|Year : 2014 | Volume
| Issue : 5 | Page : 426-428
Papillary thyroid carcinoma presenting with mandibular metastasis: An unusual presentation
Rajjyoti Das1, Mahesh Kumar1, Jagannath D Sharma2, Manigreeva Krishnatreya1, Partha S Chakraborty1, Amal C Kataki3
1 Department of Head and Neck Oncology, Dr. Bhubeneswar Borooah Cancer Institute, Guwahati, Assam, India
2 Department of Pathology, Dr. Bhubeneswar Borooah Cancer Institute, Guwahati, Assam, India
3 Department of Gynecologic Oncology, Dr. Bhubeneswar Borooah Cancer Institute, Guwahati, Assam, India
|Date of Web Publication||5-Aug-2014|
House No. 7, Bye Lane 7, Sublane No. 4, Lachit Nagar, Guwahati - 781 007, Assam
Source of Support: None, Conflict of Interest: None
Mandibular metastasis from papillary carcinoma of the thyroid is extremely rare. We report here a case of metastatic swelling on the mandible due to papillary carcinoma of the thyroid. The patient presented with jaw swelling and the thyroid lesion was an incidental finding on clinical examination. Computed tomogram scan revealed the presence of a contrast enhanced lesion in the thyroid and lytic expansile lesion in the body of the mandible. The diagnosis of papillary thyroid carcinoma (PTC) with mandibular metastasis was made after cytological examination of both the lesions. The patient was treated with surgery followed by radioiodine ablation. In conclusion, metastatic tumor to the jaw from a PTC is an extremely rare phenomenon and in the differential diagnosis of a metastatic jaw swelling small primary tumors of the thyroid should be excluded.
Keywords: Mandible, metastasis, papillary carcinoma thyroid
|How to cite this article:|
Das R, Kumar M, Sharma JD, Krishnatreya M, Chakraborty PS, Kataki AC. Papillary thyroid carcinoma presenting with mandibular metastasis: An unusual presentation. Clin Cancer Investig J 2014;3:426-8
|How to cite this URL:|
Das R, Kumar M, Sharma JD, Krishnatreya M, Chakraborty PS, Kataki AC. Papillary thyroid carcinoma presenting with mandibular metastasis: An unusual presentation. Clin Cancer Investig J [serial online] 2014 [cited 2019 Oct 13];3:426-8. Available from: http://www.ccij-online.org/text.asp?2014/3/5/426/138073
| Introduction|| |
Papillary thyroid carcinoma (PTC) accounts for approximately 80% of all thyroid cancers.  The most common presentation of carcinoma of the thyroid is a slow growing swelling in front of the neck, which is detected incidentally. PTC's are tumors with a relatively indolent behavior and favorable prognosis.  Multiple bone metastases in PTCs is noted more often than single bone metastasis.  Distant metastases of PTC to the lungs, bones, and brain occurs in 5-7% of all cases.  In PTC mode of spread is usually lymphatic invasion and it frequently metastasizes to the regional lymph nodes, though solitary distant metastases is also seen rarely.  Patients with differentiated thyroid carcinoma have a 10 year survival rate of 80-95%. However, when distant metastases are present, the overall 10 year survival rate is below 40%. Mazzaferi had reported that, 25% of the metastases from thyroid cancers are to the bones, 49% to the lungs, 15% to the lungs and bone combined, and 10% to the other soft tissues.  The common metastatic site at the mandible is the posterior body of the mandible (premolar-molar region). , PTC presenting with metastasis to the mandible is rare and only a limited number of cases has been reported in the literature.
| Case report|| |
A 55-year-old female patient reported to the outpatient Department of Head and Neck Surgery at our institute with the chief complaint of swelling on the right side of the jaw, which was of 6 months duration. The swelling was gradual in its nature. There was no associated history of pain or intake of medications. On local examination, there was a hard 4.5 × 4.5 cm sized nontender swelling over the right side of the mandible, the skin overlying the swelling was normal, and the margins of the swelling were irregular. Examination of the neck revealed a firm 2 × 2 cm nontender mobile swelling on the right thyroid lobe which moves on deglutition. Computed tomogram scan of the oral cavity and neck showed a lytic expansile lesion involving right side of the mandible [Figure 1] and a solid nodular lesion in the right lobe of the thyroid, respectively. Thyroid function tests and other hematological parameters were normal.
Fine-needle aspiration cytology (FNAC) from the thyroid swelling showed features of papillary carcinoma of the thyroid and FNAC of the right mandibular swelling was metastatic papillary carcinoma. The diagnosis of PTC with mandibular metastasis was confirmed.
|Figure 1: Axial bone window section on computed tomogram scan showed the expansile mass in the body of the mandible|
Click here to view
The patient underwent total thyroidectomy along with a right lateral segmental mandibulectomy, for the mandibular metastasis and extended supraomohyoid neck dissection was done for the lymphatic clearance. Postoperative histopathology report of the thyroid swelling showed follicular variant of papillary carcinoma thyroid with clear nuclear chromatin, nuclear groups, and intranuclear inclusions [Figure 2]a and the mandible showed metastatic papillary carcinoma [Figure 2]b.
