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Is Pancreatic Resection Justified for Metastasis of Papillary Thyroid Cancer?

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Is Pancreatic Resection Justified for Metastasis of Papillary Thyroid Cancer? ANTICANCER RESEARCH 26: 2269-2274 (2006) Is Pancreatic Resection Justified for Metastasis of Papillary Thyroid Cancer? A. MEYER and M. BEHREND Klinikum Deggendorf, Klinik für Viszeral-, Thorax-, Gefäß- und Kinderchirurgie, 94469 Deggendorf, Germany Abstract. Background: This case report describes a patient a patient with symptomatic anaemia due to a bleeding with symptomatic anaemia due to a bleeding duodenal duodenal metastasis from DTC, which was treated by partial metastasis from metastasising differentiated thyroid cancer duodenopancreatectomy (DP). (DTC), which was treated by partial duodenopancreatectomy (DP). Case Report: A 71-year old male was sent to hospital with Case Report severe anaemia. This patient had suffered multiple cervical recurrences of differentiated papillary thyroid cancer, which had A total thyreoidectomy with cervical bilateral been treated by several resections and irradiation, and an lymphadenectomy was carried out on a 62-year-old man for adrenal gland metastasis, via adrenalectomy. Abdominal DTC, which had been previously confirmed histologically by computed tomography showed an enlarged pancreatic head, an fine-needle biopsy. Histopathological examination revealed upper gastrointestinal endoscopy revealed a bleeding ulcer in the differentiated papillary thyroid cancer with invasion of the duodenum, and a biopsy revealed metastasis from DTC. Due to perithyroidal tissue, but without spread to the locoregional the symptomatic metastasis, a partial DP was performed; the lymph nodes; the tumour category was T4 N0 M0. postoperative course was uneventful. Histopathological Postoperatively, radio-iodine ablation therapy was carried examination revealed metastasis of the DTC next to the papilla out using 131-iodine at a dose of 3.7 GBq. After the ablation lying in the head of the pancreas, with growth into the therapy, suppression therapy with T4 was started. The first muscularis propria of the duodenum. The patient survived for post-dose whole-body scan showed slight tracer another 4ó years before dying from progressive metastatic accumulation corresponding to remaining thyroid tissue, disease elsewhere. Conclusion: DP for metastatic disease should while the second post-dose whole-body scan showed no be considered in selected patients for alleviation of the symptoms tracer accumulation. One year after the operation, the and prolongation of survival, as long as this operation is thyroglobulin (Tg) level, that had proved to be normal after performed by experienced surgeons who can achieve minimal the ablation therapy, increased to 13.6 ng/ml (normal <2) morbidity and mortality. and decreased to a level of 10 ng/ml during further follow-up, without any clinical or imaging suspicion of recurrence or In patients with metastasising differentiated thyroid cancer metastatic spread. Two years after the operation, the Tg (DTC), radio-iodine ablation therapy is the therapy of first level had increased to 101.6 ng/ml. Cervical imaging revealed choice and can offer the patient several years of palliation. a right-sided cervical tumour, while fine-needle biopsy If the metastases are radio-iodine-resistant, the treatment is showed papillary thyroid cancer. A whole-body scintigraphy challenging. In the case of an acute symptomatic metastasis, using 131-iodine showed no pathological tracer a surgical approach with metastasectomy may be indicated, accumulation, thus demonstrating that the new local in spite of a metastasised disease. This case report describes recurrence was non-avid to radio-iodine ablation therapy. Right-sided cervical exploration was carried out revealing eight lymph node metastases of papillary thyroid cancer. One month after this second operation, the Tg level had Correspondence to: Privatdozent Dr. med. Matthias Behrend, decreased to 14.1 ng/ml, but repeated cervical imaging again Klinikum Deggendorf, Klinik für Viszeral-, Thorax-, Gefäß- und revealed local recurrence in the right-sided space of the Kinderchirurgie, Perlasberger Straße 41, 94469 Deggendorf, former thyroid gland, which was histologically confirmed by Germany. Tel: 49-991-380-3000, Fax: 49-991-380-3010, e-mail: [email protected] fine-needle biopsy. Complete staging of the patient showed no further metastatic lesions. Surgical resection and Key Words: Metastasising thyroid cancer, bleeding duodenal lymphadenectomy revealed a local recurrence and two lymph metastasis, duodenopancreatectomy. node metastases of papillary thyroid cancer. Postoperatively, 0250-7005/2006 $2.00+.40 2269 ANTICANCER RESEARCH 26: 2269-2274 (2006) the Tg level was still elevated at 29.9 ng/ml, although imaging controls, including