Distant metastases in differentiated thyroid carcinomas: a clinical and pathologic study

Recurrent Differentiated Thyroid Cancer: The Current Treatment Options

Differentiated thyroid carcinomas (DTC) have an excellent prognosis, but this is sometimes overshadowed by tumor recurrences following initial treatment (approximately 15% of cases during follow-up), due to unrecognized disease extent at initial diagnosis or a more aggressive tumor biology, which are the usual risk factors. The possible sites of recurrence are local, regional, or distant. Local and regional recurrences can usually be successfully managed with surgery and radioiodine therapy, as are some isolated distant recurrences, such as bone metastases. If these treatments are not possible, other therapeutic options such as external beam radiation therapy or systemic treatments should be considered. Major advances in systemic treatments have led to improved progression-free survival in patients previously considered for palliative treatments; among these treatments, the most promising results have been achieved with tyrosine kinase inhibitors (TKI). This review attempts to give a comprehensive overview of the current treatment options suited for recurrences and the new treatments that are available in cases where salvage surgery is not possible or in cases resistant to radioiodine.

Synchronous Sternal Metastasectomy and Total Thyroidectomy for Differentiated Thyroid Cancer: A Rare Case Report

Bone metastases from thyroid cancer are mainly rare, while sternal metastases are extremely uncommon. Bone metastases might be either synchronous or metachronous to primary thyroid cancer. A 60-year-old male patient presented to our department with a painful, fixed and firm sternal mass. Preoperative imaging studies, such as neck ultrasound (US) and computed tomography (CT) of the chest, revealed a 6.5 cm nodule of the right thyroid lobe with high-risk malignancy characteristics and a massive metastatic mass of the anterior mediastinal, which was extended from the sternal notch to the third intercostal space. The diagnosis of papillary thyroid carcinoma with sternal metastatic lesions was established. After meticulous discussion in the multidisciplinary board of our hospital, a total thyroidectomy plus en-bloc resection of this massive sternal metastasis and adjuvant radioiodine therapy were decided. Eight months postoperatively, no recurrence has occurred in this patient. R0 resection of isolated bone metastasis of thyroid origin is still an optimal therapeutic decision for these patients. In cases of sternal metastasis, radical surgical resection with negative margins, including both resection of the lesion and reconstruction of the chest wall, in order to successfully maintain the chest wall's stability, is recommended.

Carbon Nanoparticles for Thyroidectomy and Central Lymph Node Dissection for Thyroid Cancer

PURPOSE

To evaluate whether the application of carbon nanoparticles (CNs) in total or near-total thyroidectomy combined with central lymph node dissection (CLND) for thyroid cancer (TC) is beneficial to lymph node dissection, parathyroid, and recurrent laryngeal nerve (RLN) protection.

METHODS

Relevant literatures were systematically searched on PubMed, EMBASE, and Cochrane Library Databases until March 31, 2021. All analyses were performed using Revman Manager 5.3 software. The main results were the number of central lymph nodes, the number of central metastatic lymph nodes, accidental parathyroidectomy, postoperative hypoparathyroidism, postoperative hypocalcemia, and postoperative transient RLN paralysis.

RESULTS

This meta-analysis identified 4 randomized controlled trials and 8 non-randomized controlled trials comprising 1870 patients. Compared with the control, the use of CNs was helpful to dissect more central lymph nodes (weighted mean difference [WMD]: 3.55, 95% confidence interval [CI]: 2.12-4.98, P < .00001) and central metastatic lymph nodes (WMD: 1.69, 95% CI:1.31-2.08, P < .00001), lower rate of accidental parathyroidectomy (odds ratio [OR]: .33, 95% CI: .23-.47, P < .00001), lower rate of both postoperative transient hypoparathyroidism (OR: .40, 95% CI: .31-.51, P < .00001), and transient hypocalcemia (OR: .37, 95% CI: .27-.51, P < .00001). However, there were no statistical difference between the groups for postoperative permanent hypoparathyroidism (OR: .29, 95% CI: .06-1.28, P = .10), postoperative permanent hypocalcemia (OR: .94, 95% CI: .10-9.16, P = .96), and postoperative transient RLN paralysis (OR: .66, 95% CI: .40-1.12, P = .12).

CONCLUSIONS

The application of CNs in total or near-total thyroidectomy combined with CLND for TC can better dissect the central lymph nodes and protect parathyroid glands (PGs) and their function.

Clinicopathological Characteristics and Treatment Outcome of Patients with Metastatic Differentiated Thyroid Cancer

BACKGROUND AND OBJECTIVE

Differentiated thyroid carcinoma (DTC) is a slow-growing tumour with 20% of the cases having distant metastasis. Its prognosis can vary by its histological characteristics, extension and spread. The data on metastatic DTC patients in Pakistan is scarce; therefore, the purpose of our study was to assess the clinicopathological characteristics and treatment outcomes of metastatic DTC in our population.

METHODS

This retrospective, single-centre study was carried out on 117 patients with metastatic DTC with their age at diagnosis, gender, tumour size and extent and spread of the tumour, and its histologic characteristic recorded. The treatment they received and the outcome in terms of status, at last, follow-up were also recorded.

RESULTS

The mean age of diagnosis was found to be 46.6 ± 17.2 years with an almost equal male to female ratio. The most common site of metastasis was the lung followed by bone. Papillary carcinoma was the most common subtype with 89.7% of the cases followed by follicular carcinoma occurring in 7.7%. The overall survival in years was found to be 5.6 ± 2.6 years. Ninety-six per cent had complete surgical resection followed by radioactive iodine (RAI) in 91.5%.

CONCLUSION

Our study shows that the most significant factors in predicting the outcome in metastatic DTC are age, an extrathyroidal extension of the primary tumour and distant metastasis. However, further multicentric studies done on a much larger population will be needed to further support and strengthen our results.

Follicular Thyroid Carcinoma in a Developing Country: A 10-Year Retrospective Study

Background The most common endocrine tumor is thyroid cancer. Follicular thyroid carcinoma (FTC) accounts for 5-10% of all thyroid cancers. Patients with FTC frequently present with more advanced diseases and a higher occurrence of distant metastases because of the propensity of vascular invasion. FTC is mainly treated with surgery while radioactive iodine (RAI) therapy is the main adjuvant therapy according to the American Thyroid Association guidelines. Methodology This was a retrospective observational study of FTC patients aged 18 and above conducted at a tertiary care hospital in Karachi from January 01, 2010 to December 31, 2019. Results A total of 404 patients with thyroid carcinoma were sorted, of which 40 (10.1%) were FTC cases. Overall, 50% of the patients were in the age group of 41-60 years, and the female-to-male ratio was 1.5:1. The majority of patients (60%) presented with neck swelling, followed by bone and lung metastasis in 20% and compressive symptoms in another 20%. On fine needle aspiration cytology (FNAC), 50% had Bethesda category III-IV nodules while 10% had Bethesda category II. Overall, 50% had a total thyroidectomy while 50% had a lobectomy followed by a completion thyroidectomy. On histopathology, 23 (57.5%) patients had minimally invasive FTC while 17 (42.5%) had widely invasive FTC. A total of 17 (42.5%) patients had received RAI 30-100 mCi while 10 (25%) received more than 100 mCi. Conclusions FTC can present with both local or metastatic symptoms. The atypical presentation of metastatic FTC should be considered, diagnosed, and managed early to limit mortality and morbidity. Ultrasound is the best diagnostic investigation of choice followed by FNAC. Surgery is the mainstay of treatment and should be followed by RAI in select cases. Thus, understanding the trend of FTC and proper planning and utilization of the resources will help developing countries in effectively treating the FTC.