|Figure 2: (a) Photomicrograph (×40) with H and E showing follicular variant of papillary thyroid carcinoma (PTC) with nuclear features, (b) photomicrograph (×40) showing metastatic thyroid carcinoma with nuclear features of PTC in bone|
Click here to view
Postoperative iodine 131 scan of the whole body showed residual functioning thyroid tissue in thyroid bed. Subsequently, the patient was further treated by radioiodine ablation (RIA) therapy (100 mCi). On followup after 2 year from treatment, imaging scan with positron emission tomogram (PET) was done, which revealed the patient was free from disease.
| Discussion|| |
Papillary thyroid carcinoma metastasis to the jaw is extremely rare and it accounts for about 3.85% of all jaw metastases of all head and neck carcinoma,  whereas bony metastasis of follicular carcinoma of the thyroid is relatively common. The metastasis in PTC commonly occurs to regional nodes only. Bone metastases is rare in a patient with PTC and it is seen in older patients.  In our case also the patient was relatively older. Spine is the most common site of bony metastasis from a differentiated thyroid cancer.  Both the jaw and soft-tissues of the oral cavity may be affected by metastatic cancer with a predilection for the mandible and the gingiva.  The vast majority of oral metastases from thyroid cancer were seen in the mandible.  It has been suggested that the predilection of metastasis to the ramus and angle of mandible is due to the rich blood circulation in the medullary cavity of the region, , and in the present case PTC metastasis occurred in the body of the mandible and adjacent to the ramus.
The treatment of metastatic thyroid carcinoma has varied extensively from palliative to various combinations of surgical resection, radio-iodine therapy, and radiotherapy. It has been recommended that surgical resection of the metastatic tumor in conjunction with total thyroidectomy, followed by RIA and/or external beam radiation (EBRT) may afford better survival. ,,, In our case, the patient was treated curatively with surgery followed by RIA, but the patient did not received EBRT. The patient was free from disease after treatment with surgery followed by RIA at the 2 year followup both clinically and radiologically on PET scan image (short term followup).
The extent of metastatic disease to bone in PTC and its response to radioactive iodine are predictors for better survival.  Hence, early detection of the metastatic disease along with the primary improves the overall survival rate in patients with PTC. However, in our case the patient presented with metastasis and the primary lesion was an incidental finding.
| Conclusion|| |
Metastatic tumor to the jaw from a PTC is an extremely rare phenomenon and in the differential diagnosis of a metastatic jaw swelling small primary tumors of the thyroid should be excluded.
| References|| |
|1.||Hodak SP, Burman KD. Thyroid carcinoma. Metastases to bone. In: Wartofsky L, Nostrand D, editors. Thyroid Cancer A. Comprehensive Guide to Clinical Management. 2 nd ed. Totowa: Humana Press Inc.; 2006. p. 497. |
|2.||DeGroot LJ, Sridama V. Thyroid neoplasia. In: DeGroot LJ, editor. Endocrinology. 2 nd ed. Philadelphia: W.B. Saunders Company; 1989. p. 766-7. |
|3.||Fanchiang JK, Lin JD, Huang MJ, Shih HN. Papillary and follicular thyroid carcinomas with bone metastases: A series of 39 cases during a period of 18 years. Changgeng Yi Xue Za Zhi 1998;21:377-82. |
|4.||Tachikawa T, Kumazawa H, Kyomoto R, Yukawa H, Yamashita T, Nishikawa M. Clinical study on prognostic factors in thyroid carcinoma. Nihon Jibiinkoka Gakkai Kaiho 2001;104:157-64. |
|5.||Larsen PR, Davies TF, Hay DI. The thyroid gland. In: Wilson JD, Foster DW, Kronenberg HM, Larsen PR, editors. Williams Textbook of Endocrinology. 9 th ed. Philadelphia: W.B. Saunders Company; 1998. p. 487. |
|6.||Mazzaferi E. Thyroid carcinoma: Papillary and follicular. In: Mazzaferi E, Saaman N, editors. Endocrine Tumors. Cambridge, MA: Blackwell Scientific; 1993. p. 278-33. |
|7.||Vural E, Hanna E. Metastatic follicular thyroid carcinoma to the mandible: A case report and review of the literature. Am J Otolaryngol 1998;19:198-202. |
|8.||Hirshberg A, Leibovich P, Buchner A. Metastatic tumors to the jawbones: Analysis of 390 cases. J Oral Pathol Med 1994;23:337-41. |
|9.||Clausen F, Poulsen H. Metastatic carcinoma of the JAWS. Acta Pathol Microbiol Scand 1963;57:361-74. |
|10.||Nikitakis NG, Polymeri A, Polymeris A, Sklavounou A. Metastatic papillary thyroid carcinoma to the maxilla: Case report and literature review. Head Neck Pathol 2012;6:216-23. |
|11.||Grebe SK, Hay ID. Follicular thyroid cancer. Endocrinol Metab Clin North Am 1995;24:761-801. |
|12.||Erdag T, Bilgen C, Ceryan K. Metastatic thyroid carcinoma of the mandibule. Rev Laryngol Otol Rhinol (Bord) 1999;120:31-4. |
|13.||Ostrosky A, Mareso EA, Klurfan FJ, Gonzalez MJ. Mandibular metastasis of follicular thyroid carcinoma. Case report. Med Oral 2003;8:224-7. |
|14.||Muresan MM, Olivier P, Leclère J, Sirveaux F, Brunaud L, Klein M, et al. Bone metastases from differentiated thyroid carcinoma. Endocr Relat Cancer 2008;15:37-49. |
[Figure 1], [Figure 2]