|Year : 2019 | Volume
| Issue : 4 | Page : 261-263
Cystic lateral neck mass: Papillary thyroid carcinoma metastases with concomitant lymphangioma
Chitturi Ramya, Sripriya Krishnan, Inuganti Venkata Renuka, Sowjanya Krishna Sree Kesaboyina
Department of Pathology, NRI Medical College, Chinnakakani, Guntur District, Andhra Pradesh, India
|Date of Submission||14-Oct-2019|
|Date of Acceptance||17-Oct-2019|
|Date of Web Publication||16-Dec-2019|
Dr. Inuganti Venkata Renuka
Department of Pathology, NRI Medical College, Chinnakakani - 522 503, Guntur District, Andhra Pradesh
Source of Support: None, Conflict of Interest: None
The most common presentation of papillary carcinoma thyroid is a solitary thyroid nodule but it is also known to present as cystic metastatic deposits in the neck. It has an indolent course and good prognosis. Although ultrasound is a commonly used modality to detect thyroid nodules, it should be followed by Fine needle aspiration cytology (FNAC) of the thyroid, especially when they are associated with cystic lesions of the neck. We report a rare case of papillary thyroid carcinoma presenting as a cystic mass in the neck and associated with lymphangioma.
Keywords: Lymphangioma, metastases, papillary carcinoma thyroid
|How to cite this article:|
Ramya C, Krishnan S, Renuka IV, Kesaboyina SK. Cystic lateral neck mass: Papillary thyroid carcinoma metastases with concomitant lymphangioma. J NTR Univ Health Sci 2019;8:261-3
|How to cite this URL:|
Ramya C, Krishnan S, Renuka IV, Kesaboyina SK. Cystic lateral neck mass: Papillary thyroid carcinoma metastases with concomitant lymphangioma. J NTR Univ Health Sci [serial online] 2019 [cited 2020 Jan 26];8:261-3. Available from: http://www.jdrntruhs.org/text.asp?2019/8/4/261/273138
| Introduction|| |
The differential diagnoses of cystic neck masses include cystic metastatic deposits, lymphangiomas, and branchial cleft cysts. Radiological findings and FNAC findings in such cystic neck lesions can sometimes be misleading. Thyroid function testing has limited utility in the diagnosis of Papillary Thyroid Carcinoma (PTC) because most patients have normal thyroid function. Aspirated fluid thyroglobulin and thyroid transcription factor levels may help to differentiate cystic thyroid carcinomas from benign cystic lesions. Measurement of serum thyroglobulin provides the highest sensitivity (95–100%) for the detection of persistent or recurrent disease.
| Case Report|| |
A 35-year-old female presented with a swelling in the neck for 1 month. On examination, a 3 × 2 cm vertically oval-shaped swelling was identified just anterior to left common carotid artery medial to the internal jugular vein. The swelling was not moving with deglutition. No other neck swellings were noted.
On high-resolution ultrasound, a 2.8 cm × 1.5 cm multiloculated cystic lesion with eccentric solid component showing few calcific foci and no obvious internal vascularity was noted in the carotid space between the common carotid artery and internal jugular vein indenting the adjacent vascular structures. Both lobes of the thyroid were normal in size with regular outline and echotexture. Hypoechoic nodules measuring 7.8 × 5.2 mm were noted in right lobe and 10 × 8.8 mm in the left lobe, likely to be benign nodules. Radiological differential diagnoses were lymphatic cyst and cystic neurogenic lesion of neck. Few subcentimeter lymph nodes were identified adjacent to lesion largest measuring 6.5 × 6.0 mm.
MRI done subsequently revealed a 3.2 × 2.0 × 1.9 cm multiloculated cystic lesion showing T1 hypointense, T2 and STIR hyperintense signal and minimal debris along the lower third of left sternocleidomastoid at the root of neck abutting left common carotid artery and internal jugular vein [Figure 1]a. There was a communication noted with the thoracic duct. It was reported as a multiloculated cystic lymphangioma with doubtful communication with the thoracic duct. Small bilateral heterogeneously hyperintense lesions were noted in thyroid gland 8 × 6 mm in the left lobe and 4 × 4 mm in right lobe—possible benign.
|Figure 1: (a) MRI scan of cystic neck lesion. (b) Gross specimen showing a cystic lesion with gray-brown solid areas|
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Ultrasound-guided FNAC was done from the neck swelling in our institute after 1 month, which showed scanty lymphocytes and few macrophages against an eosinophilic proteinaceous background. Hence, we reported it as a lymphangioma and advised excision biopsy.
