|Year : 2014 | Volume
| Issue : 1 | Page : 59-61
Papillary carcinoma of thyroid with an unusual coexistence of metastatic deposits and tuberculosis in the cervical lymph nodes
Nagarajan Swathanthra, Chityala Jyothi, Pidakala Premalatha, Sattiraju Satyanarayana Rao
Department of Pathology, NRI Medical College and General Hospital, Chinakakani, Guntur, Andhra Pradesh, India
|Date of Web Publication||10-Dec-2013|
Department of Pathology, NRI Medical College and General Hospital, Chinakakani, Guntur - 522 503, Andhra Pradesh
Source of Support: None, Conflict of Interest: None
Papillary carcinoma of the thyroid with clinically significant cervical lymphadenopathy is a common presentation (particularly in young patients), and it may be the first manifestation of disease. Occasionally, besides metastatic deposits, the cervical lymph nodes may harbor other diseases, and determining the etiology in such a case becomes critical for the institution of proper treatment and complete cure of the patient. Detection of tuberculous lymphadenitis and metastatic deposits by radiological and/or fine needle aspiration cytology methods may not be always easy and may be missed due to inherent defects of the techniques hence, histopathological examination still remains the final resort. We report a case of papillary carcinoma of the thyroid and its rare association with both metastatic deposits and tuberculosis of the contiguous cervical lymph node groups. We suggest that tuberculosis must always be borne in mind besides metastases while evaluating the enlarged neck nodes in papillary carcinoma of the thyroid.
Keywords: Cervical lymphadenopathy, metastasis, papillary carcinoma of thyroid, tuberculosis
|How to cite this article:|
Swathanthra N, Jyothi C, Premalatha P, Rao SS. Papillary carcinoma of thyroid with an unusual coexistence of metastatic deposits and tuberculosis in the cervical lymph nodes. Med J DY Patil Univ 2014;7:59-61
|How to cite this URL:|
Swathanthra N, Jyothi C, Premalatha P, Rao SS. Papillary carcinoma of thyroid with an unusual coexistence of metastatic deposits and tuberculosis in the cervical lymph nodes. Med J DY Patil Univ [serial online] 2014 [cited 2022 Sep 25];7:59-61. Available from: https://www.mjdrdypu.org/text.asp?2014/7/1/59/122784
| Introduction|| |
Papillary carcinoma of thyroid (PTC) is the most common primary malignant neoplasm of the thyroid arising from the follicular epithelial cells. Approximately 50% of patients with PTC have cervical lymph node metastases at the time of their initial presentation.  Cervical lymphadenopathy per se is often a diagnostic challenge to medical professionals owing to its varied etiologies. Malignancies, primary or metastatic, and infections are the main causative factors that should be included in the differential diagnoses of cervical lymphadenopathy.
In a patient with PTC, cervical lymph nodes showing tuberculous lymphadenitis have been reported. Case reports were also made of PTC with both tuberculous lymphadenitis and metastatic deposits in the same lymph node.  We present a case of PTC with a rather unusual simultaneous occurrence of both tuberculous lymphadenopathy and metastatic deposits of PTC in contiguous levels of cervical lymph nodes.
| Case Report|| |
A 26-year-old lady complained of a swelling in the right side of the neck and dysphagia for 7 months duration. On clinical examination, a solitary nodule in the right lobe of the thyroid and multiple painless significantly enlarged cervical lymph nodes were identified. Ultrasonography of the neck suggested a benign nodule in the right lobe of the thyroid, probably an adenoma with cervical lymphadenopathy. Contrast-enhanced computerized tomography of the neck revealed a well-defined solitary nodule in the right lobe of the thyroid with enlarged necrosed right cervical lymph nodes. She was in an euthyroid state clinically and her thyroid profile was also normal.
Further, fine needle aspiration cytology (FNAC) of the solitary nodule in the right lobe of the thyroid revealed cytomorphological features consistent with those of papillary carcinoma [Figure 1] and reactive lymphnodal hyperplasia of the cervical lymph nodes. A provisional clinical diagnosis of carcinoma of the thyroid with secondaries in the neck was given. The other relevant staging investigations did not reveal any distant metastasis.
Consequently, histopathological analyses were performed on (1) the subtotal thyroidectomy specimen, (2) the right side neck nodes from level II to level VI and (3) the central compartment neck nodes. Grossly, a subtotal thyroidectomy of 7 cm × 4 cm × 3 cm with a right lobe of 5 cm × 3 cm, isthmus of 2 cm × 1 cm and left lobe of 2 cm × 2 cm showed an encapsulated grey-white tumor measuring 1.5 cm in diameter in the right lobe of the thyroid with multiple papillary excrescences in its cut surface with infiltration of the thyroid capsule at one pole and compressed normal thyroid tissue at the other pole. The left lobe and isthmus were unremarkable.
|Figure 1: Fine needle aspiration cytology smear from the thyroid nodule showing features of papillary carcinoma of the thyroid -papillary structures, intranuclear inclusions and nuclear grooves. Hematoxylin and eosin stain (×100 and ×1000)|
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Histopathological analysis revealed PTC [Figure 2] with capsular infiltration and lymphatic embolization. The isthmus and left lobe were uninvolved. The 21 lymph nodes isolated from the right chain (levels II-V) revealed a gamut of findings: Two with tumor deposits, six with caseous tuberculous [Figure 3] lymphadenitis (AFB demonstrated) and the remaining 13 with non-specific reactive changes. The two lymph nodes isolated from the central compartment showed tumor deposits. In short, nodal metastases were noted in four of them, two each in the central group and the right chain (levels II-V).
