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 Table of Contents  
CASE REPORT
Year : 2017  |  Volume : 1  |  Issue : 2  |  Page : 43-45

Follicular thyroid carcinoma presenting as skull metastasis: A rare case report and literature review


1 Department of Nuclear Medicine, Salah Azaiez Institute, Tunis, Tunisia
2 Department of Neuro Surgery, Salah Azaiez Institute, Tunis, Tunisia

Date of Web Publication7-Nov-2017

Correspondence Address:
Mouna Rkami
Boulevard du 9 avril 1938 Bab Saâdoun 1007 Tunis
Tunisia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/LJMS.LJMS_10_17

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  Abstract 

Follicular thyroid carcinoma (FTC) is considered to be a well-differentiated thyroid carcinoma since it shows a low progression. Metastases occur in advanced stage by hematogenous route. Lung and bone are the two most common sites of metastases. In most of the reported cases of FTC metastasizing to the skull, metastases occurred long time after the diagnosis and establishment of adequate treatment for the primary cancer. Very few cases have been reported with FTC presenting as skull metastasis. We report the case of a 35-year-old female patient presented with a massive swelling of the right parietal skull region. Histopathologic examination confirmed that it is a FTC bone metastasis. A gross total resection of the tumor was performed. Two months later, a total thyroidectomy and lymph node resection were performed. The patient underwent radioactive-iodine (RAI) therapy and was given adjunctive Levothyroxine therapy. Five years of follow-up did not show any recurrence of the disease. Correct diagnosis of skull metastasis from preoperative FTC is difficult because of its rarity. Patients can survive several years after the therapy including total resection of metastatic tumor, radical operation of thyroid carcinoma, and adjunctive therapy by Levothyroxine and RAI therapy.

Keywords: Follicular thyroid carcinoma, radio-iodine, skull metastasis, thyroid malignancy


How to cite this article:
El Bez I, Rkami M, Letaief B, Ben Slimene MF, Sellem DB. Follicular thyroid carcinoma presenting as skull metastasis: A rare case report and literature review. Libyan J Med Sci 2017;1:43-5

How to cite this URL:
El Bez I, Rkami M, Letaief B, Ben Slimene MF, Sellem DB. Follicular thyroid carcinoma presenting as skull metastasis: A rare case report and literature review. Libyan J Med Sci [serial online] 2017 [cited 2021 May 10];1:43-5. Available from: https://www.ljmsonline.com/text.asp?2017/1/2/43/217796


  Introduction Top


Metastatic tumors to skull occur most often from lung, breast, and prostate malignancies, but rarely from thyroid cancers. In a study of 473 patients with thyroid cancers, Nagamine et al. reported skull metastases in only 2.5% of cases.[1] In most of the reported cases of follicular thyroid carcinoma (FTC), metastases occurred long time after the institution of primary cancer treatment. There have been only a handful of cases reported in literature with skull metastasis as the presenting feature of FTC.[2],[3],[4],[5] The majority of skull metastasis from thyroid cancers are misdiagnosed at a preoperative stage due to primarily their rarity and secondarily to their atypical clinical presentation and imaging findings. No definite standard postoperative management of such metastases has been yet established. In this study, we report the case of a 35-year-old woman presenting with a massive skull metastasis from a FTC and present a literature review of this subject.


  Case Report Top


A 35-year-old female patient presented with a swelling of the right parietal skull region. She had no significant past medical history. Physical examination revealed a firm, painless, and fixed mass of the right parietal skull area. Magnetic resonance imaging demonstrated an extradural tumor with bone destruction and homogeneously enhancing gadolinium [Figure 1]. A complete tumor resection and cranioplasty were performed. Histopathological examination diagnosed a FTC bone metastasis. Physical examination revealed a discrete swelling of the left side of thyroid. Ultrasound examination described a 14-mm hypoechoic nodule in the upper pole of the left side of thyroid associated with microcalcifications and heterogeneous echo-structure of ipsilateral lymph nodes. The patient underwent total thyroidectomy and lymph node resection 2 months later. The histopathological examination confirmed the diagnosis of FTC and demonstrated a capsular invasion. Five weeks later, the patient underwent radioactive-iodine (RAI) ablation with 3.7 gigabecquerel (GBq) of iodine-131. The concomitant thyroid-stimulating hormone (TSH) was 50 mIU/L (normal level: 0.4–4.5), the thyroglobulin (Tg) was 65.4 ng/mL (normal level: 2–35), and the Tg antibodies (anti-Tg) were <20 IU/mL. Her serum calcium level was 18 mg/dL (normal level: 8.9–10.1). Posttherapy iodine-131 whole body scan (WBS), performed 3 days later, revealed minimal uptake in thyroid bed, high uptake in the right parietal region of the skull, and hot round area in the right pelvis [Figure 2]. The bone scintigraphy showed isolated photopenic area in the right parietal region [Figure 3]. Hence, the patient underwent a second RAI therapy with 3.7 GBq (100 mCi). Posttherapy WBS showed interval resolution of the previously seen areas of uptake within the thyroid bed and skull and persistent increased uptake in the pelvis. The correlative axial computed tomography (CT) scan and axial fused single-photon emission computed tomography/CT localized this activity to a lytic lesion of the acetabulum, consistent with acetabular metastasis [Figure 4]. The patient was restarted on thyroid hormone replacement and the dose was adjusted to achieve the TSH goal of 0.1–0.3 mIU/L. To date, she is alive without evidence of tumor recurrence or metastasis at 5 years after surgery.
Figure 1: Magnetic resonance imaging demonstrating an extradural tumor with bone destruction which enhances gadolinium homogeneously

