Thyroid carcinoma metastatic to the skin: a cutaneous manifestation of a widely disseminated malignancy

Skin metastasis of papillary thyroid carcinoma: A case report and literature review

The present study reports a rare case of skin metastasis in a 26-year-old female patient with a history of PTC positive for the BRAF V600E mutation. During the 2.5-year follow-up period after the initial surgical treatment of PTC, no evidence of distant metastasis was found via thyroglobulin measurements, neck ultrasound, or neck and chest computed tomography. However, following this period, the patient reported two skin nodules on the left side of the neck. Ultrasound-guided punch biopsy was performed, and the pathology results demonstrated that the patient had skin metastases from the PTC. The patient received surgical resection and complete removal of nodules, and was subsequently discharged from the hospital. A literature review showed that there are numerous potential mechanisms for skin metastasis, and the treatments are diverse and dependent on the patient condition. While surgical treatment may effectively improve patient symptoms and prognosis, long-term surveillance for recurrence is recommended for high-risk cases. Skin metastasis of PTC should be suspected in patients who develop an upper body skin lesion with a history of PTC, even without evidence of disease metastasis. For high-risk patients with skin metastasis of PTC with BRAF and TERT gene mutations, long-term surveillance for recurrence should be recommended in cases with a poor prognosis, and further research of these cases should be conducted in the future to optimize surgical and medical care.

Unusual Metastatic Sites and Radioiodine Uptake in Patients of Differentiated Thyroid Carcinoma with Atypical Clinical Presentations: Utilization of 131 I-Whole-Body Scintigraphy with Regional SPECT/CT

Differentiated thyroid carcinoma (DTC) usually is slow growing and carries a good prognosis. It most commonly tends to spread locally to regional lymph nodes in 20 to 60% of patients. The presence of distant metastasis impacts overall survival and prognosis. The lungs, bones, and the brain are typically involved in distant sites with less common metastatic sites that include the liver, kidney, skeletal muscle, adrenal glands, bladder, and skin. These unusual sites are rare and pose a diagnostic challenge and impact clinical decision-making to a great extent. The radioiodine 131 I whole-body scintigraphy with single-photon emission computed tomography/computed tomography can provide a thorough investigation of unusual sites of uptake leading to diagnosis of these metastases. We present a case series of DTC showing unusual sites of metastasis and/or radioiodine uptake in urinary bladder, in the third metacarpal bone of left hand and lastly in the forearm at postoperative hypertrophic scar area.

Cutaneous metastases from solid neoplasms - Literature review

Cutaneous metastases from solid tumors are uncommon events in clinical practice. Most of the time, the patient already has the diagnosis of a malignant neoplasm when the cutaneous metastasis is detected. However, in up to one-third of cases, cutaneous metastasis is identified before the primary tumor. Therefore, its identification may be essential for starting treatment, although it is usually indicative of poor prognosis. The diagnosis will depend on clinical, histopathological, and immunohistochemical analysis. Sometimes the identification of the primary site is difficult; however, a thorough analysis using imaging tests and constant surveillance is important.

Dermatologic manifestations of thyroid disease: a literature review

Introduction

Thyroid hormone is considered one of the key regulatory hormones for skin homeostasis. Multiple organs are affected by the release of peripheral thyroid hormones (T4 and T3) further regulating various functions at a cellular level. Specifically, skin is considered an important target organ in which the thyroid hormone has a significant impact. Multiple skin diseases are associated with thyroid hormone dysregulation. However, other striking dermatologic manifestations are seen in nails and hair as well. Hypothyroidism, hyperthyroidism, and thyroid cancer can have an array of cutaneous manifestations, and we present the recent updates in this field.

Methods

A PubMed search was performed for updates in any new skin disease findings and treatments between 2010 and 2022. Research published in the past decade and previously known foundational skin findings associated with thyroid disease were presented in this review.

Conclusion

Cutaneous manifestations of thyroid disease is one of the first notable signs of thyroid hormone dysregulation. This article reviews the recent updates on the thyroid and skin interplay, and it further discusses overt visible findings and various available treatment modalities.

Efficacy of anlotinib combined with radioiodine to treat scalp metastasis of papillary thyroid cancer: A case report and review of literature

BACKGROUND

Papillary thyroid cancer (PTC) is one of the well-differentiated thyroid tumors. Cutaneous metastasis from differentiated thyroid cancers occurs in < 1% of primary thyroid carcinomas but produces the worst survival prognosis. The multi-targeting tyrosine kinase inhibitor anlotinib has been approved to treat refractory advanced non-small-cell lung cancer as well as advanced soft-tissue and clear cell sarcomas in China.

CASE SUMMARY

In a patient with scalp metastasis caused by PTC, thyroid and skull metastasis tumor sizes were significantly reduced after a trial of neoadjuvant anlotinib therapy for 3 cycles. Anlotinib maintenance medication after thyroidectomy further reduced the metastatic skull tumor size thereby preventing the requirement for craniotomy.

CONCLUSION

The outcome of the present trial confirmed the potential of anlotinib therapy to treat scalp metastasis induced by PTC and point the way for the treatment of similar diseases in the future.

Unusual Clinical Manifestations of Thyroid Carcinoma

Thyroid cancer is considered the most common endocrine malignancy, with the most frequent presentation of differentiated thyroid cancer being a neck swelling or an incidental finding of a thyroid nodule on imaging. In this case series, we describe three cases of thyroid cancer with unusual clinical manifestations. The first case describes a patient who underwent parathyroidectomy for primary hyperparathyroidism and was found to have papillary thyroid cancer on a cervical lymph node biopsy. While this may be coincidental, the literature raises the question of whether there may be an association. The second case describes a patient who presents with a suspicious thyroid nodule and was subsequently diagnosed with follicular thyroid cancer on biopsy. This raises the question of performing thyroidectomy early in patients with a suspicious thyroid nodule but a false negative biopsy. The third case describes a patient with a scalp lesion found to have poorly differentiated thyroid carcinoma, a rare presentation of this form of cancer.