Solitary metastatic deposit in the mandible from follicular thyroid carcinoma

Follicular thyroid carcinoma (FTC) is the second most common cancer of the thyroid, after papillary carcinoma. Oral metastasis arising from FTC is very rare. Mandible is more commonly affected than maxilla, with the premolar–molar region being the most frequent site of metastasis. We present the case of a 68yearold female, with swelling in the region of the parotid gland, complaining of periodic rightsided pain in the temporomandibular joint, which occurred most often in the morning with numbness and pain, and difficulty in opening the mouth. After ultrasound and X-ray, the patient was operated and the pathohistological finding was in favor of metastasis of FTC. After 3 months, a total thyroidectomy was performed, and FTC was detected in the right thyroid lobe. Laboratory results were as follows: FT₄ = 9.92 pmol/L, thyroid-stimulating hormone = 9.9 mIU/L, and hTG >300 μg/L. Bone scan showed no bone metastasis. Radioablation with ¹³¹I of 150 mCi was given to the patient, followed by substitutional therapy with levothyroxine. Mandible metastasis as a single skeletal deposit from follicular thyroid carcinomas is a rare clinical finding. Maxillofacial surgeons should consider and rule out thyroid pathology before performing operation of tumor formation in the mandible region. If feasible, surgical-based treatment options offer the best survival outcomes.

Liver metastasis from papillary thyroid carcinoma treated by laparoscopic hepatectomy 43 years after resection of the primary tumor: a case report

Background

Papillary thyroid carcinoma (PTC) generally has a good prognosis, while liver metastasis from PTC is rare and difficult to diagnose.

Case presentation

A 67-year-old woman was diagnosed with PTC and underwent a left hemithyroidectomy 43 years ago. Two years ago, thoracoscopic right middle lobectomy was performed for a lung tumor, and pathology reports confirmed a metastatic lung tumor of PTC. The patient was followed up regularly with computed tomography, and a liver tumor measuring 16 mm was found in the lateral segment of the liver. Fluorodeoxyglucose positron emission tomography (FDG-PET) was negative for liver tumor. However, FDG uptake was observed at the nodule outside the right lobe of the thyroid gland, suggesting metastasis to the right supraclavicular lymph node. Laparoscopic partial S2 hepatectomy was performed without complications. The final diagnosis was metastatic liver tumor from PTC, and the surgical margins were free of tumor. Postoperatively, the patient underwent complementary thyroidectomy and right supraclavicular lymph node dissection, followed by I-131 ablation. The final diagnosis was PTC of 7 mm and 4 mm and lymph node metastasis of 9 mm. The patient is currently doing well and has had no recurrence 1 year after surgery.

Conclusions

This case demonstrates that liver metastases from PTC may be found after long-term follow-up, and liver resection might be the most appropriate treatment.

Innovative analysis of distant metastasis in differentiated thyroid cancer

Differentiated thyroid cancer (DTC) is the most common thyroid cancer with a relatively high survival rate. The association between certain risk factors of distant metastasis (DM) remains uncertain. In order to assess the prognosis of patients with DTC better, the present study aimed to investigate the synergistic effects between histologic subtype, tumor size, lymph node metastasis (LNM) status and extrathyroidal extension (ETE) on the incidence of DM in DTC. Data of 96,788 patients with DTC were obtained from the Surveillance, Epidemiology and End Results database. The association between clinicopathological factors and DM was evaluated by univariate and multivariate analyses. The synergistic effects of relevant factors were determined by measuring the relative excess risk due to interaction (RERI), attributable proportion due to interaction (AP) and synergy index (SI). The results demonstrated that tumor size, LNM status, histologic subtype and ETE were independent risk factors for DM [odds ratio (OR)=2.433; P<0.001; OR=3.998; P<0.001; OR=6.266; P<0.001; and OR=3.873; P<0.001, respectively]. In addition, a significant additive synergistic effect on DM was identified between ETE and histologic subtype, ETE and LNM status, as well as between ETE and tumor size (RERI=34.097; AP=0.706; SI=3.585; RERI=6.425; AP=0.410; SI=1.781; and RERI=76.973; AP=0.864; SI=7.930, respectively). Therefore, the results of this study revealed that ETE with follicular thyroid histology, N1 stage or large tumor size may have a synergistic effect on the risk of DM in patients with DTC. These results suggested that individualized treatment may benefit patients with DTC, and when ETE coexists with one of the identified risk factors, radical treatments may be required.

Synergic effects of histology subtype, tumor size, and lymph node metastasis on distant metastasis in differentiated thyroid cancer

Background

Detection of distant metastasis (DM) is important in differentiated thyroid cancer (DTC). This study aimed to investigate the synergic effects of histology subtype, tumor size, and lymph node metastasis (LNM) status on the occurrence of DM in DTC.

Methods

We collected data of 96,788 patients with DTC. Univariate and multivariate analyses were conducted to identify the risk factors of DM. Relative excess risk of synergic effect, attributable proportion of synergic effect, and synergy index were then calculated to assess synergic effects. Further, Kaplan-Meier method using the log-rank test and receiver operating characteristic (ROC) curves were utilized.

Results

Age at diagnosis (P<0.001), sex (P<0.001), race (P<0.01), tumor size (P<0.001), N stage (P < 0.001), histology subtype (P<0.001), and extrathyroidal extension (P<0.001) were risk factors for DM in both univariate and multivariate analyses. We also found a significant additive synergic effect between histology subtype and LNM, and between tumor size and LNM on DM in the DTC patients. In addition, patients with follicular thyroid cancer and N1 stage had the sharpest decline in cancer-specific survival curves (P<0.001) and all-cause survival curves (P<0.001) compared to patients with other combinations of histology subtype and N stage. Similar results were obtained in patients with larger tumors (≥10 mm) and N1 stage. The areas under the curve of histology subtype, tumor size, and LNM status were 0.569, 0.744, and 0.681, respectively.

Conclusions

Age at diagnosis, sex, race, tumor size, N stage, histology subtype, and extrathyroidal extension are risk factors for DM in DTC patients. LNM has a synergic effect with either follicular thyroid histology or larger tumor size for higher risk of DM which is important for diagnosing DM.

Clinical Status and Treatment of Liver Metastasis of Differentiated Thyroid Cancer Using Tyrosine Kinase Inhibitors

BACKGROUND

Treatment of patients with liver metastasis of differentiated thyroid carcinoma (DTC) has not been sufficiently defined, because liver metastasis of DTC has been described mostly as case reports. Additionally, such patients are considered end-of-treatment responders. A relatively new approach using tyrosine kinase inhibitors (TKIs) may provide opportunities to manage systemic metastasis. This study aims to define the clinical features of DTC patients with liver metastasis and evaluate the benefits of TKIs.

METHODS

We retrospectively analyzed clinical features of 29 patients (mean age 67.8 years) diagnosed with liver metastasis of DTC at our institution between January 1981 and May 2017.

