Massive haemoptysis as an unusual symptom in a patient with papillary thyroid carcinoma

Introduction

The incidence of distant metastases is 10%, with pulmonary metastases being the most common [Shaha et al. 2001]. Radioiodine is the therapy of choice for radioiodine-avid distant metastatic thyroid carcinoma [Sabra et al. 2013].

Haemoptysis is considered to be a very unusual presenting complaint as most cases are usually asymptomatic.

Case history

A 29-year-old woman with papillary thyroid carcinoma (PTC) presented to our clinic with a 9-month history of cough with haemoptysis. Initially the production of fresh blood with cough was mild, with episodes occurring once or twice in a week. But over 5 days her haemoptysis had become massive and her cough had increased. On examination her pulse rate was 85 beats/min while her respiratory rate was 20 breaths/min and her blood pressure was 95/60 mmHg. The rest of her physical examination was unremarkable. Her laboratory reports showed decreased haemoglobin (9.1 mg/dl) and her haematocrit was 28.2%.

The patient previously underwent a left thyroid lobectomy, which on histopathology was reported to be a benign follicular adenoma. She returned a year later with an enlarged left lymph node and subsequently underwent a right thyroid lobectomy and a left modified radical neck dissection. The enlarged lymph node was diagnosed as ‘metastatic papillary carcinoma’ on fine-needle aspiration biopsy and histopathology. Surgery was followed by radioactive iodine treatment, which was performed four times. She was on a daily thyroxine dose of 150 µg.

Bronchoscopy was conducted which revealed a lobulated mass with a clot on it that was emerging from the medial segment of the right lower lobe. This was reported to be most probably an endobronchial metastatic lesion. An aspirate was sent for acid-fast bacilli smear and gram stain, and surgical resection of the right lower lobe was planned as a life-saving procedure to maintain a patent airway and prevent aspiration and further blood loss. A right posterolateral thoracotomy incision was made and the thoracic cavity was entered via the fifth intercostal space. The right lower lobe was dissected out and the vessels and bronchus to this lobe were clamped. A frozen section of the proximal margin of the bronchus showed it to be free of malignancy; this was later confirmed by the permanent section.

The removed lobe was sent for histopathology. Sections of the lobe revealed a neoplasm showing nodules of various sizes. These nodules were separated by thin fibrous septae. The cells had abundant eosinophilic cytoplasm with indistinct boundaries. Mitotic activity was also found. Sections from the margin of resection of the bronchus also showed infiltration by the tumour cells. These features were consistent with metastatic cancer of the thyroid.

Discussion

Patients with PTC are best treated with thyroidectomy and functional lymph node dissection, followed by radioiodine ablation. A post-treatment whole-body scan, along with thyroid-stimulating hormone (TSH) suppression is recommended. Detectable serum thyroglobulin (Tg) during TSH suppression (Tg-on) or Tg that rises above 2 ng/ml after TSH stimulation (TSH-Tg) are reliable indicators of residual tumour [Kloos, 2005].

Figure 1.

(a) Surgical technique and specimen. (b) Thyroglobulin immunohistochemical stain. Bronchial cartilage is seen at the upper right-hand corner.

Being a well differentiated tumour, PTC has a reasonably good prognosis; however there are several factors that determine survival. The Mayo Clinic defined prognostic factors as metastases, age, completeness of resection, invasion and size (MACIS). Completeness of resection is an important prognostic factor as the chances of local recurrence are extremely high if the entire gross tumour is not removed [Hay et al. 1993]. A long follow-up interval is required to assess treatment for well differentiated thyroid carcinoma because of its prolonged course and very slow growth rate. Iodine whole-body scanning and the determination of Tg levels are important procedures for the evaluation of such cases. Computed tomography is a useful addition to iodine whole-body scanning [Küçük et al. 2006]. The recommended treatment for lung metastases in PTC is radioactive iodine, which offers a fairly good prognosis.

In a retrospective study of 1516 patients with PTC, Lin and colleagues observed that 102 (6.7%) had lung metastases. The 10- and 20-year survival rates in such patients were 75.0% and 51.2% respectively [Lin et al. 2004]. A retrospective study of 90 patients by Ronga and colleagues analyzed the prognostic factors of lung metastases from differentiated thyroid carcinoma. Age at the time of cancer diagnosis has a considerable effect on survival rates. This was supported by the fact that all the patients considered free from disease were less than 45 years of age. Lesions with no ¹³¹I uptake always have a negative prognosis due to the lack of sensitivity to radiotherapy and chemotherapy. The percentage of survivors after 10 years was only 25% of the patients without ¹³¹I uptake versus 75% of those presenting metastases with ¹³¹I uptake. After 20 years, all patients with metastases not concentrating ¹³¹I had died versus less than 50% of those with metastases concentrating ¹³¹I. As far as the size of metastases is concerned, fine miliaric spread showed a better prognosis and longer survival time than the nodular type. The authors also concluded that histology and local lymph node involvement does not influence prognosis [Ronga et al. 2004]. A study conducted in Japan on death rate in patients with PTC showed age to be the strongest prognostic factor [Ito et al. 2012].

Lung metastases are mostly asymptomatic and haemoptysis is usually a symptom of laryngotracheal invasion. Laryngotracheal invasion by recurrent PTC is uncommon, occurring in 5.7–7% of cases [Datta and Lahiri, 2002]. Patients commonly present with symptoms like dysphasia, hoarseness, throat discomfort, dyspnoea and haemoptysis. Bronchoscopy is an effective means of establishing a diagnosis and should be considered as the first diagnostic procedure in a patient with a thyroid mass and haemoptysis [Weiland et al. 1989].

In case of the rare presentation of haemoptysis with lung metastases secondary to PTC, surgical intervention is the treatment of choice. This prevents suffocation due to bleeding or obstruction and offers a cure. Previously reported cases have been treated with surgical resection of the region of metastases [Chen et al. 1998]. In our case surgical removal was also performed as a life-saving intervention to secure the airway and prevent further complications.

If not caught and treated early and properly, PTC may metastasize to other organs such as the brain, lungs and skeletal muscles especially in the presence of poor prognostic factors and advanced patient age [Zhou et al. 2012]. Lung metastases are the most common but are mostly asymptomatic. This case serves as a reminder that lung metastases, especially endobronchial metastases, should be considered in such instances. It also confirms that surgical resection is the most appropriate treatment.