BRAFV600E and TERT promoter C228T mutations on ThyroSeq v3 analysis of delayed skin metastasis from papillary thyroid cancer: a case report and literature review

BACKGROUND

Skin metastasis from papillary thyroid cancer (PTC) is a rare entity that can occur up to decades after treatment of the primary tumor. Here, we present a patient who developed skin metastasis 10 years after treatment of her primary tumor and describe the molecular findings of the metastatic lesion.

CASE PRESENTATION

A 44-year-old female with a history of PTC who underwent a total thyroidectomy and radioactive iodine (RAI) treatment 10 years ago presented with a 1.3-cm skin lesion along the prior thyroidectomy scar. A biopsy revealed metastatic PTC, and the patient underwent surgical excision of the lesion. ThyroSeq molecular testing showed the copresence of BRAF^V600E mutation and TERT promoter C228T mutation. The patient subsequently received one round of adjuvant RAI therapy.

CONCLUSIONS

A high index of suspicion is warranted in patients with a history of PTC who develop a skin lesion, even several years after remission of the primary disease. In patients with high-risk mutations, such as BRAF^V600E and TERT promoter C228T mutations, long-term surveillance of disease recurrence is particularly important.

A Rare Case of Scalp Metastasis from Encapsulated Angioinvasive Follicular Thyroid Carcinoma

Cutaneous metastases from thyroid carcinomas are extremely rare; however, the scalp is a common site for cutaneous metastases from follicular thyroid carcinomas (FTCs). We report the case of a 77-year-old male patient with a blood-rich scalp lesion. Histopathological tests of punch biopsy specimens revealed subcutaneous well-formed follicular structures that were similar to those found in the thyroid gland. Immunohistochemistry using thyroid transcription factor-1 (TTF-1) and paired-box gene family 8 (PAX8) revealed an FTC metastasis. We performed total thyroidectomy and resection of the scalp lesion at the same time and administered postoperative radioactive iodine treatment. The primary thyroid lesion was diagnosed as an FTC based on extracapsular extension and vessel invasion. The patient has not experienced disease recurrence since the treatment. When scalp metastasis of thyroid carcinoma is suspected, we recommend total extirpation, including the primary tumor and scalp metastasis, for an improved prognosis.

MaalikBabu AN, Arumugam V. Interesting case of cutaneous metastases to thoracic skin from anaplastic carcinoma of thyroid: An unreported entity in India

Anaplastic thyroid carcinoma is a highly aggressive tumor with 100% mortality that constitutes 1%–2% of thyroid malignancies. Cutaneous metastases from thyroid carcinoma are extremely rare. We report a case of a 68-year-old male with anaplastic thyroid carcinoma with cervical lymph node and thoracic cutaneous metastases. Following the diagnosis of anaplastic carcinoma with stage IVB after thorough investigations, he was started on chemotherapy with cisplatin and adriamycin, and also radiotherapy was given subsequently. Dermatological examination showed a single ulcer of size 3 × 2 cm, hard nodules, and plaques of varied sizes present over the anterior chest. Skin biopsy from the nodule showed pleomorphic tumor cells in strands with colloid material and neutrophilic infiltrates in the deep dermis. The present case report demonstrates that thoracic skin metastases can occur from anaplastic thyroid carcinoma with nodules and ulcers and, to our knowledge, this is the first case report of such an extremely rare condition from India.

Uncommon Site of Metastasis and Prolonged Survival in Patients with Anaplastic Thyroid Carcinoma: A Systematic Review of the Literature

Simple Summary

The therapeutic strategies employed for anaplastic thyroid cancer patients seems to be insufficient to prolong their survival, but some characteristics could predict a good prognosis, so that, starting from our experience we offer a systematic review of the literature to better understand anaplastic thyroid cancers behavior and their prognostic factors, in order to recognize and select the patients with the higher probability of better outcome even if metastatic. Moreover, we described an uncommon site of metastasis in order to improve scientific knowledge about this rare and highly aggressive pathology.

Abstract

Anaplastic thyroid carcinoma (ATC) is a very rare, highly aggressive malignant thyroid tumor with an overall survival from 3 to 5 months in most of the cases. Even the modern and intensive treatments seem not to be enough to provide a cure, also for the resectable ones, and the role of chemotherapy is still unclear but does not seem to prolong survival. Nevertheless, some patients survive longer and have a better outcome, even in the presence of metastasis, than what the literature reports. We present the case of a 64-year-old female affected by ATC, treated on February 2018 with surgery followed by chemoradiation. One year after surgery, the patient developed a subcutaneous recurrence that was radically resected and is still alive 29 months after the diagnosis. We propose a systematic review of the literature to deepen the knowledge of the prognostic factors of ATC with the aim to recognize and select the patients with a better outcome, even if metastatic, and to describe a very uncommon site of metastatization.