RESULTS

All patients had distant metastasis at other organ sites upon diagnosis of liver metastasis; 41% of them developed new metastasis afterward. Management after diagnosis of liver metastasis comprised palliative care (48%), radioactive iodine therapy (28%), and TKI therapy (24%). The median survival after diagnosis of liver metastasis was only 4.8 months. Survival rates were significantly better in patients with performance statuses between 0 and 2 on the Eastern Cooperative Oncology Group scale at diagnosis of liver metastasis (n = 22, 76%) treated with TKI compared to those who were not (P = 0.017; log-rank test; hazard ratio 0.19). One-year survival rates were 71.4 and 26.7% for patients treated with or without TKI, respectively.

CONCLUSIONS

Patients with liver metastasis had poor clinical prognosis. When other distant metastases existed at diagnosis of liver metastasis, TKI therapy was considered an effective therapeutic option for patients with liver metastasis of DTC.

Synchronous colon cancer with pulmonary metastasis and follicular variant of papillary thyroid cancer metastasising to kidney

Thyroid malignancies are one of the fastest growing cancers in the world, with the majority being papillary thyroid cancer. Follicular variant of papillary thyroid cancer accounts for about 10%-20% of papillary thyroid carcinomas. The usual sites for metastases of these tumours are lungs and bones with renal metastases being extremely rare. We describe a case of a 64-year-old woman who presented with abdominal pain. On subsequent imaging, she was found to have a colonic mass with metastatic lesions in the lungs and tumour involving left kidney. On biopsy and immunohistochemical staining, the renal mass showed positivity for thyroid cancer markers. Thyroid scan was noted to be negative and the patient was placed on active surveillance after undergoing chemotherapy for colonic adenocarcinoma.

Skeletal muscle metastases from papillary and follicular thyroid carcinomas: An extensive review of the literature

Skeletal muscle metastasis of papillary or follicular thyroid cancer (PTC/FTC) is a rare finding; only 11 cases of skeletal muscle PTC or FTC metastasis have been included in medical literature reviews. The aim of this study was to identify all published cases of PTC and FTC muscle metastases and derive the true incidence of this malignancy. The probability of detecting the skeletal muscle metastasis of PTC and FTC was calculated based on epidemiological data. Databases of scientific literature on the Internet were searched for articles using relevant key words. The analysis of epidemiological data calculated the probability of detecting skeletal muscle lesions of this type as approximately zero. The literature search revealed 44 published international papers, reporting 58 cases of PTC or FTC skeletal muscle metastasis in 45 patients over 110 years, from 1907 to 2017. The most frequent PTC/FTC metastatic muscle was the gluteus. The majority of cases of muscle metastasis were caused by PTC, and metastatic tumors in the skeletal muscle negatively impacted the survival of patients with PTC or FTC.

Follicular Thyroid Carcinoma in a Country of Endemic Iodine Deficiency (1994-2013)

BACKGROUND

Follicular thyroid cancer (FTC) has historically been linked to iodine deficiency. Although Ghana is among the iodine deficient regions of the world, the proportions, trends, and the clinical features of FTCs have not been studied as a single disease entity. The aim of this study was to determine the relative frequencies, trends, and the clinicopathological characteristics of FTCs among all thyroid malignancies in our institution.

MATERIALS AND METHODS

This was a retrospective study from January 1994 to December 2013. Data were analysed using SPSS software version 23 (Chicago) and Graph pad prism version 5.00.

RESULTS

Follicular thyroid cancer was the second thyroid malignancy (35.0%) and showed a gradual rise in relative proportions over the period. The male-female ratio was 1 : 1.5. The mean ages were 46.9 (SD ±17.3) for males and 46.4 (SD ±13.3) years for females. Enlarged palpable anterior neck swelling was the commonest symptom in males (86.7%) and females (91.3%) (P = 0.730). Hurthle cell carcinoma was the commonest variant of FTC, with 26.7% males and 10.6% females (P = 0.116). Distant spread was found in 23.3% of males compared to 19.1% of females (P = 0.633). The common sites of distant spread were bones (57.2%) in males and cervical lymph nodes (44.4%) in females (P = 0.106).

CONCLUSION

Follicular thyroid cancer was the second common thyroid malignancy (35.0%) with a gradual rise in trend over the study period and male-female ratio of 1.5 : 1. Large anterior neck swelling was the commonest clinical presentation of FTC.

Real-life management and outcome of thyroid carcinoma-related bone metastases: results from a nationwide multicenter experience

PURPOSE AND PATIENTS

The M.O.S.CA.TI. (Metastases of the Skeleton from CArcinoma of the ThyroId) is a multicenter, retrospective study investigating the real-life outcome and management of bone metastases (BM) in 143 patients (63 M, 80 F; median age 64 years, range 11-87) with differentiated thyroid carcinoma (DTC).

RESULTS

Radio-active iodine (RAI) treatment was performed in 131 patients (91.6%), surgical approach and/or external radiotherapy in 68 patients (47.6%), and anti-resorptive bone-active drugs in 32 patients (22.4%; in 31 zoledronate and in one denosumab). At the start of treatment, 24 patients (75.0%) receiving anti-resorptive bone-active drugs had at least one clinical skeletal-related event (SRE) (p < 0.001). One or more clinical SREs (pathological fractures and/or malignant hypercalcemia and/or spinal cord compression) developed in 53 patients (37.1%). Development of SREs was significantly associated with metachronous BM (hazard ratio (HR) 2.04; p = 0.04), localization of BM to cervical spine (HR 3.89; p = 0.01), and lack of avid RAI uptake (HR 2.66; p = 0.02). Thirty-nine patients (27.3%) died in correlation with development of SREs (HR 6.97; p = 0.006) and localization of BM to the hip (HR 3.86; p = 0.02). Moreover, overall mortality was significantly decreased by RAI therapy (HR 0.10; p = 0.02), whereas no significant effects were induced by bone-active drugs (p = 0.36), external radiotherapy (p = 0.54), and surgery (p = 0.43) of BM.

CONCLUSIONS

SREs are very frequent in BM from DTC and they impact patient survival. In the real life, the use of bone-active drugs is currently limited to zoledronate in patients with pre-existing SREs. In this clinical setting, RAI therapy, but not zoledronate, decreased mortality.

Disease-free survival in papillary and follicular thyroid carcinoma

T stage was redefined for patients with differentiated thyroid carcinoma (DTC) between the 5th and 7th versions of the UICC tumour classification system. Patients, methods: 636 patients (486 women, 150 men; mean age 49.1 ± 15.6 years, mean follow-up 4.6 years) who had been treated with ablative radioiodine therapy after thyroidectomy for papillary (PTC) or follicular thyroid carcinomas (FTC) were retrospectively assessed on occurrence of locoregional recurrent disease, or cervical lymph node or distant metastases. Disease-free survival was calculated from initial T stage, classified according to both versions of the UICC staging system and compared with the prognostic value of primary tumour size. Kaplan-Meier method and two measures of explained variation, (1) R2 based on the (partial) likelihood ratio statistic of the Cox proportional hazards model and (2) a model-free variant of a distance measure proposed by Schemper had the aim to detect the most advantageous classification. Results: Of the 508 patients with PTC, 11 (2.2%) developed a local recurrence, 37 (7.3%) cervical lymph node and 23 (4.5%) distant metastases, 3 (2.3%), 8 (6.3%), and 18 (14.1%) were the numbers for the 128 FTC patients respectively. The two classification systems yielded an equal count of statistically significant differences regarding disease-free survival in patients with PTC while UICC 7th classification appeared slightly advantageous in patients with FTC. Regarding explained variation the UICC 7th classification tended to be superior to the UICC 5th classification, both in PTC and FTC, however statistical significance was not reached. Conclusion: The primary tumour size significantly added to the prognosis regarding local cervical and distant metastases.

