ID: 19-0148 -19-0148 APopławska-Kitaand Thyroid cancer with metastasis ID: 19-0148; March 2020 others to the pituitary and sarcoidosis DOI: 10.1530/EDM-19-0148 Thyroid carcinoma with atypical metastasis to the pituitary gland and unexpected postmortal diagnosis Anna Popławska-Kita1, Marta Wielogórska1, Łukasz Poplawski5, Katarzyna Siewko1, Agnieszka Adamska1, Piotr Szumowski2, Piotr Myśliwiec7, Janusz Myśliwiec2, Joanna Reszeć4, Grzegorz Kamiński6, Janusz Dzięcioł3, Dorota Tobiaszewska1, Małgorzata Szelachowska1 and Adam Jacek Krętowski1 Correspondence Departments of 1Endocrinology, Diabetology and Internal Medicine, 2Nuclear Medicine, 3Human Anatomy, 4Medical should be addressed Pathomorphology, 5Radiology, Medical University of Bialystok, Bialystok, Poland, 6Department of Endocrinology and toAPopławska-Kita Radioisotopy Therapy, Military Institute of Medicine, Warsaw, Poland, and 71st Clinic Department of General and Email Endocrine Surgery, Medical University of Bialystok, Bialystok, Poland [email protected] Summary Papillary thyroid gland carcinoma is the most common type of malignancy of the endocrine system. Metastases to the pituitary gland have been described as a complication of papillary thyroid cancer in few reported cases since 1965. We reportthecaseofa68-year-oldfemalepatientwithawell-differentiatedformofthyroidglandcancer.Despiteitbeing the most common malignant cancer of the endocrine system, with its papillary form being one of the two most frequently diagnosedthyroidcancers,thecasewepresentisextremelyrare.Suddencardiacarrestduringventricularfibrillation occurred during hospitalization. Autopsy of the patient revealed papillary carcinoma of the thyroid, follicular variant, with metastasis to the sella turcica, and concomitant sarcoidosis of heart, lung, and mediastinal and hilar lymph nodes. Not only does atypical metastasis make our patient’s case most remarkable, but also the postmortem diagnosis of sarcoidosis makes her case particularly unusual. Learning points: • The goal of presenting this case is to raise awareness of the clinical heterogeneity of papillary cancer and promote early diagnosis of unexpected metastasis and coexisting diseases to improve clinical outcomes. • Clinicians must be skeptical. They should not fall into the trap of diagnostic momentum or accept diagnostic labels at face value. Regardless of the potential mechanisms, clinicians should be aware of the possibility of the coexistenceofthyroidcancerandsarcoidosisasadifferentialdiagnosisoflymphadenopathy. • This case highlights the importance of the diagnostic and therapeutic planning process and raises awareness of the fact that one uncommon disease could be masked by another extremely rare disorder. Background Differentiated thyroid cancer (DTC) is the most common distant metastases with a 50% rate of 5-year survival (1, 2, endocrine malignancy with an increasing incidence 3). Pituitary metastases (PM) are found in about 1% of all of papillary thyroid cancer (PTC), which accounts for pituitary resections, occurring in 1–5% of various autopsy about 90% of all DTC. PTC has a strong propensity to series (2). They often originate from the breast, lung, and metastasize to the cervical lymph nodes (LNs). PTC gastrointestinal tract, and only 2% of these are metastases portends a favorable prognosis, even in the presence of of DTC (4, 5). It is not clear whether these tumors involve This work is licensed under a Creative Commons © 2020 The authors https://edm.bioscientifica.com/ Attribution-NonCommercial-NoDerivatives 4.0 PublishedbyBioscientificaLtd International License. Downloaded from Bioscientifica.com at 09/24/2021 10:17:16PM via free access A Popławska-Kita and Thyroid cancer with metastasis ID: 19-0148; March 2020 others to the pituitary and sarcoidosis DOI: 10.1530/EDM-19-0148 the pituitary gland primarily or by secondary extension and a fibrotic nodule within focal follicular cells in the from osseous metastasis. right lobe. She received a suppressive treatment with The published cases of metastatic thyroid cancer levothyroxine after the operation. involving the pituitary gland were diagnosed during the Following surgery, the patient started suffering from investigation of symptoms and following the resection of neurological disturbances. She presented with headaches, symptomatic sellar masses (2, 3, 4, 5, 6, 7, 8). Presenting non-vertiginous dizziness, double vision, and paresthesia symptoms of PM are usually some neurological signs and involving half of her face. No evidence of anterior or symptoms related to mass effect – central neurological posterior hypopituitarism was recorded. She was admitted impairment due to a space-occupying expansion in the to the Department of Neurosurgery for the investigation parasellar