Elimination of Locoregional Recurrences and Skin Metastases in Papillary Thyroid Cancer by Ethanol Ablation and Mohs Surgery

Ultrasound-guided percutaneous ethanol ablation procedures for locoregional recurrences in papillary thyroid carcinoma (PTC) can be repeatedly performed over years. Skin metastases (SM) from PTC generally portend a lethal prognosis. Our patient case report demonstrates the innovative use in low-risk PTC (LRPTC) of treatment modalities designed to prevent neck re-explorations and capable of eliminating both locoregional recurrences and SM. In 2004, a 48-year-old man presented with neck nodal metastases due to PTC. He underwent a near-total thyroidectomy and nodal dissection, confirming an 8-mm PTC involving 2 ipsilateral node metastases. Postoperatively, he received 2 doses of radioactive iodine (RAI) for remnant uptake (cumulative dose 338 mCi); posttherapy scanning was unrevealing. In 2007, he underwent right neck dissection for further node metastases. In 2008, a guided biopsy confirmed a level IV node metastasis. He was referred to our institution for ethanol ablation. Two node metastases were ablated and subsequently disappeared. During 2010-2016, he developed an additional 6 node metastases, which were treated with ethanol ablation; all disappeared on high-resolution sonography. FDG-PET-CT scans in 2009 and 2016 were negative for distant spread. In 2016, a SM in his right neck was removed by dermatologic surgery. In 2017-2018, 2 further SM were excised with negative margins, one after Mohs surgery. He has now been disease-free for 20 months. In conclusion, despite 3 neck surgeries and 2 RAI therapies, our patient repeatedly developed both locoregional recurrences and SM. All 11 disease foci were eliminated with minimally invasive procedures which should more often be considered as effective treatment options in LRPTC.

Unusual cutaneous metastatic carcinoma

Most of metastatic tumors to the skin are from primary tumors of the breast, lung, or from melanoma; metastases to the skin from primary carcinomas at other sites are rare. Cutaneous metastases of visceral carcinomas most often occur in patients with advanced disease, and are associated with a poor prognosis. We report 6 cases of nonmammary, nonpulmonary carcinoma metastatic to the skin. Most patients were elderly with advanced disease at the time of diagnosis of skin metastasis. The primary tumor sites included the thyroid, esophagus, biliary tract, ovary, and prostate. Awareness of these rare cases of metastasis to the skin will help pathologists and clinicians make the correct diagnosis.

Cytomorphological spectrum of scalp lesions in the population of a developing country: A retrospective study

BACKGROUND

Scalp lesions are frequently encountered in clinical practice. Fine-needle aspiration cytology (FNAC) can characterize most of these lesions; however, there is little published work on cytology of scalp lesions.

METHODS

Records of all the patients subjected to FNAC from January 2011 to August 2016 were retrieved from the archives of the Cytopathology section of our Institute. Out of the 71 852 cases reviewed, 896 patients, who presented with palpable scalp lesions, were included in the study. Aspirates were obtained with a 23-gauge needle attached to a 10 mL disposable plastic syringe. May-Grünwald-Giemsa stained and Pap stained slides were prepared. Special stains and immunocytochemical analysis were done when necessary.

RESULTS

Out of the 896 cases of aspirates from scalp lesions, 155 (17.2%) aspirates were found to be inadequate for diagnosis. One hundred and fifty-seven (21%) out of 741 adequate aspirates showed features of inflammatory or reactive pathology comprising of abscesses (57), cystic lesions (24), tubercular lesions (16), and reactive lymphadenopathy (66). Four hundred and fifteen (56%) aspirates revealed a tumor-like etiology comprising of epidermal cyst (395), sebaceous cyst (4), dermoid cyst (1), calcinosis (7), vascular malformation (7), hematoma (5), and juvenile xanthogranulomatous lesion (1). Tumorous lesions formed 22.3% of the aspirates. Of these, 7 cases (4.2%) were of metastases to the scalp.

CONCLUSION

In a developing country, FNAC is a useful and cost-effective investigation for the diagnosis of a wide spectrum of scalp lesions. It allows rapid diagnosis and permits timely intervention thereby preventing complications due to delay in diagnosis.

An H-TERT Mutated Skin Metastasis as First Occurrence in a Case of Follicular Thyroid Carcinoma

Differentiated thyroid cancer arising from thyroid follicular epithelial cells is the most frequent endocrine malignancy, and skin metastases are very rare. We describe a case of a 70-year-old women with a history of an indeterminate thyroid nodule on cytology. A painless, erythematous skin nodule of about 7 mm diameter was removed from the scalp and diagnosed as a metastasis from thyroid cancer. After total thyroidectomy, a histological diagnosis of follicular thyroid cancer was made. Two cycles of radioactive iodine were performed. Both the follicular thyroid carcinoma (FTC) and the metastasis were investigated for the presence of BRAF/RAS and TERT promoter mutations. The results showed that the cutaneous metastasis was BRAF wild-type and TERT promoter-mutated (position g.1,295,228 C>T); in contrast, the primary thyroid lesion was negative for both molecular markers.

Unusual Sites of Metastatic and Benign I 131 Uptake in Patients with Differentiated Thyroid Carcinoma

INTRODUCTION

Differentiated thyroid carcinoma (DTC) is the most common pathological type of thyroid carcinoma, which includes papillary and follicular subtypes. DTC is usually indolent, characterized by good prognosis, and long-term survival. Total thyroidectomy is the mainstay of treatment in DTC which is followed by diagnostic whole body 131I (WBI) scan. Like other primary malignancies of the head and neck, DTC follows a consistent pattern of spread in the cervical LNs. The central compartment, level VI and VII, is the first sentinel node followed by spread to the lateral compartments levels II-V, followed by the contralateral side. Inspite of nodal involvement, DTC usually have a favourable outcome. Presence of extrapulmonary distant metastases could predict a poor prognosis for high-dose ¹³¹I therapy. However, distant metastasis occurs often as a grave event and mortality rates vary depending on metastatic sites.

