Systemic Autoimmune Syndrome and Papillary Thyroid Cancer: Cause or Coincidence?

Program: Abstracts - Orals, Featured Poster Presentations, and Posters
Session: SUN 459-496-Thyroid Neoplasia & Case Reports
Clinical
Sunday, June 16, 2013: 1:45 PM-3:45 PM
Expo Halls ABC (Moscone Center)

Poster Board SUN-493
Monica G D Schwarcz*1 and Ioannis Tassioulis2
1New York Medical College, Scarsdale, NY, 2New York Medical College, Hawthorne, NY
Introduction:  Papillary thyroid cancer has been associated with tumor thrombi to deep veins but not with systemic autoimmune manifestations and/or hypercoagulable state. We report a case of systemic autoimmune syndrome that developed three months prior to diagnosis of papillary thyroid carcinoma.  The autoimmune syndrome included:  Raynaud’s phenomenon, symmetric polyarthritis, pneumonitis, positive rheumatoid factor and anti-Ro antibodies and thromboembolic disease characterized by multiple thromboses of deep veins in the lower and upper extremities.

Clinical Case: A previously healthy 53 year old male developed symmetric polyarthritis involving his wrists and small joints of the hands, bilateral Raynaud’s phenomenon and positive rheumatoid factor; diagnosed as rheumatoid arthritis and treated with glucocorticoids three months before admission to our hospital. He then developed a DVT leading to a pulmonary embolus. Despite treatment with glucocorticoids and systemic anticoagulation the patient progressed with worsening dyspnea and arthritis leading to an emergency department visit. Laboratory evaluation and imaging studies disclosed the presence of a new DVT in the upper extremity along with bilateral pneumonitis. Detailed serological evaluation showed positive high titer rheumatoid factor and anti-Ro antibodies; but was negative for ANA, anti-RNP, anti-Sm. Anti-La, anti-CCP, anti-MPO, anti-PR3, anti-cardiolipin, anti-b2-GPI and lupus anticoagulant. After infections were ruled out the patient was treated with plasmapheresis and immunosuppressive treatment, including high dose pulse glucocorticoids, cyclophosphamide and systemic anticoagulation, with excellent response.  Incidentally, during his hospitalization a right 3.3 cm thyroid nodule was discovered.

The right circumscribed thyroid nodule underwent UGFNA revealing a follicular lesion with a positive N-RAS mutation at codon 61 on genetic studies, an independent prognostic factor for aggressiveness of papillary thyroid carcinoma.  Total thyroidectomy revealed 2 foci of well differentiated follicular variant of PTC measuring 2.7cm and 1.6cm in greatest diameter.  In addition, multiple microcarcinomas in both thyroid lobes were described without lymphovascular invasion.  One metastatic level VI lymph node was identified.

Conclusion:  This is the first case demonstrating a possible association between a well differentiated papillary thyroid cancer and a systemic autoimmune syndrome.

Nothing to Disclose: MGDS, IT

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