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   Table of Contents      
CASE REPORT
Year : 2017  |  Volume : 3  |  Issue : 3  |  Page : 162-165

Massive Skull Metastasis From Follicular Thyroid Carcinoma − How Ignorance Can Harm Your Health


1 Maulana Azad Medical College; G.B. Pant Institute of Post Graduate Medical Education and Research (GIPMER), New Delhi, India
2 Sri Guru Ram Das Institute of Medical Sciences and Research, Amritsar, Punjab, India

Date of Web Publication24-Oct-2017

Correspondence Address:
Charandeep S Gandhoke
Room No.: 307, New Resident Doctor’s Hostel (NRDH), G.B. Pant Hospital, 1, Jawaharlal Nehru Marg, Near Daryaganj, New Delhi 110 002
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mamcjms.mamcjms_38_17

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  Abstract 

We report a 70 years old female, who presented with huge swellings over the left forehead, left clavicular region, anterior neck, occipital region and the right side of the scalp. The first swelling appeared 8 years back. She had deranged thyroid function tests and highly raised serum thyroglobulin levels. Her T3 level was 300.75 ng/dl (normal range: 40–181 ng/dl); T4 level was 6.7 µg/dl (normal range: 5–10.7 µg/dl) and thyroid stimulating hormone (TSH) level was 0.09 µIU/ml (normal range: 0.5–8.9 µIU/ml). Her serum thyroglobulin level was 30,000 ng/ml (normal range: 0.73–84 ng/ml). We have reported this case due to the unusual presentation of the patient with massive metastatic lesions from a primary thyroid cancer with highly raised serum thyroglobulin levels. Metastatic tumors to the skull are most often from breast, lung and prostate malignancies. In thyroid cancer, Nagamine et al. reported skull metastasis in only 2.5% of the cases. Along with radioactive iodine therapy, curative resection of solitary bone metastasis, wherever possible, is associated with improved survival, especially in younger patients of metastatic thyroid cancer. Only the light of knowledge and health education can dispel the darkness of ignorance. This rare case report highlights the importance of educating the masses, especially the people living in villages, so that it does not take 8 years, as in our case, to present oneself to a tertiary health care facility.

Keywords: Carcinoma, ignorance, metastasis, skull, thyroid


How to cite this article:
Gandhoke CS, Borde PR, Syal SK, Singh D, Saran RK, Gupta RK. Massive Skull Metastasis From Follicular Thyroid Carcinoma − How Ignorance Can Harm Your Health. MAMC J Med Sci 2017;3:162-5

How to cite this URL:
Gandhoke CS, Borde PR, Syal SK, Singh D, Saran RK, Gupta RK. Massive Skull Metastasis From Follicular Thyroid Carcinoma − How Ignorance Can Harm Your Health. MAMC J Med Sci [serial online] 2017 [cited 2019 Aug 18];3:162-5. Available from: http://www.mamcjms.in/text.asp?2017/3/3/162/217122


  Introduction Top


We report the case of a 70-year-old female who presented with huge swellings over the anterior neck, left clavicular region, left forehead, occipital region, and the right side of the scalp (in the order of appearance). The anterior neck swelling appeared 8 years ago, which was followed by the appearance of the remaining swellings [Figure 1]. The anterior neck swelling gradually progressed to the current size, was globular in shape, firm in consistency, and nontender with dilated veins seen on the surface of the swelling. It moved with deglutition, and the thyroid gland could not be felt separately from the swelling. She had deranged thyroid function tests and highly raised serum thyroglobulin levels. Her T3 level was 300.75 ng/dl (normal range: 40–181 ng/dl), T4 level was 6.7 μg/dl (normal range: 5–10.7 μg/dl), and thyroid stimulating hormone (TSH) level was 0.09 μIU/ml (normal range: 0.5–8.9 μIU/ml). Her serum thyroglobulin level was 30,000 ng/ml (normal range: 0.73–84 ng/ml). The results of a contrast-enhanced magnetic resonance imaging (CEMRI) of the brain were suggestive of multiple, large heterogeneously enhancing lesions in the calvarium. The largest lesion was noted in the left frontoparietal region with large exophytic soft tissue component. There were multiple areas of necrosis, hemorrhage and many dilated tortuous vessels noted within the lesion. The lesion extended into the left orbit with nonvisualization of the left eyeball separately.
Figure 1: A case of metastatic follicular thyroid carcinoma