AIM AND OBJECTIVES

A range of rare ¹³¹I concentrating DTC deposits in sella, orbit, choroid, skeletal muscles, liver, skin, costochondral soft tissue, pancreas and kidney, and a few benign ¹³¹I concentrating sites are being depicted.

MATERIALS AND METHODS

Metastatic sites from DTC can be easily identified by performing a whole body ¹³¹I (WBI) scan along with a stimulated thyroglobulin (Tg) estimation (TSH >30 uIU/ml). Apart from thyroid and thyroid-related diseases, certain benign non-thyroidal pathologies can concentrate radioiodine (¹³¹I). From 13,000 of our patients who underwent radioiodine scan for thyroid cancer, we have selected a few cases of ¹³¹I concentrating benign and malignant lesions for illustration.

RESULTS

Out of 13000 DTC patients who underwent whole body ¹³¹I scintigraphy in our department from Jan 2007 till Mar 2018, 25 patients revealed benign sites of ¹³¹I uptake. 61 % patients had residual thyroid tissue with or without associated nodal involvement. Remaining patients had distant metastases. Rare sites of functioning thyroid metastases and benign sites of I 131 uptake have been selected for illustration.

CONCLUSION

Apart from the WBI (two-dimensional, planar) images, single-photon emission computed tomography-computed tomography (SPECT-CT) has been incremental in localizing benign lesions which greatly depends on their location. This pictorial review highlights the need to create an awareness to detect metastatic deposits of DTC at unexpected sites. Otherwise patients will need further investigation to rule out unsuspected sites of functioning distant metastases.

Skin metastasis on the neck: an unusual presentation of recurrence of papillary thyroid carcinoma

Skin metastasis of papillary thyroid carcinoma (PTC) is rare. Here, two cases of skin metastases of PTC are presented. Both of the patients were females, one is 83 and the other is 65 years old. The patients were admitted to the hospital with a movable skin lesion on anterior neck region. Free T3 and T4 levels were in normal levels and TSH levels were low in both patients. The 83-year-old patient underwent total thyroidectomy due to papillary thyroid cancer and received ¹³¹I ablation therapy and then thyroid suppression therapy. After the surgery, the patient lived without evidence of disease for 3 years and then skin metastasis occurred. The 65-year-old patient had a total thyroidectomy 5 years ago due to PTC then neck dissection due to metastasis 3 years later and then received ¹³¹I ablation therapy. Thyroid ultrasonography of both patients showed hypoechoic nodules with central vascularization. In the histological examination of both patients, cystic lesions filled with papillary structures were seen. Fine needle aspiration biopsy (FNAB) taken from both patients were papillary carcinoma with solid trabecular pattern. PTC tends to metastasize to regional lymph nodes but distant metastasis is rare. When distant metastasis develops, prognosis of the disease is poor. Therefore, skin metastasis of papillary thyroid cancer is a poor prognostic factor. If the patient does not have a thyroid malignancy history, diagnosis of PTC metastatic to the skin may be difficult since primary skin tumors such as apocrine tumors have similar histopathological features. However, in the presented cases since there was a PTC history, the diagnosis was easier with the help of histopathological examination. Skin metastasis of PTC should be kept in mind when differential diagnosis of atypical skin lesions are made especially in the patients with thyroid malignancy history.

Unusual Thyroid Carcinoma Metastases: a Case Series and Literature Review

The most common sites of metastatic differentiated thyroid cancer are the neck lymph nodes, while distant metastases typically involve the lungs, the bones, and less frequently the brain. Uncommon metastatic sites include the liver, adrenal gland, kidney, pancreas, and skin. The epidemiological aspects of thyroid metastases in rare sites are largely unknown and their identification could have a significant impact on patients management. A mini-series of unusual metastatic sites of thyroid carcinoma is proposed as a contribution to current knowledge on anatomopathological characteristics and clinical outcome. Of the six cases that were assessed, the metastases were the following: skin metastases (2), skin and pancreas metastases (1), renal metastasis (1), adrenal metastasis (1), and liver metastasis (1). In our experience, metastases in rare sites do not always represent a negative prognostic factor for disease outcome. In fact they can occur as single distant lesion and if surgically resectable, their treatment can also lead to local disease remission.

Metastatic papillary thyroid carcinoma to the nose: report and review of cutaneous metastases of papillary thyroid cancer

Background:

Metastatic papillary thyroid carcinoma typically appears in local lymph nodes. Skin metastases are rare.

Purpose:

A man with progressive metastatic papillary thyroid carcinoma who developed a cutaneous metastasis on his nose is described. The clinical manifestations of metastatic papillary thyroid carcinoma to skin are reviewed.

Methods:

PubMed was used to search the following terms, separately and in combination: basal, cancer, carcinoma, cell, cutaneous, kinase, inhibitor, metastases, nose, papillary, rearranged during transfection, receptor, RET, thyroid, tyrosine, vandetanib.

Results:

Pathologic changes observed on the biopsy of the man’s nose lesion were similar to those of his original cancer. Genomic evaluation of the tumor revealed an aberration involving the rearranged during transfection (RET) receptor tyrosine kinase. The residual tumor was excised. Treatment with vandetanib, a RET inhibitor was initiated; his metastatic disease has been stable, without symptoms or recurrent cutaneous metastasis, for 2 years following the discovery of his metastatic nose tumor.

Conclusions:

Papillary thyroid carcinoma with skin metastases is rare. Nodules usually appear on the scalp or neck; the thyroidectomy scar is also a common site. Metastatic tumor, albeit infrequently, can present as a nose lesion. The prognosis for patients with cutaneous metastases from papillary thyroid carcinoma is poor. However, with the ability to test the tumor for genomic aberrations, molecular targeted therapies—such as tyrosine kinase inhibitors—may provide extended survival in these individuals.

