Case Report

Axillary Lymph Node Metastasis in Medullary Thyroid Cancer: Atypical Lymphatic Spread or Expression of a Systemic Disease?

by Traini E1,2, Daloiso G1, Carnassale G2, Lanzafame A1, Mattia A1, Bellantone C3, Bruno C1,4, Menghi R1.

1Department of Medical and Surgical Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.

2Endocrine Surgery Unit, Ospedale San Carlo di Nancy-GVM Care and Research, Rome, Italy.

3Department of Internal Medicine, Ospedale San Carlo di Nancy-GVM Care and Research, Rome, Italy

4Department of Clinical Endocrinology, Istituto Dermopatico dell’Immacolata-IDI IRCCS, Rom, Italy.

*Corresponding author: Traini E, Department of Medical and Surgical Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.

Received Date: 05 December 2023

Accepted Date: 11 December 2023

Published Date: 13 December 2023

Citation: Traini E, Daloiso G, Carnassale G, Lanzafame A, Mattia A, et al. (2023) Axillary Lymph Node Metastasis in Medullary Thyroid Cancer: Atypical Lymphatic Spread or Expression of a Systemic Disease? Ann Case Report 8: 1545. https://doi.org/10.29011/25747754.101545

Abstract

Medullary thyroid cancer (MTC) is a rare tumor which usually spreads to cervical lymph nodes. Axillary lymph nodes (ALN) involvement is exceptional. We describe the eighth case of ALN metastasis from MTC ever reported and discuss its unusual presentation that suggests the coexistence of undetectable visceral localization.A patient underwent total thyroidectomy with the unexpected finding of MTC when he was 69 years old. For persistent disease, he, afterward, underwent VI level lymphadenectomy, right cervical neck dissection and left cervical lymph node sampling. After 7-years he developed recurrence requiring VI level compartment revision surgery. After that calcitonin levels remained detectable but without any evident relapse at imaging till 2021 when serum calcitonin suddenly and highly increased and 18F- DOPA PET showed a left axillary relapse. A retrograde flow from lymphatics in the neck to the ipsilateral axilla was suggested as possible explanation of atypical spread of ALN. Another explanation is a regular spread of cells from visceral localization in the thorax. In the present case axillary metastases were found in the opposite side of both the primary tumor and the cervical lymph-node metastases. In addition, just after the ALN involvement, the disease showed a more aggressive progression. The high rate of visceral localization reported in patients with ALN metastases from thyroid cancer, together with the evidence, in the present case, of opposite side involvement of lymph-nodes metastases support the idea of an unrecognized visceral spread and a more aggressive behavior of the disease.

Keywords: Medullary Thyroid Cancer; Axillary Metastasis; Retrograde Lymphatic Drainage; Visceral Spread

Introduction

Medullary thyroid cancer is a rare tumor that approximately represents 3-5% of all thyroid cancers [1]. MTC prognosis is good if it is confined into the gland, but considerably declines if associated with distant metastases, with a 10-years survival rate of 40% [2]. Lymph node involvement is a very common finding. During the initial staging the reported incidence of lymph node metastases is 71% - 80% in the neck and 36% in the mediastinum [3-5]. Distant visceral metastases typically occur in the lungs, bones, liver, and brain [6]. Calcitonin is a specific marker used in the follow-up [7]. In this scenario, ALN involvement from MTC is a very rare encounter, and the present case is the eighth one ever reported. The peculiarity of the present case is the contra-laterality of the ALN metastases respect to the side of both the primary tumor and the lymph node involved in the neck. This evidence has never reported before.

Case Presentation

In February 2007 the patient, 69 years old man, underwent total thyroidectomy for preoperative diagnosis of multinodular goiter. Histology reported the unexpected finding of 1cm MTC in the right thyroid lobe. Into the sample also one lymph node positive for MTC metastasis, incidentally removed, was found. At the first follow-up control after surgery the patient showed high serum calcitonin level (140 pg/mL) suggestive for persistent disease due to inadequate primary clearance of the central compartment. Before planning the revision surgery, 18-F-DOPA PET was done with no evidence of hyperactive foci in the body. Neck ultrasonography instead showed a solid hypoechoic nodule in the right side of the central compartment (VI level) and a suspicious lymph-node at the IV level in the right cervical compartment. Fine needle aspiration biopsy of both the lymph nodes was performed and cytology revealed lymph node metastases with immunocytochemistry positive for calcitonin. In July 2007 the patient underwent right lateral and central neck dissection. Moreover, a left III-IV levels selective neck dissection was achieved for frozen section.

Histology confirmed the right cervical lymph node metastases and VI level metastases. The left lateral cervical lymph nodes had not pathological features. The patient continued the followup with serum calcitonin level and neck ultrasound check every year. In 2014, during the follow-up, he showed a new calcitonin increase (108 pg/mL). 18-F-DOPA PET confirmed the presence of right paratracheal lymph node hyperactivity. A VI level revision lymphadenectomy was performed and histology confirmed the MTC lymph node recurrence. The patient continued the followup with the evidence of a slow but continuous increase of serum calcitonin levels from 2017 to 2021 with no evidence of detectable recurrence at imaging both in the neck and the body. In 2021 the patient showed a sudden and huge increase of serum calcitonin level (1119 pg/dL) with 18-F-DOPA PET positive for a left axillary metabolic hyper-activity with no other metastases evidence in the body (Figure 1). A left radical axillary lymphadenectomy was carried out. Histology confirmed ALN metastases from MTC into two out of twenty-one lymph nodes excised. After a first dramatic drop, in February 2022 the patient showed a new serum calcitonin level rise (73,8 pg/mL), confirmed by the exams of September 2022 (245,8 pg/mL). In December 2022 18-F-DOPA PET showed a posterior and right to the trachea hyper-activity area, at the D2- vertebra level, compatible with a neck lymph node recurrence (Figure 2). After a multidisciplinary discussion including surgeons, radiologists, and oncologists, in consideration of the elder age of the patient, his co-morbidities, and his will, the patient neither started any chemotherapy nor underwent any kind of surgery.

 

Figure 1: 18-F-DOPA PET showing the presence of a hyperactivity into the left axilla.