Metastasis of esophageal squamous cell carcinoma to the thyroid gland with widespread nodal involvement: A case report

DISCUSSION

Although rare, esophageal MTG does occur. Physicians should keep in mind that it is necessary to perform further examinations of the cervical region when malignant, multifocal lesions in the thyroid gland are noted. MTG needs to be considered as a differential diagnosis, even in patients with no prior history of malignancy. MTG is generally regarded to result from the spread of a primary tumor by a hematogenous route. Despite its rich blood supply, the thyroid is a rare site for metastatic disease. This phenomenon is due to fast arterial flow that prevents cancer cell adhesion, and the high oxygen saturation and iodine content of the thyroid gland inhibit the growth of malignant cells[3]. The incidence of MTG is low and amounts to 2%-3% of all malignant tumors of the thyroid[5]. The most common primary malignancies that can metastasize to the thyroid gland are renal cell cancer, followed by lung cancer and breast cancer[6]. MTG from esophageal cancer is extremely rare, and only a few sporadic cases have been reported in the literature thus far[7-10]. To our knowledge, there has been no reported case of metastasis of esophageal cancer to the thyroid gland and widespread involvement of distant lymph nodes at the same time.

Metastatic disease that involves the thyroid gland may pose a diagnostic challenge. At presentation, MTG may share similarities with primary thyroid tumors, and most patients are asymptomatic[11]. MTG may be the sole presentation, without any primary tumor-related symptoms or previous malignancy history. This patient with MTG lacked symptoms of advanced-stage esophageal cancer like dysphagia, weight loss, and chest pain. The thyroid masses and neck nodal involvement were the only positive findings at the initial imaging and physical examination before the surgery. The fine needle aspiration cytology did not reveal MTG as well. Preoperative fine needle aspiration cytology is a reliable approach to establish the diagnosis. However, it has limitations with regard to distinguishing MTG from primary thyroid carcinoma. Therefore, this disease can confuse surgeons and masquerade the primary thyroid cancer metastases to cervical lymph nodes. Even after the thyroidectomy, the permanent section showed MTG. It was not an easy task to determine the primary tumor, and the work-up diagnostic procedures helped locate the primary tumor.

After all other routine examinations are negative for the primary tumor, FDG-PET-CT usually is the final resort; in some patients, the primary tumors cannot be found[4]. Although the indication of surgery for metastatic thyroid carcinomas is uncertain and does not impact overall survival, in some patients with MTG, a total thyroidectomy is warranted[12-14]. Especially for MTG multifocal disease, a total thyroidectomy should be considered and may achieve control of the central neck[6]. Furthermore, definitive histology by surgical excision may be required to confirm the diagnosis[15].

The differential diagnoses of MTG of ESCC include primary squamous cell carcinoma (PSCC) of the thyroid and mucoepidermoid thyroid carcinoma (MEC). PSCC of the thyroid resembles anaplastic thyroid carcinoma in clinical presentation. Patients with PSCC of the thyroid present with rapidly increasing neck mass invading the adjacent structures. Besides patients’ history, immunohistochemical panel is useful in diagnosing MTG. PSCC as well as squamous carcinoma component in association with other thyroid carcinomas have been shown to be positive for paired box gene 8 (PAX-8) protein[16]. Like anaplastic thyroid carcinoma, PSCC shows a high frequency of P53 overexpression[17]. In this case, PAX-8 and P53 were negative. The microscopic features of multifocal tumor nests along the vessels found in this case indicate MTG as well. The immunohistology characteristics of MEC generally demonstrate positive for thyroid transcription factor-1 (TTF1) and thyroglobulin. In this case, TTF1 and thyroglobulin were both negative. Furthermore, the immunohistochemical staining was positive for CK5/6 and P40. Combined with the results of FDG-PET-CT and esophagogastroscopy, the diagnosis of MTG from ESCC was confirmed.

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— Update: 25-12-2022 — We found an additional article Thyroid Cancer and Hypertension: Causes and Treatments from the website www.verywellhealth.com for the keyword esophageal and thyroid cancer linked to hypertension.

Hypertension (high blood pressure) is one of the common effects of thyroid cancer. If you have or have had thyroid cancer, there is a lasting risk of developing hypertension even after the cancer is fully treated.

The long-term effects of high blood pressure produce a number of health problems over time, including increased strokes, heart attacks, kidney disease, and dementia.

Thyroid Cancer and Hypertension

All thyroid cancers can increase or decrease the production of your thyroid hormones. Cancer can be associated with symptoms or the development of hyperthyroidism (overactivity of thyroid hormones) more than with hypothyroidism (under activity of thyroid hormones).