Cutaneous metastasis from anaplastic thyroid carcinoma exhibiting exclusively a spindle cell morphology. A case report and review of literature

Anaplastic thyroid carcinoma is a highly aggressive cancer accounting for 1-2% of thyroid malignancies. Cutaneous metastases from anaplastic thyroid carcinoma are exceedingly rare. We report a 65-year-old woman with anaplastic thyroid carcinoma (BRAF V600E mutation) who had lymph node metastases (pT4 N1b) treated by total thyroidectomy, postoperative radiotherapy, adjuvant chemotherapy (paclitaxel and pazopanib) and targeted therapy (vemurafenib). Nine months after initial diagnosis, radiographic studies revealed multiple pulmonary metastases. A dermatologic examination showed a solitary 1.2-cm chest nodule. Skin biopsy from this nodule revealed infiltrative dermal spindle cells arranged in poorly formed fascicles. Immunohistochemical studies demonstrated the tumor cells to be PAX-8 (+), pancytokeratin (+, focally), TTF-1 (-) and SOX-10 (-). Comparison with the patient's primary anaplastic thyroid carcinoma revealed focal areas of poorly differentiated spindle cells morphologically similar to the malignant spindle cells in the skin biopsy. Together, these findings confirmed the diagnosis of anaplastic thyroid carcinoma metastatic to skin. Cutaneous metastasis of anaplastic thyroid carcinoma composed exclusively of spindle cells broadens the histologic differential diagnosis of cutaneous spindle cell malignancies and presents further diagnostic challenges. PAX-8 may be useful in discerning the spindle cell component of anaplastic thyroid carcinoma from other spindle cell malignancies in the skin.

Calcitonin-Secreting Neuroendocrine Carcinoma of Larynx with Metastasis to Thyroid

Primary neuroendocrine tumors of the larynx are rare, with moderately differentiated neuroendocrine carcinoma (MDNC) being the most frequent histologic type. We report a MDNC in a 57-year-old gentleman with an enlarging right-sided neck mass. Flexible fiberoptic exam revealed a right arytenoid lesion. Histology from excisional biopsy was concerning for medullary thyroid carcinoma (MTC) versus NET of the larynx. Immunohistochemistry was diffusely positive for calcitonin and CEA and focally positive for TTF-1. Serum calcitonin was elevated. Thyroid ultrasound was unremarkable. The patient underwent laryngectomy, thyroidectomy, and neck dissection. Pathology showed neuroendocrine carcinoma of right arytenoid with positive cervical lymph nodes. A 4 mm deposit of NET was present in right thyroid with adjacent intravascular tumor consistent with thyroidal metastasis from a primary laryngeal NET (MDNC). MDNC and MTC can be microscopically indistinguishable. Both tumors can stain positively for calcitonin and CEA. TTF-1 staining has been useful to help distinguish these tumors as it is strongly and diffusely positive in MTC, but usually negative (or only focally positive) in MDNC. We report the fourth case of primary neuroendocrine carcinoma of the larynx associated with elevated serum calcitonin level and the first such case associated with metastasis to the thyroid.

Unusual Case of Papillary Thyroid Carcinoma with Choroidal Metastasis

BACKGROUND

The choroid is a rare site of thyroid cancer metastases, and has been described in patients with evidence of advanced breast, lung, and prostate carcinomas. To the authors' knowledge, only seven reported cases exist with choroidal metastasis secondary to papillary thyroid carcinoma (PTC). This study describes an additional patient with metastatic PTC with simultaneous appearance of choroidal mass and cutaneous deposits while on systemic therapy with a tyrosine kinase inhibitor (TKI). These infrequent sites of metastasis are typically associated with a dismal prognosis following the diagnoses. However, this patient has not shown evidence of choroid or cutaneous recurrence one year following local targeted and systemic therapy.

PATIENT FINDINGS

The case is presented of a 70-year-old male with widely metastatic PTC to the lymph nodes, lung, and mediastinum who was found to have choroidal metastasis six years after his initial diagnosis.

SUMMARY

The patient was asymptomatic and was found to have an incidental right choroidal mass on routine ophthalmology exam. Magnetic resonance imaging of the orbit revealed an isolated right choroid lesion suspicious for melanoma or metastasis. Concurrent to this discovery, he was noted to have progression of the lung and mediastinal disease along with new dermal lesions on the chest wall suspicious for dermal metastasis. Both the choroid and dermal metastases occurred while being on a TKI. Given his previous history of male breast carcinoma, a biopsy of the choroid was performed, which confirmed PTC. The patient developed endophthalmitis and subsequently underwent enucleation of the right eye. The choroid mass was completely excised, measured 3.5 mm×9.5 mm with negative margins, and histopathology was consistent with metastatic PTC. Pulmonary, mediastinal, and cutaneous lesions regressed after external beam radiation therapy, following which systemic therapy was changed to a different multikinase inhibitor.

CONCLUSION

A rare and unique case is reported of choroidal metastasis from PTC that presented with concurrent new dermal metastasis in addition to lung and mediastinal lymph node progression. Furthermore, the patient developed choroid and dermal lesions while on a TKI and remained stable without recurrence in these regions after switching to an alternate multikinase inhibitor.

Follicular variant papillary thyroid carcinoma with a twist

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A rare case of cutaneous metastases in a thyroid cancer reported.

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Usual features of FVPTC with a rare feature.

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High index of suspicion required to help make diagnosis.

