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Ultrasound of metastatic thyroid cancer

Thyroid metastasis is an uncommon cause of thyroid malignancy.

1. Epidemiology

Thyroid metastases account for 1.4-3% of all malignancies.

Thyroid metastases have been reported in several types of cancer, most commonly renal, lung, breast, and colon carcinomas. Although very rare, these entities must be considered during the diagnosis of new thyroid nodules. No data are available on the performance of the ultrasound risk assessment system in patients with metastatic thyroid nodules.

To address this, we reanalyzed five cases of thyroid metastases referred to our unit for thyroid nodule assessment, retrospectively calculating the FNAC indication using four (AACE, ATA). , EU-TIRADS, K-TIRADS) among the most widely used ultrasound-based systems for this purpose.

2. Clinical case:

  1. Patient 1 is a 57-year-old woman who was followed up with 3 small, seemingly benign thyroid nodules, discovered in 2005. This patient underwent total right nephrectomy and right adrenalectomy in 2003 for carcinoma. clear cell kidney but follow-up evaluations for cancer are often negative. An ultrasound of the neck area performed in November 2012 showed the development of one of the three nodules [Hình. 1 (A)]. Given its sonographic features (Table 1), this nodule was FNAC, giving indeterminate results [Bethesda nhóm III, (ICTC) . Cắt toàn bộ tuyến giáp đã được thực hiện, và nốt này được chẩn đoán về mặt mô học là ung thư biểu mô tế bào thận di căn; hai nốt khác của bệnh nhân là lành tính.
  2. Bệnh nhân 2 là nam 69 tuổi bị ung thư biểu mô tuyến phổi đã trải qua phẫu thuật cắt thùy phổi phải vào tháng 3 năm 2013. Các xét nghiệm hình ảnh theo dõi [CT toàn thân và PET-CT không có gì đáng kể cho đến tháng 4 năm 2015, khi sự hấp thu FDG khu trú được ghi nhận ở thùy trái tuyến giáp. Năm 2005, bệnh nhân đã được điều trị một nhân tuyến giáp đang hoạt động mạnh bằng radioiodine và giữ trạng thái bình giáp kể từ đó. Bệnh nhân được giới thiệu đến đơn vị chúng tôi để đánh giá về nốt mới. Với kích thước và hình dạng siêu âm của nó [Bảng 1 và Hình 1 (B)], FNAC was performed. The lesion, which was apparently malignant (Bethesda group VI; ICTC TIR5), consisted of epithelial cells compatible with lung cancer. A total thyroidectomy was performed and the lesion was confirmed histologically as metastatic lung adenocarcinoma.
  3. Patient 3 is a 47-year-old woman with metastatic ductal carcinoma (estrogen and progesterone receptor positive). In 2005, she had a right mastectomy with ipsilateral lymph node dissection, followed by adjuvant chemotherapy. A blepharoplasty performed in 2010 revealed other metastatic nodes in the right axilla, and bone metastases were discovered shortly thereafter.
    These metastases were treated with several courses of chemotherapy. In 2014, a routine ultrasound by her oncologist discovered an unsuspecting, solitary nodule in the isthmus, which was being managed with ultrasound alone. A repeat ultrasound in November 2017, due to palpation of the neck mass, revealed three additional thyroid nodules (one in the right lobe; two in the left lobe) and one suspected right cervical lymph node [Bảng 1 và Hình 1 ( C) và 1 (D)]. FNAC of the right lymph node and thyroid nodule showed epithelial cells suggestive of metastatic breast carcinoma (Bethesda group VI; ICTC TIR5). Surgery — performed mainly for diagnostic purposes (node ​​biopsies, lobectomy), cytology revealed diffuse infiltrates of ductal breast cancer.
  4. Patient 4, a 39-year-old male, was referred to our unit by an otolaryngologist in November 2017 for evaluation of recent-onset dysphagia and a palpable left neck mass. Neck ultrasound revealed a highly suspicious nodule in the left lobe of the thyroid[Hình. 1 (E)], along with other small nodules and a suspected nodule in the right neck (group III). The FNAC of the left lobe thyroid nodule and the contralateral lymph node showed neoplastic epithelial cells suggestive of a primary non-thyroid malignancy. Due to these findings, thyroid surgery was deferred and a PET-CT scan was ordered. Focal absorption was seen in the esophageal wall, and the presence of esophageal adenocarcinoma was confirmed by endoscopic biopsy.
  5. Patient 5 is a 69-year-old man undergoing follow-up in the hematology outpatient clinic for cortical lymphoma. In February 2018, a palpable lymph node was noted in the lateral neck. Ultrasound showed an enlarged thyroid gland with hypoechoic nodules in each lobe. Multiple suspicious lymph nodes were observed bilaterally. The most suspected lymph node biopsy showed connective tissue and muscle infiltrate with malignant epithelial cells, extensive necrosis, and no lymphoid tissue. Immunohistochemical markers [dương tính với cytokeratin (CK) AE1 / AE3, CK8 / 18, CK19, CK7, và yếu tố phiên mã tuyến giáp-1; âm tính với CK20, napsin A, chromogranin A, thyroglobulin, melan-A, kháng nguyên đặc hiệu tuyến tiền liệt, acid phosphatase đặc hiệu ở tuyến tiền liệt, phân tử kết dính tế bào thần kinh, p63, p40 và synaptophysin] considered compatible with metastases from the lung or possibly malignant thyroid disease.
    FNAC of the left lobe thyroid nucleus [Bảng 1 và Hình 1 (F)], performed by our staff, showed melanoma (Bethesda group VI; ICTC TIR5) with poorly differentiated epithelial cells. Whole-body CT confirmed the presence of multiple solid nodules in both lungs, the largest of which was located at the apex of the left lung (33 × 24 mm).