Hyperthyroidism results in increased metabolism and usually causes increased blood pressure. In contrast, hypothyroidism is usually associated with normal blood pressure, but it can cause low blood pressure or high blood pressure.

The reasons are complicated: Thyroid hormones act directly on blood vessels throughout the body to reduce contractility (make them less flexible), which increases blood pressure. However, blood vessels can develop increased or decreased sensitivity to thyroid hormones, making the response to altered thyroid hormone levels somewhat variable.

Keep in mind, a majority of patients diagnosed with thyroid cancer have neither hyperthyroidism or hypothyroidism.

Often, a nodule, growth, or goiter can be the first sign of thyroid cancer. Other symptoms include weight changes, fatigue, or agitation. Rarely, however, it’s unexplained hypertension, that prompts a thyroid function evaluation and may lead to a diagnosis of thyroid cancer. This is especially true if high blood pressure begins at an unusually young age or is not easily managed with medication.

The Impact of Thyroid Cancer Treatment

There are a number of treatment strategies used for thyroid cancer, including chemotherapy, radiation, surgery, and thyroid replacement medications after treatment. These approaches, while necessary, can independently induce hypertension.

Chemotherapy

Several of the chemotherapeutic medications used for thyroid cancer have been shown to cause high blood pressure. Pazopanib, cabozantinib, and vandetanib are all classified as tyrosine kinase inhibitors, a common type of chemotherapy, and they have all been linked to hypertension when used for the treatment of thyroid cancer. The exact mechanism of this effect is not known.

Surgery

Surgical treatment for thyroid cancer has also been associated with hypertension. There are several known reasons for this reaction. Removal of the thyroid gland stimulates an increase in thyroid stimulating hormone (TSH), which can cause overproduction of thyroid hormones from the remaining thyroid gland. In some instances, a condition called thyroid storm can occur, which is a severe rise in thyroid hormones that can cause a sudden increase in metabolism and blood pressure.

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Thyroid Replacement Medications

After recovery from thyroid cancer, you may need to take thyroid hormone replacement medications, especially if you have had surgery or radiation. Generally, thyroid hormone replacement is aimed at achieving optimal thyroid function. However, excess thyroid hormone replacement can induce hypertension, while inadequate levels of thyroid hormone replacement can cause your body to overcompensate, possibly producing hormones (such as adrenal hormones) that trigger hypertension.

Verywell / Emily Roberts

Over time, your thyroid replacement medication can be adjusted so that you can get just the right amount of thyroid hormone.

Recognizing and Treating Hypertension

Hypertension does not usually cause any symptoms unless there is a hypertensive crisis, which is rare. Given this, it’s unlikely you’ll notice any warning signs. Many, in fact, are surprised to learn of the diagnosis after their healthcare provider uses a blood pressure cuff during a physical examination as a matter of routine.

Your healthcare provider may also recommend that you monitor yourself at home, especially if you have other hypertension risk factors. You can purchase a blood pressure cuff for self-checks or visit a local pharmacy or community center, which may have one available for you to use.

If you are diagnosed with hypertension, there are effective prescription medications that can control your blood pressure.

Because thyroid disease, thyroid treatment, and thyroid replacement medications can all interfere with your blood pressure, you may need the dose of your blood pressure medication adjusted as your thyroid function changes during your cancer treatment and after your recovery.

Tracking your blood pressure and strategically timing your hypertension medication are helpful strategies for ensuring you stay in your goal blood pressure range.

Prognosis

If you have thyroid cancer, you are at an increased risk of developing hypertension even after you've been successfully treated. People who were 40 or older when diagnosed with thyroid cancer, for example, are about 46% more likely to develop hypertension.

Uncontrolled hypertension can put you at greater risk for serious conditions like coronary artery disease, stroke, heart failure, and dementia. This is why it's important to make sure you have your blood pressure checked regularly. If you do have high blood pressure, make sure to work with your healthcare provider to control it. 

A Word From Verywell

Hypertension is very common, but if you have or have had thyroid cancer, you have an even greater chance of developing the condition.

If you are recovering from thyroid cancer, it is a good idea to familiarize yourself with the most updated recommendations for your target blood pressure so that you can let your healthcare provider know right away if your blood pressure changes.


— Update: 25-12-2022 — We found an additional article Endocrine and Thyroid Cancer Symptoms, Diagnosis, and Risks from the website hillman.upmc.com for the keyword esophageal and thyroid cancer linked to hypertension.

Some endocrine cancers share common symptoms and signs. But, most types cause symptoms that affect the functions of the associated gland or nearby structures.