Differentiated thyroid cancer with liver metastases: lessons learned from managing a series of 14 patients

Liver metastases from differentiated thyroid carcinoma (LMDTC) are rare and usually occur in disseminated metastatic disease. The aim of this study was to review the diagnosis and management of LMDTC. Between 1995 and 2011, 14 patients with a mean age of 59.7 years (+/-10.2) were treated for LMDTC. Data were retrospectively reviewed and analyzed. Seven patients had distant metastases at diagnosis, including 2 with synchronous liver lesions. The average time of onset of LMDTC from initial diagnosis was 52.2 months (+/49.5). All LMDTC were discovered during routine radiologic monitoring. Histologic analysis confirmed LMDTC in 5 patients. Eight patients received tyrosine kinase inhibitors, 1 patient underwent resection of their LMDTC after chemotherapy. Six patients (disseminated metastases, significant comorbidities) did not receive any specific treatment. The median survival after diagnosis of LMDTC was 17.4 months (+/-3.3): 23.6 months (+/-2.9) for patients who underwent chemotherapy versus 3.9 months (+/-0.9) for patients who did not receive any specific treatment (P < 0.001). Developing DTC liver metastasis is a very poor prognostic sign. Chemotherapy by TKIs, especially, hold promise in the cure of LMDTC for selected patients.

Outcome and characteristics of patients with malignant pleural effusion from differentiated thyroid carcinoma

Metastatic differentiated thyroid carcinoma (DTC) is an uncommon cause of malignant pleural effusion (MPE) and the characteristics and clinical course have been rarely described. Herein, we report a retrospective review of the clinical course of 18 patients (15 women and 3 men) with MPE from DTC who underwent treatment at our institution between January 2005 and December 2014. MPE from DTC was diagnosed based on cytology and/or level of thyroglobulin in the pleural fluid. Pathologically, papillary carcinoma was found in 16 patients and follicular carcinoma in 2 patients. Median ages at initial diagnosis of DTC and MPE were 64 years (range, 22-79) and 74 years (range, 39-86), respectively. All patients showed radiologically apparent lung metastases, with MPE developing after 0-212 months (median, 25). In 16 patients (88.9%), other coexistent distant metastases at the time of MPE diagnosis were found in the bone (n = 10), brain (n = 5), and skin (n = 2). All patients were treated conservatively with palliative thoracentesis or chest tube drainage with or without pleurodesis. Recurrent MPE after treatment was seen in 9 patients; discharge to home health care after treatment for MPE was possible for 14 patients. The overall survival after initial diagnosis varied considerably from 14 months to 37 years, but the median survival after appearance of MPE was 10 months (range, 1-28). Systemic therapy for iodine-resistant recurrent thyroid disease may need to be considered as a treatment option for patients with MPE.

Follicular thyroid carcinoma presenting as acute cord compression due to thoracic vertebral metastasis

Thyroid carcinoma is uncommon but accounts for roughly 95% of all cancers of the endocrine system (1). The “well-differentiated” thyroid tumors include the papillary, follicular, and Hurthle cell subtypes. Although the management of these tumor types generally is similar, important diagnostic and clinical differences do exist (2). We present a case of follicular thyroid carcinoma with spinal metastasis, illustrate its imaging features on CT and MR imaging with histologic correlations, and discuss how vertebral osseous metastasis may influence clinical management of patients with differentiated thyroid cancer.

Follicular Variant of Papillary Thyroid Cancer with Bilateral Renal Metastases Discovered Incidentally During Work-Up of Primary Endometrial Cancer: A Rare Occurrence

Patient: Female, 70

Final Diagnosis: Follicular variant of papillary thyroid cancer with renal metastases

Symptoms: Bleeding per vaginum

Medication: —

Clinical Procedure: Total thyroidectomy

Specialty: Oncology

Factors affecting survival in 43 consecutive patients after surgery for spinal metastases from thyroid carcinoma

OBJECT

Spinal metastases account for the majority of bone metastases from thyroid cancer. The objective of the current study was to analyze a series of consecutive patients undergoing spinal surgery for thyroid cancer metastases in order to identify factors that influence overall survival.

METHODS

The authors retrospectively reviewed the records of all patients who underwent surgery for spinal metastases from thyroid cancer between 1993 and 2010 at the University of Texas MD Anderson Cancer Center.

RESULTS

Forty-three patients met the study criteria. Median overall survival was 15.4 months (95% CI 2.8-27.9 months) based on the Kaplan-Meier method. The median follow-up duration for the 4 patients who were alive at the end of the study was 39.4 months (range 1.7-62.6 months). On the multivariate Cox analysis, progressive systemic disease at spine surgery and postoperative complications were associated with worse overall survival (HR 8.98 [95% CI 3.46-23.30], p < 0.001; and HR 2.86 [95% CI 1.30-6.31], p = 0.009, respectively). Additionally, preoperative neurological deficit was significantly associated with worse overall survival on the multivariate analysis (HR 3.01 [95% CI 1.34-6.79], p = 0.008). Conversely, preoperative embolization was significantly associated with improved overall survival on the multivariate analysis (HR 0.43 [95% CI 0.20-0.94], p = 0.04). Preoperative embolization and longer posterior construct length were significantly associated with fewer and greater complications, respectively, on the univariate analysis (OR 0.24 [95% CI 0.06-0.93] p = 0.04; and OR 1.24 [95% CI 1.02-1.52], p = 0.03), but not the multivariate analysis.

CONCLUSIONS

Progressive systemic disease, postoperative complications, and preoperative neurological deficits were significantly associated with worse overall survival, while preoperative spinal embolization was associated with improved overall survival. These factors should be taken into consideration when considering such patients for surgery. Preoperative embolization and posterior construct length significantly influenced the incidence of postoperative complications only on the univariate analysis.

Follicular Thyroid Carcinoma Presenting With Endobronchial Metastases: Case Report and Review of Literature

Endobronchial metastasis is a rare manifestation of differentiated thyroid cancer. A 79-year-old male was admitted to the hospital with shortness of breath, chest pain, anemia, and weight loss. Computed tomography of chest revealed multiple lung nodules. Bronchoscopy showed an endobronchial lesion in the right upper lobe. The biopsy of the lesion demonstrated neoplastic cells stained positive for thyroglobulin, thyroid transcription factor-1, and cytokeratin-7, consistent with metastatic follicular thyroid cancer. Physical examination revealed a firm fixed thyroid nodule, which was confirmed by thyroid ultrasound. He subsequently underwent total thyroidectomy and neck exploration. Thyroid gland pathology revealed a nodule with features of high-grade follicular thyroid carcinoma. Metastatic thyroid cancer should be considered in workup of pulmonary nodules. We recommend an examination of thyroid gland in patients who present with pulmonary nodules associated with signs and symptoms of malignancy.

