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Choroidal metastases as initial manifestation of a papillary thyroid carcinoma: A case report
Metástasis coroidea como primera manifestación de carcinoma papilar de tiroides: a propósito de un caso
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Extensión citológica con tinción de Papanicolaou en la que se observan grupos papilares de células con citoplasma mal delimitado, núcleos redondeados u ovalados con ligera variabilidad en el tamaño nuclear. B) Corte histológico a un aumento de 20X teñido con hematoxilina-eosina de la pieza de tiroidectomía total. En la parte superior de la imagen se observa el carcinoma papilar de tiroides variante de células columnares y en la parte inferior el tejido tiroideo normal. C) En esta imagen se observa la invasión vascular del carcinoma papilar.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "M. Chacón González, A. Ibáñez Muñoz, L. Rodríguez Vicente, I. Ortega Renedo, M. Rozanova Klecheva, A. Yagüe Hernando, M.E. Lizuaín Abadia, B. Jiménez del Rio" "autores" => array:8 [ 0 => array:2 [ "nombre" => "M." "apellidos" => "Chacón González" ] 1 => array:2 [ "nombre" => "A." "apellidos" => "Ibáñez Muñoz" ] 2 => array:2 [ "nombre" => "L." 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(b) RPE alterations with photoreceptor loss in those areas (LE). (c) hypo-autofluorescent dots in posterior pole and some hyper-autofluorescent dots in the temporal zone (LE). (d) dotted pattern in the «in-face» mode (LE). (e) RE alteration-free ocular fundus. (f) autofluorescence image compatible with normality (RE). (g) small epiretinal membrane (RE).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "R. Campos Polo, D. García Guisado, C. Rubio Sánchez, P. Bueno García, N.T. Márquez Ivacevich" "autores" => array:5 [ 0 => array:2 [ "nombre" => "R." "apellidos" => "Campos Polo" ] 1 => array:2 [ "nombre" => "D." "apellidos" => "García Guisado" ] 2 => array:2 [ "nombre" => "C." "apellidos" => "Rubio Sánchez" ] 3 => array:2 [ "nombre" => "P." "apellidos" => "Bueno García" ] 4 => array:2 [ "nombre" => "N.T." 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CNVM existence was confirmed by means of macular OCT.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "E. Martín García, J.J. Chávarri García, L. Rodríguez Vicente, B. Jiménez del Río, S.M. Guallar Leza, J.L. del Río Mayor" "autores" => array:6 [ 0 => array:2 [ "nombre" => "E." "apellidos" => "Martín García" ] 1 => array:2 [ "nombre" => "J.J." "apellidos" => "Chávarri García" ] 2 => array:2 [ "nombre" => "L." "apellidos" => "Rodríguez Vicente" ] 3 => array:2 [ "nombre" => "B." "apellidos" => "Jiménez del Río" ] 4 => array:2 [ "nombre" => "S.M." "apellidos" => "Guallar Leza" ] 5 => array:2 [ "nombre" => "J.L." "apellidos" => "del Río Mayor" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0365669119303260" "doi" => "10.1016/j.oftal.2019.11.003" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0365669119303260?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173579420300037?idApp=UINPBA00004N" "url" => "/21735794/0000009500000002/v1_202002061534/S2173579420300037/v1_202002061534/en/main.assets" ] "en" => array:20 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Short communication</span>" "titulo" => "Choroidal metastases as initial manifestation of a papillary thyroid carcinoma: A case report" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "94" "paginaFinal" => "97" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "M. Chacón González, A. Ibáñez Muñoz, L. Rodríguez Vicente, I. Ortega Renedo, M. Rozanova Klecheva, A. Yagüe Hernando, M.E. Lizuaín Abadia, B. Jiménez del Rio" "autores" => array:8 [ 0 => array:4 [ "nombre" => "M." "apellidos" => "Chacón González" "email" => array:1 [ 0 => "chacongonzalezmaria@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "A." "apellidos" => "Ibáñez Muñoz" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "L." "apellidos" => "Rodríguez Vicente" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "I." "apellidos" => "Ortega Renedo" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 4 => array:3 [ "nombre" => "M." "apellidos" => "Rozanova Klecheva" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 5 => array:3 [ "nombre" => "A." "apellidos" => "Yagüe Hernando" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 6 => array:3 [ "nombre" => "M.E." "apellidos" => "Lizuaín Abadia" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 7 => array:3 [ "nombre" => "B." "apellidos" => "Jiménez del Rio" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Oftalmología, Hospital San Pedro, Logroño, La Rioja, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Anatomía Patológica, Hospital San Pedro, Logroño, La Rioja, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "<span class="elsevierStyleItalic">Corresponding author</span>." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Metástasis coroidea como primera manifestación de carcinoma papilar de tiroides: a propósito de un caso" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 311 "Ancho" => 1255 "Tamanyo" => 155344 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">(A) Cytology corresponding to PAAF of the mediastinic adenopathy. Cytological extension with Papanicolaou staining showing papillary groups of cells with poorly defined cytoplasm, rounded or oval-shaped nuclei with slight nucleus size variability. (B) Histological section with 20X increase stained with hematoxylin-eosin of the total thyroidectomy. The upper part of the image shows the columnar cell variant of the thyroid papillary carcinoma and the lower part shows normal thyroid tissue. (C) This image shows the vascular invasion by the papillary carcinoma.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Papillary thyroid cancer (PTC) is the most frequent differentiated thyroid carcinoma, accounting for 85% of cases,<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> the majority of which usually express as a thyroid mass that could disseminate to locoregional lymphatic nodes. Remote blood dissemination is unusual and occurs in only 10% of cases.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–3</span></a> The presence of choroidal metastasis is an infrequent occurrence, mostly described in patients with advanced primary carcinoma frequently originated in pulmonary or mammary neoplasias. The appearance of choroidal metastasis secondary to primary thyroid neoplasia is extremely rare but must be taken into account in the differential diagnostic of choroidal masses. The case is presented of a 78 year-old male with a choroidal mass on the right side leading to the casual diagnostic of columnar cells PTC variant.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Clinic case report</span><p id="par0010" class="elsevierStylePara elsevierViewall">Male, smoker, 78 years of age, without known oncological history who visited the Ophthalmology Dept. due to diminished visual acuity in the right eye with several months evolution. Maximum corrected visual acuity in the right eye was finger counting at 1<span class="elsevierStyleHsp" style=""></span>m and 1 in the left eye. Extrinsic and intrinsic ocular motility was normal. Slit lamp examination identified incipient cataract and intraocular pressure of 12<span class="elsevierStyleHsp" style=""></span>mmHg in both eyes. Funduscopic examination revealed a single elevated pale orange-yellow mass located in the posterior pole of the right eye (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A). Ocular echography in mode A and B showed a mass localized on the choroids without inner reflectiveness reduction, kappa angle, choroidal cup or retinal detachment (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>B). Fluorescein angiography was not allowed by the patient, for which reason autofluorescence was performed showing tumor hypoautofluorescence with hyperautofluorescent areas inside (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>C). Optical coherence tomography (OCT) showed the presence of a choroidal mass in the posterior pole associated to subretinal fluid with neurosensory retina detachment (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>D). Nuclear magnetic resonance found a choroidal mass in posterior pole without cerebral compromise (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>A–B).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Suspecting a metastatic tumor possibly of pulmonary origin, the Oncology and Pneumology Depts. Were requested to perform oncological screening tests. Analyses revealed significantly raised thyroglobulin (6926<span class="elsevierStyleHsp" style=""></span>ng/ml [2–78]) with the rest of thyroid function analytic parameters within normal ranges. Chest and abdomen computerized tomography (CT) showed the existence of a hypovascular mass located in the thyroid isthmus as well as multiple supraclavicular, hilar, paratracheal and paraesophageal adenopathies (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>C–D). It also showed numerous sub-pleural millimetric nodules and a left paravertebral extrapleural mass possibly related to secondary implants. Positron emission tomography (PET)/CT study showed a possible high histological thyroid primary tumor in the left thyroid lobe/isthmus with cervical and mediastinic adenopathies as well as pulmonary metastases. Bronchoscopy with pulmonary biopsy was compatible with carcinomatous metastases probably of thyroid origin (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>A). ECO-punction-aspiration with fine needle (PAAF) of the thyroid revealed PTC histopathological data. With the diagnostic of thyroid carcinoma, the patient underwent full thyroidectomy with partial resection of level IV adenopathy 2 months after the baseline diagnostic. Histopathology confirmed columnar variant PTC (Bethesda VI) in stage T3aN1bM1 (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>B–C). Subsequently, the patient underwent treatment with radioiodine for ablation and treatment of metastases.</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Despite successful response to radioiodine treatment, and result was amaurosis as a consequence of massive choroidal hemorrhage.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0025" class="elsevierStylePara elsevierViewall">The most frequent endocrine neoplasia is thyroid carcinoma, of which PTC is the most frequent (approximately 85% of all thyroid neoplasias).