Prostatic Adenocarcinoma Metastasis in the Thyroid Gland

Endocrine Journal 2004, 51 (4), 445–448

FAHRI BAYRAM, ISIN SOYUER*, HULUSI ATMACA, DENIZ DEMIRCI**, CUMALI GOKCE, OZLEM CANOZ*, KURSAD UNLUHIZARCI AND FAHRETTIN KELESTIMUR

Department of Endocrinology and Metabolism, Erciyes University Medical School, 38039, Kayseri, Turkey *Department of Pathology, Erciyes University Medical School, 38039, Kayseri, Turkey **Department of Urology, Erciyes University Medical School, 38039, Kayseri, Turkey

Abstract. Metastasis from prostate to thyroid gland is very uncommon. Here we report a 77-year-old man who was admitted to the hospital because of a nodular goiter. A fine-needle aspiration biopsy of the nodule showed metastatic prostatic adenocarcinoma. This is the second case of a metastatic prostate carcinoma to the thyroid gland.

Key words: Thyroid metastasis, Prostatic adenocarcinoma, Fine needle aspiration cytology (Endocrine Journal 51: 445–448, 2004)

OWING to its rich vascular supply, the thyroid gland 4 + 5) was diagnosed after transurethral prostatectomy is a common site of metastasis from malignant tumors two years ago. Prostatic cancer located in the right elsewhere. The most common sites of origin are lobe of the prostatic gland. Preoperative PSA level breast, kidney, lung, gastrointestinal tract as well as was 84.08 ng/ml (normal: 0–4 ng/ml). Combined an- lymphoma and squamous carcinoma of the head and drogen blockade (CAB) therapy consisted of gonado- neck region, and melanoma [1–3]. Prostate cancer is trophine-releasing hormone analogue (leuprolide acetate) the second leading cause of cancer death, after lung and bikalutamide was started. After 20 months of sta- cancer, among males [4]. The most frequent sites of ble disease, PSA level rose to 127 ng/ml and lumbar metastatic prostate carcinoma are regional lymph vertebrae and bilateral shoulder metastases were de- nodes, followed by bone, lung, bladder, liver, and ad- tected. Thereafter, owing to the persistence of the renal gland [5]. Here, we report an unusual metastasis patient’s complaints and high PSA levels bilateral or- of prostatic carcinoma presented as a thyroid nodule. chiectomy was performed. Clinical examination revealed a hard, palpable, painless, 2 × 1 cm nodule in the right lobe of the Case Report thyroid gland. The nodule was slightly movable on swallowing. Chest X-ray, complete blood count and A 77-year-old man with prostatic carcinoma was re- serum biochemistry were normal. Thyroid-stimulating ferred to our department for a nodular goiter. Accord- hormone (TSH), free triiodothyronine (fT3), and free ing to the patient’s history, the nodule was present for thyroxine (fT4) were 0.42 U/ml (normal: 0.1–4 U/ml), one year and was slowly growing. Medical history re- 2.01 pg/ml (normal: 1.62–3.76 pg/ml), and 1.2 ng/dl vealed that prostatic adenocarcinoma (Gleason grade (normal: 0.89–1.78 ng/dl), respectively. Thyroid auto- antibodies including anti-thyroglobulin and anti- thyroid peroxidase were negative. Thyroid scan re- Received: January 5, 2004 Accepted: May 12, 2004 vealed a large “cold” nodule (Fig. 1); ultrasonographic Correspondence to: Fahri BAYRAM, M.D., Department of Endo- examination showed a solid 2 × 2 cm in size nodule crinology, Erciyes University Medical School, 38039, Kayseri, with a nonhomogeneous structure in the right lobe of Turkey the thyroid gland (Fig. 2). 446 BAYRAM et al.

Fig. 1. Tc-99 thyroid scintigraphy (anterior view) showing a single right cold nodule in the lower part of the right Fig. 3. Metastatic prostatic adenocarcinoma; abundance of lobe. cells showing nuclear crowding and mild enlargement (MCG × 200). The cells have macronucleoli and clear or vacuolated cytoplasm. There were no cytologic findings that support the diagnosis of papillary thyroid carcinoma such as grooves, inclusions and cytoplasmic details.

Fig. 4. Immunoperoxidase staining for PSA (× 200).

thyroglobulin (Dako Corp, 1/200 dilution). Because of the widespread bony metastases, no thy- Fig. 2. Doppler color ultrasonography (not color here) showing roid surgery was considered. The patient was referred a 2 × 2 cm hypoechoic and multilobated nodule (white back to his urologist for palliative therapy and is alive arrows) in the lower pole of the right lobe of the thyroid one year later. gland.