Yamada S, Miyamoto S, Yamada S, Son JH, Nishido H, Ide F, Nagashima H, Sugaya M, Hirohata T, Mizutani A, Okinaga H, Ishii Y, Tahara S, Teramoto A, Osamura RY, Yamazaki K, Ishida Y. Clinicopathological and molecular histochemical review of skull base metastasis from differentiated thyroid carcinoma

Skull base metastasis from differentiated thyroid carcinoma including follicular thyroid carcinoma (FTC) and papillary thyroid carcinoma (PTC) is a rare clinical entity. Eighteen FTC cases and 10 PTC cases showing skull base metastasis have been reported. The most common symptom of skull base metastasis from FTC and PTC is cranial nerve dysfunction. Bone destruction and local invasion to the surrounding soft tissues are common on radiological imaging. Skull base metastases can be the initial clinical presentation of FTC and PTC in the presence of silent primary sites. The possibility of skull base metastasis from FTC and PTC should be considered in patients with the clinical symptoms of cranial nerve dysfunction and radiological findings of bone destruction. A variety of genetic alterations in thyroid tumors have been identified to have a fundamental role in their tumorigenesis. Molecular histochemical studies are useful for elucidating the histopathological features of thyroid carcinoma. Recent molecular findings may provide novel molecular-based treatment strategies for thyroid carcinoma.

Papillary thyroid microcarcinoma with fatal outcome: evidence of tumor progression in lymph node metastases: report of 3 cases, with morphological and molecular analysis

Papillary thyroid microcarcinoma generally carries an excellent prognosis, and fatal cases are becoming increasingly rare. Their pathologic and molecular features, however, remain largely unknown. We describe 3 cases of papillary thyroid microcarcinoma that, despite surgical and radioiodine treatment, recurred, metastasized, and eventually caused the death of the patients. In addition to morphology, immunohistochemical (cyclin D1 and p53) and molecular analyses (BRAF [v-raf Murine sarcoma viral oncogene homolog B1], KRAS [V-Ki-ras2 Kirsten rat sarcoma viral oncogene homolog], HRAS [v-Ha-ras Harvey rat sarcoma viral oncogene homolog], NRAS [neuroblastoma RAS viral oncogene homolog], and PIK3CA [phosphoinositide-3-kinase, catalytic, alpha polypeptide]) were performed. Interestingly, all 3 cases presented with massive lymph node metastases that showed morphological evidence of "tumor progression" (tall cell features, poorly differentiated areas, and high-grade cytologic features). Cyclin D1 was consistently immunoreactive in both primary and metastatic site, whereas p53 was negative. BRAF V600E was absent in both sites, and KRAS, HRAS, NRAS, and PIK3CA were consistently wild type. These data suggest that, in cases of metastatic papillary thyroid microcarcinoma, an accurate morphologic analysis of the metastatic deposits could contribute to a more accurate prediction of tumor behavior.

Cardiac metastasis from thyroid carcinoma

Cardiac metastasis from epithelial thyroid cancer is a very rare and potentially serious complication. We have identified only 54 reported cases over a 130-year period. Here we review this literature. Cardiac metastases are frequently asymptomatic, but when symptoms develop these tend to be severe and often fatal. The prognosis of cardiac metastases from thyroid cancer is unclear as survival data are often missing or absent in reported cases. However, as many patients died suddenly from cardiac complications, the prognosis seems poor. Of those patients who survived, all underwent surgical intervention. Trans-thoracic echocardiography is the diagnostic modality of choice as it allows dynamic evaluation of intracardiac masses. Metastatic involvement of the heart from thyroid cancer is uncommon. Left untreated this complication seems likely to be fatal. Therefore, in patients with established thyroid malignancy who develop cardiac arrhythmias, new murmurs, or signs of cardiac decompensation, we suggest that cardiac metastases be considered. Echocardiography should be performed in patients with advanced thyroid cancer and cardiac symptoms or signs. If a cardiac metastasis is present, we recommend surgical intervention if possible.

Histological subtype is the most important determinant of survival in metastatic papillary thyroid cancer

BACKGROUND

Papillary thyroid cancer (PTC) comprises the commonest type of thyroid cancer and carries the highest rate of survival. However, when metastatic disease occurs, survival is significantly affected.

METHODS

We aimed to identify prognostic histopathological and clinical factors that modify survival in metastatic PTC. All cases of metastatic PTC treated at our department in the last 20 years were reviewed and analyzed.

RESULTS

Histological subtype was the most important determinant of survival, as classic PTC demonstrated clearly improved survival compared to follicular subtype of PTC and other less frequently seen histological subtypes. The instant risk of death for the other histological subtypes was 4.56 times higher than the risk for the classic papillary type. Overall, a 10-year survival of 76.6% in our patients was seen.

CONCLUSIONS

Patients with aggressive variants of PTC are more at risk for the development of metastatic disease. In these patients, established treatment modalities (surgery, radioiodine therapy) should be offered promptly, as well as close follow-up.

Soft tissue metastasis of thyroid carcinoma in the knee region mimicking a paraarticular inflammatory lesion

We report a case of a 57-year-old male patient presenting with a painful mass in the popliteal fossa of the left knee, while the X-ray being unremarkable, MRI suggested a paraarticular lesion such as an inflamed paraarticular ganglion. A biopsy showed a poorly differentiated metastasis of a papillary thyroid carcinoma, the patient had been operated on 8 years ago. This case emphasizes that in patients with malignancies such as papillary thyroid carcinomas long-term courses (over years) with several phases of tumor spread occur finally leading to filiae in any location. Thus, in such patients, a metastatic lesion even in unusual places such as the periarticular soft tissue should be included in the differential diagnosis.

Skull base metastasis from follicular thyroid carcinoma -two case reports-

A 58-year-old woman and a 71-year-old woman presented with extremely rare skull base metastases from follicular thyroid carcinoma (FTC). Surgical removal and external radiotherapy were performed followed by iodine-131 ((131)I) brachytherapy and thyroid hormone administration. The metastatic tumors in the skull base were well controlled. Treatment for skull base metastasis from FTC includes surgical debulking of the metastatic lesion, as well as complete resection of the thyroid gland, followed by internal irradiation with (131)I, external irradiation, and administration of thyroid hormone to prevent tumor growth by suppression of endogenous thyroid-stimulating hormone. Skull base metastases may be the initial clinical presentation of FTC, with silent primary sites. The possibility of skull base metastasis from FTC should be considered in patients with clinical symptoms of cranial nerve dysfunction and radiological findings of bone destruction.

Metastases of well-differentiated thyroid cancer to the gastrointestinal system

BACKGROUND

The incidence of distant metastases at the time of initial presentation of well-differentiated thyroid cancer is approximately 4%. During the course of treatment and follow-up, the prevalence of distant metastases ranges from 2% in low-risk patients up to 33% in high-risk patients. When present, distant metastases occur primarily in the lungs and, to a lesser extent, in bones. Of all sites for distant metastasis, gastrointestinal metastases of thyroid cancer are very uncommon and account for 0.5-1% of all distant metastases.

