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Bronchoalveolar Lavage for Diagnosis of Miliary Lung Metastases From Papillary Thyroid Carcinoma

Department of General, Visceral and Vascular Surgery, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany

To the Editor:

In the December 20, 2006, issue of the Journal of Clinical Oncology, Vermeer-Mens et al¹ conclude that miliary lung metastases that visualize on chest x-ray or computed tomography in children with papillary thyroid carcinoma can be diagnosed by cytology on a bronchoalveolar lavage specimen. This statement seems to imply that bronchoalveolar lavage may have a role in the routine work-up of children with metastatic differentiated thyroid carcinoma.

Contrary to the authors' suggestion, we and others² feel that bronchoalveolar lavage as an invasive procedure should be restricted, especially in children, to those exceptional circumstances when tissue diagnosis of the miliary pulmonary lesions is indispensable on diagnostic and therapeutic grounds. This is rarely the case in children with pulmonary metastases from differentiated thyroid carcinoma after a positive fine needle aspiration biopsy of gross cervical lymph node metastases. Absent the risk factors for, and more specific symptoms of, tuberculosis the odds of a 10-year-old boy with cytologically confirmed gross lymph node metastases from a 5-cm large differentiated thyroid carcinoma to have miliary tuberculosis are remote. Owing to the strong iodine avidity of differentiated thyroid carcinoma cells, a postoperative pretreatment radioiodine scan is capable of demonstrating the metastatic origin of miliary pulmonary lesions that are large enough to appear on chest x-ray or computed tomography. Because of its noninvasiveness, the postoperative pretreatment radioiodine scan in this setting is superior to bronchoalveolar lavage cytology in verifying miliary lung metastases from a differentiated thyroid carcinoma.

Rather than subjecting a 10-year-old boy with advanced differentiated thyroid carcinoma to bronchoalveolar lavage for exclusion of miliary tuberculosis, we would have endeavored to extirpate the papillary thyroid carcinoma en bloc from the thyroid bed at the initial operation in an effort to preclude eventual tracheal, esophageal, and recurrent laryngeal nerve invasion³ and to maximize the effectiveness of radioiodine therapy. In experienced hands, complete resection of a papillary thyroid carcinoma extending into the juxtathyroidal tissue is often feasible at the initial operation, resulting in sustained local control in the neck. Conversely, the long-term effectiveness of radioiodine therapy on gross residual disease in the thyroid bed of patients with differentiated thyroid carcinoma remains unclear.

AUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST

The author(s) indicated no potential conflicts of interest.

REFERENCES

1. Vermeer-Mens JC, Goemaere NN, Kuenen-Boumeester V, et al: Childhood papillary thyroid carcinoma with miliary pulmonary metastases. J Clin Oncol 24:5788-5789, 2006[Free Full Text]

2. Mello CJ, Veronikis I, Fraire AE, et al: Metastatic papillary thyroid carcinoma to lung diagnosed by bronchoalveolar lavage. J Clin Endocrinol Metab 81:406-410, 1996[Abstract]

3. Machens A, Hinze R, Lautenschläger C, et al: Thyroid carcinoma invading the cervicovisceral axis: Routes of invasion and clinical implications. Surgery 129: 23-28, 2001[CrossRef][Medline]

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This Article Full Text (PDF) Purchase Article View Shopping Cart Alert me when this article is cited Alert me if a correction is posted Services Email this article to a colleague Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Save to my personal folders Download to citation manager Rights & Permissions Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Machens, A. Articles by Dralle, H. Search for Related Content PubMed PubMed Citation Articles by Machens, A. Articles by Dralle, H. Social Bookmarking                            What's this?