The patient was scrupulously followed-up every week in the first month, every 2 weeks in the second month and monthly in the subsequent 6 months. The patient was put on anti-tubercular therapy under DOTS category 1 for 6 months and thereafter discharged as per the pulmonologist's opinion. After surgery, radioiodine ablative treatment was given as per the protocol. The radioiodine scan performed after ablation showed no evidence of residual or recurrent disease.
|Figure 2: Histomorphology of the thyroid nodule showing features of papillary carcinoma of thyroid. Hematoxylin and eosin stain (x400)|
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|Figure 3: Histomorphology of the cervical lymph node showing features of caseous tuberculous lymphadenitis. Hematoxylin and eosin stain (×400)|
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Thus, in our case, caseating tuberculous lymphadenitis and metastatic deposits of PTC were observed in contiguous levels of cervical lymph nodes associated with primary PTC.
| Discussion|| |
Lymphadenopathy refers to enlargement and/or altered consistency of lymph nodes manifesting due to regional or systemic disease, and serves as an excellent clue to the underlying disease. PTC is the most common malignant tumor of the thyroid gland, with cervical lymphadenopathy as a frequent association. 
Neck dissection is generally indicated in PTC patients with positive lateral neck nodes. Although this procedure is reliable and relatively safe, considerable post-operative complications can occur.  Tuberculous adenitis is endemic in many parts of our country. The frequency of tuberculosis has been found to be more than that of metastatic deposits in the cervical lymph nodes associated with PTC. 
Although ultrasonography is the first line of investigation for detecting and characterizing cervical lymphadenopathy in patients with any head and neck cancer, many overlapping sonographic features between benign and metastatic lesions in the cervical lymph nodes lead to misinterpretation. 
Another technique contributing to the presumptive diagnosis, FNAC, has variable sensitivity ranging between 46% and 90%.  In our case, FNAC yielded only reactive changes in the lymph nodes in concordance with the literature. Therefore, it is recommended that even in PTC or in other head and neck malignancies with lymph node enlargement, one should never overlook tuberculosis as a co-existent cause; if in doubt, excision biopsy of the lymph node (gold standard for diagnosis) should be performed as a part of the neck dissection, as in our case. 
Proper pre-operative assessment of cervical lymphadenopathy in PTC patients cannot be underestimated as treatment for tuberculous lymphadenitis is antituberculous medication and that for metastatic cervical lymph node is neck dissection.  The deterioration of clinical status post-surgically must not only be attributed to the effects of extensive surgical procedures or progression of malignancy but also to the possible coexistent causes like tuberculosis.
Coexistence of granulomas and metastatic tumor within the lymph nodes is a rare phenomenon. Coexisting necrotizing granulomas were seen in tumor stroma and contiguous lymph nodes in association with adenocarcinoma colon, Hodgkin's lymphoma, bronchial carcinoid, infiltrating carcinoma breast, mucinous cystadenoma ovary, follicular adenoma, metastatic deposits of medullary carcinoma thyroid and ampullary carcinoma. 
Granulomatous reaction in draining lymph nodes without metastatic deposits may be attributed to a T-cell-mediated immune response to a soluble tumor-related antigen reaching the lymph nodes.  However, before labeling this reaction as an immunological response to tumor antigens, it is important to exclude other causes of granulomatous inflammation, especially tuberculosis, by polymerase chain reaction or by demonstration of acid fast bacilli.
Close association of two pathological lesions always incites a debate about their etiological relationship.  Our case had a peculiar finding in that the lymph nodes by tuberculosis were not involved by metastases. FNAC might miss one of the two pathologies because of the same reason. Coexistence of tuberculosis and carcinoma may be a simple coincidence because of the high prevalence of tuberculosis in India, or one disease process might lead to the other. Tuberculosis is known to reactivate in the setting of any immunesuppression, and malignancy is one of the causes of immunosuppression. In addition, further research is required to determine whether a tuberculous infection, being similar to other chronic infections and inflammatory conditions, may facilitate carcinogenesis. 
| Conclusion|| |
A high index of suspicion for simultaneous and/or misleading presentations of tuberculosis and malignancy should be borne in mind as tuberculosis in the lymph nodes masquerades malignant tumor deposits.
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[Figure 1], [Figure 2], [Figure 3]