SUMMARY

Indications of metastases to the gastrointestinal system can be overlooked with traditional total body radioisotope scans that image the abdomen, including both diagnostic and posttherapy scans, because of the confounding presence of physiologic enteric radioactivity. When suspected in high-risk patients, other imaging procedures such as computed tomography, magnetic resonance imaging, and PET-computed tomography should be considered. This communication will review thyroid cancer metastases to the gastrointestinal system in regard to occurrence rate, diagnosis, and treatment.

CONCLUSIONS

Because of the extreme rarity of patients with metastases of thyroid cancer to the gastrointestinal tract, long-term follow-up data as well as information on prognosis are very limited. Aggressive management may provide symptomatic relief or palliation, but cure is unlikely once widespread metastases supervene. Attempts at complete or near-complete surgical resection of the metastases invading the digestive tract, followed by 131-I treatment, offer the best opportunity for improvement but will only rarely result in cure in selected patients.

Metastatic follicular thyroid carcinoma to the mandible: a case report

INTRODUCTION

Metastatic lesions to the oro-facial region may be the first evidence of dissemination of an unknown tumour from its primary site.

CASE PRESENTATION

We described a case of metastatic follicular thyroid carcinoma to the mandible presenting with pain and loosening of teeth in a 70 years old female patient leading to extraction of the loose teeth.

CONCLUSION

The present case emphasizes the importance of considering metastasis in the differential diagnosis of swelling related to loosening of teeth, even though the patient had no history of any malignant disease.

Skull metastasis from papillary thyroid carcinoma accompanied by neurofibromatosis type 1 and pheochromocytoma: report of a case

We report here a 74-year-old woman with a skull metastasis from papillary thyroid carcinoma (PTC). In her medical history, she was diagnosed with neurofibromatosis type 1 (NF1) at age 28 years, and she underwent thyroidectomy for PTC at age 52 years and adrenectomy for pheochromocytoma (PC) at age 58 years. She was admitted to our hospital with an increased mass in the forehead. Head computed tomography (CT) showed an expansive, osteolytic, and solid tumor extending from the dura mater into the subcutis, destroying part of the frontal bone. Head magnetic resonance imaging (MRI) revealed that the tumor was chiefly extradural but partially invaded the dura mater. Cerebral angiography showed that the tumor was fed from a branch of the external carotid artery. She underwent surgery, and histological examination revealed that the skull tumor was a metastasis from PTC, indicating that skull metastasis occurred 23 years after curative surgery for PTC. The patient also underwent adjuvant radioiodine therapy. As little is known about skull metastases from PTC, we discuss its characteristics and the extremely rare combined occurrence of PC and PTC in an NF1 patient.

Genome-wide studies in thyroid neoplasia

There is much interest in the application of genome biology to the field of thyroid neoplasia, despite the relatively low mortality rate associated with thyroid cancer in general. The principal reason for this interest is that the field of thyroid neoplasia stands to benefit from the application of genomic information to address a variety of pathologic and clinical issues. In addition to practical patient care issues, there is an excellent opportunity of expand the basic understanding of thyroid carcinogenesis. In this article, the most relevant genomic work on thyroid tumors performed to date is reviewed along with some general comments about the potential impact of genomic biology on thyroid pathology and the management of patients with thyroid nodules and cancer.

Management Considerations for Differentiated Thyroid Carcinoma Presenting as a Metastasis to the Skull Base

OBJECTIVES/HYPOTHESIS

To characterize the salient features of skull base metastasis from differentiated thyroid carcinoma, discuss the diagnostic and treatment strategies, and propose rational management guidelines for such tumors.

STUDY DESIGN

Case report.

METHODS

Review of English literature from MEDLINE with the addition of our case.

RESULTS

Skull base metastasis from differentiated thyroid carcinoma is rare, with only 20 cases reported to date, including our case report. On the basis of a review of all reported cases, both follicular and papillary thyroid cancers can metastasize to the skull base. Our case is unique because the lesion extends locally into the cavernous sinus and beyond. Histopathologic diagnosis is limited by the remote location of lesions. Most tumors are highly vascular, and there is potential for significant morbidity and mortality associated with surgical resection. The overall survival ranges from less than one year to 10+ years from the discovery of the metastasis and is similar in both tumor subtypes. There is no clear consensus on the management strategy for skull base metastasis from differentiated thyroid carcinoma. Interestingly, surgical resection of both the primary and metastatic lesions yields similar survival when compared with resection of the primary tumor alone.

CONCLUSIONS

Distant metastasis from differentiated thyroid carcinoma needs to be considered in the differential diagnosis of destructive skull base lesions, regardless of the patient's age. Histopathologic tissue diagnosis should always be attempted, followed by total thyroidectomy, radioiodine, or external beam radiation, and chronic thyroid-stimulating hormone suppression. Surgical resection of the metastatic lesion should only be performed in carefully selected cases because it is associated with significant morbidity.

Clinicopathological Characteristics and Long-term Outcome in Patients with Distant Metastases from Differentiated Thyroid Cancer

BACKGROUND

Distant metastases are seen in a minority of patients with differentiated thyroid carcinoma (DTC) but account for most of its disease-specific mortality. Studies on the long-term outcome of patients with distant metastases are controversial.

MATERIALS AND METHODS

We retrospectively reviewed the medical records of 660 patients with differentiated thyroid carcinoma followed at our institution from 1994 to 2004. Forty-four patients (6.7%) had distant metastases, with a prevalence of 4.8% for papillary thyroid cancer, 21% for follicular thyroid cancer, and 10% for Hurthle cell cancer. Primary near-total thyroidectomy followed by I(131) radiation was performed in 97% of patients with metastases (86% operated on in 1980-2003). Mean age at thyroidectomy was 49+/-19 years, and the female-to-male ratio was 1.9:1.

RESULTS

The distant metastasis occurred synchronously with the primary tumor in 45.5% and after a median follow-up of 9 years in the others. Affected sites were lungs (n=24), bones (n=11), lungs and bones (n=9), brain (n=3), and uterus (n=1). Median duration of follow-up was 12 years (range: 1-42 years) from thyroidectomy and 5.5 years (range: 1-24 years) from diagnosis of distant metastases. The 5- and 10-year survival rates (all causes) after diagnosis of distant metastases were 88% and 77%, respectively. No significant differences in survival curves were found by age, sex, metastasis site, histopathology, or interval to distant metastasis.

CONCLUSIONS

We conclude that complete resection of the thyroid gland at diagnosis and high-dose adjuvant radioactive iodine are associated with improved survival in patients with metastatic DTC.

