Lingual Thyroid Carcinoma with Nodal Metastasis

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Lingual Thyroid Carcinoma with Nodal Metastasis
Waldemar Riefkohl, MD and Thomas Kennedy,
MD Dept. of Otolaryngology HNS Geisinger
Medical Center
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Case Report

• 25 year old school teacher and aspiring singer
  was referred by an outside otolaryngologist in
  September 04
• June 03 - evaluation for abnormal menstrual
  cycle led to the diagnosis of hypothyroidism.
• April 04 - she noted a left upper neck mass that
  was not painful.
• Denied dysphagia, odynophagia, otalgia, dyspnea,
  hoarseness, hemoptysis and unplanned weight loss

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Case Report

• Antibiotics had no effect and CT was ordered by
  the PCP.
• Radiologic Testing (outside facility)
• CT with contrast was reported as normal
• Ultrasound of the neck - left upper cervical
  lymph node and small normally located thyroid
  gland
• MRI of the neck - left level II lymph node but
  otherwise normal.

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Case Report

• Referred to a local Otolaryngologist who
  proceeded with an excisional biopsy of the left
  neck mass.
• Diagnosis metastatic papillary thyroid
  carcinoma

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Case Report

• PMH Petite mal seizures, hypothyroidism
• Medications Depakote and Levoxyl
• Surgical History None
• Allergies None

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Case Report

• Family History
• Father has diabetes
• Mother in good health
• Brother and a sister with seizures
  Grandfather with thyroid problems
  Grandmother with parathyroid disease.
  Great aunt died from thyroid cancer

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Case Report

• Social History
• Spanish school teacher for the 6th- 8th
  grades. Loves to sing and is in the church
  choir Regularly requested to sing at weddings
  and other social events.
• Occasional alcohol
• Denies tobacco use

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Case Report

• Examination
• Oral clear, tongue mobile.
• Indirect exam cherry red spot at the
  tongue base
• left of
  midline, vocal cords mobile
• and without
  lesions.
• Palpation firm mass at tongue base
  (tender),
• bilateral cervical
  level IIA node LR,
• no obvious palpable
  thyroid gland
• no supraclavicular or
  paratracheal mass

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Case Report

• Thyroid scan

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Case Report

• Treatment Options
• Radioactive iodine ablation of primary tumor and
  cervical metastasis.
• Bilateral cervical node dissections followed by
  radioactive iodine.
• Surgical resection of all thyroid tissue followed
  by radioactive iodine.

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Lingual Thyroid with Papillary Carcinoma
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Lingual Thyroid with Papillary Carcinoma
(Follicular variant)
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Psammoma Bodies
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Cervical Lymph Node with Papillary Carcinoma
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Postop Treatment

• Post-op thyroglobulin 53.8 ng/ml (range 4-40
  ng/ml)
• Radioactive iodine - 101.5 mCi of I131 two months
  after surgery
• Follow up thyroglobulin body scan negative

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Lingual Thyroid Carcinoma

• Rare occurs in 1 of lingual thyroid (Jarvis
  1969)
• First 2 cases reported independently by Gunn and
  Rutgers in 1910
• 40 cases in the world literature to date (Perez
  2003)
• Histopathologic subtype
• Follicular carcinoma (predominating)
• Papillary
• Medullary and anaplastic not reported

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Lingual Thyroid Carcinoma

• First case report of lingual thyroid carcinoma
  with nodal metastasis in a female with no
  orthotopic thyroid gland
• First case report to shift the predominating
  histopathology from follicular to papillary
  carcinoma

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Lingual Thyroid Carcinoma

• Surgical excision of all thyroid followed by
  radioactive iodine ablation.
• Surgical approaches include lateral pharyngotomy,
  transoral, and trans-cervical supra or transhyoid
  approaches.
• Large lesions and poor medical risk patients may
  select single modality radioactive iodine.

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Conclusion

• Patient with lingual thyroid carcinoma with nodal
  metastasis
• Treated with surgical resection and radioactive
  iodine successfully
• The patient is currently two years since her
  surgery and free from disease.
• She continues to teach foreign languages and
  remains hopeful in becoming a professional
  singer.