A Rare Presentation of Autonomously Functioning Papillary Thyroid Cancer: Malignancy in Marine-Lenhart Syndrome Nodule

Abstract

Objective. Marine-Lenhart Syndrome (MLS) is defined as concomitant occurrence of autonomously functioning thyroid nodule (AFTN) with Graves' disease (GD). Malignancy in a functional nodule is rare. We aimed to present an extremely rare case of papillary thyroid cancer in a MLS nodule with lateral lymph node metastases. Case. A 43-year-old male presented with hyperthyroidism and Graves' ophthalmopathy. On Tc99m pertechnetate scintigraphy, a hyperactive nodule in the left upper thyroid pole was detected and the remaining tissue showed a mildly increased uptake. The ultrasonography demonstrated 15.5 × 13.5 × 12 mm sized hypoechoic nodule in the left upper pole of the thyroid and round lymph nodes on the left side of the neck. Fine needle aspiration biopsy (FNAB) of the nodule and lymph node revealed cytological findings consistent with papillary cancer. Total thyroidectomy with central and left modified radical neck dissection was performed. On pathologic examination, two foci of micropapillary cancer were detected. The skip metastases were present in three lymph nodes on the neck. Conclusion. AFTN can be seen rarely in association with GD. It is not possible to exclude malignancy due to the clinical and imaging findings. In the presence of suspicious clinical and sonographic features, FNAB should be performed.

Figure 1

Anterior views of technetium 99m scan demonstrate a normal size, v-shaped thyroid gland with a hot area in the left upper pole consistent with hyperfunctioning nodule. The remaining tissue showed a slightly increased uptake but not increased as expected in GD.

Figure 2

Thyroid ultrasound disclosed a hypoechoic nodule of 15.5 × 13.5 × 12 mm in size in the left upper pole, having irregular spiculated margins, and dense millimetric microcalcifications in the central area.

Figure 3

Transverse sonogram of left lateral neck demonstrates a 12 × 10 mm sized, rounded lymph node with internal cystic component and microcalcifications. The hilum of the lymph node could not be distinguished.

Figure 4

Orbital magnetic resonance imaging showed exophthalmos with enlargement of both eye muscles specially on the right.

Figure 5

Papillary microcarcinoma focus developed in the adenomatous hyperplasia, H&E, ×40.