Clinical features of bone metastases resulting from thyroid cancer: a review of 28 patients over a 20-year period

Bone is the second most frequent site of metastasis resulting from thyroid cancer. Many studies have investigated clinical features and prognostic factors of distant metastases stemming from thyroid cancer in Western countries. The purpose of this study was to review clinical characteristics of Korean patients with bone metastasis originating from thyroid cancer. Between January 1985 and August 2004, 28 patients with thyroid cancer were diagnosed with bone metastases at the Yonsei Severance Hospital in Seoul, Korea. Their clinical characteristics were analyzed retrospectively. Incidence of bone metastasis from follicular thyroid cancer was 6.8% (9 of 132 patients), and 0.4% (13 of 3,154 patients) from papillary thyroid cancer, with an odds ratio of 17.67 (95% confidence interval; 7.41-42). Twelve patients had no symptoms of bone metastasis. Overall mean number of metastasis sites was 2.6 +/- 1.9, and 12 patients had a solitary bone metastasis. Survival rates between the synchronous and metachronous metastasis groups were not significantly different, and the number of metastasis sites did not affect survival. However, the survival of patients that underwent curative treatment was longer than those with palliation (P = 0.0317). In Korea, the overall incidence of bone metastasis resulting from thyroid cancer was less than our expectation. Many patients were asymptomatic, and had a tendency of undergoing less aggressive or palliative treatment, even though the long-term survival of distant metastasis resulting from thyroid cancer with active treatment is relatively good. Further studies of the prognostic factors and effectiveness of various treatments of these patients are needed to enhance survival.

Renal rupture associated with a poorly differentiated follicular thyroid carcinoma metastasizing to the thigh muscle, lung and kidney

A 76-year-old woman with a history of total thyroidectomy for a thyroid carcinoma at the age of 63 was admitted to our hospital for the treatment of a renal rupture induced by a tumor of about 3 cm in diameter. High levels of blood thyroglobulin (Tg>1,000 ng/ml) led us to suspect a recurrence of thyroid carcinoma. Strong accumulation in whole-body 123I and 201Tl scintigraphy scans after the nephrectomy revealed tumors in the right lung and left thigh muscle measuring 5 cm and 9 cm in diameter, respectively. The tumors of the kidney and thigh muscle were pathologically diagnosed as poorly differentiated follicular thyroid carcinoma, and the lung tumor was also suggested to be a metastasis of the thyroid carcinoma based on the scintigraphy findings. We report this rare case of follicular thyroid carcinoma associated with metastases to the thigh muscle and kidney leading to a rupture 13 years after a total thyroidectomy. Care should be taken to determine whether unknown tumors are thyroid carcinoma metastases.

The role of immunohistochemical markers in the diagnosis of follicular-patterned lesions of the thyroid

Thyroid nodules are extremely common in the general population. The differential diagnosis includes numerous entities, non-neoplastic and neoplastic, benign and malignant. However, the diagnosis of follicular-patterned lesions remains an area fraught with controversy and diagnostic criteria are highly variable. It is, therefore, a field in need of objective, scientific markers that better characterize these lesions than has been possible by classical morphology. A number of candidates have been proposed. No single marker can identify all malignant follicular-patterned lesions, however, various combinations have been proposed. They include HBME-1, high molecular weight cytokeratins and ret, galectin-3 and TPO, galectin-3, fibronectin-1, CITED-1, HBME-1, and CK19. Advances in our understanding of the molecular basis of thyroid cancer will allow the identification of new markers and more accurate characterization of specific subtypes of neoplasia and malignancy. As new markers are characterized and validated, directed by molecular profiling of thyroid lesions with characteristic morphology, behavior, and outcome, they will become available as routine immunohistochemical markers that will provide a more accurate, scientific, and clinically relevant consultation report from the pathologist for cytology and surgical pathology procedures. Application of these markers will enhance the diagnosis of thyroid nodules and better guide the management of patients with these lesions.

Papillary thyroid carcinomas with lung metastases

BACKGROUND

Limited information is available on the presentation, treatment outcomes, and prognostic factors of papillary thyroid carcinoma with lung metastases.

METHODS

This study retrospectively analyzed the data of 2003 patients with thyroid cancer who were treated and followed up at Chang Gung Memorial Hospital from January 1979 to December 2002. In total, 1516 papillary thyroid carcinomas were enrolled. One hundred two (6.7%) papillary thyroid carcinomas with lung metastases were followed including 57 women with mean age of 41.7 +/- 17.3 years and 45 men with mean age of 49.6 +/- 17.2 years. These patients included 52 patients with papillary thyroid carcinoma who presented with lung metastases at the time of diagnosis. The 102 cases of papillary thyroid carcinomas with lung metastases included 72 cases with lung metastases only, and 30 cases with other organ involvement.

RESULTS

After mean follow-up periods of 8.8 +/- 0.6 years, 28 (27.5%) of the patients with lung metastasis died, while 6 improved to clinical stage I. The 5-, 10-, 15-, and 20-year survival rates in patients with papillary thyroid carcinoma without distant metastasis and in the lung metastases groups were 99.0%, 98.5%, 98.0%, 98.0%, and 91.3%, 75.0%, 64.0%, 51.2%, respectively. Comparing the Kaplan-Meier survival curves between the patients with papillary thyroid carcinomas with lung metastases only and those with multiorgan metastases demonstrates no statistically significant difference in mortality rates. However, age, gender, postoperative thyroglobulin (Tg) level and tumor size displayed statistically significant differences between the lung metastases and no distant metastasis groups. Fifty of the 102 patients with papillary thyroid carcinomas with lung metastases developed lung metastases during follow-up. Larger amounts of remnant thyroid tissues with higher Tg levels were noted in these patients compared to those without distant metastasis.

CONCLUSIONS

The prognosis of patients with papillary thyroid carcinoma with lung metastases at time of diagnosis is the same as for those whose lung metastases are discovered later. Survival analysis demonstrates no difference between lung metastases and multiorgan metastases.

A rare case of Hurthle cell carcinoma with endobronchial metastasis

Endobronchial metastases (EBM) are frequently seen in breast, renal and colon carcinomas. However, to our knowledge, only one case has ever been reported as EBM secondary to Hurthle cell carcinoma (HCC) in the literature. A 57-year-old woman had a bilateral total thyroidectomy for thyroid mass in 1990 that was diagnosed as HCC. She was admitted to our outpatient clinic in August 1999, with symptoms of cough, sputum, and right-sided pleuritic pain for the last seven months. In the bronchoscopic examination, two endobronchial lesions were seen. Pathological evaluation of the bronchoscopic samples was diagnosed as "Hurthle cell carcinoma" of thyroid. We suggest that, although rare, HCC should be considered in the differential diagnosis of the endobronchial metastasis.

Solitary liver metastasis from Hürthle cell thyroid cancer: a case report and review of the literature

Metastasis to the liver from thyroid cancer is a rare event with a reported frequency of 0.5%. Metastatic liver involvement from differentiated thyroid cancer (DTC) is nearly always multiple or diffuse and usually found along with other distant metastases (lung, bone and brain). The authors describe a patient with a solitary liver metastasis from Hürthle cell thyroid cancer, which appeared during long-term follow-up. The lesion was diagnosed by progressive increase of thyroglobulin in the serum and imaged with I-131 whole body scan, ultrasonography, magnetic resonance imaging (MRI) and F-18 fluoro-deoxyglucose positron emission tomography (FDG-PET) scan. For patients with a Tg level above some arbitrary limit, the administration of a large dose (3.7-5.5 GBq; 100-150 mCi) of I-131, in order to obtain a highly sensitive Tx whole body scan (WBS), remains the best diagnostic strategy. However, on very rare occasions, physiological enteric radioactivity can hide possible abdominal lesions and further indepth studies, such as FDG-PET scans, are sometimes necessary.

