Gastric metastasis presenting as an overt upper gastrointestinal bleeding treated with chemoembolisation in a patient diagnosed with papillary thyroid carcinoma

Abstract

We present a case of a patient with known papillary thyroid carcinoma presenting with overt upper gastrointestinal bleeding from a metastatic gastric mass. The gastric mass was diagnosed through transnasal endoscopy with tissue biopsies, revealing papillary thyroid carcinoma cells on histopathological studies. Bleeding was persistent despite standard medical therapy. Chemoembolisation of the major feeding vessels of such tumour provided resolution of bleeding.

Background

This is a case of a papillary thyroid carcinoma (PTC) metastasis to the stomach presenting as a persistently bleeding solid mass treated and palliated with chemoembolisation. This case reports the possibility of PTC metastasising to the stomach, presumably through the lymphatics and highlights the efficacy of chemoembolisation as a palliation therapy for tumorous bleed with this type of gastric mass.

Case presentation

Our patient is a diagnosed case of PTC since 2013 that presented as a palpable anterior neck mass. She underwent a series of surgeries (from subtotal thyroidectomy (2013) to completion total thyroidectomy (2014) for tumour recurrence) with samples sent for excision histopathology. A completion thyroidectomy was done due to a new onset palpable anterior neck mass, which was reported by the patient to be a new onset focus suspicious for malignancy on the remaining thyroid lobe on repeat ultrasound imaging. There were no documented lymph node metastases on both these two surgeries. The results of the pathological examinations for both surgeries were compatible with classical PTC. Radioactive iodine (RAI) therapy in a different institution was done after the operation in 2013 (130 mCi) followed by another session in 2014 (150 mCi). In her post-therapy scan, lung metastases were already noted. She developed post-procedural hypothyroidism after these therapies. Her last RAI therapy was allegedly showing poor iodine uptake and she was advised for possible chemotherapy with kinase inhibitor but the patient was lost to follow-up. Her thyroglobulin levels were unmonitored during this time. The patient developed dysphagia over time. She was on maintenance hormone replacement with levothyroxine as previously prescribed and on mechanically soft diet as tolerated around this time.

Early 2018, she was once again diagnosed with tumour recurrence that presented as a palpable neck mass at the previous surgical site bed and scar. On consult with her endocrinologist, further imaging, metastatic work-up and proceeding with the previous aforementioned kinase inhibitor therapy were advised yet patient opted not to proceed for personal reasons. The patient, once again, was lost to follow-up. In the interim, she was experiencing intermittent passage of black tarry stools and abdominal pain relieved by intake of pain reliever prescribed to her from previous consults. She did not report of hematemesis, coffee ground vomiting, jaundice and fever.

Late 2019, she began presenting with symptoms of easy fatigability, pallor, progressive weight loss and persistent intermittent melena. These symptoms prompted her to seek consult with a gastroenterologist. Series of laboratories were done including a complete blood count revealing anaemia (haemoglobin level of 79 g/L). She was admitted for blood transfusion and endoscopy.

On admission, the patient was seen awake, ambulatory yet weak looking. She was pale with dyspnoea on minimal exertion. Physical examination was remarkable for pallor, tachycardia and a digital rectal examination of dark brown stools with black particles. She underwent blood transfusion of packed red blood cell and advised further testing.

Investigations

A repeat complete blood count revealed a haemoglobin value of 79 g/L and a hematocrit of 26%. Baseline electrolytes, liver functions tests and bilirubins were unremarkable. Coagulation parameters were within acceptable limits. Her serum albumin was low.

An upper endoscopy via a transnasal route was scheduled. On endoscopy, a polypoid solid bulky mass with irregular amorphous non-friable overlying mucosa was seen (figure 1). This was seen compressing the gastro-oesophageal junction, which can explain for the patient’s dysphagia. Multiple biopsy samples were taken for histopathology which revealed features consistent with PTC (figure 2).

Figure 1.

Endoscopic Images taken using Olympus Ultrathin scope through the transnasal route. (A) Gastric mass seen at the gastric fundus on retroflexed view. Closer view of the mass: (B) under white light endoscopy; (C) under narrow band imaging.

Figure 2.

Histopathological photomicrographs of gastric mass tissue samples taken through endoscopy: (A) low-power magnification; (B) high-power magnification. Grossly, the specimen received in formalin consists of seven white, soft tissue fragments measuring 0.1 cm in aggregate diameter. Microscopic examination shows complex, branching papillae with fibrovascular cores in a background of fibromuscular tissue fragments. The papillae are lined by cuboidal cells with moderate eosinophilic cytoplasm exhibiting nuclear enlargement, crowding, overlapping and pleomorphism. These nuclei show finely dispersed to clear, ground glass chromatin. Some cells exhibit redundancy in the nuclear membranes exhibited by longitudinal nuclear grooves.

The patient subsequently underwent abdominal and chest CT scans to further investigate the extent of the mass and assess for further intra-abdominal and intrathoracic metastasis. Significant findings were a fairly defined, mixed attenuating heterogeneously enhancing mass at the gastrosplenic region measuring 8.8×8.9×7.6 cm (figure 3) and multiple lung masses consistent with metastasis. She reported episode of headaches and a cranial CT scan with contrast was done revealing a large lesion measuring 4.2×4.7×5.6 cm at the right parietal lobe. Her thyroglobulin levels were elevated at 514.04 ng/mL.

Figure 3.

CT scan imaging of the abdomen with contrast showing a fairly defined, mixed attenuating, heterogeneously enhancing mass at the gastrosplenic region measuring 8.8×8.9×7.6 cm (as pointed by the red arrow).

