Hemoptysis as the Sole Presentation of Thyroid Carcinoma

David A. Blass, Morgan Delaney, and Samuel V. Spagnobo

Pulmonary Diseases Section, Medical Services, Veterans Administration Medical Center; and the Division ofPulmonary Diseases, George Washington Univeristy School ofMedicine and Health Sciences, Washington, D.C. A 23-year-oldmanexperiencedhemoptysisin 1968,secondaryto papillarycarcinomaof the thyroidwith metasta@sto the lungs.Thepatientwas treatedinWallywith thyroidectomy andIodine-131(1311),andsubsequentlywith redicalneckdissection.Followinga periodof fifteen years in which the patient was well clinically, he experienced recurrent hemoptysis. No othersourceof bleedingwas identified,andthe hemoptysiswas attributedto the lung metastasesof the thyroidcarcinoma.

,JNucIMed26:1039—1041,1985

apillary carcinoma of the thyroid is a slowly growing scan revealed a “cold―nodule in the right lobe of the thyroid. tumor seen in patients of all ages. It presents as a neck One week later, an open-lungbiopsywas performed and mass in the vast majority of cases, but occasionally its demonstrated papillary adenocarcinoma compatible with a presence is detected due to symptomatic metastases. thyroid origin. A week after this development, a total thyroid Early metastasis to the lung is rare. Lange reviews of ectomy was performed; the specimen revealed a 1.5 cm X 2.5 cm nodule in the right lobe of the thyroid. On histological thyroid cancer have included only sporadic cases in examination, this specimen was found to be papillary carcino which hemoptysis is an initial presentation of metastat ma with follicular elements multifocal in origin. Recovery ic disease (1,2). We present a patient with hemoptysis from surgery was uneventful and the patient was discharged on two occasions, fifteen years apart, presumably due to on thyroid hormone replacement. Eight weeks later, after an metastatic thyroid cancer. This is, to our knowledge, a 1311 scan demonstrated uptake of tracer in the neck and in phenomenon not previously reported. both lungs, 100 mCi of 1311was given. A repeat scan four mo later again demonstrated diffuse bilateral pulmonary uptake as well as uptake in the right side of the neck; a right radical CASE REPORT neck dissection was performed. Tumor was found in 6/8 A 23-year-old man was in good health until September lymph nodes, with associated lymphatic invasion. Thyroid 1968, when he was admitted to the hospital with a I-day hormone was continued in a suppressive dose. Repeat 1311 history of cough productive of a cup and a half of blood clots. scan two yr later stilt demonstrated uptake in both lungs and He denied chest pain, weight loss, night sweats, fever, or in the right neck. Two yr later, the patient discontinued the chills. There was no history ofchronic cough, sputum produc thyroid hormone and stopped coming for followup visits. tion, or prior lung disease. He had never smoked and took no After 10moreyrwithoutsymptoms,hemoptysisrecurredand medications. The patient was in no acute distress, and except he was readmitted to the hospital for evaluation. The chest for mild enlargement of a right cervical lymph node, physical examination revealed bilateral crackles at the lung bases. examination was normal. Multiple small nodules in both lung Laboratory studies were normal except for a TSH of 8.7 U/ fields were present on the chest roentgenogram. ml (normal < 7). The chest roentgenogramagain revealed Rigid bronchoscopy was normal and no bleeding site was numerous small nodules throughout both lung fields (Fig. 1). identified. A right cervical node biopsy demonstrated papil Multiple sputum cultures were negative for bacteria and lary cystadenocarcinoma with psammoma bodies. A thyroid fungi. No further hemoptysis occurred. Fiberoptic bronchoscopy revealed mild blood streaking of the left mainstem bronchus. No endobronchiat lesion was ReceivedJan.11,1985;revisionacceptedJune5,1985. found; bronchial washings were normal. An ‘@‘Iscan (Fig. 2) For reprint contact: Samuel V. Spagnolo, MD, FACP, FCCP, The demonstrated bilateral diffuse lung uptake and no tracer H. B. Burns Memorial Building, 2150 Pennsylvania Ave., NW., uptake in the neck. The patient was given 180 mCi of ‘@‘Iand Room 622, Washington, D.C. 20037. discharged on thyroid replacement.