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Histological analysis indispensible in arriving at confirmation.

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Multi-disciplinary approach in management post surgical intervention required.

Background

We report an adnexal lesion, which turned out to be a metastasis to the scalp from a left sided follicular variant papillary thyroid cancer. The patient has had history of right multi-nodular goiter 10 years prior to presentation.

Case presentation

A 75-year old lady presented with a cutaneous lesion about 1 year post left total thyroidectomy for FVPTC. She underwent surgical excision of the lesion and histology revealed it to be metastases from a thyroid carcinoma.

Discussion

Cutaneous metastases from thyroid carcinomas are relatively uncommon in clinical practice. A worldwide literature review reveals that follicular carcinoma has a greater preponderance than papillary carcinoma for cutaneous metastasis and that the majority of skin metastases from either papillary or follicular thyroid cancer are localized to the head and neck, with the scalp as the commonest site.

Conclusion

Skin metastasis from papillary and follicular thyroid carcinoma is an uncommon occurrence and these lesions should be differentiated from primary skin tumors. They are very important to recognize as early recognition can lead to accurate and prompt diagnosis leading to timely treatment. The scalp has been found to be the commonest site of cutaneous metastasis that may appear benign.

Solitary skin metastasis of papillary thyroid carcinoma

A solitary skin metastasis is a rare manifestation of papillary thyroid carcinoma (PTC). A 55-year-old woman presented with a movable subcutaneous nodule in her anterior neck for several months. Three years ago, she underwent total thyroidectomy and remnant ablation for classical PTC (pT3N0M0) and was under thyroxine suppression therapy without any evidence of recurrent disease. The subcutaneous nodule was 0.4 cm in size, firm, and movable without any change in the overlying skin. Recurrent PTC was confirmed after excision biopsy. Eight months after, she got a new nodule along the previous excision site. After punch biopsy, metastatic PTC was confirmed in the deep dermis and was re-excised with a clear resection margin. This is the first report of a case of solitary skin metastasis of PTC in Korea. Although solitary skin metastasis of PTC is rare, it should be considered in patients with a skin nodule.

Cutaneous metastasis of medullary carcinoma thyroid masquerading as subcutaneous nodules anterior chest and mandibular region

Cutaneous metastasis of underlying primary malignancies can present to dermatologist with chief complaints of cutaneous lesions. The underlying malignancy is generally diagnosed much later after a complete assessment of the concerned case. Medullary carcinoma thyroid (MCT) is a relatively uncommon primary neoplasia of the thyroid. Very few cases presenting as cutaneous metastases of MCT have been reported in the literature. Most of the cases which have been reported are of the papillary and the follicular types. We here report a case of a patient who presented in the dermatology clinic with the primary complaint of multiple subcutaneous nodules in anterior chest wall and left side of body of mandible. By systematic application of clinical and diagnostic skills these nodules were diagnosed as cutaneous metastasis of MCT bringing to the forefront a history of previously operated thyroid neoplasm. So clinically, the investigation of a flesh coloured subcutaneous nodule, presenting with a short duration, particularly in scalp, jaw, or anterior chest wall should include possibility of metastastic deposits. A dermatologist should keep a possibility of an internal organ malignancy in patients while investigating a case of flesh coloured subcutaneous nodules, presenting with short duration. A systematic application of clinical and diagnostic skills will eventually lead to such a diagnosis even when not suspected clinically at its primary presentation. A prompt and an emphatic diagnosis and treatment will have its bearing on the eventual outcome in all these patients.

Anaplastic thyroid carcinoma with diffuse thoracic skin metastasis: A case report

Anaplastic thyroid carcinoma is a significantly fatal endocrine neoplasm, with an average survival time of 4–12 months following diagnosis. The present study reports the case of a 57-year-old male patient who presented to the Bağcılar Training and Research Hospital (Istanbul, Turkey) due to swelling in the neck and difficulty swallowing. The jugular mass biopsy results were consistent with a diagnosis of anaplastic thyroid cancer. The patient was regarded to have advanced-stage subcarinal, paratracheal, aortopulmonary, trancheobronchial and mediastinal lymphadenopathies and exhibited a good prognosis following chemotherapy. However, the patient succumbed one month later due to the emergence of diffuse skin lesions. The histopathological and immunohistochemical assessment of the skin biopsy displayed the characteristics of the underlying thyroid carcinoma.

Unusual metastases from tall cell variant of papillary thyroid cancer

BACKGROUND

Tall cell variant (TCV) cancer is considered more aggressive than the classic variant of papillary thyroid cancer (PTC). Distant metastases are more common among this variant and affect survival. Little is known about the molecular pattern of this histotype.

METHODS

This is a report of 2 cases of unusual metastases from TCV, BRAF V600E-positive.

RESULTS

A 38-year-old woman developed subcutaneous metastases during short-term follow-up; at medium-term follow-up, the patient showed detectable stimulated serum thyroglobulin without disease evidence at imaging. A 33-year-old man presented incidental thymic metastases at time of surgical treatment; this is the first case of not ectopic thymic metastases from PTC.

CONCLUSION

TCV may present with unusual metastases already during early follow-up. The more aggressive behavior could be linked to the higher prevalence of BRAF point mutations, but only a long-term follow-up might clarify if this association could worsen the prognosis. Moreover, skin metastases have been predictive factors of worse outcome in our patients, but not thymic metastases.