cervical ultrasound and tumour scintigraphy with technetium, showed no suspicion of tumour recurrence. Six months after the third operation, the Tg level was 22.6 ng/ml and cervical imaging detected right-sided cervical and mediastinal recurrence. A renewed cervical exploration with resection of the right-sided tumour was carried out, showing papillary thyroid cancer as a metastasis in the cervical tissue localised between the superior caval vein, oesophagus and trachea. Postoperatively, the Tg level decreased to 15.6 ng/ml, and a fistula had developed at the right sternoclavicular junction, which was treated with excision five months later. During further follow-up, the Tg level had again increased to 115.2 ng/ml, and imaging procedures revealed a newly-developed cervical and mediastinal tumour. Because a new surgical excision was not Figure 1. Large tumour mass from DTC metastasis in the head of the favoured by the surgeons due to four previous operations pancreas leading to upper gastrointestinal bleeding with severe anaemia. and the postoperative complication after the last operation, percutaneous cervical irradiation up to a dose of 59.4 Gy with a single dose of 1.8 Gy given in 33 fractions was uneventful postoperative course. Histopathological performed. After the irradiation, the Tg level decreased examination revealed metastasis of the papillary thyroid continuously to a level of 17.2 ng/ml. One year after the cancer (Figure 2a) next to the papilla Vater lying in the irradiation, new cervical recurrence could be detected by head of the pancreas and confined by a capsule of imaging methods and the Tg level was 66.9 ng/ml. Due to the pancreatic tissue with growth into the muscularis propria radio-iodine non-responsive thyroid cancer, therapy with of the duodenum. Immunohistochemistry was positive for retinoids was started for redifferentiation of the tumour to Tg (Figure 2b). Postoperatively, the Tg level decreased to increase the radio-iodine uptake, but this therapy was 4.6 ng/ml. One year later, the Tg level had increased to stopped six months later due to severe side-effects. At the 14.2 ng/ml. New imaging revealed cervical tumour end of this treatment, restaging using cervical and thoracic recurrence and multiple metastases localised in the lung computed tomography (CT) showed stable cervical disease, and liver. Further therapy was refused by the patient. Two but the occurrence of a tumour localised at the right adrenal years later, a new metastasis in the former space of the gland. One month after completion of the redifferentiation right adrenal gland occurred with infiltration of the right therapy, the patient was admitted to hospital for severe kidney and compression of the inferior caval vein. Seven anaemia with a haemoglobin level of 6.2 g/dl. Apart from months later and 4ó years after the DP, the patient died pulmonary metastasis, thoracic and abdominal CT due to progressive abdominal metastatic spread. revealed a tumour of the right adrenal gland with a diameter of 6.5 cm. A biopsy of this tumour revealed Discussion adrenal metastasis of the DTC, therefore a right-sided adrenalectomy and resection of the tumour was carried Duodenal metastases are very uncommon, accounting for out. Histopathological examination showed metastases of 1% to 3% of all duodenal malignancies (1, 2), but they papillary thyroid cancer and the Tg level decreased to 28.1 should be taken into consideration in patients presenting ng/ml postoperatively. However, the anaemia persisted and with upper gastrointestinal bleeding and a previous history worsened. Two months later, when the patient needed of malignancy (3-5). The most common malignancies to daily units of blood due to unidentified bleeding, he was metastasise to the periampullary region occur either in the referred to our unit. A blood pool scintigraphy revealed colon, lung, breast or kidney, but there are scattered bleeding in the right lower abdomen; abdominal CT reports of metastases at other cancer sites (3, 6). In patients showed an enlarged pancreatic head (Figure 1) that had with DTC, distant metastases occur in 10%-20% of all not been detected in the previous CT scan performed for cases and are usually localised in the lung and bone (7). the adrenal metastasis. Upper gastrointestinal endoscopy Less common sites of metastases are the brain, liver and revealed a bleeding ulcer in the duodenum, and a biopsy skin. Occurrence of metastases at other sites, e.g., the showed metastasis from DTC. Because of the daily need duodenum, is exceptional. In our patient, the metastasis of for 2-4 units of blood, a resection of the metastasis was the DTC next to the papilla Vater with growth into the carried out using a partial PD Whipple-Kausch, with muscularis propria of the duodenum could be clearly 2270 Meyer and Behrend: Duodenopancreatectomy for Duodenal Metastasis
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