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11 February 2015 - Case of the Week #342

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Case of the Week #342

Clinical History:
A 54 year old woman had two firm thyroid nodules, which were excised.

Micro images:

Frozen section slides

Permanent sections

What is your diagnosis?

Leiomyosarcoma (metastatic)

Tumor cells were immunoreactive (images not provided) for actin, desmin, caldesmon and vimentin, weakly positive for CD68 and had a proliferation rate of 28% with Ki67. They were negative for pan-keratin, TTF1, CD117/c-kit, S100, PAX8, CD34 and Factor VIII.

The tumor is composed of hypercellular fascicles of spindle cells resembling smooth muscle cells, with moderate to occasionally severe pleomorphism. Although mitotic figures are not numerous in the images, Ki67 shows a high proliferation rate of 28%. These histologic features, together with immunoreactivity for smooth muscle markers (actin, desmin, caldesmon) and the high Ki67 is characteristic of leiomyosarcoma. In this case, the patient was reported to have a uterine leiomyosarcoma removed two years prior.

Although the thyroid gland is very vascular, clinical metastases to this gland are uncommon, accounting for only 1-3% of thyroid malignancies (Head Neck Pathol 2009;3:217), usually from kidney, lung, breast, esophagus or uterus (Cancer 1997;79:574). In patients dying of cancer, 10-24% have metastases at autopsy in the thyroid gland. The differential diagnosis also includes direct extension of tumors from the pharynx, larynx, trachea, esophagus and neck, which are usually squamous cell carcinomas.

Metastatic leiomyosarcoma to the thyroid gland is very rare (Thyroid 2007;17:1295, Obstet Gynecol 2002;100:1122). The differential diagnosis includes the more common anaplastic carcinoma (Cancer 1988;62:2558). Excision of isolated metastases may be effective treatment.

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