AACE ePoster Library

UVEAL MELANOMA MASQUERADING AS A NON-TOXIC MULTINODULAR GOITER
AACE ePoster Library. Thanadar R. 05/13/15; 97822; 1010
Dr. Rokshana Thanadar
Dr. Rokshana Thanadar
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Abstract
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Objective: Increase awareness of thyroid nodules in patients with previous malignancies and to consider metastases.
Introduction: An 86 year old white female with a history of hypothyroidism, mild cognitive impairment, and osteoporosis, was found, on routine eye exam, to have a retinal detachment secondary to choroidal melanoma. She was treated with γ-knife radiosurgery. During evaluation, an MRI was done which demonstrated bilateral thyroid nodules, the largest of which were > 3 cm. Her first FNA was non-diagnostic. FNAs on the dominant nodules in both lobes were repeated two more times due pathology returning as indeterminate and non-diagnostic. The final set of FNAs demonstrated malignant cells in the right nodule. Subsequent immunohistochemical staining was consistent with malignant melanoma. FDG PET scan was also consistent with malignancy in the right thyroid lobe as well as metastases to the liver, axial, and appendicular skeleton and MRI of the brain demonstrated metastases.
PE, Labs, and Imaging: Patient clinically euthyroid with reported no visual disturbances. She did have a history of large moles on her back. There was no history of previous head or neck radiation or family history of thyroid cancer. Her most recent TSH was 1.64uIU/mL. Immunohistochemistry done was positive for melanin A, Mart-1, MSA, SOX10 and negative for S100, pankeratin, TIF-1, calcitonin. BRAFV600A was not performed due to insufficient numbers of available tumor cells. Thyroid ultrasound reported the following, nodules measured in right lobe, 1. 14x10x8mm; 2. 8x10x8 mm; 3. 34x24x21mm; 4. 13x11x6mm, nodules in the left lobe 1. 12x9x6mm; 2. 11x8x7mm; 3. 34x19x25mm; 4. 12x7x7mm and in the isthmus nodule was 9x8x5mm. All were vascular.

PET/CT scan- Intense FDG uptake in right thyroid lobe is suspicious for malignancy. Intense uptake in the left posterior fossa correlates with an enhancing mass described on MRI and suspicious for malignancy. Multiple focal areas of intense uptake in the liver, axial, and appendicular skeleton are suspicious for metastatic disease. Focal uptake in the right lobe of the thyroid associated with a larger hypodense lesion on CT.

Discussion: We present a case of a woman with a unique presentation of malignant uveal melanoma and new thyroid nodules. Thyroid nodules are commonly seen and generally benign; however, 5-10% are malignant with <2% due to metastatic lesions. Prevalence at autopsy appears to be higher, with an incidence of 1.25-24.4%. Metastases to the thyroid is generally associated with RCC, but also seen with breast, lung, GI, hematologic cancers as well as melanoma and sarcoma. Malignant melanomas account for ~ 4% of thyroid metastases. Even more unusual are uveal melanomas that metastasize with incidence between 0.75 – 3%. Metastasis is typically to the liver, and search of the English literature showed only four other cases of metastasis to the thyroid reported. Metastatic melanoma is an ominous sign and carries a grim prognosis, with time between diagnosis and death 6-12 months. Metastases to the thyroid may occur at the same time as metastases to other areas or many years after the original diagnosis. Generally patients with metastatic melanoma have normal thyroid function and asymptomatic with metastases discovered incidentally during screening or surveillance exams.

Conclusion: This case demonstrates the need to consider new thyroid nodules in a patient with a history of cancer to be recurrence until proven otherwise. It also demonstrates the importance of performing FNA in any patient with a new thyroid mass and a history of malignancy and to do immunohistochemical staining at the time of the FNA for markers associated with a patient’s known malignancy.
Objective: Increase awareness of thyroid nodules in patients with previous malignancies and to consider metastases.
Introduction: An 86 year old white female with a history of hypothyroidism, mild cognitive impairment, and osteoporosis, was found, on routine eye exam, to have a retinal detachment secondary to choroidal melanoma. She was treated with γ-knife radiosurgery. During evaluation, an MRI was done which demonstrated bilateral thyroid nodules, the largest of which were > 3 cm. Her first FNA was non-diagnostic. FNAs on the dominant nodules in both lobes were repeated two more times due pathology returning as indeterminate and non-diagnostic. The final set of FNAs demonstrated malignant cells in the right nodule. Subsequent immunohistochemical staining was consistent with malignant melanoma. FDG PET scan was also consistent with malignancy in the right thyroid lobe as well as metastases to the liver, axial, and appendicular skeleton and MRI of the brain demonstrated metastases.
PE, Labs, and Imaging: Patient clinically euthyroid with reported no visual disturbances. She did have a history of large moles on her back. There was no history of previous head or neck radiation or family history of thyroid cancer. Her most recent TSH was 1.64uIU/mL. Immunohistochemistry done was positive for melanin A, Mart-1, MSA, SOX10 and negative for S100, pankeratin, TIF-1, calcitonin. BRAFV600A was not performed due to insufficient numbers of available tumor cells. Thyroid ultrasound reported the following, nodules measured in right lobe, 1. 14x10x8mm; 2. 8x10x8 mm; 3. 34x24x21mm; 4. 13x11x6mm, nodules in the left lobe 1. 12x9x6mm; 2. 11x8x7mm; 3. 34x19x25mm; 4. 12x7x7mm and in the isthmus nodule was 9x8x5mm. All were vascular.

PET/CT scan- Intense FDG uptake in right thyroid lobe is suspicious for malignancy. Intense uptake in the left posterior fossa correlates with an enhancing mass described on MRI and suspicious for malignancy. Multiple focal areas of intense uptake in the liver, axial, and appendicular skeleton are suspicious for metastatic disease. Focal uptake in the right lobe of the thyroid associated with a larger hypodense lesion on CT.

Discussion: We present a case of a woman with a unique presentation of malignant uveal melanoma and new thyroid nodules. Thyroid nodules are commonly seen and generally benign; however, 5-10% are malignant with <2% due to metastatic lesions. Prevalence at autopsy appears to be higher, with an incidence of 1.25-24.4%. Metastases to the thyroid is generally associated with RCC, but also seen with breast, lung, GI, hematologic cancers as well as melanoma and sarcoma. Malignant melanomas account for ~ 4% of thyroid metastases. Even more unusual are uveal melanomas that metastasize with incidence between 0.75 – 3%. Metastasis is typically to the liver, and search of the English literature showed only four other cases of metastasis to the thyroid reported. Metastatic melanoma is an ominous sign and carries a grim prognosis, with time between diagnosis and death 6-12 months. Metastases to the thyroid may occur at the same time as metastases to other areas or many years after the original diagnosis. Generally patients with metastatic melanoma have normal thyroid function and asymptomatic with metastases discovered incidentally during screening or surveillance exams.

Conclusion: This case demonstrates the need to consider new thyroid nodules in a patient with a history of cancer to be recurrence until proven otherwise. It also demonstrates the importance of performing FNA in any patient with a new thyroid mass and a history of malignancy and to do immunohistochemical staining at the time of the FNA for markers associated with a patient’s known malignancy.

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