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Another large heterogeneously enhancing lesion was noted in the occipital bone with the invasion of the bilateral transverse sinuses and the confluence of sinuses. A large heterogeneously enhancing lesion was also noted in the right infratemporal fossa with extension into the right orbit and the right posterior ethmoidal sinus. On CEMRI of the neck, a large multilobulated heterogeneously enhancing lesion was noted with nonvisualization of the thyroid gland separately. The lesion extended into the left paratracheal space with the displacement of the trachea towards the right. The lesion also extended retrosternally into the anterior mediastinum with an abutment of the large thoracic vessels (the arch of aorta and its branches) by the mass. The entire left clavicle could possibly be destroyed with a large supraclavicular mass [Figure 2]. A contrast-enhanced computed tomography (CECT) scan of the brain, neck, thorax, and abdomen was suggestive of multiple heterogeneously enhancing masses in the scalp with underlying cortical bone erosion. The largest of these masses of size 13.4 cm × 8.5 cm was seen in the left frontoparietal region and left infratemporal fossa. This mass was grossly invading and expanding the left bony orbit with an inferiorly displaced and compressed eyeball. The mass reached up to the orbital apex and showed gross destruction of the walls of the left bony orbit.
Figure 2: A contrast-enhanced magnetic resonance imaging (CEMRI) of the brain and neck showing multiple large heterogeneously enhancing lesions in the calvarium and neck

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A similar density mass was seen in the right infratemporal fossa of size 6.6 cm × 3.5 cm, which was grossly expanding and destroying the pterygoid plates and the greater and lesser wings of the sphenoid. Heterogeneously enhancing masses were also seen in the occipital and right temporal regions of the scalp with underlying bony erosion. In the neck, a large multilobulated, heterogeneously enhancing, necrotic mass of size 20 cm × 8.3 cm × 14 cm was present. A few nodular opacities were seen in the left lower lung in the basal segments, which could represent metastatic deposits. Minimal pericardial effusion was noted. A large heterogeneously enhancing mass of size 6 cm × 2.3 cm was also seen in the left lobe of the liver [Figure 3]. Fine-needle aspiration cytology (FNAC) from multiple swellings and biopsy from the left supraclavicular mass were suggestive of “follicular thyroid carcinoma” [Figure 4]. The patient refused any further treatment. We have reported this case because of the unusual presentation of the patient with massive metastatic lesions from a primary thyroid cancer with highly raised serum thyroglobulin levels. Serum thyroglobulin testing is mainly used as a tumor marker to evaluate the effectiveness of treatment for differentiated thyroid cancer and to monitor for recurrence. Increased thyroglobulin levels are also found in patients untreated for differentiated thyroid cancer (papillary and follicular), as seen in our patient.
Figure 3: A contrast-enhanced computed tomography (CECT) scan of the brain, neck, thorax, and abdomen showing: (a) and (b) multiple heterogeneously enhancing masses in the scalp with underlying cortical bone erosion, (c) a large multilobulated, heterogeneously enhancing, necrotic mass in the neck with the displacement of the trachea towards the right and a large supraclavicular mass, (d) minimal pericardial effusion, and (e) a large heterogeneously enhancing mass in the left lobe of the liver

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Figure 4: Cytology and histomorphology suggestive of follicular carcinoma thyroid. FNAC showing: (a) Cellular tumor arranged in variable-sized follicles with intrafollicular colloid material (Papanicolaou stain 200×). (b) The cells are relatively monomorphic showing hyperchromatic-to-vesicular nuclei, inconspicuous nucleoli, and scanty cytoplasm (Papanicolaou stain 400×). (c) and (d) Biopsy from the left supraclavicular lymph node showing a tumor comprising of variable-sized follicles with colloid in the center (hematoxylin and eosin staining 200×). (e) Hematoxylin and eosin stained (400×)

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Metastatic tumors in the skull are most often resulting from breast, lung, and prostate malignancies.[1] In thyroid cancer, Nagamine et al. reported skull metastasis in only 2.5% of the patients.[2] Along with radioactive iodine therapy, the curative resection of solitary bone metastasis, wherever possible is associated with improved survival, especially in younger patients of metastatic thyroid cancer.[3],[4] Only the light of knowledge and health education can dispel the darkness of ignorance. This rare case report highlights the importance of educating the masses, especially the people living in villages, so that it does not take 8 years, as in our patient, to present oneself to a tertiary healthcare facility.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Koppad SN, Kapoor VB. Follicular thyroid carcinoma presenting as massive skull metastasis: A rare case report and literature review. J Surg Tech Case Rep 2012;4:112-4.  Back to cited text no. 1
[PUBMED]    
2.
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. 2
[PUBMED]    
3.
Zettinig G, Fueger BJ, Passler C, Kaserer K, Pirich C, Dudezak 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. 3
    
4.
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. 4
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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