<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Hematic dissemination occurs in only 10 % of cases, preferably in the lungs followed by bones and brain.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–3</span></a> Distance hematogenous metastatic dissemination is extremely infrequent. The existence of uveal metastases secondary to primary thyroid neoplasia is an unusual event. In a series of 420 uveal metastases cases, Shields et al. found 2 cases due to thyroid carcinoma<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> while Ferry and Font only found 1 out of 227 cases.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Of all thyroid carcinoma with choroidal metastases described in the literature, 10 are derived from PTC, 7 from follicular carcinoma and 6 from medullary carcinoma.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–3</span></a> All patients had a previous record of thyroid carcinoma and exhibited advanced stages of the disease. The importance of the case is due to the unusual presentation that expressed as choroidal metastasis as the first clinical sign of the disease, and also because it is a columnar cell variant of papillary carcinoma first described by Dr. H.L. Evans in 1986.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Histologically, it is characterized by papillas or pseudo-glandular spaces covered by stratified epithelium. Mitosis figures are frequent and the ki67 proliferation index is high.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7,8</span></a> From the immunohistochemical viewpoint, thyroglobulin immunoreactivity is high while TTF-1 is always positive.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">The most frequent presentation in these patients is diminished visual acuity when the lesion is located in the macula of the optic nerve, as in the case described herein. In addition, the literature comprises cases with myodesopsia, photopsia or scotoma clinic. In a smaller number of patients asymptomatic choroidal masses could be found, usually diagnosed in a routine checkup.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">The diagnostic is based on the ocular fundus examination and radiological imaging tests such as ocular echography and MR. It is recommended to take a choroidal biopsy in the presence of an uveal mass as first expression of a tumor. In the present case, PTC diagnostic is based on funduscopic examination and lungs and thyroid samples without the necessity of performing trans-retinal biopsy due to the risk of complications this procedure entails (retina detachment, tumor dissemination and choroidal hemorrhage among others). In addition, a thorough systemic study should be made due to suspected metastatic tumor and to discard the most frequent tumors for each sex such as prostate in males and breast in females.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Treatment must be individualized taking into account prognostic factors. The literature describes several treatment options for managing choroidal metastases. The most widely utilized is radiotherapy with <span class="elsevierStyleSup">131</span>I<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,9</span></a> with total thyroidectomy that produces positive results as in the present case. Other therapies are external radiotherapy for cases refractory to radioiodine,<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,4,9,10</span></a> episcleral brachytherapy with <span class="elsevierStyleSup">125</span>I, immunotherapy and chemotherapy.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Enucleation is only for untreatable pain, neovascular glaucoma or excessive tumor growth, although it has been utilized exceptionally as a diagnostic method when the primary source of the tumor could not be determined.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Prognosis is determined by the stage of the tumor and the number of compromised nodes. Advanced stages with a high number of compromised nodes as in the case reported herein have poor prognosis.</p><p id="par0050" class="elsevierStylePara elsevierViewall">The incidence of choroidal metastases derived from PTC is low. To date, the authors were unable to find any case described in the literature.</p><p id="par0055" class="elsevierStylePara elsevierViewall">By way of conclusion, the appearance of choroidal metastases is infrequent and mostly described in patients with advanced primary carcinoma most frequently originated in pulmonary or mammary gland neoplasia.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,4</span></a> The appearance of choroidal metastases secondary to thyroid carcinoma is a rare event. Therefore, in the presence of uveal metastases of unknown origin an extensive systemic assessment of the patient must be carried out, also discarding thyroid carcinoma as possible etiology. The presence of hematogenous metastases derived from thyroid carcinoma is a factor that indicates poor evolution of the disease. It is essential to carry out an early diagnostic in order to preserve at least the ocular anatomy of the patient and visual acuity in the best of cases. The example discussed herein is an infrequent case of choroidal PTC metastasis where multidisciplinary approach is essential for adequate diagnostic and therapeutic management.