Figure 1, Table 1.
Ultrasound images of metastatic lesions:

(A) metastatic renal cell carcinoma to the thyroid gland.

  • Ultrasound characteristics: Solid, heterogeneous (center of hypoechoic), even border. Dimensions: 9.5 × 8.7 × 17.5 mm.
  • Estimated risk of malignancy: AACE: Moderate; ATA: Medium; EU-TIRADS: 4 ; K-TIRADS: 4.

(B) Thyroid metastasis from lung adenocarcinoma.

  • Ultrasound features: Solid, hypoechoic, Irregular margins. Dimensions: 13.3 × 17.6 × 20.4 mm.
  • Estimated risk of malignancy: AACE: high; ATA: high; EU-TIRADS: 5; K-TIRADS: 5.

(C) thyroid metastasis and (D) Group 2 cervical lymph node metastasis from breast cancer.

  • Ultrasound features: Solid, hypoechoic, Irregular margins. Dimensions: 20.3 × 16.9 × 25.9 mm. A suspected ipsilateral lymph node.
  • Estimated risk of malignancy: AACE: high; ATA: high; EU-TIRADS: 5; K-TIRADS: 5.

(E) Thyroid metastases from esophageal cancer;

  • Ultrasound features: Solid, clearly hypoechoic, Irregular margins. Dimensions: 20.7 × 20.8 × 32.3 mm. Suspected lymph nodes (bilateral)
  • Estimated risk of malignancy: AACE: high; ATA: high; EU-TIRADS: 5; K-TIRADS: 5.

(F) Thyroid metastases from lung cancer.

  • Ultrasound features: Solid, clearly localized hypoechoic, irregular margins. Dimensions: 23 × 22 mm. Suspected lymph nodes (bilateral)
  • Estimated risk of malignancy: AACE: high; ATA: high; EU-TIRADS: 5; K-TIRADS: 5.



The most common sites of primary malignancy include (note these will vary by region):

  1. Kidney: Renal cell carcinoma (considered the most common)
  2. Lung
  3. Head, neck
  4. Breast
  5. Gastrointestinal: Esophageal cancer, Colorectal cancer, Stomach cancer
  6. Skin: Melanoma cell cancer
  7. Neuroendocrine tumor
  8. Bile duct cancer (rare)

Features of Diagnostic Imaging

Ultrasound of thyroid metastases usually has the following features:

  • Hypoechoic lesions with poorly defined margins (80%)
  • No calcification
  • Accompanied by enlarged cervical lymph nodes (80%)

** The possibility of metastasis must be considered in the differential diagnosis of any new thyroid nodule. This is especially true in patients with a history of cancer, regardless of how long ago the disease was diagnosed and the current state of the disease. However, as illustrated in cases 4 and 5, thyroid metastases can also be the first sign of unknown cancer.

The systems currently used to assess the possibility of malignancy on ultrasound in patients with thyroid nodules are useful, but based on sonographic features alone cannot distinguish primary and secondary malignancies. thyroid metastasis.
However, all four systems we tested consistently classified a patient’s metastatic lesions among those suspicious enough to warrant cytologic evaluation and, in most cases, In some cases, cytological findings provide useful guidance for subsequent management, highlighting the need for additional diagnostic procedures rather than immediate total thyroidectomy (method selected in case 1, where FNAC is ambiguous).


ICTC (Italian Consensus for Thyroid Cytopathology)

ATA (American Thyroid Association Guidelines).

AACE (American Association of Clinical Endocrinologists).

EU-TIRADS (European Thyroid Imaging Reporting and Data System).

K-TIRADS (Korean Thyroid Imaging Reporting and Data System).

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BS. Vo Thi Thanh Huong

Reference source:

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