogra MR, Powari M, Das A, Hemachandra M. Papillary carcinoma thyroid presenting as a choroidal metastasis. Report of a case and brief review of literature. Indian J Ophthalmol 2003;51:81-83
|How to cite this URL:|
Singh U, Kaushik S, Pandav SS, Dogra MR, Powari M, Das A, Hemachandra M. Papillary carcinoma thyroid presenting as a choroidal metastasis. Report of a case and brief review of literature. Indian J Ophthalmol [serial online] 2003 [cited 2020 Sep 18 ];51:81-83
Available from: http://www.ijo.in/text.asp?2003/51/1/81/14731
The breast and lung are primary sites in the vast majority of patients with metastatic uveal tumours. Thyroid cancers rarely metastasise to the globe. We describe a patient with papillary carcinoma of the thyroid, diagnosed from the initial choroidal metastasis.
A 70-year-old man presented with pain and loss of vision in the left eye for one year. There was no antecedent ocular complaint suggestive of trauma, malaise, fatigue or other systemic disease.
Examination of the left eye showed absence of light perception, mild corneal haze, and 360 osub neovascularization of the iris and angle. The intraocular pressure (IOP) was 40 mm Hg. There was exudative total retinal detachment, with an orange-coloured mass visible underneath. The right eye was normal. B-scan ultrasonography of the left eye showed a solid tumour measuring 12 mm x 11mm x 8 mm in the posterior pole, with an associated mobile retinal detachment. There was also an echoluscent shadow behind the tumour in the orbit, suggesting an extrascleral spread [Figure 1]. A-scan showed an initial tumour spike with moderately high internal reflectivity.
These findings were suggestive of a choroidal metastasis. MRI of the orbit and brain confirmed the suspicion of an extrascleral extension. The brain study was normal. The patient was thoroughly investigated for a primary non-ocular cancer. A medical and surgical consultation for possible sites especially in the lungs, gastro-intestinal tract, kidneys, and prostate did not show any abnormality. A chest X-Ray and abdominal ultrasound revealed no suspicious findings. Renal function tests, liver function tests, and a complete haemogram were normal.
Keeping in mind the painful blind eye, and to aid in tissue diagnosis, the left eye was enucleated after proper consent.
Cut section of the specimen revealed a gray tumour in the subretinal space, 10 mm x 10 mm in size, in continuity with a 2 mm scleral nodule [Figure 2]. Histopathology revealed follicular/papillary arrangement of cells separated by fine vascular septae with intraluminal eosinophilic material suggestive of colloid. The extensive nuclear clearing (Orphan Annie-eyed appearance) was accompanied by occasional grooving [Figure 3]. These cellular features were strongly suggestive of papillary carcinoma of the thyroid. The optic nerve was not involved histologically. The tumour mass was continuous with the extrascleral nodule, the histology of which was identical to the intraocular tumour.
The patient was referred to the oncologist with a specific diagnosis of suspected primary cancer of the thyroid. Clinically, there was no palpable mass or nodule. Thyroid function tests were normal. An ultrasonogram of the thyroid gland, however, revealed a small nodule in the right lobe measuring 2.0 x 1.5 mm, from which fine needle aspiration cytology (FNAC) was done.
The smear revealed tight clusters of tumour cells arranged in a papillary pattern. The high-power view showed features of nuclear grooving [Figure 4], and inclusion bodies giving a signet-ring appearance. These features were characteristic of papillary carcinoma thyroid.
The patient was scheduled for a thyroidectomy with systemic radio- iodine therapy, but he did not return for surgery. He has been subsequently lost to follow-up in ophthalmology and oncosurgery.
Though uveal metastasis has been historically considered a rare entity, many cases have been reported since the mid-1950s, probably reflecting a larger patient population surviving systemic malignancy. Initial presentation of distant metastases in patients with thyroid carcinoma is rare. In a large series of 1038 consecutive cases with differentiated thyroid cancer, 44 (4%) patients only presented initially with a distant metastasis. Of these, only 2.3% of patients with papillary carcinoma presented with distant metastases, compared to 11% of those with thyroid follicular cancer.
Papillary carcinomas are prone to metastasise to the regional lymph nodes, whereas the follicular carcinomas usually metastasise via haematogenous routes. Medullary carcinomas are equally likely to spread to the regional lymph nodes or adjacent blood vessels. These features most likely explain the higher frequency of follicular and medullary thyroid carcinomas reported as the primary sites of uveal metastases compared to papillary carcinomas.
Ocular metastases secondary to thyroid cancer are extremely uncommon. Of 227 cases of uveal metastasis, Ferry and Font reported one case from the thyroid cancer, while Shields et al found the thyroid a primary cancer site in 2 of 420 patients with uveal metastasis. A literature search (Medline) showed 14 reported thyroid cancers metastasising to the eye; primary papillary carcinoma has been reported only twice before.
Anteby et al reported a rapidly growing choroidal metastasis from a papillary thyroid cancer treated with systemic I 131. Yunta Abarca et al have described a patient with disseminated metastatic disease to the bone, choroid and brain four years after a total thyroidectomy for a papillary carcinoma. Ritland et al have reported an 80-year-old woman with an orange-brown choroidal tumour in one eye, and multiple lung metastasis. Fine needle aspiration biopsy of the choroidal tumour revealed follicular carcinoma of the thyroid. Daicker and Gysin have described bilateral choroid, ciliary body and iris metastases from two patients of medullary carcinoma thyroid, treated with cryopexy and photocoagulation.
The characteristic orange-pink colour of choroidal metastases from thyroid (in contrast to the frequently described cream-coloured lesions), is due to macrophages laden with lipofuschin pigment released from damaged retinal pigment epithelial cells. We also observed an orange-pink mass in our patient. It initially misled us to consider the lesion clinically as a haemangioma or melanoma. The ultrasonography and the MRI helped us arrive at the final diagnosis.
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