Cutaneous metastasis as the presenting sign of papillary thyroid carcinoma

Cutaneous metastasis of visceral tumors accounts for 2% of skin tumors. We report the case of a 71-year-old male with a smoking history who presented to dermatology department with a violaceous nodule of the right sideburn skin. The lesion was interpreted as an adenocarcinoma that was completely excised and was suspicious for a metastasis. There was a recommendation for additional work-up. At a different institution, a positron emission tomography scan showed a left hilar mass and uptake in the right thyroid. He was then referred to our hospital for tissue diagnosis. Mediastinoscopy with biopsy of the left hilar mass showed metastatic follicular thyroid carcinoma. Subsequently, a thyroid fine needle aspirate showed suspicion for malignancy with similar morphology. Thyroidectomy and central neck dissection showed right thyroid papillary carcinoma extending to one margin and involving the lymph nodes. The left hilar metastasis mass resection showed similar lymph node findings. A re-review of the sideburn excision revealed similar histopathology to the thyroid and mediastinal resection. This case illustrates the opportunity of considering metastatic thyroid carcinoma to skin even in cases which lack the classic cytologic and architectural features of papillary thyroid carcinoma follicular variant.

American Thyroid Association guidelines for management of patients with anaplastic thyroid cancer

BACKGROUND

Anaplastic thyroid cancer (ATC) is a rare but highly lethal form of thyroid cancer. Rapid evaluation and establishment of treatment goals are imperative for optimum patient management and require a multidisciplinary team approach. Here we present guidelines for the management of ATC. The development of these guidelines was supported by the American Thyroid Association (ATA), which requested the authors, members the ATA Taskforce for ATC, to independently develop guidelines for ATC.

METHODS

Relevant literature was reviewed, including serial PubMed searches supplemented with additional articles. The quality and strength of recommendations were adapted from the Clinical Guidelines Committee of the American College of Physicians, which in turn was developed by the Grading of Recommendations Assessment, Development and Evaluation workshop.

RESULTS

The guidelines include the diagnosis, initial evaluation, establishment of treatment goals, approaches to locoregional disease (surgery, radiotherapy, systemic therapy, supportive care during active therapy), approaches to advanced/metastatic disease, palliative care options, surveillance and long-term monitoring, and ethical issues including end of life. The guidelines include 65 recommendations.

CONCLUSIONS

These are the first comprehensive guidelines for ATC and provide recommendations for management of this extremely aggressive malignancy. Patients with stage IVA/IVB resectable disease have the best prognosis, particularly if a multimodal approach (surgery, radiation, systemic therapy) is used, and some stage IVB unresectable patients may respond to aggressive therapy. Patients with stage IVC disease should be considered for a clinical trial or hospice/palliative care, depending upon their preference.

Cutaneous metastases from internal malignancies: a clinicopathologic and immunohistochemical review

Skin metastases occur in 0.6%-10.4% of all patients with cancer and represent 2% of all skin tumors. Skin metastases from visceral malignancies are important for dermatologists and dermatopathologists because of their variable clinical appearance and presentation, frequent delay and failure in their diagnosis, relative proportion of different internal malignancies metastasizing to the skin, and impact on morbidity, prognosis, and treatment. Another factor to take into account is that cutaneous metastasis may be the first sign of clinically silent visceral cancer. The relative frequencies of metastatic skin disease tend to correlate with the frequency of the different types of primary cancer in each sex. Thus, women with skin metastases have the following distribution in decreasing order of frequency of primary malignancies: breast, ovary, oral cavity, lung, and large intestine. In men, the distribution is as follows: lung, large intestine, oral cavity, kidney, breast, esophagus, pancreas, stomach, and liver. A wide morphologic spectrum of clinical appearances has been described in cutaneous metastases. This variable clinical morphology included nodules, papules, plaques, tumors, and ulcers. From a histopathologic point of view, there are 4 main morphologic patterns of cutaneous metastases involving the dermis, namely, nodular, infiltrative, diffuse, and intravascular. Generally, cutaneous metastases herald a poor prognosis. The average survival time of patients with skin metastases is a few months. In this article, we review the clinicopathologic and immunohistochemical characteristics of cutaneous metastases from internal malignancies, classify the most common cutaneous metastases, and identify studies that may assist in diagnosing the origin of a cutaneous metastasis.

Rare metastases of differentiated thyroid carcinoma: pictorial review

Differentiated thyroid cancer (DTC) is usually indolent with good prognosis and long-term survival. However, DTC distant metastasis is often a grave event and accounts for most of its disease-specific mortality. The major sites of distant metastases are the lung and bone. Metastases to the brain, breast, liver, kidney, muscle, and skin are rare or relatively rare. Nevertheless, recognizing rare metastases from DTC has a significant impact on the clinical decision making and prognosis of patients. (131)I single photon emission computed tomography/computed tomography ((131)I-SPECT/CT) can provide both metabolic and anatomic information about a lesion; therefore, it can better localize and define the (131)I-WBS findings in DTC patients. In this pictorial review, the imaging features of a range of rare metastases from DTC are demonstrated, with a particular emphasis on the (131)I-SPECT/CT diagnostic aspect.

Cutaneous metastases from internal malignancies

Cutaneous metastases of internal malignancies still seem to occur infrequently, although medical publications report an incidence rate of up to 10.4%. Common sense, however, fosters suspicion that we might underdiagnose the problem distracted by harder striking facets of an advanced disease. With contemporary knowledge, morphology and behavior of cutaneous metastases resemble each other regardless of the site of origin. This article itemizes clinical presentations according to organ systems, specific features, and differential diagnoses. In general, the survival turned out to be less than 12 months. But incremental awareness of cutaneous metastases proclaims this paradigm insufficient. Although excision is the local treatment of choice, investigations attempt to propose tumor-specific chemotherapeutic/immunological approaches. This paper endeavors to critically review the state of the art concerning the clinic, prognosis, and therapeutic concepts.