region (2, 4). In contrast to pituitary adenomas, of these symptoms and further management. metastatic tumors, when detected, are more likely to be The MRI of the pituitary gland performed in located in the posterior pituitary. This likely accounts for 2015 demonstrated a hypointense mass measuring diabetes insipidus being more common in patients with approximately 17 × 10 × 15 mm (AP × LR × HF) and left PM than patients with other pituitary pathology (3, 7). cavernous sinus invasion (Fig. 1A). It was regarded as Prognosis is poor for larger metastases. Early diagnosis meningioma due to its uniform enhancement after the is crucial and a comprehensive treatment strategy administration of an i.v. gadolinium contrast agent. (neurosurgery, radioiodine, external radiotherapy, and The follow-up cranial MRI scan in July 2016 revealed radiosurgery) is recommended (8). a further enlargement of the pituitary mass (Fig. 1B). Coexistence of PTC and sarcoidosis may yield a Anterior pituitary function tests performed preoperatively diagnostic challenge as both diseases might involve the suggested a non-functioning pituitary adenoma. LNs. Sarcoidosis is a multisystem granulomatous disease According to the increasing tumor size and worsening with large variability in presentation, disease behavior, neurological symptoms, neurosurgeons qualified her and outcome. The disease usually begins in the lungs, for planned surgery. In January 2017, she underwent skin, or LNs. Less commonly affected are the eyes, liver, the transsphenoidal resection of the pituitary tumor. heart, and brain. Often, no, or only mild, symptoms The postoperative period was complicated by deep vein are seen (9). The relationship between sarcoidosis and thrombosis. The patient showed no improvement in her malignancy is not clear yet. neurological condition. The surgery did not reduce the The goal of presenting this case is to raise awareness severity of symptoms, but stopped the progression of of the clinical heterogeneity of PTC and promote early decreased visual acuity and oculomotor nerve palsies. The diagnosis of unexpected metastasis and coexisting diseases histopathological examination of resected mass confirmed to improve clinical outcomes. pituitary adenoma. Due to the postoperative elevated concentration of prolactin (78.82 ng/mL), the patient was treated with a dopamine agonist - bromocriptine. Case presentation In May 2017, a follow-up cranial MRI scan revealed a A 68-year-old woman was in the care of an Endocrine Unit significant residual mass, mostly in the sellar-suprasellar since February 2013 for the management and ongoing region (Fig. 1C). Chest CT showed enlarged LNs in surveillance of multinodular goiter. An initial fine needle the mediastinum and hilar areas (subcarinal LNs with aspiration biopsy (FNAB) from the right lobe revealed dimension of 24 × 14 mm). Additionally, masses of 31 × 18 a follicular lesion of undetermined significance (FLUS) mm extending and invading the right jugular vein wall classified as Bethesda category III. She underwent the were described. In July 2017, the cytological examination removal of enlarged LNs (size 6 × 2 × 1.5 cm) of the central of the thyroid bed remnant revealed FLUS classified as neck in May 2013. The histopathological examination of Bethesda category III. resected tissue samples revealed nodular goiter in LNs. The patient failed to collect the results of the test and Investigation therefore was lost to follow-up. FNAB of the thyroid was performed in January 2015 Owing to the thyroid pathology, progressive decline in and the result was categorized as suspicious for a follicular vision, left-sided ptosis, and physical condition, the neoplasm (FN) classified as Bethesda category IV. She patient was admitted to the Department of Endocrinology underwent a total thyroidectomy in August 2015. The in January 2018, in order to identify the exact cause histopathological examination revealed nodular goiter of these symptoms. The verification of ancillary https://edm.bioscientifica.com/ 2 Downloaded from Bioscientifica.com at 09/24/2021 10:17:16PM via free access A Popławska-Kita and Thyroid cancer with metastasis ID: 19-0148; March 2020 others to the pituitary and sarcoidosis DOI: 10.1530/EDM-19-0148 immunohistochemical tests of the removed pituitary mass revealed the diagnosis of PM from the TC. Tumor cells stained positive for thyroglobulin and TTF-1 and were immunonegative for anterior pituitary hormones (PRL, GH, TSH, ACTH, FSH, and LH) and negative for CK19, chromogranin A, and synaptophysin. The patient with the concomitant diagnoses of hypertension and type 2 diabetes was admitted to Endocrinological Department again in March 2018, with symptoms of diplopia, left complete eye ptosis, and enlargement