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Figure 2: Whole body scan revealing minimal uptake in thyroid bed, high uptake in right parietal region of the skull, and hot round area in the right pelvis

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Figure 3: Bone scintigraphy showing isolated photogenic area in the right parietal region of the skull

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Figure 4: The correlative axial computed tomography and axial fused single-photon emission computed tomography/computed tomography localize this activity to a lytic bone lesion in the acetabulum, consistent with acetabular metastasis

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  Discussion Top


FTC is a subtype of thyroid cancer, associated with a good prognosis since it has a slow growth. However, in the presence of distant metastasis, the prognosis is often poorer.[6] Lung and bone are the two most common sites of metastases.[7] Bone metastases from FTC tend to be multiple and more often occur in the ribs, vertebrae, and sternum.[8] Skull is a rare site for metastases, and if this occurs, they are most commonly located in the occipital region presenting as a soft, painless lump. The presenting features of skull metastasis usually include a palpable scalp tumor. Although unusual presentations with exophthalmos, disturbance of consciousness, hemiparesis, and headache have also been reported, these lesions are osteolytic on skull X-ray and CT scan and highly vascular on angiographic assessment.[1],[2] Nagamine et al.[1] reported the largest case series of skull metastases from all types of thyroid cancers, consisting on 12 patients. In this study, the mean time from the diagnosis of thyroid cancer until the discovery of skull metastasis was 23.3 years. The prognosis is generally poor in the presence of skull metastasis. The 10-year survival rates with bone metastases from differentiated thyroid carcinoma are reported to be 27%.[7] However, in Nagamine et al's. study, the rate is as low as 4.5 years, suggesting the worseness of the disease for this subset of patients developing skull metastases. Metastatic disease is treated with RAI, especially lung metastases respond to this treatment. Unfortunately, the response of bone metastases is lower leading to a poor prognosis.[7] For this reason, the surgical approach should be taken into account in the management of these patients by surgically removing the bone lesion to avoid the administration of huge iodine activities. Curative resection of solitary bone metastasis is associated with improved survival, especially in younger patients.[8],[9]

In conclusion, skull metastases of FTC are rare, the presence of a swelling to skull must be seriously evaluated and a bone scintigraphy must be performed to evaluate the whole body if any bone tumor is suspected. A checklist for possible bone tumors must be ruled out and FTC should be kept in mind. A neck ultrasound and serum calcium level must be performed in the presence of palpable thyroid nodule, suggesting a thyroid carcinoma.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Nagamine Y, Suzuki J, Katakura R, Yoshimoto T, Matoba N, Takaya K. Skull metastasis of thyroid carcinoma. Study of 12 cases. J Neurosurg 1985;63:526-31.  Back to cited text no. 1
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2.
Akdemir I, Erol FS, Akpolat N, Ozveren MF, Akfirat M, Yahsi S. Skull metastasis from thyroid follicular carcinoma with difficult diagnosis of the primary lesion. Neurol Med Chir (Tokyo) 2005;45:205-8.  Back to cited text no. 2
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3.
Ozdemir N, Senoglu M, Acar UD, Canda MS. Skull metastasis of follicular thyroid carcinoma. Acta Neurochir (Wien) 2004;146:1155-8.  Back to cited text no. 3
    
4.
Inci S, Akbay A, Bertan V, Gedikoglu G, Onol B. Solitary skull metastasis from occult thyroid carcinoma. J Neurosurg Sci 1994;38:63-6.  Back to cited text no. 4
    
5.
Shamim MS, Khursheed F, Bari ME, Chisti KN, Enam SA. Follicular thyroid carcinoma presenting as solitary skull metastasis: Report of two cases. J Pak Med Assoc 2008;58:575-7.  Back to cited text no. 5
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6.
Cobin RH, Gharib H, Bergman DA, Clark OH, Cooper DS, Daniels GH, et al. AACE/AAES medical/surgical guidelines for clinical practice: Management of thyroid carcinoma. American Association of Clinical Endocrinologists. American College of Endocrinology. Endocr Pract 2001;7:202-20.  Back to cited text no. 6
    
7.
Schlumberger M, Tubiana M, De Vathaire F, Hill C, Gardet P, Travagli JP, et al. Long-term results of treatment of 283 patients with lung and bone metastases from differentiated thyroid carcinoma. J Clin Endocrinol Metab 1986;63:960-7.  Back to cited text no. 7
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8.
Zettinig G, Fueger BJ, Passler C, Kaserer K, Pirich C, Dudczak R, et al. Long-term follow-up of patients with bone metastases from differentiated thyroid carcinoma - Surgery or conventional therapy? Clin Endocrinol (Oxf) 2002;56:377-82.  Back to cited text no. 8
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9.
Bernier MO, Leenhardt L, Hoang C, Aurengo A, Mary JY, Menegaux F, et al. Survival and therapeutic modalities in patients with bone metastases of differentiated thyroid carcinomas. J Clin Endocrinol Metab 2001;86:1568-73.  Back to cited text no. 9
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