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Benign and cancerous tumors can cause similar symptoms.

UPMC Hillman Cancer Center specialists have experience in finding the cause of endocrine symptoms.

We’ll confirm whether your endocrine tumor is cancerous or non-cancerous. Then we’ll devise a treatment plan that works for you.

Common Symptoms of Endocrine Cancers

Adrenal cancer symptoms

  • Belly pain
  • Diabetes
  • Excessive hair growth
  • Excessive sweating
  • Headache
  • Heart palpitations
  • High blood pressure
  • Libido changes
  • Low potassium levels
  • Unexplained weight changes
  • Weakness

Pancreatic neuroendocrine cancer symptoms

Symptoms may differ depending on the site and cell type of the cancer.

They may include:

  • Belly pain
  • Bloating
  • Change in stool color or blood in the stool
  • Diarrhea
  • Heartburn
  • Heart palpitations
  • Jaundice
  • Low blood sugar levels
  • Nausea or vomiting
  • Rash
  • Rectal pain
  • Unexplained weight loss

Parathyroid cancer symptoms

These symptoms are the same as hyperparathyroidism symptoms, making a precise diagnosis crucial:

  • Bone pain
  • Confusion
  • Constipation
  • Depression
  • Excessive urination
  • Fatigue
  • Gastroduodenal ulcers
  • Kidney stones
  • Lump in the neck
  • Memory loss
  • Osteoporosis/osteopenia

Pituitary cancer symptoms

  • Excess growth hormone (acromegaly)
  • Cushing’s syndrome
  • Fatigue
  • Headache
  • Impotence
  • Infertility
  • Menstrual abnormalities
  • Mood changes
  • Vision problems
  • Unexpected lactation

Thyroid Cancer Symptoms and Signs

A thyroid cancer diagnosis most often occurs after doctors find a thyroid nodule by touching the neck or from imaging scans.

Symptoms are rare, but some symptoms in both benign and cancerous thyroid conditions may include:

  • Breathing problems
  • Trouble swallowing
  • Hoarseness
  • Lump in the front of the neck
  • Pain in the throat or neck
  • Swollen lymph nodes/glands in the neck

Endocrine Cancer Risk Factors

Doctors don’t know what causes endocrine cancer in every case, but they link some conditions or factors with increased risk.

Endocrine cancer risk factors vary based on the affected gland or system.

Adrenal cancers may be hereditary and doctors associate risks with:

  • Carney complex
  • Hereditary paraganglioma syndromes
  • Li-Fraumeni syndrome
  • Multiple endocrine neoplasia types 1 and 2
  • Neurofibromatosis type 1
  • Von Hippel-Lindau syndrome

Pancreatic neuroendocrine cancers can be hereditary and risks may include:

  • Multiple endocrine neoplasia type 1 (MEN1)
  • Von Hippel-Lindau syndrome

Other neuroendocrine cancer risk factors differ based on the subtype of disease, but — in general — can include:

  • Age over 70 (Merkel cell carcinoma)
  • Sun exposure (Merkel cell carcinoma)
  • Arsenic exposure
  • Compromised immunity (from HIV or anti-rejection drugs after transplant)
  • Being male

Parathyroid cancer risk factors are mostly genetic:

  • Familial isolated hyperparathyroidism
  • MEN1

Pituitary cancer risk factors are also genetic:

  • Carney complex
  • McCune-Albright syndrome
  • MEN1
  • Multiple endocrine neoplasia type 4

Endocrine cancer prognosis depends on a range of factors:

  • Age
  • Type of endocrine cancer
  • Functioning or non-functioning tumor status
  • Basic health
  • Response to treatment
  • Stage at time of diagnosis
  • Tumor size

Thyroid Cancer Risk Factors

Childhood exposure to radiation of the head and neck increases the risk of thyroid cancer.

Some hereditary disorders can also increase thyroid cancer risk:

  • Carney complex
  • Cowden disease
  • Familial adenomatous polyposis)
  • Familial medullary thyroid cancer
  • Multiple endocrine neoplasia type 2A
  • Multiple endocrine neoplasia type 2B

Thyroid cancer prognosis depends on factors such as:

  • Age
  • Functioning or non-functioning tumor status
  • Basic health
  • Response to treatment
  • Stage at time of diagnosis
  • Tumor size

Contact Us About Endocrine and Thyroid Cancer Symptoms

To learn more about endocrine and thyroid cancer symptoms and treatment at UPMC Hillman Cancer Center, call 412-647-2811. Or, complete an endocrine and thyroid cancer contact form.

References

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