Fine needle aspiration cytology (FNAC) of this Discussion nodule showed metastatic prostate adenocarcinoma (Fig. 3). Tumor cells were positive with prostate- Even though metastases to the thyroid gland are specific antigen (PSA) and negative with thyroglobulin usually considered rare, the overall incidence in au- in immunostaining (Fig. 4). The antibodies used were topsy series varies from 1.25% in unselected autopsy polyclonal antibodies raised in rabbits against human studies to 24% in patients with widespread malignant PSA (Neomarkers, ready to use diluted form), and neoplasm [6]. One series of nearly 25,000 FNACs of METASTASIS IN THE THYROID GLAND 447 the thyroid revealed 25 cases (0.1%) of metastases, their life-time, and 2.9% will succumb to this malig- the primary tumors were carcinomas of the kidney (8 nancy [13, 14]. Prostate cancer has been shown to me- cases), lung (7 cases), breast (5 cases), cervix uteri tastasize by following the venous drainage system (1 case), colon (1 case) and 1 case each of malignant through the lower paravertebral plexus, or Batson’s melanoma, malignant pleural mesothelioma and rhabdo- plexus [15, 16]. Although hematogenous spread of myosarcoma [7]. Another series reported rare sources other malignancies occurs most commonly to the lungs of primary tumors such as esophagus, stomach, and liver, 90% of prostatic metastases involve the skin, uterus [6], nasopharyngeal carcinoma, malignant spine, particularly the lumbar spine. Prostate cancer phyloides, osteosarcoma [8], and choriocarcinoma also spreads to the lungs in about 50% of patients with [9]. Although the majority of the secondary tumors metastatic disease, and to the liver in about 25 percent of the thyroid are carcinomas, there are also reported of those with metastases [15]. The route of spread to cases of sarcomas [8]. Secondary involvement by the thyroid gland is also most often hematogenous direct invasion of the thyroid gland from tracheal [12]. carcinoma was also reported [10]. Metastasis to a pri- FNAC is also useful at the diagnosis of thyroid mary thyroid neoplasm may also occur. Lung [11] and nodules in metastatic malignancy. FNAC can confirm prostate carcinoma [12] metastases to the follicular ad- the clinical suspicion of metastasis to the thyroid enoma of thyroid have been previously reported. In gland, with low morbidity and reasonable cost. In that case, while the metastatic tumor was a prostatic some patients, FNAC detects an unsuspected malig- adenocarcinoma, the patient had a history of prostatic nancy or may help avoid unnecessary thyroidectomy adenocarcinoma with diffuse osseous metastases and a in patients with a poor prognosis. Positive immuno- large goiter for two years. FNAC of the thyroid mass staining for thyroglobulin of aspiration material sug- showed metastatic prostate adenocarcinoma. Histo- gests a primary thyroid malignancy. However, logic examination of the surgical specimen confirmed because only 20–30% of anaplastic carcinomas are the FNAC result and also revealed that a follicular ad- also stained positively for thyroglobulin, a negative enoma of the thyroid gland was the recipient tumor result is not diagnostic [6]. The histopathologic dis- [12]. To our knowledge, this is only the second report- tinction between a clear cell thyroid tumor and renal ed case of thyroid metastasis from an adenocarcinoma cancer metastasis in the thyroid may be quite difficult. of the prostate to the thyroid gland. Metastasis to the Stains for immunoreactive thyroglobulin, if positive, thyroid gland, however, is rarely seen in clinical prac- are very helpful, but metastatic tumors may uptake tice and can be mistaken clinically and pathologically thyroglobulin from the surrounding gland [17]. In our for primary thyroid cancer [12]. Schmid et al. report- case, thyroglobulin staining was negative, whereas ed 25 metastatic tumors in their large series and among PSA staining was positive. Clinical and pathologic them, 11 patients were known to have previous malig- characterization of prostate cancer has been markedly nancy [7]. Metastasis to the thyroid gland is usually aided by the discovery of PSA. PSA, used as an considered as a terminal event. Nakhjavani et al. re- immunohistochemical marker for prostate gland epi- ported that 10 of 14 patients with renal cell carcinoma thelium, offers a highly sensitive and specific test for died after thyroid metastasis, 3 developed progressive diagnosing metastatic prostate cancer [4, 18]. disease, only one patient had prolonged survival. Five Although thyroid metastasis from a primary adeno- of 7 patients with breast adenocarcinoma had pro- carcinoma of the prostate is unusual, physicians must gressive disease after thyroid involvement, one had always consider the possibility of metastases, espe- cancer regression, and one had a stable course [6]. cially in patients with thyroid mass who had a past Prostate cancer is the second leading cause of medical history of prostate carcinoma. cancer-related deaths in men in Western countries. Histologic evidence of prostate adenocarcinoma is This case was presented at the 6th European Con- present in 30% of men older than 50 years of age and gress of Endocrinology, 26–30 April 2003, Lyon, in 70% of men older than 80 years. About 9.5% of France. men will have a clinical diagnosis of prostate cancer in 448 BAYRAM et al.

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