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conflict of interests</span><p id="par0060" class="elsevierStylePara elsevierViewall">No conflict of interests was declared by the authors.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:9 [ 0 => array:3 [ "identificador" => "xres1300364" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1199744" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1300365" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1199745" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Clinic case report" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Conflict of interests" ] 8 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2019-05-20" "fechaAceptado" => "2019-10-14" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1199744" "palabras" => array:4 [ 0 => "Thyroid cancer" 1 => "Papillary thyroid cancer" 2 => "Ocular metastasis" 3 => "Choroidal metastasis" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1199745" "palabras" => array:4 [ 0 => "Cáncer de tiroides" 1 => "Carcinoma papilar tiroideo" 2 => "Metástasis ocular" 3 => "Metástasis coroidea" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The case is presented of 78 year-old who consulted due to decreased visual acuity in right eye for several months. Indirect ophthalmoscopy revealed an orange-yellow coloured choroidal mass at the posterior pole, without retinal detachment. Computed tomography showed a thyroid mass in the isthmus, as well as multiple pulmonary nodules and metastatic foci. The findings of transbronchial lung biopsy were compatible with metastatic dissemination. Fine-needle aspiration biopsy of thyroid nodule was diagnostic for a with columnar cell variant of papillary thyroid cancer. Positron emission tomography confirmed papillary thyroid carcinoma. The patient underwent total thyroidectomy and radioactive iodine therapy.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Se presenta caso de varón de 78 años que consultó por disminución de visión en ojo derecho de meses de evolución. En la exploración funduscópica se detectó existencia de una masa coroidea de coloración amarillo-anaranjado, sin desprendimiento de retina asociado. La tomografía computarizada demostró presencia de una masa localizada en istmo tiroideo así como múltiples adenopatías y focos de diseminación de aspecto metastásico. La broncoscopia con biopsia pulmonar mostró hallazgos compatibles con diseminación metastásica. La punción-aspiración con aguja fina del nódulo tiroideo fue diagnóstica para un carcinoma papilar de tiroides subtipo células columnares y la tomografía por emisión de positrones confirmó secundarismo a carcinoma primario de tiroides. Se trató al paciente con tiroidectomía total y tratamiento sustitutivo tiroideo, y posteriormente tratamiento ablativo con radioyodo.</p></span>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Chacón González M, Ibáñez Muñoz A, Rodríguez Vicente L, Ortega Renedo I, Rozanova Klecheva M, Yagüe Hernando A, et al. Metástasis coroidea como primera manifestación de carcinoma papilar de tiroides: a propósito de un caso. Arch Soc Esp Oftalmol. 2020;95:94–97.</p>" ] ] "multimedia" => array:3 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 342 "Ancho" => 1405 "Tamanyo" => 71503 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(A) RE fundus showing the presence of a yellow-orange rounded mass in posterior pole. (B) Mode B echography shows a mass located in the choroids with defined edges and without choroidal cup. (C) Autofluorescence showing tumor hypoautofluorescence with hyperautofluorescent areas inside. (D) SD-OCT showing the choroidal mass with subretinal fluid (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article).</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 682 "Ancho" => 755 "Tamanyo" => 92625 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">(A) T2 axial orbit MR showing the presence of a hypointense mass in the right side posterior pole. (B) FSAT sequence sagittal orbit MR showing a hypointense mass in the right eye posterior pole. (C) Thoracic CT, coronal reconstruction showing mediastinic metastatic adenopathies. (D) Thoracic axial CT showing a thyroid mass which is hypointense compared to the rest of healthy, hyper-intense thyroid parenchyma, in addition to bilateral hiliar adenopathies.</p>" ] ] 2 => array:8 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 311 "Ancho" => 1255 "Tamanyo" => 155344 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">(A) Cytology corresponding to PAAF of the mediastinic adenopathy. Cytological extension with Papanicolaou staining showing papillary groups of cells with poorly defined cytoplasm, rounded or oval-shaped nuclei with slight nucleus size variability. (B) Histological section with 20X increase stained with hematoxylin-eosin of the total thyroidectomy. The upper part of the image shows the columnar cell variant of the thyroid papillary carcinoma and the lower part shows normal thyroid tissue. (C) This image shows the vascular invasion by the papillary carcinoma.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Unusual case of papillary thyroid carcinoma with choroidal metastasis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "C. Makhija" 1 => "Y.B. Su" 2 => "W. 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