Hurthle Cell Carcinoma presenting as acute vision loss

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

Poster Board SUN-469
Wenge Lu*1 and Julie Samantray2
1Wayne State University/Detroit Medical Center, Detroit, MI, 2Division of Endocrinology, Diabetes, and Metabolism. Wayne State University, Detroit, Michigan, United States
Background: Hürthle cells are follicular-derived epithelial cells with oncocytic cytology. Hürthle cell carcinoma (HCC) is considered a variant of follicular cell carcinoma. It has more aggressive clinical behavior, less ability to concentrate iodine and thus is often described as a separate entity from follicular thyroid cancer. Ocular metastases of thyroid carcinoma are uncommon. A PubMed search from 1977 to 2012 found only 32 cases, with only 2 case of Hürthle cell carcinoma. Among the 32 cases, only 4 cases, but not the Hürthle cell thyroid carcinoma, initially presented as eye metastasis. The ocular metastasis of Hürthle thyroid carcinoma is responsive to 125I radioactive plaque application but not 131I ablation, chemotherapy nor external beam irradiation.

Clinical Case: A 59 year old male with no known medical illness presented with acute onset of blurring of vision in the left eye. An ophthalmology evaluation showed hemorrhagic mass in the left eye overlying the optic disc and neovascularization of retina. The lesion was very vascular and appeared to have infiltrated choroid superonasal to the mass. There was a secondary retinal detachment due to marked vascular leakage from the mass. He was treated with Avastin Injections, with symptoms improved at the beginning but gradually got worse. Further work up revealed a large right thyroid mass (5.8 x 6.2 x 8.1 cm), bilateral pulmonary nodules, bony lesions in the thoracolumbar spine and ribs, and a spinal mass at L2. FNA exam of the thyroid mass was consistent with hurthle cell neoplasm. Biopsy of the pulmonary nodule revealed metastatic hurthle cell carcinoma. He underwent total thyroidectomy. Pathology confirmed hurthle cell carcinoma of the thyroid. Soon he developed severe pain over the left eye with complete loss of vision in that eye. Evaluation revealed neovascular glaucoma and exudative retinal detachment. Avastin was given, pain was improved within 48 hours, with decrease in intraocular pressures, but the vision didn't regain. He was given I 131 therapy, but post therapy scan revealed uptake only in the neck but not elsewhere. He was referred for brachyradiotherapy for the retinal lesion at another institute.

Conclusion: Our patient is the first documented Hürthle cell carcinoma with initial presentation as ocular metastasis. He gradually developed neovascular glaucoma, and complete loss of vision. Avastin treatment showed some effect, but only in pain control. Hürthle cell carcinoma with ocular metastasis had 131I refractory disease. Therefore, it is important to diagnose and treat Hürthle thyroid carcinoma as early as possible to prevent its devastating eye metastasis. Ocular metastasis of thyroid cancer is rare, and every case proves to be a learning experience.

Nothing to Disclose: WL, JS

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