Excision biopsy of the specimen was sent to histopathology. We received a cystic lesion measuring 2.5 cm × 1 cm. The cyst was biloculated with gray-brown solid areas [Figure 1]b. On microscopic examination, dilated lymphatic channels lined with flattened epithelium were seen [Figure 2]b. The wall was composed of fibro collagenous tissue with dense lymphocytic aggregates and adjacent tissue showed thyroid architecture with papillary patterns. The papillae were lined by cells showing nuclear grooving and Orphan Annie like intranuclear inclusions [Figure 2]a. Therefore, we reported it as metastatic deposits from papillary carcinoma thyroid with cystic change and an associated lymphangioma and alerted the clinician about the thyroid malignancy.
|Figure 2: (a) Microscopic picture of cystic papillary thyroid carcinoma metastasis. (b) Microscopic picture of lymphangioma|
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On our advice, an ultrasound-guided FNAC was done from the tiny nodules in the thyroid, which revealed papillary carcinoma. A total thyroidectomy was recommended.
| Discussion|| |
Solitary cervical cystic neck mass is an uncommon presentation of papillary thyroid carcinoma. The various common cysts in the neck include the epidermoid, branchial cysts, teratomas, lymphangiomas, and cystic hygromas. Cystic masses of the neck can also be due to lymph node metastases from head and neck tumors.
Lymphangiomas are benign lymphatic malformations and are of two types: Congenital and acquired. Acquired lymphangiomas are very rare. Lymphangiomas generally occur at birth (60%) and are detectable by two years of age (90%). Embryologically, these lesions are believed to originate from sequestration of lymphatic tissue from lymphatic sacs, during the development of lymphaticovenous sacs. These sequestered tissues fail to communicate with the remainder of the lymphatic or venous systems. Later on, dilatation of the sequestered lymphatic tissues results in cystic lesions.
In adults, lymphangiomas may occur from a delayed proliferation of cell rests, spontaneously or in response to infection, injury trauma or in a neoplasm. In our case, we consider the theory of lymphangioma development due to neoplastic cells from papillary carcinoma of the thyroid.
FNAC is less sensitive in the diagnosis of cystic neck masses compared with solid masses having a false negative rate ranging from 50 to 67%. This high level of false negativity is due to sampling error and not cytological misdiagnosis. In our case, ultrasound-guided FNAC from cystic neck mass has missed the malignant focus and the needle entered into the lymphangioma part, which yielded few lymphocytes only. If ultrasound-guided FNAC was done from the solid part of the cyst wall, it increases the accuracy of the FNAC.
Had the cystic lesion of neck not been excised considering benign findings on radiology and FNAC, the patient would have presented with metastases in multiple sites. This highlights the importance of a multimodality approach for the diagnosis of cystic neck lesions and the limitations of various diagnostic procedures.
Up to 11% of lateral neck cysts in adulthood may harbor occult papillary thyroid carcinoma. Tazegul et al. reported papillary thyroid carcinoma metastasis to the branchial cleft cyst. Rathod et al. reported papillary thyroid carcinoma arising in a thyroglossal duct cyst.
| Conclusion|| |
Papillary carcinoma thyroid is notorious for its varied presentation. In our case, it presented as occult metastases in soft tissue associated with lymphangioma. Tiny nodules in thyroid were considered to be benign by high-resolution ultrasound and MRI scan, which later turned out to be papillary thyroid carcinoma by FNAC. All the thyroid nodules should be evaluated appropriately and a high index of clinical suspicion of papillary carcinoma metastases is to be kept in mind while evaluating cystic neck masses. We report this case of papillary carcinoma thyroid metastases in the neck with cystic change and association with a lymphangioma. There are no cases in the literature where cystic papillary thyroid carcinomas are seen in association with lymphangioma.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to b'e reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Patil VS, Vijayakumar A, Natikar N. Unusual presentation of cystic papillary thyroid carcinoma. Case Rep Endocrinol 2012;2012:732715.
Nakagawa T, Takashima T, Tomiyama K. Differential diagnosis of a lateral cervical cyst and solitary cystic lymph node metastasis of occult thyroid papillary carcinoma. J Laryngol Otol 2001;115:240-2.
Ramashankar, Prabhakar C, Shah NK, Giraddi G. Lymphatic malformations: A dilemma in diagnosis and management. Contemp Clin Dent 2014;5:119-22.
Chi HS, Wang LS, Chiang FY, Kuo WR, Lee KW. Branchial cleft cyst as the initial impression of a metastatic thyroid papillary carcinoma: Two case reports. Kaohsiung J Med Sci 2007;23:634-8.
American Thyroid Association (ATA) Guidelines Taskforce on Thyroid Nodules and Differentiated Thyroid Cancer, Cooper DS, Doherty GM, Haugen BR, Kloos RT, Lee SL, Mandel SJ
, et al
. Revised american thyroid association management guidelines for patients with thyroid nodules and differentiated thyroid cancer. Thyroid 2009;19:1167-214.
Tazegul G, Bozoǧlan H, Doǧan Ö, Sari R, Altunbaş HA, Balci MK. Cystic lateral neck mass: Thyroid carcinoma metastasis to branchial cleft cyst. J Can Res Ther 2018;14:1437-8.
] [Full text]
Rathod JK, Rathod SJ, Kadam V. Papillary carcinoma of thyroid in a thyroglossal cyst. J Oral Maxillofac Pathol 2018;22:98-101.
] [Full text]
[Figure 1], [Figure 2]