Follicular thyroid carcinoma skull metastases

Skull metastases of extracranial origin is rare. The most common malignancies which metastasize to the skull are lung, breast, and prostate carcinomas ¹⁾. metastases in the skull associated with carcinoma of the thyroid accounts for only 2.5%–5.8% of cases, but the initial presentation with distant metastases is rare ²⁾ Isolated metastatic tumoral nodules have a radiological feature that strongly suggests a primary tumor, and furthermore, their macroscopic appearance during surgery may even be taken for a meningioma ³⁾.

A case who presented as isolated calvarial metastases in the form of scalp swelling and mimicked a meningioma. A 60-year-old female, a known case of goiter with hypothyroidism for 10 years and receiving Eltroxin, presented to the neurosurgery outpatient department with a complaint of left-sided scalp swelling measuring 11 cm × 9 cm, associated with headache and generalized weakness. There was no history of nausea and vomiting. Higher mental functions and cranial nerve examination were with normal limits. All the baseline investigations were within normal limits. Contrast-enhancing magnetic resonance imaging and computed tomography angiography showed left frontal calvarial mass approximately measuring 10 cm × 8 cm in size. Fine-needle aspiration cytology was done from the scalp lesion, and it was suggestive of secretory meningioma. In view of clinical and imaging findings, preoperative diagnosis of the left frontal calvarial metastases was made with differential of meningioma. Intraoperative, a tumor was identified extending from dura to both frontal bone and anterior part of the left parietal bone and causing destruction of bone. Gross total excision of the tumor was done followed by duraplasty.

On microscopy, a tumor was seen arranged in the form of well-formed back to back arranged follicles filled with colloid-like material. These tumor cells were moderately pleomorphic with round-to-oval nuclei, inconspicuous nucleoli, and moderate cytoplasm. These tumor cells were suspicious of follicular carcinoma of the thyroid. Tumor cells were seen infiltrating through the dura mater and bone Thyroid origin was confirmed by positive immunohistochemistry for thyroid-associated antigens, i.e., thyroglobulin and thyroid transcription factor-1, confirming the diagnosis of metastatic thyroid carcinoma. Based on histopathology report, ultrasonography of the thyroid gland was done and it was suggestive of malignant lesion. Fluorodeoxyglucose (FDG) positron emission tomography scan did not show any FDG-avid lesion anywhere in the body. Postoperative period was uneventful, the patient was planned for thyroid surgery ⁴⁾

Two cases of follicular thyroid cancer with skull involvement, and describe the diagnostic and therapeutic approach to metastatic thyroid cancer. We present the cases of a 70-year-old female and a 74-year-old female who presented with painless, large slow-growing masses of the skull. The patients underwent surgical excision of the skull masses, which were histologically diagnosed as metastatic follicular thyroid cancer, and total thyroidectomy, which confirmed the diagnosis of follicular thyroid carcinoma. They were treated with radioiodine and suppressive levothyroxine, which achieved local control of the disease. Management of metastatic thyroid cancer, requires a multidisciplinary approach and multimodality treatment. Distant metastases should be surgically removed whenever possible. Initial aggressive treatment is crucial in the management of metastatic thyroid carcinoma, providing the best chance to prolong patient survival ⁵⁾.

68-year-old female patient referred by the ophthalmology clinic with the preliminary diagnosis of retro-orbital tumor upon being admitted with proptosis. A soft tissue lesion at a size of 68 × 39 × 53 mm located intracranially was detected by the brain computerized tomography. The biopsy taken and the immunohistochemical results were not satisfactory. Intense fluorodeoxyglucose involvement was observed in both lobes of the thyroid gland at positron emission tomography/computerized tomography taken with the recommendation of the council. Moreover, hypermetabolic nodules were seen in both lung parenchyma areas, whereas intense hypermetabolic lytic lesions were observed in the skeletal system. Thyroglobulin and thyroid transcription factor 1 stains displayed a strong staining on paraffin block. On the basis of these characteristics, the case was regarded as compatible metastatic follicular thyroid carcinoma, with skull-base, cranial, retro-orbital, paranasal sinus, lung, and bone metastases. This case showed us that multidisciplinary work and assessment of the oncology council play a highly critical role in making the diagnosis and guiding the treatment ⁶⁾

A 48-year-old female patient presented with massive swelling in the frontal region of skull associated with swellings in occipital region. Evaluation confirmed that it is multiple metastases to skull bones from follicular thyroid carcinoma. This is a very rare presentation with such a large size of metastases. We report this case of a metastatic follicular thyroid carcinoma presenting as massive skull tumor at our institution ⁷⁾.

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