240 • ye et al.
lesions with the lesion at L2 lamina causing posterior
Figure 4. MRI of the lumbar spine showing multiple osseous
metastatic lesions (white arrow). One such lesion (black arrow)
seen at the L2 lamina causing posterior compression of the conus
medullaris.
ER, PR, and HER2 (Fig. 3). Patient was complaining
of worsening low back pain for 2 months. MRI of the
entire spine showed multiple osseous metastatic
Thyroid Nodule of the Breast
Mei-Na Ye, MD,* Wei-Hong Zhang, MS,* Yong-Xi Yuan, BS,* Xiao-Yun
Zhang, BS,† and Hong-Feng Chen, MD*
*Department of Breast Surgery, Longhua Hospital, Shanghai University of Traditional Chinese Medi-
cine, Shanghai, China; †Department of Pathology, Longhua Hospital, Shanghai University of Tradi-
tional Chinese Medicine, Shanghai, China
A 19-year-old girl presented with a nearly 3-year
old history of breast lump. She had endoscopic
thyroidectomy using a breast approach to remove a
mass in the left thyroid in July of 2010. Pathologic
report of the excised specimen from the patient indi-
Address correspondence and reprint requests to: Hongfeng Chen, MD,
Department of Breast Surgery, Longhua Hospital, Shanghai University of
Traditional Chinese Medicine, 725 South Wanping Road, Xuhui district,
Shanghai, China, or e-mail: chhfluk@126.com
DOI: 10.1111/tbj.12557
© 2015 Wiley Periodicals, Inc., 1075-122X/16
The Breast Journal, Volume 22 Number 2, 2016 240–243
compression of the conus medullaris (Fig. 4). Signs
and symptoms of cauda equina syndrome were absent.
CT scans and bone scan revealed extensive bone
metastases including the right sided ninth rib, multiple
vertebrae, proximal left humerus, and left iliac wing.
Patient received palliative radiation therapy to the L2
spine lesion and was started on systemic chemother-
apy with paclitaxel.
Adenoid cystic carcinoma of the breast is a rare
malignancy with the incidence of less than 0.1% of all
breast neoplasms. Immunohistochemistry is usually
negative for ER, PR, and HER2. It is reported to have
a very indolent course with excellent survival even in
patients with metastatic disease. Treatment strategies
have not been well studied given the rarity of this
tumor type. Despite its favorable prognosis, it is
intriguing how in this patient her disease progressed
so rapidly, experiencing risk of severe complications
such as nerve compression.
CONFLICTS OF INTEREST
VM and JPL declare no competing interests.
cated thyroid adenoma with cystic degeneration
(Fig. 1). The drainage tube was removed from the
patient 2 days after the surgery. But 3 months later,
the patient felt a lump in the right breast at the loca-
tion where the original drainage tube was placed. On
October 13, 2010, the patient had breast MRI exami-
nation which showed a space occupying lesion in the
upper inner quadrant of the right breast. The lesion
was categorized in Breast Imaging—Reporting and
Data System (BI-RADS) 4–5 (suspicious to highly sug-
gestive of malignancy), surgical removal of the lesion
was recommended (Fig. 2). The patient chose not to
 Thyroid Nodule in Breast • 241

(a) (b)

(a)
(c) (d)

(e)

Figure 1. In 2010, the endoscopic thyroid operation resection of

the pathologic specimens. (a) Hematoxylin–eosin stained section
of excised thyroid tissue. Parts of abnormal cell, nuclear crowding,
overlapping, part of the core with ground-glass attenuation (magni-
fication 9400). (b) Thyroid tissue showed negative reaction for
Cytokeratin 19 in the immunohistochemical analysis (magnification
9400). (c) Thyroid tissue showed positive reaction for Galectin-3 in
the immunohistochemical analysis (Galectin-3 staining, magnifica-
(b)
tion 9400). (d) Thyroid tissue showed positive reaction for thyroid-
peroxidasein (TPO) in the immunohistochemical analysis (TPO
Figure 3. (a) B-mode sonography shows a space-occupying
staining, magnification 9400). (e) Thyroid tissue showed positive/
lesion in gland. (b) The lesion with rich blood supply.
negative reaction for human bone marrow endothelial cell-1
(HBME-1) in the immunohistochemical analysis (HBME-1 staining,
magnification 9400).

