P-66 A INSTANCE OF PAPILLARY THYROID CANCER MANIFESTED WITH SCAPULAR METASTASIS
Authors: Salva Hazal , Yavuz Dilek Gogas 
Published: January 2025

Abstract

Introduction
Bone metastasis of well differentiated thyroid tumors observed in 2% and 13% of the patients. Bone metastasis usually occurs mostly in spine, but also in extremities, rib cage and pelvic bones. Here we present a case differentiated thyroid cancer diagnosed with scapular bone metastasis.

Clinical Case
A 58-year-old male patient had pain on his left scapula that began a year ago. The intensity of the pain worsened over the months. It did not wake him up, but it worsened when he slept on his back. There was no history of trauma, shortness of breath, or pain while swallowing. Physical examination revealed soreness and abnormality at the lateral edge of the scapula. The thyroid gland was not palpable. He was diagnosed with benign prostatic hyperplasia. His family did not have a history of malignancy. He was a lifelong nonsmoker who consumed alcohol infrequently.
A magnetic resonance imaging (MRI) of the left shoulder was scheduled due to a suspicious tumor seen on shoulder x-ray imaging. An MRI revealed a 44x40 millimeter mass lesion, T1A hypointense and T2A hyperintense, superimposed on the body of the scapula, causing bone structural enlargement (Figure 1). A tru-cut biopsy was performed, and the pathology results were consistent with thyroid cancer metastases. Positron emission tomography/computed tomography was planned for further metastatic investigation; no new metastases were identified. Hemoglobin: 14.3 g/dL, platelets: 192x109/L creatinine: 0.85 mg/dL calcium: 9.13 mg/dL, AST/ALT: 14/13 U/L, TSH: 1.67 mIU/L, free T4: 0.94 ng/dL. Ultrasonography showed 16x8x8 mm hypoechoic solid nodule with microcalcifications was seen in the posterior of the left lobe and 7x6 mm hypoechoic solid nodule was seen in the posterior right lobe, and reactive lymph nodes smaller than 1 cm were discovered in the bilateral cervical chain. A fine needle aspiration biopsy of a thyroid left lobe inferior nodule revealed follicular neoplasm bethesda V. Total thyroidectomy was performed. Pathology report revealed papillary carcinoma with a classic+follicular pattern, localized in the right lobe, invasion of the tumor capsule, and multifocal intrathyroidal and lymphatic invasion were present. The mitotic index was 0–1/2 mm². The patient’s cancer stage was T1bNxM1, STAGE 4B according to thyroid cancer staging calculator. Risk score was evaluated as high according to American Thyroid Association.
Bone metastases received 30 GY of radiation over a 10-day period. 150 mci radioactive iodine therapy (RAI) was scheduled for two months after radiation treatment. Anti-thyroglobulin antibody 12.8 U/mL (0-115), thyroglobulin 0.0693 µg/L, TSH 0.013 mIU/L, and freeT4 1.28 ng/dL at fourth month following surgery under levothyroxin suppression medication.

Conclusion
Papillary thyroid cancer with bone metastasis shortens life expectancy. Total thyroidectomy, anti-resorptive bone agents, corticosteroids, RAI, metastasectomy, radiotherapy, tyrosine-kinase inhibitors are the treatment options.Figure1:44*40 milimeter mass lesion on scapula