Volume26 •Number9 •September1985 1039 FIGURE1 Chest roentgenogram (posteroanter ior view)showingmultiplesmallnod ulesthroughoutbothlungfields

DISCUSSION dence of bess than 1%, increasing to 2-4% if delayed metastases are included (1,2). These figures reflect a Thyroid carcinoma, with an incidence of about 37 diagnosis based only on an abnormal chest x-ray; a new cases per 1 million population per year (1), is an higher incidence is seen if nuclear imaging is also used uncommon disease. for diagnosis of metastatic disease (3). Harness, et al. The presentation of hemoptysis in thyroid carcinoma (4) reportsanautopsyseriesof 50patientswiththyroid is rare. Hemoptysis in the absence ofclinicalby apparent carcinoma and found pulmonary metastases in 18, disease in the thyroid is even more unusual. In one series eight of whom had a normal chest x-ray a week before of 885 patients with thyroid carcinoma (2), six present death. ed with hemoptysis, and only two in the setting of a Our patient remained symptom free for 15 yr after clinically normal thyroid gland, as seen in our patient. diagnosis. Knessel, et at. (5) reported four cases of Papillary carcinoma is the most common histologic papillary thyroid carcinoma with pulmonary metasta type of thyroid cancer, accounting for 61%of Woolner's ses that were clinically stable for extended periods (14— series (2). It includes tumors with pure papillary ebe 25 yr after diagnosis of metastatic disease). In three of ments and mixed papillany-folbicular. It occurs in a these cases the lung findings followed the diagnosis of younger age group than most cancers, with a peak thyroid cancer by 2—14yr; in one case the disease was incidence in the third to fifth decades (1), but can occur metastatic to the lung at the time ofthe original diagno at any age. Papillary carcinoma is characterized by sis. Unlike our patient, none of these cases demonstnat slow growth and a frequently indolent clinical course, ed clinical symptoms or uptake of 131I for extended with a 10-yr survival in excess of 80% (1,2). periods. Nonetheless, approximately 40% ofpapilbany thyroid Varma, et al. (6) showed that ablation of ‘@‘Iuptake carcinomas are metastatic to local lymph nodes at the with therapeutic use of nadioiodine was associated with time of diagnosis (2), as in this case. The tumor is higher survival rates than in those in whom uptake was metastatic to lung less commonly, with an initial mci not ablated. Pulmonary metastases from thyroid carci

1040 Blass,Delaney,andSpagnolo TheJournalof NuclearMedicine @ S 55

FIGURE2 Iodine-131 scintiscan (anterior view) showing diffuse bilateral lung uptake. No uptakewas seen in neck or any other area

noma have been shown to regress following 131I treat REFERENCES ment (5). Although our patient showed 1311uptake 1. Mazzaferri EL, Young RL, Oertel JE, et at: Papillary repeatedly throughout his course, he remained thyroid carcinoma: The impact of therapy in 576 pa asymptomatic until 15 yr after the initial therapy. tients.Medicine56:171-196,1977 We have presented an unusual clinical variant with 2. Woolner LB, Beahrs OH, Black BM, et at: Classification hemoptysis as the presenting manifestation of thyroid and prognosis of thyroid carcinoma. A study of 885 cases observed in a thirty-year period. Am JSurg 102:354-387, cancer on two separate occasions. The occurrence of I961 pulmonary arteniovenous fistulae in metastatic thyroid 3. Worm AM, Holten I, and Taaning E: Nuclear imaging of carcinoma has been reported (5), and this phenomenon pulmonary metastases in thyroid carcinoma. Acta Ra may have accounted for the hemoptysis in our patient, diolOncol19:401-403,1980 although the reason for the bleeding was not 4. Harness JK, Thompson NW, Sisson JC, et at: Differenti established. ated thyroid carcinomas. Treatment of distant metasta ses. ArchSurg 108:410-419, 1974 5. Kressel HY, Gamsu G, Kalifa LG, et at: Prolonged growth arrest of pulmonary metastases in papillary thy roid carcinoma. West J Med 129:424-429, 1978 ACKNOWLEDGMENT 6. Varma VM, Beierwaltes WM, Nofal MM, et at: Treat ment of thyroid cancer. Death rates after surgery and The authors thank Kenneth L. Becker, MD, PhD, for his after surgery followed by sodium iodine 1311. JAMA review of the manuscript and thoughtful comments. 214:1437-1442,1970

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