Cavernous sinus metastasis from thyroid papillary adenocarcinoma

We report here an extremely rare case of cavernous sinus metastasis from thyroid papillary adenocarcinoma presenting long after initial diagnosis. A 41-year-old patient presented with a cavernous sinus tumor causing progressive diplopia 10 years after treatment for a papillary adenocarcinoma of the thyroid. After 5 years of close observation, subarachnoid hemorrhage developed from the cavernous sinus tumor extending to the cerebellopontine angle, at which point the patient underwent surgical removal of the tumor followed by gamma knife radiosurgery. The pathological diagnosis was papillary adenocarcinoma, indicating the distant metastasis from the thyroid. This case illustrates the unique event of a cavernous sinus metastasis long after initial treatment of the primary cancer.

Long-term follow-up of patients with bone metastases from differentiated thyroid carcinoma -- surgery or conventional therapy?

OBJECTIVE

Surgery of bone metastases from differentiated thyroid carcinoma seems indicated in individual patients. This study was performed (1) to analyse retrospectively patients with bone metastases from differentiated thyroid carcinoma and (2) to evaluate the impact of surgery of bone metastases on survival.

PATIENTS AND DESIGN

We analysed 41 consecutive patients with bone metastases from differentiated thyroid carcinoma who had undergone thyroid surgery at Vienna University Hospital since 1966. The median follow-up time was 12 years. There were 24 females and 17 males with a mean age of 60 +/- 12 years. Primary tumour histology was follicular in 35 and papillary in six patients. Radioiodine treatment was performed in 32 with a mean administered activity of 27 +/- 24 GBq 131I. Metastases restricted to the skeleton were found in 22 whereas in 19 individuals additional extraskeletal distant metastases were seen. Twenty-seven patients had multiple bone metastases. In 21 individuals, up to five bone metastases were surgically removed with the intention of cure.

RESULTS

Univariate analysis identified total thyroidectomy (P = 0.003), lymph node surgery (P = 0.001), radioiodine therapy (P = 0.036), and the absence of extraskeletal distant metastases (P = 0.017) as significant predictors of survival. Multivariate analysis failed to identify significant prognostic factors. In the subgroup of patients with distant metastases limited to the bones, univariate analysis identified, in addition to thyroid and lymph node surgery, the surgical extirpation of the bone metastases as a significant prognostic factor associated with improved survival (P = 0.025).

CONCLUSIONS

These findings indicate that in patients without additional extraskeletal distant metastases, the radical surgical extirpation of bone metastases from differentiated thyroid carcinoma might be associated with improved survival.

Unusual brain metastases from papillary thyroid carcinoma: case report

OBJECTIVE AND IMPORTANCE

Brain metastases from papillary carcinoma of the thyroid gland are unusual. No consensus regarding management has yet been reached. We report a case, review the current literature, and explain our approach on the basis of clinical, pathological, and radiological data.

CLINICAL PRESENTATION

A 33-year-old woman presented with signs of intracranial hypertension. The diagnostic evaluation included chest tomography, head computed tomography, brain magnetic resonance imaging with and without contrast enhancement, total-body scanning, and cerebral scintigraphy. Multiple supratentorial lesions and one right cerebellopontine angle lesion were observed. Histopathological analysis of the surgical specimen confirmed papillary carcinoma of the thyroid gland.

INTERVENTION

A ventriculoperitoneal shunt was placed and a right suboccipital craniotomy was performed, with complete removal of the cerebellopontine angle tumor. Total-brain irradiation with 40 Gy/lesion followed the initial operation. One year after surgery, the patient presented with signs of increased intracranial pressure. A new left frontal lobe lesion with massive peritumoral edema was identified on magnetic resonance imaging scans. The edema was treated clinically and a left frontal craniotomy was performed, with complete resection of the tumor. The patient is currently faring well, with residual expressive aphasia.

CONCLUSION

Surgery followed by radiotherapy seems to be a good alternative for the treatment of this specific type of metastasis. Thorough clinical and radiological evaluation, followed by genetic analysis of the surgical specimen, particularly with respect to the potential for tumor invasion under specific conditions, is recommended. The information obtained contributes to better management and better overall long-term outcomes for these patients.

Bone metastases from thyroid carcinoma: a histopathologic study with clinical correlates

CONTEXT

Only limited information exists on the pathologic aspects of thyroid carcinomas with bone metastases, most large studies having concentrated mainly on their clinical features.

OBJECTIVE

To study in detail the morphologic features of thyroid carcinomas with skeletal metastases.

DESIGN

Seventy-nine cases of thyroid carcinoma with bone metastases treated at Memorial Sloan-Kettering Cancer Center, New York, NY, between 1964 and 1998 were investigated, with emphasis on the pathology of the primary and/or metastatic tumors and comparison of the morphologic features of the tumors at both the sites, wherever possible. The tumors were also compared for various clinical parameters.

RESULTS

The cohort consisted of 22 papillary, 17 follicular, 16 insular, 10 anaplastic, 9 Hürthle cell, and 5 medullary carcinomas. Of these cases, 68% had poorly differentiated or undifferentiated features in the primary and/or metastatic tumors. The metastatic tumors were better differentiated than the primary in one third of the cases (6 of 18). Only one case showed a less differentiated metastasis. The overall 5- and 10-year survival probabilities after the bone metastases were 29% and 13%, respectively (Kaplan-Meier method). Although both the tumor type and differentiation seemed to affect survivals after bone metastasis (P =.007 and.012, respectively) (log-rank test), this was primarily due to the much worse prognosis in the cases of anaplastic and medullary carcinoma. Cases of Hürthle cell carcinoma showed the longest median survival. There was no significant difference in survival among patients up to or older than 45 years at the time of metastases (P =.31).

CONCLUSIONS

Most thyroid carcinomas with bone metastases are of papillary type, and most have poorly differentiated or undifferentiated features. The influence of the microscopic tumor type and tumor differentiation on survival after bone metastasis primarily appears to be due to the much worse prognosis among anaplastic and medullary carcinomas. Age at diagnosis of bone metastases does not influence survivals.

Solitary follicular thyroid carcinoma of the skull base and its differentiation from ectopic adenoma--review, use of galectin-3 and report of a new case

With only four histologically proven cases in the literature, solitary skull base metastasis of thyroid carcinoma is extremely rare. Having treated another patient harboring a lesion with osseous destruction in the petroclival region and downward soft tissue extension we analyzed this case in conjunction with previous reports. In contrast to parenchymal brain metastasis that usually consists of the papillary type, histological examination revealed differentiated follicular tumors in all cases. All were located around the clivus. The radiographic picture resembled that of chordomas or chondrosarcomas. In the tissue obtained during thyroidectomy no evidence of primary malignancy was found in any of the cases according to standard histological criteria. In our case, a recently developed immunocytological marker - galectin-3 - was applied to differentiate between ectopic thyroid adenoma and carcinoma. The results were indicative of anaplastic growth. Tumor remnants responded well to postoperative 131I internal radiation and TSH suppression therapy. Distant metastasis of follicular thyroid carcinoma has to be considered in the differential diagnosis of destructive skull base lesions. Histological evaluation should include immunohistochemistry or clonal analysis to differentiate between adenomatous and carcinomatous growth and initiate effective radiotherapy early. Prognosis is by far not as poor as in brain metastases and appears to depend largely on location, size and histological appearance.