PMC9889854_01
Examination and pathology of shoulder tumor. (A) The appearance of right shoulder. (B) The x-ray of the right humerus showed a vague high-density shadow with unclear boundary, and bone destruction near humerus and scapula. (C) Contrast-enhanced CT of the right humerus showed a soft mass replacing the normal bone structure with unclear boundary and dilated blood vessels. (D) No normal structure was found in the right humerus, shoulder joint and clavicle by MRI. T1 weighted image shows a mass with low signal intensity. T2 weighted image shows high signal intensity. (E,F) 18F-FDG PET/CT image showed that increased uptake in shoulder tumor (E) and the right supraclavicular fossa (F). (G) Needle biopsy of shoulder mass.
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F1
The movement of the right shoulder joint was obviously restricted (Figure 1A). IV segment of the right lateral neck (Figures 1B-D). In addition, multiple solid nodules in both lungs were found by lung CT (Figures 2A-C). The 18F-FDG PET/CT image also confirmed the above results (Figures 1E,F, 2D). The pathological result showed that the shoulder mass was a metastatic tumor, possibly originating from thyroid via immunohistochemistry analysis of tissue samples with CK (+), CK7 (+), Ki-67 (10%+), TTF-1(+), TG (+), HPC (-), AFP (-), Syn (-), CgA (-), SATB2 (-), CT (-), p53 (-), NapsinA (-), ER (-), PR (-), CDX2 (-) (Figure 1G).
Examination of lung. (A-C) High-resolution CT of pulmonary showed multiple solidity nodules. (D) 18F-FDG PET/CT images showed increased uptake in pulmonary nodules.
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F2
IV segment of the right lateral neck (Figures 1B-D). In addition, multiple solid nodules in both lungs were found by lung CT (Figures 2A-C). The 18F-FDG PET/CT image also confirmed the above results (Figures 1E,F, 2D).
Examination of thyroid and cervical lymph nodes. (A,B) CE-US of thyroid showed within the upper portion of the left thyroid lobe was a hypoechoic, taller than wide, irregular nodule (red arrow), deeming it a TI-RADS 5. (C,D) Contrast-enhanced CT of the thyroid identified hypodense nodules within both thyroid lobes. (E,F) CT scan showed high density nodules in the right lateral cervical region. (G) 18F-FDG PET/CT images showed increased uptake in right supraclavicular fossa.
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F3
The thyroid contrast-enhanced ultrasound (CE-US) showed 5.3 mm and 8.4 mm nodules in left and right lobes with TI-RADS 5 (Figures 3A,B). The contrast-enhanced CT of thyroid also showed the nodules in thyroid (Figures 3C,D) and enlarged lymph nodes in the right supraclavicular fossa (Figures 3E,F). However, the 18F-FDG PET/CT scan did not find any abnormal glucose metabolism in the thyroid gland and central cervical lymph nodes, but did in the right supraclavicular fossa, which was different from CE-US (Figure 3G).
Postoperative specimen and pathology. (A) Thyroid and lymph nodes specimen. Dotted line box indicates lateral cervical lymph nodes, solid line box indicates central cervical lymph nodes. (B) Pathology of thyroid and lymph nodes.
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F4
Finally, total thyroidectomy, central cervical lymph node dissection and right lateral cervical lymph node dissection were performed for the patient in March 2022 (Figure 4A). Pathological results show that the nodules in both sides were classical papillary thyroid microcarcinoma (Figure 4B). Additionally, sutures were found in the cancerous nodule in the right lobe, which came from a partial thyroidectomy for a thyroid benign nodule in 2012 (Figure 4A).