Figure 2. An MRI scan showed a space-occupying lesion in right Figure 4. Pathology specimen showing a mass with tough texture,
breast upper inner quadrant (arrow). unclear boundary, and no obvious capsule.
242 • ye et al.

have surgery, instead opted to have herbal therapy for
3 months.
In May, 2013, the patient felt that the mass in the
right breast increased obviously. B-type ultrasound
examination showed a nonhomogeneous mass with
rich blood supply in the right breast (Fig. 3). The
patient underwent right breast tumor resection on
May 28, 2013. During surgery, we found a lump in
the upper inner quadrant of the right breast, about
3.5 cm 9 2.5 cm 9 2.0 cm in size, with tough tex-
ture, unclear boundary, and rich blood supply (Fig. 4).
No capsule was noticed around the lump.
Pathologic report of the specimen from the excised
lump indicated the presence of follicle-like structures
in the specimen, accompanied by atypical nodular
hyperplasia. Combined with the clinical history of the
patient, thyroid disease was suspected. Follicular vari-
ant of papillary thyroid carcinoma was not ruled out.
Based on the pathology report, further extensive oper-
ation was performed in which both the endoscopic
thyroid operation scar and the lump surface skin were
excised. We further resected up to 2 cm of normal tis-
sue surrounding the lump, along with the removal of
tissue surrounding the original drainage incision.

(a) (b) (c)

(d) (e) (f)

(g) (h)

Figure 5. Hematoxylin–eosin stained section of excised lump in mammary gland. (a) Parts of abnormal cell, nuclear crowding, overlapping,
part of the core with ground-glass attenuation (magnification 9400). (b) The lump tissue showed negative reaction for Cytokeratin 19 in the
immunohistochemical analysis (magnification 9400). (c) The lump tissue showed positive reaction for Galectin-3 in the immunohistochemi-
cal analysis (Galectin-3 staining, magnification 9400). (d) The lump tissue showed positive reaction for thyroidperoxidasein (TPO) in the
immunohistochemical analysis (TPO staining, magnification 9400). (e) The lump tissue showed positive/negative reaction for human bone
marrow endothelial cell-1 (HBME-1) in the immunohistochemical analysis (HBME-1 staining, magnification 9400). (f) The lump tissue
showed negative reaction for Ki67 in the immunohistochemical analysis (magnification 9400). (g) The lump tissue showed positive reaction
for colloid, but negative reaction for Thyroglobulin (TG) in the immunohistochemical analysis (magnification 9400). (h) The lump tissue
showed positive reaction for Thyroid Transcription Factor 1 in the immunohistochemical analysis (TTF-1) (TTF-1 staining, magnification
9400).

Pathologic report of the tissue specimen indicated the
presence of follicular tissue at the drainage incision
site and the inner canal. Thyroid nodular hyperplasia
was observed in fiber and fatty tissue of the lesion site,
along with the discovery of some cells with irregular
shape and dense nuclei or overlapping nuclei or
nuclear clearing. Tissue from the lesion site stained
positive for Galectin-3, TPO, and TTF-1 (Fig. 5).
Since the first complete endoscopic right thyroid
lobectomy was reported in 1997, endoscopic thy-
roidectomy has been progressively accepted by sur-
geons and patients extensive worldwide. For the better
cosmetic effect, the minimally invasive thyroidectomy
was welcomed by the majority of patients. The indica-
tion for endoscopic thyroidectomy is commonly not
only the management of benign thyroid nodules but
also malignant thyroid conditions. Size of the tumor
which was removed by endoscopic thyroidectomy also
became bigger and bigger.
Compared with the traditional thyroidectomy,
endoscopic thyroidectomy means more difficult learn-
ing curve, longer operating time and more complica-
Thyroid Nodule in Breast • 243
tions, but surgeons wasn’t really pay attention to it.
Just like which we observed in this patient, thyroid
endoscopic operation resulted in the grafting of thy-
roid cells at the drainage incision site of the breast.
This case gave us deeply concerned about the safety of
endoscopic thyroidectomy.
In this case, cell morphology showed that the cells
had malignant tendency, but the results of immunohis-
tochemistry showed that the evidence for the diagnosis
of malignancy was insufficient. It suggests that thyroid
lesions can survive and proliferate in non-thyroid
organs such as breast. The girl was not the first, nor the
last one of ectopic thyroid tumors planted due to endo-
scopic thyroidectomy. We appeal surgeons should pay
attention to this phenomenon and set stricter indica-
tions. After all, for patients, health is the first one, surgi-
cal safety is more important than the scars on the neck.
Acknowledgement
We thank Dr. Chuanwei Yang from MD Anderson
Cancer Center in the US for his review and valuable
comments of the manuscript.