Treatment

During the course of her admission, she had persistent melena refractory to standard therapy. She had multiple blood transfusions. The patient was subsequently referred to general surgery, nuclear medicine, radiation oncology and interventional radiology for palliation of bleeding. Initial plans for bleeding palliation included surgery, radiation therapy, feeding vessels chemoembolisation or a combination of all modalities.

A multidisciplinary conference was done to determine the most optimal palliation modality for the bleeding. Due to the degree of metastasis and unresectability of the gastric mass, no further surgical interventions were deemed appropriate by the general surgery service. Due to contrast use during CT imaging, theoretically decreasing radioactive iodine intake by the gastric mass cells, RAI therapy was deemed only effective by the nuclear medicine service if done after 3–6 months from contrast use. This option was not considered. Chemoembolisation of the mass was then considered.

The patient eventually underwent bland embolisation with polyvinyl alcohol particles (350–500 µm) of approximately 70% of the gastric mass. This was done by the interventional radiology service.

Outcome and follow-up

After chemoembolisation, melena had not recurred, haemoglobin values were on a stable trend and symptoms of anaemia resolved. The patient was discharged, improved and stable. Future plans for the patient was palliative in nature: referral to hospice for end-of-life care and possible future referral to pain services for pain control/palliation.

On follow-up at the outpatient department 3 months post discharge, the patient reported no signs of gastrointestinal bleeding and was generally well.

Discussion

PTC is the most frequent type of thyroid malignancy accounting for 80% of all cases.¹ Usual areas of metastasis include the loco-regional lymph nodes. Distant metastases are rare and if such occurs, usually involve the lungs, liver, bones and brain.² This report shows a rare case of PTC metastasising to the stomach that presented with bleeding and its subsequent management.

PTC and documented metastasis

PTCs are typically non-aggressive tumours with a good survival rate approximating 100% for stage I diseases.³ These tumours most often show an indolent clinical course, with localised disease as a general pattern, and typically do not recur or metastasise beyond local lymph nodes.⁴ PTC is most often than not, curable with complete tumour excision through thyroidectomy.

Yet with every rule is an exception. Distant metastases have been documented for PTC. The most common site of distant metastases is the lung, followed by the bone with other distant metastases being rare or relatively rare—those involving the brain, breast, liver, kidney, muscle and skin.^{2 5–12} The presence of distant metastases is the most significant poor prognostic factor for survival, with only 50% of patients with metastasis surviving beyond 10 years.¹³

Gastric metastasis

The stomach has rarely been identified as a metastatic site for PTC. No case reports have been published on PTC as a stand-alone pathology metastasising to the stomach.

A case of gastric metastasis, yet only through the perigastric lymph nodes, was reported by Jeong et al.¹⁴ This was a case of a patient with perigastric lymph node metastatic PTC and concomitant poorly differentiated tubular adenocarcinoma of the stomach. The presence of the metastatic lymph node disease was an incidental finding from the lymph nodes removed together with the gastric mass as part of the overall management for the mass. This patient underwent laparoscopy-assisted distal gastrectomy, loop gastrojejunostomy and D2 lymphadenectomy for gastric cancer.

One study had presented gastric metastasis of PTC with concomitant poorly differentiated thyroid carcinoma (PDTC) presenting as a proximal stomach nodule. A case study by Hernandez et al⁴ presented a case of a patient diagnosed with PTC who underwent upper endoscopy due to development of post-cricoid oesophageal stricture. Endoscopy revealed a suspicious gastric nodule that turned out to be metastatic PTC with focal dedifferentiation to PDTC within gastric mucosa.

It is presumed that the route of metastasis by PTC in general is still through lymphatic spread. It is presumed that perigastric lymph nodes with eventual mass extension or infiltration were the means to access the gastric parenchyma in the case presented.

Chemoembolisation as palliation of tumour bleed from metastatic PTC

To date, no case reports has been published presenting chemoembolisation as an effective therapy in abating tumour bleed from metastatic PTC of the stomach.

In this case, CT examination revealed a hypervascular mass in the left upper quadrant supplied by the left gastric artery, left inferior phrenic artery and tiny branches of the splenic artery. A French 2.7 Progreat microcatheter was used to super-selectively catheterise the left gastric and left inferior phrenic arteries. Embolisation was done using polyvinyl alcohol particles (350–500 µm), until satisfactory devascularisation was achieved. The small feeding arteries from the splenic artery were not embolised.

RAI therapy for metastatic PTC

Low-dose whole body iodine scan may be done to assess both the extent of the metastases and the possible role of RAI in management. However, if on assessment that the patient appeared to have RAI-refractory PTC and if still deemed to be necessary, kinase inhibitors would be the next option.¹⁵

Patient’s perspective.

I have always considered my condition a hopeless case and that my time is numbered. But despite such outlook, I continue to live as normal as possible. I presented with signs of bleeding from my stomach and I was keen on knowing what the source was. Knowing that the source of bleeding was actually a metastasis from my thyroid cancer was not something unexpected to me. Yet, knowing that this was actually a rare phenomenon and was something that can be reported had given me optimism. I believe that through sharing this case of mine, physicians will be aware that gastric metastasis from a thyroid cancer is feasible and that appropriate surveillance be instituted to other patients who suffer the same condition as mine. I consider this as my legacy—I may pass yet I leave a mark that can maybe make a difference.

Learning points.

• Papillary thyroid carcinoma can spread to the stomach despite the degree of distance between the affected organs.

• Endoscopy with biopsy among patients with gastric masses will aid in determining if the mass is of primary gastric origin or a part of a metastatic process in those with pre-existing malignancy.

• Chemoembolisation has been an effective therapy for tumorous bleeding palliation in this given case.