Anaplastic thyroid carcinoma initially presented with abdominal cutaneous mass and hyperthyroidism

A 63-year-old female was admitted to our hospital with a tender abdominal wall mass about 15 cm in diameter, which she had for 1 month. About 1 week earlier, the patient had also perceived a mass in the neck area. Computed tomography revealed huge thyroid and periumbilical masses. The thyroid hormone levels were consistent with a hyperthyroid state. Pathological examination of the thyroid mass was compatible with anaplastic thyroid carcinoma (ATC) and the abdominal cutaneous mass was shown to be metastatic ATC. Despite palliative radiotherapy and chemotherapy, the patient died of respiratory failure on her 63rd day of hospitalization. This case demonstrates that abdominal cutaneous metastasis and hyperthyroidism can occur as initial manifestations of ATC. To our knowledge, this is the first reported case.

Papillary thyroid carcinoma metastatic to skin may herald aggressive disease

OBJECTIVE

To describe an unusual case of papillary thyroid carcinoma presenting as a skin lesion on the nose.

METHODS

We describe the clinical, pathologic, and immunohistochemistry findings of the patient and briefly review the relevant literature.

RESULTS

An asymptomatic 73-year-old man noted a skin lesion on his nose, which when biopsied, revealed histopathologic characteristics consistent with papillary thyroid cancer and was immunohistochemistry positive for thyroid transcription factor-1 and thyroglobulin, also consistent with a neoplasm of thyroid origin. Subsequent physical examination showed a large left thyroid mass, and further workup demonstrated invasion of the trachea and surrounding musculature. In addition, metastases to the sternum, spine, lungs, and liver were noted. Fine-needle aspiration biopsy performed on the thyroid mass confirmed papillary thyroid carcinoma. Although there was evidence of systemic metastases, total thyroidectomy was suggested to the patient to allow optimal treatment by radioactive iodine. At operation, the cancer demonstrated fixation to the trachea and musculature, as well as infiltration of the surrounding soft tissues. Only the portion of the left thyroid mass that could be mobilized was removed. Final pathologic examination confirmed papillary thyroid carcinoma. Cutaneous metastases of thyroid carcinoma are infrequent, and, as the presenting feature of thyroid carcinoma, are even more rare. This case is noteworthy because a skin lesion was the presenting feature of thyroid carcinoma and histopathologic findings together with immunophenotyping provided the initial diagnosis.

CONCLUSIONS

In this patient, as in most published cases, the cutaneous metastasis was shown to occur in the setting of extensive metastases. This case also demonstrates that papillary thyroid carcinoma in men older than age 50 years can behave very aggressively.

Primary and metastatic malignant tumors of the scalp: an update

In recent years there have been a number of interesting advances in several topics relating to the diagnosis and treatment of cutaneous lesions with particular applicability to primary and metastatic malignancies of the scalp. In this article we provide a general update of advances in this field, and cover the more salient points relating to a variety of malignant tumors that have been reported to appear on the scalp as primary or metastatic lesions. A search and review of the literature on PubMed was made to identify and discuss relevant points relating to diagnosis and treatment of primary and metastatic tumors of the scalp. We describe the anatomy of the scalp, epidemiology of scalp tumors, theories of field cancerization and field therapy, photodynamic therapy, excisional surgical techniques and reconstruction, lymphoscintigraphy, chemoprevention, as well as details relating to atypical fibroxanthoma, Brooke-Spiegler syndrome, nevus sebaceus, cutaneous lymphoma, and metastatic disease. There is a very broad differential diagnosis for scalp nodules, which includes many different benign and malignant diseases, and treatment should be tailored accordingly. Given the potential for poor prognosis with some of the more aggressive malignancies that can be found in this anatomic area, the importance of a thorough physical examination cannot be emphasized enough, and early detection is critical to provide patients with the best chance for a favorable outcome.

Cutaneous metastatic carcinoma: diagnostic and therapeutic values

OBJECTIVE

This study was to highlight the diagnostic and therapeutic values of cutaneous metastatic carcinoma.

METHODS

Presented are patients with histologic diagnosis of cutaneous metastatic carcinoma seen in the University of Calabar Teaching Hospital, Calabar, Nigeria from 2000 to 2006.

RESULTS

Six patients (2 men and 4 women) with cutaneous metastatic carcinoma whose ages ranged from 37 to 55 years presented during the study period and accounted for 6.5% of total cutaneous cancer and 0.6% of total malignancy.

CONCLUSION

Cutaneous metastatic carcinoma exhibited a pattern of clinical significance. Clinicians are urged to renew interest in cutaneous nodules, chronic discharging sinuses, and ulcers.

Unusual cutaneous metastatic follicular thyroid carcinoma

Follicular thyroid carcinoma (FTC) is the second most common thyroid cancer (TCs) after papillary carcinoma, but it is ranked first in producing distant metastases among TCs. It accounts for 10 – 20% of all thyroid malignancies and is most often seen in patients over 40 years of age. Distant metastases at the time of diagnosis are reported in 11 – 20% of the patients and may be the reason for presentation. There have been less than 30 reported cases of cutaneous metastases from FTC in the English Literature, a majority affecting the scalp. We present an unusual aggressive, hypervascular FTC in a 58-year-old man with a previous diagnosis of multinodular goiter. The difficulty in gaining his acceptability of orthodox management resulted in the development of multiple giant scalp and right facial metastatic masses associated with lytic calvarial destruction and the involvement of frontal and right maxillary sinuses. These imposed serious challenges in managing him in a resource-poor community.